Tetanus medical therapy: Difference between revisions

Jump to navigation Jump to search
(Created page with "{{Tetanus}} {{CMG}} ==Overview== The wound must be cleaned. Dead and infected tissue should be removed by surgical debridement. Metronidazole treatment decreases the...")
 
m (Bot: Removing from Primary care)
 
(28 intermediate revisions by 12 users not shown)
Line 1: Line 1:
__NOTOC__
{{Tetanus}}
{{Tetanus}}
{{CMG}}
{{CMG}}{{AE}}{{USAMA}}
 
==Overview==
==Overview==
Tetanus is a medical emergency. Medical therapy includes hospitalization, immediate treatment with human tetanus immune globulin (TIG) (or equine antitoxin if human immune globulin is not available), a [[Tdap|tetanus toxoid booster,]] agents to control [[muscle spasm]], aggressive wound care, and [[antimicrobial]] therapy. [[Mechanical ventilation]] and agents to control [[autonomic nervous system]] instability may be required among patients with severe disease.<ref name="World">{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref>


The wound must be cleaned. Dead and infected tissue should be removed by surgical [[debridement]]. [[Metronidazole]] treatment decreases the number of [[bacteria]] but has no effect on the bacterial toxin. [[Penicillin]] was once used to treat tetanus, but is no longer the treatment of choice because of a theoretical risk of increased spasms. It should still be used if metronidazole is not available. [[Passive immunization]] with human anti-[[tetanospasmin]] [[immunoglobulin]] or tetanus immune globulin is crucial. If specific anti-tetanospasmin immunoglobulin is not available, then normal human immunoglobulin may be given instead. All tetanus victims should be vaccinated against the disease or offered a booster shot.
==Medical Therapy==
[[Image:Neonatal tetanus 6374 lores.jpg|left|thumb|200px|An infant suffering from neonatal tetanus.]]
The medical therapy for tetanus may include:<ref name="pmid10945801">{{cite journal| author=Farrar JJ, Yen LM, Cook T, Fairweather N, Binh N, Parry J et al.| title=Tetanus. | journal=J Neurol Neurosurg Psychiatry | year= 2000 | volume= 69 | issue= 3 | pages= 292-301 | pmid=10945801 | doi= | pmc=1737078 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10945801  }} </ref><ref name="pmid14576357">{{cite journal| author=Lalli G, Gschmeissner S, Schiavo G| title=Myosin Va and microtubule-based motors are required for fast axonal retrograde transport of tetanus toxin in motor neurons. | journal=J Cell Sci | year= 2003 | volume= 116 | issue= Pt 22 | pages= 4639-50 | pmid=14576357 | doi=10.1242/jcs.00727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14576357  }} </ref><ref name="pmid12581644">{{cite journal| author=Rummel A, Bade S, Alves J, Bigalke H, Binz T| title=Two carbohydrate binding sites in the H(CC)-domain of tetanus neurotoxin are required for toxicity. | journal=J Mol Biol | year= 2003 | volume= 326 | issue= 3 | pages= 835-47 | pmid=12581644 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12581644  }} </ref><ref name="pmid1331807">{{cite journal| author=Schiavo G, Benfenati F, Poulain B, Rossetto O, Polverino de Laureto P, DasGupta BR et al.| title=Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin. | journal=Nature | year= 1992 | volume= 359 | issue= 6398 | pages= 832-5 | pmid=1331807 | doi=10.1038/359832a0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1331807  }} </ref><ref name="pmid12729912">{{cite journal| author=Caccin P, Rossetto O, Rigoni M, Johnson E, Schiavo G, Montecucco C| title=VAMP/synaptobrevin cleavage by tetanus and botulinum neurotoxins is strongly enhanced by acidic liposomes. | journal=FEBS Lett | year= 2003 | volume= 542 | issue= 1-3 | pages= 132-6 | pmid=12729912 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12729912 }} </ref>
It takes 2-14 days for symptoms to develop after infectionSymptoms peak 17 days after infection.


===Mild tetanus===
:*1. '''General measures''' <ref name="World">{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref>
Mild cases of tetanus can be treated with:
::*Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
* Tetanus immune globulin [[Intravenous therapy|IV]] or [[Intramuscular injection|IM]]
:*2. '''Immunotherapy'''
* metronidazole [[Intravenous therapy|IV]] for 10 days
::*Preferred regimen: Human TIG 500 units IV/IM as soon as possible {{and}} Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
* [[diazepam]]
::*Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later
* tetanus vaccination
:*3. '''Antibiotic treatment'''<ref>http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf</ref>
::*Preferred regimen: [[Metronidazole]] 500 mg IV/PO q6h {{or}} [[Penicillin G]] 100,000–200,000 IU/kg/day IV, administered in 2–4 divided doses
::*Alternative regimen: [[Tetracyclines]] {{or}} [[Macrolides]] {{or}} [[Clindamycin]] {{or}} [[Cephalosporins]] {{or}} [[Chloramphenicol]]
:*4. '''Muscle spasm control'''
::*Preferred regimen: [[Diazepam]] 5 mg IV {{or}} [[Lorazepam]] 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation
::*Alternative regimen (1): [[Magnesium]] sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved {{withorwithout}} [[Benzodiazepines]]
::*Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
::*Alternative regimen (2): [[Baclofen]] {{or}} [[Dantrolene]] 1–2 mg/kg IV/PO q4h {{or}} [[Bromocriptine]] {{or}} [[Amantadine]]
::*Alternative regimen (3): [[Barbiturates]] 100–150 mg q1-4h by any route
::*Alternative regimen (4): [[Chlorpromazine]] 50–150 mg IM q4–8h
::*Pediatric regimen: [[Lorazepam]] 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; [[Barbiturates]] 6–10 mg/kg in children by any route; [[Chlorpromazine]] 4–12 mg IM every q4–8h
::*Note: As for [[Benzodiazepines]], large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
:* 5. '''Autonomic dysfunction control'''
::*Preferred regimen: [[Magnesium]] sulphate {{or}} [[Morphine]] {{or}} [[Esmolol]]
:* 6. '''Airway/respiratory control'''
::*Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.


===Severe tetanus===
==References==
Severe cases will require admission to [[intensive care]]. In addition to the measures listed above for mild tetanus:
{{Reflist|2}}
[[Image:Lock-jaw 2857.jpg|thumb|left|150px|Lock-jaw in a patient suffering from tetanus.]]
* human tetanus immunoglobulin injected [[Intrathecal|intrathecally]] (increases clinical improvement from 4% to 35%)
* [[tracheostomy]] and [[mechanical ventilation]] for 3 to 4 weeks,
* [[magnesium]], as an [[intravenous]] (IV) infusion, to prevent muscle spasm,
* [[diazepam]] (known under the common name Valium) as a continuous IV infusion,
* the autonomic effects of tetanus can be difficult to manage (alternating hyper- and [[hypotension]], [[hyperpyrexia]]/[[hypothermia]]) and may require IV [[labetalol]], magnesium, [[clonidine]], or [[nifedipine]].


Drugs such as [[chlorpromazine]] or [[diazepam]], or other muscle relaxants can be given to control the muscle spasms. In extreme cases it may be necessary to chemically paralyze the patient with [[curare]]-like drugs and use a mechanical ventilator.
{{WH}}
{{WS}}


In order to survive a tetanus [[infection]], the maintenance of an [[airway]] and proper [[nutrition]] are required. An intake of 3500-4000 [[Calories]], and at least 150g of [[protein]], is often given in liquid form through a tube directly into the stomach, or through a drip into a vein. This high-caloric diet maintenance is required due to the increased metabolic strain brought on by the increased muscle activity.
[[Category:Disease]]
[[Category:Bacterial diseases]]
[[Category:Infectious Disease Project]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Neurology]]

Latest revision as of 00:24, 30 July 2020

Tetanus Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Tetanus from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Xray

CT scan

MRI

Ultrasound

Other Imaging Studies

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Tetanus medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Tetanus medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Tetanus medical therapy

CDC on Tetanus medical therapy

Tetanus medical therapy in the news

Blogs on Tetanus medical therapy

Directions to Hospitals Treating Tetanus

Risk calculators and risk factors for Tetanus medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Tetanus is a medical emergency. Medical therapy includes hospitalization, immediate treatment with human tetanus immune globulin (TIG) (or equine antitoxin if human immune globulin is not available), a tetanus toxoid booster, agents to control muscle spasm, aggressive wound care, and antimicrobial therapy. Mechanical ventilation and agents to control autonomic nervous system instability may be required among patients with severe disease.[1]

Medical Therapy

The medical therapy for tetanus may include:[2][3][4][5][6]

  • 1. General measures [1]
  • Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
  • 2. Immunotherapy
  • Preferred regimen: Human TIG 500 units IV/IM as soon as possible AND Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
  • Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later
  • 3. Antibiotic treatment[7]
  • 4. Muscle spasm control
  • Preferred regimen: Diazepam 5 mg IV OR Lorazepam 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation
  • Alternative regimen (1): Magnesium sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved ± Benzodiazepines
  • Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
  • Alternative regimen (2): Baclofen OR Dantrolene 1–2 mg/kg IV/PO q4h OR Bromocriptine OR Amantadine
  • Alternative regimen (3): Barbiturates 100–150 mg q1-4h by any route
  • Alternative regimen (4): Chlorpromazine 50–150 mg IM q4–8h
  • Pediatric regimen: Lorazepam 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; Barbiturates 6–10 mg/kg in children by any route; Chlorpromazine 4–12 mg IM every q4–8h
  • Note: As for Benzodiazepines, large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
  • 5. Autonomic dysfunction control
  • 6. Airway/respiratory control
  • Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.

References

  1. 1.0 1.1 "Current recommendations for treatment of tetanus during humanitarian emergencies".
  2. Farrar JJ, Yen LM, Cook T, Fairweather N, Binh N, Parry J; et al. (2000). "Tetanus". J Neurol Neurosurg Psychiatry. 69 (3): 292–301. PMC 1737078. PMID 10945801.
  3. Lalli G, Gschmeissner S, Schiavo G (2003). "Myosin Va and microtubule-based motors are required for fast axonal retrograde transport of tetanus toxin in motor neurons". J Cell Sci. 116 (Pt 22): 4639–50. doi:10.1242/jcs.00727. PMID 14576357.
  4. Rummel A, Bade S, Alves J, Bigalke H, Binz T (2003). "Two carbohydrate binding sites in the H(CC)-domain of tetanus neurotoxin are required for toxicity". J Mol Biol. 326 (3): 835–47. PMID 12581644.
  5. Schiavo G, Benfenati F, Poulain B, Rossetto O, Polverino de Laureto P, DasGupta BR; et al. (1992). "Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin". Nature. 359 (6398): 832–5. doi:10.1038/359832a0. PMID 1331807.
  6. Caccin P, Rossetto O, Rigoni M, Johnson E, Schiavo G, Montecucco C (2003). "VAMP/synaptobrevin cleavage by tetanus and botulinum neurotoxins is strongly enhanced by acidic liposomes". FEBS Lett. 542 (1–3): 132–6. PMID 12729912.
  7. http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf

Template:WH Template:WS