›Does not reverse toxin already bound to nerve terminals
›Earliest administration maximizes benefit
›Intrathecal route studied: 250–500 IU intrathecal vs. IM
›Cochrane review: intrathecal may reduce mortality vs. IM alone
›Reserve for specialist centres with intrathecal administration experience
›Equine tetanus antitoxin (eAT) — if hTIG unavailable
›Dose: 10,000–20,000 IU IM after skin test for hypersensitivity
›Skin test: 0.1 ml of 1:100 dilution intradermally; read at 15 minutes
›Desensitization protocol if skin test positive and no hTIG alternative
›Higher anaphylaxis risk than hTIG
›Epinephrine 0.01 mg/kg IM available at bedside before administration
›Serum sickness risk at 7–14 days after eAT
›Metronidazole IV — preferred antibiotic
›Neonatal dose: 7.5 mg/kg IV every 8 hours for 7–10 days
›Gestational age-based dosing adjustment for preterm neonates
›Kills vegetative C. tetani at wound site
›Mechanism advantage over penicillin
›Penicillin is a GABA-A antagonist and may theoretically worsen spasms
›Metronidazole has no GABA antagonism
›Penicillin G alternative if metronidazole unavailable
›Dose: 100,000 IU/kg/day IV divided every 6 hours for 10 days
›Theoretical risk of worsening spasms via GABA antagonism
›Used widely in resource-limited settings without clearly worse outcomes in practice
›Umbilical stump debridement and cleaning
›Thorough debridement to remove devitalized tissue and spore reservoir
›Perform under sedation to minimize stimulation-triggered spasms
›Hydrogen peroxide or povidone-iodine irrigation
›Antiseptic dressing applied after debridement
›Daily wound inspection and redressing
›Culture any purulent discharge
Autonomic dysfunction management
›Magnesium sulfate infusion
›Loading dose: 40 mg/kg IV over 30 minutes
›Monitor for respiratory depression and hypotension during loading
›Have calcium gluconate 100 mg/kg IV available as antidote
›Maintenance: 20–40 mg/kg/h continuous infusion
›Titrate to abolish tachycardia and hypertensive surges
›Target serum magnesium 2.5–4.0 mmol/l
›Check magnesium level every 4–6 hours
›Stop infusion if: respiratory rate less than 12/min, loss of patellar reflexes, urine output less than 0.5 ml/kg/h
›Beta-blockade for refractory tachycardia
›Propranolol 0.01–0.05 mg/kg IV every 6 hours cautiously
›Risk of sudden asystole — avoid in autonomic instability
›Labetalol preferred for combined alpha-beta effect
›Morphine infusion for autonomic control in mechanically ventilated patients
›Dose: 10–30 mcg/kg/h IV continuous
›Reduces sympathetic surges and provides analgesia
Neuromuscular blockade and mechanical ventilation
›Indications for neuromuscular blockade
›Refractory spasms uncontrolled by benzodiazepines plus phenobarbital
›Vecuronium 0.1 mg/kg IV bolus with continuous infusion
›Rocuronium 0.6–1.2 mg/kg IV for rapid sequence
›Laryngospasm-associated apnea unresponsive to pharmacological spasm control
›Requires simultaneous mechanical ventilation
›Continuous sedation mandatory with neuromuscular blockade
›Ventilation strategy
›Pressure-controlled ventilation preferred in neonates
›Tidal volume target 5–7 ml/kg
›PEEP 4–6 cmH2O
›Ventilator weaning begins when spasm frequency and duration decrease
›Spontaneous breathing trials after benzodiazepine reduction
›Expected ventilation duration: 2–4 weeks in severe disease
Nutrition and supportive care
›Nutritional support
›NPO during active severe spasms or when airway is not secured
›Initiate nasogastric feeding as soon as spasms are controlled
›Expressed breast milk preferred when available
›Caloric requirements elevated due to catabolic state and muscle activity
›Target 100–120 kcal/kg/day enterally
›Parenteral nutrition if enteral route not tolerated after 48–72 hours
›Immunization
›Initiate primary DTP series before hospital discharge
›Tetanus toxoid does not confer natural immunity after infection
›First DTP at 6 weeks of age or on clinical recovery