Contents
Cover art: Muscle spasms (specifically opisthotonos) in a person with tetanus. Painting by Sir Charles Bell, 1809.
Introduction
Tonic muscular contractions usually commencing at the site of infection, later becoming generalised, involving the entire somatic muscular system.
- Tetanus toxin (2nd M/lethal toxin)
- Lethal dose: 0.1mg
Etiology
Clostridium tetani
Gram-positive, anaerobic, motile, non-capsulated organism with peritrichous flagella & terminal spores (Drumstick appearance)
- No prior immunisation or partial immunisation
- Trauma with lacerations, deep wound, crush devitalized tissue, foreign body infections, etc
- Chronic suppurative otitis media (CSOM) with perforation, caries teeth
- Improper sterilisation
- Tattooing, rusted nails, earlobe prick

Presentation
- Descending paralysis
- Trismus or Lockjaw (Jaw stiffness) (M/C): Spasm of masseter & pterygoids
- Risus sardonicus (smiling facies): Spasm of facial muscles (zygomaticus major)
- Spasm & rigidity of all muscles (HALLMARK): Minimal stimuli may lead to generalized spasms
- Hyperreflexia
- Anxiousness, sweating
- Headache, delirium, sleeplessness
- Retention of urine: Spasm of urinary sphincter
- Constipation: Rectal spasm
- Dysphagia
- Dyspnoea
Autonomic instability:
Blood pressure fluctuations
- Hypertension or hypotension
- Diaphoresis
- Arrhythmias
Characteristic postures:
- Opisthotonus (backward bending)
- Orthotonus (straight posture)
- Emprosthotonus (forward bending)
- Pleurosthotonus (lateral bending)
Complications
- Fractures, joint dislocations & tendon ruptures
- Severe Tonic-clonic convulsions
- Haematoma
- Respiratory system:
- Tachypnoea, respiratory distress, respiratory infections, aspiration, cyanosis, respiratory failure
- Carditis, arrhythmias
- CVT, pulmonary embolism
- Toxaemia
- Secondary infections:
- Septicaemia
- Bedsores, malnutrition, stress gastric ulcers
- Coma & death
Cause of death (45-50% mortality):
- Respiratory failure with aspiration pneumonia & ARDS
- Severe carditis
Diagnosis
- Microscopy: Drumstick bacilli in wound
- Culture: Swarming growth
- Toxigenicity testing:
- in vitro: Nagler reaction
- in vivo
Ablett classification:

Differential diagnosis:
- Strychnine poisoning
- Trismus
- Meningitis
- Hydrophobia
- Convulsive disorders
Management
Immunization:
- Passive immunisation
- Emergency procedure, to be used only once
- Types:
- Antitetanus serum (ATS)
- Disadvantages:
- Immune elimination
- Hypersensitivity
- Disadvantages:
- Human antitetanus immunoglobulin (TIG)
- No risk of hypersensitivity
- Antitetanus serum (ATS)
- Active immunisation
- M/effective method (spaced injections)
- Available forms:
- Plain toxoid
- Adsorbed toxoid
- Given as Triple vaccine or Pentavalent vaccine
Treatment:
ICU management: Isolation in dark & quiet room
- Antitetanus globulin (ATG)
- 3000 units IM single dose
- If not available,
- Antitetanus serum (ATS)
- 1000 units IV
- Antitetanus serum (ATS)
- If not available,
- 3000 units IM single dose
- Antibiotic (benzylpenicillin)
- Tetanus toxoid (TT)
- Wound care: Debridement, drainage, local ATG injection
Specific measures:
- Antiepileptics:
- IV Diazepam (4 or 6 hourly)
- IV Phenobarbitone (4 or 6 hourly)
- IV Chlorpromazine (4 or 6 hourly)