Tetanus Treatment & Management

  • Author: Patrick B Hinfey, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 28, 2011
 

Medical Care

Passive immunization with human tetanus immune globulin (TIG) shortens the course of tetanus and may lessen its severity. A dose of 500 U may be as effective as larger doses. Therapeutic TIG (3,000-6,000 units as 1 dose) has also been recommended for generalized tetanus.[8]

  • ICU admission and supportive therapy may include ventilatory support, high-calorie nutritional support, and pharmacologic agents that treat reflex muscle spasms, rigidity, tetanic seizures and infections.
  • Benzodiazepines have emerged as the mainstay of symptomatic therapy for tetanus. To prevent spasms that last longer than 5-10 seconds, administer diazepam intravenously, typically 10-40 mg every 1-8 hours. Vecuronium (by continuous infusion) or pancuronium (by intermittent injection) are adequate alternatives.
  • Magnesium sulfate at a loading dose of 40 mg/kg, followed by continuous intravenous infusion of 1.5 g/h if the patient weighs less than 45 kg or 2 g/h if the patient weighs more than 45 kg, can be used to help control muscle spasms and tetanus-associated autonomic dysfunction.[9]
  • Penicillin G, which has been used widely for years, is not the drug of choice. Metronidazole (eg, 0.5 g q6h) has comparable or better antimicrobial activity, and penicillin is a known antagonist of GABA, as is tetanus toxin.
  • Physicians also use sedative hypnotics, narcotics, inhalational anesthetics, neuromuscular blocking agents, and centrally acting muscle relaxants (eg, intrathecal baclofen).
  • To date, reports indicate that more than 26 adults with severe tetanus have been treated with intrathecal baclofen to manage muscle rigidity and spasms. A representative dose of the continuous infusion is 1750 mcg per day. Case reports and small case series outline the efficacy of intrathecal baclofen in controlling muscle rigidity.[10, 11] The effects of baclofen begin within 1-2 hours and persist 12-48 hours. The half-life elimination of baclofen in CSF ranges from 0.9-5 hours. After lumbar intrathecal administration, the cervical-to-lumbar concentration ratio is 1:4. The major adverse effect of baclofen is a depressed level of consciousness (LOC) and respiratory compromise.
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Surgical Care

In most cases, the wound responsible for tetanus is clear upon presentation. Surgical debridement has no benefit for tetanus. If debridement is indicated, it should be undertaken after the patient has been stabilized.

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Consultations

  • Critical care - To admit the patient with tetanus
  • Toxicology - To help confirm or exclude strychnine toxicity as the cause of symptoms
  • Neurology - To confirm or exclude seizures as a possible etiology of symptoms
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Contributor Information and Disclosures
Author

Patrick B Hinfey, MD  Research Director and Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center; Clinical Assistant Professor of Emergency Medicine, New York College of Osteopathic Medicine

Patrick B Hinfey, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Stroke Association, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jill Ripper, MD, MS  Residency Director, Newark Beth Israel Medical Center

Jill Ripper, MD, MS is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Christian August Engell, MD  Attending Physician, Department of Infectious Diseases, Newark Beth Israel Medical Center

Christian August Engell, MD is a member of the following medical societies: Infectious Diseases Society of America and Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Keith N Chappell, MD  Administrative Chief Resident, Junior Attending Resident, Department of Emergency Medicine, Newark Beth Israel Medical Center

Disclosure: Newark Beth Israel Medical Center Salary Employment

Specialty Editor Board

Gregory William Rutecki  MD, Professor of Medicine, University of South Alabama Medical School

Gregory William Rutecki is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard B Brown, MD, FACP  Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Eleftherios Mylonakis, MD, to the development and writing of this article.

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