First aid and local wound care
The effectiveness of prophylaxis directly depends on how quickly and correctly the entry site of the infection is treated.
- Washing: The bite, scratch, or saliva-contaminated area must be immediately and thoroughly washed with running water and soap (or another detergent) for at least 15 minutes.
- Antiseptic treatment: After cleaning, the wound is treated with virucidal agents, such as 10% povidone-iodine solution.
- Dressing: A sterile aseptic dressing is applied over the top.
- Surgical restrictions: Physicians are strictly prohibited from performing primary surgical debridement (edge excision) during the first three days. The only exceptions are emergency interventions for life-threatening conditions. Additional trauma to nerve endings accelerates the progression of the virus toward the CNS.
In addition to specific rabies prophylaxis, the victim must obligatorily undergo emergency tetanus prophylaxis (administration of tetanus toxoid and tetanus antitoxin).
Post-exposure prophylaxis: vaccine and immunoglobulin
The rabies specialist's tactics depend on the severity of contact with the animal (according to WHO categories).
In Category II (minor scratches, abrasions without bleeding, crushing of exposed skin areas), the patient is prescribed only local wound care and an immediate course of rabies vaccination.
In Category III (severe contacts: transdermal bites with bleeding, contamination of broken skin or mucous membranes with saliva, contact with bats), combination therapy is required. Specific rabies immunoglobulin must be added to the vaccine without fail.
Particularly hazardous bite localizations are body areas with maximum innervation: the face, head, hands, fingertips, and perineum. With such injuries, the virus can reach the brain in just 7 days, so antibodies from a standard vaccine simply will not have time to develop. In these cases, the administration of immunoglobulin is vital. Its dosage is 20 IU/kg for human-derived product and 40 IU/kg for heterologous product. The main part of the dose is infiltrated around the wound, and the remainder is administered intramuscularly.
Rabies vaccination schedule
The full (unconditional) course consists of six injections. The drug is administered intramuscularly in a volume of 1 ml.
- In adults: strictly into the deltoid muscle of the arm.
- In children under 5 years old: into the upper anterolateral thigh.
Vaccination schedule: days 0, 3, 7, 14, 30, and 90. The first five doses are guaranteed to produce a protective antibody titer by day 45, and the final injection (on day 90) acts as a booster, maintaining immunity for a year. Vaccination is considered effective if initiated no later than 14 days after exposure.
Conditional indications: if the injury was inflicted by a healthy, vaccinated domestic animal, veterinary monitoring is established. If the pet remains healthy for 10 days, the vaccination course is discontinued. If the animal falls ill, dies, or runs away, the patient receives a full course of six injections.
Clinical presentation and differential diagnosis
If prophylaxis was not performed or was initiated late, the clinical picture of rabies develops. The disease proceeds in stages:
- Prodromal stage: low-grade fever, weakness, groundless fear, and specific local symptoms (burning, pulling pain, and muscle twitching in the area of the already healed bite).
- Excitation stage: agonizing paroxysms of painful laryngeal spasms occur. Hydrophobia develops (suffocation upon attempting to swallow water, or upon seeing or hearing liquid), followed by aerophobia, photophobia, and acusticophobia. Profuse sialorrhea (foaming at the mouth), hyperpyrexia, delirium, and aggression are characteristic.
- Paralytic stage: loss of sensation, flaccid limb paralysis, coma.
Rabies is differentiated from a number of other conditions:
- Lyssophobia (fear of contracting the disease): patients with psychopathic traits may experience hysterical attacks mimicking the disease. The main distinction is the absence of autonomic disorders (mydriasis, tachycardia) and the complete disappearance of symptoms under anesthesia.
- Bulbar poliomyelitis: presents with a biphasic fever pattern, profuse salivation, and swallowing disorders, but is not accompanied by phobias.
- Botulism: occurs against the background of a normal body temperature. Ophthalmoplegic syndrome and myasthenia come to the fore; swallowing disorders always precede respiratory dysfunction.
- Alcoholic delirium: occurs after a binge or withdrawal. Tremor and hallucinations are present, but hydrophobia and sialorrhea are completely absent.
Diagnosis and treatment of established infection
To rapidly confirm the diagnosis, the immunofluorescence assay (IFA) is used. The direct method detects viral antigen in corneal scrapings (antemortem test) or post-mortem brain tissue. The method provides 100% accuracy when using validity controls.
Treatment of patients with developed clinical manifestations is exclusively inpatient (in a separate dark and quiet room) and is symptomatic in nature. Sedatives (morphine, sodium thiopental), mechanical ventilation, and solutions to combat dehydration are used. Administration of immunoglobulin at this stage provides only temporary relief. The prognosis for a full-blown clinical picture is extremely unfavorable.
The rule of danger zones: "Head, Face, Hands, Perineum" — here the virus is closest to nerve ganglia, so when bitten in these areas, the incubation period drops to one week, and mandatory administration of immunoglobulin is required.
Class and exam questions
Is it permissible to suture a bite wound in the first hours?
No, primary surgical debridement of wound edges and suturing are strictly prohibited during the first three days. This traumatizes nerves and accelerates the progression of the virus to the brain.
What to do if bitten by a domestic dog without signs of illness?
A course of vaccination is prescribed under conditional indications, and the dog is placed under observation for 10 days. If the animal remains healthy, vaccination is discontinued.
How and where is the rabies vaccine administered?
The vaccine is administered intramuscularly in a volume of 1 ml. In adults, injections are given strictly into the deltoid muscle of the arm, and in children under 5 years old, into the upper anterolateral thigh.
What is the essence of the Milwaukee protocol?
This is an experimental treatment method for developed rabies. The patient is placed in an induced coma to give the body time to produce antibodies, and antiviral drugs (ribavirin, interferons) are used.
What else to study on this topic
- Criteria for the diagnosis of rabies by stages (prodromal, excitation, paralytic)
- Differences between rabies and viral (seasonal) encephalitis
- Performing an antemortem corneal test (IFA)
- Emergency active-passive tetanus prophylaxis for animal bites
- Routine rabies vaccination for high-risk groups
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