What is the management approach for a patient with tetanus?

Management of Tetanus

Immediate Life-Saving Interventions

Administer human Tetanus Immune Globulin (TIG) immediately at 250 units intramuscularly for prophylaxis or higher doses for established tetanus to neutralize circulating toxin, perform aggressive wound debridement to eliminate the source of toxin production, and initiate metronidazole as the preferred antibiotic to eradicate Clostridium tetani. 1, 2

Critical Initial Steps

• Tetanus Immune Globulin (TIG): Administer promptly—250 units IM for prophylaxis, with higher doses required for established tetanus infection 1
• Wound management: Perform thorough surgical debridement of all necrotic tissue to remove anaerobic conditions that allow C. tetani toxin production 3, 1, 2
• Antimicrobial therapy: Metronidazole is the preferred agent over penicillin G to eliminate the organism 1
• Do NOT administer tetanus vaccine (tetanus toxoid) to patients with active tetanus infection—it provides no benefit for treating established disease 1

Respiratory and Autonomic Support

Early intubation and mechanical ventilation are essential for respiratory compromise, as tetanus mortality is primarily driven by respiratory failure and autonomic instability. 1, 4

• Implement early respiratory support with mechanical ventilation for any signs of respiratory compromise, laryngeal spasm, or severe spasms 1, 4
• Perform early elective tracheostomy in moderate-to-severe tetanus to prevent aspiration and manage laryngeal stridor 4
• Monitor closely for autonomic instability (labile hypertension, tachycardia, dysautonomia), which is associated with high mortality and is difficult to manage 1, 4
• Consider magnesium sulfate infusion for autonomic overactivity management 4

Spasm Control and Sedation

• Administer benzodiazepines (diazepam) to reduce rigidity, spasms, and autonomic dysfunction—large doses may be required (0.2-1 mg/kg/h via nasogastric tube) 4, 5
• Use neuromuscular blocking agents and mechanical ventilation for refractory spasms that cannot be controlled with benzodiazepines alone 4
• Monitor for rhabdomyolysis secondary to severe muscle spasms 1

Special Population Considerations

Elderly patients require particularly aggressive management as they have significantly higher mortality rates—only 45% of men and 21% of women aged >70 years have protective antibody levels, and 38% of all tetanus cases occur in those >65 years. 2

• Elderly patients often require prolonged mechanical ventilation (median 31 days) and extended hospitalization (median 77 days) 6
• Immunocompromised patients may require additional doses of TIG regardless of vaccination history 1, 2
• The case fatality rate remains 18-21% even with modern intensive care 1, 2

Post-Recovery Immunization

Tetanus infection does NOT confer natural immunity—patients must complete a full primary immunization series after recovery. 1

• For previously unvaccinated adults, administer a 3-dose series: first dose Tdap (preferred), second dose Td or Tdap at least 4 weeks later, third dose 6-12 months after the second 1, 2
• Document vaccination status meticulously for future wound management 2

Common Pitfalls to Avoid

• Never delay TIG administration—circulating toxin must be neutralized immediately, though TIG cannot reverse toxin already bound to neural tissue 1
• Do not give tetanus vaccine during active infection—this is a common error; vaccination only helps prevent future disease, not treat current infection 1
• Do not underestimate the duration of care required—severe tetanus requires weeks of mechanical ventilation and intensive monitoring 4, 6
• Recognize that human TIG is superior to equine antitoxin, which carries 7% immediate hypersensitivity reactions and 5% serum sickness risk 1