Advanced Trauma Life Support ATLS Student Course Manual 2018

408
TETANUS IMMUNIZATION
••
Wounds containing foreign bodies (especially
wood splinters)
••
Wounds complicated by pyogenic infections
••
Wounds with extensive tissue damage (e.g.,
contusions or burns)
••
Any wound obviously contaminated with soil,
dust, or horse manure (especially if topical
disinfection is delayed more than 4 hours)
••
Reimplantation of an avulsed tooth (because
the tooth receives minimal washing and
cleaning to increase the likelihood of successful
reimplantation)
••
Wounds or burns requiring surgical
intervention that is delayed more than 6 hours
••
Wounds or burns associated with sepsis
Wounds must be cleaned, disinfected, and treated
surgically if appropriate.
Clinical Signs and Course
The excitatory impulses lead to sustained muscular
contractions, which can be localized or generalized.
Contractions may begin in the muscles surrounding
the wounded area. Lockjaw (severe contraction of
the masseter muscle) is characteristic of generalized
tetanus. Pain, headache and muscle rigidity are seen in
generalized tetanus (80% of cases). Respiratory failure
caused by laryngeal obstruction and chest wall rigidity
is the most common direct cause of death. Autonomic
dysfunction can be seen as well with accompanying
fever, diaphoresis, hypertension, arrhythmias,
and hypermetabolism. The spasms and autonomic
instability persist for weeks, and the muscular rigidity
is present for months.
Treatment Principles
Surgical Wound Care
Regardless of a patient’s active immunization status, he
or she must immediately receive meticulous surgical
care—including removal of all devitalized tissue and
foreign bodies—for all wounds. If the adequacy of
wound debridement is in question or a puncture injury
is present, leave the wound open and do not suture.
Such care is essential as part of the prophylaxis against
tetanus. Traditional clinical features that influence
the risk for tetanus infection in soft-tissue wounds
are detailed in n TABLE 1. However, clinicians should
consider all wounds to be at risk for the development
of tetanus.
Prevention
Active immunization is the mainstay of therapy for
this disease. The following general principles for
doctors who treat trauma patients concern surgical
wound care and passive immunization. Studies
demonstrate that relying on patients to recall their
immunity status may be unreliable, resulting in both
over- and under-administration of tetanus boosters.
Over-administration of tetanus prophylaxis may
diminish serologic response and increase cost of care,
whereas under-treatment exposes patients to the risk
of developing the disease and risking mortality and
morbidity. Serologic testing is available to determine
antibody levels. n BOX 1 lists potential adverse reactions
from tetanus immunization.
Passive Immunization
Passive immunization with 250 units of human tetanus
immune globulin (TIG), administered intramuscularly,
must be considered for each patient. Double the dose
if the wound is older than 12 hours, there is heavy
contamination, or the patient weighs more than 90 kg.
TIG provides longer protection than antitoxin of animal
origin and causes few adverse reactions. Characteristics
of the wound, the conditions under which it occurred,
wound age, TIG treatment, and the patient’s previous
active immunization status must all be considered.
Due to concerns about herd immunity to both
pertussis and diphtheria, and recent outbreaks of both,
box 1 adverse reactions from
tetanus immunization
• Pain
• Palpable lump
• Swelling
• Erythema at the injection site occurring in up to 20%
• Type II hypersensitivity reaction with severe swelling
and erythema of the injected arm within 2 to 8 hours of
the injection. (It usually resolves without sequelae.)
• General symptoms of malaise fever headache are
uncommon; dyspnea, urticaria, angioedema, and
neurologic reactions are rare.
• Anaphylaxis 0.6 to 3 per million doses
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