Management of Severe Tetanus

Airway Management

The American Society of Anesthesiologists recommends using ketamine with atropine pretreatment as the induction agent if intubation is needed urgently, as it maintains cardiovascular stability unlike propofol or etomidate 1, 2
The Society of Critical Care Medicine suggests avoiding delaying intubation while attempting non-invasive ventilation in patients with severe acidosis and altered mental status, as this increases mortality 2

The British Thoracic Society recommends setting initial tidal volumes at 6-8 mL/kg, respiratory rate 10-15 breaths/minute, with target SpO2 of 88-92% 3, 2
The American Thoracic Society suggests using mild hyperventilation to partially compensate for metabolic acidosis, but avoid excessive hyperventilation that could compromise venous return 4
The Society of Critical Care Medicine recommends targeting permissive hypercapnia with pH 7.2-7.4 once acidosis begins improving 2

The American College of Medical Toxicology recommends administering sodium bicarbonate 1-2 ampules (44.6-100 mEq) as rapid IV bolus initially, then 50 mL (44.6-50 mEq) every 5-10 minutes guided by arterial blood gases, as severe acidosis causes catecholamine receptor resistance and independently predicts mortality in tetanus 4
The Society of Critical Care Medicine suggests flushing the IV catheter with normal saline before administering other medications after bicarbonate to avoid incompatibilities 4
The American Association for Clinical Chemistry recommends obtaining serial arterial blood gases every 1-2 hours to guide therapy 2

The American College of Surgeons recommends administering 20-40 mL/kg of lactated Ringer's solution as initial crystalloid bolus over 15-30 minutes 4
The Society of Critical Care Medicine suggests avoiding normal saline, as it will worsen metabolic acidosis through hyperchloremic mechanisms 4
The American Heart Association recommends targeting urine output >1 mL/kg/hour as a marker of adequate resuscitation 4, 2

The American College of Cardiology recommends starting norepinephrine as first-line vasopressor targeting MAP ≥65 mmHg if hypotension persists after 40-60 mL/kg fluid resuscitation 4
The Society of Critical Care Medicine suggests considering vasopressin as adjunct in severe refractory acidosis, as it works through non-adrenergic mechanisms not attenuated by acidosis 4

The National Institute of Child Health and Human Development recommends checking and correcting potassium, magnesium, calcium, and phosphorus immediately, as acidosis correction will shift potassium intracellularly 4
The American Heart Association suggests replacing magnesium if <0.75 mmol/L, as hypomagnesemia impairs other electrolyte corrections 4
The Society of Critical Care Medicine recommends monitoring lactate levels serially, as lactic acidosis from tissue hypoperfusion indicates severity and correlates with mortality 5

The American Society of Anesthesiologists recommends avoiding the use of chlorhexidine for disinfection, as it is ineffective against tetanus organisms 6