50 kg

42 kg

32 kg

26 kg

20 kg

18 kg

16 kg

14 kg

12 kg

10 kg

8 kg

4 kg

Estimated
Weight

135
135
120
120
110
110
100
100
85
85
85
80

110-170
110-170
90-150
75-135
75-135
65-135
60-130
60-130
60-110
60-110
60-110
60-100

12-18

14-22

16-22

16-22

18-24

20-24

20-24

22-24

22-30

22-30

22-30

25-40

40-60

Normal
Respiratory
Rate
Range

Viraemia

Critical

10

IgM/lgG

Platelet

Reabsorption
Fluid overload

Recovery Phases

Organ Impairment

Hematocrit

Normal

Urine output

Tachypnoea

Normal respiratory rate for age

Respiratory
rate

<90

<90

<90

<90

<86

<82

<80

<78

Oliguria or anuria

Hyperpnoea or
Kussmauls
breathing (Metabolic acidosis)

secondary infections

post onset
Viremia coincides with fever
D
 etection by PCR highest in
first 3 days of illness
ALWAYS SEND ACUTE AND
CONVALESCENT SAMPLES
Unless 1st sample positive
for dengue by PCR paired
samples, acute (0-5 days)
and convalescent (6-21 days),
needed for diagnosis
IgM detected for up to 3
months
No IgM in 20-30% of

Virus

detected for up to 5 days

Diagnostic
Testing

Reducing trend

Narrowed pulse
pressure (<20
mmHg)
Hypotension
(see definition)
Unrecordable
blood pressure
Normal systolic
pressure but rising diastolic
pressure
Narrowing pulse
pressure
Postural hypotension
Normal blood
pressure for
age
Normal pulse
pressure for
age

<76

Blood
pressure

Severe
tachycardia or
bradycardia in
late shock

Tachycardia

Normal heart
rate for age

Heart rate

<74

Cold, clammy
Feeble or absent

Cool peripheries

<72

Weak & thready

Very prolonged,
mottled skin

Warm and pink

Prolonged
(>2 sec)

Brisk (<2 sec)

Capillary
refill time

Restless,
combative

Good volume

Clear and lucid

Clear and lucid

Conscious
level

Hypotensive
shock

Extremities

Compensated
shock

Stable
Circulation

Parameters

Hemodynamic Assessment

Peripheral
pulse
volume

<70

<70

Hypotension level
(systolic
BP)

Shock
Dehydration Bleeding

40

145

110-180

Average
HR

Normal
Heart
Rate
Range

Course of dengue illness:

rse of dengue illness: Febrile

Serology and
virology

Laboratory
changes

Potential
clinical issues

Temperature

Days of Illness

15 years

14 years

12 years

10 years

8 years

6 years

5 years

4 years

3 years

2 years

12
months

6 months

1 month

Age

Normal Pediatric Vital Signs

Dengue Case Management

ASSESSMENT

Live in / travel to endemic area plus Fever and two of the following:

Anorexia and nausea
Warning signs

Rash
Tourniquet test positive

Aches and pains
Leucopenia

Presumptive Diagnosis:

CS 125085

Warning Signs:

Abdominal pain or tenderness

Persistent vomiting
Mucosal bleed
Liver enlargement >2cm
Clinical fluid accumulation
Lethargy; restlessness
Laboratory: Increase in HCT
concurrent with rapid decrease
of platelet count

No
warning
signs

Group A

For patients with warning

signs of severe dengue OR
co-existing conditions
pregnancy
infancy
diabetes mellitus
poor social situation
old age
renal failure

Group B

For patients with any of:

Severe plasma leakage
with shock and/ or
fluid accumulation with
respiratory distress
Severe bleeding
Severe organ impairment

Group C

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
National Center for Zoonotic, Vector-Borne, and Enteric Diseases

Prevent dehydration which occurs when a person loses too much

fluid (from high fevers, vomiting, or diarrhea with poor oral intake).
Give plenty of fluids and watch for signs of dehydration. Bring patient
to clinic or emergency room if any of the following signs develop:
Decrease in urination (check number of wet diapers or trips to the bathroom).
Few or no tears when child cries
Dry mouth, tongue or lips
Sunken eyes
Listlessness or overly agitated or confused
Fast heart beat (more than 100/min)
Cold or clammy fingers and toes
Sunken fontanel in infant

Prevent spread of dengue within your house

Place patient under bed net or have patient use insect repellent while febrile
to avoid infecting mosquitoes that can infect others within 2 weeks.
KILL all mosquitoes in house and empty containers that carry water on patio.
Put screens on windows and doors to prevent mosquitoes from coming
into house.

Watch for warning signs as temperature declines 3 to 7 days after symptoms

began. Return IMMEDIATELY to clinic or emergency department if any of the
following warning signs appear:
Severe abdominal pain or persistent vomiting
Red spots or patches on the skin
Bleeding from nose or gums
Vomiting blood
Black, tarry stools
Drowsiness or irritability
Pale, cold, or clammy skin
Difficulty breathing
Group C
Emergency
Management

5-7 ml/kg/hour x 1-2 hour

then reassess clinical status,
if improving then
3-5 ml/kg/hour x 2-4 hours
and reassess Hct and clinical
status, if continued improvement then
2-3 ml/kg/hour x 2-4 hours,
reassess Hct and clinical
status and
Discontinue IV fluids
when intake and urine o
utput adequate and hematocrit below baseline value

Reduce IV fluids*

Improved

If improved,
Reduce IV fluids to 7-10ml/
kg/hour x 1-2 hours
Continue stepwise*
reduction in IV fluids

Give crystalloid 10-20 ml/kg

bolus over 1 hour

Check Hematocrit

Increasing

If not improved,
Recheck
hematocrit

Transfuse 5-10 ml/kg

PRBC or 10-20 ml/kg
whole blood ASAP,
reassess

Decreasing

Not Improved
REASSESS

Give isotonic fluid at 5-10 ml/kg/hour over 1 hour

Compensated Shock

Hypotensive Shock

Increasing

REASSESS

If improved,
Reduce colloid to 7-10ml/kg
for 1-2 hour, then
Continue stepwise*
reduction using crystalloids

If still improving,
Continue stepwise* reduction
of IV fluids
If not improved
(recheck hematocrit)

Give crystalloid or colloid

infusion at 10ml/kg/hour for
1 hour, then

Improved

Give crystalloid or colloid bolus of 20 ml/kg in 15 min

severe bleeding

severe organ impairment

No fever for at least 24-48 hours

Improvement in clinical status (general wellbeing, appetite,
hemodynamic status, urine output, no respiratory distress)
Stable hematocrit off IV fluids
Increasing trend of platelet count (usually preceded by rising WBC)

Discharge Criteria - All of the following must be met:

Give colloid 10-20 ml/kg bolus

over to 1 hour, reassess

Obtain baseline CBC and

organ function tests and
assess hemodynamic status

For patients with any of:

severe plasma leakage with shock and/ or fluid accumulation with respiratory distress

If Worsening
Vital Signs and Rapidly
Increasing Hct

Inadequate
Intake

Increase IV Fluids to 5-10 ml/kg/hour x 1-2 hours

then REASSESS HCT and clinical status

Group C Emergency Management

Reduce IV Fluids gradually when plasma leak

decreasing as indicated by
Adequate intake and urine output
Hct decreases below baseline in patient with stable
clinical status

If Unstable
Vital Signs at any Point

Start Isotonic Solutions (NS, LR)

5-7ml/kg/hour x 1-2 hours then
3 -5 ml/kg/hour x 2-4 hours then REASSESS
Hct and clinical status

Obtain Baseline Hematocrit before Starting IV Fluids

Continue IV Fluids @ 2-3 ml/kg/hour for 2-4 hours

then REASSESS Hematocrit and Clinical Status

If Clinically Stable
and Hct remains same or
changes minimally

Adequate
Intake

Control the fever

Give Tylenol every 6 hours (maximum 4 doses per day). Do not give
ibuprofen (Motrin, Alleve) aspirin, or aspirin containing drugs.
Sponge patients skin with tepid water when temperature is high
despite Tylenol.

Encourage
Oral Fluid Intake

Get adequate bed rest

Let patient rest as much as they are able.

Obtain Baseline CBC on Admission

Advise patient or their family to the the following:

Monitoring Group B

defervescence (beginning of critical phase)

warning signs (until out of critical phase)
decreasing white blood cell level, increasing hematocrit and decreasing
platelet level

Vitals signs and and peripheral perfusion checks (at least every 1-2 hours until out of
critical phase more frequently if patient is requiring fluid boluses or is in ICU)
Temperature curve (watch for defervescence)
Follow urine output closely (record volume and frequency at least every 4 hours)
Volume of fluid intake and losses (strict I/Os) at least every 4 hours
Frequent hematocrits (before and after fluid boluses) and at least every 6-8 hours
Monitor blood glucose at least every 6-12 hours
Daily complete blood counts
Other organ function tests (renal panel, liver profile, coagulation profile) as indicated
by patient status

Obtain daily CBC

Follow patient daily for:

For patients with warning signs of severe dengue OR co-existing conditions

pregnancy
poor social situation
liver enlargement >2cm
old age
lethargy/ restlessness
persistent vomiting
infancy
renal failure
increased hematocrit
diabetes mellitus
tender/ painful abdomen
fluid accumulation

mucosal bleeding

Group B Inpatient Management

Group A Outpatient Management