TETANUS
SITE HOSTED BY
DR TAJUDDIN
FCPS FRCS
ASSISTANT PROFESSOR OF SURGERY
BAQAI MEDICAL UNIVERSITY
KARACHI PAKISTAN
Tetanus
It has been estimated that, every year, between
- 300 000 and 500 000 cases of tetanus occur world-wide with an
- overall mortality of 40-45 per cent.
- In the UK, 200 cases occur annually, and
- the condition is also relatively uncommon elsewhere in Europe, in the former Soviet Union and in North America.
- The burden of this agonising infection falls on those in the other countries of the world, particularly on the children, the neonates (tetanus neonatorum) and the elderly.
- Once fixed in the nerve tissue, the toxin can no longer be neutralised by antitoxin.
Period of onset
- It should be remembered that wounds containing tetanus organisms may have healed and been forgotten for months or years before some (unknown) change produces the right conditions for the organism to multiply and produce toxin (latent tetanus').
Symptoms and signs
- Dysphagia,
- jaw stiffness and
- severe pains in
- the neck,
- back and
- abdomen
- followed by the tonic muscle spasms.
- The sardonic smile of tetanus (risus sardonicus) is evidence of the onset of tonic muscle spasm.
- Respiration and
- swallowing become progressively more difficult, and
- reflex convulsions occur affecting all muscles and causing
- opisthotonus (spasm of the extensors of the neck, back and legs to form a backward curvature) and even
- muscle rupture.
- The spasms are
- spontaneous, but
- can be induced by trivial stimuli
- such as noise or
- movement and,
- Severe spasms will
- prevent respiration and
- produce cyanosis.
- Between the reflex convulsions, the tonic muscular spasm remains, thus distinguishing tetanus from strychnine poisoning.
- The temperature is elevated,
- the pulse is rapid, and
- respiratory failure and
- death during a cyanotic attack will usually follow if treatment is not initiated.
- At an early stage, the symptoms and signs of tetanus might be mistaken for
- tonsillitis,
- flu,
- backstrain or
- an acute upper abdominal condition.
- Therefore, careful examination of the patient for a wound is of paramount importance.
Treatment
- Isolation,
- quietness and
- comfort,
- drainage of pus and
- wound toilet will be needed.
- Human anti-tetanus globulin (e.g. Humotet) is given intramuscularly (i.m.) to limit the effects of free toxins and should be used in doses of 25-500 units to give cover throughout the period of establishing active immunity by giving toxoid (tetanus vaccine, adsorbed) i.m.
- Equine tetanus antiserum has been used but about 20 per cent of patients develop serum sickness and occasional anaphylactic reactions occur.
- Antibiotics, including
- penicillin and
- metronidazole, are indicated along with measures to protect the lungs.
Stage 1.
· A mild case,
· where there is tonic rigidity alone, will require
- initial sedation,
- relaxation by drugs such as
§ promazinc up to 200 mg i.m. and
§ a barbiturate or
§ diazepam [—50 mg intravenously (i.v.)].
· These drugs will be needed approximately four times during any 24-hour period.
Stage 2.
A seriously ill patient, with
· dysphagia and
· reflex spasm,
- will need to have a nasogastric tube passed and
- sedation continued.
- The diet,
- the need for intravenous nutrition,
- the maintenance of balanced protein intake, and of
- renal function and
- cardiac function will be priorities.
- A tracheostomy should be considered if the patient has any difficulty in breathing.
- The meticulous care of the tracheostomy tube includes
- suction and
- humidification
Stage 3.
o In dangerously ill patients,
o a major cyanotic convulsion will require
o curarisation, e.g.
§ up to 40 mg tubocurarine i.v. initially and
§ afterwards i.m. to maintain relaxation.
o It should be remembered that the curarised patient, although unresponsive, is conscious and sensitive and can hear everything that is being said.
o Intermittent positive-pressure respiration should be provided, and
o intensive nursing care with increasing sedation would be needed because it has been estimated that a patient at this stage will require at least 350 individual acts of nursing each day.
o The objective is to reduce the risk of death from
o spasms or
o pneumonia wherever possible,
o while realising that a lethal amount of toxin has already caused
- severe damage to the motor neurons and
- severe damage to the brain with
- concomitant myocarditis and
- vascular failure.
o If recovery takes place the patient can be weaned off from ventilator (after about 14 days as long as convulsions do not recur when the effects of the relaxants wear off).
Results
- With the proper attention to nursing care
- prophylactic antibiotic therapy,
- active and passive immunisation against tetanus and, where indicated,
- tracheostomy,
- curarisation and
- assisted respiration,
- the death rate can be reduced to approximately 15 per cent.
- The results in the very young and very old nevertheless are still poor.
- The tetanospasmin produced by the infection is insufficient to generate an immune response so a course of immunisation is recommended on recovery.
