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Tetanus
Kristal Bae; Daniele Bourget.

Informasi dan Afiliasi Penulis

Pembaruan Terakhir: 31 Mei 2023.

Kegiatan Pendidikan Berkelanjutan

Tetanus adalah infeksi yang ditandai dengan kejang otot dan rahang terkunci, juga disebut
trismus. Racun yang dihasilkan oleh Clostridium tetani bertanggung jawab atas presentasi
karakteristik. Penyakit ini paling sering terjadi pada individu yang tidak divaksinasi atau pasien
lanjut usia dengan kekebalan yang memudar. Kampanye vaksinasi telah menurunkan kejadian
tetanus di seluruh dunia. Kegiatan ini meninjau modalitas penularan tetanus yang paling umum,
presentasi klinis dan mengilustrasikan pendekatan pengobatan sesuai dengan bukti saat ini.
Kegiatan ini menyoroti peran tim interprofesional dalam mengevaluasi dan meningkatkan
perawatan pasien tetanus.

Tujuan:

Jelaskan cara umum di mana tetanus ditularkan.

Identifikasi fitur umum tetanus.

Tinjau strategi pengobatan tetanus.

Mengidentifikasi strategi tim interprofesional untuk meningkatkan koordinasi dan hasil

perawatan pada pasien dengan tetanus.

Akses pertanyaan pilihan ganda gratis tentang topik ini.

Perkenalan
Tetanus adalah infeksi yang ditandai dengan keadaan hipertonia umum yang bermanifestasi
dalam bentuk kejang otot yang menyakitkan pada rahang dan leher. Penyakit ini paling sering
terjadi pada mereka yang tidak divaksinasi atau pada orang tua dengan kekebalan yang memudar.
Saat ini, kampanye vaksinasi telah menurunkan insiden dan prevalensi tetanus di seluruh dunia.
Kejang akibat tetanus dapat berlangsung dari beberapa menit hingga berminggu-minggu, dengan
kejang dimulai di wajah dan kemudian turun ke seluruh tubuh. Gejala disebabkan oleh racun
yang dihasilkan oleh bakteri, Clostridium tetani. Berdasarkan fitur klinis, ada empat jenis utama
tetanus.

1. Tetanus umum

2. Tetanus neonatal

3. Tetanus lokal

4. Tetanus serebral
Tetanus, diagnosis klinis, tidak memiliki tes laboratorium khusus untuk mengkonfirmasi
diagnosis. Pengobatan meliputi imunoglobulin tetanus, terapi antibiotik, blokade neuromuskular,
dan perawatan suportif untuk komplikasi pernapasan, ketidakstabilan otonom, dan kejang otot.
Imunisasi tetanus penuh diperlukan setelah sembuh dari penyakit. Gejala sisa jangka panjang
telah dilaporkan dari para penyintas. [1][2][3][4]

Etiologi
Tetanus disebabkan oleh infeksi dari bakteri, Clostridium tetani, yang ditemukan di tanah, debu,
atau kotoran hewan. Ini adalah basil anaerobik gram positif, pembentuk spora, wajib. Bakteri ini
dan sporanya ditemukan di seluruh dunia, namun, lebih sering ditemukan di iklim panas dan
basah di mana tanahnya kaya dengan bahan organik.

C. tetani dapat masuk ke tubuh manusia melalui tusukan luka, laserasi, kerusakan kulit, atau
inokulasi dengan jarum suntik yang terinfeksi atau gigitan serangga. Sumber infeksi yang paling
umum adalah luka yang seringkali sepele dan mungkin luput dari perhatian, seperti luka robek
ringan dari serpihan kayu atau logam atau duri. Populasi berisiko tinggi termasuk mereka yang
belum divaksinasi, pengguna narkoba intravena, dan mereka yang mengalami imunosupresi.
Penyebab infeksi lain telah didokumentasikan melalui prosedur bedah, suntikan intramuskular,
patah tulang terbuka, infeksi gigi, dan gigitan anjing. [5][6][7]

Tetanus spores are durable and can survive for prolonged periods in certain environments. The
source of infection, in most cases, is a wound, usually from a minor injury. A very common cause
of tetanus is a lack of immunization. Even those who are vaccinated lose immunity with
advancing age.

Tetanus can also develop as a consequence of chronic conditions such as abscesses and gangrene.
Furthermore, burn patients and patients undergoing surgery can also acquire the infection.

Tetanus usually occurs in persons who are not immunized, partially immunized, or fully
immunized but lack adequate booster doses.[8]

The risk factors for neonatal tetanus include the following:

1. Unvaccinated mother

2. Home delivery

3. Septic cutting of the umbilical cord

4. Neonatal tetanus in a previous child

5. Infectious substances applied to the umbilical stump, such as animal dung, mud, or other
such material

Epidemiology
Although tetanus affects people of all ages; however, the highest prevalence is seen in newborns
and young persons.[9] The World Health Organization (WHO) reports improvement in mortality
rates from tetanus, associated with aggressive vaccination campaigns in recent years. The WHO
estimates worldwide tetanus deaths in 1997 at around 275,000 with improved rates in 2011 at
14,132 cases. However, of these cases, the prevalence of tetanus is still disproportionately higher
(some studies showing 135 times higher) in low-resource settings than rates in developed
countries, with mortality rates of 20% to 45% with the infection. Mortality rates vary based on
the availability of resources, notably mechanical ventilation, invasive blood pressure monitoring,
and early treatment.[10]

The incidence of neonatal tetanus is decreasing due to routine vaccination worldwide, which is
combined with other vaccines, pertussis, and diphtheria (DPT). The occurrence of tetanus among
neonates is mostly due to incomplete vaccination of the infant. In 2013, approximately 84% of
children less than 12 months of age had coverage of tetanus worldwide.

In high-resource countries, such as the United States, cases of tetanus occur in the unimmunized
or in the elderly who have decreased immunity over time. Intravenous drug users are also at risk
owing to contaminated needles or drugs.

Tetanus is a disease of the underdeveloped world. It is more commonly found in areas where the
soil is cultivated, in warm climates, and among males. It is also more frequently seen in neonates
and children in countries where there is no immunization program in place.[11]

Pathophysiology
C. tetani secretes the toxins, tetanospasmin, and tetanolysin, causing the characteristic “tetanic
spasm,” a generalized contraction of agonist and antagonistic muscles. Specifically,
tetanospasmin affects the nerve and muscle motor endplate interaction, causing the clinical
syndrome of rigidity, muscle spasms, and autonomic instability. On the other hand, tetanolysin
damages the tissues.

At the site of inoculation, tetanus spores enter the body and germinate in the wound.
[12] Germination needs particular anaerobic conditions, such as dead and devitalized tissue that
has low oxidation-reduction potential. After germination, they release tetanospasmin into the
bloodstream.[13] This toxin enters the presynaptic terminals in the neuromuscular endplate of
motor neurons and destroys a vesicular synaptic membrane protein resulting in the inactivation
of inhibitory neurotransmission that usually suppresses motor neuron and muscle activity. This
paralyzes muscle fibers. Subsequently, this toxin, via retrograde axonal transport, travels to
neurons in the central nervous system, where it also inhibits neurotransmitter release; this occurs
approximately 2 to 14 days after inoculation. Since glycine and GABA are major inhibitory
neurotransmitters, cells fail to inhibit the motor reflex response to sensory stimulation, causing a
tetanic spasm. This can cause such powerful unopposed muscle activity and contraction that bone
fractures and muscle tears can occur.

The incubation period can last from one to 60 days but is, on average, around 7 to 10 days.
Symptom severity depends on the distance from the central nervous system, with more severe
symptoms associated with shorter incubation periods. Once the neurotoxin enters the brainstem,
autonomic dysfunction occurs, typically in the second week of symptom onset. With the loss of
autonomic control, patients can present with labile blood pressure and heart rate, diaphoresis,
bradyarrhythmias, and cardiac arrest. Symptoms can last for weeks to months, with a mortality
rate of 10% in those infected; it is even higher in those without prior vaccination. There have
been frequent motor and long-term neuropsychiatric complications in survivors; however, many
make full recoveries.[14]

History and Physical

The majority of cases of tetanus in the United States are reported in patients who are either
unimmunized or partially immunized. The median period of incubation is 7 days and for the
majority of cases, it is from 4 to 14 days. The patients sometimes recall the injury but more
commonly the injury goes unnoticed.

The clinical features of tetanus include lockjaw, grimace facial expression (risus sardonicus),
generalized muscle spasms associated with severe pains, drooling, uncontrolled urination and
defecation, and back arching spasm (opisthotonus) that may cause respiratory distress. Most
commonly, trismus appears as the first symptom, with the progression of spasms throughout the
rest of the body. Reflex spasms occur in most patients and can be triggered by nominal external
stimuli, such as noise, touch, or light.

There are four forms of tetanus based on clinical findings: generalized, neonatal, localized, and
cerebral tetanus.

Generalized tetanus is the most common form of tetanus, occurring in approximately 80% of
cases. Patients present with a descending pattern of muscle spasms, first presenting with lockjaw,
and risus sardonicus (rigid smile because of sustained contraction of facial musculature). This
can progress to a stiff neck, difficulty swallowing, and rigid pectoral and calf muscles. These
spasms can occur for up to 4 weeks, with full recovery taking months. Autonomic instability can
also occur in these patients with fever, dysrhythmia, labile blood pressure and heart rate,
respiratory difficulties, catecholamine excretion, and even early death.

Neonatal tetanus is a generalized form of tetanus that occurs in newborns of unimmunized

mothers or from infection through a contaminated instrument when cutting the umbilical cord.
Infants of immunized mothers generally do not get tetanus due to passive immunity from the
mother. Those who are infected, exhibit irritability, poor feeding, facial grimacing, rigidity, and
severe spastic contractions triggered by touch. There have been case reports of long-term
consequences in survivors of neurodevelopmental impairments, behavioral problems, and
deficits in gross motor, speech, and language development.

Localized tetanus and cephalic tetanus are the rarest forms of tetanus. Localized tetanus is the
persistent contraction of muscles at the site of injury that can persist for weeks. This type is
uncommonly fatal; however, it can progress to the generalized form of tetanus, which is more
life-threatening. Cephalic or cerebral tetanus is limited to the muscles and nerves of the head.
Cephalic tetanus occurs most commonly after head trauma such as a skull fracture, head
laceration, eye injury, dental procedures, otitis media, or from another injury site. It presents with
neck stiffness, dysphagia, trismus, retracted eyelids, deviated gaze, and risus sardonicus. The
facial nerve is most frequently involved. However, other cranial nerves can also be affected.
These findings can lead to further complications such as broncho-aspiration, paralysis of
respiratory and laryngeal muscles, and respiratory failure. This type can also progress to
generalized tetanus.

Physical examination findings can vary significantly from one patient to another. Spatula test is
one of the exam techniques that may provide a clue towards the diagnosis. It includes the
stimulation of the posterior pharyngeal wall that elicits the reflex spasm of the masseter muscles
causing the patient to bite down instead of gag.

Autonomic involvement leads to hypertension and tachycardia alternating with hypotension and
bradycardia. In extreme cases, cardiac arrest may also occur.

Patients may also present with abdominal tenderness and guarding, and that may be mistaken for
acute abdomen by the providers. Historically, exploratory laparotomies have been performed
before making the correct diagnosis.
Cephalic tetanus, although a rare form of tetanus, may present with various cranial nerve palsies.
The most commonly involved nerve is the 8th cranial nerve.

Evaluation
The diagnosis of tetanus is clinical with no particular laboratory test. Providers may find a
positive wound culture and the isolation of the organism; however, this occurs in only 30% of
cases. Key features to note when diagnosing tetanus include acute onset and muscle contractures
with generalized spasms without any other medical cause. Some patients can recall a history of
injury, but not all.

An assay for antitoxin levels, though not readily available, may help in excluding the possibility
of tetanus. A serum antitoxin level of 0.01 IU/mL or higher is generally accepted as
protective, making the possibility of tetanus less likely.

Spatula test that has been described before shows high specificity and sensitivity for the clinical
diagnosis of tetanus. This involves using a soft-tipped instrument to touch the posterior
pharyngeal wall. If this elicits an involuntary jaw contraction instead of the normal gag reflex,
this suggests a positive test.

It is important to note that infections occur in people with no immunity or low serum levels of
anti-tetanus antibodies. Life-threatening complications from tetanus can occur and include
pneumonia secondary to aspiration, laryngospasm, rhabdomyolysis, upper gastrointestinal bleed,
cardiovascular instability such as transient cardiac arrest, tachycardia, or bradycardia,
arrhythmias, hypertension, acute renal failure, and secondary wound infections. Mortality from
the infection occurs from respiratory failure and cardiovascular collapse, associated with
autonomic dysfunction.

Treatment / Management
The treatment of tetanus is based on the severity of the disease. However, all patients must have
the following goals of treatment:

1. Early wound debridement

2. Supportive management

3. Antibiotic therapy

4. Early intramuscular or intravenous administration of the human tetanus immunoglobulin

(HTIG)

5. Neuromuscular blockade

6. Controlling various manifestations

7. Managing complications

First-line treatment includes HTIG, which removes released tetanospasmin toxin; however, it
does not affect the toxin that is already bound to the central nervous system. HTIG also shortens
the course of illness and may help in reducing the severity. A dose of 500 U, either intramuscular
or intravenous, is as effective as larger doses. HTIG is injected intrathecally, especially in cases
of cerebral tetanus. In the case of generalized tetanus, therapeutic doses (3000-6000 U) are also
recommended. Debridement of the wound will control the source of toxin production.[15]
Although toxins are the main cause of disease, metronidazole has been shown to slow the
progression of the disease. Metronidazole has been shown to decrease mortality, as well.
[16] Penicillin, which was used in the past for treatment, is no longer recommended
after discovering that it may have synergistic effects with tetanospasmin. Antispasmodics such as
benzodiazepines, baclofen, vecuronium, pancuronium, and propofol have been used based on the
clinical scenario. Baclofen can also be given intrathecally and is found to be effective in
controlling muscle rigidity.[17][18][19]

For more severe tetanus, patients are likely hospitalized in the intensive care unit (ICU) with
sedation and mechanical ventilation, which can affect mortality and long-term sequelae.
Tracheostomy is preferred because endotracheal tubes may be a stimulus for muscle spasms.
Tracheostomy is also indicated in cases where intubation is required for more than 10 days.

Benzodiazepines are considered a cornerstone therapy for tetanus manifestations, and diazepam
is the most frequently studied and utilized drug in this regard. It not only reduces anxiety but also
causes sedation and relaxes muscles, thereby preventing lethal respiratory complications.
Intravenous magnesium has been shown to prevent muscle spasms. Diazepam or midazolam,
GABA-agonist benzodiazepines, are given as a continuous infusion to prevent respiratory or
cardiovascular complications. To prevent spasms that last more than 5-10 seconds, diazepam
should be administered IV, 10-40 mg every 1-8 hours. The dose of midazolam is 5-15 mg/hour
IV.

Providers must also provide supportive care, especially for patients with autonomic instability
(labile blood pressure, hyperpyrexia, hypothermia). Magnesium is often used in combination
with benzodiazepines to manage these complications.[20] It should be given IV in the form of a
bolus of 5 g followed by a continuous infusion at a rate of 2-3 g/hour until the spasm control has
been achieved.[21] During magnesium infusion, the patellar reflex needs to be monitored; if
areflexia develops, the dose should be reduced. Morphine is often used to manage high blood
pressure. Beta-blockers can cause hypotension and death. Esmolol in small doses can be used
under strict monitoring.

Providing high-calorie diets to compensate for increased metabolic use from muscle contractions
is also important.

Management of respiratory status, cardiovascular complications, and autonomic dysfunction are

essential for survival. Moreover, all patients require full tetanus toxoid immunization at recovery;
having the infection does not give future immunity.[22][23]

Differential Diagnosis
The only condition that mimics tetanus the most is strychnine poisoning. One of the typical
symptoms of tetanus is trismus which may be present in many other conditions. Those conditions
are mentioned below:

Localized infections

Hysteria

Neoplasms

Malignant hyperthermia

Stimulant drugs
 Acute abdomen

Dystonic drug effects

Serotonin syndrome

Black widow spider envenomation

Stiff person syndrome

Prognosis
The prognosis after tetanus depends on the time from the first symptom to the first spasm. In
general, with a short time to symptom manifestation, the prognosis is poor. The recovery after
tetanus is slow and it can take months. Both neonatal and cephalic tetanus have a poor prognosis.

Some patients develop hypotonia and autonomic dysfunction that lasts for months or years. Even
those who survive, need tetanus toxoid as the infection does not confer immunity. Usually,
patients survive this illness although recovery is slow and some patients may remain hypotonic.

An established scale can be used to predict the prognosis of tetanus. One point is given for each
of the following:

Incubation - shorter than 7 days

Onset - less than 48 hours

Causes of tetanus - burns, surgical wounds, septic abortion, umbilical stump, open
fractures, or intramuscular injection

Addiction to opiates

Generalized tetanus

Temperature - more than 104 F (40 C)

Tachycardia - more than 120/min (150/min in neonates)

The total score indicates disease severity:

0-1 - mortality of less than 10%

2-3 - mortality of 10-20%

4 - mortality of 20-40%

5-6 - mortality of more than 50%

Complications
Complications include contractions of respiratory muscles, vocal cords, and other critical areas
of the body.[24] Sympathetic overactivity is the most significant cause of tetanus-associated
mortality in critical patients. Further complications include:

Vocal cord paralysis leading to respiratory distress

Autonomic dysfunction- leading to hypertension

 Asphyxia

Long bone fractures

Paralytic ileus

Joint dislocation

Aspiration pneumonia

Pressure sores

Stress ulcers

Coma

Nerve palsy

Urine retention

Seizures

Consultations
The primary provider should be an intensivist as this is a disease that needs critical care and
robust monitoring. However, the following specialties should be consulted in order to reduce
morbidity and mortality:

1. Infectious diseases

2. Toxicology - to rule out strychnine poisoning

3. Neurology - to preclude other causes of seizures

4. Pulmonary medicine - for respiratory compromise and mechanical ventilation

5. Anesthesiology - for the administration of intrathecal drugs, such as baclofen

Deterrence and Patient Education

The importance of childhood immunizations and boosters must be stressed. In developing and
underdeveloped countries midwives and birth attendants should be given training in aseptic birth
procedures. The basics of first aid and wound care should be taught to all. The early recognition
of signs and symptoms of localized tetanus and timely seeking medical care is very essential.
Healthcare workers, including nurses and pharmacists, must emphasize the importance of
immunization. The tetanus vaccination has been considered as a routine vaccine in addition to
pneumococci and influenza vaccines among older adults. Protection against tetanus by vaccines
is essential because there is no natural immunity against tetanus. The tetanospasmin toxin is very
lethal and will cause death before initiating an immune response. After recovery from an
infection, patients must receive full immunity. In addition, post-exposure prophylaxis can also be
provided through tetanus toxoid with or without tetanus immunoglobulin intravenous or
intramuscular, depending on the wound.

Enhancing Healthcare Team Outcomes

Tetanus is a lethal infection, and it is best managed by an interprofessional team that includes an
emergency department provider, nurse practitioner, infectious disease expert, neurologist,
pulmonologist, and intensivist.

The treatment of tetanus is based on the severity of the disease. However, all patients must have
early wound debridement, antibiotic therapy, early intramuscular or intravenous administration of
the human tetanus immunoglobulin (HTIG), and neuromuscular blockade. Patients with severe
symptoms should be admitted to the ICU for close monitoring and mechanical ventilation.
Healthcare providers must also provide supportive care, especially for patients with autonomic
instability (labile blood pressure, hyperpyrexia, hypothermia). Moreover, all patients require full
tetanus toxoid immunization at recovery. For those who are treated with tetanus toxoid, recovery
is assured, but the rehabilitation may take weeks or months.[25]

Only with an interprofessional approach with regular education of the public can the morbidity
and mortality of tetanus be lowered.

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Disclosure: Crystal Bae declares no relevant financial relationships with ineligible companies.

Disclosure: Daniele Bourget declares no relevant financial relationships with ineligible companies.

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