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 Triaging at ED & OPD Indication for referrals / admission

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 Other important Onset of fever history: Oral intake a. Neighbourhood Diarrhoea history of dengue Urine output b. Travelling/ jungle Assess for warning trekking/ swimming in signs waterfall d. Recent unprotected sex or IVDU e. Co-morbidities

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 ASSESSMENT

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

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

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 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
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 CRITICAL PHASE

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

a) Notify the district health office via phone followed by disease notification form b) To determine whether the patient requires admission

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 signs arise

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

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

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

Early consultation with the nearest physician for ALL DHF or DF with organ dysfunction/ bleeding Prerequisites for transfer Optimise the patients 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)

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 Hesss test

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)