›Mechanism
›Eradicates vegetative C. tetani at wound site
›Does not neutralize already-released toxin
›Penicillin G (alternative)
›Dose: 2 to 4 million units IV every 4 to 6 hours
›Duration 10 days
›Theoretical concern about GABA-A antagonism potentiating toxin
›Metronidazole preferred over penicillin
›Avoids theoretical potentiation of neurotoxin effect
›Multiple guidelines support this preference
›Wound debridement
›Thorough exploration and irrigation
›Remove all devitalized tissue
›Remove foreign bodies including retained teeth or bone fragments
›Timing relative to antitoxin
›Administer HTIG before debridement when possible
›Debridement releases additional toxin; antitoxin neutralizes it
›Specialist involvement
›Surgery, ENT, or oral surgery as appropriate to wound site
›Culture wound before debridement if possible
›Benzodiazepines (first-line)
›Diazepam IV
›Initial dose 10 to 30 mg IV
›Titration 10 to 20 mg IV every 1 to 4 hours PRN spasms
›Maximum dose limited by respiratory depression
›Midazolam infusion alternative
›0.1 to 0.3 mg/kg per hour infusion
›Titrate to spasm cessation
›Short half-life allows rapid titration
›Propofol (second-line)
›ICU setting required
›0.5 to 4 mg/kg per hour infusion
›Monitor for propofol infusion syndrome with prolonged use
›Advantages over benzodiazepines
›Predictable sedation
›Rapid offset
›Neuromuscular blocking agents (refractory spasms)
›Vecuronium preferred
›0.1 mg/kg IV bolus then infusion at 0.05 to 0.1 mg/kg per hour
›Preferred over pancuronium; does not worsen autonomic instability
›Pancuronium contraindicated
›Worsens autonomic instability
›Avoid in all tetanus cases
›Requires mechanical ventilation
›Confirm intubation before administration
›Train-of-four monitoring
Autonomic dysfunction management
›Magnesium sulfate
›Loading dose
›40 mg/kg IV over 30 minutes
›Reduces spasm frequency and autonomic instability
›Maintenance infusion
›2 g per hour titrated to clinical effect
›Target serum magnesium 2 to 4 mmol/l
›Monitoring during infusion
›Deep tendon reflexes every 1 to 2 hours
›Loss of patellar reflex indicates toxicity
›Respiratory rate monitoring
›Evidence: Lancet RCT (Thwaites 2006) showed reduced need for ventilation
›Significant reduction in sedative drug requirements
›Not significantly different in mortality
›Labetalol
›For sympathetic hyperactivity
›IV bolus 0.25 mg/kg every 15 minutes PRN
›Or infusion 1 to 2 mg per minute
›Combined alpha and beta blockade preferred over pure beta blockade
›Pure beta blockade may cause unopposed alpha vasoconstriction
›Labetalol addresses both receptor systems
›Clonidine
›Oral or transdermal for sustained autonomic control
›0.1 to 0.3 mg oral every 8 hours
›Adjunct to labetalol and magnesium
›Central sympatholytic mechanism
›Reduces catecholamine outflow
›Monitor for hypotension
›Nutritional support
›NPO initially if significant trismus or dysphagia
›High aspiration risk during acute phase
›Initiate enteral nutrition within 24 to 48 hours via NG tube
›Nasogastric tube feeding
›Small-bore soft tube reduces stimulation
›Standard ICU enteral formula
›Parenteral nutrition if enteral route not feasible
›Central venous access required
›Transitional until enteral tolerated
›DVT prophylaxis
›Low molecular weight heparin
›Enoxaparin 40 mg SC daily for standard prophylaxis
›High-risk dose if BMI or other risk factors
›Mechanical prophylaxis
›Sequential compression devices
›Combined with pharmacological prophylaxis
›Physical therapy
›Initiate bedside physiotherapy when spasms allow
›Passive range of motion
›Prevent contractures and muscle wasting
›Intensive rehabilitation during recovery phase
›4 to 6 weeks for inhibitory neurotransmission restoration
›Median ventilation duration 16 days in severe cases