WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:46.909 fast. Welcome to the emergency room. Welcome 00:00:46.909 --> 00:00:49.429 back to the deep dive. Today, we are shifting 00:00:49.429 --> 00:00:51.909 gears pretty significantly. Yeah, we are. We 00:00:51.909 --> 00:00:54.189 aren't just summarizing an article or chatting 00:00:54.189 --> 00:00:56.670 about a trend. We are putting on a very specific 00:00:56.670 --> 00:00:59.030 hat. The educator hat. The hat of the nursing 00:00:59.030 --> 00:01:01.450 educator. We are stepping into the simulation 00:01:01.450 --> 00:01:05.269 lab, into the NCLEX prep session. It's a necessary 00:01:05.269 --> 00:01:07.790 shift, I think. We're looking at a topic that 00:01:07.790 --> 00:01:10.870 is, I mean, it's a cornerstone of pediatric critical 00:01:10.870 --> 00:01:14.730 care and a huge favorite of exam writers. Right. 00:01:14.890 --> 00:01:17.049 But it's often misunderstood. People hear it 00:01:17.049 --> 00:01:20.329 and they just think, Old history. Rusty nails. 00:01:20.870 --> 00:01:24.890 Exactly. We are analyzing tetanus, but we are 00:01:24.890 --> 00:01:26.709 not going to look at it that way. We are going 00:01:26.709 --> 00:01:29.700 to treat it for what it actually is. a neuro 00:01:29.700 --> 00:01:32.719 -exitoxin emergency. That distinction is so vital 00:01:32.719 --> 00:01:34.280 right out of the gate. Yeah. Because when you 00:01:34.280 --> 00:01:37.280 frame it as a neuro -exitoxin event, the whole 00:01:37.280 --> 00:01:39.700 clinical picture, all your priorities, they just 00:01:39.700 --> 00:01:41.680 shift immediately. They have to. It stops being 00:01:41.680 --> 00:01:44.920 just a wound care issue and it becomes this neurological 00:01:44.920 --> 00:01:47.420 airway crisis. So we've got a massive stack of 00:01:47.420 --> 00:01:50.700 materials today, CDC epidemiology data, nursing 00:01:50.700 --> 00:01:53.939 standard of care protocols, pathophysiology textbooks, 00:01:55.000 --> 00:01:57.900 the whole nine yards. And our goal is to synthesize 00:01:57.900 --> 00:02:00.980 all of this into that need -to -know versus nice 00:02:00.980 --> 00:02:02.859 -to -know framework. Exactly. We're applying 00:02:02.859 --> 00:02:05.540 the 80 -20 rule here. In clinical practice, and 00:02:05.540 --> 00:02:08.280 definitely on the board exams, about 20 % of 00:02:08.280 --> 00:02:11.120 the concepts regarding tetanus will drive 80 00:02:11.120 --> 00:02:13.479 % of your decision -making. And your patient's 00:02:13.479 --> 00:02:15.340 survival. And your patient's survival, absolutely. 00:02:15.719 --> 00:02:18.580 Our job is to isolate that 20%, those high -yield 00:02:18.580 --> 00:02:21.500 patterns, and really drill down on the why. We're 00:02:21.500 --> 00:02:24.240 not just memorizing lists today. We need to understand 00:02:24.240 --> 00:02:26.699 the physiological mechanisms so that when you're 00:02:26.699 --> 00:02:29.060 staring at a question or, you know, a real patient, 00:02:29.439 --> 00:02:31.560 the answer is intuitive. Okay, so let's start 00:02:31.560 --> 00:02:33.360 with that big picture, the master map. Right. 00:02:33.699 --> 00:02:36.139 If I'm a clinician or a student and I'm organizing 00:02:36.139 --> 00:02:38.780 my mental filing cabinet, where does tetanus 00:02:38.780 --> 00:02:41.020 live? Because it feels like a hybrid. It's not 00:02:41.020 --> 00:02:43.020 just one thing. It is a hybrid. And that's a 00:02:43.020 --> 00:02:44.479 great way to put it. You need to file this under 00:02:44.479 --> 00:02:47.360 two distinct patterns, neuroinfectious and preventable 00:02:47.360 --> 00:02:50.199 disease. OK, bring that down. So on the one hand, 00:02:50.419 --> 00:02:53.020 it shares the absolute urgency of something like 00:02:53.020 --> 00:02:55.879 a seizure disorder or bacterial meningitis because 00:02:55.879 --> 00:02:58.159 of the direct nervous system involvement. The 00:02:58.159 --> 00:03:00.479 crisis is neurological. Right. But on the other 00:03:00.479 --> 00:03:04.039 hand, it has the public health logic of vaccine 00:03:04.039 --> 00:03:06.379 schedules and prophylaxis. So you're thinking 00:03:06.379 --> 00:03:08.500 both like an ICU nurse and a public health nurse. 00:03:08.719 --> 00:03:11.080 time. And looking at our notes here, our exam 00:03:11.080 --> 00:03:13.659 winner section, there is one specific decision 00:03:13.659 --> 00:03:16.419 point that seems to be the linchpin for almost 00:03:16.419 --> 00:03:19.539 every test question. The wound management algorithm. 00:03:19.639 --> 00:03:22.460 That's the one. Without a single doubt. If you 00:03:22.460 --> 00:03:26.000 are taking the NCLE -X or a pediatric board exam, 00:03:26.419 --> 00:03:28.520 I can almost guarantee you will see a scenario 00:03:28.520 --> 00:03:31.000 involving a wound and a vaccination history. 00:03:31.159 --> 00:03:33.000 It's a classic. It's a classic. And the test 00:03:33.000 --> 00:03:35.819 is this. Do you understand the immunology well 00:03:35.819 --> 00:03:38.780 enough to decide between just the vaccine, the 00:03:38.780 --> 00:03:42.379 vaccine plus immunoglobulin, or doing nothing 00:03:42.379 --> 00:03:45.360 at all? It's a logic puzzle with very high stakes. 00:03:45.439 --> 00:03:47.439 We are absolutely going to break that algorithm 00:03:47.439 --> 00:03:49.699 down in excruciating detail later with some case 00:03:49.699 --> 00:03:51.879 studies because it is tricky. There are a few 00:03:51.879 --> 00:03:54.139 variables that can trip you up. But before we 00:03:54.139 --> 00:03:56.280 get there, let's talk about that first impression, 00:03:56.979 --> 00:04:00.500 the priority assessment cue. If I walk into a 00:04:00.500 --> 00:04:04.000 trauma bay or I'm triaging a patient, what is 00:04:04.000 --> 00:04:07.500 the immediate flag that screams tetanus? Prismus, 00:04:07.800 --> 00:04:10.180 lockjaw. But you need to look for the pattern, 00:04:10.219 --> 00:04:12.780 not just the one symptom. The pattern is descending 00:04:12.780 --> 00:04:15.039 muscle rigidity. It starts at the head, and it 00:04:15.039 --> 00:04:17.639 moves down the body. So if you miss the tight 00:04:17.639 --> 00:04:19.480 jaw, which can be subtle at first, you might 00:04:19.480 --> 00:04:22.000 catch the stiff neck. OK, so head, then neck. 00:04:22.100 --> 00:04:23.939 Right. And if you miss that, maybe you'll see 00:04:23.939 --> 00:04:25.980 the board -like abdomen. But here's the thing. 00:04:26.079 --> 00:04:28.819 By the time it hits the abdomen, you are already 00:04:28.819 --> 00:04:31.339 way behind the eight ball. You've lost critical 00:04:31.339 --> 00:04:34.129 time. And the can't miss safety item. the thing 00:04:34.129 --> 00:04:35.910 that actually kills the patient if you don't 00:04:35.910 --> 00:04:37.750 anticipate it. It's two things that are linked, 00:04:38.009 --> 00:04:40.430 airway protection and stimulus reduction. And 00:04:40.430 --> 00:04:43.269 this is really nuanced. It's not just about keeping 00:04:43.269 --> 00:04:45.410 the airway open in the usual sense. What do you 00:04:45.410 --> 00:04:47.709 mean? It's about realizing that the diaphragm 00:04:47.709 --> 00:04:50.279 and the vocal cords are muscles. And this is 00:04:50.279 --> 00:04:53.360 a disease of uncontrolled muscle spasm. So if 00:04:53.360 --> 00:04:55.660 the vocal cords spasm, what we call laryngeal 00:04:55.660 --> 00:04:58.680 spasm. You have a total airway obstruction. Instantly. 00:04:58.920 --> 00:05:01.300 Instantly. It's like a door slamming shut and 00:05:01.300 --> 00:05:03.459 you can't just bag them through that. And the 00:05:03.459 --> 00:05:05.500 stimulus reduction piece. How does that fit in? 00:05:05.519 --> 00:05:07.939 That is the second half of the safety coin. These 00:05:07.939 --> 00:05:10.720 patients, their nervous systems are hyper excitable. 00:05:10.980 --> 00:05:13.779 A loud noise from monitor alarm or a bright light 00:05:13.779 --> 00:05:16.550 flicking on. It isn't just annoying to them. 00:05:16.910 --> 00:05:19.810 It can physically trigger a generalized life 00:05:19.810 --> 00:05:22.829 -threatening spasm or seizure. So the environment 00:05:22.829 --> 00:05:25.189 itself? The environment becomes a medical intervention. 00:05:25.589 --> 00:05:29.389 A dark, quiet room is as important as the IV 00:05:29.389 --> 00:05:32.189 drip. Wow. Okay, there's one more concept on 00:05:32.189 --> 00:05:34.370 this master map that I have to admit I found 00:05:34.370 --> 00:05:36.990 really counterintuitive. We usually assume that 00:05:36.990 --> 00:05:39.509 if you survive a disease, you're immune to it, 00:05:39.850 --> 00:05:41.629 you know, like chickenpox. Right, tetanus breaks 00:05:41.629 --> 00:05:44.860 that rule. Having the disease does not confer 00:05:44.860 --> 00:05:47.399 immunity. Correct. That just seems biologically 00:05:47.399 --> 00:05:49.379 unfair. Why does that happen? It all comes down 00:05:49.379 --> 00:05:53.360 to the insane potency of the toxin. The toxin, 00:05:53.459 --> 00:05:56.459 it's called tetanospasmin, is so incredibly potent 00:05:56.459 --> 00:05:59.160 that the amount required to kill a human is... 00:05:59.160 --> 00:06:02.060 It's minuscule. We're talking nanograms. That 00:06:02.060 --> 00:06:04.860 lethal dose is actually too small to trigger 00:06:04.860 --> 00:06:08.480 a full -blown primary immune response. It doesn't 00:06:08.480 --> 00:06:10.540 stimulate the immune system enough to create 00:06:10.540 --> 00:06:13.959 memory B cells. So basically, the toxin can kill 00:06:13.959 --> 00:06:16.220 you without ever waking up the immune system's 00:06:16.220 --> 00:06:17.779 long -term memory. So you can go through this 00:06:17.779 --> 00:06:20.459 horrific experience, survive weeks in the ICU, 00:06:20.959 --> 00:06:23.709 go home. step on another rusty nail a month later, 00:06:23.990 --> 00:06:26.350 and get tetanus all over again. Precisely. Which 00:06:26.350 --> 00:06:29.069 is why post -recovery vaccination is an absolutely 00:06:29.069 --> 00:06:31.529 non -negotiable nursing action. It's a critical 00:06:31.529 --> 00:06:33.589 teaching point for the family. That sets the 00:06:33.589 --> 00:06:35.490 stage perfectly. Now, I want to go deep into 00:06:35.490 --> 00:06:37.970 the why. Let's move to the path of physiology. 00:06:38.790 --> 00:06:41.430 The one -liner definition we have is that tetanus 00:06:41.430 --> 00:06:44.629 is a non -contagious, toxin -mediated disease 00:06:44.629 --> 00:06:47.649 of the CNS caused by Clostridium tetani. And 00:06:47.649 --> 00:06:50.970 the key word there for public health is non -contagious. 00:06:51.050 --> 00:06:53.110 This is the only vaccine -preventable disease 00:06:53.110 --> 00:06:56.189 that is infectious, but not contagious. So you 00:06:56.189 --> 00:06:57.850 can't catch it from the patient in the next bed. 00:06:58.089 --> 00:07:01.209 Never. It lives in the soil, in dust, in manure. 00:07:01.329 --> 00:07:03.509 It doesn't live in people. OK, let's talk about 00:07:03.509 --> 00:07:06.870 the agent itself, Clostridium titani. The notes 00:07:06.870 --> 00:07:10.449 say it's an anaerobic gram -positive rod. Anaerobic 00:07:10.449 --> 00:07:13.529 is the key there, right? It hates oxygen. It 00:07:13.529 --> 00:07:16.649 thrives in the absence of oxygen. It absolutely 00:07:16.649 --> 00:07:19.069 requires a low oxygen environment to grow. This 00:07:19.069 --> 00:07:21.730 is why the whole rusty nail thing is the classic 00:07:21.730 --> 00:07:23.670 trope even if it's a bit of a simplification. 00:07:23.810 --> 00:07:25.629 It's not about the rest. It's not the rest at 00:07:25.629 --> 00:07:28.310 all. It's the fact that a nail creates a deep 00:07:28.310 --> 00:07:31.889 narrow puncture wound. That hole closes up pretty 00:07:31.889 --> 00:07:34.430 quickly at the top trapping the bacteria and 00:07:34.430 --> 00:07:37.470 spores in a low oxygen warm moist environment 00:07:37.470 --> 00:07:40.129 deep in the tissue. You called it a luxury condo 00:07:40.129 --> 00:07:42.939 for the spores. It's the perfect setup. The spores 00:07:42.939 --> 00:07:45.579 then germinate, they turn into active vegetative 00:07:45.579 --> 00:07:48.040 bacteria, and they start pumping out the toxin. 00:07:48.180 --> 00:07:50.000 And here's where we need to get really granular 00:07:50.000 --> 00:07:53.259 for the exam. The toxin, tetanus basmin, it doesn't 00:07:53.259 --> 00:07:56.000 just hang out in the wound. It enters the motor 00:07:56.000 --> 00:07:58.459 neurons at the neuromuscular junction and it 00:07:58.459 --> 00:08:00.819 travels retrograde. Retrograde, so backwards, 00:08:01.240 --> 00:08:04.079 up the nerve. Exactly. Normally, signals go from 00:08:04.079 --> 00:08:06.600 the brain down the nerve to the muscle, telling 00:08:06.600 --> 00:08:10.439 it to contract. This toxin hijacks the internal 00:08:10.439 --> 00:08:13.399 transport system of the axon and it rides the 00:08:13.399 --> 00:08:15.839 nerve up from the muscle into the spinal cord 00:08:15.839 --> 00:08:18.040 and then up to the brain stem. It's using the 00:08:18.040 --> 00:08:20.459 nervous system as its own private highway. A 00:08:20.459 --> 00:08:22.540 one -way street in the wrong direction. And once 00:08:22.540 --> 00:08:24.889 it gets to the central nervous system, What is 00:08:24.889 --> 00:08:28.069 the specific molecular violence it commits? We 00:08:28.069 --> 00:08:30.250 often hear the simple version, it blocks the 00:08:30.250 --> 00:08:32.429 breaks, but let's be specific for the clinicians 00:08:32.429 --> 00:08:34.389 listening. Yeah, let's get into the synapse. 00:08:35.070 --> 00:08:37.629 To really understand the spasm, you have to look 00:08:37.629 --> 00:08:41.549 at the synaptic cleft. You have excitatory neurotransmitters 00:08:41.549 --> 00:08:44.070 like acetylcholine that say go, and you have 00:08:44.070 --> 00:08:46.549 inhibitory neurotransmitters that say stop. Okay. 00:08:46.850 --> 00:08:49.669 The main inhibitory ones in the spinal cord are 00:08:49.669 --> 00:08:52.590 GABA and glycine. Think of them as the brake 00:08:52.590 --> 00:08:54.929 fluid for your muscles. So GABA is the chemical 00:08:54.929 --> 00:08:57.210 red light. It tells the muscle to relax. Correct. 00:08:57.690 --> 00:09:00.649 So tetanospasmin gets into these special inhibitory 00:09:00.649 --> 00:09:04.190 inner neurons and it acts as a protease. A protease. 00:09:04.210 --> 00:09:06.750 So it literally cuts proteins. It's like a molecular 00:09:06.750 --> 00:09:09.830 pair of scissors. Specifically, it targets and 00:09:09.830 --> 00:09:12.769 cuts a protein called synaptobrevin, which is 00:09:12.769 --> 00:09:16.509 also known as VMP2. This little protein is absolutely 00:09:16.509 --> 00:09:18.529 essential for the vesicle, the little bubble 00:09:18.529 --> 00:09:22.009 containing GABA or glycine, to fuse with the 00:09:22.009 --> 00:09:24.789 cell membrane and release its contents. So the 00:09:24.789 --> 00:09:27.070 neuron might be full of brake fluid. It might 00:09:27.070 --> 00:09:29.730 want to release GABA to tell the muscle to relax, 00:09:30.289 --> 00:09:32.649 but the mechanism to actually open the door and 00:09:32.649 --> 00:09:35.490 let it out. is physically broken. The door is 00:09:35.490 --> 00:09:38.690 welded shut. The toxin has cut the release mechanism. 00:09:39.009 --> 00:09:41.149 So the motor neurons are just getting constant 00:09:41.149 --> 00:09:43.850 unopposed go signals without any stop signals. 00:09:44.230 --> 00:09:46.690 That leads to this high frequency uncontrolled 00:09:46.690 --> 00:09:49.730 firing. And that is the spasm, the rigidity. 00:09:49.850 --> 00:09:52.289 That is the rigor and the spasm. It's a failure 00:09:52.289 --> 00:09:54.710 of inhibition. And this explains the unbound 00:09:54.710 --> 00:09:57.029 rule we see in all the treatment protocols. This 00:09:57.029 --> 00:09:59.210 is a critical point. Yes. This is so important. 00:09:59.389 --> 00:10:02.029 Once the toxin gets inside that neuron and cleaves 00:10:02.029 --> 00:10:04.370 that synaptobreven protein, the damage is done. 00:10:04.710 --> 00:10:06.909 You cannot glue that protein back together. There's 00:10:06.909 --> 00:10:10.269 no reversing it at that point. None. You literally 00:10:10.269 --> 00:10:12.990 have to wait for the nerve terminal to sprout 00:10:12.990 --> 00:10:16.610 a new ending and regenerate those proteins. And 00:10:16.610 --> 00:10:20.190 that takes weeks. So when we give anti -toxins, 00:10:20.429 --> 00:10:23.269 like tetanus immune globulin, we are only mopping 00:10:23.269 --> 00:10:25.110 up the toxin that is still floating around in 00:10:25.110 --> 00:10:27.149 the blood or in the lymph, trying to prevent 00:10:27.149 --> 00:10:29.309 more nerves from being affected. That's it. We 00:10:29.309 --> 00:10:31.429 can't do anything about the damage that has already 00:10:31.429 --> 00:10:35.690 happened. Exactly. We are trying to stop the 00:10:35.690 --> 00:10:38.750 recruitment of new nerves into the spastic state. 00:10:38.889 --> 00:10:41.549 We're containing the fire, not rebuilding the 00:10:41.549 --> 00:10:43.129 part of the house that's already burned down. 00:10:43.370 --> 00:10:45.789 That makes the timeline of the clinical presentation 00:10:45.789 --> 00:10:47.990 make so much more sense. Okay, let's transition 00:10:47.990 --> 00:10:51.370 to that. Section three, clinical presentation 00:10:51.370 --> 00:10:54.149 and assessment. We mentioned the incubation period 00:10:54.149 --> 00:10:57.330 ranges from about three to 21 days with an average 00:10:57.330 --> 00:10:59.710 of eight, but there's a really important correlation 00:10:59.710 --> 00:11:02.129 between the injury site and that timeline. Yeah, 00:11:02.169 --> 00:11:04.190 think about that retrograde transport we just 00:11:04.190 --> 00:11:06.929 discussed, that highway up the nerve. If the 00:11:06.929 --> 00:11:09.750 injury's on your big toe, the toxin has to travel 00:11:09.750 --> 00:11:11.870 the entire length of the sciatic nerve to get 00:11:11.870 --> 00:11:14.370 to the spinal cord. That's a long commute. A 00:11:14.370 --> 00:11:17.710 very long trip. But if the injury is on the face, 00:11:17.950 --> 00:11:20.509 or the neck. It's a short commute, a quick trip 00:11:20.509 --> 00:11:22.409 to the brainstem. And a shorter commute means 00:11:22.409 --> 00:11:25.389 a shorter incubation period. Clinically, a short 00:11:25.389 --> 00:11:28.309 incubation period, say under seven days, is a 00:11:28.309 --> 00:11:30.970 massive red flag. It correlates directly with 00:11:30.970 --> 00:11:33.730 more severe disease and a much, much higher mortality 00:11:33.730 --> 00:11:36.350 rate. If symptoms show up in three days, you 00:11:36.350 --> 00:11:39.090 are in for a very, very difficult fight. So let's 00:11:39.090 --> 00:11:41.470 walk through that descending pattern of symptoms. 00:11:41.950 --> 00:11:44.070 Why does it almost always start with trismus, 00:11:44.309 --> 00:11:46.289 with a lockjaw? It's a combination of a couple 00:11:46.289 --> 00:11:48.970 of things. One is the shorter neural pathways 00:11:48.970 --> 00:11:50.850 in the head and neck, especially for cranial 00:11:50.850 --> 00:11:53.990 nerves. But it's also the high density of motor 00:11:53.990 --> 00:11:56.549 units in the masseter muscles, the big jaw muscles. 00:11:57.049 --> 00:11:59.370 They are incredibly strong, and they are very 00:11:59.370 --> 00:12:02.090 sensitive to this loss of inhibition. So trismus 00:12:02.090 --> 00:12:04.029 is often the very first sign you'll see. OK, 00:12:04.149 --> 00:12:07.740 so jaw first, and then it moves down. Neck stiffness, 00:12:08.059 --> 00:12:10.820 dysphagia. In dysphagia, the difficulty swallowing 00:12:10.820 --> 00:12:13.240 is so critical. It's not just uncomfortable. 00:12:13.600 --> 00:12:16.379 It leads to drooling, pooling of secretions, 00:12:16.860 --> 00:12:19.700 and a huge aspiration risk. Then it hits the 00:12:19.700 --> 00:12:22.679 trunk. This is where you see that. classic board 00:12:22.679 --> 00:12:25.700 -like rigidity of the abdomen. The rectus abdominis 00:12:25.700 --> 00:12:28.000 muscles are contracted as hard as they can possibly 00:12:28.000 --> 00:12:30.539 be. It feels like a sheet of wood on palpation. 00:12:30.919 --> 00:12:32.759 And now for the red flags that we absolutely 00:12:32.759 --> 00:12:36.759 need to have memorized for an exam, we have largospasm, 00:12:37.080 --> 00:12:40.019 rhesus sardonicus, and opus satinus. Let's start 00:12:40.019 --> 00:12:43.269 with rhesus sardonicus. Rhesus sardonicus is 00:12:43.269 --> 00:12:46.730 Latin for sardonic smile or sardonic grin. It's 00:12:46.730 --> 00:12:49.649 really eerie to see. The facial muscles all contract 00:12:49.649 --> 00:12:51.570 at once, pulling the eyebrows up and the corners 00:12:51.570 --> 00:12:53.789 of the mouth out and down. It looks like this 00:12:53.789 --> 00:12:56.509 fixed, creepy grin on the patient's face even 00:12:56.509 --> 00:12:59.210 while they're in agony. It's pathognomonic. It's 00:12:59.210 --> 00:13:01.490 diagnostic. And opasotinous. I've seen pictures 00:13:01.490 --> 00:13:04.070 of this, and it's horrifying. It is. This is 00:13:04.070 --> 00:13:06.850 a state of global extension. What happens is 00:13:06.850 --> 00:13:10.190 the extensor muscles in the back are just anatomically 00:13:10.190 --> 00:13:12.370 stronger than the... muscles in the abdomen. 00:13:12.809 --> 00:13:14.990 So when everything contracts at once, the back 00:13:14.990 --> 00:13:17.330 wins. The stronger muscles overpower the weaker 00:13:17.330 --> 00:13:20.769 ones. Exactly. The patient arches backwards so 00:13:20.769 --> 00:13:22.809 severely that they might be resting only on the 00:13:22.809 --> 00:13:24.730 back of their head and their heels with their 00:13:24.730 --> 00:13:28.750 entire body bridged up off the bed. In neonates 00:13:28.750 --> 00:13:31.629 or small children, this force can be strong enough 00:13:31.629 --> 00:13:34.090 to cause compression fractures of the vertebrae. 00:13:34.090 --> 00:13:35.990 Just from their own muscles. Just from the force 00:13:35.990 --> 00:13:38.450 of their own muscle spasms. That leads us to 00:13:38.450 --> 00:13:40.710 the other critical piece, the autonomic dysfunction. 00:13:41.289 --> 00:13:43.990 It's not just the skeletal muscles. The fight 00:13:43.990 --> 00:13:46.529 or flight system... is completely broken too. 00:13:46.730 --> 00:13:49.409 Right. The toxin also affects the autonomic nervous 00:13:49.409 --> 00:13:51.809 system. The sympathetic nervous system just goes 00:13:51.809 --> 00:13:55.149 haywire. You get these massive, unpredictable 00:13:55.149 --> 00:13:59.309 surges of catecholamines, adrenaline, noradrenaline. 00:13:59.350 --> 00:14:01.049 So what does that look like at the bedside? You'll 00:14:01.049 --> 00:14:03.590 see wild swings, tachycardia, so a really fast 00:14:03.590 --> 00:14:06.110 heart rate, labile hypertension, where the blood 00:14:06.110 --> 00:14:09.230 pressure is spiking up to 220 over 151 minute 00:14:09.230 --> 00:14:11.889 and then dropping way down the next, profuse 00:14:11.889 --> 00:14:14.190 sweating, drenching the bed and high fevers. 00:14:14.690 --> 00:14:16.990 This autonomic storm is incredibly dangerous 00:14:16.990 --> 00:14:19.629 and can cause a cardiac arrest even if the airway 00:14:19.629 --> 00:14:21.750 is perfectly managed. OK, we have the picture 00:14:21.750 --> 00:14:26.169 of the critically ill patient. It's grim. Now 00:14:26.169 --> 00:14:28.470 let's go upstream to the decision making that 00:14:28.470 --> 00:14:31.059 prevents us from ever happening. the exam writer's 00:14:31.059 --> 00:14:34.179 favorite, the wound prophylaxis algorithm. Oh, 00:14:34.220 --> 00:14:36.840 this is it? This is the part that trips up even 00:14:36.840 --> 00:14:38.820 experienced nurses because of all the variables. 00:14:39.100 --> 00:14:40.720 It's a matrix. You just have to think of it as 00:14:40.720 --> 00:14:43.120 a two -by -two table. You have two axes. The 00:14:43.120 --> 00:14:45.259 wound condition, which is either clean, minor, 00:14:45.379 --> 00:14:49.059 or all other wounds, dirty, puncture, burn, crush. 00:14:49.240 --> 00:14:52.539 OK, clean versus dirty. And the second axis is 00:14:52.539 --> 00:14:56.080 the vaccination history. Is it unknown or incomplete, 00:14:56.419 --> 00:14:58.679 meaning less than three doses? Or is it complete, 00:14:58.899 --> 00:15:01.860 meaning three or more documented doses? And where 00:15:01.860 --> 00:15:04.100 you land on that grid tells you what to do. Precisely. 00:15:04.279 --> 00:15:06.539 Okay, let's role play this with specific case 00:15:06.539 --> 00:15:08.559 studies to really lock in the logic. Let's do 00:15:08.559 --> 00:15:10.679 it. Best way to learn. Okay, case study one. 00:15:11.159 --> 00:15:13.149 You have 12 -year -old boy... Let's call him 00:15:13.149 --> 00:15:15.509 Leo. He was helping his dad in the garage and 00:15:15.509 --> 00:15:18.309 sliced his hand on a clean new box cutter. It's 00:15:18.309 --> 00:15:19.850 a superficial cut. You wash it out. It looks 00:15:19.850 --> 00:15:22.009 very clean. His mom has his records. He had all 00:15:22.009 --> 00:15:24.830 his baby shots and his booster at age four, but 00:15:24.830 --> 00:15:26.850 he hasn't had his 11 -year -old Tdap yet. What 00:15:26.850 --> 00:15:29.309 do we do? OK, perfect. Let's use a matrix. Variable 00:15:29.309 --> 00:15:32.429 one. The wound is clean and minor. Variable two. 00:15:32.909 --> 00:15:35.470 His vaccine history is three plus doses. He completed 00:15:35.470 --> 00:15:38.230 that primary series as a baby. Right. For clean 00:15:38.230 --> 00:15:40.870 wounds in a fully vaccinated person, the rule 00:15:40.870 --> 00:15:43.149 is the 10 -year rule. We need to know when his 00:15:43.149 --> 00:15:45.529 last dose was. It was at age four. He's 12 now. 00:15:45.629 --> 00:15:47.370 So that was eight years ago. Is it eight less 00:15:47.370 --> 00:15:50.070 than 10? Yes, it is. Yeah. We do nothing. Action. 00:15:50.289 --> 00:15:52.549 Clean the wound thoroughly. No vaccine needed 00:15:52.549 --> 00:15:55.629 today. No TIG needed. He's still considered protected 00:15:55.629 --> 00:15:58.450 for a low inoculum clean wound. He's within that 00:15:58.450 --> 00:16:00.549 safety window. OK, that makes sense. Case study 00:16:00.549 --> 00:16:03.309 two. Let's change the variables. Same kid, Leo, 00:16:03.529 --> 00:16:06.429 12 years old. But this time he wasn't in the 00:16:06.429 --> 00:16:09.320 garage. He was out playing in a muddy field and 00:16:09.320 --> 00:16:11.919 he stepped on an old rusty piece of farm equipment. 00:16:12.500 --> 00:16:14.519 It's a deep puncture wound contaminated with 00:16:14.519 --> 00:16:17.820 soil. Same vaccine history. Last shot at age 00:16:17.820 --> 00:16:20.200 four. Okay, everything changes now. Variable 00:16:20.200 --> 00:16:23.559 one. This is dirty wound. It's a contaminated 00:16:23.559 --> 00:16:26.259 or all other wound. Variable two. History is 00:16:26.259 --> 00:16:28.820 still three plus doses. So what's the rule now? 00:16:29.000 --> 00:16:31.679 Because the wound is dirty, the potential antigenic 00:16:31.679 --> 00:16:34.159 load, the amount of bacteria and potential toxin 00:16:34.159 --> 00:16:36.720 is much, much higher. We can't rely on that 10 00:16:36.720 --> 00:16:39.279 -year window anymore. For dirty wounds, we switch 00:16:39.279 --> 00:16:41.620 to the five -year rule. Oh, OK, the five -year 00:16:41.620 --> 00:16:43.440 rule. It has been eight years since his last 00:16:43.440 --> 00:16:45.220 shot. That is more than five years ago. So he 00:16:45.220 --> 00:16:48.340 needs a booster. Action. Give the vaccine, in 00:16:48.340 --> 00:16:51.419 this case Tdap. We want to spike his antibody 00:16:51.419 --> 00:16:53.580 titers right now to handle that increased threat. 00:16:53.700 --> 00:16:55.620 But do we give the immunoglobulin? Do we give 00:16:55.620 --> 00:16:59.389 TIG? No. And this is a key distinction. His body 00:16:59.389 --> 00:17:01.629 still has memory from those previous vaccines. 00:17:01.850 --> 00:17:04.369 He has memory B cells. The booster shot will 00:17:04.369 --> 00:17:06.490 wake up that memory very quickly within a few 00:17:06.490 --> 00:17:09.250 days, and he'll mount a strong antibody response. 00:17:09.849 --> 00:17:12.009 The risk of fulminant tetanus is low because 00:17:12.009 --> 00:17:14.970 he has a primed immune system. TIG is not needed. 00:17:15.230 --> 00:17:17.069 Okay, now for the scenario that gives everyone 00:17:17.069 --> 00:17:20.190 anxiety. Case study three. A six -year -old girl, 00:17:20.329 --> 00:17:23.190 Maya. Her family has just immigrated, or perhaps 00:17:23.190 --> 00:17:25.859 they're vaccine hesitant. The bottom line is 00:17:25.859 --> 00:17:28.819 she has no vaccination record. Her history is 00:17:28.819 --> 00:17:31.299 unknown. She falls off her bike into gravel and 00:17:31.299 --> 00:17:33.980 has a deep, dirty abrasion that's contaminated 00:17:33.980 --> 00:17:36.359 with road debris and soil. This is the danger 00:17:36.359 --> 00:17:38.259 zone. This is the one you cannot miss. Right. 00:17:38.440 --> 00:17:40.519 Variable 1, dirty wound, high risk. Variable 00:17:40.519 --> 00:17:43.579 2, unknown or incomplete history. We have to 00:17:43.579 --> 00:17:45.720 assume she has zero protection. So we have a 00:17:45.720 --> 00:17:48.230 high risk entry. And basically no defense system. 00:17:48.589 --> 00:17:51.329 Correct. A vaccine takes weeks to build a primary 00:17:51.329 --> 00:17:53.390 immune response. We do not have weeks. She could 00:17:53.390 --> 00:17:55.230 be symptomatic in a few days. So what's the action? 00:17:55.349 --> 00:17:58.829 Action. You must give both the vaccine, in this 00:17:58.829 --> 00:18:01.210 case DTaP since she's under seven, to start that 00:18:01.210 --> 00:18:04.549 long -term training. And you give TIG the tetanus 00:18:04.549 --> 00:18:07.210 immune globulin. Okay, explain the role of TIG 00:18:07.210 --> 00:18:09.670 here again. I love your analogy for this. Think 00:18:09.670 --> 00:18:12.049 of the vaccine as a boot camp for the immune 00:18:12.049 --> 00:18:15.089 system. It takes time to recruit and train soldiers, 00:18:15.130 --> 00:18:18.630 right, to build an army. Weeks. TIG is like hiring 00:18:18.630 --> 00:18:21.529 a battalion of elite pre -trained mercenaries 00:18:21.529 --> 00:18:24.170 today. It provides immediate passive immunity. 00:18:24.670 --> 00:18:26.910 These are borrowed antibodies harvested from 00:18:26.910 --> 00:18:29.369 donors that will go in and start hunting down 00:18:29.369 --> 00:18:32.250 any circulating toxin right now while the vaccine 00:18:32.250 --> 00:18:34.430 is busy training the body's own selves for the 00:18:34.430 --> 00:18:36.930 future war. That mercenaries versus boot camp 00:18:36.930 --> 00:18:39.470 analogy is the key to remembering it. You only 00:18:39.470 --> 00:18:40.970 call in the mercenaries when you have a dirty 00:18:40.970 --> 00:18:43.769 war and no standing army of your own. Precisely. 00:18:43.930 --> 00:18:46.089 And just to round this out, there is one major 00:18:46.089 --> 00:18:48.289 special population exception we have to mention. 00:18:48.990 --> 00:18:51.349 Immunocompromised patients. Right. If Maya, in 00:18:51.349 --> 00:18:54.509 that last scenario, had HIV or was on high dose 00:18:54.509 --> 00:18:57.410 steroids or chemotherapy. The rules change. The 00:18:57.410 --> 00:19:00.329 rules change completely. Even if she had a documented 00:19:00.329 --> 00:19:03.599 history of vaccination. We cannot trust that 00:19:03.599 --> 00:19:05.960 her compromised immune system maintained that 00:19:05.960 --> 00:19:09.140 memory or could mount a response. So the rule 00:19:09.140 --> 00:19:13.240 is, if an immunocompromised patient has a dirty 00:19:13.240 --> 00:19:16.700 tetanus -prone wound, they get TIG, regardless 00:19:16.700 --> 00:19:19.099 of their vaccination history. We just don't take 00:19:19.099 --> 00:19:21.200 the gamble. That covers the algorithm beautifully. 00:19:21.460 --> 00:19:23.480 Listeners, rewind that section a few times if 00:19:23.480 --> 00:19:25.740 you need to. That logic is, I'm not kidding, 00:19:25.839 --> 00:19:28.000 probably 80 % of your exam questions on this 00:19:28.000 --> 00:19:29.759 topic. Absolutely. Now let's move to section 00:19:29.759 --> 00:19:33.240 five, medical management. The prevention failed. 00:19:33.660 --> 00:19:36.140 We're in the PICU with a child with active tetanus. 00:19:36.339 --> 00:19:38.859 We are in full crisis management mode now. The 00:19:38.859 --> 00:19:41.619 priority immediately shifts to the stop the crash 00:19:41.619 --> 00:19:43.880 list. And item number one on that list is always 00:19:43.880 --> 00:19:46.200 airway. But you mentioned earlier this isn't 00:19:46.200 --> 00:19:48.720 a standard intubation. No, it's a difficult airway 00:19:48.720 --> 00:19:51.180 by definition. Think about it. If the patient 00:19:51.180 --> 00:19:53.730 has severe trismus... You can't open their mouth 00:19:53.730 --> 00:19:55.809 to get the laryngoscope in. You can't visualize 00:19:55.809 --> 00:19:58.470 the cords. And if they're having a laryngospasm, 00:19:58.609 --> 00:20:01.009 the vocal cords are clamped shut. You often cannot 00:20:01.009 --> 00:20:03.769 physically pass an endotracheal tube. Trying 00:20:03.769 --> 00:20:06.329 to do so can make the spasm worse. So what's 00:20:06.329 --> 00:20:08.930 the solution? The clinical pearl here for your 00:20:08.930 --> 00:20:11.730 exams and practice. These patients often require 00:20:11.730 --> 00:20:14.769 an early tracheostomy. So you bypass the problem 00:20:14.769 --> 00:20:18.190 area entirely? You bypass the cords, it securely 00:20:18.190 --> 00:20:21.049 establishes the airway, and it also allows for 00:20:21.049 --> 00:20:23.250 long -term ventilation, which they are almost 00:20:23.250 --> 00:20:25.650 certainly going to need for weeks while the nerve 00:20:25.650 --> 00:20:29.230 endings regenerate. Okay. Airway is secure. Next 00:20:29.230 --> 00:20:31.670 is neutralizing the toxin. We're giving TIG again, 00:20:31.890 --> 00:20:34.250 but this time it's therapeutic, not prophylactic. 00:20:34.460 --> 00:20:37.000 Yes, much higher doses than the prophylactic 00:20:37.000 --> 00:20:40.920 shot. We're talking 500 to maybe 3 ,000 units, 00:20:41.160 --> 00:20:43.019 depending on the severity. And here's a little 00:20:43.019 --> 00:20:45.960 procedural note you might see. We often infiltrate 00:20:45.960 --> 00:20:49.059 part of that TIG dose directly into the tissue 00:20:49.059 --> 00:20:51.740 around the debrided wound. Like you're injecting 00:20:51.740 --> 00:20:53.619 a perimeter defense. That's a perfect way to 00:20:53.619 --> 00:20:56.059 put it. We're trying to neutralize any toxin 00:20:56.059 --> 00:20:58.160 being produced right there at the source before 00:20:58.160 --> 00:21:00.099 it can even enter the bloodstream and travel 00:21:00.099 --> 00:21:02.680 to the nerves. That's smart. Then we have wound 00:21:02.680 --> 00:21:05.160 care and antibiotics. Debridement is absolutely 00:21:05.160 --> 00:21:07.339 crucial. You have to surgically go in and remove 00:21:07.339 --> 00:21:10.460 all the dead necrotic tissue. Remember, the bacteria 00:21:10.460 --> 00:21:13.019 is anaerobic. Dead tissue has no blood flow, 00:21:13.059 --> 00:21:15.339 which means no oxygen. If you leave it there, 00:21:15.359 --> 00:21:17.079 it's a toxin factory. You have to shut down that 00:21:17.079 --> 00:21:19.359 factory. You have to clean it out. Then we use 00:21:19.359 --> 00:21:22.160 antibiotics. Typically metronidazole is favored 00:21:22.160 --> 00:21:26.039 now over penicillin G to kill the live vegetative 00:21:26.039 --> 00:21:28.859 bacteria that are producing the toxin. Now let's 00:21:28.859 --> 00:21:32.019 talk about spasm control. This is where the pharmacology 00:21:32.019 --> 00:21:34.420 gets really heavy. We're not just giving a little 00:21:34.420 --> 00:21:37.019 Tylenol here. No, not at all. The first line 00:21:37.019 --> 00:21:40.500 is high dose, benzodiazepines, the V. diazepam, 00:21:40.960 --> 00:21:44.799 or a midazolam infusion. These are GABA agonists. 00:21:45.000 --> 00:21:47.460 They work on the GABA receptors to try to artificially 00:21:47.460 --> 00:21:50.039 stimulate the inhibitory system that the toxin 00:21:50.039 --> 00:21:52.220 has disabled. But often that's not enough, is 00:21:52.220 --> 00:21:54.740 it? Often it's not. The next step we might add 00:21:54.740 --> 00:21:57.660 is magnesium sulfate. Magnesium. That's usually 00:21:57.660 --> 00:22:00.920 an OB drug for preeclampsia, right? It is, but 00:22:00.920 --> 00:22:03.299 it works for the same reason. Magnesium acts 00:22:03.299 --> 00:22:06.140 as a calcium antagonist at the presynaptic nerve 00:22:06.140 --> 00:22:08.859 terminal. It blocks the release of excitatory 00:22:08.859 --> 00:22:12.119 neurotransmitters like acetylcholine, and it 00:22:12.119 --> 00:22:15.019 also relaxes smooth muscle. It helps with both 00:22:15.019 --> 00:22:18.460 the skeletal muscle spasms and with that dangerous 00:22:18.460 --> 00:22:21.259 autonomic instability, the blood pressure spikes. 00:22:21.480 --> 00:22:23.359 And if that still doesn't work, if the spasms 00:22:23.359 --> 00:22:25.480 are breaking through the benzos and the magnesium, 00:22:25.759 --> 00:22:28.819 then the final step is a full neuromuscular blockade. 00:22:29.200 --> 00:22:32.660 We use drugs like vecoronium or rocoronium to 00:22:32.660 --> 00:22:35.720 induce a chemical paralysis. We stop the muscles 00:22:35.720 --> 00:22:38.019 from moving entirely. So the patient is completely 00:22:38.019 --> 00:22:40.990 paralyzed. Completely. This allows the ventilator 00:22:40.990 --> 00:22:43.390 to do all the work of breathing. It stops the 00:22:43.390 --> 00:22:45.130 patient from breaking their own bones. And it 00:22:45.130 --> 00:22:47.849 dramatically lowers that insane metabolic demand. 00:22:48.049 --> 00:22:50.029 This leads perfectly into the nursing environment. 00:22:50.049 --> 00:22:52.470 Yeah. If I'm the nurse assigned to this child, 00:22:53.049 --> 00:22:55.730 my actual behavior in the room is a critical 00:22:55.730 --> 00:22:58.009 intervention. Yes. This is the dark room protocol. 00:22:58.089 --> 00:23:00.049 You will see this on exams. The goal is to prevent 00:23:00.049 --> 00:23:03.009 seizures and prevent spasms. And the action is 00:23:03.009 --> 00:23:04.910 complete stimulus reduction. So what does that 00:23:04.910 --> 00:23:07.190 look like in practice? You keep the room as dark 00:23:07.190 --> 00:23:10.670 as possible. You minimize noise. You silence 00:23:10.670 --> 00:23:12.789 alarms when you're in the room or set them to 00:23:12.789 --> 00:23:16.309 a low volume. You avoid bumping the bed. And 00:23:16.309 --> 00:23:19.569 critically, you cluster your care. Explain what 00:23:19.569 --> 00:23:22.490 clustering care means in this context. It means 00:23:22.490 --> 00:23:24.470 you don't go in at 8 o 'clock to check the blood 00:23:24.470 --> 00:23:27.130 pressure, then go back in at 8 .15 to give a 00:23:27.130 --> 00:23:30.369 med, then back again at 8 .30 to suction. Because 00:23:30.369 --> 00:23:33.349 every interaction is a potential trigger. Every 00:23:33.349 --> 00:23:35.710 time you touch that patient, you risk triggering 00:23:35.710 --> 00:23:39.009 a titanic spasm. So you plan ahead, you go in 00:23:39.009 --> 00:23:41.569 once, maybe you give some extra sedation first, 00:23:41.789 --> 00:23:43.490 then you do everything you need to do all at 00:23:43.490 --> 00:23:45.509 once. You suction, you turn them, you give meds, 00:23:45.529 --> 00:23:47.250 you do your full assessment, you check your lines, 00:23:47.410 --> 00:23:49.809 and then you get out and you let them rest undisturbed 00:23:49.809 --> 00:23:52.250 for as long as possible. You coordinate with 00:23:52.250 --> 00:23:54.349 respiratory therapy, with physical therapy, so 00:23:54.349 --> 00:23:56.490 you're all touching the patient at the same time. 00:23:56.630 --> 00:23:59.170 It's not just minimally invasive. It's a survival 00:23:59.170 --> 00:24:01.289 interaction. That's what it is. Let's broaden 00:24:01.289 --> 00:24:03.589 our scope now to the pediatric focus. This is 00:24:03.589 --> 00:24:07.680 so important. Section 6. Age -specific presentation 00:24:07.680 --> 00:24:10.900 and developmental impact. The sources all highlight 00:24:10.900 --> 00:24:13.940 neonatal tetanus specifically. Yeah, this is 00:24:13.940 --> 00:24:15.900 a global health tragedy. It's sometimes called 00:24:15.900 --> 00:24:19.059 the seven -day death. It occurs almost exclusively 00:24:19.059 --> 00:24:22.200 in infants born to unvaccinated mothers. Because 00:24:22.200 --> 00:24:24.079 the mother has no antibodies to pass through 00:24:24.079 --> 00:24:27.000 the placenta. Exactly. The baby is born with 00:24:27.000 --> 00:24:30.200 zero passive immunity, zero protection. And the 00:24:30.200 --> 00:24:32.059 source of the infection isn't a puncture wound. 00:24:32.319 --> 00:24:35.980 No, it's the umbilical stump. In many low -resource 00:24:35.980 --> 00:24:38.019 settings or due to certain cultural practices, 00:24:38.299 --> 00:24:40.539 the umbilical cord might be cut with an unsterile 00:24:40.539 --> 00:24:43.400 instrument bamboo, a kitchen knife, or the stump 00:24:43.400 --> 00:24:46.019 might be dressed with things like mud, ash, or 00:24:46.019 --> 00:24:49.000 even cow dung. These materials are just loaded 00:24:49.000 --> 00:24:52.039 with Clostridium titani spores. And the incubation 00:24:52.039 --> 00:24:54.700 period is very short, only four to 14 days. Right. 00:24:54.880 --> 00:24:57.480 So the baby is born, seems fine, starts nursing 00:24:57.480 --> 00:24:59.960 normally for a few days, and then they stop. 00:25:00.140 --> 00:25:02.599 They stop feeding because of lockjaw, the trismus. 00:25:03.039 --> 00:25:05.740 Then comes the rigidity, the characteristic spasms. 00:25:06.099 --> 00:25:08.380 The mortality rate without modern intensive care 00:25:08.380 --> 00:25:10.900 is nearly 100%. It's devastating. OK, let's talk 00:25:10.900 --> 00:25:13.460 about the survivors, the toddlers or older kids 00:25:13.460 --> 00:25:15.400 who get tetanus and make it through the ICU. 00:25:16.220 --> 00:25:19.359 How does this disease and the treatment impact 00:25:19.359 --> 00:25:21.700 their long -term development? The physical impact 00:25:21.700 --> 00:25:24.980 can be severe and lasting. We talked about fractures. 00:25:25.460 --> 00:25:27.759 Imagine a two -year -old who has just mastered 00:25:27.759 --> 00:25:31.180 walking. They suffer vertebral compression fractures 00:25:31.180 --> 00:25:33.920 from the spasms. They're now immobilized in a 00:25:33.920 --> 00:25:36.880 back brace or even traction for months. That 00:25:36.880 --> 00:25:38.839 is a massive regression in their gross motor 00:25:38.839 --> 00:25:41.220 milestones. They may have to learn to walk all 00:25:41.220 --> 00:25:43.259 over again. And what about the nutritional aspect? 00:25:43.559 --> 00:25:46.420 The metabolic rate of a tetanus patient is sky 00:25:46.420 --> 00:25:49.400 high. That constant muscle activity burns calories 00:25:49.400 --> 00:25:52.579 like an Olympic sprinter, 247. But at the same 00:25:52.579 --> 00:25:55.059 time, they can't swallow because of the dysphagia. 00:25:55.099 --> 00:25:57.779 So you have this huge caloric need and no way 00:25:57.779 --> 00:26:00.660 to take in nutrition orally. They're in a catabolic 00:26:00.660 --> 00:26:03.839 state. A profoundly catabolic state. Severe weight 00:26:03.839 --> 00:26:06.160 loss and malnutrition are major risks, which 00:26:06.160 --> 00:26:08.720 in a young child directly affects brain development 00:26:08.720 --> 00:26:10.920 and overall physical growth. And then there's 00:26:10.920 --> 00:26:13.660 the psychological trauma of the ICU itself. Right. 00:26:14.039 --> 00:26:16.500 Prolonged hospitalization is the key phrase here. 00:26:16.900 --> 00:26:19.380 We are talking three, four, maybe five weeks 00:26:19.380 --> 00:26:22.539 in a pediatric ICU, often paralyzed and sedated. 00:26:22.700 --> 00:26:25.000 What does that do to a developing child? Well, 00:26:25.140 --> 00:26:27.700 it depends on their age. For an infant or toddler, 00:26:28.039 --> 00:26:30.240 it's a huge disruption to attachment and bonding. 00:26:30.799 --> 00:26:33.140 It can cause severe separation anxiety. They 00:26:33.140 --> 00:26:35.859 can lose newly acquired skills like toilet training 00:26:35.859 --> 00:26:37.799 or sleeping through the night. And for an older 00:26:37.799 --> 00:26:40.200 child? For a school -aged child, it's terrifying. 00:26:40.619 --> 00:26:43.539 It's fear of bodily harm, pain, loss of control. 00:26:43.819 --> 00:26:45.519 They miss their friends, their school, their 00:26:45.519 --> 00:26:48.619 routine. For an adolescent, think about body 00:26:48.619 --> 00:26:51.480 image. Waking up with a tracheostomy scar on 00:26:51.480 --> 00:26:53.990 your neck. being weak, deconditioned, having 00:26:53.990 --> 00:26:56.430 lost all your autonomy, it can be absolutely 00:26:56.430 --> 00:26:58.670 devastating to their sense of self. So as the 00:26:58.670 --> 00:27:01.549 nursing educator in this scenario, what is our 00:27:01.549 --> 00:27:03.589 key intervention to protect their development? 00:27:03.769 --> 00:27:06.849 You have to advocate fiercely for family presence. 00:27:07.130 --> 00:27:09.329 Even within that darkroom protocol, this is a 00:27:09.329 --> 00:27:11.970 critical nuance, the parent is the anchor in 00:27:11.970 --> 00:27:14.230 that storm. They shouldn't be overstimulating 00:27:14.230 --> 00:27:16.150 the child, of course, but they can sit quietly 00:27:16.150 --> 00:27:18.230 by the bed, maybe hold a hand if the child can 00:27:18.230 --> 00:27:21.430 tolerate it. That familiar tactile reassurance 00:27:21.430 --> 00:27:24.309 can reduce anxiety, which can actually lower 00:27:24.309 --> 00:27:26.880 the risk of spasms. That's a great point. So 00:27:26.880 --> 00:27:29.640 you reduce the bad stimuli, like lights and alarms, 00:27:30.119 --> 00:27:32.319 but you try to maintain the good stimuli, which 00:27:32.319 --> 00:27:34.440 is the parental presence. That's a beautiful 00:27:34.440 --> 00:27:36.799 way to put it. Safe care does not mean isolated 00:27:36.799 --> 00:27:39.700 care. Okay, let's talk prevention. Section seven, 00:27:39.940 --> 00:27:42.000 the vaccine schedule. We have this alphabet soup 00:27:42.000 --> 00:27:45.160 of vaccines. D -tap, P -T -dap, D -D -D -D -T. 00:27:45.559 --> 00:27:47.980 It can be confusing. It's a code, but it's a 00:27:47.980 --> 00:27:50.720 simple one once you learn it. The uppercase letters, 00:27:50.819 --> 00:27:53.579 the big D and the big P, denote the full strength 00:27:53.579 --> 00:27:56.200 dose of the diphtheria and pertussis components. 00:27:56.680 --> 00:27:59.700 The lowercase letters, little d and little p, 00:27:59.819 --> 00:28:02.700 mean a reduced strength dose. OK, so D TAPI. 00:28:02.779 --> 00:28:06.160 Big D, big P, full strength diphtheria and pertussis. 00:28:06.420 --> 00:28:09.220 This is for the little naive immune systems of 00:28:09.220 --> 00:28:11.759 children under seven years old. And T DAP. Little 00:28:11.759 --> 00:28:14.339 d, little p, reduced strength. This is the booster 00:28:14.339 --> 00:28:16.619 for older children. so leaven and up, and for 00:28:16.619 --> 00:28:18.759 adults. And why do we reduce the dose for older 00:28:18.759 --> 00:28:22.099 kids and adults? Primarily to reduce local reactions. 00:28:22.460 --> 00:28:24.819 As our immune systems mature, that full -strength 00:28:24.819 --> 00:28:27.480 Big D can cause a lot of sore, swollen, painful 00:28:27.480 --> 00:28:30.400 arms. The reduced dose is just as effective as 00:28:30.400 --> 00:28:32.720 a booster, but much better tolerated. And then 00:28:32.720 --> 00:28:36.380 there's TD? TD is just tetanus and reduced diphtheria. 00:28:36.509 --> 00:28:39.670 no pertussis component. This is often used for 00:28:39.670 --> 00:28:42.509 the every 10 -year adult boosters if Tdap isn't 00:28:42.509 --> 00:28:44.910 indicated or available. So let's run through 00:28:44.910 --> 00:28:47.009 the schedule quickly. OK, the primary series 00:28:47.009 --> 00:28:49.509 for infants is given at two months, four months, 00:28:49.549 --> 00:28:51.630 and six months. Then the boosters. The first 00:28:51.630 --> 00:28:54.089 booster is between 15 and 18 months. The second 00:28:54.089 --> 00:28:56.609 booster is between four and six years old. That's 00:28:56.609 --> 00:28:59.089 the kindergarten shot. And after that? The adolescent 00:28:59.089 --> 00:29:01.569 booster is at 11 to 12 years old, and that should 00:29:01.569 --> 00:29:04.470 be a Tdap to get that pertussis protection back 00:29:04.470 --> 00:29:06.599 in there. And then for adults, it's a booster 00:29:06.599 --> 00:29:09.960 every 10 years. There is one absolutely crucial 00:29:09.960 --> 00:29:13.359 core add -in here for pregnancy that connects 00:29:13.359 --> 00:29:15.339 right back to what we said about neonatal tetanus. 00:29:15.519 --> 00:29:17.680 Yes. This is part of the cocooning strategy. 00:29:18.079 --> 00:29:20.319 The current recommendation is to give a dose 00:29:20.319 --> 00:29:23.619 of Tdap during every single pregnancy. Every 00:29:23.619 --> 00:29:26.460 pregnancy. Even if the mom had a Tdap just two 00:29:26.460 --> 00:29:29.640 years ago with her last baby. Yes. every single 00:29:29.640 --> 00:29:31.640 time. Because we are not vaccinating the mom 00:29:31.640 --> 00:29:34.160 for her own sake in that moment, we are timing 00:29:34.160 --> 00:29:38.099 the vaccine ideally between 27 and 36 weeks gestation 00:29:38.099 --> 00:29:40.720 so that her antibody levels for both tetanus 00:29:40.720 --> 00:29:43.700 and pertussis will peak and then cross the placenta 00:29:43.700 --> 00:29:46.079 right before birth. So we're passively vaccinating 00:29:46.079 --> 00:29:48.779 the fetus. You're giving the baby a gift of antibodies 00:29:48.779 --> 00:29:51.319 to protect them during those first critical two 00:29:51.319 --> 00:29:53.059 months of life before they're old enough to get 00:29:53.059 --> 00:29:55.500 their own first shots. That is a definite must 00:29:55.500 --> 00:30:00.089 -know for any exam. every pregnancy. Okay, last 00:30:00.089 --> 00:30:02.730 section, section eight, complications and nice 00:30:02.730 --> 00:30:05.809 -to -know facts. What other complications can 00:30:05.809 --> 00:30:08.240 kill these patients in the ICU? We've mentioned 00:30:08.240 --> 00:30:10.579 laryngospasm and fractures, but you can't forget 00:30:10.579 --> 00:30:13.019 about blood clots. Pulmonary embolism is a real 00:30:13.019 --> 00:30:14.700 risk. These patients are completely immobile 00:30:14.700 --> 00:30:17.599 for weeks. DVT prophylaxis is standard care. 00:30:17.759 --> 00:30:20.200 And pneumonia. And aspiration pneumonia is huge. 00:30:20.539 --> 00:30:23.059 Some studies show it's found in 50 to 70 percent 00:30:23.059 --> 00:30:25.940 of autopsy tetanus cases. That combination of 00:30:25.940 --> 00:30:28.900 dysphagia, pooled secretions and heavy sedation 00:30:28.900 --> 00:30:31.299 makes the lungs a prime target for a secondary 00:30:31.299 --> 00:30:34.240 bacterial infection. OK, now for the nice to 00:30:34.240 --> 00:30:37.000 know context. Give me some history or science. 00:30:36.940 --> 00:30:39.140 trivia that will help cement this in our brains. 00:30:39.619 --> 00:30:41.400 OK, let's talk about the resilience of the spores. 00:30:41.500 --> 00:30:43.640 We mentioned boiling earlier. Right. If you boil 00:30:43.640 --> 00:30:47.539 water to 100 degrees Celsius or 212 Fahrenheit 00:30:47.539 --> 00:30:51.359 and you put Clostridium tetani spores in it, 00:30:52.180 --> 00:30:54.500 they survive. They can survive boiling for 20 00:30:54.500 --> 00:30:56.759 minutes, 30 minutes, or even longer. So home 00:30:56.759 --> 00:30:59.839 sterilization of, say, a needle or an instrument 00:30:59.839 --> 00:31:02.059 is basically impossible for this? Correct. You 00:31:02.059 --> 00:31:04.680 need an autoclave. You need both heat and pressure. 00:31:04.920 --> 00:31:08.339 You need 121 degrees Celsius, about 250 Fahrenheit, 00:31:08.500 --> 00:31:11.339 under pressure for at least 15 minutes to reliably 00:31:11.339 --> 00:31:13.839 kill the spores. This is why field surgery with 00:31:13.839 --> 00:31:16.220 improvised tools historically carried such an 00:31:16.220 --> 00:31:18.400 incredibly high risk of tetanus. Speaking of 00:31:18.400 --> 00:31:21.579 history, WWI. In the Civil War and early World 00:31:21.579 --> 00:31:25.519 War I, tetanus, or lockjaw, was a leading killer 00:31:25.519 --> 00:31:29.079 of wounded soldiers. You had these massive shrapnel 00:31:29.079 --> 00:31:31.640 wounds contaminated with soil from the trenches. 00:31:32.160 --> 00:31:35.119 It was a perfect storm. The widespread introduction 00:31:35.119 --> 00:31:38.640 and use of the tetanus toxoid vaccine in WWII 00:31:38.640 --> 00:31:42.680 caused a massive dramatic drop in cases. It was 00:31:42.680 --> 00:31:45.039 one of the first major victories of military 00:31:45.039 --> 00:31:48.240 preventive medicine. One final epidemiological 00:31:48.240 --> 00:31:50.420 paradox before we close. We started with this, 00:31:50.460 --> 00:31:51.880 but I really want to drive this point home. Let's 00:31:51.880 --> 00:31:54.440 do it. It's about tetanus and herd immunity. 00:31:55.119 --> 00:31:57.500 Herd immunity works beautifully for contagious 00:31:57.500 --> 00:32:01.059 diseases like measles. If 95 % of the herd is 00:32:01.059 --> 00:32:04.099 immune, the virus can't find a susceptible host 00:32:04.099 --> 00:32:07.279 to jump to. So the 5 % who are immune are passively 00:32:07.279 --> 00:32:09.299 protected by the vaccinated people around them. 00:32:09.400 --> 00:32:11.880 But this logic completely fails for tetanus. 00:32:12.259 --> 00:32:13.880 Completely, because tetanus doesn't jump from 00:32:13.880 --> 00:32:16.269 person to person. It's in the dirt. It's in the 00:32:16.269 --> 00:32:18.849 dirt. It does not care if your entire city is 00:32:18.849 --> 00:32:21.569 vaccinated. You could be the only unvaccinated 00:32:21.569 --> 00:32:25.289 person in a 100 % vaccinated community, step 00:32:25.289 --> 00:32:27.650 on a nail in your own backyard, and die from 00:32:27.650 --> 00:32:31.009 tetanus. Protection is strictly 100 % individual. 00:32:31.109 --> 00:32:32.970 You can't borrow it from your neighbor. That 00:32:32.970 --> 00:32:35.750 is such a powerful closing thought. It puts the 00:32:35.750 --> 00:32:38.450 responsibility squarely on the provider to check 00:32:38.450 --> 00:32:41.190 that history, to ask the right questions every 00:32:41.190 --> 00:32:43.849 single time. Every wound, every time, no exceptions. 00:32:44.029 --> 00:32:47.430 Okay, let's recap the Core 8020. The absolute 00:32:47.430 --> 00:32:49.930 must -knows. Number one. The MAP. It's a neuro 00:32:49.930 --> 00:32:52.490 -exatoxin emergency. Your first thoughts are 00:32:52.490 --> 00:32:55.380 airway and seizures. Number two, the patho. It 00:32:55.380 --> 00:32:57.920 travels retrograde up the nerve. It cleaves the 00:32:57.920 --> 00:33:00.759 VMP2 protein, which blocks GABA and glycine. 00:33:00.819 --> 00:33:03.279 It cuts the brakes, and that causes the rigidity. 00:33:03.599 --> 00:33:06.019 Three, the algorithm. This is the big one. Clean 00:33:06.019 --> 00:33:08.319 wound, you use the 10 -year rule. Dirty wound, 00:33:08.500 --> 00:33:10.220 you use the five -year rule. And the danger zone. 00:33:10.480 --> 00:33:12.680 Dirty wound plus an unknown or incomplete history. 00:33:13.240 --> 00:33:15.359 They get both the vaccine and the TIG. You call 00:33:15.359 --> 00:33:17.940 on the mercenaries. Four, the care and the ICU. 00:33:18.549 --> 00:33:22.069 Darkroom, clustered care, early airway security 00:33:22.069 --> 00:33:24.789 think track, and high dose benzodiazepine. And 00:33:24.789 --> 00:33:28.309 the final unbreakable rule. Recovery does not 00:33:28.309 --> 00:33:31.009 equal immunity. You have to vaccinate them before 00:33:31.009 --> 00:33:33.329 they go home. That is the blueprint. That's it. 00:33:33.529 --> 00:33:35.630 To all the nursing students sweating over the 00:33:35.630 --> 00:33:38.289 NCLEX and all the clinicians out there keeping 00:33:38.289 --> 00:33:42.089 the ER and the ICU safe, you are now armed with 00:33:42.089 --> 00:33:44.849 a deep dive on tetanus. Go be the expert in the 00:33:44.849 --> 00:33:47.349 room. Stay curious and check those vaccination 00:33:47.349 --> 00:33:48.930 dates. We'll see you on the next deep dive.