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Gas gangrene is a clinical diagnosis, and empiric therapy is indicated if the diagnosis is suspected Radiographic studies may show gas within the soft tissues, but this finding is not specific The smear shows absence of neutrophils and the presence of gram-positive rods Anaerobic culture confirms the diagnosis
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3 Tetanus
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Airway obstruction is common Urinary retention and constipation may result from spasm of the sphincters Respiratory arrest and cardiac failure are late, life-threatening events
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History of wound and possible contamination Jaw stiffness followed by spasms of jaw muscles (trismus) Stiffness of the neck and other muscles, dysphagia, irritability, hyperreflexia Finally, painful convulsions precipitated by minimal stimuli
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Tetanus is completely preventable by active immunization For primary immunization of adults, Td (tetanus and diphtheria toxoids vaccine) is administered as two doses 4 6 weeks apart, with a third dose 6 12 months later For one of the doses, Tdap (tetanus toxoid, reduced dose diphtheria toxoid, acellular pertussis vaccine) should be substituted for Td Booster doses are given every 10 years or at the time of major injury if it occurs more than 5 years after a dose A single dose of Tdap is preferred to Td for wound prophylaxis if the patient has not been previously vaccinated with Tdap Passive immunization should be used in nonimmunized individuals and those whose immunization status is uncertain whenever a wound is contaminated or likely to have devitalized tissue Tetanus immune globulin, 250 units, is given intramuscularly Active immunization with tetanus toxoid is started concurrently Table 33 1 provides a guide to prophylactic management
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General Considerations
Tetanus is caused by the neurotoxin tetanospasmin, elaborated by Clostridium tetani Spores of this organism are ubiquitous in soil and may germinate when introduced into a wound The vegetative bacteria produce tetanospasmin, a zinc metalloprotease that cleaves synaptobrevin, a protein essential for neurotransmitter release Tetanospasmin interferes with neurotransmission at spinal synapses of inhibitory neurons As a result, minor stimuli result in uncontrolled spasms, and reflexes are exaggerated The incubation period is 5 days to 15 weeks, with the average being 8 12 days Most cases occur in unvaccinated individuals Persons at risk are the elderly, migrant workers, newborns, and injection drug users While puncture wounds are particularly prone to causing tetanus, any wound, including bites or decubiti, may become colonized and infected by C tetani
Treatment
A Specific Measures
Human tetanus immune globulin, 500 units, should be administered intramuscularly within the first 24 hours of presentation Whether intrathecal administration has any additional benefit is controversial An unblinded, randomized trial comparing intramuscular tetanus immune globulin to intramuscular plus intrathecal tetanus immune globulin found more rapid resolution of spasms, fewer days of ventilatory support, and a shorter hospital stay in the intrathecal group However, the exact immunoglobulin preparation that was used was not specified and the total dose was 4000 units Tetanus does not produce natural immunity, and a full course of immunization with tetanus toxoid should be administered once the patient has recovered
Clinical Findings
A Symptoms and Signs
The first symptom may be pain and tingling at the site of inoculation, followed by spasticity of the muscles nearby Stiffness of the jaw, neck stiffness, dysphagia, and irritability are other early signs Hyperreflexia develops later, with spasms of the jaw muscles (trismus) or facial muscles and rigidity and spasm of the muscles of the abdomen, neck, and back Painful tonic convulsions precipitated by minor stimuli are common Spasms of the glottis and respiratory muscles may cause acute asphyxia The patient is awake and alert throughout the illness The sensory examination is normal The temperature is normal or only slightly elevated
B General Measures
Minimal stimuli can provoke spasms, so the patient should be placed at bed rest and monitored under the quietest conditions possible Sedation, paralysis with curare-like agents, and mechanical ventilation are often necessary to control tetanic spasms Penicillin, 20 million units intravenously daily, is given to all patients even those with mild illness to eradicate toxin-producing organisms
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