tetanus & rabies chapt. 146-147 january 12, 2005 dr. kiss slides by scott gunderson pgy-2
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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
Generalized TetanusGeneralized Tetanus
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
Generalized TetanusGeneralized Tetanus
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
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
PathophysiologyPathophysiology
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
PathophysiologyPathophysiology
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
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
EpidemiologyEpidemiology
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
EpidemiologyEpidemiology
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%
EpidemiologyEpidemiology
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
Not RabidDiscontinue vaccine
No Vaccine needed
Bat, skunk, raccoon, cow, bobcat, coyote, or fox
Captured and quarantined Escaped
Vaccine + HRIGSacrifice and test
Initiate vaccine +HRIG
RabidVaccine +HRIG
Not RabidDiscontinue vaccine
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
Not RabidDiscontinue vaccine
Postexposure Postexposure ProphylaxisProphylaxis
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
Postexposure Postexposure ProphylaxisProphylaxis
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
Special CircumstancesSpecial Circumstances
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
Special CircumstancesSpecial Circumstances
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
Special CircumstancesSpecial Circumstances
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
Special CircumstancesSpecial Circumstances
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
Clinical DiseaseClinical Disease
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
Clinical DiseaseClinical Disease
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