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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 development of tetanus infection.
Tetanus immunization depends on the patients
previous immunization status and the tetanus-prone
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
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
2 Tetanus Immunization
Table 1 Wound Features and Tetanus Risk
CLINICAL FEATURES OF WOUND
NONTETANUS-PRONE WOUNDS
TETANUS-PRONE WOUNDS
Age of wound
6 hours
> 6 hours
Configuration
Depth
1 cm
>1 cm
Mechanism of injury
Signs of infection
Absent
Present
Devitalized tissue
Absent
Present
Absent
Present
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.
NON-TETANUS-PRONE WOUNDS
TETANUS-PRONE WOUNDS
Tda
TIG
Tda
TIG
Unknown or < 3
Yes
No
Yes
Yes
3b
Noc
No
Nod
No
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.
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.