Contemporary management of severe generalized tetanus: an evidence-based review

Abstract Background Severe generalized tetanus remains associated with substantial mortality despite being vaccine preventable. Management is complicated by limited high-quality evidence, conflicting trial results, and the need to balance effective control of spasms and autonomic dysfunction against the risks of prolonged mechanical ventilation. Methods We describe the management of a 57-year-old man with Ablett grade III generalized tetanus and use this case as a clinical framework for an expert narrative review. The review synthesizes randomized controlled trials, systematic reviews, meta-analyses, prospective studies, and relevant observational literature addressing neuromodulatory therapy, airway management, autonomic dysfunction, intrathecal antitoxin, and supportive critical care. Results The patient was managed using a multimodal strategy comprising continuous midazolam infusion, magnesium sulphate, oral baclofen, dexmedetomidine, intramuscular and intrathecal human tetanus immunoglobulin, and meticulous low-stimulation supportive care. Therapy was titrated using serial bedside assessment of neuromuscular burden. He recovered without endotracheal intubation, neuromuscular blockade, or tracheostomy and was discharged on day 21. We argue that discordant findings in tetanus trials are substantially attributable to heterogeneity in disease severity, clinical practice, airway management thresholds, and resource availability, rather than to true therapeutic inconsistency. Available evidence supports a physiology-directed multimodal approach using agents with complementary mechanisms to suppress spasms and autonomic dysfunction while preserving spontaneous ventilation whenever safely feasible. Conclusions Management of severe tetanus should focus on achieving physiological targets rather than escalating individual drugs. A structured, individualized, multimodal neuromodulatory strategy delivered within an experienced, low-stimulation critical care environment may allow selected patients to be managed without mechanical ventilation; safety cannot be established from a single case and requires prospective evaluation. Greater emphasis should also be placed on preventive adult immunization, as vaccination remains the intervention most likely to reduce the burden of severe tetanus.