Infected Open Depressed Skull Fracture Complicated with Tetanus Grade I in an Unimmunized Child: A Rare Case Report with Literature Review

Abstract Background: Tetanus is a rare disease caused by Clostridium tetani, which produces tetanolysin and tetanospasmin. In 2018, there were only approximately ten tetanus cases reported in Indonesia. Despite widespread vaccination, especially in low-middle income countries, tetanus still occurs (mostly in adult) due to the lack of immunization related to religious tenets, cultural belief or inaccesibility to medical care. In addition, tetanus in pediatric population shows features which are quite distinct from the adult group. Case Description: We reported a 7 year old girl that presented to our institution with a history of falling 10 days prior the admission, with only skin laceration of her forehead. Since one day prior to admission, the patient looked drowsy and difficult to be awakened, accompanied with stiffness of her jaw; we diagnosed as unimmunized child with open depressed skull fracture of her frontal bone and wound infection complicated with “lockjaw”. Perioperative management of that rare case is reported and discussed. Conclusion: This case is so exceptional, since the infected open depressed skull fracture complicated with trismus in an unimmunized child occurrence in our center is extremely rare; the pediatric intensive care of such patients requires halting further toxin production, neutralisation of circulating toxin and control of the clinical manifestation induced by the toxin that has already gained access to the central nervous system. The basic tents of anaesthetic care in such case had to well managed and planned prior the surgery.