Tetanus

1. Tetanus

2. Tetanus • Tetanos – a greek word – to stretch • 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.

3. It is found worldwide in soil, in inanimate environment, in animal faeces & occasionally human faeces.

5. 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.

6. More common in areas where soil is cultivated, in rural areas, in warm climates, during summer, among males.

7. Pathogenesis • Contamination of wounds with spores of C.tetani. • Germination & toxin production – in wounds with low oxidation – reduction potential ( devitalized tissues, F.B, active infection ) • Tetanospasmin ( neurotoxin ) • Tetanolysin ( hemolysin )

9. 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

10. Traumatic Puerperal Otogenic Idiopathic Tetanus neonatorum PARK 19th Generalized Neonatal local HARRISON 17th Types

11. 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

12. 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, feetspared.

13. trismus

14. RisusSardonicus : Spasm of facial muscles ( frontalis & angle of mouth muscles ) • Opisthotonus : Painful spasms of neck, trunk and extremity. producing characteristic bowing and archingof back • Some pts develop 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.

15. Risus sardonicus

18. Mild ds ( muscle rigidity , no / few spasms ) • Moderate ds (trismus, dysphagia, rigidity, spasm) • Severe ds ( freq explosive paroxysms ) • Autonomic dysfn complicates severe cases - hyperpyrexia, profuse sweating, peripheral vasoconstriction.

19. 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

22. 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

23. 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

25. 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

26. Serum Anti toxin levels >= 0.1 IU/ml – protective & makes tetanus unlikely .

27. 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

28. 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

29. 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

30. Management of autonomic dysfn • Labetalol • Continuous infusion of esmolol • Clonidine / verapamil

31. Additional measures • Pts recovering from tetanus should be actively immunized • Hydration • Nutrition • Physiotherapy • Prophylactic anticoagulation • Bowel, bladder, back care

32. 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

33. 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

34. Monovalent vaccines • 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

35. Passive immunization • Temp protection – human tetanus immunoglobulin /ATS • Human Tetanus Hyperimmunoglobulin : • 250-500 IU

36. 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.

37. 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

38. 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

39. Immunized pregnant women : a booster is sufficient • No need of booster in every consecutive pregnancy

40. 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

41. Immunity Category A B C D Treatment Nothing more required Toxoid 1 dose Toxoid 1 dose Toxoid complete course Wounds < 6hrs, clean, non penetrating & negligible tissue damage

42. Immunity Category A B C D Treatment Nothing more required Toxoid 1 dose Toxoid 1 dose + Human Tetanus Ig Toxoid complete course + Human Tetanus Ig Other Wounds

43. Thank You