Tetanus

Dr.Vemuri Chaitanya

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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 fn 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

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 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  Generalized
 Puerperal  Neonatal
 Otogenic  local
 Idiopathic HARRISON 17th
 Tetanus neonatorum
PARK 19th

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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 sardonicus

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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

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 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  Treatment

• A •
( VIRUS) Nothing more required
• B • Toxoid 1 dose
• C • Toxoid 1 dose
• D • Toxoid complete course

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 Other Wounds
 Immunity Category  Treatment

• A • Nothing more required

• B • Toxoid 1 dose
• C • Toxoid 1 dose + Human
Tetanus Ig
• D • Toxoid complete course
+ Human Tetanus Ig

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 Upaya Pengawasan penderita, kontak dan
pencegahan lingkungan sekitarnya
1. penyuluhan ke masyarakat 1. Laporan ke Dinas Kesehatan setempat di
pemberian imunisasi TT AS, tetanus wajib dilaporkan diseluruh
negara bagian dan di banyak negara
lengkap. 2. Tindakan isolasi: Tidak ada
2. imunisasi aktif dengan TT 3. Tindakan disinfeksi segera: Tidak ada
ke anggota masyarakat 4. Tindakan karantina: Tidak ada
memberikan perlindungan 10 5. Imunisasi terhadap kontak: Tidak ada
tahun 6. Lakukan investigasi untuk mengetahui
derajat dan asal luka
3. Upaya yang dilakukan 7. Pengobatan spesifik : TIG IM dengan dosis
mencegah tetanus pada 3.000 – 6.000 I.U. Jika TIG tidak tersedia,
penderita luka tergantung berikan anti toxin tetanus (dari serum kuda)
penilaian terhadap keadaan dengan dosis tunggal intravena ,
luka sendiri dan status metronidazole intravena dalam dosis besar
diberikan untuk jangka waktu 7 -14 hari
imunisasi penderita.

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Thank You

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