Tetanus in Emergency Medicine Workup

  • Author: Daniel J Dire, MD, FACEP, FAAP, FAAEM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Sep 20, 2011
 

Laboratory Studies

No specific laboratory tests exist for determining the diagnosis of tetanus. The diagnosis is clinically based on the presence of trismus, dysphagia, generalized muscular rigidity, and/or spasm.

Laboratory studies may demonstrate a moderate peripheral leukocytosis.

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Other Tests

An assay for antitoxin levels is not readily available. However, a level of 0.01 IU/mL or greater in serum is generally considered protective, making the diagnosis of tetanus less likely.

Cerebrospinal fluid (CSF) study findings are usually within normal limits.

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Procedures

The spatula test is one diagnostic bedside test.

  • This simple test involves touching the oropharynx with a spatula or tongue blade.
  • This test typically elicits a gag reflex, and the patient tries to expel the spatula (ie, a negative test result).
  • If tetanus is present, patients develop a reflex spasm of the masseters and bite the spatula (ie, a positive test result).
  • In 400 patients, this test had a sensitivity of 94% and a specificity of 100%.[2]
  • No adverse sequelae (eg, laryngeal spasm) from this procedure were reported.
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Contributor Information and Disclosures
Author

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Specialty Editor Board

Theodore J Gaeta, DO, MPH, FACEP  Clinical Associate Professor, Department of Emergency Medicine, Weill Cornell Medical College; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine

Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Joseph U Becker, MD.

References

  1. Pascual FB, McGinley EL, Zanardi LR, et al. Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. Jun 20 2003;52(3):1-8. [Medline].

  2. Apte NM, Karnad DR. Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg. Oct 1995;53(4):386-7. [Medline].

  3. World Health Organization. WHO Technical Note: Current recommendations for treatment of tetanus during humanitarian emergencies. January 2010. [Full Text].

  4. Thwaites CL, Yen LM, Loan HT, Thuy TT, Thwaites GE, Stepniewska K. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet. Oct 21 2006;368(9545):1436-43. [Medline].

  5. Ahmadsyah I, Salim A. Treatment of tetanus: an open study to compare the efficacy of procaine penicillin and metronidazole. Br Med J (Clin Res Ed). Sep 7 1985;291(6496):648-50. [Medline].

  6. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. Dec 15 2006;55(RR-17):1-37. [Medline].

  7. Hatamabadi HR, Abdalvand A, Safari S, Kariman H, Dolatabadi AA, Shahrami A, et al. Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status. Am J Emerg Med. Sep 2011;29(7):717-20. [Medline].

  8. Bardenheier B, Prevots DR, Khetsuriani N, et al. Tetanus surveillance--United States, 1995-1997. MMWR CDC Surveill Summ. Jul 3 1998;47(2):1-13. [Medline].

  9. Checketts MR, White RJ. Avoidance of intermittent positive pressure ventilation in tetanus with dantrolene therapy. Anaesthesia. Nov 1993;48(11):969-71. [Medline].

  10. Galazka A, Gasse F. The present status of tetanus and tetanus vaccination. Curr Top Microbiol Immunol. 1995;195:31-53. [Medline].

  11. Groleau G. Tetanus. Emerg Med Clin North Am. May 1992;10(2):351-60. [Medline].

  12. Izurieta HS, Sutter RW, Strebel PM, et al. Tetanus surveillance--United States, 1991-1994. MMWR CDC Surveill Summ. Feb 21 1997;46(2):15-25. [Medline].

  13. Kefer MP. Tetanus. Am J Emerg Med. Sep 1992;10(5):445-8. [Medline].

  14. Knight AL, Richardson JP. Management of tetanus in the elderly. J Am Board Fam Pract. Jan-Feb 1992;5(1):43-9. [Medline].

  15. Murphy SM, Hegarty DM, Feighery CS, et al. Tetanus immunity in elderly people. Age Ageing. Mar 1995;24(2):99-102. [Medline].

  16. Richardson JP, Knight AL. The management and prevention of tetanus. J Emerg Med. Nov-Dec 1993;11(6):737-42. [Medline].

  17. Saissy JM, Demaziere J, Vitris M, et al. Treatment of severe tetanus by intrathecal injections of baclofen without artificial ventilation. Intensive Care Med. 1992;18(4):241-4. [Medline].

  18. Sanders RK. The management of tetanus 1996. Trop Doct. Jul 1996;26(3):107-15. [Medline].

  19. Wassilak SGF, Roper MH, Murphy TV, Orenstein WA. Tetanus. In: Plotkin SA, Orenstein WA, eds. Vaccines. 4th ed. Philadelphia, Pa: Saunders; 2003:745-81.

 
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Tetanus Cases in US from 1947-2005. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
Image from "Number of Tetanus Cases Reported and Average Annual Incidence Rates, by State." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
Image from "Number of Tetanus Cases Reported, Average Annual Incidence Rates, and Survival Status of Patients, by Age Group." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
Image from "Number of Tetanus Cases Reported Among Persons With Diabetes or Injection-Drug Use (IDU), by Age Group." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
Age Distribution of Tetanus Case in the US from 1980-2003. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
Tetanus Wound Management. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
 
 
 
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