Acute tetanus: Difference between revisions
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==Background== | ==Background== | ||
* C. tetani spores enter skin through wound, make tetanospasmin toxin | |||
**Lacs, abrasions, puncture wounds | |||
**Preferentially binds GABA and glycinergic neurons and blocks presynaptic release | |||
***Motor neurons undergo sustained excitatory discharge | |||
* Spores found in soil and human feces | |||
* 2001-2008 in US, 233 cases, 26 deaths | |||
* Mortality as high as 45% | |||
* Incubation is 2 to 56d | |||
* The majority of clinical tetanus happen in the elderly.<ref>Talan DA, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med. 2004 Mar;43(3):305-14.[http://www.ncbi.nlm.nih.gov/pubmed/14985655 Pubmed]</ref> | |||
== | ==Clinical Features== | ||
===Neonatal=== | ===Neonatal=== | ||
* from umbilical stump infection. Usually protected by passive maternal Abs | |||
* sx- poor suck, irritability, crying, grimacing | |||
* usually with in 10 d of birth | |||
===Local=== | ===Local=== | ||
*rigidity of muscles near wound- may progress to generalized | |||
===Generalized=== | ===Generalized=== | ||
* most common form | |||
* pts are conscious and alert | |||
* hypersympathetic state c sweating, HTN, tachycardia, fever | |||
===Cephalic=== | ===Cephalic=== | ||
* follow injuries to head or otitis media | |||
* get CN dysfunction- usually CN 7 | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Jaw spasms DDX}} | {{Jaw spasms DDX}} | ||
==Diagnosis== | |||
* Progressive symptoms<ref>Fernandez-Frackelton M: Bacteria, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 127:p 1681-1686</ref> | |||
**Alert and able to communicate | |||
**Trismus - lockjaw (50%-75% of patients) | |||
**Sardonic smile (risus sardonicus) - other facial muscles become involved | |||
**Minor stimuli such as touch or noise start tetanic contractions | |||
**Abd, back, diff swallowing | |||
**Long bone fractures, tendon rupture | |||
**Opisthotonus - contractures that resemble decorticate posturing | |||
* DX = clinical | |||
==Treatment== | ==Treatment== | ||
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*[[Clostridium]] | *[[Clostridium]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] | ||
Revision as of 06:03, 13 August 2015
Background
- C. tetani spores enter skin through wound, make tetanospasmin toxin
- Lacs, abrasions, puncture wounds
- Preferentially binds GABA and glycinergic neurons and blocks presynaptic release
- Motor neurons undergo sustained excitatory discharge
- Spores found in soil and human feces
- 2001-2008 in US, 233 cases, 26 deaths
- Mortality as high as 45%
- Incubation is 2 to 56d
- The majority of clinical tetanus happen in the elderly.[1]
Clinical Features
Neonatal
- from umbilical stump infection. Usually protected by passive maternal Abs
- sx- poor suck, irritability, crying, grimacing
- usually with in 10 d of birth
Local
- rigidity of muscles near wound- may progress to generalized
Generalized
- most common form
- pts are conscious and alert
- hypersympathetic state c sweating, HTN, tachycardia, fever
Cephalic
- follow injuries to head or otitis media
- get CN dysfunction- usually CN 7
Differential Diagnosis
Jaw Spasms
- Acute tetanus
- Akathisia
- Conversion disorder
- Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
- Dystonic reaction
- Electrolyte abnormality
- Hypocalcemic tetany
- Magnesium
- Mandible dislocation
- Meningitis
- Peritonsillar abscess
- Rabies
- Seizure
- Strychnine poisoning
- Stroke
- Temporomandibular disorder
- Torticollis
Diagnosis
- Progressive symptoms[2]
- Alert and able to communicate
- Trismus - lockjaw (50%-75% of patients)
- Sardonic smile (risus sardonicus) - other facial muscles become involved
- Minor stimuli such as touch or noise start tetanic contractions
- Abd, back, diff swallowing
- Long bone fractures, tendon rupture
- Opisthotonus - contractures that resemble decorticate posturing
- DX = clinical
Treatment
- Before wound debridement, apply immunoglobulin (TIG) directly into the wound and IM
- Dose: 3000-6000 units IM with adequate mL to wound
- Des not reverse toxin already fixed to CNS. Binds circulating toxin
Supportive Care
- Place patient in a quiet room
- Provide sedation with Benzodiazepines or phenobarbital
Antibiotics
- Metronidazole 500mg IV (7.5mg/kg) q6hrs OR
- Clindamycin 600mg IV (7.5mg/kg) q6hrs
Penicillin
- Although once the drug of choice it is now no longer recommended since it may potentiate the effect of tetanus toxin by inhibiting the GABA receptors[3]
See Also
References
- ↑ Talan DA, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med. 2004 Mar;43(3):305-14.Pubmed
- ↑ Fernandez-Frackelton M: Bacteria, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 127:p 1681-1686
- ↑ Ganesh Kumar AV. Benzathine penicillin, metronidazole and benzyl penicillin in the treatment of tetanus: a randomized, controlled trial .Ann Trop Med Parasitol. 2004 Jan;98(1):59-63 PMID 15000732