Updated: 6/1/2018

Tetanus

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Review Topic
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Questions
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Snapshot
  • A 4-day-old girl presents to the pediatric emergency room for inability to suck or cry. The mom reports that since birth, she has been feeding, sucking, and crying normally until this morning. She also reports that she herself had not had any of the recommended vaccines as she grew up in a family that had refused vaccines. On physical exam, the baby girl is stiff and fails to cry during exam. She is also in opisthotonos. When given a pacifier, she also fails to suck. She is given a benzodiazepine for the spasm and appropriate treatment. She is admitted for further management.
Introduction
  • Classification
    • Clostridium tetani
      • anaerobic gram + rod
      • produces tetanospasmin toxin
    • transmission
      • direct contact in contaminated soil
  • Epidemiology
    • demographics
      • rare in the US
      • more common in developing countries due to low rates of vaccination
    • risk factors
      • lack of vaccination
      • trauma
      • chronic wounds
      • lack of immunity in mothers
  • Pathogenesis
    • forms spores that are resistant to heat and chemicals
    • produces tetanospasmin, an exotoxin
      • a protease that cleaves SNARE proteins, which blocks the release of inhibitory neurotransmitters (glycine and GABA)
      • causes paralysis
  • Associated conditions
    • tetanus
    • neonatal tetanus
      • neonate who are born to unvaccinated mothers
      • inability to suck or cry after day 2 of life
      • infection of the umbilical stump
  • Prevention
    • DTap vaccine
      • vaccine against diphtheria, tetanus, and pertussis
      • 5 doses before school-age, completed by 4-6 years of age
    • Tdap vaccine
      • booster vaccine at 11-12 years of age
    • Td vaccine
      • tetanus and diphtheria toxoid vaccine at 10-year intervals
  • Prognosis
    • spasms last for ~ 1 month
    • mortality can be high if not treated
Presentation
  • Symptoms
    • spastic paralysis
      • muscle stiffness
      • spasms
    • fever
  • Physical exam
    • trismus
      • lockjaw
    • risus sardonicus
      • raised eyebrows
      • grin
    • opisthotonos
      • spinal muscle spasms
      • causes backward arching of head and spine
    • rigid abdominal muscles
    • neonates
      • foul-smelling and erythematous umbilical stump
      • failure or weakness of suck or cry
Studies
  • Serology or culture
    • rarely used due to low sensitivity and specificity
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Bacterial meningitis
    • distinguishing factor
      • nuchal rigidity without other signs of spastic paralysis
Treatment
  • Management approach
    • treat all with antitoxin and booster if needed
  • Conservative
    • wound debridement
      • indication
        • all patients
  • Medical
    • tetanus antitoxin
      • indication
        • patients with contaminated or dirty wounds
    • benzodiazepine
      • indications
        • muscle spasms
    • booster vaccine
      • indication
        • patients with > 10 years from the last dose
        • patients with < 3 or uncertain number of tetanus vaccine doses
Complications
  • Respiratory compromise from spasm of respiratory muscles
  • Aspiration pneumonia
  • Contractures
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.ID.16.4684) A 43-year-old construction worker presents to the emergency department two hours after sustaining a deep laceration to his left forearm by a piece of soiled and rusted sheet metal. His vital signs are stable, there is no active bleeding, his pain is well controlled, and a hand surgeon has been notified about damage to his forearm tendons. He does not recall receiving any vaccinations in the last 30 years and does not know if he was vaccinated as a child. What is the appropriate post-exposure prophylaxis? Review Topic | Tested Concept

QID: 107349
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IV metronidazole only

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Anthrax vaccine

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Tetanus vaccine booster only

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Tetanus immunglobulin only

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Tetanus vaccine + immunoglobulin

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