Can you figure out the tricks in the tetanus tales below?
1. THE BOOSTER SHOT
A 22-year-old male presents to your clinic with a minor laceration with a clean wound. His last vaccine was when he received Td at age 11 when he cut his finger climbing an old barbed wire fence. What vaccine should you give? (Hint: it's NOT Td)
2. THE BOMB BLAST
You are a Canadian Forces medical officer in Afghanistan and a 13-year-old girl is brought to your UMS (unit medical station). She was in the vicinity of a bomb blast and, other than coughing up a bit of sand, she has no visible wounds, fractures, or lacerations. What is your management?
3. THE BRICK WALL
A 19-year-old soccer goalie has his ball-saving dive stopped abruptly when his face strikes the goal post. His lateral incisor falls to the ground and he has the presence of mind to pick up his tooth and keep it in his cheek on the way to the hospital. He has no lacerations. What is your management?
4.THE BIG BANG
A 23-year-old was modifying legal fireworks on Diwali and unfortunately one exploded in his hand. He attends your emergency department and, after assessing his wound, what is your management?
DID YOU KNOW - Tetanus is most commonly preceded by a MINOR wound, since major wounds are more likely to be well-managed for tetanus prevention?Beyond the usual rusty nail or dirty wound, cases of tetanus have also been reported after minor surgery, injection drug use, and otitis media!
ANSWERS:
1. According to PHAC guidelines, this patient should get a Tdap - NOT Td - as the question indicates he did not receive the Tdap booster that every adult should receive once.
2. She needs a tetanus vaccination. Dirt aspiration is a risk factor for tetanus. Also, did you remember to assess for either concussion, hearing loss, C-spine injury, and rule out head trauma red flags?
3. You should have the hang of this by now - after an avulsed tooth that was replaced, tetanus prophylaxis is indicated if the tooth touched dirt. Also, did you remember to assess for concussion, C-spine injury, jaw fracture, and rule out head trauma red flags? And finally - management should include referral to a dentist! (The Snowflake management mnemonic you'll learn at The Review Course will help you NEVER forget comprehensive management steps).
4. Needless to say, patients with burn wounds require tetanus prophylaxis. Depending on the details, a radiograph may be appropriate. Also, did you remember to refer to offer analgesia, and refer to a burn centre for his major burn (major burn includes ANY burn on the hands)?
Remember, for the Canadian exam you need to know Canadian guidelines on tetanus - so be sure to review them at http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-tet-eng.php#table-1
EXAM TIP - We'd rather you get tricked by us than on the exam. Though we hope you don't see any exam questions this tricky, be sure to read or listen to all questions carefully. Finally, think beyond the obvious in the question stem: could there be anything more that needs to be considered in each scenario?
Burn Centre referral criteria - http://www.bcmj.org/sites/default/files/BCMJ_54_Vol9_burn.pdf
Tetanus caused by human bite of the finger - http://www.ncbi.nlm.nih.gov/pubmed/7741442PHAC Tetanus Guidelines - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-tet-eng.php#table-1
Dental Trauma guidelines - https://www.iadt-dentaltrauma.org/1-9%20%20iadt%20guidelines%20combined%20-%20lr%20-%2011-5-2013.pdfCDC
Tetanus information - https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf
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