The incubation period is over 14 days, trismus is the patient’s only symptom, and comes on over 6 days. Sedation and oral feeding are the main means of treatment. His prognosis is good.
The incubation period is 10 to 14 days. Symptoms come on over 3 to 6 days. Moderate trismus is combined with moderate dysphagia, rigidity and spasms. He may need nasogastric feeding, an intravenous drip, and a tracheostomy, or paralysis and IPPR.
The incubation period is less than 10 days and symptoms develop over 3 days. Other features are similar to Grade Two but are more severe, or more urgent. If possible, transfer him to a hospital where IPPR and the analysis of blood gases are possible.
CAUTION! Remember that a patient with tetanus is conscious and aware of all that is going on around him so talk to him and not about him.
CONFIRM THE DIAGNOSIS Examine the patient’s nervous system thoroughly and do a lumbar puncture to exclude menigitis, encephalitis, and subarachnoid haemorrhage. Don’t assume he has tetanus merely because he is in a surgical ward. Consider also epilepsy, rabies, and local disease of his temporomandibular joints. Disturb him as little as possible when you examine him.
SEDATION Sedate the patient heavily enough to control his spasms; each patient needs a different dose. Start with chlorpromazine 25 to 50 mg and diazepam 10 mg by intramuscular or intravenous injection, or orally, depending on his size and condition. An average dose is 100 mg 6 hourly. Continue with diazepam 10 mg, 8, 6, 4, or even 2 hourly, supplemented by chlorpromazine 25 mg 8 or 6 hourly. Or, use phenobarbitone.
If severe spasms cause him great distress, give him pethidine 50 to 100 mg as required.
CAUTION! Continue sedation for 5 to 7 days, even if he appears to be improving, or he may relapse.
RESPIRATORY SYSTEM Raise the foot of his bed 30 cm to help postural drainage, until he can sit up and move about on his own. Turn him regularly. Suck out his mouth and nose as required. If necessary intubate him and suck out his trachea (A 13.2). You will probably find that managing a tracheostomy is impractical.
THE WOUND should already have been toileted (54.1). If the toilet has been inadequate, excise the patient’s wound widely, remove all foreign bodies, pus, and clot. Handle it as little as possible. Leave it open and dress it with diluted hydrogen peroxide.
CAUTION! Handling the wound may discharge the toxin in it into the circulation, so, give him antitoxin before you operate.
ANTISERA Ideally, give the patient human tetanus immune globulin (HTIG) 30-300 U/kg intramuscularly to fix the toxin.
Or, exclude hypersensitivity and give him antitetanus serum, 750 units intramuscularly or intravenously once daily for 3 days. Or, give him a single intramuscular dose of 20,000 units. Intramuscular antitetanus serum is not of great value and regimes vary considerably.
Intrathecally as soon as he is adequately sedated, give him one dose of 200 units of antitetanus serum by lumbar puncture. Take this from the smallest ampoule obtainable (1500 units in 1 ml) and measure it with a ’tuberculin syringe.
ANTIBIOTICS Give him benzyl penicillin 1 megaunit intramuscularly every 6 hours. Culture the organisms from his respiratory tract and adjust his antibiotics accordingly.
STEROIDS The value of these are uncertain. Some surgeons give a patient betamethasone 8 mg initially, preferably intravenously, and repeat it 12 or 8 hourly.
NURSING Put the patient in the quietest part of the ward. Manage his bladder by continous catheter drainage with intermittent release (64.16). Prevent pressure sores, stop his mucosal surfaces drying, and prevent faecal impaction with suppositories or low enemata. Keep this up for several weeks.
FEEDING If possible, feed him by mouth. Even if he has trismus he can usually suck fluids through a straw. If necessary feed him through a nasogastric tube, or drip.
A suitable formula for the drip feed is: glucose 400 g, vegetable oil 100 g, dried skim milk 100 g, water 2.4 litres. This will make about 2.5 I of feed containing 12 MJ (2,900 kcals) or slightly more than an average adult’s daily needs. Give him 200 ml 2 hourly.