A 67-year-old female has presented acutely with a diagnosis of tetanus. She sustained a laceration one week earlier while gardening and has now developed generalised spasms and respiratory distress.
Outline your specific management of this patient including management of the anticipated complications of tetanus.
This case is consistent with a diagnosis of severe generalized tetanus.
Airway management with intubation and mechanical ventilation
- Respiratory distress is most likely due to involvement of muscles of respiration and/or laryngospasm but pneumonia should be looked for and treated
- Early tracheostomy may be indicated
Neutralisation of unbound toxin
- Human tetanus immune globulin 3000-6000 units IM (some authorities advocate 500 units)
- Source control and limitation of toxin production
Debridement and cleaning of wound
- Appropriate antibiotics for 7-10 days – penicillin, 3rd generation cephalosporins (nb both GABA antagonists which may aggravate symptoms), metronidazole, erythromycin, doxycycline
Control of spasms
- Sedation with benzodiazepines +/- neuromuscular blockers. Intrathecal baclofen has been used. Avoid stimulation
Management of autonomic dysfunction
- Cause of death if respiratory failure avoided by intubation and ventilation
- Magnesium sulphate has been shown to be effective and labetalol (dual alpha and beta blocker) has also been used.
- Clonidine may be useful.
Initiation of full active tetanus immunization (with diphtheria and pertussis) given at site separate from TIG injection.
- CCC — Tetanus