Despite long-standing availability of a vaccine, tetanus continues to cause high morbidity and mortality throughout the world. In the developed world, the elderly have traditionally been most at risk due to decline in protective antibody levels, however recent cases have occurred in younger people, particularly injecting drug users. Much of the management is supportive, although treatment aimed at preventing toxin release and uptake into the central nervous system should be given. Recent studies have focussed on optimizing antitoxin effect and improving control of muscle spasms and cardiovascular instability. This paper reviews these and other current concepts regarding the pathophysiology and management of tetanus. © 2005 Elsevier Ltd. All rights reserved.