TETANUS
Dr. Herry Setya Yudha Utama, SpB, MHKes, FInaCS
DEPARTMENT OF SURGERY
ARJAWINANGUN HOSPITAL 2011
Preliminary
Tetanus is an acute infectious disease that shows itself by acute neuromuscular disorder in the form of trismus, stiffness and muscle spasms caused by a specific eksotosin of anaerobic Clostridium tetani . Tetanus can occur as a complication of injury, both big and small cuts, real cuts and hidden wounds. Type of wound that tetanus is inviting injury as Vulnus laceratum (wound), Vulnus punctum(stab wounds), combustion (burns), open fracture, otitis media, contaminated wounds, cuts the umbilical cord.
Believed that the disease tetanus caused by Clostridium tetani which is a kind of gram-positive bacteria which in normal circumstances be in the form of anaerobic spores in the atmosphere and transformed into the vegetative form that produces exotoxin among other neurotoxins and tetanolysmin tetanospasmin. This toxin that causes symptoms - symptoms of tetanus disease.
Spore forms of Clostridium tetani are all around us like the soil, grass - grass, wood, animal dung and human. These germs for anaerobic growth requires an atmosphere that would occur if the wound with a lot of necrotic tissue in it, or injury to the growth of other bacteria, especially bacteria pus makers such as Staphyloccus aureus.
The term "wound tetanus prone" are wounds that tend to cause diseases such as tetanus wounds with open fractures, penetrating wounds, the wound contains a foreign body, especially the broken wood, wound with pyogenic infections, wounds with extensive tissue damage, extensive burns grade II and III, a real superficial wounds contaminated with soil or animal manure in which the injury was more than 4 hours late just got desinfektansia topical or surgical cleaning, with a septic abortion, giving birth to help labor inadequate, and cutting the umbilical cord care inadequate, animal bites with lots of necrotic tissue, skin ulceration with necrotic tissue, all types gangrena, cema surgical operation on the channel from the mouth to the anus, otitis media puralenta. The incubation period of tetanus disease is not always the same but is generally 8-12 days, but can also be two days or several weeks or several months. Increased short incubation period of disease it causes weight gain.
Disease does not cause tetanus immunity in people who have been attacked. Mortality rate of patients with tetanus is very high around 50%, that figure will grow at a hospital intensive care equipment is not yet complete, may be lower in hospitals with intensive care is complete.
Therefore, prevention of this disease is very important and should receive primary attention. Efforts taken to overcome this disease are:
a. Provide active immunity to everyone
b. Tetanus prophylactic action against those who injured a true and correct.
c. Treat people with tetanus with a multidisciplinary intensive care.
Tetanus can occur as a complication of wounds, cuts both large and small wounds, real or hidden injuries. Tetanus is an acute disease caused by the bacteria Clostridium tetani that produces exotoxin is anaerobic. Clostridium tetani is a gram positive results, and are anaerobes.
Type of wound that tetanus is inviting injury - injuries such as vulnus laceratum (wound), vulnus punctum (stab wounds), combustio (burns), open fracture, otitis media, contaminated wounds, cuts the umbilical cord.
The incubation period of this disease is 1-54 days, average - average of 8 days. The slower debrimen and antitoxin treatment, the shorter the incubation period and also the worse the prognosis. Bacteria into the wound through the soil, dust or dirt.
There are several factors that worsen the prognosis of such a short incubation period, stage of disease parahm elderly patients, neonates, the high temperature rise, the slow treatment, complications such as status konvulsivus, heart failure, vertebral fracture, pneumonia.
Characteristic of seizures in the tetanus seizures without impairment of consciousness. And the onset of disease (time from first onset of symptoms resulting in seizures) is 24-72 hours.
Pathogenesis and Pathophysiology
Clostridium tetani enter the human body through wounds. All types of wounds can be infected by the tetanus bacteria such as laceration wounds, stab wounds, gunshot wounds, burns, bites by humans or animals, wound injections and so forth. In 60% of tetanus patients, port d'entre there are areas on the feet particularly puncture wounds. Tetanus infection can also occur through the uterus after childbirth or abortion provokatus. In newborns Clostridium tetani can be through the umbilicus after the cord was cut without regard to the rules of asepsis antisepsis. Otitis media or cavities can be considered a port d'entre , if the patient is not found wound tetanus is estimated as the entry of tetanus germs. Form spores will turn into vegetative forms when the environment makes it possible to change the shape and then remove ekotoksin. Tetanusnya own germs remain in the area, there is no spread of germs. The bacteria form two kinds of exotoxin produced the tetanolisin and tetanospasmin. Tetanolisin in the experiment can destroy red blood cells but does not cause tetanus directly but rather adds to local conditions optimal for growth of bacteria. Tetanospasmin consists of proteins that are toxic to nerve cells. These toxins are absorbed by the nerve end organ on the end of the motor nerve and transmitted through the nerves to the ganglion cells and central nervous system.When it reaches the central nervous system and is bound to nerve cells, the toxin can no longer be neutralized. Nerves are cut or degenerates, slow to absorb toxins, while the sensory nerves did not absorb.
Tetanus is caused by neurotoxins (tetanospasmin) of bacteria Gram-positive anaerobes, Clostridium tetani, the first 1 to 2 weeks after inoculation the form of spores into the body to injury / wounds (incubation period). This disease is one of four important disease manifestations are the result of a major clinical effect of the power of exotoxin (tetanus, gas gangrene, diphtheria, botulism). Place the entry of germs of disease can be a wound that in dealing with local tissue damage, embedded foreign objects or sepsis with soil contamination, and a small superficial abrasions or wounds contaminated soil shear, trauma to the fingers or toes associated with broken bones finger and injuries to thesurgery and pemotonga umbilical cord that is not sterile.
In the state of the anaerobic , spore bacteria will be a cell bergerminasi vegetative when in an anaerobic environment, with low tissue oxygen tension. Furthermore, the toxin will be produced and spread throughout the body via the circulatory system of blood and spleen . The toxin will move in certain places such as central nervous system including brain. Clinical symptoms arise as a result of spinal ganglion exotoxin at the synapse and the neuromuscular junction and autonomic nerves.Toxin spreads from the site of injury to the motor endplate and after coming through the intraaxonal dijalarkan ganglioside in peripheral nerve cells, then to the spinal cord anterior horn. Eventually spread to the CNS. Clinical symptoms are evoked from the exotoxin on the edge and central nervous system is by blocking the release of neurotransmitters resulting in uncontrollable muscle contractions / spasms and continuous excitation. These neurons become unable to release neurotransmitter.Neurons, which release gamma aminobutyric acid (GABA) and glycine, the main neurotransmitter inhibitor, is very sensitive to tetanospasmin, causing failure of the reflex inhibition of motor responses to sensory stimuli. Stiffness at the site of entry of bacteria or the masseter muscles (trismus), at the time of toxin into the spinal cord occurs a severe rigor, in extremity, bergari muscles of the chest, stomach cramps and began to arise. When the toxin reaches the cerebral cortex, suffering will begin to experience a spontaneous generalized seizures. Characteristics of the spasm of tetany is caused contraction of the muscle spasms common agonists and antagonists. Toxins or neurotoxins were first attacked the shortest peripheral nerves originating from the cranial nerve system, with initial symptoms of distortion of the face and back as well as the stiffness of the neck muscles.
Tetanospasmin on the autonomic nervous system also verpengaruh, resulting in respiratory distress, metabolic, hemodynamic, hormonal, gastrointestinal tract, urinary tract, and neuromuscular. Spasm of the larynx, hypertension, rhythm disturbances janjung, hiperflexi, hyperhidrosis is a result of neurological disorders ototnom complications, once rare because the patient had died before symptoms arise. With the use of high doses of diazepam and mechanical breathing, seizures can be overcome but the autonomic nervous disorders should be identified and managed carefully.
Tetanospasmin is a toxin that causes spasms, works on several levels of the central nervous system, by the way:
· Toxins blocking the neuromuscular transmission by inhibiting the release of acethyl-choline from nerve terminals in the muscle.
· Characteristics of tetanus spasms occur because the toxins interfere with the function of reflexes in the spinal cord synaptik.
· Seizures in tetanus, probably due to binding of the toxin by cerebral ganglioside.
Some people experience disturbances of autonomic Nervous System (ANS) with symptoms: sweating, hypertension fluctuations, periodisiti takikhardia, cardiac arrhythmias, elevation cathecholamine in the urine.
Incidence of failure of normal inhibitory mechanisms, leading to increased activity of neurons that mensarafi masetter muscle resulting in trismus. Therefore masetter muscle is the muscle most sensitive to the tetanus toxin. Of afferent stimuli not only cause a strong contraction, but also the removal of agonist and antagonist contraction causing muscle spasm is typical.
There are two hypotheses about how the toxin works, namely:
A. The toxin is absorbed onto the end of the motor nerve through the anterior axis kekornu silindrik brought the central nervous system
2. Toxin absorbed by the lymphatic arrangement, entered into the arterial circulation and then into the central nervous system.
Tetanus is the result of rigid paralysis (loss of ability to move) on the voluntary muscles (muscles that movement can be controlled), commonly called lockjaw because it usually first appears in jaw and facial muscles. Death is usually caused by respiratory failure and mortality ratio is extremely high.
Signs - the signs and symptoms - symptoms of clinical
The first symptom is usually pain in the wound, followed by trismus (lockjaw, difficulty opening the mouth wide - width), rhisus sardonicus (devil face). Then followed buduk stiff, rigid abdominal muscles, typical gait like a robot, difficult swallowing, and laringospasme. On a more serious situation occurs epistothonus (tarsal cephalic position), at which time the patient's seizures and when bent and stretched only to the Tarsa feet are touching the base of the lie.
Can occur and muscle spasm of the diaphragm - other respiratory muscles. At the time of seizure the patient remained conscious. Normal body temperature until subfebris. Her whole body was sweating.
Picture: muscle spasm caused by the entry of the toxin from the bacteria Clostridium tetani
Disease Characteristics
Seizures - seizures increased burr during the first three days, persist for 5-7 days. After 10 days, the frequency of seizures began to decrease, seizures disappeared after 2 weeks. Stiff muscles and lost most rapidly from the 4th week.
Tetanus Stadium
Based on the clinical symptoms of tetanus are divided into clinical stage clinical stage and clinical stage in children in adults.
Clinical stage in children. Consists of:
Stage 1, with clinical symptoms of trisnus (3 cm) has been no seizure stimuli, and there is no spontaneous seizures.
Stage 2, with clinical symptoms of trismus (3 cm), seizure stimuli, and there is no spontaneous seizures.
Stage 3, with clinical symptoms of trismus (1 cm), excitatory seizures and spontaneous seizures.
Clinical staging in adults . Consists of:
Stage 1: trisnus
Stage 2: opisthotonus
Stage 3: Seizure of excitatory
Stage 4: spontaneous seizures
Principles - General principles of prophylaxis
Consideration of individual patients. In each patient the wound must be determined whether it is necessary prophylactic measures against tetanus by considering the circumstances / types of injuries, and immunization history.
Debridement . Regardless of immunization status. Excision of necrotic tissue and foreign bodies should be done for all types of injuries.
Active immunization. Tetanus toxoid (TFT = VST = adsorbed tetanus) administered at a dose of 0.5 cc IM, given 1 x month for 3 consecutive months - also.
DPT ( Tetanus Pertussis Dephteri ), especially in children. Administered at age 2-6 months with a dose of 0.5 cc IM, 1 x month for 3 consecutive months - also. Booster given at age 12 months, 1 x 0.5 cc IM, and between the ages of 5-6 years and 1 x 0.5 cc IM.
Tetanus toxoid . Primary immunization with 0.5 cc IM doses, given 1 x month for 3 consecutive months - also. Booster (amplifier) is given 10 years later after the third injection of basic immunization, and then every 10 years after the booster pmberian above.
Every patient should receive tetanus toxoid wound IM at the time of injury, either as primary immunization or as a booster, unless the patient has received complete primary immunization or booster within 5 years, the last.
Passive immunization . ATS ( Anti Tetanus Serum ), can be an antitoxin bovine (bovine origin) and the antitoxin equine (horse origin). Given dose for adults is 1500 IU per IM, and for children is 750 IU per IM.
Human Tetanus Immunoglobuline (human origin) , known commercially as Hypertet. Given dose for adults is 250 IU per IM (equivalent to 1500 IU ATS), is for children - children is 125 IU per IM. Hypertet given when the patient is allergic to ATS that is derived from animals.
Passive immunization depends on the nature of the injury, condition of the patient, and immunization status.
Patients who had never received active or passive immunization, is required to be immunized.Immunized by IM, do not - once the IV.
Hypertet disadvantage is its price, while the benefits of administration without first testing the sensitivity.
Prophylactic measures
Wound Types | Not to IA or in part | IA gets a complete | ||
1-5 years | 5-10 years | > 10 years | ||
Lightweight, clean | Begin or complete the IA Toks. 0.5 cc to complete | - | Toks. 0.5 cc | Toks. 0.5 cc |
Weight, clean, or tend to tetanus | ATS 1500 IU Toks. 0.5 cc | Toks. 0.5 cc | Toks. 0.5 cc | ATS 1500 IU Toks. 0.5 cc |
Tend to tetanus, debrimen late, or not clean m | ATS 1500 IU Toks. 0.5 cc ABT complete until | Toks. 0.5 cc | Toks. 0.5 cc ABT | ATS 1500 IU Toks. 0.5 cc ABT |
Description:
ATS 1500 IU is equivalent to HTIG ( Humane Immunoglobuline Tetanus ) 250 IU.
In children - children adult doses doses of ATS =
IA = Active immunization (a toxoid)
Toks = toxoid (adsorbed tetanus)
ABT = high-dose antibiotics are appropriate for Clostridium tetani
Management of tetanus
Consisting of:
A. Provision of tetanus antitoxin
2. Wound management
3. Antibiotics
4. Seizure Response
5. Supporting care
6. Prevention of complications
Provision of tetanus antitoxin . Provision of serum in the therapeutic dose for an adult is the ATS of 10000-20000 IU IM and for children - children of 10,000 IU IM, for h y pertet for adults ad a is of 300 IU - 6000 IU IM and for children - children of 3000 IU IM. Provision of therapeutic doses of antitoxin for 2-5 days at a stretch - participated.
Wound management . Excision and debridement of the wound the suspect must be done 1 hour after treatment sera (tetanus antitoxin administration). If possible wash with perhydrol. The wound was left open to prevent anaerobic condition. If you need help around the wound can be injected ATS.
Antibiotics . Penicillin is the drug choice, dose given to adults is $ 1.2 million IU / IM 8 hours, for 5 days, while for the child - the child is at 50,000 IU / kg bw / day, continued for 3 days free heat.
If the patient is allergic to penicillin, tetracycline can be given. Doses of tetracycline in adults is 4 x 500 mg / day in 4 divided doses.
Treatment with antibiotics aimed at the vegetative form of Clostridium tetani, so as a radical treatment, which is to kill the tetanus bacteria are still present in the body, so there is no longer the source of exotoxin.
ATS or HTIG intended to prevent exotoxin bind to the central nervous system (exotoxin that binds to the central nervous system will lead to seizures, and once attached to the ATS / HTIG can not neutralize it. To prevent the formation of a new exotoxin then the source is bacteria clostridium tetani must be disabled, with antibiotics.
Handling of seizures. the past to isolate the sound and light can cause a seizure. Currently the principle of isolation has been abandoned, because the provision of adequate anti-convulsive seizures can be prevented then.
Drug Types | Dose Children - children | Adult dose |
Phenobarbital (Luminal) | First - first 60-100 mg IM, then 6 x 30 mg by mouth. Maximum 200 mg / day | 3 x 100 mg IM |
Chlorpromazine (Largactil) | 4-6 mg / kg bw / day, first - first IM, then per oral | 3 x 25 mg IM |
Diazepam (Valium) | First - first 0.5 to 1 mg / kg IM, then per oral 1.5 to 4 mg / kg bw / day, divided in 6 doses | 3 x 10 mg IM |
Klorhidrat | - | 3 x 500-100 mg per rectal |
When the seizure has not been resolved, can be used muscle relaxants ( muscle relaxant ) plus the respirator (ventilator). This method is only performed in a special care (ICU = intesive care unit ) and under the supervision of an anesthesiologist.
Maintenance support. That is, with bed rest, diet per sonde, with intake of 200 calories / day for adults, and at 100 calories / kg bw / day for children - children, regularly clean the airway, provide intravenous fluids and oxygen, watch signs carefully - vital signs (such as consciousness, general condition, blood pressure, pulse, respiratory rate ), trisnus (measured by inches each day), intake / output (income and expenditure of fluid), temperature, electrolyte (if facilities allow inspection ), consult the other parts if necessary.
Prevention of complications. Preventing brain anoxia (1) provision of anticonvulsants, and prevent laringospasme, (2) an adequate airway, if necessary to do intubation (endotracheal tube installation) or do trakheotomi plan, (3) administration of oxygen.
Prevent pneumonia by clearing the airway of order, setting the position of the person is lying, of antibiotics. Prevent fracture of the vertebrae with the provision of an adequate seizure.
Complication
Complications that may arise include: pneumonia, mainly due to aspiration: asfiksi , especially during the seizure, status konvulsivus, vertebral fractures, due to seizures.
Some considerations
Treatment with ATS has so far not clear result, because there are experts who use it and some do not use it. When used, the objection is about the price, but if digunakanpun not dangerous except in patients who are hypersensitive. ATS protection capabilities are only lasts for 2-3 weeks.
Sinsitivitas test against ATS
Conducted to determine whether a patient is resistant to ATS animal or not. To perform these tests there are two ways to skin tests ( skin test and the test eye / eye test ).
Skin test . Frequent (preferably from the eye test). The way is 0.1 cc serum diluted with distilled water or liquid NaC1 0.9% to 1 cc. Inject 0.1 cc of the diluted solution on the forearm before the next voler intrakutan, wait for 15 minutes. Positive reaction (patients hypersensitive to serum) in the event of infiltrates / induration with a diameter greater than 10 mm (1 cm), which can be accompanied by a burning sensation and itching.
Eye tests . The trick is to shed one drop of serum fluid in the eye, wait 15 minutes. Positive reaction when the eyes red and swollen.
Patients who are hypersensitive to ATS Animals. In these patients there are three possibilities, namely: (1) granting hypertet (HTIG), (2) the provision of ATS animals desensitization (how Bedreska), (3) ATS is not given.
Desensitization to Bedreskad
Is the provision of ATS in patients who are hypersensitive to direct injection, but can not be HTIG for something. In this case consideration must provide ATS with the possibility of tetanus in the wound.At this Bedreska way, surveillance done gradually. If severe reactions occur, administration should not be forwarded.
Method of administration as follows:
A. Serum + 0.1 cc 0.9 cc distilled water or 0.9% NaC1 injected subkutanm wait for 30 minutes.
2. Thereafter, injections of 0.5 cc serum + 0.5 cc serum +0.5 cc of distilled water or 0.9% NaC1 subcutaneously, wait 30 minutes. Consider the reaction. If there is a hint - a sign of people with hypersensitive (anaphylactic profromalsyok sign), stop giving, and give antihistamines and corticosteroids. Ambulatory patients according to the circumstances.
3. If there is no reaction after 30 minutes of rest means the serum can be injected intramuscularly.
This desensitization lasted for 2-3 weeks, so when the next day or the day - the next day (in the 2-3 week period) repeat injection needs to be done, then no need diiulangi Bersredka way. On the way Besredka, the drug should P3K yag equipment needed to cope with anaphylactic shock remains available.
A. Provide active immunity to everyone
The meaning of all the people here ranging from infants to the elderly, decades old, even before the baby had to be given immunity lahirpun through a pregnant mother.
Anyway, all residents must already have immunity to tetanus. You do this by injecting tetanus toxoid (purified) = tetanus = tetanus vaccin absorb as much as 0.5 cc toxoidum punficatum intra muscular.
For basic immunization 3 times in a row - helped by the interval between the first injection with a second 4-6 weeks, the second with the third six months. Basic immunization should begin when the child was about 4 months old can be given along with diphtheria vaccine, pertussis vaccine in DTP or DT, or given a separate - separate. If someone has never got the basic immunization can be done at any time during his life, with the same doses and intervals as above. Someone who has got the complete basic immunization (three injections) then within 10 years after the last injection, the content of tetanus antitoxin in blood serum were above the minimal protection (= minimum protective level) is 0.01 lines iu / ml, so person is considered to be already protected against tetanus.
After the first injection of the body to stimuli arising form the tetanus antitoxin. He was present in the serum 7 days after the first injection, then titernya interesting and at day-28. If on day 28 were given a second injection, titernya will continue rising and will reach 1.0 iu on day 60 which is far above the minimal protection even then there is a decrease, an estimated titer will remain above the minimum protection for 5 years. When the third shot is given 6 months after the second injection, titernya much higher, even then there will be a decrease, but remain above the minimum of protection to 10 years, even 15-20 years obtained in 85-95% of personnel of World War II.
Yet for protection against the disease need to be a booster shot every 5 years at least 10 years or any person where the injury is expected titer tetanus antitoxin in serum has begun to decline although still above the minimal protection, especially for wounds called "tetanus Prona wound". The provision would raise the booster antitoxin titers than doubled in number. (See Figure 2)
There is a term protection against tetanus Persia, that is:
a. People - people who have received tetanus vaccine injections 3 times, but the last shot was more than 10 years.
b. People - people who have received tetanus vaccine 2 times and the time has more than 5 years.
c. People - people who received an injection of only one time only.
It should be pointed out that tetanus toxin (mummified) will not cause a hypersensitivity reaction to the injected, because it can be given repeatedly, it is very rare allergic reactions, even if there is only mild reactions.
To all doctors and health workers are responsible for providing tetanus vaccinations to members of the public under one of its members suffering from tetanus the first - first one in this case is the company doctor, why he neglected to provide active immunity against the members of which it is responsible.
B. Doing tetanus prophylaxis against people who are true and correct wound
There are four factors to consider:
A. Tetanus vaccine
2. Surgical wound care right
3. Provision of tetanus antitoxin
4. Of antibiotics and identification of emergency medical records
A. Tetanus vaccine
This provision is intended as a booster to the injured patients who had received previous tetanus vaccination, the goal to raise the titer of antitoxin and will provide effective protection in the long term.
Tetanus vaccine at the time of injury to patients who have not been vaccinated against tetanus, can not guarantee protection against tetanus, because to get the antitoxin in the serum arrived at the line minimal protection takes 2-3 weeks, while the incubation period of tetanus there is a faster . In this case required the provision of antitoxin (passive immunization) in conjunction with the provision of tetanus toksodi earlier.
2. Surgical wound care secaa correct
Surgical prevention aims to dispose of clostridium tetani contact with the wound, removing more tissue that is vital to prevent anaerobic atmosphere, and as good as possible a reconstruction of injuries resulting in aerobic atmosphere. To achieve that purpose is required:
A. Wounds treated as soon as possible
2. Aseptic technique using sterile gloves, wash the skin around the wound with enough fluids before surgery.
3. Closed the wound with sterile gauze was time to wash the wound.
4. The light should be sufficient to accurately identify the vital tissues such as nerves and blood vessels.
5. The instrument must be complete, assistant to the withdrawal of enough tissue to be smooth to prevent damage to the larger network.
6. Bleeding is controlled with the right tools and threads that are small enough so that a minimum stay of necrotic tissue in the wound.
7. Network is required to be smooth in order to increase the network of necrotic tissue in the wound.
8. Provided complete with his knife to smooth the ragged edge of the wound - camping, lifting the network that have been doubtful vitality, lift foreign body until nothing is left behind.
3. Provision of tetanus antitoxin
Tetanus antitoxin basically there are 2
a. Heterologous antitoxin
b. Tetanus immune globulin (human)
Heterologous antitoxin (ATS) derived from horse serum that had been previously vaccinated. So the horse protein (foreign protein) and the second and so giving rise to severe sensitivity reactions to anaphylactic shock can occur. Therefore need to be tested prior to first.
Tetanus immune globulin (human)
Taken from human serum. In a variety of trade - kind of like the name of Hu-Tet, Hyper-Tet, Homo-Tet, and so on. This type rarely cause reactions hipersensitivity, if there is a light antitoxin should be administered with a clear indication.
Giving an indication of tetanus antitoxin is:
A. Dirty wounds or a wound proma tetanus occur in people who have never received active immunization, or the man with tetanus protection Persia.
2. Treatment of patients with tetanus.
Doses of tetanus immuno-globulin (human) for prophylaxis are:
- Adults: 250 u - 500 u
- Children over 10 years: 250 u
- Children 5-10 years: 125 u
- Children in bawh \ ag 5 years: 75 u
Tetanus immuno-globulin (human) is to survive in the blood for 1 month. For the treatment of tetanus patients given doses of 3000 - 6000 units intra muscular gluteus muscle, partly diinfitrasikan around the wound.
Horse serum antitoxin (ATS) is given when there is no human antitoxin, the dose for the prophylaxis of 1500-3000 units for adults, children - children according to age. ATS persist in the blood 7-14 days.For the treatment of patients with tetanus dose ATS is 20000-40000 units. Antitoxin for prophylaxis administered simultaneously with tetanus vaccine, but with different syringes and needles, as well as injection site should be different, use the network to occur agglutination between the two.
Graph antitoxin titer in serum only after the issuance of toxoid, antitoxin alone, antitoxin and toxoid simultaneously.
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4. Of antibiotics and identification of emergency medical records
Patients with wounds should be asked and recorded:
A. Patients had ever received active immunization against tetanus?
2. If it had when found?
3. Is there a reaction to the tetanus toxoid it?
4. Should that person be given antitoxin?
5. Penicillin or tetracycline antibiotics for 5 days.
INDICATIONS immunization
VACCINATION DATA | CLEAN CUTS | GROSS INJURY | ||
Tetanus toxoid | Tetanus antitoxin | Tetanus toxoid | Tetanus Atoksin | |
Never been vaccinated or not known | Yes | Not | Yes | Yes |
One-time vaccination against tetanus | Yes | Not | Yes | Yes |
Twice a tetanus vaccination | Yes | Not | Yes | Yes |
Three times a tetanus vaccination | No / Yes | Not | No / Yes | No / Yes |
C. Treat people with tetanus with a multidisciplinary intensive care. After D / disease classification is determined whether enforced mild, moderate or severe. This classification as the basis for determining the grip and handling clinic as respiratory and cardiovascular complications of this disease. Tetanus treated conservatively mild, moderate and severe tetanus in the handle with endotracheal intubation and / or trekhostomi during administration of positive pressure ventilation.Immediately after the diagnosis is established the patient was taken to the room where the intensive skilled personnel have been dealing with respiratory problems and cardiac resuscitation.Given the drug - drug to prevent seizures, given tetanus antitoxin, preferably tetano globutin immune (human), when forced to be given a new ATS.
Wound debridement performed 1-2 hours after administration of antitoxin, to prevent the increased many neurotoxins tetanospasmin loose and bound to the central nervous system.Keep in mind that tetanospasmin neurotoxin that has been bound to the central nervous system can no longer be neutralized.
Antibiotics, keep breathing, cardiovascular treatment, care, smooth pasage intestinal metabolism and food handling. Some books still claim patient care in a dark room. Halnitu actually does more harm than benefit, how the correct treatment can be carried out in a dark room in the man must install equipment and close supervision.
Does the patient need to be treated in isolation rooms? Unnecessary because the spores are no where - where around us, not hurt the patient's tetanus. Obviously the patient must be multidisciplinary handlers.
· Giving antibiotics . Drug choice is penicillin, the dose given to adults is $ 1.2 million IU / IM 8 hours, for 5 days, sedng for children is at 50,000 IU / KGB / day, continued for 3 days free heat. Previously performed skin tests and in the observation well. If the patient is allergic to penicillin, tetracycline can be given. Doses of tetracycline in adults is 4x500 mg / day, whereas for children is 40 mg / kg / day in 4 divided doses. Likewise Metronidazole 3 x 1 gram IV.
5. Response seizures . First to isolate the sound and light can cause a seizure. Currently the principle of isolation has been abandoned, because the provision of adequate anti-convulsive seizures can be prevented then. Provision of midazolam 2-3 mg / hour. And Diazepam 0.2 to 0.5 mg / kg administered IV in the event of a seizure.
· Maintenance support . That is, with bed rest; diet per sonde, with the intake of 2000 calories / day for adults, and at 100 calories / kg / day for children; regularly clean the airway; give intravenous fluids and oxygen; watch carefully mark- vital signs.
· Prevention of complications . Prevent anoxia of the brain by administering anti-seizure, and prevent laringospasme, adequate airway, if necessary to do intubation or tracheotomy done planning, administration of oxygen. Prevent pneumonia by clearing the airway of order, setting the position of the person is lying, of antibiotics. Prevent fracture of the vertebrae with the provision of an adequate seizure.
REFERENCES
· Sumiardi Karakata, Bob Bachsinar; Minor Surgery, second edition, J akarta: Hippocrates, 1995
· Ismael Chairul; Prevention and Management of Tetanus in the field of surgery: ubuntu, 2000
· Hendarwanto. Science Medicine , vol 1, FK UI Hall Publishers, New York: 2001 ,
49-51 .
· Mardjono, dowry. Basis of Clinical Neurology . Dian Rakyat, Jakarta: 2004. 322.
· BOOK Teaching of Surgery. De Jong et al. Ed 2, Jakarta, 2004
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