VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
Tetnus by dr balwant
1. CASE
PRESENTATION
BY; DR BALWANT LAL
PGR M.D (INTERNAL MEDICINE)
WEST MEDICAL WARD
MAYO HOSPITAL LAHORE.
2. BIO DATA
RAFIQUE S/O AMMIR BAKSH
45 YEARS OLD /MALE
MARRIED
SHOPKEEPER BY PROFESSION
FROM SHERA KOT
DOA 23.5.2014
3. Presenting complaints
PRESENTED IN EMERGENCY WITH HISTORY OF
ROAD TRAFFIC ACCIDENT 3 DAYS
ASOC 2 DAYS
FEVER 1 DAY
LOCK JAW 1 DAY
4. HISTORY OF PRESENT ILLNESS
• ACCORDING TO THE PATIENT ATTENDENT , PATIENT GOT
SUFFERED FROM RTA 3 DAYS AGO ON MOTORBIKE,
BROUGHT TO JINNAH HOSPITAL EMERGENCY WHERE TT
INJECTED , BACKSLAB APPLIED FOR LEFT SIDED TIBIA
AND FIBULA FRACTURE AND DISCHARGED ON
ANALGESIC AND ANTIBIOTICS .
5. CONT…….
DURING HIS STAY AT HOME HE DEVELOPED
ASOC
GRADUAL ONSET & PROGRESSIVE
NO HX OF HEADACHE, FITS,
WEAKNESS OF ANY PART OF THE BODY
NO HX OF NECK STIFFNESS
NO HX OF BLEED FROM EAR NOSE AND THROAT
VOMITING 2 EPISODE
6. CONT…….
Fever
SUDDEN ONSET
CONTINUOUS
HIGH GRADE
ASSOCIATEDWITH CHILLS
Lock Jaw
SUDDEN ONSET,
HISTORY OF TRAUMA,
NO HISTORY OF DENTAL /URT INFECTION
7. • PAST HISTORY
• NOT SIGNIFICANT
• FAMILY HISTORY
• NOT SIGNIFICANT
• PERSONAL HISTORY
• MARRIED HAVING FOUR CHILDREN
• SMOKER
• SHOPKEEPER
• APPETITE AND BOWL HABBIT NORMAL
SOCIOECONOMIC HISTORY
• SATISFACTORY
8. On Examination
GENERAL PHYSICAL EXAMINATION
YOUNG MAN LYING ON BED UNCONSCIOUS WITH NORMAL
BUILT AND HEIGHT HAVING FOLLOWING VITALS
PULSE 90/MIN
BP 120/70
TEMP 100
RESP; RATE 20/MIN
BACK SLAB ON LEFT LEG
9. CNS
GCS E2 V1 M3 06/15
CRANIAL NERVES NO OBVIOUS CRANIAL NERVE PALSY
MOTOR
APPEARANCE NORMAL
TONE NORMAL
POWER
RIGHT LEFT
UPPER LIMB 1/5 UPPER LIMB 3/5
LOWER LIMB 0/5 FRACTURED
REFLEXES
PLANTERS RT; SIDE UPGOING LEFT NOT ASSESSED
SENSATIONS NOT ASSESSABLE
SOMI -VE
10. Musculoskeletal
• AT PRESENTATION
LOCK JAW
NECK RIGIDITY ABSENT
OPISTHOTONUS ABSENT
RISUS SARDONICUS ABSENT
MUSCLE SPASM ABSENT
• DURING HIS STAY IN WARD PATIENT DEVELOPED ALL OF THE ABOVE
FEATURES
11. CONT…….
RESPIRATORY SYSTEM
BILATERAL COARSE CREPTITATION THROUGHOUT THE CHEST
OTHER SYSTEMIC EXAMINATION UNREMARKABLE
18. Treatment Given in ward
INJ TAZOCIN
INJ BENZYL PENICILLINE
INJ FLAGYL
TETANUM BURNA
INJ MERONUM
INJ SULZONE
19. Treatment Given in ward
IV FLUIDS
DIAZEPAM
PHENOBARBITONE
TINAZIDINE
INJ CLEXANE
INJ RISEK
20. TETANUS
INFECTIOUS DISEASE
CHARACTERISED BY ;
ACUTE ONSET OF HYPERTONIA
PAINFUL MUSCLE CONTRACTIONS
GENERALIZED MUSCLE SPASMS
WITHOUT OTHER APPARENT MEDICAL
CAUSES.
21. PATHOPHYSIOLOGY
CLOSTRIDIUM TETANI
(gram +ve, motile, anaerobe, obligate rod)-
SPORES
(resistant to heat, desiccation and disinfectant)
WOUND
( dead tissue low oxidation/reduction potential)
TOXIN
(upon germination, spore produce tetanospasmin, most toxic
substance with lethal dose 2.5 ng /kg body wt.)
22. PATHOPHYSIOLOGY
MOTOR NEURON
( central inhibitory neuron, tetanospasmin enters in retrograde
fashion from wound to motor neuron in spinal cord where it cleaves
synaptobrevin that results in inhibition of release of GABA and
GLYCINE resulting in autonomic hyperactivity and uncontrolled muscle
contraction in response to normal stimuli).
Toxins fixed to neurons can not be neutralized with
antitoxins.
23. ETIOLOGY
CAUSATIVE AGENT;
• CLOSTRIDIUM TETNAI
SOURCE OF INFECTION;
• WOUND (65%) BY WOOD, THORN, METAL SPLINTERS
• CHRONIC SKIN ULCERS (5%)
• ABSCESS / GANGRENE
24. ETIOLOGY
• FROST BITE / BURNS
• MIDDLE EAR INFECTION
• DENTAL / SURGICAL PROCEDURES
• ABORTION / CHILD BIRTH
• I/V DRUG ABUSERS
• UNDER IMMUNIZATION. 12 to 14 %
tetanus affected patients are properly immunized.
25. EPIDEMIOLOGY
• AFFECTS;
ALL AGES / BOTH GENDERS
MORE PREVALENT IN NEWBORNS AND YOUNGS
• ANNUAL INCIDENCE;
0.5 TO 1 MILLION / YEAR (WHO)
26. PRESENTATION
• INCUBATION PERIOD 4 TO 14 DAYS
• SORE THROAT WITH DYSPHAGIA IS EARLY SIGN
• BASED ON CLINICAL PRESENTATION TETANUS IS DIVIDED INTO 4
TYPES
• GENERALIZED TETANUS
• LOCALIZED TETANUS
• CEPHALIC TETANUS
• NEONETAL TETANUS
27. PRESENTATION
GENERALIZED TETANUS;
1. MOST COMMON FORM OF TETANUS (85 TO 90 %)
2. LOCK JAW (trismus, muscle of mastication, 75%)
3. NECK RIGIDITY (neck muscles involvement)
4. FASCIAL MUSCLES CAUSE RISUS SORDONICUS
5. ABDOMINAL TENDERNESS AND GAURDING
MIMICKING ACUTE ABDOMEN
28. PRESENTATION
6. STIFFNESS AND REFLEX SPASMS
Triggered by minimal external stimuli ,
lasts seconds to minutes , more intense
and frequent with disease progression
can cause apnea , fractures , and
rhabdomyolysis. Laryngeal spasm can
occur at any time and cause asphyxia.
30. PRESENTATION
• LOCALIZED TETANUS;
INVOLVES EXTREMITY WITH INFECTED WOUND
UNUSUAL FORM , LESS SEVERE
• CEPHALIC TETANUS;
FOLLOW HEAD INJURY / EAR INFECTION
POOR OUTCOME
ISOLATED OR COMBINED INVOLVEMENT OF
CRANIAL NERVES i.e. 7TH NERVE
INCUBATION PERIOD 1 TO 2 DAYS
31. PRESENTATION
• NEONATEL TETANUS;
FORM OF GENERALIZED TETANUS IN NEONATES
IRRITABILITY , POOR FEEDING , SPASMS AND FASCIAL
GRIMASING
34. WORK UP
• CLINICAL DIAGNOSIS
• LABS HELP TO EXCLUDE DIFFERENTIALS
• CBC ; PERIPHERAL LEUCOCYTOSIS
• RAISED MUSCLE ENZYME LEVEL (CPK , ALDOLASE)
• CSF ; RAISED OPENING PRESSURE
• WOUND C/S
35. WORK UP
• SPATULA TEST ;
1. TOUCHING POSTERIOR PHARYNGEAL WALL CAUSES GAUGE
REFLEX IN NORMAL PERSONS WHILE TETANUS PATIENT
CLENCH THEIR MOUTH DUE TO REFLEX CONTRACTION OF
MASTICATION MUSCLES .
2. NO ADVERSE SEQUELE
3. 94 % SENSITIVE AND 100 % SPECIFIC
EMG ;
CONTINEOUS MOTOR UNIT DISCHARGES / ABSENT SILENT INTERVAL
36. MANAGEMENT
• MAIN GOALS OF TREATMENT ARE
1. SUPPORTIVE THERAPY
2. STOPPING PRODUCTION OF TOXIN
3. NEUTRALIZING UNBOUND TOXIN
4. CONTROLLING DISEASE MANIFESTATION
5. MANAGING COPMLICATIONS
6. DIET AND NUTRITION
37. MANAGEMENT
SUPPORTIVE THERAPY INCLUDE
ADMISSION IN ICU
DARK AND QUITE ENVIRONMENT
AIRWAY MAINTINANCE
PROPHYLACTIC INTUBATION ( 67%)
SUCCINYLCHOLINE TO AVOID REFLEX
LARYNGEOSPASM
TRACHEOSTOMY
INTUBATION > 10 DAYS
FIRST SIEZURE
38. MANAGEMENT
STOPPING PRODUCTION OF TOXIN AT WOUND SITE
BY WOUND DEBRIDEMENT
DONE WHEN PATIENT IS STABLE
TO EXCISE 2 CM OF NORMAL VIABLE TISSUE
AFTER ADMINISTERATION OF ANTITOXIN
BY ANTIBIOTICS
METRONIDAZOLE ( 0.5 GM 6 HOURLY )
OTHERS INCLUDE CLINDAMICIN , VANCOMYSIN
PENICILLIN G NO MORE RECOMMENDED AS IT IS ANTAGONIST OF GABA
39. MANAGEMENT
NEUTRALIZATION OF UNBOUND TOXIN
TETANUS IMMUNOGLOBULIN I/M
( 3000-5000 IU SINGLE DOSE , PART AROUNDWOUND)
TETANUS TOXOID
( 0.5 ML I/M , 2nd +3rd doses in non-immunized )
CONTROL OF DISEASE MANIFESTATION
BENZODIAZEPINES
DIAZEPAM , LORAZEPAM , MIDAZOLAM
DOSE 10-40 mg /1-8 hrs. MAX; 600 mg / day
42. DAKAR SCORING SYSTEM
Prognostic Factor
Score 1 Score 0
Incubation period < 7 days ≥ 7 days or unknown
Period of onset < 2 days ≥ 2 days
Entry site Umbilicus, burn, uterine,
open fracture, surgical
wound, IM injection
All others plus unknown
Spasms Present Absent
Fever > 38.4oC < 38.4oC
Tachycardia Adult > 120 beats/min
Neonate > 150 beats/min
Adult < 120 beats/min
Neonate < 150 beats/min
Total Score
43. PHILLIP SCORING SYSTEM
Factor Score
INCUBATION TIME
< 48 hours 5
2-5 days 4
5-10 days 3
10-14 days 2
> 14 days 1
SITE OF INFECTION
Internal and umbilical 5
Head, neck, and body wall 4
Peripheral proximal 3
Peripheral distal 2
Unknown 1
STATE OF PROTECTION
None 10
Possibly some or maternal immunisation in neonatal patients 8
Protected > 10 years ago 4
Protected < 10 years ago 2
Complete protection 0
COMPLICATING FACTORS
Injury or life threatening illness 10
Severe injury or illness not immediately life threatening 8
Injury or non life threatening illness 4
Minor injury or illness 2
TOTAL SCORE
44. CLINICAL ASSESSMENT OF SEVERITY
Grade 1 (Mild):
Mild to moderate trismus, general increased tone, no respiratory distress, no
spasms, and no dysphagia
Grade 2 (Moderate):
Moderate trismus, marked rigidity, short lasting spasms, tachypnoea ≥ 35minute-
1, mild dysphagia.
Grade Three (Severe):
Severe trismus, generalised increased tone, reflex spontaneous or prolonged spasms,
respiratory distress with tachypnoea ≥ 40minute-1, apnoeic spells, severe dysphagia,
tachycardia ≥120 minute-1, moderate increase in autonomic nervous system
dysfunction.
Grade Four (Very Severe):
Features of Grade III, plus severe autonomic dysfunction, persistent labile blood
pressure and pulse rate.
45. VACCINATION
Vaccine Children under 7 years
1-DPT 6-8 weeks
2-DPT 4-8 weeks after previous dose
3-DPT 4-8 weeks after previous dose
4-DPT 1 year after previous dose
Booster-DPT 4-6 years of age
Adults and children not previously vaccinated
1-Td At presentation
2-Td 4-8 weeks after previous dose
3-Td 6 months - 1 year after previous dose
Booster- Td Every 10 years after previous dose
Pregnant women previously vaccinated
Booster- TT During first six months of pregnancy
Pregnant women not previously vaccinated
1-TT First encounter during pregnancy
2-TT 4 weeks after previous dose
46. PROPHYLAXIS ( WOUND)
• Tetanus
• Prophylaxis: 250 Units IM (single dose)
• Active tetanus: 3000-6000 Units
• Clean minor wound
• # doses unknown or 0-2 doses; toxoid only
• >3 doses; toxoid if >10 years ago
• All other wounds
• # doses unknown or 0-1 doses; toxoid plus IG
• 2 doses; toxoid, but no IG if wound <24 hours old
• >3 doses; toxoid if >5 years ago, and no IG
•
