Tetanus (Lockjaw)

Tetanus is a serious bacterial infection caused by Clostridium tetani that affects the nervous system and causes painful muscle contractions, particularly in the jaw and neck. Despite being preventable through vaccination, tetanus remains a medical emergency with a mortality rate of 10-20% even with modern intensive care. The bacteria produce a powerful toxin that interferes with nerve signals, leading to the characteristic muscle spasms.

⚠️ Medical Emergency

Seek immediate medical care for: jaw stiffness or lockjaw, difficulty swallowing, painful muscle spasms, fever with muscle stiffness after a wound, or breathing difficulties. Tetanus requires immediate hospital treatment and can be fatal without proper care.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.

Understanding Tetanus

Tetanus is not contagious from person to person. The bacteria that cause tetanus are found in soil, dust, and animal feces. When they enter a deep wound, they produce a toxin (tetanospasmin) that affects the nervous system, leading to muscle stiffness and spasms.

Key Facts

  • Caused by bacterial toxin, not the bacteria itself
  • Incubation period: 3-21 days (average 10 days)
  • Shorter incubation = more severe disease
  • Can occur even in minor wounds
  • Completely preventable with vaccination
  • No herd immunity - must be individually protected

Types of Tetanus

Generalized Tetanus (80% of cases)

  • Most common and severe form
  • Affects muscles throughout the body
  • Descending pattern: jaw → neck → trunk → limbs
  • Classic "lockjaw" presentation
  • Can progress to respiratory failure

Localized Tetanus

  • Muscle spasms near wound site
  • Milder form
  • May progress to generalized tetanus
  • Better prognosis

Cephalic Tetanus

  • Rare form following head injury or ear infection
  • Affects cranial nerves
  • Facial muscle spasms
  • May progress to generalized form

Neonatal Tetanus

  • Occurs in newborns of unvaccinated mothers
  • Usually from infected umbilical stump
  • High mortality rate
  • Eliminated in developed countries
  • Still occurs in areas with poor hygiene

Signs and Symptoms

Early Symptoms

  • Trismus (lockjaw): First symptom in 50-75% of cases
  • Neck stiffness
  • Difficulty swallowing (dysphagia)
  • Abdominal muscle rigidity
  • Restlessness and irritability
  • Headache
  • Fever (usually low-grade)
  • Sore throat

Progressive Symptoms

  • Risus sardonicus: Facial grimace from facial muscle spasms
  • Opisthotonus: Severe back arching from muscle spasms
  • Board-like abdomen: Rigid abdominal muscles
  • Painful, generalized muscle spasms lasting minutes
  • Spasms triggered by:
    • Loud noises
    • Physical touch
    • Light
    • Drafts

Severe Symptoms

  • Breathing difficulties from chest muscle spasms
  • Laryngeal spasms causing airway obstruction
  • Fractures from severe muscle contractions
  • Elevated blood pressure
  • Rapid heart rate
  • Profuse sweating
  • Pneumonia
  • Pulmonary embolism

Causes and Transmission

The Bacterium

  • Clostridium tetani: Anaerobic, spore-forming bacterium
  • Spores highly resistant to heat and antiseptics
  • Found worldwide in:
    • Soil
    • Dust
    • Animal and human feces
    • Rusted metal (myth - rust doesn't cause tetanus)

How Infection Occurs

  1. Spores enter through break in skin
  2. Anaerobic conditions allow germination
  3. Bacteria multiply and produce tetanospasmin toxin
  4. Toxin travels along nerves to spinal cord
  5. Blocks inhibitory neurotransmitters
  6. Results in unopposed muscle contraction

Common Entry Points

  • Puncture wounds: Nails, splinters, needles
  • Crush injuries: Devitalized tissue
  • Burns: Second and third degree
  • Surgical wounds: Especially bowel surgery
  • Injection sites: IV drug use
  • Umbilical stump: In newborns
  • Compound fractures: Bone exposed
  • Animal bites: Deep puncture wounds
  • Chronic wounds: Ulcers, gangrene

Risk Factors

Primary Risk Factor

  • Lack of immunization: Unvaccinated or incompletely vaccinated
  • Waning immunity: No booster in >10 years

High-Risk Groups

  • Older adults (>65 years) with waning immunity
  • Newborns of unimmunized mothers
  • People who inject drugs
  • Agricultural workers
  • Those with poor access to healthcare
  • Immigrants from countries with low vaccination rates

High-Risk Wounds

  • Contaminated with dirt, feces, saliva
  • Puncture wounds
  • Avulsions
  • Wounds with devitalized tissue
  • Burns or frostbite
  • Wounds >6 hours old before treatment

Diagnosis

Tetanus is diagnosed clinically based on symptoms. No laboratory test can confirm tetanus.

Clinical Diagnosis

  • History of wound (may be minor or forgotten)
  • Characteristic symptoms:
    • Trismus (lockjaw)
    • Muscle rigidity
    • Muscle spasms
  • Absence of other causes
  • Vaccination history

Differential Diagnosis

  • Strychnine poisoning
  • Meningitis or encephalitis
  • Rabies
  • Hypocalcemia
  • Drug reactions (phenothiazines)
  • Peritonsillar abscess
  • Temporomandibular joint disorders

Laboratory Tests

  • Usually normal
  • May show:
    • Elevated white blood cells
    • Normal CSF (rules out meningitis)
    • Elevated creatine kinase from muscle damage
  • Wound culture rarely positive

Treatment

Tetanus requires immediate hospitalization, often in an intensive care unit. Treatment focuses on:

1. Neutralizing Toxin

  • Human tetanus immune globulin (TIG):
    • 3,000-6,000 units IM
    • Given before wound debridement
    • Neutralizes circulating toxin only
    • Cannot affect toxin already bound to nerves

2. Eliminating Bacteria

  • Antibiotics:
    • Metronidazole (preferred)
    • Penicillin G (alternative)
    • Doxycycline or erythromycin for allergic patients
  • Wound care:
    • Aggressive debridement
    • Remove foreign material
    • Open wound to air

3. Managing Muscle Spasms

  • Benzodiazepines: First-line for spasms
  • Baclofen: Intrathecal for severe cases
  • Neuromuscular blockers: With mechanical ventilation
  • Magnesium sulfate: May reduce autonomic instability

4. Supportive Care

  • Airway management:
    • Early intubation often needed
    • Tracheostomy for prolonged ventilation
  • Autonomic dysfunction:
    • Beta-blockers for tachycardia
    • Vasopressors for hypotension
  • Nutrition: High caloric needs from muscle spasms
  • DVT prophylaxis: Due to immobility
  • Physical therapy: After acute phase

5. Vaccination

  • Start vaccination series during recovery
  • Natural infection doesn't provide immunity
  • Complete series essential

Prevention

Primary Prevention: Vaccination

Childhood Schedule

  • DTaP vaccine: 2, 4, 6, 15-18 months, 4-6 years
  • Provides ~10 years of protection
  • >95% effective after complete series

Adult Boosters

  • Td booster: Every 10 years
  • Tdap: One dose replaces Td booster
  • Pregnancy: Tdap during each pregnancy (27-36 weeks)
  • Age >65: Ensure up to date

Wound Management

Vaccination History Clean, Minor Wounds All Other Wounds
<3 doses or unknown Tdap/Td AND TIG Tdap/Td AND TIG
≥3 doses, last <5 years Nothing needed Nothing needed
≥3 doses, last 5-10 years Nothing needed Tdap/Td only
≥3 doses, last >10 years Tdap/Td only Tdap/Td only

General Wound Care

  • Clean all wounds thoroughly
  • Remove foreign material
  • Debride devitalized tissue
  • Don't close contaminated wounds
  • Seek medical care for deep or dirty wounds

Complications

Immediate Complications

  • Laryngospasm and airway obstruction
  • Respiratory failure
  • Aspiration pneumonia
  • Fractures from severe spasms
  • Rhabdomyolysis

Secondary Complications

  • Pulmonary embolism
  • Nosocomial infections
  • Pressure ulcers
  • Contractures
  • Autonomic dysfunction:
    • Hypertension/hypotension
    • Cardiac arrhythmias
    • Cardiac arrest

Long-term Effects

  • Most survivors recover completely
  • Recovery takes weeks to months
  • Possible persistent weakness
  • Psychological effects from ICU stay

Prognosis

Prognosis depends on incubation period, time to treatment, and patient age:

Mortality Rates

  • Overall: 10-20% with ICU care
  • Neonatal tetanus: 80-90% without treatment
  • Older adults: Higher mortality
  • Severe cases: Up to 50%

Prognostic Factors

  • Good prognosis:
    • Longer incubation period (>10 days)
    • Slower progression
    • Localized disease
    • Early treatment
  • Poor prognosis:
    • Short incubation (<7 days)
    • Rapid progression
    • Neonatal or cephalic tetanus
    • Delayed treatment

With modern intensive care, most patients survive tetanus. However, prevention through vaccination remains far superior to treatment. Complete recovery is possible but may take several months.