Three things to do in medical treatment and therapy of tetanus, there are:
1. Provide supportive care until tetanospasmin which binding with tissue, has been metabolized
2. Neutralize toxins in the circulatory system
3. Eliminating sources of tetanospasmin.
1. General Goals of Treatment and Therapy of Tetanus
The purpose of this therapy is to eliminate a tetani bacteria, neutralize toxins circulation, prevent muscle spasms and to provide assistance to recover respiration. And that goal can be broken down as follows
• Maintain and clean the wound as well as possible, such as:
Clean the wound, wound irrigation, wound debridement (excision of necrotic tissue), remove foreign objects in the wound as well as compress to H202, in this treatment, the wound is performed 1 to 2 hours after ATS and provision of antibiotics, such as metronidazole. ATS injected around the wound.
• Diet enough calories and protein, a form of food depending on the ability to open the mouth and swallow. If there is trismus, or food can be given parenterally personde.
• Insulation to avoid external stimuli such as sounds and actions of patients
• Oxygen, and trachcostomi artificial respiration if necessary.
• Adjust the balance of fluids and electrolytes.
2. Toxin Neutralization
• Tetanus Immunoglobulin is a choice antitoxin; doses of 3000-10000 units
given IM or IV, despite the lower dose was also effective. Administering a single dose is adequate. Toxin that is already bound to neurons can not be eliminated by the antitoxin, but circulating toxin can be neutralized.
• TIG intratecal: an RCT stated that patients treated with intrathecal tetanus immunoglobulin through clinical progress is better than IM injection.
• Anti Tetanus Serum can be used, but previously required skin test for hypersensitivity. Usual dose of 50,000 units 50,000 units IM followed by slow IV infusion. If surgical excision wound allows, some antitoxin can be injected around the wound.
3. Elimination of Bacteria
• Cleaning the location of the wound or if necessary excised.
• wound cultures to find the bacteria, but does not always succeed.
• Penicillin is the drug of choice: give procaine penicillin, 1.2 million units IM or IV every 6 hours for 10 days.
• For patients who are allergic to penicillin may be given tetracycline, 500 mg PO or IV every 6 hours for 10 days. Giving antibiotics to eradicate Clostridium tetani above but can not affect neurological processes.
4. supportive Therapy
a. Nutrition and fluids
• IV fluid administration adjusted to circumstances, such as frequent seizures, hyperpyrexia, and so on.
• Give high calorie nutrients, if necessary by parenteral nutrition.
• When a nasogastric Sonda has to be installed (without worsening seizures), oral feeding should be immediately implemented.
b. Keeping the respiratory remain efficient
• Cleaning of airway mucus.
• Provision of additional acid.
• If necessary, perform tracheotomies
c. Reduce stiffness and spasms address
• anticonvulsants administered titration, according to the needs and clinical response.
• In patients with rapidly deteriorating (attack more often and more long time), giving anticonvulsants converted as at the beginning of therapy, that starts compounded by a bolus, followed by, more Higher maintenance doses.
• When maximal dose has been reached yet unresolved cramps, should done totally disabling muscle, assisted by respiratory mechanics
(Ventilator).
d. Neuromuscular blockers can help when other methods fail to reduce the influence spasme ingestion or respiration process. Patients should be in-mechanical ventilation when neuromuscular blockers are used. Pancuronium (Pavulon), succinylcholine, and other blockers can be beneficial if the patient was intubated. Sedation should be maintained or increased in dose when blockers are used for unpleasant for patients, when they come round body are currently aware are solely for paralysis. Intrathecal Baclofen infusion has been used also to control spasme.
e. All tetanus patients should remain in the intensive care unit in a quiet room with dim light samapai spasme, seizures, and autonomous instability (blood pressure changes) have subsided.
1. Provide supportive care until tetanospasmin which binding with tissue, has been metabolized
2. Neutralize toxins in the circulatory system
3. Eliminating sources of tetanospasmin.
1. General Goals of Treatment and Therapy of Tetanus
The purpose of this therapy is to eliminate a tetani bacteria, neutralize toxins circulation, prevent muscle spasms and to provide assistance to recover respiration. And that goal can be broken down as follows
• Maintain and clean the wound as well as possible, such as:
Clean the wound, wound irrigation, wound debridement (excision of necrotic tissue), remove foreign objects in the wound as well as compress to H202, in this treatment, the wound is performed 1 to 2 hours after ATS and provision of antibiotics, such as metronidazole. ATS injected around the wound.
• Diet enough calories and protein, a form of food depending on the ability to open the mouth and swallow. If there is trismus, or food can be given parenterally personde.
• Insulation to avoid external stimuli such as sounds and actions of patients
• Oxygen, and trachcostomi artificial respiration if necessary.
• Adjust the balance of fluids and electrolytes.
2. Toxin Neutralization
• Tetanus Immunoglobulin is a choice antitoxin; doses of 3000-10000 units
given IM or IV, despite the lower dose was also effective. Administering a single dose is adequate. Toxin that is already bound to neurons can not be eliminated by the antitoxin, but circulating toxin can be neutralized.
• TIG intratecal: an RCT stated that patients treated with intrathecal tetanus immunoglobulin through clinical progress is better than IM injection.
• Anti Tetanus Serum can be used, but previously required skin test for hypersensitivity. Usual dose of 50,000 units 50,000 units IM followed by slow IV infusion. If surgical excision wound allows, some antitoxin can be injected around the wound.
3. Elimination of Bacteria
• Cleaning the location of the wound or if necessary excised.
• wound cultures to find the bacteria, but does not always succeed.
• Penicillin is the drug of choice: give procaine penicillin, 1.2 million units IM or IV every 6 hours for 10 days.
• For patients who are allergic to penicillin may be given tetracycline, 500 mg PO or IV every 6 hours for 10 days. Giving antibiotics to eradicate Clostridium tetani above but can not affect neurological processes.
4. supportive Therapy
a. Nutrition and fluids
• IV fluid administration adjusted to circumstances, such as frequent seizures, hyperpyrexia, and so on.
• Give high calorie nutrients, if necessary by parenteral nutrition.
• When a nasogastric Sonda has to be installed (without worsening seizures), oral feeding should be immediately implemented.
b. Keeping the respiratory remain efficient
• Cleaning of airway mucus.
• Provision of additional acid.
• If necessary, perform tracheotomies
c. Reduce stiffness and spasms address
• anticonvulsants administered titration, according to the needs and clinical response.
• In patients with rapidly deteriorating (attack more often and more long time), giving anticonvulsants converted as at the beginning of therapy, that starts compounded by a bolus, followed by, more Higher maintenance doses.
• When maximal dose has been reached yet unresolved cramps, should done totally disabling muscle, assisted by respiratory mechanics
(Ventilator).
d. Neuromuscular blockers can help when other methods fail to reduce the influence spasme ingestion or respiration process. Patients should be in-mechanical ventilation when neuromuscular blockers are used. Pancuronium (Pavulon), succinylcholine, and other blockers can be beneficial if the patient was intubated. Sedation should be maintained or increased in dose when blockers are used for unpleasant for patients, when they come round body are currently aware are solely for paralysis. Intrathecal Baclofen infusion has been used also to control spasme.
e. All tetanus patients should remain in the intensive care unit in a quiet room with dim light samapai spasme, seizures, and autonomous instability (blood pressure changes) have subsided.
In short, tetanus treatment in the first hours the patient was diagnosed as tetanus are:
1. Check the airway, tracheostomy if necessary.
2. Routine blood checks, electrolytes, ureum, creatinine, urine myoglobin, AGD, cultured bacteria.
3. Finding a port d'entry, incubation, period of onset, immunization status.
4. Oxygen is given if there are signs of hypoxia, respiratory distress, cyanosis.
5. Diazepam 10 mg iv slowly for 2-3 minutes. Can be repeated if necessary, quiet space / dark.
6. Maintenance dosage given diazepam drip, to prevent formation of crystallization, liquid shaken every 30 minutes.
Medical treatment and therapy in the first 24 hours:
1. Iv ATS 10.000 UI, led skin test.
2. TT 0.5 cc im.
3. Nutrition 3500-4500 calories / day to 100-150 g of protein.
4. 4 x 500mg metronidazole iv or P.O. 7-10 days.
5. HTIG 300-5000 UI im / iv (500 effective enough).
6. Tracheostomy.
7. Wound debridement.
8. NGT, CVP, Folley catheter in grade II-IV.
9. Vancuronium diazepam or 6-8 mg / day.
10. Each stiff given diazepam bolus 1 ampil / iv slowly for 3-5 minutes,
can be repeated every 15 minutes to a maximum of 3 times. When not treated immediately resolved ICU.
11. Avoiding action / act to stimulate, including sound and light stimulation with intermittent intensity
12. Defending / freeing the airway; sucking oro / nasopharyngeal in periodically.
Prevent
1. active immunization
• initial doses of 0.5 ml toxoid by intramuscular
• 8 weeks and then repeated with the same dose
• Booster, 6-12 months later
• Subsequent booster, given the next 5 years
2. Prevent injury
3. Adequately care for the wounded
4. Provision of anti-tetanus serum (ATS) or Tetanus immunoglobulin (TIG) within a few hours after the injury will provide passive immunity, thereby preventing the occurrence of tetanus will prolong the incubation period generally given in doses of 1500 U ATS intramuscular or intramuscular TIG 250 units after the skin test
1. active immunization
• initial doses of 0.5 ml toxoid by intramuscular
• 8 weeks and then repeated with the same dose
• Booster, 6-12 months later
• Subsequent booster, given the next 5 years
2. Prevent injury
3. Adequately care for the wounded
4. Provision of anti-tetanus serum (ATS) or Tetanus immunoglobulin (TIG) within a few hours after the injury will provide passive immunity, thereby preventing the occurrence of tetanus will prolong the incubation period generally given in doses of 1500 U ATS intramuscular or intramuscular TIG 250 units after the skin test
Related Articles
1. What Tetanus is
2. Pathophysiology of Tetanus
3. Clinical Manifestations of Tetanus
4. Diagnosis and Differential Diagnosis of Tetanus
