Resource Document 6: Tetanus Immunization
Resource Document 6: Tetanus Immunization
Resource Document 6: Tetanus Immunization
I. Introduction
Tetanus immunization depends on the patient's previous immunization status and the
tetanus-prone nature of the wound. The following guidelines have been adapted from A Guide
to Prophylaxis Against Tetanus in Wound Management, prepared by the ACS Committee on
Trauma, and information available from the Centers for Disease Control (CDC). Because this
information is reviewed and updated as new data become available, the Committee on Trauma
recommends contacting the CDC for the latest information and detailed guidelines related to
tetanus prophylaxis and immunization for the injured patient.
A. Individual Assessment
The attending physician must determine the requirements for adequate prophylaxis
against tetanus for each injured patient individually.
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 doubt exists about the adequacy of the debridement of the
wound 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.
Passive immunization with 250 units of tetanus immune globuline (TIG), administered
intramuscularly, must be considered individually 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, its age, TIG treatment, and
the previous active immunization status of the patient must be considered (Table 2). When
tetanus toxoid and TIG are given concurrently, separate syringes and separate sites should be
used.
If the patient has ever received two or more injections of toxoid, TIG is not indicated,
unless the wound is judged to be tetanus prone and is more than 24 hours old. Do not
administer equine tetanus antitoxin, except when the human toxin is not available, and only
if the possibility of tetanus outweighs the potential reactions of horse serum.
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D. Documentation
For every injured patient, information about the mechanism of injury, the
characteristics of the wound, age, previous active immunization status, history of a neurologic
or severe hypersensitivity reaction following a previous immunization treatment, and plans
for follow-up should be documented. Each patient must be given a written record describing
treatment rendered and follow-up instructions that outline wound care, drug therapy,
immunization status, and potential complications. The patient should be referred to a
designated physician who will provide comprehensive follow-up care, including completion
of active immunizations.
E. Antibiotics
F. Contraindications
The only contraindication to tetanus and diphtheria toxoids in the wounded patient is
a history of neurologic or severe hypersensitivity reaction following a previous dose. Local
side effects alone do not preclude continued use. If a systemic reaction is suspected to
represent allergic hypersensitivity, immunization should be postponed until appropriate skin
testing is undertaken at a later time. If a tetanus toxoid-containing preparation is
contraindicated, passive immunization against tetanus should be considered for a tetanus-prone
wound.
For children younger than seven years of age, immunization requires four injections
of diphtheria and tetanus toxoids and pertussis vaccine adsorbed (DTP). A booster (fifth dose)
injection is administered at four to six years of age. Thereafter, a routine booster of tetanus
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and diphtheria toxoids adsorbed (Td) is indicated at 10-year intervals.
1. Fully immunized
When the attending physician has determined that the patient has been previously and
fully immunized, and the last dose of toxoid was given within 10 years:
a. Administer 0.5 mL of adsorbed toxoid for tetanus-prone wounds, if more than five
years has elapsed since the last dose.
b. This booster may be omitted if excessive toxoid injections have been given before.
2. Partially immunized
When the patient has received two or more injections of toxoid, and the last dose was
received more than ten years ago, 0.5 mL of adsorbed toxoid is administered for both tetanus-
prone and nontetanus-prone wounds. Passive immunization is not necessary.
When the patient has received only one or no prior injections of toxoid or the
immunization history is unknown:
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2. Tetanus-Prone wounds
L. Immunization Schedule
1. Adult
2. Children
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III. Specific Measures for Patients With Wounds
Recommendations for tetanus prophylaxis are based on (1) condition of the wound,
and (2) the patient's immunization history. Table 1 outlines some of the clinical features of
wounds that are prone to develop tetanus. A wound with any one of these features is a
tetanus-prone wound.
Depth 1 cm > 1 cm
Mechanism of injury Sharp surface Missile, crush, burn
(eg, knife, glass) frostbite
Signs of infection Absent Present
Devitalized tissue Absent Present
Contaminants Absent Present
(dirt, feces, soil,
saliva, etc)
Denervated, and/or Absent Present
ischemic tissue
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Table 2. Summary of Tetanus Prophylaxis for the Injured Patient
Key to Table 2
1. For children younger than seven years old: DTP (DT, if pertussis vaccine is
contraindicated) is preferred to tetanus toxoid alone. For persons seven years old and older,
Td is preferred to tetanus toxoid alone.
2. If only three doses of fluid toxoid have been received, a fourth dose of toxoid,
preferably an adsorbed toxoid, should be given.
4. Yes, if more than five years since last dose. (More frequent boosters are not needed
and can accentuate side effects.)