今日の臨床サポート

破傷風

著者: 久保健児 日本赤十字社和歌山医療センター 感染症内科部・救急科部

監修: 山本舜悟 大阪大学大学院医学系研究科 変革的感染制御システム開発学

著者校正/監修レビュー済:2022/10/12
患者向け説明資料

概要・推奨   

  1. 破傷風は先進国ではまれだが見逃すと致死的な感染症なので、早期診断が重要である。診断確定できる特異的な検査はないので、臨床症状から診断できるようにすべきである(推奨度1)
  1. 破傷風の発症には、Clostridium tetaniの芽胞が接種され発育しやすい条件に合致した外傷が先行することが多いが、約30%は先行する外傷歴が明らかではない。そのため、外傷歴がないからといって破傷風を否定しないよう推奨される(推奨度1)
  1. わが国では、三種混合ワクチン(DTP)の定期予防接種が開始された1968年以前に生まれた年齢層での発症が大半であり、破傷風を疑う例ではワクチン接種歴を聴取するよう推奨される(推奨度1)
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  1. 創部の細菌培養でC. tetaniが同定されなくても、破傷風は否定できない。したがって、C. tetaniの検出を目的としたルーチンの創部培養は推奨されない(推奨度3)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
久保健児 : 特に申告事項無し[2022年]
監修:山本舜悟 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、2016年と2018年にIASRで報告された10歳代の破傷風例について加筆修正を行った。
  1. また、日本での小児と成人における破傷風の予防接種スケジュールに関する表を追加した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 破傷風とは、Clostridium tetaniの感染と毒素により神経系が侵される感染症である。
  1. 先進国ではまれであるが、一度発症すると致死率が高いため、定期的な予防接種と外傷後の処置が予防手段として重要となる。
  1. 先⾏する外傷が明らかな場合は、潜伏期間(中央値9.5⽇、1〜60⽇)で発症する。ただし、3割で外傷歴は認めない。
  1. 発症後からけいれん出現までの時間(period of onset)は中央値48時間(0〜264⽇)である。
  1. 破傷風の診断を確実に行える検査も除外できる検査も存在しない。
  1. 治療薬であるペニシリン系抗菌薬やメトロニダゾール、抗破傷風ヒト免疫グロブリンの副作用の少なさを考えると、治療の遅れによる重症化を防ぐためには、破傷風に特徴的な症状がある場合、治療の開始を遅らせないことが重要である。
  1. 特に、破傷風予防接種歴がない場合や、最終予防接種から10年以上経過している場合(有効な防御抗体レベルを維持できていない可能性が高い)は、より強く疑う必要がある。近年、小児期の定期接種が不完全な10代での発症例の報告がある。
 
  1. 破傷風は先進国ではまれだが見逃すと致死的な感染症なので、早期診断が重要である。診断確定できる特異的な検査はないので、臨床症状から診断できるようにすべきである。なお、破傷風と診断した場合には、感染症法に則って保健所へ届出る義務がある(推奨度1O
  1. 先進国でまれなゆえに早期診断が困難で、初期には感冒や顎関節脱臼、脳卒中などと誤診されやすい。( >詳細情報 :鑑別疾患表 参照)
  1. 破傷風は、わが国では1950年には届け出患者数1,915人、死亡者数1,558人であり、致命率が高かった(81%)[1]
  1. 2000年代以降は、届出患者数毎年100人前後、死亡者数5~10人と報告されている(2008年:届出124人、死亡7例)[2]
  1. 1994年発表のSchonらの研究にあるように、英国で1991年までの8年間に届けられた116例のうち情報が得られた77例を検討した結果、発症日に入院:35%、発症から1~4日後に入院:45%、発症から5~7日後に入院:6%であった[3]
  1. 破傷風に特異的な検査はないので、臨床症状からの診断が重要である。
  1. CT、MRIは診断に有用ではない。
  1. 感染症法では5類に分類されており、全数報告対象疾患である。
  1. 届出基準によれば、臨床的特徴として、「外傷部位などで増殖した破傷風菌が産生する毒素により、運動神経終板、脊髄前角細胞、脳幹の抑制性の神経回路が遮断され、感染巣近傍の筋肉のこわばり、顎から頚部のこわばり、開口障害(trismus)、四肢の強直性けいれん、呼吸困難(けいれん性)、刺激に対する興奮性の亢進、反弓緊張(opisthotonus)など」の症状が挙げられている。
  1. これらの「筋硬直(rigidity;こわばり・開口障害)」、「有痛性の筋けいれん(spasm;脳神経細胞障害に起因するけいれんではない)」に「自律神経障害(autonomic instability)」を加えて3徴候ということがある。
  1. これらの特徴から臨床的に破傷風と診断(死亡例では検案)した医師は、法第12条第1項の規定による届出を7日以内に行わなければならない[4]
  1. 破傷風には、全身性(generalized)、局所性(localized)、脳神経性(cephalic)、新生児性(neonatal)の4つのタイプがある。
  1. cephalic tetanusでは、顔面神経麻痺など脱落症状が初期症状になることが多く注意を要する。
 
痙笑(risus sardonicus;口輪筋の硬直)

顔面筋のけいれんにより、ひきつった笑顔で眉が上がったままの特徴的表情が生じる。これを、RS(Risus sardonicus)という。

出典

img1:  Recurrent tetanus.
 
 Lancet. 2004 Jun 19;363(9426):2048. doi:・・・
 
わが国の破傷風届出患者数と死亡数の推移

1968年のDPT定期接種開始後、減少し、1980年代後半以降は横ばいである。

 
  1. 創部の細菌培養でC. tetaniが同定されなくても、破傷風は否定できない。したがって、C. tetaniの検出を目的としたルーチンの創部培養は推奨されない(推奨度3)
  1. 嫌気培養を行っても陰性であることが多く、一方で陽性であっても破傷風毒素(tetanospasmin)産生株かどうかは不明なため、診断には結びつかない[5]
 
病歴・診察のポイント  
  1. 約3割の症例で外傷歴がはっきりしない。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

F Schon, L O'Dowd, J White, N Begg
Tetanus: delay in diagnosis in England and Wales.
J Neurol Neurosurg Psychiatry. 1994 Aug;57(8):1006-7.
Abstract/Text A 7 day delay occurred in the diagnosis of cephalic tetanus in a 69 year old woman who developed an ipsilateral facial palsy 5 days after a facial laceration. Cranial nerve palsies often precede trismus in this form of tetanus.

PMID 8057093
Centers for Disease Control (CDC)
Tetanus--United States, 1985-1986.
MMWR Morb Mortal Wkly Rep. 1987 Jul 31;36(29):477-81.
Abstract/Text
PMID 3110578
Abstract/Text
PMID 6087697
J Simpson, A Inglis, M W G Gordon
Back pain as the presenting symptom of generalised tetanus.
Emerg Med J. 2007 Jan;24(1):e5. doi: 10.1136/emj.2006.041269.
Abstract/Text Back pain is a common presenting symptom in emergency departments and primary care across the UK. The extensive differential diagnosis includes mechanical, infective, thoracic, abdominal and vascular causes. This case report describes a patient who presented with lower back pain with a rare diagnosis, which is becoming more common in certain population groups, and emphasises the importance of clinical skills and insuring adequate tetanus prophylaxis.

PMID 17183029
J S Brauner, S R Rios Vieira, T P Bleck
Changes in severe accidental tetanus mortality in the ICU during two decades in Brazil.
Intensive Care Med. 2002 Jul;28(7):930-5. doi: 10.1007/s00134-002-1332-4. Epub 2002 May 28.
Abstract/Text INTRODUCTION: Tetanus is still a significant health hazard in developing countries, with high associated mortality.
OBJECTIVE: Describe the management of patients with severe tetanus in intensive care units (ICUs), in two different periods.
SETTING: ICUs of two general hospitals.
DESIGN: Concurrent cohort study.
METHODS: Follow-up of all patients hospitalized with the diagnosis of severe tetanus in the ICUs from October 1981 to March 2001. We collected data prospectively, regarding the site of injury, clinical features, frequent clinical and infectious complications, concomitant illnesses, and mortality. The patients were divided into two groups according to the treatment protocol used; before 1993 and after 1993.
RESULTS: There were 126 patients in group 1 (93 males) with a mean age of 39.0 +/- 18.8 years. There were 110 patients in group 2 (95 males) with a mean age of 48.4+/-17.8 years. Incubation period, onset period, and symptomatic period were higher in group 2 ( P < or = 0.02). The duration of neuromuscular junction blockade, benzodiazepine administration, mechanical ventilation, and ICU stay were longer in group 2, P < 0.001. Infectious complications were more frequent in group 2 ( P < 0.001). The mortality rate in group 1 was 36.5% and in group 2, 18.0% ( P = 0.002). Mortality was directly associated with symptomatic period, acute renal failure cardiac arrest and hypotension, and inversely associated with onset period in the multivariate analyses.
CONCLUSIONS: The reduced mortality in severe accidental tetanus patients in group 2 is probably related to advances in ICU management, despite the higher incidence of infectious complications, which are probably related to the longer ICU stay.

PMID 12122532
P Jolliet, J L Magnenat, T Kobel, J C Chevrolet
Aggressive intensive care treatment of very elderly patients with tetanus is justified.
Chest. 1990 Mar;97(3):702-5.
Abstract/Text Tetanus is now rare in industrialized countries, occurring mainly in elderly patients. To assess whether aggressive therapy of these patients in the intensive care unit is justified, we retrospectively studied all patients with tetanus hospitalized in our institution between 1968 and 1989. Patients over the age of 70 years fared as well as those under 70 years and recovered without sequelae. These results favor aggressive treatment of elderly patients with tetanus in the intensive care unit.

PMID 2306973
I Ahmadsyah, A Salim
Treatment of tetanus: an open study to compare the efficacy of procaine penicillin and metronidazole.
Br Med J (Clin Res Ed). 1985 Sep 7;291(6496):648-50.
Abstract/Text A prospective, open, non-randomised clinical trial was carried out to compare the efficacy of procaine penicillin with metronidazole in the treatment of moderate tetanus among 173 patients. Patients in the metronidazole group had a significantly lower mortality rate, a shorter stay in hospital, and an improved response to treatment. These results establish the value of antimicrobial treatment in the management of tetanus and show that metronidazole is more efficacious than penicillin in this respect.

PMID 3928066
N Saltoglu, Y Tasova, D Midikli, R Burgut, I H Dündar
Prognostic factors affecting deaths from adult tetanus.
Clin Microbiol Infect. 2004 Mar;10(3):229-33.
Abstract/Text The objective of this study was to determine prognostic factors related to death from adult tetanus. Fifty-three cases of tetanus, 25 females and 28 males, were treated in Cukurova University Hospital during 1994-2000. The mean age was 46.6 years. Forty-one (77.7%) patients came from rural areas. Most (64.1%) cases had minor trauma, but 19 (35.8%) had deep injuries. The mean incubation period was 11.5 days. Mortality was high (52.8%), caused by cardiac or respiratory failure or complications, and was related to the length of the incubation period. In cases with an incubation period < or = 7 days, the mortality rate was 75% (p 0.07). Mortality was significantly associated with generalised tetanus (p < 0.05), fever of > or = 40 degrees C, tachycardia of > 120 beats/min (p < 0.05), post-operative tetanus (p 0.03), and the absence of post-traumatic tetanus vaccination (p 0.068). Patients who were given tetanus human immunoglobulin or tetanus antiserum (p > 0.05) had similar outcomes. Patients who were given penicillin had a mortality rate similar to patients who were given metronidazole (p 0.15). The mortality rate was higher (92%) in patients with severe tetanus than in patients with moderate disease (53%). By multivariate analysis, the time to mortality caused by tetanus, and also the mortality rate, were both related significantly to age and tachycardia.

PMID 15008944
P A Blake, R A Feldman, T M Buchanan, G F Brooks, J V Bennett
Serologic therapy of tetanus in the United States, 1965-1971.
JAMA. 1976 Jan 5;235(1):42-4.
Abstract/Text To study the influence of tetanus antitoxins on the outcome of human tatanus, we analyzed data on 545 cases reported to the Center for Disease Control from 1965 through 1971. Patients treated with antitoxin had a significantly lower case-fatality ratio than untreated patients, and the effect of serotherapy was not modified significantly by the age or race of the subjects. Antitoxin of equine origin and human tetanus immune globulin (TIG) were equally effective. The data on the effect of different doses of TIG suggest that 500 units may be as effective as the currently recommended therapeutic dose of 3,000 to 10,000 units. The importance of possible bias introduced by unmeasured factors such as quality of supportive therapy could not be determined, but confounding by 11 recorded potentially confounding factors was minimal.

PMID 946000
J J Farrar, L M Yen, T Cook, N Fairweather, N Binh, J Parry, C M Parry
Tetanus.
J Neurol Neurosurg Psychiatry. 2000 Sep;69(3):292-301.
Abstract/Text
PMID 10945801
W Kapoor, P Carey, M Karpf
Induction of lactic acidosis with intravenous diazepam in a patient with tetanus.
Arch Intern Med. 1981 Jun;141(7):944-5.
Abstract/Text A patient with tetanus was treated with high-dose intravenous (IV) diazepam for control of muscular spasms. As the spasms were controlled with diazepam, lactic acidosis developed. The condition resolved on discontinuation of diazepam therapy and recurred with reinstitution of the drug. To our knowledge, lactic acidosis previously has not been associated with the use of high-dose IV diazepam.

PMID 7235819
C N Okoromah, F E A Lesi
Diazepam for treating tetanus.
Cochrane Database Syst Rev. 2004;(1):CD003954. doi: 10.1002/14651858.CD003954.pub2.
Abstract/Text BACKGROUND: Clinical management of the muscle spasms and rigidity of tetanus poses a difficult therapeutic problem to physicians everywhere, especially in resource poor countries. There are wide variations in therapeutic regimens commonly used in clinical practice due to uncertainties about effectiveness of conventional drugs. Diazepam compared to other drugs (eg phenobarbitone and chlorpromazine) may have advantages because of combined anticonvulsant, muscle relaxant, sedative and anxiolytic effects.
OBJECTIVES: To compare diazepam to other drugs in treating the muscle spasms and rigidity of tetanus in children and adults.
SEARCH STRATEGY: We searched the Cochrane Neonatal Group trials register (October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to October 2003), EMBASE (1980 to October 2003), LILACS (2003), CINAHL (October 2003), Science Citation Index, African Index Medicus, conference abstracts and reference lists of articles. We contacted researchers, experts and organizations working in the field and used personal communication.
SELECTION CRITERIA: Randomized and quasi-randomized controlled trials.
DATA COLLECTION AND ANALYSIS: We independently identified eligible trials, assessed trial methodological quality and extracted data.
MAIN RESULTS: Two studies met the inclusion criteria. Method of generation of allocation sequence, concealment of allocation and blinding were unclear in both studies. A total of 134 children were allocated to three treatment groups comprising diazepam alone, phenobarbitone and chlorpromazine, or phenobarbitone and chlorpromazine and diazepam.Meta-analysis of in-hospital deaths indicates that children treated with diazepam alone had a better chance of survival than those treated with combination of phenobarbitone and chlorpromazine (Relative Risk for death 0.36; 95% confidence interval 0.15 to 0.86; Risk Difference -0.22; 95% CI -0.38 to -0.06). Giving diazepam alone, or supplementing conventional anticonvulsants (phenobarbitone and chlorpromazine) with diazepam, was reported in one study to be associated with a statistically significantly milder clinical course and shorter duration of hospitalization.
REVIEWER'S CONCLUSIONS: Although there is evidence that diazepam alone compared with combination of phenobarbitone and chlorpromazine is more effective in treating tetanus, the small size, methodological limitations and lack of data on drug safety from available trials preclude definite conclusions to support change in current clinical practice. The application of the present evidence should be moderated by local needs and circumstances, pending the availability of more evidence. We recommend a large multicenter, randomized controlled trial which compares diazepam alone with combinations of other drugs (excluding diazepam).

PMID 14974046
A Borgeat, C Dessibourg, M Rochani, P M Suter
Sedation by propofol in tetanus--is it a muscular relaxant?
Intensive Care Med. 1991;17(7):427-9.
Abstract/Text We investigated the muscular relaxant properties of propofol in a 54 year-old-man with severe tetanus. Four consecutive boluses of propofol 50 mg i.v. were administered. Mean muscular activity recorded on an electromyography (EMG) decreased from 100 to 10-25 mV within 15 s after each bolus. EMG values were restored to prior levels 10 min after the last bolus. Maximum decrease of muscular activity was observed with propofol blood level between 2.90-3.20 micrograms.ml-1. Neuromuscular function recorded by means of evoked electromyography was not affected by propofol administration.

PMID 1774399
Abstract/Text A prospective observational study was conducted to examine the efficacy and safety of magnesium sulphate for control of spasms and autonomic dysfunction in 40 patients with tetanus. Magnesium was infused intravenously, aiming to control spasms despite suppression of patellar reflex or respiratory insufficiency. Spasms were controlled in 38 of the 40 patients within a serum Mg(2+) range of 2-4 mmol.l(-1) with only two patients needing additional neuromuscular blocking drugs. Seventeen of 24 patients (< 60 years) and six of 16 patients (> or = 60 years) did not require ventilatory support. Thirty-six patients were conscious and co-operative throughout their management. Sympathetic over-activity was controlled without supplementary sedation. Overall mortality was 12%; all five deaths were in patients > or = 60 years and no deaths were due to autonomic dysfunction. We recommend magnesium as possible first line therapy in the routine management of tetanus.

PMID 12133096
C L Thwaites, L M Yen, H T Loan, T T D Thuy, G E Thwaites, K Stepniewska, N Soni, N J White, J J Farrar
Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial.
Lancet. 2006 Oct 21;368(9545):1436-43. doi: 10.1016/S0140-6736(06)69444-0.
Abstract/Text BACKGROUND: The most common cause of death in individuals with severe tetanus in the absence of mechanical ventilation is spasm-related respiratory failure, whereas in ventilated patients it is tetanus-associated autonomic dysfunction. Our aim was to determine whether continuous magnesium sulphate infusion reduces the need for mechanical ventilation and improves control of muscle spasms and autonomic instability.
METHODS: We did a randomised, double blind, placebo controlled trial in 256 Vietnamese patients over age 15 years with severe tetanus admitted to the Hospital for Tropical Medicine, Ho Chi Minh City, Vietnam. Participants were randomly assigned magnesium sulphate (n=97) or placebo solution (n=98) intravenously for 7 days. The primary outcomes were requirement of assisted ventilation and of drugs to control muscle spasms and cardiovascular instability within the 7-day study period. Analyses were done by intention to treat. This trial is registered as an International Standard Randomised Clinical Trial, number ISRCTN74651862.
FINDINGS: No patients were lost to follow-up. There was no difference in requirement for mechanical ventilation between individuals treated with magnesium and those receiving placebo (odds ratio 0.71, 95% CI 0.36-1.40; p=0.324); survival was also much the same in the two groups. However, compared with the placebo group, patients receiving magnesium required significantly less midazolam (7.1 mg/kg per day [0.1-47.9] vs 1.4 mg/kg per day [0.0-17.3]; p=0.026) and pipecuronium (2.3 mg/kg per day [0.0-33.0] vs 0.0 mg/kg per day [0.0-14.8]; p=0.005) to control muscle spasms and associated tachycardia. Individuals receiving magnesium were 4.7 (1.4-15.9) times less likely to require verapamil to treat cardiovascular instability than those in the placebo group. The incidence of adverse events was not different between the groups.
INTERPRETATION: Magnesium infusion does not reduce the need for mechanical ventilation in adults with severe tetanus but does reduce the requirement for other drugs to control muscle spasms and cardiovascular instability.

PMID 17055945
S Anandaciva, C W Koay
Tetanus and rocuronium in the intensive care unit.
Anaesthesia. 1996 May;51(5):505-6.
Abstract/Text
PMID 8694180
Michael J Murray, Jay Cowen, Heidi DeBlock, Brian Erstad, Anthony W Gray, Ann N Tescher, William T McGee, Richard C Prielipp, Greg Susla, Judith Jacobi, Stanley A Nasraway, Philip D Lumb, Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians
Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.
Crit Care Med. 2002 Jan;30(1):142-56.
Abstract/Text
PMID 11902255
Charles G Durbin, Michael P Perkins, Lisa K Moores
Should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation?
Respir Care. 2010 Jan;55(1):76-87.
Abstract/Text Advances in treating the critically ill have resulted in more patients requiring prolonged airway intubation and respiratory support. If intubation is projected to be longer than several weeks, tracheostomy is often recommended. Tracheostomy offers the potential benefits of improved patient comfort, the ability to communicate, opportunity for oral feeding, and easier, safer nursing care. In addition, less need for sedation and lower airway resistance (than through an endotracheal tube) may facilitate the weaning process and shorten intensive care unit and hospital stay. By preventing microaspiration of secretions, tracheostomy might reduce ventilator-associated pneumonia. There is controversy, however, over the optimal timing of the procedure. While there have been many randomized controlled trials on tracheostomy timing, most were insufficiently powered to detect important differences, and systematic reviews and meta-analyses are limited by the heterogeneity of the primary studies. Based on the available data, we think it is reasonable to perform early tracheostomy in all patients projected to require prolonged mechanical ventilation. Unfortunately, identifying those patients can be difficult, and for many patient populations we lack the necessary tools to predict prolonged ventilation. We propose an early-tracheostomy decision algorithm.

PMID 20040126
M Pather, D Hariparsad, A G Wesley
Nasotracheal intubation versus tracheostomy for intermittent positive pressure ventilation in neonatal tetanus.
Intensive Care Med. 1985;11(1):30-2.
Abstract/Text Fifty-two neonates with tetanus who required muscle paralysis and IPPV were managed alternatively with naso-tracheal intubation or tracheostomy. The complications of the two techniques were compared. Planned extubation caused less problems in the intubated than in the tracheostomized children, and secondary infection occurred less often. Accidental extubation, however, was a significant hazard in the intubated child.

PMID 3881495
N Buchanan, L Smit, R D Cane, M De Andrade
Sympathetic overactivity in tetanus: fatality associated with propranolol.
Br Med J. 1978 Jul 22;2(6132):254-5.
Abstract/Text
PMID 678897
W W King, D R Cave
Use of esmolol to control autonomic instability of tetanus.
Am J Med. 1991 Oct;91(4):425-8.
Abstract/Text Tetanus is often accompained by autonomic instability, rendering hemodynamic management difficult. Death is frequently secondary to an inability to control this instability. A variety of modalities have been used to stabilize the cardiovascular system, but all are not ideal. Esmolol offers theoretical advantages over other modalities. We report a case of severe tetanus in which a continuous infusion of esmolol was effective in controlling the autonomic instability.

PMID 1683152
D A Rocke, A G Wesley, M Pather, A D Calver, D Hariparsad
Morphine in tetanus--the management of sympathetic nervous system overactivity.
S Afr Med J. 1986 Nov 22;70(11):666-8.
Abstract/Text Morphine was administered intravenously in bolus doses 6-hourly to 10 patients; 9 developed signs of sympathetic overactivity and required increased morphine dosage. The mean daily morphine dosage was 103 +/- 36 mg and the maximum daily dosage was 170 +/- 65 mg. In all cases morphine decreased the mean arterial blood pressure (mean 18%; P less than 0.01) and heart rate (mean 7%; P less than 0.01). In 7 cases the cardiac output fell minimally (mean 7%; P = 0.07), while the systemic vascular resistance decreased (mean 12%; P less than 0.01) in 8 cases. Nine patients survived, 1 died from renal failure and septicaemia. There were no apparent problems with either opiate withdrawal or addiction. No patient required either alpha- or beta-adrenergic blockers and the consequent simplified management constitutes a significant improvement in control of these patients.

PMID 3787380
M Lindley-Jones, D Lewis, J L Southgate
Recurrent tetanus.
Lancet. 2004 Jun 19;363(9426):2048. doi: 10.1016/S0140-6736(04)16455-6.
Abstract/Text
PMID 15207956
Shayesta Dhalla
Postsurgical tetanus.
Can J Surg. 2004 Oct;47(5):375-9.
Abstract/Text The incidence of tetanus declined dramatically in the 20th century owing to routine vaccination and prompt attention to wound care. Postsurgical tetanus is uncommon, with both exogenous and endogenous sources being responsible for disease. The majority of cases of postoperative tetanus have been observed after intra-abdominal surgery. Those at high risk for developing tetanus include immigrants, the elderly, injection drug users, patients with diabetes and people of Hispanic ethnicity. Although most patients with tetanus can recover if managed appropriately, prevention through active and passive immunization is the main goal. This paper reviews postsurgical tetanus and provides an approach to its prevention and treatment.

PMID 15540694

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