**7. Management**

There is currently no treatment for tetanus. Management of the disease requires an emergency and long term supportive care. Three strategic principles apply however apply.


## **7.1 Neutralizing toxin already in the body**

Intravenous human tetanus immunoglobulin (HTIG) 150 units/kg intramuscularly is used to neutralize free circulating toxin before it binds to neuronal cell membrane. The HTIG is an effective therapy and it is given as soon as the diagnosis of tetanus is considered. There is available an intravenous preparation of 5000–10,000 IU. HTIG is a specific solvent-detergent-treated plasma derived product obtained from donors immunized with tetanus toxoids. An initial skin sensitivity testing using a dose of 3000–6000 units intramuscularly is given. This drug does not neutralize intracellular toxin which is already fixed to the nerve terminals. HTIG is contraindicated in patients with history of anaphylactic reaction to the active substance or to any of the component of the product. Also patients with deficiency of mmunoglobulin A and the intramuscular test dose is contraindicated in those with severe thrombocytopenia or any coagulation disorder.

## *7.1.1 Airway management*

Respiratory failure has been identified as the commonest direct cause of death from tetanus in the less developed world. This may not be unconnected with

## *DOI: http://dx.doi.org/10.5772/intechopen.104876 ICU Management of Tetanus*

lack of ventilator support where it is needed. The Intensivist should anticipate patients at risk of hypoxia and airways obstruction, aspiration hypoventilation, pneumonia, and respiratory arrest. Such patients should be closely monitored and connected to ventilator support as soon as possible. Early airways protection initially with endotracheal tube or tracheostomy is often needed. Ventilator modes used depends on complexity of the ventilators available in the intensive care unit. In the early stages of the disease when rigidity and spasm are prominent, sedation, analgesia and muscular paralysis are required to allow for controlled mandatory ventilation. This mode usually provides rest to the already fatigue muscles of respiration. It is important to note that the controlled mandatory ventilation mode is used only when necessary. Poor lung compliance and oxygenation due to muscular rigidity or pulmonary complications may be overcome by a combination of pressure controlled ventilation and positive end expiratory pressure (PEEP). In the later stages of the disease, modes of ventilation that allow spontaneous ventilation (synchronised intermittent mandatory, continuous positive airway pressure and biphasic positive airway pressure ventilation) are generally preferred and may optimize the respiratory pattern, reduce sedation requirements, minimise muscle wastage, and reduce the likelihood of acquired critical illness neuropathy or myopathy. Mechanical ventilation is better and more comforting for the patient if a tracheostomy is given early. Tracheostomy increases patients comfort, reduced dead space and airway resistance with reduced risk of airway trauma especially in patients convulsing. Endotracheal intubation has been associated with more complications such as subglottic stenosis, vocal cord immobility, laryngeal granuloma, need for deeper sedation when compared to tracheostomy and higher mortality rate. Sedation is an essential component of the management of tetanus patients being ventilated in ICU. It is required to relieve the discomfort and anxiety caused by airway manipulation, ventilation, suction and physiotherapy. Sedation can also minimize agitation yet maximize rest and appropriate sleep. Analgesia is an almost universal requirement for ventilated patients. Combination of opioids and benzodiazepines used for controlling seizures in tetanus gives a good outcome. Adequate sedation and analgesia ameliorates the stress response to tracheal intubation and mechanical ventilation.

## **7.2 Destroy the organisms in the body to prevent further toxin release**

Metronidazole is used to destroy the organisms in the body. It diffuses into the organism and inhibits its protein synthesis by interacting with DNA and causes loss of helical DNA structure. A dose of 30–40 mg/kg/day in three divided doses for children and 0.5 g three times daily for up to 10 days is recommended. Other drugs that are effective include Penicillin G (100,000–200,000 IU/kg/day intravenously, given in four divided doses). Macrolides such as erythromycin given as 30–50 mg/ kg/day in three divided doses for children and 0.5 g/kg/day in three divided doses for adults has shown effectiveness. Tetracyclines, clindamycin, cephalosporins and chloramphenicol are also effective. To reduce further bacterial load and toxin, if a wound responsible for tetanus is clear, thorough cleaning of infected site with extensive surgical debridement is recommended if patient is stable. Surgical debridement helps to eradicate spores and necrotic tissues which could lead to conditions ideal for germination. To reduce the risk of releasing tetanospasmin into the bloog stream, it is advised that wound manipulation should be delayed until hours after administration of antitoxin.
