tetanus vac prev dis (nis) aefi

Slide 1: 

COL RAJAT SRIVASTAVA MBBS MD CLASSIFIED SPECIALIST (PSM) COMMANDING OFFICER SHO DELHI CANTT PROF & HEAD OF THE DEPT OF COMMUNITY MEDICINE Tuesday, August 30, 2011 1 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 2: 

STATION HEALTH ORGANISATION DELHI CANTT TETANUS COL RAJAT SRIVASTAVA MBBS MD CLASSIFIED SPECIALIST (PSM) COMMANDING OFFICER SHO DELHI CANTT PROF & HEAD OF THE DEPT OF COMMUNITY MEDICINE Tuesday, August 30, 2011 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS 2

Slide 3: 

Tuesday, August 30, 2011 3 HOD COMMUNITY MEDICINE, ARMY COLLEGE OF MEDICAL SCIENCES Tuesday, August 30, 2011 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS 3

TETANUS: 

TETANUS COL RAJAT SRIVASTAVA MBBS MD CLASSIFIED SPECIALIST (PSM) COMMANDING OFFICER SHO DELHI CANTT PROF & HEAD OF THE DEPT OF COMMUNITY MEDICINE Tuesday, August 30, 2011 4 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

HEADINGS: 

HEADINGS Introduction. Causative organism. Epidemiology 4) Pathogenesis . 5) Clinical Features . 6) Complications . 7) Diagnosis . 8) Medical Management . 9) Wound Management. 10) Prevention ( Tetanus Toxoid ). 5 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 6: 

6 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 7: 

Risus Sardonicus in Tetanus Patient A person suffering from tetanus undergoes convulsive muscle contractions of the jaw--called LOCKJAW 7 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 8: 

Opisthotonos in Tetanus Patient The contractions by the muscles of the back and extremities may become so violent and strong that bone fractures may occur 8 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 9: 

Opisthotonos in Tetanus Patient 9 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 10: 

Neck rigidity & retraction. 10 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Types of tetanus(contd): 

Types of tetanus(contd) 2)Cephalic tetanus is a rare form of the disease, occasionally occurring with otitis media(ear infections)in which C. tetani is present in the flora of the middle ear , or following injuries to the head . There is involvement of the cranial nerves, especially in the facial area. 11 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 12: 

Tetanus Neonatorum. 12 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 13: 

Newborn showing risus sardonicus and generalized spasticity 13 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 14: 

14 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 15: 

Tuesday, August 30, 2011 15 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 16: 

Tetanus is an acute , often fatal disease caused by an exotoxin produced by the bacterium C lostridium tetani. But prevented by immunization with tetanus toxoid . It is characterized by generalized rigidity and convulsive spasms of skeletal muscles . The muscle stiffness usually involves the jaw (lockjaw)and neck and then becomes generalized. Definition Introduction. 16 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Epidemiology: 

Epidemiology Tuesday, August 30, 2011 17 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 18: 

Tetanus was first described in Egypt over 3000 years ago(Edwin smith papyrus). It was again described by Hippocrates Carle and Rattone in 1884 who first noticed tetanus in animals by injecting them with pus from a fatal human tetanus case. During the same year , Nicolaier produced tetanus in animals by injecting them with samples of soil. History: 18 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 19: 

In 1889, Kitasato isolated the organism from a human victim,showed that it produced disease when injected into animals,and reported that the toxin could be neutralized by specific antibodies. Nocard demonstrated the protective effect of passively transferred antitoxin,and passive immunization in humans Passive immunization and prophylaxis for tetanus during World War I Tetanus Toxoid was first widely used during world war II History: 19 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 20: 

Acridine orange stain of characteristic C tetani with endospores wider than the characteristic drumstick shape. Causative Organism Clostridium tetani 20 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 21: 

C.tetani is : * a slender gram-positive, anaerobic rod that may develop a terminal spore giving it a drumstick appearance. * It is sensitive to heat and cannot survive in the presence of oxygen. It produces two exotoxins : 1) tetanolysin . its function of is not known with certainty. 2) tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus. Tetanospasmin estimated Human lethal dose is 2.5 ng/kg ( (a nanogram is one billionth of a gram) Clostridium tetani 21 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 22: 

22 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Spores:: 

Spores: *very resistant to heat and the usual antiseptics. They can not survive autoclaving at (121 °C)for 20 minutes. relatively resistant to phenol & other chemical agents. widely distributed in soil and in the intestines and faces of horses, sheep, cattle , dogs , cats , rats, guinea pigs and chickens. Manure-treated soil may contain large numbers of spores . Spores may persist for months to years. 23 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 24: 

24 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Epidemiology: a:Occurrence. b:Reservoir . c:Mode of Transmission d:Communicability : 

Epidemiology: a:Occurrence. b:Reservoir . c:Mode of Transmission d:Communicability 25 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 26: 

Tetanus - Greek Word -- Tetanos -to Contract Tetanus Remains a Major Public Health Problem in the Developing World and Is Still Encountered in the Developed World. There Are about 800 000 : 1 Million Deaths Due to Tetanus Each Year. 80% of These Deaths Occur in Africa and South East Asia and It Remains Endemic in 90 Countries World Wide. 1998 - U.K,USA 7 Cases, 41 Cases Including One Neonate Epidemiology: 26 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 27: 

Occurrence: Tetanus occurs worldwide but is most frequently encountered in densely populated regions in hot, damp climates with soil rich in organic matter. Reservoir : Organisms are found primarily in the soil and intestinal tracts of animals and humans. Mode of Transmission: is primarily by: * contaminated wounds, *Tissue injury ( surgery, burns, deep puncture wounds, crush wounds, Otitis media,dental infection, animal bites, abortion and pregnancy). Epidemiology(contd): 27 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Epidemiology (contd ):: 

Epidemiology (contd ): Communicability Tetanus is not contagious from person to person .It is the only vaccine-preventable disease that is : “ infectious but not contagious” . Temporal pattern : Peak in winter and summer season. Incubation Period : 8 DAYS ( 3-21 DAYS) 28 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 29: 

Age : It is the disease of active age (5-40 years), New born baby, female during delivery or abortion Sex : males > females Occupation : Agricultural workers are at higher risk Rural > Urban areas . Immunity : Herd immunity ( community immunity) does not protect the individual. Environmental and social factors : Unhygienic custom & habits, Unhygienic delivery practices. Host Factors : 29 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 30: 

Pathogenesis 30 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 31: 

*C. tetani usually enters the body through a wound. *In the presence of anaerobic conditions, the spores germinate and start to produce toxin and are disseminated via blood and lymphatics. *Toxin reaches the CNS by passing along the motor nerves to the anterior horn cells of the spinal cord. (The shortest peripheral nerves are the first to deliver the toxin to the CNS, which leads to the early symptoms of facial distortion and back and neck stiffness.) *Toxins act at several sites within the central nervous system, including : peripheral motor end plates spinal cord brain sympathetic nervous system Pathogenesis 31 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

How tetanospasmin reaches the CNS: 

How tetanospasmin reaches the CNS Tetanospasmin is taken up by motor neurons in the peripheral nerve endings through endocytosis . It then travels along the axons until it reaches the motor neuron cell bodies in the spinal cord by fast retrograde transport. 32 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Speed of toxin transport:: 

Speed of toxin transport: The toxin travels via intra axonal transport at a rate of 75 -250 mm/day. A process which takes 2 -14 days to reach the CNS. 33 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 34: 

The typical clinical manifestations of tetanus are caused when tetanus toxin interferes with release of neurotrans-mitters blocking inhibitory impulses. This leads to unopposed muscle contra-ction and spasm. Seizures may occur and the autonomic nervous system may also be affected. Pathogenesis (contd ) 34 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 35: 

Mechanism of Action of Tetanus Toxin 35 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Why there is no loss of sensory function ?: 

Why there is no loss of sensory function ? No loss in sensory function because it only affects inhibitory pathways. However, the disease is very painful because it affects our natural way to control pain. The natural pain controlling mechanism uses inhibitory pathways, and if those inhibitory receptors are blocked the Neuro-T’s can’t bind to control pain 36 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Grand Synaptic Potential: 

Grand Synaptic Potential Each motor neuron is stimulated by a large number of presynaptic endings releasing either excitatory or inhibitory chemical messages. 37 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Grand Synaptic Potential: 

Grand Synaptic Potential If the SUM of the potentials of all inhibitory and excitatory synapses do not reach threshold an action potential will not be triggered. 38 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 39: 

When no inhibitory messages are being received by the motor neuron, the excitatory potentials add up to reach threshold and send action potentials much more frequently. Our ability to move smoothly relies upon inhibitory chemical messages as well as excitatory ones. When one muscle contracts the opposing muscle must relax to allow the movement. When all excitatory neurons are firing and no inhibitory neurons are counteracting them, all the muscles contract and movement becomes jerky or impossible to control. 39 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Analogy: 

Analogy Think of the Inhibitory pathway as your parents, and the Excitatory pathway as your friends. If a group of your friends take you away for a weekend, away from your parents, then friends are like tetanospasmin because they are removing your inhibitory control. When your friends join the party you are throwing, your excitatory pathway is uncontrolled because your inhibitory pathway has been incapacitated. This results in muscle spasms and potentially death. 40 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 41: 

Clinical Features 41 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Incubation period :: 

Incubation period : I P ranges from 3 to 21 days , usually about 8 days. In general : *The further the injury site is from the CNS, the longer the I P. *The shorter the I P, the higher the chance of death. * In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. 42 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 43: 

Local tetanus is an uncommon form of the disease,in which patients have persistent contraction of muscles in the same anatomic area as the injury. Local tetanus may precede the onset of generalized tetanus but is generally milder.Only about 1%of cases are fatal. Cephalic tetanus is a rare form of the disease,occasionally occurring with otitis media (ear infections)in which C.tetani is present in the flora of the middle ear,or following injuries to the head.There is involvement of the cranial nerves,especially in the facial area. The most common type (about 80%)of reported tetanus is generalized tetanus .The disease usually presents with a descending pattern. Tuesday, August 30, 2011 43 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Types of tetanus: : 

Types of tetanus : 1) Local tetanus is an uncommon form of the disease in which patients have persistent contraction of muscles in the same anatomic area of the injury. Local tetanus may precede the onset of generalized tetanus but is generally milder .Only about 1%of cases are fatal. 44 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Types of tetanus (contd): 

2) generalized tetanus It is The most common type (about 80%)of reported tetanus .The disease usually presents with a descending pattern. Neonatal tetanus is a form of generalized tetanus Types of tetanus (contd) 45 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Sequence of events: 

Sequence of events Lock Jaw Stiff Neck Difficulty in Swallowing Muscle Rigidity Spasms 46 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 47: 

Unfortunately, the affected individual is conscious throughout the illness, but cannot stop these contractions 47 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 48: 

Rusty nail may cause prick & transmit tetanus 48 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Type of Tetanus: 

Type of Tetanus Traumatic T. Puerperal T. Otogenic T. Idiopathic T. T. Neonatorum 49 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 50: 

Complications 50 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 51: 

51 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 52: 

Diagnosis 52 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Laboratory diagnosis: 

*There are no laboratory findings characteristic of tetanus. *The diagnosis is entirely clinical and does not depend upon bacteriologic confirmation. C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus. Laboratory identification of the organism depends most importantly on the demonstration of toxin production in mice. Laboratory diagnosis 53 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 54: 

Clinically it is confirmed by noticing the following features: Risus sardonicus or fixed sneer . Lock jaw . Opisthotonos ( extension of lower extremities, flexion of upper extremities and arching of the back. The examiners hand can be passed under the back of the patient when he lies on the bed in supine position.) Neck rigidity 54 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Diagnostic tests for tetanus:: 

Diagnostic tests for tetanus: Spatula Test : Apet and Kamad described a simple bedside test to diagnose tetanus : the posterior pharyngeal wall is touched with a spatula and a reflex spasm of the masseter indicates a +ve test. This test shows 94 % sensitivity and 100 % specificity. The altered whistle : This is explained as an early effect of tone in facial muscles which causes the classic R. sardonicus 55 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 56: 

One point for each of the following 7 items : I P . < 7 days (period between injury and 1 st .symptom.) Period of onset < 48 hours ( period between 1 st . Symptom and 1 st . Spasm. ) Acquired from burns, surgical wounds, compound fractures or septic abortion. Addiction (Narcotics) Generalized tetanus Temperature greater than 104°F (40°C) Tachycardia greater than 120 beats per minute (>150 beats per min in neonates) Phillips, Dakar,. Udwadia Score scale for the severity and the prognosis of tetanus: Score : 56 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Total score indicates the severity and the prognosis as follows:: 

Total score indicates the severity and the prognosis as follows: Score Severity Prognosis (mortality rate) 0 - 1 mild < 10 % 2 - 3 moderate 10 to 20 % 4 severe 20 to 40 % 5 - 6 very severe > 50 % 57 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 58: 

Grading of tetanus severity( OXFORD ) Ablett Classification Grade I (mild): * mild to moderate trismus; * general spasticity; * no respiratory problems; * no spasms; * little or no dysphagia . 58 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Ablett Classification : 

Ablett Classification Grade II (moderate): * moderate trismus; * well-marked rigidity; *mild to moderate but short-lasting spasms; * moderate respiratory failure with tachypnoea 30-35/min; * mild dysphagia. 59 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 60: 

Grade III (severe): * severe trismus; *generalized spasticity; *reflex and often spontaneous prolonged spasms; *respiratory failure with : tachypnoea >40/min; apnoeic spells; *severe dysphagia; * tachycardia >120/min. Ablett Classification 60 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 61: 

Grade IV (very severe): features of grade III + violent autonomic disturbances involving the CVS. These include: episodes of severe hypertension and tachycardia alternating with relative hypotension and bradycardia; severe persistent hypertension (diastolic >110 mmHg); severe persistent hypotension (systolic <90) Ablett Classification 61 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 62: 

Grade 1 ( mild ) Muscle rigidity affecting one or more group of muscles sparing the muscles of deglutition. Grade 2 (moderate ) Muscle rigidity affecting muscles of deglutition. 62 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 63: 

Grade 3a (severe ): muscle rigidity and reflex spasms. Grade 3b ( very severe ): Grade 3a + autonomic nervous system changes. 63 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 64: 

Wound Management 64 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 65: 

All wounds should be cleaned with H2O2 &antiseptic. Necrotic tissue and foreign material should be removed. Passive immunization. Active immunization Or both. 65 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Differential Diagnosis: 

Differential Diagnosis Mandible dislocations, Stroke , Encephalitis Subarachnoid Haemorrhage Hypocalcaemia Dystonic Reactions Meningitis Peri-tonsillar Abscess Rabies Other Problems to be considered Intraoral disease Odontogenic infections Globus hystericus Hepatic encephalopathy Hysteria Strychnine poisoning 66 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 67: 

Treatment Medical Management . Wound Management . 67 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Medical Management : 

Medical Management Aim of Treatment: (1) provide supportive care ( until the tetano-spasmin that is fixed in tissue has been metabolized ) by : a: treatment of muscle spasm, b: prevention of respiratory complications. c: prevention of metabolic complications. (2) neutralization of circulating toxin to prevent the continued spread. (3) elimination of the source of toxin . 68 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

How to treat :: 

How to treat : 1: Admit patients with Grade III (severe): to the ICU . For controlling risk of reflex spasms: 2: maintain a dark and quiet room for the patient. 3: Avoid unnecessary procedures . 4: Seriously consider prophylactic intubation with succinylcholine in all patients with moderate-to-severe clinical manifestations. Intubation and ventilation are required in 67% of patients . 69 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

How to treat :: 

How to treat : 5:Perform tracheostomy in patients requiring intubation for more than 10 days. Tracheostomy has also been recommended after onset of the first generalized seizure. 7: Tetanus immune globulin (TIG) (passive immunization) is recommended for treatment of tetanus. TIG can only help remove unbound tetanus toxin, but it cannot affect toxin bound to nerve endings. A single 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. 70 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Marx: Rosen's Emergency Medicine, 7th ed.2009 : 

Marx: Rosen's Emergency Medicine, 7th ed.2009 *Dosage recommendations vary (500–10,000 units of TIG) but multiple injections are stimuli for spasm and most authorities note that 500 units is as effective as a higher dose. * Adult and pediatric doses are the same. If larger dose is to be given, then should be given in divided doses. *Protective antibody levels are achieved 48 to 72 hours after administration of TIG. * Because the half-life of TIG is 25 days, repeated doses are not needed. 71 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 72: 

Recovered individuals : do not necessarily develop “natural Immunity” against the infection--- because of extreme potency of the toxin and very small amount produced during the infection. It does not elicit a strong protective immune response which would produce enough antibodies against future re-infection. How to treat : 72 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

How to treat :: 

Active immunization with tetanus toxoid should begin or continue as soon as the patient’s condition has stabilized. How to treat : 73 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Drugs:: 

Drugs: 1) Penicillin G: Adult 10-24 million U/d. ( IV/IM/6h. ) Paediatric 100,000-250,000 U/kg/d. (IV/IM/6h. ) ( 10- to 14-day course of treatment is recommended ) 74 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Drugs:: 

2) Metronidazole : *considered as a drug of choice by many. * has a better safety profile, better tissue penetrability and negligible CNS excitability. (penicillin can cause seizures at high doses). It can also be given rectally Adult 500 mg orally/6h or 1 g IV /12h; not to exceed 4 g/d Paediatric 15-30 mg/kg/d IV divided /8-12h; not to exceed 2 g/d ( 10- to 14-d course of treatment is recommended.) Drugs: 75 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Drugs:: 

3) Doxycycline : Used when there is contraindication to penicillin or metronidazole. Adult 100 mg orally/IV /12h Paediatric <8 years: Not recommended <45 kg : 4.4 mg/kg/d) IV divided bid > 45 kg: Administer as in adults Drugs: 76 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Anticonvulsants:: 

Anticonvulsants: Sedative-hypnotic agents are the mainstays of tetanus treatment. 1) Diazepam (Valium): Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of GABA( γ- Amino-butyric acid ), major inhibitory neurotransmitter. Adult Mild spasms: 5-10 mg /4-6h Moderate spasms: 5-10 mg IV(diluted in 8 ml glucose 5% or saline ) Severe spasms: Mix 50-100 mg in 500 ml DNS and infuse at 40 mg/h Paediatric Mild spasms: 0.1-0.8 mg/kg/d divided tds/qid Moderate or severe spasms: 0.1-0.3 mg/kg IV 4-8h Drugs: 77 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 78: 

2) Phenobarbital: used to * prolong effects of diazepam. * treat severe muscle spasms. Adult 1 mg/kg IM 4-6h; not to exceed 400 mg/d Paediatric 5 mg/kg/d IV/IM divided tds/qid 78 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Skeletal muscle relaxants: 

Skeletal muscle relaxants These agents can inhibit both monosynaptic and polysynaptic reflexes at spinal level, possibly by hyperpolarization of afferent terminals. * Baclofen (Lioresal) a physiological GABA agonist Adult <55 years: 1000 mcg IT(intrathecal) >55 years: 800 mcg IT Paediatric <16 years: 500 mcg IT >16 years: Administer as in adults 79 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 80: 

Consultations After admission to the ICU Consult : 1:An intensive care medicine specialist should be the primary physician coordinating the patient's care. 2: A pulmonary medicine specialist for patients with severe respiratory symptoms or those requiring mechanical ventilation. 3: An anaesthesiologist if intrathecal baclofen is to be administered. 80 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

PREVENTION: 

PREVENTION 81 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 82: 

Spores are extremely stable but killed by: Immersion in boiling water for 15 minutes. Autoclaving for 15-20 minutes at 121 °c. Sterilization by dry heat for 1-3 hrs at 160 °C. Ethylene oxide sterilization is sporocidal . How to kill spores : PREVENTION 82 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Fumigation: 

Fumigation Sterilization of operation theatre by : * 500 ml of formalin, 200 gms of Pot- permanganate/30 cubic meters of space *All windows and doors are closed except one . *Fissures between the panels of the doors and windows are closed with adhesive tape *After 12 hours the doors and windows are opened and the theatre is aired for 24 hours before re-commissioning it. PREVENTION 83 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 84: 

Active Immunization Passive Immunization Active and passive Immunization. PREVENTION: 84 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Active Immunization by using Tetanus toxoid: 

Active Immunization by using Tetanus toxoid 85 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 86: 

TETANUS TOXOID 86 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

TETANUS TOXOID: 

Tetanus toxoid was developed by Descombey in 1924 Tetanus toxoid immunization was used extensively by the Armed Forces during World War II. Tetanus toxoid consists of a formaldehyde-treated toxin. There are two types of toxoid available — 1) adsorbed (aluminum salt precipitated) toxoid 2) fluid toxoid Although the rates of seroconversion are almost equal, adsorbed toxoid is preferred because the antitoxin response reaches higher titers and is longer lasting than that following the fluid toxoid. TETANUS TOXOID 87 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 88: 

Tetanus Toxoid Adsorbed USP, for intramuscular use, is a sterile suspension of alum-precipitated (aluminum potassium sulfate) toxoid in an isotonic sodium chloride solution containing sodium phosphate buffer to control pH. The vaccine after shaking is a turbid liquid, whitish-gray in colour. Clostridium tetani culture is grown in a peptone-based medium and detoxified with formaldehyde. The detoxified material is then purified by serial ammonium sulphate fractionation, followed by sterile filtration and the toxoid is adsorbed to aluminum potassium sulphate (alum).The adsorbed toxoid is diluted with physiological saline solution (0.85%) and thiomersal (a mercury derivative)is added to a final concentration of 1:10,000. Each 0.5 ml dose is formulated to contain 5 Lf (flocculation units) of tetanus toxoid and not more than 0.25 mg of aluminum. The residual formaldehyde content by assay is less than 0.02%.The tetanus toxoid induces at least 2 units of antitoxin per ml in the guinea pig potency test. COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Active Immunization: 

Active Immunization 1 st dose - 6 th week 2 nd dose - 10 th week 3 rd dose - 14 th week 1 st booster - 18 th month 2 nd booster - 5 th year 3 rd booster - 10 th year Tuesday, August 30, 2011 89 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 90: 

Passive Immunization 90 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Passive Immunization: 

Passive Immunization ATS(equine)I g. 1500 IU/s.c after sensitivity test (or) 2. ATS(human)I g. 250-500 IU, no anaphylactic shock, very safe and costly. 91 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 92: 

Assess Wound 92 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 93: 

MNT elimination 93 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 94: 

Tuesday, August 30, 2011 94 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 95: 

Tuesday, August 30, 2011 95 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 96: 

Tuesday, August 30, 2011 96 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 97: 

Tuesday, August 30, 2011 97 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 98: 

Tuesday, August 30, 2011 98 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 99: 

The Maternal and Neonatal Tetanus elimination initiative was launched by UNICEF, WHO and UNFPA( The United Nations Population Fund Agency ) in 1999, revitalizing the goal of MNT elimination as a public health problem - defined as “ less than one case of neonatal tetanus per 1000 live births in every district of every country”. *Target estimated 100 million women at risk. * 20 million women deliver in high risk areas every year. 99 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 100: 

Tuesday, August 30, 2011 100 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 101: 

Maternal tetanus: defined as tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination, It is one of the most easily preventable causes of maternal mortality. 101 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 102: 

Maternal tetanus includes: (i) postpartum or puerperal tetanus , usually resulting from septic procedures during delivery, (ii) post-abortal tetanus, following septic manoeuvres during induced abortion (iii) tetanus during pregnancy , generally resulting from inoculation through a non-genital portal of entry 102 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 103: 

Neonatal tetanus (NNT) It is a major problem and a leading cause of neonatal mortality . It is easily preventable by 2 tetanus toxoid injections and complete aseptic deliveries. 2 major programs are in operation for the prevention of NNT in the country – the immunization of pregnant women with tetanus toxoid vaccine (TT) under the expanded program on immunization (EPI) and the training of dais under the rural health program . 103 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 104: 

NNT will be prevented: If the women and the dais (who are still associated with almost 70-75% of the deliveries in many areas with high NNT mortality rates) are: 1) convinced of the need for Tetanus T. vaccination during the antenatal period. 2)practice the basic principles of cutting cord and keeping the umbilical stump free of unclean dressings. 104 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

PREVENTION OF NEONATAL TETANUS: 

PREVENTION OF NEONATAL TETANUS 2 doses of T.T to all pregnant women between 16 to 36 weeks of pregnancy with an interval of 1 to 2 months between the two doses. The first dose as early as possible & the second dose a month later preferably 3 weeks before delivery. If the pregnant woman is previously immunized, a booster dose is sufficient. If the pregnant woman is not immunized, then the newborn should be protected against tetanus by giving tetanus human immunoglobulin 750 IU within 6 hours of birth. 105 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011

Slide 106: 

Tuesday, August 30, 2011 106 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Elimination of Neonatal tetanus: 

Elimination of Neonatal tetanus High risk district: a) Neonatal death rate > 1/1000 live births b) 2 doses of tetanus toxoid coverage < 70% c) Deliveries attended by trained dais < 50% Medium risk district : a) Neonatal death rate < 1 / 1000 live births b) 2 doses of tetanus toxoid coverage> 70% c) Deliveries attended by dais > 50% 3. Low risk district : a) NNT <0.1/1000 Live Birth b) 2 Doses of T.T Coverage >90% c) Delivery attended by Trained Dais >75% Tuesday, August 30, 2011 107 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 108: 

Tuesday, August 30, 2011 108 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 109: 

Routine Immunization Tuesday, August 30, 2011 109 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 110: 

Tuesday, August 30, 2011 110 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 111: 

TYPES OF VACCINES TYPE OF ANTIGEN EXAMPLE LIVE BACTERIA, ATTENUATED BCG,TY21 LIVE VIRUS ATTENUATED OPV,MMR KILLED BACTERIA PERTUSIS,S.TYPHII KILLED VIRUS IPV,RABIES,HAV TOXOID DT,TT CAPSULAR POLYSACCHARIDE TYPHOID VI,HIB ,MENINGO & PNEUMO VIRAL SUBUNIT HBsAg BACTERIA SUBUNIT ACELLULAR PERTUSIS Tuesday, August 30, 2011 111 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 112: 

Tuesday, August 30, 2011 112 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 113: 

Tuesday, August 30, 2011 113 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 114: 

Neonatal Tetanus Any newborn baby that - sucks and cries normally during the first 2 (two) days of life; - becomes ill between 3 and 28 days of life with BOTH 1. Inability to suck - and - 2. Generalized muscle rigidity (stiffness) Tuesday, August 30, 2011 114 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

How to Prevent Neonatal Tetanus: 

How to Prevent Neonatal Tetanus Two complimentary strategies 1. Clean delivery - “ 5 cleans” Clean delivery surface Clean hands Clean Thread Clean and New Blade Clean umbilical cord and stump care 2. Immunization of mother with TT Tuesday, August 30, 2011 115 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 116: 

· Minor illnesses such as upper respiratory infections or diarrhoea, mild fever (< 38.5°C) · Allergy, asthma · Prematurity, underweight newborn child · Malnutrition · Child being breastfed · Family history of convulsions · Treatment with antibiotics · Dermatoses, eczema or localized skin infection · Chronic diseases of the heart, lung, kidney and liver · Stable neurological conditions, such as cerebral palsy and Down's syndrome · History of jaundice after birth These are not contraindications to Routine Immunization Tuesday, August 30, 2011 116 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

AEFI: 

AEFI Vaccines are safe and effective Life threatening adverse events are extremely rare Mild side effects are commonly seen and can be self limiting and easily manageable Benefits of immunization greatly outweighs the risks of AEFI Majority are due to unsafe injection practices and procedures Tuesday, August 30, 2011 117 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 118: 

Tuesday, August 30, 2011 118 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 119: 

Tuesday, August 30, 2011 119 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 120: 

Tuesday, August 30, 2011 120 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

AEFI---- Rare, more severe reactions: 

AEFI---- Rare, more severe reactions Include : seizures, thrombocytopenia, hypotonic-hypo responsive episodes, persistent inconsolable screaming In most cases they are self-limiting and lead to no long-term problems Anaphylaxis, while potentially fatal, is treatable without any long-term effects Tuesday, August 30, 2011 121 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

COLD CHAIN: 

COLD CHAIN Cold Chain is a system of transporting and storing vaccines at recommended temperature from the point of manufacture to the point of use Tuesday, August 30, 2011 122 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

COLD CHAIN: 

COLD CHAIN All Vaccines tend to lose potency on exposure to heat above +8 0 C Some Vaccines lose potency when exposed to freezing temperatures The damage is irreversible Tuesday, August 30, 2011 123 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 124: 

Tuesday, August 30, 2011 124 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 125: 

Tuesday, August 30, 2011 125 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

COLD CHAIN EQUIPMENTS: 

COLD CHAIN EQUIPMENTS WALK IN COOLERS & FREEZERS ICE LINED REFRIGERATORS DEEP FREEZERS VACCINE CARRIERS DAY CARRIERS COLD BOXES DOMESTIC REFRIGERATORS Tuesday, August 30, 2011 126 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 127: 

Tuesday, August 30, 2011 127 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

VACCINE VIAL MONITOR: 

VACCINE VIAL MONITOR 3 = bad: Don’t Utilize 4 = bad: Don’t Utilize The central square is equal to, or darker than the surrounding circle X X 1 = good: Utilize 2 = good: Utilize The central square is lighter than the surrounding circle Tuesday, August 30, 2011 128 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

AD SYRINGES: 

AD SYRINGES Impossible to reuse Lowest risk of person to person transmission of blood borne infections. Fixed needle reduces dead space so less wastages. Also eliminates chances of air bubble entry due to loose fitting earlier. Dose specific-ensure correct dose Presterilized-no use of bulky equipment. Tuesday, August 30, 2011 129 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

AD SYRINGE: 

AD SYRINGE Do not use if damaged/torn Tear pack from plunger side. Remove needle cover& discard Take dose – do not touch needle or rubber cap Draw dose. If bubble just shake, administer. Push plunger completely. Do not recap. Tuesday, August 30, 2011 130 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

AD SYRINGE: 

AD SYRINGE Cut the needle immediately from the hub with the help of the hub cutter. It will go to the white sturdy container. NO UNTREATED BIO-MEDICAL WASTE SHALL BE STORED BEYOND A PERIOD OF 48 HOURS. Tuesday, August 30, 2011 131 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Auto-Disable Syringes: 

Auto-Disable Syringes Advantages of the AD syringes: AD syringe is designed to prevent the re-use of non-sterile syringes. The fixed-needle design reduces the dead space in the syringe that wastes vaccine. And eliminates the chances of air bubble entry into the syringe due to loose fitting of the needle The AD syringe are made dose specific (0.5 ml & 0.1 ML) and hence with drawing the plunger to the full length ensures correct dose. No adjustment is required. AD syringes are pre-sterilized therefore; eliminating the need to carry bulky equipment such as pressure cooker / stove /kerosene etc to session site. AD syringes being pre sterilized will be advantageous to Health worker as they would not spend any time on sterilization Tuesday, August 30, 2011 132 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

Slide 133: 

THANK YOU Tuesday, August 30, 2011 133 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS

THANKS YOU: 

THANKS YOU 134 COL RAJAT SRIVASTAVA, PROF & HOD COMMUNITY MEDICINE ACMS Tuesday, August 30, 2011