Clinical Manifestations of Tetanus

       Clinical manifestations of tetanus varies from local muscle rigidity, trismus up strong spasms. Period until the onset of the initial symptoms of tetanus spasms known onset of disease, which affects the prognostic.

Clinical manifestations of tetanus consists of four kinds:

1. Local tetanus
    Local tetanus is a mild form of tetanus disease with a mortality rate of about 1%. Symptoms include persistent stiffness and spasm accompanied by pain in the muscles around or proximal wound. Local tetanus may develop into general tetanus.

2. Cephalic tetanus
     Local tetanus is a form of the face with an incubation period of 1-2 days, which is caused by injury to the head or chronic otitis media. Symptoms include trismus, dysphagia, risus sardonicus (Suffering smile monkey) and cranial nerve dysfunction. Cephalic tetanus is rare, can develop into a general tetanus and the prognosis is usually poor.

3. General tetanus
     Forms of tetanus are most commonly found. Clinical symptoms can be a form of trismus, iritable, neck stiffness, difficulty swallowing, chest and abdominal rigidity (opisthotonos), flexion-abduction of the arm and leg extensions, pain and great anxiety and generalized seizures that can occur with mild stimuli such as light, sound and touch with the consciousness that remains good.

4. Neonatal tetanus
     Tetanus that occurs in newborns, caused by an infection of the umbilical cord , generally because the umbilical cord cutting technique aseptic and mothers who do not receive adequate immunization. Symptoms that often arises is the inability to suckle, weakness, irritable followed by stiffness and spasms. Classical postures: trismus, stiffness in the back muscles causing severe opisthotonus with lumbar lordosis. Babies maintain upper limb flexion at the elbow with the hand clutching his chest, wrist flexion, fingers clenched, lower limb hyperextension with dorsiflexion of the ankle and flexion of the toes. Death is usually due to stopping breathing, hypoxia, pneumonia, circulatory collapse and pulmonary heart failure.
The severity of tetanus: Criteria Patel Joag
• Criterion 1: jaw stiffness, spasms limited, dysphagia and spinal muscular stiffness
• Criterion 2: Spasms, without considering the frequency and severity of
• Criterion 3: The incubation period of ≤ 7 days
• Criterion 4: time of onset ≤ 48 hours
• Criterion 5: Improved temperature; 100 º F rectal, or axillary 99 º F (37.6 º C)

       The incubation period is the time required for the bacteria Clostridium tetani from the wound until the start of the first clinical symptoms ranges from 7-14 days (1-2 days up to 60 days). Onset period is the time it takes from the start of the first clinical symptoms until the onset of muscle spasms ranged from 1-7 days. At this time fulminating tetanus retracts up to 1-2 hours. The longer the period of onset, the patients have a better prognosis.

• Grade 1 (mild cases)
   There is one criterion, usually 1 or 2 criteria (no mortality)
• Grade 2 (moderate cases)
   There are two criteria, usually the criteria 1 and 2. Usually the incubation period of 7 days and over 48 hours of onset (10% mortality)
• Grade 3 (severe cases)
    There are 3 criteria, the incubation period is usually less than 7 days or less from the onset 48 hours (32%  mortality)
• Grade 4 (very severe cases)
    There are at least 4 criteria (mortality 60%)
• Grade 5
    If there are 5 criteria including puerpurium and neonatal tetanus (mortality 84%)

According to the degree of modification of tetanus disease classification by Albleet's
• Grade 1 (mild)
Mild to moderate trismus, general spamisitas, no respiratory complications, no spasm, little or no dysphagia
• Grade 2 (moderate)
Moderate trismus, rigidity is more clear, mild or moderate spasm manun short, moderate respiratory complications with tachypnea
• Grade 3 (severe)
Severe trismus, general spasticity, spasms, confused and often spontaneous, apnoeic attacks, severe dysphagia, elongated spontaneous spasm occurs frequently and reflexes, respiratory complications accompanied by tachypnea, apnea attacks, severe dysphagia, tachycardia, autonomic nervous system activity are increasing
• Grade 4 (very severe)
Symptoms in grade 3 plus severe autonomic disturbances, often causing "autonomic storm"
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