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Good afternoon!

JI Balamban, Fabros, Pati

THE CASE

This is a case of a 25 year old


female who came in due to

fever and abdominal pain

No history of travel to other provinces


No wading in flood waters
Constant exposure to rodents and lives
near a flooded area for the past
months.
(+) Known cases of vector related
infection in her household, as her
common law partner and child were
diagnosed with the illness 2 years ago.

Patient was apparently well until

4 days PTA
Patient
woke
up
undocumented fever

with

with associated symptoms of:


sudden onset headache, frontal
to temporal in location, throbbing
in
character,
non
radiating,
described as 5/10 in severity
myalgia and arthralgia

4 days PTA
She took:
1. Phenylephrine HCl + Chlorphenamine
maleate + Paracetamol (Bioflu) 500
mg/ tab every 6 hours for the fever
and headache
2. Ibuprofen
+
Paracetamol
200mg/325mg (Alaxan FR)
for
myalgia and arthralgia
Afforded no relief

No coughs, colds, chills, throat pain,


ear pain, ear discharge, abdominal
pain, vomiting, diarrhea, dysuria,
hematuria, vaginal discharge noted
No consult done

2 days PTA
Still with above symptoms now
dizziness & sudden onset of Abdominal
pain, burning in quality, epigastric in
location, radiating to the right upper
quadrant, severity of 9/10, aggravated
by food intake and relieved by vomiting
Reported loss of appetite

2 days PTA
3 episodes of vomiting of:
previously ingested food, non-bilious,
non-bloody, watery, and approximately
100 cc in volume.
Self-medicated Simethicone (Kremil S) x
1 dose afforded no relief of abdominal
pain
There was no change in bowel movement,
melena, hematochezia, hematemesis
No consult done

1 day PTA
Fever subsided, but persistence of
abdominal pain and headache noted
which progresses from 9/10 to 10/10
Persistence of symptoms prompted
consult

Past Medical History


S/P salpingo-oophorectomy, left
secondary to ectopic pregnancy
(2014, PGH)
No hypertension
No diabetes mellitus
No kidney, liver, or thyroid diseases
No allergies to food or drugs
No previous PTB treatment

FAMILY HISTORY
No hypertension, no DM,
Bronchial asthma
No kidney, liver, or thyroid
disease
No Cancer

PERSONAL AND SOCIAL


HISTORY
Smoker, 5 pack years
Occasional alcoholic beverage
drinker
Marijuana x 1 use (3 months
ago)
Housewife

OB History
G2P1 1-0-1-1
1 living child delivered via NSD
(OMMC,2008)
S/P salpingo-oophorectomy, left,
secondary to ectopic pregnancy
(2014, PGH)

Menstrual History
Menarche at 9 years old
Average of 4 napkins a day,
soaked
No history of dysmenorrhea

SEXUAL HISTORY
Had 3 heterosexual male partner
First coitus at 14 y/o
Currently have 1 heterosexual male
partner
No history of artificial contraceptive
method use

Functional Health Pattern


Diet:
3 cups of rice/meal, varieties of
meal
Regularly uses condiments on
food: salt, soy sauce, fish sauce,
pepper, spicy powder

Fluid intake:
~500ml of Water/day (2 cups)
3
bottles
of
Coke
(8ounces/bottle)

Functional Health Pattern


Elimination Pattern:
Urination: ~5x/day, light yellow
and clear , (-) hematuria
Defecation: 2x/day, golden brown,
(-) constipation (-) gross blood

ActivityExercise
Sedentary lifestyle

Pattern:

REVIEW OF SYSTEMS

No weight changes, no anorexia


No jaundice
No coughs, colds, dyspnea
No chest pain, no palpitations, no orthopnea,
no PND
No dysuria, oliguria, hematuria
No diarrhea, constipation
No polyuria, polyphagia, polydypsia, heat
intolerance
No calf tenderness ,rashes, ecchymosis,
purpura, edema

PHYSICAL EXAM

GENERAL SURVEY
J.D. was awake, alert and
coherent and oriented to 3
spheres
Calm, no signs of
cardiorespiratory distress
Ambulatory
Ectomorphic

VITAL SIGNS

T: 35.4C (axillary)
PR: 68/MIN
RR: 15cpm
BP: 110/70 mmHg (sitting)

ANTHROPOMETRIC
Height: 1.54 meters
Weight:46kg
BMI: 19.39 (Normal)

SKIN
Light brown in color with sparse
hair, evenly distributed on all
extremities
No noticeable change in skin color
No rash, erythema, purpura,
ecchymosis
warm to touch
pinkish nail beds
Tourniquet test negative

HEAD
Normocephalic atraumatic
(NC/AT)
Hair was naturally black in
color ; texture is fine and with
normal hair distribution
No palpable lesions, masses or
tenderness

EYES
No protrusions, retraction, drooping
or edema in the eyelids.
(-) lesions, masses and periorbital
edema and tenderness
Visual acuity: OD: 20/20 OS: 20/20
visual fields intact
Sclerae white in color, (-) abrasions
Pale and moist Palpebral
conjunctivae

EYES
Pupils equal at 3 to 2mm both
responsive to light and
accommodation
Irises dark brown; no signs of cilliary
injections.
Extraocular muscle movements
intact
No tenderness on lacrimal apparatus

EARS
Bilateral kidney-shape pinna
No deformities, lesions, masses
Intact tympanic membrane, cone of
light pointing antero-inferiorly.
No pain on tug-test
(+) whispered voice hearing test :
R=L

NOSE
Nose and nasal septum midline
Patent nostrils
Frontal and maxillary sinuses nontender

THROAT
Pinkish Lips
With dental caries , incomplete set of
teeth
Pinkish buccal mucosa and gums ,No
bleeding
No ulcerations, inflammation or
bleeding
Non-inflammed Tonsils
Tongue and uvula midline

NECK

No asymmetries or masses
Non-palpable thyroid gland
No neck vein distention
Non palpable cervical lymph nodes

CHEST AND LUNGS


No deformities
Symmetric chest expansion with good
lung excursion
No visible and palpable masses
Equal and symmetric tactile fremitus
in all lung fields.
Resonant percussion notes in all lung
fields
No adventitious sound
No increase in vocal
fremitus/transmitted voice sounds (no

HEART
Adynamic precordium
No thrills, lifts or heaves
PMI: 5th left ICS LMCL 1.5
diameter
Base: S1 > S2
Apex: S2 > S1
S3 and S4 absent
No murmurs, no extra sounds

BREAST AND AXILLA


Breasts are equal and symmetrical
No skin color changes, tenderness,
edema or lesion noted
R breast: 4cm X 2cm, round and
movable solid growth mass, with
smooth edges. No dimpling,
erythema noted.
No nipple inversion, discharge or
edema noted

ABDOMEN
Shape: globular
Inverted umbilicus
Symmetrical, with vertical surgical
scar below the umbilicus,healed
No dilated veins
No visible peristalsis or pulsations
Bowel sounds: normoactive (23/min)
No bruit, thrills

ABDOMEN
Tympanitic on all four quadrants
Liver span at 6cm X 9cm
(+) epigastric pain on percussion and
palpation (direct palpation)
Negative Murphys sign
Negative Rovsings, Psoas, Obturator
sign
Spleen non-palpable
No CVA tenderness

EXTREMITIES
Arms and legs: symmetrical, warm,
no edema
No hematoma
Capillary refill: 2sec upper and
lower
Peripheral pulses: symmetric arms
and legs (2+ brachial, radial,
popliteal and dorsalis pedis)
No limitation ROM

MUSCULOSKELETAL
Muscle bulk: symmetrical, good
tone both upper and lower
No gross involuntary movements
or atrophy
Ambulatory, able to stand, slow
steady gait
Usually sitting: upper body
leaning forward
Muscle strength: 4/5 upper, 5/5
lower

NEUROLOGIC EXAMINATION

MENTAL STATUS EXAMINATION


Level of Consciousness: Alert
Awareness: Oriented to person, place and
time
Behavior: Able to maintain good eye contact,
no mannerisms
Speech and language: Moderate rate, fluent
voice, no hoarseness, dysarthria, able to
appropriately answer questions asked
Memory processing:
Immediate: Can repeat 7 numbers immediately after
being given
Recent: able to recall meals eaten for the day
Remote: Can recall past medical history

MENTAL STATUS EXAMINATION


Object recognition: Can recognize
objects seen/palpated (ballpen,
notebook and bottle of alcohol)
Affect: Appropriate
Perception: Good thought perception
Thought content: No disturbed
thoughts.

CRANIAL NERVE
CRANIAL
INTERPRETATION
NERVE
Able to smell coffee beans on both nostrils.
I
OD:20/20
OS: 20/20
II
Pupils are equally reactive to light (32mm) with direct and
consensual light reflex, (+) accommodation
III
IV
VI

Extraocular muscle movements of both eyes are intact.


Correctly identified the areas on the face where light brush strokes
were applied in.
Can close mouth and grind teeth.

CRANIAL NERVE
CRANIAL
NERVE
VII
VIII
IX
X

INTERPRETATION
Bilaterally symmetrical face
Can raise eyebrows, wrinkle forehead, close eyes tightly, and puff
cheeks.
Intact gross hearing
Intact gag reflex
No hoarseness in voice
Uvula is in midline.

XI

Able to shrug and elevate shoulders, as well as rotate head against


resistance.

XII

Tongue is in midline, not atrophied and can be moved freely and


from side to side. Patient was able to stick out tongue and move it
from left to right.

MOTOR
Symmetric muscle bulk of proximal and
distal muscles of both upper and lower
extremities.
No atrophy of muscles.
No clonus, fasciculations, seizures,
tremors, and spasm.
No involuntary movements
Arms and legs can be extended
throughout the range of movement.
No rigidity, spasticity, or flaccidity.

MUSCLE STRENGTH
Muscle strength on upper and lower
extremities are as follows:

LUE
LLE
5/5

5/5 RUE

5/5

RLE

5/5

SENSORY
LUE
100%
LLE
100%

RUE

100%

RLE

100%

Intact
pain,
light
touch,
superficial
sensation, deep sensation and vibratory
sensation on both plantar surfaces of feet,
fingertips and both U and Lextremities
Number identification, point localization and
extinction on both R and L sides were intact

REFLEXES
REFLEXES
Biceps
Triceps
Brachioradialis
Knee
Ankle

RIGHT

+2
+2
+2
+2
+2

LEFT

+2
+2
+2
+2
+2

COORDINATION AND GAIT


Finger-to-nose test was
performed with slow movement
Able to walk across the room and
can rise from sitting position with
assistance
Good balance and gait

SALIENT FEATURES

SALIENT FEATURES: PERTINENT


POSITIVE
25/ F
Undocumented Fever for three days
Lysis of fever on the fourth day

Headache (fronto-temporal,
throbbing, 5/10)
Myalgia and arthralgia

SALIENT FEATURES: PERTINENT


NEGATIVE
Abdominal pain (Epigastric, Burning,
10/10, radiating to RUQ)
Persistent nausea and vomiting (5x,
ingested food, non-bilous, no relief
upon intake of antacids)
Loss of appetite
No relief of symptoms upon intake of
medications

SALIENT FEATURES: PERTINENT


NEGATIVE
No history of travel into provinces
No history of wading into flood
waters
No previous renal, liver disease
No weight changes

SALIENT FEATURES: PERTINENT


NEGATIVE

No
No
No
No

rashes
chest pain, orthopnea, PND
dysuria, no oliguria, no hematuria
easy bruisality

SALIENT FEATURES:
PERTINENT POSITIVE FROM PE
VS: 100/70 93 20 36.495%; BMI =
19.5 kg/m2
Abdomen: Flat, (+) midline incision on
hypogastrium, hypogastric area,
23 bowel sounds per minute,
Liver span: 6 x 9 cm, (+) epigastric
tenderness upon percussion and palpation

(-) Murphys sign, (-) Rovsing sign, (-)


Psoas sign, (-) Obturator sign

APPROACH TO DIAGNOSIS

Fever
Abdominal
Pain
Acute

Chronic

Noninfectious

Infectious

Dengue
Fever

Leptospirosis

Typhoid
Fever

Appendicitis

Gastrointesti
nal

Genitourinary

Cholecystitis

Pelvic
Inflammator
y Disease

Pancreatitis

DIFFERENTIAL DIAGNOSIS

Pelvic Inflammatory Disease


RULE IN

RULE OUT

Fever
Abdominal pain

Absence of foulsmelling vaginal


discharge
(-) Uterine tenderness
Does not usually
present with myalgia
and arthralgia

ACUTE APPENDICITIS
RULE IN

RULE OUT

Fever
Loss of appetite
Episodes of vomiting

(-) Right lower quadrant


tenderness
No change in bowel
movement
Does not present with
myalgia and arthralgia
Absence of muscle rigidity
(-) Rovsing sign
(-) Obturator sign
(-) Psoas sign

ACUTE CHOLECYSTITIS
RULE IN

Female
Fever
Episodes of vomiting
Epigastric pain
(radiates to RUQ)
RUQ tenderness

RULE OUT
Pain is not generalized
on the right upper
abdomen
Pain does not radiate
to the interscapular
area, right scapula, or
shoulder
Does not present with
Myalgia and arthralgia
(-) Murphys sign

ACUTE PANCREATITIS
RULE IN

Fever
Abdominal pain
Nausea and vomiting

RULE OUT
No radiation to the back
Absent abdominal
distention
Absent muscle rigidity
Patient has normoactive bowel sounds
Myalgia and arthralgia
(-) Cullens sign
(-) Turners sign

LEPTOSPIROSIS
RULE IN

RULE OUT

No history of wading into


waters
(-) jaundice
No dysuria, no oliguria, no
hematuria
Absent maculopapular
rash
Bronchovesicular breath
sounds
Pink palpebral conjunctiva
(-) Hepatosplenomegaly

Fever
Abdominal pain
Nausea and vomiting
Myalgia

TYPHOID FEVER
RULE IN

RULE OUT

No history of prolonged
fever for up to 4 weeks if
untreated
Absence of
maculopapular rash (rose
spots)
No change in bowel
movement
(-) Hepatosplenomegaly
Normal heart rate during
time of fever

Fever
Abdominal pain
Headache
Myalgia and arthralgia
Anorexia
Nausea and vomiting
Abdominal tenderness

DENGUE FEVER
RULE IN

Fever
Abdominal pain
Headache
Persistent nausea and
vomiting
Myalgia and arthralgia

RULE OUT

Cannot be ruled out

APPROACH TO
DIAGNOSIS

PATHOGENESIS

PATHOGENESIS
A. aegypti

Environmental Risk
Factors/ Breeding sites
1. Stagnant flood
water
2. Flower vases/pots
3. Piles tires

DENGUE : PATHOGENESIS
A. aegypti
BITE OF A VIRUS carrying
mosquitoSkin

Environmental Risk
Factors/ Breeding
sites
1. Stagnant flood
water
2. Flower vases/pots
3. Piles tires

Blood
Infect cells
Infection Immune response

Activation T cell response


(memory T cell if re-exposure

Platelet shields virus


from exposure and
binding

Stimulates release of
cytokines

Activation T cell
response (memory T cell
if re-exposure

Neutralize pre-existing
antibody

Virus-antibody complex

AB enhance uptake

Phagocytosis

High fever,
body
weakness,
headache and
dizziness

Cytokines destroy cell


membrane and wall (viral
antigen in monocyte)

Cytolysis

Vasculopathy
(Plasma
leakage)

Coagulopathy
(PTT/APTT)

Direct cellular destruction


and infection of Bone
Marrow precursor cells &
shortened platelet survival
Targets liver and
causing platelet lyses
spleen parenchymal
cells

Complement system
activation

Vascular endothelial
activation

THROMBOCYTOPENIA

HEPATOSPLENOME
GALY

DENGUE HEMORRHAGIC

The Investigation:
Laboratory and Diagnostic Procedures

THE INVESTIGATION:
LABORATORY AND
DIAGNOSTICS

3 PHASES OF DENGUE

FEBRILE PHASE
Lasts 2-7 days
Monitoring for warning
signs is crucial
Mild hemorrhagic
manifestations
Progressive decrease in
WBC earliest
abnormality
Tourniquet test

Clinical problems encountered:


Dehydration
High fever febrile seizures
Neurological disturbances

CRITICAL PHASE

Defervescence on day 3-7 of illness


Temp <37.5-38C
Patient can either improve or deteriorate
Leukopenia, thrombocytopenia, increase in Hct

1. Dengue without warning signs


2. Dengue with warning signs
3. Severe dengue
Clinical problems encountered:
Shock from the plasma leakage
Severe hemorrhage
Organ impairment

CRITICAL PHASE
Warning signs:
Increase in capillary
fragility
Beginning of critical
phase

Severe Dengue:
1. Plasma leakage and/or
fluid accumulation
respiratory distress
2. Severe bleeding
3. Severe
organ
Clinical
problems
encountered:
Shock
from the plasma leakage
impairment
Severe hemorrhage
Organ impairment

CRITICAL PHASE
Dengue shock:
critical volume of plasma is lost through
leakage
Preceded by warning signs
Temp: subnormal
Prolonged shock organ hypoperfusion
organ impairment, metabolic acidosis,
DIC severe hemorrhage dec Hct,
Clinical
problems
encountered:
inc
WBC

Shock from the plasma leakage


Severe hemorrhage
Organ impairment

RECOVERY PHASE
Gradual re-absorption of extravasated fluid
(48-72 hours)
Patients general wellbeing improves,
hemodynamic status stabilizes and
diuresis ensues.
Hct stabilizes or may be lower (dilution
effect of reabsorbed fluid)
After defervescence: rise in WBC then
platelet
Clinical
problems encountered:
Hypervolemia

COURSE OF DENGUE ILLNESS

CBC
WBC
Neut
Lym
Mono
Eosi
Baso
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW
Plt
BT c Rh

PT
Control
% Act
INR
PTT

4/8
2.2
62.3
22.2
15.5
0
0
4.7
15.2
41.1
87.4
32.3
37.0
12.9
226

4/9
AM
2.5
55.3
27.2
17.5
0
0
4.51
14.4
40.1
86.7
31.9
36.8
13.1
169

12.8
14.6
114.0
6
0.88
25.4

4/9 PM 4/10
AM
3.2
4.3
21
34.3
74
45
5
20.7
0
0
0
0
4.37
4.4
14.1
13.8
37.7
38.3
86.3
87
32.3
31.4
37.4
36
12.8
12.8
94
126

4/10 PM 4/11 AM
4.8
24.6
64.3
11.
0
0
4.16
13.2
35.9
86.3
31.7
36.8
12.8
97

6.9
15.7
69.3
15.0
0
0
4.05
13.1
35.6
87.9
32.3
36.8
12.5
187

1
STAGE

Febrile

TEMP.

4 (4/8)

5 (4/9)
admit

Critical

7 (4/11)

36.7

Lysis of
fever
Headach
e
Abdomin
al pain

Epigastri
c pain
Headach
e

No ab
pain

WBC
(inc)

2.2

2.5

3.2

4.3

4.8

6.9

PLT
COUNT

226

16
9

94

12
6

97

187

HCT
(dec)

41.1

40.
1

37.
7

38.
3

35.
9

35.6

Serology

Fever
Headach
e
Myalgia
Arthralgi
a

Fever
Headach
e
Myalgia
Arthralgi
a

Fever
Headach
e
Myalgia
Arthralgi
a
Abdomi
nal pain
Vomitin
g

36.7
36.5

FEVER

IgG +

8 (4/12)
DISCHARG
ED

Recovery
36.0
36.4
36.8

SSx

Undocumented

6 (4/10)

Ab pain

Epigastri
c pain

CBC with Platelet count daily until


the critical phase is over
Hematocrit (early phase) : baseline
WBC: decreasing ; Platelet count

MANAGEMENT

ASSESSMENT

Presumptive Diagnosis:
Live in/travel to endemic
area +
Fever and 2 of the ff:
Anorexia and Nausea
Rash
Aches and pains
(myalgia, arthralgia)
Warning signs
Leucopenia
Tourniquet test
positive

Warning Signs:
Abdominal pain/tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy and restlessness
Liver enlargement >2cm
Lab: inc Hct concurrent with
rapid dec. of Pt count

Warning Signs

Coexisting conditions
Social circumstance*

Co-existing conditions
Social
that may make dengue
circumstances
or its management
more complicated
Pregnancy
living alone
infancy
living far from a
Old age
health facility
Obesity
without reliable
Diabetes mellitus
means of transport
Hypertension
Heart failure
Renal failure
Chronic hemolytic
diseases such as sicklecell disease and
autoimmune diseases

Warning Signs

Group Criteria
Patients who do
not have warning
signs
AND
who are able:
To tolerate
adequate
volumes of oral
fluids
To pass urine at
least once every
6 hours

DENGUE
WITHOUT
WARNING
SIGNS

GROUP A:
MAY BE
SENT
HOME

Coexisting conditions
Social circumstance*

Laboratory
Tests

Treatment

Monitoring

Full blood
Count (FBC)
Haematocrit
(Hct )

Advice for:

-Daily review for


disease progression:
D e creasing WBC
Defervescence
Warning signs (until
out of critical
period)

Adequate bed
rest
Adequate fluid
intake
Paracetamol, 4
gram max. per
day in adults
and
accordingly in
children

Patients with
stable Hct can be
sent home

-Ad vice for immediate


return to
hospital if
development of any
warning signs
- Written advice of
management (e.g.
home care card for
dengue)

ORAL REHYDRATION
NOTES:
Oral rehydration solution ( 3-4 sachet of
ORESOL in 1L of water) or soup and fruit
juices may be given to prevent electrolyte
imbalance.
Commercial carbonated drinks that exceed
the isotonic level (5% sugar) should be
avoided.
They may exacerbate hyperglycemia related to
physiological stress from dengue and diabetes
mellitus.

Sufficient oral fluid intake should result in a


urinary frequency of at least 4 to 6 times
per day.

Warning Signs

Warning Signs

Coexisting conditions
Social circumstance

GROUP B:
REFERRED FOR
IN-HOSPITAL
ENGUE WITHOUT WARNING SIGNS CAREDENGUE WITH WARNING SIGNS
Group Criteria

Coexisting conditons/social
circumstance
OR
Existing warning signs:
Abdominal pain or
tenderness
Persistent vomiting
Clinical fluid
accumulation
Mucosal bleeding
Lethargy/ restlessness
Liver enlargement
>2cm

Laborato
ry Tests

Full
blood
Count
(FBC)
Haemat
ocrit
(Hct )

Treatment
(without
warning sign)

Encouragement
for oral fluids
If not
tolerated,start
intravenous
fluid therapy
0,9% saline or
Ringer Lactate
at maintenance
rate

Treatment
(with
Warning
signs)
See next
slide

Treatment (with warning


signs)
Obtain reference Hct before
fluid therapy
Give isotonic solutions such as
0,9% saline, Ringer lactate,
start with:
5-7 ml/kg/hr for 1-2 hours
Then reduce to 3- 5 ml/kg/hr
for 2-4 hr
reduce to 2-3 ml/kg/hr or less
according to clinical response

Reassess clinical status


and repeat Hct
If Hct remains the same or
rises only minimally ->
continue with 2-3 ml/kg/hr
for another 2-4 hours
If worsening of vital signs
and rapidly rising Hct ->
increase rate to 5-10
ml/kg/hr for 1-2 hours

Reassess clinical status,


repeat Hct and review fluid
infusion rates accordingly :
Reduce intravenous fluids
gradually when the rate of
plasma leakage decreases
towards the end of the critical
phase.
This is indicated by:
Adequate urine output and/or
fluid intake
Hct decreases below the
baseline value in a stable

MONITORING
MONITORING
(without warning
(with warning signs)
signs)
Vital signs and peripheral
Temperature pattern
perfusion (1-4 hourly until
Volume of fluid intake
patient is out of critical
and
phase
Losses Urine output
volume and frequency Urine output (4-6 hourly)
Warning signs
Hct (before and after fluid
replacement, then 6-12
Hct, white blood cell
hourly)
and platelet counts
Blood glucose
Other organ functions
(renal profile, liver profile,
coagulation profile, as

Warning Signs

Group Criteria

GROUP C:
REQUIRE
EMERGENCY
TREATMENT

SEVERE
DENGUE

Laboratory Tests

Treatment

Monitorin
g

Patients with any of Full blood


the following
Count (FBC)
Haematocrit
features.:
(Hct )
Severe plasma
Other organ
leakage with
shock and/or fluid
function
accumulation
tests as
with
indicated
respiratory
distress
Severe bleeding
Severe organ

See next slide

See next
slide

Treatment of compensated
shock

Start I.V. fluid resuscitation with


isotonic crystalloid solutions at 510 ml/kg/hr over 1 hr
Reassess patients condition
If patient improves:
I V fluids should be reduced
gradually to 5-7 ml/kg/hr X 1-2 hr

3- 5 ml/kg/hr for 2-4 hr 2-3


ml/kg/hr for 2-4 hr and Then reduced further depending
on hemodynamic status
I V fluids can be maintained for up

atment of compensated shoc

If patient still unstable: Check


Hct after first bolus
If Hct increases/ still high (>50%)
repeat a second bolus of
crystalloid solution at 10-20
ml/kg/hr for 1 hr
If improvement after second
bolus, reduce rate to 7-10
ml/kg/hr for 1-2 hr continue to
reduce as above.
If Hct decreases
This indicates bleeding and
need to cross-match and

atment of hypotensive shoc

Initiate I.V. fluid resuscitation


with crystalloid or colloid
solution at 20 ml/kg as a bolus
for 15 min.
If patient improves:
Give a crystalloid / colloid
solution of 10 ml/kg/hr for 1
hr, then reduce gradually.

Treatment of hypotensive shock

If patient still unstable:


R e view the Hct taken before the first
bolus
If Hct was low (<40% in children and
adult females, < 45% in adult males)
this indicates bleeding, the need to
crossmatch and transfuse
If HCT was high compared to the
baseline value:
Change to IV colloids at 10-20 ml/kg as
a second bolus over to 1 hour; reassess
after second bolus
If improving reduce the rate to 7-10
ml/kgt/hr for 1-2 hours, then back to IV
crystalloids and reduce rates as above
I f condition still unstable, repeat Hct

Treatment of hypotensive shock


Treatment of haemorrhagic
complications:
Give 5-10 ml/kg of fresh packed
red cells or 10-20 ml/kg fresh whole
blood .

DISCHARGE CRITERIA
All of the following
criteria must be
present :
No fever for 48 hours
Increasing trend of platelet
count
Stable hematocrit without
intravenous fluids
Improvement in clinical