Dr Hj Rahmini Shabariah SpABagian Ilmu Kesehatan Anak FK UMJ*TETANUS ANAK

Acute toxic diseaseCaused by exotoxin (tetanospasminClostridium tetani*TETANUS

Etiology*Clostridium tetani: bacillus, anaerob, gram positive, sporaNon-invasiveProduce toxinTetanospasmin tetaniTetanolysin hemolysis (in vitro)

Pathogenesis*Spora anaerob wound vegetative exotoxin tetanus Susceptible wound: deep wound, necrotic wound, perforated otitis media

*Tetanospasmin: absorbed by motor end plate nerve cornu anteriorLymphatic system blood CNS

*Tetanospasmin motor end plateMedulla spinalisBrainSympathetic nerve system

*Tetanospasmin: inhibit choline esterase Sympathetic nerve system tachycardia, hypertention, arythmia, peripheral constriction, sweatingBound toxin couldnt be neutralized by antitoxin

Symptom*Incubation periode: 3-14 days(1-several months)Tetanus: Local Cephalic Generalized

*TetanusMild: without spasmModerate: with spasmSevere : spontaneous spasm

Local tetanus*Terderness & muscle spasmAround the wound: healing/generalized

Generalized tetanus*Trismus, neck stiffness, dysphagia, irritable, headacheRhisus sardonicus, tonic spasm, back spasm, abdominal muscle spasm, opistotonusEarly spasm: mild severeThe patient remain consious/alert

*Stimulation (eye, ear, skin) spasmLaryngospasm + respiratory muscles spasms asphyxiaVesica urinary sphincter spasm dysuria & urine retention.

*Usually moderate feverHigh fever: terminal stadiumTerminal stadium:Hyperpirexia, tachycardia, hypertention, hyperhydrosis, cardiac abnormalitiesMuscle paralysis death

*Symptoms change in 3-7 daysConsistent in 2nd weekHealing: 2-6 weeks

Periode of onset: time interval from first symptoms appearance till spasm

Cephalic tetanus*Incubation time: 1-2 daysAcute otitis media/ wound on the headUsually with N II, IV, VII, IX, X, XI impairment.N VII: the most common involvedCephalic tetanus generalized tetanus

Diagnosis*Clinical symptoms & signsLaboratory examination: might be only mild leucocytosis Elevated intracranial pressure

Differential diagnosis*Trismus:Tooth abcess, retropharingeal or pharingeal abcessSeizure/spasm:Encephalitis, meningitis, rabies, strichnine intaxication, tetaniNuchal rigidityTorticolis, cephalic spondilytis, lobar pneumonia, meningitisAbdominal spasm:Peritonitis, acute abdomen

Complication*Aspiration pneumonia, atelectasis, asphyxiaTongue and buccal mucosa laserationMusle bleedingVertebral fracturedehydration

Treatment*Eradication of tetanospasmin sourcesToxin neutralization Supportif treatment: intensive

Eradication of tetanospasmin sources*Clostridium tetani eradicationWound debridementCorpus alienum eliminationAntibiotic: metronidazol dan penisilin prokainPenicillin: 50.000-100.000 IU/kgBW/day I.MMetronidazole: 30 mg/kgBW/day; divided in 4 Tetrasiklin : 50 mg/kgBB/ day

Toxin neutralization*Anti tetanus serum (ATS)/Tetanus immune globulin (TIG)ATS: horse serum skin test & eye test. Bedreska dilution.ATS: 100.000 IU IM/day; 50.000 IU iv dan 50.000 IU imHTIG: 3000-6000 Unit IM; once onlyeye & skin test: not necessary

Supportive treatment*NursingNutritionMuscle relaxans

Muscle relaxans*Combinations:

Phenobarbital: Initial dose: 60-100 mg IMFollowing doses: 6 x 30 mg/day orally

Diazepam: initial dose 0,5-1 mg/kgBW IV slowlyFollowing dose: 1,5-4 mg/kg/day div in 4-6 doses p.o

Neonatal tetanus*Similar with tetanus in children but more severe and usually generalizedEntry site: umbilical cord due to contaminated delivery on susceptible mother. Labour process mostly helped by traditional healer

Clinical symptoms*Usually occurred on 3-10 days oldBreastfeed problemFever.

Treatment*Similar with tetanus in childrenIntravenous fluid drips:Glucose 5-10%:NaCl 0,9% 4:1 for 48-72 hoursATS: 10.000 units/days; 2 daysAnticonvulsants/muscle relaxansIn the past:Diazepam: 4-5 mg/kg/day I.V divided in 4 dosesPhenobarbital: initial dose: 30-60 mg I.M 6 x 15 mg/day

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Cefotaksim100 mg/kg/day in 4 doses OR combination withGentamycin /amikasin 5 mg/kg/day in 2 dosesOxygen, mucus suction, tracheostomi if necessaryUmbilical cord nursing.

Prevention*Immunization

*Patient with no history of immunization:PenicillinATS 750-1500 IU OR TIG 250-500 UTetanus toxoidImmunization (+): ATS/TT (-)Risky wound, TT last longer than 5 yr:Tetanus toxoid

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