Tetanus

By: Omar Ramirez

What is Tetanus?
Tetanus is an illness characterized by an acute
onset of hypertonia, painful muscular
contractions (usually of the muscles of the jaw
and neck), and generalized muscle spasms
without other apparent medical causes.
Despite widespread immunization of infants and
children in the United States since the 1940s,
tetanus still occurs in the United States.

Statistics
Tetanus has declined significantly since the mid1940s due to increased use of Tetanus
immunizations.
Overall, mortality is approximately 45%. The
mortality rate in the United States is 6% for those
who previously had received 1-2 doses of tetanus
toxoid and 15% for unvaccinated individuals.
Mortality rate is highest for those older than 60
years.
In the United States, African Americans from the
rural south have a greater risk of tetanus than
individuals of other races.

Statistics (cont.)
Men are better protected from Tetanus
because of the higher vaccinations
received during military service or other
professional activities.
Incidence of tetanus increases with
advancing age. 54% of the patients with
tetanus in the United States are older than
59 years old.

How it forms
The nonencapsulated spore-forming bacterium
Clostridium tetani causes Tetanus.
Spores that gain entry can survive for months to
years. Under anaerobic conditions, these spores
geminate and produce tetanospasmin.
Tetanospasmin that is released by the maturing
bacilli is distributed via the lymphatic and vascular
circulations to the end plates of all nerves.
Tetanospasmin then enters the nervous system
peripherally at the myoneural junction and is
transported centripetally into neurons of the
central nervous system (CNS).

How it forms (cont.)

These neurons become unable of neurotransmitter
release. The neurons, which release gammaaminobutyric acid (GABA) and glycine, the major
inhibitory neurotransmitters, are sensitive to
tetanospasmin, leading to failure of inhibition of
motor reflex responses to sensory stimulation. This
results in generalized contractions of the agonist
and antagonist musculature characteristic of a
tetanic spasm. The shortest peripheral nerves are
the first to deliver the toxin to the CNS, which leads
to the early symptoms of facial distortion and back
and neck stiffness.

Causes
In 77% of patients with tetanus in the United States,
tetanus occurred after an acute injury, including puncture
wounds (49%), lacerations (22%), abrasions (12%), and
animal bites (2.6%).
Stepping on a nail accounted for 39% of the puncture
wounds.
Tetanus can occur in burn victims, patients receiving
intramuscular injections, and with frostbite, dental
infections (such as periodontal abscesses), penetrating eye
injuries, and umbilical stump infections.
Tetanus has been reported after tooth extractions, root
canal therapy, and intraoral soft tissue trauma.

Causes (cont.)
Neonatal tetanus is caused by:
Unvaccinated mothers, home delivery, and
unhygienic cutting of the umbilical cord.
History of neonatal tetanus in a previous
child is a risk factor for subsequent
neonatal tetanus.

The Spatula Test

This simple test involves touching the
oropharynx with a spatula or tongue blade.
Usually, this test causes a gag reflex with
the patient, and the patient tries to expel
the spatula. (This means they have tested
negative.)
In tetanus, patients develop a reflex
spasm of the masseters and bite the
spatula (a positive test).

Medications Used for Treatment

Diazepam (Valium) -- Most commonly used drug
for treatment of tetanic spasms and tetanic
seizures. Depresses all levels of CNS, including
limbic and reticular formation, possibly by
increasing activity of GABA, a major inhibitory
neurotransmitter.
Tetanus immune globulins (Hyper-Tet) -- Used to
induce active immunity against tetanus in
selected patients.

Medications (cont.)
Metronidazole (Flagyl) -- Active against various
anaerobic bacteria and protozoa. Appears to be
absorbed into cells, and intermediatemetabolized compounds that are formed bind
DNA and inhibit protein synthesis, causing cell
death.
Penicillin G (Pfizerpen) -- Interferes with
synthesis of cell wall mucopeptide during active
multiplication, resulting in bactericidal activity
against susceptible microorganisms.

Complications
Long bone fractures
Glenohumeral and temporomandibular
joint dislocations
Adverse effects of autonomic instability,
such as cardiac dysrhythmias and
hypertension
Malnutrition
Coma, neuropathies, and psychological
aftereffects

Prognosis
Prognosis is dependent on incubation period, time from
spore inoculation to first symptom, and time from first
symptom to first tetanic spasm.
In general, shorter intervals indicate more severe tetanus
and a poorer prognosis.
Patients usually survive tetanus and return to their
predisease state of health.
Recovery is slow and usually occurs over 2-4 months.
Clinical tetanus does not produce a state of immunity;
therefore, patients who survive the disease require active
immunization with tetanus toxoid to prevent a
recurrence.

Works Cited
www.emedicine.com Tetanus article by
Daniel J. Dire, MD, FACEP, FAAEM
www.emedicinehealth.com Tetanus
article by Robert N Bilkovski, MD