Though rare, but got chance to treat .

1. Tetanus : Case Presentation
Anupam Ghimire
GP/EM Resident
PAHS

2. Patient Details
Name: Motilal Tamang
Age/sex: 50yr/M
Address: Ramechap
Occupation : Farmer
Date of Admisson : 2075- 1- 15

3. Chief complain
• Cut Injury over Right leg 7 days back
HOPI
• Cut injury over Right calf region while he was
ploughing field, active bleed and muscles were
exposed
• Due to pain , he couldnot walk
• No swelling , injury to other areas

4. • At Local Health center, suturing was done . No
history of TT vaccination
• Pus discharge was present- yellowish , non
foul smelling
• Arrived in Hospital , kathmandu , suture was
removed and dressing done
• No history of fever, headache, Shortness of
breathe or altered bowel/bladder habits

5. • Past history – Not significant
• Family history – Not significant
• Personal history
- Consumes alcohol occassionally
- Non- smoker

6. Physical Examination
• GC : Fair
• No PILCCOD
• Vitals – Stable
• Systemic Examination : Grossly normal

7. Local examination
• Cut injury of 15x10 cm over left calf, vertically
oriented with sharp margin and yellowish non
foulsmelling discharge
• Brownish slough were present at margin of
wound
• Local temp. raised , Tender
• DNVS intact
• ROM : Painful on ankle movement

9. Investigation
• TLC : 22500
• N90L10
• Hb: 11.2
• Platelet: 560000
• RFT – Normal

10. Management
• Dressing and posterior slab application
• IV antibiotics , Analgesic
• Debridement
• On 3rd day :
- Stifness of neck muscles
- Unable to open mouth

11. • Tetanus Diagnosed  ICU admisson
• Managed with
- Minimised sensory stimulation
- Inj. HTIG 4000 I.U IM stat
- Inj. Durataz, Vancomycin , enoxaparin
- Intubated  diazepam, propofol infusion,
vecuronium
- Daily dressing and wound care

12. Introduction: Tetanus
• Tetanos – a greek word – to strech
• Neurological disease characterized by an acute
onset of hypertonia, painful muscular
contractions and generalized muscle spasms
• Only vaccine preventable disease that is
infectious but not contagious

13. • Caused by Clostridium Tetani
• Anaerobic, Motile, Gram positive bacilli
• Oval, colourless, terminal spores – tennis
racket or drumstick shape.
• It is found worldwide in soil, in inanimate
environment, in animal faeces & occasionally
human faeces.

14. Epidemiology
• International health problem, as spores are
ubiquitous.
• Occurs almost exclusively in persons who are
unvaccinated or inadequately immunized.
• Tetanus occurs worldwide but is more
common in hot, damp climates with soil rich
in organic matter

15. Risk Factors
• Age : Active age (5-40 years),
• Sex : Higher incidence in males
• Occupation : Agricultural workers are at higher
risk
• Immunity : Herd immunity does not protect
the individual
• Environmental and social factors: Unhygienic
habits, Unhygienic delivery practices

16. Tetanus prone wound
• A wound sustained more than 6 hr before
surgical treatment
• A wound sustained at any interval after injury
which is puncture type or shows much
devitalised tissue or is septic or is
contaminated with soil or manure

17. Pathogenesis
• Spores gain entry  persist in normal tissue
for months to years under anaerobic
conditions.
• When the oxygen levels in the surrounding
tissue is sufficiently low  the implanted C.
tetani spore then germinates into a new,
active vegetative cell  grows and multiplies
and produces tetanus toxin - tetanospasmin
and tetanolysin.

18. • Tetanolysin is not believed to be of any
significance in the clinical course of tetanus
• Tetanospasmin is a neurotoxin and causes the
clinical manifestations of tetanus

19. • Toxin migrates across the synapse  binds to
presynaptic nerve terminals  inhibits release
of certain inhibitory neurotransmitters
(glycine and gamma-amino butyric acid)
• Loss of inhibition of preganglionic sym
neurons – sympathetic hyperactivity

20. • Neurons, which release gammaaminobutyric
acid (GABA) and glycine, the major inhibitory
neurotransmitters, are particularly sensitive to
tetanospasmin, leading to failure of inhibition
of motor reflex responses to sensory
stimulation.

21. • Once the toxin becomes fixed to neurons, it
cannot be neutralized with antitoxin
• Recovery of nerve function from tetanus
toxins requires sprouting of new nerve
terminals and formation of new synapses.

22. Clinical Features
• IP : Ranges from 3-21 days
• In general the further the injury site is from
the central nervous system, the longer the
incubation period
• The shorter the incubation period, the higher
the chance of death

23. • Triad of muscle rigidity, spasms & autonomic
dysfunction
• Early symptoms are neck stiffness, sore throat
and poor mouth opening.
• Patients with generalized tetanus present with
trismus (ie, lockjaw) in 75% of cases.
• Other presenting complaints include stiffness,
neck rigidity, dysphagia, restlessness, and reflex
spasms.
• Spasms usually continue for 3-4 weeks.

24. • Subsequently, muscle rigidity becomes the
major manifestation. Rigid Abdomen.
• Muscle rigidity spreads in a descending
pattern from the jaw and facial muscles over
the next 24-48 hours to the extensor muscles
of the limbs – stiff proximal limb muscles &
relatively sparing hand & feet.

25. • Risus sardonicus: Sustained contraction of
facial musculature at the angle of mouth and
frontalis
• Trismus (Lock Jaw): Spasm of Masseter
muscles
• Opisthotonus: Spasm of extensor of the neck,
back and legs to form a backward curvature

26. Sequence of events

27. Diagnosis
• No blood tests that can be used to diagnose
tetanus
• Diagnosis is done clinically
• Laboratory studies may demonstrate a moderate
peripheral leukocytosis
• Cerebrospinal fluid (CSF) study findings are
usually within normal limits.

28. Principle of treatment
1. Neutralization of unbound toxin
2. Prevention of further toxin production
- Wound debridement & antibiotics
3. Antibiotics
4. Control of spasm
- Anticonvulsants, Sedatives, Muscle relaxants
5. Management of autonomic dysfunction
- MgSO4, Betablockers
6. Supportive care
- Physiotherapy, Nutrition, Thromboembolism
prophylaxis

29. Management
• Admit patients to the intensive care unit (ICU).
• Because of the risk of reflex spasms, maintain
a dark and quiet environment for the patient.
• Avoid unnecessary procedures and
manipulations.
• Attempting endotracheal intubation may
induce severe reflex laryngospasm; prepare
for emergency tracheostomy

30. Immunogloulin
• A single intramuscular dose of 3000-5000
units is generally recommended for children
and adults, with part of the dose infiltrated
around the wound if it can be identified.
• The WHO recommends TIG 500 units by IM/IV
(depending on the available preparation) as
soon as possible; in addition, administer TT-
containing vaccine , 0.5 cc by intramuscular
injection at separate site with HTIG.

31. • TIG can only help remove unbound tetanus
toxin, but it cannot affect toxin bound to
nerve endings.

32. Prevention of further toxin production
• Debridement of Wound to remove organisms
and to create an aerobic environment
• Current recommendation is to excise at least 2
cm of normal viable-appearing tissue around
the wound margins
• Incise and drain abscesses.

33. Antibiotics
• Penicillin G aqueous : (10-12 MU IV in 2-4
divided doses- 2-4 MU IV every 4 to 6 hrs)
- 10- to 14-d course of treatment is
recommended
• Metronidazole: (5oomg 6 hrly or 1gm 12 hrly)

34. Summary
• Tetanus : Vaccine preventable
• Diagnosis clinically
• High index of suspicion
• Significant mortality and morbidity

35. • Harrison’s PRINCIPLES OF INTERNAL MEDICINE
: Eighteenth Edition
• UpToDate (http://www.uptodate.com)
• Current recommendations for treatment of
tetanus during humanitarian emergencies :
WHO Technical note

36. THANK YOU