Category: Trauma and Environmental

Rabies Prophylaxis

Introduction

  • What is rabies?
    • A very rare and aggressive encephalitis
    • Global impact with exception of UK/Australia
  • Animals whose bites/scratches may require prophylaxis
    • Bats
    • Dogs, Cats, Ferrits
    • Other carnivorous animals
    • Foxes, Coyotes, Skunks, Raccoons
  • Post exposure prophylaxis
    • Both Rabies vaccine and immunoglobulin

When Do You Give Rabies Prophylaxis?

  • Step 1: Bitten or scratched by domesticated pet?
    • Immunization status of pet does not matter
    • Animal must be monitored
    • Give prophylaxis if animal develops encephalitis
  • Step 2: Bitten or scratched by wild animal?
    • If animal is captured it can be sacrificed and tested
    • Give prophylaxis the animal is not captured and is a potential carrier
  • Step 3: Possible bat scratch/bite?
    • Give prophylaxis if the patient (or baby) cannot confidently say “NO, I DID NOT GET BITTEN OR SCRATCHED BY THE BAT”
  • Step 4: Do NOT give prophylaxis if the animal is not a carrier of rabies (check local guidance)
    • Reptiles
    • Birds
    • Small rodents
    • Rabbits/Hares
    • Livestock
  • Step 5: How to give prophylaxis
    • Only contraindication is severe egg allergy
    • Can be given to babies/pregnant women/etc
    • Rabies immunoglobulin
      • Give ONCE in the department
      • Inject as much as possible around wound
    • Rabies vaccine
      • Give first day
      • Have patient come back for more doses on day 3, 7, 14 (and SOMETIMES 28)

Pearls

  • It doesn’t matter if the bite/scratch was provoked or unprovoked
  • It doesn’t matter where on the body the patient received the bite/scratch
  • It’s a universally fatal disease
  • No rabies in small rodents, reptiles, birds, squirrels, hamsters, rats, or rabits
  • The NNT is >300,000 (but we still do it)

Additional Reading

Occupational Exposures

The only chief complaint that you are guaranteed to eventually have to manage in a colleague

Respiratory Exposures

  • Meningococcus​ (meningococcemia, meningitis, etc)
    • Give prophylaxis (ceftriaxone) if…
      • Intubated a pt without a mask
      • Suctioned a pt without a mask
      • Performed mouth to mouth resuscitation
  • Tuberculosis​ 
    • CDC recommends testing if exposed
      • Treat if positive
    • CDC recommends prophylaxis in..
      • Little children, HIV positive, immunosuppressed

Cutaneous Exposures (Broken Skin, Mucous Membranes, Needle Stick)

  • Hepatitis B​
    • Test source patient
      • If positive, 1-30% risk of transmission with needle stick exposure
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Test exposed colleague for anti-HepB surface antibody level
    • If source patient is positive and coworker is not fully immunized…
      • Treatment
        • Hep B Vaccine
        • Hep B Immunoglobulin
  • Hepatitis C​
    • Test source patient
      • If positive, 2% risk of transmission with needle stick exposure
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Get baseline hepatic function labs (LFTs) in coworker
    • Follow-up on outpatient basis, no prophylaxis available
  • HIV​
    • Test source patient with rapid HIV test
      • If positive, 1/300 risk of transmission with needle stick exposure
        • Transmission risk increases if: bloody exposure, large needle bore
        • (Mucous membrane/broken skin exposures are much lower risk)
    • Generally recommend prophylaxis if source is positive
      • Prophylaxis is potentially curative if given at exposure
      • Counsel on safe sex practices
      • Counsel on common treatment side effects
        • GI symptoms, headaches, fatigue

Additional Reading HIV Occupational Exposure Guidelines (US Public Health Service)

Gunshot Wounds (Arms and Legs)

Evaluate 5 important structures when evaluating gunshot wounds in an extremity.

Blood Vessel Injuries

  • 3 Categories
    • Hard-Signers
      • Mnemonic: HARD Bruit
        • Hypotension
        • Arterial/pulsatile bleeding
        • Rapidly expanding hematoma
        • Deficits (pulse)
        • Audible BRUIT/thrill
      • These patients likely need OR
    • Soft-Signers
      • Significant vascular oozing/bleeding
      • Large hematoma
        • These patients need to be screened with ABI (ankle brachial index)
          • ABI <0.9 or asymmetry between extremities is concerning for vascular injury
        • If abnormal, obtain a CTA
    • No-Signers
      • No additional management for vascular injury required

Nerve Injuries

  • Relatively rare
  • Document neuro exam in the extremity
  • Consult if abnormal

Bone Injuries

  • Relatively common
  • Diagnosed by x-ray
  • Consult orthopedics for fracture

Soft Tissue Injury

  • Be sure to count/document number of holes
  • Typically do not need laceration repair unless cosmetic area
  • Don’t miss compartment syndrome
    • Mnemonic: “P’s”
      • Pain out of Proportion
      • Pain with Passive range of motion
      • Paresthesias
      • Pallor
      • Paralysis
      • Poikilothermia

The Bullet: What To Do With It?

  • The bullet is almost never removed, unless…
    • Very superficial/cosmetic and easy to remove
    • In a joint

Additional Reading

Marathon Medicine

One of the best events you can volunteer for as a medical student is your local marathon. You learn about musculoskeletal injuries, heat injuries, electrolyte emergencies, as well as prepare yourself for the occasional seizure, cardiac arrest, and case of anaphylaxis. You learn procedures like starting IVs, obtaining vitals, and basic wound care. It really is a great place to learn the basics of Emergency Medicine. In this episode, we will discuss marathon related emergencies.

Laceration Evaluation

Laceration Repair is one of your core 3 procedures and is critical to master if you want to get a good SLOE. You have to very carefully consider if the wound should even be repaired at all! Otherwise it might get infected and the patient will have a bad outcome. However, if your presentation is strong, they will let you repair the wound, which will get you great scores on your SLOE.

Abdominal Trauma

Abdominal trauma is probably the most difficult and most subjective type of trauma that you can evaluate. There is no perfect decision criteria that you can use. There is no perfect test. It all comes down to some magical combination of clinical gestalt and objective findings. Sure, we can usually tell when the patient needs to go straight to the OR, and we do have some great tools such as bedside ultrasound. However, none of these work 100% of the time. That is why I always consider three things when thinking through these cases. Mechanism, Exam, and Imaging.

Cardiac Trauma

This week we are continuing our trauma series and talking about cardiac injury. There are 3 big diagnoses in this section that we will cover: cardiac tamponade, aortic dissection, and blunt cardiac injury. All 3 can kill your patient, and all 3 are easy to evaluate for if you know what to look for. We will cover all of these as well as several common pimp questions in this episode.

Thoracic Trauma

Injuries to the chest are one of the most common, most life-threatening, and most important injuries that occur during severe trauma. In this episode we will cover injuries to the lungs with a specific focus on the 3 life threatening diagnoses that must be considered during every case: tension pneumothorax, open pneumothorax, and hemothorax.

Neck Trauma

Today we will be covering neck injury. Specifically, we will cover soft tissue injury of the neck. It can be divided into blunt and penetrating trauma. And because this is where the blood vessels are located, the test of choice for these injuries will be a CT angiogram. We’ll discuss the indications for CTA, when to go straight to the OR, as well as a few other pearls during this week’s episode.

C-Spine Trauma

This episode will overview cervical spine injuries in trauma. First you put the collar on, then you take it off. The tricky part is learning WHEN to take the collar off. You have two options. Option 1 is to use a decision rule called the NEXUS criteria. Option 2 is to get a CT of the cervical spine and then “clear the collar” when the picture returns. Otherwise, the collar stays on until the patient can get follow up with a spine specialist.

Head Trauma

Over the next several weeks we are going to be doing a series of episodes on trauma. Starting today with head trauma. There are lots of critical diagnoses that you cannot miss with head injuries, and you need to order a CT head without contrast if you suspect any of them. One way to help you decided whether to order a CT is by using the Canadian Head CT Rule. We will cover all of this and more in today’s episode.

Trauma Basics

Trauma is easily the most interesting topic in all of emergency medicine. We might not see it quite as much as chest pain and abdominal pain, but trauma is certainly one of the top 10 things you will see most commonly on your clerkship. Today I am going to give you an overview of a course called ATLS- Advanced Trauma Life Support. It is the national standard of care for treating trauma. It’s very easy to understand, just remember your A-B-C-D-Es (Primary Survey) and don’t forget to do a thorough Secondary Survey.

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