Tetanus

Notes
  • The disease occurs when the spores of the bacterium Clostridium tetani (that are ubiquitous, found even in the soil) infects a wound or a newborn's umbilical stump.
  • The disease occurs when the bacteria grow in an anaerobic condition, such as dirty wounds, and produce tetanospasmin (a powerful neurotoxin) that blocks inhibitory neurotransmitters in the central nervous system - leading to powerful muscle spasms.
  • Tetanus is usually fatal in neonates, especially in the rural set-up
  • Statistics: number of deaths globally - 59,000 (in 2013); case fatality rate (even in a modern health facility) -10 to 80%; incubation period - 3 to 21days (median 7)
Symptoms
  • Painful muscle spasms and rigidity effecting the jaw, neck, shoulder and abdominal muscles. This causes:

_Trismus or lockjaw (inability to open the mouth)

_Opisthotonos (rigid arching of the back muscles).

_Risus sardonicus (sustained spasm of the facial muscles)

_Laryngospasm

_Dysphagia

  • Death is normally due to respiratory failure.
Diagnosis
  • Strictly depends on clinical evaluation ( tetani is recovered from the wound in only 30% of cases and can be isolated even from the healthy individuals).
Prevention
  • Immunization of women of childbearing age with TT protects the mother and the baby.The baby is protected through a passive process of transfer of tetanus antibodies from the mother.
  • The recovered Tetanus victims do not develop immunity against the disease.
  • Immunization:

Adults;

_Two I.M or S.C injections of 0.5ml given 1 month apart. Booster dose: Every 10yrs.

_Full immunization schedule

_For effective immunization a person needs to receive 3 doses of diphtheria/tetanus/pertussis vaccine in infancy then TT-containing booster at school-entry age (4-7 years), in adolescence (12-15 years), and in early adulthood

_For more details refer to the immunization  schedule under  Pharmacology  & Pharmatherapeutics

Management
  • Place the patient in a quiet shaded area
  • Protect the patient from tactile and auditory stimulation (to avoid stimulation of spasms).
  • Maintaining adequate airway - including intubation
  • Placing the nasogastric tube at the earliest time possible (for nutrition and medicines)
  • Clean and debride the wound
  • Neutralization of toxin;

_Im Tetanus  immunoglobulin  1,000 to 3,000 units STAT

  • Antibiotics;

Either;

_IV or oral Metronidazole 2gm/day x 7-10 days (currently the drug of choice)

Or;

_IV Penicillin G ; Adults -1 mega unit QID x 10/7. Children-50,000 IU/kg QID but BD for infants

(Penicillin G is structurally similar to GABA and competitively antagonises this neurotransmitter hence potentiating the effect of neurotoxin)

Or;

_Other antibiotics that can be include: Tetracyclines, macrolides, clindamycin, cephalosporins and chloramphenicol are also effective.

  • Muscle spasm control (optimum dose is obtained by titration);

_IV / oral Diazepam 10 – 60mg QID (at 0, 6, 12, 18 and 24hr)  and

_IV/IM Phenobarbitone 30-90mg  BD (at 0 and 24hr) and

_IM Chlorpromazine 100mg  alternation with diazepam  (i.e. 3, 9, 15 and 21hr)

Sometimes;

_Magnesium sulphate  (alone or in combination with benzodiazepines): 5 gm (or 75mg/kg) IV loading dose, then 2–3 g/hr until spasm control is achieved.

_Adequate fluids and nutrition

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