Tetanus (Lock Jaw)

Ghuncha Ashif
Acknowledgement: TCD team
 Objectives
 Discuss the web of causation of tetanus and identify
biological, physical and social factors from the web
 Demonstrate the clinical manifestation and discuss nursing
process
 Discuss the role of nurse in prevention and control of
tetanus
 Tetanus
 Tetanus is an acute, often fatal, disease caused by an
exotoxin (Tetanolysin, and Tetanospasmin –
neurotoxin) produced by the bacterium Clostridium
tetani.

 Itis characterized by generalized rigidity and

convulsive spasms of skeletal muscles.

 The muscle stiffness usually involves the jaw (lockjaw)

and neck and then becomes generalized.
 Clostridium tetani is sensitive to heat and cannot survive in the
presence of oxygen.
 The spores, in contrast, are very resistant to heat and the usual
antiseptics. They can survive autoclaving at 249.8°F (121°C) for
10–15 minutes.
 The spores are also relatively resistant to phenol and other
chemical agents.
 The spores are widely distributed in soil and in the intestines and
feces of horses, sheep, cattle, dogs, cats, rats, guinea pigs, and
chickens.
 Manure-treated soil may contain large numbers of spores. In
agricultural areas, a significant number of human adults may
harbor the organism.
 The spores can also be found on skin surfaces
 Incubation period: (range, 3-21 days)
 Reservoir:
■ soil and intestine of animals and humans
 Mode of Transmission
■ contaminated wounds
■ tissue injury
 Temporal pattern
■ peak in summer or wet season
 Communicability
■ not contagious
Factors responsible for wound contamination cont…

 Contamination of umbilical cord stump in neonates

(application of cow dung etc.)
Improper midwifery services (un-sterile equipments)
 poor tetanus immunization status of mothers
 common in warm climates, overcrowded and
agricultural regions.
 Infants and elderly have high mortality.
 Factors responsible for wound contamination
• Wounds contaminated with soil, dust and animal excreta.
 History of injury
 Traditional practices (circumcision, ear piercing and
tattooing)
 Dog bite, thorn, abortion surgery, road accidents,
drug addiction, Injections and decubitus ulcers and
gun shot wounds
• Application of any infected material to loosen the vaginal
walls during labor.
 Types
 Generalized tetanus (common 80%, life threatening)

 Cephalic tetanus (head and neck wound). (Paralysis of

the cranial and Facial nerves

 Local tetanus: Manifestations restricted to muscles near

the wound.

 Neonatal tetanus presents most often about the seventh

day of life with a short history of failure to feed. Spasms
are typical but the diagnosis can be mistaken for
meningitis or sepsis.
Path physiology
Cl. tetani enters body, multiply in devitalized tissue (less & Blood
flow)

produce exotoxins - Tetanospasmin and Tetanolysin.

Tetanospasmin taken up by neuromuscular junctions and travel via

nerves to reach the CNS

Once in CNS toxin causes blockade of the inhibitory neurons

Excitation of autonomic & motor neuron

BP & HR Alteration -------- lack of inhibition causes lack of

relaxation of muscles causes increase
in muscle tone or produces rigidity
Lack of relaxation
Clinical Features
Opisthotonus
Trismus (Lock jaw) (Back Muscle Contraction)

Dysphagia (backward arching of the head,

neck, and spin)
Risus Sardonicus: (Facial Muscles contraction

• grin smile due to muscle spasms

• Spasms of Masseter muscles (mastication)
 Clinical Features Cont.…..

• Periods of apnea may occur due to spasm of the intercostal muscles and the diaphragm.

• Autonomic dysfunction
 Severe sympathetic over activity causes
 fluctuating tachycardia, sweating and pyrexia

• Increased parasympathetic activity

 Depression of bowel motility and bladder
 dysfunction, profuse salivation and bronchial secretions.
Tonic contractions
• Backaches, abdominal pain and neck
stiffness due to tonic contractions.
• flexion of the arms, extension of the
legs, rigidity of the abdominal wall,
followed by rigidity of the trunk and
limbs.)
Diagnosis
 Mainly through Clinical observation and history.
 Lab (wound culture) are of no value.
 Complications
 Laryngospasm
 Fractures
 Hypertension and/or abnormal heart rhythm (due to
hyperactivity of the autonomic nervous system)
 Nosocomial infections
 Pulmonary embolism
 Aspiration pneumonia
 Death
 TREATMENT
 Clean wound
 excision of devitalized tissue (Metronidazole)
 Neutralization of toxin
 Human tetanus immune globulin (HTIG) I/M 500
units or anti tetanus horse serum (ATS) after sensitivity
tests (5000 units I/M and 5000 infiltrated around the
wound)
 Antibiotics (penicillin)
Symptomatic Measures

Early (Key) Management

 Control of muscle spasms, autonomic dysfunction by
drugs
 Maintain ventilation & oxygenation
 Maintenance of an adequate airway is critical
 Tracheostomy
 Avoid complications such as pulmonary aspiration.
N/G feeding
Control of Spasms
Spasms lead to compromised ventilation & often aspiration
of gastric contents, which are life threatening.

Sedation
(barbiturates, diazepam, chlorpromazine, morphine,
Magnesium sulphate) blocks the exaggerated response to
stimuli and also controls the autonomic dysfunction by
suppressing catecholamine release.
Nursing management
 High risk for airway obstruction due to spasms
 Impaired gas exchange
 Ineffective airway clearance
 Altered body temperature
 Alteration in nutrition less than body requirement
 High risk for altered elimination due to Fluid
retention due to inappropriate secretion of anti
diuretic hormone and Depression of gastro intestinal
motility
 High risk for infection transmission
 Prevention and control

• Encourage hospital deliveries (with adequate midwifery

services).
• Home deliveries should be done by trained TBA
• TBA should be trained:
 to use clean delivery Kits.
 Dai and mothers should be taught how to care for the
cord (should not apply any material on cord except
boiled water or spirit)
 Hand wash after every procedure (e.g. cord cleaning).
 Teach children about the risk factor of Tetanus (do not
walk bare foot).
 Wound Management & Tetanus
Prophylaxis

Source https://www.uptodate.com/contents/image?imageKey=PEDS%2F61087
TT vaccine
• Tetanus shot is needed every 10 years.
• The shot is needed with in 48 hours of exposure.

• Women can be given the tetanus vaccine during

pregnancy to prevent tetanus.

• The disease does not confer any significant

immunity and could be exposed again and all patients
should be actively immunized,
TT vaccine to pregnant mothers and CBA will prevent
Neonatal tetanus

• Diphtheria-tetanus-whole cell pertussis (DTP

• Diphtheria toxoid-acellular pertussis (Tdap)

• Diphtheria-tetanus toxoids adsorbed (DT)

• Tetanus toxoid (TT)

Tetanus toxoid Immunization Schedule for pregnant and
Childbearing Age women without previous exposure to TT,
Td or DTPa
Guidelines for tetanus toxoid immunization of
women who were immunized during infancy,
childhood or adolescence
 Agent

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