1. د 0عادل رضيوي
Acute disease caused by clostridium tetani , which is a G +ve
bacillus , toxin producer , grows anaerobicaly on the site of
injury & secreting exotoxin tetano spasmin (neuro toxin) that
.cause the signs & symptoms of the disease
.Traumatic:- following injury due to wound contamination -1
.Puerperal:-tetanus following abortion-2
Otogenic:-tetanus introduced through foreign bodies like -3
.pencils, match sticks…etc into the ear
Tetanus neonatorum:- commonest cause of infection is -4
through umbilical sepsis (applying cow dung on the cord
stump ,unsterilized blade for cutting umbilical cord …etc)the
symptoms usually start within 3-10days (on an average
7days) this is also known as the eighth day disease
progressive difficulty in sucking & excessive crying are
generally seen followed by difficulty in swallowing , the body
.becomes stiff & spasm develops
. Idiopathic :- no definite H /O any trauma elicited -5
-:Possible reasons could be
.a-Inhalation of tetanus spores
.b-Due to microscopic trauma
.c-Intestinal absorption of tetanus toxin

2. The secreted exotoxin (G+ve mostly secret exotoxins while
G-ve mostly secret endotoxin )→impulse →secretion of Ach in
neuromuscular junction →causes polarization(contraction of
the muscle ) of the muscle , when Ach accumulates in
synopsis→ production of Ach esterase →destruction of Ach→
.depolarization of muscle → relaxation
The exotoxin →inhibits Ach esterase →accumulation of Ach
→continuous contraction (polarization) which cause signs &
symptoms (primarily masseter muscle & neck muscle &
secondarily muscles of chest & abdomen →rigid abdomen
&extremities & in severe conditions generalized contraction
.((painful
First Sign locked jaw (contraction of masseter muscle) &it is
pathognomonic feature called Risus Sardoncous (which is the
.(contraction of the muscles of expression
Finally reflex spasm (generalized continuous severe
contraction of all muscles of the body due to any stimulus,
impulse& light (so keep the patient in dark room)
.→exhaustion or respiratory failure →death
-: The CFR is 10-90% (wide spectrum ) depend on
(.Length of incubation period (highest in the low I.P-1
. Severity of infection-2
(Age of the patient (highest in infants &elderly -3

3. Usually clinical, there is no laboratory investigation for
tetanus, the signs & . symptoms are obvious
The occurrence is world wide mostly in developing & under
developing with low sanitary measure & continuous contact
with excreta of animals , inadequate immunization of
.(population(especially in the tropical &rural areas
-
Mainly horses, man (or other animals) lives in intestine as
.(normal inhabitant (harmless
By spores (tetanus is spore formation microorganism) which is
very resistant to bad environmental conditions (so it is light &
resistant & can be transmitted easily) it sticks to vomits &
soil ,stick to the dirty wounds, burns & surgical wounds
(anaerobic area) so spores can be transmitted to distant
.areas
Necrosis -1
.Poor blood supply -2
.Dirt presence (foreign body) in wound-3
.(Bacterial infection (as it consumes oxygen-4
.Ca salts -5

4. Sometimes there is no history of wound (as a cause of
transmission ) & sometimes the circumcision . may be involved
days with range of 1-90 days mostly (21=3-4)
.(show itself after 14days (usually 10-14days
The shorter I.P. the more severe the disease is the
.higher the CFR & the poorer the prognosis
Tetanus is not communicable disease (there is no
(man to man transmission
.It is azeonotic disease
Education of population on the mode of -1
transmission & hazards of contaminated wounds
.so sacking hospital for treatment
Importance of vaccine, tetanus is prevented by -2
only 3doses of vaccine given as part of the triple
vaccine DPT (Diphtheria-Pertusis-Tetanus);I.M
.0.5ml/kg
a-2,4.6,18,60,of months 4-6 years preschool age
(primary doses while of the 60months represent
( the second Booster dose

5. b-Given to special people (high-risk group) those
work in sewage , soil policemen , those deal with
animals ,given not as a schedule. Better to be
repeated . every 10 years
c-Booster doses every 10years (the vaccine is good
.for ± 10years) not used to be given such as in Iraq
d-Immune compromised people should also receive
.vaccine
. Prophylaxis of wound management -3
-:It depend on
( a-General condition of wound (clean or not
b-Immune status of the wounded person because if
simple clean wound & ask the person if have
complete the doses of vaccine→ not given tetanus
toxoid, if dirty or deep wound or if patient is more
than 5 years from given a vaccine so we should
. give him vaccine
After 5 years of age the vaccine is given as
Td(tetanus & diphtheria but no pertusis) or
(TT(tetanus toxoid
No isolation is needed , no immunization of the -1
.contacts
Concentration on Rx of deep wound →wound -2
toilete & cleaning , whenever dirty wound→ clean

6. wound from foreign body & irrigate with
H2O2→high O2→ no anaerobic conditions ,
prevent or stop blood supply →wound
debridement (necrotic tissue remval by wound
excision )after that give antibiotics (penicillin 7-15
days) if sensitive to penicillin give Erythromycin or
metronidazole & muscle relaxant in severe spasm
like diazepam . or even curare
If suspect tetanus→antitoxin (Ig)as passive
-:immunity; Ig of two types
Human type 2- Bovine type -1
Bovine type may have hypersensitive reaction, so
there is sensitivity test as the serum from sensitized
animal. Test by 1ml of antitoxin diluted with
normal saline s 1:100 then injected intradermally in
one forearm & another normal saline injected to
the other forearm , if the wheel >3mm so it is
sensitive (we can do desensitivization by giving
small repeated doses increased gradually
recommended dose 3000-6000 I.U. (the antitoxin
.(will neutralize the circulating toxins
Locked jaw after tooth extraction problems, -1
(tersmus from meningitis (spasm of rack
.Rabies -2

7. Tetani (muscle contraction due to -3
(hypercalcemia
.Hysteria-4
(Catatonic schizophrenia (generalized spasm-5
Acute abdomen (rigidity when simulate -6
(appendicitis
Gullian-Berri syndrome of chest (paralysis of -7
(resp. muscle→ RF
(Strichen poisoning drug (stricken-8
It represents a big problem especially in
developing countries & rural areas(10% in best
(centers , in adequate child care
Mostly occur due to contamination of umbilical
cord of neonate during the process of delivery by
using dirty instruments or bad dressing or
coagulant substances used that put on the cord
(Kohil al-ain ,excreta of horses which are rich
.(media for tetanus
WHO estimates more than 500000 neonates die
annually due to tetanus neonatorum that number
is decreased due to vaccination of mothers during
pregnancy for safe neonates & pass the condition
.even if there is a dirty labor process

8. Are the same except there is no locked jaw or Risus
-: Sardonicus but there are
Whistling expression (due to contraction of all -1
. muscles of body ) & the body do not cry
(followed by convulsion & death in 90%)
Normal during the first 2-3 days after the third -2
day there is symptoms of cry, irritable & failure to
.suck
Not occur after the 30 days of life (only in the first
.(month of life
Improve maternal care &education of women -1
for safe clean delivery in hospital or well-trained
midwives if the hospital is not available or difficult
(to go to hospital (for asepsis
Immunization of the non-immunized women by -2
.tetanus toxoid
At 3-4th months of pregnancy (to prepare an -3
(immune fetus
1month after the first dose , after 6months of the
. second dose (after labour) immediately
Booster given 1year of the third dose
.1year after the forth dose
So this is the group of five doses when given fully
we can able the mother as child free of tetanus &

9. this will not be repeated for second pregnancy
.((enough for life
. Notification to CDC within days -1
Hospitalization to fever hospital with interntive -2
mortaring give I.V. fluid diluted diazepam O2
.suction
Epidemiological investigation including place -3
. delivery &individual responsible for labour
Swab taking from delivery wards &equipment -4
uses & send to the laboratory for bacteriological
.test
Vaccinated all women in area which witness the -5
.disease

10. this will not be repeated for second pregnancy
.((enough for life
. Notification to CDC within days -1
Hospitalization to fever hospital with interntive -2
mortaring give I.V. fluid diluted diazepam O2
.suction
Epidemiological investigation including place -3
. delivery &individual responsible for labour
Swab taking from delivery wards &equipment -4
uses & send to the laboratory for bacteriological
.test
Vaccinated all women in area which witness the -5
.disease