Thank you very much. So yeah, so this evening we're going to be talking about nursing the tetanus patient. And these are some of sort of the best cases to look at, look after in my opinion.
So, hopefully this evening we'll go through what tetanus actually is and the clinical signs that we expect to see with tetanus. We'll go through the diagnosis and the treatment options available. And then we'll go through the nursing skills, and some case examples at the end as well.
So what actually is tetanus? Well, we know that it's an infection and it's caused by bacteria, and the bacteria that causes it is called Clostridium tetini. And this gets into wounds, it really likes deep penetrating injuries because it really thrives in an anaerobic environment, so sort of warm and sort of no oxygen.
We can also see tetanus acquired through parttrician, so patients that are giving birth, through teething and actually in puppies, and also some surgical wounds, although that is much rarer. So we want to see some sort of wound in our patients that present to us with tetanus, because we need to have had the patient's mucous membranes exposed to that Clostridium tetini. It lives in soil, so it does tend to be wounds that have been caused outside.
So we see a lot of dogs that have broken a nail, whether they've been out in the garden and possibly teething puppies. Maybe they've been chewing on something out in the garden, but as I said, we can see them from other other injuries as well. And what does it actually do?
So once we've got these anaerobic conditions and and it's like the perfect environment for that bacteria, that bacteria releases two neurotoxins. The first one is tetannolysin, and that causes local tissue damage and causes the bacteria to multiply. And the second one is tetanus spasmin, and that prevents inhibitory neurotransmitter release, which causes the continued contraction of all skeletal muscle and a hypermetabolic state for that patient.
This travels through the peripheral nerves through to the central nervous system. And then depending on how much of that toxin is there, some patients might just have localised symptoms, sorry, apologies for the, localised symptoms. So if they've got that wound on 1 ft, they might have localised symptoms on that leg.
But some of them might spread once it's reached the CNS through the body, and that's when you'll see these patients that have definitely the facial signs and also muscle stiffness around the whole body and a different gait. So what about vaccinations? So we know that obviously we, we are vaccinated as people and especially those of us working in the veterinary industry.
If we ever have a dog bite or a cat bite and we do have to go to hospital, they will always give us a a a booster for that vaccination. But why don't we vaccinate our dogs and our cats? That's because these, these animals, so a lots of animals are affected by tetanus, but they tend to have a higher natural immunity than we do.
And cats especially have a natural higher immunity compared to dogs as well. So we do see some cats present with tetanus, although it's much rarer, and they are the ones that tend to have more localised symptoms. So they generally don't progress to their whole body.
So they might just have a stiff limb and sort of have treatment and get better from that. So we're now gonna just talk about some clinical signs that we might see. So the first one is called Rhesus sardonicus, and that's our sardonic grin.
And that is literally what we see with our, our, our face with these patients. So we have the ears pinned upright. They kind of almost look shocked or surprised all the time.
These patients will also have stiff limbs. They might have an abnormal walking gait, especially if their limbs, all of their limbs are affected. They might suffer with muscle tremors, whether that be on one limb or whether that be sort of all over their body.
And muscle tightness as well. And here are just a few examples of patients that we've seen in our hospital, of the rhesus sardonicus. So that sort of facial, facial expression that we can see.
So they kind of looked a little bit shocked and surprised. You can see that their eyes are much more open than they would normally be and their ears are pinned back, and this is kind of the classic sign that we will see with a patient walking into the practise. So I've got some videos here, so hopefully they'll work for us, just sort of demonstrating the tremors.
So this first black Labrador here, if you just noticed at the start of the video, she's got some quite severe muscle tremors in those hind limbs, and you can see also she's quite panty, she's quite distressed, and she's got this rhesus sardonicus. Much more difficult to see obviously because she's, got black fur, so her expression's more difficult to read, but it's definitely present. The second Labrador we've got here is Paddy, who we'll speak about later.
He was a long-term patient of ours, and this is actually once he's sort of been through the worst of his tetanus and he was recovering. But you can see that he is still very severely affected by those neurotoxins. He has a very severe muscle tightness and definitely an altered gait because of that.
So even though he was very happy and we did have tail wags from him, you can see that those tremors and that muscle stiffness is really affecting him as well. OK, so moving on. So, diagnosis.
Currently, we do not have an easy access to diagnosis of tetanus in veterinary patients. And so generally what will happen is a patient will present to us and based on their clinical signs and their history from the owner, we'll then treat them on that indication that it probably is tetanus. And thinking about it really, would it change our treatment if we knew for certain, actually yes, that's tetanus or not?
Probably not. I think we're gonna look at these patients and treat them supportively whether or not we have a diagnosis. And so actually it's not something that our, our vets worry about at all.
So we'll go through some treatment options. So there are 3 different aims of treatment associated with tetanus, and the first one is that we want to neutralise circulating neurotoxins. The second is to prevent multiplication of the current neurotoxins that are already there.
And the 3rd is the supportive care, which obviously includes our intensive nursing care of these patients. So our first line of treatment, we want to neutralise those circulating toxins, and we've got two ways of doing this. The first one available to us is the antitoxin.
This is given by a subcutaneous injection and it works by binding to the neurotoxins which are circulating outside of the central nervous system. For this reason, we would only really be giving this antitoxin if we're seeing patients come in to us that do not have too bad general signs. So if they've got localised symptoms to one limb, then those would be the candidates to do it for.
But if we have a patient who is really struggling and they have deteriorated quite far already, then these patients have, it's got limited efficacy in those patients, so those patients will probably not receive it. There are risks associated with giving it as well, so it is known to cause anaphylaxis in quite a large percentage of patients. And for that reason, our clinicians will give it on a case by case basis.
So we do not have a hospital protocol for giving the antitoxin. It is literally based on whichever sort of vet is looking after that case and what they would like to do. So because of that, yes, it's not something we do with all of our, our cases.
And then the second thing that we can do to neutralise the circulating neurotoxins is actually to try and remove the source. So to do that, if we've got a wound injury that is obvious to us, for example, if it is a toe injury, what we will normally do is have that patient X-rayed to look for the presence of osteomyelitis, and then depending on the severity, we might amputate that limb or do a debridement of the wound in order to try and lessen the circulating toxins from that wound. So the second line of treatment that we want to do is to prevent multiplication of the current neurotoxins, so try to sort of neutralise the ones that are already there.
The way that we do this is by administering antibiotics, and most commonly in veterinary practise, we will administer metronidazole or penicillin. And these will work by destroying the residual Clostridium tetini available to that patient, and therefore will reduce the amount of circulating toxin. So then moving on to our supportive care.
So this includes our intensive nursing. So, here's a video again of Paddy. So you can see here the severity of these muscle tremor that that they have.
So this is him sort of having a tremoring episode in this kennel. And if you can imagine actually that those muscle tremors are that severe for that length of time, we can actually get, sort of hypothermia as well. So we might have a hypothermic crisis if we let that patient continue like that.
So in order to try and control muscle spasms, we might have our vets prescribe an anti-convulsant such as diazepam or midazolam. And we would normally give this in a continuous rate infusion in order that we can titrate it effectively to that patient. All patients with tetanus will also be prescribed methocarbamol, which is a central muscle relaxant, and this is only available in tablets, really to us at the moment.
So we'll normally give this orally if the patient has come in and is able to swallow appropriately and we think it's safe, or we can give it rectally as well if the patient deteriorates. And the way that we tend To give it recti to crush it with water and use a Foley catheter just so that we can get definitely as much of that absorbed as possible. And then again, once that patient starts to recover and get better, if they're then eating orally, we will also give it orally as well, or possibly down a feeding tube.
So then our next sort of line of treatment in our supportive care will be to look at analgesia. Human literature shows that people with tetanus note that it is very painful, and not just sort of the muscle tremors, but actually you, you can cause fractures in your own body by having these muscles contract so severely. So it is a very painful thing.
And so for our patients, especially that they can't tell us how painful they are, we really need to make sure that we're on top of it. We look at opioids being our first choice for these patients, and that is because they are also helpful towards our sedation plans for them. We can titrate the doses really well, and we can reverse them in an emergency if we need to.
So we'll often give these again in a constant rate infusion. And we tend in our hospital to go for fentanyl. We favour fentanyl at the moment, followed by methadone bonuses once that patient is recovering and much more alert and better.
So then looking at the complications that we see that are associated with the tetanus, the first one, that we want to think about is aspiration pneumonia. And this is actually what most tetanus patients will die from. So this causes the most deaths in our, in our tetanus.
The next one is respiratory arrest, and that is if the neurotoxin starts to affect the respiratory muscles in the diaphragm. We see patients having upper respiratory tract obstruction, both due to laryngeal spasms, but also a buildup of mucus. And again, as you can probably imagine, this is more likely to happen in brachycephalic breeds, but it definitely does happen, and I have seen it happen in Labradors and dogs with much better confirmation.
And the last one that we know that we see quite regularly is actually something called an autonomic storm. And unfortunately this process still isn't entirely understood, but the things that we want to look out for that normally precede this autonomic storm are a sudden change in the respiratory rate or heart rate. So we'll see both Brady and tachycardias with this.
A patient might have had an unusual pyrexia for them that day. They could then have a hyper or a hypotension, and they might have urine retention or constipation, and an increase in bronchial secretions. And a combination of these will normally lead to a cardiac arrest in these patients.
And again, when that does happen, unfortunately, we're limited as to what we know about that. So now moving on to the nursing skills, because these patients are very important, sort of to nurse properly and they're very, very rewarding for us. So we know that we're gonna have to really spend a lot of time with these patients.
They normally have quite a long hospital stay if they progress further enough. And so once we've looked after them and they, they get better and they leave the hospital, it is super rewarding. So these patients, we want to think of them as a whole, they are very, very critical and so we might want to look at Kirby's rule of 20 so that we can sort of help ourselves not to forget anything.
We want to be taking care of these patients when they're recumbent, so we want to monitor them, look after their eyes and their mouths, definitely protect any airway and have an airway emergency plan. We'll look at their environment as a whole. Definitely we'll think about sedation and then their bedding, nutrition and physio.
So they're quite nursy patients. So first up is our patient monitoring. So we want to be able to monitor these patients closely, but we also don't want to disturb them too much.
So it's a bit of a catch 22. We want to to look at them really closely, because they are so critical, but at the same time, by going in and interfering with them too much or increasing the amount of noise, then actually we can make them worse. So placing them on a multi-parameter monitor with an ECG might be suitable, and we tend to do this with our patients and have them monitor outside of the kennel.
Normally with the alarms turned off, if we can be sure that somebody is definitely looking at that very frequently, just so that we don't have any sudden noises or anything around that patient. We want to really continuously look at their SPO2 as well, especially once these patients are recumbent because we are always on the lookout for respiration pneumonia. That is one of our biggest concerns.
So making sure that if even if we're not doing this on a continuous sort of rate that we are definitely checking it intermittently throughout the day and night. We want to check their blood pressure and also take regular bloods to check for electrolytes and hydration and also their glucose and lactate. We want to look after their eyes, and we want to check really regularly their corneas for any ulcerations, and we might consider fluoroce staining them every other day, possibly in these patients, because they are on long term opioids as well, and we want to make sure that we're lubricating their eyes very frequently.
And also due to the fact that they can't really blink as well as they normally would, we wanna make sure that we're flashing their eyes at least twice a day with the saline wash. But just making sure that they're lubricated really well, it normally is sufficient. For that oral care.
In our hospital, we will use Corsool, the daily one, we'll use that at a rate of 50/50 with saline, and we'll normally keep that in a bag for about 24 hours before disposing of it. And our patients are dotted up on their hospital sheets for the nurses to check them every 2 to 4 hours and just to use a swab to basically clean their teeth and then go under and around that patient's tongue. It might be worth having a suction machine nearby in our recumbent and various stated patients because light suctioning might be useful in order to try and limit the amount of secretions that are in those mouths.
We want to make sure that their mouths are really moist and that the tongue is also kept inside the mouth to prevent swelling. So unlike patients that are having a GA for a procedure where we, we will get into that habit of pulling the tongue out of the mouth to check the colour, we'll get swollen tongues very quickly with that in our patients that are awake. So we want to keep the tongue inside the mouth.
If we do. If you have any swelling, we can, we can put glucose on that tongue and keep that tongue really moist in order to try and reduce it to get it back inside the mouth. But prevention is always better than the cure here, so we don't wanna create extra worries, in terms of upper airway obstruction by by pulling that tongue out.
And then it's always worth saying in any patient that you're going to be doing anything around the mouth, just to make sure that you don't get bitten. These patients especially, they don't have a lot of control around what they're doing with their muscles, and we have had nurses bitten by patients who weren't trying to bite them, but because they've had these muscle contractions, they have been bitten while they've been doing their oral care. So just taking extra care in these patients when you're doing this.
So the next thing we want to think about is their airway and their oxygenation. And because we have these complications with aspiration pneumonia, it might mean that these patients eventually need airway protection, or possibly oxygen supplementation to get them through. So as I said earlier, we want to check really regular SPO2s, and that's very non-invasive, so that's something we can all easily do.
If we have the facilities available, it is possible to just check their oxygenation using an arterial blood sample, but the SPO2 really should be useful to us in order to gauge how that patient is doing. In patients who only have sort of mild issues, we might be able to use nasal prongs, which should be readily available with oxygen for supplementation, and that might be enough for them. But it is possible they might require intubation or, or even tracheostomy tubes in some of these patients and possibly some more interventions if they end up doing much worse.
And as we said earlier, aspiration pneumonia is the biggest reason for, for us having these patients die on us. So in the most severe aspiration pneumonia cases, we might think about mechanical ventilation. And another reason tetanus patients might end up on a ventilator would be for that respiratory arrest due to the muscles not quite working around their diaphragm.
By ventilating these patients, it does enable us to control their airway and also to be able to give them 100% inspired oxygen, which would be really great. We can also anaesthetize or at least have very heavy sedation on these patients, which might limit their muscle spasms and also help us with temperature regulation as well. However, mechanical ventilation is very costly.
It requires obviously a lot of specialist equipment, and the team sort of knows how to use the machines and also how to nurse those patients. And there are also complications associated with putting patients on a ventilator. So it's not something that is done, really quickly.
We can see ventilator acquired pneumonias amongst many other complications from doing that. So, it's definitely not something that we do a lot. So we really want to be prepared for any emergencies that happen.
So if we have a tetanus patient in the intensive care unit, the first thing that we normally do is get a tray ready by their kennel, that has a dose of propofol there, the laryngoscope, some sterile ET tubes of a couple of sizes, if we're not sure. We will try to keep a suction machine near them to be able to aspirate their airway if we need to. An amput bag in case we do have respiratory arrest, or a circuit with a bag for IPPV if that's available to you.
And then sometimes, depending on how severe the patient is, we might draw up a dose of atropine and adrenaline just ready just in case. But just making sure that your crash trolley is really well stocked and that it's regularly checked should also be enough. So then thinking about the environment, so noise and light, we want to avoid really loud and bright rooms.
So if you do have a busy hospital, trying to think about an area in the hospital that is away from other noisy inpatients. If you're seeing patients that are coming in for sort of procedures for the day, that are going to be very disturbing for those patients. So somewhere quieter.
So if you've got a dog ward, maybe the kennel at the back of the dog ward, but also knowing that you need to monitor them closely. If you've got dimmer switches, maybe dimming the lights as much as you can or off completely in some patients if they're really struggling. You can also place cotton wool balls in their ears, but just sort of make sure that everybody knows that they're in there, whether you mark mark their head with a bit of tape or something so that everybody knows that that dog has cotton wool down there just to help you with limiting the amount of exposure to sounds that they have.
Sometimes we will cover the front of their kennel if they're getting very easily disturbed by people walking in front of it, but what I would say is to have huge caution with covering the kennel, because if you're not having somebody monitor that patient very, very closely, these patients are the type of patients that could have a crisis very quietly and something could be missed. So making sure that if you are going to go down covering the kennel route, that you do so with huge caution. And definitely go slowly and calmly when treating these patients so that you're not exciting them, because especially once they are deteriorating and sort of in their most sick phase, any sort of excitement might lead them to have episodes of tremoring and hypothermic crisis, which is what we really want to try and avoid.
In order to try and do this to the best of our ability, we really must ensure that the whole team is involved and really invested in that patient's care. So, what we often find useful in our hospital, we are very large, and definitely have lots of different teams that might not be aware about what is in ICU at the time. So if we have a critically ill tetanus patient.
In ICU we'll send out emails to the team and we'll put signs on the doors so that everybody knows if they're coming into the intensive care unit that they're expected to be as quiet as possible, and sort of to only be in there if they really need to be. And that's the only way that we're going to sort of get these patients, to have the best environment is if everybody knows that that's the rule. So then our sedation plans.
Basically all of our tetanus patients, when they're admitted, end up having some form of sedation, whether that be sort of a one-off bolus if they are really not that severe, to having, as you can see here, obviously quite a complicated plan. We want to give them these sedations to try to help them with their muscle tremors and their spasms, and also to try and then prevent them having a hypothermia, which could increase the likelihood that they might have an aspiration if they're producing lots of mucus or if they have a regurgitation, if they get really, really hypothermic. And so they definitely will need some sedation.
We would always favour a continuous rate infusion over abolus in order that we can titrate it better to effect. We'll often give our patients midazolam as a CRI to treat those tremors, and we'll think about adding in possibly meatomidine or dexedatomidine. We'll keep a bottle of ACP there and available unless there are obviously any contraindications for a particular patient.
But just so that we have that as standby if our patient appears to have an episode of tremors, which can be. By by sort of an unusual amount of sounds. So for our patients, what we might see is that they've been really, really settled throughout the day or the night shift, and then it's sort of rounds time where staff are changing over and there's just a little bit more noise, you know, despite everything, trying to keep everybody calm, just that kind of change in staffing levels might be enough to set them off on having an episode.
We also will have propofol, possibly on standby for those emergencies, but also in the most severe cases, we might have continuous rate infusions of those as well. And also our opioid analgesia, which, as we discussed earlier, is important for their pain management, but also will help us in our sedation plans. So what to do if our patients do have this hypothermic crisis.
So we wanna be able to make sure that again they're in the quiet and dark room as dark as possible. We might want oxygen therapy on standby for these patients and make sure that these patients have a really good sedation plan. So if these patients are having continual bouts of tremors and hypothermia, then considering having a heavier sedative given to those patients.
We want to make sure we've got that emergency ready to go, the emergency tray ready to go, and also the suction machine by that kennel and ready to go as well. We might put some ice packs, sort of between their groyne and their axillas. So as you can see here, we've got some ice packs in incontinence sheets just so that we're trying to cool these patients down.
So where sort of there's a lot of blood flow in order to try and help us cool them down quickly. This patient does have an air fan device to try and cool the air around them, but definitely caution to not pointed at the patient's face, because again, they're not closing their eyes very brilliantly. So we want to make sure that we're reducing the impact of that fan so that we don't get any unnecessary corneal ulceration.
So then thinking about the bedding that these patients are on. We want to make sure that it's very soft and comfortable because they are normally very recumbent, and vet beds used normally are really, really good. So obviously they are designed to wick away moisture from these patients.
So using vet beds to put under patients' heads in case they've got an excess production of saliva, and definitely if these patients haven't got urinary catheters in or anything, just having these vet beds used appropriately is really good to try and wick away moisture from them. We wanna make sure we're changing the beds really often, especially if they are getting saturated and padding out the kennel, so that we try to prevent any bed sores, but also in case these patients have tremors and they sort of throw themselves about so that they're not injuring themselves. Having a really comfy squishy bed is also helpful to us with noise absorption.
And these patients also might might require some bolsters or pillows in order to try to position them appropriately, and also the appropriate physiotherapy is important as well. But just making sure you're turning them every sort of 2 to 4 hours, and pillows and bedding can help you in getting them into those positions because once they're. Very tremogenic.
They, they are very stiff, so they're very difficult to position well without, without bedding and bolsters. So looking at our nutrition options, tetanus patients require at least 200% of their resting energy requirement. And that's because of the increased sort of muscle spasms and contractions they're having, because they might have developed a pyorexia.
They have increased requirements because of their increased metabolic rate and also because these patients are also critically ill. So they they sort of meet all the general requirements of a critically ill patient to increase their RER. Most tetanus patients lose weight in recovery.
I don't think I've ever seen a patient leave the hospital the same weight that they came in, despite everybody's effort. And so it is important that we get their RER into them as soon as possible in order to aid their recovery. Some of these patients won't be safe to have oral nutrition, and so we will think about placing a feeding tube, so thinking about NGs or esophageal feeding tubes versus parentinal nutrition, as you can see in this bag here.
So when we're calculating the RER, normally we'll do the body weight times 30 plus 70, and that's a normal healthy animals, adult animals RER. So for our tetanus patient, we want to just time this by 2. So for this 30 kg Labrador, we're looking at around 2000 calories a day for that Labrador.
And then if we're thinking about placing feeding tubes, what our our clinicians will normally go for is our esophageal feeding tubes. And these are normally chosen over NGs or NO tubes due to the risks of aspiration pneumonia. So obviously the further down we go, the the sort of reduced risk of that happening.
They can also be left in for much longer than NG and NO's, and also for these patients because they're in for a long time, that might be beneficial to us. And we also can have different diets given to these patients because often the, the tubes are much larger in their diameter, so we can give thicker liquids. So if a patient requires a special diet, then we can also think about blending that and putting that down this tube as well.
However, we do have a general anaesthetic and we have to have a general anaesthetic to place these and that is risky in the tetanus patient. And so what we'll normally do is once our patient has arrived and is more stable, at the same time that we might be X-raying their affecting toe or if they're having a digit amputation, they'll also have this placed maybe along with the central line, in order that we can take bloods from them regularly and sort of give all the fluids and medications they need. When we've got a feeding tube in place, we want to ensure that the feeding tube is labelled really appropriately, especially if you're in your hospital you are using jugular catheters because they're obviously in the same sort of place, and we don't want any confusion over that.
We want to make sure we're doing daily or twice daily stoma checks of them. I would say definitely twice daily initially, but once they are more established, then daily should be fine. We want to redress them as aseptically as possible and place neck bandages, but making sure they're not too tight, because again, we want to reduce anything that might impact this patient's airway.
We want to make sure that we've got feeding plans for them, and again that is patient dependent, but we will normally do about 4 hourly feedings and that normally suits most of these patients. When feeding them, you want to feed them really slowly. You want to make sure that they are in a sternal position, as external as you can possibly get them, and you want to observe them really closely for tolerance.
So definitely stop if there's any coughing or respirate changes, but also if they look nauseous as well. We don't want to cause any nausea and alert your clinician. So I would say for these patients, these are really important that you sit with them, the whole.
Time that you're giving them this speed, and probably for at least 10 minutes afterwards to ensure that they're not having any complications and that you're happy for them to go back to lying in a lateral recumbency, because these patients, as I said, are difficult to prop up into sternal, as in sort of the worst stages of their disease. So then looking at that parental nutrition that we discussed, if we are unable to place a feeding tube immediately for whatever reason, or if this patient is unable to take food orally, then we will often put patients on parental nutrition, even if it is just sort of a temporary solution. It is just a white emulsion and it contains all the kind of sugars and amino acids that these patients need to try to sort of help them along with their recovery.
And as you can see, it comes in quite a large bag in these different sections which are separated, and then before administration, you have to kind of pop them, which is quite satisfying, and sort of mix the liquid up, and then write on the expiry date. So they only last 2 days and then you want to change them. If we are using parental nutrition, it needs to be set up aseptically, so wearing sterile gloves and making sure that everything is done as aseptically as you possibly can, because this is food that you're giving, so it is a perfect breeding ground for any bacteria.
And due to that, we will tape up all ports on the giving sets to prevent any interference from anyone else. So just in case there are anybody in the hospital that maybe is not quite as sure as you are sort of setting up with these things so that we can make sure we're not giving any flushes into that line or medications because once this line is set up and attached to the patient, it should not be removed until it is being removed finally. PN must go into a fresh IV and it needs to be a clean stick and it can't have been used for anything else.
So once you've placed the IV we can flush it with some saline, but then that must be it. We cannot administer any medications into that line or then have any flushes because all of these sort of interactions with the IV are opportunity to introduce bacteria. Once we have a patient connected, it is a closed circuit.
So if this patient is awake and going outside for walks, for example, then we would take the bag with the patient outside with us. So it's a little bit cumbersome, but it's very important that we make sure we're all doing that. Every 48 hours we will either change the bag and once we do, once we change the bag, we'll change the giving set and everything along with it, or we'll remove it fully.
And every day we want to check at least once or twice a day that we're checking the IV for phlebitis and cellulitis and infection as well. So we also want to monitor these patients' ins and outs with their fluid balances. We might want to take regular bloods in order to check their kidney function, but also to monitor their urine output.
We want to always note as well how much fluid we're giving, whether that be entrally or parentally. So maybe having a a separate sheet for recording might be useful for you, if this patient is receiving a lot of fluid. And there are different ways in which we can monitor our urine output in our tetanus cases.
And one of the most common ones that we'll have in our very recumbent patients is that we might have a urinary catheter in place. And if we do, then we'll do our urine output from that, and that's sort of very simple and very clean for us. We will also really regularly weigh that patient, so probably at least twice a day if we can.
If they're very large and very recumbent, then we will just do that once a day. And especially if it is affecting that patient in terms of making them have a sort of tremoring episodes and things, then we'll obviously not do it because that's sort of more important at the time. But definitely if they're small or if they're cats, then we can, we can weigh them really frequently.
We could also think about weighing a litter tray in cats, or at least weighing bedding again. Or we could take a free catch sample. So if our patient actually is up and walking around, then taking a free catch sample and measuring their urine output from that would also be fine.
Patients in the hospital might require fluid therapy, and we are normally instructed to match the ins and the outs with the fluid therapy as a supplement. If we do have a urinary catheter in place, we want to make sure that at least every 4 hours we are cleaning the whole line and we will normally go from the prep use or vulva all the way down to the bag. We'll never go back up from the bag because we don't want to introduce bacteria, so just always from top to bottom.
There is always a risk of a UTI in all of our catheterized patients as well. And so for that reason, our clinicians might decide that it really isn't the best thing for that patient. And so that's when we'll have to think about other ways of, of managing them, both their urine output but also their cleanliness.
So it's very important with our Titanic patients that they have regular physiotherapy from sort of the moment that we are having them in the hospital. And it has been known that patients will break bones or rupture tendons just from the strength of those contractions that they're having. So making sure regular physio is done would be really beneficial to all of them.
So sometimes we will put them on a peanut and we'll have sessions on a peanut in order to try and give them really good physiotherapy, especially if they are tolerant to that without it sort of distressing them too much. Some of them really like it and it is something that we normally do once they're starting to feel a little bit better. And just sort of a bit of TLC and getting them outside is also really important.
So, once they're up and walking, just giving them some muscle massages outside maybe especially if it's nice weather, to try. To sort of loosen those muscles up. They really enjoy it, I think, the massaging, but just making sure as well that you're not getting them too excited.
So, for example, this little dog, she would tolerate a certain amount of time outside, but then actually it would be less beneficial to her. So we would always know actually once her time was up to get her back to that kennel and pop her back on the sedation in order that she doesn't become hypothermic. So then thinking about our client communication, which is obviously super important, we want to ensure that clients are always forewarned that there is going to be an anticipated long hospital stay.
I think our average tetanus patient admitted to intensive care is there for about 3 weeks, and they normally will progress in hospital first and get worse before they start to get better. So sort of just making sure that those owners are aware that that is the case and that that will probably happen with their patients. And because of that, there is obviously a huge financial aspect involved.
These patients are not cheap to care for. The prognosis normally is pretty good, but as we said, there are lots of complications that are associated with tetanus and some of them can be very, very severe and cause fatalities. So just kind of being honest about those prognosis, but giving daily daily updates is very important.
And then sort of normally, in our normal circumstances, we actually don't often have patients with tetanus, their owners coming in to visit. And that is because they tend to get very excited, and that again causes them to have hypothermia and lots of complications. So if we're not sure how a patient will tolerate an owner visit, we might allow it once to see how it goes, but it is very uncommon that owners will visit, especially when the patient sort of is in the worst stages of the disease.
And I think again, just being honest and clear, sort of within your client communication and your team communication really will just improve everything for everyone. So now we're just gonna go through a couple of case examples. So Paddy was an absolute favourite of ours.
He was in for a really long time. He came into us, he was walking when he presented, although he had a definitely a stiff gait, and he had a nail bed injury, so I think he'd just been running out on a walk, and injured a toe, and the owners hadn't really thought much of it at the time. But actually the way, the reason that they had taken him to the vets in the first place was because his owner had taken a selfie and he was in the background of the selfie and in the selfie she thought, oh, he looks, his face looks a bit funny.
And then they noticed that his face was sort of really tight and unnatural, and that's why they took him to the vets. And so once he arrived with us, he had his digit amputated. It had quite severe osteomyelitis.
And whilst he was under the anaesthetic, he had a central line placed so that we could take bloods from his jugular really regularly and, and give him lots of fluids and medications. And we also placed an O tube as well. And we've just got a video here.
You can see he had these very, very severe, tremoring episodes in his kennel, and he had sort of repeated hypothermic episodes. He was very, very difficult to care for for a long time. But once he started feeling better, he absolutely loved going out for a, for a walk, even though he was having, he had a urinary catheter in still at that stage, and he was a very happy chap.
Unfortunately, he did get aspiration pneumonia whilst he was with us, and so he needed oxygen supplementation via some nasal prongs, and he was with us for about a month. He did do really well, so as you can see, he was very happy. And I've got a photo of him at the end as well.
I thought I'd put it in there. So then our next case was Candy, it was a lovely German short hair pointer. And again she came in with a toe wound and did have a digit amputation as well with an O tube placed.
And I've just got some photos here just to sort of demonstrate that actually once she was out of that recumbent stage and she was able to stand, we were able to hand feed her really carefully because she was swallowing really well. And then sort of as she progressed, she was able to ambulate and posture to urinate normally, so we could measure her urine output via her doing normal wes outside, which was great. And then a brachycephalic case we had was Stanley, who was a 5 year old male neuter British bulldog.
Again, he did come in and have a toe amputation with us, with an O tube place, but he also required a tracheostomy tube, because he was just really, really struggling with upper airway obstruction, I think because he was also a brachycephalic dog. And unfortunately, he did die really suddenly on a night shift in our intensive care unit, which we do believe was due to one of these autonomic storms. So the only preceding signs that he did have was that he'd had a slightly increased respiratory rates, and then he'd had a tachycardia followed by a bradycardia and unfortunately he did a rest and we did not get him back.
So that was a really sad outcome. For him. And then our final case, here was Bella, and she's just an example really to show that they don't always get as bad as that.
So, as much as in our hospital, we do see really, really severe cases, little Bella presented to us, she had a broken nail, and she definitely had the rhesus sardonicus, and she definitely had muscle tremors and a very stiff gait. But she was administered the antitoxin. She did have some sedation, and she stayed in intensive care for a couple of days, but she never actually progressed to being recumbent, and so she didn't require any, any other interventions.
So she was eating the whole time, she didn't have a feeding tube placed, and she went home within one week of being with us. So that was a really sort of clear cut case with her. And so then for their recovery.
As you can see a little Paddy there, asking for some toast once he was back at home. So there is an average hospital stay, as we said, for about 3 weeks, and so we can expect that these patients have a very long recovery. And aside really from their tetanus, once they get home, we want to make sure that they're having adequate nutrition because they normally would have lost some weight as well whilst they've been in with us.
We do send them home, not fully recovered, so we send them home obviously once they're eating and they're bright, and we're happy that they are definitely on their way to being fully recovered. But as you can see from this photo of Paddy, this was a week after discharge and you can see he still clearly has elements of the tetanus. He has the rhesus sardonicus, and he still has quite tight sort of muscles there, so he was receiving physiotherapy at home.
Another thing that lots of clients will report to us is that these dogs will have night tremors or terrors, and there's some research being done into these at the moment, but, again, once we have them in hospital, you'll often see tetanus patients in a very, very deep sleep in their kennel, and they'll suddenly look like they're possibly having a seizure. . But they are rousable from it, and it is a known phenomenon that they might have sort of nightmares, if you like, when they're having these deep sleeps.
So just warning clients that that is something that is part of the normal process for our tetanus patients is that they will have these kind of deep sleeps, but sort of horrible, episodes, if you like. And sort of recommendations for nursing these guys in a busy hospital. We want to keep them isolated from noisier inpatients, and if we can have the lights off or dimmed then that would be great.
Cotton wool balls in their ears can help you with background noise, but also maybe having the radio on, so whether a talking channel or a classical radio will just help sort of drown out any sort of other noises in the hospital. We will always, always have at least 2 people to turn these patients and do physiotherapy, unless of course they're obviously very, very small, but if they are dogs of sort of a size of 20 kg or more, you're going to need at least 2 people because they are so difficult to turn just because their muscles are really tight. So just for everybody's safety, at least 2 people.
Make sure that your patient's got enough IV lines in order to give all of the drugs and the fluids that you need to do. And make sure that if you're giving any of these constant rate infusions, that all of these calculations are at least double checked by somebody else, because that sort of easy mistakes can happen when we're doing lots of calculations with CRIs. If we're having a difficult case, and you're not sure, then ringing specialists for advice, they're always at the end of the phone to give advice to people who are not sure about a case, and also just good communication, both with clients and also your team.
So I hope today You've, you've learned some more about tetanus. So we've obviously, we've found out that tetanus is caused by a bacterial infection by Clostridium tetini. Which likes deep penetrating wounds and injuries.
And that we have quite an emotional and financial investment for difficult treatment of these cases due to a long hospital stay. They really do require intensive nursing care and they are very, very challenging, and we know that the main reason for our fatalities is aspiration pneumonia. And this is just, a lovely photo actually of one of our tetanus patients, Juno.
I met her at a dog show, I think 1 or 2 years after she'd been in with us, and I did not even recognise her. So just to show you, they can go back to normal eventually. All right, so that's it from me.
Brilliant talk Katie. Absolutely brilliant, well done. OK, so if you do have any questions, just pop them through on the Q&A box at the bottom of the toolbar, and I'll ask Katie once you've sent those through.
So I do have just one question. So you mentioned that we tend to send them home before the clinical signs have completely disappeared. Do we tend to send them home on certain medication and if so, how long do we expect those signs to go on for?
So it's very patient, dependent on how long those signs will continue, but they normally will go home on continued antibiotic therapy and also methocarbamol, and so our muscle relaxants while they're definitely displaying signs still of having muscle tightness and spasms. But I think that's normally it. They're not normally on any, any analgesia or anything by that stage.
And yes, I'm not sure how long they are recommended that these things might go on for, but they do have very frequent follow-ups with the vets. So I think it is very case by case dependent. OK, so some of them, some of them go on for a couple of months, so.
Just, yeah, I think definitely individually, the clinical signs, I think from, I think is probably just a couple of weeks, to a month rather than months, but I know that the, the night tremors that they have, which are really interesting, I don't know if you've ever seen them. They're really interesting to observe. They can go on for several months.
We've had clients report that they still see their dog, and it does almost look like a seizure, and I've tried videoing it 100 times. Every time a dog does it and I get my camera out, it stops, but they. They almost look like they're seizuring, and some of them will bark and growl, really, really aggressively in their sleep.
But the moment that you wake them up, they completely snap out of it. And so there is definitely research going into that at the moment, I think by somebody who used to work in our hospital. So, that will be interesting when that comes out, but it's something that our clients are warned about because it is so common.
Yeah, that is really interesting, actually, could take home message. Yeah. We've had somebody just put a little story on to say around 40 years ago they nursed a farm cat who had generalised tetanus who lived to discharge, who survived 2 to 3 weeks in the hospital and then was sent home.
But then sadly, once he was home, he jumped out of the van in front of a tractor and passed away. Oh no, that is so surviving tetanus. Oh, that's so sad.
We had, Paddy, the yellow Labrador that I just spoke about. He, after he went home and he'd fully recovered from the tetanus, he came back in with two other things that he had, and he is absolutely fine now, but he had two other intensive care units. With us and he is an extremely unlucky dog or lucky depending on the way you look at it, I guess.
Yeah, yeah, bless him. I've got quite a similar story actually. The one patient that I've ever nursed stayed in for around 2 months.
He was only 6 months old, Rhodesian ridge back, and then he lived until he was 2, and then he got hit by a bus and died all that time. Oh, that's so sad. I know, I know he was famous in the practise because he was known for so long.
He was in for for the two months and then yeah, and after all that hard work as well, that's. I know. OK, so it doesn't seem to, don't seem to have any more questions.
So on that note, I'll say thank you to everybody for joining us this evening. I hope you've enjoyed the webinar and I'm sure you have, as I certainly have, and thank you so much, Katie, for your hard work and enjoy the rest of your evening. No problem.
Thank you very much, guys. Thank you, bye bye.