Tetanus Prophylaxis for Head Laceration
For a patient with a head laceration, you should administer Tdap (tetanus, diphtheria, and acellular pertussis) vaccine if the patient has not received a tetanus toxoid-containing vaccine within the past 5 years or has unknown vaccination status. 1
Assessment of Wound and Vaccination Status
- Head lacerations are classified as "non-clean wounds" that may be contaminated with dirt, saliva, or other materials, requiring appropriate tetanus prophylaxis 2
- Determine if the patient has completed the 3-dose primary tetanus vaccination series; patients with unknown or uncertain previous tetanus vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine 1
- For patients with complete primary vaccination series (≥3 doses), if last tetanus toxoid-containing vaccine was <5 years ago: No tetanus toxoid or TIG needed 3
- For patients with complete primary series but >5 years since last tetanus vaccination: Administer tetanus toxoid-containing vaccine (Tdap preferred if not previously received) 1
Vaccine Selection Algorithm
- For persons aged ≥11 years who have not previously received Tdap or have unknown Tdap history, Tdap is preferred over Td 1
- For persons with documented previous Tdap vaccination who need a tetanus toxoid-containing vaccine, Td should be used 1
- If Td is unavailable, Tdap may be administered regardless of prior Tdap history 3
Tetanus Immune Globulin (TIG) Administration
- For patients with unknown or incomplete vaccination history (<3 doses), administer both tetanus toxoid-containing vaccine AND tetanus immune globulin (TIG) 1
- When both TIG and tetanus toxoid-containing vaccine are indicated, administer using separate syringes at different anatomical sites 2
- Persons with HIV infection or severe immunodeficiency who have contaminated wounds should receive TIG regardless of their tetanus immunization history 1
Special Considerations
- Pregnant women requiring tetanus prophylaxis should receive Tdap regardless of prior Tdap history 4
- Adults with a history of Arthus reaction following a previous dose of a tetanus toxoid-containing vaccine should not receive a tetanus toxoid-containing vaccine until >10 years after the most recent dose, even if they have a wound that is neither clean nor minor 1
Completion of Vaccination Series
- For patients who have never been vaccinated against tetanus, diphtheria, or pertussis, initiate the 3-dose primary series with Tdap as the first dose, followed by Td at >4 weeks and 6-12 months later 1
- Adults who received other incomplete vaccination series against tetanus and diphtheria should be vaccinated with Tdap and/or Td to complete a 3-dose primary series 1
Common Pitfalls to Avoid
- Failing to obtain an accurate immunization history - patients with unknown histories should be considered to have had no previous tetanus toxoid doses 3
- Using Td when Tdap is indicated - many trauma centers do not adhere to current CDC guidelines for tetanus/pertussis vaccination, particularly level 1 trauma centers 5
- Overlooking the opportunity to provide protection against pertussis - with increasing pertussis cases nationwide, using Tdap instead of Td when indicated can help reduce pertussis morbidity 6