You Have A New Patient!
An 11-year-old female was brought in by ambulance after being attacked by her neighbor’s American Pitbull dog approximately 1 hour prior to arrival. She had attempted to pet the dog and sustained multiple bite wounds to her face and hands. She is crying loudly and is accompanied by her mother and father, who report that she previously had “German Measles” but has no other known medical conditions, though her medical care has been inconsistent.
Her temperature is 37.0°C, pulse is 133/min, and blood pressure is 98/62 mmHg. On examination, she has a dirty, macerated, oozing wound on the left side of her face and multiple deep wounds on her hands and distal arms, all contaminated with soil.
What Do You Need To Know?
Importance
Tetanus is an acute but often fatal disease caused by an exotoxin produced by the bacterium Clostridium tetani. It remains an important public health concern worldwide, particularly in areas with low immunization rates against tetanus [1]. Tetanus infection is characterized by generalized rigidity and convulsive spasms of skeletal muscles [2]. Muscle stiffness typically begins in the head and neck region before becoming generalized.
The CDC reports that in the US, tetanus has been fatal in approximately 11% of reported cases in recent years, while global fatality rates are closer to 50% [2]. In 2019, according to the Global Burden of Disease database, there were nearly 74,000 new worldwide cases of tetanus, corresponding to an incidence rate of 0.95 [3,4]. That same year, there were just under 35,000 deaths attributed to tetanus [3,4]. Since 1990, the global death rate from tetanus has decreased by an astounding 87% [3,4]. This decline is credited to widespread vaccination, improved wound care, and the use of postexposure immunoglobulin.
Epidemiology
A tetanus infection is caused by Clostridium tetani. C. tetani is an anaerobic, spore-forming bacterium that gains access through broken human skin and causes toxin-mediated infection. The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, or barbed wire[1]. While present worldwide, it is more common in warm, damp climates with rich soil. The organism is sensitive to heat and cannot survive in the presence of oxygen. The spores, in contrast, are extremely resistant to heat and the usual antiseptics [2].
Anyone can get tetanus, but like many diseases, it has a predilection for specific groups. There is an increased risk of tetanus in newborns, pregnant persons with insufficient immunization, intravenous drug users, the elderly, and those lacking primary immunization. Typically, tetanus infections are categorized into the following four categories: generalized (full-body symptoms), localized (symptoms in one area, e.g., leg), cephalic (cranial nerve involvement), and neonatal (history of home birth, soil on umbilical stump, unsterilized instruments) [5].
Pathophysiology
Tetanus is a serious disease caused by the bacterium Clostridium tetani, which produces toxins that disrupt the nervous system, resulting in muscle spasms and rigidity. The pathophysiology of tetanus involves several key stages [6-9]. The process begins when C. tetani spores, which are commonly found in the environment, enter the body through wounds or injuries. These entry points may include minor or unnoticed injuries, burns, surgical sites, intravenous drug use, or unsanitary practices such as umbilical cord cutting in newborns. Once inside the body, the spores encounter anaerobic conditions, often in devitalized tissue, which allow them to germinate into bacteria [7].
The bacteria produce two main toxins: tetanospasmin and tetanolysin [7,8]. Tetanospasmin, a potent neurotoxin, is the primary agent responsible for the clinical features of tetanus. Tetanolysin, a hemolysin, has no clear role in the disease’s pathology. Tetanospasmin enters the lymphatic and circulatory systems, eventually binding irreversibly to receptors at the neuromuscular junctions of the peripheral nervous system. The toxin is then transported retrogradely along nerve axons to the central nervous system (CNS), where it exerts its effects on inhibitory interneurons in the spinal cord and brainstem.
Within the CNS, tetanospasmin blocks the release of inhibitory neurotransmitters such as gamma-aminobutyric acid (GABA) and glycine, disrupting the balance between excitatory and inhibitory signals [5,7,8]. This blockade leads to unregulated muscle activity, characterized by the hallmark symptoms of tetanus: severe muscle spasms and rigidity. The uninhibited release of excitatory neurotransmitters results in continuous muscle contractions, which can be painful and are often triggered by minimal external stimuli like noise, light, or touch. In severe cases, these spasms can cause fractures, tendon ruptures, or respiratory failure [6,8].
Tetanus also affects the autonomic nervous system, leading to symptoms such as fluctuating blood pressure, rapid heart rate, and excessive sweating [6,8]. This autonomic dysfunction results from the toxin’s disinhibitory effects on the sympathetic nervous system. Additionally, the uninhibited release of catecholamines by the adrenal glands contributes to hypersympathetic activity. The effects of the neurotoxin are seen until a new axon terminal is produced which takes 4-6 weeks [2]. The cumulative effects of these pathophysiological processes make tetanus a potentially life-threatening condition that requires prompt recognition and treatment.
Medical History
Tetanus infection should be suspected in any patient presenting for wound management. However, tetanus has an average incubation period of 14 days, though it can range between 3–21 days after exposure. As a result, symptoms of infection are unlikely to be present at the time of initial presentation for an injury. Symptoms of an acute infection may include jaw cramping or the inability to open the mouth, muscle spasms (often in the back, abdomen, and extremities), and sudden painful muscle spasms, which can be triggered by sudden noises. Additional symptoms include trouble swallowing, seizures, headache, fever and sweating, and changes in blood pressure or a rapid heart rate [1].
When assessing a patient for potential tetanus infection, gathering detailed information about their history is essential. Several aspects of the patient’s history can provide crucial insights into the likelihood and severity of tetanus.
Immunization History
Understanding the patient’s vaccination status is critical in evaluating tetanus risk. Key details include the number of vaccine doses received and the timing of the most recent dose. Tetanus commonly occurs in individuals who are unvaccinated, under-vaccinated, or whose immunity has diminished over time. A history of incomplete or absent immunization is a frequent factor in tetanus cases, emphasizing the importance of vaccination in preventing this disease [7,8].
Questions: What is your immunization history against tetanus? Did you receive your childhood vaccinations? When was the last time you received an immunization other than those for flu or COVID? Have you seen a doctor recently for a cut or injury and received an immunization?
- Important: Most cases occur in patients who are unimmunized or partially immunized.
Wound and Injury History
A thorough wound history is essential in identifying potential entry points for Clostridium tetani spores [6]. Recent injuries, even seemingly minor ones, should be noted, as traumatic wounds are the primary source of infection in most cases [8]. However, tetanus can sometimes develop without any obvious wounds or identifiable source of infection.
Question: How, what, and when did this injury occur?
- In 70% of patients, a history of injury is present.
- Most common points of entry include puncture wounds, abrasions, and lacerations.
- Rare points of entry include chronic wounds, dental procedures, foreign bodies, and corneal abrasions.
Question: Was the object/item clean or dirty?
- Ask about exposure to soil, ash, intestinal tracts/feces of animals and humans, or rusty tools such as nails, needles, and barbed wire.
Question: Has this happened before?
- Explore any history of previous tetanus exposure or symptoms.
Wound Characteristics
The type and nature of the wound can provide additional clues. Punctures, lacerations, burns, surgical wounds, or injuries involving intravenous drug use are particularly susceptible to tetanus [8]. Unsanitary practices, such as home deliveries with contaminated tools for umbilical cord cutting, can also introduce the bacterium [8]. Wounds that are heavily contaminated, caused by blunt trauma, or involve animal or human bites carry a higher risk of infection. High-risk wounds include those older than 6 hours, deeper than 1 cm, contaminated, infected, and ischemic.
Incubation Period
The time between the injury and the onset of symptoms (the incubation period) is a key diagnostic factor [7]. A shorter incubation period, typically less than 48 hours, is associated with more severe disease [8]. While the incubation period can range from 1 to 60 days, most cases develop within 7 to 14 days, with an average of 7–10 days [1].
Early Symptoms
Tetanus often begins with subtle symptoms that progress over time. Common early signs include trismus (lockjaw), facial and neck muscle rigidity, and difficulty swallowing (dysphagia) [6,7]. Patients may report a sore throat or localized rigidity around the site of the infection. These early symptoms are often indicative of localized tetanus, where muscle stiffness is confined to a specific area [6].
Symptom Progression
In cases of generalized tetanus, the symptoms typically spread from the face and neck to the rest of the body [7]. Generalized painful muscle spasms and reflex spasms triggered by stimuli such as noise or touch are hallmark signs [8].
Risk Factors
Specific risk factors may increase the likelihood of tetanus. These include intravenous drug use, diabetes, recent surgical procedures, or unsanitary childbirth practices [6]. Neonatal tetanus, often resulting from unclean umbilical cord cutting, underscores the importance of the mother’s immunization status and sterile delivery practices [8]. Note that patients with an impaired immune system or a history of poor healing are at increased risk.
Additional Symptoms
Other reported symptoms may include fever, sweating, high blood pressure, rapid heart rate episodes, drooling, involuntary urination or defecation, and severe back arching spasms (opisthotonus) [1,6]. These manifestations often reflect the systemic effects of the tetanus toxin and its impact on the nervous system.
Special Populations
Special populations require targeted questions to better assess risk:
- Intravenous drug users:
- Do you share needles?
- Where are your injection sites?
- Is there a history of injecting in the neck region?
- Newborns:
- What is the mother’s immunization history? Did she receive a Tdap booster during this pregnancy?
- Was the baby born at home or in a hospital?
- Was soil applied to the umbilical stump?
- What instruments were used, if any (applies to both home and hospital births)?
- Has the neonate received any immunizations?
Finally, it is important to note that not all patients will present with an obvious injury. Approximately 3–5% of patients may have cryptogenic tetanus, where no identifiable entry point can be determined [5,6].
Physical Examination
The physical examination findings in tetanus are pivotal for diagnosis, which is primarily clinical and based on the presence of characteristic signs and symptoms. These features guide timely diagnosis and intervention, as delays in treatment can result in life-threatening complications. Findings vary depending on the type and severity of the infection, but certain hallmark features are common across all forms of tetanus.
General Physical Findings
Tetanus is primarily characterized by muscle rigidity and spasms, which often begin in the jaw and neck before progressing to other parts of the body [2]. A classic early finding is trismus (lockjaw), where patients cannot open their mouths due to masseter muscle spasms [6]. Another distinctive feature is risus sardonicus, a rigid, scornful smile caused by sustained contraction of the facial muscles [6]. Neck stiffness and dysphagia (difficulty swallowing) are other early symptoms caused by pharyngeal and neck muscle spasms [2].
Patients may also exhibit reflex spasms, which are generalized muscle contractions triggered by minimal external stimuli such as noise, light, or touch [6]. Signs of autonomic dysfunction include labile blood pressure, cardiac arrhythmias, and excessive sweating. Fever may be present in some cases, although patients are often afebrile. Importantly, patients with tetanus typically maintain an intact sensorium, remaining conscious and alert unless other brain dysfunction is present [7].
Findings in Generalized Tetanus
In generalized tetanus, muscle spasms follow a descending pattern, starting with the face (trismus and risus sardonicus) and progressing to the neck, back, and extremities [2]. A characteristic posture known as opisthotonus may develop, where the back and legs hyperextend while the arms flex, resembling decorticate posturing [6]. These spasms are often intense and may come in waves. Abdominal rigidity is another common feature, with patients exhibiting tenderness and guarding, sometimes mimicking an acute abdomen [2,7].
Findings in Localized Tetanus
Localized tetanus is marked by persistent muscle contractions confined to the area of the injury [2,6]. Patients may experience localized pain and spasms near the wound [6]. While typically less severe than generalized tetanus, localized tetanus can progress to more widespread symptoms in some cases.
Findings in Cephalic Tetanus
Cephalic tetanus involves dysfunction of the cranial nerves, most commonly the facial nerve. Physical exam findings include cranial nerve palsies, such as deviation of the eyes, eyelid retraction, and facial paralysis. Other associated symptoms include neck stiffness, dysphagia, and a deviated gaze [7].
Findings in Neonatal Tetanus
Neonatal tetanus often presents with poor feeding and difficulty sucking or breastfeeding [6]. Affected infants develop generalized rigidity and spasms, including opisthotonus, along with severe spastic contractions triggered by touch [8]. Additional findings include irritability and excessive crying [1,8].
Specific Diagnostic Tests and Other Findings
The spatula test is a clinical test with high sensitivity and specificity for tetanus [7]. Normally, touching the posterior pharyngeal wall with a spatula induces a gag reflex. In tetanus, it causes a reflex spasm of the masseter muscles, leading to the patient biting down instead of gagging.
Other findings include respiratory distress caused by spasms of respiratory muscles, including the diaphragm and larynx [1,2,8]. Severe muscle contractions can lead to complications such as joint dislocations, long bone fractures, and difficulty breathing [7]. Population studies reveal that lower extremity injuries are the most common antecedent to tetanus, followed by upper extremity and head or trunk injuries.
Alternative Diagnoses
Diagnosis of generalized tetanus is based entirely on the patient’s history and physical examination. Though the majority of cases will involve a preceding injury, making the presentation quite unique, there are aspects of the presentation that may mimic other conditions, which are important to rule out.
The initial presentation could include cranial nerve palsies, particularly in cephalic tetanus. For this reason, it is important to rule out critical conditions, including strokes, neoplasms, infections, or aneurysms. To accurately rule out other diagnoses, it is essential to familiarize yourself with the risk factors and presentations of each condition. Risk factors for stroke include uncontrolled hypertension, diabetes, and hyperlipidemia. Symptomatology may also include headache and localized extremity weakness. Strokes such as venous sinus thrombosis may occur in individuals who are pregnant, have hypercoagulable blood disorders, or use hormones. Neoplasms may present with a more insidious onset and a constellation of symptoms depending on the tumor’s location [6,7], such as headaches, seizures, fatigue, vision changes, gait abnormalities, nausea, and vomiting, in addition to cranial nerve palsy.
Infections will typically have an obvious source near the affected nerve. Parotitis may affect the facial nerve, and otitis media may involve the trigeminal nerve [6,7]. Peritonsillar abscess can cause trismus and neck stiffness, and must be differentiated from tetanus. Meningitis can also lead to cranial nerve palsies but will likely present with preceding neck rigidity, altered mental status, and systemic symptoms concerning for sepsis. Lyme disease may also cause facial nerve palsy and classically follows a tick bite, often occurring after hiking in the Northeastern United States. Botulism is severe neurological condition caused by a toxin produced by Clostridium botulinum. It presents with flaccid paralysis, dysphagia, and cranial nerve palsies, but does not involve muscle spasms or hypertonia [8].
Muscle spasms and rigidity described in tetanus may also present similarly to other conditions, such as dystonic reactions or neuroleptic malignant syndrome [7,8]. However, these conditions are closely linked to the use of antipsychotic medications and could likely be ruled out after a thorough review of the patient’s medication list [7]. Administration of medications such as diphenhydramine or benztropine would reverse the symptoms in a dystonic reaction but not in tetanus. Strychnine poisoning, a chemical sometimes used in pesticides, is also associated with ingestion and presents with symptoms of hyperreflexia, clonus, and muscle rigidity [6,7]. Critical to this diagnosis is the patient’s history before presentation, as well as the rapid onset of symptoms, typically within 10–20 minutes. Serotonin Syndrome can cause muscle rigidity, and should be considered in the differential diagnosis of tetanus [7]. Low calcium levels can cause muscle spasms, but the autonomic features of tetanus, such as fluctuating blood pressure and heart rate, are usually absent [8].
In addition to contractions and cranial nerve palsies, tetanus may present with systemic symptoms related to autonomic overactivity. These include diaphoresis, tachycardia, cardiac arrhythmias, labile hypertension, and fever. These symptoms might overlap with those seen in sympathomimetic or cholinergic toxicities; however, these toxicities are usually closely tied to the patient’s medications or a reported history of ingestion.
Acing Diagnostic Testing
The diagnosis of tetanus is primarily clinical, relying heavily on the patient’s history and physical examination. There is no single diagnostic test that can definitively confirm or rule out tetanus. However, diagnostic tests may be useful to exclude other potential etiologies that mimic tetanus symptoms.
Bedside Tests
- Point-of-Care Glucose: Hypoglycemia can mimic certain neurological symptoms, such as cranial nerve palsies, and should be assessed promptly.
- Spatula Test: This bedside test involves touching the posterior oropharynx with a tongue blade [7].
- Normal Response: In normal circumstances, this action elicits a gag reflex, and the patient will try to expel the spatula.
- Positive Test (Tetanus): If tetanus is present, the patient will develop a reflex spasm of the masseter muscles and will bite down on the spatula instead of gagging. A positive response, where the patient bites down rather than gagging, is 94% sensitive and 100% specific for tetanus [6].
- Electrocardiogram (ECG): If the patient presents with tachycardia, an ECG can help evaluate for arrhythmias and identify other possible underlying causes.
Laboratory Tests
- Blood Counts and Blood Chemistry: These tests are typically unremarkable in tetanus, meaning they do not show specific changes that help in diagnosing the condition [6]. They can be useful in excluding other causes of a patient’s symptoms.
- Calcium: Hypocalcemia may cause muscle spasms and cramping, and it is important to rule this out.
- Creatine Kinase (CK): Prolonged muscle spasms and rigidity in tetanus can result in muscle damage, potentially leading to rhabdomyolysis, making CK levels crucial to monitor.
- Creatinine: Kidney function should be evaluated, particularly if rhabdomyolysis is suspected, as it can lead to acute kidney injury.
- Drug Screen: This may help rule out the ingestion of sympathomimetics, such as cocaine, which can cause symptoms similar to tetanus.
- Wound cultures: Wound cultures can occasionally isolate Clostridium tetani, but they are not a reliable diagnostic tool for tetanus. Cultures are positive in only about 30% of confirmed tetanus cases, and the organism can sometimes be isolated from wounds of individuals who do not exhibit any symptoms of tetanus. Additionally, the challenges in culturing C. tetani and the possibility of isolating non-toxigenic strains further limit the diagnostic utility of this method [2,7,8].
- The antitoxin assay measures serum levels of tetanus antitoxin. While not widely available, a serum antitoxin level of 0.01 IU/mL or higher is typically considered protective and reduces the likelihood of tetanus. However, this test is not consistently reliable and is not commonly utilized for diagnostic purposes.
Imaging
- CT of the Head: A head CT scan can help exclude intracranial pathologies, such as stroke or mass lesions, that may mimic tetanus symptoms, especially in cases involving cranial nerve palsies.
- CT of the Abdomen: In cases of localized tetanus affecting the abdomen, a CT scan might be necessary, as the presentation can resemble an acute abdomen.
Risk Stratification
The severity of a tetanus infection is multifactorial. Factors such as age, immunity, location of injury, depth of injury, and ultimately the quantity of tetanus toxin contribute to the development of generalized tetanus. A longer interval between symptom onset and the appearance of spasms has been linked to milder features. Ultimately, risk stratification after the onset is difficult to accurately assess, as all forms of tetanus may develop into generalized tetanus. Therefore, prevention via immunization and subsequent boosters for high-risk wounds is crucial.
Management
In severe cases of tetanus, critical patients should be managed systematically using the ABCDE approach [5]. This approach ensures comprehensive assessment and treatment of the patient’s condition.
Airway and Breathing
Early intubation and mechanical ventilation should be strongly considered to manage airway compromise caused by trismus, laryngospasm, and neck and chest wall rigidity, which can impair airway access and create ventilation challenges [5]. The use of succinylcholine and other depolarizing paralytic agents should be avoided due to the risk of hyperkalemia.
Circulation
For patients exhibiting systemic illness, standard sepsis treatment should be initiated, including the administration of intravenous fluids, blood cultures, and broad-spectrum antibiotics [5].
Antimicrobial therapy options include:
- Metronidazole 500 mg intravenously every 6 to 8 hours (first-line therapy).
- Penicillin G 2 to 4 million units intravenously every 4 to 6 hours (second-line therapy).
- Doxycycline 100 mg intravenously every 12 hours.
To neutralize unbound tetanus toxin, the following measures are recommended:
- Human Tetanus Immune Globulin (HTIG) 500 units intramuscularly [9]:
- Administer a portion of the dose at a different site from the tetanus toxoid vaccine.
- Inject part of the dose directly around the wound.
- This dosage is the same for adults and pediatric patients.
- If HTIG is unavailable, intravenous immune globulin should be used.
In cases of autonomic dysfunction, pharmacological interventions include:
- Labetalol (0.25 to 1 mg/minute) to block adrenergic responses through dual alpha- and beta-blockade. Note that beta-selective blockers should be avoided due to increased associated mortality [5].
- Magnesium sulfate:
- Loading dose: 40 mg/kg over 30 minutes.
- Continuous infusion: 2 g/hour for patients >45 kg or 1.5 g/hour for patients ≤45 kg.
- This is considered first-line or adjuvant therapy to reduce muscle spasms,
and toxicity monitoring should include checking for hyporeflexia.
- Morphine (0.5 to 1 mg/kg/hour) can be used as a continuous infusion for managing autonomic dysfunction and sedation.
Disability: Control of Muscle Spasms
Effective spasm control is essential to prevent complications such as rhabdomyolysis, fractures, and apnea [5]. Recommended treatments include:
- Benzodiazepines:
- Diazepam: 10–40 mg intravenously every 1 to 4 hours as needed.
- Midazolam: Continuous infusion at 5–15 mg/hour.
- If benzodiazepines fail, neuromuscular blockade may be necessary. This requires endotracheal intubation and the use of:
- Vecuronium: Initial bolus dose of 0.08 to 0.1 mg/kg, followed by continuous infusion at 0.8 to 1.7 µg/kg/minute.
- Rocuronium: Initial bolus dose of 0.6 to 1 mg/kg, followed by continuous infusion at 8 to 12 µg/kg/minute.
- Consider intravenous propofol or intrathecal baclofen for refractory spasms.
Exposure: Identifying and Managing the Source
A thorough skin examination is necessary to identify potential sites of inoculation, including acute skin breaks and chronic wounds. Proper wound care includes cleaning and debridement to remove the source of infection.
To minimize muscle spasms triggered by sensory stimuli, patients should be admitted to the ICU with precautions such as:
- Reducing exposure to loud noises, bright lights, and sudden movements.
- Avoiding other forms of sensory stimulation.
In cases where a tetanus infection is possible, but no clinical signs or symptoms are present, the patient should undergo thorough wound irrigation and debridement. In addition, the patient’s immunization record should be reviewed. If it is unclear whether the patient has ever received their initial series of tetanus shots (part of the WHO-recommended childhood immunization series), proceed with a primary series of 3 tetanus shots and boosters every 10 years. If the patient presents with high-risk wounds and their last booster was received more than 5 years prior, provide a booster.
Patients who are unimmunized, incompletely immunized, or for whom immunization history is unclear should also receive Human Tetanus Immunoglobulin (HTIG). HTIG neutralizes the tetanus toxin and provides passive immunization for 3–4 weeks while the tetanus immunization series begins to provide immunity [9]. People with severe immunodeficiency or HIV infection presenting with high-risk wounds should also receive tetanus immune globulin, regardless of vaccination history [2].
This medication is administered by intramuscular injection. A dose of 250 IU (250 IU/ml, 1 ml) is given for wounds sustained within 24 hours, or 500 IU (250 IU/ml, 2 ml) for wounds older than 24 hours [9]. HTIG is also given for the treatment of tetanus once symptoms arise, to bind any circulating tetanus toxoid not bound to neurons and prevent further binding [2]. The treatment dose is 500 IU as a single dose, to be injected into 2 different sites, for all ages, from neonates through adults [10].
Medications
Human Tetanus Immunoglobulin (HTIG)
Dosage and Administration
For wound prophylaxis, the recommended dosage of Human Tetanus Immunoglobulin (HTIG) is based on the time elapsed since the injury [9]:
- Within 24 hours: 250 IU (250 IU/mL, 1 mL).
- After 24 hours: 500 IU (250 IU/mL, 2 mL).
HTIG is administered as a single dose via intramuscular (IM) injection. It should not be given intravenously to avoid complications.
Use During Pregnancy and Breastfeeding
HTIG is considered safe in pregnancy and breastfeeding and is categorized as Category C for all trimesters [10]. A small number of case reports suggest that IgG and IgM antibodies may transfer into colostrum and breast milk [10].
Cautions and Considerations
- Allergic Reactions: Although rare, allergic reactions may occur. HTIG should not be administered to patients with a known allergy to the immunoglobulin.
- Injection Technique: Proper technique is critical to avoid complications:
- Ensure the injection does not enter a blood vessel, as this can lead to shock. To confirm, aspirate prior to administering the dose.
- General Precautions: Monitor the patient for any signs of an adverse reaction following administration.
Special Patient Groups
Pediatrics
Primary immunization is key in this group. Passive immunization from a fully vaccinated mother provides protection before infant vaccines are begun. Additionally, living environments free from high-risk exposures (e.g., rusty nails, fences) is important. Dtap is used for children ≤7 years old, while Tdap or Td is recommended for children >7 years old and adolescents [2].
Pregnant Patients
All pregnant women should receive a tetanus booster during every pregnancy, regardless of prior vaccination history, with Tdap vaccination recommended between 27–36 weeks of gestation [2,6]. This protects the newborn from pertussis, tetanus, and diphtheria by transferring maternal antibodies for passive immunity. If the childhood immunization series was completed but the last booster was over 10 years ago, a single booster dose is recommended. For unvaccinated or incompletely vaccinated individuals, at least two doses of a tetanus toxoid-containing vaccine (one of which must be Tdap) should be administered during pregnancy, with the series completed postpartum [2]. Preventive strategies to reduce neonatal tetanus risk include clean delivery practices and proper umbilical cord care, as unsanitary home deliveries or contaminated tools are common causes of neonatal infections [1,8]. For wound management, Tdap is indicated if more than five years have elapsed since the last dose, and TIG is recommended for tetanus-prone wounds in inadequately vaccinated women. Vaccination during pregnancy is safe, with no evidence of adverse outcomes, and plays a critical role in global efforts to eradicate maternal and neonatal tetanus.
Geriatrics
Tetanus in geriatric populations presents unique challenges due to waning immunity, comorbidities, and increased disease severity [6]. Older adults face a higher incidence of tetanus, with mortality rates significantly greater than in younger populations. For example, in the U.S., individuals aged 65 years or older have an incidence rate of 0.23 cases per 1 million, compared to 0.08 cases per 1 million in those under 65, and they account for the majority of tetanus deaths [6]. Waning immunity is a major factor, with only 28% of adults over 70 years immune. Clinical presentations often include trismus, rigidity, and spasms, but geriatric patients are at greater risk for complications such as respiratory failure, cardiac arrhythmias, and aspiration pneumonia, leading to poor prognosis [2]. Individuals in this group need to receive booster doses every 10 years and should have living environments free from high-risk exposures [2,6]. Intensive care management, supportive care, and public health education are crucial to improving outcomes [5,8].
When To Admit This Patient
Tetanus carries a significant burden of morbidity and mortality for patients who experience an infection. Accordingly, it is appropriate to maintain a low threshold to admit any patient in whom you suspect an acute tetanus infection.
In individuals presenting with signs or symptoms of tetanus infection, or in individuals deemed to be at high risk of developing tetanus who did not receive prophylactic vaccination or immunoglobulins after initial exposure, admission to the Intensive Care Unit (ICU) or a similarly capable unit with ventilator support is recommended. For hospitals without an ICU, it is recommended to pursue transfer to a facility with higher-level care whenever possible.
In individuals presenting immediately following exposure to tetanus toxins, risk stratification should be performed as outlined earlier, with vaccination status playing a significant role in determining intervention. Asymptomatic patients who are exposed to tetanus toxins but are adequately vaccinated or receive immunization with or without tetanus IVIG in the emergency department may be safely discharged. For discharged patients, extensive teaching about the signs and symptoms of tetanus infection should be provided, along with strict instructions to return immediately to the Emergency Department if any symptoms develop.
Revisiting Your Patient
A thorough physical exam reveals a 4 cm, linear wound on the left cheek that is oozing dark blood and contains soil. There is no disruption of the underlying buccal mucosa. Additionally, there are multiple deep, penetrating wounds to the bilateral hands and distal forearms that also contain dirt and soil but are currently hemostatic. No evidence of other injuries is observed. Visual acuity is intact in both eyes. A neurologic exam, including cranial nerves, is diffusely within normal limits. The patient is neurovascularly intact in all extremities, with no signs of cyanotic tissue. The wounds are copiously irrigated and cleansed while further information is gathered.
The patient’s parents report that she has received inconsistent medical care since birth because “she has been healthy.” They also state that they do not believe she has received standard childhood vaccinations. X-rays of the bilateral wrists and forearms do not demonstrate foreign bodies or bony injuries.
This patient is hemodynamically stable with hemostatic wounds. Based on the findings from the history and physical exam, you decide that this patient should receive tetanus immunization as well as tetanus immunoglobulin therapy. Red flags in this patient’s case include the history of inconsistent medical care, previous infection with “German Measles” (Rubella), which children are routinely vaccinated against in many countries, and the presence of deep, contaminated wounds.
Moreover, due to this child’s lack of vaccination history, it is recommended that she receive a full 3-dose primary tetanus vaccination series. Wound care should also be initiated, and sutures are likely indicated for this patient.
Authors
Grace Bunemann
Grace Bunemann, DO is an emergency medicine resident at Rush University Medical Center in Chicago, Illinois. She currently serves on the Emergency Medicine Residents’ Association Board of Directors as Director of Leadership Development. She also assists with the EMRA Global Emergency Medicine Student Leadership Program. She plans to pursue a global emergency medicine fellowship after finishing residency with a focus in equitable health systems and medical education.
Alex Gallaer
Alex Gallaer, MD is an Emergency Medicine resident in the Global Health track at the University of Utah. He is a facilitator for EMRA’s Global Emergency Medicine Leadership Program and has interests in equitable medical care, establishment of global health infrastructure, prehospital/disaster medicine, and medical education.
Jerry Oommen
Jerry Oommen, DO is a global emergency medicine fellow at The George Washington University and a fellow co-director of ACEP's Global Emergency Medicine Student Leadership Program. Primary areas of global health interest include medical education and capacity building.
Ashley Pickering
Before medical school I had a diverse career path, which included biomedical engineering, outdoor education, working as an EMT on a Colorado ski patrol, and critical care nursing. I lived out west for 15 years, mainly in CO, and went to medical school at University of Arizona in Tucson before moving to Baltimore for residency at University of Maryland. Currently I am a Global Emergency Medicine Fellow at University of Colorado. Throughout my training I have found ample opportunities to pursue my interest in building emergency care globally. I have researched the barriers to accessing emergency care in rural Uganda, helped to provide emergency care training in Sierra Leone and Liberia and am currently the Executive Director of Global Emergency Care a non-profit training non-physician clinicians in Uganda. My current focus is on quality of emergency care in LMICs. I am working on an WHO Emergency Care Toolkit implementation project which explores the impact of basic emergency care educational and process improvements on clinical indicators of quality, as well as the experiences patients and staff.
Listen to the chapter
References
- World Health Organization. Tetanus. https://www.who.int/news-room/fact-sheets/detail/tetanus. Published July 12, 2024. Accessed April 5, 2023.
- Centers for Disease Control and Prevention. Chapter 21: Tetanus. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. Updated April 25, 2024. Accessed January 7, 2025. https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-21-tetanus.html
- Behrens H, Ochmann S, Dadonaite B, Roser M. Tetanus. Our World in Data. Published March 2019. Updated January 2024. Accessed January 7, 2025. https://ourworldindata.org/tetanus
- Li J, Liu Z, Yu C, et al. Global epidemiology and burden of tetanus from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019. Int J Infect Dis. 2023;132:118-126. doi:10.1016/j.ijid.2023.04.402
- Jain Rupal, Felipe Naillid. EM:RAP. Tetanus. In: CorePendium. Accessed January 7, 2025. https://www.emrap.org/corependium/chapter/recGn75URBGNVcZTD/Tetanus
- Yabes JM Jr. Tetanus. Medscape. Updated December 15, 2024. Accessed January 7, 2025. https://emedicine.medscape.com/article/229594-overview
- Bae C, Bourget D. Tetanus. [Updated 2023 May 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459217/
- George EK, De Jesus O, Tobin EH, et al. Tetanus (Clostridium tetani Infection) [Updated 2024 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482484/
- Médecins Sans Frontières. Human Tetanus Immunoglobulin (HTIG). In: MSF Medical Guidelines. Accessed January 7, 2025. https://medicalguidelines.msf.org/en/viewport/EssDr/english/human-tetanus-immunoglobulin-htig-16688425.html
- Physician’s Desk Reference: Tetanus Immune Globulin Human. HyperTET S/D (tetanus immune globulin (human)) dose, indications, adverse effects, interactions… from PDR.net. https://www.pdr.net/drug-summary/HyperTET-S-D-tetanus-immune-globulin–human–2085.1437. Accessed April 5, 2023.
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
