DRG Category: 868
Mean LOS: 4.6 days
Description: Medical: Other Infectious and Parasitic Diseases Diagnoses With Complication or Comorbidity
Tetanus, or lockjaw, is a preventable but often fatal disorder caused by the bacterium Clostridium tetani, a spore-forming anaerobe. The bacterium exists in spore form in an aerobic environment until it is exposed to an anaerobic environment. The organism then changes to the vegetative form, multiplies, and produces neurotoxins. Less than 50 cases of tetanus occur each year in the United States, and in recent years, approximately half occurred in people with injected drug use.
When the tetanus bacteria enter an open wound, they multiply and produce a potent neurotoxin called tetanospasmin, which enters the bloodstream and acts on the spinal ganglia and central nervous system by interfering with the function of the postsynaptic inhibitory potentials. The anterior horn cells become overstimulated, resulting in excessive muscle contraction. Toxins may also act directly on skeletal muscle and cause muscle contraction. Complications include lung disorders such as pneumonia, pulmonary emboli, atelectasis, cardiac dysrhythmias, gastric ulcers, and flexion contractures. Tetanus results in approximately five deaths per year in the United States; death usually results from complications such as autonomic dysfunction leading to extremes in blood pressure, cardiac dysrhythmia, or cardiac arrest.
Because C tetani is commonly found in soil, tetanus is more common in agricultural regions. Any break in the skin or mucous membrane can result in a tetanus infection, but wounds that are contaminated with soil or those that produce a relatively anaerobic environment are at greater risk. Wounds that produce an anaerobic environment include those with purulent or necrotic tissue, puncture wounds, burns, gunshot wounds, animal bites, and complex fractures. Drug abusers who engage in “skin popping,” or subcutaneous injections, are also at risk for a tetanus infection. Bacterially contaminated quinine may be used to dilute heroin and expose the user to C tetani. Risk factors include failure to receive vaccination, history of puncture wounds or trauma, IV drug abuse, foot ulcers, and history of surgical procedures.
Heritable immune responses could be protective or could increase susceptibility.
People of all ages and genders are at risk for tetanus if they have not been vaccinated. In the United States, approximately 60% of cases and 75% of deaths occur in people age 60 years or older. Older adults are at risk even when they are immunized because of the waning effects of past immunizations. Only 28% of people over 70 years of age are immune to tetanus; the rest lack a booster dose or have never been vaccinated.
The incidence of tetanus in the United States is highest among Hispanics and White persons as compared to Black persons. Sexual and gender minority status has no known effect on the risk for tetanus.
Tetanus is generally an infection of developing regions located in warm, damp climates, and in Africa in particular. Infants, children, and young adults are particularly at risk in developing regions. In developing countries, tetanus is a common cause of neonatal death when infants are delivered in unsterile conditions. The World Health Organization has targeted vaccination programs focused on developing regions of the world to reduce the incidence of tetanus. Developed regions have incidences of tetanus similar to those in the United States.
PLANNING AND IMPLEMENTATION
Collaborative
To prevent tetanus, within 3 days of a puncture wound, patients with no previous tetanus immunization require immediate passive immunization with tetanus immunoglobulin for temporary protection. Active immunization with tetanus toxoid is also provided. If the patient had a previous immunization more than 5 years before the injury, a booster injection of tetanus toxoid is warranted at the time of injury. Goals of treatment include neutralizing the toxin, preventing complications, and eliminating the source of the toxin. One-half of the dose is administered by infiltrating the wound, and the remaining half is administered intramuscularly. Active immunity is given by administering tetanus toxoid at a site remote from the globulin injections. The affected wound is thoroughly débrided after the antitoxin has been administered. Cultures of the wound may be obtained at that time. Parenteral antibiotics (metronidazole in particular) are administered for 10 days.
Patients are generally admitted to an intensive care unit to manage airway, breathing, circulation, and the neurological manifestations of the illness. Respiratory distress may necessitate intubation or tracheostomy and mechanical ventilation with supplemental oxygen. Nasogastric tubes are inserted to prevent gastric distension. Patients with difficulty swallowing may require nutritional support with total parenteral nutrition or enteral feeding by a nasogastric or nasointestinal tube.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Human tetanus immunoglobulin | One-half dose is administered by infiltrating the wound; remaining half is administered intramuscularly; total dose is 3,000–6,000 units | Immunoglobulin | Provides passive immunization; administered immediately |
| Tetanus toxoid | Series of three 0.5-mL doses provide protection in 90% of patients; administered at a site remote from globulin injections | Toxoid | Provides active immunization against tetanus; affected wound is débrided after antitoxin has been administered; patient will need two follow-up vaccinations at 1–2 mo and then 6–12 mo |
| Antimicrobials | Metronidazole (Flagyl): Current drug of choice; 0.5 g PO every 6 hr for 7–10 days; alternatively, 1 g IV every 12 hr for 7–10 days; other antibiotics: penicillin G, clindamycin, erythromycin, tetracycline, vancomycin, doxycycline, | Antibiotic | Prevent or combat infection |
Other Drugs: Others drugs include neuromuscular blocking agents; antipyretics; analgesics; and anticoagulants; sedatives, antianxiety agents, and muscle relaxants such as diazepam are administered to decrease muscle spasms. Neuromuscular blocking agents may be required to paralyze the patient if other agents cannot control the spasms or seizures. Antidysrhythmic drugs are given if cardiac rhythm disturbances arise, antipyretics are administered for fever, and analgesics are provided for pain relief. Prophylactic anticoagulation therapy may be instituted to prevent thrombus formation.
Independent
Nursing care focuses on maintaining a patent airway, regular breathing, and adequate circulation and on providing comfort management, protection from injury, and psychosocial support of the patient and family. If muscle spasms or seizure activity places the patient at risk for airway compromise, use the chin lift or jaw thrust to maintain an open airway if possible. Insert an oral or nasal airway before seizures, but if the patient has lockjaw, do not attempt to force an airway in place because you may injure the patient and worsen the airway patency. Have intubation and suction equipment immediately available at the bedside should the patient require it. Anchor the endotracheal tube firmly, and document the lip level of the endotracheal tube in the progress notes for continuity.
Institute seizure precautions as soon as the patient is admitted to the unit. Pad the side rails of the bed and provide immediate access to oxygen, suction, intubation equipment, artificial airways, and a resuscitation bag. Place the patient in a quiet, dark room to reduce environmental stimuli. Position the patient who is unconscious or paralyzed from pharmacologic agents in a side-lying position and turn the patient every 2 hours.
Provide clarification of information about the patient's diagnosis, prognosis, and treatment to the patient and family. Make sure that the family has adequate time for expression of their feelings each day. Support effective coping mechanisms and provide appropriate referrals to the chaplain, clinical nurse specialist, or counselor if the patient or family demonstrates ineffective coping behaviors.
Evidence-Based Practice and Health Policy
Kriss, J., Albert, A., Carter, V., Jiles, A., Liang, J., Mullen, J., Rodriguez, L., Howards, P., Orenstein, W., Omer, S., & Fisher, A. (2019). Disparities in Tdap vaccination and vaccine information needs among pregnant women in the United States. Maternal and Child Health Journal, 23, 201–211.
- The authors aimed to evaluate disparities in Tdap vaccination among pregnant women in the United States and to assess if race and ethnicity were associated with factors that inform pregnant women's decisions about vaccination. They conducted a national, Web-based survey of pregnant women with the primary outcome of self-reported vaccination status during pregnancy. Secondary outcomes included factors that influenced the decision about vaccination.
- Of the women surveyed, 41% reported that they received Tdap during the current pregnancy, and of women in the third trimester, 52% had received it. Hispanic women had the highest rate of vaccination (53%) as compared to White (38%) and Black (36%) women. Higher income and residing in the western United States were associated with vaccination. Twenty-six percent of surveyed women who had not yet been vaccinated intended to receive it during pregnancy. The most common reason for not receiving the vaccine was concern about its safety.