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==Treatment Regimen==
==Treatment Regimen==
:*1. '''General measures''' <ref name=World Health Organization>{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref>
:*1. '''General measures''' <ref name=World Health Organization>{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref>
::*Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
::*Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
Line 52: Line 51:
:* 6. '''Airway/respiratory control'''
:* 6. '''Airway/respiratory control'''
::*Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.
::*Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.


==References==
==References==

Revision as of 17:32, 12 August 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Dead and infected tissue should be removed by surgical debridement. Metronidazole treatment decreases the number of bacteria but has no effect on the bacterial toxin. Passive immunization with human anti-tetanospasmin immunoglobulin or tetanus immune globulin is crucial. Drugs such as chlorpromazine or diazepam, or other muscle relaxants can be given to control the muscle spasms

Medical Therapy

The wound must be cleaned. Dead and infected tissue should be removed by surgical debridement. Metronidazole treatment decreases the number of bacteria but has no effect on the bacterial toxin. Penicillin was once used to treat tetanus, but is no longer the treatment of choice because of a theoretical risk of increased spasms. It should still be used if metronidazole is not available. Passive immunization with human anti-tetanospasmin immunoglobulin or tetanus immune globulin is crucial. If specific anti-tetanospasmin immunoglobulin is not available, then normal human immunoglobulin may be given instead. All tetanus victims should be vaccinated against the disease or offered a booster shot. It takes 2-14 days for symptoms to develop after infection. Symptoms peak 17 days after infection.

Mild Tetanus

Mild cases of tetanus can be treated with:

  • Tetanus immune globulin IV or IM
  • Metronidazole IV for 10 days
  • Diazepam
  • Tetanus vaccination

Severe Tetanus

Severe cases will require admission to intensive care. In addition to the measures listed above for mild tetanus:

Drugs such as chlorpromazine or diazepam, or other muscle relaxants can be given to control the muscle spasms. In extreme cases it may be necessary to chemically paralyze the patient with curare-like drugs and use a mechanical ventilator.

In order to survive a tetanus infection, the maintenance of an airway and proper nutrition are required. An intake of 3500-4000 Calories, and at least 150g of protein, is often given in liquid form through a tube directly into the stomach, or through a drip into a vein. This high-caloric diet maintenance is required due to the increased metabolic strain brought on by the increased muscle activity.

Treatment Regimen

  • 1. General measures
  • Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
  • 2. Immunotherapy
  • Preferred regimen: Human TIG 500 units IV/IM as soon as possible AND Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
  • Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later
  • 3. Antibiotic treatment[1]
  • 4. Muscle spasm control
  • Preferred regimen: Diazepam 5 mg IV OR Lorazepam 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation
  • Alternative regimen (1): Magnesium sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved ± Benzodiazepines
  • Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
  • Alternative regimen (2): Baclofen OR Dantrolene 1–2 mg/kg IV/PO q4h
  • Alternative regimen (3): Barbiturates 100–150 mg q1-4h by any route
  • Alternative regimen (4): Chlorpromazine 50–150 mg IM q4–8h
  • Pediatric regimen: Lorazepam 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; Barbiturates 6–10 mg/kg in children by any route; Chlorpromazine 4–12 mg IM every q4–8h
  • Note: As for Benzodiazepines, large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
  • 5. Autonomic dysfunction control
  • 6. Airway/respiratory control
  • Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.

References

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