Tetanus

By: Dr. Saurav Poudel2016.10.22

• Tetanus is due to toxin secreting clostridium tetani. Clostridium tetani is a box-car shaped, anaerobic bacterium, it is Gram-positive and its appearance on a gram stain resembles tennis rackets or drumsticks. C. tetani is found as spores in soil or in the gastrointestinal tract of animals. C. tetani produces a potent biological toxin, tetanospasmin and tetanolysin.

• Tetanolysin serves no known benefit to C. tetani. Tetanospasmin is a neurotoxin that causes the clinical manifestations of tetanus. Tetanus toxin is generated in living bacteria, and is released when the bacteria lyse, such as during spore germination or vegetative growth.

Clostridium Tetani

Mode Of Transmission

• Infection is acquired by contamination of wounds with tetanus spores.The range of injuries and accidents which may lead to tetanus comprise pin prick,skin abrasion,punctured wound,burns,human bites,animal bites,stings,compound fracture and use of unsterile instrument to cut umbilical cord etc.

• Incubation Period : 5 days to 15 weeks, with the average :- 8-12 days.

Clinical Features

• Prodromal state : -dysphagia - pain in the neck,back and abdomen -pain and tingling at the site of wound.

• Stage of tonic rigidity :- Trismus (lock-jaw):spasm of massester

muscles.- Muscle spasticity- Risus sardonicus :contraction of the muscle at

the angle of mouth and frontalis.- Opisthotonus : spasm of muscles of back and

neck.

• State of clonic spasm:-laryngeal and pharyngeal spasm-spasm of respiratory muscle-acute asphyxia• Others –-patient is awake and alert throughout the

illness.Sensory examination is normal,temperature is normal or slightly elevated.

Risus Sardonicus

Opisthotonus

Trismus

• Death results from aspiration,hypoxia,respiratory failure,cardiac arrest or exhaustion.Poor prognostic indicators include short incubation period,short onset of time and extremes of age.

• Cephalic tetanus is uncommon but invariably fatal.It usually occurs when the portal of entry of C.tetani is the middle ear. Cranial nerve abnormalities particularly of 7th,9th are usual.

• Neonatal tetanus is usually due to infection of the umbilical stump.Failure to thrive,poor sucking,grimacing & irritability are followed by the rapid development of intense rigidity and spasms.

Differential Diagnosis

-meningitis-encephalitis-tetany-epilepsy-strychnine poisoning

Investigation

• Diagnosis is clinical• Isolation of organisms from site of inoculation• Essential of diagnosis:①History of wound & possible contamination②Jaw stiffness followed by spasm of jaw muscles③Stiffness of the neck and other

muscles,dysphagia,irritable hyperreflexia④Finally painful covulsion precipitated by minimal

stimuli.

Treatment

a. Control of spasm :-inj. Diazepam 0.1-0.2mg/kg if not control, paralyze with muscle relaxant and ventilate.b.Neutralization of toxin:-tetanus immunoglobulin 3000-6000 units IM single dose or 500 unit for neonate.-tetanus antitoxin after sensitivity test:50000 to 100000 units 1/2 i.m & 1/2 i.v.

c.To eradicate vegetative form by antibiotics-Benzyl penicillin 600mg 6 hrly i.v for 10 days or-metronidazole 400-800 mg 8 hrly for 7 days-in penicillin sensitive case:Erythromycind.Local wound care:-closed wound should be opened.-all dead tissue should be removed-wash by hydrogen peroxide

e.Supporative Care:-isolation in a quite dark room-maintenance of fluid,nutrition and electrolytes-oxygen inhalation.

Prevention of Tetanus

• Active immunization: 3 doses of DPT• Use of early antibiotics• Early treatment of wound• Three cleans during delivery:*clean hand*clean delivery surface*clean cord care

Complication of Tetanus

• Acute asphyxia• Aspiration pmeumonia• Respiratory arrest• Cardiac failure• Urinary retention• Vertebra fracture• Laceration of tongue,lips,buccal mucosa.

THANK YOU From- Dr. $aurav Poudel. (

saurav7utd@hotmail.com) if any query!!