Tetanus

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

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

Rule Out

• • Associated animal bites

  • Associated injuries

• • History and physical exam

  • Careful exam of wound

  • Determine tetanus prophylaxis status

When to Admit

• • Complications of tetanus: Paralysis, respiratory compromise

• • 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

Surgery

Indications

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

Medications

• • IV high-dose penicillin

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

  • • TIG (passive immunization for contaminated wounds)

Treatment Monitoring

• • 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

Complications

• • Respiratory embarrassment

  • Paralysis

  • Death

Prognosis

• • Mortality approximately 18% in established tetanus

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