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Tetanus Diagnosis Sometimes Elusive

Nurse Practitioner, Nov 2003 by Quackenbush, Priscilla, Tuorinsky, Shirley, Rabb, Rebecca

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* Plan of Care

L.L.'s subsequent care after the diagnosis of tetanus was multifaceted. Antibiotics (Clindamycin, Cipro, Augmentin, Levaquin) were prescribed for the actual infection, and muscle relaxants (Flexeril) were given for the sporadic muscle spasms. L.L.'s pain was managed by Percocet, because she did not tolerate Oxycodone. For her neck inflammation, solumedrol was given intramuscularly, and oral Prednisone was prescribed for home use.

* Discussion

In cases of tetanus, the history of present illness usually includes a recognized wound that has been contaminated with soil, manure, or rusty metal. This wound may be trivial in nature, however, and the patient may not seek medical care. In 15% to 25% of cases, a recognized wound cannot be identified.3

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The incubation period for tetanus ranges from three to 21 days. The length of the incubation period and severity of disease depends on the proximity of the wound to the central nervous system. If the injury is distal to the central nervous system, as in this case, the incubation will be longer. Furthermore, the probability of death is greater if the incubation period is short.1

L.L. did recall minor cuts to the right hand that occurred several weeks before the onset of her signs and symptoms. The patient reported cuts on her hand caused by contact with a rusty barbed wire in stagnant water. The patient also reported that her last immunization of tetanus was in 1986. Despite these clues and the patient's concerns that her signs and symptoms could be due to tetanus, she was originally diagnosed with submandibular gland infection.

* Treatment

The recommended treatment for tetanus is tetanus immune globulin (human) (TIG), which is given intramuscularly.4 Adults and children may receive one total dose of 3,000 to 5,000 U.4 Interestingly, most tetanus patients have either not been vaccinated, or have completed the primary series, but have not had a booster in the 10 years preceding their tetanus-inflicting events.5

Any wound found on a patient should be thoroughly cleaned and debrided if there is necrosis present. Provide supportive care and pharmacotherapy to stimuli minimize, which can provoke spasms. Sedation, paralysis, and mechanical ventilation are often used to control the tetanic spasms. All patients are to receive oral or intravenous metronidazole (30 mg/kg per day at 6 hour intervals). This is the antibiotic of choice to reduce the toxin-producing forms of C. tetani. Parenteral penicillin G (100, 000 U/kg per day at 6-hour intervals) can be administered as an alternative therapy. It is recommended that treatment be given for 10 to 14 days.4 Tetanus is preventable with routine vaccination and appropriate wound management.3

Primary tetanus immunization, commonly combined with diphtheria toxoid and acellular pertussis vaccine, is recommended for all persons between the ages of 6 weeks and 7 years who do not have any contraindications. Although toxoid efficacy has not been studied in a vaccine trial, it can be inferred that a complete tetanus toxoid series has a clinical efficacy of virtually 100%. Tetanus in persons who are fully immunized and whose last dose was within the preceding 10 years is extremely rare, and is evident by the fact that 0.02 cases of tetanus per 100,000 were reported in 1999.5 Routine boosters are recommended every 10 years to maintain the antitoxin level. To ensure protective antitoxin levels are sufficient in people who have a wound that is not clean or minor, a booster is recommended if the time from the last tetanus booster is 5 years or greater. Four doses at 2, 4, 6, and 15 to 18 months of age is considered primary series. Boosters are recommended at 4- to 6-years-old, then every 10 years.5

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Tetanus Diagnosis Sometimes Elusive

Nurse Practitioner, Nov 2003 by Quackenbush, Priscilla, Tuorinsky, Shirley, Rabb, Rebecca

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