Pediatric emergency medicine trisk 2034 2034
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factors considered in selection of prophylactic antibiotics and then modified by
culture results.
Tetanus immunization status should be checked in every injury that violates the
epidermis, regardless of the cause. Recommendations for tetanus immunoglobulin
and immunization are noted elsewhere (see Chapter 94 Infectious Disease
Emergencies ).
Concern for rabies is the factor that prompts many patients to seek medical
care. Although the incidence of rabies in the United States (one to five cases per
year) is extremely low, the physician must always assess the possibility of rabies
exposure and promptly initiate prophylaxis when indicated. Dogs and cats
account for only 5% of animal rabies in the United States. The history should
include the apparent health of the animal and any provocation for attack. Wild
carnivores and bats should generally be regarded as rabid; rodents (rats, mice,
squirrels) and lagomorphs (rabbits) can usually be considered no risk. Exposure
to bats by a sleeping or very young child even without bite or scratch should
warrant serious consideration of prophylaxis. Rabies prophylaxis is not indicated
in bites by a healthy dog or cat with a known owner, assuming the animal’s health
does not deteriorate over the following 10 days. Bites by strays and other
domesticated mammals should be considered individually and with consultation
of the local health department. Scratches, abrasions, and animal saliva contact
with the victim’s mucous membranes are capable of rabies spread.
If postexposure antirabies immunization is indicated both passive antibody
(RIG, rabies immune globulin, human) and vaccine (HDCV, human diploid cell
rabies vaccine) should be given (see also Chapter 94 Infectious Disease
Emergencies ). Immunization with RIG is administered only once, in a dose of 20
IU/kg. As much as possible is infiltrated locally around the wound and the
remainder is given intramuscularly. The HDCV immunization should be
administered intramuscularly in the opposite deltoid (vastus lateralis in infants)
from RIG on days 0, 3, 7, 14 for a total of four doses, each 1.0 mL. For
immunocompromised patients a fifth dose should be given on day 28.
Suggested Readings and Key References
Drowning
Bain E, Keller AE, Jordan H, et al. Drowning in epilepsy: a population-based
case series. Epilepsy Res 2018;145:123–126.
Bauman BD, Louiselle A, Nygaard RM, et al. Treatment of hypothermic cardiac
arrest in the pediatric drowning victim, a case report, and systematic review.
