2Case study: ChandraChandra, 2 year old presented from health clinic with 4 day history of profuse diarrhoea. Vomiting everything for 2 days. Lethargic and not able to drink for 1 day.
3What are the stages in the management of any sick child?
4Stages in the management of a sick child (Ref. Chart 1, p. xxii) TriageEmergency treatmentHistory and examinationLaboratory investigations, if requiredMain diagnosis and other diagnosesTreatmentSupportive careMonitoringDischarge planningFollow-up
5What emergency and priority signs have you noticed? Temperature: 37.2°C, pulse: 145/min, weak and thready, RR: 50/ min, capillary refill time: 3-4 seconds; mouth: dry mucus membranes; eyes: sunken, dry, no tears; skin pinch goes back very slowly
6Triage Emergency signs (Ref. p. 2,6) Obstructed breathing Severe respiratory distressCentral cyanosisSigns of shockComaConvulsionsSevere dehydrationPriority signs (Ref. p. 6)Tiny babyTemperatureTraumaPallorPoisoningPain (severe)Respiratory distressRestless, irritable,lethargicReferralMalnutritionOedema of both feetBurns
9Emergency treatment □How do you treat signs of shock? Give IV fluids (Ref. Chart 7, p. 13)Insert an IV line (and draw blood for immediate investigations such as: haemoglobin, blood sugar)Attach Ringer's lactate or normal saline (0.9% NaCl) – make sure the infusion is running wellInfuse 20ml/kg as rapidly as possibleReassess child after appropriate volume has run in Do not use 5% Glucose alone or solutions containing only 0.18% NaCl
10If peripheral vein access can’t be obtained Intraosseus (Ref. p. 340)Femoral venous access (Ref. p. 342)Intraosseus needle, if not available use 19 or 21 G needle
11Emergency treatment (continued) Reassess after the first infusion of 20ml/kg (Ref. Chart 7, p. 13):If no improvement, repeat 20ml/kg as rapidly as possibleReassess the child after second infusion:After the second reassess Chandra's pulse became slower and his capillary refill faster
12Emergency treatment (continued) Switch to following treatment if child's pulse becomesslower or the capillary refill faster (Ref. Chart 11, p. 17):Give 70ml/kg Ringer's lactate solution (or normal saline) over 2,5 hoursTotal volume for Chandra: 850ml (340ml/h)Reassess the child every 1-2 hoursGive ORS as soon as the child can drinkReassess the child after 3 hours and classify dehydration
13Give emergency treatment until the patient is stable
14HistoryChandra had been well 5 days ago, but then he began to have loose watery stools 6-8 times a day. His mother reduced his intake of fluids and feed as he was having diarrhoea and she thought this might make this worse. On the second day he was taken to a local medical shop where he received a syrupy medicine and a packet of oral rehydration solution.His diarrhoea did not improve, still 6-8 times each day. He started vomiting on the third day. He was then taken to the district hospital, as he had become lethargic and had stopped eating and drinking altogether. There was no blood or pus in the diarrhoeal stool.
15Examination after stabilisation Chandra was ill-looking and floppy. He was still unable to drink.Vital signs: temperature: 37.2°C, pulse: 120/min, RR: 40/minWeight: 11 kgCapillary refill time: 2 secondsMouth: dry mucus membranesEyes: still sunken, dry, no tearsSkin: decreased skin turgor (skin pinch goes back in 3 seconds)Chest: air entry was good bilaterally and there were no added soundsAbdomen: scaphoid, soft, bowel sounds were active and there was no organomegalyNeurology: lethargic, floppy, there was no neck stiffness and no other focal signs
16Classification of the severity of dehydration in children with diarrhoea Rapid assessment of hydration status and classification of severity of dehydration in children with diarrhoea:ClassificationSigns or symptomsSeveredehydrationTwo or more of the following signs:lethargy/unconsciousnesssunken eyesunable to drink or drinking poorlyskin pinch goes back very slowly (>2 seconds)Somerestlessness, irritabilitydrinks eagerly, thirstyskin pinch goes back slowlyNoNot enough signs to classify as some or severe dehydration(Ref. Table 12, p. 128)
19Differential diagnoses List possible causes of the illnessMain diagnosisSecondary diagnosesUse references to confirm (Ref. p. 127)
20Differential diagnoses (continued) Acute (watery) diarrhoeaCholeraDysenteryPersistent diarrhoeaDiarrhoea with severe malnutritionDiarrhoea associated with recent antibiotic useIntussusception
21Additional questions on history Diarrhoeafrequency of stoolsnumber of daysblood in stoolsLocal reports of cholera outbreakRecent antibiotic or other drug treatmentAttacks of crying with pallor in an infant
22Further examination based on differential diagnoses Look for:Blood in stoolSevere malnutritionAbdominal massAbdominal distension
23What investigations would you like to do to make your diagnosis ?
24At this stage no additional investigations are necessary
25Diagnosis Summary of findings: Examination: lethargy, sunken eyes, decreased skin tugor, unable to drink History: 4 day of profuse diarrhoea and vomiting everything for 2 days.Acute diarrhoea with severe dehydration
26How would you treat Chandra after stabilisation?
27Treatment Diarrhoea treatment Plan C (Ref. Chart 13, p. 131) Antibiotic treatment is rarely necessary (Ref. p. 126)Only for:Dysentery (mostly Shigella)CholeraNeonates with diarrhoea and feverAntidiarrhoeal agentsNever necessary and often harmful
28What supportive care and monitoring are required?
29Supportive CareAll children should start to receive some ORS (about 5ml/kh/hour) by cup when they can drink without difficultyIf the child is normally breastfed, encourage the mother to continue breastfeeding frequentlyWhen severe dehydration is corrected, prescribe zinc
30MonitoringReassess every minutes until strong radial pulse is present (Ref. Chart 13 p. 131)Reassess skin pinch, capillary refill, consciousness, ability to drink - hourlyIf signs of severe dehydration are still present, repeat IV fluid infusion as outlined earlierIf the child is improving but still shows signs of some dehydration, discontinue IV treatment and give ORS for 4 hours (Treatment Plan B)If there are no signs of dehydration, follow Treatment Plan A
31SummaryChandra was rehydrated with intravenous fluids followed by oral rehydration solution.He was discharged when he was alert, able to drink and eat, and had less frequent episodes of diarrhoea.At the time of discharge his mother was given advice on how to give extra fluid, to continue feeding and to return for follow up.She was also given a Mother’s card containing this information and two packets of oral rehydration solution.