SEVERE TETANUS

SEVERE TETANUS
 PATIENT PROFILE
PATIENT PROFILE
Patient I. B.
47 years old/Male
Married

Address: Arena Blanco, Zamboanga City

Occupation: Welder
Educational Attainment: High School
Religion: Islam
 CHIEF COMPLAINT
CHIEF COMPLAINT

TRISMUS
 HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS
1 Week PTA 1 Day PTA 5 Hours PTA
Home Circumcision Trismus Worsen Increasing Trismus
Difficulty Masticating and Upper Back
4 Days PTA Upper Back Pain Pain
Multiple Punctured Consult at ZCMC Painful
Wounds on Lower Advised for Admission Contractions of
Extremities DAMA the Muscles of
Anti-Tetanus Serum the Jaw
2 Days PTA Tetanus Toxoid Severe Dysphagia
Mild Trismus Metronidazole Consult at ZCMC
Admission
 PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
(-) Diabetes Mellitus
(-) Hypertension
No history of hospitalizations
No known allergies
Unknown Immunization
 FAMILY HISTORY
FAMILY HISTORY
No family history of:
• Hypertension
• Diabetes
• Stroke
• Seizures
• Hypertension
• Cancer
 PERSONAL-SOCIAL HISTORY
PERSONAL-SOCIAL HISTORY

A Metal Welder
Smoker of 20 Pack Years
Denies Drinking
NO Illicit Drug Use
 REVIEW OF SYSTEMS
REVIEW OF SYSTEMS
General No weight changes, no changes in sensorium, no memory changes, no
seizure episodes
Skin No itchiness, no diaphoresis
Head No headache
Eyes No eye pain, noAexcess
Metal lacrimation
Welder
Ears No ear pain, no tinnitus
Nose Smoker
No stuffiness, of 20no
no epistaxis, Pack
pain Years
Throat and Mouth No soreness, no voice changes
Neck Denies Drinking
No pain, no stiffness
Respiratory No difficulty of breathing, no shortness of breath
Cardiovascular
NO Illicit Drug Use
No PND, no orthostatic hypotension, no chest pain, no palpitations
Gastrointestinal No changes sin bowel movement, No abdominal pain, no bowel
incontinence
Urinary With no urinary frequency or incontinence
Extremities No pain, no rigidity, no tingling sensation, no numbness
 PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
Awake, Conscious
Oriented to 3 Spheres PR: 84 bpm SpO2: 94%
Not in Respiratory Distress RR: 20 bpm BP: 120/70 mmHg
Temp.: 36.1°C
(+) Stiffening and Rigidity of
the Jaw and Jaw Muscles (+) Inability to Open Mouth

Rigid Neck Muscles (+) Tenderness and Rigidity

on the Upper Back Muscles
Non-Tender Abdomen,
No Rigidity Engorged, Tender Genitalia
2cmx2cm Wound on the Glans Penis
 NEUROLOGIC EXAMINATION
NEUROLOGIC EXAMINATION
Awake, Conscious
Oriented to 3 Spheres Able to Follow Commands
Intact Memory Fluent Speech with Poor Articulation
Cannot Clench or
Show Teeth
 CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS
SEVERE TETANUS;
INFECTED WOUND, GLANS PENIS
 CONCEPT MAP
CONCEPT MAP
 CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS
Diagnosis Certainty Basis for Certainty Treatment Modality

SEVERE TETANUS;
Moderate 90% Based on WOUND,
INFECTED History GLANS
of nonsterile,
PENIS Medical Management
Tetanus nonmedical Circumcision; with history for the Clostridium
of trismus tetani;
Severe Tetanus based on the Ablett Surgical management
Classification for Tetanus Severity: for securing the
(+) Severe Trismus airway via Emergency
(+) Severe Dysphagia Tracheostomy
(+) Generalized Spasticity
 CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS
ABLETT CLASSIFICATION

SEVERE TETANUS;
INFECTED WOUND, GLANS PENIS
 CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS
Diagnosis Certainty Basis for Certainty Treatment Modality

SEVERE TETANUS;
Infected 90% Based on WOUND,
INFECTED History GLANS
of nonsterile,
PENIS Medical Management
Wound, nonmedical Circumcision; and Surgical
Glans With PE findings engorged penis, management for
Penis with 2cmx2cm wound on the glans cleaning surgically the
penis, with surrounding erythema wound site, and to
assess and repair of
circumcision
 PARACLINICALS
PARACLINICALS
Diagnostic Benefit Risk Cost Availability
Procedure
Tissue Wound This would SEVERE TETANUS;
provide supportive Bleeding 1,500Php Laboratory
Gram Stain and evidence of the WOUND,
INFECTED presence of GLANS
C. Surgical site
PENIS Department,
Culture and tetani infection ZCMC
Sensitivity
 PARACLINICALS
PARACLINICALS
Diagnostic Benefit Risk Cost Availability
Procedure
Tissue Wound This would SEVERE TETANUS;
provide supportive Bleeding 1,500Php Laboratory
Gram Stain and evidence of the WOUND,
INFECTED presence of GLANS
C. Surgical site
PENIS Department,
Culture and tetani infection ZCMC
Sensitivity
 MANAGEMENT
MANAGEMENT
Treatment Benefit Risk
Modality

Emergency Secures the AirwaySEVERE TETANUS; Bleeding

Tracheostomy PreventsINFECTED
aspiration pneumonia Surgical site infection
WOUND, GLANS PENIS
Wound Eliminates entry site of tetanus, and Bleeding
Debridement eradicates spores in the site. Post-operative site infection
Promotes better healing of wound, and
decreasing favourable environment for
spore production

Metronidazole Antibiotic of choice for eradication of C. May exacerbate spasms

500mg IV q6hr tetani
 MANAGEMENT
MANAGEMENT
Treatment Benefit Risk
Modality

Tetanus SEVERE
Neutralize unbound toxins TETANUS; Fever and soreness at
Immune StandardINFECTED
treatment and improvesGLANS
WOUND, survivalPENIS
injection site, thrombosis
Globulin
Diazepam 10- To control muscle spasms May cause respiratory
40mg every 1-8 depression
hours
Tetanus Toxoid Provides active immunization Very minimal risks
Mechanical Supports respiration in severe cases Ventilator-associated
ventilation Pneumonia, pneumothorax
 MANAGEMENT
MANAGEMENT
Treatment Benefit Risk
Modality

Magnesium SEVERE TETANUS;

Manages ANS hyperactivity Dizziness, flushing,
Sulfate arrhythmias
INFECTED WOUND, GLANS PENIS
Supportive Minimizes triggers of spasms No risks
Management:
Calm, Quiet,
Dark
Environment
 MANAGEMENT
MANAGEMENT
Treatment Modality Benefit Risk

Close Cardiovascular To assess SEVERE TETANUS;

cardiovascular changes No risks
Monitoring (arrhythmias, Hypertension
INFECTED WOUND, GLANS and
PENIS
Hypotension) and be able to manage
complications
Adequate Fluids and
Nutrition To support the body’s physiologic needs Congestion
Hydration via
for optimal functioning Wrong placement of NGT
intravenous route
NGT for nutrition
 EVALUATION AND OUTCOMES
EVALUATION AND OUTCOMES
Procedure Patient Outcome
Emergency Tracheostomy and placed Maintained airway and good Respirations
on Mechanical Ventilation SEVERE TETANUS;
Wean progressively until patient was able
to breathe again on his own
Wound Debridement
INFECTED WOUND, GLANS PENIS
Better wound healing
Shortened disease (tetanus) course
Transferred to ICU, Farthest Bed from Decreased frequency of stimulated spasms
the Station, with Quiet, Calm and
Dark Environment
Given Metronidazole, Diazepam and Decreased length of spasms, decreased
TIG and ATS trismus
Shortened disease (tetanus) course
 PREVENTION AAND PROMOTION
PREVENTION AAND PROMOTION
Seek proper medical consultation
Ensure proper and clean woundSEVERE TETANUS;
and surgical site care
consult for passive andINFECTED WOUND, GLANS PENIS
active immunizations
If diagnosed with tetanus:
minimize stimulation of spasms;
watch out for difficulty breathing, loss of consciousness
 PREVENTION AAND PROMOTION
PREVENTION AAND PROMOTION
Prevention:
Proper Wound Care
SEVERE TETANUS;
Immunization (Active)
INFECTED WOUND, GLANS PENIS
3 doses , 2 weeks apart
3 doses in infancy, boosters at
4-7 years of age, and 12-15 years
of age and one booster in adult