A 7-year-old boy is brought to the emergency department by paramedics after being attacked by a dog. Approximately an hour ago, the boy was playing in a park near his house when he tried to separate 2 stray dogs that were fighting. The dogs assaulted the patient, dragged him to the ground, and bit him multiple times on the upper extremities and face. His parents were able to drive the dogs away. The boy is otherwise healthy and up to date on immunizations. Temperature is 37.1 C (98.8 F) and pulse is 138/min. The child is inconsolable; intravenous morphine and midazolam are administered to allow examination of his wounds. Multiple, deep bite wounds are found on the dorsal forearms bilaterally. There is also a 6-cm, macerated wound overlying the left mandible extending to the left ear. The upper extremity wounds are actively bleeding and contain specks of dirt and grass. Pressure is applied, and hemostasis of all wounds is achieved. The wounds are copiously irrigated and cleaned, and rabies prophylaxis is initiated. The mother asks about tetanus and says, "Please do everything you can for him! My husband was bitten by a dog last year and received several shots for tetanus." Which of the following is the most appropriate response?

Question

A 7-year-old boy is brought to the emergency department by paramedics after being attacked by a dog.  Approximately an hour ago, the boy was playing in a park near his house when he tried to separate 2 stray dogs that were fighting.  The dogs assaulted the patient, dragged him to the ground, and bit him multiple times on the upper extremities and face.  His parents were able to drive the dogs away.  The boy is otherwise healthy and up to date on immunizations.  Temperature is 37.1 C (98.8 F) and pulse is 138/min.  The child is inconsolable; intravenous morphine and midazolam are administered to allow examination of his wounds.  Multiple, deep bite wounds are found on the dorsal forearms bilaterally.  There is also a 6-cm, macerated wound overlying the left mandible extending to the left ear.  The upper extremity wounds are actively bleeding and contain specks of dirt and grass.  Pressure is applied, and hemostasis of all wounds is achieved.  The wounds are copiously irrigated and cleaned, and rabies prophylaxis is initiated.  The mother asks about tetanus and says, "Please do everything you can for him!  My husband was bitten by a dog last year and received several shots for tetanus."  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfce_e361_8f63_0f84f854d8b4_MD0005_00 Following a mammalian bite, the decision to administer tetanus prophylaxis (ie, tetanus toxoid-containing vaccine ± tetanus immune globulin) is based on the severity of the wound and the immunization status of the patient. For patients who have received ≥3 tetanus toxoid doses, a booster dose of tetanus toxoid is indicated only if their last tetanus dose was ≥10 years ago (for clean or minor wounds) or ≥5 years ago (for dirty or severe wounds). Patients who have received <3 tetanus toxoid doses (ie, incompletely immunized) or whose vaccine status is uncertain should receive a tetanus toxoid booster. If such patients have dirty or severe wounds, they should also receive tetanus immune globulin. This child has severe wounds with evidence of contamination (eg, bite wound, specks of dirt, plant matter). However, the child is up to date on immunizations, which means he has received at least 4 tetanus toxoid-containing vaccines (ie, diphtheria, tetanus toxoid, and acellular pertussis [DTaP] at age 2, 4, and 6 months and an additional DTaP at 4 years). His last dose was <5 years ago. Therefore, there is no need for either a tetanus toxoid booster or tetanus immune globulin (Choices C and D). (Choice B) Prompt cleansing of bite wounds is critical in infection prevention but does not preclude the need for tetanus prophylaxis for at-risk patients. This patient does not require a tetanus toxoid booster only because he is completely immunized and his last dose was <5 years ago. (Choice E) The availability of the animals can impact the decision to administer rabies post-exposure prophylaxis but does not factor into the decision to give tetanus prophylaxis. Tetanus prophylaxis decisions are based on the severity of the wound and immunization status. Educational objective: Fully immunized patients with dirty (eg, mammalian bite) or severe wounds should receive a tetanus toxoid booster only if their last dose was ≥5 years ago. Unimmunized or incompletely immunized patients with such wounds should receive both tetanus toxoid booster and tetanus immune globulin. References: Dog and cat bite-associated infections in children. (http://www.ncbi.nlm.nih.gov/pubmed/23404346)

A 7-Year-Old Boy Is Brought to the Emergency Department by Paramedics