The destruction caused by hurricane Ian in Florida recently was widespread and devastating. Flood waters teeming with contaminants and debris posed a hazard to all who ventured out after the storm. You can bet that there was a run on tetanus shots after citizens had a painful encounter with the proverbial “rusty nail” and other objects. In off-grid settings, tetanus is an ever-present risk. The family medic should have knowledge of risks, symptoms, treatment, and prevention.

What is Tetanus?

Tetanus (from the Greek word tetanos, meaning tight)  is an infection caused by the bacteria Clostridium tetani.  The bacteria produces spores (inactive bacteria-to-be) that primarily live in soil or the feces of animals. These spores are capable of laying dormant for years and are resistant to extremes in temperature.

Tetanus is relatively rare in the United States, with about 50 reported cases a year.  Worldwide, however, there are more than 500,000 cases a year. Most are seen in developing countries in Africa and Asia.  Still, we should realize that developed countries may be thrown into third world status in the aftermath of a mega-catastrophe.  There’ll be many more cases that could be your responsibility as medic to identify and treat.

Causes of Tetanus

Most tetanus infections occur when a person has experienced a break in the skin.  The skin is the most important barrier to infection, and any breach in the armor leaves a person open to infection. The most common cause is some type of puncture wound, such as an insect or animal bite, a splinter, or even that rusty nail.  This is because the bacteria is anaerobic (doesn’t like oxygen); deep, narrow wounds are exposed to less O2, providing a favorable environment for C. tetani. Any injury that compromises the skin, however, is eligible: Burns, crush injuries, and lacerations can also be entryways for tetanus bacteria.

When a wound becomes contaminated with Tetanus spores, the spores become full-fledged bacterium and reproduce rapidly.  Damage to the victim comes as a result of a strong toxin excreted by the organism known as tetanospasmin.  This toxin specifically targets nerves that serve muscle tissue.

Tetanospasmin binds to motor nerves, causing “misfires” that lead to involuntary contraction of the affected areas.  This neural damage could be localized or can affect the entire body. You would possibly see the classical symptom of “lockjaw”, where the jaw muscle is taut; any muscle group, however, is susceptible to the contractions if affected by the toxin.  This includes the respiratory musculature, which can inhibit normal breathing and become life-threatening.

The most severe cases seem to occur at extremes of age, with newborns and those over 65 most likely to succumb to the disease. Death rates from generalized Tetanus hover around 25-50%, higher in newborns.

You will be on the lookout for the following early symptoms:

• Sore muscles (especially near the site of injury)
• Weakness
• Irritability
• Difficulty swallowing
• Lockjaw (also called “trismus”; facial muscles are often the first affected)

Initial symptoms may not present themselves for one to two weeks. As the disease progresses, you may see:

• Progressively worsening muscle spasms (may start locally and become generalized over time)
• Involuntary arching of the back (sometimes so strong that bones may break or dislocations may occur!)
• Fever
• Respiratory distress
• High blood pressure
• Irregular heartbeats

Complications of untreated tetanus can lead to a fatal outcome in one out of four people. The death rate for newborns is even higher. 

Treating Tetanus

The first thing that the survival medic should understand is that, although an infectious disease, tetanus is not contagious. You can feel confident treating a tetanus victim safely, as long as you wear gloves and observe standard clean technique.  Begin by washing your hands and putting on your gloves.  Then, wash the wound thoroughly with soap and water, using an irrigation syringe with 3% hydrogen peroxide to repeatedly flush out any debris.  This will, hopefully, limit growth of the bacteria and, as a result, decrease toxin production.

You will want to administer antibiotics to kill off the rest of the tetanus bacteria in the system.  Although not used as prevention, antibiotics will decrease the toxin load and speed recovery. Metronidazole (Aqua-zole, Flagyl) 500mg 4 times a day or Penicillin 500 mg 4 times a day are among some of the drugs known to be effective.  Muscle relaxants like tizanidine and cyclobenzaprine are used to treat spasms, but are unlikely to be available to the off-grid caregiver.

Additional strategies include IV hydration, if available, and keeping the patient as comfortable as possible in a quiet and dimly-lit environment.

Late stage Tetanus is difficult to treat without modern technology. For this reason, it’s important for the survival medic to monitor anyone who has sustained a wound for the early symptoms mentioned earlier.

As medic, you must obtain a detailed medical history from anyone that you might be responsible for in times of trouble.  This includes immunization histories where possible.  Has the injured individual been immunized against tetanus? Most people born in the U.S. will have gone through a series of immunizations against diptheria, tetanus, and whooping cough early in their childhood. Booster injections for tetanus are usually given every 10 years (or if 5 years have passed in a person with a fresh wound, sometimes along with tetanus Immunoglobulin antitoxin).

Tetanus vaccine is not without its risks; severe complications such as seizures or brain damage occur in rare cases (less than one in a million).  Milder side effects such as fatigue, fever, nausea and vomiting, headache, and inflammation in the injection site are more common.

Given the life-threatening nature of the disease, though, this is one vaccine that you should encourage your people to receive, regardless of your feelings about vaccines in general. If not caught early, there may be little you, the off-grid medic, can do to treat your patient without all the bells and whistles of modern medicine.

Joe Alton MD

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