1. TETANUS

2. TETANUS
• Mainly classified as adult type & Neonatal Tetanus
• Historically called as locked jaw
• Acute spastic paralytic illness caused by tetanus
toxin

3. ETIOLOGY
• Clostridium tetani
• Gram positive, sporing, motile obligate anaerobe
• Spores tennis racket type
• Tetanospasmin 2nd most powerful toxin after
botulinum toxin

4. EPIDEMIOLOGY
• Rare in developed countries
• One of the leading cases of death in developing
countries
• Tetanus toxoid immunization decreased mortality
• Mortality is 40-80% in disease

5. MODE OF TRANSMISSION
• Wound contaminated by tetanus spores
• Pin prick, Animal bite, intrauterine death , ear
piercing tattooing , unsterile cutting of umbilical
cord.

6. INCUBATION PERIOD
• 6-10 days
• lesser the incubation period more the mortality

7. TYPE OF TETANUS
• Traumatic
• Puerperal
• Otogenic
• Idiopathic
• Tetanus neonatorum

8. TETANUS ( OLDER CHILDREN)
CLINICAL FEATURES
• Generalized tetanus, trismus is 1st sign
• Headache, irritability, restlessness
• Neck stiffness, locked jaw, dysphasia
• Risus sardonicus face
• Abdominal, lumbar, Hip muscles involved
• Opisthotonous ( Bow like) in extension

9. TETANUS ( OLDER CHILDREN)
CLINICAL FEATURES – Contd..
• Board like rigidity of abdomen
• Touch sound light exacerbates seizures
• Sensory system totally Normal
• Consciousness well maintained
• Urinary retention
• Cephalic tetanus rare, involve bulbar musculature

10. DIAGNOSIS
• Mainly clinical features are diagnostic
• Proper history. Immunization status
• Other tests are normal
• Clostridium tetani can be isolated from wound only
in 1/3rd cases

11. DIFFERENTIAL DIAGNOSIS
• Para pharyngeal, Retropharyngeal abscess
• Rabies
• Hypocalcaemia
• Strychnine poisoning
• Acute encephalitis

12. TREATMENT
Wound management
• Washing, debridement of Necrotic material, foreign
body removal
Eradication of Cl. tetani
• Penicillin, Metronidazole
• Erythromycin, tetracycline in penicillin allergic
patient

13. NEUTRALIZATION OF TETANUS TOXIN
• Human anti tetanus immunoglobulin long T ½ 30
days allergy absent
• Equine or horse ATS T ½ 10 days allergy present

14. CONTROL OF SEIZURES &
RESPIRATION
• Diazepam sedation with muscle relaxation
• Midazolam, Magnesium sulphate
• Baclofen, Dantrolene used for muscle relaxation
• Neuromuscular blocking drugs, vecuronium,
pancuronium can be used for generalized muscle
paralysis needs assisted ventilation

15. INTENSIVE SUPPORTIVE CARE
• Dark environment
• Minimal sound & touch
• Endotrachcal intubation may be required for
assisted ventilation & to prevent aspiration
• Cardio respiratory monitoring
• Maintain airway
• Maintain fluid, electrolyte, calorie requirement

16. COMPLICATION
• Aspiration pneumonitis
• Laryngeal spasm, apnea
• Mouth, tongue laceration
• Rhabdomyolysis, Myoglobinuria, renal failure
• Spinal fracture

17. PREVENTION - ACTIVE IMMUNIZATION
By tetanus toxoid
• Protective level of antitoxin 0.01Iu /ml
• Two types of vaccine available
Combined vaccine- DPT
• Routinely used in Universal immunization
programme
• Contain diphtheria toxoid tetanus toxoid, killed
pertussis organism. Given in 5 doses

18. PREVENTION - ACTIVE IMMUNIZATION
– Contd..
Monovalent vaccine- PTAP, APT
• Purified, adsorbed TT
• Stored at 4-100c. Only 2 doses given

19. PREVENTION - PASSIVE IMMUNIZATION
Human tetanus hyper immunoglobulin
• Best for prophylaxis
• Gives protection for 30 days
Equine anti tetanus serum
• Protect for 8-10 days
• Serum sickness, anaphylaxis, allergy common

20. PREVENTION - PASSIVE IMMUNIZATION –
Contd..
Combined active & passive immunization
• Human TIG on one arm & TT on other arm
• Followed by one dose of TT after 6 weeks
Antibiotic prophylaxis
• Single dose IM Benzathine penicillin
• 7 days erythromycin
• Started within 6 hrs. of injury

21. TETANUS NEONATORUM
• Also called as 8th
day disease
• Rare before 2 days & after 2 weeks
• C/F:- Excessive cry, refusal to feed apathy, mouth
slightly kept open due to pull of neck muscles
• Opisthotonus in extension
• Constipation, Apnea
• Touch provoked seizure

22. IN INDIA DISTRICTS CLASSIFIED FOR
NEONATAL TETANUS AS
NT high risk
• Rate > 1/1000 live birth
• TT coverage < 70%
• Attended deliveries < 50%
NT Control
• Rate < 1/1000 live birth
• TT coverage >70%
• Attended deliveries >50%

23. IN INDIA DISTRICTS CLASSIFIED FOR
NEONATAL TETANUS AS – Contd..
NT Elimination
• Rate < 0.1/1000 live birth
• TT coverage > 90%
• Attended deliveries >75%
• NT is 2nd most common cause of death in vaccine
preventable deaths after measles

24. TRANSMISSION
• Unsterile cutting of cord
• Applying cow dung on cord
• Unclean delivery surface

25. TREATMENT SAME AS ADULT
TETANUS
• Antibiotic penicillin & Erythromycin
• Diazepam sedation & muscle relaxation
• Intensive supportive care
• Avoid light, sound, touch

26. PREVENTION OF NT
• Clean delivery practice
• “5 cleans”- clean hands, clean delivery surface ,
clean cord, clean thread & clean blade
• 2 dose of TT to un immunized mother between 16-
36 weeks of gestation
• Minimum 4-6 weeks gap between 2 doses

27. PREVENTION OF NT – Contd..
Infant born to unimmunized mother Give human
anti tetanus immunoglobulin within 6 hrs. of birth

28. PROGNOSIS
• 40-80% mortality in diseased
Good prognostic signs
• Early diagnosis, long incubation period, absence of
fever
• Hypoxic brain injury can lead to cerebral palsy
• Cephalic tetanus poor prognosis
• Otogenic tetanus better prognosis

29. Thank you