Bacterial disease characterised by intermittent spasms (twitching) of voluntary muscles. Incubation period is from few days to few weeks (average7-10 days).
Cause
- Exotoxin of Clostridium tetani
- Common sources of infection: tetanus spores enter the body through deep penetrating skin wounds, the umbilical cord of the newborn, ear infection, or wounds produced during delivery and septic abortions
Clinical features
- Stiff jaw, difficulty in opening mouth (trismus)
- Generalised spasms induced by sounds and/or strong light, characterised by grimace (risus sardonicus)
- Arching of back (opisthotonus) with the patient remaining clearly conscious
- Fever
- Glottal spasms and difficulty in breathing
- Absence of a visible wound does not exclude tetanus
Differential diagnosis
- Meningoencephalitis, meningitis
- Phenothiazine side-effects
- Febrile convulsions
Management
General measures
- Nurse patient intensively in a quiet isolated area
- Maintain close observation and attention to airway, temperature, and spasms
- Insert nasogastric tube (NGT) for nutrition, hydration, and medicine administration
- Oxygen therapy if needed
- Prevent aspiration of fluid into the lungs
- Avoid IM injections as much as possible; use alternative routes (e.g. NGT, rectal) where possible
- Maintain adequate nutrition as spasms result in hugh metabolic demands
- Treat respiratory failure in ICU with ventilation
Neutralise toxin
- Give tetanus immunoglobulin human (TIG)
- 150 IU/kg (adults and children). Give the dose in at least 2 different sites IM, different from the tetanus toxoid site
- In addition, administer full course of age appropriate
TT vaccine (TT or DPT) – starting immediately
Treatment to eliminate source of toxin
- Clean wounds and remove necrotic tissue.
First line antibiotics
- Metronidazole 500 mg every 8 hours IV or by mouth for 7 days
Child: 7.5 mg/kg every 8 hours
Second line antibiotics
- Benzylpenicillin 2.5 MU every 6 hours for 10 days
Child: 50,000-100,000 IU/kg per dose
Control muscle spasms
First line
- Diazepam 10 mg (IV or rectal) every 1 to 4 hours
- Child: 0.2 mg/kg IV or 0.5 mg/kg rectal (maximum of 10 mg) every 1 to 4 hours
Other agents
- Magnesium sulphate (alone or with diazepam): 5 g (or 75 mg/kg) IV loading dose then 2 g/hour till spasm control is achieved
- Monitor knee-jerk reflex, stop infusion if absent
- Or chlorpromazine (alone or alternate with diazepam) 50-100 mg IM every 4-8 hours
Child: 4-12 mg IM every 4-8 hours or - 12.5 mg-25 mg by NGT every 4-6 hours
- Continue for as long as spasms/rigidity lasts
Control pain
- Morphine 2.5-10 mg IV every 4-6 hours (monitor for respiratory depression)
Child: 0.1 mg/kg per dose - Paracetamol 1 g every 8 hours
Child: 10 mg/kg every 6 hours
Prevention
- Immunise all children against tetanus during routine childhood immunisation
- Proper wound care and immunisation
- Full course if patient not immunised or not fully immunised
- Booster if fully immunised but last dose >10 years ago
- Fully immunised who had a booster <10 years ago do not need any specific treatment
- Prophylaxis in patients at risk as a result of contaminated wounds: give Tetanus immunoglobulin human (TIG) IM
Child < 5 years: 75 IU
Child 5-10 years: 125 IU
Child > 10 years and adults: 250 IU
Double the dose if heavy contamination or wound obtained > 24 hours.