1. Chapter 5 Diarrhoea Case II

2. 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.

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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. Give emergency treatment, then reassess, then history and examination

12. 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

13. Poor skin turgor
(Ref. p. 128)

14. (Ref. p. 127)

15. 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.

16. 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)

17. 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)

18. 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

19. 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

20. What supportive care and monitoring are required?

21. Monitoring
Reassess every 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

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

24. 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.