01Approach to the Critical Patient/attcp40

Immediate priorities

›Airway and generalisation threats

›Trismus — inability to open mouth >2 finger-breadths

›Signals cephalic or early generalised spread

›Secure airway early; RSI preferred

›Dysphagia or dysphonia

›Pharyngeal involvement

›NPO, intubation planning

›Respiratory compromise

›Dyspnoea, tachypnoea, apnoeic spells

›SpO2 <94% or rising work of breathing

›If any alarm feature present, escalate to ICU-capable environment immediately

›Resuscitation bay with airway trolley at bedside

›Anaesthesia or critical care consultation

Monitoring and targets

›Monitoring bundle

›Continuous cardiac monitoring

›Labile BP and tachycardia suggest autonomic instability

›Bradycardia with sudden cardiac arrest is a recognised complication

›Continuous pulse oximetry

›SpO2 target >94%

›Desaturation indicates impending respiratory failure

›Stimulus-triggered spasm surveillance

›Auditory, tactile, and visual stimuli as triggers

›Quiet, darkened room to minimise stimuli

›Escalation triggers

›Spread of rigidity or spasms beyond injured limb

›Reclassify as generalised tetanus

02History/hx69

Presentation pattern

›Core syndrome

›Muscle stiffness, rigidity, or spasms confined to injured limb or region

›Mild cases may present with weakness only

›Spasms exacerbated by auditory, tactile, or visual stimuli

›Site of injury

›Puncture, laceration, abrasion, burn, crush injury

›Surgical wound, injection site, umbilical stump

›Incubation period

›3 to 21 days after wound (median ~7 days)

›Shorter incubation correlates with worse prognosis

Alarm features

›Features suggesting generalisation

›Trismus (lockjaw)

›Earliest sign of cephalic or generalised disease

›Inability to open mouth fully

›Dysphagia or voice changes

›Early pharyngeal involvement

›Risk of aspiration

›Opisthotonus or generalised rigidity

›Late sign of severe generalised tetanus

›Indicates ICU-level care

›Autonomic instability

›Labile BP, tachycardia or bradycardia, profuse sweating

›Urinary retention from autonomic dysfunction

›Period of onset <48 hours

›Time from first symptom to first spasm

›<48 hours associated with high mortality

03Physical Exam/exam49

Vital signs

›Vital sign assessment

›Blood pressure

›Labile BP and hypertension suggest autonomic involvement

›Hypotension with bradycardia as dysautonomia complication

›Heart rate

›Tachycardia with autonomic instability

›Bradyarrhythmia risk in severe disease

›Respiratory rate

›Tachypnoea with pharyngeal or respiratory muscle involvement

›SpO2 baseline on room air

›Temperature

›Fever rare early; suggests superinfection if present

Wound and local findings

›Wound inspection

›Portal of entry identification

›Necrotic tissue or foreign body

›Signs of local infection or abscess

›Localised rigidity and spasms

›Increased tone confined to the injured limb or region

›Stimulus-triggered spasms of the affected area

Generalisation screen

›Signs of generalised disease

›Trismus

›Inability to open mouth >2 finger-breadths

›Masseter rigidity on palpation

›Risus sardonicus

›Sustained facial muscle spasm

04Differential Diagnosis/ddx43

Life-threatening mimics

›Strychnine poisoning

›Virtually indistinguishable from tetanus clinically

›Onset within 30 minutes of ingestion

›Absence of tonic contraction between spasms (relaxation between spasms distinguishes from tetanus)

›ICD-10 T65.1

›Confirmable by serum or urine toxicology

›Neuroleptic malignant syndrome

›Altered mental status (consciousness preserved in tetanus)

›Very high CK elevation

›Gradual onset

›ICD-10 G21.0

›Dopamine antagonist exposure

Neuromuscular mimics

›Drug-induced dystonia

›Phenothiazines, metoclopramide, haloperidol

›Rapid onset

›Absence of trismus

›ICD-10 G24.0

›Reversible with procyclidine or diphenhydramine

›Hypocalcaemic tetany

›Low serum calcium

›Absence of trismus or facial spasms

›Chvostek and Trousseau signs positive

›ICD-10 E83.51

›Stiff-person syndrome or PERM

›Positive GAD or anti-glycine antibodies

›Rapid response to diazepam

05Laboratory Tests/lt46

Diagnostic approach

›Tetanus is a clinical diagnosis

›No confirmatory laboratory test exists

›Diagnosis based on history of wound + characteristic spasms

›Culture of wound rarely yields Clostridium tetani

›Laboratory work directed at ruling out mimics and assessing complications

›Serum calcium to exclude hypocalcaemic tetany

›Toxicology screen for strychnine or drug-induced dystonia

Core labs

›Infection and metabolic assessment

›Complete blood count

›Leukocytosis suggests superinfection

›Eosinophilia may suggest parasitic alternative

›Comprehensive metabolic panel

›Renal function for drug dosing

›Electrolytes including calcium and magnesium

›Serum calcium

›Exclude hypocalcaemic tetany

›Low calcium — positive Chvostek or Trousseau

›Lactate

›Elevated with autonomic instability and poor perfusion

›Repeat if elevated to trend response

Muscle injury markers

›Rhabdomyolysis workup

›Creatine kinase

›Elevated with prolonged or severe spasms

›Serial monitoring required for renal protection

›Urinalysis

06Diagnostic Tests/dt53

Scoring Systems

›Ablett classification of tetanus severity

›Grade I — Mild

›Localised spasm, no dysphagia, no respiratory impairment

›Local tetanus typically presents here

›Grade II — Moderate

›Moderate trismus, some dysphagia, mild rigidity

›Respiratory rate >30 per minute

›Grade III — Severe

›Severe trismus, dysphagia, opisthotonus, generalised rigidity

›Severe autonomic disturbance, tachycardia >120

›Grade IV — Very Severe

›Grade III plus violent autonomic disturbance

›Sudden cardiac arrest risk

›Phillips score

›Scoring factors

›Incubation period, site of infection, immunisation status, presence of complicating factors

›Score >10 predicts severe or fatal tetanus

›Clinical utility

›Guides ICU triage

›Not validated as primary ED tool

MRI

›MRI role in tetanus

›Not a first-line diagnostic test for tetanus

›Tetanus is a clinical and toxin-mediated diagnosis

›MRI brain and spine used to exclude CNS structural causes of focal rigidity

›Indications for MRI

›Atypical presentation without identifiable wound

07Disposition/dispo46

Admission criteria

›All suspected tetanus cases admitted

›Local tetanus requires inpatient admission even in mild forms

›Risk of rapid progression to generalised disease

›No safe outpatient management protocol

›ICU admission indications

›Any respiratory compromise or apnoeic spells

›Dysphagia or trismus indicating generalisation risk

›Autonomic instability — labile BP, bradycardia, tachycardia

›Ablett Grade II or higher

›Step-down unit minimum

›Direct ICU access required

Level of care

›Step-down versus ICU decision

›Mild local tetanus without alarm features

›Step-down unit with continuous monitoring

›ICU bed availability confirmed before admission

›Any generalisation features

›Direct ICU admission

›Mechanical ventilation capability at bedside

›Monitoring frequency

›Vital signs every 1 to 2 hours initially

›Reassessment for progression every 4 to 6 hours

Consultations

›Specialist consultations

›Infectious disease

›Management of C. tetani and antibiotic selection

›Vaccination guidance

08Treatment/t108

Immediate stabilisation

›Environmental measures

›Quiet, darkened room

›Minimise auditory, tactile, and visual stimuli

›Single nurse care reduces stimulation frequency

›Secure IV access

›Two large-bore peripheral IVs

›Arterial line if autonomic instability present

›Airway preparation

›Intubation equipment at bedside for all tetanus cases

›RSI preferred if intubation required — avoid suxamethonium in severe spasms due to hyperkalaemia risk

Antitoxin

›Human tetanus immunoglobulin (HTIG)

›Dose: 500 IU IM as single dose

›Administer at a different anatomical site from the tetanus toxoid

›Neutralises unbound circulating tetanospasmin only

›Timing: As soon as clinical diagnosis made

›Does not reverse already-bound toxin

›No benefit delayed beyond 48 to 72 hours of symptom onset

›If HTIG unavailable

›Equine tetanus antitoxin with intradermal test dose first

›Anaphylaxis risk with equine preparation

Antibiotic therapy

›Metronidazole (first-line)

›Dose: 500 mg IV every 6 to 8 hours

›Duration: 10 days

›Prevents ongoing C. tetani proliferation at wound site

›Mechanism advantage

›Does not inhibit GABA-A receptors (unlike penicillin)

›Preferred over penicillin for theoretical safety

›Alternative: Benzylpenicillin IV

›Use when metronidazole unavailable

›Penicillin is a non-competitive GABA-A inhibitor

›May theoretically potentiate tetanus neurotoxin effects

›Dose: 1.2 g IV every 6 hours for 10 days

›Avoided agents

›Phenothiazines and metoclopramide contraindicated

›Cause dystonic reactions mimicking tetanus

›Confound clinical assessment

Spasm control

›Benzodiazepines (first-line)

›Diazepam IV

›Titrate 5 to 10 mg IV every 1 to 4 hours as needed

›GABA-A agonist — counteracts tetanospasmin mechanism

›Lorazepam alternative

›2 to 4 mg IV every 4 to 6 hours

›Preferred in elderly or hepatic impairment

›Midazolam infusion for severe cases

›0.05 to 0.1 mg/kg/hour continuous infusion

›Titrate to spasm-free state

›Neuromuscular blockade for refractory spasms

›Vecuronium 0.1 mg/kg IV bolus then infusion

›Only with mechanical ventilation in place

›Requires concurrent sedation to avoid awareness

›Pancuronium 0.1 mg/kg IV

›Avoid if significant tachycardia or autonomic instability

›Vagolytic properties worsen tachycardia

Autonomic dysfunction management

›Magnesium sulfate

›Loading dose: 5 g IV over 20 minutes

›Maintenance: 2 to 3 g/hour continuous infusion

›Monitor for toxicity: patellar reflex, respiratory rate, serum Mg target 2 to 4 mmol/l

›Mechanism

›Inhibits catecholamine release and sensitisation

›Reduces cardiovascular instability

›Labetalol for hypertension and tachycardia

›Dose: 0.25 to 1 mg/kg IV bolus

›Infusion: 1 to 2 mg/minute titrated to effect

›Combined alpha and beta blockade for autonomic storms

›Avoid pure beta-blockers

›Risk of unopposed alpha-adrenergic vasoconstriction

›Sudden cardiovascular collapse reported

›Morphine sulfate for refractory autonomic instability

›2 to 4 mg IV every 4 hours titrated to effect

›Reduces catecholamine surge

›Monitor for respiratory depression

Active immunisation

›Tetanus toxoid (Td or Tdap)

›Dose: 0.5 mL IM at different site from HTIG

›Given simultaneously with HTIG but different limb

›Tetanus infection does not confer natural immunity

›Full vaccination schedule

›Dose 1 at time of treatment

›Dose 2 at 1 month

›Dose 3 at 1 year

›Tdap preferred for patients without recent pertussis coverage

›Boosters every 10 years thereafter

Wound care

›Wound debridement

›Surgical debridement of all necrotic or devitalised tissue

›Removes C. tetani spore reservoir

›Performed after HTIG administration to avoid toxin release

›Foreign body removal

›Thorough wound irrigation

›Wound left open or loosely closed to allow drainage

›Wound cultures

›Identify co-infecting bacteria for directed therapy

Supportive care

›Nutritional support

›Oral diet if no dysphagia and spasms controlled

›High-calorie, high-protein intake during recovery

›Nasogastric tube if dysphagia develops

›Small-bore NG preferred

›Parenteral nutrition if NG not tolerated

›Adequate IV hydration

›Rhabdomyolysis prevention: target urine output >0.5 mL/kg/hour

›DVT prophylaxis

›Low-molecular-weight heparin

›Initiated once spasm control achieved

›Enoxaparin 40 mg SC daily (renally adjusted)

›Graduated compression stockings

›Applied from admission

›Pressure injury prevention

›Frequent repositioning every 2 hours

›Padded side rails to prevent injury during spasms

›Foam mattress

09Special Populations/sp52

Pregnancy

›Tetanus in pregnancy

›Maternal tetanus carries high fetal and maternal mortality

›Same antitoxin and antibiotic principles apply

›HTIG 500 IU IM safe in pregnancy — Class IIa recommendation

›Metronidazole safety

›Generally avoided in first trimester (teratogenic risk theoretical)

›Benzylpenicillin is the preferred antibiotic in first trimester

›Benzodiazepine use

›Diazepam crosses placenta — neonatal withdrawal and hypotonia risk

›Use minimum effective dose with fetal monitoring

›Neonatal tetanus risk

›Occurs when mother lacks protective immunity

›Maternal Tdap vaccination at 27 to 36 weeks of each pregnancy provides neonatal protection

›Obstetric consultation mandatory

›Continuous fetal monitoring during spasm episodes

›Preterm delivery risk with severe maternal disease

Geriatric

›Tetanus in older adults

›Highest risk group due to waning immunity

›Seroprevalence studies show up to 50% of adults >70 lack protective immunity

›Low rate of booster vaccination in this population

›Presentation may be atypical

›Isolated trismus can be mistaken for TMJ disease or dental pain

›Rigidity confused with Parkinson disease or musculoskeletal causes

›Pharmacological considerations

›Benzodiazepines cause excess sedation and aspiration risk

›Start at 50% of standard doses and titrate carefully

10Background/b57

Epidemiology

›Global burden

›30,000 to 60,000 deaths annually worldwide

›80% in Africa and South-East Asia

›Dramatic decline in vaccinated populations

›Local tetanus epidemiology

›Rare form accounting for <10% of tetanus cases

›More common in partially immune individuals

›Age distribution

›Older adults predominate in high-income countries due to waning immunity

›Neonatal tetanus predominates in low-income settings

›Sex distribution

›Male predominance from higher occupational wound exposure

›Women in some regions less vaccinated historically

›Mortality

›Local tetanus: favourable prognosis vs generalised

›Generalised tetanus case fatality 10 to 20% in ICU settings; up to 50% in low-resource environments

Pathophysiology

›Toxin production and spread

›Clostridium tetani

›Gram-positive, anaerobic, spore-forming rod

›Spores ubiquitous in soil, dust, and animal faeces

›Germinate in devitalised, low-oxygen tissue

›Tetanospasmin (tetanus neurotoxin, TeNT)

›Zinc-dependent metalloprotease

›Cleaves synaptobrevin (VAMP) — prevents vesicle fusion

›Blocks release of glycine and GABA at inhibitory interneurons

›Local tetanus mechanism

11Patient Discharge Instructions/pdi32

copy discharge instructions

›Discharge instructions for Tetanus (Local)

›What is local tetanus?

›A rare infection caused by a toxin from Clostridium tetani bacteria in a wound

›Causes muscle stiffness and spasms confined to the area near your wound

›Can progress to whole-body (generalised) tetanus if not fully treated

›Medications to take at home

›Complete the full course of antibiotics prescribed (do not stop early)

›Take pain or muscle relaxant medications exactly as prescribed

›Do not take phenothiazines or metoclopramide (nausea medications) — they can worsen spasms

›Wound care

›Keep wound clean and dry according to nursing instructions

›Watch for signs of wound infection: increasing redness, swelling, warmth, pus

›Follow up with your surgeon or GP for wound review

›Vaccination

›You received a tetanus vaccine today — this is only the first dose

›You must return at 1 month and 1 year for the remaining doses

›Tetanus infection does NOT protect you from getting tetanus again

›Activity

›Rest during recovery — full recovery takes 4 to 6 weeks

›Avoid strenuous physical activity until spasms have completely resolved

›A quiet, calm environment helps prevent spasm triggers during recovery

›Return to the emergency department immediately if you develop:

›Jaw stiffness or difficulty opening your mouth

›Difficulty swallowing or speaking

›Difficulty breathing or shortness of breath

›Muscle stiffness or spasms spreading beyond the original area

›Rapid or irregular heartbeat, profuse sweating, or high blood pressure

12References/r20

Guidelines and key sources

›Sudarshan R, Sayo AR, Renner DR, et al. Tetanus: Recognition and Management. Lancet Infect Dis. 2025. PMID: 40543524

›Primary grounding reference for local tetanus presentation and management

›Ablett classification, HTIG dosing, antibiotic selection, disposition

›Ergönül O, Kolsuz S, Figueroa JP. Tetanus. Lancet. 2026. PMID: 41544646

›Current epidemiology, wound classification, vaccination schedules

›Metronidazole vs penicillin evidence

›Yen LM, Thwaites CL. Tetanus. Lancet. 2019. PMID: 30935736

›Comprehensive review including autonomic dysfunction management

›Magnesium sulfate evidence and ICU care

›Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria — ACIP Recommendations. MMWR Recomm Rep. 2018. PMC5919600

›Vaccination schedules, wound prophylaxis algorithm, Arthus reaction management

›Zhou S, Malani P. What Is Tetanus? JAMA. 2026.

›Point-of-care summary for clinicians

›Confirms clinical diagnosis approach and neuromuscular blockade for refractory spasms

Additional references

›An Y, Guo Y, Li L, et al. Management and Outcome of Adult Generalised Tetanus. Front Public Health. 2023. PMID: 38425467

›Outcomes data and ICU management strategies

›Pham OKN, Tran BN, Duong MC, et al. Cardiovascular Events in Tetanus — Cohort Study of 572 Patients. Open Forum Infect Dis. 2023. PMID: 37795506

›Autonomic dysfunction cardiovascular complication data

›Thwaites CL, Beeching NJ, Newton CR. Maternal and Neonatal Tetanus. Lancet. 2015. PMID: 25149223

›Neonatal tetanus epidemiology and maternal vaccination strategies

Evidence & Review

Evidence & Review