Should tetanus immunoglobulin (TIG) be administered to a patient with a punctured wound on the foot presenting 72 hours post-injury?

Tetanus Immunoglobulin Administration for 72-Hour-Old Puncture Wound

Direct Answer

Yes, you should administer tetanus immunoglobulin (TIG) if the patient has an unknown or incomplete vaccination history (<3 doses of tetanus toxoid), regardless of the 72-hour delay. The timing of presentation does not change the indication for TIG—the critical factors are the wound type (puncture wounds are tetanus-prone) and the patient's vaccination status 1, 2.

Decision Algorithm Based on Vaccination History

If Patient Has Unknown or Incomplete Vaccination (<3 doses):

• Administer BOTH tetanus toxoid-containing vaccine (Tdap preferred) AND TIG 250 units IM 3, 1
• Use separate syringes at different anatomical sites 3, 4
• The 72-hour delay does not eliminate the need for prophylaxis, as tetanus prevention focuses on preventing disease from the current wound 2

If Patient Has Complete Primary Series (≥3 doses):

• Give tetanus toxoid booster ONLY if last dose was >5 years ago (no TIG needed) 3, 1
• If last dose was <5 years ago, no intervention needed 2

If Patient Cannot Confirm Vaccination History:

• Treat as unvaccinated—give both TIG and tetanus toxoid 3
• Patients with unknown or uncertain histories should be considered to have had no previous tetanus toxoid 3, 2

Why the 72-Hour Delay Doesn't Matter

The timing of TIG administration is based on preventing tetanus from developing, not on the wound age 2. Puncture wounds are classified as tetanus-prone because they:

• Create anaerobic conditions favorable for Clostridium tetani growth 1
• Are often contaminated with dirt, soil, or other materials 1, 2
• Have potential for deep tissue involvement 1

A recent case report documented generalized tetanus developing in a patient who received appropriate wound care but failed to receive TIG when indicated, emphasizing that lapses in prophylaxis can lead to severe outcomes 5.

Critical Dosing and Administration Details

• Standard prophylactic dose: 250 units IM for both adults and children 3, 1, 4
• Administer in deltoid muscle or lateral thigh (avoid gluteal region due to sciatic nerve injury risk) 4
• If giving tetanus toxoid simultaneously, use different extremity and separate syringe 3, 4

Special Populations Requiring Extra Attention

• Immunocompromised patients (HIV, severe immunodeficiency): Give TIG regardless of vaccination history 1, 2
• Elderly patients (>60 years): Priority for TIG in resource-limited settings 3
• Pregnant women: Follow same guidelines as non-pregnant adults 1

Common Pitfalls to Avoid

• Assuming military service or age guarantees immunity—always verify vaccination records 2
• Delaying TIG because of time elapsed since injury—the focus is prevention, not wound age 2
• Failing to complete the 3-dose primary series—if starting vaccination, ensure follow-up at 4 weeks and 6-12 months 3, 6
• Giving TIG intravenously—this can cause precipitous blood pressure drop 4

Essential Wound Management

Proper wound cleaning and debridement remain paramount regardless of immunization decisions 2, 5. The use of TIG is adjunctive to surgical wound care, not a replacement 4.