Acute tetanus: Difference between revisions
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==Background==
==Background==
# 45% mortality
*''Clostridium tetani'' spores enter skin through wound, make tetanospasmin toxin
# 2 to 56d incubation period
*2001-2008 in US, 233 cases, 26 deaths
# if pt survives, no residual sequealae
*Mortality as high as 45%
*Incubation is 2 to 56d
*Spores found in soil and human and animal feces
**Tetanus prone wounds include contaminated lacerations, abrasions, puncture wounds; crush, avulsion, or frostbite injuries are also vulnerable to tetanus <ref>Auerbach PS. Wilderness Medicine. Philadelphia: Mosby Elsevier; 2007.</ref>
**Preferentially binds GABA and glycinergic neurons and blocks pre-synaptic release
***Motor neurons undergo sustained excitatory discharge, producing spasms
*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>


==Types==
==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
*Symptoms - poor suck and failure to nurse, irritability, crying, grimacing
# usually with in 10 d of birth
*Usually with in 10 d of birth


===Local===
===Local===
#rigidity of muscles near wound- may progress to generalized
*Rigidity of muscles near wound- may progress to generalized


===Generalized===
===Generalized===
# most common form
*Most common form of tetanus
# pts are conscious and alert
*Usually begins with trismus (spasm of the masticator muscle group) with gradual onset of spasm of muscle groups in the trunk and extremities
# hypersympathetic state c sweating, HTN, tachycardia, fever
*Spasms exacerbated by external stimuli (light or sudden sound)
*Patients can lose ability to breath during prolonged spasms
*Respiratory failure is main cause of death
*Patients are conscious and alert
*Hypersympathetic state with sweating, hypertension, 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 cranial nerve dysfunction- usually cranial nerve 7


==Diagnosis==
==Differential Diagnosis==
# sxs for 2 wks- pain & stiffness of jaw, abd, back, diff swallowing, hyperactive DTRs, labile HTN,
{{Jaw spasms DDX}}
# DX = clinical


==DDx==
==Evaluation==
#dystonic rxn
*Diagnosis is clinical
#strychnine
*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>
#hypocalcemic tetany
**Alert and able to communicate
#PTA
**Trismus - lockjaw (50%-75% of patients)
#teritonitis. SAN
**Sardonic smile (risus sardonicus) - other facial muscles become involved
#meningitis
**Minor stimuli such as touch or noise start tetanic contractions
#rabies
**Difficulty swallowing
#TMJ
**Long bone fractures, tendon rupture
**Opisthotonus - lumbar lordosis with the neck and legs extended and the arms flexed at the elbows
**Laryngospasm
**Autonomic instability
**Sympathetic nervous system hyperactivity, including tachycardia, sweating, arrhythmias, and hypertension
*No laboratory testing is used to diagnose tetanus; wound cultures are often negative


==Treatment==
==Management==
# wound debridement
*Before wound debridement, immunoglobulin (TIG) directly into the wound and IM
# TIG- 3000- 10K IM- prevents additional dz but does not reverse toxin already fixed to CNS. Binds circulating toxin
**Dose: 3000-6000 units IM with adequate mL to wound
# IVF/ hyperal
**Does not reverse toxin already bound to CNS. Binds circulating toxin
# quiet room
*Tetanus toxoid; patients do NOT develop immunity after tetanus infection
# sedation with phenobarb, valium or paralytics
===Supportive Care===
# ABx- pen G or flagyl- not 100% proven
*Place patient in a quiet room
*Provide sedation with [[Benzodiazepines]] or phenobarbital
*Airway management via intubation or tracheostomy should be performed when patient exhibits dysphagia or respiratory difficulties
*Autonomic dysfunction management with magnesium sulfate or labetalol, morphine and clonidine
*Magnesium sulfate has several desirable attributes for control of spasticity and autonomic dysfunction in tetanus<ref>Wangmo KP, Teng M, Henker R, Kinnear S, Tshering J, Wang NE. Survival of a Patient With Tetanus in Bhutan Using a Magnesium Infusion Managed Only by Clinical Signs. Wilderness & Environmental Medicine. 2014;25(2):194-197. doi:10.1016/j.wem.2013.11.006.</ref>
**Acts as a presynaptic neuromuscular blocker by antagonizing calcium in the neuromuscular junction and myocardium
**Blocks the release of catecholamines and has anticonvulsant properties
**Often available in low-resource settings
 
===[[Antibiotics]]===
{{Tetanus Antibiotics}}
 
==See Also==
*[[Tetanus (Prophylaxis)]]
*[[Clostridium]]
 
==References==
<references/>
Moll JL, Carden DL. Tetanus. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109435736. Accessed December 01, 2017.


steroids & hyperbaric O2 = no evidence


[[Category:ID]]
[[Category:ID]]

Revision as of 23:58, 27 April 2018

Background

  • Clostridium tetani spores enter skin through wound, make tetanospasmin toxin
  • 2001-2008 in US, 233 cases, 26 deaths
  • Mortality as high as 45%
  • Incubation is 2 to 56d
  • Spores found in soil and human and animal feces
    • Tetanus prone wounds include contaminated lacerations, abrasions, puncture wounds; crush, avulsion, or frostbite injuries are also vulnerable to tetanus [1]
    • Preferentially binds GABA and glycinergic neurons and blocks pre-synaptic release
      • Motor neurons undergo sustained excitatory discharge, producing spasms
  • The majority of clinical tetanus happen in the elderly.[2]

Clinical Features

Neonatal

  • From umbilical stump infection. Usually protected by passive maternal Abs
  • Symptoms - poor suck and failure to nurse, irritability, crying, grimacing
  • Usually with in 10 d of birth

Local

  • Rigidity of muscles near wound- may progress to generalized

Generalized

  • Most common form of tetanus
  • Usually begins with trismus (spasm of the masticator muscle group) with gradual onset of spasm of muscle groups in the trunk and extremities
  • Spasms exacerbated by external stimuli (light or sudden sound)
  • Patients can lose ability to breath during prolonged spasms
  • Respiratory failure is main cause of death
  • Patients are conscious and alert
  • Hypersympathetic state with sweating, hypertension, tachycardia, fever

Cephalic

  • Follow injuries to head or otitis media
  • Get cranial nerve dysfunction- usually cranial nerve 7

Differential Diagnosis

Jaw Spasms

Evaluation

  • Diagnosis is clinical
  • Progressive symptoms[3]
    • 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
    • Difficulty swallowing
    • Long bone fractures, tendon rupture
    • Opisthotonus - lumbar lordosis with the neck and legs extended and the arms flexed at the elbows
    • Laryngospasm
    • Autonomic instability
    • Sympathetic nervous system hyperactivity, including tachycardia, sweating, arrhythmias, and hypertension
  • No laboratory testing is used to diagnose tetanus; wound cultures are often negative

Management

  • Before wound debridement, immunoglobulin (TIG) directly into the wound and IM
    • Dose: 3000-6000 units IM with adequate mL to wound
    • Does not reverse toxin already bound to CNS. Binds circulating toxin
  • Tetanus toxoid; patients do NOT develop immunity after tetanus infection

Supportive Care

  • Place patient in a quiet room
  • Provide sedation with Benzodiazepines or phenobarbital
  • Airway management via intubation or tracheostomy should be performed when patient exhibits dysphagia or respiratory difficulties
  • Autonomic dysfunction management with magnesium sulfate or labetalol, morphine and clonidine
  • Magnesium sulfate has several desirable attributes for control of spasticity and autonomic dysfunction in tetanus[4]
    • Acts as a presynaptic neuromuscular blocker by antagonizing calcium in the neuromuscular junction and myocardium
    • Blocks the release of catecholamines and has anticonvulsant properties
    • Often available in low-resource settings

Antibiotics

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[5]

See Also

References

  1. ↑ Auerbach PS. Wilderness Medicine. Philadelphia: Mosby Elsevier; 2007.
  2. ↑ 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
  3. ↑ 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
  4. ↑ Wangmo KP, Teng M, Henker R, Kinnear S, Tshering J, Wang NE. Survival of a Patient With Tetanus in Bhutan Using a Magnesium Infusion Managed Only by Clinical Signs. Wilderness & Environmental Medicine. 2014;25(2):194-197. doi:10.1016/j.wem.2013.11.006.
  5. ↑ 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 
Moll JL, Carden DL. Tetanus. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109435736. Accessed December 01, 2017.
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