Hello, my name's Stephanie Nash, but also known by Stevie Nash, and I'm going to talk today about tetanus treatment, monitoring and nursing care. So the objectives of this talk are to give a brief overview of causes and pathogenesis of generalised tetanus. We are not focusing on focal tetanus, treatment, monitoring and nursing care relating to signs and symptoms.
The talk is. How can I say? It all sort of links into each other, so it was quite challenging to separate it out into parts and I didn't want to separate it out into parts, so hopefully you'll see what I mean.
This ugly green highlighting is points that are of note, hence you will see more of those ugly green highlights. So causes, so Clostridium tetini is an anaerobic spore forming bacterium, which is the cause of tetanus and you can see a picture there. The entry point spores enter through wounds, especially deep punctured wounds.
Or necrotic tissues that is not exclusive, so there are other risk factors and potential causes for tetanus. So trauma being one of them, that could be something that one might think is quite innocuous, such as a tooth extraction or a nail bed infection. Something one wouldn't necessarily first jump to.
Poor wound hygiene. Incompromised sates may exacerbate the potential for this to occur, and postpartum, the placenta and other tissues can harbour bacteria. It is of great value when the patient comes into your care is to look from head to tail all over the patient as meticulously as one possibly can.
So including inside the mouth if possible, if they haven't developed lockjaw at that point in time. And also when you are doing these assessments that you're not overstimulating the patient. And making their symptoms worse.
Often we find that by the time. The patient has reached us. They have developed the condition and perhaps the puncture wound or whatever the cause may have been, may now already be resolved.
So it can take up to 2 weeks for symptoms to develop, sometimes even 3, by which time the very tiny little wound that they had on their pad may have healed, but it's given time for the bacteria. To get in there and cause problems. So pathophysiology, so toxin is produced by the bacteria bacteria, tetanospasmin is a potent neurotoxin.
Toxin travels via peripheral nerves to the spinal cord and blocks inhibitory neurotransmitter release, gamma aminobutic acid. And glycine and leads to muscle rigidity, spasms, and hyperreflexia and autonomic dysfunction. Clinical signs include a stiff gait, rhesus sardonicus.
Facial muscle contraction, transmus, locked jaw, and progression, progression to generalised tetanus if untreated. So the focal tetanus as opposed to general which we're discussing today, usually has localised muscle rigidity near the infection site. And the toxin remains confined to those regional nerves rather than progressing generally and can be seen in mild stroke early cases.
So as much as the patient that Trod on a thorn 23 weeks ago, it may be that they started to tense up their leg and it could have potentially gone unnoticed or maybe seen as some other cause or reason for that, and then it's developed into. Generalised tetanus. So here is a picture.
Of quite transparent rhesus sardonicus. Once you have seen a tetanus patient, it is quite, . You'd, it'd be challenging for you not to see it the next time.
So as you can see this patient's ears are very pulled back, as is his little forehead. And his eyelids, so that is something to be mindful of how pulled back his eyelids are, we'll go into that in a bit more detail. How tense his muzzle is.
All around here so you can really see the tension in his face. So core treatment strategies. Tetanus antitoxin, this is a controversial option, so neutralises circulating tetanospasmin toxin.
Most effective when administered early. I've already mentioned that it can quite often not necessarily be noticed that early. So in the author's experience, it is too late for this expensive option, and evidence suggests that efficacy at later stages is questionable, er.
Also there is potential for hypersensitivity reactions, which one could argue could be treated with steroids but then you have the potential, Gastrointestinal alteration, which we certainly don't want. Also, literature is unsure about the dose range, so dose ranges range from 10 international units to 1900 international units per kilogramme, and the dose is based on toxic, toxin load rather than body weight, and it can take 2 to 3 days, to reach therapeutic concentrations via subcut injections. So yes, there is the option of the antitoxin.
In my experience. We don't use it because it's usually too late. And the efficacy, questionable.
Antibiotic therapies, so Metronidazole and or penicillin. So that targets the Clostridium tetini to halt toxin production. Wound management.
So as I've said before, the wound might not be there any longer, thorough cleaning and debridement of the infected wounds, and then I've mentioned here about the wound might be healed by the time you get to it. That doesn't mean you shouldn't look. And prevent further bacterial growth and toxin release.
I would say that this is one of our primary concerns as nurses when we are treating these cases. These cases require intensive nursing and are Challenging but very, very rewarding, they are satisfying. So one of the primary things that, We will be concerned about is how tense the patient's muscles are and how we want to make them more comfortable.
So as I've already mentioned, the toxins will cause this extreme muscles rigidity. So hence we give muscle relaxants and sedatives to help reduce the painful spasms and improve comfort. Also it can be very stimulating for the patients in the environment, so it will help take that edge off of their anxiety.
So diazepam, a benzodiazepine with anticonvulsant anti, oh I can't say that word very well, anxiolytic and muscle relaxant properties, also helps with sedation and reducing anxiety. Methocarbonol, carbool, a centrally acting skeletal muscle relaxant, effective in controlling tonic muscle contractions, often used in combination with diazepam. And then an additional option is midazolam.
It obviously does depend what medications are available. So head to tail monitoring and care, as I've sort of mentioned at the start, I've combined these two elements. So we obviously have lockjaw, so accessibility to open mouth, provided you're not going to overstimulate the patient.
The issue with not being able to use their mouth properly is they may not be able to use their tongue properly either because that's also gone into spasms. So salivation, excessive drooling increases the risk of aspiration pneumonia, so they may need oral care, which one can do with some suctioning, and just a damp swab to clean all around their little faces. It does have to be used pragmatically though, because you're trying to get a balance between keeping them clean and comfortable, reducing.
The likelihood of aspiration pneumonia whilst not overstimulating them at the same time. Must be very mindful of vomiting and regurgitation in a patient that may not be able to open their mouths. Again, this leads to an increase of aspiration and pneumonia, but more significantly, an increase of occluding their airway.
So it is pertinent to always have suction nearby and an emergency airway plan because also the larynx can go into spasm. This is such an easy point to overlook is panting. I have seen, as much as they're extremely rewarding cases to nurse, I have seen a patient where this has.
Essentially resulted in their demise because we have not been able to cool them down. And they have not been able to pant. So it's very, very, very important to keep an eye on their temperature.
I cannot express that enough. And then take active measures to proactively prevent hypothermia. In my opinion, you're better off starting slightly earlier than maybe you would do for an ordinary case.
So for an, I say an ordinary case, a case that presents with hypothermia, so, ordinarily we would start active cooling at around 40. And in this case, I would start active calling at around 39.5.
This this may be even lower if your patient is a brachycephalic breed. Sir Rhesus sardonicus, as we saw in the previous picture. Facial muscle contractions indicating toxin effect, which has an effect on the eyes, so it causes constriction of the pupils.
Photophobia, which you'd think that that would be OK because their pupils are constricted. It's not, they are quite light shy, and dryness because they can't blink properly. So it's very important to use eye lube.
Frequently and minimise the light. We often keep our tetanus cases in intensive care with the lights as low as it's manageable, if not off, . Big quiet signs everywhere, so you're only allowed to creep into the ward and get whatever you need.
And that leads on to the ears being hypersensitive to sound and minimising auditory stimuli. So a point to consider with that element is how loud are your drip pumps? How loud is your ECG?
How loud is your pulse oximeter? Can you turn the volumes down as much as possible on those? And when you're opening, closing the kennel doors, can you do that as quietly as you can, because it can really make them jump if they hear a loud noise, and I think it's quite easy to overlook the volume that the equipment is set to.
Especially if you've got a line that wants to occlude all the time. It can be quite stimulating for them. So, again, head to tail monitoring.
Again, very important to monitor respiratory rate and effort as we've mentioned about. The potential for aspiration pneumonia. There is also the potential for the musculature of the thorax to start tensing up, in which case they can't then ventilate properly.
So it's important to monitor the SPO2. Plus or minus blood gas analysis if indicated, so your patient has deteriorated quite significantly. Cause this is if you're doing an arterial blood gas, it can be quite painful.
And it can be technically challenging. And it might not be available option. So be alert for signs of hypoxia and hypercapnia.
One can check mucous membranes, but they are a very poor indicator of hypercapnia. I think off the top of my head. That your oxygen levels are perhaps around 80, 85% by the time that cyanosis is becoming apparent on mucous membranes, hence not making it a good indicator.
You are better looking at the patient as a whole, their respiratory rate and effort. A plus or minus implement oxygen supplementation. Try to find the modality that is the least stimulating to the patient, so whether that is flow by near them or nasal prongs, one could consider nasal nasal cannulas but might be a bit overstimulating.
A face mask, question mark about the efficacy of it. Patients may eventually require mechanical ventilation. Fortunately, I have seen this very rarely.
Aspiration risk as previously mentioned. And going back to the potential for laryngeal spasms, it might be worth considering in your airway plan, having an emergency tracheostomy plan and equipment there as well. Positioning So regularly change body position every 2 to 4 hours.
If this is overstimulating to the patient. And there aren't concerns about pressure sores and or ectasis. 4 hours is going to be fine.
Encouraged them to be in sternal recumbency. When they are turned, so let's say you're going from left to right laterals, it is of value, depending on the patient to hold them in standing position and allow them to take a few breaths, whatever is manageable by the patient and those strong people having to hold them up. It just allows them to ventilate how they would do in a more normal posture rather than lying down, so it can actually help increase, although temporarily, their ventilation.
Plus or minus use gentle physiotherapy or passive movement to aid circulation. I would only consider implementing this when the patient is comfortable and manageable for this to be implemented. It is not nice if your muscles, I mean.
Absolute constriction slash tension for someone to then start trying to move them around, and it might be too overstimulating for them. At later stages. Perhaps this could be considered.
Heart rate monitoring and rhythm, this is very important, as I mentioned about the autonomic dysfunction, so sympathetic overdrive may cause tachycardia. Equally, we could end up with bradycardia. Er not only have you got obviously the symptoms of the disease that may lead to bradycardia and changes in the cardiac rhythm.
From the autonomic dysfunction that's going on, but you've also implemented medications that may compound these issues. So when you do auscultate their heart, make sure you're checking their pulses at the same time and they're matching. So as I've mentioned here, autonomic instability and or hypoxia or electrolyte imbalances.
So the electrolyte imbalances could be for a plethora of reasons, but one of them being eating, so we will talk about that in a bit. Blood pressure monitoring, hypertension is common in this disease due to increased sympathetic tone. So monitor for spikes.
And monitor for dips. It's all about the trends. All about the trends.
So As I've mentioned, vomiting and regurgitation, you can elevate their head so the food is going to go downward rather into the stomach rather than into their lungs. Just be mindful when you are moving them around and trying to elevate their head that that might be quite stimulating for them, but it also might be quite sore for them because their neck's all in spasm, their face is in spasm. Salivation, we've already touched upon that.
So abdominal distention, so monitor for signs of ileus or gas accumulation. Excuse me. Gentle abdominal palpation and auscultation is recommended.
Nutritional support, so this is going to help with your potassium levels. Which should help with your cardiac function. So dogs with tetanus often have reduced appetites and difficulty swallowing.
We do frequently implement, antiemetics and gastroprotectants, and we certainly provide nutritional support because that is very important. This is a picture of a no tube stoma. One can feed these patients orally, provided it's safe to do so, so they, their jaw is mobile enough, their tongue is working well enough, they do have a gag reflex, so use soft, palatable foods in small amounts, so the classic little and often.
Feeding tubes. So, obviously we have the option of nasogastric or nasoesophageal tubes. We do not usually use these in tetanus cases as just them being sat there can be quite stimulating, like constantly having something poking up your nose.
Esophagostomy tubes, those are the ones that we usually, . Use, they're good for long-term support. The bore of the tube, you can get quite a large volume of food in if you have a large patient and you can attach them to a CRI so feed them through that consistently.
And then a gasttrotomy tube. The issue with the gastrostomy tube, and this is often said in the literature, place a PEG tube or gasttrotomy tube. Is the risk of peritonitis with the gastronomy tube.
So it sort of swings and roundabouts, and I think it really depends on your practise policy. So monitoring during tube feeding, obviously one needs to check the patency of the tube and the placement to make sure you're getting negative pressure when you start the feeding of a node tube. Monitor for.
Of discomfort or reflux. It's also a value whilst you are feeding the patient to position them in an appropriate position, so preferably internal with their head up. Again, case dependent, staffing dependent.
And then Where was I? Signs of discomfort will read it. So this is if you had an NG tube checking that the stomach's empty, hydration status and electrolyte balance.
So obviously just checking that their blood's a routine. Stoma. So stoma sites should be dressed down and checked twice a day along with the tube or more often indicated and or clean around the stoma.
Or don't clean around it, it does not need cleaning. And here I just have how we calculate our calories for our dogs. There are a plethora of different methods.
This is the method that we use. 30 times weight plus 70 gives us our kilocalories required over 24 hours. As previously mentioned, these patients can be off their food.
It may be a while before they actually present to your practise, so it might be necessary to start off feeding them reduced volumes of food per day and then increasing to the full RER. So for example, starting at 33% on the 1st 24 hours, 66 and then 100% in order to manage and prevent vomiting and regurgitation. And potential for refeeding syndrome.
So Urinary and faecal output in dogs with tetanus. So again, the autonomic dysfunction can lead to urinary retention or dysura. Monitor for straining, dribbling or inability to void, distended bladder, stroke, discomfort.
If you are fortunate enough to have access to an ultrasound machine, it might be better to ultrasound their bladder rather than palpate the bladder just because it will be margin, well, I'd like to think that it is marginally less overstimulating. Plus or minus urinary catheterization, so it does help with monitoring the output, relieving retention, preventing scalding. And especially pertinent to recumbent tetanus cases in relation to the preventing scolding, there are some patients that are very, very emotionally distressed by wetting the bed.
So at times, not only is it beneficial for you as a nurse, but it may help with their. Demeanour So obviously if you have a urinary catheter in place, it must be cared for as per practise policy. Ours is every 4 hours to empty and clean.
Monitor for signs of infection or blockage. If you think that there might be a blockage, then tend to that accordingly. Faecal output, constipation may occur due to reduced mobility and autonomic dysfunction.
Also the medications that they were on, plus or minus have they been eating less, etc. Hygiene and comfort, to prevent scolding, frequent bedding change, barrier creams if needed, and nappies or absorbent pads. If you are using nappies, make sure that they are noted to be checked.
Every so often, so obviously it's case dependent, but I would recommend 2 to 4 hours, because if you leave the nappy on there, yes, the nappy's gonna suck the urine away. But it's still the humidity is not going to be very nice. So this is a patient with the classic saw horse stance of tetanus as you will see here, the tail.
This is not the normal sort of posture for a tail. There is a right back here. You, to be honest, from this picture, you can't really tell that much, it might just be a quick picture, but you get, hopefully you get the idea.
Rigid limbs that are extended, and then I've written here about assisted walking over if it doesn't overstimulate them. Be mindful of lights and sounds and touch, including sunlight. So it can be helpful to use an umbrella.
It may take a team of you to walk the patient out, one of whom is the umbrella holder, because you don't really want to hold the umbrella too close to them because it might frighten them. And it might overstimulate them, but just to shield them from the light, passive range of movement, and then recumbency care as previously mentioned. Pain assessments.
This is very important and easy to overlook cos in a sense, I certainly do anyway. I think, oh, you've got muscle contractions that must be uncomfortable. Well we've given you muscle relaxants and we've given you sedatives so all grand.
So in a way it's easy to not consider that. But it is important that that is done additionally to the other medications. So use a validated, pain scoring method.
Score every 2 to 6 hours depending on the case and the analgesia that you're using, . Pain scoring in these cases is very challenging due to the symptoms of tetanus. But it helps to just keep a consistent method of how you were assessing the pain.
And provide documentation onto what your thoughts were. So as I've written here, severe muscle contractions can cause significant pain. So while the muscle relaxants are standard, opioid adjuncts such as methadone and buprenorphine are recommended for improved comfort.
Be mindful that when one gives methadone, it can sort of affect the thermoregulatory meth centres of their brain and make them think that they're hot, so they may want to pant, which they can't really pant because their mouth is shut. So you may get a. Short period.
Of increased aspiration, but it should not be prolonged. So the nursing role is to validate scores with clinical signs, monitor response to analgesia, and advocate for timely adjustments. So IV fluid therapy is part of the supportive treatment, so again, if you're on IV fluids, you should be monitoring urine output.
To guide the fluid rate, watch for signs of overload, so it'd be very difficult to tell, is it overload or is it the tetanus in relation to respiratory rate and effort, but it's also of value to monitor for edoema and weight gain, as well as blood work. Consider potassium supplementation if indicated. Hopefully feeding them should negate that.
And this is also overlooked, so you know, it would again be easy to assume. That your tetanus case has become hypothermic rather than pyrexic. So it could be after a few days in the hospital, they've actually developed a UTI from the urinary catheter.
So it's always making sure that you're considering. All of the elements and the case as a whole, is there anything you have added to the patient such as an IV catheter or a urinary catheter or a feeding tube. Potential risks for infection.
There is benefit in having a central line placed in these patients as per the saw horse picture. Because they are multi-lumin, so you can have different types of fluids going into different ports, but you can also, . Take blood samples from them which will reduce the stress from repeated venal puncture.
I'm just gonna go back to the picture of our saw horse. So here is there. Central line, we've actually only got one port in use here, but I know that we were using other ports for blood sampling, which is really, really useful, especially if your case load is quite high because you can blood sample from this lovely boy on your own.
Which is helpful. So practical considerations in tetanus. So the sort of newer terming of gold standard care is contextualised care.
And that provides a balance of what the patient needs with what's achievable with the clinical restraints. So for example, it's all very well me saying, oh, give your patient morphine or ask for morphine, not morphine, sorry, methadone, but if you don't have methadone in house. Then buprenorphine is the best that can be achieved in the contextualised care of that patient.
Also, care for these patients is very intense. And Timely, goes on for a long time, and can cost a significant amount of money and it might not be within the owner's . Ability to be able to pay such a high amount of money as much as I'm sure I wish, you know, I think that they would wish to, it might not be a viable option.
So it's always important to prioritise comfort, safety and dignity. I'll talk about Kirby's rule shortly. TLC, so compassionate care and TLC are essential.
Remember you are the patient's advocate and voice, so as much as it's, as I said, I was sort of like, oh you've had the muscle relaxant, you'll be OK. It is important to remember the pain scoring. Element of it as well, ethical considerations, so.
In my view, it is of value to Ascertain what the owners would like to do in terms of resuscitation status, especially if the prognosis is poor. As I've already mentioned about lockjaw, it can be very challenging to establish an airway in a patient that needs to be resuscitated. You do have the option of placing an emergency tracheostomy tube, but it all adds another dynamic and challenge.
So, have a crash plan ready, have drugs ready and equipment ready should your patient be a recess. Ensure that there is clear communication with owners about goals of care. Monitoring and support, so regular assessment of pain, hydration, nutrition, and comfort.
As well as the observation we've already mentioned, such as heart rate and rhythm. Pulses, SPO2, respiratory rate and efforts, supportive nursing care makes a significant impact on recovery and welfare. In my opinion, it's only my opinion, the nursing care is about 90% of the treatment that these patients get.
And it is a, it's, it is a lot of work, but it's very, very rewarding when they, the owners send videos of them running around or they return to the practise to. Visit and have a checkup and they're running around and they're perfectly normal. So this is what I mentioned earlier, Kirby's rule, so I absolutely love Kirby's rule, it's a systematic approach written by Doctor Kirby and includes parameter monitoring and care instructions.
So we've discussed fluid balance, oxygenation and ventilation, blood pressure. Heart rate, contractility and rhythm. In my experience, glucose isn't an overly concerning point.
That doesn't mean it shouldn't be. Should the patient go on to seizure, it could, take up a lot of glucose. Should the patient develop an infection.
Again, you've got that, that sort of potential. Usually this would be part of the our blood screening anyway, just to check how the patient is doing, which we don't usually do that frequently in tetanus cases unless there is a concern. Body temperature very important.
Albumin. Not, in my experience, not usually that concerned because we have implemented a nutritional plan, hence they're getting the proteins that they need. Electrolytes.
Again, this is usually OK due to feeding. That doesn't mean to say it won't be OK, but usually this isn't an overly concerning point. Mentation, so yes, they are getting overstimulated, and it can be a bit much for them.
However, when they start to get better, they can start to get a little bit bored and a little bit fed up that their body doesn't move as they would like it to. So that's when you have to try and find that balance between Providing enough care but not being overstimulating, etc. Etc.
Red blood cells and haemoglobin, not usually a concern. GI motility and integrity, and motility is a concern due to . Derangements, nutrition, big concern, renal function.
Not usually, it's normally the urinary output part of renal function that would be a concern, not really the kidney as such. Coagulation, immune status and antibiotics, drug doses and metabolism, wound care. Already mentioned that pain control, nursing care, and TLC.
This Kebby's rule, I think, is marvellous. It's, in my view, it's very good for student nurses because you can, you can apply this to any and all patients that are in your hospital. Admittedly, a lot of it won't necessarily be relevant to a case that's just come in for a routine castration, for example, but it starts to get them thinking.
The outcome, so survival rates fully recovered, reported in 50 to 92% of cases. It's a very wide range, with appropriate care. Prognosis depends on severity, complications like aspiration pneumonia and speed of intervention.
Recovery timeline, initial signs of improvement typically seen within 5 to 12 days. This quote here may take 6 to 8 weeks to recover. I have seen literature that says much longer, so I think this quote from a paper, there's a lot of variables that I've read on recovery time.
One of the points of note, which is just, I thought it was interesting was that owners report being quite twitchy in their sleep even a long time after having recovered, and that's only the report but maybe it's just a coincidence. So key factors influencing outcome. Early wound management and antibiotic therapy, use of muscle relaxants and antitoxin, intensive nursing care and monitoring.
So this video that I'm about to play seems really quite depressing, but we were absolutely overjoyed at this video. You have to look quite closely, but he starts to open his mouth. As you will see, he's got a tracheostomy tube here.
Things did not go well for this poor fella, and he needed a lot, a lot of care. This video shows that we're starting to head in the right direction. And for those that want to know, he was OK and then he went home.
I really liked that video. It caused a lot of excitement in that video. So these are just my opinions.
It's very easy to overcomplicate veterinary nursing, in spite of everything that I've said, take it back down to the basics. So what is the TPR? Are they walking, eating, drinking, weeing and pooping?
What is their level of consciousness? Are they painful or comfortable? And then one can layer on the bricks.
So what is their respiratory effort? What is their SPO2? What is their mucous membranes, Blood pressure, pulse quality, and cardiac rhythm.
And then ask oneself, do I need to act on what I've observed. So this, obviously, it's not an exhaustive list, it's a guide, and Kirby's rule is an excellent framework, to support comprehensive care. We quite often use it as well to know from our clinicians, what do you want us to do if this happens, what do you want us to do if that happens, what number are you going to get upset about?
What number do we need to act on? And so it's a really, really useful list. I cannot recommend it highly enough.
These cases, as well as other types of cases are physically, especially when you're lifting them from side to side. Mentally And emotionally demanding, so take care of yourself as well as the patient. So thank you very much for your time.
If you have any questions, please contact me at Stevie. [email protected].
I hope you like the video. At the end. Thank you very much.