Management of Dirty Tetanogenic Wounds

Quick Guide to Emergency Pediatrics

Key History:

  • Injury mechanism: How, when and where did it happen? (bite, fall, sharp object).
  • Wound characteristics: Look for contamination with dirt, feces, saliva, dust. Presence of devitalized tissue, burns or frostbite.
  • Tetanus vaccination status: Fundamental! Request a vaccination card. Ask about previous doses and dates.
  • Allergies: Especially antibiotics or anesthetics.
  • Comorbidities: Immunosuppression, diabetes, etc.

What is a tetanogenic wound?

Any wound that is not clean and superficial. Includes contaminated wounds, puncture wounds, avulsion wounds, devitalized tissue, or those that require delayed surgical intervention (>6h).

The most important step to prevent infections. Don't underestimate it!

  1. Local anesthesia: Use 1-2% lidocaine (with or without epinephrine depending on the area) or topical anesthetics (LET) for painless cleansing.
  2. Pressure irrigation: Wash thoroughly with sterile physiological saline. Use a 20-50 ml syringe with an 18-20G angiocath catheter to generate pressure.
  3. Debridement: Remove all necrotic, devitalized tissue and any visible foreign body. This eliminates the anaerobic environment that favors C. tetani.
  4. Antiseptics: Use povidone-iodine or chlorhexidine on the perilesional skin, avoid its direct use inside the wound since it can be cytotoxic.
  5. Wound closure: Heavily contaminated or puncture wounds often benefit from closure by secondary intention or delayed closure. Evaluate case by case.

The decision is based on vaccination history and type of wound. Use this table as a guide:

Vaccination History (Dose) Minor Clean Wound Tetanogenic Dirty Wound
< 3 doses or unknown Manage Toxoid (Td/dTpa) Manage Toxoid + Immunoglobulin (IGT)
≥ 3 doses Manage Toxoid if >10 years since last dose Manage Toxoid if >5 years since last dose

Presentations and Dosage:

  • Tetanus Toxoid (Td/dTpa): 0.5 ml intramuscular (IM) in deltoid or vastus lateralis.
  • Human Tetanus Immunoglobulin (IGT): 250 IU IM. If >24 hours have passed or the wound is very serious, consider 500 IU. Administer in a different site to the toxoid.

Prophylactic Antibiotics:

Consider in bites (human or animal), highly contaminated wounds, deep puncture wounds (especially on the foot) or in immunocompromised patients.

  • Of choice: Amoxicillin-Clavulanic Acid

    Dose: 40-50 mg/kg/day (based on amoxicillin), distributed every 8-12 hours, for 5-7 days.

    Common presentations: Suspension 125/31.25 mg/5ml, 250/62.5 mg/5ml.

  • Penicillin Allergy: Clindamycin

    Dose: 10-30 mg/kg/day, distributed every 6-8 hours.

    Add Trimethoprim-Sulfamethoxazole if Gram negative is suspected.

Pain Management:

  • Ibuprofen

    Dose: 10 mg/kg/dose, every 6-8 hours.

  • Paracetamol (Acetaminophen)

    Dose: 15 mg/kg/dose, every 4-6 hours.

Registration in Clinical History:

  • Detailed description of the wound and mechanism of injury.
  • Cleaning and debridement procedure performed.
  • Patient's vaccination history.
  • Administration of toxoid and/or immunoglobulin (batch, expiration date, administration site).
  • Prescribed antibiotics and analgesics.
  • Fill out informed consent documents if applicable.

Discharge Instructions for Parents:

  • Clear instructions on wound healing at home.
  • Medication schedule (antibiotic/pain reliever) with doses and schedules.
  • Warning signs: Fever, spreading redness, increased pain, purulent discharge, bad odor.
  • Appointment for reassessment in 24-48 hours, especially in high-risk wounds.
  • Remember to complete the vaccination schedule if it was incomplete.