1. Tetanus Tetanos – a greek word – to strech
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.

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

4. 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.

5. As reporting is inaccurate & incomplete, particularly in devoleping countries, W.H.O considers reported cases to be an underestimate & takes case/death estimates to assess the burden of disease.
In 2002, the estimated deaths in all age groups 2,13,000 of which 1,80,000 were attributable to neonatal tetanus.
More common in areas where soil is cultivated, in rural areas, in warm climates, during summer, among males.

7. Tetanospasmin ( exotoxin ) produced locally , released into bloodstream .
Binds to peripheral motor neuron terminals & nerve cells of ant.horn of spinal cord
The toxin after entering axon , transported to nerve cell body in brain stem & spinal cord – retrograde intraneuronal transport
Toxin – migrates across synapse – presynaptic terminals- blocks the release of Glycine & GABA from vesicles.

8. The blocking of neurotransmitter release by Tetanospasmin involves cleavage of Synaptobrevin – essential for proper of synaptic vesicle release apparatus
With diminished inhibition – resting firing rate of alpha motor neurons increases – rigidity
Lessened activity of reflexes which limit polysynaptic spread of impulses, agonists & antagonists recruited – spasms
Loss of inhibition of preganglionic sym neurons – sympathetic hyperactivity

10. 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

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

12. 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

13. 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, feet spared.

14. trismus

15. Risus Sardonicus : Spasm of facial muscles ( frontalis & angle of mouth muscles ) producing grinning facies
Opisthotonus : Painful spasms of neck, trunk and extremity. producing characteristic bowing and arching of back
Some pts devolep 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.

16. Risus sardonicus Risus Sardonicus :
Spasm of facial muscles ( frontalis & angle of mouth muscles ) producing grinning facies

17. Opisthotonus :
Painful spasms of neck, trunk and extremity.
producing characteristic bowing and arching of back

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

20. Neonatal Tetanus Poor feeding ,rigidity and spasms
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
Serum Anti toxin levels >= 0.1 IU/ml – protective & makes tetanus unlikely .

26. Differential diagnosis
Cond producing trismus : alveolar abscess, strychnine poisoning, dystonic drug reactions, hypocalemic tetany
Meningitis/encephalitis
Marked increased tone in central muscles , with superimposed generalized spasms & relative sparing of hands & feet – sugg tetanus

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 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
Propofol, dantrolene, intrathecal baclofen, succinylcholine & magnesium sulfate can be tried

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
Treatment of intercurrent infection

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
Purified tetanus toxoid ( adsorbed ) supplanted the palin toxoid – 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 : IU
Does not cause serum sickness
Longer passive protection compared to horse ATS( 30 days / days )

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

42. Other Wounds 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. Pengawasan penderita, kontak dan lingkungan sekitarnya
Upaya
pencegahan
Pengawasan penderita, kontak dan lingkungan sekitarnya
penyuluhan ke masyarakat pemberian imunisasi TT lengkap.
imunisasi aktif dengan TT ke anggota masyarakat memberikan perlindungan 10 tahun
Upaya yang dilakukan mencegah tetanus pada penderita luka tergantung penilaian terhadap keadaan luka sendiri dan status imunisasi penderita.
Laporan ke Dinas Kesehatan setempat di AS, tetanus wajib dilaporkan diseluruh negara bagian dan di banyak negara
Tindakan isolasi: Tidak ada
Tindakan disinfeksi segera: Tidak ada
Tindakan karantina: Tidak ada
Imunisasi terhadap kontak: Tidak ada
Lakukan investigasi untuk mengetahui derajat dan asal luka
Pengobatan spesifik : TIG IM dengan dosis – I.U. Jika TIG tidak tersedia, berikan anti toxin tetanus (dari serum kuda) dengan dosis tunggal intravena , metronidazole intravena dalam dosis besar diberikan untuk jangka waktu hari