Tetanus and TEOTWAWKI. Is It Always Fatal? What Can Be Done?

You know the drill.  Step on a rusty nail.  Go to the doctor to get a tetanus shot.  I seemed to do this a lot as a child.  Maybe you were smarter and avoided the nails and trips to the doctor.

Tetanus has been a reportable disease in the US since 1947, and cases of tetanus have decreased every year since reporting began.  Annually, we have about 30 cases in the US.  And with only a few dozen cases each year, the vast majority of physicians in the US will not have any experience treating tetanus.  Tetanus is actually much more of a third world disease with about a half-million cases each year.  However, as decreasing numbers of people are immunized each year, those numbers in the US may start rising soon.  Fortunately, tetanus is not contagious.

CAUSES
There are numerous ways for people to contract tetanus.  The most common are:

• animal bites, especially from dogs and pigs;
• gunshot and knife wounds;
• barbed wire;
• puncture wounds from thorns, splinters, nails, etc.

But tetanus can develop any time the skin is compromised, including from burns, lacerations, and crush injuries.  Punctures just happen to be of greatest concern because the bacteria that cause tetanus, Clostridium tetani, are anaerobic bacteria.  They thrive in the absence of oxygen, which is exactly what happens with puncture wounds.  The wounds are deep, oxygen supply is poor, and the bacteria grow.  When these Gram-negative spores invade, they mature, become active, and start producing the tetanospasmin toxin that attacks nerves connected to muscles.

PREVENTION
The very best prevention is to be fully immunized as a child and to receive boosters every ten years.  In addition, wearing shoes when outdoors and long sleeves and gloves when working in the yard offer further protection.

PROPHYLAXIS
Prophylactic measures should be taken with every wound, no matter how "trivial."  Indeed, with many cases of tetanus, the patient has no idea how he became host to the bacteria.  Even small splinters and a little prick from a thorn can become life-threatening.  And more so when we don't have hospital facilities. 

So each and every wound gets cleaned thoroughly, no matter how small it is. Some physicians may prescribe further prophylactic treatment of taking an antibiotic such as penicillin, ampicillin, or metronidazole, to kill any Clostridium bacteria that may have entered the body.

SYMPTOMS and SIGNS
It may take up to two weeks for the first symptoms of tetanus to appear.  These symptoms include sore muscles, especially near the site of injury, weakness, irritability, difficulty and discomfort in swallowing, and then lockjaw.

An initial test a doctor may perform when examining a patient suspected of having tetanus is to test the knee reflexes.  When the doctor taps the knee, a little bit of a response is normal.  However, a significant kick up suggests tetanus (or meningitis, or poisoning).

As the disease progresses, the muscle spasms spread from the local area of injury and the jaw to the rest of the body.  During this period, bright light, loud noises, and moving or touching the patient may trigger sudden spasms, which may be strong enough to dislocate or break bones.  Accordingly, the patient must be protected as much as possible from these stimuli.   If the muscles that govern the movement of the diaphragm become affected, the patient's ability to breathe diminishes, and the patient may suffocate if mechanical ventilation is not available.  Other symptoms include fever, high blood pressure, and irregular heartbeat. 

TREATMENT  
There is no cure for tetanus.  Treatment lies in supportive care, the best methods of which may be impossible in a grid-down situation.

• First off, find the source of the infection, open it up, and clean it out.  Bear in mind, that if the cause was a minor splinter or thorn prick, there may not be a wound to clean out.  If available, a doctor will likely administer 1 million units penicillin IV, (preferred), or tetracycline. 
• If intravenous antibiotics are not available, metronidazole, 375-500 mg twice per day, or doxycycline, 100 mg twice per day, may be prescribed.  These antibiotics are not killing the toxin; they are killing the bacteria.  The bacteria cease reproducing, so they make less toxin.  There is nothing that will hasten or remove the toxins that have bound to the nerves.  
• In addition to antibiotics, valium (10-20 mg to start), diazepam, or phenobarbital may be administered to reduce spasms.  
• The patient may also require intravenous fluids.

OUTCOME
The mortality rate for tetanus cases ranges from 20 to 75%, depending on age.   There is a 50% mortality rate in hospitals for all tetanus patients treated in hospitals, 75% mortality in patients over the age of 60, and an 18% mortality rate for younger patients, except for newborns.  Their mortality rate is much higher.  And all that is with modern hospital care. 

Newborns contract tetanus when dirty instruments are used to cut the umbilical cord, when the cord is not cut close to the body, or when the cut umbilical stump is kept tightly covered and not dry.  When the mother is fully immunized, newborns are protected from tetanus.  In newborns, the first signs of tetanus appear three to ten days after birth.  The umbilical area is usually dirty or infected, and the baby usually cries continuously and is unable to suck.  If the baby stops nursing in the period from five to fifteen days after birth, suspect tetanus.  Nasogastric tubes are often inserted to feed the babies. 

You know how women get together and share labor and delivery stories of the births of their children?  The same will be happening in the afterlife, with people telling how they died.  There will be lots of heart attacks and cancer.  Diabetes.  Car accidents.  Don't be the guy who has the room rolling on the floor laughing because you died of tetanus from a splinter.  It really will be so embarrassing.  And your wife will be really mad, too.  Just get the tetanus shot and wash your wounds. 

Links to related posts:
Skin Preps and Washes   
Doxycycline
Penicillin
Animal Bites
How to Clean Abrasions 

For further reading:
Armageddon Medicine, pp 111-113.
Survival and Austere Medicine, 3rd Edition, p 270.
The Survival Medicine Handbook, pp 195-198.
Where There Is No Doctor, pp 182-184. 
https://www.mayoclinic.org/diseases-conditions/tetanus/diagnosis-treatment/drc-20351631
https://en.wikipedia.org/wiki/Tetanus

 12 february 2020