Diagnosis
Severe, intractable spasms with autonomic instability (it is the autonomic dysfunction that kills them).
Epidemiologic Risks
Contaminated wound especially if the patient never received the tetanus vaccines series: old folks and immigrants are at high risk.
Microbiology
C. tetani. A spore former, they exist forever in the environment.
Epidemiologic Risks
Found in soil and gi tracts.
Diabetes and IVDA may be risk factors.
Syndromes
Clostridia tetani: tetanus aka lock jaw.
Treatment
C. tetani: Human tetanus immune globulin (HTIG) 500 IU.
Active immunization must also be initiated; getting tetanus does not lead to immunity. Metronidazole (500 mg iv q 6) preferred, penicillin or imipenem but only metronidazole has been shown to help.
The patient will require intubation /tracheostomy and neuromuscular blockade to prevent spasms. A benzodiazepine intravenously (diazepam in 5-mg increments, or lorazepam in 2-mg increments) to control spasm and decrease rigidity. Transfer the patient to a quiet, dark room as external stimuli can set off spasms.
Débride any wounds. Treat sympathetic hyperactivity with labetalol (0.25-1.0 mg/min as needed for blood pressure control) or morphine (0.5-1.0 mg/kg/hr by continuous infusion; bradycardia may require a pacemaker.
High-dose intravenous Mg may help the tetany, keep levels between 3 and 4 mmol/l (PubMed).
Pearls
Even after tetanus, they still need the vaccine series; the disease is not enough to cause immunity.Rants
Vaccines work. Get your booster every 10 years.
Last Update: 02/27/19.