Pharmacology
Immunoglobulins and Vaccines
A 65 year old farmer presents to ED with a soiled puncture wound to his thenar eminence which he sustained whilst fixing his tractor the day before yesterday. He is wondering whether he needs a tetanus booster. He is unsure about his vaccination record. What should this patient receive in ED:
Answer:
This farmer has a high-risk (heavily contaminated with soil/manure) tetanus-prone wound with an uncertain immunisation history. The wound should be thoroughly cleaned and the presence of foreign body excluded. He should receive tetanus immunoglobulin 500 IU (given the wound was sustained over 24 hours ago) and the tetanus toxoid vaccine at a different site (with completion of the immunisation schedule followed-up by his GP). Antibacterial prophylaxis should be considered.Management of Tetanus-Prone Wounds
Pharmacology / Immunoglobulins and Vaccines
Last Updated: 13th April 2023
Tetanus is an acute disease caused by the action of the tetanus neurotoxin (tetanospasmin) produced by the bacterium Clostridium tetani, an anaerobic spore forming bacillus. Tetanus spores are widespread in the environment, including in soil and manure. They can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through a puncture wound but also through trivial, unnoticed wounds, through injecting drug use, and occasionally through abdominal surgery. The bacteria grow anaerobically at the site of the injury and have an incubation period of between four and 21 days (most commonly about ten days).
Definition of tetanus-prone wounds
Tetanus-prone wounds include:
- puncture-type injuries acquired in a contaminated environment and likely therefore to contain tetanus spores e.g. gardening injuries
- wounds containing foreign bodies
- compound fractures
- wounds or burns with systemic sepsis
- certain animal bites and scratches - although smaller bites from domestic pets are generally puncture injuries animal saliva should not contain tetanus spores unless the animal has been routing in soil or lives in an agricultural setting
High risk tetanus-prone wounds are any of the above with either:
- heavy contamination with material likely to contain tetanus spores e.g. soil, manure
- wounds or burns that show extensive devitalised tissue
- wounds or burns that require surgical intervention that is delayed for more than six hours are high risk even if the contamination was not initially heavy
Thorough cleaning of wounds is essential.
Clean wounds are defined as:
- wounds less than 6 hours old, non-penetrating with negligible tissue damage
Management of tetanus-prone wounds
| Immunisation Status | Clean Wound | Tetanus Prone Wound | High Risk Tetanus Prone Wound |
|---|---|---|---|
| Those aged ≥ 11, who have received an adequate priming course of tetanus vaccine with the last dose within 10 years
Children aged 5-10 years who have received priming course and preschool booster Children under 5 years who have received an adequate priming course |
None Required | None Required | None Required |
| Those who have received an adequate priming course of tetanus vaccine but the last dose was > 10 years ago
Children aged 5-10 years who have received an adequate priming course but no preschool booster (Includes UK born after 1961 with history of accepting vaccinations) |
None Required | Immediate reinforcing dose of vaccine | Immediate reinforcing dose of vaccine & one dose of human tetanus immunoglobulin at a different site |
| Those who have not received an adequate priming course of tetanus vaccine
Includes uncertain immunisation status and/or born before 1961 |
Immediate reinforcing dose of vaccine | Immediate reinforcing dose of vaccine & one dose of human tetanus immunoglobulin at a different site | Immediate reinforcing dose of vaccine & one dose of human tetanus immunoglobulin at a different site |
Important considerations:
- An adequate priming course is defined as at least 3 doses of tetanus vaccine at appropriate intervals. (N.B. This definition of “adequate course” is for the risk assessment of tetanus-prone wounds only. The full UK schedule is five doses of tetanus containing vaccine at appropriate intervals.)
- The dose of human tetanus immunoglobulin (IM-TIG) is normally 250 IU by intramuscular injection, or 500 IU if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns.
- In the absence of IM-TIG, the human normal immunoglobulin (HNIG) product Subgam 16% can be used instead.
- Tetanus vaccine should be injected at a different site from immunoglobulin so that it is not 'neutralised' by the passive immunisation.
- Patients who are severely immunosuppressed may not be adequately protected against tetanus, despite having been fully immunised. In the event of an exposure they may require additional boosting and/or immunoglobulin.
- For those whose immunisation status is uncertain, and individuals born before 1961 who may not have been immunised in infancy, a full course of immunisation is likely to be required.
- For those who are incompletely immunised, further doses should be offered to
complete the recommended schedule to protect against future exposures.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
