From the Pediatric Intensive Care Unit, Department of Pediatrics, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai 400 012, Maharashtra, India.

Reprint requests: Dr. C.T. Deshmukh, ‘Baug-E-Sara’, Ground Floor, 16, Nepean Sea Road, Mumbai 400 036, Maharashtra, India.

             Manuscript received: May 18, 1999;
             Initial review completed: July 7, 1999;
             Revision accepted: December 8, 1999

Tetanus is a neurological disorder with spasticity, muscle spasms and autonomic disturbances caused by the neurotoxin ‘tetano-spasmin’ produced by Clostridium tetani. Inspite of simple preventive measures available, tetanus remains a major cause of mortality in the developing countries. A 10-year retros-pective study reported a mortality of 39.3% amongst 56 cases(1). The literature has few reviews of tetanus in children(1-3). This study presents our experience as regards to the etiology, complications and outcome of post-neonatal tetanus.

The cases of tetanus between 1 month and 12 years of age admitted between October 1996 to July 1998 were evaluated retrospectively. Information including–sex, age, duration of stay in the hospital, mode of infection (otogenic/post-injury/unknown), grade of tetanus, incuba-tion period (IP), period of onset, duration of spasms, requirement of endotracheal (ET) intubation or tracheostomy, need for mechani-cal ventilation (MV), complications and out-come was recorded.

The management of tetanus cases was as per protocol. Strict aseptic technique was employed for tracheal toilet which was undertaken every 2 hourly or more frequently if required. All patients received 2000 units of tetanus immunoglobulin and 0.5 ml tetanus toxoid intramuscularly. They also received injection crystalline penicillin intravenously (1 lac units/kg/day; 4 divided doses) for 10 days.

Though many criteria have been put forth for grading tetanus(4,5), we followed the modified Patel and Joag criteria (Table I) as they were more objective. Doses of the sedatives (administered by nasogastric tube) were as follows: (i ) Mild Grade: Diazepam -20 mg/kg/day divided in 2 hourly doses; (ii ) Moderate Grade : Diazepam - 40 mg/kg/day divided in 2 hourly doses, and Chlorpromazine (CPZ) - 0.5 mg/kg/dose, 4 times a day; and (iii  ) Severe Grade: Diazepam-60 mg/kg/day divided in 2 hourly doses, Chlorpromazine (CPZ) - 0.5 mg/kg/dose, 4 times a day, and Phenobarbitone (PB) - 5 mg/kg/day in 2 divided doses.

Additional dose of diazepam (0.2 mg/kg/dose) was given for individual spasms as required. The quantity of diazepam was increased if spasms persisted. Additional drugs (CPZ and PB) were also added if the grade worsened. A dosage as high as 100 mg/kg/day of diazepam along with CPZ and PB was tolerated without MV by some of our patients. Patients who developed paralytic ileus or gastrointestinal (GI) hemorrhage were given intravenous diazepam as a continuous drip (2-3 mg/h).

Endotracheal (ET) intubation was under-taken for maintaining tracheal toilet or for MV. Specific sedatives or muscle relaxants (other than diazepam) were not used prior to ET intubation. Pancuronium (initial dose 0.1 mg/kg/dose and subsequently 0.025 mg/kg/dose) was used in patients who persisted with spasms inspite of high doses of diazepam (80-90 mg/kg/day) and when spasms made MV difficult. All patients were fed by a nasogastric tube after the first few days when stable. After 10 days of spasm-free period, the sedating drugs were first tapered and then omitted – PB, CPZ and diazepam in that order. Follow up after discharge varied between 1 and 3 months.

The Chi square test was applied to study the significance of factors affecting mortality.

Table I-- Modified Patel and Joag Criteria for Grading Tetanus

    Grade–Mild: £ 3; Moderate : 4-10; Severe : >10

The study comprised 40 patients, 23 males and 17 females with a mean age of 4.85 years (range - 6 months to 11 years). The age and mode of acquiring tetanus is shown in Table II. Otogenic tetanus was more common in the age group of 2-6 years while post-injury tetanus was seen oftner in children above 6 years of age. The duration of stay averaged 20 days (range - 2 to 51 days) for all the cases; 27.7 days (range - 9 to 51 days) for survivors and 8.4 days (range - 2 to 16 days) for patients who expired.

The average incubation period (IP) in post-injury cases was 8.6 days (range- 4 to 14 days). Determining the IP in otogenic cases was not possible because of chronicity of most otorrheas. Two cases presented with trismus and did not develop spasms. The period of onset, i.e., from trismus to the first spasm amongst the remaining 38 patients averaged 33.33 hours (range- 12 to 96 hours). All severe cases (n = 6) and 27 of the 31 moderate cases had a period of onset of less than 48 hours. The spasms lasted for an average of 4.76 days (range- 1 to 14 days). Applying the modified Patel and Joag criteria, 3 patients had mild tetanus, 31 patients had moderate tetanus and 6 patients belonged to severe grade.

Six cases (15%) underwent ET intubation for an average duration of 6 days (range- 2 to 15 days). Of these, 4 developed lower respira-tory tract infection (LRTI). A tracheostomy was required in 18 cases (45%), 16 of which were done as emergency procedure for laryngospasm or respiratory arrest. These emergency tracheo-stomies were required to be maintained for an average duration of 12.5 days. Fourteen out of 31 (45.16%) patients with moderate grade and 4 out of 6 (66.67%) patients with severe grade needed tracheostomy. Seven out of these 18 patients (38.9%) developed LRTI. Nine out of the 16 cases with emergency tracheostomy died.

MV was required in 14 patients (35%). The ventilation was via ET tube in 6 cases and tracheostomy in 9 cases with both modalities used in one patient. Ten of these (71.4%) required pancuronium in addition to the sedatives used. The average duration of MV was 113.14 hours (range - 24 to 360 hours), the indications being respiratory depression, laryngeal spasms and progressive pneumonias. Of the 14 cases with MV, 11 patients had moderate and 3 patients had severe grade tetanus.

The complications documented were - LRTI (11; 27.5%), tachycardia (9; 22.5%), hypotension (3; 7.5%), GI hemorrhage (2; 5%), paralytic ileus (1; 2.5%), and septicemia (2; 5%). These were dealt with by medical means, e.g., fluid infusion and ionotropic support for hypotension; vitamin K, ranitidine and blood replacement for GI hemorrhage, etc. In our observation, LRTI was more frequent in patients with artificial airway (i.e., ET or tracheostomy tube) with or without MV.

Fourteen out of 40 patients died (35%). Table III shows the factors affecting mortality. While sex, age, ET intubation and IP did not affect the outcome, the mortality was significantly increased in patients with tracheostomy, MV, autonomic instability, short period of onset (<48 hours) and duration of spasms of >3 days. Though the mortality was high in patients of severe tetanus (66.67%), post-injury cases (60%) and cases with LRTI (45.45%), these did not reach statistical significance.

During the short follow up of 1-3 months, no sequlae were noticed.

Table II - Age and Mode of Infection

Table III - Factors Affecting Mortality in Tetanus

Tetanus is an important cause of neonatal and childhood mortality in developing coun-tries. Fortunately, a decreasing trend in reported cases has been seen(2,6). The percentage drop in cases admitted to our institution has been from 3.84% in 1983 to 0.73% in 1996.

A male preponderance(1,2) and a high incidence in the 2-6 year age group(2) was confirmed in our study (Table II ). Prolonged hospitalization averaging 23-27 days reported by various workers(7-9) is in agreement with the 20 days amongst our patients. Only Mondal et al. report a shorter stay of 13.9 days(2).

Otogenic mode of infection was high (45%) in our study as chronic otitis media and the practice of local instillation of oil in the ear is common. Introduction of unclean fingers and contaminated objects in the ear could be additional contributory factors. Other studies have reported the incidence of otogenic tetanus to vary from 10.8% to 55%(1,2,10). The post-injury tetanus, more common in older children (Table II) and amongst boys is supported by earlier data(2) and is due to increased outdoor activities in these children.

The IP in tetanus may range between 2 days and weeks or months(11,12). A short IP and severe attack may result from a large quantity of toxin production by a highly toxigenic strain in a favorable tissue environment. The converse is also usually true; however, a moderately severe attack after a longer incubation period is known(12,13).

Complications such as respiratory infec-tions, autonomic imbalances (sudden cardiac arrest, sympathetic overactivity, hypotension/hypertension, bradycardia/tachycardia), hypox-emia, septicemia, GI hemorrhage, paralytic ileus, urinary tract infections, vertebral fractures, decubitus ulcer and constipation have been reported(2,3,5,7-9,11-16) and contribute to the high mortality rate(3,4,7,9,13-16). These may occur as a part of the disease or due to therapeutic interventions. The theory put forth to explain the occurrence of autonomic instability includes the effect of tetanus toxin on the brainstem and autonomic interneurones impairing baroreceptor reflexes and leading to refractory hypotension. Other mechanisms postulated include a direct effect of the toxin on the myocardium and a loss of adrenal inhibition(17,18). In heavily sedated patients with artificial airway and on ventilatory support, there is suppression of protective airway reflexes and pooling of secretions (inspite of appropriate airway toilet) which can be aspirated. In our experience, LRTI in patients with artificial airway and/or MV and autonomic instability were the commonest complications.

Mortality has been reported to vary from 10% to 39.3% in various series(1-3,7,9, 13,15,16) depending on the age group, grade of tetanus, availability of intensive care, complications, etc. In our study it was 35%. Measures like early tracheostomy, elective paralysis and MV, and following an established treatment protocol are said to decrease the mortality(7,13-15). Like the previous studies(4,16), we did not find any effect of age and sex on mortality. Though Mahoney(10) reported a low mortality (17%) in cases of otogenic tetanus, this observation could not be statistically supported in our study (Table III ). Unfavorable conditions for the growth of the organism in the ear-canal resulting in decreased or delayed production of toxin coupled with poor absorption is said to explain the low mortality in otogenic tetanus.

A severe attack and poor prognosis has been reported with a short IP(4,11-13) but our study did not support this. Like others(4,11-13), we found a high mortality and severe disease associated with a short period of onset (Table III ).

A factor not emphasized earlier is our observation of high mortality in patients with persistent spasms (Table III). Risk of hypoxia and aspiration associated with laryngospasm increases the risk of death. The statistically higher morality (55.55%) amongst tracheo-stomized patients in our study may be due to the severity of their disease resulting in the need for an emergency tracheostomy. Mahoney(10) has also reported mortality of 37% in tracheo-stomized patients. Early tracheostomy with good monitoring and nursing care has been advised by many(12,13,15) to decrease mortality. Critically ill patients requiring MV had higher mortality (57.14%) in our study. The need for elective MV in cases with moderate and severe tetanus has been emphasized earlier(3,12,15). Our patients were not electively ventilated.

We conclude that otogenic tetanus is the commonest mode of acquiring the disease in post-neonatal age group and the outcome of the patients depends on the severity of the disease and complications encountered.

We thank the Dean, Seth G.S. Medical College and KEM Hospital for giving us permission to publish this article.

Contributors: MST participated in data collection and drafted the paper. CTD co-ordinated the study, helped in drafting the paper and will act as the guarantor for the paper. JRK supervised the study and also helped in drafting the paper.

Source of funding: None.

Competing Interests: None stated.