Acute tetanus: Difference between revisions
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==Background== | ==Background== | ||
* C. tetani spores enter skin through wound, make tetanospasmin toxin | *C. tetani spores enter skin through wound, make tetanospasmin toxin | ||
**Lacs, abrasions, puncture wounds | **Lacs, abrasions, puncture wounds | ||
**Preferentially binds GABA and glycinergic neurons and blocks presynaptic release | **Preferentially binds GABA and glycinergic neurons and blocks presynaptic release | ||
***Motor neurons undergo sustained excitatory discharge | ***Motor neurons undergo sustained excitatory discharge | ||
* Spores found in soil and human feces | *Spores found in soil and human feces | ||
* 2001-2008 in US, 233 cases, 26 deaths | *2001-2008 in US, 233 cases, 26 deaths | ||
* Mortality as high as 45% | *Mortality as high as 45% | ||
* Incubation is 2 to 56d | *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> | *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== | ==Clinical Features== | ||
===Neonatal=== | ===Neonatal=== | ||
* From umbilical stump infection. Usually protected by passive maternal Abs | *From umbilical stump infection. Usually protected by passive maternal Abs | ||
* Sx- poor suck, irritability, crying, grimacing | *Sx- poor suck, irritability, crying, grimacing | ||
* Usually with in 10 d of birth | *Usually with in 10 d of birth | ||
===Local=== | ===Local=== | ||
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===Generalized=== | ===Generalized=== | ||
* Most common form | *Most common form | ||
* PTs are conscious and alert | *PTs are conscious and alert | ||
* Hypersympathetic state c sweating, HTN, tachycardia, fever | *Hypersympathetic state c sweating, HTN, tachycardia, fever | ||
===Cephalic=== | ===Cephalic=== | ||
* Follow injuries to head or otitis media | *Follow injuries to head or otitis media | ||
* Get CN dysfunction- usually CN 7 | *Get CN dysfunction- usually CN 7 | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Diagnostic Evaluation== | ==Diagnostic Evaluation== | ||
* 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> | *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 | **Alert and able to communicate | ||
**Trismus - lockjaw (50%-75% of patients) | **Trismus - lockjaw (50%-75% of patients) | ||
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**Long bone fractures, tendon rupture | **Long bone fractures, tendon rupture | ||
**Opisthotonus - contractures that resemble decorticate posturing | **Opisthotonus - contractures that resemble decorticate posturing | ||
* DX = clinical | *DX = clinical | ||
==Management== | ==Management== | ||
Revision as of 03:12, 6 July 2016
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
Diagnostic Evaluation
- 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
Management
- 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