Neuro

Tetanus

search

Tetanus, Lockjaw, Tetanic opisthotonus, Clostridium tetani

  • 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
  • Epidemiology
  1. Incidence (2008 U.S.): 0.06 per million persons
  • 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
  • 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
  • Complications
  1. Laryngospasm or respiratory arrest
  2. Fractures
  3. Pulmonary Embolism
  4. Aspiration Pneumonia
  5. Death
  • Differential Diagnosis
  1. Opisthotonus
    1. Strychnine Poisoning
  • 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
  • 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
  • Resources
  1. CDC Tetanus information
    1. http://www.cdc.gov/tetanus/
  2. CDC Tetanus surveillance
    1. http://www.cdc.gov/tetanus/surveillance.html
  • References
  1. Nordt, Swadron, Orman and Ran in Herbert (2015) EM:Rap 15(7):15-16