Tetanus

ICD10 CODE: A35

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	LOC
*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 Tetanus Prevention	H
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	H
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): 5 g (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 age > 5 years (Maximum 75mgs/day) : 4-12 mg IM every 4-8 hours or 12.5 mg-25 mg by NGT every 4-6 hours Child age 1-5 years (Maximum 40mgs/day) : 2.5-4mg IM every 4-8 hours or 5mg-12.5mg by NGT every 4-6 hours Child age < 1 year: Not usually recommended in children < 1 year (seek specialist advice) Continue for as long as spasms/rigidity lasts	H
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	H

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.

Neonatal Tetanus

Neonatal tetanus is a notifiable disease

Caused by infection of the umbilicus through cutting of the cord with unsterile instruments or from putting cow dung or other unsuitable materials on the stump
Usually presents 3-14 days after birth with irritability and difficulty in feeding due to masseter (jaw muscle) spasm, rigidity, generalised muscle spasms. The neonate behaves normally for the first few days before the symptoms appear.

Management

Treatment	LOC
Refer to hospital immediately General measures Nurse in quite, dark and cool environment Suction the mouth and turn the infant 30 min after sedative. A mucous extractor or other suction should be available for use prn Ensure hydration/feeding Start with IV fluids (half saline and dextrose 5%) Put NGT and start feeding with expressed breast milk 24 hours after admission– in small frequent feeds Monitor and maintain body temperature Monitor cardiorespiratory function closely. Refer for ICU management if possible	H RR
Neutralise toxin Give tetanus immunoglobulin human (TIG) 500 IU IM. Give the dose in at least 2 different sites IM, different from the tetanus toxoid site In addition give 1st dose of DPT Treatment to eliminate source of toxin Clean and debride the infected umbilicus First line antibiotics Metronidazole loading dose 15 mg/kg over 60 min then Infant <4 weeks : 7.5 mg/kg every 12 hours for 14 days Infant >4 weeks: 7.5 mg/kg every 8 hours for 14 days	H
Second line antibiotics Benzylpenicillin 100,000 IU/kg every 12 hours for 10-14 days	H
Control muscle spasm Diazepam 0.2 mg/kg IV or 0.5 mg/kg rectal every 1 to 4 hours Other medicines Chlorpromazine oral 1 mg/kg 8 hourly via NGT

Prevention

Immunise all pregnant women during routine ANC visits
Proper cord care