experience of tetanus cases from mumbai

tetanus once considered to be a deadly medical disease, has come a long way in 20th century, as an easily preventable and effectivey curable disease. So much so that its incidence has disappeared from developed countries.
Even though least cases are seen these days due to effective maternal and childhood immunisation programs; in many areas of developing countries like India, do have significant number of patients presenting as tetanus to tertiary care centers. And few of them have mortalities too.

The once famous Jog and patel clinical score criteria based on fever, tachycardia, number and areas of spasm / trismus; and autonomic disturbances is less often used by many pediatricians; and those who use modify as per their covenience, as the dosages proposed according to clinical score; can be as high as 60 to 80 mg/kg of oral diazepam which is usually not supported by standard textbooks. And also the clinical scores do change very often with or without treatment, a titration of oral dose accordingly doesnt appear a logical solution; as oral absorption of diazepam is erratic. ref 1 2 3

What is more important in management of tetanus is correct diagnosis. A lot many cases are wrongly diagnosed as tetanus; as many people are not awrae of what is trismus and how to check for it. Trismus or lock jaw is a clinical condition that is considered very diagnostic of tetanus; ( and as investigations are often useless in diagnosing tetanus, trismus serves as the sole gold standard diagnostic criteria for tetanus); it is characterised by forecful spasm of jaw muscles with inability to open mouth even under mild pressure; and it is demosntrated in best way by introducing a tongue depressor in mouth; rather attempting to do so; will fail to open mouth. Its very prudent to divert child's attention so that voluntary spasms dont coexist.

Tetanus can be diagnosed in absense of trismus from spasms, rigidity of neck trunk limbs and abdomen; with normal sensorium in a child witha focus of infection and / or history of nonimmunisation.

A wrong diagnosis of trismus will take the child for wrong line of management and vicious cycles of diazepam therapy; and lrolonged hospital stay with addition of multiple medicines; and avoiding all further tests; because once a doc makes diagnosis fo tetanus; usually others dont question it.

How does one make a wrong diagnosis of trismus?
1. false interpretation of voluntary spasm
2. examination by inexeperienced doctor
3. patient may have a seizure and may be interpreted wrongly
4. it can be associated with contradictory neurological signs
5. altered sensorium almost rules out tetanus, unless its following severe hypoxia; which is very rare.
6.if the patient presents to hospital after receiving diazepam and one has no clue to check for trismus


So please reecheck the trismus again, preferably by a senior too; and look for supprtive signs / spasms or contradicting neurological signs.

Another important thing after diagnosis of tetanus, is curtailing a spasm at the earliest. if we donot curtails spasms, they add on to precipitate sever bronchospasms and death.

a spasm should be preferably curtailed only with parenteral diazepam; preferably IV ( diluted with blood) or Intramuscular preferably in deltoid; or per rectal (when IV access is not possible); and never oral.

dose of parenteral or oral diazepam given in most books in 0.2 to 1 mg/kg / dose; which in cases of tetanus appears to be refractory. midazolam doesnt prove promising; and has no benefit in tetanus cases.
Remember diazepam almost never causes of respiratory depression even in higher doses (unless added with another drug like phenobarbitone). Almost all cases of diazepam poisoning recover satisfactorily in a week. ALso, the common morbidity follwoing diazepams is mostly due to its cumulative sedation and vasodilation causing intracranial bleeds.

In tetanus, one may need doses as high as 1-5 mg/kg bolus or tetanus preferably in divisions every 10 minutes (for those who are scared of large dose). to curtail an acute spasms. A spasm can also be controlled by giving muscle relaxants or by causing paralysis; but that make sthe child ventilator dependant.. ( and many are scared of intubations in tetanus cases and go for tracheostomies adding another morbidity.

I had used upto 10mg/kg/dose boluses without causing any problems for curtailing the spasms. Only svere bronchospasms may require high dose diazepam.

Other ways, are to start a low dose diazepam infusions after a bolus diazepam; the infusion are usually 0.2mg/kg/hr for no more than 2 days. dose can be increased gradually; till spasm, but once spasm is controlled for an hour, please taper the diazepam drip rate hourly to avoids intracranial bleeds. switch over earliest to oral or rectal diazepam therapy.

oral diazepam therapies are started at doses of 40, 60 and 80 mg/kg/day in mild , moderate amd sever tetanus respectively. With time, the doses have come down to 20. 40, 60 respectively.

The absorption is errartic with oral. addition of antacids hampers absorption and vomitting and gastritis are frequent complications but are easily treatable.

In the past various antibiotics have ben used for various reasons, but as the clostridia are anaerobes, metronidazole as a single drug chemotherapy usuallky suffices unless another bacerial contamination or pus is documented.

Other CNS dperessants like phenobarbitone, chlorpromazine and chlorzoxazone have been trie in past with erratic regimens without any evidence based benefits. Baclofen is a safer switch over drug due to safety of relaxing mainly skeletal muscles. its action usually is seen by 3rd day, dose range form 0.2 to 1 mg/kg/dose 3-4 times a day.

Tracheostomies especially emergency ones have been associated with significant morbidities.

usually the spasms get controlled in 3-5 days, diazepam can be started tapering once 3 days spasm and rigidity free are observed, but needs to be titrated judiciously. Sometimes spasms may recur again to increase the dose of diazepam. ALl can settle in 2- 4 weeks.

Not to forget, the most important therapy in tetanus management is Tetanus immunogolbulin in high dose to titrate with tetanospasmin; usually 500IU in newborns, 1500IU in infants and 2000 to 3000 IU in children to adults; alongwith primary tetanus immunisation fo child and family.


http://www.pedsccm.org/RARE/Tetanus.html
Lorazepam may be preferable . Limited experience with propofol ,Dantrolene Baclofen Further clinical studies needed. Prompt recognition and treatment of autonomic dysfunction are important in reducing the mortality in this disease.

Author Dr Kondekar Santosh is a pediatrician at Seth G S medical college at KEM Hospital Mumbai india. All of the above opinions are his personel opinions out of personel experience, for more details write to santoshkondekar@kem.edu .