What is the management of established tetanus cases?

Management of Established Tetanus Cases

Established tetanus requires immediate intensive care management with human tetanus immune globulin (TIG), antibiotics (metronidazole or penicillin), aggressive wound debridement, benzodiazepines for spasm control, and early consideration of mechanical ventilation and tracheostomy for severe cases. 1, 2

Immediate Interventions

Neutralize Circulating Toxin

• Administer human TIG immediately at a dose of 250-500 units intramuscularly to neutralize circulating tetanospasmin that has not yet bound to neural tissue 3, 1
• Use separate injection sites if administering TIG concurrently with tetanus toxoid 3, 1
• Note that TIG cannot reverse damage already caused by toxin that has bound to the central nervous system 4
• Intrathecal TIG (250 IU) may reduce disease progression, hospital stay, and need for tracheostomy in mild-to-moderate tetanus, though this remains investigational 5

Eliminate Toxin Source

• Perform thorough surgical debridement of all wounds to remove necrotic tissue and create aerobic conditions unfavorable for Clostridium tetani growth 1, 2
• Debride even seemingly minor wounds, as tetanus can develop from trivial injuries 6, 7
• Initiate antibiotic therapy immediately: metronidazole 500 mg IV every 6-8 hours OR penicillin G 2-4 million units IV every 4-6 hours for 7-14 days to eliminate the organism 4, 2, 7
• Metronidazole is often preferred as it may have better CNS penetration 2

Airway and Respiratory Management

Early Airway Intervention

• Perform early elective tracheostomy in moderate-to-severe tetanus to prevent aspiration from dysphagia and manage laryngeal spasms 2
• Tracheostomy is preferred over prolonged endotracheal intubation given the extended disease course (typically 3-6 weeks) 2
• Initiate mechanical ventilation for refractory spasms that cause apnea or respiratory compromise 2

Control of Muscle Rigidity and Spasms

Benzodiazepine Therapy

• Administer high-dose benzodiazepines as first-line therapy for muscle rigidity, spasms, and autonomic dysfunction 2
• Diazepam 0.2-1 mg/kg/hour via continuous infusion or nasogastric tube is the standard approach 2
• Benzodiazepines work by enhancing GABA activity, counteracting the toxin's inhibition of inhibitory neurotransmitters 2

Neuromuscular Blockade

• Use neuromuscular blocking agents (e.g., pipecuronium, vecuronium) with mechanical ventilation for spasms refractory to benzodiazepines 2, 8
• This requires deep sedation and prolonged ventilatory support 2

Management of Autonomic Dysfunction

Dysautonomia Control

• Administer magnesium sulfate infusion (loading dose 5g IV over 20 minutes, then 2-3 g/hour continuous infusion) to manage labile hypertension, tachycardia, and autonomic instability 2
• Dysautonomia is a leading cause of mortality in severe tetanus and typically appears 7-14 days after symptom onset 2
• Avoid beta-blockers as they may cause paradoxical cardiovascular collapse 2
• Manage hypertensive crises cautiously with short-acting agents like esmolol or nitroprusside if magnesium is insufficient 2

Supportive Care

Nutritional and General Support

• Place nasogastric tube early for enteral feeding and medication administration, as dysphagia prevents oral intake 2
• Maintain high caloric intake (3000-4000 kcal/day) due to increased metabolic demands from muscle spasms 2
• Minimize environmental stimuli (noise, light, touch) that trigger spasms 2
• Provide deep vein thrombosis prophylaxis given prolonged immobility 2

Active Immunization

• Administer tetanus toxoid vaccine as part of the treatment regimen, since natural infection does not confer immunity 1, 6, 7
• Complete the primary vaccination series during recovery and follow-up 1

Prognostic Considerations

Risk Stratification

• Mortality ranges from 5-50% even with modern intensive care, with higher rates in elderly patients and those with severe disease 1, 2
• The case-fatality rate remains 18-21% in developed countries with full ICU support 1
• Shorter incubation periods and rapid progression indicate more severe disease with worse prognosis 2, 6

Critical Pitfalls to Avoid

• Do not delay TIG administration while awaiting laboratory confirmation—tetanus is a clinical diagnosis 2, 6, 7
• Do not assume adequate immunity based on age or history—38% of cases occur in patients ≥65 years, and only 21% of women >70 years have protective antibody levels 1
• Do not use equine antitoxin if human TIG is available due to higher risk of allergic reactions and shorter duration of protection 3
• Do not underestimate sedation requirements—patients often require massive doses of benzodiazepines that would be lethal in other contexts 2