Beyond the Rusty Nail: Tetanus as a Factor in Wound Care

By Aletha Tippett MD

Tetanus is a multisystem disease caused by the bacterium Clostridium tetani. This bacterium is present in feces and soil. Tetanus has been mostly eradicated in the U.S. due to childhood immunization, however, there have been reported cases among immigrants, with higher risk behaviors such as body piercing and tattooing among young adults, and with failure to maintain adult booster immunization. Often, as adults, tetanus is not considered in overall health as evidenced by significant under-immunization with less than half of adults having current immunization. Other risk factors not well-recognized include diabetes, gangrene or chronic wounds, which increase the risk of tetanus to 50%. It is fatal in approximately 10-30% of cases. It may take anywhere from 3-21 days after exposure to the bacterium for the symptoms to become apparent. There is no test to diagnose tetanus, it is strictly a clinical diagnosis.

Since tetanus is a clinical diagnosis, it is often hard to distinguish it from some common conditions our patients might have. We had a case of an elderly male admitted to hospice that was homebound and cared for by his elderly wife. He was bed-bound, and had a severe stage IV sacral ulcer that the wife was unable to clean or treat. There was significant stool in the wound and the patient was severely malnourished. After discussion with the patient and wife he was transferred to a nursing home for wound care. Several days later he was noticed to have dysphagia and respiratory distress. By the next day he was having opisthonia and died later that day. That patient had died of tetanus due to fecal contamination of his sacral wound.

The first sign of clinical presentation of generalized tetanus is trismus, also known as lockjaw (what we thought was dysphagia in our patient). Symptoms usually proceed in a descending pattern: stiffness of neck, difficulty swallowing, and rigidity of abdominal muscles. Other symptoms include elevated temperature and blood pressure, sweating, and episodes of rapid heart rate. Spasms occur frequently and last for several minutes. The acute illness may continue for 3-4 weeks; full recovery may take several months. Complications can include: laryngospasms, fractures, hypertension, nosocomial infections, pulmonary embolism, aspiration and death.

This is a very unpleasant and painful disease that is completely avoidable with immunization. So, please, if you are treating a wound patient make sure their tetanus immunization is current. For persons over 7 years of age, previously unimmunized, the routine Td vaccine schedule is an initial dose of 0.5 ml, followed by a second dose at 4 weeks, then third dose at 6-12 months, with boosters every 10 years. The patient should receive a booster dose if a wound is present and it has been more than 5 years since the last dose. The tetanus vaccine is always given with diphtheria (Td). Remember to be wise and immunize!

About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.