Tetanus & Rabies Chapt. 146-147 January 12, 2005 Dr. Kiss slides by Scott Gunderson PGY-2.

Tetanus & RabiesTetanus & RabiesChapt. 146-147Chapt. 146-147

January 12, 2005January 12, 2005

Dr. KissDr. Kiss

slides byslides by

Scott Gunderson PGY-2Scott Gunderson PGY-2

Tetanus – EpidemiologyTetanus – Epidemiology

Uncommon in the US but not Uncommon in the US but not worldwideworldwide

1 million cases worldwide per year1 million cases worldwide per year

Mortality rate of 20-50%Mortality rate of 20-50%

Highest prevalence in developing Highest prevalence in developing countriescountries

EpidemiologyEpidemiology Fewer than 50 cases per year in the USFewer than 50 cases per year in the US

Majority of cases in temperate climates (Texas, Majority of cases in temperate climates (Texas, California, and Florida)California, and Florida)

Mortality rate of 11%Mortality rate of 11%

Most who develop it have an inadequate Most who develop it have an inadequate immunization historyimmunization history

Only 27% of Americans older than age 70 have Only 27% of Americans older than age 70 have adequate immunity to tetanusadequate immunity to tetanus

PathophysiologyPathophysiology

Wound contamination with Wound contamination with Clostridium tetaniClostridium tetani

Motile, nonencapsulated, anaerobic, Motile, nonencapsulated, anaerobic, gram positive rodgram positive rod

Spore forming and ubiquitous in soil Spore forming and ubiquitous in soil and animal fecesand animal feces

PathophysiologyPathophysiology Usually introduced in the spore forming Usually introduced in the spore forming

state, then germinates to the toxin state, then germinates to the toxin producing vegetative formproducing vegetative form

Requires decreased tissue oxygen tension Requires decreased tissue oxygen tension to germinateto germinate

Vegetative state produces two exotoxinsVegetative state produces two exotoxins TetanolysinTetanolysin TetanospasminTetanospasmin

ToxinsToxins

Tetanolysin – clinically insignificantTetanolysin – clinically insignificant

TetanospasminTetanospasmin Neurotoxin responsible for the clinical Neurotoxin responsible for the clinical

manifestations of tetanusmanifestations of tetanus Reaches peripheral nerves by Reaches peripheral nerves by

hematogenous spread and retrograde hematogenous spread and retrograde intraneuronal transportintraneuronal transport

Does not cross blood brain barrierDoes not cross blood brain barrier Reaches CNS by retrograde transportReaches CNS by retrograde transport

TetanospasminTetanospasmin

Acts on the motor end plates of Acts on the motor end plates of skeletal muscle, in the spinal cord, skeletal muscle, in the spinal cord, and in the sympathetic nervous and in the sympathetic nervous systemsystem

Prevents release of inhibitory Prevents release of inhibitory neurotransmitters neurotransmitters glycine glycine andand gamma-aminobutyric acid gamma-aminobutyric acid (GABA)(GABA)

Clinical FeaturesClinical Features Tetanospasmin responsible for generalized Tetanospasmin responsible for generalized

muscular rigidity, violent muscular muscular rigidity, violent muscular contractions, and instability of the ANS.contractions, and instability of the ANS.

Typical wound is a puncture, but no wound Typical wound is a puncture, but no wound is identified in up to 10%is identified in up to 10%

Other routes are surgical procedures, otitis Other routes are surgical procedures, otitis media, abortion, umbilical stump and drug media, abortion, umbilical stump and drug abusersabusers

Four Clinical FormsFour Clinical Forms

LocalLocal

GeneralizedGeneralized

CephalicCephalic

NeonatalNeonatal

Local TetanusLocal Tetanus

Rigidity of the muscles in proximity Rigidity of the muscles in proximity to the site of injuryto the site of injury

Usually resolves completely in weeks Usually resolves completely in weeks to monthsto months

May develop into generalizedMay develop into generalized

Generalized TetanusGeneralized Tetanus

Most common formMost common form

Most common presenting complaint Most common presenting complaint is pain and stiffness of the masseter is pain and stiffness of the masseter muscles (muscles (LockjawLockjaw))

Short axon nerves affected initially Short axon nerves affected initially therefore starts in the face, then therefore starts in the face, then neck, trunk, and extremitiesneck, trunk, and extremities


Muscle stiffness leads to rigidityMuscle stiffness leads to rigidity

Trismus and characteristic sardonic smile Trismus and characteristic sardonic smile develops (risus sardonicus)develops (risus sardonicus)

Reflex convulsive spasms and tonic Reflex convulsive spasms and tonic muscle contraction create dysphasia, muscle contraction create dysphasia, opisthotonos (arching of back and neck), opisthotonos (arching of back and neck), flexing arms, clenching fists, and lower flexing arms, clenching fists, and lower extremity extensionextremity extension

Trismus and Sardonic Trismus and Sardonic SmileSmile

OpisthotonosOpisthotonos


Autonomic nervous systemAutonomic nervous system Hypersympathetic stateHypersympathetic state Usually in the second weekUsually in the second week

TachycardiaTachycardia HTNHTN DiaphoresisDiaphoresis Increased urinary catecholaminesIncreased urinary catecholamines

Significant morbidity and mortalitySignificant morbidity and mortality

Cephalic TetanusCephalic Tetanus

Results from an injury to the head or Results from an injury to the head or otitis mediaotitis media

Cranial nerves affected most Cranial nerves affected most commonly the seventhcommonly the seventh

Poor prognosisPoor prognosis

Neonatal TetanusNeonatal Tetanus

400,000 worldwide deaths annually400,000 worldwide deaths annually

Results from inadequately Results from inadequately immunized mothersimmunized mothers

Frequent after unsterile treatment of Frequent after unsterile treatment of the cord stumpthe cord stump

Neonatal TetanusNeonatal Tetanus

SignsSigns WeaknessWeakness

IrritabilityIrritability

Inability to suckInability to suck

Presents in the 2Presents in the 2ndnd week of life week of life

DiagnosisDiagnosis

Clinical diagnosisClinical diagnosis

No laboratory confirmatory testsNo laboratory confirmatory tests

Wound cultures not very useful as Wound cultures not very useful as C. C. tetanitetani may be recovered without tetanus may be recovered without tetanus

Immunization history usually unknown or Immunization history usually unknown or inadequateinadequate

Tetanus DdxTetanus Ddx

Strychnine Strychnine poisoningpoisoning

Dystonic reactionDystonic reaction

Hypocalcemic Hypocalcemic tetanytetany

Peritonsillar abscessPeritonsillar abscess

PeritonitisPeritonitis

Meningeal irritationMeningeal irritation

RabiesRabies

TMJTMJ

TreatmentTreatment Admit to ICUAdmit to ICU

Be prepared for intubation with Be prepared for intubation with neuromuscular blockade as respiratory neuromuscular blockade as respiratory compromise may developcompromise may develop

Minimal environmental stimuli to avoid Minimal environmental stimuli to avoid reflex convulsive spasmsreflex convulsive spasms

Initial wound debridement to improve Initial wound debridement to improve oxygenationoxygenation

TreatmentTreatment

Tetanus Immunoglobulin (TIG)Tetanus Immunoglobulin (TIG) Neutralizes wound and circulating Neutralizes wound and circulating

tetanospasmintetanospasmin Does not neutralize toxin already bound Does not neutralize toxin already bound

to the nervous systemto the nervous system Does not improve clinical symptomsDoes not improve clinical symptoms Decreases mortalityDecreases mortality

TreatmentTreatment

TIGTIG Usual dose is 3,000 to 6,000 unitsUsual dose is 3,000 to 6,000 units Administered IM opposite side as Td Administered IM opposite side as Td

givengiven Give Give beforebefore wound debridement wound debridement

TreatmentTreatment

AntibioticsAntibiotics Questionable utility but usually givenQuestionable utility but usually given MetronidazoleMetronidazole

antibiotic of choiceantibiotic of choice Avoid penicillinAvoid penicillin

it is a GABAA antagonist and may worse it is a GABAA antagonist and may worse symptomssymptoms

TreatmentTreatment

Muscle relaxantsMuscle relaxants TetanospasminTetanospasmin

prevents neurotransmitter release at prevents neurotransmitter release at inhibitory interneurons and therapy of inhibitory interneurons and therapy of tetanus is aimed at restoring balancetetanus is aimed at restoring balance

MidazolamMidazolam preferred agent as it is water solublepreferred agent as it is water soluble

BaclofenBaclofen specific GABAB agonist that has also been specific GABAB agonist that has also been

usedused

TreatmentTreatment

Neuromuscular blockadeNeuromuscular blockade Blockade often required to allow Blockade often required to allow

respiration and to prevent fractures and respiration and to prevent fractures and rhabdomyolysisrhabdomyolysis

SuccinylcholineSuccinylcholine recommended for initial airway recommended for initial airway

managementmanagement VecuroniumVecuronium

treatment of choice for long term blockadetreatment of choice for long term blockade

TreatmentTreatment

ANS dysfunction treatmentANS dysfunction treatment LabetalolLabetalol

useful for treatment due to combined alpha useful for treatment due to combined alpha and beta activityand beta activity

Magnesium sulfateMagnesium sulfate inhibits the release of epinephrine and inhibits the release of epinephrine and

norepinephrine from the adrenal glandsnorepinephrine from the adrenal glands Clonidine Clonidine

central alpha receptor agonist for cardiac central alpha receptor agonist for cardiac stabilitystability

ImmunizationImmunization

Disease does not confer immunity so those Disease does not confer immunity so those that recover must undergo immunizationthat recover must undergo immunization

Tetanus toxoidTetanus toxoid 0.5 cc IM at presentation, 6 weeks, and 6 0.5 cc IM at presentation, 6 weeks, and 6

monthsmonths Local reactions are commonLocal reactions are common Less common serous reactions include Less common serous reactions include

urticaria, anaphylaxis, or neurologic urticaria, anaphylaxis, or neurologic complicationscomplications

Immunization and TIG Immunization and TIG guideguide

Td dose: 0.5cc IMTd dose: 0.5cc IM TIG dose: 250 U IMTIG dose: 250 U IM DPT given if under 7, Td given if over 7DPT given if under 7, Td given if over 7

Clean, MinorClean, Minor woundswounds

All otherAll other woundswounds

History of Td History of Td DosesDoses TdTd TIGTIG TdTd TIGTIG

Unknown or Unknown or < 3< 3 YesYes NoNo YesYes YesYes

Three or Three or moremore NoNo NoNo YesYes NoNo

RabiesRabies

RabiesRabies

Rabies ranks number 10 worldwide Rabies ranks number 10 worldwide as a cause of mortalityas a cause of mortality

50,000 – 60,000 deaths annually 50,000 – 60,000 deaths annually worldwideworldwide

Rare human cases in US but 35,000 Rare human cases in US but 35,000 people provided prophylaxis annuallypeople provided prophylaxis annually

MicrobiologyMicrobiology

Lyssavirus genus prototypeLyssavirus genus prototype Single-stranded, negative-sense, Single-stranded, negative-sense,

nonsegmented RNAnonsegmented RNA

7 rabies groups in genus7 rabies groups in genus Classic rabies virus – common rabiesClassic rabies virus – common rabies 6 others with less than 10 reported 6 others with less than 10 reported

human cases of diseasehuman cases of disease


Virus courseVirus course Initial uptake of virus by monocytes in Initial uptake of virus by monocytes in

48-96 hours48-96 hours Crosses motor end-plate to travel up the Crosses motor end-plate to travel up the

axon to the dorsal root ganglia to the axon to the dorsal root ganglia to the spinal cord and the CNSspinal cord and the CNS

Then spreads outward via peripheral Then spreads outward via peripheral nerves to infect almost all tissue of the nerves to infect almost all tissue of the bodybody


Histologically resembles other encephalitisHistologically resembles other encephalitis Monocellular infiltration with focal hemorrhageMonocellular infiltration with focal hemorrhage DemyelinationDemyelination

Perivascular gray matterPerivascular gray matter Basal gangliaBasal ganglia Spinal cordSpinal cord

Negri bodiesNegri bodies Eosinophilic intracellular lesions in cerebral Eosinophilic intracellular lesions in cerebral

neuronsneurons Highly specific for rabiesHighly specific for rabies Present in 75% of rabies casesPresent in 75% of rabies cases

Negri bodiesNegri bodies

EpidemiologyEpidemiology Primarily a disease of animalsPrimarily a disease of animals Human cases reflect the prevalence in Human cases reflect the prevalence in

animals and degree of human contact with animals and degree of human contact with themthem

Major vectors includeMajor vectors include DogsDogs FoxesFoxes RaccoonsRaccoons SkunksSkunks CoyotesCoyotes MongoosesMongooses batsbats

EpidemiologyEpidemiology

Wild animals (93%)Wild animals (93%) Raccoons (37.7%)Raccoons (37.7%) Skunks (30.2%)Skunks (30.2%) Bats (16.8%)Bats (16.8%) Foxes (6.2%)Foxes (6.2%) Others (2.2%)Others (2.2%)

Domestic animals Domestic animals (7%)(7%) Cats (3.4%)Cats (3.4%) Dogs (1.6%)Dogs (1.6%) Cattle (1.1%)Cattle (1.1%) Horses, donkeys, Horses, donkeys,

mules (0.71%)mules (0.71%) Sheep, goats, Sheep, goats,

camels (0.15%)camels (0.15%) Others and ferrets Others and ferrets

(0.06%)(0.06%)

7,369 cases of animal rabies in the US in 2000

http://www.cdc.gov/ncidod/dvrd/rabies/Epidemiology/Epidemiology.htm


DogsDogs Less than 5% of animal cases in US, Canada Less than 5% of animal cases in US, Canada

and Europeand Europe Greater than 90% of animal cases in Greater than 90% of animal cases in

developing countriesdeveloping countries Very rare documented rabies in:Very rare documented rabies in:

Squirrels, hamsters, guinea pigs, gerbils, Squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, domesticated rabbits chipmunks, rats, mice, domesticated rabbits and other small rodentsand other small rodents

Almost never requires post exposure Almost never requires post exposure prophylaxisprophylaxis


TransmissionTransmission Saliva though bite of an rabid animal most Saliva though bite of an rabid animal most

commoncommon Aerosolized in bat cavesAerosolized in bat caves Mucus membrane transmission also Mucus membrane transmission also

reportedreported Bites and scratchesBites and scratches

Risk of developing rabies dependant on the Risk of developing rabies dependant on the location injury, depth, an number of biteslocation injury, depth, an number of bites

Infection RiskInfection Risk

Risk of infectionRisk of infection

Multiple bites around the faceMultiple bites around the face 80-80-100%100%

Single biteSingle bite 15-40%15-40%

Superficial bite on the extremitySuperficial bite on the extremity 5-10%5-10%

Contamination of open wound by Contamination of open wound by salivasaliva

0.1%0.1%

Transmission via fomites (e.g. Transmission via fomites (e.g. tree branch, or animal)tree branch, or animal)

0%0%


32 cases reported from 1980 to 1996 32 cases reported from 1980 to 1996 in the USin the US 7 had a known animal bite7 had a known animal bite

6 dog bites in a foreign country6 dog bites in a foreign country 1 bat bite1 bat bite

Animal contact identified in 12Animal contact identified in 12 8 with a bat8 with a bat 2 with a dog2 with a dog 1 with a cow1 with a cow 1 with a cat1 with a cat

No identifiable source in the other 13No identifiable source in the other 13

Preexposure ProphylaxisPreexposure Prophylaxis

ProphylaxisProphylaxis Individuals with occupations or Individuals with occupations or

recreation that place them at risk should recreation that place them at risk should receive the seriesreceive the series

4 shot series with booster shots required4 shot series with booster shots required Does not eliminate need for Does not eliminate need for

postexposure prophylaxispostexposure prophylaxis No need for HRIG and less doses of vaccineNo need for HRIG and less doses of vaccine

Postexposure Postexposure ProphylaxisProphylaxis

Indicated for all persons possibly exposed Indicated for all persons possibly exposed to a rabid animalto a rabid animal Exposure is a bite, scratch, abrasion, open Exposure is a bite, scratch, abrasion, open

wounds, or mucous membrane exposurewounds, or mucous membrane exposure Contact alone, and contact with blood, urine, or Contact alone, and contact with blood, urine, or

feces does not constitute and exposurefeces does not constitute and exposure

Cleansing wound with 20% soap and water Cleansing wound with 20% soap and water has been show in experimental animals to has been show in experimental animals to markedly reduce the rate of infectionmarkedly reduce the rate of infection

BatsBats

Increasingly important wildlife vectors Increasingly important wildlife vectors of transmission of rabiesof transmission of rabies

All cases of possible bat bites the bat All cases of possible bat bites the bat should be collected and tested for should be collected and tested for rabiesrabies

Bat unavailableBat unavailable Begin postexposure prophylaxisBegin postexposure prophylaxis

Dogs, Cats, and FerretsDogs, Cats, and Ferrets

ObservationObservation CDC recommends 10 days of observation CDC recommends 10 days of observation

of a healthy dog, cat, or ferret after a biteof a healthy dog, cat, or ferret after a bite Normal behavior Normal behavior

No action neededNo action needed Unusual behaviorUnusual behavior

Sacrifice animal, test for rabies, and initiate Sacrifice animal, test for rabies, and initiate HRIG and vaccineHRIG and vaccine

Positive – Complete course of vaccinePositive – Complete course of vaccine Negative – Discontinue courseNegative – Discontinue course

Possible animal exposure

Carnivore, bat or salivary exposure

Bird, reptile, rodent or nonsalivary exposure

Dog or catBat, skunk, raccoon, cow,

bobcat, coyote, or fox

Captured and quarantined

Escaped

Vaccine + HRIG

Sacrifice and testInitiate vaccine +HRIG

RabidVaccine +HRIG

Not RabidDiscontinue vaccine

Captured

Escaped

No epidemiologic prevalence in area

No vaccine needed

Epidemiologic prevalence

Vaccine +HRIG

Normal behavior 10 days

No vaccine needed

Strange behavior

Sacrifice, initiate vaccine and HRIG

RabidVaccine + HRIG


No Vaccine needed

Bat, skunk, raccoon, cow, bobcat, coyote, or fox

Captured and quarantined Escaped

Vaccine + HRIGSacrifice and test

Initiate vaccine +HRIG

RabidVaccine +HRIG


Dog or cat

Captured Escaped

No epidemiologic prevalence in area

No vaccine needed

Epidemiologic prevalence

Vaccine +HRIG

Normal behavior 10days

No vaccine needed

Strange behavior

Sacrifice, initiate vaccine and HRIG

RabidVaccine + HRIG



CourseCourse HRIG (human rabies immune globulin)HRIG (human rabies immune globulin)

One dose initiallyOne dose initially May be given up to 7 days after an exposureMay be given up to 7 days after an exposure Infiltrate as much as possible around woundInfiltrate as much as possible around wound Give on the opposite side as the vaccineGive on the opposite side as the vaccine

VaccineVaccine 5 doses over 28 days5 doses over 28 days


Vaccine reactionsVaccine reactions Minor reactionMinor reaction

Erythema, swelling, painErythema, swelling, pain 30-74%30-74%

Systemic reactionSystemic reaction Headache, nausea, abdominal pain, muscle Headache, nausea, abdominal pain, muscle

achesaches 5-40%5-40%

Anaphylaxis and neurological symptomsAnaphylaxis and neurological symptoms Rarely reportedRarely reported

Vaccine should not be stopped for Vaccine should not be stopped for minor or systemic reactionsminor or systemic reactions

Special CircumstancesSpecial Circumstances

Prior rabies immunizationPrior rabies immunization Either prior preexposure course or full Either prior preexposure course or full

postexposure coursepostexposure course No HRIGNo HRIG Course shortened to 2 dosesCourse shortened to 2 doses

One dose on presentationOne dose on presentation One dose three days laterOne dose three days later


Immunocompromised patientImmunocompromised patient HRIG and vaccine usual courseHRIG and vaccine usual course SafeSafe

Vaccine is inactivated so no danger of Vaccine is inactivated so no danger of contractingcontracting

Stop all immunosuppressives if possibleStop all immunosuppressives if possible Measure antibody titers to assure Measure antibody titers to assure

appropriate responseappropriate response


TravelersTravelers Preexposure prophylaxisPreexposure prophylaxis

Recommended if prevalence and possible Recommended if prevalence and possible exposureexposure

Veterinarians, animal handlers, spelunkers, Veterinarians, animal handlers, spelunkers, certain lab workerscertain lab workers

Non-FDA postexposure prophylaxisNon-FDA postexposure prophylaxis If initiated in another country contact health If initiated in another country contact health

department for recommendationsdepartment for recommendations


PregnancyPregnancy No adverse effects of the vaccine or No adverse effects of the vaccine or

HRIGHRIG Follow usual course in pregnancy if Follow usual course in pregnancy if

indicatedindicated


ChildrenChildren VaccineVaccine

Same dose and same courseSame dose and same course HRIGHRIG

Dose is based on weightDose is based on weight If quantity of HRIG not sufficient to infiltrate If quantity of HRIG not sufficient to infiltrate

all wounds may be diluted with salineall wounds may be diluted with saline

Clinical DiseaseClinical Disease

Incubation periodIncubation period 20 to 90 days20 to 90 days 4 days up to 19 years have been reported4 days up to 19 years have been reported Greater than 1 year is well documentedGreater than 1 year is well documented

ProdromeProdrome Fever, sore throat, chills malaise, headache, N/V, Fever, sore throat, chills malaise, headache, N/V,

weaknessweakness May report limb pain, weakness, and paresthesiasMay report limb pain, weakness, and paresthesias Nonspecific neurologic conditions such as anxiety, Nonspecific neurologic conditions such as anxiety,

agitation, irritability or psychiatric disturbancesagitation, irritability or psychiatric disturbances


Acute neurologic phaseAcute neurologic phase Furious – 80%Furious – 80%

Hyperactivity, disorientation, hallucinations, Hyperactivity, disorientation, hallucinations, bizarre behaviorbizarre behavior

Symptoms may alternate with calmSymptoms may alternate with calm Autonomic dysfunctionAutonomic dysfunction Hydrophobia with pharynx spasms in 50%Hydrophobia with pharynx spasms in 50%

Paralytic – 20%Paralytic – 20% Paralysis in the extremity, diffuse or Paralysis in the extremity, diffuse or

ascendingascending Fever and nuchal rigidityFever and nuchal rigidity


ComaComa Almost always present within 10 daysAlmost always present within 10 days

DeathDeath Occurs from complications such as pituitary Occurs from complications such as pituitary

dysfunction, seizures, respiratory dysfunction, seizures, respiratory dysfunction, cardiac dysfunction, ANS dysfunction, cardiac dysfunction, ANS dysfunction, ARF, or infectiondysfunction, ARF, or infection

Outcome almost always fatalOutcome almost always fatal No person without post-exposure No person without post-exposure

prophylaxis in the US has survived since prophylaxis in the US has survived since 19801980

DiagnosisDiagnosis

Rabies should be in the differential of Rabies should be in the differential of any acute encephalitisany acute encephalitis

May be confused with poliomyelitis, May be confused with poliomyelitis, Guillain-Barre syndrome, transverse Guillain-Barre syndrome, transverse myelitis, postvaccinial myelitis, postvaccinial encephalomyelitis, CVA, atropine-like encephalomyelitis, CVA, atropine-like poisoning, other viral encephalitispoisoning, other viral encephalitis

DiagnosisDiagnosis

Lab testingLab testing No one test is completely informativeNo one test is completely informative Test serum, CSF, and skin for antibodies Test serum, CSF, and skin for antibodies

in a non-vacinated personin a non-vacinated person Nuchal skin biopsy most sensitive earlyNuchal skin biopsy most sensitive early PCR from saliva also usefulPCR from saliva also useful

TreatmentTreatment

LimitedLimited No specific treatment exists for clinical No specific treatment exists for clinical

coursecourse Treatment directed at the clinical Treatment directed at the clinical

complicationscomplications

ReferencesReferences Tintinalli, Judith E., Tintinalli, Judith E., Emergency Medicine a Comprehensive Study Emergency Medicine a Comprehensive Study

Guide.Guide. Sixth edition. McGrw-Hill Companies, Inc. 2004. Chapter Sixth edition. McGrw-Hill Companies, Inc. 2004. Chapter 146-147. Tetanus and Rabies. Pages 943-953.146-147. Tetanus and Rabies. Pages 943-953.

Centers for Disease Control. Centers for Disease Control. http://www.cdc.gov/ncidod/dvrd/rabies/Epidemiology/Epidemiology.htm, Accessed January 5, 2005.

QuestionsQuestions

1.1. The majority of elderly patients have The majority of elderly patients have adequate immunity to tetanus. (T/F)adequate immunity to tetanus. (T/F)

2.2. A patient with previous tetanus A patient with previous tetanus immunization (3 or greater) presents immunization (3 or greater) presents with a puncture wound by a dirty nail. with a puncture wound by a dirty nail. Appropriate tetanus prophylaxis Appropriate tetanus prophylaxis includes:includes:

a)a) Td and TIG IMTd and TIG IMb)b) Td onlyTd onlyc)c) TIG onlyTIG onlyd)d) None as he was previously vaccinatedNone as he was previously vaccinated

QuestionsQuestions

3.3. Negri bodies are always present in Negri bodies are always present in Rabies. (T or F)Rabies. (T or F)

4.4. Which is not considered to be a vector of Which is not considered to be a vector of rabies:rabies:

a)a) DogsDogs

b)b) FoxFox

c)c) BatBat

d)d) SquirrelSquirrel

e)e) RaccoonRaccoon

QuestionsQuestions

5.5. A stay dog bit a child. The dog was not A stay dog bit a child. The dog was not seen by anyone else and escaped and is seen by anyone else and escaped and is unavailable for capture. There is no unavailable for capture. There is no epidemiologic evidence of rabies in dogs in epidemiologic evidence of rabies in dogs in your area. Rabies prophylaxis includes:your area. Rabies prophylaxis includes:

a)a) Initiate rabies vaccine and administer HRIGInitiate rabies vaccine and administer HRIGb)b) Initiate vaccine only Initiate vaccine only c)c) Administer HRIG onlyAdminister HRIG onlyd)d) No prophylaxis initiated, observation.No prophylaxis initiated, observation.

Answers: 1-F, 2-B, 3-F, 4-D, 5-DAnswers: 1-F, 2-B, 3-F, 4-D, 5-D

Tetanus & Rabies Chapt. 146-147 January 12, 2005 Dr. Kiss slides by Scott Gunderson PGY-2.

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Transcript of Tetanus & Rabies Chapt. 146-147 January 12, 2005 Dr. Kiss slides by Scott Gunderson PGY-2.