2. Tetanus. What are the symptoms, course, and treatment of tetanus? What is the mortality? What if someone was unvaccinated as a child and steps on a nail?
Answer:
(From E-Medicine Textbook via Internet:)
Tetanus is an illness characterized by an acute onset of hypertonia, painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical causes.
Immunity from tetanus decreases with increasing age. Approximately 50% of adults over the age of 50 are nonimmune from having never been vaccinated or not receiving appropriate booster doses.
Patients with generalized tetanus present with trismus (lockjaw) in 75% of the cases.
- Other presenting complaints include stiffness, neck rigidity, dysphagia, restlessness and reflex spasms.
- Subsequently, muscle rigidity becomes the major manifestation.
- Spread from the jaw and facial muscles occurs over the next 24-48 hours to the extensor muscles of the limbs.
- Dysphagia occurs in moderately severe tetanus, due to pharyngeal muscle spasms, and is usually insidious in onset over several days.
- Reflex spasms develop in the majority of the patients and can be triggered by minimal external stimuli such as noise, light or touch.
- They last seconds to minutes, become more intense, increase in frequency with disease progression and can cause apnea, fractures, dislocations and rhabdomyolysis.
- Laryngeal spasms can occur at any time and can result in asphyxia.
- The sustained contraction of facial musculature produces a sneering grin expression known as risus sardonicus.
The treatment of tetanus is directed towards the treatment of muscle spasm, prevention of respiratory and metabolic complications, neutralization of circulating toxin to prevent the continued spread and elimination of the source.
Patients should be admitted to the ICU. Due to the risk of reflex spasms, the patient's environment should be dark and quiet. Unnecessary procedures and manipulations should be avoided.
Prophylactic intubation should be given serious consideration in all patients with moderate to severe clinical manifestations. Intubation and ventilation is required in 67% of patients.
Surgical therapy includes debridement of wounds to remove organisms and to create an aerobic environment.
The current recommendation is to excise at least 2.0 cm. of normal
viable-appearing tissue around the wound margins.
Abscesses should be incised and drained.
Any wound manipulation should be delayed until several hours after the
administration of antitoxin due to the risk of releasing tetanospasmin into the
bloodstream.
Drugs used to treat muscle spasm, rigidity and tetanic seizures include sedative hypnotic agents, general anesthetics, centrally acting muscle relaxants and neuromuscular blocking agents. Antibiotics are used to prevent multiplication of Clostridium tetani, thus, halting the production and release of toxins.
Overall, the mortality is approximately 45%.