Tracheostomy undertaken early in patients whose disease is not controlled with conservative sedative regimen

periosteal - calcification and myositis ossificans. Wedge fracture of thoracic vertebrae can also result from spasms. 3. Complications due to tracheostomy and prolonged respiratory support. 4. Multiple organ dysfunction - In severe fulminant tetanus. Besides respiratory system, CVS (hypotension requiring inotropic support), Gl system (ileus and massive bleeds), liver (rise in serum enzymes and bilirubin), renal insufficiency (rise in serum creatinine, rarely acute renal failure). 5. Sudden death - from cardiovascular instability, excessive vagal tone giving rise to bradycardia and cardiac arrest, hypoxia due to prolonged laryngeal spasm or continuous seizures, hyperpyrexia, massive pulmonary embolism, heart block. Prognosis - can be assessed from -1. Type of infection - Neonatal and puerperal tetanus carry a very bad prognosis. 2. Type of patient - Prognosis bad in elderly and drug addicts. 3. Frequency and severity of spasms. 4. Incubation period - Mortality higher if incubation period is short. 5. Period of onset - Interval of less than 48 hours between the first symptom (usually trismus) and the first spasm, carries double or treble the mortality. 6. Severity of tetanus - as described above. Management - AIMS OF TREATMENT - 1 .Neutralize existing toxin before it gains access to the nervous system. 2. Reduce further production of toxin. 3. Control neuromuscular and autonomic manifestations. 4. Sustain the patient until effects of the toxin resolve. 1. Neutralization of unbound toxin - Hyperimmune human anti-tetanus immunoglobulin 1000-3000 units IM/IV as a single dose or anti-tetanus serum 10,000 units IV after testing for sensitivity. Intrathecal HITG 1000-3000 units given before onset of major spasms may prevent disease progress .2. Reduction of further toxin production - (a) Care of the wound - Removal of foreign material and debridment of non-viable tissue of entry wound. (b) Antibiotic - Benzyl penicillin GOO mg G-houhy IM or IV, or Erythromydn 500 mg G-houhy for 10 days to minimize risk of bacterial infection Metronidazole can be used in patients allergic to penicillin. 3. Control of rigidity and tetanic seizures (a) Avoidance of provocative stimuli -such as noise, unnecessary movement, and keeping injections to minimum minutes 2-G hrly. Note - Respiratory depression can occur when using combinations and the doses above are for single dose regimens. If drug treatment cannot control muscle spasm and seizure without impairing consciousness or respiration, muscle paralysis and assisted ventilation become necessary. (c) Tracheostomy undertaken early in patients whose disease is not controlled with conservative sedative regimen, because inadequate control of muscle spasms results in asphyxia and depression of swallowing reflex. (d) Induced paralysis with ventilator/ support - Neuroparalytic agents pancuronium 2-4ng bolus 1/2-1 hrly initially or gallamine 20^1-Oml iv., the dose being so adjusted that the neuromuscular paralysis achieved allows or efficient ventilator/ support (PaO2 should be maintained >70mm Hg and PaCO2 at 35-40mmHg. ) When spasms abate, pancuronium or gallamine is stopped; but ventilatory support is continued till the patient is fit to be weaned 4. Autonomic circulatory disturbances - (a) Hypotension (systolic BP<70)>200, diastolic >110) - propranolol 5-1 Omg p. o. or 5mg sublingual nifedipine or both. Morphine 2-5mg as infusion may be