Tetanus

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Clinical Description

Tetanus is a nervous system disorder characterized by muscle spasms. caused by the toxin producing anaerobe Clostridium tetani. Immunization has significantly reduced occurrence of Tetanus cases and deaths. 

Clinical Features

SIGNS AND SYMPTOMS

  • Stiff neck
  • Opisthotonus
  • Risus sardonicus (sardonic smile)
  • A board-like rigid abdomen
  • Periods of apnea and/or upper airway obstruction due to vise-like contraction of the thoracic muscles and/or glottal or pharyngeal muscle contraction, respectively
  • Dysphagia

Treatment

Adult Tetanus

  • Good nursing care of the heavily sedated patient is essential
  • Give active immunization against tetanus after recovery

General measures

  • Nurse the patient in a dark quiet area
  • Maintain adequate hydration and nutrition
  • Prevent aspiration of fluid into the lungs
  • Clean and debride necrotic wounds thoroughly
  • Change from parenteral to oral medication as soon as possible
  • Avoid provoking spasms
  • Encourage active exercise after patient has recovered

Treatment

  • Medical rehabilitation plays an important role in prescribing appropriate exercises.
  • Give Diazepam 20 mg IM or IV Chlorpromazine 50mg IM or IV given alternately 3 hourly.

Alternatively

  • Give Diazepam infusion 40 mg in one liter of IV dextrose or normal saline 6-8 hourly
  • Take care: respiratory depression may occur
  • Dose sizes or frequencies of the above medicines can be increased if necessary to control spasms
    • Give Anti-tetanus serum 20,000 units IV STAT
    • Give this after a test dose of 1,500 units s/C
    • Benzyl penicillin 2 MU IV 6 hourly every for 7 days
    • Give Metronidazole 500 mg IV 8 hourly or 400 mg 8 hourly for 7 days
    • Give Tetanus toxoid vaccination: give the full course.

Neonatal TetanusClinical Description

Neonatal tetanus occurs as a result of the failure to use aseptic techniques in managing the umbilical stump in offspring of mothers who are poorly immunized.

 

TreatmentPHARMACOLOGICAL TREATMENT

Antibiotics

  • Metronidazole 30 mg/kg/day (maximum, 4 g/day) divided into 4 doses PO or IV for 10 - 14 days

Alternatively

  • Benzyl penicillin 100,000 units/kg IV 6 hourly for 10 - 14 days

Neutralization of unbound toxin

  • Human tetanus immunoglobulin (TIG) 500 units IM or IV.

Active immunization

  • All patients should complete a series of immunizations with tetanus toxoid, beginning at presentation. See immunization protocol

Sedation

  • Diazepam of 0.1-0.2 mg/kg 2-6 hourly , titrating upward as needed. If not controlling the spasms, discuss with a senior for Phenobarbital children: 5 mg/kg STAT, then 2.5 mg/kg 12 hourly . 

Neonates

  • Phenobarbital 10mg/kg STAT, then 2.5 mg/kg 12 hourly.

Monitor for respiratory arrest.

Consider ventilatory support (Indications for intubation: apnea, hypoxemia, uncontrolled spasms).

Provide adequate analgesia. 

 

NON-PHARMACOLOGICAL TREATMENT 

  • Nurse in a quiet and dark room
  • Minimal handling
  • Avoid IM injections where possible Maintain hydration
  • Maintain nutrition (use NGT feeds)

Complications 

  • Respiratory failure
  • Rhabdomyolysis
  • Fractures

 

TETANUS PREVENTION 

  • Promote Tetanus Diptheria Vaccination (Td) in pregnant women and all women of child bearing age 
  • Ensure adequate surgical toilet plus passive (ATS 1,500 units IM) and active (Td) immunization after wounds, bites and burns
  • Vaccinate all unvaccinated Childbearing age women in a locality with a confirmed case of Tetanus.

 

TETANUS TOXOID VACCINATION (TTV)

Fully immunized but last booster >10 years ago:

Give one booster dose of 0.5 mL IM

Fully immunized patients who have had a booster within the last 10 years do not need treatment with tetanus antitoxin (ATS} or tetanus toxoid vaccination (TTV)