Rabies

Background

Indication for Prophylaxis

• Bite or salivary exposure from bat, or mammalian carnivore
• Inhalation counts (e.g. dead bat in room)

Not needed if non-salivary exposure, or if bird, reptile, or rodent (rare cases)

Workup

Animal was captured

Is animal dog or cat?

1. Yes: Observe 10 days, if abnormal, sacrifice and treat patient with the vacc and RIG. Then patient treatment can be discontinued if the animal pathology is negative for rabies
2. No: Sacrifice animal and begin RIG and vaccine. Discontinue if animal negative path for rabies

Animal was not captured

Is Animal dog or cat?

1. Yes: Give vacc and RIG only if rabies risk for species in area
2. No: Treat with full course vacc and RIG

Differential Diagnosis

Jaw Spasms

• Acute tetanus
• Akathisia
• Conversion disorder
• Drug toxicity (anticholinergic, phenytoin, valproate, carbamazepine)
• Dystonic reaction
• Electrolyte abnormality
  • Hypocalcemic tetany
  • Magnesium
• Mandible dislocation
• Meningitis
• Peritonsillar abscess
• Rabies
• Seizure
• Strychnine poisoning
• Stroke
• Temporomandibular disorder
• Torticollis

Management

Immunocompetent + NOT Vaccinated

1. Clean wound
2. Rabies vaccine (human diploid cell vaccine)
   1. 1mL IM on days: 0, 3, 7, 14
   2. Give in deltoid (not buttock), since Ab not created in fat cells
3. AND, Rabies immune globulin
   1. 20 IU/kg subcutaneous
   2. Infiltrate around wound if possible
   3. place remainder opposite arm of vaccine
   4. can administer up to 7 days after the first vaccine dose

Immunocompetent + Vaccinated

1. Clean wound
2. Rabies vaccine (human diploid cell vaccine)
   1. 1mL IM on days: 0 and 3
   2. Give in deltoid (not buttock), since Ab not created in fat cells
3. NO rabies immune globulin

Immuno compromised

1. Clean wound
2. Rabies vaccine (human diploid cell vaccine)
   1. 1mL IM on days: 0, 3, 7, 14, and 28
   2. Give in deltoid (not buttock), since Ab not created in fat cells
3. AND, Rabies immune globulin
   1. 20 IU/kg subcutaneous
   2. Infiltrate around wound if possible
   3. place remainder opposite arm of vaccine
   4. can administer up to 7 days after the first vaccine dose