What is the treatment for tetanus?

Treatment of Tetanus

The treatment of tetanus requires immediate administration of human Tetanus Immune Globulin (TIG) at a dose of 250 units intramuscularly, along with proper wound cleaning and debridement, appropriate antibiotics, and supportive care to manage muscle spasms and autonomic dysfunction. 1, 2

Initial Management

• Proper wound care and thorough debridement are critical first steps in tetanus management to remove debris that might harbor Clostridium tetani spores 1
• Surgical debridement of necrotic tissue is necessary for wounds that might create anaerobic conditions favorable for C. tetani growth 1
• Human Tetanus Immune Globulin (TIG) should be administered promptly at a dose of 250 units intramuscularly to neutralize circulating toxin before it binds to neuronal cell membranes 2
• Antibiotics should be administered to eradicate C. tetani and prevent further toxin production - metronidazole or penicillin G are the preferred agents 3

Management of Clinical Manifestations

• Place the patient in a quiet, darkened room to minimize external stimuli that may trigger muscle spasms 4
• Control muscle rigidity and spasms with benzodiazepines, particularly diazepam (0.2-1 mg/kg/hour) administered via nasogastric tube 3
• For severe or refractory spasms, neuromuscular blocking agents and mechanical ventilation may be necessary 3
• Early elective tracheostomy is recommended in moderate to severe tetanus to prevent aspiration and manage laryngeal stridor 3

Management of Autonomic Dysfunction

• Autonomic instability is common in severe tetanus and requires careful monitoring 4, 3
• Magnesium sulfate infusion is often used to manage dysautonomia, which can cause labile hypertension, tachycardia, increased secretions, and urinary retention 3
• Provide supportive care including:
  • Stress ulcer prophylaxis with agents like ranitidine 4
  • Deep vein thrombosis prophylaxis with heparin 4
  • Adequate nutrition, typically via nasogastric tube 3

Tetanus Prophylaxis in Wound Management

• Assess vaccination history carefully - patients with unknown or uncertain previous vaccination histories should be considered as having had no previous tetanus toxoid doses 5
• For clean, minor wounds, administer tetanus toxoid booster if the patient has not received a dose within the past 10 years 5
• For contaminated or tetanus-prone wounds, administer tetanus toxoid if the patient has not received tetanus toxoid within the preceding 5 years 5
• Use age-appropriate vaccines:
  • Adults and children ≥7 years: Td (tetanus and diphtheria toxoids) or Tdap (tetanus, diphtheria, and acellular pertussis) if not previously given 5
  • Children <7 years: DTaP (diphtheria, tetanus, and acellular pertussis) 5
• Administer TIG (250 units IM) for patients with tetanus-prone wounds who have not completed a primary vaccination series 5, 2
• When tetanus toxoid and TIG are given concurrently, use separate syringes and separate injection sites 5, 2

Special Considerations

• Tetanus has a high case fatality rate (5-50%) even with modern medical care, with higher rates among elderly patients 1, 3
• Older adults are at higher risk due to lower prevalence of protective antibody levels against tetanus 1
• Ensure completion of the primary vaccination series for inadequately vaccinated patients during follow-up 5
• Educate patients about the importance of maintaining tetanus immunity with boosters every 10 years 5

Common Pitfalls and Caveats

• Do not delay TIG administration while waiting for wound cultures, as the diagnosis of tetanus is primarily clinical 4
• Avoid using equine tetanus antitoxin due to high risk of allergic reactions (immediate hypersensitivity reactions in approximately 7% and serum sickness in 5% of adults) 5, 2
• Do not rely on wound cultures for diagnosis, as C. tetani is often not isolated from infected wounds 4
• Recognize that approximately 10% of tetanus cases have no identifiable wound or breach in skin 2
• In mass-casualty settings or supply shortages, prioritize TIG for persons aged >60 years and immigrants from regions other than North America or Europe 5