Tetanus is a term that most of us are familiar with. It occurs when a specific bacteria, known as Clostridium tetani, enters our bodies through wounds. Even though it is rare, tetanus can be extremely dangerous and perhaps fatal if left untreated.^{1, 2} 

The problem is that we frequently overlook something crucial in properly taking care of our wounds! Ensuring the cleanliness, protection, and treatment of our wounds is crucial to prevent tetanus infection. But before exploring this further, it’s important to understand what tetanus is and how you could get it.

Understanding tetanus

Causative agent

The causative agent is Clostridium tetani which is an anaerobic spore-forming bacillus. It produces a neurotoxin, which produces tetanus. This bacteria may be found in the digestive tracts and faeces of horses and other animals. The spores of Clostridium tetani are widely distributed throughout the ecosystem, especially in the soil, and can endure even the harshest conditions for extended periods. The transmission of these tetanus spores into our wounds can result in infection.³

How do you get tetanus?

Once the bacteria Clostridium tetani enter your body through a cut, wound, or scratch, they produce a toxin called tetanospasmin. This toxin travels to your nervous system and blocks signals that normally control muscle contractions. This can lead to your muscles becoming very stiff and resulting in painful spasms. Moreover, the toxin disrupts the autonomic nervous system, triggering symptoms like profuse sweating, rapid heartbeat, and elevated blood pressure.⁴

Symptoms and complications

The condition typically takes 3 to 21 days to incubate, although it can take as little as one day or many months based on the kind, location, and size of the wound.

Early symptoms include:

• Headache
• Trismus (lockjaw)
• Stiff neck
• Having trouble swallowing
• Abdominal muscle rigidity
• Muscle spasms
• Sweating

Common severe signs include:

• Opisthotonos (a kind of body stiffness)
• Periods of apnea
• Rigid abdominal wall
• Problems with involuntary bodily functions
• Risk of cardiac arrest^{2, 3, 5}

Risk factors

Although tetanus is uncommon, there is a greater risk if:

• You have a severe or substantial wound
• The cut appears quite unclean, or something seems to be trapped in it
• You have not had all the recommended vaccinations²

High-risk wounds for tetanus

The features of the wound directly link to the risk of contracting tetanus. The least probable site for getting tetanus is a newly acquired lesion with sharp edges that is highly vascularized and uncontaminated⁵. Every other wound is thought to be tetanus-prone.

Wounds typically susceptible to tetanus/High-risk wounds include:

• Puncture-type wounds obtained in a polluted environment are probable to have tetanus spores. e.g., wounds involving gardening injuries, and contaminations with substances that might be tetanus spore-containing, such as dirt and manure
• Wounds that are stellate, ischemic, infected (including abscesses), or exposed to faeces or saliva
• Some animal bites and scratches
• Wounds with foreign bodies present, like splinters
• Wounds displaying a significant amount of devitalized tissue or that result in systemic sepsis.
• Wounds requiring surgery that is postponed for more than six hours, even in cases where the contamination was not originally severe
• Deeper cuts (>1 cm)
• Avulsions or crush injuries^3,5

Importance of proper wound management

Proper wound care is crucial for preventing tetanus infection as well as for promoting faster healing. The following steps can be taken to ensure proper wound care.

Cleaning the wound

• Cleaning the wound properly with water and mild soap is the first and most crucial procedure. This aids with the removal of impurities such as dirt, bacteria, and other contaminants that can infect you
• To further disinfect the wound, apply an antiseptic solution (such as hydrogen peroxide or povidone-iodine) after cleaning. This lowers the possibility of bacterial infection
• Examine the wound to make sure there are no splinters, glass, or other debris present. To stop infection and promote healthy healing, carefully remove any foreign items with sterile tweezers
• If there is embedded or deep debris, get medical help right away to prevent more tissue injury 

Assessing the wound

• Basic first aid generally heals minor cuts and abrasions. After cleaning the area, bandage it with adhesive tape
• Apply pressure to halt the bleeding and seek medical assistance for deeper cuts, punctures, or wounds that are heavily bleeding. Medical procedures, such as sutures, may be necessary for deep wounds
• Also, make sure to assess if the wound falls into the high-risk category for tetanus 
• You also need to examine your history of tetanus vaccinations. See a healthcare professional about the necessity of a tetanus booster or tetanus immune globulin if you are unsure or if it has been more than five years since the previous booster

Dressing and protection

• Maintaining a moist wound environment with the right dressings is important. This could speed up healing and lessen scarring
• Adhesive bandages can shield and maintain the cleanliness of small wounds, and abrasions
• Cover bigger wounds with sterile gauze pads to prevent infection. Breathable gauze aids in the absorption of any exudate
• Until the wound heals enough, change the dressing regularly and keep it covered

Monitoring and follow-up

• Monitoring the wound and providing adequate follow-up is crucial to ensuring that your wound has not gotten infected. 
• An infection may be indicated by persistent redness and swelling surrounding the wound site.
• Any combination of pus, an unpleasant smell, or more discharge coming from the cut indicates an infection and requires immediate medical treatment^{6, 7, 8, 9 , 10}

When to seek medical attention 

Seek medical attention right once: 

• If the wound does not heal or gets worse in a few days
• If the cut is deep, doesn't stop bleeding, and exhibits symptoms of infection, or if you don't know how to take care of it correctly. A medical expert can evaluate the wound and administer the proper care

The NHS recommends requesting an immediate GP appointment or calling 111 for assistance if:

• You don't know if you have had the entire tetanus vaccination, or if you haven't received it
• Despite your best efforts, if there is still dirt or soil in the wound
• The wound is swollen or heated, painful, redder than the adjacent skin, or darker than that.
• You feel hot and uncomfortable, or your temperature is elevated¹

Treating wounds to prevent tetanus

Preventive treatment for tetanus depends on:

• Your previous immunisation status
• The type of wound (low-risk vs. high-risk)⁴

If you want to learn more about the vaccination schedule and the rationale behind it, see this article on tetanus prophylaxis.⁴

Special considerations

• For pregnant women, regardless of the last dosage, the Tetanus, Diphtheria, and Pertussis vaccine (Tdap) is advised between weeks 27 and 36 of every pregnancy and three doses spaced over four weeks, if the pregnant woman is not immunised
• For HIV/AIDS patients, TIG is required independent of wound categorization or immunisation status⁴

Initial supportive therapy for tetanus

• To neutralise the tetanus toxin that is circulating in your bloodstream, TIG is administered initially.
• Neuromuscular blocker therapy combined with intubation and mechanical ventilation should be taken into consideration in cases of moderate-to-severe tetanus
• Tracheostomy is advised because of the possibility of reflex spasms upon intubation and for hospital stays longer than ten days
• Early wound debridement is advised initially, as this can both eliminate spores and stop them from germinating. Given the possibility of further tetanus toxin release during wound tampering, debridement should be done following antitoxin treatment¹¹

Pharmacologic therapy for tetanus

Elimination of toxin production

The amount of spores of Clostridium tetani in the wound is reduced with the administration of antimicrobials. These include:

• Metronidazole: g every 6 hours 
• Alternative Antimicrobials: Clindamycin, erythromycin, tetracycline, and Vancomycin

Neutralisation of unbound toxin

• TIG: 250-500 units intramuscular (IM) for children and adults
• WHO Recommendation: 250 units IM or intravenously (IV); 500 units for older wounds (>12 hours), extensive contamination, or patients >90 kg
•  Tetanus Toxoid (TT) vaccine or Tetanus and Diphtheria Toxoids vaccine (Td) (0.5 mL) IM or deep subcutaneous for >10 years; Diphtheria and Tetanus vaccine (DT) vaccine for <10 years
• Centres for Disease Control and Prevention Recommendation: 250 units TIG IM for contaminated wounds and unknown/inadequate vaccination history¹¹

Unlike some diseases that leave you immune after recovery, tetanus doesn't grant you any lasting immunity. Therefore, patients who have never received a primary TT vaccine should receive a 2nd dose 1-2 months following the initial dose and a 3rd dose 6–12 months afterwards.¹¹

Control of disease manifestations

Drugs for controlling muscular spasms and relieve symptoms:

• Benzodiazepines: Diazepam every 1-8 hours), Lorazepam (effective alternative)
• Alternatives for Spasms: Vecuronium (continuous infusion), Pancuronium (intermittent injection), and (Midazolam)
• Other Agents: Phenobarbital, baclofen, dantrolene, short-acting barbiturates, chlorpromazine, and Propofol
• Intrathecal Baclofen: For severe muscle rigidity and weaning off ventilator¹¹

Management of complications

For managing complications:

• Magnesium Sulfate: IV loading dose of, followed by 2-3 g/h infusion
• Morphine: For spasm control
• Beta Blockers: For autonomic dysfunction (use with caution due to risk of sudden cardiac death)
• Hypotension Management: Fluid replacement, dopamine or norepinephrine administration¹¹

Summary

• Tetanus is caused by Clostridium tetani
• It produces the neurotoxin tetanospasmin, leading to muscle stiffness and spasms.
• Tetanus occurs when bacteria enter the body through wounds
• Proper wound care, including cleaning, disinfecting, dressing, and assessing wounds, along with follow-up and monitoring for signs of infection is important
• For comprehensive protection, vaccination, including the tetanus toxoid vaccine, and immediate medical attention are crucial
• Toxin production and neutralisation, as well as symptoms and complications, can be managed with pharmacotherapy