Tetanus is a severe infection caused by Clostridium tetani bacterium found in soil and human and animal waste. The infection is not contagious. C. tetani is introduced into the body from a wound and produces a toxin whose action on the central nervous system is responsible for the symptoms of tetanus.
Tetanus is completely preventable by vaccination. In unvaccinated people, most breaks in the skin or mucous membranes carry a risk of tetanus, but the wounds with the greatest risk are: the umbilical stump in newborns, operative site surgical and obstetric interventions unconditionally aseptic, puncture wounds, wounds with loss of tissue or foreign material or contaminated soil, wounds by tearing or crushing, non-sterile injections sites, chronic wounds (p. ex. leg ulcers) , burns and bites.
Tetanus occurs in people who have not been properly vaccinated before exposure or have not received adequate prophylaxis immediately after exposure.
Generalized tetanus is the most common form and the more severe the infection. It is manifested by muscle rigidity rapidly spreading to the whole body and muscle spasms very breakthrough pain. Consciousness is not impaired.
In children and adults:
– Median time to onset of symptoms is 7 days (3-21 days).
– Muscle rigidity begins in the jaw muscles (difficulty and inability to open the mouth [trismus] preventing the patient from talking, eating), extends to the face (smile look forced [risus sardonicus ]), neck (difficulty swallowing), trunk (limiting respiratory movements hyperextension of the spine [opisthotonos]), abdomen (abdominal defense) and
members (legs extended, higher flexural members).
– Muscle spasms occur immediately or when muscle rigidity is widespread. They are triggered by stimuli or arise spontaneously.
Spasm of the chest and larynx may cause respiratory distress or wrong.
In the newborn:
– In 90% of cases, the first signs appear within 3 to 14 days after birth.
– The first signs are a great irritability and difficulty feeding (stiffness lips, lockjaw) and muscle rigidity becomes general, as in adults.
A child who normally head and cry over the first 2 days of life and then becomes irritable and stops sucking between the 3rd and 28th day of life and shows stiffness and muscle spasms, is a case of neonatal tetanus.
– Although the entrance is almost always the umbilical cord, cord infection (omphalitis) is obvious that in half the cases.
– Search sepsis, frequently associated.
Hospitalization is essential and lasts 3-4 weeks. Mortality can be reduced by 50% if the assumption is correct, even in resource-limited hospitals.
– The patient is placed in one room, dark, quiet; any stimulation (noise, light, touch) is likely to trigger painful spasms or vital distress.
– Handle the patient carefully sedated and as little as possible; change position every 3 to 4 hours to avoid bedsores.
– Insert an IV line: hydration, injections into the tubing of the infusion.
– Insert a gastric tube: hydration and nutrition; Administration PO drugs.
– Soft fluid aspiration (nose, oropharynx).
– Moisturize and nourish the patient meal spanned over 24 hours. In newborns, give breast milk (breast milk) every hour (risk of hypoglycaemia).
Neutralization of the toxin:
tetanus human immunoglobulin IM
Newborn, child and adult: 500 IU single dose to be injected into two separate sites
Inhibition of toxin production:
The treatment of choice is metronidazole IV for 7 days 1 (administered over 60 min in the newborn)
Newborn: a dose of 15 mg / kg and after 24 hours, 7.5 mg / kg every 12 hours
Child: 7.5 mg / kg every 8 hours
Adult: 500 mg every 8 hours
Control the stiffness and spasms and sedation of the patient:
Due to the high risk of depression / respiratory arrest during high-dose administration of diazepam, the patient should be under close and constant surveillance, with intubation and manual ventilation equipment immediately available.
The dose and rate of administration depend on the clinical response and
patient tolerance (FR or monitor oxygen saturation).
For IV administration as for intrarectale2 administration, dilute 2 ml (10 mg) of diazepam in 8 ml glucose 5% or sodium chloride 0.9%.
Child: 0.1 to 0.3 mg / kg IV slowly (3-5 minutes) or 0.5 mg / kg rectally, repeated every 1-4 hours, not to exceed 10 mg per dose 2.
Adult: 10 mg slow IV or rectally
1* Benzylpenicillin IV over 10 to 14 days can be an alternative (second choice):
Newborn: 80 000 IU / kg / day (50 mg / kg / day) in two injections 12 hours apart
Infant: 125 000 IU / kg / day (75 mg / kg / day) in 3 injections at 8-hour
Child: 200 000 to 400 000 IU / kg / day (120 to 240 mg / kg / day) in 4 injections at 6-hour
Adults: 10 MIU / day (6 g / day) in 4 doses at 6:00
Take the PO relay based on the clinical course with phenoxymethylpenicillin (penicillin V) by nasogastric tube.Child: 62.5 mg / kg / day in 4 doses; adults: 2 g / day in 4 doses.
2* For rectal administration, use a needleless syringe or adapt a stomach tube 8 cut off the tip of the syringe (leave a length of 2-3 cm).
In case of severe spasms not controlled by intermittent doses, diazepam may be administered (except in children less than one month) continuous infusion under close and constant supervision.
Children over one month and adult: 3 to 10 mg / kg administered over 24 hours, to be adapted according to clinical response.
Beginning of treatment, if necessary; the risk of respiratory depression is increased and supervision must be strengthened:
morphine slow IV (5 minutes)
Newborn: 0.05 mg / kg every 6 hours if necessary
Children from 1 to 6 months: 0.1 mg / kg every 6 hours if necessary
Children over 6 months and adults: 0.1 mg / kg every 4 hours if necessary
Treatment of the front door:
The wound should be sought systematically and treat locally sedated Cleaning; for deep wounds, irrigation, debridement.
If infection of cord: no excision or debridement; treat a bacterial omphalitis.
Tetanus vaccination will be given once the patient cured because tetanus is not an immunizing disease.
In cases of neonatal tetanus, think also to undertake vaccination of the mother.
Prevention is key given the difficulty in treating the said tetanus.
1) Post-exposure prophylaxis:
– In all cases :
• Cleaning and disinfecting the wound; removal of foreign bodies.
• No systematic antibiotics for preventive. The decision to introduce antibiotics (metronidazole or penicillin) must be taken case by case, depending on the patient’s clinical condition.
– Depending on the previous immunization status in the exhibition:
• Tetanus vaccination (VAT) 3 and immunoglobulin: see instructions below.
3* vaccine containing tetanus toxin, p. ex. TT or DT or Td or DTP or DTP + HepB + Hib or HepB + DTP according to the available vaccine and the patient’s age.
IM tetanus vaccine
Children and adults: 0.5 ml / injection
If absent or unknown vaccination status: administer 2 doses at least 4 weeks apart.
If incomplete vaccination: one dose.
Then, to obtain a long-lasting protection, complete up to 5 doses according to the scheme shown in the table below.
tetanus human immunoglobulin IM
Children and adults: 250 IU as a single dose; 500 IU for wounds> 24 hours
Injecting the vaccine and immunoglobulin in two different points, using 2 syringes.
2) Routine Immunization (PrEP):
– Children: 5 doses in total, a first series of 3 doses of DTP or DTP + HepB + Hib or HepB + DTP administered a month apart, before the age of one year (eg to.. ages 6, 10 and 14 weeks) and then a fourth dose of a vaccine containing tetanus toxoid between the ages of 4 to 7 years and a fifth dose between 12 and 15 years.
– Women of childbearing age: 5 doses during the fertile period, a series of 3 doses of Td or TT with an interval of at least one month between the 1st and 2nd dose and an interval of at least 6 months between the 2nd and 3rd dose and two doses, each with at least one year apart, p. ex. the pregnancies of opportunity (see table below).
– Pregnant women: If a woman has never been vaccinated or that its vaccine status is unknown, 2 doses of Td or TT during the current pregnancy to prevent the risk of tetanus in mothers and newborns: the first from as possible during pregnancy and the second at least 4 weeks after the first and at least 2 weeks before delivery. This vaccination protects over 80% of infants from neonatal tetanus. A single dose provides no protection. After childbirth, continue to complete 5 doses, as a woman of childbearing age.
3) Other measures:
Hygiene during delivery, including at home.