- Email: [email protected]
Tetanus prophylaxis: Are we getting it right?
Correspondence and communications non-viable tissue prior to reconstruction. However, due to the complexity of the injury, the associated fracture and bony fixation required, underlying deep seated infection may result requiring further debridements and a resultant delayed soft tissue defect. This case highlights the potential benefits of a musculocutaneous flap over a pure muscle flap, as it provided secondary flap options in addition to giving a more robust plantar tissue support. This case also demonstrated that fasciocutaneous perforator flaps can be confidently raised on a previous musculocutaneous free or pedicle flap within weeks of the primary reconstruction, resulting in further reconstructive options to these otherwise notoriously difficult wounds.
Conflicts of interest None of the authors have any conflicting interests.
Funding Not applicable.
References 1. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004 Nov;114(6):1457e66. 2. British Association of Plastic, Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. Royal Society of Medicine Press; 2009. 3. Schwabe P, Haas NP, Schaser KD. Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies. Unfallchirurg 2010 Aug; 113(8):647e70 [quiz 671e2]. 4. Lo CH, Leung M, Baillieu C, Chong EWT, Cleland H. Trauma centre experience: flap reconstruction of traumatic lower limb injuries. ANZ J Surg 2007;77(8):690e4.
A.E. Sayers R.J. Bramhall A. Akali Department of Plastic Surgery, Hull and East Yorkshire NHS Trust, Castle Hill Hospital, United Kingdom E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.010
Tetanus prophylaxis: Are we getting it right?
Dear Sir, A significant proportion of the work undertaken by Plastic Surgical and Burns teams involve traumatic wounds. Many of these wounds are susceptible to infection by the
287 Gram-positive bacterium Clostridium Tetani thereby giving rise to potential clinical tetanus. It is therefore imperative that those assessing such wounds have a thorough understanding of the guidelines, as outlined by the Department of Health, pertaining to the prophylaxis against such infection. The prophylaxis may include the tetanus toxoid (TT) vaccine (commonly administered as Revaxis) and/or tetanus immunoglobulin (TIG), depending on the previous immunisation history of the patient and the type of wound encountered (Table 1). Highrisk tetanus-prone wounds require prophylaxis, regardless of immunisation history, with tetanus immunoglobulin1 as the vaccine does not provide adequate protection in the early phases of infection. This letter provides a snapshot of current practices related to tetanus prophylaxis in Plastic Surgery Centres across the United Kingdom (UK). To identify adherence to the current guidelines we performed a telephone survey to assess the current clinical practice of tetanus prophylaxis amongst plastic surgical trainees working within the UK. 32 plastic surgery units were contacted over the space of two days. The response rate was 87.5% (n Z 28). 81.25% (n Z 26) were Senior House Officers (SHO) and 6.25% (n Z 2) were Specialist Registrars (SpR). The questionnaire consisted of asking two case-scenarios along with a question on the classification of tetanus-prone wounds (Table 2). Out of 28 plastic surgical on-call trainees contacted only 7.14% (n Z 2) correctly identified the need for immunoglobulin (TIG) in case 1. Worryingly, case 1 represented a clear case of being at ‘high-risk’ for tetanus infection. Also, only 7.14% (n Z 2) trainees (both SHO’s) correctly identified the needs for TT þ TIG in case 2. In question 3, 25% (n Z 7) trainees ‘correctly’ identified all the scenarios provided as tetanus-prone wounds. However, only 1 trainee provided the correct reason. Other reasons provided were: ‘all because contaminated’; ‘all but not sure why’; ‘all wounds are tetanus-prone’; and; ‘all wounds are contaminated so all are tetanus prone’. 8 (28.57%) out of the 28 trainees suggested giving TT (Revaxis) to case 1, where no vaccine was actually required. Tetanus infection, a notifiable disease in the UK with an incidence of 0.2 per million,2 is caused by the exotoxin tetanospasmin released from Clostridium Tetani spores in anaerobic conditions and within devitalised tissues.3 These spores are concentrated in a number of environments most notably in soil and manure. The incubation period ranges between 1 and 60 days.3 Worldwide, neonatal tetanus is the most prevalent and is caused by the use of non-sterile surgical equipment during separation of the umbilical cord at birth.4 In developed countries the majority of cases occur in patients aged over 65 years of age.2 Within the UK this probably results from the fact that primary immunisations programmes were only rolled out nationally in the early 1960’s. Symptoms of tetanus infection are variable and depend on severity of the infection: local (muscle spasms); general (systemic unwell, generalised skeletal muscle spasms, rigidity, lockjaw, opisthotonus), and; cephalic (facial spasms and symptoms associated with infection of the spinal cord).3 Immunisation schedules are combined with vaccinations for other diseases especially in children (Table 3). Five full courses of tetanus-containing vaccination provides lifelong immunity.1
288
Correspondence and communications
Table 1 Tetanus prophylaxis (TIG: Dose Z 250 IU by intramuscular injection or 500 IU if: more than 24 h since injury; risk of heavy contamination; following burns). Immunisation status
Full 5 doses at correct intervals 10 complete, boosters incomplete but up-to-date 10 incomplete, or boosters not up-to-date Not immunised or unknown/uncertain immunisation status
Table 2
Clean wound
Tetanus prone wound
Vaccine
Vaccine
TIG
Nil Nil
Nil Nil
Only high risk Only high risk
Yes (þcatch up doses if needed) Yes (þcatch up doses if needed)
Yes (þcatch up doses if needed) Yes (þcatch up doses if needed)
Yes
Questions asked in our questionnaire.
Question 1: Case 1 e A 22-year-old fit and well farmer sustained a traumatic degloving injury to his forearm and hand whilst cleaning out the pig enclosure. His wounds, exposed down to tendon and muscle, were contaminated with manure but were cleaned minimally in A&E 3 h after injury. He was upto date with his primary vaccination and had his second booster, correctly, aged 18 years old.
Questions 2: Case 2 - A 34-year-old sustained a puncture wound to his volar palm whilst playing football. He thinks he caught it on a nail in a fence. He has parasthesia over the radial aspect of his middle and ulnar aspect of his index and is booked for an operation the following day. Clinically it is not infected when seen 5 h post-injury. He had his primary vaccinations and a booster at 3 years of age.
Question 3: Which of the following scenarios represent a tetanus-prone wound: 1. Wounds greater than 6 h old requiring surgical intervention; 2. Wounds with significant devitalized tissue; 3. Puncture wounds; 4. Wounds in contact with soil/ manure; 5. Compound fractures; 6. Wounds associated with systemic sepsis;
Table 3
Tetanus immunisation schedule in the UK.1
Schedule
Children
Adults
Primary course
3 doses of vaccine (DTaP/IPV/Hib) 2, 3, 4 months of age >3 years after primary course Usually pre school (as DTaP/IPV) Aged 13-18 before leaving school (Td/IPV)
3 doses of vaccine each one month apart (Td/IPV) 10 years after primary course (Td/IPV)
4th Dose
5th Dose
10 years after 4th dose (Td/IPV)
Yes
Wounds need to be differentiated between those that are clean and those that are tetanus-prone as prophylaxis is determined by this assessment. Tetanus-prone wounds include: wounds greater than 6 h old prior to surgical intervention; wounds with significant devitalized tissue; puncture wounds; wounds in contact with soil/manure; compound fractures; wounds associated with systemic sepsis; wounds containing foreign bodies.1 In this classification wounds also include burn injuries. In addition to the classification above, particularly ‘highrisk’ wounds need to be identified. These include those with extensive contamination with material likely to contain tetanus spores (soil/manure) and/or extensive devitalised tissue.1 Immunoglobulin is important in those patients presenting with high-risk wounds or those with tetanus-prone wounds and an inadequate immunisation history. Junior trainees are often the first point of contact with patients, providing the initial vital assessment. It is therefore imperative that they are aware of the current guidelines so that appropriate timely prophylaxis is provided. Our study highlights a lack of understanding of tetanus prophylaxis guidelines as well as a poor grasp of what constitutes ‘tetanus-prone’ and ‘high-risk’ wounds. Within our study, only one of the twenty-eight trainees correctly answered all questions correctly. On exploring this further, this trainee had recently read the guidelines and hence ‘knew them’. Asking for tetanus status forms part of the assessment in any patient with open wounds. It is often the only vaccination status assessed. Despite this, plastic surgical trainees are prescribing potentially unnecessary, costly and incorrect prophylaxis to their patients. It is imperative that we as a specialty improve our clinical practice - by raising awareness amongst junior plastic surgeons and evaluating further through audit e to address the issues raised by our study.
Declarations All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data
Correspondence and communications (2) drafting the article or revising it critically for important intellectual content (3) final approval of the version to be submitted.
Conflict of interest None.
Patient consent Not required.
Sources of funding None.
Ethical consent
289
References 1. https://www.gov.uk/government/publications/tetanus-thegreen-book-chapter-30 [accessed 05.06.13]. 2. Rushdy AA, White JM, Ramsay ME, Crowcroft NS. Tetanus in England and Wales, 1984e2000. Epidemiol Infect 2003 Feb;130(1):71e7. 3. Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. Br J Anaesth 2001 Sep;87(3):477e87. 4. Galazka A, Gasse F. The present status of tetanus and tetanus vaccination. Curr Top Microbiol Immunol 1995;195:31e53.
U. Sarwar M. Javed N. Wilson-Jones Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Morriston, Swansea SA6 6NL, UK E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Not applicable. http://dx.doi.org/10.1016/j.bjps.2013.08.014
Conflicts of interest None of the authors have any conflicting interests.
Funding Not applicable.
References 1. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004 Nov;114(6):1457e66. 2. British Association of Plastic, Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. Royal Society of Medicine Press; 2009. 3. Schwabe P, Haas NP, Schaser KD. Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies. Unfallchirurg 2010 Aug; 113(8):647e70 [quiz 671e2]. 4. Lo CH, Leung M, Baillieu C, Chong EWT, Cleland H. Trauma centre experience: flap reconstruction of traumatic lower limb injuries. ANZ J Surg 2007;77(8):690e4.
A.E. Sayers R.J. Bramhall A. Akali Department of Plastic Surgery, Hull and East Yorkshire NHS Trust, Castle Hill Hospital, United Kingdom E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.010
Tetanus prophylaxis: Are we getting it right?
Dear Sir, A significant proportion of the work undertaken by Plastic Surgical and Burns teams involve traumatic wounds. Many of these wounds are susceptible to infection by the
287 Gram-positive bacterium Clostridium Tetani thereby giving rise to potential clinical tetanus. It is therefore imperative that those assessing such wounds have a thorough understanding of the guidelines, as outlined by the Department of Health, pertaining to the prophylaxis against such infection. The prophylaxis may include the tetanus toxoid (TT) vaccine (commonly administered as Revaxis) and/or tetanus immunoglobulin (TIG), depending on the previous immunisation history of the patient and the type of wound encountered (Table 1). Highrisk tetanus-prone wounds require prophylaxis, regardless of immunisation history, with tetanus immunoglobulin1 as the vaccine does not provide adequate protection in the early phases of infection. This letter provides a snapshot of current practices related to tetanus prophylaxis in Plastic Surgery Centres across the United Kingdom (UK). To identify adherence to the current guidelines we performed a telephone survey to assess the current clinical practice of tetanus prophylaxis amongst plastic surgical trainees working within the UK. 32 plastic surgery units were contacted over the space of two days. The response rate was 87.5% (n Z 28). 81.25% (n Z 26) were Senior House Officers (SHO) and 6.25% (n Z 2) were Specialist Registrars (SpR). The questionnaire consisted of asking two case-scenarios along with a question on the classification of tetanus-prone wounds (Table 2). Out of 28 plastic surgical on-call trainees contacted only 7.14% (n Z 2) correctly identified the need for immunoglobulin (TIG) in case 1. Worryingly, case 1 represented a clear case of being at ‘high-risk’ for tetanus infection. Also, only 7.14% (n Z 2) trainees (both SHO’s) correctly identified the needs for TT þ TIG in case 2. In question 3, 25% (n Z 7) trainees ‘correctly’ identified all the scenarios provided as tetanus-prone wounds. However, only 1 trainee provided the correct reason. Other reasons provided were: ‘all because contaminated’; ‘all but not sure why’; ‘all wounds are tetanus-prone’; and; ‘all wounds are contaminated so all are tetanus prone’. 8 (28.57%) out of the 28 trainees suggested giving TT (Revaxis) to case 1, where no vaccine was actually required. Tetanus infection, a notifiable disease in the UK with an incidence of 0.2 per million,2 is caused by the exotoxin tetanospasmin released from Clostridium Tetani spores in anaerobic conditions and within devitalised tissues.3 These spores are concentrated in a number of environments most notably in soil and manure. The incubation period ranges between 1 and 60 days.3 Worldwide, neonatal tetanus is the most prevalent and is caused by the use of non-sterile surgical equipment during separation of the umbilical cord at birth.4 In developed countries the majority of cases occur in patients aged over 65 years of age.2 Within the UK this probably results from the fact that primary immunisations programmes were only rolled out nationally in the early 1960’s. Symptoms of tetanus infection are variable and depend on severity of the infection: local (muscle spasms); general (systemic unwell, generalised skeletal muscle spasms, rigidity, lockjaw, opisthotonus), and; cephalic (facial spasms and symptoms associated with infection of the spinal cord).3 Immunisation schedules are combined with vaccinations for other diseases especially in children (Table 3). Five full courses of tetanus-containing vaccination provides lifelong immunity.1
288
Correspondence and communications
Table 1 Tetanus prophylaxis (TIG: Dose Z 250 IU by intramuscular injection or 500 IU if: more than 24 h since injury; risk of heavy contamination; following burns). Immunisation status
Full 5 doses at correct intervals 10 complete, boosters incomplete but up-to-date 10 incomplete, or boosters not up-to-date Not immunised or unknown/uncertain immunisation status
Table 2
Clean wound
Tetanus prone wound
Vaccine
Vaccine
TIG
Nil Nil
Nil Nil
Only high risk Only high risk
Yes (þcatch up doses if needed) Yes (þcatch up doses if needed)
Yes (þcatch up doses if needed) Yes (þcatch up doses if needed)
Yes
Questions asked in our questionnaire.
Question 1: Case 1 e A 22-year-old fit and well farmer sustained a traumatic degloving injury to his forearm and hand whilst cleaning out the pig enclosure. His wounds, exposed down to tendon and muscle, were contaminated with manure but were cleaned minimally in A&E 3 h after injury. He was upto date with his primary vaccination and had his second booster, correctly, aged 18 years old.
Questions 2: Case 2 - A 34-year-old sustained a puncture wound to his volar palm whilst playing football. He thinks he caught it on a nail in a fence. He has parasthesia over the radial aspect of his middle and ulnar aspect of his index and is booked for an operation the following day. Clinically it is not infected when seen 5 h post-injury. He had his primary vaccinations and a booster at 3 years of age.
Question 3: Which of the following scenarios represent a tetanus-prone wound: 1. Wounds greater than 6 h old requiring surgical intervention; 2. Wounds with significant devitalized tissue; 3. Puncture wounds; 4. Wounds in contact with soil/ manure; 5. Compound fractures; 6. Wounds associated with systemic sepsis;
Table 3
Tetanus immunisation schedule in the UK.1
Schedule
Children
Adults
Primary course
3 doses of vaccine (DTaP/IPV/Hib) 2, 3, 4 months of age >3 years after primary course Usually pre school (as DTaP/IPV) Aged 13-18 before leaving school (Td/IPV)
3 doses of vaccine each one month apart (Td/IPV) 10 years after primary course (Td/IPV)
4th Dose
5th Dose
10 years after 4th dose (Td/IPV)
Yes
Wounds need to be differentiated between those that are clean and those that are tetanus-prone as prophylaxis is determined by this assessment. Tetanus-prone wounds include: wounds greater than 6 h old prior to surgical intervention; wounds with significant devitalized tissue; puncture wounds; wounds in contact with soil/manure; compound fractures; wounds associated with systemic sepsis; wounds containing foreign bodies.1 In this classification wounds also include burn injuries. In addition to the classification above, particularly ‘highrisk’ wounds need to be identified. These include those with extensive contamination with material likely to contain tetanus spores (soil/manure) and/or extensive devitalised tissue.1 Immunoglobulin is important in those patients presenting with high-risk wounds or those with tetanus-prone wounds and an inadequate immunisation history. Junior trainees are often the first point of contact with patients, providing the initial vital assessment. It is therefore imperative that they are aware of the current guidelines so that appropriate timely prophylaxis is provided. Our study highlights a lack of understanding of tetanus prophylaxis guidelines as well as a poor grasp of what constitutes ‘tetanus-prone’ and ‘high-risk’ wounds. Within our study, only one of the twenty-eight trainees correctly answered all questions correctly. On exploring this further, this trainee had recently read the guidelines and hence ‘knew them’. Asking for tetanus status forms part of the assessment in any patient with open wounds. It is often the only vaccination status assessed. Despite this, plastic surgical trainees are prescribing potentially unnecessary, costly and incorrect prophylaxis to their patients. It is imperative that we as a specialty improve our clinical practice - by raising awareness amongst junior plastic surgeons and evaluating further through audit e to address the issues raised by our study.
Declarations All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data
Correspondence and communications (2) drafting the article or revising it critically for important intellectual content (3) final approval of the version to be submitted.
Conflict of interest None.
Patient consent Not required.
Sources of funding None.
Ethical consent
289
References 1. https://www.gov.uk/government/publications/tetanus-thegreen-book-chapter-30 [accessed 05.06.13]. 2. Rushdy AA, White JM, Ramsay ME, Crowcroft NS. Tetanus in England and Wales, 1984e2000. Epidemiol Infect 2003 Feb;130(1):71e7. 3. Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. Br J Anaesth 2001 Sep;87(3):477e87. 4. Galazka A, Gasse F. The present status of tetanus and tetanus vaccination. Curr Top Microbiol Immunol 1995;195:31e53.
U. Sarwar M. Javed N. Wilson-Jones Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Morriston, Swansea SA6 6NL, UK E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Not applicable. http://dx.doi.org/10.1016/j.bjps.2013.08.014