Key Principles
- Supportive care with intubation & ventilation and control of autonomic instability
- Human tetanus immunoglobulin to remove systemic toxin
- Wound debridement and antibiotics to reduce bacterial load
Initial Resuscitation & Supportive Care
- ABCDE approach treating abnormalities as found
- Intubation may be required due to:
- Airway compromise
- Respiratory failure
- Need for heavy sedation
- Consider early tracheostomy
- Vigilant monitoring of renal function to detect rhabdomyolysis
- Meticulous supportive care essential as often prolonged illness:
- Establish early enteral feeding
- Suctioning and respiratory physiotherapy
- Thromboprophylaxis
Specific Managment
Prevent Further Toxin Release
- Adequate wound toilet:
- May require repeat surgical debridement
- including surgical debridement of wounds
- Administration of IV antibiotics:
- Metronidazole 500 mg tds is the first line choice
- Penicillin second line option
Neutralise Toxin Present
- Give human tetanus immunoglobulin (HTIG):
- IV recommended (given in the form of IVIG)
- Can be given intrathecally
- Tetanus toxoid following acute phase to promote active immunity
Minimize Effects of Toxin in the CNS
- Avoid external stimuli causing spasms
- Nurse in a quiet dark room
- Minimise contact
- Management of muscle spasms:
- May require heavy sedation necessitating intubation
- Benzodiazepines and magnesium first line
- Intrathecal baclofen may have role
- Neuromuscular blockers in resistant spasms
- Management of autonomic instability:
- Clonidine
- Beta-blockers (esmolol / propanolol)
- Opiates
- Epidural bupivacaine
Monitoring, Referral & Deposition
- Patients with moderate to severe disease necessitate ICU management - consider monitoring all patient on ICU given risk of life threatening complications
- Requires comprehensive MDT involvement
- Notifiable disease - Health Protection Team should be contacted about all suspected cases