Tetanus

Tetanus General Information

Tetanus, or more commonly known as lockjaw, is a very severe disease affecting the muscle and nerve fibers in the human body. It is caused by the bacteria Clostridium Tetani which invades the system through a wound in the skin. Once it has entered the organism, the bacteria begin producing a neurotoxin (tetanospasmin) which causes muscular spasms. The toxin travels in the organism through the blood and lymph systems, interfering with the nervous system activity in ever expanding areas of the body. This will eventually lead to generalized muscle spasms, and eventually death. In most cases, Tetanus follows a cut or puncture injury that may be so small that the patient does not even worry about it, and does not see a doctor about it. Dead skin injuries, such as burns, gangrene, crush wounds or frost bites are more likely to cause this affection, as are wounds that are contaminated with feces, saliva or soil and are not properly cleaned.

Newborns that are given birth in unsanitary conditions are also at an increased risk of developing this affection, especially in cases where the umbilical cord stump is contaminated. However, recently the vaccine against this affection contains antibodies that are passed from the mother to the child at birth, reducing these situations. Generally, this affection is rare in developed countries, where the vaccine has become part of the routine immunization of the population.

Tetanus Symptoms

Tetanus has an incubation period of 3 to 21 days, with symptoms typically starting to appear at around 8 days after infection. The length of the incubation period typically depends on the distance between the injury site and the central nervous system. The shorter this distance is – and implicitly, the shorter the incubation period is – the higher is the patient’s chance of death. The cephalic type of the disease is also rare; it may occasionally appear at the same time as otitis media (infection of the ear). In this case, facial nerves and muscles are most affected.

The local version of the disease is uncommon. The patient may experience persistent contractions of the muscles situated in the area of the injury, and the contractions may be persistent for prolonged periods of time before gradually subsiding. This is a mild variation of the disease, and it also has a low mortality rate – only about 1% of the patients affected by this type of the disease die due to the condition. However, this may be a sign for the onset of generalized Tetanus.

The generalized version of the affection is also the most common, present in about 80% of the total cases. It is characterized by a descending pattern, initialized by trismus (lockjaw) and facial spasms. Afterwards, the neck becomes stiff and the patient begins to experience difficulties when swallowing. Pectoral and calf muscles become rigid and other symptoms such as sweating, high blood pressure and temperature and palpitations may appear. Spasms become frequent and may last for a few minutes at a time. During these episodes, the body takes a characteristic position known as opisthotonos.

Neonatal Tetanus is present in newborn children. While it is very rare in developed countries, it is responsible for over 15% of the infantile deaths in underdeveloped countries.

Tetanus Treatment

Tetanus can be prevented through vaccination, and it is standard procedure that adults receive a vaccine every 10 years against this disease. In many clinics, it is also standard procedure that any patient presenting a puncture wound receives a vaccine, especially if it is uncertain if and / or when the patient has received any previous anti-tetanic shots. These booster vaccines are not able to prevent potentially fatal cases in such situations, however, as it takes up to two weeks for the organism to produce the appropriate antibodies. The vaccine is also often administered as a combined vaccine in children of less than 7 years of age, together with vaccines against pertussis and diphtheria.

As immediate preventive measures, the wound needs to be cleaned and dead and infected tissue needs to be surgically removed through surgery, a procedure called debridement. Metronidazole may be administered, as this drug has a strong effect in decreasing the number of bacteria in the wound, however it does not have any effect on the neurotoxins that have been produced. Penicillin is another commonly used drug; however it is no longer the treatment of choice due to the possibility of increasing spasm frequency and severity. However, if Metronidazole is not immediately available, it should be improved as it offers a rapid means of reducing the number of bacteria.

Passive immunization is crucial – either with human anti-tetanospasmin immunoglobulin or with Tetanus immune globulin. It is very important that immunization is performed as soon as possible – if specific anti-tetanospasmin immunoglobulin is not available immediately, normal human immunoglobulin can be administered instead. All the patients that have contracted this disease should also be immediately vaccinated with the proper vaccine, or administered a booster shot. In cases of mild Tetanus, immunoglobulin should be administered, either through intravenous or intramuscular injections. Metronidazole should be administered intravenously for up to 10 days, and diazepam may also be prescribed. Of course, the patient should also be administered a vaccine as soon as possible.

In cases of severe Tetanus, intensive care may be required. Apart from the normal medication and procedures that are employed in mild cases, human immunoglobulin should be injected intrathecally as this increases the clinical improvement to 35% from 4%. Tracheostomy and mechanical ventilation should be applied for up to 4 weeks, and the patient should be administered magnesium infusion IV in order to prevent muscle spasms. Diazepam should also be administered permanently under the form of IV infusion. In most cases, the autonomic effects caused by Tetanus may be very difficult to manage – such as alternating hyperpyrexia and hypothermia, hypertension and hypotension – and as such the treatment may also require magnesium, Clonidine, labetalol or Nifedipine under the form of intravenous injections or perfusions.

Diazepam or other muscle relaxants may be administered in order to control the muscle spasms – however in severe cases, the patient may need to be paralyzed with curare-related drugs, and mechanical ventilation. Proper maintenance of the patient’s airways and nutrition are very important in order to ensure the patient’s survival. In many cases, the patient may need to be fed through gastric intubation.