Lara : her blood pressure shot up and we gave her something to bring it down, and
then it barreled and then bottomed out, and then we'd give her something to bring
her back up and we're like, at some point, what could we And there was talk about
moving her to ecmo, and her grandfather reached under the blanket and grabbed her
hand and her blood pressure stabilized.
Sam: Hi everyone, and welcome to another episode of EMPlify
I'm your host, Sam Ashoo.
Before we dive into this month's episode, I want to say thank you for joining us.
I sincerely hope that you find it to be helpful and informative for your
clinical practice, and I want to remind you that you can go to ebmedicine.net
where you will find our three journals, Emergency Medicine Practice, Pediatric
Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of
other resources, like the EKG course, the laceration course, interactive
clinical pathways, just tons of information to support your practice
and help you in your patient care.
And now, let's jump into this month's episode.
Lara: Hello.
I'm Lara Zibners.
I am a pediatric emergency medicine doctor, clinically now retired officially.
I trained at Ohio State.
I did medical school, residency, and fellowship
there, and I had great training.
I loved pediatric emergency medicine, and then I went to New York City
and was an attending at Mount Sinai.
And then in 2006 I moved to the UK because I was a trailing spouse.
Ended up getting my UK license and had an honorary consultant
post at St. Mary's and I also got a master's in medical education.
I was quite involved with Advanced Trauma Life Support, and I became the
emergency medicine rep to the steering group in the UK and then after I did
my master's, I've been the national educator for the UK program since 2018,
and I did a three year stint as educator to the board for Africa and Europe, so
I've seen it kind of at a global level.
And I also have an MBA from the University of North Carolina, and I now have a
UK based women's healthcare startup.
So I have really done everything and had about eight careers, but yes.
Sam: And you have a relationship with EB Medicine.
Lara: And I have been involved with EB Medicine since I think 2013.
I came on as international editor of the Pediatric EM Practice.
And I have done some peer reviewing for years.
I was editor in chief of the trauma supplement for, I don't
know, four or five years.
I just passed that over to a dear friend of mine.
And I, like a sucker, agreed to write a big article back in 2017 on
something close to my heart, which is I've done a lot of vaccine advocacy.
I was a regular contributor to Every Child By Two's website for a number of years.
And so when they asked for an author for diphtheria, pertussis,
and tetanus, raised my hand.
Sam: Awesome.
And we are happy that you raised your hand because it became the August
2025 issue of Pediatric Emergency Medicine Practice and the reason
why you're on the podcast today.
So thank you for doing all of that, and then agreeing to be on the podcast.
Lara: Yeah.
EB Medicine and not, you know, Women's Health in the UK.
No, I get why we're here.
Thank you for having me.
Sam: Yeah.
So now we know why diphtheria, pertussis, and tetanus as a topic.
You said a topic near and dear to your heart and for quite some
time, I will say out of these three diseases, I've only seen pertussis
in 20 years of clinical practice.
I don't think I've ever come across a case of diphtheria or tetanus, knock on wood.
Lara: You don't know for sure do you?
Sam: That's a great point.
That's a great point.
I don't know for sure.
Lara: You could have just totally missed it 'cause you didn't have this article.
I've seen tetanus, I've seen lots of pertussis, lots of little blue babies,
and lots of hacking, coughing kids.
I have seen tetanus in a child when I was a fellow and it was, you know,
we all learn from all of our patients and what I thought tetanus was before
I learned what tetanus actually is and that little girl survived.
But it was really heartbreaking.
Because her family, she was from an Amish community that wasn't anti-vaccine.
They just didn't know, they weren't connected with those community
health sources, and her father was so upset when she was diagnosed and
transferred to our that he brought in community health workers and had
their entire community vaccinated.
Sam: Wow.
That's wonderful.
What a cool outcome.
And
she survived.
And
Lara: she survived.
She had a long road, but she survived.
But that case stuck with me 'cause the whole family was there and you could
just see how riddled they were with, you know, not just concern, but they
didn't know what they didn't know.
Sam: Wow.
And probably saved her whole community just from that illness.
Lara: That's
Sam: pretty amazing.
Lara: Hope so.
Sam: What an amazing story.
Okay.
Well let's start with the diphtheria.
So, of the three diseases here in the article, I think this is probably the
one I know the least about because it's always been vaccine preventable and most
of our community has been vaccinated here in Florida where I live, until recently.
So it's going to be something that my partners and I are going to
have to become adept at diagnosing.
Tell me a little bit about what we know about diphtheria as far as
what causes it and maybe some of the mortality associated with it.
Lara: You're gonna make me go back to the thing here and look up what I said.
'cause I'll tell you.
So this article I originally wrote in 2017, it took me several months.
I went through every resource because there's so much written,
but so much of it's historical.
So, not a lot new has happened other than vaccine changes and modifications.
But diphtheria never left us.
And so I did this article in 2017.
In 2021, I think, I updated it again.
Nothing had really changed.
It had changed when I went to update it for this 2025 article,
in the reporting conditions.
Because all we used to see in the United States was cutaneous,
which is generally localized.
This is a corynebacterium.. Right.
And localized disease was considered usually non toxigenic and local, and
you could treat it with antibiotics.
And there's a difference between toxigenic and non toxigenic, right?
So the bacteria has to be infected with this toxigenic strain for it to form
the diphtheria toxin, which causes all these systemic side effects, right?
So, people think of diphtheria as just being a kid with a swollen neck 'cause
that's the picture we all saw in our Zitelli when we were in training.
But really, most people who get toxigenic diphtheria will have
cardiac and neurologic complications.
And other than with laryngeal, so you can have it in different
locations, nasal, local, laryngeal.
You get infected, the toxin starts to get produced, and then
this causes the pseudo membrane.
And in the pharynx, that pseudo membrane can obstruct the airway.
So that's one of the causes of death.
But the systemic effects of the toxin are largely cardiogenic, heart
failure, arrhythmias all the associated bits and bobs, pulmonary edema.
And then there are neurogenic complications.
It used to be that local diphtheria, was not reportable.
Because it wasn't considered a problem.
And as of, I think last year, that guidance has been changed.
So all cases of diphtheria, cutaneous or generalized, are reportable.
And there have been actually cases of significant disease in
people with non toxigenic strains.
So this idea that we had in medical school of, okay, well it's either the
good diphtheria or, as if there's good diphtheria, but you know what I mean?
Good diphtheria, bad diphtheria.
There have been cases of people getting severely ill with non toxigenic strains
and there's enough existing there.
I think the most recent big outbreak that I had read about was in parts of Russia.
So this has never gone away.
Just because we haven't seen it in the US does not mean that we haven't
had disease presence around the world.
And I think we had a death a year or so ago, not too long ago in the UK in an un
immunized child, might have been in the last few years, but it's still out there.
And I'm fearful as you just said, that we're gonna start seeing more of it.
The one we worry about the most is laryngeal.
That's the classic upper respiratory symptoms and then sore throat,
and then you see this membrane.
You do not want to pull the membrane off because it is really
stuck in there and is gonna cause bleeding, if you try to yank it out.
The bigger the membrane, probably the bigger the disease burden,
because as the bacteria starts to produce toxin, the longer you're
sick, the more toxin you produce.
What's the treatment?
Antitoxin.
It only is going to bind the circulating toxin that has
not yet clung to the tissues.
So the longer you've been sick, the less effective your antitoxin's going to be.
And then we can go into how you get antitoxin.
I'll tell you, diphtheria is the one I'm the least familiar with.
So I wrote this because I wanted people to have something you can go
flip to the page and look for some great pictures in there about it.
But I think the biggest take home for diphtheria is, it's not just
about a membrane in your throat.
Gotta make sure that you address the cardiac signs right away, getting
the EKG, get this kid on intensive levels of monitoring cardiac enzymes,
troponin, all your electrolytes, and be aware of the neurologic
complications, and then go to battle.
Sam: And those neurologic complications are treatable?
Lara: Yes, the neurologic symptoms can be localized neuropathies and neuritis
and in cases laryngeal can start sort of with some swallowing issues,
paralysis of the soft palate, and then you can actually get peripheral
neuritis that exists for weeks to months after the illness has run its course.
Sam: And then in the article you mentioned that the fatality rate is 5
to 10%, even in our modern medicine era.
Lara: If you are treated in a high resource environment.
Sam: Wow, that's crazy high.
Lara: Yeah, I mean, when you think about that in numbers, if everyone's
vaccinated and you only see one case in so many, but we're gonna
start to see more and more of this.
Sam: Yeah.
And also the children under the age of five and adults over the age of 40 are
at even higher risk for death, up to 20%.
Lara: I think that stands for most of the diseases we see, right?
It's gonna be the very young and the people my age and older that are gonna
the vulnerable populations, which is why you vaccinate everybody for these
things, because we're trying to protect the the vulnerable population, right?
A baby under six months won't have seen a DPT.
Sam: Okay.
All right.
And then, our next disease, pertussis, something we have seen here in the US
recently, but may be seeing more cases of.
Let's talk about that.
So that's caused by bordetella pertussis.
Supposedly gives you the classic whooping cough.
But then there are some cases where that's not actually the case.
Lara: So pertussis used to be called the a hundred day cough because it would give
you that classic so that you know, you have a little bit of a cold, and then you
start with this hacky, hacky, hacky cough.
That cough can be so severe that people have broken ribs.
There have been ruptured eardrums reported in literature.
Post test of emesis is very, very common.
It's just a horrible, horrible cough that disrupts people's lives.
And actually there have been intracranial brain bleeds in one series that I read.
I mean, it's not a joke, right?
This a hundred day cough.
The thing is, is the cough it is that whoop, that classic whooping cough sound
comes from deep inspiratory intake.
After your coughing, coughing, coughing.
Cough, cough, cough, cough, cough.
That's the whoop.
Babies don't have the inspiratory strength to generate that.
So they just go for the, you know, the lazy version, which
is just to kind of go apnic.
Sam: Awesome.
Lara: So the risk of apnea is highest in those youngest babies.
Again, our most vulnerable patients, so it used to be when I was a little
doctor, we just hospitalized any newborn with suspected pertussis
'cause of the risk of apnea.
Now it's young babies.
The younger you are, the more likely to be hospitalized for observation.
But yeah.
They don't whoop.
Sam: And that's like six months and under?
Lara: Six months and under will generally not whoop, but I'm not gonna put a like
a day on it like you whoop tomorrow 'cause you didn't whoop yesterday.
But you know, the weaker the baby, the sicker you are, just to remember
that's where the whoop comes from.
So if the kiddo's really knocked out, they're not gonna
be able to make that sound.
But you are gonna have some other family member in the
room who is making that sound,
Sam: Right.
Lara: Right?
So this is where when you see a baby with apnea, you need to ask who else in
the family has had a cold or a cough.
And the big challenge with pertussis is the immunity from
the vaccine wanes over time.
And with the new acellular formulations, it seems to wane quicker.
So it used to be the pertussis vaccine used to cause really
bad side effects, right?
Everyone talks about their baby having this high fever, whatever,
and it, here's what it was.
There were so many little components to the pertussis that they didn't
know which part was immunogenic, so they just basically whacked it in a
blender, chopped it all up, and then gave you whole cell pertussis vaccine.
Well, obviously if you've got stuff in there you don't need, you're
gonna have more side effects.
So then when they discovered that they could just isolate the immunogenic
factors and get acellular, we don't have to whack in the whole cell.
Acellular versions.
Great.
So many fewer side effects, but it seems that the immunity may wane a bit faster.
So really, if you've got school age kids, 7, 8, 9, their immunity's probably waning.
And that's why we've introduced this concept of boosting that
pertussis component with one of your tetanus boosters.
And also, one of the best things we can do to prevent this for our
vulnerable population, 'cause the babies can't take it when they're under six
months, is to immunize mom and then the babies get some passive immunity.
But yeah, that a hundred day cough in adults, nobody wants it.
And basically you cough, cough, cough, cough, cough.
There's nothing you can really do about it except ride it out.
But the earlier we can get in there and treat them, the less likely they
are to spread it to everyone else.
So that's why we treat pertussis antibiotics.
Sam: And it comes with its own not insignificant mortality as well.
It says here in the United States, in the US the case fatality rate is about
1% for babies age less than two months.
And 0.1% for the two to 11 month age group.
Lara: Yeah.
And it is funny, I had a conversation, my brother-in-law's also a peds EM doc.
He actually trained with me, that's how he met my sister.
But we were talking about this a few months ago and he goes, oh, I
haven't seen pertussis in forever.
And then I started looking at the numbers when I was reviewing this
and there's outbreaks are rising, so we're gonna be seeing more of it.
So I think my take home on this is to remember it's out there and so
that upper respiratory infection in a young infant, consider pertussis.
Consider swabbing them.
If there's any concern about someone in the family having been exposed
or having been recently ill with something that sounds like it could
be pertussis, consider treating them because a little macrolide might do a
lot to prevent what you just described.
Sam: Hmm.
And actually I think the last I looked, the cases are not just climbing here
in the US, but there was a recent outbreak in the UK, in Europe, recently.
I think it was three months ago.
They were reporting an increase in cases there as well.
So even if you're an international traveler, you're
at a higher risk for exposure.
Lara: This is the problem with pertussis, is it is so contagious that it really,
really, really requires herd immunity.
It is one of the most vulnerable to dropping vaccination rates, because
as soon as you get below that threshold, which is pretty high,
all of a sudden it starts running rampant through the community.
Sam: Alright.
And then lastly, let's talk about tetanus.
So, you know, it seems like everybody who comes in with a scratch in the
emergency department is getting a tetanus booster and yet in the US
we seem to have controlled the total number of tetanus cases annually.
At least the last I looked, I haven't seen any major tetanus outbreaks for now.
But this is a disease that isn't gone.
Lara: Well, no.
So, and you know why you haven't seen outbreaks?
It's because people don't get tetanus from each other, unlike the other
two we've just talked about, if you have a drop in vaccination rates,
then all of a sudden there's more circulating disease, and you're going
to see more diphtheria, and you're gonna see a whole lot more pertussis.
Tetanus is ubiquitous.
Tetanus is everywhere.
Clostridium tetani, it's everywhere.
It's like the Darwinian master survivor of all infectious agents because it
goes into a spore and just stays there.
It's in dirt, it, it's everywhere.
There have been people who have had tetanus from clean surgical wounds.
You don't even have to have a wound to have tetanus, okay?
It is in the mouth of the wasp that stings you because he was chewing up mud, right?
It is everywhere.
So, because of that, I wouldn't say we've contained the outbreak because there's
never gonna be an outbreak of tetanus.
But if we don't have high vaccination rates, we are gonna see more of it.
In the US, there's always been a few cases that were an unimmunized person,
but the majority have been in older adults because the immunity does wane.
There's never been any study that anyone could ever do to say, what is
a protective level of antibody, right?
Because it is so unbelievably fatal.
It's considered the most fatal toxin.
If the amount you need to kill you is so small that we can barely even measure
it, then you have to base your protective antibody levels on sort of an assumption.
So it doesn't help you if somebody comes in with a scrape to do an antibody
level and say, no, you don't need a jab.
What's really interesting, I did a talk years ago because the tetanus vaccine
schedules around the world differ.
And they differ for, as always whenever something differs,
follow the money, right?
So in the UK, when I first moved to the UK, they would say, oh, if you've
had your initial five injection series, you're covered for life.
And I'm like, who said that, because we know that for clean wounds, we
booster if they haven't had one in 10 years and for dirty wounds, five years.
And I went and I actually read the Green Book, the UK vaccine book,
and it said, you are covered for life unless you are going to a
place where you cannot get antitoxin because you're not covered for life.
Sam: I see.
Lara: So I don't have a problem with you giving everybody with a scratch
on their foot, a jab of tetanus.
Sam: So does that mean they're just giving out antitoxin all the
time in the UK for all wounds.
Lara: No, actually what I found was even though they were saying that, most of
the ER docs I knew, were giving it for every trauma, just like we do in the US.
So that was the message to the community, but if you actually went into a hospital,
somebody was like, look over there, jab.
and another one, in the UK in particular, another group that there were outbreaks
in for a while were intravenous drug users because the quinine that was
used to cut the heroine would somehow promote the bacterial growth of tetanus.
So, yeah, those are the groups you've seen.
I am worried that we are gonna see more younger, healthy people with
tetanus, and you have to suspect it.
I mean, this is what the WHO has done dealing with maternal
neonatal tetanus deaths.
They have dropped it close to like 99% with these very, very active
global outreaches for immunization.
This used to be the leading cause of neonatal death in most of the world.
And we're not seeing that anymore because people are immune.
Sam: So here in the US for the time being, the current vaccine
schedule is still 2, 4, 6, 15, and 18 months of age with another booster,
somewhere between ages four and six.
And then usually one of these doses is the big T, little Dap and the rest are the
big D, big T and the acellular pertussis.
And we're still giving these in the ED, like you mentioned, for wounds.
If it's been more than five years and it's a dirty wound or if it's
been more than 10 years and it's a clean wound, we give these out to
our trauma patients all the time.
And for the time being that's still not changing but also recommended in
pregnancy between 27 and 36 weeks, and like you just mentioned, that's kind
of reduced the mortality worldwide.
Lara : Right.
So going back, the Big D little D difference is the amount of the diptheria.
Little kids handle it better.
So by the time we get to after that kindergarten shot, then you're gonna
start giving the little d , and then that little DT is what we booster
the adults with, but we add back the pertussis for one of those for all adults.
And then it's also recommended for women during pregnancy and
ideally a family, the cocoon.
So grandparents and partner would also booster during that time just so
that everybody's got that extra layer of protection when baby comes home.
Sam: And that booster in adulthood is just one time in adulthood,
or is it like a every 10 years kind of thing, or do we know?
Lara : They say one time.
If I was in charge of the world, I mean, but I'm not so, I can't say anything.
Right now it's officially at least one of your adult boosters, which
you should be doing every 10 years.
Should be one of those.
Sam: All right, so let's talk about when they present to the ED, what
their clinical exam is gonna look like.
And let's start with diptheria.
You already mentioned that if they have the pharyngitis component, they're gonna
have this gray pseudo membrane from the posterior pharynx all the way down.
And then you already also mentioned the bull neck appearance.
Tell me more about the bull neck appearance.
So this is just lymphadenopathy in the neck?
Lara : It's enormous cervical lymphadenopathy.
So they get really, really big tender lymph nodes that are
like nothing you've seen before.
But then they get this membrane and it will grow, unless you get the antitoxin in
to kind of stop the disease progression.
if it's laryngeal that membrane can actually cause airway obstruction.
There is a nasal form that's much more mild, that has a little bit of
a membranous appearance in the nares.
But the one you really wanna be worried about is laryngeal.
I mean, that membrane is producing the toxin, right?
So the bigger it is, the longer it's been going, the more toxin you're
gonna see circulating, the less effective your antitoxins gonna be
Sam: Gotcha.
Lara : because it needs to get in there before that toxin binds to
the end tissues like your heart.
Sam: Okay.
And speaking of the heart, so if they were going to have some cardiac
manifestations, how does that present when we're seeing them in the ED?
We're gonna pick this up on exam, or everybody just gets a screening,
EKG, and gets telemetry or.
Lara : Screen everybody, get them on telemetry and get your labs, get
your enzymes, your electrolytes, because I think it's kind of an
all players welcome presentation.
You can see anything from arrhythmias to heart failure.
So I would whack them on monitor pretty quickly.
Sam: And the mechanism is myocarditis in diptheria,
Lara : It's the toxin effects on the myocardium.
Yeah.
Sam: Alright, so, in addition to their clinical exam, a screening, EKG,
putting 'em on telemetry and pneumonia, other respiratory complications,
hypoxia, or not necessarily.
Lara : Well, yes, and partly that's going to be because these
kids are often gonna be so sick that they're gonna be intubated.
Right.
So anything that you are gonna see in an ICU setting, you're
gonna see in one of these kids.
Plus, if you've got heart failure, that's gonna set you
up for, infection, et cetera.
Yeah.
These are ICU children.
These children go to the PICU.
Sam: On the intubation side of things, if you are in the unfortunate circumstance of
having to intubate one of these children does the pseudo membrane and the bull
neck make it just all that much more difficult to intubate these children.
Lara : So the pseudo membrane is really, really tightly attached.
And even if you tried it, you're not likely to dislodge
it easily with the tube.
But when you're intubating anyone like this have a plan B and C. and the, bull
neck, 'cause I've never seen this, right.
I'm trying to work my head around it.
It's not like a retropharyngeal abscess where you've got, you know,
a big prominent airway distortion if you can get their neck back right.
Unless there's just so much lymphadenopathy it's
compressing the airway.
Sam: In which case it's probably equally difficult to do it externally.
I'm thinking about cricing a child who is in this scenario as well
Lara : I would not wanna do that.
I would probably want to go for the straight old tube in a tube approach.
Because yeah, you're gonna have so much neck edema and surgical airways
and little kids are hard enough.
don't need to try to go through all that.
Sam: All right.
And then let's talk about pertussis.
So obviously you mentioned the cough, you said clinically children under six
months of age or so are not gonna have the whoop, so we might not recognize that.
You know, parents might say that they've seen apnea.
So we might see some of those episodes clinically or maybe just have elicited
that there's a history of some apnea.
And then looking at other members in the family for URI symptoms, congestion,
cough, low grade fevers to see if they maybe were the infectious source.
Lara : and don't forget that the number one complication with pertussis is gonna
be a secondary bacterial pneumonia.
So if you're seeing a baby who has a pneumonia, and the other thing is,
is that little ones can develop an encephalopathy that was thought to
be related to periods of hypoxia.
So you can have seizures, as one of the presentations, but now it's thought that
that could also possibly be a direct effect of the pertussis infection.
Sam: Okay.
So some neuro complications there, some pulmonary manifestations, maybe
pneumonia, and then apnea.
Lara : Pneumonia, seizing apnea.
Yep.
Sam: Okay.
And then tetanus.
So obviously if they're presenting with tetany that's something we can
characteristically see, but now in the cases where they present to the
ED and they're having tetany, we're talking about things like spasms of
the musculature, neck stiffness, back stiffness, rigidity, abdominal rigidity.
And then in the smaller children, they can also get some, facial tetany as well.
Lara : Well, so it depends.
There's different forms of tetanus.
The one we always think of is generalized, but you can get, localized.
So that's just persistent, painful, muscular contractions in one location.
And then there's also cephalic.
So you can just see, like ocular spasms and above head up, but the one we're
always thinking of is generalized.
And the WHO definition is this persistent, painful, muscular
contraction with a history of a wound.
But we know that you can get tetanus without a wound, so it's something
you have to be quite, suspicious for.
The biggest thing I think that I've taken away from just all the reading
I've done on this is: Everyone thinks of tetanus as lockjaw, right?
Oh, they must die because their jaw gets stuck.
And that's the risus sardonicus, right?
The classic picture of the grimacing face.
In a developed country, that's not what kills tetanus patients.
It's the autonomic instability, right?
You are gonna have these painful spasms, but they will be triggered
by loud noises, bright lights.
So that's why the advice is put them in a dark, quiet room, immediately start
sedating, which helps with the spasm, but also with the autonomic contribution and
one of the best treatments is mag sulfate.
And that's because it treats the muscle spasm, right?
We know it's a good, muscle relaxant, but it also deals with some of
that autonomic instability because it stabilizes magnesium levels.
So, that's what actually will kill your patient.
So you intubate them early, you move to early long-term access.
You know, that's a kid who's also gonna, the ICU, they're one who's also gonna get
a trach, 'cause they're gonna be tubed for a while because you're gonna have
them on pretty significant, sedation, and muscle relaxants for a while.
The patient that I took care of, it was, her blood pressure shot up and we gave
her something to bring it down, and then it barreled and then bottomed out, and
then we'd give her something to bring her back up and we're like, at some point,
what could we And there was talk about moving her to ecmo, and her grandfather
reached under the blanket and grabbed her hand and her blood pressure stabilized.
And I'm not a terribly religious person, but I always cite that as like the one
miracle I think I saw in my training.
Whether you wanna call it whatever it was, but I remember that.
I remember her, we were all talking about what do we do next?
We're talking to the family.
We don't have a lot of options left except ECMO and grandpa was there.
Sam: That's amazing.
Lara : So hopefully that story will remind people if you think you're seeing tetanus,
to pay attention to the cardiovascular system, the autonomic system, the
blood pressure, the heart rate.
Sam: Okay, so let's go to treatment then.
You had mentioned already that there is an antitoxin for diptheria if you're seeing
a case of this, but this is not something your local hospital is going to stock.
Right.
Lara : No, you don't Run over to Walgreens and get yourself
some DAT Diphtheria Antitoxin.
This is one that's nice because you don't have to do any decision making.
All you have to do for diptheria is suspect diptheria.
That's it, because then you call the CDC assuming they're answering
their phones, and you are put through to the diptheria person.
Who will listen to your story and say, I agree.
And they will dispatch the diptheria, antitoxin and walk you through based
on the disease progression and the age of the patient and their weight
and their symptoms, they will tailor that dose and give you very, very
specific instructions on how to give it.
You're going to need to do, some, sensitivity testing because there's about
a five to 20%, rate of allergic reactions.
But they'll walk you through all this, assuming they're answering the phone.
Sam: it's like the one person holding the DAT calculator and
has the one remaining book on dAT.
Lara : They don't even make that info like public.
I can't find it anywhere.
It's basically, here's the phone number, call us and we will walk you through it.
Because I think it's based on a number of factors that they
assume are too complicated for us
Sam: Well, thank goodness for the number, but then you did mention that
there is a time sensitivity component to this, so it has to be given sooner
to bind more of the free toxin.
Lara : right.
So the longer that you've got toxin production, the less effective this is
gonna be because the more you've got circulating toxin, the more it's bound
to the end organs and the tissues, the less likely the antitoxins gonna be able
to bind it and take it outta circulation.
So that's why the minute you suspect it, you get on the phone.
I think everyone would rather you did that.
The other thing that's important is you wanna get antibiotics on board, and that's
not going to change the progression of the disease, 'cause these patients need
to go into isolation and you're gonna need to identify close contacts and test them
and offer them, prophylactic antibiotics.
So you need antibiotics to prevent transmission that will not
abort the course of the disease.
What will affect the outcome is getting that antitoxin.
Sam: And that anti-toxin coming from the CDC has to be shipped to you.
So really, even if you're Johnny on the spot and call immediately,
it's going to be a minimum of hours, if not a day before they get it
to you, wherever you are in the US
Lara : So it's actually listed in the WHO's list of essential medicines.
I think that that is the case,
Sam: I was gonna say, there's probably very few manufacturers.
It is probably like some horse serum antitoxin or something.
Okay.
So , you're giving the antibiotics to kill off the remaining bacteria.
Reduce the continuing creation of toxin and then also make them less contagious.
And then you gotta treat family members as well.
And, when we talk about isolation, this is like respiratory isolation.
So everybody who enters the room has to be masked and gowned
and gloved and all of this.
Lara : Yeah, so it's droplet isolation, and identification of close contacts.
And regardless of whether it is, respiratory or
cutaneous, you're going to be
reporting it.
Sam: And then antibiotics in this disease for diptheria,
erythromycin, or a penicillin.
Lara : You go erythromycin or penicillin.
They're both indeterminate.
Sam: Hmm.
Great.
Lara : I don't think it's ethical to have a large perspective randomized
control study on infecting people with diptheria and seeing whether,
you know, erythromycin or penicillin is really where the money's at.
Sam: Yeah, it's interesting 'cause I always think of like, you know,
your critically sick patient is just gonna get vancomycin and zosyn or
something at every hospital or fortaz or, you're gonna give some big gun.
But in this case you're like, well, we have erythromycin and we have penicillin.
Like, that's kind of what we, know works.
But we haven't really studied it for the rest.
Lara : We, don't have antitoxin and the antibiotics aren't gonna do anything
right now, but at least you know and start passing out to the family.
That's right.
These are old school illnesses with old school antibiotics.
Sam: And then for pertussis, when it comes to treatment, if you have a
critically ill child, is there a role for antibiotics in that scenario,
specifically against pertussis?
I mean, assuming they don't have pneumonia or something.
Lara : Yeah, everybody with pertussis is gonna get, first line is azithromycin.
and, that is even for the little babies.
there was some concern for the macrolides and, development of pylori hypertrophy.
But the benefit clearly outweighs the risk.
And so for a while, I remember when I was a little doctor, there
was some concern about that.
And sometimes people go erythromycin, but it's recommended
that everybody get azithromycin.
Sam: And that's, so that's close contact again.
And then the patient, and then I assume if there was exposure for EMS personnel
who might have brought the child in, they're getting treated as well.
And same with the diptheria.
Lara : Well, so diptheria is gonna be with guidance from your department of
public health, because it depends on how close the contacts are, and the, health
status of the other people in the family.
So there's some quite complicated rules about the diptheria prophylaxis that
you can find well on the CDC website,
but that's where you notify Department of Health will walk you through
who's going to be treated there.
It's probably going to be the people actually live in the home.
And some other select cases, potentially some healthcare workers,
depending on the circumstances.
pertussis is a little more, you know,
Sam: everybody gets it.
Yes.
Nurses, techs, EMS personnel.
Everybody just put it in your water.
Okay.
And then treatment for tetanus.
Now you mentioned mag sulfate already it helps with tetany and
with the autonomic instability.
Lara : So you have two goals with someone with tetanus, which is one,
to control the tetany, the muscular spasms, and get control of that airway.
So that's one goal and that is accomplished with getting
benzodiazepines on very quickly.
and then considering mag sulfate, the benzos will sedate and help
relieve the muscular contractions.
'cause again, startling a patient, having them stressed out, that's gonna
create this vicious cycle of doom.
So that will help.
Mag sulfate is also useful for, stabilizing that autonomic response.
So everything I've looked at that seems to be everybody's go-to favorite.
A number of things have been tried.
They've tried intrathecal Baclofen, they've tried, you know, all kinds of
things have been tried in literature.
It's interesting, there are parts of the world where they have enough tetanus
patients to really do some robust studies.
but That, seems to be the number one go-to,
Sam: Gotcha.
Okay.
Lara : And then you're also gonna want antibiotics.
. And antibiotics are just going to hopefully eliminate
any more of the Clostridium.
antibiotics, whack 'em on all three across the board.
Old school antibiotics,
Sam: Yeah, so for tetanus it says metronidazole or penicillin again.
So, kind of, , something you should have at your hospital.
But again, not necessarily going to affect the course of
the disease in this scenario.
Just stop ongoing toxin creation.
Lara : Right, Because that nano toxin is so toxic.
I don't know how many times I use toxic to describe how toxic it is
Sam: Virulent potent.
Lara : Potent.
Sam: Pull out the thesaurus.
Lara : That's right.
It's considered a nano toxin, like you need less than the
pin of a head to cause disease.
And so if you've got any bacteria around that's producing it like you're kinda.
You're not doing well, but get rid of any more bacteria.
Sam: All right.
And then the clinical course.
Now, all of these children, if they're children, are going to go to the ICU,
if they're adults with these diseases, probably equally going to go to the ICU.
Lara : I would send them to the, ICU.
Yes.
Sam: then the course, if they survive the expected course.
So with tetanus, we're looking at a very long, protracted illness
in the ICU, it's similarly long with pertussis and diptheria.
Lara : No pertussis is really an illness that most people who have it probably
don't even realize they've had it.
So most adults who get it are just gonna be like, God, I had a terrible cough.
For so long.
If you are on either end of the spectrum where you're a more vulnerable person,
then you're gonna be more prone.
If you're an elderly person with pertussis, you're gonna be cracking
your ribs and then that's where we see in the case reports of the
intracranial bleeds and the pneumo mediastinum and the pneumothorax,
and the ruptured, you know, eardrum.
On the other end are the babies who are vulnerable, and that's the apnea,
the seizures, the bacterial pneumonias.
So if you were just, let's say in your twenties, cruising
around and you got pertussis.
You might not even realize you had it.
I promise you.
If you've got tetanus, you're gonna know it.
And same thing with diptheria, right?
So, both those cases with diptheria, how quickly you get that antitoxin on board,
you know, the earlier it's recognized, before it's really progressed to a genuine
pseudo membrane that's pumping out toxin with tetanus that's going to be a long
course, and with that, prolonged ICU stay.
Every other complication we see in every prolonged ICU stay is going to come
Sam: Hmm.
Well, if you're listening and you have access to the article, there
is an excellent appendix number one on page 17, which summarizes
everything we've talked about from the clinical features to the diagnostic
studies, to the initial treatment for all three of these conditions.
And there is a clinical pathway in this issue, which will
walk you through step by step.
From suspicion through diagnosis and treatment, which I also highly recommend.
And if you're working here in the US and you're not familiar with
these diseases, now is an excellent time to brush up on them and their
clinical presentation, because it's coming to a hospital near you.
So.
Thank you for agreeing to be on the podcast.
I found this article, I mean, exceedingly helpful, not just because of what we're
going through in the US but just in general, for two diseases that, you
know, we don't see in the hospital all that often, tetanus and diptheria.
If you haven't seen these cases, there's some good pictures, some great
clinical descriptors, and I think it's going to be even more valuable
now than it has been in the last 10 years that you've been writing it.
Lara : Well, thank you.
I mean, I will say it's obvious if I've written this article three times now
and I still have to go flip back and see what something says, that tells
you how rare these illnesses are.
So I really hope this article can be stuck on a wall somewhere in a department so
that you don't have to think too hard.
If you just suspect and you remember one thing from reading it or our
chat today, then you can go find it and walk yourself through it
Sam: Yeah, for sure.
Well, thank you so much for being on the podcast.
I appreciate it.
Before you leave, you have your own podcast and I want you to
share with our audience about it.
Tell me more about that.
Lara : I do.
Totally different than yours.
Mine is a little sillier.
One of my business school professors, actually, Adam Brown, he's an ER doc.
And we find ourselves rather amusing.
We're both doctors who became entrepreneurs.
And so we try to look at the business of healthcare in America and compare
it to other systems and try to look at it from all different angles.
We've had episodes on physician suicide, physician burnout, STEM
education for kids, women's health.
And , we like to think we're amusing.
So it's called unstable vitals.
You can find it wherever you find your podcast, and I hope
it brings you a little giggle.
It's not nearly as consequential as what you're doing here, Sam,
but I hope it gives people a little laugh.
Sam: Awesome.
And we will put a link to that podcast in the show notes.
Thank you so much for agreeing to be on the podcast.
It's been a pleasure.
Lara : Well, thank you.
. Sam: And that's a wrap for this month's episode.
I hope you found it educational and informative.
Don't forget to go to ebmedicine.net to read the article and claim your CME.
And of course, check out all three of the journals and the multitude of
resources available to you, both for emergency medicine, pediatric emergency
medicine, and evidence based urgent care.
Until next time, everyone be safe.