Management And Prognosis

Appropriate treatment based on the clinical diagnosis is warranted even without specific confirmatory laboratory tests. The goals of therapy are to eradicate C. tetani, neutralize its toxin, and provide appropriate supportive care. Specific therapy includes intramuscular administration of tetanus immune globulin (TIG) to neutralize circulating toxin before it binds to neuronal cell membranes. Early administration of antitoxin may prevent spread of the toxin within the CNS. The recommended dosage of TIG ranges from 500 to 3000 U. Although a dosage recommendation based on body weight is not available, it is reasonable to give a newborn a smaller dose, of a single vial of TIG (250 U). The efficacy of concomitant intrathecal administration of TIG has not been proven (11,14).

Additionally, specific therapy includes antimicrobial agents for C. tetani such as penicillin-G administered as 200,000 U/kg/day in four divided intravenous doses for 10 days. Alternatives for those allergic to penicillin include oral tetracycline (40 mg/kg/day, maximum of 2 g) or intravenous vancomycin (30-40 mg/kg/day). The cephalosporins are not reliably active against C. tetani.

Local wound care, including surgical debridement, is essential. Foreign bodies should be removed and wounds irrigated well and left open. Excision of necrotic tissue may be required, but excision of the umbilical stump is no longer recommended in cases of neonatal tetanus. Local antibiotic or TIG instillation is not needed.

Patients should be managed in an intensive care setting of a tertiary-care center whenever possible. Facilities and equipment that should be available include a quiet darkened room, suction equipment and oxygen, cardiac and respiratory monitors, a ventilator, and tracheostomy equipment. The patients must be managed by experienced caregivers skilled in ventilatory support and maintenance of cardiovascular stability. Minimizing external stimuli and maintaining intravenous hydration may be sufficient in the initial days of the illness. Sedation and muscle relaxation should be instituted, usually with diazepam (0.1-0.2 mg/kg intravenously every four to six hours). Additional sedation with phenothiazines may be needed. If spasms are not adequately controlled, therapeutic paralysis may be necessary (4).

Neuromuscular blockade can be achieved with curariform drugs. The agents used most often are pancuronium and vecuronium. Vecuronium, an intermediate-acting neuromuscular blocking agent is given in an initial dose of 0.08 to 0.1 mg/kg intravenously, with maintenance doses of 0.01 to 0.15 mg/kg every 30 to 60 minutes, as needed. Doxacurium, a long-acting agent of the same class with similar cardiovascular safety profile, offers more prolonged effect with each dose. The recommended initial dose is 0.03 to 0.05 mg/kg intravenously, followed by 0.01 mg/kg in 60 to 90 minutes, as needed. The intervals between maintenance doses may be adjusted by the administration of smaller or larger doses. Patients who undergo therapeutic paralysis must be sedated to avoid the associated anxiety.

The hypertension that results from sympathetic overactivity may require treatment. Beta-blocking agents are the most useful. Propranolol is administered most commonly (usual dose: 0.01-0.10 mg/kg every six to eight hours). Additionally, this agent may be helpful for the control of tachyarrhythmias. The duration of these therapies ranges from two to three weeks.

Maintenance of adequate nutrition and hydration is of outmost importance. Parenteral nutrition is usually required because of the likely length of the disease and the undesirability of oral or nasogastric feedings. Adequate nutritional support can minimize weight loss, maintain electrolyte balance, and improve management of arrhythmias. Attention must be paid to skin care, and excretory functions must be monitored closely for urinary retention or serious constipation. Patients must be immunized with tetanus toxoid to prevent further disease. Tracheostomy may be required to prevent laryngospasm, which greatly increases the mortality rate of the disease.

The worldwide mortality rate for generalized tetanus ranges from 45% to 55%; it is about 1% in localized tetanus and more than 60% in tetanus neonatorum (2). Although survivors generally experience no neurologic sequelae, prolonged convalescence with residual muscle rigidity is seen for several months.

The main predictors of prognosis are the rapidity of symptom onset and the rate of progression from trismus to severe spasms. Poor outcome is predicted by an interval between

TABLE 1 Tetanus Prophylaxis in Routine Wound Management

Immunization history

Type of wound

Clean, mirror

All others

Three or more doses of tetanus toxoid

No TIG; toxoid only if > 10 yr

No TIG; toxoid only if >5 yr

since last dose

since last dose

Fewer than three doses or uncertain history

No TIG; toxoid, 0.5 mL

TIG, 500 units; toxoid, 0.5 mL

Immune globulin intravenous or equine tetanus antitoxin should be used when TIG is not available. Abbreviations: TIG, tetanus immune globulin. Source: From Ref. 18.

injury and trismus shorter than seven days or by progression from trismus to spasms in less than three days (4).

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