Risus Sardonicus. (1)
Welcome to Tetanus Week! Tetanus is something we deal with every day but to which we give little educational thought. That changes this week. Up first: Are you giving the right medication?
Pearl: Patients who were incompletely immunized and have high-risk wounds require tetanus immunoglobulin (TIG) in addition to a tetanus toxoid based vaccine.
Background: Ordering a tetanus vaccine for a trauma patient (minor or major) has become as reflexive for many as ordering a pregnancy test for a female with belly pain. The logic is that the risks are low and though the NNT is extremely high, tetanus is devastating and preventable. Now, the CDC recommends a TDaP booster for previously immunized individuals for whom re-vaccination is indicated based on injury type or time since the last dose. They recommend Td only – not TDaP – for those who recently received a TDaP as part of their series (say millenials) and for those who recently received a TDaP booster (looking at you, ED frequent flier). Note, however, that this is a booster. These recommendations do not apply to those who you suspect never received any, or at least not the complete series, in childhood or adulthood.
Lesson: For patients who you suspect were inadequately vaccinated in childhood (and did not receive adult catch-ups) who have a tetanus-prone wound (per CDC: crushed, grossly soiled, older than 6 hours, devitalized) the CDC recommends a dose of Tetanus Immunoglobulin (TIG) in addition to the first TDaP dose because un-immunized individuals require two doses to achieve ~90% immunity and the patient described is too high risk. We see many patients who grew up in remote rural areas and who have not had regular contact with the formal healthcare system. When such patients come in with wounds that pose a high risk for tetanus and cannot provide a re-assuring vaccine history we should consider providing TIG in addition to TDaP for adequate prophylaxis.
(1) Di cristianocani – http://www.flickr.com/photos/cristianocani/2904063899, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=13211482