TETANUSTETANUSDr. Ankita PatelSecond year resident,Medical Unit - 1G.M.C , Surat.www.medicalgeek.com
TETANUS INTRODUCTION CAUSATIVE AGENT EPIDEMIOLOGY TRANSMISSION, HOST FACTORS, ROUTE OFENTRY MECHANISM OF ACTION OF TO...
INTRODUCTION Tetanos – a greek word – to strech First described by Hippocrates & Susruta Tetanus an neurological diseas...
CAUSATIVE AGENT Caused by CLOSTRIDIUM TETANI Anaerobic Motile Gram positive bacilli Oval, colourless, terminal spores...
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Clostridium tetani Gram StainNOTE: Round terminal spores give cells a“drumstick” or “tennis racket” appearance.www.medical...
EPIDEMIOLOGY Tetanus is an international health problem, as sporesare ubiquitous. The disease occurs almost exclusivelyin...
IndiaTetanus is important endemic infection in India.Causative factorsHand washingDelivery practicesTraditional birth cust...
TRANSMISSION :www.medicalgeek.com
Host Factors Age : It is the disease of active age (5-40 years),New born baby, female during delivery orabortion Sex : H...
ROUTE OF ENTRY Apparently trivial injuries Animal bites/human bites Open fractures Burns Gangrene In neonates usuall...
TETANUS PRONE WOUND A wound sustained more than 6 hr beforesurgical treatment. A wound sustained at any interval after i...
Sporulated Vegetative• Spores that gain entry can persist in normal tissue for months toyears under anaerobic conditions.•...
• The toxin migrates across the synapse (small spacebetween nerve cells critical for transmission of signalsamong nerve ce...
 This results in generalized contractions of the agonist andantagonist musculature characteristic of a tetanic spasm. Th...
Mechanism of Action of Tetanus Toxinwww.medicalgeek.com
1. C. tetani entersbody from throughwound.3. Germinates underanaerobic conditions andbegins to multiply andproduce tetnosp...
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 Spores are extremely stable,althoughimmersion in boiling water for 15 minuteskills most spores. Exposure to saturated st...
CLINICAL FEATURES: IP : Time from injury to the first symptom.The medianincubation period is 7 days, and, for most cases ...
 Triad of muscle rigidity, spasms &autonomic dysfunction Early symptoms are neck stiffness, sore throatand poor mouth op...
TRISMUSwww.medicalgeek.com
 Risus sardonicus: Sustained contraction offacial musculature produces a sneering grinexpression known as risus sardonicu...
RISUS SARDONICUSwww.medicalgeek.com
Opisthotonos in Tetanus PatientThe contractions by the muscles of the back and extremities may becomeso violent and strong...
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 Dysphagia occurs in moderately severe tetanus due topharyngeal muscle spasms, and onset is usuallyinsidious over several...
AUTONOMIC DYSFUNCTION Tetanospasmin has a disinhibitory effect on theautonomic nervous system (ANS) due toincreased relea...
Other symptoms include: Drooling Fever usually absent Mentation unimpaired Hand or foot spasms Irritability Uncontro...
SEQUENCE OF EVENTSLock JawStiff NeckDifficulty SwallowingMuscle RigiditySpasmswww.medicalgeek.com
THANK YOUwww.medicalgeek.com
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TYPES OF TETANUS Generalied vs Local Cephalic Traumatic Otogenic Idiopathic Puerperal Tetanus neonatorumwww.medical...
Maternal tetanus•Tetanus occurring during pregnancy or within 6 weeksafter any type of pregnancy termination, is one of th...
NEONATAL TETANUS Tetanus neonatorum (8thday disease) Usually fatal if untreated Children born to inadequately immunized...
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LOCAL TETANUS Uncommon form Manifestations are restricted to muscles near thewound. Cramping and twisting in skeletal m...
CEPHALIC TETANUS A rare form of local tetanus Follows head injury / ear infection Involves one / more facial cranial ne...
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Ophthalmoplegic tetanus is a variant thatdevelops after penetrating eye injuries and resultsin CN III palsies and ptosis.w...
DIAGNOSIS There are currently no blood tests that can beused to diagnose tetanus. Diagnosis is doneclinically based on th...
DIRECT SMEAR Show Gram-positivebacilli with drum-stickappearance. Morphologicallyindistinguishable fromsimilar nonpathog...
CULTURE Done in blood agar under anaerobiccondition or in Robertson’s cooked meatmedium. Produces swarming growth after ...
ANIMAL INOCULATION To demonstratetoxigenicity. Positive case : test animaldevelops stiffness & spasmof tail & inoculated...
 Procedures: The spatula test is one diagnostic bedsidetest. This simple test involves touching theoropharynx with a sp...
 Drug induced Dystonic Reactions e.g. Phenothiazines Strychnine poisoning Neuroleptic Malignant Syndrome, Serotonin syn...
PRINCIPLE OF TREATMENT1. Neutralization of unbound toxin-HTIG/ATS2. Prevention of further toxin production-Wound debrideme...
PRINCIPLE OF TREATMENT Admit patients to the intensive care unit (ICU). Because of the risk of reflex spasms, maintain a...
TOXIN• A single intramuscular dose of 3000-5000 units(100U/kg-half in each buttocks) is generallyrecommended for children ...
2. PREVENTION OF FURTHER TOXINPRODUCTION• Debridement of Wound to remove organisms andto create an aerobic environment.• T...
3. ANTIBIOTICS Theoretically, antibiotics may preventmultiplication of C tetani, thus haltingproduction of toxin. Penicil...
 4. Control of spasm- Nursing in quiet environment, avoid unnecessarystimuli, Protecting the airway.- Drugs used to treat...
 Diazepam reduces anxiety, produces sedation, andrelaxes muscles. Lorazepam is an effective alternative.Large amounts of ...
Skeletal muscle relaxants: These agents can inhibit both monosynaptic andpolysynaptic reflexes at spinal level, possibly ...
BACLOFEN Intrathecal (IT) baclofen, a centrally actingmuscle relaxant, has been used experimentallyto wean patients off t...
DRIP RATE OF COMMON DRUGS Diazepam 1 Amp. = 2 ml = 10 mg ( 5 mg / ml ) 5Amp in 50cc (40+10) NS – 50mg/50ml = 1mg/ml Usu...
 Atracurium 1 Amp. = 2.5 ml = 25 mg ( 10 mg / ml) 8Amp in 500cc NS/5%DW = 0.4mg/ml = 200mg 1 Amp (0.5mg/kg=25mg) IV sta...
 Vecuronium 1 Vial  = 4 mg to be reconstitutedwith 2 ml of sterile water = (2 mg / ml) 5 vial in 50 cc NS/5%DW = 20mg = ...
METHOCARBAMOL (ROBINAX) May be used as adjunct but not much useful intetanus. Skeletal muscle relaxant 100mg/ml , 10ml/...
5. MANAGEMENT OF AUTONOMICDYSFUNCTION:Fluid loading is a useful in minimizing autonomicinstability.Magnesium Sulphte:It i...
 If infusion devices are unavailable , give 2.5gm i.v.every 2 hours , titrating the frequency ofadministration to spasms....
6. SUPPORTIVE CARE:www.medicalgeek.com
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PREVENTION Tetanus is completely preventableby active tetanus immunization. Immunization is thought to provideprotection...
 1stdose - 6thweek (DPT) 2nddose - 10thweek (DPT) 3rddose - 14thweek (DPT) 1stbooster - 18thmonth (DPT) 2ndbooster - ...
MONOVALENT VACCINES Purified tetanus toxoid ( adsorbed )supplanted the plain toxoid – higher &long lasting immunity respo...
 Older teenagers and adults who havesustained injuries, especially puncture-typewounds, should receive boosterimmunizatio...
POSTEXPOSURE PROPHYLAXIS: All wound receive surgical toiletWounds less then 6 hours other woundsOld , clean, non-penetrat...
 A - has had a complete course of toxoid orbooster dose with in the past 5 year B - has had a complete course of toxoid ...
PASSIVE IMMUNIZATION Temp protection – human tetanusimmunoglobulin /ATS Human Tetanus Hyperimmunoglobulin :• 250-500 IU•...
PASSIVE IMMUNIZATION ATS ( EQUINE ) :• 1500 IU s/c after sensitivity testing• 7 – 10 days• High risk of serum sickness• I...
ACTIVE & PASSIVEIMMUNIZATION In non immunized persons 1500 IU of ATS / 250-500 units of Human Ig inone arm & 0.5 ml of a...
PREVENTION OF NEONATALTETANUS Clean delivery practices 3 cleans : clean hands, clean delivery surface,clean cord care T...
REFERECES: Harrison’s PRINCIPLES OF INTERNAL MEDICINE :Eighteenth Edition Textbook of preventive & social medicine – Par...
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  • The bacterium was first isolated in 1899 by Kitasato while he was working with R. Koch in Germany. Kitasato also found the toxin responsible for tetanus and developed the first protective vaccine against the disease
  • Tetanospasmin binds to motor nerves that control muscles, enters the axons (filaments that extend from nerve cells), and travels in the axon until it reaches the body of the motor nerve in the spinal cord or brainstem (a process termed retrograde intraneuronal transport). Tetanospasmin that is released by the maturing bacilli is distributed via the lymphatic and vascular circulations to the end plates of all nerves.
  • Usually a puncture wound or laceration, nails Dead tissue Extremely potent neurotoxin Only creates small immune response so not enough antibodies for immunity and not usually any inflamation of the wound
  • DIFFERENTIAL DIAGNOSIS — The diagnosis of tetanus is usually obvious and can generally be made based upon typical clinical findings outlined above. Tetanus should especially be suspected when there is a history of an antecedent tetanus prone injury and a history of inadequate immunization for tetanus. However, tetanus can sometimes be confused with the following mimics: Drug-induced dystonias such as those due to phenothiazines — Drug-induced dystonias often produce pronounced deviation of the eyes, writhing movements of the head and neck and an absence of tonic muscular contraction between spasms. By contrast, tetanus does not produce eye deviations and the muscles are characteristic tonically contracted between spasms. Finally, administration of an anticholinergic agent such as benztropine mesylate will usually immediately reverse the spasms seen in drug-induced dystonias. Such therapy has no effect on patients with tetanus. Trismus due to dental infection — Dental infections may produce striking trismus that may rarely be confused with cephalic forms of tetanus. However, the presence of an obvious dental abscess and the lack of progression or superimposed spasms usually make the distinction between the two diseases apparent after initial evaluation and/or a period of observation. (See "Deep neck space infections" and "Complications, diagnosis, and treatment of odontogenic infections".) Strychnine poisoning due to ingestion of rat poison — Accidental or intentional strychnine poisoning may produce a clinical syndrome similar to tetanus. Supportive care for both conditions is critical; thus, the initial treatment of both conditions is identical. Assays of blood, urine, and tissue for strychnine can be performed in Tetanus special reference laboratories. Such tests should be obtained when there is any suspicion of accidental or intentional poisoning or when a typical history of an antecedent injury or infection for tetanus is lacking or the patient has been adequately immunized for tetanus. (See "Strychnine poisoning".) Malignant neuroleptic syndrome — Patients with malignant neuroleptic syndrome can present with striking symptoms of autonomic instability and muscular rigidity. However the presence of fever, altered mental status, and recent receipt of an agent with a propensity to cause this complication usually makes the distinction from tetanus relatively easy. (See "Neuroleptic malignant syndrome".) Stiff-person syndrome — Stiff-person syndrome (SPS) is a rare neurologic disorder characterized by severe muscle rigidity. Spasms of the trunk and limbs may be precipitated by voluntary movements, or auditory, tactile or emotional stimulation, all of which can also occur in tetanus. The absence of trismus or facial spasms and rapid response to diazepam distinguish SPS from true tetanic spasms [24]. In addition, SPS is associated with autoantibodies against glutamic acid decarboxylase. (See "Stiff-person syndrome".)
  • Penicillin G : I nterferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. GABA antagonist effect of penicillins and third-generation cephalosporins,which may lead to CNS excitability. Metronidazole : Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells, and intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
  • Can be achieved by active immunization by tetanus toxoid (5 doses – 0 day, 1 month, 6 month, 1 year, 10 year).
  • Tetanus Presentation

    1. 1. TETANUSTETANUSDr. Ankita PatelSecond year resident,Medical Unit - 1G.M.C , Surat.www.medicalgeek.com
    2. 2. TETANUS INTRODUCTION CAUSATIVE AGENT EPIDEMIOLOGY TRANSMISSION, HOST FACTORS, ROUTE OFENTRY MECHANISM OF ACTION OF TOXIN CLINICAL FEATURES TYPES OF TETANUS DIAGNOSIS DIFFERENTIAL DIAGNOSIS TREATMENT PREVENTION – ACTIVE & PASSIVE IMMUNIZATIONwww.medicalgeek.com
    3. 3. INTRODUCTION Tetanos – a greek word – to strech First described by Hippocrates & Susruta Tetanus an neurological disease characterized byan acute onset of hypertonia, painful muscularcontractions (usually of the muscles of the jawand neck), and generalized muscle spasmswithout other apparent medical causes. Only vaccine preventable disease that isinfectious but not contagiouswww.medicalgeek.com
    4. 4. CAUSATIVE AGENT Caused by CLOSTRIDIUM TETANI Anaerobic Motile Gram positive bacilli Oval, colourless, terminal spores – tennis racketor drumstick shape. It is found worldwide in soil, in inanimateenvironment, in animal faeces & occasionallyhuman faeces.www.medicalgeek.com
    5. 5. www.medicalgeek.com
    6. 6. Clostridium tetani Gram StainNOTE: Round terminal spores give cells a“drumstick” or “tennis racket” appearance.www.medicalgeek.com
    7. 7. EPIDEMIOLOGY Tetanus is an international health problem, as sporesare ubiquitous. The disease occurs almost exclusivelyin persons who are unvaccinated or inadequatelyimmunized. Entirely preventable disease by immunization Tetanus occurs worldwide but is more common in hot,damp climates with soil rich in organic matter. More common in developing and under developingcountries. More prevalent in industrial establishment, whereagricultural workers are employed. Tetanus neonatorum is common due to lack of MCHcare.www.medicalgeek.com
    8. 8. IndiaTetanus is important endemic infection in India.Causative factorsHand washingDelivery practicesTraditional birth customsInterest in immunizationPrior to the national immunization programme estimated3.5 lakh children were dying annually. 70,000 casescontinue to occur largely in the states – Orissa, Bihar,MP, Aasam, Rajasthan, UP ,where TT immunizationcoverage is less than national coverage(70%) .www.medicalgeek.com
    9. 9. TRANSMISSION :www.medicalgeek.com
    10. 10. Host Factors Age : It is the disease of active age (5-40 years),New born baby, female during delivery orabortion Sex : Higher incidence in males than females Occupation : Agricultural workers are at higherrisk Rural –Urban difference: Incidence of tetanus inurban areas is much lower than in rural areas Immunity : Herd immunity does not protect theindividual Environmental and social factors: Unhygieniccustom habits,Unhygienic delivery practiceswww.medicalgeek.com
    11. 11. ROUTE OF ENTRY Apparently trivial injuries Animal bites/human bites Open fractures Burns Gangrene In neonates usually via infected umbilical stumps Abscess Parenteral drug abusewww.medicalgeek.com
    12. 12. TETANUS PRONE WOUND A wound sustained more than 6 hr beforesurgical treatment. A wound sustained at any interval after injurywhich is puncture type or shows muchdevitalised tissue or is septic or is contaminatedwith soil or manure.www.medicalgeek.com
    13. 13. Sporulated Vegetative• Spores that gain entry can persist in normal tissue for months toyears under anaerobic conditions.• When the oxygen levels in the surrounding tissue is sufficientlylow, the implanted C. tetani spore then germinates into a new, activevegetative cell that grows and multiplies and most importantlyproduces tetanus toxin - tetanospasmin and tetanolysin.• Tetanolysin is not believed to be of any significance in the clinicalcourse of tetanus.•Tetanospasmin is a neurotoxin and causes the clinicalmanifestations of tetanus.www.medicalgeek.com
    14. 14. • The toxin migrates across the synapse (small spacebetween nerve cells critical for transmission of signalsamong nerve cells) where it binds to presynaptic nerveterminals and inhibits or stops the release of certaininhibitory neurotransmitters (glycine and gamma-aminobutyric acid).• Loss of inhibition of preganglionic sym neurons –sympathetic hyperactivity• These neurons become incapable to releaseneurotransmitter. The neurons, which release gamma-aminobutyric acid (GABA) and glycine, the majorinhibitory neurotransmitters, are particularlysensitive to tetanospasmin, leading to failure ofinhibition of motor reflex responses to sensorystimulation.www.medicalgeek.com
    15. 15.  This results in generalized contractions of the agonist andantagonist musculature characteristic of a tetanic spasm. The shortest peripheral nerves are the first to deliverthe toxin to the CNS, which leads to the early symptoms offacial distortion and back and neck stiffness. Once the toxin becomes fixed to neurons, it cannot beneutralized with antitoxin. Recovery of nerve function fromtetanus toxins requires sprouting of new nerve terminals andformation of new synapses.www.medicalgeek.com
    16. 16. Mechanism of Action of Tetanus Toxinwww.medicalgeek.com
    17. 17. 1. C. tetani entersbody from throughwound.3. Germinates underanaerobic conditions andbegins to multiply andproduce tetnospasmin.2. Stays in sporulatedform until anaerobicconditions arepresented.4. Tetnospasmin spreadsusing blood and lymphaticsystem, and binds to motorneurons.5. Travels along theaxons to the spinal cord.6. Binds to sites responsiblefor inhibiting skeletalmuscle contraction.www.medicalgeek.com
    18. 18. www.medicalgeek.com
    19. 19.  Spores are extremely stable,althoughimmersion in boiling water for 15 minuteskills most spores. Exposure to saturated steamunder 15 lbs.of pressure for 15-20 minutes at121°c is highly effective against spores . Sterilization by dry heat is slower than bymoist heat (1 -3 hrs at 160 °C),but it is alsoeffective against spores. Ethylene oxide sterilization is also sporocidal. Autoclaving at 121°C for 15min kills the sporesreadily. Iodine(1% aqueous soon) and H2O2 (10 volume)kills spores within few hours.www.medicalgeek.com
    20. 20. CLINICAL FEATURES: IP : Time from injury to the first symptom.The medianincubation period is 7 days, and, for most cases (73%),incubation ranges from 3-21 days. Period of onset : It is the time from first symptoms tothe reflex spasm. In general the further the injury site is from thecentral nervous system, the longer the incubationperiod. The shorter the incubation period, the higher thechance of death.www.medicalgeek.com
    21. 21.  Triad of muscle rigidity, spasms &autonomic dysfunction Early symptoms are neck stiffness, sore throatand poor mouth opening. Patients with generalized tetanus present withtrismus (ie, lockjaw) in 75% of cases. Other presenting complaints include stiffness,neck rigidity, dysphagia, restlessness, and reflexspasms. Spasms usually continue for 3-4weeks. Subsequently, muscle rigidity becomes the majormanifestation. Rigid Abdomen. Muscle rigidity spreads in a descendingpattern from the jaw and facial muscles over thenext 24-48 hours to the extensor muscles of thelimbs – stiff proximal limb muscles & relativelysparing hand & feet.www.medicalgeek.com
    22. 22. TRISMUSwww.medicalgeek.com
    23. 23.  Risus sardonicus: Sustained contraction offacial musculature produces a sneering grinexpression known as risus sardonicus. Contraction of the muscles at the angle of mouthand frontalis Trismus (Lock Jaw): Spasm of Massetermuscles. Opisthotonus: Spasm of extensor of the neck,back and legs to form a backward curvature. Muscle spasticity Poor cough, inability to swallow, gastric stasisall increase the risk of aspiration. Respiratoryfailure continues to be a major cause ofmortality in developing countries, whereassevere autonomic dysfunction causes mostdeaths in the developed world.www.medicalgeek.com
    24. 24. RISUS SARDONICUSwww.medicalgeek.com
    25. 25. Opisthotonos in Tetanus PatientThe contractions by the muscles of the back and extremities may becomeso violent and strong that bone fractures may occurwww.medicalgeek.com
    26. 26. www.medicalgeek.com
    27. 27.  Dysphagia occurs in moderately severe tetanus due topharyngeal muscle spasms, and onset is usuallyinsidious over several days. Reflex spasms develop in most patients and can betriggered by minimal external stimuli such as noise,light, or touch. The spasms last seconds to minutes;become more intense; increase in frequency with diseaseprogression; and can cause apnea, fractures,dislocations, and rhabdomyolysis. Laryngeal spasms can occur at any time and canresult in asphyxia.www.medicalgeek.com
    28. 28. AUTONOMIC DYSFUNCTION Tetanospasmin has a disinhibitory effect on theautonomic nervous system (ANS) due toincreased release of catecholamines it causes : Hyperpyrexia Sweating Peripheral vasoconstriction Labile/Sustained Hypertension Episodic tachycardia, dysrhythmias and cardiacarrest Occasionally period of bradycardia & hypotensionwww.medicalgeek.com
    29. 29. Other symptoms include: Drooling Fever usually absent Mentation unimpaired Hand or foot spasms Irritability Uncontrolled urination or defecation Duration of illness — Tetanus toxin-induced effects are long-lasting becauserecovery requires the growth of new axonalnerve terminals. The usual duration of clinicaltetanus is four to six weeks.www.medicalgeek.com
    30. 30. SEQUENCE OF EVENTSLock JawStiff NeckDifficulty SwallowingMuscle RigiditySpasmswww.medicalgeek.com
    31. 31. THANK YOUwww.medicalgeek.com
    32. 32. www.medicalgeek.com
    33. 33. TYPES OF TETANUS Generalied vs Local Cephalic Traumatic Otogenic Idiopathic Puerperal Tetanus neonatorumwww.medicalgeek.com
    34. 34. Maternal tetanus•Tetanus occurring during pregnancy or within 6 weeksafter any type of pregnancy termination, is one of themost easily preventable causes of maternal mortality.•It includes postpartum or puerperal tetanus(i) postpartum or puerperal tetanus, usually resultingfrom septic procedures during delivery,(ii) postabortal tetanus, following septic maneuversduring induced abortion(iii) Tetanus during pregnancy, generally resulting frominoculation through a nongenital portal of entrywww.medicalgeek.com
    35. 35. NEONATAL TETANUS Tetanus neonatorum (8thday disease) Usually fatal if untreated Children born to inadequately immunizedmothers, after unsterile treatment of umbilicalstump During first 2 weeks of life. Poor feeding ,rigidity and spasms It is easily preventable by 2 tetanus toxoidinjections and ‘5 cleans’ while conductingdeliveries.www.medicalgeek.com
    36. 36. www.medicalgeek.com
    37. 37. www.medicalgeek.com
    38. 38. LOCAL TETANUS Uncommon form Manifestations are restricted to muscles near thewound. Cramping and twisting in skeletal musclessurrounding the wound – local rigidity Prognosis – excellentwww.medicalgeek.com
    39. 39. CEPHALIC TETANUS A rare form of local tetanus Follows head injury / ear infection Involves one / more facial cranial nerves Trismus and localised paralysis ,usuallyfacial nerve, often unilateral. Involvement of cranial nerves VI,III, IV, and XIImay also occur either alone or in combinationwith others Incubation period : few days Mortality : highwww.medicalgeek.com
    40. 40. www.medicalgeek.com
    41. 41. Ophthalmoplegic tetanus is a variant thatdevelops after penetrating eye injuries and resultsin CN III palsies and ptosis.www.medicalgeek.com
    42. 42. DIAGNOSIS There are currently no blood tests that can beused to diagnose tetanus. Diagnosis is doneclinically based on the presence of trismus,dysphagia, generalized muscular rigidity, and/orspasm. Laboratory studies may demonstrate a moderateperipheral leukocytosis. An assay for antitoxin levels is not readilyavailable. However, a level of 0.01 IU/mL orgreater in serum is generally consideredprotective, making the diagnosis of tetanus lesslikely. Cerebrospinal fluid (CSF) study findings areusually within normal limits.www.medicalgeek.com
    43. 43. DIRECT SMEAR Show Gram-positivebacilli with drum-stickappearance. Morphologicallyindistinguishable fromsimilar nonpathogenicbacilli.www.medicalgeek.com
    44. 44. CULTURE Done in blood agar under anaerobiccondition or in Robertson’s cooked meatmedium. Produces swarming growth after 1-2 daysof incubation. In contaminated specimen heat at 80°Cfor 10mins before culture to destroy non-sporing organisms.www.medicalgeek.com
    45. 45. ANIMAL INOCULATION To demonstratetoxigenicity. Positive case : test animaldevelops stiffness & spasmof tail & inoculated hindlimb within 12-24hrswhich spreads to rest ofthe body. Death occurs in1-2 days.www.medicalgeek.com
    46. 46.  Procedures: The spatula test is one diagnostic bedsidetest. This simple test involves touching theoropharynx with a spatula or tongue blade. This test typically elicits a gag reflex, and thepatient tries to expel the spatula (ie, a negativetest result). If tetanus is present, patients develop a reflexspasm of the masseters and bite the spatula (ie, apositive test result). Sensitivity of 94% and a specificity of 100%.[2] No adverse sequelae (eg, laryngeal spasm) fromthis procedure were reportedwww.medicalgeek.com
    47. 47.  Drug induced Dystonic Reactions e.g. Phenothiazines Strychnine poisoning Neuroleptic Malignant Syndrome, Serotonin syndrome Trismus d/t Peritonsillar Abscess/Dental infection Stiff person syndrome Acute abdominal emergencies Dislocations, Mandible Encephalitis, Meningitis Hysteria Hypocalcemia Rabies Seizure disorder (partial or generalized) Spider Envenomations, Widow Stroke, Hemorrhagic Stroke, ischemic (cephalic tetanus) Subarachnoid HemorrhageDIFFERENTIAL DIAGNOSISwww.medicalgeek.com
    48. 48. PRINCIPLE OF TREATMENT1. Neutralization of unbound toxin-HTIG/ATS2. Prevention of further toxin production-Wound debridement & antibiotics3. Antibiotics4. Control of spasm-Anticonvulsants, Sedatives, Muscle relaxants etc.5. Management of autonomic dysfunction-MGSO4, Betablockers etc.6. Supportive care-Physiotherapy, Nutrition, Thromboembolismprophylaxis ABC etc…www.medicalgeek.com
    49. 49. PRINCIPLE OF TREATMENT Admit patients to the intensive care unit (ICU). Because of the risk of reflex spasms, maintain adark and quiet environment for the patient.Avoid unnecessary procedures andmanipulations. Attempting endotracheal intubation may inducesevere reflex laryngospasm; prepare foremergency tracheostomy.  Seriously consider prophylactic tracheostomyin all patients with moderate-to-severe clinicalmanifestations. Intubation and ventilation arerequired in 67% of patients. Tracheostomy has also been recommended afteronset of the first generalized seizure.www.medicalgeek.com
    50. 50. TOXIN• A single intramuscular dose of 3000-5000 units(100U/kg-half in each buttocks) is generallyrecommended for children and adults, with part ofthe dose infiltrated around the wound if it can beidentified.• The WHO recommends TIG 500 units by IM/IV(depending on the available preparation) as soon aspossible; in addition, administer age-appropriateTT-containing vaccine (Td, Tdap, DT, DPT, DTaP, orTT depending on age or allergies), 0.5 cc byintramuscular injection at separate site with HTIG.• TIG can only help remove unbound tetanustoxin, but it cannot affect toxin bound to nerveendings.• 250 U/vial available in our hospital, so 10 vial ineach buttock is usual dose.www.medicalgeek.com
    51. 51. 2. PREVENTION OF FURTHER TOXINPRODUCTION• Debridement of Wound to remove organisms andto create an aerobic environment.• The current recommendation is to excise at least2 cm of normal viable-appearing tissue aroundthe wound margins.• Incise and drain abscesses.• Delay any wound manipulation until severalhours after administration of antitoxin due torisk of releasing tetanospasmin into thebloodstream.www.medicalgeek.com
    52. 52. 3. ANTIBIOTICS Theoretically, antibiotics may preventmultiplication of C tetani, thus haltingproduction of toxin. Penicillin G was the drug ofchoice initially but now Metronidazole ispreffered drug. Penicillin G aqueous : (10-12 MU IV in 2-4divided doses- 2-4 MU IV every 4 to 6 hrs) A 10- to 14-d course of treatment is recommended Metronidazole: (5oomg 6 hrly or 1gm 12hrly) A 10- to 14-d course of treatment is recommended. Someconsider this the DOC since penicillin G is also a GABAagonist, which may enhance effects of the toxin. Doxycycline, Clindamycin and Erythromycin arealternative for penicillin allergic patients who can nottolerate metronidazole.www.medicalgeek.com
    53. 53.  4. Control of spasm- Nursing in quiet environment, avoid unnecessarystimuli, Protecting the airway.- Drugs used to treat muscle spasm, rigidity, andtetanic seizures include sedative-hypnotic agents,general anesthetics, centrally acting musclerelaxants, and neuromuscular blocking agents.- Anticonvulsants- Sedative-hypnotic agents are the mainstays of tetanustreatment. Benzodiazepines are the most effective primaryagents for muscle spasm prevention and work by enhancingGABA inhibition. Diazepam : Mainstay of treatment of tetanic spasms and tetanicseizures. Depresses all levels of CNS, including limbic andreticular formation, possibly by increasing activity ofGABA, a major inhibitory neurotransmitter.www.medicalgeek.com
    54. 54.  Diazepam reduces anxiety, produces sedation, andrelaxes muscles. Lorazepam is an effective alternative.Large amounts of either may be required (up to 600mg/d). Diazepam or Midazolam can be used as 5-10mg iv/imevery 1-4 hrly. Midazolam can be given as an intravenous infusion (5-15 mg/hr). Phenobarbitone (up to 200 mg IV or PO/NG 12-hourly),and phenothiazines (usually chlorpromazine-25mg/ml,100mg IM f/b 50-100mg 12hrly) may be added as anadjunctive sedative. Propofol, dantrolene, intrathecal baclofen,succinylcholine & magnesium sulfate can be triedwww.medicalgeek.com
    55. 55. Skeletal muscle relaxants: These agents can inhibit both monosynaptic andpolysynaptic reflexes at spinal level, possibly byhyperpolarization of afferent terminals. Muscle relaxation is indicated where sedation aloneis inadequate. Vecuronium (0.1 mg/kg IV as needed)or atracurium (0.5 mg/kg IV) are appropriate. Pancuronium may worsen autonomic instability byinhibiting catecholamine reuptake. Prolonged usage of aminosteroid muscle relaxants hasbeen associated with critical illness neuropathy andmyopathy.www.medicalgeek.com
    56. 56. BACLOFEN Intrathecal (IT) baclofen, a centrally actingmuscle relaxant, has been used experimentallyto wean patients off the ventilator and to stopdiazepam infusion. IT baclofen is more potentthan PO baclofen. May induce hyperpolarization of afferentterminals and inhibit both monosynaptic andpolysynaptic reflexes at spinal level. Entire dose of baclofen is administered as a bolusinjection. Dose may be repeated after 12 h ormore if spontaneous paroxysms return. It can also be given as T. Baclofen 5mg tds,increase 5mg/day every 3 days,maximumdose 80mgwww.medicalgeek.com
    57. 57. DRIP RATE OF COMMON DRUGS Diazepam 1 Amp. = 2 ml = 10 mg ( 5 mg / ml ) 5Amp in 50cc (40+10) NS – 50mg/50ml = 1mg/ml Usually needed 5-10ml/hr (10ml/hr=240mg/hr),may need even more than that. Ideally not given by continuous infusion becauseof precipitation in IV fluids & absorption of druginto infusion bags & tubing. Usually 10-40mgevery 1-8 hours needed. Midazolam  1 vial = 5 ml =  5 mg ( 1 mg / ml) 10 vial = 50cc @ 5ml/hr (=5mg/hr) Usually 5-15mg/hr (5-15ml/hr) neededwww.medicalgeek.com
    58. 58.  Atracurium 1 Amp. = 2.5 ml = 25 mg ( 10 mg / ml) 8Amp in 500cc NS/5%DW = 0.4mg/ml = 200mg 1 Amp (0.5mg/kg=25mg) IV stat f/b 5-10 µg/kg/min=0.25-0.5 mg/min = 15-30 mg/hr = 37.5-75ml/hr Maintainance dose : 11-13 µg/kg/min For infusion pump in 50cc, divide drip rate by 10.www.medicalgeek.com
    59. 59.  Vecuronium 1 Vial  = 4 mg to be reconstitutedwith 2 ml of sterile water = (2 mg / ml) 5 vial in 50 cc NS/5%DW = 20mg = 0.4mg/ml 0.1mg/kg bolus = 5mg = 2.5 ml f/b 0.8 -1.7µg/kg/min (1 µg/kg/min = 50µg/min = 3mg/hr =7.5 ml/hr Maintainance dose : 0.8 – 1.2 µg/kg/minwww.medicalgeek.com
    60. 60. METHOCARBAMOL (ROBINAX) May be used as adjunct but not much useful intetanus. Skeletal muscle relaxant 100mg/ml , 10ml/vial – total 1gm/vial Tablet : 500/750mg IV : 1-2gm direct IV injection (at 3ml/min =300mg/min). Additional 1-2gm IV infusion fortotal dose of 3gm initially.May repeat 1-2 gm IVevery 6 hourly untill can give TRT/PO. Injectionshould not be used for more than 3 consecutivedays. Total oral daily dose upto 24gm may beneded. Oral : 1.5-2.0 gm QID for 48-72 hrs, thendecrease to 1 gm every 6 hr, <8gm/daywww.medicalgeek.com
    61. 61. 5. MANAGEMENT OF AUTONOMICDYSFUNCTION:Fluid loading is a useful in minimizing autonomicinstability.Magnesium Sulphte:It is an effective adjunct in relaxation , sedation &controlling the autonomic disturbance in tetanus.It is a pre-syneptic neuromuscular blocker, reducescatecholemine release from nerves & adrenal medulla;and reduces responciveness to released catechlemines.A loading dose of 5gm should be given over 20minutes, followed by intravenous infusion of 2gm/hr. thedose can be incresed by upto 0.5g/hr until spasms arerelieved or the patellar reflex disappears.www.medicalgeek.com
    62. 62.  If infusion devices are unavailable , give 2.5gm i.v.every 2 hours , titrating the frequency ofadministration to spasms. To avoid overdose, monitor patellar reflex asareflexia(absence of patellar reflex) occurs at the upperend of the therapeutic range (4mmol/L). If areflexiadevelops, dose should be decreased. By antagonizing the calcium metabolism MgSO4causes weakness & paralysis in overdose. Monitoring ofserum magnesium level is important to prevent this:the normal serum magnesium level is 0.7- 1.0 mmol/l &acceptable therapeutic level is 2-3.5 mmol/l. Another drugs: Labetalol Continuous infusion of esmolol Clonidine / verapamil Morphinewww.medicalgeek.com
    63. 63. 6. SUPPORTIVE CARE:www.medicalgeek.com
    64. 64. www.medicalgeek.com
    65. 65. PREVENTION Tetanus is completely preventableby active tetanus immunization. Immunization is thought to provideprotection for 10 years. Begins in infancy with the DTPseries of shots. The DTP vaccine isa "3-in-1" vaccine that protectsagainst diphtheria, pertussis, andtetanus.www.medicalgeek.com
    66. 66.  1stdose - 6thweek (DPT) 2nddose - 10thweek (DPT) 3rddose - 14thweek (DPT) 1stbooster - 18thmonth (DPT) 2ndbooster - 6thyear (DT) 3rdbooster - 10thyear (TT)ACTIVEIMMUNIZATIONwww.medicalgeek.com
    67. 67. MONOVALENT VACCINES Purified tetanus toxoid ( adsorbed )supplanted the plain toxoid – higher &long lasting immunity response Primary course of immunization – 3 doses Each 0.5 ml , injected into arm given atintervals of 0,1,6 months The longer the interval b/w two doses,better is the immune response Booster doses : After 1 yr f/b Every 10 yrswww.medicalgeek.com
    68. 68.  Older teenagers and adults who havesustained injuries, especially puncture-typewounds, should receive boosterimmunization for tetanus if more than 10years have passed since the last booster. Recovered clinical tetanus does notproduce immunity to further attacksbecause very small amount of tetanus toxinproduced can not elicit strong protectiveimmune response.Therefore, even afterrecovery patients must receive a full courseof tetanus toxoid.www.medicalgeek.com
    69. 69. POSTEXPOSURE PROPHYLAXIS: All wound receive surgical toiletWounds less then 6 hours other woundsOld , clean, non-penetrating,& with negligible tissue damageimmunity treatment immunity treatmentcategory categoryA nothing more required A nothing morerequiredB toxoid 1 dose B toxoid 1 doseC toxoid 1 dose C toxoid 1 dose +D toxoid complete course human tetanus Ig.D toxoid completecourse +human tetanus Igwww.medicalgeek.com
    70. 70.  A - has had a complete course of toxoid orbooster dose with in the past 5 year B - has had a complete course of toxoid or boosterdose more then 5 years ago & less then 10 yearsago C - has had a complete course of toxoid or abooster dose more then 10 year ago D - has not had a complete course of toxoid orimmunity status unknownwww.medicalgeek.com
    71. 71. PASSIVE IMMUNIZATION Temp protection – human tetanusimmunoglobulin /ATS Human Tetanus Hyperimmunoglobulin :• 250-500 IU• Produces protective antibody level for atleast 4-6weeks.• Does not cause serum sickness• Longer passive protection compared to horseATS( 30 days / 7 -10 days )www.medicalgeek.com
    72. 72. 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 , hencea person who has once received ATS tends torapidly eliminate subsequent doses.www.medicalgeek.com
    73. 73. ACTIVE & PASSIVEIMMUNIZATION In non immunized persons 1500 IU of ATS / 250-500 units of Human Ig inone arm & 0.5 ml of adsorbed tetanus toxoid intoother arm /gluteal region 6 wks later, 0.5 ml of tetanus toxoid 1 yr later , 0.5 ml of tetanus toxoidwww.medicalgeek.com
    74. 74. PREVENTION OF NEONATALTETANUS Clean delivery practices 3 cleans : clean hands, clean delivery surface,clean cord care Tetanus toxoid protects both mother & child Unimmunized pregnant women : 2 doses tetanustoxoid (16th-36thweek)• 1stdose as early as possible during pregnancy• 2nddose – at least a month later / 3 wks beforedelivery Immunized pregnant women : a booster issufficient No need of booster in every consecutivepregnancy To newborn of unimmunized mother, 500U HTIGwithin 6 hours of birth.www.medicalgeek.com
    75. 75. REFERECES: Harrison’s PRINCIPLES OF INTERNAL MEDICINE :Eighteenth Edition Textbook of preventive & social medicine – Park – 19thEdition UpToDate (http://www.uptodate.com) eMedicine (http://www.emedicine.com) Current recommendations for treatment of tetanusduring humanitarian emergencies : WHO TechnicalNote World Federation of Societies of Anaesthesiologists -WFSA CDC Article - Tetanuswww.medicalgeek.com
    76. 76. www.medicalgeek.com
    77. 77. www.medicalgeek.com

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