What is the management of established tetanus?

Management of Established Tetanus

Patients with established tetanus require immediate administration of human Tetanus Immune Globulin (TIG) at 250-500 units intramuscularly, aggressive wound debridement, antibiotic therapy with metronidazole, high-dose benzodiazepines for muscle spasms, early tracheostomy for moderate-to-severe cases, and intensive care unit monitoring for autonomic dysfunction—the leading cause of death in modern management. 1, 2

Immediate Pharmacological Interventions

Tetanus Immune Globulin (TIG)

• Administer human TIG immediately at 250-500 units intramuscularly to neutralize circulating tetanospasmin that has not yet bound to neural tissue 1, 2
• TIG cannot reverse damage from toxin already bound to the central nervous system, making prompt administration critical 2
• Human TIG is superior to equine antitoxin, which carries 7% immediate hypersensitivity reactions and 5% serum sickness risk 1
• If administering TIG concurrently with tetanus toxoid (for post-recovery immunization), use separate injection sites 2

Antibiotic Therapy

• Initiate metronidazole 500 mg IV every 6-8 hours as first-line therapy to eliminate Clostridium tetani 1, 2
• Alternative: penicillin G 2-4 million units IV every 4-6 hours if metronidazole unavailable 2
• Continue antibiotics for 7-14 days 2
• Antibiotics eliminate the organism but do not affect toxin already released, emphasizing the need for concurrent TIG 2

Surgical Management

Wound Care

• Perform thorough surgical debridement of all wounds to remove necrotic tissue and create aerobic conditions unfavorable for C. tetani growth 1, 2
• Wound debridement is critical because it removes the source of ongoing tetanospasmin production 1
• Even in cases where no obvious wound is identified (4% of cases), search for nonacute skin lesions such as ulcers or abscesses 3

Control of Muscle Spasms and Rigidity

Benzodiazepine Therapy

• Administer high-dose diazepam as the cornerstone of spasm control: 0.2-1 mg/kg/hour via nasogastric tube 4
• For acute severe spasms, give diazepam 5-10 mg IV initially, repeated every 3-4 hours as necessary 5
• In tetanus, larger doses than standard may be required—up to 20 mg IV or more for refractory spasms 5
• Diazepam reduces rigidity, spasms, and autonomic dysfunction through GABA-ergic mechanisms 4

Neuromuscular Blockade

• Use neuromuscular blocking agents with mechanical ventilation for refractory spasms uncontrolled by benzodiazepines 4
• This intervention is reserved for severe cases where spasms threaten respiratory function 4

Airway Management

Early Tracheostomy

• Perform early elective tracheostomy in moderate or severe tetanus to prevent aspiration and manage laryngeal stridor 4
• Tracheostomy is preferred over prolonged endotracheal intubation given the typical disease course of 2-4 weeks 6
• Median duration of mechanical ventilation in severe cases is 16 days [IQR 12-24 days] 6

Respiratory Support

• Facilities for respiratory assistance must be readily available before administering IV diazepam 5
• Mechanical ventilation is required in approximately 50% of tetanus patients 6
• Monitor for apnea triggered by severe spasms, which can cause rhabdomyolysis 4

Management of Autonomic Dysfunction

Recognition and Monitoring

• Autonomic nervous system dysfunction (dysautonomia) is the leading cause of death in modern tetanus management, occurring in 25% of patients 4, 6
• Manifestations include labile hypertension, tachycardia, increased secretions, sweating, urinary retention, and unexpected cardiac arrest 4, 7
• Dysautonomia typically occurs in severe tetanus and is difficult to manage 4

Magnesium Sulfate

• Administer magnesium sulfate infusion to control autonomic overactivity 4
• Magnesium helps stabilize cardiovascular parameters and reduce catecholamine surges 4

Supportive Care in the ICU

Nutritional Support

• Place nasogastric tube for feeding and medication administration due to dysphagia and trismus 4
• Maintain adequate nutrition throughout the prolonged ICU course (median 15 days, IQR 8-23 days) 6

Infection Prevention

• Hospital-acquired infections occur in 43% of tetanus patients, requiring vigilant infection control measures 6
• Monitor for ventilator-associated pneumonia, catheter-related infections, and other nosocomial complications 6

Environmental Control

• Minimize stimuli that trigger spasms: reduce touch, pain, bright lights, and loud sounds 4
• Maintain a quiet, darkened ICU environment when possible 4

Critical Pitfalls to Avoid

• Do NOT delay TIG administration while awaiting laboratory confirmation—tetanus is a clinical diagnosis based on trismus, rigidity, and spasms 2
• Do NOT administer tetanus vaccine (tetanus toxoid) during acute infection—it provides no benefit for treating established tetanus and should only be given after recovery 1
• Do NOT assume adequate immunity based on age—38% of cases occur in patients ≥65 years, and 49-66% of adults ≥60 years lack protective antibody levels 3, 2
• Do NOT use equine antitoxin if human TIG is available due to higher allergic reaction risk and shorter protection duration 2

Prognostic Considerations

• Overall mortality ranges from 5-50% depending on disease severity and ICU capabilities 4
• Case-fatality rate in the United States is 18-21% even with modern intensive care 3, 1
• Elderly patients have higher mortality rates due to lower baseline immunity and comorbidities 1
• Before ICU protocols, mortality was 43.58%; with intensive care management, mortality decreased to 15% 7
• Unexpected cardiac arrest from autonomic dysfunction has replaced early respiratory failure as the primary cause of death in ICU-managed patients 7

Post-Recovery Immunization

• Tetanus infection does NOT confer natural immunity—patients must complete a full primary immunization series after recovery 1, 2
• Administer first dose of Tdap (preferred over Td) after clinical recovery 1
• Give second dose at least 4 weeks after first dose 1
• Give third dose 6-12 months after second dose to complete the primary series 1
• Maintain documentation for future wound management and 10-year booster schedule 1