Page 147 - 2025 Ranger Medic Handbook

Rabies Post-Exposure Prophylaxis
DESCRIPTION: An RNA virus transmitted through the saliva of an infected animal by biting, licking of an abrasion/
wound, or contact with mucosa.
Hx: Hx of being bitten/licked by potentially infected dogs, bats, raccoons, coyotes, foxes, skunks, cats, horses, cows,
sheep, or around aerosolized excrements of bats.
S/Sx: Incubation period: Incubation in humans typically 4 days–3 months. Period can be shorter if bitten in the face
or bitten by an animal with a high viral count in its saliva. PT will have intense pruritus, pain, paresthesia at the bite
sight, malaise, fatigue, HA, fever, anorexia, apprehension, anxiety, insomnia, depression. Classic rabies patients
will progress into coma ending with death.
MANAGEMENT:
1. If suspected bite from infected animal. Evacuate at earliest opportunity for vaccine but absolutely within 48 hours. SECTION 3
2. Initially debride, vigorously clean, and copiously irrigate the wound using iodine solution which will increase the ef-
ficacy (vaccine failures are associated with poor wound care).
3. Give tetanus booster
4. IF PREIMMUNIZED, purified chick embryo cell (PCEC) vaccination 2 doses 1.0mL IM day 0 and 3, administered in
deltoid area (for children anterolateral aspect of the thigh is acceptable) and NEVER in the gluteal area.
5. IF NOT PREIMMUNIZED, inject Human Rabies Immunoglobulin around the site and remaining (< 50%, not able to
be injected around wound) deep IM distant from vaccine site. Also, 4 doses of PCEC IM in deltoid days 0, 3, 7, 14.
Immunoglobulin should never be administered in the same syringe or in the same anatomical site as the day 0 PCEC
dose.
SPECIAL CONSIDERATIONS: Rabies is a universally fatal disease. Rabies virus can live dormant in bat feces, so
exercise caution when going into caves. Bat bites often are unnoticed. They may only manifest by small abrasions with
prolonged bleeding. If there is a suspected bat bite or PT awakens with bat in room; consider evacuation for vaccine
and HRIG.

Rectal Bleeding
DEFINITION: Bleeding per rectum.
S/Sx: Bright red blood per rectum. Anal pain with defecation usually indicates hemorrhoids or anal fissures. Significant
bleeding can result in hypotension. Red flags include dark/tarry stools (melena), abdominal pain, postural hypotension,
fever, weight loss.
MANAGEMENT: Obtain vitals. If hemodynamically stable, perform rectal exam in an attempt to identify external source
of bleeding. If hemorrhoid or anal fissure is identified as source of bleeding, treat conservatively with increased fiber
intake and topical creams. If hemodynamically unstable, continue to monitor, volume resuscitate as needed, and evacu-
ate to higher care.
DISPOSITION: Urgent evacuation if hemodynamically unstable or there is persistent significant bleeding. Priority evacu-
ation if red flags are present.
SPECIAL CONSIDERATIONS: Certain medications (iron supplements, bismuth subsalicylate [Pepto-Bismol]) can cause
dark stools that may be mistaken for melena.

2025 RANGER MEDIC HANDBOOK 133