Wound management is an important aspect of care in the Peds ED. We have covered several related topics (ex, Plantar Wounds, Road Rash, Fish hook FB, Absorbable Sutures). Aside from the initial assessment, irrigation, FB removal, associated injury evaluation, and wound closure, one aspect that often gets less attention in children is tetanus prevention. Obviously, children should benefit from recent vaccination, but, in an effort to not be dismissive (and to know what to do when someone is under-immunized), let us take a minute to review Tetanus Prevention.

Tetanus: Basics

• Tetanus is caused by Clostridium tetani.
  • Clostridium tetani is ubiquitous and worldwide.
  • It resides in animal and human intestines and in soil contaminated by feces.
  • Clostridium tetani does not cause tissue destruction or inflammation.
  • It multiplies in wounds and generates its toxin in anaerobic conditions.

• The Clostridium tetani produces a neurotoxin that leads to 4 clinical forms that overlap: [AAP Redbook]
  • Local
    • Muscle groups adjacent to the wound develop spasms [Fiorillo, 1999]
  • Cephalic
    • Cranial nerve dysfunction seen with head and neck wounds
  • Generalized
    • Known as Lockjaw.
    • Severe muscle spasms (like risus sardonicus).
    • Autonomic dysfunction (ex, diaphoresis, tachycardia, arrhythmias, labile BPs)
  • Neonatal
    • A generalized tentanus that occurs in neonates born to mothers who are not immunized properly and, therefore, don’t pass on protective antibodies passively.
    • More prevalent in developing countries where maternal vaccination rates are low and where umbilical cord care is not optimal.

• Symptoms usually develop gradual over the 1st week.
• Severe spasms may persist for more than 1 week.
• Symptoms may take several weeks to resolve if the patient recovers.

• The diagnosis is made clinically. [Grunau, 2010]
• Important to evaluate for other causes of tetany:
  • Hypocalcemia
  • Dystonic reaction from medications
  • Strychnine poisoning

Tetanus: Prevention

• Primary immunization confers protection for at least 10 years. [AAP Redbook]
  • DTaP
    • Diphtheria toxoid, Tetanus toxoid, and acellular Pertussis vaccine
    • Used in children < 7 years of age (little kids need to BUILD UP their immunity, so we use the one with more TALL letters).
    • Primary vaccination consists of 5 doses of DTaP
      • First three given at 2, 4, and 6 mos
      • Remaining two given between 15-18 mos and 4-6 yrs.
    • Can be used for wound prophylaxis for children 6 weeks to 6 years, unless pertussis vaccine is contraindicated.
  • Tdap
    • Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis Booster (Boosters need smaller dose, so smaller letters)
    • Used in patients 7 years and older.
    • Due to waning immunity to pertussis, Tdap is preferred to Td for booster immunization
  • Td
    • Tetanus toxoid and diphtheria toxoid Booster
    • Use for wound prophylaxis in children 7 – 10 years who have completed vaccination schedule.
    • If under-immunized or >10 years of age, use Tdap.

• Booster immunization with/without Human Tetanus Immune Globulin (TIG): [AAP Redbook]
  • Depends on the wound characteristics and the patient’s immunization status.
  • Wound Characteristics:
    • Clean / Minor Wounds
      • Low risk for tetanus
    • All Other Wounds (let’s call these “High Risk”)
      • Contaminated w/ dirt, feces (yuk), or saliva (animal bites)
      • Puncture wounds
      • Avulsions
      • Wounds due to missiles, crushing, or thermal injury (burns or frostbite)
      • I’d argue that a significant portion of the wounds we care for in the ED are higher risk wounds based on these definitions.
  • Immunization Status:
    • < 3 vaccinations (or unknown)
      • TIG?
        • Needs TIG if wound is High Risk.
        • If wound is clean/minor, does not need TIG.
      • DTaP/Tdap/Td?
        • All should get vaccination regardless of time from last tetanus vaccination.

• • • 3 or more vaccinations
      • TIG?
        • Does not need TIG (even if wound is High Risk).
      • DTaP/Tdap/Td?
        • High Risk Wound – give booster if last tetanus vaccine was 5 or more years ago.
        • Clean Wound – give booster if last tetanus vaccine was 10 or more years ago.
    • For High Risk wounds, patients with HIV or other severe immunodeficiencies should receive TIG regardless of immunization record.

Tetanus: Disease Treatment

• Wound care is important!
  • Debride necrotic tissue
  • Remove foreign bodies and dirt, etc!
  • May benefit for surgical debridement.
  • Puncture wounds do not need to be extensively debrided.

• Human Tetanus Immune Globulin (TIG)
  • 3,000 – 6,000 Units given IM x 1
  • Many recommend administering TIG in close proximity to the wound, but this hasn’t been proven. [AAP Redbook]

• Tetanus Toxoid
  • Anti-tetanus antibodies don’t reach maximum concentration until 2-4 weeks after administration.
  • Does not prevent current tetanus disease.
  • Useful in helping to prevent subsequent disease.

• Supportive Care
  • Control of muscle spasms
  • Airway support
  • Manage autonomic instability

• Metronidazole (PO or IV)
  • Can reduce the number of Clostridium tetani in vegetative form.
  • 30 mg/kg/Day x 7-10 days
  • Penicillin G Is an alternative.

Moral of the Morsel

• “Give Life Saving Tetanus” is often announced in jest, but Tetanus Toxoid is important!
• Don’t assume that the pediatric patient is up to date with Tetanus Vaccinations.
• The magic number is 3. Less than 3 vaccinations, you may need to give TIG too!

References