TETANUS AND GG

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• TETENUS AND GAS GANGRENE
• DR MZIRAY

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Tetanus Introduction
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Tetanus Introduction
Tetanus is a non communicable infectious disease
characterized by an acute onset of hypertonia,
painful muscular contractions (usually of the
muscles of the jaw and neck), a11d generalized
muscle spasms .
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Etiology
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Etiology

• Chronic skin Ulcers .
• no obvious source
• abscesses and gangrene
• burns,
• frostbite,
• middle ear infections, dental or surgical
  procedures, abortion, childbirth, and intravenous
• (IV) or subcutaneous drug use.

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Etiology

• dental or surgical procedures,
• abortion,
• childbirth,
• and intravenous (IV) or subcutaneous drug use.
• tooth extractions,
• root canal therapy,
• intraoral soft tissue trauma

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Etiology

• Unvaccinated mother, home delivery, and
  unhygienic cutting of the umbilical cord increase
  susceptibility to tetanus
• A history of neonatal tetanus in a previous child
  is a risk factor for subsequent neonatal tetanus
• Potentially infectious substances applied to the
  umbilical stump (eg, animal dung, 111ud,
  or clarified b11tter) are risk factors for
  neonates

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Pathophysiology
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Pathophysiology

• Clostridium tetani is an obligate anaerobic,
  motile, grain-positive bacillus.
• They are found in soil, house dust, animal
  intestines, and human feces. Spores can persist
  in normal tissue for months to years.
• To germinate, the spores require specific
  anaerobic conditions, such as wounds with low
  oxidation-reduction potential (eg, dead or
  devitalized tissue, foreign body, active
  infection).

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Pathophysiology

• Infection by C tetani results in a benign
  appearance at the portal of entry because of the
  inability of the organism to evoke an
  inflammatory reaction
• Trauma gtEntry of SporesgtAnerobic
  conditions.gtMultiplication of bacteriagt Toxin -
  TetanospasmingtEntry into motor nerve
  endingsgtTravel to spinal cord gtEntry into Central
  Inhibitory neurongtLoss of inhibitory action on
• motor and autonomic neuronsgtPotentiating of
  muscle response to rnild stimulus autonomic
  overactvity.

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Pathophysiology

• Once the toxin becomes fixed to neurons, it cant
  be neutralized with antitoxin. Recovery of nerve
  function from tetan1.1s toxins requires sprouting
  of new nerve te1minals and formation of new
  synapses.
• Localized tetanus develops when only the nerves
  supplying the affected 1n11scle are involved.
• Generalized tetanus develops when the toxin
  released at the wound spreads through the
  lymphatics and blood to mttltiple nerve
  terminals.
• The blood-brain barrier prevents direct entry of
  toxin to the CNS.

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Pathophysiology

• Mortality t1sually results from autonomic
  dysfunction
• extremes in blood pressure
• Dysrhythmias
• cardiac arrest.

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Clinical Features
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Clinical Features

• Demography
• Symptoms
• Signs
• Complications
• Prognosis

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Demography
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Demography

• Less in developed countries.but still occurs.
• In developing countries neonatal tetanus is a
  public health problem approx.200,000 cases per
  year.
• Young adults are next.
• Tetanus is predo1ninantly a disease of
  underdeveloped countries.

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Demography

• It is common in areas where-
• soil is cultivated
• in rural areas
• in warm climates
• during summer months,
• among males.
• In countries without a comprehensive
  im1nunization program, tetanus predominantly
  develops in neonates and young children.

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Clinical Types

• Localised Tetanus.
• Generalised Tetanus
• Neonatal Tetanus
• Cephalic Tetanus

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History
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History

• Underimmunization.
• Incubation Period -Average 7 days.
• 4-14 days
• Short gtWorse prognosis.

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Presenting complaints
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Presenting complaints

• Sore Throat
• Dysphagia
• Lockjaw(Trismus)
• Localised stiffness,
• Neck rigidity
• Restlessness
• Reflex spasms.
• Abdominal rigidity

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Chief Menifestations
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Chief Menifestations

• Muscle rigidity
• Muscle Spasms Leading to
• Opisthotonus
• Risus Sardonicus
• -Apnea,
• Fractures, dislocations,
• Rbabdon1yolysis.
• Laryngeal spasms gtasphyxia.

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Other Menifestations
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Other Menifestations

• Dysphagia/Hydrophobia
• Drooling
• Sweating
• Fever
• Hypertension
• Tachycardia
• During these episodes, patients have an intact
  sensorium and feel severe pain

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Neonatal Tetanus
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Neonatal Tetanus

• Aka tetanus neonatorum is a major cause of infant
  mortality in underdeveloped countries
• Rare in the developed coutries.
• Infection results from umbilical cord
  contamination during unsanitary delivery, coupled
  with a lack of matemal immunization

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Neonatal Tetanus

• At the end of the first week of life,
• Irritability
• Poor feeding
• Rigidity, Opisthotonus
• Facial grimacing
• Severe spasms with touch.
• Poor prognosis.

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localized Tetanus
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localized Tetanus

• Persistent rigidity in the muscle group close to
  the injury site.
• The muscular rigidity is caused by a dysfunction
  in the inteneurons that inhibit the alpha motor
  neurons of the affected muscles.
• No further central nervous system (CNS)
  involvement occurs in this form, and mortality is
  very low.

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Cephalic tetanus
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Cephalic tetanus

• is unconunon and usually occurs after head trauma
  or otitis media.
• Patients with this form present with cranial
  nerve (CN) palsies.
• The infection may be localized or may become
  generalized.

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Prognosis

• Dependent on-
• incubation period
• the time from spore inoculation to first symptom
• time from first symptom to first tetanic spasm.
• In general, shorter intervals indicate more
  severe.
• Delay in treatment
• Contaminated lesions of the head and the face

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Prognosis

• Patients who survive tetanus and return to their
  predisease state of health
• Recovery is slow and usually occurs over 2- 4
  months
• Some patients remain hypotonic
• Clinical tetanus does not produce a state of
  immunity gt vaccinate.

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Prognosis rating scale
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Prognosis rating scale

• 1 point is given for each of the following
• Incubation period shorter than 7 days
• Period of onset shorter than 48 hours
• Tetanus acquired from burns, surgical wounds,
  compot1nd fractures, septic abortion, umbilical
  stun1p, or intramuscular injection
• Narcotic addiction
• Generalized tetanus
• Temperature l1igher than 104F (40C)
• Tachycardia exceeding 120 beats/min (150
  beats/min in neonates)

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Prognosis rating scale

• The total score
• 0 or 1 - Mild tetanus mortality below 10
• 2 or 3 - Moderate tetanus mortality of 10- 20
• 4 - Severe tetanus 1nortality of 20-40
• 5 or 6 -Very severe tetanus mortality above 50
• Cephalic tetanus is always severe or very severe.
• Neonatal tetanus is always very severe.

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Prognosis

• Mortality is higher for people older than 60
  years.
• Mortality is higher in who require 1nechanical
  ventilation.
• Less severe among patients wl10 have received a
  primary series of teta11us toxoid sometime dm-ing
  their life.

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Diagnostic Studies
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Diagnostic Studies

• Spatula Test
• Touch the oropharynx with a spatula or tongue
  blade. In normal circumstances, it elicits a gag
  reflex, and the patient tries to expel the
  spatula (ie, a negative test result). If tetanus
  is present, patients develop a reflex spasm of
  the masseters and bite the spatula (ie, a
  positive test result).

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Differential Diagnosis
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Differential Diagnosis

• Strychnine poisoning (Rat poison)the onset of
  symptoms is fast and the duration much lesser
• Epilepsy
• Rabies
• Hysteria
• Malignant hyperthermia.
• Dystonic drug reactions

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Management
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Management

• Initiating supportive therapy
• Debriding the wound to eradicate spores and alter
  conditions for gennination
• Stopping the production of toxin within the wound
• Neutralizing unbound toxin
• Controlling disease manifestations
• Ma.naging complications

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Initial Supportive Therapy
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Initial Supportive Therapy

• ICU care dark quiet avoid unnecessary touch
• Intubation/Tracheosto1ny-
• Prophylactic intubation sl1ould be seriously
  considered in all patients with moderate-to
  severe clinical manifestations
• Tracbeostomy should be perfonned in patients
  reqt1iring intt1bation for 111ore tl1an 10 days.
• Tracheostomy bas also been reco1nmended after
  onset of the first generalized seizure.

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Wound Care
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Wound Care

• Wounds should be explored, carefully cleansed,
  and properly debrided.
• Excise at least 2 cm of normal viable- appearing
  tissue around the wound margins.
• Abscesses should be incised and drained.
• After the patient has been stabilized.
• Several hours after administration of antitoxin.

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Pharmacological Therapy
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Pharmacological Therapy

• Benzodiazepine
• Barbiturates
• Propofol
• Midazolam
• Intrathecal Baclofen
• Magnesium sulphate
• Esomolol

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Antotoxin
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Antotoxin

• TIG Tetanus Immunoglobin.
• A single intramuscular (IM) dose of 3000- 5000
  units is generally recommended for children and
  adults, with part of the dose infiltrated around
  the wound if it can be identified.

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Antibiotic

• Metronidazole

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Prevention
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Prevention

• Adequate lifelong active immunization.
• TIG
• Tetanus prone wo11nds.
• Inadequate vaccination status
• Immunocomproised host.

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TIGTetanits imniunoglobitlin (hitman
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TIGTetanits immunoglobitlin (hitman

• 250 units by intramusc11lar injection
• 500 units if
• wound older than 12 hottrs
• presence, or risk of, heavy contamination
• if patient weights more than 90 kg.

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Tetanus-prone wounds
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Tetanus-prone wounds

• If they are sustained either more than 6 hot1rs
  before s11rgical treatn1ent of the wound.
• Puncture-type wound, a significant degree of
  devitalized tissue
• Clinical evidence of sepsis
• Contamination with soil/manure
• Burns
• Frostbite
• High velocity missile injuries
• Bites

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Gas Gangrene
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Gas Gangrene

• Gas gangrene//clostridial myonecrosis -an
  infection of muscle tissue by toxin prod11cing
  clostridia.

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Etiology
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Etiology

• In 1861, Louis Pasteur identified the first
  clostridial species, Clostridiitni bittyricum.
• Bacillits aerogenes capsulatus, was later
  rena1ned Bacillus perfringens, and
• then Clostridiitni welchii. The organism is now
  na1ned Clostridiuni perfringens.

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Etiology

• Anaerobic, gram-positive, spore-forming bacillus
  of tl1e genus Clostridium.
• C pe,frin.gen.s is tl1e most common
• Clostridiuni bifernien.tans,
• Clostl'idi'un1septicum, Clostridiu1n sporogenes,
  Clostridiitni novyi, Clostridium.fallax,
  Clostridium histolyticum, and Clostridium tertium.

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Etiology

• Posttraumatic
• Postoperative
• Spontaneous.

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Pathophysiology
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Pathophysiology

• Anerobic conditions of wound-
• Dead tissue
• Foreign bodies
• infection

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PathophysiologyExotoxins

• Alpha toxin - Lethal, lecithinase, necrotizing,
  hemolytic, cardiotoxic
• Beta toxin - Lethal, necrotizing
• Epsilon toxin - Lethal, pennease
• Iota toxin - Lethal, necrotizing
• Delta toxin - Lethal, hemolysin
• Phi toxin - Hemolysin, cytolysin
• Kappa toxin - Letl1al, collagenase, gelatinase,
  necrotizing

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PathophysiologyExotoxins

• Lambda toxin - Protease
• Mu toxin - Hyaluronidase
• Nu toxin - Lethal, deoxyribonuclease, hemolytic,
  necrotizing
• Lethal as tested by injection in mice

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Clinical FeaturesDemography
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Clinical FeaturesDemography

• Less co1nmon in developed countries.

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Clinical FeaturesHistory

• Trauma Crush injuries,open fractures.
• Cornmomn in war injuries.
• Abortion
• Post op GI Biliary, liposuction
• Occult malignancy

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Symptoms
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Symptoms

• A sudden onset of pain .
• Feeling ofl1eaviness in the affected extremity.
• A low-grade fever
• Apathetic mental status

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Examination
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Examination

• Local swelling to 1nassive edema
• Skin discoloration with hen1orrhagic blebs and
  bullae
• Serosanguineot1s exudate
• Sweet odor
• Crepitus
• Fever
• Relative tachycardia,

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Differential Diagnosis
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Differential Diagnosis

• Abscess
• Cellulitis
• Toxic Shock Syndrome

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Diagnostic Studies
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Diagnostic Studies

• Gram's Stain-"box-car," large gram-positive
  bacilli without neutrophils.
• Rapidly developing he1nolytic anemia witl1 an
  increased lactate dehydrogenase (LDH) level.
• The chemistry profile may show significant
  metabolic abnormalities (metabolic acidosis and
  renal failure) .
• Operative exploration

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Diagnostic StudiesImaging
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Histologic Findings

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Histologic Findings

• Widespread myonecrosis, destruction of otl1er
  connective tissues
• Paucity of neutrophils in the infected area.

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Management
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Management

• The combination of aggressive surgical
• debridement and effective antibiotic therapy.

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Antibiotics
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Antibiotics

• Penicillin and clindamycin combination.
• Combination of clindamycin and metronidazole is a
  good choice for patients allergic to penicillin.

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HBO
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HBO

• Hyperbaric oxygen (HBO) therapy

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Operative Therapy
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Operative Therapy

• Debridement
• Fasciotomy
• Excision of abd.wall
• Hysterecto1ny.

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• The END