2. Objectives
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Course of Dengue Illness
Approach to Suspected Dengue Patient
Recognizing Severe Dengue
Clinical Management
Good vs Bad Practice
3. Course of Dengue Fever
• After incubation, Dengue Fever begins abruptly.
• Three Phases; Febrile, Critical and Recovery.
• Severe Dengue may occur from Day 4-5 instead of
the recovery phase. This may involve
Hypovolemic/Hypotensive shock, Coagulation
abnormalities or Severe Organ impairment.
• Most cases recover without hospital management.
• Triage, Guidelines and management decisions at the
primary care level can help in identifying those at risk
of severe Dengue and needing hospital care.
5. At the Primary Care Level
• Recognize the Febrile patient could have Dengue.
• Notify the Public Health Authorities early about suspected
cases.
• Managing the early Febrile Phase of Dengue.
• Recognize the Critical Phase as plasma leakage and to
initiate fluid therapy.
• Recognize the Warning Signs and the need for referral.
• Recognize and manage severe plasma leakage and shock,
severe bleeding and organ impairment promptly and
adequately.
6. Approach to Suspected Dengue Patient
• Stepwise approach
• Step 1 – Overall Assessment
1. History
2. Physical Examination
3. Investigations
• Step 2 – Diagnosis, assessment of disease phase
and severity
• Step 3 – Management
1. Group A, B or C
7. History
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Date of onset of fever/illness
Quantity of oral intake
Assessment of Warning Signs
Diarrhoea
Change in mental state/seizures/dizziness
Urine output
Other – neighbourhood dengue, travel to endemic
areas, co-existing conditions, risk factors for
Leptospirosis, Malaria, HIV
10. • “ isles of white in the sea of red”
• Hemorrhagic Rash
11. Tourniquet Test
• Blood Pressure Cuff is applied and inflated midway
between the systolic and diastolic pressures
• Leave on for five minutes
• Positive if there are more than 10 petechiae in one
inch circle.
• Dengue Hemorrhagic Fever usually results in 20 or
more petechiae.
• Confounding factors include
premenstrual/postmenstrual women and sundamaged skin
14. Management
• Disease Notification – suspected and confirmed
cases in Dengue endemic countries. Confirmation can
come later for suspected cases. Early notification is
key to initiate vector eradication.
• Clinical manifestations and circumstances leads to
patient being sent home (Group A), referred for inhospital management (Group B) or emergency
treatment and urgent referral (Group C.)
• Education of patient and relatives on disease and
vector management
15. Group A
• No Warning Signs
• No significant co-morbid conditions or social
circumstances
• Must be able to tolerate adequate oral fluids
• Must be passing urine at least every six hours
• May be sent home with instructions and plans for
follow-up
• Bed rest; fluid intake; paracetamol
• Daily review for disease progression
16. Group B
• Stable patients with Warning Signs or patients without the
warning signs but have significant co-morbid conditions
or social circumstances.
• Referral for in-hospital care
• Obtain baseline CBC with HCT
• Encourage oral fluids; if not tolerating for 0.9% N/S or
Ringer’s Lactate at maintenance rate.
• For those with Warning signs give 0.9% N/S or Ringer’s
Lactate at 5-7ml/kg/hr for 1-2 hrs, then reduce to 35ml/kg/hr for 2-4 hrs, then reduce to 2-3 ml/kg/hr
according to clinical response.
17. Group B
• Reassess, repeat HCT
• If HCT is stable then continue at 2-3ml/kg/hr.
• If worsening of vital signs or rising HCT increase to 510 ml/kg/hr for 1-2 hrs then reassess
• Observe urine output and fluid intake
18. Group C
• Warning signs present plus features of:
Severe plasma leakage and shock
Fluid accumulation with respiratory distress
Severe bleeding
Severe Organ impairment
• For Emergency Treatment and Referral
• CBC and baseline HCT
• Other organ function tests
• Start IV fluid resuscitation with crystalloid solutions at 510 ml/kg/hr for 1 hr.
• Reassess patient
19. Group C
• If patient improves gradually reduce to 5-7 ml/kg/hr for
1-2 hrs, then 3-5 ml/kg/hr for 2-4 hrs then 2-3 ml/kg/hr
for 2-4 hrs
• If patient is still unstable check HCT
If HCT increases or is still high repeat a second bolus
at 10-20 ml/kg/hr for one hr. If there is improvement
reduce to 7-10 lm/kg/hr for 1-2 hrs and continue to
reduce as the above
• If HCT decreases this indicates bleeding and need for
transfusion
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25. Conclusion
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Course of Dengue Illness
Primary Approach to Suspected Dengue Patient
Recognizing Severe Dengue
Clinical Management of Groups A, B, C
Good vs Bad Practice