tetanus notes pptx with full explanations

tetanus

1. TE T ANUS

2. Etiology The most common way the bacterium enters the body is through wounds which are susceptible to infection if they are: Contaminated with soil, feces, or saliva, Puncture wounds including unsterile injection sites, Devitalized tissue including burns, avulsions and de-gloving injuries

3. PATHOGENESIS Once the bacteria C. tetani enters the body the spores multiply and germinate due to the anaerobic environment. In the body, two toxins are released: tetanospamin and tetenolysin.

4. T etano l ys i n Hemolytic toxin Potentiates infection but does not cause disease process T etanospa s m i n Binds to NM junction at the site of injury and undergoes retrograde axonal transport to reach presynaptic nerve terminal where it prevents the inhibitory neurotransmitters GLYCINE AND GABA. In normal states these neurotransmitters prevent release of Ach from excitatory neurons thus prevent muscle contraction.in the presence of toxins these inhibitory impulsesare prevented leading to uncontrolled contraction of muscles, PATHOGENESIS

5. Tetanospamin reaches the peripheral nerves by retrograde neuronal transport through the blood or lymphatic system. The length of the peripheral nerves determines how long it takes for the neurotoxins to reach the CNS and cause symptoms. The toxin tetanospamin disrupts the release of the inhibitory neurotransmitters glycine and GABA throughout the CNS but most commonly at the motor end plates, spinal cord, brain, and sympathetic nervous system. The disinhibition allows for unopposed muscular contraction followed by muscular rigidity and spasms.

6. INCUBATION PERIOD Once the bacteria has entered the body the incubation period may range from days to months. The average incubation period is around 4- 14 days. The incubation period is shorter the closer the injury site is to the CNS. A shorter incubation period usually correlates with poor prognosis due to a more severe disease.

7. Characteristics/Clinical Presentation There are four different forms of tetanus: Generalized tetanus Local tetanus Cephalic tetanus Neonatal tetanus.

8. Generalized tetanus Generalized tetanus attacks muscles throughout the entire body the most common form of tetanus (about 80% of the cases) Generalized Muscular rigidity and spasms Tetanospamin attacks and inhibits mostly the motor neurons of the CNS and later the neurons of the ANS as well. As a result a person experiences uncontrollable intense muscle contractions

9. The first muscles affected are the facial and jaw muscles because of their short nerve pathways. This condition is commonly referred to as lock jaw or trismus.

10. As the disease progresses the person will experience stiffness of the neck, difficulty swallowing, and stiffness of the abdominal muscles. Followed by Generalized Muscular spasm

11. OPISTHOTONOS Spasm of the muscles causing backward arching of the head, neck, and spine, as in severe tetanus, some kinds of meningitis, and strychnine poisoning.

12. RISUS SARDONICUS Uninhibited muscle contractions cause trismus (“ lockjaw ”), facial grimacing, an odd but characteristic smile (“ RISUS SARDONICUS ”)

13. Spasms can be produced by a stimulus such as light, noise, touch, or happen unexpectedly with no specific cause. Spasms are extremely painful and can occur frequently and can last for several minutes.

14. In generalized tetanus “spasms continue for 3- 4 weeks and complete recovery may take months.” After several days, the ANS will be affected showing others signs such as fever, sweating, elevated blood pressure, and increased or rapid heart rate.

15. Local tetanus Local tetanus can occur before generalized tetanus but this is a much milder form with a decreased amount of associated toxin release. Local tetanus, for the most part, just attacks muscles in a specific (local) area of the body

16. Local tetanus Localized tetanus is rare, but there is a better prognosis with only about 1% of the cases resulting in death. The presentation of local tetanus is muscle rigidity and continuous contractions close to the injury site.

17. Cephalic tetanus Cehalic tetanus is also rare Shows a combination of both generalized and local tetanus. The characteristics are facial spasms and paralysis as a result of involvement of the cranial nerves.

18. Cephalic tetanus Head wounds are the main cause with occasional occurrence found with ear infections (otitis media) associated with a head wound. Cephalic tetanus can progress to generalized tetanus and can be associated with a high fatality rate.

19. Neonatal tetanus Neonatal tetanus (which is found in newborn babies) is a form of generalized tetanus which also has a high fatality rate. The diagnosis is determined from the symptoms that present. When the baby is born they are able to suck and swallow normally for 2- 3 days and then they lose that ability.

20. The symptoms of neonatal tetanus are muscle rigidity and spasms which appear around "4- 14 days after birth”.

21. Neonatal tetanus The most common way neonatal tetanus occurs is due to non- immune mothers and poor hygiene during the delivery process . Most of the cases of infected infants is a result of infection of the unhealed stump of the umbilical cord especially if the cord has been cut with unsterile instruments . Neonatal tetanus is very common in third world countries.

22. Systemic Involvement Cardiovascular : Hyperkinetic circulation is a result of elevated basal sympathetic and muscle activity. Tachycardia with hypertension Increased stroke volume Thromboembolus

23. Systemic Involvement Respiratory: Muscular spasms: chest wall, diaphragm, abdomen, pharyngeal, and laryngeal tract (can lead to an obstructed airway which can be life threatening) Atelectasis, pneumonia, and aspiration: inability to cough secondary to muscular rigidity, spasms, and being sedated. Hyperventilation: common because of fear and autonomic disturbances.

24. Systemic Involvement Renal Renal involvement is only found in severe cases of tetanus. Dehydration Urinary stasis and infection Renal failure Altered renal blood flow secondary to catecholamine surges

25. Systemic Involvement Gasto- intestinal: Gastric statis Illeus Diarrhea Hemorrhage Weight loss: As a result of the inability to swallow

26. Systemic Involvement Neuromuscular: Autonomic dysfunction: Leads to excess sympathetic activation and catecholamine levels Musculoskeletal: Muscle rigidity and spasms Lock- jaw (trismus) Risus sardonicus Opisthotonos (reactions of the head) Tendon avulsions: a result of spasms Fractures: a result of spasms

27. Differential Diagnosis Infections of the head, neck, and central nervous system Orofacial infection Dystonic drug reactions: HALOPERIDOL, METOCLOPROMIDE (PERINORM), Anti- depressants, Anti- Epileptics, Midazolam. Hypocalcaemia Strychnine poisoning Seizures

28. Diagnosis The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. There are no specific laboratory or diagnostic tests used to diagnosis tetanus.

29. Medical Management Categorized into three steps. First the organism in the body needs to be destroyed to prevent further release of the toxin. Next the toxin in the body outside of the CNS needs to be neutralized and finally the effects of the toxin in the CNS need to be minimized

30. Surgical Management WOUND DEBRIDEMENT , if possible, should be done to help remove the toxin from the body

31. HUMAN TETANUS IMMUNOGLOBULIN Neutralization of free toxin TIg cannot dislodge toxins in the nerve root. The route of administration is intra muscular or intra- thecal. Dose:500 – 1000 IU

32. General Medical Management AIRWAY MANAGEMENT & Respiratory support: Maintenance of oxygen is essential Supportive care: Control fluid and electrolyte balance Maintain adequate hydration, Early detection of myoglobinuria Prevention of renal shutdown. Oropharyngeal secretions should be sucked periodically. Prevent other infections

33. General Medical Management Oral feeding should be stopped and IV line should be established for providing adequate fluids , calories , electrolytes and for administration of various drugs. After 3 – 4 days of treatment milk feeding through nasogastric tube may be started.

34. Controlling the spasms Spasms are precipitated by minimal stimuli therefore efforts should be made to avoid noxious stimuli including bright lights, pain , loud noises. So ,Patient should be kept in dark quiet and isolated rooms. I.M injections should be avoided. Temperature should be maintained within normal limits.

35. Controlling the spasms Relief of Spasm is by using sedation and muscle relaxants like benzodiapenes DIAZEPAM – prevents spasms by causing GABA mediated central inhibition. – it promotes muscle relaxation.

36. Medications Antibiotic therapy is needed to abolish bacteria from the wound site. Most commonly used Penicillin and Cephalosporins Metronidazole: for treating and preventing anaerobic bacterial diseases Erythromycin, Tetracycline, Chloramphenicol, and Clindamycin.

37. ANS Instability treated by: alpha and beta blockers, IV magnesium. The prognosis of individuals with tetanus depends on the supportive care and ventilatory access.

38. ROLE OF PHYSIOTHERAPIST Currently research is limited on the Physical therapy management of individuals with tetanus. Cardiopulmonary physical therapy can be used to help in the prevention of respiratory complications. Physical therapy can also be used to help with muscle rigidity and spasms.

39. Vaccinations Tetanus can be prevented through vaccinations. The vaccination consists of being injected with the tetanus toxoid. The toxoid is available in two different forms: Absorbed toxoid and Fluid toxoid.

40. TETANUS TOXOIDS The toxoids work by producing specific antitoxins that will neutralize the bacteria The toxoid is inactivated and does not contain any live organisms. Therefore, the toxoids can not replicate themselves once injected

41. DPT VACCINE The tetanus vaccine has been combined with pertussis and diptheria to make the DPT vaccine for infants. The vaccination is started in infants at 6 weeks of age & repeated twice at 4 weeks intervals.

42. Age National Rural Heath Mission Birth BCG, OPV(0), Hep B Birth dose (To be given at the place of delivery) 6 Weeks OPV1, Penta1( DPT +HepB+HiB) 10 Weeks OPV2, Penta2( DPT +HepB+HiB) 14 Weeks OPV3, Penta3( DPT +HepB+HiB), IPV 9 Months MMR- 1, /MR/Measels, JE Vaccine- 1 16-24 Months MMR- 1, OPV Booster, DPT 1st Booster , JE Vaccine- 2 5-6 Years DPT 2nd Booster 10 Years TT1 16 Years TT2 Vaccination as per the National Immunization schedule by Government of India

43. For adolescents and adults : the Tdap vaccine combination of tetanus and diphtheria toxin with acellular pertussis It is recommended to get a booster shot every 10 years.