Treatment for Tetanus in Children

Management of tetanus requires eradication of C. tetani and the wound environment conducive to its anaerobic multiplication, neutralization of all accessible tetanus toxin, control of seizures and respiration, palliation and provision of meticulous supportive care, and, finally, prevention of recurrences.

Surgical wound excision and debridement are often needed to remove the foreign body or devitalized tissue that created anaerobic growth conditions.

Tetanus toxin cannot be neutralized by TIG after it has begun its axonal ascent to the spinal cord. TIG should be given as soon as possible in order to neutralize toxin that diffuses from the wound into the circulation before the toxin can bind at distant muscle groups. The optimal dose of TIG has not been determined. A single intramuscular injection of 500 U of TIG is sufficient to neutralize systemic tetanus toxin, but total doses as high as 3,000–6,000 U are also recommended. Infiltration of TIG into the wound is now considered unnecessary.

If TIG is unavailable, use of human intravenous immunoglobulin (IVIG), may be necessary. IVIG contains 4–90 U/mL of TIG; the optimal dosage of IVIG for treating tetanus is not known and it is not approved for this indication.

Another alternative is equine- or bovine-derived tetanus antitoxin (TAT). The usual dose of TAT is 50,000–100,000 U, with half given intramuscularly and half intravenously, but as little as 10,000 U may be sufficient. TAT is not available in the USA. Approximately 15% of patients given the usual dose of TAT experience serum sickness. When using TAT, it is essential to check for possible sensitivity to horse serum and desensitization may be needed. The human-derived immunoglobulins are much preferred because of their longer half-life (30 days) and the virtual absence of allergic and serum sickness adverse effects.

Penicillin G (100,000 U/kg/day divided every 4–6 hr IV for 10–14 days) remains the antibiotic of choice because of its effective clostridiocidal action and its diffusibility, which is an important consideration because blood flow to injured tissue may be compromised. Metronidazole (500 mg every 8 hr IV for adults) appears to be equally effective. Erythromycin and tetracycline (for persons >8 yr of age) are alternatives for penicillin-allergic patients.

All patients with generalized tetanus need muscle relaxants. Diazepam provides both relaxation and seizure control. The initial dose of 0.1–0.2/kg every 3–6 hr given intravenously is subsequently titrated to control the tetanic spasms, after which it is sustained for 2–6 wk before its tapered withdrawal. Magnesium sulfate, other benzodiazepines (midazolam), chlorpromazine, dantrolene, and baclofen are also used. Intrathecal baclofen produces such complete muscle relaxation that apnea often ensues; like most other agents listed, baclofen should be used only in an intensive care unit setting.

The highest survival rates in generalized tetanus are achieved with neuromuscular blocking agents such as vecuronium and pancuronium, which produce a general flaccid paralysis that is then managed by mechanical ventilation. Autonomic instability is regulated with standard alpha- and beta- (or both) blocking agents; morphine has also proved useful.

SUPPORTIVE CARE.
Meticulous supportive care in a quiet, dark, secluded setting is most desirable. Because tetanic spasms may be triggered by minor stimuli, the patient should be sedated and protected from all unnecessary sounds, sights, and touch; and all therapeutic and other manipulations must be carefully scheduled and coordinated. Endotracheal intubation may not be required, but it should be done to prevent aspiration of secretions before laryngospasm develops. A tracheostomy kit should be immediately at hand for unintubated patients. Endotracheal intubation and suctioning easily provoke reflex tetanic seizures and spasms, and early tracheostomy should be considered in severe cases not managed by pharmacologically induced flaccid paralysis. Cardiorespiratory monitoring, frequent suctioning, and maintenance of the substantial fluid, electrolyte, and caloric needs are fundamental. Careful nursing attention to mouth, skin, bladder, and bowel function is needed to avoid ulceration, infection, and obstipation. Prophylactic subcutaneous heparin may be of value but must be balanced with the risk for hemorrhage.