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Tetanus & Animal

Lecture Block 19 th

Bite
F R T Z N A H U S U LY

D e p a r t m e n t o f S u r g e r y, F a c u l t y o f M e d i c i n e ,
Mulawarman University
SAMARINDA

General Surgeon
at The A W Syahrani Regional General Hospital
SAMARINDA
2021
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Tetanus

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Introduction

Definition
• Tetanus is an acute disease caused by the
toxin released by the anaerobic gram-
positive bacillus, i.e. Clostridium tetani.

A soldier dying from tetanus. Painting by Charles Bell

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History
• Etiology discovered in 1884
 Antonio Carle and Giorgio Rattone
Produced tetanus in rabbits by injecting their
sciatic nerve with pus from a fatal human
tetanus case
Arthur Nicolaier discovered that
Clostridium tetani was the bacteria that
caused tetanus and its origin by
injecting animals with soil samples
• Shibasaburo Kitasato in 1889 isolated the
organism from a human victim, showed
that it produced disease when injected
into animals
• Emil Adolf von Behring and Shibasaburo
Kitasato in 1890 reported that toxin could
be neutralized by specific antibodies
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History

Arthur Nicolaier Emil Adolf von Behring Shibasaburo Kitasato

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History

• In 1897, Edmond Isidore Etienne Nocard

demonstrated the protective effect of passively
transferred antitoxin
 Passive immunization was used for treatment and
prophylaxis during World War I
• Tetanus toxoid was developed by Pierre Descombey
in 1924
 Widely used during World War II

Edmond Isidore Etienne Nocard

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Tetanus Epidemiology
• Reservoir soil and intestine of animals and
humans
• Transmission contaminated wounds
• tissue injury
• Temporal pattern peak in summer or wet
season
• Communicability not contagious
Clostridium tetani
• Anaerobic gram-positive, spore-forming
bacteria
• Most species are obligate anaerobes, some
will grow under microaerophilic conditions.
• Very active metabolisms, ferment a variety
of sugars, very short generation times.
• Spores found in soil, animal feces
• two exotoxins produced with growth of
bacteria
• Tetanospasmin estimated human lethal
dose = 2.5 ng/kg
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C. tetani: key characteristics
• Ferments: proteins or amino acids.
• Produces: acetic acid, fatty acids, NH3,
CO2, H2, and a strong exotoxin.
• Large, spore-forming, motile, obligate
anaerobic bacillus (see below).
• Tetanospasmin, a powerful neurotoxin.
Pathogenesis
• Anaerobic conditions allow germination of
spores and production of toxins
• Toxin binds in central nervous system
• Interferes with neurotransmitter release to
block inhibitor impulses
• Leads to unopposed muscle contraction
and spasm
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Pathogenesis

Tetanus neurotoxin (TetNT) is directed by

retrograde transport into motor neurons by
the action of microtubules and actin
microfilaments. TetNT inhibits the
exocytosis of specific synaptic vesicles at
inhibitory neuronal terminals. Thus the
action of the inhibitory neuron is not
exerted on the motor neuron, resulting in
spasticity

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Symptoms & signs

• Painful involuntary contraction of skeletal • Other symptoms include:

muscles.  Febrile (feverish), irritability, heavy
• Facial muscle spasms sweating
 risus sardonicus or rictus grin • A stiff neck and difficulty swallowing
• Lockjaw or trismus • In advanced stages, tetanus spasms can
• Opisthotonos, as in Charles Bell's break bones.
painting, caused spasms of the back • Respiratory complications are common
muscles and death rates high, especially in
children and elderly persons.

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Symptoms & signs

Risus sardonicus Opisthotonos

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Diagnosis of tetanus

• Diagnosis of tetanus is made on the basis of the clinical

disease, and the patient’s history may indicate inadequate
immunization.

• As stated earlier, C. tetani is a common contaminant of

wounds and may be found in patients who do not develop
tetanus.

• Hence, isolation of the bacteria from a patient may not be

diagnostic.

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Treatment
As soon as clinical tetanus is suspected, steps to neutralize existing toxin and
prevent the formation of new toxin must begin.

• Antitoxin (tetanus immune globulin) should be administered

immediately. This will inactivate toxins in the blood.
• Wounds should be debrided to remove dead tissue or foreign bodies.
• Antibiotics should be given to inhibit growth of C. tetani.
• A tetanus toxoid booster immunization should be given to patients
who have not received one within the last 5 years.
• If spasms occur, antispasmodic drugs should be used and respiration
maintained by a breathing apparatus if necessary.
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 Prognostic scoring systems in tetanus: Phillips score
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Factor Factor
Score Score
Incubation time State of protection
<48 hours 5 None 10

Possibly some or maternal immunisation 8

2–5 days 4
inneonatal patients
5–10 days 3 Protected >10 years ago 4

10–14 days 2 Protected <10 years ago 2

>14 days 1 Complete protection 0

Site of infection Complicating factors

Internal and umbilical 5 Injury or life threatening illness 10
Severe injury or illness not immediately 8
Head, neck, and body wall 4
life threatening
Peripheral proximal 3 Injury or non-life threatening illness 4
Peripheral distal 2 Minor injury or illness 2
Unknown 1 ASA Grade 1 0
Total

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Adapted from: Farrar, Yen, Cook, et al. Tetanus. J Neurol Neurosurg Psychiatry 2000;69:294
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Prognostic Scoring Systems in Tetanus: Dakar Score

Prognostic  Factor Score 1 Score 0

Incubation period < 7 days ≥ 7 days or unknown
Period of onset < 2 days ≥ 2 days
Umbilicus, burn, uterine,
Entry site open fracture, surgical All others plus unknown
wound, IM injection
Spasms Present Absent
Fever > 38.4oC < 38.4oC
Adult   > 120 beats/min Adult   < 120 beats/min
Tachycardia
Neonate > 150 beats/min Neonate < 150 beats/min
Total Score    

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Adapted from: Farrar, Yen, Cook, et al. Tetanus. J Neurol Neurosurg Psychiatry 2000;69:294
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Table

Grade Clinical Features

Mild-moderate trismus; general spasticity; no spasms; no respiratory
I
embarrassment; little or no dysphagia
Moderate trismus; well marked rigidity; mild-moderate but short spasms;
II
moderate respiratory embarrassment with RR.30/min; mild dysphagia
Severe trismus; generalised spasticity; reflex prolonged spasms; RR .40/min;
III
severe dysphagia; HR .120/min
Grade III and severe autonomic disturbances affecting cardiovascular system (for
IV example, severe hypertension and tachycardia alternating with relative
hypotension and bradycardia, either of which may be persistent)

HR, heart rate RR; respiratory rate.

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Scoring style in Tetanus: Grading of Severity
Systems
( Udwadia’s grading5)

Grade Clinical Findings

Grade I (Mild):
 Grade II (Moderate):
 Grade III (Severe):
 Grade IV (Very Severe):
Mild to moderate trismus, general increased tone, no
respiratory distress, no spasms, and no dysphagia
Moderate trismus, marked rigidity, short lasting spasms,
tachypnoea ≥ 35minute-1, mild dysphagia. 
Severe trismus, generalised increased tone, reflex
spontaneous or prolonged spasms, respiratory distress with
tachypnoea ≥ 40minute-1, apnoeic spells, severe dysphagia,
tachycardia ≥120 minute-1, moderate increase in autonomic
nervous system dysfunction.
Features of Grade III, plus severe autonomic dysfunction,
persistent labile blood pressure and pulse rate.

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Adapted from: Campbell J, Farrar J. Clostridium tetani (Tetanus). Retrieved 10 September 2020
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Tetanus prone wounds
• Any wound or burn sustained more
than six hours before surgical treatment
• Any wound or burn at any interval after
injury that shows one or more of the
following:
 a significant degree of devitalised
tissue
 a puncture type wound
 contact with soil or manure likely
 to harbour tetanus organisms
 clinical evidence of sepsis
Adapted from: Campbell J, Farrar J. Clostridium tetani (Tetanus). Retrieved 10 September 2020
The use of tetanus immunoglobulin
For prophylaxis
• Intramuscular (IM) for tetanus prone wounds (licensed)
• Available in 1 ml ampoules containing 250 IU
 250 IU for most uses
 500 IU if more than 24 hours have passed since injury
or there is heavy contamination,or after burns
For treatment
• Intravenous (IV) for clinical tetanus (unlicensed: available
on named patient basis only)
• The IM preparation should not be given IV
• 5,000-10,000IU by infusion.
• If IV administration impossible, 150IU/kg of IM preparation
can be given in multiple sites
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to use tetanus immunisations
Patient’s immunisation status
Immunised fully: has received a
total of five doses of tetanus
vaccine at appropriate intervals
Primary immunisation complete,
and boosters incomplete but up
to date
Primary immunisation
incomplete or boosters not up
to date
Not immunised or immunisation
status unknown or uncertain
Wound type
Not tetanus prone Tetanus prone
No vaccine required No vaccine required Only if high risk
None required unless the next As for not tetanus Only if high risk
dose is due soon and prone
convenient to give immediately
A reinforcing dose of vaccine As for not tetanus Yes: one dose of
and further doses as required prone human tetanus
to complete the immunoglobulin in a
recommended schedule to different site from the
ensure future immunity toxoid
An immediate dose of vaccine As for not tetanus
followed, if records confirm this prone Yes: one dose of
is needed, by completion of a human tetanus
full five‑dose course to ensure immunoglobulin in a
future immunity different site from the
toxoid
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Table
Vaccine  Children under 7 years
1-DPT  6-8 weeks
2-DPT  4-8 weeks after previous dose
3-DPT  4-8 weeks after previous dose
4-DPT  1 year after previous dose
Booster-DPT  4-6 years of age 
 Adults and children not previously vaccinated
1-Td  At presentation
2-Td  4-8 weeks after previous dose
3-Td  6 months - 1 year after previous dose
Booster- Td  Every 10 years after previous dose 
Pregnant women previously vaccinated
Booster- TT  During first six months of pregnancy
 Pregnant women not previously vaccinated
1-TT  First encounter during pregnancy
2-TT  4 weeks after previous dose

2020
Adapted from: Campbell J, Farrar J. Clostridium tetani (Tetanus). Retrieved 10 September 2020
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Conclusion

• Tetanus is an acute disease caused by the tetanospasmin toxin

produced by the bacteria Clostridium tetani.
• There are still many tetanus incidents in the world, as well as in
Indonesia and it needs the concern of all parties
• The principle of tetanus prevention can use a combination of antitoxin
(Human Tetanus Immunoglobulin or Anti Tetanus Sera) and tetanus
toxoid

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Animal Bite

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Introduction

• An animal bite is a wound caused by the teeth.

• Rare
• Common animal bites are pet bites (e.g. cats, dogs, monkeys, large birds,
etc.) but also wild animals (e.g. tigers, crocodiles, snakes etc.)
• 80-90% dog bites, 10% cat bites
• The bite wound is usually laceration or puncture of skin and a contusion
cause excessive pressure due bite.
• The depth of the wound can involve the subcutaneous tissue to bone
fractures, even avulsion of a compartment tissue.

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• 9-36% of dog bite sites are on the neck and head,

• Location of cat bites on neck and head 6-20%
• Bite wounds should get serious attention, because the wound
becomes infected, contracting rabies and can be deadly, e.g
venomous snake bite.
• Use of rabies and venomous snake bites protocols.

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Dog Bite

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Click to edit MasterBacteria
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from Dog Bites

DF-2 or Capnocytophaga
Staphylococcus species
canimorsus
Streptococcus species Bacteroides species

Eikenella species Moraxella species

Pasteurella species Corynebacterium species

Proteus species Neisseria species

Klebsiella species Fusobacterium species

Haemophilus species Prevotella species

Enterobacter species Porphyromonas species

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Bites / Herbivorous Animals

Cat
Herbivorous Animals
Pasteurella species
Actinomyces species
Actinobacillus lignieresii
Propionibacterium species
Bacteroides species Actinobacillus suis
Fusobacterium species
Clostridium species Pasteurella multocida

Wolinella species
Peptostreptococcus species Pasteurella caballi

Staphylococcus species
Staphylococcus hyicus subsp hyicus
Streptococcus species
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Bacteria stylePig/Primate Bites

Pig Primate
Pasteurella aerogenes Bacteroides species

Pasteurella multocida Fusobacterium species

Bacteroides species Eikenella corrodens

Proteus species Streptococcus species

Actinobacillus suis Enterococcus species
Streptococcus species Staphylococcus species

Flavobacterium species Enterobacteriaceae

Mycoplasma species Simian herpes virus

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from Rat Bites

Streptobacillus moniliformis

Spirillum minus

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prophylaxis measures

Post-exposure prophylaxis
Categories of contact with suspect rabid animal
measures
Category I
Washing of exposed skin surfaces, no
Touching or feeding animals, animal licks on intact skin (no
PEP
exposure)
Category II
Wound washing and immediate
Nibbling of uncovered skin, minor scratches or abrasions
vaccination
without bleeding (exposure)
Category III
Single or multiple transdermal bites or scratches, Wound washing, immediate vaccination
contamination of mucous membrane or broken skin with and administration of rabies
saliva from animal licks, exposures due to direct contact with immunoglobulin
bats (severe exposure)

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"Rabies ". World Health Organization. April 2020. Retrieved 10 September 2020
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Snakebites

• Morbidity and mortality due to venomous snake bites is still

high.
• There is no definite incidence rate for Indonesia, perhaps due
to incomplete recording and reporting, the type of snake in
each region has its own name.
• anti-snake venom still uses polyvalent

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The type of snake in medicine is a venomous snake

• Coral snake : Cobra
• Russel Viper
• Rattle snake
• Copperhead pit Viper

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Cobra Malayan krait

(Naja naja) (Bungarus candidus)

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Russel viper Green pit viper

(Daboia russelii) (Trimeresurus trigonocephalus) 3636
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Venom

• Venom in the form of enzymes

• Proteolytic
• Peptidase
• Metalloprotein
• Injection through fang causes local destruction (cytotoxic)
• Hemotoxic
• Neurotoxic

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• Direct intravascular injection causes secondary
bleeding
• Hemolysis can cause ATN
• Myonecrosis, shock and pituitary dysfunction
• Severity: mild, moderate and severe
• Mild: fang marks – local swelling and less
painful
• Moderate: fang marks + , local swelling
and pain
• Severe: fang marks + , progressive Fang mark
widespread swelling and pain

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Broken neck sign in a child envenomed by a krait in

Sri Lanka (Copyright DA Warrell) Examination for ability to open the mouth and
protrude the tongue in a patient with neurotoxic
envenoming from the Malayan krait
(Copyright DA Warrell)

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First aid: DO NOT

• Panic
• Incision and other measures
• Suction
• Put on ice pack
• Torniquet too tight
• Drink alcohol and aspirin

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First Aid: WHAT TO DO

• Assess the bite wound and undress
• Wash the wound
• Place the extremity lower than the heart
• Put a splint
• Refer to a hospital that has adequate facilities
• As soon as possible, transport to an adequate
hospital

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In the hospital Anti-venom

• ABCDE • Coagulopathy
• WBCT check : first 20 minutes • Thrombocytopenia
and next every 24 hours; • Symptoms of neurotoxic
• CBC, BUN-SC, Urine test cardiomyopathy
• ECG
• BGA
• Fluid balance

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References Master title style
1. Anonyme. The Pink Book: Course Textbook - 13th ed. Epidemiology and Prevention of Vaccine-
Preventable Diseases. Chapter 21: Tetanus, CDC Centers for Disease Control and Prevention.
2015;341-351. Retrieved 16 September 2015
https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html#:~:text=Although%20records%20from
%20antiquity%20(5th,a%20fatal%20human
2. Winau F, Winau R. Emil von Behring and serum therapy. Microbes and Infection. 2002; 4: 185–
188. doi.org/10.1016/S1286-4579(01)01526-X
3. Farrar J J, Yen L M, Cook T, Fairweather N, Binh N, Parry J, Parry C M. Tetanus. J Neurol
Neurosurg Psychiatry 2000;69:292–301
4. Goonetilleke A, Harris J B. CLOSTRIDIAL NEUROTOXINS J Neurol Neurosurg Psychiatry
2004;75(Suppl III):iii35–iii39. doi: 10.1136/jnnp.2004.046102
5. Udwadia FE, Lall A, Udwadia ZF, Sekhar M, Vora A. Tetanus and its complications: intensive
care and management experience in 150 Indian patients. Epidem Infect 1987; 99: 675-84.
doi.org/10.1017/s095026880006653x

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6. Campbell J, Farrar J. Clostridium tetani (Tetanus). Retrieved 10 September 2020

http://www.antimicrobe.org/b100.asp

7. Fooks A R. RABIES Scientific Basis of the Disease and Its Management. Elsevier Inc. London 2020
8. WHO. Rabies. April 2020. Retrieved 10 September 2020. https://www.who.int/en/news-room/fact-sheets/detail/rabies
9. Warrell D. Guidelines for the Management of Snakebites. World Health Organization 2016

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External linksMaster title style

1. Picture of Prof Nocard :

https://archive.org/details/Prof-Nocard-PHAIDRA_o_2428
2. A soldier dying from tetanus. Painting by Charles Bell:
https://upload.wikimedia.org/wikipedia/commons/archive/d/d8/20070
120203641%21Opisthotonus_in_a_patient_suffering_from_tetanus_
-_Painting_by_Sir_Charles_Bell_-_1809.jpg
3. Pathogenesis of tetanus
https://www.researchgate.net/figure/Pathogenesis-of-tetanus-Tetanu
s-neurotoxin-TetNT-yellow-asterisks-is-directed-by_fig1_336127914
4. Whole Blood Clotting Test (WBCT)
https://www.snakebitefoundation.org/whole-blood-clotting-test-wbct

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Thank You

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