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Current Management of Tetanus

Current Management of Tetanus

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Published by Rajiv
This is an update on management of still dreaded disease - Tetanus.
This is an update on management of still dreaded disease - Tetanus.

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Published by: Rajiv on Dec 13, 2008
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11/10/2012

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Tetanus in Indian ICU: Is it still a commonproblem?
Tetanus is a preventable infectious disease with high mortality.Tetanus is a disease which affects people all over world. There arevery few cases of tetanus in developed world. In US only 33 caseswere reported in 1999. In developing countries it remains a major public health problem. There is no systematic collection of dataavailable from India. In a recent study by Anuradha, 217 cases of tetanus were reported over three years with mortality rate of 38%
1
.Such a high number of tetanus assumes much more significance inlight of very limited ICU resources in India. In our institution, over aperiod of two years and four months (September 2004 December 2006) 528 patients were admitted in medical ICU out of which 34(6.43%) were of tetanus. This number of patients put tremendouspressure on already limited resources of ICU.Treatment of tetanus has undergone little pharmacological changesince early 20th century. Tetanus has traditionally been treated withheavy sedation and supportive treatment in quite, dark room tominimize external stimulation. This treatment is still prevalent inthose parts of world where mechanical ventilatory support is notreadily available. These areas comprise of majority of developingworld including a significant portion of India.A significant reduction in mortality due to tetanus was observed after introduction of muscle relaxants, mechanical ventilation andintensive care in routine management of tetanus. Mortalitydecreased from 43 to 15% in a study by
Trujillo
, analyzing 641 casesof tetanus managed by such intensive care
2
. In a similar study by
 
Udwadia
, analyzing 150 cases of tetanus, reported that intensivecare, proper nutrition, early tracheostomy and ventilator support insevere tetanus were chiefly responsible for an overall reduction inmortality from 30 to 12% while the mortality in severe tetanus wasreduced from 70 to 23%
3
. Both studies reported cardiac abnormalitydue to autonomic dysfunction as major cause of mortality, instead of respiratory failure which has been predominant cause of mortalityprior to use of intensive care practices in management of tetanus.The aspects which should be considered while managing a patientwith tetanus are:
1.
Early diagnosis
2.
Specific treatment, which includes wound management,antibiotic therapy, neutralization of unbound toxin, control of muscle spasms, management of autonomic instability,
3.
Prevention of early complications
4.
Supportive treatment
Early diagnosis
The diagnosis of tetanus is primarily clinical with laboratoryinvestigations being virtually of no use. History of injury, or presenceof a wound aids in strengthening the diagnosis. Clinical diagnosisrequires high index of suspicion especially in areas with loweincidence of disease.Tetanus follows an injury with a median
incubation period
of 7days; 15% of cases occur with in 3 days and 10% after 14 days. In15 to 30% of patients, where the portal of entry is not evident, acareful search for signs of parentral drug abuse, otitis media,instrumentation like septic abortion, injections or minor surgicalprocedures should be inquired.
 
The first
symptoms of tetanus
is due to rigidity of musclessupplied by cranial nerves, trismus being the most commonpresentation, followed by risus sardonicus and neck stiffness.Patients complain of dysphagia and stiffness in the jaw, abdomen, or back. Generalized rigidity of facial muscles causes the characteristicexpression of risus sardonicus. Reflex spasms develop within 1 to 4days of the first symptoms. Spasm may be precipitated by minimalstimuli such as noise, light, or touch and last from seconds tominutes. In severe tetanus respiration may be compromised becauseof generalized spasms. In very severe tetanus autonomicdysfunction predominates.
Spatula test
is a practical simple bedside test
for early diagnosis
of tetanus. A positive test result (reflex spasm of the masseters ontouching the posterior pharyngeal wall) was seen in 359 (94%) of 380 patients with tetanus and in no patient without tetanus. The testperformed on presentation had a high specificity (100%) andsensitivity (94%) for diagnosing tetanus
4
.
Differential diagnosis
of tetanus includes a number oconditions that can simulate one or more of the clinical findings of tetanus. Early symptoms of tetanus may be mimicked by either 
strychnine poisoning
or a dystonic reaction to
phenothiazines
.Phenothiazine reactions can cause trismus, but the associatedtremors, athetoid movements, and torticollis should make onesuspect this drug reaction. Trismus tends to appear late, andsymptoms and signs develop much more rapidly in strychninepoisoning than in tetanus. Most common local condition that resultsin trismus is an
alveolar abscess.
 
Purulent meningitis
can beexcluded by examination of the cerebrospinal fluid.
Encephalitis
is

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