›Administer at different site from vaccine
›Timing: administer as early as possible
›If hTIG unavailable, equine tetanus antitoxin
›Administer intradermal test dose first (hypersensitivity risk)
›10,000-20,000 IU IV or IM
›Wound debridement
›Remove all necrotic and devitalized tissue
›Eliminate anaerobic microenvironment for C. tetani
›Irrigate with hydrogen peroxide or dilute povidone-iodine
›Delay debridement until after hTIG administration when possible
›Debridement may release toxin into circulation
›Metronidazole (first-line)
›500 mg IV every 6-8 hours for 10 days
›Kills C. tetani vegetative forms at wound site
›Preferred over penicillin
›Oral switch when patient can tolerate
›Penicillin (avoid as first-line)
›Non-competitive GABA-A receptor antagonist
›Can potentiate tetanus neurotoxin-mediated disinhibition
›Theoretical risk of increased spasm severity
›Use only if metronidazole contraindicated
›Tetanus toxoid vaccine
›Td or Tdap 0.5 mL IM
›Administer at different site from hTIG
›Regardless of prior vaccination status
›Prior tetanus infection does not confer immunity
›Complete 3-dose primary series if previously unvaccinated
›0, 4-8 weeks, 6-12 months schedule
›Td booster every 10 years lifelong thereafter
Autonomic dysfunction management
›Magnesium sulfate infusion
›Loading dose 40-80 mg/kg IV over 30 minutes
›Reduces neuromuscular junction acetylcholine release
›Adjunctive spasm control and autonomic stabilization
›Continuous infusion 1-3 g/hour
›Titrate to loss of deep tendon reflexes as endpoint
›Monitor serum magnesium level every 4-6 hours
›Target magnesium 2-4 mmol/l
›Calcium gluconate 10 mL of 10% IV at bedside for magnesium toxicity
›Labetalol for sympathetic hyperactivity
›0.25-1 mg/min IV infusion
›Combined alpha and beta blockade
›Preferred for catecholamine surges
›Oral labetalol transition when stable
›Morphine sulfate for autonomic storm
›0.5-1 mg/hour IV infusion
›Adjunct for catecholamine surge and pain
›Vasopressors for hypotensive episodes
›Norepinephrine 0.05-0.5 mcg/kg/min IV
›Hypotension from sudden vasodilation during autonomic cycling
›Dopamine as alternative
›5-20 mcg/kg/min IV
Supportive and preventive care
›Airway and ventilation
›Early intubation for Ablett Grade 3-4 disease
›Tracheostomy for prolonged ventilation >14 days
›Lung-protective ventilation 6 mL/kg IBW tidal volume
›Nutrition
›NPO if significant trismus or dysphagia
›Aspiration risk from dysphagia
›Nasogastric tube feeding when safe
›High caloric needs: 35-45 kcal/kg/day from hypermetabolic state
›Parenteral nutrition if enteral not tolerated
›Venous thromboembolism prophylaxis
›Heparin 5000 units subcutaneous every 8-12 hours
›Mandatory during prolonged immobility
›Pneumatic compression devices when anticoagulation contraindicated
›Rhabdomyolysis management
›IV fluid resuscitation: normal saline or lactated Ringer
›Target urine output 200-300 mL/hour until myoglobinuria clears
›Urinary catheter to monitor output
›Environmental control
›Quiet, dark room with minimal stimuli
›Earplugs and light-blocking blinds
›Limit nursing interventions to minimum required
›Oral hygiene
›Chlorhexidine mouth rinse every 4-6 hours
›Aspiration pneumonia prevention