Gwange Paediatrics Hospital Maiduguri Tetanus Management Review By Dr. Fwachabe Fanya D.

Posted on: Fri 22-05-2020


  • 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


  • 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

NO. OF ADM84001114
NO. OF ADM34402114

2019 Tetanus Patient Demography

Total Admissions28
Male : Female17: 11
1 – 5 Yrs: 6 -10 Yrs: 11 – 14 Yrs12: 11: 5
Spontaneous: Referred28: 0
Triage (Yellow: Red)12: 16
Admitted: Referral24: 2: 2

Tetanus Admissions 2020

NO. OF ADM442111

2020 Tetanus Patient Demography

Total Admissions11
Male : Female10:1
1 – 5 Yrs: 6 -10 Yrs: 11 – 14 Yrs2:  6: 3
Spontaneous: Referred10: 1
Triage (Yellow: Red)5: 6
Admitted: Referral10: 1

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


  • 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


  • 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