Treatment of Grade 3 Tetanus
For a patient with grade 3 (severe) tetanus, immediate administration of high-dose human Tetanus Immune Globulin (TIG), aggressive wound debridement, intravenous metronidazole, benzodiazepines for spasm control, and early mechanical ventilation are essential—with mortality remaining high (18-21%) even with optimal intensive care. 1, 2
Immediate Pharmacological Interventions
Administer TIG at higher doses than prophylactic dosing (prophylactic dose is 250 units IM; treatment doses for established tetanus range from 3,000-6,000 units) to neutralize circulating tetanospasmin toxin 1, 3
Initiate intravenous metronidazole as the preferred antibiotic (or penicillin G as alternative) to eliminate Clostridium tetani and halt further toxin production 4, 1, 5
Do NOT administer tetanus toxoid vaccine during active infection, as it provides no therapeutic benefit for established tetanus—vaccination should only occur after recovery 1
Surgical Management
Perform thorough surgical debridement of all necrotic tissue and wound cleaning to remove the anaerobic environment where C. tetani produces toxin 4, 1, 2, 5
Wound debridement is critical even if cultures are negative, as C. tetani isolation has limited diagnostic value 6
Neuromuscular Symptom Control
Administer high-dose benzodiazepines (diazepam 0.2-1 mg/kg/hour via nasogastric tube) for muscle rigidity, spasm control, and autonomic dysfunction management 5, 6
Add neuromuscular blocking agents (pancuronium bromide) with mechanical ventilation for refractory spasms that cannot be controlled with benzodiazepines alone 5, 6
Consider adjunctive narcotics (morphine) and chlorpromazine for additional sedation and muscle relaxation 6
Respiratory Support
Perform early elective tracheostomy in moderate-to-severe tetanus to prevent aspiration and manage laryngeal stridor, as respiratory compromise is a leading cause of mortality 5
Implement mechanical ventilation for patients with progressive descending paralysis or refractory spasms causing apnea 5, 6
Autonomic Dysfunction Management
Monitor closely for dysautonomia (labile hypertension, tachycardia, increased secretions, sweating, urinary retention), which typically occurs during weeks 2-3 and is a common cause of death 5, 6, 7
Administer intravenous magnesium sulfate infusion as the preferred agent for controlling autonomic instability 5, 7
Maintain cardiac output monitoring, as autonomic instability may resolve without specific treatment in some cases 6
Supportive Care Measures
Place patient in a semidark, quiet room to minimize triggers (touch, pain, bright light, sounds) that precipitate severe spasms 6
Insert nasogastric tube for feeding and medication administration, as dysphagia is common 5
Administer ranitidine or equivalent for stress ulcer prophylaxis 6
Provide heparin for deep-vein thrombosis prevention during prolonged immobilization 6
Monitor for rhabdomyolysis due to severe muscle spasms 1
Special Considerations for Elderly Patients
Elderly patients require particularly aggressive management, as they have higher mortality rates due to lower prevalence of protective antibody levels (only 21% of women and 45% of men >70 years have protective levels) 1, 2
Consider additional doses of TIG for elderly patients regardless of vaccination history 1
Expected Clinical Course
Patients typically require several weeks of intensive care hospitalization (5-6 weeks for ventilatory support in severe cases) 6, 7
Autonomic instability peaks during weeks 2-3 of illness 5, 6
Mortality ranges from 18-21% with modern intensive care, and remains as high as 50% without access to mechanical ventilation 1, 2, 5, 7
Patients are vulnerable to secondary complications including hospital-acquired infections and pulmonary complications 7
Post-Recovery Immunization
Tetanus infection does NOT confer natural immunity, so patients must complete a full primary immunization series after recovery 1, 2
For previously unvaccinated adults: First dose Tdap (preferred), second dose Td/Tdap at least 4 weeks later, third dose Td/Tdap 6-12 months after second dose 1
Critical Pitfalls to Avoid
Do not delay TIG administration while awaiting culture results, as C. tetani isolation is unreliable and diagnosis is clinical 6
Do not administer tetanus toxoid during active infection—this is a common error that provides no benefit 1
Do not underestimate the need for prolonged intensive care monitoring, as autonomic dysfunction can be life-threatening 5, 7
Recognize that even with complete vaccination history, severe tetanus can occur if post-exposure prophylaxis was inadequate 8