Introduction: Tetanus is a neurotoxin-mediated, vaccine-preventable disease caused by Clostridium tetani, rarely seen in developed nations. Affecting motor neurons and the autonomic nervous system, this disease is characterized by spastic paralysis, opisthotonos, and dysautonomia. We report the case of a five-year-old, unvaccinated male with tetanus. Description: A five-year-old, unvaccinated patient presented eight days post sheet metal laceration to his ankle. Medical care was sought after developing symptoms of back arching and the inability to open his mouth. His initial exam was consistent with opisthotonos and spastic rigidity of his extremities. He was empirically treated with clindamycin, ceftriaxone, metronidazole, tetanus immune globulin, and DTaP. He then went to the operating room for wound debridement and returned to the intensive care unit (ICU) intubated. ICU course was protracted and significant for requirement of intubation, mechanical ventilation, and 15 days of neuromuscular blockade therapy due to severe opisthotonos. Additional pharmacologic therapy for muscle relaxation included midazolam infusion, diazepam, and baclofen. Intermittent cessations in neuromuscular blockade resulted in endotracheal tube obstruction, hypoxia, and hypercarbia. On day 8, he developed dysautonomia with tachycardia, hypertension, and hyperthermia requiring initiation of dexmedetomidine infusion and external cooling followed by a magnesium infusion with a goal level of 4 mg/dL and dantrolene. His symptoms resolved by ICU day 15, with subsequent discontinuation of neuromuscular blockade and extubation. He was discharged home with good neurologic and neuromuscular function. Discussion: As illustrated by this case, management of spasms and dysautonomia can be difficult and often requires multimodal therapy. Current practice includes mechanical ventilation and neuromuscular blockade to support oxygenation and ventilation, preventing early mortality as the effects of the toxin resolve and new neuromuscular connections are formed. A paucity of evidence exists regarding management of tetanus associated dysautonomia, likely due to the low incidence and historically high early mortality rate. This case represents a strategy for treatment through successful recovery and hospital discharge.