Tetanus Prophylaxis Research Articles

MINOR PEDIATRIC INJURIES

Injuries are a common source of childhood morbidity and mortality. The initial evaluation should follow in a sequential fashion to determine the extent of injuries. Most minor injuries can be treated safely and cost-effectively in an office setting. The principles of wound care include adequate hemostasis, tissue debridement, removal of imbedded foreign bodies, and appropriate closure or coverage of the wound to optimize healing. Appropriate use of antibodies, tetanus prophylaxis, and rabies immunization will minimize complications. With proper selection and treatment, the outcome of children with minor injuries should be excellent.

Managing Arthropod Bites and Stings

Most arthropod bites and stings cause limited swelling, itching, Md pain, and redness and can be managed by ice application and tetanus prophylaxis as necessary. Stings by bees, wasps, and stinging ants can cause anaphylaxis that may require treatment with epinephrine and antihistamines and respiratory and cardiac maintenance measures. Widow spider bite management is controversial, but interventions for systemic reactions include calcium gluconate, methocarbamol, diazepam, narcotics, and antivenom. Victims of brown spider bites may need hospitalization if lesions enlarge rapidly or there are signs of systemic poisoning. Those stung by a bark scorpion may require oxygen, an intravenous line, pulse oximetry, and cardiac monitoring.

Case report of an unusual source of tetanus

We report a case of generalized tetanus in a 31-year-old male originating from a surgical wound after repair of an achilles tendon rupture. Our case illustrates an unusual source of tetanus, the need for tetanus prophylaxis before surgery, and the importance of asking about primary tetanus immunization, particularly in immigrants.

PRODUCTION OF AN EFFECTIVE ANTI-Bothrops-TETANUS MIXED HYPERIMMUNE SERUM OF EQUINE ORIGIN

The present investigation reveals the possibility of simultaneous immunization of horses with Bothrops or Crotalus snake venoms and Tetanus antigens for the production of anti-Bothrops-Tetanus or anti-Crotalus-Tetanus mixed serum, with high titers of the respective specific antibodies. Bothrops antivenoms with an average neutralizing titer of 4.16 mg venom/ml were obtained from plasma of horses with titers lower than 0.5 mg venom/ml when Tetanus antigens were not used. This suggests the existence of a synergism between Bothrops venoms and Tetanus antigens in the stimulation of the antibody response. The pooled plasma of the animals had a neutralizing titer of 21.0 mg/ml reference Bothrops venoms and 3,300 IU/ml to Tetanus antigens after purification by enzymatic digestion and ammonium sulphate precipitation. These experiments lead us to conclude that Bothrops envenomation therapy can be successfully performed using anti-Bothrops-Tetanus serum also serving as Tetanus prophylaxis. Anti-Crotalus-Tetanus serum can also be produced, although it is not of medical interest as Crotalus envenomation rarely results in local necrotizing lesions.

Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting.

Approximately 32 000 nonpowder firearm injuries are reported annually with more than 60% occurring in the pediatric population. Case reports of serious and fatal injuries have been described; however, no large inclusive series have been published. We reviewed an 11-year experience of an urban pediatric emergency department to evaluate the circumstances, spectrum of injuries, and outcomes attributable to nonpowder firearms. A retrospective, descriptive case series of all children 18 years of age or younger evaluated at an urban children's hospital from January 1983 through December 1994 were eligible for study. Patients were identified using a computerized database, the National Electronic Injury Surveillance System, and the trauma registry in the department of surgery. Medical records were reviewed to collect demographic information, circumstances of injury, anatomic site and type of injury, treatment, and outcomes for nonpowder firearm injuries. One hundred eighty patients were identified, and a complete data set was available for 166 (92%). The mean age was 12 +/- 3.7 years, 24% of children were <10 years old, and 71% of the children were male. Three patients returned with a second nonpowder firearm injury during the study period. Forty-nine percent of injuries were intentional and 44% of all injuries occurred during the summer and early fall months. The most common sites of injury were the extremity/buttocks (39%), head and neck (33%), thorax (13%), and eye (8%). Serious injuries included intracranial hemorrhage, cardiac right ventricle laceration, hyphema, and abdominal visceral injury (liver laceration, pancreatic laceration, intestinal perforation). The majority of wounds required local wound care, and the children (74%) were discharged from the emergency department. Of the patients admitted to the hospital (27%), 45% required operative intervention. There were no deaths. Seven percent (12/166) of patients sustained some functional deficit with 42% (5/12) the result of an ocular injury. The majority of nonpowder firearm injuries are minor; however, the potential for serious injury should not be underestimated. Minor injuries can be treated with local wound care and tetanus prophylaxis, and patients can be discharged from the emergency department. Education of parents and children to the potential risks associated with these weapons is essential. Stricter regulations regarding ownership of nonpowder firearms and mandatory safety instruction should be considered.

A study of primary closure of human bite injuries to the face

Purpose: This study evaluated the management of human bite injuries to the face during the period from May 1995 to April 1996. Patients and Methods: Data on 30 patients presenting with human bite injuries during this period were collected on specially designed forms. The information was pooled and analyzed. A standardized surgical treatment consisting of thorough debridement of the wound followed by primary closure either by direct suturing, a local flap, or skin grafting on the day of presentation was used. Most of the cases were treated under local anesthesia. Patients were prescribed tetanus prophylaxis and a course of antibiotics for 1 week. Suture removal was done 1 week postoperatively except for the skin grafts, which were uncovered at 10 days postoperation. Results: There were 21 males and 9 females ranging in age between 17 and 55 years, with a mean age of 31.8 years. Sixty-six percent of the bites involved the lips. The duration of injury before presentation ranged from 1 to 4 days. In 27 of the cases (90%), wound healing was complete at the time of suture removal. Conclusion: The results indicate that immediate closure of human bite injuries is safe, even with old injuries.

Lionfish envenomations in an urban wilderness

Marine envenomations are commonly encountered along coastal regions of the United States. Although less frequent, marine bites and stings do occur in landlocked locales, such as the Midwest, because of an increased interest in keeping these exotic creatures as pets. We report 33 cases of envenomations by captive lionfish (Pterois volitans) called to a regional Chicago poison control center over a 2-year period. All stings were accidental, and 10 (30%) were treated in an emergency department. The wounds were uniformly on the hand, and all presented with local, intense pain. The majority of envenomations were responsive to prompt immersion in nonscalding water within 90 min, and all were advised on tetanus prophylaxis and local wound care. Two patients (6%) required hospitalization. In all cases, those patients envenomated recovered without permanent sequelae. As a result of increasing encounters with lionfish as pets, health care providers. regardless of their locale, should be familiar with the current treatment recommendations.

ANORECTAL DISORDERS

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

Rattlesnake venom poisoning in horses: 32 cases (1973-1993)

Objective To determine the clinical manifestations, morbidity, mortality, and treatment methods for rattlesnake venom poisoning in horses. Design Retrospective analysis of medical records. Animals 27 horses with acute venom poisoning attributable to prairie rattlesnakes, and 5 with chronic problems subsequent to a rattlesnake bite. Results Most horses were bitten on or near the muzzle while on pasture, resulting in head swelling, dyspnea, and epistaxis. Additional manifestations of acute poisoning included fever, tachycardia, tachypnea, cardiac arrhythmia, hemolytic anemia, thrombocytopenia, hemorrhage, thrombosis of venipuncture sites, colic, diarrhea, and prehensile and masticatory dysfunction. Chronic problems included cardiac disease, pneumonia, laminitis, pharyngeal paralysis, and wound complications. The most common chronic problem was cardiac disease. The most commonly used treatments were antibiotics, nonsteroidal anti-inflammatory drugs, tetanus prophylaxis, and airway support. Mortality in the 27 acutely affected horses was 18.5%; the overall mortality was 25%. Clinical Implications Horses bitten by prairie rattlesnakes may develop multiple, often severe, acute or chronic manifestations of poisoning involving various organ systems. Thorough clinical evaluation, effective treatment, supportive care, and close observation are indicated in horses with rattlesnake venom poisoning. (J Am Vet Med Assoc 1996;208:1866-1871)

Thoracolumbar Infections in Penetrating Injuries to the Spine

A detailed review of the TJUH experience and the published literature on gunshot and stab wounds to the spine has been presented. The following statements are supported. (1) Military (high-velocity) gunshot wounds are distinct entities, and the management of these injuries cannot be carried over to civilian (low-velocity) handgun wounds. (2) Gunshot wounds with a resultant neurologic deficit are much more common than stab wounds and carry a worse prognosis. (3) Spinal infections are rare following a penetrating wound of the spine and a high index of suspicion is needed to detect them. (4) Extraspinal infections (septic complications) are much more common than spinal infections following a gunshot or stab wound to the spine. (5) Steroids are of no use in gunshot wounds to the spine. In fact, there was an increased incidence of spinal and extraspinal infections without a difference in neurologic outcome compared with those who did not receive steroids. (6) Spinal surgery is rarely indicated in the management of penetrating wounds of the spine. The recommendations for treatment at TJUH of victims of gunshot or stab wounds with a resultant neurologic deficit are as follows. (1) Spine surgery is indicated for progressive neurologic deficits and persistent cerebrospinal fluid leaks (particularly if meningitis is present), although these situations rarely occur. (2) Consider spine surgery for incomplete neurologic deficits with radiographic evidence of neural compression. Particularly in the cauda equina region, these surgeries may be technically demanding because of frequent dural violations and nerve root injuries/extrusions. These cases must be evaluated in an individual case-by-case manner. The neurologic outcomes of patients with incomplete neurologic deficits at TJUH who underwent acute spine surgery (usually for neural compression secondary to a bullet) were worse than the outcomes for the patients who did not have spine surgery. A selection bias against the patients undergoing spine surgery was likely present as these patients had evidence of ongoing neural compression. (3) A high index of suspicion is necessary to detect spinal and extraspinal infections. (4) Do not use glucorticoid steroids for gunshot wound victims. (5) Conservative (nonoperative) treatment with intravenous broad spectrum antibiotics and tetanus prophylaxis is the sole therapy indicated in the majority of patients who sustain a penetrating wound to the thoracic or lumbar spines.

Health hazards to humans associated with domestic pets.

Allergy to pets, particularly when manifested as asthma, is an important health hazard. The health impact of severe clinical disease associated with allergy to pets can be minimized by avoidance of pets. Many individuals with milder disease keep their pets and obtain medications for relief of their allergy symptoms. Bird fancier's disease can result in profound deterioration of pulmonary function, and requires avoidance of bird exposure. Animal bites are the commonest health hazard of domestic pets and result in tissue damage and infection risk. Bites are treated by cleaning the wound, and appropriate use of antibiotics and tetanus prophylaxis. Diverse infectious diseases are transmitted to humans by their pets; these diseases are particularly dangerous to immunocompromised individuals. The infectious diseases can be partly prevented by avoiding ill animals and by washing of hands following exposure to pets or pet-derived secretions. They can be treated by appropriate antibiotics and/or specific immune globulins and/or vaccines.

Management of occupational exposure to HIV.

Many health care workers (HCWs) are potentially at risk for occupationally acquired human immunodeficiency virus (HIV) infection. 1,z Although improved methods of exposure prevention remain the mainstay of further risk reduction efforts, the likelihood that exposures will nevertheless continue to occur has made it necessary for institutions to develop and continually update procedures for postexposure management.-7 This chapter focuses on the management of occupational exposures and discusses issues regarding attempted postexposure prophylaxis with antiviral agents such as zidovudine. Many such incidents also require evaluation and management of possible exposure to other blood-borne pathogens (e.g., hepatitis B and C viruses) and tetanus prophylaxis, as discussed elsewhere.s’9

Tetanus Caused by Human Bite of the Finger

A case of generalized tetanus after human bite of the finger is reported. The patient recovered with institutional care. We propose that secondary invasion by Clostridium tetani is the cause for infection. It could be prevented by immediate tetanus prophylaxis, thorough debridement, and primary repair of the wound.

When a snake bites

Primary care physicians may be required to treat snake-bitten patients and must differentiate between venomous and nonvenomous snakes. The chief distinguishing characteristics of venomous snakes are fangs and a single row of subcaudal anal plates. The physiologic effects of snake venom are on the cardiovascular, hematologic, and neurovascular systems. The snake-bitten patient first needs supportive treatment and stabilization. Then, the physician must establish whether envenomation has occurred, grade it, and monitor edema around the bite. Local treatment, broad-spectrum antibiotics, and tetanus prophylaxis should be used for all envenomation grades. The decision to administer antivenin therapy should be made on clinical grounds and the envenomation grade. Its use, however, can lead to anaphylaxis and anticomplement reactions.

Crotalidae envenomation in children.

Poisonous snakebites cause a severe envenomation syndrome in children, yet treatment remains controversial. Sixty-seven patients were treated for poisonous snakebites at our institution between 1975 and 1990; 18 were children < or = 12 years old. There were 13 rattlesnake bites, 4 copperhead bites, and 1 unidentified bite. Initial management included intravenous fluids and antibiotic administration, laboratory studies, tetanus prophylaxis, affected limb elevation, and a limited excision of the bite site in the emergency room. Antivenin was administered only if signs of systemic involvement such as shock, coagulopathy, gastrointestinal cramping, or neurological involvement were present. Children developed systemic involvement 72% of the time, 9 children (50%) developed coagulopathy. Consequently, 11 (61%) children received antivenin. The dose of antivenin they received was 3.2 ml/kg and the children tolerated it well with only 36% of them demonstrating adverse reactions to the antivenin. Clinically, the pediatric patients demonstrated signs and symptoms of a fulminant envenomation syndrome (8 days, average hospital stay), yet, they had a good eventual outcome. Only 11% of children reported long-term morbidity. No deaths occurred and 100% of patients were able to return to full preinjury activities. We conclude that Crotalidae envenomation in children is a serious disease and warrants hospitalization, early surgical involvement, and frequent use of antivenin.

Quokka bites. The first report of bites from an Australian marsupial.

To describe the incidence and natural history of bites from the quokka, a small wallaby. A prospective case series. Rottnest Island Nursing Post, a small hospital staffed by registered nurses on call 24 hours a day, located on Rottnest Island 18 km off the coast of Western Australia near Perth. All patients presenting after a bite from a quokka. Seventy-two patients (30 males and 42 females) presented after a bite. All but two patients were patting or feeding a quokka at the time of being bitten, and all but two were bitten on a finger or the thumb. Sixty-one per cent of patients were followed up; all wounds healed without complications. No wound pathogens were cultured from either wound swabs or swabs of the mouths of quokkas. Bites from quokkas heal without complications, usually in two to three weeks. Simple first aid and tetanus prophylaxis where appropriate are all that is required. Antibiotics are not indicated.

Tetanus in the Elderly

To the Editor.— Preventive health care is a relatively ignored discipline of geriatric medicine, consequently I applaud the publication of the article on tetanus in the elderly by Richardson and Knight.1Although rare in the general population, most deaths secondary to tetanus occur among older persons, augmenting the importance of preventive immunization. However, Table 3 in the article by Richardson and Knight is not what the Advisory Committee of Immunization Practices guidelines suggest for tetanus prophylaxis in wound management; rather, the Committee advises that patients with an unknown history of tetanus immunization or less than three doses of tetanus toxoid and a wound that is not clean receive an injection of tetanus toxoidandtetanus immune globulin (Table 1). Prophylactic immunization is an elemental component of geriatric care; however, several studies2-5suggest that tetanus immunization is lamentably inadequate. Accordingly, clinicians must become cognizant of the potential for tetanus

Office care of wounds.

All children experience a variety of minor injuries, the vast majority of which can be cared for easily by a competent parent. Wounds of a larger scope, wounds of a complex nature, or wounds with secondary complications require consultation with the pediatrician. Knowledge of the principles of treatment is essential and must be tailored to individual parental abilities, home environment, and emotional concerns. The purpose of this article is to outline common problems and to give suggestions for efficient office management. Tetanus Prophylaxis All wounds, regardless of etiology or size, should be considered as potential sources of tetanus. Therefore, it is incumbent upon the primary provider to ensure adequacy of tetanus prophylaxis (Table). Lacerations Pediatricians see a variety of lacerations. Those which do not come to medical attention through the emergency department are usually within the scope of the primary provider. Occasional surgical referral may be necessary because of the nature of location of the wound. If bleeding has not ceased by the time of initial presentation, a small gauze dressing should be applied with direct, constant pressure for 15 min. Large, bulky dressings are inefficient for applying pressure at the exact bleeding site. Careful documentation should include location, orientation, depth, and exact length of the laceration.

Office Care of Wounds

All children experience a variety of minor injuries, the vast majority of which can be cared for easily by a competent parent. Wounds of a larger scope, wounds of a complex nature, or wounds with secondary complications require consultation with the pediatrician. Knowledge of the principles of treatment is essential and must be tailored to individual parental abilities, home environment, and emotional concerns. The purpose of this article is to outline common problems and to give suggestions for efficient office management. Tetanus Prophylaxis All wounds, regardless of etiology or size, should be considered as potential sources of tetanus. Therefore, it is incumbent upon the primary provider to ensure adequacy of tetanus prophylaxis (Table). Lacerations Pediatricians see a variety of lacerations. Those which do not come to medical attention through the emergency department are usually within the scope of the primary provider. Occasional surgical referral may be necessary because of the nature of location of the wound. If bleeding has not ceased by the time of initial presentation, a small gauze dressing should be applied with direct, constant pressure for 15 min. Large, bulky dressings are inefficient for applying pressure at the exact bleeding site. Careful documentation should include location, orientation, depth, and exact length of the laceration.

Open fractures of the tibia in children.

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment.