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  1. Pharmacology. Tetanus is caused by tetanospasmin, a protein toxin produced by Clostridium tetani (see Tetanus).

    1. Tetanus toxoid uses modified tetanospasmin, which has been made nontoxic but still retains the ability to stimulate the formation of antitoxin. Tetanus toxoid provides active immunization to those with known, complete tetanus immunization histories as well as those with unknown or incomplete histories.

    2. Human tetanus immune globulin (TIG) is an antitoxin that provides passive immunity by neutralizing circulating tetanospasmin and unbound toxin in a wound. It does not have an effect on toxin that has already bound to neural tissue. Tetanus antibody does not penetrate the blood-brain barrier. Note: Some international products may be equine based.

  2. Indications. All wound injuries require consideration of tetanus prevention and treatment. This includes animal and insect bites and stings, injections from contaminated hypodermic needles, deep puncture wounds (including high-pressure, injection-type chemical exposures such as those from paint guns), burns, and crush wounds.

    1. Tetanus toxoid prophylaxis (active immunization) is given as a primary series of three doses in childhood. The first and second doses are given 4–8 weeks apart, and the third dose is given 6–12 months after the second. A booster dose is required every 10 years.

      1. Unknown or incomplete history of a previous primary series of three doses: tetanus toxoid is indicated for all wounds, including clean, minor wounds.

      2. Known complete histories of a primary series of three doses: tetanus toxoid is indicated for clean, minor wounds if it has been longer than 10 years since the last dose and for all other wounds if it has been longer than 5 years since the last dose.

    2. Tetanus Immune Globulin (TIG) (passive immunization) is an antitoxin indicated for persons with tetanus. TIG is also indicated as prophylaxis for wounds that are neither clean nor minor in persons who have unknown or incomplete histories of the primary three-dose series of tetanus toxoid.

  3. Contraindications

    1. Toxoid

      1. History of a severe allergic reaction (acute respiratory distress and collapse) after a previous dose of tetanus toxoid.

      2. History of encephalopathy within 72 hours of a previous dose of tetanus toxoid.

      3. Precautions should be taken in individuals with histories of fever higher than 40.5°C (104.9°F) within 48 hours of a previous dose, collapse or a shock-like state within 48 hours of a previous dose, or seizures within 72 hours of a previous dose.

    2. Antitoxin. The human tetanus immune globulin product is the only one available in the United Sates and no contraindications are listed by the manufacturer. Equine tetanus antitoxin (potentially available internationally) is contraindicated in persons who have had previous hypersensitivity or serum sickness reactions to other equine-derived products.

  4. Adverse effects of the toxoid

    1. Local effects, including pain, erythema, and induration at the injection site. These effects are usually self-limiting and do not require therapy.

    2. Exaggerated local (Arthus-like) reactions. These unusual reactions may present as extensive painful swelling from the shoulder to the elbow. They generally occur in individuals with preexisting high serum levels of ...

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