Tetanus: Follow-Up
Follow-Up
Complications:
- 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.
- Further complications include the following:
- Long bone fractures
- Glenohumeral joint and temporomandibular joint dislocations
- Hypoxic injury, aspiration pneumonia, and pulmonary emboli
- 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
Prognosis:
- 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.
Patient Education:
- For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education article Tetanus.
Miscellaneous
Special Concerns:
- Prevention of tetanus is accomplished through vaccination with DTP at ages 2, 4, 6, and 12-18 months and 4-6 years.
- For an unimmunized person aged 7 years or older, administer tetanus and adult-strength diphtheria toxoids (Td) with a subsequent dose 1-2 months later and a third dose 6-12 months after the second dose.
- Secondary prevention of tetanus is accomplished postexposure through appropriate wound cleansing and debridement and the administration of Td and human tetanus immune globulin (TIG), when indicated. 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.
- 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 in opposite extremity) 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 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.
- 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.
- 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.
| Caption: Picture 1. Image from Tetanus morbidity and mortality rates, by year. Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ 2003 Jun 20; 52(3): 1-8. | |
 | View Full Size Image | Picture Type: Graph |
| Caption: Picture 2. 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. | |
 | View Full Size Image | Picture Type: Graph |
| Caption: Picture 3. 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. | |
 | View Full Size Image | Picture Type: Photo |
| Caption: Picture 4. 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. | |
 | View Full Size Image | Picture Type: Graph |
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Synonyms And Related Keywords
Clostridium tetani, C tetani, tetanus immunization, tetanus vaccination, tetanus toxoid, diphtheria and tetanus toxoids plus pertussis vaccinations, DPT vaccination, lockjaw, stiffness of the jaw, risus sardonicus, hypertonia, tetanus, muscle spasms, lacerations, puncture wounds, burns, abrasions
