Tetanus is a serious disease characterized by muscle spasm and rigidity. The mortality rate is approximately 20% and is due to spasm of the muscles of respiration. Tetanus is an illness preventable through primary immunization and regular booster shots.

The Emergency Department patient encounter provides an ideal opportunity to screen for adequate tetanus immunization and to provide it, when necessary. In North America, the vast majority of people seen in the Emergency Department will have received primary immunization. Groups that may have missed primary immunization include elderly patients and immigrants.

Primary immunization involves a series of four toxoid injections for preschool children or three toxoid injections if started at age 7 or older. Following primary immunization, children receive a booster shot at age 5 and additional boosters every 10 years subsequent to that.

Patients seen in the Emergency Department with clean, minor wounds are considered adequately immunized if they have received primary immunization and have had a booster within the past 10 years. If a wound is "dirty" (which includes wounds contaminated with saliva, feces or dirt, and burn injuries) then a booster within the past 5 years is necessary to ensure immunization.

If the patient has not received primary immunization, (or if the patient is unsure) then passive immunity with tetanus immune globulin (T.I.G.) is provided. At the same time, but with a different injection site, tetanus and diphtheria toxoid should be given. This initiates primary immunization but adequate follow-up should be arranged to ensure completion of the series. Note that the diphtheria toxoid is added to ensure adequate immunity to diphtheria in the population.

Patients will occasionally present stating they have an allergy to the toxoid. Adverse reactions such as local pain, erythemia, fever, malaise or rash are common but should not preclude further immunization. A true anaphylactic or serious neurologic reaction to the toxoid are the only contraindications to further immunization with the tetanus and diphtheria toxoid.

If a patient has had a true serious reaction in the past, they should receive a T.I.G. in the Emergency Department and then follow-up with an allergist to assess immunization status. The table below summarizes the CDC guidelines for tetanus prophylaxis.

Tetanus Immunization:

For clean, minor wounds:

For all other wounds: