Anthony Karabanow, MD
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1 Anthony Karabanow, MD
2 Epidemiology ~ 1 million cases per year worldwide 200,ooo to 300,000 deaths annually Neonatal tetanus was targeted for elimination by the WHO in 95 Neonatal tetanus still causes 5-7% of neonatal deaths
3 Pathology Spores of Clostridium tetani are found widely in soil Innoculated into wounds Transforms into active bacterium, produces tetanus toxin Toxin binds to neuroreceptors Disinhibits excitatory impulses Causes increased muscle tone, painful spasms and autonomic instability
4 Clinical scenario Generalized tetanus Local tetanus Cephalic tetanus Neonatal tetanus
5 Generalized tetanus Autonomic overactivity: - irritability - diaphoresis - tachycardia - labile BP - fever
6 Generalized tetanus Tonic contraction of skeletal muscles Intermittent, painful muscle spasms These cause classic signs/symptoms: - trismus - apnea - risus sardonicus - abdominal rigidity - opisthotonus
7 Localized tetanus Rare Tonic and spastic muscle contractions in one extremity or body region Usually evolves into generalized tetanus
8 Cephalic tetanus Due to injuries of head, neck Involves only cranial nerves Usually evolves into generalized tetanus
9 Neonatal tetanus Due to umbilical stump infection (eg application of cow dung to stump) versus non- sterile delivery Manifests as: - inability to suck - seizures - rigidity - spasms
10 Diagnosis Clinical: - tetanus prone wound - inadequate vaccination - consistent signs/symptoms
11 Management Wound care Antibiotics Neutralize toxin Control spasms Immunize
12 Wound care Aggressive wound debridement to: - remove spores - remove necrotic tissue necessary for spore germination
13 An>bio>cs Play minor role Penicillin traditional drug of choice Metronidazole now preferred Given likelihood of mixed infection: - ceftriaxone for 5-7 days
14 Toxin neutraliza>on Symptom causing tetanus toxin is irreversibly bound Can only neutralize unbound toxin HTIG 3000 to 6000 units IM ETIG 1500 to 3000 units IM
15 Symptom control Spasms are life threatening Put pt in a quiet room Drugs: - Benzodiazepines - Vecuronium - Propofol - Baclofen
16 Symptom control Autonomic dysfunction: - magnesium - labetolol - morphine
17 Immuniza>on Disease does NOT confer immunity If primary immunization series in doubt: 3 doses of tetanus toxoid Booster every 10 years
18 Other care Bound tetanus toxin cannot be displaced Recovery requires re- growth of nerve terminals (4-6 weeks) Severe tetanus means a prolonged hospital course Consider: - nutritional support - ventilatory support - early PT
19 Prognosis Neonatal: % fatality - may have long term neurologic deficits Non- neonatal: % fatality
20 Tetanus in Hai>
21 Tetanus in Hai> 4 yr old female brought to triage area Found under ruble in Port au Prince Presenting for evaluation of L LE injury
22 AF 90 BP unavailable General: Crying Heart: RRR Lungs: CTA Abd: NT, ND Tetanus in Hai> Extrems: large lacerations deep to muscle involving the R lateral calf and L shin
23 Tetanus in Hai> Wounds cleaned and bandaged Tetanus prophylaxis given Empiric abx (IM ceftriaxone) Plans for further debridement in OR
24 Tetanus in Hai> Following day, Febrile to 39.1, nuchal rigidity and intermittent arching of the back Consult re? meningitis
25 Tetanus in Hai> General: Awake, alert, crying HEENT: Teeth clenched, neck stiff Heart: RRR Lungs: CTA Abd: NT, ND Wound: unchanged Neuro: Globally increased muscle tone
26 Tetanus in Hai> Clinical tetanus diagnosed Management: High dose tetanus IgG Continue Ceftriaxone To OR for wound debridement Diazepam prn
27 Tetanus in Hai> Following day: Decreased muscle rigidity Decreased spasms Increased BP lability Mg ggt added
28 That night: IV loss Benzos not given Mg ggt not given Tetanus in Hai> Intractable spasms, trismus Vecuronium given, ventilation support started
29 Tetanus in Hai> Next AM: Navy helicopter transfer to USS Comfort Informed child coded and died shortly after arrival
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