What is the recommended acute management for tetanus, including wound debridement, tetanus immune globulin (TIG), tetanus‑diphtheria (Td) or tetanus‑diphtheria‑pertussis (Tdap) vaccination, antibiotics, muscle‑spasm control, and supportive care?

Acute Management of Tetanus

Immediate Life-Saving Interventions

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

• The case fatality rate remains 18-21% even with modern intensive care, primarily due to respiratory complications and autonomic dysfunction. 1
• Mortality ranges from 5-50% overall, with higher rates in elderly patients and those with severe disease. 2

Neutralize Circulating Toxin

Administer human tetanus immune globulin (TIG) 250-500 units intramuscularly immediately to neutralize circulating tetanospasmin that has not yet bound to neural tissue. 2

• TIG cannot reverse damage already caused by toxin that has bound to the central nervous system, making prompt administration critical. 2
• Never delay TIG administration while awaiting laboratory confirmation—tetanus is a clinical diagnosis. 2
• Use separate injection sites when administering TIG concurrently with tetanus toxoid to prevent interference with the immune response. 2, 1
• Human TIG is strongly preferred over equine antitoxin due to longer duration of protection and lower risk of allergic reactions. 2

Intrathecal TIG Consideration

• Intrathecal TIG 250 IU may reduce disease progression and mortality compared to intramuscular administration alone (3% vs 31% worsening; 2% vs 21% mortality in one study), though this is not standard practice in most guidelines. 3

Eliminate the Toxin Source

Perform thorough surgical debridement of all wounds immediately to remove necrotic tissue and create aerobic conditions unfavorable for Clostridium tetani growth. 2, 1

Initiate antibiotic therapy with metronidazole 500 mg IV every 6-8 hours for 7-14 days as the preferred agent. 2

• Metronidazole is preferred over penicillin G due to concerns about GABA antagonist properties of penicillin, though penicillin G 2-4 million units IV every 4-6 hours is an acceptable alternative. 2
• Antibiotics eliminate the organism but do not neutralize toxin already produced. 2

Active Immunization

Administer tetanus toxoid vaccine (Td or Tdap) immediately during acute management at a separate anatomic site from TIG because natural tetanus infection provides no immunity whatsoever. 1

• Patients who survive tetanus remain fully susceptible to future infections unless actively immunized. 1
• Tdap is preferred for adults who have not previously received it to provide additional pertussis protection. 1
• Use separate syringes and anatomic sites when giving TIG and tetanus toxoid concurrently. 1

Control Muscle Spasms

Initiate benzodiazepines as first-line therapy for muscle spasm control, with escalation to neuromuscular blockade and mechanical ventilation for severe cases. 2

• Prolonged sedation and analgesia are often required for severe dysautonomia. 4
• Prepare for intensive care unit admission for all but the mildest cases. 2

Supportive Care Priorities

Provide comprehensive supportive care including:

• Continuous cardiorespiratory monitoring for autonomic dysfunction 4
• Maintenance of fluid and electrolyte balance 2
• Nutritional support for prolonged illness 2
• Prevention of nosocomial complications during extended ICU stay 2

Critical Pitfalls to Avoid

Do not assume adequate immunity based on age or history—38% of tetanus cases occur in patients ≥65 years, and only 21% of women >70 years have protective antibody levels. 2

Do not delay treatment for laboratory confirmation—tetanus is diagnosed clinically based on trismus, muscle rigidity, and spasms in the setting of a wound. 2

Do not use equine antitoxin if human TIG is available due to higher risk of allergic reactions and shorter duration of protection. 2

Do not forget to administer tetanus toxoid vaccine—this is essential because surviving tetanus does not confer immunity. 1

Special Population Considerations

• Elderly patients have significantly higher mortality and are less likely to have protective antibody levels. 1
• In resource-limited settings, prioritize TIG administration to patients >60 years if supplies are limited. 1
• Severely immunocompromised patients require TIG regardless of vaccination history. 1

Prognostic Factors

• The mortality rate correlates with severity of disease, age >60 years, and time from symptom onset to treatment. 2
• Even with optimal intensive care, case-fatality rates remain 18-21% in developed countries. 2, 1
• Recovery is typically slow, requiring weeks to months of rehabilitation. 4