URGENT input requested, please. Tetanus-prone injury? - Mothering Forums

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#1 of 13 Old 06-18-2010, 12:45 PM - Thread Starter
 
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On Wednesday afternoon my daughter got a small puncture wound. She was at MIL's and apparently jumping on the sofa and some sort of pin or needle that had been in the sofa forever (MIL thinks since she bought it 20 years ago) pierced the side of her foot. MIL wasn't sure how deep it went in, but said it was stuck in and she had to pull it out.

It only bled a tiny bit - maybe a drop or two.

It is a small puncture wound and it looks fine for now - slightly raised bump, slightly red around the injury.

MIL has a dog and two cats, and has always had cats, in case that is relevant at all (I was under the impression it could be).

My daughter is 4 years old and had one DTaP at 7 mos.

My understanding is that TIG would be appropriate if it were a tetanus-prone injury with that low level of vaccination. I called her doctor as soon as I found out about the injury, which was yesterday around noon. I thought she might need TIG. I unfortunately was not able to speak with her doctor and the nurse gave me, apparently, completely incorrect information. Based on that info, we went to the local acute care center (for a shot - TIG). They were awesome and didn't give us a hard time about not being "up to date." However, the doctor there didn't think it was a tetanus-prone injury since it was small and occurred inside the home, not an especially "dirty" place.

He didn't know a whole lot about TIG, although he did show me a package insert and talk with me about it. They did not have the TIG for kids under 7. They also did not have the pediatric DTaP, which is of course what he was recommending for her.

Does the ped DTaP protect against tetanus after exposure? I thought you were supposed to get TIG if you were concerned about low vaccination status and possible tetanus.

I'm also not sure if the wound qualifies; that's really what I wanted to hear from my daughter's doctor. It is a puncture wound, it was at least a somewhat dirty needle/pin, and the wound hardly bled. However, it's also small and occurred indoors. It's not clear to me how risky that is.

I know she needs something within 72 hours to prevent tetanus if tetanus risk is there. Because of the high mortality rate with tetanus, it really does concern me (at least 20% mortality, not to mention the horrible suffering). I would rather she get one shot now and know that we have eliminated that preventable risk. She was all ready to get the shot and then it didn't happen (I had prepared her and promised ice cream afterwards).

The nurse and receptionist at my daughter's doctor's office treated me horribly and with zero respect. I don't even want to get into that aspect of it. But I need more, any info anyone can give me to get a better handle on this. I've read the TIG package insert. It doesn't tell me enough.

Also, I don't understand the recommendation to get the DTaP. Does it have a protective/preventative effect in this kind of case? I thought the ONLY reason it was recommended was to make sure someone with low vax status got vaccinated, not to prevent a case of tetanus. I would be furious if we got DTaP unnecessarily and she DIDN'T get what she actually needed, if she needed TIG.

Thanks to anyone who can help. I'm also going to follow-up with her doctor today, but I would like as much information as possible since it has now been almost 48 hours since the injury and we are running out of time on that 72-hour window, especially with the weekend coming.
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#2 of 13 Old 06-18-2010, 12:54 PM
 
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This web site says and/or for the TIG and DTAP. I think you need to take your daughter in.

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Post-exposure tetanus prophylaxis also involves getting tetanus shots, but after an injury occurs. Shots given will depend on the number of years since the patient's last booster, the total number of tetanus vaccinations the patient has received, and the nature of the wound. The doctor may recommend a tetanus booster (Td , DTaP, or Tdap, depending on the patient's age and previous immunizations) and/or an injection of tetanus immune globulin (TIG)...
http://kidshealth.org/parent/infecti.../tetanus.html#

you can also call your local health dept if there is a problem finding the vax.
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#3 of 13 Old 06-18-2010, 01:06 PM
 
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My understanding is that a tetanus vaccination shot now will not prevent tetanus. Only TIG or if that is not available, I believe IVIG can work also.

I've had IVIG during fertility treatments. Not sure if TIG is like IVIG, but if it is, it is dripped in via an IV and can take a couple of hours depending on the dose.

I'm going to do some googling and see what else I can find for you... but wanted to start with what I recalled off the top of my head.

Poppan ~ twins born April 2007
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#4 of 13 Old 06-18-2010, 01:20 PM
 
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How much deeper did this needle go than a splinter? Did your mom clean the wound? Does your dd have any circulatory issues?

What makes you think this is a tetanus prone injury? It just sounds like a little needle prick to me and not a deep puncture wound.

I guess I probably wouldn't worry about it. If the doctors aren't freaking out, that should tell you something... they seem to really like to panic over tetanus.
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#5 of 13 Old 06-18-2010, 01:24 PM - Thread Starter
 
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Sleepless, I did take her in. The acute care doctor said (1) they did not have pediatric DTaP, and (2) they did not recommend the TIG. However, it's my understanding that only TIG will be beneficial to her at this point to prevent tetanus if she's at risk. The way the acute care doc talked about it, he didn't think the wound merited TIG. He was not going to give her the TIG unless specifically ordered to by her doctor.

Poppan, that is what I've been finding, but the recommendation still exists to give the DTaP and the acute care doctor couldn't tell me why. Doesn't it take time for the DTaP to induce immunity? I had always throught the recommendtion to get the DTaP wasn't related to the current injury but instead was an attempt to prevent a future problem/make sure people are "up to date." If that's the case, getting the DTaP wouldn't protect her now and whether we get that is a separate matter - and certainly the timing is irrelevant; I don't have to make a split-second decision. I don't think the DTaP would be effective as a booster at this point, since she's only had one and it was so long ago.

I did a bunch of searching in this forum and found basically that kind of info, but I'm struggling with getting factual confirmation as opposed to conversation.

Quote:
If the event of a puncture or other deep wound, clean the wound and call the doctor to discuss whether your child should receive post-exposure tetanus prophylaxis.
Exactly what I did. Now if we had just received the care we NEEDED from her doctor, I wouldn't be in this position. I'm so angry about that.
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#6 of 13 Old 06-18-2010, 01:29 PM - Thread Starter
 
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Originally Posted by ammiga View Post
How much deeper did this needle go than a splinter? Did your mom clean the wound? Does your dd have any circulatory issues?

What makes you think this is a tetanus prone injury? It just sounds like a little needle prick to me and not a deep puncture wound.
I don't know how deep the needle/pin was in there. It was my MIL who pulled it out and she wasn't sure when I asked her. Apparently my daughter was jumping on the sofa and suddenly started screaming; MIL went over, saw the pin sticking out of her foot, had her sit down, and then pulled it out. There was a tiny bit of blood - drop or two, she said - and that was it.

My concern as to it possibly being a tetanus prone injury is that it is a puncture wound. The link Sleepless posted said unsanitary needles can result in tetanus infection. But it's part of my question. What really IS a tetanus-prone injury? Does this count? I'm concerned because it is a puncture wound that essentially did not bleed, and I wouldn't call a 20-year-old needle in MIL's house "sanitary."

My daughter does not have any circulatory issues. She's 100% perfectly healthy, thankfully.
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#7 of 13 Old 06-18-2010, 01:31 PM - Thread Starter
 
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You also asked if MIL cleaned the wound. She didn't think anything of the injury, really. I think she might have wiped it off and that's all. When my daughter came home, she was wearing socks and sandals and the wound had fully closed since it had been 24+ hours.

ETA: Correction - MIL did clean the wound. It bled one drop of blood. She washed it with antibacterial dish soap and then put hydrogen peroxide on it.
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#8 of 13 Old 06-18-2010, 01:41 PM
 
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Just read the CDC's MMWR Tetanus Surveillance Report... it was reassuring to see that it was an average of 41 cases per year from 1995-1997 (the last years for which a surveillance report is available).
http://www.cdc.gov/mmwr/preview/mmwrhtml/00053713.htm
Worth noting that approximately 1/3 of the cases happened with injuries sustained indoors; however, a number of them were drug users and I assume many of them shot up indoors? Also, three cases were post-surgery and I guess that also counts as indoors. I am concluding that outdoors injuries are more risky.

ACIP/CDC recommendation for wound management apparently says:
http://www.medscape.com/druginfo/mon...mune+Globulin+
Quote:
The US Public Health Service Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) state that TIG is not necessary for postexposure prophylaxis in patients with clean, minor wounds (regardless of their immunization status)
Also, from the tetanus surveillance report it seemed in most cases they administered TIG only after onset of disease. Another thing worth noting is that tetanus is more prevalent in certain geographical areas, and some areas seem to report cases only very rarely, if ever. The "safer" areas are the rocky mountains and parts of new england (unfortunately it didn't get more specific than that in the surveillance report). Also, it affects old people (age >60) more than young people, but that could be because kids mostly get vax'd on schedule (???).

I personally think your daughter is probably OK.

Poppan ~ twins born April 2007
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#9 of 13 Old 06-18-2010, 01:44 PM
 
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Originally Posted by Romana View Post
Also, I don't understand the recommendation to get the DTaP. Does it have a protective/preventative effect in this kind of case? I thought the ONLY reason it was recommended was to make sure someone with low vax status got vaccinated, not to prevent a case of tetanus.
The toxoid vaccine can in fact have a protective effect in the case of acute injury. The spores can hang out before they germinate, and TIG only binds free tetanospasmin for a while. In the case of active C. tetani infection, there's still the question of how quickly a booster shot can ramp up the immune response versus how fast tetanospasmin might be advancing toward the CNS for someone with limited existing immunity, but that's not a question I can meaningfully answer.
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#10 of 13 Old 06-18-2010, 02:00 PM - Thread Starter
 
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So Otto, it is thought that boosting might help, but not known if it actually does.

Poppan, I'm not sure this is a "clean" wound. Minor, yes, but it's a puncture that hardly bled at all. If dirty needles are the source in some cases, it could be here, right?

I also think she is most likely fine. I'm just not sure if the benefits of prophylaxis for this injury wouldn't still be worth it. And I'm having trouble figuring that out with limited information, you know?

My husband is calling the doctor for his opinion. After the horrible treatment I got yesterday from the receptionist and nurse, I am just not up to being the one to have that conversation right now. The kids see a good family practice physician who has a number of unvaxed kids in the practice. He should understand the issues with this kind of injury and tetanus/vax status and hopefully will be able to give us an opinion and information we can rely on.
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#11 of 13 Old 06-18-2010, 02:24 PM
 
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Quote:
Originally Posted by Romana View Post
So Otto, it is thought that boosting might help, but not known if it actually does.
In terms of the latter scenario, it's not known by me. I imagine it's a question for an immunologist or infectious disease specialist. As for the possibility of late-germinating spores, I think the logic is clear, but I'd rather have a clinician determine whether it's actually applicable in any given case.

FWIW, the susceptibility of those who "skin pop" prepowdered street opiates has been suggested to be related to the use of quinine as a cutting agent. I suspect that you're at very low risk, but I've thought that about myself in the past and been quite wrong.
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#12 of 13 Old 06-18-2010, 02:37 PM
 
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Interesting, this just happened to me a couple nights ago. I stepped on a sewing needle (in my home) that went pretty deep into my foot. It just bled a little bit, I washed it, and that was that. I didn't feel TIG was necessary...I'm healthy, no immune problems, etc.

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#13 of 13 Old 06-18-2010, 05:56 PM
 
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I can't even remember the number of time's I've stepped on a thumb tack or pricked myself with pins or gotten splinters. It's been over 25 years since I've gotten a tetanus shot. I haven't thought twice about any of those injuries. Tetanus is really rare. It's more likely I'll be struck by lightning sometime in my lifetime. 1/6250 http://www.weather.gov/om/lightning/medical.htm

Wife to DH, Mom to my Intact Boys DS1: Born 02 Pain Med Free Hospital Birth, BF'ed for 9 Months, Partially Vax'd DS2: Born 06 via UC, BF'ed 3 years 10 months, and UnVax'd
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