10.20 Tetanus Prophylaxis

agk’s Library of Common Simple Emergencies

Presentation

The patient may have stepped on a nail, or sustained any sort of laceration, abrasion or puncture wound, when the question of tetanus prophylaxis comes up.

What to do:

• If the patient has not had tetanus immunization in the past 5 years, give adult tetanus and diphtheria toxoid (Td) 0.5ml im. Give pediatric diptheria and tetanus toxoid (DT) to children under seven years old.
• If there is any doubt the patient has had his original series of three tetanus immunizations, add tetanus immune globulin (e.g., Hyper-Tet) 250mg im, and make arrangements for him to complete the full series with additional immunizations at 4 to 6 weeks and 6 to 12 months.
• With a history of true hypersensitivity to tetanus toxoid, provide passive immunity with tetanus immune globulin. Instruct the patient that he does not have protection from tetanus from future injuries.

What not to do:

• Do not assume adequate immunization. The groups most at risk in the US today are immigrants, elderly women, and rural southern blacks. Veterans usually have been immunized. Many patients incorrectly assume they were immunized during a surgical procedure. Having had the disease tetanus does not confer immunity.
• Do not give tetanus immunizations indiscriminately. Besides being wasteful, too-frequent immunizations are more likely to cause reactions, probably of the antigen-antibody type. (Surprisingly, the routine of administering toxoid and immune globulin simultaneously in two deltoid muscles does not seem to cause mutual inactivation or serum sickness.)
• Do not believe every story of allergy to tetanus toxoid (which is actually quite rare). Is the patient actually describing a local reaction, the predictable serum sickness of horse serum, or a reaction to older, less pure preparations of toxoid? The only absolute contraindication is a history of immediate hypersensitivity--urticaria, bronchospasm, or shock. Tetanus toxoid is safe for use in pregnancy.
• Do not give pediatric tetanus and diphtheria toxoid (TD) to an adult. TD contains 8 times as much diphtheria toxoid as Td.

Discussion:

There continue to be 50-100 cases of tetanus in the US each year. The CDC recommends everyone receive Td every 10 years, but somehow physicians and patients alike forget tetanus prophylaxis except after a wound. Because tetanus has followed negligible injuries and spontaneous infections, the concept of the “tetanus-prone wound” is not really helpful. The CDC recommends including a small dose of diphtheria toxin (Td) but, because this is more apt to cause local reactions, you may want to revert to plain tetanus toxoid (TT) in patients who have complained of such reactions.

Diptheria-pertussus-tetanus (DPT) vaccine is given at two, four and six months, with a fourth dose at 12 to 18 months (six months after the last dose), a fifth dose at four to six years, and a sixth dose at eleven to sixteen. Thereafter, tetanus toxoid with a reduced dose of diptheria (Td) is given every ten years, and boosters within five for “tetanus-prone” wounds.

References:

• Macko MB, Powell CE: Comparison of the morbidity of tetanus toxoid boosters with tetanus-diptheria toxoid boosters. Ann Emerg Med 1985;14:33-35.
• Giangrasso J, Smith RK: Misuse of tetanus immunoprophylaxis in wound care. Ann Emerg Med 1985;14:573-579.
• Gergen PJ, McQuillan GM, Kiely M et al: A population-based serologic survey of immunity to tetanus in the United States. N Eng J Med 1995;332:761-766.

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