Tetanus
Clinical forms
- Generalized tetanus (most common form — 80% %): Incubation 3–21 days (median 7 days) → the shorter the incubation period, the more severe the prognosis → invasion phase: trismus (masseter muscle contracture → inability to open the mouth — first sign in 75 % of cases) + risus sardonicus (facial muscle contraction → characteristic grimace) → state phase: opisthotonus (arching of the back + neck + limbs due to simultaneous contraction of extensor + flexor muscles) + intense paroxysmal spasms triggered by any stimulus (noise + light + touch) → asphyxia due to spasm of respiratory muscles → risk of death from respiratory arrest + dysautonomia (tachycardia + hypertension + hypotension + arrhythmias)
- Localized tetanus contractures limited to muscles adjacent to the inoculation wound + more favorable prognosis + may progress to generalized tetanus
- Cephalic tetanus (Rose's form): face or head wound → cranial nerve involvement (facial paralysis + trismus + oculomotor nerve involvement) + frequent progression to generalized tetanus + poor prognosis
- Neonatal tetanus: Umbilical cord contamination during non-sterile deliveries + developing countries ++ + infant with feeding difficulties + trismus + spasms + mortality 70-100% % without treatment
Treatment
- Mandatory intensive care hospitalization: Quiet environment + dim lighting + minimized stimuli (spasms are triggered by any external stimulus) + continuous monitoring + peripheral IV line + preparation for emergency orotracheal intubation if laryngeal or respiratory spasm occurs
- Toxin neutralization — human tetanus immune globulins (TIG): 3,000–6,000 IU IM in one or more injections (adult dose) + neutralizes circulating toxin not yet bound to neurons → does NOT neutralize toxin already bound to the nervous system → must be administered as soon as possible + concurrently with wound debridement (at an anatomical distance to avoid neutralization of IGAT by local toxin) + tetanus toxoid vaccine must be administered simultaneously at a different site (tetanus does not confer lasting immunity)
- Surgical debridement of the wound: excision of large necrotic tissue + cleaning + debridement (oxygenation → inhibits anaerobic bacteria growth) + after administration of IGAT
- Antibiotic therapy: metronidazole 500 mg IV q6h x 7-10 days (treatment of choice) + or penicillin G 1-2 million units IV q4-6h (alternative) → eliminates vegetative bacteria + reduces toxin production
- Spasm control Benzodiazepines (IV diazepam 5–10 mg + or midazolam) → sedation + central muscle relaxation + high doses necessary + intrathecal baclofen (refractory forms) + IV magnesium sulfate (reduces neurotransmitter release + muscle relaxation + treatment of dysautonomia)
- Dysautonomia Management: labetalol IV + or morphine + or magnesium sulfate + or dexmedetomidine → hypertension + paroxysmal tachycardia with poor prognosis + thoracic epidural block in severe forms
- Mechanical ventilation laryngeal spasms + respiratory insufficiency + or spasm control requiring muscle relaxation → early tracheotomy recommended (long predictable duration)
Prevention — Tetanus Vaccination
| Situation | Action to take |
|---|---|
| Primary vaccination (infant) in Quebec | DTaP-IPV-Hib-HepB at 2 + 4 + 6 months + booster at 18 months + DTaP-IPV booster at 4 years + DTaP booster at 14–16 years |
| Adult — Decennial reminder | dTap (diphtheria + tetanus + acellular pertussis) booster every 10 years → not permanent protection → very often overlooked in adults (leading cause of tetanus in Canada) |
| Minor wound + up-to-date vaccination (last dose < 10 years ago) | Wound cleaning + no tetanus treatment needed |
| Minor wound + incomplete or expired vaccination (≥ 10 years) | Tetanus, Diphtheria, and Pertussis Vaccine (DTaP) 1 IM dose |
| High-risk wound (soiled + deep + necrotic + bite + burn + puncture) + up-to-date vaccination | Cleaning + debridement + dTap vaccine if last dose > 5 years |
| High-risk wound + incomplete or unknown vaccination | IGAT 250 IU IM (passive prophylaxis) + dTap vaccine simultaneously (different site) + complete primary vaccination |
| Pregnancy | Tdap vaccine recommended for every pregnancy (27–32 weeks) → passive protection of newborn + placental transfer of maternal antibodies |
Call 911 or go to the emergency room immediately if an unvaccinated person (or if vaccination status is unknown or expired) has jaw stiffness (trismus) + difficulty swallowing + stiff neck + or muscle spasms after a dirty wound – these signs suggest early tetanus, a medical emergency requiring immediate intensive care hospitalization. For tetanus vaccination updates (Tdap booster) + post-exposure prophylaxis (TIG + vaccine) after at-risk wounds, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's physician associates and nurse practitioners (NPs) assess tetanus vaccination status during all wound consultations, prescribe appropriate post-exposure prophylaxis (TIG + DTaP vaccine based on vaccination status and wound type), administer decade-long DTaP booster shots in adults, recommend the DTaP booster during pregnancy (27–32 weeks), and immediately refer patients to the emergency room at the slightest suspicion of early-stage tetanus. Consultations are available at several service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not substitute for medical advice. Tetanus is a medical emergency with a mortality rate of 10-30% % even with modern intensive care. Prevention through vaccination is the only effective strategy—ten-year dTap boosters are essential in adults as protection wanes over time. Recovery from tetanus does not confer lasting immunity.
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