Tetanus: The Daily PANCE Blueprint

The answer is C. Series of 3 vaccinations (Td) with the first two doses 4–6 weeks apart, and the third dose 6–12 months later

• For persons aged 19 years and older who have never been vaccinated against tetanus, a series of 3 vaccinations (Td) should be given with the first two doses 4–6 weeks apart, and the third dose 6–12 months later.
• Substitute a one-time dose of Tdap for one of the doses in the series

Pearls

Tetanus results from a toxin produced by the anaerobic bacteria Clostridium tetani. The toxin makes muscles become rigid and contract involuntarily (spasm).

• Clostridium tetani spores are ubiquitous in soil. The spores germinate in wounds where the bacteria produce a neurotoxin (tetanospasmin), which interferes with neurotransmission at spinal synapses of inhibitory neurons. The result is uncontrolled spasms and exaggerated reflexes.
• Puncture wounds are most susceptible. The elderly, migrant workers, newborns, and injection drug users are at particular risk.
• The incubation period is from 5 days to 15 weeks.

Diagnosis

The diagnosis of tetanus is usually obvious and can generally be made based upon typical clinical findings

• Tetanus should especially be suspected when there is a history of an antecedent tetanus-prone injury and a history of inadequate immunization for tetanus
• The bacteria can sometimes be grown (cultured) from a sample taken from the wound. However, culture results sometimes indicate tetanus when it is not present (a false-positive result), and tetanus may be present even if no bacteria are detected (a false-negative result). Do not rely on culture to diagnose tetanus.

Treatment

Post-exposure prophylaxis

• Vaccination (Td, Tdap)
  •  Given to anyone with a clean wound and vaccination history out of date or unknown
• Hyperimmune human globulin (TIG) neutralizes the toxin
  •  Given to anyone with a contaminated wound and no vaccination history
• Metronidazole or penicillin is given to all patients to eradicate toxin-producing organisms. Mortality is high.
• Spasmolytic drugs treat symptoms (e.g. diazepam)
• Bed rest, sedation, and mechanical ventilation often are necessary to control tetanic spasms

Prevention: Vaccine made of tetanus toxoid: formaldehyde-inactivated

• DTap vaccine: 5 doses before school-age, completed by 4-6 years of age (2,4, and 6 months, 15-18 months and 4-6 years)
• Tdap booster: for preteens 11-12 years of age
• Td vaccine: at 10-year intervals
• 1 dose Tdap during each pregnancy, preferably in the early part of gestational weeks 27–36
• Tetanus prophylaxis for
  • Burns
  • Open fractures