What are the steps for a tetanus (Tetanus) workup?

Tetanus Workup

The tetanus workup is primarily clinical and does not require laboratory testing or cultures; it centers on obtaining a detailed vaccination history, assessing wound characteristics, and determining the need for tetanus toxoid-containing vaccine and/or Tetanus Immune Globulin (TIG) based on a standardized algorithm. 1

Step 1: Obtain Detailed Vaccination History

• Determine the total number of lifetime tetanus toxoid doses received (not just the interval since the last dose), as this is the most critical factor in deciding prophylaxis. 1
• Patients with unknown or uncertain vaccination histories should be considered to have received zero previous doses. 1
• Verify whether the patient has ever received Tdap (tetanus, diphtheria, acellular pertussis vaccine), as this influences vaccine selection. 2
• For patients who served in the military, assume they received a primary series, though policies varied by branch and era. 1
• Common pitfall: Asking only "when was your last tetanus shot?" is insufficient—you must establish whether a complete primary series (3 doses) was ever completed. 1

Step 2: Classify the Wound

Clean, Minor Wounds

• Superficial wounds with minimal tissue damage and no contamination. 1
• These wounds require a booster only if ≥10 years have elapsed since the last dose. 1

Contaminated/Tetanus-Prone Wounds

• Puncture wounds, wounds contaminated with dirt/soil/feces/saliva, wounds with devitalized tissue, wounds from crush injuries, burns, or frostbite. 1, 2
• These wounds require a booster if ≥5 years have elapsed since the last dose. 1, 2
• This 5-year interval (not 10 years) is the most commonly missed detail in tetanus prophylaxis. 2

Step 3: Apply the Vaccination Algorithm

For Patients with ≥3 Previous Doses (Complete Primary Series)

Clean, Minor Wounds:

• If last dose was <10 years ago: No vaccine or TIG needed. 2
• If last dose was ≥10 years ago: Give tetanus toxoid-containing vaccine (Tdap preferred if never received Tdap or Tdap history unknown; otherwise Td). No TIG needed. 2

Contaminated/Tetanus-Prone Wounds:

• If last dose was <5 years ago: No vaccine or TIG needed. 2
• If last dose was ≥5 years ago: Give tetanus toxoid-containing vaccine (Tdap preferred if never received Tdap or Tdap history unknown; otherwise Td). No TIG needed. 2

For Patients with <3 Previous Doses or Unknown History

All Wound Types:

• Give BOTH tetanus toxoid-containing vaccine (Tdap preferred) AND TIG 250 units IM at separate anatomic sites using separate syringes. 2, 3
• Complete the primary vaccination series: second dose at ≥4 weeks, third dose at 6-12 months after the second dose. 2, 3

Step 4: Special Population Considerations

Pregnant Women

• If tetanus toxoid-containing vaccine is indicated for wound management, use Tdap regardless of prior Tdap history. 2

Immunocompromised Patients

• Patients with HIV infection or severe immunodeficiency should receive TIG regardless of tetanus immunization history when they have contaminated wounds. 2, 3

Elderly Patients (≥60 years)

• At least 40% of persons aged >60 years lack protective antibody levels, making careful assessment critical. 1
• In mass-casualty settings with limited TIG supply, prioritize elderly patients and immigrants from regions outside North America/Europe. 3

Patients with History of Arthus Reaction

• Do not give tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of wound severity. 2

Step 5: Wound Management

• Perform thorough wound cleaning and surgical debridement of necrotic tissue to remove C. tetani spores and prevent anaerobic conditions. 1, 3
• Antibiotic prophylaxis is NOT indicated for tetanus prevention. 2

Step 6: Documentation and Follow-Up

• Document the vaccine type, manufacturer, anatomic site, route, date of administration, and administering facility name to minimize unnecessary future vaccinations. 2
• Ensure patients with incomplete primary series complete all remaining doses. 3
• Educate patients about the importance of routine boosters every 10 years. 3

Critical Clinical Pearls

• Tetanus diagnosis is entirely clinical—cultures for C. tetani are of limited value and should not delay treatment. 4
• The case-fatality ratio for tetanus remains 18-21% even with modern medical care. 1, 5
• Complete primary vaccination with tetanus toxoid is nearly 100% effective in preventing tetanus and provides long-lasting protection for at least 10 years. 1, 2
• More frequent doses than recommended may increase the incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions. 2
• If the vaccination schedule is delayed, continue from where the patient left off—do not restart the series. 2