TETANUS

 

Tetanus

Tetanus is a bacterial disease caused by the neurotoxin tetanospasmin , elaborated by Clostridium tetani. Spores of this organisms are ubiquitous in soil. When introduced into a wound , spores may germinate.

Incubation period : 

5 days to 15 weeks , with the average of 8-12 days.

Pathogenesis : 

The vegetative bacteria produce tetanospasmin. It interferes with neurotransmission at spinal synapses of inhibitory. As a result , minor stimuli result in uncontrolled spasms and reflexes are exaggerated.

Clinical Features : 

(A) Prodromal State 

       - Dysplasia

       - Pain in neck , back and abdomen

       - Pain in tingling at the site of wound 

(B) Stage of tonic rigidity :

- Trismus ( lock-jaw): spasm if the masseter muscles.

- Muscle spasticity

- Risus Sardonicus : contraction of the muscle at thee angles of mouth and frontalis.

- Opisthotonus : spasm of muscle of back and neck 

(C) State of clonic spasm ; 

- Laryngeal and pharyngeal spasm 

- Spasm of respiratory muscles =acute asphyxia

(D) Others ; 

- patient is awake and alert throughout the illness . Sensory examination is normal , temperature is normal or only slightly elevated.

Differential Diagnosis : 

- Meningitis

- Encephalitis

- Epilepsy

- Strychnine poisoning

Investigations : 

- Diagnosis is clinical

- Isolation of organisms from site if inoculation (rarely)

* Essentials of Diagnosis

  • history of wound and possible contamination

  • jaw stiffness

  • stiffness of neck and other muscle

  • dysplasia

  • irritable hyperreflexia

  • painful convulsions precipitated by minimal stimuli.

Treatment : 

1) Control of spasm 

  - Inj. Diazepam 0.1-0.2 mg/kg of not control , 

  - Paralyze with muscle relaxant and ventilate

2) Neutralisation of toxin : 

- Tetanus immunoglobulin 3000-6000 units I.M. single dose or (500 unit for neonate)

- Tetanus antitoxin after sensitivity test 50000-100000 units - 1/2 I.M. and 1/2 I.V.

3) To eradicate vegetative form of antibiotics 

- Benzyl penicillin 600 mg × 6 hourly IV × 10 days or 

- Metronidazole 400-800 mg × 8 hourly for 7 days 

- In penicillin sensitive case : Erythromycin

4) Local wound care 

- Closed wound should be opened 

- All dead tissue should be removed

- Wash by hydrogen peroxide

5) Supportive care 

- Isolate in a quiet dark room 

- Maintenance of fluid , nutrition and electrolytes 

- Oxygen inhalation

Prevention of tetanus 

- Active immunization : 3 doses of DPT 

- Use if early antibiotics

- Early treatment of wound 

- Three cleans during delivery

   √ clean hand 

   √ clean delivery surface

   √ clean cord care 

Complications of tetenus 

✓ Acute asphyxia

✓ Aspiration pneumonia

✓ Respiratory arrest 

✓ Cardiac Failure 

✓ Urinary retention

✓ Vertebral fraction 

✓ Laceration of tongue , lips , buccal , mucosa .