What are the steps for managing tetanus?

Management of Tetanus

Tetanus management requires prompt wound care, immunization, and supportive care to reduce mortality and morbidity. The following steps should be taken when managing tetanus:

Wound Management

• Proper wound care and debridement are critical first steps in tetanus prevention 1
• Thoroughly clean the wound to remove debris that might harbor Clostridium tetani spores 1
• Surgical debridement of necrotic tissue is essential for wounds that might create anaerobic conditions favorable for C. tetani growth 1

Immunization Strategy

• Assess vaccination history carefully; patients with unknown or uncertain previous vaccination histories should be considered to have had no previous tetanus toxoid doses 1
• For clean, minor wounds: administer tetanus toxoid booster if the patient has not received a dose within the past 10 years 1
• For contaminated or tetanus-prone wounds: administer tetanus toxoid if the patient has not received tetanus toxoid within the preceding 5 years 1
• For adults ≥7 years of age, Td (tetanus and diphtheria toxoids) is the preferred preparation; Tdap (tetanus, diphtheria, and acellular pertussis) is preferred if not previously given 1
• For children <7 years of age who are not adequately vaccinated, DTP (diphtheria, tetanus, and pertussis) should be used 1

Passive Immunization

• Human Tetanus Immune Globulin (TIG) is indicated for patients with tetanus-prone wounds who have not completed a primary vaccination series 1
• The recommended prophylactic dose of TIG is 250 units intramuscularly for wounds of average severity 1
• When tetanus toxoid and TIG are given concurrently, use separate syringes and separate injection sites 1
• If TIG supplies are limited, prioritize persons aged >60 years and immigrants from regions other than North America or Europe 1

Treatment of Active Tetanus

• Place patient in a quiet, low-stimulation environment to reduce triggers for muscle spasms 2, 3
• Administer appropriate antibiotics to eliminate C. tetani (penicillin G or erythromycin if penicillin-allergic) 3
• Provide TIG at higher therapeutic doses (3,000-6,000 units) to neutralize unbound toxin 3
• Control muscle spasms and rigidity with benzodiazepines (diazepam is first-line) 2, 3
• For severe cases, consider neuromuscular blocking agents and mechanical ventilation 3, 4
• Manage autonomic instability, which commonly occurs in the second and third weeks of illness 3
• Provide supportive care including DVT prophylaxis, stress ulcer prevention, and nutritional support 3

Prevention of Complications

• Monitor closely for respiratory compromise requiring ventilatory support 4
• Watch for and aggressively treat secondary infections, particularly pneumonia 3, 4
• Prevent complications of immobility including pressure ulcers and deep vein thrombosis 3
• Address cardiovascular instability from autonomic dysfunction, which may require specific interventions 4

Special Considerations

• Tetanus can present atypically; maintain high suspicion in patients with muscle rigidity and history of contaminated injury 5
• The disease is more common in older adults and those without adequate vaccination history 1
• Case fatality rate remains high (18-21%) even with modern medical care 1
• Complete recovery may take weeks to months, requiring prolonged intensive care in severe cases 2, 4

Follow-up

• Ensure completion of primary vaccination series for inadequately vaccinated patients 1
• Educate patients about the importance of maintaining tetanus immunity with boosters every 10 years 1
• Rehabilitation may be necessary for patients who experience prolonged muscle rigidity or immobility 2