Did you get your Tetanus Shot?

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Name that Sign!  Hint: It’s not a Glasgow Smile
Answer:  Risus Sardonicus.  Caused by spasms of the facial muscles.  Also seen in Wilson’s Diseases and Strychnine poisoning.
TETANUS
  • Caused by Clostridium Tetani, which is present in soil, animal feces
  • Typical presentation of “Stepped on a rusty name” and didn’t get their tdap.
    • Also in IVDU, abdominal surgeries
  • Per CDC, leads to death in 1 in 10 cases, usually in the elderly.
SIGNS AND SYMPTOMS
  • Initial signs are trismus or “lock jaw”- spasms of muscles of mastication
  • If not treated, progresses to sustained muscles of the back:  Opisthotonus
  • By second week, tachycardia, labile HTN, sweating, hyperpyrexia, increased urinary excretion of catecholamines
PATHOPHYSOLOGY
  • Ubiquitous spores in soil and animal feces
  • Introduced into skin as spore-forming, non-invasive state
  • Germinates into toni-producing, vegetative form if oxygen tension is reduced
    • e.g. crushed, devitalized tissue
  • Toxins=Tetanolysin and Tetanospasmin
  • Tetanospasmin does not cross BBB but CAN enter via retrograde intraneuronal transport
  • Acts on motor endplates of skeletal muscle, spinal cord, CNS, and sympathetics
  • Inhibits glycine and GABA
    • In short get sympathetic overactivity and high circulating catecholamines
TREATMENT
  • Admit to ICU
  • Needs intubation if respiratory compromised
    • Succinylcholine for intubation, Vecuronium for longer blockade
  • Minimize environmental stimuli to avoid convulsive spasms
  • Tetanus Immunoglobulin 3K-6K units IM helps locally but not if it is in the CNS
    • Nevertheless, reduces mortality
  • Can give parenteral metronidazole
  • Do NOT give PCN because central acting GABA antagonist which may potentiate tetanospasmin
  • Mag sulfate to help inhibit release of catecholamines/reduce autonomic instability/spasms
  • Midazolam for muscle spasm
SUMMARY
  • Clinical dx- look for autonomic instability, muscle spasms
  • Tx w/ ICU, intubation, Midazolam, Mag sulfate, Flagyl but NO PCN
REFERENCES
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Compartment Syndrome

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Cue Scene:

  • 20yoM w/ no pmh who hurt his leg while playing basketball.  He tried to walk it off but the pain keeps getting worse.  He arrives via EMS, screaming in pain and clutching his leg.  You get an x-ray which shows a fibula fracture.
Remember your Ps:
1.  Pain out of proportion
2.  Pallor
3.  Paresthesias
4.  Paralysis- late finding!
5.  Pulseless- late finding!
 
Compartment syndrome is most commonly seen in legs and forearms.  Often seen in crush injuries, circumferential burns, constrictive dressings (e.g. casts that aren't bivalved), or ischemia-reperfusion injuries.  In Tibial Fractures the most common is the deep posterior compartment followed by the anterior compartment.
 
 
Here's a cool video for you to watch:  https://www.youtube.com/watch?v=ewMD0OUlpqg
 
Treatment:  Fasciotomy is indicated if the difference between patient's diastolic pressure and the compartment pressure is less than 30mmHg or if the compartment pressure itself alone is over 30mmHg.  Get ortho involved ASAP if available.  Otherwise you have to perform the fasciotomy.
 
Now let's review with a little Board question:
  • 24M presents as a trauma code shortly after a motorcycle accident. Pt was thrown from his motorcycle when a car suddenly braked in front of him, and his leg was caught under the wheel of the vehicle. Airway is intact, he is complaining of severe leg pain, and his blood pressure is stable. He was helmeted, and his injuries appear to be isolated to the left lower extremity. When you move to the secondary survey, you note severe left lower extremity edema, and the patient screams and writhes in pain upon palpation of the distal pulses. You observe diffuse road rash but no open lacerations. His peripheral pulses are palpable and strong. Radiograph of his left lower extremity is shown in Figure A. What is the next best step in management?
  • Next best step?
    • A.  Admission for observation and pain control
    • B.  Closed reduction and splinting
    • C.  Percutaneous pinning and casting
    • D.  Multi-compartment fasciotomy
    • E.  Physical and occupational therapy
 
 
 
 
 
 
 
 
 
 
 
 
Answer:  D
 
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POTD Tuesday. Tricky TrickY Tuesday

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FIRST AND FOREMOST, GO BRONCOS!

Today's POTD is a shoutout to Dr. John "Fearless Leader" Marshall, as brought up at last weeks CQI.

ABDOMINAL EXAMS AND A COMMON PITFALL

There was a recent case of a PERFORATED VISCOUS (of course he presented with SOB, but that's another story). The XR was extremely clear. Of course it was missed. The patient had no abdominal TTP, no rebound/guarding/rigidity. Completely non surgical. The free air was missed because they weren't looking for it. (Even the radiologist only read this obvious free air as "possible free air")

 

HOW THE HELL WAS HE NON-TENDER!?!?!?!?!?!? THESE PATIENTS ABDOMEN'S SHOULD BE A BOARD THEY'RE SO RIGID

 

 

 

CHRONIC STEROIDS (*ominous sounds*)

  • Patients on long term steroids (for asthma, auto-immune dz, etc...) can mask a surgical abdominal exam. They may have no tenderness, nothing.
  • Again, patients on long term steroids may have a completely normal abdominal exam, even with having surgical pathology.

Don't believe me? While there may be no true RCT, or even a retrospective trial, there are case studies and anecdotal cases (such as the one above). The best one I found is linked right below.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391396/

 

From Medscape: "Remember that the presentation and the findings on clinical examination may be entirely inconclusive or unreliable in patients with significant immunosuppression (eg, severe diabetes, steroid use, posttransplant status, HIV infection)"

 

So Be DILIGENT. Have a HIGH-LEVEL OF SUSPICION.

And as Dr. Marshall would say, "Anoscope, Anoscope, Anoscope"

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