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. Labetalol, magnesium 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