Take a bite out of this podcast on rabies

Yes, I know that I just posted on rabies yesterday – but let’s face it – different people like to learn different ways. So, for those of you who like to listen to educational podcasts on the way into work – this is for you. And for those of you that listen to podcasts while running outdoors – watch out for the raccoons.

You can check out all of the episodes of PEM Currents on iTunes

Or, you can download the mp3 right here

Or, even listen in your browser – the choice is yours!

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Briefs: Rabies

Let me get the obvious out of the way – I’ve never seen a case of rabies. In fact, in the county in which I work there has not been a case of rabies in over 60 years. But, you will all see children bitten by some sort of creature. So, when should we worry about rabies? Which animals are high risk? How do I know what to give and when to give it? Read on and learn more!

What does rabies actually look like in a human?

Bad. It looks bad. And it’s almost uniformly fatal. Most patients die within 2 weeks after onset of coma. Here are some specifics:

Prodrome (up to one week)

Non-specific symptoms, including fever, chills, malaise, myalgia, nausea, vomiting, headache, photophobia and a lot more. Patients can have paresthesias radiating from the wound site as well as localized pain due to the wound response and local injury. These are somewhat specific for rabies actually.

Encephalitic rabies (80%)

“Furious” rabies presents with fever, hydrophobia (pathologic fear of drinking water!), pharyngeal spasms (triggered after a draft of air), facial grimace (opisthotonos) and hyperactivity later leading to paralysis, coma and death

Paralytic rabies (20%)

Ascending paralysis – kind of like Guillain-Barré syndrome. Initially patients develop flaccid paralysis most prominent in the bitten limb then it spreads. Patients have fasciculations and DTRs are lost.

How does one make the diagnosis?

It’s hard and you need a high index of suspicion, which is the most important thing in the ED really. techniques include immunofluorescent antibodies of skin samples, virus isolation from saliva or anti-rabies antibodies in the CSF.

How is it treated?

Since most of you will never see rabies I’ll keep this part brief – It’s hard and requires ICU level management with induction of coma and multiple parallel therapies. I’ve linked to an article below that describes the Milwaukee protocol. For the more “human” side of things you should listen to the RadioLab episode on this topic. it’s excellent!

OK, how about prophylaxis? That’s what I’ll do in the ED anyway.

Most of your patients have never been vaccinated against rabies, so this is the immediate Day Zero regimen.

Rabies Immune Globulin (RIG)

Dose 20 units/kg . As much of the full dose as feasible should be infiltrated around the wound(s). Give the remaining IM at a separate site.

Rabies Vaccine

Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1 mL, IM (deltoid) – on days 0, 3, 7 and 14. I like to remember these dates as first half score tallies from an American Football game.

Previously vaccinated patients shouldn’t get RIG, and then get the vaccine on days zero and 3. Patients with immune compromise get five doses of vaccine on days 0, 3, 7, 14, and 28. Also, check out this algorithm to help decide when to employ post-exposure prophylaxis.

Courtesy of Alfred DeMaria Jr, MD and the Massachusetts Department of Public Health

Courtesy of Alfred DeMaria Jr, MD and the Massachusetts Department of Public Health

Which animals are highest risk for rabies?

A lot of this depends on where you live – so check out the following CDC figure.

Distribution of major rabies virus variants among mesocarnivores in the United States and Puerto Rico from 2008 to 2014.

Distribution of major rabies virus variants among mesocarnivores in the United States and Puerto Rico from 2008 to 2014.

Most cases of rabies are acquired through exposure to saliva from a bite. Per the CDC “Raccoons continued to be the most frequently reported rabid wildlife species (accounting for 30.2 percent of all animal cases during 2014), followed by bats (29.1 percent), skunks (26.3 percent), and foxes (4.1 percent).” Rarely persons are exposed to aerosolized virus in bat caves our labs (no, not where Batman works).

What about kids bitten by a stray dog?

Rabies cases among domestic animals is very rare in the US. Dogs are more likely to have it along the United States-Mexico border. Overall though more rabid cats than dogs are reported in the US – which is likely due to vaccination laws and a greater number of free-range cats. So, ultimately, the odds of getting rabies after being bitten by a dog in a public location are super low. Bacterial wound infections are far more likely. Animals uniformly get sick and die within 10 days (usually 5-7) once the rabies virus moves from the CNS to the salivary glands. If possible a healthy domestic dog, cat, or ferret that bites a patient should be confined for 10 days. Any sign of illness should be evaluated by a vet – and any ill animals should be euthanized. The head is then shipped under refrigeration to a lab certified to test for rabies. Conversely, if the animal survives for 10 days then it didn’t have rabies virus in it’s saliva when it bit the patient. So, in summary, if a child is bitten every effort should be made to locate, sequester and observe the animal for 10 days.

Obviously patients exposed to symptomatic animals should get post-exposure prophylaxis. Special care should be given if the exposure was to the head out neck, since it can worsen in 4-5 days (faster than other sites). You can always stop prophylaxis if the animal is negative. If the animal cannot be located you’ll have to have a risks and benefits discussion with the patient and family.

Since dogs, cats and ferrets are required to be vaccinated, inquiring as to whether or not the animal is vaccinated is a mandatory part of the history. Other important questions are whether the bite was provoked or not. Remember, most dog bites occur when the dog is approached by a child or with handling and feeding. Obviously, rabid animals are more likely to bite in an unprovoked fashion.

References

Human rabies: a disease of complex neuropathogenetic mechanisms and diagnostic challenges. Hemachudha et al. Lancet Neurol. 2002;1(2):101.

CDC: Rabies

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Unsure about sedating your patient? Ask a Child Life Specialist

This excellent post was written by Stephanie Davis, a senior pediatric resident from Cincinnati Children’s Hospital Medical Center.

To sedate or not to sedate… That is the question you may want to ask Child Life.

For me, sedation encompasses oral or intranasal midazolam and IV ketamine. There are a variety of other options out there including dexmedetomidine and propofol. Because the majority of what we use here is midazolam and ketamine, that’s where I’ll focus my efforts. Choosing sedation is tricky, and there is overall a lack of research on which agent is best at which age, which procedures, and at what dose. There is good data, however, showing both midazolam and ketamine are safe in kids. So you have options! I enlisted the help of a few different EM Attendings and Child Life staff to offer some advice.

Too often as a resident I’ve had that 4-year-old girl with a facial laceration that I thought was going to do well with local anesthesia, and it turns out both the patient and I could have benefited from a little midazolam on board. Because I’m the type of physician that likes a minimalist approach, I often try to perform procedures with the least amount of sedation required. I’ve had success with this approach in some children, but not in others. I wanted to spend some time this month figuring out what went wrong and how to more appropriately choose sedation for my patients.

First off, there are many different types of 4-year-olds with facial lacerations. Before the provider even walks in the room, there are inherent qualities to the situation that are going to make it a more or less difficult procedure – patient developmental stage, anxiety, pain, child-parent relationship, previous experiences with healthcare, etc. CALL CHILD LIFE! They will help you navigate through this information. Not only are they experts in child development and coping, but they have the time and the techniques to really tease out what is the best option for the child. It is totally within their scope of practice to make recommendations regarding sedation. So call Child Life early, and ask for their opinion about sedation if it is not readily offered.

Here are some general tips from our Child Life friends in the ED:

Assess not only the child, but also the parent-child interaction

This is important. I do this each time I enter a room, but I don’t always think about how it relates to procedural anxiety. An anxious or upset parent makes for a very anxious and very upset child, irrespective of a pain. Even if the laceration is on the face, and you see beautiful blanching from the LET you placed on there 45 minutes ago so you know it is pain-free, if the parents are not on board your chances of cooperation from the child is minimal without taking some additional steps. If you encounter a situation like this, it is probably best the parent not be involved in the procedure. Instead, Child Life can take the responsibility of distracting and comforting the child.

Offer to let parents leave the room during the procedure

Along the same lines as above, some parents just make the situation worse (to no fault of their own). Let them know it is okay to leave the room. Many will want to step out but feel they should stay to be with the child. Child Life can take on this role instead, allowing parents to be more comfortable leaving the room.

Involve Child Life before you’ve made a decision regarding sedation

Go see the patient. Take mental notes about the patient’s developmental stage, affect, distractibility, and the parent-child interaction. Discuss options for sedation and feel out the parents’ thoughts about how their child will do with the procedure and what their preferences are. Then leave it open ended, step out of the room, and call Child Life to come assess. Child Life can spend much more time with the family exploring what works well for the patient before the procedure starts. Some of this happens by talking to the family, but a lot of the information they gather is from observation, how the child reacts during the prep phase (playing with the tools you will use), and from other procedures the child has (i.e. IV placement). Ask their opinion about sedation and make a multidisciplinary decision about what will work best.

Some general tips:

  • At 2 years, children develop recall. Prior to 2 years, however, most children will not remember (and therefore not be traumatized by) a procedure. In these cases, you can consider just using local anesthetic.
  • At 3 years, most children can engage in pre-procedure prep (playing with and learning about the tools you will use). This looks different depending on how old the child is.
  • Think about what you need the sedation for. Local anesthetic is usually sufficient anesthesia for laceration repairs. Depending on the child, you may consider midazolam for anxiolysis. More painful procedures such as extensive I&D’s or reductions usually require IV ketamine for its anesthetic and amnestic properties (and immobilization).

Setting up for the procedure is a crucial step and can make or break the experience

This is another reason to involve Child Life. They have a ton of experience in manipulating the room to make the procedure more comfortable for everyone (including the provider!).

A few tips I’ve learned this month:

  • Burrito Roll: Similar to swaddling a baby, roll the child in a sheet tucking the edges in snuggly. This helps your holder and increases safety of the procedure.
  • For anything on the forehead, position yourself at the head of the bed. This way the patient does not see your tools and can focus his/her attention forward to engage with Child Life.
  • Think of your holder. Adjust the bed and find positions that are comfortable for BOTH of you.

As the provider doing the procedure, keep quiet!

This was new to me. As the person doing the procedure, any attention you draw to yourself will remind the child they are having a painful procedure done. It is best to keep quiet and work quickly. Let Child Life or the caregiver distract the child. Although we all want to say, “You’re doing a great job!,” try to refrain.

If you’d like to read more about procedural sedation

Pacheco GS, Feravorni A. Pediatric procedural sedation and analgesia. Emerg Med Clin North Am. 2013 Aug;31(3):831-52. PMID: 23915606

Hartling L, Milne A, Fois M, Land ES, Sinclair D, Klassen TP, Evered L. What Works and What’s Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews. Acad Emerg Med. 2016 May;23(5):519-30. PMID: 26858095

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A podcast on bloody baby barf

Hematemesis in the newborn period is scary for parents but fortunately it is most often due to benign causes such as swallowed maternal blood or GERD. learn more about this surprisingly common problem on this edition of PEMCurrents, the Pediatric Emergency Medicine Podcast.

Check out more episodes on iTunes

Download the mp3 file right here

You can also listen to the whole thing right here

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Briefs: Dealing with acute agitation in the Pediatric Emergency Department

Unfortunately the Emergency Department is a place where you will see many agitated patients who are displaying or are at risk for violent behavior. You should always try non-physical and non-pharmacological de-escalation techniques first. remember, the patient, especially a young child is likely very scared. Being surrounded by unfamiliar faces and by people who are bigger than you can trigger aggression. Talk to the child. be calm. Show them that you care and offer them something to drink and a snack. This often goes a long way. When working with developmentally delayed patients consider medications early. Once agitated, it may be hard to reason with them  and de-escalate verbally. Always ask caregivers what has worked for their child in the past and involve them heavily in the decision making.

 

For younger patients (<10 years of age)

Verbal aggression alone and if they will take a PO medication, options in order of preference include:

  1. Zyprexa zydis 5mg PO
  2. Risperdal 0.5mg PO
  3. Lorazepam 0.5mg PO

For physically aggressive patients, and those who won’t take an oral med you will need to go IM. Options, again in order of preference include:

  1. Geodon 10mg IM
  2. Zyprexa 5mg IM
  3. Lorazepam 1mg IM
  4. Diphenhydramine 1mg/kg (max 50mg) IM

For older patients (>10 years of age)

Verbal aggression alone and if they will take a PO medication, options in order of preference include:

  1. Zyprexa zydis 10mg PO
  2. Risperdal 2mg PO
  3. Lorazepam 1mg PO
  4. Haldol 2mg PO + Benztropine 1mg PO

For physically aggressive patients, and those who won’t take an oral med you will need to go IM. Options, again in order of preference include:

  1. Geodon 20mg IM
  2. Zyprexa 10mg IM
  3. Lorazepam 2mg IM
  4. Haloperidol lactate 5mg IM + Benztropine 1mg PO/IM
  5. Diphenhydramine 1mg/kg (max 50mg) IM

Other pearls

  • Avoid Geodon in cardiac patients and those with known prolonged QTc
  • Follow Geodon with lorazepam or diphenhydramine if you need more
  • Always call psychiatry if you experience an unexpected reaction

 

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