Treatment of Tetanus According to Latest Guidelines
The treatment of tetanus requires a comprehensive approach including neutralization of unbound toxin with human tetanus immunoglobulin (TIG) 250 units intramuscularly, elimination of the bacterial source with metronidazole or penicillin G, control of muscle spasms with diazepam (5-10 mg IV/IM initially, then repeated as needed), and supportive care in an ICU setting. 1
Core Treatment Components
1. Neutralize Circulating Toxin
- Administer human tetanus immunoglobulin (TIG) 250 units intramuscularly at a site different from toxoid injection 1
- For severe cases, higher doses may be required 1
2. Eliminate Bacterial Source
- Thoroughly clean and debride the wound to remove anaerobic conditions 1
- Administer antibiotics to eliminate C. tetani:
- First choice: Metronidazole
- Alternative: Penicillin G
- Note: Metronidazole is preferred as penicillin may theoretically antagonize GABA inhibition and worsen symptoms 2
3. Control Muscle Spasms
- Diazepam: 5-10 mg IV/IM initially, then 5-10 mg every 3-4 hours as needed 3
- For severe tetanus, larger doses may be required 3
- For tetanus in infants over 30 days of age: 1-2 mg IV/IM slowly, repeated every 3-4 hours as necessary 3
- For children 5 years or older: 5-10 mg repeated every 3-4 hours 3
4. Manage Autonomic Dysfunction
- Monitor for cardiovascular instability, hypertension, tachycardia
- Beta-blockers may be used for severe autonomic instability 1
- Continuous monitoring in ICU setting is necessary 1
5. Respiratory Support
- Ensure respiratory assistance is readily available 3
- For severe cases, neuromuscular blocking agents and mechanical ventilation may be required 1
- Use of neuromuscular blocking agents should be guided by train-of-four monitoring 1
Tetanus Prevention
Wound Management
- Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years 4
- Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given 4
- For dirty wounds, administer booster if >5 years since last dose; for clean wounds, if >10 years 1
Vaccination Schedule
Special Considerations
- Elderly patients (>60 years) are at higher risk due to inadequate protection, with up to 40-66% lacking protective antibody levels 1
- Case fatality rate can reach up to 18% even with modern medical care 1
- Shorter incubation periods (typically 3-21 days, median 7 days) are associated with more severe disease and poorer prognosis 1
- Primary wound closure is not recommended except for facial wounds, which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics 4
Rehabilitation
- Early physiotherapy to prevent contractures and muscle atrophy 1
- Occupational therapy to recover functional skills 1
- Respiratory rehabilitation if prolonged ventilation was required 1
- Psychological support and neurological evaluation to identify and treat sequelae 1
The management of tetanus requires prompt intervention with multiple therapeutic approaches to reduce mortality and morbidity. Despite being preventable through vaccination, tetanus remains a potentially fatal disease that requires intensive medical care when it occurs.