“LOCKJAW”

What is Tetanus?
 An infectious disease caused by
contamination of wounds from the
bacteria Clostridium tetani, or the
spores they produce that live in
the soil, and the animal manure.
 Greek word “Tetanos” meaning to
stretched, which describe the
condition of the muscles affected
by the toxin, tetanospasmin,
produced by Clostridium tetani.
 It is a neurological disease
characterized by acute onset of
hypertonia, painful muscular
contractions such as jaw tightness Risus sardonicus

(lockjaw), dysphagia, risus,

opisthotonus and generalized
muscle spasms without other
apparent medical causes.

Ophisthotonus
Causes?
 Tetanus spores are found
throughout the
environment, usually in
soil, dust and animal
manure.
 Tetanus is acquired
through contact with the
environment; it is not
transmitted from person to
person.
Causative agent
 Caused by Clostridium tetani
o Anaerobic (absence of free oxygen)
o Motile (movement by means of rotary
flagellum in the peritrichous orientation)
o Gram positive baccili
o Oval colorless, terminal spores-
tennis racket or drumstick-shaped when
forming spores)

 Spores of tetani is very resistant to heat, radiation, chemicals and

drying which is why it can survived for a hundred years.
Tetanus may follow burns, deep puncture wounds, ear or dental
infections, animal bites, and abortion.
Host factors

 Age: It is a disease of active age (5-40 years)

Newborn baby, female during delivery or abortion
 Gender: Higher incidence in males than females
 Occupation: Agricultural workers are at higher risk
 Rural area – Urban differences: Incidence of tetanus in urban areas
is much lower than in rural areas
 Environmental and social factors: Unhygienic custom habits,
unhygienic delivery practices.
Mode of transmission
 Tetanus is acquired through
contact with the environment; it is
not transmitted from person to
person. (WHO)
 C. Tetani can live for years as
spores in animal feces and soil. As
soon as it enters the human body
through a major or minor wound
and the conditions are anaerobic,
the spores germinate and release
the toxins.
 Infection occurs when C.tetani are introduced
into acute wounds from trauma, surgeries and
injections, or chronic skin lesions and infections.

 Cases have resulted from wounds that were

considered too trivial to warrant medical
attention.
Route of entry

 Apparently trivial injuries

 Animal bites/human bites
 Open fractures
 Chronic skin ulcers, Eye infection
 Unsterile surgery/Injections
 Burns
 Gangrene
 In neonates usually via infected umbilical stumps
 Abscess
 Parenteral drug abuse
Prognosis in infected
 Prognosis is dependent on incubation period,
time from spores inoculation to first
symptom, and time from first symptom to
first tetanic spasm
 In general, shorter intervals indicate more

severe tetanus and a poorer prognosis

 Patient usually survive tetanus and return to

their pre-disease state of health

 Recovery is slow and usually occurs over 2-4

months.
 The total score indicates disease severity and
prognosis as follows:
 0 or 1 – Mild tetanus; mortality below 10%
 2 or 3 – Moderate tetanus; mortality of 10-

20%
 4 – Severe tetanus; mortality of 20-40%
 5 or 6 – Very severe tetanus; mortality above

50%

(Source: https://emedicine.medscape.com/article/229594-overview#a6)
Epidemiology (Worldwide)
 Worldwide - present in the environment.
 Tetanus is first described in Egypt around 3000 years ago, and is
considered to be prevalent throughout the ancient world. [1]. Tetanus
would be a major menace and a master killer in all the wars during
most of history
 In 2001 an estimated 282,000 died worldwide from tetanus, mostly in
Asia, Africa and South America.
 The incidence of tetanus in the UK decreased following the
introduction of national tetanus immunisation in 1961 2.
 Between 1984 and 2002, there were 186 cases of tetanus in England
and Wales, of which 74% occurred in individuals aged over 45 years 2.
 Neonatal tetanus is an important cause of mortality in many countries
in Asia and Africa due to infection of the baby's umbilical stump.
(Source:https://www.healthknowledge.org.uk
/public-health-textbook/disease-causation-diagnostic/2b-epidemiology-diseases-phs/infectious-diseases/tetanus)
 In 2015, about 34 000 newborns died from neonatal
tetanus worldwide, a 96% reduction since 1988,
largely due to scaled-up immunization with TTCV.
 In 2016, 86% of infants worldwide were vaccinated
with 3 doses of diphtheria-tetanus-pertussis (DTP)
containing vaccine.
 Maternal and Neonatal Tetanus (MNT) has been
among the most common life threatening
consequences of unclean deliveries and umbilical
cord care practices, and are indicators of inequity in
access to immunization and other maternal,
newborn, and child health services.
Epidemiology
 Tetanus is an international health problems, as
spores are ubiquitous. The disease occurs almost
exclusively in persons who are unvaccinated or
inadequately immunized
 Entirely preventable disease by immunization
 Tetanus occur worldwide but is more common in

hot damp climates with soil rich in organic matter.

 More common in developing and under
developing countries
 More prevalent in industrial establishment, where

agricultural workers are employed

 Tetanos neonatorum is common due to lack of

medical center health care.

 The majority of reported tetanus cases are birth-

associated among newborn babies and mothers

who have not been sufficiently vaccinated with
TTCV.
Epidemiology in Philippines
 According to the latest WHO data published in 2018
Tetanus Deaths in Philippines reached 690 or 0.11% of
total deaths. The age adjusted Death Rate is 0.80 per
100,000 of population ranks Philippines #43 in the world.
(source:https://www.worldlifeexpectancy.com/country-health-profile/philippines)

 After three decades of hard work and collaboration with

partners, the Philippines, through the leadership of the
Department of Health (DOH), has achieved Maternal
and Neonatal Tetanus Elimination (MNTE) status.
 MNTE is achieved when there is less than one case of
neonatal tetanus per 1000 live births in every province or
city every year.
 This was declared by a joint UN mission comprising of
technical experts from United Nations Children’s Fund
(UNICEF) and the World Health Organization (WHO).
Prior to this declaration, the Philippines was one of the
16 remaining countries in the world that have not
eliminated maternal and neonatal tetanus.
 With full support from UNICEF and WHO and the
tireless efforts of frontline health workers and local
leaders, the campaign reached almost every
corner and every reproductive age woman,
especially those living in isolated and island
communities. This lead to successful elimination
of MNT form the most difficult region of the
country.(Source:https://www.unicef.org/philippines/press-releases/philippines
-eliminates-maternal-and-neonatal-tetanus)
Pathogenesis/Pathophysiology
Wound puncture, burns, Blood stream (via uterus-septic
lacerations (surgery),frost abortion) or Through the stump of
bites umbilical cord of new born

Bacillus (Clostridium tetani) entry

Fires up the nerve cells
excitability (over excitation)
Autonomic dysfunction occur
Wounds spores blocking the release of the
contaminated with C. inhibitory neurotransmitters
tetani glycine and gamma-amino
butyric acid (GABA)

Stays in sporulated form Sign and symptoms:

until anaerobic conditions
are presented (Dead
cells/tissue)
Germination and toxin
(tetanospasmin)
production take place
Tetanospasmin release in
the wound via lymphatic
system then binds to
peripheral motor neuron
terminals
Toxins then migrate
across synapse to
presynaptic terminals
Transported to spinal cord and
brain stem by retrograde
intraneural transport
Travel to enter axon
• Muscle spasm and rigidity
·Trismus (lockjaw)
·Dysphagia
·Tendon rupture
·Opisthotonus
·Respiratory difficulty
·Presents labile blood
pressure and heart rate
·Diaphoresis
·Bradyrhytmias
·Cardiar arrest
DEATH
Classification

 GENERALIZED TETANUS
- is the most common form of tetanus, occurring in
approximately 80% of cases. Patients present with a
descending pattern of muscle spasms, first presenting
with lockjaw, and risus sardonicus (rigid smile because
of sustained contraction of facial musculature)
Sign and Symptoms:
 Painful muscle spasms and stiff, immovable muscles (muscle

rigidity) in your jaw

 Tension of muscles around your lips, sometimes producing a

persistent grin
 Painful spasms and rigidity in your neck muscles

 Difficulty swallowing

 Rigid abdominal muscles

Classification..
 LOCALIZED TETANUS
- is an unusual form of the disease consisting of muscle
spasms in a confined area close to the site of the injury.
Although localized tetanus often occurs in people with
partial immunity and is usually mild, progression to
generalized tetanus can occur.

Sign and symptoms:

 painful spasm of muscles adjacent to the wound site and may
precede generalised tetanus
Classification
 CEPHALIC TETANUS
- is defined as a combination of trismus and paralysis of
one or more cranial nerves. Cranial nerves III, IV, VI, VII,
and XII may be affected, but the facial nerve is most
frequently implicated.
- occurs with ear infections or following injuries of the
head; facial muscle contractions.
- Incubation period is short, usually 1 to 2 days.
Sign and Symptoms:
 Dysphagia
 Trismus (lockjaw)
 Spasm
Classification
 NEONATAL TETANUS
- is a generalized tetanus infection of the newborn. It
usually gets transmitted from an unvaccinated mother
and enters the body through infection of unhealed
umbilical stump. This typically happens when the
umbilical cord is cut using unsterile instruments.
- it occurs within 14 days following birth
Sign and symptoms:
 inability to suck or breastfeed and excessive crying (first sign of
tetanus in neonates)
 Characteristic features are trismus (lockjaw, or inability to open the
mouth), risus sardonicus (forced grin and raised eyebrows) and
opisthotonus (backward arching of the spine)
NEONATAL TETANUS

Infant with tetanus demonstrating signs of Infant with tetanus demonstrating

trismus and risus sardonicus opisthotonus

Source: https//WHO_SurveillanceVaccinePreventable_14_NeonatalTetanus_R1%20(1)
Stages/Severity
Clinical Features:

 The incubation period ranges from 3 to 21 days,

averaging about 10 days.
 In general, the further the injury sites is from the

central nervous system, the longer the incubation

period.
 A shorter incubation period is associated with

more severe disease, complications, and a higher

chance of death.
 In neonatal tetanus, symptoms usually appear

from 4 to 14 days after birth, averaging about 7

days.
Clinical manifestations
 Jaw cramping
 Sudden, involuntary muscle tightening (muscle

spasms)-often in stomach
 Painful muscle stiffness all over the body
 Trouble swallowing
 Jerking or staring (seizures)
 Headache
 Fever and profuse sweating
 Changes in blood pressure and fast heart rate
Diagnosis
 Base on Physical exam- clinically presence of by a triad of
muscle rigidity, muscle spasms and autonomic instability
 Medical and vaccination history
 Sign and symptoms - presence of trismus (lockjaw), risus
sardonicus(raised eyebrows and grinning distortion of the face),
 Laboratory test result –it would likely used only if doctor
suspects another condition causing the sign and symptoms (There are no
hospital lab tests that can confirm tetanus – according from CDC)
(Source: www.mayoclinic.org/tetanus)
Complication
 Laryngospasms
 Fractures
 Hypertension
 Tetanic seizures
 Nosocomial infections
 Pulmonary embolism
 Aspiration pneumonia
 Severe kidney Failure
 Death
 Treatment

 Hospitalization
 Maintenance of an airway –respiratory support with oxygen or
endotracheal tube, and mechanical ventilation may be necessary
 Administration of antitoxin as soon as possible –
Tetanus antitoxin (TAT- a tetanus immune serum that neutralizes
exotoxins in tetanus infection)
 Immediate treatment with human tetanus immune globulin
(TIG)
 Sedation - To keep the patient calm
 Agents to control of the muscle spasm – muscle relaxant
such as benzodiazepines.
Treatment continuation..

 Assurance of a normal fluid balance

 Antibiotics:
 Benzodiazepines maybe given to reduce hypertonicity.
 Penicillin G is administered for infection (100,000-200,000IU/kg/day
IV, 2-4 divided doses)
 Metronidazole (500mg every 6Hr IV or per orem) –
 Clindamycin – if patient allergic to penicillin.
 Tracheostomy is performed and oxygen given for
ventilation.
 Wound debridement –removing of dead tissue of wounds
 Tetanus vaccination – It is given after the treatment for
prevention of exposing again.
Nursing management
 Monitored Vital signs every 2Hr. To observe sign and
symptoms such as dyspnea, cyanosis (is a sign of breathing
disorder) which is accompanied by decreased cardiac work.
 Provide patient bed rest with a non-stimulating environment

(dim light, reduce noise, and stable temperature)

 Administering Sedation may be necessary. To keep the

affected person calm and manage the autonomic

dysfunction and avoid exhaustion.
 Provide respiratory support oxygen, (endotracheal tube, and

mechanical ventilation may be necessary). Provision of

adequate oxygen can supply and provide backup oxygen,
thus preventing hypoxia.
 Observation of the onset of respiratory failure. The
inability of the body in the respiratory process required critical
interventions by using a breathing (mechanical ventilation)
 Educate patient relaxation techniques. To decrease
muscle tension
 Reposition the client by adjusting the position of the
head. To clear airway so that the process of respiration is still
running smoothly by removing the blockage of the airway.
 Clean the mouth and respiratory tract of mucus with a
secret and do section.
 Provide emotional support and
Prevention
 Tetanus is completely
preventable by active
tetanus immunization
 Immunization is thought to
provide protection for 10
years
 Active immunization
Combined Monovalent

 Educate uninfected person

who are at increased risk for
contracting infections.
 For person who have contaminated and dirty wounds
and are either unvaccinated or have not received a
primary series of tetanus toxoid containing vaccines
should received TIG for prophylaxis (The dose of TIG for
prophylaxis is 250IU administered intramuscularly).
 The DTaP vaccine is used to prevent tetanus (along with
diphtheria and pertussis) and your child will get their first
series of shots at 2, 4, and 6 months. Your child will
also need another tetanus shot between the ages of 15
to 18 months old and between 4-6 years old.
 Tdap (Tetanus, Diptheria /Pertussis) –recommended
during pregnancy preferably 27 and 36 weeks’ gestation,
to protect the baby from whooping cough.