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Dengue Hemorrhagic Fever

Clinical Spectrum
Asymptomatic

dengue viral infection


Symptomatic

Undifferentiated febrile illness (Viral syndrome)


With bleeding

Dengue Fever

Dengue Hemorrhagic Fever (DHF)


Plasma Leakage

(DF)

Without bleeding

With shock

Without shock

DF

DHF
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Criteria from WHO (1999)


Clinical :
Fever 2 7 days Bleeding : RL test (+)/spontaneous bleeding Hepatomegaly Shock 2 clinical + lab

Laboratories :
Low platelet count (<100.000 /ul) Hemoconcentration (>20%)
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DHF Grading of Illness


Grade I Unspecified febrile, Tourniquet test positive Grade II Grade I + spontaneous bleeding Grade III Circulatory failure (restless, fast & small pulse, pulse pressure < 20mmHg, hypotension, cyanosis, cold & moist extremities) Grade IV Shock, undetected pulse and blood pressure
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Management
Febrile < 7 days ?
No 1 (hospitalized) Dangerous signs: - decrease of consciousness - vomiting - seizure - routine - GI tract bleeding

No 2 (non-hospitalized) Without Dangerous signs : 1.Physical & routine lab studies (3rd day) (dengue blot isnt necessary yet) 2.Education (control) 3.Social indication * : hospitalized (parent request, the house is far from hospital)

Other Differentials 7 days DELAY/ reassess carefully


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Early Management (Home Care)


1. Drink as much as possible (avoid tea, coffee, and chocolate-to differentiate the bleeding) 2. Record micturition, frequency and quantities. 3. Gives food if possible 4. Antipyretic for the fever ( > 38 C dose 10mg/kg/times (4-5 x/day) 5. Control to the doctor/primary health care/ hospital everyday 6. Laboratory checkup (Hematocrit and platelet count) (day 3)

INSTRUCTION FOR PARENTS

Name Registry Date & Hours in Emergency Dept


Instruction 1. Control to
Outpatient Clinic : Date :

: : :

2. Immediately go to the emergency dept with this card, if one of the following sign had shown up:
Severe vomiting Faint Cannot eat/drink Hand/feet are cold and/or restlessness Seizures Epistaxis, Hematemesis, Hematoschezia, or any other bleeding sign
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Hematocrit range based by age


Age 2 weeks 3 months 6 mo-6 yrs 7 yrs-12 yrs male female Range ( %) 42-66 31-41 33-42 34-40 42-52 37-47 Mean ( %) 50 36 37 38 47 42
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Nelson Text book of Pediatrics, 2004.

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30/06/05

Right Pleural effusion PEI=27%


B

PEI : A / B x 100 %

Ht, Platelet and Blue Plasma Lymphocyte Changes in DHF Nature Illness
50 45 40 35 30 % 25 20 15 10 5 0 1 2
Fever Phase
250 200 150 X 1000 100 LPB Ht Trombosit 50 0

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Shock Phase

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Healing Phase
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General Policy in DHF Management


In-patient care depends on the grade
Grade I/II: Primary Health Care / One Day Nursing Grade III/IV: Hospital, ICU if indicated (severe shock, repeated shock, GI tract bleeding, encephalopathy)

Laboratory (24 hours) Trained Nurses Blood Bank


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Primary Health Care


1. Nursing care (Monitoring and equipment) * Suspected DHF * Grade 1 DHF * Grade 2 DHF 2. Refer if indicated: * Shock (overcome the shock) * Bleeding (massive) * Short-winded * Encephalopathy
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Primary Health Care


3. If referring to the hospital, you should:
* Write the diagnose completely

* Write the measures and drugs that given to the patient (solution) 4. Follow-up and epidemiological study in the society
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Dangerous sign for dengue shock syndrome


Dangerous sign : Severe Stomached Sever Vomiting Changes from fever to cold. Decrease of consciousness Restlessness
When DSS occur 3 6 days after the manifestation/signs occur
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Four Criteria of DHF: Fever Bleeding manifestation Increased capillary permeability Platelet count<100.000/mm3

Early dangerous sign: Relieve of the fever Low platelet count Increased hematocrit

When to go to the hospital ( 6 S ) (especially when the fever is relieved)


S : Severe vomit/cannot eat S : Severe Stomached S : Severe bleeding (skin, nose, mouth)
S : Since the last 6 hours, hasnt micturition / low urine output S : Skin and foot are cold, moist S : Seizures / Decrease in Consciousness
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Monitoring The Illness


Vital sign monitoring (take caution for signs of early shock) Consciousness: decreased/restless Blood pressure: can be normal Pulse, respiratory rate: increased Hepatomegaly Pain in right hypochondriac Urine output (caution if urine output is low, maintain : >1ml/kgBW/hour)
Ht: start to increase.
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Vital sign in baby and children


Age
0- 1 week 1 week-1 month 1 month-1 year 2-5 years 6-12 years 13 - < 18 years

Tachycardia
>180 >180 >180 >140 >130 >110

Bradicardia Respiratory rate/min


< 100 < 100 < 90 > 50 > 40 > 34 > 22 > 18 > 14

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Temperature curve for dengue infection

Temp

Time of defervescence

Days of illness
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Management of suspect DHF


High fever, unknown origin <7 days faint, no respiratory infection
Emergency cases Shock Leucopenia Seizures Decrease consciousness positive Bleeding Platelet count 100.000/ul Inpatient care No emergency Torniquet test

negative

Platelet count >100.000/ul Outpatient care Control everyday until the fever is relieved Advise the parents

Still Fever >3 days Check Hb, Ht, leukocyte, platelet count

Chart 1 a

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Management of suspect DHF (Inpatient setting)


Can drink
Can not drink Severely vomiting

Drink much 2l/day Paracetamol Anticonvulsive if indicated Clinical & Lab monitoring Shock sign Urine output Bleeding Hb,Ht, platelet every 6-12 hours Get better Home

D5% : NaCl 0.9% = 3:1 Maintanace Check Hb, Ht, platelet every 6 12 hours

Increase Ht, Decrease platelet See chart 2 Change IVF to Ringer Lactate 20 DHF

Chart 1 b

Management of DHF Original IVF

RL/RA/NaCl 0,9% or RLD5/NaCl 0,9%+D5, 6-7 ml/kgBW/hour Monitor vital sign/Ht and platelet count every 6 hours
Get better Unrestlessness Strong pulse Blood pressure stable Good urine output (check twice)

Not better/ No shock


Shock-see shock chart (chart 3)
Decrease vital sign Increase Ht

Restlessness Respiratory Distress Increase pulse frequency Increase Ht Pulse pressure <20 mmHg Low urine output
Increase IVF speed 10-15 ml/kgBW/hour Increase the IVF speed

Reduce the IVF

5 ml/kgBW/hour
Get better Reduce the IVF

Get better
Chart 2

Evaluate 12-24 hour


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Vital sign unstable

3 ml/kgBW/hour

Respiratory distress Increase Ht

Decrease Ht

IVFD stop pada 24-48 jam Bila tanda vital/Ht stabil, diuresis cukup

Colloid 20-30 ml/kgBW

Blood transfusion 10 ml/kgBW

Get better

Management of DHF
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Temperature Curve for Dengue Hemoragic Fever


Clinilcal getting worse, faint, restless, cold hands and feet, increase RR, low urine output, loss of appetite

Shock

Days of illness

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Shock DHF

O2 2-4 l/minute Isotonic solution 20ml/kgbw/ as fast as possible(bolus in 30 minutes)

Evaluate (soon) / 30 minutes, has shock been recover?


Yes Reassess fluid No Continue IVF Colloid Acidosis correction Evaluate 1 hour Recover Clinically stable Ht Stop IVF not >48 hours after the shock has been recover Decrease Transfusion Increase
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Monitoring

Not recover

Returning Home Criteria for the Patient


No fever for 24 hours without antipyretic Good appetite Clinically better Stable Hematocrit Three days after shock recovery Platelet count increased (>50.000/ul) No respiratory distress found (because of pleural efusion or acidosis)
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Conclusion
Dengue viral infection is varies, DHF must be differed with DF Additional work up and monitoring is the key for managing DHF Diagnose criteria from WHO can only be used for DHF Outcome is depends on the duration of shock recovery
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