Tetanus in Emergency Medicine Follow-up

Autonomic dysfunction can be controlled with magnesium sulphate as above; or morphine. Beta-blockers such as propranolol were used in the past but can cause hypotension and sudden death; only esmolol is currently recommended.

Institute prevention measures for deep venous thrombosis, gastrointestinal ulcer, and decubitus ulcer.

The maintenance of nutrition is extremely important and should be carried out in seriously ill patients via nasoduodenal tubes, gastrostomy tube feedings, or parenteral hyperalimentation.

Prevention of tetanus is accomplished through vaccination with DTP or DTaP at ages 2, 4, 6, 12-18 months, and 4-6 years.

For persons aged 7 years or older who have never been vaccinated against tetanus, diphtheria, or pertussis (no dose of DTP/DTaP/DT or Td), administer a series of 3 vaccinations containing tetanus and diphtheria toxoids.

• The preferred schedule is a single dose of Tdap, followed by a dose of Td > 4 weeks after Tdap and another dose of Td 6-12 months later. However, Tdap can be given one time as a substitute for Td in the 3-dose primary series.^[6]
• Alternatively, in situations in which the adult probably received vaccination against tetanus and diphtheria but cannot produce a record, vaccine providers may consider serologic testing for antibodies to tetanus and diphtheria toxin to avoid unnecessary vaccination. If tetanus and diphtheria antitoxin levels are each >0.1 IU/mL, previous vaccination with tetanus and diphtheria toxoid vaccine is presumed, and a single dose of Tdap is indicated.^[6]
• Adults who received other incomplete vaccination series against tetanus and diphtheria should be vaccinated with Td to complete a 3-dose primary series of tetanus and diphtheria toxoid-containing vaccines. One dose of Tdap should be used in place of Td if the patient has never received a dose of Tdap.
• Pregnancy is not a contraindication to the use of Tdap in the second and third trimester.

Secondary prevention of tetanus is accomplished postexposure through appropriate wound cleansing and debridement and the administration of tetanus toxoid (Td, Tdap, DT, DPT, or DTaP as indicated) and human tetanus immune globulin (TIG), when indicated. Pediatric formulations (DT and DTaP) contain a similar amount of tetanus toxoid as adult Td, but contain 3-4 times as much diphtheria toxoid.

• Consider the following wounds to be prone to tetanus: those present longer than 6 hours; deep (>1 cm); grossly contaminated; exposed to saliva or feces, stellate, and ischemic or infected (including abscesses); as well as avulsions, punctures, or crush injuries.
• Of 2 licensed Tdap products, only Adacel is licensed and recommended for use in adults. Boostrix is licensed for persons aged 10-18 years and should not be administered to persons older than 19 years. DTaP and Tdap vaccines do not contain thimerosal as a preservative. It is not necessary to wait the typical 10 years to get the adult dose of Tdap after the last dose of Td. An interval as short as 2 years from the last Td is suggested to reduce likelihood of increased reactogenicity. Even shorter intervals may be appropriate if the patient is at high risk for contracting pertussis, has close contact with infants, or in situations where another vaccination may not be possible. Providers should know that shorter intervals are not contraindicated and accumulating data reinforce safety of the vaccine. Furthermore, no concerns exist about immunogenicity with this decreased interval between Td and Tdap administration.
• Administer Td or DTP intramuscularly to patients with tetanus-prone wounds if they are younger than 7 years and if it has been more than 5 years since their last dose of tetanus.
• Administer TIG (250-500 U IM always in the opposite extremity of the toxoid) if patients previously have received fewer than 3 doses of tetanus toxoid and for patients aged 60 years or older.
• In adults without tetanus-prone wounds, administer Td or Tdap to patients who previously have received fewer than 3 doses of tetanus toxoid or if more than 10 years have passed since their last dose. Tdap is preferred to Td for adults vaccinated more than 5 years earlier who require a tetanus toxoid as part of wound management and who have not previously received Tdap. Tdap is indicated only once; therefore, for adults previously vaccinated with Tdap (after age 7 y), Td should be used if a tetanus toxoid-containing vaccine is indicated for wound care.
• Review the immunization status for all patients who present to an ED for any care (regardless of chief complaint). Administer immunizations if a lapse of more than 10 years has occurred since their last booster.
• If a patient does not remember or cannot give a history of immunization, Hatamabadi et al suggested that an immunochormatographic dipstick test (Tetanus Quick Stick) may be appropriate and cost-effective in determining tetanus immunity in the ED, although further study is needed to determine the applicability of this approach.^[7]

The Advisory Committee on Immunization Practices recommends vaccination at primary care visits for adolescents aged 11-12 years and for adults aged 50 years, review of vaccination histories, and updating of their tetanus vaccination status. This is in addition to recommending booster doses of tetanus-diphtheria toxoid every 10 years.

Worldwide, neonatal tetanus may be eliminated by increasing immunizations in women of childbearing age, especially pregnant women, and by improving maternity care.

• Tetanus toxoid twice during pregnancy (4-6 wk apart, preferably in the last 2 trimesters) and again at least 4 weeks before delivery is recommended for previously unimmunized gravid women.
• Maternal antitetanus antibodies are passed to the fetus, and this passive immunity is effective for many months.

Prior to 1954, asphyxia from tetanic spasms was the usual cause of death. However, with the advent of neuromuscular blockers, mechanical ventilation, and pharmacologic control of spasms, sudden cardiac death has become the leading cause of death. Sudden cardiac death has been attributed to excessive catecholamine productions, direct action of tetanospasmin, or tetanolysin on the myocardium.

Nosocomial infections are common when hospitalization is prolonged. Secondary infections may include sepsis from decubitus ulcers, hospital-acquired pneumonias, and indwelling catheters. Pulmonary embolism is particularly a problem in drug users and elderly patients.

Further complications include the following:

• Long bone fractures
• Glenohumeral joint and temporomandibular joint dislocations
• Hypoxic injury and aspiration pneumonia is a common late complication of tetanus, found in 50–70% of autopsied cases.
• Adverse effects of autonomic instability, including hypertension and cardiac dysrhythmias
• Paralytic ileus, pressure sores, and urinary retention
• Malnutrition and stress ulcers
• Coma, nerve palsies, neuropathies, psychological aftereffects, and flexion contractures

The 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.

Some patients remain hypotonic.

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.

For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education article Tetanus.