Death from tetanus after a pretibial laceration

It is important to follow the guidelines for treating wounds prone to tetanus

Clinicians should be familiar with Department of Health guidelines for immunoprophylaxis when wounds through which tetanus can be acquired occur.¹ I report on a patient in whom tetanus immunoprophylaxis did not follow the guidelines.

Case report

A 76 year old woman fell in her garden and sustained a pretibial laceration. Her wound was cleaned and approximated with Steri-strips (3M; Loughborough) at an emergency department. Her status for tetanus immunisation at the time was recorded as “?no previous tetanus injection,” and a course of antitetanus treatment was started. However, no immunoglobulin was given.

She returned one week later with a necrotic and malodorous wound. She was unwell and complained of diffuse pains. She was admitted for debridement and split skin grafting.

Her condition worsened. Twenty four hours later she developed the signs and symptoms of tetanus, with increasing jaw stiffness, opisthotonos, and generalised limb spasticity. Cultures from the wound produced a heavy growth of Clostridium tetanii. She was transferred to intensive care but died 22 days later.

Discussion

Between 1984 and 1995, 145 cases of tetanus occurred in England and Wales, 75% in people over 45.¹ Tetanus may result from minor wounds as well as from those caused by major trauma and burns.²

Prevention is the key to eradicating tetanus. The Department of Health advocates a national immunisation programme and wound immunoprophylaxis (box).¹

Department of Health guidelines for antitetanus prophylaxis of wounds according to immunisation status

Last of three dose course or reinforcing dose within past 10 years

Clean wound—no antitetanus treatment needed

Tetanus prone wound—no antitetanus treatment needed unless risk is thought to be extremely high, for example, contact with manure

Last of three dose course or reinforcing dose more than 10 years previously

Clean wound—reinforcing dose of adsorbed vaccine needed

Tetanus prone wound—give reinforcing dose of adsorbed vaccine and a dose of human tetanus immunoglobulin needed

Not immunised or immunisation status not known with certainty

Clean wound—full three dose course of adsorbed vaccine needed

Tetanus prone wound—full three dose course of vaccine and a dose of immunoglobulin at different site needed

An immunisation programme started in the United Kingdom in 1961. However, anyone over 40 in 2001 has not necessarily been immunised. The uptake of childhood immunisation in some parts of the country may be less than 80%.³ Background immunisation in the population is poor; in one general practice only 13% of the population was adequately vaccinated.⁴ Therefore correct wound assessment and immunoprophylaxis is important.⁵,⁶ This can be divided into two parts. Firstly, the patient should be asked whether they have received a full course of tetanus vaccine and when they last received a booster injection. Secondly, to determine whether the wound is tetanus prone it should be examined and its history ascertained. Correct immunoprophylaxis should follow the published guidelines.¹

A wound that is prone to tetanus is defined as a wound or burn sustained more than six hours before surgical treatment or with any of the following characteristics: a significant degree of devitalised tissue, a puncture-type wound, contact with soil or manure likely to harbour tetanus organisms, and clinical evidence of sepsis.¹ The only variable that can be altered after wounding is the time from wounding to surgical treatment. This identifies a group of patients, often with relatively minor injuries, whom if treated promptly in the emergency department would never enter this category. This may reduce the requirement for immunoglobulin but will undoubtedly add another pressure to the emergency system.

The management of wounds prone to tetanus in emergency departments can vary. An audit of doctors found that only 49% of patients were treated correctly, and that there was no improvement over three months despite instruction and reminders. However, when triage nurses became involved 80% of patients were treated correctly.³ Another study showed that 23% of patients were incorrectly treated in emergency rooms, with those in the highest risk group being the least likely to receive correct treatment for tetanus.⁷ Elsewhere, less than 10% of patients referred for plastic surgery were correctly questioned about their tetanus immunisation status.⁸

Adverse reactions to adsorbed tetanus vaccine occur in less than 1% of patients; most commonly these are local reactions such as pain, redness, and swelling.⁹ General reactions, including lethargy, malaise, myalgia, and pyrexia, are less common.¹ Anaphylaxis is rare.

On the basis of the low adverse reaction rate and noticeable benefit, resources are already allocated to the national immunisation programme. As immunity in the community improves the use of tetanus immunoglobulin will decrease and will be required only for highly contaminated wounds.

This case shows how the omission of the smallest detail can have a fatal outcome. Complete management of an injured patient includes a full history of tetanus immunisation and adherence to the Department of Health's immunoprophylaxis protocol.