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Dengue case assessment

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Dengue case assesment

Warning sign of dengue fever:- Abdominal pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy; restlessness Liver enlargement >2cm Laboratory: Increase in HCT concurrent with rapid decrease in

platelet count.

Probable Dengue

Live in / travel to dengue endemic area Fever and 2 of the following criteria:

Nausea, vomiting Rash Aches and pains Tourniquet test +ve Leucopenia ,thrombocytopenia Any warning sign

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Tourniquet Test

Febrile phase

Sudden onset of high-grade fever

Lasts for 2-7 days facial flushing skin erythema generalized body ache myalgia and arthralgia headache Sore throat, injected

pharynx, and conjunctival injection

anorexia, nausea and vomiting

Critical phase temperature drops to 37.5-38

(days 3-7) (+) increase in capillary

permeability with increasing hematocrit levels

significant plasma leakage lasts for 24-48 hours

progressive leukopenia followed by rapid decrease in platelet precedes plasma leakage

if (-) increase in capillary permeability improve

if (+) increase in capillary permeability pleural effusion and ascites

degree of increase above the baseline hematocrit reflects the severity of plasma leakage

shock: critical volume of plasma is lost

temperature may be subnormal

prolonged shock organ hypo perfusion organ impairment, metabolic acidosis, and DIC severe hemorrhage

severe hepatitis, encephalitis or myocarditis

Recovery phase

gradual reabsorption of extravascular compartment fluid (48-72 hours)

general well-being improves, appetite returns, GI symptoms abate, hemodynamic status stabilizes and diuresis ensues

(+) rash: isles of white in the sea of red

hematocrit stabilizes or may be lower due to dilutional effect of reabsorbed fluid

WBC starts to rise recovery of platelet

count occurs later

Clinical phases of

dengue fever

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Tourniquet test

Inflate blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes

After deflating the cuff, wait for the skin to return to its normal color, and then count the number of petechial visible in a one-inch- square area on the ventral surface of the forearm.

Positive test: 20 or more petechial rash per 1 inch ((6.25 cm))

(+) TT increases the

probability of dengue (+) hemorrhagic

manifestations enlarged and tender

liver earliest abnormality:

progressive decrease in

total WBC

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Classification according to severity (WHO classification)

Renal function

test that include(

S.CrB.urea)

CBC see for:

( WBC , HCT ,PLT )

RBS

Serology ( dengue antibodies IgM ,IgG when fever at 5th

day or more , dengue

antigen when fever less than 4 day )

Liver function test mainly ( ALT ,AST , S,Albumin ,total bilirubin)

Abdominal ultrasound

Chest X-ray

PT,PTT ,INR

Urine exam for microscopic hematuria

Other test to rule out

Investigation should be done for any dengue

case admission

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Dengue Clinical Syndromes

Undifferentiated fever

Classic dengue Fever Headache, retro orbital pain Muscle and joint pain Nausea/vomiting Rash

Hemorrhagic manifestations

Dengue hemorrhagic fever (DHF) Fever, or recent history of acute fever

Hemorrhagic manifestations Low platelet count (100,000/mm3 or less)

Objective evidence of leaky capillaries

Dengue shock syndrome (DSS) The four criteria for DHF +

Evidence of circulatory failure

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evidence of capillary leakage

Evidence of

circulatory failure

Elevated hematocrit (defined as 20% or more over baseline, or a similar drop after volume replacement treatment); Low protein; or Pleural or other effusions.

Indirect manifestation rapid and weak pulse; narrow pulse pressure of 20 mmHg or hypotension for age; and cold, clammy skin and altered mental status. (All three of these conditions must be met to indirectly demonstrate circulatory failure). Direct manifestation = frank shock.

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Approach to the Management

Groups A

may be sent home

tolerate adequate volumes of oral fluids and pass urine at least once every 6 hours

no warning signs

Groups B referred for

in-hospital management

with warning signs, co-existing conditions,

with certain social circumstances

Groups C require

emergency treatment and urgent referral

severe dengue (in critical phase)

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Plan for group A:-

Encourage intake of ORS, fruit juice and other fluids Paracetamol for fever Advise to come back if with

no clinical improvement

severe abdominal pain

persistent vomiting

cold and clammy extremities,

lethargy or irritability or restlessness,

bleeding

not passing urine for more than 46 hours.

Group B (with warning signs)

Action Plan( Modified)

N/S 500 - during 1hr then 1000 cc during 4h ( ASSESS HCT ) 500 cc during another 4hr 500 cc during 8h 500cc during 8hr

Reassess Hematocrit remains the same or rise minimally {500 cc

during 6 to 8 hourly)

worsening vital signs and rising hematocrit 250 cc to 500cc during 1 hr then reassess

Calculation assuming

BW 45-50kg

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N/S 500 - during 2hr then

1000 cc during 4h

500 cc during another 4hr

500 cc during 8hr

500cc during 8hr

Monitor HCT 8-12hr

NO

yes

HCT

Given fresh whoole

blood or packed RBC

PLT transfusion given if less than 10000 without overt bleeding and

normal or elevated HCT

Group C

Compensated Shock

500- 1000 cc during 1hr.

improve

Increase

decrease

Compensated shock rapid and weak pulse; narrow pulse pressure of 20 mmHg or hypotension for age; and cold, clammy skin and altered mental status.

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2n

Crystalloid solution 500cc /hr N/S 500 - during 1hr then 1000 cc during 4h 500 cc during 4hr 500 cc during 8h 500cc during 8hr

HCT 6hourly Monitor if improve decrease fluid if increase another bolus

if decrease FWB/PRB

Group C Hypovolemic shock

HCT assess 1000 cc /15 minute

Improve

2nd bolus

500 1000 -1hr Consider significant overt /occult blood

FWB/PRBC

yes NO HCT

improve

2nd

HCT

3rd

bolus

500 1000 cc 1hr

improve NO 3rd

HCT

decrease increase

yes

NO

decrease

increase

yes

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dfd

Criteria for discharge dengue case from hospital

Absence of fever for 48 hours (without anti-fever therapy) and return of appetite

Visible improvement in clinical picture, Stable hematocrit 3 days after recovery from

shock

Platelet 50,000mm

No respiratory distress from pleural effusions/ascites

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