A 35-year-old man is brought to the emergency department after cutting his finger with a rusty knife while doing yard work. It is a deep cut, and his wife had immediately applied a pressure dressing to stop the bleeding. His immunization status is unknown. The patient last saw his doctor about 10 years ago, and cannot recall if he received all of his childhood vaccinations. He has a deep laceration on the palmar aspect of his right middle finger. Cleaning of the wound and other wound-care measures are initiated. Which of the following is the best next step in management of this patient?

Question

A 35-year-old man is brought to the emergency department after cutting his finger with a rusty knife while doing yard work.  It is a deep cut, and his wife had immediately applied a pressure dressing to stop the bleeding.  His immunization status is unknown.  The patient last saw his doctor about 10 years ago, and cannot recall if he received all of his childhood vaccinations.  He has a deep laceration on the palmar aspect of his right middle finger.  Cleaning of the wound and other wound-care measures are initiated.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bde1_b9d9_8f63_49bb96d717b0_MD0005_00 Tetanus immune globulin (TIG) provides passive and immediate but temporary immunity. Tetanus toxoid-containing vaccines provide active and prolonged but delayed immunity. These vaccines are recommended once every 10 years and can be given as tetanus/diphtheria toxoids adsorbed (Td), tetanus toxoid/reduced diphtheria toxoid/acellular pertussis (Tdap), tetanus toxoid (TT), or diphtheria/tetanus toxoids adsorbed (DT). Patients with a clean or minor wound who have had >3 tetanus vaccinations and a booster within the past 10 years do not require an additional vaccine booster. A tetanus toxoid-containing vaccine is recommended for patients who received their last tetanus vaccine >10 years ago or who have an unimmunized, uncertain, or incomplete vaccination status (<3 doses). Incomplete vaccination status is more commonly encountered in intravenous drug users, immigrants, individuals from rural areas, and the elderly. Patients with dirty (eg, dirt, feces, saliva) or severe (eg, punctures, avulsions, crush injuries, burns, frostbite) wounds have a higher risk for Clostridium tetani due to a favorable anaerobic growth environment. These patients require a tetanus booster alone (no TIG) if their vaccination history is up to date but their last vaccination was >5 years ago. Patients with dirty or severe wounds who are significantly immunocompromised (eg, HIV), or have an unimmunized, uncertain, or incomplete tetanus vaccination status should receive TIG and tetanus vaccine booster. This is because the early doses of tetanus toxoid only prime the immune system but do not confer immunity. TIG provides immediate, temporary immunity in these patients. (Choices A, C, and D) This patient has a severe wound in his hand due to a rusty knife. He is at increased risk for developing tetanus and needs tetanus prophylaxis. His immunization status is unknown, and so he should be given both TIG and tetanus toxoid-containing vaccines. Educational objective: Tetanus/diphtheria toxoid vaccines should be given to patients with severe or dirty wounds who received their most recent tetanus vaccine >5 years ago and to those with minor, clean wounds who received a booster >10 years ago. In addition, tetanus immune globulin should be given to any individual with a severe or dirty wound who has an unimmunized, unclear, or incomplete immunization history. References: Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. (http://www.ncbi.nlm.nih.gov/pubmed/21228763)

A 35-Year-Old Man Is Brought to the Emergency Department After