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Human tetanus immunoglobulin 150 units/kg should be given intramuscularly at multiple sites to neutralise unbound toxin. Where present, wounds should be debrided. Metronidazole is an antibiotic of choice for Clostridium tetani, but penicillin, erythromycin, tetracycline, chloramphenicol and clindamycin are acceptable alternatives (see p. 211).

Avoid unnecessary stimulation, which may induce rigidity and spasms. The primary treatment for spasms and rigidity is sedation with a benzodiazepine, such as midazolam or diazepam. Additional sedation may be provided with propofol or a phenothiazine, usually chlorpromazine. In severe disease prolonged spasms and respiratory dysfunction will necessitate tracheal intubation and mechanical ventilation will be required. If the patient has been intubated and sedation alone is inadequate to control spasms, a neuromuscular blocking drug, e.g., intermittent doses of pancuronium or a continuous infusion of atracurium, will be required.

Tetanus toxin often causes disturbances in autonomic control, resulting in sympathetic overactivity and high plasma catecholamine concentrations. The first-line treatment for autonomic dysfunction is by sedation with a benzodiazepine and opioid. Infusion of the short-acting fi-blocker esmolol, or the a2-adrenergic agonist clonidine, helps to control episodes of hypertension. Intravenous magnesium sulphate is also used to reduce autonomic disturbance.

Severe cases of tetanus generally require admission to an intensive care unit for 3-5 weeks. Weight loss is universal in tetanus and these patients require enteral nutrition. Other important measures include: close control of fluid balance, chest physiotherapy to prevent pneumonia, prophylaxis of thromboembolism and intensive nursing care to prevent pressure sores.

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