Rabies PEP Management Summary with ID Preference + Tetanus Immunization After Wounds (หมากัด แมวข่วน รถล้ม แผลถลอก)

💉 Rabies PEP Management Summary with ID Preference

Exposure Category	Immune Status	Vaccination History	Management	Vaccine Schedule	RIG Required?
CAT 1	All	Any	❌ No treatment needed	–	❌ No
CAT 2	Normal	Vaccinated <6 months	Booster	✅ Day 0 only (1 dose) • IM or ID 2-site	❌ No
CAT 2	Normal	Vaccinated >6 months	Booster	✅ Day 0, 3 • IM or ID 2-site or ID 4-site Day 0	❌ No
CAT 2	Normal	Never vaccinated	Full vaccine	✅ ID 2-site Days 0, 3, 7, 28 or IM Days 0, 3, 7, 14, 28	❌ No
CAT 2	Immuno compromised	Any	Full vaccine + RIG	❗ IM only: Days 0, 3, 7, 14, 28	✅ Yes
CAT 3	Normal	Vaccinated <6 months	Booster + RIG	✅ Day 0 only (1 dose) • IM or ID 2-site	✅ Yes
CAT 3	Normal	Vaccinated >6 months	Booster + RIG	✅ Day 0, 3 • IM or ID 2-site or ID 4-site Day 0	✅ Yes
CAT 3	Normal	Never vaccinated	Full vaccine + RIG	✅ ID 2-site Days 0, 3, 7, 28 or IM Days 0, 3, 7, 14, 28	✅ Yes
CAT 3	Immuno compromised	Any	Full vaccine + RIG	❗ IM only: Days 0, 3, 7, 14, 28	✅ Yes

💉 Vaccine Administration Details

🧪 Intradermal (ID) Regimens

• Dose: 0.1 mL per injection site

• Sites:

  • 2-site: One injection in each deltoid

  • 4-site: Both deltoids + both anterior thighs or scapulae (only Day 0)

💉 Intramuscular (IM) Regimens

• Dose: 0.5–1.0 mL depending on brand

• Site: Deltoid (or anterolateral thigh for infants)

⚠️ Do NOT mix ID and IM regimens during the course — EXCEPTION: if vaccine shortage on Day 3.

🧪 Rabies Immune Globulin (RIG)

Type	Dose	Administration
ERIG (Equine)	40 IU/kg	Infiltrate around the wound as much as anatomically feasible
HRIG (Human)	20 IU/kg	Same as above; dilute for mucosal contact (1:10 with NSS if to eye/oral mucosa)

❗ Do not inject remaining RIG elsewhere (e.g., gluteus)✅ Administer only once, within 7 days of first vaccine dose

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💉 Tetanus Immunization After Wounds

Ready-to-Use Clinical & Exam Sheet

Step 1: Identify the wound

• Clean wound = clean, minor, superficial

• Dirty wound = contaminated, puncture, soil/feces/saliva, devitalized tissue, burns, crush injuries, bites
  

🧾 Tetanus Immunization Table (COMPLETE)

Situation	Action
No or unknown tetanus history	🧷 Start full primary course (3 doses)   • Dose 1: day 0 • Dose 2: ≥4 weeks after dose 1 • Dose 3: 6–12 months after dose 2 ➕ Add TIG if dirty wound
<3 doses received (incomplete series)	🧷 Complete the remaining doses   • Continue where left off • Do NOT restart series   ➕ Add TIG if dirty wound
≥3 doses, clean wound, last dose ≥10 years	💉 Booster dose (Td or Tdap) x1
≥3 doses, clean wound, last dose <10 years	✅ No booster needed
≥3 doses, dirty wound, last dose >5 years	💉 Booster dose (Td or Tdap) x1
≥3 doses, dirty wound, last dose ≤5 years	✅ No booster needed

✅ This row completes the table and avoids confusion in exams and practice.

💉 Vaccine Details

• Vaccine: Td or Tdap

• Dose: 0.5 mL IM x1

• Tdap preferred if patient has never received Tdap before
  

🧪 TIG (Tetanus Immune Globulin) — Quick Rules

TIG is used ONLY if BOTH are present:

1. Dirty / high-risk wound

2. Inadequate (<3 doses) OR unknown vaccination history
   

❌ Never needed if:

• Clean wound

• AND ≥3 documented doses
  

TIG Dose

• 250 IU IM once

• May increase dose in heavily contaminated wounds

• Administer at a separate site from vaccine

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📌 High-Yield Exam Memory Box

• “Full course” = 3 doses → builds immunity

• “Booster” = 1 dose → maintains immunity

• Dirty wound rules:

  • ≥5 years → booster

  • <5 years → no booster

• Clean wound rules:

  • ≥10 years → booster

  • <10 years → no booster

• Never restart the series