Tetanus medical therapy: Difference between revisions
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{{Tetanus}} | {{Tetanus}} | ||
{{CMG}} | {{CMG}}{{AE}}{{USAMA}} | ||
==Overview== | ==Overview== | ||
Tetanus is a medical emergency. Medical therapy includes hospitalization, immediate treatment with human tetanus immune globulin (TIG) (or equine antitoxin if human immune globulin is not available), a [[Tdap|tetanus toxoid booster,]] agents to control [[muscle spasm]], aggressive wound care, and [[antimicrobial]] therapy. [[Mechanical ventilation]] and agents to control [[autonomic nervous system]] instability may be required among patients with severe disease.<ref name="World">{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref> | |||
The | ==Medical Therapy== | ||
The medical therapy for tetanus may include:<ref name="pmid10945801">{{cite journal| author=Farrar JJ, Yen LM, Cook T, Fairweather N, Binh N, Parry J et al.| title=Tetanus. | journal=J Neurol Neurosurg Psychiatry | year= 2000 | volume= 69 | issue= 3 | pages= 292-301 | pmid=10945801 | doi= | pmc=1737078 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10945801 }} </ref><ref name="pmid14576357">{{cite journal| author=Lalli G, Gschmeissner S, Schiavo G| title=Myosin Va and microtubule-based motors are required for fast axonal retrograde transport of tetanus toxin in motor neurons. | journal=J Cell Sci | year= 2003 | volume= 116 | issue= Pt 22 | pages= 4639-50 | pmid=14576357 | doi=10.1242/jcs.00727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14576357 }} </ref><ref name="pmid12581644">{{cite journal| author=Rummel A, Bade S, Alves J, Bigalke H, Binz T| title=Two carbohydrate binding sites in the H(CC)-domain of tetanus neurotoxin are required for toxicity. | journal=J Mol Biol | year= 2003 | volume= 326 | issue= 3 | pages= 835-47 | pmid=12581644 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12581644 }} </ref><ref name="pmid1331807">{{cite journal| author=Schiavo G, Benfenati F, Poulain B, Rossetto O, Polverino de Laureto P, DasGupta BR et al.| title=Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin. | journal=Nature | year= 1992 | volume= 359 | issue= 6398 | pages= 832-5 | pmid=1331807 | doi=10.1038/359832a0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1331807 }} </ref><ref name="pmid12729912">{{cite journal| author=Caccin P, Rossetto O, Rigoni M, Johnson E, Schiavo G, Montecucco C| title=VAMP/synaptobrevin cleavage by tetanus and botulinum neurotoxins is strongly enhanced by acidic liposomes. | journal=FEBS Lett | year= 2003 | volume= 542 | issue= 1-3 | pages= 132-6 | pmid=12729912 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12729912 }} </ref> | |||
== | :*1. '''General measures''' <ref name="World">{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref> | ||
::*Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated | |||
* | :*2. '''Immunotherapy''' | ||
* | ::*Preferred regimen: Human TIG 500 units IV/IM as soon as possible {{and}} Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site | ||
* [[ | ::*Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later | ||
* | :*3. '''Antibiotic treatment'''<ref>http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf</ref> | ||
::*Preferred regimen: [[Metronidazole]] 500 mg IV/PO q6h {{or}} [[Penicillin G]] 100,000–200,000 IU/kg/day IV, administered in 2–4 divided doses | |||
::*Alternative regimen: [[Tetracyclines]] {{or}} [[Macrolides]] {{or}} [[Clindamycin]] {{or}} [[Cephalosporins]] {{or}} [[Chloramphenicol]] | |||
:*4. '''Muscle spasm control''' | |||
::*Preferred regimen: [[Diazepam]] 5 mg IV {{or}} [[Lorazepam]] 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation | |||
::*Alternative regimen (1): [[Magnesium]] sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved {{withorwithout}} [[Benzodiazepines]] | |||
::*Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased | |||
::*Alternative regimen (2): [[Baclofen]] {{or}} [[Dantrolene]] 1–2 mg/kg IV/PO q4h {{or}} [[Bromocriptine]] {{or}} [[Amantadine]] | |||
::*Alternative regimen (3): [[Barbiturates]] 100–150 mg q1-4h by any route | |||
::*Alternative regimen (4): [[Chlorpromazine]] 50–150 mg IM q4–8h | |||
::*Pediatric regimen: [[Lorazepam]] 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; [[Barbiturates]] 6–10 mg/kg in children by any route; [[Chlorpromazine]] 4–12 mg IM every q4–8h | |||
::*Note: As for [[Benzodiazepines]], large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest | |||
:* 5. '''Autonomic dysfunction control''' | |||
::*Preferred regimen: [[Magnesium]] sulphate {{or}} [[Morphine]] {{or}} [[Esmolol]] | |||
:* 6. '''Airway/respiratory control''' | |||
::*Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise. | |||
=== | ==References== | ||
{{Reflist|2}} | |||
{{WH}} | |||
{{WS}} | |||
[[Category:Disease]] | |||
[[Category:Bacterial diseases]] | |||
[[Category:Infectious Disease Project]] | |||
[[Category:Emergency mdicine]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Neurology]] | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]
Overview
Tetanus is a medical emergency. Medical therapy includes hospitalization, immediate treatment with human tetanus immune globulin (TIG) (or equine antitoxin if human immune globulin is not available), a tetanus toxoid booster, agents to control muscle spasm, aggressive wound care, and antimicrobial therapy. Mechanical ventilation and agents to control autonomic nervous system instability may be required among patients with severe disease.[1]
Medical Therapy
The medical therapy for tetanus may include:[2][3][4][5][6]
- 1. General measures [1]
- Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
- 2. Immunotherapy
- Preferred regimen: Human TIG 500 units IV/IM as soon as possible AND Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
- Note: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later
- 3. Antibiotic treatment[7]
- Preferred regimen: Metronidazole 500 mg IV/PO q6h OR Penicillin G 100,000–200,000 IU/kg/day IV, administered in 2–4 divided doses
- Alternative regimen: Tetracyclines OR Macrolides OR Clindamycin OR Cephalosporins OR Chloramphenicol
- 4. Muscle spasm control
- Preferred regimen: Diazepam 5 mg IV OR Lorazepam 2 mg IV titrating to achieve spasm control without excessive sedation and hypoventilation
- Alternative regimen (1): Magnesium sulphate 5 g (or 75mg/kg) IV loading dose, then 2–3 g per hour until spasm control is achieved ± Benzodiazepines
- Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
- Alternative regimen (2): Baclofen OR Dantrolene 1–2 mg/kg IV/PO q4h OR Bromocriptine OR Amantadine
- Alternative regimen (3): Barbiturates 100–150 mg q1-4h by any route
- Alternative regimen (4): Chlorpromazine 50–150 mg IM q4–8h
- Pediatric regimen: Lorazepam 0.1–0.2 mg/kg IV q2–6h, titrating upward as needed; Barbiturates 6–10 mg/kg in children by any route; Chlorpromazine 4–12 mg IM every q4–8h
- Note: As for Benzodiazepines, large amounts may be required (up to 600 mg/day); oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
- 5. Autonomic dysfunction control
- 6. Airway/respiratory control
- Note: Drugs used to control spasm and provide sedation can result in respiratory depression. If spasm, including laryngeal spasm, is impeding or threatening adequate ventilation, mechanical ventilation is recommended when possible. Early tracheostomy is preferred as endotracheal tubes can provoke spasm and exacerbate airway compromise.
References
- ↑ 1.0 1.1 "Current recommendations for treatment of tetanus during humanitarian emergencies".
- ↑ Farrar JJ, Yen LM, Cook T, Fairweather N, Binh N, Parry J; et al. (2000). "Tetanus". J Neurol Neurosurg Psychiatry. 69 (3): 292–301. PMC 1737078. PMID 10945801.
- ↑ Lalli G, Gschmeissner S, Schiavo G (2003). "Myosin Va and microtubule-based motors are required for fast axonal retrograde transport of tetanus toxin in motor neurons". J Cell Sci. 116 (Pt 22): 4639–50. doi:10.1242/jcs.00727. PMID 14576357.
- ↑ Rummel A, Bade S, Alves J, Bigalke H, Binz T (2003). "Two carbohydrate binding sites in the H(CC)-domain of tetanus neurotoxin are required for toxicity". J Mol Biol. 326 (3): 835–47. PMID 12581644.
- ↑ Schiavo G, Benfenati F, Poulain B, Rossetto O, Polverino de Laureto P, DasGupta BR; et al. (1992). "Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin". Nature. 359 (6398): 832–5. doi:10.1038/359832a0. PMID 1331807.
- ↑ Caccin P, Rossetto O, Rigoni M, Johnson E, Schiavo G, Montecucco C (2003). "VAMP/synaptobrevin cleavage by tetanus and botulinum neurotoxins is strongly enhanced by acidic liposomes". FEBS Lett. 542 (1–3): 132–6. PMID 12729912.
- ↑ http://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf