Case 1

A 55-year-old famer attends the emergency department four days after a laceration to her right hand. She describes onset of stiffness in her jaw before going to bed the following evening and awakening with stiffness and intermittent painful spasms in her back and upper arms on the day of presentation. She is normally fit and well, with no recent illness and no medications taken. Her routine observations are normal.

Tetanus vaccination is incomplete due to allergy to the vaccine. You wonder whether she might have tetanus.

What are the diagnostic criteria for acute generalised tetanus?

Despite your initial interventions in the ED, the patient’s symptoms progress rapidly over the course of a few hours. Her spasms become more frequent and prolonged despite your initial treatment.

What additional problems do you anticipate, and how should you prepare for them?

Complete the sentences by selecting the appropriate option from the drop down menu.

She does not respond to treatment and requires RSI and ventilation. The junior intensive care unit (ICU) doctor in attendance proclaims little knowledge of acute tetanus. They ask whether suxamethonium is safe in acute tetanus, and what clinical complications might occur in addition to the normal risks of invasive ventilation.

Clarify what agents are suitable for neuromuscular blockade in acute tetanus and describe the complications which need to be anticipated.