Tetanus 1

Approach to Tetanus patient.
PRESENTER: DR MUNIRA THABIT

outline
• Case scenario
• Introduction
• Epidemiology
• Microbiological features of C. tetani
• Pathogenesis
• Types of tetanus
• Clinical presentations
• Investigations
• Principles of treatments
• Complications
• References
Case Scenario
• Name: V.K.P
• Sex: Male
• Age: 18 years
• Residence: Mlandizi
• DOA:12/7/2023
• C/C: upper limb muscle stiffness-1/7
HPI
• Presented with muscle spasm for one day prior to admission which
was more marked on the right upper limb, stiffness and associated
with inability to tolerate sound, voice and touches
• Also presented with headache and dizziness but no convulsion,
photophobia, hyersalivation and barking voices
• Reported no difficulty in swallowing, abdorminal, diarrhea pain
difficulty in breathing, fever
• Had open wound due dog bite but received three doses of tetanus
toxoid
..
• ROS
• PMH
• FSH
GENERAL EXAMINATION:
Conscious, not pale, not jaundiced, not cyanosed, no signs of
respiratory distress, no lower limb edema, healed wound around right
thumb.
Vitals: BP=123/84, PR=84, SPO2=98%, RR=16bpm, Temp=37.4
• CNS EXAMINATION:
• GCS-15, Oriented to TTT, No signs of meningism, speech intact.
• Cranial nerves 3,4,6,7,12 were assessed, normal
• Normal muscle bulkiness
• Increased right upper limb muscle tone
• 5/5 power
• Normal reflexes.
• Sensation intact.
Conclusion: spasticity of the right upper limb.
• Provisional diagnosis
Localized Tetanus.
Investigations
• Full blood picture
WBC-13.1
Neutro-10.2
Hb-13.9
Platelets-263
Cont…
• Mrdt – Negative
• CRP- 23.1
• Serum Potassium- 4.8
• Serum Sodium-142
Cont…
• Paracetamol PO/NGT 1g 8 hourly 5/7
• Amoxicillin PO/NGT 500mg 8 hourly 5/7
• IV Phenobarbitone 100mg + Chlorpromazine 25 mg + diazepam 10
mg stat, then oral
• Tabs Phenobarbitone 90mg bd 6/7
• Tabs Diazepam 10mg tds
• Tabs Chlorpromazine 25 mg tds 6/7
• NGT for feeding
• Tetanus immunoglobulin 6000 IU{ not given,}
Introduction
• Tetanus is a nervous system disorder characterized by
muscle spasms that is caused by the toxin- producing
anaerobe Clostridium tetani.
• Produces powerful neurotoxin [tetanospasmin]
transported to the CNS where it produces spastic
paralysis.
Epidermiology
• Because of immunization the incidence of tetanus has declined
substantially
• It affects both sexes and races almost equally
• The prognosis is dependent on incubation period, the time from spore
inoculation to first symptom, and the time from first symptom to first
tetanic spasm in general shorter intervals indicate more severe
tetanus and poorer prognosis
• Clinical tetanus is less severe among patients who have received a
primary series of tetanus toxoid sometime during their life than
among patients who are inadequately vaccinated or unvaccinated
Microbiology
• Is caused by a bacteria called Clostridium tetani
• Anaerobic spore forming bacillus
• Found in the soil and animal feces.
• Produce two kinds of toxins.
Tetanospasmin- responsible for the clinical manifestation of
tetanus.
Tetanolysin- this substance is a hemoysin with no recognized
pathologic activity.
Pathogenesis
• Spore inoculated into wound
• The toxin binds to receptors on the presynaptic membranes of motor
neurons.
• Migrates by retrograde axonal transport system to the cell bodies of
neurons, spinal cord and brain stem.
• Binding is irreversible
• Blocks release of inhibitory neurotransmitters [GABA] resulting in
spastic paralysis.
• The toxin degrades small synaptic vesicles protein, required for docking
neurotransmitters vesicles on presynaptic membrane.
Types of Tetanus
• Generalized
• Involvement of bulbar and paraspinal muscles: Trismus
(lockjaw), risus sardonicus, opisthotonos
• Autonomic involvement: Sweating, hyperthermia,
cardiac arrythmias, labile BP
• Cephalic: Involvement of cranial nerves only
• Localized: Involvement of muscles in primary are of injury
• Neonatorum: Generalized in neonates; infected umbilical
stump
Cont…..
• Clostridium tetani has incubation period of 3 days as long as 3 weeks.
• A shorter period is usually associated with more severe disease and
wounds closer to the brain.
Clinical presentations
• Jaw stiffness { most frequent}
• Stiff neck, arms, or legs
• Irritability
• Restlessness
• Arching of the back. { Opisthotonus}
• Tonic spasm
• Difficulty in swallowing.
• Facial spasm produces expression with fixed smile and elevated eye
brows { Risus sardonicus}
Cont….
• Painful generalized tonic spasms with profuse sweating, precipitated
by minor disturbance such as noise, movement.
Diagnosis
• Clinical evaluation
Thoroughly history taking
 physical examination
General principles of treatment
• Prevent further toxin release by debriding the wound and giving
antibiotics
• Neutralize unbound toxin outside the CNS with human tetanus
immune globulin.
• Controlling the disease manifestation
• Management of complications.
Treatment
• Wound care, and dead tissues promote C. tetani growth, prompt
thorough debridement should be done.
• For prevention of further absorption of toxin from the wound
Human tetanus immunoglobulin IM 3000IU stat
Amoxicillin PO/NGT 500mg 8 hourly for 5 days.
Metronidazole PO/NGT 400mg hourly for 5 days.
• Pain management as the spasms can be very painful. PO Paracetamol
Ig 8 hourly for 5 days.
Cont….
• Control of spasms. Give a sedative cocktail via NGT of the flowing
medications.
• Diazepam PO/NGT 10-30 mg -6 hourly 7-14 days
• Chlorpromazine PO/NGT 100-200 mg 8 hourly 7-14 days.
• Phenobarbital PO/NGT 50-100mg 12 hourly 7-14 days.
Non-pharmacological treatment
• Admit in ICU
• Nurse in dark, quiet room to avoid unnecessary eternal stimuli which
can trigger spasm
• Thorough cleaning of the site of entry site, leaving it exposed without
dressing.
• Avoid giving medications via IV/IM route as injections can trigger
spasms.
• Sedation and care as for unconscious patient.
Complications
• Hypoxic injury
• Aspiration pneumonia
• Glenohumeral joint and temporalmandibular joint dislocations
• Malnutrition and stress ulcers
• Flexion contractures.
References
• Microbiology Lippincot
• Medscape
• Up to date
• STG 2021

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Approach to Tetanus patient.

PRESENTER: DR MUNIRA THABIT

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