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124
Manipal Manual of Surgery
Organisms
Staphylococcus aureus remains the most common SSI
pathogen, followed by coagulase negative staphylococci, enterococci and Escherichia coli.
Risk factors for the development of SSIs are presented
Key Box 22.13.
in
Key Box 22.13
Risk Factors for Development of Surgical Site Infections
Patient-related (Remember as PATIENT)
Peripheral vascular disease and smoking
Anaemia
Trauma
Immunosuppression including diabetes
Elderly (old age)
Nutritional: Malnutrition
Too much obesity
Local features (Remember as LOCAL)
Long (prolonged) surgical procedure
Oxygenation is poor (hypoxia)
Contamination of instruments and skin (poor skin
preparation)
Antibiotic prophylaxis is inadequate
Local tissue necrosis and low temperature (hypo-
thermia)
Principles of Treatment of Established Surgical Site
Infections
• Antibiotics: Empirical broad-spectrum antibiotics
that cover all likely organisms must be started, and
later switched to the appropriate antibiotic(s) as per
the culture-sensitivity report.
• Care of the wound: Wound dressings
• Exploration of wound/peritoneal cavity, removal of
source of sepsis, draining abscess cavity.
What is the decisive period? It takes about 4 hours after surgery
for the mobilisation of inflammatory, humoral, and cellular
defences. This is the time when invading bacteria get
established. Hence, prophylactic antibiotics should be given in
this period.
Preventing Sources of SSIs
Surgical site infections may be largely prevented or
reduced by an approach called the surgical care bundle
approach. A bundle refers to a structured processes of
care that improves patient outcomes. Surgeons may
develop their own surgical care bundle for SSIs. This
Section II • General Surgery
approach may be summarised by 6 Ss.
1. Standardised antibiotic prophylaxis: Antibiotics
should be administered ideally 1 hour before the skin
incision. It should be repeated every 3 hours if the
surgery is prolonged.
2. Skin is prepared by iodophors (povidone iodine 10%)
or chlorhexidine gluconate 4% in alcohol. Povidone
iodine is safe, fast acting, and has broad-spectrum
(with some sporicidal) activity. Preoperative hair
removal (clipping) should be done immediately
before any operation.
3. Sterile dressings and proper wound care help protect
the incision.
4. Safe operating room: Environmental cleaning and
disinfection of the operating room (OR),
maintenance
of the ventilation system (the bacterial threshold limit
3
for an empty OR is 35 CFU/m
), and minimizing the
OR traffic with continuous monitoring. SSI may be
prevented by maintaining positive pressure in the
operating rooms, mechanical ventilation, airconditioning providing filtered air, maintaining
temperature, etc. The surgeon and team should scrub
for at least 3–5 minutes with 4% chlorhexidine
gluconate. However, chlorhexidine alcohol-based
‘fast rub’ is more popular now. OT attire and drapes:
Scrub suits, caps, masks, double gloves, and
dedicated footwear are used as barriers. The life of a
sterile glove is 3 hours. It should be changed if the
surgery lasts > 3 hours.
5. Showers and decolonization with chlorhexidine
gluconate 4% during the hospital stay.
6. Screening for colonization of the surgical site.
Bacterial factors
• Klebsiella Surface capsule Inhibit phagocytosis
• Streptococcus Surface capsule Inhibit phagocytosis
pneumoniae
• Coagulase Slime, on the surface
negative
staphylococci
• Gram-negative Endotoxins or lipopolysaccharide
bacteria
• Clostridia, Powerful exotoxins
streptococci
Thus, good surgical technique, gentle tissue
handling, perfect haemostasis, removal of dead tissues,
and appropriate use of sutures, drains, and antibiotics
play a major role in preventing SSI.
Blood sugar level <200 mg/dl in the perioperative period is
recommended to decrease morbidity and mortality.
Acute Infections, Sinuses, Fistula and Surgical Site Infections
A summary of prevention of SSIs is given in Fig. 22.24.
Fig. 22.24: Prevention of surgical site infections
125
Prevention of Hospital Infection
• Avoid unnecessary antibiotics to prevent the develop-
ment of resistant organisms
• Autoclaving and sterilisation should be done optimally
• Proper ventilation of the wards
• Proper scrubbing before any procedure
• Proper disposal of urine, faeces, sputum
• Use of disinfectants
• Antibiotic prophylaxis (Key Box 22.14)
Key points regarding SSI are presented in Key
Box 22.15.
Key Box 22.14
Antimicrobial Prophylaxis
Operation Likely pathogens
Breast S. aureus, coagulase-negative,
staphylococci
Appendicectomy Gram-negative bacilli, anaerobes
Biliary tract Gram-negative bacilli, anaerobes
Upper GI Gram-negative bacilli, strepto-
cocci, oropharyngeal anaerobes
(peptostreptococci)
Cefazolin is generally accepted as the antimicrobial agent
of choice for clean-contaminated operations.
Dose: 1–2 g/adult dose.
Timing: No more than 30 minutes before skin is incised.
Prophylactic regimens
Vascular: 3 doses of flucloxacillin with or without
gentamicin, vancomycin.
Oesophagogastric: 1 dose of 2nd generation cephalo-
sporin and metronidazole.
Biliary: One dose of 2nd generation of cephalosporin.
Small bowel: 1 dose of 2nd generation of cephalosporin
with metronidazole.
Appendix/colorectal: 1 dose of 2nd generation of
cephalosporin with metronidazole.
Key Box 22.15
Key Points in SSI
SSI within 24 hours is caused by clostridia and strepto-
cocci
SSI after 48 hours (5 days) is caused by gram-negative
and other bacteria.
Nasal carriers of Staph. aureus have ↑ risk of SSI.
Prevention of SSI is by aseptic and antiseptic technique
in OT as introduced by Lister, use of prophylactic
antibiotics and patient’s own ability to prevent
infection.
Skin to be prepared by germicidal antibiotics such as
tincture of iodine, povidone iodine or chlorhexidine.
The first dose of prophylactic antibiotics is given
intravenously at the induction of anaesthesia.
Monofilament sutures are better to decrease the
SSI.
ASEPSIS AND ANTISEPSIS
Strictly speaking, they are equivalent and there is not
much of a difference between them.
Asepsis refers to precautions taken before any
surgical procedure to prevent against the development
of infection. Some examples are: wearing gloves, cleaning
the patient’s abdomen with iodine and spirit, sterilisation of
instruments, and autoclaving.
Antisepsis: It is defined as the practice of using antiseptics to eliminate disease-causing microorganisms. All
surgical procedures today are performed only after
taking aseptic precautions.
• Dressing of an already contaminated wound using
carbolic acid, iodine.
• Broad-spectrum antibiotics are used in the presence
of infection.
• Wearing a mask and cap in the operation theatre.
Section II • General Surgery
126
Manipal Manual of Surgery
TRANSMISSIBLE VIRAL INFECTIONS
HEPATITIS B
• It is a viral infection caused by hepatitis B virus
(HBV). It injures the liver. It can result in both acute
and chronic disease. It is a major global health
problem. Chronic disease results in death from
cirrhosis and hepatocellular carcinoma.
• Method of transmission: Contact with blood or other
body fluids, including sexual intercourse with an
infected partner, injections-drug use that involves
sharing needles, syringes. It can also occur with
needle sticks or exposures to sharp instruments. It
can also occur from tattooing, piercing
• Hepatitis B can be prevented by vaccines that are safe,
available and effective.
• Symptoms: There can be febrile illness. It may last
from a few days to several weeks. Jaundice, yellow
urine, weakness, nausea, vomiting are other features.
Abdominal pain is due to enlarged liver. A few
patients with acute hepatitis can develop acute liver
failure, which can lead to death.
• Diagnosis: It is done by detection of the hepatitis B
surface antigen HBsAg.
• Methods of prevention: Prophylaxis by taking
vaccine. In the hospitals, all blood donations should
be tested for hepatitis B virus infections. Thus to avoid
accidental transmission to people who receive blood
products. This can happen more so in patients who
require massive blood transfusions, urgent transfusions and multiple transfusions such as haemophilia
etc. All health care workers should not only wear
cases,
double gloves but to avoid accidental pricks during
suturing of tissues, or splashing of fluids during
dental extractions etc.
• Treatment: Acute illness require treatment with
paracetamol if fever is present. Otherwise no specific
drugs are used. Tenofovir or entecavir—are the drugs
to suppress hepatitis B virus.
• Initial presentation after the exposure of the virus is
acute illness that lasts for the first 6 months which
can be in the form of fever, clay stools, high coloured
urine, loss of appetite, etc. Some of these cases may
be completely free by 6 months of time. However, in
majority of patients, viral infection progresses to
chronic hepatitis stage.
• Complications: Cirrhosis and liver cancer: Both these
can occur in hepatitis B infections also but in cases of
hepatitis C virus infections, these complications can
occur early. Very advanced patients can have multiple
organ involvement resulting in renal failure, cerebral
dysfunction ascites, etc. Intractable itching is also a
feature.
• Diagnosis is established by demonstrating Anti-
Hepatitis C Virus (HCV) antibodies. Like many other
viral infections, they are demonstrated after about
12 weeks.
• Treatment: No specific treatment or drugs for this
condition but symptomatic treatment is given. A few
drugs have been used—they are interferon, and ribavirin.
• Prophylaxis: There is vaccine for hepatitis C. The best
way is to use universal precautions such as using
double glove, avoid prick injuries, avoid needle
sharing, avoid direct exposure to blood and blood
products and practise safe sex.
SINUSES AND FISTULAS
Sinus
• It is a blind track from the surface down into the
tissues (Fig. 22.25). It is lined by granulation tissue.
A few examples are listed below:
1. Congenital sinus: Pre-auricular sinus, post-auricular
sinus (Fig. 22.26).
HEPATITIS C
• Hepatitis C is caused by hepatitis C virus which
belongs to RNA virus. There are many forms of
hepatitis C—most common being type 1.
• Incubation period is an average of 45 days—however,
it can be anywhere between 2 weeks and 12 weeks.
• Method of transmission: Almost similar in the lines
of hepatitis B infections such as body fluids, injection
drugs and needles, etc. Transmission does not occur
via breast milk, kissing or coughing, sneezing,
Section II • General Surgery
touching, etc.
Fig. 22.25: Sinus (blind track)
Fig. 22.26: Postauricular sinus
Acute Infections, Sinuses, Fistula and Surgical Site Infections
2. Acquired sinus:
– Median mental sinus (see page 370): Results from
a tooth abscess.
– Pilonidal sinus: Occurs in the midline of the anal
region (Fig. 22.27).
– Osteomyelitis: Gives rise to a sinus that discharges
pus ± bony spicules (Fig. 22.28).
• Most common sinus in the neck is due to tubercular
lymphadenitis (Fig. 22.29). It discharges cheesy
material. Skin surrounding the sinus shows bluish
discolouration.
Fistula
It is an abnormal communication between the lumen of
one viscus and the lumen of another (internal fistula)
or a communication
between a hollow viscus and the
exterior, i.e. body surface (external fistula) (Fig. 22.30).
127
Fig. 22.30: Enterocutaneous fistula (communication)
Examples of Internal Fistulas
• Tracheo-oesophageal fistula
• Colovesical fistula
Examples of External Fistulas
• Orocutaneous fistula due to carcinoma of the oral
cavity infiltrating the skin
• Branchial fistula (see page 328
)
• Thyroglossal fistula (see page 324)
• Enterocutaneous fistula
Fig. 22.27: A patient with pilonidal sinus positioned in jack-knife
position for excision
Fig. 22.28: Mandibular sinus due to badly infected caries teeth,
osteomyelitis of mandible
Fig. 22.29: Tuberculous sinuses in the chest wall. Observe that
the edges of the sinuses are in flush with the skin
Causes of Persistence of a Sinus or Fistula
1. Presence of foreign body
. Persistent infection
2
3. Distal obstruction
4. Absence of rest
5. Epithelialisation of the track
6. Malignancy
7. Nondependent drainage, inadequate drainage
8. Dense fibrosis
9. Irradiation
10. Specific causes—tuberculosis, actinomycosis
Please refer to Manipal Manual of Clinical Methods, 1st
edition, for clinical examination of a sinus or fistula.
Investigations
• Complete blood picture (CBP)—haemoglobin, total
and differential count, erythrocyte sedimentation rate
(ESR): ESR may be increased in tuberculosis.
Increased total count suggests infection.
• Urine sugar, fasting blood sugar (FBS) and post-
prandial blood sugar (PPBS) to rule out diabetes.
• X-ray of the part: To look for osteomyelitis of the
mandible,
toe, and any foreign body (Fig. 22.31).
• X-ray kidney, ureter, bladder region (KUB), ultra-
sound abdomen: Staghorn calculi in lumbar urinary
fistula.
Section II • General Surgery
128
Fig. 22.31: Persisting sinus due to osteomyelitis of distal phalanx
of great toe
Manipal Manual of Surgery
• Fistulography or sinusography to determine the
exact extent or origin of the sinus or fistula. A dye
such as lipiodol (poppy seed oil containing 40%
iodine) is used.
• Biopsy from the edge of the sinus is done if a specific
aetiology is suspected (e.g. tuberculosis, malignancy).
Management (Key Box 22.16)
Following are a few examples:
• Sequestrectomy for osteomyelitis.
• Control of tuberculosis for tubercular sinus in the neck.
• Removal of the foreign body, if present (clinical notes)
• If the track is well formed and epithelialised, the
entire track should be removed even if the disease is
under control.
Key Box 22.16
Basic Principles
Antibiotics
Adequate rest
Adequate excision
Adequate drainage
Please note: Details regarding individual fistula and sinus have
been discussed in their respective chapters.
1. A patient who had undergone surgery for varicose
veins had persistent seropurulent discharge from the
inguinal incision. Initially, it was thought to be due to
infection. The discharge persisted for a period of two
months. The wound was explored. A gauze piece
was found and removed. The wound healed well.
Retrospective analysis of the surgery revealed slipping
of the ligature applied to the long saphenous vein and
several gauze pieces were used to control the bleeding
point.
2. We had a 60-year-old man who had a small sinus in
the loin with watery discharge. He had seen many
doctors over many years. He was treated with
antibiotics and antitubercular treatment without any
relief. X-ray KUB revealed a staghorn calculus.
Section II • General Surgery
Acute Infections, Sinuses, Fistula and Surgical Site Infections
129
1. Treatment of cold abscess is:
A. Excision
B.
Incision and drainage
C. Marsupialisation
D. Nondependent aspiration
2. The following are true about tubercular sinuses in
the neck except:
A. Usually multiple
Edge is bluish in colour
B.
C. Induration is highly characteristic
D. Jugulodigastric nodes are commonly affected
3. The ideal treatment of a carbuncle is:
A. Drainage
B
Incision and drainage
.
C. Excision
D. Aspiration
4. The following are true about Ludwig’s angina except:
A. It is caused by Staphylococcus aureus
B.
Diffuse swelling in the submental and submandi-
bular region is common
C. Putrid halitosis is common
D. It may also give rise to mediastinitis
5. The following are true about pyaemic abscess except:
A. They are usually multiple
B.
They are deep to the deep fascia
C. The diagnostic feature is a high local rise in
temperature
D. It occurs due to a pyaemic process
6. The following are true about carbuncles except:
A. Nape of the neck is the most common site
. Cribriform appearance is diagnostic
B
C. Abscesses do not communicate with each other
D. Staphylococcus is the most common organism
7. The following are true about erysipelas except:
A. Rose pink rash is common
Cuticular lymphangitis is an important component
B.
C. The pinna never gets affected in facial erysipelas
D. It is caused by Streptococcus pyogenes
8. Muscles are spared in which condition?
A. Gas gangrene B. Necrotising fasciitis
C
Pyomyositis D. Acute embolic gangrene
.
9. The following are features of necrotising fasciitis
type II except:
A. It is monomicrobial—β-haemolytic streptococci
.
It may also occur in young, healthy individuals
B
C. The organism is not sensitive to clindamycin
D. It may give rise to toxic shock syndrome
10. Which of the following is true regarding prevention
of surgical site infections?
A. Preoperative hair clipping should be done just
prior to the surgical procedure
.
Skin is prepared by 20% povidone iodine
B
C. Blood sugar levels should be maintained within
200 mg/dl
D. Positive pressure ventilation at a temperature of
25°C is ideal
Answers
1. D 2. C 3. C 4. A 5. C 6. C 7. C 8. B 9. C 10. A
Section II • General Surgery
23
Tetanus and Gas Gangrene
Tetanus
A case report of neck rigidity
TETANUS
Introduction
A nonimmunised, 18-year-old girl was admitted with
moderate tetanus following a nail prick in her foot. In
the hospital, she developed convulsions, laryngeal
oedema, and cardiac arrest. She was resuscitated and
shifted to the intensive care unit under an anaesthesio-
logist’s care. Tracheostomy, ventilation, and paralysing
agents were used. Unlike many others, she was lucky.
She walked home after two months of stay in the
intensive care unit after a lot of suffering and spending
a lot of money. This happened in early 90s. Due to
extensive immunisation programmes in the last few
decades, tetanus has become a rare disease in India. Case
history has been presented here to allow students to
reflect on the following:
. How important is immunisation to prevent tetanus?
1
2. How serious is this disorder?
3. Is it possible to save these patients if they are critically
ill?
Definition
Tetanus is a serious disorder caused by toxin of the
Clostridium tetani affecting nervous system, gives rise
to muscle contraction of the neck, back and jaw muscles.
It is popularly called lock jaw.
Aetiopathogenesis
It is caused by Clostridium tetani, an anaerobic sporeforming bacillus with terminal spores that have a
drumstick-like appearance.
Narcotic addicts who inject themselves beneath the skin at
many sites are vulnerable—‘Skin Poppers’.
Gas gangrene
Possible Routes of Infection
• Umbilical cord (in neonates)—seen in communities that
practise cow dung application on the umbilical stump.
• Wound, as a complication of road traffic accidents
where other aerobic organisms reduce oxygen
tension in the wound, thereby facilitating growth of
anaerobic Clostridium tetani (Key Box 23.1).
• Minor injuries with rusted nails, ear piercings,
tattooing, injections, etc.
• Endogenous infection after septic abortion or
surgical operations on the gastrointestinal tract.
• Tetanus due to infection acquired in the operation
theatre.
Thus, tetanus is a wound infection. “No wound, no
tetanus” is true. Having entered the wound, the
organisms multiply and produce powerful exotoxins
which produce the disease. Thus, the organisms by
themselves do not produce the disease. The toxins
produced by the organisms are tetanospasmin
(neurotoxin) and tetanolysin (haemolysin).
• Tetanospasmin has affinity towards nervous tissues.
It reaches the central nervous system along the axons
of motor nerve trunks. The toxin gets fixed to motor
Key Box 23.1
Wounds which are more Prone to Tetanus
Time—wound more than 6 hours old
Extensive contamination by soil, faeces, rust
Tissue devitalised or denervated
Animal or human bites
No less than 1 cm (more than 1 cm)
Ulcer or wound—deeper
Stellate wounds—burst type
Remember as TETANUS
130
Tetanus and Gas Gangrene
131
cells of the anterior horn cells. The toxin, which is fixed
to the motor end plate, acts in the following ways:
1. It inhibits the release of cholinesterase, leading
to the accumulation of acetylcholine at the motor
end plate. This causes tonic rigidity of limb, trunk,
abdominal, and neck muscles.
2. It acts at the spinal level and causes reflex muscle
contraction due to minor stimuli.
• The toxin, once fixed to the nervous tissue, cannot
be neutralised. However, circulating toxins may be
neutralised. The incubation period varies from a few
days to months or years and is not important. The
interval between the first symptom (dysphagia and
stiffness of jaw) and reflex spasm is called the period
of onset. If this is less than 48 hours, the prognosis is
poor, whereas if it is more than 48 hours, the prognosis is better.
• Tetanolysin also contributes to pathogenesis of
tetanus, but its action is not clear. It is a type of protein
which is oxygen sensitive haemolysin.
Favourable Conditions for the Development of Tetanus
• No immunisation
• Foreign body
• Injury
• Improper sterilisation
• Devitalised tissues
• Anaerobic conditions
Special Types of Tetanus
. Tetanus neonatorum: It occurs due to contamination
1
of the umbilical cord in children born to nonimmunised mothers. It usually manifests around
6–8 days of birth and is called eighth day disease. It
carries almost 100% mortality.
2. Local tetanus: In this, muscle contraction occurs in
the neighbourhood of the wound.
3. Cephalic tetanus: Usually occurs after a wound over
the head and/or face. Cranial nerves, such as the
facial and oculomotor nerves, may get paralysed. It
carries a poor prognosis.
4. Bulbar tetanus: It involves the muscles of deglutition
and respiration and is fatal.
5. Latent tetanus: It develops after a few months to years
following a wound that might have been forgotten.
6. Puerperal tetanus: It occurs as a complication of
abortion or puerperal sepsis.
7. Postoperative tetanus: It occurs due to improper
sterilisation of instruments and carries 100%
mortality. This type of tetanus should not occur in a
modern operation theatre.
8. Otitis tetanus: It is due to chronic suppurative otitis
media. In these cases, the wound is a tear in the
tympanic membrane. It may occur in any age group,
but is more common in children and young adults.
Clinical Features (Table 23.1)
• Autonomic dysfunction: Increased basal sympa-
thetic tone, manifesting as tachycardia, bladder/
bowel dysfunction, labile hypertension, pyrexia,
pallor, sweating, and cyanosis of the digits.
• Episodes of bradycardia, low central venous
pressure, and even cardiac arrest have been reported
due to parasympathetic dysfunction.
• Complications include pneumonia, urinary tract
infection, etc.
TREATMENT OF ESTABLISHED TETANUS
I. General management
Specific management
II.
Table 23.1 Clinical features with differential diagnosis
Symptoms and signs Differential diagnosis
• Trismus or lock jaw, occurs due to severe contraction • Alveolar abscess or temporomandibular
of the masseter muscle, resulting in inability to open
the mouth. It is the most common symptom of tetanus.
• Dysphagia occurs due to sp
• Neck rigidity • Meningitis
• Rigidity of back muscles • Orthopaedic disorder
• Risus sardonicus due to sp
• Generalised convulsions wherein every muscle is • Epilepsy
thrown into contraction, with severe clenching of teeth,
arched back and extended limbs are described as
opisthotonos (bow-like body; hence the name dhanurvatha).
• Mild temperature and tachycardia • Sympathetic hyperactivity
asm of pharyngeal muscles. • Tonsillitis
asm of facial and jaw muscles. • Anxiety neurosis
joint involvement
Section II • General Surgery
132
Manipal Manual of Surgery
I. General Management
1
• Admission and isolation
in a quiet room, to avoid even
minor stimuli that may precipitate spasm (Fig. 23.1).
• Wound care—drainage of pus, excision of necrotic
tissue, removal of any foreign body, and proper dressing.
Exudate or pus may demonstrate gram-positive rods.
• Inj. Tetanus toxoid 0.5 ml intramuscularly (IM).
• Antitetanus serum (ATS) 50,000 units IM and 50,000
units slow intravenously (IV). This should be given only
after giving a small subcutaneous test dose of serum
diluted with ten times saline. It has become less popular
due to the availability of human antitetanus globulin.
• Human antitetanus globulin 3000–4000 units intra-
muscular. It is better and safer than ATS, does not
cause anaphylaxis, and does not require a test dose.
• Inj. crystalline penicillin 10 lakh units IM 6th hourly
is the drug of choice against Clostridium tetani. It may
have to be given for 7–10 days.
• Metronidazole 500 mg IV 8th hourly for 10 days. It
is more effective than penicillin.
• After recovery, full immunisation with tetanus toxoid
is required.
Table 23.2 Method of treatment
Drug Dosage Time
Chlorpromazine 50–100 mg 8 am, 2 pm,
8 pm and 2 am
Phenobarbitone 30–60 mg 10 am, 4 pm,
10 pm and 4 am
Diazepam 10–20 mg 12 noon, 6 pm,
12 midnight and 6 am
• These drugs are repeated in such a way that the patient
receives some sedative every two hours. The dosage
of the drugs is adjusted once every 2 or 3 days to get
the maximum effect of sedation or muscle relaxation.
• Injection diazepam 10 mg, a tracheostomy set, and a
resuscitation set with a laryngoscope and endotracheal
tubes should be kept ready by the side of the patient.
• When high dose of diazepam is used, it can give rise
to hyper-osmolarity and metabolic acidosis because
of propylene glycol (vehicle). Midazolam is better.
• Labetalol has both alfa and beta blocking properties.
It also can be used. Dose is: 0.25 mg to 1 mg/mt.
II. Specific Management
. Mild Cases
A
• There is only tonic rigidity without spasm or
dysphagia. These patients are managed by heavy
sedation with a combination of drugs to prevent
spasms or convulsions. The treatment method
followed in our hospital is given in Table 23.2.
• Benzodiazepines and morphine act centrally to
minimise the effects of tetanospasmin.
• Chlorpromazine, an α-receptor blocker, may decrease
sympathetic activity. Other α-blockers like phenoxybenzamine and phentolamine have also been used.
Fig. 23.1: Tetanus patient recovering in an intensive care unit
B. Seriously Ill Cases
• They have dysphagia and reflex spasms.
• A nasogastric tube is introduced for feeding purposes
and to administer the drugs.
• Tracheostomy, if breathing difficulty arises.
C. Dangerously Ill Cases
This group includes patients with major cyanotic
convulsions. In addition to continuing sedatives, these
patients are paralysed with muscle relaxants (neuromuscular blocking agents) and are mechanically
ventilated till they recover. The duration of required
ventilatory support cannot be predicted. During this
period, supportive therapy, such as adequate nutrition,
bladder and bowel care, and frequent change of position
to avoid bedsores, is required.
Magnesium sulphate may be used to treat autonomic
complications and control spasms. It may be used alone
or in combination with benzodiazepines. A loading dose
of 5 g over 20 min is followed by infusion, the rate of
which is titrated to control spasm as well as reduce
muscle rigidity to a level acceptable by the patient for
swallowing saliva, mouth care, and limb physiotherapy.
Total abolition of muscle rigidity is not required and
may lead to hypotonia.
1
Isolation for tetanus has been misunderstood by surgeons. In many hospitals, tetanus patients are isolated in a remote corner of the hospital, well
away from the reach of a skilled person. Many cases die due to convulsions and laryngeal spasm before they are intubated and resuscitated. The
critically ill patients are admitted in an intensive care unit under the supervision of an anaesthesiologist’s care in our institution (Fig. 3.1). Tetanus
Section II • General Surgery
is not communicable from person to person.
Tetanus and Gas Gangrene
133
Loss of patellar reflex may not be a valid indicator of
hypermagnesaemia in all patients, as the reflex is
sometimes masked by rigidity and tends to be lost early
in elderly patients. The patients, therefore, should be
monitored closely for ventilatory depression. Magnesium
sulphate may not reduce the need for mechanical
ventilation in patients with severe tetanus, but may help
in reducing the requirement of other sedatives.
PROPHYLAXIS
1. Tetanus neonatorum may be prevented by administer-
ing two tetanus toxoid injections, 0.5 ml IM, to the
mother in the second trimester of pregnancy.
Infants and children are immunised with tetanus
2.
toxoid, diphtheria, and pertussis vaccine (DPT–triple
antigen) at 6, 10, and 14 weeks of age, with a booster
dose at 18 months 5 years, followed by 0.5 ml tetanus
toxoid once every five years.
3. Immunised individuals who receive a provocative
injury are administered a booster dose if they have
not received one in the previous 5 years.
Tetanus may be prevented by giving tetanus anti-
toxin in the following situations: Wounds of head and/
or face, penetrating wounds, wounds with contused and
devitalised tissues and war wounds and road traffic
accidents. 1,500 IU of antitoxin should be given subcutaneously or intramuscularly as early as possible.
Treatment of wound is done. In severe wounds, the dose
may be doubled.
Complications: Most of these may also be the causes of
death.
1. Aspiration of pharyngeal contents into the lungs,
resulting in aspiration pneumonia.
2. Laryngeal spasm and respiratory arrest, resulting in
cardiac arrest.
3. Autonomic disturbances, resulting in cardiac
arrhythmias: In some patients, pacemaker insertion
may help if there is refractory bradycardia.
A Case Report of Neck Rigidity
A 48-year-old lady who had undergone vaginal hysterectomy 10 days prior was brought to our hospital as a case of
‘tetanus.’ On examination, she had neck rigidity and
difficulty in mouth opening. Abdominal rigidity was mild.
She appeared pale. Pallor was attributed to anaemia caused
by ‘dysfunctional uterine bleeding’ (DUB), for which she
was operated. She was diagnosed with postoperative tetanus
and was started on treatment. The next day, she was
unresponsive to commands. Laboratory reports, which had
been sent the previous day, showed a total WBC count of
44,000 cells/mm3 clinching the diagnosis of ‘leukaemia.’
Neck rigidity was due to leukaemic infiltrates in the
meninges. Now you know the cause of uterine bleeding!!!
GAS GANGRENE
Definition: It is a highly fatal, rapidly spreading infection
caused by clostridial organisms that results in myonecrosis.
• Gas produced by organisms consists of predominantly
nitrogen, and others are hydrogen, carbon dioxide
and oxygen. (E. coli, Klebsiella, Proteus, Candida,
Bacteroides, Peptostreptococcus are a few other gas
forming organisms.)
• Other names for gas gangrene are clostridial myositis,
clostridial myonecrosis, infective gangrene of the muscles.
Aetiology
The disease is most commonly (60%) caused by
Clostridium perfringens (Clostridium welchii). Other
organisms include Clostridium septicum, Clostridium
oedematiens, and Clostridium histolyticum. These are
gram-positive, anaerobic, spore-forming bacilli.
MacLennan Anaerobic Wound Infection Types
1. Simple wound contamination—no invasion of
underlying tissue
. Anaerobic cellulitis—invades fascial planes with
2
minimal toxins in muscles
3. Anaerobic myositis—muscle necrosis
Sources of Infection and Predisposing Factors
(Table 23.3)
Manured soil or cultivated soil, normal intestines.
Types of Gas Gangrene Infections
. Clostridial cellulitis: In this condition, healthy muscles
1
are not involved. It involves necrotic tissues and produces features of cellulitis such as tense, swollen parts
with palpable crepitus. However, it is a mild infection
and may be managed conservatively with antibiotics.
2. Local type: It refers to infection confined to a single
muscle.
3. Group type: It refers to infection confined to a group
of muscles in a single compartment. Such cases
benefit from a compartmental excision.
4. Massive type: Gas gangrene involving the entire limb
and requiring amputation.
Section II • General Surgery