QUICK RECERTIFICATION SERIES
Tetanus
David Gelbart, MMS, PA-C
GENERAL FEATURES
• Tetanus is a disorder of the nervous system that results
in uncontrollable muscle spasms
• Caused by inoculation of the bacteria Clostridium tetani
° Bacteria is found in soil and animal feces (flora of the
mammalian gut)
° Gram-positive, spore-forming anaerobe that produces
the neurotoxin tetanospasmin (tetanus toxin)
° Once in human tissue, bacteria travel in retrograde
fashion up axons to the spinal cord and brainstem
° Toxin blocks GABA (an inhibitory neurotransmitter) in
motor neurons, causing intense, diffuse spastic paralysis
• Extremely rare in developed countries due to widespread
vaccination
° In the United States, overall annual incidence is 0.1
cases per million
° Worldwide, annual incidence is 500,000 to 1 million
° Afflicted patients are not immunized or underimmunized
• Is a reportable disease to health departments in all US
states and territories
° Information is sent to the CDC for disease surveillance
CLINICAL ASSESSMENT
• Presents as one of four patterns: generalized, local, cephalic,
or neonatal
° Generalized pattern is the most common and most severe
t Hallmark symptom is trismus (lockjaw)
t Intensely painful muscle spasms
Ø Risus sardonicus (smile or grin resulting from intense
facial muscle spasm)
Ø Opisthotonus (backward arching or the neck and
back resulting from extensor muscle spasm)
t Other clinical features include rigid abdomen, bone
fractures, fever, tachycardia, diaphoresis, hyperten-
sion, headache, laryngospasm (dysphagia and apnea)
° Local tetanus is localized to one body region such as
an extremity
t May evolve into generalized tetanus
° Cephalic tetanus is localized to the cranial nerves (espe-
cially cranial nerve VII)
t Focal deficits may mimic cerebrovascular accidents
David Gelbart is a medical student at Lake Erie College of Osteopathic
Medicine and a PA in emergency medicine. The author has disclosed
no potential conflicts of interest, financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI:10.1097/01.JAA.0000526785.27024.bb
Copyright © 2017 American Academy of Physician Assistants
46 www.JAAPA.com
Copyright © 2017 American Academy of Physician Assistants
° Neonatal tetanus occurs in infants within 24 days of
birth
t Due to contamination of the umbilical cord or stump
t Trismus leads to poor feeding
• Incubation period is variable (2 to 38 days)
° Mean incubation period is 7 to 10 days postexposure
° Longer incubation for inoculation sites more distal to
the central nervous system
DIAGNOSIS
• Diagnosis is made clinically on the basis of history and
physical examination
° History of soft tissue injury allowing bacteria access
through the broken skin
t Wounds, IV or subcutaneous drug abuse (especially
heroin)
t Cutting of umbilical cord with unsterile instrumenta-
tion (neonatal tetanus)
° Physical examination findings as noted above
QUESTIONS
1. A 35-year-old man presents with a 5-hour history of
progressively worsening, generalized, intensely painful
muscle spasms. History indicates the patient sustained
a puncture wound to the foot from broken glass 1 week
ago. He has not been vaccinated in more than 10 years.
Physical examination reveals spastic paralysis with an
abnormally appearing grin and a markedly arched back.
Which of the following additional physical examination
findings would be most consistent with this presentation?
a. generalized urticaria
b. heart rate of 135 beats/minute
c. positive Homan sign
d. positive Kernig sign
2. A 35-year-old man presents to the ED with rapidly worsening
trismus and diffuse muscle cramps. Generalized tetanus
is quickly diagnosed. Which of the following is the most
probable mode of transmission of this infection?
a. IV drug use
b. unprotected sexual intercourse
c. ingestion of undercooked meat
d. ingestion of contaminated water
Volume 30 • Number 12 • December 2017

TREATMENT
• Management is largely supportive: airway management,
benzodiazepines for muscle cramps, anticoagulants for
deep vein thrombosis prophylaxis
• Magnesium sulfate to control autonomic dysfunction
° Loading dose of 40 mg/kg IV over 30 minutes, then 2
g/h continuously for patients weighing 45 kg (99 lb)
or more, or 1.5 g/h continuously for patients weighing
less than 45 kg
• Human tetanus immune globulin (HTIG) to neutralize
unbound toxin
• Wound debridement to eradicate spores at inoculation
site
• Antibiotics: metronidazole is first-line, penicillin is second-
line
° Metronidazole 500 mg IV every 6-8 hours for 7-10
days
° Penicillin G, 2-4 million units IV every 4-6 hours for
7-10 days
• Tetanus toxoid vaccine (part of DTap, Tdap, Td booster)
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2017 American Academy of Physician Assistants
Tetanus
° Infection does not confer immunity, so infected patients
require vaccination
° Td generally given every 10 years
° Should be administered to women during every preg-
nancy JAAPA
sexual intercourse, or contaminated food or water.
central nervous system. Tetanus is not contracted through
allow C. tetani access to the body and ultimately to the
layers of the skin, including punctures from needles, may
2. A. Any compromise in the structural integrity of the protective
manifestation of DVT; neither involve tetanus.
of meningeal irritation and Homan sign is a clinical
mediated allergy. Kernig sign is a clinical manifestation
urticaria, which is a cutaneous manifestation of IgE-
tachycardia. Tetanus would be an unlikely source of
1. B. Tetanus may cause autonomic instability leading to
Answers
www.JAAPA.com 47