Last edited 11/2019

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    • Metronidazole  - is the antibiotic of choice and has superseded penicillin, is used for 7 days (1g PR three times daily)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)