Tetanus 1349.
e3
BASIC INFORMATION
DEFINITION
Tetanus is a life-threatening illness manifested
by muscle rigidity and spasms; it is caused
by a neurotoxin (tetanospasmin) produced by
Clostridium tetani.
SYNONYMS
Lockjaw
Generalized tetanus
Neonatal tetanus
Cephalic tetanus
Localized tetanus
ICD-10CM CODES
A33 Tetanus neonatorum
A34 Obstetrical tetanus
A35 Other tetanus
EPIDEMIOLOGY & DEMOGRAPHICS
INCIDENCE (IN U.S.): 264 cases between 2009
and 2017. Overall case fatality was 13.2%, but
31.3% for people over 65. More than 60% of
cases were among people aged 20 to 64 yr.
Diabetes, immunosuppression, and IVDA may
be risk factors for tetanus. Diabetes accounted
for 13% of cases and a quarter of all tetanus
deaths. IVDA accounted for 17% of the cases.
INCIDENCE (WORLDWIDE): About 1 million cases
of tetanus are reported worldwide annually, sug-
gesting a global incidence of about 18 per 100,000
persons per yr and an estimated 300,000 to
500,000 deaths per yr. Tetanus is an expected com-
plication when disasters strike in developing coun-
tries where tetanus immunization coverage is low.
PREDOMINANT AGE: >60 yr of age
GENETICS: Neonatal infection:
• Rare in the U.S.
• Among the leading causes of neonatal mor-
tality in many parts of the world (caused by
infection of the umbilical cord stump)
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
• Trismus (“lockjaw”)
• Risus sardonicus (peculiar grin), character-
istic grimace that results from contraction of
the facial muscles (Fig. E1)
FIG. E1  Facial muscle involvement in tetanus,
producing characteristic “risus sardonicus.”
(From Vincent JL et al: Textbook of critical care, ed
6, Philadelphia, 2011, Saunders.)
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• Generalized muscle spasms causing severe 2. U
 nopposed motor activity results in tonic
pain and, at times, respiratory compromise contractions of muscles.
and death
• Rigid abdominal muscles, flexed arms, and
extended legs (Fig. E2)
DIAGNOSIS
• Autonomic dysfunction several days after DIFFERENTIAL DIAGNOSIS
onset of illness
• Strychnine poisoning
• Leading cause of death: Fluctuations in heart
• Dystonic reaction caused by neuroleptic
rate and blood pressure
agents: Neuroleptic malignant syndrome
• Usually, absence of fever
• Local infection (dental or masseter muscle)
• Localized tetanus
causing trismus
1. Rigidity of muscles near the injury
• Severe hypocalcemia
2.  Weakness as a result of lower motor
• Hysteria
neuron injury
3. May be self-limited and resolve sponta- WORKUP
neously
• Positive wound culture is not helpful in
4.  More often progresses to generalized
diagnosis.
tetanus
• Isolation of organism is possible in patients
5. Cephalic tetanus:
without the illness.
a. May occur with head injuries or
chronic otitis with localized ear or LABORATORY TESTS
mastoid infection with C. tetani
• Usually, normal blood counts and chemistries
b. Can manifest as cranial nerve dys-
• Toxicology of serum and urine to rule out
function
strychnine poisoning
ETIOLOGY
• C. tetani is a gram-positive, spore-forming
bacillus (Fig. E3) that resides primarily in the
soil.
• Majority of cases are caused by punctures
and lacerations (Fig. E4).
• Toxin is elaborated from organisms in a con-
taminated wound.
• Local symptoms are caused by inhibition of
neurotransmitter at presynaptic sites.
1. Over the next 2 to 14 days, the toxin
travels up the neurons to the CNS, where
it acts on inhibitory neurons to prevent
neurotransmitter release.
FIG. E3  Clostridium tetani: A gram-positive
bacillus with terminal spores. (Courtesy J.
Campbell, Oxford University Clinical Research Unit,
Hospital for Tropical Diseases, Ho Chi Minh City,
Vietnam. From Vincent JL et al: Textbook of critical
care, ed 6, Philadelphia, 2011, Saunders.)
FIG. E4  Lacerations to the feet are the most
common focus of Clostridium tetani infection.
FIG. E2  Neonatal tetanus. (From Vincent JL et al: Note clawing of toes secondary to increased tone in
Textbook of critical care, ed 6, Philadelphia, 2011, surrounding muscles. (From Vincent JL et al: Textbook
Saunders.) of critical care, ed 6, Philadelphia, 2011, Saunders.)
Tetanus 1349.e4

dantrolene, barbiturates, and chlorproma-

TREATMENT
NONPHARMACOLOGIC THERAPY
• Monitoring in a hospital ICU: Keep surround-
ings dark and quiet
• Intubation or tracheostomy for severe
laryngospasm
• Prompt irrigation and debridement of wound
to eliminate spores and necrotic tissue that
can favor germination
ACUTE GENERAL Rx
• Passive immunization with human tetanus
immunoglobulin (HTIG) 500 U as soon as
possible via IM injection in thigh or deltoid
muscle. Some studies recommend 3000 to
6000 U for generalized tetanus.
• Tetanus toxoid (Td) 0.5 ml by IM injection at
a different site. Redose later for a total of 3
doses spaced at least 2 weeks apart to elicit
active immunization.
• Antibiotics alone may fail without adequate
debridement. Metronidazole 500 mg IV q6h
to 8 h, or penicillin G 2 to 4 million U IV q4h
to q6h for 7 to 10 days, or doxycycline 100
mg IV q12h.
• IV diazepam 10 to 30 mg to control muscle
spasms. Alternative agents are midazolam,
baclofen, IV magnesium sulfate, propofol,
zine. Intrathecal antitoxin also can be used to
control muscle spasms and avoid intubation.
• Neuromuscular blockade if necessary with
pancuronium or vecuronium.
• Beta-blockers (e.g., labetalol: 0.25 to 1 mg/
min) to control sympathetic hyperactivity.
CHRONIC Rx
• Supportive care. Beta-blockers (labetalol),
magnesium sulfate, and morphine (0.5-1.0
mg/kg/h continuous infusion) can improve
autonomic dysfunction
• Possible mechanical ventilation. Consider
tracheostomy. If ventilator support is not
available, benzodiazepines are the preferred
agent to manage respiratory failure
• Minimal external stimuli
• Control of heart rate and blood pressure:
1. Labetalol for sympathetic hyperactivity
2. Pacemaker for sustained bradycardia
• Physical therapy once spasms subside
DISPOSITION
Full recovery over weeks to months if complica-
tions can be avoided
REFERRAL
• To emergency department
• To infectious disease specialist
PEARLS &
CONSIDERATIONS
COMMENTS
• Illness is preventable. Table E1 describes
tetanus prophylaxis in routine wound
management.
• Boosters of Td should be given every 10 yr to
maintain immune status.
• The tetanus-diphtheria-acellular pertussis
vaccine (Tdap) may be used instead of Td,
but if used, Tdap should be used only once
in adults, except in pregnant women, who
should receive Tdap during each pregnancy.
• Passive as well as active immunization (HTIG
and Td) should be given for patients with
tetanus-prone wounds who have not been
adequately immunized in the previous 5 yr.
• A recent U.S. study showed that only 72% of
people older than 6 yr had protective levels of
antibody.
RELATED CONTENT
Tetanus (Patient Information)
AUTHOR: Glenn G. Fort, MD, MPH

TABLE E1  Tetanus Prophylaxis in Routine Wound Management

Clean, Minor Wounds Other Wounds*

History of Absorbed Tetanus Toxoid Tdap or Td† TIG‡ Tdap or Td† TIG‡
Uncertain, or <3 doses Yes No Yes Yes
3 or more doses No§ No No¶ No
DT, Diphtheria and tetanus toxoid vaccine; DTaP, combined diphtheria toxoid–tetanus toxoid–acellular pertussis vaccine; Td, tetanus toxoid and reduced diphtheria toxoid vaccine; Tdap, tetanus toxoid,
reduced diphtheria toxoid, and acellular pertussis vaccine; TIG, tetanus immune globulin.
*Such as, but not limited to, wounds contaminated with dirt, feces, or saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.
†For children <7 yr of age, DTaP is preferred to tetanus toxoid alone if <3 doses of DTaP have been given previously. If pertussis vaccine is contraindicated, DT is given. For persons ≥7 yr of age, Td

(or Tdap for adolescents 11 to 18 yr of age) is preferred to tetanus toxoid alone. Tdap is preferred to Td for adolescents 11 to 18 yr of age who have never received Tdap. Td is preferred to tetanus
toxoid for adolescents who received Tdap previously or when Tdap is not available.
‡TIG should be administered for tetanus-prone wounds in HIV-infected patients regardless of the history of tetanus immunizations.
§Yes, if ≥10 yr since the last tetanus toxoid–containing vaccine dose.
¶Yes, if ≥5 yr since the last tetanus toxoid–containing vaccine dose. (More frequent boosters are not needed and can accentuate adverse events.)

SUGGESTED READINGS
Afshar M et al: Narrative review: tetanus—a health threat after natural disasters
in developing countries, Ann Intern Med 154:329-335, 2011.
Aronoff DM: Clostridium novyi, sordelli, and tetani: mechanisms of disease,
Anaerobe 24:98-101, 2013.
Demicheli V et al: Vaccines for women to prevent neonatal tetanus, Cochrane
Database Syst Rev 4, CD002959, 2015.
Ergonul O et al: An unexpected tetanus case, Lancet Infect Dis 16:746-752, 2016.
Thwaites CL et al: Maternal and neonatal tetanus, Lancet 385:362-370, 2015.
Thwaites CL, Loan HT: Eradication of tetanus, Br Med Bull 116:69-76, 2015.
Yen LM, Thwaites CL: Tetanus, Lancet 393:1657-1668, 2019.

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