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Anthony	
  Karabanow,	
  MD	
  
Epidemiology	
  
  ~	
  1	
  million	
  cases	
  per	
  year	
  worldwide	
  
  200,ooo	
  to	
  300,000	
  deaths	
  annually	
  
  Neonatal	
  tetanus	
  was	
  targeted	
  for	
  	
  elimination	
  by	
  the	
  
   WHO	
  in	
  ‘95	
  
  Neonatal	
  tetanus	
  still	
  causes	
  5-­‐7%	
  of	
  neonatal	
  deaths	
  
Pathology	
  
  Spores	
  of	
  Clostridium	
  tetani	
  are	
  found	
  widely	
  in	
  soil	
  
  Innoculated	
  into	
  wounds	
  
  Transforms	
  into	
  active	
  bacterium,	
  produces	
  tetanus	
  
   toxin	
  
  Toxin	
  binds	
  to	
  neuroreceptors	
  
  Disinhibits	
  excitatory	
  impulses	
  
  Causes	
  increased	
  muscle	
  tone,	
  painful	
  spasms	
  and	
  
   autonomic	
  instability	
  
Clinical	
  scenario	
  
  Generalized	
  tetanus	
  
  Local	
  tetanus	
  
  Cephalic	
  tetanus	
  
  Neonatal	
  tetanus	
  
Generalized	
  tetanus	
  
  Autonomic	
  	
  overactivity:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  irritability	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  diaphoresis	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  tachycardia	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  labile	
  BP	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  fever	
  
Generalized	
  tetanus	
  
  Tonic	
  contraction	
  of	
  skeletal	
  muscles	
  
  Intermittent,	
  painful	
  muscle	
  spasms	
  
  These	
  cause	
  classic	
  signs/symptoms:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  trismus	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  apnea	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  risus	
  sardonicus	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  abdominal	
  rigidity	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  opisthotonus	
  
Localized	
  tetanus	
  
  Rare	
  
  Tonic	
  and	
  spastic	
  muscle	
  contractions	
  in	
  one	
  
   extremity	
  or	
  body	
  region	
  
  Usually	
  evolves	
  into	
  generalized	
  tetanus	
  
Cephalic	
  tetanus	
  
  Due	
  to	
  injuries	
  of	
  head,	
  neck	
  
  Involves	
  only	
  cranial	
  nerves	
  
  Usually	
  evolves	
  into	
  generalized	
  tetanus	
  
Neonatal	
  tetanus	
  
  Due	
  to	
  umbilical	
  stump	
  infection	
  (eg	
  application	
  of	
  
             cow	
  dung	
  to	
  stump)	
  versus	
  non-­‐sterile	
  delivery	
  
  Manifests	
  as:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  inability	
  to	
  suck	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  seizures	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  rigidity	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  spasms	
  
Diagnosis	
  
  Clinical:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  tetanus	
  prone	
  wound	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  inadequate	
  vaccination	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  consistent	
  signs/symptoms	
  
Management	
  
  Wound	
  care	
  
  	
  Antibiotics	
  
  Neutralize	
  toxin	
  
  Control	
  spasms	
  
  Immunize	
  
Wound	
  care	
  
  Aggressive	
  wound	
  debridement	
  to:	
  


	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  remove	
  spores	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  remove	
  necrotic	
  tissue	
  necessary	
  for	
  	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  spore	
  germination	
  
An>bio>cs	
  
  Play	
  minor	
  role	
  


  Penicillin	
  traditional	
  drug	
  of	
  choice	
  
  Metronidazole	
  now	
  preferred	
  


  Given	
  likelihood	
  of	
  mixed	
  infection:	
  


	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  ceftriaxone	
  	
  for	
  5-­‐7	
  days	
  
Toxin	
  neutraliza>on	
  
  Symptom	
  causing	
  tetanus	
  toxin	
  is	
  irreversibly	
  bound	
  
  Can	
  only	
  neutralize	
  unbound	
  toxin	
  
  HTIG	
  3000	
  to	
  6000	
  units	
  IM	
  
  ETIG	
  	
  1500	
  to	
  3000	
  units	
  IM	
  
Symptom	
  control	
  
  Spasms	
  are	
  life	
  threatening	
  
  Put	
  pt	
  in	
  a	
  quiet	
  room	
  
  Drugs:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  Benzodiazepines	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  Vecuronium	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  Propofol	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  	
  Baclofen	
  
Symptom	
  control	
  
  Autonomic	
  dysfunction:	
  


	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  magnesium	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  labetolol	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  morphine	
  
Immuniza>on	
  
  Disease	
  does	
  NOT	
  confer	
  immunity	
  
  If	
  primary	
  immunization	
  series	
  in	
  doubt:	
  
      3	
  doses	
  of	
  tetanus	
  toxoid	
  
      Booster	
  every	
  10	
  years	
  
Other	
  care	
  
  Bound	
  tetanus	
  toxin	
  cannot	
  be	
  displaced	
  
  Recovery	
  	
  requires	
  re-­‐growth	
  of	
  nerve	
  terminals	
  (4-­‐6	
  
             weeks)	
  
  Severe	
  tetanus	
  means	
  a	
  prolonged	
  hospital	
  course	
  
  Consider:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  nutritional	
  support	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  ventilatory	
  support	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  early	
  PT	
  
Prognosis	
  
  Neonatal:	
  	
  	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  10-­‐60%	
  fatality	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  may	
  have	
  long	
  term	
  neurologic	
  deficits	
  

  Non-­‐neonatal:	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  -­‐	
  	
  8-­‐50%	
  fatality	
  
Tetanus	
  in	
  Hai>	
  
Tetanus	
  in	
  Hai>	
  
  4	
  yr	
  old	
  female	
  brought	
  to	
  triage	
  area	
  1-­‐17-­‐10	
  
  Found	
  under	
  ruble	
  in	
  Port	
  au	
  Prince	
  
  Presenting	
  for	
  evaluation	
  of	
  L	
  LE	
  injury	
  
Tetanus	
  in	
  Hai>	
  
  AF	
  	
  90	
  	
  BP	
  unavailable	
  
  General:	
  	
  Crying	
  
  Heart:	
  RRR	
  
  Lungs:	
  	
  CTA	
  
  Abd:	
  	
  NT,	
  ND	
  
  Extrems:	
  	
  large	
  lacerations	
  deep	
  to	
  muscle	
  involving	
  
   the	
  R	
  lateral	
  calf	
  and	
  L	
  shin	
  
Tetanus	
  in	
  Hai>	
  
  Wounds	
  cleaned	
  and	
  bandaged	
  
  Tetanus	
  prophylaxis	
  given	
  
  Empiric	
  abx	
  (IM	
  ceftriaxone)	
  
  Plans	
  for	
  further	
  debridement	
  in	
  OR	
  
Tetanus	
  in	
  Hai>	
  
  Following	
  day,	
  
  Febrile	
  to	
  39.1,	
  nuchal	
  rigidity	
  and	
  intermittent	
  
   arching	
  of	
  the	
  back	
  
  Consult	
  re	
  ?	
  meningitis	
  
Tetanus	
  in	
  Hai>	
  
  General:	
  	
  Awake,	
  alert,	
  crying	
  
  HEENT:	
  	
  Teeth	
  clenched,	
  neck	
  stiff	
  
  Heart:	
  	
  RRR	
  
  Lungs:	
  	
  CTA	
  
  Abd:	
  	
  NT,	
  ND	
  
  Wound:	
  	
  unchanged	
  
  Neuro:	
  	
  Globally	
  increased	
  muscle	
  tone	
  
Tetanus	
  in	
  Hai>	
  
  Clinical	
  tetanus	
  diagnosed	
  
  Management:	
  
     High	
  dose	
  tetanus	
  IgG	
  
     Continue	
  Ceftriaxone	
  
     To	
  OR	
  for	
  wound	
  debridement	
  
     Diazepam	
  prn	
  
Tetanus	
  in	
  Hai>	
  
  Following	
  day:	
  
      Decreased	
  muscle	
  rigidity	
  
      Decreased	
  spasms	
  
      Increased	
  BP	
  lability	
  
      Mg	
  ggt	
  added	
  
Tetanus	
  in	
  Hai>	
  
  That	
  night:	
  
      IV	
  loss	
  
      Benzos	
  not	
  given	
  
      Mg	
  ggt	
  not	
  given	
  
      Intractable	
  spasms,	
  trismus	
  
      Vecuronium	
  given,	
  ventilation	
  support	
  started	
  
Tetanus	
  in	
  Hai>	
  
  Next	
  AM:	
  
     Navy	
  helicopter	
  transfer	
  to	
  USS	
  Comfort	
  
     Informed	
  child	
  coded	
  and	
  died	
  shortly	
  after	
  arrival	
  

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Tetanus in Haiti Symposia - The CRUDEM Foundation

  • 2. Epidemiology     ~  1  million  cases  per  year  worldwide     200,ooo  to  300,000  deaths  annually     Neonatal  tetanus  was  targeted  for    elimination  by  the   WHO  in  ‘95     Neonatal  tetanus  still  causes  5-­‐7%  of  neonatal  deaths  
  • 3. Pathology     Spores  of  Clostridium  tetani  are  found  widely  in  soil     Innoculated  into  wounds     Transforms  into  active  bacterium,  produces  tetanus   toxin     Toxin  binds  to  neuroreceptors     Disinhibits  excitatory  impulses     Causes  increased  muscle  tone,  painful  spasms  and   autonomic  instability  
  • 4. Clinical  scenario     Generalized  tetanus     Local  tetanus     Cephalic  tetanus     Neonatal  tetanus  
  • 5. Generalized  tetanus     Autonomic    overactivity:                              -­‐  irritability                              -­‐  diaphoresis                              -­‐  tachycardia                              -­‐  labile  BP                              -­‐  fever  
  • 6. Generalized  tetanus     Tonic  contraction  of  skeletal  muscles     Intermittent,  painful  muscle  spasms     These  cause  classic  signs/symptoms:                                                  -­‐      trismus                                                  -­‐      apnea                                                  -­‐      risus  sardonicus                                                  -­‐      abdominal  rigidity                                                  -­‐      opisthotonus  
  • 7. Localized  tetanus     Rare     Tonic  and  spastic  muscle  contractions  in  one   extremity  or  body  region     Usually  evolves  into  generalized  tetanus  
  • 8. Cephalic  tetanus     Due  to  injuries  of  head,  neck     Involves  only  cranial  nerves     Usually  evolves  into  generalized  tetanus  
  • 9. Neonatal  tetanus     Due  to  umbilical  stump  infection  (eg  application  of   cow  dung  to  stump)  versus  non-­‐sterile  delivery     Manifests  as:                                                              -­‐  inability  to  suck                                                              -­‐  seizures                                                              -­‐  rigidity                                                              -­‐  spasms  
  • 10. Diagnosis     Clinical:                                            -­‐  tetanus  prone  wound                                            -­‐  inadequate  vaccination                                            -­‐  consistent  signs/symptoms  
  • 11. Management     Wound  care      Antibiotics     Neutralize  toxin     Control  spasms     Immunize  
  • 12. Wound  care     Aggressive  wound  debridement  to:                                                -­‐    remove  spores                                                -­‐    remove  necrotic  tissue  necessary  for                                                        spore  germination  
  • 13. An>bio>cs     Play  minor  role     Penicillin  traditional  drug  of  choice     Metronidazole  now  preferred     Given  likelihood  of  mixed  infection:                                      -­‐    ceftriaxone    for  5-­‐7  days  
  • 14. Toxin  neutraliza>on     Symptom  causing  tetanus  toxin  is  irreversibly  bound     Can  only  neutralize  unbound  toxin     HTIG  3000  to  6000  units  IM     ETIG    1500  to  3000  units  IM  
  • 15. Symptom  control     Spasms  are  life  threatening     Put  pt  in  a  quiet  room     Drugs:                                    -­‐    Benzodiazepines                                    -­‐    Vecuronium                                    -­‐      Propofol                                    -­‐      Baclofen  
  • 16. Symptom  control     Autonomic  dysfunction:                                    -­‐    magnesium                                    -­‐    labetolol                                    -­‐    morphine  
  • 17. Immuniza>on     Disease  does  NOT  confer  immunity     If  primary  immunization  series  in  doubt:     3  doses  of  tetanus  toxoid     Booster  every  10  years  
  • 18. Other  care     Bound  tetanus  toxin  cannot  be  displaced     Recovery    requires  re-­‐growth  of  nerve  terminals  (4-­‐6   weeks)     Severe  tetanus  means  a  prolonged  hospital  course     Consider:                                              -­‐    nutritional  support                                              -­‐    ventilatory  support                                              -­‐    early  PT  
  • 19. Prognosis     Neonatal:                                                    -­‐  10-­‐60%  fatality                                                -­‐  may  have  long  term  neurologic  deficits     Non-­‐neonatal:                                                -­‐    8-­‐50%  fatality  
  • 21. Tetanus  in  Hai>     4  yr  old  female  brought  to  triage  area  1-­‐17-­‐10     Found  under  ruble  in  Port  au  Prince     Presenting  for  evaluation  of  L  LE  injury  
  • 22. Tetanus  in  Hai>     AF    90    BP  unavailable     General:    Crying     Heart:  RRR     Lungs:    CTA     Abd:    NT,  ND     Extrems:    large  lacerations  deep  to  muscle  involving   the  R  lateral  calf  and  L  shin  
  • 23. Tetanus  in  Hai>     Wounds  cleaned  and  bandaged     Tetanus  prophylaxis  given     Empiric  abx  (IM  ceftriaxone)     Plans  for  further  debridement  in  OR  
  • 24. Tetanus  in  Hai>     Following  day,     Febrile  to  39.1,  nuchal  rigidity  and  intermittent   arching  of  the  back     Consult  re  ?  meningitis  
  • 25. Tetanus  in  Hai>     General:    Awake,  alert,  crying     HEENT:    Teeth  clenched,  neck  stiff     Heart:    RRR     Lungs:    CTA     Abd:    NT,  ND     Wound:    unchanged     Neuro:    Globally  increased  muscle  tone  
  • 26. Tetanus  in  Hai>     Clinical  tetanus  diagnosed     Management:     High  dose  tetanus  IgG     Continue  Ceftriaxone     To  OR  for  wound  debridement     Diazepam  prn  
  • 27. Tetanus  in  Hai>     Following  day:     Decreased  muscle  rigidity     Decreased  spasms     Increased  BP  lability     Mg  ggt  added  
  • 28. Tetanus  in  Hai>     That  night:     IV  loss     Benzos  not  given     Mg  ggt  not  given     Intractable  spasms,  trismus     Vecuronium  given,  ventilation  support  started  
  • 29. Tetanus  in  Hai>     Next  AM:     Navy  helicopter  transfer  to  USS  Comfort     Informed  child  coded  and  died  shortly  after  arrival