Pediatric emergency medicine trisk 4552 4552
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effected in a biosafety level 4 laboratory by emergent notification and specimen
transport to the CDC.
Based on past experience, vaccination (with vaccinia, an orthopoxvirus closely
related to variola) of smallpox-exposed persons within the first 4 days after
exposure may prevent the development of overt disease. Although the vaccine has
been used safely and successfully in even young infants, it has a relatively high
rate of serious complications in certain patients. Notably, fetal vaccinia and
resultant fetal demise can occur when pregnant women are vaccinated. Vaccinia
gangrenosa, a frequently fatal complication, occurred when immunocompromised
persons were inadvertently vaccinated. Eczema vaccinatum may occur in those
with pre-existing skin conditions and can be serious. Myocarditis and pericarditis
may occur. A severe postvaccinal encephalitis was well known, albeit relatively
rare, during the era of widespread vaccination, because this complication occurs
only after primary vaccination, it would disproportionately affect pediatric
patients. Autoinoculation can occur when virus from the primary lesion arising at
the site of vaccination is transferred by scratching or rubbing to other areas of the
skin or to the eye. To manage these complications, vaccinia immune globulin
(VIG) should be available when undertaking a vaccination campaign. VIG (0.6
mg/kg intramuscular [IM]) may be given to vaccine recipients who experience
severe complications or to significantly immunocompromised individuals
exposed to smallpox in whom vaccination would be unsafe. Today, stocks of
vaccine and VIG are controlled by the CDC. There is also a nonreplicating
smallpox vaccine (IMVAMUNE) for immune-compromised patients that is not
yet FDA approved but is stocked by the CDC for emergency use.
Even a single case of smallpox occurring anywhere in the world today would
represent a grave public health emergency. A suspected case should thus prompt
immediate notification and consultation with health authorities. Strict airborne,
droplet, and contact precautions should be instituted immediately for victims and
should continue until all scabs have separated. Decontamination of symptomatic
patients is unnecessary. Contacts must be observed closely for 17 days following
their last potential exposure. The development of fever during this period would
be a cause for isolation. Multiple victims would ideally be managed as a cohort at
dedicated sites removed from conventional hospital facilities.
Botulism
Background. Botulism occurs as a result of exposure to one of eight botulinum
neurotoxins (A through H). Only types A, B, E, and, rarely, F appear to cause
human botulism in nature. Botulinum toxin was included in the U.S. biologic
