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)
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