II. Pathophysiology

  1. Suppresses inhibitory neurotransmitters (Glycine, GABA)
  2. Course
    1. Incubation period: 3 to 21 days (10 days on average)
    2. Earlier onset after exposure is associated with more aggressive infection and worse prognosis

III. Epidemiology

  1. Incidence (2008 U.S.): 0.06 per million persons

IV. Risk Factors

  1. Contaminated wounds or Puncture Wounds (e.g. open Fractures, ocular injuries)
    1. However up to 30% of Tetanus cases occur in clean wounds (e.g. surgical wounds)
  2. Inadequate Tetanus vaccination (or large pathogen burden)
  3. Advanced age (waning immunity)
  4. HIV Infection
  5. Diabetes Mellitus
  6. Corticosteroids or other immunosuppressants

V. Signs

  1. Opisthotonus (arching of back)
    1. Diffuse muscle firing of both the stronger extensor and weaker flexor back muscles
  2. Lockjaw
    1. Painful, contractions of the masseter and neck muscles
  3. Abdominal rigidity (older children and adults)
  4. Hypertension

VI. Complications

  1. Laryngospasm or respiratory arrest
  2. Fractures
  3. Pulmonary Embolism
  4. Aspiration Pneumonia
  5. Death

VII. Differential Diagnosis

  1. Opisthotonus
    1. Strychnine Poisoning

VIII. Management

  1. Anti-Tetanus agents
    1. Human Tetanus immune globulin (TIG)
      1. Equine Tetanus immune globulin (TIG) may be used if human formulation is not available
      2. Equine Tetanus antitoxin may be used if immune globulin is not available (test hypersensitivity first)
    2. Metronidazole or Penicillin
    3. Tetanus Toxoid booster
  2. Other measures
    1. Ensure adequate airway (Advanced Airway)
    2. Control muscle spasm (Sedation and muscle relaxants)
    3. Wound care

IX. Prevention

  1. Tetanus Vaccine
  2. Tetanus Immunoglobulin
    1. Dirty wound with <3 doses of tetanus Vaccine in Primary Series
  3. Clean wounds well
    1. Irrigate extensively with adequate pressure
    2. Debride necrotic tissue

X. Resources

  1. CDC Tetanus information
    1. http://www.cdc.gov/tetanus/
  2. CDC Tetanus surveillance
    1. http://www.cdc.gov/tetanus/surveillance.html

XI. References

  1. Nordt, Swadron, Orman and Ran in Herbert (2015) EM:Rap 15(7):15-16

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Ontology: Clostridium tetani (C0009064)

Definition (NCI) A species of anaerobic, Gram positive, rod shaped bacteria assigned to the phylum Firmicutes. This species is motile by peritrichous flagella, indole and lipase positive, lecithinase negative, hydrolyzes gelatin, ferments inositol and does not ferment glucose or maltose. C. tetani may colonize the intestinal tract of humans and is pathogenic, being the causative agent of Tetanus infection.
Definition (NCI_CDISC) Any bacterial organism that can be assigned to the species Clostridium tetani.
Definition (MSH) The cause of TETANUS in humans and domestic animals. It is a common inhabitant of human and horse intestines as well as soil. Two components make up its potent exotoxin activity, a neurotoxin and a hemolytic toxin.
Concepts Bacterium (T007)
MSH D003017
SnomedCT 30917009
LNC LP16678-2
Swedish Clostridium tetani
Czech Clostridium tetani
Finnish Clostridium tetani
English C. tetani, clostridium tetany, tetani bacillus, c. tetani, clostridium tetani, c tetani, bacillus tetani, Clostridium tetani (Flugge 1886) Bergey et al. 1923, Bacillus tetani, CLOSTRIDIUM TETANI, Clostridium tetani (organism), Clostridium tetani
Polish Clostridium tetani, Laseczki tężca
Norwegian Clostridium tetani
Spanish Clostridium tetani (organismo), Clostridium tetani
French Clostridium tetani
German Clostridium tetani
Italian Clostridium tetani
Dutch Clostridium tetani, Tetanusbacterie
Portuguese Clostridium tetani

Ontology: Tetanus (C0039614)

Definition (MEDLINEPLUS)

Tetanus is a serious illness caused by Clostridium bacteria. The bacteria live in soil, saliva, dust, and manure. The bacteria can enter the body through a deep cut, like those you might get from stepping on a nail, or through a burn.

The infection causes painful tightening of the muscles, usually all over the body. It can lead to "locking" of the jaw. This makes it impossible to open your mouth or swallow. Tetanus is a medical emergency. You need to get treatment in a hospital.

A vaccine can prevent tetanus. It is given as a part of routine childhood immunization. Adults should get a tetanus shot, or booster, every 10 years. If you get a bad cut or burn, see your doctor - you may need a booster. Immediate and proper wound care can prevent tetanus infection.

Definition (NCI) A serious infectious disorder that follows wound contamination by the Gram-positive bacterium Clostridium tetani. The bacteria produce a neurotoxin called tetanospasmin, which causes muscle spasm in the jaw and other anatomic sites.
Definition (MSH) A disease caused by tetanospasmin, a powerful protein toxin produced by CLOSTRIDIUM TETANI. Tetanus usually occurs after an acute injury, such as a puncture wound or laceration. Generalized tetanus, the most common form, is characterized by tetanic muscular contractions and hyperreflexia. Localized tetanus presents itself as a mild condition with manifestations restricted to muscles near the wound. It may progress to the generalized form.
Definition (CSP) disease caused by tetanospasmin, a powerful protein toxin produced by Clostridium tetani; tetanus usually occurs after an acute injury, such as a puncture wound or laceration; generalized tetanus, the most common form, is characterized by tetanic muscular contractions and hyperreflexia; localized tetanus presents itself as a mild condition with manifestations restricted to muscles near the wound.
Concepts Disease or Syndrome (T047)
MSH D013742
ICD9 037
ICD10 A35
SnomedCT 76902006, 154312006, 276202003
English Tetanus, clostridial tetanus, TETANUS, tetanus, tetanus (diagnosis), Tetanus NOS, Tetanus [Disease/Finding], Infection due to Clostridium tetani, Infection due to Clostridium tetani (disorder), Tetanus (disorder)
Japanese 破傷風, ハショウフウ
Swedish Stelkramp
Czech tetanus, Tetanus
Finnish Jäykkäkouristus
Spanish infección por Clostridium tetani, infección debido al Clostridium tetani (trastorno), infección debida a Clostridium tetani (trastorno), infección debido al Clostridium tetani, infección debida a Clostridium tetani, Tétano, tétanos (trastorno), tétanos, Tétanos
Croatian TETANUS
Polish Zakażenie Clostridium tetani, Tężec
Hungarian tetanus
Norwegian Stivkrampe, Tetanus
Dutch tetanus, Tetanus
French Tétanos
German Tetanus, Wundstarrkrampf
Italian Tetano
Portuguese Tétano

Ontology: Lockjaw (C0343495)

Concepts Finding (T033)
MSH D014313
SnomedCT 76902006, 240432006
French TRISMUS, Trismus
English LOCKJAW, Lock Jaw, jaw lock, jaw locked, jaw locking, jaw locks, lock jaw, lockjaw, Tetanus with trismus, Tetanus with trismus (disorder), Lockjaw
Portuguese TRISMO, Trismo
Dutch kaakklem, Kaakklem
German Kiefersperre, Tetanische Kiefersperre
Italian Trisma, Mandibola serrata, Mascella serrata
Japanese 牙関緊急, ゲカンキンキュウ, ガカンキンキュウ
Spanish Trismus, trismo, tétanos con trismo (trastorno), tétanos con trismo, tétanos con trismus (trastorno), tétanos con trismus
Czech Zablokovaná čelist
Hungarian Szájzár
Norwegian Låst kjeve, Kjevesperre

Ontology: Tetanic opisthotonus (C0343496)

Concepts Disease or Syndrome (T047)
SnomedCT 240433001
English Tetanic opisthotonus, Tetanic opisthotonus (disorder)
Spanish opistótono tetánico (trastorno), opistótono tetánico