Tetanus after I and D

[alphaholic06]

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How many you do this? Some of my attendings do and some don't? What say the SDN EM forum? Is there any evidence one way or another?

 

[name?]

I don't, but it certainly seems like it'd be just as tetanus prone as anything else that we update for. Plus, with the pertussis outbreaks around the country, it'd be a great excuse to get some public health vaccination done. This question might just change my practice...

 

[la gringa]

i was taught to, and continue to do so.

the reasons stated are as good as any.

 

[Daiphon]

I look at it this way:

skin violation = risk for tetanus (if not pre-ED, then post- when they leave)
I&D = iatrogenic skin violation
dT/DTaP= won't really hurt anyone & as above, pertussis cases are on the rise

No loss, easy gain, and they're good for 10. Not EBM-based, but easy peasy.

Cheers!
-d

 

[GeneralVeers]

Has anyone actually seen someone with Tetanus? Going on 10 years including med school and haven't seen one yet.

 

[Rendar5]

Well, it's up to you. What I will say is that people with abscesses, along with IVDA patients, diabetics with ulcers, and recent surgeries make up like 4% of US cases of tetanus total. Keep in mind that this is a disease with on the order of 2:10,000,000 in the US where we typically are giving boosters for any open wounds requiring ED evaluation, but we're not routinely doing it for those above causes.

If you're giving boosters for abscesses, you're giving it to treat that above incidence number. That incidence number is similar to the incidence number of the super-rare vaccine side effects. So you may prevent an ultra-rare disease by treating a rare cause, or you may cause an ultra rare vaccine side effect.

I don't really think you can get burned either way honestly, risk and benefit are insanely low either way.

 

[BADMD]

Has anyone actually seen someone with Tetanus?

I haven't seen tetnus, but I did get a call once about botulism. It was a case of wound botulism, post api. I have to assume that tetnus would also be possible.

 

[deleted65604]

I saw tetanus in an 8 year old kid in residency on my PICU rotation. He had trismus and opisthotonus. He'd scream in pain and lock up with the least bit of stimulation. He was un-vaccinated because his parents were organic farmers and didn't believe in unnatural things. The only portal of entry we could find was a subungual hematoma that had happened 2 weeks before.

Needless to say, I am the tetanus nazi. 1 million people die a year world-wide from tetanus (don't quote me on that). It is a stupid disease to die of now.

 

[WilcoWorld]

Has anyone actually seen someone with Tetanus? Going on 10 years including med school and haven't seen one yet.

I hope I've misread you and that you're not seriously suggesting that because you haven't seen a case of tetanus in 10 years we thus shouldn't vaccinate? To me that's proof of just the opposite.

 

[GeneralVeers]

I hope I've misread you and that you're not seriously suggesting that because you haven't seen a case of tetanus in 10 years we thus shouldn't vaccinate? To me that's proof of just the opposite.

Completely not my point. I think the vaccinations are fine in the pediatrician's office or at the PMD. But we tetanize for every little open wound, and I think it's probably one of those superstitions.

Among the adult population who received vaccinations appropriately as children, what is the incidence of Tetanus infection for a minor wound?

 

[WilcoWorld]

Completely not my point. I think the vaccinations are fine in the pediatrician's office or at the PMD. But we tetanize for every little open wound, and I think it's probably one of those superstitions.

Among the adult population who received vaccinations appropriately as children, what is the incidence of Tetanus infection for a minor wound?

Glad to know that was not your point. And I don't have an EBM answer to your question, but I'll go ahead an admit that with tetanus vaccinations at least half my motivation is to vaccinate against pertussis (I never order pure tetanus vaccine anymore).

 

[FLTDOC1]

I havent given Td for minor wounds for years. Why? If you administer tetanus toxiod to a person with even zero immunity - it will take 6-8 weeks to develop antibodies. This "immunization" will do nothing to prevent tetanus from the wound. They can follow up with their PCP for Td and all other routine immunizations

The ridiculous thing is that I have seen massively contaminated dirty wounds in agricultural trauma in questionable immunized patients. Everyone is concerned about the lifesaving Td - but no one brings up the idea of giving TIG.

Bottom line -giving Td is practicing "community preventive medicine" - - it makes much more sense to give flu shots or Hep B vaccines in the ED -

How many people die from complications of influenza or Hep B? ( quite a few - tens of thousands)

Administering Td at the time of injury does nothing/zero/zilch to decrease the incidence of tetanus possibly contracted from that wound

 

[WilcoWorld]

I havent given Td for minor wounds for years. Why? If you administer tetanus toxiod to a person with even zero immunity - it will take 6-8 weeks to develop antibodies. This "immunization" will do nothing to prevent tetanus from the wound. They can follow up with their PCP for Td and all other routine immunizations

The ridiculous thing is that I have seen massively contaminated dirty wounds in agricultural trauma in questionable immunized patients. Everyone is concerned about the lifesaving Td - but no one brings up the idea of giving TIG.

Bottom line -giving Td is practicing "community preventive medicine" - - it makes much more sense to give flu shots or Hep B vaccines in the ED -

How many people die from complications of influenza or Hep B? ( quite a few - tens of thousands)

More people in the US die every year from being crushed by soda machines than die of tetanus

Good points, but trauma is a recurrent illness, and we're it's population's PMDs.

 

[pickupthepace]

Well.... where I work, the "follow with PCP" is very rarely an option (I'd say 2 or 3 patients a shift have one). We are the PCP... we can refer them all to PCP, they may get an appointment in 3 months.... maybe. I'm giving the shot, period.

 

[pinipig523]

I havent given Td for minor wounds for years. Why? If you administer tetanus toxiod to a person with even zero immunity - it will take 6-8 weeks to develop antibodies. This "immunization" will do nothing to prevent tetanus from the wound. They can follow up with their PCP for Td and all other routine immunizations

Makes sense...

 

[deleted65604]

Could you give references for your 6-8 weeks for time to antibody production?

What do you think of the following studies?

http://www.ncbi.nlm.nih.gov/pubmed/21946190

http://www.ncbi.nlm.nih.gov/pubmed/21864613

Here is a textbook chapter:

http://www.who.int/immunization/documents/Elsevier_Vaccine_immunology.pdf

What do you think about the graph on page 7?

To me, this data says that the immune response is revving up in days and roaring one week after vaccination.

 

[SpunkyDucky]

Interesting conversation. I have never heard anyone recommend this so it may be a local variation theme (as much of abscess management is)

I do give Td for eye trauma, wounds etc, but not iatrogenic wounds. I bandage wounds and recommend keeping them covered for 6 hours. I have no reason to believe people are rolling in dirt after abscess drainage. I am a fan of some public health issues in the ED, but to advocate from this route would suggest that all patients without a recent vaccination and with no contraindication should receive it. (I am not actually even opposed to this, but if I was going to do it for this reason, I would apply it across the board).

Nice conversation

 

[FLTDOC1]

The incubation period of tetanus is 3 to 21 days with an average of 10 days. The infection would be very well established before any theoretical rise in ab levels. There is much debate if elevated Ab levels mean immunity. In addition Tetanus has been well described in a significant number of patients with "protective " antibody levels.

http://www.neurology.org/content/42/4/761

Administering Td has little, if any probability of preventing tetanus in a contaminated wound in the absence of immunity ( unless given with TIG). It will prevent tetanus if a patient has new tetanus prone wound several weeks later

In this public health mindset we should be giving flu shots to high risk , unimmunized pts in the ED regardless of complaints - we would save many more lives

 

[deleted65604]

The articles I showed you say different. Antibody levels are peaking at 10 days. That would tell me that there is protection. What, pray tell, would you look for a measure of immunity other than antibody levels? Please give me some evidence to back up your claim, rather than repeating yourself emphatically, as if that is evidence.

Saying there is zip, zilch evidence, is overstating the strength of your position. At least admit that.

 

[Apollyon]

I find such a dogmatic statement slightly disheartening, especially from someone 25+ years into their EM physicianhood. The lesser trained and experience might get the wrong idea.

I've ordered the TIG when it wasn't clear if someone had a complete series; in HI, we have a goodly number of Micronesians. At the same time, even if that wound right there isn't the one to give them tetanus, it is an opportunity to do a little preventive medicine that is not onerous for us, while we have the pt in the ED.

As far as tetanus, that is something that is prone to the "fallacy of the anecdote" - "I've never seen it, so I discount it". And, to be quite sanguine, if you use all the evidence in the world that the incubation period is 10 days, and Ab formation takes weeks, you don't reimmunize, and the patient gets tetanus, just pull out the checkbook, even if it isn't your fault. Since the vaccine has been watered down to minimize side effects, the only real detriment is the shot itself.