Case Report

Seorang Laki-laki 64 Tahun dengan abdominal

pain suspek Tetanus
Oleh:
Dr Rico Pratama
IDENTITAS PASIEN
Nama : Tn. MM
Usia : 64 tahun
Tanggal masuk : 7 Maret 2019
Masuk IGD : 20.35
Masuk Bangsal : 24.00
ANAMNESIS
• Pasien dari IGD dengan keterangan GMO + Obs. Febris Hari ke-
3. Pasien mengeluhkan nyeri seluruh lapang perut (+), disertai
demam 3 hari sebelum MRS, demam naik turun, mual (+), muntah
(-), pasien malas berbicara dan melantur sejak 3 hari yang lalu.
Riwayat melantur sebelumnya disangkal. Pasien kejang jika
disentuh. Riwayat luka di ibu jari kaki kiri kena cangkul namun
sudah 3 bulan yang lalu. Riwayat kebiasaan memakai tusuk gigi
yang tidak bersih.
• mendapat infus RL 18 tpm dan terapi injeksi ondansentron 3 x 4
mg, injeksi santagesik 3 x 1 ampul, injeksi ranitidine 2 x 50 mg.

RPS
 RPD
Riwayat Trauma kepala :-
Riwayat luka :
• luka di ibu jari kaki kena cangkul 3 bulan yang lalu
Riwayat DM :-
Riwayat HT :-
Riwayat Jantung :-
Riwayat kejang :-
Riwayat pemakaian alkohol :-
Riwayat pemakaian obat-obatan :-

Riwayat kebiasaan : menggunakan lidi untuk tusuk gigi yang tidak bersih
PEMERIKSAAN FISIK
Tanggal pemeriksaan: 9 Maret 2019 pk 11.00
Saat pemeriksaan pasien kejang 2x tonik-klonik + 4 menit terutama muncul saat
disentuh, suara berisik, atau ada cahaya
KU : buruk
GCS : E4V2M5
Vital sign :
TD : 130/80 mmHg
HR : 87 x/menit
RR : 20 x/menit
T : 36,5°C
SpO2 : 99%
• Kepala: A/I/C/D = -/-/-/- , Trismus (+), Risus Sardonicus (+)
• Thorax: simetris, retraksi (-)
• Cor: S1S2 tunggal, M(-), G(-)
• Pulmo: ves/ves, Rh (-/-), Wh (-/-)
• Abdomen:
• I: distended
• A: BU (+) N
• P: timpani
• P: teraba keras, opistotonus (+) maksimal
• Ekstremitas: Akral hangat

Status Interna
Fungsi Motorik: sulit dievalusi
Fungsi Sensorik: sulit dievalusi

Refleks Fisiologis:
Refleks bisep : +4
Refleks trisep : +4
Refleks patella : +4
Refleks Achilles : +4

Refleks Patologis: -

Status Neurologis
Rangsang Meningeal
Kaku kuduk :-
Brudzinski I :-
Brudzinski II :-
Kernig :-

Fungsi N. Cranialis :
NII dan NIII : Pupil Bulat isokor 3mm/3mm, Refleks cahaya +/+
(7 Maret 2019)
DL Kimia Darah:
• Hb: 13,7 g/dL • SGPT: 25 U/L
• Leukosit: 6.500 /ul • SGOT: 38 U/L
• Neutrofil: 74% • GDA: 161 mg/dL
• Limfosit: 14,9% • Creat: 2,02 mg/dL
• Plt: 113.000/ul • Na: 133 mmol/L

Pemeriksaan Penunjang
DIAGNOSIS
Abdominal pain ec Tetanus dd
Peritonitis generalisata
TATALAKSANA
• KIE keluarga: perawatan lama dan kondisi pasien labil serta disarankan untuk dirujuk
ke RSUD, karena tidak ada ruang isolasi khusus Tetanus, namun Ruang isolasi RSUD
juga penuh
• Rawat ruang gelap dan tenang
• Inf. PZ 500 cc/24 jam
• Inj. HTIG 3000 IU IM
• Setiap kejang  Inj. Diazepam 1 Amp dalam 10 cc PZ bolus pelan
• Maintenance  Drip Diazepam 0,5 cc/jam dengan Syringe pump
• Inj. Ceftriaxone 2x1 g
• Inj. Santagesik 3x1 amp
• Inj. Ranitidine 2x 50 mg
• Inj. Ondansentron 3x4 mg
• Inj. Pantoprazol 1x 40 mg
FOLLOW UP
 11 Maret 2019 (13.40)
11 Maret 2019 (10.30)
S: sesak (+), penurunan kesadaran (+)
S: kejang parsial tangan O: GCS 111
10 Maret 2019  O: HR 113x/m, RR 28x/m TD 130/90, N 120x/m, RR 40x/m, SpO2 97% dgn
kejang (-), demam A: Tetanus NRBM 10 lpm
(-) C/P dbn
P: O2 simple mask  SpO2 98%
A: Tetanus
Maintenance Drip Diazepam 0,5
cc/jam P: KIE obs ICU  keluarga menolak
Terapi lanjut

11 Maret 2019 (15.45)

S: Kejang seluruh tubuh (+) 4x, demam (+)
11 Maret O: GCS 111
2019 (23.35) 11 Maret
2019 (23.25) TD 170/94, S 38,9; N 125x/m; RR 52x/m, SpO2 98% dgn NRBM 10 lpm
Pasien  Cardiac C/P dbn, Abd dbn, Akral hangat
dinyatakan Arrest  RJP
meninggal A: Tetanus
P: Inj. Diazepam 1 amp dlm 10 cc PZ
Inj Santagesik 3x1 k/p
TINJAUAN PUSTAKA
 Tetanus is a nervous system disorder characterized
by muscle spasms that is caused by the
toxin-producing anaerobe Clostridium tetani, which
is found in the soil.

 Greek words -“tetanos and teinein”, meaning rigid

and stretched, which describe the condition of the
muscles affected by the toxin, tetanospasmin,
produced by Clostridium tetani

What is Tetanus?
Sporulated Vegetative
 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.

Etiology
  Absence of antibodies (ie, inadequate vaccination) plus two
or more of the following:
● A penetrating injury  the inoculation of C. tetani spores
● Coinfection with other bacteria
● Devitalized tissue
● A foreign body
● Localized ischemia

Predisposing factors
• tetanus-prone injuries include splinters and • Postsurgical patients (with necrotic
other puncture wounds, gunshot infections involving bowel flora)
wounds • Adolescents and adults undergoing male
• compound fractures, circumcision in sub-Saharan Africa
• burns, • Patients with dental infections
• Animal bites/human bites • Diabetic patients with infected extremity
• Abscess ulcers
• Parenteral drug abuse
• Neonates (due to infection of the umbilical
stump)
• Obstetric patients (after septic abortions)

Route of Entry
• Without an identifiable cause — Presumably, minor unnoticed abrasions or
skin injuries are
responsible ("cryptogenic" cases)
• Tetanus has occurred rarely in patients who have
received a timely and correct series of tetanus immunizations

Route of Entry
 epidemiology
• Tetanus is an international health problem, as spores are ubiquitous. The
disease occurs almost exclusively in persons who are unvaccinated or
inadequately immunized.
• Tetanus is more common in hot, damp climates with soil rich in organic
matter.
• More common in developing and under developing countries.
• More prevalent in industrial establishment, where agricultures workers are
employed.
pathogenesis
 1. C. tetani enters body from 2. Stays in sporulated form until
through wound. anaerobic conditions are presented.

4. Tetnospasmin spreads using blood and

3. Germinates under anaerobic conditions
lymphatic system, and binds to motor
and begins to multiply and produce neurons.
tetnospasmin.

5. Travels along the axons to the spinal 6. Binds to sites responsible for inhibiting
cord. skeletal muscle contraction.
 Generalized Local

Cephalic Neonatal

Clinical features
• The incubation period of tetanus is approximately 8 days but ranges from 3 to
21 days.

• The incubation period is typically shorter in neonatal tetanus than in non-

neonatal tetanus.

• Inoculation of spores in body locations distant from the central nervous

system (eg, the hands or feet) results in a
longer incubation period than inoculation close to the central nervous system
(eg, the head or neck).

Incubation Period
• The most common and severe clinical form.
• The presenting symptom in more than half of such patients is trismus (lockjaw)
• Autonomic overactivity:
• in the early phases  irritability, restlessness, sweating, and tachycardia.
• In later phases  profuse sweating, cardiac arrhythmias, labile hypertension or
hypotension, and fever are often present.
• Reflex spasms of their masseter muscles (the spatula test).
• Tonic contraction of their skeletal muscles and intermittent intense muscular spasms.
• no impairment of consciousness or awareness  intensely painful.
• triggered by loud noises or other sensory stimuli such as physical contact or light.

Generalized Tetanus
• ● Stiff neck
● Opisthotonus
● Risus sardonicus (sardonic smile)
● A board-like rigid abdomen
● Periods of apnea and/or upper airway obstruction due to vise-like
contraction of the thoracic muscles and/or
glottal or pharyngeal muscle contraction, respectively
● Dysphagia

Classic clinical findings of tetanus

• tonic and spastic muscle contractions in one extremity or body
region.
• often evolves into generalized tetanus.
• Diagnosis in local tetanus can be difficult.
• For example, rarely patients with early tetanus may develop board-like
abdominal rigidity that mimics an
acute surgical abdomen.

Local tetanus
• injuries to the head or neck, involving initially only cranial nerves.
• often subsequently develop generalized tetanus.
• dysphagia, trismus, and focal cranial neuropathies  misdiagnosis of stroke.
• The facial nerve is most commonly in cephalic
tetanus, but involvement of cranial nerves VI, III, IV, and XII may also occur

Cephalic tetanus
• result of the failure to use aseptic techniques in managing the umbilical stump in
offspring of mothers who are poorly immunized.
• The application of unconventional substances to the umbilical stump
• Unclean hands and instruments or other nonsterile materials in the delivery field.
• refusal to feed and difficulty opening the mouth due to trismus
• Sucking then stops
• risus sardonicus (sardonic smile).
• The hands are often clenched, the feet become dorsiflexed, and muscle tone
increases.
• opisthotonus (spasm of spinal extensors)

Neonatal Tetanus
 Diagnosis is done clinically.
 be suspected when there is a history of an antecedent
tetanus-prone injury and a history of inadequate immunization for tetanus

Diagnosis
• A wound sustained more than 6 hr before surgical treatment.
• A wound sustained at any interval after injury which is puncture type or shows
much devitalised tissue or is septic or is contaminated with soil or manure.

Tetanus prone wound

 Drug-induced dystonias such as those due to phenothiazines
 Trismus due to dental infection
 Strychnine poisoning due to ingestion of rat poison
 Malignant neuroleptic syndrome
 Stiff-person syndrome

Differential Diagnosis
Best performed in the ICU in consultation with an anesthesiologist or critical
care specialist

● Halting the toxin production

● Neutralization of the unbound toxin
● Airway management
● Control of muscle spasms
● Management of dysautonomia
● General supportive management

Principle of Treatment
• Wound management
• Antimicrobial therapy
•

Halting the toxin production

• Active immunization

Neutralization of unbound toxin

• Benzodiazepines and other sedatives
• Neuromuscular blocking agents

Control of muscle spasms

• Magnesium sulfate
• Beta blockade
• Other drugs — Other drugs for the treatment of various autonomic events,
which have been reported to be
useful, are atropine, clonidine, and epidural bupivacaine.

Management of autonomic
dysfunction
• Endotracheal intubation is justified initially, but early tracheostomy is
frequently indicated
• early nutritional support
• Prophylactic treatment with sucralfate or acid blockers may be used to prevent
gastroesophageal hemorrhage from stress ulceration.
• Prophylaxis of thromboembolism
• Physical therapy

Airway management and other

supportive measures
 Tetanus is completely preventable by active
tetanus immunization.

 Immunization is thought to provide protection for

10 years.

 Begins in infancy with the DTP series of shots.

The DTP vaccine is a "3-in-1" vaccine that
protects against diphtheria, pertussis, and
tetanus.

Prevention
 Can be achieved by active immunization by tetanus toxoid (5 doses – 0 day,
1 month, 6 month, 1 year, 1 year).
 Older teenagers and adults who have sustained injuries,
especially puncture-type wounds, should receive booster
immunization for tetanus if more than 10 years have passed
since the last booster.
 Clinical tetanus does not produce immunity to further attacks. Therefore,
even after recovery patients must receive a full course of tetanus toxoid.

Prevention
Thank you