• Tetanus is caused by an exotoxin, tetanospasmin, produced by Clostridium tetani, an anaerobic gram-positive bacillus.
• Tetanospasmin prevents the release of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the spinal cord, brainstem motor nuclei, and the brain, producing muscle rigidity and tonic spasms.
• Trismus (lockjaw), dysphagia, laryngeal spasms, rigidity of limbs and paraspinal muscles, and opisthotonic posture are common.
• Frequent severe spasms triggered by touch, pain, bright light, or sounds may produce apnea and rhabdomyolysis.
• Autonomic overactivity occurs in severe tetanus causing labile hypertension, tachycardia, increased secretions, sweating, and urinary retention. Dysautonomia is difficult to manage and is a common cause of mortality; magnesium sulfate infusion is often used.
• Antibiotics (penicillin or metronidazole) and wound care reduce toxin production and human tetanus immune globulin neutralizes the circulating toxin.
• Nasogastric tube placement for feeding and medications is needed.
• Early elective tracheostomy is performed in moderate or severe tetanus to prevent aspiration and laryngeal stridor.
• Benzodiazepines help reduce rigidity, spasms, and autonomic dysfunction. Large doses of diazepam (0.2–1 mg/kg/h) are administered via nasogastric tube.
• Neuromuscular blocking agents and mechanical ventilation are used for refractory spasms.
• Mortality ranges from 5% to 50%.
Karnad DR. Tetanus. In: Kellerman RD, Rakel D, eds. Conn's Current Therapy 2021. Elsevier, PA; 2021. pp. 660–663.
Farrar JJ, Yen LM, Cook T,Fairweather N, Binh N, Parry J, et al. Tetanus. J Neurol Neurosurg Psychiatry 2000;69(3):292–301. DOI: 10.1136/jnnp.69.3.292.
World Health Organization. WHO vaccine-preventable diseases: monitoring system. 2020 global summary. Incidence time series for India (IND). Available from: https://apps.who.int/immunization_monitoring/globalsummary/incidences?c=IND [Accessed 21 March 2021].
World Health Organization. Immunization, Vaccines and Biologicals>Disease surveillance and Burden>National Passive Surveillance—Tetanus. Available from: https://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/passive/tetanus/en/ [Accessed on 21 March 2021].
Njuguna HN, Yusuf N, Raza AA, Ahmed B, Tohme RA. Progress toward maternal and neonatal tetanus elimination—worldwide, 2000–2018. MMWR Morb Mortal Wkly Rep 2020;69(17):515–520. DOI: 10.15585/mmwr.mm6917a2.
Kole AK, Roy R, Kole DC. Tetanus: still a public health problem in India—observations in an infectious disease hospital in Kolkata. WHO SouthEast Asia J Public Health 2013;2(3):184–186. DOI: 10.4103/2224-3151.206766.
Angurana SK, Jayashree M, Bansal A, Singhi S, Nallasamy K. Post-neonatal tetanus in a PICU of a developing economy: intensive care needs, outcome and predictors of mortality. J Trop Pediatr 2018;64(1):15–23. DOI: 10.1093/tropej/fmx020.
Spruyt GLM, van den Heever T. The treatment of autonomic dysfunction in tetanus. S Afr J Crit Care 2017;33(1):28–31. DOI: 10.7196/SAJCC.2017.v33i1.274.
Apte NM, Karnad DR. Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg 1995;53(4):386–387. DOI: 10.4269/ajtmh.1995.53.386.
Lisboa T, Ho YL, Henriques Filho GT, Brauner JS, Valiatti JL, Verdeal JC, et al. Guidelines for the management of accidental tetanus in adult patients. Rev Bras Ter Intensiva 2011;23(4):394–409.
Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: an evidence-based review. CritCare 2014;18(2):217. DOI: 10.1186/cc13797.
Ganesh Kumar AV, Kothari VM, Krishnan A, Karnad DR. Benzathine penicillin, metronidazole and benzyl penicillin in the treatment of tetanus: a randomized, controlled trial. Ann Trop Med Parasitol 2004;98(1):59–63. DOI: 10.1179/000349804225003037.
Attygalle D, Rodrigo N. Magnesium as first line therapy in the management of tetanus: a prospective study of 40 patients. Anaesthesia 2002;57(8):811–817. DOI: 10.1046/j.1365-2044.2002.02698_6.x.
Thwaites CL, Yen LM, Loan HT, Thuy TT, Thwaites GE, Stepniewska K, et al. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet 2006;368(9545):1436–1443. DOI: 10.1016/S0140-6736(06)69444-0.
Gregorakos L, Kerezoudi E, Dimopoulos G, Thomaides T. Management of blood pressure instability in severe tetanus: the use of clonidine. Intensive Care Med 1997;23(8):893–895. DOI: 10.1007/s001340050428.
Gibson K, Bonaventure Uwineza J, Kiviri W, Parlow J. Tetanus in developing countries: a case series and review. Can J Anaesth 2009;56(4):307–315. DOI: 10.1007/s12630-009-9058-1.