Tetanus is a devastating disease with significant morbidity and mortality rates, and all patients must be asked about their immunization status, even those with clean, "minor" wounds. Of the 124 cases of tetanus reported in the United States during 1995 through 1997, a total of 93 were related to acute injury. 18 Importantly, the most common injury type that preceded tetanus infection was a puncture wound in 46 cases (49 percent). Since the incubation period is from 7 to 21 days, it is acceptable to give the adsorbed tetanus toxoid days after injury. The concept of "tetanus-prone wounds" is still cited, although the incidence of tetanus occurring in minor wounds makes this distinction suspect. Tetanus-prone wounds are considered to be those that are older than 6 h; stellate or avulsion; over 1 cm deep; due to a missile, crush, or frostbite; or have visible contamination with dirt or saliva.
Guidelines for tetanus prophylaxis in wound management have been developed by several public and professional organizations. Most clinicians refer to the recommendations developed by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practice (ACIP)19 (Ta.b]§.,.3.6.:2). Tetanus immune globulin (TIG) will provide passive protection for several weeks and can be given days after an injury, particularly in patients presenting with high-risk wounds and not up to date on vaccination. TIG and toxoid should be given at separate sites. Due to the large number of inadequately immunized adults, a liberal policy should be used with regard to prophylaxis. Immunization and immune globulin administration are safe during pregnancy.
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