TETANUS

Dr Samra Ahmad
 OBJECTIVES
At the end of presentation you will be able to learn
• about tetanus
• its causative organism
• its Diagnosis
• Pathophysiology of tetanus
• Incubation period of tetanus
• Clinical features and tetanus triad
• Generalized tetanus & Localized tetanus and their features
• Cephalic Tetanus
• neonatal tetanus
• complications of tetanus
• Classification of tetanus severity
• Management of tetanus
• Prevention of tetenus
 SCENARIO
• A 35 yr old female P1 with a history of SVD with episiotomy 10 days back
presented with a complaint of generalized body stiffness, breathing
difficulty as well as an inability to chew and swallow food for 4 days. the
woman experienced neck pain and numbness in her face. Her symptoms
got worse over the next 24 hours — her neck and jaw became stiff, and
she had difficulty swallowing and breathing and presented in emergency
with following vitals
• BP 101/63mmHg
• PR 110 bpm
• RR 25 /min
• SPO2 90% at Room air
EXAMINATION
• Slurred speech
• Stiffness of neck and back present
• Limited mouth opening due to the mild facial muscle spasm
• rest of the examination was un remarkable
INVESTIGATIONS
LABS LABS
HB 11 T Bil 0.4 mg/dl
TLC 20 PH 7.35
PLT 200 PaCO2 38
UREA 25 mg/dl Pa O2 65 mmHg
CRET 0.5mg/dl HCO3 25
Na 145 BLOOD CULTURES neg
k 4.5 URINE CULTURES neg

ECG CXR
NORMAL SINUS RHYTHM UNREMARKABLE
What is your differential diagnosis?
• Tetanus • Intracranial hemorrhage
• Strychnine poisoning • Sepsis
• Dental infections • Seizure disorder (partial or
• Hysteria generalized)
• Serotonin syndrome
• Malignant hyperthermia • Stroke, ischemic (cephalic
• Hypocalcemia tetanus)
• Local infections • Meningitis
• TMJ Dislocation
 WHAT IS TETANUS?

Bacterial infection characterized by acute onset of hypertonia, painful

muscle contractions and spasms without any medical cause .

TETANOS- Greek word means stretch

WHAT ARE TYPES OF TETANUS?

LOCALIZED GENERALIZED
TYPES
NEONATAL CEPHALIC
WHAT IS THE CAUSATIVE ORGANISM?
• gram-positive bacillus - Clostridium tetani
• found in soil ,animal or human faeces
• motile, spore forming, obligate anaerobe
• Spores are not destroyed by boiling
• eliminated by autoclaving at 120°C for 15 min 1 (at one atmosphere
pressure)
 DIAGNOSIS

Clinical

Bacterium is rarely cultured

SPATULA TEST
 CAN YOU NAME TETANI EXOTOXINS?
• TETANOSPASMIN
• Enter peripheral nerves
• Binds to gangliosides of neurons
• Axonal retrograde transport to cell body of neurons
• Transport occurs first in motor, and later in sensory and autonomic
nerves
• in the cell body the toxin can diffuse out, affect and entering
nearby neurons.
• spinal inhibitory interneurones are affected, symptoms occur.
• Further retrograde intraneural transport occurs with toxin
spreading to the brainstem and midbrain.
• Inhibit GABA & Glycine from presynaptic vesicles
• relative deficiency of synaptic acetylcholine (similar to botulinum
toxin) causes flaccid paralysis
• Disinhibition of motor & autonomic neurons
• Cause rigidity , spasm , autonomic dysfunction
• High toxin load diffusion via blood to nerves
TETANOLYSIN

• Damages the surrounding tissue

• Optimizes conditions for bacterial multiplication
INCUBATIO
N
•7-10 DAYS
PERIOD

CLINICAL
ONSET
•1-7 DAYS
TIME
WHAT ARE ROUTES OF TRANSMISSION?
BURNS

IM /IV
CHILD BIRTH INJECTIONS

SURGERY
ULCERS

SEPTIC
GANGRENE ABORTION

SNAKEBITE
WHAT ARE ITS CLINICAL FEATURES?

Muscle
rigidity

TETANUS
TRIAD

Autonomic
Spasms
dysfunction
 WHAT ARE THE CLINICAL FEATURES?

• MUSCLE RIGIDITY
• First week
• Reduce after 2 , 3 week
• Autonomic disturbance
• occurs in 1 week
• Occurs several weeks after spasm
• Persists 1-2 weeks
• SPASM
WHAT ARE THE SIGNS AND
SYMPTOMS?
• EARLY SYMPTOMS
• Neck stiffness
• Sore throat
• Poor mouth opening
• Increased muscle tone
• Pharyngeal and laryngeal spasm
• Rigidity of the neck muscles leads to retraction of the head
• Mimic convulsions
• Continuous spasm – RESPIRATORY FAILURE
WHAT ARE SIGNS OF GENERALIZED
TETANUS?
TRISMUS • Masseter muscle
LOCK JAW spasm

• Facial expression
RISUS
• Facial muscle spasm
SARDONICUS • Sarcastic smile

• Truncal rigidity
• Extensor muscles
OPISTHOTONUS spasm
• Arched back
TRISMUS / LOCK JAW
OPISTHOTONUS
RISUS SARDONICUS
WHAT ARE THE COMPLICATIONS?
 POOR GASTRIC STASIS
ASPIRATION
COUGH SALIVATION
AUTONOMIC INCREASED SYMPATHETIC TACHYCARDIA, HTN
DYSFUNCTION ACTIVITY

MYOCARDIAL
CARDIOMYOPATHY
INFARCTION

RENAL FAILURE

GIT DIARRHEA ILEUS

DEHYDRATION SWEATING SALIVATION

LOCALIZED TETANUS
Limited body area involved
LESS MORTALITY

LOWER TOXIN LOAD

CEPHALIC CRANIAL HIGH
TETANUS NERVES MORTALITY
CEPHALIC TETANUS
 NEONATAL TETANUS
TETANUS NEONATORUM
High mortality
PRESENTS 1 week after birth
Convulsions, fever, vomiting

Poor umbilical cord hygiene

d/d meningitis, sepsis, seizures
Prevention- maternal vaccination
HOW DO YOU CLASSIFY SEVERITY?
 ABLETT CLASSIFICATION OF SEVERITY
GRADE SEVERITY SYMPTOMS
I MILD • Mild trismus ,
• general spasticity
• no respiratory embarrassmen
• no spasms, no dysphagia
II MODERATE • Moderate trismus, rigidity
• short spasms
• mild dysphagia,
• respiratory rate > 30,
• mild dysphagia
III SEVERE • Severe trismus
• generalized spasticity,
• prolonged spasms,
 • prolonged spasms,
• respiratory rate > 40,
• apnoeic spells
• severe dysphagia,
• pulse > 120

IV VERY SEVERE • Grade 3 plus severe autonomic

disturbances
• cardiovascular system involvement
WHAT IS THE MANAGEMENT?

PREVENT FURTHER TOXIN RELEASE

NEUTRALIZE TOXIN PRESENT IN THE BODY OUTSIDE CNS

MINIMIZE EFFECT OF TOXIN ALREADY PRESENT IN CNS

HOW CAN YOU PREVENT FURTHER TOXIN RELEASE?

WOUND ANTIBIOTIC

METRONIDAZOLE
Debridement 500mg IV 8h

Additional ERYTHROMICIN, TETRACYCLIN ,

Antibiotic cover CLARITHROMICIN
How can we Neutralize toxin present in the body
outside the CNS?
HUMAN TETANUS
ANTI TETANUS HORSE
IMMUNOGLOBULIN SERUM
Ig

IM:150 units /kg

IM : 1500-
Within 24 h 10000IU
(3000-6000 IU)

A/E
Anaphylaxis
IV: 5000-
10000IU
How to Minimize the effects of the toxin already
in the CNS?

SEDATION

RESPIRATORY SUPPORT

CONTROL AUTONOMIC
DISTURBANCE
WHAT SEDATION CAN YOU GIVE TO THESE PATIENTS?

• BENZODIAZIPINES
• DIAZEPAM 0.1mg/kg IV 4h
• MIDAZOLAM 0.1 mg/kg IV 4h OR Infusion 2-10 mg/H
• OPIOIDS
• MORPHINE 0.1mg/kg IV or IM 2-6h
• PETHIDINE 1 mg/kg IV or IM 2-6h
• COMBINATION
• BENZODIAZIPINES + MORPHINE
• 1-10 mg / h IV
• ANTICONVULSANTS
• PHENOBARBITONE 200 mg IV, PNG, PO 12H
• PHENOTHIAZINE

• PROPOFOL
• 25 -50 ug/kg/min IV
WHAT MUSCLE RELAXANTS TO USE?

VECURONIUM • 0.1 mg /kg IV

ATRACURIUM • 0.5 mg/ kg IV

• Worsen autonomic instability

PANCURONIUM • Inhibiting catecholamine uptake
What is the Treatment of autonomic dysfunction?

FLUID • Minimize autonomic instability

• Presynaptic NMB, reduces catecholamine

release from nerves & adrenal medulla
MAGNESIUM SULFATE • LOADING 5g in 20 min ,INFUSION 2g/h
• Therapeutic range of Mg 2-4 mmol/l

• ESMOLOL short acting

BETA BLOCKERS • Long acting are not recommended

• CLONIDINE
ALPHA 2 AGONIST • Inhibits norepinephrine from nerve endings
WHAT ICU CARE WILL YOU GIVE
THESE PATIENTS?
• Enteral feeding - nutrition
• Prevention of Respiratory Complication
• Semi recumbent position
• Suctioning
• Oral care
• Tracheostomy IF Ventilation > 8-10 days
• Pressure sore care
• Minimize thromboembolism
• Psychological support
PREVENTION Active
immunization
Tetanus
Toxoid
vaccinatio • At 2 months of age
• 3 inj at ONE month interval
n • BOOSTER 5 years of age

Neonatal • Maternal vaccination

• Transplacental transfer of
immunity immunoglobulin

Revacci • Immunity is not long lasting

nation • 2 boosters 10 years apart
T H A N K
Y O U