TETANUS AND TETANUS PROPHYLAXIS

1. Discuss Tetanus And Tetanus
Prophylaxis
By
Dr Salihi Abdulmalik
National Orthopaedic Hospital, Dala
16th February 2018

2.  Introduction
 Microbiology
 Types
 Pathogenesis
 Prophylaxis
 Management
 Prognosis
 Differential diagnosis
 Complications

3.  ‘Tetanos’, meaning “taut” or “rigid”
 An acute infection that is characterized by spasms of
skeletal muscles ,rigidity and convulsion due to exotoxins
released by Clostridium tetani
 Important cause of death worldwide
 High mortality rate
15% in best of centers
50-60%
 1 million deaths worldwide 1992 (WHO)
 300 cases/year in South Africa

4. First described by Hippocrates
Etiology discovered in 1884 by Carle and Rattone
ATS used for treatment and prophylaxis during
World War I
TT first widely used during World War II

5.  Clostridium tetani is an anaerobic gram-positive, spore
forming bacteria
 Spores found in soil, dust, animal faeces, may persist for
months to years
 Clostridium tetani produces 2 forms of exotoxins
Tetanospamin (lethal dose 2.5ng/kg)
Tetanolysin

6.  Generalized
 Localized
 Cephalic
 Neonatal

8.  Active immunization
 More effective
 Takes 2 to 3 months to become operational
 Passive immunization
 Less effective
 Immediately operational
 Can precipitate anaphylaxis

9.  Traditionally
0.5ml of toxoid stat, 6 weeks, 6 month and every 10 years
 Rapid method using alum-precipitated toxoid
1st, 4th and 7th day following injury to develop active immunity at 28th
day
 DPT (3 primary doses at 6, 10 and 14 weeks, 2 booster doses
at 15 months and 5 years)
 Pregnant women (stat, 1/12, 6/12, 1 yr or next pregnancy, 1
yr or next pregnancy
 Efficacy of 100%

10.  Human immunoglobulin
250 – 500IU stat
Protection for 4-6weeks
No serum sickness
 Equine immunoglobulin
1500 IU sat
Protection for 7-10 days
Test dose to prevent serum sickness
 Bovine immunoglobulin

11.  Fully immunized
 Had conventional doses, a booster dose every 10 years
with last dose being less than 5 years
 Partially immunized
 Completed toxoid with last booster dose greater 5 but less
than 10years
Unimmunized
 No immunization
 Can’t remember
 Last booster dose greater than 10 years

12.  Fully immunized + clean wound
 Nothing
 Fully immunized + dirty wound
 Debridement + antibiotics
 Partially immunized + clean wound
 Complete immunization
 Partially immunized + dirty wound
 Give TT and complete booster after + debridement +
antibiotics

13.  Unimmunized + clean wound
Give TT + and to complete immunization
 Unimmunized + dirty wound
Give TT and ATS
To complete TT dose
Wound debridement
Antibiotics

14.  Patient in shock
 Allergic reaction
To TT?, consider ATS
 In setting of moderate to severe acute illness
Differ vaccination

15.  Clinical emergency
 Multidisciplinary
Surgeons
Physicians
Anaesthesiologist
Nurses
 Best managed in ICU

16.  History of wound contamination
 Dysphagia, dysphonia
 Headache, delirium, sleeplessness
 Hesitancy in micturition, constipation
 Convulsion
 Can be triggered by touch, noise, light, movement

17.  Tetanus prone wounds
◦ Wound sustained in farm land
◦ Gunshot wound
◦ Wound contaminated with saliva (human or animal)
◦ Wound contaminated with faeces (human or animal)
◦ Wounds sustained in lakes or ponds

18.  Anxiousness, sweating
 Fixed and staring eyes
 Trismus
 Risus sardonicus
 Nuchal rigidity
 Spasm and rigidity of all muscles
 Opisthotonus/Orthotonus/
Emprosthotonus
 Fever, tachycardia
 Open injury
 Diagnosis is clinical

19.  Incubation period 6-10 days
 Onset period 3 days to 3 weeks
 Muscle rigidity and spasm 1st week
 Autonomic disturbance starts several days after spasm and
persist for 1-2 weeks
 Spasm reduces after 2-3 weeks

20.  Goals
 Neutralize toxins
 ATS
 Human Ig 500IU o.d X 6 days
 Equine Ig 15000 IU o.d X 10-12 days (after test dose)
 Prevent further toxin production by removing source of infection
 Antibiotics; Penicillin, Metronidazole, Erythromycin
 Wound debridement
 Controlling muscle spasms
 anticonvulsants
 Maintaining airway
 General supportive therapy

21.  Isolation
 Avoid noise, light
 IVF
 TPN
 Urethral catheterization
 NGT
 Regular suction of throat
 Oxygen
 Prevention of pressure sore

22.  Mild cases
 Tonic rigidity, spasms
 Sedation
 Seriously ill
 Tonic rigidity,spasms, swallowing difficulty, respiratory
infection
 Sedation, NG tube, IPPV
 Dangerously ill
 Major cyanotic convulsive attacks, respiratory failure

23.  Laryngospasm
 Fractures
 Hypertension
 Nosocomial infections
 Pulmonary embolism
 Aspiration
 Death

24.  High mortality
 Incubation period
 Onset period, if less than 48hours death is very likely
 Immune status of the patient
 Degree of wound contamination
 Entry point proximity to the brain
 Frequency of spasms
 Autonomic complication
 Neonate

25.  Trismus – dental, oral, tonsillar sepsis
 Strychnine poisoning
 Meningitis
 Convulsive disorder
 Torticolis
 Rabies

26.  A medical emergency
 Diagnosis is clinical
 Management is multidisciplinary and best done in ICU
 A very high mortality, hence the need for early diagnosis
and prompt treatment
 Tetanus prophylaxis has greatly reduced the incidence of
tetanus

28.  E. A. Badoe, E. Q. Archampong, J.T. da Rocha.Baja’s principles and
Practice of Surgery including pathology in the tropics, 5th ed. Dept.
of Surgery, University of Ghana Medical School: Repro India Ltd;
2015.p.17-20
 Sriram Bhat M, SRB’S Manual of Surgey, 4th ed., Department of
Surgery Kasturba Medical College Mangalore, Karnataka, India.
P49-52
 T. M. Cook, R.T Protheroe and J.M. Handel, Review Article, Tetanus:
a review of the literature, British Journal of Anaesthesia 87 (3):
p477-87 (2000)
 American Academy of Paediatric tetanus in pickering L,ed Red book
2003 26th edition 611-16