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TETANUS

TETANUS. LOCKJAW. Tetanus. An Acute Neurologic Disease due to A Microbial Toxin. Etiology. C.tetani An Anaerobe G+ Bacill Flagellated Immature 1 - Vegetative ……Tennis Rocket 2 - Spore ……Round Terminal. Epidemiology 1. RESERVOIR :

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TETANUS

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  1. TETANUS LOCKJAW

  2. Tetanus • An Acute Neurologic Disease due to A Microbial Toxin

  3. Etiology • C.tetani • An Anaerobe G+ Bacill • Flagellated Immature • 1 - Vegetative ……Tennis Rocket • 2 - Spore ……Round Terminal

  4. Epidemiology 1 RESERVOIR : Spores in Soil ,Animal Stool, Human Stool House Dust ,Operating Room Dust, Contaminated Heroin TRANSMISSION : Spore To Ulcer. (Anaerobic Condition)

  5. Epidemiology 2 HOST: Nonimmune (Antibody --,Vaccination--) 7% Cryptogenic AcuteUlcer,(Trauma),ChronicUlcers,Absces Gangrene, IVDA, Chronic Otitis Media, Unsteril Abortion, Retained Placenta, Unstrile Injection, Contaminated Umbilical Stump,Earpiercing, Scarification Rituals (Infection, Forignbody, Devitalized Tissue)

  6. Pathogenesis 1 • Spore…Ulcer...(Dys,Mons,Ys)…VegetativeGrowth…Lysis…Neurotoxin.(Tetanospasmin)...Blood & Lymph...Myoneural Junction of a-motor neuron. • Retrograde Axonal Transport to Neuroaxis + Brain Stem, Cardiovascular, Respir &Temp disturbances • Transynaptically to other Neurons. • Bind To Presynaptic Inhibitory Synapses • Prevent Transmitter Release

  7. Pathogenesis (2) Tetanospasmin ↓ Peripheral Nervous System ↓ Motor neuron in brainstem & spinal cord (by retrograde axonal transport ) ↓ Block inhibitory neurotransmitter: Glycine Gamma-Amino Butyric Acid (GABA) ↓ SDS

  8. Pathogenesis (3) • Disinhibition of anterior horn cells • Disinhibition of autonomic neurons Disinhibition of neurotransmitters release Rigidity & Tonic Spasms Leading cause of Death Hyper sympathetic & Hyper para sympathetic state SDS

  9. Pathogenesis 2 • Direct Muscle Contraction :Severe Tetanus • Inhibition Of Acetylcholin Release. Paralytic Cephalic Tetanus. . VII Cranial Nerve. (Butolism).

  10. Pathogenesis 3 • Clinical Course: -Length of Neural Pathway to Neuraxis . Quality of Toxin • Subcortical Level of CNS Involvement: (Spinal Cord) ….Concious Patient. Anoxia, Metabolic Derangement, Sedatives. • Permanent Damage: New Synapses……………...Recovery

  11. Clinical Manifestations 1 • Incubation Period: 3-14 dys (1week) 2dys …months Microbe Entrance ……….…First Symptom Shorter I.P. …..More Severe Dis. (<1wk) • Unknown IP : Spores in Prior Injury & . . . Activation by Minor Trauma.

  12. Clinical Manifestations 2 • Concious Patient • Weakness (Local, General) • Stifness, Cramping, • Difficult Chewing or Swallowing, • Trismus : Spasm of Maseter Muscle • LOCK JAW • Progressive Muscular Spasm. • 1- 4 days …Reflex Spasms. Convultion. • ONSET PERIOD : • First symtom ………..Reflex Spasms. OP < 2days : Sever Disease

  13. Clinical Manifestations 3 • GENERALIZEDTETANUS: Risus Sardonicus : Facial Muscle Spasms Aspiration : Laryngospasm & Respiratory Muscls Spasms. Dysphagia. Reflex Spasms : Generalized Opisthotonus Abdominal & Proximal Extrimities Rigidity (Not Hands & Feet) Seconds to Minutes : Painful & Conciouse Stimuli: Noise, Light, Touch, Spontaneouse ***Apnea,….Decrease Conciousness.

  14. Risus Sardonicus SDS

  15. Risus Sardonicus SDS

  16. SDS

  17. Opthisthotonus Back spasm seen in tetanus SDS

  18. SDS

  19. HyperpyrexiaSweatingIleusLabile or sustained ↑BP TachycardiaBradycardia Arrhythmia Peripheral vasoconstriction Myocarditis, Sudden cardiac arrest Negative Nitrogen Balance ↑Urinary Catecholamine Clinical Manifestations 4 Autonomic Dysfunction: Severe case

  20. Clinical Manifestations 5 • LOCALIZED TETANUS : • LMN manifestation (Semiimm, Chronic) • Spasms Localized to Anatomic Area of the Inciting Wound. • Spasms & Relaxes, • Rigidity after Voluntary Movements • Duration : Weeks • SUBSIDING OR GENERALIZED

  21. Clinical Manifestations 6 • CEPHALIC TETANUS • Head Wound OR Otitis Media • Dysfunction Of One or More Cranial Nerves (VII). • Paretic …..To …... Spasms. • COURSE: Localized OR • Rapidly Sever Generalized

  22. Clinical Manifestations 7 • NEONATAL TETANUS: • Sever Generalized • 12th Day of Birth • Unable to Suck…..Deyhydration, • Rigidity, Spasms. • Pneumonia, Pulmonary Hemorrhage. • 90% Mortal, Developmental Delay. • 1st Week : Apnea, 2nd Week : Umblic.Sepsis

  23. SDS

  24. Poor PrognosisFever 5 dys manifes before HospitalizationAge ↓10 dys Resus sardonicus SDS

  25. SDS

  26. COMPLICATIONS • RESPIRATORY: • Hypoxia, Pneumonia, Atelectasis, Aspiration, Pulmonary Emboli. • CARDIOVASCULAR: • Arhythmia, < & > BP, Myocarditis, • <Intravascular Volume,Venous Thrombosis • BONES:Fracture of Spine & Long Bones. • Sublax. TM Joint, Glenohumeral • SUPERINFECTIONS: • Wond, Bed Sore, Catheters • GIT : Acute Peptic Ulcer, Bleeding

  27. DIAGNOSIS • CLINICAL • HISTORY of IMMUNIZATION • < 0.01 u/ml Anti Tetanus

  28. DIFFERENTIAL DIAGNOSIS • Meningitis, Encephalitis, Rabies, Epilepsy, • Decerebrate Posturing, S.A.H. • Alcohol & Narcotic Withdrawal , Hypocalcemic & Alcalotic Tetany, Peritonitis, Dental Abscess, Drugs :Anti Psychotic, Phenothiazines, Metoclopramid, Strychnine, (Pathophysiology & Tr Similar to Tetanus) . Rx: Diphenhydramin 50mg -IV • or Benztropine 1-2mg -IV

  29. TREATMENT 1 • ADDMISSION IN ICU OR WARD • NO: Noise ,Light ,Touch • 1 . SUPPORTIVE CARE : • Respiratory Support : • Endotracheal Tube :Assesing Airway Function • Tracheostomy : If Laryngospasms or Hypoventilation or Aspiration or Dysphagia • ELECTIVE & EARLY • Nutrition : NGT, CVL : Hyprealimentation High Calori & ↓ Proteine

  30. TREATMENT 2 • ……..SUPPORTIVE CARE • Control of Bowel , Bladder, & Renal Function • GIB : Sucralfate, • ARF : Rhabdomyolysis, Diuresis • Bed sore, Superinfection, • Pulmonary Emboli : Heparin, Anticoagulant, • Hyperthermia : Cooling Blanket • Contractures : Physiotherapy • Psychologic Problems : Psychotherapy

  31. TREATMENT 3 ELIMINATION SOURCE OF TOXIN Antibiotic Therapy:Metronidazole 500mg/6h ,1gr/12h 10dys Penicillin 10-20 mu/d 10dys Act as a central GABA competitive antagonistexacerbating the effects of tetanus toxin. Clindamycin, Erythromycin, Cephalosporin Imipenem, Tetracyclin,

  32. TREATMENT 4 NEUTRALIZE UNBOUND TOXIN Antitoxin HTIG : 250- IU/IM Intratechal : ↓ Spasm Duration, Hospital Stay, Ventilator 500 units : Dirty , Sever A further dose after 4 weeks If the wound is still not clean or healed. ETIG :1500 IU/IV or IM Anaphylaxis, Serum Sickness Pooled IVIG :

  33. TREATMENT 5 CONTROL O F MUSCLE SPASMS & SEDATION Benzodiazepines : GABA Agonist, Brain Stem, & Spinal cord. Diazepam : 5 mg/h …240 --480 mg/d 2 weeks (> 40 mg/h Propylenglycol Vehicle : Lactic Acidosis) Lorazepam (longer duration of Action). Midazolam (Short half life) 5-15mg/h & ↑ 24h inf usio . Without PG Vehicle.

  34. TREATMENT 6 • INVESTGATIONAL MUSCLE RELAXAN • Profocol. Expensive ↑Dose& LipidVehicle • Dantrolen. Muscle (Hepatic Dysfun) • Baclofen Intratechal. • Mg Sulfate Patellar Ref, Serum Mg Respiratory Function Tr Cariovascular instability • Pancuronium Br 1/day DC : Progression, Side eff • Vecuronium • Cisatracurium

  35. TREATMENT 7 TR OF AUTONOMIC DYSFUNCTION Sympathetic Overactivity: Labetalol: (a+B Adrenergic Blocker) . 0.25-1mg/min Sudden death Esmolol (B Blocker Short Acting) Clonidine (Central Acting Antiadren) Morphin S. 0.5-1mg/kg/h (cont Inf) Mg Sulfate Spinal Or Epidural Anesthesia Block Renal Nerves

  36. TREATMENT 8 • TR of AUTONOMIC DYSFUNCTION • Hypotention : • Volum Expander • Serum • Vasopressor • Norepinephrin • Dopamine • Bradycardia : • Atropin • Isoproterenol • Pace Maker

  37. TREATMENT 9 ACTIVE IMMUNIZATION: 3 Does Tetanus Toxoid: (DNA Based ↓Effect) In Addmissio, 4 & 8 Week Tdap : One Dose Contraindicated in Pregnancy Tdap 2 Years After Td if need of Pertusis

  38. TREATMENT 10 • SURGERY • Debridement (After TIG) • Nerve Block

  39. TREATMENT GROUP • Infectiouse Disease Specialist • Internist • General Surgeon • Neurosurgeon • Anesthesiologist • Cardiologist • ENT Specialist • Physiotherapist • Psychiatrist

  40. PROGNOSIS Age : Neonatal >90% Others : No Difference Severity: Mild & Moderaate: 6% Sever : 60%

  41. CLINICAL COURSE • Duration: • Spasms 10-14 Day 1-2Wks Disapp . Total 1-2Months (3-6Weeks) • Weakness, Stiffness Complete Recovery • ±Psychologic Problems

  42. WOUND MANAGEMENT • 1. Wound Treatment • 2. Antibiotic • 3. Immunization (Tetanus)

  43. Wound Classification SDS

  44. TABLE 1 GUIDELINES FOR TETANUS PROPHYLAXIS IN WOUNDS

  45. RESEARCHES • Intratechal Tetabulin • Intratechal Baclofen 21/22 • Tablet Antivenom • Conjugated Tetanus Toxoid (LPS of E.coli) • . Better AB Response • rIL-2 Short Term Treatment • . Potentiate AB Response in Aged Pts

  46. BE SUCCESS& HEALTH

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