Transcript TETANUS
Tetanus
Tetanus
Tetanos – a greek word – to stretch
First described by Hippocrates & Susruta
A Neurological disease characterised by
increased muscle tone & spasms.
Caused by CLOSTRIDIUM TETANI
An anaerobic, motile, gram positive rod that
forms oval, colourless, terminal spores –
tennis racket or drumstick shape.
It is found worldwide in soil, in inanimate
environment, in animal faeces &
occasionally human faeces.
Epidemiology
Occurs sporadically
Affects unimmunized, partially immunized &
fully immunized who fail to maintain adequate
immunity with booster doses of vaccine.
Although it is an entirely preventable disease by
immunization , the burden of disease worldwide
is great.
More common in areas where soil is cultivated, in
rural areas, in warm climates, during summer,
among males.
Pathogenesis
Contamination of wounds with spores of
C.tetani.
Germination & toxin production – in
wounds with low oxidation – reduction
potential ( devitalized tissues, F.B, active
infection )
Tetanospasmin ( neurotoxin )
Tetanolysin ( hemolysin )
Mode of transmission
Infection is acquired by contamination of wounds
with tetanus spores.
Range of injuries & accidents – trivial pin prick,
skin abrasion, puncture wounds, burns, human
bites, animal bites & stings, unsterile surgery,
IUD, bowel surgery, dental extractions, injections,
unsterile division of umbilical cord, compound #,
otitis media, chr.skin ulcers, eye infections,
gangrene
NOT TRANSMITTED FROM PERSON TO
PERSON
Types
Traumatic
Puerperal
Otogenic
Idiopathic
Tetanus neonatorum
PARK 19th
Generalized
Neonatal
local
HARRISON 17th
Clinical features
May begin from 2 days to several weeks after the
injury – USUALLY 1 WEEK
Remember
Shorter the incubation period
More severe the attack
Worse the prognosis
Clinical features
•
•
•
•
•
•
•
GENERALIZED TETANUS
Most common
Increased muscle tone & generalized spasms
Median time of onset after injury – 7 days
Pt 1st notices increased tone in masseter
( Trismus, lock jaw )
Dysphagia
Stiffness / pain in neck, shoulder, back muscles
appear concurrently / or soon thereafter
Rigid abd & stiff prox.limb muscles . Hands, feet
spared.
trismus
Risus Sardonicus : Spasm of facial muscles ( frontalis
& angle of mouth muscles )
Opisthotonus : Painful spasms of neck, trunk and
extremity. producing characteristic bowing and
arching of back
Some pts develop paroxysmal, violent, painful,
generalized muscle spasms – cyanosis . Spasms
occur repetitively & may be spontaneous / provoked
by slightest stimulation.
Constant threat during gen.spasm is reduced
ventilation, apnea / laryngospasm.
Risus sardonicus
Mild ds ( muscle rigidity , no / few spasms )
Moderate ds (trismus, dysphagia, rigidity,
spasm)
Severe ds ( freq explosive paroxysms )
Autonomic dysfn complicates severe cases hyperpyrexia, profuse sweating, peripheral
vasoconstriction.
Neonatal Tetanus
Usually fatal if untreated
Children born to inadequately immunized
mothers, after unsterile treatment of
umbilical stump
During first 2 weeks of life.
Poor feeding ,rigidity and spasms
Local Tetanus
Uncommon form
Manifestations are restricted to muscles near
the wound.
Cramping and twisting in skeletal muscles
surrounding the wound – local rigidity
Prognosis – excellent
Cephalic Tetanus
A rare form of local tetanus
Follows head injury / ear infection
Involves one / more facial cranial nerves
Trismus and localised paralysis ,usually
facial nerve, often unilateral.
Incubation period : few days
Mortality : high
Diagnosis
Based entirely on clinical findings
Examine all cases with wound infection & muscle
stiffness
Wound cultures – in suspected cases
C.tetani can be isolated from wounds of pts
without tetanus & freq cannot be isolated from
wounds of those with tetanus
Electromyograms – continous discharge of motor
units, shortening / absence of silent interval seen
after AP.
Muscle enzymes – raised
Serum Anti toxin levels >= 0.1 IU/ml –
protective & makes tetanus unlikely .
Treatment – general measures
Goal is to eliminate the source of toxin,
neutralize the unbound toxin & prevent
muscle spasm & providing support - resp
support
Admit in a quiet room in ICU .
Continuous careful observation &
cardiopulmonary monitoring
Minimize stimulation
Protect airway
Explore wounds – debridement
•
•
•
•
•
NEUTRALIZE TOXIN :
Inj.Human Tetanus Immunoglobulin 3000 – 6000 units IM,
usually in divided doses as volume is large.
ANTIBIOTIC THERAPY :
Although of unproven value , antibiotics adm to eradicate
vegetative cells – the source of toxin
IV Penicillin 10 -12 million units daily for 10 days
IV Metronidazole 500mg Q 6 hrly / 1gm Q 12 hrly
Allergic to Penicillin : consider Clindamycin &
Erythromycin
Control of Spasms
Nurse in a quiet dark room
Avoid noise & other stimuli
IV Diazepam / Lorazepam / Midazolam
Barbiturates & Chlorpromazine –2nd line
drugs
Continued spasms : intubate & ventilate
Management of autonomic dysfn
Labetalol
Continuous infusion of esmolol
Clonidine / verapamil
Additional measures
Pts recovering from tetanus should be
actively immunized
Hydration
Nutrition
Physiotherapy
Prophylactic anticoagulation
Bowel, bladder, back care
Prevention – Active Immunization
For partially immunized, unimmunized and
recovering from tetanus
It stimulates production of protective antitoxin
2 prep : combined vaccine : DPT
monovalent vaccine : plain / formol
toxoid
tetanus vaccine , adsorbed
Combined vaccine
According to National Immunization, 3
doses of DPT – at intervals of 4-8 wks,
starting at 6 wks age, followed by
booster at 18 months age
2nd booster (only DT) at 5-6 yrs
3rd booster ( only TT) after 10 yrs age
Monovalent vaccines
higher & long lasting immunity response
Primary course of immunization – 2 doses
Each 0.5 ml , injected into arm given at intervals of 1-2
months
The longer the interval b/w two doses, better is the
immune response
1st booster – 1 yr after the initial 2 doses
2nd Booster : 5 yrs after the 1st booster ( optional )
Freq boosters to be avoided
Passive immunization
•
Temp protection – human tetanus
immunoglobulin /ATS
Human Tetanus Hyperimmunoglobulin :
250-500 IU
Passive immunization
•
•
•
•
ATS ( EQUINE ) :
1500 IU s/c after sensitivity testing
7 – 10 days
High risk of serum sickness
It stimulates formation of antibodies to it ,
hence a person who has once received ATS
tends to rapidly eliminate subsequent doses.
Active & Passive Immunization
In non immunized persons
1500 IU of ATS / 250-500 units of Human Ig
in one arm & 0.5 ml of adsorbed tetanus
toxoid into other arm /gluteal region
6 wks later, 0.5 ml of tetanus toxoid
1 yr later , 0.5 ml of tetanus toxoid
Prevention of neonatal tetanus
•
•
Clean delivery practices
3 cleans : clean hands, clean delivery surface,
clean cord care
Tetanus toxoid protects both mother & child
Unimmunized pregnant women : 2 doses
tetanus toxoid
1st dose as early as possible during pregnancy
2nd dose – at least a month later / 3 wks before
delivery
Immunized pregnant women : a booster is
sufficient
No need of booster in every consecutive
pregnancy
Prevention of tetanus after injury
All wounds should be thoroughly cleaned soon after
injury
Remove all foreign bodies, soil, dust, necrotic tissue
A – completed course of toxoid/booster < 5 yrs ago
B- completed course of toxoid / booster >5 yrs ago &
< 10 yrs ago
C- completed course of toxoid / booster >10 yrs ago
D- not completed course of toxoid / immunity status
unknown
Wounds < 6hrs, clean, non
penetrating & negligible tissue
damage
Immunity Category
Treatment
•
A
B
C
D
•
Nothing more required
Toxoid 1 dose
Toxoid 1 dose
Toxoid complete course
•
•
•
•
•
•
Other Wounds
Immunity Category
Treatment
•
•
•
A
B
C
•
D
•
Nothing more required
Toxoid 1 dose
Toxoid 1 dose + Human
Tetanus Ig
Toxoid complete course
+ Human Tetanus Ig
•
•
•
Thank You