Tetanus-prone wounds:
- Any wound or burn sustained more than 6 hours
- Any wound or burn at any interval after injury that shows one or more of:
- significant degree of devitalised tissue
- puncture-type wound
- contact with soil or manure likely to harbour tetanus organisms
- clinical evidence of sepsis
Thorough surgical toilet of the wound is essential irrespective of patients tetanus status.
Tetagam
In the Mx of tetanus-prone wounds, tetanus immunoglobulin of human origin (‘HTIG’) should be used in addition to wound cleansing and, where appropriate, antibacterial prophylaxis and a tetanus-containing vaccine. The preparation of tetanus immunoglobulin currently available from the pharmacy in MUH/CUH is Tetagam®.
Indications for use of anti-tetanus immunoglobulin;
- Those with tetanus-prone wounds who have not received at least 3 doses of tetanus toxoid and their last dose within 10 years
- Patients with impaired immunity who suffer a tetanus-prone wound – may in addition require anti-tetanus immunoglobulin
- Patients who have suffered a high-risk wound, regardless of vaccine history
Tetagam
- Is a blood product so we are obliged to record patient details
- The record (held in the CUH fridge with the tetagam®)
- Pharmacy fill out the tetagam batch number and expiry
- Then when this pre-filled syringe is used, staff administering it are to record the date of admin., affix the patient's addressograph and enter your details
However trivial the wound, ask about the patient's immune state and offer booster doses to those patients who are not up-to-date and encourage non-immunised people to have a full course.
Risk assessment of wounds for tetanus immunoglobulin (TIG)
| Vaccination status | Clean wound | Tetanus prone wound | |
|---|---|---|---|
| Fully immunisted (5 doses at appropriate intervals) | Nil | No vaccine required unless more than 10 years since previous tetanus vaccine | Consider TIG * |
| Primary immunistation and age appropriate boosters complete | Nil | Nil | Consider TIG * |
| Primary immunisation or age appropriate boosters incomplete | Age appropriate tetanus vaccine and complete vaccine schedule | Age appropriate tetanus vaccine and complete vaccine schedule | TIG |
| Unimmunised or unknown vaccine status | Age appropriate tetanus vaccine and complete vaccine schedule | Age appropriate tetanus vaccine and complete vaccine schedule | TIG |
*Consider TIG (Tetagam®)for fully vaccinated patients with:
- Impaired immunity (e.g. diabetes, immunosuppressed and IV drug use)
- A wound contaminated with stable manure, or extensive devitalised tissue regardless of vaccine status
- HIV positive
TIG = Tetanus Immunoglobulin
DTaP/IPV/Hib = Diphtheria, Tetanus and acellular Pertussis vaccine/Inactivated Polio Virus vaccine/ Haemophilius influenzae b vaccine
DTaP/IPV = Diphtheria, Tetanus and acellular Pertussis vaccine/Inactivated Polio Virus vaccine
Td/IPV = Tetanus, low-dose diphtheria/ Inactivated Polio Virus vaccine
Tdap = Tetanus, low-dose diphtheria and low-dose acellular pertussis vaccine.
Prophylactic Adult dose of tetanus immunoglobulin (Tetagam®)
- 250 iu IM: standard dose
- 500 iu IM: if > 24 hours since injury, patient >90kg or heavily contaminated wound or burn wound or open fracture wound
Therapeutic dose of tetanus immunoglobilin (established tetanus)
- 150 IU/kg IM (given in multiple sites
- If a large volume (>2ml for children) is required, it is recommended to administer this in divided doses at different sites
When simultaneous vaccination and immunoglobulin are needed they should be administered at two different sites.
- For prophylaxis, if intramuscular administration is contra-indicated (coagulation bleeding disorders), the injection can be administered subcutaneously. However, it should be noted that there are no clinical efficacy data to support administration by the subcutaneous route
Please Note: Tetagam (immunoglobulin) should not be administered IV (anaphylaxis risk).
Note
- Patients born before 1961 may not have been immunised
- Immunocompromised patients may not respond to vaccination & may need immunoglobulin
- In the absence of other contraindications, immunocompromised and HIV+ patients can be given tetanus vaccine