Rosen & Barkin's 5-Minute Emergency Medicine Consult (706 page)

CT brain for altered mental status:

• Normal in tetanus
  

• Strychnine poisoning
  
• Jaw muscles usually spared or not involved early in strychnine poisonings
  
• Dystonic reaction to dopamine blockade
  
• Infection:
  
  • Meningitis
    
  • Rabies
    
  • Encephalitis
    
  • Peritonitis
    
  • Alveolar abscess
    
• Black widow spider envenomation
  
• Botulism
  
• Serotonin syndrome
  
• Hypocalcemic tetany
  
• Bell palsy (cephalic form, before trismus)
  

TREATMENT

• Evaluate airway carefully:
  
  • Endotracheal intubation complicated by trismus, vocal cord paralysis, and facial/neck rigidity
    
• Avoid excessive stimulation because it may provoke tetany of musculature.
  

• ABCs:
  
  • Prophylactic intubation
    
  • Require neuromuscular blockade due to trismus
    
  • Establish IV 0.9% NS
    
  • Monitor BP and cardiac rhythm (autonomic instability).
    
• Administer benztropine or diphenhydramine to exclude dystonic reaction.
  

• Focuses on 3 goals:
  
  • Stabilizing the patient and supportive care
    
  • Neutralizing the toxin
    
  • Removing any remaining organism
    
• Stabilization and supportive care:
  
  • Secure airway:
    
    • Prophylactic intubation may be necessary.
      
  • Paralytic agent may be needed in the setting of trismus:
    
    • Succinylcholine should be used with caution due to the risk of hyperkalemia from upregulation of acetylcholine receptors.
      
  • Treat muscle spasms with benzodiazepines; if large doses fail, can administer dantrolene.
    
• Autonomic instability therapy:
  
  • Occurs days to weeks after the onset of symptoms
    
  • Tachydysrhythmia and hypertension:
    
    • No treatment universally effective
      
    • α- and β-blockers can be tried but may cause worsening of symptoms (labetalol has been used for its α- and β-blocking effects).
      
    • Clonidine, magnesium, morphine, fentanyl, and epidural anesthesia may be tried.
      
  • Hypotension:
    
    • Rule out septicemia and hypovolemia.
      
    • Initiate dopamine or dobutamine when low cardiac output.
      
    • Neutralization of the toxin
      
• Human tetanus immune globulin (TIG):
  
  • 3,000–6,000 U IM for both adults and children
    
  • Administer
    before
    débridement of wound.
    
  • Neutralizes unbound toxins
    
  • No effect on toxin already bound in CNS
    
• Removal of remaining organism:
  
  • Limits the severity of the infection
    
  • Débridement removes any necrotic tissue.
    
  • Antibiotics are effective in eliminating
    C. tetani
    when used in conjunction with débridement
    
  • Metronidazole is the antibiotic of choice.
    
  • Penicillin is a viable alternative.
    
• Prevention:
  
  • Primary vaccination series should be completed by age 18 mo; children receive the booster at ages 4, 11, and then every 10 yr after.
    
  • Diphtheria, pertussis, and tetanus vaccine for children <7 yr
    
  • Tetanus diphtheria (Td) can be used for children >7 yr and adults.
    
  • 1 dose of Tdap should be administered to everyone >11 yr of age if not received previously to address increase in pertussis.
    
  • Clinical tetanus does not confer immunity.
    
  • For clean, minor wounds:
    
    • Td should be given if unknown prior vaccination history or >10 yr since last booster.
      
  • For tetanus-prone wounds:
    
    • Td should be given if unknown vaccination history or >5 yr since last booster.
      
    • TIG should be given if unknown vaccination or patient has never received the primary series.
      

• Benztropine: 1–2 mg IV
  
• Chlorpromazine: 10–50 mg IM
  
• Diazepam (benzodiazepine): 5–10 mg (peds: 0.2–0.4 mg/kg) IV
  
• Diphenhydramine: 50 mg IV
  
• Dobutamine: 2.5–15 μg/kg/min IV
  
• Dopamine: 2–20 μg/kg/min IV
  
• Doxycycline: 100 mg IV q12h
  
• Erythromycin: 500 mg IV q6h
  
• Labetalol: 20 mg (peds: 0.3–1 mg/kg/dose) IV q10min up to 300 mg PRN—start infusion 2 mg/min (peds: 0.4–1 mg/kg/h max. 3 mg/kg/h as needed)
  
• Metronidazole: 1 g (peds: 15 mg/kg) load, followed by 500 mg (7.5 mg/kg) IV q6h
  
• Penicillin G: 1.2 mU on 2 separate entries (peds: 100,000 IU/kg/24 h) IV q6h for 10 days
  
• Propranolol: 0.5–1 mg (peds: 0.01–0.1 mg/kg) IV
  
• TIG:
  
  • 250 IU IM
    
  • Administer in separate site from Td toxoid
    
  • For unimmunized or incompletely immunized in presence of tetanus prone wound
    
• Td 0.5 mL IM
  

FOLLOW-UP

All patients should be admitted to an ICU.

None for suspected generalized tetanus

Aggressive management is indicated for tetanus-prone wounds.

• American Academy of Pediatrics.
  Report of the Committee on Infectious Diseases.
  29th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.
  
• Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP), 2012.
  MMWR Morb Mortal Wkly Rep.
  2012;61:468–470.
  
• Hsu SS, Groleau G. Tetanus in the emergency department: A current review.
  J Emerg Med
  . 2001;20:357–365.
  
• McQuillan GM, Kruszon-Moran D, Deforest A, et al. Serologic immunity to diphtheria and tetanus in the United States.
  Ann Intern Med
  . 2002;136:660–666.
  

See Also (Topic, Algorithm, Electronic Media Element)

Immunizations

CODES

• 037 Tetanus
  
• 771.3 Tetanus neonatorum
  

BASICS

• Theophylline causes:
  
  • Release of endogenous catecholamines resulting in stimulation of β
    ₁
    - and β
    ₂
    -receptors
    
  • Adenosine antagonism
    
  • Inhibition of phosphodiesterase (at supratherapeutic levels)
    
• Available in immediate- and sustained-release formulations
  
• Peak absorption is 60–90 min with immediate-release and 6–10 hr with sustained-release formulations
  
• Acute overdose
  :
  
  • Ingestion within an 8-hr interval in a patient with no prior theophylline use
    
• Acute-on-chronic overdose
  :
  
  • Single excessive dose in a patient previously receiving usual therapeutic doses for ≥24 hr
    
• Chronic intoxication
  :
  
  • Accumulation of theophylline >20 μg/mL associated with prior therapeutic use for ≥24 hr secondary to:
    
    • Drug–drug, drug–diet, or drug–disease interactions
      
  • Use of serial excessive doses
    

• Acute ingestions require larger concentrations to achieve specific toxic effects compared with acute-on-chronic or chronic overdoses.
  
• Drug–drug interactions:
  
  • Inhibiting theophylline metabolism (leads to toxicity when started):
    
    • H
      ₂
      -receptor antagonists
      
    • Macrolide antibiotics
      
    • Fluoroquinolones
      
    • Allopurinol
      
    • Influenza vaccine
      
    • Interferons
      
  • Enhances theophylline metabolism (leads to toxicity when discontinued):
    
    • Carbamazepine
      
    • Barbiturates
      
    • Smoking
      
    • Rifampin
      
• Chronic theophylline accumulation:
  
  • Uncontrolled CHF
    
  • Liver disease (cirrhosis or severe hepatitis)
    
  • Acute viral infections