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Sr.

Contents Page No.


No.

1 Medicine 1-153

2 Pediatrics 154-246

3 Obstetrics and Gynaecology 247-309

4 Dermatology 310-338

5 Psychiatry 339-361

6 ENT 362-397

7 Ophthalmology 392-450

8 Surgery 451-511

9 Orthopaedics 512-556

10 ANAESTHESIOLOGY 557-581

11 Pathology 582-609

12 DENTRISTRY 610-646
Index
1. Medicine
Sr. No. Contents Page No.
1 Fever 2
2 CAP 6
3 Bronchial Asthama 8
4 Pleural Effusion 11
5 COPD 13
6 Bronchiectasis 15
7 Lung abcess 17
8 Pneumothorax 19
9 Lung Cancer 21
10 Pulmonary Embolism 23
11 Hypertension 25
12 Heart Failure 30
13 Ischaemic Heart Disease 32
14 Acute Rheumatic Fever 35
15 Infective Endocarditis 36
16 Diabetes mellitus 40
17 Thyroid 52
18 Cerebrovascular Accident 55
19 Sub-archnoidHaemorrhage 57
20 Pyogenic Meningitis 58
21 Tubercular Mengitis 60
22 Viral Meningitis 61
23 Viral Encephalitis 63
24 Epilepsy 65
25 GBS (Guillainbarre syndrome) 68
26 Apthous ulcer 69
27 Oesophageal candidiasis 70
28 Dyspepsia 71
29 Gastro-oesophageal Reflux 72
30 Peptic ulcer disease 73
31 Vomiting 76
32 Constipation 77
33 Irritable Bowel Syndrome 78
Sr. No. Contents Page No.
34 Ulcerative Colitis 79
35 Amoebic liver abscess 81
36 Pyogenic Liver Abscess 83
37 IntesitinalProtozoal Infection 85
38 Ascitis 89
39 Hepatitis 90
40 Hepatic Coma 92
41 Nephrotic Syndrome 93
42 Acute Nephritic Syndrome 94
43 Acute Renal failure 95
44 Chronic kidney disease 97
45 Malaria 99
46 Dengue 107
47 Leptospirosis 111
48 Influenza A- H1N1 113
49 Diarrhoeal Diseases 116
50 Rheumatoid Arthritis 121
51 Snake bite 123
52 Scorpion Sting 127
53 Dog Bite 129
54 Poisoning 132
55 Alcohol Intoxication 135
56 Anaemia 136
57 Heat Stroke 138
58 Tuberculosis (RNTCP) 142
59 Leprosy (NLEP) 151
2. Pediatrics
Sr. No. Contents Page No.
1 Emergency Management in Pediatrics 155
2 Neonatal Resuscitation Guidelines 167
3 Guidelines For Management Of Normal Newborn 169
4 Care of at Risk Neonates 175
5 Care of Sick Neonates 177
6 Management of Low Birth Weight Babies 181
7 Neonatal Sepsis 185
8 Treatment Of Respiratory Distress In Newborn 189
9 Meconium Aspiration Syndrome 191
10 Bleeding Neonate 193
11 Jaundice in the Newborn 196
12 Management of Surgical Neonate 201
13 Vitamin A Deficiency 202
14 Rickets 203
15 Management of Children with SAM 204
16 Mumps 207
17 Case Management of Children with Sever Acute Malnutrition (SAM) 209
18 Fever with Rash 214
19 Enteric fever / Typhoid 216
20 Acute Meningoencephalities 217
20 Tuberculous Meniingities 219
21 Acute Respiratory Infection 221
22 Bronchial Asthama 226
23 Breath holding spell 228
24 Bronchiolitis 229
25 Empyema 230
26 Approach to Fever 231
27 Acute Flaccid Paralysis (AFP) 232
28 Febrile seizures 235
29 Acute Nephritis 237
30 Nepharotic Syndrome 238
30 Congestive Heart Failure (CHF) 240
31 PICA 242
32 Nocturnal Enuresis 243
33 Thrush / Candiasis 244
34 Congenital Hypothyroidism 245
35 Urinary Tract Infection (UTI) (UTI) 246
3. Obstetrics and Gynaecology
Sr. No. Contents Page No.
1 Normal Pregnancy 248
2 Normal Labour 253
3 Clinical Care for high risk pregnancy 257
4 Obstetric complications 265
5 Medical disorders complicating pregnancy 285
6 Comprehensive Abortion Care 295
7 Common gynecological problems 298

4. Dermatology
Contents Page No.
Sr. No.
1 Infections of Skin 311
Bacterial
Viral
Fungal
Parasitic

2 Non infectious Skin Conditions 319


Urticaria
Psoriasis
Lichen Planus
PityriasisRosea
Pityriasis Alba
Acne
Miliaria
Eczema / Dermatitis
Atopic Dermatitis

3 Sexually Transmitted infections (STI) 324


Syphilis
Chancroid
LymphoGranuloma Venereum (LGV)
Gonorrhoea
Chlamydial infection
Bacterial Vaginosis
Trichomoniasis
Candidiasis
Wart
Herpes Genitalis

4 Syndromic management of STDS 329

5 HIV AIDS 331


5. Psychiatry
Sr. No. Contents Page
No.
1 Mental illness- Introduction 340
2 Evaluation: History and MSE 341
3 Schizophrenia 342
4 Bipolar Mood Disorder 344
5 Major Depressive Disorder 347
6 Anxiety Disorder 349
7 Somatization Disorder 351
8 Organic Brain Syndrome 352
9 Drug Abuse And Substance use disorder 354
10 Intellectual Subnormality 356
11 Child and Adolescent Psychiatry 358
12 Psychiartric Emergencies 360
13 Procedure For Admission to A Mental Hospitel 361
6. Ent
Sr. No. Contents Page No.
1 Acute Otitis Media 363
2 Chronic suppurative Otitis Media 366
3 Acute Parotis 367
4 Furuncle 368
5 Otomycosis 369
6 Neck Swellings 370
7 Atrophic Rhinities 371
8 NasalMyasis 372
9 Forign body in the Nose 373
10 Deviated nasal septum 374
11 Nasal obstruction 375
12 Tonsillitis 376
13 Adenoiditis 377
14 Peritonsillar abscess 378
15 Acute Pharyngitis 379
16 Hoarsness of voice 380
17 Stridor 381
18 Facial Palsy 382
19 Sensory Neural Hearing Loss 384
20 Vertigo 386
21 Fracture Involving Nasal Bone 388
22 Fracture Involving Maxilla 389
23 Penetrating neck injury 391
24 Blunt External Laryngeal Trauma 393
25 Epistaxis 394
26 Premalignant lesion of oral cavity 395
27 Acute upper airway obstruction 396
28 Deaf mutism 397
7. Ophthalmology
Sr. Contents Page
No. No.
1 Lid 399
2 Dacryocystitis 402
3 Conjunctiva 405
4 Cornea / Ulcer 409
5 Sclera 412
6 Uveitis 414
7 Glaucoma 416
8 Cataract 421
9 Ophthalmitis 425
10 Retinal Detachment 428
11 Refractive Error 429
12 Diabetic Retinopathy 434
13 Ocular injuries 437
14 Ocular Emergencies 441
15 Pediatric Ocular Problems 443
16 Low Vision 448
17 Eye Banking 449
8. Surgery
Sr. No. Contents Page No.
1 452
Abdominal Pain
2 456
Wounds & Abscess Management
3 458
Head Injury
4 460
Chest Injury
5 465
Abdominal Injury
6 466
Gangrene
7 468
Burn
8 470
Dressings
9 472
Breast
10 477
Congenital Anomalies
11 488
Venous Thromboembolism
12 490
Varicose Veins
13 492
Genito Urinary Disorder
14 493
Ano-rectal diseases
15 497
Tracheostomy
499
16 Urinary Catheterization
17 506
Triage
9. Orthopaedics
Sr. No. Contents Page No.
1 Infections in Orthopaedics 513
2 Arthritis 516
3 Congenital Disroderrs 518
4 Metabolic Disorders of Bone 520
5 Regional Conditions 521
6 Common Spine Disorders 524
7 General fracture management 526
8 Poly Trauma 530
9 Pelvic Injury 531
10 Fractures of upper limb 533
11 Fractures of lower limb 539
12 Dislocatons 544
13 Ligamentous injuries 547
14 Spinal trauma 548
15 Mangled Extremeties ( amputation) 552
16 Common Fractures in children 553
17 Bone Tumors 554

10. Anaesthesiology
Sr. Contents Page
No. No.
1 Introduction: General Protocol of Anaesthesia 558
2 Protocol of Difficult Air way 567

3 Pre AnaesthesiaCheck up Protocol 568


4 Conduct of Anaesthesia 569
5 Complications of Anaesthesia 570
6 Regional Anaesthesia Clinical Protocol 571
7 Cardio Pulmonary Resuscitation 573
8 Anaesthesia Obstetric Protocol 577
9 Spinal Anaesthesia 580
11. Pathology
Sr. No. Contents Page No.
1 Introduction 583
2 Haematology 584
3 Serology 595
4 Biochemistry 598
5 Histopathology 599
6 Cytology study 600
7 Blood Bank 601
8 Normal Lab Values 603
9 Laboratory tests performed at PHC/RH/SDH/DH 609

12. Dentistry
Sr. No. Contents Page No.
1 Dental Caries 611
2 Diseases of Dental Pulp &Periapical Tissues 614
3 Periodontal Diseases 619
4 Spread of Oral Infection 625
5 Oral Mucosal Diseases 627
6 Premalignant lesions and conditions 630
7 Orofacial Pain 635
8 Traumatic injuries to teeth 636
9 Discoiouration of Teeth 638
10 Maxillofacial Injuries 639
11 Temporomandibular Joint disorders 642
12 Dental Impactions 645
Abbrevations Used
Sr.No. Abbreviation Forms
1 ASHA Accredited Social Health Activist
2 AFB Acid Fast Bacillus
3 AIDS Acquired Immuno Deficiency Syndrome
4 AMTSL Active Management of Third Stage of Labor
5 AFP Acute Flaccid Paralysis
6 ARF Acute Renal Failure
7 ARDS Acute Respiratory disease syndrome
8 ARDS Acute Respiratory Distress Syndrome
9 ANC Ante Natal Care
10 APH Ante Partum Hemorrhage
11 ARV Anti Rabies Vaccine
12 ART Anti Retroviral Treatment
13 ASV Anti Snake Venom
14 ATT/AKT Anti Tuberculosis Treatment
15 ARM Artificial Rupture of Membranes
16 BSL Blood Sugar Level
17 BUN Blood Urea Nitrogon
18 BMI Body Mass Index
19 CRP C Reactive Protein
20 CRT Capillary Refill Time
21 CPD Cephalo Pelvic Disproportion
22 CPK ceratinizephospho kinase
23 CVA CerebvoVasculan Accident
24 CIN Cervical Intra epithelial Neoplasia
25 CS Cesarean Section
26 COPD Chronic Obstructive Pulmonary Disease
27 CRF Chronic Renal Failure
28 CAP Community Acquired Pneumonia
29 CQS Complete Blood Count
30 CT Scan Computerized Tomography
31 CTEV Congenital TalipesEquinoVarus
32 CCF Congestive Cardiac Failure
33 CPAP Continuous Positive Ambulatory Pressure
34 CMV CytoMegalo Virus
Sr.No. Abbreviation Forms
35 DHF Dengue Hemorrhagic fever
36 DNS Dextrose Normal Saline
37 D&C Dilatation and Curettage
38 DOT Directly Observed Treatment
39 DMARDS Disease Modifying Anti Rheumatic Drugs
40 DIC Disseminated Intra vascular Coagulation
41 DIC Disseminated Intravascular Coagulation
42 DUB Dysfunctional Uterine Bleeding
43 ECG Electro Cardiograph
44 EEG Electro Encephalon Graph
45 ELISA Enzyme Linked Immuno Assay
46 EBV Epstein Barr Virus
47 ESR Erythrocyte Sedimentation Rate
48 ESR Erythrocyte Sedimentation Role
49 EDD Expected Date Of Delivery
50 FBM Expressed Breast Milk
51 XDRTB Extensive Drug Resistant Tuberculosis
52 F-IMNCI Faculty based Integrated Management of Newborn Child and
Infant
53 FHR Fetal Heart Rate
54 FHS Fetal Heart Sound
55 FNAC Fine Needle Aspiration cytology
56 FRU First Referral Unit
57 FRU First Referral Unit
58 FFP Fresh Frozen Plasma
59 GERD Gastro Esophageal Reflux Disease
60 GIT Gastro Intestinal Tract
61 GDM Gestational Diabetes Mellitus
62 GFR Glomerular Filteration Rate
63 HA Health Assistant
64 HCC
65 HDN Hemolytic Disease of Newborn
66 HE Hepatic Encephalopathy
67 HSV Herpes Simplex Virus
68 HDL High Density Lipids
69 HCG Human Chorionic Gonadotropins
Sr.No. Abbreviation Forms
70 ADCV Human Diploid Cell Vaccine
71 HIV Human Immune Deficiency Virus
72 HPV Human Papilloma Virus
73 HTN Hypertension
74 HSG HystroSalpingoGraphy
75 IG Immunoglobulin
76 IVF In Vitro Fertilization
77 IVC Inferior Vena Cava
78 IDDM Insulin Dependent Diabetes Mellitus
79 ICTC Integrated Counseling and Testing Centre
80 IMNCI Integrated Management of Newborn Child and Infant
81 ICU Intensive Care Unit
82 ICCU Intensive Coronary Care Unit
83 IPPR Intermittent Positive Pressure Respiration
84 IHBD Intra Hepahic Biliary Duct
85 IUD Intra Uterine Death
86 IUGR Intra Uterine Growth Retardation
87 IUI Intra Uterine Insemination
88 IDA Iran Deficiency Anemia
89 IFA Iran Folic Acid
90 IBS Irritable Bowel syndrome
91 IHD Ischemic Heart Disease
92 JVP Jugular Venus Pressure
93 KMC Kangaroo Mother Care
94 KFT Kidney Function Test
95 LMP Last Menstrual Period
96 LVH Left Ventricular Hypertrophy
97 LFT Liver Function Test
98 LBW Low Birth Weight
99 LDL Low Density Lipids
100 LRTI Lower Respiratory Tract Infections
101 LSCS Lower Segment Cesarean Section
102 MRI Magnetic Resonance Imaging
103 MVA Manual Vacume Aspiration
104 MCV Mean Cell Volume
105 MCHC Mean Corpuscular Hemoglobin Concentration
Sr.No. Abbreviation Forms
106 MMR Vaccine Measles, Mumps, Rubella Vaccine
107 MTP Medical Termination of Pregnancy
108 MAM Medium Acute Malnutrition
109 MOHFW Ministry of Health and Family Welfare
110 MDRTB Multi Drug Resistant Tuberculosis
111 MPW Multi Purpose Worker
112 MI Myocardial Infration
113 NACP National Aids Control Programme
114 NICU Neonatal Intensive Care Unit
115 NBSU New Born Stabilization Unit
116 NGO Non Government Organization
117 NSAID Non Steroidal Anti Inflammatory Drug
118 OC Oral Contraceptive
119 ORS Oral Rehydration Salt
120 PCV Pack Cell Volume
121 PEF Peak Expiratory Flow
122 PEFR Peak Expiratory Flow Rate
123 PID Pelvic Inflammatory disease
124 PUD Peptic Ulcer Disease
125 PMN Poly Morpho Nuclear
126 PCR Polymerase Chain Reaction
127 PEEP Positive End Expiratory Pressure
128 PEP Post Exposure Prophylaxis
129 PET Scan
130 PPH Post Partum Hemorrhage
131 PROM Premature Rupture of Membranes
132 PID Prolapse Intervertebral disc
133 PT Prothrmbin Time
134 PPD Purified Prohine Derivative
135 RDT Radical Drug Treatment
136 RF Renal Failure
137 RNTCP Revised National Tuberculosis Control Programme
138 RVH Right Ventricular Hypertrophy
139 RL Ringer Lactate
140 SAM Sever Acute Malnutrition
141 STD Sexually Transmitted Disease
Sr.No. Abbreviation Forms
142 STI Sexually Transmitted Infections
143 SGA Small for Gestational Age
144 SNCU Special New Born Care Unit
145 SLR Test Straight Leg Raising Test
146 SAH Sub Arachnoid Hemorrhage
147 SVC Superior Vena Cava
148 TSH Thyroid Stimulating Hormone
149 TIA Transient Ischemic Attack
150 UC Ulcerative Colitis
151 USG Ultra Sonography
152 URTI Upper Respiratory Tract Infections
153 VLBW Very Low Birth Weight
154 VIA Visual Inspection of Cervix with Acetic Acid
155 WHO World Health Organization
MEDICINE

Page 1
1. FEVER
Body temperature is controlled by the hypothalamus.
The normal core body temperature is 36.5-37.5C
2. Causes
(97.7-99.5F).The morning temperature of >98.9F
Malaria
and the evening temperature of >99.9F defines
Sepsis
fever. Abscess
Brucellosis
1. Definition Lymphoma
Since an oral temperature is 0.5F (0.3C) to 1F Night sweats Characteristic of Tuberculosis, but
(0.6C) lower than a rectal or tympanic temperature: sweating from any cause is usually worse at
Rectal temperature 100.4F - Core temperature night.
Recurrent fever Cholecystitis, Cholangitis and
Tympanic temperature 100.4F - Core Temperature Urinary tract infection with obstruction or
Oral temperature 99.5F-99.9F calculi.
Headache Fever due to any cause can produce
Axillary temperature 99.0F-99.5F headache. If severe and with photophobia
Note: suspect- Meningitis.
Delirium Common in elderly and young ones.
This is not absolute, remember that fever is a
relative condition. Muscle pain Myalgia classical of viral fever,
Have a lower threshold for fever at 6am or 6pm. Influenza, Malaria, Leptospirosis and
Keep antipyretics and recent intake in mind Brucellosis.
when considering fever.
Feeling hot-does not necessarily imply fever. 3. Evaluation of Febrile Patient
Rigors profound chills accompanied by Although fever is a normal response, prolonged
chattering of teeth &severe shivering implies a episodes can cause damage so always evaluate for
rapid rise in body temperature. stability of patient (regardless of what you think is
the cause).

Table 1: Evaluation of fever patient


1.Temperature Axillary temperature >990F
2.White Blood Cell Count >12,000 or <4,000 or
>10% bands
3.Heart Rate >90 bpm*
4.Respiratory Rate >24 bpm^ or PaCO2<32mm Hg
Sepsis = SIRS** + infection
Severe sepsis = SIRS** + infection + end organ damage
Septic shock = Severe sepsis + refractory hypotension
(<90 mm Hg or 40% below baseline)
* beats per minute
^ breaths per minute
**SIRS- systemic inflammatory response syndrome
3.1. Fever Pattern 3.2. Relation to Pulse
It is important to note that the cycle of fever pattern is Liebermeisers rule: For everyone degree rise of
often not very helpful in determining the cause of the temperature above normal, the pulse will increase by
disease. 8-10 beats per minute.
Possible exceptions are: Tertian and quartan Malaria, Fagets Sign: The exception to Liebermeisers Rule.
Abscesses, Pel-Ebstein fever and drug fever.

Page 2
This Relative bradycardia may be useful when
present, although it is associated with a substantial
6. Common associated
differential diagnosis, including Typhoid fever, symptoms
Rickettsial diseases, Yellow fever, Legionnaire's
disease, Psittacosis, Leptospirosis, Drug fever, i.Fever only
Brucellosis, Mycoplasma infections, Neoplasm and ii.Neurologic
Factitious fever. iii. Abdominal
iv. Pulmonary
4. Types of fever v. Rash
vi. Haemorrhage
Continuous fever - Does not fluctuate more than vii. Bone and joint
1C in 24 hr. e.g. Lobar Pneumonia, Typhoid viii. Gynaecologic
fever, Brucellosis, Urinary tract infection.
Intermittent fever- Temperature elevation for a
certain period then returning back to normal. eg. 6.1 Fever only
Malaria, Pyaemia, Septicemia. Malaria
Quotidian- Periodicity of 24 hr- Plasmodium Typhoid fever
Falciparum Malaria. Dengue
Tertian fever- 48 hr periodicity- Plasmodium Leptospirosis
Vivax and Ovale. Rickettsia
Quartan fever - 72 hr periodicity-Plasmodium Relapsing fever
Malaria Other viral illnesses
Remittent fever- Temprature remains above HIV
normal throughout the day with fluctuations
more than 1C in 24 hr eg. Infective
Endocarditis. 6.2 Neurologic symptoms
Fever, headache, altered mental status, convulsions,
5. Hints to be obtained from coma
Cerebral malaria
history Meningitis
Encephalitis
(Since Presentation can be non- specific) Chronic Meningitis: TB, Cryptococcal
Meningitis
Detailed fever history Rabies
Medication review Japanese Encephalitis
Family illnesses West Nile Encephalitis
Ethnicity HIV
Detailed history of past surgeries Toxoplasmosis
Recent sick contacts and TB contacts/risks HIV dementia
Host factors (Immunocompromised) Trypanosomiasis (Sleeping Sickness)
Recent travel
Environmental exposures associated with jobs
or hobbies 6.3 Abdominal symptoms
Animal exposure Fever, abdominal pain
Unusual dietary habits Typhoid
High risk behavior Infectious colitis: Shigella, E. coli, salmonella,
Sexual history including Contraceptives Campylobacter, Ameba
Gynecologic history Amebic liver abscess
Hypersensitivities to environmental Abdominal TB
agents/medicines or family history of such Appendicitis, Pyelonephritis
diseases HIV

Page 3
6.4 Fever and rash i. Urinary tract infection
Fever and skin rash ii. Pelvic inflammatory disease
iii. Sexually transmitted disease
Chicken pox
Measles
Dengue 7.3. Abdominal symptoms
Other viruses Diarrhoea with or without blood, weight loss
and abdominal pain
i. Gastroenteritis
6.5 Haemorrhagic symptoms ii. Intra-abdominal sepsis
Hematemesis, melena, epistaxis, petechiae, purpura, iii. Inflammatory bowel disease
puncture site bleeding iv. Malignancy
Dengue
Relapsing fever
Ebola, Lassa, Marburg 7.4. Skin rash-appearance &
Yellow fever distribution will give a clue
i. Macular - Measles, Rubella, Toxoplasmosis
ii. Haemorrhagic - Meningococcal, Viral
6.6 Bone and Joint haemorrhagic fever
Fever with joint or bone pain
iii. Vesicular - Chicken Pox, Shingles, Herpes
Sickle cell disease
Simplex
Septic arthritis iv. Nodular - Erythema nodosum- TB & Leprosy
Osteomyelitis v. Erythematous - Drug rash and Dengue fever.
Pyomyositis
Rheumatic fever 7.5 Joint symptoms-
Chickungunya Joint pain, swelling or limitation of movement is
Brucellosis suggestive of active arthritis
i. Distribution-mono, oligo, polyarticular
ii. Appearance-fleeting-Rheumatic fever
6.7 Gynaecological symptoms iii. Oligoarthritis-infective, Kochs
Fever, pelvic pain, vaginal discharge
iv. Polyarticular-Rheumatoid arthritis, Osteoarthritis
PID v. Axial skeleton involvement
Tubo-ovarian abscess Spondyloarthropathy, Psoratic
Postpartum endometritis
Septic abortion
8. Hints to obtain from
7. Symptom Analysis of Fever examination
i. Verify presence of fever- true/factitious Vital Signs: Monitor all of the vital signs for
ii. Duration-acute/chronic stability
iii. Mode of onset- abrupt/gradual General appearance: Do they look sick?
iv. Progression- continuous/intermittent Anxious? Do they have altered sensorium?, look
v. Severity- how it affects the daily work /physical for pallor, icterus, cyanosis, clubbing and
activities? lymphadenopathy.
vi. Relieving and aggravating factors Oral examination: Oral cavity infections, dental
vii. Treatment received and outcome examination, gum examination, sinuses
viii. Associated symptoms- localising features. Cardio vascular examination: Any murmurs
Respiratory examination: Bronchial sounds,
7.1. Respiratory tract symptoms Decreased breath sounds, Adventitious sounds
i. Sore throat, nasal discharge, sneezing-URTI Central nervous system examination: Fundus
ii. Sinus pain & headache- Sinusitis examination, Mental Status, Encephalopathy,
iii. Cough, sputum, wheeze or breathlessness-LRTI
look for any neurological deficit.
Per abdomen: Tenderness, Organomegaly,
7.2. Genitourinary Symptoms Ascites
Frequency of micturition, loin pain, vaginal or Skin: Rashes, Nail Exam, Wounds/Decubitus
urethral discharge suggesting Ulcers

Page 4
Musculoskeletal examination: Joint examination, Sputum Cultures
Muscle tenderness. Skin biopsy
Genital/pelvic examination and rectal
examination. 10.3. ESR
Look for indwelling devices. Normal: Men = Age/2, Women = Age+10/2
Elevated in:
9. Differential diagnosis Acute or Chronic Inflammation
Infection (TB, UTI/Prostatitis, Endocarditis, Infection
Abscess, Line Infection, Sinusitis, Meningitis, Tissue Injury
Arthritis, Osteomyelitis, Wound infectious, Thyroid Disease
Diarrhea) Azotemia
Inflammatory (Rheumatic Disorders, An elevated ESR does not rule in or out disease
Vasculitis) As opposed to the ESR, the CRP increases more
Drug Fever (Beta-Lactam antibiotics, quickly with an acute process, and decreases for
Amphotrecin B, Chemotherapy, Drug quickly when the underlying state resolves.
Interactions)
Thrombotic (DVT/PE/MI) ESR > 100
Neurologic (Hypothalamic disorder, Spinal Cord T - TB
Injuries, ICH) O - Osteoarthritis
Endocrine (Thyrotoxicosis, Adrenal E - Endocarditis
Insufficiency, Subacute Thyroiditis) V - Vasculitis (Temporal Arteritis)
Gastrointestinal (IBD, Pancreatitis, A - Abscess
Cholecystitis) N - Neoplasm (especially Lymphoma, Plasma
Malignancy Cell dyscariasis)

10. Fever Workup 10.4. Blood cultures


The bacteriologic burden is highest in the blood
10.1 Minimum in all patients stream approximately 1 hour before fever spikes.
So collect blood cultures 1 hour before fever
CBC with differential and micro review spike.
Blood smear- for malarial parasites If you are suspecting Endocarditis, tell the lab to
CXR PA and Lateral. Add Decubitus if needed. continue following the cultures for at least 4
Infiltrates negative if dry weeks.
Urine analysis (with Microscopy) and Urine
Culture 11. Treatment of Fever Itself
2 sets of blood cultures + Cultures from any
central catheter Give empiric Antibiotics when there is high
Electrolytes and Metabolic Panel, LFTs, suspicion of the source of infection or if the
Hepatitis Panel, HIV Test source is unknown and the patient is unstable.
Tab Paracetamol 500mg orally 4 times a day for
10.2 Other Specific procedures/labs most fevers with discomfort.
to obtain data Dont always lower the temperature so readily.
Autoimmune Workup (RF, ANA, etc as history
This decreases your ability to know when to draw
guide, ESR, CRP)
cultures and may lower the patients defense
Specific Viral Serologies
mechanism. Once workup has been performed (and
Lumbar Puncture, Thoracentesis, Arthrocentesis, possibly repeated) then temperature can be lowered.
Paracentesis However, have low threshold for lowering the
CT Scan of Head temperature when there is a hypermetabolic state that
CT PE Protocol/Dopplers of extremities would be damaging (i.e concurrent MI, CVA) or if
Echocardiogram the patient is very symptomatic.
Stool Cultures - Gram Stain, Clostridium difficle
toxin etc

Page 5
2. COMMUNITY ACQUIRED PNEUMONIA
[CAP]
Other presentations may include headache and
1. Introduction myalgia
Pneumonia is an infection of pulmonary
Certain etiologies, such as legionella, also may
parenchyma that causes them to function
produce gastrointestinal symptoms
abnormally
Signs -
Classified as typical or atypical, although the
clinical presentations are often similar. Tachycardia
Approximately 20-33% of episodes result in
hospitalization Tachypnoea

Typical: Up to 70% usually caused by Streptococcus Dullness to percussion of chest, crackles or rales
pneumoniae on auscultation, bronchial breath sounds, tactile
fremitus, and egophony (E to A changes)
Atypical: 30-40%(My Lungs Contain Viruses)
Patients with typical pneumonia are more likely
Mycoplasma pneumoniae to present with dyspnea and bronchial breath
sounds on auscultation
Legionella pneumophila
Chlamydia pneumoniae 3. Radiological imaging
Viruses: Influenza, Adenovirus 1) Chest x ray (PA and Lateral)
2. Clinical features Lobar consolidation more common in typical
pneumonia
Symptoms:
Bilateral, diffuse infiltrates commonly seen in
Cough, fever, chills, fatigue, dyspnea, rigors, and atypical pneumonia
pleuritic chest pain
If performed early in the course of the disease,
cough may be persistent and dry, or it may may be negative
produce sputum

Figure 1 - Chest X-Ray PA VIEW - CAP


2) CT scan- Could be performed in patients 4. Laboratory Diagnosis
with a negative chest radiograph when there is a high
clinical suspicion for pneumonia and to rule out other Complete blood count, sputum, gram stain and
pathologies. cultures, blood sugars, blood urea, serum creatinine.

Page 6
Cap Amoxicillin 1gm thrice a day x 5 days plus
5. Treatment TabAzithromycin/Clarithromycin as above
Initial treatment of CAP is based on physical doses
examination findings, laboratory results and patient OR
characteristics. After examination you must decide Cap Amoxicillin and Clavulunate 2gm twice a
whether to treat patient on OPD basis or to admit the day x 5 days plus a tab
patient. Azithromycin/Clarithromycin as above doses
OR
Patients with any one of following features must be
Tab Levofloxacin 750mg OD, OR
admitted
Moxifloxacilline 400mg OD, OR Gemifloxacin
Respiratory rate >30/min 320mg OD x 5-7 days
Systolic BP<90mmHg or diastolic <60mmHg OR
New onset confusion or impaired level of Tab Cefpodoxime 200mg BD or Tab
consciousness Cefuroxime 500mg BD Plus macrolide
Comorbid illness- Diabetes, Ischaemic Heart antibiotics
Disease, Alcoholics, Immunocompromised,
Multilobar pneumonia 5.4. Inpatients
Therapy for pneumonia is empiric because specific - I.V. Cefotaxime 1-2 gm 8 hrly or
pathogens usually are not identified at the time
treatment is initiated. - I.V. Ceftriaxone 1-2 gm OD or
- I.V. Ampicilin 1-2 gm 4-6 hrly or
5.1. Duration of therapy
- I.V. Ampicillin Sulbactum 2 gm 8 hrly x 4 days
S. pneumoniae: 7-10 days or until afebrile 3 days
Mycoplasma/Chlamydia pneumoniae: 10-14 plus
days, up to 21 days Tab Azithromycin or in severe cases I.V.
Legionella: 10-21 days Azithromycin 1gm on day one and then 500mg
OD next 4 days orTab levofloxacin,
5.2. CAP, not hospitalized moxifloxacinas above.
No comorbidities After clinically stable (T<100.00F, HR<100
beats/min, RR<24/min, SBP>90mmsg, O2
Cap Amoxycillin 500mg three times a day x 5 sat>90%) and able to tolerate oral intake, may be
days switched to oral antibiotics for remainder of
Tab Azithromycin 500mg PO x 1, then 250mg therapy
once a day -5 days OR
Tab Clarithromycin 500mg twice a day -5 -7 PPV23 is recommended for all adults65 years
days OR of age and in younger patients with a number of
Cap Doxycycline 100mg twice a day -10 days conditions that increase the risk of invasive
pneumococcal disease.
5.3. CAP, not hospitalized
With comorbidities 6. Complications
Lung abscess, pleural effusion, empyema. These
patients need to be referred to district hospital.

Page 7
3. BRONCHIAL ASTHMA
Peak expiratory flow- by using peak expiratory
1. Introduction flow meter >20% of diurnal variation on 3 days
Asthma is defined as a chronic inflammatory disease in a week for 2 week.
of airway that is characterized by increased
Diagnosis of asthma is established by
responsiveness of tracheobronchial tree to a
demonstrating reversible airway obstruction.
multiplicity of stimuli.
Reversibility is defined as 12%
a increase in
FEV1 15 minutes after two puffs of a
2. Precipitating factors adrenergic agonist (salbutamol) on spirometry.
Childhood infections Respiratory syncytial
virus 6. Treatment
Allergen exposure Allergy to feathers, animal Drug treatment: Classified in to:
danders, dustmites, molds
6.1. Controller: To be taken on longterm basis
NSAID, aspirin, beta blocker, sulfite containing to control asthma through their anti-inflammtory
topical ophthalmic solution, food preserving effects
agent
(a) Inhaled corticosteroids(ICS)
Wood and vegetable dust, industrial chemicals
and plastic Beclomethasone 200mcg/metered dose twice a day
OR
Exercise, emotional stress.
Budesonide 200-400 mcg/metered dose twice a day
3. Symptoms OR
Fluticasone- 100-250mcg/metered dose twice a day
Dysponea, cough and wheezing
Sense of constriction in the chest (b) Systemic corticosteroids
Cough that produces thick, stringy mucus. Oral Prednisone or Prednisolone once daily for 5 to
Increase mucus production, typically tenacious 10 days
mucus.
(c) Leukotriene modifier
4. Signs Tab Montelukast 10mg once a day X 5 days.
Tachyponea, tachycardia, mild systolic hypertension (d) Long acting inhaled 2 agonist-
Respiration become audibly harsh, rhonchi heard on -Salmeterol (MDI 21ug/puff, 2 puff 12 hourly OR
auscultation.
- Formeterol (1 to 2 puffs 12 hourly)
In severe cases - Accessory muscle become visibly
active, Paradoxical pulse, Cyanosis, Silent chest. In (e) Theophylline-Tab Deryphylline 150 mg twice a
some severe cases patients may land in to respiratory day X 5 days.
failure.

5. Investigation 6.2. Reliever: Used on or as needed basis to


Sputum and blood examination for eosinophilia quickly relieve symptoms by their bronchodilator
properties. These are:
Chest X-ray showing hyperinflated lungs
Simple spirometry shows air flow limitation with
deceased FEV1, FEV1 / FVC and PEF.

Short acting inhaled 2 agonist (SABA) Salbutamol 100mcg/metered dose 1-2 puffs, Levosalbutamol
50mcg/metered dose 1-2 puffs as needed, Terbutaline

Page 8
Systemic glucocorticoid - Tab Prednisolone 40-60mg/day

Short acting oral 2 agonist - Tab Salbutamol 2-4mg/day

Anti cholinergic - Ipratropium inhaler

Theophylline - 100-300mg three times a day

6.3. Combinations available as Formoterol/Budesonide 1-2 puffs twice daily


Salbutamol/Beclomethasone.
inhaler and rotacaps Inhaled drugs are preferred over oral due to less dose,
Salmeterol/Fluticasone 1-2 puffs twice daily less side effects, quick onset of action.

OCS
LABA LABA LABA
ICS ICS ICS ICS
Low dose Low dose High dose High dose
Short acting 2 agonist as required for symptom relief
Mild persistent Moderate Severe persistent Very severe
Mild intermittent
persistent persistent
Figure-1: Step wise approach to asthma therapy according to the severity of asthma and ability to control
symptoms.

ICS = Inhaled corticosteroid; Bradycardia or arrhythmia


LABA = Long acting 2 agonist Confusion, coma.
OCS = Oral corticosteroid
7. Acute severe asthma: (Status 7.3. Treatment
asthamaticus) Oxygen 40-60 % nasally to achieve oxygen
Can be fatal and must be treated promptly. saturation >90%
Inj Hydrocortisone-200mg I.V. stat and then
7.1. It is characterized by 100mg 8 hrly
Severe dyspnoea Salbutamol (2.5-5mg) and Ipratropium Bromide
Respiratory rate 25/min (0.5mg) alternately inhaled through the
Heart rate 110/min. nebulizer.
Inability to complete sentence in single breath. Inj. Aminophylline 500mg in 500 ml of 5%
PEF (peak expiratory flow)35-50% predicted Dextrose over 12 hours if patient is not receiving
theophylline previously.
7.2. Life threatening features Inj. Ampicillin 500 mg 6 hrly till patient is stable
PEF<33% predicted and then oral Ampicillin 500 mg TDS X 5 days.
SpO2<92% silent chest In very severe cases patient may require
ventilatory support.
Cyanosis
Normal or raised PaCO2 (suggests impending
respiratory failure) Refer to higher center with above life threatening
signs.
Feeble respiratory effort

Page 9
Rotahaler Spacer Metered dose inhaler

Figure 2 Types of Devices used in Bronchial Asthma

Page 10
4. PLEURAL EFFUSION
A pleural effusion is an abnormal excess amount of Cancer
fluid in the pleural space Liver disease (Cirrhosis)
End-stage renal disease
1. Symptoms Nephrotic syndrome
Breathlessness Congestive heart failure
Cough Pulmonary embolism
Fever Constrictive pericarditis
Pleuritic chest pain Lupus and other autoimmune conditions

2. Signs 4. Investigations
Decreased breath sounds 4.1. Chest X-ray film
Stony dullness on percussion P-A view, lateral decubitus, lateral view
Decreased vocal resonance
Blunting of CP angle, Ellis S shaped in large
3. Common Causes effusions

Tuberculosis
Pneumonia

Figure 1: Chest radiograph showing left-sided pleural effusion

Figure 2: Massive right pleural effusion with shift of mediastinum towards left

4.2. Ultrasound 4.3. Blood tests


Useful in small amounts of fluid, loculated, CBC, ESR, Renal and liver function blood tests:
septations

Page 11
4.4. Thoraco centesis 5. Treatment
Once a pleural effusion is identified on imaging, a Management of common pleural effusions
fluid sample is usually taken to determine the pleural
effusion's character and seriousness, a procedure 5.1. Tuberculosis
called thoraco centesis.
Is the commonest cause of pleural effusion?
A sample of fluid is removed with a needle inserted
between the ribs Straw coloured effusion
Cell count - lymphocyte predominance
Pleural fluid tests: routine, microscopy cytology and Pleural fluid protein > 3g/dl
ADA (Adenosine diaminase) levels
Cob web formation
There are two different types fluid ADA level is high.
Transudative OR Exudative Tubercular pleural effusion is treated as per RNTCP
guidelines
i. Transudative: clear fluid
Clear fluid, low protein content, cell count is low. 5.2. Para pneumonic effusion
eg. Congestive cardiac failure, liver cirrhosis,
Nephrotic syndrome. Chest X-ray consolidation features along with
effusion
ii. Exudative: Cell count predominantly neutrophilic
Straw coloured, high protein content, cell count Appropriate antibiotics
is high. Thoracocentesis toensure that empyema has not
By the gross characteristics of the fluid. developed
Frankly purulent fluid indicates an empyema.
A putrid odor suggests an anaerobic empyema. 5.3. Malignant effusion
A milky, opalescent fluid suggests a chylothorax,
Cytology positive
resulting most often from lymphatic obstruction
Refer to higher centre
by malignancy or thoracic duct injury by trauma
Treatment of underlying cause in heart failure,
Grossly bloody fluid result from trauma, malignancy,
nephroticsyndrome, liver cirrhosis

Page 12
5. CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD)
cause cough with expectoration on most days for at
1. Introduction least 3 months a year for more than 2 consecutive
COPD is a chronic lung disease characterized by years.
airflow limitation that is not fully reversible.
ii. Emphysema
It includes chronic bronchitis and emphysema.
It is defined as distension of air spaces distal to the
i. Chronic Bronchitis terminal bronchiole with destruction of alveolar
This is a condition associated with excessive septa.
tracheobronchial mucus production sufficient to

Table-1: Differentiating features between Emphysema and Bronchitis


Features Predominant emphysema (Pink Predominant bronchitis (Blue
puffer) bloater)
1. Age of onset 6th decade 5th decade
2. Cough After dyspnea Before dyspnea
3. Dyspnea Severe Mild
4. Sputum Scanty, mucoid Copious, purulent
5. Infections Less common Common
6. Respiratory insufficiency Often terminal Repeated attacks
7. Chest x-ray Hyperinflation +/- bullous changes; Increased bronchovascular marking;
small heart large heart
8. PaCO2 (mm Hg) 35-40 50-60
PaO2 (mm Hg) 65-75 45-60
9. Pulmonary hypertension Mild Moderate to severe
10. Cor pulmonale Preterminal stage Common
11. Diffusing capacity Decreased Normal to slight reduction

Table-2: Differences between Pink puffer and Blue bloater

Pink puffer Blue bloater


1. Course Progressive dyspnea Intermittent dyspnea

2. Sputum Scanty Profuse

3. Polycythaemia Uncommon Common

4. X-ray Attenuated peripheral vessels Normal peripheral vessels

5. pCO2 Normal Increased

6. Alveolar gas transfer Reduced Normal

2. Etiology 3. Signs
Smoking (active and passive), Smoke from biomass Sitting and bending forward with hands on
fuel (firewoods, burnt plastics) knees(tripod position).

Page 13
Pursed lip breathing Inhaled bronchodilators include -
Cyanosis Ominous sign Short acting beta agonists -Salbutamol, 1-2 puffs
three times a day, terbutaline 1.5mg three times a day
Forced expiratory time Normal - 4 secs, COPD - 6
secs and above Long acting beta agonis (Salmeterol, Formoterol), 1-
2 puffs twice a day
Barrel chest
Short acting anticholinergics (Ipratropium) 1-2 puffs,
Hyper resonant chest 2-3 times a day
Diminished breath sound and bilateral wheeze Long acting anticholinergic (Tiotropium) 1-2 puffs
Spirometry showing obstruction (Fev1 / Fvc < 70%) once a day.
even after bronchodilator confirms the diagnosis of (d) Theophylline
COPD.
Inj Aminophylline 250mg in 500 ml of 5 % Dextrose
4. Treatment slowly over 8-10 hrs in acute attacks.
Tab Theophylline 100-300mg three times a day
4.1. Non pharmacological
Side effects: tachycardia, nausea, arrhythmias and
Rehabilitation convulsions
Exercise
Nutrition (e) Glucocorticoids
Education Inhaled corticosteroids should be given in severe
Avoid smoking COPD or in those with repeated exacerbation.

4.2. Pharmacological Fluticasone 1-2 puffs twice a day

(a) Oxygen therapy Budesonide 1-2 puffs twice a day

(b) Antibiotics Systemic corticosteroids should be given only in


patients with acute exacerbationof COPD.
Antibiotics are required as infection often precipitates
acute attacks. Inj benzyl penicillin 10 lakhs units 6 Tab Prednisolone 30-40 mg /day for 8-10 days in
hrly 5-7 days or Inj ampicillin 500mg 6 hrly 5-7 days tapering doses

(c) Bronchodilators 5. Complications


Inhaled bronchodilators are preferred to oral i. Pneumothorax
formulations in view of better efficacy and lesser side ii. Respiratory failure
effects. iii. Cor pulmonale

Page 14
6. BRONCHIECTASIS
1. Defination 3. Symptoms
Bronchiectasis is chronic, irreversible dilation and Cough with production of large quantities of purulent
distortion of the bronchi caused by inflammatory and often foul-smelling sputum.
destruction of the muscular and elastic components of Fever, generalized malaise, weight loss, Hemoptysis
the bronchial walls. It may be focal or diffuse. It is Dry bronchiectasis; usually involve the upper lobes
categorized as cylindrical, tubular, varicose or cystic.
Recurrent pneumonia
2. Etiology 4. Signs
Conditions associated with the development of
bronchiectasis Early phases or dry variety: normal
Severe or secondary infection: persisting
2.1. Post infection crackling rales in the same part of lung
Later stage: Emphysema and cor pulmonale.
Bacterial pneumonia Moist crackles at lung bases
Tuberculosis Halitosis, skin pallor
Pertussis
Measles 5. Laboratory tests
Influenza
Fungus Sputum for Gram stain, C&S, and acid-fast
bacteria (AFB)
2.2. Proximal airway obstruction CBC with differential (leukocytosis with left
shift, anemia).
Foreign body aspiration Serum protein electrophoresis to evaluate for
Benign airway tumors hypogammaglobulinemia.
Antibody test for aspergillosis.
2.3. Abnormal host defense Sweat test in patients with suspected cystic
Ciliary dyskinesia (Kartageners syndrome) fibrosis.
Alpha 1 antitrypsin deficiency
6. Evaluation
2.4 Immuno deficiency
6.1. Chest x-ray:
HIV, Hypogamaglobulenimia
Increased in size and numberof ronchovascular
2.5 Genetic disorders markings (quiet nonspecific). Presence of Tram-
track indicates dilated airways suggestive of
Cystic fibrosis bronchiectasis.

6.2. CT or HRCT:
High sensitivity and specificity

Page 15
Figure 1- HRCT showing Bronchiectasis

Tram track sign: The bronchial wall is thicken and 8.2. Acute General Treatment
visible; the bronchi lose the trend of narrowing from
proximal end to distal end. Supplemental oxygen for hypoxemia.
The choice of antibiotics should be accurate by
Signet ring sign: Dilated bronchi appear as ring
the results of sputum culture and drug sensitivity
structures with internal diameters greater than those
test.
of their accompany pulmonary artery branches.
Empirical therapy - Antipseudomonal
antibiotics. Cipofloxacin and Gentamicin or
7. Differential diagnosis Antibiotic therapy is based on the results of
Differentiate from: sputum, Gram stain, and C&S
Chronic bronchitis, Lung abscess, Tuberculosis Bronchodilators are useful in patients with
Congenital pulmonary cyst. demonstrable airflow obstruction.

8. Treatment 8.3. Chronic Treatment


Avoidance of tobacco.
8.1.Non-Pharmacologic Therapy Maintenance of proper nutrition and hydration
Chest physiotherapy helps the Postural drainage Prompt identification and treatment of infections.
and enhances removal of respiratory secretions. Pneumococcal vaccination and annual influenza
Adequate hydration, mucolytic administration vaccination

Page 16
7. LUNG ABSCESS

Symptoms are generally insidious and


1. Introduction prolonged, occurring for weeks to months
A lung abscess is an infection of the lung Fever, chills, and sweats
parenchyma resulting in a necrosis and cavitation Cough
of lung. Sputum production (purulent with foul odor)
Commonest site is right lung and involves the Pleuritic chest pain
posterior segment of the right upper lobe, the Hemoptysis
superior segment of the lower lobe, or both Dyspnea
The bacterial infection may reach the lungs in Malaise, fatigue, and weakness
several ways that most common is aspiration of Tachycardia and tachypnea
oro-pharyngeal contents.
Dullness to percussion, whispered pectoriloquy, and
2. Microbiology bronchophony

The most common anaerobes are 4. Lab.Studies


Peptostreptococcus, Bacteroids, Fusobacterium
species & Microaerophilic streptococcus. CBC- leukocytosis
Other organisms that may infrequently cause Sputum for gram stain, culture & sensitivity.
lung abscess include Staphylococcus aureus, If T.B. is suspected, acid fast bacilli stain &
Streptococcus pyogens, Streptococcus mycobacterial culture is requested.
pneumoniae (rarely), Hemophilus influenza, Blood culture may be helpful in establishing the
Actinomyces species, Nocardia species, & Gram etiology.
negative bacilli (Pseudomonas) Obtain sputum for ova & parasite whenever a
Mycobacterial tuberculosis is a common cause. parasitic cause for lung abscess is suspected.
Non-bacterial pathogens may also cause lung
abscesses. Parasites [Paragonimus, Entamoeba] 5. Radiological imaging
Fungi [Aspergillus, Cryptococcus, Histoplasma,
Blastomyces, Coccidioides] seen in 5.1. CXR
immunocompromised patients. Lung abscesses are most commonly found in the
posterior segment of the right upper lobe. They
3. Clinical presentation appear as irregularly sharp cavity with an air-fluid
level inside.

Figure 1- X-Ray Showing Lung Abscess

Page 17
5.2. CT Scan
- An abscess is rounded radio-lucent lesion with a
thick wall & ill-defined irregular margins.

Figure 2 CT-SCAN Showing Lung Abscess

Cephalosporins that have gram-positive, gram-


6. Medical care negative, and anaerobic coverage, may be used
Antibiotic therapy: when a polymicrobial infection is suspected as
cause of lung abscess.
IV Clindamycin 600mg 3 times a day, till Duration of therapy is generally for 4-6 weeks to
afebrile then oral 300mg four times a day for 7 as long as 14 weeks.
days.
Alternative is IV Amoxycillin/Clavulanate Antibiotic treatment should be continued until the
1.2gm thrice a day or I.V. Ampicillin chest radiograph has shown either the resolution of
/sulbactum 1.5gm thrice a day then to oral lung abscess or the presence of a small stable lesion.
Amoxicillin/Clavulanate for 7 days, with I.V. Patients with poor response to antibiotic therapy
Metronidazole 500mg 8 hrly is an effective drug include bronchial obstruction with a foreign body or
against anaerobic bacteria for 7 days. neoplasm or infection with a resistant bacteria,
In hospitalized patients who have aspirated and Mycobacteria, or fungi.
developed a lung abscess, antibiotic therapy
should include coverage against staph aureus and 7. Complication
Enterobacter and Pseudomonas species and as
per the identified pathogen. Rupture into pleural space causing empyema, Pleural
fibrosis, bronchopleural fistula.

Page 18
8. PNEUMOTHORAX

Stature.
1. Definition
3.2 Secondary spontaneous - less
The presence of air within the pleural cavity.
common
2.Classification Chronic bronchitis &emphysema, (35%).
Asthma,(0.8).
2.1.Spontaneous Suppurative pneumonia like staphylococci,
klebsiella, HIV (2-4%).
Primary. TB of lungs.
Secondary.
3.3 Traumatic Iatrogenic
2.2.Traumatic Paracentesisthoracis, (28%).
Central venous cannulation, (22%).
Non-iatrogenic. Barotrauma (mechanical ventilation).
Iatrogenic. Tracheostomy.

3.4 Traumatic non iatrogenic


2.1 Spontaneous pneumothorax
Pneumothorax occuring in the absence of trauma may
be described as spontaneous. Open & closed chest injury, (road traffic
Presents in 3 ways: accident).
Open Pneumothorax- air moves freely in & out Stab or gun shot wounds.
of pleural space during breathing. Rib fractures.
Closed pneumothorax- no movement of air from
the pleural space due to closure of the 4. Symptoms
communication, air slowly gets absorbed & the
lung re-expands. Small pneumothorax is asymptomatic.
Tension pneumothorax- a check valve Chest pain - Sharp unilateral associated with
mechanism is produced; this allows air to enter shortness of breath is commonest presentation.
pleura & accumulate to raise the intrapleural Sharp & stabbing Chest pain exacerbated by
pressure above the atmospheric pressure and deep inspiration & postural change.
leads to compression on lung & shifting of Anxious, restless, tachypnoeic, struggling for
mediastinum to opposite side. breath, rapid low volume pulse & hypotension.
May large pneumothorax produce respiratory
a. Primary spontaneous distress, signs of shock.
pneumothorax Closed pneumothorax usually does not produce
severe symptoms.
Commonly occurs in healthy subjects with no Tension pneumothorax medical emergency.
h/o of pre-existing lung disease.
Disease of young adult. 5. Physical signs
b. Secondary spontaneous Small pneumothorax difficult to detect on
pneumothorax physical examination.
Absence or diminished breath sounds on affected
Coexisting structural or functional abnormality side.
in the lung. Chest movement diminished on affected side
Decreased vocal fremitus.
3. Causes of Pneumothorax Hyper resonant percussion note.
Ipsilateral enlargement of chest due to decrease
3.1 . Primary spontaneous elastic recoil of the collapsed lung.
Apical blebs (90%). Shift of mediastinum on opposite side.

Page 19
Increased JVP. ECG- Diminished anterior QRS amplitude.
Respiratory distress. Radiographic appearances.
Diaphoresis.s
Cyanosis. X-ray chest-sharply defined lung edge convex
Hypotension. outwards separated from chest wall by translucency
Crepitus is seen if there is associated with no lung markings &mediastinal displacement
subcutaneous emphysema. depending upon the extent of pneumothorax.

6. Diagnosis

Plain X-ray film of the chest showing


hyperleucency without any lung
markings on right side of the chest
(Pneumothorax)

Figure 1 X-Ray Showing Pneumothorax

If pneumothorax small but patient mild


7. Differential diagnosis symptomatic, admit the pt& administer high.
Transmural myocardial infarction-ECG changes flow oxygen, resulting nitrogen gradient will
& left sided pneumothorax changes resolve once speed resorption.
re-expansions. If pneumothorax larger than 15% to 20% or
Emphysema confused with pneumothorax but x- more than mildly symptomatic, insert a
ray main diagnostic tool. thoracostomy tube.
Massive emphysematous bulla or congenital Secondary pneumothorax- pts are symptomatic
cyst, when ruptures may confused with & require lung re-expansion.
pneumothorax but previous x-ray, lateral Often bronchopleural fistula persists & larger
decubitus view helpful in differentiating upper thoracostomy tube & suction are required.
lobe bulla/cyst. Iatrogenic pneumothorax--due to barotrauma
from mechanical ventilation always persistent air
8. Complications leak & should be managed with a chest tube &
suction.
Recurrence, Haemopneumothorax, Pyopneumothorax Tension pneumothorax--decompress the affected
and Respiratory failure when tension pneumothorax hemithorax immediately with a14 gauge needle
present. attached to a fluid filled syringe, release of air
with clinical improvement confirms the
9. Treatment diagnosis. Seal chest wound with an occlusive
T/T depends on cause, size, degree of physiological dressing & arrange the placement of a
derangement Primary pneumothorax-smaller without thoracostomy tube.
pleural air leak may resolve spontaneously.

Page 20
9. LUNG CANCER

1. Definition 3. Risk factors


Uncontrolled growth of malignant cells in one or Smoking: Smokers have 10 fold or greater
both lungs and tracheo-bronchial tree. increase in risk.
Radiation Exposure.
2. Epidemiology Family history: 1st degree relatives 2 to 3 fold
increase risk.
Lung cancer was initially thought to be
Environmental/ Occupational Exposure:
infrequent in India.
Asbestos, arsenic, chromium, mustard gas,
Rare below age 40.
nickel, Radon, polycyclic & hydrocarbons.
Increasing until age 80 after which rate tapers
Scarring.
off.
Probability developing lung cancer
approximately 8% & 6% in males & females.
4. Signs and Symptoms

Table No. 1
Signs & symptoms Range of frequency
Cough (persistent for > than 2 weeks) 8-75%
Weight loss 0-68%
Dyspnoea 3-60%
Chest pain (poorly localized deep chest discomfort) 20-49%
Hemoptysis (seen more in central tumours) 6-35%
Bone pain 6-25%
Clubbing 0-20%
Fever 0-20%
Weakness 0-10%
SVC syndrome 0-4%
Dysphagia 0-2%
Wheezing & stridor 0-2%
Large cell Carcinoma 10-15%,
undifferentiated, giant or clear ce
5. Types of Lung Cancer
5.2. Small cell Carcinoma (20-25%,
5.1. Non small cell carcinoma oat, intermediate cell)
Squamous Cell Carcinoma (25-40%, epidermoid
derived). 6. Diagnosis
Adenocarcinoma (25-40%, bronchial, acinar, History and Physical exam: Physical signs like
papillary, solid, broncioalveolar). clubbing, lymphadenopathy, hoarseness of voice
(vocal cord palsy on indirect larygoscopy) along with
chest x ray signs of mass lesion and. collapse which
are pointers towards the diagnosis of malignancy.

Page 21
Non resolving pneumonia in an elderly individual or Chest X-ray identifies nodules usually >1cm
in smoker, lung malignancy needs to be excluded. HRCT Chest- mass lesion along with its
morphology and vascularity can be better
6.1. Diagnostic tests visualised

Figure 1: Chest X ray showing Left parahilar lung mass

Bronchoscopy - It is the most useful Focal neurologic signs, papilledema.


investigation. Soft tissue mass.
Pleural tapping - cytological examination of the Hematocrit < 40%in men, <35%in women.
pleural fluid is necessary to establish the Elevated alkaline phosphatase, GGT, SGOT,
diagnosis. calcium levels.
Esophageal compression dysphagia.
6.2. Staging tests Laryngeal nerve paralysis hoarseness.
CT chest/abdomen. Symptomatic nerve paralysis - Horners
Bone scan. syndrome.
Bone marrow aspiration. Cervical/thoracic nerve invasion - Pancoast
PET scan helpful in staging to determine tumour.
degree of metastases Lymphatic obstruction _- pleural effusion.
MRI/CT brain useful in looking at CNS Vascular obstruction - SVC syndrome.
involvement. Pericardial/cardiac extension - effusion,
tamponade.
7. Clinical findings suggestive of
metastatic disease 8. Treatment
Medical, surgical and radiation therapy modalities
Lymphadenopathy [>1 cm]. considered according to the type and stage of the
Bone tenderness. cancer.
Hepatomegaly [>13cm span].

Page 22
10. PULMONARY EMBOLISM

Sometimes patients are asymptomatic.


1. Introduction
Differential Diagnosis - Myocardial ischemia-angina,
Thrombosis that originates in the venous system and myocardial infarct, pneumonia, pericarditis,
embolizes to the pulmonary arterial circulation .DVT congestive heart failure etc.
in veins of leg above the knee (>90%), DVT
elsewhere (pelvic, arm, calf veins, etc.), Cardiac
thrombi.
3. Investigations
Risk factors-obesity, smoking, OC pills, surgery, Chest xray- atelectasis, westermark sign
trauma, malignancy, thrombophilia. increased lucency in area of embolism,
Hamptons hump-peripheral wedge shaped
density above diaphragm, pleural effusion.
2. Signs and symptoms ECG- Sinus tachycardia, Classic S1Q3T3
Massive PE Severe dyspnoea, hypotension, pattern, signs of RV strain-Rin V1 V2 with t
cyanosis, tachycardia. inversion.
ABG - hypoxia, hypocapnia, respiratory
Moderate PE- cough, pleuritic pain,hemoptysis
alkalosis Normal does not rule out PE.
fever.Other signs are anxiety agitation, raised JVP,
loud P2, right ventricular heave.

ECG Findings

Figure-1: ECG changes seen in Pulmonary Embolism

Page 23
D-dimer is raised (high sensitivity but poor
specificity).
4.Treatment
CT Pulmonary Angiography is gold standard. Thrombolysis in massive PE. Inj streptokinase
V/Q Lung scan identifies areas of lung that are 2.5 lakhs bolus then 1.0 lakh per hour.
ventilated but not perfused. Unfractionated heparin 80u/kg bolus then
US Venous Doppler to detect deep venous 18u/kg/hr with goal of PTT 46-70 secs.
thrombosis. LMWH-inj enoxaparin 1 mg/kg 12 hrly. To
overlap with warfarin and to continue it for 3-6
months.

Page 24
11. HYPERTENSION

Blood pressure is lateral pressure exerted by column


of blood on the walls of artery when it flows through 4.2. Basic investigations for initial
it. evaluation: Always includes
Hematocrit / Hb.
1. Definition
Serum BUN, Creatinine.
Hypertension - Defined as any one of the
following: Serum potassium.

Systolic blood pressure > 140 mmHg and / or Fasting blood sugar.
Diastolic blood pressure >90 mmHg, Total cholesterol, S Triglycerides.
Patient taking antihypertensive medications. Urine analysis for albumin, blood, glucose.
Essential HT: When the cause is not known (90 ECG for left ventricular hypertrophy and ST-T
to 95 % cases).
changes.
Secondary HT: Specific organ dysfunction is Fundoscopy for HT retinopathy.
detected (5 to 10 % cases).
4.3. Investigations usually included
2. Symptoms depending on cost & other
Often asymptomatic (silent killer). factors
Due to Elevated pressure: Headache (Occipital), i. TSH
vomiting, giddiness, breathlessness, palpitations. ii. Complete blood count.
Due to Vascular disease: Cerebrovascular iii. HDL, LDL cholesterol.
accident, Acute Myocardial Infarction.
iv. Serum calcium, phosphorus.-
Due to Underlying disease: symptoms of
underlying organ affected. v. Serum Uric Acid.
vi. Chest X-ray - Cardiomegaly.
3. Signs
vii. USG renal system - cortical scarring, shrunken
Blood vessels Bruits over carotid. size, obstructive uropathy.
Abdominal Bruit To rule out reno-vascular viii. Echocardiography LVH, Diastolic
hypertension. dysfunction, Ejection Fraction.
Spells of sweating, tachycardia 4.4. Special tests to screen for
Pheochromocytoma.
secondary HT(only in indicated
Tremors, neck swelling Thyroid Disorder.
cases)
Snoring, Daytime somnolence Obstructive Renovascular disease: renal doppler, MR
sleeps Apnoea. angiography, DTPA scan.
Asymmetry of pulses, Radiofemoral delay Renal parenchymal: kidney biopsy.
Takayasu Disease, Coarctation of Aorta.
Pheochromocytoma: 24 hr urine metanephrine
4. How to investigate? & catecholamines.
Cushings syndrome: Sr cortisol,
4.1. Accurate BP measurement dexamethasone suppression test.
The average of two or more seated blood pressure Aldosteronism: plasma aldosterone:renin ratio.
during each of two or more outpatient visits.

Page 25
4.5. Annual tests in hypertensive Fundoscopy.
subjects 5. How to treat?
Hemogram.
Renal profile. 5.1. Goal BP 150/90 mm Hg in elderly and
140/90 mmHg in all others (including DM, CKD).
Lipid profile.
5.2. Life style changes
Urinalysis.
ECG.

Table 1: Lifestyle changes to manage hypertension

Modification Aim
Weight reduction Attain and maintain BMI < 25 kg/m2
Adopt DASH eating plan Diet rich in fruits, vegetables & low-fat dairy products with
reduced content of saturated and total fat
Dietary sodium reduction < 4.8-7.4 g NaCl/d
Physical activity Regular aerobic activity- brisk walking for 30 min/d

5.3. Guidelines for management


Table 2: Hypertension management guidelines
Lifestyle
BP Classification SBP mmHg DBP mmHg Drug Therapy
Modification
Normal <120 and <80 Encourage No
Prehypertension 120-139 or 80-89 Yes No
Stage 1 Hypertension 140-159 or 90-99 Yes Single Agent
Stage 2 Hypertension 160 or 100 Yes Combo

Page 26
5.4. Treatment protocol
Figure 1: Treatment Protocol for HT Age > 30 Yr.

History & Physical examination

Confirmation of diagnosis by
BP > 140/90 mm of Hg.

Educate Patient on nutrition, saltrestrictions, physical activity


de-addiction and regular follow up. ( Refer to Health Workers Manual )

Start the Treatment

Age 60 Yr. Age < 60 Yr.


Goal of Treatment Goal of Treatment
BP < 150/90 mm Hg. BP < 140/90 mm Hg.

1) IF BP is 140-160 1) IF BP is 140-100
Start CCB Start ACE inhib.*( Not recommended in Renal Failure)
T. Amlodipine 5mg OD T. Enalpril 5 mg OD

Goal achieved Goal achieved


Cont. Rx Cont. Rx

Goal Not Achieved Goal Not Achieved

T. Enalpril 10 mg OD
T. Amlodipine 10 mg OD

Goal achieved Goal achieved


Cont. Rx Cont. Rx

Goal Not Achieved


Goal Not Achieved

Goalachieved
Goalachieved Cont. Rx
Cont. Rx
T. Enalpril + T. Hydrochlorthizide
T. Amlodipine + T. Hydrochlorthizide 5 mg OD + 12.5 mg OD
5 mg OD + 12.5 mg OD

Goal not achieved


Goal Not Achieved

Page 27
Goalachieved
Cont. Rx
Age 60 Yr.
Goal of Treatment
BP < 150/90 mm Hg.
Age < 60 Yr.
Goal of Treatment
BP < 140/90 mm Hg.
2) If BP is>160 mm of Hg

2) If BP is>160 mm of Hg
Start

T. Amlodipine + T. Hydrochlorthizide
Start
5 mg (OD) + 12.5 mg (OD)
T. Enalpril + T. Hydrochlorthizide
Goal achieved 5 mg (OD) + 12.5 mg (OD)
Cont. Rx
Goal achieved
Goal not achieved Cont. Rx

Goal not achieved


T. Amlodipine + T. Hydrochlorthizide
10 mg (OD) + 25 mg (OD)
T. Enalpril + T. Hydrochlorthizide
10 mg (OD) + 25 mg (OD)
Goal achieved
Cont. Rx
Goal achieved
T. Amlodipine + T. Hydrochlorthizide + T. Enalpril cont. Rx
10 mg OD + 25 mg OD + 5mg OD
Goal not Achieved

Goal not Achieved


T. Enalpril + T. Hydrochlorthizide + T. Amlodipine
10 mg OD + 25 mg OD + 5mg OD
Goal achieved
Cont. Rx
Goal achieved
Goal not Achieved Cont. Rx

Goal not Achieved


T. Amlodipine + T. Hydrochlorthizide + T. Enalpril
10 mg OD + 25 mg OD + 10mg OD
T. Enalpril + T. Hydrochlorthizide + T. Amlodipine
10 mg OD + 25 mg OD + 10mg OD
Refer to DH

Goal Achieved Refer to DH


Cont. Rx
Goal Achieved
Cont. Rx
Goal not achieved
Goal not achieved

Page 28
If age < 30 yr & BP> 140/90 - immediately refer
to DH (District hospital).
6. Vigilance for End Organ
When patient is on drug if systolic BP is < 100 Damage in hypertensive
mm of Hg withhold the drugs (anti-hypertensive
drugs) and refer to DH. patients
BP >160/100, Start min 2 anti-hypertension Congestive heart failure.
If initial BP is > 200/100 refer to DH after a shot IHD.
of Inj. Frusemide 60 mg stat. Chronic kidney Disease.
If Sr. Creatinine > 1.5mg% refer to DH. Stroke.
Hypertensive Retinopathy.
5.5. Hypertension in Pregnancy
Tablet Methyl Dopa -500mg-1000mg/Day in 7. When to refer?
three divided dose.
Tablet Nifedepine Extended Release Preparation Annual Work-up of known Hypertensive
30- 60 mg OD/BD. subjects.
Other drugs that can be given-Labetalol, Young Hypertensive/ secondary HT.
Hydralizine, Beta Blocker. Resistant Hypertension (Target BP not achieved
ACE inhibitors and ARBS avoided. with 3 drugs including diuretics).
Pregnant subjects.
Hypertensive emergencies (BP > 180/ 110 mm
Hg with e/o end organ damage).

Page 29
12. HEART FAILURE
ii. Also, once the features can be demonstrated on
1. Introduction clinical examination, the underlying causes of
It and congestion in the veins that drains into it. right heart failure should be looked for; e.g.
History of smoking and signs of COPD, or signs
2. Types of heart failure of Mitral Valve Disease.

The heart consists of two distinct parts; right and left Investigations for Right Heart Failure:
receiving blood from different venous system and The diagnosis of Right Heart failure is a clinical one.
perfusing distinct parts of the body; the right heart Investigations are basically to diagnose the
perfusing Heart Failure is a condition where the heart underlying cause of right heart failure.
is unable to perform its functions optimally; leading
to decreased perfusion of the tissues supplied by the Treatment of Right Heart Failure:
lungs for gaseous exchange and the left heart Right heart failure is not a medical emergency and
perfusing the systemic circulation. doesnot cause immediate fatality. There is no direct
Hence there are two types of heart failure. treatment of Right Heart failure. This condition is
alleviated by effective treatment of the cause of
Right heart failure. failure.
Left heart failure. Hence attempts should be made to manage COPD
effectively, like:
2.1 Right Heart Failure
Antibiotics in acute exacerbation.
The right receives blood from the systemic veins and Effective bronchodilation using inhalers and oral
pumps blood into the pulmonary artery through the long acting Xanthines (Deriphyllin).
pulmonary valve. Low flow oxygen inhalation which is the
Hence the cause of Right heart failure would be; treatment of choice for Cor Pulmonale.
increased pressure in the pulmonary artery Effective treatment of Mitral stenosis including
(Pulmonary Hypertension) or pulmonary valve Low salt diet, Diuretics, and Digoxin.
stenosis. When to Refer a Case of Right Heart Failure to
Causes of Pulmonary Hypertension: Higher Centre:
i. Chronic obstructive Pulmonary disease (COPD)
A case of right heart failure needs to be referred for
seen commonly in smokers. Cor Pulmonale.
specialized treatment only for management of non
ii. Mitral valve stenosis seen in Rheumatic heart
responsive chronic obstructive airway disease. Incase
diseases.
the cause of right heart failure is Mitral valve disease
Clinical features of Right heart failure: which is not amenable to medical management, such
cases should be referred to a cardiac centre for
As the right heart receives blood from the systemic definitive management of the condition.
veins, the main clinical features involves features of
congestion in the systemic venous system. 2.2. Left Heart Failure:
i. Raised Jugular Venous Pressure with engorged [Pulmonary Oedema]
superficial neck veins.
ii. Tender Hepatomegaly: Painful, soft liver The left heart receives blood from the pulmonary
palpable in the right hypochondrium. vein and pumps blood in the systemic circulation.
iii. Dependent Oedema: Pitting oedema Causes of left heart failure:
demonstrable on the shin of the tibia and ankles.
i. Systemic Hypertension is the commonest
When to Suspect Right Heart Failure: cause for left ventricular failure
i. Right heart failure should be suspected if the ii. Valvular heart diseases: Aortic stenosis, Aortic
clinical features are present like swelling in the regurgitation and Mitral regurgitation are all
legs and engorged neck vein. causes or acute left heart failure.
iii. Myocardial infarction involving significant
part of left ventricle can cause L.V.failure.

Page 30
Clinical features: i. The patient should be treated in the propped up
position using a backrest or raised head end of
i. Sudden onset breathlessness is the main
the bed.
symptom.
ii. There may be continuous cough with pink ii. High flow Oxygen inhalation should be given.
frothy sputum.
iii. Sedation preferably with Morphine 10mg I.V or
iii. The patient will be very anxious and restless.
Pentazocin 30 mg is the management of choice.
iv. The patient will choose to be in the sitting
position and unable to lie down. If these powerful narcotics are not available, any
v. On auscultation of the chest, crepitations will form of sedation will be of help.
be heard most prominently in the bases.
vi. General examination will reveal high blood iv. Intravenous Frusemide (Lasix) 60mg I.V should
be administered.
pressure which is the commonest cause.
vii. Such patients are likely to present with v. Acute reduction of blood pressure must be done
cyanosis. (Bluish discoloration of tonque, lip, if the cause of left heart failure is Hypertension:
oral mucosa and fingers and toes. I.V. infusion of Nitroglycerine (5 microg/kg) by
BP monitoring, should be tried for the purpose.
Investigations:
Left ventricular failure is a medical emergency and vi. Anti platelets, statins to be continued.
time should not be wasted in any investigation. When to Refer the Patient:
However after stabilizing the patient investigations Treatment of left heart failure must be attempted at
may be carried out to find the underlying cause. the peripheral level. Once stabilized the patient may
be referred to higher centre for management of the
Treatment:
underlying cause.
Left heart failure or Pulmonary oedema is a medical
emergency and speed of administration of treatment Failure of the patients breathlessness to resolve, may
require, endotracheal intubation or non invasive
is of paramount significance.
positive pressure ventilation and patient should be
referred to such a centre if facilities for the same is
not available.

Page 31
13. ISCHAEMIC HEART DISEASE AND
ACUTE CORONARY SYNDROME

ECG taken at that time may show ST elevation or


1. Introduction depression or T inversion. In between anginal
episodes, the ECG may be normal.
1.1. Ischemic heart disease (IHD) A treadmill stress test would confirm angina in over
It is a condition in which there is an inadequate 95% of these cases in referral hospital.
supply of blood and oxygen to a portion of the Echocardiography to measure left ventricular
myocardium. It typically occurs when there is an function and rule out segmental dyskinesia
imbalance between myocardial oxygen supply and suggestive of earlier myocardial infarction.
demand.

1.2. Patients with ischemic heart 2.3. Treatment


disease fall into two large Daily exercise, Stop smoking,Dietary modification
groups. low cholesterol, low fat diet with high roughage.
i. Patients with chronic coronary artery disease Control of hypertension, Diabetes Mellitus and
(CAD) who most commonly present with Dyslipidemia.
stable angina.
ii. Patients with acute coronary syndromes
(ACSs). Drug Treatment

a. Patients with acute myocardial infarction (MI) Tab Aspirin 75 mg once daily.
with ST-segment elevation on their Tab Clopidogrel 75 mg per day.
presenting electrocardiogram (ECG).
Tab Atorvastatin 40 mg per day.
b. With unstable angina (UA) and non-ST-
segment elevation MI. Nitrates -Sublingual glyceryl trinitrate300-500
microgram tds or Isosorbide dinitrate 10 mg
2. Stable Angina thrice a day. If there is headache lower dose of 5
mg twice or thrice daily can be tried.
2.1. Clinical Presentation
Chest pain Retrosternal, dull aching, constricting or Betablockers - Tab Metoprolol 50 200 mg /
burning, radiating to neck, jaw, shoulders or arms day (PO in divided dose).
usually precipitated by exertion or stress and relieved
by rest or nitrates. Angina is crescendo and Potassium channel activators- Nicorandril 10mg
decrescendo in nature and typically last for 2-5 BD.
minutes. Calcium channel blockers like Tab Amlodepine
The physical examination is often normal in patients 5-10 mg OD.
when asymptomatic. Examination during an anginal Refer for coronary angiogram and revascularisation
attack and transient left ventricular failure, there can therapy.
be a third, fourthheart sound, and systolic murmur of
mitral regurgitation.

2.2. Investigations 3. Unstable Angina and Non-


CBC, Urine, Blood sugar, Lipidprofile, and Xray
ST-Segment Elevation
chest PA view may be helpful. Myocardial Infarction

Page 32
UA is defined as angina pectoris or equivalent
ischemic discomfort with at least one of three
4. ST segment elevated
features: Myocardial Infarction
(1) It occurs at rest (or with minimal exertion), 4.1. Clinical Presentation
usually lasting >10 minutes. Chest Pain- commonly occurs at rest, severe, and
lasts longer. Typically, the pain involves the central
(2) It is severe and of new onset (i.e., within the prior
portion of the chest and/or the epigastrium, and, on
46 weeks); and/or
occasion, it radiates to the arms, abdomen, back,
(3) It occurs with a crescendo pattern (i.e., distinctly lower jaw, and neck.
more severe, prolonged, or frequent than previously).
Sudden-onset breathlessness, Sweating, loss of
consciousness, a confusional state.
3.1. Clinical Presentation Sensation of profound weakness, the appearance of
Chest pain, typically located in the substernal region an arrhythmia, an unexplained drop in arterial
or sometimes in the epigastrium that radiates to the pressure.
neck, left shoulder, and/or the left arm.
4.2. Laboratory Findings
3.2. Electrocardiogram CBC, Blood sugar, lipid profile, Xray chest.
ST-segment depression, transient ST-segment
elevation, and/or T-wave inversion. Cardiac markers-CPK-MB elevated.
TrpT,I released within 4-6 hours and elevated for
3.3. Cardiac Biomarkers 2 weeks.
CPK-MB and troponin raised in Non ST segment
elevated MI. Electrocardiogram Convex ST segment
elevation with either peaked upright or inverted
T waves. Q waves if necrosis occurs.
3.4. Treatment
Bed rest. Echocardiogram - regional wall motion
abnormality.
Sublingually Nitroglycerin .3-.6 mg stat can
repeat after 5 min - 3 Doses.
If symptoms persist, intravenous Nitroglycerin 4.3. Complications
infusion at dose of 5-10. microgm/min. once Arrhythmias.
pain has resolved Oral isosorbitrate dinitrate 10
Acute Heart failure.
mg BD can be given.
Rupture of papillary muscle.
Asprin initial dose of325 mg followed by
150mg/day lifelong. Embolism leading to stroke.
Clopidogrel -Loading dose of 300mg followed Ventricular remodelling.
by 75 mg/.day for 2 years.
Ventricular aneurysm.
Tab Atorvastatin 40mg / day lifelong.
Intravenous beta blocker metoprolol 5-15 mg 4.4. Treatment
over 5 mins followed by tab metoprolol 50-
Bed rest.
100mg/day in divided doses with BP check.
Oxygen therapy-2-4L/min.
Unfractionated Heparin (UFH) bolus 6070
U/kg (maximum 5000 U) IV followed by Sublingually Nitroglycerin .3-.6 mg stat can
infusion of 1215 U/kg per h (initial maximum repeat after 5 min - 3 Doses if symptoms persist,
1000 U/h) titrated to A PTT 5070 s. intravenous Nitroglycerin infusion at dose of 5-
10 microgm/min. once pain has resolved Oral
or
isosorbitratedinitrate 10 mg BD can be given.
Enoxaparin 1 mg/kg SC every 12 hr.
Aspirin 325mg and then 150mg OD.
Clopidogrel 300mg and then 75mg BD.

Page 33
Atorvastatin 80mg and then 40mg HS. Stool softeners Bisacodyl (Dulcolax) 10 mg at
night.
Reperfusion therapy: If presenting within 12
hours of chest pain with ECG showing ST Message
elevation > 1 mm then give Inj. Streptokinase 1.5
Acute myocardial infarction is an emergency
million units over 1 hour (contraindications- a
whatever treatment possible should be started at the
history of cerebrovascular hemorrhage at any
center and patient should be transferred to District
time, a nonhemorrhagic stroke or other
Hospital or any hospital where ICU facility is
cerebrovascular event within the past year,
available in a cardiac ambulance. Patient should not
marked hypertension at any time during the acute
be allowed to walk for even short distances and
presentation, suspicion of aortic dissection, and
absolute Bed Rest is important. Treatment of
active internal bleeding).
complications like Heart failure, Arrythmias may
Beta blockers: ), Metoprolol 25 to 50 mg BD, need expert opinion.
Atenolol 25 to 100 mg OD(if pulse rate > Coronary Angiography and revascularisation therapy
60/mm, BP > 90/60 mm Hg ,lung fields clear). should be advised.
ACE inhibitors Enalapril 2.5 20 mg / day in
divided doses twice a day.

Page 34
14. ACUTE RHEUMATIC FEVER (ARF)

Acute rheumatic fever (ARF) is a multisystem


1. Introduction disease resulting from an autoimmune reaction to
infection with group A streptococcus.

2. Criteria for diagnosis of ARF


Major manifestations Carditis (Pancarditis)
Polyarthritis (Migratory)
Chorea
Erythema marginatum
Subcutaneous nodules
Minor manifestations Clinical: fever, polyarthralgia
Laboratory: elevated erythrocyte sedimentation rate or leukocyte
count
Electrocardiogram: prolonged P-R interval
Supporting evidence of a preceding Elevated or rising anti-streptolysin O or
streptococcal infection within the last 45 days
other streptococcal antibody, or
A positive throat culture, or
Rapid antigen test for group A streptococcus, or
Recent scarlet fever

Two major or one major and two minor precipitating group A streptococcal infection.
manifestations plus evidence of preceding group A Penicillin is the drug of choice and can be given
streptococcal infection. orally [as phenoxymethyl penicillin, 500 mg (250 mg
for children 27 kg) PO twice daily, or Amoxicillin 50
3. Investigations mg/kg (max 1 g) daily, for 10 days] or as a single
White blood cell count, Erythrocyte sedimentation dose of 1.2 million units (600,000 units for children
rate, C-reactive protein, Blood cultures if 27 kg) IM Benzathine Penicillin G.
febrile, Electrocardiogram, Chest x-ray if clinical or 4.2 Aspirin in initial dose of 80100 mg/kg per
echocardiographic evidence of carditis, day in children (48 g/d in adults) in 45 divided
Echocardiogram (consider repeating after 1 month if doses is used for the treatment of arthritis, arthralgia,
negative). Throat swab (preferably before giving and fever for 4 weeks.
antibiotics)culture for group A streptococcus.
4.3 Inj. Benzathine Penicillin G 1.2 IU (6 lakhs
Anti-streptococcal serology: both anti-streptolysin O units for children 27 kg) IM every 3 weeks as
and anti-DNase B titres, if available. prophylactic dose up to the age of 25 years.
4. Treatment 5. When to refer
4.1 Antibiotics Evidence of Congestive cardiac failure, Arrhythmia.
All patients with Acute rheumatic Fever (ARF)
should receive antibiotics sufficient to treat the

Page 35
15. INFECTIVE ENDOCARDITIS

1. Definition Streptococci, Pneumococci Enterococci,


Staphylococcus aureus, Coagulase-negative
Infective endocarditis is a form of endocarditis, or staphylococci. Fastidious gram-negative coccobacilli
inflammation, of the inner tissue of the heart (such as (HACEK group i.e. Haemophilus species,
its valves) caused by infectious agents. The agents Aggregatibacter Aphrophilus, Cardiobacterium,
are usually bacterial, but other organisms can also be Eikenella, Kingella), Gram-negative bacilli,Candida
responsible. spp.
Infection most commonly involves heart valves either
native or prosthetic.
3. Clinical Manifestations
2. Organisms Causing Major (Symtoms and signs)
Symptoms- Fever, chills, arthralgia, Fatigue.
Clinical Forms of
Endocarditis
Figure 1: Signs of Infective EndcarditisSigns

Page 36
haemorrhages,conjuctival
4. Diagnosis haemorrhages,Janeway lesion
iv. Immunological
Modified Dukes Criteria phenomenon;(glomerulonephritis;Oslernodes;
Roths spots;rheumatoid factor)
4.1 Major Criteria v. Microbiological evidence positive blood
cultures but not meeting major criteria or
i. Positive blood culture serological evidence of active infection with
Two separate positive blood cultures with organism consistent with infective
microorganism(s) typical for infective endocarditis.
endocarditis:viridians.
streptococci,streptococcus bovis HACEK Documentation of 2 major / one major and 3 minor/5
group, staphylococcus aureus, community minor criteria allow a diagnosis Infective
acquired enterococci endocarditis.
or
Persistently positive blood culture defined as
5. Investigations
presence of micro organism consistent with
infective endocarditis from blood cultures
drawn >12 hrs apart. CBC-Anaemia,Leucocytosis.
or Urine-Microscopic haematuria.
Single positive blood culture for coxiella Elevated ESR, Elevated CRP.
burnetti or phase one IgG antibody titer of >1 : Blood culture 3 sets of two bottle blood. culture
800. from different venipuncture site separated from
one another by atleast one hour over 24 hours.
ii. Echocardiographic evidence of endocardial Echocardiography.
involvementTypicalvalvular
lesions;vegetations,abscess,or new partial 6. Complications
dehiscence of a prosthetic valveNew Valvular
regurgitation. Blood clots or emboli that travel to brain,
kidneys, lungs, or abdomen.
4.2 Minor Criteria Brain abscess.
Congestive heart failure.
i. Predisposition;predisposingheart condition or Glomerulonephritis.
intravenous drug use. Jaundice.
ii. Temperature greater than 38.0 C. Neurological changes.
iii. Vascular phenomenon;major arterial Rapid or irregular heartbeats, including atrial
emboli,septic pulmonary infarcts,mycotic fibrillation.
aneurisms,intracranial Severe valve damage.
Stroke.

Page 37
7. Treatment
Table 1: Antimicrobial Therapy

Organism Drug (Dose, Duration


Penicillin-susceptible streptococci Inj. Penicillin G (23 mU IV q4h for 4 weeks) or
Inj. Ceftriaxone (2 g/d IV as a single dose for 4 weeks) plus
Inj. Vancomycin (15 mg/kg IV q12h for 4 weeks)
Moderately penicillin-resistant streptococci Inj. Penicillin G (45 mU IV q4h) or ceftriaxone (2 g IV qd)
for 6 weeks plus
Inj. Gentamicin (3 mg/kg qd IV or IM as a single dosee or
divided into equal doses q8h for 6 weeks) Plus
Inj. Vancomycin (15 mg/kg 12 hourly) as noted above for 4
weeks
Enterococci Inj. Penicillin G (45 mU IV q4h) plus
Inj. Gentamicin (1 mg/kg IV q8h), both for 46 weeks
Staphylococci (native valve) Inj. Vancomycin (15 mg/kg IV q12h for 46 weeks)
Staphylococci (prosthetic valves) Inj. Vancomycin (15 mg/kg IV q12h for 68 weeks) plus
Inj. Gentamicin (1 mg/kg IM or IV q8h for 2 weeks) plus
Rifampin (300 mg PO q8h for 68 weeks)

8. Prevention
High Risk cardiac lesions where antibiotic
prophylaxis is needed.

1. Prosthetic heart valve.


2. Prior endocarditis.
3. Unrepaired cyanotic congenital heart disease.
4. Completely repaired cyanotic heart disease
within 6 months.
5. Incompletely repaired cyanotic heart disease
with residual defects.

Page 38
Table: 2: Antibiotic Regimens for Prophylaxis of Endocarditis in Adults with High-Risk Cardiac
Lesion

A. Standard oral regimen

1. Amoxicillin: 2 g PO 1 h before procedure

B. Inability to take oral medication

1. Ampicillin: 2 g IV or IM within 1 h before procedure

C. Penicillin allergy

1. Clarithromycin or azithromycin: 500 mg PO 1 h before procedure

2. Cephalexin: 2 g PO 1 h before procedure

3. Clindamycin: 600 mg PO 1 h before procedure

D. Penicillin allergy, inability to take oral medication

1. Cefazolin or ceftriaxone: 1 g IV or IM 30 min before procedure

2. Clindamycin: 600 mg IV or IM 1 h before procedure

Message- If any valvular heart disease or prosthetic valve patient develops fever, infective
endocarditis should be thought of apart from other normal causes of fever.

Page 39
16. DIABETES MELLITUS
Genetic defects of insulin action.
1. Introduction
Diseases of exocrine pancreas Trauma,
Diabetes mellitus is a clinical syndrome characterized
Pancreatitis, Pancreatectomy, Cystic fibrosis,
by hyperglycemia due to absolute or relative
Fibrocalculous Pancreatic diabetes,
deficiency of insulin.
Haemochromatosis.
Gestational Diabetes Mellitus (GDM) Onset /
2.Classification of Diabetes Recognition of glucose intolerance in pregnancy.
Mellitus
2.1. Type 1 Diabetes Mellitus 3. Diagnosis of DiabetesMellitus
Autoimmune pancreatic B cell destruction; absolute Symptoms of Diabetes Mellitus and Random
insulin deficiency. Blood Sugar > 200 mg% (mg / dl)
Fasting blood sugar > 126 mg % on more than
2.2. Type 2 Diabetes Mellitus one occasion.
Characterized by peripheral tissue Insulin Resistance
/ Relative Insulin deficiency. 2 hours Plasma glucose > 200 mg% during oral
glucose tolerance test with glucose 75g
2.3. Other Specific Types glucose.

Genetic defects of B cell function Maturity


Onset Diabetes in Young (MODY).

Table 1: Criterion for Diagnosis based on blood glucose levels

Normal Glucose Prediabetic Diabetes mellitus


Impairedglucose
tolerance

FPG <100mg/dl 100-125 mg/dl >126 mg/dl

2hr PG <140mg/dl 141-199 mg/dl >200 mg/dl

A1C (Glycosulated <5.6% 5.7-6.4% >6.5 mg/dl


Hemoglobin)

4. Clinical symptoms
Common symptomsare
Other symptoms are tiredness, fatigue, pruritis vulvae
1. Polyuria {increased frequency of micturition), giddiness, burning over feet, and can present with
2. Polydipsia (increased thirst), complications of diabetes.
3. Polyphagia (increased appetite),
4. Weight loss. Table -2: Major differentiating features of Type 1 and
Type 2 diabetes are as follows-

Page 40
5. Management
Type 1 Diabetes Mellitus:

5.1 Type 1 Diabetes Mellitus e) glucosidase inhibitors - acarbose, voglibose,


miglitol
Strict meal plan * Carbohydrate: 50 - 60% * f) DPP4 inhibitors- sitagliptin, vidagliptin
Protein: 10 20% * Fat: 30% (If patient is
dyslipidemic, fat should be 15%) * Caloric Parenteral agents
intake: 30Kcal / kg 1. Insulin
Physical exercise 2. GLP-1 receptor agonist- Liraglutide,Exenatide

Only Insulin (a) Bi-guanides


Dose- 500mg-2000mg/day.
5.2 Type 2 Diabetes Mellitus:
Contra-indications to Bi-guanide therapy: 1. Renal
Strict meal plan failure when creatine clearance < 40 ml / min 2.
Physical exercise Arteriography or intravenous urography as
Oral hypoglycemic agents intravenous iodinated products may precipitate lactic
acidosis on patients with bi-guanides 3. Advanced
Insulin
liver cell failure 4.Alcoholism 5.Cardiac diseases
Oral Hypoglycemic Agents: 6.Diabetes with significant acute and late
complications 7.Pregnancy 8. Old age > 70 years.
a) Biguanides - Metformin
b) Sulphonylureas - Glibenclamide, Glipizide,
Glimeperide,, Gliclazide
(b) Sulphonylureas
c) Glinides (nonsulphonylurea secretogouge) - Mechanism of action- Increases insulin secretion
repaglinide from the beta cells through the ATP sensitive K
channels.
d) Thiazolidinediones pioglitazone

Page 41
Table-3: Sulphonylurea drugs with dosage and side effects

Drug Dose Side effets


Glibenclamide 1.25-20 mg Hypoglycaemia, weight gain
Glimeperide 1-8 mg Hypoglycaemia
Glipizide 2.5 -25 mg Hypoglycaemia
Gliclazide 30-240 mg Hypoglycaemia

Contraindications for sulphonylurea therapy thereby increasing insulin secretion only with the
intake of food. They do not cause hypoglycaemia.
1. Insulin dependent diabetes mellitus (IDDM)
Dose- vidagliptin 50 mg BD, Sitagliptin 100mg OD.
2. Pregnancy
Insulin
3. Patients with severe infections
Consider insulin as initial therapy in patients
4. Allergic reactions
with:
5. Significant liver and kidney disease
Fasting plasma glucose > 250 - 300 mg/dl since
6. Patients undergoing surgery more rapid glycemic control will reduce glucose
toxicity to islet cells, improve insulin secretion
(c) Glinides-(Nonsulphonylureas) secretogoue-
and possibly make oral hypoglycemic agents
Increase insulin secretion
more effective.
Dose-Repaglinide 0.5-3 mg/day.
Lean patients or those with severe weight loss.
(d) Thiazolidinediones-These are insulin sensitisers
Pioglitazone is commonly used. Underlying renal or hepatic disease.

Dose- 15- 45 mg/day. Hospitalized or acutely ill patients.

Side effects- Weight gain, congestive cardiac failure, If response to oral hypoglycemics is not
fractures, adequate. Consider insulin as initial therapy

(e) Glcosidase inhibitors Decreases intestinal Pregnancy


glucose absorbtion and reduce postprandial Types of Insulin
hyperglycemia.
1. Rapid-acting insulin: aspart insulin and lispro
Dose- Acarbose -25 -100 mg/day to be taken with insulin
food. 2. Regular or Short-acting insulin
Voglibose-. 0.2- 0.3 thrice a day 3. Intermediate-acting insulin: lente insulin and
NPH insulin
(f) DPP 4 Inhibitors 4. Long-acting insulin: Insulin detemir and insulin
Mechanism of action They inhibit the enzyme glargine
DPP 4 and increase endogenous GLP-1 action

Figure-1: Treatment Protocol for DM Type II

History & Physical examination


RBS>140 mg/dlSuspect

Page 42
Confirmation of diagnosis by
Fasting bllood sugar - >126 mg/dl OR
Post Prandial B.S->200 mgCC/dl OR
Random Blood Sugar -> 200 mg/dl

Educate Patient on Diet, Physical activity,


De-addiction Foot care and regular follow up.
(Refer to Health Workers Manual)

Take blood for Sr. Creatinine & Other investigation Urine


Start the albumin &Sugar treatment

Fasting B.S:> 126-200 or/and Fasting B.S:>200-300and/orPost Prandial B.S:


>300-350
Post Prandial B.S:> 200-300
Start with combination therapy
Start with monotherary Metformin + Sulphonyl Urea
Tab. Metformin 500mg BD 500mg BD (Glimiprideor Glipizide)
(1 mg OD) (2.5mg OD)

Evaluate after
15 days with Sr. Creat Report
> 1.5 mg%

If Sr. Creat is
< 1.5 mg% Urgent Referral to DH

Target to be achieved with therapy


Fasting 100 126 mg/dl

Target to be achieved with therapy


Fasting 100 126 mg/dl

Target achieved with given Target not achieved with giventherapy


therapy

Continue the Rx and regular follow up Step wise increase the dose of medicine
after 15-30 days.

Page 43
Target achieved Target not achieved

Follow up after 15-30 days. Refer to DH

Steps to increase dose in: 3) 1 gm BD + 2 mg BD Or 5 mg BD (If target


not achieved)
A) Monotherapy: Refer the patients to DH.
I. Start with T. Metformin 500mg BD
( If target not achieved ) * The main aim of this protocol to control raised
II. T. Metformin 750 mg BD ( If Blood sugar however not to complicate by
target not achieved ) Hypoglycemia.
III. T. Metformin 1 gm BD ( If
target not achieved )
Refer the patients to DH. Instruction: - Dont allow patients to fast while
on medication.
B) Combination therapy: -Strict De-addiction state should be
Metformin + Glimepride OrGlipizide. maintained.
1) 500mg BD + 1mg OD Or 2.5mg BD - If sudden rise in blood sugar
(If target not achieved) observed then urgent referral to District Hospital.
2) 750mg BD + 1mg OD Or 2.5mg BD
(If target not achieved)

6. Check list

Page 44
Microvascular complications
7. Complications of Diabetes
Mellitus Eye disease- Retinopathy, Macular edema.
7.1 Acute complications Neuropathy- Sensory and motor neuropathy (mono
and poly),
Hypoglycemia
Diabetic Ketoacidosis (DKA) Autonomic neuropathy
Diabetes and infections
Hyperosmolar Hyperglycemic coma (HHNKC). Nephropathy

7.2 Chronic complications Macrovascular complications

Coronary heart disease


8. Hypoglycemia
Cerebrovascular disease Hypoglycemia is a clinical emergency occurring in
Peripheral arterial disease diabetes characterized by either autonomic or
neuroglycopenic symptoms (or) biochemically
Other gastroparesis, sexual dysfunction, random blood sugar < 60mg, due to antidiabetic
dermatologic agent, food and activity mismatch.

Table-4: Clinical presentation of Hypoglycemia

8.1 Management Dextrose supplementation - Conscious: Oral


Glucose, Sugar, Fruit Juice, Unconscious: 50%
Draw blood sample immediately Dextrose 100ml IV Stat. Followed by 10%

Page 45
Dextrose then by 5% DNS maintenance (or) Inj. Important Note Patient Education:
Glucagon 1mg im if not accessible to Educate patient and his family members about
intravenous route low blood sugars and symptoms
Patient still remains unconscious - To rule out Never miss a meal after insulin / Oral
cerebral edema, If present IV mannitol + Inj. hypoglycemic agents
Dexamethasone 8mg IV Be cautious of unaccustomed physical activity
Stop the antidiabetic agents for 3 days in Type 2 To carry diabetic identity card
Diabetic mellitus patients and recheck blood Always carry simple sugar (biscuits and toffee)
sugars. In Type 1 Diabetic mellitus patients, to avoid low sugar.
recheck blood sugars after 6 hrs and adjust
insulin dose accordingly. 9. Diabetic Ketoacidosis (DKA)
Identify the cause of hypoglycemia Ketoacidosis is a major medical emergency and
If recurrent hypoglycemia, rule out - Renal remains a serious cause of morbidity, principally in
function disorder, Liver function disorder people with type 1 diabetes, which should be treated
Repeat blood sugar value after hypoglycemia in hospital.Patient should be referred to tertiary
correction and monitor blood sugars health centre after the primary management.
Referral: If the patient remains unconscious
even after dextrose administration refer the
9.1 Manifestation of DKA
patient immediately to higher centre for further
evaluation.
Table 5

Page 46
9.2 Investigations ABG for pH and bicarbonate
Urine sugar [positive]
Blood glucose [usually > 250 mg %] Urine acetone [positive]
Blood urea [may or may not be ] Chest X-ray
Serum creatinine [may or may not be ] ECG
Serum electrolyte [Na or , K or decreased] Ultrasonogram abdomen / KUB.
Serum bicarbonate < 10 mmol / l
9.3 Management of DKA

9.4 Referral Anuric


Elevated renal parameters
Refer the patient to a higher centre if:
Evidence of septicaemia
Patient is comatose
Hypotension requiring ionotropic support

Page 47
9.5 Complications of Diabetic Ketoacidosis

10. Hyperglycemic
Hyperosmolar Non-Ketotic
Coma (HHNKC)
10.2 Symptoms
It is an acute metabolic complication in middle aged
and elderly diabetics with high morbidity and Polyuria
mortality. Polydipsia
Severe hyperglycemia (Blood sugar > 600
10.1 Causes mg%)
Profound dehydration
Precipated by Elevated osmolality
Hemianopia, muscle fasciculation, seizures
Infection
Altered sensorium, coma
Trauma
Burns 10.3 Treatment
Infarction
Hyper-alimentation 1. Fluid replacement: normal saline at the rate of
Drugs like - Thiazide, Cimetidine, Phenytoin 2 litre in 1st 2 hours and 1 litre in another 2
and Parentral diuretics hours
2. Low dose insulin.
3. Correction of electrolytes and hyperosmolality.
4. Low-dose heparin to prevent vascular
thrombosis intravascular coagulation.

Page 48
10.4 Distinguishing features
Table-6: Distinguishing features between DKA and HHNKC

Moderate worker 40 kcal/kg Ideal body weight


11. Medical Nutrition Therapy For heavy worker
A non-pharmacological mode of management of In obese people - Reduce 500 kcal from the
diabetes. Medical Nutrition therapy is individualized calculated energy requirement
and should be a tailor made regimen. It is used as a
compliment for an oral glucose lowering agent / For under weight- Add 500 kcal to the calculated
insulin therapy. energy requirement of the total kcal, 45 - 65 %
kcal from carbohydrate and 10-25 % kcal from
Energy Recommendations: proteins
This depends on body weight and physical Fat recommendation - 500ml / month of a blend
activity. 20 kcal/kg Ideal body weight of oils / individual Gingelly oil and any refined
Sedentary worker 30 kcal/kg Ideal body weight

Page 49
vegetable oil could be used (or) Rice brand oil and any refined vegetable oil
Fibre recommendation - 14gm/1000kcal
12. Gestational Diabetes
provided.
Mellitus
Fluid recommendation - 8 to 10 glasses / day of
water except in LVF, CKD, Cirrhosis etc. Gestational Diabetes mellitus is defined as
carbohydrate intolerance of variable severity with
11.1 MNT in Gestational Diabetes onset or first recognition during the present
pregnancy.
Mellitus
12.1 Risk for gestational diabetes
30 kcal / kg Instant Body weight in first trimester
mellitus
30 kcal / kg Instant Body weight + 300 kcal/day
in II and III trimester Age more than 25 years
Protein - 1gm/kg Instant Body weight + 10gm Family history of diabetes mellitus
daily throughout pregnancy
History of unexplained fetal loss
Avoid hypocaloric diets in obese GDM
History of baby being large for gestational age
Provide compulsory bed time and evening snack
to avoid accelerated starvation and nocturnal History of congenitally malformed infant
hypoglycemia Maternal obesity
Gestational Diabetes mellitus:
History of Polycystic ovarian disease
Strict meal plan
Polyhydramnios
Physical exercise
Pre-eclampsia
Insulin
Unexplained intrauterine death
Other specific types
12.2 Methods of screening
Strict meal plan
Physical exercise Spot test: Fasting < 90 mg% [normal 2 hr post-
prandial < 120 mg%, random < 105 mg% values]
Insulin with or without oral hypoglycemic agents
ADA recommendation
Figure-2: Methods of Screening

Page 50
12.3 Diagnostic Criteria Target Glycemic Level

WHO criteria (with 75 gm of glucose ) F - 95 mg % Fasting glucose 90 mg %

1 hr - 180 mg % 2 hr - 155 mg % If any two values 2 hr postprandial 120 mg %

equals or crosses normal value, it is termed as Monitoring Glycemic Control


Gestational Diabetes mellitus. Blood glucose fasting and postprandial every

Important Note OGTT value should never be treated. three days till glycemia is achieved; then every
fortnightly, throughout first and second trimester.
12.4 Treatment Every week in third trimester.
1. Medical Nutrition Therapy [refer MNT] 2. Insulin Glycemic profile monitoring once in 1st and 2nd
is essential if MNT fails to achieve euglycemia trimester and then every month.

Page 51
17. THYROID DISORDERS
* When full replacement is achieved then follow up
1. Hypothyroidism measurement at annual intervals and later by a 2 - 3
yearly interval
Hypothyroidism may be
* Ensure ongoing compliance.
1 Primary 1.4. Special treatment considerations
Common causes of which are autoimmune, iatrogenic
due to Iodine131, antithyroid or lithium treatment A hypothyroid woman should be euthyroid prior
and thyroidectomy to conception and during early pregnancy (effect
on fetal neuronal development). Thyroid profile
2 Secondary should be immediately done after confirmation
of pregnancy and in second and third trimester.
1. Pituitary disease
2. Hypothalamic disease. Dose of Thyroxine should be increased by 50%
during pregnancy and return to previous level
1.1. Symptoms after delivery
Elderly require less Thyroxine (less by upto
Coarse dry skin
20%) especially those with coronary artery
Hoarseness of voice disease, starting dose 12.5 mcg/day with similar
increments every 2 - 3 months until TSH level is
Facial puffiness, weight gain normalized.
Cardiac enlargement and/or pericardial effusion, In hypothyroidism due to low TSH (supra-
thyroid cause is suspected) detailed
Goiter with or without prolonged relaxation investigations are required and patient should be
phase of deep tendon reflexes. referred to a tertiary care level
Myxedema coma is a rare complication of severe Asses the response clinically and by serum TSH
hypothyroidism with hypothermia, hy- (serum T3 in suprathyroid type) at 8 weekly
poventilation, hyponatremia, hypoxia, intervals
hypercapnoea and hypotension. Once euthyroid state is restored, follow-up at 6 -
12 monthly intervals.
1.2. Diagnosis is confirmed by
1.5. Treatment of Myxedema coma
Low serum free T3 and T4
Warm blankets, mechanical ventilation for
Serum TSH raised respiratory failure.
Other investigation blood sugar level and lipid Correction of metabolic disturbances and treat
profile precipitating factors.
Drugs * L-Thyroxine 500 mcg IV bolus, then
1.3. Treatment 50-100mcg IV daily * If intravenous preparation
not available, the same dose is administered
Pharmacological through Ryles tube.
* Tab. L -Thyroxine- 1.6 mcg per kg body weight or * Once acute phase is over, maintain L-Thyroxine
Start with 50 100mcg/day as above.
* Dose to be adjusted based on TSH levels * Inj.Hydrocortisone 100 mg IV stat, 25-50 mg 8
* Goal is normal TSH (lower half of reference range hourly.
* Measure TSH levels after about 6 wks of instituting Caution: Avoid sedatives
therapy
* Adjust by 12.5 or 25 mcg increments if TSH is
high; decrement of the same if TSH is
suppressed.

Page 52
1.6. Patient Education Explain to the patient that the treatment is life
long. Do not modify dose or stop treatment with-
L-Thyroxine should be taken as a single daily out consultation.
dose, ideally on awakening, at least 30 minutes
before breakfast. Over treatment may lead to decreased bone
mineral density and adverse cardiac
Fibre and bran products (e.g., Isapghola husk) complications.
may impair absorption, as also cholestyramine,
cholestipol, iron sulphate, sucralfate, aluminium 2. Hyperthyroidism
hydroxide
Thyrotoxicosis is defined as the state of thyroid
Metabolism of L-Thyroxine is increased by
hormone excess and is not synonymous with
Phenytoin, Rifampicin and carbamazepine.
hyperthyroidism, which is the result of excessive
thyroid function. However, the major etiologies of
thyrotoxicosis are hyperthyroidism caused by Graves'
disease, toxic MNG, and toxic adenomas
2.1. Symptoms

Graves disease is characterized by diffuse goiter, Adjunctive treatment * For adrenergic symptoms
Ophthalmopathy and Dermopathy in varying such as sweating, tremor and tachycardia. Tab.
combinations. Propranalol 40 120 mg a day. Or atenolol 25
mg to 50 mg
Ophthalmopathy in Graves' disease; lid retraction,
periorbital edema, conjunctival injection, and Anti thyroid drug-
proptosis are marked Tab. Propylthiouracil 100 150 mg every 6
8 hours or Tab. Carbimazole 10 20 mg every
2.2. Diagnosis 8 12 hours; After euthyroid state is achieved
in 6 8 weeks once daily dosage. Review with
Diagnosis is confirmed by low to undetectable serum serum TSH and FT3 after 3 4 weeks treatment
TSH and increased Serum free (FT3) and free (FT4) has been initiated.
Once controlled reduce to the smallest effective
Ultra sonography of neck dose or continue initial dose combined with L-
Thyroid scan (if available) Thyroxine
Drugs are given for an average of 2 years.
2.3. Treatment Definitive treatment is surgery/ablation of
thyroid tissue
Pharmacological Subtotal thyroidectomy in younger patients (<30
years) in whom antithyroid therapy has been
unsuccessful and in very large goiters.

Page 53
Radioactive iodine (I131): Method of choice in Treatment with antithyroid drugs given till
* Elderly * Younger patients who have patient is euthyroid.
completed family with recurrent thyrotoxicosis Propranalol may be useful before and after
following surgery or when surgery is refused or radioactive iodine administration.
contraindicated. Caution Radioactive iodine
should never be given in pregnancy. In woman 2.6. Thyrotoxic crisis or thyroid
of childbearing age if radioactive iodine is
planned, a pregnancy test should always be
storm
carried out.
Refer to a tertiary care centre.
2.4. Pregnancy Life threatening hyperthyroidism with fever,
vomiting, diarrhoea, jaundice, delirium and
In pregnant woman surgery should not be coma.
performed in 1st or 3rd trimesters Usually precipitated by acute illness such as
Antithyroid drugs are less risky but may induce stroke, infection, diabetic ketoacidosis, trauma,
hypothyroidism in the foetus and should be used patients undergoing surgery or radioactive iodine
in the smallest necessary dose to keep serum treatment in a poorly prepared patient:
TSH and FT4 in normal range. Tab. Propylthiourcil 600 mg loading dose, then
Propylthiouracil is preferred usual maintenance 200 300 mg every 6 hours orally or through
is 200 mg/day. If > 300 mg/day required during Ryles tube. (or) Tab. Carbimazole 15 25 mg 6
1st trimester, Subtotal thyroidectomy is indicated hourly.
in 2nd trimester 1 hour after the 1st dose of antithyroid drug,
Propranolol should be avoided as it can cause saturated solution of Potassium iodide (SSKI) 5
foetal growth retardation and neonatal drops every 5 hours. (or) Lugols iodine 10 drops
respiratory depression. 3 times a day. (or) Sodium iodide 1 g IV slowly.
Tab. Propranalol 40 60 mg 4 hourly or 0.5 2
Ophthalmopathy: Refer to ophthalmologist. Initiate mg IV every 4 hours.
therapy in mild cases with elevation of head at night, Inj. Dexamethasone 2 mg IV 6 hourly
diuretics to decrease edema, use of tinted sunglasses Continue iodides and dexamethasone until
and 1 % methyl cellulose eye drops to prevent drying normal metabolic stage is achieved and give sup-
and refer patients with severe and progressive portive treatment such as cooling, antipyretics,
exophthalmos to an ophthalmologist. antibiotics for infection, intravenous fluids, etc.
2.5. Toxic multinodular goiter Once euthyroid status is achieved, manage as
already outlined.
Radioactive iodine is the treatment of choice.
Large doses are usually required.

Page 54
18.Cerebrovascular Accidents
sensory aphasia (inability to comprehend) if
1. Definition there is cortical involvement of dominant
A stroke, or cerebrovascular accident, is defined by hemisphere(right side in left handed people, left
this abrupt onset of a neurologic deficit that is side in 90% of right handed people).
attributable to a focal vascular cause. Transient or permanent loss of central vision
due to involvement of ophthalmic artery a
Thus, the definition of stroke is clinical, and branch of internal carotid artery.
laboratory studies including brain imaging are used to
Difficulty in swallowing, speaking due to bulbar
support the diagnosis.
involvement could be a presentation. In cases
The clinical manifestations of stroke are highly where patient has previously had
variable because of the complex anatomy of the brain cerebrovascular accident, fresh infarct now
and its vasculature. TIA (Transient Ischemic Attack) causing bilateral cortical involvement may lead
is a brief episode of neurological dysfunction lasting to dysphagia and dysarthria causing what is
1 hr to 24 hrs without residual deficit. Stroke in known as peudobulbar palsy. On examination in
evaluation means when deficit worsens after patient these patients jaw jerk is brisk.
first presents. Midbrain lesions have ocular involvement.
Cerebral ischemia is caused by a reduction in blood Sensory involvement occurs in stroke involving
thalamus or medulla.
flow that lasts longer than several seconds. If the
cessation of flow lasts for more than a few minutes, The neurological deficit may be preceeded by
infarction or death of brain tissue results. When tingling numbness.
blood flow is quickly restored, brain tissue can TIA - Transient Ischaemic Attack is a
recover fully and the patient's symptoms are only neurological deficit that recovers completely
transient. within 24 hours.
A focal deficit progressing over a period of
Focal ischemia or infarction, conversely, is usually hours and is characteristic of thrombotic. stroke.
caused by thrombosis of the cerebral vessels Any focal deficit preceded by a prolonged
themselves or by emboli from a proximal arterial headache could be due to infarct with
source or the heart. haemorrhagic conversion secondary to cerebral
Intracranial hemorrhage is caused by bleeding venous sinuous thrombosis.
directly into or around the brain; it produces Focal deficit could be accompanied by
neurologic symptoms by producing a mass effect on convulsions.
neural structures, from the toxic effects of blood
itself, or by increasing intracranial pressure. 3. Examination
Patient may have bradycardia if he is on beta
2. Clinical features blockers or due to raised intractanial pressure
Most of the patients are elderly. secondary to cerebral oedema.
There could be a history of hypertension, Blood pressure should be recorded and
diabetes, ischaemic heart disease monitored.
Past history of cerebrovascular accident may be The power of all 4 limbs should be graded and
present. any improvement or deterioration in the power
Hemiplegia or hemiparesis: Paralysis or should be recorded.
weakness of right or left half of the body with Reflexes on the involved side are brisk and
deviation of one side of the face seen. plantar reflex is extensor on the involved side.
Lower limb monoparesis or monoplegia. History of headache, altered sensorium, fever,
Faciobrachial stroke : involving right or left vomiting.
upper limb along with ipsilateral facial
weakness. 4. Investigations
Rarely bilateral lower limb weakness in Non contrast CT scan brain to differentiate
unpaired anterior cerebral artery thrombosis. between infarct and haemorrhage and site of
Hemiplegia or hemiparesis may be accompanied lesion.
by motor aphasia(patient unable to speak) or Routine investigations like HB,CBC,ESR, liver

Page 55
function test , renal function test, serum started in cases of cerebral infarction. As
electrolytes, fasting and post prandial glucose, intracranial bleed is ruled out.
complete lipid profile. Tab atorvastatin 40mg OD H.S.
ECG, X- ray chest, 2D echo especially in young Antiepileptics (inj Eptoin 100mg tds) if
patients to rule out cardiac source of embolism. convulsions are present. But in case the bleed is
Ideally MR angiography in cases of infarction to large and if the patient is going to be shifted to a
look for the stenosis in intracranial vessels. higher centre it may be advisable to give anti-
SOS MR venography if any doubt of cerebral epileptics as the patients general condition might
venous thrombosis. worsen if he gets a convulsion.
Half an hour before ryles tube feeding
5. Complications Domperidom should be administered. Ryles
tube feeding in strict propped up position.
Aspiration pneumonia Inj. Heparin (5000 IU IV bolus and then once a
Deep vein thrombosis in lower limb day to keep PT (INR) 2 to 3 times of normal
complicating further as pulmonary embolism. value) for prophylaxis of deep vein thrombosis
Bed sore in cases of cerebral infarction (not in intracranial
bleed) in patient of hemiplegia.
6. Treatment Physiotherapy.
Blood pressure, blood glucose and temperature Early detection and treatment of complications.
of patients of acute cerebral infarction should be
controlled. 7. When to refer
Anti - hypertensive medication. A blood All young patients of stroke, intracranial bleed
pressure of 150/90 mmhg can be maintained or infarction.
initially to prevent cerebral ischaemia due to Patients diagnosed with cerebral venous
hypoperfusion. thrombosis.
IV Mannitol 100cc 8 hourly in cases of Subarachnoid haemorrhage if seen on the CT.
intracerebral bleed, in large infarcts, brainstem Patient suspected to have AV malformation.
infarction, cerebellar lesions and all patient
Large intracerebral bleeds who might require
having altered sensorium. Serum electrolytes
evacuation to be transferred after stabilizing
and urine output should be monitored (on
blood pressure.
mannitol.)
Tab Aspirin 75-150 mg od after lunch should be

Page 56
19. SUBARACHNOID HEMORRHAGE (SAH)

Excluding head trauma, the most common cause of A detailed history should be sought for use of oral
SAH is rupture of a saccular aneurysm. Other causes contraceptive pills in young females to rule out SAH
include bleeding from a vascular malformation secondary to cerebral venous thrombosis as could
(arteriovenous malformation or dural arterial-venous occur in any procoagulant state.
fistula) and extension into the subarachnoid space
from a primary intracerebral hemorrhage. 2. Investigations
1. Clinical features CT brain, MRI angiography and MRI venography to
rule out cerebral venous thrombosis which could
Most unruptured intracranial aneurysms are present as subarachnoid haemorrhage.
completely asymptomatic. Symptoms are usually due
to rupture and resultant SAH, although some 3. Treatment: Subarachnoid
unruptured aneurysms present with mass effect on
cranial nerves or brain parenchyma. At the moment
Hemorrhage
of aneurysmal rupture with major SAH, the ICP 1. Protecting the airway.
suddenly rises. This may account for the sudden
transient loss of consciousness that occurs in nearly 2. Managing blood pressure before and after
half of patients. Sudden loss of consciousness may be aneurysm treatment, with antihypertensive agent.
preceded by a brief moment of excruciating Preventing rebleeding prior to treatment.
headache. 3. Managing vasospasm, treating hydrocephalus.
The most important characteristic is sudden onset or 4. Maintaining electrolyte balance and hydration
as a change in the patient's usual headache pattern.
The headache is usually generalized, often with neck 5. IV mannitol 100cc 8 Hourly to treat raised Intra
stiffness and vomiting is common. cranial pressure.

Although sudden headache in the absence of focal 6. Treatment with the calcium channel
neurologic symptoms is the hallmark of aneurysmal antagonist nimodipine (60 mg PO every 4 h)
rupture, focal neurologic deficits may occur. The improves outcome, perhaps by preventing
deficits that result can include hemiparesis, aphasia, ischemic injury rather than reducing the risk of
and abulia. vasospasm.

Occasionally, prodromal symptoms suggest the 7. Volume expansion helps prevent hypotension,
location of a progressively enlarging unruptured augments cardiac output, and reduces blood
aneurysm. viscosity by reducing the hematocrit. This
method is called "triple-H" (hypertension,
A third cranial nerve palsy, particularly when haemodilution, and hypervolemic) therapy.
associated with pupillary dilation, loss of ipsilateral
(but retained contralateral) light reflex, and focal pain 8. Acute hydrocephalus can cause stupor or coma.
above or behind the eye, may occur with an It may clear spontaneously or require temporary
expanding aneurysm at the junction of the posterior ventricular drainage. When chronic
communicating artery and the internal carotid artery. hydrocephalus develops, ventricular shunting
Visual field defects can occur with an expanding is the treatment of choice.
supraclinoid carotid or anterior cerebral artery
aneurysm. 4. When to refer
Aneurysms can undergo small ruptures and leaks of A patient diagnosed to be having SAH should be
blood into the subarachnoid space, so-called sentinel transferred to a higher centre at the earliest after
bleeds. Sudden unexplained severe headache at any stabilizing blood pressure for further management.
location should raise suspicion of SAH and be
investigated, because a major hemorrhage may be
imminent.

Page 57
20. PYOGENIC MENINGITIS

Meningitis is a serious disease in which there is On examination meningial signs are positive.
inflammation of the meninges that cover the brain
and spinal cord. Meningeal signs (Can be found in any type of
meningitis)
Bacterial meningitis can be deadly and contagious
among people in close contact. i. Neck stiffness: Stiffness of neck & resistance to
passive movements, with pain & spasm on attempted
Viral meningitis tends to be less severe and most motion. The chin cannot be placed upon the chest.
people recover completely.
ii. Kernigs sign:
Fungal meningitis is a rare form of meningitis and
generally occurs only in people with weakened With the hip flexed, the knee is extended.
immune system. Normally it can be done up to 135 degree. In
meningitis it is restricted due to spasm of
hamstrings.
1. Clinical Presentation
iii. Brudzinskis sign:
Meningitis can present as either an acute
fulminant illness that progresses rapidly in a Neck sign- on flexing the neck, there is flexion
few hours or as a subacute infection that of hips & knees.
progressively worsens over several days.
Leg sign- on flexing one leg, other leg also
The classic clinical triad of meningitis is fever, flexes.
headache, and nuchal rigidity. Nausea, iv. Straight leg raising test (SLR):
vomiting, and photophobia are also common
complaints. With the patient supine & both legs extended, one leg
is passively flexed at the hip keeping the knee
Seizures occur as part of the initial presentation extended. Normally it can be lifted up to 90 degree. It
of bacterial meningitis or during the course of is restricted in meningitis.
the illness in 2040% of patients. Generalized
seizure activity and status epilepticus may be due
to hyponatremia, cerebral anoxia.
2. Diagnosis
CSF Studies
Raised Intracranial Pressure (ICP) is an
expected complication of bacterial meningitis The classic CSF abnormalities in bacterial meningitis
and the major cause of obtundation and coma in are (1) polymorphonuclear (PMN) leukocytosis
this disease. (>100 cells/L in 90%), (2) decreased glucose
concentration [<2.2 mmol/L (<40 mg/dL) and/or
Signs of increased ICP include a deteriorating CSF/serum glucose ratio of <0.4 in 60%,hence it is
or reduced level of consciousness, mandatory that a blood glucose levels be estimated
papilledema, dilated poorly reactive pupils, simultaneously with the CSF study], (3) increased
sixth nerve palsy, decerebrate posturing. protein concentration [>0.45 g/L (>45 mg/dL) in
Cushing reflex (bradycardia, hypertension, 90%], and (4) increased opening pressure (>180
and irregular respirations). mmH2O in 90%). CSF bacterial cultures are positive
in >80% of patients, and CSF Gram's stain
The rash of meningococcemia for demonstrates organisms in >60%
meningococcal meningitis, which begins as a
diffuse erythematous maculopapular rash 3. Treatment
resembling a viral exanthem; however, the skin
lesions of meningococcemia rapidly become i. Intravenous fluids.
petechial. Petechiae are found on the trunk and ii. Inj Mannitol 100mg 8 hourly to 6 hourly.
lower extremities, in the mucous membranes and iii. Inj Dexamethasone 4mg 8 hourly but first
conjunctiva, and occasionally on the palms and dose to be given 20 minutes before first dose
soles. of antibiotics.

Page 58
iv. Antimicrobial therapy of For gram-negative bacillary meningitis, the
third-generation cephalosporins - cefotaxime
(Ceftriaxone 2g twice a day intravenously,
(2gm 4 hourly i.e. total 12 gm per day),
cefotaxime, or cefepime) A 2-week course of
intravenous antimicrobial therapy is ceftriaxone (2gms 12 hourly), and ceftazidime
recommended for pneumococcal meningitis. (2gms 8 hourly) - are efficacious for the
treatment of, with the exception of meningitis
Or ampicillin IV 2 gm 4 hourly (total 12 gm per due to P. aeruginosa, which should be treated
day) for at least 3 weeks. Gentamicin is added in with ceftazidime, cefepime, or meropenem.
critically ill patients (2 mg/kg loading dose, then (2gms 8 hourly). A 3-week course of
7.5 mg/kg per day given every 8 hrs. and intravenous antibiotic therapy is recommended
adjusted for serum levels and renal function). for meningitis due to gram-negative bacilli.
The combination of Trimethoprim (1020
mg/kg per day) and Sulfamethoxazole (50100 4. When to refer
mg/kg per day) given every 6 h may provide an
alternative in penicillin-allergic patients. i. Lumbar puncture requires to be done and facility
not available.
Vancomycin 2g 12 hourly is the drug of choice
ii. Presence of any focal deficit.
for methicillin-resistant staphylococci and for
patients allergic to penicillin. (3 weeks). Note: If meningitis is suspected empirical antibiotic
treatment has to be started immediately.

Page 59
21. TUBERCULOUS MENINGITIS

1. Clinical Manifestations 3. Treatment


The disease often presents subtly as headache IV fluids
and slight mental changes after a prodrome of Inj. Mannitol 100cc thrice a day to four times a
weeks of low-grade fever, malaise, anorexia, and day, should be tapered and stopped to be
irritability. overlapped with oral glycerol 1oz three times a
If not recognized, tuberculous meningitis may day. Patient may have worsening of headache or
evolve acutely with severe headache, confusion, get signs of raised ICT, mannitol should be
lethargy, altered sensorium, and neck rigidity. reinstituted and tapered again.
Typically, the disease evolves over 12 weeks, a For treatment of tubercular meningitis, first-line
course longer than that of bacterial meningitis. drugs are Isoniazid (5mg/kg) along with
Since meningeal involvement is pronounced at pyridoxine 50mg, Rifampin(10mg/kg) given
the base of the brain, paresis of cranial nerves before breakfast, Pyrizinamide (25 mg/kg), and
(ocular nerves in particular) is a frequent finding, Ethambutol (15 mg/kg).
and the involvement of cerebral arteries may Duration of treatment is upto 9 months to 1 year.
produce focal ischemia. Steroids are given as Inj. Dexamethasone 4mg
The ultimate evolution is toward coma, with three times a day for 3 weeks to be continued as
hydrocephalus and intracranial hypertension. Tab Prednisolone 1mg/kg and tapered and
omitted over 1 and a half months duration.
2. Diagnosis
CSF Studies
4. Complications
Hydrocephalous.
In adults, the mean white blood cell (WBC) count
(range, 0-4000 cells/L) with lymphocytic Vasculitis induced stroke.
predominance. The mean protein level in adults Drug induced hepatitis.
averages 224 mg/dL (range, 20-1000 mg/dl). The
proportion with depressed glucose levels (< 45
mg/dL or 40% of serum glucose). 5. When to refer
Patient having any focal deficit.
Diminution of vision.
Patient not improving on treatment.

Page 60
22. VIRAL MENINGITIS
Constitutional signs can include malaise,
1. Clinical features myalgia, anorexia, nausea and vomiting,
Immuno compromised adult patients with viral abdominal pain and/or diarrhea.
meningitis usually present with. Patients often have mild lethargy or drowsiness;
however, profound alterations in consciousness,
Headache, fever, and signs of meningeal such as stupor, coma, or marked confusion do
irritation coupled with an inflammatory CSF not occur in viral meningitis and suggest the
profile. presence of encephalitis or other alternative
Headache is almost invariably present and often diagnoses.
characterized as frontal or retroorbital and
frequently associated with photophobia and pain
on moving the eyes.

2. Etiology
Acute Meningitis

Common Less Common

Enteroviruses (coxsackieviruses, echoviruses, and human Lymphocytic choriomeningitis virus


enteroviruses 6871)

Varicella zoster virus Cytomegalovirus

Epstein-Barr virus

Herpes simplex virus 2

Arthropod-borne viruses

HIV

Acute Encephalitis

Common Less Common

Herpesviruses Rabies

Herpes simplex virus 1 Powassan virus

Varicella zoster virus (VZV) Enteroviruses

Epstein-Barr virus (EBV) Mumps

Arthropod-borne viruses

Cytomegalovirus

Table No.1- Etiology

Page 61
Fluid and electrolyte status should be monitored.
3. Diagnosis IV fluids should be administered.
The most important laboratory test in the diagnosis of Oral or intravenous acyclovir may be of benefit
viral meningitis is examination of the CSF. The in patients with meningitis caused by Herpes
typical profile is a lymphocytic pleocytosis (25500 simplex virus -1 or -2 and in cases of severe
cells/L), a normal or slightly elevated protein Epstein-Barr virus or Varicella zoster virus
concentration [0.20.8 g/L (2080 mg/dL)], a normal infection. Seriously ill patients should receive
glucose concentration, and a normal or mildly intravenous acyclovir (1530 mg/kg per day in
elevated opening pressure (100350 mmH2O). three divided doses for 7-10 days i.e. which can
be followed by an oral drug such as acyclovir
4. Treatment: Acute Viral (800 mg, five times daily. Patients with HIV
meningitis should receive highly active
Meningitis antiretroviral therapy).
Treatment of almost all cases of viral meningitis
is primarily symptomatic and includes use of
analgesics, antipyretics, and antiemetics.

Page 62
23. VIRAL ENCEPHALITIS
In rare cases, a pleocytosis may be absent on the
1. Definition initial LP but present on subsequent LPs.
In contrast to viral meningitis, where the infectious
Patients who are severely immunocompromised
process and associated inflammatory response are
by HIV infection, glucocorticoid or other
limited largely to the meninges, in encephalitis the
immunosuppressant drugs, chemotherapy, or
brain parenchyma is also involved. Many patients
lymphoreticular malignancies may fail to mount
with encephalitis also have evidence of associated
a CSF inflammatory response.
meningitis (meningoencephalitis) and, in some cases,
involvement of the spinal cord or nerve roots CSF cell counts exceed 500/L in only about 10%
(encephalomyelitis, encephalomyeloradiculitis). of patients with encephalitis. Infections with
certain arboviruses (e.g., EEE virus or California
2. Clinical Manifestations encephalitis virus), mumps, and LCMV may
In addition to the acute febrile illness with evidence occasionally result in cell counts >1000/L, but
of meningeal involvement characteristic of this degree of pleocytosis should suggest the
meningitis, the patient with encephalitis commonly possibility of nonviral infections or other
has an altered level of consciousness (confusion, inflammatory processes.
behavioral abnormalities), or a depressed level of
Atypical lymphocytes in the CSF may be seen in
consciousness ranging from mild lethargy to coma,
EBV infection and less commonly with other
and evidence of either focal or diffuse neurologic
viruses, including CMV, HSV, and
signs and symptoms.
enteroviruses.
Patients with encephalitis may have hallucinations,
agitation, personality change, behavioral disorders, However, persisting CSF neutrophilia should
and, at times, a frankly psychotic state. Focal or prompt consideration of bacterial infection,
generalized seizures occur in many patients with leptospirosis, amoebic infection, and
encephalitis. noninfectious processes such as acute
hemorrhagic leukoencephalitis. About 20% of
Virtually every possible type of focal neurologic patients with encephalitis will have a significant
disturbance has been reported in viral encephalitis; number of red blood cells (>500/L) in the CSF in
the signs and symptoms reflect the sites of infection a nontraumatic tap. The pathologic correlate of
and inflammation. this finding may be a hemorrhagic encephalitis
of the type seen with HSV; however, CSF red
The most commonly encountered focal findings are
blood cells occur with similar frequency and in
aphasia, ataxia, upper or lower motor neuron patterns
similar numbers in patients with nonherpetic
of weakness, involuntary movements (e.g.,
focal encephalitis.
myoclonic jerks, tremor), and cranial nerve deficits
(e.g., ocular palsies, facial weakness). A decreased CSF glucose concentration is
distinctly unusual in viral encephalitis and
3. Laboratory Diagnosis should suggest the possibility of bacterial,
3.1. CSF Examination fungal, tuberculous, parasitic, leptospiral,
CSF examination should be performed in all syphilitic, sarcoid, or neoplastic meningitis.
patients with suspected viral encephalitis unless
contraindicated by the presence of severely
3.2. MRI, CT, EEG
increased intracranial pressure (ICP). Patients with suspected encephalitis almost
invariably undergo neuroimaging studies and
The characteristic CSF profile is often EEG. These tests help identify or exclude
indistinguishable from that of viral meningitis alternative diagnoses and assist in the
and typically consists of a lymphocytic differentiation between a focal, as opposed to a
pleocytosis, a mildly elevated protein diffuse, encephalitic process.
concentration, and a normal glucose
concentration. A CSF pleocytosis (>5 cells/L) Focal findings on MRI in a patient with
occurs in >95% of immunocompetent patients encephalitis should always raise the possibility
with documented viral encephalitis. of HSV encephalitis. Approximately 10% of
patients with PCR-documented HSV encephalitis

Page 63
will have a normal MRI, although nearly 80% Prior to intravenous administration, acyclovir should
will have abnormalities in the temporal lobe, and be diluted to a concentration 7 mg/mL. (A 70-kg
an additional 10% in extratemporal regions. person would receive a dose of 700 mg. which would
be diluted in a volume of 100 mL.) Each dose should
4. Treatment be infused slowly over 1 h, rather than by rapid or
Vital functions, including respiration and blood bolus infusion, to minimize the risk of renal
pressure, should be monitored continuously and dysfunction. Care should be taken to avoid
supported as required. In the initial stages of extravasation or intramuscular or subcutaneous
encephalitis, many patients will require care in an administration. The alkaline pH of acyclovir can
intensive care unit. cause local inflammation and phlebitis (9%). Dose
adjustment is required in patients with impaired renal
i. Intravenous fluids. glomerular filtration. Penetration into CSF is
ii. IV mannitol 100cc 12 hourly for 3 days excellent, with average drug levels 50% of serum
levels. Complications of therapy include elevations in
Seizures should be treated with standard blood urea nitrogen and creatinine levels (5%),
anticonvulsant regimens (Inj. Diazepam 10 mg, thrombocytopenia (6%), gastrointestinal toxicity
IV or Inj. Midazolam 2mg), and prophylactic (nausea, vomiting, diarrhea) (7%), and neurotoxicity
therapy should be considered in view of the high (lethargy or obtundation, disorientation, confusion,
frequency of seizures in severe cases of agitation, hallucinations, tremors, seizures) (1%).
encephalitis.
iv. Antipyretics for fever
iii. Acyclovir is of benefit in the treatment of HSV
and should be started empirically in patients with
suspected viral encephalitis, especially if focal
5. Complications
Aspiration pneumonia, stasis ulcers and decubitus
features are present, while awaiting viral
ulcer, contractures, deep venous thrombosis and its
diagnostic studies. complications, and infections of indwelling lines and
Adults should receive a dose of 10 mg/kg of catheters.
acyclovir intravenously every 8 h (30 mg/kg per
day total dose) for 1421 days. 6. When to refer
Ideally all suspected patients of viral encephalitis
CSF PCR can be repeated at the completion of this
after starting therapy as mentioned above and patients
course, with PCR-positive patients receiving
of viral meningitis not improving over or worsening
additional treatment, followed by a repeat CSF PCR
over 48 hours should be referred to a higher centre.
test.

Page 64
24. EPILEPSY

1. Definition 3. Investigations
This is a condition characterized by recurrent
Apart patients of epilepsy can be further
episodes of seizures which are paroxysmal abnormal
investigated with an EEG and MRI. from routine
discharges at high frequency from an aggregate of
laboratory investigations.
neurons in cerebral cortex.
4. Treatment
2. Types of epilepsy 1. Correct any metabolic cause (hypo or
2.1 Grand mal epilepsy or Tonic-Clonic Seizures-
hyperglycaemia, hypo or hypernatremia).
Aura, epileptic cry, sudden fall due to tonic
2. Stop drugs like theophylline (CNS Stimulant)
convulsions followed by clonic convulsions
which may cause seizures.
and then prolonged sleep and depression. The
3. Look for any structural CNS lesions like Brain
attack lasts for 1-2 min. Tongue bite, urinary
tumour, vascular lesions, meningitis, CVST or
incontinence may occur.
abscess and treat them.
2.2 Petit mal epilepsy or Absence seizures - No
4. Avoid precipitating factors like sleep
aura, no loss of consciousness. Prevalent in
deprivation, Fasting, video games.
children and episode lasts for few seconds.
There is momentary loss of consciousness 4.1 Antiepileptic should be started
hardly for 5 sec without loss of postural
control. Presence of freezing or staring in one when
direction. 1. A history suggestive of recurrent epileptic
2.3 Partial seizures- Most common seizure types seizure is established.
occurring in 80% of epileptic patients. Seizure 2. An abnormal neurological examination.
activity is restricted to a discrete area 3. Presenting as status Epilepticus.
belonging to one cerebral hemisphere only. 4. Abnormal EEG suggestive of general seizure.
2.4 Other types of seizures: Myoclonic seizures, 5. Family history of epilepsy.
Atonic seizures, tonic seizures.
To start anti epileptics in single isolated seizure is not
2.5 Febrile seizures- Young children develop yet established. Monotherapy should be the mantra of
seizures during high fever. treatment.

4.2 Anti epileptic drugs


Table No.1: Antiepileptic Drugs & their Doses with type of seizure

Seizure Drug Dose


Generalized onset tonic clonic Valproic acid 750-2000mg/day
convulsions
(20-60mg/kg/day)
In divided doses
Phenytoin 300-400mg/day
(3-6mg/kg/day for adult, 4-8mg/kg/day for
Children) BD doses
1 gm 3gm per day
Levetiracetam
1000-3000mg/day BD doses
Lamotrigine
150-500mg/day, BD doses
Topiramate

Page 65
Focal onset tonic clonic Carbamezapine 600-1800mg/day (15-35mg/kg, child) in BD
convulsions doses
Lamotrigine
Same as Above
Levetiracetam
Same as Above
Oxcarbazepine
900-2400mg/day (30-45mg/kg, child) BD
doses
Typical Absence Valproic acid Same as Above
Ethosuximide 750-1250mg/day in BD doses, 20 40 mg
per kg divided in BD doses
Atypical Absence, myoclonic, Valproic Acid, Same as Above
Atonic Seizures Lamotrigine, Topiramite
Same as Above

Phenytoin 15-20 mg/kg, at a rate not to exceed 50


5. Status Epilepticus mg/min (Never mix Phenytoin with a 5% dextrose
Status Epilepticus refers to continuous seizures or solution) put it in a normal saline solution to
repetitive discrete seizures with impaired minimize the risk of crystal precipitation or
consciousness in the interictal period for duration of fosphenytoin 20mg/kg iv to maximum
15-30 minutes traditionally but practically for 150mg/minute.
generalized convulsive status Epilepticus the duration Correct any metabolic imbalances. Control
is 5 minutes. hyperthermia.
It is a medical emergency and must be treated If seizures continue after 20 minutes, give maximum
immediately. rate 50mg/minute or Fosphenytoin 7 to 10 mg/kg to
Monitor vital signs. Maintain airway, breathing, and maximum rate of 150mg/minute.
circulation. Administer supplemental oxygen by If seizures continue after 20 minutes, give
mask. Phenobarbital (20 mg/kg IV at 60 mg/min)
Laboratory analysis-glucose, electrolytes, calcium, Other Antiepileptic Drugs which can be given IV are
magnesium, creatinine, CBC and urine analysis. - Valproate sodium 30mg/kg IV bolus or IV
Establish intravenous access. Levetiracetam 10-50mg/kg
Lorazepam (0.1 mg/kg) IV over 1-2 min, Repeat if no If seizures continue, consider administering general
response after 5 minutes. anesthesia with medications such as propofol,
midazolam, or pentobarbital.
Figure-1: Management of Status Epilepticus algorithm

Page 66
Figure 2: Pharmacological treatment algorithm of non-convulsive status epileptics

Lorazepam (0.1, 0.15 mg/IV) (repeat once if no Admit to ICU and EEG monitoring
seizure supprenssion

Seizures continuing

Phenytoin (7-10 mg/kg Iv) or Fosphenytoin Consider valproate in absence SE (30


(Phenytoin equivalent dose) mg/kg IV)

Seizures continuing

Phenytoin (7-10 mg/kg Iv) or Fosphenytoin (Phenytoin equivalent Consider valproate in absence SE (30
dose) mg/kg IV)

Refractory NCSE

Intravenous anesthetic agents


Midazolam/propofol/pentobarbital

Seizures continuing

Newer AEDs - Topiramate/Ievetiracetam

or

Inhalational anesthestics - Isoflurance/desflurance

All the Patients after initial IV Antiepileptic Drug should be followed by maintenance doses with the oral
antiepileptic drugs regularly.

Page 67
25. GUILLAIN-BARRE SYNDROME (GBS)

1. Definition 4. Investigations
Guillain-Barre syndrome (GBS) is an acute, CSF analysis by lumbar puncture by the end of first
frequently severe, and fulminant polyradiculopathy week Elevated CSF protein 100-1000mg/dl without
that is autoimmune in nature. pleocytosis called as albumino cytological
dissociation.
2. Clinical Features Can refer for electrodiagnosis- Demyelination or
GBS manifests as rapidly evolving areflexic motor axonal involvement seen according to the variant
paralysis with or without sensory disturbance. Usual type
pattern is an ascending paralysis. Weakness typically
evolves over hours to a few days and frequently 5. Treatment
accompany by tingling dysesthesias in extremities.
Treatment should be initiated at the earliest. Each day
Legs are usually more affected than arms. Facial
counts. >2 weeks after the first motor symptoms,
diparesis is present in 50% of affected individuals.
immunotherapy is no longer effective. Either high
The lower cranial nerves are also frequently
dose intra-venous immune globulin (IVIg) or
involved, causing bulbar weakness with difficulty
plasmapheresis can be initiated, as they are equally
handling secretions and maintaining airway. Pain in
effective.
the neck, shoulder or back is also common in the
early stages. 1. Intra-venous immune globulin (IVIg): Total dose
of 2g/kg body weight divided into 5 doses given
Fever and constitutional symptoms are absent at the
over 5 consecutive days.
onset, and if present cast a doubt on the diagnosis.
2. Plasmapheresis: 40-50ml/kg plasma exchange
Deep tendon reflexes disappear within the first few
four times over a week.
days of onset. Bladder dysfunction may occur in
In the worsening phase of GBS, most patients require
severe cases but is usually transient. Autonomic
monitoring in a critical care setting, with particular
involvement is common, usually presenting as wide
attention to vital capacity, heart rhythm, blood
fluctuation in blood pressure, postural hypotension &
pressure, nutrition, DVT prophylaxis and chest
cardiac dysrhythmias.
physiotherapy. Nearly 30% of patients with GBS
Approximately 70% of cases of GBS occur 1-3 require ventilator assistance.
weeks after an acute infectious process, usually
respiratory or gastro-intestinal. 6. When to refer: Any of the
3. Differential diagnosis following
The diagnosis is made by recognizing the pattern of Single breath count 12/min

rapidly evolving paralysis with areflexia, absence of
fever or other systemic symptoms, and characteristic Respiratory failure.
antecedent events. Other disorders that may enter into
the differential diagnosis include:
Fulminant quadriparesis.

Acute myelopathies prolonged back pain and


Poor Gag reflex with risk of aspiration.
sphincter disturbances. Autonomic dysfunction
Botulism pupillary reactivity lost early. Recurrent GBS.
Poliomyelitisfever and meningismus is common.

Page 68
26. APTHOUS ULCERS
Important note Repeated ulcers at the same site or
1. Introduction slow healing ulcers with systemic symptoms eg,
Recurrent aphthous stomatitis (RAS) is a common uveitis, arthritis, fever adenopathy are
condition, restricted to the mouth, that typically starts worrisome.Malignancy should be excluded.
in childhood or adolescence as recurrent small,
round, or ovoid ulcers with circumscribed margins, 4. Treatment
erythematous haloes, and yellow or gray floors. A
positive family history of similar ulcers is common, 4.1 Topical and systemic
and the natural history is typically of resolution in the antibiotics
third decade of life.
Tetracycline 250 mg dissolved in 180 ml of water
and used as swish andspit 4 times a day for several
2. Causes days.Avoid in children and pregnancy.
2.1. Some RAS cases involve a familial and genetic 4.2Probiotics in powder form
basis; approximately 40% of patients with RAS
have a familial history, but inheritance may be placed in oral cavity and
polygenic with penetrance dependent on other swallowed 3 -4 times a day
factors.
2.2. Most relevant studies have found hematinic 4.3 Antiinflammatory
(e.g. iron, folic acid, vitamin B-12) deficiencies
in as many as 20% of patients with recurrent Hydrocortisone pellets 5 mg kept at ulcer base and
ulcers. In addition, deficiencies of vitamins B-1, swallowed every 4 hrs for 3-4 days.Triamcinolone
B-2, and B-6 have been noted in some patient 0.1 % applied to ulcers 2-4 times a day.
cohorts. Betamethasone (Betnesol) mouthwash -0.5 mg tab
dissolved in 5-10 ml of water for mouth wash 6 hrly
during attack.
3. Symptoms
4.4 Immune modulators
Significant pain while chewing food. Minor
apthae are recurrent, painful, single or multiple,
Levamisole 50 mg twice a day
shallow surrounded by erythematous mucosa for three consecutive days for 4
anywhere in the oral cavity. Small ulcers heal weeks, no medication for 2
without scar, while larger and deep ulcers leave a
scar. weeks; then levamisole 150 mg
Fever, adenopathy, gastrointestinal sympyoms
tab, half tab twice daily for 3
are typically absent. days for 2 weeks.

Page 69
27. OESOPHAGEAL CANDIDIASIS

1. Introduction
Oesophageal candidasis is an oppurtunistic infection AIDS, postchemotherapy, uncontrolled diabetes
of the oesophagus by Candida albicans. Occurs in mellitus, chronic steroid therapy.
immune compromised patients like

Figure 1: Endoscopic view of Oesophageal Candidiasis

2.Signs and symptoms 4. Treatment


Oral lesions are painless but oesophageal lesions Nysyatin suspension local application in mouth.
produce painful dysphagia.Discrete or confluent
curdy plaques on the oesophageal mucosa. Clotrimazole oral lozenges 10 mg dissolve 1
lozenge 5 times a day.
3. Investigations Tab flucanozole 100 mg/day for 10-14 days.

Demonstration of pseudohyphae on wet smears and


culture.

Page 70
28. DYSPEPSIA

1. Introduction 5. Treatment
Non specific group of symptoms related to upper Cap Omeperazole 20 mg once a day taken 45
GITract. Also reffered to as non-ulcer dyspepsia, min before breakfast for 4 weeks. or Tab
functional dyspepsia, GERD. Ranitidine 150mg twice a day before food 45
mins for 4-6 weeks.
2. Symptoms For those with dysmotility symptoms-tab
Domperidone 10 mg three times a day 30 mins
Upper abdominal symptoms simulating an ulcer
before food.
disease or heart burn with or without regurgitation,
heaviness, post-prandial fullness or early Antacids 2-3 teaspoon when symptomatic.
satiety.Symptoms of gas in abdomen is common.
Anti H.Pylori treatment is recommended for
those on long term NSAIDS, those with
3. Red flag signs duodenal/gastric ulcers.
Anorexia, weight loss, anemia, dysphagia and mass Treatment of H Pylori- Combination of
in abdomen.
Cap. Omeperazole 20 mg twice a day plus
4. Investigations Cap. Amoxicillin 1gm bd or Tab. Metronidazole
500mg bd for 14 days plus
History and upper GI scopy.
Tab clarithromycin 500mg bd for 14 days

Page 71
29. GASTROOESOPHAGEAL REFLUX

1. Introduction 3. Treatment
GERD is a common disorder caused by retrograde Antacid with or without alginate acid liquid or
flow of gastric contents through an incompetentent tab 2-3 chewed- 4-6 times a day1/2-1 hr after a
gastroesophageal junction.There are two groups- meal.
erosive GERD and non erosive GERD. Untreated
may result in to oesophagitis, ulceration, stricture, Cap. Omeperazole 20 mg OD/BD OR
and rarely adenocarcinoma. Rabeprazole 20mg OD or Pantoprazole 40mg
OD.
2. Symptoms Esomeprazole 40mg OD, OR

Retrosternal pain, heart burn, regurgitation mostly Lansoprazole 30mg OD.


after meals. Rarely present with chronic cough, All taken 45 mins before meals for 4-6 weeks.
laryngitis, bronchospasm, recurrent
pulmonaryinfections, otitis media etc. Add prokinetic Domperidone10 mg thrice a day
30 mins before meals if regurgitation is
significant.

Page 72
30. PEPTIC ULCER DISEASE

a posterior penetrating gastric ulcer


1. Introduction complicated by pancreatitis.
Peptic ulcer is an important organic gastrointestinal
disease.
4. Alarm features that warrant
prompt gastroenterology
2. Etiology
referral include the
Peptic ulcer disease (PUD) may be due to any of the
following: following
H pylori infection Bleeding or anemia
Drugs Early satiety
Lifestyle factors Unexplained weight loss
Severe physiologic stress Progressive dysphagia or odynophagia
Hypersecretory states (uncommon) Recurrent vomiting
Genetic factors Family history of GI cancer
There is ulceration of the gastric and duodenal
mucosa due to acid and pepsin. 5. Physical Examination
In uncomplicated PUD, the clinical findings are few
3. Clinical features and nonspecific and include the following:

3.1 Obtaining a medical history, especially for


Epigastric tenderness (usually mild)
peptic ulcer disease, H pylori infection,
ingestion of NSAIDs, or smoking, is essential Right upper quadrant tenderness may suggest a
in making the correct diagnosis. Gastric and biliary etiology or, less frequently, PUD.
duodenal ulcers usually cannot be
Guaiac-positive stool resulting from occult blood
differentiated based on history alone, although
loss
some findings may be suggestive.
Malena resulting from acute or subacute
3.2 Epigastric pain is the most common symptom gastrointestinal bleeding
of both gastric and duodenal ulcers. It is
characterized by a gnawing or burning 6. Differential Diagnosis
sensation and occurs after mealsclassically,
shortly after meals with gastric ulcer and 2-3
hours afterward with duodenal ulcer. Food or Acute Coronary Syndrome
antacids relieve the pain of duodenal ulcers but
Aneurysm, Abdominal
provide minimal relief of gastric ulcer pain.
Cholangitis
3.3 Duodenal ulcer pain often awakens the patient
at night. About 50-80% of patients with Cholecystitis
duodenal ulcers experience nightly pain, as Cholecystitis and Biliary Colic in Emergency
opposed to only 30-40% of patients with Medicine
gastric ulcers and 20-40% of patients with
nonulcer dyspepsia (NUD). Pain typically Cholelithiasis
follows a daily pattern specific to the patient.
Diverticular Disease
Pain with radiation to the back is suggestive of

Page 73
Esophageal Perforation, Rupture and Tears 7.1 H pylori Testing
Esophagitis
Gastritis, Acute Testing for H pylori infection is essential in all
patients with peptic ulcers.
Gastritis, Chronic
Endoscopic or invasive tests for H pylori include
Gastroenteritis a rapid urease test, histopathology, and culture.
Rapid urease tests are considered the endoscopic
Gastroesophageal Reflux Disease
diagnostic test of choice. The presence of H
Inflammatory Bowel Disease pylori in gastric mucosal biopsy specimens is
detected by testing for the bacterial product
Viral Hepatitis urease
7. Approach Considerations 7.2 Endoscopy
Testing for H pylori infection is essential in all Upper GI endoscopy is the preferred diagnostic test
patients with peptic ulcers. In most patients with in the evaluation of patients with suspected PUD. It is
uncomplicated peptic ulcer disease (PUD), highly sensitive for the diagnosis of gastric and
routine laboratory tests usually are not helpful. duodenal ulcers, allows for biopsies and cytologic
Documentation of PUD depends on radiographic brushings in the setting of a gastric ulcer to
and endoscopic confirmation. differentiate a benign ulcer from a malignant lesion,
and allows for the detection of H pylori infection
If the diagnosis of PUD is suspected, obtaining with antral biopsies for a rapid urease test and/or
CBC count, liver function tests (LFTs), amylase, histopathology in patients with PUD. (See the images
and lipase may be useful. CBC count and iron below.)
studies can help detect anemia, which is an alarm
signal that mandates early endoscopy to rule out
other sources of chronic GI blood loss.

Figure-1: Endoscopic view of Peptic Ulcer

Hpylori treatment
8. Treatment
Anti H pylori treatment is recommended for patients
on long term NSAIDS, bleeding peptic ulcer.

Drugs Dose(mg) Frequency Duration

PPI Clarithromycin 20mg BD 14 days


Metronidazole 500 400 BD BD

Page 74
PPI Amoxycillin Metronidazole 20mg BD 14 days
1gm bd TDS
400
PPI Amoxycillin Clarithrmycin 20mg BD 14 days
1gm 500 BD BD

Tab ranitidine (150mg)BD, 9. Dos and donts


Famotidine (40mg) OD equally efficacious, but
Avoid alcohol
takes longer time.
Stop smoking
Maintenance dose of PPI for patients on
NSAIDS, IHD patients. Avoid NSAIDs
Prefer paracetamol, avoid foods that aggravate
symptoms
No role of bland diet
Excess milkMeals at regular intervals.

Page 75
31. VOMITING

1. Introduction 4. Treatment
Vomiting is the forceful expulsion of the gastric Intravenous fluids if dehydrated. Start oral fluids
contents due to contraction of abdominal musculature as soon as patient tolerates.
and simultaneous relaxation of gastric fundus and
lower oesophageal sphincter. Rule out gastric outlet obstruction then

Inj Metoclopramide 10 mg IM repeat after 6 hrs


2. Causes if needed or
1. Central (stimulation of vomiting centre)
neurological disease raised intracranial pressure. Tab Mozapride 5 mg thrice a day, or
2. Vestibular system disorders
Tab Domperidone 10 mg thrice a day or
3. Drugs and toxins
4. Toxic and metabolic disorderssuch as
Tab Metoclopramide 10 mg thrice a day or
ketoacidosis
5. Systemic infections Tab Prochlorperazine 5 mg thrice a day repeat
6. Pregnancy after 4- 6 hrs if needed,or
7. Psychogenic vomitting
8. Obstructive diseases of GIT Tab /inj Ondensetron 8 mg stat dose and
9. Acute gastritis, gastroenteritis repeated 8 hrly.
10. Radiation exposure.
In Pregnancy Tab /Inj Promethazine 25 mg is
3. Investigations safe in the first trimester.

Evaluation should exclude CNS causes and upper GI For motion sickness Tab Cyclizine 50 mg thrice
endoscopy to rule out upper GI pathology. Barium a day.
meal is recommended if upper GI scopy is normal.
Psychogenic vomiting is considered after excluding If vomiting is part of suspected acute abdomen,
organic cause. acute MI, refer for further evaluation.

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32. CONSTIPATION

1. Introduction 5. Treatment
Bisacodyl, oral, Adults10-20 mg at night
Common causes of constipation are Diet deficient in
roughage Ignoring the urge to defaecate e.g. due to Or
immobility, lack of exercise. Psyllium (ispaghula husk), oral, Adults5-10 ml once
Other causes are neurological, myxoedema, drugs or twice a day
like Atropine, Codeine, and Malignancy Or
2. Symptoms Liquid paraffin, oral,10-30 ml at night Or Glycerol
suppositories Adults 4mg at night ; 1 mg at night Or
Constipation itself is a symptom. When associated Lactulose liquid, oral, Adults 15-30 ml orally daily
with inability to pass flatus, severe abdominal pain, until response then 10-20 ml daily
or vomiting there may be the need for urgent referral
to a surgeon.
Alternative treatment - Magnesium sulphate,
oral, Adults5-10 g in a glass of water, once or
3. Signs twice daily
Constipation, if associated with frequent high pitched
bowel sounds or absent bowel sounds 6. Dos and Donts
Advice patients to take plenty of fluids, high
4. Investigations fiber diet green leafy vegetables, fruits, avoid
caffeinated drinks.
Stool routine examination
Regular walk and exercise to 1 hr daily,
Stool for occult blood abdominal exercise.
Sigmoidoscopy/Colonoscopy To use Indian closet as far as possible (this will
straighten the anorectal angle).
A rectal examination with a short length colonoscopy
is a must for all patients with recent onset of Avoiding suppression of urge to defecate,
constipation irrespective of bleeding per (making a regular habit).
rectum.When acute, the constipation may be a part of
Avoid purgative frequently to treat constipation,
a serious illness such as acute bowel obstruction.
as it may be habit forming.
These patients present with abdominal pain, vomiting
and distension and non-passage of flatus. These Suppository or simple enema is preferred in IHD
patients should be referred immediately to a higher
center after rectal examination, passage of rectal tube
(for passage of flatus) and a plain X-ray abdomen.

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33. IRRITABLE BOWEL SYNDROME
Antispasmodics Anticholinergic drugs
1. Definition (dicyclomine)
A constellation of gastrointestinal symptoms Antidiarrhoels Tab Loperamide 2 to 4 mg daily
associated with lower bowel symptoms that occur in for several days
absence of an organic disease.
Anti depressants IBD Diarrhoeal type TCA (
Imipramine)
2. Symptoms IBD constipation type SSRI (paroxetine)
Clinically the diagnosis is made when continuous or Calcium channel activators Lubiprostone
recurrent symptoms of abdominal pain are associated 8microgm x 3 months
with any of the three features viz. Relief by
defecation and / or onset with change in stool Any IBS patient with change in presentation e.g.
frequency or consistency for at least 3 months. change in bowel habit requires re-evaluation.
Supportive symptoms of IBS include passage of
mucous, abnormal stool passage (straining, urgency,
and feeling of incomplete evacuation) and feeling of 4. Dos and Donts
abdominal fullness. Exclude IBS if individual has
alarm symptoms such as fever, weight loss, bleeding Diet should contain high fibre and supplemented
per rectum or anaemia with bulk forming agents such as isaphghul husk
Avoid caffeine and alcohol

3. Treatment Avoid milk and other dietary constituents, which


worsens the symptoms
Stool bulking agents High fibre diet Psychotherapy may be helpful in selected cases

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34. ULCERATIVE COLITIS
Sulpha-salazine has a higher incidence of side
1. Introduction
effects compared with newer 5-ASA drugs.
Ulcerative colitis is a chronic inflammatory bowel
Selected patients, such as those with a reactive
disease of unknown aetiology.
arthropathy, may benefit.
2. Symptoms Prednisolone 40 mg daily is appropriate for
During the first attack the patient often presents with patients in whom a prompt response is required,
bloody diarrhoea, with systemic symptoms of low to or those with mild to moderate active disease, in
moderate fever, backache, arthralgia.The first attack whom Mesalazine in appropriate dose has been
is a close mimicker of acute infective diarrhoea. A unsuccessful. It should be reduced gradually
stool examination followed by sigmoidoscopy is according to severity of the patient.
mandatory, especially if the bloody diarrhoea persists
Long-term treatment with steroids is undesirable.
for more than a month. It is important to exclude
Patients with chronic active steroid dependent
amoebic infection prior to institution of steroids.
disease should be treated with Azathioprine 1.5
Rectum is uniformly involved in these patients.
2.5 mg/kg/day
Frequency of stool can provide information on
severity of the disease: mild (2 - 4 stools/day), Topical agents (either steroids or Mesalazine)
moderate (4 6 stools/day) or severe (> 6 may be added to the above agents. Although they
stools/day). During remission, patient may be are unlikely to be effective alone, they may
asymptomatic or may have extra-intestinal benefit some patients with troublesome rectal
symptoms. symptoms.

Severe UC: close monitoring at a tertiary centre.


3. Treatment
These patients require a referral to a tertiary unit. 3.2 Maintenance of remission
Aim is induction of remission in acute stage and then Lifelong maintenance therapy is generally
maintenance of remission. recommended for all patients, especially those
Therapeutic decisions depend on disease activity and with leftsided or extensive disease, and those
extent. Patients with severe disease require hospital with distal disease who relapse more than once a
admission, whereas those with mild/moderate disease year.
can generally be managed as outpatients. Discontinuation of medication may be
Disease extent can broadly be divided into reasonable for those with distal disease who have
distal and more extensive disease. been in remission for 2 years and are averse to
such medication. However, there is some
Distal disease (proctitis/procto-sigmoiditis): Topical evidence that maintenance therapy reduces the
management is appropriate.
risk of colo-rectal cancer.
Extensive disease: Oral or parenteral therapy is the
For the maintenance of remission in UC:
mainstay of treatment.
Most patients require lifelong therapy, although
3.1 Choice of drugs some patients with very infrequent relapses
Mesalamine preparations and Steroid preparations (especially if with limited extent of disease) may
remain in remission without maintenance
Treatment of active left sided, or extensive UC:
therapy.
Mesalazine 2 4 g daily or Balsalazide 6.75 g
Oral Mesalazine 1 2 g daily or Balsalazide 2.5
daily are effective first line therapy for mild to
g daily should be considered as first line therapy.
moderate active disease.

Page 79
Sulpha-salazine 24 g daily has a higher Important Note
incidence of side effects compared with newer 5-
Regular surveillance is necessary for UC lasting
ASA drugs.
for more than 10 years.
Topical Mesalazine 1 g daily may be used
Explain to the patient the chronic nature of the
Steroids are ineffective at maintaining remission. disease and continuation of maintenance

Azathioprine 1.5 2.5 mg/kg/day or Treatment for life with regular follow-up. Risk
mercaptopurine 0.75 1.5 mg/kg/day are of colonic cancer after 10 years of disease onset
effective at maintaining remission in UC. must be explained
However, in view of toxicity they should be
reserved for patients who frequently relapse 3.3 Dos and Donts
despite adequate doses of amino-salicylates, or Milk is preferably avoided during the acute phase of
are intolerant of 5-ASA therapy. It is a common illness.
practice to continue amino-salicylates with
azathioprine, but limited evidences that this is
necessary.

Page 80
35. AMOEBIC LIVER ABSCESS
1. Introduction 3.2. Imaging Studies
Liver abscess is the commonest extra-intestinal form Ultrasonography is the preferable initial
of amoebiasis, caused by E. histolytica infection but diagnostic test. It is rapid, inexpensive, and is
occurs in only less than 1% of E. histolytica only slightly less sensitive than CT scan (75-
infections. The disease usually affects young males, 80% sensitivity vs 88-95% for CT scan).
particularly chronic alcoholics, in endemic areas.
Patients commonly affected are between 20 to 40 4. Treatment
years of age with residence in or recent travel to or
emigration from an endemic region. 4.1 Medical Management
1. Tab. Metronidazole 800 mg three times orally
2. Clinical Manifestations (or IV, if necessary) daily for 5-10 days or Tab.
Tinidazole 600 mg 2 times a day for 7-10 days
2.1. History 2. If the patient is very toxic, Inj. Metronidazole
500 mg given 8 hourly until patient improves.
The signs and symptoms of amebic liver abscess Switch over to oral therapy whenever
often are nonspecific, resembling those of pyogenic possible.Followed by Diloxanidefuroate (luminal
liver abscess or other febrile diseases. agent for cysts) 500 mg three times a day for 10
days
Abdominal pain
3. Chloroquine 600 mg orally daily 2 days,
Weight loss
followed by 300 mg daily for 2 weeks; dose is
Fever with rigors
calculated as chloroquine base. Drug is active
Diarrhoea/Dysentry against E.histolyticatrophozoites
2.2. Physical
Fever is the most common sign and is found in
4.2 Indications for drainage of an
as many as 99% of cases. abscess
Hepatomegaly is present in some cases.
1. If pyogenic abscess cannot be excluded
2. No improvement with medical therapy in 72
Signs of complications hours
Signs of peritoneal irritation, such as rebound 3. Impending rupture of abscess (severe pain,
tenderness, guarding, and absence of bowel pleuritic pain, hiccups) - one very close to the
sounds, are present when the abscess ruptures in surface of the liver
the peritoneal cavity. Peritonitis occurs in 2-7% 4. Large left lobe abscess, to prevent rupture in to
of cases. the pericardium

Pericardial friction rub can be audible when the 4.3 Follow-up


abscess extends into the pericardium. This sign is
1. Monitor the patient for resolution of symptoms
associated with very high mortality.
with medical treatment and aspirate if there is
Signs of pleural effusion are present when the any indication.
abscess ruptures in the pleural cavity 2. Abscess cavity may persist for several weeks
even after cure of infection. Frequent US scan is
3. Investigations unnecessary unless patient develops fever etc.
Scan may be repeated after 4 - 6 weeks, after
3.1. Laboratory Studies thepatient becomes asymptomatic.
Examination of the stool for hematophagous
trophozoites of E histolytica must be made on at least
3 fresh specimens because the trophozoites are very
sensitive and may be excreted intermittently

Page 81
4. Maintain good hygiene during food intake to
5. Dos and Donts prevent enteric infections
1. Avoid taking alcohol, specifically if on treatment
with Metronidazole 6. Refer
2. Avoid contaminated food and drinking water.
Vegetables should be cooked or washed well. Patients with abscesses that are large or not
3. Use boiled water (kills the cyst) or bottled water responding to treatment will need to be referred to a
from a known source. physician or surgical specialist.

Page 82
36. PYOGENIC LIVER ABSCESS
Ampicillin: 2 g I/V 6 hourly
1. Introduction
Liver abscess constitutes about 48% of all visceral Gentamicin: 2 mg/kg load, then adjust for renal
abscesses. Pyogenic liver abscess is usually caused function
by spread of infection from peritoneum, abdominal Ciprofloxacin: 400 mg I/V 12 hourly for 10 days
viscera such as appendicitis/ diverticulitis/portal
pyemia or diseases of biliary tract. It is most or
commonly caused by coliform organisms. Inj. Ceftriaxone 1-2 g IV every 12 hours 2 times a
day
2. Clinical Manifestation
or
Fever, abdominal pain, toxaemia, features of
associated problems such as appendicular pain/ Inj. Cefotaxmine 2 g 8-hrly for 10 days
massetc. Mostly abscesses are small and multiple.
Combination of Amoxycillin +Ciprofloxacin
+Metronidazole is also a recommended schedule
3. Investigations
Diagnostic investigations include total counts, USG In the elderly or those with renal impairment: a
scan of the abdomen, blood culture, and pus culture. Penicillin (such as amoxicillin) plus an injectable
CECT and MRI is seldom indicated. Cephalosporin (such as cefotaxime or
cefuroxime) plus metronidazole is recommended
4. Treatment Inj penicillin allergic patients: ciprofloxacin
plus clindamycin
4.1. Drainage
Once the sensitivity is known, antibiotic therapy
Percutaneous catheter or open surgical- remains the is amended accordingly. Duration of therapy is
mainstay of treatment for a large abscess usually from 24 weeks or longer depending on
Patient should be kept nil by mouth and given IV number of abscesses and the clinical response.
fluids if toxic and sick.
5. Follow-up
4.2 Recommended antibiotics 1. Monitor for clinical improvement and modify the
therapy based on culture sensitivity report.
Metronidazole plus ampicillin and gentamicin,
2. Abscess should always be drained.
ciprofloxacin, or a third-generation cephalosporin
3. Surgery is considered if no improvement with
Standard dosage medical treatment and percutaneous drainage
in4-7 days.
Ceftriaxone 2 g intravenously every 24 hours, or
cefotaxime 2 g intravenously every 8 hours. Important Note
Initial empirical treatment should include broad 1. Avoid taking alcohol, specifically if on treatment
spectrum antibiotics. with Metronidazole.
2. Maintain good hygiene regarding food intake to
Various combinations recommended are: prevent enteric infections.
Metronidazole: 500 mg I/V three times daily

Page 83
Figure-1: Approch to Pyogenic Liver Abscess

Page 84
37. INTESTINAL PROTOZOAL INFECTION
giardiasis may contribute to protein-energy
1. Amoebiasis malnutrition in children.
Entamoeba Histolytica is the most prevalent Protein-losing enteropathy has also been described.
intestinal protozoa in India.

1.1 Clinical Features 2.2. Investigations


Diagnosis is made by stool examination and looking
Intestinal Amoebiasis / Amoebic Dysentery: for cysts and trophozoites.
Patient with acute amoebic dysentry present with a 1-
2 weeks history of abdominal pain, tenesmus, and Parasites are best seen in fresh watery stools.
frequent loose stools containing blood and mucus.
Duodenal aspirate is better for isolation but invasive.
Fever may or may not be present.

1.2 Investigations 2.3. Treatment


Treatment is Metronidazole 400mg TID for 5 days
Despite thepresence of ulcerations and occult blood
orally or Tinidazole 2gm PO once is equally
in stools, leucocytes may not be present in stools.
effective.
A definite diagnosis is made by the demonstration of
E. Histolytica cysts/ trophozoites in stools by a WET Furazolidone 6 mg/kg q.i.d for 7-10 days is effective
MOUNT PREPARATION. and well tolerated in children.

1.3 Treatment 3. Spore forming protozoa


The drug of choice for amebic colitis is These include:
tinidazole/metronidazole Doses are:
Tinidazole: 2g/day with food for 3 days or Cryptosporidium parvum
Metronidazole: 750 mg tid orally /iv for 5-10 days. Isospora belli
Cyclospora cyatenensis
Treatment of intraluminal amoebiasis is Diloxanide Microsporidia
Furoate 500mg PO-TID for 20 days or paromomycin The spectrum of diseases caused by these is as
30 mg/kg qd in 3 divided doses for 5-10 days. follows:

2. Giardiasis 3.1 Asymptomatic infection


It is a parasitic infection caused by Giardia Lamblia a This can be seen in immunocompetant as well as
single celled organism. immunocompromised patients.
3.2 Acute infectious diarrhea in
2.1 Clinical Features immunocompetent hosts
Acute symptoms include: Acute watery diarrhea with abdominal pain, with
malaise with or without fever can be seen in all
Crampy abdominal pain
except microsporidia. (generally pathogenic only for
Watery diarrhoea, vomiting and fever which last for immunocompromised patients)
few days.
In the chronic stage: 3.3 Infections in immune
Patients have bloating, nausea, abdominal fullness, compromised hosts
epigastric or substernal burning, malaise and fatigue. All spore-forming protozoa have a predisposition for
more frequent and prolonged infections in patients
Although severe forms of chronic giardiasis may who are immunodeficient.
occur in otherwise healthy individuals, they are Patients with HIV especially with low CD4 count
common in patients with hypoglobulinemia, (<50-100) are more prone.
particularly IgA deficiency in association with
lymphoid hyperplasia of the bowel. Chronic

Page 85
Severe life-threatening watery diarrhea, dehydration Stool examination with a wet mount preparation is
and chronic malabsorption leading to lethargy, failure required for isolation of the parasites.
to thrive, and malnutrition may occur. Modified acid fast staining is used to identify
3.4. Investigations cryptosporidium, isospora and cyclospora as these are
acid fast.

3.5. Treatment

PATHOGEN TREATMENT
Cryptosporidim Nitazoxanide 500 mg b.d for 3 days
Paromomycin 30 mg/kg per day divided
Isospora Septran (TMP/SMX,160/800 MG) four times a day for 10 days and
then 3 times a day for 21 days
Microsporidia No definite drug but albendazole 400- 800 mg/day divided in b.d
can be given
Cyclospora Septran ( TMP/SMX , 160/800 MG)twice daily for 7 days

Supportive treatment with ORS or iv fluids for fluid Pulmonary consolidations


and electrolyte supplementation is necessary.
Eosinophilia

4. Intestinal helminthic Urticaria

(nematodes) infections Asthma


Nematodes are round worms infesting the intestines. Angioneurotic edema
The infective forms are the eggs/larvae transmitted
by the feco oral route. Intestinal invasion:
Generally seen in low socio economic states with
poor sanitation and hygiene. May be asymptomatic (small number).
Their life cycle is complex with stage of passage
through lungs in some worms (ascaris, hookworm, Abdominal pain (usually vague).
strongyloids) leading to various manifestations like Abdominal cramps/colic.
LOEFFLERS SYNDROME.
Diarrhea.
Several clinical signs and symptoms can occur as
Vomiting (rarely).
follows:
Constipation (occasionally).
Lung invasion - Leffler or Leffler like Intestinal obstruction due to worm mass.
syndrome (ascariasis, hookworm infections, The common nematode infections are described
strongyloidiasis) below:

Fever 4.1 Ascariasis


Ascaris Lumbricoides is the largest of the intestinal
Cough nematodes. Symptoms can be divided into 2
Blood-tinged sputum categories: early larvae migration and late
mechanical effects.
Wheezing
In the early phase (4-16 hours after eggs ingestion),
Rales respiratory symptoms occur because of migration of
larvae through the lungs with symptoms of
Dyspnea eosinophilic pneumonia (Loffler Syndrome). Patient
Substernal pain may have fever, non-productive cough, dyspnoea or
wheezing.

Page 86
In the late phase (6-8 weeks after egg ingestion) Inflammatory diarrhea, with eosinophilia.
gastrointestinal symptoms may occur. Patient may
Chronic hookworm infection:
vomit out worms from mouth, nose.
Generally presents with Iron deficiency anemia,
Diffuse abdominal pain, nausea, vomiting, billiary
Hypoproteinemia.
and intestinal obstruction, appendicitis and
pancreatitis. Diagnosis:
Ascarisworms invade the biliary duct and cause Demonstration of eggs in stool examination.
pancreatic-biliary ascariasis. The most common Sensitivity improved with stool concentration.
presenting feature is abdominal pain, observed in
98% of patients. Less common features include Microcytic hypochromic anemia with proteinemia
ascending cholangitis, acute pancreatitis, and, rarely, may be seen in chronic cases. Eosinophilia may be
present.
obstructive jaundice.
Treatment:
Diagnosis
i. In early infection (larval migration): Albendazole 400 mg once/ Mebendazole 500 mg
CBC may show peripheral eosinophilia once/ pyrantel pamoate 11 mg/kg for 3 days.
Sputum may show charcot layden crystals.
Chest X Ray may show patchy infiltrates of Treat anemia with iron supplements.
eosinophilic pneumonia.
4.3 Enterobiosis
ii. In the late stage(adult worm): Enterobius vermicularis / pinworm is prevalent in
most tropical countries.
Stool microscopic examination shows eggs.
The adult worms migrate to perianal area at night and
USG may be used for ascariasis related biliary
release upto 10,000 eggs which after hatching are
disease.
transmitted by hand to mouth passage.
CT abdomen may show adult worms or
Clinical features-
obstruction due to worm mass.
The infection is generally asymptomatic.
Treatment:
The primary symptoms of pinworm infestation occur
Albendazole 400mg one dose orally is the drug of at night which include pruritus in the perianal region.
choice OR Mebendazole 100 mg twice daily for 3
Heavy infection can cause abdominal pain and
days. It is contraindicated in pregnancy.
weight loss.
4.2 Anclostoma Duodenale: Diagnosis:
(Hookworm) Since pinworm eggs are not released in feces stool
Many patients may be asymptomatic carriers. examination is not informative.

Clinical features - Detection of worms/ eggs in perianal cellophone


swab/ cellophane tape applied in the early morning
The symptoms are classified into 2 phases: establishes diagnosis.
Treatment:
In the migratory phase: Single dose Mebendazole 100 mg once /Albendazole
Pruritus and erythema and vesiculation will occur 400 mg once.
once the falciform larvae have penetrated the skin of
the feet and hands. This is called as ground/dermal
4.4 Strongyloidosis
itch in people who goes barefeet.
S. stercoralis is the only intestinal nematode with the
The pulmonary symptoms may develop with A. ability to replicate inside humans, thus leading to
Duodenale during the phase of lung migration like repeated auto infection.
mild transient pneumonitis.
In immunocompramised hosts it can lead to invasive
In the intestinal phase: and disseminated infection which can be fatal.
Patients may present with abdominal pain (often Clinical features:
epigastric).

Page 87
Many patients are asymptomatic. Treatment:
Cutaneous manifestations include recurrent Ivermectin (200 mcg/kg daily for 2 days) is most
urticaria involving buttocks and wrists. effective. In cases with disseminated infection extend
Larva currens: cutaneous migration of larvae the duration for 5 to 7 days or upto clearance of
results in serpiginous eruption which is pruritic, parasites. Albendazole (400 mg daily for 3 days.) is
erythematous. also effective.
Burning or colicky abdominal pain, often
epigastric, occurs and is associated with 4.5 Trichuris Trichura
diarrhea and the passage of mucus. Pain is
aggravated by food. Also called as whip worm.
Some patients with strongyloidosis report Most infections are asymptomatic. Heavy infections
nausea, vomiting, and weight loss, with evidence can cause gastro intestinal symptoms.
of malabsorption or of protein-losing
Common in low socio economic status with children
enteropathy. especially affected.
Massive larval invasion of the lungs and other
tissues may occur with hyperinfection, usually in
immunocompromised hosts. Clinical features:
Disseminated infection in immunocompramised
hosts severe generalized abdominal pain, diffuse Usually mild symptoms with abdominal pain,
pulmonary infiltrates, ileus, shock, and anorexia, diarrhea which can be bloody/mucoid.
meningitis or sepsis due to gram-negative bacilli Rectal prolapse may occur in massive infections in
may occur. children.
Diagnosis:
Stool examination for rhabditiform larvae is Diagnosis:
diagnostic.
Stool examination for eggs.
Doudenal aspirate may reveal the larvae if stool is Proctoscopy for adult worms.
persistently negative.
In disseminated infections filariform larvae should be Treatment:
sought in stool, sputum, broncho alveolar lavage etc. Mebendazole 500 mg once/ albendazole 400 mg
daily for 3 days.

Page 88
38. ASCITES
1. Causes
Cirrhosis is the common cause of ascites. Other Lab tests
causes are malignancy, cardiac failure, tuberculous
ascites, pancreatitis, nephrotic syndrome, alcoholic In general, start with cell count and differential,
hepatitis, acute liver cell failure etc. TP and albumin when uncomplicated ascites due
to cirrhosis is suspected. Culture is also usually
2. Physical Exam sent.
In patients with PMN >250, only 50% of cultures
grow bacteria if sent down to lab in a syringe or
Almost all patients with cirrhosis severe enough plain tube. 80% grow bacteria if inoculated into
to cause ascites will have stigmata of cirrhosis blood culture vials at bedside (prior to
spider angiomata, palmar erythema, and caput antibiotics).
medusiae.
Glucose < 50, LDH > upper limit of normal for
Elevated JVP should raise suspicion of heart serum, TP >1, and culture results can help
failure or constrictive pericarditis as a cause, differentiate secondary from spontaneous
although cirrhosis with tense ascites or peritonitis.
pulmonary HTN may cause this.
SAAG (serum albumin and ascitic albumin
Sister Mary Joseph nodule with ascites may be gradient) > or = 1.1 has ~97% accuracy for
caused by gastric or colon CA, HCC, or portal hypertension.
lymphoma. If found, FNAC can provide a rapid
TP > or = 2.5 can help differentiate cardiac from
tissue diagnosis.
cirrhosis ascites.
When PMN > or = 250, but less than 50% of
3. Investigations WBC, consider peritoneal carcinomatosis and
tuberculous ascites.
Ultra sonography of abdomen is useful to
confirm/refute presence of ascites, cirrhosis,
splenomegaly, biliary obstruction, vessel patency,
4. Management
Goal is to minimize ascitic fluid volume and
signs of portal hypertension, and cancer.
peripheral edema without intravascular volume
CT-abdomen, tumour markers, HBsAg Anti HCV, depletion.
serum amylase are other investigations. First line treatment includes 2 gram per day
sodium restricted diet and oral diuretics
Abdominal paracentesis (spironolactone / lasix).
Along with history and physical exam, ascitic The usual diuretic regimen is single morning
fluid analysis helps in the diagnosis of etiology. doses of 100mg spironolactone and 40mg
It is a safe procedure Ascitic fluid analysis. frusemide (lasix).
The 100:40 ratio generally maintains
Appearance.
normokalemia. Usual max dose is 400mg and
Turbid/cloudy 98% sensitive but only 23% 160mg per day.
specific for SBP.
Other specific management as per the cause of
Milky chylous ascites, TG level usually greater ascites.
than serum TG level and >200mg/dl.
Bloody/pink usually a traumatic tap, but seen 5. When to Refer
in 50% of patients with HCC and 22% with
Acute ascites, bleeding tendency, refractory ascites,
malignancy overall.
hepatic encephalopathy.
Dark brown if bilirubin level is higher than in
serum, worry about ruptured gallbladder or
perforated duodenal ulcer.

Page 89
39. HEPATITIS
hypertension and end stage liver disease
1. Introduction develops.
Onset is gradual or sometimes rapid.
There is fever, fatigue and nausea for a few days 4. Obstructive jaundice
followed by jaundice accompanied by dark urine
Sometimes jaundice is due to obstruction to flow
and sometimes clay- coloured stools.
of bile and not due to a virus.
The severity of jaundice varies.
On such cases the yellowing of eyes is very
On examination liver may be mildly enlarged marked and may even be greenish.
with mild tenderness.
There is much itching and the stools are always
This being the most common cause one must whitish in colour.
always make this clinical diagnosis after the
Usually the liver is enlarged.
exclusion of obstructive or haemolytic jaundice.
In most cases this can be done on clinical Ultrasound of the liver confirms obstruction best
grounds alone. and the patients should be referred to a centre
with ultrasonography facilities.
There are five viruses that are commonly
associated with hepatitis called Hepatitis A, B, Refer to higher centre as these cases need
C, D and E virus. Of these two, hepatitis A and E surgery.
spread through faecal contamination of water.
When there is an outbreak of jaundice in a 5. Haemolytic jaundice
village it is probably this virus. Almost always
this jaundice becomes alright on its own. Except Sometimes jaundice is due to increased
in pregnant women where it can be life breakdown of haemoglobin secondary to
threatening. Three other types of viruses spread destruction of RBCs in a haemolytic anaemia.
through the blood and through unprotected Jaundice is invariable light coloured, and urine is
sexual contact (hepatitis B, C, D). These types also normal in colour.
are more severe, tend to worsen and have more
long term complications. Diagnosis needs to be established by blood
smear examination, by ruling out hepatitis by
2. Acute fulminant hepatitis liver function tests and by specific tests for
Sometimes, especially with hepatitis B and D haemolytic anaemia.
hepatitis turns severe due to cell necrosis.
Patient develops confusion, stupor and then 6. Alcoholic hepatitis
coma and it is difficult to save the life.
Excessive alcohol consumption is a significant cause
Pregnant women are prone to develop this of hepatitis and liver damage (cirrhosis). Alcoholic
picture with all viruses but commonly with hepatitis usually develops over years-long exposure
hepatitis E. to alcohol. Alcohol intake in excess of 80 grams of
alcohol a day in men and 40 grams a day in women is
3. Chronic hepatitis associated with development of alcoholic hepatitis.
Sometimes the liver disease goes on for years Alcoholic hepatitis can vary from mild asymptomatic
without becoming well. disease to severe liver inflammation and liver failure.
Symptoms and physical exam findings are similar to
Such patients have frequent intermittent episodes other causes of hepatitis. Laboratory findings are
of jaundice. significant for elevated transaminases, usually with
elevation of aspartate transaminase (AST) in a 2:1
Elevated liver enzymes over 6 months is enough
ratio to alanine transaminase (ALT).
to make this diagnosis.
Alcoholic hepatitis may lead to cirrhosis and is more
Eventually it can become well but more often common in patients with long-term alcohol
leads to cirrhosis of the liver and portal consumption and those infected with hepatitis C.

Page 90
Patients who drink alcohol to excess are also more 8.1. Treatment for Acute fulminant
often than others found to have hepatitis C. The
combination of hepatitis C and alcohol consumption hepatitis
accelerates the development of cirrhosis. Patient needs hospitalization.
Treatment is supportive & consists of
maintaining parenteral fluids.
7. Investigations for jaundice
Care is taken to treat infections or other
These tests are needed to establish diagnosis & precipitating factors like haematemesis.
monitor improvement.
Urine examination for bile salts & pigments. Gut sterilization with capsule amoxicillin and/or
metronidazole may help.
Serum bilirubin & Serum liver enzymes level.

8.2. Treatment for obstructive


8. Treatment for hepatitis jaundice
Only supportive: rest, hydration, correct but not Refer for Surgery.
specific diet.
Avoid oily spicy foods that are ill tolerated. 8.3. Treatment for Haemolytic
Avoid corticotherapy. NEVER give steroids. anaemia
There are no specific drugs to cure jaundice. Referral for further work up in higher centre with
Fortunately most persons become well on their tests for type of haemolysis.
own.
Remember many drugs commonly used are harmful
when given to a person with jaundice.
9. Vaccine
Vaccine against hepatitis B is available.
Hepatitis-B Vaccine is included in National
Immunization Schedule.

Page 91
40. HEPATIC COMA
coma. Asterixis / flapping tremors is also commonly
1. Introduction seen.
Hepatic Encephalopathy is a term used to describe a Search for precipitating factors every advanced
spectrum of neuropsychiatric abnormalities occurring cirrhotic patient displaying a change in mental status
in patients with significant liver disease and/or porto is septic until proven otherwise. Common
systemic shunting of blood. precipitating are GI bleeding, sepsis, hypokalemia,
high protein load, constipation, hyponatriemia, Other
2. Diagnosis causes include sedative
drugs, superimposed liver injury.
There are 2 major components of HE, altered mental
status and generalized motor disturbance. 3.Grade / Stage the severity of
Disturbunces in awareness and mentation from
forgetfulness and confusion to stupor and finally disease
Table-1: West-Haven Criteria for Hepatic Encephalopathy (HE)

Stage Consciousness Intellect and Behavior Neurologic Findings


0 Normal Normal Normal examination; if impaired psychomotor
testing, consider MHE*
1 Mild lack of awareness Shortened attention span Impaired addition or subtraction; mild asterixis or
tremor

2 Lethargic Disoriented; Inappropriate Obvious asterixis; Slurred speech


behavior
3 Somnolent but arousable Gross disorientation; Muscular rigidity and clonus;
Bizarre behavior Hyperreflexia
4 Coma Coma Decerebrate posturing
*MHE, minimal hepatic encephalopathy.

ii. Rifaximin 400mg PO tid marginally better


4. Treatment than lower doses(400mg-550mg bid) or
A. 4-pronged approach to treatment Neomycin 1gm PO q6 hourly for up to 6 days
Supportive care. (if used chronically, 1-2gm/day).
Search for and correct precipitating factors iii. Dietary protein restriction no longer
Exclude and treat other causes of altered mental recommended.
status. iv. L-ornithine-aspartate promotes waste nitrogen
Start empiric therapy for HE excretion.
i. Lactulose : 30cc bid-qid titrated to goal 2-4 v. Antibioics if sepsis suspected.
soft BMs/day or retention enema 300cc
lactulose + 700cc tap water retained for 1 hour
reduces the ammonia production and 5. When to refer
absorption. Deteriorating sensorium, hematemesis, malena,
bleeding tendencies.

Page 92
41. NEPHROTIC SYNDROME
6. Renal Function Test: Blood Urea Level and
1. Definition Serum Creatinine Level
Nephrotic Syndrome is a clinical complex 7. Renal Biopsy: In Adult patients for a)
characterized by a number of renal and extrarenal Establishing a Definitive Diagnosis b) Guiding
features, the most prominent of which are Therapy & c) Assessing Prognosis.
Proteinuria of 3-3.5gm / 24 hour,
Hypoalbuminemia,
Edema, 5. Treatment
Hyperlipidemia, Lipiduria i. Steroid: Minimal change disease accounts for
about 80% of Nephrotic Syndrome in children
younger than 16 year and 20% of adult.
2. Symptoms and Signs Adult: Tab Prednisolone 1-1.5 mg/kg body
Puffiness of face, increase in morning weight per day for 4 week followed by
Ankle pitting edema with increasing severity to 1mg/kg/day on alternate day for 4 week.
generalised anasarca Ascites, Pleural Effusion Check for urine protein after four weeks if nil
no treatment needed and if present start with
Prednisolone 1.5 mg for 2 weeks
3. Complications ii. HMG Co A Reductase Inhibitor: Tab
Recurrent Infections, hypocalcemia, Anemia,
Atorvastatin 10 Mg Od
Thrombotic Tendencies
iii. Loop Diuretic
iv. Salt Restriction 1-2 Gram per Day.
4. Investigation v. High Protein Diet
1. Urine Analysis for Proteinuria, Protein / vi. Vitamin D Supplementation.
Creatinine ratio
2. Urine Microscopy for Deposit 6. When to Refer
3. 24 Hour Urinary Protein
i. For Renal Biopsy
4. Serum albumin
ii. When Dialysis is required.
5. Ultra sonography abdomen and pelvis

Page 93
42. ACUTE NEPHRITIC SYNDROME
It is Clinical Correlate of Acute Glomerular Blood Urea and Serum Creatinine elevations.
Inflammation Which May Be a Primary Disease OR
Decrease C3 Level, Normal C4 Level
Secondary to Systemic Process.
ASO Titer
1. Definition Ultra sonography renal
It is characterized by sudden onset (over days to
Renal Biospy
weeks) of acute renal failure and Oliguria (400ml/day
of urine) and renal blood flow and GFR fall as a
result of obstruction of the glomerular capillary
4. Treatment
lumen. 4.1 General Management
2. Clinical Features Bed Rest
Tetrad of
Adequate Fluid Intake to ensure 400 ml Urine per
Edema Day
Hypertension mild Salt restriction especially if edema present
Hematuria [macroscopic]
4.2 Managementof Renal Failure
Proteinuria (Subnephrotic Range < 3g/24 Hr)
Tab Frusemide if volume overload hypertension
Symptom:
Not to be given if no evidence of fluid excess
Puffiness of Face
Rarely require Dialysis
Edema of Feet
Cola Coloured Urine
4.3 Antihypertensive Drug
Dyspnea If Pulmonary Edema 4.4 Controlof Infection
Hypertension
Generalized Symptoms- Anorexia, Nausea, 4.5 Renal Biopsy
Vomiting, Malaise, Flank OR Back Pain. If features not suggestive of Post Streptococcal
Glomerulonephritis.
3. Investigation
Urine Microscopy: Dysmorphic RBCs and RBC 5. When to Refer
Cast, Leucocytes
i. For Renal Biopsy
Urine- Gross Hematuria (Red or Smoky Urine) ii. When Dialysis is required.
Subnephrotic range Proteinuria

Page 94
43. ACUTE RENAL FAILURE / ACUTE KIDNEY
INJURY

1. Definition 3. Acute tubular necrosis


AKI is a syndrome characterized by rapid decline in Ischemia, Exogenous toxins: radiocontrast,
glomerular filtration rate (hours to days), retention of chemotherapy, acetaminophen, Endogenous toxins:
nitrogenous waste products and perturbation of rhabdomyolysis, hemolysis, myeloma.
extracellular fluid volume and electrolyte and acid
base homeostasis. 4. Interstitial nephritis
AKI is defined as any of the following (Not Graded): Antibiotic, NSAID, Sulfonamide, eta lactam
Increase in Sr.Creatinine by X0.3 mg/dl (X26.5
Post renal:
lmol/l) within 48 hours; or
Increase in Sr.Creatinine to X1.5 times baseline, Ureter: calculi, blood clot, carcinoma
which is known or presumed to have occurred
Bladder neck: prostatic hypertrophy, calculi,
within the prior 7 days; or
carcinoma
Urine volume 0.5 ml/kg/h for 6 hours
Urethra: stricture, phimosis.
2. Classification
3. Symptoms
Prerenal:
a. Hypovolemia: 3.1. Prerenal
Haemorrhage, burns, dehydration, vomiting, diarrhea, Evidence of true volume depletion- thirst,
pancreatitis, peritonitis. postural or absolute hypotension and
b. Low cardiac output: tachycardia, dry mucous membrane.
Urine- low volume, low sodium and high
CCF, Disease of myocardium, valves and osmolality.
pericardium,
Pulmonary hypertension, pulmonary emboli. 3.2. Renal
c. Altered renal systemic vascular resistence ratio; Symptom and sign of underlying disease affecting
glomeruli or tubule.
Systemic vasodilatation- sepsis, antihypertensive
drug 3.3. Postrenal
Renal vasoconstriction: hypercalcemia
Abdominal or flank pain, palpable bladder.
Cirrhosis with ascitis- hepatorenal syndrome.
Intrinsic renal: 3.4. Symptoms of uremia
1. Renovascular obstruction: Anorexia, nausea, vomiting, Mental status changes,
Pruritus, shortness of breath
Renal artery obstruction: atherosclerosis, thrombi,
emboli, Renal vein obstruction: thrombi, compression
4. Signs
2. Disease of glomeruli: Asterixis, Pericardial rub, Pedal edema, pulmonary
Glomerulonephritis and vasculitis, Hemolytic uremic edema, Raised JVP
syndrome, DIC, toxemia of pregnancy, Accelerated
hypertension. 5. Investigation
Urine analysis: routine microscopy

Page 95
Routine blood chemistry: BUN, creatinine, Serology: ANA, ANCA, anti GBM, complement,
electrolyte, ca, po4 ASO
Complete hemogram Imaging: Renal ultrasound, Plain radiograph of
abdomen.
Special test: bence jones protein
Renal biopsy.

6. Staging of aki

STAGE Serum creatinin criteria Urine output criteria


I 1.5 to 2 fold increase <0.5 ml/kg/hr for > 6 hr
II 2 to 3 fold increase <0.5 ml/kg/hr for >12 hr
III >3 fold increase , absolute value > 4 mg/dl < 0.3 ml/kg/hr for 24 hr or anuria
for 24 hr.

IV.Calcium gluconate (10ml 10% solution)


7. Treatment Inhaled 2 agonist- Salbutamol
IV glucose insulin infusion (100ml 25% dextrose
7.1. Prerenal with 10 unit of human actrapid in 1 hour)
Restore blood volume (with isotonic saline 0.9%, or Dialysis.
blood, plasma)
Treat underlying cause.
7.5. Treatment of metabolic
7.2 Renal acidosis
Inj Na bicarbonate iv
Eliminate toxins, Nephrology consultation

7.3. Postrenal 7.6. Dialysis: indication


Metabolic acidosis, Hyperkalemia, Encephalopathy,
Relieve obstruction, Urology consultation Volume overload, Pericarditis

7.4. Hyperkalemia

8. Complication
COMPLICATION MANIFESTATION
1.Metabolic Hyperkalemia, hypocalcemia, hyperphosphatemia, hypermagnesaemia,
hyperuricemia, metabolic acidosis.
2.Cardiovascular Cardiac arrhythmia, pulmonary edema, pericardial effusion, pericarditis
3.Gastrointestinal Gastrointestinal hemorrhage
4.Neurological Altered sensorium, seizures
5.Hematological Anaemia, bleeding.

9. Prevention
Nephrotoxic drug should be stopped if patient is at
Apropriate and adequate fluid management
Optimization of hemodynamic risk of developing AKI.
Management and prevention of sepsis

Page 96
44. CHRONIC KIDNEY DISEASE
3. Nondiabetic glomerular disease- Nephritic and
1. Definition nephrotic presentation
4. Cystic kidney disease
A. Presence of marker of kidney damage more than 5. Tubulo interstitial disease.
3 month as defined by structural or functional
abnormality of the kidney with or without decrease 3. Staging
GFR manifested by either pathological abnormality According to GFR (glomerular filtration rate)
or other marker of kidney damage. Cockcroft-Gault equation for calculation of
B. GFR < 60 ml/min/1.73m2 for more than 3 month creatinine clearance:
with or without sign of kidney damage.
(140- Age) Body weight (kg)
2. Causes 72 plasma creatinine (mg/dl)
1. Diabetes Multiply by 0.85 for women.
2. Hypertension

Table-1: Staging of CKD

STAGE DESCRIPTION GFR(ml/min/1.73m2


1 At increased risk of kidney damage with normal or raised 90
GFR
2 Kidney damage with mildly Decreased GFR 60-89
3 Moderately decreased GFR 30-59
4 Severelydecreased GFR 15-29
5 Renal failure <15

4. Symptoms and signs 6. Evaluation and


Hypertension, proteinuria, anemia, deep
respiration(Kussmauls respiration), tiredness,
management of patient of
breathlessness, pruritus, anorexia, nausea, vomiting. ckd
5. Risk factors 6.1. History and physical
Age> 65yr examination
Diabetes
H/O HTN, DM, use of analgesic Measure blood
Family h/o renal disease pressure

Autoimmune disease 6.2. Laboratory investigation


Systemic infection
Haemoglobin level.

Urine for proteinuria and hematuria


UTI, stone, urinary tract obstruction,
Blood urea,serum creatinine
HTN

Page 97
Blood sugar level 6.3. Imaging study
Serum electrolyte
USG abdomen for the renal size and
Serum calcium,phosphorus level Corticomedullary differentiation.

Table-2: To Delay Progression to Next Stage:

MEASURES GOAL
1.ACE inhibitors/ARB Proteinuria <0.5 g/day and GFR decline<2ml/min/yr.
2.Additinoal antihypertensive drug as needed BP<130/80 if proteinuria<1 gm/day
BP<125/75 if proteinuria>1gm/day
3.Dietary protein restriction 0.6 to 0.8 gm/kg/day
4.Glycaemic control HbA1C <7 %
5.Anaemia correction Target Hb 10 to 12 gm/dl
6. Cholesterol lowering agent LDL <100 mg/dl
7. Dietary salt restriction 3 to 5 gm/day

6.4. Treatment diseases, Anaemia: target Hb 11 gm/dl, Use of iron


and erythropoietin injection, Renal osteodystrophy:
1. Slowing the progression of CRF:
target Ca 8.8 9.7, phosphorus 3.5 5.5, Use of
Protein restriction 0.6gm/kg/day calcium carbonate, phosphorus restriction avoid

2. Slowing diabetic renal disease: dairy product,meat,colas Oral calcitriol.

Glucose control target HbA1c <7.2 4. Renal replacement therapy:

3. Managing complications of CRF:Cardiovascular Dialysis: refer to higher center, A-V fistula; if GFR
complication-yearly screening of cardiovascular <25ml/min Serum creatinine> 4 mEq/L.

Page 98
45. MALARIA
Fever comes down with profuse sweating. The
1. Introduction temperature drops rapidly to normal and skin is cool
Malaria is a protozoal disease caused by infection and moist. The pulse rate becomes slower; patient
with parasites of the genus plasmodium and feels relieved and often falls asleep. This stage lasts
transmitted to man by female anopheles mosquito. It for 2-4 hours.
is a very important public health problem in India The febrile paroxysms occur with definite
particularly due to Plasmodium falciparum which is intermittent periodicity repeating every third or
prone to various complications. fourth day depending upon the species of the parasite
involved. The classical 3 stages (cold, hot and
2. Agent sweating) may not always be observed due to
Malaria in man is caused by Plasmodium vivax, maturation of generations of parasite at different
Plasmodium falciparum, Plasmodium ovale and times. The disease has a tendency to relapse and is
Plasmodium malaria. Out of these, Plasmodium characterized by enlargement of the spleen and
vivax and Plasmodium falciparum are very common secondary anaemia.
in India including Maharashtra. In patients with P.falciparum infection the primary
fever in its first few days is usually irregular or even
3. Mode of transmission continuous and then the classical 48 hour periodicity
Direct through blood or plasma. becomes established or the fever may continue to be
irregular and the hot and cold stages, so typical of
Vectors bite of female anopheles mosquito. other malarial infections are less clearly separated
from one another, in persons with poor immunity.
4. Incubation Period The paroxysms are associated with marked
prostration. Headache, nausea and vomiting are
The duration varies with species of parasite.
usually more severe, and there is greater tendency
12(9-14) days for falciparum malaria. towards the development of delirium, haemolytic
14(8-17) days for vivax malaria. jaundice and anaemia. The mortality is much greater
than in other forms of malaria.
5. When to suspect With P. vivax infection, symptoms are same but are
usually milder and more regularly divided into hot
The typical attack comprises three distinct stages viz.
and cold stages than in P.falciparum infections.
cold stage, hot stage and sweating stage.
Cold Stage:
6. Complications
The onset is with lassitude, headache, nausea and
chilly sensation followed in an hour or so by rigors. The complications of P. falciparum malaria are
The temperature rises rapidly to 39-41C. Headache cerebral malaria, acute renal failure, liver damage,
is often severe and commonly there is vomiting. In gastro-intestinal symptoms, dehydration, collapse,
early part of this stage, skin feels cold; later it anaemia, black water fever etc. The complications of
becomes hot. Parasites are usually demonstrable in P. vivax, infection are anaemia, splenomegaly,
the blood. The pulse is rapid and may be weak. This enlargement of liver, herpes, renal complications,
stage lasts for -1 hour. ARDS etc.
Hot Stage:
7. Investigations
The patient feels burning hot and casts off his
clothes. The skin is hot and dry to touch. Headache is
intense but nausea commonly diminishes. The pulse Diagnosis of Malaria: One of the above clinical
is full and respiration rapid. This stage lasts for 2 to 6 features, supported by blood smear examination
hours. for malarial parasites.
Fever with splenomegaly in a patient with the
Sweating Stage: above mentioned clinical features make
diagnosis of malaria more likely.

Page 99
Confirmation of diagnosis always depends on ensure treatment with full therapeutic dose with
seeing the parasite in the blood. In all cases, appropriate drug to all confirmed cases. Presumptive
thick and thin smears should be examined. treatment of malaria with a single dose of
Blood smears may be negative in severe and chloroquine has been stopped.
chronic forms and this would need repeated All fever cases diagnosed as malaria by either RDT
smears. or microscopy should be promptly given effective
treatment. The medicine chosen will depend upon
8. Diagnosis of Malaria whether the patient has vivax malaria or falciparum
It is stressed that all fever cases should be suspected malaria as diagnosed by the blood test. The flow
of malaria after ruling out other common causes and charts in different settings for diagnosis and drug
should be investigated for confirmation of malaria by selection for the treatment of malaria are mentioned
Microscopy or Rapid Diagnostic Kit (RDK) so as to below.

Where microscopy result available within 24 hours

Suspected malaria case

Take slide and send for microscopic examination

Result?

Positive for Positive for Positive for Negative


P. vivax P. falciparum Mixed infection No anti-malarial
Treat with: Treat with: SP-ACT 3 days Treatment.
CQ 3 days + ACT-SP + Treat as per
PQ 0.25 mg for 3 days + PQ 0.75mg Primaquine clinical
per kg body per kg body 0.25 mg per kg diagnosis
weight daily for weight body weight
14 days Single dose on daily for
second day 14 days.

Figure-1: Management chart for suspected Malaria case

Page 100
ACT-SP- Artemisinin-based Combination Where microscopy result is not available within 24
Therapy(Artesunate+Sulfadoxine-Pyrimethamine)CQ hours and Monovalent RDT is used
Chloroquine PQ Primaquine
TfR= Test falciparum rate

Suspected malaria case

Where TfR>=1%, and In other areas, if


Pf %> 30% in any of Patient not
last at high risk of Pf*
3 years

Do RDT for detection Wait for slide result. Give


of CQ 25mg/kg over 3 days
Malaria & only if high suspicion of
Prepare slide malaria

Positive for Positive for


Positive for RDT Negative:
P. vivax P. falciparum
P. falciparum Wait
CQ if not In other states:
Treat with: ACTSP for slide result.
already Treat with: ACTSP
for 3 days + Give CQ 25mg/kg
given + for 3 days
PQ Single dose over 3 days, if
PQ 0.25 + PQ Single
on second day high suspicion of
mg/kg single dose onPQ 0.75mg
dose for 14 per kg body
If confirmed as days over weight
Pv 3days, if high Single dose on
CQ if not already suspicion of second day
Given PQ 0.25 malaria
mg/kg/day over
14 days

Figure-2: Management of suspected Malaria

Note: if a patient has severe symptoms at any ACT-SP- Artemisinin-based Combination


stage, then immediately refer to a facility with Therapy (Artesunate+Sulfadoxine-
indoor patient management. Pyrimethamine) CQ Chloroquine PQ
Primaquine.
Note: PQ is contra-indicated in pregnancy
and in children under 1 year (Infant). Where microscopy result is not available
within 24 hours and Bivalent RDT is used

Page 101
Suspected malaria case

Do blood test with RDT

Positive for Positive for Positive for Negative


P. falciparum P. vivax Mixed infecion No anti-
Treat with: ACTSP Treat with: SP-ACT 3 days + malarial
for 3 days + CQ 3 days Primaquine 0.25 mg per Treatment
PQ Single dose on second + PQ 14 days kg body weight daily for
day malaria case 14 days.

Figure-3: Suspected Malaria management based on RDT results

ACT-SP- Artemisinin-based Combination Therapy Drug schedule for treatment of P vivax malaria:
(Artesunate+Sulfadoxine-Pyrimethamine).
i. Chloroquine:
CQ Chloroquine PQ - Primaquine
25 mg/kg body weight divided over three days i.e.
Differential Diagnosis:
10 mg/kg on day 1,
Other causes of fever like Dengue, UTI, URTI. All
10 mg/kg on day 2 and
D/D can be excluded by using lab investigation
(microscopy/RDT). 5 mg/kg on day 3.
ii. Primaquine:
0.25 mg/kg body weight daily for 14 days.
9. Treatment
Primaquine is contraindicated in infants, pregnant
9.1. Treatment of Vivax Malaria women and individuals with G6PD deficiency.
Diagnosis of vivax malaria may be made by the use
of RDT (Bivalent) or microscopic examination of the 14 day regimen of Primaquine should be given under
blood smear. On confirmation following treatment is supervision.
to be given:

Table-1: Dosage Chart for Treatment of Vivax Malaria


Day 4 to 14
Day 1 Day 2 Day 3
Age
CQ (150 PQ CQ (150mg PQ (2.5 CQ (150mg PQ (2.5mg) PQ (0.25
mg base) (2.5mg) base) mg) base) mg)
Less than
0 0 0 0
1 yr
1-4 years 1 1 1 1 1 1
5-8 years 2 2 2 2 1 2 2
9-14 years 3 4 3 4 1 4 4

Page 102
15 yrs or
4 6 4 6 2 6 6
more*
Pregnancy 4 0 4 0 2 0 0

Note: Chloroquine250mg tablet is having 150 mg base

9.2. Treatment of Falciparum Treatment of uncomplicated P.falciparum cases in


pregnancy:
Malaria 1st Trimester: Quinine salt 10mg/kg 3 times
Diagnosis of falciparum malaria may be made by the daily for 7 days.Quinine may induce
use of RDT (Monovalent or Bivalent) or microscopic hypoglycemia; pregnant women should not start
examination of the blood smear. It is imperative to taking quinine on empty stomach and should eat
start the treatment forfalciparum malaria immediately regularly, while on quinine treatment.
on diagnosis. The treatment for falciparum malaria is 2nd and 3rd trimester: ACT as per dosage
as follows: schedule given above.
Dose schedule for Treatment of uncomplicated
P.falciparum cases:
i. Artemisinin based Combination Therapy (ACT- 9.3. Treatment of mixed infections
SP)* (P.vivax + P.falciparum) cases
Artesunate 4 mg/kg body weight daily for 3 days Plus All mixed infections should be treated with full
Sulfadoxine (25 mg/kg body weight) course of ACT and Primaquine 0.25 mg per kgbody
Pyrimethamine (1.25 mg/kg body weight) on first weight daily for 14 days.
day. SP-ACT 3 days + Primaquine 0.25 mg per kg body
* ACT is not to be given in 1st trimester of wt. daily for 14 days.
pregnancy.
ii. Primaquine: 0.75 mg/kg body weight on day 2.

Table-2: Treatment of mixed infections

Day 4to
Day 1 Day 2 Day 3
14
Age As tablet SP tablet PQ (2.5 As tablet PQ (2.5 As tablet PQ PQ (0.25
(50 mg) mg) (50mg) mg) (50 mg) (2.5mg) mg)
Less than
1 yr 0 0 0 0

1-4 years 1 1 1 1 1 1 1 1
5-8 years 2 1 2 2 2 2 2 2
9-14 years 3 2 4 3 4 3 4 4
15 yrs or
more 4 3 6 4 6 4 6 6

All cases of mixed infection are to be treated as Pf treatment and is still having symptoms after 72 hours,
plus primaquine for 14 days. treatment failure may be suspected.

When a patient fails to respond to treatment The course of action when a patient has persistent
(symptoms fail to disappear, or they reappear), one symptoms is:
should think of the possibility of drug resistance in Ask the patient and the family a series of
such case refer patient to FRU. In the absence of any questions to help rule out some of the causes
of these conditions, if a patient has completed full (Did the patient get the drug from an authentic,
designated provider? Did the patient get the right

Page 103
amount of the drug? Was all of it swallowed as Macroscopic haemoglobinuria.
prescribed? Was the drug vomited out? How Hyperthermia.
many days has it been since drug treatment was Hyperparasitaemia.
begun (if it is not yet72 hours, one can wait)? Foetal and maternal complications are more common
Can you see the packing to check the expiry in pregnancy with severe malaria; therefore, they
date? Are there symptoms of other obvious need prompt attention.
causes of fever? If the symptoms had
disappeared and then reappeared, how long was 10.2 In children, febrile convulsions, repeated
the interval (if more than 15 days, it could be a vomiting and dehydration are common if the
fresh infection)?) temperature is high due to any cause.
If it appears that the drug was not adequately Therefore, these symptoms are not
taken or retained, a fresh course may be given necessarily indicative of severe malaria.
unless the patient has symptoms of severe However, children with such symptoms
malaria. Take a fresh blood11smear (take two, should be managed as severe malariain
for checking in different laboratories, if need be), routine program situations, and a diagnosis
and ask the nearest health care provider to keep of malaria should be confirmed at the
an eye on the patient. earliest.
Refer any patient who has symptoms despite
taking and retaining a full course of treatment, or 10.3 In pregnancy, malaria, especially
who has developed symptoms of severe malaria. P.falciparum is a serious disease because
with each bout of malaria, there is a
reduction in haemoglobin and profound
10. Severe and complicated anaemia may develop rapidly. They are also
malaria at high risk of abortions or intrauterine
growth retardation because sequestration of
10.1. Clinical Features parasites in placenta restricts oxygen and
Severe manifestations can develop in P. falciparum nutrients flow to the fetus. The management
infection over a span of time as short as 12-24 hours of severe malaria is possible in health
and may lead to death, if not treated promptly and facilities which are equipped with the
adequately. Severe malaria is clinically characterized following:
by confusion or
Parenteral Antimalarials, antibiotics,
Drowsiness with extreme weakness (prostration) anticonvulsants, antipyretics.
along with one or more of the following features: Intravenous infusion equipment and fluids.
Impaired consciousness/coma Special nursing for patients in coma.
Repeated generalized convulsions Facilities for blood transfusion.
Renal failure (Serum Creatinine>3 mg/dl) Well-equipped laboratory.
Jaundice (Serum Bilirubin >3 mg/dl) Oxygen respirator.
Severe anaemia (Hb<5 mg/dl) Often these items are not available at the PHC level.
Pulmonary oedema/acute respiratory distress Under such circumstances, the MedicalOfficer, PHC
syndrome and paramedical staff should be able to administer
Hypoglycaemia (Plasma glucose <40 mg/dl) emergency treatment and refer the case without delay
to other institutions where such facilities are
Metabolic acidosis
available.
Circulatory collapse/shock (Systolic BP<80 mm
Hg, <50 mm Hg in children). 10.4. Treatment of severe malaria
Abnormal bleeding and disseminated
intravascular coagulation. cases
Haemogolobinuria. Severe malaria is an emergency and treatment should
Hyperthermia (Temperature >106F or 42C). be given as per severity and associated complications
which can be best decided by the treating physicians.
Hyperparasitaemia (<5% parasitized RBCs in
low endemic and >10% in hyperendemic areas). The guidelines for specific antimalarial therapy is as
follows:
Metabolic acidosis.
Circulatory collapse/shock. Parenteral artemisinin derivatives or quinine should
Spontaneous bleeding and laboratory evidence of be used irrespective of chloroquine resistance status
DIC. of the area with one of the following options:

Page 104
Table 3: Chemotherapy of severe and complicated malaria

Initial parenteral treatment for at least48hours:CHOOSE Follow-up treatment, when patient can takeoral
ONE of following four options medication following parenteral treatment
Artesunate: 2.4 mg/kg i.v. or i.m. given on admission Full oral course of Area-specific ACT:
(time=0), then at 12 h and24 h, then once a day.
In other states: Treat with: ACT-SP for 3days + PQ
Single dose on second day
Quinine: 20mg quinine salt/kg body weight on Quinine 10 mg/kg three times a day
admission (IV infusion or
with:
divided IM injection) followed by maintenance dose
doxycycline 100 mg once a day or
of10 mg/kg 8 hourly;
Clindamycin in pregnant women and children under 8
Infusion rate should not exceed 5 mg/kg per hourin
years of age,- to
normal saline. Loading dose of 20mg/kg should not be
given, if the patient has already received quinine. Complete 7 days of treatment.

Note: The parenteral treatment in severe malaria cases should be given for minimum of 24 hours once started
(irrespective of the patients ability to tolerate oral medication earlier than24 hours).

Note:
The parenteral treatment should be given for minimum of 48 hours.
Once the patient can take oral therapy, give:
Quinine 10 mg/kg three times a day with doxycycline 100 mg once a day orclindamycin in pregnant women and
children under 8 years of age, to complete 7days of treatment, in patients started on parenteral quinine.
Full course of ACT to patients started on artemisinin derivatives.
Use of mefloquine should be avoided in cerebral malaria due to neuro psychiatric complications associated with
it.

Supplementary treatment
In unconscious patient, monitor blood glucose level every 4 to 6 hours and treat hypoglycemia with IV dextrose. If
blood sugar estimation is not available one can presume hypoglycemia in all cases of severe and complicated
malaria especially cerebral malaria and treat with intravenous glucose 100 ml of 25% glucose before giving
quinine.
All unconscious patients on quinine should receive a continuous infusion of 5 to10%dextrose.
Parasite count and hematocrit level should be measured every 6 to 12 hourly.
Transfuse whole blood or packed cell concentrate when hematocrit drops to <20%.
Renal function should be checked daily, institute early hemodialysis if necessary.
Fluid management should be carefully done.
Treat convulsions with IV diazepam and shift the patient to an Intensive Care Unit with facilities for ventilator
support.

10.5. Some donts in severe malaria case management


Do not use corticosteroids, give intravenous mannitol, use heparin as anticoagulant, administer adrenaline or
overhydrate.

In recent years, increased attention has been drawn to severe malaria caused by P.vivax, especially in Indonesia and
Papua New Guinea, where this parasite has become chloroquine resistant. Some cases have been found in India, and
there is reason to fear that this problem will become more common in the coming years. Historically, P.vivax has
been an important cause of death in India and in Europe, and this parasite can no longer be considered as benign.

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10.6. When to refer: Any of the following
i. Platelet count 20,000/cmm.
ii. Pregnancy with malaria.
iii. Any feature of complicated malaria.
iv. Renal failure.
v. ARDS.
vi. Malaria with sepsis.
vii. Malaria with shock.

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46. DENGUE
DF/DHF is caused by a group B arbovirus
1. Introduction (Flavivirus) and includes serotypes 1, 2, 3 and 4
(Den-1, Den-2, Den-3 and Den-4). Infectionwith any
In Maharashtra State, cases of Dengue Fever / one serotype confers lifelong immunity to thevirus
Dengue Hemorrhagic Fever occur eitherin post- serotype, but no cross protection for other serotypes.
monsoon period when breeding of mosquitoes is It is caused due to bite of an infected female Aedes
highest due to accumulation of rainwater in discarded aegypti mosquito.
materials or during scarcity season due to Aedes
breeding in stored waterin cement tanks and earthen Mode of Transmission It is transmitted through
pots which are not emptied regularly. bite of Ades aegypti mosquito.
Incubation period: Varies from 5-10 days.
2. Etiologic agent
3. Diagnosis
Table-1: Recommended diagnostic tool according to laboratory service level

Primary health District health Reference


care centres centres centres
Genome Detection Yes
NS1 Ag detection Rapid tests Yes Yes Yes
ELISA Yes Yes
IgM detection Rapid tests Yes Yes Yes
ELISA Yes Yes
IgG detection ELISA Yes
IHA Yes
Neutralization assay Yes

ELISA = enzyme-linked immunosorbent assay; IgG = immunoglobulin G; IgM = immunoglobulin M; IHA = indirct
haemagglutination; NS1 Ag =non- structural protein 1 antigen.

4. Clinical spectrum
Following is the spectrum of dengue viral
infection.

Figure-1: Dengue Clinical Spectrum

Dengue Viral infection

Asymptomatic Symptomatic

MILD MODERATE SEVERE

Undifferentiated fever Dengue fever Dengue Hemorrhagic fever

Without Bleeding With bleeding DHF DSS

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precedes rise in hematocrit. A rise of more than
5. Clinical management 20% indicates need for intravenous fluid
Depending upon severity of infection, management therapy.
of the cases differs. Early diagnosis & admission of If hematocrit determination is not possible,
DHF patients is important in order to reduce case hemoglobin estimation may be carried out as an
fatality rates. alternative.
Hematocrit should be determined daily from
5.1. Dengue fever the third day until the temperature remains
normal for one or two days.
Management of Dengue fever is symptomatic and
supportive. Paracetamol is recommended to keep
temperature below 400c. Dosages of
Bed rest is advisable during acute febrile phase.
paracetamol recommended are: 1 - 2 years: 60-
Antipyretics and sponging is essential to keep
120 mg/dose, 3 - 6 years: 120 mg/dose & 7 - 12
body temperature of patient below 370C. Do
years: 240 mg/dose.
not prescribe Salicylates (Aspirin) to suspected
Plenty of fluids like ORS & or fruit juices
DF patient. Paracetamol is preferred.
should be given orally, to the extent patient
Analgesic or a mild sedative may be prescribed
tolerates.
for severe pain.
Management of Grade II DF/DHF
ORS solution is recommended for patients with
excessive sweating, nausea, vomiting or Any person who has DF with
diarrhoea to prevent dehydration. thrombocytopenia & hemoconcentration &
Patients should be monitored in DHF area until presents with abdominal pain, black tarry
they become afebrile & after platelet & stools, epistaxis, bleeding from gums etc. needs
hematocrit determinations are normal. to be hospitalized. Such patient should be
observed for signs of shock.
5.2 Dengue Hemorrhagic Fever The critical period for development of shock is
transition from febrile to afebrile. phase of
Management of Grade I DF/DHF
illness, which usually occurs after third day of
Management during febrile phase is similar to
illness.
that of DF.
A rise of hematocrit of 20% or more reflects
Patient should be monitored closely. Critical
need for IV fluid therapy.
period for monitoring is transition from febrile
to afebrile stage, which usually occurs after If despite of treatment, patient develops features
third day of illeness. of shock, management of grade III & IV should
be started.
Platelet count & hematocrit estimation is
essential. Blood transfusion may be indicated in patients
with severe shock, massive bleeding and DIC.
Drop in platelet count to <1,00,000/cumm i.e.
1-2 platelets per oil immersion field usually

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5.3. Figure-2: Management of grade I & II DHF - Volume replacement flow chart

Hemorrhagic tendencies, Thrombocytopenia, hematocrit rise, pulse


pressure low

Initiate IV therapy 6ml/kg/hr with crystalloid solution for 1 - 2 hours

Improvement No Improvement

Reduce IV 3ml/kg/hr Increase IV 10ml/kg/hr


crystalloid solution, 6-12 hrs crystalloid solution, 2 hrs

Further Improvement

No Improvement
Improvement
Unstable vital signs
Discontinue IV after
24 hrs

Hematocrit rises Hematocrit falls


Reduce IV 6ml/kg/hr
cry. solution, with
further reduction to IV colloid Dextran Blood transfusion
3ml/kg/hr, discontinue (40) 10ml/kg/hr, 10ml/kg/hr,
after 24-48 hrs duration 1 hr duration 1 hr

Improvement

IV therapy by crystalloid. Successively reduce the flow from 10 to 6 & 6


to 3ml/kg/hr. Discontinue after 24 - 48 hours

Improvement: Hematocrit falls, pulse rate & BP stable, urine output rises
No improvement: Hematocrit, pulse rate rises, pulse pressure falls below 20 mm Hg, urine
output falls
Unstable vital signs: Urine output falls, signs of shock

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Figure-3: Management of grade III & IV DHF - Volume replacement flow chart

Unstable vital signs


Urine output falls, signs of shock

Immediate, rapid volume replacement: Initiate IV


therapy 10-20 ml/kg/hr crystalloid solution for 1 hr

Improvement No improvement

IV therapy by crystalloid. Oxygen

Successively reduce the flow from 20


to 10, 10 to 6 & 6 to 3ml/kg/hr.

Hematocrit Hematocrit falls


Further RISESRISESNBN
Improvement

IV colloid (Dextran 40) or plasma Blood transfusion 10


Discontinue IV 10 ml/kg/hr as IV bolus (repeat if ml/kg/hr if, hematocrit is
after 24 hrs necessary) still more than 35%

Improvement

IV therapy by crystalloid.

Successively reduce the flow from 10 to 6 & 6 to


3ml/kg/hr. Discontinue after 24 - 48 hours

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47. LEPTOSPIROSIS
Hypotension & circulatory collapse.
1. Introduction
Jaundice Important clinical feature.
Leptospira is an infectious disease caused by
spirochetes leptospire interrogans Mild to severe.

Leptospires enter the host through abrasions in the Starts after 4 to 7 days of illness.
skin or through intact mucosa, especially the Hepatomegaly liver tenderness usually present.
conjunctiva and the lining of oro- and nasopharynx
when they come in contact with water contaminated Almost invariably present is renal involvement.
with leptospira. ATN and interstitial nephritis are pathologic
features.
2. High risk group
Hematuria and cola coloured urine with RBC
Agricultural workers. casts.
Fisherman,sewer workers. Oliguria and anuria.
Lorry drivers and masons. Edema, facial puffiness, breathlessness,
Usually starts at the onset of rainy season and convulsions.
declines as the rains recede. Renal impairment worsens in 1st to 2nd week,
recovers by the end of 4th week with treatment.
3. Anicteric leptospirosis
Lung-Hemorrhagic pneumonitis with interstitial
Acconts for 90% cases, usually recover completely and alveolar hemorrhages.
with proper treatment.
High mortality.
Fever - with chills. Moderate to severe.
Death occurs within few hrs to 2 days.
Myalgia very characteristic finding. Calf,
abdominal& lumbosacral muscles are very Mild cases- cough, chest pain and hemoptysis.
painful & severely tender. Increase in serum
Severe cases- breathlessness increases and
Creatinine Phosphokinase.
patient goes into respiratory failure.
Conjunctival Suffusion reddish colouration.
Pancreatitis and acalculous cholecystitis can
Headache commonly in frontal region.
occur.
Renal involvement is invariable.Asymptomatic
Cardiac involvement
in the form of mild proteinuria with few casts in
urine. Hypotension shock- cold clammy skin,
tachycardia and hypotension due to dehydration
Cough chest pain & few cases hemoptysis.
and peripheral vasodilation.
Bleeding tendency in few cases.
Arrhythmias- palpitations, syncope and irregular
All cases of fever with myalgia & conjunctival pulse, AV blocks and ST and T wave changes.
suffusion should be considered as a suspect case
CNS Meningitis usually present. Headache,
of leptospirosis.
irritability, restlessness, seizures and late stage is
coma.
4. Icteric leptospirosis
Maculopapular erythematous skin lesions over
Weils disease. face, trunk and extrimities.
Fever, Myalgia, Headache, Conjunctival Bleeding in leptospira not directly related to the
suffusion. level of thrombocytopenia.
Oliguria, anuria, proteinuria.
Nausea, vomitting,diarrhoea, abominal pain.

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Rise in enzyme level is not very high as
5. Investigations compared to that in viral or alcohalic hepetitis.
CBC Thrombocytopenia is characteristic. Raised CPK helps to differentiate from viral and
LFT direct hyperbilirubinemia., raised alcoholic hepatitis.
Alk.PO4 ,rise in bilirubin is very fast & reaches Raised serum creatinine levels.
high level. Urine albuminuria.

Table 1: Lab Investigations for Leptospirosis

CULTURE MICROSCOPY IMMUNOLOGICAL MOLECULAR

Blood (10 days) Dark Field MAT PCR


Urine (10-30 days) Silver impregnation ELISA
CSF (5-10 days) Latex agglutination tests

Labotratory diagnosis for current leptospirosis AVOID NEPHROTOXIC DRUGS in cases with
renal involvement
Culture positive
Severe cases- meticulous correction of
MAT- seroconversion/four fold rise in the titre
hypovolumia and electrolyte imbalance, fluid
High titre management as per CVP.
ELISA/Latex agglutination positive. Patient with renal failure may require
hemodialysis.
6. Treatment
6.1 Mild Case 7. Complications
Tab. Doxy 100 mg BD for 7 days Fluid overload, hyperkalemia, acidosis
Cap. Ampi and Cap. Amox 30-50 mg/kg 5-7
LUNG INVOLVEMENT-Continue O2 therapy
days.
Inj. CP 20 lac units 6 hrly AST for 5-7 days or In patients with alveolar hemorrhages with
Inj ampicillin 500mg-1 gm 6 hrly 5-7 days ARDS, they require mechanical ventilation with
low tidal volume and high PEEP.
Mortality is very high.
6.2 Severe case Supportive treatment with Platelet conc, FFP, Vit
K.
Inj. Ceftriaxone/ Cefotaxime or Erythromycin

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48. INFLUENZA A- H1N1 (SWINE FLU)

We have faced pandemic of this Communicable air


borne disease in 2009. This is commonly known as
5. Mode of transmission
swine flu. Influenza spreads form person to person by droplet
infection created by sneezing, coughing or talking.
1. Epidemiological factors The portal of entry is the respiratory tract.

Pandemic Influenza A (H1N1) 2009, currently the


most common circulating strain of influenza virus
6. Incubation period
globally, first caused illness in Mexico and the It could range from one to seven days, and most
United States in March and April, 2009. likely from one to four days.

2. Agent factors 7. Signs and symptoms


The causative agent is Influenza virus. It is an An acute Respiratory Tract Infection (RTI), caused
enveloped RNA virus and belongs to the family by Influenza virus, characterised by sudden onset of:
Fever/chills, Headache, myalgia, Sore throat, Cough,
orthomyxoviridae. The size of the virus is 80-200 nm
Coryza, and Prostration.
/.08 -0.12 micron in diameter. There are three types Range of symptoms differs by age. Vomiting &
of influenza viruses, namely A, B & C which are diarrhea in children/elderly. Fever alone in infants
characteristically distinct and bear no cross may be atypical in elderly. Serious complications can
immunity. The virus contains two surface antigens H occur among high risk groups.
(hemagluttinin) and N (neuraminidase).
8. Diagnosis
3. Host factors The recommended test to confirm the diagnosis of
H1N1 influenza A virus is real-time Polymerase
The disease can occur in all ages and both sexes. Chain Reaction (RT-PCR) in designated laboratories.
Also viral culture and four-fold rise in new influenza
4. High Risk Groups A (H1N1) virus-specific eutralizing antibodies can be
done.
These risk groups include:
8.1. What sample to be collected?
Children younger than 5 years old;
Nasopharyngeal/oropharyngeal swabs.
Adults 65 years of age and older;
Brochoalveolar lavage.
Chronic pulmonary condition (including
Tracheal aspirates.
asthma), cardiovascular (except hypertension),
renal, hepatic, hematological (including sickle
Nasopharyngeal/oropharyngeal aspirates as
washes.
cell disease), neurologic, neuromuscular, or
metabolic disorders (including diabetes Samples should be collected in VTM.
mellitus);
8.2. Transportation of samples:
Immunosuppression, including that caused by
medications or by HIV; All samples should be kept at 2-8 degree Celsius
Pregnant women; until they can be placed at -70 C.
Residents of nursing homes and other chronic- Samples transported on dry ice in triple
care facilities; packaging.
Obesity. Clear labels with patients complete information.
Samples should be sent to within 24 hrs.

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9. Treatment Patients on long term cortisone therapy.
Obese persons.
Treatment with oseltamivir or zanamivir is
No tests for H1N1 is required for Category-B
recommended for all people with suspected or
confirmed influenza who require hospitalization. It is (1) and (2).
given in a dose of 75 mg Bid in adults.
All individuals seeking consultations for flu like All patients of Category-B (1) & (2) should
symptoms should be screened at healthcare facilities confine themselves at home and avoid mixing
both Government and private or examined by a with public and high risk members in the family.
doctor and these will be categorized as under: Broad Spectrum antibiotics as per the Guideline
for Community-acquired pneumonia (CAP) may
9.1. Category- A be prescribed.

Patients with mild fever plus cough / sore


throat with or without bodyache, headache,
9.3. Category-C
diarrhoea and vomiting will be categorized as In addition to the above signs and symptoms of
Category-A. They do not require Oseltamivir Category-A and B, if the patient has one or more of
and should be treated for the symptoms the following:
mentioned above. The patients should be
Breathlessness, chest pain, drowsiness, fall in
monitored for their progress and reassessed at 24
blood pressure, sputum mixed with blood, bluish
to 48 hours by the doctor.
discolouration of nails;
No testing of the patient for H1N1 is required.
Children with influenza like illness who had a
Patients should confine themselves at home and
severe disease as manifested by the red flag signs
avoid mixing up with public and high risk
(Somnolence, high and persistent fever, inability
members in the family.
to feed well, convulsions, shortness of breath,
difficulty in breathing, etc).
9.2. Category-B Worsening of underlying chronic conditions.

1. In addition to all the signs and symptoms


All these patients mentioned above in Category-C
mentioned under Category-A, if the patient has
require testing, immediate hospitalization and
high grade fever and severe sore throat, may
treatment.
require home isolation and Oseltamivir;
2. In addition to all the signs and symptoms
mentioned under Category-A, individuals having 9.4. Oseltamivir Medication -Doses
one or more of the following high risk conditions Details
shall be treated with Oseltamivir:
Children with mild illness but with predisposing Oseltamivir is the recommended drug for treatment.
risk factors.
In the current phase, if a person confirms to the case
Pregnant women;
definition of suspect case, should be provided
Persons aged 65 years or older;
Patients with lung diseases, heart disease, liver Oseltamivir.
disease,kidney disease, blood disorders, diabetes,
neurological disorders, cancer and HIV/AIDS;

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Dose for treatment is as follows:
By Weight:
For weight <15kg 30 mg BD for 5 days
15 -23kg 45 mg BD for 5 days
24 -<40kg 60 mg BD for 5 days
>40 kg 75 mg BD for 5 days

risk persons (DM, HT, Obese, Respiratory diseases,


10. Vaccine Immuno comproised).
A Vaccine is available for swine flu. It gives imunity
for one year. It is given to pregnant mothers, high

Page 115
49. DIARRHOEAL DISEASES
Diarrhoeal diseases include acute diarrhoea, Acute diarrhoea Cholera, Rota virus, Food
persistent diarrhoea (diarrhoea duration two weeks poisoning, gastrointestinal disorders and
or more) and dysentery (blood stained stools with medications (rare).
fever). Diarrhoeal diseases are one of the most
common causes of epidemic in our State. Most of Persistent diarrhoea Chronic bacterial
the deaths in diarrhoeal diseases are due to infections, inflammatory bowel disorders,
dehydration which is preventable by timely and malabsorption syndrome.
adequate replacement of fluids. Dysentery Amoebiasis, Giardiasis,
Shigellosis.
1. Following are important
causes of diarrhoeal
diseases in rural areas

Table-1: Diagnosis of diarrhoea


Sign/symptom Acute diarrhoea Persistent diarrhoea Dysentery
Frequency of stools/day Three or more Three or more Three or more
Consistency of stools Watery Variable Variable
Duration of diarrhea Less than 2 weeks Two or more weeks Less than 2 weeks
H/o fever No Variable Yes
H/o blood stained mucus No Variable Yes
Effect on appetite No Loss of appetite Loss of appetite
Dehydration Important, may lead to Patient may have Patient may have
severe dehydration if not some dehydration. some dehydration
treated in time.
Treatment principle Management of Start management of Start management of
dehydration is priority dehydration. dehydration.
Simultaneously find Simultaneously start
cause of persistent appropriate
diarrhoea and treat antibiotics.
accordingly.
Long term effects No long term effect for If not treated Repeated attacks may
occasional episodes. correctly, child may lead to Protein
Repeated attacks may get severe Protein Energy Malnutrition
lead to PEM. Energy Malnutrition

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Table-2: Dehydration Diagnosis Chart
Severity of symptoms and signs (Encircle the finding)
Sign/Symptom
No dehydration Some dehydration Severe dehydration
General condition of Patient well alert Restless and irritable Lethargic, unconscious,
Patient floppy
Presence of thirst Normal/not thirsty Thirsty, drinks water Not able to drink
immediately when
offered
Dryness of mouth and Moist mouth and tongue Mouth and tongue dry Mouth and tongue very
tongue dry
Condition of eyes Normal Sunken Very sunken, patients
face looks like old
man's face.
Condition of tears Tears appear while Tears appear while No tears, dry eyes even
crying crying in crying child
Skin turgor Normal. Pinch to skin Pinch slowly goes back Pinch remains as it is
immediately goes back and takes some time to for 2-3 seconds and then
to normal. become flat. slowly goes back.
Classification of No dehydration Some dehydration Severe dehydration
dehydration
Treatment of Plan A Plan B Plan C
dehydration

Symptoms and signs of cholera are entirely due to


2. Important diseases causing loss of large volume of isotonic fluid and resultant
diarrhoea or dysentery in depletion of intravascular and extra vascular fluid
leading to severe dehydration, metabolic acidosis
adults and hypokalemia. Patient develops thirst, cramps,
Cholera and anxiety due to depleting isotonic fluid.

Cholera is the most important diarrhoeal disease Diagnosis


which leads to rapid dehydration. Suspect cholera when patient has severe watery
Etiologic agent diarrhoea and vomiting. Collect stool sample of
suspected cases in Cary Blair media and transport to
Cholera is caused by bacteria Vibrio cholerae which District Public Health Laboratory. However,
exists in two biotypes, Classical and El tor. Each treatment and control measures should be started
biotype is further divided into two subgroups Inaba immediately on the basis of clinical
and Ogawa. symptomatology without waiting for laboratory
Clinical manifestations confirmation.

Cholera is an acute infection of small intestine Treatment


manifested as watery diarrhoea and vomiting. Carefully examine patient for signs of dehydration
Clinical spectrum of cholera is broad, ranging from and treat as per dehydration status. Most important
in-apparent infection to cholera gravis, which may treatment of cholera is rehydration of patient with
be fatal in few hours. Incubation period of 24 to 48 ORS and Ringers Lactate. In addition to this, start
hours is followed by abrupt onset of painless, one of the following antibiotics to patient -
profuse and watery diarrhoea associated with
vomiting. Cap. Doxycycline 6 mg/kg/ day as a single
dose for 3 days OR

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Cap. Tetracycline 50mg/kg/day in 4 divided Principle of treatment
doses for 3 days OR
As diarrhoea is continuing, there is continuous loss
Tab. Erythromycin 30mg/kg/day in 3 divided of water and electrolytes from body of patient
doses for 3 days. which may lead to dehydration. Therefore principle
of Plan-A schedule is correction of whatever loss of
3. Diagnosis of dehydration water and electrolytes before the patient develops
signs of dehydration. Plan-A can be advised at
Although number of organisms are responsible for home to caretaker of patient. However make sure
causing diarrhoea, clinical presentation is same i.e. that care taker has understood danger signs of
passage of watery stools leading to dehydration in dehydration (like thirst). Following steps are
all these cases. Therefore assessment of recommended in Plan-A.
dehydration status and correct management of
dehydration by ORT is mainstay of diarrhoeal a. Home available fluids
disease control programme. Advise to give Home Available Fluids (HAF)
e.g. sarbat, lassi, vegetable soup, khir,
4. Management of buttermilk, tea, coconut water, etc. i.e. any
dehydration liquid available at home to patient as much
he/she can drink.
Most important aspect in management of diarrhoeal
diseases is correction of dehydration. Continue breast feeding and feeding If child
is being breastfed, then breast-feeding should
Treatment of dehydration is divided into three plans be continued. Regular feeding of non-breast fed
as follows - child should also be continued.
Plan-A: For patients with no dehydration b. ORS to prevent dehydration
principle is to prevent dehydration.
If frequency and amount of diarrhoea is not
Plan-B: For patients with some dehydration declining or amount of stool is large, then start
principle is treatment of some dehydration and ORS.
preventing patient from going into severe
dehydration. Contents of WHO ORS are as follows (New
low osmolarity ORS).
Plan-C: For patients with severe dehydration -
This is life saving plan. Rehydrate patient as Sodium chloride - 2.6 grams
early as possible and prevent from going again Potassium Chloride - 1.5 grams
into severe dehydration.
Trisodium Citrate - 2.9 grams
Description of treatment plans in details is as
follows. Glucose - 13.5 grams

4.1. Plan-A
Plan-A is for patients who are having diarrhoea but
no signs of dehydration.

Dissolve the packet in one litre of water to prepare Add whole packet of ORS into one-litre of
ORS. water and stir till all powder is dissolved. Now
ORS is ready for use.
Show caretaker how to prepare ORS.
Following steps should be carried out for Give ORS by cup or spoon to small children
preparation of ORS - and by glass to bigger children and to adults as
per indicated dose.
Take clean pot of one and half litre capacity
and one clean spoon. If patient has vomiting, wait for 5 minutes and
start again.
Pour 1 litre of clean drinking water in the pot.
(No need to boil water). Keep ORS covered. Once prepared ORS should
be used within 24 hours. Do not use ORS

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beyond 24 hours, as there are chances of Less than 6 months - 50ml
contamination.
6 months to 2 years - 50 - 100 ml
If child develops swelling on eyelids, stop ORS
2 to 5 years - 100 - 200 ml
as it indicates overdose.
Ask her to give ORS in following doses after
passage of each liquid stool.
4.2. Plan -B Principle of treatment

Start Plan-B treatment to patients showing signs and Patient with some dehydration should be given ORS
symptoms of some dehydration as per dehydration for correction of dehydration.
diagnosis chart. Aim of this plan is to correct Dose of ORS: Dose of ORS is calculated preferably
dehydration and prevent patient from going into according to weight of patient. Give ORS in a dose
severe dehydration. of 100ml/kg in 4 hrs. If weighing is not possible,
calculate age wise ORS requirement for four hours
as follows
Table -3: Age wise ORS requirement for four hours
Age < 4 months 411 months 1223 months 2 4 years 5 14 years 15 + years
Dose 200-400 ml 400 600 ml 600 800 ml 800 1200 ml 1200 2200 ml 2200-4000 ml

Continue breast feeding and feeding If child is Re-examination of patient


being breastfed, then breast-feeding should be Re-examine patient after every four hours for status
continued. Regular feeding of non-breast fed child of dehydration with the help of Dehydration.
should also be continued.

Table-4: Management advice based on re-examination findings


Condition of patient on re-examination Management advise
Patient improves, no signs of dehydration on Keep patient under observation for 24 hours. Continue
examination and diarrhoea stops HAF. Observe if diarrhoea and/or vomiting start again.
Patient improves, no signs of dehydration on Continue giving ORS in doses suggested in Plan-A, re-
examination but diarrhoea continues examine after four hours.
Dehydration status same Continue with Plan-B. Check whether ORS is being
given in correct dose. Re-examine after four hours.
Signs of severe dehydration appear Switch on to Plan - C (start IV fluids). Continue to give
ORS as much as possible.

4.3. Plan C
If signs and symptoms of patient are suggestive of Principles of management
severe dehydration, start Plan C. This is Principle of management of severe dehydration is
emergency plan. Incorrect or incomplete replacing fluid loss by giving rapid IV infusion.
management of severely dehydrated patient may Only Ringer's lactate should be used as IV fluid and
lead to death of patient. Medical Officer must the dose is 100ml/kg body weight.
personally examine patient and treat for severe
dehydration.

Page 119
Table -4: Details of Ringers Lactate administration
Duration of
Age group Intensive phase Maintenance phase Remarks
treatment
Infants (0-1 30-ml/kg body wt. 70ml/kg body wt in Assess patient after
6 hrs
year) during first 1 hour. next 5 hours. every 6 hours
Older children 30-ml/kg body wt. 70ml/kg body wt in Assess patient after
3 hrs
and adults in first half hour. next 21/2 hrs. every 3 hours
Re-examination of patient dehydration with the help of dehydration diagnosis
chart and decide management plan as follows -
Re-examine patient after every six hours in infants
and three hours in adults for status of
Table-5: Treatment advice based on condition of patient
Condition of patient Treatment advise
Patient improves, no signs of dehydration on Keep patient under observation for 24 hours as patient
examination and diarrhoea stops may start diarrhoea/vomiting again
Patient improves, no signs of dehydration on Continue giving ORS (Plan-A)
examination but diarrhoea continues
Patient improves, signs of some dehydration Stop IV fluids after required dose is administered.
on examination. Continue giving ORS (Plan-B)
Dehydration status same Continue with Plan-C. Check for any complications
like anuria. If yes carefully examine the patient and
decide for referral. Continue giving IV during
transportation of patient.

ORS or Oral rehydration therapy (in case ORS is


5. Use of antibiotics and not available), irrespective of type of dehydration.
other drugs Zinc administration as per age of child:

Antibiotics are recommended only to suspected a) Children from 2-6 months:


patients of cholera and dysentery. Other drugs like Children aged between 2-6 months should be given
anti motility drugs, binding agents, anti secretary 10 mg of elemental zinc per day for a total period of
agents and steroids are not of any use in 14 days from the day of onset of diarrhoea. A tablet
management of diarrhea. They are harmful to of zinc contains 20 mg of elemental zinc. Therefore
patients and therefore not at all recommended for half tablet should be given to the children in this age
treatment. Judicious use of antibiotics is appropriate group. Zinc when supplied in the form of
in selected patients. Severely ill patients with febrile dispersible tablets, easily dissolves in breast milk or
dysentery can be treated with ciprofloxacin 500mg water. Therefore, in infants below 6 months of age,
bd for 3-5 days. the tablet should be given by dissolving in breast
Use of Zinc Tablets milk and in infants above 6 months of age, it should
be given by dissolving in breast milk or water.
Zinc Dosage Recommendation:
b) Children above 6 months:
Zinc is very safe drug and has a very large window
of safety. Zinc dispersible tablets are to be given in One full tablet (20mg) should be given to all
each diarrhoeal episode along with low osmolality children with diarrhoea above 6 months of age. It
should start from the day of onset of diarrhoea and
continued for a total period of 14 days.

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50. RHEUMATOID ARTHRITIS
Early morning joint stiffness lasting more than 1
1.Introduction hour and easing with physical activity.
Rheumatoid arthritis (RA) is a chronic inflammatory Earliest involved joints typically the small joints
disease of unknown etiology marked by a symmetric, of the hands and feet.
peripheral polyarthritis. It is the most common form The wrists, metacarpophalangeal (MCP), and
of chronic inflammatory arthritis and often results in proximal interphalangeal (PIP) joints stand out
joint damage and physical disability. as the most frequently involved joints.
Flexor tendon tenosynovitis is a frequent
hallmark of RA.
2. When to suspect Deformities are swan-neck deformity,
boutonnire deformity, Z-line deformity.
The incidence of RA peaks between 25 and 55
years of age.

Figure-1: Hand changes in RA

Extra-articular features
i. Neurologic-atlanto-axial dislocation, cervical
3. Investigations
myelopathy. The clinical diagnosis of RA is largely based on signs
ii. Hematological-anemia of chronic disease, and symptoms of a chronic inflammatory arthritis,
neutropenia, splenomegaly, feltys syndrome. with laboratory and radiographic results providing
iii. GI-vasculitis. important supplemental information.
iv. Skeletal- osteoporosis.
v. Ocular-episcleritis, scleritis, 3.1 Rheumatoid factor
keratoconjunctivitis sicca.
Serum IgM RF found in 75-80% of RA patients;
vi. Oral -xerostomia, periodontitis.
therefore the negative result does not exclude RA.
vii. Pulmonary pleural effusion, pulmonary
nodules, interstitial lung disese, pulmonary Found in other connective diseases as well.
vasculitis, organizing pneumonia.
viii. Cardiac- pericarditis, IHD, myocarditis, 3.2 Anti CCP antibodies
cardiomyopathy, mitral regurgitation.
Highly specific 95%
ix. Renal membranous nephropathy.
x. Skin rheumatoid nodules, pyoderma So, useful for distinguishing RA from other forms of
gangrenosum. arthritis.

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3.3 Synovial fluid analysis- Other findings include soft tissue swelling,
symmetric joint space loss, subcondral erosions.
Inflammatory state.
Synovial fluid WBC count ranges from 5000 to
3.5 MRI
50000 WBC/u3. Offers greatest sensitivity for detecting synovitis,
joint effusions as well as early bone and bone marrow
Useful for confirming inflammatory arthritis,
changes.
excluding infection or crystal induced arthritis.

3.4 X ray hands


Juxta articular osteopenia, 4. Treatment
Table-1: Treatment of RA

Non pharmacologic treatment Pharmacologic treatment


Counselling, physical therapy, diet NSAIDS
Stress reduction, exercise Glucocorticoids
DMARDS

4.1 NSAIDs 4.3 DMARDS


Tab. Ibuprofen (200 mg BD or TDS) / Tab. Hydroxycloroquine, Methotrexate, Leflunomide,
Diclofenac (50 mg BD) - Now considered to be Sulfasalazine, Biologicals, anti TNF agents,
adjunctive therapy for management of symptoms Rituximab.
uncontrolled by other measures.
5. When to refer
4.2 Glucocorticoids Severe case of rheumatoid arthritis not responding to
first line therapy (Hydroxycloroquine, Methotrexate,
May be administered in low-to-moderate doses to NSAIDS), with extra articular manifestations should
achieve rapid disease Control before the onset of be referred to Higher institute for further work up.
fully effective DMARD therapy, which often takes
several weeks or even months.

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51. SNAKE BITE
Immobilisation of the part, Getting to Hospital
1. Introduction without delay and Telling the doctor of any
Envenoming by poisonous animals (Snakes, symptoms that develops.
Scorpions, Wasps, Ants and Spiders) is an
occupational hazard often faced by farmers, farm
laborers. Poisoning by venomous snakebite is a 2. Common Poisonous snakes
common acute life-threatening time-limiting medical
emergency.The majority of current first aid methods in India
adopted by the victims such as tourniquet, cutting and
suction and herbal remedies are completely (1) Cobra (2) Krait (3) Russells Viper (4) Saw
ineffective and dangerous. It is now recommended to Scaled Viper (5) Indian Pit Viper
adopt what has been called the Do it R.I.G.H.T. (6) Sea snake
approach, stressing the need for Reassurance,

HISTORY OF SNAKE BITE

ABSENT LOCAL EDEMA PRESENT

Floor bed BLEED


Neuroparalysis DIC Bleeding
SHOCK
Abdominal colic l RF

Pain Pain

Neuro-paralysis

RUSSELLS ECHIS
KRAIT COBRA VIPER CARINATUS

ASV, Ventilator ASV, N + A, ASV, Dialysis, ASV, Dialysis,


N+A Ventilator Blood transfusion Blood transfusion

Snake Bite: Diagnostic Algorithm and Treatment


(ASV- Antisnake venom, N- Neostigmine, A- Atropine, RF- renal failure, DIC- Disseminated intravascular
coagulation)

(Bungarus Caeruleus)
3. Clinical manifestations
Local Names- Kala gandait, Kala taro, Kandar,
3.1. Common Indian Krait Manyar chitti, kattu viriyan and valla pamboo.The

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common krait is regarded as the most dangerous AChEI or not can be confirmed by putting ice-filled
species of venomous snakes in the Indian glove finger over eyelid. Hypothermia sensitizes the
subcontinent. Majority of krait bite cases are reported Ach receptors of acetyl choline. If there is slight
between 11pm 5 am. improvement in ptosis, you can try AChEI.
Neostigmine 50ug/kg over first hr. & then 25 ug/kg
Symptoms
in the next hour preceded by Atropine
Mild pain at the site
Parasthesia or numbness 3.2. Cobra Bite
Abdominal pain/vomiting/chest pain Cobra bite tends to occur during day time.
Difficulty in bringing tongue beyond teeth
margin Symptoms
Slurred speech Pain at site
Difficulty in breathing Progressive swelling /ecchhymosis
Signs Blurred vision

Bradycardia, hypotension Signs


Bilateral ptosis, external ophthalmoplagia, Sinus bradycardia, hypotension
dysphagia Ptosis, bulbar palsy
Paralysis, coma Respiratory depression
Management Management
(a) First aid at home or place where bite happens: Victim should not be allowed to walk or run and the
If one succeeds in locating the bite site on the bitten part should be kept below heart level.
victims body, clean the surface where venom is On arrival 100ml (10 vial) ASV to be added to 200
deposited by clean cloth or cotton. Keep the bitten c.c. of normal saline run over 30-50 minutes.
part below heart level.
Maximum dose 200-250ml (20-25 vials).
Neostigmine 50ug/kg over first hr. & then 25 ug/kg
(b) At hospital: in the next hr preceded by Atropine
Thorough clinical examination including If patient develop respiratory paralysis intubate the
neurological exam patient and refer to higher centre
Haemogram, urine exam, ECG, serum electrolytes, Local wound care is done by intravenous antibiotic,
renal profile sterile dressing and skin grafting of all victims with
Anti-snake venom (ASV): non-healing wound.

- On arrival 100ml (10 vials) ASV to be added to 3.3. Sea snakes


200 cc of normal saline run over 30-50 minutes. Sea snake bite cases are reported from coastal region.
- Repeat dose of 100ml (10 vials) after 30 min if Fishermen accidentally handle sea snake resulting in
no improvement in neurological manifestation. envenoming. Its venom is neurotoxin, myotoxic and
haematotoxic.
- Maximum dose 200ml (20vials).
Symptoms
Ventilation
Indicated if victim has pooling of saliva, unable to lift Headache
the neck from pillow, reduction in oxygen saturation, Nausea
respiratory failure, abdominal-thoracic respiration, Vomiting
suffocation and signs of cerebral hypoxia. Tinglingnumbness
Refer the patient to higher centre with intubation and Foreign body sensation in throat
Ambu bag ventilation Swelling of tongue
Severe muscle pain
Anticholine esterase inhibitor (AChEI): Brown coloured urine
Indian common krait venom contains both pre and Signs
post synaptic blocker. Whether victim responds to

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Trismus Management
Muscular paralysis - No tourniquet
Respiratory arrest
Myoglobinuria - Bitten part should be kept below heart level

Management - No intramuscular injection unless 20MWBCT is


done and blood clots within 20 minutes.
On arrival 100ml (10 vial) ASV to be added to 200 cc
of normal saline run over 30-50 minutes. 20 minutes whole blood clotting test (20 MWBCT)
Ventilator for respiratory failure. Refer to higher Before injection of ASV take 2-3 ml of blood in a
centre with intubation. new dry glass test tube which is not irrigated by any
detergents. Keep the tube undisturbed for 20 minutes
Correction of hyperkalemia- Calcium gluconate, and then tip it off. If blood does not clot, it confirms
insulin glucose drip (10% dextrose 100ml add 12 hypofibrinogemia. ASV 100 ml (10 Vials) ASV
units insulin for 6hrs), salbutamol nebulization or diluted in 200 ml of 5% dextrose run over 30 minute
dialysis. by intravenous route. If external bleeding does not
stop within 20-30 minutes one can repeat 50 ml of
3.4. Russells viper ASV. Thrombocytopenic, abnormal fragmented
RBCs are a diagnosis of DIC. In addition, if victim
It is found in South Asian Countries. In Pakistan,
is too late in such situation in addition to ASV one
India, Sri Lanka, Bangladesh, Burma and Thailand it
has to try plasma products and whole blood
ranks amongst the most important causes of snakebite
transfusion which is rarely required if ASV is
mortality. With protecting the paddy, wheat by
administered in time with adequate dose.
containing rodents (rats), the Russells viper kills
Hypotension is to be managed with fluid and
many farmers unlucky enough to treat on it during
inotropic agents. Severe hypotension due to bleed in
harvesting.
adrenal and pituitary glands and abdominal bleed and
Symptoms endothelial dysfunction with capillary leak needs
heavy doses of intravenous methyl-prednisolone and
Severe local pain at the site of bite. correction of electrolytes.
Rapid swelling progresses to whole limb
within six to eight hours. Renal failure
Signs One should keep in mind and look for renal failure
from the time of admission. Risk factors such as
Regional lymphagntis with ecchymosed hypotension, hypovolumia can be corrected.
skin. Intravenous frusemide 80-100 mg and oral acetyl
Development of compartment syndrome cysteine 600mg three times a day may help to arrest
characterized by swelling, hypotension and the renal damage.
shock.
Refer to higher centres for haemo-dialysis, if needed.

Renal dysfunction 3.5. Saw scaled viper or Carpet


20-40% cases subsequently develop anuria, oliguria, viper or Echis-cariniatus
acute renal failure. Renal angle tenderness is most Farmers, hunters, labourers and persons walking bare
important clinical sign for early diagnosis of renal foot or in jungle and rocky areas are often bitten by
failure. There is serial rise in blood urea and serum this snake.
creatinine with acidosis and hyperkalaemia.
Generalized anasarca, renal failure is due to tubular Clinical manifestations
damage by venom itself.
Soon after the bite within one hour there is
Hemoglobinuria, hypotension and micro thrombi in development of swelling over the bitten part.
the kidney contribute to the acute tubular necrosis Swelling progresses in more than one segment. The
which is the most common cause of death. Ptosis, victim experiences a painful lymphadenopathy at the
bulbar palsy, internuclear opthlamoplegia and drainage area of the bitten part.
respiratory paralysis due to presynaptic
neuromuscular block in a Russells viper bite At times if the patient remains untreated, bleeding
poisoning are often seen and reported from kerala persists for 1-2 weeks in the form of blood stain
(South India) and Sri Lanka. sputum, haematuria and disappears on its own. Such

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patients are markedly anemic and report to hospital The approximate serum half life of antivenom in
for weakness or non-healing cellulites with envenomed victims ranges from 26 to 95 hours.
uncontrolled bleeding from cellulites. Before discharge envenomed victims should be
closely observed daily for minimum 3 to 4 days.
Management
ASV doses and repeat doses
Local wound care
The recommended initial dose of ASV is 8 to 10 vials
ASV required is 30-50 ml administered over 1 hr.

3.6. Green pit viper and bamboo Repeat doses for neurotoxic species is based on 1-2
hr rule.
pit (Trimeresurus)
Repeat doses for haematotoxic species is based on
Pit viper victims report during the monsoon season. the 6 hr rule.
Clinical manifestation The maximum recommended dose for neurotoxic bite
is 20 vials of ASV.
It shows up in sudden rapid development of massive
edema without regional involvement. Rarely the The maximum recommended dose for haematotoxic
victim manifests external bleeding or renal failure. bite is 30 vials of ASV.

Management
ASV Reactions
Antivenom should be administered as soon as signs
of systemic or severe local swelling are noted. No ASV test doses are to be administered.
At the first sign of an adverse reaction the ASV is
The mean times between envenoming and death are
halted
8 hours (12 minutes to 120 hours) in cobras, Adrenaline 0.5 ml is given SC

18 minutes (3-63 hours) in bungarus caeruleus, Steroid and antihistamine perform a secondary
supportive function to Adrenaline.
3 days (15 minutes to 264 hours in Russells viper (National Snakebite Management Protocol 2008)
5 days (25 to 41 days) for echis carinatus.

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52. SCORPION STING

1. Introduction Grade 1: Severe excruciating local pain at the


sting site radiating along with corresponding
Scorpion envenomation is an occupational dermatomes, mild local oedema with sweating at the
hazard for farmers, farm labourers, migrating sting site, without systemic involvement.
population and hunters.
Grade 2: Pain, paresthesias remote from the site
The endemic areas are western Maharashtra, of sting, in addition to local findings.
Karnataka and Konkan Region.
Severe Scorpion stings are due to Grade 3: Either cranial nerve / autonomic
MesobuthusTamulus species of scorpion. dysfunction.
Cold extremities, tachycardia, hypotension
2. Clinical features (Respiratory rate > 24 perminute, basal rales or
crackles in lungs).
2.1. The venoms of genera Hadrurus,Vejovis and
Uroctonus has local effects only including sharp Grade 4: Combined cranial nerve / autonomic
burning, swelling and discoloration at the bite site. dysfunction and somatic nerve dysfunction.

2.2. The second type of venom produced by the 4. Investigations


genera of the poisonous varieties of Centruroides and ECG- Tall T waves is a common finding. Others are
Mesobuthus contain neurotoxins which block sodium atrial arrhythmias, non sustained ventricular
channels. This leads to spontaneous depolarization of tachycardia, and various conduction defects seen.
parasympathetic and sympathetic nerves which Chest Xray- shows pulmonary edema.
results in stimulation.
In adults, the first time is rarely dangerous. But if the 5. Management
second time, the person may die if not treated soon. If it is for the first time in adult, do the following:
The body becomes allergic after the first sting. So it
Give Paracetamol if possible, put ice on sting.
is important to find out if he had an earlier scorpion
Infiltration of site with local anaesthetic may
sting. relieve pain and anxiety.
Anti histaminic tablets can be given
2.3. Severe pain, redness and swelling at the site of If the sting is for the second time in adult, or is
the sting. in children under 5, do the following
- IV Fluid management
2.4. Clinically autonomic storm evoked due to - Inj. Scorpion antivenom 30ml in 200ml of
venomous envenoming is characterized by transient normal saline neutralises circulating venom.
parasympathetic stimulation- vomiting, profuse - If evidence of myocarditis and pulmonary
sweating, ropy salivation bradycardia, ventricular pre oedema, strict bed rest and management of
heart failure is indicated.
mature contraction, priapism in male, hypotension
- Prazosin 0.5mg 3hrly orally for first 2 days
and prolonged sympathetic stimulation - cold (or 0.25mg in children and for adults) is
extremities, hypertension, tachycardia, pulmonary acceptable therapy
edema and shock. - Injection Frusemide 20 to 60mg I.V. to
control Pulmonary edema
3. Gradation - Inj.Dobutamine 5-20 microgram/kg/min I.V.
given in heart failure, tachycardia ,
On basis of clinical manifestations at the time of pulmonary edema with warm extremities
arrival to hospital and according to severity they are - Patients in Pulmonary edema may need inj
graded in 4 grades. NTG drip 5 microgram/kg

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- At times with severe respiratory distresss mechanical ventilation.
may need non invasive ventilation or

Stage- 1 - Stage- 2 Stage-3 - Stage-4 - Stage-5 -


(0-4hrs) (4-6hrs) (6-10hrs) (10-12hrs) (>12hrs)

- - - - - - - - - -
Sweating Hypertension - Tachycardia - Massive - Warm -
Salivation Tachycardia Hypotension pulmonary extremities
Mydriasis Cold extremiries Pulmonary edema edema Tachycardia
Priapism Cold extremities Hypotension
Hypertension Pulmonary
Hypotension edema
Cold Gray
extremities pallor(warm
shock)

- - - - - - - - - -
ASV + Prazosin ASV + - ASV +Prazosin - ASV - Dobutamine -
Prazosin + +
Dobutamine SNP or NTG
+
NIV/MV

Scorpion sting: stages, clinical presentation and treatment.ASV Anti Scorpion Venom, SNP- Sodium Nitro
Prusside, NTG- Nitroglycerine, NIV-Non inavasive ventilation, MV Mechanical Ventilatioin

Page 128
53. DOG BITE (RABIES)
Rabies can be transmitted by dog bites or licks of Treatment (post-exposure prophylaxis)
rabid animals on abraded skin and intact mucosa.
Other animals which can transmit rabies are cat, 2. Categories of dog bite
monkey, horse, sheep, goat, mongoose, jackal, fox,
Category I Touching or feeding animals, licks
hyena and bat. Exposure to rodents, rabbits and hares
on the intact skin
seldom, if requires specific anti-rabies treatment.
Category II Nibbling of uncovered skin, minor
1. Clinical features scratches or abrasions without bleeding, licks on
Prodromal symptoms- such as headache, malaise, broken skin
sore throat and fever last about 3-4 days. Pain and Category III Single or multiple transdermal
tingling at the bitten site. bites or scratches, contamination of mucous
Stage of excitation- Patient is intolerant to noise; membrane with saliva from licks; exposure to
bright light or a cold draught. Aerophobia may be bat bites or scratches
present. Hydrophobia is a characteristic symptom of The WHO recommended classification of animal bite
rabies. Examination shows increased reflexes, for post-exposure treatment should be followed.
dilatation of pupils, increased sweating, lacrimation Every instance of human exposure to a suspected
and salivation. Mental changes include fear of death, rabid or wild animal must be treated as a category III.
anger, irritability and depression. Convulsions may The post-exposure treatment is a three-pronged
occur resulting in death.The last stage is that of approach. All three carry equal importance and
paralysis and coma. The total duration of illness lasts should be done simultaneously:
for 2-3 days.
Table-1: WHO Guide for post-exposure treatment against rabies

Category
Type of contact with a suspect or confirmed rabid Recommended treatment.
domestic or wild animal or animal unavailable for
observation
I. Touching or feeding of animals Licks on None, if reliable case history is available
intact skin
Administer vaccine immediately. Stop treatment if
II. Nibbling of uncovered skin Minor scratches animal remains healthy throughout an observation
or abrasions without bleeding Licks on period of 10 days or if animal is killed humanely and
broken skin found to be negative for rabies by appropriate
laboratory techniques
III. Single or multiple transdermal bites or
scratches Contamination of mucous Administer rabies immunoglobulin and vaccine
membrane with saliva (i.e. licks) immediately. Stop treatment if animal remains healthy
throughout an observation period of 10 days or if
animal is killed humanely and found to be negative
for rabies by appropriate laboratory techniques.

A. Exposure to rodents, rabbits and hares seldom, if ever, requires specific anti-rabies treatment
B. If an apparently healthy dog or cat in or from a low-risk area is placed under observation, The situation
may warrant delaying initiation of treatment.

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C. This observation period applies only to dogs and cats. Except in the case of threatened or endangered
species, other domestic and wild animals suspected as rabid should be killed humanely and their tissues
examined using appropriate laboratory techniques.

Equine antirabies serum (ERIG) 40 IU/kg (max 3000


3. Treatment of dog bite IU), available in concentration of 300 IU/ml, given
3.1. Management of wound after prior skin sensitivity testing, single dose on day
0. Half the dose is infi ltrated around the bitten
Immediate washing of the wound is a priority. wound and the rest is given I.M.
Wound toilet must be done even if several hours or (Caution: A negative skin test must never reassure
days have elapsed. The wound is immediately the physician that no anaphylactic reaction will
flushed and washed with plenty of soap and water occur. Avoid alcohol, glucocorticoids and
(avoid direct touching of wounds with bare hands). chloroquine during vaccination; avoid multiple
Punctured wounds should be irrigated with the help needle injections into the wound. Must not exceed the
of catheters followed by 70% alcohol or povidone total recommended dose of IG as it may reduce the
iodine application.The application of irritants (like efficacy of the vaccine).
chillies, oil, turmeric, lime, salt etc.) is unnecessary
If the calculated dose of IG is insufficient to cover
and damaging.
infiltration in all wounds, sterile saline can be used to
Do not suture bite wounds immediately. If suturing is dilute 2 or 3 fold to permit thorough infiltration.
required, hold it for 24-48 hours, applying minimum
RIG is notindicated beyond the seventh day after
number of stitches under the cover of antirabies
administration of the first dose of vaccine.
Immunoglobulin locally. Anti tetanus treatment can
be given after local wound treatment.

3.2. Passive immunization with 3.3. Active immunization with


rabies immunoglobulin RIG) antirabies vaccine:
Local infiltration of RIG in category III rabies-RIG Antirabies vaccine (ARV)
should be infiltered in the depth and around the Intramuscular schedule.
wound even if the lesion has begun to heal followed
The course for post-exposure prophylaxis consists of
by administration of antirabies vaccine.
five injections (days 0, 3, 7, 14 and 28) irrespective
(Caution: RIG should never be administered in the of severity of exposure. The 6th injection (day 90) is
same syringe or at the same anatomical site as optional for immunologically deficient and extremes
vaccine). of age and on steroid therapy. The dose of vaccine
Doses of rabies immunoglobulin (IG) per injection is 2.5 IU/dose/ml for HDCV. Preferable
site is deltoid; anterolateral thigh in children
Human rabies immunoglobulin (HRIG) 20 IU/kg (Caution: Must NOT be given into gluteal muscle).
(max 1500 IU), available in concentration of 150
IU/ml, it does not require any prior sensitivity testing. Intradermal (ID) schedule.
SHOULD NEVER BE INJECTED (i) The 2 site ID TRC schedule (2-2-2-0-1-1) to be
INTRAVENOUSLY. The antirabies sera should administered: One ID injection of 0.1 ml per ID site
always be brought to room temperature (20-25C) over each right and left deltoid on days 0, 3, 7 and 0.1
before use. ml at a single site on days 28 and 90 or as per
Or updated TRC schedule (2-2-2-0-2) on days 0, 3, 7
and 28.

Page 130
Note: Correct ID injection should result in a raised at 1 site) on days 0 and 3, but no rabies
papule with an orange peel appearance. If a papule is immunoglobulin. Proper wound toilet should be
not observed, the needle should be withdrawn and done.
vaccine re-administered correctly nearby.
(ii) The 8-site ID method (8-0-4-0-1-1) for use with
4. Pre-exposure prophylaxis
HDC/PCECV in emergency, when no RIG is Indications: Laboratory staff working with rabies
available. virus, veterinarians, animal handlers and wildlife
officers. Three full IM or ID doses of tissue culture
The intradermal route is preferred as it reduces cost
vaccine given on days 0, 7, and 28. Laboratory staff
but must not be used in case of immunocompromised
and others at high continuing risk of exposure should
patients, individuals receiving long-term
have their neutralizing antibody titer checked every 6
corticosteroids or other immunosuppressive therapy
months. If it is less than 0.5 IU/ml, a booster dose of
or chloroquine.
vaccine should be given. Such individuals on getting
Antirabies vaccine should be kept and transported at exposed to rabies virus after successful pre-exposure
a temperature range of +2C to 8C. The immunization require only two booster injections of
reconstituted vaccine should be used immediately or vaccine given on days 0 and 3 without any antirabies
within 6-8 hours of reconstitution. serum/RIGs.

3.4. Post-exposure treatment of 5. Patient education


persons previously vaccinated Dog bite (category II and III) is an emergency and as
Managing re-exposure following post-exposure a general rule rabies postexposure treatment should
treatment with tissue culture vaccine (TCV) not be delayed or deferred.

If re-exposed, persons who have previously received Immediate washing with plenty of water and
full post-exposure treatment with a potent cell-culture disinfecting with alcohol/iodine.
vaccine should be given only two booster doses,
intramuscularly (0.5 ml/1 ml)/intradermally (0.1 ml

Page 131
54. POISONING

Anilides
1. Introduction
Poisoning due to the pesticides is increased due to the 3. Stepwise Case Approach
accessibility to the pesticides used in agriculture. Of
the total burden of acute pesticide poisoning the Diagnosis - Suspect and identify poison, if
majority of deaths are from self-poisoning with possible.
organophosphorus pesticides, aluminium phosphides Management includes basic principles,
and paraquat. antidotes, symptomatic and supportive
treatment.
2. Classification of Pesticides Anticipate complications, preserve evidence and
prevent sequelae as well as recurrence
2.1. Insecticides
Acetylcholinesterase inhibitors 4. Organophosphorus
Organophosphates
Carbamates
Compounds
Organochlorines Broadly OP compounds can be divided in to
Pyrethrins 1] Dimethyl compounds - Dichlorvos, Fenthion,
Pyrethroids Malathion, Methamidophos, Dimethoate
2.2. Herbicides 2] Diethyl compounds Chlorpyrifos, Diazinon,
Parathion-ethyl, quinalph
Dipyridyl pesticides
Paraquat and diquat 4.1. Mechanism of toxicity
Chlorphenoxyacetate weed killers
Bromoxynil, 2,4-D 1] Organophosphosphorus compounds inactivate
acetylcholinesterase by phosphorylation leading to
2.3. Fungicides accumulation of acetylcholine at cholinergic
synapses.
Substituted benzene
Chloroneb The rate of spontaneous reactivation of AChE is very
Chlorothalonil slow with diethyl OPs while it is relatively fast with
Thiocarbamates dimethyl OPs. Further, there is ageing of the
Organomercurials phosphorylated enzyme after which the enzyme
Methylmercury cannot be reactivated by oximes. The half-life of
Phenylmercuric acetate ageing of dimethlyphosphorylated and
diethylphosphorylated AChE in vitro is 3.7 hours and
Molluscicides Metaldehyde
33 hours, respectively, and the therapeutic windows
2.4. Rodenticides therefore are 13 and 132 hours, respectively (4 times
the half-life).
Aluminium phosphide
Zinc phosphide 4.2. Organophosphorus intoxication
Warfarin and superwarfarin compounds
Yellow phosphorus results in triphasic illness
Heavy metal : Thallium containing pesticides including
2.5. Insect repellants (a) Acute cholinergic syndrome
Diethyl toluamide (DEET) (b) Intermediate syndrome
2.6. Miscellaneous (c) Organophophate-induced delayed polyneuropath

Page 132
(a) Acute cholinergic syndrome 2. Further contamination is prevented by removal
from the site of exposure and of contaminated
Acute cholinergic syndrome may occur within clothing. Skin should be cleaned thoroughly with
minutes water.
Pathognomonic features via muscarinic and
nicotinic receptors- 3. The airway is cleared and high-flow oxygen is
administered.
Muscuranic effects Include miosis, bronchorrhoea,
salivation, lacrimation, pain in abdomen, bradycardia, 4. Direct mouth to mouth and nose resuscitation
urination, defecation must be avoided.
Nicotinic effects Muscle fasciculation, muscle 5. Following ingestion, gastric lavage must be done
cramps, flaccid muscle weakness with reduced within an hour of intake, followed by activated
tendon reflexes, tachycardia, hypertension charcoal via nasogastric tube after establishing
intravenous and airway protection.
Central nervous systemeffects Headache, dizziness,
confusion, convulsions, central respiratory Sample should be collected from the gastric lavage,
depression, coma sealed and handed over to the police registering the
medicolegal case.
(b) Intermediate syndrome
6. Convulsions are treated with intravenous
This begins 48 hours after poisoning in diazepam 10mg or midazolam 2mg.
approximately 20% of patients but may be
delayed for 72-96 hours. 7. Monitoring of ECG, blood gases, temperature,
The onset is often rapid with progression of muscular blood urea and serum electrolytes, amylase and
weakness from ocular muscles to neck and proximal glucose is mandatory.
limbs to respiratory muscles over 24 hours.
For muscuranic effects
Endotracheal intubation and ventilation are to be
Injection Atropine 1.8-3mg bolus immediately
done, if not instituted early, cyanosis, coma and
double the dose every 5minutes until atropinized.
death may follow rapidly.
Once patient is atropinized give 20%- 30% dose
(c) Organophosphate induced delayed required for atropinization as infusion/hour
polyneuropathy [5mg/hour]. The best guide to adequate atropinisation
is to monitor features of cholinergic poisoning
This occurs 1-3 weeks after acute exposure and (Bradycardia, Sweating, miosis, bronchorroea and
uncertain period following chronic exposure due hypotension). A confused, agitated, febrile patient
to degeneration of long myelinated nerve fibres. with no bowel sounds and a full bladder with urinary
Cramping muscle pain in the legs are followed retention certainly has atropine toxicity, indicating
by numbness and parasthesia in distal upper and the need to reduce or stop atropine temporarily.
lower limbs.
Symmetrical flaccid paralysis in distal muscles
especially in the legs. The dominant hand may For nicotinic effects
be more affected.
Pralidoxime chloride- Cholinesterase reactivator
4.3. Investigations which reverses the nicotinic effects and some CNS
effects. It is given 1gm bolus in 30minutes then
Plasma cholinesterase (pseudocholinesterase) is less infusion at 0.5gm/hour. (Loading dose of 30mg/kg
reliable. Red cell cholinesterase level falls to 20% of and 10mg/kg/hour infusion).
normal when symptoms appear.

4.4. Treatment of Treatment of the intermediate syndrome


Organophosphorus Poisoning
Early institution of ventilatory support, which may be
1. Airway, breathing and circulation should be required for a prolonged duration, is essential for
ensured and monitored. management. Close monitoring of respiratory
function such as chest expansion, arterial blood gas

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monitoring and oxygen saturation is essential to related to OCs, associated solvents may produce
identify the onset and monitor the progress of the aspiration pneumonitis.
intermediate syndrome. Some patients develop an
offensive and profuse diarrhoea and it is important to
maintain a close watch and a positive fluid balance. 5.5. Management
Recovery usually occurs without residual deficit.
Nasogastric aspirate may be useful if liquid
preparation has been taken and should be kept and
5. Organochloride handed over to medical official for medicolegal
purposes.
Compounds (OC)
Activated charcoal is given within 1hour of
5.1. The commonly used OC insecticides are Endrin, ingestion.
Aldrin, Benzene Hexachloride (BHC), Endosulphan, Seizures should be treated with Benzodizapenes.
Dieldrin, Toxaphene, DDT, Heptachlor, Kepone, (Diazepam 10mg or Midazolam 2mg I.V.)
Dicofol, Methoxychlor, etc. DDT, the most toxic OC, Patients should be kept on cardiac monitor. Use
is available in dry powder form or as a mixture with Dopamine instead of Epinephrine if patient has
other pesticides in powder or liquid form. hypotension, as OC compounds sensitise the
myocardium.
5.2. Mechanism of toxicity
OC compounds impair nervous system function by 6. Carbamate Poisoning
depolarization of the nerve membranes they also
Carbamate insecticides- Aldicarb,
cause sensitization of the myocardium to both
Carbofuranmethomyl inhibit a number of tissue
endogenous as well as exogenous catecholamines and
esterases-AchE. Aldicarb, Benomyl, Carbaryl,
predispose to arrhythmias.
Carbendazim, Carbofuran, Propuxur, Triallate, etc.
5.3. Clinical effects within minutes are the commonly used carbamates.

to hours
Nausea
6.1. Clinical features
Vomiting Clinical featuresare similar and less severe compared
Agitation to organophosphorus poisoning.
Fasciculations
Parasthesia of face and extremities 6.2.Complications
Seizures dizziness
Tremors Pancreatitis and death.
Myoclonus
Coma 6.3. Treatment
Respiratory depression and death
Nasogastric aspirate may be useful if liquid
5.4. Complications preparation has been taken and should be kept and
handed over to medical official for medico-legal
Hyperthermia, Rhabdomyolysis, Pulmonary oedema purposes.
and Disseminated intravascular coagulation. Lindane
is particularly toxic to the central nervous system. It Injection Atropine 0.5-1mg I.V. in small doses for an
can also produce alterations in the ECG including adult till atropinization occurs.
rhythm abnormalities and changes in STT waves
suggesting hyperkalaemia. Besides the features Role of PAM is unclear.

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55. ALCOHOL INTOXICATION /ALCOHOL
WITHDRAWL
7.1. When to Suspect iii. CBC, LFT, obtaining toxicology screens for
opioids or other CNS depressants
Alcohol has CNS depressant effect; hence person
intoxicated with alcohol will present with depressed iv. Neuroimaging
level of consciousness, sometimes with respiratory
depression, cardiac arrhythmia, or blood pressure
7.3. Treatment
i. Adequate nutrition and oral or I.V. Vitamin B
instability.
complex, including 50100 mg of Thiamine daily for
If the patient agrees to stop drinking, sudden a week
decreases in alcohol intake can produce withdrawal
ii. Inj Dextrose 25% in patients of altered sensorium
symptoms, many of which are the opposite of those
(dose 100 cc 25% dextrose)
produced by intoxication. Features include tremor of
the hands (shakes); agitation and anxiety; autonomic iii. Administering any depressant in doses that
nervous system overactivity including an increase in decrease the agitation- 2550mg of Chlordiazepoxide
pulse, respiratory rate, and body temperature; and or 10mg of Diazepam given PO every 46 hr on the
insomnia. These symptoms usually begin within 510 first day, with doses then decreased to zero over the
hrs of decreasing ethanol intake, peak on day 2 or 3, next 5 days.
and improve by day 4 or 5. About 25% of alcoholics
experience a withdrawal seizure. iv. Rehabilitation

7.2. Investigation 7.4. When to Refer


i. History of Alcoholism i. Those with poor Glasgow coma scale, Recurrent
Seizure, Focal neurological deficits or with delirium
ii. Blood ethanol level (Avoid cleaning with spirit tremens / korsakoff psychosis.
while collecting Sample)

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56. ANAEMIA
vii. H/O chronic diarrhea, malabsorption
1. Introduction viii. H/O chronic illness e.g. chronic renal failure,
Anemia is one of the most common disease a TB or any other causing anemia of chronic
physician can come across in the community. It can disease
be defined as HB < 13 g/dLfor male and < 12 g/dL ix. H/O blood transfusion in the past
for females as per WHO. x. H/O similar complaints in the past
xi. H/O pure vegetarian diet causing Vit. B12
Anemia can be due to nutritional deficiency, blood
deficiency causing Megaloblastic Anemia
loss, and increase in destruction of RBCs or due to
disturbance in formation of RBCs in bone marrow.
Detailed history and clinical examination is must to
4. Signs
reach the diagnosis. Patients especially females dont i. Pallor Conjunctiva, mucous membranes, skin
report to clinics until they have severe anemia. ii. Nails platynychia (flat) or koilonychias
Chronic anemia patients are usually well adjusted to (spoon shaped) nails in iron deficiency anemia
HB as low as 5 g/dL. (IDA)
iii. Severe anemia signs of hyper dynamic
2. When to suspect circulation eg. tachycardia, flow murmurs
(ejection systolic loudest at apex),
Symptoms cardiomegaly
i. Easy fatigability iv. Congestive Heart failure with edema feet,
ii. Breathlessness right hypochondriac tenderness, raised JVP
iii. Swelling of feet and basal crepitation
iv. Hypomenorrhea, amenorrhea v. Other signs of etiology may be found eg.
v. Stunted growth in adolescent icterus, Lymphadenopathy, stigmata of TB

3. History to be inquired for


etiology of anemia 5. How to Investigate
3.1. Acute 5.1. Complete blood count
The most important investigation gives maximum
i. H/O blood loss hematemesis, hemoptysis or information regarding diagnosis.
any other Mean Cell Volume (MCV) -Normal 76 -96
ii. H/O Fever or jaundice acute blood loss due
to either hemolysis or blood loss due to Low MCV (microcytic anemia)
coagulopathy
Iron deficiency anemia (IDA) most common
iii. H/O petaeche, ecchymosis or
Hereditary hemolytic anemia eg Thalassemia
lymphadenopathy with fever Acute
Leukemia Normal MCV (normocytic anemia)
iv. Recovering from recent surgery
Acute blood loss
Hemolysis
3.2. Chronic Anemia of chronic disease
i. Antenatal or postnatal female Chronic renal failure
ii. H/O passage of worms in stool causing Pregnancy
chronic blood loss
Bone marrow failure e.g Aplastic anemia
iii. H/O Chronic blood loss Hemorrhoids,
Hypothyroidism
Malena, Menorrhagia
iv. H/O Chronic Alcoholism leading to Vit. B12 High MCV (Macrocytic anemia)
deficiency
v. H/O Anorexia or any GI complaints leading Vit. B12 or folate deficiency (strict vegetarian
to malnutrition diet, Pernicious anemia)
vi. Poor socioeconomic status leading to Alcoholism
malnutrition Mylodysplastic syndromes(MDS)

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Drug induced e.g Phenytoin - Elemental Iron 100mg once daily can be
5.2. Stool examination increase up to 300mg OD
Parasites, occult blood, malabsorption Repeat HB at the end of 1 month to confirm
response to treatment, if HB is increasing then
5.3. Other Baseline investigations repeat after 3months.
FBS, Creatinine, Liver enzymes, reticuolyte count, ii. Megaloblastic anemia-
LDH Oral supplementsVit. B12 (7.5mcg) +Folate
(0.75mg) BD for 1 month.
5.4. Iron studies, serum folic / Vit. iii. Deworming - All patients Tab Albendazole
(400mg) 1 stat, can be repeated after 2 weeks
B 12 levels iv. Treat etiology if possible
v. Packed cell transfusion if hemoglobin is less
5.5. Bone marrow biopsy if than 7
malignancy suspected 7. When to refer
Severe anemia (HB < 4g /dL) requiring blood
transfusion
6. Treatment Signs of Heart failure
i. IDA No response to oral supplements of Iron or B12
and folate at the end of 2 months
Oral iron Ferrous Sulphate (200mg) thrice a
Any suspicion of leukemia, lymphoma, MDS or
day for 3 months.
Aplastic anemia
Or (300mg) BD No apparent cause found
- Ferrous fumarate, Ferrous ascorbate can also
be used

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57. HEAT STROKE
central nervous system (CNS) depression, core
1. Definition temperatures usually above 40C (1050F), and typical
Heat Stroke is a syndrome of acute thermoregulatory biochemical and physiologic abnormalities.
failure in warm environments characterized by

Figure 1: Effects of Heat Exhaustion and Stroke

Hyperthermia: Hypothalamic set point is Heat Exhaustion


unchanged; does not respond to antipyretics.
Distinct from fever (pyrogens change Heat Stroke
Hypothalamic temperature set point).

Uncontrolled increase in body temperature


3. When to Suspect Heat
that exceeds the body's ability to lose heat Stroke
due to failed thermoregulation. i. In any patient exercising in hot weather or in
susceptible individuals; mainly elderly
Life-threatening medical emergency. population.
ii. Coma or profound stupor is nearly always
Core temperature >40 C (105 F) & CNS present.
disturbances in patients with a history of iii. Diagnostic criteria for Heat Stroke should
heat exposure. include
a. A core temperature above 40C
2. Clinical spectrum of heat b. Severely depressed mental status or
Coma on Central Nervous System examination
illness
c. Elevated Serum Creatinine and Serum
Heat Edema Electrolyte levels (Hyperkalemia)
d. Compatible historical setting.
Heat Rash (miliaria)

Heat Cramps 4. Causes


1) Increased Heat production- Exercise,
Heat Tetany Fever, Thyrotoxicosis, Amphetamines, Atropine
toxicity.

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2) Impaired Heat loss- High ambient temperature or Exertional: Typically seen in healthy young
humidity, Ineffective voluntary control, Lack of adults who over exert themselves in high
acclimatization, Dehydration, Cardiovascular ambient (Surrounding) temperatures or in a hot
diseases. environment to which they are not acclimatized
(To adapt). Sudden inability to dissipate / Lose
3) Drugs- Anticholinergics, Phenothiazines,
body heat through perspiration (evaporation) or
Butyrophenones, Thiothixenes, Barbiturates,
cutaneous vasodilatation (convection),
Anti-Parkinson's agent, Alcohol.
especially after strenuous physical activity in hot
4) Debilitating conditions- Skin diseases, Cystic weather. (Increased heat production).
fibrosis, Central nervous system lesion, older
age. Non-exertional (classic): Usually affects elderly
and debilitated patients with chronic underlying
5. Clinical examination of disease. Result of impaired thermoregulation
combined with high ambient temperatures. Often
patient with Heat Stroke due to impaired sweating.

Anhidrosis often present (but is no longer a 7. Management


criteria for diagnosis)
Primary therapy includes cooling and decreasing
(hot, dry skin) thermogenesis.
Altered mental State. i. Evaporative cooling methods involve placing a
Often missed in physically inactive patients. nude patient in a cool room, wetting the skin
with water and encouraging evaporation by the
Baseline body temperature increased (core use of fans.
temperature).
ii. Direct external cooling involves immersing the
Non-glass medical thermometer. patient in water. Close monitoring of
Rectum preferred site haemodynamics i.e Pulse, Blood pressure,
respiration and urine output is mandatory.
Axillary and inguinal sites are unreliable

6. Types

Figure: Primary therapy of hyperthermia

Seek medical attention immediately-continue It is not advisable to give the victim anything by
first aid to lower temprature until medical help mouth (even water) until the condition has been
takes over. stabilized.
Do NOT give any medication to lower fever- It Body cooling methods
will not be effective and may cause further harm.
Body immersion in iced water
Do NOT use an alcohol rub

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Evaporative cooling: Spraying water and the use - Avoid alcohol and caffeine, which dehydrate the
of fans over the patient facilitates evaporation body.
and convection
- Avoid foods that are high in protein, which
Gastric lavage with cold water / ice, bladder, or increase metabolic heat.
peritoneal lavage - Stay indoors when possible.
Immersion method of body cooling - Take regular breaks when engaged in physical
Aggressive ice water immersion is gold standard activity on warm days.
for life threatening heat stroke - Take time out to find a cool place.
Advantages: Cools patients faster; cooling rate of
0.20C/min for iced water 9. Complications
Disadvantages Acute renal failure
Rhabdomyolysis
- May cause peripheral vasoconstriction (not Liver failure
clinically relevant in RCT) Disseminated intravascular coagulation(DIC)
Acute respiratory distress syndrome (ARDS)

- Difficult in patients with reduced level of

CNS: Altered Mental state, confusion, delirium
Seizure, decorticate posture
consciousness
Coma and Death
Dehydration
- For alert - It is uncomfortable and often Caution - Overhydration
intolerable
Electrolyte Imbalance
Hypernatremia
- Shivering leads to worsening Hyperkalemia
Other cooling methods Hypokalemia
Localized muscle pain on active/passive flexion
(a) Placement of ice packs in the axillae, groin, of limbs
and neck Urine- Hemoglobinuria, Myoglobinuria
- Easy method, slower cooling
(b) Gastric, peritoneal, and bladder lavage with 10. Management of
cold water
complications
- Used in resistant cases i. Benzodiazepines- Lorazepam (2 to 4mg I.V.
(c) Cooling gloves slowly) or Midazolam (2 to 5mg I.V. slowly)
Indicated in patients with agitation & shivering to
Supportive treatment prevent heat production. Also given in patients with
convulsions.
- Treated in ICU settings
- IV Fluids, treat electrolyte disturbance ii. Rhabdomyolysis- Common in Exertional heat
stroke & in patients with hypotension.
- Mechanical Ventilation
Signs& symptom
8. Preventing heat- related - Dark urine
illness - Acute renal failure
- Treatment
- Wear loose, lightweight, light-coloured clothing. - I.V. fluids
Light colours will reflect away some of the suns - Alkalinisation of urine sodium Bicarbonate
energy.
iii. Metabolic support- Correcting the electrolyte
- Wear hats or to use an umbrella. disturbances like hyponatremia, hypercalcemia,
- Drink water- Carry water or juice with you and hypocalcemia, hyperphosphatemia
drink continuously even if you do not feel iv. Hepatic injury- Monitor liver function tests
thirsty. - Avoid hypoglycemia

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- Early recognisation & treatment of DIC
- Respiratory support
11. When to Refer
v. Pulmonary injury- Pulmonary edema is ii. Evaporative and direct external cooling
common complication. methods fail to reduce the temperature.
ARDS- Patient should be referred for iii. Arrhythmias, metabolic acidosis and
mechanical Ventilation. cardiogenic failure complicate the early
management of hyperthermic crises.
iv. Those with evidence of renal failure,
vi. Renal injury- ARF may develop due to many disseminated intravascular coagulation or
reasons. These patients may need hemodialysis superadded infections.
& so referred to higher centre.

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58. TUBERCULOSIS (RNTCP)
evening rise, night sweats, chest pain, shortness of
1. Introduction breath, anorexia and haemoptysis.
Tuberculosis is an infectious disease caused a. Pulmonary TB Suspects
predominantly by Mycobacterium tuberculosis.
Pulmonary tuberculosis is the most common form of A pulmonary TB suspect is defined as:
TB (more than 85% of all TB cases), while extra
pulmonary tuberculosis can affect almost any organ An individual having cough of 2 weeks or more.
in the body. Transmission occurs by the airborne Contacts of smear-positive TB patients having
spread of infectious droplets and droplet nuclei cough of any duration.
containing the tubercle bacilli. The source of Suspected/confirmed extra-pulmonary TB
infection is a person with sputum smear-positive having cough of any duration.
pulmonary TB. Transmission often occurs indoors, HIV positive client having cough of any
where droplets and droplet nuclei can stay in the air duration.
for a long time.
b. Extra-Pulmonary TB Suspects
2. Epidemiology of A patient with extra-pulmonary TB (EP TB) may
Tuberculosis have general symptoms like weight loss, fever with
evening rise and night sweats. Other symptoms
TB is a bacterial disease caused by depend on the organ affected.
Mycobacterium tuberculosis. These organisms
are also known as tubercle bacilli or as acid-fast Examples of these symptoms are, swelling of a
bacilli. lymph node in TB lymphadenitis, pain and swelling
of a joint in TB arthritis, neck stiffness and
Transmission of tuberculosis occurs by airborne disorientation in a case of TB meningitis. Patients
spread of infectious droplets and droplet nuclei. with EP TB, who also have cough of any duration,
Source of infection is patient of tuberculosis who should have sputum samples examined. If the smear
spreads tuberculosis bacilli during coughing, result is positive, the patient is classified as
sneezing, etc. pulmonary TB and his/her treatment regimen will be
that of a case of smear-positive pulmonary TB.
Most common symptom of pulmonary TB is
persistent cough for two weeks or more, usually
with expectoration. Persistent cough for 2 weeks
4. Screening for TB among
or more may be accompanied by one or more high risk groups
symptoms such as weight loss, loss of appetite,
tiredness, evening rise fever, chest pain, a) Contact investigation among the diagnosed
shortness of breath and hemoptysis. smear-positive cases is to be systematically
implemented and monitored, and it offers a
Incidence of tuberculosis is usually similar in major opportunity for early case detection.
both sexes below 15 years of age, thereafter b) HIV care centres: Intensified TB case finding
incidence is higher in males than females and should be implemented in all facilities providing
difference is greatest in old people. HIV care, like ICTCs, ART Centres, Care and
support centres etc.Involve NGOs working with
Early detection of sputum positive tuberculosis
HIV programmes in TB case finding activities.
case and conversion into sputum negative by
c) Diabetic patient: regularly screening for TB in all
effective treatment are most important measures
diabetic patients at each visit.
for tuberculosis control.
d) Elderly patients.
e) Smokers.
3. Diagnosis of TB f) Other High risk groups: Malnutrition, patients
Identification of Tuberculosis Suspects with silicosis, patients on corticosteroids and
other chronic diseases need to be screened for
The most common symptom of pulmonary TB is TB regularly.
persistent cough, usually with expectoration.
Persistent cough may be accompanied by other
symptoms such as weight loss, tiredness, fever with

Page 142
5. Tools for diagnosis of TB 7. Management of Patient
Following are RNTCP recommended diagnostics after receiving the sputum
tests for TB results
Sputum smear microscopy.
Histopathology/cytology/radiology. 7.1 Smear positive pulmonary TB.
Solid/liquid culture and DST for diagnosis TB
and Drug Resistant TB. Patients with at least one sputum positive smear
PCR based newer rapid diagnostic tools for resultout of two samples are diagnosed by the
diagnosis of TB/drug resistant TB eg. physician as having smear-positive pulmonary TB.
Line probe assay (LPA), CBNAAT. They are further classified as a new or re-treatment
case based on their previous treatment history and
6. Guidelines for collecting appropriate regimen is prescribed.

sputum 7.2 Follow up of the sputum


negative symptomatic
The patient is given the sputum container with
Laboratory Serial Number written onits side. The Patients, who are negative for AFB in both the
patient is instructed to inhale deeply 23times samples, will be prescribed a course of antibiotics for
with mouth open, cough out deeply from the duration of 10-14 days. In such cases antibiotics such
chest, open the container and spitout the sputum as fluoroquinolones (Ciprofloxacin, Ofloxacin,
into it. Sample should be at least 2 ml. If the Levofloxacin, and Moxifloxacin etc.),
quantity is less, then the procedure can be clavulunatemacrolides, rifampicin or streptomycin,
repeated. Once adequate quantity of sample is which are active against tuberculosis, are not to be
collected, the container should be closed. This is used. Antibiotics of choice include Cotrimoxazole,
the first spot specimen (A). Amoxycillin, & doxycycline. Most patients are likely
The patient is given a labelled container with to improve with antibiotics if they are not suffering
instructions to cough out sputum intothe from TB. If the symptoms persist after a course of
container early in the morning after rinsing the broad spectrum antibiotics, repeat sputum smear
mouth, before breakfast. This is the early examination (2 samples) must be done for such
morning specimen (B). patients.
The person collecting the sputum specimens should However, if repeat sputum examination turns to be
follow the guidelines specified below: negative, they are subjected for chest x-ray
If the sputum specimens are to be sent examination. If chest x-ray is suggestive of
immediately to the laboratory, the person should pulmonary TB, they will be diagnosed as smear
put the container into a special box meant for negative pulmonary TB and treated accordingly. If
transport. chest x-ray is not suggestive of TB, then they should
be evaluated for other respiratory diseases.
If the sputum specimens are not being sent
For patients infected with HIV, antibiotic trial is not
immediately to the laboratory, these should be
indicated and Chest X-ray needs to be taken to avoid
stored in a cool and shady place in the referring
delay in diagnosis of smear negative TB.
health facility.
Patients with suspected EP TB should be referred to a
The person should wash hands thoroughly with
competent medical practitioner / doctor / specialist
soap and water every time when the material is
for expert opinion. Diagnosis of such patients may be
handled.
made using appropriate diagnostic procedures (such
Patients should be told to come back to receive as FNAC/Biopsy/Radiology) as well as clinical
the results of sputum examination. methods.
Alternatively, sputum results may be sent to the Diagnosis of TB by chest X-ray alone is unreliable
referring health facility by hand. Laboratory because no radiological pattern is pathognomic of
serial number (and/or specimen identification pulmonary TB. Unless the prescribed algorithm is
number) should be clearly written on the side of followed, a large number of patients who do not have
the sputum container. TB will be falsely diagnosed and treated.

Page 143
its duration, and the need for prompt evaluation of
8. Diagnostic Algorithm children under six years or contacts with cough of
any duration living in the household. The patient
When the referring doctor receives the results of
should also be informed that his address would be
sputum examination, and it is decided to put the
verified by a competent person prior to the start of
patient on chemotherapy, health education must be
treatment.
imparted to the patient. The patient is told about TB,
how it spreads, precautions to be taken to prevent the
spread, importance of directly observed treatment and

Figure-1: Diagnostic Algorithms for Pulmonary Tb

9. Treatment of TB
MO must undertake detailed clinical examination and V. Culture / Drug Susceptibility Test (DST)
history before starting the TB treatment. report from RNTCP certified laboratory (if
available).
The following is required before starting treatment:
I. History of patient, including history of any 9.1. Directly Observed
previous treatment for TB.
II. Sputum smear examination results from an Treatment (DOT)
approved DMC.
RNTCP Definitions: Case Definitions, Types of
III. Chest X-ray report if the case warrants
Cases and Treatment outcomes
radiographic examination.
IV. Other supporting investigation reports, if any.

Page 144
Table-1: Definitions under RNTCP

alternate days and lasts for 2 months (8 weeks, 24


9.2.Treatment Regimens doses).
For the purpose of treatment regimen to be used, TB This is followed by the continuation phase, which
patients are classified into two groups, namely, consists of 4 months (18 weeks; 54 doses) of
New or Previously Treated, based on the history isoniazid and rifampicin given thrice a week on
of previous treatment. alternate days with at least the first dose of every
week being directly observed. If the sputum smear is
i. Regimen for New cases positive after 2 months of treatment, the intensive
This regimen is prescribed to all new pulmonary phase of four drugs (H, R, Z and E) are continued for
(smear-positive and negative), new extra pulmonary another one month (12 doses), and sputa sent for
and new others TB patients. culture and drug susceptibility testing (C&DST) to an
The regimen is 2H3R3Z3 E3 / 4 H3R3. accredited RNTCP C&DST laboratory. Treatment
remains continued as per regimen if C&DST report is
Treatment is given in two phases. For New Rifampicin-sensitive. Sputum is examined after the
patients, the intensive phase consists of isoniazid (H), completion of the extension of intensive phase.
rifampicin (R), pyrazinamide (Z) and ethambutol (E) Irrespective of the sputum results after this extension
given under direct observation thrice a week on of the intensive phase, the 4 months (18 weeks) of the
continuation phase is started.

Page 145
If the sputum smear is positive after 5 or more duration of treatment is 8 months. Relapses,
months of treatment, the patient is declared as a Treatment after Default, Failures and Others are
Failure and is placed on the Previously Treated treated with this regimen.
treatment regimen afresh. If patient remains smear
The regimen is IP: 2S3H3R3Z3 E3+ 1H3R3Z3 E3
positive in any follow-up sputum examination, then
CP: 5 H3R3 E3.
sputum samples are sent for culture and drug
susceptibility testing (C&DST) to an certified Treatment is given in two phases. For Previously
RNTCP C&DST laboratory. If the report indicates Treated cases, the intensive phaseconsists of two
Rifampicin resistant, then the Cat I regimen is months (24 doses, 8 weeks) of isoniazid (H),
stopped and patient is counselled and referred to rifampicin (R), pyrazinamide(Z), ethambutol (E) and
District / Drug Resistance TB centre for pre- streptomycin (S), followed by one month (12 doses, 4
treatment evaluation and treatment initiation.While weeks) ofisoniazid, rifampicin, pyrazinamide and
treating TB meningitis(TBM) in New patients, ethambutol, all given under direct observation thricea
streptomycin is to be used in place of ethambutol week on alternate days. Patient is subjected for
during the intensive phase (H3R3Z3S3 instead of follow-up sputum examination at theend of three
H3R3Z3E3). The continuation phase of treatment for months. If the sputum smear is positive at the end of
patients with TBM or spinal TB is for 7 months. 3 months of treatment, the intensive phase drugs (H,
Hence, the total duration of treatment will be for 9 R, Z and E) are extended for another one month (12
months. doses,4 weeks). Irrespective of the sputum results at
the end extended intensive phase, 5 months(22
ii. Regimen for Previously Treated weeks) of continuation phase is started. If the sputum
cases remains positive at the end ofthe extended intensive
This regimen is prescribed for TB patients who have phase, sputum is sent to an accredited RNTCP
had more than one month anti-tuberculosis treatment C&DST laboratory for culture and drug susceptibility
previously. These patients are at a higher risk of testing. The continuation phase consists of 5 months
having drug resistance. Hence all such patients are (22 weeks; 66 doses) of isoniazid, rifampicin and
also subjected to C&DST for identification of ethambutol given thrice a week on alternatedays,
MDRTB. If C&DST report is expected beyond 7 with at least the first dose of every week being
days, then patients are initiated on Cat II regimen directly observed.
with 5 drugs in the intensive phase, and the total

Table-2: Treatment regimine under RNTCP

Regimen1
Treatment groups
Type of patient Intensive phase (IP) Continuation phase
(category)
(CP)
New Sputum smear-positive 2H3R3Z3E3 4H3R3
(Cat I: Red Box) Sputum smear-negative
Extra-pulmonary
Others
Previously Smear-positive relapse 2H3R3Z3E3S3 5H3R3E3
Treated** Smear-positive failure / 1H3R3Z3E3
/Retreatment case Smear-positive treatment after
(Cat II: Blue Box) default
Others2

1. The number before the letters refers to the number 1500 mg, Ethambutol (E) 1200 mg, Streptomycin (S)
of months of treatment. The subscript after the letters 750 mg.
refers to the number of dosesper week.
Patients who weigh 60 kg or more receive
The dosage strengths are as follows: Isoniazid (H) additional rifampicin 150 mg.
600 mg, Rifampicin (R) 450 mg, Pyrazinamide (Z) Patients who are more than 50 years old receive
streptomycin 500 mg. Patients who weigh less

Page 146
than 30 kg, receive drugs as perPaediatric weight
band boxes according to body weight.
9.3. Pediatric TB
Pediatric cases are to be treated under RNTCP with
2.In rare and exceptional cases, patients who are the same thrice weekly short course chemotherapy
sputum smear-negative or who have extra-pulmonary regimens (New or Previously Treated) given
disease can have recurrence or nonresponse.This under DOT as for adult patients. They are to be
diagnosis in all such cases should always be made by registered in the respective RNTCP TB Register.
an MO and should be supported by culture or Pediatric patient-wise boxes are available with
histological evidence ofcurrent, active TB. In these different dosages as two product codes to be used
cases, the patient should be typed as Others and under four weight bands for children weighing 6 to
given treatment regimen for previously treated. 10 kgs, 11 to 17 kgs, 18 to 25 kgs and 26 to 30 kgs.
Note: - All doses in Intensive phase and at least first
dose in Continuation phase should be directly
observed by DOT provider.
Table-3: Pediatric patient wise boxes for new cases according to weight band

INH Chemoprophylaxis
9.4. Monitoring of Treatment
All children aged < 6 years in contact with smear- Follow up of patient
positive pulmonary TB case are screened by MO to
rule out TB. If suffering from TB, should be treated
appropriately. Children not having TB are to be
administered preventive chemotherapy with INH,
10mg/kg body weight for 6 months.

Table-4: Follow up of DOTS patients


CAT Follow up sputum If smear + at the end of IP Remarks
Action Follow up
sputum
CAT-I At 2,4,6 months of Extend IP for another one 3,5,7 months If sputum +ve at 5 months,
treatment month of treatment declare patient as failure and
put on CAT-II
CAT-II At 3,5,8 months of If +ve at 3 months then 4,6,9 months -
treatment extend IP, 4 drugs for one of treatment
more month

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Default retrieval action Definitions
In spite of counseling and health education at the MDR-TB case: A TB patient whose sputum is
time of diagnosis and follow up by health workers, culture positive for Mycobacteriumtuberculosis and
some patients remain irregular for treatment. is resistant in-vitro to isoniazid and rifampicin with
Defaulter retrieval action is action taken to bring or without otheranti-tubercular drugs based on DST
back patients for treatments who do not take results from an RNTCP-certified Culture &
medicines regularly. DOT provider should take DSTLaboratory.
defaulter action. Following actions are suggested
under RNTCP for defaulter patients- XDR TB case: An MDR TB case whose recovered
M. tuberculosis isolate is resistant toat least isoniazid,
If patient does not come as scheduled during rifampicin, a fluoroquinolones (Ofloxacin,
Intensive Phase (IP) then health worker / DOT Levofloxacin, orMoxifloxacin) and a second-line
provider makes home visit immediately same injectable anti-TB drug (Kanamycin, Amikacin,
day or next day and brings patient for regular orCapreomycin) at a RNTCP-certified Culture &
treatment. DST Laboratory.
If patient is in Continuation Phase (CP) home Diagnosis of MDR-TB
visit should be made and patient should be
retrieved within a period of a week after missed Presently, 3 technologies are available for diagnosis
dose. of MDR TB viz. the conventional solidEgg-based
In case of community DOT provider / ASHA/ Lowenstein-Jensen (LJ) media, the liquid culture
Anganwadi, the respective ANM/MPW of that areas (MGIT), and the rapid molecular assays such as Line
should supervise the DOT provider fortnightly for Probe Assay (LPA) and similar Nucleic Acid
ensuring DOT implementation and assist in ensuring Amplification Tests likeXpert MTB/Rif (CBNAAT).
patient adherence, timely follow-up. Molecular/genotypic tests are much faster than
phenotypic tests, as molecular tests dont require
growth of the organism, and M. tuberculosis is
9.5. Programmatic notoriously slow growing. The turnaround time for
Management of Drug C-DST results by Solid LJ media is around 84 days,
by Liquid Culture (MGIT) is around 42 days, by LPA
Resistant TB (PMDT) is around 72 hours and by CBNAAT is around 2
MDR-TB Suspects hours. Currently LPA does the DST of INH and
Rifampicin and CBNAAT gives the DST of
The following are the criteria to label a patient as Rifampicin. Liquid culture DST is used to do the
MDR-TB suspect. DST of second line drugs Oflox/Kanamycin.

All previously treated pulmonary TB cases at RNTCP MDR/XDR-TB Treatment


diagnosis.
Any smear positive follow up result in new or As per PMDT guidelines, a specializedcenters named
previously TB cases. Drug Resistant TB Centres are been established at
tertiary care hospitals like medical college/ TB
HIV TB co-infected cases at diagnosis.
hospitals/civil hospital for admission of MDR TB
All pulmonary TB caseswho are contacts of
patients for pre-treatment evaluation and to initiate
known MDR TB case
treatment.Patients should receive counselling at every
Once the districts will have adequate laboratory
level on 1) the nature and duration of treatment, 2)
capacity for DST, all TB patients will be
need forregular treatment, 3) possible side effects of
provided DST at the time of diagnosis.Two fresh
these drugs and 4) the consequences of irregular
sputum samples (Spot and early morning) are to
treatment or pre-mature cessation of treatment.
be collected from MDR TB suspects and
transported from DMC/PHIto the RNTCP Regimen for MDR-TB
certified C & DST laboratory in cold chain by
using transport mechanism (courier/post/human This regimen comprises of 6 drugs - Kanamycin,
carrier) within 72 hrs. Levofloxacin, Ethionamide, Pyrazinamide,

Ethambutol and Cycloserine during 6-9 months of the


Intensive Phase and 4 drugs-Levofloxacin,

Page 148
Ethionamide, Ethambutol and Cycloserine during the Follow-up monitoring in XDR TB
18 months of theContinuation Phase.
XDR TB requires more intensive monitoring during
All drugs should be given in a single daily dosage follow-up.
under directly observed treatment (DOT) by a DOT
Provider. All patients will receive drugs under direct Complete Blood Count with Platelets Count:
observation on 6 days of the week. On Sunday, the weekly in first month, then monthly torule out
oral drugs will be administered unsupervised whereas bone marrow suppression and anaemia as a side
injection Kanamycin will be omitted. If intolerance effect of Linezolid.
occurs to the drugs, Ethionamide, Cycloserine and, Kidney Function Test- monthly creatinine and
addition of monthly serum electrolytesto the
PAS may be split into two dosages and the morning monthly creatinine during the period that Inj
dose administered under DOT. The evening dose will Capreomycin is being administered.
be self-administered. The empty blister packs of the Liver Function Tests: monthly in IP and 3
self-administered doses will be checked the next monthly during CP.
morning during DOT. Pyridoxine should be CXR every 6 months.
administered toall patients on Regimen for MDR TB. No difference to follow-up Culture for patients on
Drugs are provided to the DOT provider in monthly regimen for MDR TB and XDR TB.
patient wise boxes (PWB). PWBs are prepared at
State Drug store as per the five weight bands- <16kg, M/XDR TB Treatment Outcome definitions
16-25Kg, 26-45kg, 46 -70kg and > 70kg.
Standardised treatment outcome definitions are to be
If patient gains or loses >5 kg weight during used following treatment of an MDRTBcase. These
treatment and crosses the weight band range, definitions apply to patients with rifampicin
Committee may consider moving the patient in higher resistance (who are taken to beMDR TB for
or lower weight band in next supply of drugs. management purposes), and XDR TB cases as well:

Follow-up investigations during MDR TB Cure: A patient who has completed treatment
treatment and has been consistently culture negative (with
at least 5 consecutive negative results in the last
One specimen for follow up culture at the end of 12 to 15 months). If one follow-up positive
3,4,5,6,7,9,12,15,18,21,24 months of treatment. culture is reported during the last three quarters,
Monthly weight. patient will still be considered cured provided
Chest X-ray during pretreatment evaluation, end this positive culture is followed by at least 3
of IP, end of treatment and whenever indicated. consecutive negative cultures, taken at least 30
Physician evaluation every month for 6 months days apart, provided that there is clinical
and then every 3months for 2 years. evidence ofimprovement.
Serum Creatinine monthly for first 3 months and Treatment completed: A patient who has
then every 3 months till inj. Kanamycin is given. completed treatment according to guidelinesbut
TSH during pretreatment evaluation and when does not meet the definition for cure or treatment
indicated. failure due to lack of bacteriological results.
Patients will be considered culture converted Treatment failure: Treatment will be
after having two consecutive negative cultures considered to have failed if two or more of the
taken at least one month apart. Based on culture fivecultures recorded in the final 12-15 months
conversion patient is shifted from IP to CP. are positive, or if any of the final threecultures
are positive.
Regimen for XDR TB Death: A patient who dies for any reason during
the course of M/XDR-TB treatment.
The Intensive Phase will consist of 7 drugs Treatment default: A patient whose treatment
Capreomycin (Cm), PAS, Moxifloxacin (Mfx), High was interrupted for two or more
dose-INH, Clofazimine, Linezolid, and Amoxyclav. Consecutive months for any reasons.
Transfer out: A patient who has been
The Continuation Phase will consist of 6 drugs
transferred to another reporting unit (DR-TB
PAS, Moxifloxacin (Mfx), High dose-INH,
Centre in this case) and for whom the treatment
Clofazimine, Linezolid, and Amoxyclav.
outcome is not known.

Page 149
Switched to Regimen for XDR TB: A By an RNTCP certified C-DST laboratory,
MDR-TB patient who is found to have who subsequently switched to a regimen
XDR-TB. forXDR TB treatment initiated.

Page 150
59. LEPROSY (NLEP)
2) Thick and/or Tender nerve
1. Cardinal signs of leprosy Selection of Leprosy case on clinical sign &
1) Hypopigmented / Erythematousanesthetic symptoms.
patch/s.

Figure-1: Algorithm for Confirmation

Treatment for 6
PB case month (6 BCP in
Confirmation of
9 Month)
Suspect Case cases at
PHC/RH
MB case Treatment for 12
month (12 BCP
in 18 Month)

Table-1: Cardinal signs for classification of Leprosy Case

Clinical aspects PB (Paucibacillary) MB (Multibacillary)


Skin lesions 1 to 5 skin Patches with definite sensory 6 & 6 + skin Patches with
deficit definite sensory deficit
Nerve involvement And/or one definite thicken or tender And/or More than one definite
peripheral nerve involvement thicken or tender peripheral nerve

If any one or both signs present in suspected case then it is diagnosed as leprosy.

2. Management
Table-2: Management of Leprosy case as per classification2
Multi Drug Treatment for PB leprosy
Drug Adult Children 10- Children below 10 years Frequency
14 yrs
Rifampicin 600 mg 450 mg 300 mg
Once a month
Dapsone 100 mg 50 mg 25 mg
25 mg daily or 50 mg alternate day Daily/ alternate
Dapsone 100 mg 50 mg
day

Page 151
Multi Drug Treatment for MB leprosy.

Drug Adult Children 10-14 yrs Children below 10 years Frequency


Rifampicin 600 mg 450 mg 300 mg
Dapsone 100 mg 50 mg 25 mg Once a month
Clofazimine 300 mg 150 mg 100 mg
Dapsone 100 mg 50 mg 25 mg Daily
50 mg 50 mg 50 mg
Clofazimine weekly twice
(Daily) (Alternate day)

The appropriate dose for children under 10 Dapsone: 2 mg per kilogram body weight daily.
years of age can be decided on the basis of
MDT Multi drug Treatment is safe and well tolerated
body weight. by most of the patients.
Rifampicin: 10 mg per kilogram. 3. Management of Reaction
Clofazimine:6mgperkilogrammonthlyand1mgper
kilogramperbody weight daily.

Table-3: Features of Lepra Reaction


Features Type I Type-II
Skin Existing lesions suddenly become red, Red, painful, tender, subcutaneous (deep)
swollen, warn and tender. New lesions nodules (ENL) appear commonly on face,
may appear arms and legs. They appear in groups and
subside within a few days.
Lesions when subsiding, may show scales
on surface
Nerves Nerves close to skin become enlarged, Nerves may be affected but not as common as
tender and painful with loss of nerve in Type-I reaction
function.
Other organs Not common Fever, joint pains fatigue

Treatment of Lepra Reaction (Type-I and Type 15 mg OD for first7-8 weeks.


II) 10 mg OD for first 9-10 weeks.
5 mg OD for first 11-12 weeks.
Assurance to the patient & family (The total duration should not exceed 12 weeks even
in type 2).
Early diagnosis & prompt treatment to prevent
Cap Clofazimine 100mg T.D.S. in type 2 reaction for
deformity.
12 weeks,followed by 100 mg od for 12 weeks &
Removal of precipitating factor wherever 100 mg od for 12-24 weeks.
possible. Rest: Adequate rest to the affected nerve until
symptoms clear, by applying a padded splint or
Tab.Prednisolone
any other suitable material to immobilize the
40 mg OD for first 2 weeks.
joints near the affected nerve.
30 mg OD for first 3-4 weeks.
20 mg OD for first 5-6 weeks.

Page 152
Continuation of Anti Leprosy Treatment only if the appearance of reactions with new
not completed. development of the disease.
It has been observed that many medical officers
become panicky and start MDT again equating

Figure-2: MDT Blister Packs

Page 153
PEDIATRICS

Page 154
1. Emergency Management in Paeditrics

In children under five years of age Pneumonia, Keepthebabyunderaradiantwarmerandre-


diarrhoea, Birth asphyxia, Low birth weight and warmsoastobringthechildstemperatureto36.5
neonatal infections were the most important causes C.Payspecialattentiontoavoidchillingtheinfantdur
of death. Many children suffer from more than one ingexaminationorinvestigation.
illness at a time and also many different diseases
presents with similar symptoms. It describes a Monitortemperature everyhalfhourly
sequential process for managing sick young infants forfirst2hrsandthenevery2hourly.
and children as soon as they arrive in the facility.
Only the key protocols from Integrated Management 4. How to Treat Hypoglycemia
of Childhood Illness (IMNCI) and Facility Based
Check for blood glucose in all children presenting
IMNCI (F IMNCI) are re-emphasized.
with emergency sign, those with severe acute
malnutrition and all sick young infants (0-2
1. Emergency Management months):
process of the sick child (0- i. Ifhypoglycemiadetecteddefinedas
5 years) ii. a) <45mg/dlforyounginfants andb)
<54mg/dlinoldersickchildrenbeyond2 months.
The firststep in assessing children referred to a iii. GiveI.V.
hospital should be triage The process of rapid bolusdoseof10%dextrose,inthedoseof2ml/kgfory
screening to decide to which of the following ounginfants,and5ml/kgforolderchildren.
group(s) a sick child belongs: iv. Ifyoucannotmeasurebloodglucose,givebolusdose
Firstassesseverychildforemergencysigns.Thos asabove. Refer the case to higher center.
ewithemergency signs require immediate 5. Airway and Breathing :
emergency treatment.
Ifemergencysignsarenotpresent,lookforpriorit
ysigns.Thosewithpriority signs should alert
you to a patient who is seriously ill and needs
immediate assessment and treatment.
Childrenwithnoemergencyorprioritysig
nsaretreatedasnon-urgent cases.

2. Triage
All sick children are assessed for Airway,
Breathing, Circulation, Coma, Convulsions and
Severe Dehydration (ABCD). Table 1
Efforts should be made to maintain euglycemia and
euthermia while managing ABCD. Thus Blood
sugars should be done for every sick
Newborn,Infant and older children.

3. How to keep baby warm


Keeptheinfantdryandwellwrapped.
Cap,glovesandstockingsarehelpfultoreduceheatl
oss.
Keeptheroomwarm(atleast25C)makingsurethatt
hereisnoheatsourcedirectedstraightatthenewbor
n.

Page 155
Table-1: Assessment of Airway and Breathing

Table-1: Assessment of Airway andBreathing


No Manageairway
ASSESS AIRWAY
breathingorgaspingor Providebasiclifesupport
AND BREATHING
Centralcyanosis (No breathing/gasping)
ANY SIGN POSITIVE
Or Giveoxygen
Severerespiratorydistre Makesurechildiswarm
ss

Severe lower chest in-drawing


5.1. Signs of severe respiratory Head nodding
distress Grunting
Apnoeic spells
Respiratory rate Unable to feed due to respiratory distress
0 -2 months > 60,
Stridor in a calm child
2 months 1 year > 50 &
>1 year 5 years > 40.

5.2. Management of airway in a child with gasping or who has just stopped
breathing.
Table-2: Positioning to Improve the Airway when no neck trauma suspected.

Child Conscious Child Unconscious


Inspectmouthandremoveforeignbody,ifpresent. Opentheairwayby Head tilt andChinliftmethod.
Clearsecretionsfromthroatusingsuctioncatheter. Inspectmouthandremoveforeignbody,ifpresent.
Letchildassumepositionofmaximalcomfort. Clearsecretionsfromthroat.
GiveOxygen. Checktheairwaybylookingforchestmovements,
Continuewith furtherassessment. listening for breath sounds and feeling for breath.

5.2.1. Head tilt-chin lift maneuver (Fig 1)


Theneckisslightlyextendedandtheheadistiltedbyplacin Figure-1: Position for opening airway
gonehandontothechildsforehead.Liftthemandibleup
and outward by placing the fingertips of other hand Children of all age.
under the chin.
a) Positioning to improve the Airway when
neck trauma suspected b) Neck trauma suspected (possible cervical
To limit the risk of aggravating a potential cervical spine injury)
spine injury, open the airway with a jaw thrust while Stabilizetheneck,asshowninfigure2.
you immobilize the cervical spine. It is safe to use in
cases of trauma for Inspectmouthandremoveforeignbody,
ifpresent.
Clearsecretionsfromthroatbysuctioncatheter.
Checktheairwaybylookingforchestmovements,li
steningforbreathsoundsandfeelingforbreath.
5.2.2 Jaw thrust maneuver
The jaw thrust is achieved by placing two or
three fingersunder the angle of the jaw on
both sides, and lifting the jaw upwards and
outward. The jaw thrust maneuver is
alsoused to open the airway when bag-mask
ventilation is performed.

Page 156
Figure-2: Using Jaw thrust without head tilt
If after any of these maneuvers the child starts
breathing, an oropharyngeal airway should be put
and start oxygen.
If the child is not breathing even after the above Figure-3: Difference in padding for an infant and
maneuvers or spontaneous ventilation is older child
inadequate (as judged by insufficient chest Bags and masks should be available in sizes for
movements and inadequate breath sounds), the entire pediatric range (size 0, 1 and 2).
ventilate with a self-inflating bag and mask
It is important for the mask to be the correct
5.3. Ventilation with Bag and mask size for the child;it must completely cover
the
Positioning (Fig 3)
Mouth and nose without covering the eyes
A sniffing position (padding under
or overlapping the chin.
theshouldertopreventexcessiveflexionofthenec
kthatoccurswhentheirprominentocciputrestsont
hesurface onwhich the child lies without
hyper-extension of the neck) is usually
appropriate for children less then 2 years old. .
In correct sniffingposition, the opening of the
external ear canal should be in line with or in
front of (anterior to) the anterior aspect of the
shoulder. Extreme hyperextension of the infant
neck can produce airway obstruction.
In children older than 2 years you may need to Figure-4: Bag and mask ventilation
give padding under the occiput to
The correct size and position are shown in
Obtain optimal airway position. the figure4 & 5

Figure 5: Choosing the correct mask size

Page 157
Self-inflating bags of minimum volume 450- the chest by completely releasing the pressure
500ml should be used. Use force and tidal but maintaining contact with the compression
volume just enough to cause the chest to rise site.
Minimize interruptions in chest compressions.
visibly.
During cardiopulmonary resuscitation, chest
Reservoir and oxygen (5-6 L/min) compressions must always be accompanied by
should be connected to the self inflating positive-pressure ventilation.
bag during resuscitation. Avoid giving a compression and ventilation
After two effective ventilations, check simultaneously, because one will decrease the
the pulse (femoral, brachial or carotid) efficacy of the other.
for no more than ten seconds. If pulse is Therefore, the 2 activities must be coordinated,
with one ventilation interposed after every third
absent, the second person should start
compression (3 compressions followed by one
chest compression. ventilation), for a total of 30 breaths and 90
compressions per minute
5.3. Chest compressions:
The techniques for chest compression vary
for a child under 1 year and those between
1-8 years and are detailed below: 5.3.2 Chest compressions for the child (1 to 8
years of age)
Place the heel of one hand over the lower half of the
5.3.1 Chest compression in the infant (less sternum. Lift your fingers to avoid pressing on the
than 1 year of age) ribs.
There are two techniques for performing chest
compression. These techniques are:
Thumb technique, where the 2 thumbs are
used to depress the sternum, while the
hands encircle the torso and the
fingerssupport the spine

Figure-7: Chest compression for the child (1 to 8


years of age)
Figure-6: Thumb technique
Depress the sternum 1/3 to 1/2 of the depth of
2-fingertechnique, where the tips of the middle the chest. This corresponds to a 1 to 1- inches.
fingerand either the index fingeror ring
fingerof one hand are Compress at the rate of approximately 100
times per minute.
usedtocompressthesternum,whiletheotherhandi
susedtosupportthebabysback(unlessthebabyiso Theratioofchestcompressionsandventilationshou
naveryfirmsurface). ldbe 15:2(Fifteen compressions followed by
two ventilation).
Using either method to give chest
compressions, compress the lower half of the Bag and mask ventilation is a very effective
sternum but do not compress over the xiphoid. way of ventilation if done correctly.
After each compression allows the chest to
recoil fully because complete chest re- Setup an intravenous or an intraosseous line for
expansion improves blood flow into the heart. use of any drugs, whereneeded.
Push hard: push with sufficient force to
depress the chest approximately one third to
one half the anterior- posterior diameterof the 6. Use of Adrenaline
chest. Adrenaline 0.1 ml /kg (1:10,000) intravenous can be
Push fast: push at a rate of approximately 100 used in a child who does not respond toinitial
compressions per minute. ventilation and chest compressions and his pulses
Release completely to allow complete recoil of are absent. Two such doses can be used 3-5 minutes
apart.

Page 158
7. Giving Oxygen to a child
with respiratory distress
With a Head box (8-10 L/min) or a Face mask
(5-6 L/min).
Should be allowed to take a comfortable
position of his choice and should be given
oxygen.
Continue giving oxygen continuously until the
child is able to maintain a SaO2 > 92% in
room air. When the child is stable and
improving, take the child off oxygen for a few
minutes. If the SaO2 remains above 92%,
discontinue oxygen, but check again hour
later, and 3 hourly thereafter on the first day
off oxygen to ensure the child is stable. Where
pulse oximetry is not available, the duration of
oxygen therapy is guided by clinical signs,
which are less reliable. Figure-8: Capillary refill time

Any child who has been successfully


resuscitated or any unconscious child who is 8.1.1 Checking capillary refill
breathing and keeping the airway open should Weak & Fast Pulse: Evaluation of pulses is critical
be placed in the recovery position. This to the assessment of systemic perfusion. The radial
position helps to reduce the risk of vomit pulse should be felt. If it is strong and not obviously
entering the childs lungs. It should only be fast the pulse is adequate; no further assessment is
used in children who have not been subjected needed.
to trauma. A child with cyanosis or severe Weak and fast pulse is defined:
respiratory distress should be allowed to take a
comfortable position of his choice. In Infants : >160 per min.

Organize Urgent Transfer to higher centers in In children - > 140 per min.
Ambulance and ensure doctor accompanies the Thus if the child has cold extremities, a capillary
sick child. refill time more than 3 seconds, and a fast weak
pulse, then he or she is in shock.

8. Circulation: 9. Treatment of Shock:


After the Airway has opened, assess if a child has a If the child has any bleeding, apply pressure
circulation problem you need to know: to stop the bleeding. Do not use a tourniquet.
The letter Cin ABCD stands for Circulation, Give oxygen.
Coma and Convulsions.
Give fluids and other treatment for shock.
Assess the circulation for signs of shock
Themostcommoncauseofshockinchildrenisduetoloss 9.1 Young Infants:
offluidfromcirculation,eitherthroughlossfromthebody Fluid bolus of 20ml/kg of normal saline over
as in severe diarrhoea or when the child is bleeding, 20-30 minutes.e.g. in a baby weighing 3 kg,
or through capillary leak in a disease such as severe 60 ml of normal saline should be infused over
Dengue fever. 20-30 minutes. If no or partial improvement
Inallcases,itisimportanttoreplacethisfluidquickly.Anin (i.e. tachycardia and CRT still prolonged),
travenouslinemustbeinsertedandfluidsgivenrapidlyins repeat a bolus of 20 ml/kg of normal saline.
hocked children without severe malnutrition.
If the signs of poor perfusion persist despite 2
Capillary Refill Time: To assess the fluid boluses, start vasopressor support,
circulation, take the childs hand and feet in your except in infants with severe dehydration
own. If it feels warm, the child has no circulation who should be treated as per Plan C of
problem and you do not need to assess capillary diarrhea management.
refill or pulse. If the childs hands and feet feel cold,
you need to assess the capillary refill.
9.2 Children above 2 months of

Page 159
age:The recommended volumes of fluids to Managethe Airway
treat shock depending on the age/weight of a) Coma
child.If the child has severe malnutrition, you
must use of different fluid and a different rate Managing the airway is done in the same way
of administration and monitor the child very as treating any child with an airway or
closely. Therefore a different regime is used breathing problem. This has been discussed
for these children. earlier. Give oxygen for the emergency
setting.
b) Convulsion
10. Coma and Convulsion
Calso represents Coma and Convulsion. To manage the airway of a convulsing child
gentle suction of oropharyngeal secretions
Assess the child for coma and convulsion should be done & child put in recovery
10.1 Coma position and oxygen started.

Table-3: For assessment of the conscious level of a Do not try to insert anything in the mouth to
child is, a simple scale (AVPU) is used. keep it open.

A isthechildAlert?Ifnot,
V isthechildrespondingtoVoice? Ifnot, 10.3.2 Put the child in Recovery Position
P isthechildrespondingtoPain? Any unconscious child who is breathing and
keeping the airway open should be placed in
U the child who is Unresponsive to voice (or being the recovery position.
shaken) AND to pain is Unconscious.
T hispositionhelpstoreducetherisk
A child who is not alert, but responds to voice, is
ofvomitenteringthechildslungs.
lethargic.
An unconscious child may or may not respond to Ifneck trauma is not suspected
pain. Turnthechildonthesidetoreducerisk
A child with a coma scale of P or U will ofaspiration
receive emergency treatment for coma as described Keeptheneckslightlyextendedandstabilizebypl
below. acingthecheekononehand
10.2 Convulsions Bendonelegtostabilizethebodyposition
The child must be seen to have a Position of unconscious child (trauma
convulsion during the triage process for
emergency treatment for convulsion.
Convulsion ARE RECOGNIZED by the
sudden loss of consciousness associated
withuncontrolledjerkymovementsoftheli
mbsand
ortheface.Thereisstiffeningofthechildsarm
sandlegsanduncontrolled movements of
the limbs. The child may lose control of
the bladder, and is unconscious during Position of unconscious child (no trauma)
and after the convulsion.
Sometimes, in infants, the jerky Figure-9: Position of Unconsious child
movements may be absent, but there may
be twitching (abnormal facial If trauma is suspected
movements) and abnormal movements of - Stabilize the child while lying on the back.
the eyes, hands or feet.
- When the patient is not being moved, a
sandbag placed on each side or a cervical
collar can splint the neck.
10.3 Treatment of Coma - Use bottles or rolled towels in case
&Convulsions is similar and is sandbag
LogareRoll
not available as shown in the
as follows: figure10 belo

Page 160
Figure 12
10.3.4 Inserting an oropharyngeal airway in
an infant: convex side up
Selectanappropriatesizedairway
Positionthechildtoopentheairwayasdescribeda
bove, taking
carenottomovetheneckiftraumasuspected.

Figure 10 Usingatonguedepressor,inserttheoropharyngea
lairwaytheconvexsideup.
Use the log roll technique to turn the child
on the side if the child is Re-checkairwayopening.

Vomiting. Useadifferentsizedairwayorrepositionifnecess
ary.
Giveoxygen.
Management of Convulsions in
infantup to 2 weeks of age :
SecureIVaccess.
Ifbloodsugar<45mg/dl,give2ml/kg10%dextros
e.
Ifseizurescontinue:IV10%Calciumgluconate2ml
/kg to be diluted in distilled water in proportion
1:1over10minutes to be diluted in
whilemonitoringheartrate(in younginfants).
Ifseizurescontinue:IVphenobarbitone20mg/kg
Figure 11 in 20ml of 5% dextrose or saline
Insertionof an oropharyngeal (Guedel) over20min(Table1).
airway Ifnocontrol:Repeatphenobarbitone10mg/kgtill
atotalof40mg/kg.
The oropharyngeal or Guedel airway can be
used in an unconscious patient to improve Ifseizurescontinue:Givephenytoin20mg/kg in
airway opening. 20 ml of normal saline over20min.
It may not be tolerated in a patient who is Inj. Phenobarbitone intravenous dose
awake and may induce choking or vomiting. (200mg/ml)

Guedel airways come in different sizes


(Guedel size 000 to 4). An appropriate sized Weight Initial Repeat dose
airway goes from the centre of the teeth of Infant dose
(incisors) to the angle of the jaw when laid
on the face with the convex side up.
2 kg or 0.2 0.1 ml
less ml

2 to 4 kg 0.3 0.15 ml
ml

Page 161
Dose of Phenobarbitone for young convulsing in front of you. No drug should
infants (Table 4) be given if the convulsion has stopped.
Caution: Diazepam can be given by the rectal or
DonotuseDiazepamforcontrolofconvulsionsin intravenous route.
Neonates<2weeks. Rectal diazepam dose is 0.5mg/kg (0.1ml/kg)
Managingconvulsions more than 2 by tuberculin syringe or a catheter acts within
weeks of age: 2 to 4 minutes. Hold the buttocks together for
Diazepam is the firstdrug used to stop a few minutes
convulsions (anticonvulsant), if the child is
Intravenous dose is 0.25mg/kg (0.05 ml/kg)
over 1 minute.Diazepamcan
affectthechildsbreathing,soitisimportanttore
assesstheairwayandbreathingregularly.

Per rectal dose of Diazepam (Table 5)


Diazepam given rectally 10 mg / Diazepam given IV
2 ml solution 10 mg / 2 ml solution
Age / weight
Dose 0.1 ml/kg Dose 0.05 ml/kg
2weeksto2months(<4kg) 0.3 ml 0.15 ml
2-<4months(4-<6kg) 0.5 ml 0.25 ml
4-<12months(6-<10kg) 1.0 ml 0.5 ml
1-<3years(10-<14kg) 1.25 ml 0.6ml
3-<5years(1419kg) 1.5 ml 0.7ml

12. Dehydration
If convulsions do not stop after 10 minutes The letter D in the ABCD formula stands for
of second dose of diazepam. Dehydration. Assess for severe

Inj Phenytoin can be given intravenously if Dehydration:To assess if the child is severely
access has been achieved. 15 - 20 mg/kg dehydrated ask for:
Phenytoin is diluted in about 20 ml of saline Lethargic
and given slowly (not more than 1 mg/kg
Phenytoin per minute). Childhavesunkeneyes

Alternatively phenobarbitone can be used in Skinpinchtakelongerthan2secondstogo back


a dose of 15- 20mg/kg IV (in 20 ml 5%
dextrose or saline) or IM.
At this stage, seek help of a senior or more
experienced person, if available If child has diarrhea with any two of the above signs
he is classified to have severe dehydration.
11. If there is high fever: 12.1 Treatment of severe
Spongethechildwithroom- dehydration in an emergency
temperaturewatertoreducethefever.
setting
Donotgiveoralmedicationuntiltheconvulsionhas
beencontrolled(dangerofaspiration).
Page 162
12.1.1 Severe dehydration (without severe IV fluidsfor severe dehydration (Table 6)
acute malnutrition)
StartIVfluidimmediately.Ifthechildcan AGE First give 30 Then give 70
drink,giveORSbymouthwhilethedripissetup.Gi ml/kg in ml/kg in
ve100ml/kgRingerslactatesolution (or
ifnotavailable,normalsaline)dividedasfollows:
*Repeatonceifradialpulseisstillveryweakornot
detectable.
Reassessthechildevery15-
30minutes.Ifhydrationstatusisnotimproving,giv Infants (Under 12 1hour* 5 hours
etheIVdripmorerapidly. months)

AlsogiveORS(about5ml/kg/hour)assoonasthechi
ldcandrink:usuallyafter3-4hours(infants)or1-
2hours(children).

Volume of ORS (Table 7) Children (12 months 30minutes* 2 hours


up to 5 years)

Weight Volume of ORS solution per hour

<4kg 15 ml

4-<6kg 25 ml

6-<10kg 40 ml

10-<14kg 60 ml

14 19 kg 85 ml

Themothercanmaintainhydration by giving the


If IV treatment not possible, give ORS 20 child ORS solution by mouth.
ml/kg/hour for 6 hours (120 ml/kg/day) by NG tube 12.1.2 Severe dehydration with severe acute
Reassessaninfantafter6hoursandachildafter3h malnutrition
ours.Classifydehydration.Thenchoosetheappr It is difficult to determine dehydration status in a
opriateplan(A,B, or C) to continue treatment severely malnourished child, as the usual signs
as you have learned in IMNCI / F-IMNCI. of dehydration (Such as lethargy, Sunken eyes)
may be present in these children all of the time
Giveoralantibioticforcholeraifchild2is whether or not they are dehydrated.
yearsorolder.
Signs of Dehydration
Lethargy
Restless, irritable:
Ifpossible,observethechildforatleast6hoursaft
errehydrationtobesurethat Sunken eyes
Thirsty
Page 163
Skin pinch goes back slowly RECORD the respiration rate.
Treatment of dehydration in the children In addition the following should be recorded:
with SAM without shock Pulse rate.

If the child has had watery diarrhea or vomiting, The capillary refill time
assume dehydration and give ORS. WHO The malnourished child is managed preferably by:
recommends use of ReSoMal, which is not available
commercially. Use either WHO-low Osmolarity Clinical signs of improvement and
ORS with potassium supplements (15 ml Clinical signs of over-hydration.
ofpotassium chloride syrup added to one litre ORS)
as mentioned in step 4 or ReSoMal prepared from 13. MANAGEMENT OF
WHO-low Osmolarity ORS
SHOCK IN CHILDREN
Calculate amount of ORS to give WITH SAM
Table-8: Give ORS as follows in amounts based on Give this treatment only if the child has signs of
the childs weight shock and is lethargic or has lost consciousness

How often to give ORS Amount to give 13.1 Weigh the child Estimate the
Every 30 minutes for the 5 ml/kg body weight weight if child cannot be
first 2 hours
Alternate hours for up to 5-10 ml/kg weighed or weight not
10 hours known
The amount offered in this range should be based on
the childs willingness to drink and the amount of
13.2 Give oxygen
ongoing losses in the stool. Starter (diet is given in 13.3 Make sure child is warm
alternate hours during this period until the child is 13.4 Insert an IV line and draw
rehydrated.
blood for emergency
BEFORE starting any rehydration treatment:
laboratory
WEIGH the child (The weight should be taken on
admission)
MARK the edge of the liver and the costal margin
on the skin

Page 164
Investigations

Give IV 10% Glucose (5ml/kg)

Give IV fluid 15 ml/kg over 1 hour of either ringers lactate in 5%

Dextrose or half-normal saline with 5% glucose

Measure the pulse and breathing rate at the start and every 5-10 minutes

If the child fails to


Improve after the first If the child deteriorates
15ml/kg IV During the IV
(RR increases by 5/min or
PR by 15 beats per min)
Repeat same fluid IV
15ml/kg over 1 hour
more; then Stop the infusion and reassess

Give maintenance IV
fluid (4 ml/kg/hr) Assume
The child has septic shock
Start dopamine
Sign of improvement
(PR and RR fall)
Rehydration
Review antibiotic treatment

Switch to oral or nasogastric rehydration


With ORS 10ml/kg/hr up to 10hours Initiate re-feeding as soon as
Initiate feeding with starter formula Possible

Figure-13:Treatment of shock

Page 165
The management of shock in child with severe acute 13.6 How to give Dopamine (By
malnutrition is given is char3
infusion pump)
13.5 Broad spectrum antibiotic Amount of dopamine (mcg) to be added =
should be administered weight in kgX6
Immediately to all SAM with septic shock (table2) To convert this dose into amount to ml of
packed RBCs 10ml/kg should be given over dopamine dived by 40 (1 ml of dopamine=
40mg of doplamine
4-6 Hours if HB is less than 4 gm/dl or active Add this amount of dopamine (ml) to make 10
bleeding. If there is no improvement with fluid ml of total fluid.
Bolus start dopamine at 10pg/kg/min if there is no 0.1 ml/hour of this fluid gives 1 mcg/kg/minute
improvement in next 24-48 hours upgradesan To give 10 mcg/kg/minute gives infusion at the
ntibiotics. rate on 1ml /hr
Amount of dopamine to be added = 5X6=
30mcg

Page 166
2. NEONATAL RESUSCITATION GUIDELINES
Stabilization (warm, position, clear airway, dry,
1. What is Neonatal stimulation, reposition )
Resuscitation? Ventilation
Neonatal resuscitation means to revive orrestore life Chest compression
to a baby from the state of asphyxia. Intubation
The following guidelines are intended to neonates Drug administration
undergoing transition from intrauterine to extra (The decision to progress from one category to
uterine life. another should be assessed by vital signs;
respiration, heart rate, colour. Approximately 30
seconds is allotted to complete each step)
2. A rapid assessment of the
following 4 characteristics: 3. Preparing for Birth
Was the infant born full-term gestation? Essential:
Is the amniotic fluid clear of meconium and i. A draught free, warm room with
evidence of infection? temperature >25 degree Centigrade
Is the infant crying or breathing, colour of ii. A clean, dry and warm delivery surface
baby? iii. A radiant warmer / overhead lamp with
Does the infant have good muscle tone? 200 watt bulb if available
iv. A newborn size self inflating bag
If the answer is to all 4 of these question is yes, the v. Infant masks in two sizes: size 1 for
infant does not need resuscitation and should not be normal weight baby and 0 for small baby.
separated from mother. vi. A suction device, feeding tube 6F/8F/9F
Observation of breathing, activity, and colour vii. Oxygen (if available)
should be ongoing. viii. Endotracheal Tube size 2.5/3/3.5

If answer is no then the infant should receive 1 or


more of the following 4 categories in sequence.
ix. Laryngoscope 0/1

Page 167
Table-1: Immediate Newborne Care

Immediate Newborn Care

Assess by checking
Is the baby term gestation?
Is the amniotic fluid clear?
Is the baby Breathing or crying?
Does the baby have Good muscle tone?

If yes, provide Routine careRoutine If no

Place the baby on the mother's abdomen. Dry the baby


with a warm clean sheet. Do not wipe off vernix. Proceed for
Wipe the, mouth and nose with a clean cloth. resuscitation
Clamp the cord after 1-3 min and cut with a sterile instrument. Tie the cord with a sterile tie.
Examine the baby quickly for malformations/birth injury.
Leave the baby between the mother's breasts to start skin-to skin care.
Support initiation of breastfeeding.
Cover the baby's head with a cloth. Cover the mother and baby with a warm cloth.
Place an identity label on the baby.
Give Inj Vit K 1 mg IM (0.5mg for preterm).
Record the baby's weight
Refer if birth weight <1500g. has major congenital malformations or has severe respiratory
distress

Page 168
3. GUIDELINES FOR MANAGEMENT OF
NORMAL NEWBORN

- Endotracheal tubes (3, 3.5 mm)


1. Care at Birth:
The four basic needs of ALL newborns at the time - IV cannula (24G)
of birth and for the firstfew weeks of life are:
- Drugs (Inj. Epinephrine , Normal saline,
1. To be warm Inj.Vitamin K)
2. To breathe normally
3. Immediate Newborn Care
3. To be protected (prevent infection)
of a NormalNewborn at
4. To be fed
the time ofBirth:
Most babies would require routine care; 5-10%
Module I : Care ofthe normal baby atbirth

2. Newborn Care Corner may need assistance to establish adequate


breathing and therefore will need resuscitation.
2.1 This is a space within the Deliverthebabyontoawarm,cleananddrytowell
delivery room for facilitating orclothandkeeponmother's
immediate care of the abdomenorchest(betweenthebreasts).
Dry the Baby with a warm clean sheet. Do not
newborn. This area is wipe off vernix
mandatory for all health Wipeboththeeyesseparatelywithsterileswab.
facilities where deliveries take Clampandcuttheumbilicalcordafter1to
place. 3minute,ifbabyisbeathing.

2.2 Equipment and supplies that Well.


should be available in the Assessthebaby'sbreathingwhiledrying.
corner: Examine the baby quickly for Malformation and
birth injury.
2.2.1 Equipment: - Radiant warmer with
bassinet Leavethebabybetweenthemother'sbreaststostartskin
- Suction equipment -to-skincareforatleastan hour.

- Weighing machine Coverthebaby'sheadwithacap.Coverthemotherandb


abywithawarmcloth.
- Self inflatingresuscitation bag (500 ml) with masks
(size 0, 1) Placeanidentitylabel/band/tag onthebaby and mother

- Oxygen source Encouragemothertoinitiatebreastfeeding(withinhalf


anhourofbirth).
- Laryngoscope (straight blade, size 0,1)
- Wall Clock
- Room thermometer
4. Ensuring WARM
CHAIN'
2.2.2 Supplies: - Clean baby sheets
4.1. At delivery
- Sterile cord ties Ensurethedeliveryroomiswarm(25-
- Sterile Gloves 28C),withnodraughtsofair
Drythebabyimmediately; removethewetcloth.
- Sterile blade/scissors Put the baby on the mothers abdomen.
- Mucus extractors Coverthebaby and mother withcleandrycloth
Keep the baby in skin to skin contact with mother
- Suction catheters (10F, 12F) on chest or abdomen
- Feeding tube (6F, 8F) Postpone bathing/sponging for at least 12 hours or
next day
Page 169
4.2. After delivery stump.
Keep the baby clothed and wrapped with the head Leave stump uncovered and dry.
covered.
Avoid bathing especially in cool weather or for 5.4. Care of the eyes
small babies. No routine eye care is required
Keep the baby close to the mother
Use kangaroo care for stable LBW babies and Do not instill any medicine in the eyes
for re-warming stable bigger babies
Show the mother how to avoid hypothermia, 6. Weighing the baby
how to recognize it, and how to re-warm a cold Weigh all babies before transfer from the delivery
baby. room
The mother should aim to ensure that the
baby's feet are warm to touch Initiate breastfeeding within 1 hour
Support mother to initiate breast feeding within
4.3 If mother and babys the first hour.
separation is necessary, do the The babys first feed of colostrum is very
following. important because it helps to protect against
Wrap the baby in a clean dry warm cloth and place infections.
under a radiant warmer. If warmer is not available
ensure warmth by wrapping the baby in a clean dry The baby can feed from its mother whether she is
warm cloth and cover with a blanket. Ensure babys lying down or sitting; baby and mother must be
head, hands and feet are covered. comfortable

Re-start Skin-to-skin contact as soon as mother and Do not give artificial teats or pre-lacteal feeds to the
baby can be roomed-in newborn e.g. sugar water or local foods or even
water.
5. Prevention of infections: 7. Examine the baby
CLEAN CHAIN' 7.1 A complete examination should
5.1. Clean delivery (WHOs six be performed within about 60
cleans) minutes after birth
Clean attendant's hands (washed with soap)
Clean delivery surface Count the number of breaths during one minute.
Clean cord- cutting instrument (i.e. razor, blade) Observe the movement of the limbs when
Clean string to tie cord awake, their position when not moving and
Clean cloth to cover the baby their tone.
Clean cloth to cover the mother Observe the skin color.
Inspect the following body areas for
abnormalities: head, face, mouth and palate,
5.2. After delivery chest, abdomen, genitalia, anus, limbs and skin
All caregivers should wash hands before handling
the baby 7.2 A well baby should have
Feed only breast milk
Keep the cord clean and dry; do not apply anything Normal temperature , warm to touch, pink with
Use a clean absorbent cloth as a diaper/napkin Weight > 2.5 kg
Wash your hands after changing diaper/napkin. Breathe easily at 40-60 breathes/minute
Keep the baby clothed and wrapped with the head Move arms and legs equally when active and
covered rest with limbs flexed
Explain to mother the examination findings to
allay her concern.
5.3. Immediate Cord Care Document in case record and ask her to inform
Clamp the cord after 1-3 min of delivery and cut you , in case any other concerns develop
with a sterile instrument subsequently.
Tie the cord between 2 to 3 cms from the base and 8. Give Vitamin K
cut the remaining cord. Vitamin K will protect babies from serious
bleeding.
Observe for oozing blood. If blood oozes, place a
second tie between the skin and first tie. Give Vitamin K by intramuscular (IM)
injection 1.0 mg for every newborn (0.5 mg
Do not apply any medication/substance on the for <1000 gms).
Page 170
Encourage mothers to breastfeed their baby skincontactasanyothermotherandbaby.
during the injection for comfort.
Exclusivebreastfeedingistherecommendedfeedingch
oiceintheir first6
9. Monitoring the Baby months,irrespectiveofthefactthatthemotherisonARTe
Table-1: Monitoring the baby in the first hour after arly(or)infantis
birth providedwithprophylaxisfor6weeks.(preferably)*

Parameter Whattolookfor? If mother chooses replacement feeding,


prepare formula for the first few
feeds.Ensureitissafe,affordableandsustaina
bleforfamily.
Allothercare(includingcordcareandeyecare)remainst
Breathing Listenforgrunting;Lookforchestin- hesame.
drawingandfastbreathing
Giveoralnevarapineforsixweekstotheneonateaspernat
ionalpolicy.
Mothershouldbecounseledregardingthemodeoff
Warmth Check to see if baby's feet are eedingbeforedelivery
cold to touch (by using dorsum of anddangersofmixedfeeding.
your hands)
11. Postnatal Care of
Normal Baby
Ideally, allpregnant women should be counseled
regarding the care of the baby during the
Color Evaluatethecolorofthetrunkandextremitie antenatalperioditself.Thiswouldhelpthemtobementa
s llypreparedtotakecareoftheirbabies afterbirth.

11.1. Postnatal environment


Ensure that the room is warm without air currents.
Keep mother and baby close together in same room
10. Special Situations and same bed.
10.1 Caesareansection,instrumentaldelivery:
Provide bed nets to sleep.
Skin-to-skin contact and breastfeeding in
difficult deliveries (caesarean section, 11.2 The key areas of every day
instrumentalandbreechdelivery):
Breastfeedingcanbegivnassoonasthemotherisco
care of a newborn baby
mfortableandabletorespondto include:
herbaby.Itdoesnothavetobedelayed
11.2.1. Breastfeeding
Amotherwhowasgivenageneralanaestheticagent
Supportexclusivebreastfeedingondemanddayan
shouldbegivenskin-to-skincontact
dnight.
assoonassheisabletorespondtoherbaby.Thismayb
Askthemothertogethelpifthereisabreastfeedingdi
einitiatedwithinonehourof birth.
fficulty.
Amotherwhohashadanepidural
Assessbreastfeedingineverybabybeforeplanning
(spinal)anaesthetiamaybeabletostartskin-to-
fordischarge.
skincontactverysoonaftersurgery
If
Thesemotherswill
themotherreportsabreastfeedingdifficulty,assess
needadditionalassistanceinpositioningandattachi
breastfeeding
ngthebaby
andhelpherwithattachmentandpositioning.
comfortably.Breastfeedinginlyingdownposition
DONOTdischargethebabyifbreastfeedingisnotes
maybemorecomfortableinthefirst days
tablished.
10.2 HIV and newborn care at birthCare of a baby
born to HIV+ve mother 11.2.2Keeping the cord healthy
Care of the baby at delivery should be no different Washhandsbeforeandaftercordcare.
PutNOTHINGonthestump.
from the care already described.
Foldnappy(diaper)belowthelevelofthestump.
Standardsafetyprecautionsmustbefollowedaswithany Keepcordstumplooselycoveredwithcleanclothes.
otherdelivery. If stump is soiled, wash it with clean water and
soap.
Babycanhaveimmediateskin-to-

Page 171
Dry it thoroughly with clean cloth.
Lookforsignsof infection (daily).
12. Ensure immunization
Allbabiesshouldreceivethefollowingvaccinesim
- Pusdischargefromthecordstump. mediately after birth
beforedischargefromthehealthfacility:
-
- BCG,
Rednessaroundthecordespeciallyifthereissw
elling. - OPV-0,
- High temperature (more than 37.5C) or other - Hepatitis B(HB-0)
signs of infection 13. Criteria for discharge
Explain to the mother that she should seek care
if the umbilicus is red or draining pus or blood.
from a health facility
Feeding well (suckling effectively) at least 8
It is important to teach the mothers that the times in 24 hours
umbilical stump should be left dry; they SHOULD No danger signs
NOT APPLY ANYTHING on the stump. Mother is confident to take care of baby
11.2.3 Ensuring hygiene Understands the need for follow up and danger
Wash the face, neck, and underarms of the baby signs when to report early
daily. For small baby below 2500gms: feeding well
Do not bathe the baby before 24 hours of age or and gaining weight adequately
if the baby is cold.
In case of small babies, bathe only 14. Advise on essential care
after the baby reaches a weight of
2000g.
for neonate at discharge
If bath is given 14.1. Feed breast milk
Ensureroom is warm and there is no draught Breast milk is the best and is the only food
while changing clothes, washing and bathing baby needs for first six months Mother needs
Use warm water for bathing to breastfeed day and night, at least eight
Thoroughly dry the baby, dress and cover after times in 24 hours Mothers need to take
bath nutritious meals and should drink lots of
Take extra precautions if the baby is small clean water.
Wash the buttocks when soiled. Dry thoroughly. For a smallbaby who finds difficult to
Use cloth diaper on baby's bottom suckle,express breast milk and collect in a
to collect stool. Dispose off the clean cup to feed the baby with a paladai, cup
stool as for woman's pads. Wash or spoon.
hands after disposing.
Do not apply Kajal on eyes 14.2. Keep clean
Wash your hands with clean water and soap
11.2.4 Looking for danger signs and giving before every feed and after visiting toilet and
treatment handling baby's faeces / urine.
Itisimportantthatmothers,caregiversandhealthwork Keep the surroundings clean
ersareableto recognize thesigns Keep the cord stump clean; do not apply
andsymptomswhichindicatethatthebabyisnot well anything on cord
('DANGERSIGNS').
Earlyrecognition of the danger signs will help in 14.3. Keep warm
identifying those babies who need urgent care and Keep the baby well wrapped in a clean dry
treatment. cloth or blanket (in cold season) Cover baby's
head with part of cloth / blanket or put a cap
Danger Signs are - on the head Keep the room warm avoid direct
Not feeding well draught of air
No movement Keep next to mother for warmth; it promotes
Fast breathing (more than 60 breaths per lactation and mother-baby bonding
minute) Encourage KMC for Low birth weight babies
Moderate or severe chest in-drawing
Jaundice on day 1 or palms or sole stained 14.4 Counsel and educate the
yellow any age abnormal movements. mother and family
Fever (temperature >37.5C) Build confidence of the family intaking care
Temperature <35.5C or not rising after re- of baby at home
warming Ensure that the family understands
Normal neonate: Preparing for discharge importance of administering prescribed

Page 172
medicines for the whole duration. term neonates which begins on the face and
Educate mother when to reportfor follow up spreads down to the trunk and extremities in
after discharge about 24 hours. This should be differentiated
Educate mother when to reportearly if from pustules which need treatment.
thereisworsening of condition at any time It disappears spontaneously after two to three
after discharge days without any specific treatment. The
Educate mother for signs of well babyfeeds exact cause is not known.
on breast, active behavior,pink extremities
and trunk &extremities are warm to touch. Weight loss of 6-8% (10-12% in preterm
Ensure baby is infants) in the first few days of life is normal
gaining weight on and most infants regain their birth weight by
follow up. 10-14 days.
Advicefor timely immunization
15.5. Bowel disorders.
No medication should be prescribed for passage of
15. Management of Common stools after each feed (exaggerated gastrocolic
Clinical Conditions in reflex) as this is normal in some babies. From 3rd to
14 days many exclusively breasfed babies pass
New Borns loose stools (10-15 times/day) without
There are several phenomena after birth that are illness/dehydration. These are transitional stools and
normal and mothers only need reassurance. These require no medication.
include:
Developmental variations & Physiological
15.6. Delayed passage of urine.
conditions
Non-passage of urine by 48 hours after birth may
Knowledge of developmental variations, suggest urinary tract anomalies. Such babies need to
physiological conditions and their evolution be investigated. Crying before passing urine is
innewborns is important for advising and assuring normal.
the mother. Mothers observe their babies very
Jitteriness is abnormal only when it is excessive or
carefully and are often worried by minor physical
persists even during feeding and then it may suggest
peculiarities, which may be of noconsequence and
hypoglycaemia or hypocalcaemia.
do not warrant any therapy.
15.7. Dehydration fever.
15.1. Mastitis neonatorum
Engorgement of breasts occurs in term babies Transitory moderate fever (up to 38.50C) usually
of both sexes on the third or fourth day and during the second or third day of life in summer
may last for days or even weeks which is due months in an active baby, who sucks well, is normal
to persistence of maternal hormones for some and responds to lowering the environmental
time. temperature.
Local massage, fomentation and expression
of milk should not be done as it may lead to 15.8. Excessive crying.
infection. Mother should be reassured that
this regresses on its own. Most baby cry when either they are hungry or are
having discomfort such as due to full bladder before
15.2. Vaginal bleeding passing urine, wet napkin, nose block, etc.
Vaginal bleeding may occur in female babies Excessive inconsolable crying or high-pitched
about three to five days after birth which is crying is indicative of meningitis or any other
because of withdrawal of maternal hormones. painful inflammatory conditions.
The bleeding is mild and lasts for two to four
days. 15.9. Umbilical granuloma.
Additional vitamin K is unnecessary.
A red flesh-like nodule at the base of umbilical cord
15.3. Mucoid vaginal secretions can be managed by cautery with Silver Nitrate or
Most female babies have a thin, grayish, application of common salt for 3 to 4 days.
mucoid, vaginal secretion, which should not
be mistaken for purulent discharge. 16. Normal phenomena in
15.4. Toxic erythema or Erythema new born
Peeling skin: Dry skin with peeling and
neonatorum exaggerated transverse sole creases is seen in
This is an erythematous rash with a central all postterm and some term babies.
pallor appearing on the second or third day in

Page 173
Milia: Yellow white spots on the nose or face hard palate. Similar lesions may be seen on the
due to retention of sebum, are present in prepuce. They are of no significance.
practically all babies and disappear Sucking callosities: The presence of these
spontaneously. buttons like, cornified plaques over the centre
Storkbites (Salmon patches or nevus simplex): of upper lip has no significance.
These are discrete, pinkish- gray, sparse, Tongue Tie: It may be in the form of a fibrous
capillary hemangiomata commonly seen at the frenulum with a notch at the tip of the tongue.
nape of neck, upper eyelids, forehead and root This does not interfere with sucking or later
of the nose.. They invariably disappear after a speech development.
few months. Non retractable prepuce: The prepuce is
Mongolian blue spots: In babies of Asiatic normally nonretractable in all male newborn
origin irregular blue areas of skin pigmentation babies and should not be diagnosed as
are often present over the sacral area and phimosis. The urethral opening is often pinpoint
buttocks, though extremities and rest of the and is visualized with difficulty. The mother
trunk may also be affected. These spots should be advised against forcibly retracting the
disappear by the age of six months. foreskin.
Subconjunctival hemorrhage: A semilunar arc Hymenaltags: Mucosal tags at the margin of
of sub-conjuctival hemorrhage is a common hymen are seen in two-third of female infants.
finding in normal babies. The blood gets
reabsorbed after a few days without leaving any Umbilical hernia: Umbilical hernia may
pigmentation. manifest after the age of two weeks or later.
Epstein Pearls: These are white spots, usually Most of these disappear spontaneously by one
one on either side of the median raphe of the or two years of age.

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4. CARE OF AT-RISK NEONATES

The care of 'at-risk' neonate should be initiated at


1. An 'at-risk' neonate has the health facility itself under direct supervision.
one or more of the After initial improvement, further care can be
provided at home
following features:
Weight 1500-2499g 2. The care of at-risk babies
Temperature (axillary) 36.0C-36.4C
Babies with moderate or severe hypothermia
is outlined below:
who respond to warming 2.1. Warmth:
Cried late (>1min) but within 5 minutes of Grading of hypothermia
birth
Sucking poor, but not absent sucking reflex Normal temperature: 35.5-36.5C
Depressed sensorium, but is arousable Cold stress : 36.4-36.0C
Respiratory rate of over 60 per minute, but no Moderate hypothermia : 35.5-
chest retractions 32C
Jaundice present, but no staining of Severe hypothermia : <32C
Module 8:Care ofAt-risk and Sick Neonates

palms/soles
Presence of any one of the following:
- Diarrhea or vomiting or abdominal distension
- Umbilicus draining pus or pustules on skin
- Fever

The steps are dependent up on the current temperature of the baby (see below). (Table 1)

Temperature Management
Normal -Prevent hypothermia
temperature - Wrap the baby in layers of clothing
- Cover the head and limbs
- Place the baby in direct contact with mother
- In winter months, the room may have to be warmed with heater,
etc

Cold stress -Treat hypothermia


(temperature - Wrap the baby with extra layers of clothing
36.0C and 36.4C) - Cover the head and limbs
-Place the baby in close contact with the mother, preferably skin-to skin
In winter months, heat the room with a heater , etc.

Hypothermia - Requires immediate exposure to a radiant


(Temperature heat source (such as radiant warmer) or heater
2.2. Stabilization Most of these babies do not require stabilization

Page 175
other than prevention for hypothermia as above. If sucking well, she is provided expressed breast milk
there is occasional apnea, physical stimulation may by spoon or paladai. Occasionally, expressed
be provide breast milk may have to be given by gavage
feeding.
2.3. Feeds
The baby is started on direct breast feeding. If not 2.4. Specific therapy

Some simple conditions can be readily treated at the health facility and later at home. (Table 2)
Condition Treatment
Umbilical redness - Local application of 1% gentian violet
And Discharge -Syrup Amoxycillin 1.25ml TDSx7days
Skin pustules Local application of 1% gentian violet.
Syrup Amoxycillin 1.25ml TDSx7days

Module 8:Care ofAt-risk and Sick Neonates


Pneumonia (Respiratory
rate >60/min, no chest syrup Amoxycillin 1.25ml TDSx7days) retractions)

2.5. Monitoring 2.7. Communication


The following signs should be monitored everytwo Communication with the family, especially the
hours: mother is very important during the management of
at-risk and sick neonates.
Signs to be monitored
Communication with the family
Temperature
1. Reassure the mother and family.
Convulsion
Sucking
2. Prepare a note regarding baby's condition and
care.
Bleeding
3. If baby improves and is to be sent home,
Sensorium explain care of the baby at home.
Diarrhea 4. If baby does not improve or worsens,
explain the need for referral and care
Respiration
during transport.
Vomiting
Apnea
3. FOLLOW - UP
Advice about follow-up visits
Abdominal distension
Keep the baby warm
Cyanosis
Provide exclusive breast milk feeding
2.6. Re-evaluation Continue the prescribed treatment
Observe progress of baby
After stabilization and/or specific therapy, the baby
Counsel and educate the mother and family
has to be re-evaluated for improvement.The two
Follow-up:
cardinal signs of improvement are:
A home visit by the health worker one day after
i. The temperature will become normal evaluation at hospital is desirable. Thereafter
(36.5C -37.5C) and the baby should be seen again after 2 and 7
ii. The baby will accept feeds well. days by health worker.

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5. CARE OF SICK NEONATES
Infuse IV 10% Dextrose @ 60ml/kg/day
1. A sick neonate is the one Inject Vitamin K 1.0 mg intramuscular
who has any of the Provide oxygen
Consider and assess for sepsis
following features:
Weight <1500 g 3. Prevent hypothermia: warm
Temperature <36C despite warming for one
hour chain
Cried after 5 minutes of birth Baby must be kept warm at all times right from
Absent sucking birth. The "warm chain" is a set of 10 interlinked
Not arousable procedures carried out at birth and later
Respiratory rate more than 60/min with chest
retractions Warm delivery room (>25C)
Apnea or gasping respiration Warm resuscitation
Central cyanosis Immediate drying
Jaundice staining palms/soles
Skin-to-skin contact between baby and the
Convulsions
Bleeding mother
Major malformation Breast feeding
Presence of two of the following Bathing and weighing postponed
- Diarrhea or vomiting or abdominal distension Appropriate clothing and bedding
- Umbilicus draining pus Mother and baby together
- Multiple skin pustules Warm transportation
- Fever
Training/awareness-raising of healthcare
Alsorememberthatifan'at- provider
risk'neonatedoesnotimprovewhilebeing
observedunderyourcare,heisalsoconsideredasickneo 4. Expression of breast milk
nate. Breast milk expression is required for optimal
feeding of newborns for preterm, low birth weight
2. Grading and management and sick newborns that cannot breastfeed but can
of hypothermia tolerate assisted feeding.
Baby who is cold to touch both centrally and Expressing breast milk
peripherally or temperature is less than 35.5C
4.1. Teach the mother to:
2.1. Management of hypothermia Wash hands with soap and water before
expression. Hold, handle or cuddle the baby
Record the actual body temperature Sit comfortably and hold the clean container
Re-warm a hypothermic baby as quickly as near the breast
possible: Put thumb and index finger on the breast at the
Severe hypothermia Radiant warmer rim of the areola opposite each other. Support
Mild to moderate hypothermia- Kangaroo the breast with other three fingers.
Press thumb and index finger slightly inward
mother care or Radiant warmer
towards the chest wall
If hypothermia still persists despite taking above Press the breast between the fore-finger and
measures, infection should be suspected thumb. Press and release, press and release.
This should not hurt
Press the areola in the same way from the sides,
this ensures that milk is expressed from all
2.2. Management of severe segments of the breast
Avoid rubbing or sliding fingers along the skin
hypothermia Express one breast for at least 3-5 minutes until
Keep under radiant warmer the flow slows; then expresses the other side;
Reduce further heat loss and then repeats on both sides

Page 177
To express breast milk adequately it may take Feed with cup or spoon or paladai, never feed
20-30 minutes with bottle

4.2. Storing expressed breast milk 5. Assisted feeding of low


(EBM) birth weight neonates
Cover the container of EBM with a clean cloth
or a lid 5.1. Newborns that require
EBM can be kept at room temperature for 8 assisted feeding:
hours and in the refrigerator for 24 hours Preterm <34 weeks or birth <1800 g
EBM stays in good condition longer than Babies having mild respiratory distress
animal milk. Do not boil the EBM. For Babies with inability to feed at breast or by
warming place the container in a bowl of warm katorispoon/paladai
water Oro-facial defects/malformation (Cleft lip or
Before feeding gently shake the container or palate)
use a stirrer to recombine the separated fat
globules with the rest of the milk

Table 1
Guidelines for the modes of providing fluids and feeding

Birth weight (grams) < 1200 1200-1800 >1800


Gestation (weeks) < 30 30-34 >34
Initial feeding Intravenous fluids try Gavage, try katori- Breastfeeding, if
gavage feeds, if not spoon if not sick unsactisfactory, give
sick katori-spoon feeds
After 1-3 days Gavage Katori-spoon Breastfeeding
Later (1-3 weeks) Katori-spoon Breastfeeding Breastfeeding
After some more time Breastfeeding Breastfeeding Breastfeeding
(4-6 weeks)

5.2. Mode for providing fluids and Leave oro-gastric tube in situ
Pinch the oro-gastric tube during withdrawal
feeds Measure pre-feed abdominal girth just above
Breast milk is the ideal feed for low birth weight
the umbilical stump. Do not attempt pre-feed
babies.
aspirates
Those unable to feed directly on the breast can be Evaluate baby for ileus, if abdominal girth
fed expressed breast milk (EBM) by gavage OR increases by >2cm from baswline
katori-spoon or paladai.

5.3. Techiques of assisted feeding: 5.4. ROUTINE RE-FEED


Gavage feeds GASTRIC ASPIRATES ARE
Place an oro-gastric feeding catheter of size 5-6 NOT RECOMMENDED
Fr after measuring the correct insertion length Katori-spoon/paladai feeds
from ala of nose to tragus and from tragus to Place the baby in a semi-upright posture
midway between xiphisternum and umbilicus Place the milk filled spoon at the corner of
Check correct placement by pushing in air with mouth
10 ml syringe and listening with stethoscope Allow milk flow into baby's mouth slowly,
over upper abdomen allowing him to actively swallow, avoiding
Attach 10 ml syringe (without plunger) at the the spill
outer end of the tube, pour measured amountof Reapeat process till required amount has been
fed
milk and allow milk to trickle by gravity. Close
Try gently stimulation if baby does not
outer end of tube after feeding actively accept and swallow the feed
Place baby in left lateral position for 15 to 20 If unsuccessful, switch back to gavage feeds.
minutes to avoid regurgitation

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Change the IV infusion set and fluid bag
6. Intravenous fluid therapy every 24 hours
for newborn: Before infusing IV fluid, carefully check:
Expiry date of the fluid
6.1. Criteria for starting Seal of the infusion bottler or bag
intravenous fluids Fluid is clear and free from any visible
Among newborns particles
Neonates with lethargy and refusal to feed
Moderate to severe breathing difficulty 6.4. Monitoring of babies receiving
Babies with shock
Babies with severe asphyxia
IV fluid:
Inspect infusion site every hour for redness
Abdominal distension with bilious or blood
and swelling
stained vomiting
If redness and/or swelling is present, stop
6.2. Choice of intravenous fluids infusion, remove cannula, and establish a
Determine required volume of fluid as per new IV line in a different vein
birth weight and age (Table 2) Check the volume of fluid infused, compare
Use 10% Dextrose for initial 48 hours of life to the prescribed volume and record all
After 48 hours, if baby is passing urine, use findings
commercially available IV fluids such as Measure blood glucose every nursing shift,
lsolyte P i.e. 6-8 hours
If the premixed solution is not available or If the blood glucose is less than 45 mg/dl,
baby requires higher GIR (Glucose infusion treat for low blood glucose
rates) If the blood glucose is more than 150 mg/dl
Take normal saline (NS) 20 ml/kg body on two consecutive reading: Change to 5%
weight Dextrose solution-measure blood glucose
Add remaining fluide volume as 10% again in three hours
Dextrose Weigh the baby daily. If the daily weight loss
Add 1 ml KCL/100 ml of prepared fluide is more than 5% increase the total volume of
fluid by 10 ml/kg body weight for one day
6.3. Administration of IV fluid If there is no weight loss in the initial 3 days
Use micro-drip infusion set (where 1 ml=60 of life, do not give the daily increment
microdrops) If there is excessive weight gain (3-5%)
In this device, ml of fluid per hour is equal to decrease t he fluid intake by 15-20 ml/kg/day
number of micro-drops per minute Check urine output: Normally a baby passes
e.g. 6ml/hr = 6 micro-drops/minute urine 5-6 ml/kg/day
Calculate rate of administration, monitor to Check urine output: Normally a baby passes
ensure that micro-dropper deliver requires urine 5-6 times everyday
rate Fluid requirements of newborns
Establish an IV line. Infuse a bolus of 2 ml/kg
Table 2 body weight of 10% dextrose slowly over 5 min
If baby had convulsions, give bolus of 4-5 ml/kg of
Day of life Amount of fluids required 10% dextrose
(ml/kg/day)
Birth weight > Birth weight
7. Management of
1500 g <1500 g hypoglycaemi
1 60 80 Hypoglycemia in newborns is defined as blood
2 75 95 glucose levels less than 45 mg/dl
3 90 110 Management of hypoglycaemia
4 105 125 Establish an IV line. Infuse a bolus of 2 ml/kg
5 120 140 body weight of 10% dextrose slowly over 5 min
6 135 150 If baby had convulsions, give bolus of 4-5
ml/kg of 10% dextrose
Day 7 150 150
If an IV line is not available, administer 2 ml/kg
onwards body weight of 10% dextrose by gastric tube
Hypoglycemia in newborns is defined as blood Start infusion of dextrose at the daily
glucose levels less than 45 mg/dl maintenance volume to provide at the rate of 6
Management of hypoglycaemia mg/kg/min

Page 179
Measure blood glucose after 30 min and then Repeat bolus of dextrose as above
every four to 6 hrs Increase to infusion rate of 8 mg/kg/min
If blood glucose < 25 mg/dl:

Page 180
6. Management of Low Birth Weight Babies

Nearly 75 percent neonatal deaths and 50 percent Low birth, weight may result from either
infant deaths occur among the low birth weight prematurity (gestational age <37 weeks) or
neonates. Even after recovering from neonatal intrauterine growth retardation (IUGR), which is
complications, some LBW babies may remain more also called small for date baby (SFD).
prone to malnutrition, recurrent infections, and
Preterm babies have distinct physical features
neurodevelopment handicaps. Low birth weight,
that help in their recognition These are:
therefore, is a key risk factor of adverse outcome in
early life. 1.2.1 Skin:The skin of preterm neonate is thin,
transparent and gelatinous whereas that of aterm
1. Low birth weight neonate is thick gelatinous and keratinized.
Low birth weight (LBW) baby is the one who Hair: The back of the preterm babies has abundant
weighs less than 2500 g at birth. growth of fine hair called lanugo.

1.2.2 Ear Cartilage:The external ear or the pinna is soft and devoid of
cartilage in preterm neonates and hence, it does not recoil back promptly
on being folded. In a term baby there is instant recoil.

Figure 1

1.2.3 Breast Nodule:Breast nodule measures less than 5mm in


preterm neonates and 5 mm or more in term babies.

Figure 2

1.2.4 Sole Creases:Anterior one third of the sole reveals a deep


transverse skin crease in preterm neonates and in term neonates they are
present over the anterior two-thirds.

Figure 3

1.2.5 External Genitalia:In males, the scrotum does not have rugae
and testes are not descended into the scrotum. In female infants, the labia
are widely separated, not covering the labia minora, resulting in the
prominent appearance of the clitoris.

Page 181
Figure 4

1.3 Pre-Term Full-Term spells. In an apneic spell the baby stops


Small-for-dates neonates have an emaciated look breathing; develops slow heart rate and turns
and loose folds of skin because of lack of blue.
subcutaneous tissue. These are particularly Intra-ventricular hemorrhage (IVH): Preterm
prominent over the buttocks and the thighs. They infants also have immature vascular bed around
look alert and often plethoric. the brain ventricles. These delicate vessels may
rupture and cause intra-ventricular hemorrhage.
2. Problems of preterm Hypoglycemia - Immature metabolic pathways
of preterm infants predispose them to develop
neonates hypoglycemia.
The basic underlying feature of the preterm LBW Hyperblirubinemia
infant is immaturity of its organ system. They are Infection is another major problem among
prone to develop preterm babies and indeed an important killer
because they are immuno-compromised hosts.
Asphyxia necessitating resuscitation.
Retinopathy of Prematurity (ROP):Preterm
Hypothermia
infants given excess oxygen may develop
Feeding problems - Preterm neonates less than
blindness because of damage to the immature
34 weeks of gestation cannot coordinate
retina.
sucking and swallowing. Therefore, they are
unable to feed from the breast.
Respiratory distress syndrome (RDS): Preterm 3. Problem of SGA neonates
babies especially those less than 34 weeks have
immature lungs, hence they develop RDS The basic underlying problem amongst them is in-
characterized by rapid and labored respiration, utero undernutrition and hypoxia. They are prone to:
indrawing of the chest, grunting and cyanosis. Fetal distress,meconium passage in utero and
Apneic spells: Because of the immature birth asphyxia.
respiratory control mechanisms these babies Hypothermia.
also have a tendency for apneic Hypoglycemia
Congenital malformations.
provided by the father or any other adult.
Request the mother to sit or recline comfortably.
Undress the baby gently, except for cap, nappy
4. Treatment: and socks.
Indication for hospitalization are : Place the baby prone on mother's chest in an
upright and extended posture, between her
Birth weight of less than 1800g; Gestational age breasts, in Skin to Skin contact; turn baby's head
of less than 34 weeks; to one side to keep airways clear.
Neonate who is not able to take feeds from the Cover the baby with mother's blouse, 'pallu' or
breast or by cup (Katori) and gown; wrap the baby-mother duo with an added
A sick neonate (irrespective of birth weight and blanket or shawl.
gestation). Breastfeed the baby frequently.
If possible, warm the room (>250C) with a
4.1. Keeping LBW Babies warm: heating device.
Room temperature should be kept between Skin to Skin contact is the most practical,
28to300C. preferred method of warming a hypothermic
Baby should be provided skin to skin contact infant in a primary health care facility. If not
care (KMC) in the following ways : possible:
Provide privacy to the mother. If mother is not Cloth the baby in 3-4 layers, cover head with a
available, skin to skin contact may be cap and body with a blanket or a shawl; hold

Page 182
baby close to caregiver's body, OR katori-spoon feds should be put on the breasts
Place the baby under overhead radiant warmer, before each feed for 5 to 10 minutes. This will
if available. promote lactational and enable the baby to learn
Keep the young infant warm on the way to the how to suck.
hospital When shifting a baby from one mode of feeding
By Skin to Skin contact OR to another, be very careful. Introduce in new
Clothe the baby in 3-4 layers, cover head with a mode for only some of the feeds to begin with.
cap and body with a blanket or a shawl; hold The feeding of every baby should be
baby close to caregiver's body. individualized. The above recommendations
4.2. Nutrition & Fluids should only serve as broad guidelines.
Neonates weighing less than 1200 g. or those Ensure use of expressed breast milk & start with
having sickness should receive intravenous fluid small volume, and gradually build up.
initially. Most LBW babies weighing more than 1800 g
Enteral feeds should be introduced gradually by are able to feed directly from the breast. In a
gavage as the baby's acute problem begins to stable, growing LBW baby daily intake of feeds
settle. should be gradually built upto 180-200ml/kg.
Infants weighing 1200-1800 g and not having LBW babies should be fed every 2-3 hours
significant illness should be put on gavage feeds starting at 2 hours of age.
initially.
In order to promote lactation and enable the
baby to learn sucking, all babies on gavage or

Table 1

Guidelines for the modes of providing fluids and feeding


Age Categories of neonates
Birth weight (gm) < 1200 1200-1800 > 1800
Gestation (weeks) < 30 30-34 > 34
Initial - IV fluids Gavage feeds - Breast feeds
- Triage - If unsatisfactory, give
- Gavage feeds if not cup-spoon feeds
sick
After 1-3 days Gavage feeds Cup-spoon feeds Breast feeds
Later (1-3 wks) Cup-spoon feeds Breast feeds Breast feeds
After some time Breast feeds Breast feeds Breast feeds
(4-6 wks)

Note: 4 weeks (to ascertain a weight gain of at least


i. On the first day the fluid requirements range 200-300g) and then every month. Hospitalized
from 60 to 80 ml/kg. LBW babies should be weighed every day on
ii. The daily increment in all the groups is the same weighing machine.
around 15 ml per kg till 150 ml/kg is reached. Excessive weight loss, or inadequate weight gain
iii. Adequacy of therapy is indicated by weight indicates inadequate feeding, cold stress, excessive
pattern in the expected range. insensible water loss or systemic illness (like
4.2.1 Judging adequacy of nutrition anemia, sepsis, late metabolic acidosis etc).
The key measure of optimal feeding is the
weight pattern of the baby. A pretermLBW
baby loses upto 1 to 2 percent weight every day 4.3 LBW babies require dose
amounting to 10 percentcumulative weight loss
during the first week of life. Birth weight is
monitoring and follow up of
regained bythe14th day. Growth monitoring- head circumference and
SGA-LBW babies who are otherwise healthy weight
should not have any appreciable weight loss at Developmental assessment and early
all and they should start gaining weight early. stimulation
It is desirable to weigh all LBW babies at 2
weeks (to check regaining of the birth weight),

Page 183
Intraventricularhaemorrhage screening by receive Injection Vitamin K 1 mg and 0.5 mg,
ultrasound cranium on day 1, 3,7& at 4-6 Intramuscular, as per the birth weight > = 1000
weeks. gm and < 1000 gm respectively.
Screening tests for hearing at discharge
All pre-terms < 2000gms should receive oral
Retinopathy of pre maturityscreening at 1
Vitamin and mineral supplement in doses shown
month of age
below:
Screening for osteopenia of prematurity
Multivitamin preparation 0.3-0.6 ml (5-10
4.4. Vitamin Supplements: drops) / day (which usually provides vitamin A
All LBW Babies should receive intramuscular of 1000 IU/day and vitamin D 400 IU/day)
Vitamin K at birth. Every new born should
Calcium 80-100 mg/kg/day.
Phosphorous 40-50 mg/kg/day

4.4.3 All these supplements to be given till at 5.3 Children awaiting splenectomy
least 6 months of age.
Iron should be started at a dose of age. Immunization with pneumococcal, Hib, and
1mg/kg/day at 4 weeks of age and provided till meningococcal vaccine should be initiated a
12 months of few weeks prior to splenectomy.
Vaccination in LBW Babies
5.4Vaccination in children with
If the LBW baby is not sick, the vaccination
schedule is the same for as the normal babies. A
HIV infection:
sick LBW babies however, should receive these Immune response may be suboptimal as it
vaccines only on recovery. depends on the degree of immunodeficiency at
that point of time. Re-administration of
Vitamin A 1000 IU orally daily from 1 week
childhood immunization may be considered
age onwards
when their immune status has improved
following anti-retroviral therapy.
5.. Immunization in special
circumstances 5.5Lapsed immunization:
There is no need to restart a vaccine series
5.1Immunization in preterm regardless of the time that has elapsed between
infants: individuals doses. In case of unknown or
uncertain immunization status, however, it is
In general, all vaccines may be administered as appropriate to start the schedule as for an
per schedule according to the chronological age unimmunized child.
irrespective of birth weight or period of
gestation. Very low birth weight / preterm 5.6Minor illnesses,
babies can be given or period of gestation. Very
low birth weight / preterm babies can be given e.g. fever, diarrhea, respiratory infections and
immunization, if they are stable otherwise. malnutrition should not be construed as
contraindications to immunization.
5.2Children receiving
corticosteroids: 6. Prognosis
Mortality of LBW babies is inversely
Children receiving oral conticosteroids in high
related to gestation and birth weight and directly
doses (Prednisolone 1-2 mg/kg/day) for more
tothe severity of complication.
than 14 days should not receive live virus
vaccines until the steroid has been discontinued In general, over 90% Low birth weight
for at least one month. Killed vaccines are safe babies who survivethe newborn period have no
but may not be completely effective in such neurodevelopment handicaps.
situations. Patients on topical or inhaled
steroids should not be denied their age Therefore, essential care of theLBW
appropriate vaccine. neonates is a highly rewarding exper

Page 184
7.Assessment of Neonatal Sepsis
Neonatal sepsis is one of the three major causes of 1.5 CNS:
neonatal mortality. Sepsis is largely preventable.
Fever, seizures, blank look, high pitched cry,
1. Clinical manifestations of excessive crying/irritability, neck retraction, bulging
fontanel
neonatal sepsis
2. Laboratory diagnosis of a
1.1 Non-specific:
newborn with sepsis
Lethargy, refusal to suckle, poor cry, not arousable,
comatose Sepsis Screening: Any of two tests that come
positive out of the following five tests strongly
1.2 Gastrointestianal: indicate presence of sepsis:
Abdominal distension, diarrhea, vomiting, poor 1. Leukopenia (TLC/ Total leucocyte count
weight gain <5000/cmm)

1.3 Cardiovascular: 2. Neutropenia (ANC/ Absolute neutrophil count


<1800/cmm)
Hypothermia, poor perfusion, shock, bleeding and
sclerema 3. Immature neutrophil to total neutrophil (I/T) ratio
(>0.2)
1.4 Respiratory: 4. Micro ESR/Erythrocyte sedimentation rate
Cyanosis, tachypnea, chest retractions, grunt, (>15mm 1st hour)
apnea/gasping 5. Positive CRP/ C-reactive protein

Page 185
3. Figure-1: Approach to newborns at- risk of sepsis

Neonate at risk of sepsis

Symptomatic Asymptomatic

High suspicion Low suspicion Do sepsis screen


Blood culture

Blood culture Sepsis Screen Negative Positive


Blood Culture Take blood
culture
And start antibiotics

Start antibiotic Negative screen Repeat sepsis screen


After 12 hr after 12 hr
Positive screen

Negative screen Duration - acc


to
Clinical
Course& culture*

Duration according Monitor clinically Monitor clinically


To clinical course

Culture sterile - 7-10 days Culture Positive - 10-14 days

Escherichia coli, Staphylococcus aureus and


4. Antibiotic therapy for a Klebsiella pneunoniae
newborn with sepsis A combination of Ampicillin and Gentamicin is
recommended for treatment of sepsis and
4.1 Choice of antibiotics pneumonia
Antibiotic therapy should cover the In suspected or confirmed meningitis, add
Cefotaxime with an aminoglycoside
common causative bacteria, namely
Page 186
Following table provides the antibiotics and
dosages of antibiotics for newborn sepsis

4.2 Antibiotic therapy of


neonatal sepsis
4.2.1 Septicemia of Pneumonia

Table-1: Antibiotic Management for Septicemia of Pneumonia

Antibiotic Each dose Frequency Route Duration


<7 days age >7 days age
Inj Ampicillin or 50 mg/kg/kg/dose 12 hourly 8 hourly IV 7-10 days
Inj Cloxacillin 50 mg/kg/kg/dose 12 hourly 8 hourly IV 7-10 days
and
Inj Gentamicin or 5 mg/kg/kg/dose 24 hourly 24 hourly IV 7-10 days

Inj Amikacin 15 mg/kg/kg/dose 24 hourly 24 hourly IV 7-10 days

4.2.2 Meningitis

Table-2: Antibiotic management of Meningitis

Antibiotic Each dose Frequency Route Duration


<7 days age >7 days age
Inj Ampicillin or 100 mg/kg/kg/dose 12 hourly 8 hourly IV 3 weeks
and
Inj Gentamicin 2.5 mg/kg/kg/dose 12 hourly 8 hourly IV 3 weeks
OR
Inj Gentamicin or 50 mg/kg/kg/dose 12 hourly 8 hourly IV 3 weeks

and
Inj Amikacin 2.5 mg/kg/kg/dose 12 hourly 8 hourly IV 3 weeks
Infuse 10% dextrose 2 ml/kg stat
Inject Vitamin K1 mg intramuscularlyStart
5. Supportive care of a oxygen by hood or mask, if cyanosed or
grunting
newborn with sepsis Provide gentle physical stimulation, if apneic.
Provide warmth, ensure consistently normal Provide bag and mask ventilation with oxygen
if breathing inadequate
temperature
Avoid enteral feed if hemodynamically
compromised, give maintenance IV fluids
Consider use of dopamine if perfusion is
Start intravenous line persistently poor

If CFT >3 seconds, infuse normal saline 10


ml/kg over 20-30 minutes, repeat the same 1-2
times, if perfusion continues to be poor

6. Summery of commonly used doszge in neonates


Page 187
Table-3: Administration of commonly used drugs

Drug Dose Route


Ampicillin Age <7 days: 50 mg/kg/dose, q 12 hour IV

Age <7 days: 50 mg/kg/dose, q 8 hour


Gentamycin Sepsis/ pneumonia IV

5 mg/kg/dose, q 24 hour

Meningitis

Age <7 days: 2.5 mg/kg/dose, q 12 hour

Age <7 days: 2.5 mg/kg/dose, q 8 hour


Amikacin <7 days: 15 mg/kg/dose, q 24 hour IV
Cefotaxime <7 days: 50 mg/kg/dose, q 12 hour IV

<7 days: 50 mg/kg/dose, q 8 hour


Chloramphenicol 12 mg/kg/dose, q 12 hour IV
Aminophylline 5 mg/kg loading, IV

then 2 mg/kg/dose q 8-12 hour


Vitamin K 1 mg IM
Phenobarbitone 20 mg/kg loading over 10-15 minutes Loading IV Then
IV, IM or oral
then 3-4 mg/kg q 24 hour
Phenytoin 15-20 mg/kg loading over 10-15 minutes IV

then 5 mg/kg q 24 hour


Dopamine/ Dobutamine 5-20 micro g/kg/minute IV continuous

Page 188
8. Treatment of Respiratory Distress
In Newborn
im od for
1. Incidence:Increases as 2 days
Gestation age decreases OR
28 weeks => 60 %
Dexamethasone => 6mg im bd 2 Days
28-34 weeks => 30%
(NOTE: validity of this injection is for one week
34 weeks => 5-10%
And have to repeat after that if more delay in
delivery
2. Prevention: Can be
prevented by giving steroid 3. Assessment after delivery:
gestational age
to mother
Temperature
Antenatally
Indicated for those who are at risk for Heart rate
preterm
Sao2
delivery in next 8 days
Treatment for Prevention Capillary refill time
Betamethas
one 12 mg

Silverman anderson score


Figure 1

4. Scoring Chart
Table 1: Scoring Chart

Page 189
Interpretation: Start CPAP
SA score=> 3 Oxygen by hood CPAP Begin With 4-6 cm of waterpressure
3 -7 => CPAP ventilation And use Fio2 10
% more than required
>7Mechanical ventilation
Monitor ABG
4.2 Investigation : W/F Apnea
X ray chest: PA view Increase CPAP BY 1-2cm up to 8cm water pressure

Septic screening And Fio2 up to 100%

Blood culture Start Mechanical ventilator: if with Fio2 of 100% and


CPAP of 8cm
Serum electrolyte
ABG
Blood glucose

SA score is > 7
5. Management:
In general: OR
Maintain temperature = Baby with persistent Apnea
36.5 -37.5 c
Other
Restrict fluid to 2/3 maintenance Watch for diuresis
Maintain Sao2 88-95% Watch for clinical improvement
Give maintenance of fluid
Antibiotics if septic screen +ve
Main management 5.4 Fluid management
If fio2 requirement is < 30% & SA score <3 If CRT is more than 3
Oxygen by hood
Watch for diuresis Give 10ml/kg NS bolus
If improvement noticed give maintenance Monitor liver size
Fluid and start feed
If require give Dopamine 5-10 microgr/kg/min
If fio2 Requirement is > 30% & SA score >3
OR Dobutamine 10 microgr/kg/min

Page 190
9. MECONIUM ASPIRATION SYNDROME

1. Management in delivery
Vertex or breech presentation
room
1.1 If MAS watch for Colour Birth Asphyxia

/consistency of meconium Perineal suction With Dee Lee mucus Aspirator at


delivery of Head of baby

Figure-1: Indication of Endotracheal intubation

MAS -----------------> IF babys cry is vigorous

If cry is not vigorous No Intubation

ROUTINE CARE

Intubation ------------------ Meconium not retrieved

Under cord suction No suction

Meconium retrieved

Continue suction HR < 100/min

HR > 100 /min IPPR

Continue suction

Page 191
2. Management in NICU
2.1 Assessment of baby: 2.2 Interpretation
Gestational age score
r/o IUGR 1 -3 => mild respiratory distress => Oxygen by
r/oU.cord /nail/skin hood
staining
4-6 => moderate respiratory distress=> CPAP
Downe ventilation
score >6 => severe respiratory distress => Ventilator
0 1 2 3. Investigation: CBC, ABG, x
Respiratory rate <60 ray chest, blood culture
60-80 >80
Grunting NO Audible with
4. Supportive management
Audible without Pass infant feeding tube=> gastric lavage
Stethoscope Stethoscope Iv fluid initially if require
Antibiotic if respiratory distress OR
Cyanosis NO In room air If septic screen is positive
with 40% oxygen Treat complication
Ventilator if required along with surfactant
Air entry good decrease
markedly decrease
5. Complication
Retraction NO mild
severe Atelectasis
Hypoxic Ischaemic encephalopathy
Pneumothorax
PPHN (Persistant primary pulmonary hyper
tension) requiring nitrousoxide and sildenafil

Page 192
10. BLEEDING NEONATE
Slipped ligature
1. Common causes Vit k deficiency
G I BLEEDING Skin: petechiae
Swallowed maternal blood Sepsis
Hemorrhagic disease of New Born Platelet disorder
Sepsis Ecchymosis
Stress ulcer
Platelet defect Sepsis
Clotting factor deficiency Clotting factor deficiency
Umblical cord

1.4 Occult blood Cephalehematoma Preterm


Intra VentricularHaemorrhage Vit.k deficiency
Subdural Heaemrrahe sick neonate

2. APPROCH
Maternal History INCREASE RISK OF
2.1.1 Antenatal infection
eg. TORCH Thrombocytopenia

2.1.2 Drugs given to mother


Phenytoin
Phenobarbitone Heamorrhagic disease of NB
Aspirin/Anticoagulant
2.1.3 Bleeding in mother = Thrombocytopenia
eg.ITP /SLE
Birth Asphyxia
Trauma DIC

Time of Bleeding
2.2.1< 24hrs = Swallowed maternal blood
Hemorrhagic disease of NB
2.2.2> 24 hrs = Classical hemorrhagic disease
of NB
Sepsis /DIC
Platelet abnormality
Trauma
Liver dysfunction
2.1.3 Other clinical features
Petechiae Jaundice
Echymosis Hepatosplenomegaly
Pallor Bulging Ant .fontannel

3. Investigation

Page 193
Figutre-1: Apt .test:

1 ml gastric aspirate + 5ml distilled water

Centrifuge to formSupernatant

4 ml of Supernatant + 1ml NAOH 1%

Change of colour to colour remains to pink


Yellow /brown

Maternal blood fetal blood

Figure-2: Differential Diagnosis

Platelet PT PTT

Thromobocytopenia N N

Haemohagic disease N
Of newborn

Clotting factor N N
Deficiany

Dic

Page 194
4. Management
A) If APT test showns Maternal =>parental counseling
B) If APT test shows fetal blood
a) Injvit k 1 mg IV stat
b) if PT/PTT increases OR in sick neonate

10-15ml /kg FFP (IF required repeat after 12hrs)


c) If Hb<10 gm% = Give fresh blood transfusion
d) If platelet <50000 in sick Neonate
OR <25000 in Healthy Neonate

Platelet transfusion 10-20ml/kg

C) Treat for sepsis / DIC / primary disease


Antibiotics: Ampicilline 50 to 100 mg/kg in divided doses IV.
Gentamycin 7.5 mg/kg in divided doses IV. If not responding to these then start higher antibiotics such
as ceftriaxone, merupenum etc.
Treatment of DIC.
Treatment of primary disease.

Page 195
11. JAUNDICE IN THE NEWBORN
1. Introduction: 3. Pathological jaundice:
Hyperbilirubinemia is the commonest morbidity in A TSB concentration exceeds 5 mg/dl on first
the neonatal period and 5-10% of all newborns day of life in term neonate, 10 mg/dl on second
require intervention for pathological day, or 12-13 thereafter.
jaundice.Nearly 60% of term newborn becomes Any TSB elevation exceeding 17 mg/dl.
visibly jaundiced in the firstweek of life. In most Appearance of jaundice within 24 hours, peak
cases, it is benign and no intervention is required. TSB levels above the expected normal range,
Presence of clinical jaundice beyond 3 weeks
2. Physiological jaundice: and conjugated bilirubin (dark urine staining
the clothes and light colored stool)
Jaundice attribute to physiological immaturity of
neonates to handle increased bilirubin production. 4. Signs &Symptons:
Visible jaundice usually appears between 24-72
hours of age. Total serum bilirubin (TSB) level 4.1 Clinical examination of
usually rises in full-term infants to a peak of 6 to 8
mg/dL by 3 days of age and then falls. A rise to jaundice:
12mg/dL is in the physiologic range. In premature The newborn should be examined in good
infants, the peak may be 10 to 12 mg/dL on the fifth daylight.
day of life, possibly rising over 15 mg/dL without
any specific abnormality of bilirubin metabolism. The skin should be blanched with digital
pressure and the underlying color of skin and
subcutaneous tissue should be noted.
Dermal staining in newborn progress in a
cephalo-caudal direction. Newborns detected to
have yellow discoloration of the skin beyond the
legs should have an urgent laboratory confirmation
for levels of TSB.

Fig. 1: Levels of Jaundice


4.2 Clinical determination of jaundice by Kramers criteria

Area of body Range of serum bilirubin (mg%)


Head and neck 4-8
Upper trunk 5-12
Lower trunk and thigh 8-16
Arms and lower limbs 11-18

Palms and soles >15

5.
Page 196
This is suspected by increasing lethargy with
Investigations: risingbilirubin levels but recovery following or
Following investigations must be done in a prompt exchange transfusion.
case of neonatal jaundice
6.2 Kernicterus.:
Serum bilirubin direct and indirect.
This term has been traditionally used to describe the
Blood grouping of mother and child ABO and
pathological findings of bilirubin toxcity within the
Rh.
brain. This includes staining and necrosis of neurons
Direct coombs test in infant. in the basal ganglia, hippocampal cortex,
Haematocrit and peripheral smear for RBC subthalamic nuclei and cerebellum followed by
morphology and reticulocyte count. gliosis of these areas, should the baby survive. The
Indirect coombs test in mother if she is Rh cerebral cortex is generally spared, but 50 % of
negative babies have extraneuronal lesions with necrosis of
renal tubular cells, intestinal mucosa and pancreatic
6. Complication: cells. They may manifest as gastrointestinal
Transient encephagopathic: Early bilirubin induced hemorrhage or hematuria
neurologic dysfunction is transient and reversible.
Clinically, kernicterus is described in phases, which
may progress over 24 hour to 7 days:

FIGURE-1: DIAGNOSTIC WORKUP FOR HYPERBILIRUBINEMIA


Page 197
IN NEWBORN

Clinical jaundice

Measure bilirubin( total serum bilirubin-TSB)

Bilirubin >12mg/dl bilirubin <12mg/dl


Age <24hrs old age >24hrs old
(pathological) (physiological)

Coombs test observe

POSITIVE NEGATIVE Follow


bilirubin
Rh
ABO Direct bilirubin
Kell
Less than 2mg%

Hct

NORMAL OR LOW HIGH POYCYTHEMIA

RBC morphology
Reticulocyte count

ABNORMAL NORMAL
Spherocytosis Enclosed hemorrhage
ABO incompatibility Brestmilk jaundice
Red cell enzyme defect Hypothyroidism
Alpha thalassemia Crigler-najjar syndrome
Gilbert syndrome
7.
Page 198
TREATMENT HYPERBILIRUBINEMIA
MODALITIES OF
Hydration 7.2. Phototherapy (table 1 and 2)
Phototherapy (Do not keep in sunlight).
Exchange transfusion Special blue lights to be used

Drugs to increase conjugation. 45cm distance between baby and phototherapy


unit
7.1. HYDRATION Eys and genitelia shuld be covered
Double surface phototherapy is preferred
Countinued and frequent breast feeding 8-10
Watch for side effects(diarrhoea, skin rash,
times/day
hyper/hypothermia)

TABLE 1- Guidelines for Phototherapy according to APP

Healthy, term newborn (>37 weeks)

Age (hours) ConsiderPhototherapy TBS (mg/dl) Phototherapy


TSB (mg/dl)
< 24
25-48 >12 >15
49-72 >15 >18
>72 >17 >20

NOTE: TSB-Total serum bilirubin


TABLE 2- Phototherapy indications

7.2.2 Based on birth weight and health of the newborn

Borth weight(grms) Healthy; TSB Sick ; TSB


(mg/dl) (mg/dl)
<1000 5-7 4-6
1001-1500 7-10 6-8
1501-2000 10-12 8-10
2001-2500 12-15 10-12
TERM
>2500 15-18 12-15

Page 199
Fig. 2 : Namogram for age & serum bilirubin level

7.3 Points to remember 7.4 Exchange transfusion.


Try to establish diagnosis before instituting Choice of blood
phototherapy by carrying out necessary
7.4.1 Choice of blood
investigations.
If baby and mother is Rhve use only Rh-ve
Check blue light functioning; life of these light
blood.
is 1500-2000hrs(appox 3 months). Keep lights
Always cross match donors blood with both
at distance of 18 from the baby.
mothers and babys blood.
When blue lights are not available four pairs of
white tube light may be usedinstead. 7.4.2Criteria for Exchange Transfusion
Change the position of baby after every 2 hrs. Cord bilirubin more than or equal to 4.5mg%
Babies can be taken out of phototherapy for and Hb < 11g%
breast feeding Rate of rise of bilirubin >1mg/dl despite
Monitor babys temperature 2 hourly. phototherapy
Monitor fluid balance daily weight and urine In LBW babies indirect bilirubin> (weight in
output. Increase fluid as necessary. g)/100
Shield the eyes in both sexes to prevent the Exchange earlier at level of 2 mg% less for
retinal damage and genitals in male to prevent following criteria-
mutation defect in adulthood. Sepsis
Monitor rise or fall of bilirubin every 12 hourly. RDS
Do not give phototherapy for direct Asphyxia
hyperbilirubinemia. Acidosis
Hypoglycemia.

Page 200
12. MANAGEMENT OF SURGICAL NEONATE
Neonatal surgical problems 1.2.2 Gastrointestinal

1.1 Major: Esophageal Atresia


Cong. Hyperpyloric stenosis (CHPS)
Tracheoesophagial fistula Gastrochiasis
Diaphragmatic hernia Abdominal wall defect
Intestinal Obstruction
Neural tube defect Omphalocele
Omphalitis
Other:
Chest Deformities
1.2.1 Orofacial
Congenital Lobar emphysema
Cleft lip Vascular Ring
Cleft palate Orthopedic
ChoanalArtesia CTEV (Cong Talipus Equine Varus)
Pierre robin sequel Developmental dysplasia of hip
Laryngeal web Other
Clavicle fracture
Humerus fracture
Femur fracture

Page 201
13. VITAMIN A DEFICIENCY

1. Introductions 3.2 Importatant aspects of Vit A


Vit A deficiency Symptons If the child more than 1 year of age and weighing
Delayed dark adaptation less than 8 kg., then Vit A dose is 1,00,000 IU to
More prone for intestinal , respiratory and avoid hypervitaminosis A
urogenital infections Give oil based preparation
Bottles have solution strength of 100000IU Vitamin
2. Classification A/ml
XN------Night Blindness Cold chain is not required.
X1A----ConjunctivalXerosis Shelf life of unopened opaque container is 2 years.
X1B-----Bitot Spots Opened liquid is to be used in 6to 8 weeks.
X2-----Corneal Xerosis Capsules are partially protected against loss of
X3A---Corneal Ulceration <1/3 potency.
X3B---Corneal Ulceration >1/3 3.3 Treat Night blindness
XS----Corneal Scarring Conjunctivalxerosis, Bitotspots, Cornealxerosis,
XF---Xeropthalmic Fundus Cornealulceration, Keratomalacia in all except
3 Treatment immediately women of reproductive age group.
In acute corneal lesion, patient should be referred to
after diagnosis hospital on emergency basis.
3.1 Age wise doses of Vit A High dosages of Vit A can causes pseudotumar
<6 months-----------50,000IU VitaminA orally cerebri which will manifest as vomiting headache
6 to 12 months------100000IU Vitamin A orally and bulging anterior fontenelle
>12 months----------200000IU Vitamin A orally
Next day-------------------------Same age specific 3.4 Corneal Xeropthalmia
dose i. Topical Antibiotic ointment (Tetracycllin 1%, eye
At least 2 weeks later-------Same age specific dose oitment, Tobramycin eye ointment 3% bd)
ii. Eye protection

Page 202
14. RICKETS
1. Metabolic disease of childhood in which the Malabsorption
osteoid, the organic matrix of bone fails to Renal disease
mineralise, due to interference with calcium Celiac disease
metabolism. Hepatic osteodystrophy
Anti - epileptic drugs
Vitamin D deficiency

Fig. 1 : Clinical features in Rickets

Investigations Loss of transverse trabeculae

3.1 Seriology No sub-periosteal resorption of bone

Serum calcium - normal or decreased, 4. Treatment:


Serum phosphorus - decreased, Single oral dose of 6 lakh IU of vitamin D
Alkaline phosphotase - increased 2nd dose after 3 to 4 weeks (if no sclerotic
change is seen in x-ray)
3.2Urine Exam If the child responds to above treatment
maintenance dose of 400 IU of vitamin D is
Urinary calcium - decreased given once Serum alkaline phosphotase is
nomal, consider corrective surgery, If any.
3. X- ray: Calcium - 0.5 to 3 gm/day for 3 months
Generalized demineralization Vitamin D - 10,000 IU/day once a month
High protein diet

Page 203
15. MANAGEMENT OF CHILDREN WITH
ANAEMIA

Mild to moderate anaemia is a common co- mayhavehyperpigmentationofknucklesandocca


morbidity in children attending health facility sionally bleeding manifestations due to
for various conditions. Hence, anaemia/pallor thrombocytopenia.
should be looked for in each patient attending The onset of anaemia in young children is
the health facility. generally after 6 months of age. Before this,
Severe anemia in a child is suggested by the iron in breast milk is sufficient to meet the
presence needs of a breastfed child.
ofseverepalmarpallorandmaybeassociatedwitha In India, diets for children in the age group 6
fastpulserate,difficultyinbreathing,orconfusionor 23 months are predominantly plant-based and
restlessness. provide insufficient amounts of micronutrients
Nutritionalanaemiaisthemostcommoncauseofan to meet the recommended nutrient intakes.
aemiainchildren.
Nutritionalanaemiaresultsfromdeficiency
ofiron,folicacidandvitaminB12.
Childrenhavinganaemiaduetofolicacidand/orB1
2deficiency (megaloblasticanaemia)

Table 1
Clinicalassessmentofanaemiainchildrenlessthan5years

Findings on anaemia in children


History Examination
Durationofsymptoms Severepalmarpallor
Usualdiet(beforethecurrentillness) Skinbleeds(petechialand/orpurpuricspots)
Familycircumstances(tounderstandthechildssocialbackgr Lymphadenopathy
ound)
Hepato-Splenomegaly
Prolongedfever
Signsofheartfailure(galloprhythm,raisedJVP,
Worminfestation
respiratory distress, basal crepitations)
Bleedingfromanysite
Lymphnodeenlargement
Previousbloodtransfusions
Similarillnessinthefamily(siblings)

Facility level management All children referred from field to health


Any child reporting to any facility (PHC level facility due to palmar pallor will undergo Hb
and above) with any illness will be assessed level estimation before initiating treatment
clinically by the attending Medical Officer for Children will be categorised as having mild,
anaemia routinely and should undergo Hb moderate and severe anaemia on the basis of
estimation if found to be anaemic clinically Hb levels and will be managed as per Table
below.

Page 204
Table 2
Treatment of Anaemia

Level of HB Treatment Follow-up Referral


No Anaemia (>11 20 mg of elemental iron and 100 mcg of folic acid in biweekly regimen
gm/dl)
Mild Anaemia (10 3 mg of iron/ Kg/ day for Follow-up every 14 In case the child has not
10.9 gm/dl) 2 months days by ANM responded to the treatment of
anaemia with daily dose of
And Hb estimation after
iron
completing 2 months
Moderate Anaemia
of treatment to for 2 months, refer the child to
(79.9 gm/dl) document Hb>11 the FRU/DH with F-IMNCI
gm/dl trained MO/ Paediatrician /
Physician for further
investigation

Severe Anaemia Refer urgently to DH/FRU


(<7 gm/dl)

Note: malnutrition and in a known case of


After completion of treatment of anaemia and haemoglobinopathy and anaemia in these cases
attaining Hb level >11.5 gm/dl, the should be treated as per the standard treatment
IFAsupplementation to be resumed guidelines, by the attending physician, as per
Treatment of anaemia with iron should be the merit of the individual case.
withheld in case of acute illness, severe acute

3.1 Dose of IFA surup


Table 3
Dose of IFA syrup for anaemic children 6 months5 years
Age of Child Dose and Frequency
6 months12 months (610 kg) 1 ml of IFA syrup Once a day

1 year3 years (1014 kg) 1.5 ml of IFA syrup Once a day


3 years5 years (1419 kg) 2 ml of IFA syrup Once a day

Page 205
Table 4
Management of severe anaemia at FRU/DH (as per F-IMNCI) in children 6 months5 years and 5-10 years

3.2.1 History of Examination

History to be taken for Examination for


Duration of symptoms Severe palmar pallor
Usual diet (before the current illness) Skin bleeds (petechial and/or purpuric spots)
Family circumstances (to understand the Lymphadenopathy
childssocial background) Hepato-splenomegaly
Prolonged fever Signs of heart failure (gallop rhythm, raised
Worm infestation JVP, respiratory distress, basal crepitations)
Bleeding from any site
Any lumps in the body
Previous blood transfusions
Similar illness in the family (siblings)

3.2.1 Investigation & blood transfusion indication

Table 5: Investigation & Management

Investigations Indication for Blood Transfusion Blood Transfusion


Full blood count and All children with Hb 4 gm/dl If packed cells are available, give
examination of a thin film Children with Hb 46 gm/dl with any 10 ml/kg over 34 hours
forcell morphology of the following: preferably. If not, give whole
Blood films for Dehydration blood 20 ml/kg over 34 hours.
malariaparasites Shock
Stool examination for ova, Impaired consciousness
cystand occult blood Heart failure
Deep and laboured breathing
Very high parasitaemia
(>10% of RBC)

Page 206
16. MUMPS

1. Introduction:
Mumps is swelling of parotid glands due to
infection of the parotids by mumps virus. Apart
from parotids, it affects some other vital organs and Un-immunized host gets infected from a case.
systems in the body and can have serious Patient is infective l-2 days before appearance
complications with risk of morbidity and mortality. to 2-3 days after disappearance of parotid
Therefore it is important to know the course of swelling. Incubation period ranges between 2-3
illness, various complications, early detection for weeks. 30-40% infections are sub clinical. After
prompt management, and preventive measures. entry through air, the virus multiplies in
respiratory tract and reaches all organs via
blood. Prodromal symptoms are in the form of
2. Signs &Symptons: fever, muscle pains, neck pain, and malaise.

Fig. 1: Mumps : Paritid Swelling

are presenting symptoms in a patient with


3. Investigation: mumps
Diagnosis: is mainly clinical more suggestive with Deafness - transient or permanent unilateral or
the history of contact. Typical painful tender bilateral nerve deafness may follow mumps.
bilateral parotid swelling with systemic symptoms is Arthritis - Migratory ploy arthralgia or even
diagnostic. arthritis may be seen. These complications
should be treated symptomatically.
4. Complication:
4.1 CNS-Aseptic meningitis-meningoencepnalitis 5. Management:
along with parotitis or 10 days later. Meningitis
indistinguishable from other meningitis. Treatment:
Orchitis,Epididymitis - Occurs in older pts. Mainly symptomatic with paracetamol and
Occurs one week following parotitis with frequent gargling with warm saline.
painful swelling of testes. Illness lasts for about Watch for evidence of complications. If orchitis
4 days. Testicular atrophy may follow in l/3 or arthritis occurs, prednisolone can be used to
patients with rare affection of fertility. reduce pain.
Oopharitis in females may rarely occur.
Pancreatitis -Epigastric pain, tenderness, 6. Prevention:
vomiting, fever are suggestive. Laboratory MMR vaccine - combination of mumps,
evidence of raised amylase confirms the measles, and rubella offers above 95%
diagnosis. protection. Primary immunization at the age of
Thyroiditis - May follow after one week in 15 months, followed by revaccination at l0
adults with development of antithyroid anti years,
bodies. Since it is a live viral vaccine, immuno-
Myocarditis - Mild- moderate myocarditis with compromised hosts should not be vaccinated.
ST changes on ECG is found in some older Isolation of the affected child is not useful to
patients. Chest pain, bradycardia and fatigue prevent spread to other children in usual
contact. However, fresh contacts like guest

Page 207
children can be protected if the affected child is always gives lifelong protection against
isolated from them. another, therefore, such children do not benefit
Children usually recover from mumps in about from any immunization later.
10-12 days- First arrack of mumps almost

Page 208
17. SEVER ACUTEMALNUTRITION (SAM)
Standardsor

1. Introduction Bipedaledema.

Malnutritionremainsoneofthemostcommoncauses If weight-for-height or weight-for-length cannot be


ofmorbidityandmortalityamongchildren.Thehighc measured, use the clinical signs for visible severe
asefatalityratesamongseverelymalnourishedchildr wasting
encan
bereducedbyusingstandardizedandeasilyimplemen 3. Assessment of severely
tableprotocols. malnourished child
2. Criteria for hospital A good history and physical examination is
required for deciding the treatment but always start
admission the emergency
Weightforheight/length<-3z Treatment
scoreofmedianofWHOchildgrowth first.Thedetailsofhistoryandexaminationcan
berecorded later.

Table 1:

History Examination

Recentintakeoffoodandfluids Anthropometry-weight,height/length,midarm
Usualdiet(beforethecurrentillness) circumference
Breastfeeding Oedema
Durationandfrequencyofdiarrhoeaandvomiting Pulse,respiratoryrate
Typeofdiarrhoea(watery/bloody) Signsofdehydration
Lossofappetite Shock(coldhands,slowcapillaryrefill,weakandrapid
Familycircumstances(tounderstandthechildssocial pulse)
backgronnd) Severepalmarpallor
Chroniccough EyesignsofvitaminAdeficiency:
Contactwithtuberculosis - dry conjunctiva or cornea,
Recentcontactwithmeasles -Bitotsspots
Known orsuspectedHIVinfection. -Cornealulceration
Immunizations -Keratomalacia
Localizingsignsofinfection,includingearandthroatinfection
s, skin infection or pneumonia
Fever(temperature37.5Cor99.5F)or
hypothermia(axillarytemperature <35.0 Cor<95.0 F)
Mouthulcers
Skinchangesofkwashiorkor:
- Hypo or hyperpigmentation
-Desquamation
-Ulceration(spreadingoverlimbs,thighs,genitalia,groin,and
behind the ears)
-Exudativelesions(resemblingsevereburns)oftenwith
secondaryinfection(includingCandida)

Serum electrolytes (sodium, potassium)


3. Laboratory Tests
Screeningforinfections:

Haemoglobinorpackedcellvolumeinchildrenwit - Total and differential leukocyte count,


hseverepalmarpallor. blood culture (If possible)
Bloodsugar. - Urineroutineexamination
Page 209
- Urineculture preparationofappropriatefeeds,andtocarryoutreg
ular feeding during the day and night. Accurate
- Chestx-ray
weighing machines are needed, and records
should be kept of the
4. Organization of care feedsgivenandthechildsweightsothatprogresscan
On admission, the child with severe malnutrition bemonitored.
should be separated from infectious children and
kept in a warm area (2530C, withnodraughts), 5. Providing general
and
constantlymonitored.Washingshouldbekepttoamini
treatment for malnutrition
mum, after whichthechildshould be dried Thereare10essentialstepsintwophases: an
immediately. initialstabilizationphaseandalongerrehabilitationphase
.
Facilitiesandsufficientstaffshouldbeavailabletoensu
recorrect

Table-2: Treatment for Malnutrition

Stabilization Rehabilitation
Days1-2 Days3-7 Weeks2-6
1. Hypoglycaemia
2.
3.
4. Electrolytes
5. Infection
6.Micronutrient Noiron withiron
7. Initiate
8. Catch-
9. Sensory stimulation
10. Prepareforfollow-up

rferewiththebodysimmunemechanismsagainstprolife
5.1 Important things not to do and ratingbacteria.
why?
5.1.1Do not give I/V fluids
routinely.I/Vfluidscaneasilycausefluidoverloadandhea 5.2 Treat hypoglycaemia
rtfailure.OnlygiveI/Vfluidstochildren with signs of
shock. Ifthechildislethargic,unconscious,orconvulsing,
giveIV10%glucose5ml/kgfollowedby50mlof10%gluc
5.1.2Do not gives diuretics to treat oedema. The oseorsucrosebyNGtube.IfIVdosecannotbegivenimme
oedema will go away withproper feeding. Giving diately, givetheNGdosefirst.Give appropriate
diuretics will antibioticsandstart feeding as soon as possible.
worsenchildselectrolyteimbalanceandmaycausedeat
h. Ifnotlethargic,unconscious,orconvulsing,givethefirstf
eedofstarterformula(75cals/100ml),ifitisquicklyavaila
5.1.3Do not gives high protein formula. Almost all
severely malnourished children have infections, bleandthencontinuewith2hourly feeds.
impaired liver and intestinal function. Because of Ifthefirstfeedisnotquicklyavailablegive50mlof10%gluc
these problems, they are unable to tolerate the usual oseorsugarsolution(4roundedteaspoonofsugarin200
amount of dietary protein.
mloronecupofwater)orallyorbynasogastrictube,follo
5.1.4 Do not give iron during the initial feeding wedbythefirstfeedassoonaspossible.
phase.
Give2-
Add iron only after the child has been on catch-up hourlyfeeds,dayandnight,atleastforthefirstday.
formula for2days Giveappropriateantibiotics.
(usuallyduringweek2).Givingironearlyintreatmenthas
beenassociatedwithfreeradicalgenerationandmayinte Keepthebabywarmandchecktemperature.

Page 210
Prevent hypoglycaemia/Begin Starter Formula antibiotics.Ifaspecificinfectionisidentified(suchasShige
Feed2hrly,startingimmediatelyor,ifnecessary,rehydra lla),givespecificappropriateantibioticsaccordingtocond
tefirst.Continuefeedingthroughoutthenight. ition
5.3 Infection identified.Hypoglycaemiaandhypothermiaareoftensign
sofsevereinfection.
5.3.1 Presume and treat infection
5.3.2 Select antibiotics and prescribe regimen
Assume all children with severe malnutrition Select antibiotics as shown in the chart below.
admitted in a hospital have an infection and give
broad spectrum

Table 3: Antibiotic Treatment

Status Antibiotic
All Inj.Ampicillin50mg/kg/dose6hrlyandInj.Gentamicin7.5mg/kgoncea
admitte day for 7 days
d cases AddInj.Cloxacillin50mg/kg/dose6hrlyif staphylococcalinfectionis
suspected
Revisetherapybasedonsensitivityreport
For septic IVCefotaxime50mg/kg/dose6hrlyorInj.Cerftriaxone50mg/kg/dose12hrlyplusInj.A
shock or mikacin15mg/kg/onceaday
worsening/ no
improve
ment in
initial
ho urs
Meningi IVCefotaxime50mg/kg/dose6hrlyorInj.Ceftriaxone50mg/kg/dose12
tis hrlyplusInj.Amikacin15mg/kg/onceaday

Dysente Inj.Ceftriaxone100mg/kgonceadayfor5days
ry

5.3.3 Duration of antibiotic therapy depends on the InvestigateandfollowHIVguidelines.


diagnosis i.e.: 5.4.5
Suspicion of clinical sepsis: at least 7 days Severeanaemia:Givewholebloodorpackedcelltransfus
Culturepositivesepsis: 10-14days Meningitis: ionifHbis<4g/dlorHbis4-
atleast14-21days 6g/dlandchildhasrespiratorydistress.Give10ml/kgslo
Deepseatedinfectionslikearthritisandosteomyelitis: wlyover4-
atleast4weeks 6hoursandgiveInj.Frusemide1mg/kgatthestartofthetra
nsfusion.Donotrepeatbloodtransfusionwithin4days.
5.4.5 Ifeyeproblems(keratomalacia) due
tovitaminAdeficiency,inadditiontovitaminAdosesinsti
5.4 Treat Associated Conditions llciprofloxacineyedrops2-3hourly
5.4.1 Giveantimalarials andatropineeyedrops3timesadayfor7-
ifbloodsmearpositiveformalariaparasites. 10days.Alsocovertheeyeswithpadandbandage.

5.4.2 5.4.6Skinlesions:Batheorsoaktheaffectedareasfor10
StartATTiftuberculosisisdiagnosedorstronglysuspect minin1%potassium
ed(Mountaux TestandXraychest). permanganatesolutionandapplygentianvioletornystati
ncreamifavailable
5.4.3 toskinsoresandanybarriercream(zinccream)totheraw
SuspectHIVifhehasalsootherproblemslikepersistentd areas.
iarrhoea,oral
5.4.7
Thrush, Persistentdiarrhoea:Diarrhoeaiscommoninseveremal
pneumonia,parotidswellingorgeneralizedlymphaden nutritionbutwithcautiousrefeeding,itshouldsubsidedu
opathys. ringthefirstweek.Intherehabilitationphase,
Page 211
thepoorlyformedloosestoolsarenotacauseforconcern, severeoedema),80-
providedthechildsweightgainissatisfactory.Ifthechild
100Kcal/kg/dayand1-1.5g/kg/dayofproteins.
has persistentdiarrhoea,screenfornon-
intestinalinfectionsandtreatappropriately.Continuebr
eastfeedingandtrytogivefeedswithlowlactoseinitiallya Usenasogastricfeedingtillchildtakesorally75%ofallfee
ndsubsequently change to lactose free options if ds.
diarrhoea persists.

Ifchildbreastfed,continuebreastfeedingbutgivethefeed
first.
5.4 Micronutrients
5.4.1 Give oral vitamin A in a single dose. Ensurenightfeeds.

Vitamin A orally in single dose as given below:


5.6.1 Starter Formula
<6months :50000IU (if
clinicalsignsofdeficiencyarepresent). Starterformulaistobeusedduringinitialmanagement.Iti
sstartedassoonaspossibleandcontinuedfor2-7days
6-12months:1lakhIU.
untilthechildisstabilized.Severelymalnourishedchildr
Olderchildren: 2lakhIU. encannottolerateusualamountsofproteinsandsodium
atthisstage, or high amounts of fat. They may die if
Children<8kgirrespectiveofageshouldreceive1la given too much protein or sodium. Starter formula is
khIUorally. specially made to
meetthechildsneedswithoutoverwhelmingthebodys
Givehalfoftheabovedoseifinjectable systemsintheinitialstageoftreatmentwhichprovides75
(intramuscular)vitaminAneedstobegiven. calories/100mland0.9gmofprotein/100ml.
GivesamedoseonDay0, 1and14 5.6.2 Feed the child Starter formula orally, or by NG
ifthereisclinicalevidenceofvitaminAdeficiency. tube if
Necessary: Oral feeding
5.5.2 Other micronutrients should be given Itisbesttofeedthechildwithacupandspoon.Encourag
daily for at least 2 weeks: ethechildtofinishthefeed.Ittakesskilltofeedaverywea
kchild,sonursingstaffshoulddothistaskfirstandmothe
Multivitaminsupplement(shouldcontainvitaminA, rmayhelpwithfeedinglaterwhenchildbecomesstrong
C,D,EandB12&
er.Encouragebreastfeedingondemandbetweenstarte
NotjustvitaminB-complex): r formulafeeds.
2RecommendedDailyAllowance.
Nasogastric feeding
Folicacid:5mgonday1,then1mg/day.
ItmaybenecessarytouseaNGtubeifchildisveryweak.U
Zinc: 2mg/kg/day. seanNGtubeifthechilddoesnottake75%ofthefeedfor2
Copper:0.3mg/kg/day -3consecutivefeeds.
(ifseparatepreparationnotavailableuse Remove the NG tube when the child takes:
Commercialpreparationcontainingcopper). 75%ofthedaysamountorally;or
Whenweightgaincommencesandthereisno Twoconsecutivefeedsfullybymouth.
diarrhea add3mgofiron/kg/day.

5.6Initiate feeding
Essentialfeaturesofinitial feedingare:
Startfeedingasearlyaspossible.
5.6.3 Record intake and output on a 24-Hour
Feedthechildifalertanddrinkingevenduringrehydratio food intake chart.
n.
Criteriaforincreasingvolume/decreasingfrequencyoff
eeds
Givefrequentandsmallnutrientrichfeedsoflowosmolar
ityandlowlactose. 1. Ifthereisvomiting,significant
diarrhoea,orpoorapetite,continue2-hrlyfeeds.
Offer130ml/kg/dayofliquids(100ml/kg/dayifchildhas

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2.
Ifthereislittleornovomiting,diarrhoeaislessthanbefore,and 5.6.4 Monitoring
mostfeedsareconsumed,changeto3-hrlyfeeds. Monitorandrecord(seeAppendixformonitoringcharts
3. Afteradayon3- )
hrlyfeeds:Ifthereisnovomiting,occasionaldiarrhoea,andm Amountsoffeedofferedandleftover
ostfeedsareconsumed,changeto4-hrly.
Stoolfrequencyandconsistency
Recommended schedule with gradual increase in Vomiting
feed volume is as follows
Canreplacefreshmilk30mlwith3.5gmwholedriedmilk Dailybodyweight

Page 213
18. FEVER WITH RASHES
Varicella, herpesvirus, coxackievirus, enterovirus,
1. Introduction : meningococcal, group A streptococcal and
Fevers associated with generalized skin eruptions/
rashes (exanthematous fevers) are common in Pseudomonas infections.
childhood. These are often seen as epidemics in the
periods of 'season change' like March-April and 4. Petechial/purpuric
October-November when adenoviruses become
active.
Epstein barr virus, echovirus 9, cytomegalovirus,
Differential Diagnosis of Exanthema
Macular and/or papular rash rickettsial, malaria, pneumococcal, meningococcal
and Listeria infections.
a) Measles, rubella, erythema infectiosum, roseola,
coxackievirus, echovirus, CMV, hepatitis B 1. Measles
infections. Measles is a communicable disease manifesting
with fever, cough, coryza, lacrimation and Koplik
b) Erythema multiforme due to herpesvirus, Epstein spots in the pre-eruptive phase and a maculopapular
barr rash starting on 4th or 5th day of illness. The rash
virus,adenovirus,chlamydiae,Salmonella,Mycobacte heals leaving brawny pigmentation.It is caused by a
ria,histoplasma or coccidioses. RNA virus classified as Morbillivirus, belonging to
paramyxovirus family.Clinical Features: Incubation
2. Nodular period is 8-12 days.
a)Fungal diseases, atypical mycobacterial and
pseudomonas infections. Prodromal Phase: The onset is acute with moderate
elevation of temperature, dry hacking cough,
b) Erythema nodosum. Due toStreptococcus, running of nose, sneezing, redness of the eyes and
Mycobacterium tuberculosisand leprae, Yersinia, excessive lacrimation.
hepatitis C, sarcoidosis, drugs and inflammatory
bowel diseases. 1.1. Signs &Symptons:
Diffuse erythematous with peeling or desquamation Typical measly look in young babies is due to
conjunctivitis, stomatitis and rhinitis due to viral
Scarlet fever, toxic shock syndrome, Kawasaki rash. The first place for the rash to be seen is around
opening of parotid ducts in the mouth/inner cheeks
disease, staphylococcal scalded skin syndrome,
(Koplik's spots). Rash appears on face and
Stevens Johnson syndrome. progresses to appear on trunk and limbs over the
following three to four days. Drying of rash and
3. Vesiculobullous peeling of skin appears in the same sequence in
next4- 5 days.
1.3. Complication:
Acute precipitation of Vitamin A deficiency in a
child with measles can occur and hence corneal
ulceration is a complication to watch out for and to
prevent. All children with measles should routinely
receive vitamin A orally 2 lakh units each on day
l, 2 and 14 (for infants the dose is half)
Due to depressed immunity due to measles, child
can catch infections like diarrhoea, otitis media,
pneumonia and TB. If the child continues to get
fever even after the rash is dry, bacterial pneumonia
Figure 1 : Various types of Rashes
should be suspected. Continued low fever and lack
of appetite should make one suspect TB infection.
1.2. Investigation: Extra-feeding during convalescence and when
HB,TLC, DLC, X-RAY Chest, measle the child gets well is important to prevent
antibody test. malnutrition after measles.

Page 214
1.4. Management: Measles immunization as routine immunization
Symptomatic treatment should be given should be promoted.
Paracetamol 10 to 15 mg per kg for fever and Immunization given early to contact of measles
Antihistaminics (Cetrizine) 0.5 to 1mg per kg for case can prevent severe disease in the contact.
itching and rhinitis. Advice continued feeding. Keep 2. Chicken-pox:
baby clean by sponging or quick clean bath.
Treatment with antibiotics (Amoxycilline 30 2.1. Signs &Symptons:
mg per kg per day in 2 to 3 divided doses for 5 Symptom of chicken-pox is characteristic rash.
days) for superadded bacterial infections when The rash is often more severe in older children and
detected. adolescents. The rash appears in several "crops" of
macules (red spots) quickly turning into watery
1.5. Prevention: vesicles and pustules over the next 2 to 3 days and
then drying after scab formation over next 5 days.

Figure 2: Chicken Pox Rash


Due to multiple 'trops" appearing over a week or so, symptoms. Chicken-pox patient is infective till all
one can observe all types of lesions simultaneously scabs are formed. Itching is prominent and
on a patient's body. The rash is more on covered scratching can lead to super added staphylococcal
areas like trunk of body, and can appear inside infection.
mouth. conjunctivae. Vagina leading to irritation
o

Figure 3: Vescicles & umbilication in chicken pox

2.2. Investigation: available; as this is a very serious condition with


Clinically Diagnosed high mortality rate.

2.3. Complication: 2.4. Management:


Aspirin given to a child with chicken-pox infection Sympromatic treatment with Paracetamol 10
may precipitate acute fatty infiltration of liver. Liver to 15 mg per kg per day for 5 days and anti-
failure and encephalopathy (Reye's syndrome). histaminics (Cetrizine) 0.5 to 1mg per kg per day for
Reyes' syndrome is to be suspected if there is 5 days is advised. Daily bath is also advised.
disproportionate vomiting, rapid breathing (in the Acyclovir in the dose of 20mg/kglday in 4 divided
absence of chest signs suggestive of pneumonia) doses for 5 days can be given to immuno-
and altered sensorium. The patient should be compromized patients and patients with
referred for specialist care, where respirator is encephalopathy.


Page 215
19 ENTERIC FEVER / TYPHOID

1. Introduction: 2. Clinical Manifestations :


Although Enteric fever is still a common infection Classical presentations are becoming rare. Common
its presentation has changed partly due to specific manifestations are -
vaccination and partly due to institution of Relative bradycardia compared to fever.
antibiotics early in the course of illness. Tumid tender abdomen (abdomen feels like balloon
filled with water)
Diagnosis is problematic since blood
Cloudy sensorium.
cultures may not reveal much and Widal test is
Maculopapular erythematous rash on abdomen
positive only after 1 week and has many false
blanching on pressure (Rose. spots)
positive and false negative results. Bone marrow
Centrally coated tongue.
culture is more informative, but not practical.
Soft spleen - 1-2 cm tender.
Hence possibility of enteric fever must be Continuous fever, not touching the baseline. (If
borne in mind while treating any pyrexia, which antipyretics are not given)
shows toxicity, and signs suggestive of enteric like Pea soup diarrhea, nausea, vomiting.
confused sensorium, (no meningeal focal Headache, myalgia, anorexia, malaise.
neurological signs). Enteric fever in children.is more severe as compared
to adults.


Fig. 1: Rose spot in typhoid
Chloramplenicol -75 mg/kg/dayOr
3. Investigation: Amoxiycillin 100mg/kg/day (with clavulinic acid)
HB, TLC, DLC, WIDAL TEST (RISING
Or
TITERS),BLOOD CULTURE.
Trimethoprim Sulphamethaxazole 10& 50
Complication: Shock, enteric perforation, mg/kg/day are also used with some success.
haemorrhagemeningits, myocarditis. can complicate
the illness. 4.3 Early institution of steroids
Management: Dexamethasone 3 mg / Kg
stat dose followed by:
4.2 Drug Treatment 1 mg/kg 6 hourly for 48 hours improves the survival
Multi-drug resistant typhoid fever has emerged and of patients in shock, myocarditis' CNS
is difficult to treat. Following drugs are found to be complication.
useful:
Third generation cephalosporins
Cefixime 20 mg /kg 1 day in 2 divided doses 4.4 Intestinal perforation
Or Ceftriaxone 50 mg/Kg per day requires broader spectrum
OrCiprofloxacin 20 mgl Kg per day,
Or Ofloxacin15 mg/Kg 1 day. antibiotics,
Platelet transfusions for severe thrombocytopenia
with haemorrhages' This treatment demands
referral to higher level'
The antibiotics should be continued at least 5-7
days after effervescence.

Page 216
20.ACUTE MENINGOENCEPHALITIS

1. Introduction 2. Clinical Manestations


Acute meningoencephalitis is an acute infl Fever, headache, vomiting, irritability altered state
ammatory process involving meninges andbrain of consciousness signs of meningeal irritation and
tissue, due to infectious causes. The common seizures.
aetiological agents are viruses and bacteria.
Children of any age may be affected.
3. Investigations
CSF examination differentiates the viral from
bacterial cause of acute meningoencephalitis
CSF findings in meningoencephalitis

Table 1: CSF Findings

Pressure Glucose
(mmH2O) Leucocytosis Protein (mg/dl)
(mg/dl)
(mm3)
Normal 50-80 <5, >75% 20-45 >50 or
lymphocytes
75% serum
glucose

Acute bacterial Meningitis Usually 100-10,000 100-500 Decreased


Elevated PMNs*
(<40)
(100-300) predominate

Acute viral Normal or r Rarely 50-200 Normal


Meningoencepha litis elevated >1000 PMNs early
rarely decreased
but
lymphocytes
predominate in
the most of the
course
Tubercular Usually elevated 100-500 PMNs 100-3000 <50
Meningoencephalitis early but later
lymphocytes
predominate
*PMNs = Polymorphonuclear leucocytes

Treatment
Supportive treatment is the mainstay of therapy and is started immediately.
a. Maintain airway, breathing and circulation.
b. Control of seizures with IV injection of Diazepam 0.2 to 0.4 mg/kg stat followed by Inj. Phenytoin 10-20
mg/kg stat followed by 5 mg/kg/day in divided doses.
c. Increased intracranial tension is treated by proper positioning of patient with headelevated at 15-30 position,
fluid restriction to 2/3rd of maintenance, 20% Mannitol5 ml/kg over 10-15 min followed by 3 ml/kg every 6
hourly for 48 hours and thenSOS. Or Acetazolamide 50-75 mg/kg/day in 3 divided doses through feeding tube Or
Glycerine 1 ml/kg/day through feeding tube may be added, if increased intracranial tension persists.
d. Fever is controlled as given in section on fever.
(Caution: Never give aspirin).
e. The intravenous fluid at two-thirds of the maintenance requirement initially. The electrolyte concentration of
the blood is monitored very closely. Any imbalance is treated promptly. Fluid restriction is not done, if patient is
dehydrated or is inshock.

Page 217
f. Feeding: Initially the patient is kept nil orally for first 24-48 hours. Later on the feeding is guided by the level of
sensorium. A tube feeding is helpful for feeding as well as for giving medicines.

4.2 Specific treatment


Until a bacterial cause is excluded, parenteral antibiotic therapy should be administered.The choice of antibiotics
depends upon age of the patient and prevalence of organismin the area.

4.2.1 Age 0-3 months


1. Inj Cefotaxime 200 mg/kg/day IV in 4 divided doses for 14 days.
2. Inj Ampicillin 300 mg/kg/day IV in 4 divided doses for 14 days.

4.2.2 Age 3 months-12 years


1. Inj Ceftriaxone 100 mg/kg/day IV over 30-60 minutes in 2 divided doses for 10 days Or Inj Cefotaxime 200
mg/kg/day IV in 3 divided doses for 10 days
Or Inj Ampicillin 300 mg/kg/day IV in 4 divided doses for 10 days
2. Inj Chloramphenicol 100 mg/kg/day in 4 divided doses for 10 days
If Meningococci is suspected/isolated, Inj Penicillin G 300,000-400,000 IU/kg/day in 4 divided doses for 7-10
days.

4.2.3 Treatment of Viral meningoencephalitis


Herpes simplex virus (generally diagnosed by focal encephalitis or CT scan):
Inj Acyclovir 30 mg/kg/day in 3 divided doses for 14-21 days. Non-HSV viral
Encephalitis is treated by supportive therapy only.
Lumbar puncture is repeated at 48 hours to see the response. However, if the patient is improving well, a repeat
lumbar puncture may not be necessary.

5. Advice at discharge
Regular follow-up for neurological assessment including deafness is advised.
Anticonvulsant therapy to be continued, if seizures are recurrent during course of meningitis. Children with
sequalae would require assessment of handicap and multidisciplinary management.
Occupational/physiotherapy may be taught during hospital stay itself.

Page 218
21. TUBERCULOUS MENINGITIS

1. Introduction
Tuberculous meningitis is the inflammation of MRI of brain maybe normal during early stages
meninges due to lymphohaematogenous spread of of the disease. Later, it can show exudates in
the primary infection of tuberculosis to the thebasal cisterns of brain, periventricular ooze
meninges, found in about 0.3% of untreated primary and hydrocephalus. Some may
infection in children. It is the most dangerous form showtuberculomas even.
of extrapulmonary tuberculosis. 70% of the cases
are found in children less than 5 years of age.
6 Treatment
Treatment consists of proper supportive care,
2. Clinical Manifestations including nonpharmacological treatment, specific
The clinical progression of tubercular antitubercular therapy, treatment of increased
meningitis (TBM) may be rapid or gradual.The intracranial tension and, if required, surgical
signs and symptoms progress slowly over treatment.
several weeks and can be divided into three
stages. 6.1 Nonpharmacological
Nutrition: After initial stabilization, nutritional
2.1 Stages rehabilitation should be done as given in section on
protein energy malnutrition.
2.1.1 The 1st stage, which typically lasts 1-2 Skin care and prevention of bedsores.
weeks, is characterized by non-specific symptoms, Care of bowel and bladder.
such as fever, headache, irritability, drowsiness and Physiotherapy and occupational therapy should be
malaise. Focalneurologic signs are absent. instituted early to preventdeformities and
3.1.1 The 2nd stage usually begins more contractures.
abruptly. The most common featuresare lethargy,
neck-rigidity, seizures, positive Kernig or 6.2 Pharmacological
Brudzinski signs, Hypertonia, vomiting, cranial 1. Appropriate fluid therapy to correct dehydration
nerve palsies and other focal neurologic signs. due to frequent vomiting anddecreased oral intake.
3.1.2 The 3rd stage is marked by coma, 2. Treatment of SIADH. Fluid restriction to three
hemiplegia or paraplegia, hypertension, fouth or two third of maintenance. Treatment of
Decerebrate posturing, deterioration of vital signs, raised intracranial tension
and eventually, death. 3. Inj. Dexamethasone: 0.15 mg/kg IV 6 hourly for
2 weeks followed by Tab.Prednisolone 1.5
4 Complications: mg/kg/day orally through feeding tube for 4 week
Survivors may have motor deficits, cranial this should be tapered over another 2 weeks. A total
nerve deficits, mental retardation, learning of 6-8 weeks therapy with steroid is recommended.
disabilities, seizures, hydrocephalus, blindness, 4. Mannitol (20% solution) 1.5 to 2 g/kg or 8-10
deafness and diabetes insipidus. ml/kg over 30-60 minutes. Repeat every 6-8 hours
for 7 days. Lower doses (0.25 g/kg/dose) can also be
tried. Or Glycerol 1 ml/kg/dose every 6-8 hours,
5 Investigations diluted in orange juice or water, given through
The diagnosis is made by analysis of CSF on feeding tube. Or Tab. Acetazolamide 50 mg/kg/day
lumbar puncture, which shows lymphocytic in 3 divided doses for 2-3 weeks.
leucocytosis with elevated protein and a low 5. Presence of seizures necessitates treatment with
sugar (for details see Table 19.21 in section on phenytoin or carbamazepine in appropriate doses
Meningoencephalitis). (for details see section on Epilepsy in Chapter).
Demonstration of AFB in CSF confirms the 6. Specific antitubercular therapyas given in
diagnosis, but the yield is very poor. management of tuberculosis (seeSection on
Culture of CSF shows growth of M. Tuberculosis).
tuberculosis, takes too much time. 7. Surgical treatmentventriculoperitoneal shunt
Positivetuberculin skin test corroborates the (VP shunt): TBM shows somedegree of
diagnosis but may be negative in hydrocephalus by 4 weeks. Obstructive
severelymalnourished/disseminated disease. 20- hydrocephalus should be shunted immediately. Non-
50% of children have a normal chestradiograph obstructive hydrocephalus with increased
others may show primary disease. CT scan or intracranial pressure as shown by ventricular tap or

Page 219
CT scan will also be benefi ted by VP shunt. An causes of increased ICP is untreated hydrocephalus
early shunt is preferable. or blocked shunt.
2. Check compliance to drugs and ensure that
occupational therapy/physiotherapy isbeing
continued.
3. Assess physical, mental, visual and auditory
handicap and take expert opinion for rehabilitation
from other specialists. Patient/parent education
Seriousness of disease must be explained.
Contact survey should be done and any other
member in the family found to have active TB
should be counselled to attend TB clinic for therapy.
6.3 Follow-up Need for compliance should be emphasized.
1. Patient should be kept under follow-up after Drug toxicity and side effects must be explained.
discharge from the hospital andassessed for Neurological defi cits may appear even in a patient
neurological deficit and features of increased on therapy.
intracranial pressure(ICP). One of the common

Page 220
22. ACUTE RESPIRATORY INFECTION
disease and can be managed in the community with
1. Introduction oral co-trimaxazole. Severe ARI cases require
Acute Respiratory Infection (ARI) is an important urgent referral to a facility where injectable
cause of infant and child mortality and also the antibiotic therapy and supportive care are available.
commonest cause of morbidity among children
below five years. ARI is the infection of any part of 2. Diagnosis & management
respiratory tract, which includes cough, common
cold, pharyngitis, pneumonia, laryngitis and ear
of ARI
infection. Classification and management of ARI is based
Acute respiratory infections in children can involve upon three important factors. These are age of the
upper respiratory tract (nose, throat) or lower child, respiratory rate and danger sign like chest in-
respiratory tract (bronchi, lung). Lower respiratory drawing.
tract infections (broadly termed as pneumonias) are
a major cause of death of infants and children in
2.1Age of the child and respiratory
India, accounting for about 30% under-five deaths. rate
Timely treatment, based on well-researched
Children are classified into three age groups for ARI
algorithms can save most children with ARI.
management. These age groups and criteria for fast
Majority of the cases of ARI have non-severe
breathing are given in table below

Table 1 : Cut of points for fast breathing


Sr. Age group Criteria for fast breathing
1 0 - 2 months Respiratory rate more than 60 / minute
2 2 months to 1 year Respiratory rate more than 50 / minute
3 1 year to 5 years Respiratory rate more than 40 / minute
No pneumonia
Chest in-drawing Severe pneumonia/Very severe illness
In normal child, during respiration, chest expands
when the child breathes in and compresses when the 2.3.1 No pneumonia
child breathes out. In children with severe
pneumonia, chest moves in when the child breathes
If respiratory rate of child is less than 60/minute
in. This is called chest in-drawing.
then the child is classified as 'No Pneumonia'.
2.3 Pneumonia in 0-2 months age
Give Paracetamol tablet if there is fever and
group demonstrate to the mother how to clean nose
Important aspects about pneumonia in age group 0-2 with normal saline drops.
months are as below: Advise mother to continue breast-feeding.
In these children, there are no usual features of Inform mother about danger signs of
pneumonia like fever, cough, etc. pneumonia, e.g. breathlessness (rapid
Child may have only fast breathing and/or chest movement of abdomen), inability to drink,
in-drawing. excessive drowsiness, hypothermia, high fever
etc. Ask mother to immediately bring the child
Pneumonia in child less than 2 months age is back to health facility, if she observes any of
always severe & mortality is high the signs mentioned above.
Severe pneumonia/Very severe illness
If child below 2 months presents with fast breathing
Such cases should be treated in the facility where (RR > 60/minute) and/or chest in-drawing
specialist & ICU are available. Plus
Classification
Page 221
One or more of the following signs - - Cyanosis
- Inability to drink - Hypothermia
- Excessive drowsiness - Convulsions
- Stridor, wheeze Such child shouldbe referred to specialist.

In case referral can not be executed treat the child as below


Table 2: Treatment of Pneumonia

Antibiotic Dosage Frequency Route


Age < 7 days Age > 7 days - 2
months
Inj Benzyl penicillin 50,000 12 hrly 6 hrly IV/IM
OR IU/kg/dose
12 hrly 8 hrly IV/IM
Inj Ampicillin AND 50 mg/kg/dose
12 hrly 8 hrly IV/IM
Inj Gentamycin 2.5 mg/kg/dose
tohealth facility if she observes any of the
danger sign.
2.4 Pneumonia in 2 months to 5
years age group 2.4.2 Pneumonia
Children with ARI of 2 months to 5 years age are If child has fast breathing (RR: 2-12 mts > 50/ min.
classified into four groups as follows - & 1-5 yrs. > 40/ min.) and no chest in-drawing,
diagnose child as Pneumonia
- No pneumonia
a. Treatment of pneumonia
- Pneumonia
Give child Cotrimaxazole for 48 hrs. Treatment
- Severe pneumonia schedule for pediatric cotrimaxazole is -
- Very severe illness 2-12 months:
2.4.1 No pneumonia 2 tablets twice daily or syrup 5 ml. twice daily
When respiratory rate is normal and no sign of chest 1-5 yrs: 3 tablets twice daily or syrup 7.5 ml. twice
in-drawing is seen child is disgnosed as no daily.
pneumonia. These children should be treated at
home & observed for appearance of danger signs Pediatric tablet contains Sulphamethaxazole 100 mg
(increase in RR and chest in-drawing) by mother. & Trimethoprim 20 mg.
Following points should be advised to mother - Syrup 5 ml. contains Sulfamethaxazole 200 mg
Continue breast-feeding if child is breast-fed. and Trimethoprim 40 mg.

Give plenty of oral fluids including water or If fever is present, give Tab. Paracetamol. (5 to
ORS to child. 10 mg./kg)

If fever is present, give Tab. Paracetamol. Teach mother how to clean nose with normal
saline. This will clear airway of child and
Teach mother how to clean nose with saline improve breast-feeding.
water. This will clear airway of child and
improve breast-feeding. Keep baby warm by covering with warm
clothes and keeping in lap.
Assess child after 48 hrs:
In community, many home remedies are used
If improvement - Continue CTZ for 3 Days
for ARI. One of the best among them
Child has: - Chest in-drawing
is honey & ginger. Advise mother to give honey
and ginger to child. And
Inform mother about danger signs of RR may be fast complete 5 days course
pneumonia, e.g. breathlessness, inability to
If no improvement or child gets deteriorated
drink, excessive drowsiness, hypothermia, high
refer child to specialist.
fever etc. Advise her to bring child back

Page 222
Severe pneumonia: - Child with chest in- Treatment
drawing & having RR normal or fast is
a. Treat for first 48 hrs by
diagnosed as severe pneumonia should be
treated by specialist. Give oxygen if child has
cyanosis till the child is referred.
Table 3
Treatment of severe Pneumonia
Antibiotic Dosage Interval Route
Inj Benzyl penicillin OR 50,000 IU/kg/dose 6 hrly IM
Inj Ampicillin OR 50 mg/kg/dose 6 hrly IM
Inj Chloramphenicol 25 mg/kg/dose 6 hrly IM

b. Assess after 48 hrs


i. If improvement, continue for next 3 days as below
Table 4
Treatment of severe Pneumonia
Antibiotic Dosage Interval Route
Inj Procaine penicillin OR 50,000 IU/kg (Max 4 lac units) Once IM
Tab Ampicillin OR 50 mg/kg/dose 6 hrly Oral
Tab Chloramphenicol 25 mg/kg/dose 6 hrly Oral

ii. If no improvement, change antibiotic as below


If Ampicillin was given earlier then change 2.4.4 Very severe illness
to Inj Chloramphenicol a) Child has:
If Chloramphenicol was given earlier change Chest in-drawing and RR may be fast or normal
to Inj Cloxacillin 25 mg/kg/dose 6 hrly IM + plus
Gentamycin 2.5 mg/kg/dose 8 hrly IM.
One or more of following signs -
iii. Important aspects of antibiotic treatment
Inability to drink
Treatment with antibiotics should be
continued for at least five days. Excessive drowsiness
Stridor, wheeze
Cyanosis
Hypothermia
Convulsions
Continue treatment for at least 3 days after child
recovers. Diagnose the child as suffering from very severe
illness & refer the child to specialist having facility
If cloxacillin & gentamycin are started continue for of intensive care unit.
three weeks.
In addition to this give following 3. Treatment of childhood
Administer Oxygen if required community-acquired
Continue breast feeding during illness pneumonia
If fever, give tablet or syrup Paracetamol Themanagementofpneumoniaisguidedbytheseverity
ofthediseaseaslistedinTable below:

Table 5: Signs & symptems

Page 223
Sign or symptom Classification Treatment

Centralcyanosis Very severe pneumonia Admittohospital


Severerespiratorydistress Managetheairway
Not abletodrinkduetorespiratory Giveoxygen
Distress. Giverecommendedantibiotic
Treathighfeverifpresent

Chestindrawing Severe pneumonia Admittohospital


Giverecommendedantibiotic

Fastbreathing Pneumonia Giveappropriateantibioticfor5


days
2monthsupto12months:50breaths/
Soothethethroatandrelievecough
min
with a safe remedy

(a) There is a rapid progression of the disease, or


3.2 Treatment of very severe
illness (b) There is pneumatocoele, or pneumothorax, or
effusion on chest X-ray, or
3.2.1 Admit the child in hospital
3.2.2 Obtain a radiograph (c) Child has large skin boils or abscess or infected
scabies, or
ofthechestiffacilities
areavailableforthesame.Radiographyinverysever (d) post-
epneumoniaisrequired at admission to assess measlespneumoniawhichisnotrespondingwithin48ho
the extent of disease and to rule out presence of urstotheinitialtherapy.Ifstaphylococcalpneumoniaissu
puemothorax or effusion In case spected,addInjCloxacilin(50mg/kg/dose,every6hourl
ofseveredistress,stabilizeandoxygenatethechildb y)toanyoftheabovechoice of antibiotics.
eforesendingforradiograph. Whenthechildimproves,continueCloxacillinorally4ti
3.2.3 Give antibiotics mesadayforatotalcourseof3weeksatleast.Childrenwit
hcomplicatedpneumonia(Empyema)needlongerthera
- pyfor4-6weeks.
GiveInjectableAmpicillin(50mg/kgIM/IVevery6hours
)andGentamicin(7.5mg/kgIM/IVonceaday).Ifthechild 3.2.4 Give Oxygen
respondswell,dischargeafter5daystocontinuetreatm -
ent Wherepulseoxymeterisavailable,useoxygensaturatio
athomewithoralAmoxicillin(15mg/kgperdosethreeti noftheblood(SaO2)toguideoxygentherapy.Maintain
mesaday)plusIMGentamicinoncedailyforafurther5da SaO292%.Continuewithoxygenuntilthesignsofhyp
ys. oxia(suchasseverelowerchestwallin-drawing or
breathing rate of 70/min)arenolongerpresent.
-Alternatively,
giveInjectableChloramphenicol(25mg/kgIMorIVever 3.2.5 Give supportive care
y8hours)untilthechildhas -
improved.Thencontinuethesamedrugorallyinthesa Ensurethatthechildreceivesdailymaintenancefluidsap
medosefor3timesadayforatotalcourseof10days. propriatetochildsage.Encouragebreastfeedingandora
- lfluidsoncethedistresssettlesandthechildisabletofeed.
Ifthechilddoesnotimproveby48hourstoanyoneofthe
- If the child has fever
setreatments,reassessforcomplicationsandswitchto
(38.5C)whichappearstobecausingdistress,gi
InjectionCeftriaxone(80mg/kgIMorI/Voncedaily )
veoralParacetamol(15mg/kg/dose).
for10days.
-Ifwheezeispresent,givearapid-
- Staphylococcal pneumonia is suspected if:
Page 224
actingbronchodilator(asdescribedinthenextsection). - Improved ability to eat and drink.
- 3.2.7 Watch for complications
Removeanythicksecretionsinthenose/throat,whichth -
echildcannotclear,bygentlesuction. Ifthechildhasnotimprovedaftertwodays,orifthechild
3.2.6 Monitor the child sconditionhasworsened,lookforcomplicationsoroth
erdiagnoses.Ifpossible,obtainarepeatchestX-
- ray.Considertransfertoahigherfacilityincaseofpoor
Thechildshouldbecheckedbynursesatleastevery3hou response or deterioration despite second-line
rsandbyadoctoratleasttwiceaday.Monitorfor signs of therapy.
improvement. A patient who is improving on
treatment should have: 3.2.8 Monitoring
Thechildshouldbecheckedbynursesatleastevery6ho
- An improvement in the respiratory rate.
ursandbyadoctoratleastonceaday.Monitorforsignso
- Less indrawing of the lower chest wall. f improvement as discussed above.
- Less fever, and /or Table 5

Table 6 : summary of management of ARI cases.


No. Type Who can manage Where can be managed
Age group 2 months to five years
1 No pneumonia ASHA Anganwadi Worker, MPW Home management
2 Pneumonia MPW/HA, MO Management at home or PHC
3 Severe pneumonia PHC MO / specialist PHC/ referral center
4 Very severe illness Specialist Specialist with ICU facility
Age group below 2 months
Child should be referred immediately after giving one dose of CTZ

Page 225
23. BRONCHIAL ASTHAMA

Less Preferred treatment: Monteleukast


1. Introduction: Theophylline Chromoglycate and treatment of mild
Bronchial asthma is a disease characterized by an intermittent asthama
increased responsiveness of the trachea and bronchi
to various stimuli. It manifests by widespread 3.2 Moderate persistent
narrowing of the airways causing paroxysmal Symptoms > 2 times/ week
dyspnea, wheezing or cough. The diffuse
obstruction to the airflow is reversible in a large Nocturnal symptoms >1/week
majority of cases, either spontaneously or in PEFR 60-80%
response to treatment. Bronchial reactivity is a
necessary component of asthma. Asthma is a result 3.2.1 Treatment
of multifactorial inheritance. Inhaled steroid med dose

2. Signs &Symptons: If response not satisfactory


Recurrent cough Add inhaled LABA
Breathlessness Salmederol/ Formeterol/Monteleukast/ long acting
Wheezing theophylline

3. Clinical classification
1) Mild Intermittent 3.3 Severe Persistent
2) Persistant Daily symptoms often severe
a) Mild Activity limited
b) Moderate Growth affected
c) Severe Frequent Nocturnal symptoms

3.1 Mild Intermittent Frequent hospitalization


Symptoms < 2times a week and asymptomatic in PEFR<60%
between
3.3.1 Treatment
Nocturnal symptoms < 2 times /month
Inhaled steroids high dose
3.1.1 Treatment
Salbutamol inhaled (100 MCG/puff) Inhaled LABA / Monteleukast / long acting
theophylline
1-2 puffs as per requirement
If response not satisfactory
For children less than 2 years use face mask with
spacer Oral Prednisolone2mg/kg/day in three divided doses
& inhaled salbutamol as required
OR
1) Pulmonary function test
Salbutamolsyrup/tablet
0.1-0.2 mg/kg/dose three times a day till symptoms 2) Absolute Eosinophili count
subside 3) Chest X-ray
Mild Persistent 4) Skin test & Allergy test
Symptoms > 2times/week but, 1time/day
Nocturnal symptoms > 2 times / month
Asymptomatic in between exacerbations peak flow
3.4 Treatment Guidelines for acute
rate( PEFR) > 80% exacerbation of Asthama
3.1.2 Preferrence of Treatment O2 by mask (4-6 liters /min)
Preferred treatment: Inhaled steroids (low dose) 2 Salbutamol MDI (100MCG/puff)with spacer and
puffs twice / day mask for < 2 years 4-8 puffs every 20 min x 3 OR
Salbutamol nebulization 0.15mg/kg(min 2-5mg)

Page 226
diluted in 3 ml saline can be repeated 3 times every Good response
20 min
Send home: salbutamol MDI+ Tab Pednisolone
InjAdrenaline (1:1000) or Terbutaline (0.01mg/kg) 2mg/kg/Day x 5-7 days
s/c may be repeated thrice every20 min if both
above are not available
AND Inj Hydrocortisone hemisuccinate 4. Investigation:
10mg/kg/dose 4 times a day OR Inj
1) Pulmonary function test
Dexamethasone0.2 mg /kg/dose
This must be converted to oral prednisolone once 2) Absolute Eosinophili count
patient is stable 3) Chest X-ray
If response not satisfactoryRefer to higher center
4) Skin test & Allergy test
statIMP: Evaluate after 1 hour

Medication Dosage form Dosage

Formoterol DPI: 12 ug per single-use capsule 1. Capsule every 12


years
Salmeterol MDI: 25 ug per puff 1-2 puff every 12 hours
Fluticasone/salmeterol DPI:100, 250, or 500 ug of fluticasone 1 inhalation twice daily;
with 50 ug of salmeterol dosage depends on
severity of asthma

Cromolyn MDI: 1 mg per puff 1-2 puffs 3 to 4 times


daily
Nebulizer solution :
1 ampule 3 to 4 times
20 mg per ampule
daily

Nedocromil MDI: 1.75 mg per puff 1-2 puffs 2 to 4 times


daily
Montetelukast 4 or 5 mg chewable tablets, Age 12-23 months: 4 mg
oral
4 mg packet of oral granules,
granules at bedtime
10 mg tablets
Age 2-5 years: 4 mg at
bedtime

Zafirlukast 10 & 20 mg tablets Age 7-11 years: 20


mg daily in

Theophylline Liquids, sustained- release Starting dosage is 10 mg /kg


per day
Tablets and capsules.
< 1 years : ( 0.2 [age in
weeks] ) + 5
= mg per kg day 1 years :
16 mg
per kg per day

Table1. Drugs used in the long-term control of asthma in children

Page 227
24. BREATH HOLDING SPEL

1. Introduction: 3. Complication:Local trauma,


Aspiration pneumonia.
A baby with crying followed by loss of
consciousness, tonic posturing (features of cerebral
anoxia). Cyanotic Breath holding spell more
4. Management:
common form: Usual age of onset is 6 months, peak Examination to rule out other seizure mimicking
by 2 years, abate by 5 years. After a shrill cry, conditions.
forced expiration followed by apnea and cyanosis
leading to loss of consciousness associated with i. Reassurance of parent that these are not
clinical jerks or posturing. seizures, EEG not required, inter-ictal EEG is
normal.
2. Signs &Symptons: ii. Should not reinforce this behavior, put the
child in safe place and avoid cuddling.
Baby may be cyanosed (blue)\ Baby may be pale iii. Iron supplements if anemia, delayed weaning
etc.(3 mg/kg for 3 months.)
History of a predictable stubborn behavior,
iv. Syrup Piracetam( 40-100 mg /kg in BD) may
precipitating event like upsetting the infant
be used for few months if the breath holding
History of painful stimulus or hit on head cyanosis spells are very frequent,
leading to loss of consciousness associated with v. Parental counseling to prevent reinforcement
clinical jerks or posturing Less common, Apnoea of this behavior.
followed by pallor, hypotonia and tonic seizure.

Page 228
25. BRONCHIOLITIS

Supportive measures such as oxygen by hood (10


1. Introduction: litres / mt) or by mask (5 lits / mt); IV fluids if child
is not able to feed orally.
Viral in aetiology (Respiratory syncitial virus) most
frequently in children < 12 months of age
IV fluids if child is not able to feed orally.
2. Signs &Symptoms:
An antibiotic has no role.
Initial URI symptoms followed by Increasing
cough, Respiratory distress, Wheeze and feeding
difficulty
4.2 Monitoring
(RR, Respiratory distress, pulse oximetry) - A trial
3. Investigations: dose of Nebulised salbutamol / epinephrine if
wheezing is marked as child improves wean off
CXR: Hyperinflated lungs with patchy infiltrates oxygen and increase oral feeds if child develops
severe respiratory distress, increasing hypoxemia,
4. Management: cyanosis or fatigue ventilatory support may be
4.1 Treament of bronchiolitis is essentially required.
symptomatic.Child should be treated in a humid
atmosphere preferably in sitting position with head
and neck elevated.

Page 229
26. EMPYEMA
USG chest: size, site of effusion, adhesions or
1. Introduction: loculations can be made out.
Characterised by presence of pus or microorganisms Diagnostic thoracocentesis: usually in fifth
in the pleural fluid occurs as a complication of intercostal space over mid-axillary line using a
Pneumonia, Influenza. Streptococcus Pyogenes, large bore needle Pleural fluid for Gram stain,
Staph aureus, Streptococcus Pneumoniae, culture and sensitivity, Pleural fluid pH, sugar
Hemophilus are the common organisms. are reduced and protein is elevated.

2. Signs &Symptoms: 5. Management:


Common symptoms are 5.1 Treatment comprises of chest drain and
Fever antibiotics.

Chills Chest drainage using an intercostal drainage tube


inserted in the region of maximal dullness (usually
Toxaemia V or VI intercostal space in axillary region) and
connecting to a sterile under water drainage bottle
Respiratory distress
Chest drainage is kept till the drainage decreases to
Grunt and < 25 ml/day and there is good lung expansion. If
there is no chest expansion by clinical or
Chest pain (pleuritic pain)
radiological methods, surgical opinion is sought
3. on examination 5.2 Antibiotics
Decreased chest expansion Cloxacillin with cefotaxime or ceftrioxone is the
Diminished breath sounds first line antibiotic; switch over to oral antibiotics
after child becomes afebrile and chest tube is
Dullness on percussion on affected side and removed. Total duration of 4 - 6 weeks of antibiotic
Mediastinal shift to opposite side therapy or
Cloxacillin: 100 - 200 mg/kg/day in 4 div. doses
4. Investigations:
Cefotaxime: 150 - 200 mg/kg/day in 3 or 4 div.
Chest X-Ray: obliteration of costophrenic doses
angle; diffuse homogenous opacity.
Supportive care: oxygen, good nutrition

Page 230
27. APPROACH TO FEVER

1. History: 3. Basic investigations


Type of fever
Associated symptoms chills / rigor, cough, sore
In high risk group and
throat, ear pain, urinary symptoms, bleeds etc. fever beyond 5 days in low
Previous illness and treatment. if any Feeding
difficulty, respiratory distress. risk:
Total count, differential count, peripheral smear,
2. Clinical Examination Platelet count
Check Temperature, Blood pressure, Pulse,
Perfusion Urine analysis, urine c/s

Skin: Rashes, Bleed, Cyanosis Blood culture and sensitivity

Eyes: Pallor, Icterus Chest x-ray

Mouth: Ulcer, Thrush C-reactive protein

Ear: Discharge, Redness, Tenderness Mantoux test

Throat: Congestion, Tonsillitis CSF analysis if required

CNS: Meningeal irritation, altered sensorium Other investigations

Abdominal examination: Hepatomegaly, Liver function test


Splenomegaly Renal function test
Respiratory System: Tachypnoea, Retraction, Creps, USG abdomen
Wheeze
Blood for leptospirosis
Serology for dengue
Widal
Bone marrow

4. Refer if,
Fever with unconsciousness
Fever with shock
Severe respiratory diseases
Bleeding diathesis
Refractory seizures

Page 231
28. ACUTE FLACCID PARALYSIS (AFP)

1. Defination :
A case of AFP is defined as any child aged <15
1. SALIENT FEATURES
years, with acute onset of Flaccid paralysis without The paralysis is of acute onset (<4 weeks) and the
any obvious cause (e.g. severe trauma or electrolyte affected limb(s) are flaccid (floppy or limp). If the
imbalance like (hypokalaemia). AFP is a notifiable AFP is due to polio, then sensation is never affected.
disease and all cases must be reported immediately Other important differentials to be considered in
to Nodal Officer and District Surveillance Officer, cases with AFP are detailed in Table-1. This
NPSP Unit, Directorate of Family Welfare. India includes possible illness due to Guillian-Barre
has shifted to the virological system of case syndrome, transversemyelitis, traumatic neuritis;
classification, i.e. within 90 days of paralysis onset; viral infections caused by other enteroviruses,
all cases should undergo final classification as toxinsand tumours. Isolated facial paralysis is also
confirmed polio, non-polio AFP or compatible with included.Pseudoparalysis due to pain in congenital
poliomyelitis. India has been declared polio free syphilis, osteomyelitis, abscess, scurvy,
since 3 years. unrecognized trauma leading to contusions, slipped
epiphysis or fractures, etc. can also mimicAFP.

2. Differential Diagnosis:
Table 1- Important differential diagnosis of AFP (adapted from Field Guide, MOHFW, GOI)

Signs and Polio GBS Transverse Traumatic


symptoms myelitis or injection
neuritis
Age Most cases occur Usually above 2 Mostly above 4 No age limit
under 3 years of years of age years of age
age

Progression of 24-48 h onset to Hours to days Hours to 4 days Hours to 4 days


paralysis full paralysis

Fever onset High always Not common Rare Commonly


present at onset of present before,
flaccid paralysis during and after
disappears the paralysis
following day

Flaccidity Acute, Acute, Acute Acute,


asymmetrical, symmetrical, lower limbs asymmetrical
Proximal Distal symmetrical Limb

Muscle tone Diminished Diminished Diminished in Diminished in


lower limbs affected limb

Deep Decreased or Absent Absent in lower Decreased or


tendon absent extremities, later absent
refl exes hyper-refl exia

Sensation Severe myalgia but Cramps, tingling Pain in gluteal


no sensory defi cit hypoanaesthesia of Anaesthesia of region
palms and soles the lower limbs
with sensory loss

Cranial nerve Only in bulbar or Often present Absent Absent


bulbospinal cases. affecting VII, IX,

Page 232
Loss of gag reflex X, XI, XII
most common Only
in bulbar or
bulbospinal cases.
Loss of gag reflex
most common
Respiratory Only when bulbar In severe cases Sometimes Absent
insufficiency and bulbospinal
involving
respiratory muscles
CSF WBCs High WBCs. <10 Normal Normal
proteins Normal or slightly High Normal or Normal
increased slightly elevated
Bladder Absent Transient Present Never
dysfunction
Nerve Abnormal, anterior Abnormal, Normal of Abnormal in
conduction horn cell disease demyelination abnormal has no sciatic nerve
velocity in 3rd diagnostic value

EMG 3rd week Abnormal Normal Normal Normal


Sequelae at 3 Severe Symmetrical Flaccid Moderate
months and up asymmetrical atrophy of distal atrophy only in
to a year atrophy, skeletal muscles, diplegia, affected lower
deformities may atrophy after years limb
develop later

laboratory in good condition (i.e., no desiccation, no


3. Confirmation leakage, with adequate documentation and evidence
An AFP case is confirmed as Polio only by the that the cold chain was maintained.)
isolation of wild poliovirus from any stool
specimen.An AFP case is classified as non-polio 4. Treatment for acute POLIO
AFP if wild poliovirus is not isolated from
adequate stool specimens.If stool specimens are
like illness
inadequate, final classification of the AFP case as All cases should be treated as below except patients
either nonpolio AFP or compatible with Polio will with isolated single lowerlimb involvement and
depend on the results of 60 days follow-up reporting after 4 days of onset of paralysis and
examination. If the 60 days follow-up examination currently not progressing for more than 48 hours.
shows no residual weakness, the case is classified as
non-polio AFP. The final classification of the case
4.1 Nonpharmacological
as compatibleor discarded as non-polio AFP is Complete bed rest and correct positioning of the
determined by the National Expert Review affected limbs in the optimal
Committee (ERC) which meets every month in New Position as follows:
Delhi to review all such cases.
Hipslight flexion, knee5 flexion, foot90
3.1 Adequate stool: Two specimens collected within with support against the soles. Both legs should be
14 days of paralysis onset and at least 24 hours supported from the lateral sides with pillows or
apart;each specimen must be of adequate volume (8- rolled towels
10 grams) and arrive at a WHO-accredited
or salt/sand packs to prevent rotation. relieving painthe jointsfor about 10 minutes, 2-3
If transient urinary retention occurs times a day.
When pain subsides passive movements of
alternate hot and cold compresses over the
suprapubic region.
4.2 Pharmacological
(Caution: No massage or intramuscular injections as There is no specific drug therapy for polio. For fever
it may further precipitateparalysis. Watch for and pain, use paracetamol or ibuprofen (see section
progression, particularly for the involvement of the on Fever in Chapter 1). Referral to a tertiary care
respiratorymuscles.) centre witha ventilatory support facility, if there is
progression of paralysis, respiratory distress,bulbar
Warm water fomentation using hot packs with
involvement, paralysis of upper limbs which is <3
soaked towels wrapped around the affected partsfor
days old (there is higherrisk of diaphragmatic
about 10 minutes, 2-3 times a day help in
Page 233
involvement in such cases), marked drowsiness or Note: Post-polio residual paralysis should be
any other complication. referred for rehabilitative services to an appropriate
centre.
Patient/parent education No dietary restrictions,
however, continue breastfeeding or other
regular feeding.
5 Action expected on
Paralysis progresses usually for about 4-7 days admission of suspected
after onset. Recovery may startthereafter over AFP case:
days to weeks with little recovery of strength - Report to higher authority immediately
after 6 months ofillness. A regular
physiotherapy facilitates recovery of muscles. - Take adequate stool sample
- Send the stool sample maintaining cold chain to
district headquarte

Page 234
29. FEBRILE SEIZURES

aprolonged or atypicalfebrile seizure, delayed


1. Introduction developmental milestones and an abnormal
neurologicalexamination.
Febrile seizures are brief (2-5 min), generalized
tonic-clonic and self-limited seizures followed by a 5. Treatment
brief post-ictal period of drowsiness, in an otherwise Most febrile seizures are brief and would be over by
healthy, febrilechild of 6 months to 5 years of age, the time a child is brought to the doctor or health
without any evidence of underlying facility. Management includes definitive diagnosis,
neurologicaldisease. They are the most common restraint in investigations, treatment of an acute
seizure disorder during childhood, with a episode, prophylaxis for future episodes and family
uniformlyexcellent prognosis. They occur rarely counselling. Role of defervescence in preventing
before 6 months and after 5 years of age. The peak febrile seizures is questionable.
age of onset is approximately 14-18 months of age, 5.1. Nonpharmacological
found in 3-4% of young children. There is a strong Clear the airway, semi-prone lateral position and
family history of febrile convulsions in siblings and oxygen therapy.
parents, suggesting a genetic predisposition. Except
for the cases at high risk, simple febrile seizures 5.2. Pharmacological
rarely develop into epilepsy. 5.2.1 In cases presenting with seizures, the mainstay
of management is prompt administration of
2. SALIENT FEATURES anticonvulsants.
5.2.2 Thebest drug
Febrile seizures usually occur when the temperature
isDiazepam/Midazolam/Lorazepam in a dose of 0.3
is rising rapidly, to generally 39C (102F) or more
of core temperature. They are of two types: mg/kg by slow intravenous or rectal route. It can be
repeated, if seizures do not subside (per rectal dose
(i) Typical (simple) febrile seizure occurs on day 1 may be given up to 0.5 mg/kg/dose).
of fever, does not last formore than 10 minutes; 5.2.3 Intermittent prophylaxis (during febrile
generalized tonic-clonic; generally not more than illness)
oneepisode within 24 hours. 5.2.4 It is a safe and effective method of prophylaxis
but does not reduce the risk of future epilepsy.
(ii) Atypical or complex febrile seizure may persist
Tab Clobazam 0.75 mg/kg for 2-3 days in 2 divided
for more than 15 minutes;it could be focal in nature;
doses during fever or Tab/Syr. Diazepam 0.3
more than one episode of seizure in 24
mg/kg/dose every 8 hours (1 mg/kg/day) for 2-3
hours;associated with abnormal neurological
days of febrile illness,started on the day of onset of
findings or deficits. An organiccause such as an
fever. Dose can be adjusted, if over sedation or
infectious or toxic process should be considered
ataxia noted.
andinvestigated.Late onset febrile seizures,
persistent febrile seizures, generalized epilepsy 5.3 Continuous prophylaxis
andfebrile seizure plus (GEFS+) and febrile status
epilepticus (FSE) are part of thespectrum of febrile Febrile status, complex and recurrent febrile
seizures seizures (>6/year in spite of intermittent
prophylaxis) may need EEG, neuroimaging and
continuous prophylaxis with AED.Phenobarbitone
3. Investigations and valproate may be used in infants and older
3.1 Lumbar puncture: A lumbar puncture with
children, respectively, for 1-2 years. Carbamazepine
examination of CSF is essential to rule out
and phenytoin are not useful.
possibility of meningitis in cases with first episode
of febrile seizures.

3.2 EEG has no role in case of simple febrile 6. Patient/parent education


seizures. However, in cases withatypical febrile The parents and caretaker should be assured of
seizure or in a child with high risk for developing the benign nature of the disease andshould be
epilepsy, itmay be helpful. told that no neurological deficit or mental
4. High risk for developing retardation occurs as a result ofsimple febrile
seizure. They should be taught about control of
epilepsy, fever at home. They can be taught to give
It include a positive family history of epilepsy,initial diazepam per rectally at home.
febrile convulsion prior to 9 months of age,

Page 235
Routine immunization as per schedule should 4th day from the day of vaccination and given
be followed. After DPT vaccination, oral for 3 to 4 days to avoid precipitation of febrile
paracetamol 15 mg/kg/dose every 6 h for 2 or 3 seizures.
days and similarly, after measles vaccination,
oral paracetamol in the same dose started on the

Page 236
30. ACUTE NEPHRITIS

1. Introduction:
It follows streptococcal infection of throat or skin by 1-2 weeks. Glomerular injury will clinically present as acute
nephritis In majority of pediatric patients it is PSGN Age group 3-12 years. Disease is self-limiting and generally
resolves in one moth; however, microscopic urinary changes may perists up to one year.

2. Signs &Symptons:
Hematuria, Oedema, Hypertension, Varying degree of oliguria or anuria May present with CCF Many primary or
secondary Glomerular diseases will present as acute Nephritis.

3. Lab Investigations:
3.1 Urine exam: RBCs, RBC casts, significant proteinuria2+/3+
3.2 ASO titre increases
3.3 Chest X-ray:
Cardiomegaly, Pulmonary vascular congestion, Effusion
3.4 Hemogram: Normocytic normochromic anaemia
3.5 BUL, SerCreatinine raised

4. Complication:
Congestive heart failure, encephalopathy may occur in a few patients.

5. Treatment
5.1 Diet-Proteins,
Sodium, potassium should be restricted. Urine output should be measured accurately.

5.2 Daily monitoring of weight.


Protein restriction up to 0.6mg/kg/day

5.3 Drugs:
Oral Penicilline 25000-50000u/kg/Day OR
Inj Penicliilne 25000-50000 u/kg/Day im/iv in 4 divided doses x 7 days
OR
5.4 Erythromycin 40mg/kg/dayin 4 divided doses X 7 days
5.5 Diuretics: Frusemide1-2mg/kg/day in 1-2 divided doses
5.6 Antihypertensives: Nifidepine 1 to 2 mg per kg/ Atenolol 0.08 mg per kg/Enalapril 50 mg per day
5.7 Rest

6. Refer patient to higher center


CCF
Uncontrolled HTN or its complications

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31. NEPHROTIC SYNDROME
Serum cholesterol raised

1. Introduction: 4. Management
Nephrotic syndrome ischaracterized by massive 4.1 1st Episode
proteinuria, hypoalbuminemia and edema.
Hyperlipidemia is usually associated; hematuria, The child should receive a high protein diet no extra
hypertension and impaired renal function are salt is given.
occasionally seen.
Prednisolone (2mg/kg/Day)in 2-3 divided doses
More than 90% of childhood nephrotic syndrome is along with antacid Given till patient goes into
primary (idiopathic). Other causes are amyloidosis, remission(Urine Albumin 1+/absent for 5 days)
vasculitis, SLE; post-infectious GN and hepatitis B
OR up to 8 weeks and then tapered to
nephropathy.Nephrotic syndrome in children can be
2mg/kg/alternate day x3-6 months and then stopped
divided into two groups based on renal histological
characteristics: Ideal calculation 60mg/m2 BSA
i)Minimal change nephritic syndrome(MCNS).
4.2 Relapse:
This is usually sensitive to steroids with a
satisfactory long-term outcome. Urine Albumin 2+ >5 days / oedema

ii) Nephrotic syndrome with significant lesions. Sometimes resolves in a week if precipitated by
infection, then infection is treated. If not resolved
It is usually associated with less satisfactory continue Prednisolone 2mg/kg/day in 2-3 doses till
course, tends to be steroid resistant and a significant urine is protein free for 5 days then taper alternate
proportion progress to chronic renal failure. day x 4 week and then stop

General care
2. Clinical Features:
Ca++ & K+ supplement if on frusemide
The onset is insidious with edema first noticed
around the eyes and subsequently around the Frusemide1-2mg/kg/day for edema with expert
legs.Gradually edema may become generalized, advise
with ascites, hydrothorax and hydrocele. A severe
muscle wasting is seen. It is a triad of 4.3 Treatment of frequent
hypoproteinemia, hypercholesterolemia and
proteinuria.
relapses:
i) Long term alternate day prednisolone. Following
3. Investigations: completion of treatment for relapse, alternate day
prednisolone is slowly taoered to minimum
Urine >3+ proteinuria maintenance dose (0.3 0.7mg/kg). The dose is
maintained for 9-12 months.
No RBCs/ Casts
ii) Levamisole: After inducing a remission,
Azotemia not significant
levamisole is administered at a dose of 2-2.5 mg/kg
on alternate days. Alternate day prednisolone is
given in decreasing doses, until a dose of 0.3-
0.5mg/kg is reached, for 2-3 months.

Serum proteins< 3.2gm/dL Cyclophosphamide and cyclosporine A are used in


some cases.
Page 238
Persistence of Hypertension /azotemia/ Hematuria
5. Refer to higher center
Steroid dependent or resistant or frequent relapse
For confirmation of diagnosis

Systemic features: arthritis/ Rash /


Hepatospleenomegaly

Page 239
32. CONGESTIVE HEART FAILURE (CHF)

1. Rheumatic fever and RHD


Introduction:
Every Cardiac patient has potential to develop CHF. 2. CHD complicated by anemia infection
It is not a diagnosis; it is a clinical syndrome due to
an underlying anatomical or pathological cause 3. Hypertension
which is the primary diagnosis.
4. Mycarditis
Definition:
5. Upper respiratory obstruction.
Congestive cardiac failure is defined as inability of
the heart to maintain an output, at rest or during Symptoms:
stress , necessary for the metabolic needs of the
body(systolic failure) and inability to receive blood Slow weight gain, easy fatiguiability, persistant
into the ventricular cavities at low pressure during horse crying, wheezing, excessive perspiration,
diastolic(diastolic failure) . puffiness of face, edema.

Signs:
Etiology
The causes of diastolic failure are given below: Left sided failure is indicated by tachypnea and
i) Mitral or tricuspid stenosis. tachycardia, Persistant cough, wheezing, crepts in
the chest.Right sided failure signs are hepatomegaly,
ii)Constrictive pericarditis
facial edema, edema on feet.
iii)Restrictive cardiomyopathy
Treatment:
iv)Acute volume over load (acute aortic or mitral
regurgitation) It is based on following principles:
v)Myocardial ischemia i)Reducing cardiac work.
vi)Marked ventricular hypertrophy
ii)Augmenting myocardial contractility.
vii)Dilated cardiomyopathy
iii)Improving cardiac performance by reducing the
The causes of systolic failure or mixed systolic
heart size.
diastolic failure can be divided into two groups
according to age (refer to causes of CCF below). iv)Correcting the underlying cause.
The commonest cause of CCF in infants is
congenital heart disease, whereas in the older Control of excessive salt and water retention with
children it is rheumatic fever and rheumatic heart diuretics. Improve cardiac contractility with
disease. digoxin. Prevent and reverse neurohormonal
changes that lead to progressive worsening of
Causes of Congestive Cardiac Failure cardiac status with beta blockers, ACE inhibitors.

Infants: Digoxin
Drug of choice in chronic CHF with atrial
1. Congenital heart disease fibrillation

2. Myocarditis and primary myocardial disease In CHF with sinus rhythm it gives
symptomaticbenefit
3. Paroxysmal tachycardia Dose
Total digitalizing dose in children 30 - 40 mcg/kg
4. Anemia the total dose stat: after 8 hrs; after 16 hrs Daily
maintenance dose of total digitalizing dose. Once
Children in day or two divided doses.

Page 240
Note: Enalapril: 0.1 mg/kg/dose oral every 12 - 24 hourly
Hypokalemia may aggravate digitalis toxicity upto 0.5 mg/kg/day or
especially with concomitant diuretic administration.
-blockers is an integral part of congestive heart
Use oral Kcl supplement or use potassium sparing
failure therapy nowadays.
diuretics such as spironolactone.
Metaprolol or carvedilol is also used
Oral Diuretics Diet Calories
Frusemide: 1 - 2 mg/kg/day or Recommended daily dietary allowance plus 20 -
30% in shunt lesions Avoid salty foods and
Hydrochlorothiazide: 1 - 1.5 mg/kg/dose every 12 -
additional salt in cooking Iron supplementation
24 hours or
When to refer
Spironolactone: 1 - 2 mg/kg/day
Severe respiratory distress
ACE inhibitors
Acute pulmonary oedema
Indicate for all patients with congestive heart
failure. Refractory CCF
Captopril: 0.1 to 0.5 mg/kg/dose oral every 8 to 12 Cardiogenic shock
hourly upto 4 mg/kg/day or

Page 241
33. PICA

1. Introduction: 3. Treatment
Pica involves repeated and chronic ingestion of non- - Pica below two years does not need any
nutrient substances including mud, plaster, paint, intervention.
earth, clay, etc. Children with PICA usually have
- Children with pica are at increased risk of lead
history of neonatal insults. Most of the time, it is
poisoning, iron deficiency, and parasitic
self-limiting and represents manifestations of family
infections. They should be investigated for
disorganization, poor supervision, and affectional
these problems and if present, treated suitably.
neglect. Testing or mouthing of strange objects is
normal in infant and children up to age of 2 years. - Education, guidance and counselling of the
Common in children from lower socieoeconomic family.
strata and at times in the malnourished and mentally
- The child has to be kept occupied in other tasks
subnormal children.
and provided with the environmental
stimulation.
2. Signs &Symptoms:
Pallor and chronic abdominal pain are main
complaints.

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34. NOCTURNAL ENURESIS

1. Introduction: Rule out organic causes. Restrict fluid intake in


Enuresis is defined as normal nearly complete the evening.
evacuation of the bladder at a wrong place and time Bladder exercises:
at least twice a month after the fifth year of life.
Bedwetting at night is known as nocturnal (i) Hold urine as long as possible during the day.
enuresis.Enuresis may be primary or secondary: (ii) Practice repeated starting and stopping the
stream at the toilet bowl.
2. Primary enuresis: (iii) Emotional supportto child.
Repeated passage of urine into clothes/bed during
night in a child more than 5 years of age. Most (iv) Behaviour modification- Child should not be
common cause in primary enuresis is inappropriate given liquids after meal in the evening. Practice
toilet training. Other causes could be genetic, sleep getting up from bed and going to the bathroom at
disorder, reduced ADH at night. In some cases there bedtime before sleep.
may be organic etiology such as obstructive
uropathy or UT. There may be associated with (v) Alarm device- alarm device is used to elicit a
mental retardation or spinal cord abnormalities. conditioned response of awakening to the sensation
of a full bladder.
3. Secondary enuresis: 6.2. Pharmacological
The child has been dry for several months and again Indicated only in children > 6 years where sufficient
starts bedwetting. Too enthusiastic and immature trial of non pharmacological management has failed
toilet training, emotional stress, parent child with following:
maladjustment, urinary tract infections, diabetes
mellitus or diabetes insipidus. can cause secondary Tab. Imipramine: (0.9-1.5 mg/kg/day/PO) 6-8 year
enuresis. (25 mg), 9-12 year (50 mg), >12 year (75 mg) once
a day at bedtime. Success rate 30-60%, relapse rate
4. Signs &Symptoms: 90%. or
SALIENT FEATURES Tab. Desmopressin: 0.1-0.5 mg at bedtime.
Involuntary discharge of urine after the age at Or
which bladder control should have been
established (5 years). Desmopressin acetate (nasal spray, 10 mcg per
spray): Start with 10 mcg given at bedtime daily and
In primary nocturnal enuresis, child has never increase gradually by 10 mcg/per week to a
been dry at night while in secondary, child has maximum of 40 mcg per day. If effective, it should
been continent for at least 6 months before the be used for 3-6 months. Success rate is 40-60%,
child begins to wet again. relapse rate is 90%.
5. Investigations: (Caution: Not effectively absorbed in rhinorrhoea. If
Full medical history not used properly may cause hyponatraemia)
Genital and neurological examination 7. Referral
Urine for albumin, sugar, microscopy, specific
Refer the patient to a higher centre, if organic cause
gravity and culture.
is suspected or when
USG voiding cystourethrogram and Diagnosis is in doubt.
urodynamic studies.
8. Parent education
Reassure the parents that condition is self-limiting.
Ask the parents to maintain a diary record of dry
6. Treatment nights; reward the child for such nights. Avoid
6.1. Nonpharmacological punitive measures.
(Effective in 30% cases)

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35. THRUSH / CANDIDIASIS

1. Introduction:- 2. Salient Diagnostic Features:


Candida fungal infection in the oral cavity is Thick white patches on an angry red base in the
common and may be seen as early as 7_10 days mouth may spread to involve the lips, buccal
of age (peak 4th week of life). mucosa, tongue and palate.
After infancy it is usually secondary to Asymptornatic or may cause pain in the mouth,
treatment with broad-spectrum antibiotic. discomfort, anorexia and feeding difficulty.
Chronic or recurrent oral candidiasis is seen in Diagnosis is confirmed by the fact that on
children having immuno-deficiency. HIV removing the plaques, spots of bleeding are
AIDS, undergoing cancer therapy and in severe seen on the mucosal surface.
malnutrition. Avoid bottle feeding. Faulty sterilization of
Hypoparathyrodism, Addison's disease, bottle and nipple causes persistent or recurrent
autoimmune disorders are other rare causes. infections / thrush.

Fig. 1: Candidiasis / oral thrush.

In resistant/ chronic cases (patients with major


3. Treatment: underlying disease)

Drugs Tab. Fluconazole 3-6 mg/kg once daily for 5-7


days.
In case of breast fed baby, the medicine has to be
applied to mothers nipples also to prevent cross / Prevention:
re-infection. Emphasize on avoiding bottle feeding
3.1 clotrimazole 1% cream, gel or lotion, oral /bottle hygiene, care/ hygiene of the nipple and
application 3-4 times/day after feeding for 5-7 treatment of vaginal candidiasis in expectant
days (or 1-2 days beyond recovery). mother.
Or
Gentian violet 1% aqueous solution, 1-2 times a
day, for 5-7 days (can stain tissues and clothes).

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36. CONGENITAL HYPOTHYROIDIM

Aim: to normalize serum T4, avoid


1. Introduction: hyperthyroidism,promote normal growth and
It may be familial or sporadic, goitrous or development
nongoitrious. In about 85% cases the etiology is
dysgenesis. All new born babies should be screened.
4.3 Repeat T4 and TSH at 2 and 4
2. Signs &Symptons: weeks after initiation of
At birth hypothermia/bradycardia, shock therapy.
Develop with passage of time
Large tongue After one year tests to be done 1-2 monthly
Hoarse cry
Facial Puffiness Between 1 and 3 years do tests 2 to 3 monthly
Umbilical Hernia
Hypotonia Over 3 years do tests yearly till growth is complete
Mottling
Cold hands and feet
Lethargy
ProlongedUnconjugated Hyperbilirubinemia
Constipation
Hypothermia
Large Anterior fontanelle
Posterior fontanellemore than 0.5 cm

3. Investigation:
TSH level should be estimated after 72 hours of life
if TSH is more than 20 mu / L then
Hypothyroidism is considered and Eltroxin should
be started.
Second screening at 2 to 6 weeks (routinely in
VLBW and NICU graduates)

4 Treatment of Congenital
Hypothyroidism
As soon as possible diagnosis.

4.1 Counseling of Parents

4.2 Eltroxin 10-15 microgram/kg---


start higher dose
Do NOT use liquid preparation

On above dose, T4 Normalises in 1 weekand TSH in


one month

Page 245
37. URINARY TRACT INFECTION (UTI)

indicate significant bacteriuria. Presence of any


1. Introduction : bacteriuria in suprapubic specimenis significant. For
the purpose of management UTI is divided into
Approximately 8% of girls and 1 - 2% of boys are complicated and uncomplicated UTI.
likely to get UTI during childhood. A significant
proportion of children less than 2 years developing
UTI have underlying urinarytract anomalies, most
5. Complicated UTI
Temperature > 39C, persistent vomiting, renal
often vesico ureteric reflux (VUR). UTI in a setting of
angle tenderness and systemic toxicity are featuresof
VUR may lead to renal scarring, an important cause of
complicated UTI Infants below 3 months of age and
chronic renal disease. Early recognition and treatment
those with complicated UTI should receive parenteral
of UTI and urinary anomalies is essential to
antibiotics initially.
preventsuch complications.

2. Signs & Symptoms 6. Treatment


2.1 Neonates 6.1 In young infants (< 3 months) entire treatment is
Sepsis like features with fever or hypothermia, parenteral
lethargy, poor feeding, poor weight gain, aundice and
shock; urinary symptoms may be absent.Infants and 1. Cefotaxime 100 - 150 mg/kg/day in 3 div doses, or
children below 2 yearsUnexplained fever; urinary 2. Ceftriaxone 75 mg/kg/day in 1-2 doses, or
symptoms minimal or absent.
3. Gentamycin 5 - 7.5 mg/kg/day single dose, or
2.2 Adolescents 4. Amikacin 15 - 20 mg/kg/day single dose, or
Mostly related to lower urinary tract such as dysuria,
frequency, urgency and suprapubicpain. Renal In young infants (< 3 months) entire treatment is
parenchymal involvement is indicated by high fever, parenteral
chills, rigors and flankpain.
6.2 For older children, after first 2 - 3 days, oral
antibiotics may be started based on
3. Investigations: antimicrobialsensitivity Total duration of treatment is
3.1 Urine analysis 10 - 14 days.
May suggest UTI in the form of increased leukocytes
in urine. Gram stain of centrifugedurine specimen may Oral antibiotics
show bacteria.Dipstick for nitrite reduction and Amoxicillin 20 - 40 mg/kg/day in 2 - 3 doses, or
leukocyte esterasemay help in rapid diagnosis.
Cefadroxil 30 mg/kg/day in 2 doses, or
3.2 Urine culture Cephalexin 50 mg/kg/day in 3 doses, or
This is the only confirmatory test for UTI. Every
effort must be made to properly collect and senda Cefixime 8 mg/kg/day in 2 doses, or
urine sample before antibiotic is started. In infants and
young children UTI should be suspected if there is Ciprofloxacin 10 - 20 mg/kg/day in 2 doses
unexplained fever.A midstream clean catch specimen
is ideal. Soap or antiseptic solution should not be used 7. Uncomplicated UTI
beforecollection. In infants urine can be obtained by Children > 3 months of age and those who do not have
suprapubic aspiration. features of complicated UTI can be treated withoral
amoxicillin (10 to 15 mg per kg) or cefadroxil (5 to
4. Common organisms 10 mg per kg) for 7 to 10 days (based on sensitivity).
Though fluoroquinolones are effective and safe for
responsible for UTI are UTI, they are not the first-line antibiotics
E. coli, Occasionally Klebsiella, Staph epidermidis or
Strep fecalis may be responsible.
A colony count of > 105 colony forming units (CFU)
/ ml of single species in a clean catchspecimen

Page 246
OBSTETRICS
AND
GYNAECOLOGY

Page 247
1.NORMAL PREGNANCY

Antenatal period is the most crucial period as the complications during after delivery (PPH,
services provided during this period can have positive Retained Placenta, Infection)
impact on health of both the mother and her child. Past history: Hypertension, Diabetes Mellitus,
Tuberculosis, Asthma, Heart disease, any other,
1. Essential obstetric care to surgical procedures undergone, medications
taken during pre conceptional period, history of
every pregnant woman bleeding.
Registration of all pregnant women before 12 H/O current symptoms, perception of fetal
weeks. movements if pregnancy> 16 weeks.

2. Detailed history at first visit 3. Schedule of Examination


Menstrual histor y: Regularity of cycles, date of Ideally all the ANCs should be examined monthly
LMP, calculate EDD and record on Mother after registration. If it is not possible to attend ANC
Child Protection (MCP) card clinic monthly, then checkup should be carried out at
Obstetric history:Number of prior pregnancies least five times during the pregnancy. First 8-12
and outcome of each pregnancy (full term birth, weeks, second between 14-20 weeks, third at 22-26
preterm birth, abortion), place and mode of weeks, fourth at 28-32 weeks and fifth at 36-40
delivery, weight of baby, Live birth/stillbirth, weeks.

Table 1: Examination at antenatal clinic


*Height *Breast examination
*Weight : Compare with previous visit (calculate *Systemic examination : Auscultate chest
BMI in first trimester)

*Pallor, icterus *P/A: Fundal height & its correlation with period of
amenorrhoea (POA)
*Edema over feet, hands, face *Fetal presentation and position after 32 weeks
*Blood pressure *Fetal heart rate

* During first check up


The last two visits are important as many of the Medical officer should perform at least one
pregnancy complications are detected during last checkup during the third trimester and auscultate
trimester. For 'high risk' mothers more frequent her chest to r ule out any systemic abnor mality.
examinations will be required.

Page 248
4. Investigations
Table 2:
Hemoglobin estimation VDRL
Urine Analysis: Protein and s ugar Voluntary HIV testing
Test for sickling in selected tribal area Blood sugar testing
Blood grouping, Rh typing Hepatitis B surface antigen (HBsAg)
Ultrasonography (16 to 18 weeks) Malarial parasite in Ende mic area.

5. Examination and action to be taken during ANC check up


Table 3:

Examination Action

Ede ma Examine whether ede ma is on one leg or both legs and is it pitting. Look for
edema over face, hands, and abdomen. Check for proteinuria and
hypertension.
High blood pressure and albuminuria, refer to specialist as she has pre-
eclampsia.
History of kidney disease, if yes refer to specialist.
If edema is on one leg, refer to specialist.
If bilateral pedal edema without albuminuria and normal BP: Reassure
mother, c heck for anemia and give IFA tablets as required

Weight gain Record monthly weight on MCP card of mother, calculate weight gain since
the previous visit
Weight gain more than 3 kg. in a month: Suspect pre-eclampsia
Weight gain less than 1 kg. in a month: Suspect fetal growth retardation.

Blood Pressure If 140 / 90 mm Hg or more, advise mother to rest for half hour and then
repeat the BP recording. Check for proteinuria
If systolic between 140-160 and /or diastolic 90 or above: advise extra rest
and refer to MO PHC
If systolic 160 or more or diastolic > 100 : refer to specialist

Fundal Height Examine fundal height in weeks and compare with calculated duration of
pregnancy as per LMP. If it is greater or lesser refer to specialist. Causes of fundal
height less or more than expected are given in table below.

Fetal Presentation Noncephalic (correction can be attempted at 36 weeks in suitable cases)


byObs/Gyn specialist.

Fetal Heart Rate FHR < 120 or > 160 /minute : Refer to specialist.

Hemoglobi n % Hb 11 gm% or more: IFA 100 tablets


Hb between 7-11 gram%: Start IFA double dose* and re-examine after one month
- If improvement of Hb by more than 1gm%, continue IFA. Give tab

Page 249
Examination Action
Albendazole(during second trimester)
Hb< 7 gm % - Refer anemia treatment guidelines

Proteinuria If proteinuria present suspect pre-eclampsia and refer to specialist.

Risk factors All high-risk pregnancies should be checked by MO and then referred to specialist
if necessary for further checkup or during delivery depending upon the risk factor.

* For better absorption, IFA tablets should be taken 1.30 hours before meals
Table 4:
Fundal height < Period of Amenorrhea Fundal height > Period of Amenorrhea
Wrong dates Wrong dates
Infrequent periods prior to conception Poly hydramnios
Intrauterine Growth retardation(IUGR) Twins
Oligohydramnios Big baby
Intrauterine fetal death. Hydatidiform mole
Uterine fibroids

discharge per vaginum, blurred vision, excessive


6. Education and counseling vomiting, reduced fetal movements.
regarding care during Consumption of iron folic acid 100 tablets for
anemia prophylaxis.
pregnancy Tetanus Toxoid 2 doses/booster dose.
Calcium through diet and Calcium carbonate
6.1. First and second trimester: tablets 1.2 Gm daily.
Diet: More than one meal a day and evening
snacks (mos t impor tant), inclusion of sprouted 6.2. Third trimester:
legumes, pulses, green leafy and other Avoid heavy work and jerky travel on bad roads.
vegetables, seasonal fruits.
Importance of institutional delivery, safe
Rest: 2 Hours in afternoon and 8 hours at night delivery, inform TOLL free No.102 and 108 for
in lateral position. free ambulance service, JSY, JSSK and other
Exercise: Walking for 30 minutes daily. benefits, Plan for place of delivery, preparation
Habits: Avoid tobacco in any form, avoid for delivery.
alcohol. Importance of early initiation of colostrum
Practicing safe sex. feeding within Half an hour of birth & exclusive
Self-reporting of danger signals, e.g.Abdominal breast-feeding for 6 months, child immunization
pain, severe headache, giddiness, palpitations, and contraception especially PPIUCD.
easy fatigability, breathlessness, fever, Ask about birth companion.
generalized edema, vaginal bleeding, watery

Page 250
1. Identify high-risk mothers:
Table 5:

Risk factors detectable during Abnormalities developing during


first check up Current pregnancy

Age : Teenage/ elderly primi, Anemia


Para 4 and above Hypertension, proteinuria
Short stature, limping gait, vertebral spine Vaginal bleeding during pregnancy
abnormalities
Premature rupture of membranes (PROM)
Bad obstetric history: H/O stillbirth, neonatal
death, LBW baby, recurrent abortions Gestational diabetes mellitus (GDM)
Fundal height < POA or > POA
Previous Caesarean delivery
H/O PE/eclampsia, PPH, retained placenta Uterus over distension: Twins,
Polyhydramnios
during previous pregnancies
Fetal malpresentation persisting near term
Preexisting medical conditions : Heart
disease, diabetes mellitus, renal disease Pregnancy > 41 w eeks
HIV /VDRL positive gravida Reduced fetal movements
Rh negative gravida

2. Actions sugge sted for some high risk indicators:

Table 6:
RISKS ACTION
1. Elderly Primi
Hypertension during pregnancy Refer to specialist soon after registration for evaluations to
exclude fetal anomalies (biochemical markers and
Gestational diabetes ultrasonography)
Difficult labour - Chances of Regular ANC: B.P, urine analysis every month
caesarean section are higher
Pelvic assessment at or after 36 weeks.
Fetal abnormalities.
Institutional delivery under care of specialist.
2. Teenage primi

Hypertension during pregnancy Regular antenatal care


Anemia Hb%, BP, urine analysis more frequently
Pre-term labour Adequate rest
Fetal growth retardation. IFA tablets, nutrition guidance
Difficult labour Pelvic assessment at 36 weeks
Hospital delivery.
3. Primi : Height less than 145 cms Regular ANC check. Assessment of place of delivery by

Page 251
RISKS ACTION
specialist. Observe progress of labourpartographically.
4.Primi having vertebral /limb deformity Regular check up at PHC, Assessment by specialist for place of
delivery.
5. Grand multipara (para 4 and more)
Anemia Supplement IFA, nutrition guidance
Malpresentation At 34 and 36 weeks look for fetal malpresentation
Atonic PPH Hospital delivery - Avoid Injudicious use of oxytocics for
augmenting labour
Uterine rupture
Active management of 3rd stage of labour - Keep IV line
ready

Page 252
2.NORMAL LABOUR
1. Pelvic Assessment
Table 1:

Parameter Adequate Suggestive of abnormality


Sacral promontory Not felt Felt easily
Diagonal Conjugate* >11.5 cms < 11.5 cms
Sacral curvature Well curved Flat
Lateral Pelvic walls Parallel Converging
Ischial spines Both cannot be palpated simultaneously Both spines can be palpated
simultaneously
Subpubic Angle Accommodates two fingers (850) Acute
Inter tuberous diameter Accommodates closed fist (4 Knuckles) Cannot accommodate 4 knuckles
* If sacral promontory is felt, the distance between the sacral promontory and the lower border of pubic symphysis
is measured.

Push the head into the pelvic inlet and note


2. Clinical Examination for whether it descends into the pelvis (felt by
CPD fingers in vagina) or overhangs on the public
symphysis.
Place the woman in dorsal position. If head descends with no overlap at public
Hold the fetal head by left hand. symphysis: No inlet CPD.
Place two fingers of gloved right hand into the If the head is engaged it indicates that the pelvic
vagina at the level of ischial spines. inlet is adequate.
Place the thumb of right hand on the pubic Get urine sample tested for protein, sugar and note
symphysis. volume.
3. Monitoring during active phase
Table 2:

Examination / Observation Periodicity

Maternal pulse and FHR Every 30 minutes

Uterine contractions Every 30 minutes

Maternal temperature, BP, urine volume Every four hours

Vaginal Examination Every four hours

Note the time of rupture of membranes and To assess cervical dilatation, station and position
perform va ginal examination immediately of vertex.
To rule out cord prolapse and see the color of Assess and monitor the progress of LABOUR by
liquor. using Simplified Partograph adopted by GOI to

Page 253
record FHR, liquor, cervical dilatation, uterine a) First stage of labour showing satisfactory
contractions, medications administered during labour, progress: Continue observation till second stage
maternal pulse, blood pressure and temperature. starts.
b) Second stage of Labour:
Points to Reme mber
Cervix is fully dilated.
This graph is used only during active phase of Signs of imminent delivery: Mother starts
labour. pushing (bearing down). Fetal scalp seen at
The complications requiring immediate vulva, perineum bulges, anus gapes. Mother gets
interve ntion need to be excluded first. sensation of defecation.
Encourage the mother to push only during
3.1. Partograph contraction.
On this graph, one square represents one hour on Monitor progress and fetal wellbeing during
horizontal axis. On vertical axis, one square second stage.
represents cervical dilation of one centimeter. Note FHR every 15 minutes.
Assess descent of presenting part (fetal station)
3.1.1 Phases of first stage and alert and action every 15 min.
line: Look for caput, molding, meconium staining of
Latent phase: Cervix dilates very slowly up to 4 liquor.
centimeters. It may take up to eight hours for Suppor t the perineum and de liver the head gently
this. Deliver the shoulders
Active phase: 4 cm onwards; cervix dilates Keep the baby on mothers abdomen on a pre-
rapidly at the rate of about 1 centimeter per hour. warmed towel and give immediate care.
Alert Line: An obl ique line on the graph from 4 Conduct delivery. Follow universal bio safety
to 10 centimeters progressing at the rate of 1 precautions.
centimeter per hour.
Delivery of baby takes place usually within 30
Action Line: Parallel line Four hours to the right minutes in a multi and 60 minutes in a primi
of alert line para.
Give mediolateral episiotomy under local
3.1.2 Recording o n partog raph: infiltration anesthesia by Injecting 1%
Initiate recording when cervix is 4 cm dilated lignocaine, if mother is unable to push or if there
and immediately if the cevix is > 4 cm dilated on is undue delay.
admission to the Labo ur ward.
Record the dilatation in cm (symbol x) on the
alert line and record the time at which c) Third stage of Labour: Deliver the placenta by
observation has been made on the horizontal axis active management of third stage of LABOUR
below this point.
Perfor m vaginal examination every 4 hours and 4. Active Management of Third
note the cervical dilatation and mark it on the Stage of labour (AMTSL)
graph.
Join the points and interpret the observations. Active management of 3 rd stage of LABOUR reduces
the amount of blood loss due to uterine atony,
3.1.3 Interpretation: reduces the chances of having atonic PPH and
Satisfactory progress: Cervical dilatation lies requirement of blood transfusion significantly
on left side of alert line, active phase progression thereby helping to reduce maternal mortality due to
> 1 cm/ hour, Fetal and maternal health severe PPH.
parameters are normal. It is an integral part of skilled attenda nce at birth and
Slow progress: Alert line crossed, careful is mandatory for all deliveries (vaginal and
monitoring to note the progress. At subcentre abdominal). The steps are as follows:
and PHC the arrangements for referral to FRU.
Action line reached or crossed: Careful review After the childbirth, exclude presence of another
to find the cause for delay followed by baby by abdominal palpation
appropriate interventions. Give Inj. oxytocin 10 IU IM. immediately after
birth (Oxytocin should be kept in refrigerator).
When oxytocin is unavailable, tabletmisoprostol
600 mcg (3 tablets) may be given orally.

Page 254
Check for uterine contraction. traction by other hand pushing the uterus
Clamp and cut the cord. upwards towards umbilicus. Repeat this during
Deliver the placenta by controlled cord traction. contraction as required.
When the uterus is well contracted , give gentle After delivery of placenta, give uterine massage
downward traction on cord while giving counter to keep the uterus contracted.

Figure 1: Controlled Cord Traction

If vertex is engaged and cervix is well applied to


5. After delivery the vertex then controlled ARM can be
performed to hasten the progress.
Examine the perineum, vulva, lower vagina for
tears. After ARM review progress after two hours. If
progress is still slow, assess uterine contractions.
Examine the placenta and membranes carefully
If uterine contractions are infrequent and weak
for completeness and any abnormality.
then consider oxytocin augmentationafter
Observe the mother every 15 minutes for two excludi ng contraindications.
hours for general condition, pulse, vaginal
If there is no progress after augmentation or if
bleeding, pallor, uterine contraction.
signs of fetal distress develop, an emergency
Repeat uterine massage every 15 minutes for 2 caesarean section might be required. Hence such
hours. a woman should be referred to a well-equipped
Encourage mother to take the baby to breast maternity unit.
within hour of delivery.

6.2.Oxytocin Augmentation: (only


6. Augmentation of Labour where specialist is available)
6.1. Care of woman showing slow Exclude contraindications before starting oxytocin
/unsatisfactory progress of
Labour CPD, Fetal distress
Grandmultiparity, Malpresentations, Scar on the
Alert line crossed or the action line reached uterus
Causes: Hypotonic uterine action, occipito
posterior position, deflexed head, CPD etc. Refer 6.2.1 Dose and Administration
the case to higher level of care.
Add 2.5 IU to 500 ml of normal saline or
Labo uraugmentation by amniotomy (artificial Ringers lactate. Start infusion at the rate of 8-10
rupture of membranes) and oxytocin infusion are drops/min. Observe uterine contractions.
offered as per the clinical situation. If contractions are mild increase the drip rate by
Labo uraugmentation should be done in places 8-10 drops /min every 30 min until she gets 3
where clinical expertise and facilities for contractions in 10 minutes, each contraction lasts
operative delivery are available.

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for 40-45 seconds and there is good relaxation of Discontinue the drip
uterus in between the contractions (optimum Maternal repositioning (left lateral position),
response). Oxygen therapy
Drip rate can be increased maximum up to 60 Terbutaline 250 mcg can be given IV slowly for
drops/minutes. If the contractions are inadequate tocolysis if required
at this rate, prepare another drip with 5 IU /500
ml and start it at the rate of 30 drops/min, Caution:
increase by 5 drops every 30 minutes and
observe the response
For augmentation of Labour oxytocin should
never be give n intramuscularly.
6.2.2 Monitoring:Monitorfollowing parameters
Cautious use in multiparous women as the uterus
every 15 minutes,
tends to rupture.

Drip rate, Uterine contractions frequency and 6.2.5 When to discontinue the drip:
intensity
FHR and Maternal pulse
If six hours of strong stimulated uterine activity
Progress of labour
is unable to bring progress of labour, discontinue
the drip and review the case.
6.2.3 Complications: If there are signs suggestive of fetal distress.
If after initial satisfactory progress, cervical
Hyperstimulation : > 5 uterine contractions / 10 dilatation does not progress for two hours or
minutes, each lasting for > 60 sec more in established active phase of Labo ur then
Uterus failing to relax between the contractions review her. This could be due to cephelo-pelvic
Fetal bradycardia (distress) disproportion or large head with deflexion. Such
Uterine rupture if drip is not supervised patient may need operative intervention.
vigilantly.
Water intoxication if too much of electrolyte free Prolonged second stage
infusion is administered. If second stage is prolonged for more than 2 hours in
Neonatal hyperbilirubinaemia primi and for > 1 hour in multi, then
Assess size of baby and pelvis again.
6.2.4 Treatment of Hyperstimulation: See whether fetal head is still palpable in
suprapubic region.

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3. CLINICAL CARE OF HIGH RISK
PREGNANCY
Common Risk Indicators: 1.1.3 Risk Factors:

Bad obstetric history: Previous history of pre- Risk is highest among couples where the age of
term Labo ur, stillbirth, early neonatal death, woman is 35 years.
recurrent pregnancy loss. The risk increases after each successive
Post caesarean pregnancy. pregnancy loss, reaching approximately 40%
Vaginal bleeding during pregnancy. after three consecutive pregnancy losses.
Rh negative pregnant woman , husband Rh +ve
Fetal malpresentation (Breech/transverse lie) 1.1.4 History:
persisting at 36 weeks.
Diagnosed twins, polyhydramnios. Detailed obstetric history about each pregnancy.
Pregnancy be yond 41 w eeks. Duration of pregnancy at mishap. Whether USG
documented cardiac activity was seen, fetus was
Medical diseases: Anemia, diabetes mellitus,
live born/stillborn ( fresh/macerated stillbirth),
cardiac disease, chronic hypertension, kidney
baby normal/abnormal.
disease, tuberculosis.
H/O Consanguinity, history of infertility,
Refer to other high risk indicators mentioned in
menstrual abnormality, infections, STD.
earlier chapter.
Personal history: Tobacco, alcohol, caffeine,
1. Bad Obstetric History medications.
Personal/familial H/O thrombosis, autoimmune
Bad obstetric history is a term used in day to day disorder.
practice for describing unsuccessful pregnancy
outcome in previous pregnancies. A variety of 1.1.5 Physical examination:
unsuccessful outcomes are included in this such as a) Look for obesity, hirsutism, acanthosis, thyroid
previous H/O stillbirth, preterm delivery, recurrent enlargement, galactorrhoea
midtrimester/early abortions. b) P/S & P/V examination: Look for uterine
fibroids, double uterus, bicornuate uterus, genital
1.1. Recurrent Pregnancy Loss infection, torn or short cervix
(RPL) c) Investigations: Carry out the relevant
investigations as indicated and available
1.1.1 Definition:Three or more consecutive depending on whether the woman has presented
pregnancy losses during pregnancy or after the mishap.
d) During pregnancy:
1.1.2 Causes: Hematology, blood group and Rh typing, VDRL
Urine analysis
Genetic Rule out diabetes
Environmental and occupational exposure to Antiphospholipid antibody testing
organic solvents, ionizing radiation, toxins, USG: For uterine abnormalities, Monitoring
tobacco, alcohol early pregnancy
Uterine anomalies, Cervical incompetence, Thyroid function, Prolactin
Uterine synechiae (adhesions), Uterine fibroids
Infections e) Non pregnant state:
Endoc rine Dysfunction: Polycystic ovary Pelvic USG for polycystic ovaries (PCOS),
syndrome (PCOS), Luteal phase inadequacy Hysterosalpingography(HSG), Hysteroscopy for
(LPI), Diabetes mellitus, Thyroid dysfunction, uterine abnormalities
Prolactin disorders. Parental karyotype
Antiphospholipid antibody syndrome (APLAS) Mid luteal serum progesterone and
Unexplained: In some cases no cause can be thrombophilia profile if available
detected. f) Soon after miscarriage:Chromosomal studies of
conceptus

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1.1.6 General Measures:
3. Infections
Quitting cigarette smoking, tobacco, alcohol and Generally cause sporadic pregnancy loss.
caffeine consumption Toxoplasmosis, rubella, cytomegalovirus, herpes and
Weight reduction in PCOS cases listeria infections do not cause recurrent pregnancy
Therapies depending upon cause. loss and routine TORCH screening is not indicated.
Psychological counseling & support is extremely Active syphilis during pregnancy can lead to
helpful. recurrent pregnancy loss.
50% Success even if no treatment is given.
3.1. Syphilis during pregnancy
Some common conditions are as follows:
3.1.1 Effects: Late abortions, stillbirths, neonatal
deaths, infant having active congenital
2. Cervical incompetence syphilis.
Premature softening and dilatation of internal 3.1.2 Diagnosis is serological: VDRL at booking.
cervical os during pregnancy can lead to Note titers, titers 1:8 or more are significant.
protrusion of membranes, rupture of membranes Treponemal test (TPHA) is confirmatory.
and fetal expulsion during second trimester or 3.1.3 Treatment: Treatment of maternal disease
early third trimester can prevent fetal infection and also treat
Typical obstetric history is diagnostic: Repeated established fetal disease
midtrimester or early third trimester pregnancy Benzathine penicillin single Injection 2.4 Mega
terminations, relatively painless, rapid, often units deep IM after sensitivity test as Penicillin is
preceded by rupture of membranes followed by the only antibiotic that can cross the placenta in
expulsion of fresh or live fetus adequate amounts to treat the fetus.
Symptoms : Low backache, mucoid vaginal For latent disease > 1 year duration, 3 Injections
discharge at weekly interval.
P/S: Bag of membranes may be seen through the Penicillin sensitive individuals require
cervical os desensitization.
Vaginal examination: Internal cervical os dilated Erythromycin 2 gms daily in divided doses for
in absence of uterine contractions, cervix may be 14 days can be considered however Penicillin is
short. more effective.
Infant of a VDRL positive mother needs care by
specialist.
2.1 Investigation: Safe sex counseling.
USG may show short cervix, funneling of
cervix, membranes dipping into the cervical 4. Hypothyroidism
canal.
USG assessment of cervical length (25mm or Hypothyroidism can be due to iodine deficiency
less) bytransvaginal scan before 24 weeks in or thyroid autoantibodies.
women having previous history of preterm Infertility, menstrual problems due to Ovulation
LABOUR is considered significant for disturbances.
prediction of preterm LABOUR. Increased risk of miscarriage due to luteal phase
insufficiency.
2.2 Treatment: PHC: Anemia, gestational hypertension, placental
Refer the case to specialist soon after abruption and postpartum hemorrhage are
registration. common.
At RH/DH:Prophylactic cervicalos tightening at Fetal/neonatal problems: Preterm birth, low birth
16 weeks by McDonald method under short weight, congenital malfor mations, neonatal
general anesthesia. respiratory distress, perinatal death. Cretinism.
Follow up: Extra rest, avoid exertion. TSH. If elevated thyroid function tests and
Stitch removal at 37 weeks or at the onset of antibod y testing.
LABOUR whichever is earlier. Anticipate rapid Treatment by thyroxine can correct ovulatory
delivery. dysfunction and help achieving pregnancy and
successful outcome.

Page 258
Counsel pregnant women for consumption of should be followed by administration of anti D
iodized salt. immunoglobulin.
Targeted case finding approach is followed. It is recommended to give 300 mcg anti D
Universal TSH screening is currently not immuno globulin during pregnancy at 28 weeks
recommended. for reducing the risk of antepartum sensitization.
At delivery, cord blood sample to be tested for:
Infants Rh, ABO grouping, hemoglobi n and
5. Rh Negative Pregnant hematocrit.
Woman Direct Coombs test, Direct and indirect bilirubin
estimation.
A major cause of hemolytic disease of newborn Administration of 300 mcg of anti D Ig IM to
(HDN) is Rh blood group incompatibility between mother within 72 hours of delivery (earlier
the mother and her fetus. When Rh negative mother within 24 hours is still better). 300 mcg
bears Rh positive fetus, the Rh antigen from fetal red neutralizes 15 ml of fetoplacental hemorrhage
cells enters the maternal circulation and results in (FMH). If it has not been given within 72 hours,
antibody formation in mother. These antibodies cross should be given up to one week with some
the placenta and cause destruction of fetal red cells benefit.
resulting in fetal Anemia. Prevention of such The baby is referred to neonatology specialist
sensitization is pos sible by antenatal screening and and is observed for icterus, anemia.
appropriate care.
5.2.2 Sensitized woman:
5.1. Pregnancy outcome
If ICT is positive, it indicates that the woman is
First child usually escapes. Subsequent babies suffer sensitized and has got antibodies against Rh
from mild hemolytic anemia, rapidly increasing antigen in her blood. Note the titres reported.
hyperbilirubinemia within 24 hours of birth or There is no use of giving Anti D Ig to sensitized
hydrops fetalis resulting in intrauterine fetal death. mother.
The adverse perinatal outcome occurs earlier during Sensitized woman must be referred to a tertiary
pregnancy with each subsequent pregnancy. care centre having equipment and expertise for
cordocentesis and intravascular fetal transfusion.
5.2. Management
Every pregnant woman should be tested for Rh 6. Post Caesarean Pregnancy
typing at registration.
Those testing negative should have their Pregnancy with h/o previous caesarean section (CS)
husba nds Rh typi ng done. is a high risk condition as there is increased risk of
Take detailed histor y about every pregnancy and complications during childbirth after each caesarean
its outcome. H/O neonatal jaundice, hydrops, section (Scar rupture, placenta previa, adherent
stillbirths etc. placenta, PPH)
Note history of receiving anti D
immunoglobulin, time, dose during/following
every pregnancy.
Perform indirect Coombs test (ICT) on blood
sample to detect maternal sensitization.

5.2.1Nonsensitized woman:

Negative ICT indicates that the woman does not


have detectable antibodies against Rh antigens.
Refer her to gynecologist at FRU. ICT is
repeated monthly.
Do not perform external cephalic version for
malpresentations. Any episode of bleeding or
manipulation, procedure such as amniocentesis

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6.1 Risks
Table 1: Risk Factors

Maternal Fetal/neonatal

Scar dehiscence during Labour Fetal distress

Scar rupture leading to severe Fetal death due to scar


haemorrhage& shoc k rupture

Chances of repeat CS are high Neonatal asphyxia

All cases having CS in previous delivery should be Perform clinical pelvic assessment at or after 36
referred to specialist at FRU/district hospital during weeks.
third trimester. At 36 weeks she should have a
review by specialist regarding plan for delivery
either by repeat elective CS or trial for vaginal birth 6.4 Investigations
USG assessment of fetal weight, localization of
after CS which depends on indication of prior CS
placenta. Look for morbidly adherent placenta if
and assessment of scar integrity.
placenta previa.
6.2 History 6.5 Selection for Trial of Labour
Indication for CS, elective or emergency, when after caesarean section
in labour it was done.
Place and person operating , performed at term Indication for previous CS non recurrent (fetal
or preterm. distress, breech, placenta previa.)
Type of CS :Lower segment transverse incision Only one prior low transverse CS delivery. No
or classical . other uterine scars or previous rupture.
(Vertical scar is very weak having high chances Vertex presentation, Clinically adequate pelvis.
of scar rupture which is likely to happen during No other obstetric complication ( APH, breech
late pregnancy and during labour with increased presentation)
risk to the mother and fetus hence elective Surgeon, anesthetist immediately available for
caesarean section should be performed at term in emergency CS.
such cases)
Review operation notes regarding Repeat CS: Women not eligible for vaginal trial will
complications, inverted T extension of incision, need an elective repeat CS. which should be
lateral extension of tears, post-operative performed at 39 weeks for the best neonatal
infection, blood transfusion, prolonged hospital outcome, if there is no maternal or fetal indication to
stay. perform it earlier.
Inter pregnancy interval < 24 months increases
the risk.
All post caesarean pregnancies should only be
6.3 Examination managed in equipped hospitals with personnel
Anemia:Correction before term is important as readily available for emergency caesarean section
the chances of requiring repeat CS are high. when needed carefully selected women can be
Note the size of baby, presentation, presence of
any other risk factor or complication in current allowed to have trial of vaginal birth under expert
pregnancy. supervision.
Pregnancy complication: Twins,
polyhydramnios, APH.
Look for scar tenderness.

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6.5.1 Manage ment of labour following caesarean
section:
7. Twin Pregnancy
Refer post caesarean delivery to higher centers. 7.1 Antenatal Diagnosis and
Counseling and informed consent for trial of Management
Labo ur.
Keep operation theatre ready for CS, arrange The incidence of twin gestation is increasing as a
blood. result of infertility treatment. With modern assisted
Monitor progress of labour. reproduction techniques higher order of multifetal
Watch for early signs of fetal distress, scar gestation is common.
dehiscence and perform immediate caesarean
7.1.1 History:
section if these signs appear.
If satisfactory progress, cut short the second Ovulation induction by clomiphene or
stage of labour and deliver. gonadotropin Injections for infertility.
After vaginal delivery, watch for PPH/intra Maternal family histor y of twins, adva nced age,
peritoneal hemorrhage. high parity.
6.5.2 Symptoms & Signs of impe nding rupture 7.1.2 Signs:
during labour:
Suprapubicpain persisting in between uterine Suspect twins when the fundal height is greater
contractions. than the period of amenorrhoea and multiple
Slight fresh vaginal bleeding. fetal parts are felt.
Unexplained tachycardia, tenderness over Palpation of 2 heads, 3 major poles
uterine scar. May have associated polyhydramnios
Alteration in fetal heart rate, sudden signs of Two pe rsons simultaneously hearing FHS at two
fetal distress. different locations with a difference of > 10
Hematuria. beats/min.
Falling BP with increasing pallor is a late sign
of uterine rupture.
7.1.3 Investigation:
6.5.3 Contraception:
Ultrasonography. Early sonographyin second
Counseling for contraception for increasing inter trimester helps in assessing chorionicity
pregnancy interval.
Postpartum IUCD insertion at operation before
closure of uterine incision is safe.

7.2Risks
Table 2: Risk to baby according to type of complication
Pregnant Woman Baby

Hyperemesis gravidarum Prematurity


Anemia IUGR
Pre-eclampsia Malpresentations
Antepartum haemorrhage due to Placenta previa and Fetal asphyxia
also abruptio placentae is likely
Preterm LABOUR Twin-to-twin transfusion
Hypotonic uterine action, prolonged LABOUR Fetal malformations
Postpartum haemorrhage Fetal death

Page 261
Difficult delivery Perinatal mortality is high

7.3 Management during pregnancy 8.2. Causes


Detection and correction of anemia. Fetal anomalies: Anencephaly, esophageal
Nutrition counseling, extra nutrients to meet the atresia.
need of two fetuses.
Maternal diabetes, Multiple pregnancy.
Avoiding exertion, extra rest in left lateral
position. Idiopathic, Placental chorioangioma.
Early diagnosis of preeclampsia.
Can be mild, moderate or severe. Development can
Refer to specialist for antenatal care and delivery be acute or chronic
at FRU.
Explaining warning signals for preterm Labo ur.

8. Polyhydramnios
8.1. Definition 8.3 Risks
Excessive volume of amniotic fluid
Table 3: Risk according to complication type

Pregnant Woman Baby


Hypertension Prematurity
Risks due to associated diabetes mellitus Malpresentations
Risks due to associated twins Fetal asphyxia due to cord prolapse or placental
abruption
APH : Placental abruption Fetal malformations
Preterm labour, PROM, cord prolapse Problems due to associated complications :
twins/preeclampsia/APH
Hypotonic uterine action, prolonged labour
Postpartum haemorrhage

Difficult delivery

8.4. Diagnosis Hydramnios should be differentiated from ascites


and large ovarian cyst.
Fundal height is > POA. Abdomen is over
distended.
Fluid thrill can be demonstrated.
8.5 Management
Fetal parts are not well felt if the abdomen is
tense. FHS may not be clearly heard. Mild cases: No intervention required. Extra rest in
USG confirms the diagnosis by demonstrating comfortable position.
large amount of amniotic fluid. Amniotic fluid
Symptomatic women need to be hospitalized.
index (AFI) 24-25 cm
Association with twins and fetal malformations Specialist can offer following interventions
need to be looked for. depending upon the case.
Severe hydramnios can lead to edema, severe
Tablet Indomethacin: 50-100 mg stat followed
breathlessness, inability to sleep and may require
by maximum 200 mg in 24 hrs for 24-48 hrs. at
immediate attention by specialist.
< 30-32 weeks of pregnancy (As there is risk of
Maternal diabetes mellitus needs to be excluded. premature closure of fetal ductusarteriosus)

Page 262
Amniocentesis to relieve the maternal distress. 9.3 . Risk Factors
The success is transient and repeated fluid Primiparity, pervious history of post term
removal is required. Complications such as pregnancy, sedentary life style, anencephalic
preterm Labo ur, rupture of membranes, fetus. Genetic predisposition
chorioamnionitis, and placental abruption are
likely.
Delivery in a well-equipped institution under
9.4 Prevention
care of a specialist.
Accurate calculation of EDD. Ask whether
Oxytocin augmentation if contractions are weak. menstrual cycles before conception had been
Risk of placental abruption is high when the regular.
membranes rupture and a large volume of Instruct ASHA, ANM to refer a woman who has
amniotic fluid is drained sudde nly. Preserving crossed her EDD to the medical officer.
membranes is important. When required,
At 40 weeks: Check for any complications. In
controlled ARM is done.
pregnancies complicated by hypertension,
Active management of third stage as there is a preeclampsia, IUGR the fetus is at greater risk of
risk of atonic PPH. asphyxia. Hence these women should not be
Examine the baby for congenital malformations allowed to cross their EDD. They should be
(Esophageal atresia or trachea- esophageal referred to specialist as they need to be delivered
fistula) early.
Uncomplicated pregnancy: Wait until 41 weeks.
Instruct the woman to report if fetal movements
9. Prolonged Pregnancy are reduced.
Vaginal examination: Assess whether the cervix
9.1. Definitions is ripe or unripe (Bishop Score).
Sweeping of membranes should be done during
Post term pregnancy: Pregnancy that has crossed 42
this examination as it decreases the chances of
weeks.
post term pregnancy.
At 41 weeks: At PHC, once pregnancy has
9.2. Risks reached 41 weeks, refer her to FRU for further
Post maturity syndrome: In about 20 % cases evaluation and i nterve ntions.
of prolonged pregnancy there is placental
insufficiency which results in a pathologic 9.5 Management of post term
syndrome in which there is fetal growth
retardation associated with meconium stained pregnancy at FRU
amniotic fluid, oligohydramnios and fetal There are two options of managing 41 weeks
distress. The newborn is at risk of meconium pregnancy: Immediate induction of labouror
aspiration syndrome. The baby shows loss of expectant management until 42 weeks, while
subc utaneous fat, wrinkled, dry, cracked skin monitoring the fetal wellbeing.
(old man look). It has long thin body and long 9.5.1In low-risk pregnancies routine induction of
nails. Associated oligohydramnios increases the labour at 41 weeks is associated with reduction in
likelihood of postmaturity. perinatal mortality. The risk of fetal distress is
In other cases not complicated by placental reduced by induction of labour.
insufficiency, there is continued growth of the
fetus leading to macrosomia, with increased risk 9.5.2 Follow up:If expectant management option is
of abnormal labour, shoulder dystocia, and chosen, the mothers should be advised to come for
Injuries to baby. fetal surveillance test at 41 weeks and twice between
41 and 42 weeks.
Increased perinatal mortality in pregnancies
continuing > 42 weeks. History:
Mother: Difficulties in labour due to fetal a) Accurate assessment of gestational age to
macrosomia, Shoulder dystocia. avoid delivery of a preterm baby. Errors likely if
Increased chance of caesarean delivery. prior irregular menstrual cycles or if she has
conceived soon after cessation of oral contraceptive
pills.

Page 263
Review the early USG reports and the date of 9.6 Induction of labour
detection of positive UPT.
Cervix unfavorable (Bishops score < 6):
Ask about history of di minished fetal movements. Vaginal misoprostol 25 mcg 6 hourly for
induction of Labo ur. Oral misoprostol 25 mcg 2
b) On examination: hourly can be used.
Less amount of liquor on abdominal palpation, Pre induction cervical ripening can also be
achieved by intra cervical PGE2 gel or by Foley
Baby may be of large size. catheter. Cervix is reassessed for improvement in
c) USG: bishop score. Induction can then be carried out
with oxytocin infusion.
Look for oligohydramnios: Amniotic fluid index Favorable cervix: Induction with oxytocin
(AFI) 5 cm or less or there is no vertical pocket > 2 infusion and ARM.
cm. This is a marker for fetal compromise. Note:
estimated fetal weight and check for macrosomia. 9.7 During labour (Induced or
d) Nonstress test: spontaneous)
Reactive or nonreactive. [FHR increased by > 15
Partographic monitoring of Labo ur. Monitor
beats lasting for 15 seconds in response to fetal
FHS and color of liquor, (electronic monitoring
movement is assuring]
if available). watch for signs of fetal distress.
Fetal compromise is indicated by reduced AFI, CS is indicated for intra partum fetal distress and
nonreactive NST, reduced fetal movements when for large baby.
immediate delivery is indicated. Second stage : Risk of shoulder dystocia.
e) At 42 weeks:Labour is induced. If the baby is too Episiotomy, assisted delivery may be performed
large or severely compromised, caesarean section is as required.
performed.

Table 4: Bischop score

Parameters 0 1 2 3

Cervical dilatation in cm Closed 1-2 3-4 5+

Cervical effacement in % 0-30 40-50 60-70 80+

Fetal station -3 -2 0 +1 +2, +3

Cervical consistency Firm Medium Soft

Cervical position Posterior Middle Anterior

Page 264
4. OBSTETRIC COMPLICATIONS
1. Preeclampsia and Eclampsia Proteinuria: One plus or more.
Pre-eclampsia is a condition specific to pregnancy,
Oedema of hands, face, abdominal wall (generalized
arising after the 20th week of gestation, characterized
by hypertension and proteinuria. edema) may be present but it is not a diagnostic
Eclampsia is pre-eclampsia with convulsions. feature. Excessive weight gain. 1 kg or more in a
week or 3 kg in a month could be a warning signal.
1.1. Signs of preeclampsia
1.2 Classification of pre-eclampsia
Hypertension: BP 140/90 mmHg or more on at
least 2 occasions 4 hours apart after 20 weeks of Mild and severe.
gestation.
Table-1: Classification of PIH

Finding Mild Pre-eclampsia Severe Pre-eclampsia


Blood Pressure (BP) BP > 140/90 but <160/110 BP 160/110 mm Hg or
mmHg more

Proteinuria Present, 2+ or less *3+ or greater


GeneralisedOedema (including in the face & hand) May or may not be Present
present
Headache Absent Present

Visual Disturbances Absent Present


Upper abdominal pain Absent Present

Oliguria Absent Present


Fetal growth restriction (IUGR) Absent Present
Pulmonary Oede ma Absent Present

Decreased foetal Movement Absent Present


Platelet count Nor mal Less than 1 lac

It is not necessary that all these signs are present in all cases

1.3. Diagnosis At each prenatal visit, check the woman's BP, urine
for presence of protein; look for oedema and record
There are no symptoms in mild preeclampsia. Look her weight. If there is a rise in BP, monitor the
for signs woman's BP weekly.

Page 265
Table-2: Dangers

Maternal Fetal/Neonatal

Eclampsia IUGR
Cerebral haemorrhage, thrombosis, oedema Stillbirth

Acute renal failure Neonatal asphyxia


Aspiration bronchopneumonia, Pulmonary oedema,

HELLP syndrome (haemolysis, elevated liver enzymes, low platelet count)


Disseminated intravascular coagulopathy (DIC) leading to hemorrhage

1.4 Management of mild pre- Biweekly LFT, KFT, Platelet count, NST,
umbilical artery doppler weekly if available.
eclampsia
Antihypertensive drugs are not beneficial in mild
1.4.1 Gestation more than 37 weeks: hypertension.
Admit the woman to a hospital. Check BP. Test Diuretics are not recommended.
for proteinuria. Monitor FHR. During observat ion if BP starts rising,
Assess cervix. Induce labour if cervix is ripe. Do (diastolic BP 100 mm Hg or more) start
not allow her to cross her EDD. antihypertensive .
In mild cases when maternal and fetal condition Tab Alpha methyl dopa 250-500 mg 6-8 hourly
is well, can await spontaneous onset of labour orally (maximum up to 2 gm in 24 hours) OR
until 37-38 weeks. Tab Nifedipine sustained release preparation 10