Tetanus is an infectious but not contagious

1. TETANUS DR . Rabie Zahran. Tropical M . Consultant. Damietta Fever Hospital. Egypt. [email_address]

3. Tetanus is an acute , often fatal disease caused by an exotoxin produced by the bacterium C lostridium tetani. But prevented by immunization with tetanus toxoid . It is characterized by generalized rigidity and convulsive spasms of skeletal muscles . The muscle stiffness usually involves the jaw (lockjaw)and neck and then becomes generalized. Definition Introduction. [email_address]

6. Acridine orange stain of characteristic C tetani with endospores wider than the characteristic drumstick shape. Causative Organism Clostridium tetani [email_address]

8. Courtesy : Google Image on tetanus [email_address]

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11. Epidemiology: a:Occurrence. b:Reservoir . c:Mode of Transmission d:Communicability Source : CDC.,google pictures [email_address]

16. Pathogenesis . [email_address]

19. Speed of toxin transport: The toxin travels via intra axonal transport at a rate of 75 -250 mm/day . A process which takes 2 -14 days to reach the CNS. [email_address]

20. The typical clinical manifestations of tetanus are caused when tetanus toxin interferes with release of neurotrans-mitters blocking inhibitory impulses. This leads to unopposed muscle contra-ction and spasm. Seizures may occur, and the autonomic nervous system may also be affected. Pathogenesis (con ) [email_address]

21. Mechanism of Action of Tetanus Toxin [email_address]

27. Clinical Features [email_address]

28. Incubation period : I P. ranges from 3 to 21 days , usually about 8 days. In general : *The further the injury site is from the CNS, the longer the I P. *The shorter the I P, the higher the chance of death. * In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. [email_address]

29. Types of tetanus : (On the basis of clinical findings, three different forms of tetanus have been described) . 1) Local tetanus is an uncommon form of the disease,in which patients have persistent contraction of muscles in the same anatomic area of the injury. Local tetanus may precede the onset of generalized tetanus but is generally milder .Only about 1%of cases are fatal. Source : CDC. [email_address]

30. Types of tetanus(con) 2)Cephalic tetanus is a rare form of the disease, occasionally occurring with otitis media(ear infections)in which C. tetani is present in the flora of the middle ear , or following injuries to the head . There is involvement of the cranial nerves, especially in the facial area. [email_address]

31. 3) generalized tetanus It is The most common type (about 80%)of reported tetanus .The disease usually presents with a descending pattern. Neonatal tetanus is a form of generalized tetanus Types of tetanus(contu) [email_address]

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34. Risus Sardonicus in Tetanus Patient A person suffering from tetanus undergoes convulsive muscle contractions of the jaw--called LOCKJAW [email_address]

35. Opisthotonos in Tetanus Patient The contractions by the muscles of the back and extremities may become so violent and strong that bone fractures may occur [email_address]

36. Opisthotonos in Tetanus Patient [email_address]

37. Oposotinus postion in tetanus [email_address]

38. Neck rigidity & retraction. [email_address]

39. Unfortunately, the affected individual is conscious throughout the illness, but cannot stop these contractions [email_address]

40. Rusty nail may cause prick & transmit tetanus [email_address]

41. Type of Tetanus Traumatic T. Puerperal T. Otogenic T. Idiopathic T. T. Neonatorum [email_address]

42. Complications . [email_address]

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44. Diagnosis [email_address]

47. Diagnostic tests for tetanus: Spatula Test : Apet and Kamad discribe a simple bedside test to diagnose tetanus : the posterior pharyngeal wall is touched with a spatula and a reflex spasm of the masseters indicates a +ve.test. This test shows 94 % sensitivity . and 100 % specificity. The altered whistle : This explained as an early effect of tone in facial muscles which causes the classic R . sardonicus [email_address]

49. Total score indicates the severity and the prognosis as follows: [email_address] Score Severity Prognosis (mortality rate) 0 -1 mild < 10 % 2 -3 moderate 10 : 20 % 4 severe 20 : 40 % 5 : 6 very severe > 50 %

50. Grading of tetanus severity( OXFORD ) Ablett Classification Grade I (mild): * mild to moderate trismus; * general spasticity; * no respiratory problems; * no spasms; * little or no dysphagia . [email_address]

51. Ablett Classification Grade II (moderate): * moderate trismus; * well-marked rigidity; *mild to moderate but short-lasting spasms; * moderate respiratory failure with tachypnoea 30-35/min; * mild dysphagia. [email_address]

52. Grade III (severe): * severe trismus; *generalized spasticity; *reflex and often spontaneous prolonged spasms; *respiratory failure with : tachypnoea >40/min; apnoeic spells; *severe dysphagia; * tachycardia >120/min. Ablett Classification [email_address]

53. Grade IV (very severe): features of grade III + violent autonomic disturbances involving the CVS. These include: episodes of severe hypertension and tachycardia alternating with relative hypotension and bradycardia; severe persistent hypertension(diastolic >110 mmHg); severe persistent hypotension (systolic <90) Ablett Classification [email_address]

54. Imbaba Fever hospital Cairo Egypt Grading: We adopted a modification of Ablett classification which we consider to be more useful in the prognosis and management : [email_address]

55. Grade 1 ( mild ) Muscle rigidity affecting one or more group of muscles sparing the muscles of deglutition. Grade 2 (moderate ) Muscle rigidity affecting muscles of deglutition. [email_address]

56. Grade 3a (severe ): muscle rigidity and reflex spasms. Grade 3b ( very sever ): Grade 3a + autonomic nervous system changes. [email_address]

59. How to treat : 1: Admit patients with Grade III (severe): to the ( ICU ). For risk of reflex spasms . 2: maintain a dark and quiet room for the patient. 3: Avoid unnecessary procedures . 4: Seriously consider prophylactic intubation with succinylcholine in all patients with moderate-to-severe clinical manifestations. Intubation and ventilation are required in 67% of patients . [email_address]

61. Marx: Rosen's Emergency Medicine, 7th ed.2009 *Dosage recommendations vary (500–10,000 units of TIG), but multiple injections are stimuli for spasm and most authorities note that 500 units is as effective as higher doses. * Adult and pediatric doses are the same. If the larger doses are used, they should be given in divided doses. *Protective antibody levels are achieved 48 to 72 hours after administration of TIG. * Because the half-life of TIG is 25 days, repeated doses are not needed. [email_address]

62. Recovered individuals : do not necessarily develop “natural Immunity” against the infection--- because of extreme potency of the toxin and very small amount produced during the infection, It does not elicit a strong , protective immune response which would produce enough antibodies against future re-infection. How to treat : [email_address]

63. SO Active immunization with tetanus toxoid should begin or continue as soon as the person’s condition has stabilized. How to treat : [email_address]

64. Drugs: 1) Penicillin G: Adult 10-24 million U/d. ( IV/IM/6h. ) Pediatric 100,000-250,000 U/kg/d. (IV/IM/6h. ) ( 10- to 14-d course of treatment is recommended.) [email_address]

65. 2) Metronidazole : *considered as a drug of choice by many. * has a better safety profile, better tissue penetrability and negligible CNS excitability. (penicillin can cause seizures at high doses). It can also be given rectally Adult 500 mg orally/6h or 1 g IV /12h; not to exceed 4 g/d Pediatric 15-30 mg/kg/d IV divided /8-12h; not to exceed 2 g/d ( 10- to 14-d course of treatment is recommended.) Drugs: [email_address]

66. 3) Doxycycline : Used when there is contraindication to penicillin or metronidazol. Adult 100 mg orally/IV /12h Pediatric <8 years: Not recommended <45 kg : 4.4 mg/kg/d) PO/IV divided bid > 45 kg: Administer as in adults Drugs: [email_address]

67. Anticonvulsants: Sedative-hypnotic agents are the mainstays of tetanus treatment. 1) Diazepam (Valium): Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of GABA( γ- Amino-butyric acid ), a major inhibitory neurotransmitter. Adult Mild spasms: 5-10 mg PO /4-6h Moderate spasms: 5-10 mg IV(diluted in 8 ml glucose 5% or saline ) Severe spasms: Mix 50-100 mg in 500 mL D5W and infuse at 40 mg/h Pediatric Mild spasms: 0.1-0.8 mg/kg/d PO divided tid/qid Moderate or severe spasms: 0.1-0.3 mg/kg IV q4-8h Drugs: [email_address]

68. 2) Phenobarbital: used to * prolong effects of diazepam. * treat severe muscle spasms. Adult 1 mg/kg IM q4-6h; not to exceed 400 mg/d Pediatric 5 mg/kg/d IV/IM divided tid/qid [email_address]

69. Skeletal muscle relaxants These agents can inhibit both monosynaptic and polysynaptic reflexes at spinal level, possibly by hyperpolarization of afferent terminals. * Baclofen (Lioresal) a physiological GABA agonist Adult <55 years: 1000 mcg IT(intrathecal) >55 years: 800 mcg IT Pediatric <16 years: 500 mcg IT >16 years: Administer as in adults [email_address]

70. Consultations After admission to the ICU Consult : 1:An intensive care medicine specialist should be the primary physician coordinating the patient's care. 2: A pulmonary medicine specialist for patients with severe respiratory symptoms or those requiring mechanical ventilation. 3: An anesthesiologist after if intrathecal baclofen is to be administered. [email_address]

71. Differential Diagnoses Mandible dislocations, Stroke , Encephalitis Subarachnoid Hemorrhage Hypocalcemia Dystonic Reactions Meningitis Peri-tonsillar Abscess Rabies Other Problems to Be Considered Intraoral disease Odontogenic infections Globus hystericus Hepatic encephalopathy Hysteria Strychnine poisoning [email_address]

72. Wound Management . [email_address]

74. PREVENTION [email_address]

78. Active Immunization by using tetanus toxoid [email_address]

79. TETANUS TOXOID [email_address]

81. Tetanus Toxoid Adsorbed USP,for intramuscular use,is a sterile suspension of alum-precipitated (aluminum potassium sulfate)toxoid in an isotonic sodium chloride solution containing sodium phosphate buffer to control pH.The vaccine,after shaking,is a turbid liquid,whitish-gray in color. Clostridium tetani culture is grown in a peptone-based medium and detoxified with formaldehyde.The detoxified material is then purified by serial ammonium sulfate fractionation,followed by sterile filtration,and the toxoid is adsorbed to aluminum potassium sulfate (alum).The adsorbed toxoid is diluted with physiological saline solution (0.85%)and thimerosal (a mercury derivative)is added to a final concentration of 1:10,000. Each 0.5 mL dose is formulated to contain 5 Lf (flocculation units)of tetanus toxoid and not more than 0.25 mg of aluminum. The residual formaldehyde content,by assay,is less than 0.02%.The tetanus toxoid induces at least 2 units of antitoxin per mL in the guinea pig potency test. [email_address]

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84. Immunization requires at least 3 doses of Td . 1 st dose (at First visit) 2 nd dose. 3rd dose. booster dose throughout life Doses to complete the primary series . 4-8 weeks 6 months Every 10 years [email_address]

85. Passive Immunization [email_address]

87. Assess Wound [email_address]

88. Tetanus Wound Management * Tdap may be substituted for Td if the person has not previously received Tdap and is 10 years or older + Yes, if more than 10 years since last dose ** Yes, if more than 5 years since last dose [email_address] Vaccination History Unknown or less than 3 doses 3 or more doses Td* TIG Yes No No + No Td* TIG Yes Yes No** No Clean, minor wounds All other wounds

89. MNT elimination [email_address]

90. The Maternal and Neonatal Tetanus elimination initiative was launched by UNICEF, WHO and UNFPA( The United Nations Population Fund Agency ) in 1999, revitalizing the goal of MNT elimination as a public health problem - defined as “ less than one case of neonatal tetanus per 1000 live births in every district of every country”. *Target estimated 100 million women at risk. * 20 million women deliver in high risk areas every year. [email_address]

94. Tetanus Neonatorum. [email_address]

95. Newborn showing risus sardonicus and generalized spasticity [email_address]

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100. THANK YOU [email_address]