Survival depends on expert and constant nursing in an intensive care unit and may be necessary for weeks. Tracheostomy is a requisite in all patients with recurrent generalized tonic spasms and should not be delayed until apnea or cyanosis has occurred. The patient must be kept as quiet as possible to avoid stimulus-induced spasms. This requires a darkened, quiet room and the judicious use of sedation. The benzodiazepines are the most useful drugs for both sedation and muscle relaxation; diazepam 120 mg/d or more can be given in frequent divided doses if ventilatory support is available; alternatively, midazolam or propofol can be used in a continuous intravenous infusion. Short-acting barbiturates and chlorpromazine may also be useful, as may be morphine. Intrathecal baclofen and continuous atropine infusions have been used with success in severe cases, and intramuscular injections of botulinum toxin may be used for trismus and local spasm. The aim of therapy is to suppress muscle spasms and to keep the patient drowsy to avoid the horrible discomfort of the spasms. All treatments and manipulations should be kept to a minimum and coordinated so that the patient may be sedated beforehand.
Failure of these measures to control the tetanic paroxysms requires that intravenous administration of neuromuscular blocking agents such as pancuronium or vecuronium be used to abolish all muscle activity; appropriate sedative medication is instituted for as long as necessary, breathing being maintained by mechanical ventilation. Many intensive care units favor the use of neuromuscular paralytic drugs in all but the mildest cases. Further details concerning treatment can be found in the review by Farrar and colleagues.
All persons should be immunized against tetanus and receive a booster dose of toxoid every 10 years—a practice that is frequently neglected in the elderly. Injuries that carry a threat of tetanus should receive toxoid if the patient has not received a booster injection in the preceding year, and a second dose of toxoid is needed 6 weeks later. If the injured person has not received a booster injection since the original immunization, he should receive an injection of both toxoid and human antitoxin; the same applies to the injured person who has never been immunized. An attack of tetanus does not confer permanent immunity and persons who recover should be actively immunized.
Diphtheria, an acute infectious disease caused by
Corynebacterium diphtheriae, is now quite rare in the United States and Western Europe. The faucial-pharyngeal form of the disease, which is the most common clinical type, is characterized by the formation of an inflammatory exudate of the throat and trachea; at this site, the bacteria elaborate an exotoxin, which affects the heart and nervous system in approximately 20 percent of cases.