Tetanus — recognition and emergency management

Diagnosis: generalised tetanus (clinical). The combination of trismus (lockjaw), risus sardonicus, board-like abdominal rigidity, stimulus-triggered reflex spasms and a PRESERVED sensorium, with a contaminated puncture wound and absent vaccination history, is diagnostic. Tetanus is a clinical diagnosis — there is no confirmatory test; treatment begins on recognition.^[3][2]

Immediate assessment — ABCDE with tetanus priorities.

• Airway/Breathing: nurse in a quiet, dark room with minimal stimulation (any stimulus can trigger fatal laryngospasm); high-flow oxygen; have suction, bag-valve-mask, intubation and tracheostomy equipment immediately at the bedside (low threshold for elective intubation if grade III/IV or recurrent laryngospasm).
• Circulation: IV access; prepare for autonomic storms (labetalol, morphine, magnesium, vasopressors).
• Disability: give IV diazepam 10 mg immediately (or midazolam) for spasm control and sedation.
• Exposure: examine every skin break (the foot puncture); grade severity with Ablett (this patient — prolonged spasms, beginning autonomic signs — is at least grade III → ICU).^[2][5]

Definitive management — the four pillars.^[3]

1. Neutralise unbound toxin: human tetanus immunoglobulin (HTIG) ~500 IU IM, with a portion infiltrated around the wound, ideally before debridement. It neutralises only free toxin and cannot reverse toxin already bound to nerves.
2. Eradicate the organism and remove the source: IV metronidazole 500 mg q8h for 7-10 days (avoid high-dose penicillin G — a GABA antagonist that worsens spasms); surgical wound debridement of all necrotic tissue and foreign body.
3. Control spasms and support vital functions (ICU): benzodiazepines (diazepam boluses or midazolam infusion 0.05-0.2 mg/kg/h) titrated to spasm control; IV magnesium sulphate (load 40 mg/kg, infusion 1-3 g/h titrated to patellar reflex; target serum magnesium 2-4 mmol/L) for severe disease; neuromuscular blockade (vecuronium/rocuronium) plus mechanical ventilation for grade IV or refractory spasms; early tracheostomy for the prolonged course; treat autonomic instability (morphine infusion, magnesium, esmolol/labetalol — avoid long-acting propranolol).
4. Active vaccination: give a full primary course of tetanus toxoid (3 doses), because the dose of toxin causing disease is too small to induce immunity — surviving tetanus does NOT confer protection.^[3]

Disposition and monitoring. ICU (grade III/IV); continuous ECG and arterial BP for arrhythmias/autonomic storms; SpO2 and blood gases; serum magnesium every 6-12 h; nutrition (NG/parenteral), DVT prophylaxis, pressure-area care, stress-ulcer prophylaxis.^[5]

Prognostic note. The 2-week incubation is near-median (less adverse); the onset-to-spasm interval should be watched — under 48 hours implies severe disease and high mortality.^[3]