Tetanus Wound Treatment

Overview

Part 1: Wound Management & Prophylaxis

Step 1 - Wound Assessment & Care

• Small cuts, superficial abrasions with no contamination

• Penetrating or puncture wounds
• Wounds contaminated with dirt, soil, feces, or saliva (animal/human bites)
• Burns, crush injuries, compound fractures, frostbite
• Necrotic or gangrenous tissue
• Devitalized tissue (provides the anaerobic environment C. tetani needs)

1. Clean the wound thoroughly
2. Remove all dirt and foreign material
3. Debride necrotic/devitalized tissue - this is essential, as devitalized tissue creates the anaerobic conditions that allow C. tetani to replicate
4. Antibiotics are NOT recommended for tetanus prophylaxis (topical or systemic) - per CDC guidance (updated June 2025); treat infection if present, but not prophylactically for tetanus

Step 2 - Tetanus Vaccination (Active Immunization)

Note: Tetanus disease itself does NOT confer immunity - patients recovering from tetanus must still be actively immunized.

Step 3 - Tetanus Immune Globulin (TIG) - Passive Immunization

• Give TIG and vaccine at separate anatomical sites when both are needed
• Part of the TIG dose may be infiltrated around the wound if the wound site can be identified
• TIG is commercially available - the CDC does not stockpile it

Part 2: Treatment of Established Tetanus

1. Supportive Care - Muscle Spasm Control

• Minimize all sensory stimulation (noise, light, touch trigger spasms)
• Benzodiazepines are the mainstay - they are GABA agonists that indirectly antagonize tetanospasmin effects:
  • Diazepam - most studied; can be given orally, rectally, or IV; rapid onset
  • Lorazepam / Midazolam - equally effective alternatives
  • Note: IV diazepam and lorazepam contain propylene glycol - at high doses this can cause lactic acidosis
• Magnesium sulfate infusion - effective as adjuvant or first-line for mild-to-moderate tetanus to control spasms and rigidity
• Dantrolene - direct muscle relaxant, adjunctive use
• If spasms cannot be controlled: neuromuscular blockade + mechanical ventilation
  • Avoid succinylcholine (risk of severe hyperkalemia in neuromuscular disease after ~day 4)
  • Prefer non-depolarizing agents: vecuronium, rocuronium (fewer cardiovascular effects)

2. Eliminate Unbound Toxin - TIG (Treatment Dose)

• TIG 3,000-6,000 units IM as a single dose for generalized tetanus
• Some evidence supports intrathecal TIG for faster neutralization of CNS-bound toxin
• Equine antitoxin (available in some countries) is an alternative if human TIG is unavailable

3. Prevent Further Toxin Production - Wound Debridement + Antibiotics

• Surgical wound debridement - remove all necrotic and devitalized tissue; eliminate the anaerobic environment
• Antibiotics:
  • Metronidazole (preferred) - 500 mg IV/oral every 6-8 hours
  • Penicillin G - alternative (note: some sources suggest it may potentiate tetanospasmin by antagonizing GABA, making metronidazole preferable)
  • Duration: 7-10 days

4. Active Immunization

• Give tetanus toxoid vaccine during hospitalization (disease does not confer immunity)
• Complete the 3-dose primary series if not previously vaccinated:
  • 2nd dose: 1-2 months after 1st
  • 3rd dose: 6-12 months after 1st

Part 3: ICU Care

• Airway management (laryngospasm risk)
• Autonomic dysfunction management (hypertension, tachycardia, hypotension - use labetalol, magnesium, or morphine)
• Nutritional support (prolonged course)
• Prevention of complications (DVT, pressure ulcers, aspiration pneumonia)

Quick Reference: Prophylaxis Decision Table

Tetanus Wound - Visual Guide

What Makes a Wound "Tetanus-Prone"?

• Puncture/penetrating injuries in a contaminated environment
• Animal or human bites
• Compound fractures
• Foreign bodies embedded in tissue
• Wounds with systemic sepsis

• Heavy soil/manure contamination
• Extensive devitalized tissue
• Burns, crush injuries, frostbite
• Surgery delayed >6 hours

Image 1 - Grossly Contaminated Facial Wound (pre-debridement)

Image 2 - After Surgical Debridement and Delayed Primary Closure

Image 3 - Risus Sardonicus ("Lockjaw" Smile)

Image 4 - Extensive Soft Tissue Injury Post-Debridement (Intraoperative)

Key Visual Points

Important: A wound does not need to look dramatic to carry tetanus risk. A small nail puncture from a rusty, soil-exposed nail is often MORE dangerous than a clean surgical incision, because the deep, narrow track creates the anaerobic pocket where C. tetani thrives.

Neonatal Jaundice (Neonatal Hyperbilirubinemia)

Pathophysiology

1. Increased bilirubin production - neonates have a higher red cell mass, shorter RBC lifespan (~70-90 days vs. 120 days in adults), and more rapid breakdown
2. Decreased clearance/excretion - immature hepatic glucuronyl transferase activity
3. Increased enterohepatic resorption - intestinal bacteria that convert bilirubin to urobilinogen are absent in neonates; beta-glucuronidase in the gut deconjugates bilirubin back for reabsorption

Classification

Unconjugated (Indirect) Hyperbilirubinemia - Most Common

Conjugated (Direct) Hyperbilirubinemia - Always Pathologic

Key rule: Conjugated hyperbilirubinemia in a neonate is always pathologic and requires urgent investigation.

Physiologic vs. Pathologic Jaundice

Risk Factors for Severe Hyperbilirubinemia

• Prematurity (gestational age 35-37 weeks)
• Isoimmune hemolytic disease (ABO or Rh incompatibility)
• G6PD deficiency
• Sepsis / asphyxia / acidosis
• Significant lethargy
• Temperature instability
• Albumin < 3.0 g/dL
• Cephalohematoma
• East Asian ethnicity

Complications - Kernicterus

• Poor feeding, lethargy
• High-pitched cry
• Rigidity, opisthotonus (backward arching)
• Fever, seizures

• Choreoathetoid cerebral palsy
• High-frequency sensorineural deafness
• Cognitive impairment / learning deficits
• ~50% mortality in untreated severe cases; 70% of affected infants die in first week

Diagnosis

When to Evaluate (Red Flags - Box 166.1)

• Jaundice within 24 hours of birth
• Any elevated direct (conjugated) bilirubin
• Rapidly rising TSB unexplained by history
• TSB approaching exchange transfusion threshold or not responding to phototherapy
• Jaundice persisting beyond 3 weeks
• Sick-appearing infant

Tests

• Transcutaneous bilirubin (TcB) - rapid bedside screen (valid after 24 hrs of life, within 7 days; not for infants who have had phototherapy)
  • If TcB ≥ 15 mg/dL or within 3 mg/dL of phototherapy threshold → confirm with serum
• Total serum bilirubin (TSB) + direct fraction - fractionation identifies conjugated vs. unconjugated
• CBC + peripheral smear - for hemolysis (spherocytes, elliptocytes)
• Direct Coombs test (DAT) - for immune-mediated hemolysis
• Blood group typing of mother and infant
• In sick infants: blood glucose, electrolytes, urine reducing substances, ammonia, lactate, blood culture

Management

1. Encourage Feeding

2. Phototherapy

• Lower risk (≥38 wk, well): phototherapy threshold ~15-21 mg/dL depending on age
• Medium risk (38 wk + risk factors, or 35-37 wk well): lower threshold
• Higher risk (35-37 wk + risk factors): lowest threshold

3. Exchange Transfusion

• TSB above age-specific exchange transfusion threshold (see chart)
• Failure of phototherapy (TSB continues rising despite intensive phototherapy)
• Signs/symptoms of acute bilirubin encephalopathy (hypertonia, arching, opisthotonus, high-pitched cry, fever)
• TSB ≥ 5 mg/dL above exchange threshold lines

4. Treatment of Conjugated Hyperbilirubinemia

• Treat the underlying cause (antibiotics for sepsis, surgery consult for biliary atresia)
• Biliary atresia requires Kasai portoenterostomy before 8 weeks of age for best outcomes
• All infants with direct hyperbilirubinemia require hospital admission

Disposition Summary

Neonatal Jaundice - Detailed Treatment

STEP 1: General Supportive Measures

Adequate Feeding

• Stimulates intestinal motility and bile flow, reducing enterohepatic recirculation of bilirubin
• Prevents dehydration (which concentrates bilirubin)
• Breastfeeding must be encouraged and continued - do not stop it
• If breastfeeding is inadequate, supplement with formula; supplementing with water or dextrose water is not effective and not recommended (AAP 2022: strong recommendation against)
• Target: 8-12 feeds per 24 hours in the first days of life

Avoid Exacerbating Factors

• Avoid drugs that displace bilirubin from albumin (e.g., sulphonamides, ceftriaxone in neonates)
• Treat any underlying sepsis, dehydration, or metabolic disturbance promptly

STEP 2: Phototherapy

Mechanism

1. Photo-isomerization - converts toxic Z,Z-bilirubin to water-soluble E,Z or Z,E isomers (reversible; major pathway, fast)
2. Lumirubin formation - irreversible structural isomer, rapidly excreted in bile and urine without hepatic conjugation
3. Photo-oxidation - minor pathway, slow

Types of Phototherapy

Key Technical Points for Effective Phototherapy

• Maximize skin surface exposure - remove clothing except nappy; cover eyes with opaque shields (prevents retinal damage)
• Optimal irradiance: Standard phototherapy ≥ 8-10 μW/cm²/nm; intensive phototherapy ≥ 30 μW/cm²/nm in the 460-490 nm range
• Distance: Position light source as close as safely possible to infant (typically 20-30 cm for LED units - follow manufacturer guidance)
• Turning the infant is not necessary with overhead lights if back is exposed
• Goal: Intensive phototherapy should produce a TSB decline of 1-2 mg/dL within 4-6 hours
• Cover phototherapy lights when drawing bilirubin (light degrades bilirubin in samples)

Monitoring During Phototherapy (AAP 2022)

• Measure TSB within 12 hours of starting phototherapy
• Repeat TSB every 6-12 hours initially based on age, risk factors, and TSB trajectory
• Once TSB is falling and clearly below the exchange threshold, can extend to every 12-24 hours
• Do not subtract direct (conjugated) fraction from TSB when making treatment decisions

Discontinuing Phototherapy

• Stop when TSB falls 2-3 mg/dL below the phototherapy threshold
• Check rebound TSB 6-12 hours after stopping, then again the day after
• Risk of rebound is higher in: hemolytic disease, prematurity, early discharge

Home Phototherapy

• An option for well-appearing infants, reliable caregivers, access to emergency care
• Follow-up within 24 hours mandatory
• Never use for infants with neurotoxicity risk factors

STEP 3: Intravenous Immunoglobulin (IVIG)

Mechanism

Indications (Harriet Lane Handbook)

• Isoimmune hemolytic disease (positive DAT)
• TSB rising despite intensive phototherapy, AND
• TSB within 2-3 mg/dL of exchange transfusion threshold

Dose

• 0.5-1 g/kg IV over 2 hours (Harriet Lane: 0.5-1 g/kg; Medscape: 500 mg/kg)
• May repeat dose in 12 hours if needed
• Start immediately - continue during transfer if transport is required
• Evidence: Reduces need for exchange transfusion in Rh and ABO isoimmunization; 2022 AAP includes it as a specific recommendation

STEP 4: Escalation of Care (NEW in AAP 2022)

When TSB reaches this zone, it is a medical emergency.

Escalation Protocol

1. Transfer to NICU urgently - must be capable of performing exchange transfusion
2. Intensive phototherapy immediately - do not wait for lab results
3. IV hydration - supports albumin levels and bilirubin excretion
4. STAT labs: TSB + direct fraction, CBC, serum albumin, electrolytes, blood culture, type and crossmatch
5. Measure TSB every 2 hours until out of escalation zone
6. Consult neonatologist immediately
7. Start IVIG if hemolytic disease is present

STEP 5: Exchange Transfusion

Indications

• TSB at or above the exchange transfusion threshold (AAP Fig. 166.1B) despite intensive phototherapy
• TSB 5 mg/dL above exchange threshold lines
• Any signs of acute bilirubin encephalopathy regardless of TSB level: hypertonia, arching, retrocollis, opisthotonus, fever, high-pitched cry
• Failure of intensive phototherapy with rising TSB

Procedure Details (Harriet Lane Handbook)

• Blood removed via umbilical arterial catheter (UAC)
• Equal volume infused via umbilical venous catheter (UVC)
• If UAC unavailable: peripheral arterial line or single venous catheter

Pre-Procedure Checklist

• CBC, reticulocyte count, peripheral smear, bilirubin, Ca²⁺, glucose, total protein, blood type and Coombs test must be drawn on pre-exchange sample (these are diagnostically useless after exchange)
• Save sample for newborn screening, serologic or genetic studies
• Intensive phototherapy should be continued throughout the exchange transfusion procedure

Complications of Exchange Transfusion

STEP 6: Management of Conjugated Hyperbilirubinemia

Summary Treatment Algorithm

Measure TSB (TcB screen → confirm with serum if ≥15 mg/dL or within 3 mg/dL of threshold)
          │
          ▼
Is jaundice < 24 h, or conjugated? → ALWAYS PATHOLOGIC → Investigate + admit
          │
          ▼
Plot TSB on AAP nomogram (age in hours + gestational age + risk factors)
          │
    ┌─────┴──────────────────┐
    ▼                        ▼
Below phototherapy       At phototherapy        At escalation zone        At exchange level
threshold                threshold              (within 2 mg/dL of        or above
    │                        │                  exchange threshold)             │
    ▼                        ▼                       │                          ▼
Encourage feeding,       Phototherapy            MEDICAL EMERGENCY:        Exchange transfusion
close follow-up         (home or inpatient)      NICU transfer +           + intensive
                        IVIG if hemolytic +      intensive phototherapy    phototherapy throughout
                        TSB within 2-3 mg/dL     + IV fluids + IVIG
                        of exchange level        + STAT labs

Phototherapy Thresholds for Preterm Infants (Harriet Lane, Table 18.9)

Pharmacological Adjuncts (Limited Role)