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Dengue case assessment

Dengue case assesment


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

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.

Clinical phases of
dengue fever

Febrile phase

Critical phase

temperature drops to 37.5-38


(days 3-7)
Sudden onset of high (+) increase in capillary
grade fever
permeability with increasing
Lasts for 2-7 days
hematocrit levels
facial flushing
significant plasma leakage
skin erythema
lasts for 24-48 hours
generalized body ache progressive leukopenia
myalgia and arthralgia
followed by rapid decrease in
headache
platelet precedes plasma
leakage
Sore throat, injected
if (-) increase in capillary
pharynx, and
permeability improve
conjunctival injection
if (+) increase in capillary
anorexia, nausea and
permeability pleural
vomiting
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
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hemorrhage
severe hepatitis, encephalitis
or myocarditis

Tourniquet Test

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

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-inchsquare 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

Classification according to severity (WHO classification)

Investigation should be done for any dengue


case admission

CBC see for:

Renal function
test that include(
S.CrB.urea)

( 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
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Other test to rule out

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

evidence of capillary leakage

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

Evidence of
circulatory failure

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.

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, coexisting
conditions,
with certain
social
circumstances

Groups C

require
emergency
treatment and
urgent
referral
severe dengue
(in critical
phase)

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

Calculation assuming
BW 45-50kg

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

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Group C
Compensated Shock
500- 1000 cc during 1hr.

yes

improve

N/S 500 - during 2hr then

NO

1000 cc during 4h
500 cc during another 4hr
500 cc during 8hr

Increase

HCT

500cc during 8hr


Monitor HCT 8-12hr
decrease

Given fresh whoole


blood or packed RBC

PLT transfusion given if less than 10000 without overt bleeding and
normal or elevated HCT

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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Group C
Hypovolemic shock
HCT assess
1000 cc /15 minute

Improve

yes
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
2n
Monitor HCT 6hourly
if improve decrease
fluid
if increase another
bolus
if decrease FWB/PRB

HCT

NO

decrease

increase

2nd bolus
500 1000 -1hr

yes

Consider significant
overt /occult blood
FWB/PRBC

improve
NO
nd

decrease

2 HCT
increase
rd

3 bolus
500 1000 cc 1hr

yes

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improve

NO

rd

3 HCT

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
dfd

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