CHAPTER 7: TRAUMA

Dr. Leopold Lucero, MD, FPCS

(Transcribed by: Alugbating Salad Jadis)

The young ones are usually the ones being treated from Trauma, because it’s the younger ones who are more prone to
accidents/Trauma.

Categories: (Triage)
- Triage is a system where you classify the patients according to the three:
o Level I: (Mild)
 Not so much injury and maybe treated later on
 Just put the patient on the side and attend more to the patient who needs more medical
attention.
o Level II: (Moderate)
 Patients need immediate attention (Dextrose, NGT’s, remove the blood and etc.)
o Level III (Severe)
 The worst type of patient.
 No matter what you do, no matter how you treat, the patient is sure to die, so you cannot do
anything about this patient anymore.
- You have to prioritize the Mild and the Moderate injured patients. Because these are the patients that can be
saved compared to the severe injured patients.
- ATLS = Advanced Trauma Life Support

ABC’s of Trauma:
- A = Airway Management and Cervical Spine Control
o Always consider the cervical spine because the brachial plexus is there and especially C4
o C4 arises from Phrenic Nerve (innervates the diaphragm)
o Any injury here can paralyze the diaphragm ... when the phrenic nerve is cut, you cannot longer
breath.
- B = Breathing
o If there is sternocostal retraction (?) the patient has a tendency to breathe heavily.
- C = Circulation
o Always check the pulse
- D = Disability prevention
o When you face a patient with a deformity on a certain area, then expect trauma … if you have a
fracture, then you put a splint, so as you will not continue the disability
- E = Exposure
o When a patient arrive in the ER, always place curtains so as to set privacy.
o Use your Scissors and expose everything in the patient because you might miss an injury.
o When tearing up the underwear, make sure to put on the curtains so that parents will not misinterpret
your actions.
- BUT, the latest in Basic Life Support, (they will always ask you what is the ABC’s) they will ask for the
CIRCULATION right away. So they will do compression right away.
- AED = Ambulatory External Defibrillator (because heart attack is the number 1 cause of death in the USA)

AMPLE History:
- A = Allergies (food, drugs, etc)
- M = Medications (High blood, Asthma)
- P = Past illnesses/Pregnancies
- L = Last Meal (if scheduled for an abdominal surgery, usually no food intake for the last 6 hrs is advised,
unless it is an emergency)
- E = Events (ask for the event preceding to the injury)

- Always assume of a possible Cervical Spine Injury for Vehicular accidents and do Cervical Spine X-ray lateral
view when the patient comes in. (Transcervical and Translateral)
- If it’s negative, then thats the time you remove the cervical collar. In hospitals which have no cervical collars,
we ask the patient to lie down flat on a board and place sand bags on the side so that the patients will not turn
to the right or to the left.
How to secure the airway:
- Chin Lift and tilt the head upward
- In cases of cervical spine injury, the safest among the three is the Jaw thrust .. just lower the head to secure
the airway.
- For cricothyroidotomy, puncturing between the thyroid cartilage and cricoid cartilage (the crico-thyroid
membrane) and place a tube (this is only temporary)
- But for caution, if you don’t know how to do it, then do not do it!.
- Tracheostomy - You incise tracheal rings 2, 3 and 4. Do not incise tracheal ring 1, you might get subglotic
stenosis. Don’t go below 4 because you might hit your innominate or brachiocephalic artery

 Carotid Pulse = at least, 60 mmHg (SBP)

 Femoral Pulse = 70 mmHg (SBP)
 Radial Pulse = 80 mmHg (SBP)
 Avoid hypotension
 Any bleeding must be stop by applying pressure using your finger.

Glasgow Coma Scale (Table 7-3, page 145)

Score ADULTS
4 Spontaneous
3 To voice
EYE OPENING
2 To Pain
1 None
5 Oriented
4 Confused
VERBAL 3 Inappropriate Word
2 Incomprehensible
1 None
6 Obeys Command
5 Localizes Pain
4 Withdraws
MOTOR RESPONSE
3 Abnormal Flexion
2 Abnormal Extension
1 None

GCS Scoring:
- 3 = Lowest
- 15 = Normal
- 13-15 = Mild Head Injury
- 9-12 = Moderate Injury
- <9 = Severe Injury (or <7)

Abnormal Flexion = Decorticate Position-- (arms flexed over the chest)

Abnormal Extension = Decerebrate Position– (arms extended at the sides)

Adequate Urine Output for Adult: = 0.5 mL/kg per hour (60kgs patient, its 30 mL/hr)
Adequate Urine Output for Children: = 1 mL/Kg per hour
Adequate Urine Output for Infant <1 yr old: = 2 mL/kg per hour

Three Categories of patient based on initial response to Fluid resuscitation (Hypotension):

- Responders:
o Patients who have good response to initial fluid therapy.
o Producing normal vital signs. Mental status and urine output
- Nonresponders:
o Have persistent hypotension despite aggressive resuscitation
 o Soured of hypotension must be identified immediately to prevent fatal outcome.

- Transient Responders:
o Patients who respond initially to volume loading by an increase in blood pressure only to then
hemodynamically deteriorate once more.

Signs & Symptoms of Advancing stages of hemorrhagic Shock: (Table 7-4, page145)
CLASS I CLASS II CLASS III CLASS IV
Blood Loss (mL) Up to 750 750-1500 1500-2000 >2000
Blood Loss (%BV) Up to 15% 15-30% 30-40% >40%
Pulse Rate <100 >100 >120 >140
Blood Pressure Normal Normal Decreased Decreased
Pulse Pressure (mmHg) Normal / Increased Decreased Decreased Decreased
Respiratory Rate 14-20 20-30 30-40 >35
Urine Output (mL/h) >30 20-30 5-15 Negligible
CNS/mental status Slightly Anxious Mildly Anxious Anxious & Confused Confused & Lethargic

4 types of Shock:
- Hypovolemic or Hemorrhagic Shock = Most common
- Cardiogenic Shock = Myocardial Infarction
- Neurogenic Shock = Fainting
- Septic Shock = due to infections

Pericardial Tamponade:
- A condition where the pericardial sac (has a small amount of pericardial fluid), in cases of stab wound or
gunshot wound, where blood fills up the entire pericardial sac to which there is no more space for the heart to
expand.
- Patient will then manifest Beck’s triad:
o Hypotension
o Muffled Heart Tones
o Jugular Vein Distension
- Management of Beck’s Triad is Pericardiocentesis

Trendelenburg position:
- So that you have increased venous blood flow to your heart.
- If bed can’t be elevated, put pillows.
Satinsky Clamp = used for Vascular injury
FAST = Focused Abdominal Sonography for Trauma

Lung Injuries:
- Hemothorax = blood that accumulated in the pleural sac due to a Stab wound in the chest
- Pneumohemothorax = air and blood accumulated in the pleural sac due to a stab wound (usually in the apex)
- Insert a chest tube at the 5th Intercostal Space, Mid Clavicular Line or Anterior Axillary Line & Mid Axillary Line.
- Why not Posterior Axillary Line? – because when you lay down, it may compressed the chest tube where fluid
and air can pass through the chest tube
- How to know the 5th intercostal space – use the sternal angle of louis which is the T2 (not the nipple (T4)
because sometimes the nipple is pendulous)
- 75% of lung injuries are treated with chest tube. However, if you have inserted a chest tube and the initial
blood will come out is 1 Liter of blood … that is an indication to do thoracotomy – open up the chest and go
after the bleeding site.
- Also, if you don’t get such 1 Liter, but there is subsequent chest tube drainage of more than 200 cc for the
.next consecutive 3hrs (that means you have persistent bleeding), you really have to open up the chest.
- Always monitor your Chest Tube drainage.
- EDT – Emergency Department Thoracostomy
- CTT – Chest Tube Thoracostomy

Impaled Knife Injury:

- Do not remove the knife because you might have bleeding that you cannot control.
 - Bring the patient to the OR and request for blood in advance.
- Gored Injury – an injury that is caused by an attack of the Carabao or Bull.
In Femoral Fractures, you might loose 1 liter of blood or more

Secondary Survery
- Done after doing the ABC’s
- Check again the patient because you might have missed an injury
- Do the AMPLE history – Physical Diagnosis

Rectal Examination:
- it is important during spinal cord injury, so always do rectal exams.
- Check for the sphincter tone, blood in the finger or high ride of prostate.
- In Spinal Cord injury, the anal Sphincter tone is lax.

Gunshot Wounds:
- Always take the AP and Lateral View for x-ray.
- In AP view, you might think that the wound is only in the heart, but in the lateral view it is actually in the spine

Blunt Trauma:
- Patient with acute abdomen, it was examined that there is a small contusion in the peri-umbilical area, when
operated, there was a perforation which you don’t know, and it was only after the surgery where history was
extracted were the contusion was induced, where there was a perforation.
- Be careful with your history, so always examine your patients.
- SPLEEN = Most common injured organ in BLUNT TRAUMA followed by the LIVER
- SMALL INTESTINE = Most common injured organ in PENETRATING TRAUMA (Stab Wound or Gunshot
Wound) followed by the LIVER.
- Gunshot Wounds are more dangerous than Stab Wounds, because of the shot, it can bounce or ricochet
which becomes more injurious unlike Stab wounds, where you can simply follow the tract of the injury.

Epidural Hematoma
- Is more dangerous because the bleeding is arterial compared to Sub Dural and sub Arachnoid.
- If CT scan show 30cc and above, then it must undergo crainiostomy

Neck:
- An indication for the exploration of the neck is - if an injury has violated our go beyond the PLATYSMA and
must undergo surgery (same with the abdomen, if it goes beyond the peritoneum, that’s an indication for
exploring)
- Has 3 distinct Zones: (Monson)
o ZONE I = between Clavicles and Cricoid Cartilage (Cricoid going down to the thoracic Inlet)
o ZONE II = Between the Cricoid Cartilage and the angle of the mandible
o ZONE III = above the Angle of the Mandible.
- ZONE I and III are very hard to control

Tension Pneumothorax
- Pneumothorax - due to Stab wound or Gunshot … if you puncture the lungs, air will escape and will
accumulate on your chest cavities.
- Tension Pneumothorax – if the increased pressure in a certain area of the lungs continuously leaks and there
is nothing being done with the patient and when undergone x-ray, normally your trachea is in the midline, felt
above the supersternal notch, but with the presence of pneumothorax, later on this will be pushed to the other
side of your mediastinum (and it will compress the normal) …. the other side will try to compensate for the
collapse because of the pressure … so in tension pneumothorax the mediastinal structures are pushed to the
normal side compressing the involved lung and instead of the negative pressure of your chest cavity there will
be diminished venous return leading to dropping of your blood pressure and will lead to cardiac failure.
- Advise to insert chest tube.

Open Pneumothorax
- If you have a certain defect in the lungs, there will be communication with the outside ... air will be sucked in
- Often called as the sucking chest wound.
- Initial treatment is to cover the defect with any cloth including your handkerchief.
Flail chest
- You have fractures in 2 or 3 ribs with 3 or more continuous ribs in 2 separate locations or segments.
- So when you breathe in, instead of expanding, the ribs will go in so you can imagine how painful that is.
- Treatment is to intubate the patient and do mechanical ventilation.

Hypotension
- SBP is <90
- Monitor whether the BP is more than 140/90 or less than 90/60

Cut down
- Venous cutdown … you use your lower extremities
- Look for the Saphenous vein where you will place your catheter to push fluids.
- Blood vessels are collapsed so you need to hydrate your patients via cutdown especially in pediatric patients.

Massive hemothorax
- More than 1 liter of blood loss when you insert your chest tube and as a ground to open up the chest.

Basilar skull fracture

- If you have a head injury and had ecchymosis behind your ear (bluish discoloration or Battle Sign)
- Check if there is otorrhea, rhinorrhea or fluid coming out could be your csf or even having raccoon like eyes
(black eyes/wolves eye) are signs of basilar skull fracture

Spinal Cord injury

- Anterior Cord Syndrome
o is characterized by diminished motor functionand pain and temperature sensation below the level of
the injury, but position sensing, vibratory sensation, and crude touch are maintained. Prognosis for
recovery is poor
- Posterior Cord Syndrome
o Is when the damage is towards the back of the spinal cord. This type of injury may leave the person
with good muscle power, pain and temperature sensation, however they may experience difficulty in
coordinating movement in their limbs
- Central cord syndrome
o usually occurs in older persons who experience hyperextension injuries. Motor function and pain and
temperature sensation are preserved in the lower extremities but diminished in the upper extremities.
Some functional recovery usually occurs, but is often not a return to normal.
- Brown-Sequard Syndrome
o is usually the result of a penetrating injury in which the right or left half of the spinal cord is transected.
This rare lesion is characterized by the ipsilateral loss of motor function, proprioception, and vibratory
sensation, whereas pain and temperature sensation are lost on the contralateral side.

Findings on Chest X-Rays suggestive of a descending thoracic aortic tear. (Table 7-5, page 152)
1.) Widened Mediastinum
2.) Abnormal Aortic Contour
3.) Tracheal Shift
4.) Nasogastric tube shift
5.) Left apical cap
6.) Left or right paraspinal stripe thickening
7.) Depression of the left main bronchus
8.) Obliteration of the aorticopulmonary window
9.) Left pulmonary hilar hematoma
DPL = (Diagnostic Peritoneal Lavage)
- If you have a patient experiencing abdominal pain, blunt abdominal trauma, you monitor the patient … instead
of frequent monitoring, in between frequent monitoring and opening up the patient halfway between the two
you can do DPL  where you open up the abdomen from the umbilical and bring it down to your peritoneum
and insert a catheter with 1L NSS (shake the body)
- Initially, if there is 10cc of blood aspirated, that is positive DPL and an indication for operation.
- Criteria for positive finding on DPL: (Table 7-6 page 155)

Anterior Abdominal Anterior Abdominal

Stab Wounds Stab Wounds
RBC >100,000 /ml > 10,000 /ml
WBC >500 /ml >500 /ml
Amylase >19 IU/L >19 IU/L
Alkaline Phosphate >2 IU/L >2 IU/L
Bilirubin >0.01 mg/dL >0.01 mg/dL

Urethral Injury
- Normally when you have coma patient, you insert NGT and Foley Catheter … but do not insert Foley
Catheter if patients have blood at the tip of the external urethral meatus, scrotal perineal hematoma and
if you have high ride in prostate when doing a rectal exam.
- So do not insert a Foley catheter otherwise it will go to another area.
- You have to do suprapubic cystostomy where you puncture the suprapubic area and allow the urine to pass
out there.

Pelvis
- when the pelvis is fractured it takes a tremendous amount of energy or trauma to fracture a pelvis
- If there is pelvis fracture, just imagine the amount of blood loss … so always request blood
- K-wire = Kirschner Wire is used for pelvic fractures

Extremeties
- When encountered, always asses the blood vessel distal … if you have a gunshot wound in the arm, palpate
the radial artery
- When Gunshot wound in the thigh, palpate for the posterior Tibial Artery .or Dorsalis Pedis but the former is
more important
- Why is the Posterior Tibial Artery more important than Dorsal Pedis?
o Your foot is divided into Thirds – a Proximal, a Medial and a Distal third, the dorsalis pedis provides
blood supply to the proximal third only
- If you have a fracture, always splint joint proximal and distal to it.

Vascular Innjuries (Table 7-8, page 158)

- Signs and symptoms of peripheral arterial injury:

Hard Signs Soft Signs

(Operation Mandatory) (further Evaluation Indicated)
Pulsatile Hemorrhage Proximity to Vasculature
Absent Pulses Significant Hematoma
Acute Ischemia Associated Nerve Injury
A-A Index of <0.9
Thrill or Bruit
** A-A Index = Systolic Blood Pressure on the injured Side compared with that on the uninjured side

The 5 P’s of Vascular Injuries

- Pain, Pallor, Paresthesia, Paralysis and Pulselessness
American Association for the Surgery of Trauma grading scales for Solid Organ Injuries (Table 7-7, page 157)
Subcapsular Hematoma Laceration
LIVER INJURY GRADE
Grade I <10% of Surface Area <1cm in depth
Grade II 10-50% of Surface Area 1-3 cm
Grade III >50% of Surface area or >10 cm in depth >3cm
Grade IV 25-75% of a Hepatic Lobe
Grade V >75% of a hepatic Lobe
Grade VI Hepatic Avulsion
SPLENIC INJURY GRADE
Grade I <10% of surface area <1 cm in depth
Grade II 10-50% of surface area 1-3 cm
Grade III >50% of surface area or >10 cm in depth >3 cm
Grade IV >25% devascularization Hilum
Grade V Shattered spleen & Complete devascularization

Hemoglobin count is important otherwise, oxygen transport is compromised.

If patient has Abrasion and laceration, what antibiotics should you give?
- Give 1st generation cephalosporins, because its coverage is against Gram Positive organisms like Staph and
Strep.

Thoracic Incisions
- The most common is the anterolateral thoracotomy
- For lung exploration, the fastest incision is midline vertical (from the pubic symphysis to your xyphoid process)
… but if your under the age of 6 or pediatric surgery, its always transverse incision.
- Why Midline Vertical is the fastest?
o Because the abdominal wall has 9 layers, so just imagine how long it will take to open compared to
the midline where you just incise to the Linea Alba.
o And you easily gain access for exploration (accessibility) for the upper quadrants to the lower
quadrants.
o Its vertical incision gives you extensibility, because if the injury goes beyond the heart you can just
extend your midline-vertical incision.

Pringle Maneuver
- In liver injury, insert your finger to the Foramen of Winslow … where you have your hepatodoudenal ligament
there … so compress it because underneath the hepatodoudenal ligament is your common bile duct, portal
vein and common hepatic artery … then you press the portal vein and common hepatic because that is
where the blood supply of the liver.
- Portal Vein = 75% blood supply to the liver
- Common hepatic = 25% blood supply to the liver
- Use this maneuver to control the bleeding up to 1 hr.

3 Principles when you open up the Abdomen

- [1] Control Bleeding
o If you see a bleeder apply a clamp
o If you see a major bleeder apply a vascular clamp
- [2] Control Sillage of your vascular intestinal contents
o If your small bowel Is perforated and contents are coming out, apply your babcock forceps
o When the colon is open and is spilling feces use your babcock forceps to minimize spillage.
- [3] Definitive Repair

Vascular Repair
- In vascular Injury, the best hemostat is your finger … stop the bleeding right away.
- Arterial Repair:
o Aorta & carotid o Innominate o Brachial
 o Superior mesenteric o Renal o Femoral
o Proper hepatic o Iliac o Popliteal
- Venous Repair
o Superior Vena Cava
o Inferior Vena Cava proximal to the renal veins
o Portal vein

Damage Control Surgery

- Remember the 3 Principles in Abdominal Surgery
- In a case where the patient has shattered Liver and there is bleeding all over, you have to place a pack (LAP
PADS – Laparotomy Pad Packing) … with this you are avoiding the Bloody Vicious Cycle
- Bloody Vicious Cycle
o Coagulopathy
o Hypothermia
o Metabolic Acidosis

Head Injury
- After scanning the head, when there is epidural hematoma you do Burr Holing

Maxillofacial Injury
- The 3 Le Fort Fractures:
o Le Fort I: (Transmaxillary)
 The fracture occurs along the nasal and maxillary floor
 Almost always involves the pterygoid process of the sphenoid bone
 May involve the maxillary sinuses
 The resultant “floating” component is the lower part of the maxilla and its teeth

o Le Fort II: (Pyramidal / Subzygomatic)

 Result from a downward force on the nose
 The fracture runs from the peak of the nasal bone laterally beneath the orbits.

o Le Fort III: (Craniofacial)

 Most severe
 Often associated with extensive soft tissue injury
 Large force is necessary to cause this type of fracture
 The resultant “floating” component is virtually the entire face

Chest Injury
- When will you remove your chest tube?
o 1st Indication = when there is <40 cc amount of drainage for the next 24 Hrs.
o 2nd Indication = have a chest x-ray and see if the lungs have expanded
o 3rd Indication = when you hear Breath sounds in all the lung fields when doing Auscultation, an
indication that your lungs has expanded

Heart Injury
- The most common injured chamber is the right ventricle.
** In every cases of Vehicular accidents, Lacerations, Contusions, Abrasions and etc … always prescribe for
Tetanus Immunization to your patients.
- In children, always ask for the history of Tetanus Immunizations
- But In adults, seldom they remember, so give Active and Passive Tetanus Immunization
- In the RX, Prescribe:
o Tetanus Toxoid = 1amp – IM now
o Teta Vax (Tetanus Vaccine) = 1 amp – IM now
o Teta Gab (Tetanus Globulin) = 1 amp – IM now
- Why should you give active and passive?
o The Vaccine takes time to develop your antibodies against tetanus. While your Tetanus globulin will
take care of the tetanus for the first few days.
o The Tetanus Globulin will take care of the anti tetanus for the first few days, or weeks or month while
onward, your Tetanus Vaccine will protect you for as long as 10 yrs.
- 3 A’s In Trauma that must be given:
o Anti tetanus
o Anti-Biotic
o Analgesic
o But! … don’t give Analgesic on head injuries because it is best for the patient to be awake to feel the
pain rather than the patient asleep unknowingly going all the way down to coma.

Diaphragmatic Injury
- How much of Diaphragmatic injury that indicates for repair?
o If the injury is less than 2cm, you can leave it alone but more than 2cm, you need to repair … so that
there will be no herniation of the intra abdominal contents to your chest cavity.
- If the diaphragmatic injury is on the right, not much of a problem because the liver is there to cover … but if
you have a stab wound in the left part and penetrated the diaphragm, it would be a problem because if it is big
enough, due to the negative pressure, the stomach, your bowel and even your spleen can go up every time
you breath.
- Any injury below the nipple, don’t only think of chest injury, also think of the possibility of intra abdominal …
why? … so that your diaphragm won’t rise into your nipple during maximum exhalation.

Spleen
- The trend now is to conserve for we now have hemostatic agents (Gelfoam, Surgicel and etc.) to stop the
bleeding but if not, you have to remove your spleen (splenectomy).
- OPSS = Overwhelming Post-Splenectomy Sepsis
o Typically characterized by meningitis or sepsis
o Caused by encapsulated organism including Streptococcus Pneumoniae (50%-90%), Neisseria
meningitides, Hemophilus influenzae, and Streptococcus pyogens (25%)
o Prevention includes Vaccination … it is recommended to Revaccinate the patient given at least 2
weeks before surgery … it is also recommended to revaccinate the patient (after Operation)
frequently in shorter intervals between revaccinations to keep antibody concentrations at a level
sufficient by probability to confer protection (because removing the spleen means removing the
source of your immune system)

Stomach
- In cases of gunshot wounds, it come in pairs … don’t just look at the anterior side but also the posterior side
or else you have a missed injury.
- Same goes with your bowel … run through the bowel from proximal to distal and anterior to posterior.

Doudenum
- If there are injuries, you can do primary repair
- If it is duodenal hematoma, you don’t have to do surgery … conservative only  bowel rest, antibiotics and
analgesics.
- Pyloric exclusion – is used to divert the GI stream after high risk, complex duodenal repairs.
Colon
- Flint colonic Injury grades: (old edition of Schwartz)
o GRADE I = Isolated colonic, minimal contamination, no shock, minimal delay
o GRADE II = Through and through perforation, laceration, moderate contamination
o GRADE III = Severe tissue loss, devascularization, heavy contamination
- Grade 1  Primary repair is the ideal approach for most colonic injury ... especially from the time of onset of
injury to the time of admission in less than 6 hrs  more than 6 hrs would be a critical window.
- If the patient has Grade II or III injury, through and through perforations, massive spillage, hypotension then
don’t do primary repair do diversion techniques … If the injury is in the descending colon, then you can do co-
transverse colostomy ... then exteriorize the bowel, repair the injured part and give it time to heal … so you
divert the flow of the bowel / feces away from the injury.
Genitourinary Tract
- You have an injury to your left kidney, there is bleeding after a gunshot wound. .. If you decide to remove that,
FIRST you should palpate the other side if there is another kidney, because if there is no other kidney on the
other side, then you must save the injured kidney.
Postinjury Resuscitation
- Remember the ABCDE, your AMPLE history and hydrate the patient.
Abdominal Compartment Syndrome
- A condition where any condition in the abdomen because of the edema, of the bowels and fluids … if you
close the abdomen, and because of the increased pressure on a certain area, it can push through the
diaphragm upwards … so you’re compressing your normal Lungs and heart … and will have difficulty in
breathing and have an increase return of flow of your blood
- Do not expose your bowel or else it will dry up and die (as well as the bone).
Pregnant Patients
- This is unique because you are not only thinking of the mother but you are also thinking of the baby.
- Most common are vehicular accidents … so try to assess the patient by doing x-ray otherwise just do
conservative approach or treatment.
Pediatrics
- Always include the possibility of Child abuse (as well as domestic violence) in your history.
Dog Bites
- [A] What to do when bitten by a NEIGHBOR’S DOG?
o [1] Wash the wound with Soap and Water (the best Anti-septic)
o [2] Observe the Dog for 10 days
 If the dog doesn’t die – NOT RABID nad there is no need for antibodies
 If the dog dies in less than 10 days – send the dog for autopsy and look for pathologic signs
of rabies called “Negri Bodies”
o [3] Give your Anti-tetanus vaccination = Toxoid and Immunoglobulin (active & passive)
o [4] Ask for the history whether the Dog Bite was Provoked or Unprovoked
 If you provoke the dog … then likely it does not have rabies.
 The history of rabies is more on the unprovoked bite

- [B] What to do when bitten by a STRAY DOG?

o [1] Think of Rabies immediately – because Stray Dog is considered Rabid (no need for observation)
o [2] Give anti tetanus
o [3] Wash with Soap and Water
o [4] Start giving your anti-bodes immunization (Rabies Vaccine)
 Give (rabies vaccine) 1ml or 1cc on Day 0, 3, 7, 14, & 28 (5 doses)
 Rabipur and Verorab
o [5] Give right away Rabies Immunoglobulin (Anti-Rabies Immunization)
 V-Rab or Rabuma
 Give 20 IU/kg x Body Weight then ½ around the wound and ½ IM

- [C] What to do when there is already RABIES MANIFESTATION?

 If the patient comes to you complaining with seizures, drooling of the saliva with a history of
dog bite 2 weeks ago, what will you do?
o [1] Hospitalize and secure isolation (the IMPRESSION is that, the patient has already Rabies)
o [2] Give Supportive management (dextrose to hydrate, antipyretics for fever, analgesic for pain)
o [3] Pray (there is NO CURE for rabies so the patient will most likely to die)