TETANUS Flashcards
- acute disease manifested by skeletal muscle spasm and autonomic nervous system disturbance
- caused by a powerful neurotoxin produced by the bacterium Clostridium tetani and is completely preventable by vaccination
Tetanus
“an illness occurring in a child who has the normal ability to suck and cry in the first 2 days of life but who loses this ability between days 3 and 28 of life and becomes rigid and has spasms .”
Neonatal tetanus
tetanus occurring during pregnancy or within 6 weeks after the conclusion of pregnancy (whether with birth, miscarriage, or abortion)
Maternal tetanus
- anaerobic, gram-positive, spore-forming rod spores are highly resilient and can survive readily in the environment throughout the world
- Spores resist boiling and many disinfectants
- Very low concentrations of this highly potent toxin can result in tetanus (minimal lethal human dose, 2.5 ng/kg)
C. tetani
- Tetanus is a rare disease in the _____
- Most cases occur in _____
- Persons ___ years of age are at greater risk of tetanus because antibody levels decrease over time
- People who inject ____ 15% of all cases (2001-2008)
- developed world
- incompletely vaccinated or unvaccinated individuals
- > 60
- drugs
- is intra-axonally transported to motor nuclei of the cranial nerves or ventral horns of the spinal cord.
- This toxin is produced as a single 150-kDa protein that is cleaved to produce heavy (100-kDa) and light (50-kDa) chains linked by a disulfide bond and noncovalent forces.
Tetanus toxin
The clinical manifestations of tetanus occur only after tetanus toxin has reached
presynaptic inhibitory nerves
If the cranial nerves are involved in localized cephalic tetanus, the ____ may spasm, with consequent aspiration or airway obstruction, and the prognosis may be poor.
pharyngeal or laryngeal muscles
ALGORITHM FOR CLINICAL AND PATHOLOGIC PROGRESSION OF TETANUS
- Before 7-10 days
No symptoms
ALGORITHM FOR CLINICAL AND PATHOLOGIC PROGRESSION OF TETANUS
- 7-10 days
- muscle aches,
- trismus,
- myalgia
ALGORITHM FOR CLINICAL AND PATHOLOGIC PROGRESSION OF TETANUS
- 24-72 hrs ?? (days?)
- Muscle spasm: local and generalized
- CArdiovascular instability: labile BP, tachy- or bradycardia
- Pyrexia, increased respiratory and GI secretions
ALGORITHM FOR CLINICAL AND PATHOLOGIC PROGRESSION OF TETANUS
- 4-6 weeks
- Cessation of spasms, restoration of normal muscle tone
- CArdiovascular and autonomic control
measured in a sample taken before the administration
of antitoxin or immunoglobulin; levels >0.1 U/mL (measured by standard ELISA) are deemed protective and
do not support the diagnosis of tetanus
Serum anti-tetanus immunoglobulin G
used for detection of tetanus toxin, but its sensitivity is unknown.
Polymerase chain reaction
If possible, the entry wound should be ________ in order to remove anaerobic foci of infection and prevent further toxin production.
- identified,
- cleaned, and
- debrided of necrotic material
preferred for antibiotic therapy for tetanus
Metronidazole
Alternative drug although this drug theoretically may exacerbate spasms and in one study was associated with increased mortality.
penicillin
Two preparation of antitoxin
- human tetanus immune globulin (TIG) 2
- equine antitoxin.
is the preparation of choice, as it is less likely to be associated nate with anaphylactoid reactions. A single IM dose (3000-5000 IU) is given, with a portion injected around the wound.
tetanus immune globulin (TIG)
available widely and is used in low-income countries; after hypersensitivity testing, 10,000-20,000 U is administered IM as a single dose or as divided doses.
Equine-derived antitoxin
Spasms are controlled by heavy sedation with
benzodiazepines.
used as a muscle relaxant.
IV magnesium sulfate
are commonly used worldwide tx for tetanus
Chlorpromazine and phenobarbital
patients should be nursed in _____ because light and noise can trigger spasms.
calm, quiet environments
_____are increased in tetanus, and ____ due to pharyngeal involvement combined with hyperactivity of laryngeal
muscles makes endotracheal intubation difficult.
- Tracheal secretions
- dysphagia
is the usual method of securing the airway in severe tetanus.
tracheostomy
Cardiovascular stability is improved by increasing sedation with ____ (plasma concentration, 2-4 mmol/L or titrated against disappearance of the patella reflex),
- lV magnesium sulfate
- morphine,
- fentanyl,
- or other sedatives.
drugs that allow rapid titration are preferred
Short-acting drugs
Complications arising from treatment are common and include:
- thrombophlebitis associated with diazepam injection
- ventilator associated pneumonia
- central-line infections,
- septicemia.
Recovery from tetanus may take
4-6 weeks
Factors Associated with a Poor Prognosis in Adult Tetanus
- Age >70 years
- Incubation period <7 days
- Short time from first symptom to admission
- Puerperal, IV, postsurgery, burn entry site
- Period of onset <48 h
- Heart rate >140 beats/min
- Systolic blood pressure >140 mmHg
- Severe disease or spasms
- Temp >38.5C
Factors Associated with a Poor Prognosis in Neonatal Tetanus
- Younger age, premature birth
- Incubation period <6 days
- Delay in hospital admission
- Grass used to cut cord
- Low birth weight
- Fever on admission
The WHO guidelines for tetanus vaccination consist of a
primary course of ____ doses in infancy, boosters at ____ years of age, and ____ booster in adulthood.
- three
- 4- 7 and 12-15
- one
“Catch-up” schedules recommend a ___ primary course with 4 weeks between doses, followed by two boosters 6 months apart.
three-dose
For persons who have received a complete primary course in childhood but no further boosters, ____ doses at least 4 weeks apart are recommended.
two
Tetanus Vaccines fpr young children
- 2, 4 and 6 months
- 15 through 18 months
- 4 though 6 yrs
DTaP
Tetanus Vaccine for preteens
- 11 through 12 yrs
Tdap
Tetanus Vaccine for adults
- every 10 yrs
Td or Tdap
Standard WHO recommendations for prevention of maternal and neonatal tetanus call for administration of ___ doses of tetanus toxoid at least 4 weeks apart to previously
unimmunized pregnant women.
2 doses
Individuals sustaining tetanus-prone wounds should be ____ if their vaccination status is incomplete or unknown or if their last booster was given >10 years earlier.
immunized
Patients with an inadequate vaccine status who sustain wounds not classified as clean or minor should also undergo ____ immunization with TIG.
passive
It is recommended that tetanus toxoid be given in conjunction with ____ in a preparation with or without acellular pertussis: DTaP for children ___ years old, Td for 7- to 9-year-olds, and Tdap for children ___ years old and adults.
- diphtheria toxoid
- <7
- > 9
