Tetanus Prophylaxis in Road Traffic Accidents
Direct Answer
In road traffic accidents, tetanus prophylaxis depends on two factors: the wound type and the patient's vaccination history—for tetanus-prone wounds (contaminated with dirt, soil, or involving tissue damage), give tetanus toxoid if the last dose was ≥5 years ago, and add tetanus immune globulin (TIG) if vaccination history is unknown or incomplete (<3 doses). 1
Wound Classification
First, classify the wound from the RTA:
- Clean, minor wounds: Small, superficial wounds with minimal tissue damage, <6 hours old 1, 2
- Tetanus-prone wounds (most RTA wounds fall here): Wounds contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; wounds from crushing, burns, or missiles 1, 3
Critical pitfall: Most RTA wounds are tetanus-prone due to road contamination with dirt and the mechanism of injury. 1
Vaccination History Assessment
Attempt to determine if the patient completed a 3-dose primary tetanus series. 1
Key considerations:
- Patients with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses 1, 4
- Military service since 1941 suggests at least one dose, but completion cannot be assumed 5, 6
- Persons who completed the primary series and received tetanus toxoid <5 years earlier are protected and require no additional prophylaxis for wound management 1
Treatment Algorithm
For Clean, Minor Wounds:
| Vaccination History | Tetanus Toxoid | TIG |
|---|---|---|
| Unknown or <3 doses | Yes | No |
| ≥3 doses | Only if ≥10 years since last dose | No |
For Tetanus-Prone Wounds (Most RTAs):
| Vaccination History | Tetanus Toxoid | TIG (250 units IM) |
|---|---|---|
| Unknown or <3 doses | Yes | Yes |
| ≥3 doses | Only if ≥5 years since last dose | No |
Administration details:
- TIG dose: 250 units intramuscularly for adults and children 3, 6
- When giving both TIG and tetanus toxoid, use separate syringes at different anatomical sites 1, 3, 6
- For adults ≥7 years: Use Td (or Tdap if not previously received) 1, 4
- For children <7 years: Use DTaP 1, 6
Special Populations
Immunocompromised patients (including HIV): Give TIG for contaminated wounds regardless of vaccination history 1, 3, 5
Elderly patients (>60 years): Prioritize for TIG if supplies are limited, as only 21% of women and 45% of men >70 years have protective antibody levels 1, 4
Pregnant women: Follow the same guidelines as non-pregnant adults 3
Critical Contraindication
Patients with a history of Arthus reaction following previous tetanus toxoid should not receive tetanus toxoid until >10 years after the most recent dose, regardless of wound severity. 1, 3 In these cases, base TIG administration solely on the primary vaccination history. 1
Essential Wound Management
Thorough wound cleaning and surgical debridement of necrotic tissue are paramount, as tetanus prophylaxis is adjunctive to proper wound care. 4, 2 Remove all debris that might harbor Clostridium tetani spores. 4
Follow-Up Requirements
Critical: Patients receiving their first tetanus toxoid dose must complete the primary series with additional doses at 1 month and 1 year—without this, active immunization is incomplete. 1, 6 Emphasize the need for routine boosters every 10 years thereafter. 1, 4
Avoid this pitfall: In one study, only 38% of patients who received initial toxoid in the emergency department completed the full course. 7