Death Round Presentation

DEATH ROUND
PRESENTATION
PRESENTER:- Dr. Natnael Getachew (MI)
03/20/2024 Death Round Presentation On Autonomic Dysfunction In A Pati 1

ent With Tetanus
Outlines
• Case presentation
• Scientific background
• Strength and weakness of the management
• References

ent With Tetanus
Case Presentation
• Name =XXX
• Age = 30
• Sex = M
• MRN = 004225/2014
• Date of admission = 16/02/14

ent With Tetanus
C/C:-Neck stiffness of 3 days
duration(16/02/14)
• HPI:-This is a 30 years old male patient presented with a
compliant of neck stiffness of 3 days duration which is
exacerbated during movement.
• He also had Hx of difficulty to open his mouth, swallow and chew
of same day duration
• He has Hx of back pain same day duration
• He has also a Hx of excessive sweating of same day duration,
otherwise
He has no Hx of trauma
He has no Hx of DM, HTN
He has no Hx of ABM, LOC
ent With Tetanus
Physical Examination
G/A= Acutely sick looking

 V/S= BP-153/82mmHg PR =128 RR =24 T = 36.3℃
Spo2=95%
HEENT= Pink conjunctivae, Non icteric sclera
LGS= No LAP
Chest= Clear chest with good breath sound
CVS=S1 & S2 well heard
No murmur, No gallop

ent With Tetanus
Cont’d
Abdomen= Flat abdomen which moves with respiration.
GUS= No CVA & SPT
INT= No palmar pallor, No rash
MSK= No edema
CNS= Conscious and oriented with GCS = 15/15
Tone hypertonic in all extrimities
Power 5/5 in all extremity
Meningeal signs are –ve
Ass’t:-Generalized Tetanus
ent With Tetanus
Plan
• To investigate with CBC, U/A and RBS
• Diazepam 10mg IV QID
• Metronidazole 500mg IV QID
• TAT 5000 IU IM stat on each right and left thigh
• Put on NG tube feeding

ent With Tetanus
Cont’d
CBC U/A
WBC Microscopy:- RBC/HPF 0-2
19500
Gran 70.3% WBC/HPF 0-4
Hgb Dipstick:- -Ve
16.9gm/dl RBS:- 112mg/dl
Hct 39.8%
PLT 314000
Lym 8.1%
Mcv 86.7fl
ent With Tetanus
Admission History(16/02/14)
• This is a 30yrs old male patient admitted with a diagnosis of
generalized tetanus after presented with compliant of neck
stiffness of 3 days duration & associated to this he has a Hx of
inability to move his back with related back pain which is
exacerbated during movement of 1day duration.
• He also had Hx of difficulty to open his mouth & swallow of solid
foods for the last 1 day
• He has Hx of excessive sweating of same day duration,
• otherwise,
He has no Hx of trauma ,fever and headache
He has no Hx of DM,HTN
He has no Hx of abnormal body movement, LOC
ent With Tetanus
Plan
• Put on NG tube feeding 300ml/4hr
• Chlorpromazine 25mg PO QID(added order)

ent With Tetanus
Progress Note(17/02/14)
• This is a 30yrs old male patient admitted with a diagnosis
of generalized tetanus after presented with compliant of
neck stiffness of 3 days duration & associated to this he
has history of inability to move his back with related back
pain which is exacerbated during movement of 1day
duration.
• He also had Hx of difficulty to open his mouth & swallow
of solid foods for the last 1 day
• He has Hx of excessive sweating of same day duration

ent With Tetanus
Physical Examination
G/A = Acutely sick looking

 V/S = BP-140/70mmHg PR =130 RR =20 To = 37.1℃
HEENT = Pink conjunctivae, Non icteric sclera
LGS = No LAP
Chest = There is coarse crackle over bilateral lower
posterior 1/3 of lung field
CVS = S1 & S2 well heard
No murmur, No gallop
ent With Tetanus
Cont’d
Abdomen = Flat abdomen which moves with respiration.
GUS = No CVA & SPT
INT = No palmar pallor, No rash
MSK = No edema
CNS = Conscious and oriented with GCS = 15/15
Tone hypertonic in all extremity
Meningeal signs are –ve
Ass’t:- Severe Generalized Tetanus + ?Aspiration
Pnumonia
ent With Tetanus
Vital Signs on 16/02/14
Date 1 2 3 4 5 6 7 8 9 10 11
BP 140/70 140/7 143/ 139/ 140/ 143/

0 87 94 80 84
PR 134 109 120 116 116 110
RR 20 18 20 24 24 24
Temp 37.3 37.4 37.6 37.4 36.7 36.5

r.
SPO2 95
(%)
RBS( 140
mg/
dl)
ent With Tetanus
Vital Signs on 17/02/14
Date 1 2 3 4 5 6 7 8 9 10 11
BP 150/70 142/78 143/87 142/72 140/85 155/84
PR 134 140 144 140 144 160
RR 24 28 30 34 32 38
Tem 37.3 37.4 37.6 38.4 37.7 38.5
SPO2(% 92 89
)
RBS(mg 140
/dl)

ent With Tetanus
Spasm chart
1 2 3 4 5 6 7 8 9 10 11 12
Date
16/02/1 √ √ √ √ √ √ √ √√ √√ √√ √ √√
4
17/02/1 √√ √ √ √√√ √√√ √√√ √√√ √√√ √√√ √√√√ √√√ √√√√
4 √

ent With Tetanus
Investigations after admission
 RFT :-Cr -1.62 CBC
BUN-53 WBC-23400
 LFT :- AST-26 Gran%-70.8%
ALT-22 Lymp%-11.9%
 RBS :-132mg/dl Hgb-14.6gm/dl
142mg/dl Hct-42.3%
Plt-278,000
MCV-87fl

ent With Tetanus
Plan
• Chlorpromazine 25mg PO QID
• Put on NG tube feeding 300ml/4hr
• Put him on INo2-5L/min
• Mgso4 40mg/kg IV loading dose
• Ceftriaxone 1gm IV BID
• Consider ICU Transfer

ent With Tetanus
ICU Admission History(18/02/14)
• This is a 30yrs old male patient admitted with a diagnosis
of generalized tetanus after presented with compliant of
neck stiffness of 3 days duration & associated to this he
also has history of inability to move his back with related
back pain which is exacerbated during movement of 1day
duration.
• He also had Hx of difficulty to open his mouth & swallow
of solid foods for the last 1 day
• He has Hx of excessive sweating of same day duration,
otherwise

ent With Tetanus
Physical examination
G/A = Acutely sick looking
 V/S = BP-153/82mmHg PR =164 RR =25 To =
39.1℃ Spo2=95%
HEENT = Pink conjunctivae, Non icteric sclera
LGS = No LAP
Chest = There is coarse crackle over posterior 1/3 of
bilateral lung field
CVS =S1 & S2 well heard, No murmur or gallop

ent With Tetanus
Cont’d
Abdomen = Flat abdomen which moves with respiration.
GUS = No CVA & SPT
INT = No palmar pallor, No rash
MSK = No edema
CNS = Conscious ,GCS 15/15
Tone-hypertonic in all extremity

ent With Tetanus
Cont’d
• In the process of taking consent at 12:59pm the patient
became bradycardic, restless for which atropine 1mg was
pushed and CPR was started immediately and continued
for 2 minutes where 1 mg adrenaline was given and the
pulse became 77 and patient intubated with ketamine
and the patient became bradycardic again. where 2 cycles
of CPR and 150J shock delivered for ventricular
fibrillation and CPR continued and rescue was achieved.

ent With Tetanus
Cont’d
G/A = Sedated
 V/S = BP-108/75mmHg PR =152 RR =28 To =
39.1℃ Spo2=97%
M.V. = T.V:-420
PEEP:-5
FIO2:-100

ent With Tetanus
Ass’t:- Severe Generalized Tetanus + ?
Aspiration Pneumonia + Immediate post cardiac
arrest
Plan
• Chlorpromazine 25mg IV QID
• Put on NG tube feeding 300ml/4hr & determine RBS QID
• Ceftriaxone 1gm IV BID
• UFH 5000IU SC BID
• PCM 1gm IV QID

ent With Tetanus
Cont’d
• Omeprazole 20mg po BID(NG tube)
• Morphine 5mg IV TID
• Propofol infusion 600mg/200ml NS and start infusion
16ml/hr escalate every 30min according to sedation
• Vecuronium 10mg/100ml NS and infuse 6ml/hr
• Repeat RFT
• Mgso4 1gm(50ml)/hr infusion after RFT

ent With Tetanus
ICU-V/S 18/02/14
1 2 3 4 5 6 7 8 9 10 11 12
BP 160/80 130/80 140/80 150/80 140/100 130/100 120/100 130/100 140/10 140/90 180/80 190/90
0
PR 180 175 165 172 175 178 165 165 170 150 80 60
RR 24 24 28 27 26 25 29 40 33 45 43 43
Tem 37.1 37.8 37.6 37.9 37.7 37.9 37.7 37.8 38.1 37.9 38.8 38.2
SPO2(%) 92 95 95 97 96 97 98 97 100 98 98 98
RBS(mg/ 139 148

dl)
ent With Tetanus
Immediate Cause of Death
(19/02/14)
• Cardiac Arrest Secondary to Autonomic
Dysfunction

ent With Tetanus
Scientific background

ent With Tetanus
Definition
• Tetanus is an acute disease manifested by skeletal
muscle spasm and autonomic nervous system
disturbance.
• It is caused by a powerful neurotoxin produced by the
bacterium Clostridium tetani and is completely
preventable by vaccination.

ent With Tetanus
Cont’d
• The Centers for Disease Control and Prevention (CDC)
defines probable tetanus as “an acute illness with muscle
spasms or hypertonia in the absence of a more likely
diagnosis.”
• Neonatal tetanus is defined by the World Health
Organization (WHO) as “an illness occurring in a child
who has the normal ability to suck and cry in the first 2
days of life but who loses this ability between days 3 and
28 of life and becomes rigid and has spasms.

ent With Tetanus
ent With Tetanus
Clinical Manifestations
• Tetanus produces a wide spectrum of clinical features
that are broadly divided into generalized (including
neonatal) and local.
• The clinical manifestations of tetanus occur only after
tetanus toxin has reached presynaptic inhibitory nerves.
• The most common initial symptoms are trismus (lockjaw),
muscle pain and stiffness, back pain, and difficulty
swallowing.

ent With Tetanus
Cont’d
• Spasm of the respiratory muscles results in respiratory
failure.
• Without ventilatory support, respiratory failure is the
most common cause of death in tetanus.
• Autonomic disturbance is maximal during the second
week of severe tetanus, and death due to cardiovascular
events becomes the major risk.

ent With Tetanus
Diagnosis
• The diagnosis of tetanus is based on clinical findings.
• History of an antecedent tetanus-prone injury and a
history of inadequate immunization for tetanus
• Culture of C. tetani from a wound provides supportive
evidence.
• Spatula test

ent With Tetanus
Ablett Classification of Severity of Tetanus

ent With Tetanus
Differential Diagnosis
• Drug-induced dystonias
• Trismus due to dental infection
• Strychnine poisoning due to ingestion of rat poison
• Malignant neuroleptic syndrome
• Stiff-person syndrome

ent With Tetanus
Management
• The goals of treatment include:
Airway and general supportive management
Halting the toxin production
Neutralization of the unbound toxin
Control of muscle spasms
Management of dysautonomia
Active immunization

ent With Tetanus
Airway and general supportive
management
• Admit patients to a quiet place, and in severe cases, to an ICU
• Bed sore prevention measures
• Intubation or tracheostomy, and mechanical ventilation in
severe cases
• Adequate hydration and early nutritional support
• Prophylactic acid blockers or sucralfate to prevent
gastroesophageal hemorrhage from stress ulcer
• Thromboembolism prophylaxis with heparin, or LMWH
• Physical therapy should be started as soon as spasms have
ceased
ent With Tetanus
Halting Toxin Production
1.Wound management
2.Antimicrobial therapy
Metronidazole (500 mg intravenously [IV] every six to eight
hours) is the preferred treatment for tetanus
Penicillin G (2 to 4 million units IV every four to six hours) is a
safe and effective alternative

ent With Tetanus
Neutralization of Unbound Toxin
Human tetanus immune globulin (HTIG)
A single IM dose (3000–5000 IU) is given
Equine antitoxin
10,000–20,000 U is administered IM as a single dose or as
divided doses

ent With Tetanus
Control of Muscle Spasms
1. Non pharmacologic- placing the patient in separate ward
or room designated for patients with tetanus, and Keeping
sensory stimuli to a minimum
2. Pharmacologic-
• Benzodiazepines and other sedatives —Diazepam has been
used most frequently, usual starting dose of diazepam for an
adult is 10 to 30 mg IV and repeated as needed every 1 to 4
hours, Large doses as much as 250mg QD could be used.
• Chlorpromazine, 25-50mg I.M. QID alternated with diazepam
• Neuromuscular blocking agents — cardiovascularly inert
non-depolarizing neuromuscular blockers are preferred

ent With Tetanus
Autonomic Dysfunction in
Tetanus

ent With Tetanus
Autonomic Dysfunction in Tetanus
• Autonomic disturbance is maximal during the second
week of severe tetanus, and death due to cardiovascular
events becomes the major risk.
• Autonomic involvement is evidenced by gastrointestinal

stasis, sweating, and increased tracheal secretions

ent With Tetanus
Cont’d
• Autonomic NS manifestations: tachycardia, arrhythmias,
labile hypertension, diaphoresis, and fever
• A combination treatment plan is recommended in the
treatment of autonomic dysfunction
• Several drugs have been used to produce adrenergic
blockade and suppress autonomic hyperactivity

ent With Tetanus
Treatment of autonomic dysfunction
• Sedation
• Deep sedation has been found to be important in
overcoming autonomic dysfunction
• Sedation on its own does not control sympathetic
overdrive and a combination of medication is therefore
advised.
• Benzodiazepines are the drug of choice
• Propofol has also been used as an adjunct to sedation

ent With Tetanus
Magnesium Sulphate
• The use of magnesium in the treatment of tetanus was
described in the beginning of the last century
• Magnesium acts as a muscle relaxant, blocks neuronal
and adrenal catecholamine release,
• Causes antagonism of calcium with subsequent
cardiovascular effects such as vasodilatation
• Dose = loading dose of 40mg/kg IV over 30 min, followed
by IV infusion of 2g/h for patients over 45kg and 1.5g/h
for patients 45kg or under
• Magnesium levels should be kept at 2 - 4 mmol/L
ent With Tetanus
Opiates
• In 1972, Rie and Wilson reported the successful use of
morphine to control autonomic dysfunction in a case of
tetanus
• Attenuates sympathetic efferent discharge within the
central nervous system
• Morphine sulphate maintains cardiac stability,
decreasing blood pressure and heart rate
• Fentanyl has been reported in to have the same effect as
morphine in tetanus

ent With Tetanus
Clonidine
• Clonidine is an α-2 agonist which works centrally in the
brain stem
• It decreases sympathetic outflow, inducing peripheral
vasodilatation, thus reducing arterial pressure
• It increases vagal tone, acts as a sedative and also
decreases motor activity
• It may be used in combination with magnesium, sedation
and neuromuscular blockade

ent With Tetanus
Dexmedetomidine
• Dexmedetomidine use has been reported in cases with
paroxysmal autonomic instability with dystonia and in
tetanus
• It is highly lipophilic and has an affinity for α-2 receptors,
with analgesic, anxiolytic, sedative and anti-sympathetic
effects
• It reduces plasma levels of catecholamines, maintaining
haemodynamic stability

ent With Tetanus
β-blockers
• β-blockers such as propranolol were used in the past but
can cause hypotension and sudden death.
• Only esmolol is currently recommended
• One of the earliest drugs attempted in the treatment of
sympathetic overdrive in tetanus was labetalol

ent With Tetanus
Cont’d
• Several drugs have been investigated or reported in case
studies for the treatment of autonomic instability in
tetanus
• As yet there is no single drug that will control autonomic
instability on its own, therefore combination therapy is
advocated.
• Dexmedetomidine holds promise for the treatment of
autonomic instability, although more studies are needed
• Treatment of autonomic instability in tetanus should be
individualised.
ent With Tetanus
Prognosis

ent With Tetanus
Management Pitfalls
• RFT test was not done at emergency
• History of vaccination was not documented
• Diagnosis of AKI is not included
• Urine output not followed at ward stay

ent With Tetanus
References
• Harrison's Principles of Internal Medicine 20 th Ed, (pages 1102-1105)
• UpToDate 2022 on the section “Tetanus”
• Medscape, on the section “Tetanus”
• STANDARD TREATMENT GUIDELINE FOR GENERAL HOSPITALS IN ETHIOPIA 4th Ed.,
(pages 478-482)
• BJA, Tetanus: a review of the literature T. M. Cook, R. T. Protheroe1 and J. M. Hande
• Hindawi, Tetanus Complicated by Dysautonomia: A Case Report and Review of
Management
• Pharmacological management of tetanus: an evidence-based review
• The treatment of autonomic dysfunction in tetanus G L Maryke Spruyt, MB ChB, MMed
(Surg); T van den Heever, MB ChB, MMedSc (Crit Care)
• CASE REPORT- Autonomic dysfunction in tetanus – what lessons can be learnt with
specific reference to alpha-2 agonists?
• CASE REPORT-Autonomic Dysfunction Because of Severe Tetanus in an Unvaccinated
Child
ent With Tetanus
Thank you

ent With Tetanus

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DEATH ROUND

03/20/2024 Death Round Presentation On Autonomic Dysfunction In A Pati 1

03/20/2024 Death Round Presentation On Autonomic Dysfunction In A Pati 2

• Date of admission = 16/02/14

G/A= Acutely sick looking

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G/A = Acutely sick looking

BP 140/70 140/7 143/ 139/ 140/ 143/

PR 134 109 120 116 116 110

Temp 37.3 37.4 37.6 37.4 36.7 36.5

BP 150/70 142/78 143/87 142/72 140/85 155/84

PR 134 140 144 140 144 160

Tem 37.3 37.4 37.6 38.4 37.7 38.5

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RBS(mg/ 139 148

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• Autonomic involvement is evidenced by gastrointestinal

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