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