Tetanus

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Bacterial disease characterised by intermittent spasms (twitching) of voluntary muscles. Incubation period is from few days to few weeks (average 7-10 days).

Cause

• Exotoxin of Clostridium tetani
• Common sources of infection: tetanus spores enter the body through deep penetrating skin wounds, the umbilical cord of the newborn, ear infection, or wounds produced during delivery and septic abortions

Clinical features

• Stiff jaw, difficulty in opening mouth (trismus)
• Generalised spasms induced by sounds and/or strong light, characterised by grimace (risus sardonicus)
• Arching of back (opisthotonus) with the patient remaining clearly conscious
• Fever
• Glottal spasms and difficulty in breathing
• Absence of a visible wound does not exclude tetanus

Differential diagnosis

• Meningoencephalitis, meningitis
• Phenothiazine side-effects
• Febrile convulsions

Management

Treatment

General Measures

• If at HC2 or 3, refer to hospital
• Nurse patient intensively in a quiet isolated area
• Maintain close observation and attention to airway, temperature, and spasms
• Insert nasogastric tube (NGT) for nutrition, hydration, and medicine administration
• Oxygen therapy if needed
• Prevent aspiration of fluid into the lungs
• Avoid IM injections as much as possible; use alternative routes (e.g. NGT, rectal) where possible
• Maintain adequate nutrition as spasms result in high metabolic demands
• Treat respiratory failure in ICU with ventilation 

Neutralise toxin

• Give tetanus immunoglobulin human (TIG)
  
  • 150 IU/kg (adults and children). Give the dose in at least 2 different sites IM, different from the
    tetanus toxoid site
• In addition, administer full course of age-appropriate TT vaccine (TT or DPT) – starting immediately
• See also Tetanus prevention 

Treatment to eliminate source of toxin

• Clean wounds and remove necrotic tissue.

First line antibiotics

• Metronidazole 500 mg every 8 hours IV or by mouth for 7 days
  • Child: 7.5 mg/kg every 8 hours

Second line antibiotics

• Benzylpenicillin 2.5 MU every 6 hours for 10 days
  • Child: 50,000-100,000 IU/kg per dose

Control muscle spasms

First line

• Diazepam 10 mg (IV or rectal) every 1 to 4 hours
  • Child: 0.2 mg/kg IV or 0.5 mg/kg rectal (maximum of 10 mg) every 1 to 4 hours

Other agents

• Magnesium sulphate (alone or with diazepam): 5g (or 75 mg/kg) IV loading dose then 2 g/hour till spasm control is achieved
• Monitor knee-jerk reflex, stop infusion if absent
• Or chlorpromazine (alone or alternate with diazepam) 50-100 mg IM every 4-8 hours
  • Child: 4-12 mg IM every 4-8 hours or 
• 12.5 mg-25 mg by NGT every 4-6 hours

Continue for as long as spasms/rigidity lasts

Control pain

• Morphine 2.5-10 mg IV every 4-6 hours (monitor for respiratory depression)
  
  • Child: 0.1 mg/kg per dose
• Paracetamol 1 g every 8 hours
  
  • Child: 10 mg/kg every 6 hours 

Prevention

• Immunise all children against tetanus during routine childhood immunisation
• Proper wound care and immunisation: (see Immunizations)
• Full course if patient not immunised or not fully immunised
• Booster if fully immunised but last dose >10 years ago
• Fully immunised who had a booster <10 years ago do not need any specific treatment
• Prophylaxis in patients at risk as a result of contaminated wounds: give Tetanus immunoglobulin human (TIG) IM
  • Child < 5 years: 75 IU
  • Child 5-10 years: 125 IU
  • Child > 10 years and adults: 250 IU
• Double the dose if heavy contamination or wound obtained > 24 hours.