communicable diseases

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TABLE OF CONTENTS

Page

Editorial Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

How to Use this Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Acronym Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Common Diseases in Evacuation Centers During Disasters

Section I. Viral Exanthems

Measles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Rubella (German Measles) . . . . . . . . . . . . . . . . . . . . . . 2

Varicella . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Section II. Respiratory Diseases

Upper Respiratory Tract Infection (Common Colds and Cough) . . . . . . . . . . 4

Bronchial Asthma . . . . . . . . . . . . . . . . . . . . . . . . . 5

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Pneumonia - Adult . . . . . . . . . . . . . . . . . . . . . . . . . 7

Pneumonia - Pedia . . . . . . . . . . . . . . . . . . . . . . . . . 8


Section III. Systemic Diseases

Dengue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Leptospirosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Mumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Section IV. Gastro-intestinal Diseases

Acute Gastroenteritis (Diarrhea) . . . . . . . . . . . . . . . . . . . . 13

Typhoid Fever . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Viral Hepatitis A . . . . . . . . . . . . . . . . . . . . . . . . . 15

Section V. Other Diseases

Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Skin Diseases

Contact Dermatitis . . . . . . . . . . . . . . . . . . . . . . . 18

Tinea Corporis (Body ringworm) . . . . . . . . . . . . . . . . . . 19

Tinea Pedis (Athlete’s foot) . . . . . . . . . . . . . . . . . . . . 20

Tinea Versicolor (Tinea Flava) . . . . . . . . . . . . . . . . . . . 21

Tetanus Non-Neonatorum . . . . . . . . . . . . . . . . . . . . . . 22

Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Dog/ Cat Bite . . . . . . . . . . . . . . . . . . . . . . . . . 24

Snake Bite . . . . . . . . . . . . . . . . . . . . . . . . . . 25


Annexes

1a Assessment Table for Dehydration in Acute Gastroenteritis (Diarrhea) . . . . . . . . 26

1b Treatment Plan A & B for Acute Gastroenteritis (Diarrhea) . . . . . . . . . . . . 27

1c Hospital Management Protocol for Acute Gastroenteritis (Diarrhea) . . . . . . . . . 28

2 Hospital Management Protocol for Bronchial Asthma . . . . . . . . . . . . . 31

3 Hospital Management Protocol for Dengue . . . . . . . . . . . . . . . . . 34

4a Table of Oral Anti-Hypertensive Drugs . . . . . . . . . . . . . . . . . . 38

4b Hospital Management Protocol for Hypertensive Emergency . . . . . . . . . . . 39

5 Hospital Management Protocol for Influenza . . . . . . . . . . . . . . . . 43

6a Hospital Management Protocol for Leptospirosis . . . . . . . . . . . . . . . 46

6b Management of Oliguria-Anuria in Leptospiral Acute Renal Failure . . . . . . . . 49

7 Hospital Management Protocol for Malaria . . . . . . . . . . . . . . . . . 51

8 Hospital Management Protocol for Measles . . . . . . . . . . . . . . . . . 57

9 Hospital Management Protocol for Mumps . . . . . . . . . . . . . . . . . 59

10 Hospital Management Protocol for Pneumonia-Adult . . . . . . . . . . . . . 60

11a Clinical Diagnosis of Pneumonia for Specific Pediatric Age Groups . . . . . . . . . 63

11b Hospital Management Protocol for Pneumonia-Pedia . . . . . . . . . . . . . 64

12 Hospital Management Protocol for Rubella (German Measles) . . . . . . . . . . 67

13 Hospital Management Protocol for Snakebite . . . . . . . . . . . . . . . . 68

14 Hospital Management Protocol for Tetanus Non-Neonatorum . . . . . . . . . . . 71

15 Hospital Management Protocol for Typhoid Fever . . . . . . . . . . . . . . . 77


16 Hospital Management Protocol for Varicella . . . . . . . . . . . . . . . . 79

17 Hospital Management Protocol for Viral Hepatitis A . . . . . . . . . . . . . . 81

18a Local Wound Management . . . . . . . . . . . . . . . . . . . . . . 84

18b Management Protocol for Dog/ Cat bite . . . . . . . . . . . . . . . . . . 86

19 Management Protocol of Shock . . . . . . . . . . . . . . . . . . . . . 92

20 Management Protocol for Cardiopulmonary Resuscitation (CPR) . . . . . . . . . . 93

21 Immunization Schedule for Children . . . . . . . . . . . . . . . . . . . 94

22 Immunization Schedule for Adults . . . . . . . . . . . . . . . . . . . . 95

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97


EDITORIAL BOARD

CHAIRPERSON

CARMENCITA A. BANATIN, MD, MHA Director III

Health Emergency Management Staff Department of Health

MEMBERS

JOSE BENITO R. VILLARAMA, MD, MPH

Chief Medical Professional Staff San Lazaro Hospital

EUMELIA P. SALVA, MD, DTMH, MPH, FPSMID

Head, Public Health Service San Lazaro Hospital

EFREN M. DIMAANO, MD, FPSMID

Head, Clinical Division San Lazaro Hospital

FERDINAND S. DE GUZMAN, MD, FPSVi

Head, Family Medicine Infectious Disease & Tropical Medicine Department

San Lazaro Hospital i


INTRODUCTION

One of the risks brought about by health emergencies and disasters is the occurrence of diseases, communicable and non – communicable. The synergism between poor environmental sanitation, delayed medical services, and inadequate resources including food and water can give rise to diseases with epidemic potential and other opportunistic infections. Records review revealed that there are diseases that commonly affect the population at the evacuation centers and at the disaster site. Immediate and definitive treatment and management of diseases during emergencies and disasters is a norm in order to prevent outbreak and possible episodes of debilitation among the sick and the injured. The Department of Health has developed several treatment protocols for specific diseases, especially to those who have its corresponding program like Dengue, Diarrhea, Acute Respiratory Infection and others. Predicament lies in those diseases that do not have an attached program. Experiences at the evacuation centers revealed that many of the health personnel had difficulty in extending immediate management in some of the diseases and they clamor for treatment protocols that are presented in flow chart algorithm that are easily accessible and can be effortlessly followed. This Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments during Emergencies and Disasters was conceptualized in order to address the need of the health responders in managing diseases that commonly exist at the community level, at the impact site, evacuation centers and during transport to a health facility. The Health Emergency Management Staff through the financial assistance from the World Health Organization has commissioned the San Lazaro Hospital Medical Staff Association, Incorporated to develop a treatment protocol of the common diseases that exist at the above mentioned sites. The development process entails consultation with the different medical societies and specialty hospitals that caters to specific diseases. Comprehensibility test was also administered to the end user to ensure that the manual will cater to the needs of the target user. It is with great confidence that this manual will enable the health responders in giving immediate and definite care and management to their patient in order to alleviate their illness and their health needs during the times they need it most.

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ACKNOWLEDGMENT

The Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments during Emergencies and Disasters is made possible and available to the Medical Community in the Philippines because of the support and participation of the different organizations, institutions, hospitals and committees. The Health Emergency Management Staff would like to thank the following: For contributing their technical expertise, our gratitude to Dr. Dominga Padilla-Lopez, Philippine Academy of Ophthalmology, Inc.; Dr. Maria Nanette A. Pamatian, Philippine Academy of Family Physicians, Inc.; Dr. Ma. Encarnita B. Limpin, Philippine College of Physicians; Dr. Epifania S. Simbul, Philippine Pediatric Society; Dr. Lita C. Vizconde, Philippine Society for Microbiology and Infectious Diseases; Dr. Susan C. Lee, San Lazaro Hospital; Dr. Albert G. Lu, San Lazaro Hospital; Dr. Jerome Laceda, San Lazaro Hospital; Dr. Rosario Jessica T. Abrenica, San Lazaro Hospital; Dr. Lester A. Deniega, University of Santo Tomas Hospital; Dr. Emmanuel F. Montaña, Jr., Jose R. Reyes Memorial Medical Center; Dr. Joseph T. Juico, Jose R. Reyes Memorial Medical Center; Dr. Cecilia C. Dizon, National Children’s Hospital; Dr. Mary Antonnette C. Madrid, Philippine Children’s Medical Center; Dr. Regina Berba, Philippine General Hospital; Dr. Beatriz P. Quiambao, Research Institute for Tropical Medicine; Dr. Gerard Belimac, NCDPC-DOH; Dr. Eric A. Tayag, NEC-DOH; Mr. Noel T. Orosco, NEC-DOH and Dr. Marilyn Go, DOH-HEMS. For their untiring assistance during the conduct of the comprehensibility assessment, we would like to extend our deep gratitude to Director Nestor Santiago, Dr. Virgilio Ludovice, Dr. Juancho Torres, Dr. Alan Lucañas, Dr. Aurora M. Daluro and Mr. Camilo H. Aquino of the Center for Health Development V. For their active participation through the comments and suggestions given during the focus group discussion during the pre-testing, we would like to give our gratitude to Dr. Anna Lynda Bellen, ICP Consultant and Ms. Rosario G. Coralde, Nurse IV of BRTTH; Mr. Noel B. Pitapit and Ms. Emerly D. Ostonuse, Nurses of JBDMDH; Dr. Shiela M. Cao, Municipal Officer III of ZMNH, Tabaco City; Dr. Ma. Crispa L. Florece, MHO, Ms. Gisela Buiza, PHN and Ms. Arlyn S. Obispo, RHM of Camalig-RHU; Ms. Dolores T. Adornado, PHN and Ms. Mardi G. Aragon, RHM of Daraga-RHU; Dr. Joann M. Limos, MHO, Ms. Gloria P. Oringo, PHN and Ms. Hospicia P. Morta, RHM of Guinobatan-RHU; Dr. Rosa Maria B. Rempillo, MHO and Ms. Rosemarie M. Nacion, Nurse II of Sto. Domingo-RHU.

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The manual would not have reached its realization if not for the prudence and indefatigable efforts of the officers and members of the San Lazaro Hospital Medical Staff Association Incorporated namely Dr. Jose Benito R. Villarama, Chief of Clinics; Dr. Eumelia P. Salva, Head, Public Health Service; Dr. Efren M. Dimaano, Head, Clinical Division; Dr. Ferdinand S. de Guzman, President, SLH-MSA, Inc. and Dr. Alexis Q. Dimapilis, SLH-HEMS Coordinator that comprises the Core Group. Indebtedness is likewise given to the members of the Technical Group from the different Medical Department of San Lazaro Hospital namely the Adult Infectious Disease and Tropical Medicine composed of Dr. Emilio S. Pandong – Team Coordinator, Dr. Ma. Luisa Nallica; Family Medicine Infectious Disease and Tropical Medicine composed of Dr. Shane D. Marte – Team Coordinator, Dr. Harold A. Sosa, Dr. Ricardo H. Tandingan, Jr., Dr. Sharonda G. Abriam and the Pediatrics Infectious Disease and Tropical Medicine composed of Dr. Ethel C. Daño – Team Coordinator, Dr. Philip A. Morales, Dr. Farah Josefa Nerves, and Dr. Marco Ferdinand W. Torres. And last but not the least, we are commending the invaluable patience of the secretarial staff Ms. Ma. Lourdes Carina D. Lacuata and Ms. Delma R. Eliserio. Special gratitude is given to Ms. Susana G. Juangco, who had generously shared her time and effort in finalizing this manual. Finally, our indebtedness to the World Health Organization, Philippines (WHO) for providing the financial assistance in the development and production of this Manual of Treatment Protocol. HEALTH EMERGENCY MANAGEMENT STAFF

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HOW TO USE THE MANUAL

The Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments during Emergencies and Disasters covers a wide range of illnesses frequently encountered by health worker/s during emergencies and disasters. This guidebook consist of management algorithms which illustrate general signs and symptoms (green box) of a specific disease for easy detection, trailed by local measures (blue box) that can be done in evacuation areas, warning signs (yellow box) of said diseases, and the corresponding emergency measures (blue box) that can be performed before or during transport of patient to the hospital. It also contains hospital management protocols to guide health worker/s in the hospital where the patient is referred. A format known as the management flow-chart algorithm is used in presenting this manual. It is constructed in such a way that clinical manifestations (general signs and symptoms/ warning signs) are shown as top boxes and the courses of action (local measures/ emergency measures) in bottom boxes. It is hoped that health worker/s will find the flow chart easy to follow and understand. The broad orange arrow pointing to the right warns health worker/s on worsening condition of the patient that warrants referral to the hospital or medical specialists (red box). The broad orange curved line connecting the top box to the bottom box defines the appropriate courses of action to be undertaken by the health worker/s. The Acronym Guide provides the list of abbreviations while the Glossary of Terms defines the medical terminologies used in this manual to assist health worker/s in easily understanding its contents. Annexes in the guidebook include further details that are too lengthy to be contained in the box/es and management of patient in a hospital set-up. These are vital to the algorithm to expand details and clarify the courses of action (treatment guidelines).

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DISCLAIMER

The Manual contains management guidelines which is authored and approved for publication by various medical organizations and institutions. Thus, the treatment protocols published herein represent the collective knowledge, experience and skills of participating medical practitioners as well as latest consensus guidelines. Although every effort has been made in compiling and checking the information contained in this guidebook to ensure that they are accurate and valid up to the time of publishing, there is no absolute claim or certainty for this treatment guidelines to work and/or be effective at all times. This manual is intended to guide health worker/s (physicians, nurses and midwives under the supervision of physicians) in evacuation areas/centers and hospitals in an emergency or disaster setting where urgency is the key. The inclusion or exclusion of any medical procedure does not mean to advocate or reject its use either generally or in any particular field of circumstances. Thus, the management guidelines should not be regarded as absolute rules since nuances and peculiarities in individual cases or particular disaster areas may entail differences in the specific approach. In the end, the recommendations should supplement, and not replace sound clinical judgment.

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GLOSSARY OF TERMS

ammonia - a nitrogenous waste product of protein/amino acids breakdown anaphylaxis - exaggerated allergic reaction to a foreign protein resulting from previous exposure to it ancillary - supplementary test antihistamine - a drug that neutralize/ inhibit the effect of histamine in the body, used in the treatment of allergic disorders antiseptic solution - antimicrobial substance that are apply in the skin and living tissues to reduce the occurrence of infections anti-toxin - a substance formed in the body that counteracts a specific toxin or antibody formed in immunization with a given toxin,

used in treating or immunizing against infectious diseases anti-venin - an antitoxic serum obtained from the blood of an animal following repeated injections of venom anuria - urine output less than 100 ml/day aspiration - the act of inhaling fluid or a foreign body into the bronchi and lungs, often after vomiting atri- ventricular block - a disorder in conduction in which the sino-atrial impulse are not conducted to the heart ventricle avulsion - complete or incomplete tearing of body parts body mass index - a measure of body fat based on height and weight bolus - large dose of drug given IV for the purpose of rapidly achieving the needed therapeutic concentration in blood stream booster dose (booster shot) - a dose of an immunizing substance given to maintain or enhance the effect of a previous one bradycardia - heart rate below60 beats per minute bronchodilator - a substance that dilate constricted bronchial tubes to aid breathing, used especially for relief of asthma calf muscle - muscular structure at the posterior aspect of the leg carcass - the dead body of an animal catecholamine - any of a group of chemically related neurotransmitters such as epinephrine and dopamine, that have similar effects on the sympathetic nervous system cerebral edema - swelling of the brain central venous pressure - venous pressure as measured at the right atrium chemoprophylaxis - prevention of disease by means of chemical agents or drugs or food nutrients chest in-drawing (retraction) - a definite inward motion of the lower chest wall on breathing in cholestyramine - ion-bonding resin that form insoluble complex with bile acid clotting factors - plasma proteins involved in blood coagulation

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coagulopathy - a condition characterized by abnormality in blood clotting co-morbid illness - co-existing illness complement fixation - demonstration of specific antibody based on fixing of known quantity of complement to the antigen the

binding of complement to immune complexes or to certain foreign surfaces, as those of invading microorganisms crackles - short, sharp or rough sounds heard with a stethoscope over the chest, most often heard in pleurisy with fibrinous exudates cryoprecipitate blood component - rich in factor VIII and fibrinogen cyanosis - bluish coloration of the skin, mucous membranes, and nail-beds, resulting from a lack of oxygenated hemoglobin in the blood defervescence - period of abatement of fever dehydration - an abnormal loss of water from the body, especially from illness or physical exertion desensitization - the elimination or reduction of natural or acquired reactivity or sensitivity to an external stimulus, as an allergen. diastolic pressure - arterial pressure during myocardial relaxation disseminated intravascular coagulation - a hemorrhagic syndrome that occurs following uncontrolled activation of clotting factors

and fibrinolytic enzymes down syndrome - chromosomal dysgenesis caused by translocation of chromosome 21 droplet transmission - contact involving conjunctivae or mucous membranes of the nose or mouth of a susceptible person with large

droplet (larger than 5 um in size) particle containing microorganisms dyslipidemia - abnormal level of lipid & lipoprotein in the blood dysphonia - difficulty in voice production due to laryngeal/ pharyngeal diseases or anatomical abnormality eclampsia - a form of toxemia of pregnancy, characterized by albuminuria, hypertension, and convulsions electrolyte - any inorganic compounds (sodium, potassium, magnesium, calcium, chloride, and bicarbonate), that dissociate in biological

fluids as ions capable of conducting electrical currents that constitute a major force in controlling fluid balance in the body endemicity - presence of the disease in a particular geographic area, prevailing continually in an area envenomation - injection of poisonous material (venom) by an animal bite epiphora - overflow of tears due to obstruction of lacrimal duct exudates - fluid with high content of protein and cellular debris which has escaped from blood vessel as a result of inflammation fluorescent antibody technique (rabies) - immuno-staining assay using fluorescein-labeled marker coupled with anti-immunoglobulin hemagglutination - inhibition-test to detect the amount of specific antigen in the blood/serum hematocrit - percentage of the volume of a blood sample occupied by cell hematuria - presence of blood cell and blood in urine hemoculture - blood culture

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hemoglobinopathy - a genetic defect resulting in abnormal structure of one of the globin chains of the hemoglobin molecule hemolysis - liberation and separation of hemoglobin from the red cells and its appearance in the plasma hepatic encephalopathy - complication of liver failure resulting from accumulation of toxic substances high caloric diet - food having high energy producing value homeostasis - state of balance in the body with respect to various function and chemical composition of the fluid and tissues hydration - fluid treatment/ replacement hypertensive encephalopathy - transient neurologic symptoms associated with severe elevation in blood pressure hyperventilate - to breathe rapidly & deeply ICT/Opti-Mal-ParaSight F, ICT-Malaria Pf, OptiMAL - dipstick antigen tests useful in confirming malarial infection (P. falcifarum) incubation period - development of disease from the time of exposure to development of clinical signs and symptoms isotonic solution - same salt concentration as in normal cell and blood jaundice - yellowish discoloration of skin & mucus membrane kawasaki syndrome - an acute illness of unknown cause, occurring primarily in children, characterized by high fever, swollen lymph

glands, rash, redness in mouth and throat, and joint pain koplik spots - small, white spots (often on a reddened background) occuring on the inside of the cheeks early in the course of measles Kulantro (Tag.); uan-suy (Tag.); coriander (Engl.) - medicinal plant use for various ailments like erythema and colic loss of skin turgor - persistence of skin fold in the skin after pinching with the thumb and index finger malaise - a vague feeling of discomfort malignancy - neoplastic growth having the properties to be locally invasive and able to metastasize malnutrition - condition caused by improper nutrition or insufficient diet mean arterial pressure - mean pressure during the entire cardiac cycle measles IgM - antibody assay for acute measles metabolic acidosis - a disturbance in which acid-base status shifts toward acidic body condition because of loss of base or retention of

non-carbonic or fixed acids metabolic encephalopathy - temporary or permanent damage to brain that occurs when body metabolic process is seriously impaired microscopic agglutination test (MAT) - gold standard serological assay for leptospirosis antibody detection using 23 leptospire antigens myalgia - muscle pain myocardial ischemia - tissue hypoperfusion due to obstruction of inflow of arterial blood in the heart myoglobinuria - presence of myoglobin in urine myotoxic - destructive to muscle tissue

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nasal prong - tubular plastic with a prong used in the delivery of oxygen nasogastric - intubation of stomach by way of nasal passage neurotoxic - poisonous to nervous system non-neonatal - refers to more than 28 days old infants oliguria - urine output less than 400 cc/24 hours otitis media - inflammation of the middle ear papule - small circumscribed solid elevation in the skin parasitemia - presence of parasite (malaria)in the blood parenteral - intravenous injection paresis - weakness passive immunization - transfer of preformed antibody to non-immuned individuals peak expiratory flow rate - measurement tool to assess the severity of asthma and response to treatment period of onset - the time when the first symtom manifested petechiae - raised < 3 mm in diameter lesion due to inflammation of vessel wall with subsequent hemorrhage portal hypertension - hypertension of portal system due to venous obstruction/ occlusion causing splenomegaly post-auricular lymph node - circumscribed swelling at the back of the ear preeclampsia - a form of toxemia of pregnancy, characterized by hypertension, fluid retention, and albuminuria, sometimes

progressing to eclampsia pressure bandage - elastic bandage or any cloth use to immobilize the bitten limb as in snake bite primigravid - first pregnancy pro re nata (prn) - as needed pruritus - itchiness pulsus paradoxus - an exaggerated drop (> 10mm Hg) in the systolic arterial blood pressure upon inspiration wherein the drop is

larger than the decrease that normally occurs upon inspiration pyrethroid - any of various synthetic compounds that are related to the pyrethrins that contain insecticidal properties rabid - suffering from rabies rhonhi - snoring sound when airway channels are partly obstructed rose spot - erythematous maculo-papular rash on the trunk salmonella EIA - immunoassay for the diagnosis of Typhoid Fever using monoclonal antibody sardonic smile - sustained contraction of facial muscle

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seizure - transient disturbance of brain function that maybe manifested as episodic impairment or loss of consciousness, abnormal motor and sensory phenomena

sensorium - ability of the brain to receive and interpret sensory stimuli serum sickness - hypersensitivity response to the injection of anti-serum caused by formation of soluble immune complex soluset - a tubular plastic calibrated devise used as a second infuser in the administration of intravenous medications stage I hypertension - based on BP reading > 140 – 159 SBP, DBP> 90 – 99 mmHg stage II hypertension - based on BP reading > 160 SBP, DBP > 100 mmHg standard precautions - used to reduce the risk of transmission of microorganisms for both recognized and unrecognized sources of

infection in the hospitals stat - without delay stridor - a high-pitched, noisy respiration denoting respiratory obstruction, especially in the trachea or larynx subcutaneous - injection of drug into fatty tissue (below dermis & epidermis) sub-lingual - administration of drug under the tongue sub-occupital - located below the occiput sympathetic crisis - excess level of cathecolamines systolic pressure - maximum arterial pressure during cardio/ myocardial contraction tongue guard - flat thin wooden instrument use to protect tongue torniquet test - a procedure to test capillary fragility by inflating a BP cuff placed above the ante-cubital area for five minutes at mean

blood pressure (obtained by getting the systolic blood pressure plus diastolic blood pressure divided by two). The test is positive if there are more than 20 petechiae (a small red or purple spot in the body) per square inch

Trendelenburg position - a supine position in which the pelvis is higher than the head tubex TF - rapid diagnostic test for Typhoid Fever that detects O9 antigen of Salmonella typhi vasculotoxic - destructive to blood vessels venom - poisonous fluid secreted by snake viper - venomous (poisonous) snake belonging to species Vipera wheezes - continuous whistling sounds produced in narrowed or obstructive airways

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ACRONYM GUIDE

ABC …………………….…..……………….. Airway Breathing Circulation ABG …. ………………....….……………….. Arterial Blood Gas AIDS …. ………………....….……………….. Acquired Immunodeficiency Syndrome ALT …………………….…..……………….. Alanine Aminotransferase ANST ………………… ……..……………….. After Negative Skin Test anti–HAV IgM ………………….……..……………….. anti-Hepatitis A Immunoglobulin M (A)PTT ……… ………………..……………….. (Activated) Partial Thromboplastin Time AST ………………….……..……………….. Aspartate Aminotransferase ATS ………………….……..……………….. Anti-Tetanus Serum BUN ………………….……..……………….. Blood Urea Nitrogen BID ………………….……..……………….. twice a day BP ………………….……..……………….. Blood Pressure bpm ………………….……..……………….. breaths per minute BT ………………........…..………………... Bleeding Time oC ………………………..………………... degrees Celcius CAD ………………….……..……………….. Coronary Artery Disease CAP ………………….……..……………….. Community Acquired Pneumonia CBC ………………….……..……………….. Complete Blood Count cc ………………………..………………... cubic centimeter CDD ………………….……..……………….. Control of Diarrheal Diseases COPD ………………….……..……………….. Chronic Obstructive Pulmonary Disease CP ………………………..………………... Cardio-pulmonary CPR ………………………..………………... Cardio-Pulmonary Resuscitation CPK ………………………..………………... Creatinine Phosphokinase CQ+SP ………………………..………………... Chloroquine + Sulfadoxine + Phyrimethamine CR ………………………..………………... Cardiac Rate CSF ………………………..………………... Cerebrospinal Fluid

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CT ………………………..………………... Clotting Time cv ………………………..………………... cardio-vascular CVP …. ………………....….……………….. Central Venous Pressure CXR ………………………. ………………... Chest X-ray dl …. ………………....….……………….. deciliter DM ………………………..………………... Diabetes Mellitus DPT ………………………..………………... Diphtheria, Pertussis, Tetanus D5W …. ………………....….……………….. 5% Dextrose in Water D5LRS …………………………………………. Dextrose in lactated ringer’s solution D5IMB / D5NM …………………………………………. Balance Multiple Maintenance Solution with Dextrose D5 0.3% NaCl ………………………. ………………... Dextrose in 0.3% Sodium Chloride D5 0.9% NaCl …………………………………………. Dextrose in 0.9% Sodium Chloride EIA ………………………. ………………... Enzyme Immunoassay ff ………………………. ………………... following FFP ………………………..………………... Fresh Frozen Plasma FWB …………………………………………. Fresh Whole Blood gm ………………….……..……………….. gram HBsAg …………………….…..……………….. Hepatitis B antigen Hct ………………………..………………... Hematocrit Hib ………………………..………………... Hemophilus influenza type B hr/ hrs ………………………..………………... hour/ hours HTN ………………………..………………... Hypertension I.U. ………………………..………………... International Units ICU ………………………..………………... Intensive Care Unit IFAT ………………………..………………... Immune Fluorescent Antibody Test Ig M ………………………..………………... Immunoglobulin M IM ………………………..………………... Intramuscular IV ………………………..………………... Intravenous IVP ………………………..………………... Intravenous Push IVT ………………………..………………... Intravenous Therapy/Transfusion

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JVP ………………………..………………... Jugular Venous Pressure K+ ………………………..………………... potassium KBW ………………………..………………... Kilogram Body Weight kg ………………………..………………... kilogram KVO ………………………..………………... Keep Vein Open LBM …. ………………....….……………….. Loose Bowel Movement LD ………………………..………………... Loading Dose LR ………………………..………………... Lactated Ringers max ………………………..………………... maximum MD ………………………..………………... Maintenance Dose mg ………………………..………………... milligram min …. ………………....….……………….. minute/s mkBW ………………………..………………... milligram per kilogram body weight mkd ………………………..………………... milligram per kilo gram body weight per dose mkD ………………………..………………... milligram per kilo gram body weight per day ml ………………………..………………... milliliter mos ………………………..………………... month/s MMR ………………………..………………... Measles, Mumps, Rubella MU ………………………..………………... Million Units Na+ ………………………..……………....... sodium NGT ………………………..………………... Nasogastric Tube NSS ………………………..………………... Normal Saline Solution NT ………………………..………………... Nose and Throat O2 ………………………..………………... Oxygen OB ………………………..………………... Obstetrician OD ………………………..………………... once a day ORS ………………………..………………... Oral Rehydrating Solution Pa02 ………………………..………………... partial arterial oxygen tension PaC02 ………………………..………………... partial arterial carbon dioxide tension po ………………………..………………... per orem

xv


PEFR ………………………..………………... Peak Expiratory Flow Rate PEP ………………………..………………... Post-Exposure Prophylaxis PET ………………………..………………... Post-Exposure Treatment Plain LR ………………………..………………... Lactated Ringer’s Solution Plain NSS ………………………..………………... Normal Saline Solution prn ………………………..………………... as needed PT ………………………..………………... Prothrombin Time q ………………………..………………... every QID ………………………..………………... four times a day RBC ………………………..………………... Red Blood Cell(s) RFFIT ………………………..………………... Rapid Fluorescent Flocculation Inhibition Test RIG ………………………..………………... Rabies Immuneglobulin RR ………………………..………………... Respiratory Rate SC ………………………..………………... subcutaneous sec …. ………………....….……………….. second/s To ………………………..………………... temperature TB ………………………..………………... Total Bilirubin TID ………………………..………………... three times a day TIG ………………………..………………... Tetanus Immune Globulin (human) TMP ………………………..………………... Trimethoprim TPA/G …. ………………....….……………….. Total Protein Albumin/Globulin Tsp …. ………………....….……………….. teaspoon TT ………………………..………………... Tetanus Toxoid TU ………………………..………………... Thousand Units U ………………………..………………... Units UDV ………………………..………………... unit dose vial ug ………………………..………………... microgram URTI ………………………..………………... Upper Respiratory Tract Infection y/o ………………………..………………... years old

xvi


SECTION I

VIRAL EXANTHEMS

MEASLES

RUBELLA (GERMAN MEASLES)

VARICELLA (CHICKEN POX)


MEASLES

Warning Signs

Tachypnea and/or difficulty of breathing

Seizure or changes in sensorium Dehydration Immunocompromised status

(malignancy, AIDS, Asthma, Down’s syndrome),

Grossly malnourish History of coriander (kulantro,

uan-suy) intake or inappropriate application

For Hospital Management (see annex 8)

Emergency Measures

Assess ABC & monitor vital signs Do CPR for CP arrest (see annex 20)

Start IV line [Plain LR/Plain NSS if with shock (see annex 1c);D5 0.3% NaCl (<12 y/o); D5NM (>12y/o)]

Give O2 (2-4 L/min by nasal prong) inhalation for difficulty of breathing and cyanosis

Give Salbutamol inhalation (2 puffs) or nebulization (1/2-1 neb) q 20 min for wheezes until arrival at the hospital

Give Diazepam (0.2-0.4 mkd, max 10mg) for seizure

Refer to hospital with referral note

Local Measures

Isolate patient Give Paracetamol (10-15 mkd)

for fever Give Vitamin A* as follows:

>12 mos: 200,000 units 6-12 mos:100,000 units Repeat dose next day and 4

weeks after for patients with ophthalmologic evidence of Vitamin A deficiency

Do measles IgM determination (c/o NEC) Observe for warning signs

General Signs & Symptoms

Fever Maculopapular rash

(starts from face spreads to body and extremities)

3 Cs (cough, colds, conjunctivitis)

May have Koplik spots on the buccal mucosa


RUBELLA (GERMAN MEASLES) Warning Signs

Seizure or changes in sensorium (encephalitis)

Immunocompromised/ special conditions

malignancy/ AIDS/ Diabetes / chronic debilititating diseases

Pregnancy

Hospital

Management (see annex 12)

Emergency Measures

Assess ABC and monitor vital signs Do CPR for CP arrest

(see annex 20) Start IV line [D5 0.3% NaCl

(<12 y/o); D5NM (>12 y/o)] Give Diazepam (0.2-0.4 mkd,

max 10mg) for seizure Refer to hospital with referral

note

Local Measures

Isolate patient Give Paracetamol

(10-15 mkd) for fever Do Measles IgM

determination (c/o NEC) Observe for warning signs


Fever Malaise/ anorexia Maculopapular rash Swelling of lymph nodes

on sub-occipital and post-auricular area


VARICELLA (CHICKEN POX)

Warning Signs

Seizure or changes in sensorium Difficulty of breathing Bleeding from any site including

skin Immunocompromised/ special conditions

malignancy/ AIDS/ Diabetes/ chronic debilititating diseases

Pregnancy/ newborns/ persons > 50 y/o


Emergency Measures


Start IV line [D5 0.3% NaCl (<12 y/o); D5NM (>12y/o)]

Give O2 (2-4L/min by nasal prong) inhalation for difficulty of breathing

and cyanosis Give Salbutamol inhalation (2 puffs)

or nebulization (1 neb) q 20 min for wheezes until arrival at the hospital

Give Diazepam (0.2-0.4mkd, max 10mg) for seizure


Local Measures

Strict isolation precaution Give Paracetamol (10-15 mkd)

for fever. Do not give Aspirin May give anti-viral (see annex for

indications) Give Cloxacillin (50-100 mkD) for

7 days for secondary bacterial skin infections

Give Diphenhydramine (1 mkd) for pruritus

Advise personal hygiene Observe for warning signs


Fever Generalized papulo-

vesicular eruption (starts from trunk and face then spreads to the extremities)


SECTION II

RESPIRATORY DISEASES

UPPER RESPIRATORY TRACT INFECTION (COMMON COLDS AND COUGH)

BRONCHIAL ASTHMA

INFLUENZA

PNEUMONIA - ADULT

PNEUMONIA - PEDIA


UPPER RESPIRATORY TRACT INFECTIONS (COMMON COLDS & COUGH)


Cough/ colds With any of the following:

Fever/ headache Cough-induced

abdominal/ chest pains Nausea/ vomiting Body malaise/ weakness Sore throat Ear/ nasal and postnasal/

eye discharge

Local Measures Give Paracetamol (10-15 mkd) for fever or

pain every 4 hours Give Amoxicillin (30-50 mkd TID for 7-10

days) if symptoms persist > 10 days May give oral Phenylpropanolamine w/ or

w/o Chlorpheniramine (syrup/drops) q 6hrs 7 y/o - 12 y/o – 1 tsp.

3 y/o - 6 y/o – ½ tsp. >12 mos - 2 y/o – 1 ml 7 mos - 12 mos. – 0.75 ml 4 mos - 6 mos. – 0.50 ml 1 mo. - 3 mos. – 0.25 ml

Advise adequate fluids/ nutrition Reassess patient after 3 days Observe for warning signs

Warning Signs

Difficulty of breathing/ chest indrawing/ retractions/ alar flaring/ cyanosis

Wheezing/ stridor w/ or w/o drooling/ dysphonia

Poor feeding/ unable to drink

Seizure/ decrease level of consciousness

Irritability/ restlessness

Emergency Measures




Give Salbutamol inhalation (2 puffs) or nebulization (1 neb) q 20 min for wheezes until arrival at the hospital

Give Diazepam (0.2-0.4mkd, max 10 mg) for seizure


See Annex for Management of

Specific Complications



Difficulty of breathing with any of the ff: cough and/or wheeze chest tightness breathlessness gurgly chest (“halak”) exertional difficulty of

breathing/ talks in sentence or phrases/ may be agitated

Associated with any of precipitating factors:

Exercise Seasonal change Exposure to allergens

(Dust, Odors, Pollens, Pets)

Warning Signs

Breathless at rest/ agitated to drowsy or confused/ increase RR at

> 60 bpm for less than 2 mos old > 50 bpm for 2 to 12 mos old > 40 bpm for >12mos to 5 y/o > 30 bpm for >5 to 13 y/o

Loud to absence of wheezes Severe tachycardia to bradycardia at

160 bpm or < 110 bpm for 2-12 mos 120 bpm or < 90 bpm for >1-2 y/o >110 bpm or < 60 bpm for >2 y/o

Cyanosis History of severe asthma requiring

hospitalization Poor response to therapy after 1 hour

treatment

Local Measures

Give Salbutamol by inhaler (2 puffs) or nebulization (1 nebule) 3 x in 1 hr

Reassess patient, if with good response (improved air entry) and sustained for 4 hours, may send home give oral/ inhaled Salbutamol

every 4-6 hours for 3-5 days give oral Prednisone (1 mkD) for

5 days as prescribed by physician Advise adequate fluid intake/

nutrition Start asthma education (see annex 2) Observe for warning signs

Emergency Measures





Give Hydrocortisone 10 mg/kg (max 250 mg) as IV bolus then maintain at 5-10 mkD (max 100 mg) given in 4 divided doses



BRONCHIAL ASTHMA



Fever and chills of < 5 days duration

Body malaise/ myalgia/ headache

Plus any of the following: Non-productive cough Colds Sore throat Nausea and vomiting

Warning Signs

Difficulty of breathing Seizures and/ or changes in

sensorium Poor feeding and activity Chest pains/ irregular heart

beat Dehydration Immunocompromised status/

chronic debilitating illnesses (malignancy, grossly malnourish, elderly > 60 y/o)

Local Measures

Isolate patient Give Paracetamol (10-15

mkd) q 4 hrs for fever, headache, and body pains. Do not give Aspirin.

Increase oral fluid intake Maintain adequate nutrition Avoid strenuous physical

activities Observe for warning signs

Emergency Measures


Start IV line[D5 0.3% NaCl (<12 y/o); D5NM (>12y/o)]





INFLUENZA



7

Warning Signs Worsening vital signs (RR > 30 breaths/

min, CR > 125 beats/min , T <35°C or > 40°C) or no improvement of condition for 3 days

Respiratory failure (RR < 12 breaths/min or cyanosis)

Suspected aspiration Hypotension/ altered mental state Extra pulmonary evidence of sepsis (bleeding/ jaundice) Co-morbid /debilitating conditions

(diabetes mellitus, malignancies, neurologic disease, heart diseases, on prolonged steroid use, renal failure, COPD)

Inability to take in food or medicine Severe malnutrition

General Signs & Symptoms Cough Any abnormal vital sign:

tachypnea (RR > 20 breaths/ minutes)

tachycardia (CR > 100/ minutes)

fever (To > 37.8 °C) With at least one abnormal chest

finding: diminished breath sounds rhonchi crackles wheeze


Local Measures 1

Isolate patient and observe proper bed-spacing Give oral antibiotic therapy

Give Salbutamol 2 mg tablet 3-4x/day for wheezing Give Paracetamol 500 mg tablet q 4 hrs for fever Increase oral fluid intake Advise balanced nutrition & regular exercise Observe for warning signs

Emergency Measures

Assess ABC and monitor vital signs Do CPR for CP arrest (see annex 20)

Start IV line with D5LRS Give O2 (2-4L/min by nasal

prong) inhalation for difficulty of breathing and cyanosis

Place patient on moderate high back rest


PNEUMONIA - ADULT

Antimicrobial Therapy for Low Risk CAP Drugs of choice: Amoxycillin 1 gm po q 8 hrs x 7 days Alternative drugs: Azithromycin 500 mg po OD x 3-5 days Clarithromycin 500 mg po BID x 7 days Roxithromycin 150 mg BID po or 300 mg po OD x 7 days Cotrimoxazole 160/800 mg po BID x 7 days



Cough May have fever Rapid breathing

> 50 bpm for 2 - 12 mos old > 40 bpm for >12mos - 5 y/o > 30 bpm for >5 – 13 y/o

Any of the following abnormal lung sounds: Diminished breath sounds Rhonchi (snoring sound) Crackles (short, sharp, rough

sounds)

Local Measures

Give Paracetamol (10-15 mkd) q 4 hrs for fever

Advise adequate fluid intake and nutrition

Give oral antibiotics: Co-trimoxazole (TMP 5mg/kg) BID

for 5 days or Amoxicillin (40–50 mkd) TID for 5

days Give oral Salbutamol (0.15 mkd) for

wheezes Instruct caregiver to follow-up after 2

days and to observe for warning signs

Warning Signs

Chest in-drawing/stridor (noisy breathing)/wheezing in < 2 months old/alar flaring/head lagging/ cyanosis

Rapid breathing (RR > 60 breaths/ min) for less than 2 mos old

Irritability/ restlessness Seizure/ decreasing level of

consciousness Poor feeding/ unable to drink Dehydration/ persistent vomiting Grossly malnourish No improvement or worsening of

condition

Emergency Measures



Give O2 (2-4L/min by nasal prong) inhalation for difficulty of breathing & cyanosis

Give Salbutamol nebulization (1 nebule) for wheezes

Give Diazepam (0.2-0.4 mkd, max 10mg) for seizures


For Hospital Management (see annex 11b)

PNEUMONIA - PEDIA


SECTION III

SYSTEMIC DISEASES

DENGUE

LEPTOSPIROSIS

MALARIA

MUMPS


DENGUE Warning Signs

Spontaneous bleeding Pallor/ cyanosis/ difficulty of breathing Hypotension and weak pulses/ frequent

dizziness and faintings (for >5 y/o) cold, clammy skin

Plasma leakage: cherry red lips, pleural effusion, ascites

Restlessness/ listlessness/ seizure Severe persistent abdominal pains/

severe tenderness Signs of dehydration secondary to

persistent vomiting, diarrhea or poor intake especially of fluids

Jaundice/ tea-colored urine Platelet count of <100,000 cells/ul


Emergency Measures


Start IV line [Plain LR/Plain NSS if with shock (see annex 3); D5LR if w/o shock]


Give Diazepam (0.2-0.4 mkd max 10 mg) for seizure

Do nasal packing for nose bleeding, or use Epinephrine-soaked nasal pack in severe bleeding


Local Measures

Give Paracetamol (10-15 mkd) for fever. Do not give Aspirin

Give ORS by mouth at 3cc/kg/hr

Assess patient daily until 3 days without fever

Request for CBC, platelet count and monitor hct and platelet count daily, if feasible

Observe for warning signs


Fever of 2-7 days With 2 or more of the ff:

Headache/ eyepains Arthralgia/ myalgia/

generalized body malaise Generalized flushing of

the skin/rash Positive tourniquet test

( > 20 petechiae per square inch)



Fever (TO > 38OC) and headache/ body malaise/

abdominal discomfort in patient With any of the following:

Red eyes (conjunctival suffusion) Yellow skin Muscle tenderness/ pain

(esp. calf muscle)

history of exposure to contaminated water (flood/ ponds/sewage) or infected urine droplets in a rat-infested areas/ farms

Warning Signs

Hypotension Cold, clammy skin Difficulty of breathing/ cyanosis Seizure or changes in

sensorium Decrease or no urine output Bleeding manifestations

Emergency Measures

Assess ABC & monitor vital signs Do CPR for CP arrest

(see annex 20) Start IV line [Plain LR/Plain NSS

if with shock (see annex 19); D5NSS if w/o shock]


Give Diazepam (0.2-0.4 mkd max. 10 mg) for seizure



LEPTOSPIROSIS


General Signs & Symptoms*

Cyclical pattern of chills, fever and sweating Other signs as follows:

headache generalized body weakness abdominal pain

* strongly consider in a patient

who had recent travel/exposure in an area endemic for malaria

Warning Signs Changes in sensorium, seizures,

very severe headache and signs of motor deficit

Decreased BP, abnormal heart rate Cyanosis, difficulty of breathing Yellowish discoloration of skin and

sclera Decreased urine output/tea colored

urine Severe dehydration Bleeding tendencies (e.g. nose/gum

bleeding, black tarry stool ) Marked pallor or < 7 mg/dl Hgb

5% parasetemia or > 100,000 count Special conditions: pregnancy, infancy

Emergency Measures


Start IV line [[Plain LR/Plain NSS if with shock (see annex19); D5LR if w/o shock]

Give O2 (2-4 L/min) inhalation for difficulty of breathing and cyanosis

Start oral Quinine po/ NGT Refer to hospital w/ referral note

Local Measures

Give Paracetamol (10-15 mkd) q 4 hrs for fever or pain Do CBC Do daily malarial smear for

3 days Give anti-malarial treatment

for uncomplicated malaria (see annex 7)

Observe for warning signs


MALARIA


MUMPS

Warning Signs

Testicular swelling and pain (orchitis) Seizure/ changes of sensorium (encephalitis) Severe abdominal pain & vomiting (pancreatitis) Chest pains (myocarditis)

Emergency Measures

Assess ABC & monitor vital signs Do CPR for CP arrest

(see annex 20) Start IV line [D5 0.3% NaCl

(<12 y/o); D5NM (>12y/o)] Give O2 (2-4 L/min by nasal

prong) inhalation for difficulty of breathing and cyanosis



Local Measures

Isolate patient Give Paracetamol (10-15mkd) q 4 hrs for fever or pain Advise soft diet Advise not to apply indigo dye Observe for warning signs


Fever Swelling and tenderness

of submandibular and/ or pre-auricular area (involvement of one or more of the salivary glands)



SECTION IV

GASTRO-INTESTINAL DISEASES

ACUTE GASTROENTERITIS (DIARRHEA)

TYPHOID FEVER

VIRAL HEPATITIS A


20

ACUTE GASTROENTERITIS (DIARRHEA)


Passage of > 3 liquid stools in 24 hrs

With any of the following: Fever Vomiting Abdominal pain Poor appetite Signs of some dehydration

o thirst/irritability/ sunken eyeballs/ poor skin turgor

Emergency Measures


Start IV line [Plain LR/ Plain NSS using large bore needle (gauge 21 for adult & gauge 22-24 for pedia), see annex 1c]

Start 2 IV lines for patients w/ possible cholera

Give ORS by NGT (20ml/kg for 6 hrs) if IV therapy is not feasible for patients who cannot drink (see annex 1c)

Give O2 (2-4 L/min by nasal prong) inhalation for difficulty of breathing

Give Diazepam (0.2-0.4 mkd, max 10 mg) for seizure


Warning Signs

Signs of severe dehydration Lethargic or unconscious/ floppy infant/

sunken eyes/ unable to drink/drinks poorly/ poor skin elasticity

Cold clammy extremities/pallor/ weak pulse Difficulty of breathing Seizure Absent or decrease urine output Persistent vomiting Persistent diarrhea of > 14 days w/

dehydration Bloody stools/ rice watery voluminous stools Abdominal distention Muscle cramps Grossly malnourished No clinical improvement after 4-6 hrs of ORS

Local Measures

Give home fluids (soup, rice gruel) Give ORS (see annex 1b) Continue feeding or increase frequency

of breastfeeding Do not give anti-diarrheal or anti-

spasmodic drugs Give Zinc supplementation to children

at 20 mg/day for 10-14 days (10 mg/day for infants < 6mos old)

Give Paracetamol (10-15 mkd) for fever every 4 hours

Do rectal swab (c/o NEC) Advise good personal hygiene Observe for warning signs

For Hospital Management (see annex 1c)



Persistent fever ( > 7 days) Abdominal manifestations

(abdominal pain, vomiting, bloatedness, constipation, soft stools)

With any of the following: Weakness Poor appetite Enlarged liver and spleen Rose spots (transient macular

rash) on chest/ abdomen Relative bradycardia

Warning Signs

Dehydration/ exhaustion Unable to feed/ take oral

medications Bloody/ black tarry stool Severe abdominal pain/

abdominal rigidity/ absence of bowel sounds

Cold, clammy skin with hypotension

Pallor Behavioral change (typhoid

psychosis)

Local Measures Give Paracetamol (10-15 mkd) q 4 hrs for fever Give oral antibiotics

ANTIBIOTICS ADULT PREGNANT CHILDREN CHLORAMPHENICOL 3-4 gm/day in

3-4 divided doses x 14 days

not recommended

75-100 mkBW in 4 divided doses x 14 days

AMOXICILLIN 3 gm/day in 3 divided doses for 14 days

3 gm/day in 3 divided doses for 14 days

75-100 mg/kg/day in 3 divided doses for 14 days

COTRIMOXAZOLE 800/160 mg 1 tab BID for 14 days

not recommended

8 mg/kg/day of TMP in 2 divided doses x 14 days

Increase fluid intake if tolerated Advise good personal hygiene

Wash hands after using bathroom and before handling food & eating

Proper waste disposal Limit close contact with susceptible individual during acute

phase of infection

Emergency Measures

Assess ABC and monitor vital signs Do CPR for CP arrest

(see annex 20) Start IV line [Plain LR/

Plain NSS if with shock (see annex19);D5 0.3% NaCl (<12 y/o); D5NM (>12y/o) if w/o shock]



TYPHOID FEVER


Warning Signs

Persistent vomiting or dehydration

Changes in sensorium Deepening/persistent

jaundice Special Conditions Elderly/pregnancy/

patient with serious underlying medical conditions


Yellow eyes and/or skin Fever/malaise/muscle aches/

abdominal discomfort Plus any of the following Loss of appetite Nausea/vomiting Loose stools Dark or “tea-colored”

urine

Local Measures Advise high-caloric diet Increase oral fluid intake, avoid alcoholic beverages Advise to limit physical

activities Advise good personal hygiene

Wash hands after using bathroom and before handling food and eating

Refrain from eating uncooked shellfish/ vegetables & fruits that are not peeled

Emergency Measures

Assess ABC and monitor vital signs

Do CPR for CP arrest (see annex 20)




VIRAL HEPATITIS A


SECTION V

OTHER DISEASES

CONJUNCTIVITIS

HYPERTENSION

SKIN DISEASES

CONTACT DERMATITIS

TINEA CORPORIS

TINEA PEDIS

TINEA VERSICOLOR

TETANUS NON-NEONATORUM

WOUNDS

DOG/CAT BITE

SNAKE BITE


CONJUNCTIVITIS

Warning Signs

Blurring/loss of vision Significant pain in the

affected eye Presence of eye

complications (ulceration, blood-shot eyes)

Newborns Signs and symptoms that do

not improve after 7 days


Itchiness/ redness/ foreign body sensation in one or both eyes

Eye discharge*/ tearing

Abundant exudates suggests bacterial inflammation; stringy, sparse exudates suggests an allergy, and watery discharge or epiphora suggests adenoviral infection (with some exceptions)

LocaI Measures Instill eyedrops (Erythromycin or Gentamycin) q 3-4 hrs to affected eye for at least

7 days for bacterial infection Use eyedrops with antihistamines, decongestants, steroids or anti-inflammatory

drops for allergic conjunctivitis Use artificial tears or compress to relieve symptoms of viral/allergic conjunctivitis Keep affected eye clean

Wipe crust gently by using cotton dipped in clean water or use a solution containing 1 part of baby shampoo in 10 parts of clean water

Apply cool compress to the affected eye using a clean washcloth or dipped in a bowl of cold water for 5-10 mins 3-4 x a day

Practice good personal hygiene Wash hands thoroughly and frequently Avoid touching eyes with bare hands; instead use clean cloth/tissue Avoid sharing towel/pillowcase and change frequently Avoid using eye cosmetics Protect eyes with sunglasses

Refer to an

Ophthalmologist



BP* of >140 systole and/or diastole of >90 mm Hg

BP* of >130 systole and/or > 80 diastole among diabetics and renal patients

based on average of 2 or more BP readings taken at 2 or more consultations after initial screening

Warning Signs

Hypertensive Emergency BP of > 180 systole or >120 diastole

Any of the following: Headache, pre-syncope/

syncope, altered sensorium, neurologic deficit, blurring of vision, shortness of breath, chest pain, vomiting, nose bleed, muscle tremors, oliguria, anuria and hematuria

Uncontrolled persistent elevation of blood pressure

Emergency Measures


Start IV line with D5W Give O2 (2-4 L/min by nasal prong)

inhalation for difficulty of breathing Give any short-acting anti-HTN drug

Clonidine at 0.1-0.2 mg po followed by 0.1 mg/hr q hr or 2 hrs (max 7 mg)

Captopril at 12.5-25 mg po, may repeat at intervals of 30-60 mins

Furosemide at 20-40 mg IV Refer to hospital with referral note

Local Measures*

Administer oral anti-HTN drugs (see annex 4a for class of drugs, dosages & indications) Low-dose thiazide diuretics Beta-blockers ACE inhibitors

Advise lifestyle modification (see annex 4b) Refer to Internist/Cardiologist for uncontrolled hypertension

All cases should be seen by a physician

HYPERTENSION

For Hospital Management (see annex 4b)



Acute lesions at site of contact:

itchy raised red patches/ wheals

vesicles/exuding punctuate erosions and crusts

Chronic lesions at site of contact: dry, thick and scaly with

pigmentation

Local Measures

Thoroughly clean skin with mild soap and water

Apply Betamethasone cream (for wet lesion) or ointment (for dry lesion) to affected areas 2-3x a day

Give Loratadine at 5-10 mg/day for itching and redness


Warning Signs

Severe, persistent itching Worsening of skin lesions Secondary bacterial

infection

CONTACT DERMATITIS

Refer to

Dermatologist



Itchy, round, scaly lesions with central clearing and elevated reddened edges with sharp margins found on trunk, extremities or face

Local Measures

Apply any of the following topical antifungal agents on affected areas: Tolnaftate 1% cream/ ointment 2x

daily for 2-3 weeks or Terbinafine 1% cream once daily for

one week Advise patient on the following: keep skin dry wear loose clothing of cotton materials avoid sharing garments practice personal hygiene avoid application of irritants (kerosene,

battery liquid) to skin lesions


Warning Signs

Severe, persistent itching Widespread infection

Refer to

Dermatologist

TINEA CORPORIS (BODY RINGWORM)



Maceration, scaling, fissuring of toe webs with red underlying skin

Sole of foot if affected, covered with fine silvery scales

Itching or burning sensation of affected area

Local Measures

Apply any of the following topical antifungal agents on affected areas:

Clotrimazole 1% cream 2x a day for 2 weeks or

Tolnaftate 1% cream 2x a day for 2-3 weeks

Advise patient on the following: keep feet dry wear cotton socks and change socks

daily wear open-toed shoes or sandals avoid walking barefoot practice good personal hygiene


Warning Signs

Worsening of skin lesions Failure of topical

treatment Severe secondary

bacterial infection

Refer to

Dermatologist

TINEA PEDIS (ATHLETE’S FOOT)



Mild itchy pigmentation of skin either tan, pink, white or brown on face, neck, arms, chest and/or back with fine scales

Local Measures

Apply any of the following topical antifungal agents on affected areas:

selenium sulfide (2.5%) lotion or shampoo for 10-15 mins once a day followed by a shower, for 1 week or

Terbinafine 1% cream once or twice daily for 2 weeks

Advise good personal hygiene All cases should be seen by a physician

Warning Signs

Persistence or worsening of skin lesions despite adequate treatment

Refer to

Dermatologist

TINEA VERSICOLOR (TINEA FLAVA)


Warning Signs


Spasms/ stiffening in any parts of the body (eg. jaw, neck, extremities, back) Manifested as any of the ff:

o Lock jaw o Sardonic smile o Abdominal rigidity o Difficulty in swallowing

History of wound exposure to contaminated materials,

dental carries/ otitis media


Emergency Measures




Give Diazepam (0.2-0.4mkd, max 10mg) for seizure

Insert tongue guard Refer to hospital with referral note

TETANUS NON-NEONATORUM

Warning Signs

Persistent and frequent spasms

Difficulty of breathing Cyanosis


WOUNDS

Warning Signs

Hypotension, cold clammy extremities, cyanosis, restlessness

Any deep extensive wound like hacking, avulsion or penetrating

Severe and/or uncontrolled bleeding

Embedded foreign object in the wound

For Hospital Management

(Refer to Surgeon)

Emergency Measures


Start IV line [Plain LR/Plain NSS if w/ shock (see annex 19); D5LR if w/o shock]


Apply pressure bandage for severe bleeding

Elevate the affected extremity Refer to hospital with referral note

Local Measures Examine wounds and remove dirt

and foreign objects Clean wound and apply antiseptics

and dressing Apply direct pressure to any

bleeding wound Appose gaping wound by suturing

or use of adhesive plaster, when feasible

Give appropriate oral antibiotics and pain reliever (see annex)

Give tetanus prophylaxis (see annex 18a)

Observe warning signs


Lacerations, abrasions, puncture (single/ multiple) with or without bleeding resulting from any trauma



Any skin break (punctured, abrasions, scratches) resulting from bite of dog/ cat

non-bite exposure (licking of mucous membrane and open wounds, eating carcass, and aerosol exposure)

Warning Signs

Gaping wound/ avulsion with or without vessel injury

Local Measures

Wash wound thoroughly and immediately with soap and running water

Remove foreign materials (dirt, broken teeth)

Apply antiseptic solution (Povidone iodine) Give Mefenamic acid (25 mkD) and

antibiotic (see annex 18a) Do not suture wound Give the following instructions: Observe biting animal for 14 days for

signs of rabies Do not use garlic, stones (‘tandok’),

tourniquet nor induce bleeding on the wound

For other animal bites (see annex 18b) Refer to animal bite center for

immunization (see annex 18b)

Emergency Measures

Control bleeding by direct/ pressure dressing

Bring avulsed body part wrapped in clean plastic and place in a container with ice

Refer to hospital for surgical management

For Hospital Management

(Refer to Surgeon)

DOG/CAT BITE


Warning Signs

Seizures or changes in sensorium (lethargy) Loss of consciousness Cold skin, dilated pupils, insensitive to light Circulatory failure (hypotension, bradycardia, rapid feeble pulse) Cyanosis Signs of respiratory failure Spreading paralysis causing difficulty in

speaking and breathing Muscle weakness Increase salivation, vomiting, frothing

around mouth Burning pain, redness, swelling, superficial

necrosis, bleeding on site of bite, numbness on site of bite

Abnormal bleeding


History of snakebite with or without signs of envenomation

Emergency Measures


Start IV line [Plain NSS/ Plain LR if with shock (see annex 19); D5LR if w/o shock]


Apply pressure bandage to control bleeding Use of tourniquet is no longer recommended Refer to hospital with referral note

Precautionary Measures Do not place any cooling materials on the site

of bite Do not elevate bitten extremity above the

level of the heart Do not incise nor suck the wound


SNAKE BITE

Warning Signs

Persi


ANNEXES


26

Annex 1a

ASSESSMENT TABLE FOR DEGREE OF DEHYDRATION IN DIARRHEA

Assessment Criteria

A

B

C

1. General Appearance

Eyes

Thirst

Well, alert

Normal

Drinks normally, Not thirsty

Restless, irritable*

Sunken

Thirsty, Drinks eagerly

Lethargic or Unconscious

Floppy* sunken

Drinks poorly Unable to drink*

2. Skin Elasticity (Abdominal skin pinch)

Goes back quickly Goes back slowly Goes back very slowly (>2 seconds)*

3. Degree of Dehydration No Signs of dehydration

Not enough to classify as some/ severe dehydration

Some dehydration If patient has at least 2 or more of

the above criteria

Severe dehydration If patient has 2 or more of the

above criteria

4. Treatment Use Treatment Plan A Weigh patient and use Treatment Plan B

Weigh patient and use Treatment Plan C

Legend: * major signs of severe dehydration


27

Annex 1b

TREATMENT PLAN A and B FOR DIARRHEA

A. TREATMENT PLAN A FOR NO SIGNS OF DEHYDRATION

AGE

AMOUNT OF ORS AFTER EACH LBM

AMOUNT OF ORS FOR USE AT HOME

< 24 months old 50 – 100 ml 500 ml

2 – 10 years old 100 – 200 ml 1000 ml/day

10 years old or older As much as wanted 2000 ml/day

1. If patient shows no signs of dehydration after 6 hrs of observation, patient may be sent home with instructions and health

teachings. 2. If after 6 hrs of rehydration, patient still shows signs and symptoms of some dehydration with persistent vomiting (3- 4

episodes/hr) or condition has progressed to severe dehydration, said patient should be admitted to a hospital.

B. TREATMENT PLAN B FOR SOME SIGNS OF DEHYDRATION

AGE < 1 mo 1-11 mos 12-23 mos 2-4 yrs. 5-14 yrs. > 15 yrs. WT. < 5 kg 5-7.9 kg 8-10 kg 11-15.9 kg 16-29.9 kg > 30 kg

Amt. in ml (ORS) 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

1. Patient’s age should be used only when weight is unknown. The approximate amount of ORS required in 1 ml can also be calculated by multiplying patient’s weight in grams times 0.75.

2. Patient should be observed and checked from time to time to see if there are problems such as vomiting and eyelids puffiness. After 4 hours, patient should be reassessed using the Assessment Table to select the appropriate Treatment Plan (A, B, or C).

3. If after 4 hours of rehydration, patient still shows signs/symptoms of some dehydration, the amount of ORS to be given within 4 hours can be repeated until patient is rehydrated. But if there’s persistent vomiting and condition has progressed to severe dehydration, said patient should be admitted to a hospital.


28

Annex 1c HOSPITAL MANAGEMENT PROTOCOL FOR ACUTE GASTROENTERITIS

(DIARRHEA)

I. Routine Laboratory Examination

- Fecalysis

Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines

A. TREATMENT PLAN C FOR SEVERE DEHYDRATION

1. Start IV fluids immediately by giving Ringer’s Lactate Solution at 100 ml/kg divided as follows:

AGE First give 30 ml/kg Then give 70 ml/kg Infants (< 12 months old) 1 hour 5 hours

Older 30 minutes 2 ½ hours

a. Give ORS by mouth while the drip is being set up if patient can drink. b. Repeat above rehydration course if radial pulse is still very weak or not detectable. c. Reassess patient every 1 – 2 hrs. If hydration is not improving, give the IV drip more rapidly. d. Give ORS (5 ml/kg/hr) as soon as patient can drink, usually after 3–4 hrs for infants or 1-2 hrs for older patients. e. Evaluate patient using the Assessment Table after 6 hours of rehydration for infants or 3 hrs for older patients.

Then choose the appropriate plan (A, B, or C) to continue treatment.

2. If IV therapy is not feasible, start rehydration by NGT with ORS at 20 ml/kg/hr for 6 hrs (total of 120 ml/kg).

a. Reassess patient q 1–2 hrs. If there is repeated vomiting or increasing abdominal distention, give the fluid more slowly.

b. After 6 hrs, reassess the patient and choose the appropriate treatment plan (A,B or C)


29

B. Antimicrobial Therapy

Antibiotic is not essential for successful treatment of diarrhea, but it shortens the duration of illness and period of excretion of organisms in severe cases.

Table on Antimicrobial Agents in the Treatment of Specific Diarrheal Diseases

Disease Antibiotics of Choice Alternative(s)

CHOLERA

Children: Tetracycline 12.5 mkBW 4x a day x 3days Adults: Tetracycline 500 mg 4x a day x 3 days Pregnant: Furazolidone: 100 mg 4x a day x 3 days

Children: Furazolidone 1.25 mkBW 4x a day x 3 days Co-trimoxazole (TMP 5 mkd) 2x a day for 5days Adults: Furazolidone 100 mg 4x a day x 3 days Doxycycline: 300 mg single dose Ciprofloxacin 500 mg single dose Co-trimoxazole 160/800 mg 1 tab 2x a day for 3 days

SHIGELLA DYSENTERY

Children: Co-trimoxazole (TMP 5 mkd) 2x a day x 5 days Adults: Co-trimoxazole (160/800 mg) 1tab 2x a day for 5 days

Children: Ciprofloxacin 10 mkBW 2x a day for 3 days Adults: Ciprofloxacin 500 mg po BID x 3 days

SALMONELLOSIS

Antimicrobials are given only in patients with increased risk of invasive disease:

1. infants <3months old 2. persons with malignancy 3. hemoglobinopathies 4. HIV infection/ other immunosuppressive illness or therapy 5. chronic gastrointestinal

disease/ severe colitis

Infants < 3months: Ampicillin 50 – 100 mkd at 6 hourly interval by IV or

IM x 3-5 days

Infants > 3months and children: Ampicillin 50 – 100 mkd at 6 hourly interval by IV or

IM x 3-5 days or

Co-trimoxazole (TMP 5 mkd) 2x a day x 5 days Adults: Ciprofloxacin 500 mg po BID X 3-5 days

or Ofloxacin 200 mg po BID x 3-5 days

Children: Ceftriaxone 75–80 mkd single dose x 3-5 days Adults: Co-trimoxazole 160 mg/ 800 mg BID x 5 days Ceftriaxone: 3 – 4 gms/ IV single dose daily for 5-7days


30

C. Symptomatic and Supportive Treatment

1. Correct electrolyte disturbances: If after 4 hrs of initial rehydration, patient still shows manifestations like convulsive seizure (hypernatremia), lethargy (hyponatremia), muscle weakness/ ileus/ abdominal disturbances (hypokalemia), perform serum electrolytes determination and correct accordingly. Repeat serum electrolytes determination 24 – 48 hrs after correction.

2. Give Paracetamol at 10 – 15 mg/kg q 4 hours, but not > 6 times daily for fever. 3. Give 1.0 ml/kg of 50% glucose solution or 2.5 ml/kg of 20% glucose solution intravenously over 5 mins for

hypoglycemia. 4. Give Zinc supplementation as soon as child can drink and after initial hydration as follows: 20mg/day for > 6 months

old and 10mg/day for < 6 months old for 2 weeks.

III. Guidelines for Patient’s Discharge

A. Criteria for Discharge: Patient properly and adequately rehydrated or clinically improved/ recovered B. Follow-up Advice: Patient/ mothers/ relatives are given 2 sachets/ packs of ORS and to follow-up 2 days after discharge

at health center. Home treatment of diarrhea and “Three Rules for Treating Diarrhea at Home” is explained as follows: 1. Give child more fluids than usual to prevent dehydration. 2. Give child plenty of food to prevent undernutrition.

3. Instruct guardian to bring child to Health Center if child develop any of the following: - watery stools > 3x/day - repeated vomiting - marked thirst - eats or drinks poorly

- fever - blood in the stools

IV. Preventive Measures

Educate mother/ guardian/ relatives on: 1. Hygienic Practices:

a. Hand washing before eating or after toilet use. b. Proper or sanitary disposal of stools. c. Drinking water or eating food only from safe sources or boiling of drinking water from doubtful sources. d. Proper practices in cooking and storage of food

2. Correct weaning practices 3. Environmental sanitation 4. Importance of measles immunization and breastfeeding till 4-6 months of age 5. Rotavirus vaccine for infants < 6months old. (see annex 21a on Immunization Schedule for Children)


31

Annex 2

HOSPITAL MANAGEMENT PROTOCOL FOR BRONCHIAL ASTHMA

I. Routine Laboratory Examinations

1. CBC 2. ABG/ Oxygen saturation



Cases with poor response (PEFR <40% baseline, increase heart rate, increase RR, pulsus paradoxus ≤ 15 mmHg, inspiratory and expiratory wheezing on auscultation, moderate to severe usage of accessory muscles, moderate to severe dyspnea, O2 saturation at > 91% after initial aggressive management) to therapy requires hospital admission.

A. Ward Management

*Criteria for Ward Admission: PEFR >30% baseline and/or PaCO2 <40mmHg, O2 saturation ≥ 90% Auscultation: moderate wheezing (entire expiration) Accessory muscles; moderate usage Dyspnea: moderate (one sentence) Pulsus paradoxus: ≤ 15 mmHg

1. Give oxygen to keep O2 saturation at > 93% 2. Nebulize with Salbutamol or Terbutaline at 1 neb q 1-2 hrs or may use Salbutamol with Ipratropium at 1 UDV 3. Give Oral or IV Methylprednisolone at 1-2 mkd (max 150mg) or Hydrocortisone at 250 mg then 100mg q 6 hr

(pediatric: 10 mkBW LD, then 5-10 mkD MD), shift to oral if oral medication is tolerated to complete 5 days therapy.

4. Give Paracetamol (10 – 15 mg/kg q 4 hours) for fever 5. Hydrate patient


32

6. Reassess condition of patient q 1-2 hours

a. No Improvement of Condition (PEFR < 30% baseline and paCO2 > 40mmHg & other parameters worsening)

1) Admit patient to ICU 2) Refer to Pulmonologist

b. With Improvement of Condition 1) Decrease aerosol frequency as tolerated 2) Continue steroids

B. Intensive Care Unit Management

*Criteria for ICU Admission: PEFR <30% baseline and/or PaCO2 >40mmHg, O2 sataturation < 90% Auscultation: severe wheezing (inspiratory and expiratory) Accessory muscles: severe usage Dyspnea: severe (1-2 words) Pulsus paradoxus: > 15 mmHg

1. Consult Pulmonologist 2. Give oxygen to keep O2 saturation >93% 3. Continue nebulization with Salbutamol 4. Consider giving any of the following:

a. SC Epinephrine at 0.01mkd (0.3mg max dose) b. SC Terbutaline at 0.005 – 0.01mkd q 15 – 20 min x 2 doses c. Inhaled Ipratropium

5. Give Methylprednisolone at 1-2 mkd q 6 hr or Hydrocortisone at 250 mg then 100 mg q 6 hr (pediatrics: 10 mkBW LD, then 5-10 mkD MD), shift to oral if oral medication is tolerated to complete 5 days therapy

6. Give Aminophylline drip at 250 mg in 250 ml D5W with a LD of 5 mkBW in a soluset for 4- 6 hrs then MD of 0.4-0.8 ml/ kg/hour

7. Give Paracetamol (10 – 15 mg/kg q 4 hours) for fever 8. Hydrate patient 9. Re-assess condition of patient frequently (if PaCO2 is 55mmHg or rising at 5-10mmHg/hr, increasing dyspnea

and fatigue with accessory muscle use, pulsus paradoxus > 30mmHg, acidosis and O2 desaturation a. Continue medications b. Consider mechanical ventilation


33

III. Guidelines For Patient’s Discharge

A. Criteria for Discharge

Improved condition of patient as follows:

1. Patient able to walk comfortably 2. Patient not waking up at night or early morning needing a bronchodilator 3. Use of short acting inhaled B2-agonist at no more than every 4 hours 4. Clinical examination is normal or near normal (PEFR >90% baseline, heart and respiratory rate: normal,

auscultation: minimal to no wheezing, no accessory muscle use, no dyspnea, pulsus paradoxus: ≤ 5mmHg, O2 saturation: ≥ 94%)

B. Follow-up Advice

1. advise patient to use inhaler devices other than nebulizers 2. educate patient on medications and follow-up plan


Patients/ guardians/ relatives should be given Asthma Education as follows:

1. Keep home free of dust and pet hair. 2. Change air filters at least twice a year. 3. Keep child’s room fabric-free as possible using wood furniture and window shades. 4. Do not allow anyone to smoke in the house or around the child. 5. Avoid use of hair spray, powder, perfume or make-up around the child. 6. Find out what foods trigger an asthma attack in the child and remove these foods from diet. 7. Keep child indoors when pollution levels are high by not letting the child play near streets or parking lots. 8. Avoid exposure of child from sudden extreme temperature changes. 9. Encourage open communication and keep child calm if stress triggers child’s attacks and let child understand that the situation is best handled by remaining cool, calm, and collected.


34

Annex 3

HOSPITAL MANAGEMENT PROTOCOL FOR DENGUE

I. Laboratory Procedures

A. Routine Examinations

1. Baseline CBC, platelet count with blood typing 2. Serial hematocrit* depending on patient’s condition, platelet count**

* A drop of 20% in hct indicates signs of plasma leakage, thus, search for concealed hemorrhage. ** Platelet count may be requested at least daily until increasing trend is noted.

3. Serologic test to confirm diagnosis may be any of the following: a. HI test b. Dengue Duo c. Dengue IgM d. Dengue blot

B. Ancillary Examinations

These tests are requested when there are signs of bleeding and impending shock or in shock.

Ancillary Test Indication/s

Protime Partial Thromboplastin Time

For patients presenting with hemorrhagic manifestations in any form not responsive to usual treatment

Serum albumin, ALT, AST, Total and direct bilirubin

For assessment of patients with liver dysfunction which is not unusual in DHF

Urinalysis, Serum Creatinine For patients in shock who require assessment of renal function

Chest x-ray For patients in respiratory failure whether due to effusion or pneumonia/ pulmonary edema

Thoracic/ abdominal ultrasound For evaluation of patients with lung problems/ effusion/ organomegaly/ ascites

ECG 12 leads For evaluation of patients with possible myocarditis


35


A. Specific Therapy: None

B. Symptomatic and Supportive Treatment

1. Intravenous Fluid (IVF) Therapy

a. Protocol for fluid correction with no shock:

1) Give IVF crystalloids – Start IVF, preferably D5LR or D5 0.9 NaCl or Plain LR at 5-7 ml/kg/hr.

2) If there is improvement reduce IVF to 3 ml/kg/hr (up to 2-3 L/day in adults) and maintain at same rate for first to second hospital day using D5LR alternating with D5MB (<2 y/o) or D5 0.3NaCl (>2 y/o).

3) If there is no improvement, increase IVF rate by 3-5 ml/KBW/hr increments up to 15 ml/KBW/hr then adjust accordingly as above.

b. Protocol for fluid correction with shock:

1) Give IVF crystalloids - Plain LR or Plain 0.9 NSS at 20ml/KBW IV bolus in < 20minutes (20/20 rule) in <20 minutes, may repeat twice if no improvement. If there is still no improvement, follow-up with colloids (Dextran, Haemacel, Haesteril) at 10 ml/kg bolus in <20 minutes, may repeat if no improvement.

2) If there is still no improvement with colloids, may give Fresh Frozen Plasma at 15cc/kg in 2 hrs and start

inotropes (Dopamine at 7-15ug/kg/min). .


36

2. Blood/Blood Products Transfusion

Blood/ Blood Products Indication/s and Dosage

Platelet Concentrate Give platelet concentrate at 1 unit/5-7 kg if platelet count is <50,000 among patients with significant bleeding or if platelet count is <20,000 even if there is no significant bleeding.

Cryoprecipitate Give at 1 unit/5 kg if with prolonged PTT (>50 sec or 10 sec more than the upper limit of normal or 20 sec more than the control) or with signs of DIC

Fresh Frozen Plasma Give in normotensive patient with prolonged PT (2 times the control) at 15 ml/kg x 2-4 hrs plus Furosemide at 1-2 mg/kg given at mid-transfusion or if patient is in impending shock despite crystalloid solution and in the absence of colloids.

Fresh Whole Blood

Give at 20 cc/kg if with significant active/ gross bleeding or blood loss is 25% or more of blood volume or if hct falls by 20% (>10% blood loss in adults or 25% blood loss in pediatrics of total blood volume of 80 ml/kg). Calcium gluconate can be given if FWB is given more than 4 – 6 units/bags. However, it is essential to check for patient’s calcium level prior to administration.

Packed Red Blood Cells Give at 10 cc/kg in 4 hours when blood loss is <25% or if there is no more active bleeding but with low hct and hemoglobin (<8 gm/dL or 80 gm/L).

3. Other Symptomatic Treatment

a. Give Paracetamol (10 – 15 mg/kg q 4 hours) for febrile episodes. Do not use Aspirin. b. Give Sucralfate as cytoprotector of the gastric mucosa, at 1 gm q 6 hrs for adults and 40-80 mkD q 6 hrs for

pediatric. c. Give H2 blockers (Ranitidine at 1-2mkd) to patients with severe epigastric pain and/or gastric bleeding. d. Do gastric lavage with cold saline after NGT insertion for patients with gastric bleeding. e. Give Albumin infusion for hypoalbuminemia (<26mg/dl) f. Place in Trendelenberg position patient with circulatory failure. g. Do nasal packing with Epinephrine for epistaxis. h. Give O2 (2-4L/min via nasal prong) inhalation for difficulty of breathing/ cyanosis/ shock i. Use mechanical ventilation when necessary j. Monitor vital signs as often as necessary k. Monitor urine output and level of consciousness

*All Dengue patients must not be given with medications through intramuscular injections.


37


A. Criteria for Discharge: Improved clinical and laboratory status as follows:

1. Afebrile and stable vital signs for 3 days and with good appetite. 2. Resolution of complications such as encephalopathy, seizures, bleeding, arrhythmias, pneumonia, ascites, hematuria,

and/or oliguria. 3. Normal laboratory examinations: platelet count (increasing trend); PT (Control 70-120%); PTT (control 30-45 sec); hct

(0.38-0.45); Creatinine (54-133 mmol/L).

B. Follow–up Advice: Advise patient to follow-up at any health care facility 1 week after discharge.


Educate patient/ guardian/ parent/ relatives on:

1. Environmental sanitation and destruction of mosquito breeding places such as clogged gutters, old tires, cans, uncovered water containers.

2. Personal protection by use of repellants and mosquito nets or wearing of long trousers and long sleeved shirts/ blouses.


38

Annex 4a

Table of Oral Anti-Hypertensive Drugs

Class of Anti-Hypertensives Indications Contraindications Ace – Inhibitors Imidapril 5-10 mg OD Quinapril 5-10 mg OD

Stage I hypertension diabetes mellitus, post-myocardial infarction, heart failure, chronic renal disease

Bilateral renal vascular disease Creatinine >2mg/dl

Angiotensin II antagonists Losartan 50 mg OD

Stage I hypertension diabetes mellitus, post-myocardial infarction, heart failure, chronic renal disease

Bilateral renal vascular disease Creatinine > 2mg/dl

Beta –blockers Metoprolol 50,100 mg BID Propanolol 10-40 mg TID Carvedilol 12.5-25 mg OD-BID

Prior myocardial infarction, Stage I hypertension, coronary artery disease (preferred therapy), diabetes mellitus without nephropathy

Asthma, severe peripheral arterial disease, acute decompensated heart failure, advanced heart block

Calcium Antagonists Felodipine 2.5, 5, 10 mg OD Diltiazem 30, 60mg,120 mg OD BID

Stage I hypertension (alternative therapy) peripheral vascular disease, coronary artery disease Systolic hypertension (Felodipine)

Congestive heart failure, heart block (Diltiazem)

Diuretics Thiazide HCTZ(Hytaz)12.5-25 mg/day

Stage I hypertension, uncomplicated hypertension, Systolic hypertension in elderly (preferred therapy), for older patients without nephropathy

Gout, dyslipidemia

Two drug combination for most cases (Thiazide and ACE or ARB or BB or CCB) Losartan 50 mg + thiazide 12.5 mg (Combizaar) OD Metoprolol 50 mg-100 mg BID + Thiazide 6.25-25 mg OD

Stage II hypertension


39

Annex 4b

HOSPITAL MANAGEMENT PROTOCOL FOR HYPERTENSIVE EMERGENCY

I. Treatment Guidelines Immediate control of BP using IV antihypertensive drugs is essential to terminate on-going target organ damage by:

1. Reduce the mean arterial pressure by approximately 20-25% or reduce diastolic pressure to 100-110 mmHg in one hour. 2. Admit patients to ICU with intra-arterial BP monitoring.

Anti-hypertensive Therapy (Parenteral)

1. May use any of the following anti-hypertensive agents alone or in combination depending on the clinical situation or presence of co-morbid illness (see Table 1).

Table 1: Clinical Conditions and Anti-Hypertensive Drugs of Choice

Conditions

First Line Drug/s

Dosages

Uncontrolled Hypertension Despite Initial Treatment

Intracerebral Hemorrhage

● Nitroprusside

infusion (treat only if diastolic pressure is >130mmHg)

Initial Dose: 0.25-0.3 mcg/kg/min IV infusion. Gradually titrate up every few min until BP is controlled. Usual dose range: 0.25-10 mcg/ kg/min IV

Max dose: 10mcg/kg/min


40

Conditions First Line Drug/s Dosages Uncontrolled Hypertension Despite Initial Treatment

Myocardial Ischemia

Nitroglycerin infusion

PLUS

Labetalol

OR

Esmolol

Initial Dose: 5-10mcg/ min IV infusion. Increase by 5mcg/min every 3-5 min until some response is noted. Usual Dose: 5-100mcg/min IV infusion. Once a partial response is obtained, increases in dose increments

Loading dose: 20mg IV over 2 min.. Follow by: Boluses of 20-80mg IVevery 10. OR IV infusion: Starting at 2mg/min IV titrated to desired response

Loading dose= 250mcg IV over 1 min.Follow by: 50-100 mcg/min.IV over 4 min

If there is still no response at 20mcg/min: May increase at increments of 10mcg/min& later if required, 20mcg/min increments can be used

Max cumulative dose: 300mg/24 hr. min.(max 300mg)

If necessary, repeat the loading dose or IV infusion rate maybe increased to 300 mcg/kg/min as tolerated

Congestive Heart Failure

Nitroprusside infusion

PLUS

Nitroglycerin infusion

PLUS

Loop diuretic (Furosemide)

Initial Dose: 0.25-0.3mcg/kg/min IV infusion. Gradually titrate up every few min until BP is controlled. Usual dose range: 0.25-10mcg/kg/min IV

Initial Dose: 5-10mcg/ min IV infusion. Increase by 5mcg/min every 3-5 min until some response is noted. Usual Dose: 5-100mcg/min IV infusion.Once a partial response is obtained, increases in dose increments

Concentration=1mg/ml Drip of 5-30ugtts/min is equivalent to 5-30mg/hour

Max dose: 10mcg/kg/min

If there is still no response at 20mcg/min: May increase at increments of 10mcg/min& later if required, 20mcg/min increments can be used

Continuous IV


41

Conditions First Line Drug/s Dosages Uncontrolled Hypertension Despite Initial Treatment

Acute Renal Failure/ Microangiopathic Anemia

● Nicardipine

IV infusion: 5mg/hr IV titrated to desired effect. May increase dose by 2.5mg/hr IV every 5 min

Max dose: 15mg/hr

Acute Aortic Dissection ● IV antihypertensive

therapy should be started as soon as aortic dissection is suspected Surgical CV

consult is needed

● Labetalol

OR

Nitroprusside

PLUS

● Esmolol


Initial Dose: 0.25-0.3mcg/kg/min IV infusion. Gradually titrate up every few min until BP is controlled. Usual dose range: 0.25-10mcg/kg/min IV Loading dose= 250mcg IV over 1 min.Follow by: 50-100 mcg/min.IV over 4 min

Max cumulative dose: 300mg/24 hr. min.(max=300mg)

Max dose: 10mcg/kg/min If necessary, repeat the loading dose or IV infusion rate maybe increased to 300 mcg/kg/min as tolerated

Antihypertensive withdrawal

Labetalol

OR

Phentolamine


Hypertensive crisis associated with excess circulating cathecolamines: 5-15mg IV bolus

Max cumulative dose: 300mg/24 hr. min.(max=300mg)

Continuous IV

Sympathetic Crisis

Nicardipine

IV infusion: 5mg/hr IV titrated to desired effect. May increase dose by 2.5mg/hr IV every 5 min

Max dose: 15mg/hr

Preeclampsia/Eclampsia Hydralazine 5-20mg IV (10-50mg IM) Dose (Use the lower range doses initially for BP control)

may be increased & repeated every 20-30 min as required


42

2. Monitor patient closely and watch out for sudden drop of BP within a few minutes particularly in patients with the

following conditions with desired BP goals: a. Diabetes and kidney disease at not < 130/80 mmHg b. Without cardiovascular risk factors at not <140/90mmHg

II. Measures to Prevent Cardiovascular Events in Hypertensive Patients

Advise hypertensive patients to:

1. Stop smoking 2. Control blood sugar if diabetic 3. Treat dyslipidemia 4. Reduce intake of sodium and diet rich in fat 5. Consume a diet rich in vegetables, fruit and low fat dairy products. 6. Maintain a body mass index of (BMI) between 18.5-24.9kg/m2 7. Engage in regular aerobic exercise or engage in brisk walking at least 30 minutes a day once BP is controlled 8. Limit alcohol intake to less than 1 oz./day of ethanol (24 oz of beer, 8 oz of wine or 2 oz 80-proof whiskey)


43

Annex 5

HOSPITAL MANAGEMENT PROTOCOL FOR INFLUENZA

I. Routine Laboratory Examination - CBC



A. Specific therapy

May give anti-viral drugs within 48 hrs of onset of illness for 3-5 days or 1-2 days after the disappearance of symptoms in the following cases:

a. immuno-compromised status/ chronic debilitating illnesses (AIDS, malignancy, severe malnutrition, elderly > 60 y/o)

b. severe co-morbid illnesses (Kawasaki) c. those with special environmental, family, or social situations, such as examinations in school, athletic

competitions, and those with high-risk family members.

1. OSELTAMIVIR – for both influenza A and B. Dose: Children and Adults : 75 mg capsule po BID for 5 days

For 1- 12y/o : 2mg/kg max 75mg po BID

2. AMANTADINE HCL (decreases the severity of Influenza A if given) Dose: 1 – 9 y/o : 5 mkd, max 75mg po BID

10 – 65y/o : 100 mg po BID > 65y/o : 100mg po q 24 hr (adjust for decrease renal function)


44

B. Symptomatic or Supportive Therapy

1. Give Paracetamol for fever at 10-15 mkd q 4-6 hr and avoid Aspirin. 2. Manage encephalitis accordingly. 3. Give antibiotics for secondary bacterial infection. 4. Hydrate patient adequately.



1. Afebrile and active for at least 2 days 2. Resolution of other symptoms or complications such as dyspnea and seizure.


1. Isolate patients

a. Standard and droplet precautions are recommended for the whole duration of the illness. b. Respiratory tract secretions should be considered infectious, and strict hand washing procedures should be used.

2. Give Chemoprophylaxis (Amantadine/Oseltamivir) in the following:

a. For > 1y/o at high risk who were immunized after circulation of Influenza A in the community has begun. Beneficial during the interval before a vaccine response.

b. Unimmmunized persons providing care to high-risk persons c. Immunodeficient persons whose antibody response to vaccine is likely to be poor. d. Persons at high risk for whom vaccine is contraindicated as in anaphylactic hypersensitivity to egg protein who do

not receive desensitization. e. Any healthy child with age-appropriate development for whom prevention of influenza is considered desirable.

Dosages for chemoprophylaxis: Amantadine : same dose as for treatment Oseltamivir (for >12yo) : 75 mg OD for the duration flu epidemic


45

3. Give yearly vaccination before the start of influenza season, February to June. (see annex 21a and 21b on Immunization Schedule for Children and Adults, respectively)

Priority should be given to targeted high-risk group:

a. Children and adolescents with the following high-risk factors: 1) Chronic cardiovascular disease (congenital heart disease, valvular heart disease) 2) Chronic lung disease (asthma) 3) Chronic metabolic disorders (diabetes) 4) Renal disorders and hemoglobinopathies 5) Condition requiring long term aspirin treatment (Kawasaki, rheumatoid arthritis) 6) On immunosuppressive therapy 7) HIV infection

b. Close contacts of high risk patients 1) All health care personnel in contact with pediatric patients in hospital and outpatient care settings. 2) Household contacts, including siblings and primary caregivers of high-risk children. 3) Children who are members of households with high-risk adults, including those with symptomatic HIV

infection. 4) Providers of home care to children and adolescents in high-risk groups.

c. Pregnant women in second/ third trimester of pregnancy since pregnancy increase the risk of complications and hospitalizations from influenza.

d. Persons traveling to foreign areas where influenza outbreaks may be occurring.


46

Annex 6a

HOSPITAL MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS


1. CBC with platelet count 2. Clotting time, bleeding time with blood typing 3. APTT, Protime for patients with hemorrhages and initial thrombocytopenia 4. BUN, Creatinine, Uric acid, CPK 5. AST, ALT, Alk phosphatase 6. TB, B1, B2, TPAG 7. Serum electrolytes 8. Serologic test (EIA, MAT- LAAT) to confirm diagnosis 9. Urinalysis



A. Antimicrobial Therapy

The maximum benefit of shortening the clinical course of the disease is achieved if antibiotic therapy is started before the onset of the immune phase.

Antibiotics Dosage Drug of Choice Adult Pregnant Children

PENICILLIN G

1.5-2 MU IV q 6hrs for 7-10 days

1.5-2MU IV q 6hrs for 7-10 days

200,000 U/kg/day IV in 4 divided doses for 7-10 days


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Antibiotics Dosage Alternative Drug Adult Pregnant Children

CEFTRIAXONE 2 gm/day IV OD for 7 days 2 gm/day IV OD for 7 days 100 mg/kg IV OD for 7 days

DOXYCYCLINE 100 mg BID for 7-10 days Not recommended Not recommended below 8 yrs old 3 mkD in 2 divided doses for 7-10 days

TETRACYCLINE

500 mg q 6 hrs for 7-10 days Not recommended

Not recommended below 8 y/o 20-40 mkD in 4 divided doses

ERYTHROMYCIN 500 mg q 6 hrs for 7-10 days 500 mg q 6 hrs for 7-10 days 40-50 mkD in 4 divided doses for 7-10 days

AMOXICILLIN 3 gm/day in 3 divided doses for 7-10 days

3 gm/day in 3 divided doses for 7-10 days

50 mkD in 3 divided doses for 7-10 days

B. Symptomatic and Supportive Therapy

1. Give Paracetamol (10-20 mkd (IV), max of 300 mg) for fever. Do not use aspirin. Pedia: Paracetamol at 5-10 mkd q 4 hr po. Adult: Paracetamol at 500 mg q 4 hr po.

2. Maintain adequate hydration with isotonic solution. 3. Apply Povidone Iodine solution/ Mupirocin cream or ointment for wound care. 4. Correct fluid & electrolytes for gastrointestinal disturbances 5. Correct deranged hematologic functions for bleeding

a. use the protocol on use of platelet concentrate/fresh frozen plasma/cryoprecipitate b. give Vitamin K at 10 mg STAT dose.

6. Use Dobutamine (4-20ug/KBW/min) or Norepinephrine (4-12 ug/min) as cardiac support to maintain MAP above 65mmHg or maintain systolic BP 110-120mmHg.

7. Correct acid base imbalance for metabolic encephalopathy 8. Give the following for massive proteinuria / hypoalbuminemia

a. Albumin: 0.5-1 g/kg/dose to be given in 2-4 hours period b. Furosemide: 0.5-1 mkd to be given mid-way the infusion of albumin


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9. Use the Management Guidelines of Oliguria-Anuria (see annex 6b) and monitor patient’s response to fluid challenge by:

a. Insertion of CVP line b. Monitoring of input & output



Improved clinical and laboratory status as follows:

1. Resolution of signs and symptoms such as fever, jaundice, hypoalbuminemia. 2. Normal laboratory examination: BUN, creatinine 3. Urine output of at least 1 cc/kg/hour

B. Follow-up Advice: Advise patient to follow-up 1 week after discharge at health center.


1. Educate patients/ guardians on the disease emphasizing the mode of transmission, to avoid swimming or wading in potentially contaminated waters, and use protective gears when work requires such exposure or when exposure cannot be avoided.

2. May give chemoprophylaxis using Doxycyline at: a. 200 mg once a week in high risk groups with short term exposure b. 100 mg BID for 3-5 days for persons whose wounds are exposed to potentially contaminated environment.


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Annex 6b

MANAGEMENT OF OLIGURIA-ANURIA IN LEPTOSPIRAL ACUTE RENAL FAILURE

I. Additional Laboratory Examinations

1. Chest x-ray (PA view) 2. ABG (for correction of metabolic acidosis to improve cardiac contractility) 3. Electrolytes (for correction of hypokalemia/ hyperkalemia, and hypocalcemia) 4. TPA/G (for correction of low albumin in septic patient)


A. Group A Patient:

[With signs of volume depletion (dehydrated, positive thirst, dry axilla, flat neck veins, JVP of <5cm, no rales, tachycardic) plus urine output of < 400 ml/day with normal systolic BP (>90mmHg)]

1. Institute fluid resuscitation by hydrating with normal saline or half saline (0.45%) NSS for elderly patients with

cardiovascular abnormality 2. Diuretics is not indicated when there is adequate diuresis (urine output of >30 cc/hr and increasing) in 2-4 hours after

fluid hydration

B. Group B Patient:

[With signs of volume depletion (dehydrated, positive thirst, dry axilla, flat neck veins, JVP of <5cm, CVP<10 cm, no rales, tachycardic) plus urine output of < 400 ml/day with low systolic BP ( <90mmHg)]

1. Insert central venous catheter if feasible for CVP reading (guide for fluid challenge to target CVP reading of 10-12 cm) 2. Institute fluid resuscitation by hydrating with normal saline or half saline (0.45%) NSS for elderly patients with

cardiovascular abnormality.


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3. Give diuretics as indicated below, if there is no response to fluid hydration in 2-4 hours a. Give Hydrochlorothiazide( Hytaz)* at 25mg to 50 mg tablet OD-BID plus any loop diuretics as follows:

1) Furosemide: doubling dose at 20mg-40-80-160 mg IV q 2 hr or initial dose of 100mg-200mg q 2 hr 2) Bumetanide: doubling dose at 1mg-2-4-8 mg

b. or may give loop diuretics as infusion in D5Water, 250cc + 240 mg Furosemide or 12 mg Bumetanide in 24 hours

*Give Hydrochlorothiazide 1 hour earlier before giving intravenous (IV) loop diurectics

4. May give Vasopressors (Dobutamine at 4-20 ug/KBW/min, Norepinehrine at 4-12 ug/min) to support BP after hydration if patient remain hypotensive and need to challenge with diuretics

5. May consider to combine Albumin 25% as fast drip at 1 vial OD-BID plus loop diuretics

Target Urine Output: 30cc/hr or 700-800cc/day and increasing

6. Refer to Nephrologist for dialysis

*Indications for Dialysis: uremic manifestations unresponsiveness to medical treatment, persistent hyperkalemia, intractable metabolic acidosis, worsening pulmonary congestion

C. Group C Patient:

[With signs of volume excess (engorged neck veins, pulmonary rales, tachycardiac, edema) plus urine output of <400cc/day and borderline unstable BP with CVP reading of >10 cm (>15 cm or frank fluid overload)]

1. Give fluids using D5Water as KVO 2. Support BP with vasoppressors (Dobutamine at 4-20 ug/kg/min, Norepinephrine at 4-12 ug/min) to maintain BP at

110-120 mmHg systolic 3. Give loop diuretics as bolus using Furosemide at 80-100mg, and if still has no response, then may give another

Furosemide at 200mg IV after 2 hours or Bumetanide at 2-4 mg then another 8 mg 4. Refer to Nephrologist if patient remain unresponsive (no urine output or inadequate urine output) for dialysis


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Annex 7

HOSPITAL MANAGEMENT PROTOCOL FOR MALARIA


1. malaria blood film (thick and thin smears) upon admission and q 12 hrs thereafter for the first 48 hrs, daily for the next 5 days or until negative for asexual forms of parasites

2. CBC, platelet count, blood typing 3. urinalysis and urine urobilinogen 4. CT, BT, APTT



A. Anti-Malaria Therapy

1. For Uncomplicated Malaria

a. For probable malaria and confirmed P. falciparum cases, except for pregnant women, use Chloroquine (CQ) plus Sulfadoxine/Pyrimethamine (SP) and Primaquine as follows:

Table 1. Dose and Schedule of CQ + SP and Primaquine

Age (yrs)

No. of Chloroquine Tablet (150 mg base/tablet)

Day 1 – 10mg base/kg body weight Day 2 – 10mg base/kg body weight Day 3 – 5 mg base/ kg body weight Day 1 Day 2 Day 3

Sulfadoxine/Pyrimethamine (500 mg/25 mg/tab)

No. of Tablet

Single dose only Day 1

Primaquine (15 mg/tablet)

No. of Tablet


0-4 mos. ½ ½ ½ ¼ Not indicated 5-11 mos. ½ ½ ½ ½ Not indicated 1-3 yrs. 1 1 ½ 1 ½ 4-6 yrs. 1 ½ 1 ½ 1 1 1 7-11 yrs. 2 2 1 1 ½ 2

12-15 yrs. 3 3 1 ½ 2 3 16 yrs. & above 4 4 2 3 3


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b. For confirmed P. vivax cases, administer orally CQ and Primaquine as follows:

Table 2. Dose and Schedule of CQ and Primaquine

Age (yrs)



Primaquine* (15 mg/tablet)

1-14 days treatment

0-4 mos. ½ ½ ½ Not indicated 5-11 mos. ½ ½ ½ Not indicated 1-3 yrs. 1 1 ½ ½ daily 4-6 yrs. 1 ½ 1 ½ 1 ½ daily

7-11 yrs. 2 2 1 ¾ daily 12-15 yrs. 3 3 1 ½ 1 daily 16 yrs. &

above 4 4 2 1 daily

* contraindicated in pregnant women but may be given after the termination of pregnancy c. For cases with mixed P. falciparum and P. vivax infection, except for pregnant women, give CQ+SP and

Primaquine as follows:

Table 3. Dose and Schedule of CQ +SP and Primaquine

Age (yrs)



Sulfadoxine/Pyrimethamine (500 mg/25 mg/tab)

No. of Tablet


Primaquine (15 mg/tablet)

No. of Tablet For 14 days

0-4 mos. ½ ½ ½ ¼ Not indicated 5-11 mos. ½ ½ ½ ½ Not indicated 1-3 yrs. 1 1 ½ 1 ½ daily 4-6 yrs. 1½ 1½ 1 1 ½ 7-11 yrs. 2 2 1 1½ ¾

12-15 yrs. 3 3 1½ 2 1 16 yrs. & above 4 4 2 3 1


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d. Assessment of Uncomplicated Malaria Response to CQ+SP Anti-Malarial Regimen

Evaluate the adequacy of clinical and parasitological response among patients with uncomplicated malaria treated with CQ+SP anti-malarial regimen, using the table below.

Table 4. Grading of Clinical and Parasitological Response to CQ+SP Treatment Clinical and Parasitological Response to Treatment Level of Clinical Response

Absence of parasitemia on D28 irrespective of temperature; not treatment failure Adequate Clinical Response (ACR)

1. Presence of any of signs of severe symptoms plus repeated vomiting in the presence of parasitemia from Day 1, Day 2, or Day 3

2. Parasitemia on Day 3 3. Parasitemia on Day 2 higher than Day 0 count 4. Parasitemia on Day 3 > or = to 25% of count on Day 1

Early treatment failure (ETF)

5. Development of signs of severe malaria plus repeated vomiting after Day 3 in the presence of parasitemia

6. Presence of parasitemia and axillary temperature >37.5°C on any day between Day 4 to Day 28 without previously meeting any of the criteria of ETF

Late clinic-parasitological failure (LCF)

Presence of parasitemia on any of the scheduled return on Day 7, Day 14, Day 21 or Day 28, and axillary temperature <37.5°C without previously meeting of any of the criteria of ETF

Late parasitological failure (LPF)

2. Complicated Malaria

a. For cases with multi-drug resistant P. falciparum, give Artemether 20 mg/Lumefantrine 120 mg Combination Tablet (Co-Artem) as the drug of choice as follows:

Table 5. Dose and Schedule of Artemether 20 mg/Lumefantrine 120 mg Combination Tablet (Co-Artem)* Schedule Adults and

children above 13 years Pediatrics

9 to 13 years 4 to 8 years 1 to 3 years Day 1

8 hrs after Day 2 Day 3 Day 4

4 tabs 4 tabs 4 tabs BID 4 tabs BID Give primaquine as in Table1

3 tabs 3 tabs 3 tabs BID 3 tabs BID Give primaquine as in Table1

2 tabs 2 tabs 2 tabs BID 1 tab BID Give primaquine as in Table1

1 tab 1 tab 1 tab BID 1 tab BID

*Contraindicated in infants < 1 year old


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b. For treatment failure or in the absence of Co-Artem and for pregnant women, give Quinine-plus as follows:

Table 6. Dose and Schedule for Quinine-plus

Age group/ Condition

Quinine sulfate

(300 or 600 mg per tablet)

Plus any of the three drugs below: Primaquine

Doxycycline Tetracycline Clindamycin

Adults 10 mg/kg/dose q 8 hrs x 7 days

3 mg/kg OD x 3 days

250 mg QID x 7 days

10 mg/kg BID x 3 days

Table 1

Children > 8 years old

As above As above As above As above Table 1

Children < 8 years old

As above Contraindicated Contraindicated As above Table 1

Pregnant As above Contraindicated Contraindicated As above At termination of pregnancy

c. For severe form of malaria, use Quinine dihydrochloride as shown in the table below:

Table 7. Dose and Schedule of Quinine for Severe Malaria

Age group Quinine diHCl (600 mg/2 ml) Tetracycline Clindamycin

Loading dose Maintenance Dose

Adult

20 mg salt/kg in 10 ml/kg 0.9 NaCl or D5W x 4 hrs. IV drip (Total not to exceed 2,000 mg)

10 mg salt/kg in 10 ml/kg 0.9 NaCl or D5W IV drip x 4 hrs. every 8

hours

500 mg QID x 7 days

10 mg/kg BID x 3 days

Children 8-16 y/o

15 mg salt/kg IV drip x 4 hrs. 10 mg. salt/kg IV drip x 4 hrs.every 8 hrs.

4 mg/kg QID not to exceed 250 mg/dose

As above

Children 7 y/o and below

10 mg salt/kg in IV drip x 4 hrs.

10 mg. salt/kg IV drip every 12 hrs.

Contraindicated As above


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B. Supportive Management

1. Replace fluid losses following CDD guidelines. 2. Give IV Paracetamol for fever. 3. Control seizures with any of the following:

a. Diazepam - 10mg IV(adult) 0.3mg/kg IV (Pedia) b. Phenobarbital - LD 10-20mg/kg slow IV divided into 2-4 doses at 30-60min interval, MD 1-5 mg/kg/day (Adult)

- LD 15-20mg/kg slow IV push in single or divided dose, MD 5-7mg/kg/day IV in 2-4 divided doses (Pedia)

c. Phenytoin - LD 13-18mg/kg, MD 3-5mg/kg/day (Adult) - LD 15-20mg/kg slow IV push, MD 5 mg/kg IV in 2 divided dose (Pedia)

4. Transfuse blood/blood products in the following conditions: a. for severe anemia (<8 mg/dl Hgb)

1) Packed RBC (10cc/kg) infuse at 2-3 mg/kg/hr in high output failure otherwise 1 ml/kg/hr 2) Fresh whole Blood – 20cc/kg at 10mg/kg/hr

b. for thrombocytopenia with platelet count below 60,000 in adults and 30,000 in children 1) Platelet concentrate at 1 unit/7 kg body weight

5. Assess renal status of patient based on the following parameters:

Table 8. Assessment Parameters for Renal Failure Renal Failure Parameters

Adults Children Infants

1. Urine output

2. Urine specific gravity

3. serum creatinine

< 1 ml/kg/hr

< 1.015

elevated

< 300 ml/m2/24 hrs or

< 1 ml/kg/hr <1.010

elevated

< 1.0 ml/kg/hr

elevated

a. Give Furosemide at 1mg/kg or Dopamine at renal dose (2-5ug/kg/min.) b. Refer to Nephrologist when patient failed to respond to fluid management.

6. Assess for the presence of acute pulmonary edema and when present refer to pulmonologist.


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III. Preventive Measures

A. Chemoprophylaxis

This is recommended for persons who are at high risk for severe and complicated malaria, particularly non-immune travelers to endemic areas and primigravids during entire pregnancy and who reside in endemic cases. Chloroquine as a chemoprophylactic drug is generally safe and has little teratogenic risk. It is administered from the second trimester of pregnancy to six weeks after delivery.

Table 9. Dose and Schedule for Anti-Malaria Chemoprophylaxis Drug Schedule Adult dose Pediatric dose

Doxycycline tablet (100 mg); start two to three days prior to travel; continue up to four weeks upon leaving the area

Mefloquine tablet (250 mg base); start one week before travel; continue up to four weeks upon leaving the area

100 mg daily (contraindicated in pregnant and lactating women)

250 mg weekly

2 mg/kg up to 100 mg daily (not recommended for seven years and younger)

> 45 kg = 250 mg < 45 kg = 5 mg/kg up to maximum of 250 mg

Table 10. Dose and Schedule for Anti-Malaria Chemoprophylaxis Among Pregnant Women

Stage of pregnancy

Chemoprophylactic drug

Standby treatment First trimester

Second and third trimesters

Chloroquine tablets at two tablets weekly two weeks before travel, during stay, and until four weeks after leaving the area.

Pyrimethamine-sulfadoxine (as in Table 1) for each trimester of stay

Quinine alone as in Table 6

Chemoprophylaxis alone does not give 100% protection against infection with the Plasmodium parasite and personal protective measures are just as important.

B. Personal Protective Measures in Areas Endemic for Malaria

1. Wear light-colored, long-sleeved clothing and trousers when going out at night. 2. Screen doors and windows or otherwise windows and doors should be closed at night. 3. Use mosquito net, preferably impregnated with permethrin or deltamethrin in endemic areas.


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Annex 8

HOSPITAL MANAGEMENT PROTOCOL FOR MEASLES I. Routine Laboratory Examinations

1. CBC 2. Measles IgM determination (as per DOH’s Measles Elimination Campaign)



A. Specific therapy: None


1. Give Vitamin A using the following dosages:

a. For infants less than one year : 100,000 I.U. b. For children > one year : 200,000 I.U.

Dose should be repeated the next day and 4 weeks later if with ophthalmologic evidence of Vitamin A deficiency.

2. Give Paracetamol at 10-15 mg/kg/BW q 4 to 6 hr for fever. 3. Give oral bronchodilator to patients with wheezes or acute respiratory distress if tolerated. However, if unresponsive shift

to nebulization (0.5 ml Salbutamol plus 2 ml sterile water) q 2 - 4 hours. As the severity of the attack decreases, change from nebulization to oral Salbutamol using the following dosages:

a. 2-12 months (<10kg) : ½ tab (2mg tab) or ¼ tab (4 mg tab) b. >12 months : 1 tab (2mg tab) or ½ tab (4 mg tab)

4. Give oxygen if child is cyanotic or unable to drink, restless and with chest in-drawing. 5. Suction secretions if necessary for airway clearance. 6. Advise complete bed rest until temperature returns to normal. 7. Encourage breast-feeding /frequent meals and increase fluid intake.


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B. Management of Complications

1. Pneumonia: follow management guidelines for Pneumonia 2. Meningitis/Encephalitis: follow management guidelines for Meningitis/ Encephalitis 3. Severe dehydration: follow CDD guidelines 4. Otitis Media: give Procaine Penicilllin at 300,000 - 600,000 U IM 2 x a week for 2 weeks then shift to oral medications 5. Stomatitis (Oral Thrush): give Nystatin at 25,000 - 250,000 U 3 x a day for 3 - 5 days



1. Afebrile for 2 days

2. Normal RR

3. Able to feed and drink

B. Follow-up Advice: Advise patient/ parent to follow-up 1 week after discharge at any health care facility.


1. Educate parents/guardian/ relatives on the importance of measles vaccination. 2. Give measles immunization (see annex 21a on Immunization Schedule for Children)

a. Live measles vaccine if given within 72 hours of exposure may be protective in some cases. b. May give passive immunization (Measles IG) at a dose of 0.25 mkBW, 0.5ml/kg for immuno-compromised patient

(max 15ml) within 6 days of exposure to prevent or modify measles.


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Annex 9

HOSPITAL MANAGEMENT PROTOCOL FOR MUMPS


- CBC



A. Specific Therapy: none B. Supportive and Symptomatic therapy

1. Give Paracetamol (10-15mkd q 4-6 hr) for fever. 2. May give analgesic for pain. 3. Manage complications:

a. Encephalitis: follow management guidelines for Encephalitis b. Pancreatitis: follow management guidelines for Pancreatitis c. Orchitis: follow management guidelines for Orchitis

III. Guidelines For Patient’s Discharge


1. Afebrile and active for at least 2 days 2. Resolution of other symptoms or complications


1. Isolate patient and observe droplet precautions until 9 days after onset of parotid swelling 2. Mumps vaccine as part of MMR (see annex 21a and 21b on Immunization Schedule)


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Annex 10

HOSPITAL MANAGEMENT PROTOCOL FOR PNEUMONIA - ADULT


1. CBC 2. Blood culture and sensitivity 3. Chest x-ray



A. Antibiotic Therapy

1. For Moderate Risk CAP: (Unstable vital signs, unstable co-morbid condition, evidence of extrapulmonary sepsis, suspected aspiration, CXR findings of multilobar infiltrates, pleural effusion or abscess, progression of findings to > 50% in 24 hours)

Etiology: S. pneumoniae, M. pneumoniae, C. pneumoniae, H. influenzae, M. catarrhalis, L. pneumophilia, Enteric gram negative bacilli and Anaerobes (in patients with risk of aspiration)

Antibiotics Dosages Drugs of Choice

Co-Amoxiclav IV 1.2 g every 8 hours

Ampicillin-Sulbactam IV 1.5 g every 8 hours

Plus any of the following

Azithromycin p.o. or IV 500 mg OD x 3 days

Clarithromycin p.o. or IV 500 mg BID x 7 days

Roxithromycin p.o. 150 mg BID or 300 mg OD x 7 days

Alternative Drugs

Levofloxacin p.o. or IV 500 mg every 24 hours

Moxifloxacin p.o. or IV 400 mg every 24 hours


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2. For High Risk CAP: [With any of the clinical features of Moderate Risk CAP plus any of the following: shock or signs of hypoperfusion (hypotension, altered mental state, urine output <30 ml/hr), hypoxia (PaO2 <60 mm Hg) or acute hypercapnea (PaCO2 >50 mm Hg), CXR as in moderate risk CAP]

Etiology: same as Moderate risk CAP III plus P. aeruginosa and S. aureus

High Risk CAP No Risk for P. aeruginosa High Risk CAP With Risk for P. aeruginosa

Drugs of Choice Dosages Drugs of Choice Dosages

Ceftriaxone IV 3-4 g OD Ceftazidime IV 2 g every 8 hours

Ampicillin-Sulbactam IV 1.5 g every 6-8 hours Cefepime IV 2 g every 8-12 hours

Plus any of the following: Piperacillin-Tazobactam IV 2.25-4.5 g every 6-8 hours

Azithromycin IV 500 mg OD Sulbactam-Cefoperazone IV 1.5 g every 12 hours

Clarithromycin IV 500 mg BID Imipenem IV 500 mg every 6 hours

Alternative Drugs: Meropenem IV 1-2 g every 8 hours

Levofloxacin IV 500 mg every 24 hours Plus any of the following:

Moxifloxacin IV 400 mg every 24 hours Azithromycin IV 500 mg OD

Clarithromycin IV 500 mg BID

Levofloxacin IV 500 mg every 24 hours

Moxifloxacin IV 400 mg every 24 hours

With or without any of the following

Amikacin IV 10-15 mg/kg every 24 hours

Gentamicin IV 3-5 mg/kg every 24 hours

Netilmicin IV 5-7 mg/kg every 24 hours

Ciprofloxacin IV 400 mg every 12 hours

3. Duration of antibiotic therapy: 7-10 days


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4. May step-down IV to oral after 3-4days if patient is afebrile for > 24 hours, resolution of symptoms, etiology is not a highly virulent pathogen, no unstable co-morbid condition and can tolerate oral medications.


1. Give IV Fluids 2. Give Paracetamol (500 mg q 4 hrs) prn for fever (To > 38 oC). 3. Start nebulization with Salbutamol 2 ml q 4 hrs for dyspnea and wheezes. As the severity of the attack decreases shift to

oral salbutamol (2mg/tablet) at 2 tablets 3 x a day. May give Aminophylline 250 mg ampule in 250 cc D5W to run at 0.4 -0.8 mkd via soluset for 4-6 hours

4. Give O2 inhalation for dyspnea



1. temperature of 36-37.5°C 2. pulse < 100/min 3. RR between 16-24/min 4. systolic BP > 90 mm Hg 5. blood oxygen saturation > 90%

B. Follow-up Advice

1. Advise patient to complete duration of treatment regimen and follow-up 1 week after discharge to any health care facility.

2. Advise a repeat chest x-ray 4 to 6 weeks after hospital discharge to establish a new radiographic baseline and to exclude the possibility of malignancy associated with CAP, particularly in old smokers.


1. Educate patient to improve/ maintain body resistance by proper nutrition and healthy lifestyle 2. Advise Pneumococcal vaccination (see annex 21b on Immunization Schedule for Adults) for > 60 years old , with chronic

illness, immunosuppression and residents of nursing homes and other long-term care facilities 3. Advise Influenza vaccination (see annex on Immunization Schedule for Adults) for persons aged > 50 yrs, with chronic

illness, immunosuppression, residents of nursing homes and other long-term care facilities, pregnant women on their 2nd or 3rd trimester, health care workers, household contacts and caregivers of persons with medical conditions, person who provide essential and emergency community services or in institutional settings


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Annex 11a

CLINICAL DIAGNOSIS OF PNEUMONIA FOR SPECIFIC PEDIATRIC AGE GROUPS

I. For > 5-13 years old with fever, cough, signs of respiratory distress/ crackles on auscultation.

II. For 2 months-5 years old

A. Very Severe Pneumonia with fever, cough, tachypnea/ retractions plus 1 or more of the following danger signs:

1. unable to drink 2. cyanosis 3. convulsion 4. abnormally sleepy 5. severe under nutrition 6. dehydration

B. Severe Pneumonia with fever, cough, tachypnea with chest in-drawing without the danger signs.

C. Pneumonia with fever, cough with fast breathing without chest in-drawing.

III. For < 2 months old

A. Very Severe Pneumonia with fever or hypothermia, RR of > 60/ minute, central cyanosis and severe chest in-drawing plus one or more of

the following: 1. poor feeding 2. convulsion 3. stridor in a calm child 4. abnormally sleepy 5. wheezing

B. Severe Pneumonia with fever or hypothermia, sustained RR of > 60/ minute and severe chest in-drawing.


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Annex 11b

HOSPITAL MANAGEMENT PROTOCOL FOR PNEUMONIA - PEDIA

I. Routine Laboratory Examinations 1. Chest x-ray 2. CBC with differential count



A. Antimicrobial Therapy:

1. For 2 months to > 5 years old a. For severe pneumonia: Benzyl Penicillin 50,000 U/KBW/dose IM (ANST) q 6 hrs for 4 days; when child improves,

shift to oral Amoxycillin to complete 7 days course of treatment. If no improvement within 72 hours after proper assessment, treat as very severe pneumonia.

b. For very severe pneunomia: Chloramphenicol 25 mkd IM or IV q 6 hours for 4 days; when child improves, shift to oral chloramphenicol to complete 10 days course of treatment.

c. If no improvement in 24 - 48 hours, suspect staphylococcal pneumonia especially if patient has been on antibiotic therapy for quite a time. If patient deteriorates within 24 hours, add Cloxacillin/oxacillin 25 mkBW IM or IV q 6 hrs plus Gentamycin or Netilmycin at 2.5 mkd IM ANST q 8 hrs.

d. If patient is still unresponsive after proper assessment, may shift to other antimicrobials based on culture and sensitivity results and treat co-morbidity.

2. Infant less than 2 months old a. Very Severe Pneumonia/Severe Pneumonia:

1) Benzyl Penicillin at 50,000 U/ KBW/dose IM (ANST) q 12 hrs for infants < 1 week old and q 6 hrs for > 1 week old plus any of the following aminoglycoside:

Gentamycin at 3-5 mkD or Netilmycin at 5-7 mkD or Amikacin at 10-15 mkD OD 2) Alternative Antibiotic Therapy:

a) Chloramphenicol at 25 mg/ KBW every 12 hours in young infants > 1 week old. Do not give to premature infants.

b) Streptomycin 1.25 mg/kg every 12 hours can be substituted if gentamicin, Netilmicin, Kanamycin or Amikacin is not available. Streptomycin should be reserved for treatment of TB, if possible.


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c) If aminoglycoside is unavailable, give Benzyl penicillin plus cotrimoxazole. Do not give cotrimoxazole if neonate is jaundiced or premature.

b. For > 1 month old, step-down from parenteral to oral antibiotics may be initiated 48-72 hours after defervescence and infant can tolerate oral medications.


1. Paracetamol for To > 38oC at 10-15 mkBW q 4-6 hrs and give tepid sponge bath. Chilling should be avoided since it increases O2 consumption and CO2 production that will precipitates respiratory failure.

2. Determine the cause of wheezing and treat accordingly. a. If wheezing is due to asthma give bronchodilator.

1) Start patient on inhaled bronchodilator (Salbutamol 1 nebule) every 30 minutes (max 3 doses) then assess and reduce frequency as necessary. As the severity of the attack decreases change from nebulization to oral salbutamol using the following dosages:

a) for < 10 kg child : ½ tab (2mg tab) or ¼ tab (4 mg tab) b) for > 10 kg child : 1 tab (2mg tab) or ½ tab (4 mg tab)

2) May give Aminophylline if there is no improvement at a LD of 3-6 mg/kg, given IV over 20-30 minutes. Give IV maintenance dosage as mg/kg/hour as follows:

a) Infants (<12 mos.) : 0.008/kg/hour b) 1-9 y/o : 0.8/kg/hour c) 10-12 y/o : 0.7/kg/hour d) 13-16 y/o : 0.5/kg/hour

b. For status asthmaticus, give Hydrocortisone at a LD of 10 mkd then maintain at a dose of 5-10 mkD q 6 hrs. c. If wheezing is due to respiratory secretions, do chest tapping.

3. Give oxygen if child is cyanotic or unable to drink/feed, restless and with severe chest in-drawing. Consider ventilation/ intubation if there is no response to O2 inhalation.

4. Suction secretions if necessary for airway clearance. 5. Continue breast-feeding and/ or give frequent small feedings with aspiration precautions. 6. Hydrate patient adequately.


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C. Special Supportive Care for Infants

1. Maintain a good thermal environment.

a. Infant should be kept in a warm room (To = 25oC) because they lose heat rapidly especially when they are wet. Thus, infants need to be kept dry and well wrapped or held close to mother’s body. A hat or bonnet is valuable to prevent heat loss from the head.

b. Avoid use of heat lamp (the bulb may break) or radiant warmer unless a nurse can be at bedside. Incubator is hazardous unless it is functioning correctly and electric supply is constant.

c. Hands and feet should be warm and rectal temperature should be between 36.50C to 37.50C. 2. Careful fluid management.

a. Continue frequent breastfeeding unless child is in respiratory distress b. If infant is unable to drink for >2 days, give 20 ml of milk by NGT 6 times a day (total 120 ml/kg/day). Expressed

breast milk is best.


A. Criteria for Discharge 1. afebrile 2. absence of difficulty of breathing (normal RR, no chest in-drawing) for 2-3 days 3. able to eat and drink

B. Follow-up Advice: Parents are advised to continue and complete medication of child, follow-up 1 week after discharge at any health care facility


Educate or inform parents on:

1. importance of primary immunization against diphtheria, pertussis, measles, Haemophilus influezae (Hib), invasive pneumococcal disease (IPD) and tuberculosis (see annex 21a on Immunization Schedule for Children)

2. importance of breastfeeding/ proper feeding practices 3. proper sanitation and hygiene 4. timely consultation for illness at health centers or hospitals.


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Annex 12

HOSPITAL MANAGEMENT PROTOCOL FOR RUBELLA (GERMAN MEASLES)


1. CBC 2. Measles IgM determination (as per DOH’s Measles Elimination Campaign)



A. Specific Therapy: none


1. Give Paracetamol (10-15mg/kg/dose q 4-6 hr) for fever 2. Give pain relievers for arthritis/ arthralgia 3. Manage encephalitis if present 4. May give Immune Globulin to susceptible pregnant women within 1st week of exposure 5. Refer pregnant women to Obstetrician if with labor pains 6. Advise bed rest and keep patient warm and comfortable



1. afebrile for 2 days 2. good appetite and activity 3. resolution of complications

B. Follow-up Advice: Instruct patient to follow-up one week after discharge to any health care facility.


1. Isolate patient until 7 days from onset of rash and practice standard and droplet precautions. 2. Give Rubella vaccine (see annex 21a and 21b on Immunization Schedule for Children and Adults, respectively).

Contraindicated in the following conditions: a. with Immunodeficiency diseases b. ongoing suppressive therapy for malignancy or on prolonged steroid use c. pregnancy or those who plan to get pregnant in next 3 months


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Annex 13

HOSPITAL MANAGEMENT PROTOCOL FOR SNAKE BITE


1. CBC with platelet count 2. Urinalysis



Table on Types and Signs of Envenomation and Implicated Snake

Type of Envenomation

Local Effect Systematic Effects Snake

NEUROTOXIC Slow swelling, then necrosis

ptosis, glossopharyngeal palsy, respiratory paralysis, cardiac effect, effect such as hypotension, bradycardia, arrhythmias or an abnormal ECG

cobra

MYOTOXIC None myalgia on moving, paresis, myoglobinuria, hyperkalemia

sea snake

VASCULOTOXIC Rapid swelling, then necrosis

abnormal bleeding, non-clotting blood, shock vipers

A. Anti-venin Therapy

1. Observe patients without signs of envenomation for 24 hours for development of signs of envenomation (see above table).

2. Give anti-venin therapy for those with signs of envenomation.

a. Anti-venin should be used with extreme caution and only in life-threatening situation as in Neurotoxic and Myotoxic envenomation.


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b. The therapy is contraindicated in patients with known allergic history to horse serum. If anti-venin must be used, patients should be pre-treated with:

Pre-Treatment

Drugs

Dosage

Adult Pedia

Epinephrine (1:1,000) 0.5 mg SQ 0.01 mg/kg SQ

OR

Diphenhydramine 25-50 mg/dose IM 1-2 mg/kg IM

AND

Hydrocortisone 250 mg IV initially, then 100 mg q 6 hr for 3 doses 5 mg/kg q 6 hr IV

c. Late serum sickness type of reactions to anti-venin may occur 5-24 days after anti-venin treatment in about 75% of patients.

d. It is never too late to give anti-venin if indicated. There is no standard dose for anti-venin because it is difficult to determine the amount of venom to be neutralized. In children, the same or larger dose than adults may be given because the same volume of venom is injected which is distributed in a smaller body fluid volume.

e. The dosage of Philippine Cobra antivenin is based on the toxic symptoms present in patients as follows:

1) Mild envenomation 2 - 5 ampules (local signs/symptoms, no systemic symptoms)

2) Moderate envenomation 6 - 10 ampules (swelling spread beyond the bite, mild systemic and/or hematological symptoms)

3) Severe envenomation 11 - 15 ampules (marked local and systemic effects, evidence of abnormal bleeding or hemolysis)

f. Antivenin should always be given by intravenous infusion, which is the safest and most effective route. Depending on the severity of poisoning, 2-5 ampules diluted in 500 cc of isotonic fluid should be given by intravenous infusion over 1-2 hours. It is repeated every 1- 2 hours until the neurologic signs are resolved.


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B. Prostigmine

1. Use Prostigmine at 50-100 ug/kg/dose q 8 hr by IV infusion over 4 hours in the absence of anti-venin. 2. Administer Atropine at 0.6 mg/dose q 6-8 hr IV push or infusion by titration using a different syringe or infusion

bag from Prostigmine to counteract the side effects of Prostigmine, particularly increased secretions, abdominal pain, and loose bowel movement.

C. Antimicrobial Therapy

Give antibiotics to patients with infected snakebite wound only. May use any of the following: 1. Sulbactam/Ampicillin at 750 mg/dose/IVT x 3 days then shift to oral preparation for 4 more days 2. Co–amoxiclav 600 mg/dose/IVT q 8 hr x 3 days then shift to oral preparation for 4 more days

D. Blood Transfusions

Transfuse blood and blood products to patients with vasculotoxic envenomation to correct defects in homeostasis including coagulopathies and to replace destroyed RBC in patients with active bleeding as follows:

1. Whole Blood at 20 cc/KBW if with active bleeding/ shock. 2. Frozen plasma at 10 -15 ml/KBW given at 10ml/ minute if with prolonged PTT & PT, normal platelet & BT. 3. Platelets at 1 unit/7 kg given at 5 ml/ min if with platelet <100,000/mm3, prolonged BT & normal PTT & PT. 4. Cryoprecipitate at 1 unit/ 5kg given at 10 ml/minute if with prolonged PTT and normal PT, Platelet, and BT.

E. Symptomatic and Supportive Therapy

Give IV fluids (Lactated Ringer’s solution or Normal Saline) to run at KVO.



1. No signs of envenomation after 24 hours of observation. 2. Twenty-four hours after complete resolution of signs of envenomation.

B. Follow-up Advice: Patient should be advised to follow-up one week after discharge particularly those who had signs of envenomation.


Educate the patient to wear protective clothing and/or to carry light when walking in grass fields especially at night.


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Annex 14 HOSPITAL MANAGEMENT PROTOCOL FOR TETANUS NON-NEONATORUM


- CBC



Classify tetanus by clinical stages using the table below:

Clinical Stages of Tetanus

CRITERIA STAGE I STAGE II STAGE III

(Mild) (Moderate) (Severe)

Incubation period > 11 days 8-10 days < 7 days

Period of onset > 7 days 4-6 days < 3 days Trismus (difficulty in opening the mouth) mild or absent moderate severe

Dysphagia (difficulty of swallowing) absent present present Muscular rigidity mild or localized pronounced severe, boardlike Paroxysmal spasm absent mild and short frequent, violent, prolonged & asphyxial Sympathetic overactivity absent absent or mild hypotension unstable BP (hypertension/

paroxysmal tachycardia & other cardiac arhythmias

Dyspnea or cyanosis absent absent present


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A. Antitoxin Administration

1. Use Anti-Tetanus Serum (ATS) after negative skin test; if skin test is positive, give Tetanus Immune Globulin (TIG) using the following dose:

Adult, infant, and children ATS: 40,000 IU given at ½ IM, ½ IV

TIG: 3,000 IU, IV drip or IM

2. Give the whole dose of antitoxin on the day of admission. Serum intended for intramuscular route should be warmed prior to injection to facilitate absorption.

3. If TIG is given by IV drip, administer at a high dilution (at least 1:20) and give very slowly (15 drops/minute) while the patient is kept under close clinical supervision. If any signs of intolerance occur such as hypotension, the intravenous treatment must be stopped immediately and the patient is kept under close observation for the next 4-6 hours.

B. Tetanus Toxoid (TT) Administration

1. Give TT as follows:

TT 1 - on discharge TT 2 - at least a month after TT 1 TT 3 - 6 months after TT 2 TT 4 - 1 year after TT 3 TT 5 - 1 year after TT 4

2. For children < 7 yrs old, may add Pertussis and Diphtheria toxoid to TT as a combination (DPT).

C. Antimicrobial Therapy

1. For Uncomplicated Tetanus

Antibiotics Dosage Drug of Choice Adult Children

Metronidazole 500 mg IV infusion q 8 hr x 10 days 30 mkD (4 divided doses) x 10 days Alternative Drugs

Penicillin G Sodium 2-3 MU q 4 hr IV x 10-14 days 200,000 U/kg/dose x 10-14 days Chloramphenicol 500 mg to 1 gm IV q 6 hr 250 mg IV q 6 hr


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2. With Concomitant Sepsis/ Pneumonia Add any one in group A antibiotics and +/- any of the group B antibiotics:

Antibiotics Dosage Adult Children

Group A Ceftazidime 3-6 gm/day (divided into 3 doses) x 7-10

days 100 mg/kg/day in 3 divided doses x 7-10 days

Piperacillin-Tazobactam

2.25 to 4.5 mkd q 6-8 hr x 7-10 days 100-200 mkD (Piperacillin) in 4 divided doses x 7-10 days

Imipenem 500 mg q 6-8 hr x 7-10 days 60 mkD in 4 divided doses x 7-10 days Meropenem 500 mg q 8 hr x 7-10 days 60 mkD in 3 divided doses x 7-10 days

Group B Amikacin 10-15 mg/kg OD IV 10-15 mg/kg OD

Netilmycin 5-7 mg/kg OD IV 5-7 mg/kg OD IV Gentamycin 3-5 mg/kg OD IV (max 160 mg/day) 3-5 mg/kg OD IV

D. Control of Spasms

1. Give Diazepam as follows:

a. In stage I and II, Diazepam should be given by IV bolus at 0.2-0.4 mkd, max 10 mg q 4-6 hrs. b. In stage III cases (severe), Diazepam is given by continuous IV drip and IV bolus as follows:

1) Adults: 60 mg/500 cc D5W to run in 8 to 12 hrs plus 5-10 mg/ IVP q 2-4 hr then reduce frequency accordingly (q 4–6 hr) as soon as spasms lessen in frequency and intensity (see example). Some adults tolerate the maximum dose of 300 mg/24 hours.

2) Pedia: Increase IVP q 2-4 hr then reduce frequency accordingly (q 3-4 hr) as soon as spasms lessen in frequency and intensity (see example).

a) Diazepam/IV push should be used with caution in patients with respiratory problems. b) Shift to oral Diazepam or other muscle relaxant as soon as the spasm is controlled (see example below).


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Step-Down Approach in Diazepam Administration in Tetanus Management

For Example: if patient presents spasm with: frequency of > 24/day and duration of > 60 second/attack

May give Diazepam as follows: Total dose: 240 mg-300 mg 60 mg q 8 hr IV (in D5W) drip to run for 8 hrs (max dose 180 mg) 10 mg q 2-4 hr IV bolus (60-120 mg)

After 48-72 hours, may start to taper Diazepam, if spasm with: frequency of 12-24/day & duration of 30-60 second/attack

Suggested Diazepam dose as follows: Total dose: 180 mg-200 mg 60 mg q 12 hr IV drip to run for 12 hrs 10 mg q 3-4 hr IV bolus

May further taper Diazepam if spasm with: frequency of < 12/day and duration of < 30 seconds

Give Diazepam at the following dose: Total dose: 120 mg-140 mg 80 mg OD IV drip or 40 mg IV q 12 hrs to run for 12 hrs 10 mg q 4-6 hr IV bolus

Then give Diazepam as follows: Total dose: 80-100 mg 40 mg OD IV drip to run for 24 hrs 10 mg q 4-6 hr IV bolus

Further taper Diazepam if spasm with: frequency of < 6/day and duration of < 10 seconds Discontinue IV drip Continue with 10 mg q 4-6 hr IV bolus Total dose: 40-60 mg

May shift Diazepam IV to po in the absence of spasm and taper dose in 5 to 7 days


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2. Add either Chlorpromazine (Thorazine) or Phenobarbital for Spasms not controlled by Diazepam alone

a. Chlorpromazine for Adult and Children Chlorpromazine and Diazepam should be given alternately at an interval of 6 hours. The doses are staggered so that the patient receives one of the two drugs q 3 hrs to ensure an adequate level of both drugs throughout but prevents a toxic level of either. However, close monitoring is essential for possible respiratory and circulatory depression.

Example: Chlorpromazine*: 0.5 mkBW IVP q 6 hr (check IV line before IVP, the drug is irritating to tissues)

Time: 9 – 3 – 9 – 3 o’clock

Diazepam* : 5-10 mg IV push q 6 hr Time: 6 – 12 – 6 – 12 o’clock

* Reduce to about ½ the dose of each drug as spasm lessens in frequency or intensity.

b. Phenobarbital Children : LD of 10-15 mg/kg then maintained at 5mkD slow IV in 3 divided doses Adult : 130 mg every 6 hours

E. Symptomatic and Supportive Therapy

1. Minimize unnecessary maneuvers/manipulations that will stimulate tetanospasms. 2. Perform wound debridement after the patient has received optimal sedation and relaxation. 3. Monitor closely input and output, and vital signs 4. May start NGT feeding as soon as tolerated.

*May do Tracheostomy/ intubation to patients who have respiratory distress/ impending respiratory failure

IV. Guidelines for Patient’s Discharge

1. Criteria for Discharge

a. Ability to open the mouth and swallow liquid/solid foods. b. No spasms for 7 days.

2. Follow-up advice

a. All children < 7 y/o are advised to complete the DPT immunization. b. Patients are advised to follow-up a week after discharge to evaluate if home medications needs to be continued.


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Educate on proper wound management as follows:

1. All wounds must be thoroughly cleansed, foreign materials removed and necrotic tissues debrided. Povidone-iodine is the most effective agent for skin decontamination.

2. Antimicrobials may be given to deal with wound infection or to kill the vegetative forms of Clostridium tetani.

a. Active and passive anti-Tetanus immunization. (see annex 18a on anti-Tetanus immunization) b. Practice universal precautions. c. Educate patient and the public on the necessity of completing immunization, the kind of injury prone to tetanus,

and proper wound care.


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Annex 15

HOSPITAL MANAGEMENT PROTOCOL FOR TYPHOID FEVER


1. CBC, platelet count 2. Blood culture and sensitivity test before antibiotic therapy 3. Stool/ urine culture and sensitivity test - 2nd to 3rd week 4. Serologic test (Salmonella EIA, Tubex TF)



A. Antimicrobial therapy

1. For Uncomplicated Typhoid Fever

Give any of the following antibiotics of choice and switch parenteral to oral treatment within 48 hours after resolution of fever and if patient can tolerate oral medications.

Antibiotics Dosage Adult Pregnant Children

CHLORAMPHENICOL IV/ Oral

3-4 gm/day in 3-4 divided doses for 2 weeks

NOT RECOMMENDED 75-100 mkBW in 4 divided doses for 2 weeks

AMOXICILLIN Oral 3 gm/day in 3 divided doses for 2 weeks

3 gm/day in 3 divided doses for 2 weeks

75-100 mkD in 3 divided doses for 2 weeks

COTRIMOXAZOLE Oral 800/160mg 1 tab BID for 2 weeks

NOT RECOMMENDED 8 mkD of TMP in 2 divided doses for 2 weeks


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2. For Complicated / Suspected Drug Resistant Typhoid Fever Give any of the following antibiotics of choice and switch parenteral to oral treatment, within 48 hours

after resolution of fever and if patient can tolerate oral medications.

Antibiotics Dosage Drugs of Choice Adult Pregnant Children

CEFTRIAXONE 3-4 IV gm/day for 5-7 days

3-4 IV gm/day for 5-7 days

Ceftriaxone 80-100 mkBW for 5-7 days

OFLOXACIN* 200-400 mg IV q 12 hrs for 7-10 days

NOT RECOMMENDED NOT RECOMMENDED

CIPROFLOXACIN* 200-400 mg IV q 12 hrs for 7-10 days

NOT RECOMMENDED NOT RECOMMENDED

Alternative Drugs AZITHROMYCIN 1 gm initially then

500mg OD for 7 days 1 gm initially then 500 mg OD for 7 days

8-10 mkd OD for 7 days

CEFIXIME 400 mg BID for 7-14 days

400 mg BID for 7-14 days 15-20 mkD for 7-14 days

*Not recommended in patients <18 years

B. Supportive and Symptomatic Treatment of Typhoid Fever 1. Give soft diet 2. Hydrate patient adequately with IV fluids and correct any electrolyte imbalance 3. Give Paracetamol and tepid sponge bath for fever 4. Ambulate patients in gradual manner

C. Management of Complications 1. Give high-dose dexamethasone at 3 mkd IV LD followed by 8 doses of 1 mg/kg q 6 hrs for typhoid toxemia 2. Transfuse appropriate blood components for the following conditions:

a. Give FWB at 10-15 ml/KBW for significant blood loss b. Give FFP at 10 ml/KBW for adult & 15 ml/KBW for cases of DIC and prolong Pro-time c. Give platelet concentrate at 1 unit/ 7-10 KBW for platelet count <10,000

3. Refer severe intestinal bleeding or bowel perforation for surgical evaluation

III. Preventive Measures Advice personal hygiene and proper environmental sanitation


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Annex 16

HOSPITAL MANAGEMENT PROTOCOL FOR VARICELLA (CHICKEN POX)


- CBC



A. Anti-viral Therapy*

1. Give oral Acyclovir at 20 mkd (max 800 mg/dose) 5 x a day for 5 days within 24-48 hrs from onset of rash in the following cases:

a. > 12 years old b. with chronic cutaneous or pulmonary disorder c. on long term salicylate therapy or on short/intermittent/aerosolized courses of corticosteroid d. adult secondary household cases e. pregnancy during the second and third trimester

* Alternative anti-viral drugs for adults and adolescence: Valacyclovir 1 gram TID for 5days

2. Give IV acyclovir at 10-15 mkd as 1 hr infusion q 8 hrs for at least 5 days in immuno-compromised cases (including newborns).


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1. Give Paracetamol (10-15 mkBW q 4-6 hr) for fever. Avoid aspirin. 2. Apply NSS or aluminum acetate compression on lesions. 3. Give anti-histamine for itchiness. 4. Give antibiotics if with secondary bacterial infections.

C. Management of Complications

Give IV Acyclovir at 10-15 mkd as 1 hr infusion q 8 hrs for at least 5 days if with the following complications:

1. Pneumonia: follow management guidelines for Pneumonia 2. Meningitis/Encephalitis: follow management guidelines for Meningitis/ Encephalitis 3. Varicella with hemorrhagic rashes/ bleeding complications:

a. Transfuse blood if bleeding is severe to replace blood loss b. Correct abnormal bleeding parameters.



1. Afebrile for 2 days 2. All lesions have crusted 3. Constitutional signs & symptoms have resolved

B. Follow-up Advice: Instruct patient to follow-up one week after discharge at any health care facility.


1. Isolate patient using standard precaution (airborne and contact). 2. Recommend Varicella Zoster immune globulin prophylaxis at 1 vial/10 KBW given within 48 hrs after exposure for

high-risk individuals (immunocompromised children, pregnant women, newborn infants exposed to maternal varicella).

3. May initiate active immunization among contacts with Live Varicella vaccine (see annex 21a and 21b on Immunization Schedule for Children and Adults, respectively)


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Annex 17

HOSPITAL MANAGEMENT PROTOCOL FOR VIRAL HEPATITIS A


1. CBC, platelet 2. urinalysis 3. fecalysis 4. ALT/ALT, alkaline phosphatase, total bilirubin, direct and indirect bilirubin 5. Anti-HAV IgM

Other examinations may be requested depending on co-morbid conditions/ complications II. Treatment Guidelines

A. Specific Treatment: None B. Symptomatic and Supportive Treatment

1. Give Cholestyramine at 8 gm po OD/BID or Hydroxyzine at 10-25 mg (pedia 0.6mgkd) BID for pruritus 2. Give Hyoscine N-Butyl Bromide at 1 ampule IV q hr prn as pain reliever

3. Give high caloric diet 4. Provide adequate hydration

5. Advise bed rest for the very ill

C. Management of Complications

1. Hepatic Encephalopathy a. Restrict protein intake (0.5g/KBW/day) for a limited period of time b. Institute gut-cleansing and ammonia-lowering measures as follows:

1) Give Lactulose at 15 to 60 ml/dose orally or nasogastrically. 2) Give Neomycin at 1 gm q 6 hrs po or Metronidazole at 250 mg 1 tab q 6 hr po (max of 2 weeks) 3) Give L-ornithine L-aspartate at 4-8 ampules (0.5 gm/ml)/day


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2. Cerebral Edema a. Administer Mannitol IV at 100 cc IV drip q 4-6 hrs b. Give Phenytoin at 100 mg q 8-12 hrs for convulsion/seizure (not indicated for first episode of seizure) c. Hyperventilate patient

3. Bleeding Secondary to Decreased Clotting Factors a. Give phytomenadione at 10 mg/ml SQ/IV OD for three days b. Transfuse blood and blood products for active bleeding and for those undergoing invasive procedures

4. Gastrointestinal Bleeding Give Proton-pump inhibitor (Omeprazole) at 40 mg IV OD or H 2 receptor antagonist (Ranitidine, Famotidine) at 50

mg IV q 8-12 hrs with Sucralfate at 1 gm 1 tablet q 4-6 hrs

5. Portal Hypertension Give Propanolol at 10 mg TID or Isosorbide dinitrate 10-20 mg BID

6. Ascites and Edema a. Limit fluid intake to 1.0 to 1.4 liter/day for patient with moderate to massive ascites b. Give Furosemide at 20-40 mg OD/BID &/or Spironolactone 25 mg BID/QID c. Do serial paracentesis for very tense ascites d. Give Albumin 25% infusion for hypoalbuminemia

7. Hypoglycemia a. Give 50% ml Dextrose solution IV over a period of 5 min, then follow with continuous infusion of D5W or D10W b. Monitor hemoglucotest as frequently needed

III . Guidelines for Patient’s Discharge

A. Criteria for Discharge 1. Improved condition

a. afebrile for 72 hours b. resolutions of signs and symptoms

2. Improved laboratory status At least 50% improvement in values of monitored laboratory parameters or less than 10 fold increase

B. Follow-up Advice: Advise the patient to follow-up one week after discharge to any health care facility.


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IV. Preventive Measures 1. Educate on good personal hygiene 2. May give vaccination as follows:

a. Inactivated Hepatitis A vaccine (see annex 21b on Immunization Schedule for Adults) in the following individuals: 1) Travelers to areas or countries with highly endemic Hepatitis A 2) Persons in prostitution (PIP) 3) Intravenous drug users 4) Persons with clotting disorders 5) People with chronic liver disease

b. Immune globulin as pre-exposure and post-exposure prophylaxis at 0.06 mL/kg IM


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Annex 18a

LOCAL WOUND MANAGEMENT

I. Treatment Guidelines

A. Antimicrobial Therapy for Local Measures

Oral Antibiotic for 3-7 days Adult Pedia Cloxacillin 500 mg 1cap q 6 hr 50-100 mkD in 4 divided doses Amoxicillin 500 mg 1 cap q 8 hr 30-50 mkD in 3 divided doses Co-amoxiclav 625 mg 1 tab q 12 hr 30-50 mkD in 2 divided doses

B. Supportive Therapy

Pain Reliever Adult Pedia

Mefenamic acid 500 mg 1 cap q 8 hr 25 mkD in 3-4 doses

Ibuprofen 200-400 mg 1 cap q 6-8 hr 5-10 mkd q 6-8 hr

C. Anti-Tetanus Immunization

Anti-Tetanus immunization should be based on patient’s immunization status and type of wound by exposure.

Immunization Status

Dirty Wound Anti-Tetanus Immunization

Clean Wound Anti-Tetanus Immunization

Unknown or < 3doses* ≥ 3 doses* not more than 5 years ≥ 3 doses* more than 5 to 10 years ≥ 3 doses* more than 10 years

Active Passive Active Passive TT 1,2,3 None Booster dose (1 TT)

Booster dose (1 TT)

TIG or ATS None None TIG or ATS

TT 1,2,3 None None Booster Dose (1 TT)

None None None None

*completed 3 doses of tetanus immunization (DPT1, 2, 3/TT 1, 2, 3)


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Types of Wound by Exposure Clinical Features Dirty Wound Clean Wound

Duration of wound Configuration Depth Mechanism of entry Devitalized Tissue Contamination (dirt, saliva, etc.)

> 6 hours stellate, avulsion

> 1 cm missile, crush, burn

present present

≤ 6 hours linear

≤ 1 cm sharp surface (glass, knife)

absent absent

D. Recommendation on Anti-Tetanus Immunization

1. Give Tetanus Toxoid (TT) 0.5 ml intramuscularly as follows: TT 1 - upon consult TT 2 - a month after TT 1 TT 3 - 6 months after TT 2

a. one booster dose of TT every 10 years b. should be administered on the deltoid area and must be opposite the TIG or ATS injection site

2. Give Tetanus Immune Globulin (TIG) 250 IU intramuscularly* regardless of age/weight or Anti-Tetanus Serum (ATS) intramuscularly after negative skin test as follows:

Pediatric Dose by age: Adult Dose by weight:

< 5 yrs. old - 1500 IU weight < 50 kg – 4,500 IU 5-13 yrs old - 3000 IU weight > 50 kg – 6,000 IU >13 yrs old - 4500 IU

* preferred injection site for pediatric patients is the anterolateral aspect of the thigh


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Annex 18b

MANAGEMENT PROTOCOL OF DOG/CAT BITE

I. Post-Exposure Treatment (PET)

1. Do not delay initiation of PET for any reason regardless of interval between exposure and consultation as it increases the risk of rabies and it is associated with treatment failure.

2. Assess and classify according to the three categories of exposure and follow its corresponding management as shown in the following table:

Table 1. Management Based on Categories of Exposure to Rabid Animal or Animal Suspected to be Rabid

Category of Exposure Management CATEGORY I 1) feeding/touching an animal 2) licking of intact skin (with reliable history and thorough

physical examination)

1) Wash exposed skin immediately with soap and water 2) 2. No vaccine or RIG needed

CATEGORY II

1) nibbling/nipping of uncovered skin with bruising 2) minor scratches/abrasions without bleeding** 3) licks on broken skin ** includes wounds that are induced to bleed

Start active immunization immediately and depending on the condition of the biting animal: 1) give complete vaccination regimen until day 90 if: a) animal is rabid, killed, died or unavailable for 14-day observation

b) animal under observation died within 14 days and had signs of rabies IFAT is positive or no IFAT testing was done

2) give complete vaccination regimen until day 30 if: a) animal is alive and remains healthy after 14-day observation

period b) animal under observation died within 14 days but had no signs of

rabies and IFAT negative


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CATEGORY III

1) single or multiple transdermal bites or scratches (include puncture wounds, lacerations, avulsions)

2) contamination of mucous membrane with saliva (ie. licks) 3) exposure to a rabies patient through bites, contamination of

mucous membranes or open skin lesions with body fluids (except blood/feces) through splattering, mouth-to-mouth resuscitation, licks of eyes, lips, vulva, sexual activity, exchanging kisses on the mouth or other direct mucous membrane contact with saliva

4) handling of infected carcass or ingestion of raw infected meat

5) all Category II exposures on head and neck area

Start active and passive immunization (RIG) immediately and depending on condition of the biting animal: 1) give complete vaccination regimen until day 90 if: a) animal is rabid/ killed/ died or unavailable for 14-day

observation b) animal under observation died within 14 days and had signs of

rabies IFAT positive or no IFAT testing was done 2) give complete vaccination regimen until day 30 if: a) animal is alive and remains healthy after 14-day observation

period b) animal under observation died within 14 days but had no signs

of rabies and IFAT negative

A. Immunization 1. Active Treatment Regimen

a. Use the Thai Red Cross Intradermal (ID) Regimen (see Table 2) in the following situations: 1) when two or more cases are seen at a time (within 8 hours) in the health facility 2) presence of trained personnel on intradermal injection +

Table 2. Thai Red Cross Intradermal (ID) Regimen

Schedule of Immunization

Types and Dose of Active Anti-Rabies Vaccine

Site of injection

PVRV PCECV Day 0 0.1 ml 0.2 ml Left and right deltoids or anterolateral thighs in infants

Day 3 0.1 ml 0.2 ml Left and right deltoids or anterolateral thighs in infants

Day 7 0.1 ml 0.2 ml Left and right deltoids or anterolateral thighs in infants

Day 14 None None None

Day 30 0.1 ml 0.2 ml One deltoid or anterolateral thigh in infants

Day 90 0.1 ml 0.2 ml One deltoid or anterolateral thigh in infants


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b. Use the Zagreb Intramuscular (IM) Regimen (see Table 3) in the following situations:

1) when only one case is seen at a time (within 8 hours) in the health facility 2) among patients under treatment with choloroquine, anti-epileptic drugs and systemic steroids 3) immunocompromised individuals (such as those with HIV infections, cancer/transplant patients on

immunosuppressive therapy, etc.)

Table 3. Zagreb Intramuscular (IM) Regimen

Schedule of Immunization

Types and Dose of Active Anti-Rabies Vaccine Site of Injection PVRV PCECV

Day 0 0.5 ml 1.0 ml Left and right deltoids or antero-lateral thigh in infants Day 7 0.5 ml 1.0 ml One deltoid or antero-lateral thigh in infants Day 21 0.5 ml 1.0 ml One deltoid or antero-lateral thigh in infants

2. Passive Treatment Regimen

a. Give Rabies immune globulins (RIG) once only at the bite site by infiltration. If the computed amount is not

anatomically feasible for single infiltration, the remaining RIG is given by deep IM at a site distant from the vaccine injection.

Table 4. Types, Preparation and Dose of Rabies immune globulins

Rabies Immune globulins Preparation Dose Human rabies immune globulin (HRIG) 150 IU/ml in 2 ml vial 20 IU/kg Equine rabies immune globulin (ERIG)* 200 IU/ml in 5 ml vial 40 IU/kg

*After negative skin test. If positive, give HRIG. b. Administer RIG as follows:

1) RIG should be administered ideally at the same time with the first dose of vaccine (day 0) or within 7 days from day 0.

2) RIG should not exceed the computed dose. If the computed volume is insufficient to infiltrate all bite wounds, it may be diluted with sterile saline 2 or 3 fold for thorough infiltration of all wounds.

3) Use a gauge 23 or 24 needle, 1 inch length for infiltration. Multiple needle injections into the same wound should be avoided.


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4) Give HRIG in patients with the following conditions: a) Positive skin test to ERIG or history of hypersensitivity to equine sera b) Multiple severe exposures (especially where dog is sick or suspected of being rabid) c) Symptomatic HIV infected patients

B. Local Wound Treatment

1. Wash wounds immediately and vigorously and flush with soap and water preferably for 10 minutes. 2. Apply povidone iodine or any antiseptic. 3. Suture wounds only if absolutely necessary, and after RIG infiltration. 4. Do not apply garlic or use “tandok”/”tawak” on the bite site. 5. Give anti-tetanus immunization, if indicated. (see annex 18a on anti-Tetanus Immunization Schedule)

C. Antimicrobial Treatment

1. Antimicrobials are recommended for the following conditions: a. All frankly infected wounds b. All category III cat bites c. All other category III bites that are either deep, penetrating, multiple or extensive or located on the

hand/face/genital area

2. Use any of the following antibiotics:

Table 5. Dose and Schedule of Antibiotics for Dog/Cat Bite

Antibiotic Dosage

Adult Pedia Amoxicillin 500 mg 1 cap q 8 hr 30-50 mkD in 3 divided doses

Co-amoxiclav 625 mg 1 tab q 12 hr 30-50 mkD in 2 divided doses

II. Post-Exposure Treatment under Special Conditions

1. Exposed persons who present for evaluation or treatment weeks or months after the bite should be treated as if exposure has occurred recently. However, if the biting animal has remained healthy and alive until 14 days after the bite, no treatment is needed.

2. Bites by rodents, rabbits and domestic animals other than dogs and cats do not require rabies PET unless the animal is proven rabid. Anti-tetanus prophylaxis should be given.

3. Patients bitten by monkeys and other wild animals should be managed similarly as patients bitten by dogs and cats.


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III. Post-Exposure Treatment of Previously Immunized Animal Bite Patients

1. Local wound treatment should always be carried out. 2. Persons with a second exposure after having previously received full course of PET should be vaccinated as follows:

Table 6. PET Schedule for Previously Immunized Patients

Time interval Treatment Dose and Schedule < than 3 months No booster dose

3 months - 1 year 1 booster dose (D0) given ID at 0.1 ml for PVRV or 0.2 ml for PCEC or IM at 1 vial of PVRV or PCEC

1 year to 3 years Two booster doses (D0, D3) given ID at 0.1 ml. for PVRV or PCEC or IM at 1 vial of PVRV or PCEC

> than 3 years Full course of active immunization, no RIG

IV. Post-Exposure Treatment for Patients with PEP with First Exposure

1. Persons with first exposure after having received PEP should be vaccinated as follows: Table 7: PET for Patients with PEP (for Category II & III) with First Exposure

PEP Status

Time Interval

(from the last dose of PEP) Treatment

Complete Primary Vaccination

(no booster yet)

< 2 years

2 Booster doses (D0, D3) no RIG

> 2 years Full active immunization no RIG

Complete Primary

Vaccination with booster shots

< 2 years

1 Booster dose (D0) no RIG

> 2 years but < 3 years

2 Booster Doses (D0, D3) no RIG

* > 3 years

Full active immunization no RIG

* Advise RFFIT to determine level of neutralization antibody titer (adequate level: 0.5 IU)


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V. Pre-Exposure Prophylaxis (PEP)

May give pre-exposure prophylaxis (see Table 8) for non-bite exposures such as: 1. contact with rabies patients thru sharing of eating/drinking utensils 2. casual contact to patient with signs and symptoms of rabies

Table 8. Schedule, Dose and Route of Anti-Rabies Vaccine for Pre-Exposure Prophylaxis

Route of

Administration

Schedule and Dose PVRV PCECV

Day 0 Day 7 Day 21/28 Day 0 Day 7 Day 21/28 Intradermal 0.1 ml 0.1 ml 0.1 ml 0.1 ml 0.1 ml 0.1 ml Intramuscular 1 vial

(0.5 ml) 1 vial

(0.5 ml) 1 vial

(0.5 ml) 1 vial

(1.0 ml) 1 vial

(1.0 ml) 1 vial

(1.0 ml)


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Annex 19

MANAGEMENT PROTOCOL OF SHOCK Treatment Guidelines

1. Secure airway of the patient. Give O2 inhalation or intubate patient if necessary and monitor vital signs.

2. Start double intravenous lines with large bore needles (gauge 16 or 18 for adults, gauge 22 for pediatrics and gauge 24 for infants).

3. Give an initial bolus of Plain LRS/NSS at 1-2 L in an adult or 10-20 cc/kg for pediatrics, and then assess patient’s response.

This may be repeated up to 3 cycles. May use D5NSS/D5LRS if Plain LRS/NSS are not available.

4. Start Dopamine drip (7-15 ug/kg/min) and/or Dobutamine drip (10-20 ug/kg/min) for persistent hypotension after fluid resuscitation with Plain LRS/NSS.

5. Transfuse whole blood for severe blood loss.


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Annex 20

MANAGEMENT PROTOCOL FOR

CARDIOPULMONARY RESUSCITATION (CPR)

After assessing the ABC (airway, breathing and circulation) and patients is noted to have no pulse or cardiac rate, do the following:

1. Feel for the patient’s substernal notch. Place the middle finger in the substernal notch and the index finger on the lower end of the sternum. Then place the heel of the hand beside the index finger. Then place the hand used for measuring the notch on the top of the other hand and interlace the fingers and start the compression with locked elbows. Do effective 4-5 cms sternal compressions at 30 compressions: 2 ventilations x 5 cycles in 2 minutes.

2. If patient is cyanotic or not breathing, check airway and do the following:

a. ambubagging with ‘tight’ face mask. Give 100% Oxygen. Make sure ambubag is connected to the oxygen tank. Suction secretions. Hyperventilate initially. Intubate patient if necessary. Continue CPR.

b. if no portable oxygen is available, open the patient’s airway (head tilt, chin lift maneuver) then give two slow breaths (1 breath 1.5 to 2 seconds). Continue CPR.

3. Ensure that the IV access is patent.

4. If with asystole, give Epinephrine (1 mg/amp) 1-2 ampules IV stat every 3-5 minutes continuously until there is a cardiac rhythm or until CPR is stopped. May give Epinephrine 1 mg ampule in 10 ml NSS via ET tube every 3-5 minutes if no IV line is inserted yet.

5. If still pulse-less, give Epinephrine and continue CPR. Consider Bicarbonate 1 ampule (1 meq/kg) if more than 15 minutes

have elapsed since the heart has stopped.

6. Stop chest compressions every 1-2 minutes to check the cardiac rhythm. Check pulses throughout the duration of the CPR.


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McGraw-Hill Companies, Inc. 2004 3. Bruce JE, Carabasi AR, Radomski JS, et al: Wound Healing. Surgery. 4th Ed. Lippincott Williams and Wilkins. 2000; 17-20 4. Del Mundo, Fe. Textbook of Pediatrics and Child Health. 2000 5. Fitzpatrick, Thomas B., et al. Color Atlas and Synopsis of Clinical Dermatology. Common and Serious Diseases. 3rd ed. 1997 6. Gilbert DN, Moellering RC, Eliopoulis GM. Sanford Guide to Antimicrobial Therapy. 35th ed. 2005 7. Gilbert, David N. The Sanford Guide to Antimicrobial Therapy. 2006 8. Haist, Steven A. and Robbins, John B. Edited by Comella, Leonard G. Internal Medicine on Call. 4th ed. International ed. 2005 9. Hayman David. Control of Communicable Diseases in Man. 18th ed. 2004 10. Latta L, Sarmiento A, Zych G. Principles of Non-Operative Fracture Treatment. In: Browner BD, Jupiter JB, Levine AM,

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6th ed. McGraw-Hill; 2004: 219-225 17. San Lazaro Hospital’s Manual on Medical Standard Operating Procedure. 2000 18. Southwick, Frederick S. Infectious Diseases Quick Glance. 2005 19. Tintinalli JE, Menkes JS. Immobilization Techniques. Tintinalli JE, Kelen GD, eds. Emergency Medicine: A Comprehensive

Study Guide. 5th ed. New York, NY: McGraw-Hill; 2000:1747-1753 20. Tropical Disease Foundation. Guidelines on Antiimicrobial Therapy. 7th ed. 2004 21. WHO. Implementing the New Recommendations on the Clinical Management of Diarrhoea. Guidelines for Policy makers and

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