Tetanus
Tetanus
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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.
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It is found worldwide in soil, in inanimate
environment, in animal faeces &
occasionally human faeces.
Epidemiology
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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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More common in areas where soil is cultivated, in
rural areas, in warm climates, during summer,
among males.
Pathogenesis
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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 )
Mode of transmission
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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
Types
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Traumatic
Puerperal
Otogenic
Idiopathic
Tetanus neonatorum
PARK 19th
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Generalized
Neonatal
local
HARRISON 17th
Clinical features
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May begin from 2 days to several weeks after the
injury – USUALLY 1 WEEK
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Remember
Shorter the incubation period
More severe the attack
Worse the prognosis
Clinical features
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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.
trismus
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Risus Sardonicus : Spasm of facial muscles ( frontalis
& angle of mouth muscles )
Opisthotonus : Painful spasms of neck, trunk and
extremity. producing characteristic bowing and
arching of 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.
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 hyperpyrexia, profuse sweating, peripheral
vasoconstriction.
Neonatal Tetanus
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Usually fatal if untreated
Children born to inadequately immunized
mothers, after unsterile treatment of
umbilical stump
During first 2 weeks of life.
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Poor feeding ,rigidity and spasms
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Local Tetanus
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Uncommon form
Manifestations are restricted to muscles near
the wound.
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Cramping and twisting in skeletal muscles
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surrounding the wound – local rigidity
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Prognosis – excellent
Cephalic Tetanus
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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
Diagnosis
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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 .
Treatment – general measures
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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
Control of Spasms
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Nurse in a quiet dark room
Avoid noise & other stimuli
IV Diazepam / Lorazepam / Midazolam
Barbiturates & Chlorpromazine –2nd line
drugs
Continued spasms : intubate & ventilate
Management of autonomic dysfn
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Labetalol
Continuous infusion of esmolol
Clonidine / verapamil
Additional measures
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Pts recovering from tetanus should be
actively immunized
Hydration
Nutrition
Physiotherapy
Prophylactic anticoagulation
Bowel, bladder, back care
Prevention – Active Immunization
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For partially immunized, unimmunized and
recovering from tetanus
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It stimulates production of protective antitoxin
2 prep : combined vaccine : DPT
monovalent vaccine : plain / formol
toxoid
tetanus vaccine , adsorbed
Combined vaccine
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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
Monovalent vaccines
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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
Passive immunization
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Temp protection – human tetanus
immunoglobulin /ATS
Human Tetanus Hyperimmunoglobulin :
250-500 IU
Passive immunization
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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.
Active & Passive Immunization
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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
Prevention of neonatal tetanus
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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
Prevention of tetanus after injury
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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
Wounds < 6hrs, clean, non
penetrating & negligible tissue
damage
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Immunity Category
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Treatment
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B
C
D
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Nothing more required
Toxoid 1 dose
Toxoid 1 dose
Toxoid complete course
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Other Wounds
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Immunity Category
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Treatment
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A
B
C
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D
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Nothing more required
Toxoid 1 dose
Toxoid 1 dose + Human
Tetanus Ig
Toxoid complete course
+ Human Tetanus Ig
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Thank You