383
The response to vaccination too decrease with age (figs. 1 and 2). The reason for these findings remains
people.
appeared
to
lower incidence of lower case mortality.
a
bronchopneumonia
and thus
a
conjectural. 1
We thank Prof. R. E. O. Williams for editorial advice; the Epidemiological Research Laboratory, Colindale, for general support and supply of vaccine; the technical staff of the Cardiff
hormonal deterioration and alteration of lymphocytes with age are thought to operate. The usefulness of influenza vaccine in this age-group
Public Health Laboratory for their assistance; Dr Donald Anderson (late medical officer of health for Cardiff) and Dr Philip Revington (late medical officer of health for Glamorgan) and their staffs for cooperation; and Mr R. G. Newcombe for statistical advice.
Possibly immunological
senescence occurs
and tissue
response decreases with age. Certainly, Makinodan has found this effect in animals where such factors as
to assess because of some of the of the present study. Not only did the idea of a controlled trial prove unacceptable to the authorities at that time, but there were also difficulties in demonstrating that the respiratory illnesses were always influenzal in origin. Thus, despite all efforts, there was often a delay in notification so that the viraemic phase may have been over by the time swabs were taken. Again, in some cases there was a determined reluctance for further venesection by some patients so that specimens could not be taken. In addition, several patients developed bronchopneumonia (occasionally fatal) with few preliminary upperrespiratory symptoms before investigations could be started. Notwithstanding these limitations the vaccinated group did indeed have a better experience than the unvaccinated, particularly with regard to bronchopneumonia and mortality. In the absence of any other detectable factor which could have accounted for this difference, therefore, it seems reasonable to attribute it to the vaccination. Thus, it appears that there is some justification for the official advice to give vaccine in this age-group. Before vaccination there may be a low antibody level, so presumably resistance to infection is small. After vaccination a serological response can be expected in the majority, although the magnitude of this response may be smaller than in younger subjects. Finally, and most importantly, the giving of vaccine may result in
is
more
difficult
special problems
REFERENCES 1.
Makinodan, T. in Tolerance, Autoimmunity and Aging (compiled and edited by M. M. Sigel and R. A. Good). Springfield, Illinois, 1972.
Howells, C. H. L., Evans, A. D., Vesselinova-Jenkins, C. Lancet, 1973, i, 1436. 3. Hoskins, T. W., Davies, Joan R., Allchin, A., Miller, Christine L., Pollock, T. M. ibid. 1973, ii, 116.
2.
Occasional
Survey
TETANUS IN HAITI FLORENCE N. MARSHALL* MULLER J. GARNIER KENNETH J. DAVISON † FRANK J. LEPREAU, JR. &Dag er; Departments of Anesthesia, Pediatrics, and Surgery,
Hôpital Albert Schweitzer, Deschapelles, Haiti
1958-72, 985 cases of tetanus (excluding tetanus of the newborn) were admitted to a hospital in Haiti. Mortality was 22 %, and in later years (1966-72) mortality fell. During this period the dosage of tetanus antitoxin was lowered to 10,000 units and, for sedation, diazepam has satisfactorily replaced multiple-drug regimens used in earlier years. However, good nursing, including close attention to breathing, is probably the most important item in treatment. As a result of a programme of maternal immunisation, admissions for neonatal tetanus have fallen, and mortality for this condition has been reduced to 26%. Sum ary
In
INTRODUCTION
Hopital Albert Schweitzer is a general charity hospital of 162 beds which has often had 2 or 3 children in a bed. In 1972 we had 74,570 outpatient visits, excluding those coming for immunisation. The hospital serves primarily a district of 90,000-100,000 people in 110 square miles of the Artibonite Valley which extends inland from St. Marc, but tetanus patients come from beyond this area. PATIENTS
We have analysed all 985 cases of tetanus seen since the hospital opened in 1957, paying special attention to the 663 cases treated in the seven years 1966-72. Of the entire group, 64% were children with 19% mortality and 36% were adults with 29% mortality. Few adults were over fifty years of age; the oldest was eightyone. Most patients were slender, muscular, and in good general health before their tetanus. Of the 663 cases
Fig. 2-Geometric mean titre of H.I. level to influenza A (N) and B (8) among 900 inhabitants of Cardiff before and after vaccination.
* Present address: 312 Greenwich Street, Hempstead, N.Y. 11550. &dag er; Present address: Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts 02109. ‡ Present address: Frontier Nursing Service, Hyden, Leslie County, Kentucky 41749.
384 studied from 1966 to 1972, 63% were male and 37% female. Only 54% of these had a recognisable wound, and 32% of the wounds were on the feet. The common signs and symptoms of tetanus are trismus, local or generalised muscle stiffness, convulsions, opisthotonos, and fever-in that order of frequency. The illness is often recognised promptly by friends or relatives, and the patient is on his way to hospital within twentyfour hours of the first symptom, the journey taking not more than twelve hours. All patients seen in 1966-72 have been graded according to the following criteria:
were
Mild.-Some trismus; no spontaneous convulsions (convulsions when they do occur are rare and of short duration); no opisthotonos. 236 patients; 3% mortality. Moderate.-Trismus; convulsions; spontaneous opisthotonos. 214 patients; 14% mortality. Severe.-Severe trismus; long and frequent convulsions ; respiratory distress, or apnoea, or cardiac arrest. 213 patients; 51% mortality. Seizure activity and respiratory distress often got much worse in the first two days. Over 50% of the patients who died from tetanus did so in the first three days after admission to hospital, and over 80% of the deaths happened in the first week. Death associated with complications of tetanus happened later in the course of illness. If a patient had improved at the end of a week, he had a good chance for survival, and deaths after that time were usually due to a preventable situation-most often inadequate observation, inappropriate sedation, or airway problems. TREATMENT
Personnel No patients have been " specialed ". One registered nurse is in charge of the 6 beds in the tetanus room as well as the 20-bed adult medical ward. The tetanus room is covered by one nurses’ aide with no more than an 8th grade education. When the room is not fully occupied with tetanus patients, a sick cardiac or eclamptic patient may be put there. Nursing care is vital, and our results would be better if we could consistently provide trained intelligent bedside care. We have trained a small cadre of nurses’ aides assigned to the tetanus room. These girls give general care and pay special attention to the comfort of the individual which can make the difference between relaxation and frequent spasms. They can recognise when additional sedation is required, and they are reasonably skilled in resuscitative techniques with the Ambu bag and external cardiac massage; they are alert to the need for suctioning in a clean and careful manner. Constant observation is the key. The tetanus room is both noisy and light. It is equipped with an Ambu bag, oxygen, airways, endotracheal tubes, laryngoscopes, drugs, and suction machines.
General Care Patients are not allowed to eat or drink until we determine their tolerance of oral intake. Penicillin is given for the first seven days. If voiding is poor, a Foley catheter is inserted for comfort and to record output. Urinary infection from indwelling catheters has not been a problem. Many changes of sheets are unwarranted in tetanus care. Patients are turned on alternate sides every two to four hours, encouraging drainage of secretions and lessening the risk of decubitus ulcers.
Wounds antitoxin is
cleaned, debrided, and drained; injected around the wound. are
no
Tetanus Antitoxin
40,000 to 100,000 units (T.A.T.). Beginning in 1968 we lowered gradually dosages, and 10,000 units has been
In the early years of tetanus antitoxin
we
gave
standard since 1970. Table i shows that this dosage has not adversely affected our mortality. Allergic reactions were very rare. So that it is not forgotten, active immunisation is begun on admission and continued after discharge. Tetanus confers no immunity.
Sedation We have used
barbiturates, chlorpromazine, mephenesin, meprobamate, and methocarbamol. In 1967 we began using diazepam alternating with pentobarbitone sodium as the anticonvulsants in all patients over six years of age, and since 1969 diazepam has been used alone in almost every case. Moderately and severely ill patients are given intramuscular or intravenous diazepam immediately on admission. For maintenance
the
usual dose is 4-10
mg.
intra-
muscularly at intervals of one hour or more. A few patients received it every thirty minutes and several received i.v. increments between intramuscular doses. Table 11 shows that sedation with diazepam alone has not adversely affected mortality.
Airway Management and Tracheostomy At the first sign of mucus accumulation,
we
apply
and mouth and continue suctioning as necessary through the mouth because nasal bleeding can be serious. An oral airway reduces the vapour to
the
nose
TABLE I-T.A.T. DOSAGE REDUCTION IN RELATION TO MORTALITYRATE
*
complete the total of 663 cases, 21 other dosages.
To
cases
had
no T.A.T.
and 22 had
TABLE 11-CHANGES IN SEDATION IN RELATION TO MORTALITY-RATE
*
An additional 24
cases
received combinations
of other medications
385
incidence of tongue-biting. Oral or nasal endotracheal tubes are not used. Indications for tracheostomy are inefficient suctioning, inadequate airway, and fear of impending cardio-
TABLE III-MORTALITY YEARS
1958-72
pulmonary arrest due to anoxia during prolonged convulsions. Tracheostomy is done under general anxsthesia with the patient intubated. A respiratory arrest may be prevented by close observation with the indications for tracheostomy clearly in mind. The mortality increases if tracheoin 84 cases where tracheostomy patients (44%) died compared with of 29 patients whose arrest preceded
stomy is
delayed:
preceded 16 (55%)
arrest out
37
tracheostomy. Few arrests occurred after tracheostomy, despite the severity of disease, because secretions no longer accumulated to irritate or block the larynx, and the undesirable stimulation of frequent oropharyngeal suctioning was eliminated. There were 3 deaths associated with the 113 tracheostomies ; these were due to a tracheostomy tube plugged with dried blood, blood-clots in both bronchi, and tracheooesophageal fistula. Of the 13 non-fatal complications 5 patients had anterior and posterior erosion of the tracheal mucosa seen at necropsy but not the of death; 3 patients had the tracheostomy tube placed too low; in 2 patients the tube was difficult to remove; in 1 patient the tube twice became badly plugged with mucus; 1 patient had a wound infection ; 1 patient had a tracheal stenosis. We did not use pliable plastic tubes in this series, but are now using them with satisfaction. In children it is best to leave the tracheostomy tube in place until opisthotonos is minimal or gone.
cause
Gastrostomy The report of Femi-Pearse and Sodipo showing a in 80 consecutive patients1 stimulated
mortality of 16 %
add a gastrostomy whenever we did a tracheostomy. Nutrition can be better maintained and the Theirritation of a nasogastric tube is avoided. is less has and there patient already airway problems, likelihood of regurgitation and aspiration with gastrostomy. In 2 children the skin suture around the gastrostomy tube cut through, so the Foley balloon prolapsed through the pylorus causing duodenal obstruction. Traction on the catheter replaced it in the stomach. 1 Foley tube was plugged with an ascarid worm. There were 4 dehiscences. There have been no other complications in 44 consecutive gastrostomies.
us to
RESULTS
The annual mortality has dropped slightly concomitant with fewer patients, better nursing care, the use of diazepam alone, and the reduction in antitoxin dose to 10,000 units (table III). DISCUSSION
produce statistical proof we are convinced that constant intelligent bedside care is the single most important part of treatment and has reduced our mortality. Rey in Dakar reported a mortality of 26 % in 413 patients treated in 1963-64-a formidable number to be cared for by a small staff, which included relatives.2 At the University Hospital Although
we cannot
I Among children (630) the mortality-rate was 19% compared with 26% among 355 adults.
in Kingston, Jamaica, Back has provided round-theclock high-grade bedside care and in 1971 reported only 1 death in 50 consecutive children treated. This was over a period of thirteen years, so there was never at any one time a large number of patients.3 Intelligent bedside nursing means good airway and The decision to perform a tracheostomy care. tracheostomy depends on whether or not it can be properly managed. Tracheostomy can be life-saving, and makes for easier resuscitation, but without good care it is a disaster. Even more skilled attention is required if one uses a respirator. We used a Bird in 3 cases, probably saving the life of 1 boy, but in general it proved too much for our staff. Oxygen in severe cases has been helpful. In 1964 Weinberg first reported using diazepam with success in tetanus 44 Judicious use of any type of sedation in tetanus comes only with experience in learning to appreciate the narrow margin between too much and too little. Diazepam is satisfactory and has two advantages: it is much easier to learn the use of one drug rather than multiple drugs, and diazepam can be given by mouth or by i.v. or i.m.
injection. Patel’s report in 1967 prompted us to use a standard dose of 10,000 units of T.A.T. when our own experience was also indicating smaller amounts.5 We are now confident that 10,000 units is adequate. Of the 21 patients who did not receive T.A.T., 7 died, but these numbers are too small to prove anything, and 2 of the 21 were mild cases. We have no experience with human tetanus hyperimmune globulin (T.I.G.H.) except in a few babies. Our percentage of mild, moderate, and severe cases has remained the same, about a third in each category. As in other series the mortality is highest in the severe group. Because there is often rapid progression from mild to severe tetanus, we emphasise the need for careful observation of even the mildest case. Severity is not related to the presence of a wound. In 1968 our community health department, under Dr Warren Berggren, began a mass immunisation programme using chiefly non-professionals and the jet injector.6 In five years more than 266,000 people in and around our " district " were immunised with two or three toxoid shots. Admissions for neonatal tetanus immediately dropped sharply, and this benefit should continue for at least five years after the mother’s immunisation. Admissions of children and adults with tetanus have continued to decrease.
386 NEONATAL TETANUS
Between September, 1957, and May, 1966, 2198 cases of neonatal tetanus were treated at Hopital Albert Schweitzer with a mortality of z In 1967 461 cases were admitted, and our facilities were greatly overstrained; mortality rose to 57%. Since that time there has been a steady drop in mortality to 26 % in 1972. The number of admissions fell to less than one-fifth of that in the peak year, 1967 (table iv). TABLE IV-MORTALITY IN NEONATAL TETANUS
Point of View HÆMODYNAMIC SETTING OF ESSENTIAL HYPERTENSION AS A GUIDE TO MANAGEMENT W. H. BIRKENHÄGER G. KOLSTERS A. WESTER
T. L. KHO M. A. SCHALEKAMP G. A. ZAAL
Department of Internal Medicine, Zuiderziekenhuis, Rotterdam, Netherlands ALTHOUGH the mechanism of essential hypertension be studied from many angles, all converge on a basic disorder-disproportion between the " filling " of the arterial system and the internal diameter of the arterioles. It is not practicable to measure these two variables in hypertensive patients: the nearest approach is to determine cardiac output as an indicator of arterial-system filling and to calculate total peripheral vascular resistance (from mean arterial pressure and cardiac output) as a reflection of arteriolar " tone ". There are objections to the use of total peripheral vascular resistance as a measure of the tone of the arteriolar wall: firstly, it is not calculated independently, being partly derived from its haemodynamic counterpart the cardiac output; secondly, it is a can
The smaller number of cases has allowed better individual care, and this, more than any other factor, has increased survival. A vigorous programme for immunisation of pregnant women has been responsible for reducing the disease by providing passive protection for the infants. Most cases now come from outside the hospital district. Therapy consisted of T.A.T., penicillin, and a sedative-relaxant combination of phenobarbitone, chlorpromazine, and mephenesin. Pentobarbitone injections were given as needed for severe seizures. Since April, 1972, no sedation or relaxant other than diazepam has been used in the newborn, and the mortality has remained the same. Feedings and drugs are given by nasogastric tube. No tracheostomies nor endotracheal intubations have been done in this series of 3696 cases. Until mid-1966, equine T.A.T. 80,000 units i.m. was our standard dose. Subsequent reductions to 50,000 units, then to 20,000 units, were given adequate trials. Since mid-1969 the standard dose has been 10,000 units.This appears satisfactory, and has caused no significant reactions. For designated periods over the last three years we have used human tetanus hyperimmune globulin (T.I.G.H.) in controlled studies, 500 units of which seemed no more effective than 10,000 units of equine antiserum. Final analysis of data on a trial of 1500 units of the T.I.G.H. is not yet available, but the higher dosage seems to offer no advantage in the therapy of
heterogeneous entity, reflecting changes all along different vascular
trees.
Still, for investigating
the
newborns.s Requests for reprints should be addressed
to
M. J. G.
REFERENCES 1. 2.
3. 4.
5. 6. 7. 8.
Pemi-Pearse, D., Sodipo, J. O., Jr. W. Afr. med. J. 1967, 16, 155. Rey, M., Mar, I. D. in Principles on Tetanus (edited by L. Eckman); p. 501. Bern, 1967. Back, E. H. W. Indian med. J. 1971, 20, 111. Weinberg, W. A. Clin. Pediat. 1964, 3, 226. Patel, J. C., Mehta, B. C. in Principles on Tetanus (edited by L. Eckman); p. 471. Bern, 1967. Berggren, W. L. Bull. Pan. Am. Hlth Org. 1974, 8, 24. Marshall, F. N. in Advances in Pediatrics (edited by S. Z. Levine); p. 65. Chicago, 1968. McCraken, G. M., Jr, Dowell, D. L., Marshall, F. N. Lancet, 1971, i, 1146.
(dyne’s sec. em- 11.73 m )j Fig. 1-Distribution of cardiac output and total peripheral resistance in patients with essential hypertension. Open circles represent effects of 300 ml. 5% saline i.v. Hatched area: normotensive range (mean arterial pressure up to 95 mm.
Hg).
The response to vaccination too decrease with age (figs. 1 and 2). The reason for these findings remains
people.
appeared
to
lower incidence of lower case mortality.
a
bronchopneumonia
and thus
a
conjectural. 1
We thank Prof. R. E. O. Williams for editorial advice; the Epidemiological Research Laboratory, Colindale, for general support and supply of vaccine; the technical staff of the Cardiff
hormonal deterioration and alteration of lymphocytes with age are thought to operate. The usefulness of influenza vaccine in this age-group
Public Health Laboratory for their assistance; Dr Donald Anderson (late medical officer of health for Cardiff) and Dr Philip Revington (late medical officer of health for Glamorgan) and their staffs for cooperation; and Mr R. G. Newcombe for statistical advice.
Possibly immunological
senescence occurs
and tissue
response decreases with age. Certainly, Makinodan has found this effect in animals where such factors as
to assess because of some of the of the present study. Not only did the idea of a controlled trial prove unacceptable to the authorities at that time, but there were also difficulties in demonstrating that the respiratory illnesses were always influenzal in origin. Thus, despite all efforts, there was often a delay in notification so that the viraemic phase may have been over by the time swabs were taken. Again, in some cases there was a determined reluctance for further venesection by some patients so that specimens could not be taken. In addition, several patients developed bronchopneumonia (occasionally fatal) with few preliminary upperrespiratory symptoms before investigations could be started. Notwithstanding these limitations the vaccinated group did indeed have a better experience than the unvaccinated, particularly with regard to bronchopneumonia and mortality. In the absence of any other detectable factor which could have accounted for this difference, therefore, it seems reasonable to attribute it to the vaccination. Thus, it appears that there is some justification for the official advice to give vaccine in this age-group. Before vaccination there may be a low antibody level, so presumably resistance to infection is small. After vaccination a serological response can be expected in the majority, although the magnitude of this response may be smaller than in younger subjects. Finally, and most importantly, the giving of vaccine may result in
is
more
difficult
special problems
REFERENCES 1.
Makinodan, T. in Tolerance, Autoimmunity and Aging (compiled and edited by M. M. Sigel and R. A. Good). Springfield, Illinois, 1972.
Howells, C. H. L., Evans, A. D., Vesselinova-Jenkins, C. Lancet, 1973, i, 1436. 3. Hoskins, T. W., Davies, Joan R., Allchin, A., Miller, Christine L., Pollock, T. M. ibid. 1973, ii, 116.
2.
Occasional
Survey
TETANUS IN HAITI FLORENCE N. MARSHALL* MULLER J. GARNIER KENNETH J. DAVISON † FRANK J. LEPREAU, JR. &Dag er; Departments of Anesthesia, Pediatrics, and Surgery,
Hôpital Albert Schweitzer, Deschapelles, Haiti
1958-72, 985 cases of tetanus (excluding tetanus of the newborn) were admitted to a hospital in Haiti. Mortality was 22 %, and in later years (1966-72) mortality fell. During this period the dosage of tetanus antitoxin was lowered to 10,000 units and, for sedation, diazepam has satisfactorily replaced multiple-drug regimens used in earlier years. However, good nursing, including close attention to breathing, is probably the most important item in treatment. As a result of a programme of maternal immunisation, admissions for neonatal tetanus have fallen, and mortality for this condition has been reduced to 26%. Sum ary
In
INTRODUCTION
Hopital Albert Schweitzer is a general charity hospital of 162 beds which has often had 2 or 3 children in a bed. In 1972 we had 74,570 outpatient visits, excluding those coming for immunisation. The hospital serves primarily a district of 90,000-100,000 people in 110 square miles of the Artibonite Valley which extends inland from St. Marc, but tetanus patients come from beyond this area. PATIENTS
We have analysed all 985 cases of tetanus seen since the hospital opened in 1957, paying special attention to the 663 cases treated in the seven years 1966-72. Of the entire group, 64% were children with 19% mortality and 36% were adults with 29% mortality. Few adults were over fifty years of age; the oldest was eightyone. Most patients were slender, muscular, and in good general health before their tetanus. Of the 663 cases
Fig. 2-Geometric mean titre of H.I. level to influenza A (N) and B (8) among 900 inhabitants of Cardiff before and after vaccination.
* Present address: 312 Greenwich Street, Hempstead, N.Y. 11550. &dag er; Present address: Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts 02109. ‡ Present address: Frontier Nursing Service, Hyden, Leslie County, Kentucky 41749.
384 studied from 1966 to 1972, 63% were male and 37% female. Only 54% of these had a recognisable wound, and 32% of the wounds were on the feet. The common signs and symptoms of tetanus are trismus, local or generalised muscle stiffness, convulsions, opisthotonos, and fever-in that order of frequency. The illness is often recognised promptly by friends or relatives, and the patient is on his way to hospital within twentyfour hours of the first symptom, the journey taking not more than twelve hours. All patients seen in 1966-72 have been graded according to the following criteria:
were
Mild.-Some trismus; no spontaneous convulsions (convulsions when they do occur are rare and of short duration); no opisthotonos. 236 patients; 3% mortality. Moderate.-Trismus; convulsions; spontaneous opisthotonos. 214 patients; 14% mortality. Severe.-Severe trismus; long and frequent convulsions ; respiratory distress, or apnoea, or cardiac arrest. 213 patients; 51% mortality. Seizure activity and respiratory distress often got much worse in the first two days. Over 50% of the patients who died from tetanus did so in the first three days after admission to hospital, and over 80% of the deaths happened in the first week. Death associated with complications of tetanus happened later in the course of illness. If a patient had improved at the end of a week, he had a good chance for survival, and deaths after that time were usually due to a preventable situation-most often inadequate observation, inappropriate sedation, or airway problems. TREATMENT
Personnel No patients have been " specialed ". One registered nurse is in charge of the 6 beds in the tetanus room as well as the 20-bed adult medical ward. The tetanus room is covered by one nurses’ aide with no more than an 8th grade education. When the room is not fully occupied with tetanus patients, a sick cardiac or eclamptic patient may be put there. Nursing care is vital, and our results would be better if we could consistently provide trained intelligent bedside care. We have trained a small cadre of nurses’ aides assigned to the tetanus room. These girls give general care and pay special attention to the comfort of the individual which can make the difference between relaxation and frequent spasms. They can recognise when additional sedation is required, and they are reasonably skilled in resuscitative techniques with the Ambu bag and external cardiac massage; they are alert to the need for suctioning in a clean and careful manner. Constant observation is the key. The tetanus room is both noisy and light. It is equipped with an Ambu bag, oxygen, airways, endotracheal tubes, laryngoscopes, drugs, and suction machines.
General Care Patients are not allowed to eat or drink until we determine their tolerance of oral intake. Penicillin is given for the first seven days. If voiding is poor, a Foley catheter is inserted for comfort and to record output. Urinary infection from indwelling catheters has not been a problem. Many changes of sheets are unwarranted in tetanus care. Patients are turned on alternate sides every two to four hours, encouraging drainage of secretions and lessening the risk of decubitus ulcers.
Wounds antitoxin is
cleaned, debrided, and drained; injected around the wound. are
no
Tetanus Antitoxin
40,000 to 100,000 units (T.A.T.). Beginning in 1968 we lowered gradually dosages, and 10,000 units has been
In the early years of tetanus antitoxin
we
gave
standard since 1970. Table i shows that this dosage has not adversely affected our mortality. Allergic reactions were very rare. So that it is not forgotten, active immunisation is begun on admission and continued after discharge. Tetanus confers no immunity.
Sedation We have used
barbiturates, chlorpromazine, mephenesin, meprobamate, and methocarbamol. In 1967 we began using diazepam alternating with pentobarbitone sodium as the anticonvulsants in all patients over six years of age, and since 1969 diazepam has been used alone in almost every case. Moderately and severely ill patients are given intramuscular or intravenous diazepam immediately on admission. For maintenance
the
usual dose is 4-10
mg.
intra-
muscularly at intervals of one hour or more. A few patients received it every thirty minutes and several received i.v. increments between intramuscular doses. Table 11 shows that sedation with diazepam alone has not adversely affected mortality.
Airway Management and Tracheostomy At the first sign of mucus accumulation,
we
apply
and mouth and continue suctioning as necessary through the mouth because nasal bleeding can be serious. An oral airway reduces the vapour to
the
nose
TABLE I-T.A.T. DOSAGE REDUCTION IN RELATION TO MORTALITYRATE
*
complete the total of 663 cases, 21 other dosages.
To
cases
had
no T.A.T.
and 22 had
TABLE 11-CHANGES IN SEDATION IN RELATION TO MORTALITY-RATE
*
An additional 24
cases
received combinations
of other medications
385
incidence of tongue-biting. Oral or nasal endotracheal tubes are not used. Indications for tracheostomy are inefficient suctioning, inadequate airway, and fear of impending cardio-
TABLE III-MORTALITY YEARS
1958-72
pulmonary arrest due to anoxia during prolonged convulsions. Tracheostomy is done under general anxsthesia with the patient intubated. A respiratory arrest may be prevented by close observation with the indications for tracheostomy clearly in mind. The mortality increases if tracheoin 84 cases where tracheostomy patients (44%) died compared with of 29 patients whose arrest preceded
stomy is
delayed:
preceded 16 (55%)
arrest out
37
tracheostomy. Few arrests occurred after tracheostomy, despite the severity of disease, because secretions no longer accumulated to irritate or block the larynx, and the undesirable stimulation of frequent oropharyngeal suctioning was eliminated. There were 3 deaths associated with the 113 tracheostomies ; these were due to a tracheostomy tube plugged with dried blood, blood-clots in both bronchi, and tracheooesophageal fistula. Of the 13 non-fatal complications 5 patients had anterior and posterior erosion of the tracheal mucosa seen at necropsy but not the of death; 3 patients had the tracheostomy tube placed too low; in 2 patients the tube was difficult to remove; in 1 patient the tube twice became badly plugged with mucus; 1 patient had a wound infection ; 1 patient had a tracheal stenosis. We did not use pliable plastic tubes in this series, but are now using them with satisfaction. In children it is best to leave the tracheostomy tube in place until opisthotonos is minimal or gone.
cause
Gastrostomy The report of Femi-Pearse and Sodipo showing a in 80 consecutive patients1 stimulated
mortality of 16 %
add a gastrostomy whenever we did a tracheostomy. Nutrition can be better maintained and the Theirritation of a nasogastric tube is avoided. is less has and there patient already airway problems, likelihood of regurgitation and aspiration with gastrostomy. In 2 children the skin suture around the gastrostomy tube cut through, so the Foley balloon prolapsed through the pylorus causing duodenal obstruction. Traction on the catheter replaced it in the stomach. 1 Foley tube was plugged with an ascarid worm. There were 4 dehiscences. There have been no other complications in 44 consecutive gastrostomies.
us to
RESULTS
The annual mortality has dropped slightly concomitant with fewer patients, better nursing care, the use of diazepam alone, and the reduction in antitoxin dose to 10,000 units (table III). DISCUSSION
produce statistical proof we are convinced that constant intelligent bedside care is the single most important part of treatment and has reduced our mortality. Rey in Dakar reported a mortality of 26 % in 413 patients treated in 1963-64-a formidable number to be cared for by a small staff, which included relatives.2 At the University Hospital Although
we cannot
I Among children (630) the mortality-rate was 19% compared with 26% among 355 adults.
in Kingston, Jamaica, Back has provided round-theclock high-grade bedside care and in 1971 reported only 1 death in 50 consecutive children treated. This was over a period of thirteen years, so there was never at any one time a large number of patients.3 Intelligent bedside nursing means good airway and The decision to perform a tracheostomy care. tracheostomy depends on whether or not it can be properly managed. Tracheostomy can be life-saving, and makes for easier resuscitation, but without good care it is a disaster. Even more skilled attention is required if one uses a respirator. We used a Bird in 3 cases, probably saving the life of 1 boy, but in general it proved too much for our staff. Oxygen in severe cases has been helpful. In 1964 Weinberg first reported using diazepam with success in tetanus 44 Judicious use of any type of sedation in tetanus comes only with experience in learning to appreciate the narrow margin between too much and too little. Diazepam is satisfactory and has two advantages: it is much easier to learn the use of one drug rather than multiple drugs, and diazepam can be given by mouth or by i.v. or i.m.
injection. Patel’s report in 1967 prompted us to use a standard dose of 10,000 units of T.A.T. when our own experience was also indicating smaller amounts.5 We are now confident that 10,000 units is adequate. Of the 21 patients who did not receive T.A.T., 7 died, but these numbers are too small to prove anything, and 2 of the 21 were mild cases. We have no experience with human tetanus hyperimmune globulin (T.I.G.H.) except in a few babies. Our percentage of mild, moderate, and severe cases has remained the same, about a third in each category. As in other series the mortality is highest in the severe group. Because there is often rapid progression from mild to severe tetanus, we emphasise the need for careful observation of even the mildest case. Severity is not related to the presence of a wound. In 1968 our community health department, under Dr Warren Berggren, began a mass immunisation programme using chiefly non-professionals and the jet injector.6 In five years more than 266,000 people in and around our " district " were immunised with two or three toxoid shots. Admissions for neonatal tetanus immediately dropped sharply, and this benefit should continue for at least five years after the mother’s immunisation. Admissions of children and adults with tetanus have continued to decrease.
386 NEONATAL TETANUS
Between September, 1957, and May, 1966, 2198 cases of neonatal tetanus were treated at Hopital Albert Schweitzer with a mortality of z In 1967 461 cases were admitted, and our facilities were greatly overstrained; mortality rose to 57%. Since that time there has been a steady drop in mortality to 26 % in 1972. The number of admissions fell to less than one-fifth of that in the peak year, 1967 (table iv). TABLE IV-MORTALITY IN NEONATAL TETANUS
Point of View HÆMODYNAMIC SETTING OF ESSENTIAL HYPERTENSION AS A GUIDE TO MANAGEMENT W. H. BIRKENHÄGER G. KOLSTERS A. WESTER
T. L. KHO M. A. SCHALEKAMP G. A. ZAAL
Department of Internal Medicine, Zuiderziekenhuis, Rotterdam, Netherlands ALTHOUGH the mechanism of essential hypertension be studied from many angles, all converge on a basic disorder-disproportion between the " filling " of the arterial system and the internal diameter of the arterioles. It is not practicable to measure these two variables in hypertensive patients: the nearest approach is to determine cardiac output as an indicator of arterial-system filling and to calculate total peripheral vascular resistance (from mean arterial pressure and cardiac output) as a reflection of arteriolar " tone ". There are objections to the use of total peripheral vascular resistance as a measure of the tone of the arteriolar wall: firstly, it is not calculated independently, being partly derived from its haemodynamic counterpart the cardiac output; secondly, it is a can
The smaller number of cases has allowed better individual care, and this, more than any other factor, has increased survival. A vigorous programme for immunisation of pregnant women has been responsible for reducing the disease by providing passive protection for the infants. Most cases now come from outside the hospital district. Therapy consisted of T.A.T., penicillin, and a sedative-relaxant combination of phenobarbitone, chlorpromazine, and mephenesin. Pentobarbitone injections were given as needed for severe seizures. Since April, 1972, no sedation or relaxant other than diazepam has been used in the newborn, and the mortality has remained the same. Feedings and drugs are given by nasogastric tube. No tracheostomies nor endotracheal intubations have been done in this series of 3696 cases. Until mid-1966, equine T.A.T. 80,000 units i.m. was our standard dose. Subsequent reductions to 50,000 units, then to 20,000 units, were given adequate trials. Since mid-1969 the standard dose has been 10,000 units.This appears satisfactory, and has caused no significant reactions. For designated periods over the last three years we have used human tetanus hyperimmune globulin (T.I.G.H.) in controlled studies, 500 units of which seemed no more effective than 10,000 units of equine antiserum. Final analysis of data on a trial of 1500 units of the T.I.G.H. is not yet available, but the higher dosage seems to offer no advantage in the therapy of
heterogeneous entity, reflecting changes all along different vascular
trees.
Still, for investigating
the
newborns.s Requests for reprints should be addressed
to
M. J. G.
REFERENCES 1. 2.
3. 4.
5. 6. 7. 8.
Pemi-Pearse, D., Sodipo, J. O., Jr. W. Afr. med. J. 1967, 16, 155. Rey, M., Mar, I. D. in Principles on Tetanus (edited by L. Eckman); p. 501. Bern, 1967. Back, E. H. W. Indian med. J. 1971, 20, 111. Weinberg, W. A. Clin. Pediat. 1964, 3, 226. Patel, J. C., Mehta, B. C. in Principles on Tetanus (edited by L. Eckman); p. 471. Bern, 1967. Berggren, W. L. Bull. Pan. Am. Hlth Org. 1974, 8, 24. Marshall, F. N. in Advances in Pediatrics (edited by S. Z. Levine); p. 65. Chicago, 1968. McCraken, G. M., Jr, Dowell, D. L., Marshall, F. N. Lancet, 1971, i, 1146.
(dyne’s sec. em- 11.73 m )j Fig. 1-Distribution of cardiac output and total peripheral resistance in patients with essential hypertension. Open circles represent effects of 300 ml. 5% saline i.v. Hatched area: normotensive range (mean arterial pressure up to 95 mm.
Hg).
