Tetanus

Types

1. Generalized tetanus including neonatal tetanus (Common)
2. Localized tetanus (rare)
3. Cephalic
4. Neonatal

Important points in history

Neonatal tetanus (common)

• Place of delivery
• Application of soil, cow dung and other substances to umbilical cord
• Use of unclean instruments to cut umbilical cord (traditional or home birth)
• History of ante-natal attendance/ immunization of the mother
• Poor feeding, especially difficulty attaching to the breast

Non Neonatal Tetanus

• Penetrating wound inflicted by a dirty object (splinter, fragment of glass, non-sterile injection)
• Animal bites
• Abscesses (including dental abscesses)
• Ear piercing
• Chronic skin ulceration
• Burns
• Compound fractures
• Gangrene
• Intestinal surgery
• Foreign bodies in the nostrils
• Middle ear infections

Important points on examination

• Assess ABC
• Vital signs (Temp, BP, pulse rate, RR)
• Conscious level and full neurological assessment
• trismus (lockjaw)
• Stiff neck
• Opisthotonus
• Risus sardonicus (sardonic smile)
• Rigid abdomen
• Periods of apneaand/orupper airway obstruction
• Dysphagia
• Dirt, dung, clotted blood or serum on umbilicus

Differential Diagnosis

Neonatal tetanus

• Meningitis, kernicterus, birth asphyxia Neonatal chapter

Non Neonatal Tetanus

• Rabies (hydrophobia, marked dysphagia, clonic seizures, CSF pleocytosis)
• Hypocalcaemia (trismus will be absent)
• Parapharyngeal, retropharyngeal or dental abscess (trismus)

Investigations

• LP (if diagnosis in doubt)

Treatment

Wound management

• Surgical wound excision and debridement if applicable

Antibiotics

• Metronidazole 30 mg/kg/day (maximum, 4 g/day) divided into 4 doses PO or IV for 10 - 14 days
  OR
  
• Xpen 100,000 units/kg/day (maximum, 12 million units/day) divided into 4 doses IV for 10 - 14 days

Neutralization of unbound toxin

• Human tetanus immunoglobulin (TIG) 500 units IM or IV.
• TIG is not currently available in our setting.

Active immunization

• All patients should complete a series of immunizations with tetanus toxoid, beginning at presentation Immunisation

Sedation

• Diazepam start with doses of 0.1-0.2 mg/kg every 2-6 hours, titrating upward as needed.
• If not controlling the spasms, discuss with a senior for Phenobarbital (children: 5 mg/kg stat, then 2.5 mg/kg BD; neonates: 10mg/kg stat, than 2,5 mg/kg BD). Monitor for respiratory arrest.
• Consider ventilatory support (Indications for intubation: apnoea, hypoxaemia, uncontrolled spasms).

Supportive care

• High-flow oxygen via nasal cannula
• Insert NGT or cannula for feeds and i.v fluids respectively
• Keep patient in a quiet, dark, secluded room with minimal handling
• Adequate pain control
• 2-hourly bed turning to prevent bed sores (in older children)
• Orthopaedic review for long bone or spinal fractures

Surveillance