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.

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College Answer

This case is consistent with a diagnosis of severe generalized tetanus.

Management comprises:

  • 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.

Salient points

Management of tetanus:

  • ABCs
  • neutralise toxin with IM immunoglobulin
  • control sympathetic storm with labetalol/magnesium/clonidine
  • kill Clostridium with metronidazole and control the source

Discussion

This question would have killed most people.

Oh well. One approaches this as any other "outline your management" question.

A more generic discussion of tetanus is carried out in the Required Reading section.

  • Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history.
  • Airway
    • Intubate the patient for airway protection; laryngospasm is likely.
    • NIV with high PEEP could be a temporising measure
  • Breathing/ventilation
    • Adequate ventilator support with MV titrated to accomodate the increased CO2production in the context of increased muscular metabolic acivity.
  • Circulatory support
    • Tetanus is characterised by massive sympathetic stimulation, with tachycardia and hypertension. Labetalolmagnesium sulfate and clonidine have been used as antagonists.
  • Specific management
    • Administration of human tetanus immunoglobulin
    • Administration of antibiotics targeted at Clostridium tetani (metronidazole and benzylpenicillin)
    • Source control by wound debridement
    • Control of spasms with a neuromuscular junction blocker or benzodiazepine
    • Tetanus immunisation

References

Rodrigo, Chaturaka, Deepika Fernando, and Senaka Rajapakse. "Pharmacological management of tetanus; an evidence based review." Crit Care18 (2014): 217.

Cook, T. M., R. T. Protheroe, and J. M. Handel. "Tetanus: a review of the literature." British Journal of Anaesthesia 87.3 (2001): 477-487.

Wesley, A. G., et al. "Labetalol in tetanus." Anaesthesia 38.3 (1983): 243-249.

Attygalle, D., and N. Rodrigo. "Magnesium as first line therapy in the management of tetanus: a prospective study of 40 patients*." Anaesthesia 57.8 (2002): 778-817.