Emergency Medicine

SOFT-TISSUE INJURIES

Musculoskeletal and Soft-tissue Emergencies 321

Tetanus prophylaxis

DIAGNOSIS

1 Routine tetanus immunization was progressively introduced into Australa-

sia and the UK after the second world war, so elderly people are now the most

likely to be non-immune.

2 Virtually any wound can become contaminated, however trivial.

3 Meticulous wound toilet is an essential part of tetanus prophylaxis, rather

t han simply rely ing on tetanus immunization or antibiotics.

4 Treat patients according to their immune status and the type of wound (see

Table 10.1):

(i) Tetanus-prone wound

Wounds at significant risk of developing tetanus include:

(a) wounds or burns with extensive tissue damage

(b) deep penetrating wound

Table 10.1 Guide to tetanus prophylaxis in wound management

History of

tetanus

vaccination

Time since

last dose

Type of

wound

DTPa, DTPa-

combinations,

dT, dTpa, as

appropriate

Tetanus

immunoglobulin*

(TIG)

≥3 doses <5 years All wounds No No

≥3 doses 5–10 years Clean minor

wounds

No No

≥3 doses 5–10 years All other

wounds

Yes No

≥3 doses >10 years All wounds Yes No

<3 doses or

uncertain†

Clean minor

wounds

Yes No

<3 doses or

uncertain†

All other

wounds

Yes Yes

*The recommended dose for TIG is 250 IU, given by i.m. injection using a 21-gauge

needle, as soon as practicable after the injury. If more than 24 h has elapsed, 500 IU
should be given.
†Individuals who have no documented history of a primary vaccination course (three

doses) with a tetanus toxoid-containing vaccine should receive all missing doses.
DTPa, age <8 years child formulations of diphtheria, tetanus and acellular pertussis-
containing vaccines
dT/dTpa, adolescent/adult formulations (much less amounts of diphtheria toxoid and
pertussis antigens)
Reproduced with permission from The Australian Immunisation Handbook, 9th edn,
2008.