Category: International EM
Posted: 3/13/2013 by Walid Hammad, MD, MBChB
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Case Presentation: A 31 yo Hispanic male presents to your emergency department with extensive facial abrasions and contusions from an assault 7-8 days ago, c/o difficulty swallowing for 1-2 days. He was seen at that time in a nearby emergency department for his abrasions and contusions.
Upon examination, you find him to be irritable and restless, diaphoretic, tachycardic, and with mild neck stiffness. Over the course of his stay in the ED, he develops generalized muscle rigidity, severe neck stiffness and opisthotonic posturing.
Clinical Question: What is the diagnosis? And what went wrong?
Answer: This is an early presentation of generalized tetanus.
Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only nine randomized trials reported in the literature over the past 30 years. The goals of treatment include:
. At risk populations:
o Elderly patients are substantially less likely than young individuals to have adequate immunity against tetanus.
o Immigrants from Mexico had a 67% non-protective anti-tetanus antibody (ATA) level.
o In a pilot study 86% of Korean immigrants did not have protective ATA levels
o Emergency physicians were less likely to adhere to the tetanus guidelines when admitting patients to the hospital.
· Halting the toxin production: wound management and antimicrobial therapy
o Metronidazole 500mg IV q 6-8 hrs or Penicillin-G 2-4M units IV q4-6 hrs for 7-10 days
· Neutralization of the unbound toxin
o Human Tetanus Immunoglobulin (HTIG): A dose of 3000 to 6000 units intramuscularly should be given ASAP
o Since tetanus is one of the few bacterial diseases that does NOT confer immunity following recovery from acute illness, all patients with tetanus should receive FULL active immunization immediately upon diagnosis
· Treatment of generalized tetanus: this is best performed in the ICU and includes:
o Early and aggressive airway management
o Control of muscle spasms
o Management of dysautonomia
o General supportive management
Bottom Line:
o EP’s consistently under-immunize for tetanus, especially in elderly and immigrant populations, who have a much higher risk of under-immunization.
o Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.
o Emergency physicians must comply with immunization guidelines for injured patients to assure adequate protection from both tetanus and diphtheria.
University of Maryland Section of Global Emergency Health
Author: Terry Mulligan DO, MPH
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Alagappan K, McGowan J, DeClaro D, Ng D, Silverman RA, Tetanus antibody protection among HIV-infected US-born patients and immigrants. International Journal of Emergency Medicine, Vol 2 : 123-126, June 2008
Alagappan K, Park R, Kuo T, Naderi S, Silverman R. Seroprevalence of tetanus antibody titers among Korean Americans in the New York City area -a pilot study, J Immigrant Minority Health. 11:105-107, 2009.
World Health Organization. Immunization surveillance, assessment and monitoring. Maternal and Neonatal Tetanus (MNT) elimination. http://www.who.int/immunization_monitoring/diseases/MNTE_initiative/en/index.html (Accessed on March 14, 2011).
