PEDI | Tetanus

Tetanus is an acute, potentially fatal disease caused by the neurotoxin of the bacterium Clostridium tetani. While the spores are ubiquitous in the environment, the disease is entirely preventable through vaccination.

Pathology and Clinical Presentation

• Mechanism: C. tetani spores, found in soil and animal manure, enter the body through wounds. In anaerobic conditions (lack of oxygen), spores germinate and produce tetanospasmin, a potent neurotoxin.

• Neurotoxicity: The toxin disseminates via blood and lymphatics to the central nervous system, where it blocks inhibitory neurotransmitters. This results in unopposed muscle contraction and severe spasms.

• Symptoms: The incubation period averages 8 days (range 1–21 days).

◦ Trismus (Lockjaw): The most common early sign, followed by neck stiffness and difficulty swallowing.

◦ Generalized Rigidity: Abdominal stiffness and painful spasms that can fracture bones or cause respiratory failure (laryngospasm).

◦ Fatality: Approximately 11% of cases are fatal, often due to respiratory or cardiac complications.

Vaccination Protocols (Prevention)

Immunization is the primary defense, as recovering from the disease does not confer immunity.

• Children (DTaP): The CDC recommends a 5-dose series of Diphtheria, Tetanus, and acellular Pertussis vaccine at ages 2, 4, 6 months, 15–18 months, and 4–6 years.

• Adolescents & Adults (Tdap/Td):

◦ Adolescents receive a Tdap booster at age 11–12.

◦ Adults should receive a booster (Td or Tdap) every 10 years.

• Pregnancy: Women should receive a Tdap dose during every pregnancy (weeks 27–36) to pass immunity to the infant and prevent neonatal tetanus.

Clinical Management and Wound Prophylaxis

Diagnosis is clinical; there are no effective laboratory tests. Treatment focuses on neutralizing the toxin and supportive care.

• Immediate Treatment: Airway maintenance, sedation for spasms, and thorough wound cleaning.

• Tetanus Immune Globulin (TIG): Recommended for active cases to remove unbound toxin. TIG provides temporary immediate immunity.

• Antibiotics: Secondary to wound cleaning and immunization; prophylaxis alone is not useful.

The "Dirty Wound" Decision Matrix Clinicians must decide between giving a vaccine booster, TIG, or both, based on the wound type and vaccination history:

Vaccination History

Clean, Minor Wound Action

All Other Wounds (Dirt, Feces, Puncture)

Unknown or <3 doses

Give Vaccine (No TIG)

Give Vaccine + TIG

3+ doses

No action unless >10 years since last dose

No action unless >5 years since last dose

Key Takeaway: For dirty or complex wounds, the threshold for a booster drops from 10 years to 5 years, and those with incomplete vaccination history require immediate passive immunity via TIG