54.11 Preventing surgical tetanus

The prevention of surgical tetanus depends on: (1) A thorough wound toilet (54.1). (2) The active immunization of everyone in childhood. Further methods at the time of the injury are: (3) Passive immunization to give immediate cover. (4) Active immunization with tetanus toxoid. (5) Antibiotics, usually penicillin, to limit the multiplication of Clostridium tetani. Vary your regime according to the patient’s immune state and the nature of his injury by following the methods below.

Toxoid is cheap, widely available, and seldom causes reactions. When they do occur, they are unlikely to be serious, so there is no need to test for sensitivity. The disadvantage of tetanus toxoid is that it does not provide immediate cover. If a non–immune patient has a high risk wound, you can either give him human tetanus immune globulin (HTIG) which is expensive and scarce, but has few side effects, or horse antitetanus serum, which is cheaper, and more widely available, but is more likely to cause serious hypersensitivity.

In practice, passive immunization is much less valuable than the other methods of prevention, and one experienced contributor advised us to leave it out entirely. In a busy hospital, where most patients do not know if they have been immunized or not, you will need a simple regime, so give 0.5 ml of tetanus toxoid to ALL patients with any wound, however small. If you wish, you can combine this with passive immunization of the most dangerous cases only.

The prevention of tetanus is one of the targets of WHO’s global EPI program. As more children are immunized and populations become increasingly immune, it should become rarer.

AZIZ (26 years) fell drunk from a second floor verandah and dug both his forearm bones into the earth. His wound was closed by primary suture without a wound toilet. 5 days later he developed tetanus and died. At post mortem a quantity of earth was found in his wounds. LESSON The critical step in preventing tetanus is a thorough wound toilet.