Tetanus

A35

*Notifiable condition.

• Description
• Diagnostic criteria
• General and supportive measures
• Medicine treatment
• Referral

DESCRIPTION

Tetanus is an acute spastic paralytic illness caused by tetanospasmin, the neurotoxin produced by Clostridium tetani . The toxin prevents neurotransmitter release from spinal inhibitory neurons.

Complications include:

• asphyxia,
• bronchopneumonia,
• dehydration,
• respiratory failure,
• hyperpyrexia,
• laryngospasm,
• inability to suck, chew and swallow.

DIAGNOSTIC CRITERIA

The diagnosis is made on clinical grounds.

Clinical

• Unimmunised/incompletely immunised child.
• History of wound/trauma or unhygienic care of umbilical cord/stump.
• Trismus.
• Stiffness of the neck, back and abdominal muscles.
• Pharyngospasm, laryngospasm, dysphagia, inability to suck, chew and swallow which severely compromises feeding and eating activities.
• Spontaneous muscle contractions/spasms or muscle contractions/ spasms triggered by minimal stimuli such as touch, sound, light or movement.
• No involvement of sensorium, i.e. consciousness is not disturbed.
• Autonomic nervous system instability with hypertension, tachycardia and dysrhythmias.

GENERAL AND SUPPORTIVE MEASURES

• Admit to high or intensive care unit, if available.
• Ventilatory support, if needed.
• Monitor:
  • temperature,
  • blood pressure,
  • respiration,
  • blood glucose,
  • heart rate,
  • electrolytes,
  • blood gases,
  • acid-base status,
  • SaO₂ .
• Protect the patient from all unnecessary sensory and other stimuli.
• Ensure adequate hydration and nutrition.
• Wound care and debridement/umbilical cord care.
• Educate parents/caregivers regarding prevention of tetanus by vaccination.

MEDICINE TREATMENT

For hypoxia:

• Oxygen 100% by nasal cannula.
• Tetanus immunoglobulin, IM,3000IU as a single dose.
• Tetanus toxoid (TT),IM,0.5mL
  • Not required in immunised patients who have received a booster within the past 5 years.
• Metronidazole, IV,7.5mg/kg/dose 8 hourly for 10 days duration.

For control of muscle spasms:

• Diazepam, IV, 0.1–0.2 mg/kg/dose 4–6 hourly, titrated according to response.
  • Do not exceed 10 mg/dose.
  • After improvement, use enteral form in high care setting.
  • For ventilation and muscle relaxants, see ICU sedation, infant and child .

After recovery from tetanus, patients should be actively immunised as the disease does not confer immunity.

Prevention of tetanus

Minor wounds

Children with clean minor wounds do not require tetanus immunoglobulin or antibiotics. Tetanus vaccine should be given, except in fully immunised patients who have received a booster within the past 5 years.

For more severe wounds

If child with penetrating wound not completely immunised:

• Tetanus immunoglobulin (TIG), IM.
  • If < 5 years of age: 75 IU.
  • If 5–10 years of age: 125 IU.
  • If > 10 years of age: 250 IU.

• Tetanus toxoid (TT), IM, 0.5 mL.
  • Not required in immunised patients who have received a booster within the past 5 years.

REFERRAL

• All cases.