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TETANUS FINAL.pptx
- 2. OBJECTIVES At the end of presentation you will be able to learn • about tetanus • its causative organism • its Diagnosis • Pathophysiology of tetanus • Incubation period of tetanus • Clinical features and tetanus triad • Generalized tetanus & Localized tetanus and their features • Cephalic Tetanus • neonatal tetanus
- 3. • complications of tetanus • Classification of tetanus severity • Management of tetanus • Prevention of tetenus
- 4. SCENARIO • A 35 yr old female P1 with a history of SVD with episiotomy 10 days back presented with a complaint of generalized body stiffness, breathing difficulty as well as an inability to chew and swallow food for 4 days. the woman experienced neck pain and numbness in her face. Her symptoms got worse over the next 24 hours — her neck and jaw became stiff, and she had difficulty swallowing and breathing and presented in emergency with following vitals • BP 101/63mmHg • PR 110 bpm • RR 25 /min • SPO2 90% at Room air
- 5. EXAMINATION • Slurred speech • Stiffness of neck and back present • Limited mouth opening due to the mild facial muscle spasm • rest of the examination was un remarkable
- 6. INVESTIGATIONS LABS LABS HB 11 T Bil 0.4 mg/dl TLC 20 PH 7.35 PLT 200 PaCO2 38 UREA 25 mg/dl Pa O2 65 mmHg CRET 0.5mg/dl HCO3 25 Na 145 BLOOD CULTURES neg k 4.5 URINE CULTURES neg ECG CXR NORMAL SINUS RHYTHM UNREMARKABLE
- 7. What is your differential diagnosis? • Tetanus • Strychnine poisoning • Dental infections • Hysteria • Malignant hyperthermia • Hypocalcemia • Local infections • Intracranial hemorrhage • Sepsis • Seizure disorder (partial or generalized) • Serotonin syndrome • Stroke, ischemic (cephalic tetanus) • Meningitis • TMJ Dislocation
- 8. WHAT IS TETANUS? Bacterial infection characterized by acute onset of hypertonia, painful muscle contractions and spasms without any medical cause . TETANOS- Greek word means stretch
- 9. WHAT ARE TYPES OF TETANUS? LOCALIZED GENERALIZED NEONATAL CEPHALIC TYPES
- 10. WHAT IS THE CAUSATIVE ORGANISM? • gram-positive bacillus - Clostridium tetani • found in soil ,animal or human faeces • motile, spore forming, obligate anaerobe • Spores are not destroyed by boiling • eliminated by autoclaving at 120°C for 15 min 1 (at one atmosphere pressure)
- 11. DIAGNOSIS Clinical Bacterium is rarely cultured SPATULA TEST
- 12. CAN YOU NAME TETANI EXOTOXINS? • TETANOSPASMIN • Enter peripheral nerves • Binds to gangliosides of neurons • Axonal retrograde transport to cell body of neurons • Transport occurs first in motor, and later in sensory and autonomic nerves • in the cell body the toxin can diffuse out, affect and entering nearby neurons. • spinal inhibitory interneurones are affected, symptoms occur. • Further retrograde intraneural transport occurs with toxin spreading to the brainstem and midbrain.
- 13. • Inhibit GABA & Glycine from presynaptic vesicles • relative deficiency of synaptic acetylcholine (similar to botulinum toxin) causes flaccid paralysis • Disinhibition of motor & autonomic neurons • Cause rigidity , spasm , autonomic dysfunction • High toxin load diffusion via blood to nerves
- 14. TETANOLYSIN • Damages the surrounding tissue • Optimizes conditions for bacterial multiplication
- 16. WHAT ARE ROUTES OF TRANSMISSION? BURNS IM /IV INJECTIONS SURGERY SEPTIC ABORTION SNAKEBITE GANGRENE ULCERS CHILD BIRTH
- 17. WHAT ARE ITS CLINICAL FEATURES? Muscle rigidity Spasms TETANUS TRIAD Autonomic dysfunction
- 18. WHAT ARE THE CLINICAL FEATURES? • MUSCLE RIGIDITY • First week • Reduce after 2 , 3 week • Autonomic disturbance • occurs in 1 week • Occurs several weeks after spasm • Persists 1-2 weeks • SPASM
- 19. WHAT ARE THE SIGNS AND SYMPTOMS?
- 20. • EARLY SYMPTOMS • Neck stiffness • Sore throat • Poor mouth opening • Increased muscle tone • Pharyngeal and laryngeal spasm • Rigidity of the neck muscles leads to retraction of the head • Mimic convulsions • Continuous spasm – RESPIRATORY FAILURE
- 21. WHAT ARE SIGNS OF GENERALIZED TETANUS? TRISMUS LOCK JAW • Masseter muscle spasm RISUS SARDONICUS • Facial expression • Facial muscle spasm • Sarcastic smile OPISTHOTONUS • Truncal rigidity • Extensor muscles spasm • Arched back
- 22. TRISMUS / LOCK JAW
- 23. OPISTHOTONUS
- 24. RISUS SARDONICUS
- 25. WHAT ARE THE COMPLICATIONS?
- 26. ASPIRATION POOR COUGH GASTRIC STASIS SALIVATION AUTONOMIC DYSFUNCTION INCREASED SYMPATHETIC ACTIVITY TACHYCARDIA, HTN MYOCARDIAL INFARCTION CARDIOMYOPATHY RENAL FAILURE GIT DIARRHEA ILEUS DEHYDRATION SWEATING SALIVATION
- 27. LOCALIZED TETANUS Limited body area involved LESS MORTALITY LOWER TOXIN LOAD
- 29. CEPHALIC TETANUS
- 30. NEONATAL TETANUS TETANUS NEONATORUM High mortality PRESENTS 1 week after birth Convulsions, fever, vomiting Poor umbilical cord hygiene d/d meningitis, sepsis, seizures Prevention- maternal vaccination
- 31. HOW DO YOU CLASSIFY SEVERITY?
- 32. ABLETT CLASSIFICATION OF SEVERITY GRADE SEVERITY SYMPTOMS I MILD • Mild trismus , • general spasticity • no respiratory embarrassmen • no spasms, no dysphagia II MODERATE • Moderate trismus, rigidity • short spasms • mild dysphagia, • respiratory rate > 30, • mild dysphagia III SEVERE • Severe trismus • generalized spasticity, • prolonged spasms,
- 33. • prolonged spasms, • respiratory rate > 40, • apnoeic spells • severe dysphagia, • pulse > 120 IV VERY SEVERE • Grade 3 plus severe autonomic disturbances • cardiovascular system involvement
- 34. WHAT IS THE MANAGEMENT? PREVENT FURTHER TOXIN RELEASE NEUTRALIZE TOXIN PRESENT IN THE BODY OUTSIDE CNS MINIMIZE EFFECT OF TOXIN ALREADY PRESENT IN CNS
- 35. HOW CAN YOU PREVENT FURTHER TOXIN RELEASE? WOUND Debridement Additional Antibiotic cover ANTIBIOTIC METRONIDAZOLE 500mg IV 8h ERYTHROMICIN, TETRACYCLIN , CLARITHROMICIN
- 36. How can we Neutralize toxin present in the body outside the CNS? HUMAN TETANUS IMMUNOGLOBULIN Ig IM:150 units /kg Within 24 h (3000-6000 IU) IV: 5000- 10000IU ANTI TETANUS HORSE SERUM IM : 1500- 10000IU A/E Anaphylaxis
- 37. How to Minimize the effects of the toxin already in the CNS? SEDATION RESPIRATORY SUPPORT CONTROL AUTONOMIC DISTURBANCE
- 38. WHAT SEDATION CAN YOU GIVE TO THESE PATIENTS? • BENZODIAZIPINES • DIAZEPAM 0.1mg/kg IV 4h • MIDAZOLAM 0.1 mg/kg IV 4h OR Infusion 2-10 mg/H • OPIOIDS • MORPHINE 0.1mg/kg IV or IM 2-6h • PETHIDINE 1 mg/kg IV or IM 2-6h • COMBINATION • BENZODIAZIPINES + MORPHINE • 1-10 mg / h IV
- 39. • ANTICONVULSANTS • PHENOBARBITONE 200 mg IV, PNG, PO 12H • PHENOTHIAZINE • PROPOFOL • 25 -50 ug/kg/min IV
- 40. WHAT MUSCLE RELAXANTS TO USE? • 0.1 mg /kg IV VECURONIUM • 0.5 mg/ kg IV ATRACURIUM • Worsen autonomic instability • Inhibiting catecholamine uptake PANCURONIUM
- 41. What is the Treatment of autonomic dysfunction? • Minimize autonomic instability FLUID • Presynaptic NMB, reduces catecholamine release from nerves & adrenal medulla • LOADING 5g in 20 min ,INFUSION 2g/h • Therapeutic range of Mg 2-4 mmol/l MAGNESIUM SULFATE • ESMOLOL short acting • Long acting are not recommended BETA BLOCKERS • CLONIDINE • Inhibits norepinephrine from nerve endings ALPHA 2 AGONIST
- 42. WHAT ICU CARE WILL YOU GIVE THESE PATIENTS? • Enteral feeding - nutrition • Prevention of Respiratory Complication • Semi recumbent position • Suctioning • Oral care • Tracheostomy IF Ventilation > 8-10 days • Pressure sore care • Minimize thromboembolism • Psychological support
- 44. • At 2 months of age • 3 inj at ONE month interval • BOOSTER 5 years of age vaccination • Maternal vaccination • Transplacental transfer of immunoglobulin Neonatal immunity • Immunity is not long lasting • 2 boosters 10 years apart Revaccination
- 45. T H A N K Y O U