What is the appropriate evaluation and management of a scalp laceration in a 47-year-old male with no loss of consciousness or neurological deficits, presenting 2 hours post-injury, with his last Tetanus (tetanus toxoid) shot in 2015?

From the Guidelines

This patient requires a tetanus booster since his last tetanus vaccination was in 2015, which is more than 5 years ago for a wound that can be considered contaminated or not minor, given the mechanism of injury and potential exposure to dirt or other contaminants from the van door. The laceration should be thoroughly cleaned with sterile saline or antiseptic solution, and depending on its size and depth, may need sutures, staples, or adhesive strips for closure. Local anesthetic like lidocaine 1% may be administered before suturing if needed. According to the guidelines from 1, for wounds that are not clean and minor, a tetanus toxoid–containing vaccine booster is recommended if the patient has not received it within the preceding 5 years. The patient should be instructed to keep the wound clean and dry for 24-48 hours, then gently clean with mild soap and water daily. Signs of infection to watch for include increasing pain, redness, swelling, warmth, pus, or fever. While the patient denies significant neurological symptoms, he should return if he develops worsening headache, vomiting, confusion, or other concerning symptoms that might indicate a concussion or more serious head injury. The mild nausea he experienced initially is not uncommon after a head injury but doesn't necessarily indicate a serious condition given the absence of other neurological symptoms.

The decision to administer a tetanus booster is based on the primary vaccination history for tetanus, as outlined in 1, which provides the most recent and highest quality guidelines for tetanus prophylaxis in wound management. The guidelines from 1 are older and, while they provide useful background information, should not take precedence over the more recent recommendations from 1.

Key points to consider in the management of this patient's wound and tetanus prophylaxis include:

• Thorough cleaning and assessment of the wound
• Consideration of tetanus toxoid–containing vaccine booster based on the timing of the last vaccination and the nature of the wound
• Monitoring for signs of infection and neurological symptoms
• Patient education on wound care and when to seek further medical attention.

From the Research

Patient Evaluation

• The patient is a 47-year-old male who presents with a laceration to the top of his head, which occurred a couple of hours ago while working on his car.
• He reports mild nausea at the time of the incident but denies any loss of consciousness, headache, vision changes, dizziness, or unsteady gait.
• The patient's last tetanus shot was in 2015.

Head Injury Assessment

• According to 2, head injury is common and accounts for a significant proportion of patient attendances at emergency departments and minor injury units.
• The study emphasizes the importance of assessment, investigation, and early management of head injury to reduce the potential risk of disability or even death.

Wound Management

• The patient initially cleaned the laceration with water and applied pressure, which is a suitable initial management step.
• However, the patient may require further evaluation and management to prevent infection, as suggested by 3, which compared the clinical efficacy of two-day and five-day regimens of prophylactic antimicrobial agents in simple traumatic but highly contaminated wounds.

Antibiotic Prophylaxis

• The use of prophylactic antibiotics in traumatic wounds is discussed in 4, which analyzed the selection of antibiotics in head-injured patients.
• The study highlights the importance of preventing antibiotic resistance by selecting appropriate antibiotics and using them judiciously.
• Additionally, 5 reviews the literature on antibiotic prophylaxis in penetrating trauma and discusses the challenges of providing optimal care in prolonged casualty care settings.

Initial Diagnostic Strategy

• According to 6, the initial diagnostic strategy for severe head-injured patients includes maintaining mean arterial pressure, avoiding hypoxaemia, and maintaining arterial PCO2 near to 35 mmHg.
• The study also recommends the use of cerebral tomodensitometry (TDM) as an initial diagnostic procedure, but notes that TDM may be delayed in case of haemorrhage, which requires rapid treatment.