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Clinical management of dengue in the primary care

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Clinical management of dengue in the primary care

  1. 1. Clinical Management of Dengue in the Primary Care Setting Andre Sookdar
  2. 2. Objectives • • • • • Course of Dengue Illness Approach to Suspected Dengue Patient Recognizing Severe Dengue Clinical Management Good vs Bad Practice
  3. 3. Course of Dengue Fever • After incubation, Dengue Fever begins abruptly. • Three Phases; Febrile, Critical and Recovery. • Severe Dengue may occur from Day 4-5 instead of the recovery phase. This may involve Hypovolemic/Hypotensive shock, Coagulation abnormalities or Severe Organ impairment. • Most cases recover without hospital management. • Triage, Guidelines and management decisions at the primary care level can help in identifying those at risk of severe Dengue and needing hospital care.
  4. 4. Course of Dengue Fever
  5. 5. At the Primary Care Level • Recognize the Febrile patient could have Dengue. • Notify the Public Health Authorities early about suspected cases. • Managing the early Febrile Phase of Dengue. • Recognize the Critical Phase as plasma leakage and to initiate fluid therapy. • Recognize the Warning Signs and the need for referral. • Recognize and manage severe plasma leakage and shock, severe bleeding and organ impairment promptly and adequately.
  6. 6. Approach to Suspected Dengue Patient • Stepwise approach • Step 1 – Overall Assessment 1. History 2. Physical Examination 3. Investigations • Step 2 – Diagnosis, assessment of disease phase and severity • Step 3 – Management 1. Group A, B or C
  7. 7. History • • • • • • • Date of onset of fever/illness Quantity of oral intake Assessment of Warning Signs Diarrhoea Change in mental state/seizures/dizziness Urine output Other – neighbourhood dengue, travel to endemic areas, co-existing conditions, risk factors for Leptospirosis, Malaria, HIV
  8. 8. Examination • • • • • • • • Mental State Hydration Status Hemodynamic Status Tachypnea/Acidotic Breathing/Pleural Effusion Abdominal Tenderness/Hepatomegaly/Ascites Rash and Bleeding manifestations Tourniquet Test Temperature
  9. 9. • “ isles of white in the sea of red” • Hemorrhagic Rash
  10. 10. Tourniquet Test • Blood Pressure Cuff is applied and inflated midway between the systolic and diastolic pressures • Leave on for five minutes • Positive if there are more than 10 petechiae in one inch circle. • Dengue Hemorrhagic Fever usually results in 20 or more petechiae. • Confounding factors include premenstrual/postmenstrual women and sundamaged skin
  11. 11. Positive Negative
  12. 12. Investigations • CBC – baseline HCT, low WBC, low Platelet • Rising serial HCT – plasma leakage/critical phase • Confirmatory tests (not necessary in acute management) • LFT’s, Glucose, Electrolytes, Urea, Creatinine, Bicarbonate, Cardiac Enzymes, ECG, Urinalysis
  13. 13. Management • Disease Notification – suspected and confirmed cases in Dengue endemic countries. Confirmation can come later for suspected cases. Early notification is key to initiate vector eradication. • Clinical manifestations and circumstances leads to patient being sent home (Group A), referred for inhospital management (Group B) or emergency treatment and urgent referral (Group C.) • Education of patient and relatives on disease and vector management
  14. 14. Group A • No Warning Signs • No significant co-morbid conditions or social circumstances • Must be able to tolerate adequate oral fluids • Must be passing urine at least every six hours • May be sent home with instructions and plans for follow-up • Bed rest; fluid intake; paracetamol • Daily review for disease progression
  15. 15. Group B • Stable patients with Warning Signs or patients without the warning signs but have significant co-morbid conditions or social circumstances. • Referral for in-hospital care • Obtain baseline CBC with HCT • Encourage oral fluids; if not tolerating for 0.9% N/S or Ringer’s Lactate at maintenance rate. • For those with Warning signs give 0.9% N/S or Ringer’s Lactate at 5-7ml/kg/hr for 1-2 hrs, then reduce to 35ml/kg/hr for 2-4 hrs, then reduce to 2-3 ml/kg/hr according to clinical response.
  16. 16. Group B • Reassess, repeat HCT • If HCT is stable then continue at 2-3ml/kg/hr. • If worsening of vital signs or rising HCT increase to 510 ml/kg/hr for 1-2 hrs then reassess • Observe urine output and fluid intake
  17. 17. Group C • Warning signs present plus features of: Severe plasma leakage and shock Fluid accumulation with respiratory distress Severe bleeding Severe Organ impairment • For Emergency Treatment and Referral • CBC and baseline HCT • Other organ function tests • Start IV fluid resuscitation with crystalloid solutions at 510 ml/kg/hr for 1 hr. • Reassess patient
  18. 18. Group C • If patient improves gradually reduce to 5-7 ml/kg/hr for 1-2 hrs, then 3-5 ml/kg/hr for 2-4 hrs then 2-3 ml/kg/hr for 2-4 hrs • If patient is still unstable check HCT If HCT increases or is still high repeat a second bolus at 10-20 ml/kg/hr for one hr. If there is improvement reduce to 7-10 lm/kg/hr for 1-2 hrs and continue to reduce as the above • If HCT decreases this indicates bleeding and need for transfusion
  19. 19. Conclusion • • • • • Course of Dengue Illness Primary Approach to Suspected Dengue Patient Recognizing Severe Dengue Clinical Management of Groups A, B, C Good vs Bad Practice
  20. 20. Thank You

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