Advertisment Fosfocin
Indian Journal of Critical Care Medicine
An open access publication of ISCCM™ 
 
Users online: 254 
     Home | Login 
  About Current Issue Archive Search Instructions Online Submission Subscribe Etcetera Contact  
  NAVIGATE Here 
  Search
 
 » Next article
 » Previous article 
 » Table of Contents
  
 RESOURCE Links
 »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
 »  Article in PDF (34 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free) 

  IN THIS Article
 »  Abstract
 »  Introduction
 »  Materials and Me...
 »  Statistical analysis
 »  Results
 »  Discussion
 »  Conclusion
 »  Acknowledgement
 »  References
 »  Article Tables

 Article Access Statistics
    Viewed10285    
    Printed223    
    Emailed7    
    PDF Downloaded670    
    Comments [Add]1    
    Cited by others 2    

Recommend this journal

 


 
ORIGINAL ARTICLE
Year : 2004  |  Volume : 8  |  Issue : 3  |  Page : 168-172

A proposed new scoring system for tetanus


1 Departments of Medicine, Christian Medical College and Hospital, Vellore, Tamilnadu, India
2 Departments of Medicine, Christian Medical College and Hospital, Vellore, Tamilnadu, Australia
3 Departments of Bio-Statistics, Christian Medical College and Hospital, Vellore, Tamilnadu, India

Correspondence Address:
H S Subhash
Department of Respiratory Medicine, Repatriation General Hospital, Daws Road, Daw Park, South
Australia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions


 » Abstract 

INTRODUCTION: Tetanus in adults continues to be a major public health problem in developing countries. Prognosis in tetanus is largely dependent on the various clinical characteristics. This study was carried out to develop a clinical prognostic scoring system according to the natural progression of the disease and to assess its ability to predict the need for specific therapeutic interventions and mortality. MATERIALS AND METHODS: Sixty-five patients were studied, 15 prospectively and 50 retrospectively with an age range between 12 to 70 years. RESULTS: The incubation period was > 7 days in 26 patients (40%), <24 hours in 25 patients (38%), 53 patients (81.5%) had generalized rigidity and 19 (29%) had autonomic dysfunction. Forty-eight (74%) patients needed tracheostomy and 29 (45%) needed mechanical ventilation. The overall mortality was 34%. There was a linear correlation between the grade of tetanus and mortality, (score <2 = 1%, <4 = 3%, >5 = 26%), need for Tracheostomy, (score <4 = 18%, 5 = 26%, >5 = 47%), need for ventilation (scores <4 = 6-8%, 5 = 12%, >5 = 34%), diazepam requirement (scores <4 mean 1500 mg, >5 mean 4000-5000 mg) and duration of ICU stay (score <4 mean of 1 week, > 5 mean 2 to 3 weeks. The overall sensitivity and specificity was 61% and 87% respectively for severe tetanus (score > 6). Multivariate logistic regression analysis showed patients above the age of 50 years (P = 0.003) and need for mechanical ventilation (P = 0.009) were significantly associated with high mortality. DISCUSSION: Prognostication of tetanus with this system was better in comparison with the existing scoring systems in predicting mortality and the need for specific therapeutic interventions. CONCLUSION: The proposed scoring system is a good indicator of the severity of tetanus and use of this system will help in identifying high-risk patients enabling early therapeuticintervention.


Keywords: Tetanus, scoring system, prognosis, grading


How to cite this article:
Sidhartha S S, Peter J V, Subhash H S, Cherian M, Jeyaseelan L, Cherian A M. A proposed new scoring system for tetanus. Indian J Crit Care Med 2004;8:168-72

How to cite this URL:
Sidhartha S S, Peter J V, Subhash H S, Cherian M, Jeyaseelan L, Cherian A M. A proposed new scoring system for tetanus. Indian J Crit Care Med [serial online] 2004 [cited 2017 Dec 14];8:168-72. Available from: http://www.ijccm.org/text.asp?2004/8/3/168/13930



 » Introduction Top


Tetanus in adults continues to be a major public health problem in developing countries.[1],[2],[3],[4],[5] Published data report a mortality around 48 to 50 percent[1],[6] in young adults, and between 25 to 86% in patients above 30 years of age.[5],[6] Tetanus progresses from mild to a severe phase and then resolves gradually. Since prognosis in tetanus is largely dependent on the various clinical characteristics there have been several attempts to quantify the prognosticating factors by utilizing clinical scoring systems.[6],[7],[8],[9]

A good scoring system should ideally follow the natural progression of the disease and identify high-risk patients so that specific therapeutic interventions can be initiated without delay. In areas where there are limited resources and financial constraints, the role of a prognostic scoring system among patients presenting with tetanus in predicting the need for specific therapeutic interventions (such as mechanical ventilation) and their outcome is helpful in delivering appropriate care.

This study was carried out to develop a clinical prognostic scoring system in adult patients presenting with tetanus according to disease severity. We also made an attempt to validate this prognostic scoring system with the existing ones in predicting the need for specific therapeutic interventions and mortality.


 » Materials and Methods Top


This study was conducted in Christian Medical College and Hospital a tertiary care 1800-bed University Teaching Hospital in South India. Fifteen patients with the clinical diagnosis of tetanus were prospectively recruited into the study. A retrospective chart review of fifty patients over a four-year period was included in the database. The demographic characteristics, onset time (interval between the first symptom and the first spasm) and incubation period (time between injury and first symptom/sign) as well as the need for tracheostomy, the total dose of diazepam, days on mechanical ventilatory support, overall mortality and the duration of ICU stay were ascertained. Autonomic dysfunction was diagnosed if there were two or more of the following. 1. Labile blood pressure, 2. High fever in the absence of infection 3. Tachycardia / dysrhythmia in the absence of fever, 4. Sudden diaphoresis in the absence of fever.[10],[11]

A score of 1 to 8 was given based on the severity of the disease in [Table - 1].

These 8 scores were compared to the various clinical parameters. Scoring was also done as recommended by Singh et al[6] and by the modified scoring system [Table - 2] derived from Singh[6] and Patel,[7] which is traditionally used for grading tetanus at our institute. This scoring system has been used to assess treatment outcomes in previous trial.[8],[12] Scoring was done at admission and at the end of 24 hours after admission and upgraded if the disease had progressed. All patients received standard treatment for tetanus.[12],[13],[14],[15]


 » Statistical analysis Top


Data from the retrospective and prospective groups of patients were analyzed together. The sensitivity specificity and predictive values for various cut of points in the scores in each scoring system was ascertained. Using these, the various scoring systems were compared with each other to ascertain which one predicts mortality and morbidity best for the scores obtained. This proposed scoring system was compared with two of the three existing scoring systems namely GP Singh et al,[6] and the modified scoring system of Singh and Patel.[8] Joag's[7] scoring system could not be used for comparison due to limited parameters. A risk analysis was done at the end of the study using a multivariate analysis to look at the significance of the variables included in the outcome.


 » Results Top


There were a total of 65 patients. Fifteen in the prospective group and fifty in the retrospective group.The age ranged from 12-70 years.Twenty-six (40%) patients had an incubation period of <7 days, 25 (38%) patient had an onset time of <24 hours. Fifty-three (81.5%) patients had generalized rigidity, 19 (29%) had autonomic dysfunction and 39 (60%) had infection during the hospital stay (mostly lower respiratory tract infection). Forty-eight (74%) patients needed tracheostomy, 29 (45%) needed mechanical ventilation and the overall mortality was 22 (34%).

Diazepam Requirement

For those patients with a score of < 4 the diazepam requirement was noted to be 1500 mg per 24 hours and for those with a score of 5 and above the diazepam requirement was 4000 to 5000 mg.

Need for Tracheostomy

Among those patients with a score <4 the need for tracheostomy was 18% increasing to 26% among patients with score 5 and 47% in those with a scores of >5. The sensitivity and specificity for predicting the need for tracheostomy was 35% and 76% respectively. Comparison of the present scoring system and the existing system in predicting the need for tracheostomy is given in [Table - 3].

Need for Ventilation

Among patients with a score of < 4 and 5 the need for mechanical ventilatory support was noted in 8% and 12% respectively. Among those with a score of > 5 the need for mechanical ventilatory support increased more than 34%. Comparison of the present scoring system and the existing system in predicting the need for mechanical ventilation is given in [Table - 4].

Mortality

The mortality in the group of patients with a score of <2 was 1%. The mortality was linearly related to the score, 3% with a score of<4, five percent with a score 5 and 26% with a score of >5. The sensitivity and specificity for predicting outcome were 64% and 85% respectively.Comparison of the effect of each scoring system on mortality is given in [Table - 5].

Duration of ICU stay

The mean duration of ICU stay was one week for those patients with a score <4 and for those with a score >5 the mean duration of stay was two to three weeks. Comparison of the scoring systems in predicting duration of ICU stay are given in [Table - 6].

Risk factor analysis

Multivariate logistics regression analysis showed that patients above the age of 50 years (P = 0.003) and the need for mechanical ventilation (P = 0.009) were independently associated with high mortality. There was no significant statistical association noted with mortality in those presenting with rigidity (P = 0.370), spasms (P = 0.289), autonomic dysfunction (P = 0.790) and in those who required tracheostomy (P = 0.282). The overall sensitivity was 61% and specificity of 87% for patients with severe tetanus (score > 6). The sensitivity and specificity values for different scoring systems are given in respective tables.


 » Discussion Top


Several 'scoring systems' have been designed in the past to assess the severity of tetanus by using certain clinical parameters.[6],[7],[8],[9] A numerical score is given according to the clinical symptom and signs and the patient classified to have mild, moderate or severe disease. Tetanus follows a natural progression, which is well identifiable by clinical manifestations. Spasms occurs as a neuromuscular manifestation in tetanus, and indicate a severe form of disease in the absence of other parameters. Therefore a good scoring system should center on this dangerous manifestation of the disease.

Though the existing scoring systems are excellent in assessing the severity of tetanus, there are a few practical problems such as inclusion of the incubation period and onset time in grading tetanus.[6],[7],[8] Many patients may not recall an injury,[16] and the assessment of the 'incubation period' becomes difficult .In some cases spores may lie dormant for a long period before the disease manifests. Patients who present with severe spasms and advanced disease are unable to give an accurate history and paradoxically high or low scores may be obtained because of cofounding factors in the history.

The scoring system adopted in this present study however is based on the natural progression of the disease and the clinical presentation and any patient can be assigned a grade of severity with a simple clinical assessment without other confusing parameters.

In the present study the scoring system showed a sharp increase in the mortality and morbidity once the spasms had become significant (score >5). We could infer that any patient with a score >5 has a high likelihood of needing tracheostomy and requires close follow up during the initial period, and may need ventilatory support. It is important to assess the need for ventilation because it is shown that the utilization of early ICU services and mechanical ventilatory support along with other supportive measures reduces the mortality in tetanus.[17],[18]

In this present study mortality among patients who required mechanical ventilation was high indicating that these patients have a far advanced and serious disease. Giving a score for mechanical ventilation as done in the present study is useful in predicting the outcome. Earlier studies have shown that significant autonomic dysfunction occur among patients with tetanus.[18],[19],[20] In this present study 29% of the patients were noted to have autonomic dysfunction.

The proposed new scoring system had a prognostic value in tetanus and predicted the need for specific therapeutic interventions (mechanical ventilation). There was a linear correlation between the increasing grade and increasing mortality and morbidity. The linear correlation was also consistent in the other outcome parameters like need for tracheostomy and ventilation. Among patients presenting with severe tetanus the overall sensitivity was 61% and specificity was 87% in the new scoring system.

There were some limitations in this study. The prospective study group had a relatively small number of patients. Though this was balanced by the combination of the prospective and retrospective study, it would be ideal to study a larger group prospectively. Further prospective studies are needed to validate this proposed scoring system.


 » Conclusion Top


The proposed scoring system is a useful in grading the severity of tetanus and in predicting mortality.The use of this system will be helpful in identifying high risk patients enabling one to intervene early with therapeutic measures such as tracheostomy and mechanical ventilation.


 » Acknowledgement Top


We thank Mr. Jamal from the clinical Epidemology unit and all the staff members from the Intensive care unit, Christian Medical College and Hospital, Vellore, India for his valuable support during this study.

 
 » References Top

1.Patel JC, Mehta BC. Tetanus: Study of 8697 cases. Indian J Med Sci 1999;53:393-401.  Back to cited text no. 1  [PUBMED]  
2.Garnier MJ, Marshall FN, Davison KJ, Lepreau FJ. Tetanus in Haiti. Lancet 1975;1:383-6.  Back to cited text no. 2    
3.Afonja AO, Jaiyedla BO, Tunwasha OL. Tetanus in Lagos. J Trop Med Hyg 1973;76:171-4.  Back to cited text no. 3    
4.Majundar DN, Chakraborty AK. Problems of tetanus in Calcutta. Indian J Publ Health 1974;18: 68-78.  Back to cited text no. 4    
5.Bildhaiya GS. A study of tetanus in a hospital at Ahmedabad. JIMA 1983;80:21-3.  Back to cited text no. 5  [PUBMED]  
6.Singh GP, Sikka PK, Gupta MM. Tetanus - a method of scoring to determine the prognosis. Indian J Med Sci 1986;40:124-8.  Back to cited text no. 6  [PUBMED]  
7.Patel JC, Joag GG. Grading of tetanus to evaluate prognosis. Indian J Med Sci 1959;13:834-40.  Back to cited text no. 7  [PUBMED]  
8.Chandy ST, Peter JV, John L, Nayyar V, Mathai D, Dayal AK, et al. Betamethasone in tetanus patients: An evaluation of its effect on the mortality and morbidity. J Asso Phy India 1992;40:373-6.   Back to cited text no. 8  [PUBMED]  
9.Osinusi K, Njinyam MN. A new prognostic scoring system in neonatal tetanus. Afr J Med Med Sci 1997;26:123-5.  Back to cited text no. 9  [PUBMED]  
10.Udwadia FE, Lall A, Udwadia ZF, Sekhar M, Vora A. Tetanus and its complications: Intensive care and management experience in 150 Indian patients. Epidemiol Infect 1987;99:675-84.  Back to cited text no. 10  [PUBMED]  
11.Wright DK, Lalloo UG, Nayiager S, Govender P. Autonomic nervous system dysfunction in severe tetanus: Current perspectives. Crit Care Med 1989;17:371-5.  Back to cited text no. 11  [PUBMED]  
12.Ernst ME, Klepser ME, Fouts M, Marangos MN. Tetanus: Pathophysiology and management. Ann Pharmacother 1997;31:1507-13.  Back to cited text no. 12  [PUBMED]  
13.Agarwal M, Thomas K, Peter JV, Jeyaseelan L, Cherian AM. A randomized double-blind sham-controlled study of intrathecal human anti-tetanus immunoglobulin in the management of tetanus Natl Med J India 1998;11: 209-12.  Back to cited text no. 13  [PUBMED]  
14.Knight AL, Richardson JP. Management of tetanus in the elderly. J Am Board Fam Pract 1992;5:43-9.  Back to cited text no. 14  [PUBMED]  
15.Richardson JP, Knight AL. The management and prevention of tetanus. J Emerg Med 1993;11:737-42.  Back to cited text no. 15  [PUBMED]  
16.Richardson JP, Knight AL. The prevention of tetanus in the elderly. Arch Intern Med 1991;151:1712-7.  Back to cited text no. 16  [PUBMED]  
17.Dastur FD. Emergency treatment of tetanus. J Asso Phy India 1997. p. 44-6.  Back to cited text no. 17    
18.Trujillo MH, Castillo A, Espana J, Manzo a Zerpa R. Impact of intensive care management on the prognosis of tetanus. Chest 1987;92:63-5.  Back to cited text no. 18    
19.Peetermans WE, Schepens D. Tetanus - still a topic of interest: A report of 27 cases from a Belgian Referral Hospital. J Intern Med 1996;239:249-52.  Back to cited text no. 19  [PUBMED]  
20.Udwadia FE, Sunavala JD, Jain MC, D'costa R, Jain PK, Lall A, et al. Haemodynamic studies during management of severe tetanus. Q J M 1992;302:449-60.  Back to cited text no. 20    


Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]

This article has been cited by
1 Tetanus in adults: Clinical presentation, treatment and predictors of mortality in a tertiary hospital in Ethiopia
Amare, A. and Melkamu, Y. and Mekonnen, D.
Journal of the Neurological Sciences. 2012; 317(1-2): 62-65
[Pubmed]
2 Case-fatality of adult Tetanus at Jimma University Teaching Hospital, Southwest Ethiopia
Amare, A. and Yami, A.
African Health Sciences. 2011; 11(1): 36-40
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article
Online since 7th April '04
Published by Wolters Kluwer - Medknow