Tetanus prone wounds

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of tetanus prone wounds.

Background

Tetanus can follow apparently trivial, even unnoticed wounds. However, some wounds tend to favour the growth of tetanus organisms; these include:

  • compound fractures
  • deep penetrating wounds
  • bite wounds
  • wounds containing foreign bodies (especially wood splinters)
  • wounds complicated by pyogenic infections
  • wounds with extensive tissue damage
  • any superficial wound obviously contaminated with soil, dust or animal manure
  • tooth re-implantation. 

Contraindications3

  • Anaphylaxis following a previous dose of any tetanus containing vaccine
  • Anaphylaxis following any vaccine component

Alternative measures including the use of tetanus immunoglobulin can be considered if a person with a tetanus prone wound has had a severe adverse event following a tetanus vaccine.

Assessment

Guide to Tetanus Prophylaxis in Wound Management2

Vaccination history

Type of wound  Tetanus vaccine booster Tetanus immunoglobulin
3 or more doses < 5 years since last dose All wounds No  No
5-10 years since last dose Clean minor wounds No No
  All other wounds Yes No
> 10 years since last dose All wounds Yes No
< 3 doses or uncertain   Clean minor wounds Yes No
  All other wounds Yes Yes

Management

Tetanus vaccination

  • Tetanus toxoid vaccines in Australia are only available in combination with diphtheria and other antigens.
  • If a child has not had 3 doses of tetanus vaccine (or if there is uncertainty) and meets the criteria above:
    • A patient ≤ 10 years of age should be given DTPa-IPV (Infanrix-IPV or Quadracel)
    • A patient > 10 years of age should be given dTpa (Boostrix or Adacel)
  • A combination vaccine with pertussis is preferable in order to increase community protection. However if a pertussis vaccine is contraindicated, then another tetanus vaccination combination may be used.
  • If a patient is given a tetanus vaccination and has not received a previous primary course they should be advised to complete the course with a further 2 vaccinations.

Tetanus Immunoglobulin (TIG)

  • TIG is used for passive protection of people who have not had three or more doses of tetanus vaccine or where there is any uncertainty regarding immunisation status who have a tetanus prone wound.
  • The dose is 250 international units irrespective of age
  • It should be given IM, slowly using a 23 gauge needle in children because of its viscosity.
  • A tetanus vaccine must be given at the same time in the opposite limb. Arrangements should be made for catch up vaccines if required.
  • At PCH, TIG is available from the Transfusion Medicine Unit, to order contact the transfusion medicine scientist and provide patient details and clinical history.
  • Refer to the Transfusion Medicine Protocols for further information.

Nursing

Vaccines should be given, as follows:

  • Refer to the Australian Immunisation Handbook – vaccination procedures (external link)
  • Vaccines are prescribed on the medication sheet by the patient’s doctor and given by either a doctor or nurse according to CAHS medication policy
  • Recipients of vaccines should remain under close observation for at least 15 minutes to ensure they do not experience an immediate adverse event
  • Immediately notify medical staff of adverse events following immunisations
  • Report adverse events to the Western Australian Vaccine Safety Surveillance system or email
  • Document incident in patient medical notes.

Record vaccine/s given in the following documentation

  • ACIR online (only for children under 7 years of age). At PCH refer to immunisation regarding the process 
  • Personal health record book or provide a WA Childhood Vaccination Record Card
  • Patient medical notes.

Further immunisation advice can be obtained by contacting one of the following PCH staff:

  • Clinical nurse consultant - Immunisation
  • Paediatric Infectious Diseases Services 
  • Dr Peter Richmond – Immunologist.

Bibliography

  1. National Health and Medical Research Council. Australian Immunisation Handbook 10th Edition 2013. Australian Government Department of Health and Ageing
  2. National Health and Medical Research Council. Australian Immunisation Handbook 10th Edition 2013. Australian Government Department of Health and Ageing - Guide to tetanus prophylaxis in wound management - Table 4.19.1, pg 404
  3. National Health and Medical Research Council. Australian Immunisation Handbook 10th Edition 2013. Australian Government Department of Health and Ageing - 4.19.10 Contraindications, pg 404
  4. Australian Product Information - Quadracel® Accessed online 26 March 2015 at: http://products.sanofi.com.au/vaccines/QUADRACEL_AUS_PI.pdf
  5. Australian Product Information - Infanrix® IPV Accessed online 26/3/2015 at: https://www.gsk.com.au/resources.ashx/vaccineproductschilddataproinfo/424/FileName/522B159E43356E2F4B1CF38BA566099B/INFANRIX-IPV_PI_004_clean_pdf.pdf
  6. External Review: Clinical Nurse Consultant Immunisation March 2015

Endorsed by:  Director, Emergency Department  Date:  Feb 2017


 Review date:   Feb 2020


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