Pengurusan denggi

1. DENGUE
MANAGEMENT

2. INTRODUCTION
Dengue Fever??

3. • Dengue fever is a disease caused by a
family of viruses transmitted by
MOSQUITOES.
• It is transmitted by Aedes aegypti and
Aedes albopictus.

4. • It is an ACUTE ilness of sudden onset that
usually follows with symptoms such as:
• 1.Fever
• 2.Headache
• 3.Severe Muscle and joint pain
• 4.Swollen lymph node
• 5.Rash
• 6.Chills

6. EPIDEMIOLOGY
• In Malaysia increase from 32 cases per 100,000
populations to 361 cases per 100,000 populations in
2014.
• The dengue incidence rate is higher in the age
group of 15-49 years.
• Most of the dengue cases reported were from
URBAN areas(70-80%)

7. Dengue Virus & Serotype
• DEN 1-4 Serotypes, cross reaction but not cross protective
• Primary vs Secondary infection,
• Antibody Dependent Enhancement (ADE) in secondary
infections, more prone to develop severe dengue

8. DIAGNOSTIC TEST
• 1. Dengue Rapid Test
• 2. Dengue Antigen & Serology Tests by ELISA (NS1,
IgM, IgG
• 3. Dengue Viral RNA Detection
• 4. Virus Isolation(IMR)

9. Clinical Diagnosis
• Symptomatic Dengue infection is a
systemic and dynamic disease
• Its clinical course changes as the
disease progresses
• 3 phases of dengue infection:
1. Febrile Phase
2. Critical Phase
3. Recovery Phase
9

10. 10
3 phases:
-Febrile
-Critical (48 h)
-Recovery
(Reabsorption)
1 2 3 4 5 6 7 8 9 10
40
Viraemia
Temperature
Shock
Haematocrit
Platelet count
IgG/M
LCS Lum
Clinical Course of DHF

11. Clinical Course of Dengue Illness
11

12. FEBRILE PHASE
• Lasts 2-7 days
• Rashes, myalgia, arthralgia & headache
• Anorexia, nausea & vomiting
• Mild haemorrhagic manifestations:
• Positive tourniquet test
• Petechiae & mucosal bleeding
• PV bleeding (female)
• Tender hepatomegaly (DHF)
• FBC - ↓ WCC (earliest abnormality)
12

13. 13
Rashes In Dengue Infection
Generalised erythema
Petechiae
Haemorrhage

14. CRITICAL PHASE
• 3rd to 5th day of illness, or can be earlier,
lasts 24-48 hours
• Rapid drop T, ↑capillary permeability,
plasma leakage
• Varying circulatory disturbances, minimal
and transient or severe.
• Recover spontaneously or after fluid
therapy

15. CRITICAL PHASE
• Around the time of defervescence, patients can
either improve or deteriorate.
• Those who improve after defervescence
have dengue without warning signs
• Those who deteriorate will manifest warning signs:
dengue with warning signs

16. CRITICAL PHASE
• Thrombocytopaenia
• Haemoconcentration
• Leucopaenia relative lymphocytosis
• Clotting abnormalities
• Elevation of AST,ALT
• Hypoproteinaemia, hypoalbuminaemia

17. CRITICAL PHASE
Warning signs are the result of a significant increase in capillary
permeability.
-- Marks the beginning of the critical
phase.
• Abdominal pain or tenderness
• Persistent vomiting or Persistent diarrhoea
• Clinical fluid accumulation
• Mucosal bleed
• Lethargy; Restlessness; Confusion
• Liver tenderness
• Laboratory: Increase in HCT concurrent with rapid
decrease in platelet count

18. CRITICAL PHASE
Warning signs:
• May deteriorate to severe dengue with:
– Severe plasma leakage leading to shock
(dengue shock) ± respiratory distress
– Severe bleeding and/or
– Severe organ impairment
• The period of clinically significant plasma
leakage usually lasts 24 to 48 hours

19. 19
Haemodynamic instability
Prolonged capillary refill time (>2 sec)
Cool peripheries, Tachycardia &
weak pulse volume
Narrowing pulse pressure
(<20 mmHg) & postural hypotension

20. 20
LCS Lum
“Isles of white in a sea
of red”
- Convalescent rash of
dengue
Rashes in Dengue Infection

21. Evidences of
plasma
leakage in
DHF:
Pleural Effusion
21

23. ADMISSION CRITERIA
Symptoms:
1. Warning signs
2. Bleeding
manifestations
3. Unable to tolerate oral
fluids
4. Reduced urine output
Signs:
1. Dehydration
2. Shock
3. Bleeding
4. Any organ failure
Laboratory Criteria:
1. Rising haematocrit
accompanied by
reducing platelet count

24. Dengue with Warning
Signs
• Should be monitored until risk period is over
• Parameter should be monitored:
- Vital signs and perfusion
- GCS
- Urine output
- Warning signs sx
- FBC, other marker (other organ fn as indicated)

25. HOME CARE FOR DENGUE
What should be done?
• Adequate bed rest
• Adequate fluid intake (2-3 litres per day)
– Milk, fruit juice (caution with diabetes patient) and
isotonic electrolyte solution (ORS) and barley / rice
water / clear soup
– Plain water alone may cause electrolyte imbalance
• Take paracetamol (not more than 4 gram per day for
adults)
• Tepid sponging

26. HOME CARE FOR DENGUE
What should be avoided?
• Do not take steroids or NSAIDS e.g. Acetyl-salicylic
acid (aspirin), Mefenemic Acid (Ponstan), Voltaren
tablets, Intramuscular injections or suppositories

28. Group C: Emergency treatment
Compensated shock (1)
• Start i.v. fluid resuscitation with isotonic crystalloid
solutions at 5-10 ml/kg/hr over 1 hour,
• Then reassess the patient’s condition (vital signs, pulse
volume, temp of extremities, capillary refill time, HCT)
and decide depending on the situation:
1. If the patient’s condition improves,
i.v. fluids should be gradually reduced
- to 5-7 ml/kg/hr for 1-2 hr, then reduce
- to 3-5 ml/kg/hr for 2-4 hr, then
- to 2-3 ml/kg/hr for 2-4 hr, and then
- to reduce further depending on haemodynamic
status, which can be maintained for up to 24 – 48 hr.

37. TANGGUNGJAWAB
PARAMEDIK
• 1.NOTIFIKASI
> Borang Notifikasi dilengkapkan oleh Doktor & beritahu
PHI dengan segera dalam masa 24 JAM
> Dokumen dengan lengkap di dalam BHT pesakit.
• 2.BORANG-BORANG YANG DIGUNAKAN MENGIKUT
CPG
- Dengue Assessment(Appendix 8)
- Inpatient Dengue Monitoring Chart (Appendix 10)
- Senarai semak pemantauan Denggi

38. KES PENYAKIT
BERJANGKIT DIDIAGNOS
Klinik Kesihatan
Klinik Swasta
Hospital
Kerajaan dan
Hospital
Swasta
ISI BORANG NOTIS
DENGAN LENGKAP
(Oleh Pengamal Perubatan)
TELEFON
(Bagi Penyakit
Berjangkit Yang
Perlu Notifikasi
Dalam Tempoh
24 jam)
BORANG NOTIS
DI KIRIM
(Dengan tangan,
pos atau faks)
NOTIFIKASI DITERIMA/
BORANG NOTIS DITERIMA
DAN DISEMAK
SIASATAN DIBUAT
INPUT BORANG
NOTIFIKASI
(Komputer On
line)
Pejabat
Kesihatan
Daerah
Pejabat
Rekod
CARTA ALIR NOTIFIKASI PENYAKIT BERJANGKIT YANG TERSENARAI DI
BAWAH AKTA PENCEGAHAN DAN PENGAWALAN PENYAKIT BERJANGKIT 1988

39. PILIHANSYARAT UJIAN, KEPUTUSANDAN STATUS DIAGNOSIS UNTUKTUJUAN NOTIFIKASIPENYAKIT BERJANGKIT
Penyakit Syarat Ujian Option Keputusan Ujian
Cholera Tidak Mesti Positif/ Belum Siap
Dysentery Tidak Mesti Positif/ Belum Siap
Food Poisoning Tidak Mesti Tidak perlu
Typhoid/ Paratyphoid Tidak Mesti Positif/ Belum Siap
Viral Hepatitis Tidak Mesti Positif/ Belum Siap
Poliomyelitis Tidak Mesti Positif/ Belum Siap
Diphteria Tidak Mesti Positif/ Belum Siap
Measles Tidak Mesti Tidak perlu
Tetanus Neonatal Tidak Mesti Tidak perlu
Tetanus Others Mesti Ada Mesti Positif
Whooping Cough Tidak Mesti Positif/ Belum Siap
Dengue Fever/DHF Tidak Mesti Positif/ Belum Siap
Malaria Mesti Ada Mesti Positif

40. TANGGUNGJAWAB
PARAMEDIK
• 3. Monitor keadaan pesakit dengan rapi:
- Keadaan Pesakit (GCS)
- Tanda Vital mengikut tahap penyakit:
>Tekanan darah, Nadi, Pernafasan, Suhu
Badan, Painscore
- Intake/Output pesakit (STRICT I/O CHART)
- Aduan Pesakit(Sakit perut,muntah,nausea,sakit
kepala)
- Tanda-tanda perdarahan(perdarahan di
gusi,hidung, PV bleed)

41. TANGGUNGJAWAB
PARAMEDIK
• 4. Pastikan kekerapan pengambilan darah mengikut arahan
dari Doktor
-4jam, TDS, QID
• 5.Pemberian IVD mengikut regime yang telah ditetapkan oleh
Doktor dan direkodkan dengan betul.
-Maklumkan segera kepada Doktor sekiranya terdapat
sebarang KEABNORMALAN (Keadaan pesakit &
keputusan makmal)
6.Diet Pesakit
-Beri pesakit makanan yang lembut
-Galakkan pesakit mengambil minuman mengikut
arahan doktor.

42. PENGAMBILAN DARAH
• FULL BLOOD CULTURE
-TWBC
-HEMOGLOBIN
-PLATLET
-HEMATOCRIT
• RENAL PROFILE
-Buse, creat,
• Electrolite: Serum calcium, Magnesium,
• Liver Function Test
• Coagulation Profile: PT, APTT, INR

43. Discharge Criteria
• No fever for 24 – 48 hours
• Improvement in clinical status
(general well being, appetite,
haemodynamic status, urine
output, no respiratory distress)
• Increasing trend of platelet count
(usually preceded by rising WBC)
• Stable haematocrit without
intravenous fluids