What tetanus toxoid-containing vaccine (Td or Tdap) should be administered to a patient with a hand laceration, considering their tetanus vaccination history and overall health status?

Tetanus Prophylaxis for Hand Laceration

For a hand laceration, administer Tdap (not Td) if the patient has ≥3 previous tetanus doses and the last dose was ≥5 years ago; no tetanus immune globulin (TIG) is needed unless the patient has <3 documented doses or unknown vaccination history, in which case give both Tdap AND TIG 250 units IM at separate sites. 1, 2

Wound Classification

Hand lacerations are classified as contaminated, tetanus-prone wounds because they may be contaminated with dirt, soil, saliva, or other debris, which determines the critical 5-year interval (not 10-year) for booster administration rather than the standard clean wound interval. 2

Vaccination Algorithm Based on History

Patients with ≥3 Previous Doses

• If last dose was <5 years ago: No tetanus vaccine or TIG needed—the patient is already protected. 2, 3, 4

• If last dose was ≥5 years ago: Administer tetanus toxoid-containing vaccine WITHOUT TIG. 1, 2, 3

  • Tdap is strongly preferred over Td for adults ≥11 years who have not previously received Tdap or whose Tdap history is unknown, as this provides additional protection against pertussis. 1, 2, 5
  • For non-pregnant persons with documented previous Tdap vaccination, either Td or Tdap may be used. 2, 5

Patients with <3 Previous Doses or Unknown History

• Administer BOTH tetanus toxoid-containing vaccine (Tdap preferred) AND TIG 250 units IM at separate anatomical sites using separate syringes. 1, 2, 5, 3, 4

• Patients with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses. 1, 5, 4

• These patients must subsequently complete a 3-dose primary vaccination series for long-term protection. 2, 5

Special Populations

Pregnant Women

• If tetanus toxoid-containing vaccine is indicated, Tdap should be used regardless of prior Tdap history. 2, 5

Immunocompromised Patients

• Persons with HIV infection or severe immunodeficiency should receive TIG regardless of their tetanus immunization history when they have contaminated wounds. 2, 5

History of Arthus Reaction

• Patients with a history of Arthus reaction should not receive tetanus toxoid-containing vaccine until >10 years after the most recent dose, even with contaminated wounds; TIG decision is still based on primary vaccination history. 1, 2

Critical Clinical Pearls

• Do not confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds—this is the most common error in tetanus prophylaxis. 2

• More frequent doses than recommended may be associated with increased incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions. 2

• When administering both TIG and tetanus toxoid concurrently, use separate syringes at different anatomical sites to prevent interference with immune response. 1, 2, 5, 3, 4

• Proper wound cleaning and debridement are crucial components of tetanus prevention in addition to vaccination. 2, 5

• Tdap should be administered regardless of the interval since the last tetanus or diphtheria toxoid-containing vaccine when indicated. 2