Tetanus (lockjaw)

Tetanus is a severe illness in which the muscles of the whole body are gripped by painful spasms and a person can die because they stop breathing. It is caused not by the bacterium itself but by the toxin it produces once it is inside a wound. Wherever everybody is vaccinated and vaccinated on time, tetanus has become a rarity, and that is exactly why it gets forgotten: the wound is rinsed, a plaster goes on, and nobody asks the one question that really matters here, which is when the last vaccination was. This page is mostly about what to do in the first few hours after an injury, because later on there is very little that can be done.

Where it comes from

The organism that causes tetanus lives in soil, in street dust, in manure and in the intestines of animals. It forms spores, tough dormant forms that survive in the ground for years and withstand drying and heat. Being infected means getting those spores into a wound along with a speck of earth.

What happens next is decided by oxygen. Deep in a wound, where air does not reach, the spores wake up and start producing toxin. The toxin travels along the nerves and removes the brake from the motor neurones: the muscles get the order to contract and never get the order to relax.

Tetanus does not pass from person to person. You can be beside someone with tetanus without any fear, look after them and live in the same flat: you cannot catch it from them. That is an important difference from the familiar infections, because quarantine is beside the point here and the only things that protect are vaccination and a properly cleaned wound.

And one very common misunderstanding: rust is not the issue. A rusty nail is dangerous not because it is rusty but because it has been lying in the soil and leaves a deep, narrow puncture. A clean new nail driven in just as deep is dangerous too.

Which wounds are dangerous

It is not only large wounds that are dangerous. If anything the rule runs the other way: the deeper and narrower the track and the worse it rinses out, the better the conditions for the organism.

• Deep puncture wounds: a nail, a garden fork, wire, a thorn, a splinter, a jab from a garden tool.
• Animal and human bites, and scratches from claws.
• Any wound that has had soil, sand, manure or street dirt in it.
• Burns and frostbite injuries where the skin is broken.
• Crush wounds, wounds with dead tissue and wounds with a foreign body still inside.
• Wounds more than a day old that nobody has cleaned.
• Long-standing ulcers, including diabetic foot ulcers.
• Injections with non-sterile needles.

Gravel rash from coming off a bicycle counts as a dirty wound too, however trivial it looks. Sometimes tetanus follows an injury the person has forgotten entirely: a splinter, a jab from a rose thorn, a blister rubbed inside a rubber boot.

What to do with the wound straight away

First aid is simple, but it should not be rushed.

• Wash the wound under running water with soap and be generous with the time: several minutes, not a couple of seconds.
• Remove visible dirt, soil and grit. Anything lodged deeply that will not come out should be left to a clinician.
• Apply an antiseptic to the skin around the wound.
• Cover it with a clean dressing. Do not seal a deep puncture airtight or smother it in ointment: air is helpful here.
• Do not cauterise the wound or pour spirit into it. That damages tissue and does not kill spores.

Washing is not enough. Neither water nor antiseptic destroys the spores. So once the wound is cleaned the main step remains: get medical help the same day so that a clinician can decide about vaccination and immunoglobulin. That applies particularly if the wound is deep, dirty or a bite, if it is many years since your last vaccination, or if you simply do not know your vaccination status.

Vaccine and immunoglobulin after an injury

The clinician weighs up two things: how favourable that wound is to tetanus, and what is known about your vaccinations. The decision comes out of combining the two answers.

If the primary course was completed and the last dose was not long ago, usually nothing needs to be given. If the interval has run out, a vaccine is given; it sets your own antibody production going, though not instantly. And if there were no vaccinations at all, the course was never finished, or the person remembers nothing, and the wound is deep and dirty, then tetanus immunoglobulin is given alongside the vaccine: these are ready-made antibodies that start protecting immediately, while your own are still being made. They go into different sites because they do different jobs.

"I don't know whether I've been vaccinated" is a very common answer and nothing to be embarrassed about. It is easier for a clinician to assume the worst case than to guess. If you still have your vaccination records, bring them or photograph them. It is best to seek help within the first hours, but coming a day or two later is not too late either: it is still far better than not coming at all.

How tetanus shows itself

The first signs usually appear between a few days and a couple of weeks after the injury, most often around a week. The shorter that interval, the more severe the illness. By the time symptoms start the wound itself has often healed, and nobody thinks to connect the two.

• Stiffness of the chewing muscles: the mouth opens poorly or will not open at all.
• Spasm of the facial muscles, with raised eyebrows and stretched corners of the mouth, giving a fixed grimace that looks like a forced smile.
• Difficulty swallowing and a feeling of a lump in the throat.
• Stiffness and pain in the muscles of the neck, back and abdomen, with the tummy going board-hard.
• Attacks of painful spasm in which the body arches and breathing is interrupted.
• Attacks triggered by light, noise, touch or a draught.
• High temperature, sweating, a fast pulse, swings in blood pressure.

One thing deserves saying separately because it frightens people most and is rarely mentioned: consciousness is preserved in tetanus. The person understands everything and feels the spasms in full. That is why medicines that stop the spasm and switch off awareness are given in hospital from the outset; that is part of the treatment, not a last resort.

When to call an ambulance

If any of the following appears after a wound, even one that healed long ago, help is needed immediately.

• The mouth will not open and the jaw feels locked.
• The muscles of the face or neck have gone into spasm and turning the head is hard.
• Swallowing or breathing is difficult.
• Painful spasms of the trunk and limbs have begun.
• A loud noise or a bright light sets off an attack.

This is an emergency and not an hour can be wasted. Call an ambulance: in Spain, Italy, Portugal, Poland and Ukraine the single European number 112 works. Do not drive yourself and do not try to get there by public transport, because a spasm may start on the way. While the crew is on its way, settle the person in a quiet, darkened room and handle them as little as possible. Be sure to tell the paramedics about any wound in the past month, however trivial the splinter, and about when vaccinations were given.

How it is treated

Tetanus is treated only in hospital, usually in intensive care, and the treatment is a long one.

• The wound is opened and cleaned out, with dead tissue and foreign bodies removed.
• Tetanus immunoglobulin is given to bind toxin that has not yet reached the nerves.
• Antibiotics are prescribed against the bacterium itself.
• Medicines are given to relax the muscles and control the spasms.
• In severe cases a ventilator takes over breathing until the effect of the toxin wears off.

Recovery takes weeks and sometimes months: the toxin binds irreversibly to the nerve endings, and the body has to grow them again. There is one more detail that surprises many people: having had tetanus leaves no immunity. The amount of toxin that is enough to make you ill is not enough to teach the immune system. That is why vaccination is started in hospital, during the recovery.

Vaccination: the primary course and boosters

The only reliable protection is the vaccine, and it is on the schedule in every country. The principle is the same everywhere: a primary course of several doses in the first year of life, then further doses in childhood, and after that periodic boosters in adult life. Exact timings and the names of the combined vaccines differ from country to country, so check the national schedule of the country where you live rather than someone else's.

What an adult should know:

• Childhood vaccination does not protect for life: adults need boosters.
• The tetanus vaccine is given as part of combined preparations, most often together with a diphtheria component.
• Vaccination in pregnancy protects the mother and also the newborn: neonatal tetanus, which arises when the umbilical cord is handled in unsterile conditions, still takes lives where women are not vaccinated.
• Before travelling somewhere medical help is far away, it is sensible to check whether a booster is due.
• Anyone who works with soil regularly, in the garden, on a farm or on a building site, should watch the intervals particularly closely.

Online consultation

Sorting out your vaccination status is easily done without leaving home. In an online consultation the doctor can help you read old vaccination records, work out when the last dose was given, and understand whether a booster is due and when. It is also a convenient way to plan vaccinations before travelling or before a pregnancy.

If the wound has already happened, an online consultation can help judge how serious the situation is and point you to the right place to be seen in person. But the decision to give a vaccine and immunoglobulin is made face to face: the wound has to be looked at and cleaned, and the injections are given on the spot. So with a deep, dirty or bite wound, an online appointment is a step towards being seen, not a replacement for it.

And if jaw stiffness, difficulty swallowing or spasms have already started, there is no consultation to wait for: call an ambulance.

This material is for information only and does not replace medical advice.