Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch...

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Tetanus Tetanus

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Page 1: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

TetanusTetanus

Page 2: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

TetanusTetanus

Tetanos – a greek word – Tetanos – a greek word – to stretchto stretch First described by Hippocrates & First described by Hippocrates &

SusrutaSusruta A Neurological disease characterised A Neurological disease characterised

by increased muscle tone & spasms.by increased muscle tone & spasms. Caused by Caused by CLOSTRIDIUM TETANICLOSTRIDIUM TETANI An anaerobic, motile, gram positive An anaerobic, motile, gram positive

rod that forms oval, colourless, rod that forms oval, colourless, terminal spores – terminal spores – tennis racket or tennis racket or drumstick shape.drumstick shape.

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It is found worldwide in soil, in It is found worldwide in soil, in inanimate environment, in inanimate environment, in animal faeces & occasionally animal faeces & occasionally human faeces.human faeces.

Page 4: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.
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Epidemiology Epidemiology

Occurs sporadically Occurs sporadically Affects unimmunized, partially Affects unimmunized, partially

immunized & fully immunized who immunized & fully immunized who fail to maintain adequate immunity fail to maintain adequate immunity with booster doses of vaccine.with booster doses of vaccine.

Although it is an entirely Although it is an entirely preventable disease by immunization preventable disease by immunization , the burden of disease worldwide is , the burden of disease worldwide is great.great.

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More common in areas where soil is More common in areas where soil is cultivated, incultivated, in rural rural areas, in areas, in warm warm climatesclimates, during, during summer summer, among , among malesmales..

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PathogenesisPathogenesis

Contamination of wounds with Contamination of wounds with spores of C.tetani.spores of C.tetani.

Germination & toxin productionGermination & toxin production – – in wounds with low oxidation – in wounds with low oxidation – reduction potential ( devitalized reduction potential ( devitalized tissues, F.B, active infection )tissues, F.B, active infection )

TetanospasminTetanospasmin ( neurotoxin ) ( neurotoxin ) Tetanolysin ( hemolysin )Tetanolysin ( hemolysin )

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Mode of transmission Mode of transmission Infection is acquired by contamination Infection is acquired by contamination

of wounds with tetanus spores.of wounds with tetanus spores. Range of injuries & accidents – Range of injuries & accidents – trivial pin trivial pin

prick, skin abrasion, puncture wounds, prick, skin abrasion, puncture wounds, burns, human bites, animal bites & burns, human bites, animal bites & stings, unsterile surgery, IUD, bowel stings, unsterile surgery, IUD, bowel surgery, dental extractions, injections, surgery, dental extractions, injections, unsterile division of umbilical cord, unsterile division of umbilical cord, compound #, otitis media, chr.skin compound #, otitis media, chr.skin ulcers, eye infections, gangreneulcers, eye infections, gangrene

NOT TRANSMITTED FROM PERSON TO NOT TRANSMITTED FROM PERSON TO PERSONPERSON

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Types Types

TraumaticTraumatic PuerperalPuerperal OtogenicOtogenic IdiopathicIdiopathic Tetanus Tetanus

neonatorumneonatorum

PARK 19PARK 19thth

GeneralizedGeneralized NeonatalNeonatal locallocal

HARRISON 17thHARRISON 17th

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Clinical featuresClinical features

May begin from 2 days to several weeks May begin from 2 days to several weeks

after the injury – USUALLY 1 WEEK after the injury – USUALLY 1 WEEK

RememberRemember

Shorter the incubation period Shorter the incubation period

More severe the attackMore severe the attack

Worse the prognosisWorse the prognosis

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Clinical featuresClinical features GENERALIZED TETANUSGENERALIZED TETANUS• Most commonMost common• Increased muscle tone & generalized Increased muscle tone & generalized

spasmsspasms• Median time of onset after injury – Median time of onset after injury – 7 days7 days• Pt 1Pt 1stst notices increased tone in masseter notices increased tone in masseter

( ( Trismus, lock jawTrismus, lock jaw ) )• Dysphagia Dysphagia • Stiffness / pain in neck, shoulder, back Stiffness / pain in neck, shoulder, back

muscles appear concurrently / or soon muscles appear concurrently / or soon thereafterthereafter

• Rigid abd & stiff prox.limb muscles . Rigid abd & stiff prox.limb muscles . Hands, Hands, feetfeet spared.spared.

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trismustrismus

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Risus SardonicusRisus Sardonicus : Spasm of facial muscles : Spasm of facial muscles ( frontalis & angle of mouth muscles )( frontalis & angle of mouth muscles )

OpisthotonusOpisthotonus : Painful spasms of neck, : Painful spasms of neck, trunk and extremity. producing trunk and extremity. producing characteristic characteristic bowing bowing and and archingarching of backof back

Some pts develop paroxysmal, violent, Some pts develop paroxysmal, violent, painful, generalized muscle spasms – painful, generalized muscle spasms – cyanosis . Spasms occur repetitively & may cyanosis . Spasms occur repetitively & may be spontaneous / provoked by slightest be spontaneous / provoked by slightest stimulation.stimulation.

Constant threat during gen.spasm is Constant threat during gen.spasm is reduced ventilation, apnea / laryngospasm.reduced ventilation, apnea / laryngospasm.

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Risus sardonicusRisus sardonicus

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Mild dsMild ds ( muscle rigidity , no / few ( muscle rigidity , no / few spasms )spasms )

Moderate dsModerate ds (trismus, dysphagia, (trismus, dysphagia, rigidity, spasm)rigidity, spasm)

Severe dsSevere ds ( freq explosive paroxysms ) ( freq explosive paroxysms ) Autonomic dysfn complicates severe Autonomic dysfn complicates severe

cases - hyperpyrexia, profuse cases - hyperpyrexia, profuse sweating, peripheral sweating, peripheral vasoconstriction.vasoconstriction.

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Neonatal TetanusNeonatal Tetanus

Usually fatal if untreated Usually fatal if untreated Children born to inadequately Children born to inadequately

immunized mothers, after immunized mothers, after unsterile treatment of umbilical unsterile treatment of umbilical stumpstump

During first 2 weeks of life.During first 2 weeks of life. Poor feeding ,rigidity and Poor feeding ,rigidity and

spasmsspasms

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Local TetanusLocal Tetanus

Uncommon form Uncommon form Manifestations are restricted to Manifestations are restricted to

muscles near the wound.muscles near the wound.

Cramping and twisting in Cramping and twisting in

skeletal muscles surrounding the skeletal muscles surrounding the

wound – wound – local rigiditylocal rigidity Prognosis – excellentPrognosis – excellent

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Cephalic TetanusCephalic Tetanus

A rare form of local tetanusA rare form of local tetanus Follows head injury / ear infectionFollows head injury / ear infection Involves one / more facial cranial Involves one / more facial cranial

nervesnerves Trismus and localised

paralysis ,usually facial nerve, often unilateral.

Incubation period : few daysIncubation period : few days Mortality : Mortality : highhigh

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Page 25: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

DiagnosisDiagnosis Based entirely on Based entirely on clinical findingsclinical findings Examine all cases with wound infection Examine all cases with wound infection

& muscle stiffness& muscle stiffness Wound culturesWound cultures – in suspected cases – in suspected cases

C.tetani can be isolated from C.tetani can be isolated from wounds of pts without tetanus & freq wounds of pts without tetanus & freq cannot be isolated from wounds of cannot be isolated from wounds of those with tetanusthose with tetanus

ElectromyogramsElectromyograms – continous discharge – continous discharge of motor units, shortening / absence of of motor units, shortening / absence of silent interval seen after AP.silent interval seen after AP.

Muscle enzymes – raisedMuscle enzymes – raised

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Serum Anti toxin levels >= 0.1 Serum Anti toxin levels >= 0.1 IU/ml – protective & makes IU/ml – protective & makes tetanus unlikely .tetanus unlikely .

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Treatment – general Treatment – general measuresmeasures

Goal is to eliminate the source of Goal is to eliminate the source of toxin, neutralize the unbound toxin toxin, neutralize the unbound toxin & prevent muscle spasm & providing & prevent muscle spasm & providing support - resp supportsupport - resp support

Admit in a quiet room in ICU .Admit in a quiet room in ICU . Continuous careful observation & Continuous careful observation &

cardiopulmonary monitoringcardiopulmonary monitoring Minimize stimulationMinimize stimulation Protect airwayProtect airway Explore wounds – Explore wounds – debridementdebridement

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NEUTRALIZE TOXINNEUTRALIZE TOXIN : :• Inj.Human Tetanus Immunoglobulin 3000 – 6000 Inj.Human Tetanus Immunoglobulin 3000 – 6000

units IM, usually in divided doses as volume is units IM, usually in divided doses as volume is large.large.

ANTIBIOTIC THERAPYANTIBIOTIC THERAPY : :• Although of unproven value , antibiotics adm to Although of unproven value , antibiotics adm to

eradicate vegetative cells – the source of toxineradicate vegetative cells – the source of toxin• IV PenicillinIV Penicillin 10 -12 million units daily for 10 days 10 -12 million units daily for 10 days• IV MetronidazoleIV Metronidazole 500mg Q 6 hrly / 1gm Q 12 hrly 500mg Q 6 hrly / 1gm Q 12 hrly• Allergic to Penicillin : consider Allergic to Penicillin : consider Clindamycin & Clindamycin &

ErythromycinErythromycin

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Control of SpasmsControl of Spasms

Nurse in a quiet dark roomNurse in a quiet dark room Avoid noise & other stimuliAvoid noise & other stimuli IV DiazepamIV Diazepam / Lorazepam / / Lorazepam /

MidazolamMidazolam Barbiturates & Chlorpromazine –Barbiturates & Chlorpromazine –

2nd line drugs2nd line drugs Continued spasms : intubate & Continued spasms : intubate &

ventilateventilate

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Management of Management of autonomic dysfnautonomic dysfn

LabetalolLabetalol Continuous infusion of esmololContinuous infusion of esmolol Clonidine / verapamilClonidine / verapamil

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Additional measuresAdditional measures

Pts recovering from tetanus Pts recovering from tetanus should be actively immunized should be actively immunized

HydrationHydration NutritionNutrition PhysiotherapyPhysiotherapy Prophylactic anticoagulationProphylactic anticoagulation Bowel, bladder, back careBowel, bladder, back care

Page 32: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

Prevention – Active Prevention – Active ImmunizationImmunization

For partially immunized, unimmunized and For partially immunized, unimmunized and

recovering from tetanus recovering from tetanus It stimulates production of protective It stimulates production of protective

antitoxinantitoxin 2 prep : 2 prep : combined vaccinecombined vaccine : DPT : DPT

monovalent vaccinemonovalent vaccine : plain / formol : plain / formol

toxoidtoxoid

tetanus vaccine , tetanus vaccine , adsorbedadsorbed

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Combined vaccineCombined vaccine

According to National According to National Immunization, 3 doses of DPT – Immunization, 3 doses of DPT – at intervals of 4-8 wks, at intervals of 4-8 wks, starting starting at 6 wks ageat 6 wks age, followed by , followed by

booster at booster at 18 months age18 months age 22ndnd booster (only DT) booster (only DT) at 5-6 yrs at 5-6 yrs 33rdrd booster ( only TT) booster ( only TT) after 10 yrs after 10 yrs

ageage

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Monovalent vaccinesMonovalent vaccines higher & long lasting immunity responsehigher & long lasting immunity response Primary course of immunization – 2 doses Primary course of immunization – 2 doses Each 0.5 ml , injected into arm given at Each 0.5 ml , injected into arm given at

intervals of 1-2 monthsintervals of 1-2 months The longer the interval b/w two doses, The longer the interval b/w two doses,

better is the immune responsebetter is the immune response 11stst booster – booster – 1 yr after the initial 2 doses1 yr after the initial 2 doses 22ndnd Booster : Booster : 5 yrs after the 15 yrs after the 1stst booster booster

( optional )( optional ) Freq boosters to be avoidedFreq boosters to be avoided

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Passive immunization Passive immunization

Temp protection – human Temp protection – human tetanus immunoglobulin /ATStetanus immunoglobulin /ATS

Human Tetanus Human Tetanus HyperimmunoglobulinHyperimmunoglobulin : :

• 250-500 IU250-500 IU

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Passive immunizationPassive immunization

ATS ( EQUINE ) :ATS ( EQUINE ) :• 1500 IU s/c after sensitivity testing1500 IU s/c after sensitivity testing• 7 – 10 days7 – 10 days• High risk of serum sicknessHigh risk of serum sickness• It stimulates formation of antibodies It stimulates formation of antibodies

to it , hence a person who has once to it , hence a person who has once received ATS tends to rapidly received ATS tends to rapidly eliminate subsequent doses.eliminate subsequent doses.

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Active & Passive Active & Passive ImmunizationImmunization

In non immunized personsIn non immunized persons 1500 IU of ATS / 250-500 units of 1500 IU of ATS / 250-500 units of

Human Ig in one arm & 0.5 ml of Human Ig in one arm & 0.5 ml of adsorbed tetanus toxoid into other adsorbed tetanus toxoid into other arm /gluteal regionarm /gluteal region

6 wks later, 0.5 ml of tetanus 6 wks later, 0.5 ml of tetanus toxoidtoxoid

1 yr later , 0.5 ml of tetanus 1 yr later , 0.5 ml of tetanus toxoidtoxoid

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Prevention of neonatal Prevention of neonatal tetanustetanus

Clean delivery practicesClean delivery practices 3 cleans : clean hands, clean delivery 3 cleans : clean hands, clean delivery

surface, clean cord caresurface, clean cord care Tetanus toxoid protects both mother & Tetanus toxoid protects both mother &

childchild Unimmunized pregnant women : 2 doses Unimmunized pregnant women : 2 doses

tetanus toxoidtetanus toxoid• 11stst dose as early as possible during dose as early as possible during

pregnancypregnancy• 22ndnd dose – at least a month later / 3 wks dose – at least a month later / 3 wks

before deliverybefore delivery

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Immunized pregnant women : a Immunized pregnant women : a booster is sufficientbooster is sufficient

No need of booster in every No need of booster in every consecutive pregnancyconsecutive pregnancy

Page 40: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

Prevention of tetanus Prevention of tetanus after injury after injury

All wounds should be thoroughly cleaned soon after All wounds should be thoroughly cleaned soon after injury injury

Remove all foreign bodies, soil, dust, necrotic Remove all foreign bodies, soil, dust, necrotic tissuetissue

AA – completed course of toxoid/booster < 5 yrs ago – completed course of toxoid/booster < 5 yrs ago BB- completed course of toxoid / booster >5 yrs ago - completed course of toxoid / booster >5 yrs ago

& < 10 yrs ago& < 10 yrs ago CC- completed course of toxoid / booster >10 yrs - completed course of toxoid / booster >10 yrs

agoago DD- not completed course of toxoid / immunity status - not completed course of toxoid / immunity status

unknownunknown

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Wounds < 6hrs, clean, non Wounds < 6hrs, clean, non penetrating & negligible penetrating & negligible

tissue damagetissue damage

Immunity CategoryImmunity Category

• AA• BB• CC• DD

TreatmentTreatment

• Nothing more Nothing more requiredrequired

• Toxoid 1 doseToxoid 1 dose• Toxoid 1 doseToxoid 1 dose• Toxoid complete Toxoid complete

coursecourse

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Other WoundsOther Wounds

Immunity Category Immunity Category

• AA• BB• CC

• DD

TreatmentTreatment

• Nothing more Nothing more requiredrequired

• Toxoid 1 doseToxoid 1 dose• Toxoid 1 dose + Toxoid 1 dose +

Human Tetanus IgHuman Tetanus Ig• Toxoid complete Toxoid complete

course + Human course + Human Tetanus IgTetanus Ig

Page 43: Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

Thank YouThank You


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