Tetanus

• Tetanus:

  • Caused by the tetanospasmin exotoxin released from Clostridium tetani
  • Tetanus spores are present in soil and may be introduced into the body from a wound
  • Tetanospasmin prevents the release of GABA
  • May be seen in IV drug users
• Features:

  • prodrome fever, lethargy, headache
  • Trismus (lockjaw)
  • Risus sardonicus (facial spasms)
  • Opisthotonus - arched back, hyperextended neck
  • spasms
• Management:

  • Supportive therapy including ventilatory support and muscle relaxants
  • IM human tetanus immunoglobulin for high-risk wounds
  • Antibiotics - metronidazole
• Tetanus vaccine is currently given in the UK as part of the routine immunisation schedule:

  • 2 months (6-in-1)
  • 3 months (6-in-1)
  • 4 months (6-in-1)
  • 3-5 years (4-in-1 preschool booster)
  • 13-18 years (3-in-1 teenage booster)
• Wound classified into:

  • Clean wound
  • Tetanus prone wound
  • High-risk tetanus prone wound
• Clean wound:

  • Less than 6 hours old
  • Non-penetrating
  • Negligible tissue damage
• Tetanus prone wound:

  • Puncture type injuries acquired in a contaminated environment e.g. gardening injuries
  • Wounds containing foreign bodies
  • Open fractures
  • Wounds or burns with systemic sepsis
  • Certain animal bites and scratches
• High-risk tetanus prone wound:

  • Heavy contamination with material likely to contain tetanus spores e.g. soil, manure
  • Wounds or burns that show extensive devitalised tissue
  • Wounds or burns that require surgical intervention
• Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago:

  • no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity
• Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago

  • Clean wound: no action required
  • if tetanus prone wound: reinforcing dose of vaccine
  • high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue): reinforcing dose of vaccine + tetanus immunoglobulin
• If vaccination history is incomplete or unknown

  • reinforcing dose of vaccine, regardless of the wound severity
  • for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin