Tetanus: Case Presentation
Download as PPTX, PDF9 likes6,505 views
This document presents a case report of a 50-year-old male farmer who was admitted to the hospital with symptoms of tetanus. He had sustained a deep cut on his right calf while working in his field one week prior that had been sutured at a local health center. On admission, he exhibited stiffness of the neck muscles and inability to open his mouth. He was diagnosed with tetanus and admitted to the intensive care unit for management. Treatment included wound debridement, antibiotics, tetanus immunoglobulin, sedation and muscle relaxants. Tetanus is a vaccine-preventable neurological disease caused by Clostridium tetani spores entering the body through wounds. It causes painful muscle
Tetanus: Case Presentation
- 1. Tetanus : Case Presentation Anupam Ghimire GP/EM Resident PAHS
- 2. Patient Details Name: Motilal Tamang Age/sex: 50yr/M Address: Ramechap Occupation : Farmer Date of Admisson : 2075- 1- 15
- 3. Chief complain • Cut Injury over Right leg 7 days back HOPI • Cut injury over Right calf region while he was ploughing field, active bleed and muscles were exposed • Due to pain , he couldnot walk • No swelling , injury to other areas
- 4. • At Local Health center, suturing was done . No history of TT vaccination • Pus discharge was present- yellowish , non foul smelling • Arrived in Hospital , kathmandu , suture was removed and dressing done • No history of fever, headache, Shortness of breathe or altered bowel/bladder habits
- 5. • Past history – Not significant • Family history – Not significant • Personal history - Consumes alcohol occassionally - Non- smoker
- 6. Physical Examination • GC : Fair • No PILCCOD • Vitals – Stable • Systemic Examination : Grossly normal
- 7. Local examination • Cut injury of 15x10 cm over left calf, vertically oriented with sharp margin and yellowish non foulsmelling discharge • Brownish slough were present at margin of wound • Local temp. raised , Tender • DNVS intact • ROM : Painful on ankle movement
- 9. Investigation • TLC : 22500 • N90L10 • Hb: 11.2 • Platelet: 560000 • RFT – Normal
- 10. Management • Dressing and posterior slab application • IV antibiotics , Analgesic • Debridement • On 3rd day : - Stifness of neck muscles - Unable to open mouth
- 11. • Tetanus Diagnosed ICU admisson • Managed with - Minimised sensory stimulation - Inj. HTIG 4000 I.U IM stat - Inj. Durataz, Vancomycin , enoxaparin - Intubated diazepam, propofol infusion, vecuronium - Daily dressing and wound care
- 12. Introduction: Tetanus • Tetanos – a greek word – to strech • Neurological disease characterized by an acute onset of hypertonia, painful muscular contractions and generalized muscle spasms • Only vaccine preventable disease that is infectious but not contagious
- 13. • Caused by Clostridium Tetani • Anaerobic, Motile, Gram positive bacilli • Oval, colourless, terminal spores – tennis racket or drumstick shape. • It is found worldwide in soil, in inanimate environment, in animal faeces & occasionally human faeces.
- 14. Epidemiology • International health problem, as spores are ubiquitous. • 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
- 15. Risk Factors • Age : Active age (5-40 years), • Sex : Higher incidence in males • Occupation : Agricultural workers are at higher risk • Immunity : Herd immunity does not protect the individual • Environmental and social factors: Unhygienic habits, Unhygienic delivery practices
- 16. 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
- 17. Pathogenesis • Spores gain entry persist in normal tissue for months to years under anaerobic conditions. • When the oxygen levels in the surrounding tissue is sufficiently low the implanted C. tetani spore then germinates into a new, active vegetative cell grows and multiplies and produces tetanus toxin - tetanospasmin and tetanolysin.
- 18. • Tetanolysin is not believed to be of any significance in the clinical course of tetanus • Tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus
- 19. • Toxin migrates across the synapse binds to presynaptic nerve terminals inhibits release of certain inhibitory neurotransmitters (glycine and gamma-amino butyric acid) • Loss of inhibition of preganglionic sym neurons – sympathetic hyperactivity
- 20. • Neurons, which release gammaaminobutyric acid (GABA) and glycine, the major inhibitory neurotransmitters, are particularly sensitive to tetanospasmin, leading to failure of inhibition of motor reflex responses to sensory stimulation.
- 21. • Once the toxin becomes fixed to neurons, it cannot be neutralized with antitoxin • Recovery of nerve function from tetanus toxins requires sprouting of new nerve terminals and formation of new synapses.
- 22. Clinical Features • IP : Ranges from 3-21 days • In general the further the injury site is from the central nervous system, the longer the incubation period • The shorter the incubation period, the higher the chance of death
- 23. • Triad of muscle rigidity, spasms & autonomic dysfunction • Early symptoms are neck stiffness, sore throat and poor mouth opening. • Patients with generalized tetanus present with trismus (ie, lockjaw) in 75% of cases. • Other presenting complaints include stiffness, neck rigidity, dysphagia, restlessness, and reflex spasms. • Spasms usually continue for 3-4 weeks.
- 24. • Subsequently, muscle rigidity becomes the major manifestation. Rigid Abdomen. • Muscle rigidity spreads in a descending pattern from the jaw and facial muscles over the next 24-48 hours to the extensor muscles of the limbs – stiff proximal limb muscles & relatively sparing hand & feet.
- 25. • Risus sardonicus: Sustained contraction of facial musculature 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
- 27. Diagnosis • No blood tests that can be used to diagnose tetanus • Diagnosis is done clinically • Laboratory studies may demonstrate a moderate peripheral leukocytosis • Cerebrospinal fluid (CSF) study findings are usually within normal limits.
- 28. Principle of treatment 1. Neutralization of unbound toxin 2. Prevention of further toxin production - Wound debridement & antibiotics 3. Antibiotics 4. Control of spasm - Anticonvulsants, Sedatives, Muscle relaxants 5. Management of autonomic dysfunction - MgSO4, Betablockers 6. Supportive care - Physiotherapy, Nutrition, Thromboembolism prophylaxis
- 29. Management • Admit patients to the intensive care unit (ICU). • Because of the risk of reflex spasms, maintain a dark and quiet environment for the patient. • Avoid unnecessary procedures and manipulations. • Attempting endotracheal intubation may induce severe reflex laryngospasm; prepare for emergency tracheostomy
- 30. Immunogloulin • A single intramuscular dose of 3000-5000 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified. • The WHO recommends TIG 500 units by IM/IV (depending on the available preparation) as soon as possible; in addition, administer TT- containing vaccine , 0.5 cc by intramuscular injection at separate site with HTIG.
- 31. • TIG can only help remove unbound tetanus toxin, but it cannot affect toxin bound to nerve endings.
- 32. Prevention of further toxin production • Debridement of Wound to remove organisms and to create an aerobic environment • Current recommendation is to excise at least 2 cm of normal viable-appearing tissue around the wound margins • Incise and drain abscesses.
- 33. Antibiotics • Penicillin G aqueous : (10-12 MU IV in 2-4 divided doses- 2-4 MU IV every 4 to 6 hrs) - 10- to 14-d course of treatment is recommended • Metronidazole: (5oomg 6 hrly or 1gm 12 hrly)
- 34. Summary • Tetanus : Vaccine preventable • Diagnosis clinically • High index of suspicion • Significant mortality and morbidity
- 35. • Harrison’s PRINCIPLES OF INTERNAL MEDICINE : Eighteenth Edition • UpToDate (http://www.uptodate.com) • Current recommendations for treatment of tetanus during humanitarian emergencies : WHO Technical note
- 36. THANK YOU