## Tetanus Prophylaxis in Contaminated Wounds ### Wound Classification & Risk This is a **contaminated, high-risk wound** (soil exposure, >6 hours old, visible organic matter). The patient has **no prior tetanus immunity** (unimmunized status). ### Tetanus Prophylaxis Algorithm ```mermaid flowchart TD A[Contaminated Wound] --> B{Prior Tetanus Doses?} B -->|None or Unknown| C[Unimmunized] B -->|1-2 Doses| D[Partially Immunized] B -->|≥3 Doses| E[Fully Immunized] C --> F[Toxoid + TIG] D --> G[Toxoid + TIG] E --> H{Last Dose >10 yrs?} H -->|Yes| I[Toxoid only] H -->|No| J[No prophylaxis] ``` ### Rationale for Toxoid + TIG **Key Point:** In unimmunized patients with high-risk wounds, both active and passive immunization are required: - **Tetanus toxoid** = active immunity (takes 1–2 weeks to develop) - **Tetanus immunoglobulin (TIG)** = passive immunity (immediate protection) TIG provides immediate protection while the immune system mounts a response to the toxoid. ### Comparison of Prophylaxis Regimens | Scenario | Regimen | Rationale | |----------|---------|----------| | Unimmunized + High-risk wound | Toxoid + TIG | Both active and passive immunity needed | | Partially immunized (1–2 doses) + High-risk | Toxoid + TIG | Booster + passive coverage | | Fully immunized (≥3 doses) + >10 yrs since last | Toxoid only | Booster sufficient | | Fully immunized + <10 yrs since last | None | No prophylaxis needed | ### High-Yield Facts **High-Yield:** TIG dose is **250–500 IU IM** (or 3000–6000 IU IV if available). Toxoid is given as a separate injection at a different anatomic site. **Clinical Pearl:** Never give toxoid and TIG in the same syringe or at the same site — TIG antibodies will neutralize the toxoid antigen. **Mnemonic:** **HIT** — **H**igh-risk wound + **I**mmunized status unknown = **T**oxoid + TIG.
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