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  • • Anaerobic infection mediated by a neurotoxin that causes nervous irritability and tetanic muscular contraction

    • Causative organism, Clostridium tetani

    • Wounds contaminated with soil or feces (eg, deep puncture from stepping on a nail)

    • Tetanus-prone wound is usually a puncture wound or one containing devitalized tissue or a foreign body

    • Tetanus-prone wounds are characterized by:

    • -Elapsed time from injury (more than 6 hrs)

      -Deeper than 1 cm

      -Contaminated by soil, feces, rust

      -Stellate configuration

      -Caused by missile, crush, burn, or frostbite

      -Characterized by devitalized or denervated tissue

      -Cause by animal or human bite

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Epidemiology

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  • • Occurrence of tetanus in United States has dropped over the last 5 decades

    • Improvement is attributed to the increasingly widespread use of tetanus toxoid and improved wound management

    • Tetanus continues to be a severe disease primarily of older adults who are unvaccinated or inadequately vaccinated

    • Disproportionately high number of cases (35%) was reported in persons aged 60 or older

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Symptoms and Signs

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  • • Tetanus is a clinical diagnosis, as confirmatory laboratory tests are not routinely available

    • Symptoms of tetanus may occur as soon as 1 day following exposure or as long as several months later

    • First symptoms are usually pain or tingling in the area of injury

    • "Lockjaw" (limitation of movements of the jaw)

    • Spasms of the facial muscles (risus sardonicus)

    • Neck stiffness

    • Dysphagia

    • Laryngospasm

    • Chest and diaphragm spasms occur, longer and longer periods of apnea follow

    • Temperature is normal or slightly elevated

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Laboratory Findings

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  • • Wound isolation of the organism is neither sensitive nor specific

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Rule Out

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  • • Associated animal bites

    • Associated injuries

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  • • History and physical exam

    • Careful exam of wound

    • Determine tetanus prophylaxis status

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When to Admit

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  • • Complications of tetanus: Paralysis, respiratory compromise

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  • • Imperative that all patients with traumatic wounds be asked about previous tetanus prophylaxis

    • Neutralization of the toxin with tetanus immune globulin (TIG)

    • IV high-dose penicillin

    • Ventilator support if indicated

    • Surgical wound debridement

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Surgery

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Indications

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  • • If tetanus is suspected, perform excision and debridement of the wound

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Medications

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  • • IV high-dose penicillin

    • Tetanus-diphtheria (Td) booster (active immunization for clean wounds)

    • • TIG (passive immunization for contaminated wounds)

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Treatment Monitoring

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  • • An attack of tetanus does not confer lasting immunity, and patients who have recovered from the disease require active immunization according to the usual recommended schedules

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Complications

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  • • Respiratory embarrassment

    • Paralysis

    • Death

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Prognosis

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  • • Mortality approximately 18% in established tetanus

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Prevention

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  • • Each person should ...

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