Tetanus

Question 1

What is tetanus

Answer 1

An acute spastic paralytic illness caused by the exotoxin of clostridium tetani

Question 2

What are the 2 exotoxins produced by clostridium tetani

Answer 2

Tetano spasmin (causes tetanus)
Tetano lysin

Question 3

Clostridium tetani properties

Answer 3

Gram positive
Obligate anerobe
Spore forming (makes it resistant)
Flagellated
Non invasive
Bacilli

Question 4

What is the only vaccine preventable disease that is non communicable?

Answer 4

Tetanus

Question 5

tetanus transmission

Answer 5

Found in soil, animal dungs, dust and gotten from contact with open wound

Question 6

Pathophysiology

Answer 6

After entry, they stay in there spore form until anaerobic condition is present. They germinate, multiply and produce toxins (tetanospasmin). This travels to the motor neurons and binds at the neuromuscular junction where it enters motor nerves and spinal inhibitory interneurons where it prevents release off inhibitory neurotransmitters like glycine and GABA.

Question 7

What is the Incubation period for tetanus.

Answer 7

From inoculation to time of first symptom (trismus). Usually 14 days.
If shorter, it means the amount of toxins released is larger and that is a poor prognostic factor.

Question 8

What is Period of onset

Answer 8

Time from 1st symptom to 1st spasm.
If it happens in <48 hrs, it is poor prognosis.

Question 9

What are the Forms is tetanus

Answer 9

1) Generalized
2) Cephalic (poor prognosis)
3) Neonatal (poor prognosis)
4) Localized (favorable prognosis)

Question 10

What is the portal of entry of the cephalic form

Answer 10

Middle ear (associated with cranial nerve abnormalities especially CN 7)

Question 11

What are the clinical features of tetanus

Answer 11

1) General malaise
2) Trismus (masseter muscle involved)
3) Resus sardunicus (facial muscles involved)
4) Opistotonus
5) Spasms of the extensors of the neck, back and legs
6) Oesphageal spasms causing dysphagia
7) Urethral spasms causing urinary retention
8) Laryngeal spasms causes apnea (one of the major causes of death in tetanus)
9) Autonomic dysfunction (tachycardia, arrhythmia, fluctuations in BP, diaphoresis)

Question 12

Precipitates of spasms

Answer 12

Light
Noise
Handling

Question 13

What are the poor prognostic factors for tetanus

Answer 13

Short incubation period
Short period of onset
Extremes of age
Fever

Question 14

Managing principles for tetanus

Answer 14

1) CONTROL SPASMS:- using diazepam (up to 320mg per day if patient is intubated), using triple regimen (diazepam, chlopromazine and phenobarbital), using magnesium sulphate (25-50mg/kg/dose), using neuromuscular blocker (pancuronium)

2) NEUTRALIZE CIRCULATING TOXINS:- using ATS (anti tetanus serum). For ATS they have prophylactic dose of 3000IU (2000IU subcutaneous and 1000 around site of injury) and therapeutic dose is 10000IU (5000IU for IV and 5000IU for IM) and human TIG (tetanus immunoglobulin). For TIG they have prophylactic dose (250-500IU) and therapeutic dose (5000IU)

3) ERADICATION OF ORGANISMS:- using antibiotics (metronidazole) and debridement

4) SUPPORTIVE CARE:- nurse in dim and quiet room, NG insertion for feeding, suctioning to avoid aspiration, monitor input and output, hydrate with about 4L of fluid per day, nurse with water bed to avoid bed sores.

5) PREVENT REOCCURRENCE:- using vaccination, and safe practices.
NEONATAL
DPT at 6wks, 10wks and 14wks
DPT at 18mnths
DT at 5 years
TT at 10 years and 16 years
ADULT
TT at contact, 4wks after, 6-12mnths after and 5-10 years after
PREGNANT WOMEN
TT at contact, 4wks, 6mnths, 1 year and 1 year