5-101
neonatal). There are four subtypes described for tetanus: generalized, localized, cephalic and neonatal.
Subjective: Symptoms
Neonatal cases: Weakness, irritability, trouble nursing, unable to suck
Specific: Acute (1-7days): Pain at wound site, local muscle spasticity Sub-acute (7-14 days): Trismus
(lockjaw), painful tetanic spasm, glottic or respiratory muscle spasm, urinary retention, constipation, rigid
abdominal wall muscles, trouble swallowing Chronic (>2 weeks): Slow recovery phase (4 weeks)
Focused History: Have you received a tetanus immunization? If so, when was the last one? (If within
5-10 years, then tetanus is very unlikely. Also if mother of baby had tetanus vaccination, then neonatal
tetanus is unlikely.) Have you recently had a potentially contaminated wound? (typical exposure) Does loud
noise/coughing/people touching you/gusts of air trigger painful muscle spasms? (typical stimuli for spasms)
Objective: Signs
Inspection: Acute (1-7 days): Afebrile; localized muscle spasticity, localized pain at inoculation site,
neonatal cases: unable to nurse, with stiff muscles or spasming Sub-acute (7-14 days): Afebrile, tetanic
spasm (stimulus induced) trismus (lockjaw), opisthotonos (arched back spasm), glottic/respiratory muscle
spasm, cyanosis/asphyxia, profuse sweating
Palpation: Sub-acute (7-14 days): Abdominal muscle wall rigidity
Percussion: Acute (1-7 days): Brisk local deep tendon reflexes
Assessment: Diagnose from the history and physical findings/clinical observation.
Differential Diagnosis
Meningoencephalitis - usually associated with fever; true seizures and mental status changes not seen in
tetanus.
Strychnine poisoning - mimics tetanus; abdominal wall muscle rigidity more often seen in tetanus; ask about
an ingestion history
Hypocalcemic tetany - involves extremities; rare to see lockjaw; tapping on facial nerve (over parotid) can
induce facial muscle spasm in low calcium states (Chvostek’s sign)
Generalized seizures - associated with loss of consciousness, no trismus
Phenothiazine toxicity - drug history; can see torticollis (not in tetanus); relieved with Benadryl (not in tetanus)
Plan:
Treatment
Primary:
- Maintain airway (ET tube can stimulate spasm so may need early tracheostomy for respiratory difficulty)
- Medications:
a. Tetanus (human) immune globulin (HTIG, Hyper-tet) 500 IU intramuscularly or injected directly into
wound
b. Tetanus immunization 0.5 ml IM at site away from HTIG administration. See Table 5-4.
c. Narcotic analgesia with codeine
d. Diazepam titrated for effect 5-10 mg q 2-4 hours to control muscle spasms (lorazepam or midazolam
are also effective)
e. Metronidazole 30 mg/kg/day divided in q 6 hour dosing for 7-10 days (average about 500 mg q 6 hrs
IV); can also be given 1 gm per rectum q 8 hrs - Nursing: Keep patient in a quiet, darkened room; avoid unnecessary touching; use Foley catheter for
urinary retention.
Alternate Antibiotics: Penicillin G 4 million units IV q 6 hrs for 10 days or doxycycline 100 mg q 12 hrs IV
Patient Education
Activity: Bedrest