Tetanus

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Tetanus is a disease caused by a bacterium, which produces a neurotoxin responsible for the clinical features. These bacteria live predominantly in the soil, so it is easy to get this infection whenever a break in the skin is not cleaned properly. Tetanus-prone wounds include burns, puncture injuries, or those contaminated by soil/manure, septic  wounds, and those with much devitalised tissue and compound fractures. The use of non-sterilised instruments or dressings on the umbilical cord predisposes to neonatal tetanus. The incubation period is 3-21 days. 

Tetanus should be treated as a medical emergency. Tetanus immunisation is the key for prevention (See section in full STG on ‘Immunisation’).

Cause

  • Clostridium tetani 

Symptoms

  • Difficulty or inability to open mouth
  • Constipation
  • Stiff body
  • Spasms- these are painful and are triggered by noise, bright light or touch; spontaneous in severe cases.

Signs

  • Umbilicus may be infected
  • Presence of wound (but may have healed)
  • Irritability
  • Cyanosis during spasms
  • Sardonic (mocking) smile
  • Lock jaw (cannot open the mouth)
  • Opisthotonus (stiff arched back)
  • Rigid abdomen and stiff neck and limbs

Investigations

  • No confirmatory test (diagnosis is clinical)

TreatmentTreatment Objectives

  • To prevent further spasms
  • To eliminate Clostridium tetani to stop further toxin production
  • To neutralise circulating toxin
  • To provide adequate hydration and nutrition
  • To provide supportive care till spasms cease completely 

Non-pharmacological treatment

  • Always admit a suspected case of tetanus 
  • Maintain a clear airway
  • Avoid noise, bright light and unnecessary physical examination of the patient
  • Clean the infected umbilicus or wound with soap and water or antiseptic solution (See section on ‘Wound management’)
  • Surgical debridement of the wound when necessary

Pharmacological treatment 

Eradication of bacteria in a patient diagnosed to have tetanus

1st Line Treatment

Evidence Rating: [A]

  • Metronidazole, IV,

Adults

500 mg 6 hourly for 7-10 days 

Children

> 1 month 7.5 mg/kg 8 hourly for 7-10 days 

Neonates

> 7 days; 7.5 mg/kg 12 hourly

< 7 days; 7.5 mg/kg 48 hourly 

2nd Line Treatment

Evidence Rating: [B]

  • Benzylpenicillin, IV, 

Adults

50,000 units/kg stat, then 4 MU 6 hourly for 5 days 

Children

50,000 units/kg 6 hourly for 5 days

Neonates

250,000 units 6 hourly for 7 days 

And 

  • Gentamicin, IV, (neonates only), 4 mg/kg 24 hourly 

To neutralize free circulating toxin

Evidence Rating: [B]

  • Human Tetanus Immunoglobulin, IM or IV, 

Adults and Children

500 units stat.

Neonates

250 units stat.

And

  • Tetanus Toxoid, IM, (inject at different site from Human Tetanus Immunoglobulin) 

Adults and Children

> 2 years; 0.5 ml stat. Repeat at 4-8 weeks (2nd dose) and at  6-12 months (3rd dose)

< 2 years; 3 doses of Pentavalent vaccine at intervals of four weeks

To control spasms

Evidence Rating: [C]

Adults

  • Chlorpromazine, IM, 50 mg 4-8 hourly 

And 

  • Diazepam, IV or IM, (by slow IV at a rate of not more than 5 mg/minute), 5-10 mg 3-6 hourly when required

Or

  • Phenobarbitone, IM, 200 mg 8-12 hourly, gradually reduce sedation after about 2 weeks 

Children

  • Chlorpromazine,  IM  or  oral  (via  nasogastric  tube),  12.5-25  mg  8 hourly 

And 

  • Diazepam, IV/IM/nasogastric tube/suppository, 0.3 mg/kg 3-6 hourly when required (by slow IV at a rate of not more than 5 mg/minute)

Or

  • Phenobarbitone, IM or oral (via nasogastric Tube), 10 mg/kg stat., then 2.5 mg/kg 12 hourly 

Neonates

  • Chlorpromazine, IM or oral (via nasogastric tube), 7.5 mg 8 hourly 

And

  • Phenobarbital (Phenobarbitone), IM or oral (via nasogastric tube), 30 mg stat. then 7.5 mg 12 hourly

Neonates-if spasms are not controlled with the above treatment

Add

  • Diazepam, rectal, 0.5 mg/kg 3-6 hourly when required

Tetanus Immunizations

  • Start Immunisation before discharge from hospital in all patients because tetanus infection does not provide immunity against future episodes
  • An adult who has received a total of 5 doses of tetanus toxoid is likely to have life-long immunity 
  • A course of tetanus toxoid vaccinations should be given to any previously unimmunised patient older than 2 years of age. Dose: 0.5 ml, IM or deep  SC, repeat at 4 weeks and 8 weeks (primary course) 
  • If 10 or more years (5 or more years for children below age 15 years) have elapsed since primary course or last booster, give booster dose of 0.5 ml 
  • In tetanus-prone wounds start the primary course in the non-immunised patient. A booster dose may be given if more than five years have elapsed  since the last dose 
  • Survivors of neonatal tetanus should follow the normal schedule for “Five-in-One” (Penta-) vaccine
  • Previously unimmunised children below the age of 2 years should receive 3 doses of 5 in 1 at intervals of four weeks.
  • Cut umbilical cord with sterile instrument, clean with methylated spirit (alcohol) and leave uncovered 
  • To prevent tetanus in patients with potentially contaminated wounds (tetanus  prone  wound),  provide  adequate  wound  toileting and also provide tetanus prophylaxis
  • Tetanus Immunisation in pregnancy (See full STG section on Antenatal care)

Referral Criteria

  • Refer patients to a specialist if spasms cannot be controlled