Emergency tetanus prophylaxis

When is emergency prophylaxis necessary?

Tetanus is a typical wound infection. Infection occurs when the spores of the pathogen enter a wound. Emergency protective measures are indicated in any situation involving a breach of the integrity of the skin and mucous membranes, which creates a portal of entry for the infection.

The main indications include:

• Any wounds (especially puncture wounds, lacerations, or contaminated wounds).
• Burns and frostbite of grade II and III.
• Home births.
• Illegal abortions.
• Surgical interventions on the gastrointestinal tract.

Pathogen and mechanism of disease progression

To understand the importance of prophylaxis, one must know the characteristics of the pathogen. It is Clostridium tetani, a Gram-positive anaerobic spore-forming bacillus belonging to the family Bacillaceae. Its spores are extremely resistant to environmental factors.

Upon entering a wound defect where anaerobic conditions are created (without oxygen access), the spores germinate into vegetative forms. These forms actively produce a dangerous exotoxin (neurotoxin). The toxin spreads through the body via three pathways: hematogenous, lymphogenous, and retrograde axonal. Upon reaching nervous tissue, it binds there and causes a selective blockade of the inhibitory action of interneurons on motor neurons. As a result, the slightest stimulus leads to the development of severe tonic and tetanic muscle spasms.

Emergency immunization regimens

The physician's tactics differ radically depending on whether the patient has been previously vaccinated.

For vaccinated individuals: If the person has previously undergone routine vaccination, their immune system is already familiar with the antigen. In this case, it is sufficient to administer 0.5 ml of tetanus toxoid. This stimulates the production of their own antibodies and provides reliable protection.

For unvaccinated individuals (active-passive immunization): If the patient is not vaccinated, incompletely vaccinated, or their vaccination history is unknown, a combined approach is used:

1. Administration of 1.0 ml of tetanus toxoid (to trigger active immunity).
2. Simultaneous administration of 3000 IU of tetanus antiserum. This dose is standard and does not depend on the patient's age. The antiserum provides immediate passive protection by neutralizing the toxin until the body begins producing its own antibodies.

Important rule: The toxoid and antiserum must be administered using different syringes and at different injection sites. The administration of antiserum requires adherence to a special technique. As a modern alternative to antiserum, human tetanus immunoglobulin can be used (intramuscularly at a dose of up to 250 IU). Subsequently, the unvaccinated patient must continue the course of toxoid vaccination according to the standard routine schedule.

Clinical presentation and consequences of refusing prophylaxis

If prophylaxis was not performed or the patient did not seek medical attention (e.g., washed the wound themselves with unboiled water and applied iodine tincture), there is a high risk of developing generalized tetanus.

During the fully developed clinical stage, the following are observed:

• Trismus (spasm of the masticatory muscles, making it impossible to open the mouth).
• Specific "sardonic smile" (risus sardonicus).
• Dysphagia (swallowing disorders).
• Descending involvement of skeletal musculature with the formation of permanent muscle hypertonus.
• Intense muscle pain and seizure attacks causing the body to arch (opisthotonos).

Treatment of severe forms requires emergency hospitalization in the intensive care unit (ICU). Maximum doses of neuroplegics, barbiturates, diazepam, and in very severe cases, muscle relaxants (e.g., tubocurarine) are used, with mandatory mechanical ventilation for a period of 1 to 3 weeks. Mortality for moderately severe cases is 5–10%, and for severe cases, the prognosis is always guarded. In the absence of complications, complete recovery without residual effects is possible, as the action of the exotoxin is reversible.

Class and exam questions

What else to study on this topic

• Routine specific tetanus prophylaxis in children and adults.
• Pathogenesis of tetanus and the mechanism of action of the exotoxin on the nervous system.
• Clinical presentation of generalized form (trismus, sardonic smile, opisthotonos).
• Anticonvulsant and intensive care for severe forms of the disease.
• Outcomes of tetanus, causes of mortality, and follow-up observation rules.

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