Tetanus

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Tetanus

  1. 1. TETANUS
  2. 2. TETANUS • Mainly classified as adult type & Neonatal Tetanus • Historically called as locked jaw • Acute spastic paralytic illness caused by tetanus toxin
  3. 3. ETIOLOGY • Clostridium tetani • Gram positive, sporing, motile obligate anaerobe • Spores tennis racket type • Tetanospasmin 2nd most powerful toxin after botulinum toxin
  4. 4. EPIDEMIOLOGY • Rare in developed countries • One of the leading cases of death in developing countries • Tetanus toxoid immunization decreased mortality • Mortality is 40-80% in disease
  5. 5. MODE OF TRANSMISSION • Wound contaminated by tetanus spores • Pin prick, Animal bite, intrauterine death , ear piercing tattooing , unsterile cutting of umbilical cord.
  6. 6. INCUBATION PERIOD • 6-10 days • lesser the incubation period more the mortality
  7. 7. TYPE OF TETANUS • Traumatic • Puerperal • Otogenic • Idiopathic • Tetanus neonatorum
  8. 8. TETANUS ( OLDER CHILDREN) CLINICAL FEATURES • Generalized tetanus, trismus is 1st sign • Headache, irritability, restlessness • Neck stiffness, locked jaw, dysphasia • Risus sardonicus face • Abdominal, lumbar, Hip muscles involved • Opisthotonous ( Bow like) in extension
  9. 9. TETANUS ( OLDER CHILDREN) CLINICAL FEATURES – Contd.. • Board like rigidity of abdomen • Touch sound light exacerbates seizures • Sensory system totally Normal • Consciousness well maintained • Urinary retention • Cephalic tetanus rare, involve bulbar musculature
  10. 10. DIAGNOSIS • Mainly clinical features are diagnostic • Proper history. Immunization status • Other tests are normal • Clostridium tetani can be isolated from wound only in 1/3rd cases
  11. 11. DIFFERENTIAL DIAGNOSIS • Para pharyngeal, Retropharyngeal abscess • Rabies • Hypocalcaemia • Strychnine poisoning • Acute encephalitis
  12. 12. TREATMENT Wound management • Washing, debridement of Necrotic material, foreign body removal Eradication of Cl. tetani • Penicillin, Metronidazole • Erythromycin, tetracycline in penicillin allergic patient
  13. 13. NEUTRALIZATION OF TETANUS TOXIN • Human anti tetanus immunoglobulin long T ½ 30 days allergy absent • Equine or horse ATS T ½ 10 days allergy present
  14. 14. CONTROL OF SEIZURES & RESPIRATION • Diazepam sedation with muscle relaxation • Midazolam, Magnesium sulphate • Baclofen, Dantrolene used for muscle relaxation • Neuromuscular blocking drugs, vecuronium, pancuronium can be used for generalized muscle paralysis needs assisted ventilation
  15. 15. INTENSIVE SUPPORTIVE CARE • Dark environment • Minimal sound & touch • Endotrachcal intubation may be required for assisted ventilation & to prevent aspiration • Cardio respiratory monitoring • Maintain airway • Maintain fluid, electrolyte, calorie requirement
  16. 16. COMPLICATION • Aspiration pneumonitis • Laryngeal spasm, apnea • Mouth, tongue laceration • Rhabdomyolysis, Myoglobinuria, renal failure • Spinal fracture
  17. 17. PREVENTION - ACTIVE IMMUNIZATION By tetanus toxoid • Protective level of antitoxin 0.01Iu /ml • Two types of vaccine available Combined vaccine- DPT • Routinely used in Universal immunization programme • Contain diphtheria toxoid tetanus toxoid, killed pertussis organism. Given in 5 doses
  18. 18. PREVENTION - ACTIVE IMMUNIZATION – Contd.. Monovalent vaccine- PTAP, APT • Purified, adsorbed TT • Stored at 4-100c. Only 2 doses given
  19. 19. PREVENTION - PASSIVE IMMUNIZATION Human tetanus hyper immunoglobulin • Best for prophylaxis • Gives protection for 30 days Equine anti tetanus serum • Protect for 8-10 days • Serum sickness, anaphylaxis, allergy common
  20. 20. PREVENTION - PASSIVE IMMUNIZATION – Contd.. Combined active & passive immunization • Human TIG on one arm & TT on other arm • Followed by one dose of TT after 6 weeks Antibiotic prophylaxis • Single dose IM Benzathine penicillin • 7 days erythromycin • Started within 6 hrs. of injury
  21. 21. TETANUS NEONATORUM • Also called as 8th day disease • Rare before 2 days & after 2 weeks • C/F:- Excessive cry, refusal to feed apathy, mouth slightly kept open due to pull of neck muscles • Opisthotonus in extension • Constipation, Apnea • Touch provoked seizure
  22. 22. IN INDIA DISTRICTS CLASSIFIED FOR NEONATAL TETANUS AS NT high risk • Rate > 1/1000 live birth • TT coverage < 70% • Attended deliveries < 50% NT Control • Rate < 1/1000 live birth • TT coverage >70% • Attended deliveries >50%
  23. 23. IN INDIA DISTRICTS CLASSIFIED FOR NEONATAL TETANUS AS – Contd.. NT Elimination • Rate < 0.1/1000 live birth • TT coverage > 90% • Attended deliveries >75% • NT is 2nd most common cause of death in vaccine preventable deaths after measles
  24. 24. TRANSMISSION • Unsterile cutting of cord • Applying cow dung on cord • Unclean delivery surface
  25. 25. TREATMENT SAME AS ADULT TETANUS • Antibiotic penicillin & Erythromycin • Diazepam sedation & muscle relaxation • Intensive supportive care • Avoid light, sound, touch
  26. 26. PREVENTION OF NT • Clean delivery practice • “5 cleans”- clean hands, clean delivery surface , clean cord, clean thread & clean blade • 2 dose of TT to un immunized mother between 16- 36 weeks of gestation • Minimum 4-6 weeks gap between 2 doses
  27. 27. PREVENTION OF NT – Contd.. Infant born to unimmunized mother Give human anti tetanus immunoglobulin within 6 hrs. of birth
  28. 28. PROGNOSIS • 40-80% mortality in diseased Good prognostic signs • Early diagnosis, long incubation period, absence of fever • Hypoxic brain injury can lead to cerebral palsy • Cephalic tetanus poor prognosis • Otogenic tetanus better prognosis
  29. 29. Thank you

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