DefinitionBy Mayo Clinic staff

Tetanus is a serious bacterial disease that affects your nervous system, leading to

painful muscle contractions, particularly of your jaw and neck muscles. Tetanus can

interfere with your ability to breathe and, ultimately, threaten your life. Tetanus is

commonly known as "lockjaw."

Thanks to the tetanus vaccine, cases of tetanus are rare in the United States and the

developed world. The incidence of tetanus is much higher in less-developed countries.

Around a million cases occur worldwide each year.

Tetanus can be treated, but not always effectively. Fatality is highest in individuals who

haven't been immunized and in older adults with inadequate immunization — wherever

they may live. In countries with low vaccine rates, infants also are at high risk of severe

illness and death.

SymptomsBy Mayo Clinic staff

Signs and symptoms of tetanus may appear anytime from a few days to several weeks

after tetanus bacteria enter your body through a wound. The average incubation period

is seven to eight days.

Common signs and symptoms of tetanus, in order of appearance, are:

Spasms and stiffness in your jaw muscles Stiffness of your neck muscles Difficulty swallowing Stiffness of your abdominal muscles Painful body spasms, lasting for several minutes, typically triggered by minor

occurrences, such as a draft, loud noise, physical touch or lightOther signs and symptoms may include:

Fever Sweating Elevated blood pressure Rapid heart rate

Causes

By Mayo Clinic staff

The bacteria that cause tetanus, Clostridium tetani, are found in soil, dust and animal

feces. When they enter a deep flesh wound, spores of the bacteria may produce a

powerful toxin, tetanospasmin, which actively impairs your motor neurons, nerves that

control your muscles. The effect of the toxin on your nerves can cause muscle stiffness

and spasms — the major signs of tetanus.

Risk factorsBy Mayo Clinic staff

In addition, certain factors are necessary for tetanus bacteria to proliferate in your body.

These include:

Lack of immunization or inadequate immunization — failure to receive timely booster shots — against tetanus

A penetrating injury that results in tetanus spores being introduced to the wound site The presence of other infective bacteria Injured tissue A foreign body, such as a nail or splinter Swelling around the injury

Tetanus cases have developed from the following types of injuries: Puncture wounds — including from splinters, body piercings, tattoos, injection drugs Gunshot wounds Compound fractures Crush injuries Burns Surgical wounds Ear infections Dental infections Animal bites Infected foot ulcers in people with diabetes Infected umbilical stumps in newborns born of inadequately immunized mothers

ComplicationsBy Mayo Clinic staff

Once tetanus toxin has bonded to your nerve endings it is impossible to remove.

Complete recovery from a tetanus infection requires the growth of new nerve endings

and can take up to several months.

Complications of tetanus infection may include:

Disability. Treatment for tetanus typically involves the use of powerful sedatives to

control muscle spasms. Prolonged immobility due to the use of these drugs can lead to

permanent disability. In infants, tetanus infections may cause lasting brain damage,

ranging from minor mental deficits to cerebral palsy.

Death. Severe tetanus-induced (tetanic) muscle spasms can interfere with your

breathing, causing periods in which you can't breathe at all. Respiratory failure is the

most common cause of death. Lack of oxygen may also induce cardiac arrest and

death. Pneumonia is another cause of death.

PreventionBy Mayo Clinic staff

You can easily prevent tetanus by being immunized against the toxin. Almost all cases

of tetanus occur in people who've never been immunized or who haven't had a tetanus

booster shot within the preceding 10 years.

The primary vaccine series 

The tetanus vaccine usually is given to children as part of the diphtheria and tetanus

toxoids and acellular pertussis (DTaP) vaccine. This vaccination provides protection

against three diseases: diphtheria (a throat and respiratory infection), pertussis

(whooping cough) and tetanus.

The DTaP vaccine consists of a series of five shots, typically given in the arm or thigh to

children at ages:

2 months

4 months

6 months

15 to 18 months

4 to 6 years

The booster 

A booster of the tetanus vaccine is typically given in combination with a booster of

diphtheria vaccine (Td). In 2005, a tetanus, diphtheria and pertussis (Tdap) vaccine was

approved for use in teens and adults under age 65 to ensure continuing protection

against pertussis.

It's recommended that adolescents get a dose of Tdap, preferably between the ages of

11 and 12, and that a Td booster be given every 10 years thereafter. If you've never

received a dose of Tdap, substitute it for your next Td booster dose and then continue

on with Td boosters.

If you're traveling internationally, it's a good idea to have up-to-date immunity because

tetanus may be more common where you're visiting, especially if you're traveling to a

developing country. If you receive a deep or dirty wound and it's been more than five

years since your last booster shot, get another booster shot.

In order to stay up to date with all of your vaccinations, request that your doctor review

your vaccination status on a regular basis.

If you were never vaccinated against tetanus as a child, see your doctor about getting

the Tdap vaccine. You can't get a tetanus infection from the vaccine.

Tests and diagnosisBy Mayo Clinic staff

Doctors diagnose tetanus based on a physical exam, medical and immunization history,

and the signs and symptoms of muscle spasms, stiffness and pain. Laboratory tests

generally aren't helpful for diagnosing tetanus.

Treatments and drugsBy Mayo Clinic staff

Since there's no cure for tetanus, treatment consists of wound care, medications to

ease symptoms and supportive care.

Wound care 

Cleaning the wound is essential to preventing growth of tetanus spores. This involves

removing dirt, foreign objects and dead tissue from the wound.

Medications

Antitoxin. Your doctor may give you a tetanus antitoxin, such as tetanus immune

globulin. However, the antitoxin can neutralize only toxin that hasn't yet bonded to nerve

tissue.

Antibiotics. Your doctor may also give you antibiotics, either orally or by injection, to

fight tetanus bacteria.

Vaccine. Having tetanus once doesn't make you immune to the bacteria afterward. So

you'll need to receive a tetanus vaccine in order to prevent future tetanus infection.

Sedatives. Doctors generally use powerful sedatives to control muscle spasms.

Other drugs. Other medications, such as magnesium sulfate and certain beta blockers,

may be used to help regulate involuntary muscle activity, such as your heartbeat and

breathing. Morphine may be used for this purpose as well as sedation.

Supportive therapies 

Tetanus infection often requires a long period of treatment in an intensive care setting.

Since sedatives may result in shallow breathing, you may need to be supported

temporarily by a ventilator.

Lifestyle and home remediesBy Mayo Clinic staff

Puncture wounds or other deep cuts, animal bites or particularly dirty wounds may put

you at increased risk of tetanus infection. Get medical attention if the wound is deep and

dirty, and particularly if you're unsure of your immunization status. Leave unclean

wounds open to avoid trapping bacteria in the wound with a bandage.

Your doctor may need to clean the wound, prescribe an antibiotic and give you a

booster shot of the tetanus toxoid vaccine. If you've previously been immunized, your

body should quickly make the needed antibodies to protect you against tetanus.

If you have a minor wound, these steps will help prevent you from getting tetanus:

Control bleeding. If the wound is bleeding, apply direct pressure to control the

bleeding.

Keep the wound clean. After the bleeding has stopped, rinse the wound thoroughly

with clean running water (or saline solution if available). Clean the area around the

wound with soap and a washcloth. If debris is embedded in a wound, see your doctor.

Use an antibiotic. After you clean the wound, apply a thin layer of an antibiotic cream

or ointment, such as the multi-ingredient antibiotics Neosporin and Polysporin. These

antibiotics won't make the wound heal faster, but they can discourage bacterial growth

and infection and may allow the wound to heal more efficiently. Certain ingredients in

some ointments can cause a mild rash in some people. If a rash appears, stop using the

ointment.

Cover the wound. Exposure to the air may speed healing, but bandages can help keep

the wound clean and keep harmful bacteria out. Blisters that are draining are

vulnerable. Keep them covered until a scab forms.

Change the dressing. Apply a new dressing at least once a day or whenever the

dressing becomes wet or dirty to help prevent infection. If you're allergic to the adhesive

used in most bandages, switch to adhesive-free dressings or sterile gauze and paper

tape.

TEXTBOOK DISCUSSIONPATHOPHYSIOLOGY

TETANUS

Tetanus is an acute, often fatal diseasecaused by an exotoxin produced in a woundby

Clostridium tetani. Clostridium tetani is agram-positive, nonencapsulated,

motile,obligatively anaerobic bacillus. It exists invegetative and sporulated forms.

Spores arehighly resistant to disinfections by chemicalor heat, but vegetative forms are

susceptibleto the bactericidal effect of heat, chemicaldisinfectants, and a number of

antibiotics.Clostridium tetani is a noninvasive organism. It is found in soil and in

theintestine and feces of horses, sheep, cattle, dogs, cats, rats, guinea pigs andchicken.

Manure-treated soil may contain large numbers of spores too.Tetanus occurs after

spores or vegetative bacteria gain access to tissues andproduce toxin locally. The usual

mode of entry is trough a puncture wound orlaceration. Tetanus may also follow elective

surgery, burn wounds, otitis media,dental infection, abortion and pregnancy. Neonatal

tetanus usually follows infectionof the umbilical stump.In the presence of anaerobic

conditions, the spores germinate.Toxins,including tetanolysin (which potentiates

infection) and tetanospasmin (apotent neurotoxin) are produced. Tetanospasmin, often

referred to as tetanustoxin, causes clinical tetanus. The toxin produced is disseminated

through thebloodstream and lymphatic system. However, it does not enter the central

nervoussystem through this route, as it cannot cross the blood brain barrier except at

thefourth ventricle. The toxin is exclusively taken up by the neuromuscular junction,

where it migrates retrograde transynaptically at the rate 75-250mm/day, a process

which takes 3-14 days, protected from neutralizing antitoxin, predominantly to inhibitory

synapses to prevent the release of acetylcholine. The toxin acts after the incubation

period (3-14) days) at several sites with int he central nervous system, including

peripheral motor end plates, spinal cord,brain and sympathetic nervous system. The

typical clinical manifestations of tetanus are caused when tetanus toxin interferes with

release of neurotrasmitters, blocking inhibitor impulses

Blockade of spinal inhibition is produced when the toxin acts at the synapse of inter

neurons of inhibitory pathways and motor neurons. General muscle rigidity arises from

uninhibited afferent stimuli entering the central nervous system from the periphery. The

effect of the toxin on the brain is controversial; direct inoculation can cause seizures.

One of the many complications from tetanus is respiratory failure secondary to spasms,

obstruction by secretions, exhaustion and pulmonary aspiration. Cardiovascular

complications thought to be due to hyperactivity of the sympathetic nervous system

include tachycardia, with heart rates over 180 beats per minute, severe vasoconstriction

and hypertension. Autonomic dysfunction is seen as increased basal sympathetic

activity and episodes of sympathetic over activity.

Tetanus Symptoms

In generalized tetanus, the initial complaints may include any of the following:

•

Irritability, muscle cramps, sore muscles, weakness, or difficulty swallowing are

commonly seen.

•Facial muscles are often affected first.Trismus or lockjaw is most common. This

condition results from spasms of the jaw muscles that are responsible for chewing. A

sardonic smile --medically termed risussardonicus-- is a characteristic feature that

results from facial muscle spasms.

•Muscle spasms are progressive and may include a characteristicarching of the back

known as opisthotonus. Muscle spasms may be intenseenough to cause bones to break

and joints to dislocate.

•Severe cases can involve spasms of the vocal cords or musclesinvolved in breathing. If

this happens, death is likely, unless medical help(mechanical ventilation with a

respirator) is readily available.

Complications of Tetanus

In cases of severe tetanus infection, a number of possible complications candevelop

Fractures

The repeated muscle spasms and convulsions that are caused by a tetanusinfection

may lead to fractures in the vertebrae (bones in the back), as wellas in other bones.

Bone fractures can sometimes result in a condition calledmyositis ossificans

circumscripta, which is where bone begins to form in thesoft tissues, often around a

joint.

Aspiration pneumonia

If you have a tetanus infection, muscle rigidity (stiffness) can make coughingand

swallowing difficult. This can cause aspiration pneumonia to develop.Aspiration

pneumonia occurs as a result of inhaling the secretions, orcontents, of the stomach,

which can lead to a lower respiratory tractinfection.

Laryngospasm

Laryngospasm is where the larynx (voicebox) goes into a brief, temporaryspasm that

usually lasts for between 30-60 seconds. Laryngospasm preventsoxygen from reaching

your lungs, making breathing difficult.

Tetanic seizures

Tetanic seizures are convulsions (fits) that are similar to epileptic fits. Theycan occur in

severe cases of tetanus where the infection has spread to thebrain. Someone with a

severe tetanus infection may experience severe andfrequent tetanic seizures.

Pulmonary embolism

A pulmonary embolism is a serious and potentially life-threatening condition.It is caused

by a blockage in a blood vessel in the lungs that can affectbreathing and circulation. It is

therefore vital that treatment is givenimmediately in the form of anti-clotting medication

and, if required, oxygentherapy.

Acute renal failure

The severe muscle spasms that are associated with a tetanus infection cancause a

condition that is known as rhabdomyolysis. Rhabdomyolysis is wherethe skeletal

muscles are rapidly destroyed, resulting in myoglobin (a muscleprotein) leaking into the

urine. This can lead to acute (severe) renal failure(kidney failure).

Preventing tetanus

Immunisation is the best way to prevent a tetanus infection from occurring.The complete

course of the tetanus vaccination consists of five doses. Thevaccine enables your body

to create antibodies against the tetanus toxin(tetanospasmin), providing protection from

the illness should you be exposedto the Clostridium tetani bacterium in the future.

Symptoms of Tetanus

Stiffness of your abdominal muscles

Painful body spasms

Fever

Sweating

Spasms and stiffness in your jaw muscles

Stiffness of your neck muscles

Difficulty swallowing

Elevated blood pressure

Rapid heart rate

Nursing Diagnosis for Tetanus

Increased body temperature (hyperthermia) related to the effects of toxins (bacteremia)

Changes in nutrition, less than body requirements related to the mastication muscle

stiffness

Disturbed interpersonal relationships related to speech difficulties

Impaired daily needs related to the condition of weak and frequent seizures

The risk of fluid and electrolyte imbalances related to intake of less and oliguria

Risk of injury related to frequent seizures

Ineffective airway clearance related to the accumulation of sputum in the trachea and

respiratory muscle spasms.

Lack of rest requirements related to frequent seizures.

Breathing pattern disorders related to impaired airway due to spasm of respiratory

muscles

Lack of knowledge of the client and family about tetanus disease related to lack of

information.

Nursing Intervention for Tetanus Client

Protect the client from injury.

Provide comfort measures.

Monitor client for signs of arrythmias.

Prevent client from having spasms by:

   Controlling the environment

   Avoiding stress, pain, coughing, or flatus to occur to the patient

   Avoid touching, turning, and jarring the bed of the client

   The nurse should organize the activity of the client. Provision of cluster care is a must.

cluster care is doing all nursing measures in one setting. Gentle nursing care is also

required. The nurse should also turn the client to prevent respiratory problems.

Maintain adequate airway and ventilation.

Maintain an intravenous line.

  Treatment, prevention and control of tetanus

Once a person has tetanus, he or she will be treated by an antibiotic drug. Antibiotics are medicines that destroy bacteria, or stop them from multiplying in the body. However, many people who have tetanus die despite the treatment. Hence, prevention is the best strategy, and vaccination is the best way to prevent tetanus.

Tetanus toxoid (TT) vaccination

The tetanus vaccine contains inactivated tetanus toxoid (poison), which is why it is often called TT vaccine. Tetanus toxoid vaccination is given routinely to newborns and infants as part of the threefold DPT vaccine (with diphtheria and pertussis vaccines), or the pentavalent (fivefold) vaccine, which includes vaccines for diphtheria, tetanus, pertussis, Hepatitis B (a virus), and a bacterium called Haemophilus influenzae type B (Hib). Neonatal tetanus can also be prevented by vaccinating women of childbearing age with tetanus toxoid vaccine, either during pregnancy or before pregnancy. This protects the mother and enables anti-tetanus antibodies to be transferred to the growing fetus in her uterus.

What is the name given to this mode of transmission? (You learned about it in Study Session 1 in reference to infectious agents being transferred from mother to baby).

Reveal answer

Cleanliness is also very important, especially when a mother is delivering a baby, even if she has been vaccinated with TT vaccine.

People who recover from tetanus do not have increased natural immunity and so they can be infected again. Therefore they will need to be vaccinated.

The World Health Organization (WHO) and UNICEF set a goal to eliminate neonatal tetanus by 2005. Elimination in this case would mean that the number of neonatal tetanus cases would have to be reduced to below one case per 1,000 live births per year in every district. Notice that elimination of a communicable disease does not mean there are no cases — just very few right across a country or region. Eradication means the total and sustained disappearance of the disease from the population.

Do you think that tetanus can ever be eradicated? Explain why, or why not.

Reveal answer

To achieve the elimination goal, countries like Ethiopia, with a high number of tetanus cases every year, need to implement a series of prevention strategies, which include those listed in Box 3.1.

Clean delivery practices are described in the Labour and Delivery

Care Module.

Box 3.1  Strategies to prevent and control tetanus

Vaccinating a higher percentage of pregnant women against tetanus with

vaccines containing tetanus toxoid (TT).

Vaccinating all females of childbearing age (approximately 15–45 years) with

TT vaccine in high-risk areas where vaccination coverage is currently low.

Outreach vaccination campaigns where health workers go to rural villages and

give TT vaccine, usually three times at intervals (known as a ‘three-round’

vaccination campaign).

Promoting clean delivery and childcare practices, through better hygiene and

care of the newborn’s umbilicus.

Improving surveillance and reporting of cases of neonatal tetanus. The case

finding and reporting will help us to give appropriate treatment and vaccination

to children.