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Clinical phases of
dengue fever
Febrile phase
Critical phase
Tourniquet Test
Recovery phase
gradual reabsorption
of extravascular
compartment fluid
(48-72 hours)
general well-being
improves, appetite
returns, GI symptoms
abate, hemodynamic
status stabilizes and
diuresis ensues
(+) rash: isles of
white in the sea of
red
hematocrit stabilizes
or may be lower due
to dilutional effect of
reabsorbed fluid
WBC starts to rise
recovery of platelet
count occurs later
Tourniquet test
Inflate blood pressure cuff to a point midway between systolic and
diastolic pressure for 5 minutes
After deflating the cuff, wait for the skin to return to its normal
color, and then count the number of petechial visible in a one-inchsquare area on the ventral surface of the forearm.
Positive test:
20 or more petechial rash per 1 inch ((6.25 cm))
(+) TT increases the
probability of dengue
(+) hemorrhagic
manifestations
enlarged and tender
liver
earliest abnormality:
progressive decrease in
total WBC
Renal function
test that include(
S.CrB.urea)
Serology ( dengue antibodies IgM ,IgG when fever at 5th day or more , dengue
antigen when fever less than 4 day )
Liver function test mainly ( ALT ,AST , S,Albumin ,total bilirubin)
Abdominal ultrasound
Chest X-ray
PT,PTT ,INR
Urine exam for microscopic hematuria
6
Dengue
Clinical
Syndromes
Undifferentiated fever
Classic dengue
Fever
Headache, retro orbital pain
Muscle and joint pain
Nausea/vomiting
Rash
Hemorrhagic manifestations
Elevated hematocrit
(defined as 20% or more over baseline, or a similar drop after volume
replacement treatment);
Low protein; or
Pleural or other effusions.
Indirect manifestation
Evidence of
circulatory failure
Groups A
may be sent
home
tolerate
adequate
volumes of
oral fluids
and pass
urine at least
once every 6
hours
no warning
signs
Groups B
referred for
in-hospital
management
with warning
signs, coexisting
conditions,
with certain
social
circumstances
Groups C
require
emergency
treatment and
urgent
referral
severe dengue
(in critical
phase)
Plan for group A: Encourage intake of ORS, fruit juice and other fluids
Paracetamol for fever
Advise to come back if with
no clinical improvement
severe abdominal pain
persistent vomiting
cold and clammy extremities,
lethargy or irritability or restlessness,
bleeding
not passing urine for more than 46 hours.
Calculation assuming
BW 45-50kg
Reassess
Hematocrit remains the same or rise minimally {500 cc
during 6 to 8 hourly)
worsening vital signs and rising hematocrit 250 cc
to 500cc during 1 hr then reassess
10
Group C
Compensated Shock
500- 1000 cc during 1hr.
yes
improve
NO
1000 cc during 4h
500 cc during another 4hr
500 cc during 8hr
Increase
HCT
PLT transfusion given if less than 10000 without overt bleeding and
normal or elevated HCT
Compensated shock
rapid and weak pulse;
narrow pulse pressure of 20 mmHg or hypotension for
age; and
cold, clammy skin and altered mental status.
11
Group C
Hypovolemic shock
HCT assess
1000 cc /15 minute
Improve
yes
Crystalloid solution
500cc /hr
N/S 500 - during 1hr
then
1000 cc during 4h
500 cc during 4hr
500 cc during 8h
500cc during 8hr
2n
Monitor HCT 6hourly
if improve decrease
fluid
if increase another
bolus
if decrease FWB/PRB
HCT
NO
decrease
increase
2nd bolus
500 1000 -1hr
yes
Consider significant
overt /occult blood
FWB/PRBC
improve
NO
nd
decrease
2 HCT
increase
rd
3 bolus
500 1000 cc 1hr
yes
12
improve
NO
rd
3 HCT
13
14