30.3.4   Treatment of patient with tetanus-prone wounds

The following are considered tetanus-prone wounds:

a.    Any wound or burn sustained more than six hours before surgical treatment of the wound or burn.

b.   Any wound or burn at any interval after injury that shows one or more of the following characteristics:

(i)   A significant degree of devitalised tissue.

(ii)   Puncture-type wound.

(iii)    Contact with soil or manure likely to harbour tetanus organisms.

(iv)   Clinical evidence of sepsis.

Thorough surgical toilet of the wound is essential whatever the tetanus immunisation history of the patient.

Immunisation status	Type of Wound	Type of Wound
	Clean	Tetanus Prone
Last of 3 dose course, or reinforcing dose within last 10 years	Nil.	Nil (A dose of human tetanus immunoglobulin may be given if risk of infection is considered especially high, e.g. contamination with stable manure.
Last of 3 dose course or reinforcing dose more than 10 years previously.	A reinforcing dose of adsorbed vaccine.	A reinforcing dose of adsorbed vaccine plus a dose of human tetanus  Immunoglobulin.
Not immunised or immunisation status not known with certainty.	A full 3 dose course of  adsorbed vaccine.	A full 3 dose course of vaccine, plus a dose of tetanus immunoglobulin in a different site.

 

Dosage human tetanus immunoglobulin
Prevention 250 iu by intramuscular injection or 500 iu, if more than 24 hours have elapsed since injury, or there is risk of heavy contamination or following burns. Available in 1ml ampoules containing 250 iu.	Treatment 150 iu/kg given in multiple sites.

30.3.5   Routine tetanus immunisation began in 1961, thus individuals born before that year will not have been immunised in infancy.  After a tetanus-prone injury such individuals will therefore require a full course of immunisation unless it has previously been given, as for instance in the armed services.

30.3.6   Immunised individuals respond rapidly to a subsequent single injection of adsorbed tetanus vaccine, even after an interval of years.

30.3.7   For wounds not in the above categories, such as clean cuts, antitetanus immunoglobulin should not be given.

30.3.8   Patients with impaired immunity who suffer a tetanus-prone wound may not respond to vaccine and may therefore require antitetanus immunoglobulin (see 7.3 and 30.7) in addition.

30.3.9   HIV positive individuals should be immunised against tetanus in the absence of contraindications (see 7.4 and 30.7).