A newborn presented with generalized body stiffness and an unhealed umbilical stump. The mother did not receive the tetanus vaccine. Examination found the infant was restless with clenched fists and frothy saliva. Tetanus was diagnosed based on clinical signs. Treatment included wound debridement, antibiotics, tetanus immune globulin, benzodiazepines for spasms, and supportive care. Tetanus prevention relies on childhood immunization and wound care. Prognosis depends on onset and severity of symptoms, and neonatal tetanus carries a poorer prognosis than adult tetanus.

1. C:ME: Tetanus
1
4/6/2022 CME: TETANUS
1
4/6/2022
2021--2022

2. C:ME: Tetanus 2
OUTLINE
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3. A 8 days old newborn presented with Generalized body
stiffness for 2 days and triggered by stimulation of light or
loud Noise , lasting 1-3 mins and Inability to feed, cry were
muffled, the umbilical stump was tight with plastic gloves,
Mother didn’t receive vaccine Tetanus Toxoid .
O/E patient is conscious, Restless, afebrile, Unhealed
umbilicus and discharge (Oozing), Generalized stiffness
with frothy saliva.. Clenched fists
4/6/2022 CME: NEONATAL TETANUS 3

4. Abnormal body movement and stiffness
Lock jaw
Mother didn’t receive vaccine T.T
discharge on umbilicus (Unhealed)
The umbilicus stump was cut by non-sterile instrument
The umblical Stump tight with plastic gloves
Poor socioeconomic
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5. 4/6/2022 C:ME: Tetanus 5

6. Tetanus is an acute, often fatal disease.
 but prevented by Immunization with tetanus toxoid
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7. •Occurence: Tetanus occurs worldwide but is more
common in hot, damp climates
•Reservoir: Organism Found primarily in the soil, intestine of
animal and humans
•Mode of transmission: Primarily by contaminated wounds,
animal bites
•Incubation Period: 8 days (3-21 days)
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8. • Communicability: Not Contagious from person to
person
• Age: Active age 5-40 years, newborn baby, female
during delivery or abortion
• Occupation: Agricultural workers are at higher risk
• Environmetal and social factors: Unhygienic custom
habit, Unhygienic delivery practices
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…
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9. Transmission of tetanus

10. Tetanus Caused by Clostridium tetani obligate intracellular
spore forming anaerobe. gram-positive,
Spores found in soil, house dust, animal intestine.
 Enter normal tissues and persist for several months.
Germinate under anaerobic conditions and produce
toxin(Tetanolysis and Tetanospasmin)
Tetanospasmin estimated human lethal dose = 2.5 ng/kg
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12. C:ME: Tetanus 12
4. Tetnospasmin spreads using blood and
lymphatic system, and binds to motor
neurons.
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14. Generalized tetanus: Most commonly encountered form of tetanus 80%, its
characterized by Headache, trismus or lockjaw, restlessness, neck muscle
spasm
Localized Tetanus: Its is milder form characterized by pain and stiffness to
the site of wound
Cephalic Tetanus: It is Uncommon and fatal, primarily affect one or several
muscles in the face rapidly after a head injury or ear infection. Trismus may
occur, the disease can easily progress to Generalized
Neonatal Tetanus: Occurs within 3-12 days of birth as progressive difficult in
feeding with associated hugger and crying
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15. C:ME: Tetanus 15
Opisthotonus Risus Sardonicus Trismus
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16. The Diagnosis of Tetanus is Basically clinical.
The are no specific confirmatory Test
The routine blood and CSF investigation are normal
 Some baseline investigations could be carried out on admission Like
CBC,Rapid Blood Sugar, Blood culture.
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17. The Spatula Test
This simple test involves touching the oropharynx with a
spatula or tongue blade.
Usually, this test causes a gag reflex with the patient, and
the patient tries to expel the spatula. (This means they
have tested negative.)
In tetanus, patients develop a reflex spasm of the
masseters and bite the spatula (a positive test).
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18. Drug-induced dystonias such as those due to
phenothiazines(absence of tonic muscular contraction between
spasms,eye deviations )
Trismus due to dental infection
Strychnine poisoning due to ingestion of rat poison
Malignant neuroleptic syndrome (presence of fever, altered mental
status,rapid response to Diaspam )
Meningitis or Encephalitis & Sepsis
Dystonic reaction to Metoclopromide, promethazine
Stiff-person syndrome (The absence of trismus or facial spasms )
Epilepsy
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20. GOALS OF TREATMENT
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21. Principle of Treatment
1. Halting toxin production(Prevention of further toxin production )
Wound management (wound debridement)
Antimicrobial therapy
Metronidazole 500 mg intravenously [IV].30mg/kg/day in divided
doses 4 times daily for 7 to 10 days.
penicillin G 2 to 5 million units IV, 100,000 unit/kg/day in divided doses
every six hour for 7 to 10 days
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22. 2.Neutralization of unbound toxin
Since tetanus toxin is irreversibly bound to tissues.
Passive immunization to neutralize unbound toxin.
Human tetanus immune globulin (HTIG) is the preparation of choice
Dosing: Pediatric
Dosing: Neonatal
Administration
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23. Dosing: Pediatric
Tetanus, prophylaxis:
Infants and Children <7 years: IM: 250 units as a single dose or 4 units/kg
Children ≥7 years and Adolescents: IM: 250 units as a single dose (Red
Book [AAP 2018]
Tetanus, treatment: Infants, Children, and Adolescents
IM: 3,000 to 6,000 units as a single dose. (around the wound is
recommended)
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24. Administration: Pediatric
Administer into lateral aspect of thigh or deltoid muscle of upper arm
Avoid gluteal region due to risk of injury to sciatic nerve
Do not administer tetanus toxoid and tetanus immune globulin in
same syring
tetanus toxoid may be administered at the same time in separate
limbs
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26. Tetanus, prophylaxis:
IM: 250 units as a single dose.
May also calculate 4 units/kg; however, full dose of 250 units is
recommended (Bradley 2021; Red Book [AAP 2018]);
Tetanus, treatment:
dosing regimens variable: IM: 3,000 to 6,000 units as a single dose.
experts recommend a lower 500 unit dose (Bradley 2021; Red
Book [AAP 2018]; WHO 2010).
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Dosing: Neonatal

27. 3. Control of spasm
- Nursing in quiet
environment
- avoid unnecessary stimuli
- Protecting the airway
- Use sedative drugs
C:ME: Tetanus 27
4. Supportive care
- Adequate hydration
- Nutrition (Breast feeding
with NG tube )
- Treatment of secondary
infection
- prevention of bed sores.
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28. Benzodiazepines : Diazepam ing IV or infusion of IV Midazolam
Diazepam -- Most commonly used drug for treatment of tetanic spasms and tetanic
seizures.
 Infants:>30 days and Children <5 yr. IV 1 to 2mg every 3 to 4 hours as needed
Children > 5 years and adolescents IV 5 to 10 mg every 3 to 4 hours as needed
WHO2010: infant, children and adolescents IV 0.1 to 0.2 mg /kg /dose every 2 to
6hours titrate as needed
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29. Management of autonomic dysfunction
Several drugs have been used to produce adrenergic
blockade and suppress autonomic hyperactivity
Only treatment with magnesium sulfate has been
studied in a randomized clinical trial in tetanus
Magnesium sulfate 25mg/kg/dose
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30. STANDARD OF CARE
Rapid sequence intubation to prevent reflex laryngospasm .
Tetanus toxoid
Human Tetanus immunoglobulin I/M ( 500 to 6000 IU)
Surgical wound debridement
SEDATION AND PAIN CONTROL
Hydration (MIXED SOLUTION) Or Nutritional feeding through NG
tube
C:ME: Tetanus 30
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31. Aspiration Pneumonia
Laceration of mouth and tongue
Vertebral Fractures
Laryngospasm
Autonomic disturbance
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32. Prognosis
• Prognosis is dependent on incubation period, time from spore inoculation
to first symptom, and time from first symptom to first tetanic spasm.
• In general, shorter intervals indicate more severe tetanus and a poorer
prognosis.
• Clinical tetanus does not produce a state of immunity; therefore, patients
who survive the disease require active immunization with tetanus toxoid to
prevent a recurrence.
• N.B ; Neonatal tetanus are poor prognosis than Adult.
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33. Prevention
 Tetanus is completely preventable by active
tetanus immunization.
 Immunization is thought to provide protection
for 10 years.
 Begins in infancy with the PENTA series of
shots.
 The PENTA vaccine is a “5-in-1" vaccine that
protects against diphtheria, pertussis, and
tetanus.
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34. Prevention
Tetanus carries a 35% mortality rate, making prevention very
important!
The best course is childhood immunizations, with consistent booster
doses, and prompt cleaning of wounds with hydrogen peroxide.
C:ME: Tetanus 34
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35. REFERENCES
• Centers for Disease Control and Prevention. Tetanus.
https://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-
tetanus.html (Accessed on February 24, 2020).
• World Health Organization. Immunization surveillance, assessment
and monitoring. Maternal and Neonatal Tetanus (MNT) elimination.
• Uptodate: Literature review current through: Nov 2021. | This topic
last updated: Nov 18, 2021.
• Nelson Textbook edition 21 .(2020)
• Redbook Infectious disease last edition and AAP
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