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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 (antitoxin) provides passive immunity by neutralizing circulating tetanospasmin and unbound toxin in a wound. It does not have an effect on toxin that already is bound to neural tissue, and tetanus antibody does not penetrate the blood-brain barrier.

  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 (passive immunization) is indicated for persons with tetanus. Antitoxin also is 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 shocklike state within 48 hours of a previous dose, or seizures within 3 days of a previous dose.

    2. Antitoxin. The equine tetanus antitoxin is contraindicated in persons who have had previous hypersensitivity or serum sickness reactions to other equine-derived products. Preferably, use the human tetanus immune globulin product in all cases if it is available.

  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 very high serum levels of tetanus antitoxin.

    3. Severe systemic reactions such as generalized urticaria, anaphylaxis, and neurologic complications have been reported. A few cases of peripheral neuropathy and Guillain-Barré syndrome have also been ...

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