Tetanus

A35

*Notifiable medical condition.

DESCRIPTION

Painful muscle spasms and rigidity following inoculation by trauma of Clostridium tetani spores, which germinate and produce toxins. The wound may be trivial and healing may have occurred before presentation. Incubation period is 3-21 days. Tetanus may be localised, with muscle spasms near the site of inoculation, or generalised, with spasm of the jaw muscles being a common presenting sign.

GENERAL MEASURES

These patients need to be managed in a high care setting where ventilation is available.

Maintain and protect airway.

Monitor ECG and blood pressure.

Maintain and replace IV fluids.

Wound management is essential with debridement and removal of any foreign bodies.

Alleviate fever with mechanical cooling methods.

MEDICINE TREATMENT

For rigidity, spasms: (R25.2)

  • Diazepam, IV, 10 mg 4 hourly, for 24 hours, then consider oral route as high doses of parentral diazepam can cause an acidosis.
    • Titrate to effect.
    • Doses as high as 50–100 mg 2 hourly are sometimes required.
    • Higher doses require monitoring for respiratory depression.

LoEI [26]

Use muscle relaxants sparingly as these may exacerbate autonomic instability.

Antibiotic treatment:

  • Metronidazole, IV, 500 mg 8 hourly for 10 days.

LoEIII [27]

For passive immunisation: (Z23.5)

  • Tetanus immunoglobulin, IM, 3 000 units as a single dose.

For active immunisation of all patients:(as clinical tetanus does not always confer immunity) (Z23.5)

  • Tetanus toxoid vaccine, IM, 0.5 mL, total of 3 doses:
    • on admission,
    • at 4 weeks, and
    • at 6 months.
    • Administer at a different site to that used for administering tetanus immunoglobulin.

For pain:

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum daily dose: 4 g in 24 hours.

LoEI [28]

  • Morphine, IV, to a total maximum dose of 10 mg (See
  • MORPHINE, IV for individual dosing and monitoring for response and toxicity).

For shock, dehydration, maintenance of hydration: R57.9+ (A35)

  • IV fluids.

For prophylaxis for deep vein thrombosis: (Z29.2)

See Venous thrombo-embolism

REFERRAL

All cases to a facility with resources for artificial mechanical ventilation.