›Site of administration
›IM injection away from wound and vaccine site
›If hTIG unavailable
›Equine tetanus antitoxin 10,000-20,000 IU IV or IM
›Skin test for hypersensitivity before equine product
›Metronidazole — preferred antibiotic
›500 mg IV every 6 hours for 10 days
›Eradicates C. tetani vegetative forms
›Class I recommendation, Level B evidence
›Mechanism advantage over penicillin
›Penicillin is a GABA antagonist — may theoretically worsen spasms
›Metronidazole does not interfere with inhibitory neurotransmission
›Oral metronidazole equivalent once tolerating enteral
›400 mg orally every 8 hours
›Td or Tdap 0.5 mL IM
›Administer on admission at site different from hTIG
›Natural infection does not confer immunity
›Full 3-dose primary series required after recovery
›Tdap preferred for adults not previously vaccinated
›ACIP guideline recommendation
›Surgical debridement
›Remove necrotic tissue and foreign material
›Reduces ongoing toxin production
›Delay debridement until after hTIG administered
›Wound irrigation and anaerobic coverage
›Hydrogen peroxide irrigation for anaerobic environment disruption
Autonomic dysfunction management
›Cardiovascular stabilization
›Labetalol IV for sympathetic hyperactivity
›0.25 mg/kg IV bolus, then infusion 1-3 mg/min
›Combined alpha and beta blockade
›Avoid pure beta-blockers — rebound alpha stimulation risk
›Magnesium sulfate IV infusion
›Loading dose 40 mg/kg over 30 minutes
›Maintenance 2-3 g/hour
›Monitor reflexes, serum Mg target 2-4 mmol/l
›Reduces both spasm severity and autonomic instability
›Clonidine or dexmedetomidine for refractory sympathetic storm
›Central alpha-2 agonist effect
›Bradycardia management
›Pacing consideration for symptomatic bradycardia
›Atropine use controversial — may worsen surges
›Cautious use only for haemodynamically significant bradycardia
›Mechanical ventilation strategy
›Lung-protective ventilation
›Tidal volume 6 ml/kg ideal body weight
›PEEP 5-8 cmH2O
›Plateau pressure < 30 cmH2O
›Tracheostomy
›Consider at day 7-10 if prolonged ventilation anticipated
›Reduces airway stimulation triggers
›Facilitates weaning and spasm management
Nutrition and supportive care
›Enteral feeding
›Nasogastric tube — soft, small-bore
›Initiate within 24-48 hours of admission
›NPO only during active spasms and laryngospasm risk
›Caloric targets
›High metabolic demand from sustained muscle activity
›35-40 kcal/kg/day in severe disease
›DVT prophylaxis
›Prophylactic heparin 5000 units SC every 8-12 hours
›Mechanical compression stockings if heparin contraindicated
›VTE risk elevated from prolonged immobility
›Weaning protocol
›Begin taper at day 14-21 as spasms diminish
›Reduce dose by 10-20% every 48-72 hours
›Monitor for withdrawal: anxiety, tremor, seizures
›Physical therapy initiated early
›Passive ROM to prevent contractures
›Progressive mobilization as spasms resolve