The overall rigidity of the animal can increase the risk of spasms of the respiratory , laryngeal and abdominal muscles , which can ultimately lead to respiratory failure if not treated [ 3 ] .
Diagnosis is often based on the clinical signs and a history of a wound . Blood tests can be carried out to test for the presence of the toxin and to eliminate other conditions or other possible causes of muscle rigidity [ 7 ] . In Luther ' s case , blood samples were taken on admission for haematology , biochemistry and C-reactive protein profiles . The results were unremarkable .
Nursing and treatment
Luther was immediately put on intravenous fluid therapy and admitted to the intensive care unit ( ICU ), where he remained for the duration of his stay . Based on the clinical signs ( rigidity of the base of the pinna , the neck and the face ), a tetanus antitoxin was administered as a precaution . However , this treatment is not beneficial if the toxin has already attached to the animal ' s nerves [ 2 ] , so aggressive antibiotic treatment was also started , with amoxicillin – clavulanic acid ( Synulox ; Zoetis ) 8.75 mg / kg and metronidazole 10 mg / kg administered every 12 hours , subcutaneously ( SC ) and intravenously ( IV ), respectively . Debridement of the wound area can reduce the number of C . tetani bacteria , and thereby the amount of toxin , making the condition more manageable , but this was not carried out in this case .
Lockjaw causes dysphagia , which reduces the amount of food an affected animal is able to take in , so anorexia and malnutrition are additional concerns . An oesophagostomy tube was placed to ensure Luther was receiving adequate nutrition . He did not have a period of starvation , so was not at risk of developing refeeding syndrome and was started on 100 % of his resting energy requirement ( RER ). The high metabolic rate of tetanus patients means they can lose weight quickly , so Luther was given a high-energy liquid food ( Royal Canin High Energy Liquid ). However , despite receiving 100 % of his RER , he began to lose a substantial amount of weight . His nutrition was increased to 130 % RER and then increased again , to 150 – 170 % RER , as he was still losing weight .
Administration of large volumes of enteral nutrition can increase the risk of aspiration pneumonia , so care was taken to ensure Luther was fed slowly and the oesophagostomy tube was correctly positioned . Monitoring of the stoma site and oesophagostomy tube management were also a priority . This included re-dressing the site every 12 hours to ensure there were no signs of infection , and flushing the tube with saline pre- and post-feeding to reduce the risk of blockages .
Over the first 24 hours of Luther ' s stay , his condition deteriorated . He was unable to open his mouth or support his own weight and was extremely rigid , with tremors in his tail . He remained in lateral recumbency , so had to be rotated every 4 hours to reduce the risk of atelectasis and other cardiovascular or respiratory issues .
Luther was started on diazepam to treat the rigidity ( 0.4 mg / kg IV every 4 hours ) and buprenorphine for pain relief ( 0.02 mg / kg IV every 6 hours ). Pain relief was later increased to methadone ( 0.2 mg / kg every 4 hours ) in response to Luther ' s high pain scores . He had a urinary catheter placed for hygiene and urine monitoring .
Luther was monitored with an electrocardiogram ( ECG ), to ensure that his normal cardiovascular parameters were not declining , and his blood pressure was monitored frequently . He became bradycardic , with a heart rate of 30 – 40 beats per minute ( bpm ); normal heart rate is 60 – 120 bpm . There were no pulse deficits and his ECG trace was normal , but atropine at a dose of 0.02 mg / kg IV was administered . The bradycardia was attributed to the tetanus causing a parasympathetic response . After receiving the atropine , Luther ' s heart rate increased to 70 – 80 bpm . He was closely monitored for the remainder of his stay and there were no further issues with his heart rate .
Luther ' s muscle tremors worsened , so he was started on another muscle relaxant , methocarbamol , at a dose of 40 mg / kg every 8 hours , administered via the oesophagostomy tube . At this point in his hospital stay Luther was receiving six medications ( Table 1 ).
Table 1 . Six of the medications Luther received in hospital .
Medication
Amoxicillin – clavulanic acid
Dose ( mg / kg )
Frequency
8.75 12 hours SC
Metronidazole 10 12 hours IV Paracetamol 10 12 hours IV Methadone 0.2 4 hours IV Diazepam 0.4 4 hours IV Methocarbamol 40 8 hours OT
Delivery method
SC = subcutaneously ; IV = intravenously ; OT = oesophagostomy tube .
Acepromazine at 0.01 mg / kg IV was also introduced , as Luther became stressed by his inability to move . This was given as required , up to three times a day . His vital parameters were monitored every hour . The auscultation of his heart and chest remained normal , and his pulse remained strong and synchronous .
Tetanus patients are hypersensitive , so eye masks , ear plugs and environmental calm can reduce stimulation . Luther tolerated an eye mask and ear plugs , but some patients can find them too stimulating , so alternative
42 Veterinary Nursing Journal