Rabies Vaccine Guidelines (WHO-based, per Park's Textbook of Preventive and Social Medicine, and cross-checked against CDC/WHO current recommendations)

1. Wound/Local Treatment (do this immediately, regardless of vaccination plan)

• Flush and wash the wound(s) with soap and plenty of running water for at least 15 minutes. If soap unavailable, flush with water alone.
• Irrigate with a virucidal agent (70% alcohol, tincture of iodine, or povidone-iodine).
• Do not suture immediately (risk of driving virus deeper); if suturing is unavoidable, delay 24-48 hours and cover with rabies immunoglobulin (RIG) locally first.
• Give tetanus prophylaxis and antibiotics as indicated.
• Local wound treatment alone can reduce the risk of developing rabies by up to 80%.

2. WHO Categories of Exposure and PEP Decision

3. Vaccination Regimens (unvaccinated individuals, Category II/III)

• Essen regimen (5-dose): 1 dose IM on days 0, 3, 7, 14, 28
• Zagreb/"2-1-1" regimen (4-dose): 2 doses on day 0 (one in each deltoid/thigh), then 1 dose each on days 7 and 21
• 4-dose alternative (healthy, immunocompetent patients with good wound care + RIG + WHO-prequalified vaccine): days 0, 3, 7, 14

• 2-site regimen: 0.1 mL at 2 sites on days 0, 3, 7, and 28 (day 14 skipped) - "2+2+2+0+2"

4. Rabies Immunoglobulin (RIG)

• Given once only, at or as soon as possible after starting vaccination; not indicated beyond day 7 after the first vaccine dose (active antibody response presumed to have started).
• Human RIG (HRIG): 20 IU/kg body weight
• Equine RIG/F(ab')2: 40 IU/kg body weight
• Infiltrate as much as anatomically possible into/around the wound; any remainder given IM at a site distant from the vaccine. No skin test is needed before equine RIG (doesn't predict reactions; anaphylaxis risk ~1/45,000).

5. Immunocompromised Patients (including HIV/AIDS)

• Full 5-dose IM series plus wound management and local RIG infiltration for Category II/III exposures.
• Check neutralizing antibody response 2-4 weeks post-vaccination to assess need for an extra dose.
• CDC notes an added 5th dose on day 28 for immunocompromised individuals even on standard PEP schedules.

6. Previously Vaccinated Individuals (prior complete PrEP or PEP)

• Only 2 booster doses needed: day 0 and day 3 (IM), or intradermal equivalent.
• No RIG required.

7. Pre-Exposure Prophylaxis (PrEP)

• Recommended for those with continual/frequent exposure risk: lab workers handling rabies virus/lyssaviruses, veterinarians, animal handlers, travelers to high-risk areas, and children in rural high-risk regions.
• Schedule: IM 1.0 or 0.5 mL (vaccine-dependent) or intradermal 0.1 mL, on days 0, 7, and 21 or 28.
• No routine booster needed after a complete primary PrEP/PEP series unless continual occupational risk; antibody monitoring preferred over routine boosters (every 6 months for high-risk lab workers, every 2 years for others at intermittent risk).

Key principle

• Park's Textbook of Preventive and Social Medicine, pp. 323-325 (WHO PEP/PrEP guidance)
• Rosen's Emergency Medicine, Concepts and Clinical Practice, ch. 119 (Rabies epidemiology/risk)
• Supplementary current recommendations: WHO rabies PEP decision tree, CDC rabies PEP guidance

Criteria for ICU Admission

1. General Prioritization Model (SCCM)

• Priority 1 – Critically ill, unstable patients needing intensive treatment/monitoring that cannot be provided outside the ICU (e.g., mechanical ventilation, continuous vasoactive drug infusions). No limits placed on the extent of therapy.
• Priority 2 – Patients who need intensive monitoring and are at risk of needing immediate intervention (e.g., a patient with significant comorbidity who develops an acute severe illness).
• Priority 3 – Critically ill patients with a reduced likelihood of recovery because of underlying disease or the nature of their acute illness; intensive treatment may relieve the acute illness, but limits on therapeutic effort (e.g., no intubation, no CPR) may be set.
• Priority 4 – Generally not appropriate for ICU admission: patients too well to benefit (better managed on a ward) or too sick to benefit (e.g., irreversible/terminal illness with no realistic chance of recovery), admitted only on an individualized basis.

2. Objective "Warning" Parameters That Commonly Trigger ICU Transfer

• Threatened or compromised airway
• Respiratory rate >35/min (or <8/min)
• Acute respiratory failure needing invasive or noninvasive ventilation
• SpO2 <90% despite supplemental oxygen; PaO2/FiO2 ratio low (severe hypoxemia)
• Worsening hypercapnia or respiratory acidosis

• Systolic BP <90 mmHg (or a drop >40 mmHg from baseline) unresponsive to fluids
• Heart rate <40 or >150/min with hemodynamic compromise
• New/worsening cardiac arrhythmia with hemodynamic instability
• Need for vasopressor/inotropic support
• Cardiac arrest or shock of any etiology

• Acute, significant drop in level of consciousness/GCS, new-onset coma
• Repeated or prolonged seizures
• Sudden loss of movement/sensation in a limb (impending herniation, cord compromise)

• Acute anuria/severe oliguria
• Severe electrolyte derangements (e.g., severe hyperkalemia, hyponatremia)
• Diabetic ketoacidosis with complications, severe metabolic acidosis
• Toxic drug level with hemodynamic or neurologic compromise

• Any patient requiring close, continuous monitoring that cannot be delivered on a ward
• Post-op patients needing hemodynamic monitoring/ventilatory support
• Failure to respond to therapy on a lower level of care, or a Rapid Response Team activation that doesn't stabilize on the ward

3. Disease-Specific Examples (from textbook sources)

• Major: need for invasive mechanical ventilation; septic shock requiring vasopressors
• Minor: RR ≥30/min; PaO2/FiO2 ≤250; multilobar infiltrates; confusion/disorientation; BUN ≥20 mg/dL; leukopenia (WBC <4000); thrombocytopenia (<100,000/mm³); hypothermia (<36°C); hypotension requiring aggressive fluid resuscitation (Rosen's Emergency Medicine, Box 62.1)

4. Practical Bottom Line

1. Needs a level of monitoring or intervention (ventilator, vasopressors, continuous invasive monitoring) that cannot be safely delivered on a general ward, and
2. Has a reasonable chance of benefiting from that intensive support (i.e., is not Priority 4), and/or
3. Meets specific vital-sign/organ-dysfunction thresholds or disease-specific severity criteria as above.

• Rosen's Emergency Medicine, Concepts and Clinical Practice - Box 62.1 (severe CAP criteria)
• The Washington Manual of Medical Therapeutics - COPD exacerbation chapter
• Current Surgical Therapy, 14e - rib fracture admission criteria
• Tintinalli's Emergency Medicine; Schwartz's Principles of Surgery - pancreatitis
• SCCM ICU Admission, Discharge, and Triage Guidelines (Crit Care Med 2016;44(8):1553-1602)

When to Extubate

1. Readiness Screening Criteria (before attempting a trial)

• The underlying disease process causing respiratory failure has improved or resolved
• The patient is awake and largely off sedatives
• FiO2 ≤0.5 and PEEP <8 cm H2O (i.e., ventilator support requirements are low)
• Hemodynamically stable (no/minimal vasopressors)
• No uncontrolled myocardial ischemia
• Adequate cough/airway clearance and manageable secretions

2. The Spontaneous Breathing Trial (SBT)

• Performed by placing the patient on minimal support - either a T-piece (no pressure support) or low-level pressure support ventilation (e.g., PSV 5-8 cm H2O with minimal/no supplemental O2), for roughly 30-120 minutes
• Important update: The 2024 AARC guideline (Roberts et al., Respir Care, PMID 38443142) changed several prior standards - SBTs should be completed before noon when feasible, low-level pressure support is no longer required (T-piece is acceptable), FiO2 should not be increased during the trial, and the rapid shallow breathing index (RSBI) is no longer recommended as a required criterion, since relying on it was shown to slow liberation from ventilation.
• About 60-75% of patients succeed on their first SBT; patients who pass an SBT have a >70% chance of successful extubation.

3. Airway Protection Assessment (before pulling the tube)

• Cuff leak test: after deflating the ETT cuff, a loss of 10-20% of the ventilated tidal volume should be observed. Absence of a leak suggests airway edema; consider IV steroids and reassessment in 24 hours, though extubation may still proceed cautiously with reintubation equipment ready if the leak remains absent over multiple days.
• Ability to protect the airway: assessed via GCS and ability to follow commands, plus adequate cough strength and secretion burden. Inability to follow commands is not an absolute contraindication (especially in neurosurgical patients) but requires experienced clinical judgment.

4. Practical Bedside Checklist (commonly used combined criteria)

• RR <30/min (some protocols <35)
• Tidal volume >5 mL/kg
• Minute ventilation <12 L/min
• Negative inspiratory force -20 to -80 cm H2O
• Vital capacity >10-15 mL/kg
• SpO2 >90-92% on FiO2 ≤40-50%
• Secretions moderate or less, and patient able to clear them
• Patient alert/cooperative or able to protect airway
• Cuff leak present (specifically required in high-risk groups: cervical spine injury, prolonged intubation, multiple prior reintubations, airway/neck trauma, esophageal injury)

5. Post-Extubation Support (reduces reintubation risk)

• COPD/chronic hypercapnic respiratory failure: extubate to noninvasive positive pressure ventilation (NIV/NPPV) - reduces mortality and reintubation.
• Other/low-risk patients: high-flow nasal cannula (HFNC) is noninferior to NIV and generally better tolerated for preventing reintubation.
• Close monitoring is required regardless, since a meaningful proportion of patients (especially those who fail extubation) have higher mortality than those never extubated.

Failure to Wean

• Harrison's Principles of Internal Medicine, 22nd Ed. - "Liberation From Mechanical Ventilation," pp. 2350-2352
• Sabiston Textbook of Surgery - "Extubation or Tracheostomy," p. 939
• The Washington Manual of Medical Therapeutics - "Liberation From Mechanical Ventilation"
• Roberts KJ, et al. AARC Clinical Practice Guideline: Spontaneous Breathing Trials for Liberation From Adult Mechanical Ventilation. Respir Care 2024 (PMID: 38443142) - this recent guideline updated several extubation-readiness practices noted above, so it's worth flagging if your institutional protocol still relies on RSBI as a mandatory cutoff.
• Girard T, et al. ATS Clinical Practice Guideline on cuff leak tests and ventilator liberation protocols, Am J Respir Crit Care Med 2017 (cited in Harrison's)