What is the recommended treatment for established tetanus?

Management of Established Tetanus

Established tetanus is a medical emergency requiring immediate intensive care with a focus on airway management, muscle spasm control with benzodiazepines, surgical wound debridement, passive immunization with human tetanus immunoglobulin (TIG), and active immunization with tetanus toxoid. 1

Immediate Priorities in Established Tetanus

Airway and Respiratory Management

• Secure the airway immediately and prepare for mechanical ventilation, as respiratory failure from laryngospasm and respiratory muscle rigidity is the leading cause of death in tetanus 1
• Facilities for respiratory assistance must be readily available before initiating any pharmacologic treatment 2
• The case fatality rate remains 18-21% even with modern intensive care, primarily due to respiratory complications and autonomic dysfunction 3

Muscle Spasm Control with Benzodiazepines

• Administer diazepam 5-10 mg IV or IM initially, then repeat 5-10 mg every 3-4 hours as necessary 2
• For severe tetanus, larger doses than the standard range may be required 2
• In children 5 years or older, give 5-10 mg repeated every 3-4 hours to control tetanus spasms 2
• For infants over 30 days, administer 1-2 mg IM or IV slowly, repeated every 3-4 hours as necessary 2
• Inject diazepam slowly IV, taking at least one minute for each 5 mg (1 mL) given 2
• Recent case reports confirm diazepam remains the cornerstone of muscle spasm management in tetanus 4

Wound Management

• Perform thorough surgical debridement of all necrotic tissue to remove anaerobic conditions favorable for Clostridium tetani growth 1, 3
• Proper wound cleaning and debridement are as critical as immunization in tetanus management 3
• Remove all debris that might harbor C. tetani spores 3

Immunologic Treatment

Passive Immunization with TIG

• Administer human TIG 250 units IM immediately for prophylactic dosing in established tetanus 5, 1, 3
• Human TIG is the product of choice because it provides longer protection than animal-origin antitoxin and causes fewer adverse reactions 5
• When giving TIG concurrently with tetanus toxoid, use separate syringes at separate anatomic sites 5, 3
• The ACIP recommends using only adsorbed toxoid when TIG and tetanus toxoid are given together 5

Intrathecal TIG remains investigational: While some studies suggest intrathecal administration may reduce mechanical ventilation requirements and mortality compared to IM-only routes 6, 7, no definitive blinded randomized controlled trials have established superiority 6. The standard of care remains IM administration 5, 1, 3.

Active Immunization

• Administer tetanus toxoid vaccine immediately during acute management, as tetanus infection does not confer immunity 1
• Use Td (tetanus-diphtheria toxoid) as the preferred preparation for adults ≥7 years of age 3
• For children <7 years who are inadequately vaccinated, use DTP 3
• Ensure completion of the primary vaccination series during recovery and follow-up 5, 3

Supportive Care and Monitoring

Autonomic Dysfunction Management

• Monitor closely for autonomic nervous system dysfunction, which is a major complication of tetanus 1, 6
• Autonomic instability can manifest as labile blood pressure, tachycardia, arrhythmias, and hyperpyrexia 8

Antibiotic Therapy

• Administer antibiotics as part of comprehensive management 4
• Note that chemoprophylaxis with antibiotics is NOT recommended for tetanus prevention in wound management, but antibiotics are used in established disease 3

Critical Pitfalls to Avoid

• Do not assume tetanus infection provides immunity—active vaccination must begin during recovery 1
• Do not delay wound debridement—proper surgical management is as critical as pharmacologic treatment 1, 3
• Do not omit respiratory support preparation—have mechanical ventilation immediately available before administering sedatives 2
• Do not use small veins for IV diazepam administration (such as dorsum of hand or wrist), and avoid intra-arterial administration or extravasation 2
• Do not mix or dilute diazepam with other solutions or drugs in syringe or infusion container 2

Special Population Considerations

Elderly Patients

• Older adults have significantly higher mortality from tetanus 3
• Use lower diazepam doses (usually 2-5 mg) with slow titration in elderly or debilitated patients 2
• Prioritize TIG administration in patients >60 years if supplies are limited, as they are less likely to have protective antibody levels 1, 3

Immunocompromised Patients

• Severely immunocompromised patients require TIG regardless of vaccination history 1
• These patients may not respond adequately to standard active immunization 8