• Caused by Clostridium tetani
• Rare in the UK, but common in the developing world because of inadequate vaccination

Risk factors

• A high risk is associated with wounds contaminated with garden soil, manure or caused by rusty metals
• Can also complicate ulcers, gangrene, burns, snakebites, septic abortion and poor obstetric techniques (tetanus neonatorum)

Features of tetanus

• Toxin-mediated generalised tetanus is the most common presentation
  • descending pattern of symptoms following prodromal malaise and fever
  • muscular spasms, abdominal rigidity, dysphagia, opisthotonus, trismus and 'risus sardonicus'
  • can lead to aspiration pneumonia, fractures, laryngospasm (causing asphyxia) and respiratory failure

Diagnosis

Diagnosis is clinical and patients need to be managed in ITU.

Treatment

• Prone wounds: these include those with a large amount of contact with soil/manure or containing foreign bodies, compound fractures or those associated with sepsis ,so wound debridement is important
• Metronidazole is recommended in conjunction with wound management
• Tetanus immunoglobulin (antitoxin) must be given IV; however, any toxin already fixed to neurones cannot be neutralised and recovery of nerve function depends on regrowth and formation of new synapses
• Supportive care, with sedation and intubation common
• Muscle stiffness and clonus can last months after recovery
• Prevention – vaccination (part of the vaccination schedule for those under the age of 10 years, with boosters for those with unknown or incomplete status or travellers to remote areas)