Rosen & Barkin's 5-Minute Emergency Medicine Consult (595 page)

• Thoroughly wash wound with soap and water.
  
• If safely able, capture wild animal for sacrifice and testing.
  

• Airway, breathing, and circulation
  
• Intubation as needed
  
• Treatment of seizures
  

• Wound cleansing and irrigation
  
• Tetanus immunization
  
• Determine if exposure requires prophylaxis:
  
  • Consult local health department
    
  • Domestic animal bite:
    
    • Home monitoring of animal for 10 days
      
    • If animal displays no signs of illness, patient does not need PEP.
      
  • Wild animal bite:
    
    • Rabies testing of sacrificed animal head-Negri bodies are diagnostic
      
    • Start PEP and stop if test is negative
      
    • Treat if animal not captured.
      
  • Unprovoked attacks should be assumed high risk for exposure.
    
• PEP:
  
  • Passive immunization with human rabies immune globulin (HRIG)
    
  • HRIG: 20 IU/kg:
    
    • Majority infiltrated in and around wound
      
    • Remainder given IM (gluteus)
      
    • Active immunization with rabies vaccine
      
  • Rabies vaccine: 1 mL (2.5 IU) IM days 0, 3, 7, 14, add day 28 if immunocompromised
    
  • 3 vaccines approved in US:
    
    • Imovax–human diploid cell culture
      
    • RabAvert–chick embryo cell culture
      
    • Rabies vaccine adsorbed–inactivated virus, for US military
      
  • Administration location:
    
    • Deltoid in adults or anterior thigh in small children or infants
      
• For those with pre-exposure prophylaxis and rabies exposure:
  
  • Do not require HRIG
    
  • Need vaccine booster on days 0 and 3
    
• If care delayed after rabies exposure:
  
  • HRIG not indicated >7 days after exposure
    
  • Vaccine should be administered as usual
    
• Pre-exposure prophylaxis:
  
  • Rabies vaccine on days 0, 7, 21, 28
    
  • Target groups: Veterinarians, animal handlers, virus lab workers, foreign travelers in endemic regions
    

Treat as in adults.

Treatment considered safe during pregnancy.

FOLLOW-UP

Ensure adequate access for subsequent vaccine administration post rabies exposure.

Patient with clinical signs of rabies

• Stable patient
  
• No evidence of reaction to vaccine
  

Public health and CDC for suspicious cases

• Ensure access to subsequent vaccine doses
  
• Patient should follow up with animal control if source animal has been sacrificed or is being observed.
  

• PEP is only proven treatment after exposure.
  
• PEP should be given in all high-risk exposures regardless of timing
  
• Vaccine should only be given in deltoid in adults: Treatment failures reported with inadvertent SC administration in gluteus injections.
  

• American Academy of Pediatrics.
  Report of the Committee on Infectious Report
  . 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
  
• Centers for Disease Control and Prevention. Rabies. Available at
  http://www.cdc.gov/rabies./
  Updated December 13, 2012.
  
• Centers for Disease Control and Prevention (CDC). Recovery of a patient from clinical rabies–California, 2011.
  MMWR Morb Mortal Wkly Rep.
  2012;61(4):61–65.
  
• Franka R, Rupprecht CE. Treatment of rabies in the 21st century: Curing the incurable.
  Future Microbiol.
  2011;6:1135–1140.
  
• Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention—United States, 2008: Recommendations of the Advisory Committee on Immunization Practices.
  MMWR Recomm Rep
  . 2008;57:1–28.
  
• Willoughby RE Jr, Tieves KS, Hoffman GM, et al. Survival after treatment of rabies with induction of coma.
  N Engl J Med.
  2005;352:2508–2514.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Encephalitis
  
• Meningitis
  

CODES

• 071 Rabies
  
• V01.5 Contact with or exposure to rabies
  

BASICS

• Radiation
  in this chapter refers to ionizing radiation.
  
• Alpha (
  α
  )—helium nucleus; does not penetrate skin
  
• Beta (
  β
  )—electron; penetrates tissue a few cm
  
• Gamma (
  γ
  )—photon; penetrates body
  
• Neutron—very penetrating; not detected by Geiger counter, but neutron emitters
  also emit γ radiation
  
• Radioisotope/radionuclide—chemical element that emits radiation from its nucleus:
  
  • Radioactivity cannot be destroyed, only relocated or shielded.
    
  • Being radioactive does not change element’s other chemical and physical properties, such as heavy metal toxicity.
    
• Exposure/irradiation—patient has been in presence of ionizing radiation:
  
  • Whole body or only certain areas may be exposed.
    
• Contamination—radioactive material where it is not desired:
  
  • Internal—within body (e.g., lung)
    
  • External—outside body (skin, hair, clothing)
    
• Dose—amount of radiation energy absorbed by tissue:
  
  • Units and conversions:
    
    • 1 gray (Gy) = 100 rad
      
    • 1 sievert (Sv) = 100 rem
      
  • For β and γ radiation:
    
    • 1 Gy = 1 Sv = 100 rad = 100 rem
      

• Children are more sensitive to radiation injury.
  
• Potassium iodide is most protective for children and should be given promptly if contamination with radioactive iodine (I-131) is suspected.
  

• Developing fetus is very sensitive to radiation.
  
• Pregnant staff should not care for radioactively contaminated patients.
  

• Ionizing radiation leads to cellular injury.
  
• Damage to blood vessels leads to endarteritis and loss of tissue blood supply.
  
• Higher rates of cell division within an organ make it more sensitive to radiation:
  
  • Bone marrow and GI tract are very sensitive.
    
  • Skin and nerve are less sensitive.
    
• Acute radiation syndrome
  (ARS) occurs in stages following whole-body exposure:
  
  • Prodromal: Acute radiation injury leads to acute inflammation (0–48 hr).
    
  • Latent: If the acute phase of injury is survived, inflammation and symptoms subside (0–2 wk).
    
  • Manifest illness: At higher radiation doses, organ failure then develops.
    
  • Recovery or death (usually from infection) follows.
    
• Sources of radiation include medical devices, therapeutics, nuclear weapons, and industry.
  

DIAGNOSIS

• Diagnosing contamination is fairly easy.
  
• Diagnosing and quantifying exposure is more difficult and probably require expert consultation.
  

• Vary based on dose; see:
  http://www.afrri.usuhs.mil/outreach/pdf/AFRRI-Pocket-Guide.pdf
  for quick reference.
  
• Overall:
  
  • Whole-body exposure: Syndrome similar to high-dose chemotherapy toxicity
    
  • ARS progresses more rapidly the higher the absorbed dose.
    
• Local exposure:
  
  • Early resembles thermal or UV burn
    
  • Later resembles ischemic ulcer