Tetanus Prophylaxis Research Articles

Evaluating acute hand injuries in the emergency department: A comparison of physicians with varying postgraduate training backgrounds

This study compared the quality of the history, physical examination, and treatment of patients with hand injuries performed by emergency physicians with varied training backgrounds. Four hundred ninety-seven patients with isolated hand injuries were evaluated by 97 physicians, who were classified into four groups: (1) emergency medicine board certified, (2) primary care specialty board certified, (3) non-board certified, and (4) moonlighting residents. The history and physical examination were separated into several variables to define deficiencies. Adequacy of treatment was determined by two emergency physicians and an orthopedic surgeon. Significant differences were found in five categories. Group no. 4 documented the history and followed the Centers for Disease Control tetanus prophylaxis guidelines better than did groups no. 1 or 2. Group no. 1 obtained x-rays less often than any other group and had a better treatment score, but the latter did not reach statistical significance. Physicians of lesser training are more meticulous about documenting a history and following treatment protocols than are residency-trained or boarded emergency physicians, but order more tests and are less likely to document adequate treatment.

Quality assurance and clinical indicators in emergency medicine

Quality assurance and clinical indicators in emergency medicine

Poisonous Snakebite in Central Texas Possible Indicators for Antivenin Treatment

Sixty-seven patients hospitalized for poisonous snakebite between 1975 and 1990 were managed by elevation, tetanus prophylaxis, intravenous fluids and antibiotics, and often by a limited excision of the bite site in the Emergency Department, with sequential laboratory studies as needed. Antivenin was used for systemic envenomation, and 23 of the 67 patients (34%) received 133 vials. Thirteen of the twenty-three patients (56%) had adverse reactions to the antivenin. Two significant observations arose. First age was an indicator. Eleven of eighteen patients 12 years or younger (61%) received antivenin, whereas 12 of 49 patients older than 12 years (24%) received antivenin (p = 0.0085, Fisher's exact test). Second species of snake was an indicator. Sixty-two snakes were identified (93%). Of 39 rattlesnake (Crotalus and Sistrurus) bites, 20 patients received antivenin (53%), but of 23 copperhead and water moccasin (Agkistrodon) bites, only three patients (12.5%) received antivenin (p = 0.0025). Antivenin may be indicated for use in systemic rattlesnake envenomation, especially in younger patients.

Catfish sting

ABSTRACTThis case serves as a reminder of the effectiveness of immersion in very warm water in the early management of pain following catfish and other marine stings. The importance of tetanus prophylaxis in such patients is emphasized.

Neonatal Tetanus in Babies of Women Immunized with Tetanus Toxoid during Pregnancy

In a study of 52 cases of neonatal tetanus admitted to Wesley Guild Hospital, Ilesha, it was found that 17 (33%) of the babies were delivered to mothers who had received adequate tetanus toxoid immunization during pregnancy. The 17 babies were compared with the remaining 35 babies whose mothers had not received tetanus prophylaxis. The case fatality rates in these two groups were 12.5% and 60% respectively (P less than 0.01). This report shows that neonatal tetanus can occur in babies of mothers who were immunized with tetanus toxoid during pregnancy. Maternal immunity may, however, improve the prognosis in such infants.

Tetanus complicating frostbite

The need for tetanus prophylaxis in trauma including bums has been well documented (Smith et al., 1975; Amy, 1985). In cold injury, the guidelines are unclear (Kyosola, 1974; Rains and Ritchie, 1984; Sabiston, 1986; Weatherall, 1986; Macleod, 1987; Wyngaarden and Smith, 1988). We report a case of tetanus following frostbite, emphasizing the importance of routine tetanus prophylaxis in this circumstance.

Management of Low Velocity Gunshot-Induced Fractures

Bullets fired from civilian weapons are usually of low velocity, resulting in minimal tissue cavitation as compared to high-velocity weapons. A prospective protocol was initiated for patients sustaining a low-velocity gunshot to the extremity resulting in a stable, nonoperative fracture configuration. Treatment consisted of local irrigation and débridement, tetanus prophylaxis as required, a long acting cephalosporin intramuscularly, and splinting or casting of the fractured extremity. Twenty-five patients were managed by this protocol. This patient population was compared to a random retrospective sample of 25 patients with similar ballistic induced fractures and wounds managed by local débridement and 48 h of intravenous antibiotics. One infection occurred in each group, requiring further therapy. We conclude that the patient with a low-velocity gunshot induced fracture can be managed without the use of short-term intravenous antibiotics with no increased risk of infection.

Penetrating knee injuries: The nail gun

Since the development of the nail gun in the 1950s, various reports cite injuries to the head, chest, abdomen, and extremities. Few of these reports mention any nail gun injuries to the knee joint. A total of 33 patients with penetrating injuries to the knee was identified. Of these, 13 had penetrating wounds caused by power nail guns or staplers. The average age was 25 years (range, 17–40). In 10 of the 13 patients, bone involvement (femur in 6, patella in 2, tibia in 1, and both femur and patella in 1) occurred. Treatment consisted of arthroscopy with irrigation of the knee and nail removal in 10 patients. The other 3 patients underwent arthrotomy in conjunction with nail removal and irrigation. No drains were used postoperatively. I.v. cephalosporin antibiotics were given initially in all cases and were continued orally after hospital discharge. Immediate post injury follow-up varied from a few days to 3 months. Six of the 13 patients were found for follow-up 10–33 months (average 19 months) post injury. All of these returned to full duty in the home construction industry. None developed an infection or needed additional surgery. Based on this series, power nail gun knee joint wounds should have tetanus prophylaxis, arthroscopic evaluation, and irrigation of the knee joint in conjunction with nail removal, i.v. antibiotics for 12–48 h, followed by a 10-day course of oral antibiotics. Unless cultures indicate differently, a first-generation cephalosporin is recommended.

Acute arthropod envenomation. Incidence, clinical features and management.

Black widow spider (Latrodectus mactans) envenomation is found throughout both the temperate and tropical latitudes, and is one of the leading causes of death from arthropod envenomations worldwide. The venom is highly neurotoxic, affecting the presynaptic motor endplate to allow massive noradrenaline (norepinephrine) and acetylcholine release into synapses causing excessive stimulation and fatigue of the motor end plate and muscle. Clinically, patients develop a bite site lesion and pain, abdominal pain and tenderness, and lower extremity pain and weakness within minutes to hours of envenomation. Symptoms progress over several hours, then subside over 2 to 3 days. The recommended treatment of 'common' envenomation is calcium gluconate 10% intravenously, titrated to relief of symptoms; antivenin, although effective, may cause hypersensitivity and serum sickness reactions, and should be restricted to life-threatening envenomations only. Brown recluse spider (Loxosceles reclusa) envenomations are seen in the Americas and in Europe, and are endemic to the south and central United States. The venom contains at least 8 enzymes, consisting of various lysins (facilitating venom spread) and sphingomyelinase D, which causes cell membrane injury and lysis, thrombosis, local ischaemia, and chemotaxis. Local envenomations begin as pain and itching that progresses to vesiculation with violaceous necrosis and surrounding erythema, and ultimately ulcer formation. Systemic envenomations may be life threatening, and present with fever, constitutional symptoms, petechial eruptions, thrombocytopenia, and haemolysis with haemoglobinuric renal failure. Treatment of local envenomations is conservative (local wound care, cryotherapy, elevation, tetanus prophylaxis, and close follow-up); systemic envenomation requires supportive care and treatment of arising complications, corticosteroids to stabilise red blood cell membranes, and support of renal function. Dapsone 100mg daily has emerged as a promising therapeutic agent in both animal studies and clinical trials. Over 650 species of scorpions are known to cause envenomation (mostly in children under 10 years); they are endemic mostly in arid and tropical areas. Different venoms and clinical presentations are seen across the different species. Most commonly, an inflammatory local reaction occurs with envenomation, which is treated with wound debridement and cleaning, tetanus prophylaxis, and antihistamines. Occasionally the venom is allergenic, and the resultant allergic reaction is treated in a standard fashion.(ABSTRACT TRUNCATED AT 400 WORDS)

Cost–benefit analysis of tetanus prophylaxis by a mathematical model

A mathematical model has been developed which allows estimation of the epidemiological and economic effects of different tetanus vaccination strategies. The model was used to simulate the epidemiology of tetanus in Italy from 1955 to 1982, and then applied to a district of Tuscany by utilizing data obtained from a seroepidemiological survey carried out in the same area. For this district we simulated vaccination programmes designed to reach, within 1 or 10 years, coverages of 60 or 90% of the population aged over 10 years who had not been exposed to the neonatal vaccination programme. The most effective strategy, from both the epidemiological and economic point of view, seems to be 90% coverage reached in 1 year's time. Benefits would be increased by improving the reliability of vaccinal anamnesis.

The Therapy of Genital Trauma by Dog Bite

Genital trauma by dog bite rarely is reported. We present 2 cases of dog bite to the external genitalia involving male infants. Rabies precautions, tetanus prophylaxis and antimicrobial therapy are reviewed. Both children required surgical débridement and split thickness skin grafts for repair. Since pediatric genital trauma may be the result of negligence or even deliberate abuse, a thorough investigation of the child’s environment is mandatory in such situations.

Snake Envenomation Incidence, Clinical Presentation and Management

Snake envenomation is a major cause of death and disability in the developing countries, particularly India and Southeast Asia. Species variation in venom components, yield, and lethality leads to quite different clinical presentations and mortality. Venomous snakes are divided into 5 families. Bites of the Viperidae, Crotalidae and Colubridae usually cause primarily local effects and bleeding; the Elapidae most commonly cause neurological symptoms, particularly paralysis; while the Hydrophidae cause paralysis and myolysis. Venoms are complex mixtures of enzymes, peptides and metalloproteins. 26 enzymes have been identified, and 10 of those are found in most venoms. Components have been identified that act as procoagulants, anticoagulants, hyaluronidases, RNases, DNases, postsynaptic toxins and presynaptic toxins. Other peptides induce capillary leak syndrome, haemolysis and shock. The clinical results of envenomation vary widely, and there may be no envenomation with a bite. Syndromes reported include oedema, haemolysis, shock, bleeding, pituitary failure, renal failure, myonecrosis, and combinations of the above. First aid measures that have been proposed include tourniquets, constricting bands, tight crepe bandages, incision and suction, cryotherapy, and high voltage electric shock. None of these has been shown to be effective except usage of a crepe bandage for Australian elapid bite. Tourniquets or cryotherapy, if used for extended periods may lead to gangrene. The most important first aid measure is rapid transport to comprehensive medical care. There is some controversy about medical treatment in the United States, but less in other countries. Supportive measures routinely required include intravenous fluids, tetanus prophylaxis and antibiotics. Anticholinergics may be useful in elapid bite. Intubation and ventilation may be necessary. Unproven surgical approaches include excision of envenomated tissues and fasciotomy. The former is disfiguring, the latter should be reserved for those patients with demonstrated increased intracompartmental pressure. More than 100 antivenins are produced by about 36 laboratories worldwide. The products are effective, but carry a high risk of serum sickness and a lesser risk of anaphylaxis. A more effective and less reactive product is under development.

Crotalid envenomation in children: selective conservative management.

Snake bites in children remain an uncommon injury. In general, there is a wide disagreement by knowledgeable authorities on a uniform approach to therapy. In the last 5 years, 29 children have been treated in our institution for snake bites, all with signs of envenomation. Treatment consisted of diagnostic laboratory studies, intravenous fluids, tetanus prophylaxis, antibiotics, bed rest, elevation, and observation. There were no deaths. A fasciotomy was required in three children. Cryotherapy initiated elsewhere resulted in tissue loss. Seven children received antivenin. All developed signs and symptoms to serum sickness. From this experience, it appears that the majority of snake bites in children, especially copperhead bites, can be treated selectively and conservatively. Care must be exercised in using antivenin as it is associated with a high rate of serum sickness. Cryotherapy adds to the morbidity of the bite and is not to be used.

The treatment of crotalid envenomation without antivenin.

Eighty-one patients were treated for crotalid envenomation over the past 12 years at the Ben Taub General Hospital, Houston. Bites were inflicted by copperheads (56%), water moccasins (15%), and rattlesnakes (12%). In 17% of patients the species of snake was not identified. Using a grading scale of one to four from minimal to severe envenomation, 54% were grade I, 29% grade II, 7% grade III, 6% grade IV, and 4% were not graded because the patients were seen more than 12 hours after envenomation and not evaluated by other physicians. Five patients received one dose (10 cc) of crotalid antivenin each before transfer to our Emergency Center. All patients were treated with intravenous fluids, antibiotics, tetanus prophylaxis, immobilization of the injured part, and elevation of the extremity to the level of the heart. No patients received antivenin or excisional therapy at this institution and one minor digital fasciotomy was performed. There were no deaths or amputations in this series. Eight patients developed superficial necrosis of the skin but only one required a skin graft. Three patients developed hematologic abnormalities and were treated with either platelet transfusions or fresh-frozen plasma. One patient required dopamine for hypotension refractory to fluid resuscitation. This experience supports a conservative approach to venomous snakebites and raises the question about the need to utilize traditional therapy for snakebites caused by species seen in our locality.

Traumatic fixation of the hip by a bolt fired from a bolt gun

A 25-year-old building worker was struck in the left hip by a 12.7-cm long bolt fired from a bolt gun. The bolt penetrated deeply into the pelvis, through the acetabulum, the joint cavity and the head of the femur leading to fixation of the hip. In spite of immediate extraction of the nail, cleansing, immobilization, antibiotics and tetanus prophylaxis, the wound became infected. The tips of the modern types of nails used in nail guns may be coated with a plastic material which can constitute a troublesome foreign body if left behind, because the nail is merely extracted without opening and exploring the track.

Epidemiology, Classification, Initial Care, and Administrative Considerations for Critically Burned Patients

The care of major burn injuries is a critical care endeavor from the initial evaluation and admission until the patient is discharged from the burn intensive care unit. A thorough history and physical examination are essential and require expertise to classify each burn injury. The initial treatment of the burn must address stopping the burning process, insuring a patient airway, assessing inhalation injury, initiation of adequate fluid and electrolyte resuscitation, appropriate wound care, and institution of ancillary care, such as insertion of nasogastric tubes and urinary catheters, narcotic dosage, tetanus prophylaxis, laboratory studies, and environmental temperature control. Critical care units must be designed, equipped, and staffed to facilitate the safe and effective care of burned patients. A well trained and experienced multidisciplinary burn team under the direction of a surgeon who specializes in burns is essential to the ultimate outcome of the seriously burned patient. Effective communication among the burn team and with the burned patients requires formal protocols for general treatment as well as dynamic individualized care based on careful comprehensive observations and monitoring. The prognosis for these critically injured and ill patients depends on attention to every detail of their care, which can only be accomplished in a sophisticated critical care atmosphere with personnel skilled in intensive care techniques.

Rat bites: Fifty cases

A prospective study of 50 patients with uninfected rat bite wounds was undertaken to determine the natural incidence of wound infection without prophylactic antibiotics. All open wounds were cultured; bacterial isolates were cultured from 30% of wounds. Of bacterial isolates, 43% were Staphylococcus epidermidis and the remainder were Bacillus subtillus, diphtheroids, and alpha hemolytic Streptococcus. Only one patient (2%) developed an infection. Seventy-two percent of the bites occurred while the patient was sleeping, probably accounting for the fact that 84% of the wounds were on the exposed areas of the upper extremities and face. Treatment recommendations include good surgical management and avoidance of prophylactic antibiotics due to a low natural infection rate. If the wounds become infected, then a cephalosporin or penicillinase-resistant penicillin should be sufficient for treatment with appropriate surgical care of the wounds. Rabies prophylaxis usually is not required, but we suggest that tetanus prophylaxis is mandatory because most of our patients were deficient in this regard.

First aid at the accident site--immediate measures at the hospital in burn cases

First aid on the scene of the accident consists in case of burns in removal of clothing, cooling with water (20 degrees C) and wrapping in metallic sheet dressing or sterile linen. Hands are dressed with non-adherent gauze and immobilized on splints in a functional position. No application of burn ointment, powder or cream. I.v. pain therapy with morphine derivates. Intravenous infusion (30 ml Ringer's lactate/kg bodyweight/h) tetanus prophylaxis. Hospitalization of all burn wounds of 15% of the body surface or more. Continuation of infusion therapy according to the exact balancing of water and electrolyte metabolism.

Tetanus After Anorectal Abscess

As illustrated by this case report, tetanus can occur as a complication of anorectal surgical procedures or abscesses just as it can in other wounds. A synergistic infection of the perineum occurred in a 62-year-old man 8 days after drainage of an anorectal abscess. He was treated with vigorous debridement and antibiotics and was given tetanus prophylaxis. The next day, tetanus developed, presumably from the original abscess. The patient recovered after aggressive therapy, including muscle relaxants and ventilatory support.

Tetanus in Victoria, 1957–1980

The records of 106 patients with tetanus who received treatment in Fairfield Hospital, Melbourne, over a 24-year period were reviewed. There were 19 deaths, all before 1975, and mortality was highest in patients over 60 years of age. During the second half of the study period, very few young people with tetanus were admitted to hospital, whereas the admission rate of those over 40 years of age was constant. Sixty-four patients were known not to be immunized; 19 patients had received at least one prior dose of tetanus toxoid. Ninety-one patients had identifiable injuries, most of which were minor. Medical treatment for an injury was given to 43 patients; 35 of these received tetanus prophylaxis, but only eight received tetanus immunoglobulin. In the last six years of the survey, improved treatment techniques have helped to reduce the mortality from tetanus. The accumulated experience at Fairfield Hospital provides a basis for the proposal that all patients with tetanus in Victoria should be referred to one hospital for management.