Aggressive Intensive Care Treatment of Very Elderly Patients with Tetanus Is Justified: MATERIAL AND METHODS
Case 1
An 85-year-old female patient was hospitalized on July 7, 1984, for an open heal fracture. She had never been vaccinated against tetanus. She received a tetanus Iwoster injection, was operated on, and was put on a regimen of intravenous (IV) penicillin. On the fifth hospital day she experienced difficulty opening her mouth, and by the next day she presented with trismus and diffuse muscular contractures. Tetanus was diagnosed and she was transferred to the medical intensive care unit. Tracheostomy was performed and mechanical ventilation was started along with myorelaxation with a continuous infusion of diazepam and hourly injections of pancuronium bromide and sedation with a continuous infusion of a meperidine (pethidine), promethazine, and chlorpromazine combination. Treatment also included local debridment and lavage, antitetanic 7-globulin, penicillin, parenteral nutrition, gastric protection with ranitidine, heparin prophylaxis, nursing, and early passive mobilization. Complications consisted of sympathetic hyperactivity and pneumonia due to Klebsiella pneumoniae. Weaning from mechanical ventilation was successful on day 38, and the patient was transferred to the ward on day 42. The tracheostomy tube was removed on day 55. Progressively active mobilization was undertaken, and she was discharged from the hospital on day 142, free of any invalidating sequelae. Five years later, she was still leading an active and independent life.
Case 2
An 83-year-old woman was hospitalized on September 10, 1988, for progressive, diffuse muscular contractures, trismus, and swallowing difficulty seven days after incurring two superficial wounds while gardening. 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 on day 23 by a tracheostomy, and mechanical ventilation was initiated, as well as sedation and muscle paralysis with a continuous infusion of either diazepam or midazolam and hourly injections of pancuronium bromide. The treatment regimen was nearly identical to that of patient 1. Complications consisted of initial pulmonary dysfunction due to aspiration pneumonia, dysau- tonomic hemodynamic instability, a sacral pressure sore, and postsedative neuropsychiatry disorders. Total mechanical ventilation time was 54 days, and she was transferred to the ward on day 59. The tracheostomy tube was removed on day 90, and the patient was definitely discharged from the hospital on day 173, free of any incapacitating complication.
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