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id.tetanus.v1PRODUCTION
id.tetanus.v1

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

infectious_diseaseacutesubacuteadultpediatricpregnancygeriatricneonatal
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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Tetanus phenotype framed (active disease vs PEP decision) and posture activated

Patient inputs (17)

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)

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)

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)

Pregnancy + 27-36 wk gestation = Tdap each pregnancy (transplacental antibody → prevents neonatal tetanus + boosts pertussis immunity) (Liang ACIP MMWR 2018 PMID 29702631)

IDU + diabetes + geriatric (waning immunity) + immune compromise are CDC high-risk cohorts for tetanus (Liang ACIP MMWR 2018; CDC Tetanus Surveillance 2024-2025)

Trismus ("lockjaw") + risus sardonicus + opisthotonos + tetanic spasms = pathognomonic combination in unvaccinated; clinical diagnosis is primary (Cook BJA 2001 PMID 11517134)

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)

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)

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

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)

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)

CT/MRI for deep wound, retained foreign body, suspected osteomyelitis, or necrotising fasciitis differential; surgical eval for debridement is mandatory (Cook BJA 2001)

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

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 > 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)

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)

Continuous magnesium sulfate infusion target 2.5-4 mmol/L for autonomic + spasm control (Thwaites Lancet 2006 PMID 17055945); monitor for hyporeflexia / respiratory depression

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningtetanus_with_generalized_spasms
    Generalized tetanus (trismus + risus sardonicus + opisthotonos + tetanic spasms triggered by minimal stimuli) — life-threatening; admit ICU + airway protection (intubation low threshold + tracheostomy at 1-2 wk anticipating prolonged spasm) + diazepam continuous infusion (50-200 mg/d titrated) + magnesium sulfate continuous infusion (target serum 2.5-4 mmol/L per Thwaites Lancet 2006 PMID 17055945) + TIG 3000-6000 IU IM + metronidazole 500 mg IV q8h × 7-10 d + wound debridement + active Td/Tdap during convalescence (natural infection no immunity) (Cook BJA 2001 PMID 11517134; Rodrigo Crit Care 2014 PMID 25029486; WHO 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrespiratory_failure_from_spasms
    Spasm-induced respiratory failure / inability to handle secretions / Ablett III-IV severity — life-threatening; intubation low threshold + mechanical ventilation + tracheostomy at 1-2 wk anticipating prolonged spasm (Rodrigo Crit Care 2014 PMID 25029486) + continuous diazepam + magnesium + autonomic management
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningneonatal_tetanus_in_unvaccinated_mother
    Newborn 3-14 d post-birth with poor suck → generalized spasms; unvaccinated mother + unsterile umbilical cord care (cow dung, ghee, unsterile blade) — neonatal tetanus; life-threatening; mortality 50-90% globally; NICU + airway + diazepam + magnesium + TIG 500 IU IM + metronidazole + supportive parenteral nutrition; WHO Maternal + Neonatal Tetanus Elimination (MNTE) Initiative — global priority; maternal 2-dose Td during pregnancy + clean delivery prevent (WHO MNTE 2018; Cook BJA 2001)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereautonomic_dysfunction_severe
    Autonomic dysfunction in week 2 of generalized tetanus (labile BP + arrhythmia + hyperthermia + profuse sweating) — modern mortality driver per Rodrigo CCM 2014 PMID 25029486 + Rodrigo Crit Care 2014 PMID 25029486; magnesium sulfate continuous infusion (target serum 2.5-4 mmol/L) + labetalol or esmolol for hypertensive surges + atropine or pacing for bradyarrhythmia; intrathecal baclofen for refractory spasm
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretig_indicated_post_exposure
    Acute wound + post-exposure prophylaxis decision per CDC MMWR wound-stratified table — TIG 250 IU IM + Td/Tdap (separate sites) for all-other wound + < 3 doses or unknown vaccination history; passive + active immunization combination (Liang ACIP MMWR 2018 PMID 29702631; CDC MMWR)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecephalic_tetanus_facial_palsy
    Head/neck wound + cranial nerve palsy (most commonly CN VII facial palsy) — cephalic tetanus; severe; admit + TIG 3000-6000 IU IM + Td/Tdap + metronidazole + wound care + close observation for progression to generalized (~ 30-40% progress); mortality 15-30% in cephalic form alone (Cook BJA 2001 PMID 11517134; WHO 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatewound_classification_severe_dirty
    All-other wound (puncture, contamination with dirt/feces/saliva, devitalized tissue, crush, frostbite, burn, missile, > 6 h since injury) — moderate; risk stratification + appropriate PEP per CDC MMWR table; surgical evaluation for debridement (Liang ACIP MMWR 2018 PMID 29702631; CDC MMWR)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateinadequate_vaccination_history_unknown
    Inadequate vaccination history (< 3 doses tetanus-toxoid-containing vaccine OR unknown) — moderate; Td/Tdap + TIG 250 IU IM if all-other wound (per CDC MMWR); Td/Tdap alone if clean-minor wound; complete Td/Tdap 3-dose primary series + lifelong 10-yr boosters (Liang ACIP MMWR 2018 PMID 29702631; CDC MMWR)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedebridement_and_metronidazole
    Established tetanus or significant wound — wound debridement surgical consult (source control) + metronidazole 500 mg IV q8h × 7-10 d (preferred over pen-G per Cook BJA 2001 + Rodrigo Crit Care 2014 PMID 25029486 — additive GABAergic effect of pen-G with benzodiazepines used for spasm control debated)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Tetanus acute management (diazepam + magnesium + autonomic support + TIG + metronidazole + wound care) + wound-stratified post-exposure prophylaxis (CDC MMWR table) + active Td/Tdap during convalescence (natural infection does NOT confer immunity)
axis: tetanus_acute_management_and_pep_and_active_vaccinationstep tig_for_established_tetanus - TIG (human tetanus immune globulin) for established tetanus
Selected step "TIG (human tetanus immune globulin) for established tetanus" — Established active tetanus disease (generalized / localized / cephalic / neonatal) — passive immunization to neutralize unbound toxin (toxin already retrograde-transported to CNS is NOT reversed)
  • tetanus_immune_globulin_human
    first line
    immune_globulin
    Adult/adolescent: 3000-6000 IU IM single dose (some protocols divide across multiple sites); neonatal: 500 IU IM single dose; pediatric: 3000-6000 IU IM single dose • IM • single dose
    triggers: established_tetanus_any_form
    Cook BJA 2001 PMID 11517134 + WHO 2018 — TIG neutralizes unbound circulating tetanospasmin; intrathecal administration explored but not standard; FDA-approved for established disease
    rxcui 1727875

outpatient playbook — drug actions (5)

  1. 1. Td or Tdap IM (PEP per CDC MMWR or active during convalescence)
    0.5 mL IM single dose (PEP) OR 3-dose primary series + lifelong 10-yr boosters (convalescence) • IM • single dose (PEP); 3-dose primary series in convalescence + 10-yr boosters
    trigger: Wound + PEP per CDC MMWR table OR tetanus survivor convalescence OR routine 10-yr booster
    Liang ACIP MMWR 2018 + Liang ACIP MMWR 2018 — Tdap preferred when patient has not received Tdap previously; Td for subsequent doses
  2. 2. TIG (tetanus immune globulin, human) IM (PEP)
    250 IU IM single dose (separate injection site from Td/Tdap) • IM • single dose
    trigger: All-other wound + < 3 doses or unknown vaccination history (PEP)
    CDC MMWR Liang 2020 PMID 29702631
  3. 3. Tdap (pregnancy 27-36 wk each pregnancy)
    0.5 mL IM single dose each pregnancy 27-36 wk • IM • each pregnancy 27-36 wk
    trigger: Pregnancy 27-36 wk gestation
    Liang ACIP MMWR 2018 PMID 29702631 — Tdap each pregnancy for transplacental antibody → prevents neonatal tetanus + boosts pertussis
  4. 4. diazepam PO (mild localized tetanus)
    Adult: 5-10 mg PO q6-8h PRN; pediatric: 0.1-0.3 mg/kg/dose PO q6-8h • PO • q6-8h PRN
    trigger: Mild localized tetanus (Ablett I) with reliable follow-up
    Cook BJA 2001 — outpatient management appropriate only for mild localized form with close follow-up
  5. 5. metronidazole PO (mild localized tetanus + wound)
    Adult: 500 mg PO q8h × 7-10 d • PO • q8h × 7-10 d
    trigger: Mild localized tetanus + wound source control
    Cook BJA 2001

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Trismus ("lockjaw") + risus sardonicus + generalized tetanic spasms triggered by minimal stimuli (light, sound, touch) — generalized tetanus presentation (Cook BJA 2001 PMID 11517134; WHO 2018); Opisthotonos (back arching) + neck rigidity + abdominal-board rigidity — generalized tetanus advanced sign (Cook BJA 2001); Persistent muscle contractions limited to wound-adjacent muscles — localized tetanus (Cook BJA 2001; WHO 2018).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Tetanus — generalized + localized + cephalic + neonatal forms + post-exposure prophylaxis (wound-stratified) + active Td/Tdap vaccination during convalescence** (id.tetanus.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Tetanus acute management (diazepam + magnesium + autonomic support + TIG + metronidazole + wound care) + wound-stratified post-exposure prophylaxis (CDC MMWR table) + active Td/Tdap during convalescence (natural infection does NOT confer immunity)** — step "TIG (human tetanus immune globulin) for established tetanus".
1. tetanus_immune_globulin_human Adult/adolescent: 3000-6000 IU IM single dose (some protocols divide across multiple sites); neonatal: 500 IU IM single dose; pediatric: 3000-6000 IU IM single dose IM single dose (immune_globulin, first line) — Cook BJA 2001 PMID 11517134 + WHO 2018 — TIG neutralizes unbound circulating tetanospasmin; intrathecal administration explored but not standard; FDA-approved for established disease

Setting playbook (outpatient) — Manage Ablett I localized tetanus with PO supportive care + active Td/Tdap during convalescence; PEP for wound + appropriate vaccination history per CDC MMWR table; routine Td/Tdap booster schedule (10-yr); pregnancy Tdap 27-36 wk each pregnancy; convalescence follow-up after ICU/inpatient discharge; rehabilitation; family education (Cook BJA 2001; Liang ACIP MMWR 2018 PMID 29702631; Liang ACIP MMWR 2018 PMID 29702631)
2. Td or Tdap IM (PEP per CDC MMWR or active during convalescence) 0.5 mL IM single dose (PEP) OR 3-dose primary series + lifelong 10-yr boosters (convalescence) IM single dose (PEP); 3-dose primary series in convalescence + 10-yr boosters — Wound + PEP per CDC MMWR table OR tetanus survivor convalescence OR routine 10-yr booster (Liang ACIP MMWR 2018 + Liang ACIP MMWR 2018 — Tdap preferred when patient has not received Tdap previously; Td for subsequent doses)
3. TIG (tetanus immune globulin, human) IM (PEP) 250 IU IM single dose (separate injection site from Td/Tdap) IM single dose — All-other wound + < 3 doses or unknown vaccination history (PEP) (CDC MMWR Liang 2020 PMID 29702631)
4. Tdap (pregnancy 27-36 wk each pregnancy) 0.5 mL IM single dose each pregnancy 27-36 wk IM each pregnancy 27-36 wk — Pregnancy 27-36 wk gestation (Liang ACIP MMWR 2018 PMID 29702631 — Tdap each pregnancy for transplacental antibody → prevents neonatal tetanus + boosts pertussis)
5. diazepam PO (mild localized tetanus) Adult: 5-10 mg PO q6-8h PRN; pediatric: 0.1-0.3 mg/kg/dose PO q6-8h PO q6-8h PRN — Mild localized tetanus (Ablett I) with reliable follow-up (Cook BJA 2001 — outpatient management appropriate only for mild localized form with close follow-up)
6. metronidazole PO (mild localized tetanus + wound) Adult: 500 mg PO q8h × 7-10 d PO q8h × 7-10 d — Mild localized tetanus + wound source control (Cook BJA 2001)

Non-pharmacologic actions:
- Wound debridement + irrigation in clinic for minor wounds (if appropriate; surgical referral for complex)
- Counseling on lifelong 10-yr Td/Tdap booster schedule
- Pregnancy Tdap 27-36 wk each pregnancy + neonatal tetanus prevention counseling (clean delivery + clean cord care per MNTE)
- Convalescence rehabilitation referrals (physical + occupational + cognitive + psychological)
- Family + caregiver education on return precautions + wound care + booster schedule
- Public health follow-up if active disease

AVOID / contraindication checks:
- Tig iga deficiency screen anaphylaxis monitor (FDA label)
- Tig serum sickness counsel (FDA label)
- Td tdap arm reaction counsel (CDC; FDA label)
- Td tdap gbs rare counsel (CDC; FDA label)
- Td tdap contraindicated anaphylaxis prior dose (CDC; FDA label)
- Tdap pregnancy 27 36 weeks each pregnancy (CDC ACIP; Liang ACIP MMWR 2018)
- Diazepam respiratory depression monitor continuous infusion (FDA label)
- Diazepam tolerance during prolonged icu stay (Rodrigo Crit Care 2014)
- Diazepam active metabolite accumulates in renal impairment (FDA label)
- Magnesium sulfate hyporeflexia respiratory depression monitor serum mg (FDA label)
- Magnesium sulfate target serum 2.5 4 mmol L thwaites lancet 2006 (Thwaites Lancet 2006)
- Magnesium sulfate renal cleared dose adjust in aki (FDA label)
- Metronidazole peripheral neuropathy prolonged courses counsel (FDA label)
- Metronidazole disulfiram like reaction with alcohol counsel (FDA label)
- Metronidazole preferred over pen g additive gabaergic with benzodiazepines debated (Rodrigo Crit Care 2014; Cook BJA 2001)
- Pen g alternative only when metronidazole contraindicated (WHO 2018)
- Baclofen intrathecal requires institutional protocol neurology anesthesia coordination (Rodrigo CCM 2014)
- Baclofen intrathecal withdrawal life threatening taper carefully (FDA label)
- Neuromuscular blockade vecuronium cisatracurium last resort critical illness myopathy prolonged icu (Rodrigo Crit Care 2014)
- Neuromuscular blockade requires mechanical ventilation tof monitoring sedation analgesia continuation (Rodrigo Crit Care 2014)
- Labetalol mixed alpha beta blocker preferred over pure beta blocker unopposed alpha effect (Rodrigo CCM 2014)
- Atropine for symptomatic bradyarrhythmia pacing if refractory (Rodrigo CCM 2014)
- Tracheostomy at 1 to 2 wk anticipating prolonged spasm (Rodrigo Crit Care 2014)
- Active td tdap during convalescence natural infection no immunity (Cook BJA 2001; WHO 2018)
- Tetanus notifiable disease state local public health report (CDC)
- Wound debridement surgical consult source control (Cook BJA 2001; WHO 2018)
- Cdc mmwr wound stratified pep table clean minor vs all other x vaccination history (Liang ACIP MMWR 2018; CDC MMWR)
- Tig 250 iu im pep vs 3000 to 6000 iu im established tetanus dosing (Cook BJA 2001; WHO 2018; CDC MMWR)

Monitoring

Regimen monitoring:
- State/local public health notification — tetanus is a notifiable disease per CDC; outbreak surveillance + case characterization
- Continuous cardiopulmonary monitoring in ICU; spasm frequency + severity + airway patency
- Daily creatinine + UOP + magnesium / calcium / glucose; magnesium target 2.5-4 mmol/L per Thwaites Lancet 2006
- Tracheostomy care + secretion management; weaning ventilatory support per Ablett class
- Intrathecal baclofen catheter monitoring if used; abrupt withdrawal life-threatening
- Neuromuscular blockade TOF (train-of-four) monitoring if used; sedation + analgesia continuation
- Autonomic instability surveillance (BP, HR, temperature, sweating); week 2 onset typical
- Wound healing + serial recheck; complete Td/Tdap primary series + lifelong 10-yr boosters in tetanus survivors (natural infection no immunity)
- PEP completion tracking: Td/Tdap series completion if started at PEP; lifelong 10-yr booster reminder
- Pregnancy Tdap 27-36 wk each pregnancy + clean delivery counseling for neonatal tetanus prevention
- Rehabilitation referral after ICU/inpatient discharge: physical + occupational + cognitive + psychological (post-ICU PTSD common)
- Family + caregiver education on lifelong booster schedule + wound care + return precautions

Setting (outpatient) monitoring:
- Wound recheck 48-72 h after PEP
- Vaccination completion tracking (3-dose primary series + 10-yr boosters)
- Convalescence functional + cognitive + psychological recovery
- Return precautions for new spasms / progression in localized form

Follow-up plan: 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
- Close-out criterion: Follow-up + vaccination plan + rehabilitation referrals + public health closure complete

Monitoring phase: 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

Disposition

Current setting: outpatient — Manage Ablett I localized tetanus with PO supportive care + active Td/Tdap during convalescence; PEP for wound + appropriate vaccination history per CDC MMWR table; routine Td/Tdap booster schedule (10-yr); pregnancy Tdap 27-36 wk each pregnancy; convalescence follow-up after ICU/inpatient discharge; rehabilitation; family education (Cook BJA 2001; Liang ACIP MMWR 2018 PMID 29702631; Liang ACIP MMWR 2018 PMID 29702631)

Disposition criteria:
- Sustained recovery — spasms resolved + tracheostomy decannulated (if applicable) + vaccination plan in progress + family education delivered + rehabilitation engaged + outpatient follow-up scheduled

Escalation triggers (move to higher acuity):
- Progression of localized to generalized tetanus → urgent ED + ICU
- New autonomic dysfunction → urgent ED
- Wound infection / source control failure → surgical evaluation
- Cephalic tetanus suspected → urgent ED for admission

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Generalized tetanus (trismus + risus sardonicus + opisthotonos + tetanic spasms triggered by minimal stimuli) — life-threatening; admit ICU + airway protection (intubation low threshold + tracheostomy at 1-2 wk anticipating prolonged spasm) + diazepam continuous infusion (50-200 mg/d titrated) + magnesium sulfate continuous infusion (target serum 2.5-4 mmol/L per Thwaites Lancet 2006 PMID 17055945) + TIG 3000-6000 IU IM + metronidazole 500 mg IV q8h × 7-10 d + wound debridement + active Td/Tdap during convalescence (natural infection no immunity) (Cook BJA 2001 PMID 11517134; Rodrigo Crit Care 2014 PMID 25029486; WHO 2018)
- [LIFE_THREATENING] Spasm-induced respiratory failure / inability to handle secretions / Ablett III-IV severity — life-threatening; intubation low threshold + mechanical ventilation + tracheostomy at 1-2 wk anticipating prolonged spasm (Rodrigo Crit Care 2014 PMID 25029486) + continuous diazepam + magnesium + autonomic management
- [LIFE_THREATENING] Newborn 3-14 d post-birth with poor suck → generalized spasms; unvaccinated mother + unsterile umbilical cord care (cow dung, ghee, unsterile blade) — neonatal tetanus; life-threatening; mortality 50-90% globally; NICU + airway + diazepam + magnesium + TIG 500 IU IM + metronidazole + supportive parenteral nutrition; WHO Maternal + Neonatal Tetanus Elimination (MNTE) Initiative — global priority; maternal 2-dose Td during pregnancy + clean delivery prevent (WHO MNTE 2018; Cook BJA 2001)

Citations

- CDC/ACIP Prevention of Pertussis, Tetanus & Diphtheria with Vaccines — Liang et al, MMWR Recomm Rep 2018 PMID 29702631 (Td/Tdap schedule + wound-stratified PEP + Tdap-in-pregnancy 27-36 wk) + WHO Tetanus position/guidelines 2018 (wound classification + MNTE Elimination Initiative for neonatal tetanus). Clinical management: Cook TM, Br J Anaesth 2001 PMID 11517134 (tetanus review) + Thwaites CL, Lancet 2006 PMID 17055945 (magnesium sulphate RCT) + Rodrigo C, Crit Care 2014 PMID 25029486 (evidence-based pharmacological management). [PMID:11517134](https://pubmed.ncbi.nlm.nih.gov/11517134/)
- Cited evidence (PMID 17055945) [PMID:17055945](https://pubmed.ncbi.nlm.nih.gov/17055945/)
- Cited evidence (PMID 25029486) [PMID:25029486](https://pubmed.ncbi.nlm.nih.gov/25029486/)
- Cited evidence (PMID 29702631) [PMID:29702631](https://pubmed.ncbi.nlm.nih.gov/29702631/)

Last reconciled with current guidelines: 2026-05-22.
References
  • CDC/ACIP Prevention of Pertussis, Tetanus & Diphtheria with Vaccines — Liang et al, MMWR Recomm Rep 2018 PMID 29702631 (Td/Tdap schedule + wound-stratified PEP + Tdap-in-pregnancy 27-36 wk) + WHO Tetanus position/guidelines 2018 (wound classification + MNTE Elimination Initiative for neonatal tetanus). Clinical management: Cook TM, Br J Anaesth 2001 PMID 11517134 (tetanus review) + Thwaites CL, Lancet 2006 PMID 17055945 (magnesium sulphate RCT) + Rodrigo C, Crit Care 2014 PMID 25029486 (evidence-based pharmacological management). — PMID:11517134
  • Cited evidence (PMID 17055945) — PMID:17055945
  • Cited evidence (PMID 25029486) — PMID:25029486
  • Cited evidence (PMID 29702631) — PMID:29702631