eMedicine Specialties > Emergency Medicine > Infectious Diseases
Tetanus: Treatment & Medication
Updated: Mar 17, 2009
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Treatment
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.
- 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.
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.
Medication
Drugs used to treat muscle spasm, rigidity, and tetanic seizures include sedative-hypnotic agents, general anesthetics, centrally acting muscle relaxants, and neuromuscular blocking agents. Antibiotics are used to prevent multiplication of C tetani, thus halting production and release of toxins.
Anticonvulsants
Sedative-hypnotic agents are the mainstays of tetanus treatment. Benzodiazepines are the most effective primary agents for muscle spasm prevention and work by enhancing GABA inhibition. Diazepam is the most frequently studied and used drug. Diazepam reduces anxiety, produces sedation, and relaxes muscles.
Phenobarbital is another anticonvulsant that may be used to prolong effects of diazepam. Phenobarbital is also used to treat severe muscle spasms and provide sedation when neuromuscular blocking agents are used.
Diazepam (Valium)
Mainstay of treatment of tetanic spasms and tetanic seizures. Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of GABA, a major inhibitory neurotransmitter.
Adult
Mild spasms: 5-10 mg PO q4-6h prn
Moderate spasms: 5-10 mg IV prn
Severe spasms: Mix 50-100 mg in 500 mL D5W and infuse at 40 mg/h
Pediatric
Mild spasms: 0.1-0.8 mg/kg/d PO divided tid/qid
Moderate or severe spasms: 0.1-0.3 mg/kg IV q4-8h
Toxicity of benzodiazepines in CNS is increased when used concurrently with alcohols, phenothiazines, barbiturates, and MAOIs; cisapride can increase diazepam levels significantly
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients receiving other CNS depressants; caution in patients with low albumin levels or hepatic failure because diazepam toxicity may increase
Phenobarbital (Barbita, Luminal)
Drug dose must be small enough so that respirations are not depressed. If patient is already on a ventilator, higher doses may provide desired sedation.
Adult
1 mg/kg IM q4-6h; not to exceed 400 mg/d
Pediatric
5 mg/kg/d IV/IM divided tid/qid
May decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase phenobarbital toxicity; rifampin may decrease phenobarbital effects; induction of microsomal enzymes may result in decreased effects of oral contraceptives in women (must use additional contraceptive methods to prevent unwanted pregnancy; menstrual irregularities also may occur)
Documented hypersensitivity; marked impairment of liver function; severe respiratory disease; nephritic patients
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, evaluate hematopoietic, renal, hepatic, and other organ systems; caution in fever, hyperthyroidism, diabetes mellitus, and severe anemia since adverse reactions can occur; caution in myasthenia gravis and myxedema
Skeletal muscle relaxants
These agents can inhibit both monosynaptic and polysynaptic reflexes at spinal level, possibly by hyperpolarization of afferent terminals.
Baclofen (Lioresal)
Intrathecal (IT) baclofen, a centrally acting muscle relaxant, has been used experimentally to wean patients off the ventilator and to stop diazepam infusion. IT baclofen is 600 times more potent than PO baclofen. Repeated IT injections have been efficacious in limiting duration of artificial ventilation or preventing intubation.
May induce hyperpolarization of afferent terminals and inhibit both monosynaptic and polysynaptic reflexes at spinal level.
Entire dose of baclofen is administered as a bolus injection. Dose may be repeated after 12 h or more if spontaneous paroxysms return.
Continuous IT baclofen has been reported in a very small number of patients with tetanus. Refer to manufacturer's product information on Lioresal IT for further information.
Adult
<55 years: 1000 mcg IT
>55 years: 800 mcg IT
Pediatric
<16 years: 500 mcg IT
>16 years: Administer as in adults
Opiate analgesics, benzodiazepines, alcohol, TCAs, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase baclofen effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with history of autonomic dysreflexia and when spasticity is used to obtain increased function; autonomic dysreflexia can result from withdrawal of this medication
Dantrolene (Dantrium)
Stimulates muscle relaxation by modulating skeletal muscle contractions at a site beyond the myoneural junction and by acting directly on the muscle. Not FDA approved for use in tetanus but has been described in a small number of case reports.
Adult
1 mg/kg IV over 3 h; repeat q4-6h prn
Pediatric
0.5 mg/kg IV bid initial; increase to 0.5 mg/kg IV bid/qid, then by increments of 0.5-3 mg/kg bid/qid prn; not to exceed 100 mg qid
Toxicity may increase with coadministration of clofibrate and warfarin; coadministration with estrogen may increase hepatotoxicity in women >35 y
Documented hypersensitivity; active hepatic disease (hepatitis, cirrhosis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause hepatotoxicity (use only for recommended indications); caution in impaired pulmonary function and severe cardiac insufficiency; may cause photosensitivity with exposure to sunlight
Antitoxins
These agents are used to neutralize any toxin that has not reached the CNS.
Tetanus immune globulins (Hyper-Tet, Bay-Tet)
Used as prophylaxis against tetanus and to treat patients with circulating tetanus toxin. TIG provides passive immunity. TIG should be used to treat all patients with active tetanus, in combination with other supportive and therapeutic treatments. Should also be used to prevent tetanus in patients with inadequate or unknown immunization status after an acute injury.
Adult
Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM
Pediatric
Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: Administer as in adults
Live-virus vaccines may not replicate successfully, and antibody response could be reduced when vaccine is administered after tetanus immune globulin because of presence of antibodies in the immune globulin; live-virus vaccines should ideally be administered at least 3 mo after therapy with tetanus immune globulin; if administration of an immune globulin preparation becomes necessary because of exposure to disease, live-virus vaccines can be given simultaneously with immune globulin at site remote from that chosen for immune globulin; vaccine virus replication and stimulation of immunity occurs 1-2 wk after vaccination, therefore, if interval between administration of vaccine and immune globulin is <14 d or if they were administered simultaneously, vaccination should be repeated at least 3 mo after immune globulin preparation was given, unless serologic testing indicates that adequate antibodies were formed
Patients with hypersensitivity to horse or cow proteins should not receive the equine or bovine antitoxins; do not inject in same site or with same syringe as tetanus toxoid; not to be administered intravenously
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with prior systemic allergic reactions following administration of human immunoglobulin preparations; caution in severe thrombocytopenia or any coagulation disorder that would contraindicate IM injections
Antibiotics
Administer to patients with clinical tetanus. However, efficacy is questioned. Theoretically, antibiotics may prevent multiplication of C tetani, thus halting production of toxin. Nevertheless, a study of 364 patients found no difference in fatality rates between patients who received antibiotics and those who did not. Penicillin G is the drug of choice. Metronidazole is considered by some to be a better drug. One study demonstrated a lower mortality for patients administered metronidazole compared with penicillin.3 Tetracycline is an alternative drug for patients who are allergic to penicillin or metronidazole. Large doses of antibiotics are recommended to favor diffusion into devitalized tissue.
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
A 10- to 14-d course of treatment is recommended. Large IV doses of penicillin may cause hemolytic anemia and neurotoxicity. Cardiac arrest has been reported in patients administered massive doses of penicillin G potassium. Patients with renal failure are particularly at risk.
Adult
10-24 million U/d IV/IM divided qid
Pediatric
100,000-250,000 U/kg/d IV/IM divided qid
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Metronidazole (Flagyl)
Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells, and intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
A 10- to 14-d course of treatment is recommended. Some consider this the DOC since penicillin G is also a GABA agonist, which may enhance effects of the toxin.
Adult
500 mg PO q6h or 1 g IV q12h; not to exceed 4 g/d
Pediatric
15-30 mg/kg/d IV divided q8-12h; not to exceed 2 g/d
Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol
Documented hypersensitivity; first trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Doxycycline (Vibramycin, Doxychel)
Inhibits protein synthesis and thus bacterial growth by binding with 30S and possibly 50S ribosomal subunits of susceptible bacteria. A 10- to 14-d course of treatment is recommended.
Adult
100 mg PO/IV q12h
Pediatric
<8 years: Not recommended
<100 lb (45 kg): 2 mg/lb/d (4.4 mg/kg/d) PO/IV divided bid
>100 lb (45 kg): Administer as in adults
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Neuromuscular blocking agents
These agents inhibit the transmission of nerve impulses at neuromuscular junctions of skeletal muscles and/or autonomic ganglia.
Vecuronium (Norcuron)
Prototypic, nondepolarizing neuromuscular blocking agent that reliably results in muscular paralysis. For maintenance of paralysis, a continuous infusion may be used.
Infants are more sensitive to neuromuscular blockade activity, and although the same dose is used, recovery is prolonged by 50%. Not recommended for use in neonates.
Adult
0.08-0.1 mg/kg IV; may reduce to 0.05 mg/kg if patient has been treated with succinylcholine
Maintenance of paralysis: 0.025-0.1 mg/kg/h IV; may titrate to desired train-of-4 response (commonly 2 of 4 twitches)
Pediatric
7 weeks to 1 year: 0.08-0.1 mg/kg/dose followed by maintenance dose of 0.05-0.1 mg/kg q1h prn
1-10 years: May require higher initial dose and more frequent supplementation
>10 years: Administer as in adults
When vecuronium is used concurrently with inhalational anesthetics, neuromuscular blockade is enhanced; renal or hepatic failure as well as concomitant administration of steroids may result in prolonged blockade despite withdrawal of the agent
Documented hypersensitivity; myasthenia gravis or related syndromes
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In myasthenia gravis or myasthenic syndrome, small doses of vecuronium may have profound effects
More on Tetanus |
| Overview: Tetanus |
| Differential Diagnoses & Workup: Tetanus |
 Treatment & Medication: Tetanus |
| Follow-up: Tetanus |
| Multimedia: Tetanus |
| References |
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References
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Further Reading
Keywords
tetanus, Tdap, DPT, tetanus shot, tetanus vaccine, tetanus vaccination, Clostridium tetani, C tetani, lockjaw, treatment, infection, tetanus symptoms, tetanus immunization, tetanus toxoid, booster, diphtheria and tetanus toxoids plus pertussis vaccinations, DPT vaccination, stiffness of the jaw, risus sardonicus, hypertonia, muscle spasms, lacerations, puncture wounds, burns, abrasions
