TETANUS M&P
-
Upload
siti-munirah -
Category
Documents
-
view
224 -
download
0
Transcript of TETANUS M&P
-
8/12/2019 TETANUS M&P
1/35
TETANUSMANAGEMENT ANDPREVENTION
-
8/12/2019 TETANUS M&P
2/35
Definition
Tetanus is an illness characterized by an acute
onset of hypertonia, painful muscular
contractions (usually of the muscles of the jaw
and neck), and generalized muscle spasmswithout other apparent medical causes.
-
8/12/2019 TETANUS M&P
3/35
Management
Objectives of management of tetanus are:
provide supportive care until the
tetanospasmin that is fixed in tissue has been
metabolized
Neutralize circulating toxin
remove the source of tetanospasmin
-
8/12/2019 TETANUS M&P
4/35
Patient Care
All patients should be admitted to a medical orneurological intensive care unit where they can bemonitored and observed continuously
Some hospitals in which tetanus is frequently
encountered have specially constructed, quiet,dark rooms to minimize extrinsic stimuli that mighttrigger paroxysmal spasms
Patients must be allowed to rest quietly to limitperipheral stimuli, and they must be positionedcarefully to prevent aspiration pneumonia
Intravenous fluids should be instituted, andelectrolytes and blood gases are essential toguide therapy.
-
8/12/2019 TETANUS M&P
5/35
Antibiotics
Penicillin is the standard therapy for tetanus inmost parts of the world, although antibiotics forC.tetani probably play a relatively minor role in thespecific treatment of this disease. The
recommended dose is 100,000200,000 IU/dayintramuscularly or intravenously for 710 days.
Metronidazole is also considered as therapy andis a safe alternative to penicillin. Rectaladministration of metronidazole is rapidly
bioavailable and produces fewer spasms thanrepeated intravenous or intramuscular injections.Consequently, metronidazole is considered as thedrug of choice in the treatment of tetanus. / e doseis 400 mg rectally or 500 mg intravenously every 6
hours for 710 days.
-
8/12/2019 TETANUS M&P
6/35
Muscle Spasm Therapy
Vigorous and aggressive management of muscle
spasms is a cornerstone of therapy. The objective
of the first approach is to mildly sedate the patient
without affecting respiratory function. The sedatedpatient is less affected by peripheral stimuli and
less likely to develop muscle spasms.
The short-acting barbiturates such as secobarbital
and phenobarbital are useful in sedating patientswith mild tetanus. Initial doses of 1.52.5 mg/kg
for children or 100150 mg intramuscularly for
adults may be used.
-
8/12/2019 TETANUS M&P
7/35
Phenobarbital may be given in a dose of 120200
mg intravenously, and diazepam may be added in
divided doses up to 120 mg/day.
Diazepam may prevent or control seizures.Chloropromazine, given every 48 hours in doses
from 412 mg in the infant to 50150 mg in the
adult, may be effective in controlling tetanic
convulsions. Mechanical ventilatory support is often required to
counteract the drug-induced ventilatory
depression that becomes apparent in the intervals
between spasms.
-
8/12/2019 TETANUS M&P
8/35
Muscla spasm also may be controlled primarily byneuromuscular blocking agents, such as d-tubocurarine chloride or pancuronium bromide,while sedation is induced with smaller doses of
the central depressant drugs. Magnesium is a physiological calcium antagonist
in which there is a signifi cant correlation betweenthe depression of neuromuscular transmissionand serum magnesium concentrations. The
infusion rate of magnesium sulphate wasincreased to control spasms, while retaining thepatella tendon reflex, which proved a valuableguide to prevent overdose.
-
8/12/2019 TETANUS M&P
9/35
Nutritional Imbalance
tetanus is associated with clinical and biochemicalevidence of sympathetic overdischarge andprotein catabolism
Consequently, the resulting loss of body weight
encountered must reflect a diminution of leanbody cell mass. The consequent protein depletionwill result in reduced host defenses and maythereby worsen prognosis
A rational approach to achieving metabolic controlwould be the use of adrenergic blocking agents,although it remains to be seen whether suchtherapy can suppress the hypermetabolic state
-
8/12/2019 TETANUS M&P
10/35
other therapeutic alternative is by parenteralfeeding. Total parenteral nutrition containinghypertonic glucose and insulin, in sufficientquantities to control blood sugar, can suppress
this protein catabolism. The use of amino acidformulations containing increased branched chainamino acid concentrations is another helpfulapproach to limit protein catabolism
Physical therapy should be started early in the
convalescent period of the disease. Ifneuromuscular blocking agents are used intreatment, passive movements of the patientsarms and legs should be instituted.
-
8/12/2019 TETANUS M&P
11/35
Anti Tetanus Serum
After the initial evaluation, human tetanus immuneglobulin (TIG) should be injected intramuscularly in atotal dose of 3000 units, injected in three equalportions into three separate sites. Because the halflifeof TIG is 2530 days, only a single treatment isrequired.
Antiserum does not neutralize tetanospasmin alreadyfi xed in the nervous system, nor does it have anyspecial effect when administered locally in the wound
Consequently, active immunization should beinstituted concomitantly with the passiveimmunization. The combined active and passiveprophylaxis of tetanus does not decrease thesubsequent development of antibodies from tetanustoxoid
-
8/12/2019 TETANUS M&P
12/35
TIG is a solution of gamma globulin preparedfrom the venous blood of humans,hyperimmunized with tetanus toxoid.
This immune globulin has been found to benonreactive for hepatitis B surface antigen,using the radioimmunoassay method ofcounterelectrophoresis.
It is administered by a deep intramuscularinjection in a different extremity from thatreceiving the intramuscular injection of vaccine
-
8/12/2019 TETANUS M&P
13/35
Wound Care
The wound should be cleansed thoroughly and
debrided. Abscesses should be drained, and
foreign bodies and necrotic tissue should be
removed.
-
8/12/2019 TETANUS M&P
14/35
Cardiovascular Disturbances
Because pulmonary embolism has been a
common cause of death in tetanus patients,
many employ anticoagulants routinely during
treatment. Although subcutaneous heparin hasbeen used to anticoagulate these patients,
complete protection against thromboembolism
has not always been obtained, and the risks of
hemorrhage are always present
-
8/12/2019 TETANUS M&P
15/35
Tetanus Prevention
Because there is essentially no natural
immunity to tetanus toxin, the only effective
way to control tetanus is by prophylactic
immunization. / us, universal primaryimmunization with subsequent maintenance of
adequate antitoxin levels by means of
appropriately timed boosters is necessary to
protect all age groups.
-
8/12/2019 TETANUS M&P
16/35
Tetanus toxoid was developed by Descombeyin1924,
Tetanus toxoid immunizations were usedextensively in the armed services during World
War II. Tetanus toxoid consists of a formaldehyde-
treated toxin.
There are two types of toxoid available adsorbed (aluminum salt precipitated)toxoid andfluid toxoid.
Although the rates of seroconversion are aboutequal,the adsorbed toxoid is preferred becausethe antitoxin response reaches higher titersand
is longer lasting than that following the fluid
TETANUS TOXOID
S f
-
8/12/2019 TETANUS M&P
17/35
Tetanus Toxoid Adsorbed USP,for intramuscular use,is a sterile
suspension of alum-precipitated (aluminum potassium
sulfate)toxoid in an isotonic sodium chloride solution containing
sodium phosphate buffer to control pH.The vaccine,after
shaking,is a turbid liquid,whitish-gray in color.
Clostridium tetani culture is grown in a peptone-based medium
and detoxified with formaldehyde.The detoxified material is then
purified by serial ammonium sulfate fractionation,followed by
sterile filtration,and the toxoid is adsorbed to aluminumpotassium sulfate (alum).The adsorbed toxoid is diluted with
physiological saline solution (0.85%)and thimerosal (a mercury
derivative)is added to a final concentration of 1:10,000.
Each 0.5 mL dose is formulated to contain 5 Lf (flocculation
units)of tetanus toxoid and not more than 0.25 mg of aluminum.
The residual formaldehyde content,by assay,is less than
0.02%.The tetanus toxoid induces at least 2 units of antitoxin
per mL in the guinea pig potency test.
-
8/12/2019 TETANUS M&P
18/35
Active Immunization
1stdose - 6thweek
2nddose - 10thweek
3rddose - 14thweek
1stbooster - 18thmonth
2ndbooster - 6thyear
3rdbooster - 10thyear
-
8/12/2019 TETANUS M&P
19/35
-
8/12/2019 TETANUS M&P
20/35
Active Immunization for Normal
Infant and Children
Immunization should begin in early infancy andrequires four injections of DTaP administered at 2months, 4 months, 6 months, and 15-18 months
A fi fth dose is administered at 46 years of age.
Ten years after the fifth dose (1416 years of age), aninjection of Td, which contains the same dose oftetanus toxoid as DTP and a reduced dose ofdiphtheria toxoid, should be administered andrepeated every 10 years throughout the individuals
life in the event that there have been no significantreactions to DTP or Td.
Adsorbed preparations should be administeredintramuscularly. Vaccine administration by jet injectionmay be associated with more frequent reactions.
-
8/12/2019 TETANUS M&P
21/35
Active Immunization for Normal Infants and
Children Up to Age 7 Not
Immunized at Early Infancy
DTP should be administered on the first visit and2 and 4 months after the first injection.
A fourth dose should be administered 612months after the first injection.
The fifth dose is administered between 4 and 6years of age. Ten years after the fifth dose (1416years of age), an injection of Td should beadministered and repeated every 10 yearsthroughout the individuals life in the event thatthere have been no significant reactions to DTP orTd.
The preschool dose is not necessary if the fourthdose of DTP is administered after the fourth
birthday.
-
8/12/2019 TETANUS M&P
22/35
regnan omen o ave o
-
8/12/2019 TETANUS M&P
23/35
regnan omen o ave oBeen
Immunized Neonatal tetanus is preventable by active
immunization of the pregnant mother. A previouslyunimmunized pregnant woman who may deliver herchild under unhygienic conditions should receive twoproperly spaced doses of Td before delivery,
preferably during the last two trimesters, given 2months apart.
After the delivery, the mother should be given the thirddose of Td 6 months after the second dose tocomplete the active immunization
An injection of Td should be repeated every 10 yearsthroughout life in the event that there have been nonsignificant reactions to Td. If a neonate is borne by anon immunized mother without obstetric care, theinfant should receive 250 units of human TIG. Activeand passive immunization of the mother should also
Children under Seven with a
-
8/12/2019 TETANUS M&P
24/35
Children under Seven with a
Contraindication
to Pertussis Vaccination
DT (for pediatric use) should be used rather than DTaP.Unimmunized children under 1 year old receiving their firstDT dose should receive a total of four doses of DT as theprimary series, the first three doses at 4- to 8-week intervalsand the fourth dose 612 months later. If further doses ofpertussis vaccine become contraindicated after beginning aDTaP series in the first year of life, DT should be substitutedfor each of the remaining scheduled DTaP doses.
Unimmunized children one year old or above for whom DTaPis contraindicated should receive two doses of DT 48 weeksapart, followed by a third dose 612 months later to complete
the primary series. Children one year old or above who have received 12 doses
of DT or DTaP and for whom further pertussis vaccine iscontraindicated should receive a total of three doses of DT,with the third dose administered 612 months after thesecond dose.
-
8/12/2019 TETANUS M&P
25/35
Infants with, or Unimmunized Infants Suspected of
Having, Underlying Neurologic Disease
It is prudent to delay initiation of immunizationwith DTaP or DT until further observation andstudy have clarified the childs neurologicstatus.
The effect of treatment, if any, can beassessed.
The decision whether to commence
immunization with DTaP or DT should bemade no later than the childsfirst birthday.
In addition, because of neurologic disabilities,these children may be in greater jeopardy from
complications of the disease.
-
8/12/2019 TETANUS M&P
26/35
Infants With Neurologic Events Temporarily
Associated with DTaP Vaccination
Infants and children who experience a seizure
within 3 days of receipt of DTaP or an
encephalopathy within 7 days should not
receive pertussis vaccine, even though causeand effect may not be established.
Incompletely Immunized Children with
-
8/12/2019 TETANUS M&P
27/35
Incompletely Immunized Children withNeurologic Events Occurring Between
Vaccination Doses
If the seizure or other disorder occurs before the firstbirthday and completion of the first three doses of theprimary series of DTaP, deferral of further doses ofDTaP or DT is recommended until the infants statushas been clarified.
The decision whether to use the DTaP or DT tocomplete the series should be made no later than thechildsfirst birthday and should take into considerationthe nature of the childsproblem and the benefits andrisks of the vaccine.
If the seizure or other disorder occurs after the firstbirthday, the childs neurologic status should beevaluated to ensure that the disorder is stable beforea subsequent dose of DTaP is given.
-
8/12/2019 TETANUS M&P
28/35
Infants and Children with Stable Neurologic
Conditions
Infants and children with stable neurologic conditions,including well-controlled seizures, may be vaccinated.
The occurrence of single seizures (temporarily associatedwith DTaP) in infants and young children, while necessitatingevaluation, need not contraindicate DTaP immunization,
particularly if the seizures can be satisfactorily explained. Anticonvulsant prophylaxis should be considered when giving
DTaP to
such children.
Parents of infants and children with histories of convulsions
should be made aware of slightly increased chance ofpostimmunization seizures.
A static neurologic condition, such as cerebral palsy or afamily history of a neurologic disease or convulsions, is not acontraindication to giving vaccines containing pertussisantigen.
ren w eso ve or
-
8/12/2019 TETANUS M&P
29/35
ren w eso ve orCorrected
Neurologic Disorders DTaP immunization is recommended for
infants with certain neurologic problems that
have clearly subsided without residue or have
been corrected, such as neonatalhypocalcemic tetany or hydrocephalus
(following placement of a shunt and without
seizures).
Contraindications to pertussis
-
8/12/2019 TETANUS M&P
30/35
Contraindications to pertussis
vaccine personal history of a prior convulsion
the presence of an evolving neurologic disorder
(e.g., uncontrolled epilepsy, infantile spasm,
progressive encephalopathy, etc.)
adverse reactions to DTaP or single antigen
pertussis vaccination that include any of the
following: allergic hypersensitivity
fever of 40.5 C (105 F) or greater within 48 hours
collapse or shock-like (hypotonic-hyporesponsive episode) within 48
hours
ersisting, inconsolable crying, lasting 3 hours or more, or an unusual
high-pitched cry, occurring within 48 hours
convulsion(s) with or without fever, occurring within three days (such
seizures do not predispose to permanent brain damage)
-
8/12/2019 TETANUS M&P
31/35
-
8/12/2019 TETANUS M&P
32/35
History of tetanus immunization should be verified frommedical records so that appropriate tetanus prophylaxis canbe accomplished.
Patients with unknown or uncertain previous immunizationhistories should be considered to have no previous tetanus
toxoid doses meticulous surgical care using aseptic technique that includes
removal of all devitalized tissue and foreign bodies should beprovided immediately for all wounds
Td is the preferred preparation for active tetanusimmunization in wound management in the adult. Thispreparation immunizes the patient against tetanus,
while enhancing diphtheria protection in a large proportion ofthe adult population who are susceptible to diphtheria.
For routine wound management of children under 7 years ofage, DTaP should be used instead of a single-antigen tetanus
toxoid.
-
8/12/2019 TETANUS M&P
33/35
-
8/12/2019 TETANUS M&P
34/35
For every wounded patient, record in a permanentmedical record pertinent information about theclinical features of the wound, previous activeimmunization status, history of a neurologic or
severe hypersensitivity reaction,immunoprophylaxis (manufacturer, lot number,and site of injection), and plans for follow-up.
Tetanus infection may not confer immunity;
therefore, active immunization should be initiatedat the time of recovery from the illness.
Arrangements should be made to ensure that theremaining doses of a primary series are
administered as early as possible.
-
8/12/2019 TETANUS M&P
35/35