外科ICU诊治的6例成人重症破伤风患者临床特点和治疗经验

Clinical characteristics and experience of management of six adult patients with severe tetanus

目的分析成人重症破伤风患者的临床诊治关键环节。方法回顾性分析2013年1月至2019年6月西安交通大学第一附属医院外科ICU收治的6例成人重症破伤风患者的临床特点和治疗方法。结果6例成人重症破伤风患者均有明确外伤史,但预防接种史不详。平均年龄(49.5±7.25)岁,潜伏期(4~12)d,其中Ablett分级Ⅲ级2例(33.3%),Ⅳ级4例(66.7%)。张口困难是早期和典型的临床症状。5例患者气管切开并行机械通气,平均机械通气时间(9.67±4.13)d,后均继发肺部感染;4例患者并发自律性不稳定;2例患者并发横纹肌溶解,其中1例行连续肾脏替代疗法(CRRT)治疗。经积极治疗后,2例Ⅳ级患者放弃治疗,自动出院后死亡,死亡原因为难以控制的抽搐、感染及多脏器功能不全;4例患者(2例Ⅲ级,2例Ⅳ级)治愈后出院。ICU平均住院时间(25.33±13.92)d,死亡率为33.3%。结论以控制抽搐和自律性不稳定为重点,以积极的气道管理为核心,通过早期评估分级和重症监护,制定个体化精准镇静方案,结合并发症处理和接种免疫是治疗重症破伤风的有效措施。

Objective To analyze the clinical characteristics and management of adult patients with severe tetanus in surgical ICU.Methods We retrospectively analyzed 6 adult patients with severe tetanus treated in the surgical ICU of The First Affiliated Hospital of Xi'an Jiaotong University from January 2013 to June 2019.Results We collected 6 cases of severe tetanus with left untreated wound and uncertain vaccination over the studied period.The patients average age was(49.5±7.25),and incubation period varied from 4 to 12 d.There were 2 cases of Ablett gradeⅢand 4 cases of gradeⅣ.The diagnosis was mainly based on clinical manifestations,trismus was an early and the most characteristic symptom.Pulmonary infection(5/5,100%)occurred after mechanical ventilation(average 9.67±4.13 days)with tracheostomy in 5 cases.Four patients suffered from autonomic dysfunction,2 developed rhabdomyolysis and 1 underwent continuous renal replacement therapy(CRRT).Among the 6 patients,2 of gradeⅣgave up treatment and died,4 patients were cured and discharged from hospital.The average length of ICU stay was(25.33±13.92)days,and mortality rate was 33.3%.Conclusion Treatment of severe tetanus is lengthy,costly and complex,requiring close monitor and ICU care.Control of muscle spasm and autonomic dysfunction are the key,early tracheotomy and effective sedation are critical to successful treatment,and support therapy is the guarantee.Vaccination is the only way to prevent this potentially fatal disease.