What is the treatment for tetanus?

Treatment of Tetanus

The treatment of tetanus requires immediate administration of human Tetanus Immune Globulin (TIG), thorough wound cleaning and debridement, antimicrobial therapy with metronidazole as the preferred agent, and comprehensive supportive care including respiratory support and control of muscle spasms. 1, 2

Immediate Management

• Administer human Tetanus Immune Globulin (TIG) promptly to neutralize circulating toxin (250 units intramuscularly for prophylaxis; higher doses for established tetanus) 1, 2
• Perform thorough wound cleaning and surgical debridement of necrotic tissue to remove the source of tetanus toxin production 1, 2
• Initiate antimicrobial therapy with metronidazole (preferred) or penicillin G to eliminate Clostridium tetani 2, 3
• Note that tetanus vaccine (tetanus toxoid) should NOT be administered to patients with active tetanus infection as it provides no benefit for treating the established infection 2

Supportive Care

• Place patient in a quiet, dimly lit room to minimize external stimuli that may trigger muscle spasms 3
• Control muscle spasms and rigidity with benzodiazepines (diazepam is first-line) 2, 3
• Provide adequate analgesia with opioids such as morphine 3
• Use neuromuscular blocking agents (e.g., pancuronium) for severe spasms not controlled by benzodiazepines 3
• Implement early respiratory support with mechanical ventilation for respiratory compromise 2, 4
• Monitor and manage autonomic instability, which is associated with high mortality 2, 4
• Provide prophylaxis for stress ulcers (e.g., ranitidine) and deep vein thrombosis (e.g., heparin) 3
• Ensure adequate nutrition, typically requiring parenteral or enteral feeding 3

Monitoring and Complications Management

• Closely monitor for respiratory complications, which are a leading cause of mortality 4, 5
• Vigilantly assess for cardiovascular instability, particularly autonomic dysfunction 4
• Watch for secondary infections, especially pneumonia in ventilated patients 4
• Monitor for rhabdomyolysis due to severe muscle spasms 2

Special Considerations

• Elderly patients require particularly careful management as they have higher mortality rates due to lower prevalence of protective antibody levels 1, 4
• Immunocompromised patients may require additional doses of TIG regardless of vaccination history 2
• The case fatality rate remains high (18-21%) even with modern medical care, necessitating aggressive treatment 1, 6

Post-Recovery Management

• Tetanus does not confer natural immunity, so patients must complete a full primary immunization series after recovery 2
• For previously unvaccinated adults, the recommended schedule is:
  • First dose: Tdap (preferred over Td) 2
  • Second dose: Td or Tdap at least 4 weeks after first dose 2
  • Third dose: Td or Tdap 6-12 months after second dose 2
• Ensure complete documentation of tetanus vaccination status for future wound management 2

Prevention in Wound Management

• For clean, minor wounds, administer tetanus toxoid if the patient has not received a dose within the past 10 years 7, 1
• For contaminated or tetanus-prone wounds, administer tetanus toxoid if the patient has not received tetanus toxoid within the preceding 5 years 7, 1
• For patients with tetanus-prone wounds who have not completed a primary vaccination series, TIG is necessary in addition to tetanus toxoid 1
• When tetanus toxoid and TIG are given concurrently, use separate syringes and separate injection sites 1