21st February 2024

Tetanus exposure

Treatment

Tetanus is an acute condition caused by Clostridium tetani through its tetanus toxin. The bacterium infiltrates the patient via its spores, which are ubiquitous in the soil and manure. Spores will enter the patient via an open wound or cut and will grow over a mean period of 10 days. Release of the tetanus toxin results in its classic symptoms of rigidity and skeletal muscle spasms. This can result in lockjaw and respiratory failure. 

Most patients should be fully vaccinated against tetanus as it forms part of the national immunisation schedule for children in the UK. Primary immunisation is done at ages 2, 3 and 4 months old. Booster immunisation is provided at three years post-primary immunisation and ten years post-1st booster. This should be sufficient to provide long-term immunisation against the tetanus toxoid. 

When faced with a wound, it is essential to determine if this is a tetanus-prone wound and the status of the patient’s tetanus immunisation. A tetanus-prone wound includes the following characteristics:

• Wounds that require surgical intervention that is delayed for > 6 hours,
• Puncture-type injury in an environment that likely resulted in contamination of material that likely contains tetanus spores ( soil/manure),
• Wounds containing foreign bodies,
• Compound fracture,
• Wounds resulting in systemic sepsis.  

High-risk tetanus-prone wounds are classified as any of the above, along with the following:

• Heavy contamination of materials, including soil/manure
• Wounds/burns with significant devitalised tissue
• Wound/burns requiring surgical intervention that has been delayed for over 6 hours. 

The treatment of choice for tetanus exposure involves tetanus immunoglobulin and tetanus vaccination. The need to administer the vaccine and tetanus immunoglobulin varies depending on the immunisation status and the tetanus-prone risk of the wound. The summary of treatment is as below and is adapted from the Green Book:

*A clean wound is < 6 hours old, with minor tissue damage, and non-penetrating. 

References

• UK Health Security Agency, & Department of Health & Social Care. (2020). Tetanus. Accessed on 2022 Mar 28. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859519/Greenbook_chapter_30_Tetanus_January_2020.pdf. 
• Hibberd, P. (2021). Tetanus-diphtheria toxoid vaccination in adults. Accessed on 2022 Mar 28. Available from: https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-vaccination-in-adults#H7. 
• National Institute for Health and Care Excellence clinical Knowledge Summary. (2021). Scenario: Laceration – High infection risk. Accessed on 2022 Mar 28. Available from: https://cks.nice.org.uk/topics/lacerations/management/laceration-high-infection-risk/.