What is the management of tetanus?

Management of Tetanus

The management of tetanus requires immediate administration of tetanus immune globulin (TIG) to neutralize circulating toxin, along with appropriate antibiotics, wound care, and supportive measures to control muscle spasms and autonomic dysfunction. 1, 2

Immediate Interventions

• Administer human tetanus immune globulin (TIG) promptly at a dose of 250 units intramuscularly for wounds of average severity to neutralize circulating toxin 3, 1
• Higher doses of TIG may be required for established tetanus infection 1, 4
• Perform thorough wound cleaning and debridement of necrotic tissue to remove the source of ongoing toxin production 3, 2
• Administer appropriate antibiotics to eliminate Clostridium tetani:
  • Metronidazole is preferred 1, 4
  • Penicillin G or erythromycin are acceptable alternatives 5, 4

Control of Muscle Spasms and Rigidity

• Place patient in a quiet, dimly lit room to minimize external stimuli that can trigger spasms 5, 4
• Administer benzodiazepines as first-line therapy for muscle spasms:
  • Diazepam is most commonly used, often requiring high doses (0.2-1 mg/kg/hour) 5, 4
• For severe or refractory spasms, consider:
  • Additional muscle relaxants such as baclofen 4
  • Neuromuscular blocking agents with mechanical ventilation 4
• Provide adequate analgesia with opioids such as morphine 5

Management of Autonomic Dysfunction

• Monitor for signs of autonomic instability including labile hypertension, tachycardia, sweating, and urinary retention 4
• Magnesium sulfate infusion is often used to manage dysautonomia 4
• Provide cardiovascular support as needed to maintain hemodynamic stability 5

Respiratory Support

• Perform early elective tracheostomy in moderate to severe cases to prevent aspiration and manage laryngeal spasms 4
• Provide mechanical ventilation for patients with respiratory compromise or those requiring heavy sedation 5, 4

Supportive Care

• Administer deep vein thrombosis prophylaxis with heparin due to prolonged immobility 5
• Provide stress ulcer prophylaxis with agents such as ranitidine 5
• Ensure adequate nutrition, preferably via nasogastric tube 4
• Monitor for and treat complications such as pulmonary infections 5

Vaccination Considerations

• Do NOT administer tetanus vaccine during active tetanus infection as it provides no benefit for the current infection 1
• After recovery, patients should complete a full primary immunization series since tetanus infection does not confer natural immunity 1
• For adults who have never been vaccinated, the recommended schedule is:
  • First dose: Tdap (preferred over Td) 1
  • Second dose: Td or Tdap at least 4 weeks after first dose 1
  • Third dose: Td or Tdap 6-12 months after second dose 1

Special Considerations

• Mortality from tetanus remains high (5-50%) even with modern medical care 4
• Elderly patients are at higher risk for severe disease and have higher mortality rates 1
• Immunocompromised patients may require additional doses of TIG regardless of vaccination history 1
• Complete documentation of tetanus vaccination status after recovery is essential for future wound management 1

Common Pitfalls to Avoid

• Delaying administration of TIG in favor of tetanus toxoid - TIG provides immediate passive immunity and is critical 1
• Assuming tetanus infection confers natural immunity - it does not, and patients will need vaccination after recovery 1
• Inadequate wound debridement, which is essential for removing the source of ongoing toxin production 2
• Underestimating the need for intensive care support, especially for respiratory and autonomic complications 4