新人999如何治疗破伤风配图，仅供参考
Table 3:Management of tetanus
Goal
Treatment
Stop toxin production
Wound care,including d?bridement if necessary
Antimicrobial therapy targeting Clostridium tetani
Neutralize unbound toxin
Tetanus immune globulin
Active immunization with tetanus toxoid
Control of muscle spasms
Intravenous benzodiazepines
Long-term neuromuscular blockade for refractory tetany
Management of dysautonomia
β-blockers,morphine,epidural blockade and/or magnesium sulfate for sympathetic hyperactivity
Pacemaker if bradycardic
General supportive measures
Intubation and ventilation; consider early tracheotomy
Adequate nutrition
Prevention of nosocomial complications
[Open in a separate window](https://ncbi.nlm.nih.gov/pmc/articles/PMC3114896/table/t3-1831045/?report=objectonly)
The unbound toxin in the body must then be neutralized with human TIG at a dose of 3000 to 6000 U intramuscularly,with observational data suggesting shorter disease course and lower mortality rates as a result. The optimal route of administration of TIG is unclear. A meta-analysis of 12 clinical trials comparing intrathecal TIG or equine tetanus antitoxin with intramuscular administration showed a mortality benefit of the intrathecal route over intramuscular preparations (relative risk 0.71 [95% confidence interval 0.62–0.81]). However 7 of the 12 studies used equine tetanus antitoxin,limiting the generalizability of these findings to the developed world where equine tetanus antitoxin is not used. In addition,there was risk of bias associated with the included trials because of lack of blinding. Thus,TIG is typically administered intramuscularly in developed countries,but further trials are needed to definitively address this question.
Tetanus infection does not confer immunity and the effect of TIG is temporary,so it is recommended to actively immunize the patient with a full course of tetanus toxoid vaccination starting early in the course of illness.
Management recommendations for spasms and autonomic dysfunction are based largely on case reports and series. Muscle spasms should be treated with intravenous benzodiazepines; alternative treatments for refractory spasticity include baclofen,barbiturates,dantrolene,propofol and long-term neuromuscular blocking agents such as vecuronium. Autonomic dysfunction,particularly sympathetic hyperactivity,is another common clinical feature and can be treated with labetalol or morphine. Consideration can be given to magnesium sulfate infusion,which was shown in a randomized placebo-controlled trial to reduce the need for other drugs to control muscle spasm and cardiovascular instability,but with no difference in mortality or need for mechanical ventilation. General supportive care should be continued throughout the clinical course,including adequate nutrition and measures to prevent nosocomial complications. With aggressive management,mortality from tetanus is approximately 18%.
In the case presented above,a number of management challenges arose that complicated the patient’s clinical course and ultimately contributed to her death. First,generalized tetanus developed in the patient despite documented postexposure prophylaxis with tetanus toxoid after her fall. This may have been due to an unrecognized humoral immune deficiency that would have resulted in suboptimal response to the tetanus toxoid or due to the initial injury being more contaminated than initially suspected. Canadian guidelines recommend a dose of TIG in addition to tetanus toxoid for prophylaxis in the setting of wounds that are not clean,but the delay before the patient’s initial emergency department presentation may have masked the fact that the wound was contaminated. Second,she had a protracted clinical course,which we hypothesize was related to her age,comorbidities and early onset of autonomic instability. Finally,the patient developed serial nosocomial complications related to her prolonged hospital stay.","department":"
