Tetanus and the evolution of intensive care in Australia

A review of two series of patients with tetanus from the Royal Adelaide Hospital provides a historical perspective on the evolution of intensive care in Australia. Nine consecutive severe cases presenting in 1957 constituted one of the first series published. Four patients died. The second series of 38 severe cases, among a total of 56 cases presenting between 1967 and 1985, included two deaths, comparing favourably with survival in other contemporary series. The specialty of intensive care evolved considerably during this time. Neuromuscular blockade introduced in the first series produced radical changes in management. Supportive measures that were not then widely practised, involving intermittent positive pressure ventilation, were used in the second series for up to 46 days and evolved into standard ICU practice. The option of using a tank respirator was rejected. Older patients were susceptible to complications commonly related to respiratory, cardiovascular and diabetic comorbidities, but most returned to their previous lifestyle. Severe tetanus often resulted from mild injuries in patients who were incompletely immunised. Four patients developed tetanus following surgical procedures. The use of nitrous oxide in the first series was abandoned owing to adverse effects on bone marrow function. Complications reported in early literature, such as fractures and myositis ossificans, presumably related to unrelieved spasm, are no longer seen. Clinicians are now likely to see the condition only if working with counter-disaster teams overseas.