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Objective: Signs
Using Basic Tools: Vitals: fever; rapid, shallow respirations; occasionally irregular RR and HR in later
stages. Inspection: Agitated or frightened appearance is characteristic after CNS involvement with rabies.
Classical spasms of pharynx or larynx during attempts to eat or drink (‘hydrophobia’) are seen in 50% of cases.
Often ascending paralysis from bitten limb spreads to bulbar muscles and then causes coma.
Neurological: Use Glasgow coma scale to track progression of mental status changes, and help gauge need
for medical evacuation or consultation. (see Appendices: GCS)
Auscultation: Late cardiac dysrhythmias coincident with myocardial involvement.
Using Advanced Tools: Confirmation of rabies diagnosis requires special clinical specimens (corneal
scraping, skin biopsy, brain material) and specialized laboratory facilities for immunofluorescence or PCR
unavailable in the field.
Assessment:
Differential Diagnosis: Pathognomonic (indicative) features - hydrophobia, inspiratory spasms
Polio - asymmetric ascending paralysis after minor febrile illness; encephalitic symptoms are rare
Viral encephalitides - respiratory symptoms not as prevalent as with rabies.
Intoxication (tetanus, botulism, drugs, etc.) - does not present with progression of CNS changes.
Plan:
Treatment after credible rabies exposure
- Immediately scrub wounds or broken mucous membranes with soap or detergent and water.
- Debride or irrigate wounds with water or sterile saline (preferred) using a 19 gauge blunt needle and a
35ml syringe to provide adequate pressure (7 psi) and volume. Flush individual punctures with approxi
mately 200cc of irrigation solution. Treat with antiseptics. Do not close the wound. - Infiltrate around inoculation site with half of dose of human rabies immune globulin (HRIG 20 IU/kg) and
give remaining half IM into gluteal region. - If patient is not immunized against rabies, give human diploid cell rabies vaccine (1 ml IM in deltoid x
- beginning immediately. For individuals who have been previously fully vaccinated against rabies
(including ID and IM protocols given to most SOF personnel), give 1 ml IM booster dose in deltoid
immediately at presentation and again 3 days later. Pre-exposure vaccination does not guarantee
protection against rabies, but it does buy time to get to definitive treatment if bitten, and it does decrease
the number of post-exposure boosters required.
- Give tetanus prophylaxis and antibiotic treatment (See Trauma: Human and Animal Bites).
- Use narcotics or benzodiazepines judiciously for agitation (see Procedure: Pain Assessment and Control).
- If possible, isolate suspected animal source and observe 10 days for signs of rabies.
Patient Education
General: Keep body fluids isolated from others (body fluid precautions).
Activity: Rest
Diet: As tolerated, but swallowing may be difficult with advanced disease.
Prevention and Hygiene: Pre-exposure prophylactic vaccination is strongly recommended for travelers in
rabies enzootic for > 30 days, including most SOF personnel and is very effective.
Follow-up Actions
Wound Care: Usually no special care required after initial treatment.
Return Evaluation: Evaluate for progression of neurological signs.
Evacuation/Consultation criteria: Evacuate personnel suspected of exposure to rabies or a rabid animal.
Consult infectious disease or preventive medicine specialists for any suspicion of rabies.
Zoonotic Disease Considerations
Principal Animal Hosts: Wild and domestic canids, raccoons, skunks, bats
Clinical Disease in Animals: Acute neurologic dysfunction, ataxia, progressive paralysis, absent reflexes;
behavioral changes: anorexia, nervousness, irritability, hyperexcitability, uncharacteristic aggressiveness
(wildlife lose fear of man; nocturnal animals seen during the daytime); furious form: pronounced aggressive-