TETANUS

TETANUS

• Mainly classified as adult type & Neonatal Tetanus • Historically called as locked jaw • Acute spastic paralytic illness caused by tetanus

toxin

ETIOLOGY

• Clostridium tetani • Gram positive, sporing, motile obligate anaerobe • Spores tennis racket type • Tetanospasmin 2nd most powerful toxin after

botulinum toxin

EPIDEMIOLOGY

• Rare in developed countries • One of the leading cases of death in developing

countries • Tetanus toxoid immunization decreased mortality • Mortality is 40-80% in disease

MODE OF TRANSMISSION • Wound contaminated by tetanus spores • Pin prick, Animal bite, intrauterine death , ear

piercing tattooing , unsterile cutting of umbilical cord.

INCUBATION PERIOD

• 6-10 days • lesser the incubation period more the mortality

TYPE OF TETANUS

• Traumatic• Puerperal • Otogenic • Idiopathic • Tetanus neonatorum

TETANUS ( OLDER CHILDREN) CLINICAL FEATURES

• Generalized tetanus, trismus is 1st sign• Headache, irritability, restlessness • Neck stiffness, locked jaw, dysphasia • Risus sardonicus face• Abdominal, lumbar, Hip muscles involved • Opisthotonous ( Bow like) in extension

TETANUS ( OLDER CHILDREN) CLINICAL FEATURES – Contd..

• Board like rigidity of abdomen• Touch sound light exacerbates seizures • Sensory system totally Normal • Consciousness well maintained • Urinary retention • Cephalic tetanus rare, involve bulbar musculature

DIAGNOSIS

• Mainly clinical features are diagnostic• Proper history. Immunization status • Other tests are normal • Clostridium tetani can be isolated from wound only

in 1/3rd cases

DIFFERENTIAL DIAGNOSIS

• Para pharyngeal, Retropharyngeal abscess • Rabies • Hypocalcaemia• Strychnine poisoning • Acute encephalitis

TREATMENT

Wound management • Washing, debridement of Necrotic material, foreign

body removal Eradication of Cl. tetani• Penicillin, Metronidazole • Erythromycin, tetracycline in penicillin allergic

patient

NEUTRALIZATION OF TETANUS TOXIN

• Human anti tetanus immunoglobulin long T ½ 30 days allergy absent

• Equine or horse ATS T ½ 10 days allergy present

CONTROL OF SEIZURES & RESPIRATION

• Diazepam sedation with muscle relaxation • Midazolam, Magnesium sulphate • Baclofen, Dantrolene used for muscle relaxation• Neuromuscular blocking drugs, vecuronium,

pancuronium can be used for generalized muscle paralysis needs assisted ventilation

INTENSIVE SUPPORTIVE CARE

• Dark environment • Minimal sound & touch • Endotrachcal intubation may be required for

assisted ventilation & to prevent aspiration • Cardio respiratory monitoring • Maintain airway • Maintain fluid, electrolyte, calorie requirement

COMPLICATION

• Aspiration pneumonitis • Laryngeal spasm, apnea• Mouth, tongue laceration• Rhabdomyolysis, Myoglobinuria, renal failure • Spinal fracture

PREVENTION - ACTIVE IMMUNIZATION

By tetanus toxoid • Protective level of antitoxin 0.01Iu /ml • Two types of vaccine availableCombined vaccine- DPT • Routinely used in Universal immunization

programme• Contain diphtheria toxoid tetanus toxoid, killed

pertussis organism. Given in 5 doses

PREVENTION - ACTIVE IMMUNIZATION – Contd..

Monovalent vaccine- PTAP, APT• Purified, adsorbed TT• Stored at 4-100c. Only 2 doses given

PREVENTION - PASSIVE IMMUNIZATION

Human tetanus hyper immunoglobulin • Best for prophylaxis• Gives protection for 30 days Equine anti tetanus serum• Protect for 8-10 days • Serum sickness, anaphylaxis, allergy common

PREVENTION - PASSIVE IMMUNIZATION – Contd..

Combined active & passive immunization • Human TIG on one arm & TT on other arm• Followed by one dose of TT after 6 weeksAntibiotic prophylaxis• Single dose IM Benzathine penicillin • 7 days erythromycin• Started within 6 hrs. of injury

TETANUS NEONATORUM

• Also called as 8th day disease • Rare before 2 days & after 2 weeks • C/F:- Excessive cry, refusal to feed apathy, mouth

slightly kept open due to pull of neck muscles • Opisthotonus in extension • Constipation, Apnea• Touch provoked seizure

IN INDIA DISTRICTS CLASSIFIED FOR NEONATAL TETANUS AS

NT high risk • Rate > 1/1000 live birth• TT coverage < 70% • Attended deliveries < 50%NT Control • Rate < 1/1000 live birth• TT coverage >70% • Attended deliveries >50%

IN INDIA DISTRICTS CLASSIFIED FOR NEONATAL TETANUS AS – Contd..

NT Elimination • Rate < 0.1/1000 live birth• TT coverage > 90% • Attended deliveries >75%• NT is 2nd most common cause of death in vaccine

preventable deaths after measles

TRANSMISSION

• Unsterile cutting of cord • Applying cow dung on cord • Unclean delivery surface

TREATMENT SAME AS ADULT TETANUS

• Antibiotic penicillin & Erythromycin • Diazepam sedation & muscle relaxation • Intensive supportive care • Avoid light, sound, touch

PREVENTION OF NT

• Clean delivery practice • “5 cleans”- clean hands, clean delivery surface ,

clean cord, clean thread & clean blade• 2 dose of TT to un immunized mother between 16-

36 weeks of gestation• Minimum 4-6 weeks gap between 2 doses

PREVENTION OF NT – Contd..

Infant born to unimmunized mother Give human

anti tetanus immunoglobulin within 6 hrs. of birth

PROGNOSIS

• 40-80% mortality in diseasedGood prognostic signs • Early diagnosis, long incubation period, absence of

fever • Hypoxic brain injury can lead to cerebral palsy • Cephalic tetanus poor prognosis • Otogenic tetanus better prognosis

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