Tetanus in Emergency Medicine Treatment & Management

  • Author: Daniel J Dire, MD, FACEP, FAAP, FAAEM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Sep 20, 2011
 

Emergency Department Care

Treatment of tetanus is directed toward the treatment of muscle spasm, prevention of respiratory and metabolic complications, neutralization of circulating toxin to prevent the continued spread, and elimination of the source.

Admit patients to the intensive care unit (ICU). Because of the risk of reflex spasms, maintain a dark and quiet environment for the patient. Avoid unnecessary procedures and manipulations.

Seriously consider prophylactic intubation in all patients with moderate-to-severe clinical manifestations. Intubation and ventilation are required in 67% of patients.

  • Attempting endotracheal intubation may induce severe reflex laryngospasm; prepare for emergency surgical airway control. Rapid sequence intubation techniques (eg, with succinylcholine) are recommended to avoid this complication.
  • Perform tracheostomy in patients requiring intubation for more than 10 days. Tracheostomy has also been recommended after onset of the first generalized seizure.

Tetanus immune globulin (TIG) is recommended for treatment of tetanus. TIG can only help remove unbound tetanus toxin, but it cannot affect toxin bound to nerve endings. A single intramuscular dose of 3000-5000 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified. The World Health Organization recommends TIG 500 units by intramuscular injection or intravenously (depending on the available preparation) as soon as possible; in addition, administer age-appropriate TT-containing vaccine (Td, Tdap, DT, DPT, DTaP, or TT depending on age or allergies), 0.5 cc by intramuscular injection at separate site.

Tetanus disease does not induce immunity; patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6-12 months later.

Surgical therapy includes debridement of wounds to remove organisms and to create an aerobic environment.

  • The current recommendation is to excise at least 2 cm of normal viable-appearing tissue around the wound margins.
  • Incise and drain abscesses.
  • Delay any wound manipulation until several hours after administration of antitoxin due to risk of releasing tetanospasmin into the bloodstream.
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Consultations

  • An intensive care medicine specialist should be the primary physician coordinating the patient's care.
  • Consult a pulmonary medicine specialist after admission to the ICU for patients with severe respiratory symptoms or those requiring mechanical ventilation.
  • Consult an anesthesiologist after admission to the ICU if intrathecal baclofen is to be administered.
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Contributor Information and Disclosures
Author

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Specialty Editor Board

Theodore J Gaeta, DO, MPH, FACEP  Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency 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

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Joseph U Becker, MD.

References

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  2. Apte NM, Karnad DR. Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg. Oct 1995;53(4):386-7. [Medline].

  3. World Health Organization. WHO Technical Note: Current recommendations for treatment of tetanus during humanitarian emergencies. January 2010. [Full Text].

  4. Thwaites CL, Yen LM, Loan HT, Thuy TT, Thwaites GE, Stepniewska K. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet. Oct 21 2006;368(9545):1436-43. [Medline].

  5. Ahmadsyah I, Salim A. Treatment of tetanus: an open study to compare the efficacy of procaine penicillin and metronidazole. Br Med J (Clin Res Ed). Sep 7 1985;291(6496):648-50. [Medline].

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  7. Hatamabadi HR, Abdalvand A, Safari S, Kariman H, Dolatabadi AA, Shahrami A, et al. Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status. Am J Emerg Med. Sep 2011;29(7):717-20. [Medline].

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  19. Wassilak SGF, Roper MH, Murphy TV, Orenstein WA. Tetanus. In: Plotkin SA, Orenstein WA, eds. Vaccines. 4th ed. Philadelphia, Pa: Saunders; 2003:745-81.

 
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Tetanus Cases in US from 1947-2005. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
Image from "Number of Tetanus Cases Reported and Average Annual Incidence Rates, by State." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
Image from "Number of Tetanus Cases Reported, Average Annual Incidence Rates, and Survival Status of Patients, by Age Group." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
Image from "Number of Tetanus Cases Reported Among Persons With Diabetes or Injection-Drug Use (IDU), by Age Group." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
Age Distribution of Tetanus Case in the US from 1980-2003. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
Tetanus Wound Management. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
 
 
 
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