Tetanus Wound Prophylaxis Pathway

Evidence-Based Pearls

1. The Prophylaxis Table

The rule that governs the table: an unknown or uncertain vaccination history counts as zero previous doses. Surviving tetanus confers no immunity either: a patient who has recovered from clinical tetanus still needs the full vaccination course.

Vaccination History	Clean, Minor Wound	Tetanus-Prone Wound
Unknown or <3 doses	Td/Tdap: YES TIG: No	Td/Tdap: YES TIG: YES (250 IU)
≥3 doses, booster <5 yrs	Td/Tdap: No TIG: No	Td/Tdap: No TIG: No
≥3 doses, booster 5-10 yrs	Td/Tdap: No TIG: No	Td/Tdap: YES TIG: No
≥3 doses, booster >10 yrs	Td/Tdap: YES TIG: No	Td/Tdap: YES TIG: No*

*The exception for immunocompromised patients: where there is HIV/AIDS or severe immunodeficiency and the wound is contaminated, give TIG regardless of what the vaccination history says. The history is a poor guide to protection when the immune response to toxoid may never have been made.

2. Wound Classification: Clean vs Tetanus-Prone

Feature	Clean, Minor	Tetanus-Prone
Age of wound	<6 hours	>6 hours
Configuration	Linear, sharp edge	Stellate, avulsion, crush, missile
Depth	<1 cm	>1 cm (deep)
Mechanism	Sharp object (knife, glass)	Puncture, crush, burn, frostbite
Contamination	None / minimal	Soil, faeces, saliva, dirt, rust
Tissue viability	Viable, well-perfused	Devitalised, ischaemic, necrotic
Infection	Absent	Signs of infection present

Pearl: If ANY single feature from the tetanus-prone column is present, classify the wound as tetanus-prone. When in doubt, treat as tetanus-prone.

3. Which Vaccine? Td vs Tdap vs DTaP

Patient Age	Preferred Vaccine	Alternative
<7 years	DTaP (or DTwP in NIS context)	DT if pertussis contraindicated
7-18 years	Tdap (if never received Tdap)	Td if Tdap previously received or unavailable
≥19 years	Tdap (if never received Tdap)	Td if Tdap previously received
Pregnant	Tdap 27-36 weeks (each pregnancy)	Td if Tdap unavailable

Key Difference: Lowercase letters (d, p) denote reduced antigen content in adult formulations. Paediatric DTaP has 3-4 times more diphtheria toxoid than adult Td.
Tdap Priority: Every adult should receive at least 1 lifetime dose of Tdap. If Tdap status is unknown, use Tdap for wound management rather than Td.
Indian Context: Td replaced TT in the NIS (2018-19). In government settings, Td is the standard. Tdap availability is primarily in private practice.

4. Tetanus Immunoglobulin (TIG): The Details

Parameter	Detail
Product	Human TIG (preferred). Equine ATS if human TIG unavailable (higher anaphylaxis risk; requires sensitivity testing).
Dose	250 IU IM for wounds of average severity. 500 IU if wound >24 hours old or heavily contaminated.
Administration	IM injection. When given with Td/Tdap, use separate syringes at different anatomical sites.
Mechanism	Provides immediate passive immunity by neutralising circulating tetanus toxin. Cannot reverse toxin already bound to nerve endings.
Duration	Passive protection only. Patient still requires active immunisation (Td/Tdap) for long-term immunity.

5. Wound Management: The Surgical Essentials

Practice advisory: vaccine and TIG do not stand in for wound care. Clean the wound thoroughly and debride devitalised tissue, whatever prophylaxis has been given.

Debridement: Excise devitalised, necrotic, and ischaemic tissue. C. tetani thrives in anaerobic, devitalised tissue.
Closure: Tetanus-prone wounds should generally be left open or closed by delayed primary closure to avoid creating anaerobic conditions.
Antibiotics: Routine antibiotic prophylaxis is NOT indicated solely for tetanus prevention. However, contaminated wounds may warrant antibiotics for polymicrobial infection risk (Metronidazole or Penicillin if clinical tetanus is suspected).

6. Cautions in the Emergency Department

What the surveillance shows: in a California study covering 2008-2014, of the tetanus patients who had presented for care after the injury, only 22% were given appropriate prophylaxis at that visit. Case fatality is still 13-18% with full intensive care.

Caution: Assuming "rusty nail" is the only mechanism. Tetanus-prone wounds include garden injuries, animal bites, burns, compound fractures, and even surgical wounds.
Caution: Not completing the primary series. If <3 doses have been received, the patient needs a full primary series: dose 2 at ≥4 weeks, dose 3 at 6-12 months after dose 2.
Pearl: Do not restart a vaccine series if doses are delayed. Continue from where the patient left off.
Pearl: ~25% of tetanus cases have no identifiable wound or portal of entry. Ensure routine 10-year boosters are up to date.

7. Tetanus in India: Context

Maternal & Neonatal Tetanus: India was certified for elimination of MNT by WHO in July 2016. However, neonatal tetanus cases continue to be reported (409 cases per HMIS 2021-22).
Adult Tetanus: Cases are primarily in unvaccinated or partially vaccinated elderly agricultural workers. Td vaccine is now given at 10 and 16 years and to pregnant women under NIS.
Diphtheria Resurgence: The shift from TT to Td in 2018-19 was driven by rising diphtheria cases in older age groups with waning immunity. Td provides dual protection.
Equine ATS Availability: Where human TIG cannot be had, equine ATS (1,500-3,000 IU IM after a sensitivity test) may be used. Human TIG is strongly preferred, because serum sickness follows the equine product far more often.

8. Special Populations

Population	Key Consideration
Pregnant Women	Td/Tdap is safe. Tdap is preferred at 27-36 weeks (each pregnancy) for passive neonatal pertussis protection. Category C vaccine.
HIV/AIDS	Give TIG for ALL contaminated wounds regardless of vaccination history. Immune response to toxoid may be impaired.
Elderly (≥65 yrs)	Incidence is twice that in younger adults. Immunosenescence, outdoor and agricultural work, and boosters nobody offered all contribute. Check that the 10-year booster is up to date.
Infants <6 weeks	No tetanus toxoid vaccine is licensed. Give TIG only for contaminated wounds.
Arthus reaction history	Do not give Td/Tdap booster more frequently than every 10 years. For wound management, give TIG alone if within 10 years of last dose.

9. What This Tool Does Not Print

A sensitivity test method for equine ATS. Section 7 says to use one and gives none.
A serological test for immunity. The decision runs on the vaccination history and the wound alone.
An antibiotic regimen for the wound itself. Section 5 gives the tetanus position and nothing wider.