History

Fact Explanation
A predisposing condition Tetanus is a syndrome caused by the powerful exotoxin of a Gram‐positive bacillus, Clostridium tetani. This is a saprophytic bacterium with a natural habitat of soil, but can also be isolated from stools of domestic animals and humans. It is a motile, spore‐forming obligate anaerobe. [1, 2, 3] Contact with surfaces which contain the spores of this bacteria will cause infection with it. (i.e. suboptimally cleansed surgical instruments, illegally attempted abortions, penetrating injuries with rusty soil covered objects) Tetanus has been reported following a myriad of injuries, including intravenous and intramuscular injections, acupuncture, ear piercing, and even from toothpicks, and also following chronic otitis media. [4, 5, 6, 7, 8, 9, 10, 11]
Spasm of muscles The incubation period is about 24 hours. Spasm are the first clinical feature to manifest, and the spasm of jaw muscles or lock-jaw (trismus) is the first to be seen. The spasms are painful, can spread in to other muscle groups such as neck. chest, back and abdomen. Later whole body goes into spasms, which is also known as ophisthotonos. [3, 4, 12]
Acute difficulty in swallowing Due to laryngeal obstruction and spasm. There can be drooling of saliva too. [3, 4, 13, 14, 15]
Acute difficulty in breathing Due to spasm of respiratory muscles. [3, 4, 16]
No fever Patients usually have no fever. [17]
Profuse sweating Due to autonomic neurotoxicity. [3,17]
References
  1. SANADA I, NISHIDA S. Isolation of Clostridium tetani from Soil J Bacteriol [online] 1965 Mar, 89(3):626-629 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC277512
  2. BROOK I. Current concepts in the management of Clostridium tetani infection. Expert Rev Anti Infect Ther [online] 2008 Jun, 6(3):327-36 [viewed 31 August 2014] Available from: doi:10.1586/14787210.6.3.327
  3. CAMPBELL J, FARRAR J. Clostridium tetani (Tetanus). [web] [viewed 31 August 2014] Available from: http://www.antimicrobe.org/new/b100.asp
  4. COOK TM, PROTHEROE RT, HANDEL JM. Tetanus: a review of the literature. Br J Anaesth [online] 2001 Sep, 87(3):477-87 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11517134
  5. KASHER JA, MATHISEN G. Acquiring Tetanus After Hemorrhoid Banding and Other Gastrointestinal Procedures J Gastrointest Surg [online] 2007 Apr, 11(4):515-519 [viewed 31 August 2014] Available from: doi:10.1007/s11605-006-0079-6
  6. DHALLA S. Postsurgical tetanus Can J Surg [online] 2004 Oct, 47(5):375-379 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211939
  7. POSTOPERATIVE TETANUS. The Lancet [online] 1984 October, 324(8409):964-965 [viewed 31 August 2014] Available from: doi:10.1016/S0140-6736(84)91174-7
  8. STUBBLEFIELD PHILLIP G, GRIMES DAVID A. Septic Abortion: Prevention and Management. GLOWM [online] 2009 December [viewed 31 August 2014] Available from: doi:10.3843/GLOWM.10438
  9. AWOYEMI BOSEDE O, NOVIGNON JACOB. Demand for abortion and post abortion care in Ibadan, Nigeria. Array [online] 2014 December [viewed 31 August 2014] Available from: doi:10.1186/s13561-014-0003-9
  10. PATEL JC, MEHTA BC. Tetanus: study of 8,697 cases. Indian J Med Sci [online] 1999 Sep, 53(9):393-401 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10710833
  11. SATTLER R. Penetrating Injury Limited to the Eyeball Followed by Acute Tetanus Trans Am Ophthalmol Soc [online] 1917:234-237 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1318123
  12. HASSEL B. Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins (Basel) [online] 2013 Jan 8, 5(1):73-83 [viewed 31 August 2014] Available from: doi:10.3390/toxins5010073
  13. RAUCH A., DROZ S., ZIMMERLI S., LEIB S. L.. Dysphagia in Elderly Women: Consider Tetanus. Infection [online] 2006 February, 34(1):35-38 [viewed 31 August 2014] Available from: doi:10.1007/s15010-006-4151-7
  14. SCHOLZ DAVID G., OLSON JEANETTE M., THURBER DELORAN L., LARSON DAVID E.. Tetanus: An Uncommon Cause of Dysphagia. Mayo Clinic Proceedings [online] 1989 March, 64(3):335-338 [viewed 31 August 2014] Available from: doi:10.1016/S0025-6196(12)65253-7
  15. BHADAURIA R.S., PADMAN P.V.. Two cases of acute dysphagia. Medical Journal Armed Forces India [online] 2013 January, 69(1):61-64 [viewed 31 August 2014] Available from: doi:10.1016/j.mjafi.2011.12.006
  16. BUNCH T. JARED. Respiratory Failure in Tetanus . Chest [online] 2002 October [viewed 31 August 2014] Available from: doi:10.1378/chest.122.4.1488
  17. WELLS C.L. and WILKINS T.D. Medical Microbiology. 4th edition. Chapter 18: Clostridia: Spore forming Anaerobic Bacilli. [web] [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK8219/

Examination

Fact Explanation
A recent wound The site where the Clostridium bacteria entered. In most cases a wound is not found. [1, 2, 3, 4]
Rigidity Local rigidity (i.e. lock-jaw, facial muscles causing the typical facial expression ‘risus sardonicus’) or truncal rigidity can be observed. (i.e. opisthotonos) [3, 4, 5]
Neck stiffness Manifestation of muscle spasm. [4, 6]
Episodic muscle spasms Due to stimuli like light, noise. These tonic contractions have a convulsion‐like appearance affecting agonist and antagonist muscle groups together. [4, 7, 8]
Tachycardia and hypertension Unless complicated by shock. Due to sympathetic overdrive. [4]
References
  1. SANADA I, NISHIDA S. Isolation of Clostridium tetani from Soil J Bacteriol [online] 1965 Mar, 89(3):626-629 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC277512
  2. BROOK I. Current concepts in the management of Clostridium tetani infection. Expert Rev Anti Infect Ther [online] 2008 Jun, 6(3):327-36 [viewed 31 August 2014] Available from: doi:10.1586/14787210.6.3.327
  3. CAMPBELL J, FARRAR J. Clostridium tetani (Tetanus). [web] [viewed 31 August 2014] Available from: http://www.antimicrobe.org/new/b100.asp
  4. COOK TM, PROTHEROE RT, HANDEL JM. Tetanus: a review of the literature. Br J Anaesth [online] 2001 Sep, 87(3):477-87 [viewed 31 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11517134
  5. HASSEL B. Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins (Basel) [online] 2013 Jan 8, 5(1):73-83 [viewed 31 August 2014] Available from: doi:10.3390/toxins5010073
  6. EDMONDSON RS, FLOWERS MW. Intensive care in tetanus: management, complications, and mortality in 100 cases. Br Med J [online] 1979 May 26, 1(6175):1401-1404 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1598922
  7. STERN L.Z. and BERNICK C. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Chapter 53: Muscle Cramps. [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK376/
  8. GOONETILLEKE A. Clostridial neurotoxins. Journal of Neurology, Neurosurgery & Psychiatry [online] 2004 September, 75(suppl_3):iii35-iii39 [viewed 01 September 2014] Available from: doi:10.1136/jnnp.2004.046102

Differential Diagnoses

Fact Explanation
Oro-facial infection Especially in local tetanus. (i.e. tetanus following ocular injuries) But tetanus can follow oro-facial infections, so the diagnosis has to be done carefully. In doubt, managing as tetanus can save a life. [1, 2, 3]
Drug induced dystonia Consider in patients who have been taking antipsychotic drugs and had a psychiatric history. [1, 4, 5]
Hypocalcemia Hypocalcemia can also present with muscle spasms. Serum calcium studies should be done before arriving at a diagnosis. [1, 6, 7, 8, 9]
Meningitis Since there are episodic spasms, it could be difficult to diagnose between them and tonic-clonic convulsions of meningitis. CSF fluid analysis following ruling out of increased intra-cranial pressure should be done where it is deemed necessary. [10, 11, 12]
References
  1. COOK T. M., PROTHEROE R. T., HANDEL J. M.. Tetanus: a review of the literature. British Journal of Anaesthesia [online] 2001 September, 87(3):477-487 [viewed 01 September 2014] Available from: doi:10.1093/bja/87.3.477
  2. KETTERIDGE D. Differentiation of newly isolated strains of Trypanosoma (Schizotrypanum) cruzi by agglutination and precipitation reactions. Acta Trop [online] 1975, 32(3):173-89 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1982
  3. CAMPBELL J, FARRAR J. Clostridium tetani (Tetanus). [web] [viewed 31 August 2014] Available from: http://www.antimicrobe.org/new/b100.asp
  4. MAGNUSON T. M.. Medication-Induced Dystonias in Nine Patients With Dementia. [online] 2000 May, 12(2):219-225 [viewed 01 September 2014] Available from: doi:10.1176/appi.neuropsych.12.2.219
  5. CHRISTODOULOU C.. Antipsychotic drug-induced acute laryngeal dystonia: two case reports and a mini review. Journal of Psychopharmacology [online] 2005 September, 19(3):307-311 [viewed 01 September 2014] Available from: doi:10.1177/0269881105051543
  6. FONG J, KHAN A. Hypocalcemia: updates in diagnosis and management for primary care. Can Fam Physician [online] 2012 Feb, 58(2):158-62 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22439169
  7. TORER N, TORUN D, TORER N, MICOZKADIOGLU H, NOYAN T, OZDEMIR FN, HABERAL M. Predictors of early postoperative hypocalcemia in hemodialysis patients with secondary hyperparathyroidism. Transplant Proc [online] 2009 Nov, 41(9):3642-6 [viewed 01 September 2014] Available from: doi:10.1016/j.transproceed.2009.06.207
  8. COOPER MS, GITTOES NJ. Diagnosis and management of hypocalcaemia BMJ [online] 2008 Jun 7, 336(7656):1298-1302 [viewed 01 September 2014] Available from: doi:10.1136/bmj.39582.589433.BE
  9. PAI SG, SHIVASHANKARA K, PANDIT V, SHESHADRI S. Symptomatic Hypocalcemia in Primary Hyperaldosteronism: A Case Report J Korean Med Sci [online] 2009 Dec, 24(6):1220-1223 [viewed 01 September 2014] Available from: doi:10.3346/jkms.2009.24.6.1220
  10. BRIGO F, AUSSERER H, ZUCCOLI G, TEZZON F, NARDONE R. Seizure heralding tuberculous meningitis. Epileptic Disord [online] 2012 Sep, 14(3):329-33 [viewed 01 September 2014] Available from: doi:10.1684/epd.2012.0516
  11. JONES TONIA. Childhood Febrile Seizures: Overview and Implications. Int. J. Med. Sci. [online] 2007 December [viewed 01 September 2014] Available from: doi:10.7150/ijms.4.110
  12. PATWARI A.. Convulsions in tuberculous meningitis. Journal of Tropical Pediatrics [online] 1996 April, 42(2):91-97 [viewed 01 September 2014] Available from: doi:10.1093/tropej/42.2.91

Investigations - Fitness for Management

Fact Explanation
12 lead Electrocardiogram It's common to have cardiac arrhythmias in tetanus due to sympathetic overactivity. [1, 2, 3]
Lung function tests Truncal tetanus is very commonly associated with respiratory failure due to respiratory muscle spasms. [3, 4]
Renal function tests i.e. serum creatinine, serum urea, serum electrolytes. Tetanus can cause acute renal failure. [3, 4, 5, 6, 7]
Obstetric ultrasound scan To confirm the wellbeing of the fetus as well as to assess the gestational age and exclude structural anomalies. The fetus can be immunized through trans-placental route. [8, 9, 10, 11, 12]
References
  1. COLE L, YOUNGMAN HR. Sympathetic nervous overactivity in tetanus. Br Med J [online] 1969 Aug 23, 3(5668):474 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1984182
  2. HENRIQUES FILHO GT, LACERDA HR, ALBUQUERQUE A, XIMENES RA. Sympathetic overactivity and arrhythmias in tetanus: electrocardiographic analysis. Rev Inst Med Trop Sao Paulo [online] 2007 Jan-Feb, 49(1):17-22 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17384815
  3. COOK T. M., PROTHEROE R. T., HANDEL J. M.. Tetanus: a review of the literature. British Journal of Anaesthesia [online] 2001 September, 87(3):477-487 [viewed 01 September 2014] Available from: doi:10.1093/bja/87.3.477
  4. BUNCH T. JARED. Respiratory Failure in Tetanus . Chest [online] 2002 October [viewed 31 August 2014] Available from: doi:10.1378/chest.122.4.1488
  5. WEISS M.F., BADALAMENTI J., FISH E.. Tetanus as a cause of rhabdomyolysis and acute renal failure. CN [online] 2010 January, 73(01):64-67 [viewed 01 September 2014] Available from: doi:10.5414/CNP73064
  6. DAHER ELIZABETHF, MOURA FILHO FRANCISCO JOSER, MENDONCA PATRICIAR, LIMA ERICAB, SILVA JOSE MARIAS, PINHO MARCOSL.M, MOTA ROSAM.S, SILVA GERALDOB. Acute renal failure and other clinical features in tetanus patients from northeastern Brazil. Ann Trop Med Public Health [online] 2008 December [viewed 01 September 2014] Available from: doi:10.4103/1755-6783.50684
  7. KAUR SATNAM, MISHRA DEVENDRA, JUNEJA MONICA. Acute Renal Failure in Tetanus. Indian J Pediatr [online] December, 81(2):207-207 [viewed 01 September 2014] Available from: doi:10.1007/s12098-013-1008-9
  8. GILL TJ 3RD, REPETTI CF, METLAY LA, RABIN BS, TAYLOR FH, THOMPSON DS, CORTESE AL. Transplacental immunization of the human fetus to tetanus by immunization of the mother. J Clin Invest [online] 1983 Sep, 72(3):987-96 [viewed 01 September 2014] Available from: doi:10.1172/JCI111071
  9. SAVITZ DAVID A., TERRY JAMES W., DOLE NANCY, THORP JOHN M., SIEGA-RIZ ANNA MARIA, HERRING AMY H.. Comparison of pregnancy dating by last menstrual period, ultrasound scanning, and their combination. American Journal of Obstetrics and Gynecology [online] 2002 December, 187(6):1660-1666 [viewed 01 September 2014] Available from: doi:10.1067/mob.2002.127601
  10. NEWNHAM J.P., EVANS S.F., MICHAEL C.A., STANLEY F.J., LANDAU L.I.. Effects of frequent ultrasound during pregnancy: a randomised controlled trial. The Lancet [online] 1993 October, 342(8876):887-891 [viewed 01 September 2014] Available from: doi:10.1016/0140-6736(93)91944-H
  11. WHITWORTH M, BRICKER L, NEILSON JP, DOWSWELL T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev [online] 2010 Apr 14:CD007058 [viewed 01 September 2014] Available from: doi:10.1002/14651858.CD007058.pub2
  12. STOCH YONIT K., WILLIAMS CORI J., GRANICH JOANNA, HUNT ANNA M., LANDAU LOU I., NEWNHAM JOHN P., WHITEHOUSE ANDREW J. O.. Are Prenatal Ultrasound Scans Associated with the Autism Phenotype? Follow-up of a Randomised Controlled Trial. J Autism Dev Disord [online] December, 42(12):2693-2701 [viewed 01 September 2014] Available from: doi:10.1007/s10803-012-1526-8

Management - General Measures

Fact Explanation
Patient education Educate the mother and the family about the infection, immunization and prevention, along with the trans-placental immunity of the fetus following maternal infection. [1, 2, 3]
Wound excision The offending or suspicious wound should be excised with a margin of healthy tissue. The wound is not usually sutured but kept open and dressed with antiseptics. [4, 5]
Management of respiratory distress Some patients might need intensive care. Respiratory muscle spasm is managed with sedatives and diazepam. In severe cases artificial ventilation might be necessary. [6, 7, 8]
Managing the pregnancy and delivery Tetanus in pregnancy affects the female just like it would a non-pregnant female. Apart from tetanus, the pregnancy and delivery also should be managed accordingly. i.e. nutrition, weight management, folic acid supplements, monitoring of labor. [9, 10, 11]
References
  1. RASHEED P, AL-SOWIELEM LS. HEALTH EDUCATION NEEDS FOR PREGNANCY: A STUDY AMONG WOMEN ATTENDING PRIMARY HEALTH CENTERS J Family Community Med [online] 2003, 10(1):31-38 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3425755
  2. MADICO G, SALAZAR G, MCDONALD J, CHECKLEY W, CALDERóN M, VERASTEGUI M, GILMAN RH. Rates of tetanus protection and transplacental tetanus antibody transfer in pregnant women from different socioeconomic groups in Peru. Clin Diagn Lab Immunol [online] 1996 Nov, 3(6):753-755 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC170442
  3. GILL TJ 3RD, REPETTI CF, METLAY LA, RABIN BS, TAYLOR FH, THOMPSON DS, CORTESE AL. Transplacental immunization of the human fetus to tetanus by immunization of the mother. J Clin Invest [online] 1983 Sep, 72(3):987-996 [viewed 01 September 2014] Available from: doi:10.1172/JCI111071
  4. EDMONDSON RS, FLOWERS MW. Intensive care in tetanus: management, complications, and mortality in 100 cases. Br Med J [online] 1979 May 26, 1(6175):1401-1404 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1598922
  5. O'DELL M.L. Skin and Wound Infections: An Overview. Am Fam Physician. [online] 1998 May 15;57(10):2424-2432. [viewed 01 September 2014] Available from: http://www.aafp.org/afp/1998/0515/p2424.html
  6. BUNCH T. JARED. Respiratory Failure in Tetanus . Chest [online] 2002 October [viewed 01 September 2014] Available from: doi:10.1378/chest.122.4.1488
  7. SHEFFIELD JEANNE S, RAMIN SUSAN M. Tetanus in Pregnancy. Am J Perinatol [online] 2004 May, 21(4):173-182 [viewed 01 September 2014] Available from: doi:10.1055/s-2004-828605
  8. MIGHTY HUGH E.. Acute Respiratory Failure in Pregnancy. Clinical Obstetrics and Gynecology [online] 2010 June, 53(2):360-368 [viewed 01 September 2014] Available from: doi:10.1097/GRF.0b013e3181deb3f1
  9. Weight gain during pregnancy. Committee Opinion No. 548. American College of Obstetricians and Gynecologists. Obstet Gynecol [online] 2013;121:210–2. [viewed 01 September 2014] Available from: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Weight-Gain-During-Pregnancy
  10. ROMANO AM, LOTHIAN JA. Promoting, protecting, and supporting normal birth: a look at the evidence. J Obstet Gynecol Neonatal Nurs [online] 2008 Jan-Feb, 37(1):94-104; quiz 104-5 [viewed 01 September 2014] Available from: doi:10.1111/j.1552-6909.2007.00210.x
  11. SCHNEIDER G. Management of normal labour and delivery in the case room: a critical appraisal. Can Med Assoc J [online] 1981 Aug 15, 125(4):350-352 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1862180

Management - Specific Treatments

Fact Explanation
Metronidazole The drug of choice was procaine penicillin, but it potentiate the effects of toxin, and the recovery period is longer, so in the drug of choice is now metronidazole. [1, 2, 3]
Tetanus immune globulin (TIG) They are Anti-tetanus antibodies. For prophylaxis and against neonatal tetanus. The immunoglobulins bind to circulating antigens and neutralize them. It provides temporary passive immunization. [4, 5, 6, 7, 8, 9]
Magnesium sulphate Intravenous magnesium sulphate is the first line treatment option for severe tetanus spasms. The drug inhibits the afferent and efferent nerve impulses. [10, 11, 12, 13]
Diazepam For very severe cases, to provide muscle relaxation and sedation. [14, 15, 16]
References
  1. AHMADSYAH I, SALIM A. Treatment of tetanus: an open study to compare the efficacy of procaine penicillin and metronidazole. Br Med J (Clin Res Ed) [online] 1985 Sep 7, 291(6496):648-50 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3928066
  2. TAYLOR WI, NOVAK M. Prophylaxis of Tetanus with Penicillin-procaine Ann Surg [online] 1951 Jan, 133(1):44-49 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1616651
  3. Penicillin-Procaine in Tetanus Can Med Assoc J [online] 1951 May, 64(5):450 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1821822
  4. STEVENS RH, SAXON A. Immunoregulation in humans: control of antitetanus toxoid antibody production after booster immunization. J Clin Invest [online] 1978 Dec, 62(6):1154-1160 [viewed 01 September 2014] Available from: doi:10.1172/JCI109234
  5. BRENNER MK, MUNRO AJ. Human anti-tetanus antibody response in vitro: autologous and allogeneic T cells provide help by different routes. Clin Exp Immunol [online] 1981 Oct, 46(1):171-177 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1536322
  6. FOWKES F. J. I., MCGREADY R., JOHNSTONE-ROBERTSON S., NOSTEN F., BEESON J. G.. Antibody Boosting and Longevity Following Tetanus Immunization During Pregnancy. Clinical Infectious Diseases [online] December, 56(5):749-750 [viewed 01 September 2014] Available from: doi:10.1093/cid/cis979
  7. ABACIOǦLU Y.HAKAN, ESKIşAR TUǦBA, YULUǦ NURAN. Concentration and avidity of anti-tetanus antibodies in mother-infant pairs: Relation to immunization time. [online] 1995 July, 11(4):273-277 [viewed 01 September 2014] Available from: doi:10.1111/j.1574-695X.1995.tb00156.x
  8. FOWKES FJ, MCGREADY R, JOHNSTONE-ROBERTSON S, NOSTEN F, BEESON JG. Antibody Boosting and Longevity Following Tetanus Immunization During Pregnancy Clin Infect Dis [online] 2013 Mar 1, 56(5):749-750 [viewed 01 September 2014] Available from: doi:10.1093/cid/cis979
  9. RUBBO SD, SURI JC. Passive Immunization Against Tetanus with Human Immune Globulin Br Med J [online] 1962 Jul 14, 2(5297):79-81 [viewed 03 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1925306
  10. PULIYEL M. M., PILLAI R., KORULA S.. Intravenous Magnesium Sulphate Infusion in the Management of Very Severe Tetanus in a Child: A Descriptive Case Report. Journal of Tropical Pediatrics [online] 2007 November, 55(1):58-59 [viewed 04 September 2014] Available from: doi:10.1093/tropej/fmn066
  11. KATI ISMAIL, GOKTAS UGUR, CAGAN EREN, GUZEL ABDULMENAP, BARTIN SERAP. The Effect of Magnesium Sulfate on Uncontrollable Contractions in a Tetanus Case. Pediatric Emergency Care [online] 2012 April, 28(4):366-367 [viewed 04 September 2014] Available from: doi:10.1097/PEC.0b013e31824d9f17
  12. BLAKE JA. II. The Treatment of Tetanus by Magnesium Sulphate Ann Surg [online] 1906 Sep, 44(3):367-373 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414180
  13. RODRIGO C., SAMARAKOON L., FERNANDO S. D., RAJAPAKSE S.. A meta-analysis of magnesium for tetanus. [online] December, 67(12):1370-1374 [viewed 04 September 2014] Available from: doi:10.1111/anae.12020
  14. CHUKWUBIKE OA, GOD'SPOWER AE. A 10-year review of outcome of management of tetanus in adults at a Nigerian tertiary hospital. Ann Afr Med [online] 2009 Jul-Sep, 8(3):168-72 [viewed 04 September 2014] Available from: doi:10.4103/1596-3519.57239
  15. KOLE ALAKESKUMAR, ROY RAMMOHAN, KAR SUVRENDUSANKAR, KOLE DALIACHANDA. Experience of use of magnesium sulfate in the treatment of tetanus in a tertiary referral Infectious Disease Hospital, Kolkata, India. Ann Trop Med Public Health [online] 2013 December [viewed 04 September 2014] Available from: doi:10.4103/1755-6783.127799
  16. OKOROMAH CN, LESI FE. Diazepam for treating tetanus. Cochrane Database Syst Rev [online] 2004:CD003954 [viewed 04 September 2014] Available from: doi:10.1002/14651858.CD003954.pub2