Adult dengue infection 1st encounter identification risk stratification management
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ADULT DENGUE INFECTION 1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION & MANAGEMENT PowerPoint PPT Presentation


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ADULT DENGUE INFECTION 1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION & MANAGEMENT. Dr Ho Bee Kiau / Dr Faizal Salikin. OBJECTIVES: TO IDENTIFY AND MANAGE DENGUE INFECTION AT 1ST ENCOUNTER. Outpatient management & monitoring Stepwise approach Diagnostic challenges

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ADULT DENGUE INFECTION 1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION & MANAGEMENT

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Adult dengue infection 1st encounter identification risk stratification management

ADULT DENGUE INFECTION1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION & MANAGEMENT

Dr Ho Bee Kiau

/ Dr Faizal Salikin


Objectives to identify and manage dengue infection at 1st encounter

OBJECTIVES: TO IDENTIFY AND MANAGE DENGUE INFECTION AT 1ST ENCOUNTER

  • Outpatient management & monitoring

    • Stepwise approach

  • Diagnostic challenges

  • Triaging at ED & OPD

  • Indication for referrals / admission


Outpatient management monitoring

OUTPATIENT MANAGEMENT & MONITORING

  • Symptomatic and supportive

  • Should be assessed with stepwise approach

  • Focus of management - 3 phases of the clinical course

  • Frequent monitoring to recognise plasma leakage and shock early

  • Dengue monitoring record as an outpatient monitoring tool

  • Refer if no immediate HCT facilities


Step 1 overall assessment

1.History

• Onset of fever

• Oral intake

Diarrhoea

• Urine output

Assess for warning signs

Other important history:

a. Neighbourhood history of dengue

b. Travelling/ jungle trekking/ swimming in waterfall

d. Recent unprotected sex or IVDU

e. Co-morbidities

STEP 1 - OVERALL ASSESSMENT


Warning signs

WARNING SIGNS

  • Abdominal pain or tenderness

  • Persistent vomiting

  • Clinical fluid accumulation (pleural effusion, ascites)

  • Mucosal bleed

  • Restlessness or lethargy

  • Liver enlargement > 2 cm

  • Laboratory : Increase in HCT with rapid decrease in platelet


Step 1 overall assessment1

2. Physical examination

i. Assess mental state & GCS

ii. Assess hydration

iii. Assess haemodynamic

• Skin colour

• Cold/ warm extremities

• Capillary filling time (normal < 2 sec)

• Pulse rate & pulse volume

• BP & pulse pressure

STEP 1 - OVERALL ASSESSMENT


Step 1 overall assessment2

STEP 1 - OVERALL ASSESSMENT

2. Physical examination

iv. Look out for tachypnoea/ acidotic breathing/ pleural effusion

v. Check for abdominal tenderness/ hepatomegaly/ ascites

vi.Examine for bleeding manifestation

vii.Tourniquet test (repeat

if previously negative)


Tourniquet test

How to perform?

Inflate the BP cuff on the upper arm to a point midway between the SBP & DBP for 5 min.

A positive test : ≥20 petechiae per 6.25 cm2

(1 inch2)

Note:

Helpful in the early febrile phase (< 3 days) esp. when the platelet count is still normal

TOURNIQUET TEST


Step 1 overall assessment3

STEP 1 - OVERALL ASSESSMENT

3. Investigation

i. Serial FBC and HCT

ii. Dengue serology

  • Leucopaenia followed by progressive thrombocytopaenia (dengue infection)

  • Rising HCT accompanying progressive thrombocytopaenia (DHF)

  • In the absence of a baseline HCT level, a HCT value of >40% in female adults and >46% in male adults should raise the suspicion of plasma leakage


Step 2 diagnosis disease staging and severity assessment

STEP 2: DIAGNOSIS, DISEASE STAGING AND SEVERITY ASSESSMENT

a) Dengue diagnosis (provisional)

b) The phase of dengue illness

(febrile/critical/recovery)

c) The hydration and haemodynamic status

(in shock or not)

d) If admission indicated (triage)


Diagnostic challenges

DIAGNOSTIC CHALLENGES

  • Clinical features of dengue infection are rather non-specific and can mimic many other diseases

  • A high index of suspicion and appropriate history taking (e.g. dengue hotspots) are useful

  • May have co-infection

  • Syndromic approach - helpful


Differential diagnoses during febrile phase

DIFFERENTIAL DIAGNOSES DURING FEBRILE PHASE


Differential diagnoses during critical phase

DIFFERENTIAL DIAGNOSES DURING CRITICAL PHASE


Triaging at ed opd

TRIAGING AT ED & OPD

  • To determine whether urgent attention required

  • Look out for warning signs of shock

  • Triage Checklist

    1. History of fever

    2. Abdominal Pain

    3. Vomiting

    4. Dizziness/ fainting

    5. Bleeding

  • Vital parameters to be taken:

    • Mental state, BP, pulse, temp., cold or warm peripheries


Step 3 plan of management

STEP 3: PLAN OF MANAGEMENT

  • Notify the district health office via phone followed by disease notification form

  • To determine whether the patient requires admission


If admission not indicated what next

IF ADMISSION NOT INDICATED WHAT NEXT?

  • Daily or more frequent f/u from day 3 of illness until afebrile for at least 24–48 hours

  • Provide Dengue monitoring record & Home Care Advice Leaflet

  • Advise patient to return to hospital as soon as the warning signsarise


Home care advice leaflet

HOME CARE ADVICE LEAFLET

  • Encourage adequate intake of fluids

    • eg: fruit juice/barley water/isotonic drink/milk

  • Ensure patient pass urine every 4-6 hours

  • PCM/ tepid sponging for fever

  • Avoid NSAIDs !


Home care advice leaflet for dengue patients

HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS


Criteria for hospital referral admission

Symptoms:

1. Warning signs

2. Bleeding

manifestations

3. Inability to tolerate oral

fluids

4. Reduced urine output

5. Seizure

Signs:

1. Dehydration

2. Shock

3. Bleeding

4. Any organ failure

CRITERIA FOR HOSPITAL REFERRAL / ADMISSION


Consider early admission

CONSIDER EARLY ADMISSION

  • Co-morbidity e.g. DM, HPT, IHD,

  • Coagulopathies, Morbid Obesity, Renal

  • failure, Chronic Liver disease, COPD

  • Elderly > 65

  • Pregnancy

  • Social factors: living far, living alone etc

  • Lab. criteria

  • Rising HCT with reducing platelet count


Referral from hosp without specialist to hosp with specialists

REFERRAL FROM HOSP. WITHOUT SPECIALIST TO HOSP. WITH SPECIALISTS

  • Early consultation with the nearest physician for ALL DHF or DF with organ dysfunction/ bleeding

    Prerequisites for transfer

  • Optimise the patient’s condition before & during transfer

  • The ED/ Medical Department of the receiving hospital must be informed

  • Adequate information to be sent together e.g. fluid chart, monitoring chart & investigation results


Common errors at opd a e department 1

COMMON ERRORS AT OPD & A&E DEPARTMENT (1)

  • Failure to recognise dengue infection in a febrile patient

  • In febrile phase, always have high index of suspicion in

    • febrile patients coming from dengue areas

    • patients with symptoms of dengue

    • patients with positive Hess’s test


Common errors at opd a e department 2

Common Errors at OPD & A&E Department (2)

  • Failure to recognise dengue shock in an afebrile patient

  • In the afebrile patient, always have high index of suspicion for

    • Nausea, vomiting, abdominal pain & warning signs

    • Manifestations of compensated and decompensated shock

    • Changing HCT (rather than platelet count)


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