Anaerobic gas gangrene yog ib yam kab mob sib kis uas tshwm sim tawm tsam keeb kwm ntawm kev loj hlob thiab kev loj hlob ntawm cov kab mob ntawm genus Clostridium hauv tib neeg cov ntaub so ntswg, feem ntau ntawm cov ceg. Cov kab mob nkag mus rau hauv lub cev thaum daim tawv nqaij tawg.
Definition
Qhov txhab raug suav tias yog kev phais mob hnyav, uas yog tsim los ntawm kev kis kab mob anaerobic hauv qhov txhab, uas ua rau cov nqaij mos necrosis tseem ceeb. Tus kab mob no txaus ntshai nrog rau cov tshuaj lom neeg hauv lub cev, uas tseem ua rau tuag taus yog tias tsis muaj kev pab kho mob hauv lub sijhawm. Vim yog cov haujlwm tseem ceeb ntawm cov kab mob hauv lub qhov txhab, cov pa loj tshwm sim, uas sib sau ua npuas hauv cov ntaub so ntswg.
Gas gangrene tuaj yeem tshwm sim thaum qee yam kab mob nkag mus rau hauv lub qhov txhab, uas kis rau cov ceg thiab ua rau cov ntaub so ntswg tuag.
Cl. perfringens yog cov loj thiab immobile polymorphic rods uas tsim oval spores. Lawv nyob subterminally thiab tsim nyob rau hauvlub cev yog ib hom tshuaj ntsiav. Microbes muaj me me proteolytic zog thiab tsim ib pawg loj ntawm saccharolytic enzymes. Yog li ntawd, qab zib yog fermented nrog ntxiv tsim cov roj thiab acid. Cov kab mob pathogenic tau muab faib ua rau lub serovars (A, B, C, D, E, F), uas muaj ntau yam necrotic yam ntxwv. Clostridia "A" yog thawj tus neeg sawv cev ntawm cov pa roj gangrene thiab tsim cov kab mob hauv 70-80% ntawm cov neeg mob. Cov spores tuaj yeem tiv taus qhov mob ntawm 100 ° C rau 1 txog 6 teev.
Cl. novyi yog cov loj thiab tuab Gram-zoo motile rods uas tsim oval spores thiab nyob rau hauv tsis muaj capsules thiab subterminally. Lawv muaj cov yam ntxwv tsis muaj zog proteolytic. Cov khoom saccharolytic tau nthuav tawm tsawg dua. Muaj plaub serovars (A, B, C, D) uas tuaj yeem tso cov co toxins ntawm ntau yam tshuaj tiv thaiv kab mob uas muaj hemolytic thiab necrotic zog. Spores stably hnov mob rau ntau yam ib puag ncig thiab muaj sia nyob kub hnyiab tau ob peb teev, lawv tuaj yeem nyob hauv av rau 7-8 xyoo hauv daim ntawv nquag.
Cl. Septicum yog polymorphic, motile, thiab Gram-zoo rods uas tsim oval spores, tsis tsim capsules, thiab nyob rau hauv subterminally. Qhov no causative tus neeg sawv cev ntawm gas gangrene muaj me ntsis saccharolytic thiab proteolytic zog. Nws muaj 6 hom serological (A, B, C, D, E, F), secretes necrotic, lethal thiab hemolytic toxins.
Cl. Histolyticum yog me me, txawb thiab Gram-zoo rods uas tsim spores tsis tsim tshuaj ntsiav. Lawv muaj zog proteolytic zog. Lawv koom nrog hauv kev tsim cov exotoxin, uas ua rau necrotic thiab tuag taus. Cov yam ntxwv no yog tsim los ntawm kev tso tawm enzymes xws li hyaluronidases, collagenoses thiab lecithinases.
Yog vim li cas
Gas gangrene yog tshwm sim los ntawm rods ntawm tsev neeg Clostridium, uas feem ntau nyob hauv cov hnyuv ntawm herbivores thiab los ntawm qhov ntawd nkag mus rau hauv av, ntawm khaub ncaws thiab txoj kev plua plav. Qee zaum, cov kab mob tuaj yeem pom ntawm daim tawv nqaij thiab hauv cov quav ntawm cov neeg noj qab haus huv. Cov kab mob me me tsuas yog nyob hauv ib puag ncig tsis muaj oxygen, tab sis yog tias huab cua nkag rau hauv lawv, lawv nyob twj ywm rau lub sijhawm ntev hauv daim ntawv spores, thiab nyob rau hauv cov xwm txheej zoo rov ua dua thiab ua rau muaj kev phom sij.
Feem ntau, cov kab mob tshwm sim los ntawm ntau qhov txhab, qhov txhab ntau thiab kev puas tsuaj ntawm cov ceg, tsis tshua muaj tshwm sim - vim yog cov kab mob ntawm cov hnyuv loj tom qab noj cov khoom txawv teb chaws. Qee qhov xwm txheej, cov cim qhia ntawm cov pa roj gangrene tuaj yeem tshwm sim vim muaj kev txiav me me uas muaj cov kab mob hauv av thiab cov khaub ncaws tawg.
Nws txhim kho li cas
Clostridia yog dav faib nyob rau hauv ib puag ncig, nrog rau hauv av, qhov twg nws muaj nyob rau hauv daim ntawv ntawm spores thiab nkag mus rau tib neeg lub cev los ntawm abrasions thiab khawb yog tias lawv tsis kho raws sij hawm. Lub ntsiab tseem ceeb hauv kev txhim kho cov kab mob anaerobic gas gangrene yog cov cim hauv qab no:
- Ntau zaus qhov xwm txheej tshwm simnyob rau hauv kev ua txhaum ntawm oxygenation thiab nyob rau hauv kev sib txuas lus tsis zoo ntawm cov kab noj hniav thiab sab nraud ib puag ncig. Tsis tas li ntawd, qhov txhab raug tsim thaum lub hemostatic tourniquet tau hnav ntev ntev ntawm cov extremities nyob rau hauv cov ntaub ntawv ntawm kev raug mob rau lub ntsiab hlab ntsha thiab nyob rau hauv cov neeg mob uas muaj mob ntev arterial insufficiency.
- Cov keeb kwm zoo yog qhov muaj qhov loj ntawm cov nqaij ntshiv thiab tawg, nrog rau yam uas ua rau lub cev tsis muaj zog.
- Tus neeg sawv cev ntawm cov pa roj gangrene tau qhib thaum muaj xwm txheej zoo anaerobic tsim. Cov kab mob microorganisms pib ua kom muaj zog thiab tsim cov co toxins, uas muaj kev puas tsuaj rau cov ntaub so ntswg, thiab tseem ua rau muaj kev sib kis sai ntawm necrosis.
- Vim yog lub luag haujlwm saccharolytic, glycogen raug rhuav tshem, thiab qhov kev ua haujlwm proletic ua rau cov proteins yaj thiab rhuav tshem.
- Clostridia yog tus yam ntxwv los ntawm kev tsim cov edema thiab roj.
- Vim qhov kev ua ntawm cov tshuaj lom, arterial thiab vein thrombosis tsim, tuag tes tuag taw thiab kev puas tsuaj ntawm vascular permeability tshwm sim.
- Enzymatic cov ntsiab lus ntawm cov ntshav thiab ntshav nkag mus rau thaj tsam necrosis, uas ua rau nqus tau cov kab mob toxins sai, thiab cov khoom lwj ua rau muaj kev qaug cawv loj.
- Lub sijhawm incubation yog los ntawm ob peb teev mus rau 2-3 lub lis piam. Qhov nruab nrab, lub sijhawm no yuav siv sijhawm 1-7 hnub, thiab lub sijhawm luv dua, qhov tsis zoo thiab nyuaj rau kev kawm thiab kev kwv yees.
Clostridia zais cov exotoxins uas muaj ob peb feem, uas muaj cov teebmeem hauv zos thiab lub cev, uasxa mus rau:
- lecithinase C - muaj cov nyhuv hemolytic thiab necrotic;
- collagenase - thaiv cov qauv protein;
- hemolysin - muaj cov nyhuv cardiotoxic thiab necrotizing;
- fibrinozolin;
- hyaluronidase - yog qhov tseem ceeb hauv kev nkag mus ntawm cov kab mob;
- hemagglutinin - inhibits qhov tsim ntawm phagocytosis;
- neuraminidase - neutralizes lub cev tiv thaiv kab mob ntawm cov qe ntshav liab.
Symptoms
Crepitus suav hais tias yog ib qho cim tshwj xeeb - ntawm palpation, koj tuaj yeem hnov suab zoo ib yam li cov daus daus. Feem ntau, qhov pib ntawm tus kab mob yog sai heev nrog rau kev loj hlob ntawm intoxication loj heev. Cov tsos mob classic ntawm gas gangrene yog:
- pronounced edema, dhau tsis muaj hyperemia;
- npuas uas muaj cov tshuaj hemorrhagic thiab cov pob ntsuab ntawm daim tawv nqaij;
- mass necrosis ntawm cov leeg thiab cov ntaub so ntswg;
- txo qis hauv qhov kub;
- tsim ntawm huab exudate ntawm tsis-purulent manifestation, nrog rau ib qho tsis kaj siab tsw;
- gas khaws cia.
x
Tus kab mob anaerobic feem ntau tshwm sim los ntawm kev nce sai hauv cov tsos mob hauv zos ntawm gas gangrene, nrog rau cov txheej txheem thoob plaws hauv cov ceg. Tom qab ob peb hnub, raws li txoj cai, aerobic microflora pib koom nrog, nrog rau cov kab mob purulent.
Stages
- Ua ntej. Thaum lub sij hawm no, cov neeg mob yws ntawm qhov mob. Lub qhov txhab zoo li qhuavtshwm qias neeg grey txheej. Necrosis daws nrog me me los yog tsis muaj paug ntawm brownish exudation. Muaj qhov o me ntsis ze ntawm qhov txhab, daim tawv nqaij daj ntseg me ntsis.
- Kev faib khoom theem. Nrog nws, cov txheej txheem ntawm kev tsim roj thiab edema nce. Qhov mob acquires bursting zog. Tus neeg sawv cev ntawm cov roj gangrene pib tua cov ntaub so ntswg, lawv tau txais lub cev tsis muaj zog thiab qhuav, cov leeg zoo li tsis yooj yim, npub thiab los ntshav. Cov xim icteric ntawm cov epidermis ncua deb ntawm qhov txhab.
- Nyob rau theem no, tus ceg tawv yuav txias, tsis muaj peripheral pulsation nyob rau hauv nws, nws rhiab heev yog rhiab heev, thiab qhov mob nres. Lub integument ua daj ntseg, thiab qhov chaw lesion nce loj loj. Gases thiab edema kis mus rau lub cev, hlwv nrog hemorrhagic los yog xim av exudate raug pom. Lub qhov txhab tsis muaj sia, thiab cov leeg hauv nws zoo li cov nqaij boiled. Ntshav-purulent tso tawm yog ua tau los ntawm qhov tob ntawm qhov txhab.
- Sepsis. Pus sau nyob rau hauv qhov teeb meem, intoxication hnyav thiab metastatic foci raug soj ntsuam.
Kev faib tawm
Muaj peb daim ntawv tseem ceeb:
- clostridial myositis - tus cwj pwm los ntawm cov leeg nqaij puas;
- clostridial cellulitis - subcutaneous rog thiab cov ntaub so ntswg sib txuas yog feem ntau puas;
- mixed form.
Diagnosis
Ua ntej ntawm tag nrho, nws yuav tsum tau ua qhov kev kuaj mob thiab txheeb xyuas tus kab mob anamnesis:
- hauv qhov txhabxyaum tsis muaj paug;
- muaj xim dub thiab crepitus ntawm thaj chaw cuam tshuam;
- pua npuas npuas tsim nyob rau hauv siab;
- nqaij tawv zoo li nqaij npuas;
- txawm hais tias muaj kab mob hnyav heev, tsis muaj qhov ntsuas kub nce ntxiv.
Thaum kuaj X-ray, cov nqaij ntshiv yog tshwm sim. Kev kuaj mob gas gangrene kuj suav nrog kev sim kuaj. Cov khoom yog cov khoom ntawm cov ntaub so ntswg necrotic, scraps ntawm khaub ncaws, edematous kua, ntshav thiab hais txog lub ntiaj teb. Cov txheej txheem bacteriological muaj xws li inoculation ntawm Wilson-Blair ntshav agar, Kitt-Tarozzi nruab nrab thiab kev txheeb xyuas cov kab lis kev cai.
Kev kho mob
Rau kev kho mob, tus neeg mob yuav tsum raug cais tawm hauv ib chav sib cais nrog kev saib xyuas kev huv thiab huv. Nyob rau hauv tsev, nws yog ib qhov tsim nyog los tshem tawm qhov muaj peev xwm ntawm kev sib cuag kis ntawm tus neeg sawv cev ntawm cov roj gangrene. Yuav tsum muaj tshuaj tua kab mob kom txaus thiab raws sijhawm ntawm cov cuab yeej kho mob, hnav khaub ncaws thiab khoom siv chav dej.
Cov txheej xwm muaj xws li cov khoom hauv qab no:
- sijhawm thiab kev debridement ntawm qhov txhab;
- tiv thaiv kev sib kis thiab kev tsim tawm ntawm cov kab mob yog ua nrog kev pab ntawm oxygenation, siv cov tshuaj tua kab mob thiab cov tshuaj tshwj xeeb;
- hloov pauv hauv kev ua haujlwm ntawm lub cev thiab tag nrho cov tshuab raug kho nrog kev siv tshuaj tiv thaiv kab mob thiab kev ua kom infusion, immunostimulation thiabimmunocorrection;
- txoj hauv kev sib kis rau cov roj gangrene raug thaiv los ntawm kev ua kom tsis zoo ntawm cov tshuaj lom neeg los ntawm kev tswj hwm cov tshuaj toxoids tshwj xeeb thiab kev siv cov txheej txheem kev tshem tawm cov kab mob extracorporeal.
Kev phais tuaj yeem qhia tau hauv peb kis.
- Yog tias muaj kev sib cais dav ntawm cov ntaub so ntswg, uas yog, "teeb" incisions nrog qhib lub fascial sheaths rau pob txha thiab aponeuroses. Txhua yam kev ua ub no yog ua kom txaus aerate lub qhov txhab thiab tshem tawm edematous kua, raws li nws muaj ib tug loj npaum li cas ntawm toxins.
- Yog tias muaj cov nqaij ntshiv excised.
- Thaum kev txiav tawm ntawm cov ceg ceg tau ua tiav siab dua qib ntawm cov ntaub so ntswg uas pom tsis tau siv cov txheej txheem suturing thawj zaug.
txhawm rau txhim kho cov txheej txheem oxygenation, uas yog qhov tsim nyog rau kev kho tus kab mob, cov txheej txheem raug sau rau hauv lub siab chamber, qhov twg cov pa oxygen nkag rau hauv lub zog thiab lub hom phiaj, kom nws nkag mus rau hauv cov ntaub so ntswg zoo dua.. Intravenous tswj ntawm antigangrenous ntshav yog yuav tsum tau. Nws yog pre-diluted nyob rau hauv ib nrab nrog sov saline. Kev kho cov kab mob tua kab mob yog nqa tawm nrog kev kis kab mob clostridial nkaus xwb nrog cov koob tshuaj tseem ceeb ntawm penicillin (20-30 lab units ib hnub hauv cov hlab ntsha).
Lub sijhawm kho yog nyob ntawm daim duab kho mob ntawm tus neeg mob rov zoo. Yog hais tias muaj kev loj hlob sai heev necrosis nrog ib tug ntse deterioration nyob rau hauv tus mob, ces yuav tsum tau amputation raws sij hawm. Kev ua haujlwm tsuas yog ua kom cawm tau txoj sia,raws li tus kab mob kis tau sai heev, thiab ib tug neeg yuav tuag.
Nws twb paub tias gas gangrene kis tau li cas thiab nws kis tau sai npaum li cas, yog vim li cas nws txoj kev kho sai yog qhov tseem ceeb heev. Ntau tus kws kho mob pom zoo kom siv cov txheej txheem nyuaj. Ib txoj hauv kev zoo dua yog siv kev sib xyaw ntawm aminoglycosides thiab penicillins, aminoglycosides thiab cephalosporins. Cov tshuaj uas xaiv ua rau anaerobes tau siv dav, xws li Chloramphenicol, Metronidazole, Clindamycin, Rifampicin, Carbenicillin.
Kev siv serotherapy muaj nyob rau hauv kev taw qhia ntawm anti-gangrenous sera. Ib qho ampoule muaj cov tshuaj toxoids tawm tsam cov hom kab mob tseem ceeb, uas yog nquag nruab nrab, yog li rov pib ua haujlwm rau cov ntaub so ntswg. Yog tias muaj qee qhov kev puas tsuaj loj lossis kis kab mob hnyav, tom qab ntawd qhov yuav tsum tau qhia cov tshuaj polyvalent ntawm qhov kev saib xyuas nruab nrab ntawm 30,000 ME yuav tsum tau.
Kev Tiv Thaiv Gas gangrene
Nrog ntau qhov txhab, lub luag haujlwm tseem ceeb los tiv thaiv tus kab mob yog lub sijhawm tshem tawm ntawm lub qhov txhab, nrog rau kev siv cov ntaub qhwv los tiv thaiv kev sib kis ntawm qhov chaw.
Nws tseem pom zoo kom qhia cov kab mob tetanus thiab cov tshuaj tiv thaiv kab mob hauv thawj ob peb teev yog tias muaj qhov txhab, qhov tob tob, incised lossis kis kab mob. Thaum siv lub tourniquet, nws yog ib qho tsim nyog los qhia lub sijhawm ntawm cov txheej txheem nyob ze, thiab tseem, yog tias xav tau ntev.thaum thauj tus neeg mob mus rau hauv tsev kho mob, loosen cov ntaub qhwv txhua ob teev kom rov pib cov ntshav ntws mus rau qhov kawg ntawm lub caj dab. Daim ntawv yuav tsum tau muab kho dua tom qab txhua tus txheej txheem. Tom ntej no, koj yuav tsum tau ua raws sijhawm raws sijhawm ntawm tag nrho cov ntim ntawm kev kho mob ntawm cov nqaij mos thiab cov pob txha.
