Post exposure management for Tetanus Prone Wounds

Post exposure management for Tetanus Prone Wounds

underappreciated and is not as simple as is often perceived. The end points of surgical debridement can sometimes be di ffi cult to determine. Healthy subcutaneous fat is yellow and soft. Muscle viability is judged by its colour, capacity to bleed and contractility . Contaminated, complex and complicated wounds often requir e more than one surgical debridement before definitive repair and closure; for example, blast injuries and necrotising fasciitis (see Part 4 ). Other types of debridement are summarised in Table 3.4 . All wounds should be irrigated at the first available oppor- tunity to reduce bacterial contamination. This also allows bet - ter visualisation for wound assessment. W arm normal saline

Immunisation Status Clean wound Those aged 11 years and over , who have received 1 with an adequate priming course of tetanus vaccine the last dose within 10 years None required Children aged 5-10 years who have received priming course and pre-school booster Children under 5 years who have received an adequate priming course Received adequate priming course of tetanus 3 vaccine but last dose more than 10 years ago None required Children aged 5-10 years who have received an adequate priming course but no pre-school booster (Includes UK born after 1961 with history of accepting vaccinations) Immediate Not received adequate priming course 3 of tetanus vaccine reinforcing (Includes uncertain immunisation status and/or born before 1961) dose of vaccine 1 Clean wounds are de /f_i ned as wounds less than six 3 At least three doses of tetanus vaccine at Patients who are severely hours old, non-penetrating with negligible tissue appropriate intervals. This de /f_i nition of “adequate immunosuppressed may not be adequately damage. course” is for risk assessment of tetanus-prone protected against tetanus, despite having wounds only. The full UK schedule is /f_i ve doses been fully immunised and additional booster 2 If TIG is not available, HNIG may be used as an of tetanus containing vaccine. alternative. Figure 3.6 Postexposure management for tetanus-prone wounds. (Redrawn with permission from https://www.gov.uk/government/publica tions/tetanus-prone-wounds-posters. © Crown copyright 2019. 2019TET02 10K OCT 2019 (APS). TABLE 3.4 Types of debridement. Excision of non-viable tissue using surgical Surgical instruments such as a scalpel, curette, scissors or rongeur until healthy bleeding occurs at the wound edges Non-selective debridement such as using irrigation, Mechanical wet-to-dry dressings and hydrotherapy. Both non viable and viable tissue may be removed Using dressings such as hydrocolloids or Autolytic transparent /f_i lms to retain moisture and allow wound enzymes to selectively liquefy non-viable tissue Chemically liquefy necrotic tissue with enzymes Enzymatic using topical agents such as collagenase or papain– urea Medical-grade larvae of Lucilia sericata r elease Biological proteolytic and antimicr obial substances to remove necr otic tissue. They also directly promote wound healing Immediate treatment Later treatment 1 Tetanus prone High risk tetanus prone None required None required Further doses as required to complete the recommended Immediate One dose of Immediate reinforcing schedule (to reinforcing human tetanus 2 dose of vaccine ensure future dose of immunoglobulin immunity) in a different site vaccine Immediate One dose of Immediate One dose of reinforcing human tetanus reinforcing human tetanus 2 2 dose of immunoglobulin dose of immunoglobulin in a different site vaccine in a different site vaccine doses or treatment may be required.

Figure 3.7 Meshing a split-thickness skin graft. (Reproduced with per- mission of MA Healthcare Limited from Hili S, Wong KY , Stephens /uni00A0 P . Pretibial lacerations. Br J Hosp Med 2017; 78 : C162–6.)

such as water and antiseptic solutions. Irrigation can also be performed with a soft brush or sponge to clear particulate mat ter prior to preoperative application of skin antiseptic prepa ration. Wounds should be explored to determine the extent of injury , including any damage to underlying neurovascular structures, tendons, joints and bones. Careful tissue handling and meticulous technique are important throughout. Repair of all damaged structures may be attempted once the wounds are clean. Repair of nerves and vessels should be performed under magnification using loupes or a microscope. Skin closure should always be without tension. Direct clo sure is not always possible and other reconstruction methods should be considered. Historically , the reconstructive ladder 8 and its variants such as the reconstructive elevator have been used as a framework to consider the simplest means to achieve wound closure for the desired goal. Advances in technology and surgical techniques have led to ongoing adjustments of these frameworks. Although these frameworks do not guide the useful reminder of the options available ( Summary box 3.4 ). - A skin graft has no inherent b lood supply and is dependent - on a well-vascularised recipient site for survival and wound healing. Split-thickness skin grafts ( Figur e 3.7 ) consist of the epidermis and a small portion of dermis whereas full-thickness skin grafts consist of the epidermis and the majority of the dermis. A flap contains tissue with its intrinsic blood supply that is transferred from one part of the body (donor) to another (recipient). The blood supply of the flap therefore does not rely on the recipient site like a skin graft. A free flap contains - tissue with its vascular pedicle that is surgically detached and transferred from its original location to a distant recipient site ( Figure 3.8 ). A microscope is used to perform microvascular anastomoses to connect the blood vessels in the free flap to blood vessels close to the recipient site. Since its development in the 1990s, negative-pressure wound therapy (NPWT) is now widely used. It is not a replace - ment for definitive wound closure but is a useful adjunct

(a) (b) Figure 3.8 Left mastectomy (a, b) and delayed left breast reconstruction with a deep inferior epigastric artery perforator free /f_l ap and nipple reconstruction (c) (d) (c, d) (©Addenbrookes Hospital).

( Figure 3.9 ). Negative pressure helps draw the wound edges together, remove exudate, reduce oedema and promote gran ulation tissue formation. NPWT is not recommended in the setting of exposed vessels, malignancy , untreated osteomyelitis, necrotic tissue or non-enteric and unexplored fistulae.

Figure 3.9 Negative-pressure wound therapy for a lower limb wound. (Reproduced with permission of MA Healthcare Limited from Hili S, Wong KY , Stephens P . Pretibial lacerations. Br J Hosp Med 2017; C162–6.) Figure 3.10 Degloving injury of the right little and ring /f_i ngers.

Post exposure management for Tetanus Prone Wounds

underappreciated and is not as simple as is often perceived. The end points of surgical debridement can sometimes be di ffi cult to determine. Healthy subcutaneous fat is yellow and soft. Muscle viability is judged by its colour, capacity to bleed and contractility . Contaminated, complex and complicated wounds often requir e more than one surgical debridement before definitive repair and closure; for example, blast injuries and necrotising fasciitis (see Part 4 ). Other types of debridement are summarised in Table 3.4 . All wounds should be irrigated at the first available oppor- tunity to reduce bacterial contamination. This also allows bet - ter visualisation for wound assessment. W arm normal saline

Immunisation Status Clean wound Those aged 11 years and over , who have received 1 with an adequate priming course of tetanus vaccine the last dose within 10 years None required Children aged 5-10 years who have received priming course and pre-school booster Children under 5 years who have received an adequate priming course Received adequate priming course of tetanus 3 vaccine but last dose more than 10 years ago None required Children aged 5-10 years who have received an adequate priming course but no pre-school booster (Includes UK born after 1961 with history of accepting vaccinations) Immediate Not received adequate priming course 3 of tetanus vaccine reinforcing (Includes uncertain immunisation status and/or born before 1961) dose of vaccine 1 Clean wounds are de /f_i ned as wounds less than six 3 At least three doses of tetanus vaccine at Patients who are severely hours old, non-penetrating with negligible tissue appropriate intervals. This de /f_i nition of “adequate immunosuppressed may not be adequately damage. course” is for risk assessment of tetanus-prone protected against tetanus, despite having wounds only. The full UK schedule is /f_i ve doses been fully immunised and additional booster 2 If TIG is not available, HNIG may be used as an of tetanus containing vaccine. alternative. Figure 3.6 Postexposure management for tetanus-prone wounds. (Redrawn with permission from https://www.gov.uk/government/publica tions/tetanus-prone-wounds-posters. © Crown copyright 2019. 2019TET02 10K OCT 2019 (APS). TABLE 3.4 Types of debridement. Excision of non-viable tissue using surgical Surgical instruments such as a scalpel, curette, scissors or rongeur until healthy bleeding occurs at the wound edges Non-selective debridement such as using irrigation, Mechanical wet-to-dry dressings and hydrotherapy. Both non viable and viable tissue may be removed Using dressings such as hydrocolloids or Autolytic transparent /f_i lms to retain moisture and allow wound enzymes to selectively liquefy non-viable tissue Chemically liquefy necrotic tissue with enzymes Enzymatic using topical agents such as collagenase or papain– urea Medical-grade larvae of Lucilia sericata r elease Biological proteolytic and antimicr obial substances to remove necr otic tissue. They also directly promote wound healing Immediate treatment Later treatment 1 Tetanus prone High risk tetanus prone None required None required Further doses as required to complete the recommended Immediate One dose of Immediate reinforcing schedule (to reinforcing human tetanus 2 dose of vaccine ensure future dose of immunoglobulin immunity) in a different site vaccine Immediate One dose of Immediate One dose of reinforcing human tetanus reinforcing human tetanus 2 2 dose of immunoglobulin dose of immunoglobulin in a different site vaccine in a different site vaccine doses or treatment may be required.

Figure 3.7 Meshing a split-thickness skin graft. (Reproduced with per- mission of MA Healthcare Limited from Hili S, Wong KY , Stephens /uni00A0 P . Pretibial lacerations. Br J Hosp Med 2017; 78 : C162–6.)

such as water and antiseptic solutions. Irrigation can also be performed with a soft brush or sponge to clear particulate mat ter prior to preoperative application of skin antiseptic prepa ration. Wounds should be explored to determine the extent of injury , including any damage to underlying neurovascular structures, tendons, joints and bones. Careful tissue handling and meticulous technique are important throughout. Repair of all damaged structures may be attempted once the wounds are clean. Repair of nerves and vessels should be performed under magnification using loupes or a microscope. Skin closure should always be without tension. Direct clo sure is not always possible and other reconstruction methods should be considered. Historically , the reconstructive ladder 8 and its variants such as the reconstructive elevator have been used as a framework to consider the simplest means to achieve wound closure for the desired goal. Advances in technology and surgical techniques have led to ongoing adjustments of these frameworks. Although these frameworks do not guide the useful reminder of the options available ( Summary box 3.4 ). - A skin graft has no inherent b lood supply and is dependent - on a well-vascularised recipient site for survival and wound healing. Split-thickness skin grafts ( Figur e 3.7 ) consist of the epidermis and a small portion of dermis whereas full-thickness skin grafts consist of the epidermis and the majority of the dermis. A flap contains tissue with its intrinsic blood supply that is transferred from one part of the body (donor) to another (recipient). The blood supply of the flap therefore does not rely on the recipient site like a skin graft. A free flap contains - tissue with its vascular pedicle that is surgically detached and transferred from its original location to a distant recipient site ( Figure 3.8 ). A microscope is used to perform microvascular anastomoses to connect the blood vessels in the free flap to blood vessels close to the recipient site. Since its development in the 1990s, negative-pressure wound therapy (NPWT) is now widely used. It is not a replace - ment for definitive wound closure but is a useful adjunct

(a) (b) Figure 3.8 Left mastectomy (a, b) and delayed left breast reconstruction with a deep inferior epigastric artery perforator free /f_l ap and nipple reconstruction (c) (d) (c, d) (©Addenbrookes Hospital).

( Figure 3.9 ). Negative pressure helps draw the wound edges together, remove exudate, reduce oedema and promote gran ulation tissue formation. NPWT is not recommended in the setting of exposed vessels, malignancy , untreated osteomyelitis, necrotic tissue or non-enteric and unexplored fistulae.

Figure 3.9 Negative-pressure wound therapy for a lower limb wound. (Reproduced with permission of MA Healthcare Limited from Hili S, Wong KY , Stephens P . Pretibial lacerations. Br J Hosp Med 2017; C162–6.) Figure 3.10 Degloving injury of the right little and ring /f_i ngers.

Post exposure management for Tetanus Prone Wounds

underappreciated and is not as simple as is often perceived. The end points of surgical debridement can sometimes be di ffi cult to determine. Healthy subcutaneous fat is yellow and soft. Muscle viability is judged by its colour, capacity to bleed and contractility . Contaminated, complex and complicated wounds often requir e more than one surgical debridement before definitive repair and closure; for example, blast injuries and necrotising fasciitis (see Part 4 ). Other types of debridement are summarised in Table 3.4 . All wounds should be irrigated at the first available oppor- tunity to reduce bacterial contamination. This also allows bet - ter visualisation for wound assessment. W arm normal saline

Immunisation Status Clean wound Those aged 11 years and over , who have received 1 with an adequate priming course of tetanus vaccine the last dose within 10 years None required Children aged 5-10 years who have received priming course and pre-school booster Children under 5 years who have received an adequate priming course Received adequate priming course of tetanus 3 vaccine but last dose more than 10 years ago None required Children aged 5-10 years who have received an adequate priming course but no pre-school booster (Includes UK born after 1961 with history of accepting vaccinations) Immediate Not received adequate priming course 3 of tetanus vaccine reinforcing (Includes uncertain immunisation status and/or born before 1961) dose of vaccine 1 Clean wounds are de /f_i ned as wounds less than six 3 At least three doses of tetanus vaccine at Patients who are severely hours old, non-penetrating with negligible tissue appropriate intervals. This de /f_i nition of “adequate immunosuppressed may not be adequately damage. course” is for risk assessment of tetanus-prone protected against tetanus, despite having wounds only. The full UK schedule is /f_i ve doses been fully immunised and additional booster 2 If TIG is not available, HNIG may be used as an of tetanus containing vaccine. alternative. Figure 3.6 Postexposure management for tetanus-prone wounds. (Redrawn with permission from https://www.gov.uk/government/publica tions/tetanus-prone-wounds-posters. © Crown copyright 2019. 2019TET02 10K OCT 2019 (APS). TABLE 3.4 Types of debridement. Excision of non-viable tissue using surgical Surgical instruments such as a scalpel, curette, scissors or rongeur until healthy bleeding occurs at the wound edges Non-selective debridement such as using irrigation, Mechanical wet-to-dry dressings and hydrotherapy. Both non viable and viable tissue may be removed Using dressings such as hydrocolloids or Autolytic transparent /f_i lms to retain moisture and allow wound enzymes to selectively liquefy non-viable tissue Chemically liquefy necrotic tissue with enzymes Enzymatic using topical agents such as collagenase or papain– urea Medical-grade larvae of Lucilia sericata r elease Biological proteolytic and antimicr obial substances to remove necr otic tissue. They also directly promote wound healing Immediate treatment Later treatment 1 Tetanus prone High risk tetanus prone None required None required Further doses as required to complete the recommended Immediate One dose of Immediate reinforcing schedule (to reinforcing human tetanus 2 dose of vaccine ensure future dose of immunoglobulin immunity) in a different site vaccine Immediate One dose of Immediate One dose of reinforcing human tetanus reinforcing human tetanus 2 2 dose of immunoglobulin dose of immunoglobulin in a different site vaccine in a different site vaccine doses or treatment may be required.

Figure 3.7 Meshing a split-thickness skin graft. (Reproduced with per- mission of MA Healthcare Limited from Hili S, Wong KY , Stephens /uni00A0 P . Pretibial lacerations. Br J Hosp Med 2017; 78 : C162–6.)

such as water and antiseptic solutions. Irrigation can also be performed with a soft brush or sponge to clear particulate mat ter prior to preoperative application of skin antiseptic prepa ration. Wounds should be explored to determine the extent of injury , including any damage to underlying neurovascular structures, tendons, joints and bones. Careful tissue handling and meticulous technique are important throughout. Repair of all damaged structures may be attempted once the wounds are clean. Repair of nerves and vessels should be performed under magnification using loupes or a microscope. Skin closure should always be without tension. Direct clo sure is not always possible and other reconstruction methods should be considered. Historically , the reconstructive ladder 8 and its variants such as the reconstructive elevator have been used as a framework to consider the simplest means to achieve wound closure for the desired goal. Advances in technology and surgical techniques have led to ongoing adjustments of these frameworks. Although these frameworks do not guide the useful reminder of the options available ( Summary box 3.4 ). - A skin graft has no inherent b lood supply and is dependent - on a well-vascularised recipient site for survival and wound healing. Split-thickness skin grafts ( Figur e 3.7 ) consist of the epidermis and a small portion of dermis whereas full-thickness skin grafts consist of the epidermis and the majority of the dermis. A flap contains tissue with its intrinsic blood supply that is transferred from one part of the body (donor) to another (recipient). The blood supply of the flap therefore does not rely on the recipient site like a skin graft. A free flap contains - tissue with its vascular pedicle that is surgically detached and transferred from its original location to a distant recipient site ( Figure 3.8 ). A microscope is used to perform microvascular anastomoses to connect the blood vessels in the free flap to blood vessels close to the recipient site. Since its development in the 1990s, negative-pressure wound therapy (NPWT) is now widely used. It is not a replace - ment for definitive wound closure but is a useful adjunct

(a) (b) Figure 3.8 Left mastectomy (a, b) and delayed left breast reconstruction with a deep inferior epigastric artery perforator free /f_l ap and nipple reconstruction (c) (d) (c, d) (©Addenbrookes Hospital).

( Figure 3.9 ). Negative pressure helps draw the wound edges together, remove exudate, reduce oedema and promote gran ulation tissue formation. NPWT is not recommended in the setting of exposed vessels, malignancy , untreated osteomyelitis, necrotic tissue or non-enteric and unexplored fistulae.

Figure 3.9 Negative-pressure wound therapy for a lower limb wound. (Reproduced with permission of MA Healthcare Limited from Hili S, Wong KY , Stephens P . Pretibial lacerations. Br J Hosp Med 2017; C162–6.) Figure 3.10 Degloving injury of the right little and ring /f_i ngers.