||nevin chinnan, 4/26/2005 5:13:41 PM
| ||Dear Dr. Subhash |
It was a pleasure to note that you had taken a lot of effort to validate a prognostic scoring system for tetanus, and thereby anticipate and guide the appropriate treatment. I have a few queries regarding the management of tetanus at your centre-
1. Diazepam Requirement- for scores < 4, 1500 mg per 24 hours and for scores 5 and above, 4000 to 5000 mg per 24 hours. At this very high dosage did you encounter any toxicity due to preservative (documented above 300-400 mg per 24 hours) or you were using preservative free diazepam?
2. Need for Tracheostomy (for score <4, 18%, for score 5, 26% and for score >5, 47%) was much more than the Need for Ventilation (for score <4, 8%, for score 5, 12% and for score >5, 34%) suggesting many patients who were tracheostomized did not need mechanical ventilation. From the above data, I presume that tracheostomy was performed for protecting the lower airway, maintain airway patency during spasms, and facilitate suctioning and tracheal toilet. The same objectives could have been realized using an endotacheal tube (preferably naso-tracheal to avoid biting during spasms) and a tracheostomy avoided in those patients with lower scores. Is there any specific reason why such a low threshold for tracheostomy was practiced at your centre?
3. For patients with autonomic instability, were drugs like magnesium sulphate, high dose opioids or epidural local anaesthetics tried? Or was the management restricted to high dose of benzodiazpenes and symptomatic treatment?