Tetanus Post-Exposure Prophylaxis — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Wound type
   Which wound type? (Clean minor wound vs tetanus-prone wound (contaminated with soil/feces/saliva, puncture, crush, missile, burns/frostbite, necrotic tissue, compound fracture). Thorough wound debridement is required regardless of type.)
   • Clean minor wound → Clean minor wound · history
   • Tetanus-prone wound → Tetanus-prone wound · history
2. [Decision] Clean minor wound · history
   Tetanus vaccination history? (Those with a prior complete ≥3 doses are decided by time since the last dose; <3 doses or unknown are treated as unimmunized. The threshold for a clean minor wound is 10 years.)
   • ≥3 doses and last <10 years → No vaccine or TIG needed
   • ≥3 doses but last ≥10 years → Booster vaccine (no TIG)
   • <3 doses or unknown → Booster vaccine (no TIG)
3. [Decision] Tetanus-prone wound · history
   Tetanus vaccination history? (Tetanus-prone wounds have a stricter threshold (5 years); <3 doses or unknown history need TIG.)
   • ≥3 doses and last <5 years → No vaccine or TIG needed
   • ≥3 doses but last ≥5 years → Booster vaccine (no TIG)
   • <3 doses or unknown → Vaccine + TIG
4. [End] No vaccine or TIG needed
   Primary immunization complete and within the valid window: no tetanus vaccine or TIG needed. Thorough debridement, counsel and observe.
5. [End] Booster vaccine (no TIG)
   Give a tetanus-toxoid-containing vaccine (Tdap preferred, otherwise Td), no TIG needed. Thorough debridement; if primary immunization is incomplete, arrange the remaining doses.
6. [End] Vaccine + TIG
   Tetanus-prone wound with <3 doses/unknown history: a tetanus-toxoid-containing vaccine + tetanus immune globulin (TIG) 250 U IM, given at the same time at different sites with different syringes. Thorough debridement; arrange to complete primary immunization. HIV/severe immunodeficiency with a contaminated wound get TIG regardless of history.

Source guidelines & references

• CDC/ACIP tetanus prophylaxis in wound management. MMWR 2018 (and updates)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways