Ui - Tetanus

Surgery Lecture on
TETANUS
Dr. Ehsanur Reza
MBBS, FCPS
Assistant Professor
Surgery Unit III
MMCH
WTetanushat is Tetanus?
 An infectious disease caused by

contamination of wounds from the
bacteria Clostridium tetani, or the
spores they produce that live in the
soil, and animal feces
 Greek words -“tetanosand teinein”,

meaning rigid and stretched, which
describe the condition of the muscles
affected by the toxin, tetanospasmin,
produced by Clostridium tetani
Sporulated Vegetative
Causes
 Tetanus spores are found throughout the
environment, usually in soil, dust, and animal waste.
 Tetanus is acquired through contact with the

environment; it is not transmitted from person to
person.
 The usual locations for the bacteria to enter the body:
Causes
 Puncture wounds (such as those caused by rusty
nails, splinters, or insect bites.)
 Burns, any break in the skin, and IV drug access

sites are also potential entryways for the bacteria.
Route of Entry
 Apparently trivial injuries
 Animal bites/human bites
 Open fractures
 Burns
 Gangrene
 In neonates usually via infected umbilical
stumps
 Abscess
 Parenteral drug abuse
 In 20% of cases of tetanus, no puncture entry
wound is found. Superficial abrasions to the
limbs are the commonest infection sites in
adults. Deeper infections (e.g., attributable to
open fracture, abortion, or drug injection) are
associated with more severe disease and
worse outcomes
epidemiology
Tetanus is an international health problem, as spores are
ubiquitous. The disease occurs almost exclusively in persons
who are unvaccinated or inadequately immunized.
Tetanus occurs worldwide but is more common in hot,
damp climates with soil rich in organic matter.
More common in developing and under developing
countries.
More prevalent in industrial establishment, where
agricultures workers are employed.
Tetanus neonatorum is common due to lack of MCH care.
Incubation Period
 Varies from 1 day to several months. It is

defined as the time from injury to the first
symptom.
Period of onset
 It is the time from first symptoms to the

reflex spasm.
 An incubation period of 4 days or less

or
 A period of onset of less than 48 hr is
associated with the development of severe
tetanus.
pathogenesis
C. tetani produces two exotoxins: tetanolysin and
tetanospasmin. Tetanolysin, which is related to the
clostridial toxins and streptolysin, plays no role in the
pathogenesis of the disease. Tetanospasmin,
generally referred to as "tetanus toxin," is the
neurotoxin that causes the manifestations of disease
1. C. tetani enters body 2. Stays in sporulated
form until anaerobic
from through wound.
conditions are presented.
3. Germinates under 4. Tetnospasmin spreads using

anaerobic conditions and blood and lymphatic system,
begins to multiply and and binds to motor neurons.
produce tetnospasmin.
6. Binds to sites responsible for

5. Travels along the axons
inhibiting skeletal muscle
to the spinal cord. contraction.
•Initially binds to peripheral
nerve terminals
•Transported within the axon and
across synaptic junctions until it
reaches the central nervous
system.
•Becomes rapidly fixed to
gangliosides at the presynaptic
inhibitory motor nerve endings,
then taken up into the axon by
endocytosis.
How the toxin acts?
Blocks the release of inhibitory
neurotransmitters (glycine and gamma-
amino butyric acid) across the synaptic
cleft, which is required to check the nervous
impulse.
If nervous impulses cannot be checked by
normal inhibitory mechanisms, it leads to
unopposed muscular contraction and
spasms that are characteristic of tetanus.
Tetanus prone wound
 A wound sustained more than 6 hr before

surgical treatment.
 A wound sustained at any interval after injury
which is puncture type or shows much
devitalised tissue or is septic or is
contaminated with soil or manure.
GAMBARAN KLINIS
 Generalisata
 Sefalik
 Lokalisata
 neonatorum
Clinical features
 Risus sardonicus: Contraction of the muscles at the

angle of mouth and frontalis
 Trismus (Lock Jaw): Spasm of Masseter muscles.
 Opisthotonus: Spasm of extensor of the neck, back
and legs to form a backward curvature.
 Muscle spasticity
 Prolonged muscular action causes sudden,
powerful, and painful contractions of muscle
groups. This is called tetany. These episodes
can cause fractures and muscle tears.
 If respiratory muscle is involved – apnoea.

Signs and Symptoms
Other symptoms include:
 Drooling
 Excessive sweating
 Fever
 Hand or foot spasms
 Irritability
 Swallowing difficulty
 Uncontrolled urination or defecation
 Autonomic disturbance is maximal during the
second week of severe tetanus, and death
due to cardiovascular events becomes the
major risk. Blood pressure is usually labile,
with rapid fluctuations from high to low
accompanied by tachycardia. Episodes of
bradycardia and heart block can also occur.
Autonomic involvement is evidenced by
gastrointestinal stasis, sweating, increased
tracheal secretions, and acute (often high-
output) renal failure.
Diagnosis
 There are currently no blood tests that can be used to diagnose tetanus. Diagnosis is done
clinically.
 Centers for Disease Control and Prevention (CDC) defines tetanus as "the acute onset of
hypertonia or. . .painful muscular contractions (usually of the muscles of the jaw and neck) and
generalized muscle spasms without other apparent medical cause
 Neonatal tetanus is defined by the World Health Organization (WHO) as "an illness occurring in a
child who has the normal ability to suck and cry in the first 2 days of life but who loses this ability
between days 3 and 28 of life and becomes rigid and has spasms
 Maternal tetanus is defined by the WHO as tetanus occurring during pregnancy or within 6 weeks
after the conclusion of pregnancy (whether with birth, miscarriage, or abortion).
Differential Diagnosis
 Masseter muscle spasm due to dental abscess
 Dystonic reaction to phenothiazine
 Rabies
 Hysteria
Principle of Treatment
 1. Neutralization of unbound toxin with

Human tetanus immunoglobulin
 2. Prevention of further toxin production by
-Wound debridement
-Antibiotics (Metronidazole)
 3. Control of spasm
- Nursing in quiet environment
- avoid unnecessary stimuli
- Protecting the airway
 4. Supportive care
- Adequate hydration
- Nutrition
- Treatment of secondary infection
- prevention of bed sores.
Prevention
 Tetanus is completely preventable

by active tetanus immunization.
 Immunization is thought to provide

protection for 10 years.
 Begins in infancy with the DTP

series of shots. The DTP vaccine is
a "3-in-1" vaccine that protects
against diphtheria, pertussis, and
tetanus.
Prevention
 Can be achieved by active immunization by tetanus

toxoid (5 doses – 0 day, 1 month, 6 month, 1 year, 1
year).
 Older teenagers and adults who have
sustained injuries, especially puncture-type
wounds, should receive booster immunization
for tetanus if more than 10 years have passed
since the last booster.
 Clinical tetanus does not produce immunity to

further attacks. Therefore, even after recovery
patients must receive a full course of tetanus toxoid.
Thank You

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Surgery Lecture on

 An infectious disease caused by

 Greek words -“tetanosand teinein”,

 Tetanus is acquired through contact with the

 Burns, any break in the skin, and IV drug access

 Varies from 1 day to several months. It is

 It is the time from first symptoms to the

 An incubation period of 4 days or less

3. Germinates under 4. Tetnospasmin spreads using

6. Binds to sites responsible for

 A wound sustained more than 6 hr before

 Risus sardonicus: Contraction of the muscles at the

 If respiratory muscle is involved – apnoea.

 1. Neutralization of unbound toxin with

 Tetanus is completely preventable

 Immunization is thought to provide

 Begins in infancy with the DTP

 Can be achieved by active immunization by tetanus

 Clinical tetanus does not produce immunity to

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