Educating patients on the importance of obtaining vaccinations can be a challenge if you don’t have a clear understanding of the diseases they help to prevent. This article will attempt to provide a short review of tetanus, its symptoms, diagnosis, and treatment with hopes to provide clinicians with clearer understanding of its pathophysiology. So, let’s dive right in…
History, Etiology and Pathogenesis: Tetanus is also widely known as “lockjaw.” The reason for this is, historically, one of the common features of tetanus included spasms of the masseter muscle, preventing the individual from opening his or her mouth.
Thanks to continued vaccination since the 1940s, development of tetanus is rare in the U.S., but poses a threat to individuals in developing countries and for those who are not vaccinated.
Clostridium tetani is the causative agent. It is a gram-positive anaerobe bacteria with a terminal spore. The toxins produced can effect neuromuscular function. It is primarily found in the soil and is not transmitted from person to person.
There are five different classifications of tetanus including: Generalized (most common), localized, cephalic, neonatal, and maternal. It enters the body primarily through injured skin that could have resulted from a deep penetration injury, cut, burn, frostbite, ulcer, etc. On average, it takes roughly 7-21 days before symptoms present.
Symptoms: The CDC provides a clear list symptoms possible with the development of tetanus. These include:
- Jaw cramping
- Sudden, involuntary muscle tightening – often in the stomach (muscle spasms)
- Painful muscle stiffness all over the body
- Trouble swallowing
- Jerking or staring (seizures)
- Fever and sweating
- High blood pressure and fast heart rate
Diagnosis: Diagnosis of tetanus is primarily based on symptoms. There is currently no test to specifically confirm tetanus, but there are some tests that can be done to help support a diagnosis of Tetanus. Checking a serum toxin level for the presence of tetanus, obtaining a would culture to evaluate for the presence of Clostridium tetani, or obtaining a blood sample to evaluate for tetanus toxin antibodies are all options to help support a diagnosis of suspected tetanus. Obtaining an EEG, LP or even an EMG may help in ruling out other disease processes.
Differential Diagnosis: Ok… there are several differentials that you could consider for tetanus, let’s look at some that might be more common.
- Generalized seizures (specifically in children): The patient will likely have a postictal state where muscles are flaccid and weak and have an altered level of consciousness. This is a time when obtaining an EEG would come into play. If seizures are causing the symptoms, then this will be apparent on EEG.
- Meningitis: In meningitis, patients are not likely to have risus sardonicus (sustained abnormal spasms of the facial muscle). Also, if you were to obtain a lumbar puncture, findings suggestive of meningitis would show an elevated cell count, whereas in tetanus cell count would be WNL.
- Hypocalcemia: Serum ionized calcium would be elevated and a prolonged QT interval may be noted on ECG.
Treatment: If you have a patient that has suspected tetanus, they need to be treated in the hospital setting. UpToDate provides a detailed list of the main focuses for patients requiring treatment. These include:
●Halting the toxin production
●Neutralization of the unbound toxin
●Control of muscle spasms
●Management of dysautonomia
●General supportive management
Prevention/Patient teaching: The most effective way to prevent tetanus is through obtaining the tetanus vaccine. DtaP/Tdap are given as part of the childhood immunization schedule. The other, Td, is given every 10 years or with a severe injury, to help boost immunity. If injury occurs, clean the wound thoroughly with soap and water and see a provider if it has been longer than five years since your last tetanus shot.
By Tracy Lindstrom RN, BSN, DNP-s
CDC. (2013). About tetanus. Obtained from http://www.cdc.gov/tetanus/about/index.html
Cottle, L., Beeching, N., Carrol, E., Parry, C., Thwaites, L., Kretsinger, K. (2015). Tetanus. Epocrates App
Farrar, J., Yen, L., Cook, T., Fairweather, N., Binh, N., Parry, J., Parry, C. (2000). Tetanus. Journal Neurology, Neurosurgery and Psychiatry. 69(3). 292.
Muazzam, M., Mansoor, S., Badar, S., Nadeem, A., Anwar, B., Waseer, M., Ali, S. (2013). Tetanus still cannot be prevented, a three year retrospective study in DHQ hospital, Faisalabad. Professional Med Journal. 20(6). 1026-1034.
Sexton, D. (2015). Tetanus. UpToDate. Obtained from http://www.uptodate.com.proxy.wichita.edu/contents/tetanus?source=search_result&search=tetanus+and+contagious&selectedTitle=1~150#H9
Thwaites, C., Beeching, N., Newton, C. (2015). Maternal and neonatal tetanus. Lancet. 385(9965). 362