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- Tetanus is characterized by muscle rigidity and spasms due to production of a neurotoxin in infected wounds by Clostridium tetani, an anaerobic spore-forming gram-positive bacillus.
- There are four clinical forms of tetanus: generalized, neonatal, localized, and cephalic.
- Tetanus is rare in the United States, with an average of 29 reported cases per year. Nearly all cases are in unvaccinated individuals.
- Rare cases have been reported in patients with protective levels of antitetanus antibodies.
- Tetanus continues to occur in countries in which mothers are not immunized and nonsterile care of the umbilical cord is practiced. Worldwide, it is estimated that >250,000 deaths from neonatal tetanus occurred between 2000 and 2003.
- Generalized tetanus is the most common form of disease.
- Inadequate immunization
- Neonate born to unimmunized mother
- Elderly with declining immune status
- Injection drug use
- Chronic wounds
- Acute traumatic injury
- Foreign bodies
- Nonsterile delivery conditions and practice of applying mud or feces to umbilical cord
- All wounds should be cleaned with soap and water and foreign bodies should be removed.
- Universal immunization with tetanus toxoid (For details and information on catch-up schedules, refer to Centers for Disease Control and Prevention (CDC) Web site.)
- Tetanus postexposure prophylaxis should be initiated at the time of injury:
- For clean minor wounds:
- If patient has had ≥3 prior doses of tetanus toxoid (DTaP, Tdap, or Td) and it has been <10 years since the last dose, no prophylaxis is indicated; if it has been ≥10 years since last dose, give tetanus toxoid.
- If patient has had <3 prior doses of tetanus toxoids, give tetanus toxoid.
- For all other wounds:
- If patient has had ≥3 prior doses of tetanus toxoid and it has been <5 years since the last dose, no prophylaxis is indicated; if it has been ≥5 years since the last dose, give tetanus toxoid.
- Patients with <3 prior doses of tetanus toxoid should receive tetanus immune globulin (TIG) and tetanus toxoid at separate sites.
- Patients with HIV or severe immunodeficiency should receive TIG regardless of prior immunization history.
- In neonates or infants <6 months of age who have not received 3 doses of DTaP, the decision to use TIG should be based on mother’s tetanus immunization status; if unknown or inadequate, should give TIG
- Type of tetanus toxoid to use for prophylaxis:
- For children <7 years old, use DTaP; if pertussis vaccine is contraindicated, use DT.
- For a child 7 to 10 years old, use Tdap.
- For an adolescent 11 to 18 years old who has not received Tdap, use Tdap; for those who have received Tdap or for those whom pertussis is contraindicated, use Td.
- TIG dose is 250 U IM for wound prophylaxis (regardless of age or weight); if TIG is unavailable, use IV immunoglobulin (IVIG) or tetanus antitoxin (TAT).
- Because TAT is equine in origin, test patient for sensitivity prior to use.
- TAT is no longer available in the United States.
- For clean minor wounds:
- C. tetani produces tetanospasmin, a powerful metalloprotease neurotoxin.
- Tetanospasmin can be absorbed directly into skeletal muscles adjacent to the injury.
- Tetanospasmin can travel to the CNS via retrograde axonal transport through peripheral nerves or via lymphocytes.
- In the CNS, tetanospasmin prevents the release of γ-aminobutyric acid (GABA) and glycine in inhibitory nerve terminals, resulting in sustained excitatory discharges (motor spasms and increased muscle tone) and autonomic instability; tetanospasmin does not directly affect cognitive processes.
- In the peripheral nervous system, tetanospasmin may block inhibitory impulses to motor neurons.
- Loss of regulation of adrenal catecholamine release precipitates tachycardia, hypertension, and sweating.
- Infection does not confer immunity; all patients need to be immunized during recovery.
- Tetanus is caused by C. tetani, a spore-forming, anaerobic gram-positive bacillus.
- C. tetani is found in soil, animal and human feces, house dust, and salt and fresh water.
- Under anaerobic conditions, spores become vegetative and produce tetanospasmin; anaerobic conditions in wounds are promoted by extensive necrosis, foreign bodies, or other suppurative infections.