Tetanus

Introduction:
Tetanus is an infectious disease of central nervous system
characterized by tonic and clonic contraction of muscle caused by
exotoxin liberated by clostridium tetani which is a Gm+ ve bacilli.
Causative organism: clostridium tetani
Incubation period: 3 days to 3 weeks
Mode of entry:
1. Through deep seated penetrated contaminated wound
2. During surgery
Pathogenesis:
a. Contaminated wound with anaerobic condition created by usued
up of minimal O2
by aerobic organism in puncture site
↓
Contamination of anaerobic organism to form vegetative form
↓
Release of exotoxin
↓
Haemolysin causes breakdown of RBC

b. After peripheral absorption

↓
Toxin reaches the central nervous system via retrograde axonal
transport or blood
Passing along the motor trunk
↓
Acts on motor end plate, anterior horn cell and sympathetic neuron
with inhibition process at the motor neuron

c. In the motor end plate

↓
Inhibition of cholinesterase & inhibits release of inhibitory
neurotransmitter eg glycin
↓
No break down of Acetylcholine
↓
Persistent action of
acetylcholine Bacteriology
↓ Criteria of organism
Contraction of skeletal muscle  Gm +ve spore bearing
d. In the anterior horn cell of spinal organism
cord  Spore lies in terminal edge of
organism – so drum stick
↓
appearance
Organism found in
Direct excitation Soil, intestine
e. In the cerebrum Biochemical properties
↓  No sacrolytic or
proteolytic action only secrets
Suppress the inhibitory action exotoxin
↓ Incubation period – 3 days to 3
Upper motor type of lesion week
f. Sympathetic Toxin – Exotoxin
 Tetano plasmin
(Neurotoxin)
 Tetano lysin
( Haemolysin)
 Activation of ANS

Management of tetanus patient

History
1. Pin prick or needle prick injury
2. Abrasion with highly contaminated wound
Complain of
Pain at the site of inoculation
Pain in the abdomen and limb
On examination
a. General examination
i. Pulse – increased
ii. Temperature - increased
iii. Bp - fall
iv. Dyspnoea
v. Unconsciousness
b. Local examination
i. Local muscle spasm
ii. Lock jaw / trismus– due to masseteric muscle
spasm
iii. Dysphagia
iv. Risus sardonicus – due to facial muscle spasm
v. Opisthotonus – due to contraction of back and neck
muscle
vi. Hard board rigidity of abdominal muscle

In ENT ward
Cephalic form due to CSOM Classification of tetanus:
A. Clinically
Diagnosis (detection)
i. Localized form –
1. Present of stiffness and spasm confined to
generalized feature of tetanus the area of infection
2. Involvement of ii. Generalized form
cranial nerve 3,4,9,10,11 – Generalized muscle spasm
iii. Cephalic form –
In obstetric ward due to CSOM
Tetanus neonatorum: 3 to 4 days of iv. Tetanus
life neonatrum
Diagnosis (detect) v. Latent tetanus
B. According to severity
1. History of
i. Stage I – Mild
contaminated umbilicus titanic –Tonic rigidity
2. Difficulty on ii. Stage II – Severely
swallowing and sucking ill with mild convulsion
3. In sever case iii. Stage III –
Dysphagia with reflex spasm
develop opisthotonus iv. Stage IV – Reflex
i. Neck spasm with cyanotic convulsion
stiffness
ii. Tonic – clonic convulsion
Investigation:
1. Diagnosis is clinically
2. Isolation of organism by Gm staining – drum stick appearance
3. Culture Robertson cooked media
4. Blood gas analysis
D/D –
1. Tetani
2. Meningi
tis
3. Rabies
4. Poliomy
elitis
5. Epilepsy
6. Convers
ion disorder
Treatment:
1. Supportive care
2. Neutralization of the toxin
3. Control of infection
4. Prevention of tetanus
5. Isolation

1. Supportive care
i. Isolation of patient in a calm and quiet dark room
ii. O2 inhalation
iii. Maintain nutrition
NG tube feeding or
IV nutrition, electrolytes
iv. Control of convulsion by
Inj. Diazepum
Inj. Chlorpromazine
Inj D-tubocurarine
v. May need tracheostomy
vi. May need positive pressure ventilation
vii. Intensive nursing care

2. Neutralization of toxin:
a. By antitoxin TIG - bolus dose (even upto 1 lac I.U) I/M stat
[ ½ life of TIG – 3 -4 weeks]
3. Control of infection:
i. Antibiotic
1. Inj Pen–a 10 – 14 million unit I/V daily
2. Inj Metronidazole – 400mg I/V daily
ii. Management of wound – wound debridement with
removal of FB
4. Prevention:
By active and passive immunization
- active by Tetanus toxoid (TT)
- Passive by TIG
a) Active immunization in children by DPT
i. Dose - 6 week, 10 week, 14 week
ii. Booster dose – after 5 week
b) Active immunization in pregnant lady by TT
i. Dose – 2 dose 6th month and 7th month of pregnancy
c) Protection of adult male and female by TT
i. Dose – 1st dose: 0
2nd dose: after 1 month
3rd dose: after 6 month
4th dose: after 1 year
Booster dose: after 5 year
Controversy about 10 yearly
d) Prevention of tetanus after trauma/ in a wound
i. Wound care
- Aseptic procedure during operation
- Thorough wash with normal saline, H2O2,
Povidone iodine
- Extensive debridement of wound
- I/V antibiotic
 ii. Immunization
- H/O booster dose < 5 years
i. Simple wound – only wound
management
ii. Tetanus prone wound – wound
management + TT
Complication: - H/O booster dose 5 – 10 years
1. Aspiration i. Simple wound – wound
pneumonia management + TT
2. Vertebral
ii. Tetanus prone wound – Wound
fracture
3. Mediastinal management + TIG + TT
emphysema - No H/O immunization / booster dose > 10
4. Rupture of year/ H/O incomplete immunization
rectus abdominis i. Any type of wound – wound
muscle
5. Death due to
management + TIG + TT
opisthotonis Risus sardonicus