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.
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