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Clinical Guidelines Private Tetanus Prophylaxis
in Wound Management
Dr. Jamshaid Sadiq Sulehri

BACKGROUND: Most individuals in developed countries including Ireland have an underlying level of immunity to tetanus.   While this general trend is positive the level of immunisation at various stages of life is variable from place to place.   Whereas very high percentages of patients receive their tetanus prophylaxis systematically at the appropriate age in the UK the situation is not quite so good in Ireland.   Recently a national initiative has been commenced to have GPs responsible for childhood immunisation and to encourage same although so far this has been patchy.
There is a balance between ensuring that the patient is adequately protected against tetanus and at the same time ensuring that patients do not receive additional tetanus boosters needlessly.   Such patients may develop significant local reactions which are both painful and distressing.   There is also the potential that needless and thoughtless administration of a tetanus toxoid booster could be regarded as negligent should a patient suffer an untoward reaction.  Immunisation advice has changed recently and many are unaware of the implications of same.

NORMAL PATTERN OF IMMUNISATION:

Infants receive either DTP (Diphtheria, Tetanus, Pertussis vaccine) or DT (Diphtheria, Tetanus vaccine) if Pertussis vaccine is contraindicated.   Normally in the North West the injections are given in a sequence of 3 at 2, 4 & 6 months of age.
Normally a further booster injection of DT is given in the 4-6 age group.   There is a misconception that a further booster is given as a teenager;  this is not the case in Ireland although it does occur in the U.K.  The approximate estimate for uptake rates for the various vaccination milestones are as follows:
Infant immunisation 70-80%
4-6 year old immunisation 40-50%
 

It is important therefore to ask about immunisation history when dealing with children and young adults and not make assumptions that due vaccination has been given.

 PRINCIPLES OF TETANUS PREVENTION:
The tetanus vaccine is a toxoid which has been inactivated.   After a primary course of 3 injections then by a further booster at 10 yearly intervals it is hoped that immunity can be preserved against tetanus which is a potentially fatal disease if contracted.  Tetanus is most likely to be a complicating feature of wounds in which there is a significant degree of contamination with soil and animal excrement or where there is a significant amount of devitalised tissue. 

It is important to remember that the most efficient way of preventing tetanus is by appropriate and thorough wound management. 
Dead and devitalised tissue and dirt must be rigorously debrided and a cleansed wound produced.  If necessary this will have to be done under general anaesthetic.  Antibiotics, tetanus toxoid or tetanus immunoglobulin are not substitutes for proper wound care. 

TETANUS IMMUNOGLOBULIN (TIG):
In situations where the risk of tetanus is very significant and the underlying level of immunity is poor TIG may be required.   This is a preparation of specific anti-tetanus antibody which is commercially produced.   Unlike antiserum that was used in the past which was extracted from horses and therefore a highly antigenic foreign protein, modern TIG is much safer and much more specific

Revised advice from the National Immunisation Advisory Committee of the Royal College of Physicians in Ireland was issued in June 2002 and the following is based on that advice.
SUGGESTED SCHEME FOR TETANUS PROPHYLAXIS
:

For practical purposes wounds can be divided into 2 groups. 

a)         "Normal" wounds.
b)         Tetanus prone wounds.
 

NORMAL WOUNDS:
These are the regular wounds which turn up in Accident and Emergency Departments including simple lacerations, clean abrasions etc.

TETANUS PRONE WOUNDS:

These essentially are wounds in which the likelihood of contracting tetanus is significantly greater.   These include - 

1)         Wounds contaminated with obvious dirt, faeces, soil or saliva.
            NB. Human and animal bites.

2)         Wounds with a significant amount of devitalised tissue ie. those resulting from missiles eg. gunshots, burns, frostbite and where there is a significant crushing component.

3)         Deep puncture wounds or wounds which have involved avulsion of significant amounts of tissue. 

History of dsorbed

Tetanus Toxoid

Years Since

Last Dose

Normal Wounds

Toxoid       TIG

Tetanus Prone Wounds

Toxoid        TIG

     Unknown or £ 2

             -

  YES*         NO

(Course)

  YES*          YES

(Course)

                    ³ 3

 

           <5

  NO           NO

  NO             NO

                    ³ 3

          5-10

  NO           NO

  YES            NO

(Booster)

                    ³ 3

          >10

  YES          NO

(Booster)

  YES            NO

(Booster)

 * A course of three tetanus injections should be started.   These should be given on the day of presentation, 6 weeks later and 6 months later.   The latter two injections should be given by the patients General Practitioner. 

Note
- For children <7 years of age DTP is used or DT if Pertussis vaccine is contraindicated.
- If the child is aged from 7-10yrs DT is preferred to tetanus toxoid alone.
-
Subsequent booster doses in patients >10yrs of age should be with Td (Adsorbed tetanus toxoid plus adult diphtheria).
This is a change from previous guidelines.
Tetanus Toxoid is a highly effective vaccine.   Protective antibody levels are generally maintained for at least 10 years.
-           The standard dose of Tetanus Toxoid is 0.5ml to be given either IM or SC.
-           The standard dose of Tetanus Immunoglobulin (TIG) is 250 i.u. to be given IM.

PRESCRIPTION & ADMINISTRATION OF TETANUS TOXOID:
Tetanus toxoid should be treated the same as any other prescribed drug.   It should be prescribed by the doctor who is seeing the patient and the order to give it documented in the notes.   The nursing staff should administer tetanus toxoid as prescribed.

It is important that nursing staff continue to question the patient about their tetanus status and bring this to the attention of the doctor if they feel tetanus prophylaxis is indicated but has been overlooked by the doctor.

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