The modem management of tetanus has aroused recent interest. There are, however, few reports in the English literature on the use of hypothermia in tetanus in children. The following case, despite the unsuccessful outcome, is considered worthy of comment, as an illustration of the present-day approach, and the problems that arise in the treatment of tetanus

Chigier, E.

Rotem, Y.

English

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South African Medical JournalSuid--Afrikaanse Tydskrif vir GeneeskundeP.G. Box 643, Cape TownCope Town, 9 November 1957Weekly 2s. 6d.,Vol. 31 No. 45Posbus 643, KaapstadKoopstod, 9 November 1957Weekliks 2s. 6d.A FATAL CASE OF TETANUS TREATED WITH TRACHEOTOMY ANDHYPOTHERMIAY. ROTEM, M.D.andE. CmGlER, M.B., B.CH. (RAND), M.R.C.P., D.C.H.Paediatric Department, Tel-Hashomer Government Hospital, IsraelThe modem management of tetanus has aroused recentinterest.l-4 There are, however, few reports in the Englishliterature on the use of hypothermia in tetanus in children.The following case, despite the unsuccessful outcome, isconsidered worthy of comment, as an illustration of thepresent-day approach, and the problems that arise in thetreatment of tetanus.CASE REPORTA 4!-year-01d boy fell down a few steps and sustained an openwound over the occiput, which was treated by the mother. Tendays later, the child fell ill, refusing to open his mouth, andcomplained of a stiff neck. During the night, he had a convulsion,and was admitted to hospital the following morning.On admission the classical features of tetanus were present,viz. trismus, meningismus and opisthotonus, with a septic woundover the occiput. The patient was fully conscious. Soon afteradmission a tetanic convulsion occurred. For the 1st day treatmentconsisted of sedation, nursing in a darkened room, intravenousfluids and large doses of antitoxin and penicillin. The followingday the patient had a severe convulsion with pharyngospasm,cessation of breathing, cyanosis, and temporary loss of conscious-ness. As these convulsions were repeated and swallowing becameimpossible, tracheotomy was performed, gastric contents weresucked out, the wound was excised, further sedation was given,and fluids were administered intravenously.To induce hypothermia, treatment with Largactil (chlorpro-mazine) was commenced on the 2nd hospital day, with anintravenous dose of 2S mg., and was continued with 2S mg.intramuscularly every 4 hours. Within 24 hours, the body tempera-ture (rectal) dropped from 38°C (101°F) to 31°C (82°F) and thendown to 2rC (71· 8°F) remaining at this point during the last2 days of life.On the 3rd day, diminished air-entry was noted on the leftside, while a chest X-ray suggested a possible atelecta is at theleft base. Despite the hypothermia and the state of unconsciousness,severe convulsions occurred on the 3rd evening. Curare wasadministered 'intravenously (7 mg.), resulting in complete muscularparalysis. Intermittent positive-pressure respiration (manualmethod) was carried out for about 6 hours.The following day (4th day) the patient's condition deteriorated,with occasional convulsions and an increase of tracheo-bronchialsecretion. Blood-electrolyte studies gave normal results.On the Sth day disturbances in respiration made furthercurarization (7 mg. intravenously) and intermittent positive-pressure respiration necessary to maintain life. Urinary retentionrequired catheterization. .An electro-encephalogram was attempted but, owing to technicalreasons, it was not successful.An electrocardiogram done 18 hours before death (bodytemperature 28°C) showed normal sinus rhythm with a rate of80 per minute. A prolongation of the Q-T interval to 0·48 secondswas pres.ent in all leads. The pattern suggested hypocalcaemia (?).The patient's condition gradually deteriorated, with poorair entry over the left chest, and death occurred on the morningof the 6th day in hospital.Post-mortem examination revealed emphysema with patchyatelectasis of the right lung, and an almost complete collapseof the left lung. Thick purulent secretions were present in thetrachea and bronchi, blocking the left main bronchus.COMMENTAny analysis of the result in a case of tetanus requires acareful as essment of the prognosis, since the severity ofthe condition may vary to a great degree from patient topatient. The factors to be considered are:1. Incubation Period. If this is less than 7 days, theprognosis is bad; if more than 14 days, the prognosis isu ually good. With an incubation period of 10 days, as inthis case, the prognosis is equivocal.2. Period of Onset (i.e. between first symptom and fir tconvul ion). This is considered a more accurate index ofseverity than the incubation period. I ,7 A period of lessthan 48 hour (in this patient the period of onset was 20hours) carries a bad prognosis.113321134 S.A. MEDICAL JOURNAL 9 November 19573. Clinical Severity. With severe and frequent spasms,involving the laryngeal and respiratory muscles, prognosisis poor. In this patient, the severity of the reflex spasms,causing cyanosis, and the temporary cessation of breathing,made radical treatment a necessity.TREATMENTTreatment was instituted along the following lines:1. Rest, dark-room nursing, sedatives (chloral hydrate,30 c.c. per day).2. Excision of the septic wound.3. Anti-tetanus antitoxin, a total of 300,000 units, ofwhich one-half was given intravenously.4. Antibiotics (penicillin and streptomycin) to preventsecondary infection).5. Feeding by intravenous drip and then by an indwellinggastric tube.6. Tracheotomy, carried out within 24 hours of admission,because of laryngospasm, difficulty in swallowing, andcomatose condition of patient.7. Chlorpromazine (Largactil) is considered to have aspecific action on the neuromuscular endings. 5,6 In addition,there is a sedative central effect occuring at a differentlevel from that of the narcotics.! The atropine-like actionhelps in diminishing bronchial secretions, which is importantin tracheotomized cases. Finally the hypothermia, probablydue to peripheral vasodilatation, is considered to aid intreatment by diminishing metabolic needs.Kelly and Laurence6 used chlorpromazine alone in thesuccessful treatment of a 2-t-year-old boy, with severe spasms,an incubation period of 11 days, and a period of onset of3 days. Over 16 days a total of 3,145 mg. was given (intra-venously), as much as 330 mg. being given over one 24-hourperiod. Cyanotic episodes occurred, but tracheotomy wasnot performed. No mention is made of hypothermia resultingwith these doses of chlorpromazine.In our patient, aged 4-t, a daily dose of 150 mg. of chlorpro-mazine combined with 30 c.c. of chloral hydrate resultedin a state of hypothermia and stupor which was maintainedfor 3 days, until death. It is doubtful whether the hypothermiawas caused solely by the chlorpromazine, or whether otherfactors, such as central involvement, were concerned. Inview of the rapid development of the state of hypothermia,we are inclined to consider that perhaps other factors (e.g.toxic or anoxic damage to the brain) contributed to the hypo-thermia.8. Complete relaxation was not achieved with this therapyalone; on 2 occasions frequent spasms called for curarizationwith intermittent positive-pressure respiration, carried outmanually for periods of 6-8 hours. Despite tbis therapy,our patient died of a massive atelectasis. We are, however,convinced that without this active form of treatmentrespiratory complications would not have allowed thispatient to survive 5 days.Was it possible to save this patient? In the light of furtherexperience with respiratory problems in poliomyelitis,we believe the answer is probably in the affirmative. Successin critical cases of tetanus depends on the management ofthis difficult method of treatment.SUMMARYA fatal case of severe tetanus in a 4-t-year-old boy, treatedwith tracheotomy, hypothermia, curarization, and inter-mittent positive-pressure respiration, is described. Deathon the 6th day was due to pulmonary atelectasis. Despitethe difficulty in treatment, it is considered that the wayto better results lies along the methods attempted.We are indebted to Dr. D. Benveniste, anaesthetist at Tel-Hashomer Hospital, for his invaluable assistance.REFERENCESI. Ablett, J. J. L. (1956): Brit. J. Anaesth., 28, 258.2. Andrews, J. D. B., Marcus, A. and Muirhead, K. (1956):Lancet, 2, 652.3. Bodman, R. 1., Morton, H. J. V. and Thomas, E. T. (1955):Ibid., 2, 230.4. Forbes, G. B. and Auld. M. (1955): Amer. J. Med., 18, 1947.5. Hougs, W. and Anderson, E. W. (1954): Acta pharmacol.(Kbh.), 10, 227.6. Kelly, R. E. and Laurence, D. R. (1956): Lancet, I, 118.7. Shackleton, P. (1955): Ibid., 2, 155.BOOKS RECEIVED : BOEKE 0 TVANGAnatomies o/Pain. By K. D. Kee1e, M.D., F.R.C.P. Pp. x + 206.Plates XIII. Figures 14. 27s. 6d. net. Oxford: BlackwellScientific Publications. 1957.A Theory of Disease. By Arthur Guirdham, MA., D.M., B.Sc.(Oxon), D.P.M. Pp. 204. 2]s. net. London: George Allen& Unwin Ltd. ]957.British National Formulary 1957. By Joint Formulary Committee.Pp. 226. 6s. 6d. (Ordinary) plus 5d. postage, 10s. (inter-leaved) plus 8d. postage. London: The PharmaceuticalPress. 1957.The British Encyclopaedia of Medical Practice-Pharmacopoeia]957. Second Edition. By Charles Rob, M.Chir., F.R.C.S.and Rodney Smith, M.S., F.R.C.S. Pp. viii + 32. £3 7s. 6d.postage 2s. extra. London: Butterworth & Co. (publishers)Ltd. South African Office: Butterworth & Co. (Africa)Ltd.. P.O. Box 792, Durban. 1957.Expert Committee on Insecticides. Seventh Report. TechnicalReport Series, o. 125. Pp. 31. ]. 9d. Also available inFrench and Spanish. Geneva: World Health Organization.]957. Local Sales Agent: Van Schaik's Bookstore (Pty.)Ltd., P.O. Box 724, Pretoria.Expert Committee on Biological Standardization. Tenth Report.Technical Report Series, No. 127. Pp. 35. Is.9d. Availablealso in French and Spanish. Geneva: World Health Organi-zation. ]957. Loca] Sales Agent: Van Schaik's Bookstore(pty.) Ltd., P.O. Box 724, Pretoria.Role of Hospitals in Programmes of Community Health Protection.First Report of the Expert Committee on Organization ofMedical Care. Technical Report Series, o. 122. Pp. 34.Is. 9d. Geneva: World Health Organization. 1957. LocalSales Agent: Van Scbaik's Bookstore (pty.) Ltd., P.O. Box724, Pretoria.The Clinical Examination ofPatients with Organic Cerebral Disease.By R. Klein, M.D. and W. Mayer-Gross, M.D., FR.C.P.Pp. xiii + 96. Figures 9. 15s. London: Cassell & Co. Ltd.1957.Pneuntoencephalography. By E. Graeme Robertson, M.D. (Melb.),F.R.C.P., F.R. .C.P. Pp. xxi + 482. Figs. 209. £5 ]Os.Oxford: 13lackwell Scientific Publications. 1957.Studies on Fertility 1956. Volume VITr. Edited by R. G. Harrison,M.A., D. . Pp. x + 138. Illustrations. 25s. Oxford:BlackweU Scientific Publications. ]957.

A fatal case of tetanus treated with tracheotomy and hypothermia

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A fatal case of tetanus treated with tracheotomy and hypothermia

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