2Tetanus Tetanos – a greek word – to stretch First described by Hippocrates & SusrutaA Neurological disease characterised by increased muscle tone & spasms.Caused by CLOSTRIDIUM TETANIAn anaerobic, motile, gram positive rod that forms oval, colourless, terminal spores – tennis racket or drumstick shape.
3It is found worldwide in soil, in inanimate environment, in animal faeces & occasionally human faeces.
5Epidemiology 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.
6More common in areas where soil is cultivated, in rural areas, in warm climates, during summer, among males.
7Pathogenesis 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 )
9Mode of transmissionInfection 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, gangreneNOT TRANSMITTED FROM PERSON TO PERSON
10Types Traumatic Puerperal Otogenic Idiopathic Tetanus neonatorum PARK 19thGeneralizedNeonatallocalHARRISON 17th
11Clinical featuresMay begin from 2 days to several weeks after the injury – USUALLY 1 WEEKRememberShorter the incubation periodMore severe the attackWorse the prognosis
12Clinical features GENERALIZED TETANUS Most common Increased muscle tone & generalized spasmsMedian time of onset after injury – 7 daysPt 1st notices increased tone in masseter ( Trismus, lock jaw )DysphagiaStiffness / pain in neck, shoulder, back muscles appear concurrently / or soon thereafterRigid abd & stiff prox.limb muscles . Hands, feet spared.
19Neonatal Tetanus Poor feeding ,rigidity and spasms Usually fatal if untreatedChildren born to inadequately immunized mothers, after unsterile treatment of umbilical stumpDuring first 2 weeks of life.Poor feeding ,rigidity and spasms
22Local Tetanus Uncommon form Manifestations are restricted to muscles near the wound.Cramping and twisting in skeletal muscles surrounding the wound – local rigidityPrognosis – excellent
23Cephalic Tetanus A rare form of local tetanus Follows head injury / ear infectionInvolves one / more facial cranial nervesTrismus and localised paralysis ,usually facial nerve, often unilateral.Incubation period : few daysMortality : high
25Diagnosis Based entirely on clinical findings Examine all cases with wound infection & muscle stiffnessWound cultures – in suspected cases C.tetani can be isolated from wounds of pts without tetanus & freq cannot be isolated from wounds of those with tetanusElectromyograms – continous discharge of motor units, shortening / absence of silent interval seen after AP.Muscle enzymes – raised
26Serum Anti toxin levels >= 0 Serum Anti toxin levels >= 0.1 IU/ml – protective & makes tetanus unlikely .
27Treatment – general measures Goal is to eliminate the source of toxin, neutralize the unbound toxin & prevent muscle spasm & providing support - resp supportAdmit in a quiet room in ICU .Continuous careful observation & cardiopulmonary monitoringMinimize stimulationProtect airwayExplore wounds – debridement
28NEUTRALIZE 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 toxinIV Penicillin million units daily for 10 daysIV Metronidazole 500mg Q 6 hrly / 1gm Q 12 hrlyAllergic to Penicillin : consider Clindamycin & Erythromycin
29Control of Spasms Nurse in a quiet dark room Avoid noise & other stimuliIV Diazepam / Lorazepam / MidazolamBarbiturates & Chlorpromazine –2nd line drugsContinued spasms : intubate & ventilate
30Management of autonomic dysfn LabetalolContinuous infusion of esmololClonidine / verapamil
31Additional measuresPts recovering from tetanus should be actively immunizedHydrationNutritionPhysiotherapyProphylactic anticoagulationBowel, bladder, back care
32Prevention – Active Immunization For partially immunized, unimmunized and recovering from tetanusIt stimulates production of protective antitoxin2 prep : combined vaccine : DPTmonovalent vaccine : plain / formoltoxoidtetanus vaccine , adsorbed
33Combined vaccineAccording to National Immunization, 3 doses of DPT – at intervals of 4-8 wks, starting at 6 wks age, followed bybooster at 18 months age2nd booster (only DT) at 5-6 yrs3rd booster ( only TT) after 10 yrs age
34Monovalent vaccines higher & long lasting immunity response Primary course of immunization – 2 dosesEach 0.5 ml , injected into arm given at intervals of 1-2 monthsThe longer the interval b/w two doses, better is the immune response1st booster – 1 yr after the initial 2 doses2nd Booster : 5 yrs after the 1st booster ( optional )Freq boosters to be avoided
36Passive immunization ATS ( EQUINE ) : 1500 IU s/c after sensitivity testing7 – 10 daysHigh risk of serum sicknessIt stimulates formation of antibodies to it , hence a person who has once received ATS tends to rapidly eliminate subsequent doses.
37Active & Passive Immunization In non immunized persons1500 IU of ATS / units of Human Ig in one arm & 0.5 ml of adsorbed tetanus toxoid into other arm /gluteal region6 wks later, 0.5 ml of tetanus toxoid1 yr later , 0.5 ml of tetanus toxoid
38Prevention of neonatal tetanus Clean delivery practices3 cleans : clean hands, clean delivery surface, clean cord careTetanus toxoid protects both mother & childUnimmunized pregnant women : 2 doses tetanus toxoid1st dose as early as possible during pregnancy2nd dose – at least a month later / 3 wks before delivery
39Immunized pregnant women : a booster is sufficient No need of booster in every consecutive pregnancy
40Prevention of tetanus after injury All wounds should be thoroughly cleaned soon after injuryRemove all foreign bodies, soil, dust, necrotic tissueA – completed course of toxoid/booster < 5 yrs agoB- completed course of toxoid / booster >5 yrs ago & < 10 yrs agoC- completed course of toxoid / booster >10 yrs agoD- not completed course of toxoid / immunity status unknown
41Wounds < 6hrs, clean, non penetrating & negligible tissue damage Immunity CategoryABCDTreatmentNothing more requiredToxoid 1 doseToxoid complete course
42Other Wounds Immunity Category A B C D Treatment Nothing more required Toxoid 1 doseToxoid 1 dose + Human Tetanus IgToxoid complete course + Human Tetanus Ig