What is the recommended treatment for a patient with a puncture wound from a nail, who reports their last tetanus (Td) shot was 5 years ago and is currently experiencing discomfort?

From the Guidelines

For a patient with a puncture wound from a nail who had their last tetanus shot 5 years ago and is experiencing discomfort, a booster dose of tetanus toxoid is recommended if the wound is considered dirty or contaminated, as the patient's last dose was more than 5 years ago. The wound should be thoroughly cleaned with soap and water, and an antiseptic like povidone-iodine should be applied 1. The patient should monitor for signs of infection such as increasing pain, redness, swelling, warmth, or discharge from the wound site. For the discomfort, over-the-counter pain relievers like acetaminophen (325-650 mg every 4-6 hours, not exceeding 3000 mg daily) or ibuprofen (400-600 mg every 6-8 hours with food) can be used. Some key points to consider in the management of this patient include:

• The type of wound: puncture wounds from nails are considered contaminated and at higher risk for tetanus infection
• The timing of the last tetanus shot: 5 years ago, which is less than the 10-year booster interval but may be indicated for a contaminated wound
• The patient's symptoms: currently experiencing discomfort but no pain, which may indicate a lower risk of infection but still requires monitoring
• The need for antibiotic prophylaxis: may be necessary if the wound is deep or particularly dirty, or if the patient develops signs of infection. According to the most recent guidelines, for all other wounds, a booster is appropriate if the patient has not received tetanus toxoid during the preceding 5 years 1. However, the most recent and highest quality study 1 supports the use of either Td or Tdap where previously only Td was recommended, increasing provider point-of-care flexibility.

From the FDA Drug Label

Guide to Tetanus Prophylaxis in Wound Management(3 ) History of Tetanus Immunization (Doses)Clean, Minor WoundsAll Other Wounds* Td†TIG‡TdTIG Uncertain or less than 3YesNoYesYes 3 or more§No¶NoNo#No

The patient reports their last tetanus shot was 5 years ago and has a puncture wound from a nail. According to the guide, for puncture wounds (classified as All Other Wounds), if it has been more than 5 years since the last dose of tetanus toxoid, a booster dose of Td is recommended.

• The patient's wound is a puncture wound, which is considered an All Other Wound.
• The patient's last tetanus shot was 5 years ago, which means it has been more than 5 years since their last dose.
• Therefore, the recommended treatment for this patient is a booster dose of Td 2.

From the Research

Puncture Wound Treatment and Tetanus Prophylaxis

• The patient's puncture wound from a nail and reported last tetanus shot 5 years ago necessitate consideration of tetanus prophylaxis 3, 4.
• According to the studies, tetanus is a preventable disease with proper immunization, and emergency physicians play a crucial role in providing tetanus vaccination 4.
• The patient's wound, although not severe, still poses a risk of tetanus infection, especially since the nail did not go all the way through and the patient pulled his foot off the nail, potentially pushing bacteria deeper into the wound.

Tetanus Prophylaxis Recommendations

• The Advisory Committee on Immunization Practices (ACIP) recommends that adults receive a tetanus toxoid booster every 10 years 5, 6.
• However, if the patient has a high-risk wound, such as a puncture wound, and it has been more than 5 years since their last tetanus shot, prophylaxis with tetanus toxoid (TTV) should be considered 3.
• The study by 6 recommends tetanus toxoid in adults only if it has been more than 10 years since their last immunization, but this may not apply in cases of high-risk wounds.

Treatment Considerations

• The patient's current discomfort and lack of pain do not rule out the possibility of tetanus infection, as the disease can present with different clinical forms and severity 3, 7.
• Vital treatment measures, including wound debridement and antibiotic therapy, can be completed in the emergency department 4.
• Tetanus immunoglobulin (TIG) may be reserved for patients with wounds who had never received primary immunization against tetanus or have a high-risk wound and uncertain immunization status 6.