Just To Be Safe, Get A Laceration by Neal Little, M.D.

Neal Little, MDHow crazy are our immunization practices in the emergency department? And I'm not talking about the current recommendations and guidelines concerning seasonal influenza and H1N1 and one.  At least there rational thought has prevailed, we've identified high-risk groups, we've mobilized not only the emergency department, but the rest of the medical community and possibly schools etc. and come up with what sound like rational plans.

But, consider this: we pay great attention to tetanus immunization status.  We have systems, and checkboxes, and fuss over the patient with a break in the skin ( or the cornea!).  We then sort them into the neat categories, and provide immunization per guidelines. There are on average 43 cases per year of tetanus in the US ( most in those never immunized, many in IV drug abusers) with about 18% mortality.  This translates to about eight deaths per year.  Perhaps it's because we greatly overdo the tetanus issue that we have so few deaths, but like anything else, we've diverted resources from more important problems. I won't get into the craziness about how every break in the skin needs consideration of tetanus status.  Does everyone do that when they cut themselves with a razor while shaving?  And what about puncture wounds? Needle sticks are puncture wounds, and IV sticks puncture wounds.  Isn't the actual giving of a vaccine, a puncture wound?  And, don’t get me started on parents who don’t immunize their children. If they wouldn’t let us treat their serious infection, we’d get a court order. But I digress.

How many deaths are there from meningococcal disease in the US? There about 2,500 cases per year, with a mortality rate of around 14%, but as high as 40% for patients with meningococcemia.  So, just under 400 deaths per year, and lots of morbidity. What are our immunization practices for meningococcal disease in the ER?  Does anyone have one? The military does.

How about pertussis?  At least in 2003 we had almost 12,000 cases, with 10 deaths in 2007 and lots of morbidity. The biggest problem is that we can't diagnose pertussis in a stage when antibiotics might be useful, so we mainly diagnose it with prolonged disabling cough. So, that’s why immunization make good sense. But now we've combined the pertussis vaccine with the tetanus diphtheria.  This seems like good public health policy- we want to prevent pertussis. But, in the ER we only want to prevent it for those people who have a laceration, not those with sprained ankles, chest pain or even influenza. 

So, just to be safe, hope that if you have to go to the ER it’s for laceration.  Then we got you covered.

 

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