10b-Discussion of The Disease

Republic of the Philippines Founded 1907 RA 9299
NEGROS ORIENTAL STATE UNIVERSITY

Dumaguete, Bais, Guihulngan, Mabinay, Pamplona, Siaton and Bayawan-Sta. Catalina
COLLEGE OF NURSING, PHARMACY AND ALLIED HEALTH SCIENCES
MEDICAL, SURGICAL, AND PHARMACOLOGICAL MANAGEMENT
The management of tetanus is categorized into three steps. First the organism in the body needs to be destroyed to prevent further release of the toxin. Next the
toxin in the body outside of the CNS needs to be neutralized and finally the effects of the toxin in the CNS need to be minimized. Wound debridement, if possible, should
be done to help remove the toxin from the body. The general medical management consists of controlling the spasms, prevent other infections, control fluid and electrolyte
balance, and respiratory support. The primary way to control muscle spasms is sedation and muscle relaxants. The prognosis of individuals with tetanus depends on the
supportive care and ventilatory access.
Management of tetanus patients involves a team approach. The defined goals of treatment include the following:
A. HALTING PRODUCTION OF TOXIN WITHIN THE WOUND
Wound Management
o Eradicate spores and change conditions for germination, thereby preventing further elaboration and absorption of the neurotoxin.
o All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue, which could lead to conditions ideal for
germination.

Antibiotic Therapy
o Penicillin still remains a standard therapy in many parts of the world, although metronidazole seems to be replacing it and is being considered as a
drug of choice by.
o The usual dose of penicillin is 100,000 – 200,000 IU/kg/day given intravenously or intramuscularly. Metronidazole is used at a dose of 500 mg every
6 hours intravenously or per orally and 400 mg rectally every 6 hours for 7-10 days.
B. NEUTRALIZATION OF THE UNBOUND TOXIN
 This is achieved through passive immunization with either human or equine tetanus immunoglobulin. Should be undertaken as early as possible since the
toxin becomes inaccessible once it is bound to the nerve terminus.
 The usual dose of equine preparation is 500 – 1000 IU/kg given intravenously or intramuscularly.
 The dose of HTIG is 500 – 8000 IU intramuscularly.
 Usual dose for prophylaxis is 1,500 – 3,000 of equine and 250 – 500 IU of human preparation.

C. CONTROL OF MUSCLE SPASMS
 Generalized muscle spasms are life threatening since they can cause respiratory failure, lead to aspiration, and induce generalized exhaustion in the patient. Several
drugs may be used to control these spasms.
 Benzodiazepines and other sedatives — Benzodiazepines have been used traditionally and are generally effective in controlling the rigidity and spasms
associated with tetanus. They also provide a sedative effect. Diazepam has been used most frequently, but other benzodiazepines are as effective as
diazepam.
 Diazepam
 Midazolam
 Profolol
 Neuromuscular blocking agents — Neuromuscular blocking agents are used when sedation alone is inadequate.
 Vecuronium
 Pancuronium
 Baclofen

D. MANAGEMENT OF DYSAUTONOMIA (AUTONOMIC DYSFUNCTION)
 Several drugs have been used to produce adrenergic blockade and suppress autonomic hyperactivity; only treatment with magnesium sulfate has been studied in a
randomized clinical trial in tetanus because of its use in clinical series for the management of autonomic dysfunction and as adjunctive treatment for controlling
spasms.
Magnesium sulfate — Magnesium sulfate acts as a presynaptic neuromuscular blocker, blocks catecholamine release from nerves, and reduces receptor
responsiveness to catecholamines. It has the advantage of worldwide experience in the treatment of eclampsia. Magnesium may also have the benefit of
reducing muscle spasm. In two small unblinded trials, magnesium sulfate infusion (with infusion rate titrated against patella reflex) reduced spasm compared
with diazepam.
Beta blockade — Labetalol (0.25 to 1 mg/min) has frequently been administered because of its dual alpha- and beta-blocking properties. Beta blockade
alone with propranolol, for example, should be avoided because of reports of sudden death. Morphine sulfate (0.5 to 1 mg/kg per hour by continuous
intravenous infusion) is commonly used to control autonomic dysfunction as well as to induce sedation.
Other drugs — Other drugs for the treatment of various autonomic events, which have been reported to be useful, are
dextometomidine, atropine, clonidine, and epidural bupivacaine.

E. SUPPORTIVE MANAGEMENT
 Secure airway/tracheostomy/ventilator support

 Pts recovering from tetanus should be actively immunized
 Hydration
 Nutrition
 Physiotherapy
 Prophylactic anticoagulation
 Bowel, bladder, back care
 Treatment of intercurrent infection
F. PREVENTION
Active Immunization
o For partially, unimmunized and recovering from tetanus
o It stimulates production of protective antitoxin
o 2 prep:
 Combine vaccine: DPT
 Monovalent vaccine: plain/formal tetanus vaccine, adsorbed

 Combined vaccine
o According to National Immunization, 3 doses of DPT – at intervals of 4-8 weeks, starting at 6 weeks age, followed by booster at 18 months age.
o 2nd booster (only DT) at 56 years
o 3rd booster (only TT) after 10 years of age
 Monovalent vaccines
o Purified tetanus toxoid (adsorbed) supplanted the plain toxoid – higher and long lasting immunity response
o Primary course of immunization – 2 doses
o Each 0.5 ml injected into arm given at intervals of 1-2 months
o The longer the interval between two doses, the better is the immune response
o 1st booster – 1 year after the initial 2 doses
o 2nd booster – 5 years after the 1st booster (optional)
o Frequent boosters to be avoided
Passive Immunization
 Human Tetanus Hyperimmunoglobulin

o 250-500 IU
o Does not cause serum sickness
o Longer passive protection compared to horse ATS (30 days / 7*10 days)

 ATS (Equine)
o 1500 IU s/c after sensitivity testing
o 7-10 days
o High risk of serum sickness
o It stimulates formation of antibodies to it, hence a person who has once received ATS tends to rapidly eliminate subsequent doses.
 Active & Passive immunization

o In non-immunized persons
o 1500 IU of ATS / 250-500 units of Human Ig in one arm & 0.5 ml of adsorbed tetanus toxoid into the other arm/gluteal region
o 6 weeks later, 0..5 ml of tetanus toxoid
o 1 year later, 0.5 ml of tetanus toxoid

10b-Discussion of The Disease

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Republic of the Philippines Founded 1907 RA 9299

NEGROS ORIENTAL STATE UNIVERSITY

MEDICAL, SURGICAL, AND PHARMACOLOGICAL MANAGEMENT

A. HALTING PRODUCTION OF TOXIN WITHIN THE WOUND

NEGROS ORIENTAL STATE UNIVERSITY

B. NEUTRALIZATION OF THE UNBOUND TOXIN

 The dose of HTIG is 500 – 8000 IU intramuscularly.

NEGROS ORIENTAL STATE UNIVERSITY

C. CONTROL OF MUSCLE SPASMS

NEGROS ORIENTAL STATE UNIVERSITY

D. MANAGEMENT OF DYSAUTONOMIA (AUTONOMIC DYSFUNCTION)

NEGROS ORIENTAL STATE UNIVERSITY

 Secure airway/tracheostomy/ventilator support

NEGROS ORIENTAL STATE UNIVERSITY

 Human Tetanus Hyperimmunoglobulin

NEGROS ORIENTAL STATE UNIVERSITY

 Active & Passive immunization

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