16/07/2021 Tetanus and Tetanus Prone Wounds - MRCEM Success

DASHBOARD
STATISTICSREVIEW TEXTBOOK

START REVISING

← Back to Search Results

SEARCH TEXTBOOK
Search textbook...

Tetanus and Tetanus Prone

Wounds
Neurology
MRCEM Success

USEFUL LINKS
 PHE Guidelines

CURRICULUM CODE
NeuP8 Weakness and Paralysis
NeuC13 Tetanus
TP10 Wounds

KEYWORDS
Tetanus
Wound Management

RELATED TOPICS
Neurology
Trauma

https://intermediate.mrcemsuccess.com/explanation/tetanus-and-tetanus-prone-wounds/?_sft_qc=neurology&sf_paged=2 1/5
16/07/2021 Tetanus and Tetanus Prone Wounds - MRCEM Success

Something wrong?

Tetanus and Tetanus Prone LAST UPDATED: 1 2TH

FEBRUARY 2021
Wounds  Bookmark
NEUROLOGY / TRAUMA

Tetanus is an acute disease caused by the action of the tetanus neurotoxin (tetanospasmin)
produced by the bacterium Clostridium tetani, an anaerobic spore forming bacillus. Tetanus
spores are widespread in the environment, including in soil and manure. They can survive
hostile conditions for long periods of time. Transmission occurs when spores are introduced
into the body, often through a puncture wound but also through trivial, unnoticed wounds,
through injecting drug use, and occasionally through abdominal surgery. The bacteria grow
anaerobically at the site of the injury and have an incubation period of between three and
twenty one days.

Tetanus

Clinical features:
The most common presentation of tetanus is generalised tetanus, however two
other forms, local and cephalic, are also described:
Generalised tetanus is characterised by trismus (painful muscular
contractions primarily of the masseter and neck muscles leading to facial
spasms), tonic contractions and spasms. Tonic contractions and spasms
may lead to dysphagia, opisthotonus and a rigid abdomen. In severe cases
they may cause respiratory difficulties. Autonomic instability is typical.
Consciousness is not affected.
Localised tetanus is rigidity and spasms confined to the area around the
site of the infection and may be more common in partially immunised
individuals. Localised symptoms can continue for weeks or may develop
into generalised tetanus.
Cephalic tetanus is localised tetanus after a head or neck injury, involving
primarily the musculature supplied by the cranial nerves.
Investigations:
Tetanus is primarily a clinical diagnosis. The key clinical features of generalised
tetanus include at least two of: 1) trismus, 2) painful muscular contractions of trunk

https://intermediate.mrcemsuccess.com/explanation/tetanus-and-tetanus-prone-wounds/?_sft_qc=neurology&sf_paged=2 2/5
16/07/2021 Tetanus and Tetanus Prone Wounds - MRCEM Success

muscles and 3) generalised spasms.

Laboratory tests are available to support the clinical diagnosis. Although a serum
sample should be taken before administering immunoglobulin, treatment of clinical
case of tetanus should never be delayed to wait for the laboratory results.
Laboratory investigations available to support a diagnosis of tetanus are:
Detection of C.tetani in wound material or from a pure isolate (most
sensitive test)
Detection of toxin in serum
Detection of IgG against tetanus toxin in serum
Management:
Wound debridement
Antimicrobials including agents reliably active against anaerobes such as
intravenous benzylpenicillin, metronidazole can be used,  discuss with local
Microbiology team about choice of antibiotics and doses
Intravenous Immunoglobulin (IVIG) based on weight (5,000 IU if < 50 kg or 10,000
IU if > 50 kg)
Vaccination with tetanus toxoid following recovery
Supportive care (benzodiazepines for muscle spasms, treatment of autonomic
dysfunction, maintenance of ventilation, nursing in a quiet room etc.)

Definition of tetanus-prone wounds

Clean wounds are defined as:

wounds less than 6 hours old, non-penetrating with negligible tissue damage
Tetanus-prone wounds include:
puncture-type injuries acquired in a contaminated environment and likely therefore to
contain tetanus spores e.g. gardening injuries
wounds containing foreign bodies
compound fractures
wounds or burns with systemic sepsis
certain animal bites and scratches - although smaller bites from domestic pets are
generally puncture injuries animal saliva should not contain tetanus spores unless the
animal has been rooting in soil or lives in an agricultural setting
High risk tetanus-prone wounds are any of the above with either:
heavy contamination with material likely to contain tetanus spores e.g. soil, manure
wounds or burns that show extensive devitalised tissue

https://intermediate.mrcemsuccess.com/explanation/tetanus-and-tetanus-prone-wounds/?_sft_qc=neurology&sf_paged=2 3/5
16/07/2021 Tetanus and Tetanus Prone Wounds - MRCEM Success

wounds or burns that require surgical intervention that is delayed for more than six
hours are high risk even if the contamination was not initially heavy

Management of tetanus-prone wounds

Thorough cleaning of wounds is essential and surgical debridement of devitalised tissue in high
risk tetanus–prone wounds is crucial for prevention of tetanus. If the wound, burn or injury
fulfils the above criteria, IM-TIG or HNIG should be given to neutralise toxin. A reinforcing dose
of tetanus-containing vaccine should also be considered based on the immunisation status.
Consider treating tetanus prone wounds with antibiotics (metronidazole, benzylpenicillin or co-
amoxiclav) depending on clinical severity with a view to preventing tetanus.
Determination of vaccination status may not be possible at the time of assessment and
therefore a number of Point of Care antibody (POC Ab) have been developed. There is currently
a lack of evidence on use of point of care antibody testing in the clinical pathway, and this it is
currently not recommended for use in assessment of tetanus-prone wounds or diagnosis of
suspected tetanus by the WHO. Determination of vaccination status using vaccination records
remains the preferred method.

Immunisation Status Clean Tetanus High Risk

Wound Prone Wound Tetanus
Prone Wound
Those aged ≥ 11, who have None None Required None Required
received an adequate priming Required
course of tetanus vaccine with
the last dose within 10 years
Children aged 5-10 years who
have received priming course
and preschool booster
Children under 5 years who
have received an adequate
priming course

Those who have received an None Immediate Immediate

adequate priming course of Required reinforcing reinforcing
tetanus vaccine but the last dose of vaccine dose of vaccine
dose was > 10 years ago & one dose of
human tetanus
Children aged 5-10 years who immunoglobulin
have received an adequate at a different
priming course but no site
preschool booster

https://intermediate.mrcemsuccess.com/explanation/tetanus-and-tetanus-prone-wounds/?_sft_qc=neurology&sf_paged=2 4/5
16/07/2021 Tetanus and Tetanus Prone Wounds - MRCEM Success

Immunisation Status Clean Tetanus High Risk

Wound Prone Wound Tetanus
Prone Wound
Those who have not received Immediate Immediate Immediate
an adequate priming course of reinforcing reinforcing reinforcing
tetanus vaccine dose of dose of vaccine dose of vaccine
vaccine & one dose of & one dose of
Includes uncertain human tetanus human tetanus
immunisation status and/ or immunoglobulin immunoglobulin
born before 1961 at a different at a different
site site
Important considerations:
An adequate priming course is defined as at least 3 doses of tetanus vaccine at
appropriate intervals. (N.B. This definition of “adequate course” is for the risk
assessment of tetanus-prone wounds only. The full UK schedule is five doses of tetanus
containing vaccine at appropriate intervals.)
The dose of human tetanus immunoglobulin (IM-TIG) is normally 250 IU by intramuscular
injection, or 500 IU if more than 24 hours have elapsed since injury or there is a risk of
heavy contamination or following burns. The dose is the same for both adults and
children.
In the absence of IM-TIG, the human normal immunoglobulin (HNIG) product Subgam
16% can be used instead.
Tetanus vaccine should be injected at a different site from immunoglobulin so that it is
not 'neutralised' by the passive immunisation.
Patients who are severely immunosuppressed may not be adequately protected against
tetanus, despite having been fully immunised. In the event of an exposure they may
require additional boosting and/or immunoglobulin.
For those whose immunisation status is uncertain, and individuals born before 1961 who
may not have been immunised in infancy, a full course of immunisation is likely to be
required.
For those who are incompletely immunised, further doses should be offered to complete
the recommended schedule to protect against future exposures.

https://intermediate.mrcemsuccess.com/explanation/tetanus-and-tetanus-prone-wounds/?_sft_qc=neurology&sf_paged=2 5/5