Acute tetanus

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  • C. tetani spores enter skin through wound, make tetanospasmin toxin
    • Lacerations, abrasions, puncture wounds
    • Preferentially binds GABA and glycinergic neurons and blocks pre-synaptic release
      • Motor neurons undergo sustained excitatory discharge
  • Spores found in soil and human feces
  • 2001-2008 in US, 233 cases, 26 deaths
  • Mortality as high as 45%
  • Incubation is 2 to 56d
  • The majority of clinical tetanus happen in the elderly.[1]

Clinical Features


  • From umbilical stump infection. Usually protected by passive maternal Abs
  • Symptoms - poor suck, irritability, crying, grimacing
  • Usually with in 10 d of birth


  • Rigidity of muscles near wound- may progress to generalized


  • Most common form
  • PTs are conscious and alert
  • Hypersympathetic state with sweating, hypertension, tachycardia, fever


  • Follow injuries to head or otitis media
  • Get cranial nerve dysfunction- usually cranial nerve 7

Differential Diagnosis

Jaw Spasms


  • Diagnosis is clinical
  • Progressive symptoms[2]
    • Alert and able to communicate
    • Trismus - lockjaw (50%-75% of patients)
    • Sardonic smile (risus sardonicus) - other facial muscles become involved
    • Minor stimuli such as touch or noise start tetanic contractions
    • Abd, back, diff swallowing
    • Long bone fractures, tendon rupture
    • Opisthotonus - contractures that resemble decorticate posturing


  • Before wound debridement, immunoglobulin (TIG) directly into the wound and IM
    • Dose: 3000-6000 units IM with adequate mL to wound
    • Does not reverse toxin already bound to CNS. Binds circulating toxin
  • Tetanus toxoid

Supportive Care

  • Place patient in a quiet room
  • Provide sedation with Benzodiazepines or phenobarbital
  • Respiratory management
  • Autonomic dysfunction management with magnesium sulfate or labetalol, morphine and clonidine



  • Although once the drug of choice it is now no longer recommended since it may potentiate the effect of tetanus toxin by inhibiting the GABA receptors[3]

See Also


  1. Talan DA, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med. 2004 Mar;43(3):305-14.Pubmed
  2. Fernandez-Frackelton M: Bacteria, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 127:p 1681-1686
  3. Ganesh Kumar AV. Benzathine penicillin, metronidazole and benzyl penicillin in the treatment of tetanus: a randomized, controlled trial .Ann Trop Med Parasitol. 2004 Jan;98(1):59-63 PMID 15000732
Moll JL, Carden DL. Tetanus. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. Accessed December 01, 2017.