Tetanus

The most common sign of this infection is tightening of the jaw muscles. Tetanus infection can lead to serious health problems, including being unable to open the mouth and having trouble swallowing and breathing. Other symptoms include:

• Jaw cramping
• Sudden, involuntary muscle spasms, often in the stomach
• Painful muscle stiffness all over the body
• Trouble swallowing
• Seizures (jerking or staring)
• Headache
• Fever and sweating
• Changes in blood pressure and heart rate

Tetanus is caused by a toxin produced by Clostridium tetani bacteria spores found in dust, animal feces, and soil. When these spores enter a deep flesh wound, they transform into bacteria that release a lethal toxin known as tetanospasmin.

The toxin damages the muscles, specifically the motor neurons that control muscle function. This results in muscle spasms and stiffness, which are major symptoms of tetanus.

Tetanus cases are frequently observed in individuals who have never been immunized or in adults who have not received their 10-year booster shot. Tetanus is not a contagious disease and cannot be transmitted from person to person.

Other ways the bacteria can infect an individual include:

• Clean superficial wounds (when only the topmost layer of skin is scraped off)
• Surgical procedures
• Insect bites
• Dental infections
• Compound fractures (an exposed broken bone)
• Chronic sores and infections
• Intravenous (IV) drug use
• Intramuscular injections (shots given in a muscle)

Tetanus usually occurs in individuals who are not immunized, partially immunized, or fully immunized but lack adequate booster doses. The risk factors for neonatal tetanus include the following:

• Contaminated cuts or wounds: Tetanus bacteria are more likely to infect certain breaks in the skin through feces or saliva, and wounds caused by objects, such as nails or needles, breaking the skin.
• Unvaccinated mother: Vaccination helps protect babies during this vulnerable time. Women should receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.
• Delivery in contaminated areas: Obstetric tetanus occurs during pregnancy or within 6 weeks of the end of pregnancy, following the contamination of wounds with Clostridium tetani spores during pregnancy or the use of contaminated tools during deliveries or abortions.
• Septic cutting of the umbilical cord: Neonatal tetanus can occur when non-sterile instruments are used to cut the umbilical cord or when contaminated material is used to cover the umbilical stump.
• Family history: A history of neonatal tetanus in a previous child increases the risk for neonatal tetanus in subsequent children.
• History of immunosuppression: Individuals on medications for autoimmune conditions or post-organ transplant have low immunity, which can increase their chances of tetanus infections.
• Sharing contaminated needles: Skin punctures by contaminated needles, such as those used to inject illegal drugs or for tattoos and body piercings, can also lead to tetanus.
• Diabetes: Patients with diabetes and chronic wounds are more prone to tetanus than other populations.

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No confirmatory laboratory testing is available; the diagnosis is made clinically. Other factors that can help confirm the diagnosis include:

• History: A history of a prior tetanus-prone injury and insufficient tetanus immunization raises suspicion for tetanus. It can be identified through the patient's recent history of trauma, wounds, scrapes, and punctures, along with specific symptoms and indicators observed by the doctor.
• Spatula Test: The spatula test is a simple diagnostic procedure. In normal patients, touching the throat with a spatula elicits a gag reflex, resulting in efforts to expel the spatula—a negative result. If tetanus is present, a reflex spasm occurs, and the patient bites the spatula—a positive result.

Vaccination and good wound care are the cornerstones in the prevention of a tetanus infection. They are discussed as follows:

I. Vaccination

The only way to prevent a tetanus infection is by getting vaccinated on time. The tetanus vaccine shot is usually given in the deltoid muscle. The tetanus vaccine is given as part of the following vaccines:

• Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine: Contains full doses of diphtheria, tetanus, and pertussis (whooping cough) vaccines.
• Diphtheria and tetanus (DT) vaccine.
• Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine: Contains a full dose of the tetanus vaccine and a lower dose of diphtheria and whooping cough vaccines.
• Tetanus and diphtheria (Td) vaccine.
• Tetanus Toxoid (TT) vaccine.

Note: DTaP/DT are only given to babies and children younger than 7 years, whereas Tdap/Td/TT are given to adolescents and adults.

Who should take tetanus vaccination and when?

Children

• Children between 2 months to 6 years should get 5 DTaP shots: Three doses at 6, 10, and 14 weeks, and two booster doses at 16-24 months and 5-6 years of age respectively.
• Children who had a very bad reaction to DTaP can receive the DT vaccine. However, they will not receive any protection against whooping cough.
• Children aged 11-12 years should get 1 booster shot of Tdap.

Adults

• Adults over 18 years who did not receive primary immunization should receive three doses of Td vaccine. Two doses are administered at least 4 weeks apart, and the third dose is given 6-12 months after the second dose. The Tdap vaccine can substitute any one of the Td doses.
• Adults who have completed their primary vaccination schedule should get a TT or Td shot every 10 years until the age of 65. One dose of Tdap vaccine may be administered in place of TT/Td vaccine.

Pregnant women

• The national immunization schedule in India recommends 2 doses of TT/Td regardless of the immunization status of pregnant women. There should be a minimum gap of 4 weeks between the two doses. Tdap vaccination can also be considered instead of the second dose of TT/Td injection.
• If a mother received 2 TT/Td doses in the last pregnancy and gets pregnant within 3 years, only one booster dose is recommended.

Contraindications of Tetanus vaccination

• History of a severe adverse reaction to any vaccination ingredient.
• If within seven days following vaccination and without apparent explanation, the individual suffered encephalopathy (such as coma, diminished level of consciousness, or persistent seizures).
• History of Guillain-Barré syndrome (GBS).

Immunization is one of the most effective tools to prevent severe infections in both children and adults. Know more about 7 vaccinations to protect against deadly diseases.

II. Appropriate wound care

Proper care is essential if you sustain any cut, wound, or injury, especially if it is contaminated. Here are a few tips to follow for minor wounds or injuries:

• Control bleeding: Use a clean tissue, gauze, or clean cloth to apply direct pressure to the cut or wound until the bleeding stops. To aid in reducing bleeding, elevate the arm or leg above the heart if possible.
• Maintain hygiene: Wash your hands before cleaning and dressing the wound. Once the bleeding has stopped, rinse the wound with a saline solution, bottled water, or clear running water.
• Cover the wound: Use a sterile bandage after applying an antibiotic cream to reduce the chance of infection. Change the bandage frequently to keep the wound clean and dry, preventing harmful bacteria from entering.
• Change the dressing: Replace the bandage at least once every day or whenever the dressing is soiled or wet. You can also use an antibiotic ointment.
• Manage adverse reactions: If you notice any rash or if the wound worsens due to antibiotic use, or if you are allergic to the adhesive used in bandages, switch to adhesive-free dressings or sterile gauze and paper tape.

Watch this informative video to know more about how to manage wounds efficiently.

Tetanus is a medical emergency and its management comprises the following:

1. Early and aggressive wound debridement
   It is advisable to surgically debride any wounds that are present. It's essential to clean the wound with sterile or clean water and an antiseptic solution to eliminate any dirt, debris, or foreign objects that could harbor bacteria. Always keep your first aid kit handy in case of an emergency.
2. Antimicrobial therapy
   Although antibiotics are always advised, they likely play a minor role in the treatment of tetanus. It is crucial to note that without proper wound debridement, appropriate antibiotic therapy may not effectively eliminate C. tetani. Drugs used include:
   • Metronidazole
   • Penicillin G
   • Cefuroxime
3. Human tetanus immune globulin (HTIG)
   Neutralization of unbound toxins with Human tetanus immune globulin is administered. All patients with suspected tetanus should immediately receive both passive (with TIG) and active (tetanus toxoid-containing vaccines).
4. Drugs to control muscle spasms
   Generalized muscle spasms are life-threatening as they can lead to respiratory failure, aspiration, and generalized exhaustion in the patient. Long-term muscle contractions result in abrupt, strong, and painful contractions known as tetany. These episodes can cause fractures and muscle tears. Several drugs may be used to control these spasms, including:
   • Benzodiazepines (like diazepam)
   • Pancuronium
   • Antispasmodics (like baclofen)
   • Magnesium sulfate
5. Hospitalization and supportive care
   Patients with severe tetanus require an intensive care environment. As sedatives can inhibit breathing, temporary ventilation may be necessary. Nutritional support should be initiated early due to high energy demands from repeated spasms, excessive sweating, and muscular contractions. Heparin or another anticoagulant should be administered early to prevent blood clotting in veins. Tetanus often begins with mild spasms in the jaw muscles, which can eventually affect the chest, neck, back, and abdominal muscles. Therefore, physical therapy is recommended as soon as spasms have ceased.
6. Vaccination during recovery
   Tetanus disease does not provide immunity against future infections. Active immunization should be initiated or continued with a tetanus toxoid-containing vaccine as soon as the person’s condition has stabilized.

Serious health problems that can happen because of tetanus include:

• Laryngospasm: Uncontrolled or involuntary tightening of the vocal cords may lead to interference with breathing.
• Fractures: Fractures of the spine or long bones may result from involuntary muscle movements.
• Hypertension and/or abnormal heart rhythm: Hyperactivity seen in tetanus may lead to hypertension and can also cause abnormal heart rhythm.
• Nosocomial infections: Infections acquired during medical care that were absent at the time of admission, also known as healthcare-associated infections (HAI).
• Pulmonary embolism: A blood clot that passes through the bloodstream from another part of the body and blocks a major artery of the lung or one of its branches.
• Aspiration pneumonia: A lung infection that develops when substances like saliva or vomit accidentally enter the lungs.
• Death: Tetanus can be fatal, particularly in individuals aged 60 years or older and those who have never received a vaccination.

A few alternative therapies that have shown some promise in the management of tetanus include:

• Botulinum toxin: Botulinum toxin, also known as "miracle poison," is a neurotoxin produced by the bacterium Clostridium botulinum. Studies indicate that, aside from immunization, the administration of this toxin has been used in recent years to reduce rigidity and spasms in tetanus patients.
• Vitamin C: Research suggests that vitamin C may play a significant role in preventing tetanus and reducing mortality. It acts as an antioxidant, aids in wound healing, and enhances immunity.

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Tetanus can have various adverse effects on the patient's lifestyle, depending on the severity of the symptoms. The challenge or ease of living with tetanus varies for each survivor, subject to the availability of medical care, rehabilitation opportunities, and their family and social support. Various forms of rehabilitation and support include:

• Physical therapy to help with muscle rigidity and spasms, increase mobility and movement, and maximize function and quality of life.
• Cardiopulmonary physical therapy to help prevent respiratory complications.
• Emotional support and caretaking, which are essential for individuals dealing with tetanus. Assistance from family on an emotional level can significantly aid in recovery.

Caregivers play a crucial role in the overall disease outcome of patients diagnosed with tetanus. The responsibilities of nurses include:

• Recording medical information.
• Creating care plans tailored to the individual needs of the patient.
• Providing wound care and infection control.
• Offering emotional support to ensure the patient does not feel alone.