New trends in the management of tetanus

Abstract

The prevalence of tetanus reflects a failure of immunization. Prompt diagnosis and prediction of severity are crucial for the prevention of early life threatening complications and the institution of appropriate management. The current symptomatic treatment of heavy sedation, paralysis and artificial ventilation for 3-5 weeks for moderate and severe tetanus, is, even in the best centers, still associated with unacceptably high mortality, due to the disease and complications of the therapy itself. It is especially inappropriate for the developing world where intensive care resources are minimal. New options reported to avoid artificial ventilation and sedation are dantrolene (Dantrium, Procter and Gamble Pharmaceuticals), baclofen (Lioresal, Novartis) and magnesium. Magnesium therapy has the advantages of controlling spasms and sympathetic over activity without sedation. This simplifies nursing care and minimizes the need for ventilatory support except in the very severe disease and the elderly. Magnesium is recommended as the first-line therapy in tetanus.

Tendência temporal do tétano acidental no período de 1981 a 2004 em Pernambuco com avaliação do impacto da assistência em unidade de terapia intensiva sobre a letalidade

“…O tratamento sintomático atual envolve suporte em unidade de terapia intensiva (UTI) com sedação intensa, bloqueio neuromuscular e assistência ventilatória mecânica por semanas nos casos de tétano moderado a gravíssimo 1 17 . Mesmo nos melhores centros, a letalidade ainda é alta, talvez devido à doença ou a complicações associadas à terapia intensiva 1 . Brauner e cols 2 demonstraram decréscimo da mortalidade pelo tétano, após melhorias nos cuidados de UTI e tratamento da instabilidade autonômica, caindo de 36,5% para 18% 2 .…”

Diretrizes para o manejo do tétano acidental em pacientes adultos

“…Such patients therefore require a more aggressive approach. (5,6,24,25,(27)(28)(29)(30)(31)(32)(33) Mortality is also related to the severity classification. Although the mortality rate of mild tetanus is low, patients with severe and very severe disease are more likely to die and should be intensively monitored and treated.…”

“…(89,90) However, it should be noted that higher diazepam doses are used in more severely ill patients at sites that have difficulty accessing ventilatory care, which could impact the outcomes. (30) For analgesia and sedation in tetanus patients, opioids have always been used in combination with other drugs. Reports on the intravenous use of fentanyl, (91) , alfentanyl, remifentanyl (92) and epidural sulfentalyl (in association with bupivacaine) (93) show that this group of drugs is an option, especially in patients with autonomic hyperactivity.…”

“…(113) The lability of blood pressure levels means that drugs with a shorter half-life are preferred; this property would allow rapid reversal of or compensation for their effects. (30,107) Most of the clinical experience in medically managing dysautonomia has been with opiates. Morphine has been shown to be effective in tetanus-related autonomic disorders, although its mode of action is unclear.…”

A five-year-old boy with fever, headache, disturbances in walking, erect posture and speech - Case of the Month

“…Tetanoz olgular›n›n y›llara göre da¤›l›m› incelendi¤inde tüm ülkelerde son on y›l içerisinde y›ll›k görül-me s›kl›¤›n›n yaklafl›k yar›s› kadar azald›¤› görülmektedir. Ancak, gerçek s›kl›k ço¤unlukla bildirilenden daha fazlad›r (5,6).…”