Tetanus: Difference between revisions

No edit summary
(Removed copyright violation image)
 
(125 intermediate revisions by 8 users not shown)
Line 1: Line 1:
 
<div class="editorbox">
<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
'''Original Editors '''- Natalie Gutmann [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''- Natalie Gutmann [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; [[Physiopedia:Editors|Read more.]]
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
</div>  
</div>  
== Definition/Description  ==
== Introduction ==
[[File:Tetanus-death-rate.png|alt=|right|frameless|499x499px]]
Tetanus is an infection causing generalised [[Hypertonia Assessment Tool|hypertonia]] presenting with painful muscle spasms of the jaw and neck. Tetanus commonly occurs in the unvaccinated or in the [[Older People Introduction|elderly]] with reduced immunity.


&nbsp;Tetanus is an acute disease caused by the anaerobic (without oxygen), gram positive, non-capsulated spore forming bacteria Clostridium tetani. C. tetani can resist very high temperatures and is not spread from person to person. Tetanus is a rare and often fatal neurological disease that causes increased tone and muscle spasms due to the bacteria.<sup>1,2</sup> The most common way the bacterium enters the body is through wounds which are susceptible to infection if they are: “contaminated with soil, feces, or saliva, puncture wounds including unsterile injection sites, devitalized tissue including burns, avulsions and degloving injuries”.<sup>3 </sup><br> The disease tetanus extends all the way back to the fifth century BC. However, it was not untill the late 1800s that the discovery of the toxins that caused tetanus had the ability to infect several species and that protection could be provided by passive transfer of an antitoxin.<sup>2</sup> In 1924, the immunization to protect people against tetanus was developed and by 1940 the tetanus immunization has become a routine in children’s vaccinations.<sup>1</sup><br><br>
* Vaccination campaigns have decreased the incidence and prevalence of tetanus worldwide.
* Symptoms are caused by toxins produced by the [[Bacterial Infections|bacterium]], Clostridium tetani.<ref name=":0">Bae C, Bourget D. [https://www.statpearls.com/articlelibrary/viewarticle/29997/ Tetanus].[Updated 2020 May 28]. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2021.Available:https://www.statpearls.com/articlelibrary/viewarticle/29997/ (accessed 17.12.2022)</ref>  


== Prevalence  ==
== Etiology ==
The most common way the bacterium enters the body is through [[Wound Assessment|wounds]] which are susceptible to infection if they are: contaminated with soil, feces, or saliva; puncture wounds including unsterile injection sites; devitalized tissue including [[Burns Overview|burns]], avulsions and degloving injuries.


&nbsp;In the United States, from 2000-2007 there has been an “average of 31 reported cases per year with the majority of them being over the age of 40.”<sup>4</sup> In recent years the percent of people who contracted the bacteria to those that die from it has decreased from 30% to 10%. Since 1989 there has only been 2 reported cases of tetanus in the neonatal population.<sup>4</sup> It is estimated that about 800,000 to one million people die of tetanus every year worldwide.<sup>1</sup> The majority of the cases are found in underdeveloped countries with children and neonates representing most of the cases due to inadequate immunizations and unhealthy medical procedure especially during childbirth.<sup>3</sup> The prevalence of Tetanus has been identified in males over the age of 50, women without formal education, African American of south. Recently immigrants and intravenous drug users have had a higher prevalence for contracting Tetanus. Anyone over the age of 60 are at an increases risk for contracting tetanus due to the face that they may not have received the protective immunity.<sup>1</sup> <br>
When in the body the bacterium secretes toxin,<ref name="Ewcombe">Ewcombe P. Treating and preventing tetanus in A&amp;E. Emergency Nurse. October 2004;12(6):23-29.</ref>Tetanus toxin causes the typical clinical manifestations of tetanus by interfering with the release of neurotransmitters and blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. Seizures may occur, and the autonomic nervous system may also be affected.<ref>NSN search How does tetanus affect muscle contraction? Available: https://nsnsearch.com/how-to/how-does-tetanus-affect-muscle-contraction/ (accessed 18.12.20220</ref>  


== Characteristics/Clinical Presentation  ==
The two toxins secreted into the bloodstream are:


There are four different forms of tetanus: generalized tetanus, local tetanus, cehalic tetanus, and neonatal tetanus
# Tetanospasmin affects the [[Neurone|nerve]] and muscle motor endplate interaction, causing the clinical syndrome of rigidity, muscle spasms, and autonomic instability.
# Tetanolysin damages the tissues.<ref name=":0" />
== Epidemiology ==
[[File:The-number-of-deaths-from-tetanus-by-world-region.png|right|frameless|555x555px|Number of-deaths-from-tetanus]]
The highest prevalence is seen in newborns and young persons.


'''Generalizes tetanus'''<br> This is the most common form of tetanus resulting in about 80% of the cases.<sup>4</sup> In generalized tetanus the tetanospsmin attacks and inhibits mostly the motor neurons of the CNS and later the neurons of the ANS as well. As a result a person experiences uncontrollable intense muscle contractions.<sup>3</sup> The first muscles affected are the facial muscles and the jaw (commonly referred to as lock jaw or trismus) because of their short nerve pathways. As the disease progresses the person will experience stiffness of the neck, difficulty swallowing, and stiffness of the abdominal muscles.<sup>3,4</sup> Spasms can be produced by a stimulus such as light, noise, touch, or unexpectedly with no specific cause.3 Spasms are extremely painful and can occur frequently and can last for several minutes. <sup>3,4</sup> In generalized tetanus “ spasms continue for 3-4 weeks and complete recovery may take months.”<sup>4 </sup>After several days the ANS will be affected showing others sings such as fever, sweating, elevated blood pressure, and increased or rapid heart rate.<sup>3,4 </sup>  
* The World Health Organization (WHO) reports improvement in mortality rates from tetanus, due to vaccination campaigns in recent years.  
* The WHO estimates worldwide tetanus deaths in 1997 at around 275,000 with improved rates in 2011 at 14,132 cases.<ref name=":0" />


'''Local tetanus'''<br> Local tetanus can occur before generalized tetanus but this is a much milder form with a decreased amount of associated toxin.<sup>3</sup> Local tetanus is rare there is a better prognosis with only about 1% of the cases resulting in death. <sup>4</sup> The presentation of local tetanus is muscle rigidity and continuous contractions close to the site to injury.<sup>3,4</sup>
== Presentation ==
The incubation period of tetanus varies between 3 and 21 days after infection, with most cases occur within 14 days.


'''Cehalic tetanus'''<br> Cehalic tetanus is also rare and shows a combination of both generalized and local tetanus.<sup>3</sup> The characteristics of this type of tetanus are facial spasms and paralysis as a result of involvement of the cranial nerves. Head wounds are the main cause with occasional occurrence found with ear infections (otitis media) associated with a head wound.<sup>2,3,4</sup> Cehalic tetanus can progress to generalized tetanus and can be associated with a high fatality rate.<sup>3</sup>
Symptoms can include:


'''Neonatal tetnus'''<br> In neonatal tetanus is a form of generalized tetanus found in newborn babies with a high fatality rate.<sup>3</sup> The symptoms usually “appear 4-14 days after birth”<sup>4</sup> and occurs due to non immune mothers and poor hygiene during the delivery process.<sup>3</sup> Most of the cases of infected infants is a result of infection of the unhealed stump of the umbilical cord especially if the cord has been cut with unsterile instruments. Neonatal tetanus is common in third world countries.<sup>4</sup>  
* Jaw cramping/inability to open the mouth
* Muscle spasms commonly in torso, abdomen and extremities
* Painful muscle spasms triggered by eg sudden noises
* Dysphagia
* Seizures
* Headache
* Fever
* Unstable [[Blood Pressure|blood pressure]] or [[tachycardia]].<ref name=":1">World Health Organisation [https://www.who.int/news-room/fact-sheets/detail/tetanus Tetanus] Available:https://www.who.int/news-room/fact-sheets/detail/tetanus (accessed 17.12.2022)</ref>
[[Image:Neonatal tetanus.jpg|thumb|right|Neonatal muscluar rigidity and spasms]]Neonatal tetanus causes more than 50% of deaths from tetanus worldwide but is very rare in developed countries. Neonates present within a week of birth with a short history of failure to feed, vomiting, and ‘convulsions’. Spasms are generalized and mortality is high. Poor umbilical hygiene is the cause of the disease which is preventable by maternal [[Vaccines|vaccination]], even during pregnancy.<ref>Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. British Journal of Anaesthesia. 2001 Sep 1;87(3):477-87. Available: https://academic.oup.com/bja/article/87/3/477/333174?login=false<nowiki/>(accessed 18.12.2022)</ref>
== Treatment ==
Tetanus, a medical emergency, requires


<br>
* Hospitalisation
* Early intramuscular or intravenous administration of the human tetanus immunoglobulin (HTIG).
* Combative wound care
* Antispasmodics eg benzodiazepines, baclofen, vecuronium, pancuronium, and propofol
* Antibiotic therapy (metronidazole, slows progression of disease)<ref name=":0" />
* Tetanus vaccination.


== Associated Co-morbidities  ==
Patients with severe symptoms need to be admitted to the ICU for close monitoring and mechanical ventilation. Healthcare providers need to provide supportive care, especially for patients with autonomic instability.


*Laryngospasm: Spasms in the muscles of respiration can interfere with breathing4
Rehabilitation may take weeks or months.<ref name=":1" />
*Fractures: As a result of spasms, most frequently affected the spine and long bones4
*Hypertension or abnormal heart rhythem: Hyperactivity of the ANS4
*Nosocomial infections: Due to prolonged hospitalization4
*Pulmonary Embolism: Mostly seen in the elderly and drug users4
*Aspiration pneumonia: Found in the elderly and late stages of tetanus4


<br>
== Diagnosis ==
There are no specific laboratory or diagnostic tests used to diagnosis tetanus. The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. <ref name="CDC">CDC. Tetanus: Questions and Answers. November 2010.www.immunize.org.</ref><ref name="Grunau">Grunau BE, Olson J. [https://pubmed.ncbi.nlm.nih.gov/20078924/ An interesting presentation of pediatric tetanus.] Canadian Journal of Emergency Medicine. 2010 Jan;12(1):69-72. Available:https://pubmed.ncbi.nlm.nih.gov/20078924/ (accessed 23.12.2022)</ref>“C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus.”<sup><ref name="CDC" /></sup>
== Physical Therapy Management ==


== Medications  ==
Currently research is limited on the Physical therapy management of individuals with tetanus. Cardiopulmonary physical therapy can be used to help in the prevention of respiratory complications.<ref name="Cook">Cook T, Protheroe R, Handel J. Tetanus: a review of the literature. British Journal Of Anaesthesia. September 2001;87(3):477-487. Available from: MEDLINE, Ipswich, MA. Accessed April 2, 2011.</ref>&nbsp; Physical therapy can also be used to help with muscle rigidity and spasms.


add text here <br>
== Diagnostic Tests/Lab Tests/Lab Values  ==
There are no specific laboratory or diagnostic tests used to diagnosis tetanus. The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. 4,5 “C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus.”4<br>
== Etiology/Causes  ==
Once the bacteria C. tetani enters the body the spores multiply and germinate due to the anaerobic environment. In the body two toxins are released tetanospamin and tetenolysis.1,5 It is not certain the exact role that tetanolysin but it is believed that it works with the toxin tetanospamin.1,4 Tetanospamin reaches the peripheral nerves by retrograde neuronal transport through the blood or lymphatic system.1,5 “The length of the peripheral nerves determines how long it takes for the neurotoxins to reach the central nervous system (CNS) and cause systems. The toxin tetanospamin disrupts the release of the inhibitory neurotransmitters glycine and GABA throughout the CNS but most commonly at the motor end plates, spinal cord, brain, and sympathetic nervous system”.1 “The disinhibition allows for unopposed muscular contraction followed by muscular rigidity and spasms”.1 Once the bacteria has entered the body the incubation period may range from days to months. The average incubation period is around 4-14 days the incubation period is shorter the closer the injury site is to the CNS.1,2,4 A shorter incubation period usually correlates with poor prognosis due to a more severe disease.2
<br>
== Systemic Involvement  ==
add text here
== Medical Management (current best evidence)  ==
add text here
== Physical Therapy Management (current best evidence)  ==
add text here
== Alternative/Holistic Management (current best evidence)  ==
add text here
== Differential Diagnosis  ==
add text here
== Case Reports/ Case Studies  ==
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
== Resources <br>  ==
add appropriate resources here
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Bellarmine_Student_Project]]
[[Category:Bellarmine_Student_Project]]

Latest revision as of 15:19, 23 July 2023

Original Editors - Natalie Gutmann from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Natalie Gutmann, Elaine Lonnemann, Lucinda hampton, Admin, Kim Jackson, WikiSysop, Wendy Walker and 127.0.0.1  

Introduction[edit | edit source]

Tetanus is an infection causing generalised hypertonia presenting with painful muscle spasms of the jaw and neck. Tetanus commonly occurs in the unvaccinated or in the elderly with reduced immunity.

  • Vaccination campaigns have decreased the incidence and prevalence of tetanus worldwide.
  • Symptoms are caused by toxins produced by the bacterium, Clostridium tetani.[1]

Etiology[edit | edit source]

The most common way the bacterium enters the body is through wounds which are susceptible to infection if they are: contaminated with soil, feces, or saliva; puncture wounds including unsterile injection sites; devitalized tissue including burns, avulsions and degloving injuries.

When in the body the bacterium secretes toxin,[2]Tetanus toxin causes the typical clinical manifestations of tetanus by interfering with the release of neurotransmitters and blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. Seizures may occur, and the autonomic nervous system may also be affected.[3]

The two toxins secreted into the bloodstream are:

  1. Tetanospasmin affects the nerve and muscle motor endplate interaction, causing the clinical syndrome of rigidity, muscle spasms, and autonomic instability.
  2. Tetanolysin damages the tissues.[1]

Epidemiology[edit | edit source]

Number of-deaths-from-tetanus

The highest prevalence is seen in newborns and young persons.

  • The World Health Organization (WHO) reports improvement in mortality rates from tetanus, due to vaccination campaigns in recent years.
  • The WHO estimates worldwide tetanus deaths in 1997 at around 275,000 with improved rates in 2011 at 14,132 cases.[1]

Presentation[edit | edit source]

The incubation period of tetanus varies between 3 and 21 days after infection, with most cases occur within 14 days.

Symptoms can include:

  • Jaw cramping/inability to open the mouth
  • Muscle spasms commonly in torso, abdomen and extremities
  • Painful muscle spasms triggered by eg sudden noises
  • Dysphagia
  • Seizures
  • Headache
  • Fever
  • Unstable blood pressure or tachycardia.[4]
Neonatal muscluar rigidity and spasms

Neonatal tetanus causes more than 50% of deaths from tetanus worldwide but is very rare in developed countries. Neonates present within a week of birth with a short history of failure to feed, vomiting, and ‘convulsions’. Spasms are generalized and mortality is high. Poor umbilical hygiene is the cause of the disease which is preventable by maternal vaccination, even during pregnancy.[5]

Treatment[edit | edit source]

Tetanus, a medical emergency, requires

  • Hospitalisation
  • Early intramuscular or intravenous administration of the human tetanus immunoglobulin (HTIG).
  • Combative wound care
  • Antispasmodics eg benzodiazepines, baclofen, vecuronium, pancuronium, and propofol
  • Antibiotic therapy (metronidazole, slows progression of disease)[1]
  • Tetanus vaccination.

Patients with severe symptoms need to be admitted to the ICU for close monitoring and mechanical ventilation. Healthcare providers need to provide supportive care, especially for patients with autonomic instability.

Rehabilitation may take weeks or months.[4]

Diagnosis[edit | edit source]

There are no specific laboratory or diagnostic tests used to diagnosis tetanus. The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. [6][7]“C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus.”[6]

Physical Therapy Management[edit | edit source]

Currently research is limited on the Physical therapy management of individuals with tetanus. Cardiopulmonary physical therapy can be used to help in the prevention of respiratory complications.[8]  Physical therapy can also be used to help with muscle rigidity and spasms.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Bae C, Bourget D. Tetanus.[Updated 2020 May 28]. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2021.Available:https://www.statpearls.com/articlelibrary/viewarticle/29997/ (accessed 17.12.2022)
  2. ↑ Ewcombe P. Treating and preventing tetanus in A&E. Emergency Nurse. October 2004;12(6):23-29.
  3. ↑ NSN search How does tetanus affect muscle contraction? Available: https://nsnsearch.com/how-to/how-does-tetanus-affect-muscle-contraction/ (accessed 18.12.20220
  4. ↑ 4.0 4.1 World Health Organisation Tetanus Available:https://www.who.int/news-room/fact-sheets/detail/tetanus (accessed 17.12.2022)
  5. ↑ Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. British Journal of Anaesthesia. 2001 Sep 1;87(3):477-87. Available: https://academic.oup.com/bja/article/87/3/477/333174?login=false(accessed 18.12.2022)
  6. ↑ 6.0 6.1 CDC. Tetanus: Questions and Answers. November 2010.www.immunize.org.
  7. ↑ Grunau BE, Olson J. An interesting presentation of pediatric tetanus. Canadian Journal of Emergency Medicine. 2010 Jan;12(1):69-72. Available:https://pubmed.ncbi.nlm.nih.gov/20078924/ (accessed 23.12.2022)
  8. ↑ Cook T, Protheroe R, Handel J. Tetanus: a review of the literature. British Journal Of Anaesthesia. September 2001;87(3):477-487. Available from: MEDLINE, Ipswich, MA. Accessed April 2, 2011.
Retrieved from "https://www.physio-pedia.com/index.php?title=Tetanus&oldid=338877"