Advanced Trauma Life Support ATLS Student Course Manual 2018

TETANUS IMMUNIZATION
Overview
Tetanus is a potentially fatal noncommunicable
disease caused by the toxin (tetanospasmin).
It is produced by the spore-forming bacteria
Clostridium tetani, an anaerobic Gram-positive bacillus.
The spores are hardy, resistant to heat and antiseptics,
and found ubiquitously in the soil and feces of humans
and animals. Successful treatment depends on proper
care and treatment of wounds and traumatic injuries and
prevention through appropriate tetanus immunization.
Worldwide, tetanus still accounts for 1 million
hospital admissions. Most of these cases are in Africa
and Southeast Asia, but they are decreasing with
immunization initiatives directed to these areas. In
2012, tetanus caused 213,000 deaths worldwide. Most
of these deaths occurred in developing countries, and
one-half were in neonates. Mortality in these areas
remains high (30% to 70%). In industrialized countries,
mortality from tetanus is lower. The CDC reports case
fatality of 13.2% in the United States.
Tetanus is almost entirely preventable with adequate
immunization. The disease has been central to the World
Health Organization (WHO) Expanded Programme on
Immunization since 1974. The incidence of tetanus
decreases when immunization programs are in place.
Unfortunately, under-immunized populations exist
even in high-income countries. During the surveillance
period of 2001–2008 in the United States, 233 cases
associated with 26 deaths were reported. Individuals
over the age of 50 represented one-half of those cases,
and individuals over 65 represented 30% of the cases.
Death was five times more likely in people older than
65. Older women are particularly at risk, because most
of those over age 55 do not have protective levels of
tetanus antibody. Diabetics and injection drug users
are other high-risk groups. Tetanus can occur in nonacute
wounds, and 1 of 6 cases surveyed was associated
with non-acute wounds.
Inadequate tetanus toxoid vaccination and
inadequate wound prophylaxis are the most important
factors associated with the development of tetanus.
Tetanus surveillance data have demonstrated two
interesting findings: Fewer than 4% of those with acute
wounds who sought treatment received appropriate
prophylaxis. Only 36.5% sought immediate medical
care for their wounds. All medical professionals must
be cognizant of these factors when providing care to
injured patients.
Tetanus immunization depends on the patient’s
previous immunization status and the tetanus-prone
nature of the wound. The following guidelines are
adapted from the literature, and information is available
from the Centers for Disease Control and Prevention
(CDC). Because this information is continuously
reviewed and updated as new data become available,
the American College of Surgeons Committee on
Trauma recommends contacting the CDC for the most
current information and detailed guidelines related
to tetanus prophylaxis and immunization for injured
patients. National guidelines may vary.
Pathophysiology
Clostridium tetani spores are found in the soil and in
the feces of animals and humans. The spores access
the body through breaks in the skin and grow under
low oxygen conditions. Wounds that tend to propagate
spore development are typically puncture wounds
and wounds with significant tissue destruction.
Tetanospasmin causes tetanus by blocking inhibitory
pathways (gamma-aminobutyric acid), producing
sustained excitatory nervous impulses that give rise
to the typical clinical symptoms. Once the spores
gain access to the body through an open wound, they
undergo an incubation period of from 1 to 2 days and
as long as 7 to 21 days. The diagnosis is usually clinical,
and the treatment is supportive. Prevention is the
mainstay of treatment.
Types of wounds likely to encourage the growth of
tetanus organisms include
••
Open fractures
••
Deep penetrating wounds (> 1 cm)
••
Stellate or avulsion configuration
••
Wounds containing devascularized tissue
••
Wounds resulting from a missile (gunshot
wound)
••
Wounds from burns or frostbite
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