Approach to the Critical Patient

Immediate stabilization

Airway and respiratory threats

Hemodynamic and autonomic threats

CNS agitation and seizure control

Monitoring and targets

Essential monitoring bundle

Escalation triggers

Consults and public health

Mandatory consults

Public health obligations

History

Exposure history

Animal contact

Exposure characteristics

Prodromal and neurological symptoms

Early prodromal phase (2-10 days)

Encephalitic phase features

Risk factors and background

High-risk occupations and exposures

Prior vaccination and medical history

Pediatric exposure features

Physical Exam

Vital signs and general appearance

Hemodynamic and autonomic profile

General appearance

Neurological examination

Provocative tests

Consciousness and cognition

Cranial nerves and motor

Autonomic and systemic signs

Autonomic features

Cardiac and wound examination

Differential Diagnosis

Infectious encephalitides

Herpes simplex encephalitis (HSV-1)

Arboviral encephalitides

Enteroviral encephalitis

Non-infectious and autoimmune

Autoimmune encephalitis

Tetanus

Delirium tremens

Neuromuscular and toxic causes

Guillain-Barre syndrome

Hysterical pseudohydrophobia

Anticholinergic toxidrome

Laboratory Tests

Antemortem rabies diagnostic panel

Saliva RT-PCR

Nuchal skin biopsy

CSF analysis for rabies

Routine laboratory studies

Complete blood count

CSF routine analysis

Metabolic and organ function panel

Cardiac and inflammatory markers

Cardiac evaluation

Emerging biomarkers

Diagnostic Tests

Scoring Systems

Encephalitis severity and etiology tools

Prognosis indicators

MRI

MRI brain indications and findings

MRI limitations in rabies

CT

CT head indications

CT chest

Ultrasound

Cardiac POCUS

General resuscitation POCUS

Limited role in rabies diagnosis

Disposition

ICU admission

All symptomatic cases require ICU admission

No role for observation unit or outpatient management

Infection control and transfer

Infection control precautions

Transfer considerations

Palliative and goals of care

Early goals-of-care conversation

Palliative care consultation

Treatment

Airway and ventilatory management

Early intubation strategy

Ventilator management

Sedation and symptom control

Agitation and spasm management

Seizure management

Autonomic and cardiac management

Dysautonomia treatment

Hemodynamic support

Post-exposure prophylaxis (PEP) — pre-symptomatic only

PEP is the only effective intervention

Unvaccinated PEP schedule (ACIP 2022)

Previously vaccinated PEP schedule

Treatment not recommended

Milwaukee Protocol — abandoned

Agents contraindicated

Supportive care and complication management

Fluid and nutritional support

Complication management

Special Populations

Pregnancy

Rabies in pregnancy

Medication safety in pregnancy

Geriatric

Modified clinical presentation in older adults

Drug considerations in older adults

Goals-of-care emphasis

Pediatrics

Pediatric-specific features

Pediatric PEP dosing

Pediatric sedation and seizure management

Background

Epidemiology

Global burden

United States and Americas epidemiology

Case fatality and survivors

Pathophysiology

Viral entry and transport

CNS invasion and spread

Cardiac pathophysiology

Therapeutic Considerations

No curative antiviral therapy exists

Treatment goal dichotomy

Prevention is the only reliable intervention

Patient Discharge Instructions

copy discharge instructions

You have been evaluated for possible rabies exposure

Warning signs — return to the emergency department immediately if you develop

Wound care instructions

Follow-up instructions

Animal reporting

References

Guidelines and key sources

ACIP rabies prevention guidelines

CDC resources

Key clinical studies

Pathogenesis and clinical features

Treatment evidence

Diagnostics and neuroimaging

Epidemiology and PEP outcomes