TETANUS M&P

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TETANUSMANAGEMENT ANDPREVENTION


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Definition

Tetanus is an illness characterized by an acute

onset of hypertonia, painful muscular

contractions (usually of the muscles of the jaw

and neck), and generalized muscle spasmswithout other apparent medical causes.


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Management

Objectives of management of tetanus are:

provide supportive care until the

tetanospasmin that is fixed in tissue has been

metabolized

Neutralize circulating toxin

remove the source of tetanospasmin


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Patient Care

All patients should be admitted to a medical orneurological intensive care unit where they can bemonitored and observed continuously

Some hospitals in which tetanus is frequently

encountered have specially constructed, quiet,dark rooms to minimize extrinsic stimuli that mighttrigger paroxysmal spasms

Patients must be allowed to rest quietly to limitperipheral stimuli, and they must be positionedcarefully to prevent aspiration pneumonia

Intravenous fluids should be instituted, andelectrolytes and blood gases are essential toguide therapy.


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Antibiotics

Penicillin is the standard therapy for tetanus inmost parts of the world, although antibiotics forC.tetani probably play a relatively minor role in thespecific treatment of this disease. The

recommended dose is 100,000200,000 IU/dayintramuscularly or intravenously for 710 days.

Metronidazole is also considered as therapy andis a safe alternative to penicillin. Rectaladministration of metronidazole is rapidly

bioavailable and produces fewer spasms thanrepeated intravenous or intramuscular injections.Consequently, metronidazole is considered as thedrug of choice in the treatment of tetanus. / e doseis 400 mg rectally or 500 mg intravenously every 6

hours for 710 days.


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Muscle Spasm Therapy

Vigorous and aggressive management of muscle

spasms is a cornerstone of therapy. The objective

of the first approach is to mildly sedate the patient

without affecting respiratory function. The sedatedpatient is less affected by peripheral stimuli and

less likely to develop muscle spasms.

The short-acting barbiturates such as secobarbital

and phenobarbital are useful in sedating patientswith mild tetanus. Initial doses of 1.52.5 mg/kg

for children or 100150 mg intramuscularly for

adults may be used.


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Phenobarbital may be given in a dose of 120200

mg intravenously, and diazepam may be added in

divided doses up to 120 mg/day.

Diazepam may prevent or control seizures.Chloropromazine, given every 48 hours in doses

from 412 mg in the infant to 50150 mg in the

adult, may be effective in controlling tetanic

convulsions. Mechanical ventilatory support is often required to

counteract the drug-induced ventilatory

depression that becomes apparent in the intervals

between spasms.


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Muscla spasm also may be controlled primarily byneuromuscular blocking agents, such as d-tubocurarine chloride or pancuronium bromide,while sedation is induced with smaller doses of

the central depressant drugs. Magnesium is a physiological calcium antagonist

in which there is a signifi cant correlation betweenthe depression of neuromuscular transmissionand serum magnesium concentrations. The

infusion rate of magnesium sulphate wasincreased to control spasms, while retaining thepatella tendon reflex, which proved a valuableguide to prevent overdose.


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Nutritional Imbalance

tetanus is associated with clinical and biochemicalevidence of sympathetic overdischarge andprotein catabolism

Consequently, the resulting loss of body weight

encountered must reflect a diminution of leanbody cell mass. The consequent protein depletionwill result in reduced host defenses and maythereby worsen prognosis

A rational approach to achieving metabolic controlwould be the use of adrenergic blocking agents,although it remains to be seen whether suchtherapy can suppress the hypermetabolic state


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other therapeutic alternative is by parenteralfeeding. Total parenteral nutrition containinghypertonic glucose and insulin, in sufficientquantities to control blood sugar, can suppress

this protein catabolism. The use of amino acidformulations containing increased branched chainamino acid concentrations is another helpfulapproach to limit protein catabolism

Physical therapy should be started early in the

convalescent period of the disease. Ifneuromuscular blocking agents are used intreatment, passive movements of the patientsarms and legs should be instituted.


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Anti Tetanus Serum

After the initial evaluation, human tetanus immuneglobulin (TIG) should be injected intramuscularly in atotal dose of 3000 units, injected in three equalportions into three separate sites. Because the halflifeof TIG is 2530 days, only a single treatment isrequired.

Antiserum does not neutralize tetanospasmin alreadyfi xed in the nervous system, nor does it have anyspecial effect when administered locally in the wound

Consequently, active immunization should beinstituted concomitantly with the passiveimmunization. The combined active and passiveprophylaxis of tetanus does not decrease thesubsequent development of antibodies from tetanustoxoid


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TIG is a solution of gamma globulin preparedfrom the venous blood of humans,hyperimmunized with tetanus toxoid.

This immune globulin has been found to benonreactive for hepatitis B surface antigen,using the radioimmunoassay method ofcounterelectrophoresis.

It is administered by a deep intramuscularinjection in a different extremity from thatreceiving the intramuscular injection of vaccine


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Wound Care

The wound should be cleansed thoroughly and

debrided. Abscesses should be drained, and

foreign bodies and necrotic tissue should be

removed.


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Cardiovascular Disturbances

Because pulmonary embolism has been a

common cause of death in tetanus patients,

many employ anticoagulants routinely during

treatment. Although subcutaneous heparin hasbeen used to anticoagulate these patients,

complete protection against thromboembolism

has not always been obtained, and the risks of

hemorrhage are always present


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Tetanus Prevention

Because there is essentially no natural

immunity to tetanus toxin, the only effective

way to control tetanus is by prophylactic

immunization. / us, universal primaryimmunization with subsequent maintenance of

adequate antitoxin levels by means of

appropriately timed boosters is necessary to

protect all age groups.


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Tetanus toxoid was developed by Descombeyin1924,

Tetanus toxoid immunizations were usedextensively in the armed services during World

War II. Tetanus toxoid consists of a formaldehyde-

treated toxin.

There are two types of toxoid available adsorbed (aluminum salt precipitated)toxoid andfluid toxoid.

Although the rates of seroconversion are aboutequal,the adsorbed toxoid is preferred becausethe antitoxin response reaches higher titersand

is longer lasting than that following the fluid

TETANUS TOXOID

S f


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Tetanus Toxoid Adsorbed USP,for intramuscular use,is a sterile

suspension of alum-precipitated (aluminum potassium

sulfate)toxoid in an isotonic sodium chloride solution containing

sodium phosphate buffer to control pH.The vaccine,after

shaking,is a turbid liquid,whitish-gray in color.

Clostridium tetani culture is grown in a peptone-based medium

and detoxified with formaldehyde.The detoxified material is then

purified by serial ammonium sulfate fractionation,followed by

sterile filtration,and the toxoid is adsorbed to aluminumpotassium sulfate (alum).The adsorbed toxoid is diluted with

physiological saline solution (0.85%)and thimerosal (a mercury

derivative)is added to a final concentration of 1:10,000.

Each 0.5 mL dose is formulated to contain 5 Lf (flocculation

units)of tetanus toxoid and not more than 0.25 mg of aluminum.

The residual formaldehyde content,by assay,is less than

0.02%.The tetanus toxoid induces at least 2 units of antitoxin

per mL in the guinea pig potency test.


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Active Immunization

1stdose - 6thweek

2nddose - 10thweek

3rddose - 14thweek

1stbooster - 18thmonth

2ndbooster - 6thyear

3rdbooster - 10thyear


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Active Immunization for Normal

Infant and Children

Immunization should begin in early infancy andrequires four injections of DTaP administered at 2months, 4 months, 6 months, and 15-18 months

A fi fth dose is administered at 46 years of age.

Ten years after the fifth dose (1416 years of age), aninjection of Td, which contains the same dose oftetanus toxoid as DTP and a reduced dose ofdiphtheria toxoid, should be administered andrepeated every 10 years throughout the individuals

life in the event that there have been no significantreactions to DTP or Td.

Adsorbed preparations should be administeredintramuscularly. Vaccine administration by jet injectionmay be associated with more frequent reactions.


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Active Immunization for Normal Infants and

Children Up to Age 7 Not

Immunized at Early Infancy

DTP should be administered on the first visit and2 and 4 months after the first injection.

A fourth dose should be administered 612months after the first injection.

The fifth dose is administered between 4 and 6years of age. Ten years after the fifth dose (1416years of age), an injection of Td should beadministered and repeated every 10 yearsthroughout the individuals life in the event thatthere have been no significant reactions to DTP orTd.

The preschool dose is not necessary if the fourthdose of DTP is administered after the fourth

birthday.


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regnan omen o ave o


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regnan omen o ave oBeen

Immunized Neonatal tetanus is preventable by active

immunization of the pregnant mother. A previouslyunimmunized pregnant woman who may deliver herchild under unhygienic conditions should receive twoproperly spaced doses of Td before delivery,

preferably during the last two trimesters, given 2months apart.

After the delivery, the mother should be given the thirddose of Td 6 months after the second dose tocomplete the active immunization

An injection of Td should be repeated every 10 yearsthroughout life in the event that there have been nonsignificant reactions to Td. If a neonate is borne by anon immunized mother without obstetric care, theinfant should receive 250 units of human TIG. Activeand passive immunization of the mother should also

Children under Seven with a


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Children under Seven with a

Contraindication

to Pertussis Vaccination

DT (for pediatric use) should be used rather than DTaP.Unimmunized children under 1 year old receiving their firstDT dose should receive a total of four doses of DT as theprimary series, the first three doses at 4- to 8-week intervalsand the fourth dose 612 months later. If further doses ofpertussis vaccine become contraindicated after beginning aDTaP series in the first year of life, DT should be substitutedfor each of the remaining scheduled DTaP doses.

Unimmunized children one year old or above for whom DTaPis contraindicated should receive two doses of DT 48 weeksapart, followed by a third dose 612 months later to complete

the primary series. Children one year old or above who have received 12 doses

of DT or DTaP and for whom further pertussis vaccine iscontraindicated should receive a total of three doses of DT,with the third dose administered 612 months after thesecond dose.


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Infants with, or Unimmunized Infants Suspected of

Having, Underlying Neurologic Disease

It is prudent to delay initiation of immunizationwith DTaP or DT until further observation andstudy have clarified the childs neurologicstatus.

The effect of treatment, if any, can beassessed.

The decision whether to commence

immunization with DTaP or DT should bemade no later than the childsfirst birthday.

In addition, because of neurologic disabilities,these children may be in greater jeopardy from

complications of the disease.


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Infants With Neurologic Events Temporarily

Associated with DTaP Vaccination

Infants and children who experience a seizure

within 3 days of receipt of DTaP or an

encephalopathy within 7 days should not

receive pertussis vaccine, even though causeand effect may not be established.

Incompletely Immunized Children with


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Incompletely Immunized Children withNeurologic Events Occurring Between

Vaccination Doses

If the seizure or other disorder occurs before the firstbirthday and completion of the first three doses of theprimary series of DTaP, deferral of further doses ofDTaP or DT is recommended until the infants statushas been clarified.

The decision whether to use the DTaP or DT tocomplete the series should be made no later than thechildsfirst birthday and should take into considerationthe nature of the childsproblem and the benefits andrisks of the vaccine.

If the seizure or other disorder occurs after the firstbirthday, the childs neurologic status should beevaluated to ensure that the disorder is stable beforea subsequent dose of DTaP is given.


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Infants and Children with Stable Neurologic

Conditions

Infants and children with stable neurologic conditions,including well-controlled seizures, may be vaccinated.

The occurrence of single seizures (temporarily associatedwith DTaP) in infants and young children, while necessitatingevaluation, need not contraindicate DTaP immunization,

particularly if the seizures can be satisfactorily explained. Anticonvulsant prophylaxis should be considered when giving

DTaP to

such children.

Parents of infants and children with histories of convulsions

should be made aware of slightly increased chance ofpostimmunization seizures.

A static neurologic condition, such as cerebral palsy or afamily history of a neurologic disease or convulsions, is not acontraindication to giving vaccines containing pertussisantigen.

ren w eso ve or


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ren w eso ve orCorrected

Neurologic Disorders DTaP immunization is recommended for

infants with certain neurologic problems that

have clearly subsided without residue or have

been corrected, such as neonatalhypocalcemic tetany or hydrocephalus

(following placement of a shunt and without

seizures).

Contraindications to pertussis


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Contraindications to pertussis

vaccine personal history of a prior convulsion

the presence of an evolving neurologic disorder

(e.g., uncontrolled epilepsy, infantile spasm,

progressive encephalopathy, etc.)

adverse reactions to DTaP or single antigen

pertussis vaccination that include any of the

following: allergic hypersensitivity

fever of 40.5 C (105 F) or greater within 48 hours

collapse or shock-like (hypotonic-hyporesponsive episode) within 48

hours

ersisting, inconsolable crying, lasting 3 hours or more, or an unusual

high-pitched cry, occurring within 48 hours

convulsion(s) with or without fever, occurring within three days (such

seizures do not predispose to permanent brain damage)


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History of tetanus immunization should be verified frommedical records so that appropriate tetanus prophylaxis canbe accomplished.

Patients with unknown or uncertain previous immunizationhistories should be considered to have no previous tetanus

toxoid doses meticulous surgical care using aseptic technique that includes

removal of all devitalized tissue and foreign bodies should beprovided immediately for all wounds

Td is the preferred preparation for active tetanusimmunization in wound management in the adult. Thispreparation immunizes the patient against tetanus,

while enhancing diphtheria protection in a large proportion ofthe adult population who are susceptible to diphtheria.

For routine wound management of children under 7 years ofage, DTaP should be used instead of a single-antigen tetanus

toxoid.


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For every wounded patient, record in a permanentmedical record pertinent information about theclinical features of the wound, previous activeimmunization status, history of a neurologic or

severe hypersensitivity reaction,immunoprophylaxis (manufacturer, lot number,and site of injection), and plans for follow-up.

Tetanus infection may not confer immunity;

therefore, active immunization should be initiatedat the time of recovery from the illness.

Arrangements should be made to ensure that theremaining doses of a primary series are

administered as early as possible.


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