EPILEPSY : STATUS EPILEPTICUS

Definition
Status epilepticus is a medical emergency defined as a seizure disorder that persists for 30 minutes or longer, or is repeated frequently enough to prevent recovery of consciousness in between attacks. Status may be generalised or partial, convulsive or non-convulsive.

Diagnostic criteria
Clinical: Seizures lasting 30 minutes or longer, or a series of seizures without complete recovery of consciousness in between attacks. Hyperpyrexia, blood pressure disturbances, cerebral oedema, acidosis, blood glucose disturbances. Investigations: Consider once seizures have been terminated. CT scan or MRI scan may be useful to exclude intracranial pathology. Lumbar puncture may be considered in the absence of increased intracranial pressure or focal neurological signs/seizures.

Pathogenesis
Continuous or recurrent episodes of neuronal discharge of which the precipitating event is either unknown (idiopathic) or secondary to an insult to the brain, e.g. encephalitis, hypoxic episode, trauma, complex febrile seizures, toxins, hypertension and encephalopathy. Non-compliance and changes in anticonvulsant therapy may also be precipitating factors. After 30 minutes of seizures, the brain begins to suffer from hypoxia, acidosis, depletion of local energy stores, cerebral oedema and structural damage. Complications include hyperpyrexia, respiratory depression, cerebral oedema, inappropriate antidiuretic hormone (ADH) secretion, blood pressure disturbances, acidosis, disturbances of blood glucose, renal failure, and hypoxic, ischaemic damage to brain, myocardium and muscles.

Referral criteria
Status epilepticus is a medical emergency. Attempt to control seizures and stabilise the patient before referral.

Treatment objectives

Control or termination of seizures and prevention of recurrences (maintenance therapy). Prevention of further damage to the brain and other organs. Identification and treatment of underlying cause or precipitating event. Symptomatic and supportive treatment.

Treatment guidelines
STATUS EPILEPTICUS Management Non-drug treatment Admit to high care or intensive care facility if available. Make the patient comfortable preferably lying on his/her side. Maintain an open airway. Heart rate, respiratory rate, blood pressure, electrolytes, blood glucose, minerals, acidbase status, blood gases, SaO2, neurological status, fluid balance, osmolality, anticonvulsant blood levels. Tepid water sponges, fan, antipyretics (see drug treatment below). Administer 100% oxygen by facemask, nasal cannulae or head box to maintain SaO2 of 95%. Start IV infusion with 510% dextrose water; maintenance fluid volume according to the age of the patient. Cardiovascular and/or respiratory support if the patient is unable to maintain blood gases and blood pressure within the normal physiological range. Moderate hyperventilation (PaCO2 2835 mmHg) may be considered as part of the management of cerebral oedema. Mannitol, slow IV, 0.251 g/kg over 30 minutes, in the absence of shock. Diazepam, slow IV, 0.20.5 mg/kg over 5 minutes. Maximum dose: 13 years 10 mg; 315 years 15 mg. If response is unsatisfactory, repeat once after 15 minutes. OR Diazepam, IV given rectally, 0.50.75 mg/kg. If response is unsatisfactory, repeat once after 15 minutes. Respiratory depression may develop. Consider bag and mask ventilation, or intubate and ventilate. Comments Identify and treat underlying disorder or precipitating factor.

Monitor:

Hyperpyrexia: Oxygenation: IV fluids: Cardiovascular and respiratory support:

Fluid restriction may be necessary if evidence of inappropriate ADH secretion (hyponatraemia, low serum osmolality, high urine osmolality) is present.

1 kPa = 7.5 mmHg; 1 mmHg x 0.133 = 1 kPa

Drug treatment Cerebral oedema: Anticonvulsant therapy:

Treatment guidelines: STATUS EPILEPTICUS (continued from previous page)

Management Anticonvulsant therapy (continued): If above measures fail, ADD: Phenobarbital, slow IV, 20 mg/kg over 5 minutes. If no response after 15 minutes, repeat once 10 mg/kg IV. Favourable response: Maintenance therapy: Phenobarbital, oral or IV, 510 mg/kg/24 hours as a single evening dose. If seizures do not cease, ADD: Phenytoin, slow IV, 1520 mg/kg in 0.9% sodium chloride solution over 15 minutes with ECG monitoring if possible. Refractory status epilepticus: If all measures fail, give: Thiopental sodium, slow IV, 25100 mg until seizures stop. Comments

Do not give phenytoin IM. Note: All patients with refractory status epilepticus must be admitted to an intensive care unit with monitoring and laboratory services available. Cardiovascular and respiratory support (intubation + ventilation) will always be necessary.

Metabolic acidosis:

Maintain normal acidbase status. If pH 7.2, give: Sodium bicarbonate 8.5%, IV (diluted to 4.2% with sterile water). Use formula: HCO3 needed (mmol) = base excess x 0.3 x body mass (kg) If facilities to assess acidbase status are unavailable, administer sodium bicarbonate 4.2% solution, IV, 2 mL/kg as a single dose.

1 mL sodium bicarbonate 8.5% = 1 mmol HCO3

Other biochemical disorders: Antipyretics:

Correct abnormalities, if present (glucose, calcium and sodium). Paracetamol, 10 mg/kg 46 hourly via a nasogastric tube.

EPILEPSY : NEONATAL SEIZURES

Definition
Typical or atypical seizures occurring in the neonatal period.

Pathogenesis
Neonatal seizures are usually secondary to a serum biochemical disorder or an underlying brain disturbance/injury. They may be subtle due to the relatively underdeveloped cortex, and do not stop when limbs are flexed (as opposed to jitteriness). The most likely causes are perinatal asphyxia, birth trauma, intracranial haemorrhage, meningitis, hypoglycaemia, hypocalcaemia, hypomagnesaemia, hyponatraemia, and narcotic or alcohol withdrawal.

sucking and chewing movements, swimming movements of the arms, cycling movements of the legs, apnoea, vasomotor changes. Tonic clonic movements. Focal clonic movements. Myoclonic movements. Tonic movements.

Referral criteria

Neonatal convulsions not responding to adequate therapy. Neonatal convulsions where the underlying cause is unclear.

Diagnostic criteria
Categories of convulsions: Subtle seizures: Tonic deviation of the eyes, fluttering of the eyelids,

Treatment objectives

Determination and treatment of the underlying cause/disorder. Control of seizures with anticonvulsants. Symptomatic and supportive treatment.

Treatment guidelines
NEONATAL SEIZURES Management Non-drug treatment Identify and treat the underlying cause (e.g. meningitis, hypoxicischaemic encephalopathy). Ensure an open airway and administer oxygen if necessary. Neutral thermal environment. Adequate nutrition and hydration. Monitor: Respiration, heart rate, blood pressure, blood gases, SaO2, acidbase status, electrolytes, minerals, blood glucose, haematocrit, body temperature and maintain within accepted physiological range. Administer phenobarbital AND / OR phenytoin with concomitant monitoring of cardiorespiratory function. Loading dose: Slow IV, 20 mg/kg over 5 minutes. If seizures persist, administer a further 20 mg/kg IV in aliquots of 510 mg/kg as required. Maintenance: Oral or IV, 510 mg/kg/24 hours as a single dose or in 2 divided doses. If seizures are refractory to phenobarbital, add phenytoin. Loading dose: Slow IV, 15 mg/kg in 0.9% sodium chloride solution over 15 minutes under ECG control. Maintenance: Oral or IV, 58 mg/kg/24 hours in 3 divided doses. Consider clonazepam for seizures refractory to phenobarbital and phenytoin. Slow IV, 0.250.5 mg. Repeat as required to a maximum of 1 mg per 24 hours. Maintenance: Oral or IV, 0.51 mg per 24 hours in 4 divided doses. Comments Follow-up by medical practitioner or at clinic/hospital.

Drug treatment Seizure control: Phenobarbital:

Maintenance anticonvulsant therapy is usually considered for neonates with underlying brain damage due to hypoxic ischaemic encephalopathy, meningitis, intracranial haemorrhage or birth trauma. Continue until neonate is seizure-free for 2 weeks, then slowly taper to stop. If seizures recur during tapering of anticonvulsant, continue with maintenance therapy. Phenytoin must not be given in glucose/dextrosecontaining solutions. To minimise risk of precipitation administer phenytoin in 0.9% sodium chloride solution, concentration < 4 g/L, and use within 1 hour. Cardiorespiratory support is usually indicated in this category of infants.

Phenytoin:

Clonazepam:

Treatment guidelines: NEONATAL SEIZURES (continued from previous page)

Management Underlying biochemical disorders: Hypocalcaemia: Serum total calcium 1.7 mmol/L, or ionised calcium < 0.7 mmol/L. Calcium gluconate 10%, IV, 0.20.5mL/kg, diluted 1:4 with 5% dextrose water. Give preferably under ECG control over 15 minutes or until seizure ceases. Repeat if necessary. Serum glucose < 2.5 mmol/L Dextrose water, IV bolus, 250500 mg/kg, followed by dextrose water, IV, 46 mg/kg/minute or more until blood glucose is within the physiological range. Serum magnesium < 0.6 mmol/L Magnesium sulphate 50%, IV, 0.2 mL/kg slowly over 5 minutes as a single dose. Use 50% dextrose water or 10% dextrose water. (250500 mg/kg = 0.51 mL of 50% dextrose) Dilute 50% before administering. Comments

Hypoglycaemia:

Hypomagnesaemia:

INVOLUNTARY MOVEMENTS
Definition
Abnormal involuntary movements that may mimic seizures. Abnormal movements often mimic seizures, but may be distinguished from them in the following ways: Involuntary moments Disappear during sleep. More stereotyped and persistent. No loss of consciousness. No EEG abnormalities. Seizures May persist or worsen during sleep. Less stereotyped and persistent. Often characterised by loss of consciousness or awareness. Often accompanied by EEG abnormalities.

Pathogenesis
Most cases of involuntary movements refer to a pathological process of the basal ganglia, midbrain and cerebellum. This could be secondary to trauma, infection, tumours, toxins or a degenerative process. Although some involuntary movements in children may have a benign course, they should always be considered as signs of an intracranial pathological process.

Diagnostic criteria
Involuntary movements include: Involuntary contractions that do not move a joint fasciculation, myoclonus. Low amplitude jerking movements chorea, tics, hemifacial spasms, myoclonus. High amplitude jerking movements ballismus, myoclonus. Slow writhing movements and abnormal posturing athetosis, dystonia. Rhythmic movements tremors, myoclonus.

Referral criteria
Refer for exclusion of an intracranial pathological process.

Treatment objectives

Determination and treatment of the underlying cause. Supportive treatment. Non-drug treatment and drug treatment depend on the underlying pathological process.

Treatment guidelines

Remember the association of Sydenhams chorea with rheumatic fever.

NEUROCYSTICERCOSIS
Definition
Neurocysticercosis is the commonest parasitic disease affecting the central nervous system in children. abnormalities such as seizures, raised intracranial pressure/hydrocephalus, focal neurological deficits, cranial nerve palsies, meningoencephalitis, meningitis, behavioural disorders, headache. Investigations: Positive serological tests for cysticercosis (blood, cerebrospinal fluid). Computed tomography (CT scan) and/or magnetic resonance imaging (MRI scan) of brain showing cysts, peri-lesional oedema or calcification of cysts. MRI scan may identify more calcifications and viable cystic lesions than the CT Scan. Soft tissue radiology (muscles of lower limbs) may demonstrate calcified cysticerci in muscles.

Pathogenesis
Neurocysticercosis is caused by the cysticercal form (larval form) of the pork tapeworm (Taenia solium). Clinical features may vary and are largely determined by the location and stage of the life cycle of the parasite in the brain. The larvae may locate in the brain parenchyma, intraventricular and meningeal areas, spinal canal/cord and eye, or a combination of these regions. Viable cysticerci incite little inflammatory response, but when they calcify they elicit an increased inflammatory response. Complications: Cysticerci in the brain may remain dormant or may cause complications such as headache, behavioural disorders, visual disturbances, seizures, focal neurological deficits, increased intracranial pressure, hydrocephalus, meningitis, meningo-encephalitis, spinal cord compression.

Referral criteria

Neurocysticercosis not responding to adequate therapy. Neurocysticercosis with complications, such as hydrocephalus. Prevention or early treatment of complications. Eradication of cysticerci. Symptomatic and supportive treatment. Prevention.

Treatment objectives

Diagnostic criteria

Clinical: Suspect if children from endemic areas present with neurological

Treatment guidelines
NEUROCYSTICERCOSIS Management Non-drug treatment Prevention see comments. Follow-up CT scans and/or MRI scans may help to assess the response to therapy. Comments Preventative measures include: - prolonged freezing or thorough cooking of beef and pork to kill the parasite. - thorough washing of fresh fruit and vegetables in areas endemic for T. solium. - attention to personal hygiene. - provision of proper sanitary facilities. - avoiding the use of human excreta as fertiliser. Specific drug therapy with praziquantel (or albendazole) and dexamethasone is reserved for symptomatic patients with active disseminated disease with multiple viable brain cysts, widespread peri-lesional oedema and numerous calcifications.
Albendazole is not registered for neurocysticercosis.

Drug treatment Active disease:

See comments. Praziquantel, oral, 50 mg/kg/24 hours as a single daily dose or in divided doses, for 15 days. OR Albendazole, oral, 15 mg/kg/24 hours in 3 divided doses for at least 8 days.

Neurological manifestations: Inactive disease: Anticonvulsants:

Dexamethasone, oral or IM, 0.250.5 mg/kg/24 hours for 24 hours prior to praziquantel or albendazole therapy. Continue for the duration of the therapy. See comments. For seizure control, see EPILEPSY, page 88.

Dexamethasone is used for patients with severe neurological manifestations and raised intracranial pressure. Patients with inactive disease (e.g. a single or a few calcified brain lesions without viable cysts and perilesional oedema) require only symptomatic treatment, e.g. appropriate anticonvulsants.

Surgical treatment

Ventricular peritoneal shunt procedure for hydrocephalus; removal of cysts.

POLYNEUROPATHY (Guillain-Barr Syndrome)

* Notifiable disease

Definition
Guillain-Barr is the most common polyneuropathy in children, characterised mainly by motor weakness and areflexia (absence of tendon reflexes).

Pathogenesis
Autoimmune-mediated demyelination is precipitated by a preceding viral or other infection.

Diagnostic criteria
Clinical: Preceding respiratory tract infection or gastrointestinal infection. Symmetrical, flaccid muscle weakness with early areflexia. The muscle weakness may ascend rapidly upwards to involve the trunk, arms, face and cranial nerves. Bulbar paralysis and respiratory failure may develop. Autonomic dysfunction. Relatively mild, or absence of, sensory signs. Miller-Fisher variant presents with ataxia and ophthalmoplegia. Guillain-Barr is not to be confused with other more rare causes of polyneuropathies such as poliomyelitis, transverse myelitis, diphtheria, and botulism.

Poliomyelitis a rare cause of hypotonia with abrupt onset of weakness (often asymmetrical) in association with a febrile illness. Transverse myelitis initial flaccid weakness and areflexia, but rapidly progressing to spasticity and hyperreflexia; also a sensory level on trunk, and bladder and rectal sphincter involvement. Botulism (food poisoning caused by Clostridium botulinum, with incubation period of 1236 hours) presents with nausea and vomiting, diplopia, dysphagia, dysarthria, weakness and postural hypotension. Diphtheria see page 170. Investigations: CSF findings (after 1 week) show elevated protein and no cells or only a few cells (albumino-cytological dissociation). Glucose is normal. Guillain-Barr syndrome with bulbar paralysis and/or early signs of respiratory failure.

Referral criteria

Treatment objectives

Supportive treatment. Appropriate treatment of infection/s. Prevention and early treatment of complications.

Treatment guidelines
POLYNEUROPATHY Management Non-drug treatment Admit to high care or intensive care unit. Monitor autonomic functions closely respiratory effort and rate, forced vital capacity (FVC), blood pressure, heart rate, bulbar functions and arterial blood gases. Ventilation see comments opposite. Provide adequate nutrition. Bladder and bowel care; pressure-point care. Routine physiotherapy for chest and lower limbs; ankles must be kept in dorsiflexion. Eyes must be protected and kept moist. Plasmapheresis seldom used in children. Immunoglobulin, IV, 0.4 g/kg as a single daily dose on 5 consecutive days early in the disease process. Comments Notifiable condition. Ventilation is recommended when: - PCO2 levels start rising; - the FVC or peak expiratory flow rate drops below 1215 mL/kg body mass; - tachycardia and sweating occur; - inspiratory efforts are weak. Note: These changes precede hypoxaemia detected on blood gas analysis, and ventilation should begin before frank hypoxaemia occurs. Respiratory toilet must be impeccable. For rapidly progressive ascending paralysis. To be used under supervision of a specialist in an intensive care setting.
Immunoglobulin is not registered for this indication.

Drug treatment

Secondary infections

Treat as indicated.

PSYCHOPHARMACOLOGY GUIDELINES IN CHILDREN AND ADOLESCENTS

Effective and safe use of psychiatric drug therapy in children and adolescents is based on: - a reliable diagnosis; - appropriate administration of the drug therapy (monotherapy, starting with low dosage and increasing slowly, and periodic reevaluation for side effects); - ongoing training in the skills of assessment and diagnosis of children and adolescents, taking age and developmental status into account; - ongoing interaction with patients and their families or caregivers throughout treatment. depressive disorder with of without psychoses (irritable mood and failure to gain expected weight); dysthymic disorder (one-year period of irritable mood); cyclothymic disorder (one-year period of numerous mood swings); schizo-affective disorder; and depressive disorder not otherwise specified. The DSM IV criteria for adults apply to children and adolescents, but with some modifications which should be noted.

Diagnostic criteria
Major Depressive Episode: The following depressive symptoms are commonly seen: Young children and adolescents: Persistence of irritable mood (instead of depressed mood as in adults); failure to gain expected weight; suicidal ideation; insomnia; diminished ability to concentrate; patient feels sad/blue/ miserable/unhappy/ a bad feeling inside. Young children: Withdrawn and sad appearance, poor self-esteem, somatic complaints, mood-congruent auditory hallucinations. Late adolescence: Severe psychomotor retardation, delusions, pervasive anhedonia, sense of hopelessness, negativistic or frank antisocial behaviour, feelings of restlessness, aggression, reluctance to co-operate, school difficulties.

Depressive states in childhood and adolescence

Moods of children and adolescents are especially vulnerable to the influence of severe psychosocial stressors such as: - family discord; - abuse and neglect; - academic failure. Because children and adolescents do not easily or accurately verbalise their affective states, symptoms of these states are hard to recognise. Depressive symptoms and diagnostic criteria are equivalent to those found in adults. Children and adolescents with attention deficit hyperactivity disorder, oppositional defiant deficit disorder and/or conduct disorder should be screened for mood disorders because of the high prevalence of mood disorders. The following mood disorders are distinguished in children and adolescents: adjustment disorder with depressive mood; substance or medicine-induced depressive mood disorder; bipolar 1 disorder; major

Referral criteria

Suicidal thoughts and attempted suicide. Major depressive mood disturbance with psychosis. Depression not improving on medication (treatment-resistant or refractory depression).

Treatment approach
PSYCHOPHARMACOLOGY GUIDELINES IN CHILDREN AND ADOLESCENTS Management Non-drug treatment Exclude substance abuse using screening tests (e.g. urine toxicological screen for cannabis abuse). Exclude underlying medical conditions (thorough medical and neurological assessment). Psychotherapy: family therapy, individual psychotherapy, cognitive therapy, social and problem solving skills, supportive therapy. Comments Note: Immediate hospitalisation is indicated if patient is suicidal and/or to protect patient against own impulsive/dangerous behaviour.

Drug treatment Antidepressants:

Pharmacotherapy is indicated in major depressive episodes, dysthymic disorders, depressive disorders not otherwise specified, and bipolar 1 disorders. Tricyclic antidepressants, e.g. Imipramine or amitriptyline, oral, < 14 years, 2575 mg/day, > 14 years, up to 100 mg/day. OR (in late adolescence) Selective serotonin re-uptake inhibitors, e.g. fluoxetine. Tricyclic antidepressants are the mainstay of the treatment of depressive disorders. Note: Overdosage with these agents can be fatal. Caution parents/caregivers to keep medicine out of reach of children.
Fluoxetine is not registered for use in children. Mood stabilisers should be initiated by a psychiatrist or designated specialist only.

Mood stabilisers:

Indications: bipolar disorders in children and adolescents, emotional dyscontrol/aggression, intermittent explosive disorder. Carbamazepine, oral, initially 10 mg/kg/day; may be increased to 2030 mg/kg/24 hours. OR Sodium valproate, oral, 2050 mg/kg/24 hours in 23 divided doses.

Monitor blood levels. Therapeutic range: 412 mg/L. Monitor full blood count (FBC) for possible leucopenia. An uncommon reaction is the worsening of the aggressive behaviour and impulsivity in hyperactive and conduct-disordered children. Monitor blood levels. Therapeutic range: 50100 mg/L Monitor liver function for possible liver toxicity.

RABIES
* Notifiable disease

Definition
Rabies is a viral infection of the central nervous system.

Pathogenesis and complications

The rabies virus is usually introduced by infectious saliva in bite wounds, and travels via the peripheral nerves to the central nervous system, where it causes an encephalomyelitis with widespread degeneration, demyelination and necrosis of neurons. The incubation period is variable and is related to the distance of the bite from the head, the severity of the bite and the amount of virus in the wound. It usually varies between 3 days and 3 months. The pathognomonic sign in the neuronal cytoplasm and dentritic processes is the Negri inclusion body.

food may precipitate spasms. Abnormal behaviour may be present. Aerophobia may be present and is elicited by fanning a current of air across the face, causing spasms of the pharyngeal muscles. Progressive paralysis and coma. Investigations: CSF may show pleocytosis and elevated protein, or may be normal. Positive fluorescent antibody test on brain tissue of the animal.

Type of exposure:
First risk category: Touching/feeding animal; licking of intact skin. (No treatment necessary.) Second risk category: Nibbling of uncovered skin, superficial scratch; no bleeding or licking of broken skin. Third risk category: Bites or scratches that penetrate the skin and draw blood; licking of mucous membranes.

Diagnostic criteria
Clinical: History of a bite or contact with an animal with abnormal or unusual behaviour. Prodromal phase: Headache, fever, anxiety, insomnia and malaise. Paraesthesias/numbness and a tingling, burning or cold sensation at the site of the wound may be early signs. Excitation phase: Convulsions, delirium, and painful spasms of the larynx and pharynx elicited by attempts to swallow food or water (hydrophobia). Later, even the sound, smell or sight of liquid and

Referral criteria
Rabies where the diagnosis is uncertain.

Treatment objectives

Preventative measures. Symptomatic and supportive treatment.

Treatment guidelines
RABIES Management Non-drug treatment Post-exposure prophylaxis: Prompt cleansing of the bite/wound with soap and water followed by application of an antiseptic solution such as povidone iodine 10 % or chlorhexidine 0.05 % in water. Avoid suturing use compressive dressing if necessary. Symptomatic and supportive treatment. Human rabies immunoglobulin, 20 IU/kg/dose. Infiltrate as much as anatomically possible subcutaneously at the site of the wound and into the depth of the wound. The remainder of the dose is injected IM (buttock). PLUS Rabies vaccine (human diploid cell strain virus, HDCV), IM, 1 mL into the deltoid muscle. Repeat 3, 7, 14, 28 and 90 days after exposure. (Course of 6 injections.) Benzylpenicillin, IV, 200 000 units/kg in 4 divided doses for 5 days OR Phenoxymethylpenicillin, oral, < 1 year, 62.5 mg 6 hourly for 5 days, 16 years, 125 mg 6 hourly for 5 days, > 6 years, 250 mg 6 hourly for 5 days. Tetanus toxoid, IM, 0.5 mL. Rabies vaccine (HDCV), IM, 1 mL. Repeat on day 3 after exposure. No rabies immunoglobulin should be administered. Symptomatic and supportive treatment. Specific chemotherapy for rabies is not available. High-risk individuals, veterinarians, health workers, etc.: Rabies vaccine (HDCV), IM, 1 mL, repeated on days 7 and 28. A single booster dose is given every 23 years. Only 2 boosters are required after an incident of exposure to infection on days 0 and 3. Immunoglobulin and vaccine are contraindicated in frank rabies. Vaccinate domestic animals; keep them fenced in or tied up. Restrict movement of domestic animals between rabies and non-rabies areas. Comments The aim is to prevent infection becoming established in a patient who has been bitten by an animal with rabies, by cleaning the bite/wound and immunising the patient. Rabies is unlikely if the animal remains alive for more than 10 days. Consult with veterinarian. Rabies is a notifiable disease.

Drug treatment Post-exposure prophylaxis: (second and third risk categories) Unimmunised patient:

Rabies vaccine adsorbed (inactivated) RVA can be used in infants.

Antibiotic therapy:

Tetanus prophylaxis: Immunised patient: Frank/confirmed rabies: Pre-exposure prophylaxis

5. CELLULITIS
Definition
Infection of the skin and subcutaneous tissue.

Dermatology

Diagnostic criteria

Pathogenesis and complications

Any area of the body may be affected. The port of entry of microorganisms is often an insect bite, superficial abrasion or penetrating wound. Cellulitis may also be preceded by a skin infection, e.g. impetigo, ecthyma, folliculitis. There is a rapid, local spread of the infection involving the skin, subcutaneous tissue and lymphatic pathways. Minimal local suppuration occurs, and the infection may spread to involve other structures or enter the bloodstream to cause septicaemia. Cellulitis is commonly associated with streptococci, H. influenzae type b and sometimes, staphylococci.

Acutely ill child; fever, malaise. Involved area is swollen, indurated, erythematous and painful/tender with regional lymphadenopathy. If the affected area involves the face, and the area is well demarcated, very tender and warm with a bright red, swollen appearance and firm borders, the condition is called erysipelas, and is generally caused by streptococci. Cellulitis not responding to adequate therapy.

Referral criteria Treatment objectives

Eradication of the infection. Symptomatic and supportive treatment.

Treatment guidelines
CELLULITIS Management Non-drug treatment Drug treatment If streptococci are suspected: Ensure adequate nutrition and hydration. Benzylpenicillin, IV, 200 000 units/kg/24 hours in 4 divided doses (6 hourly) for 5 days. OR Phenoxymethylpenicillin, oral, 125250 mg 6 hourly for 5 days. Cloxacillin, IV, < 2 years, 62.5125 mg 6 hourly for 5 days, 2 years, 250500 mg 6 hourly for 5 days. OR Flucloxacillin, oral, < 2 years, 62.5 mg 6 hourly for 7 days, 210 years, 125 mg 6 hourly for 7 days, > 10 years, 250 mg 6 hourly for 7 days. Ampicillin, IV, 50100 mg/kg/24 hours in 4 divided doses for 5 days. OR Amoxicillin, oral, < 20 kg, 2040 mg/kg/24 hours in 3 divided doses, > 20 kg, 250500 mg 8 hourly, for 5 days. Erythromycin, oral, 3050 mg/kg/24 h in 4 divided doses for 5 days OR Chloramphenicol, oral or IV, 50100 mg/kg/24 hours in 4 divided doses for 57days. Tilidine, oral, 1 drop for each year of age plus 2 drops, 68 hourly for 4872 hours. Maximum 10 drops/dose. OR Pethidine, IM or IV, 0.52 mg/kg 68 hourly for 4872 hours. Maximum 6 mg/kg/24 hours. Paracetamol, oral, 10 mg/kg 6 hourly. Ibuprofen, oral, 20 mg/kg/24 hours in 4 divided doses for 72 hours. (Under 30 kg, maximum 500 mg/day). If no response to erythromycin suspect H. influenzae. Comments Observe for complications, e.g. septicaemia. Choice of intravenous or oral antibiotics depends on the severity of the condition.

If staphylococci are suspected:

If H. influenzae is suspected:

Penicillin-allergy: If H. influenzae is suspected: Analgesics: Severe pain:

1 drop = 2.5 mg (50 mg per 0.5 mL = 20 drops) Not recommended for infants < 1 year of age.

Antipyretic/analgesic/ anti-inflammatory:

ERYTHEMA MULTIFORME / STEVENS-JOHNSON SYNDROME

Definition
Acute, vesico-bullous disorder with numerous manifestations on the skin, mucous membranes and, occasionally, internal organs.

Pathogenesis
Pathogenesis is unknown, but erythema multiforme is generally regarded as a hypersensitivity reaction triggered by drugs (sulphonamides, phenytoin), infections (herpes simplex, Mycoplasma) or exposure to toxic substances. Complications include conjunctivitis, uveitis, corneal scarring, fluid loss, infections, anaemia, and oesophageal strictures.

Erythematous macules that evolve into papules, vesicles, bullae, urticarial plaques or patches of confluent erythema. The centre of the lesion may be vesicular, purpuric or necrotic. Erythema multiforme major (Stevens-Johnson syndrome): A serious, systemic condition involving the skin and at least two mucous membranes. Eruption may be preceded by non-specific prodromal symptoms like malaise, fever, chills or upper respiratory infection. Cutaneous lesions tend to rupture, leaving the skin denuded, with fluid loss, anaemia and high risk of infection. Involvement of oral mucosa is common.

Diagnostic criteria

Referral criteria

Erythema multiforme minor: Prodromal symptoms are generally absent. Symmetric crops of skin lesions of diverse morphology, primarily on the extensor surfaces of the arms and legs (often including soles and palms) with relative sparing of the mucous membranes and the trunk. Iris or target lesions (pathognomonic for erythema multiforme) consisting of a dark centre, an inner pale ring and an erythematous outer border.

Erythema multiforme minor or major not responding to adequate therapy. Erythema multiforme minor or major with ocular involvement. Avoidance of the triggering event/agent. Symptomatic and supportive treatment.

Treatment objectives

Treatment guidelines
ERYTHEMA MULTIFORME / STEVENS-JOHNSON SYNDROME Management Non-drug treatment Frequent mouth washes for oral lesions. Nasogastric feeds if unable to eat. IV alimentation if enteral feeds are not possible. IV infusion with dextrose-containing paediatric maintenance solution. Cool compresses and wet dressings. Fresh frozen plasma, IV, 20 mL/kg over 4 hours. If anaemic: Blood, IV, 1020 mL/kg over 2 hours. Promethazine, oral, 0.125 mg/kg 6 hourly, OR oral or IV, 0.5 mg/kg as a single dose at night. Prednisone, oral, 12 mg/kg/24 hours as a single dose or in divided doses. Maximum 60 mg per 24 hours. OR Dexamethasone, IV, 12 mg/kg/24 hours in 3 divided doses for 5 days. Systemic antibiotics: (if infection is suspected) Erythromycin, oral, 3050 mg/kg/24 hours in 4 divided doses for 10 days. OR Amoxicillin, oral, < 20 kg, 2040 mg/kg/24 hours in 3 divided doses, > 20 kg, 125250 mg 8 hourly, for 10 days. Tilidine, oral, 1 drop for each year of age plus 2 drops, 68 hourly as needed. Maximum 10 drops/dose. OR Pethidine, IM or IV, 1 mg/kg 68 hourly as needed. Paracetamol, oral, 10 mg/kg 6 hourly as needed. Chlorhexidine gluconate solution 0.2 %. Rinse mouth as needed. Do not swallow. Send blood and skin lesion specimens for culture and sensitivity before initiating antibiotic therapy. Reassess choice of antibiotic when culture and sensitivity results become available. Use IV antibiotics if the oral route cannot be used. 1 drop = 2.5 mg (50 mg per 0.5 mL = 20 drops) Not recommended for infants < 1 year of age. Comments Admit to high care or intensive care unit if available. Examine daily for infection and ocular lesions. Do not puncture bullae or vesicles.

Drug treatment

Analgesics:

Less severe pain: Mouth wash:

6. EPIGLOTTITIS
Definition

Ear, nose and throat

Life-threatening upper airway obstruction at the level of the supraglottic structures (epiglottis and arytenoids).

Pathogenesis
Acute infection/inflammation and swelling of the epiglottis and other supraglottic structures, usually caused by H. influenzae type b. Epiglottis is an upper airway emergency. Complications include acute total airway obstruction with hypoxia.

Position of comfort to protect the upper airway: sitting upright, head forward, open mouth, neck in extension. Cherry red swollen epiglottis. Total upper airway obstruction is imminent by the time stridor appears.

Referral criteria
Compromised airway and intubation inevitable.

Treatment objectives
Medical emergency. Relieve airway obstruction/secure airway. Prevent hypoxia. Treat underlying infection.

Diagnostic criteria

Acute onset, fever, sore throat, dysphagia, refusal to eat or swallow, drooling, muffled voice, toxic appearance.

Treatment guidelines
EPIGLOTTITIS Management Non-drug treatment Provide supplemental humidified oxygen and monitor oxygen saturation of haemoglobin (pulse oximeter). Maintain oxygen saturation at 95%. Prepare equipment for bag-mask ventilation, endotracheal intubation, needle cricothyrotomy and tracheostomy. Carefully start an IV line and administer appropriate antibiotic/s. If airway obstructs completely or respiratory arrest occurs, attempt to establish an airway by any means to prevent hypoxia and death. 1) Attempt bag-mask ventilation. 2) If unable to ventilate, intubate. 3) If unable to intubate, perform needle or surgical cricothyrotomy. Attempt extubation after 4872 hours. After an open airway has been secured: - Take blood for cultures and a swab from the epiglottis for microscopy, culture and sensitivity. - Monitor heart rate, respiratory rate, blood pressure, and SaO2. - Ensure adequate nutrition and hydration. Drug treatment Antibiotics: Cefotaxime, IV, 100 mg/kg/24 hours in 3 divided doses (8 hourly) for 7 days. OR Ampicillin, IV, < 20 kg, 50100 mg/kg/24 hours in 4 divided doses (6 hourly) for 7 days, > 20 kg, 250500 mg 6 hourly for 7 days, plus Chloramphenicol, IV, 50100 mg/kg/24 hours in 4 divided doses (6 hourly) for 7 days. Dexamethasone, IV, 1 mg/kg daily as a single dose, until extubation. Comments Do not interfere with the protective mechanism of the patient. Allow the child to remain sitting up. Avoid all measures that could agitate the patient; - make no attempt to see the epiglottis; - do not ask for X-rays of neck and chest routinely; - delay blood sampling until after airway is secured. Under ideal conditions, the patient should be intubated before referral as total airway obstruction may occur suddenly and quite unpredictably. If intubation before referral is not possible, transport patient immediately to a centre where laryngoscopy and intubation/tracheostomy can be performed, preferably under general anaesthesia in an operating theatre. Inform the hospital before departure. A person able to perform an emergency intubation or tracheostomy must accompany the patient during transport.

Airway obstruction:

Steroids:

EPISTAXIS (Nose bleed)

Definition
Nasal bleeding.

Pathogenesis
Nasal bleeding may be spontaneous or precipitated by minor trauma, fever, infection or allergic rhinitis. Bleeding usually arises from a rich blood vessel plexus on the caudal part of the septum (Littles area). Epistaxis may also be a sign of a more serious underlying disorder such as haemophilia/von Willebrands disease, thrombocytopenia, hypertension, tumour, or may be due to anticoagulant therapy. Complications include recurrent epistaxis, anaemia and hypovolaemic shock.

Recurrent nose bleeds. Signs and symptoms of an underlying disorder which may cause epistaxis.

Referral criteria
Epistaxis caused by a serious underlying disorder. Epistaxis which fails to respond to treatment. Recurrent epistaxis.

Treatment objectives

Diagnostic criteria

Stop the bleeding. Identification and treatment of underlying disorder. Treatment of anaemia and/or shock.

History of spontaneous nose bleeds.

Treatment guidelines
EPISTAXIS (Nose bleed) Management Non-drug treatment Digital pressure: See comments. Apply direct digital pressure to the lower nose over the bleeding site for 10 minutes; place ice over the nasal bridge. If not effective, clots should be removed by suction or blowing nose. If simple measures fail to control the bleeding: Visualise the bleeding site and insert a small piece of gelatin sponge or topical thrombin over the bleeding site. Cauterise the bleeding point (chemical or electrical cauterisation). OR Anterior nasal packing, using BIPP-coated ribbon gauze soaked in a topical vasoconstrictor such as adrenaline 1:1000. Pack is introduced along the floor of the nose and built up in loops towards the roof, applying even pressure to the nasal mucosa. If bleeding is from far back, insert a post nasal pack under general anaesthesia. Pass a catheter through the nose and bring it out through the mouth. The post nasal pack (a ball of gauze with tapes attached) is fixed to the oral end of the catheter. The nasal end is then withdrawn to pull the pack into the mouth. Position the pack behind the soft palate with your finger. Further traction on the catheter will pull the pack firmly into the back of the nose. Surgical intervention if all the above measures fail. Blood, IV, 10 mL/kg, if anaemic (Hb 7 g%). Topical application of a cotton wool plug soaked in a mixture of adrenaline 1:1000 and lidocaine 1%. Amoxicillin, oral, 125250 mg 8 hourly for 7 days OR, if allergic to penicillin, Erythromycin, oral, 3050 mg/kg/24 hours in 4 divided doses for 7 days. Avoid drugs interfering with platelet function. Give antibiotic therapy to patients with a nasal pack. Apply a topical anaesthetic agent before attempting cauterisation, or perform under general anaesthetic. Anaesthetise the nasal mucosa with a topical anaesthetic agent before inserting the anterior nasal pack. Comments The child should sit up and lean forward so as not to swallow the blood, and should breathe through the mouth.

Local haemostatic: Cauterisation: Anterior nasal pack:

Post nasal pack:

Secure the pack to avoid obstruction of the airway. Leave the pack in place for 24 hours.

Surgical intervention: Anaemia: Drug treatment Antibiotics:

LARYNGOTRACHEOBRONCHITIS, ACUTE VIRAL (CROUP)

Definition
Potentially life-threatening airway obstruction in children. Assessment of severity of airway obstruction Severity Grade 1 Grade 2 Grade 3 Grade 4 Inspiratory obstruction + + + + (passive expiration) + (active expiration using abdominal muscles) + Expiratory obstruction Pulsus paradoxus

Pathogenesis
Viral infection and inflammation of the larynx, vocal cords, subglottic part of larynx and nearby structures. Viruses responsible for most cases are: para-influenza virus (most common), measles, herpes simplex and adenovirus. Acute viral laryngotracheobronchitis is one of the commonest causes of stridor in children aged between 6 months and 2 years. Complications include airway obstruction with hypoxia and respiratory failure.

Cyanosis, apathy, marked retractions, impending apnoea

Diagnostic Criteria
Clinical: Previously healthy child who develops progressive inspiratory obstruction, with a barking cough and stridor, a day or two after the onset of an upper respiratory tract infection. A mild fever may be present. Systemically, the child is not ill and physical findings are limited to the respiratory system. Stridor becomes softer as airway obstruction becomes more severe. The following features suggest a different diagnosis: - Acute onset of obstruction (foreign body or angioneurotic oedema); - Incomplete immunisation and a membrane in the upper airway (diphtheria); - Dysphagia, drooling and sitting position (epiglottitis, retropharyngeal abscess); - Erythematous rash in a very ill child (staphylococcal disease).

Referral criteria

Grade 3 airway obstruction, not responding to adequate treatment. Grade 4 airway obstruction. Under ideal conditions, patient should be intubated before referral. If this is not possible, a person able to perform an emergency intubation should accompany the patient.

Treatment objectives

Relieve obstruction. Exclusion of other causes of airway obstruction, such as foreign body, angioneurotic oedema, epiglottitis and diphtheria. Prevention of hypoxia and hypercarbia. Supportive treatment.

Treatment guidelines
ACUTE VIRAL LARYNGOTRACHEOBRONCHITIS (CROUP) Management Non-drug treatment Admit to high care or intensive care ward, depending on severity. Minimal handling. Keep child comfortable and avoid painful procedures. Maintain adequate hydration. Continue with oral feeds if possible. Monitor oxygen saturation, heart rate, respiratory rate, blood gases and acidbase status. Supportive treatment. Prednisone, oral, 2 mg/kg as a single dose OR Dexamethasone, IV or IM, 0.5 mg/kg as a single dose. Repeat after 1224 hours if no improvement. Steroids as for grade 1 obstruction. Nebulised adrenaline with oxygen, 1 mL adrenaline 1:1000 + 1 mL 0.9% sodium chloride solution. Repeat every 1530 minutes until expiratory obstruction is abolished. Give steroids and nebulised adrenaline inhalations as above. If no improvement within 1 hour, intubate under general anaesthesia or perform a tracheostomy under general anaesthesia. Give steroids and continue with adrenaline nebulised with 100% warm humidified oxygen. Emergency intubation or intubation under general anaesthesia if circumstances permit. Paracetamol, oral, 10 mg/kg 46 hourly until fever subsides. Comments Note: The early clinical picture of bacterial tracheitis (pseudomembranous croup) is very similar to that of viral croup. However, instead of gradual improvement, patients develop high fever, toxicity, and progressive airway obstruction unresponsive to viral croup therapy. Bacterial tracheitis treatment includes appropriate intravenous antibiotics. Organisms most commonly involved are S. aureus and S. pneumoniae.

Drug treatment Grade 1 obstruction:

Observation. Mist therapy may have soothing effect. Do not give steroids to patients with measles or herpes infection.

Grade 2 obstruction:

Monitor oxygen saturation and heart rate.

Grade 3 obstruction:

Monitor oxygen saturation and heart rate.

Grade 4 obstruction:

Antipyretics:

OTITIS MEDIA, COMPLICATIONS

Definition
Infection and inflammation of the middle ear with complications. - Temporal lobe abscess: dysphasia, contralateral upper quadrantic homonymous hemianopia, paralysis contralateral face and arm, rarely leg, hallucinations of taste and smell. CT scan and/or MRI scan for confirmation and localisation of the abscess. Labyrinthitis: Vertigo, nausea, vomiting, nystagmus towards opposite side, and deafness.

Pathogenesis
Pathogenic micro-organisms from the nasopharynx reach the middle ear via the eustachian tube. Infection and inflammation may spread to all other adjacent anatomical structures with suppuration, bone necrosis or septic thrombophlebitis. Micro-organisms involved include pneumococci, streptococci, H. influenzae, staphylococci, Pseudomonas, M. catarrhalis, and anaerobes. Complications include acute mastoiditis, meningitis, extradural abscess, brain abscess (temporal lobe and cerebellum), labyrinthitis, lateral sinus thrombosis, cranial nerve paralysis, petrositis.

Diagnostic criteria
Acute mastoiditis: Fever, severe pain, increasing deafness, tenderness over mastoid antrum. Swelling in post-auricular area. Pinna is pushed down and forward. Tympanic membrane is usually perforated with otorrhoea. Occasionally, pus breaks through the mastoid tip and forms an abscess in the neck (Bezolds abscess). Mastoid X-rays show opacity and air-cell coalescence.

Lateral sinus thrombosis: Symptoms and signs may be indistinguishable from those of acute mastoiditis, with or without features of meningitis or brain abscess. Compression of the contralateral internal jugular vein may increase cerebrospinal fluid pressure. No rise in cerebrospinal fluid pressure with compression of the ipsilateral internal jugular vein.

Facial paralysis/paresis: Lower motor neuron paresis/paralysis: whole side of face is affected on the side of pathology; inability to close the eye and upward rolling of the eye on the affected side. Drooping of angle of the mouth and loss of nasolabial fold on the affected side; inability to cause wrinkles of the forehead on the affected side. Petrositis: Diplopia (palsy of lateral rectus eye muscle). Pain in distribution of trigeminal nerve. Otitis media where intracranial suppuration is suspected. Otitis media with complications not responding to adequate treatment. Eradication of the infection with antibiotics. Drainage of abscess/pus. Corrective and/or palliative surgical interventions. Symptomatic and supportive treatment.

Meningitis discussed on page 178. Extradural abscess usually with clinical features of acute mastoiditis. Brain abscess (cerebellum or temporal lobe): Systemic effects of infection: Malaise, pyrexia. Raised intracranial pressure: headache, drowsiness, confusion, impaired consciousness, papilloedema, bradycardia, hypertension. Localising signs (any of the following): - Cerebellar abscess: neck stiffness, weakness and loss of tone on same side as abscess, ataxia (falling to same side), intention tremor with past pointing, dysdiadochokinesis, nystagmus, vertigo.

Referral criteria

Treatment objectives

Treatment guidelines
OTITIS MEDIA, COMPLICATIONS Management Non-drug treatment Surgical treatment Drug treatment Mastoiditis: Ear toilet. Corrective and/or palliative surgical interventions such as mastoidectomy, drainage of brain abscess through burr hole or craniotomy. Initiate treatment with ampicillin + cloxacillin + metronidazole. Ampicillin, IV, < 20 kg, 50100 mg/kg/24 hours in 4 divided doses for 14 days, > 20 kg, 250500 mg 6 hourly for 14 days. PLUS Cloxacillin, IV, 50100 mg/kg/24 hours in 4 divided doses for 14 days. PLUS Metronidazole, oral, 7.5 mg/kg 8 hourly for 14 days. Ceftriaxone + cloxacillin + metronidazole. Ceftriaxone, IV or IM, 2050 mg/kg/24 hours as a single dose or in 2 divided doses for 14 days. PLUS Cloxacillin, IV, 50100 mg/kg/24 hours in 4 divided doses for 14 days. PLUS Metronidazole, oral, 7.5 mg/kg 8 hourly for 14 days. Amoxicillin, oral, < 20 kg, 2040 mg/kg/24 hours in 3 divided doses for 714 days, > 20 kg, 250500 mg 8 hourly for 714 days. Flucloxacillin, oral, < 2 years, 62.5125 mg 6 hourly for 714 days, > 2 years, 125500 mg 6 hourly for 714 days. Oral antibiotics may be considered after 7 days of IV antibiotic treatment (except meningitis and brain abscess) if there are clear signs of improvement. If oral antibiotics are considered, replace ampicillin with amoxicillin, and cloxacillin with flucloxacillin. Collect blood, pus and other specimens for Gram stain, microscopy, culture and sensitivity tests before initiation of antibiotic therapy. Reassess antibiotic therapy as soon as culture results become available or if response to antibiotic therapy is unsatisfactory. Complications following acute otitis media are usually caused by Gram-positive organisms. Complications in patients with chronic otitis media are usually caused by Gram-negative organisms and anaerobes. Comments

Suspected meningitis or brain abscess:

Oral antibiotics:

Treatment guidelines: OTITIS MEDIA, COMPLICATIONS (continued from previous page)

Management Penicillin allergy: Erythromycin + (clindamycin or metronidazole). Erythromycin, IV or oral, 2550 mg/kg/24 hours in 4 divided doses for 14 days. PLUS Clindamycin, IV or oral, 1540 mg/kg/24 hours in 4 divided doses, or Metronidazole, IV or oral, 7.5 mg/kg 8 hourly for 14 days. Ceftriaxone + (clindamycin or metronidazole). Ceftriaxone, IV or IM, 2080 mg/kg/24 hours as a single dose or in 2 divided doses for 14 days. PLUS Clindamycin or metronidazole, dosages above. Chloramphenicol, oral or IV, 50100 mg/kg/24 hours in 4 divided doses for 14 days. Vancomycin, IV infusion over at least 1 hour, 20 mg/kg 12 hourly for 1014 days. Ceftazidime, IV, 30150 mg/kg/24 hours in 3 divided doses for 14 days. Paracetamol, oral, 10 mg/kg 6 hourly. OR Ibuprofen, oral, 20 mg/kg/24 hours in 3 divided doses for 5 days. (Under 30 kg, maximum 500 mg/day). Replace ceftriaxone with chloramphenicol in patients allergic to penicillin and cephalosporins. Monitor vancomycin blood levels. Comments Patients allergic to penicillin may also be allergic to cephalosporins and carbapenems.

Suspected meningitis or brain abscess:

Penicillin and cephalosporin allergy: Resistant staphylococci: Pseudomonas: Analgesic/antipyretic/ anti-inflammatory:

SINUSITIS, CHRONIC AND COMPLICATED

Definition
Chronic or recurrent inflammation of the paranasal sinuses. - signs of involvement of orbital structures (periorbital oedema, erythema, chemosis, proptosis, vision loss, ophthalmoplegia); - signs of brain involvement (neurological signs, ataxia, paresis, paralysis, convulsions, altered level of consciousness). Investigations: X-ray or CT scan may show opacities and fluid levels. CT scan will show if there is involvement of intracranial structures, e.g. brain abscess. Pus, cerebrospinal fluid (CSF) and blood for culture and sensitivity tests. Microscopy and Gram-staining of pus and CSF specimens may give some indication of the micro-organism/s involved.

Pathogenesis
Chronic infection and inflammation of the paranasal sinuses, with or without complications, may result from an underlying abnormality, e.g. allergic rhinitis, polyp, foreign body, septal deviation, diving sports, immune defect. Causative pathogens include S. pneumoniae, H. influenzae, S. aureus, Moraxella catarrhalis and anaerobes. Complications include: Spreading of infection to orbital structures: periorbital cellulitis, subperiosteal or intraorbital abscess. Central nervous system involvement: cavernous sinus thrombosis, meningitis, epidural, subdural or intracerebral abscess. Bone and soft tissue involvement: osteomyelitis.

Referral criteria
Spread of infection to eye/orbital structures or intracranial structures/brain necessitates immediate referral.

Diagnostic criteria
Clinical: Chronic purulent postnasal drip, nasal congestion, headache, facial pain or percussion tenderness, periorbital swelling, fever. Signs and symptoms of complications: - signs of meningeal irritation (neck stiffness, positive Kernigs and Brudzinskis signs); - signs of increased intracranial pressure (hypertension, bradycardia, papilloedema, headache);

Sinusitis not responding to adequate treatment. Lavage, drainage and other surgical procedures.

Treatment objectives

Identification and treatment of underlying predisposing factors. Eradication of the infection. Prevention or early treatment of complications. Symptomatic and supportive treatment.

Treatment guidelines
SINUSITIS, CHRONIC AND COMPLICATED Management Non-drug treatment Drug treatment Less severe cases: (oral antibiotics) Identify and treat the underlying cause, e.g. nasal allergy. See comments. Amoxicillin + flucloxacillin + metronidazole for 1014 days. Amoxicillin, oral, < 20 kg, 2040 mg/kg/24 hours in 3 divided doses, > 20 kg, 250500 mg 8 hourly. PLUS Flucloxacillin, oral, < 2 years, 62.5125 mg 6 hourly, > 2 years, 125500 mg 6 hourly. PLUS Metronidazole, oral, 7.5 mg/kg 8 hourly. Ampicillin + cloxacillin + metronidazole for 1014 days. Ampicillin, IV, < 20 kg, 50100 mg/kg/24 hours in 4 divided doses, > 20 kg, 250500 mg 6 hourly. PLUS Cloxacillin, IV, < 2 years, 62.5125 mg 6 hourly, > 2 years, 125500 mg 6 hourly. PLUS Metronidazole, oral, 7.5 mg/kg 8 hourly. Ceftriaxone + metronidazole + vancomycin for 1014 days. Ceftriaxone, IV, 80 mg/kg/24 hours as a single daily dose. Maximum 4 g per 24 hours. PLUS Metronidazole, oral, 7.5 mg/kg 8 hourly. PLUS Vancomycin, IV infusion over at least 1 hour, 20 mg/kg 12 hourly. Comments Follow-up by medical practitioner or at clinic/hospital. Use appropriate antibiotic therapy based on culture and sensitivity results. Initiate empirically and reassess as soon as culture and sensitivity results become available or if there is no improvement within 4872 hours. Intravenous antibiotics are indicated for sinusitis with orbital or intracranial complications and for severe sinusitis without complications. Oral antibiotics may be considered after 7 days of IV antibiotics in severe sinusitis without complications, if there are clear signs of improvement.

Severe sinusitis without complications:

Sinusitis with intracranial complications:

Monitor vancomycin blood levels.

Treatment guidelines: SINUSITIS, CHRONIC AND COMPLICATED (continued from previous page)
Management Sinusitis with orbital complications: Ceftriaxone + clindamycin for 1014 days. Ceftriaxone, IV, 80 mg/kg/24 hours as a single daily dose. Maximum 4 g per 24 hours. PLUS Clindamycin, IV or oral, 2540 mg/kg/24 hours in 4 divided doses. Comments

Clindamycin: Dilute IV infusion to concentrations of 6 mg/mL.

Penicillin / cephalosporin allergy: Sinusitis, less severe and severe without complications:

Erythromycin + (clindamycin or metronidazole) for 1014 days. Erythromycin, IV or oral, 2550 mg/kg/24 hours in 4 divided doses. PLUS Clindamycin, IV or oral, 2540 mg/kg/24 hours in 4 divided doses, or Metronidazole, IV or oral, 7.5 mg/kg 8 hourly. Vancomycin + metronidazole + chloramphenicol for 1014 days. Vancomycin, IV infusion over at least 1 hour, 20 mg/kg 12 hourly. PLUS Metronidazole, IV or oral, 7.5 mg/kg 8 hourly. PLUS Chloramphenicol, oral or IV, 50100 mg/kg/24 hours in 4 divided doses. Clindamycin + chloramphenicol for 1014 days. Clindamycin, IV or oral, 2540 mg/kg/24 hours in 4 divided doses. PLUS Chloramphenicol, oral or IV, 50100 mg/kg/24 hours in 4 divided doses. Vancomycin, IV infusion over at least 1 hour, 20 mg/kg 12 hourly for 1014 days. Monitor blood levels.

Sinusitis with intracranial/central nervous system complications:

Monitor vancomycin blood levels.

Sinusitis with orbital complications:

Resistant staphylococci:

Treatment guidelines: SINUSITIS, CHRONIC AND COMPLICATED (continued from previous page)
Management Amoxicillin and ampicillin resistance: Amoxicillin and clavulanic acid combination, oral, amoxicillin 2040 mg/kg/24 hours + clavulanic acid 5 mg/kg/24 hours in 3 divided doses for 1014 days. Comments Consider oral amoxicillin + clavulanic acid where there is evidence that the micro-organism sensitivity patterns for ampicillin and amoxicillin are becoming less favourable and higher doses are required for treatment.

Nasal decongestant: Analgesic/antipyretic/ anti-inflammatory:

Oxymetazoline 0.025% nose drops, 2 drops in each nostril 8 hourly for a maximum of 5 days. Paracetamol, oral, 10 mg/kg 6 hourly until fever subsides. OR Ibuprofen, oral, 20 mg/kg/24 hours in 34 divided doses for 5 days. (Under 30 kg, maximum 500 mg/day). Sinus lavage/wash out, drainage procedures.

Surgical treatment

TONSILLITIS, COMPLICATED (Peritonsillar cellulitis, peritonsillar abscess, retropharyngeal abscess)

Definition
Infective process involving the tonsils.

Pathogenesis
Infective process involving the tonsils and peritonsillar tissues caused by bacteria (e.g. beta-haemolytic streptococci, H. influenzae, staphylococci, diphtheroids, anaerobes) and viruses. Complications: Local complications include peritonsillar cellulitis and abscess (quinsy), parapharyngeal abscess, retropharyngeal abscess and suppurative cervical adenitis. Systemic complications include glomerulonephritis, rheumatic fever, and bacterial endocarditis.

Enlarged hyperaemic tonsils with pus exuding from the crypts. Signs of peritonsillar abscess: Usually unilateral; soft palate and uvula on the infected side are oedematous and displaced medially towards the uninvolved side. Signs of retropharyngeal abscess: Swelling on one side of posterior pharyngeal wall and hyperextension of the neck. Investigations: Lateral X-ray of the neck may show the retropharyngeal space to be wider than the C4 vertebral body when a retropharyngeal abscess is present. Tonsillitis with local and/or systemic complications not responding to adequate treatment.

Referral criteria

Diagnostic criteria
Clinical: Pyrexia, headache, malaise. Sore throat, dysphagia, refusal to eat, drooling. Earache (referred otalgia). Tender and enlarged cervical lymph nodes.

Treatment guidelines
Eradication of the offending micro-organism. Drainage of abscesses. Symptomatic and supportive treatment. Tonsillectomy.

Treatment guidelines
TONSILLITIS, COMPLICATED (Peritonsillar cellulitis, peritonsillar abscess, retropharyngeal abscess) Management Non-drug treatment Abscesses must be drained: - Peritonsillar abscess could be drained by aspiration (needle/ syringe). Intra-oral incision or Quinsy tonsillectomy under general anaesthesia is preferred in a small child. - Parapharyngeal abscess bulging in the neck should be drained externally. - Retropharyngeal abscess could be drained by aspiration, but preferably by intra-oral incision. - Suppurative cervical adenitis is drained externally. Initiate treatment with benzylpenicillin and metronidazole, IV, until culture results are available. Benzylpenicillin, IV, 250 000 units/kg/24 hours in 4 divided doses for 7 days. OR Phenoxymethylpenicillin, oral, < 5 years, 125 mg 6 hourly for 7 days, > 5 years, 250 mg 6 hourly for 7 days. Cloxacillin, IV, 50100 mg/kg/24 hours in 4 divided doses for 7 days OR Flucloxacillin, oral, < 2 years, 62.5 mg 6 hourly for 7 days, 25 years, 125 mg 6 hourly for 7 days, > 5 years, 250 mg 6 hourly for 7 days. Metronidazole, oral, 7.5 mg/kg 8 hourly for 7 days. In children who have difficulties in swallowing, administer IV antibiotics until swallowing becomes easier. Comments Tonsillectomy is usually performed 6 weeks after abscess has been drained or systemic complications have settled.

Drug treatment Empirical treatment: Streptococci:

Staphylococci:

Anaerobes:

Treatment guidelines: TONSILLITIS, COMPLICATED (continued from previous page)

Management H. influenzae: Ampicillin, IV, 50100 mg/kg/day in 4 divided doses for 7 days OR Amoxicillin, oral, < 20 kg, 2040 mg/kg/24 hours in 3 divided doses for 7 days, > 20 kg, 250 mg 8 hourly for 7 days. Clindamycin, IV, 1040 mg/kg/24 hours in 3 divided doses for 7 days oral, 1525 mg/kg/24 hours in 3 divided doses for 7 days. Erythromycin, oral or IV, 2550 mg/kg/24 hours in 4 divided doses for 7 days. Cefotaxime, IV, 50100 mg/kg/24 hours in 3 divided doses for 7 days. Chloramphenicol, oral or IV, 50100 mg/kg/24 hours in 4 divided doses for 7 days. Paracetamol, oral, 10 mg/kg 6 hourly. OR Ibuprofen, oral, 20 mg/kg/24 hours in 3 divided doses for 35 days. (Under 30 kg, maximum 500 mg/day). Tonsillectomy usually performed 6 weeks after abscess has been drained or systemic complications have settled. Patients allergic to penicillin may also be allergic to cephalosporins and carbapenems. In children who have difficulties in swallowing, administer IV antibiotics until swallowing becomes easier. Comments

Penicillin allergy: Staphylococci: Streptococci: H. influenzae: Penicillin and cephalosporin allergy Analgesic/antipyretic/ anti-inflammatory treatment:

Surgical treatment