Tetanus

A major public health problem in the developing world, but improving; responsible for 200,000–300,000 deaths/y in 2000 and only 60,000 in 2013, and the vast majority were neonatal deaths.

Incidence in USA: 0.16 cases/million population (1998–2000).

Highest incidence in USA is among the elderly (>60 y), persons of Hispanic ethnicity, older adults with diabetes, and parenteral drug users.

Difficult airway or intubation in the presence of masseter spasm, neck rigidity, or opisthotonus

Autonomic instability with sudden fluctuations in BP, arrhythmias, cardiac failure, and cardiac arrest

Spasms of the laryngeal and respiratory muscles can be life-threatening as a result of airway obstruction or chest wall rigidity respectively, and may mandate urgent ET intubation.

Respiratory failure may require NM paralysis in addition to sedation for effective PPV in the presence of severe spasms.

Autonomic instability: Tachycardia, bradycardia, Htn, hypotension, arrhythmias, cardiac failure, and repeated cardiac arrest.

Pneumonia, sepsis, myoglobinuria, pulm embolism, bony fractures, and hyperthermia.

Infection of penetrating wounds or devitalized tissue with spores of anaerobic gram-positive bacillus Clostridium tetani ; enters the CNS via peripheral nerves and spreads via retrograde intraneuronal transport to disable inhibitory pathways in the spinal cord and brain (glycine and GABA).

CNS disinhibition characteristically begins with spasms of the masseter muscles (“risus sardonicus,” lockjaw) and progresses to involve rest of the body, including spasms of respiratory muscles (“respiratory convulsions”) that cause glottic spasm, airway obstruction, hypoxia, and respiratory failure.

Autonomic instability is a hallmark of the disease and may cause fatal cardiac arrest.

Initial injury may be insignificant or unnoticed by the pt.

Neonatal tetanus typically presents 6–8 d after birth with trismus and inability to feed.

Tetanus may follow surgery (usually intraabdominal or on contaminated tissues), burns, gangrene, dog bites, chronic infection, parenteral drug use, dental infection, abortion, and childbirth.