Rabies

General

Dogs account for < 5% cases where controlled, whereas they account for >90% causes in other parts of the world. Other animals: foxes, skunks, mongooses, bats. For US, most cases (not human infection, just diagnosed rabies in the wildlife) were with raccoons (36.6%), bats (27.2%), skunks (20.4%), foxes (6.7%), and other animals including coyotes, opossums, otters, bobcats, rodents and lagomorphs (rabbits, hares, picas).

Animal bites not causing rabies: squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, domesticated rabbits, other small rodents. Nonbite exposures very rarely cause rabies. Dogs/cats with two vaccines will never get rabies from exposure. Have been cases with aerosolized virus in bat caves.

Most human infections are associated with bats (80%, specifically the silver-haired bat) with most other cases related to dog bites from other countries. Highest risk for transmission with multiple bites around the face.

Features

No great test for confirmation. Negri bodies on autopsy. Most reliable test: nuchal skin biopsy with immunofluorescent rabies antibody staining. If did not receive vaccine or IG, serum rabies antibodies confirms diagnosis.

Tetanus does not have altered mental status. Rabies does.

Basically is an encephalitis. Incubation period 20-90 days (though some documented much earlier and much later).

Prodromal period: fever, sore throat, chills, malaise, anorexia, headache, nausea. Sometimes get early limp pain, limb weakness, paresthesia at exposure site.

Acute neurologic phase: Two forms: furious and paralytic. Furious: 80% of patients, hyperactivity, disorientation, hallucinations, bizarre behavior. Sympathetic surge. 50% have hydrophobia in which they get pharynx/larynx/diaphragm spasm with drinking fluid.  Aerophobia occurs with pharyngeal spasm triggered by feeling draft of wind. Paralytic: paralysis primarily in the bitten extremity, though can have diffuse or symmetric paralysis as well.

Coma usually occurs within 10 days of onset of symptoms. Death occurs due to seizures/respiratory dysfunction. Only 6 people have survived with all but one receiving pre or post exposure prophylaxis.

Treatment

Clean (soap/water) the wound immediately. Found in animal experiments that simple cleaning reduced risk of rabies.

Patients suspected of having rabies should have contact isolation and healthcare workers wear masks/eye protection (though no healthcare associated transmission documented).

No treatment for patient with rabies. One case report of ketamine, versed, ribavirin, and amantadine (‘Milwaukee protocol’) saved patient’s life (NEJM, 2005).

Prophylaxis

Pre-Exposure: For people at risk for possible rabies exposure. Primary vaccinations given IM HDCV (Human diploid cell vaccine) or PCECV (purified chick embryo cell vaccine) 1.0mL on days 0, 7, 21 and 28. Still will need treatment after possible rabies exposure, though much less treatment. Wont need immune globulin. Vaccine given to people who work in rabies labs, vets, animal-control, wildlife, spelunkers. Serology testing in the higher risk individuals and booster given if antibody titer below normal range. If exposed after this, only need vaccine on day 0 and day 3 with no HRIG.

Post-Exposure: If animal exposure with bite/salivary exposure, if cat/dog and can be captured, then it will be quarantined for 10 days and released if normal behavior at that time. No prophylaxis at all. If the cat/dog can not be captured, check epidemiological data for area and if low risk, no prophylaxis. If unavailable or higher risk, give vaccine + HRIG. If animal is other carnivore or bat/raccoon, bobcat, fox, cow, if can be captured and quarantined, it will be sacrificed and sent to lab and patient given vaccine. If results negative for rabies, no HRIG. If animal can not be captured, patient receives HRIG and vaccine. It states consider post-exposure prophylaxis for persons who were in the same room as a bat and who might be unaware that a bite or direct contact had occurred. Contact public heath officials if unsure of therapy. Treatment: 1 dose of HRIG 20 IU/kg (as much can be injected in wound and then distal site) and 4 doses (0,3,7,14) of rabies vaccine over 14 days. Give first doses within 24 hrs. Vaccine must be injected IM into the deltoid.

Clinical Cases

Hydrophobia in Rabies Video

Rabies Patient, Aerophobia with acute hydrophobia Video

Extraordinary People, The Girl Who Survived Rabies Video

EM:RAP, January 2010, Al Sacchetti, A Bizarre Rabies Case Audio

References / Resources

Tintinalli, Seventh Edition, Chapter 152: Rabies

Crashing Patient, Scott Weingart, Rabies

CDC, Rabies, Reviewed 3/8/14

Clinical Infectious Diseases, A. Jackson, 2003, Management of Rabies in Humans

UptoDate, Clinical Manifestations and Diagnosis of Rabies, Reviewed on 3/8/14

EM:RAP, July 2004, Richard Harrigan, Rabies Audio

Feeding Tubes

Tube Nomenclature

Categorized by location of the tip of the tube.

Gastrostomy or PEG tube – terminates in the stomach

Jejunostomy – terminates in the stomach

PEG-J tube or GJ tube – terminates in both the stomach and the small intestine

PEG (Gastrostomy tubes)

Placed endoscopically, no surgical incision

Can temporarily keep stoma patent with a foley catheter. Need bolster to prevent further migration (can use 3 cm segment of another foley with hole in the middle to act as temporarily bolster if one is not available).

Replacing blindly must only be done on a mature stoma track (2-3 weeks) for possible complication of placing tube into peritoneal cavity. Stomach most likely adhered to abdominal wall by that time.

For clogged or leaking G-tubes without balloon that need to be removed, traction/countertraction should be enough force to squeeze the mushroom out of the stomach. Will likely hear or feel a pop.

Tintinalli recommends consulting the GI or surgeon initially before applying traction depending on the internal bolster.

If still unable to remove, can pull out the tube as much as possible and cut it at the skin to allow rectal passage. Have been reported cases of obstruction, though rare. Still better to consult surgeon prior to doing this.

Can verify placement with Gastrograffin (water-soluble, diatrizoate meglumine-diatrizoate sodium). Barium is contraindicated due to potential peritoneal contamination. Inject 20-30mL, take supine abdominal film 1-2 minutes after dye instillation to optimize gut visualization.

Irregular or rounded blotch with wispy edges or streamers suggests peritoneal leakage.

Entry site irritation: common, can be treated with silver nitrate at time of dressing change to prevent granuloma.

Large stomas: can cause leak. Though insertion of larger tube or firmer traction can be temporarily effect, this often results in further stoma enlargement. Need to replace to pliant soft tube or just remove to allow stoma to shrink. Large amounts of drainage can also be due to high residual volumes – consider checking for residuals after feeds and holding anything further until residual is < 100 mL.

Clogged tubes: can use roter-rooter type wire to drill the clog out. Using guidewire or needle is contraindicated. If unsuccessful, should inject with contrast with imaging to check tube integrity.

Jejunosotomy tubes

Placed surgically under general anesthesia, require a surgical incision and have surgical scar at insertion site.

Less likely to cause aspiration or reflux compared to PEG tubes.

If foley catheter used to replace dislodged J-tube stoma, DO NOT INFLATE BALLOON. Advance 20cm and keep in place.

Does not have balloon on end of it. Generally, jejunum is sutured to abdominal wall. If patient pulls it out, can just place tube back in place and then adhere it to the skin by suture or tape until surgeon sees it again. Needs to have been in place for at least 2-6 weeks though.

 

Roberts and Hedges, Expert Consult, 2013.

Tintinalli, Chapter 89, 2011.

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Bedside Echo – Time is Myocardium

51 year old male, PMH significant only for hypertension presents with sudden onset, heavy chest pain and diaphoresis after running to a code blue in the hospital. Vital signs are normal. He looks pale and sweaty.

Here’s his ECG:

Patient ECG

Patient ECG

 

Although the ST segments in V3 appear concerning, this ECG is ultimately nondiagnostic. Based on the patient’s presentation, there was still significant concern for an acute coronary syndrome. The patient was uncertain he was willing to undergo cardiac catheterization. A bedside ultrasound was performed by the emergency physician.

Here’s a sample:

 

 

As you can see in the clips shown, there is apical hypokinesis, indicative of regional ischemia.

After discussing the findings of his bedside echocardiogram with the patient and cardiology consultant, the patient agreed to immediate cardiac catheterization where he had PCI to his completely occluded LAD. The remainder of his course was unremarkable.

Bedside echocardiogram is a powerful tool that can assist the emergency physician in making critical diagnoses, adding information beyond history, physical, and ECG. If you order an ECG, you should strongly consider performing a bedside echocardiogram.

#FOAMed memes

So if you don’t know what a meme is, you probaby should. Its basically a picture with a backstory that people add text to to fit their own inside joke or amusement (better explanation here). So you would think with how involved the emergency medicine community is with the internet through twitter / facebook / podcasts / Life in the Fast Lane, that there would be a plethora of EM memes that docs have created.

Sadly, there are few if any.

I’m wanting this to change; mainly because I’m a dork and like these sorts of things (Im a frequent flyer to Reddit and Imgur). This may just be a fad and die quickly, but Im currently enjoying them and hoping others will jump on as well.

Heres just a few I have made recently. Also the last one was done recently by Joe Lex of Free Emergency Talks. You’re interested in making one, just go to memegenerator.net and find the pic you want that matches your joke. Feel free to tweet me yours @emchatter and I’ll likely retweet it or place it on the site. Enjoy!

photo

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The JAMA article he is referring to is here.