What is the management of tetanus?

Management of Tetanus

The management of tetanus requires immediate administration of human tetanus immune globulin (TIG), wound cleaning and debridement, antimicrobial therapy, and supportive care including control of muscle spasms and respiratory support when needed. 1, 2

Initial Management

1. Neutralization of Unbound Toxin

• Tetanus Immune Globulin (TIG)
  • Administer 250 units intramuscularly for prophylaxis in wounds of average severity 1
  • For established tetanus, higher doses (3,000-6,000 units) are recommended
  • TIG should be administered at a site different from tetanus toxoid if both are given concurrently 2

2. Wound Management

• Thorough wound cleaning and debridement is essential 1
• Remove all foreign bodies and necrotic tissue
• Surgical exploration of suspected gas gangrene sites 1

3. Antimicrobial Therapy

• Metronidazole is the preferred antibiotic
• Alternative options include:
  • Penicillin G (10-12 million units/day divided q6h)
  • Doxycycline (100 mg IV/PO q12h)
  • Treatment duration: 7-10 days 1

Supportive Care

1. Control of Muscle Spasms

• Benzodiazepines:

  • Diazepam: 5-10 mg IV/IM initially, then 5-10 mg every 3-4 hours as needed 1, 3
  • For severe tetanus, larger doses may be required 3
  • For children over 5 years: 5-10 mg repeated every 3-4 hours as needed 3
  • For infants over 30 days: 1-2 mg IM/IV slowly, repeated every 3-4 hours as needed 3

• Muscle Relaxants:

  • For severe spasms not controlled by benzodiazepines, consider neuromuscular blocking agents
  • Respiratory support must be available when using these agents

2. Airway Management

• Early intubation and mechanical ventilation should be considered for:
  • Severe spasms
  • Respiratory compromise
  • Autonomic instability 4

3. Management of Autonomic Dysfunction

• Monitor for cardiovascular instability
• Treat hypertension and tachycardia with:
  • Beta-blockers
  • Magnesium sulfate
  • Morphine

4. Nutritional Support

• Early enteral nutrition via nasogastric tube
• Adequate hydration and electrolyte management

Prevention of Complications

• DVT prophylaxis
• Pressure ulcer prevention
• Ventilator-associated pneumonia prevention
• Regular physiotherapy

Tetanus Prophylaxis in Wound Management

For Clean Minor Wounds:

• Complete vaccination history (3+ doses):
  • Last dose <10 years ago: No tetanus toxoid needed
  • Last dose ≥10 years ago: Tetanus toxoid (Td/Tdap) needed 2
  • No TIG needed

For Contaminated Wounds:

• Complete vaccination history (3+ doses):
  • Last dose <5 years ago: No tetanus toxoid needed
  • Last dose ≥5 years ago: Tetanus toxoid (Tdap/Td) needed 2
  • No TIG needed

For Patients with Incomplete/Unknown Vaccination History:

• Tetanus toxoid (Tdap preferred if not previously received)
• TIG 250 units IM at a different site 1, 2

Special Considerations

1. Intrathecal TIG: Some research suggests potential benefit of intrathecal TIG administration in reducing mortality compared to intramuscular administration alone 5, but this is not yet part of standard guidelines.

2. Immunocompromised patients: Persons with HIV infection or severe immunodeficiency who have contaminated wounds should receive TIG regardless of their tetanus immunization history 2.

3. Elderly patients: May require lower doses of sedatives and slower dose escalation 3.

Common Pitfalls to Avoid

• Delayed recognition: Tetanus can present atypically, including as acute abdomen 6, leading to delayed diagnosis.
• Inadequate wound care: Proper wound cleaning and debridement are as critical as immunization 2.
• Insufficient respiratory monitoring: Patients can rapidly deteriorate and require ventilatory support.
• Inadequate prophylaxis: Failure to provide appropriate prophylaxis after high-risk exposure can lead to tetanus even in previously vaccinated individuals 7.
• Administering TIG and tetanus toxoid at the same site: These should be given at different anatomical sites 2.