Tetanus is an infection caused by bacteria called Clostridium tetani. When these bacteria enter the body, they produce a toxin that causes painful muscle contractions. Another name for tetanus is “lockjaw”. It often causes a person’s neck and jaw muscles to lock, making it hard to open the mouth or swallow.
Tetanus consequences might be fatal if they are severe. Tetanus has no known treatment. The goal of treatment is to control symptoms and side effects while the tetanus toxin’s effects are still present.
Tetanus cases are uncommon in the United States and other industrialized nations due to the extensive use of vaccinations. Those who are not up to date on their vaccinations continue to be at risk from the disease. It occurs more frequently in underdeveloped nations.
Life-threatening tetanus complications can occur. Tetanus cannot be cured. Up until the tetanus toxin’s effects are gone, treatment concentrates on controlling symptoms and consequences.
Tetanus cases are extremely uncommon in affluent nations like the United States due to the extensive use of vaccinations. Those who don’t have the necessary vaccines continue to be at risk from the disease. In underdeveloped nations, it occurs more frequently.
Pathophysiology of Tetanus
Often, C. tetani spores enter through infected wounds. Tetanospasmin, an exotoxin created when bacteria lyse, is what causes tetanus symptoms. The toxin reaches peripheral nerve endings, where it attaches irreversibly. It then moves retrogradely via axons and synapses before entering the central nervous system (CNS). As a result, the release of inhibitory transmitters from nerve terminals is inhibited, leading to unopposed acetylcholine-induced muscular activation and generalized tonic spasticity, frequently accompanied by concurrent intermittent tonic seizures. Autonomic instability and a hypersympathetic condition result from the disinhibition of autonomic neurons and loss of control over the release of catecholamines from the adrenal glands. The toxin cannot be removed after it has been bonded.
Tetanus often affects all of the body’s skeletal muscles and is generalized. Tetanus can, however, occasionally be limited to muscles close to an entrance incision.
The incubation period, or the amount of time between an infection and the onset of symptoms, is typically 10 days. The incubation phase may last three to twenty one days.
Tetanus is most frequently known as generalized tetanus. Over the course of two weeks, signs and symptoms steadily intensify after a modest start. Usually, they begin at the jaw and work their way down the body.
Signs and symptoms of generalized tetanus include:
- Painful muscle spasms and stiff, immovable muscles (muscle rigidity) in your jaw
- Tension of muscles around your lips, sometimes producing a persistent grin
- Painful spasms and rigidity in your neck muscles
- Difficulty swallowing
- Rigid abdominal muscles
Repeated, agonizing, seizure-like spasms that linger for many minutes are a symptom of tetanus progression (generalized spasms). Typically, the fists are clinched, the knees stiffen, the neck and back arch, and the arms are dragged up to the body. Breathing issues could be brought on by neck and abdominal muscle tightness.
Little occurrences that activate the senses, such as a loud noise, a physical contact, a draft, or light, might cause these severe spasms.
As the disease progresses, other signs and symptoms may include:
- High blood pressure
- Low blood pressure
- Rapid heart rate
- Extreme sweating
A characteristic expression with a frozen smile and raised eyebrows results from facial muscular spasm (risus sardonicus). Abdominal, neck, and back muscles may become rigid or tense, and opisthotonos—generalized body rigidity accompanied by an arched back and neck—can also happen. Constipation or urine retention are caused by sphincter spasm. Nutritional needs may be hampered by dysphagia.
Little disruptions like a draft, noise, or movement might cause the recognizable painful, widespread tonic spasms and excessive sweating. Mental status is typically obvious, however coma may occur after numerous spasms. Patients with generalized spasms are unable to talk or cry out due to glottal spasm or rigidity of the chest wall. Rarely do prolonged spasms lead to fractures.
Spasms can also impair breathing, leading to cyanosis or deadly hypoxia.
This uncommon form of tetanus results in muscles spasms near the site of a wound. While it’s usually a less severe form of disease, it can progress to generalized tetanus.
This rare form of tetanus results from a head wound. It results in weakened muscles in the face and spasms of the jaw muscles. It also can progress to generalized tetanus.
Tetanus in neonates is usually generalized and frequently fatal. It often begins in an inadequately cleansed umbilical stump in children born of inadequately immunized mothers. Onset during the first 2 weeks of life is characterized by rigidity, spasms, and poor feeding. Bilateral deafness may occur in surviving children.
The greatest risk factor for tetanus infection is not being vaccinated or not keeping up with the 10-year booster shots.
Other factors that increase the risk of tetanus infection are:
- Cuts or wounds exposed to soil or manure
- A foreign body in a wound, such as a nail or splinter
- A history of immune-suppressing medical conditions
- Infected skin lesions in people living with diabetes
- An infected umbilical cord when a mother isn’t fully vaccinated
- Shared and unsanitary needles for illegal drug use
Complications of tetanus infection may include:
- Breathing problems. Life-threatening breathing problems can occur from tightening of the vocal cords and muscle rigidity in the neck and abdomen, especially during a generalized spasm.
- Blockage of a lung artery (pulmonary embolism). A blood clot that has traveled from elsewhere in your body can block the main artery of the lung or one of its branches.
- Pneumonia. A lung infection caused by accidentally inhaling something into the lungs (aspiration pneumonia) may be a complication of generalized spasms.
- Broken bones. Generalized spasms may cause fractures of the spine or other bones.
- Death. Death from tetanus is often caused by a blocked airway during spasms or damage to the nerves that regulate breathing, heart rate or other organ functions.
- Clinical evaluation
Tetanus should be considered when patients have sudden, unexplained muscle stiffness or spasms, particularly if they have a history of a recent wound or risk factors for tetanus.
Tetanus can be confused with meningoencephalitis of bacterial or viral origin, but the following combination suggests tetanus:
- An intact sensorium
- Normal cerebrospinal fluid
- Muscle spasms
Trismus must be distinguished from peritonsillar or retropharyngeal abscess or another local cause. Phenothiazines can induce tetanus-like rigidity (eg, dystonic reaction, neuroleptic malignant syndrome).
C. tetani can sometimes be cultured from the wound, but culture is not sensitive; only 30% of patients with tetanus have positive cultures. Also, false-positive cultures can occur in patients without tetanus.
Vaccination for children
The tetanus vaccine is given to children as part of the diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). Diphtheria is a serious bacterial infection of the nose and throat. Acellular pertussis, also called whooping cough, is a highly contagious respiratory infection.
Children who do not tolerate the pertussis vaccine may receive the alternative vaccine called DT.
The DTaP is a series of five shots typically given in the arm or thigh to children at ages:
- 2 months
- 4 months
- 6 months
- 15 to 18 months
- 4 to 6 years
Vaccination for children ages 7 to 18
A booster shot is recommended for children at age 11 or 12. This booster is called the Tdap vaccine. If your child didn’t get a booster shot as this age, talk to your doctor about appropriate options.
Vaccination for adults age 19 and older
A booster shot is recommended for adults once every 10 years. This may be one of two vaccines, Tdap or Td. If you weren’t vaccinated against tetanus as a child or are unsure about your vaccination status, see your doctor about getting the Tdap vaccine.
Vaccination during pregnancy
A booster is recommended during the third trimester of a pregnancy, regardless of the mother’s vaccination schedule.
There’s no cure for tetanus. A tetanus infection requires emergency and long-term supportive care while the disease runs its course. Treatment consists of wound care, medications to ease symptoms and supportive care, usually in an intensive care unit.
The disease progresses for about two weeks, and recovery can last about a month.
Care for your wound requires cleaning to remove dirt, debris or foreign objects that may be harboring bacteria. Your care team will also clear the wound of any dead tissue that could provide an environment in which bacteria can grow.
- Antitoxin therapy is used to target toxins that have not yet attacked nerve tissues. This treatment, called passive immunization, is a human antibody to the toxin.
- Sedatives that slow the function of the nervous system can help control muscle spasms.
- Vaccination with one of the standard tetanus vaccinations helps your immune system fight the toxins.
- Antibiotics, given either orally or by injection, may help fight tetanus bacteria.
- Other drugs. Other medications might be used to regulate involuntary muscle activity, such as your heartbeat and breathing. Morphine might be used for this purpose as well as for sedation.
Tetanus Prophylaxis in Routine Wound Management
|History of Adsorbed Tetanus Toxoid||Clean, Minor Wounds||All Other Wounds*|
|Unknown or < 3 doses||Yes||No||Yes||Yes|
|≥ 3 doses||Yes if > 10 years since last dose||No||Yes if > 5 years since last dose||No|
|* Such as (but not limited to) wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; crush injuries; avulsions; and wounds resulting from missiles, burns, or frostbite.|
|† For patients ≥ 10 years who have not previously received a dose of Tdap, a single dose of Tdap should be given instead of one Td booster. Children < 7 years should be given DTaP or, if pertussis vaccine is contraindicated, DT. Children aged 7–9 years should be given Td.|
|‡ TIG 250–500 units IM. People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.|
|DT = diphtheria and tetanus toxoids (for children); DTaP = diphtheria and tetanus toxoids, acellular pertussis (for children); Td = tetanus and diphtheria toxoids adsorbed (for adults); Tdap = tetanus and diphtheria toxoids, acellular pertussis (for adults); TIG = tetanus immune globulin (human).|