Initial and Secondary Management Strategies


Initial management  – make the diagnosis and manage the patient


ABCDE – perform a full assessment, providing airway, respiratory or circulatory support as needed.

Environment – dark and quiet to minimise external stimulation and resultant spasms.

IV access – and take routine bloods, creatine kinase, and serum to test for tetanus toxin and serology.

Get help – this is not a patient to manage on your own, they will need early multidisciplinary input such as airway management, supportive therapy, and wound debridement.

Reassess – monitor vital signs and ECG to detect respiratory compromise or autonomic instability.


Secondary management – prevent further toxin release and control symptoms


Antibiotics – metronidazole is the drug of choice and stops bacterial replication and therefore production of new toxin.

Immunoglobulin – the mainstay of treatment is intravenous tetanus immunoglobulin (TIG), however this is no longer available in the UK. If TIG is not available then intravenous Intravenous Immunoglobulin (IVIG) should be used, at a dose of 5,000 units in patients under 50kg, and 10,000 units in those over.

Wounds – should be debrided to remove the reservoir of tetanus bacilli, however IVIG can cause release of toxin from the wound site so surgery should be delayed until several hours after administration.

Muscle spasms – diazepam is the most common treatment [15] though this can be combined with other therapies such as chlorpromazine and phenobarbitone. A Cochrane review [16] found there was insufficient evidence to recommend a change from local usual practice though there was a suggestion that combination therapy did not give any further benefit and may cause harm. If diazepam is not sufficient, ventilation and neuromuscular blockade may be required.

Analgesia – should be given as needed.

Autonomic dysfunction – no drug has been consistently proven effective in treating autonomic dysfunction, though beta blockade has been generally unsuccessful, with increased rates of profound hypotension and sudden death. [17]