Tetanus

Introduction
• Tetanus is a neurological disease characterized by an acute onset of
hypertonia, painful muscular contractions (usually of the muscles of
the jaw and neck), and generalized muscle spasms without other
apparent medical causes.
• Only vaccine preventable disease that is infectious but not contagious.
CAUSATIVE AGENT
• Caused by CLOSTRIDIUM TETANI
• Anaerobic
• Motile
• Gram positive bacilli
• Oval, colourless, terminal spores - tennis racket or drumstick shape.
• It is found worldwide in soil, in inanimate environment, in animal
faeces & occasionally human faeces.
EPIDEMIOLOGY
• Tetanus is an international health problem, as spores are ubiquitous. The
disease occurs almost exclusively in persons who are unvaccinated or
inadequately immunized.
• Entirely preventable disease by immunization
• More common in developing and under developing countries.
• More prevalent in industrial establishment, where agricultural workers are
employed.
• Tetanus neonatorum is common due to lack of MCH care.
• Tetanus is important endemic infection in India.
• Causative factors
• Hand washing
• Delivery practices
TRANSMISSION
• Tetanus is not transmitted from person to person. Infection occurs
when C. tetani spores are introduced into acute wounds from trauma,
surgeries and injections, or chronic skin lesions and infections.
• The incubation period of tetanus is usually between 3 and 21 days
(median 7 days).
• Shorter incubation periods (<7 days) along with delays in seeking
treatment are associated with fatal outcomes.
• Outbreaks of tetanus related to injuries associated with natural
disasters such as earthquakes and tsunamis have been documented
Host Factors
• Age : It is the disease of active age (5-40 years), New born baby, female
during delivery or abortion
• Sex : Higher incidence in males than females
• Occupation: Agricultural workers are at higher risk
• Rural -Urban difference: Incidence of tetanus in urban areas is much
lower than in rural areas
• Immunity : Herd immunity does not protect the individual
• Environmental and social factors: Unhygienic custom habits,
Unhygienic delivery practices
ROUTE OF ENTRY
• Apparently trivial injuries
• Animal bites/human bites
• Open fractures
• Burns
• Gangrene
• In neonates usually via infected umbilical stumps
• Abscess
• Parenteral drug abuse
CLINICAL FEATURES:
• IP : Time from injury to the first symptom.The median incubation
period is 7 days, and, for most cases (73%), incubation ranges from 3-
21 days.
• Period of onset : It is the time from first symptoms to the reflex
spasm.
• In general the further the injury site is from the central nervous
system, the longer the incubation period.
• The shorter the incubation period, the higher the chance of death.
• Triad of muscle rigidity, spasms & autonomic dysfunction
• Early symptoms are neck stiffness, sore throat and poor mouth opening.
• Patients with generalized tetanus present with trismus (ie, lockjaw) in
75% of cases.
• Other presenting complaints include stiffness, neck rigidity, dysphagia,
restlessness, and reflex spasms. Spasms usually continue for 3-4 weeks.
• Subsequently, muscle rigidity becomes the major manifestation. Rigid
Abdomen.
• Muscle rigidity spreads in a descending pattern from the jaw and facial
muscles over the next 24-48 hours to the extensor muscles of the limbs -
stiff proximal limb muscles & relatively sparing hand & feet.
• Risus sardonicus: Sustained contraction of facial musculature produces
a sneering grin expression known as risus sardonicus.
• Contraction of the muscles at the angle of mouth and frontalis
• Trismus (Lock Jaw): Spasm of Masseter muscles.
• Opisthotonus: Spasm of extensor of the neck, back and legs to form a
backward curvature.
• Muscle spasticity
• Poor cough, inability to swallow, gastric stasis all increase the risk of
aspiration. Respiratory failure continues to be a major cause of
mortality in developing countries, whereas severe autonomic
dysfunction causes most deaths in the developed world.
NEONATAL TETANUS
• Neonatal tetanus is defined by the World Health Organization (WHO)
as “an illness occurring in a child who has the normal ability to suck
and cry in the first 2 days of life but who loses this ability between
days 3 and 28 of life and becomes rigid and has spasms.”
• Children born to inadequately immunized mothers, after unsterile
treatment of umbilical stump.
• During first 2 weeks of life.
• Poor feeding , rigidity and spasms
• It is easily preventable by 2 tetanus toxoid injections and '5 cleans'
while conducting deliveries.
LOCAL TETANUS
• Uncommon form
• Manifestations are restricted to muscles near the wound.
• Cramping and twisting in skeletal muscles surrounding the wound -
local rigidity
• Prognosis - excellent
Diagnosis
• Diagnosis is done clinically based on the presence of trismus,
dysphagia, generalized muscular rigidity, and/or spasm.
• An assay for antitetanus IgG levels is not readily available. However, a
level of 0.01 IU/mL or greater in serum is generally considered
protective, making the diagnosis of tetanus less likely.
DIFFERENTIAL DIAGNOSIS
• Drug induced Dystonic Reactions e.g. Phenothiazines
• Strychnine poisoning
• Neuroleptic Malignant Syndrome, Serotonin syndrome
• Trismus d/t Peritonsillar Abscess/Dental infection
• Dislocations, Mandible
• Encephalitis, Meningitis
• Hysteria
• Hypocalcemia
• Rabies
• Seizure disorder (partial or generalized)
• Stroke, Hemorrhagic
• Stroke, ischemic (cephalic tetanus)
• Subarachnoid Hemorrhage
Treatment
• 1.Wound Management:
• Debridement: Surgical removal of necrotic tissue to reduce bacterial load.

• 2.Antibiotics:
• First-line: Metronidazole 500 mg IV q6–8h for 7–10 days
• Alternative: Penicillin G 2–4 million units IV q4–6h
• (Metronidazole preferred now because Penicillin may potentiate GABA antagonism
and worsen spasms).

• 3.Neutralization of Toxin:
• Human Tetanus Immunoglobulin (TIG):
• Dose: 3000–6000 units IM as a single dose (infiltrate part of the dose around the
wound if possible).
• If TIG unavailable → Equine antitoxin (20,000–100,000 units IV after test dose).
• 4. Control of Muscle Spasms:
• Benzodiazepines (drug of choice):
• Diazepam 10–40 mg IV every 1–4 hours or continuous infusion (0.1–0.3 mg/kg/hr).
• Alternative: Midazolam infusion (0.1–0.2 mg/kg/hr).
• Severe spasms or rigidity:
• Neuromuscular blockade with agents like vecuronium or pancuronium + mechanical ventilation.

• 5.Supportive Care:
• ICU care: Required for most moderate-to-severe cases.
• Airway management: Endotracheal intubation or tracheostomy may be necessary in severe
cases.
• Nutrition: High caloric requirements (40–50 kcal/kg/day) due to hypermetabolic state. Enteral
feeding preferred.
• Autonomic dysfunction management:
• Labetalol or magnesium sulfate infusion for sympathetic overactivity.
Prevention
• Tetanus is completely preventable by active tetanus immunization.
• Immunization is thought to provide protection for 10 years.

• Begins in infancy with the DTP series of shots. The DTP vaccine is a "3-
in-1" vaccine that protects against diphtheria, pertussis, and tetanus.
Active Immunization
A - has had a complete course of toxoid or booster dose with in
the past 5 year
B - has had a complete course of toxoid or booster dose more
then 5 years ago & less then 10 years ago
C - has had a complete course of toxoid or a booster dose more
then 10 year ago
D - has not had a complete course of toxoid or immunity status
unknown