1/10. Esmolol in a case of severe tetanus. Adequate haemodynamic control achieved despite markedly elevated catecholamine levels.A patient with severe tetanus, who had a sympathetic crisis while sedated with 30 mg/h diazepam and 30 mg/h morphine, is described. Satisfactory control of the haemodynamic crisis was achieved with bolus doses of esmolol to a total of 180 mg. A disturbing finding was that although there was adequate control of the tachycardia and hypertension, arterial catecholamine levels remained markedly elevated. Adrenaline levels of 531 pg/ml (normal 10-110 pg/ml) and noradrenaline levels of 1,036 pg/ml (normal 100-500 pg/ml) were recorded when the patient had a systolic arterial pressure of 110 mmHg and a heart rate of 97/min. The implications of this finding are discussed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/10. Cardiovascular instability and baroreflex activity in a patient with tetanus.In a patient with tetanus we tested the hypothesis that the hyperadrenergic cardiovascular instability might be due to impairment of the baroreceptor reflex by the tetanus toxin. baroreflex sensitivity assessed with the phenylephrine method was found to be normal. Changes in arterial pressure correlated inversely with relative changes in plasma volume but not with plasma catecholamine levels. There were both extreme hypo- and hyper-adrenergic episodes. We conclude that sympathetic overactivity in tetanus temporarily overrules a functionally intact baroreflex leading to severe blood pressure instability with episodes of hypertension.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
3/10. Intravenous infusion of midazolam, propofol and vecuronium in a patient with severe tetanus.An adult patient with severe tetanus was successfully treated with alternating long-term infusions of propofol (20-80 mg/h, 8 3 days) and midazolam (5-15 mg/h, 29 days) for sedation, and with vecuronium infusion (6-8 mg/h, 35 days) for muscle relaxation. In addition, continuous infusion of labetalol (10-20 mg/h, 39 days) was given to control arterial blood pressure. Blood samples were taken daily for assays of propofol, midazolam and vecuronium plasma concentrations. No accumulation of propofol and vecuronium could be detected. There was an increase in liver enzyme activity at the end of the first 8-day propofol infusion. During the 4-week midazolam infusion, there were two marked plasma concentration peaks at times when the infusion rate was fairly stable. These changes coincided with pulmonary infection (c-reactive protein elevated) and ciprofloxacin treatment. The patient awoke rapidly after the last propofol infusion. He was unable to recall anything about his stay in the intensive care unit.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/10. Treatment of tetanus-induced autonomic nervous system dysfunction with continuous epidural blockade.A patient with tetanus had a labile blood pressure caused by marked fluctuations in systemic vascular resistance. During hypotensive episodes, mixed venous oxygen saturation decreased below 60%. Hemodynamic instability was controlled after institution of a continuous lumbar epidural local anesthetic block.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/10. Dysfunction of the sympathetic nervous system in tetanus. A study of 3 cases.In severe cases of tetanus an overactivity of the sympathetic nervous system has been postulated because of the clinical symptoms including hypertension, fluctuating blood pressure, tachycardia, tachyarrhythmia and peripheral vasoconstriction. In the present study the involvement of the sympathetic nervous system in tetanus was investigated by serial determinations of plasma adrenaline (A) and noradrenaline (NA) in 2 patients who developed severe symptoms of tetanus and the characteristic cardiovascular disturbances. Sustained high circulating levels of NA and A could be observed indicating a prolonged overactivity of the sympathetic nervous system. In one case, the elevation of the NA level in plasma persisted until the disturbances of the motor nervous system ceased. In a third case of tetanus without cardiovascular abnormalities, the plasma NA and A only increased slightly on a few occasions. The results demonstrate that an overactivity of the sympathetic nervous system can complicate the course of severe tetanus.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/10. Hyperadrenergic syndrome in severe tetanus: extreme rise in catecholamines responsive to labetalol.The hyperadrenergic syndrome that occurs in tetanus is characterised by hypertension, tachycardia, and increased systemic arteriolar resistance. A 74 year old man with tetanus was found to have very high catecholamine concentrations--as high as those in phaeochromocytoma--and the fluctuations in blood pressure and heart rate were measured to see whether they paralleled changes in the catecholamine values. A labetalol infusion of 0.25-1 mg/min gradually stabilised the cardiovascular disturbances and the patient recovered.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/10. Evaluation of left ventricular performance during sympathetic nervous storm in a case with severe tetanus by transesophageal M-mode echocardiography.Transesophageal M-mode echocardiography was applied for the evaluation of left ventricular performance in a case of severe tetanus with labile hypertension due to sympathetic nervous 'storm'. When systemic blood pressure was elevated, increases in pulmonary arterial pressure, cardiac output, left ventricular enddiastolic diameter, fractional shortening and mean velocity of circumferential fiber shortening were noted. No changes were found in total peripheral vascular resistance or left ventricular endsystolic diameter. Positive pressure ventilation, rendered standard transthoracic echocardiography ineffective.- - - - - - - - - - ranking = 3keywords = pressure (Clic here for more details about this article) |
8/10. Anaesthetists and Dutch Elm disease.Undiagnosed tetanus can be a rare cause of acute intestinal obstruction followed by respiratory failure after surgery and general anaesthesia. The anaesthetist should always read the general practitioner's referring letter (so should the surgeon). Equally, the general practitioner's letter should record normal physiological values for that patient, such as pulse rate and blood pressure. The current shortage of anaesthetists might partly be related to inadequate exposure of medical students to the specialty. The anaesthetist's prime task is the relief of a pain during surgery: but his contract might allow sufficient time outside the operating theatre for the nurture of diagnostic skills basic to clinical competence and survival of the patient inside the operating theatre.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/10. Autonomic disturbance in severe tetanus: failure of parenteral clonidine to control blood pressure.In this paper we describe a typical case of tetanus and report our observations with the centrally acting alpha 2-adrenoreceptor agonist clonidine. Previous work with this agent has suggested that it may be of value in tetanus.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |
10/10. Avoidance of intermittent positive pressure ventilation in tetanus with dantrolene therapy.Two patients with features of severe tetanus who were successfully treated with dantrolene are reported. Neither patient required treatment with neuromuscular blocking agents so mechanical ventilation, with all its disadvantages, was avoided.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |
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