PEP consists of the following steps:
- All bite wounds and scratches should be attended to as soon as possible after the exposure; thorough washing and flushing of the wound for approximately 15 minutes, with soap or detergent and copious
amounts of water, is required. Where available, an iodine-containing, or similarly viricidal, topical
preparation should be applied to the wound.
- RIG should be administered for severe category III exposures. Wounds that require suturing should be
sutured loosely and only after RIG infiltration into the wound.
- A series of rabies vaccine injections should be administered promptly after an exposure.
A strong recommendation against spinal stabilisation of patients with isolated penetrating trauma; a weak recommendation against the prehospital use of a rigid cervical collar and a hard backboard for ABCDE-stable patients; and a weak recommendation for the use of a vacuum mattress for patient transportation. Finally, our group recommends the use of our clinical algorithm to ensure good clinical practice.
TXA is a safe, inexpensive medication that prevents fibrin breakdown. In traumatic bleeding, it conveys a significant mortality benefit with an impressive NNT for mortality between 7 and 67, depending on injury severity, without apparent serious safety issues. This benefit is associated with early administration. TXA should not be given more than three hours after injury as it may increase mortality after this timeframe. It appears to have equal benefit in a variety of trauma practice environments.
CRASH-3 Trial examined the effect of tranexamic acid on head injury-related death in adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major
The results indicated a reduction in the risk of head injury-related death with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64–0·95]) but in patients with severe head injury (0·99 [0·91–1·07]) there was no clear evidence of a reduction (p value for heterogeneity 0·030).
The effect of tranexamic acid on head injury-related death stratified by time to treatment and recorded no evidence of heterogeneity (p=0·96). The RR of head injury-related death with tranexamic acid was 0·96 (95% CI 0·79–1·17) in patients randomly assigned within 1 h of injury, 0·93 (0·85–1·02) in those randomly assigned within more than 1 h and 3 h or fewer after injury, and 0·94 (0·81–1·09) in those randomly assigned more than 3 h after injury.
- When there is concern for physical abuse, the physical examination should be completed with the child undressed (in a gown), with specific attention to the skin, scalp and fontanel, mouth and oral cavity (including frena), ears, genitalia, and growth chart.
- Any injury in a preambulatory child, including bruises, mouth injuries, fractures, and intracranial or abdominal injury, should raise concern for abuse.
- The “TEN 4” rule: bruising of the Torso, Ears, or Neck in children <4 years old and any bruising in children <4 months old should raise concern.
- Radiographic skeletal survey should be performed using proper technique for children <2 years old with concern for abuse. Repeating the skeletal survey 2–3 weeks later can identify additional fractures that were not seen initially.
- Young (<2 years old) siblings and household contacts of abused children should be examined for abusive injuries and undergo skeletal survey.
- Infants evaluated for physical abuse may benefit from neuroimaging even if they don’t have neurological symptoms.
- Retinal examination is indicated for children with concern for abusive head trauma but may not be indicated for children without intracranial injury.
- Health care providers with a reasonable suspicion of physical abuse have a legal mandate to report their concern to child protective services.