Tetanus

Pankaj Satapathy(1), Kounaina K(2), Huded SP(2), Aishwarya T Devi(3), Avinash MG(4), Shubha Gopal(4), Nagendra Prasad MN(3), Sudarshan S(1), Sunil S More(1), Ravish H(5), Farhan Zameer(1)
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Management
There are two types of treatment for tetanus: Preventive treatment - For people who are assumed to be completely or partially vaccinated against tetanus and who have an injury that makes them susceptible to a tetanus infection. Medication called tetanus immunoglobulin (TIG) is recommended if have a tetanus-prone wound and there is a high risk that it could be contaminated by tetanus bacteria [2]. Symptomatic treatment - For people who have shown the symptoms of an active tetanus infection. Three main types of medication are used to overcome the symptoms of tetanus: (1). Sedatives, (2). Muscle Relaxants and (3). Neuromuscular blocking agents.

Latest observations:
For vaccine application aldehyde (formaldehyde) detoxification is used to covert toxin into toxoid. It was observed that when formaldehyde was induced in tetanus toxin then out of the 1315 amino acids 41 were modified, of which 5 repeated modifications were observed in lysine residue of tetanus toxoid [19]. This finding could be a milestone in identification of specific amino acid responsible for the toxicity and target specific approaches. Adequate sedation is one of the possible treatments to prevent the severity of tetanus toxins [20]. In recent years, the studies underlining the mechanism of neuroaxial blocks in controlling sympathetic over activity is been elucidated. Since the major cause of death is circulatory collapse, yet the mechanism of action is unclear and it is predicted that, this might be because of altered myocardial functions affects the catecolamine levels.

Tetanus can be prevented by vaccinating with tetanus toxoid (Table-1). There are four combination vaccines used to prevent tetanus: DTaP (diphtheria, tetanus, and pertussis) and Tdap (tetanus, diphtheria, and pertussis) or Dt and Td. Two of these (DTaP and DT) are vaccinated to children younger than 7 years of age and two (Tdap and Td) are vaccinated to older children and adults. As recommended by CDC for every ten years adults should receive a booster vaccine. Some the most common myths are made clear in table-3. Further this could be prevented as suggested in Figure 3.

Figure 3: Patient education and awareness
Patient Awareness


Table.2. Generic trade names of available vaccine/drugs for tetanus infection.
Description Type Prescribed for
DPT Active immunization Vaccine Diphtheria, tetanus and pertussis (whooping cough)
Haemophilus B Conjugate Active immunization Vaccine for infants and children Haemophilus influenza type B, diphtheria, tetanus, and pertussis infections.
Pediarix Vaccine Immunization agent Diphtheria, tetanus, pertussis, hepatitis B and polio infections in infants and children.
Tdap Immunization agent Tetanus, diphtheria, and pertussis as a single dose in persons 11 to 64 years.
Tetanus Toxoid Immunization Tetanus


Ayurvedic perspectives on treatment of tetanus (based on probable correlation to Dhanustmbha):
In Ayurveda the similar kind of signs and symptoms to tetanus are explained in the different context according to different authors and are specifically compared with different Vata vyadhis explained in Ayurveda, like Dhanurvata, Dhanustmbha, Antarayama (abhyantarayama), Bahirayama etc. Dhanustambha was first described by Acharya Sushruta in the context of vata vyadhi. While Acharya Charaka described it in two terminologies namely Antarayama and Bahirayama. According to Acharya vagbhata, it is explained in the context of Bahyayama (dhanushkamba, vegi). The disease is comparable to tetanus of modern medicine.

Disease description:
Dhanustambha: It is caused when the vitiated vata affects the network of snayu (tendons/ligaments) making the body bent like a bow and hence the name. It is of two types namely Abhyantarayama and Bahyayama. Vitiated vata affects the snayu located in the toes, heels, abdomen, chest and throat leads to muscular spasm, fixed gaze, lock jaw, rib fractures, kapha vamana (vomiting) and inward bending of the body is Abhyantarayama (emprosthotonos). Vitiated vata affects the external ligaments by which the body bends outwards like a bow is Bahyayama (opisthotonos) [Ref: su.s.ni 1].

Antarayama: It is the vata dosha which gets aggravated throughout the body and finally lodges in manya pradesha (carotid region) resulting in inward bending of the neck. It is associated with stiffness in manya pradesha and greeva (neck). Further, it is characterized by clenching of teeth, excessive salivation, stiffness from head to lower back and rigidity of face [Ref: c.s.chi.28/43-45]. Greevashritha dhamani are affected [Ref: a.h.ni.15/22-23].

Bahirayama: It is caused due to vata dosha that aggravates in greeva (backside of neck) causing constriction of siras (external vessel) which leads to bending of the jaw backward like a bow, head moves towards back, neck becomes rigid and squeezed, teeth are clenched along with yawning and excessive salivation. There is aphasia and chest is protruded [Ref: c.s.chi.28/45-48]. Excessive sweating, discolouration of teeth and face. It is Bahyayama, Dhanushkamba, vegi [Ref: a.h.ni.15/24-26].

According to Yogarathnakara, two context i.e., namely Dhanurvata and Dhanustambha have been mentioned which is caused because of vitiated vata associated with kapha affecting the Dhamanis (vessels) leading to the stiffness, bending of the body like a bow hence referred as Dhanustambha [yo.r.ni.vata vyadhi nidana pg-507 Vaidhya Shri Lakshmipathi Shastry, Chaukambha Prakashan, Varanasi, 2012]. The other conditions can also be considered based on the signs and symptoms like Dantapatanaka/ Dandaka: this is a condition in which the hands, feet, head, back and hip becomes rigid and body becomes stiff and still, like a rod due to vitiation of vata dosha [ref: c.s.chi28/51]. Abhighataja: could be considered as traumatic. The signs and symptoms similar to Bahirayama are also seen in the shava graha peeditha lakshana. [Ref: a.s.u.3/23]

Complications:
If the condition persists and leads to the fracture of lumbar, spine, thigh; which is untreatable. [Ref: su.s.ni.1/57]. Patient with the following signs like decolouration of face, closed mouth, wasting of muscles, loss of conscious, profuse sweating, will die within 10 days. [yo.r.ni. vatavyadhi nidana]

Treatment: Dhanustambha is said to be asadhya (untreatable) disease as per Ayurveda (c.s.chi-28/su.Ni-1). Based on the signs and symptoms, the treatment protocols are be employed. Snehana (oleation), Swedana (sudation), Basthi (Enema - with medicated oils etc.), Nasya (Nasal drops) and Paana (oral medication). In Bahyayama and Abhyantarayama Sneha karma, sweda karma and Guggulu sevana is advised. [Ref: yo.r.ni. vatavyadhi nidana]
The treatment guidelines of Ardita Roga could be followed [Bharapraksha madhyama Khandha 24/186].

In every disorder, treatment follows a particular step which depends on location, dushya etc. Ghee, oil, fat and marrow are used and ingested, massage, enema, unctuous fomentations, wind-free place, wrappers, meat soups, mild, sweet sour and salty edibles, whatever is bulk promoting is used on the patients of Vatika disorder [ch.s.chi.ch-28]. Oil cooked with equal quantity of the juice taken out of the root and leaves of Nirgundi (Vitex negundo) vatika disorders. Oil cooked in decoction of Karpasa seeds and horse gram also alleviates vata. [ch.s.chi.ch-28]. It is also found that; Nirgundi extract (juice) with honey thrice a day effectively cures tetanus. Chandra shekhara rasa (60-120 mg) mixed mother’s milk or madhu (honey). Lakshmi narayana rasa (30-60 mg) with adraka swarasa or madhu (honey) [Ref: text book of kaumarabhritya pg: 598-599, ayodhya prasad achal, chaukambha surabharathi prakashan 2009].

Thought the bacterium Clostridium tetani is being studied for more than a century but still the mechanism has not been thoroughly understood. The practice of prevention is prevalent rather than treatment which is a cause of concern. Initial studies has been performed on the tetanus toxic protein by identifying the amino acids involved but the toxicity is not clear which is an area to explore and to come up with a solution. If the main amino acid constituents of toxin can be identified then the disease can be treatable at any stage of the infection. In conclusion, more awareness and care has to be taken in order to prevent tetanus. Climatic changes also aid to the bacterial growth and production. The studies has to be widened which can cover the low income countries which don’t have proper mass immunization. Farmers who are always exposed to soil need to have frequent monitoring for the disease. If tetanus is identified early then it is curable so “prevention is better than cure”.


References
Tetanus Tetanus 09/04/2018
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