What is the management and treatment of tetanus?

Management and Treatment of Tetanus

Immediate Life-Saving Interventions

For active tetanus infection, immediately administer Human Tetanus Immune Globulin (TIG) at treatment doses of 3,000-6,000 units intramuscularly to neutralize circulating tetanospasmin toxin, perform aggressive surgical debridement of all necrotic tissue, and initiate antimicrobial therapy with metronidazole (preferred) or penicillin G. 1, 2, 3

Critical First Steps

• Administer TIG immediately - Use treatment doses (3,000-6,000 units IM) for active tetanus, NOT the prophylactic dose of 250 units used for wound management 3
• Perform thorough wound debridement - Surgically remove all necrotic tissue and foreign material to eliminate the anaerobic environment where Clostridium tetani produces toxin 1, 2, 3
• Start antimicrobial therapy - Metronidazole is preferred over penicillin G to eliminate vegetative bacteria 3
• Do NOT administer tetanus vaccine during active infection - Tetanus toxoid provides no benefit for treating established infection and should only be given during convalescence 2

Supportive Care and Complications Management

Respiratory Support

• Implement early mechanical ventilation for respiratory compromise, as patients typically require prolonged ICU care for ≥4 weeks of intense symptoms 2, 3
• Tracheostomy and paralysis should be considered early in severe cases to reduce mortality 4

Autonomic Instability

• Monitor closely for cardiovascular instability, which is associated with high mortality and typically occurs during weeks 2-3 of illness 3, 5
• Maintain cardiac output without aggressive intervention when possible 5

Muscle Spasm Control

• Use benzodiazepines (diazepam), narcotics, and neuromuscular blockers to control severe muscle rigidity and spasms 6, 5
• Monitor for rhabdomyolysis secondary to severe muscle spasms 2, 3

Prognosis and Long-Term Sequelae

• The case-fatality rate remains 8-21% even with modern intensive care, with higher mortality in elderly patients 7, 2, 3
• Long-term neurologic sequelae and behavioral abnormalities may follow recovery 7, 3
• The disease course is typically intense for ≥4 weeks before subsiding, with a protracted convalescent period 7

Post-Recovery Immunization Protocol

Tetanus infection does NOT confer natural immunity - patients must complete a full primary immunization series after recovery. 2, 3

Vaccination Schedule for Previously Unvaccinated Adults

• First dose: Tdap (preferred over Td) during convalescence 2, 3
• Second dose: Td or Tdap at least 4 weeks after first dose 2
• Third dose: Td or Tdap 6-12 months after second dose 2

Special Population Considerations

Elderly Patients (≥60 years)

• Prioritize aggressive treatment - Elderly patients have higher mortality rates and represent 38% of tetanus cases despite being a smaller population proportion 3
• Only 45% of men and 21% of women aged ≥70 years have protective antibody levels 3
• Administer TIG liberally in elderly patients with uncertain vaccination history 1, 3

Immunocompromised Patients

• May require additional doses of TIG regardless of vaccination history 2

Critical Pitfalls to Avoid

• Never delay wound debridement - Surgical management is as critical as immunization 3
• Never assume natural immunity develops - Complete primary immunization series is mandatory after recovery 3
• Never withhold TIG in severe cases - Human TIG is vastly superior to equine antitoxin, which carries 7% immediate hypersensitivity reactions and 5% serum sickness risk 2
• Never administer tetanus vaccine during active infection - It provides no therapeutic benefit 2

Wound Management for Prevention (Not Active Tetanus)

Clean, Minor Wounds

• Administer tetanus toxoid booster if patient has not received a dose within 10 years 7, 1
• No TIG needed if primary series completed 1

Tetanus-Prone Wounds (Contaminated, Puncture, Necrotic)

• Administer tetanus toxoid if patient has not received dose within 5 years 7, 1
• Administer TIG 250 units IM if patient has not completed primary vaccination series (≥3 doses) 7, 1
• Use separate syringes and injection sites when giving both TIG and tetanus toxoid concurrently 7, 1

Preferred Vaccine Preparations

• Adults ≥7 years: Td or Tdap (preferred if not previously given) 1
• Children <7 years: DTP for inadequately vaccinated patients 7, 1