Tetanus(lockjaw)

Definition
• Tetanus is a neurological syndrome caused by the EXO-toxin
(tetanospasmin) of the vegetative form Clostridium tetani

• Clostridium tetani-gram positive, obligate anaerobic ,cultured

under anaerobic conditions

• Exist as spores in nature

• Spores are resistant to extremes of heat, moisture and stable at

atmospheric oxygen tension-can be killed by boiling @1000C
for 4 hours or autoclaving @ 1210C @103KPa for 15 mins or
exposre to iodine,H2O2 and glutaraldehyde

• Spores are ubiquitous-found every where-soil, animal feaces,

old carpets etc
 Epidemiology

• 1 million cases world wide-BUT there is under reporting

• Case fatality 30-50%

• 500,000 deaths/year from neonatal tetanus -1994 estimates

• 120,000 deaths/ year in Africa form neonatal tetanus-1994

estimates

• 80% of world wide cases occur in China, Ethiopia,India, Bangladesh,

Kenya, Nepal, Nigeria,Somali, Sudan, Uganda, Pakistan, Vietnam,
Zaire
 Pathophysiology
• Spores enter body (usually does not evoke an inflammatory reaction except
with co-infection)- germinates to vegetative form under low oxidation-
redox potentials-release exotoxins tetanolysin and tetanospasmin-
tetanospasmin diffuses into tissues and enters peripheral motor neuron
terminal- travels in retrograde manner (250mm/day) crosses synapse and
cleaves synaptobrevin needed for the docking and release of GLYCINE &
GABA (neuro-inhibitory transmitters) hence blocking their release along
the neuroaxis
• N.B it tetanospasmin can also block release of neuro-transmitter at the
neuro-muscular junction
Clinical Classification
• Based on age and extent

• 4 categories-Generalized, Localized, Neonatal, Cephalic

Generalized tetanus
• Most commonly recognized form of disease

• Spasm of masseters trismus risus-sardonicus wrinkling of

forehead, raised eyelids, lateral extension of the corners of the
mouth-usually most common presentation.

• Spasms-sudden tonic contractions of back musculature

(ophisthonos),flexion and adduction of the arms,clenched fists
and lower extremity extension

• Incubation period-infection to first symptom (trismus) average

7-21 days (range 1-60 days) but may extend to weeks, months
and years

• Period of onset - trismus to first spasm(1-7 days)

• Spasms spread to neck, thorax, abdomen and extremities

Generalized Tetanus contd

• Spasms-repeated sustained muscle contractions ffg discharge of post

motor neurons in spinal cord-N.B very different from
Seizures/Convulsions which result from discharge of cortical neurons and
affect sensorium. Consciousness retained in former and lost in later.

• Spasms may be provoked or unprovoked-external or internal stimuli may

be sound/noise, touch, temp changes, cough sneezing, full bladder

• Spasms are PainFul!!!

• Involvement of the autonomic nervous system will cause hyperpyrexia,

labile hyper/hypo-Tension, hyperhydrosis
 Neonatal Tetanus
• A form of generalized tetanus

• short incubation period-3-10 days

• Portal of entry usually cord

• Risk factors-where baby was born, what was used in cutting

cord, what was used in dressing and and caring for cord-wet/dry
heat fomentation, dung
 Localized Tetanus
• weakness Fixed rigidity at or near site of injury
• Myalgia
• Hyper-reflexia
• if untreated may progress to generalized tetanus
•
 CEPHALIC TETANUS
• A form of localized tetanus

• Usually occurs with injuries/instrumentation to the head

• Can complicate CSOM and or CSOE

• Greater risk with piercing of cartilaginous part of ear

• very short incubation period 1-2 days

• Facial paresis, dysfunction of ocular muscles, dysphagia

• Can evolve to generalized form

• High risk of fatality

 Presentation in NewBorn

• trismus-refusal/inability to suck/feed

• Generalized rigidity-hypertonia-ophistotonus

• Spasms-might be called convulsions however baby might also

suffer HIE from repeated and prolonged spasms

• Autonomic dysfunction - fever/hyper-pyrexia, labile

hypo/hyper-tension NB fever can arise from co-morbidities e.g.
sepsis, pneumonia, UTI etc
 Presentation infant/older child
• Incubation period 7-21 days however may be extended for
weeks, months, years

• trismus-inability to open mouth, eat or talk

• risus sardonicus

• hypertonia-generalized rigidity-ophistotonus

• autonomic dysfunction-fever labile hyper/hypo-tension NB five

can be from co-morbidity e.g sepsis, pneumonia, UTI
Clinical Approach
History
• place of birth-home/TBA

• instrument used in cutting cord-old/new razor,

• cord care-dung, wet/dry heat fomentation, hot stone in rag

• instrumentation- uvulectomy, circumcision, ear piercing,

scarification/tribal marks

• other treatments-massage, concoctions, palm oil, palm kernel

oil, smoke inhalation, over the counter, medications

• Maternal ANC-doses of TT in previous and recent pregnancy

 Clinical Approach
Infant/Older Child
• instrumentation- uvulectomy, circumcision, tribal marks,
criminal abortion

• trauma-usually to lower limbs, puncture wounds-rusty

nails/metals, thorn pricks, cuts/abrasions, bites, insect
stings, beatings, burns injury

• ear discharge

• Medications given-dystonic reactions are a differential

• dog bite-Rabies is a differential

Ablett Classification
 Diagnosis

• Diagnosis is CLINICAL!!!
• Samples may be taken from dead tissues for anaerobic and aerobic cultures
studies-but this is not the norm
Investigations
• RBS
• FBC – may show abnormalities if co-attendant systemic infection
• Blood Culture-usually to detect co-infection
• ABG-Hypoxemia, Hypercapnia, Acidaemia
• Serum ATS levels equal to or >0.01 are considered protective and
make tetanus unlikely
Differentials

• Siezures/Convulsions-Hypoglycemia, HIE, Hypocalcemia,

Hypomagnesemia, Severe Malaria, Meningitis
• Acute dystonic reactions-phenothiazines, metoclopramide-usually have
torticollis and oculogyric crises which are almost never seen in tetanus
• Strychnine Poisoning-abdomen usually more relaxed between spasms
and trismus a later sign
• Rabies-history of dog or animal bite
• Hyperekplexia/Stiffman Syndrome
Treatment

• 1. Supportive
• 2 Specific
Management Principles

• Abort spasms-IV Diazepam/IM Paraldehyde, IV Midazolam

• Check-Blood glucose and draw samples for Blood culture, E&U/Cr, FBC, ABG
• Quick targeted but meticulous examination
• Pass NGT for medication if risk of laryngeal spasm use IV for medication and
nutrition
• Nurse in quiet room
• Educate parents on diseases process and management
 Supportive treatment

• If risk of laryngeal spasm or intractable spasms with severe autonomic

instability-paralyze , intubate and take over ventilation.
• If in hypoperfusion/shock give IV Bolus 10 ml/kg-Neonates, 20 ml/kg other
children over 30mins to 1 hour, may give four boluses before inotropes-
Dopamine or and Dobutamine Note be very careful because tetanus patients
also have labile hypertension
• Pain control may also give PCM-might be advantageous in controlling fever
• Metabolic-ensure normoglycemia, normocalcemia, normonatraemia and
Acid-Base status
Supportive treatment
• Nurse in VERY QUIET environment with minimal external stimuli-
VERY GOOD NURSING Care is very necessary for a good outcome.
• Open spasm chart for monitoring of frequency duration and
intensity of spasms
 Specific treatment

• IV Diazepam 1-2 mg/kg at rate not exceeding 1mg/kg/minute to

immediately abort spasms some authors prefer 0.2-0.3 mg/kg or IM
Paraldehyde 0.3 ml/kg or 1 ml/age in years to maximum of 5mls
• Maintenance Diazepam-5-20 mg/kg/day in 4 divided dosed with additional
0.2-0.3 mg/kg/dose for break through spasms
• Phenobarbitone 5-36 mg/kg/day in 4 divided doses
• Chlorpromazine-5-10 mg/kg/day in 4 divided doses
 Specific treatment
• It is usually advised that the medications are each given at 3-4 hour
intervals to prevent toxicity and over sedation
• IM ATS-10,000-100,000 IU after subcut test dose of 0.5ml you read
after 30mins-note that the ATS is to mop up the tetanospasmin in the
circulation and tissues, the toxin bound to the nerves are not affected
hence spasms and stiffness will persist for sometime after treatment
 Specific treatment
• Medications are titrated according to the severity of spasms and as
spasms reduce in severity are discontinued in the sequence-
Chlopromazine-Phenobarbitone-Diazepam. Patient is usually sent home
on diazepam on account of residual stiffness
• NB-Residual stiffness called “Stiffman syndrome” but there are several
distinct clinical entities call by same name e.g. “Stiffman Syndrome” and
Hyperekplexia
Specific(other medications)

• IV Midazolam GA <32 weeks 0.03mg/kg/hr, GA.32weeks 0.06

mg/kg/hr, Others-0.05-0.2 mg/kg Bolus then 0.06 mg/kg/hr
• *** IV MgSO4 is a medication that has great promise in the
management of the severe forms of tetanus
Specific treatment contd
• IV Penicillin G 100,000 IU/kg/day 4 divided dosed 6 hourly-most
popular
• IV Metronidazole
• Pyridoxine for nerve healing and integrity-evidence for reduced
severity and mortality
• In NDUTH-because of the high risk of co-infection in neonates first
line antibiotics-Ceftazidime and Gentamicin are used-note
Gentamicin is not useful in anaerobic and CNS infections
• A Cochrane review has showed survival to be better using
metronidazole compared to penicillin-this is attributed to a possible
contribution of penicillin's to neuro-excitation
Specific treatment contd

• Autonomic instability-due release of Catecholamine's-Beta Blockade-

Propanolol, Esmolol
• Analgesia-PCM, Morphine Sulphate has the added benefit of
ameliorating autonomic instability
• Local toileting/dressing-iodine, hydrogen peroxide, glutaraldehyde-
these can kill the spores
• Surgical Debridement
• NB-Cochrane review reports of High dose Vitamin C 1gram/day
reducing mortality by 45-100%.
 Specific contd
• Child to start tetanus immunization at or prior to discharge from hospital-
Lethal dose (amount needed to kill) of tetanospasmin <<< Immunogenic
dose(amount needed to generate an immunologic response)
Clinical Tip/s
• Break Thru Spasms-”Spasm occurring after significant or relative
period of quiescence”-Note this is MY definition (Adeyemi)
• Give IV bolus diazepam or IM Paraldehyde
• Double check medication dosage/s and dosing
• Check for provocative stimulus
• If no provocative stimulus increase antispasmodic medication
• Search for remaining foci of Infection
• May repeat ATS-
 Complications
• CNS-hypertonia, spasms, HIE, Autonomic dysfunction-cause of late deaths
• CVS-tachycardia, arrthymias, labile hyper/hypo-tension, hypernatremia,
shock
• RS-aspiration pneumonia/pneumonitis, tachypnea,pulmonary embolism,
laryngeal spasm-usual cause of early death
• GIT-inability/refusal to feed, dehydration,
• Metabolic-hypoglycemia, hypernatremia, acidemia, hypocalcemia
• MSS-fracture of long bones, compression fracture of vertebral column,
muscle rupture, tendon avulsion, rhabdomyolysis-AKI
• Nosocomial Sepsis-prolonged stay
Risk factors for mortality
• Severity of Disease
• Neonate
• Short incubation and period of onset
• Associated Comorbidities-Sepsis, Pneumonia/Pneumonitis, Meningitis
 Prevention
• Appropriate immunization of mothers during pregnancy TT1 0
immunity,TT2 @4-6 weeks after TT1 or subsequent pregnancy 80%
immunity-protects for 3years, TT3 6 months after TT2 or subsequent
pregnancy 95% immunity protects for 5 years, TT4 1year after TT3 or
subsequent pregnancy 99% immunity protects for 10 years, TT5 1year after
TT4 or subsequent pregnancy 99% immunity protects for life.
• Newborn immunized according to schedule with booster shots when
entering primary and secondary school
 Prevention

• Introduction of school targeted school based immunization .

• Health education
• Development and implementation of appropriate evidence backed
protocols for management
• Upgrading hospital facilities for management