Aggressive Intensive Care Treatment of Very Elderly Patients with Tetanus Is Justified: MATERIAL AND METHODS part 2
Case 3
An 81-year-old female patient was hospitalized on March 28, 1989, for progressive cervical and dorsal muscle contractures, trismus, and swallowing difficulty for eight days before hospitalization. A superficial wound on the left foot was noted, tetanus was diagnosed, and she was transferred to the medical intensive care unit. She had never been vaccinated against tetanus. An orotracheal tube was inserted, later to be replaced by a tracheostomy on day 20. Mechanical ventilation, sedation (diazepam), and curarization (pancuronium bromide) lasted 45 days. The treatment regimen was similar to that of patients 1 and 2. She presented cardiac dysrhythmia in the form of bradycardia and tachycardia during the first two weeks of mechanical ventilation. The patient was discharged from the intensive care unit on day 47, from the hospital on day 124, and she is now free from any incapacitating problem.
Table 1—Fourteen Tetanus Cases
|
Patient |
Admission |
Type of |
Tracheal |
Hospital |
|
|
Sex/Age, у |
Year |
Tetanus* |
Intubation |
(Days) |
Outcomef |
|
l/F/63 |
1968 |
G |
+ |
14 |
D |
|
2/M/27 |
1975 |
L |
- |
80 |
R |
|
3/M/74 |
1976 |
G |
+ |
50 |
R |
|
4/F/45 |
1976 |
G |
+ |
180 |
D |
|
5/F/40 |
1976 |
L |
- |
208 |
R |
|
6/F/44 |
1977 |
G |
+ |
111 |
R |
|
7/M/86 |
1978 |
С |
- |
38 |
R |
|
8/M/74 |
1979 |
С |
- |
23 |
R |
|
9/F/79 |
1982 |
G |
+ |
45 |
R |
|
10/M/23 |
1982 |
с; |
+ |
43 |
R |
|
1 l/F/85 |
1984 |
G |
+ |
142 |
R |
|
12/F/61 |
1987 |
G |
+ |
68 |
R |
|
13/F/83 |
1988 |
G |
+ |
173 |
R |
|
14/F/81 |
1989 |
G |
+ |
124 |
R |
Reports of all tetanus cases in patients seen in our medical intensive care unit since 1968 were retrospectively collected through hospital registry. Fourteen patients were identified, four with localized tetanus and ten with the generalized form (Table 1). The diagnosis of tetanus was made on typical clinical findings, after exclusion of local causes of trismus and of dnig toxicity. When present, wounds were carefully excised after immunization and bacteriologic sampling were performed. Cultures yielded positive results for Clostridium tetani in only four cases. Except patients 6 and 10, all patients were Swiss national. The immune status of patients for tetanus was not known for each case. Ten patients intubated and sedated for the severe, generalized form make up the study group.
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