Scabies Treatment

Overview

First-Line Treatments

• Patient preference (topical vs. oral)
• Drug interactions with ivermectin: azithromycin, trimethoprim/sulfamethoxazole (Bactrim), cetirizine (Zyrtec)
• Cost
• Ivermectin: no renal dose adjustment needed; caution in severe liver disease

Crusted (Norwegian) Scabies

1. Topical scabicide (choose one):
   • 5% permethrin cream — full-body daily for 7 days, then twice weekly until cured
   • 25% benzyl benzoate
2. Plus oral ivermectin 200 µg/kg on Days 1, 2, 8, 9, and 15
   • Severe cases may need additional doses on Days 22 and 29

⚠️ Avoid lindane in crusted scabies — risk of neurotoxicity with heavy application on denuded/broken skin.

General Management Principles

• Treat all household/close contacts simultaneously, even if asymptomatic
• Wash all clothing, bedding, and towels in hot water (≥50°C) on the day of treatment
• Items that cannot be washed should be sealed in a plastic bag for 72 hours (mites cannot survive off a host for >2–3 days)
• Pruritus may persist for 2–4 weeks after successful treatment — this is a hypersensitivity reaction to dead mite proteins, not treatment failure
• Oral antihistamines and topical corticosteroids can manage post-treatment itch
• Treat secondary bacterial superinfection (commonly S. aureus or Streptococcus) with appropriate antibiotics

Special Populations

ATLS Protocol — Road Traffic Accident

Pre-hospital

• Scene safety, extrication with spinal precautions
• C-spine immobilization (hard collar + blocks + tape)
• Airway, oxygen, IV access, splinting
• Scoop and run vs. stay and play — minimize scene time (<10 min for critical patients)
• Alert receiving trauma team with MIST handover: Mechanism / Injuries / Signs / Treatment

Primary Survey — cABCDE

c — Catastrophic Haemorrhage

• Control external life-threatening bleeding immediately
• Direct pressure, wound packing, tourniquets for limb hemorrhage
• Pelvic binder if pelvic fracture suspected

A — Airway + C-Spine Control

Always assume C-spine injury in RTA until ruled out. Maintain inline manual stabilization during intubation.

B — Breathing + Ventilation

• Look, Listen, Feel — RR, SpO₂, chest expansion, tracheal deviation, JVD
• Give high-flow O₂ (15 L/min via non-rebreather mask)

C — Circulation + Haemorrhage Control

• Two large-bore IV cannulas (14–16G antecubital) or IO access
• FAST exam (Focused Assessment with Sonography in Trauma): pericardium, hepatorenal, splenorenal, pelvis

• Activate Massive Transfusion Protocol (MTP) early if Class III/IV
• Target ratio: pRBC : FFP : Platelets = 1:1:1
• Avoid aggressive crystalloid (worsens coagulopathy, acidosis, hypothermia)
• Permissive hypotension: target SBP 80–90 mmHg (or MAP 50 mmHg) until surgical hemorrhage control — except in TBI (target SBP ≥90–100)
• Give TXA (tranexamic acid) 1g IV over 10 min within 3 hours of injury, then 1g over 8 hours
• Treat the lethal triad: Hypothermia + Acidosis + Coagulopathy

• Skeleton (fractures), Chest, Abdomen, Long bones (femur ~1.5L per fracture), Pelvis (up to 4L)

D — Disability (Neurological Status)

• GCS (Eyes + Verbal + Motor)
• Pupils: size, symmetry, reactivity
• BGL — check and correct hypoglycemia
• AVPU scale as quick screen (Alert / Voice / Pain / Unresponsive)
• Signs of herniation: unilateral fixed dilated pupil, Cushing's triad (HTN + bradycardia + irregular breathing) → urgent neurosurgical referral

E — Exposure + Environment

• Fully undress the patient — log roll to examine posterior
• Prevent hypothermia: warm blankets, warmed IV fluids, warm environment
• Document all injuries found

Adjuncts to Primary Survey

• FAST ultrasound
• 12-lead ECG (cardiac contusion, arrhythmia)
• CXR + Pelvic XR (portable if unstable)
• Urinary catheter (if no urethral injury) — monitor UO (target: 0.5 mL/kg/hr adults, 1 mL/kg/hr children)
• NG/OG tube
• Arterial blood gas — assess pH, lactate, base deficit

Secondary Survey

• Head-to-toe physical examination
• AMPLE history: Allergies / Medications / Past medical history / Last meal / Events/Environment
• Detailed neurological exam
• Re-examine all body regions: scalp, face, neck, chest, abdomen, pelvis, perineum, limbs, spine (log roll)
• Whole-body CT (WBCT) — standard in major trauma centres; accelerates diagnosis, though radiation dose ~12–16 mSv (Bailey & Love's, p. 370)
• Tertiary survey (repeated after 24h and when patient wakes in ICU) to identify missed injuries

Definitive Care Priorities

Paediatric Modifications (cABCDE, Bailey & Love's p. 294)

• Airway is more anterior/superior — use uncuffed ETT in young children
• Children compensate well and then deteriorate suddenly — don't be falsely reassured by normal BP
• Fluid bolus: 10–20 mL/kg crystalloid; escalate to blood products early
• Normal vitals are age-dependent

Key Mnemonics Summary