Tetanus is explained in very simple wording and style by the help of a scenario. Easy to memorize and present due to related pictures. Helpful for medical students, and knowledge seekers.

1. TETANUS
Dr. Maria Sheraz Khan

2. SCENARIO
 A 7 days old boy is brought to ER with complaint of
irritability, rigidity, facial grimacing and severe
spasm with touch previously he was reluctant to
feed with excessive cry. The baby was delivered at
home by a local dai.
 A-) What is the most likely diagnosis?
 B-) Prevention?
 C-) Complications?

3. CATCH POINTS
 A 7 days old boy is brought to ER with complaint of
irritability, rigidity, facial grimacing and severe
spasm with touch previously he was reluctant
to feed with excessive cry. The baby was
delivered at home by a local dai.
 A-) What is the most likely diagnosis?
 B-) Prevention?
 C-) Complications?

4. DIAGNOSIS:
TETANUS NEONATORUM

5. Prevention:
 1- Conduct deliveries at hospital.
 2- Train health workers for aseptic
technique.
 3- It is not recommended to excise the
umbilical stump in neonatal tetanus.

6.  4- Immunize the mother during
pregnancy by giving 2 injections of
tetanus toxoid 4 weeks apart in the 2nd
trimester of pregnancy. Last injection
should be given at least 4 weeks
before delivery. Antibodies transferred
to the baby protect against neonatal
tetanus. If mother is previously
immunized then one injection is
sufficient.

7. COMPLICATIONS
 Aspiration of secretions and pneumonia.
 Vertebral fractures during seizures.
 Autonomic disturbances.
 Lacerations of mouth and tongue due to
seizures.

8.  Seizures may cause intramuscular
hematoma or rhabdomyolysis leading to
hemoglobinuria and renal failure.
 Decubitus ulceration (also known as
pressure ulcers).

9. NEONATAL TETANUS

10. TETANUS
 It is a an acute, spastic paralytic disease caused by
Clostridium tetani, which is spore forming,
anaerobic gram-positive bacillus.
 Spores are resistant to heat or boiling.

11. TOXINS
 It produces two exotoxins:
• 1- Tetanoplasmin
• 2- Tetanolysin
 It is the tetanoplasmin, which is neurotoxic while
tetanolysin potentiate the effect of tetanus toxin.
 Each milligram of crystallized toxin contains 50-57
million mouse lethal dose.

12. EPIDEMIOLOGY
 Tetanus is a major cause of mortality in
unvaccinated persons and newborns of
unvaccinated mothers.
 Incubation period is usually 2 -14 days after injury
 Tetanus is not a communicable disease.

13. PATHOGENESIS
 Spores of C.tetani are introduced in the wound,
which are converted to vegetative forms.
 Vegetative organisms produce an exotoxin
tetanospasmin under low ambient oxygen
 Tetano-spasmin binds irreversibly to motor neurons
at neuromuscular junction and it travels retrograde
towards the CNS where it inhibits spinal
presynaptic inhibitory synapses.

14.  Net result of loss of inhibitory neurons,
which manifests as spasm of agonist and
antagonist muscles. This result in muscle
contraction, characteristic localized spasm
and rigidity.
 Toxin has no effect on conscious level,
however autonomic dysfunction can occur
characterized by tachycardia, arrhythmias,
labile hypertension, cutaneous vaso-
constriction etc.

15. Once the toxin has attached to
neurons, it cannot be neutralized by
antitoxin.
In newborn infants contamination of
umbilical cord is the most common
source of infection whereas in older
children deep punctured wounds
cause tetanus.

16. TYPES
Tetanus neonatorum
Localized tetanus
Generalized tetanus
Cephalic tetanus

17. TETANUS NEONATORUM
 Usually symptoms begin after 3- 10 days after birth
and pattern is generalized.
 Initial symptom is failure to suck and inability to
open mouth known as trismus,
irritability and excessive cry.
 Then develop risus sardonicus.

18.  With in 12-24 hour tonic muscular convulsion can
occur.
 Initially spasm are mild then become severe.
 Opisthotonos may occur.

20. LOCALIZED TETANUS
 In the proximity of the injury there is pain,
continuous rigidity and spasm of the muscles.
 It resolve with in weeks without any complication
 This is rare in children with fatality rate of 1%.

21. GENERALIZED TETANUS
 It is the most common form of tetanus in children
and new born.
 The characteristic seizures or spasm in tetanus is
that they may be initiated by a stimulus such as
noise, light, or touch.
 Trismus is present in 50% of cases.

22. CEPHALIC TETANUS
 This is rare form is due to any injury near head.
 Incubation period is short (1-2 days).
 Cranial nerve involvement is the most characteristic
feature of this form of tetanus.

23. DIAGNOSIS
 It is mainly clinical
 History of non-vaccination is present in most of the
cases.
 In tetanus neonatorum babies are usually delivered
at home , are approximately 7 days old, they fail to
suck, develop trismus and muscular spasm help in
the diagnosis.

24.  In a child a history of a wound or bite, the
characteristic facial appearance, and spam help in
the diagnosis.
 Laboratory studies are of little value and are usually
normal.
 Gram stain of C.tetani is positive in only 1/3rd of the
cases.

25. Differential Diagnosis:
1- Tetany
2- Encephalitis
3- Strychnine Poisoning
4- Rabies
5- Bacterial meningitis
6- Birth Trauma
7- Epilepsy

26. MANAGEMENT
Aims of treatment are:
 Remove the source of exotoxin.
 Neutralize remaining circulating toxin before it
reach the CNS.
 Provide supportive care.

27. SPECIFIC
ANTI TOXIN:
 To neutralize the toxin.
 Horse anti tetanus serum.(50,000-100000)
minimum 10 thousand units.
 Human tetanus immuno-globulin 3 thousand to 6
thousand units and minimum dose is 500 units.

28. ANTIBIOTICS
 Crystalline penicillin 200,000 units /kg/day
 Gentamycin 5mg/kg/day
 Metronidazole is equally effective as penicillin in a
dose of 15ml /kg /8 hour
 Erythromycin or tetracyclin are used in patients
allergic to penicillin.

29. SUPPORTIVE MEASURES
Sedation:
 Inj. Diazepam 0.1- 0.2 mg/kg I.V every 3-6 hour to
control muscular spasm.
 Add Chlorpromazine syrup 10-15mg/kg/day to
control fits
 Phenobarbitone may be given.
 An adequately sedated child is one whose
respiration is not depressed and occasional muscle
spasm is acceptable

30.  Over sedation is represented by shallow respiration
and diminution of muscle tone
Feeding:
 Give feeding by NG tube half oz every hour during
1st week then 1 oz every 2 hour till oral feeding is
possible.

31. NURSING CARE
 Clean the umbilicus in the newborn or wound in
infants and children and place a patient in quiet
environment free from noise and visual stimuli
 Change the posture and observe for apneic spells
 Cardio-respiratory monitoring and frequent suction
is done.

32.  Mouth, skin, bladder care is necessary
 If needed give artificial respiration.

33. PROGNOSIS
 Fatality rate depend on quality of supportive care.
 Main cause of death are respiratory failure and
pneumonia.
 Mortality rate is 60% in tetanus neonatorum and 20-
50% in children. Most mortality occur in first week
of illness.

34. GOOD PROGNOSTIC FACTORS
 Incubation period of 8-10 days.
 Progression longer than 60 hrs
 Absence of fever
 Local disease
 Survival for 10 days

35. POOR PROGNOSTIC FACTOR
 Duration between trismus and injury less than 7
days.
 Duration between trismus and tetanic spasm less
than 3 days.

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