Tetanus prone wounds

Aim

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 (e.g. burns)
• any superficial wound obviously contaminated with soil, dust or animal manure
• tooth re-implantation. 

Contraindications²

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

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

Table 1: Guide to Tetanus Prophylaxis in Wound Management³

*Patients with humoral immune deficiency and those with HIV (regardless of CD4+ count) are recommended to receive tetanus immunoglobulin if they have a tetanus prone wound, regardless of the time since their last dose of tetanus-containing vaccine.

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 outlined in Table 1 above:
  • A patient < 10 years of age should be givendiphtheria-tetanus-acellular pertussis combination vaccine (DTPa) (Tripacel®).
  • For infants < 6 weeks of age refer to the Infectious Diseases Department (WA Health only) for advice.
  • A patient ≥ 10 years of age should begiven Diphtheria-tetanus-acellular pertussis combination vaccine (reduced antigen formulation) (dTpa) (Boostrix® or Adacel®)
• If a patient is given a tetanus vaccination and is not up to date with DTPa/dTpa vaccines according to the Australian Immunisation register (AIR), they should be given a copy of their AIR Immunisation history statement (which includes the vaccines overdue) and be advised to complete these immunisations with a community immunisation provider or at the PCH Stan Perron Immunisation centre (Level 1 clinic D, week days).

Tetanus Immunoglobulin (TIG)³

• 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 (irrespective of age and weight) is:
  • 250 international units if ≤ 24 hours since injury
  • 500 international units if >24 hours since injury
• Administer by slow IM injection, using a 23 gauge needle because of its viscosity.
• TIG is not needed for clean minor cuts, even if the person has no history of tetanus vaccination.
• A tetanus vaccine must be given as well as the TIG in the opposite limb. This combination provides both active and passive protection. 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
• As per the Immunisations procedure; verbal or written consent is required from the parent/legal guardian prior to administering vaccinations and this must be documented in the patient’s medical record.
• Vaccines are prescribed on the once only section of the paediatric National Inpatient Medication Chart (pNIMC) by the doctor and given by either a doctor or nurse according to CAHS medication policies and procedures. Vaccines are prescribed using brand names e.g., Boostrix^® / Adacel^®, Tripacel^®
• 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.
• It is mandatory to report adverse events to the Western Australian Vaccine Safety Surveillance system.
• Document adverse event in the patient’s medical record as per the CAHS Allergy and Adverse Drug Reaction Management Policy (WA Health only).

Record vaccine/s given in the following documentation

• Australian Immunisation Register (AIR) online. At PCH refer to the Immunisations procedure 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 - Clinical Practice Manual (internal WA Health only)
• Immunisation registrar
• Paediatric Infectious Diseases Services – PCH intranet page (internal WA health only)

Bibliography

1. National Health and Medical Research Council. Australian Immunisation Handbook 10th Edition 2020. 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. Tetanus. (Online - last updated September 2019)
3. National Health and Medical Research Council. Australian Immunisation Handbook 10th Edition. Tetanus. (Online - last updated September 2019)
4. Australian Product Information - Quadracel® Accessed online 26 March 2015 at: http://products.sanofi.com.au/vaccines/QUADRACEL_AUS_PI.pdf
5. GlaxoSmithKline Australia. Infanrix IPV Product Information. Accessed online July 2020