10.20 Tetanus Prophylaxis
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- If the patient has not had tetanus immuniz- 
    ation 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 immuniz- 
    ations, 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:
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- 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:
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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:
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- 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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