What is the management of tetanus?

Management of Tetanus

Tetanus management requires immediate wound debridement, human tetanus immune globulin (TIG) administration, antibiotic therapy with metronidazole or penicillin, aggressive control of muscle spasms with benzodiazepines, and intensive supportive care including early tracheostomy for moderate-to-severe cases. 1, 2, 3

Immediate Wound Management

• Perform thorough surgical debridement of all necrotic tissue to eliminate the anaerobic environment where Clostridium tetani produces tetanospasmin 1, 2
• Cleanse wounds extensively with sterile normal saline to remove debris and spores 1
• Debridement is critical because it removes the source of ongoing toxin production 4

Neutralization of Circulating Toxin

• Administer human TIG 500-3,000 units intramuscularly immediately (some protocols use up to 6,000 units for severe cases) to neutralize circulating toxin before it binds to neuronal membranes 2, 3
• TIG cannot reverse damage already done by bound toxin, making early administration crucial 2
• Use a separate injection site from tetanus toxoid administration 1

Antibiotic Therapy

• Metronidazole 500 mg IV every 6-8 hours for 7-10 days is the preferred antibiotic to eliminate C. tetani and stop further toxin production 2, 3
• Alternative: Penicillin G 2-4 million units IV every 4-6 hours, though metronidazole is preferred as penicillin may theoretically worsen spasms by acting as a GABA antagonist 3, 4

Control of Muscle Spasms and Rigidity

• Benzodiazepines are first-line therapy: Diazepam 0.2-1 mg/kg/hour via continuous infusion or nasogastric tube in large doses (up to 240 mg/day or higher) 3
• Benzodiazepines reduce rigidity, control spasms, and help manage autonomic dysfunction 3
• For refractory spasms unresponsive to benzodiazepines: Use neuromuscular blocking agents (vecuronium, rocuronium) with mechanical ventilation 3

Airway Management

• Perform early elective tracheostomy in moderate-to-severe tetanus to prevent aspiration from dysphagia, manage laryngeal spasms, and facilitate prolonged mechanical ventilation 3
• Tracheostomy is preferred over prolonged endotracheal intubation given the extended disease course (weeks) 3

Management of Autonomic Dysfunction (Dysautonomia)

• Magnesium sulfate infusion (loading dose 5 g IV over 20 minutes, then 2-3 g/hour continuous infusion) is commonly used to control labile hypertension, tachycardia, and autonomic instability 3
• Dysautonomia is a major cause of mortality and is notoriously difficult to manage 3
• Avoid beta-blockers as they may cause sudden cardiovascular collapse 3

Active Immunization

• Administer tetanus toxoid 0.5 mL intramuscularly at a site separate from TIG, as natural infection does not confer immunity 1, 4
• Complete the primary vaccination series during recovery, as tetanus disease does not provide protective immunity 4

Supportive Care

• Place nasogastric tube for feeding and medication administration due to dysphagia and trismus 3
• Maintain in a quiet, darkened room to minimize stimuli that trigger spasms (touch, light, sound) 3
• Provide adequate nutrition and hydration 2
• Monitor for complications including rhabdomyolysis, aspiration pneumonia, and respiratory failure 3

Special Considerations for Severity

• Mortality ranges from 5-50% depending on severity and quality of intensive care, with higher rates in elderly patients and those with severe dysautonomia 1, 3
• The case-fatality rate remains 18-21% even with modern medical care 1
• Recovery takes weeks to months as fixed toxin must be metabolized; supportive care continues until tetanospasmin bound to neural tissue is cleared 4

Common Pitfalls

• Failing to administer TIG in patients with adequate vaccination history: Even fully vaccinated patients can develop tetanus if they don't receive TIG for tetanus-prone wounds when indicated (>5 years since last booster) 5
• Delaying tracheostomy in moderate-severe cases increases risk of aspiration and respiratory complications 3
• Using inadequate benzodiazepine doses—severe tetanus requires very high doses that would be excessive in other conditions 3