Posted on: Fri 22-05-2020

Outline

• Tetanus Overview
• Tetanus Admission 2019
• 2019 Tetanus Patient Demography 
• Tetanus Admission 2020
• 2020 Tetanus Patient Demography 
• Atypical Presentation
• Typical Presentation
• Challenges in our Settings/Solutions

Tetanus Overview

• Tetanus is a nervous system disorder characterized by muscle spasm.
• Caused by clostridium tetanus found in soil, and in human and animal excrement.
• It is endemic in children in development countries.
• Incidence increases following natural disaster & in conflict and post-conflict 
• Incubation Period: ranges from 2days to several months, Mean: 8days
• Generalized, Neonatal, Local, cephalic

Diagnosis

• Based on history & and classical findings. Always think about associated meningitis (LP recommended for confirmation)
• Treatment consists of 
• supportive measures including airway management,
• wound cleaning & excision of devitalized tissue,
• Neutralization of unbound tetanus toxin
• Halting toxins production
• Control of spasms, 
• pain management
• Treatment of associated infections
• Nutrition 

Tetanus Admissions 2019

MONTHS	JAN	FEB	MAR	APR	MAY	JUN	TOTAL
NO. OF ADM	8	4	0	0	1	1	14
MONTHS	JUL	AUG	SEP	OCT	NOV	DEC	TOTAL
NO. OF ADM	3	4	4	0	2	1	14

2019 Tetanus Patient Demography

Total Admissions	28
Male : Female	17: 11
1 – 5 Yrs: 6 -10 Yrs: 11 – 14 Yrs	12: 11: 5
Spontaneous: Referred	28: 0
Triage (Yellow: Red)	12: 16
Admitted: Referral	24: 2: 2
Discharges	28

Tetanus Admissions 2020

MONTHS	JAN	FEB	MAR	APR	TOTAL
NO. OF ADM	4	4	2	1	11

2020 Tetanus Patient Demography

Total Admissions	11
Male : Female	10:1
1 – 5 Yrs: 6 -10 Yrs: 11 – 14 Yrs	2:  6: 3
Spontaneous: Referred	10: 1
Triage (Yellow: Red)	5: 6
Admitted: Referral	10: 1
Discharge	11

Atypical Presentation

• FM, a 9Yr old girl presented with fever, convulsion and poor appetite  X3/7 admitted on 22/03/2020 into Yellow (observation)
•  RDT+, HB=10.8g/dl, RBS=5.6mmol/L, HR=140, RR=42, sPO2=99%, wt=18kg, Temp=36.5C
• Initial Diagnosis: Malaria
• Reviewed Diagnosis: Generalised Tetanus (23/03/2020) No obvious focus

Treatment

• Initial Tx: Artesunate, IVF and Diazepam
• Reviewd Tx: ceftriaxone added 0n 23/3/2020
• Discharged: 8/04/2020
• Hospital Stay: 17 Days

Review of Treatment

• Artesunate: 3 doses served and continued on coartem (received 7doses)
• Ceftriaxone: 5 doses served
• Metronidazole: received 19 doses
• HTIG: 2 doses
• TT: 1 dose
• Diazepam & Tramadol: 

Typical Presentation

• BG, 9yr old boy presented with trauma to the R foot X 1/52 that became infected. Admitted on 8/1/2020 into tetanus cubicle.
• RDT-ve, HB=12.3g/dl, RBS=5.2mmol/L, HR=71, RR=32, sPO2=99%, wt=17kg, Temp=34.9C
• Initial Diagnosis: Septic laceration of the dorsum of the R foot complicated by tetanus

Treatment

• Initial Tx: Ceftriaxone, flagyl,HTIG, Diazepam, IVF
• Reviewed Tx: Pcm commenced (9/1/2020), Tramadol (10/1/2020)
• Discharged: 24/01/2020
• Hospital Stay: 16 Days

Review of Treatment

• Ceftriaxone: 9 doses served
• Metronidazole: received 25 doses
• HTIG: 1 doses
• TT: not given
• Diazepam & Tramadol: 

Challenges in Our Setting

• Pain Control: occasional delay in prescription. Morphine rarely available (Tramadol mostly used)
• Antibiotics: ideally Metronidazole @ 7.5mg/kg 8hourly for 7days. Either incompletely served or given more than required.
• If mixed infection (sepsis, skin infection e.t.c) is suspected, add Ceftriaxone IV and/or cloxacillin IV, or others according to protocol.
• HTIG & TT: HTIG should be administered immediate after diagnosis. Occassionally HTIG is rarely available and served much later. Since active immunization of 3 doses is recommended, then TT can be given at presentation and 2weeks later. Where a patient stayed for 4weeks the 3 doses can be given. TT also occassionally unavailable and served throughout duration of admission  
• Cardiorespiratory Monitoring: because they can have periods of apnoea and airway obstruction.
• Suctioning: keep suction and bag and mask at bedsite at all times. Suction with caution, as this can provoke spasms.
• Diazepam Use: Emulsion rather than Aqueous diazepam is recommended especially for children <3yrs (less toxic). 
•  We hardly use diazepam continuous infusion even though some patients have been reported to have repeated spasm despite on hourly diazepam.  3 – 12mg/kg in 24hours.
• Administration of diazepam slowly for 3 -5 min is hardly done. Hypotension and respiratory depression. 
• Don’t stop diazepam abruptly – causes spasm.
• Documentation: there is need to review this type regularly especially whenever there is report of a complain.
• Counseling and Follow-up.

Thanks for Listening

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