Back in 2018
there was one case

“Salam, ni Dr Far** ke,houseman Peadiatrics in-charge ED kan? Haa ni ada satu patient,kami dh refer pada your senior Mo peads oncall dh just now. I think you guys kena dtg ASAP la.This child look stupor and got some abnormal movement.Looks like..

fit but the movement mcm weird.” said ED houseofficer over the phone.

me : Okey im coming stat with the bosses!

2 years 6month old,boy
no known drug allergy,no known medical illness
no blue book(rekod kesihatan) brought.
was brought to casualty by mother around 4pm.

according to mother,she noticed her child having

fever for past 3 days,become less active and refused for solid food in past 2 days.Only took bottlemilk fed for past 2 days.
Just realised today,the son having few episodes of grunting at home with difficulties in swallowing milk and saliva.

owh and also,mother claimed today..

nak xdpt articulate and utter speech properly!

patient appear weak in ED with on and off abnormal plateau tonic spasm of hand and leg.Uptriage to redzone and was given early intervention meds for fitting (seizure) and oxygenation(high flow oxygen)

then refer to peadiatric team for futher management.Patient was stablised when our team came by to resus area.

vital sign
BP within normal range+- high
HR 120
Temp 39.+
RR 25-27
Audible sound - stridor like /on and off ++grunting like sound

after 10min review :

noted there were
trismus ++
drooling of saliva
on and off tonic spasm
episthotonus

neurology examination
hypertonia ++
hyperreflexia ++
unable to assest other component because condition of the boy.

vid**

This part suppose i post vid of the kid having the symptom.But due certain reason - I’ll pass-

——- imagine ———

Child lie over left lateral position with high flow mask on face
+ongoing opistothonus
+clenching his teeth
+drooling of salive
Spasm of bilateral leg

Futher history taking
family was a foreigner (PATI) in here working in nearby estate.He was born at home and never been vaccinated.(the reason why no blue baby book) because not even documented born.
Been well until last week.mother bgthu anak dia ada luka 3 days before fever.

Luka sbb jatuh masa berlari dkt luar rumah.Luka tu terkena duri pokok sawit.Mother sdri kluarkan sndiri duri tu.

then only been using minyak gamat utk sapu di luka then balut!

“There faruq,u can see symptoms and complications of fulminant manifestation of disease called “Tetanus”,said my paediatrician.

We havent see this case for long-long time since introduction of DPT vac and immunized child.

Now prepared all the blood abd blood gases.If worsen.

if worsen we might need to intubated this fella.

Clenching of teeth/drooling of saliva - looks like NMJ of muscle@of mastication already bind with active agent from tetani itself.
Next stage will be muscle of respiratory.

You can see and heard intermettent stridor and grunting.

those are symptom involving upper and lower respiratory tract that might just show how progress the disease is.

Next what we expect is - muscle of respiratory will dysfunction and causing stop breathing, said peadiatrician.

Now,lets take this kids to our acute cubicle STAT!

Blood gases show still acceptable parameters.

“faruq,call pharmacist oncall now,say to them we need TIG(Tetanus Immunoglobulin) ASAP! Give them weight of this patient and asked for recommend route of injection too! ##

“hye Dr, Pharmacist **** here, we receive your prescription for a xase of tetanus is it?
Ok recommended dose for the kids was *****. it must be administered INTRAMUSCULAR. Recommended for different site each injection.

Me : Gulp! this mean 8 injections at 8 different site??

i watched my Mos inject the kid with 8 times jabs at different site.Each needle enter inside muscle itself.The cry, the lack of voice in cry to express pain(due vocal@cord involvement).for sure pain was agonizingly at highest level.

Now, what we can do is observe and do offer supportive care for him.Said peadiatrician to me.

For those who doesnt know tetanus, #Tetanus is disease cause by clostridium tetani,widely available in whole world.Mostly obtain in rusted steel/sand/soil/ground

Wound from any incident/accident or soiling from animal fecal material/dirty soiling can cause tetani to florish.

Once tetanus release tetanoplasmin(active neurotoxin) to body,it will bind to NMJ (neuromuscular junction) and IRREVERSIBLE.

hence actually TIG wont give benefit in

TIG wont give benefit at late stage(in fulminant tetanoplasmin spread)
the only function of TIg is compete with tetanoplasmin and to avoid tetanoplasmin bind to NMJ of our muscle. - this is physiology and pathophysiology for tetanus.

One day after multiple injection dkt bdan kanak2 tadi,

Pkul 2 pgi, nurse yg ditugaskan di acute bed pggil Ho bertugas,masa tu i still remember i xtertugas that night.
(Diceritakan oleh my colleague yg bertugas)

dktr,spo2 adik tetanus drop to 80% la despite high flow mask!

Cpt nurse call specialised oncall skrg! My friend called Mo oncall that particular day,

Proceed for intubation in view of respiratory muscle collapse!

Paru2 xdpt kembang dgn elok sbb diaphram muscle paralysed!

Now the kids totally on ventilator support for respiratory.

The next morning at 8am,i assign to be in acute bed,shocked to see the kids already being intubated and ventilated.Blood parameters all worsening.

At this stage, fungsi paru2 dan pergerakan nafas totally dicontrol oleh ventilator itself. very weak respond from body himself...

clearly, tetanoplasmin already disperse all@over the body and causing multiple organs damage!

What make me even sad was,one day after,i bought the kid car lego and assembled it with him.And today he ventilated and sedated (put into coma) with that car in his graps.

The kid was ventilate for about 2 days
and suddenly cardiac monitor show flat line cardiac activities.

CPR commencing.45minutes pass,no sign of vital sign or spontaneous circulation revive.

Later than pronounce death by me to parents.

All@case later that involve wound that i encounter in district hosp, surely i will asked MA or Nurse to give jap of IM ATT to prevent tatanus.

Good to know, in malaysia we provide IM ATT injection to pregnant mother to avoid neonatal tetanus.

Nk explain in detail http://lg.Tp  terlmpau pnjg.kalau ada yg xfaham,boleh google or dm me anypart yg xclear