Normal Vital Signs Dengue Management DO’s and DON’Ts Ideal Body Weight Tables* Dengue Case Management

X DtheON’T
Age Estimated Normal Average Normal Hypotension
Weight Heart Rate HR Respiratory Level Boys and Girls Adult Males and Females ASSESSMENT
Range Rate Range (Systolic BP)
use corticosteroids. They are not indicated and can increase
risk of GI bleeding, hyperglycemia, and immunosuppression.
Presumptive Diagnosis
X Dtransfusions
1 month 4 kg 110-180 145 40-60 <70
Age Boys Girls Males Females
ON’T give platelet transfusions for a low platelet count. Platelet Height Live in / travel to endemic area plus fever and two of the following:
6 months 8 kg 110-170 135 25-40 <70 (yr) (kg) (kg) (kg) (kg)
12 months 10 kg 110-170 135 22-30 <72
do not decrease the risk of severe bleeding and may Nausea and vomiting  arning signs
W
instead lead to fluid overload and prolonged hospitalization. 2 13 12 5’ (152 cm) 50 45 Rash Tourniquet test positive

X DnotON’T
2 years 12 kg 90-150 120 22-30 <74 Aches and pains (headache, eye Leukopenia
3 years 14 kg 75-135 120 22-30 <76 give half normal (0.45%) saline. Half normal saline should 3 14 14 5’ 1” (155 cm) 52 48 pain, muscle ache or joint pain)
4 years 16 kg 75-135 110 22-24 <78 be given, even as a maintenance fluid, because it leaks into third
spaces and may lead to worsening of ascites and pleural effusions. 4 16 16 5’ 2” (157 cm) 54 50
X Dpatient
5 years 18 kg 65-135 110 20-24 <80
ON’T assume that IV fluids are necessary. First check if the Warning Signs
6 years 20 kg 60-130 100 20-24 <82 5 18 18 5’ 3” (160 cm) 57 52 Severe abdominal pain or tenderness
8 years 26 kg 60-130 100 18-24 <86 can take fluids orally. Use only the minimum amount of IV
Persistent vomiting
fluid to keep the patient well-perfused. Decrease IV fluid rate as 6 21 20 5’ 4” (163 cm) 59 55
10 years 32 kg 60-110 85 16-22 <90 Mucosal bleed
hemodynamic status improves or urine output increases.
12 years 42 kg 60-110 85 16-22 <90 7 23 23 5’ 5” (165 cm) 61 57 Liver enlargement >2cm
Clinical fluid accumulation
14 years 50 kg 60-110 85 14-22 <90
≥15 years 60-100 80 12-18 <90 Dsigns
O tell outpatients when to return. Teach them about warning
and their timing, and the critical period that follows
8 26 26 5’ 6” (168 cm) 64 59 Lethargy; restlessness
Increase in HCT concurrent with rapid decrease in platelet count
9 29 29 5’ 7” (170 cm) 66 62
defervescence.
Hemodynamic Assessment Ddefervescence
O recognize the critical period. The critical period begins with
10 32 33 5’ 8” (173 cm) 68 64
Hemodynamic Stable Compensated Hypotensive and lasts for 24–48 hours. During this period, some 11 36 37 5’ 9” (175 cm) 71 66 No For patients with warning For patients with
Parameters Circulation Shock Shock patients may rapidly deteriorate. warning signs of severe dengue any of
Conscious level
Capillary refill
Clear and lucid
Brisk ( 2 sec)
Clear and lucid
Prolonged (>2 sec)
Restless, combative
Very prolonged, mottled skin
Dhematocrit
O closely monitor fluid intake and output, vital signs, and
levels. Ins and outs should be measured at least every
12 40 42 5’ 10” (178 cm) 73 69 signs OR co-existing conditions
Pregnancy
S
 evere plasma
leakage with shock
13 45 46 5’ 11” (180 cm) 75 71 Infancy and/or fluid
Extremities Warm and pink Cool peripheries Cold, clammy shift and vitals at least every 4 hours. Hematocrits should be measured accumulation with
Diabetes mellitus
Peripheral Good volume Weak and thready Feeble or absent every 6–12 hours at minimum during the critical period. 14 51 49 6’ (183 cm) 78 73 Poor social situation
respiratory distress


pulse volume Severe bleeding
DO recognize and treat early shock. Early shock (also known as Old age
Heart rate Normal heart rate Tachycardia for age Severe tachycardia or
15 56 52 6’ 1” (185 cm) 80 75 Renal failure
S
 evere organ
for age bradycardia in late shock
compensated or normotensive shock) is characterized by narrowing impairment
pulse pressure (systolic minus diastolic BP approaching 20 mmHg), 16 61 54 1 kg = 2.2 pounds
Blood Normal blood Normal systolic Narrow pulse pressure
increasing heart rate, and delayed capillary refill or cool extremities.
pressure pressure for age pressure, but rising (≤ 20 mmHg)
17 65 55
Normal pulse
pressure for age
diastolic pressure
Narrowing pulse
Hypotension
Unrecordable blood DPatients
O administer colloids (such as albumin) for refractory shock.
who do not respond to 2–3 boluses of isotonic saline 18 67 56
Group A
Outpatient management
Group B
Inpatient management
Group C
Inpatient management
pressure pressure

Postural should be given colloids instead of more saline.
19 69 57
DIf Ohematocrit
hypotension
give PRBCs or whole blood for clinically significant bleeding.
Respiratory Normal respiratory Tachypnea Hyperpnea or Kussmaul’s
rate rate for age breathing (metabolic acidosis) is dropping with unstable vital signs or significant
bleeding is apparent, immediately transfuse blood.
Urine output Normal Reducing trend Oliguria or anuria *Use Ideal Body Weight to calculate IV fluid rates in patients who weigh
more than their Ideal Body Weight (i.e. in overweight patients)
CS261232-A

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 Group A Group B — Inpatient Management for Dengue Patients with Group C ­— Emergency Management for Dengue Patients with Group C — Emergency Management for Dengue Patients with
Outpatient Management Warning Signs Compensated Shock Hypotensive Shock
During the febrile phase (may last 2–7 days) and
subsequent critical phase (1–2 days), your clinic should Patient admitted
to hospital
Patient admitted to hospital
or intensive care unit for
Patient admitted
to intensive care unit for
Follow CBCs emergency treatment emergency treatment
Watch for dehydration Monitor fluid
Obtain baseline Monitor vital signs
Watch for warning signs, including decreasing platelet count and complete blood intake/output and every 4 hours or Obtain baseline
Closely monitor fluid
Assess hemodynamic Obtain baseline
Closely monitor fluid
Assess hemodynamic
encourage oral fluid intake hematocrit (HCT) and status and monitor vital hematocrit (HCT) and status and monitor
increasing hematocrit count (CBC) more frequently
organ function tests intake/output signs every 1–2 hours organ function tests intake/output vital signs hourly
Watch for defervescence (indicating beginning of critical phase)
Adequate Oral Fluid Intake Inadequate Oral Fluid Intake Patient is in Compensated Shock Patient is in Hypotensive Shock
Does Box A Box A
Continue

monitoring patient 1. Check hematocrit (HCT) Give isotonic crystalloid or
Advise patient or their family to do the following vital signs Yes
have adequate
No
2. Give intravenous
Closely monitor fluid
intake/output Reassess clinical status colloid bolus of 20 ml/kg Reassess clinical status
Observe for early signs
oral fluid isotonic crystalloid in 15 minutes
Control the fever Prevent spread of dengue of shock intake? solution (NS, LR)* Hemodynamic Status
 ive acetaminophen every 6
G within your house Observe
 for warning Improved Has Has
signs of severe dengue Box B patient’s Hemodynamic Status Improved
hours (maximum 4 doses per day).  lace patient under bed net
P Give isotonic crystalloids in patient’s
Yes hemodynamic Yes hemodynamic
stepwise manner: Reduce intravenous Give isotonic crystalloid
Do not give ibuprofen, aspirin, or have patient use insect


fluids in stepwise status or colloid infusion at status

or aspirin-containing drugs. repellent while febrile to avoid 1. 5–7 ml/kg/hour for 1–2 hours manner: Increasing HCT improved? improved?
10 ml/kg/hour over 1 hour
Clinically Stable and 2. 3–5 ml/kg/hour for 2–4 hours
Sponge patient’s skin with infecting mosquitoes that can No Change or Minimal Change in HCT 1. 5–7 ml/kg/hour for Give isotonic Reassess
 clinical status Increasing HCT
tepid water when temperature infect others within 2 weeks. 2–4 hours crystalloid at
Continue isotonic crystalloids at Recheck HCT 10–20 ml/kg No Give colloid No

2. R
 eassess clinical
is high. KILL all mosquitoes in house. 2–3 ml/kg/hour for 2–4 hours status bolus over 1 hour Has 10–20 ml/kg
Reassess
 clinical status Hemodynamic Status bolus over
Empty containers that carry of patient Not Improved clinical status No Recheck HCT
½–1 hour Hemodynamic Status
Prevent dehydration which water on patio. Recheck

HCT If improving: Reassess clinical Box C improved? Go to Box A
Not Improved
occurs when a person loses too Put screens on windows and Reassess
 clinical status of patient status
Recheck HCT Box C
much fluid (from high fever, Give

3–5 ml/kg/hour Reassess clinical
doors to prevent mosquitoes Is patient for 2–4 hours Box B Yes status Recheck HCT
vomiting, or poor oral intake). from coming into house. If: clinically stable Recheck
 HCT and Reduce intravenous fluids in
Give plenty of fluids (not only Yes and has no change reassess clinical status Has clinical Is HCT stepwise manner. Reassess
Adequate

fluid intake and urine Yes
water) and watch for signs of Watch for warning signs as output or minimal status increasing or clinical status and HCT before
change in improved? decreasing? each change.
dehydration. Bring patient to temperature declines 3 to 8 HCT decreases to baseline or slightly

If continued improvment: Clinical Status Yes Has clinical Is HCT
below baseline, but clinically stable HCT? is Improving 1. 5–7 ml/kg/hour for 1–2 hours status
clinic or emergency room if any days after symptoms began. improved?
increasing or
Then: Give

2–3 ml/kg/hour Reduce 2. 3–5 ml/kg/hour for 2–4 hours decreasing?
of the following signs develop: Return IMMEDIATELY to clinic No for 2–4 hours
No
3. 2–3 ml/kg/hour for 2–4 hours
Reduce isotonic crystalloids intravenous Decreasing HCT
or emergency department if any


Worsening Vital Signs and

Recheck HCT and
crystalloids to Clinical Status
 ecrease in urination (check
D Has Not Transfuse No
of the following warning signs Rapidly Increasing HCT reassess clinical status 7–10 ml/kg/hour
Improved If:
number of wet diapers or trips appear: Patient Develops for 1–2 hours 5–10

ml/kg packed
Compesated or Increase isotonic crystalloid Recheck HCT red blood cells Adequate

fluid intake Decreasing HCT
to the bathroom) Hypotensive Shock If:

and urine output Clinical Status
Severe abdominal pain or to 5–10 ml/kg/hour for If:
and reassess or

10–20 ml/kg Clinical Status Has Not Transfuse
F
 ew or no tears when child cries persistent vomiting Follow steps for 1–2 hours Adequate
 fluid intake clinical status whole blood
HCT at baseline or
is Improving Improved
and urine output Continued slightly below baseline 5–10

ml/kg packed
Dry mouth, tongue or lips improvement Go
 to Box C immediately Reduce colloid Recheck HCT red blood cells
Red spots/patches on skin Group C Emergency HCT

at baseline Then:


Sunken eyes Reduce isotonic crystalloids in Management Recheck HCT or slightly below 7–10 ml/kg/hour and reassess or
 10–20 ml/kg
Bleeding from nose or gums stepwise manner. Reassess Then:
Go to Box A Discontinue

for 1–2 hours clinical status whole blood
Reassess
 clinical status of baseline Go to Box B
Listlessness, agitation, or Vomiting blood clinical status before each patient
intravenous fluids Go

to Box C immediately
Then: Patient Develops
confusion Black, tarry stools change.
Hypotensive Shock If:
1. 5–10 ml/kg/hour for 1–2 hours Discontinue

Continued
Fast heartbeat (>100/min) Drowsiness or irritability intravenous fluids Follow steps for
Go to Box A
2. 3–5 ml/kg/hour for 2–4 hours Is patient improvement
C  old or clammy fingers and toes Yes
Pale, cold, or clammy skin 3. 2–3 ml/kg/hour for 2–4 hours improving?
Group C Emergency
Then:
Sunken fontanel in an infant Management for Dengue Patients
Difficulty breathing with Hypotensive Shock Go to Box B
*NS: Normal saline, LR: Ringer’s lactate No

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