Abstract Introduction Tetanus, a toxin-mediated infection caused by Clostridium tetani, is characterized by diffuse muscle spasms, trismus, and laryngospasm, often resulting in airway compromise and the need for intubation. The principal toxin, tetanospasmin, cleaves the SNARE membrane protein required for exocytosis of gamma-aminobutyric acid (GABA) and glycine in anterior horn inhibitory interneurons, leading to unopposed muscle excitation. Standard treatment includes vaccination, wound debridement, metronidazole, and intravenous immunoglobulin (IVIG). Despite appropriate therapy, neurotoxic effects can persist for weeks, and airway management remains challenging. Benzodiazepines are the recommended agents for spasm control, though their use in intensive care settings is often limited due to associations with increased mortality. Because tetanus is rare in the United States (0.01 cases per 100,000), large-scale studies guiding management are lacking. This case highlights the adjuvant use of propofol in facilitating intubation and reducing muscle spasms in generalized tetanus. Case Description An unvaccinated 52-year-old Amish woman with no past medical history presented with three days of trismus, dysphagia, and neck stiffness. She denied wounds, but oral examination revealed multiple periapical abscesses. She was clinically diagnosed with generalized tetanus, vaccinated, and treated with tetanus immunoglobulin, metronidazole, and ceftriaxone before ICU admission for airway management. Due to worsening trismus and secretion control, elective intubation was planned. Both otolaryngology and anesthesia teams prepared for possible nasotracheal or surgical airway. However, following induction with 130 mg propofol, the patient’s trismus transiently resolved, allowing uncomplicated oral intubation.In the ICU, trismus and spasms recurred under light sedation. Oral diazepam (75–150 mg/day) was administered alongside continuous propofol infusion, which reduced spasm frequency and benzodiazepine requirements. Propofol was discontinued after eight days due to rising triglycerides, after which spasms intensified, requiring diazepam up to 300 mg/day. On day 11, she underwent tracheostomy and PEG placement and was subsequently discharged to a long-term acute care hospital. Discussion Laryngospasm and trismus complicate airway management in generalized tetanus. In this case, propofol rapidly reversed trismus, enabling straightforward intubation and subsequently reducing daily benzodiazepine requirement. Mechanistically, propofol acts by enhancing GABA-A receptor activity, counteracting tetanospasmin’s inhibition of GABA and glycine release.Given tetanus’s rarity, evidence guiding therapy is limited. Diazepam efficacy is based on small pediatric trials comparing it with phenobarbitone and chlorpromazine. Propofol’s potential benefit has been described in several case reports, however no large-scale trials have investigated its efficacy. This case supports further investigation into propofol’s therapeutic role as an adjuvant in the management of tetanus. This abstract is funded by: None
Alihsan et al. (Fri,) studied this question.