TetanusTetanus

Dr.Vemuri ChaitanyaDr.Vemuri Chaitanya

TetanusTetanus

Tetanos – a greek word – Tetanos – a greek word – to strechto strech First described by Hippocrates & SusrutaFirst described by Hippocrates & Susruta A Neurological disease characterised by A Neurological disease characterised by

increased muscle tone & spasms.increased muscle tone & spasms. Caused by Caused by CLOSTRIDIUM TETANICLOSTRIDIUM TETANI An anaerobic, motile, gram positive rod An anaerobic, motile, gram positive rod

that forms oval, colourless, terminal that forms oval, colourless, terminal spores – spores – tennis racket or drumstick tennis racket or drumstick shape.shape.

It is found worldwide in soil, in It is found worldwide in soil, in inanimate environment, in animal inanimate environment, in animal faeces & occasionally human faeces.faeces & occasionally human faeces.

Epidemiology Epidemiology

Occurs sporadically Occurs sporadically Affects unimmunized, partially Affects unimmunized, partially

immunized & fully immunized who immunized & fully immunized who fail to maintain adequate immunity fail to maintain adequate immunity with booster doses of vaccine.with booster doses of vaccine.

Although it is an entirely Although it is an entirely preventable disease by immunization preventable disease by immunization , the burden of disease worldwide is , the burden of disease worldwide is great.great.

As reporting is inaccurate & incomplete, particularly As reporting is inaccurate & incomplete, particularly in devoleping countries, in devoleping countries, W.H.O W.H.O considers reported considers reported cases to be an underestimate & takes cases to be an underestimate & takes case/death case/death estimatesestimates to assess the burden of disease. to assess the burden of disease.

In 2002, the estimated deaths in all age groups In 2002, the estimated deaths in all age groups 2,13,0002,13,000 of which of which 1,80,0001,80,000 were attributable to were attributable to neonatal tetanus. neonatal tetanus.

More common in areas where soil is cultivated, inMore common in areas where soil is cultivated, in rural rural areas, in areas, in warm climateswarm climates, during, during summer summer, , among among malesmales..

PathogenesisPathogenesis

Contamination of wounds with Contamination of wounds with spores of C.tetani.spores of C.tetani.

Germination & toxin productionGermination & toxin production – in – in wounds with low oxidation – wounds with low oxidation – reduction potential ( devitalized reduction potential ( devitalized tissues, F.B, active infection )tissues, F.B, active infection )

TetanospasminTetanospasmin ( neurotoxin ) ( neurotoxin ) Tetanolysin ( hemolysin )Tetanolysin ( hemolysin )

Tetanospasmin ( exotoxin ) produced locally Tetanospasmin ( exotoxin ) produced locally , released into bloodstream ., released into bloodstream .

Binds to peripheral motor neuron terminals Binds to peripheral motor neuron terminals & nerve cells of ant.horn of spinal cord& nerve cells of ant.horn of spinal cord

The toxin after entering axon , transported The toxin after entering axon , transported to nerve cell body in brain stem & spinal to nerve cell body in brain stem & spinal cord – cord – retrograde intraneuronal transportretrograde intraneuronal transport

Toxin – migrates across synapse – Toxin – migrates across synapse – presynaptic terminals- blocks the release of presynaptic terminals- blocks the release of Glycine & GABAGlycine & GABA from vesicles. from vesicles.

The blocking of neurotransmitter release The blocking of neurotransmitter release by Tetanospasmin involves by Tetanospasmin involves cleavage ofcleavage of SynaptobrevinSynaptobrevin – essential for proper fn of – essential for proper fn of synaptic vesicle release apparatussynaptic vesicle release apparatus

With diminished inhibition – resting With diminished inhibition – resting firing rate of alpha motor neurons firing rate of alpha motor neurons increases – increases – rigidityrigidity

Lessened activity of reflexes which limit Lessened activity of reflexes which limit polysynaptic spread of impulses, agonists polysynaptic spread of impulses, agonists & antagonists recruited - & antagonists recruited - spasmsspasms

Loss of inhibition of preganglionic Loss of inhibition of preganglionic sym neurons – sympathetic sym neurons – sympathetic hyperactivity hyperactivity

Mode of transmission Mode of transmission Infection is acquired by contamination of Infection is acquired by contamination of

wounds with tetanus spores.wounds with tetanus spores. Range of injuries & accidents – Range of injuries & accidents – trivial pin trivial pin

prick, skin abrasion, puncture wounds, prick, skin abrasion, puncture wounds, burns, human bites, animal bites & stings, burns, human bites, animal bites & stings, unsterile surgery, IUD, bowel surgery, unsterile surgery, IUD, bowel surgery, dental extractions, injections, unsterile dental extractions, injections, unsterile division of umbilical cord, compound #, division of umbilical cord, compound #, otitis media, chr.skin ulcers, eye infections, otitis media, chr.skin ulcers, eye infections, gangrenegangrene

NOT TRANSMITTED FROM PERSON TO NOT TRANSMITTED FROM PERSON TO PERSONPERSON

Types Types

TraumaticTraumatic PuerperalPuerperal OtogenicOtogenic IdiopathicIdiopathic Tetanus Tetanus

neonatorumneonatorum

PARK PARK 1919thth

GeneralizedGeneralized NeonatalNeonatal locallocal

HARRISON HARRISON 17th17th

Clinical featuresClinical features

May begin from 2 days to several weeks May begin from 2 days to several weeks

after the injury – USUALLY 1 WEEK after the injury – USUALLY 1 WEEK

RememberRemember

Shorter the incubation period Shorter the incubation period

More severe the attackMore severe the attack

Worse the prognosisWorse the prognosis

Clinical featuresClinical features GENERALIZED TETANUSGENERALIZED TETANUS• Most commonMost common• Increased muscle tone & generalized spasmsIncreased muscle tone & generalized spasms• Median time of onset after injury – Median time of onset after injury – 7 days7 days• Pt 1Pt 1stst notices increased tone in masseter notices increased tone in masseter

( ( Trismus, lock jawTrismus, lock jaw ) )• Dysphagia Dysphagia • Stiffness / pain in neck, shoulder, back Stiffness / pain in neck, shoulder, back

muscles appear concurrently / or soon muscles appear concurrently / or soon thereafterthereafter

• Rigid abd & stiff prox.limb muscles . Rigid abd & stiff prox.limb muscles . Hands, Hands, feetfeet spared.spared.

trismustrismus

Risus SardonicusRisus Sardonicus : Spasm of facial muscles : Spasm of facial muscles ( frontalis & angle of mouth muscles ) ( frontalis & angle of mouth muscles ) producing grinning faciesproducing grinning facies

OpisthotonusOpisthotonus : Painful spasms of neck, trunk : Painful spasms of neck, trunk and extremity. producing characteristic and extremity. producing characteristic bowing bowing and and archingarching of backof back

Some pts devolep paroxysmal, violent, Some pts devolep paroxysmal, violent, painful, generalized muscle spasms – painful, generalized muscle spasms – cyanosis . Spasms occur repetitively & may cyanosis . Spasms occur repetitively & may be spontaneous / provoked by slightest be spontaneous / provoked by slightest stimulation.stimulation.

Constant threat during gen.spasm is reduced Constant threat during gen.spasm is reduced ventilation, apnea / laryngospasm.ventilation, apnea / laryngospasm.

Risus sardonicusRisus sardonicus

Mild dsMild ds ( muscle rigidity , no / few ( muscle rigidity , no / few spasms )spasms )

Moderate dsModerate ds (trismus, dysphagia, (trismus, dysphagia, rigidity, spasm)rigidity, spasm)

Severe dsSevere ds ( freq explosive paroxysms ) ( freq explosive paroxysms ) Autonomic dysfn complicates severe Autonomic dysfn complicates severe

cases - labile htn, hyperpyrexia, cases - labile htn, hyperpyrexia, profuse sweating, peripheral profuse sweating, peripheral vasoconstriction, raised catecholamines.vasoconstriction, raised catecholamines.

Neonatal TetanusNeonatal Tetanus

Usually fatal if untreated Usually fatal if untreated Children born to inadequately Children born to inadequately

immunized mothers, after immunized mothers, after unsterile unsterile treatment of umbilical stumptreatment of umbilical stump

During first 2 weeks of life.During first 2 weeks of life. Poor feeding ,rigidity and Poor feeding ,rigidity and

spasmsspasms

Local TetanusLocal Tetanus

Uncommon form Uncommon form Manifestations are restricted to Manifestations are restricted to

muscles near the wound.muscles near the wound.

Cramping and twisting in skeletal Cramping and twisting in skeletal

muscles surrounding the wound – muscles surrounding the wound –

local rigiditylocal rigidity Prognosis – excellentPrognosis – excellent

Cephalic TetanusCephalic Tetanus

A rare form of local tetanusA rare form of local tetanus Follows head injury / ear infectionFollows head injury / ear infection Involves one / more facial cranial Involves one / more facial cranial

nervesnerves Trismus and localised

paralysis ,usually facial nerve, often unilateral.

Incubation period : few daysIncubation period : few days Mortality : Mortality : highhigh

DiagnosisDiagnosis Based entirely on Based entirely on clinical findingsclinical findings Examine all cases with wound infection & Examine all cases with wound infection &

muscle stiffnessmuscle stiffness Wound culturesWound cultures – in suspected cases – in suspected cases

C.tetani can be isolated from wounds C.tetani can be isolated from wounds of pts without tetanus & freq cannot be of pts without tetanus & freq cannot be isolated from wounds of those with isolated from wounds of those with tetanustetanus

ElectromyogramsElectromyograms – continous discharge of – continous discharge of motor units, shortening / absence of silent motor units, shortening / absence of silent interval seen after AP.interval seen after AP.

Muscle enzymes – raisedMuscle enzymes – raised

Serum Anti toxin levels >= 0.1 IU/ml Serum Anti toxin levels >= 0.1 IU/ml – protective & makes tetanus – protective & makes tetanus unlikely .unlikely .

Differential diagnosisDifferential diagnosis

Cond producing trismus : alveolar Cond producing trismus : alveolar abscess, strychnine poisoning, dystonic abscess, strychnine poisoning, dystonic drug reactions, hypocalemic tetanydrug reactions, hypocalemic tetany

Meningitis/encephalitisMeningitis/encephalitis Marked increased tone in central Marked increased tone in central

muscles , with superimposed muscles , with superimposed generalized spasms & relative sparing generalized spasms & relative sparing of hands & feetof hands & feet – sugg – sugg tetanus tetanus

Treatment – general Treatment – general measuresmeasures

Goal is to eliminate the source of toxin, Goal is to eliminate the source of toxin, neutralize the unbound toxin & prevent neutralize the unbound toxin & prevent muscle spasm & providing support - muscle spasm & providing support - resp supportresp support

Admit in a quiet room in ICU Admit in a quiet room in ICU Continuous careful observation & Continuous careful observation &

cardiopulmonary monitoringcardiopulmonary monitoring Minimize stimulationMinimize stimulation Protect airwayProtect airway Explore wounds – Explore wounds – debridementdebridement

NEUTRALIZE TOXINNEUTRALIZE TOXIN : :• Inj.Human Tetanus Immunoglobulin 3000 – 6000 Inj.Human Tetanus Immunoglobulin 3000 – 6000

units IM, usually in divided doses as volume is large.units IM, usually in divided doses as volume is large. ANTIBIOTIC THERAPYANTIBIOTIC THERAPY : :• Although of unproven value , antibiotics adm to Although of unproven value , antibiotics adm to

eradicate vegetative cells – the source of toxineradicate vegetative cells – the source of toxin• IV PenicillinIV Penicillin 10 -12 million units daily for 10 days 10 -12 million units daily for 10 days• IV MetronidazoleIV Metronidazole 500mg Q 6 hrly / 1gm Q 12 hrly 500mg Q 6 hrly / 1gm Q 12 hrly• Allergic to Penicillin : consider Allergic to Penicillin : consider Clindamycin & Clindamycin &

ErythromycinErythromycin

Control of SpasmsControl of Spasms

Nurse in a quiet dark roomNurse in a quiet dark room Avoid noise & other stimuliAvoid noise & other stimuli IV DiazepamIV Diazepam / Lorazepam / Midazolam / Lorazepam / Midazolam Barbiturates & Chlorpromazine –2nd line Barbiturates & Chlorpromazine –2nd line

drugsdrugs Continued spasms : intubate & ventilateContinued spasms : intubate & ventilate Propofol, dantrolene, intrathecal Propofol, dantrolene, intrathecal

baclofen, succinylcholine & magnesium baclofen, succinylcholine & magnesium sulfate can be triedsulfate can be tried

Management of Management of autonomic dysfnautonomic dysfn

LabetalolLabetalol Continuous infusion of esmololContinuous infusion of esmolol Clonidine / verapamilClonidine / verapamil

Additional measuresAdditional measures

Pts recovering from tetanus should Pts recovering from tetanus should be actively immunized be actively immunized

HydrationHydration NutritionNutrition PhysiotherapyPhysiotherapy Prophylactic anticoagulationProphylactic anticoagulation Bowel, bladder, back careBowel, bladder, back care Treatment of intercurrent infectionTreatment of intercurrent infection

Prevention – Active Prevention – Active ImmunizationImmunization

For partially immunized, unimmunized and For partially immunized, unimmunized and

recovering from tetanus recovering from tetanus It stimulates production of protective antitoxinIt stimulates production of protective antitoxin 2 prep : 2 prep : combined vaccinecombined vaccine : DPT : DPT

monovalent vaccinemonovalent vaccine : plain / formol : plain / formol

toxoidtoxoid

tetanus vaccine , tetanus vaccine , adsorbedadsorbed

Combined vaccineCombined vaccine

According to National Immunization, According to National Immunization, 3 doses of DPT – at intervals of 4-8 3 doses of DPT – at intervals of 4-8 wks, wks, starting at 6 wks agestarting at 6 wks age, followed , followed by by

booster at booster at 18 months age18 months age 22ndnd booster (only DT) booster (only DT) at 5-6 yrs at 5-6 yrs 33rdrd booster ( only TT) booster ( only TT) after 10 yrs after 10 yrs

ageage

Monovalent vaccinesMonovalent vaccines Purified tetanus toxoid ( adsorbed ) supplanted Purified tetanus toxoid ( adsorbed ) supplanted

the palin toxoid – higher & long lasting the palin toxoid – higher & long lasting immunity responseimmunity response

Primary course of immunization – 2 doses Primary course of immunization – 2 doses Each 0.5 ml , injected into arm given at Each 0.5 ml , injected into arm given at

intervals of 1-2 monthsintervals of 1-2 months The longer the interval b/w two doses, better is The longer the interval b/w two doses, better is

the immune responsethe immune response 11stst booster – booster – 1 yr after the initial 2 doses1 yr after the initial 2 doses 22ndnd Booster : Booster : 5 yrs after the 15 yrs after the 1stst booster booster

( optional )( optional ) Freq boosters to be avoidedFreq boosters to be avoided

Passive immunization Passive immunization

Temp protection – human tetanus Temp protection – human tetanus immunoglobulin /ATSimmunoglobulin /ATS

Human Tetanus Human Tetanus HyperimmunoglobulinHyperimmunoglobulin : :

• 250-500 IU250-500 IU• Does not cause serum sicknessDoes not cause serum sickness• Longer passive protection compared Longer passive protection compared

to horse ATS( 30 days / 7 -10 days )to horse ATS( 30 days / 7 -10 days )

Passive immunizationPassive immunization

ATS ( EQUINE ) :ATS ( EQUINE ) :• 1500 IU s/c after sensitivity testing1500 IU s/c after sensitivity testing• 7 – 10 days7 – 10 days• High risk of serum sicknessHigh risk of serum sickness• It stimulates formation of antibodies It stimulates formation of antibodies

to it , hence a person who has once to it , hence a person who has once received ATS tends to rapidly received ATS tends to rapidly eliminate subsequent doses.eliminate subsequent doses.

Active & Passive Active & Passive ImmunizationImmunization

In non immunized personsIn non immunized persons 1500 IU of ATS / 250-500 units of 1500 IU of ATS / 250-500 units of

Human Ig in one arm & 0.5 ml of Human Ig in one arm & 0.5 ml of adsorbed tetanus toxoid into other adsorbed tetanus toxoid into other arm /gluteal regionarm /gluteal region

6 wks later, 0.5 ml of tetanus toxoid6 wks later, 0.5 ml of tetanus toxoid 1 yr later , 0.5 ml of tetanus toxoid1 yr later , 0.5 ml of tetanus toxoid

Prevention of neonatal Prevention of neonatal tetanustetanus

Clean delivery practicesClean delivery practices 3 cleans : clean hands, clean delivery 3 cleans : clean hands, clean delivery

surface, clean cord caresurface, clean cord care Tetanus toxoid protects both mother & Tetanus toxoid protects both mother &

childchild Unimmunized pregnant women : 2 doses Unimmunized pregnant women : 2 doses

tetanus toxoidtetanus toxoid• 11stst dose as early as possible during dose as early as possible during

pregnancypregnancy• 22ndnd dose – at least a month later / 3 wks dose – at least a month later / 3 wks

before deliverybefore delivery

Immunized pregnant women : a Immunized pregnant women : a booster is sufficientbooster is sufficient

No need of booster in every No need of booster in every consecutive pregnancyconsecutive pregnancy

Prevention of tetanus Prevention of tetanus after injury after injury

All wounds should be thoroughly cleaned soon after All wounds should be thoroughly cleaned soon after injury injury

Remove all foreign bodies, soil, dust, necrotic Remove all foreign bodies, soil, dust, necrotic tissuetissue

AA – completed course of toxoid/booster < 5 yrs ago – completed course of toxoid/booster < 5 yrs ago BB- completed course of toxoid / booster >5 yrs ago - completed course of toxoid / booster >5 yrs ago

& < 10 yrs ago& < 10 yrs ago CC- completed course of toxoid / booster >10 yrs - completed course of toxoid / booster >10 yrs

agoago DD- not completed course of toxoid / immunity status - not completed course of toxoid / immunity status

unknownunknown

Wounds < 6hrs, clean, non Wounds < 6hrs, clean, non penetrating & negligible penetrating & negligible

tissue damagetissue damage

Immunity CategoryImmunity Category

• AA• BB• CC• DD

TreatmentTreatment

• Nothing more Nothing more requiredrequired

• Toxoid 1 doseToxoid 1 dose• Toxoid 1 doseToxoid 1 dose• Toxoid complete Toxoid complete

coursecourse

Other WoundsOther Wounds

Immunity Category Immunity Category

• AA• BB• CC

• DD

TreatmentTreatment

• Nothing more Nothing more requiredrequired

• Toxoid 1 doseToxoid 1 dose• Toxoid 1 dose + Toxoid 1 dose +

Human Tetanus IgHuman Tetanus Ig• Toxoid complete Toxoid complete

course + Human course + Human Tetanus IgTetanus Ig

Thank YouThank You