Столбняк: обзор современных рекомендаций по эпидемиологии, этиологии, патогенезу, клинике, интенсивной терапии в период войн и в мирное время

Abstract

В статье представлен обзор современных данных по эпидемиологии, этиологии, патогенезу, клинике, интенсивной терапии столбняка. Отмечено, что наибольшее число заболеваний столбняком отмечается в период войн. Однако и в мирное время столбняк встречается довольно часто: ежегодно в мире умирает около 160 000 человек. В разделе «Этиология, патогенез» отображены данные, касающиеся биохимии тетанолизина и тетаноплазмина, дано определение автономной дисфункции. Представлены классификация тяжести столбняка (ABLETT), диагностические тесты столбняка (Tetanus Outbreak Control Guidelines February 2014). Декларировано, что Intravenous immuneglobulin — IVIG содержит столбнячный антитоксин и может быть использован, если противостолбнячный иммуноглобулин недоступен. Отображены рекомендации по ведению столбняка (Guidelines for the management of accidental tetanus in adult patient 2011). Прогноз исхода заболевания соответствует динамике Control Guideline for Public Health Units 2012. The article presents an overview of current data on the epidemiology, pathogenesis, clinical picture, intensive care of tetanus. It is noted that the largest prevalence of tetanus disease is in wa rtime. However, even in peacetime, tetanus often kills about 160000 people in the world daily. In developed countries, tetanus is rare as a result of the introduction of effective immunization programs. The part of the etiology, pathogenesis presents the data on the biochemistry of tetanolisin and tetanospasmin, gives the definition of autonomic dysfunction. The paper considers the classification of tetanus severity (Ablett), tetanus diagnostic tests (Tetanus Outbreak Control Guidelines February 2014) as follows: 1) the level of serum tetanus antibodies is determined prior to the introduction of tetanus toxoid or immunoglobulin, but the disease can develop at the ‘protective’ level of antibodies (‘protection’ titre); 2) the diagnosis of tetanus is exposed on the basis of clinical and epidemiological data; 3) human immunoglobulin contains tetanus antitoxin and can be used if tetanus immunoglobulin is not available. The article shows recommendations for intensive therapy of tetanus, which is graded as severe (grade 1) and mild (grade 2) by the GRADE system. Grade 1 includes the following items: 1) patients with tetanus moderate to severe are recommended to be hospitalized and treated in the Intensive Care Unit; 2) early passive immunization with human tetanus immunoglobulin (or PPP); 3) administration of antibiotics active against Slostridium tetani. Grade 2 includes the following as: 1) do not use the advisability peritraumatic and intrathecal immunoglobulin; 2) debridement within 1–6 hours after immunoglobulin; 3) imposition of tracheostomy within the first 24 hours after intubation in patients requiring restrictive support; 4) control AVL mode in volume and pressure; 5) the use of muscle relaxants with the ineffectiveness of other anticonvulsants; 6) the use of opioids with a central α-agoistami and/or propofol; 7) monitoring of creatinine phosphokinase levels to assess the effectiveness of anticonvulsant therapy. The prediction of disease outcome is consistent with a Control Guideline for Public Health Units in 2012 and is based on the epidemic parameters, the incubation period duration, prodromal period duration