ADULT DENGUE INFECTION1ST ENCOUNTER: IDENTIFICATION, RISK

STRATIFICATION & MANAGEMENT

Dr V ParanthamanFamily Medicine Specialist

OBJECTIVES: TO IDENTIFY AND MANAGE DENGUE

INFECTION AT 1ST ENCOUNTER

• Outpatient management & monitoring– Stepwise approach

• Diagnostic challenges• 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 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 ASSESSMENT1. History• Onset of fever• Oral intake• Diarrhoea• Urine output

• Other important history:a. Neighbourhood history of dengue

• Urine output • Assess for warning

signs

b. Travelling/ jungle trekking/ swimming in waterfall d. Recent unprotected sex or IVDU e. Co-morbidities

STEP 1 - OVERALL ASSESSMENT

2. Physical examinationi. Assess mental state & GCS ii. Assess hydration iii. Assess haemodynamic • Skin colour• Cold/ warm extremities• Cold/ warm extremities• Capillary filling time (normal < 2 sec)• Pulse rate & pulse volume• BP & pulse pressure

STEP 1 - OVERALL ASSESSMENT

2. Physical examinationiv. Look out for tachypnoea/

acidotic breathing/ pleural effusion

v. Check for abdominal 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 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

Paediatric HCT >40%-Alert

WARNING SIGNS

• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation (pleural effusion,

ascites)ascites)• Mucosal bleed • Restlessness or lethargy• Liver enlargement > 2 cm• Laboratory : Increase in HCT with rapid

decrease in platelet

STEP 2: DIAGNOSIS, DISEASE STAGING AND SEVERITY ASSESSMENT

a) Dengue diagnosis (provisional)b) The phase of dengue illness

(febrile/critical/recovery)(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 • 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 Pain2. 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 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• 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• 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

Signs:1. Dehydration2. Shock 3. Bleedingmanifestations

3. Inability to tolerate oral fluids

4. Reduced urine output5. Seizure

3. Bleeding4. Any organ

failure

*All Paediatric cases diagnosed as Dengue

CONSIDER EARLY ADMISSION

• Co-morbidity e.g. DM, HPT, IHD, Coagulopathies, Morbid Obesity, Renal failure, Chronic Liver disease, COPD

• Elderly > 65• 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 & • 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 infectionin a febrile patient

• In febrile phase, always have high index of suspicion in 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 index of suspicion for

–Nausea, vomiting, abdominal pain & warning signs

–Manifestations of compensated and decompensated shock

– Changing HCT (rather than platelet count)

Diagnosis• Diagnosis & Classify• URTI/TRO Dengue- Not encouraged• Preferably diagnosed as:Common Cold,

ILI, Pharyngitis, Dengue Fever, Bronchitis,Pneumonia,etcILI, Pharyngitis, Dengue Fever, Bronchitis,Pneumonia,etc

•

Don’t forget to NOTIFY!!

Don’t forget to NOTIFY!!

DOCUMENTATION!

Don’t forget to NOTIFY!!

DOCUMENTATION!DOCUMENTATION!

Don’t forget to NOTIFY!!

DOCUMENTATION!DOCUMENTATION!DOCUMENTATION!

• Thank you