Gibson Kara, Bonaventure Uwineza J, Kiviri Willy, Parlow Joel
Department of Anesthesiology, Queen's University, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
Can J Anaesth. 2009 Apr;56(4):307-15. doi: 10.1007/s12630-009-9058-1. Epub 2009 Feb 14.
Few anesthesiologists have expertise in the diagnosis and treatment of tetanus, a disease that remains prevalent in developing countries. We report on a series of four cases of tetanus cases recently encountered in Rwanda. We review the clinical epidemiology, pathophysiology, diagnosis and the treatment of tetanus, and provide implications for anesthesiologists and critical care physicians.
We report four cases, two involving adults who were inadequately vaccinated and experienced injuries, and two involving neonates, both of whom underwent umbilical cord transection using unsterilized equipment. All patients required tracheal intubation, and were mechanically ventilated when equipment was available. One adult and one neonate succumbed to the disease. These cases highlight the difficulties of diagnosis and management of complicated diseases in the resource-challenged health care setting of developing countries.
The differential diagnosis of tetanus may be confusing, and survival depends on the rapidity of treatment with antitoxin, as well as adequate supportive care. High doses of sedatives and muscle relaxants, as well as prolonged mechanical ventilation, are usually necessary. Mortality remains high, usually resulting from late respiratory failure and cardiovascular collapse, associated with autonomic instability. Anesthesiologists and critical care physicians have an important role to play in the management of these patients. Increased involvement in humanitarian health organizations, immigration from developing countries, and emergence of high risk groups in developed countries will likely result in more exposure of anesthesiologists to the complexities of this disease.
很少有麻醉医生具备破伤风诊断和治疗方面的专业知识，而破伤风在发展中国家仍很常见。我们报告近期在卢旺达遇到的4例破伤风病例。我们回顾了破伤风的临床流行病学、病理生理学、诊断和治疗方法，并为麻醉医生和重症监护医生提供相关启示。
我们报告了4例病例，其中2例为成人，他们接种疫苗不足且有受伤经历；另外2例为新生儿，均使用未消毒的设备进行了脐带切断术。所有患者均需要气管插管，有设备时即进行机械通气。1名成人和1名新生儿死于该病。这些病例凸显了在发展中国家资源匮乏的医疗环境中诊断和管理复杂疾病的困难。
破伤风的鉴别诊断可能令人困惑，生存取决于抗毒素治疗的及时性以及充分的支持治疗。通常需要大剂量使用镇静剂和肌肉松弛剂，以及延长机械通气时间。死亡率仍然很高，通常是由晚期呼吸衰竭和心血管衰竭以及自主神经不稳定所致。麻醉医生和重症监护医生在这些患者的管理中发挥着重要作用。人道主义卫生组织的参与增加、来自发展中国家的移民以及发达国家高危人群的出现，可能会使麻醉医生更多地接触到这种疾病的复杂性。
