Materiały źródłowe

• #1 Tetanus – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/tetanus/symptoms-causes/syc-20351625

  Severe complications of tetanus can be life-threatening. There’s no cure for tetanus. Treatment focuses on managing symptoms and complications until the effects of the tetanus toxin resolve. […] Seek medical care in the following cases: […] Contaminated wounds require a vaccination booster if it’s been five or more years since your last tetanus shot. […] You can prevent tetanus by being vaccinated. […] A booster shot is recommended for adults once every 10 years. This may be one of two vaccines, Tdap or Td. If you weren’t vaccinated against tetanus as a child or are unsure about your vaccination status, see your doctor about getting the Tdap vaccine.

• #2 Tetanus – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/tetanus/diagnosis-treatment/drc-20351631

  Doctors diagnose tetanus based on a physical exam, medical and vaccination history, and the signs and symptoms of muscle spasms, muscle rigidity and pain. […] A tetanus infection requires emergency and long-term supportive care while the disease runs its course, often in an intensive care unit. Any wounds are cared for and the healthcare team will make sure that the ability to breathe is protected. Medicines are given that ease symptoms, target the bacteria, target the toxin made by the bacteria and boost immune system response. […] Antitoxin therapy is used to target toxins that have not yet attacked nerve tissues. This treatment, called passive immunization, is a human antibody to the toxin. […] Sedatives that slow the function of the nervous system can help control muscle spasms. […] Vaccination with one of the standard tetanus vaccinations helps your immune system fight the toxins.

• #3 Clinical Care of Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-care/index.html

  Tetanus is a medical emergency that requires hospitalization. […] Tetanus treatment often involves several types of medications and supportive care. […] Complete recovery can take several months. […] Tetanus infection doesn’t provide immunity, so vaccination is recommended during recovery. […] Medical experts recommend a single, 500 international unit (IU) dose of TIG for tetanus treatment. […] TIG helps remove unbound tetanus toxin from the body. […] Healthcare providers should use sedation and muscle relaxant drugs as indicated to control muscle spasms. […] Appropriate antibiotic therapy is recommended to reduce the number of tetanus bacteria. […] Vaccination, if indicated, is recommended as soon as the patient’s condition has stabilized.

• #4 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #5 Tetanus Treatment & Management: Approach Considerations, Initial Supportive Therapy and Wound Care, Pharmacologic Therapy

  https://emedicine.medscape.com/article/229594-treatment

  The goals of treatment in patients with tetanus include the following: […] Passive immunization with human tetanus immune globulin (TIG) shortens the course of tetanus and may lessen its severity. […] Initial care includes administration of human tetanus immunoglobulin to bind circulating tetanus toxins. […] In moderate-to-severe presentations of tetanus, neuromuscular blocker therapy with intubation and mechanical ventilation should be considered. […] Antimicrobials are used to decrease the number of vegetative forms of C tetani (the toxin source) in the wound. […] Tetanus immune globulin (TIG) is recommended for treatment of tetanus. […] Benzodiazepines have emerged as the mainstay of symptomatic therapy for tetanus. […] Specific therapy for autonomic system complications and control of spasms should be initiated.

• #6 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #7 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #8 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #9 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #10 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #11 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #12 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #13 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  TREATMENT […] Overview — Treatment of tetanus is best performed in the intensive care unit in consultation with an anesthesiologist or critical care specialist trained in the management of the complications of this disease, including early and aggressive airway management. The goals of treatment include: […] Halting the toxin production […] Neutralization of the unbound toxin […] Airway management […] Control of muscle spasms […] Management of dysautonomia […] General supportive management […] Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only six randomized trials reported in the literature over the past 20 years. […] Halting toxin production […] Wound management — All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for germination.

• #14 Tetanus – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/tetanus/

  Treatment includes airway management, wound debridement, immunoglobulin therapy (e.g., human tetanus immune globulin), antibiotics (e.g., metronidazole), and pharmacological management of severe muscle spasms. […] The following relates to the treatment of clinically apparent tetanus. […] Immediately manage life-threatening and severe symptoms (see Acute stabilization). […] Administer passive immunization, e.g., human tetanus immunoglobulin, as soon as possible. […] Manage acute wounds, e.g., wound irrigation and debridement. […] Initiate antibiotics, preferably PO metronidazole. […] Wound care and antibiotics decrease bacterial load and toxin production. Immunoglobulin therapy neutralizes free toxins. […] Laryngospasm or respiratory muscle spasms: airway management with rapid sequence intubation (RSI).

• #15 Tetanus – Infectious Diseases – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/infectious-diseases/anaerobic-bacteria/tetanus

  Treatment of tetanus requires maintaining adequate ventilation. […] Additional interventions include early and adequate use of human tetanus immune globulin (TIG) to neutralize nonfixed toxin; prevention of further toxin production; sedation; control of muscle spasm, hypertonicity, fluid balance, and intercurrent infection; and continuous nursing care. […] The patient should be kept in a quiet room. Several principles should guide all therapeutic interventions: […] Prevent further toxin release by debriding the wound and giving an antibiotic. […] Neutralize unbound toxin outside the CNS with TIG. […] Immunize using tetanus toxoid, taking care to inject it into a different body site than the antitoxin. […] Minimize the effect of toxin already in the CNS. […] Because dirt and dead tissue promote C. tetani growth, prompt, thorough debridement, especially of deep puncture wounds, is essential. Antibiotics are not substitutes for adequate debridement and immunization but typically are given.

• #16 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Antimicrobial therapy — Although antibiotics probably play a relatively minor role in the management of tetanus, they are universally recommended. However, it is important to emphasize that appropriate antimicrobial therapy may fail to eradicate C. tetani unless adequate wound debridement is performed. This was illustrated by one study in which 45 isolates of C. tetani were obtained at the time of wound debridement from 84 Vietnamese patients with severe tetanus. All 45 isolates were susceptible by disc diffusion and E-test to penicillin and metronidazole, and all were resistant to trimethoprim-sulfamethoxazole. However, C. tetani was isolated from the wounds of two patients who underwent debridement after more than two weeks of high doses of penicillin. […] Metronidazole (500 mg intravenously [IV] every six to eight hours) is the preferred treatment for tetanus, but penicillin G (2 to 4 million units IV every four to six hours) is a safe and effective alternative. We suggest a treatment duration of 7 to 10 days.

• #17 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Antimicrobial therapy — Although antibiotics probably play a relatively minor role in the management of tetanus, they are universally recommended. However, it is important to emphasize that appropriate antimicrobial therapy may fail to eradicate C. tetani unless adequate wound debridement is performed. This was illustrated by one study in which 45 isolates of C. tetani were obtained at the time of wound debridement from 84 Vietnamese patients with severe tetanus. All 45 isolates were susceptible by disc diffusion and E-test to penicillin and metronidazole, and all were resistant to trimethoprim-sulfamethoxazole. However, C. tetani was isolated from the wounds of two patients who underwent debridement after more than two weeks of high doses of penicillin. […] Metronidazole (500 mg intravenously [IV] every six to eight hours) is the preferred treatment for tetanus, but penicillin G (2 to 4 million units IV every four to six hours) is a safe and effective alternative. We suggest a treatment duration of 7 to 10 days.

• #18 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Antimicrobial therapy — Although antibiotics probably play a relatively minor role in the management of tetanus, they are universally recommended. However, it is important to emphasize that appropriate antimicrobial therapy may fail to eradicate C. tetani unless adequate wound debridement is performed. This was illustrated by one study in which 45 isolates of C. tetani were obtained at the time of wound debridement from 84 Vietnamese patients with severe tetanus. All 45 isolates were susceptible by disc diffusion and E-test to penicillin and metronidazole, and all were resistant to trimethoprim-sulfamethoxazole. However, C. tetani was isolated from the wounds of two patients who underwent debridement after more than two weeks of high doses of penicillin. […] Metronidazole (500 mg intravenously [IV] every six to eight hours) is the preferred treatment for tetanus, but penicillin G (2 to 4 million units IV every four to six hours) is a safe and effective alternative. We suggest a treatment duration of 7 to 10 days.

• #19 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Antimicrobial therapy — Although antibiotics probably play a relatively minor role in the management of tetanus, they are universally recommended. However, it is important to emphasize that appropriate antimicrobial therapy may fail to eradicate C. tetani unless adequate wound debridement is performed. This was illustrated by one study in which 45 isolates of C. tetani were obtained at the time of wound debridement from 84 Vietnamese patients with severe tetanus. All 45 isolates were susceptible by disc diffusion and E-test to penicillin and metronidazole, and all were resistant to trimethoprim-sulfamethoxazole. However, C. tetani was isolated from the wounds of two patients who underwent debridement after more than two weeks of high doses of penicillin. […] Metronidazole (500 mg intravenously [IV] every six to eight hours) is the preferred treatment for tetanus, but penicillin G (2 to 4 million units IV every four to six hours) is a safe and effective alternative. We suggest a treatment duration of 7 to 10 days.

• #20 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  The first study to compare penicillin and metronidazole found a greater reduction in mortality in the metronidazole group (7 versus 24 percent). However, in three subsequent studies, there was no difference in mortality in patients treated with penicillin and those treated with metronidazole. In one of the former studies, patients receiving metronidazole required fewer muscle relaxants and sedatives. It is possible that the observed difference in outcomes may not be due to differences in the antimicrobial activity of the two agents but rather may be explained by the GABA antagonist effect of penicillins and third-generation cephalosporins, which may lead to central nervous system (CNS) excitability. […] If a mixed infection is suspected, a first-, second-, or third-generation cephalosporin such as cefazolin (1 to 2 g IV every 8 hours), cefuroxime (2 g IV every 6 hours), or ceftriaxone (1 to 2 g IV every 24 hours) can be used.

• #21 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  The first study to compare penicillin and metronidazole found a greater reduction in mortality in the metronidazole group (7 versus 24 percent). However, in three subsequent studies, there was no difference in mortality in patients treated with penicillin and those treated with metronidazole. In one of the former studies, patients receiving metronidazole required fewer muscle relaxants and sedatives. It is possible that the observed difference in outcomes may not be due to differences in the antimicrobial activity of the two agents but rather may be explained by the GABA antagonist effect of penicillins and third-generation cephalosporins, which may lead to central nervous system (CNS) excitability. […] If a mixed infection is suspected, a first-, second-, or third-generation cephalosporin such as cefazolin (1 to 2 g IV every 8 hours), cefuroxime (2 g IV every 6 hours), or ceftriaxone (1 to 2 g IV every 24 hours) can be used.

• #22 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  An alternative agent is doxycycline (100 mg every 12 hours); other agents with activity against C. tetani are macrolides, clindamycin, vancomycin, and chloramphenicol. The efficacy of these agents has not been evaluated but, based upon in vitro susceptibility data, it is likely that they are effective. […] Neutralization of unbound toxin — Since tetanus toxin is irreversibly bound to tissues, only unbound toxin is available for neutralization. The use of passive immunization (ie, antitoxin) to neutralize unbound toxin is associated with improved survival and it is considered to be standard of care. […] Intramuscular antitoxin – Human tetanus immune globulin (HTIG) is the antitoxin of choice to neutralize unbound toxin. The United States Centers for Disease Control and Prevention (CDC) recommends a single dose of 500 units intramuscularly (IM). The previously recommended dose range was 3000 to 6000 units.

• #23 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  An alternative agent is doxycycline (100 mg every 12 hours); other agents with activity against C. tetani are macrolides, clindamycin, vancomycin, and chloramphenicol. The efficacy of these agents has not been evaluated but, based upon in vitro susceptibility data, it is likely that they are effective. […] Neutralization of unbound toxin — Since tetanus toxin is irreversibly bound to tissues, only unbound toxin is available for neutralization. The use of passive immunization (ie, antitoxin) to neutralize unbound toxin is associated with improved survival and it is considered to be standard of care. […] Intramuscular antitoxin – Human tetanus immune globulin (HTIG) is the antitoxin of choice to neutralize unbound toxin. The United States Centers for Disease Control and Prevention (CDC) recommends a single dose of 500 units intramuscularly (IM). The previously recommended dose range was 3000 to 6000 units.

• #24 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  An alternative agent is doxycycline (100 mg every 12 hours); other agents with activity against C. tetani are macrolides, clindamycin, vancomycin, and chloramphenicol. The efficacy of these agents has not been evaluated but, based upon in vitro susceptibility data, it is likely that they are effective. […] Neutralization of unbound toxin — Since tetanus toxin is irreversibly bound to tissues, only unbound toxin is available for neutralization. The use of passive immunization (ie, antitoxin) to neutralize unbound toxin is associated with improved survival and it is considered to be standard of care. […] Intramuscular antitoxin – Human tetanus immune globulin (HTIG) is the antitoxin of choice to neutralize unbound toxin. The United States Centers for Disease Control and Prevention (CDC) recommends a single dose of 500 units intramuscularly (IM). The previously recommended dose range was 3000 to 6000 units.

• #25 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  HTIG should be administered as soon as the diagnosis of tetanus is considered, with part of the dose infiltrated around the wound. HTIG should be administered at different sites than tetanus toxoid. […] If HTIG is not available, human immunoglobulin or equine antitoxin are reasonable alternatives. In a blinded, randomized trial of 215 adults with tetanus in Vietnam that compared intramuscular equine antitoxin (21,000 international units) with HTIG (3000 international units), there were no differences in mechanical ventilation rate, hospital/intensive care unit (ICU) length of stay, mortality, or adverse events. […] When equine antitoxin is used, an intradermal test dose of 0.1 mL in a 1:10 dilution should be administered prior to giving the full dose in order to evaluate for hypersensitivity reactions. In contrast, antecedent skin testing is not needed if a human preparation is to be used.

• #26 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  HTIG should be administered as soon as the diagnosis of tetanus is considered, with part of the dose infiltrated around the wound. HTIG should be administered at different sites than tetanus toxoid. […] If HTIG is not available, human immunoglobulin or equine antitoxin are reasonable alternatives. In a blinded, randomized trial of 215 adults with tetanus in Vietnam that compared intramuscular equine antitoxin (21,000 international units) with HTIG (3000 international units), there were no differences in mechanical ventilation rate, hospital/intensive care unit (ICU) length of stay, mortality, or adverse events. […] When equine antitoxin is used, an intradermal test dose of 0.1 mL in a 1:10 dilution should be administered prior to giving the full dose in order to evaluate for hypersensitivity reactions. In contrast, antecedent skin testing is not needed if a human preparation is to be used.

• #27 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  HTIG should be administered as soon as the diagnosis of tetanus is considered, with part of the dose infiltrated around the wound. HTIG should be administered at different sites than tetanus toxoid. […] If HTIG is not available, human immunoglobulin or equine antitoxin are reasonable alternatives. In a blinded, randomized trial of 215 adults with tetanus in Vietnam that compared intramuscular equine antitoxin (21,000 international units) with HTIG (3000 international units), there were no differences in mechanical ventilation rate, hospital/intensive care unit (ICU) length of stay, mortality, or adverse events. […] When equine antitoxin is used, an intradermal test dose of 0.1 mL in a 1:10 dilution should be administered prior to giving the full dose in order to evaluate for hypersensitivity reactions. In contrast, antecedent skin testing is not needed if a human preparation is to be used.

• #28 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Role of intrathecal antitoxin – In general, there is no role for intrathecal antitoxin in addition to IM antitoxin since intrathecal therapy is of unclear benefit. As an example, in the trial of 215 patients from Vietnam described above, the rate of mechanical ventilation among those who received intrathecal antitoxin in addition to IM antitoxin was similar to those who received IM antitoxin alone (43 versus 50 percent, respectively; relative risk 0.87, 95% CI 0.66 to 1.13). In another trial of 120 patients from Brazil evaluating the use of intrathecal immunoglobulin in addition to intramuscular therapy, patients receiving intrathecal therapy had a shorter duration of spasms, shorter hospital stay, and a decreased requirement for respiratory assistance; however, mortality was not significantly affected.

• #29 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Role of intrathecal antitoxin – In general, there is no role for intrathecal antitoxin in addition to IM antitoxin since intrathecal therapy is of unclear benefit. As an example, in the trial of 215 patients from Vietnam described above, the rate of mechanical ventilation among those who received intrathecal antitoxin in addition to IM antitoxin was similar to those who received IM antitoxin alone (43 versus 50 percent, respectively; relative risk 0.87, 95% CI 0.66 to 1.13). In another trial of 120 patients from Brazil evaluating the use of intrathecal immunoglobulin in addition to intramuscular therapy, patients receiving intrathecal therapy had a shorter duration of spasms, shorter hospital stay, and a decreased requirement for respiratory assistance; however, mortality was not significantly affected.

• #30 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Active immunization — Since tetanus is one of the few bacterial diseases that does not confer immunity following recovery from acute illness, all patients with tetanus should receive active immunization with a full series (eg, three doses in adults and children >7 years old) of tetanus and diphtheria toxoid-containing vaccines, commencing immediately upon diagnosis. Such vaccines should be administered at a different site than tetanus immune globulin. […] Control of muscle spasms — Generalized muscle spasms are life threatening since they can cause respiratory failure, lead to aspiration, and induce generalized exhaustion in the patient. Several drugs may be used to control these spasms. Attention to placement of the patient and control of light or noise in the room in an effort to avoid provoking muscle spasms was an important component of care for patients with tetanus in the past before the availability of drugs to prevent spasms. These measures are still vital in regions where the availability of neuromuscular blocking agents may be limited.

• #31 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Active immunization — Since tetanus is one of the few bacterial diseases that does not confer immunity following recovery from acute illness, all patients with tetanus should receive active immunization with a full series (eg, three doses in adults and children >7 years old) of tetanus and diphtheria toxoid-containing vaccines, commencing immediately upon diagnosis. Such vaccines should be administered at a different site than tetanus immune globulin. […] Control of muscle spasms — Generalized muscle spasms are life threatening since they can cause respiratory failure, lead to aspiration, and induce generalized exhaustion in the patient. Several drugs may be used to control these spasms. Attention to placement of the patient and control of light or noise in the room in an effort to avoid provoking muscle spasms was an important component of care for patients with tetanus in the past before the availability of drugs to prevent spasms. These measures are still vital in regions where the availability of neuromuscular blocking agents may be limited.

• #32 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Active immunization — Since tetanus is one of the few bacterial diseases that does not confer immunity following recovery from acute illness, all patients with tetanus should receive active immunization with a full series (eg, three doses in adults and children >7 years old) of tetanus and diphtheria toxoid-containing vaccines, commencing immediately upon diagnosis. Such vaccines should be administered at a different site than tetanus immune globulin. […] Control of muscle spasms — Generalized muscle spasms are life threatening since they can cause respiratory failure, lead to aspiration, and induce generalized exhaustion in the patient. Several drugs may be used to control these spasms. Attention to placement of the patient and control of light or noise in the room in an effort to avoid provoking muscle spasms was an important component of care for patients with tetanus in the past before the availability of drugs to prevent spasms. These measures are still vital in regions where the availability of neuromuscular blocking agents may be limited.

• #33 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Benzodiazepines and other sedatives […] Benzodiazepines – Benzodiazepines have been used traditionally and are generally effective in controlling the rigidity and spasms associated with tetanus. They also provide a sedative effect. Diazepam has been used most frequently, but other benzodiazepines are as effective as diazepam. […] For tetanus, the usual starting dose of diazepam for an adult is 10 to 30 mg IV and is repeated as needed every 1 to 4 hours. Patients with tetanus often show tolerance to the sedating effects of benzodiazepines and may remain awake and alert after receiving doses that would sedate or cause anesthesia in other patients. […] Since benzodiazepines may be required for a prolonged period of time (often weeks), they should be tapered gradually to avoid withdrawal reactions and ventilator weaning.

• #34 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Benzodiazepines and other sedatives […] Benzodiazepines – Benzodiazepines have been used traditionally and are generally effective in controlling the rigidity and spasms associated with tetanus. They also provide a sedative effect. Diazepam has been used most frequently, but other benzodiazepines are as effective as diazepam. […] For tetanus, the usual starting dose of diazepam for an adult is 10 to 30 mg IV and is repeated as needed every 1 to 4 hours. Patients with tetanus often show tolerance to the sedating effects of benzodiazepines and may remain awake and alert after receiving doses that would sedate or cause anesthesia in other patients. […] Since benzodiazepines may be required for a prolonged period of time (often weeks), they should be tapered gradually to avoid withdrawal reactions and ventilator weaning.

• #35 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Benzodiazepines and other sedatives […] Benzodiazepines – Benzodiazepines have been used traditionally and are generally effective in controlling the rigidity and spasms associated with tetanus. They also provide a sedative effect. Diazepam has been used most frequently, but other benzodiazepines are as effective as diazepam. […] For tetanus, the usual starting dose of diazepam for an adult is 10 to 30 mg IV and is repeated as needed every 1 to 4 hours. Patients with tetanus often show tolerance to the sedating effects of benzodiazepines and may remain awake and alert after receiving doses that would sedate or cause anesthesia in other patients. […] Since benzodiazepines may be required for a prolonged period of time (often weeks), they should be tapered gradually to avoid withdrawal reactions and ventilator weaning.

• #36 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Other sedatives – Infusion of the anesthetic propofol may also control spasms and rigidity. Its prolonged use has been associated with lactic acidosis, hypertriglyceridemia, and pancreatic dysfunction. […] Neuromuscular blocking agents — Neuromuscular blocking agents are used when sedation alone is inadequate. Options depend on availability. Vecuronium or other cardiovascularly inert neuromuscular blockers are preferred. Pancuronium, a long-acting agent, has been traditionally used, but it may worsen autonomic instability because it is an inhibitor of catecholamine reuptake. Neuromuscular blocking agents are generally given as continuous infusions. Monitoring of patients on these drugs is extremely important to avoid or recognize complications. […] Baclofen, which stimulates postsynaptic GABA beta receptors, has been used in a few small studies. The preferred route is intrathecal, and it may be given either in a bolus of 1000 mcg or by continuous intrathecal infusion. Intrathecal baclofen given as an initial bolus in a dose ranging from 40 to 200 mcg followed by a continuous infusion of 20 mcg/hour was found to control spasms and rigidity in 21 out of 22 patients with grade III tetanus in a retrospective outcome study from a single medical center in Portugal. One of 22 patients developed meningitis secondary to infection of the intrathecal catheter despite the fact that most patients required such therapy for at least three weeks (range 8 to 30 days). In some cases, baclofen has been used without the need for mechanical ventilation. Phenothiazines and barbiturates were used in the past to control spasms but have largely been displaced by neuromuscular blocking agents.

• #37 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Other sedatives – Infusion of the anesthetic propofol may also control spasms and rigidity. Its prolonged use has been associated with lactic acidosis, hypertriglyceridemia, and pancreatic dysfunction. […] Neuromuscular blocking agents — Neuromuscular blocking agents are used when sedation alone is inadequate. Options depend on availability. Vecuronium or other cardiovascularly inert neuromuscular blockers are preferred. Pancuronium, a long-acting agent, has been traditionally used, but it may worsen autonomic instability because it is an inhibitor of catecholamine reuptake. Neuromuscular blocking agents are generally given as continuous infusions. Monitoring of patients on these drugs is extremely important to avoid or recognize complications. […] Baclofen, which stimulates postsynaptic GABA beta receptors, has been used in a few small studies. The preferred route is intrathecal, and it may be given either in a bolus of 1000 mcg or by continuous intrathecal infusion. Intrathecal baclofen given as an initial bolus in a dose ranging from 40 to 200 mcg followed by a continuous infusion of 20 mcg/hour was found to control spasms and rigidity in 21 out of 22 patients with grade III tetanus in a retrospective outcome study from a single medical center in Portugal. One of 22 patients developed meningitis secondary to infection of the intrathecal catheter despite the fact that most patients required such therapy for at least three weeks (range 8 to 30 days). In some cases, baclofen has been used without the need for mechanical ventilation. Phenothiazines and barbiturates were used in the past to control spasms but have largely been displaced by neuromuscular blocking agents.

• #38 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Other sedatives – Infusion of the anesthetic propofol may also control spasms and rigidity. Its prolonged use has been associated with lactic acidosis, hypertriglyceridemia, and pancreatic dysfunction. […] Neuromuscular blocking agents — Neuromuscular blocking agents are used when sedation alone is inadequate. Options depend on availability. Vecuronium or other cardiovascularly inert neuromuscular blockers are preferred. Pancuronium, a long-acting agent, has been traditionally used, but it may worsen autonomic instability because it is an inhibitor of catecholamine reuptake. Neuromuscular blocking agents are generally given as continuous infusions. Monitoring of patients on these drugs is extremely important to avoid or recognize complications. […] Baclofen, which stimulates postsynaptic GABA beta receptors, has been used in a few small studies. The preferred route is intrathecal, and it may be given either in a bolus of 1000 mcg or by continuous intrathecal infusion. Intrathecal baclofen given as an initial bolus in a dose ranging from 40 to 200 mcg followed by a continuous infusion of 20 mcg/hour was found to control spasms and rigidity in 21 out of 22 patients with grade III tetanus in a retrospective outcome study from a single medical center in Portugal. One of 22 patients developed meningitis secondary to infection of the intrathecal catheter despite the fact that most patients required such therapy for at least three weeks (range 8 to 30 days). In some cases, baclofen has been used without the need for mechanical ventilation. Phenothiazines and barbiturates were used in the past to control spasms but have largely been displaced by neuromuscular blocking agents.

• #39 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Other sedatives – Infusion of the anesthetic propofol may also control spasms and rigidity. Its prolonged use has been associated with lactic acidosis, hypertriglyceridemia, and pancreatic dysfunction. […] Neuromuscular blocking agents — Neuromuscular blocking agents are used when sedation alone is inadequate. Options depend on availability. Vecuronium or other cardiovascularly inert neuromuscular blockers are preferred. Pancuronium, a long-acting agent, has been traditionally used, but it may worsen autonomic instability because it is an inhibitor of catecholamine reuptake. Neuromuscular blocking agents are generally given as continuous infusions. Monitoring of patients on these drugs is extremely important to avoid or recognize complications. […] Baclofen, which stimulates postsynaptic GABA beta receptors, has been used in a few small studies. The preferred route is intrathecal, and it may be given either in a bolus of 1000 mcg or by continuous intrathecal infusion. Intrathecal baclofen given as an initial bolus in a dose ranging from 40 to 200 mcg followed by a continuous infusion of 20 mcg/hour was found to control spasms and rigidity in 21 out of 22 patients with grade III tetanus in a retrospective outcome study from a single medical center in Portugal. One of 22 patients developed meningitis secondary to infection of the intrathecal catheter despite the fact that most patients required such therapy for at least three weeks (range 8 to 30 days). In some cases, baclofen has been used without the need for mechanical ventilation. Phenothiazines and barbiturates were used in the past to control spasms but have largely been displaced by neuromuscular blocking agents.

• #40 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Other sedatives – Infusion of the anesthetic propofol may also control spasms and rigidity. Its prolonged use has been associated with lactic acidosis, hypertriglyceridemia, and pancreatic dysfunction. […] Neuromuscular blocking agents — Neuromuscular blocking agents are used when sedation alone is inadequate. Options depend on availability. Vecuronium or other cardiovascularly inert neuromuscular blockers are preferred. Pancuronium, a long-acting agent, has been traditionally used, but it may worsen autonomic instability because it is an inhibitor of catecholamine reuptake. Neuromuscular blocking agents are generally given as continuous infusions. Monitoring of patients on these drugs is extremely important to avoid or recognize complications. […] Baclofen, which stimulates postsynaptic GABA beta receptors, has been used in a few small studies. The preferred route is intrathecal, and it may be given either in a bolus of 1000 mcg or by continuous intrathecal infusion. Intrathecal baclofen given as an initial bolus in a dose ranging from 40 to 200 mcg followed by a continuous infusion of 20 mcg/hour was found to control spasms and rigidity in 21 out of 22 patients with grade III tetanus in a retrospective outcome study from a single medical center in Portugal. One of 22 patients developed meningitis secondary to infection of the intrathecal catheter despite the fact that most patients required such therapy for at least three weeks (range 8 to 30 days). In some cases, baclofen has been used without the need for mechanical ventilation. Phenothiazines and barbiturates were used in the past to control spasms but have largely been displaced by neuromuscular blocking agents.

• #41 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Management of autonomic dysfunction — Several drugs have been used to produce adrenergic blockade and suppress autonomic hyperactivity; only treatment with magnesium sulfate has been studied in a randomized clinical trial in tetanus. […] Magnesium sulfate — Magnesium sulfate acts as a presynaptic neuromuscular blocker, blocks catecholamine release from nerves, and reduces receptor responsiveness to catecholamines. In patients with tetanus, several clinical series have described the use of magnesium for the management of autonomic dysfunction and as adjunctive treatment for controlling spasms. […] In a randomized, double blind trial in 256 hospitalized patients with severe tetanus in Vietnam, magnesium sulfate infusion compared with placebo controlled autonomic dysfunction. The patients were randomly assigned to magnesium sulfate (loading dose 40 mg/kg over 30 minutes, followed by continuous infusion of either 2 g per hour for patients over 45 kg or 1.5 g per hour for patients ≤45 kg) versus placebo (5 percent glucose in water) infusion. Magnesium infusion significantly reduced the requirement for other drugs to control muscle spasms, and patients treated with magnesium were 4.7 times (95% CI 1.4 to 15.9) less likely to require verapamil to treat cardiovascular instability than those in the placebo group. Magnesium sulfate infusion did not reduce the need for mechanical ventilation.

• #42 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Management of autonomic dysfunction — Several drugs have been used to produce adrenergic blockade and suppress autonomic hyperactivity; only treatment with magnesium sulfate has been studied in a randomized clinical trial in tetanus. […] Magnesium sulfate — Magnesium sulfate acts as a presynaptic neuromuscular blocker, blocks catecholamine release from nerves, and reduces receptor responsiveness to catecholamines. In patients with tetanus, several clinical series have described the use of magnesium for the management of autonomic dysfunction and as adjunctive treatment for controlling spasms. […] In a randomized, double blind trial in 256 hospitalized patients with severe tetanus in Vietnam, magnesium sulfate infusion compared with placebo controlled autonomic dysfunction. The patients were randomly assigned to magnesium sulfate (loading dose 40 mg/kg over 30 minutes, followed by continuous infusion of either 2 g per hour for patients over 45 kg or 1.5 g per hour for patients ≤45 kg) versus placebo (5 percent glucose in water) infusion. Magnesium infusion significantly reduced the requirement for other drugs to control muscle spasms, and patients treated with magnesium were 4.7 times (95% CI 1.4 to 15.9) less likely to require verapamil to treat cardiovascular instability than those in the placebo group. Magnesium sulfate infusion did not reduce the need for mechanical ventilation.

• #43 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Management of autonomic dysfunction — Several drugs have been used to produce adrenergic blockade and suppress autonomic hyperactivity; only treatment with magnesium sulfate has been studied in a randomized clinical trial in tetanus. […] Magnesium sulfate — Magnesium sulfate acts as a presynaptic neuromuscular blocker, blocks catecholamine release from nerves, and reduces receptor responsiveness to catecholamines. In patients with tetanus, several clinical series have described the use of magnesium for the management of autonomic dysfunction and as adjunctive treatment for controlling spasms. […] In a randomized, double blind trial in 256 hospitalized patients with severe tetanus in Vietnam, magnesium sulfate infusion compared with placebo controlled autonomic dysfunction. The patients were randomly assigned to magnesium sulfate (loading dose 40 mg/kg over 30 minutes, followed by continuous infusion of either 2 g per hour for patients over 45 kg or 1.5 g per hour for patients ≤45 kg) versus placebo (5 percent glucose in water) infusion. Magnesium infusion significantly reduced the requirement for other drugs to control muscle spasms, and patients treated with magnesium were 4.7 times (95% CI 1.4 to 15.9) less likely to require verapamil to treat cardiovascular instability than those in the placebo group. Magnesium sulfate infusion did not reduce the need for mechanical ventilation.

• #44 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Magnesium may also have the benefit of reducing muscle spasm. In two small unblinded trials, magnesium sulfate infusion (with infusion rate titrated against patella reflex) reduced spasm compared with diazepam. […] Beta blockade — Labetalol (0.25 to 1 mg/min) has frequently been administered because of its dual alpha- and beta-blocking properties. Beta blockade alone with propranolol, for example, should be avoided because of reports of sudden death. Morphine sulfate (0.5 to 1 mg/kg per hour by continuous intravenous infusion) is commonly used to control autonomic dysfunction as well as to induce sedation. […] Other drugs — Other drugs for the treatment of various autonomic events, which have been reported to be useful, are dexmedetomidine, atropine, clonidine, and epidural bupivacaine.

• #45 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Magnesium may also have the benefit of reducing muscle spasm. In two small unblinded trials, magnesium sulfate infusion (with infusion rate titrated against patella reflex) reduced spasm compared with diazepam. […] Beta blockade — Labetalol (0.25 to 1 mg/min) has frequently been administered because of its dual alpha- and beta-blocking properties. Beta blockade alone with propranolol, for example, should be avoided because of reports of sudden death. Morphine sulfate (0.5 to 1 mg/kg per hour by continuous intravenous infusion) is commonly used to control autonomic dysfunction as well as to induce sedation. […] Other drugs — Other drugs for the treatment of various autonomic events, which have been reported to be useful, are dexmedetomidine, atropine, clonidine, and epidural bupivacaine.

• #46 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Magnesium may also have the benefit of reducing muscle spasm. In two small unblinded trials, magnesium sulfate infusion (with infusion rate titrated against patella reflex) reduced spasm compared with diazepam. […] Beta blockade — Labetalol (0.25 to 1 mg/min) has frequently been administered because of its dual alpha- and beta-blocking properties. Beta blockade alone with propranolol, for example, should be avoided because of reports of sudden death. Morphine sulfate (0.5 to 1 mg/kg per hour by continuous intravenous infusion) is commonly used to control autonomic dysfunction as well as to induce sedation. […] Other drugs — Other drugs for the treatment of various autonomic events, which have been reported to be useful, are dexmedetomidine, atropine, clonidine, and epidural bupivacaine.

• #47 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Magnesium may also have the benefit of reducing muscle spasm. In two small unblinded trials, magnesium sulfate infusion (with infusion rate titrated against patella reflex) reduced spasm compared with diazepam. […] Beta blockade — Labetalol (0.25 to 1 mg/min) has frequently been administered because of its dual alpha- and beta-blocking properties. Beta blockade alone with propranolol, for example, should be avoided because of reports of sudden death. Morphine sulfate (0.5 to 1 mg/kg per hour by continuous intravenous infusion) is commonly used to control autonomic dysfunction as well as to induce sedation. […] Other drugs — Other drugs for the treatment of various autonomic events, which have been reported to be useful, are dexmedetomidine, atropine, clonidine, and epidural bupivacaine.

• #48 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Airway management and other supportive measures — Since tetanus toxin cannot be displaced from the nervous system once bound to neurons, supportive care is the main treatment for tetanus. In patients with severe tetanus, prolonged immobility in the intensive care unit is common, much of which is on mechanical ventilation and may last for weeks. Such patients are predisposed to nosocomial infections, decubitus ulcers, tracheal stenosis, gastrointestinal hemorrhage, and thromboembolic disease. […] Endotracheal intubation is justified initially, but early tracheostomy is frequently indicated because of the likelihood of prolonged mechanical ventilation. The latter allows better tracheal suctioning and pulmonary toilet. […] Energy demands in tetanus may be extremely high, so early nutritional support is mandatory. Enteral feeding is preferred. Prophylactic treatment with sucralfate or acid blockers may be used to prevent gastroesophageal hemorrhage from stress ulceration.

• #49 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Airway management and other supportive measures — Since tetanus toxin cannot be displaced from the nervous system once bound to neurons, supportive care is the main treatment for tetanus. In patients with severe tetanus, prolonged immobility in the intensive care unit is common, much of which is on mechanical ventilation and may last for weeks. Such patients are predisposed to nosocomial infections, decubitus ulcers, tracheal stenosis, gastrointestinal hemorrhage, and thromboembolic disease. […] Endotracheal intubation is justified initially, but early tracheostomy is frequently indicated because of the likelihood of prolonged mechanical ventilation. The latter allows better tracheal suctioning and pulmonary toilet. […] Energy demands in tetanus may be extremely high, so early nutritional support is mandatory. Enteral feeding is preferred. Prophylactic treatment with sucralfate or acid blockers may be used to prevent gastroesophageal hemorrhage from stress ulceration.

• #50 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Airway management and other supportive measures — Since tetanus toxin cannot be displaced from the nervous system once bound to neurons, supportive care is the main treatment for tetanus. In patients with severe tetanus, prolonged immobility in the intensive care unit is common, much of which is on mechanical ventilation and may last for weeks. Such patients are predisposed to nosocomial infections, decubitus ulcers, tracheal stenosis, gastrointestinal hemorrhage, and thromboembolic disease. […] Endotracheal intubation is justified initially, but early tracheostomy is frequently indicated because of the likelihood of prolonged mechanical ventilation. The latter allows better tracheal suctioning and pulmonary toilet. […] Energy demands in tetanus may be extremely high, so early nutritional support is mandatory. Enteral feeding is preferred. Prophylactic treatment with sucralfate or acid blockers may be used to prevent gastroesophageal hemorrhage from stress ulceration.

• #51 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Prophylaxis of thromboembolism with heparin, low molecular weight heparin, or other anticoagulants should be administered early. […] Physical therapy should be started as soon as spasms have ceased, since tetanus patients often are left with disability from prolonged muscle wasting and contractures. […] Considerations in resource-limited settings — Critical care services are often unavailable or rudimentary in many resource-limited countries. When ICUs are not available, acute respiratory failure is a leading cause of death from tetanus. In the absence of an ICU, ideally a separate ward or room should be designated for patients with tetanus, and sensory stimuli should be kept to a minimum since loud noises, physical contact, and light can trigger tetanic spasms. Other options include eye shades and ear plugs to reduce stimuli. Nondepolarizing paralytic agents, such as vecuronium and pancuronium, are not safe to use in the absence of ventilatory support. However, benzodiazepines and baclofen can be used in such situations if doses are carefully titrated to avoid respiratory depression.

• #52 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Prophylaxis of thromboembolism with heparin, low molecular weight heparin, or other anticoagulants should be administered early. […] Physical therapy should be started as soon as spasms have ceased, since tetanus patients often are left with disability from prolonged muscle wasting and contractures. […] Considerations in resource-limited settings — Critical care services are often unavailable or rudimentary in many resource-limited countries. When ICUs are not available, acute respiratory failure is a leading cause of death from tetanus. In the absence of an ICU, ideally a separate ward or room should be designated for patients with tetanus, and sensory stimuli should be kept to a minimum since loud noises, physical contact, and light can trigger tetanic spasms. Other options include eye shades and ear plugs to reduce stimuli. Nondepolarizing paralytic agents, such as vecuronium and pancuronium, are not safe to use in the absence of ventilatory support. However, benzodiazepines and baclofen can be used in such situations if doses are carefully titrated to avoid respiratory depression.

• #53 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Prophylaxis of thromboembolism with heparin, low molecular weight heparin, or other anticoagulants should be administered early. […] Physical therapy should be started as soon as spasms have ceased, since tetanus patients often are left with disability from prolonged muscle wasting and contractures. […] Considerations in resource-limited settings — Critical care services are often unavailable or rudimentary in many resource-limited countries. When ICUs are not available, acute respiratory failure is a leading cause of death from tetanus. In the absence of an ICU, ideally a separate ward or room should be designated for patients with tetanus, and sensory stimuli should be kept to a minimum since loud noises, physical contact, and light can trigger tetanic spasms. Other options include eye shades and ear plugs to reduce stimuli. Nondepolarizing paralytic agents, such as vecuronium and pancuronium, are not safe to use in the absence of ventilatory support. However, benzodiazepines and baclofen can be used in such situations if doses are carefully titrated to avoid respiratory depression.

• #54 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Prophylaxis of thromboembolism with heparin, low molecular weight heparin, or other anticoagulants should be administered early. […] Physical therapy should be started as soon as spasms have ceased, since tetanus patients often are left with disability from prolonged muscle wasting and contractures. […] Considerations in resource-limited settings — Critical care services are often unavailable or rudimentary in many resource-limited countries. When ICUs are not available, acute respiratory failure is a leading cause of death from tetanus. In the absence of an ICU, ideally a separate ward or room should be designated for patients with tetanus, and sensory stimuli should be kept to a minimum since loud noises, physical contact, and light can trigger tetanic spasms. Other options include eye shades and ear plugs to reduce stimuli. Nondepolarizing paralytic agents, such as vecuronium and pancuronium, are not safe to use in the absence of ventilatory support. However, benzodiazepines and baclofen can be used in such situations if doses are carefully titrated to avoid respiratory depression.

• #55 Clinical Guidance for Wound Management to Prevent Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html

  The best ways to prevent tetanus are vaccination and wound management. […] There are steps healthcare providers can take during wound care to minimize the risk of tetanus. […] Antibiotics (topical or systemic) aren’t recommended during wound care to protect against tetanus. […] Healthcare providers should take the following steps to prevent tetanus: Provide appropriate wound care, Evaluate the patient’s tetanus vaccination status, Assess the need for prophylactic tetanus immune globulin (TIG). […] Healthcare providers shouldn’t use antibiotics (topical or systemic) to try to prevent tetanus after a wound injury (potential tetanus exposure). However, healthcare providers should observe wounds for signs of infection and promptly treat infected wounds after a wound injury (potential tetanus exposure).

• #56 Clinical Care of Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-care/index.html

  Tetanus is a medical emergency that requires hospitalization. […] Tetanus treatment often involves several types of medications and supportive care. […] Complete recovery can take several months. […] Tetanus infection doesn’t provide immunity, so vaccination is recommended during recovery. […] Medical experts recommend a single, 500 international unit (IU) dose of TIG for tetanus treatment. […] TIG helps remove unbound tetanus toxin from the body. […] Healthcare providers should use sedation and muscle relaxant drugs as indicated to control muscle spasms. […] Appropriate antibiotic therapy is recommended to reduce the number of tetanus bacteria. […] Vaccination, if indicated, is recommended as soon as the patient’s condition has stabilized.

• #57 Clinical Guidance for Wound Management to Prevent Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html

  The best ways to prevent tetanus are vaccination and wound management. […] There are steps healthcare providers can take during wound care to minimize the risk of tetanus. […] Antibiotics (topical or systemic) aren’t recommended during wound care to protect against tetanus. […] Healthcare providers should take the following steps to prevent tetanus: Provide appropriate wound care, Evaluate the patient’s tetanus vaccination status, Assess the need for prophylactic tetanus immune globulin (TIG). […] Healthcare providers shouldn’t use antibiotics (topical or systemic) to try to prevent tetanus after a wound injury (potential tetanus exposure). However, healthcare providers should observe wounds for signs of infection and promptly treat infected wounds after a wound injury (potential tetanus exposure).

• #58 Clinical Guidance for Wound Management to Prevent Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html

  The best ways to prevent tetanus are vaccination and wound management. […] There are steps healthcare providers can take during wound care to minimize the risk of tetanus. […] Antibiotics (topical or systemic) aren’t recommended during wound care to protect against tetanus. […] Healthcare providers should take the following steps to prevent tetanus: Provide appropriate wound care, Evaluate the patient’s tetanus vaccination status, Assess the need for prophylactic tetanus immune globulin (TIG). […] Healthcare providers shouldn’t use antibiotics (topical or systemic) to try to prevent tetanus after a wound injury (potential tetanus exposure). However, healthcare providers should observe wounds for signs of infection and promptly treat infected wounds after a wound injury (potential tetanus exposure).

• #59 Clinical Guidance for Wound Management to Prevent Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html

  TIG contains antibodies against tetanus toxin and functions as an antitoxin. TIG can provide temporary protection against tetanus by directly binding and neutralizing circulating toxin. TIG cannot neutralize toxin that’s already bound to nerve endings. […] If indicated, administer 250 international units of TIG intramuscularly. TIG is commercially available for purchase. CDC doesn’t stockpile or supply TIG.

• #60 Clinical Guidance for Wound Management to Prevent Tetanus | Tetanus | CDC

  https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html

  TIG contains antibodies against tetanus toxin and functions as an antitoxin. TIG can provide temporary protection against tetanus by directly binding and neutralizing circulating toxin. TIG cannot neutralize toxin that’s already bound to nerve endings. […] If indicated, administer 250 international units of TIG intramuscularly. TIG is commercially available for purchase. CDC doesn’t stockpile or supply TIG.

• #61 Tetanus

  https://www.nhs.uk/conditions/tetanus/

  Tetanus is a medical emergency that needs to be treated immediately in hospital. […] If you have tetanus, or a wound that has a high risk of being infected, you’ll be treated in hospital. Treatments for tetanus include: cleaning the wound any dirt, soil or dead tissue will be removed, an injection with a medicine called tetanus immunoglobulin, other medicines, such as antibiotics and medicines to help control painful muscle spasms and stiffness, help with breathing using a machine that gives you oxygen. […] You may need a tetanus vaccine or booster if you’ve not been fully vaccinated (5 doses in total), or if your vaccination history is uncertain.

• #62 Tetanus – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/tetanus/symptoms-causes/syc-20351625

  Severe complications of tetanus can be life-threatening. There’s no cure for tetanus. Treatment focuses on managing symptoms and complications until the effects of the tetanus toxin resolve. […] Seek medical care in the following cases: […] Contaminated wounds require a vaccination booster if it’s been five or more years since your last tetanus shot. […] You can prevent tetanus by being vaccinated. […] A booster shot is recommended for adults once every 10 years. This may be one of two vaccines, Tdap or Td. If you weren’t vaccinated against tetanus as a child or are unsure about your vaccination status, see your doctor about getting the Tdap vaccine.

• #63 Intensive Care Management of Severe Tetanus

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8327798/

  Early tracheostomy is advisable in these patients, often within a few hours of admission. […] Infection does not confer natural immunity against tetanus. Therefore patients require a full course of primary immunization. […] The prognosis in severe tetanus depends on the experience of the treating center and the availability of intensive care facilities. […] Despite good intensive care, mortality ranges from 5% to 50%.

• #64 Intensive Care Management of Severe Tetanus

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8327798/

  Early tracheostomy is advisable in these patients, often within a few hours of admission. […] Infection does not confer natural immunity against tetanus. Therefore patients require a full course of primary immunization. […] The prognosis in severe tetanus depends on the experience of the treating center and the availability of intensive care facilities. […] Despite good intensive care, mortality ranges from 5% to 50%.

• #65 Tetanus (Lockjaw) Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23582-tetanus-lockjaw

  Tetanus isnt curable. Once youve developed symptoms, the disease needs to run its course. But proper treatment can help manage symptoms and prevent complications. […] Treatment for tetanus (lockjaw) depends on the severity of your condition. But if you have tetanus, you need immediate medical care. Your healthcare provider may treat tetanus with: […] Your healthcare provider may use various medicines to treat tetanus. These medications include: […] Once tetanus symptoms develop, it can take two to three weeks for the disease to run its course. With proper treatment, most people recover. But it can take several months to fully recover from tetanus. […] If tetanus symptoms have developed, the disease has to run its course. This can take several weeks. With proper treatment, most people recover. But it can take several months to fully recover.

• #66 Tetanus (Lockjaw) Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23582-tetanus-lockjaw

  Worldwide, one in four people infected with tetanus will die without treatment. The death rate for newborns with untreated tetanus is even higher. With proper treatment, less than 15% of infected people die. In the U.S., tetanus is rarely fatal with proper treatment. […] Tetanus is a rare but serious bacterial infection. Getting vaccinated against tetanus is the best way to prevent getting the disease. If you injure yourself and have an open wound, its important to treat your wound right away. If youre not sure if youre up to date on your vaccines, seek medical treatment right away. Your healthcare provider can help you manage your symptoms and prevent further complications.

• #67 Pharmacological management of tetanus: an evidence-based review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC4057067/

  Tetanus is becoming rarer in both industrialized and developing nations due to an effective vaccination program. […] Without timely diagnosis and proper treatment, severe tetanus is fatal (mortality is also influenced by the comorbidities of the patient). The principles of treating tetanus are: reducing muscle spasms, rigidity and autonomic instability (with ventilatory support when necessary); neutralization of tetanus toxin with human antitetanus immunoglobulin or equine antitetanus sera; wound debridement; and administration of antibiotics to eradicate locally proliferating bacteria at the wound site. […] Treatment in tetanus is based on several key principles: a) sedation and paralysis to control the progressive spasms and autonomic dysfunction and to avoid exhaustion; b) surgical debridement and antibiotic treatment for the source of infection; c) neutralization of the circulating toxin; and c) supportive care in an ICU.

• #68 Tetanus – UpToDate

  https://www.uptodate.com/contents/tetanus

  Prophylaxis of thromboembolism with heparin, low molecular weight heparin, or other anticoagulants should be administered early. […] Physical therapy should be started as soon as spasms have ceased, since tetanus patients often are left with disability from prolonged muscle wasting and contractures. […] Considerations in resource-limited settings — Critical care services are often unavailable or rudimentary in many resource-limited countries. When ICUs are not available, acute respiratory failure is a leading cause of death from tetanus. In the absence of an ICU, ideally a separate ward or room should be designated for patients with tetanus, and sensory stimuli should be kept to a minimum since loud noises, physical contact, and light can trigger tetanic spasms. Other options include eye shades and ear plugs to reduce stimuli. Nondepolarizing paralytic agents, such as vecuronium and pancuronium, are not safe to use in the absence of ventilatory support. However, benzodiazepines and baclofen can be used in such situations if doses are carefully titrated to avoid respiratory depression.

• #69 Tetanus (Lockjaw) Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/23582-tetanus-lockjaw

  Worldwide, one in four people infected with tetanus will die without treatment. The death rate for newborns with untreated tetanus is even higher. With proper treatment, less than 15% of infected people die. In the U.S., tetanus is rarely fatal with proper treatment. […] Tetanus is a rare but serious bacterial infection. Getting vaccinated against tetanus is the best way to prevent getting the disease. If you injure yourself and have an open wound, its important to treat your wound right away. If youre not sure if youre up to date on your vaccines, seek medical treatment right away. Your healthcare provider can help you manage your symptoms and prevent further complications.

• #70

  https://www.who.int/news-room/fact-sheets/detail/tetanus

  Tetanus is a medical emergency requiring: […] immediate treatment with medicine called human tetanus immune globulin (TIG) […] People who recover from tetanus do not have natural immunity and can be infected again, and therefore need to be immunized.

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