What Is Tetanus;What Are Different Types of Tetanus

Different types of Tetanus are being discussed in this article.Tetanus, also known as lockjaw, is an infection characterized by muscle spasms.It Can be further classified in following types.

Mild Tetanus

The patient with mild tetanus needs only these general measures, including a relaxant and seda­tive such as diazepam. The patient should be encouraged to drink water under supervision every two hours in the early stage of the disease when it may be progressing. If a patient*coughs or splutters while drinking, dysphagia is present, and the patient moves into the moderate group

Moderate Tetanus

The patient with moderate tetanus differs from the mild case by the presence of dysphagia. ,He needs the general measures applicable to all pa­tients with tetanus, but in addition he must have a tracheostomy and have a cuffed tracheostomy tube inserted into the trachea to make inhalation of pharyngeal contents impossible. The operation is performed under general anesthesia with a cuffed endotracheal tube in situ so that the opera­tion may be careful and unhurried. A cuffed tracheostomy tube should be inserted through a high U-shaped incision into the trachea so that the tube lies easily in the trachea where it is approximately parallel to the skin. If the tracheos­tomy is high, there is sufficient distance between the tracheostome and the carina to make it un­likely that the tube will enter the right main bronchus. The wound should not be covered and should be cleaned frequently with a mild anti­septic.

It is necessary to aspirate secretions from the trachea, and disposable gloves should be worn during this procedure, not only to prevent contami­nation of the trachea with organisms carried on the aspirating catheter, but also to avoid con­tamination of the tracheostomy wound. The pa­tient with moderate tetanus must be fed by naso­gastric tube, and may require large amounts of fluid to offset excessive sweating. A high calorie diet of about 3000 calories a day is necessary, but too much protein should not be given. Patients with moderate tetanus may have a considerable degree of muscle rigidity and may even have occa­sional mild reflex spasms. Diazepam in divided doses of up to 400 mg. intravenously per day has a considerable effect on the rigidity of tetanus with­out interfering with ventilation. In spite of treat­ment, muscular rigidity is painful and -uncomfor- table, and the patient should be turned every two hours to lessen this discomfort and avoid pressure sores.

Severe Tetanus

The patient with severe tetanus differs from th« patient with moderate tetanus in that he has frequent reflex spasms that cannot be controlled by muscle relaxants other than curare, and needs to be paralyzed with curare or another powerful relaxant. Curare may be given by intramuscular injection of 15 to 30 mg.; if the patient must be paralyzed, there seems little to be gained by with­holding the drug. At Oxford the nurses are in­structed to give a further dose of curare when reflex spasms become obvious, and 400 mg. of cu­rare per day has been necessary. The high inci­dence of pulmonary embolus in patients with severe tetanus has led to the use of anticoagulantsin patients severely enough affected to require treatment with curare and IPPV. Anticoagulants are not, however, used within 24 hours of tra­cheostomy. The treatment of a paralyzed patient with IPPV is complex, and appropriate mono­graphs should be consulted . The patient cannot breathe, and IPPV must be applied through the cuffed tracheostomy tube.

It has become common practice in recent years to ventilate with a large tidal volume at a slow rate, for example, with a tidal volume of 1 liter and a rate of 12 to 14 per minute. An artificial dead space is introduced between ventilator and patient so that rebreathing of expired air may bring the tension of carbon dioxide in the arterial blood to about 30 mm. Hg. Large tidal volumes seem to contribute to the health of the lungs, but the patient must also be turned every two hours to promote lung drainage, the inspired air must be fully humidified and at body temperature, and chest physiotherapy three times a day is indicated.

Here You Can understand Different Types of Tetanus

Frequent chest films are necessary, and tracheal aspiration must be carried out with aseptic precautions. The patient cannot drink and must be fed by nasogastric tube or by vein if absorption fails. Patients with severe teta­nus sweat profusely and may need large quantities of fluid, but the urine specific gravity is not always a good guide to hydration, and the patient should be weighed daily. It is not uncommon to observe a patient seriously ill with tetanus who is having a large fluid intake and gaining weight, but who still produces a high specific gravity urine. Later in the disease a diuresis may occur, and the pa­tient may lose weight abruptly.

A patient with severe tetanus needs 3000 calories per day, but too much protein is not advised, even though the patient, being functionally denervated by curare, may show muscle wasting. Urine is voided normal­ly, but manual extraction of feces may be neces­sary. The patient cannot communicate, and seda­tion is probably indicated for patients paralyzed with curare. Withdrawal of sedation in severely ill patients may, however, disclose that the pa­tient is unconscious.

Some patients most severely affected by tetanus develop a.syndrome suggesting sympathetic over­activity. The cardiovascular component of this syndrome, tachycardia, arrhythmias, and hyper­tension, should be treated wifh beta and alpha adrenergic blockers (Prys-Roberts et al.). If it is thought necessary to administer a beta blocker intravenously, this should be done with great caution. Propranolol in 0.2 mg. aliquots to a total of 2 mg. has been successfully used to control arrhythmias and severe tachycardia.

Control can sometimes be maintained by intragastric pro­pranolol, 10 mg. every eight hours, but larger doses may be required. In some cases, when hyper­tension is not severe, control of the heart rate may be all that, is necessary, but if the blood pressure is elevated, alpha adrenergic blockade is also indicated. Bethanidine, 5 mg. by nasogastric tube every two hours, has been used successfully, and as this drug acts at postganglionic nerve endings, an overdose could be counteracted by presser agents.

The receptors, however, remain susceptible orperhaps hypersensitive to circulating catechol­amines, and other combinations of antihyper- tensive drugs may be more effective. The author is aware of a patient successfully treated with propranolol, reserpine, and bethanidine. It is important not to reduce the heart rate to a point at which the cardiac output fails, because the depressed heart is working against an increased peripheral resistance. Moderate control of heart rate should be effected with a beta blocker, but hypertension when the heart rate is 100 or less must be controlled by alpha blockade.

In summary, in a mild, case the patient needs (1) wound excision, (2) human or equine antitoxin, (3) penicillin or another appropriate antimicrobial drug, and (4) a centrally acting relaxant and seda­tive drug, such as diazepam.

In the moderate case the patient needs in addi­tion (5) tracheostomy and the insertion of a cuffed rubber tracheostomy tube to separate the pharynx from the trachea and to make inhalation of foreign material impossible, and (6) nasogastric tube feed­ing.

In the severe case the patient needs in addition (7) virtually complete paralysis with curare or another powerful relaxant and IPPV, (8) antico­agulant drugs, and (9) if sympathetic overactivity is present, treatment with alpha and beta adrener­gic blockers.

by Abdullah Sam
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