Tetanus Immunization
Introduction Adequate tetanus prophylaxis is important in patients with multiple injuries, particularly when open-extremity trauma is present. The average incubation period for tetanus is 10 days; most often it is 4 to 21 days. In severe trauma cases, tetanus can appear as early as 1 to 2 days after injury. All medical professionals must be cognizant of this important fact when providing care to injured patients. Recent studies conclude that it is not possible to determine clinically which wounds are prone to tetanus; tetanus can occur after minor, seemingly innocuous injuries, yet it is rare after severely contaminated wounds. Thus, all traumatic wounds should be considered at risk for the developmen developmentt of tetanus infection. Tetanus immunization depends depends on the patient’s previous immunization status and the tetanus-pron tetanus-prone e nature of the wound. The following guidelines are adapted from the literature, and information is available from the Centers for Disease Control and Prevention (CDC). Because this information is continuously reviewed and updated as new data become available, the American College of Surgeons Committee on Trauma recommends contacting the CDC for the most current information and detailed guidelines related to tetanus prophylaxis and immunization for injured patients.
General Principles The following general principles for doctors who treat trauma patients concern surgical wound care and passive immunization.
SURGICAL WOUND CARE Regardless of the active immunization status of the patient, meticulous surgical care—including removal of all devitalized tissue and foreign bodies—should be provided immediately for all wounds. If the adequacy of wound debridement is in question or a puncture injury is present, the wound should be left open and not closed by sutures. Such care is essential as part of the prophylaxis against tetanus. Traditional clinical features that influence the risk for tetanus infection in soft tissue wounds are listed in Table 1. However, all wounds should be considered at risk for the development of tetanus.
PASSIVE IMMUNIZATION Passive immunization with 250 units of human tetanus immune globulin (TIG) administered intramuscularly must be considered for each patient. TIG provides longer protection than antitoxin of animal origin and causes few adverse reactions. The characteristics of the wound, conditions under which it occurred, wound age, TIG treatment, and the previous active immunization status of the patient must all be considered (Table 2). Due to the concerns about herd immunity to both pertussis and diphtheria, and recent outbreaks of both, Tdap (tetanus, diphtheria, and pertussis) is preferred to Td (tetanus and diphtheria) for adults who have never received Tdap. Td is preferred to TT (tetanus toxoid) for adults who received Tdap previously or when Tdap is not available. If TT and TIG are both used, Tetanus Toxoid Adsorbed rather than tetanus
1
2
Tetanus Immunization
Table 1 Wound Features and Tetanus Risk CLINICAL FEATURES OF WOUND
NON–TETANUS-PRONE WOUNDS
TETANUS-PRONE WOUNDS
Age of wound
6 hours
> 6 hours
Configuration
Linear wound, abrasion
Stellate wound, avulsion
Depth
1 cm
> 1 cm
Mechanism of injury
Sharp surface (e.g., knife, glass)
Missile, crush, burn, frostbite
Signs of infection
Absent
Present
Devitalized tissue
Absent
Present
Contaminants (e.g., dirt, feces, soil, saliva)
Absent
Present
Denervated and/or ischemic tissue
Absent
Present
Adapted with permission from the Centers for Disease Control and Prevention, Atlanta, GA, www.cdc.gov/epo/mmwr/preview/mmwrhtml/00041645.htm., last updated 2007.
Table 2 Summary of Tetanus Prophylaxis for Injured Patients HISTORY OF ADSORBED TETANUS TOXOID (DOSES)
NON-TETANUS-PRONE WOUNDS
TETANUS-PRONE WOUNDS
Tda
TIG
Tda
TIG
Unknown or < 3
Yes
No
Yes
Yes
≥ 3b
Noc
No
Nod
No
Td = Tetanus and diphtheria toxoids adsorbed, for adult use. TIG = Tetanus immune globulin, human. a
For children younger than 7 years old: DTP (DT, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone. For patients 7 years old and older: Td is preferred to tetanus toxoid alone. b If only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an adsorbed toxoid, should be given. c Yes, if more than 10 years since last tetanus-toxoid containing dose. d Yes, if more than 5 years since last tetanus-toxoid containing dose. (More frequent boosters are not needed and can accentuate side effects.) Adapted with permission from the Centers for Disease Control and Prevention, Atlanta, GA, www.cdc.gov/epo/mmwr/preview/mmwrhtml/00041645.htm., last updated 2007.
toxoid for booster use only (fluid vaccine) should be used. When tetanus toxoid and TIG are given concurrently, separate syringes and separate sites should be used. If the patient has ever received a series of three injections of toxoid, TIG is not indicated, unless the wound is judged to be tetanus-prone and is more than 24 hours old.
Bibliography 1. Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and
acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR 2006;December 15. 2. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: a review and recommendation. J Trauma 2005;58:1082-1088. 3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Tetanus. http:// www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf. Accessed June 8, 2012.
