In the emergency department, it is common to encounter patients with superficial abrasions who have finished treating their wounds at a community hospital and traveled to a higher level hospital to get a tetanus shot. Do all superficial traumas require tetanus shots? I believe that many people have such a doubt, let’s talk about tetanus today. Clostridium tetani is widespread in the environment and proliferates under hypoxic conditions. The spasmodic toxin produced by the death of the clostridium can irreversibly bind to nerve receptors in the spinal cord and brain stem, etc., and is the main factor causing the disease, with a mortality rate as high as 10 – 30%. Which wounds can be infected with tetanus? Although Clostridium tetani is widely distributed, only a very small percentage of wounds actually develop tetanus. The conditions for tetanus infection are: an open tissue injury with a deep wound, invasion by Clostridium tetani from outside, presence of inactivated tissue in the wound, or ischemia and hypoxia of the local tissue. It follows that tetanus infection does not usually occur in superficial wounds. Simple epidermal abrasions, after timely debridement, there is no need to take a tetanus shot for prophylaxis. The first symptoms of tetanus are not typical If the patient has typical symptoms such as corns, a bitter smile, a slab-like abdomen, and respiratory obstruction, the diagnosis is relatively easy, but the condition is already in moderate to severe, and the patient’s prognosis is often poor. In fact, the precursor symptoms of tetanus are generalized weakness, dizziness, headache, weakness in chewing, local muscle tightness, tugging pain, hyperreflexia, etc. Patients tend to manifest lumbar and leg pain, sciatica, difficulty in opening the mouth, increased muscle tone, etc., which are easy to be misdiagnosed as temporomandibular joint arthritis, neuritis, cervical and lumbar spondylolisthesis, etc. If the patient has a positive tongue compression test, it is relatively easy to be diagnosed. If the patient’s tongue depressor test is positive (pressing down hard on the middle of the tongue with a tongue depressor, the patient’s teeth immediately appear to be closed and bite the tongue depressor), it should be highly suspected to be tetanus. Two principles of tetanus prevention – thorough debridement and early prophylaxis – need to be corrected is the misconception that some clinicians only know about prophylaxis but not debridement in patients with deep soft tissue injuries. In fact, soft tissue debridement is much more important than tetanus prophylaxis, and in the extreme, tetanus prophylaxis may not even be necessary for a thoroughly debrided soft tissue injury. Tetanus prophylaxis is necessary 24 hours after injury, and early prophylaxis, as many clinicians know, is usually recommended within 24 hours, and the earlier the better. Many people feel that tetanus prophylaxis for soft tissue injuries that are more than 24 hours old no longer makes much sense. In fact, depending on the individual, the incubation period for Mycobacterium tetani infection is 3-21 days, usually 7 days. According to its pathogenesis, although the spasmodic toxin binds irreversibly to nerve receptors, prophylaxis is effective when symptoms have not yet appeared. Therefore, tetanus prophylaxis is essential for patients who present to the doctor even very late after a soft tissue injury. Tetanus prophylaxis strategies include active immunization (tetanus toxoid antigen) and passive immunization (tetanus antitoxin serum and tetanus immunoglobulin). However, the majority of patients presenting to the emergency department may be unaware of previous tetanus immunization, and for simplicity, tetanus antitoxin serum (1500-3000 IU) or tetanus immunoglobulin (250 IU) is recommended. What should I do with a person who is allergic to the tetanus antitoxin skin test? If human immunoglobulin is unavailable in this group of patients in the emergency setting, classic tetanus desensitization can be used: dilute the required dose of antitoxin 10-fold in saline and inject it in several small doses: start with 0.2 ml, observe for half an hour, if there is no reaction, inject 0.4 ml. Continue to observe, if there is no reaction, double the dose to 0.8 ml; continue observing, and if there is no reaction, no dilution is necessary! If there is no reaction, no dilution is required, inject the remaining dose of tetanus antitoxin, a process that takes about 4 injections over 2 hours. If a violent reaction occurs during the injection of a particular dose, or if the patient’s skin test is strongly positive, then the dose should be reduced in each increment. The treatment of tetanus is basically symptomatic because the binding of the tetanus toxin to the nerve receptors is irreversible, and therefore the treatment of tetanus is basically symptomatic. The onset of tetanus lasts about 1-2 months, and many patients do not last that long, resulting in a high mortality rate among tetanus patients. To summarize the symptomatic treatment of tetanus, it consists of stopping the continued production of the toxin, neutralizing the free toxin in the serum, controlling tonic spasms of the general muscular system and general supportive therapy. The mainstay of tetanus antitoxin production is thorough debridement. Antibiotics are recommended for tetanus patients because the wounds of soft tissue injuries in such patients are usually not debrided and are prone to co-infection with multiple bacterial infections. The main drug for neutralizing serum free toxins is the tetanus antitoxin mentioned earlier, but the dose used needs to be increased to more than 10 times. Control of generalized muscle tonic spasms includes endotracheal intubation for respiratory control, sedation, nerve blockers, and magnesium sulfate for relief of muscle tonus. Other symptomatic measures include: nutritional support, as tetanus patients have extremely high energy requirements due to persistent muscle spasms; and low molecular heparin to prevent venous thrombosis.