Tetanus Management
For active tetanus infection, immediately administer Human Tetanus Immune Globulin (TIG) at higher doses than prophylaxis, perform aggressive wound debridement, start metronidazole as the preferred antibiotic, and prepare for intensive care management with mechanical ventilation—notably, do NOT give tetanus vaccine during active infection as it provides no benefit for established disease. 1
Immediate Management of Active Tetanus
Critical First Steps
- Administer TIG promptly to neutralize circulating toxin—use 250 units intramuscularly for prophylaxis but higher doses for established tetanus infection 1
- Perform thorough wound cleaning and surgical debridement of all necrotic tissue to eliminate the source of ongoing toxin production 2, 1
- Start antimicrobial therapy with metronidazole as the preferred agent, or alternatively penicillin G, to eliminate Clostridium tetani 1
- Do NOT administer tetanus vaccine to patients with active tetanus—this is a critical pitfall, as the vaccine provides no therapeutic benefit for established infection 1
Intensive Care Management
- Initiate early respiratory support with mechanical ventilation for any respiratory compromise, as respiratory failure is a leading cause of death 1, 3
- Control muscle spasms with propofol for both spasm control and sedation 3
- Manage autonomic instability with magnesium sulfate, as autonomic dysfunction is associated with high mortality 1, 3
- Monitor for rhabdomyolysis due to severe muscle spasms, including intramuscular hemorrhage particularly in lumbar muscles 3
Prognostic Considerations
- The case fatality rate remains 18-21% even with modern intensive care, necessitating aggressive early intervention 2, 1
- Elderly patients require particularly careful management as they have higher mortality rates and lower prevalence of protective antibodies (only 21% of women >70 years have protective levels) 2
- The Tetanus Severity Score (TSS) is useful for predicting clinical outcomes—shorter onset time to generalized convulsion correlates with longer hospital stays 3
Wound Prophylaxis Management (Prevention)
Wound Assessment and Care
- Classify the wound as either clean/minor or tetanus-prone (contaminated wounds, puncture wounds, wounds with necrotic tissue creating anaerobic conditions) 2
- Thoroughly clean and debride all wounds to remove debris harboring C. tetani spores 2
- Surgically debride necrotic tissue for any wound creating anaerobic conditions 2
Immunization Algorithm for Prophylaxis
For Clean, Minor Wounds:
- Administer tetanus toxoid booster if >10 years since last dose 2, 1
- Use Td for adults ≥7 years (or Tdap if not previously given) 2
- Use DTaP for children <7 years 2
- TIG is NOT needed for clean wounds with adequate vaccination history 2
For Tetanus-Prone/Contaminated Wounds:
- Administer tetanus toxoid if >5 years since last dose 2, 1
- Administer TIG (250 units IM) for patients who have not completed a primary vaccination series (fewer than 3 doses or uncertain history) 2, 1
- Use separate syringes and separate injection sites when giving both TIG and tetanus toxoid concurrently 2, 1
- Consider patients with unknown vaccination history as having had NO previous doses 2
Special Population Considerations
- Prioritize TIG for persons >60 years and immigrants from regions other than North America or Europe when supplies are limited 2
- Elderly patients with uncertain vaccination history should receive TIG for tetanus-prone wounds, as 38% of tetanus cases occur in those >65 years 2
- Immunocompromised patients may require additional TIG doses regardless of vaccination history 1
Post-Recovery Management
Critical Pitfall to Avoid
- Tetanus infection does NOT confer natural immunity—patients must complete a full primary immunization series after recovery from active tetanus 1
Vaccination Schedule After Recovery
For previously unvaccinated adults:
- 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