Wound Classification

The first step in the emergency room is to classify the tetanus risk of the injury.

Low Risk Clean Wound

  • Evolution less than 6 hours.
  • Linear or incised, clean edges.
  • Depth less than 1 cm.
  • No devitalized or necrotic tissue.
  • No signs of infection or obvious contaminants.

High Risk Tetanus Wound

  • Evolution greater than 6 hours.
  • Puncture wounds, avulsive, stellate.
  • Depth greater than 1 cm.
  • Presence of foreign bodies, bruises, ischemia or devitalized tissue.
  • Burns, frostbite or bites.
  • Contamination with dirt, dust, feces or saliva.

Extreme Risk High Risk Tetanus Wound

They are tetanus wounds that also have one of the following characteristics:

  • Massive pollution: Especially with material containing spores (soil, manure, feces).
  • Large amount of necrotic/devitalized tissue.

Action Algorithm

Cross the type of wound with the vaccination status (doses well documented in medical history or vaccination card).

Incomplete vaccination (< 3 doses) or Unknown

Clean Wound:

YES Vaccine NOT IGT

Administer 1 dose of vaccine and refer to PC to complete the regimen.
Tetanus or High Risk Wound:

YES Vaccine YES IGT

Administer 1 dose of vaccine + Tetanus Immune Globulin (IGT) in different anatomical sites.

Complete Vaccination (≥ 3 doses)

Clean Wound:
  • Does < 10 years from the last dose: NOTHING
  • Does ≥ 10 years from the last dose: YES Vaccine
Tetanus Wound:
  • Does < 5 years from the last dose: NOTHING
  • Does ≥ 5 years from the last dose: YES Vaccine
High Risk Wound / Immunocompromised:

If you are immunosuppressed or a parenteral drug user, administer ALWAYS IGT regardless of vaccination status, in addition to assessing the vaccine according to the time elapsed.

Preparations, Dosage and Route of Administration

Vaccines (according to pediatric age in the emergency room)

single dose of 0.5 ml intramuscularly (Deltoid muscle or anterolateral aspect of the thigh in infants).

Patient age Recommended preparation
< 7 years DTPa, Hexavalent or dTpa (depending on what is missing from your calendar).
≥ 7 years (and adults) dTpa (Tetanus, diphtheria, low load acellular pertussis) or td (Tetanus, diphtheria).

Tetanus Immunoglobulin (IGT)

It is passive prophylaxis (preformed antibodies). It is administered Deep intramuscular route, in an area other than the vaccine.

  • Standard Dose: 250 IU.
  • Double Dose (500 IU) if:
    • More than 24 hours have passed since the injury.
    • Patients with body weight > 90 kg.
    • Very high risk wounds or serious burns.

Expert Module: Tetanus Vaccine

Advanced information to address queries and master the type of biological.

Vaccine Type

The tetanus vaccine is a Toxoid (inactivated toxin). It belongs to the group of vaccines inactivated/dead.

Absolute Contraindications

  • Severe anaphylactic reaction to previous doses or components (e.g. formaldehyde).
  • Encephalopathy (coma, decreased level of consciousness, prolonged seizures) within 7 days after a previous dose of *Pertussis* (pertussis) component not attributable to another cause (In this case, monovalent T or bivalent Td vaccine without the pertussis component is used).

Safe Situations (False Contraindications)

  • Immunosuppression or HIV: When inactivated, it CANNOT cause the disease. It is completely safe (although the immune response may be lower).
  • Pregnancy: Not only is it safe, but it is indicated (usually dTpa at week 27-36) to protect the newborn against neonatal tetanus and pertussis.
  • Mild fever or use of antibiotics.

Addressing Myths (Emergency Box)

Myth 1: "Rusty iron gives tetanus"

The pediatrician explains: "Rust itself does not cause tetanus. Tetanus is caused by a bacteria (Clostridium tetani) that lives in dust, dirt, and animal feces. An old nail in the ground has tetanus from the dirt, not from the rust. A wound from a rose bush, a splinter, or a fall in the park are equally if not more dangerous."

Myth 2: "I already cleaned the wound with alcohol/peroxide, there is no need for a vaccine"

The pediatrician explains: "The tetanus bacteria form 'spores', which are like super-resistant seeds. Neither alcohol, nor iodine, nor boiling water destroys them easily. Once inside the skin (where there is no oxygen), the spore 'germinates' and releases a toxin that attacks the nervous system. Only the antibodies in the vaccine can neutralize that toxin."

Myth 3: "The wound bled a lot, so it cleaned itself"

The pediatrician explains: "If the wound is deep (more than 1 cm), punctured or has crushed edges, the underlying tissues are left without blood supply (ischemia) and without oxygen. That is the perfect environment for tetanus, bleeding or not bleeding superficially."

Protocol Source

Official Documents

This tool is based on current clinical practice guidelines and consensus documents:

  • Recommendations for the use of Td vaccines (Interterritorial Council of the National Health System, Ministry of Health of Spain).
Health Protocol (ESP)