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Tetanus
Tetanus
Tetanus
Tetanus occurs after introduced spores germinate, multiply, and produce tetanus
toxin
Tetanus toxin binds at the neuromuscular junction and enters the motor nerve by
endocytosis, after which it undergoes retrograde axonal transport to the cytoplasm
of the α-motoneuron.
The toxin exits the motoneuron in the spinal cord and next enters adjacent spinal
inhibitory interneurons, where it prevents release of the neurotransmitters glycine
and γ-aminobutyric acid.
The incubation period typically is 2-14 days but may be as long as months
after the injury.
In generalized tetanus
Early symptoms :
◦ Headache
◦ restlessness
◦ irritability
Often followed by :
◦ stiffness
◦ difficulty chewing
◦ dysphagia
◦ neck muscle spasm
CLINICAL MANIFESTATIONS (cont…)
Opisthotonos
extreme hyperextension of the body occur
When the paralysis extends to abdominal,
lumbar, hip, and thigh muscles, the patient
may assume an arched posture
CLINICAL MANIFESTATIONS
(cont…)
Laryngeal and respiratory muscle spasm can lead to airway obstruction and
asphyxiation.
Because tetanus toxin does not affect sensory nerves or cortical function, the patient
unfortunately remains conscious
Dysuria and urinary retention result from bladder sphincter spasm
Forced defecation may occur.
Fever, occasionally as high as 40°C (104°F), is common because of the substantial
metabolic energy consumed by spastic muscles.
Notable autonomic effects include tachycardia, dysrhythmias, labile hypertension,
diaphoresis, and cutaneous vasoconstriction.
CLINICAL MANIFESTATIONS
(cont…)
In extreme pain, and in fearful, anticipation of the next tetanic seizure.
The seizures are characterized by :
• Sudden, severe tonic contractions of the muscles,
• Fist clenching
• Flexion, and adduction of the arms
• Hyperextension of the legs.
The smallest disturbance by sight, sound, or touch may trigger a tetanic
spasm.
The tetanic paralysis usually becomes more severe in the 1st wk after
onset, stabilizes in the 2nd wk, and ameliorates gradually over the
ensuing 1-4 wk.
CLINICAL MANIFESTATIONS
(cont…)
Neonatal tetanus
The infantile form of generalized tetanus, typically manifests within 3-12 days
of birth as progressive difficulty in feeding (sucking and swallowing), associated
hunger, and crying.
Characteristic feature :
◦ Paralysis
◦ diminished movement
◦ stiffness and rigidity to the touch
◦ spasms with or without opisthotonos
CLINICAL MANIFESTATIONS (cont…)
Localized tetanus
Results in painful spasms of the muscles adjacent to the wound site and may precede generalized tetanus.
Cephalic tetanus
is a rare form of localized tetanus involving the bulbar musculature that occurs with wounds or foreign bodies in the
head, nostrils, or face. It also occurs in association with chronic otitis media.
Cephalic tetanus is characterized by
◦ Retracted eyelids
◦ Deviated gaze
◦ Trismus
◦ Risus sardonicus
◦ Spastic paralysis of the tongue and pharyngeal musculature.
DIAGNOSIS
The picture of tetanus is one of the most dramatic in medicine, and the
diagnosis may be established clinically.
The typical setting is an unimmunized patient (and/or mother) who was
injured or born within the preceding 2 wk, who presents with trismus,
other rigid muscles, and a clear sensorium.
Results of routine laboratory studies are usually normal
The cerebrospinal fluid is normal
Neither the electroencephalogram nor the electromyogram shows a
characteristic pattern.
C. tetani is not always visible on Gram stain of wound material and is
DIFFERENTIAL DIAGNOSIS
Infections
• Parapharyngeal abscess
• Retropharyngeal abscess
• Dental abscess
• acute encephalitis involving the brainstem
Rabies
Hypocalcemia
Epileptic seizures
Narcotic withdrawal
Strychnine poisoning may mimic generalized tetanus
TREATMENT
Goal of Rx
◦ Eradication of C. tetani and
◦ The wound environment conducive to its anaerobic multiplication
◦ Neutralization of all accessible tetanus toxin
◦ Control of seizures and respiration
◦ Palliation
◦ Provision of meticulous supportive care
◦ Prevention of recurrences.
TREATMENT (cont..)
MEDICATION (DRUGS)
Neutralization of unbound neurotoxin:
– Human TIG 3,000–6,000 U IM as a single dose.
Infiltration of TIG into the wound is now considered unnecessary.
– Administer prior to antibiotics and wound manipulation.
If TIG is not available:
IVIG 200–400 mg/kg may be used (IVIG contains 4-90 units/mL of TIG)
Equine or bovine-derived tetanus antitoxin (TAT) can be given in doses
of 50,000-100,000 units, with half given intramuscularly and half intravenously
TREATMENT (cont..)
Metronidazole
(500 mg every 8 hr IV for adults) appears to be equally effective.
Metronidazole 30 mg/kg/d PO or IV in 4–6 divided doses. Maximum 4 g/d.
Erythromycin and tetracycline (for persons >8 yr of age) are alternatives for
penicillin-allergic patients.
TREATMENT (cont..)
General Measures
◦ Keep patient in a quiet, darkened room with minimum stimulus.
◦ Monitor cardiac and respiratory status closely.
◦ Be prepared to perform a tracheotomy to prevent fatal laryngospasm.
◦ Monitor for and treat urinary retention and constipation.
◦ Parenteral nutrition is usually required to maintain adequate nutrition and
hydration.
◦ Monitor for and correct electrolyte abnormalities, especially hyperkalemia.
SURGERY/OTHER PROCEDURES
◦ Aggressive surgical debridement and removal of foreign bodies from the infected
wound is crucial.
COMPLICATIONS
Fatality rates :
Generalized tetanus are 5-35%
Neonatal tetanus they extend from <10% with intensive care treatment to
>75% without it.
Active immunization
(DTaP) vaccine at 2, 4, 6 and 15-18 mo of age, with boosters at 4-6 yr (DTaP) and 11-12 yr (Tdap)
of age and at 10 yr intervals thereafter throughout adult life with tetanus and reduced diphtheria
toxoid (Td).
Prophylaxis in Routine Wound Management