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\author{Bernard Karani (Bernard Karani)}
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  /Title (tetanus.pdf)
  /Creator (Cheatography)
  /Author (Bernard Karani (Bernard Karani))
  /Subject (Tetanus Cheat Sheet)
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        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
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    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{Tetanus Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{Bernard Karani (Bernard Karani)} via \textcolor{DarkBackground}{\uline{cheatography.com/123206/cs/23128/}}}
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  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}Bernard Karani (Bernard Karani) \\
  \uline{cheatography.com/bernard-karani} \\
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  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Published 10th June, 2020.\\
   Updated 9th June, 2020.\\
   Page {\thepage} of \pageref{LastPage}.
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  %\includegraphics[width=48px,height=48px]{dave.jpeg}
  Measure your website readability!\\
  www.readability-score.com
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Clinical presentation patterns}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Generalized tetanus} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Neonatal tetanus} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Localized tetanus} \tn 
% Row Count 3 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Cerebral tetanus} \tn 
% Row Count 4 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Since C. {\emph{tetani}} spores cannot be eliminated from the environment, immunization and proper treatment of wounds and traumatic injuries are crucial for tetanus prevention.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Etiology}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Tetanus is due to infection from the bacterium {\emph{Clostridium tetani}} a gram-positive, spore-forming, obligate anaerobic bacillus. This bacteria and its spores are frequently found in hot and wet climates where the soil is rich with organic matter. \newline % Row Count 5 (+ 5)
C. {\emph{tetani}} may enter the human body through wound puncture, laceration, skin breaks, or inoculation with an infected syringe or insect bites. \newline % Row Count 8 (+ 3)
High-risk populations include those that have not been vaccinated, intravenous drug users, and those who are immunosuppressed. Other causes of infection are through surgical procedures, intramuscular injections, compound fractures, dental infections, and dog bites.% Row Count 14 (+ 6)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Tetanus can also develop as a consequence of chronic conditions such as abscesses and gangrene. Burn patients and patients undergoing surgery can also acquire the infection.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{pathophysiology}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{17.67cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/bernard-karani_1591565933_tetanus pathogenesis.jpg}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{C. {\emph{tetani}} secretes the toxins, tetanospasmin, and tetanolysin. Tetanospasmin enters the presynaptic terminals in the neuromuscular endplate of motor neurons and inhibits neurotransmitter release of glycine and GABA. \newline The incubation period can last from one to 60 days but is, on average, around 7 to 10 days.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{x{5.5264 cm} x{11.7436 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{2}{x{17.67cm}}{\bf\textcolor{white}{Clinical features}}  \tn
% Row 0
\SetRowColor{LightBackground}
Generalized Tetanus & typically have symptoms of autonomic over-activity. Tonic and periodic spastic muscular contractions are responsible for most of the classic clinical findings of tetanus such as:  ●Stiff neck  ●Opisthotonus  ●Risus sardonicus (sardonic smile)  ●A board-like rigid abdomen  ●Periods of apnea and/or upper airway obstruction due to vise-like contraction of the thoracic muscles and/or glottal or pharyngeal muscle contraction, respectively  ●Dysphagia \tn 
% Row Count 18 (+ 18)
% Row 1
\SetRowColor{white}
Duration of illness & Tetanus toxin-induced effects are long lasting because recovery is believed to require the growth of new axonal nerve terminals. The usual duration of clinical tetanus is four to six weeks. \tn 
% Row Count 25 (+ 7)
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\SetRowColor{LightBackground}
\mymulticolumn{2}{x{17.67cm}}{The severity is related to the incubation period of the illness and the interval from the onset of symptoms to the appearance of spasms,  the longer the interval, the milder the clinical features of tetanus. More severe illness is seen in those with deep penetrating wounds}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}--}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Risk factors for neonatal tetanus}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{1. Unvaccinated mother} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{2. Home delivery} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{3. Septic cutting of the umbilical cord} \tn 
% Row Count 3 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{4. Neonatal tetanus in a previous child} \tn 
% Row Count 4 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{5. Infectious substances applied to the umbilical stump, such as animal dung, mud} \tn 
% Row Count 6 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Tetanus usually occurs in persons who are not immunized, partially immunized or fully immunized but lacking adequate booster doses.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{x{3.7881 cm} x{4.1175 cm} x{4.2822 cm} x{4.2822 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{4}{x{17.67cm}}{\bf\textcolor{white}{Treatment and Management}}  \tn
% Row 0
\SetRowColor{LightBackground}
\seqsplit{Treatment} modality & \seqsplit{Advantages} and \seqsplit{Disadvantage} & Summary of findings and level of \seqsplit{confidence} & \seqsplit{Recommendation} \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
\mymulticolumn{4}{x{17.67cm}}{Halting toxin production} \tn 
% Row Count 6 (+ 1)
% Row 2
\SetRowColor{LightBackground}
Wound \seqsplit{management} & Eliminate \seqsplit{conditions} ideal for spore \seqsplit{germination} &  & All patients with tetanus should undergo wound \seqsplit{debridement} to eradicate spores and necrotic tissue \tn 
% Row Count 16 (+ 10)
% Row 3
\SetRowColor{white}
\seqsplit{Antimicrobial} therapy & \seqsplit{Metronidazole} use has a \seqsplit{theoretical} advantage over \seqsplit{penicillin} use as the latter can \seqsplit{potentially} \seqsplit{facilitate} \seqsplit{tetanospasmin} activity & The first study to compare \seqsplit{penicillin} and \seqsplit{metronidazole} found a greater reduction in mortality in the \seqsplit{metronidazole} group. However, in three \seqsplit{subsequent} studies, there was no \seqsplit{difference} in mortality in patients treated with \seqsplit{penicillin} and those treated with \seqsplit{metronidazole}. In one of the former studies, patients receiving \seqsplit{metronidazole} required fewer muscle relaxants and \seqsplit{sedatives.} Level of \seqsplit{confidence} B & \seqsplit{Metronidazole} (500 mg \seqsplit{intravenously} {[}IV{]} every six to eight hours) is the preferred treatment for tetanus, but \seqsplit{penicillin} G (2 to 4 million units IV every four to six hours) is a safe and effective \seqsplit{alternative}. Suggested treatment duration of 7 to 10 days \tn 
% Row Count 57 (+ 41)
\end{tabularx}
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\begin{tabularx}{17.67cm}{x{3.7881 cm} x{4.1175 cm} x{4.2822 cm} x{4.2822 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{4}{x{17.67cm}}{\bf\textcolor{white}{Treatment and Management (cont)}}  \tn
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{4}{x{17.67cm}}{Neutralization of unbound toxin} \tn 
% Row Count 1 (+ 1)
% Row 5
\SetRowColor{white}
\seqsplit{Administration} of \seqsplit{immunoglobulins} & \seqsplit{Administration} of \seqsplit{immunoglobulins} is \seqsplit{beneficial}. The best route of \seqsplit{administration} \seqsplit{(intramuscular} alone versus \seqsplit{intrathecal} plus \seqsplit{intramuscular)} is debatable & Evidence from two \seqsplit{meta-analyses} are \seqsplit{conflicting} & Human tetanus immune globulin (HTIG) is the \seqsplit{preparation} of choice. recommend a single dose of 500 units \seqsplit{intramuscularly}. The \seqsplit{previously} \seqsplit{recommended} dose range was 3000 to 6000 units. Given as soon as the diagnosis of tetanus is \seqsplit{considered}, with part of the dose \seqsplit{infiltrated} around the wound \tn 
% Row Count 30 (+ 29)
\end{tabularx}
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\begin{tabularx}{17.67cm}{x{3.7881 cm} x{4.1175 cm} x{4.2822 cm} x{4.2822 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{4}{x{17.67cm}}{\bf\textcolor{white}{Treatment and Management (cont)}}  \tn
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{4}{x{17.67cm}}{Control of muscle spasms} \tn 
% Row Count 1 (+ 1)
% Row 7
\SetRowColor{white}
\seqsplit{Benzodiazepines} and other \seqsplit{sedatives} & \seqsplit{Advantages:} combined sedative, \seqsplit{anticonvulsant} and muscle relaxant effects \seqsplit{Disadvantages:} prolonged duration of action with \seqsplit{long-acting} drugs. & Used as standard therapy & Usual starting dose of diazepam for an adult is 10 to 30 mg IV and repeated as needed every 1 to 4 hours. \tn 
% Row Count 16 (+ 15)
% Row 8
\SetRowColor{LightBackground}
\seqsplit{Neuromuscular} blocking agents & Used when sedation alone is \seqsplit{inadequate}. \seqsplit{Pancuronium}, a \seqsplit{long-acting} agent, has been \seqsplit{traditionally} used, but it may worsen autonomic \seqsplit{instability} because it is an inhibitor of \seqsplit{catecholamine} reuptake & Evidence is limited to a few case series (level of evidence C) & \seqsplit{Vecuronium} or other \seqsplit{cardiovascular} inert \seqsplit{neuromuscular} blockers are \seqsplit{preferred.} \seqsplit{Intrathecal} baclofen given as an initial bolus in a dose ranging from 40 to 200 mcg followed by a \seqsplit{continuous} infusion of 20 mcg/hour was found to control spasms and rigidity \tn 
% Row Count 42 (+ 26)
\end{tabularx}
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\begin{tabularx}{17.67cm}{x{3.7881 cm} x{4.1175 cm} x{4.2822 cm} x{4.2822 cm} }
\SetRowColor{DarkBackground}
\mymulticolumn{4}{x{17.67cm}}{\bf\textcolor{white}{Treatment and Management (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
\mymulticolumn{4}{x{17.67cm}}{Autonomic dysfunction} \tn 
% Row Count 1 (+ 1)
% Row 10
\SetRowColor{white}
\seqsplit{Magnesium} sulphate & \seqsplit{Advantages:} readily available in \seqsplit{resource-limited} settings, has \seqsplit{anticonvulsant}, muscle relaxant \seqsplit{properties}, \seqsplit{Disadvantages:} needs close \seqsplit{monitoring}, Risk of \seqsplit{hypocalcaemia}, Less effective in severe disease & \seqsplit{Meta-analysis} shows no mortality benefit (level of evidence A) & Magnesium sulfate (loading dose 40 mg/kg over 30 minutes, followed by \seqsplit{continuous} infusion of either 2 g per hour for patients over 45 kg or 1.5 g per hour for patients ≤45 kg). During magnesium infusion, the patellar reflex needs to be monitored \tn 
% Row Count 26 (+ 25)
% Row 11
\SetRowColor{LightBackground}
Beta blockade & Labetalol has \seqsplit{frequently} been \seqsplit{administered} because of its dual alpha- and \seqsplit{betablocking} \seqsplit{properties.} Beta blockade alone \seqsplit{(propranolol)should} be avoided because of reports of sudden death & Evidence limited to case reports and few case series (level of evidence C) & Use may be \seqsplit{reasonable} on a case by case basis Labetalol (0.25 to 1 mg/min) Morphine sulfate (0.5 to 1 mg/kg per hour by \seqsplit{continuous} \seqsplit{intravenous} infusion) \tn 
% Row Count 45 (+ 19)
\hhline{>{\arrayrulecolor{DarkBackground}}----}
\SetRowColor{LightBackground}
\mymulticolumn{4}{x{17.67cm}}{Level of evidence:A, data derived from multiple randomized clinical trials or meta-analysis; B, data derived from a single randomized trial or non-randomized trials; C, only consensus opinion of experts, case studies or standard of care. \newline GABA antagonist effect of penicillins and third-generation cephalosporins, may lead to central nervous system (CNS) excitability thus not recommended during treatment.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}----}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Supportive management}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Prophylactic treatment with sucralfate or protein pump inhibitors may be used to prevent gastroesophageal hemorrhage from stress ulceration} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Prophylaxis of thromboembolism with heparin, low molecular weight heparin, or other anticoagulants should be administered early} \tn 
% Row Count 6 (+ 3)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Physical therapy should be started as soon as spasms have ceased, since tetanus patients often are left with disability from prolonged muscle wasting and contractures} \tn 
% Row Count 10 (+ 4)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{All patients require full tetanus toxoid immunization at recovery; having the infection does not give future immunity} \tn 
% Row Count 13 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{HTIG should be administered at different sites than tetanus toxoid.  \newline Intravenous immune globulin may be administered as an alternative if HTIG is not available}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Prognosis}}  \tn
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{An established scale can be used to predict the prognosis of tetanus. One point is given for each of the following: \newline % Row Count 3 (+ 3)
- Incubation - shorter than 7 days \newline % Row Count 4 (+ 1)
- Onset - less than 48 hours \newline % Row Count 5 (+ 1)
- Causes of tetanus - burns, surgical wounds, septic abortion, umbilical stump, compound fractures, or intramuscular injection \newline % Row Count 8 (+ 3)
- Addiction to opiates \newline % Row Count 9 (+ 1)
- Generalized tetanus \newline % Row Count 10 (+ 1)
- Temperature - more than 104 F (40 C) \newline % Row Count 11 (+ 1)
- Tachycardia - more than 120/min (150/min in neonates) \newline % Row Count 13 (+ 2)
The total score indicates disease severity: \newline % Row Count 14 (+ 1)
    0-1 - mortality of less than 10\% \newline % Row Count 15 (+ 1)
    2-3 - mortality of 10-20\% \newline % Row Count 16 (+ 1)
    4 - mortality of 20-40\% \newline % Row Count 17 (+ 1)
    5-6 - mortality of more than 50\%.% Row Count 18 (+ 1)
} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Some patients develop hypotonia and autonomic dysfunction that lasts for months or years. Even those who survive, need tetanus toxoid as the infection does not confer immunity.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Differential diagnosis}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{1. Drug-induced dystonias such as those due to phenothiazines} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{2. Trismus due to dental infection} \tn 
% Row Count 3 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{3. Strychnine poisoning due to ingestion of rat poison} \tn 
% Row Count 5 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{4. Malignant neuroleptic syndrome} \tn 
% Row Count 6 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{5. Stiff-person syndrome} \tn 
% Row Count 7 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{The only condition that mimics tetanus the {\bf{most}} is strychnine poisoning. One of the typical symptoms of tetanus is trismus which may be present in many other conditions.}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{Complications}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Vocal cord paralysis leading to respiratory distress} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Hysteria} \tn 
% Row Count 3 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Neoplasms} \tn 
% Row Count 4 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Malignant hyperthermia} \tn 
% Row Count 5 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Autonomic dysfunction- leading to hypertension} \tn 
% Row Count 6 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Asphyxia} \tn 
% Row Count 7 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Long bone fractures} \tn 
% Row Count 8 (+ 1)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Paralytic ileus} \tn 
% Row Count 9 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Joint dislocation} \tn 
% Row Count 10 (+ 1)
% Row 9
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Aspiration pneumonia} \tn 
% Row Count 11 (+ 1)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Pressure sores} \tn 
% Row Count 12 (+ 1)
% Row 11
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Stress ulcers} \tn 
% Row Count 13 (+ 1)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Coma} \tn 
% Row Count 14 (+ 1)
% Row 13
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Nerve palsy} \tn 
% Row Count 15 (+ 1)
% Row 14
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Urine retention} \tn 
% Row Count 16 (+ 1)
% Row 15
\SetRowColor{white}
\mymulticolumn{1}{x{17.67cm}}{Seizures} \tn 
% Row Count 17 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{17.67cm}}{Sympathetic overactivity is the most significant cause of tetanus-associated mortality in critical patients}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
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\begin{tabularx}{17.67cm}{X}
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\mymulticolumn{1}{x{17.67cm}}{\bf\textcolor{white}{References}}  \tn
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\mymulticolumn{1}{x{17.67cm}}{Bae C, Bourget D. Tetanus. {[}Updated 2020 Feb 28{]}. In: StatPearls {[}Internet{]}. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: \seqsplit{https://www.ncbi.nlm.nih.gov/books/NBK459217/}} \tn 
% Row Count 4 (+ 4)
% Row 1
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\mymulticolumn{1}{x{17.67cm}}{Centers for Disease Control and Prevention. Tetanus. \seqsplit{https://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.html} (Accessed on February 24, 2020).} \tn 
% Row Count 8 (+ 4)
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\mymulticolumn{1}{x{17.67cm}}{Kyu HH, Mumford JE, Stanaway JD, et al. Mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015. BMC Public Health 2017; 17:179.} \tn 
% Row Count 12 (+ 4)
% Row 3
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\mymulticolumn{1}{x{17.67cm}}{Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: an evidence-based review. Crit Care 2014; 18:217.} \tn 
% Row Count 15 (+ 3)
% Row 4
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\mymulticolumn{1}{x{17.67cm}}{Yen LM, Dao LM, Day NPJ. Management of tetanus: a comparison of penicillin and metronidazole. Symposium of antimicrobial resistance in southern Viet Nam, 1997.} \tn 
% Row Count 19 (+ 4)
% Row 5
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\mymulticolumn{1}{x{17.67cm}}{Thwaites CL, Yen LM, Loan HT, et al. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet 2006; 368:1436.} \tn 
% Row Count 22 (+ 3)
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\mymulticolumn{1}{x{17.67cm}}{Buchanan N, Smit L, Cane RD, De Andrade M. Sympathetic overactivity in tetanus: fatality associated with propranolol. Br Med J 1978; 2:254.} \tn 
% Row Count 25 (+ 3)
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\end{tabularx}
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