2. What is Tetanus?What is Tetanus?
Tetanus is an illness characterized by an acuteTetanus is an illness characterized by an acute
onset of hypertonia, painful muscularonset of hypertonia, painful muscular
contractions (usually of the muscles of the jawcontractions (usually of the muscles of the jaw
and neck), and generalized muscle spasmsand neck), and generalized muscle spasms
without other apparent medical causes.without other apparent medical causes.
Despite widespread immunization of infants andDespite widespread immunization of infants and
children in the United States since the 1940s,children in the United States since the 1940s,
tetanus still occurs in the United States.tetanus still occurs in the United States.
3. StatisticsStatistics
Tetanus has declined significantly since the mid-Tetanus has declined significantly since the mid-
1940’s due to increased use of Tetanus1940’s due to increased use of Tetanus
immunizations.immunizations.
Overall, mortality is approximately 45%. TheOverall, mortality is approximately 45%. The
mortality rate in the United States is 6% for thosemortality rate in the United States is 6% for those
who previously had received 1-2 doses of tetanuswho previously had received 1-2 doses of tetanus
toxoid and 15% for unvaccinated individuals.toxoid and 15% for unvaccinated individuals.
Mortality rate is highest for those older than 60Mortality rate is highest for those older than 60
years.years.
In the United States, African Americans from theIn the United States, African Americans from the
rural south have a greater risk of tetanus thanrural south have a greater risk of tetanus than
individuals of other races.individuals of other races.
4. Statistics (cont.)Statistics (cont.)
Men are better protected from TetanusMen are better protected from Tetanus
because of the higher vaccinationsbecause of the higher vaccinations
received during military service or otherreceived during military service or other
professional activities.professional activities.
Incidence of tetanus increases withIncidence of tetanus increases with
advancing age. 54% of the patients withadvancing age. 54% of the patients with
tetanus in the United States are older thantetanus in the United States are older than
59 years old.59 years old.
5. How it forms…How it forms…
The nonencapsulated spore-forming bacteriumThe nonencapsulated spore-forming bacterium
Clostridium tetani causes Tetanus.Clostridium tetani causes Tetanus.
Spores that gain entry can survive for months toSpores that gain entry can survive for months to
years. Under anaerobic conditions, these sporesyears. Under anaerobic conditions, these spores
geminate and produce tetanospasmin.geminate and produce tetanospasmin.
Tetanospasmin that is released by the maturingTetanospasmin that is released by the maturing
bacilli is distributed via the lymphatic and vascularbacilli is distributed via the lymphatic and vascular
circulations to the end plates of all nerves.circulations to the end plates of all nerves.
Tetanospasmin then enters the nervous systemTetanospasmin then enters the nervous system
peripherally at the myoneural junction and isperipherally at the myoneural junction and is
transported centripetally into neurons of thetransported centripetally into neurons of the
central nervous system (CNS).central nervous system (CNS).
6. How it forms… (cont.)How it forms… (cont.)
These neurons become unable of neurotransmitterThese neurons become unable of neurotransmitter
release. The neurons, which release gamma-release. The neurons, which release gamma-
aminobutyric acid (GABA) and glycine, the majoraminobutyric acid (GABA) and glycine, the major
inhibitory neurotransmitters, are sensitive toinhibitory neurotransmitters, are sensitive to
tetanospasmin, leading to failure of inhibition oftetanospasmin, leading to failure of inhibition of
motor reflex responses to sensory stimulation.motor reflex responses to sensory stimulation.
This results in generalized contractions of theThis results in generalized contractions of the
agonist and antagonist musculature characteristicagonist and antagonist musculature characteristic
of a tetanic spasm. The shortest peripheral nervesof a tetanic spasm. The shortest peripheral nerves
are the first to deliver the toxin to the CNS, whichare the first to deliver the toxin to the CNS, which
leads to the early symptoms of facial distortionleads to the early symptoms of facial distortion
and back and neck stiffness.and back and neck stiffness.
7. CausesCauses
In 77% of patients with tetanus in the United States,In 77% of patients with tetanus in the United States,
tetanus occurred after an acute injury, including puncturetetanus occurred after an acute injury, including puncture
wounds (49%), lacerations (22%), abrasions (12%), andwounds (49%), lacerations (22%), abrasions (12%), and
animal bites (2.6%).animal bites (2.6%).
Stepping on a nail accounted for 39% of the punctureStepping on a nail accounted for 39% of the puncture
wounds.wounds.
Tetanus can occur in burn victims, patients receivingTetanus can occur in burn victims, patients receiving
intramuscular injections, and with frostbite, dentalintramuscular injections, and with frostbite, dental
infections (such as periodontal abscesses), penetrating eyeinfections (such as periodontal abscesses), penetrating eye
injuries, and umbilical stump infections.injuries, and umbilical stump infections.
Tetanus has been reported after tooth extractions, rootTetanus has been reported after tooth extractions, root
canal therapy, and intraoral soft tissue trauma.canal therapy, and intraoral soft tissue trauma.
8. Causes (cont.)Causes (cont.)
Neonatal tetanus is caused by:Neonatal tetanus is caused by:
Unvaccinated mothers, home delivery,Unvaccinated mothers, home delivery,
and unhygienic cutting of the umbilicaland unhygienic cutting of the umbilical
cord.cord.
History of neonatal tetanus in a previousHistory of neonatal tetanus in a previous
child is a risk factor for subsequentchild is a risk factor for subsequent
neonatal tetanus.neonatal tetanus.
9. The Spatula TestThe Spatula Test
This simple test involves touching theThis simple test involves touching the
oropharynx with a spatula or tongue blade.oropharynx with a spatula or tongue blade.
Usually, this test causes a gag reflex withUsually, this test causes a gag reflex with
the patient, and the patient tries to expelthe patient, and the patient tries to expel
the spatula. (This means they have testedthe spatula. (This means they have tested
negative.)negative.)
In tetanus, patients develop a reflexIn tetanus, patients develop a reflex
spasm of the masseters and bite thespasm of the masseters and bite the
spatula (a positive test).spatula (a positive test).
10. Medications Used for TreatmentMedications Used for Treatment
Diazepam (Valium) -- Most commonly used drugDiazepam (Valium) -- Most commonly used drug
for treatment of tetanic spasms and tetanicfor treatment of tetanic spasms and tetanic
seizures. Depresses all levels of CNS, includingseizures. Depresses all levels of CNS, including
limbic and reticular formation, possibly bylimbic and reticular formation, possibly by
increasing activity of GABA, a major inhibitoryincreasing activity of GABA, a major inhibitory
neurotransmitter.neurotransmitter.
Tetanus immune globulins (Hyper-Tet) -- UsedTetanus immune globulins (Hyper-Tet) -- Used
to induce active immunity against tetanus into induce active immunity against tetanus in
selected patients.selected patients.
11. Medications (cont.)Medications (cont.)
Metronidazole (Flagyl) -- Active against variousMetronidazole (Flagyl) -- Active against various
anaerobic bacteria and protozoa. Appears to beanaerobic bacteria and protozoa. Appears to be
absorbed into cells, and intermediate-absorbed into cells, and intermediate-
metabolized compounds that are formed bindmetabolized compounds that are formed bind
DNA and inhibit protein synthesis, causing cellDNA and inhibit protein synthesis, causing cell
death.death.
Penicillin G (Pfizerpen) -- Interferes withPenicillin G (Pfizerpen) -- Interferes with
synthesis of cell wall mucopeptide during activesynthesis of cell wall mucopeptide during active
multiplication, resulting in bactericidal activitymultiplication, resulting in bactericidal activity
against susceptible microorganisms.against susceptible microorganisms.
12. ComplicationsComplications
Long bone fracturesLong bone fractures
Glenohumeral and temporomandibularGlenohumeral and temporomandibular
joint dislocationsjoint dislocations
Adverse effects of autonomic instability,Adverse effects of autonomic instability,
such as cardiac dysrhythmias andsuch as cardiac dysrhythmias and
hypertensionhypertension
MalnutritionMalnutrition
Coma, neuropathies, and psychologicalComa, neuropathies, and psychological
aftereffectsaftereffects
13. PrognosisPrognosis
Prognosis is dependent on incubation period, time fromPrognosis is dependent on incubation period, time from
spore inoculation to first symptom, and time from firstspore inoculation to first symptom, and time from first
symptom to first tetanic spasm.symptom to first tetanic spasm.
In general, shorter intervals indicate more severe tetanusIn general, shorter intervals indicate more severe tetanus
and a poorer prognosis.and a poorer prognosis.
Patients usually survive tetanus and return to theirPatients usually survive tetanus and return to their
predisease state of health.predisease state of health.
Recovery is slow and usually occurs over 2-4 months.Recovery is slow and usually occurs over 2-4 months.
Clinical tetanus does not produce a state of immunity;Clinical tetanus does not produce a state of immunity;
therefore, patients who survive the disease require activetherefore, patients who survive the disease require active
immunization with tetanus toxoid to prevent aimmunization with tetanus toxoid to prevent a
recurrence.recurrence.
14. Works CitedWorks Cited
www.emedicine.comwww.emedicine.com – Tetanus article by– Tetanus article by
Daniel J. Dire, MD, FACEP, FAAEMDaniel J. Dire, MD, FACEP, FAAEM
www.emedicinehealth.comwww.emedicinehealth.com – Tetanus– Tetanus
article by Robert N Bilkovski, MDarticle by Robert N Bilkovski, MD
