Pediatric Tetanus Prophylaxis: When to Use TIG?

[StrangerX]

-11 y/o boy with a 4 cm laceration from a rusty piece of metal from a junkyard
-Previous booster >5 years ago
-Answer: Give him only Td

However I think the wound is dirty, not clean, and given the time-frame from the booster merits both Td and immunoglobulin. Is there something I am missing? Is tetanus prophylaxis different for kids?

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[Bagheera]

Is this a UWORLD questions?. I thought if the pt has had <3 lifetime toxoids and if it is dirty wound, then TIG is given with the tetanus toxoid......

 

[StrangerX]

No its from Peds Lange Q&A.

I thought about this question some more after looking at UWORLD and it turns out if you are immunized and received your last booster <10 yrs ago but >5 yrs ago, you only need Td and NOT TIG for a dirty wound. I reread the question and the fact that they got a tetanus booster, implies that they were fully vaccinated against tetanus previously.

 

[illegallysmooth]

Just remember that immune globulin is given in the WORST scenario - never finished the tetanus series or it's been over 10 years since booster AND the wound is dirty as crap.

 

[ajs321]

Just remember that immune globulin is given in the WORST scenario - never finished the tetanus series or it's been over 10 years since booster AND the wound is dirty as crap.

Truth.

 

[Bagheera]

Stranger,

I thought it said in UWORLD If the pt has had <3 boosters with a dirty wound >5 years from last booster, then TIG is given with toxoid.... Also unknown immune status also warrants using TIG with toxoid.....

 

[StrangerX]

Stranger,

I thought it said in UWORLD If the pt has had <3 boosters with a dirty wound >5 years from last booster, then TIG is given with toxoid.... Also unknown immune status also warrants using TIG with toxoid.....

In the question in my original post, the child was fully vaccinated.

I was looking at UWORLD ID 3566 (in the table in this question...the bottom, rightmost box). I may have read to quickly but I didn't spot the phrasing with 3 doses of booster (I also don't have access to all of the UWORLD questions anymore as I reset it so it may be possible you are looking at a different question- I have noticed that sometimes the guidelines used are not consistent between questions...most notably with the ATP III cutoffs). Lange Q&A Peds references the CDC and it discusses 3 doses of Td. In searching their website they say:

"Children should get 5 doses of DTaP, one dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years. DT does not contain pertussis, and is used as a substitute for DTaP for children who cannot tolerate pertussis vaccine."

It may be semantics but I think booster would refer any vaccine given after the normal vaccination schedule (i.e. other than the 2, 4, 6 mo etc schedule). So given the fact the child is up to date with his vaccination schedule, and the timeline I elucidated earlier it would make sense that the child only get the Td and NO TIG. If the child had been 5 mo and not gotten all three vaccine doses, THEN you would give the Td and TIG.

Its safe to say, remembering vaccination intricacies ranks up there with pediatric milestones as my least favorite things to try to remember.

 

[Bagheera]

thanks for the reply stranger... Yes, peds guidelines esp vaccination and milestones give me quite some trouble as well....

 

[drk]

As per UWORLD it's pretty easy to remember. Unvaccinated and vaccine > 10 years ago are essentially the same and treated as the same condition. Minor wound/clean: Td & Major wound/dirty: Td/TIG.

Vaccinated recently in last 10 years is treated as: Minor/clean: Nothing and Major/Dirty Nothing if Vaccine <5 years ago and Td if vaccine >5 years ago.

I also can't seem to recall the mention of if you have had 3 boosters then you follow a different schedule..I just remember the above merging unvaccinated/>10 years as one condition and <10 years as another. Less to remember!

 

[dhavalp]

as per uworld it's pretty easy to remember. Unvaccinated and vaccine > 10 years ago are essentially the same and treated as the same condition. Minor wound/clean: Td & major wound/dirty: Td/tig.

Vaccinated recently in last 10 years is treated as: Minor/clean: Nothing and major/dirty nothing if vaccine <5 years ago and td if vaccine >5 years ago.

I also can't seem to recall the mention of if you have had 3 boosters then you follow a different schedule..i just remember the above merging unvaccinated/>10 years as one condition and <10 years as another. Less to remember!

+1

 

[ferroportin]

One caveat is that any child with HIV or who got a BMT within a year should get TIG for any tetanus-prone wound regardless of vaccination status.

 

[StrangerX]

I can't believe NOBODY mentioned the most important indication for vaccination...

If you get bit by a werewolf and are <6 but >5 years of age at the time of the bite, you must be vaccinated on Feb 29th of the next leap year, but only if you were wearing red at the time of the bite and were eating an ice cream cone with vanilla ice cream sprinkled with...and this is the most important part...CHOCOLATE sprinkles. You can have all the qualifiers previously but if the sprinkles are not chocolate, you DO NOT, I repeat you DO NOT need the vaccination. Additionally you need two doses if somebody watched you getting bit.

 

[dhavalp]

I can't believe NOBODY mentioned the most important indication for vaccination...

If you get bit by a werewolf and are <6 but >5 years of age at the time of the bite, you must be vaccinated on Feb 29th of the next leap year, but only if you were wearing red at the time of the bite and were eating an ice cream cone with vanilla ice cream sprinkled with...and this is the most important part...CHOCOLATE sprinkles. You can have all the qualifiers previously but if the sprinkles are not chocolate, you DO NOT, I repeat you DO NOT need the vaccination. Additionally you need two doses if somebody watched you getting bit.

Additionally, the werewolf must be captured and remain under a 10 day observation for any signs of being "rabid". If suspicious, the werewolf's brain must be autopsied to confirm. If confirmed, post exposure prophylaxis (both passive and active immunizations) is indicated. If the werewolf cannot be captured, assume it has rabies and administer the prophylaxis.

[this is really what a uworld explanation says on a question about dog bites]

 

[evilbooyaa]

Additionally, the werewolf must be captured and remain under a 10 day observation for any signs of being "rabid". If suspicious, the werewolf's brain must be autopsied to confirm. If confirmed, post exposure prophylaxis (both passive and active immunizations) is indicated. If the werewolf cannot be captured, assume it has rabies and administer the prophylaxis.

[this is really what a uworld explanation says on a question about dog bites]

B/c that is all stuff that you need to know about rabies PEP. Seriously. Just replace werewolf with dog.

If they ask you a question about rabies PEP, they'll make sure to insinuate whether it was an aggravated or unaggravated bite.