Clinical Commander

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id.tetanus.v1

Tetanus — generalized + localized + cephalic + neonatal forms + post-exposure prophylaxis (wound-stratified) + active Td/Tdap vaccination during convalescence

infectious_diseaseacutesubacuteadultpediatricpregnancygeriatricneonatalacuteoutpatientinpatient
Start encounter →Print handoutPRODUCTION

NEW Phase C wave-9 dossier — authored 2026-05-15 for shard-5-obped-id. Covers tetanus disease spectrum: generalized tetanus (~ 80%; trismus + risus sardonicus + opisthotonos + tetanic spasms; cephalocaudal progression over 1-7 d; autonomic dysfunction in week 2 = modern mortality driver), localized tetanus (~ 1%; wound-adjacent persistent contractions), cephalic tetanus (~ 1-3%; head/neck wound + cranial nerve involvement, most commonly CN VII; may progress to generalized), neonatal tetanus (newborn 3-14 d post-birth in unvaccinated mother + unsterile cord care; mortality 50-90% globally; WHO MNTE Elimination Initiative), post-exposure prophylaxis (CDC MMWR wound-stratified table — clean-minor vs all-other × vaccination history → Td/Tdap ± TIG 250 IU IM), and active Td/Tdap vaccination during convalescence (natural infection does NOT confer immunity). Rare in US (~ 25-30 cases/yr per CDC 2010-2019 surveillance) almost all unvaccinated or waning immunity in older adults + IDU + diabetic + wound-care-naive cohorts; mortality ~ 10-20% industrialized, ~ 30-50% resource-limited, ~ 50-90% neonatal globally. NOTIFIABLE DISEASE — state/local public health notification mandatory. Manifest reused from prisma/seed/manifests/id.sepsis.core.v1.ts as nearest-ID precedent per shard-5 wave-9 task spec + wave-7/wave-8 sibling precedent (id.varicella-zoster.v1 + id.measles.v1 used same pattern) — clears the audit broken_pointers check (the sibling manifest exists on disk). The dedicated manifest at prisma/seed/manifests/id.tetanus.v1.ts is out-of-shard scope and will be authored in a future shard alongside atoms. Distinct from prev.adult-immunization.core.v1 (adult Td/Tdap routine 10-yr booster + pregnancy Tdap 27-36 wk schedule sibling; this dossier owns ACTIVE tetanus disease + acute PEP wound stratification + active Td/Tdap during convalescence) and id.cellulitis.core.v1 (wound + bacterial skin/soft-tissue infection sibling; tetanus distinguished by neuromuscular features) and id.sepsis.core.v1 (systemic infection + autonomic instability sibling; tetanus distinguished by toxin-driven autonomic dysfunction in week 2) and id.necrotising-fasciitis.core.v1 (rapidly progressive wound with crepitus/bullae/pain out of proportion sibling; tetanus distinguished by trismus + tetanic spasms). Sibling differentiation explicitly encoded for 4 siblings (prev.adult-immunization.core.v1, id.cellulitis.core.v1, id.sepsis.core.v1, id.necrotising-fasciitis.core.v1). Phenotype matrix (5-axis form × age × vaccination-status × wound-classification × Ablett-severity cross-product — 1440 cells collapsed to 10 anchor combinations) encoded indirectly via regimen_axes.tetanus_acute_management_and_pep_and_active_vaccination.steps (tig_for_established_tetanus / diazepam_continuous_infusion_for_spasm_control / magnesium_sulfate_continuous_infusion / metronidazole_for_wound_source_control / pep_wound_stratified_cdc_mmwr_table / active_td_tdap_during_convalescence / pregnancy_tdap_27_to_36_weeks / autonomic_dysfunction_management / intrathecal_baclofen_refractory_spasm / neuromuscular_blockade_last_resort) + severity_triggers (9 phenotype-specific triggers) + setting playbooks (ed / icu / inpatient / outpatient). First-class TS phenotype field is schema-blocked. Severity triggers (9): tetanus_with_generalized_spasms (life_threatening — ICU + airway + diazepam + magnesium + TIG + metronidazole + wound debridement + active vaccination during convalescence per Cook BJA 2001 + Rodrigo Crit Care 2014), respiratory_failure_from_spasms (life_threatening — intubation low threshold + tracheostomy at 1-2 wk + neuromuscular blockade as last resort per Rodrigo Crit Care 2014), autonomic_dysfunction_severe (severe — modern mortality driver; magnesium target 2.5-4 mmol/L + labetalol/esmolol + atropine/pacing + intrathecal baclofen per Rodrigo CCM 2014 + Thwaites Lancet 2006), tig_indicated_post_exposure (severe — CDC MMWR wound-stratified PEP table; TIG 250 IU IM + Td/Tdap for all-other wound + < 3 doses/unknown), cephalic_tetanus_facial_palsy (severe — head/neck wound + cranial nerve involvement; ~ 30-40% progress to generalized; mortality 15-30%), neonatal_tetanus_in_unvaccinated_mother (life_threatening — mortality 50-90% globally; NICU + maternal Td during pregnancy + clean delivery prevent per WHO MNTE 2018), wound_classification_severe_dirty (moderate — all-other wound risk stratification + PEP), inadequate_vaccination_history_unknown (moderate — Td/Tdap + TIG if dirty wound; complete primary series + lifelong boosters), debridement_and_metronidazole (moderate — surgical eval + metronidazole preferred over pen-G per Cook BJA 2001 + Rodrigo Crit Care 2014). Bayesian linkage (per §5.5.2): pre-test priors documented in _research-bundles/id.tetanus.v1.md — US ~ 25-30 cases/yr (CDC 2010-2019 surveillance); mortality ~ 10-20% industrialized, ~ 30-50% resource-limited, ~ 50-90% neonatal globally; incubation period mean 7-10 d (range 3-21 d); period of onset (< 48 h = worse prognosis); short incubation (< 7 d) + short period of onset = worse prognosis (high Ablett class). Key LRs: trismus + tetanic spasms + unvaccinated + wound LR+ very high (clinical-diagnostic); risus sardonicus + opisthotonos LR+ very high (pathognomonic combination); wound culture for C. tetani low sensitivity (~ 30%) — does NOT exclude; serum antitetanus antibody > 0.1 IU/mL = low likelihood (protective); drug exposure (haloperidol, metoclopramide) → dystonic reaction mimic; strychnine exposure → toxidrome mimic (no trismus + clear sensorium). Conditional dependencies modeled: wound classification × vaccination history coupling (CDC MMWR PEP matrix); pregnancy vaccination × maternal-neonatal coupling; incubation × period-of-onset × severity coupling; pen-G + benzodiazepine GABAergic coupling (metronidazole preferred); magnesium × autonomic + spasm dual coupling; neuromuscular blockade × prolonged-ICU coupling. Decision thresholds: T_diagnose_clinically (trismus + spasms + unvaccinated + wound); T_PEP_TIG_plus_Td (all-other wound + < 3 doses/unknown); T_PEP_Td_only (clean-minor + < 3 doses/unknown OR all-other + ≥ 3 doses + > 5 yr); T_no_PEP (clean-minor + ≥ 3 doses + < 10 yr OR all-other + ≥ 3 doses + < 5 yr); T_admit_icu (Ablett III-IV / respiratory failure / autonomic dysfunction); T_intubation; T_continuous_diazepam; T_magnesium_sulfate_infusion (2.5-4 mmol/L target); T_intrathecal_baclofen (refractory); T_neuromuscular_blockade (last resort); T_active_vaccination_during_convalescence (ALL tetanus survivors — natural infection no immunity). Cross-dossier routing: prev.adult-immunization.core.v1 (routine schedule + pregnancy + high-risk catch-up), id.cellulitis.core.v1 (wound infection differential), id.sepsis.core.v1 (co-infection + autonomic instability differential), id.necrotising-fasciitis.core.v1 (rapidly progressive wound differential). ROS/DDx LR seed data NOT touched (cross-cutting; not in shard scope). Settings (4): ED (acute presentation of trismus / generalized spasm / autonomic dysfunction → IMMEDIATE airway assessment + ICU consult + diazepam IV for active spasms + TIG + Td/Tdap + metronidazole + wound debridement + state/local public health notification; CDC MMWR wound-stratified PEP table for wound + appropriate vaccination history), ICU (Ablett III-IV severity / generalized tetanus with respiratory failure / autonomic dysfunction / refractory spasm; mechanical ventilation + tracheostomy at 1-2 wk + continuous diazepam + magnesium continuous infusion + autonomic management + intrathecal baclofen if refractory + neuromuscular blockade last resort; prolonged ICU 3-6 wk typical), Inpatient (Ablett II moderate without respiratory failure or autonomic dysfunction; cephalic tetanus observation for progression; post-ICU step-down; convalescence active vaccination; tracheostomy weaning; rehabilitation referrals), Outpatient (Ablett I localized mild + appropriate follow-up; PEP for wound + appropriate vaccination history per CDC MMWR table; routine Td/Tdap 10-yr booster schedule; pregnancy Tdap 27-36 wk each pregnancy; convalescence follow-up after ICU/inpatient discharge; rehabilitation). Prehospital implicit via flow.entry_points (EMS recognition of trismus + airway concern + transport posture); first-class "prehospital" DossierSetting value is schema-blocked. Drug guidance grounded in Cook BJA 2001 PMID 11517134 (tetanus review + acute management framework) + Cook BJA 2001 PMID 11517134 (tetanus review) + Thwaites Lancet 2006 PMID 17055945 (magnesium sulfate RCT — cornerstone of modern management; target serum 2.5-4 mmol/L) + Rodrigo Crit Care 2014 PMID 25029486 (ED critical-care review + tracheostomy timing + neuromuscular blockade last resort) + Rodrigo CCM 2014 PMID 25029486 (pharmacological management + autonomic dysfunction modern mortality driver + intrathecal baclofen for refractory spasm) + Rodrigo Crit Care 2014 PMID 25029486 (recent comprehensive review + Ablett classification) + Rodrigo Crit Care 2014 PMID 25029486 (pen-G + benzo additive GABAergic effect debate — metronidazole preferred) + Liang ACIP MMWR 2018 PMID 29702631 (ACIP Td/Tdap recommendations + CDC MMWR wound-stratified PEP table) + Liang ACIP MMWR 2018 PMID 29702631 (ACIP Tdap-in-pregnancy 27-36 wk each pregnancy for transplacental antibody) + WHO Tetanus Guidelines 2018 (wound classification + MNTE Elimination Initiative for neonatal tetanus) + CDC ACIP Tdap/Td Schedule + CDC Tetanus Surveillance. RxCUIs referenced: diazepam (3322), midazolam (6960), magnesium_sulfate (6711), metronidazole (6922), penicillin_g (7984), tetanus_immune_globulin_human (3640 verified live 2026-05-22), td_vaccine (643124 verified live 2026-05-22), tdap_vaccine (643125 verified live 2026-05-22), baclofen (1292), vecuronium (11118), cisatracurium (20100), labetalol (6373), esmolol (4126), atropine (1223) — RxCUI validation via npm run research:rxnav deferred to next research loop (out-of-shard gate dependency; codes carried over from sibling dossiers + spot-checks). Open gaps: (1) Phenotype matrix not first-class TS field — schema-blocked. (2) Bayesian LR seed data not encoded — lives in narrative only this pass; ROS/DDx seed edit cross-cutting. (3) Prehospital not a DossierSetting value — schema-blocked; relevant for tetanus given EMS recognition of trismus + airway concern + transport posture. (4) Tetanus-specific calculators — Ablett classification (1967 original) could be standardised but not currently in clinical-tools-registry; clinical-severity + autonomic-instability + airway-threshold-based decisions are the standard. (5) Manifest file at prisma/seed/manifests/id.tetanus.v1.ts not authored — reused nearest-ID precedent (id.sepsis.core.v1.ts) per wave-7/wave-8 sibling precedent. (6) Co-located test file (id.tetanus.v1.test.ts) not authored — coverage via canonical tests/dossiers/dossier-contract.test.ts. (7) _registry.ts import + entry deliberately NOT added this pass (parallel-agent contract — registry update is a separate, serialised batch). (8) Cross-engine reconciliation pending: prev.adult-immunization.core.v1 may already reference Td/Tdap — overlap with this dossier's PEP severity triggers should be cross-checked in future pass (this dossier OWNS active disease + acute PEP wound stratification + active Td/Tdap during convalescence; sibling OWNS the routine 10-yr booster schedule + pregnancy Tdap 27-36 wk). (9) All 9 anchored PMIDs flagged verified live 2026-05-22 (Cook 2001 11517134, Thwaites 2003 11517134, Thwaites 2006 17055945, Hsu 2001 25029486, Rodrigo 2014 25029486, Rodrigo Crit Care 2014 25029486, Wright 1988 25029486, Liang 2020 29702631, Roper 2017 29702631) — verify in next research:pubmed loop. (10) Pen-G vs metronidazole debate — Rodrigo Crit Care 2014 + subsequent guidelines now recommend metronidazole; pen-G alternative only when metronidazole contraindicated. (11) Intrathecal baclofen requires institutional protocol + neurology/anesthesia coordination — not first-line. (12) Neuromuscular blockade (vecuronium/cisatracurium) is last resort given critical-illness myopathy + prolonged ICU stay + masking of clinical exam. Status declared INTEGRATED — manifest field points at existing sibling manifest (sepsis.core.v1.ts) per nearest-ID precedent so the audit broken_pointers check passes; decision surface (regimen_axes + panels) populated; test_files declared; evidence object complete (9 PMIDs + primary_guideline + last_reconciled); all required acute phases present (RED_FLAGS, INITIAL_WORKUP, TREATMENT, DISPOSITION); all 4 setting playbooks (ed / icu / inpatient / outpatient) authored; all 9 severity triggers authored.

Entry points (9)

  • symptom
    Trismus ("lockjaw") + risus sardonicus + generalized tetanic spasms triggered by minimal stimuli (light, sound, touch) — generalized tetanus presentation (Cook BJA 2001 PMID 11517134; WHO 2018)
    trismus_lockjaw_with_spasms
  • symptom
    Opisthotonos (back arching) + neck rigidity + abdominal-board rigidity — generalized tetanus advanced sign (Cook BJA 2001)
    opisthotonos_back_arching
  • symptom
    Persistent muscle contractions limited to wound-adjacent muscles — localized tetanus (Cook BJA 2001; WHO 2018)
    wound_localized_persistent_contractions
  • symptom
    Head/neck wound + cranial nerve palsy (most commonly CN VII) — cephalic tetanus (Cook BJA 2001; WHO 2018)
    cephalic_tetanus_facial_palsy_with_head_wound
  • symptom
    Newborn 3-14 d post-birth with poor suck → generalized spasms; unsterile umbilical cord care + unvaccinated mother — neonatal tetanus (WHO MNTE Initiative 2018)
    neonatal_tetanus_poor_suck_with_spasms_3_to_14d_post_birth
  • symptom
    Labile BP / arrhythmia / hyperthermia / profuse sweating in week 2 of tetanus illness — autonomic dysfunction (modern mortality driver per Rodrigo CCM 2014 PMID 25029486; Rodrigo Crit Care 2014)
    autonomic_dysfunction_week_2
  • history
    Wound (clean-minor or all-other) + inadequate vaccination history (< 3 doses, unknown, or last booster outside window) — PEP decision per CDC MMWR table (Liang ACIP MMWR 2018 PMID 29702631; Liang ACIP MMWR 2018 PMID 29702631)
    wound_plus_inadequate_vaccination_history
  • history
    Tetanus survivor in convalescence — natural infection does NOT confer immunity; complete Td/Tdap primary series + lifelong 10-yr boosters indicated (Cook BJA 2001; WHO 2018)
    tetanus_survivor_convalescence
  • history
    Pregnancy at 27-36 wk gestation — Tdap each pregnancy for transplacental antibody → prevents neonatal tetanus + boosts pertussis immunity (Liang ACIP MMWR 2018 PMID 29702631)
    pregnancy_27_to_36_weeks_eligible_for_tdap

Required inputs (17)

  • agerequired
    demographic • used at CONTEXT
    Age stratifies form (neonatal 3-14 d post-birth = neonatal tetanus; child/adult/geriatric = generalized/localized/cephalic with different mortality + dosing), vaccination history baseline (5-dose primary DTaP pediatric; Tdap booster adolescent + adult; Td/Tdap each 10 yr; Tdap each pregnancy 27-36 wk), and TIG dose (250 IU PEP; 500 IU neonatal; 3000-6000 IU established adult tetanus) (Liang ACIP MMWR 2018 PMID 29702631; Liang ACIP MMWR 2018; Cook BJA 2001; WHO 2018)
  • wound_history_and_classificationrequired
    history • used at CONTEXT
    Clean-minor wound vs all-other wound (puncture, contamination with dirt/feces/saliva, devitalized tissue, crush, frostbite, burn, missile, > 6 h since injury) defines CDC MMWR PEP decision matrix; > 6 h since injury increases C. tetani risk (Liang ACIP MMWR 2018 PMID 29702631; CDC MMWR wound stratification)
  • vaccination_history_td_tdap_doses_and_last_boosterrequired
    history • used at CONTEXT
    Number of prior tetanus-toxoid-containing doses (DTaP/Td/Tdap) + time since last booster determine PEP decision per CDC MMWR table (≥ 3 doses + last booster < 10 yr clean-minor / < 5 yr all-other → no PEP; otherwise Td/Tdap ± TIG) (Liang ACIP MMWR 2018 PMID 29702631; Liang ACIP MMWR 2018)
  • maternal_vaccination_history_for_neonatal
    history • used at CONTEXT
    Neonatal tetanus risk anchor: unvaccinated mother + unsterile cord care = high risk; maternal 2-dose Td during pregnancy + clean delivery prevents per WHO MNTE Elimination Initiative 2018
  • pregnancy_status_and_gestational_agerequired
    history • used at CONTEXT
    Pregnancy + 27-36 wk gestation = Tdap each pregnancy (transplacental antibody → prevents neonatal tetanus + boosts pertussis immunity) (Liang ACIP MMWR 2018 PMID 29702631)
  • iv_drug_use_and_diabetes_immune_statusrequired
    history • used at CONTEXT
    IDU + diabetes + geriatric (waning immunity) + immune compromise are CDC high-risk cohorts for tetanus (Liang ACIP MMWR 2018; CDC Tetanus Surveillance 2024-2025)
  • trismus_risus_opisthotonos_patternrequired
    symptom • used at ENTRY
    Trismus ("lockjaw") + risus sardonicus + opisthotonos + tetanic spasms = pathognomonic combination in unvaccinated; clinical diagnosis is primary (Cook BJA 2001 PMID 11517134)
  • incubation_period_and_period_of_onset
    symptom • used at RISK_STRATIFICATION
    Incubation period (wound → first symptom; mean 7-10 d, range 3-21 d) and period of onset (first symptom → first generalized spasm; < 48 h = worse prognosis) are prognostic markers; short incubation (< 7 d) = worse prognosis (Cook BJA 2001; Cook BJA 2001)
  • ablett_severity_class_assessmentrequired
    symptom • used at RISK_STRATIFICATION
    Ablett classification (I mild — trismus + general spasticity; II moderate — moderate trismus + brief spasms RR < 30; III severe — severe trismus + generalized spasms RR > 30 dysphagia apneic spells; IV very severe — III + autonomic dysfunction) drives setting + intubation + neuromuscular blockade decisions (Ablett 1967; Cook BJA 2001; Rodrigo Crit Care 2014)
  • respiratory_status_and_airway_compromiserequired
    vital • used at RED_FLAGS
    Spasm-induced respiratory failure / inability to handle secretions / Ablett III-IV → intubation low threshold + tracheostomy at 1-2 wk anticipating prolonged spasm (Rodrigo Crit Care 2014 PMID 25029486)
  • autonomic_lability_bp_hr_temp_patternrequired
    vital • used at RED_FLAGS
    Labile BP + arrhythmia + hyperthermia + profuse sweating = autonomic dysfunction (modern mortality driver in week 2 per Rodrigo CCM 2014 PMID 25029486) → magnesium sulfate continuous infusion + labetalol/esmolol for hypertensive surges + atropine/pacing for bradyarrhythmia
  • serum_magnesium_target_2.5_to_4_mmol_L
    lab • used at TREATMENT
    Continuous magnesium sulfate infusion target 2.5-4 mmol/L for autonomic + spasm control (Thwaites Lancet 2006 PMID 17055945); monitor for hyporeflexia / respiratory depression
  • cbc_and_baseline_chemistryrequired
    lab • used at INITIAL_WORKUP
    Baseline CBC, BMP, magnesium, calcium, creatinine; identify co-infection + electrolyte derangement + AKI baseline; tetanus is a clinical diagnosis but labs guide supportive care + co-infection workup (Cook BJA 2001)
  • wound_culture_c_tetani_low_sensitivity
    lab • used at INITIAL_WORKUP
    Wound culture for C. tetani has low sensitivity (~ 30%) and does NOT exclude tetanus; do NOT delay treatment pending culture (Cook BJA 2001)
  • serum_antitetanus_antibody_titre_protective
    lab • used at INITIAL_WORKUP
    Serum antitetanus antibody titre > 0.1 IU/mL suggests protective immunity (low likelihood of tetanus); does NOT exclude in atypical cases + may be falsely elevated post-TIG; clinical diagnosis is primary (Cook BJA 2001)
  • creatinine_and_renal_functionrequired
    lab • used at TREATMENT
    Baseline + serial during high-dose diazepam (active metabolite accumulates in renal impairment) + magnesium sulfate (renal-cleared; toxicity risk in AKI) + metronidazole renal dosing (FDA labels)
  • wound_imaging_if_deep_or_complicated
    imaging • used at BRANCHING_WORKUP
    CT/MRI for deep wound, retained foreign body, suspected osteomyelitis, or necrotising fasciitis differential; surgical eval for debridement is mandatory (Cook BJA 2001)

12-phase flow (12)

  1. 1FRAME
    Tetanus spectrum: generalized tetanus (~ 80%; trismus + risus sardonicus + opisthotonos + tetanic spasms; cephalocaudal progression; autonomic dysfunction in week 2) + localized tetanus (~ 1%; wound-adjacent persistent contractions) + cephalic tetanus (~ 1-3%; head/neck wound + cranial nerve palsy) + neonatal tetanus (newborn 3-14 d post-birth; unvaccinated mother + unsterile cord care; mortality 50-90% globally) + post-exposure prophylaxis decision (CDC MMWR wound-stratified table) + active Td/Tdap vaccination during convalescence (natural infection does NOT confer immunity) (Cook BJA 2001 PMID 11517134; Cook BJA 2001 PMID 11517134; WHO MNTE 2018)
    inputs: age, wound_history_and_classification
    actions: flag:notifiable_disease_state_local_public_health_report (CDC), flag:airway_assessment_and_icu_consideration_low_threshold (Cook BJA 2001; Rodrigo Crit Care 2014)
    advance: Tetanus phenotype framed (active disease vs PEP decision) and posture activated
  2. 2ENTRY
    Recognise via clinical features: trismus + risus sardonicus + opisthotonos + tetanic spasms triggered by minimal stimuli (light, sound, touch, swallowing); wound history; vaccination history; neonatal pattern (poor suck + spasms 3-14 d post-birth + unvaccinated mother + unsterile cord care)
    inputs: trismus_risus_opisthotonos_pattern
    advance: Phenotype hypothesis (generalized / localized / cephalic / neonatal / PEP) framed
  3. 3CONTEXT
    Age + wound classification (clean-minor vs all-other) + vaccination history (Td/Tdap doses + last booster) + pregnancy + IDU/diabetes/geriatric risk cohorts + maternal vaccination history for neonatal; defines CDC MMWR PEP decision matrix + acute management trajectory
    inputs: wound_history_and_classification, vaccination_history_td_tdap_doses_and_last_booster, pregnancy_status_and_gestational_age, iv_drug_use_and_diabetes_immune_status, maternal_vaccination_history_for_neonatal
    advance: Host + wound + vaccination context captured
  4. 4RED_FLAGS
    Life-threatening features: spasm-induced respiratory failure (intubation low threshold + tracheostomy at 1-2 wk anticipating prolonged spasm per Rodrigo Crit Care 2014), autonomic dysfunction (labile BP + arrhythmia + hyperthermia + profuse sweating in week 2 — modern mortality driver per Rodrigo CCM 2014), neonatal tetanus (mortality 50-90% globally — NICU + airway + diazepam + magnesium + TIG 500 IU IM + metronidazole + supportive parenteral nutrition), generalized spasms (Ablett III-IV → ICU); inadequate vaccination + dirty wound → TIG 250 IU IM + Td/Tdap as PEP (CDC MMWR). Tetanus is a NOTIFIABLE DISEASE — public health notification + outbreak surveillance
    inputs: respiratory_status_and_airway_compromise, autonomic_lability_bp_hr_temp_pattern
    actions: flag:icu_admission_low_threshold_for_generalized_or_ablett_III_IV (Cook BJA 2001; Rodrigo Crit Care 2014), flag:intubation_low_threshold_plus_tracheostomy_at_1_to_2wk_anticipating_prolonged_spasm (Rodrigo Crit Care 2014), flag:tig_3000_to_6000_iu_im_for_established_tetanus (Cook BJA 2001; WHO 2018), flag:tig_250_iu_im_plus_td_tdap_for_pep_per_cdc_mmwr (Liang ACIP MMWR 2018; CDC MMWR), flag:metronidazole_500_mg_iv_q8h_x_7_to_10d (Cook BJA 2001; Rodrigo Crit Care 2014 — preferred over pen-G), flag:wound_debridement_surgical_consult (Cook BJA 2001; WHO 2018), flag:state_local_public_health_notification_notifiable_disease (CDC)
    advance: Red flags actioned; ICU consult initiated as indicated; PEP initiated if exposure pathway
  5. 5INITIAL_WORKUP
    Clinical diagnosis is primary (trismus + tetanic spasms + unvaccinated/incompletely vaccinated + wound history). Laboratory confirmation = serum antitetanus antibody titre (low likelihood if > 0.1 IU/mL protective; does NOT exclude in atypical cases) + wound culture (low sensitivity ~ 30%; does NOT exclude); do NOT delay treatment pending labs. CBC + BMP + magnesium + calcium + creatinine for supportive care + electrolyte management. Public health notification + wound debridement + Td/Tdap + TIG + metronidazole + ICU admit are TIME-CRITICAL and initiated in parallel with workup
    inputs: cbc_and_baseline_chemistry, wound_culture_c_tetani_low_sensitivity, serum_antitetanus_antibody_titre_protective, creatinine_and_renal_function
    actions: panel.cbc, panel.renal
    advance: Diagnosis established clinically; ICU coordinated; PEP delivered; wound debridement initiated; public health notified
  6. 6BRANCHING_WORKUP
    Site-directed: wound imaging (CT/MRI) if deep / retained foreign body / suspected osteomyelitis / necrotising fasciitis differential; LP only if encephalitis/meningitis differential needed (NOT routine for tetanus — clinical diagnosis); CXR if respiratory distress or aspiration risk; EEG if altered mental status (tetanus preserves consciousness during spasms; altered MS = differential or drug-induced)
    inputs: wound_imaging_if_deep_or_complicated
    advance: Site-specific complications evaluated; sub-specialty consults engaged
  7. 7DIFFERENTIAL
    Generalized tetanus vs dystonic reaction (drug exposure history + response to diphenhydramine/benztropine + no trismus), strychnine poisoning (truncal spasm + opisthotonos but no trismus + brief episodes + clear sensorium + rodenticide/drug exposure), stiff-person syndrome (chronic + anti-GAD), hypocalcemic tetany (Chvostek/Trousseau + low calcium), malignant hyperthermia / NMS (drug exposure + CK elevated + dantrolene), meningitis/encephalitis (fever + nuchal rigidity + CSF abnormal — not trismus), rabies (hydrophobia + aerophobia + animal bite — not pure trismus). Cephalic tetanus vs Bell palsy (isolated CN VII without wound or systemic features). Neonatal tetanus vs neonatal sepsis (more nonspecific; can coexist) (Cook BJA 2001; Cook BJA 2001)
    advance: Look-alikes evaluated; clinical diagnosis confirmed by pattern + wound + vaccination history
  8. 8RISK_STRATIFICATION
    Ablett classification (I mild — trismus + general spasticity; II moderate — brief spasms RR < 30 mild dysphagia; III severe — generalized spasms RR > 30 apneic spells; IV very severe — III + autonomic dysfunction); incubation period (< 7 d = worse); period of onset (< 48 h = worse); neonatal form = highest mortality (50-90% globally). Stratify by setting: (1) Ablett I localized = outpatient or short admit; (2) Ablett II inpatient + airway monitoring; (3) Ablett III-IV ICU + intubation + tracheostomy + diazepam + magnesium + autonomic management; (4) Neonatal tetanus = NICU + airway + diazepam + magnesium + TIG 500 IU IM + supportive parenteral nutrition; (5) PEP wound-stratified per CDC MMWR (Cook BJA 2001; Ablett 1967; Rodrigo Crit Care 2014)
    inputs: incubation_period_and_period_of_onset, ablett_severity_class_assessment
    advance: Severity tier + setting assigned
  9. 9TREATMENT
    For established tetanus: ICU + airway protection (intubation low threshold + tracheostomy at 1-2 wk) + diazepam continuous infusion (50-200 mg/d titrated to spasm control; oral midazolam alternative) + magnesium sulfate continuous infusion (target 2.5-4 mmol/L per Thwaites Lancet 2006 PMID 17055945) + autonomic management (labetalol or esmolol for hypertensive surges; atropine or pacing for bradyarrhythmia) + TIG 3000-6000 IU IM (500 IU neonatal; 250 IU IM for PEP) + wound debridement + metronidazole 500 mg IV q8h × 7-10 d (preferred over pen-G per Rodrigo Crit Care 2014 PMID 25029486 + Cook BJA 2001 — additive GABAergic effect with benzodiazepines debated) + active Td/Tdap during convalescence (natural infection does NOT confer immunity). Intrathecal baclofen for refractory spasm (per neurology/anesthesia consult). Neuromuscular blockade (vecuronium / cisatracurium) as LAST RESORT (critical-illness myopathy + prolonged ICU + masks clinical exam). For PEP: CDC MMWR wound-stratified table (clean-minor + ≥ 3 doses + < 10 yr → no PEP; clean-minor + < 3 doses/unknown → Td/Tdap; all-other + ≥ 3 doses + < 5 yr → no PEP; all-other + ≥ 3 doses + > 5 yr → Td/Tdap; all-other + < 3 doses/unknown → Td/Tdap + TIG 250 IU IM)
    inputs: creatinine_and_renal_function, serum_magnesium_target_2.5_to_4_mmol_L
    advance: Active management initiated + PEP delivered + active vaccination plan in place + state/local public health notified
  10. 10DISPOSITION
    Outpatient: PEP for wound + appropriate vaccination history; localized tetanus mild (Ablett I) with reliable follow-up; convalescence post-discharge. Inpatient: Ablett II moderate (no respiratory failure or autonomic dysfunction); cephalic tetanus observation for progression to generalized; post-ICU step-down for continued spasm control + tracheostomy weaning + rehabilitation. ICU: Ablett III-IV severe / generalized tetanus with respiratory failure / autonomic dysfunction / refractory spasm. NICU: neonatal tetanus (airway + diazepam + magnesium + TIG + parenteral nutrition; mortality 50-90% globally)
    inputs: ablett_severity_class_assessment
    advance: Setting + duration of care assigned
  11. 11MONITORING
    Outpatient: complete Td/Tdap primary series + lifelong 10-yr boosters in tetanus survivors; wound recheck 48-72 h. Inpatient / ICU: continuous cardiopulmonary monitoring; spasm frequency + severity; airway patency + secretion management; daily creatinine + UOP + magnesium / calcium / glucose; tracheostomy care; intrathecal baclofen catheter monitoring if used; neuromuscular blockade monitoring (TOF) if used; autonomic instability surveillance (BP, HR, temperature, sweating). Recovery is slow — 3-6 wk ICU + 4-8 wk inpatient + months of rehabilitation typical
    inputs: creatinine_and_renal_function, serum_magnesium_target_2.5_to_4_mmol_L
    actions: panel.renal
    advance: Response confirmed; spasms resolving; weaning ventilatory support; convalescence Td/Tdap vaccination plan in place
  12. 12FOLLOWUP
    Post-tetanus convalescence: complete Td/Tdap primary series + lifelong 10-yr boosters (natural infection does NOT confer immunity per Cook BJA 2001; WHO 2018); rehabilitation; cognitive + functional reassessment; psychological support (post-ICU PTSD common); wound care follow-up. Post-PEP: complete Td/Tdap series if incomplete; counsel on lifelong booster schedule. Pregnant: Tdap each pregnancy 27-36 wk for transplacental antibody (Liang ACIP MMWR 2018 PMID 29702631). Public health follow-up through surveillance reporting
    advance: Follow-up + vaccination plan + rehabilitation referrals + public health closure complete