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[MEDSCAPE测试]:你对破伤风知道多少?(6/6)
2016年10月26日 临床话题, 模拟诊室 评论数 1

Quiz: How Much Do You Know About Tetanus?

Michael Stuart Bronze, MD

September 08, 2016

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Tetanus is characterized by an acute onset of hypertonia, painful muscular contractions (usually of the muscles of the jaw and neck), and generalized muscle spasms without other apparent medical causes. Despite widespread immunization of infants and children since the 1940s, tetanus still occurs in the United States. Currently, tetanus primarily affects older adults because of their higher rate of nonvaccination or inadequate vaccination. What do you know about this condition? Test yourself with our quick quiz.

破伤风的特点是急性起病的肌张力升高,痛性肌肉收缩(常累及下颌及颈部肌肉),以及无明显原因的全身性肌肉痉挛。尽管从1940年代以来对婴儿和儿童广泛采取了免疫接种措施,但破伤风在美国仍有发生。目前,破伤风主要累及老年人,因为这些人未经过接种或接种不充分的比例很高。

你对这种疾病的认识如何?

请参加我们的快速测试。

问题1:Which is currently the most common source of infection that leads to tetanus? 目前,引起破伤风最常见的感染来源是什么?

答案:小伤口

868516-figure1The source of infection usually is a wound (approximately 65% of cases), which often is minor (eg, from wood or metal splinters or thorns). Frequently, no initial medical treatment is sought. Chronic skin ulcers are the source in approximately 5% of cases. In the remainder of cases, no obvious source can be identified.

感染源通常为伤口(约占65%),且经常为小伤口(如木头或金属碎片或刺)。很多情况下,患者均未接受初始的治疗。约有5%的病例为慢性皮肤溃疡。其他病例则没有明显的感染源。

Tetanus can also develop as a complication of chronic conditions such as abscesses and gangrene. It may infect tissue damaged by burns, frostbite, middle ear infections, dental or surgical procedures, abortion, childbirth, and intravenous or subcutaneous drug use. Possible sources not usually associated with tetanus include intranasal and other foreign bodies and corneal abrasions.

破伤风也可以作为慢性疾病如脓肿或坏疽的并发症出现。破伤风能够对烧伤、冻伤、中耳炎、口腔科或外科操作、流产、顺产及静脉或皮下用药所引起的组织损伤造成感染。经鼻吸入及其他异物和角膜损伤通常不会导致破伤风。

For more on the etiology of tetanus, read here.

如需了解破伤风病因的更多内容,请参阅here

问题2:In the United States during the current vaccination era, which is the most common form of tetanus? 在美国目前疫苗接种的情况下,哪种类型的破伤风最为常见?

答案:全身性破伤风

Illustration of a human hand with tophi, or swelling, at the joints of the fingers, due to gout. Gout is caused by elevated levels of uric acid in the blood, which crystallizes and deposits in joints and tendons.

Generalized tetanus is the most commonly found form of tetanus in the United States, accounting for 85%-90% of cases. The extent of the trauma varies from trivial injury to contaminated crush injury. The incubation period is 7-21 days, largely depending on the distance of the injury site from the central nervous system.

全身性破伤风是美国最常见的破伤风,约占85-90%的病例。创伤的程度不等,从轻微损伤到受到污染的挤压伤都可见到。潜伏期为7-21天,主要取决于损伤部位到中枢神经系统的距离。

Localized tetanus involves an extremity with a contaminated wound and is highly variable in severity. It is an unusual form of tetanus, but the prognosis for survival is excellent. Cephalic tetanus may remain localized or may progress to generalized tetanus. It is an unusual form of tetanus with an incubation period of 1-2 days. The prognosis for survival is usually poor. Neonatal tetanus (tetanus neonatorum) occurs primarily in underdeveloped countries.

局限性破伤风仅累及有污染伤口的肢体,严重程度差异很大。局限性破伤风是破伤风的罕见类型,但患者预后很好。头面部破伤风可能表现为局限性,或逐渐发展为全身性破伤风。头面部破伤风并不常见,潜伏期为1-2天,预后通常较差。新生儿破伤风主要见于不发达国家。

For more on the presentation of tetanus, read here.

有关破伤风临床表现的更多内容,请参见here

问题3:Which is the leading cause of death associated with tetanus? 以下哪个是破伤风患者的首要死因?

答案3:心源性猝死

868516-figure3Before 1954, asphyxia from tetanic spasms was the usual cause of death in patients with tetanus. However, with the advent of neuromuscular blockers, mechanical ventilation, and pharmacologic control of spasms, sudden cardiac death has become the leading cause of death. Sudden cardiac death has been attributed to excessive catecholamine production or the direct action of tetanospasmin or tetanolysin on the myocardium.

在1954年以前,破伤风痉挛造成的窒息是破伤风患者死亡的常见原因。然而,随着神经肌肉阻滞剂、机械通气及药物控制痉挛的发展,心源性猝死成为死亡的首要原因。心源性猝死源于大量儿茶酚胺释放或破伤风痉挛毒素/破伤风溶血素对心肌的直接作用。

For more on the complications of tetanus, read here.

有关破伤风并发症的更多内容,请参见here

问题4:Which statement about the workup of tetanus is accurate? 有关破伤风检查的哪种说法是正确的?

答案5:诊断破伤风没有特异性的实验室检查

868516-figure4No specific laboratory tests are indicated for determining the diagnosis of tetanus. The diagnosis is clinically based on the presence of trismus, dysphagia, generalized muscular rigidity, spasm, or combinations thereof. Although the laboratory findings are not diagnostically valuable, they may help exclude strychnine poisoning. A lumbar puncture is not necessary for diagnosis. Blood counts and blood chemical findings are unremarkable. Imaging studies of the head and spine reveal no abnormalities.

确诊破伤风没有特异性的实验室检查方法。通常根据下颌肌肉痉挛、吞咽困难、全身肌肉强直痉挛等表现,即可做出临床诊断。尽管实验室检查没有诊断价值,但有助于排除马钱子碱中毒。诊断破伤风无需通过腰穿检查。血常规和血生化无异常表现。头部和脊髓的影像学检查也无异常发现。

For more on the workup for tetanus, read here.

有关破伤风诊断的更多内容,请参见 here

问题5:Which is true regarding the treatment of tetanus? 有关破伤风治疗的哪种说法是正确的?

答案5:需要气管插管超过10天的患者应当进行气管切开

fig5_DT_13365948 [Converted]The goals of treatment should include stopping the production of toxin and its neutralization, airway management, and control of muscle spasm and dysautonomia. Prophylactic intubation should be seriously considered in all patients with moderate to severe clinical manifestations. Intubation and ventilation are required in 67% of patients. Attempting endotracheal intubation may induce severe reflex laryngospasm; preparations must be made for emergency surgical airway control. Rapid-sequence intubation techniques (eg, with succinylcholine) are recommended to avoid this complication. Tracheostomy should be performed in patients requiring intubation for more than 10 days. Tracheostomy has also been recommended after onset of the first generalized seizure.

治疗目标包括终止毒素产生及中和毒素,气道管理,以及控制肌肉痉挛及自主神经功能障碍。对所有中重度临床表现的破伤风患者,均应考虑预防性气管插管。约有67%的患者需要气管插管和机械通气。尝试气管插管的过程中可能诱发严重的反射性喉痉挛;因此必须做好紧急外科气道的准备。推荐使用快速顺序诱导插管技术(如琥珀酰胆碱)避免这一并发症。需要气管插管超过10天的所有患者均应进行气管切开。首次发作全身性癫痫后也推荐进行气管切开。

Antimicrobials are used to decrease the number of vegetative forms of Clostridium tetani (the toxin source) in the wound. For years, penicillin G was used widely for this purpose, but it is not currently the drug of choice. Metronidazole (eg, 0.5 g every 6 hours) has comparable or better antimicrobial activity, and penicillin is a known antagonist of gamma-aminobutyric acid (GABA), as is tetanus toxin. Metronidazole is also associated with lower mortality. Human immune tetanus globulin is administered to neutralize the toxin.

抗生素用于减少伤口中破伤风梭状芽孢杆菌的繁殖体(毒素来源)数目。多年以来,青霉素得到广泛使用,但是目前并非首选药物。甲硝唑(0.5 g q6h)的具有相似或更佳的抗生素活性,而青霉素与破伤风毒素相似,均为gamma-氨基丁酸(GABA)的拮抗剂。甲硝唑治疗病死率较低。人破伤风免疫球蛋白可用于中和毒素。

In many cases, the wound responsible for tetanus is clear at presentation, in which case surgical debridement offers no significant benefit. If debridement is indicated, it should be undertaken only after the patient has been stabilized. The current recommendation is to excise at least 2 cm of normal viable-appearing tissue around the wound margins.

对于很多病例,就诊时导致破伤风的伤口即很明确,此时进行外科清创并无益处。如果需要进行清创,应当在患者病情稳定后进行。目前推荐切除伤口边缘至少2 cm的正常组织。

For more on the treatment of tetanus, read here.

有关破伤风治疗的更多内容,请参见here

目前有 1 条留言 其中:访客:1 条, 博主:0 条

  1. xwx20002000 : 2016年10月26日15:34:17  -49楼

    第一题答案在第一期的时候是小伤口,后面变成了角膜损伤,是否是排版错误。

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