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• Onset of fever• Oral intake• Diarrhoea• Urine output • Assess for warning

signs

• Other important history:a. Neighbourhood history of dengueb. Travelling/ jungle trekking/ swimming in 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 ASSESSMENT2. Physical examinationi. 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 ASSESSMENT2. Physical examinationiv. 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 TESTTOURNIQUET TESTHow 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. Investigationi. Serial FBC and HCTii. 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 fever2. Abdominal Pain3. Vomiting4. Dizziness/ fainting5. 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 manifestations3. Inability to tolerate oral fluids4. Reduced urine output5. Seizure

Signs:1. Dehydration2. Shock 3. Bleeding4. 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 patient’s 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 Hess’s 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)