When is tetanus immunoglobulin (TIG) recommended for individuals with wounds?

Tetanus Immunoglobulin (TIG) Administration Guidelines for Wound Management

Tetanus immunoglobulin (TIG) is indicated for individuals with tetanus-prone wounds who have unknown or incomplete tetanus vaccination history (fewer than 3 doses), regardless of the time since their last tetanus vaccination. 1, 2

Wound Classification and TIG Indications

Tetanus-Prone Wounds

• TIG (250 units intramuscularly) should be administered for tetanus-prone wounds in patients with unknown or incomplete (<3 doses) tetanus vaccination history 3, 1
• Tetanus-prone wounds include those contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite 3, 2
• Persons with HIV infection or severe immunodeficiency who have contaminated wounds should receive TIG regardless of their tetanus immunization history 3, 1

Clean, Minor Wounds

• TIG is NOT indicated for clean, minor wounds, regardless of vaccination history 3, 2
• For clean, minor wounds, only tetanus toxoid-containing vaccine is needed if vaccination history is unknown or incomplete 3

Vaccination Status Assessment

Unknown or Incomplete Vaccination History

• Patients with unknown or uncertain previous tetanus vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine 3, 2
• Military service since 1941 suggests at least one dose of tetanus toxoid, but complete primary series cannot be assumed 2
• For patients with unknown/incomplete history (<3 doses):
  • Clean, minor wounds: Tetanus toxoid-containing vaccine only (no TIG) 3, 2
  • Tetanus-prone wounds: Both tetanus toxoid-containing vaccine AND TIG 3, 2

Complete Vaccination History

• Patients who have completed a 3-dose primary series:
  • Clean, minor wounds: No tetanus toxoid-containing vaccine needed unless >10 years since last dose 3, 2
  • Tetanus-prone wounds: No TIG needed; tetanus toxoid-containing vaccine only if >5 years since last dose 3, 2

Administration Guidelines

• Standard prophylactic dose of TIG is 250 units administered intramuscularly for both adults and children 1, 2
• For small children, dosing may be calculated by body weight (4.0 units/kg), though administering the full 250 units is often advised regardless of size 2
• When TIG and tetanus toxoid-containing vaccines are administered concurrently, they must be given at separate anatomical sites using separate syringes 3, 1

Special Considerations

• Pregnant women follow the same TIG guidelines as non-pregnant adults 1
• Persons with a history of Arthus-type hypersensitivity reactions to tetanus toxoid should not receive tetanus toxoid-containing vaccines more frequently than every 10 years, regardless of wound condition 3, 1
• In mass-casualty settings with limited TIG supply, priority should be given to persons aged >60 years and immigrants from regions other than North America or Europe 1

Treatment of Active Tetanus

• For active tetanus cases, TIG is indicated as part of standard therapy, though evidence of effectiveness is limited 2
• Dosage for active tetanus should be adjusted according to the severity of the infection 2

Common Pitfalls to Avoid

• Failing to properly assess vaccination history - make a thorough attempt to determine whether a patient has completed primary vaccination 3, 2
• Overlooking the need for TIG in immunocompromised patients with contaminated wounds, regardless of vaccination history 3, 1
• Administering TIG and tetanus toxoid at the same anatomical site 3, 1
• Neglecting to complete the full vaccination series after initial wound management 2