Chapter 59

• Tetanus is a toxin-mediated disease caused by Clostridium tetani and characterized by trismus, dysphagia, and localized muscle rigidity near a site of injury, often progressing to severe generalized muscular spasms complicated by respiratory failure and cardiovascular instability.
• The diagnosis of tetanus is made on clinical grounds alone. A clinical diagnosis of presumed tetanus is sufficient to initiate treatment.
• Patients with tetanus should be managed in an ICU. In severe cases, the first priority is control of the airway to ensure adequate ventilation and correction of hypotension related to hypovolemia and/or autonomic instability.
• Antitoxin therapy with human tetanus immune globulin is given intramuscularly (3000 to 6000 IU) as early as possible. In cases that have not yet progressed to generalized spasms, 250 IU given intrathecally by lumbar puncture may be of benefit.
• Treatment to limit continued production and absorption of toxin includes surgical débridement of the site of injury and antimicrobial therapy with intravenous metronidazole.
• Traditionally muscle rigidity and spasms have been treated with high-dose benzodiazepines and narcotics. However, intravenous magnesium therapy should also be considered.
• Cardiovascular instability due to autonomic dysfunction is managed by ensuring normovolemia and using benzodiazepine, narcotic, and/or magnesium sulfate infusions when needed.
• Supportive measures include early provision of nutrition, correction of electrolyte disturbances, subcutaneous heparin administration for prophylaxis of deep venous thrombosis, and prompt antimicrobial therapy for nosocomial infection.
• With meticulous management of the manifestations of this disease and careful attention to prevention of its major complications, complete recovery is possible in most cases.

Tetanus is one of the best examples of a disease for which modern intensive care can offer a truly major improvement in long-term useful survival. Often a disease of otherwise healthy active people, the fully developed form is frequently rapidly fatal unless the patient is supported through a lengthy period of painful muscle spasms complicated by respiratory failure, cardiovascular instability, and increased risk of pulmonary embolism and nosocomial infection. However, if all these problems are meticulously managed, complete recovery can be expected. In developed countries, this disease is likely to remain an uncommon but challenging problem that demands an alert and aggressive approach to initial diagnosis and management, coupled with careful attention to supportive care and avoidance of complications over a period of weeks to months to achieve the eventual excellent outcome possible in most cases.

Although tetanus is primarily a disease of underdeveloped countries, there are approximately 36 to 48 cases per year reported in the United States.1 The male:female ratio is approximately 3:2, representing a greater incidence of tetanus-prone wounds in males. Because preformed circulating antibody to tetanospasmin can completely prevent development of the disease, tetanus occurs primarily in nonimmunized or inadequately immunized patients, particularly the poor and elderly.1,2 However, in rare instances tetanus has developed in patients who had received their primary series, as well as proper booster doses of toxoid,3,4 so a history of proper immunization does not exclude the diagnosis of ...

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