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Tetanus Tetanos – a greek word – to strech 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.

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

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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.

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As reporting is inaccurate & incomplete, particularly in devoleping countries, W.H.O considers reported cases to be an underestimate & takes case/death estimates to assess the burden of disease.

In 2002, the estimated deaths in all age groups 2,13,000 of which 1,80,000 were attributable to neonatal tetanus.

More common in areas where soil is cultivated, in rural areas, in warm climates, during summer, among males.

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Tetanospasmin ( exotoxin ) produced locally , released into bloodstream .

Binds to peripheral motor neuron terminals & nerve cells of ant.horn of spinal cord

The toxin after entering axon , transported to nerve cell body in brain stem & spinal cord – retrograde intraneuronal transport

Toxin – migrates across synapse – presynaptic terminals- blocks the release of Glycine & GABA from vesicles.

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The blocking of neurotransmitter release by Tetanospasmin involves cleavage of Synaptobrevin – essential for proper of synaptic vesicle release apparatus

With diminished inhibition – resting firing rate of alpha motor neurons increases – rigidity

Lessened activity of reflexes which limit polysynaptic spread of impulses, agonists & antagonists recruited – spasms

Loss of inhibition of preganglionic sym neurons – sympathetic hyperactivity

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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

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Types Traumatic Puerperal Otogenic Idiopathic Tetanus

neonatorum PARK

19th

Generalized Neonatal local HARRISON

17th

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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

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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.

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trismus

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Risus Sardonicus : Spasm of facial muscles ( frontalis & angle of mouth muscles ) producing grinning facies

Opisthotonus : Painful spasms of neck, trunk and extremity. producing characteristic bowing and arching of back

Some pts devolep 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.

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Risus sardonicusRisus Sardonicus : Spasm of facial muscles ( frontalis & angle of mouth muscles ) producing grinning facies

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Opisthotonus :Painful spasms of neck, trunk and extremity. producing characteristic bowing and arching of back

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Mild ds ( muscle rigidity , no / few spasms )

Moderate ds (trismus, dysphagia, rigidity, spasm)

Severe ds ( freq explosive paroxysms )

Autonomic dysfn complicates severe cases - labile htn, hyperpyrexia, profuse sweating, peripheral vasoconstriction, raised catecholamines.

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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

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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

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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

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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 .

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Differential diagnosis Cond producing trismus : alveolar

abscess, strychnine poisoning, dystonic drug reactions, hypocalemic tetany

Meningitis/encephalitis Marked increased tone in central

muscles , with superimposed generalized spasms & relative sparing of hands & feet – sugg tetanus

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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

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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

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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 Propofol, dantrolene, intrathecal

baclofen, succinylcholine & magnesium sulfate can be tried

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Management of autonomic dysfn

Labetalol Continuous infusion of esmolol Clonidine / verapamil

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Additional measures Pts recovering from tetanus should

be actively immunized Hydration Nutrition Physiotherapy Prophylactic anticoagulation Bowel, bladder, back care Treatment of intercurrent infection

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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

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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

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Monovalent vaccines Purified tetanus toxoid ( adsorbed )

supplanted the palin toxoid – 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

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Passive immunization Temp protection – human tetanus

immunoglobulin /ATS Human Tetanus

Hyperimmunoglobulin : • 250-500 IU• Does not cause serum sickness• Longer passive protection compared

to horse ATS( 30 days / 7 -10 days )

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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.

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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

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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

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Immunized pregnant women : a booster is sufficient

No need of booster in every consecutive pregnancy

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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

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Wounds < 6hrs, clean, non penetrating & negligible

tissue damage Immunity Category

• A• B• C• D

Treatment

• Nothing more required• Toxoid 1 dose• Toxoid 1 dose• Toxoid complete course

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Other Wounds Immunity Category

• A• B• C

• D

Treatment

• Nothing more required• Toxoid 1 dose• Toxoid 1 dose + Human Tetanus Ig• Toxoid complete course + Human

Tetanus Ig

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Upaya pencegahan

Pengawasan penderita, kontak dan lingkungan sekitarnya

1.penyuluhan ke masyarakat pemberian imunisasi TT lengkap.

2.imunisasi aktif dengan TT ke anggota masyarakat memberikan perlindungan 10 tahun

3.Upaya yang dilakukan mencegah tetanus pada penderita luka tergantung penilaian terhadap keadaan luka sendiri dan status imunisasi penderita.

1.Laporan ke Dinas Kesehatan setempat di AS, tetanus wajib dilaporkan diseluruh negara bagian dan di banyak negara

2.Tindakan isolasi: Tidak ada3.Tindakan disinfeksi segera: Tidak

ada 4.Tindakan karantina: Tidak ada 5.Imunisasi terhadap kontak: Tidak

ada 6.Lakukan investigasi untuk

mengetahui derajat dan asal luka 7.Pengobatan spesifik : TIG IM

dengan dosis 3.000 – 6.000 I.U. Jika TIG tidak tersedia, berikan anti toxin tetanus (dari serum kuda) dengan dosis tunggal intravena , metronidazole intravena dalam dosis besar diberikan untuk jangka waktu 7 -14 hari

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