Gastro: Abdominal pain/ Tetanus

What is FAP and how do you diagnose?

Location of pain?

Likely cause?

Abdominal pain that cannot be explained by any definite structural abnormality

episodic or continuous abdominal pain

does not occur solely during physiologic events (eg, eating, menses)

occurring at least 4 times per month

and not explained by another medical condition.

ParaUmbilical region

gut in affected children may be more sensitive to triggers that normally do not cause significant pain, such as gut peristalsis and gas bloating.

Treatment of FAP

Reassurance and education;

Dietary changes may sometimes be helpful: avoidance of greasy/high-fat foods, spicy foods, sugary juices and carbonated drinks; avoidance of gas-producing food items e.g. beans; adequate fiber in food

Some may require medications: antacids, antispasmodic medications

What is colic?

Wessel’s cirteria?

Begins when?

Peaks when?

Resolves when?

Treatment?

excessive paroxysmal crying, without any identifiable cause

Crying for ≥3 hours/day, ≥3 days/week, for ≥3 weeks.

two weeks of age and peaks at about six

• Symptoms usually resolve by 3 to 6 months.

It is a self-limiting and benign condition.

Reassurance, burping after feeds, repositioning the baby ± probiotics

What is tetanus?

It is an acute toxigenic infection caused by the

exotoxin produced by Clostridium tetani.

Features of C tetani

gram-positive anaerobe

spore-producing

to produce two exotoxins:

– Tetanospasmin: which is a very powerful neurotoxin.

– Tetanolysin: a haemolysin that does not play a significant role

Pathogenesis

Spores produce tetanospasmin which binds to NMJ and enters spinal inhibitory interneuronz

At the SII, it inhibits release of glycine and gaba(inhibitory neurotransmitters)

Causes excessive discharge from alpha motor neurons and affected muscles sustain maximal contractions and can’t relax

Incubation period

Clinical manifestations

3days -3weeks (on average 1week)

Earliest symptom is trismus or lockjaw - masseter muscle spasm

Non specific symptoms: Headache, restlessness and irritability are other early, non-specific symptoms that may occur.

• These are followed by body stiffness, rigidity and finally muscle spasms.

Risus sardonicus: Facial and buccal muscle spasms

• Opisthotonus results from hyperextension of the muscles of the back.

• Abdominal rigidity results from spasm of abdominal muscles.

• Pharyngeal spasm usually results in excessive salivation and may lead to upper airway

Laryngeal spasms: sudden asphyxiation and death

Diagnosis

Clinical

Immunization history( child not immunized, mother did not get TT in pregnancy)

First symptom in neonatal tetanus

The first symptom in neonatal tetanus is inability to sucK

Hypoglycaemia and sepsis are common co- morbidities.

• Apnoeic episodes occur frequently.

Principles of management

Control of spasms.

2. Neutralization of circulating toxins.

3. Eradication of causative organism.

4. Supportive/Nursing care.

5. Prevention of recurrence.

How to control the spasms

continuous sedation through the use of a staggered dose of antispasmodics.

Diazepam, Phenobarbitone and chlorpromazine. Promethazine and paraldehyde are also useful.

Pancuronium may be used to achieve muscle paralysis in severe cases

How to neutralize circulating toxins?

Anti-tetanus serum (ATS) 10,000-20,000 IU stat intravenously (OR half IV, half IM).

– OR Human tetanus Immunoglobulin (TIG) 3,000-6,000 IU intramuscularly.

– TIG is preferable, because ATS can cause severe hypersensitivity reaction.

If using ATS there should be bedside adrenaline or epi in case of anaphylaxis

How to eradicate the organism?

Wound debridement

Antibiotics: IV Penicillin G, metronidazole, Ceftriaxone, aminoglycosides

Supportive care

Prevention of recurrence

Thus, all survivors of the disease should be immunized.

– Five doses of Tetanus toxoid are recommended for full protection.

• First dose at point of discharge.

• 2nd-5th doses are given at intervals of 4weeks, 6months, 1yr and 1yr, respectively, after previous dose.

Complications

Aspiration of secretions, resulting in respiratory distress, pneumonitis and pneumonia.

• Laryngeal spasm.

• Exhaustion from spasms, when frequent. • Apnea (neonates).

• Fractures.

• Pressure sores.

• Umbilical hernia (neonates).

Prognostic factors

Age: mortality highest at extremes of age

Incubation period: less than 7 days poor prognosis (presenting on 8th day is good prognosis)

Period of onset( from trismus to first spasm): less than 3 days

Inaccessibility of portal of entry: ie deep wounds

Proximity of site of wound to the brain: poor prognoss

Fever

Autonomic dysfunction: hypotension, tachycardia, sweating, bradycardia, syncope.

Comorbidies; sepsis, pneumonia