How should I manage a patient with a dirty wound who has uncertain tetanus vaccination history?

For a patient with a contaminated wound and an uncertain tetanus vaccination history, treat the wound as tetanus-prone and administer an immediate reinforcing dose of tetanus vaccine plus one dose of human tetanus immunoglobulin (HTIG) at a different site.

If HTIG is not available in primary care, refer the patient urgently to the emergency department for administration.

A full course of tetanus immunization will likely be required to complete future protection.

Advise the patient to keep the wound clean and dry, monitor for signs of infection such as increasing pain, redness, swelling, fever, or malaise, and to seek medical attention if these occur.

Use clinical judgment to assess the wound’s risk, noting that wounds with heavy contamination, devitalized tissue, or delayed surgical intervention (>6 hours) are high-risk tetanus-prone wounds.