Magnesium Sulfate for

Tetanus

Philia Setiawan
Dep. Of Anesthesiology and Reanimation
Dr. Soetomo Hospital- Faculty of Medicine,
Univ. Of Airlangga Surabaya
 The Incidence of Tetanus in developing countries is still
high with a high mortality rate.

 The high morbidity and mortality are mainly caused by:

Respiratory complication, Autonomic disturbance and
Gastro-intestinal bleeding.

 MAGNESIUM SULFATE offers a promising alternative

over Benzodiazepine, for it has effects on either
spasm or autonomic over-activity without disturbing
consciousness and respiratory system in therapeutic
dose
Clostridium
tetani
 Gram + anaerobic bacillus
 Non-capsulated
 Forms spore which is resistant to heat,
desiccation and disinfectants
 Exotoxin :
Tetanolysin : local necrosis facilitating
bacterial growth
Tetanospasmin : responsible for muscle
spasm and sympathetic over activity
Tetanospasmin pathway
Lymphatic & vascular circulations

End plate of all nerves

Peripheral nerve systems →myo-neural junction

Neuron of CNS

Neurotransmitter release especially from inhibitory nerve

─ GABA
Failure of inhibition of motor reflex response
Clinical features
- The incubation period averages 7-10 days (1-60). The onset time
varies between 1-7 days after the first symptom

- Spasm of facial muscles, progression to the neck, trunk and

limbs. Trismus,risus sardonicus, dysphagia, nuchal rigidity, pain
and stiffness in the shoulders and back muscles, abdominal
rigidity, stiffness and extension of the limbs and opistotonus.

- Recovery occurs because of re-growth of axon terminals and by

toxin destruction

- Autonomic disturbance usually starts several days after the

spasms and persist for 1-2 weeks
Symptoms increase in severity in the first
week and reduce after 2 or 3 weeks.
Stiffness can stay longer.
3 major complications
cause death
 Ventilatory restriction leading to respiratory
complication and sepsis
 Autonomic disturbance
 Stress ulcer/gastric bleeding
Ventilation
complication
 Ventilation restricted leading to
hypoxia, atelectasis.
 Pneumonia
 Apnea
Sympathetic Over
Activity
 Autonomic disturbance with sustained labile
hypertension, tachyarrhythmia,
vasoconstriction and sweating is common in
severe cases.

 Profound bradycardia and hypotension may

occur and recurrent or pre-terminal event
 Ablett Classification of Severity

GRADE Clinical features

trismus spasm resp.embar. Dysphagia SOA

I (mild) mild rigid no no no

II (moderate) mode short RR>30 mild

III (severe) severe prolonged RR>40 severe pulse>120

Apnoeic spell

IV (very severe) Grade III + severe autonomic disturbances involving the

cardiovascular system
DAKAR scoring
system
Principles of specific
management
1. Prevent further toxin release
- Early surgical debridement of wounds
- Antibiotics : Metronidazole 500mg 8 hourly and Penicillin 1 MU 6-8 hourly.
Others are acceptable choices :
Clindamycin,Erythromycin,Tetracycline,Chloramphenicol.
Heavily contaminated wound may need additional antibiotics.

2. Neutralize toxin outside of CNS

Human Tetanus Immunoglobulin 150 units/kg IM or 5,000-10,000 units IV

3. Minimize the effects of toxin already exists in CNS

Control rigidity and spasm, respiratory support as necessary and control
autonomic dysfunction.
Therapeutic
Management
 Wound debridement
 Control muscle spasm
 Control Autonomic Disturbance
 Immunization
 Antibiotics
 Other supportive therapy
 Drug used to control
spasm and autonomic
disturbance
 Benzodiazepine
 Morphine
 Muscle relaxant: vecuronium, rocuronium, pancuronium
 Magnesium sulfate
 Dantrolen
 Baclofen
 Bupivacain, atropine,
Benzodiazepine

 Common used as anticonvulsant in tetanus.

 Has sedative effect
 Preservative used can cause acidosis in
large dose
 No/little effect on autonomic disturbance

Respiratory depression and

acidosis may occur
Magnesium Sulfate

- Pre synaptic neuromuscular blocker

- Blocks catecholamine release from nerve and
adrenal medulla
- Reduce receptor responsiveness to release
catecholamines

Anticonvulsant-vasodilator
Magnesium
sulfate
 It antagonizes calcium in myocardium and
at the neuromuscular junction
 Inhibits parathyroid hormone release
 Dose
 Adult : a loading dose of 5 gram over 20
minutes IV followed by 1g hourly increasing
to 2.5 gram hourly when necessary. Titrate to
symptoms

 Pediatrics : 100mg /kg/24 hours, can be

increased when necessary. Titrate to
symptoms
Sometimes MgSO4 is inadequate to be used alone,
combination with benzodiazepine is also mandatory
Monitoring of possible side
effects
- Patellar reflex
Diminished at the level of Magnesium >4 mmol/L
- Respiratory depression because of muscle
paralysis (>Mg 6 mmol/L)
- Bradyarrhythmia, hypotension
- Urine output
Low output causes drug accumulation
- Blood Calcium level, blood Magnesium level
should be checked regularly
- Overdose may cause sedation and anesthesia.
Case

 A 4 y.o, 10 kg boy was admitted in the

hospital with difficulty of opening his mouth
since 3 days ago and followed by seizure
without fever. He went on convulsion despite
repeated bolus and continuous drips of
diazepam during 4 days of hospital stay
Treatment
 Source Control
 Anti Tetanus Serum
 Antibiotics : Pennicillin procain 1x 1 million unit,
Metronidazole 3 x 150 mg
 Anticonvulsant
- Diazepam a bolus of 10 mg followed by 9 mg/hour (ward)
- Magnesium sulfate in ICU

No ventilatory support was needed

 Magnesium sulfate in
ICU
 I : Diazepam 5 mg/hr + MgSO4 50 mg/kg/24hrs.

 II : Diazepam 2.5 mg/hr + MgSO4 85 mg/kg/24 hrs.(12 hrs. later)

 III : MgSO4 100 mg/kg/24 hrs.

No signs of magnesium overdose or hypocalcaemia

were detected during magnesium administration
Day 4 Day 6
Magnesium can be a prospective
alternative for treatment of tetanus,
especially when there are mass
casualties since it reduces the need for
mechanical ventilation, however,
meticulous ICU monitoring is needed with
ready for use ventilator.