tetanus

I Made Adhiatma
• Nama : Tn. Y
• Usia : 52 TH
• Jenis kelamin : laki-laki
• Alamat : mapin
• No. RM : 024511

Identitas
• KU : kejang 2 hr smrs
• A : Clear, paten
• B : Spontan, simetris ka-ki, RR 30 x/menit, SpO2 99%,
auskultasi vesikuler ka-ki, perkusi sonor
• C : Nadi 111 x/menit, , crt <2 detik, terpasang IVDF RL
20 tpm
• D : GCS total 15 : E4V5M6, pupil reactive 4/4

Primary Survey
• Pasien ditempatkan di P2
• IVFD rl 20 tpm
• O2 4 lpm nassal canul
• Pasien rujukan dari pkm dengan keluhan kejang,
kekakuan seluruh tubuh, mulut tidak bisa dibuka.
Keluhan mulai dirasakan sejak 2 hari yang lalu. Os
mengaku jatuh di tepi sungai 7 hari yang lalu, os terkena
bebatuan pada kaki kanan dan tangan kanan. Luka
dibersihkan di pkm namun tidak diberikan anti tetanus.
Keluhan mulai bertambah berat hingga mulut susah
digerakkan, perut seperti papan, sulit menelan dan sulit
bicara.
• Riwayat imunisasi tetanus tidak jelas

Anamnesis
• Keadaan umum : Lemas
• Kesadaran : Compos mentis
• GCS : E4V5M6
• Tensi : 130/80 mmHg
• RR : 30 x/menit
• Nadi : 111 x/menit
• Temperatur : 37,4 o C
• SpO2 : 99 %

Pemeriksaan Fisik
Kepala : Normocephal, KA -/-, SI -/-, trismus +
Leher : JVP 5+2, kaku kuduk +
Thoraks paru :
• I : simetris ka/ki
• P : gerak dada ka/ki simetris
• P : sonor seluruh lap.paru
• A : Vesikuler ka/ki, Rh -/-, Wh -/-
Thoraks Jantung :
• I : IC tampak
• P : IC teraba
• A : Reguler, Murmur (-), gallop (-)

Abdomen :
• I : epistotonus
• A : BU (+) normal
• P : tegang, nt -
• P : Timpani seluruh lap.abdomen

Pemeriksaan Ekstremitas :
• Akral hangat, edema tungkai kanan (-)/ kiri (-), sianosis -/- spasme
• Meningeal sign
kaku kuduk +
brudzinski sign I -
brudzinski sign II –
kernig –
• Reflek patologis -
Hematologi
• Leukosit : 7,41 ul (4,10-10,90)
• Eritrosit : 4,55 ul (P 4,6-6 / W 4,5-5)
• Trombosit : 294.000 ul (150-450)
• HB : 13,0 ug/dL (P 14-18 / W 12-16)
• Hematokrit : 39,9% (P 42-52 / W 37-47)

• GDS : 159 (N <160)

• SGOT : 64 U/L
• SGPT : 58 U/L
• Ureum : 45 mg/dl
• Kreatinin : 1,5 mg/dl

Hasil Lab
• Tetanus generalisata
• v,. Appertum cruris

diagnosis
• Ivfd rl 20 tpm
• Debridement luka
• O2 4l nassal canul
• Inf metronidazol 500 mg
• Inj. Diazepam 1 amp
• Drip diazepam 8 amp dlm 500 D5 dalam 24 jam,
mikroset

s. kejang, demam, perut keras
o. Vs: td :130/80, n :120 t:38 rr:
38
Trismus + episiotonus +
a.Tetanus generalisata
V. appertum cruris D
Follow up 8/7/2017
• Ngt, diet cair 8 x 250cc
• O2 masker 6 lpm
• Inj. Ceftriaxone 2x1gr
• Drip metronidazole 3x500
• Ivfd rl : D5 = 1: 1 dalam 24
jam
• Ivfd diazepam 8 amp daam d5
500/24 jam (mikro)
• Tetagam 1x1
• Inj. Omeprazole 2x1
• Rawat luka
• Monitor cairan.
S . Pasien kejang spontan, berulang kali selam 5-10 menit.
Sesak +
O . Td
Advice ; drip diazepam 2 amp dalam d5
Jika kembali kejang bolus diazepam extra.

8/7/2017 pkl 10.00

• Tetanus is a serious and a life-threatening infectious disease
with a grave outcome if not detected and treated at an early
stage. An infection found more frequently in Tropical climates;
it accounted for 58,900 deaths worldwide in 2013 (1).

Introduction
• Clostridium tetani is an anaerobic gram-positive bacillus.
Tetanus occurs when a wound is contaminated with C.
tetani spores, the anaerobic environment of the wound
allows the spores to germinate and produce a toxin,
tetanospasmin, which is transported to the central nervous
system (2).
 Tetanus spores are found throughout the environment,
usually in soil, dust, and animal waste.

 Tetanus is acquired through contact with the environment;

it is not transmitted from person to person.

Causes
 The usual locations for the bacteria to enter the body:

 Puncture wounds (such as those

caused by rusty nails, splinters,
or insect bites.)

 Burns, any break in the skin, and IV

drug access sites are also potential
entryways for the bacteria.

Causes
• Varies from 1 day to several months. It is defined as the
time from injury to the first symptom.

Incubation Period
pathogenesis
1. C. tetani enters body 2. Stays in sporulated
form until anaerobic
from through wound.
conditions are presented.

3. Germinates under 4. Tetnospasmin spreads using

anaerobic conditions and blood and lymphatic system,
begins to multiply and and binds to motor neurons.
produce tetnospasmin.

6. Binds to sites responsible for

5. Travels along the axons
inhibiting skeletal muscle
to the spinal cord. contraction.
 Clinical presentation

Cook TM. Protberoc RT. Handel JM. Tetanus; a review of the

literature. BrJ Anaesth 2001;87:477-87.
•

Classification of severity
• <9 ringan
• 9-18 sedang
• >18 berat
• 0-1 mortalitas
ringan 10%
• 2-3 mortalitas
sedang 20-30%
• 4 mortalitas berat
40%
• 5-6 mortalitas
sangat berat >50%
• strychnine poisoning
• dystonic reactions to neuroleptic drugs >>> Neuroleptic
malignant syndrome
• stiff man syndrome,
• seizures and meningitis

Differential diagnostic (4)

Management
• Muscle spasms should be treated with intravenous
benzodiazepines
• metronidazole is generally the drug of choice based on a
nonrandomized trial that showed lower mortality rates
compared with penicillin (5)
• The unbound toxin in the body must then be neutralized
with human TIG at a dose of 3000 to 6000 U
intramuscularly
• Current recommendations are that Canadians receive
primary tetanus immunization in childhood, followed by
boosters every 10 years. (1)

Prevention
1. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional,
and national age-sex specific all-cause and cause-specific mortality for
240 causes of death, 1990-2013: A systematic analysis for the Global
Burden of Disease Study 2013. Lancet 2015;385(9963):117-171.
2. Farrar,J.J .,Yen,L.M., Cook,T., Fairweather,N., Binh,N.,
Parry,J.&Parry,C.M. (2000).Tetanus. Journal of Neurology, Neurosurgery
and Psychiatry , inVietnam[L.M.Yen,L.M.Daoand 69, 292–301.
3. Cook TM. Protberoc RT. Handel JM. Tetanus; a review of the literature.
BrJ Anaesth 2001;87:477-87.
4. Jocelyn A. Srigley MD, Shariq Haider MD, Jennie Johnstone MD. A lethal
case of generalized tetanus. CMAJ 2011. DOI:10.1503
5. Ahmad.syab I. Salim A. Treatment of tetanus; an open study to compare
tbe efficacy of procaine penicillin and metronidazole. Br Med.I (Clin Res
Ed) 1985;29[ ;648-50.

references