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

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Posted on: Fri 22-05-2020
OutlineTetanus OverviewTetanus Admission 20192019 Tetanus Patient Demography Tetanus Admission 20202020 Tetanus Patient Demography Atypical PresentationTypical PresentationChallenges in our Settings/SolutionsTetanus OverviewTetanus 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: 8daysGeneralized, Neonatal, Local, cephalicDiagnosisBased 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 toxinHalting toxins productionControl of spasms, pain managementTreatment of associated infectionsNutrition Tetanus Admissions 2019MONTHSJANFEBMARAPRMAYJUNTOTALNO. OF ADM84001114MONTHSJULAUGSEPOCTNOVDECTOTALNO. OF ADM344021142019 Tetanus Patient DemographyTotal Admissions28Male : Female17: 111 – 5 Yrs: 6 -10 Yrs: 11 – 14 Yrs12: 11: 5Spontaneous: Referred28: 0Triage (Yellow: Red)12: 16Admitted: Referral24: 2: 2Discharges28Tetanus Admissions 2020MONTHSJANFEBMARAPRTOTALNO. OF ADM4421112020 Tetanus Patient DemographyTotal Admissions11Male : Female10:11 – 5 Yrs: 6 -10 Yrs: 11 – 14 Yrs2:  6: 3Spontaneous: Referred10: 1Triage (Yellow: Red)5: 6Admitted: Referral10: 1Discharge11Atypical PresentationFM, 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=36.5CInitial Diagnosis: MalariaReviewed Diagnosis: Generalised Tetanus (23/03/2020) No obvious focusTreatmentInitial Tx: Artesunate, IVF and DiazepamReviewd Tx: ceftriaxone added 0n 23/3/2020Discharged: 8/04/2020Hospital Stay: 17 DaysReview of TreatmentArtesunate: 3 doses served and continued on coartem (received 7doses)Ceftriaxone: 5 doses servedMetronidazole: received 19 dosesHTIG: 2 dosesTT: 1 doseDiazepam & Tramadol: Typical PresentationBG, 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=34.9CInitial Diagnosis: Septic laceration of the dorsum of the R foot complicated by tetanusTreatmentInitial Tx: Ceftriaxone, flagyl,HTIG, Diazepam, IVFReviewed Tx: Pcm commenced (9/1/2020), Tramadol (10/1/2020)Discharged: 24/01/2020Hospital Stay: 16 DaysReview of TreatmentCeftriaxone: 9 doses servedMetronidazole: received 25 dosesHTIG: 1 dosesTT: not givenDiazepam & Tramadol: Challenges in Our SettingPain 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

ABUJA: Training Schedule for Basic Life Support BLS, Pediatric Advanced Life Support (PALS), Advanced Cardiovascular Life Support ACLS, First Aid, CPR, AED
PORTHARCOURT: Training Schedule for Basic Life Support BLS, Pediatric Advanced Life Support (PALS), Advanced Cardiovascular Life Support ACLS, First Aid, CPR, AED
LAGOS: Training Schedule for Basic Life Support BLS, Pediatric Advanced Life Support (PALS), Advanced Cardiovascular Life Support ACLS, First Aid, CPR, AED

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