Chapter 5 Diarrhoea Case II

Case study: Chandra Chandra, 2 year old boy referred from health centre with 4 days of profuse diarrhoea. Vomiting everything for 2 days. Lethargic and not able to drink for 1 day.

What are the stages in the management of any sick child?

Stages in the management of a sick child (Ref. Chart 1, p. xxii) Triage Emergency treatment History and examination Laboratory investigations, if required Main diagnosis and other diagnoses Treatment Supportive care Monitoring Discharge planning Follow-up

At Triage – how to quickly assess for emergency signs Take a brief history of the presenting problem Take temperature and weigh the child Listen for stridor or obstructed breathing Look for cyanosis and for signs of respiratory distress (chest indrawing, tracheal tug), check SpO2 Feel the skin temperature of the hands and feet, feel the peripheral pulses for volume, check capillary refill time Assess for lethargy and level of interaction.

Triage: What emergency and priority signs have you noticed? Weight 11.1 kg Temperature: 37.2°C, pulse: 174/min, weak pulses, RR: 50/ min, capillary refill time: 5 seconds; mouth: dry mucus membranes; eyes: sunken, dry, no tears; skin pinch goes back very slowly Blood pressure 65/30

Triage Emergency signs (Ref. p. 2,6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

Emergency treatment Treatment of shock: Give IV fluids (Ref. Chart 7, p. 13) Insert an IV line Take blood for investigations: haemoglobin, electrolytes, acid-base, blood sugar) Attach Ringer's lactate or normal saline (0.9% NaCl) – make sure the infusion is running well Infuse 20ml/kg as rapidly as possible Reassess child after appropriate volume has run in  Do not use 5% Glucose alone or solutions containing only 0.18% NaCl

If peripheral vein access can’t be obtained Nasogastric tube…or if in shock… Intraosseus (Ref. p. 340) Femoral venous access (Ref. p. 342) Intraosseus needle, if not available use 19 or 21 G needle

Emergency treatment (continued) Reassess after the first infusion of 20ml/kg (Ref. Chart 7, p. 13): If no improvement, repeat 20ml/kg as rapidly as possible Reassess the child after second infusion: After the second reassessment Chandra's pulse volume became stronger and capillary refill faster

Give emergency treatment, then reassess, then history and examination

History Chandra was well until 5 days ago, then he had 5 days of loose watery stools, 8-10 times a day. His mother reduced his intake of fluids and food as he was having diarrhoea and she thought this might make this worse. His diarrhoea did not improve. He started vomiting on the third day, many times. He was then taken to the district hospital, as he was lethargic and had stopped eating and drinking. There was no blood or pus in the diarrhoea

Poor skin turgor (Ref. p. 128)

(Ref. p. 127)

Examination - after emergency treatment Chandra was ill-looking and floppy. Not able to drink. Vital signs: temperature: 37.2°C, pulse: 150/min, RR: 45/min Weight: 11 kg (check WFA z-score) Capillary refill time: 3 seconds Mouth: dry mucus membranes Eyes: still sunken, dry, no tears Skin: decreased skin turgor (skin pinch goes back in 3 seconds) Chest: air entry was good bilaterally Abdomen: scaphoid, soft, bowel sounds were active, no liver or spleen enlargement Neurology: lethargic, floppy, there was no neck stiffness and no other focal signs. Not alert, not responding to voice. Moved only with handling.

Classification of the severity of dehydration in children with diarrhoea Signs or symptoms Severe dehydration Two or more of the following signs: lethargy/unconsciousness sunken eyes unable to drink or drinking poorly skin pinch goes back very slowly (>2 seconds) Some restlessness, irritability drinks eagerly, thirsty skin pinch goes back slowly No Not enough signs to classify as some or severe dehydration (Ref. Table 12, p. 128)

Differential diagnoses Acute (watery) diarrhoea Cholera Dysentery Persistent diarrhoea Diarrhoea with severe malnutrition Antibiotic-associated diarrhoea Intussusception Sepsis (e.g. UTI) Use references to distinguish (Ref. p. 127)

Investigations Blood glucose 3.2 mmol/L Electrolytes Na+, K+, acid base What changes in electrolytes might you see? Stool specimen – if you were considering cholera or dysentery

Treatment Diarrhoea treatment Plan C (Ref. Chart 13, p. 131) Antibiotic treatment is rarely necessary (Ref. p. 126) Only for: Dysentery (mostly Shigella) Cholera Neonates with diarrhoea and fever Anti-diarrhoeal agents Never necessary and often harmful

What supportive care and monitoring are required?

Monitoring Reassess every 15-30 minutes until strong radial pulse is present (Ref. Chart 13 p. 131) Reassess skin pinch, capillary refill, consciousness, ability to drink – hourly Use a Paediatric Monitoring and Response chart

Supportive Care Encourage Chandra’s mother to continue breastfeeding when he tolerates it Zinc sulphate to reduce the severity of diarrhoea

Summary Chandra was rehydrated with intravenous fluids followed by oral rehydration solution (ORS). He was discharged when he was alert, able to drink and eat well without vomiting, and had less frequent episodes of diarrhoea. At the time of discharge his mother was given advice on how care for Chandra at home, to continue feeding, to give ORS and to return in 2 days for follow-up. She was shown how to make up ORS, and given 2 packets.