What are the steps for managing tetanus?

Tetanus Management

Proper wound care, appropriate immunization, and administration of Human Tetanus Immune Globulin (TIG) are the critical steps in managing tetanus, with specific interventions based on wound type and vaccination history. 1

Initial Wound Management

• Thorough wound cleaning and debridement are essential first steps to remove debris that might harbor Clostridium tetani spores 1
• Surgical debridement is necessary for wounds with necrotic tissue that could create anaerobic conditions favorable for C. tetani growth 1
• Early recognition of tetanus symptoms (such as trismus/lockjaw) is crucial for prompt diagnosis and treatment 2

Immunization Strategy Based on Wound Type and Vaccination History

For Clean, Minor Wounds:

• Administer tetanus toxoid booster if the patient has not received a dose within the past 10 years 1
• For adults ≥7 years: Use Td (tetanus and diphtheria toxoids) as the preferred preparation, or Tdap (tetanus, diphtheria, and acellular pertussis) if not previously given 1
• For children <7 years who are not adequately vaccinated: Use DTP (diphtheria, tetanus, and pertussis) 1

For Contaminated or Tetanus-Prone Wounds:

• Administer tetanus toxoid if the patient has not received tetanus toxoid within the preceding 5 years 1
• Human Tetanus Immune Globulin (TIG) is necessary 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 administering tetanus toxoid and TIG concurrently, use separate syringes and separate injection sites 1

Management of Established Tetanus

Medication Management:

• Antibiotics: Administer to eliminate C. tetani and prevent further toxin production 3
• Muscle Relaxants: Control muscle spasms with benzodiazepines (diazepam) 3
• Magnesium sulfate: Consider as first-line therapy for controlling spasms and sympathetic overactivity without causing excessive sedation 4
• For severe cases: Propofol is useful for spasm control and sedation 2

Supportive Care:

• For severe tetanus: Early tracheostomy and mechanical ventilation may be necessary 5
• Intensive care monitoring for respiratory function and autonomic instability 5
• Management of complications, particularly respiratory failure and autonomic disturbances 3

Special Considerations

• Elderly patients (>60 years) and immigrants from regions other than North America or Europe should be prioritized for TIG if supplies are limited 1
• Older adults have lower prevalence of protective antibody levels against tetanus (45% of men and only 21% of women aged >70 years) 1
• The case fatality rate remains high (18-21%) even with modern medical care, with higher rates among elderly patients 1

Follow-up Care

• Ensure completion of the primary vaccination series for inadequately vaccinated patients 1
• Educate patients about maintaining tetanus immunity with boosters every 10 years 1
• Assess Tetanus Severity Score (TSS) to predict clinical outcomes 2

Common Pitfalls and Caveats

• Misdiagnosis is common - tetanus may initially be confused with ENT disorders, dental problems, or psychosis 2
• Assuming vaccination status based on country of origin - always verify vaccination history 1
• Failing to recognize that even minor wounds can lead to tetanus infection 5
• Neglecting to provide both active (toxoid) and passive (TIG) immunization when indicated 6