Tetanus: recognition, spasm control and prevention

Manage now— do this, in order

• Nurse at once in a quiet, isolated, darkened, well-ventilated room and undertake no procedure — suction, nasogastric tube, oral examination, wound care — on an unsedated patient. Minimising noise, light and handling measurably reduces drug requirement and laryngeal spasm; this is treatment, not comfort.
• Protect the airway before it is lost: intubate and ventilate early for any laryngeal spasm, inability to swallow secretions, rising PaCO₂, exhaustion, or sedation deep enough to abolish spasms. Treat this as a difficult airway — trismus may prevent mouth opening and laryngoscopy provokes laryngospasm — and have a surgical airway plan.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Give human tetanus immunoglobulin (HTIG) 500 units IM within the first 24 hours, without waiting for any investigation (Kumar and Clark specify 250 units; 3,000–6,000 units are widely quoted but not superior). In children and neonates the dose is NOT weight-based — the same 500 units, split between two sites in a small infant. Draw the pre-treatment serum antibody sample first only if it takes seconds. Where no human product exists: equine antitoxin 10,000–20,000 units IM/IV after test dosing.Doctor / Nurse
• Give an antibiotic even when no wound is found: metronidazole 500 mg IV every 8 hours for 7–10 days (paediatric 7.5 mg/kg IV every 8 hours); alternative benzylpenicillin 1.2 g IV every 6 hours (paediatric 50 mg/kg) — prefer metronidazole, since penicillin is itself a GABA antagonist and may aggravate spasm.Doctor / Nurse
• Clean and débride the wound, excising necrotic tissue and leaving it open — but only after antitoxin has been given and the patient is sedated, because manipulating the wound is a powerful spasm trigger.Doctor / Nurse
• Control spasm: diazepam 5–10 mg IV slowly over at least 2 minutes, repeated every 5–15 minutes and titrated to abolition of spasm (paediatric 0.1–0.3 mg/kg per dose, usual maximum 10 mg), or midazolam 2–5 mg IV boluses then infusion 5–15 mg/hour (paediatric 0.1 mg/kg). There is no fixed ceiling — but every increment moves the patient closer to apnoea. Morphine 2.5–5 mg IV titrated is not optional (paediatric 0.05–0.1 mg/kg): the spasms are agonising in a fully conscious patient and morphine blunts autonomic instability.Doctor / Nurse
• Add magnesium sulphate as the principal adjunct: 5 g (or 75 mg/kg) IV over 20–30 minutes, then 2 g/hour if over 45 kg (1.5 g/hour if under 45 kg), titrated to spasm control, target serum magnesium about 2–4 mmol/L. Loss of the patellar reflex is the earliest sign of toxicity — keep calcium gluconate immediately available as antidote.Doctor / NurseNot available at your setup — Infusion pump.
• Uncontrollable spasm needs neuromuscular blockade (vecuronium or rocuronium infusion) with full mechanical ventilation — never paralyse without secure ventilation, and never stop the sedation, because a paralysed patient with tetanus is fully aware. Avoid pancuronium and never use propranolol, associated with sudden death in tetanus.Doctor / NurseNot available at your setup — Mechanical ventilator. No ventilator, intensive care or tracheostomy set: nurse in the darkest quietest space available, cluster all interventions, titrate diazepam to the least dose that abolishes spasms while watching for apnoea, keep the recovery position with suction to hand, feed by nasogastric tube, catheterise, and arrange transfer early — before the airway is lost.
• Immunise during the illness, because tetanus confers no immunity: toxoid in a different limb with a different syringe from the immunoglobulin — Td two doses 4–6 weeks apart, a third at 6–12 months (substituting Tdap for one), then boosters every 10 years for life. Add the supportive care that carries most of the benefit: nasogastric feeding under sedation, generous fluids, urinary catheterisation (a distended bladder is a spasm trigger) and low-molecular-weight heparin prophylaxis.