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Pharmacology

Immunoglobulins and Vaccines

Question 84 of 180

A nurse practitioner working in minors is concerned about a patient's wound and asks for your advice. All of the following are considered to be tetanus prone wounds EXCEPT for:

Answer:

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

Management of Tetanus-Prone Wounds

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

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