A&E Clinical Guideline No.

2 Wound Management and Tetanus Prophylaxis

(Revised Feb 2002, last reviewed Nov 2004)

Dr K H Chan, Dr C C Lau
I. A. Introduction The A&E Triage Nurse should be capable of initiating Tetanus Prophylaxis Schedule according to the given guidelines based on her/his professional judgement. However, in case of doubt, medical advice should be sought. Remember even the most trivial wound can cause Tetanus. Antibiotic prophylaxis is not useful in wound management and cannot replace proper wound cleaning, debridement and proper immunisation. Take every opportunity to immunise the general population. Only rarely have cases of Tetanus occurred among persons with a documented primary series of toxoid injections. Immune pregnant women transfer temporary protection against Tetanus to their infants through transplacental maternal antibody. Tetanus-prone Wound Tetanus-prone wound is not a well-defined term. Tetanus-prone wound may include wound complicated by delay in treatment (for over 6 hours), deep puncture wounds, avulsions, heavily contaminated wounds (especially with agricultural, horticultural materials or soil) and wounds resulting from missiles, crushing, burns and frostbite. Special attention should be given to excision and exploration as necessary, and local antisepsis merits special consideration. Prompt and thorough surgical wound toilet is of key importance. Foreign materials and devitalised tissues must be removed if possible. Such wounds should not be sutured as a routine. Alternatively, packing with delayed primary closure should be considered with follow-up wound inspection after 48 to 72 hours. E. In Hong Kong, the high risk group of persons for Tetanus are drug addicts and elderly people with neglected wounds.

B.

C.

D.

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II. A.

Active Immunisation Evidence indicates that a complete course of primary vaccination with Tetanus Toxoid (TT) provides long lasting protection greater than or equal to 10 years for most recipients. Boosters are recommended at 10-year intervals. Immunisation Programme 3 doses of 0.5 ml Tetanus Toxoid (TT) by intramuscular route for all ages 1st on the day of attendance 2nd 1 to 2 months after 1st dose 3rd 6 to 12 months after 2nd dose

B.

Individuals born in Hong Kong after 1965 should have received immunisation as a pre-school child with boosters at Primary 1 and Primary 6. For patient who had completed primary vaccination, and the injury incurred within 10 years, no booster dose is required except for tetanus prone wound. If the patient is uncertain or unable to indicate about previous active immunisation for Tetanus, start a full course of TT and consider simultaneous passive immunisation.

C.

D.

The purpose of multiple dosing is to maximise the booster effect. With the best result being achieved by spreading out the vaccination interval one month or more between doses. Persons who have received at least 2 doses of TT rapidly develop antitoxin antibodies. TT booster is advised as part of wound management.

E.

Ensure that the patient understands the contents of the Tetanus Advice Form and advise the patient to complete the course in government or private clinics. Complications Usually, there is no major complication except fever and/or painful local erythematous or nodular reactions at injection site. Unnecessary TT injections should be avoided. A severe local reaction occurring 2-8 hours after TT is probably an Arthus-type reaction. In that case further TT dose may be administered only if the last dose was greater than 10 years previously irrespective of the nature of the wound. In exceptional cases (anticoagulation, haemorrhagic diasthesis), the toxoid can also be administered by deep subcutaneous route.

F.

A&E Clinical Guidelines No. 2

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Revised Feb 2002, last reviewed Nov 2004

II. G.

Active Immunisation (Continued) Contraindications Previous history of anaphylactic reaction is a contraindication to further use of the vaccine. Acute respiratory infection or other active infections are reasons for deferring administration of routine primary immunising or booster dose, but not booster dose for emergency wound.

H.

Pregnancy There is no convincing evidence of risk to the foetus from tetanus immunisation of pregnant women.

III. Passive Immunisation A. Human Tetanus Immune Globulin (HTIG) should be reserved for protecting non-immunised patients or patients having existing immune deficient conditions with wounds that are considered to be Tetanus-prone. Advice from senior medical staff should be sought when in doubt. HTIG is safe and indicated for patients with a contraindication to TT (such as anaphylaxis) and have a Tetanus-prone wound. B. Dosage The prophylactic dose of HTIG is 250 units IMI and TT can safely be given at the same time but at different sites. Different syringes should be used. 500-unit dose is recommended if : (a) there is gross contamination of wound; (b) wound is older than 12 hours; or (c) patients body weight exceeds 90 kg. C. The HTIG will not guarantee that a non-immunised patient will not develop Tetanus after injury.

A&E Clinical Guidelines No. 2

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Revised Feb 2002, last reviewed Nov 2004

IV. Clinical Guidelines for Tetanus Prophylaxis History of Full TT Course or TT Booster No or Unknown Full TT course < 5 years Full TT course between 5 - 10 years Full TT course > 10 years Simple Wounds (non-Tetanus prone) TT Full Course No HTIG No No Complicated Wounds (Tetanus-prone) TT Full Course No HTIG Consider No

No

No

Booster

No

Booster

No

Booster

Consider *

* There were reports of delay anti-toxin response in old aged patients. V. 1. References Update on Adult Immunisation Recommendations of the Immunisation Practices Advisory Committee. MMWR 1991; 40: 1-52. ACEP. Tetanus Immunisation Recommendations for Persons Seven Years of Age and Older. Ann Emer Med 1986;15: 1111-1112. ACEP. Tetanus Immunisation Recommendations for Persons Less than Seven Years Old. Ann Emer Med 1987; 16: 1181-1183. Plotkins & Mortimer. Vaccines, 2nd Edition, P.70 McCarroll JR, Abrahams I, Skudder PA. Antibody response to tetanus toxoid 15 years after initial immunisation. AM J Public Health 52:1669-1675, 1962

2.

3.

4. 5.

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Revised Feb 2002, last reviewed Nov 2004

HOSPITAL

AUTHORITY

HOSPITAL

Name Age AE No. w}-g`g Anti-Tetanus Immunisation Record aPAUCEAw}- -]`gG Please bring along this record to a near-by public Out-Patient Department for Anti-Tetanus Toxoid Injections on the following dates : `g Date of Injection @ 1st G 2nd T 3rd / / @hp Nurse Signature Sex Male / Female

/ / (@`g@G- ) (1-2 months after 1st injection) / / (G`gQG- ) (6-12 months after 2nd injection)

U-YN~Aq@H-w}--]`gC If you are injured again, please inform your doctor or nurses that you have received ATT injections. `N G UT-]`gA~iQ~KC G You MUST complete all 3 injections in order to have Note 10 years immunisation. `gti|_uoN `gX{ , ~khC You may have transient fever, localised painful red swelling at the injection site.

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Appendix
PROGRAMME OF IMMUNISATION, DEPARTMENT OF HEALTH Public Health and Epidemiology Bulletin. Special Edition: Recommendations of the Advisory Committee on Immunisation (Dec 2002). AGE New born IMMUNISATION RECOMMENDED B.C.G. Vaccine Polio Type I Hepatitis B Vaccine - First dose 1 month 2-4 months Hepatitis B Vaccine - Second dose DPT Vaccine (Diphtheria, Pertussis & Tetanus) - First Dose Polio Trivalent - First Dose 3-5 months DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Second Dose 4-6 months 6 months 1 year 1 1/2 year DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Third Dose Polio Trivalent - Second Dose Hepatitis B Vaccine - Third Dose MMR Vaccine (Measles, Mumps & Rubella) - First Dose DPT Vaccine (Diphtheria, Pertussis & Tetanus) - Booster Dose Polio Trivalent - Booster Dose DT Vaccine (Diphtheria & Tetanus) - Booster Dose Primary 1 Polio Trivalent - Booster Dose MMR Vaccine (Measles, Mumps & Rubella) - Second Dose Primary 6 DT Vaccine (Diphtheria & Tetanus) - Booster Dose Polio Trivalent - Booster Dose Note: Hepatitis B vaccination was introduced in 1988. MMR was introduced in 1990 and booster dose is recommended at Primary since 1997.

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Revised Feb 2002, last reviewed Nov 2004