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Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates.

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Presentation on theme: "Tetanus. Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates."— Presentation transcript:

1 Tetanus

2 Tetanus Tetanos – a greek word – to stretch Tetanos – a greek word – to stretch First described by Hippocrates & Susruta First described by Hippocrates & Susruta A Neurological disease characterised by increased muscle tone & spasms. A Neurological disease characterised by increased muscle tone & spasms. Caused by CLOSTRIDIUM TETANI Caused by CLOSTRIDIUM TETANI An anaerobic, motile, gram positive rod that forms oval, colourless, terminal spores – tennis racket or drumstick shape. 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. It is found worldwide in soil, in inanimate environment, in animal faeces & occasionally human faeces.

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5 Epidemiology Occurs sporadically Occurs sporadically Affects unimmunized, partially immunized & fully immunized who fail to maintain adequate immunity with booster doses of vaccine. 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. 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. 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. Contamination of wounds with spores of C.tetani. Germination & toxin production – in wounds with low oxidation – reduction potential ( devitalized tissues, F.B, active infection ) Germination & toxin production – in wounds with low oxidation – reduction potential ( devitalized tissues, F.B, active infection ) Tetanospasmin ( neurotoxin ) Tetanospasmin ( neurotoxin ) Tetanolysin ( hemolysin ) Tetanolysin ( hemolysin )

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9 Mode of transmission Infection is acquired by contamination of wounds with tetanus spores. 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 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 NOT TRANSMITTED FROM PERSON TO PERSON

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

11 Clinical features May begin from 2 days to several weeks after the injury – USUALLY 1 WEEK May begin from 2 days to several weeks after the injury – USUALLY 1 WEEK Remember Remember Shorter the incubation period Shorter the incubation period More severe the attack More severe the attack Worse the prognosis Worse the prognosis

12 Clinical features GENERALIZED TETANUS GENERALIZED TETANUS Most common Most common Increased muscle tone & generalized spasms Increased muscle tone & generalized spasms Median time of onset after injury – 7 days Median time of onset after injury – 7 days Pt 1 st notices increased tone in masseter ( Trismus, lock jaw ) Pt 1 st notices increased tone in masseter ( Trismus, lock jaw ) Dysphagia Dysphagia Stiffness / pain in neck, shoulder, back muscles appear concurrently / or soon thereafter Stiffness / pain in neck, shoulder, back muscles appear concurrently / or soon thereafter Rigid abd & stiff prox.limb muscles. Hands, feet spared. Rigid abd & stiff prox.limb muscles. Hands, feet spared.

13 trismus

14 Risus Sardonicus : Spasm of facial muscles ( frontalis & angle of mouth muscles ) 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 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. 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. Constant threat during gen.spasm is reduced ventilation, apnea / laryngospasm.

15 Risus sardonicus

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

19 Neonatal Tetanus Usually fatal if untreated Usually fatal if untreated Children born to inadequately immunized mothers, after unsterile treatment of umbilical stump Children born to inadequately immunized mothers, after unsterile treatment of umbilical stump During first 2 weeks of life. During first 2 weeks of life. Poor feeding,rigidity and spasms Poor feeding,rigidity and spasms

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22 Local Tetanus Uncommon form Uncommon form Manifestations are restricted to muscles near the wound. Manifestations are restricted to muscles near the wound. Cramping and twisting in skeletal muscles surrounding the wound – local rigidity Cramping and twisting in skeletal muscles surrounding the wound – local rigidity Prognosis – excellent Prognosis – excellent

23 Cephalic Tetanus A rare form of local tetanus A rare form of local tetanus Follows head injury / ear infection Follows head injury / ear infection Involves one / more facial cranial nerves Involves one / more facial cranial nerves Trismus and localised paralysis,usually facial nerve, often unilateral. Incubation period : few days Incubation period : few days Mortality : high Mortality : high

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25 Diagnosis Based entirely on clinical findings Based entirely on clinical findings Examine all cases with wound infection & muscle stiffness 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 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. Electromyograms – continous discharge of motor units, shortening / absence of silent interval seen after AP. Muscle enzymes – raised Muscle enzymes – raised

26 Serum Anti toxin levels >= 0.1 IU/ml – protective & makes tetanus unlikely. 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 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. Admit in a quiet room in ICU. Continuous careful observation & cardiopulmonary monitoring Continuous careful observation & cardiopulmonary monitoring Minimize stimulation Minimize stimulation Protect airway Protect airway Explore wounds – debridement Explore wounds – debridement

28 NEUTRALIZE TOXIN : NEUTRALIZE TOXIN : Inj.Human Tetanus Immunoglobulin 3000 – 6000 units IM, usually in divided doses as volume is large. 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 Although of unproven value, antibiotics adm to eradicate vegetative cells – the source of toxin IV Penicillin million units daily for 10 days IV Penicillin million units daily for 10 days IV Metronidazole 500mg Q 6 hrly / 1gm Q 12 hrly IV Metronidazole 500mg Q 6 hrly / 1gm Q 12 hrly Allergic to Penicillin : consider Clindamycin & Erythromycin Allergic to Penicillin : consider Clindamycin & Erythromycin

29 Control of Spasms Nurse in a quiet dark room Nurse in a quiet dark room Avoid noise & other stimuli Avoid noise & other stimuli IV Diazepam / Lorazepam / Midazolam IV Diazepam / Lorazepam / Midazolam Barbiturates & Chlorpromazine –2nd line drugs Barbiturates & Chlorpromazine –2nd line drugs Continued spasms : intubate & ventilate Continued spasms : intubate & ventilate

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

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

32 Prevention – Active Immunization For partially immunized, unimmunized and recovering from tetanus For partially immunized, unimmunized and recovering from tetanus It stimulates production of protective antitoxin It stimulates production of protective antitoxin 2 prep : combined vaccine : DPT 2 prep : combined vaccine : DPT monovalent vaccine : plain / formol monovalent vaccine : plain / formol toxoid toxoid tetanus vaccine, adsorbed 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 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 booster at 18 months age 2 nd booster (only DT) at 5-6 yrs 2 nd booster (only DT) at 5-6 yrs 3 rd booster ( only TT) after 10 yrs age 3 rd booster ( only TT) after 10 yrs age

34 Monovalent vaccines higher & long lasting immunity response higher & long lasting immunity response Primary course of immunization – 2 doses Primary course of immunization – 2 doses Each 0.5 ml, injected into arm given at intervals of 1-2 months 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 The longer the interval b/w two doses, better is the immune response 1 st booster – 1 yr after the initial 2 doses 1 st booster – 1 yr after the initial 2 doses 2 nd Booster : 5 yrs after the 1 st booster ( optional ) 2 nd Booster : 5 yrs after the 1 st booster ( optional ) Freq boosters to be avoided Freq boosters to be avoided

35 Passive immunization Temp protection – human tetanus immunoglobulin /ATS Temp protection – human tetanus immunoglobulin /ATS Human Tetanus Hyperimmunoglobulin : Human Tetanus Hyperimmunoglobulin : IU IU

36 Passive immunization ATS ( EQUINE ) : ATS ( EQUINE ) : 1500 IU s/c after sensitivity testing 1500 IU s/c after sensitivity testing 7 – 10 days 7 – 10 days High risk of serum sickness 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. 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 In non immunized persons 1500 IU of ATS / units of Human Ig in one arm & 0.5 ml of adsorbed tetanus toxoid into other arm /gluteal region 1500 IU of ATS / 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 6 wks later, 0.5 ml of tetanus toxoid 1 yr later, 0.5 ml of tetanus toxoid 1 yr later, 0.5 ml of tetanus toxoid

38 Prevention of neonatal tetanus Clean delivery practices Clean delivery practices 3 cleans : clean hands, clean delivery surface, clean cord care 3 cleans : clean hands, clean delivery surface, clean cord care Tetanus toxoid protects both mother & child Tetanus toxoid protects both mother & child Unimmunized pregnant women : 2 doses tetanus toxoid Unimmunized pregnant women : 2 doses tetanus toxoid 1 st dose as early as possible during pregnancy 1 st dose as early as possible during pregnancy 2 nd dose – at least a month later / 3 wks before delivery 2 nd dose – at least a month later / 3 wks before delivery

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

40 Prevention of tetanus after injury All wounds should be thoroughly cleaned soon after injury All wounds should be thoroughly cleaned soon after injury Remove all foreign bodies, soil, dust, necrotic tissue 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 & 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 Wounds < 6hrs, clean, non penetrating & negligible tissue damage Immunity Category Immunity Category A B C D Treatment Nothing more required Toxoid 1 dose Toxoid complete course

42 Other Wounds Immunity Category 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

43 Thank You


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