V. Table of contents of teaching

TETANUS. Known in year one. Most often meets during the military operations. Hippocrates described his 2500 years ago. M.I.Pirogov foresaw the contagious origin of tetanus. In 1889 N.D. Monastirsky an exciter in strokes from a wound exposed, and a 1884 year Nicolayer – in soil. In 1883 S. Citazato got the clean culture of microbe.

Etiology, epidemiology: Exciter of tetanus - a tetanus stick (Cl.tetani) is a gram positive, sporogenous, anaerobic microorganism, by length 2-4 mcm. Has the characteristic form of drumstick. Very firm – keep boil of water to the 1 hour. In an external environment the spores are saved during years.

Sources:The bacteria of tetanus live in the digestive channel of man and domestic animals. On external Wednesday get with emptying. Meet everywhere where a man lives: in ground, to the street dust, on a muddy skin, clothes, linen and hair.

Accidental wounds can be entrance gates for a tetanus stick, including small, superficial as a scratch, scratch, surface of thermal damages. Possible penetration of exciter during the operations in connected with the defect of treatment of the operating field, sterilization of catgut, by deleting of foreign bodies, from opening of colon, injection, at criminal abortion, births, through an umbilical cord at new-born. In a recent year on Ukraine the morbidity on a tetanus went down perceptibly. The 1998 year a 41 case is registered only (0.8 on 100000). However lethality remained at the level of 60% that was conditioned:

• by an age-old structure (85% diseased people senior made 60 you the years);

• by violations of the planned and urgent immunization;

• by absence of the proper sanitary instructive works (80 % the victim too late or not at all appealed for the medical help after traumas;)

• by the presence of regions with the high risk of disease (degree of semination by a –soil tetanus stick 95-98%).

Classification of tetanus: (see Illustrative material)

Pathogenesis:

Natural immunity against a tetanus is absent, however unspecific protective forces of organism usually is enough, that to overcome an infection.

To development of tetanus assist:

• large wounds (especially shotgun) with the considerable damage of fabrics and necrosis;

• contamination of wound by earth (especially at railway and agricultural traumas), fecal;

• presence in the wound of foreign bodies;

• association of tetanus stick with putrid bacteria;

• overdrives, cooling, blood loss.

Frequency of complications by a tetanus has a seasonal character: more frequent meets by a summer, less often – in a winter.

The exciters of tetanus do not get to fabrics deeply and propagate oneself directly in the area of infection.

A tetanus stick selects exotoxin which is folded with tetanospazmin and tetanohemolizin. The first causes tonic and clonic cramps of transversal-striped of muscles, second – destroys red corpuscles. Influence of toxins on an organism determines the displays of illness. They quickly by resorption lymphatic vessels, farther get to the bloody river-bed, where plasma contacts with globulins. The toxins of tetanus have considerable cognation to the central nervous system; operate on a spinal, prolate cord, agile centers of cerebrum, where the cells of excitation appear. To these structures a toxin gets through the axial cylinders of peripheral nerves or with the current of blood. In a result from overwhelming action of toxins on the gamut-neurons of spinal cord, the function of braking suffers, there are cramps. The toxins of tetanus also strike myocardium, parenchymatosis organs, vegetative centers to the trunk of brain and other systems of organism. The carried tetanus does not abandon of long duration immunity.

Clinic of tetanus. A latent period proceeds from 3-4 to 20 and anymore days. Shorter can be at a laboratory infection only.

Early symptoms:

• violation of swallowing and pain in a throat;

• pain in the area of wound, it is possible with convulsion of muscles of injury extremity;

• pain on motion of nervous trunks at pressing on, dental pain;

• rise of tendons reflexes, appearance of pathological reflexes;

• head pain, pallor, illness, promoted excitability, trouble, sense of fear, insomnia;

• increased sweating, subfebril temperature, dysuria;

• spasm of muscles of person after pattering by the ends of fingers of around ear area;

• convulsive abbreviations of masticator muscles in investigation of pattering on the spatula fixed on lower teeth (symptom Lorin-Epshtein).

Basic symptoms:

• pain in an epigastria area and lateral departments of breasts;

• rigidity of masticator and mimic muscles, which results in trizm – impossibility widely to expose mouth, “sardonic smile”, or mournful type of person;

• rigidity of muscles of the back of head, pelting of head backwards;

• dysphagia, disorders of articulation;

• tonic and clonic cramps to the trunk and extremities, with development of opistotonus, position of the embryo. During cramps the breaks of bones and breaks of muscles are possible;

• tetanus abbreviation of intercostals muscles, with disorders of breathing which gains diaphragm character;

• convulsive abbreviation of glottis, and diaphragms, during which can arise up stop of breathing, asphyxia and death;

• Rise of temperature to 40-42 ^oС.

Development of cramps has the noted sequence: at first there is trizm, then abbreviation of muscles of person, farther the muscles of the back of head drawing in a process, then long muscles of the back and muscles of stomach. Less for all the spasms strikes the muscles of extremities especially overhead. In the last turn swallowing, intercostals muscles and diaphragm are struck. It is explained by interrelation of muscles of antagonists of different groups.

The clinic of tetanus quickly makes to progress. The clonic cramps of all skeletal muscles become the basic display of disease. Intensity of cramps is inclined to the increase. Before their origin lead the least sounds, light, or mechanical irritants. Depending on heavy of motion cramps proceed from 1-2 seconds with intervals at a few o'clock, to 1-2 minutes with intervals 10-15 minutes, a few times per one hour, sometimes serially and even continuously.

Loss of consciousness and sensitiveness for a tetanus not characteristic. Tetanus is polisystems disease. At his heavy forms are violated:

• activity of the cardio-vascular system;

• processes of the external and tissue breathing ;

• in 2-3 times the consumption of oxygen grows anymore;

• formation of heat rises considerably;

• there is massive swelling with the loss of far of water and electrolytes;

• there are vegetative disorders, violation of trofic of fabrics;

• are violated specific immunological reactivity against bacterial antigens that unspecific immunological system of defense.

A sharp widespread (generalization) tetanus has motion, that to a certain extent is determined by duration of latent and initial periods (initial, prodromal or period Koul – time from appearance of the first signs to the generalization disease). Than they shorter is the more heavy motion. However these criteria have not the absolute value. Exactly deciding a question about weight of disease is possible only in 2-3 days after hospitalization.

An easy form (I degree of weight) has a latent period by duration 3-4 weeks, initial –5-6 days. Shows up muscular pains, by widespread tonic tension of muscles, more frequent all in the area of person, head and neck. , there can be trizm, insignificant dysphagia. Violations of breathing, circulation of blood and in., are not. Temperature of body normal or subfebril. The common state is satisfactory. Duration of disease 1-1.5 weeks. Prognosis favorable.

The tetanus of middle weight (The ІІ degree) has a latent period – 2-3 weeks, initial - 3-4 days. It is characterized by pain, generalization tonic tension of muscles, partial, or complete immobilization patients, considerable trizm and dysphagia, which do not enable independently to adopt a meal. There is increased swelling, hyperthermia within the limits of 38-39 ^oС, tachycardia, hypertension, tachypnoe with the accordingly considerable rise of consumption of oxygen, the promoted secretion in trachea and in bronchial tubes, disorders of cough act. The state of patients is heavy. Absence of clonic cramps is the criterion of this form. Duration of disease 1.5-2 weeks.

Possible complications: obstructive respiratory insufficiency, atelectasis of lights with transition in pneumonia, cardiac insufficiency, second adrenal insufficiency, pathological hypertension, edema of brain. Prognosis: at timely valuable medical treatment there is possible complete convalescence.

A heavy form (ІІІ degree) has a latent period - 1-2 weeks, initial - 2-3 days. On a background there is the display, characteristic for ІІ degrees of weight, are observed clonic and clonic-tonic cramps. A temperature arrives at 40 ^oС. Cramps are very sickly, frequent, forces of patient are exhausted, sometimes result in the breaks of bones and break of muscles. On a background the cramps possible development of asphyxia crisis – in investigation of pharynx spasm and spasm of respiratory musculature during 5-10 seconds heavy hypoxia with cyanosis, expansion of pupils, faintness and stop of heart develops. Patients often perish during 4-5 days.

An as heavy as a lead form (ІV degree) has a latent period - 5-7 days, initial - 24-48 hours. It is characterized by protracted, or serial cramps which can become continuous. Typical their resistant to ordinary contra convulsion facilities and even muscular relaxants. A temperature exceeds 40 ^oС. Especially often there are cardio-vascular insufficiency, sharp asphyxia, hypertension, edema of brain. Death can come during 1-2 days. In the case of convalescence, after a sharp period long time there are tachycardia, hypotension, weakness, swelling, contracture of joints, deformations of spine.

A chronic tetanus, meets rarely, is characterized by soft motion with the limitation injury of muscles in the area of wound. It follows to remember that a local tetanus can pass to general.

Late and relapse tetanus arise up in a few months or years after the wound, in investigation of activating of latent infection. A trauma, operative interference, attends by provoking factors, in particular late deleting of foreign body.

A diagnosis is set on the basis of mainly clinical display of disease, bacterioscopy and the exposures of tetanus toxin in a culture have the second-rate value.

Medical treatment: tetanus is carried out in the separations of intensive therapy, by specialists, which have an experience herein, anesthetists, surgeons and in. Medical measures are included:

• Surgical treatment of wounds with carving of nonviable fabrics, wide opening of abscesses and races, by deleting of strange bodies, scabs. It is necessary directed to search abscess. It follows to abandon wounds by opened, irrigated by solutions of peroxide of hydrogen, antiseptics. If a wound healed over the shown repeated, still more radical treatment.

• Specific therapy by a antitetanus serum (ATS)which neutralizes an only circulatory toxin, and antitetanus still human immunoglobulin (ATHI), to which it is considered the far best measure – provides more protracted circulation of antitoxin in a blood during minimum allergy. Parallel introduction of tetanus to anatoxin is now considered inadvisable, as resulted in fastening of the entered antibodies. A vaccine ATS is brought into the first 2-3 days, simultaneously intravenous, in a dose 500 IU/kg in breeding 1:10. ATHI is used mainly, when contra-indicated ATS, is entered simultaneously intramuscular in a dose 1000 – 10000 IU. During conducting of active immunization TA it follows to take into account that ATS effective during 2-3 weeks, ATHI – 4-6 weeks.

• Antibacterial therapy with the use in the first days of penicillin and streptomycin, to which sensible exciter of tetanus, and then antibiotics of wide spectrum and metronidazol, for the fight against festering complications.

• Anticonvulsant therapy with the use of barbiturates, neuroplegic mixture, neuroleptics, narcotic and non narcotic analgesics, ataractic in different combinations. Against convulsive measures are not laid in standard charts. The best there is combination of barbiturates with fenotiazimin (aminazin) and Benz diazepam (sibazon) barbiturates (0.5% solution of hexenal or thiopental) are appointed while at the irritation there will be even insignificant tonic tension. At the heavy and as heavy as a lead flow of illness muscular relaxants of antidepolarization action (tubarin, tubocurarin) are used, artificial ventilation of lights is conducted.

• Tracheotomy which is shown at the III-IV degree of weight of disease, with the purpose of improvement of alveolar ventilation, warning of sharp asphyxia, evacuations of secret from a trachea and bronchial tubes. Imposition of tracheostomy expedient in the earliest terms.

• Prophylaxis and medical treatment of the second pneumonia with the use of antibiotics of wide spectrum of action, taking into account the sensitiveness of microflora, heparin, jar massage, vibration massage. Systematic inverting of patient.

• Providing of large energy losses and losses of liquid. At the heavy form of tetanus patients require 30 kcal/kg a day with addition 10% on every degree of rise of temperature over 37.5 ^oС. A liquid and semi-fluid meal is appointed. At violation of swallowing the feed is used through a noose-gastric probe or gastrostomy.

• Infusion therapy for correction of hemodynamic and electrolyte violations, paranteral feed. Optimum a dose is considered 70-75 ml/kg taking into account the liquid of entered through a probe.

• Hypothermia, if a temperature exceeds 38 ^oС, by means medicinal and physical measures (muffling by the sheets moistened by cold water and divorced vinegar, cold on the projection of main vessels, head, application of vehicle “Cold”).

• Application of the special methods of disintoxication: hemodilution, forced dieresis, plasmapheresis, hyperbaric oxygenation.

• Careful care of skin (prophylaxis of bedsores), mouth cavity. Timely emptying of intestine, urination, prophylaxis of keratitis, and others like that.

Patients with tetanus do not present an epidemic danger.

Immunity at having by had does not develop as a result of weakness of antigen irritation - lethal dose of toxin less than immunogenic.

Prophylaxis: Active immunization by tetanus anatoxin is the most effective method of warning of disease (TA-a). To active immunization all persons who have not contra-indications are subject.

Complete primary (planned) immunization foresees three inoculations by adsorbed bobbin-diphtherias by a tetanus vaccine beginning with the three lunar ages, with an interval in one month and first revaccination in 18 months of life. In future every 10 years revaccination behaves by non-permanent introduction TA-a. To the persons who the inoculation in good time is not conducted to, enter TA-a on 0.5 ml 2 times with an interval 30-40 days, then in 9-12 months and every 8-10 years. After completion of course of immunization an organism saves power quickly (during 2-3 days) to produce antitoxins in reply to the repeated introduction TA-a. The planned active immunization is carried out after Calendar of prophylactic inoculations, by ratified ministry of the public health of Ukraine.

The urgent prophylaxis of tetanus includes primary surgical treatment of wound and simultaneous specific immune prophylactics, shown at:

• traumas by s violation of integrity of skin and mucus shells;

• getting and burns (thermal, chemical and in.) of the II-III-IV degree frost-bitten;

• penetrate damages of gastric-intestine highway;

• extra hospital abortions that extra hospital births;

• gangrene or necrosis be what stage, abscesses;

• bites of animals;

It follows to spare the special attention:

• to all wounds of war-time and all gunshot wounds;

• to all wounds got at agricultural and transport traumas.

• to the wounds muddy by earth, street dust, intestinal maintenance, saliva;

• to the wounds, that contain foreign bodies;

• to the wounds with a plenty of nonviable fabrics.

The volume of surgical treatment is stipulated by the character of damage, presence and distribution of inflammatory-festering complications. Expedient prophylactic application of antibiotics, metronidazol.

A prognosis at correction relies on a form and weight of motion, reactivity of organism, timeliness and quality of specific and unspecific prophylaxis and medical treatment. Lethality and until now arrives at 60-80%. At persons which carried tetanus in 84% cases there are the various pathological changes:

• from the side of the cardio-vascular system – tachycardia, change of arterial pressure, hypertrophy of right departments of heart, blockades of the leading system, arrhythmia;

• rise of consumption of oxygen at the lowered coefficient of his use, violation of functional performance indicators of lights;

• compression deformation and compression of bodies of vertebrae, degenerative-dystrophic changes of spine and joints.

• the residual changes need rehabilitation measures: special medical treatment during 3-5 months, clinical supervision. Renewal of capacity is observed in 60% having by had. Other need translation on more soft snap or disability.

ANTHRAX or sibiries (Anthrax) is sharp communicable, mortally dangerous infectious disease of human and animals. In the pas was one of the most widespread infections. In our time in the world of 25-100 000 is annually registered. Cases of diseases of man are mainly in economic backward, agrarian countries. In Ukraine is marked sporadically, anymore in south districts. Today there is the real danger of the use of sibiries, as a biological weapon, and also mean of bioterrorism. Illness known in year one under the name is a “Persian fire”. In 1787 during an epidemic on Ural the Russian scientific S.S.Andriivsky by itself-infection led to unity of etiology of disease of man and animals and gave her the name – “anthrax”. In 1876 R. Koch described and got the clean culture of exciter, and in 1881 L.Paster created a living vaccine for immune prophylactics of disease of animals.

Etiology and epidemiology. Bacillus Anthraces is the exciter of anthrax – large stick size 5-8х1-1.5 mcm, aerobe or optional anaerobe (better grows in the presence of oxygen, but can without him), from development – t 37 ^oС, Ph 7.4. There are the R and S forms. Virulent only first from them, she forms spores which very much bars in an external environment, where save viability to 100 years, keep boiling to 120 degrees during 2 hours. In the organism of man, an exciter forms a vegetative form as the stick, surrounded by a capsule which protects him from absorption by phagocytes, warns formation of specific antibodies. Virulence of exciter of sibiries is also related to the toxin complex which is folded with swelling-inflammation, protective and lethal factors.

The sibiries undercutting is typical antropozoonoz . Herbivorous animals mainly are the source of infection of man, but there can be dogs, cats, rats, white mouse, bears, birds. Possible transmission of exciters by of the circulatory system insects. The infection originates from the dead bodies of lost, at the care of sick animals, treatment of meat, skins and in., the use in the meal of products of impregnated by the spores of sibiries. More often the disease is observed warm time of year. Artificial infection most reliable by spore forms as a dropping mixture or powder. In the military relation the exciter of sibiries comes into notice the possibilities of the easy, long saving, creation of areas of long duration firm infection, by absence of danger of wide epidemic among own warriors. The infection of healthy man from sick at the direct contact had possible.

Most often distribution of exciter takes place by a contact way, possible also alimentary, air, and transmission mechanism of transmission.

Pathogenesis: By the entrance gates of infection, more frequent in the form of spores, can be damage of area of skin, mucus respiratory tracts and digestive channel. Development of disease is conditioned by action of endotoxin and relied on the state of the immune system of organism and dose of exciter, that acts from the place of primary localization.

In our time the existence of the localized (skin) and septic forms of anthrax is acknowledged. The pulmonary and intestinal displays of disease arise up depending on the ways of penetration of spores. In the first stage, not depending on entrance gates, is struck regional lymphatic knots, in the second, there is the breach of infection in a bloody river-bed, generalization process: making toxemia, toxic-infection shock which most often ends with death to progress. A latent period can proceed from a few o'clock of to one week, more frequent all - 2-3 days. Most often (to 99%) meet localized – skin forms of sibiries. Coagulation necrosis of skin and hypodermic basis, considerable edema, develops in the town of penetration of exciter. Joining of unspecific infection is not almost observed. The skin form of anthrax is very rarely closed to the generalization process. If it takes place local display almost no denotation.

Inflammation in the lymphatic knots of thorax or abdominal region develops at the visceral forms of sibiries. Lymphadenitis - more frequent remote from the gates of penetration of infection – is a primary septic hearth. Contact, lymph-, and hematogenic ways a process passes to the cellulose of mediastinum, lights, pleura, pericardium, digestive channel, brain and his shells. For an anthrax there is characteristic sharp hemorrhagic inflammation with serous one, fibrin or necrotic by components. In the organs of immune genesis there are the signs of oppression of immune defense.

Clinical picture: For all forms of anthrax characteristic symptoms of heavy intoxication: rise of temperature to 39-40 ^oС, general weakness, head pain, violation of sleep, absence of appetite, delirium, cramp, vomits, sometimes cerebral disorders.

A pulmonary form shows up:

• by a short latent period;

• by a cold, tearing;

• by the selection of liquid, foamy, bloody sputum, with large maintenance of exciters;

• by quickly increasing cardio-vascular insufficiency;

• by death of patient in 2-3 days.

The gastric-intestine form of sibiries is characterized:

• by the sharp beginning;

• frequent, liquid, by the blood emptying, vomit;

• by cutting stomach-aches;

• by stormily increasing cardio-vascular insufficiency;

• by death of patient in 1-2 days.

The skin form of anthrax more frequent all is observed on the opened areas: cheeks, lobbies, neck, brushes, forearm. Possible plural localization. Hands, ends of fingers, auricles, are not struck, carried.

Select: carbuncle, edema, bulosis and erysipelas varieties.

The sibiries carbuncle is observed more frequent (99.1%) all, has the periodically noted displays:

• In 2-14 days the dense appears on the month of embodiment of infection, itch, red spot look like on the bite of insect.

• For a 1 time of itch increases considerably, pain passes to burning. The bubble filled by a dark liquid appears in the center of compression, and then an ulcer size 8-15 mm appears in his place, with a black bottom, which gets the name to the carbuncle. A temperature rises from this moment, there is head pain, sleep is violated, appetite and in.

• In following 5-6 days the inflammatory platen appears round an ulcer, was swollen, soft slight swelling of fabrics. The bottom of ulcer falls back, presses in, a serous-hemorrhagic liquid is abundantly selected. On an edge there is daughter's vesicle, which for days burst, get dry, on the change to them, moved aside to periphery, the new appear. It stipulates the eccentric increase to the carbuncle the size of which achieves the ten of sm.

• In the period of most clinical displays in the places of the developed hypodermic cellulose, on some removal from to the carbuncle there can be the expressly limited areas of the second necrosis, last sometimes meet with a primary hearth. A size to the carbuncle does not determine size of necrosis, but characterize weight of flow of illness.

• During following 7-14 days the edema disappears gradually, on a city to the carbuncle a scab is formed, with a demarcation area round about. The common state is normalized.

• To the C end 2-3 weeks a scab is torn away. In his place there is a granulating wound with the festering selection. Defect of skin, depending on a depth, substitutes by young connecting fabric and epitelization.

A carbuncle sibiries differs from banal:

• absence of pain;

• by a characteristic kind and character of excretions;

• by regional lymphadenitis, with painless lymphatic knots.

The edematous form of anthrax, meets rarely, differs by as heavy as a lead motion, can pass to the generalization form. The considerable, making to progress painless, dense edema which afterwards takes shelter by shallow bubbles with a serous liquid and areas of necrosis is distinguishing its feature. On a 3-4 day the bubbles burst, with the selection of a plenty of serous liquid. A scab appears on 8-10 day, subsequent motion reminds the carbuncle form of sibiries.

The bulosis form is also liquid. For her the origin in place of entrance gates of infection of bubbles with a hemorrhagic liquid is characteristic, which are quickly multiplied. On a 5-10 day the bubbles are opening or necrotic, widespread ulcerous surfaces look like on a carbuncle sibiries appear. Subsequent motion is identical.

The erysipelas form – is least widespread, is characterized by easy motion and favorable prognosis. Shows up the origin on the slightly swollen, turning red skin of a plenty of white bubbles of different sizes. In 3-4 days there are the bubbles opening, plural, shallow ulcers appear, with a bluish bottom. They quickly get dry, a scab is formed.

A sepsis sibiries is characterized by appearance in a blood, lymph, internal organs, large exciters. The symptoms of intoxication grow, a temperature rises, and then falls than norm below, rolling up of blood is violated, that is accompanied by the plural, hemorrhagic displays. The clinical picture of bacterial-toxic shock, polyorgan insufficiency develops.

Diagnosticsof anthrax includes:

• Bacterioscopy maintenance of vesicle to the carbuncle, blood, sputum, emptying.

• Bacteriological method – hung to material on the special environment with blood.

• Biological method – introduction of material to the laboratory animals which at presence of exciter of sibiries perish in 24-48 hours from a sepsis.

• Reaction of thermo-precipitation on Ascoli, which is based on the exposure of thermo stabile antigens of sibiries in excretions by means the serum, got during hyper immunization of horses the killed culture of microbes.

• Allergic method – is used for retrospective diagnostics. Hypodermic enter antraxin – the difficult complex got the hydrolysis of bacilli of sibiries. Appearance in 24 o'clock of area of inflammation is considered as a positive reaction.

• The method of molecular diagnostics and immune fermenting method is lately used.

Medical treatment of all forms of anthrax must be complex and conservative.

• Local medical treatment of skin forms consists in the grant of rest to the staggered area aseptic or ointment bandage.

• Specific therapy includes introduction of specific serum from 40 to 100 ml and parallel application of specific antisibiries gamut-globulin from 20 to 150 ml on a day, to 450 ml on a course, depending on heavy of motion.

• Antibiotic therapy derivative penicillin, tetracycline, hentamicin, levomicin, cephalosporin, phtorchinolon.

• In addition it is necessary to conduct infusion detoxication therapy, correction of hemodynamic and water-electrolyte violations, to enter corticosteroids, sympatolitics and principles of intensive therapy of sepsis depending on the state of sick.

Prophylaxis: On territories of dangerous in the relation of origin of anthrax a complex is entered dignity epidemic measures. To the persons which are engaged in research of infection material, work with animals materials of animal origin the planned active immunization is conducted. Scarification or hypodermic, with an interval 20-30 days, a living spore dry encapsulated vaccine is entered, through a year revaccination is executed.

An urgent prophylaxis is conducted in the first 5 days after the contact with infection materials, sick people and animals. It is recommended 5-ti daily course of antibiotics (docsitsiclin, rifampitsin, phtorchinol), and also antisibiries gamaglobulin (20-25ml). After contact persons on 8-9 days medical observation is kept under.

Patients with anthrax are hospitalized to the infectious separations, as that such possibility is not present, they can be insulated in separate therapeutic chambers.

In permanent establishment is an entered daily fluid disinfection excretion of patient, crockery, articles of the medical setting and care of patient. The final disinfection is executed after excerption or death of patient. Quarantine is taken off after 15 days, from the day of the last case of disease.

Troupes of deceased from sibiries in the case confirmed laboratory, to dissection are not subject. In the case of absolute necessity the dissection is executed by a doctor in the presence of doctor-epidemiologist, specialist on to the especially dangerous infections, is executed disinfection apartment and all articles of contact with deceased one.

DIPHTHERIA (diphtheria) – sharp infectious disease, that will be characterized by local fibrous-necrotic inflammation (most often mucus shells of pharynx), by the phenomena of general intoxication with the overwhelming impression of the cardio-vascular and nervous systems.

From the surgical point of view diphtheria of wounds is of interest (Diphtheria vulnerum). In a before antiseptics period was very widespread. In our time does not meet almost, but such possibility is not eliminated.

Now not to the end the removed consequences of epidemic of diphtheria 90 years ХХ of century, when morbidity in Ukraine attained 2.2 on a 100000 population. The actual level of morbidity is not known, because even in the developed countries 11-63% cases are officially registered only. Lethality from diphtheria among adults makes 3-7%.

Etiology the Exciter of diphtheria (Corynebacterium diphtherias) was opened almost simultaneously Clebs (1883) and Leffler (1884). Diphtherias stick (stick Lefflera), gram positive, immobile, not formative spores microbe, by length 2-8 mcm. In a clean culture quickly perishes at a temperature 60 ^oС. In fibrin tapes covering the areas of inflammation and wound, more firm – keep a temperature 100 ^oС during one hour. Long time saves virulence in a mouth cavity; in an external environment viable to 15 days, in water and milk – 1-3 weeks. The presence of other microbes strengthens action of diphtherias stick.

Epidemiology. Diphtheria is human infection. Patients or transmitters of toxigen diphtherias sticks are the sources of its distribution. Transmitters are especially dangerous, as rarely turn out. Consider that with them are linked to 90% diseases on diphtheria.

Way of transmission of exciter – mainly air-dropping. Especially a plenty of diphtherias sticks find in nose-pharyngeal excretions in the first days of disease on diphtheria and at the respirator diseases at transmitters. Possible infection through a crockery, toys.

Most often the mucus shell of tonsil and pharynx (92%) is entrance gates and place of development of inflammation, rarely to the nose (0.5%), larynx (1%), very rarely eyes (0.3%), privy parts, skin (0.2%).

The maximum of cases of diseases is on an autumn-winter period, when supercooling and respirator infections lower protective possibilities of organism. In our time the disease is observed:

• as sporadic cases or flashes, that rely on the level of collective immunity;

• not vaccinated or vaccinated with violation of rules are ill mainly;

• more often illness arises up at adults;

• a plenty of atypical forms which in good time are not diagnosed is marked.

Receptivity of people to diphtheria is determined by the presence of antitoxic diphtheria immunity. Defense from the disease provides maintenance in the blood of 0.03 IU/ml specific antibodies. However this level abandons possibility of forming of transmitter.

After the carried disease short antitoxic immunity is formed and in 1-1.5 years the diphtheria can arise up again. The inoculation also does not guarantee absolute defense, however at immunized illness has more easy motion.

Pathogenesis. Toxigen corinebacteria are incarnated in fabrics in close proximity of entrance gates. Multiply oneself they select exotoxin, neuraminidase and row biologically active matters, these products stipulate all local and general displays of pathological process.

• Diphtherias exotoxin on force of action on an organism yields only to the toxins of sausage-poisoning and tetanus. His thermo labile fragment determines specificity, halts a biosynthesis to the albumen by cages that conduces them to death. A thermo stabile fragment recognizes cages– targets and is fixed on them.

• Gialuronidaze destroys gialurone acid of capillaries, multiplies their permeability, results in an output in fabrics of plasma of blood with considerable maintenance of fibrin.

• Necrotoxin causes necrosis of epithelium that is accompanied by the selection of trombokinase. The last is caused by transition of fibrinogen in fibrin, satiation to them the fabrics and education on the surface of characteristic tape.

The local inflammatory reaction at first shows up the edema and hyperemia. The hearths of necrosis appear a little rather, most marked on periphery reproduction of exciters. Strengthening of local inflammation is accompanied by paralytic expansion and rise of permeability of vessels. To the area of inflammation and necrosis macrophages are concentrated. In exudates appear a plenty of fibrin, which satiates all layer of fabrics and forms the firmly soldered tape. On necrotic fabrics easily grow and multiplies second microflora (streptococci, staphylococci) propagates oneself, that burdens the flow of illness.

Common displays of diphtheria. Distribution of toxin and biologically active matters by lymphatic ways results in the increase of peripheral lymphatic knots, development of toxigen lymphadenitis, reactive edema.

By the hematogen way a toxin arrives at and is fixed on the surface of cages of organ- dartboard, quickly gets to their middle, halts the synthesis of albumens, causes death of cages. To the diphtherias toxin there are sensible all organs. Most impressionable there are the cages of cardiac to the muscle, nervous cages, suprarenal, buds. Clinical signs appear after a latent period duration of which relies on concentration of circulatory toxin and biologically active matters. So peripheral neuritis, myocarditis can show up in 5-7 days and even earlier. The possible development of polyorgan insufficiency, related not only to the results from action of toxins, but also with metabolic violations. The common displays of diphtheria are most marked in the case of localization of process in pharynx, least – at the impression of privy parts, skin.

Classification.

According to localization, diphtheria of pharynx, larynx is distinguished, to the nose, eyes, genital parts, skin, and wounds.

Depending on motion of process select:

• subtoxic, toxic (I–III go degree) forms;

• atypical (catarrhal) and typical (pellicle) forms;

Typical diphtheria is: localized, widespread, toxic.

The clinical picture of diphtheria of wounds is characterized:

• by the origin on the surface of wounds of grey-yellow fibrin raids, firmly soldered with inferior fabrics;

• by development under tape of necrosis of fabrics;

• by appearance of serous-hemorrhagic excretions;

• by the edema and hyperemia of surrounding fabrics;

• by the increase of regional lymphatic knots;

• by considerable oppression of processes of cicatrisation.

At diphtheria of wounds general reaction of organism often had marked, or is absent. How that is, shows up typical for diphtheria symptoms: by intoxication, toxic impression of cardiac muscle, paralysis of separate nerves, sudden death. The exact diagnosis of diphtheria of wounds can be set only by means bacteriological research.

Medical treatment of diphtheria includes:

• bed mode;

• high-calorie diet;

• early – the best in the first 1-2 days - application of antitoxic antidiphtherias serum in a dose:

• a 30-40 000 IU - at the satisfactory state;

• a 50-80 000 IU - at the state of middle weight;

• a 90-120 000 IU - at the grave condition;

• a 120-150 000 IU at the as heavy as a lead state;

A serum is entered, intramuscular or intravenous in isotonic solution of sodium chloride, together with glucocorticoids, slowly, with frequency of drops 8-10 on a minute.

• antibiotic therapy (erythromycin to 2 g on a day, ampicilin to 3 g on a day, penicillin to 6 millions on a day);

• detoxication therapy;

• cardiac;

• prophylaxis of complications

Local medical treatment must be conservative. Wounds are closed by aseptic or moist bandages with antiseptics. Surgical interference can be applied only in the case of appearance of festering complications.

During medical treatment, patients with diphtheria of wounds must be isolated.

Prophylaxis. Common measures consist in the exposure and isolation of patients and transmitters, inspection of contact persons. In a hearth disinfection is conducted, on 7 days quarantine is imposed.

A specific prophylaxis is directed on creation of collective immunity, by immunization of all population by diphtherias anatoxin.

Representatives of groups of risk – above all things medical workers, must pass annual revaccination.

VІ.The Oriented basis of action.

Patients with a sharp specific surgical infection are the source of infection. Infection can happen at the hit of exciters of gas gangrene on the damaged covers or mucus shells with dirty linen, clothes, and also at the use of the not enough sterilization instruments, syringes, needles, stitch and bandaging materials.

For medical treatment of patients with a sharp specific surgical infection separate chambers are selected on possibility with the special entrance, operation-dressing room, equipped by wave-drawing ventilation that is not reported with other separations.

The walls of apartments are to face by the tiled tile on the height of no less 2nd meters; a floor is covered by a plastic or linoleum. Surface of furniture, apparatus and equipment cover by smooth, unporous materials, which are easily added to the mechanical cleaning and disinfection treatment.

At the receipt of patient with a sharp specific surgical infection in the induction centre complete or partial sanitary treatment is conducted (on possibility): shower, cutting away of nails and others like that. In the heavy case without treatment a patient with a sharp specific surgical infection is transported escorted by a medical sister in a chamber.

Before the receipt and after excerption of patient bed, stand, process support for a ship (if such is) 6 % by solution of peroxide of hydrogen with 0.5 % by solution of cleanser. A bed is refueled by bed linen, that passed chamber disinfection treatment on the mode for the spore forms of bacteria.

During time of stay of patient with a sharp specific surgical infection in a chamber disinfect dirty linen by wetting and subsequent boiling in 2 % solution of soda and 0.5% solution of cleanser during 120 minutes from the moment of effervescence.

To the patient the individual articles of departure are selected: spittoon, ship, which after the use washes. After excerption of patient the articles of departure add disinfections.

For washing of hands and rest room of patients soap is used in the shallow packing.

Crockery after the use is released from tailings of meal, moisten in 2 % solution of soda and boil during 90 minutes. Then wash by running water and save in the closed.

Cleaning up of chambers is conducted not rarer, than 2 times per a day by a moist method with application 6 % solution of peroxide of hydrogen with 0,5 % by solution of cleanser.

Mark a harvest inventory (buckets, pelvis, rags and t. d.) and use only on purpose. After the use of autoclave at 2 kg/sm. 132 ^oC during 20 minutes, save in the taken place.

The special value has the feed of sick, on a tetanus which must be found in a noise isolation chamber. A meal must be valuable, mainly milk-vegetable, in a liquid kind, saturated by vitamins. Quite often the patient with a tetanus feed through the probe conducted in a stomach through a nose.

To flame for medical treatment of patients with tetanus must be equipped by a sterile tool for tracheotomy, by bandaging materials, an aesthetic and respiratory apparatus.

During bandaging of patient with a sharp specific surgical infection, bandaging is to be equipped stationary bactericidal lamps. For the decline of microbe contamination in bandaging setting used cleaning of air.

Surgeon, medical sister before the entrance in bandaging put on mask, bachils. During the operation or bandaging put on oilcloth apron which after every operation or bandaging wipe by a rag, abundantly moistened in 6 % solution of peroxide of hydrogen with 0.5 % by a cleanser.

Bandaging material is used non-permanent, during the operation or bandaging, and then collects him in specially selected bics, autoclave at 2 kg/square sm. 132 ^oC during 20 minutes and annihilate. It is banned to throw out material without disinfection.

The tool used during the operation or bandaging is collected in a capacity.

Cleaning up of operating-bandaging conduct by a moist method not rarer than 2 times per a day with application of solution of peroxide of hydrogen with 0,5 % by solution of cleanser with the use of individual facilities of defense: respirators of type ROu-60-60 and glove. After disinfection of apartment wash by hot water and include bactericidal lamps (OBN-150-150 or OBP-300-300) on 1.5 - 2 hours.

After conducting of operation or bandaging all tool, syringes, needles are dipped in 6 % solution of peroxide of hydrogen with 0.5 % cleanser on 60 minutes or boil during 90 minutes.

Subsequent method used of before sterilization treatment of instruments and his sterilization similar to standard technology.

During conducting of hyperbaric oxygenation to the patient with a sharp specific surgical infection the single-seat altitude chambers set in specially selected baroroom are used.