Instruments, Sutures, Staples, Tape, and Tissue Adhesives
The technical approach for wound closure depends on the host and wound factors of the laceration. Sutures, staples, surgical tape, closure devices, and tissue adhesives each have intrinsic pros and cons for their use (Table 32-1). Most wound repairs can be accomplished with basic instruments and supplies (Fig. 32-2) as well as gloves,7,8 personal protective equipment, anesthetic agent(s), and irrigation equipment.
TABLE 32-1Advantages and Disadvantages of Common Wound Closure Techniques |Favorite Table|Download (.pdf) TABLE 32-1 Advantages and Disadvantages of Common Wound Closure Techniques
Greatest tensile strength
Lowest dehiscence rate
Greatest tissue reactivity
Highest risk of needle stick
Low tissue reactivity
Low risk of needle stick
Less meticulous closure
May interfere with imaging techniques
Resistant to bacterial growth
No need for removal
Low or no risk of needle stick
Lower tensile strength than sutures
Dehiscence over high-tension areas
Not useful on hands
Lowest infection rates
No risk of needle stick
Frequently falls off
Lower tensile strength than sutures
Highest rate of dehiscence
Requires use of toxic adjuncts
Cannot be used in areas with hair
Cannot get wet
Standard laceration equipment.
A number of needle types are available for use, and manufacturers generally place a life-size and cross-sectional diagram of the needle on each suture package. Typical ED wound repair can be accomplished with reverse precision point cutting needles that are manufactured in various sizes, curvatures, and paired with differing thread types.
Suture choice is one of the most fundamental options in wound and laceration repair. Each suture type has inherent characteristics that are suited for specific uses. The most basic choice is absorbable versus nonabsorbable suture material. Historically, absorbable suture was relegated to use as a deep (nonepidermal) closure, whereas nonabsorbable sutures were used externally (epidermal). Recently, strong consideration has been given toward the use of absorbable suture externally to eliminate the need for return visit for suture removal.9 Because of the inflammatory response that absorbable sutures generate during the degradation process, the cosmetic outcome must be considered. Using absorbable sutures on noncosmetically important areas (extremities, trunk) has been studied and accepted10; the use of absorbable sutures on cosmetically critical regions (the face) has been studied with good outcomes compared with other standard methods.11 Each wound requires a certain tensile strength for a certain amount of time and the characteristics of each suture type should be understood (Table 32-2).
TABLE 32-2Suture Types and Characteristics |Favorite Table|Download (.pdf) TABLE 32-2 Suture Types and Characteristics
Type and Material
Easy to handle
Lies flat when tied
Forms secure knot because of presence of braid
Induces more tissue reaction and has higher infection potential than other nonabsorbable materials
Less tissue reactivity and infection potential
Does not tend to lie flat
More difficult to handle than silk
Decreased knot security because of lack of braid requires more throws per knot
Similar to the properties of nylon sutures, although slightly easier to handle
Infection potential greater than nylon and polypropylene, but less than silk and cotton
Easier to handle and better knot security than nylon and polypropylene
Low tissue reactivity and infection potential
Difficult to handle
Uncomfortable for patient during healing
Equivalent to nylon and polypropylene in tensile strength and low infection potential
Stretches easily, thus advantageous for wounds that tend to swell
Phagocytized by macrophages
Maintains tensile strength for ∼7 d
High tissue reactivity and infection potential
Similar to the properties of plain gut sutures, but maintains tensile strength for ∼2–3 wk
Similar to the properties of plain gut sutures, but breaks down gut within 5–7 d, thus does not require removal with scissors
Polyglycolic acid and polyglactin
Cause less tissue reactivity and have lower infection potential than gut sutures
Absorbed by enzymatic hydrolysis
Braided, thus hold knots well, but have lots of drag through tissues if not coated with materials that reduce friction
Gradually loses tensile strength over ∼4 wk
Polydioxanone, polyglyconate, poliglecaprone, and glycoside
Synthetic monofilament (pass more smoothly through tissues)
Cause less tissue reactivity than gut sutures
Absorbed by enzymatic hydrolysis
Retain ∼60% of tensile strength at 28 d
Surgical staples are a useful alternative to suturing for selected wounds. Sharp lacerations of the scalp, trunk, and extremities are rapidly and effectively closed using staples. Staples induce a minimal inflammatory reaction and produce similar cosmetic results compared with suturing. Staples are often not well suited for use in stellate or angulated wounds, hand wounds, or wounds which sit in recessed contours of the body. Recall that staples are hard and relatively nonmalleable when compared with sutures (Fig. 32-3). When stapling the scalp, ask the sleep position preference for patients or consider the position in which they will lay while hospitalized. Metallic staples are also radiopaque and give off a significant artifact when CT scan imaging is obtained. Magnetic resonance imaging (MRI) of metallic staples is safe as long as consideration is given to the heat that may be generated during the MRI. Absorbable intradermal staples offer the advantage of rapid closure without the side effects of CT scan artifact or MRI heat development.
Steri-strips are an effective alternative for the closure of small linear lacerations that are under minimal tension (Fig. 32-4). Taped wounds offer an advantage over sutured wounds in that they do not require return to the ED for removal. If applied with an adhesive, such as tincture of benzoin, tape should remain in place for several days. Tape can also be used for skin closure of partial-thickness wounds and of wounds that are closed in a layered fashion with well-approximated wound edges. Tape closure is a reasonable alternative technique for the repair of multiple tangential skin flaps.
Skin-closure tapes should be applied perpendicular to the wound edges and spaced so that the edges do not gape.
Tissue adhesives have been used for many years and remain another option for rapid repair of pediatric lacerations. Adhesives have less tensile strength across wound edges and are therefore suited for use in low-tension wounds.12,13 The failure of adhesives is typically because of the poor choice of wound type for adhesive use. Adhesives should not be used in wounds with high mobility (fingers, across joints). If you have concern that adhesives would not provide the strength, consider using deep absorbable sutures to provide that necessary strength, or avoid adhesives altogether. If tissue adhesives are to be used near the eye, use a ribbon of petroleum as a barrier to protect against inadvertent instillation of the adhesive into the eye. If the eye is accidentally glued shut, careful use of nail polish remover will free the eyelashes—do not cut the lashes. Although tissues adhesives provide their own waterproof and antimicrobial barrier, wound preparation remains very important for wounds repaired with tissue adhesives as it does with any other wound closure method. Take care to ensure that adequate anesthesia, wound irrigation, and wound exploration occur regardless of the method of closure. With the right choice of wound, noninvasive repair can be faster, less painful, require no suture removal follow-up, and results in patient and parental satisfaction.14
Analgesia, Local Anesthesia, Nerve Blocks, and Sedation
Most wounds are adequately anesthetized using local infiltration of lidocaine, 1% to 2% with or without epinephrine. Lidocaine has a rapid onset of action and duration of action of approximately 1 to 2 hours. Commercial preparations/dilutions of epinephrine containing anesthetics are safer than older literature suggests and their use in regions supplied by end-arteries has been shown to be safe.15 Consider the use of a longer-acting agent, such as bupivacaine, to spare patient repeated injections if wound repair may be interrupted. Bupivacaine's onset of action is moderate, and duration of action is approximately 2 to 6 hours.16 Take care not to use more than the recommended dose per kilogram of the local anesthetic agent. For plain lidocaine and lidocaine with epinephrine, 4.5 and 7 mg/kg are the recommended maximum doses, respectively.17 Buffering lidocaine with bicarbonate, in a 10:1 dilution, and warming the anesthetic agent may also reduce the pain of injection.18,19
Anesthetic infiltration should be performed prior to irrigation; however, for grossly contaminated wounds, it is occasionally necessary to irrigate away gross contaminates first. Infiltration is achieved by means of a 25- to 27-gauge needle, injected slowly into the wound margins.20
Strongly consider the use of topical anesthetics on any wound prior to injectable anesthetics as an adjuvant to care.21 Topical lidocaine–adrenaline–tetracaine (LAT), as well as tetracaine–adrenaline–cocaine (TAC), provides effective anesthesia for pediatric facial and scalp lacerations.22,23 Use of LAT has compared favorably with TAC without the risks and administrative complications of cocaine.24 The mixture can be applied to the wound by using saturated sponges, gauze pads, or cotton swabs held in place by a parent or caregiver wearing gloves. Transient anesthesia can also be obtained by applying a solution of 4% lidocaine to a wound prior to infiltration anesthesia or to an abrasion that requires mechanical scrubbing.
Use regional nerve blocks for large lacerations and for lacerations in areas where the anatomy will be distorted if local infiltration is performed. They are especially useful for anesthetizing digits, for facial lacerations, and wounds of the foot.
Moderate sedation is usually not required for the management of wounds in older children. However, for the child who is too uncooperative to permit adequate wound management, consider sedation with agents such as midazolam, nitrous oxide, or ketamine. Perform appropriate cardiac and respiratory monitoring during sedation. There should be constant attendance of the patient, and have available airway management equipment at the bedside, as well as having readily available reversal agents (naloxone and flumazenil). The patient should be discharged after the agents have worn off and the child has returned to an appropriate level of consciousness.
Some form of physical restraint during wound assessment and management may be necessary for children younger than 2 years and sometimes is required for children up to 5 or 6 years. A child may be immobilized using a folded sheet or a commercially available papoose board. Neither method provides adequate immobilization of the head. The perceived time benefit obtained through the use of physical restraints should be carefully balanced against the potential psychologic stressors that physical restraints might put on a child and/or the parents. Careful selection of a case for either chemical and/or physical restraint requires a thorough discussion of risk/benefit of each modality with the parents.
Hemostasis is necessary during all stages of wound management and usually is achieved by applying direct pressure for 10 to 20 minutes. For control of more brisk bleeding, include elevation of the wound, infiltration of lidocaine with epinephrine, packing with absorbable gel foam, temporary instillation of hemostatic topical agents into the wound, or direct visualization and cautery or ligation of the offending vessel. Short-term (<30 minutes) tourniquet use may be helpful for control of persistent, profound, or multiple sites of distal blood loss. Do not suture or clamp vessels blindly because of the risk of injuring adjacent structures.
Clean the skin surrounding the wound prior to wound irrigation and repair. Various antiseptic skin cleansers can be used, including povidone-iodine and chlorhexidine gluconate. Avoid mechanical scrubbing of the wound unless there is gross contamination. Although scrubbing can remove debris from the wound, it increases wound inflammation. If it is decided to perform scrubbing, use a fine-pore sponge to minimize tissue abrasion and a nonionic surfactant to minimize tissue toxicity and inflammation.
As infection rates are significantly greater in wounds that are shaved, remove hair by clipping if it interferes with the procedure. In almost all wounds, even those to the scalp, hair removal is not necessary. Moistening the hair in the area of the laceration with lubricating jelly usually keeps it out of the way. Never shave or clip the eyebrows. They serve as valuable landmarks for alignment during wound repair and, if removed, can take a long time to grow back.
Irrigation with between 5 and 8 psi of normal saline is the method of choice for removing bacteria and debris from most wounds.25 Low-pressure irrigation with a bulb syringe does not adequately remove bacteria and debris from a wound. The pressure delivered by a simple assembly consisting of an 18- to 20-gauge plastic catheter or needle attached to a 30-mL syringe is 6 to 8 psi. Commercial systems to facilitate irrigation are available, including spring-loaded syringes with one-way valves connected to a standard intravenous (normal saline) setup, prepackaged irrigation fluids with irrigation nozzles, and cap devices that attach to standard fluid containers. Regardless of the system used, maintain the tip of the irrigation device between the wound and 5 cm above the intact skin. Use between 50 and 100 mL per centimeter of length or per square centimeter of wound, with more irrigation for increasing wound complexity or contamination.
Normal saline remains the default irrigation fluid, and is relatively inexpensive, decreases bacterial loads, and reduces wound infection rates. However, it is not bactericidal. Commercial strength povidone-iodine solution is tissue toxic and has no beneficial clinical effect on wound infection rates. When it is diluted to a 1% solution, however, it does not damage tissue and still retains its bactericidal properties but has no proven clinical benefit.26 Tap water is cheaper than normal saline and is without tissue toxicity. Various methods of tap water irrigation have been evaluated, and as long as irrigation pressures remain in the 5 to 8 psi range, tap water is equivalent to normal saline.27–29
A consequence of irrigation is splatter, which can be minimized using one of many techniques.30 Commercially available plastic shields that attach directly to the irrigation syringe provide good protection against splatter while permitting visualization of the wound. An inexpensive version of these plastic shields is formed by puncturing the base of a plastic medication cup with the irrigation needle.
After anesthesia, perform wound exploration on all injuries to determine the extent of damage and to remove foreign material. The failure to diagnose foreign bodies in wounds is a frequent cause of litigation against emergency physicians.31 Remove large debris from the wound with forceps. Inert foreign bodies such as glass or metal should be removed if possible (Fig. 32-5). Radiographs are occasionally required for precise localization of a foreign body, which can be aided by taping a radiopaque marker such as a paper clip to the skin overlying the suspected location. Other studies that can aid in the localization of foreign bodies include ultrasonography, CT scan, and MRI. If an inert foreign body is small and cannot easily be removed, it may be left in place and the patient or parent informed of its presence. Organic foreign bodies require urgent removal to prevent inflammatory reactions and potential infection. Consultation or urgent follow-up for surgical removal is warranted in cases where this type of material cannot be removed in the ED. Regardless of the findings on examination, or your ability to remove foreign bodies from the wound, parents and patients should be warned of potential residual contaminants in dirty wounds.
Debridement is necessary in the management of contaminated wounds or wounds with nonviable tissue. Through removal of contaminants and devitalized tissue from wounds, debridement increases a wound's ability to resist infection, shortens the period of inflammation, and creates a sharp, trimmed wound edge that is easier to repair and more cosmetically acceptable. If the devitalized edge of an irregular wound is debrided, the subcutaneous tissue of the wound can be undermined to avoid excess tension on the wound.
Perform primary closure, using sutures, staples, tape, or tissue adhesive on lacerations that were recently sustained (<24 hours on the face and <12 hours on other areas of the body), are relatively clean, and have minimal tissue devitalization. Before beginning closure, identify all the injured layers, such as fascia, subcutaneous tissue, muscle, tendon, and skin. During repair, always match each layer edge to its counterpart and ensure that when the sutures are placed, they enter and exit the appropriate layer at the same level so there is no overlapping of layers. A laceration that has been appropriately closed in layers usually does not need large or tight skin sutures to complete the closure. However, in hands and feet, placement of deep sutures increases the risk of infection, and they should be avoided in these areas.
The size of suture to be used for wound closure depends on the tensile strength of the tissue in the wound. Use 3-0 suture for tissues with strong tension, such as fascia in an extremity, and 6-0 suture for tissues with light tension, such as the subcutaneous tissue of the face.
Deep (buried) sutures serve four key functions and are required for many lacerations to ensure the best cosmetic result. They provide 2 to 3 weeks of additional support to the wound after skin sutures or tape is removed. They help preserve normal function of the underlying or involved muscles if the muscular fascia is sutured. They reduce the likelihood of development of a hematoma or abscess by minimizing the potential space. They avoid pitting in the injured region caused by inadequate healing of the deep tissues.
Unfortunately, deep sutures can result in damage to nerves, arteries, and tendons and can increase the risk of infection. As suture material is a foreign body, even in clean or minimally contaminated wounds, use as few deep sutures as necessary. The most common deep suture for laceration repair is the buried knot stitch, where one begins and ends at the base of the wound so as to bury the knot (Fig. 32-6).
Buried subcutaneous stitch. This is particularly useful when approximating the subcutaneous tissue just beneath the skin edge, because it prevents irritation of the skin edge by the knot.
The buried horizontal mattress stitch results in passage of suture material at the dermal–epidermal junction, with the knot placed subcuticularly below the dermis. The subcuticular stitch is a running buried suture at the dermal–epidermal junction that is actually used for skin closure (Fig. 32-7). Enter the skin initially, approximately 3 mm to 2 cm from one end of the laceration, and allow the needle to emerge at the subcuticular plane at the wound apex. Pass the suture through the subcuticular tissue on alternate sides of the laceration. The point of entry of each stitch should be directly across from or slightly behind the exit point of the previous stitch. At the other end of the laceration, burrow the needle again into the dermis to exit the skin 3 mm to 2 cm from the end. Ensure that there is no skin puckering, and then tape the free suture at both ends of the laceration in place. This stitch can be left in place if absorbable suture is used, or can be removed in 2 to 3 weeks if nonabsorbable suture is used.
Subcuticular stitch. (See text for discussion.)
If you choose to repair the epidermis and superficial layer of the dermis with sutures, place sutures such that the same depth and width is entered on both sides of the incision. A key to cosmetically acceptable closure is edge eversion, which is obtained by entering the skin at a 90-degree angle, and, in some cases, by using a skin hook. For wounds whose edges tend to invert despite proper technique, vertical mattress stitches can be used (Fig. 32-8). The number of sutures used to repair a laceration will vary with each case. For facial lacerations, sutures are generally placed 2 to 4 mm apart and 2 to 3 mm from the wound edge.
A–E. Vertical mattress stitch. (See text for discussion.)
Simple Interrupted Stitch
The simple interrupted stitch is used most frequently for skin closure (Fig. 32-9). It involves placing separate loops of suture using proper eversion technique, followed by tying and cutting each stitch. Although it is time-consuming, if one stitch in the closure fails, the remaining stitches will hold the wound together. This technique is useful for stellate lacerations, wounds with multiple components, and lacerations that change direction. It is also helpful for approximation of landmarks on the skin, to achieve the best cosmetic result.
Simple interrupted stitch (with buried subcutaneous stitch). (See text for discussion.)
The running or continuous stitch is well suited for pediatric laceration repair for numerous reasons (Fig. 32-10): first, it is rapid; second, removal is easier; third, it provides more effective hemostasis; and finally, it distributes tension evenly along its length. The technique cannot be used over joints because if one point were to break, the entire stitch would unravel.
The simple continuous stitch. A, B. This continuous suture is begun with a single suture that is tied to anchor the rest of the suture. The needle should be passed perpendicular to the skin edge and the suture threads should lie perpendicular to the wound margin, as with the simple interrupted suture. C. To finish and tie off this continuous suture, grab the loop formed at the free end after insertion of the needle through the skin at its midpoint with the needle holder and pull on this loop. It will come together as if it were a single thread. Tie the needle end of the suture material and this “looped” free end as a simple interrupted suture would be tied. To complete the simple continuous stitch, a series of square knots is tied, with the loop as one of the ties.
To begin a simple running stitch, place an interrupted stitch at one end of the wound and cut only the free end of the suture. Continue suturing in a coil pattern, ensuring that the needle passes perpendicularly across the laceration with each pass. After each pass, tighten the loop slightly so that tension is equally distributed. To complete the stitch, place the final loop just beyond the end of the laceration and tie the suture with the last loop used as the tail. An interlocking continuous stitch can be used to reduce slippage of loops and for more irregular lacerations (Fig. 32-11). It is performed by pulling the needle through the previous loop each time it exits the skin. However, if the loops are tied too tightly, the resultant imprinting of the skin can increase tissue scarring.
Continuous single lock stitch. (See text for discussion.)
The horizontal mattress stitch can be used for single-layer closure of lacerations under tension (Fig. 32-12). It approximates skin edges closely while providing some eversion, and decreases the time needed to suture because half the number of knots are tied. A running horizontal mattress suture can be used in areas of the body where loose skin could overlap or invert easily, such as the upper eyelids (Fig. 32-13).
Horizontal mattress stitch. A. The needle is passed 0.5 to 1 cm away from the wound edge deeply into the wound. B. The needle is then passed through the opposite side and reenters the wound parallel to the initial suture. C. One must enter the skin perpendicularly to provide some eversion of the wound edges and must enter and exit both the wound and skin at the same depth, otherwise “buckling” and irregularities occur in the wound margin. D. The suture loop is then tied as shown.
Continuous mattress stitch. (See text for discussion.)
The half-buried horizontal mattress stitch (corner stitch) is the suture of choice for closure of complex wounds with angulated (V-shaped) flaps (Fig. 32-14). Enter and exit the skin directly across from the flap and course the suture loop within the subcuticular tissue of the flap to maximize blood supply to the tip of the flap.
A, B. Half-buried horizontal mattress stitch. This minimizes the vascular compromise at a corner flap. (See text for discussion.)
The vertical mattress stitch is helpful to evert skin edges (Fig. 32-8). It is useful in areas of the body with little subcutaneous tissue. The stitch begins in the same way as a simple interrupted stitch, but after the loop is made, re-enter and re-exit the skin approximately 1 to 2 mm from the wound edge and tie. A common technique is to alternate vertical mattress stitches with simple interrupted stitches to close a wound.
When wound edges are not precisely aligned, an excess of skin on one or both ends (dog-ears) result. A dog-ear can be corrected using the following technique (Fig. 32-15). First, elevate the excess skin with a skin hook and make an oblique incision from the apex of the wound toward the side of the dog-ear. Then undermine the flap and lay it flat, excise the excess triangle of skin, and complete the closure.
A–C. The dog-ear. (See text for discussion.)
Secondary closure is a technique that allows wounds to heal by granulation and re-epithelialization. It is used to manage ulcerations, drained abscess cavities, deep puncture wounds, older or infected lacerations, and many animal bites. Daily packing may be performed with saline-soaked gauze until granulation tissue closes the potential space.
Delayed Primary (Tertiary) Closure
Delayed primary closure with sutures is performed on wounds 3 to 5 days after they have been initially cleansed, debrided, and dressed appropriately.32 Wounds amenable to this form of closure are those too contaminated for primary closure but not associated with significant tissue loss or devitalization. The utility of antibiotics during this “watch and wait” approach has not been closely studied.
Wound Dressing, Drains, and Immobilization
Sutured and stapled lacerations heal best in a moist environment. Thus, after laceration repair with sutures or staples, cleanse the skin of residual blood and povidone-iodine, and apply a light coat of antibiotic ointment. 33 If the antibiotic ointment is to be used only for maintaining a moist environment, apply a nonadherent dressing to the laceration instead. Use a second layer of sterile gauze, or adhesive bandage. Alternatively, use an occlusive or semiocclusive dressing. If there is potential for the formation of a hematoma, apply a pressure dressing, taking care to avoid compression of arterial, venous, and lymphatic circulations.
Drains should rarely be used in sutured wounds. They act as foreign bodies and may promote rather than prevent infection. If a wound is considered a high risk for infection, attempt delayed primary closure rather than suturing and placing a drain in the wound. Drains should also not be used for hemostasis, which is better achieved by proper laceration repair, electrocauterization, and pressure dressings.
Splint a wound overlying a joint in the position of function for 7 to 10 days. For children, a bulky dressing may act as a splint and minimize motion at the wound, as well as prevent the child from tampering with the wound repair; it is especially helpful for hand and foot wounds.
Antibiotic use and Tetanus Prophylaxis
More than 95% of wounds treated in the ED heal without complications if given appropriate wound care. Antibiotics should be considered in a few instances.34 Antibiotics should be given to patients who present with a wound infection. Other indications are for wounds heavily contaminated with feces or saliva, which may best be treated initially with secondary or delayed primary closure. Intraoral lacerations may benefit from a short course (5 days) of penicillin.35 Consider antibiotic use for any high-risk wounds in which there is involvement of cartilage, joint spaces, tendon, or bone; and despite literature that refutes the necessity, wounds of the hand are often treated with antibiotics.34,36,37 Finally, consider antibiotics for high-risk wounds (contaminated or devitalized), especially in compromised hosts, such as children with sickle cell disease, diabetes, steroid use, or lymphoma.
When antibiotics are indicated, their effectiveness depends on early administration. Give the first dose in the ED (preferably within 3 hours of the injury), regardless of the route of administration. The choice of antibiotics depends on the type of wound, although most infections are caused by sensitive staphylococci and streptococci that will respond to penicillin, first-generation cephalosporins or erythromycin for penicillin-allergic patients. Consideration of methicillin-resistant Staphylococcus aureus infection as a pathogen should be given, particularly to those patients who worsen or do not improve with standard therapy. Wounds contaminated with feces require coverage against facultative organisms, coliforms, and obligate anaerobes. Reasonable choices would include second- and third-generation cephalosporins, or the combination of clindamycin and an aminoglycoside.
Mammalian bite wounds are a complex subject. The cumulative research suggests that dog bites in normal hosts with low-risk wounds will do well with meticulous wound care, closure, splinting, elevation, and close follow-up without antibiotics.38 All noncanine bites merit a short course of antibiotics. Generally, 3 to 5 days of oral antibiotics are prescribed for these bite injuries, but no definitive studies have examined appropriate duration of therapy.
Tetanus prophylaxis begins with appropriate wound care. If the wound is tetanus prone, determine the child's immunization status (Fig. 32-16). If the child was not immunized or only partially immunized, or if their immunization status is unknown, treat the child as if they have no protection. Give human tetanus immune globulin (HTIG) 250 U IM and complete or initiate primary immunization. If a child has completed primary immunization and has received appropriate boosters, then HTIG is not required.39
Tetanus immunization guidelines.