Lockjaw Tetanus is infection of the nervous system with the potentially deadly bacteria Clostridium tetani (C. tetani).

Causes, incidence, and risk factors Spores of the bacteria C. tetani live in the soil and are found around the world. In the spore form, C. tetani may remain inactive in the soil, but it can remain infectious for more than 40 years. Infection begins when the spores enter the body through an injury or wound. The spores release bacteria that spread and make a poison called tetanospasmin. This poison blocks nerve signals from the spinal cord to the muscles, causing severe muscle spasms. The spasms can be so powerful that they tear the muscles or cause fractures of the spine. The time between infection and the first sign of symptoms is typically 7 to 21 days. Most cases of tetanus in the United States occur in those who have not been properly vaccinated against the disease. Tetanus often begins with mild spasms in the jaw muscles (lockjaw). The spasms can also affect the chest, neck, back, and abdominal muscles. Back muscle spasms often cause arching, called opisthotonos. Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems. Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups. This is called tetany. These episodes can cause fractures and muscle tears. Other symptoms include drooling, excessive sweating, fever, hand or foot spasms, irritability, swallowing difficulty, uncontrolled urination or defecation. Tetanus affects skeletal muscle, a type of striated muscle used in voluntary movement. The other type of striated muscle, cardiac or heart muscle, cannot be tetanized because of its intrinsic electrical properties. Mortality rates reported vary from 48% to 73%. In recent years,[when?] approximately 11% of reported tetanus cases have been fatal. The highest mortality rates are in unvaccinated people and people over 60 years of age.[3] The incubation period of tetanus may be up to several months but is usually about eight days.[4][5] In general, the further the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the more severe the symptoms.[6] In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, four different forms of tetanus have been described.[3]

Generalized tetanus is the most common type of tetanus, representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is trismus, or lockjaw, and the facial spasms called risus sardonicus, followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. Spasms continue for up to 4 weeks, and complete recovery may take months. Neonatal tetanus is a form of generalized tetanus that occurs in newborns. Infants who have not acquired passive immunity because the mother has never been immunized are at risk. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. Neonatal tetanus is common in many developing countries and is responsible for about 14% (215,000) of all neonatal deaths, but is very rare in developed countries.[7] Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus. Cephalic tetanus is a rare form[8] of the disease, occasionally occurring with otitis media (ear infections) in which C. tetani is present in the flora of the middle ear, or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area

Other symptoms include:

Drooling Excessive sweating Fever Hand or foot spasms Irritability Swallowing difficulty Uncontrolled urination or defecation

Signs and tests Your doctor will perform a physical exam and ask questions about your medical history. No specific lab test is available to determine the diagnosis of tetanus.

Treatment Treatment may include:

and quiet environment for the patient. Avoid unnecessary procedures and manipulations. Seriously consider prophylactic intubation in all patients with moderate-to-severe clinical manifestations. Intubation and ventilation are required in 67% of patients.

Antibiotics, including penicillin, clindamycin, erythromycin, or metronidazole (metronidazole has been most successful) Bedrest with a nonstimulating environment (dim light, reduced noise, and stable temperature) Medicine to reverse the poison (tetanus immune globulin) Muscle relaxers such as diazepam Sedatives Surgery to clean the wound and remove the source of the poison (debridement)

Attempting endotracheal intubation may induce severe reflex laryngospasm; prepare for emergency surgical airway control. Rapid sequence intubation techniques (eg, with succinylcholine) are recommended to avoid this complication. Perform tracheostomy in patients requiring intubation for more than 10 days. Tracheostomy has also been recommended after onset of the first generalized seizure.

Breathing support with oxygen, a breathing tube, and a breathing machine may be necessary. Complications

Nursing Management: Nursing Considerations Although nurses in the United States rarely have the opportunity to manage a patient who has tetanus, they still must be prepared to deliver competent care. The toxins can cause intense muscle spasms and autonomic nervous system dysfunction. Astute and prompt recognition of complications followed by proficient intervention is crucial. During the course of tetanus, patients linger in a vulnerable state in which unrecognized or untreated complications of therapy can be overwhelming. An extensive assessment should form the foundation in developing the plan of care. Collaborative actions by the nursing staff with other members of the interdisciplinary team can sustain patients while the disease is being treated. Outcome criteria for patients with tetanus should include (1) maintenance of the airway; (2) prevention of the complications of respiratory dysfunction, such as atelectasis; (3) treatment of autonomic nervous system dysfunction, such as cardiac dysrhythmias; (4) maintenance of proper gastrointestinal function; (5) maintenance of skin integrity; and (6) compliance with the prescribed immunization schedule. Different aspects of nursing involved here are neurological considerations; pulmonary consideration; wound management;administration of antitoxin ; cardiovascular considerations; immobility considerations, Psychosocial ; GI and metabolic and rehab phase. Penicillin, the drug of choice in tetanus, may potentiate the effect of tetanus toxin by inhibiting the type-A (GABAA) receptor for gamma-amino-n-butyric acid. Metronidazole has therefore been suggested as an alternative. Intramuscular benzathine penicillin (1.2

Airway obstruction Respiratory arrest Heart failure Pneumonia Fractures Brain damage due to lack of oxygen during spasms

Calling your health care provider Call your health care provider if you have an open wound, particularly if:

You are injured outdoors. The wound has been in contact with soil. You have not received a tetanus booster (vaccine) within 5 years or you are not sure of your vaccination status.

Call for an appointment with your health care provider if you have never been immunized against tetanus as an adult or child, if your children have not been immunized, or if you are unsure of your tetanus immunization (vaccine) status. Treatment of tetanus is directed toward the treatment of muscle spasm, prevention of respiratory and metabolic complications, neutralization of circulating toxin to prevent the continued spread, and elimination of the source. Admit patients to the intensive care unit (ICU). Because of the risk of reflex spasms, maintain a dark

million units as a single dose; N=56), enteral metronidazole (600 mg every 6 h for 10 days; N=55) and intravenous benzyl penicillin (2 million units every 4 h for 10 days; N=50) were therefore compared, in a randomized, controlled trial, among patients with all grades of tetanus. On presentation, the three treatment groups were similar in terms of age and sex distributions, immune statuses, durations of illness, and their APACHE-II scores and Ablett's grades of tetanus. Of the patients given benzathine penicillin, 36 required tracheostomy, 10 neuromuscular blockade, and 23 mechanical ventilation; the corresponding numbers for the metronidazole (34, 12 and 18, respectively) and benzyl-penicillin groups (39, 12 and 25, respectively) were similar (P>0.10). The incidences of dysautonomia and nosocomial pneumonia and the numbers of inhospital deaths (26 with benzathine penicillin, 19 with metronidazole and 22 with benzyl penicillin; P=0.392) were also similar in each treatment arm. The length of the hospital stay was longer in the patients receiving benzyl penicillin than in the benzathine-penicillin or metronidazole groups, with means (S.D.) of 21.9 (15), 16.9 (11) and 19.9 (15) days, respectively, but the difference was not statistically significant (P=0.09). Although the three antibiotic regimens investigated appear equally effective, benzathine penicillin offers the convenience of a single, intramuscular injection instead of the 10 days of therapy needed with the other two drugs. Tetanus toxoid vaccine can help prevent tetanus. Tetanus toxoid vaccine is made for people 7 years of age and older. After a person completes the primary immunization schedule, a tetanus toxoid booster dose is needed every 10 years all through life. Talk to your doctor about the tetanus immunization and booster schedule.Anti-tetanus serum is a preparation of tetanus antibodies administered for the prevention and treatment of tetanus, also known as lockjaw, a serious bacterial infection. In patients with tetanus, bacteria in the body produce a compound known as tetanus toxoid, leading to muscle spasms and decreased muscle control. The condition can be fatal once the airway is involved and the patient is having trouble breathing. It is preventable with anti-tetanus serum. Terms like tetanus immune globulin may also be used to refer to this preparation. Historically, it has been produced by stimulating animals to produce tetanus antibodies and preparing a serum from their blood. Routine tetanus vaccination introduces the body to antibodies of tetanus, providing passive immune protection. The body can also start making its own antibodies. The passive nature of the protection is one reason why people need periodic boosters, to make sure protection is present in the event of tetanus exposure. The vaccine is routinely given in a combination vaccination for tetanus, diphtheria, and pertussis (DPT). When people are at special risk of developing tetanus, as is the case with puncture wounds with unclean

materials, an administration of anti-tetanus serum may be given to jolt the immune system into action with the goal of trapping any tetanus toxin produced in the body before it has a chance to lock on to muscles. Serum is also used in the treatment of patients with known tetanus infection. Mild tetanus Mild cases of tetanus can be treated with: tetanus immunoglobulin IV or IM metronidazole IV for 10 days diazepam Severe tetanus Severe cases will require admission to intensive care. In addition to the measures listed above for mild tetanus: human tetanus immunoglobulin injected intrathecally (increases clinical improvement from 4% to 35%) tracheotomy and mechanical ventilation for 3 to 4 weeks magnesium, as an intravenous (IV) infusion, to prevent muscle spasm diazepam as a continuous IV infusion the autonomic effects of tetanus can be difficult to manage (alternating hyper- and hypotension hyperpyrexia/hypothermia) and may require IV labetalol, magnesium, clonidine, or nifedipine. Drugs such as diazepam or other muscle relaxants can be given to control the muscle spasms. In extreme cases it may be necessary to paralyze the patient with curarelike drugs and use a mechanical ventilator. In order to survive a tetanus infection, the maintenance of an airway and proper nutrition are required. An intake of 3500-4000 calories, and at least 150 g of protein per day, is often given in liquid form through a tube directly into the stomach (percutaneous endoscopic gastrostomy), or through a drip into a vein (parenteral nutrition). This high-caloric diet maintenance is required because of the increased metabolic strain brought on by the increased muscle activity. Full recovery takes 4 to 6 weeks because the body must regenerate destroyed nerve axon terminals.