The treatment of tetanus involves intensive care, muscle relaxant drugs and often assisted ventilation.
- patient should be nursed in a dark, quiet room to reduce the risk of precipitating spasms
- a low threshold to secure the airway must be maintained at all times and immediate intubation should be carried out in patients with respiratory distress (1)
Neutralization of unbound toxin
- human antitetanus immunoglobulin is given intramuscularly (IM) to neutralise the free circulating toxins
- 150units/kg of IM preparation may be given in multiple sites (IM preparations should not be given intravenously) (2)
Wound toilet
- should also be carried out to reduce the bacterial and toxin load.
Antibiotic therapy
- several antibiotics are useful against the tetanus bacterium
- Metronidazole - is the antibiotic of choice and has superseded penicillin, is used for 7 days (1g PR three times daily)
- the importance of penicillin in tetanus remains controversial : in a randomized, controlled trial mortality rate was higher in patients treated with penicillin when compared to metronidazole (24% vs 7%; P < 0.01)
- acceptable alternatives include - erythromycin, tetracycline, chloramphenicol and clindamycin
Control of muscle rigidity and spasms
- muscle spasms may be controlled effectively by sedation with
- benzodiazepine - considered to be the first line treatment
- diazepam (0.05-0.2mg/kg/h IV)
- midazolam
- opioids, such as morphine - can be equally efficacious and is usually used as an adjunct to benzodiazepine sedation
- alternatively, phenobarbitone (1.0mg/kg/6h IM) or IV with chlorpromazine (0.5mg/kg/6h IM). The chlorpromazine is started 3h after the phenobarbitone
- if all the above fails, then the patient is paralysed with tubocurarine 15mg IV and then ventilated.
Control of autonomic instability
- circulatory collapse caused by autonomic instability is responsible for a majority of deaths in tetanus
- sedation is the first line manoeuvre to control autonomic instability
- other treatment methods used in autonomic instability include
- magnesium sulphate - is useful in blocking catecholamine release from nerves and the adrenal medulla, and also reducing receptor responsiveness to released catecholamines. It is also a useful adjunct in the control of rigidity and spasms
- atropine
- clonidine
- beta-blockade - although theoretically useful, sudden cardiovascular collapse, pulmonary oedema and death has been implicated
Supportive therapy
- majority will require around 4-6 weeks of supportive therapy
- nutritional support should be initiated early with enteral feeding since dysphagia, altered gastrointestinal function and increased metabolic rate will result in poor nutrition and weight loss
- mouth care, chest physiotherapy and tracheal suction to prevent respiratory complication
- sufficient sedation when invasive procedures are being carried out (to avoid provoking spasm or autonomic instability)
- thromboembolism prophylaxis to prevent pulmonary embolism
- psychological support (1)
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