A 35-year-old man comes to the emergency department after stepping on a nail that punctured his right sole while jogging at a park. He brought the nail, which is about 4 cm long and rusty, with him. The patient's medical history is unremarkable and he takes no medications. He received a 3-dose primary tetanus vaccination series in childhood but has not received any booster doses since then. Vital signs are within normal limits. Physical examination shows a puncture wound at the middle of the right plantar area with some dry blood and tenderness. There is no surrounding erythema. Radiographs of the right foot reveal no bony injury or foreign body. The wound is cleaned with iodine solution. Which of the following additional interventions for tetanus prevention is most appropriate in this patient?

Question

A 35-year-old man comes to the emergency department after stepping on a nail that punctured his right sole while jogging at a park.  He brought the nail, which is about 4 cm long and rusty, with him.  The patient's medical history is unremarkable and he takes no medications.  He received a 3-dose primary tetanus vaccination series in childhood but has not received any booster doses since then.  Vital signs are within normal limits.  Physical examination shows a puncture wound at the middle of the right plantar area with some dry blood and tenderness.  There is no surrounding erythema.  Radiographs of the right foot reveal no bony injury or foreign body.  The wound is cleaned with iodine solution.  Which of the following additional interventions for tetanus prevention is most appropriate in this patient?

Quizplus · Accepted Answer

11ec25c8_d46f_66b2_bc81_a1dd2b7e1213_MD0003_00 Clostridium tetani is an anaerobic, spore-forming, gram-positive bacillus that is found in soil. Following traumatic tissue inoculation, it can release a neurotoxin (tetanus toxin), leading to symptomatic tetanus. Typical symptoms include tonic contraction and spasm of skeletal muscle (eg, neck stiffness, masseter spasm), which can last up to 4-6 weeks. The risk for tetanus is greatest in wounds that are deep (eg, puncture wounds) or contain devitalized tissue (eg, burns, crush injuries). Tetanus is a vaccine-preventable illness, and symptomatic cases are uncommon in developed countries. Current recommendations are for children to receive a primary 3-dose vaccine series at ages 2, 4, and 6 months, with additional doses recommended at 15-18 months and 4-6 years. Adults should receive a single dose of tetanus-diphtheria-acellular pertussis (Tdap), followed by revaccination (booster) for tetanus and diphtheria (Td) every 10 years thereafter. Patients (such as this one) with significant or dirty puncture wounds who have received >3 tetanus toxoid doses but have not received revaccination for tetanus within 5 years should be vaccinated. This patient has not received Tdap in adulthood and should therefore receive a single dose of Tdap at this time (Choices B and E). > (Choices A and D) Tetanus immune globulin (TIG), which provides immediate passive (but temporary) immunity, is used to treat symptomatic tetanus. It is also recommended (in addition to tetanus vaccination) for prophylaxis following severe or contaminated wounds in patients who have not received at least 3 doses of tetanus vaccine or whose vaccine status is uncertain. TIG is never administered without tetanus vaccination. Educational objective: Patients with significant puncture wounds who have not received revaccination for tetanus within 5 years should be vaccinated. In addition, tetanus immune globulin should be given to patients with significant or dirty wounds who have not previously received at least 3 doses of tetanus vaccine or whose vaccine status is uncertain. References: Are current UK tetanus prophylaxis procedures for wound management optimal? (http://www.ncbi.nlm.nih.gov/pubmed/19934122)

A 35-Year-Old Man Comes to the Emergency Department After Stepping