Last updated: September 18, 2023

Summarytoggle arrow icon

Tetanus (lockjaw) is an acute disease caused by neurotoxins from the bacterium Clostridium tetani. C. tetani is ubiquitous in spore form and enters the body through broken skin (e.g., deep puncture wounds). Its toxins then cause uncontrolled activation of alpha motor neurons, leading to muscular rigidity and spasms. Patients classically present with a triad of trismus, risus sardonicus, and opisthotonus. Tetanus is a clinical diagnosis, but diagnostic testing may help confirm the diagnosis. Treatment includes airway management, wound debridement, immunoglobulin therapy (e.g., human tetanus immune globulin), antibiotics (e.g., metronidazole), and pharmacological management of severe muscle spasms. Prevention of tetanus involves routine immunization with tetanus vaccines and administering postexposure prophylaxis for wounds.

Etiologytoggle arrow icon

  • Pathogen
  • Route of infection
    • Clostridial spores contaminate a wound (e.g., through dirt, saliva, feces).
    • Localized ischemia, necrosis, foreign bodies and/or coinfection with other bacteria predispose to infection.
    • Wounds with compromised blood supply create anaerobic conditions that are required for the germination and multiplication of C. tetani.
  • Groups with a higher risk: : non-immunized individuals, those with diabetes, neonates, people who inject drugs (PWID), certain patient groups (i.e., postsurgical, obstetric, dental)

Pathophysiologytoggle arrow icon

Ubiquitous C. tetani spores contaminate a wound bacterial reproduction under anaerobic conditions → production of the neurotoxins tetanospasmin and tetanolysin

Neurotoxins (not the pathogen itself) cause tetanic contractions.

Tetanospasmin causes tetanic spasms.

Clinical featurestoggle arrow icon

  • Incubation period: 3–21 days (average: ∼ 10 days)
  • Generalized tetanus: painful muscle spasms and rigidity
    • Trismus: lockjaw due to spasms of jaw musculature (commonly the first tetanus-specific symptom)
    • Risus sardonicus: sustained facial muscle spasm that causes a characteristic, apparently sardonic grin and raised eyebrows
    • Opisthotonus: backward arching of spine, neck, and head caused by spasms of the back muscles
    • Neck stiffness
    • Abdominal rigidity
  • Life-threatening complications

Subtypes and variantstoggle arrow icon

Neonatal tetanus

  • Occurs in infants of inadequately immunized mothers after unsterile management of the umbilical stump
  • Typically occurs 5–8 days after birth, but the incubation period can take up to several weeks
  • Typically a rapid onset of symptoms as axonal length in infants is shorter than in adults [4]
  • Symptoms

Other types [5]

  • Localized tetanus: Patients present with painful muscle contractions in areas surrounding the injury site only.
  • Cephalic tetanus

Diagnosticstoggle arrow icon

Treatmenttoggle arrow icon

The following relates to the treatment of clinically apparent tetanus. See "Tetanus prophylaxis after injury" for preventing tetanus in individuals with acute wounds.

Approach [7][8][9][10]

Wound care and antibiotics decrease bacterial load and toxin production. Immunoglobulin therapy neutralizes free toxins. [9][13]

Acute stabilization [7][8][9][10]

Prepare for difficult airway management and consider early RSI, as trismus and laryngospasm can limit successful intubation.

Prolonged mechanical ventilation is often required; consider early tracheostomy. [13]

Antibiotics [7][8][9][10]

Immunization [7][8][9][10]

Following immunoglobulin therapy, live vaccines (e.g., MMR vaccine, varicella vaccine) should not be given for 3–8 months (see “Contraindications to live vaccines”). [7]

Preventiontoggle arrow icon

Tetanus vaccine [17][18]

Routine immunization is recommended for all individuals.

Boosters with Td or Tdap are recommended every 10 years for all adolescents and adults who have completed the primary Tdap and DTaP series. See “ACIP immunization schedule” for details. [18][20][21]

Acellular pertussis-containing vaccines are contraindicated in patients who previously developed unexplained encephalopathy within a week after receiving an acellular pertussis vaccine (i.e., DTaP or Tdap). [19]

Tetanus prophylaxis after injury [7][8][9][22]

Postexposure tetanus prophylaxis [8][9][22]
Tetanus vaccine history Clean and minor wounds Tetanus prone wounds

Unknown or < 3 doses

≥ 3 doses

Administer HTIG to patients with severe immunodeficiency or HIV infection and a tetanus-prone wound regardless of tetanus vaccine history. [9]

Referencestoggle arrow icon

  1. Moss. Handbook of Natural Toxins: Bacterial Toxins and Virulence Factors in Disease, Band 8. Marcel Dekker, Inc. ; 1995
  2. Tetanus toxin: direct evidence for retrograde intraaxonal transport.. Updated: May 30, 1975. Accessed: August 29, 2016.
  3. Epidemiology and Prevention of Vaccine-Preventable Diseases. Updated: September 8, 2015. Accessed: September 19, 2016.
  4. Roper MH, Vandelaer JH, Gasse FL. Maternal and neonatal tetanus. . 2007; 370 (9603): p.1947-59.doi: 10.1016/S0140-6736(07)61261-6 . | Open in Read by QxMD
  5. Tetanus: For Clinicians. Updated: January 23, 2020. Accessed: November 17, 2020.
  6. Andrew Michael Taylor, FRCA. Tetanus. . 2006; 6 (3): p.101-104.doi: 10.1093/bjaceaccp/mkl014 . | Open in Read by QxMD
  7. AAP Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. American Academy of Pediatrics ; 2021
  8. Hall E, Wodi AP, Hamborsky J, et al. Epidemiology and Prevention of Vaccine-Preventable Diseases 14th ed. Public Health Foundation ; 2021
  9. Nemhauser JB. CDC Yellow Book 2024. Oxford University Press ; 2023
  10. Current recommendations for treatment of tetanus during humanitarian emergencies. Updated: January 11, 2010. Accessed: August 16, 2023.
  11. Tetanus: For Clinicians. Updated: August 29, 2022. Accessed: August 17, 2023.
  12. Freshwater-Turner D, Udy A, Lipman J, et al. Autonomic dysfunction in tetanus – what lessons can be learnt with specific reference to alpha-2 agonists?. Anaesthesia. 2007; 62 (10): p.1066-1070.doi: 10.1111/j.1365-2044.2007.05217.x . | Open in Read by QxMD
  13. Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: an evidence-based review. Crit Care. 2014; 18 (2): p.217.doi: 10.1186/cc13797 . | Open in Read by QxMD
  14. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007; 35 (10): p.S65-S164.doi: 10.1016/j.ajic.2007.10.007 . | Open in Read by QxMD
  15. Lee DC, Lederman HM. Anti-Tetanus Toxoid Antibodies in Intravenous Gamma Globulin: An Alternative to Tetanus Immune Globulin. J Infect Dis. 1992; 166 (3): p.642-645.doi: 10.1093/infdis/166.3.642 . | Open in Read by QxMD
  16. Orenstein W, Orenstein W, MD W, et al. Plotkin's Vaccines. Elsevier ; 2023
  17. Tetanus (Lockjaw) Vaccination: What Everyone Should Know. Updated: February 3, 2016. Accessed: September 20, 2016.
  18. Child and Adolescent Immunization Schedule. Recommendations for Ages 18 Years or Younger, United States, 2023. Updated: February 10, 2023. Accessed: March 24, 2023.
  19. CDC Diphtheria, Tetanus, and Pertussis Vaccine Recommendations.,of%20DTP%2C%20DTaP%2C%20or%20Tdap. Updated: March 10, 2023. Accessed: August 9, 2023.
  20. Catch-up Immunization Schedule for Children and Adolescents Who Start Late or Who Are More than 1 Month Behind Recommendations for Ages 18 Years or Younger, United States, 2023. Updated: February 10, 2023. Accessed: March 24, 2023.
  21. Adult Immunization Schedule by Age Recommendations for Ages 19 Years or Older, United States, 2023. Updated: February 10, 2023. Accessed: March 24, 2023.
  22. Liang, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018.
  23. Brown. Nerve Cells and Nervous Systems: An Introduction to Neuroscience. Springer Science & Business Media ; 2012
  24. Hinfey PB, Brusch JL. Tetanus Clinical Presentation. Tetanus Clinical Presentation. New York, NY: WebMD. Updated: June 16, 2016. Accessed: August 29, 2016.
  25. Hinfey PB. Tetanus Treatment & Management. In: Brusch JL, Tetanus Treatment & Management. New York, NY: WebMD. Updated: June 16, 2016. Accessed: September 20, 2016.

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