Tetanus

Tetanus: Excerpt from The 5-Minute Pediatric Consult

Joanne N. Wood, MDJim Callahan, MD (4th Edition)

Tetanus - BASICS

Tetanus - description

• Tetanus is a disease characterized by muscle rigidity and spasms due to a neurotoxin produced by Clostridium tetani in infected wounds.
• There are 4 clinical forms of tetanus: Generalized, localized, cephalic and neonatal.

Tetanus - general prevention

• All wounds should be cleaned with soap and water and foreign bodies should be removed.
• Universal immunization with tetanus toxoid is vital.
  • Primary series: DTaP given at 2, 4, 6, 15–18 months and 4–6 years.
  • Booster dose: Tdap at 11–12 years.
  • Unimmunized pregnant women should complete primary series prior to delivery if possible or at least receive 2 doses of Td 4 weeks apart.
• Tetanus prophylaxis should be initiated at the time of injury in the following manner for clean, minor wounds:
  • If the patient has had ≥3 prior doses of tetanus toxoid and it has been <10 years since the last dose, no tetanus prophylaxis is indicated. If it has been ≥10 years since the last dose, tetanus toxoid is indicated.
  • If the patient has had <3 prior doses of tetanus toxoids, tetanus toxoid is indicated.
• Tetanus prophylaxis should be initiated at the time of injury in the following manner for all other wounds:
  • If the patient has had ≥3 prior doses of tetanus toxoid and it has been <5 years since the last dose, no tetanus prophylaxis is indicated. If it has been ≥5 years since the last dose, tetanus toxoid is indicated.
  • If the patient has had <3 doses of tetanus toxoid, tetanus toxoid and Tetanus Immune Globulin (TIG) should be given at separate sites.
• Type and dose of IM tetanus toxoid for wound prophylaxis:
  • For a child <7 years old use DTaP. If pertussis vaccine is contraindicated use DT.
  • For a child 7–10 years old use Td.
  • For an adolescent 11–18 years old who has not received Tdap, give Tdap. For those who have received Tdap or for whom pertussis is contraindicated, administer Td.
• TIG dose is 250–500 U IM.
• If TIG is unavailable, IV immunoglobulin (IVIG) can be administered.

Tetanus - epidemiology

• Tetanus remains a major problem in developing countries but is rare in the developed world because of widespread immunization.
• Rare cases have been reported in patients with protective levels of antitetanus antibodies.

Tetanus - incidence

• In the US the incidence of tetanus is <0.2 per 1,000,000 people per year.
• Most of the 800,000–1,000,000 yearly deaths from tetanus occur in sub-Saharan Africa.
• Generalized tetanus is the most common form.
• Neonatal tetanus is rare in the US but ~150,000 cases occur each year worldwide.

Tetanus - risk factors

• Inadequate immunization
• Neonate born to unimmunized mother
• Elderly with declining immune status
• Injection drug use
• Chronic wounds
• Acute traumatic injury
• Nonsterile delivery conditions and practice of applying mud or feces to umbilical cord

Tetanus - pathophysiology

• C. tetani produces tetanospasmin, a powerful neurotoxin, which binds irreversibly to neurons.
• Tetanospasmin can be absorbed directly into skeletal muscles adjacent to the injury.
• Tetanospasmin can travel to the CNS through peripheral nerves or via lymphocytes.
• Tetanospasmin affects the peripheral nervous system, CNS, and autonomic nervous system:
  • At the neuromuscular junction:
    • Blocks the release of acetylcholine, preventing the inhibition of sustained excitatory nervous impulses
  • In the CNS neuronal membranes:
  • Binds to gangliosides and blocks inhibitory signals (γ-aminobutyric acid and glycine) to motor neurons.
  • In the autonomic nervous system:
    • Mechanism by which tetanospasmin causes autonomic instability and respiratory failure is not well understood.
• Tetanospasmin does not directly affect cognitive processes.

Tetanus - etiology

• Tetanus is caused by C. tetani, a spore forming, anaerobic, Gram-positive bacillus.
• C. tetani is found in soil, animal and human feces, house dust, salt and fresh water.
• Under anaerobic conditions inoculated spores become vegetative and produce tetanospasmin.
• Anaerobic conditions in wounds are promoted by large amounts of necrosis, foreign bodies and other ongoing infections with suppuration.

Tetanus - DIAGNOSIS

Tetanus - signs & symptoms

Tetanus - history

• Incubation period is usually 3–21 days but can vary.
  • Sites of inoculation farther from the CNS are associated with longer incubation periods.
• Generalized tetanus:
  • “Lockjaw” or trismus is initial symptom in 50–75% of cases.
  • Other early complaints include dysphagia, neck pain and stiffness, stiffness and pain in other muscle groups, urinary retention, restlessness, irritability, and headache.
  • More muscles groups involved as disease progresses
  • Noise, light, touch, and other stimuli can trigger painful spasms.
• Local tetanus:
  • Painful muscle contractions and stiffness limited to the area near the wound
  • Can persist for several weeks
  • Can progress to generalized tetanus
• Cephalic tetanus:
  • Caused by C. tetani infections of head and neck wounds
  • May complicate chronic infections of the head and neck including chronic otitis media.
  • Affects cranial nerves, especially cranial nerve VII
  • Can progress to generalized tetanus
• Neonatal tetanus:
  • Occurs following vaginal delivery to unimmunized mothers
  • Presents at around 1 week of life with irritability and poor feeding
  • Rapidly progresses to generalized tetanic spasms

Tetanus - physical exam

• Vital sign abnormalities:
  • Severe and labile episodes of hypertension and tachycardia
  • Hypotension may be a late feature.
  • Initially, patients are afebrile.
    • Fever may develop with sustained contractions or from superinfections.
• Trismus is often initial presenting sign.
• Persistent trismus causes risus sardonicus.
  • Wrinkling of the forehead and distortion of the eyebrows and the corners of the mouth
• As the disease progresses, other muscle groups develop tetanic contractions and spasms:
  • Can lead to a severe opisthotonic posture
  • Can mimic seizures
  • Can be extremely painful
  • Can be associated with potentially fatal laryngospasm and tetany of the respiratory musculature
  • The anxiety and pain associated with these spasms may precipitate additional spasms.
• Sweating can occur from autonomic instability.
• Normal mental status usually seen
• Cephalic tetanus:
  • Cranial nerve palsies and muscle spasms including trismus can be seen.
  • Look for underlying wound or chronic infection of the face, scalp, neck, or ear.

Tetanus - tests

• Laboratory tests often yield little information.
• Gram stain and anaerobic wound cultures yield C. tetani in <1/3 of cases.
• The WBC count is usually normal or mildly elevated.
• Presence of protective tetanus antibody titer does not exclude possibility of disease.
• CSF studies are unremarkable.
• EEG and electromyelogram findings are nonspecific.

Tetanus - differencial diagnosis

• Infections:
  • Retropharyngeal and peritonsillar abscesses, poliomyelitis, viral encephalitis, and meningoencephalitis may present with trismus or cranial nerve findings.
• Toxin:
  • Dystonic reactions to phenothiazine medications may resemble tetanus.
  • Diphenhydramine will effectively treat these reactions.
  • Strychnine poisoning may mimic generalized tetanus.
• Metabolic:
  • Hypocalcemic tetani is usually not as severe as the contractions seen with tetanus.
• Bell palsy may resemble cephalic tetanus.

Tetanus - TREATMENT

Tetanus - initial stabilization

• Prompt recognition of clinical signs of tetanus and initiation of emergency care are critical.
• All suspected cases of tetanus should be rapidly transferred to a tertiary care center capable of providing sophisticated ventilatory and cardiovascular support in an intensive care setting.
• In the emergency department, supportive care including aggressive airway management, ventilatory support, and pharmacologic interventions to promote sedation and muscle relaxation are the most important therapies.
• Treatment with TIG should be initiated.

Tetanus - general measures

• Keep patient in a quiet, darkened room with minimum stimulus.
• Monitor cardiac and respiratory status closely.
• Be prepared to perform a tracheotomy to prevent fatal laryngospasm.
• Monitor for and treat urinary retention and constipation.
• Skin care

Tetanus - diet

• Parenteral nutrition is usually required to maintain adequate nutrition and hydration.
• Monitor for and correct electrolyte abnormalities, especially hyperkalemia.

Tetanus - medication

Tetanus - first line

• Human TIG neutralizes toxin that has not already irreversibly bound to neurons:
  • 500–6,000 U IM. Part of the dose may be infiltrated around the wound.
  • Infants with neonatal tetanus should be given 250 U IM.
  • Repeated doses are not indicated.
  • Administer prior to antibiotics and wound manipulation
• Tetanus toxoid should be administered IM at a site contralateral to where TIG is given.
• Antibiotics are used to eradicate the C. tetani.
  • Metronidazole: 30 mg/kg/d PO or IV in 4–6 divided doses. Maximum: 4 g/d.
  • Penicillin G: 100,000–200,000 U/kg/d IV in 4–6 divided doses may be used instead.
  • Treat for 10–14 days
  • Cephalosporins are not effective.
• Sedation and muscle relaxation:
  • Diazepam 0.1–0.2 mg/kg IV q4–6h.
  • Phenothiazines, especially chlorpromazine, may be helpful.
  • Carefully titrate sedation to desired effect and monitor for respiratory depression.
• Nondepolarizing neuromuscular blockade and mechanical ventilation:
  • Use if spasms cannot be adequately controlled or if spasm of airway and respiratory musculature compromises ventilation:
  • Vecuronium 0.08–0.1 mg/kg IV followed by a continuous infusion or hourly dosing intervals.
  • Pancuronium or doxacorium can be used.
  • Avoid use of succinylcholine because of increased risk of hyperkalemia and arrhythmia.
• Beta-blocking agents may be needed to control HTN and arrhythmias:
  • Propranolol 0.01–0.1 mg/kg IV q6–8h.

Tetanus - second line

If TIG is not available:

• IVIG 200–400 mg/kg may be used but is not FDA approved for this use.
• Equine tetanus antitoxin (TAT) can be given if a skin test for sensitization is negative or desensitization has been performed:
  • TAT is not available in the US.

Tetanus - surgery

Aggressive surgical debridement and removal of foreign bodies from the infected wound is crucial.

Tetanus - FOLLOW UP

Tetanus - prognosis

• Signs and symptoms usually progress for ~1 week. The patient’s condition plateaus for ~1 week and then gradually improves over the next 2–6 weeks.
• Overall mortality rates have decreased with advances in the ability to provide respiratory support in an intensive care setting.
• Mortality rates vary from 1–18% for localized tetanus, 15–30% for cephalic tetanus, 45–55% for generalized tetanus to 50–100% for neonatal tetanus.
• Children and young adults have a better prognosis than older individuals.
• A more rapid onset and progression of disease from trismus to generalized spasms is associated with a more severe course.
• In the absence of complications, survivors usually recover fully without long-term sequelae.

Tetanus - complications

• Most complications are related to the severe tetanic muscle contractions:
  • Rhabdomyolysis and hyperkalemia
  • Vertebral body and other fractures
  • Muscle hemorrhages
• Respiratory failure from spasms of the upper airway or diaphragm is the most common cause of death in acute phase.
• Arrhythmias and myocardial infarctions are most common cause of death later in disease.
• Cerebrovascular hemorrhages may be seen in rare cases, especially in neonatal tetanus.
• Pneumonia, including aspiration, can occur.

Tetanus - bibliography

1. Abrahamian FM, Pollack CV Jr, LoVecchio F, et al. Fatal tetanus in a drug abuser with protective antitetanus antibodies. J Emerg Med. 2000;18:189–193.
American Academy of Pediatrics. Tetanus. In: Pickering LK, Baker CJ, Long SS, et al, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:648–653.Baron S, ed. Medical Microbiology. 4th ed. Galveston: University of Texas Medical Branch, 1996: Section 18
2. Brook I. Tetanus in children. Pediatr Emerg Care. 2004;20:48–51.
3. Howdieshell TR, Heffernan D, Dipiro JT. Surgical infection society guidelines for vaccination after traumatic injury. Surg Infect. 2006;3(3):275–303.
4. Rhee P, Nunley MK, Demetriades D, et al. Tetanus and trauma: A review and recommendations. J Trauma. 2005;58:1082–1088.

Tetanus - CODES

Tetanus - icd9

037.0 Tetanus

Tetanus - FAQ

• Q: What are characteristics of a tetanus-prone wound?
• A: Puncture and avulsion wounds

  Crush injuries and burns

  Wounds from frostbite or missiles

  Wounds contaminated with saliva, soil, or feces

  ALL wounds even minor wounds may be inoculated with spores and lead to the development of tetanus.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Tetanus

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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