Tetanus clinical features and management

Epidemiology and pathogenesis Cl. tetani is found in human and animal faeces and itsspores abound in soil. It is anaerobic and proliferates inischaemic or necrotic tissue, usually in a poorly tendedwound. In rural areas farm workers or gardeners areinfected, but in cities the disease has been observed in drugaddicts. Because immunization against tetanus toxin isstandard in western countries, tetanus is rare. In poorercountries immunization is variable.Tetanospasmin is a neurotoxin which acts in several differentways. It inhibits the release of acetylcholine fromnerve endings in muscle, but more importantly it interfereswith synaptic reflexes in the spinal cord, causing disinhibitionwhich results in muscle spasms.

Clinical features The incubation period can be up to 3 weeks, depending oninoculation dose and site. Disease is most severe in thecompletely non-immune, in drug addicts and at extremesof age. The outcome is worst when the incubation periodis short and there is rapid onset of the first spasm.The first (and sometimes the sole) sign of tetanus is oftenmuscle spasm local to the wound; in most the CNS isinvolved, and trismus (lockjaw) heralds the onset of generalizedtetanus. The patient notices difficulty in opening themouth and swallowing, followed by stiffness in the neck,and back. Examination reveals the initial site of infectionand \'risus sardonicus\', the facial expression caused bytrismus and contraction of facial muscles. The muscles ofthe back and abdomen become stiff, and painful spasms,provoked by sudden movement or noise, occur in the backmuscles, causing opisthotonos. Autonomic involvementcauses sweating and cardiovascular instability. Death isfrom exhaustion, aspiration or secondary infection.

Management Further toxin production is prevented by local debridementof wounds and treatment with metronidazole 500 mgintravenously 6-hourly. Human immunoglobulin containingantibodies to tetanus toxin in high titre is given to neutralizefree toxin; 500 units are administered i.m. If surgeryis indicated, it should be delayed for an hour after theadministration of antibody.The patient is nursed in a quiet room to avoid stimulilikely to provoke spasms. Benzodiazepines such asdiazepam are used to control spasms, as well as for theiranxiolytic and amnesic effects. Neuromuscular block maybe required, and then the patient is ventilated (see p. 737).Because prolonged ventilation is usual, tracheostomy isperformed early. Nutrition is maintained enterally orparenterally.An attack of tetanus does not render the patient immuneand a full course of immunization should be given afterrecovery.

Prevention Immunization with tetanus toxoid is the only way to prevent the disease altogether. A full course of toxoidconfers immunity for at least 5 years. Neonatal tetanus canbe prevented by immunizing the mother during pregnancy.Patients with wounds at risk from Cl. tetani infection aremanaged according to their state of immunity. All patientsrequire local wound toilet. Fully immunized patientsreceive a booster dose of toxoid. Unimmunized patientswith a wound considered susceptible to Cl. tetani receivehuman tetanus immunoglobulin, and active immunizationwith adsorbed tetanus toxoid is started simultaneously.Injection of long-acting penicillin, followed by a course oforal penicillin, is also indicated in these cases.
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