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Intensive Care Management of Tetanus: Current Strategies and Challenges

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 Intensive Care Management of Tetanus: Current
Strategies and Challenges
Indunil Karunarathna 1, K.Kusumarathna1 , P.Jayathilaka2 , B.Rathnayake 2 , T.Wijewardane 3 , M Abeykoon 4 , N Priyalath 5, I
Gunarathna 6, D Disanayake 7 , P Kurukulasooriya 7, Achala Samarasinghe 8

1. Department of Anaesthesiology , Intensive Care and Pain Medicine, Teaching Hospital Badulla, Sri Lanka.
2. Department of Medicine, Teaching Hospital Badulla, Sri Lanka.
3. Department of Microbiology, Teaching Hospital Badulla, Sri Lanka.
4. Department of Microbiology, National Hospital Kandy, Sri Lanka.
5. Department of Emergency Medicine, Teaching Hospital Badulla, Sri Lanka.
6. Department of Anaesthesiology , Intensive Care and Pain Medicine, National Hospital Kandy, Sri Lanka.
7. Department of Surgery, Teaching Hospital Badulla, Sri Lanka.
8. Department of Surgery, Base Hospital Diyatalawa, Sri Lanka.

Abstract:

Tetanus is caused by the exotoxin tetanospasmin, produced by Clostridium tetani, an anaerobic gram-positive bacillus[3,14].
Tetanospasmin disrupts the release of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the spinal cord,
brainstem motor nuclei, and the brain, leading to muscle rigidity and tonic spasms[4,16]. Common manifestations include trismus
(lockjaw), dysphagia, laryngeal spasms, limb and paraspinal muscle rigidity, and opisthotonic posture[2,23]. Touch, pain, bright
light, or sounds can trigger severe spasms, potentially causing apnea and rhabdomyolysis. Severe tetanus often presents with
autonomic overactivity, marked by labile hypertension, tachycardia, increased secretions, sweating, and urinary retention[3,12].
Dysautonomia, a significant challenge to manage, frequently contributes to mortality, with magnesium sulfate infusion
commonly employed for treatment[1,16].

Treatment strategies encompass antibiotics (penicillin or metronidazole) to curtail toxin production, along with human tetanus
immune globulin to neutralize circulating toxin[1,4]. Nasogastric tube placement for feeding and medication administration is
essential, and early elective tracheostomy is often indicated in moderate to severe cases to mitigate aspiration and laryngeal
stridor[2,24]. Benzodiazepines play a crucial role in reducing rigidity, spasms, and autonomic dysfunction, with diazepam
typically administered via nasogastric tube at high doses (0.2–1 mg/kg/h)[2,8]. Neuromuscular blocking agents and mechanical
ventilation are employed for refractory spasms[6,22].

Mortality rates for tetanus vary widely, ranging from 5% to 50%[4,7].

Keywords: Autonomic dysfunction, Benzodiazepine, Immunization, Intensive care unit, Laryngospasm, Muscle spasm,
Rhabdomyolysis, Severe tetanus, Tracheostomy, Tropical infections.

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Key Points: Autonomic Dysfunction: Severe tetanus often presents with

autonomic overactivity, including labile hypertension,
Etiology: Tetanus is caused by the exotoxin tetanospasmin, tachycardia, increased secretions, sweating, and urinary
produced by the anaerobic gram-positive bacillus Clostridium retention. Dysautonomia poses a significant challenge in
tetani. management and contributes to mortality.
Pathophysiology: Tetanospasmin disrupts the release of Treatment Strategies: Treatment involves antibiotics
gamma-aminobutyric acid (GABA) in the spinal cord, (penicillin or metronidazole) to inhibit toxin production,
brainstem motor nuclei, and the brain, leading to muscle human tetanus immune globulin to neutralize circulating
rigidity and tonic spasms. toxin, and supportive measures such as nasogastric tube
Clinical Manifestations: Common symptoms include trismus placement, tracheostomy, and benzodiazepines to manage
(lockjaw), dysphagia, laryngeal spasms, limb and paraspinal spasms and autonomic dysfunction.
muscle rigidity, and opisthotonic posture. Trigger factors like
touch, pain, bright light, or sounds can induce severe spasms.

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 1
Mortality Rates: Mortality rates for tetanus vary widely, births worldwide[9,14]. However, as of April 2018, 14
ranging from 5% to 50%, depending on the severity of the countries had yet to achieve this target. Despite an 85%
disease and the effectiveness of treatment. decline in deaths attributable to neonatal tetanus, an estimated
Keywords: Autonomic dysfunction, Benzodiazepine, 25,000 neonatal deaths still occur annually due to tetanus
Immunization, Intensive care unit, Laryngospasm, Muscle worldwide[4,12].
spasm, Rhabdomyolysis, Severe tetanus, Tracheostomy,
Tropical infections. This review primarily focuses on the intensive care
management of non-neonatal tetanus.
Questions:
Etiology: Clostridium tetani (C. tetani) is an anaerobic spore-
1. What is the primary cause of tetanus? forming gram-positive bacillus, widely present in soil,
2. How does the tetanus toxin affect the body? surfaces, and the feces of certain mammals[13]. These spores,
3. What are the common symptoms of tetanus? capable of surviving for months, typically enter the body
4. What triggers severe spasms in tetanus patients? through wounds, minor abrasions, animal bites, or
5. How is tetanus diagnosed by healthcare contaminated needles. While dormant in the wound, they
professionals? germinate under anaerobic conditions, producing the potent
6. What are the treatment options available for tetanus? metalloprotease toxin tetanospasmin[4,23], responsible for
7. What preventive measures can be taken to avoid tetanus. Immunization provides protection by neutralizing the
tetanus infection? toxin, rendering tetanus rare in developed nations but still
8. How is the severity of tetanus determined, and what prevalent in areas with poor vaccination coverage[9].
are the associated mortality rates?
Pathogenesis: Upon entry into the body, C. tetani spores
9. What complications can arise from severe tetanus?
germinate in anaerobic environments, releasing potent toxins
10. How is tetanus managed in an intensive care unit
disseminated via the bloodstream and lymphatic system.
(ICU) setting?
These toxins target various sites in the central nervous system,
including motor end plates, spinal cord, brain, and sympathetic
Introduction: nervous system. By disrupting neurotransmitter release and
inhibitory impulses, tetanus toxin induces uncontrolled muscle
Tetanus, caused by the neurotoxin produced by the spore- contraction, spasms, seizures, and autonomic nervous system
forming bacterium Clostridium tetani, remains a significant dysfunction[12].
concern globally despite being a vaccine-preventable disease.
In 2019, the World Health Organization (WHO) reported Risk Groups: Most tetanus cases in the United States occur
14,751 cases of tetanus, with a substantial portion—7071 among individuals either unvaccinated or inadequately
cases—emerging from India alone[1,4,25]. Particularly vaccinated. Adults, particularly those aged 20 to 59, constitute
prevalent in developing nations, tetanus carries a considerable the majority of reported cases, with a significant portion
mortality rate. among individuals aged 60 and older. Risk factors include
lack of tetanus immunization, diabetes, history of
The clinical presentation of tetanus includes muscle rigidity, immunosuppression, and intravenous drug use[25]. Disaster
paroxysmal muscle spasms, respiratory distress, and survivors and emergency responders should prioritize
autonomic dysfunction, often necessitating prolonged vaccination and wound care to minimize tetanus risk during
intensive care over a 4–6 week period[2,7,23]. While tetanus natural disasters.
affects individuals of all ages in developing countries,
mortality rates are generally lower in children and adults This comprehensive understanding of tetanus etiology,
compared to neonates[3,8]. Neonatal tetanus, resulting from C. pathogenesis, and risk factors is crucial for effective
tetani infection of the umbilicus in newborns of non- prevention and management strategies.
immunized mothers, presents a significant public health
Pathophysiology:
challenge in many regions[5,17].
Tetanus, caused by Clostridium tetani, is a serious condition
Prevention of neonatal tetanus is achievable through the
stemming from the neurotoxin tetanospasmin[2]. This potent
administration of tetanus toxoid to pregnant women during
toxin is responsible for the characteristic symptoms of the
mid-pregnancy[6,12]. In 1989, the WHO launched the global
disease.
maternal–neonatal tetanus elimination program with the aim
of reducing neonatal tetanus to fewer than 1 case per 1000 live

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 2
Introduction of Spores: The C. tetani spores, found in soil, Additional Findings: Other clinical manifestations may
dust, and animal feces, enter the body through a wound, burn, include fever, sweating, rapid heart rate, elevated blood
surgery site, or even during childbirth[7,26]. pressure, and irritability.
Germination and Toxin Production: Once inside the body, Laboratory Tests: While there are no specific laboratory tests
the spores germinate under anaerobic conditions. C. tetani to confirm tetanus, blood tests may be performed to rule out
then produces exotoxins, primarily tetanospasmin[7]. other possible causes of symptoms, such as infections or
Toxin Spread: Tetanospasmin, the neurotoxin, binds to the metabolic disorders.
neuromuscular junctions and is transported retrogradely into Neurological Evaluation: In severe cases, a neurological
the nerve cell body. It then spreads trans-synaptically to evaluation may be conducted to assess the extent of neurologic
adjacent motor and autonomic nerves. involvement and monitor for complications.
Effect of Tetanospasmin: Tetanospasmin disrupts Imaging Studies: Imaging studies such as CT scans or MRI
neurotransmitter release by cleaving synaptobrevin, an may be performed in certain cases to evaluate for any
essential protein for vesicle fusion and neurotransmitter underlying injuries or complications, although they do not
release. This disruption primarily affects inhibitory pathways directly confirm the diagnosis of tetanus.
by preventing the release of glycine and gamma-aminobutyric Given the clinical nature of the diagnosis, healthcare providers
acid (GABA). must maintain a high index of suspicion for tetanus,
Clinical Manifestations: The inhibition of inhibitory particularly in individuals with a history of inadequate
pathways leads to increased muscle tone and rigidity, vaccination or recent injuries. Prompt recognition and
interspersed with sudden, severe muscle spasms. Muscles of initiation of appropriate treatment are essential to improve
the face are often affected first due to their shorter axonal outcomes and prevent complications associated with the
pathways. As the disease progresses, sympathetic neurons disease.
become affected, resulting in autonomic dysfunction and
sympathetic overactivity. Clinical Manifestation:
Irreversible Binding and Recovery: Tetanospasmin
irreversibly binds to neurons. Recovery requires the growth of Tetanus can manifest in various forms, each with distinct
new nerve terminals, which explains the prolonged duration of clinical features and presentations:
the disease. Generalized Tetanus: This is the most common form,
Understanding the pathophysiology of tetanus helps in its accounting for about 80% of cases. It affects muscles
prevention, diagnosis, and management. Vaccination against throughout the body, primarily targeting motor neurons of the
tetanus and prompt wound care are crucial preventive central nervous system (CNS) and later the autonomic nervous
measures, while early recognition and treatment of tetanus system (ANS). Symptoms typically begin with muscle
symptoms are essential for patient management. stiffness and spasms of the face and jaw (trismus), followed by
stiffness of the neck, difficulty swallowing, and rigidity of
Diagnosis: abdominal muscles. Other symptoms include fever, sweating,
elevated blood pressure, and rapid heart rate. Muscle spasms
Diagnosing tetanus primarily relies on clinical assessment, as can be frequent and last several minutes, continuing for 3–4
there are currently no confirmatory laboratory tests available. weeks, with complete recovery potentially taking months.
Here's a breakdown of the diagnostic process: Localized Tetanus: This is less common and involves
Medical History: Gathering a thorough medical history is persistent muscle contractions in the same area as the injury. It
essential, including information about vaccination status, often affects the extremities and may precede the onset of
recent injuries or wounds, and any symptoms suggestive of generalized tetanus but is generally milder, with contractions
tetanus. persisting for weeks before subsiding.
Physical Examination: A comprehensive physical Cephalic Tetanus: A rare form resulting from head injuries or
examination is conducted to assess for signs and symptoms of otitis media where C. tetani is present in the middle ear flora.
tetanus. Key indicators include muscle rigidity, muscle It involves cranial nerves, particularly facial nerves, leading to
spasms, and autonomic instability. facial nerve palsies. Cephalic tetanus can become generalized.
Clinical Presentation: The classic triad of muscle rigidity, Neonatal Tetanus: This occurs in newborns lacking passive
muscle spasms, and autonomic instability strongly suggests immunity due to non-immune mothers. It has a high mortality
the presence of tetanus. Muscle rigidity typically involves the rate, especially in developing countries, often arising from
jaw muscles (resulting in trismus or "lockjaw"), followed by unsanitary delivery practices or unhygienic umbilical cord
stiffness and spasms of other muscles in the body. care. Symptoms typically appear 4 to 14 days after birth and
include stiffness, trismus, and difficulty feeding.

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 3
General symptoms of tetanus include neck stiffness, sore against tetanus and prompt wound care to prevent infection in
throat, dysphagia, and trismus. Muscle spasms are severe and susceptible individuals.
may lead to tendon rupture, joint dislocation, or bone
fractures. Facial muscle spasms can cause the characteristic Severity and Prognostic:
"risus sardonicus" expression, while truncal spasms can lead
to opisthotonus. Hypertension and tachycardia result from The severity of tetanus infection can be classified using the
increased sympathetic tone, alternating with episodes of Ablett classification system, which ranges from Grade I (mild)
hypotension, bradycardia, and asystole. Autonomic to Grade IV (very severe). Additionally, prognostic scoring
disturbances include salivation, sweating, increased bronchial systems like the Dakar score and the Phillips score help assess
secretions, hyperpyrexia, gastric stasis, and ileus. Severe prognosis based on various factors. Here's a summary of these
hypoventilation and life-threatening apnea may occur during grading and scoring systems:
prolonged spasms. Ablett Classification of Severity:
Grade I (Mild): Mild trismus, general spasticity, no respiratory
Complications: compromise, no spasms, no dysphagia.
Grade II (Moderate): Moderate trismus, rigidity, short spasms,
Tetanus can lead to a range of complications affecting mild dysphagia, moderate respiratory involvement (ventilatory
multiple systems in the body: frequency >30).
Respiratory System: Life-threatening complications include Grade III (Severe): Severe trismus, generalized rigidity,
apnea, hypoxia, respiratory failure, laryngeal spasm, prolonged spasms, severe dysphagia, apnoeic spells, pulse
atelectasis, and aspiration pneumonitis. Prolonged ventilation >120, ventilatory frequency >40.
may result in ventilator-associated pneumonia (VAP) and Grade IV (Very Severe): Grade III symptoms with severe
complications from tracheostomy, such as tracheal stenosis. autonomic instability involving the cardiovascular system,
Breathing difficulties arise from the tightening of vocal cords including severe hypertension and tachycardia alternating with
and muscle rigidity. relative hypotension and bradycardia.
Cardiovascular System: Complications stem from autonomic
dysfunction and are among the most serious. These include Prognostic Scoring Systems:
tachycardia, hypertension, myocardial ischemia, hypotension,
various arrhythmias (such as tachyarrhythmias and Dakar Score:
bradyarrhythmias), asystole, and heart failure. Excessively
high levels of circulating catecholamines contribute to these Factors: Incubation period, period of onset, entry site,
cardiovascular manifestations. presence of spasms, fever, and tachycardia.
Renal and Gastrointestinal Systems: Complications in these Total Score: Determines severity and mortality risk.
systems include high-output renal failure, oliguric renal failure Severity:
resulting from rhabdomyolysis, urinary stasis, urinary tract 0–1: Mild (˂10% mortality).
infections, gastric stasis, ileus, diarrhea, and hemorrhage. 2–3: Moderate (10–20% mortality).
Thromboembolism and skin breakdown are also reported. 4: Severe (20–40% mortality).
Dislocations of the temporomandibular and shoulder joints 5–6: Very severe (˃50% mortality).
have been observed. Sepsis with multiple organ failures can
occur as the disease progresses. Phillips Score:
Musculoskeletal System: Muscle spasms and rigidity can
lead to complications such as tendon rupture, joint dislocation, Factors: Incubation time, site of infection, state of protection,
and bone fractures. complicating factors.
Nervous System: Tetanus can cause central nervous system Total Score: Determines severity.
manifestations including seizures, coma, and neurological Severity:
deficits. Mild: <9.
General: Tetanus-induced complications can result in Moderate: 9–16.
prolonged hospitalization, disability, and even death if not Severe: >16.
promptly and effectively managed. These scoring systems aid in assessing the severity of tetanus
Given the potential severity of these complications, prompt infection and predicting prognosis based on clinical factors
recognition and aggressive management of tetanus are such as symptom presentation, incubation period, and
essential to mitigate adverse outcomes and improve patient immunization status. They assist healthcare providers in
prognosis. This underscores the importance of vaccination

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 4
tailoring management strategies and predicting patient Table 3: Total score, severity, and disease prognosis:
outcomes. Score Severity Mortality
Table 1: Ablett classification of severity for tetanus:
0–1 Mild ˂10%
Grade Characteristics
2–3 Moderate 10–20%
Mild trismus, general spasticity, no respiratory
1 compromise, no spasms, no dysphagia 4 Severe 20–40%

Moderate trismus, rigidity, short spasms, mild 5–6 Very severe ˃50%
dysphagia, moderate respiratory involvement,
2 ventilatory frequency >30 Table 4:Prognostic scoring systems in tetanus: Phillips
Severe trismus, generalized rigidity, prolonged score
Mild <9, moderate 9–16, severe >16.
spasms, severe dysphagia, apnoeic spells, pulse
3 >120, ventilatory frequency >40 Category Score
Grade 3 with severe autonomic instability Incubation time:
involving the cardiovascular system, severe <48 h 0
hypertension and tachycardia, alternating with
2–5 days 4
relative hypotension and bradycardia, either of
4 which may be persistent 5–10 days 3
This classification system helps healthcare professionals to 10–14 days 2
categorize the severity of tetanus infection based on specific >14 days 1
clinical characteristics, aiding in treatment decisions and
prognosis assessment. Site of infection:
Internal and umbilical 5
Head, neck, and body wall 4
Table 2: Prognostic scoring systems in tetanus: Dakar
Peripheral proximal 3
score
Prognostic Peripheral distal 2
factor Score 1 Score 0 Unknown 1
Incubation >7 days or State of protection:
period <7 days unknown None 10
Period of Possibly some or maternal immunisation
onset <2 days >2 days in neonatal patients 8
Umbilicus, burn, Protected > 10 years ago 4
uterine, open
fracture, surgical Protected < 10 years ago 2
wound, Complete protection 0
intramuscular All others plus Complicating factors:
Entry site injection unknown
Injury or life-threatening illness 10
Spasms Present Absent
Severe injury or illness not immediately
Fever >38.4°C <38.4°C
life-threatening 8
Neonate > 150 Neonate < 150 Injury or non-life-threatening illness 4
beats/min Adult > beats/min Adult <
Tachycardia 120 beats/min 120 beats/min Minor injury or illness 2
ASA grade 1 0
Total score Total
This table outlines various categories related to prognostic
scoring in tetanus, along with their corresponding scores.

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 5
Management: aimed at neutralizing free circulating toxin before it binds to
neuronal cell membranes. Here are some key points regarding
Managing tetanus involves emergency and long-term its use:
supportive care aimed at neutralizing the toxin, eliminating the Dosing: HTIG is administered intramuscularly at a dose of
bacteria, and minimizing the effects of the toxin. Here are 150 units/kg of body weight. An intravenous preparation is
some key strategies: available, typically ranging from 5000 to 10,000 IU.
Neutralization of Toxin: Timing: HTIG should be administered as soon as the
Administration of tetanus immune globulin (TIG) can help diagnosis of tetanus is considered to effectively neutralize
neutralize circulating tetanospasmin. circulating toxin.
Antitoxin therapy with human or equine antitoxins may be Composition: HTIG is a specific solvent-detergent-treated
considered to bind and neutralize circulating toxin. plasma-derived product obtained from donors immunized with
Intravenous immunoglobulin (IVIG) may be used in some tetanus toxoids. It contains antibodies against tetanus toxin.
cases to provide passive immunity and neutralize the toxin. Safety Precautions:
Destroying Organisms: Prior to administration, an initial skin sensitivity test should be
Wound debridement and irrigation help remove contaminated performed using a dose of 3000–6000 units intramuscularly to
tissue and bacteria, reducing further toxin production. assess for potential allergic reactions.
Antibiotic therapy with agents effective against Clostridium HTIG is contraindicated in patients with a history of
tetani, such as metronidazole or penicillin, can help eradicate anaphylactic reactions to the active substance or any
the bacteria. components of the product.
Minimizing Toxin Effects: Patients with deficiency of immunoglobulin A should not
Symptomatic treatment focuses on managing muscle spasms, receive HTIG due to the risk of anaphylaxis.
rigidity, and autonomic dysfunction. The intramuscular test dose is contraindicated in individuals
Muscle relaxants such as benzodiazepines (e.g., diazepam) or with severe thrombocytopenia or any coagulation disorder due
baclofen can help alleviate muscle rigidity and spasms. to the risk of bleeding.
Sedatives may be used to control agitation and anxiety. Mechanism of Action: HTIG functions by providing passive
Mechanical ventilation may be necessary to manage immunity through the transfer of antibodies against tetanus
respiratory compromise due to muscle rigidity or spasms. toxin. These antibodies bind to circulating toxin molecules,
Supportive care includes wound care, hydration, nutrition, and preventing their interaction with neuronal cells and subsequent
monitoring for complications such as respiratory failure, neurotoxic effects.
cardiovascular instability, and renal dysfunction. Limitations: HTIG does not neutralize intracellular toxin that
Prevention: has already bound to nerve terminals. Therefore, its
Tetanus vaccination is the most effective preventive measure. effectiveness is primarily in neutralizing free circulating toxin.
Routine immunization with tetanus toxoid-containing vaccines In summary, HTIG plays a critical role in the management of
(e.g., DTaP, Tdap) and booster doses every 10 years are tetanus by neutralizing circulating tetanus toxin and
recommended. preventing its binding to neuronal cells. Its timely
Prompt wound care, including cleaning and proper dressing of administration, appropriate dosing, and safety precautions are
wounds, helps prevent tetanus infection. essential for optimizing patient outcomes in tetanus cases.
Monitoring and Complication Management:
Continuous monitoring of vital signs, neurological status, and Managing the Airway:
cardiac function is essential.
Prompt recognition and management of complications such as Managing the airway in tetanus patients, particularly those at
respiratory failure, cardiovascular instability, and renal risk of respiratory failure, is crucial for optimizing outcomes.
dysfunction are crucial for improving outcomes. Here are key points regarding airway management in tetanus:
Management of tetanus requires a multidisciplinary approach Respiratory Support: Respiratory failure is a common cause
involving critical care physicians, infectious disease of death in tetanus, particularly in less developed regions
specialists, neurologists, and supportive care teams to provide where ventilator support may be limited. Patients at risk of
comprehensive care and optimize patient outcomes. hypoxia, airway obstruction, aspiration, hypoventilation,
pneumonia, and respiratory arrest should be closely monitored
Tetanus immunoglobulin (HTIG): and connected to ventilator support promptly.
Early Airway Protection: Early airway protection with
Intravenous human tetanus immunoglobulin (HTIG) is an endotracheal intubation or tracheostomy may be necessary,
essential component of tetanus management, specifically

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 6
especially in the presence of rigidity and spasm that can Tetracyclines, clindamycin, cephalosporins, and
compromise ventilation. chloramphenicol are also effective against Clostridium tetani.
Ventilator Modes: The choice of ventilator modes depends In addition to antibiotic therapy, thorough cleaning of the
on the available equipment and the patient's condition. In the infected site and extensive surgical debridement are
early stages of the disease, when rigidity and spasm are recommended if the patient is stable and the wound
prominent, controlled mandatory ventilation may be used to responsible for tetanus is identifiable. Surgical debridement
provide rest to fatigued respiratory muscles. Pressure- helps eradicate spores and necrotic tissues, which could
controlled ventilation and positive end-expiratory pressure provide ideal conditions for bacterial germination.
(PEEP) may help overcome poor lung compliance and It's crucial to delay wound manipulation until hours after
oxygenation. administration of antitoxin to reduce the risk of releasing
Modes Favoring Spontaneous Ventilation: As the disease tetanospasmin into the bloodstream. This precaution helps
progresses, modes of ventilation that allow for spontaneous minimize the spread of the toxin and improves the
breathing (e.g., synchronized intermittent mandatory effectiveness of treatment.
ventilation, continuous positive airway pressure, biphasic
positive airway pressure ventilation) are preferred. These Minimizing the Effects of Tetanus Toxin:
modes can optimize respiratory patterns, reduce sedation
requirements, minimize muscle wastage, and decrease the risk Minimizing the effects of circulating tetanus toxin, which
of acquired critical illness neuropathy or myopathy. manifest as muscle rigidity, spasms, and autonomic instability,
Early Tracheostomy: Early tracheostomy may be beneficial is crucial in tetanus management. Here's how these effects are
as it improves patient comfort, reduces dead space and airway addressed:
resistance, and decreases the risk of airway trauma, especially Sedation and Muscle Relaxation:
during convulsions. Tracheostomy has been associated with Sedation and limiting unnecessary stimulation are key to
fewer complications compared to endotracheal intubation and managing muscle rigidity and spasms effectively.
may result in lower mortality rates. Benzodiazepines, such as diazepam and midazolam, are the
Sedation and Analgesia: Sedation and analgesia are essential first-line agents for treating tetanus-induced muscle rigidity
components of airway management in tetanus patients. They and spasms. They act by increasing GABA agonism, resulting
help relieve discomfort, anxiety, and agitation caused by in muscle relaxation and sedation.
airway manipulation, ventilation, suction, and physiotherapy. Diazepam is particularly effective due to its anticonvulsant,
Adequate sedation and analgesia also minimize the stress muscle relaxant, sedative, and anxiolytic properties. It can be
response to tracheal intubation and mechanical ventilation. administered in large doses, up to 100 mg/h, to control
Overall, a proactive approach to airway management, symptoms, although caution is needed due to the risk of mild
including early identification of patients at risk of respiratory respiratory depression.
failure and prompt initiation of appropriate interventions, is Midazolam, a short-acting benzodiazepine, can be used as an
essential for optimizing outcomes in tetanus patients requiring alternative to diazepam.
ventilator support. Adjunctive Medications:
Morphine can be used adjunctively with benzodiazepines to
Eradicate the Bacteria: provide additional sedation and analgesia.
Propofol is another option for sedation and muscle relaxation,
To eradicate the bacteria responsible for tetanus and prevent with rapid recovery upon discontinuation. However,
further toxin release, several antibiotics are effective. mechanical ventilation is necessary to achieve adequate
Metronidazole is commonly used due to its ability to penetrate plasma concentrations.
bacterial cells and disrupt protein synthesis by interacting with Anticonvulsants like phenobarbitone, which enhances GABA
DNA, causing a loss of helical DNA structure. It is typically activity, and phenothiazines such as chlorpromazine may be
administered at a dose of 30–40 mg/kg/day in three divided used to augment sedation.
doses for children and 0.5 g three times daily for up to 10 Neuromuscular Blocking Agents (NMBAs):
days. In cases where muscle spasm persists despite sedation,
Other antibiotics effective against Clostridium tetani include: NMBAs can be used to achieve muscle relaxation.
Penicillin G: Given intravenously at a dose of 100,000– Vecuronium, a short-acting NMBA with minimal
200,000 IU/kg/day in four divided doses. cardiovascular effects, is preferred in tetanus patients on
Macrolides (e.g., erythromycin): Administered at a dose of mechanical ventilation. It does not release histamines, making
30–50 mg/kg/day in three divided doses for children and 0.5 it suitable for use in this population.
g/kg/day in three divided doses for adults.

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 7
Pancuronium and atracurium are generally not recommended Overall, the management of autonomic instability in tetanus
due to their potential cardiovascular effects, which can involves a combination of sedatives, neuromuscular blockers,
exacerbate complications in tetanus patients. and medications aimed at modulating sympathetic and
Baclofen: parasympathetic activity to stabilize cardiovascular function
Baclofen, a structural analogue of GABAB receptor agonist, and reduce mortality risk. Close monitoring and prompt
inhibits presynaptic acetylcholine release and medullary intervention are essential in managing these potentially life-
reflexes, resulting in anti-spastic action. threatening complications.
Intrathecal administration of baclofen has been effective in
reducing muscle spasms in generalized tetanus. Supportive Care:
In cases where sedation alone is inadequate, a combination of
sedatives, NMBAs, and intermittent positive pressure Supportive care plays a crucial role in the management of
ventilation may be required for a prolonged period to manage patients with tetanus, addressing various aspects of their
tetanus-induced muscle rigidity and spasms effectively. condition and preventing complications. Here are some key
components of supportive care:
Autonomic Instability: Nutritional Support:
Due to difficulties in swallowing and altered gastrointestinal
Autonomic instability in tetanus can lead to circulatory function, patients with tetanus often experience weight loss
collapse, which is a significant contributor to mortality. and increased metabolic demands. Early establishment of
Sudden cardiac arrest is common and may result from the nutrition is essential.
combination of elevated catecholamine levels and direct action Nasogastric tube feeding should be initiated promptly due to
of the tetanus toxin on the myocardium. Prolonged trismus preventing oral feeding.
sympathetic activity can lead to profound hypotension and High-calorie nutritional supplements are necessary to meet the
bradycardia, while parasympathetic overactivity may result in increased metabolic demands.
sinus arrest. Damage to the vagal nucleus by the tetanus toxin Prevention of Nosocomial Infections:
has been implicated in these autonomic disturbances. Ventilator-associated pneumonia (VAP) is common among
Managing autonomic instability in tetanus involves several critically ill, ventilated patients, including those with tetanus.
strategies: Preventive measures include:
Sedation and Medication: Strict hand hygiene before airway management.
Benzodiazepines, anticonvulsants, and morphine are the first- Continuous aspiration of subglottic secretions.
line medications to control autonomic instability. They help to Oral hygiene using chlorhexidine.
dampen sympathetic activity and stabilize cardiovascular Semi-recumbent positioning of patients when possible.
function. Selective decontamination of the digestive tract or selective
Magnesium sulfate is used as a preventive measure due to its oropharyngeal decontamination.
ability to inhibit catecholamine release and reduce receptor Prevention of Venous Thromboembolism (VTE):
responsiveness. It also acts as a calcium antagonist, further VTE is a significant complication in critically ill patients.
stabilizing myocardial function. Loading doses are typically Measures to prevent VTE include:
administered followed by maintenance infusions, adjusted Intermittent pneumatic compression or graduated compression
based on patient age. stockings.
Morphine is beneficial for maintaining cardiovascular stability Regular turning of the patient to prevent stasis.
by reducing sympathetic reflex activity and histamine release. Prevention of Musculoskeletal Complications:
Phenothiazines: Foot drop splints can prevent ankle contractures.
Phenothiazines, such as chlorpromazine, possess Limb and chest physiotherapy are essential to maintain
anticholinergic and α-adrenergic antagonistic properties, mobility and prevent complications.
contributing to cardiovascular stability. They are also used as Prevention of Pressure Ulcers:
sedatives in tetanus management. Regular turning of the patient or the use of air/water
Beta-Blockers: mattresses helps prevent decubitus ulcers.
While beta-blockers may theoretically be useful in controlling Environmental Considerations:
hypertension and tachycardia, their use in tetanus is associated Care should be provided in a quiet, dark room with minimal
with significant risks, including sudden cardiovascular stimulation to reduce the risk of exacerbating muscle spasms.
collapse, pulmonary edema, and death. Therefore, beta- Psychosocial Support:
blockers are generally avoided in tetanus management.

Uva Clinical | Intensive Care Management of Tetanus: Current Strategies and Challenges 8
Providing psychosocial support is important for the well-being such as inadequate vaccine coverage, poverty, and limited
of the patient and their family members, given the severity of access to healthcare and education. It's crucial to understand
the condition and its potential long-term effects. that tetanus is a vaccine-preventable disease, and efforts to
Overall, supportive care in tetanus management aims to improve vaccination rates are essential in reducing its burden.
address the diverse needs of the patient, prevent Diagnosing tetanus relies primarily on clinical evaluation, and
complications, and optimize outcomes. It requires a prompt recognition is paramount as it can be a fatal condition
multidisciplinary approach involving healthcare professionals if left untreated. Management of tetanus requires a
from various specialties to provide comprehensive care multidisciplinary approach, with a focus on supportive care,
tailored to the individual needs of the patient. including airway management, neutralizing circulating toxins,
preventing further toxin release, and minimizing the effects of
Prevention: toxins already in the body.
Complications of tetanus can be severe, and mortality rates
Prevention of tetanus primarily relies on immunization with remain high, underscoring the importance of early diagnosis
tetanus toxoid-containing vaccines. Here are key points and comprehensive management. Prolonged intensive care
regarding tetanus prevention: may be necessary for patients with tetanus, highlighting the
Vaccination: need for resources and expertise in critical care settings.
Tetanus toxoid vaccines are highly effective, affordable, and Ultimately, the outcome of tetanus depends on timely
safe for individuals of all age groups. intervention, effective management of complications, and the
In children, vaccination typically starts as early as six weeks quality of supportive care provided to the patient. By
of age, with three doses administered at intervals of four addressing vaccination gaps, improving access to healthcare,
weeks. and enhancing awareness, we can work towards reducing the
Booster doses are recommended throughout life to maintain burden of tetanus and preventing needless suffering and loss
lifelong immunity. Three booster doses are usually given. of life.
Pregnant women receive tetanus toxoid vaccination as part of
antenatal care to protect both the mother and the newborn. Authors’ Contributions:
Individuals with cuts or open wounds should receive tetanus
toxoid-containing vaccines to prevent tetanus infection. The manuscript's conception and writing were undertaken by
Vaccine Schedule: I.K. Contributions to the manuscript's revision were made by
The vaccine schedule typically includes a primary series of KK, PJ, BR, TW, MA, NP, IG, DD, PK and AS. All authors
doses followed by booster doses at appropriate intervals to participated in the article's creation, provided substantial input
maintain immunity. during the revision process, and approved the final submitted
The specific schedule may vary depending on age, previous version.
vaccination history, and individual risk factors.
Antenatal Care: Declaration of Interest:
Tetanus toxoid vaccination is an integral part of antenatal care,
aiming to protect both pregnant women and their unborn No conflicts of interest were declared by the authors.
babies from tetanus infection.
Wound Management: References:
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