DEPARTMENT OF HEALTH, GOVERNMENT OF BIHAR

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eq[; eysfj;k dk;kZy;] LokLF; Hkou] lqYrkuxat] fcgkj] iVuk& 800 006nwjHkkk ,oa QSDl% 0612-2370131, bZ&esy% gomjebihar@gmail.com, spomalariabihar@gmail.com

This can be downloaded from Health Deptt. GoB web portal as- www.health.bih.nic.in in its Operational Guidelines section

for

Treatment of AES cases in Bihar

STANDARD OPERATING

PROCEDURE (SOP)

2018 (Revised)

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lans'k

o"kZ 2012 eas efLr"d Toj ,-bZ-,l- ds fu;a=.k gsrq jkT; ds f'k'kq jksx fo'ks"kKkas ds lg;ksx ls ekud

lapkyu izf;k (Standard Operating Procedure) dk lw=.k fd;k x;k FkkA foxr o"kksZa esa ekud lapkyu

izf;k ds vfLrRo esa vkus ,oa blds vk/kkj ij efLr"d Toj ds ejhtksa dk mipkj xzke Lrj ls ysdj

fpfdRlk egkfo|ky; vLirkyksa rd fd, tkus ds dkj.k efLr"d Toj ds ejhtksa dk le; ij lQy

mipkj fd;k tk ldk ,oa ejhtksa dh la[;k ,oa e`R;q esa visf{kr deh ikbZ xbZA

foxr o"kksZa ds vuqHko ds vk/kkj ij ;g eglwl fd;k x;k fd ekud lapkyu izf;k esa dqN

vko';d la'kks/ku fd, tk,A bl dk;Z gsrq efLr"d Toj ds fu;a=.k gsrq LokLF; foHkkx] fcgkj ljdkj }kjk

jkT; dksj dfeVh dk xBu fd;k x;k ftlesa LokLF; foHkkx ds inkf/kdkfj;ksa ds vykok vU; foHkkxksa ds

fo'ks"kKksa dh Hkh lykg yh xbZA rRi'pkr la'kksf/kr ekud lapkyu izf;k& 2018 la'kksf/kr dk lw=.k

fd;k x;k gSA

LokLF; foHkkx ds vfrfjDr vU; foHkkxksa ;Fkk uxj fodkl ,oa vkokl foHkkx] lekt dY;k.k

foHkkx] xzkeh.k fodkl foHkkx] yksd LokLF; vfHk;a=.k foHkkx] f'k{kk foHkkx] f"k foHkkx] lkekftd lqj{kk

,oa fu%'kDrrk funs'kky; ,oa thfodk ds vFkd ifjJe ls foxr o"kksZa esa efLr"d Toj ,-bZ-,l- dh

foHkhf"kdk ij fu;a=.k ikus esa dqN gn rd lQyrk feyh gSA

eSa vk'kk djrk gw fd ekud lapkyu izf;k& 2018 la'kksf/kr lHkh vk'kk] ,-,u-,e-] vkxuckM+h

dk;ZdrkZvksa] fpfdRldksa@f'k'kq jksx fo'ks"kKksa rFkk efLr"d Toj ds fu;a=.k gsrq dk;Zjr vU; foHkkxksa ds

fy, efLr"d Toj ds ihfM+rksa dk lE;d bykt lqfuf'pr djus gsrq ekxZn'kZd dk dk;Z djsxhA bl volj

ij eSa LokLF; foHkkx ds lacaf/kr inkf/kdkfj;ksa rFkk jkT; dksj dfeVh ds lHkh lnL;ksa dks c/kkbZ nsrk gw rFkk

vk'kk djrk gw fd ge lHkh feydj efLr"d Toj dh fofHkf"kdk dks vkSj de djus esa lQy gksaxsA

uhrh'k dqekj

lqkhy dqekj eksnhmieq[;ea=h] fcgkj

lans'k

foxr dqN o"kksZa ls jkT; ds dbZ ftyksa ls efLr"d Toj ds ejhtksa ds izfrosfnr gksus dh lwpuk izkIr

gksrh jgh gSA efLr"d Toj ls u dsoy fcgkj oju ns'k ds vU; dbZ jkT; Hkh izHkkfor gSA Hkkjr ljdkj }kjk

Group of Ministers (GoM) dh vuq'kalk ij 18 vDVwcj 2012 dks laiUu dSfcusV dh cSBd esa Multi

Pronged Strategy ds varxZr LokLF; foHkkx ds vfrfjDr vU; foHkkxksa dks Hkh blds fu;a=.k dh j.kuhfr esa

'kkfey fd;k x;k gSA blds varxZr ns'k ds ikp lokZf/kd efLr"d Toj izHkkfor jkT;ksa ,oa buds 60 fpfUgr

ftyksa esa fo'kss"k HkkSfrd ,oa fokh; xfrfof/k;ksa dk f;kUo;u fpfUgr fd;k x;k gSA blesa fcgkj ds 15 ftys]

N% fpfdRlk egkfo|ky; vLirkyksa dks Sentinal Site ds :i esa ,oa nks Physical Medicine &

Rehabilitation (PMR) dsUnzksa dks 'kkfey fd;k x;k gSA

bu 15 fpfUgr GoM ftyksa esa ICU dh LFkkiuk dh tkuh gSA N% fpfdRlk egkfo|ky; vLirkyksa ds

ekbksokW;ksykWth foHkkxksa esa fu%'kqYd JE dh tkp ds lkFk&lkFk vU; chekfj;ksa dh tkp dk izko/kku fd;k

x;k gSA jkT; dks nks PMR ;Fkk vuqxzg ukjk;.k ex/k esfMdy dkWyst ,oa vLirky (ANMMCH) x;k ,oa

iVuk esfMdy dkyst ,oa vLirky (PMCH) iVuk esa efLr"d Toj ls fnO;kax ejhtksa dks iquZokflr djus

gsrq iz;kl fd;k tk jgk gSA

efLr"d Toj ejhtksa dh fpfdRlk gsrq o"kZ 2012 esa gh Standard Operating Procedure (SOP) dk

lw=.k fd;k x;k A foxr o"kksZa ds vuqHko ds vk/kkj ij o"kZ 2018 esa bls iqu% la'kksf/kr fd;k x;k gS A eSa SOP

ds o"kZ 2018 ds la'kksf/kr laLdj.k ij blesa lg;ksx djus okys lHkh inkf/kdkfj;ksa ,oa lg;ksfx;ksa dks

/kU;okn nsrk gw ,oa mEehn djrk gw fd blls efLr"d Toj ds Rofjr bykt esa enn feysxh ,oa jksfx;ksa dh

tku cpkbZ tk,xhA

lq'khy dqekj eksnh

eaxy ik.Ms;ea=h] LokLF; foHkkx]

fcgkj ljdkj

lans'k

;g tkudj vfrizlUurk gksxh fd jkT; esa efLr"d Toj tSlh xEHkhj chekjh dk rsth ls lQk;k gks jgk gSA bl chekjh dh jksdFkke ds fy, jkT; dksj dfeVh ds lnL;ksa] fpfdRldksa ,oa fo'ks"kKksa dh lewg }kjk ekud lapkyu izf;k ds la'kks/ku 2018 ls ,sls ejhtksa dk vkSj csgrj bykt gksxkA

foxr o"kksZa ds vuqHko ds vk/kkj ij jkT; ds 24 ftyksa esa ts-bZ- dk Vhdkdj.k y{k dk iwjk gksuk xoZ dh ckr gSA 'ks"k 14 ftyksa esa ls 11 ftyksa esa Vhdkdj.k dh lS)kafrd lgefr Hkh Hkkjr ljdkj }kjk fey pqdh gSA ckdh rhu ftyksa esa rhu o"kksZa ls fdlh Hkh ejhtksa dh igpku ugha gks ikbZ gSA

fofHkUu foHkkxksa ,oa xzke Lrj rd bl chekjh ds izpkj&izlkj] izf'k{k.k ,oa VsfDudy ekykfFk;ku QkWfxax ds lkFk&lkFk vke tu dh lgHkkfxrk ls foxr o"kksZa dh rqyuk esa bl chekjh dh fofHk"kdk dks de djus esa visf{kr lQyrk izkIr djuk vfriz'kaluh; ,oa ljkguh; gSA

efLr"d Toj fu;a=.kkFkZ LokLF; foHkkx ds vfrfjDr uxj fodkl ,oa vkokl foHkkx] lekt dY;k.k foHkkx] fcgkj ty ,oa LoPNrk fe'ku] yksd LokLF; vfHk;a=.k foHkkx] f'k{kk foHkkx] i'kq ,oa eRL; lalk/ku foHkkx] efgyk fodkl fuxe] lkekftd lqj{kk ,oa fu%'kDrrk funs'kky;] thfodk ,oa Hkkjr ljdkj ds lkFk leUo; LFkkfir dj efLr"d Toj dh foHkhf"kdk dks de djus esa dkQh enn feyh gSA

efLr"d Toj ls xzflr fnO;kax cPpksa dks fpfr dj iquokZflr fd;k tk jgk gS rkfd oSls cPps Hkh lekt dh eq[; /kkjk esa 'kkfey gks ldsaA MsoyiesaV ikVZulZ ds lg;ksx ls jkT; ds fpfdRlk inkf/kdkfj;ksa] vk;q"k fpfdRldksa ,oa ikjk esfMdy LVkWQ dks efLr"d Toj tSlh chekjh ij fu;a=.k ds fy, izf'kf{kr fd;k tk pqdk gSA lkFk gh LokLF; foHkkx ds vU; dfeZ;ksa] vkaxuckM+h lsfodk] thfodk nhfn;ksa vkSj iapk;rh jkt izfrfuf/k;ksa ds vykos lekt ds x.kekU; O;fDr;ksa dks Hkh bl chekjh ls lacaf/kr izf'k{k.k fn;k x;k gSA

jkT; ljdkj efLr"d Toj ihfM+rksa ds bykt ds fy, iwjh rjg rRij gSA bl la'kksf/kr ekud lapkyu izf;k& 2018 ds lw=.k gsrq eSa LokLF; foHkkx ds inkf/kdkfj;ksa] efLr"d Toj fu;a=.kkFkZ xfBr jkT; dksj dfeVh ds lnL;ksa] fo'ks"kKksa ,oa blls tqM+s vU; foHkkxksa ds inkf/kdkfj;ksa ,oa dfeZ;ksa dks c/kkbZ nsrk gwA

eaxy ik.Ms;

Contents

1 Abbreviations 1-2

2 Protocol for Management of AES (Members of State Core Committee) 3

3 Acute Encephalitis Syndrome- Case Classification of AES & Definitions 4

4 Case Classification of AES 4

5 Etiology/Causes of AES 5

6 Causes of Acute Encephalitis Syndrome- 2016 6

7 Causes of Acute Encephalitis Syndrome- 2017 7

8 Management/Treatment of AES 8

9 Treatment at Community Level (ANM, ASHA & AWW) 9-18

10 Practical Aspect of Initial Management (At PHC Level) 19

11 Management of AES at PHC/Referral/Sub Divisional Hospital Level 20

12 Management of AES at District Level (Sadar Hospital) 21

13 Management of AES at Medical College 22

14 Management of Airway and Breathing 23

15 Position of the Patient 23

16 Management of Circulation 24

17 Maintenance Fluid 24

18 Management of Dehydration 25

19 Control of Convulsions & Maintenance Dose 26

20 Management of Increased Intra Cranial Pressure 27

21 Control of Temperature 28

22 Calories/Nutrition 29

23 General Management 30

24 Indications of Ventilatory Support 31

25 Treatment of Specific cause if any 32

26 Treatment of other associated complications 33-35

27 Investigations, Sample Collection & Transportation 36-37

28 Lumbar Puncture & CSF Examination 38

29 Rehabilitation 39

30 Case Investigation Form (Annexure-A) 40

31 Laboratory Request Form (Annexure-B) 41

32 Essential Equipments at the PHC/Referral/SDH/Sadar Hospital/Med.Coll. (Annexure-C) 42

33 Essential Drugs at the PHC/Referral/Sub Divisional Hospital (Annexure-D) 43

34 Essential Drugs at the Sadar Hospital/Medical College Hospital (Annexure-E) 44

35 Components of Paediatric Intensive Care Unit (PICU) (Annexure- F) 45

36 List of Equipment/Furniture required for PMR Department (Annexure-G) 46-47

37 (Annexure-H)Verbal Autopsy 48

Abbreviations

ABG Arterial Blood Gas

AES Acute Encephalitis Syndrome/Acute Encephalopathy Syndrome

ANM Auxiliary Nurse Midwifery

ASHA Acredited Social Health Activist

AVPU Alert Voice Pain Unresponsive

AWW Angan Wadi Worker

BP Blood Pressure

CCF Congustive Cardiac Failure

CNS Central Nervous System

CRT Capillary Refilling Time

CSF Cerebrospinal Fluid

CT Computed Tomography

ECG Electrocardiogram

ECHO Echocardiography

EEG Electroencephalogram

ELISA Enzyme Linked Immuno- Absorbent Assay

FRU First Referral Unit

GIH Gastro Intestinal Haemorrhage

GIT Gastro Intestinal Tract

Hb Himeoglobine

HBsAg Hepatitis B surface Antigen

ICT Intra Cranial Tension

ICU Intensive Care Unit

IgM Immunoglobulin

IM Intra Muscular

IRL Infra Red Lamp

IV Intra Venous

IVIG Intravenous Immunoglobulin

JE Japanese Encephalitis

1

Contd....

2

KFT Kidney Function Test

KGMU King George Medical University

LFT Liver Function Test

LP Lumber Puncture

MRI Magnetic Resonance Imaging

NIBP Non Invasive Blood Pressure

NS Normal Saline

ORS Oral Rehydration Solution

PaCo2 Partial Pressure of Carbondioxide

PCR Polymerase Chain Reaction

PHC Primary Health Centre

PICU Paediatric Intensive Care Unit

PMR Physical Medicine and Rehabilitation

PR Per Rectal

R/T Ryle's Tube

RBC Red Blood Corpuscle

RDT Rapid Diagnostic Test

RL Ringer Lactate

RMRI Rajendra Memorial Research Institute

RNA Ribose Nucleic Acid

RT Suction Ryle's Tube Suction

SDH Sub Divisional Hospital

SGOT Serum Glutamic Oxaloacetic Transaminase

SGPT Serum Glutamic Pyruvic Transaminase

SOS A Latin word minining- if require/if necessary

SpO Oxygen Saturation2

TBM Tuberculous Meningitis

UTI Urinary Track Infection

VEE Venezuelan Equine Encephalitis

WHO World Health Organisation

WNE West Nile Encephalitis

VA Verbal Autopsy

3

Protocol for Management of AES

Guide :-

Sanjay Kumar, I.A.S. Principal Secretary, Health Department, Government of Bihar

Members of State Core Committee on AES/JE :-

Dr. R. D. Ranjan Director in Chief, Disease control, Deptt. of Health, Bihar

Dr. M. P. Sharma Addl. Director cum State Programme Officer (VBDCP), Deptt. of Health, Bihar

Dr. Arvind Kumar Associate Professor & HoD, Deptt. of Paediatrics, SKMCH, Muzaffarpur

Dr. Bankey Bihari Singh Associate Professor & HoD, Deptt. of Paediatrics, ANMMCH, Gaya

Dr. Gopal Shankar SahniAssistant Professor, Deptt. of Paediatrics, SKMCH, Muzaffarpur

Dr. Syed Hubbe AliHealth Specialist, UNICEF Office for Bihar

Special Invitees :-

Dr. A. K. Jaiswal Professor & HoD, Deptt. of Paediatrics, PMCH, Patna

Dr. Alka Singh Associate Professor & HoD, Deptt. of Paediatrics, NMCH, Patna

Dr. Sanjay Kumar Associate Professor, Deptt. of Neurology, PMCH, Patna

Dr. Nigam P. Narain Retd. Professor & HoD, Deptt. of Paediatrics, PMCH, Patna

Dr. Braj Mohan Retd. Professor & HoD, Deptt. of Paediatrics, SKMCH, Muzaffarpur

Dr. S. M. Hassan Sr. Program Officer, PATH

Assisted by :-

Sanjay Kumar State Incharge, AES/JE Technical Cell, Chief Malaria Office, Patna

(Developed in Consultation with the following Members of State Core Committee)

4

Acute Encephalitis SyndromeDefined as a person of any age, at any time of the year with acute onset of fever and a change in mental status (including symptoms such as confusion, disorientation, coma or inability to talk) and/or new onset of seizures .(excluding simple febrile seizures)

In Bihar a few cases of such encephalopathy / AES have been observed without fever also. (Japanese encephalitis is a type of viral disease which is transmitted by bites of female mosquitoes

belonging to culex species. The disease affects the central nervous system and can cause severe complications, seizures and even death)

1. Laboratory-confirmed JE : Patient having any one of the following-

i) Presence of IgM antibodies specific to JE virus in a single sample of Cerebrospinal Fluid (CSF) or serum, as detected by an IgM-capture ELISA specifically for JE virus.

ii) Detection of a fourfold or greater rise in antibodies specific to JE virus as measured by Haemagglutination Inhibition(HI) or Plaque Reduction Neutralization Assay(PRNT) in serum collected during the acute and convalescent phase of illness. The two specimens for IgG should be collected at least 14 days apart. The IgG test should be done in parallel with other confirmatory tests to eliminate the possibility of cross-reactivity.

iii) Isolation of JE- virus in serum, plasma, blood, CSF or tissue.

iv) Detection of JE- virus antigens in tissue by Immunohistochemistry.

v) Detection of JE- virus genome in serum, plasma, blood, CSF or tissue by reverse transcriptase Polymerase Chain Reaction (PCR) or an equally sensitive and specific nucleic acid amplification test.

2. Probable JE: A Suspected case that occurs in close geographic and temporal relationship to laboratory-confirmed case of JE, in the context of an outbreak.

3. Acute Encephalitis Syndrome (due to agent other than JE): A suspected case in which diagnostic testing is performed and an etiological agent other than JE virus is identified.

4. Acute Encephalitis Syndrome (due to unknown agent ): A suspected case in which no diagnostic testing is performed or in which testing was performed but no etiological agent was identified or in which the test results were indeterminate.

Case Classification of AES

Definitions 1. Encephalitis: An inflammation of the brain, usually caused by a direct

invasion by micro-organism or hyper sensitivity reaction to a micro-organism or foreign protein

2. Encephalopathy: A syndrome caused by disease, damage or dysfunction of the brain and may be attributed to infectious, toxic, immune mediated or metabolic causes

5

Etiology/Causes of AESM

AIN

HE

AD

Dis

ea

se

s o

f K

no

wn

AE

S

* th 1. At AESTAG (Technical Advisory Group) meeting held at RMRI, Patna on 29 November, 2016 and chaired by Dr. Soumya Swaminathan, Secretary DHR & DG, ICMR, New Delhi in presence of Principal Secretary, Health, Govt. of Bihar, Dr. S. Venkatesh, Director NCDC, GoI, Delhi, Dr. P. K. Sen, Additional Director, NVBDCP, GoI, Delhi and others, the decision taken was as The cases diagnosed as Dengue, Malaria, Scrub Typhus and T.B. should be removed from the AES pool to avoid unnecessary inflation in AES figure.

2. As per above decision causes of Dengue, Malaria, Scrub Typhus & T.B. are to be reported concerned division only and not as AES cases.

Viral Encephalitis (Except JE)

Entero-Viral Encephalitis

Non-Polio

Single Stranded RNA Virus of Flaviviridae family (Mosquito is vector)

Polio

Coxsackie A&B

Echo Virus

Others

Measles

Mumps

Dengue

Herpes Encephalitis

Nipah Encephalitis

Chandipura Virus

Varicella (Chicken Pox)

Unknown (eg- Aseptic Meningitis, Acute Disseminated Encephalomylitis (ADEM).

*

Non Viral Encephalitis

Arbovirus WNE (Arthopod is vector) (West Nile Encephalitis in North America)

VEE (Venezuelan Equine Encephalitis)

Tick Borne Encephalitis & others

Dawson Encephalitis

I) Infections :-

Bacterial (Pyogenic Meningitis) * TBM (Tubercular Meningitis) * * Parasitic (Malaria , Round Worm, NCC)

Toxoplasmosis Leptospirosis

* Rickettsial Infection (Scrub Typhus) Protozoal (Amoebic) Spirochetal (Syphilis) Fungal (Cryptococal)

Trypanosomiasis

II) Hyper Pyrexia (Heat Stroke)

III) Hypoglycemia

IV) Chemicals (No fever)

V) Toxins (Toxins of some fruits and insecticides)

VI) Dyselectrolytemia

Usually not

Found inIndia

UnknownAES

JapaneseEncephalitis

KnownAES

AES

6

Unknown AES

JE (+ve)

Known AES

AES Classification Cases AES Classification (%)

Unknown AES 224 52.8%

JE (+ve) 100 23.6%

Known AES 100 23.6%

Total 424 100%

Etiology of AES Cases 2016 Cases Etiology of AES Cases (%)

Pyogenic Meningitis 67 67.0%

Herpes Encephalitis 10 10.0%

Measles Encephalitis 5 5.0%

Chandipura Virus 4 4.0%

Chicken Pox Encephalitis 4 4.0%

Post Measles Encephalitis 4 4.0%

ADEM 2 2.0%

Aseptic Meningitis 2 2.0%

Dyselectrolytemia 1 1.0%

Mumps Encephalitis 1 1.0%

Total 100 100.0%

Pyogenic Meningitis

Herpes Encephalitis

Measles Encephalitis

Chandipura Virus

Chicken Pox Encephalitis

Post Measles Encephalitis

ADEM

Aseptic Meningitis

Dyselectrolytemia

Mumps Encephalitis

Etiology of Known AES Cases- 2016, Bihar

AES Classification- 2016, Bihar

Based on AES Cases of Bihar in Year 2016

Causes of Acute Encephalitis Syndrome

(n=424)

52.8%

23.6%

23.6%

(Unknown AES)

[JE (+ve)]

(Known AES)

(n=100)

67.0%

10.0%

5.0%

4.0%

4.0%

4.0%

2.0%

2.0% 1.0% 1.0%

7

Etiology of AES Cases Cases Etiology of AES Cases (%)

Herpes Encephalitis 19 49%

Hypoglycemia 9 23%

Dyselectrolytemia 5 13%

Pyogenic Meningitis 4 10%

NCC 1 3%

West Nile Encephalitis 1 3%

Total 39 100.0%

Etiology of Known AES Cases- 2017, Bihar

AES Classification- 2017, Bihar

Based on AES Cases of Bihar in Year 2017

Causes of Acute Encephalitis Syndrome

Unknown AES

JE (+ve)

Known AES

50%32%

17%

(n=228)

Herpes Encephalitis

Hypoglycemia

Dyselectrolytemia

Pyogenic Meningitis

NCC

West Nile Encephalitis

49%

23%

13%

10%

3%3%

(n=39)

AES Cases AES

Classification Classification (%)

Unknown AES 115 50%

JE (+ve) 74 32%

Known AES 39 17%

Total 228 100%

(Unknown AES)

(Known AES)

[JE (+ve)]

8

A. History and Clinical examination

1. Detailed clinical examination of the patient including status of hydration and level of consciousness

2. History of previous similar illness in the patient/ neighboring community

3. History of preceding day / nights diet including consumption of any fruits and vegetables

B. Site of Management/Treatment of AES

1. At Community level

2. Practical aspect of initial Management at PHC

3. At PHC/Referral/Sub. Divisional Level

4. At District Level

5. At Medical College Level

C. Details of Systematic Management of AES at Facility Level-

1. Management of airways and breathing

2. Management of circulation

3. Management of dehydration

4. Control of convulsions

5. Management of increased intracranial pressure

6. Control of Temperature

7. Calories & Nutrition

8. General management

9. Indications of ventilatory support

10. Treatment of specific cause if any

11. Treatment of other associated complications

12. Investigations, sample collection & transportation

13. Lumbar puncture & CSF examination

14. Rehabilitation

15. Reporting of a case

ANM/ASHA/AWW Medical Officer & Specialist

Management/Treatment of AES

}

9

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efLr"d Toj ds ejhtksa dh igpku ,oa blds y{k.k %

1- ljnnZ] rst cq[kkj vkuk tks 5&7 fnukas ls T;knk dk uk gksA

2- v}Z psruk ,oa ejht esa igpkuus dh {kerk ugha gksuk@ Hkze dh fLFkfr esa gksuk @ cPps dk csgks'k gks tkukA

3- 'kjhj esa pedh gksuk vFkok gkFk iSj esa FkjFkjkgV gksukA

4- iwjs 'kjhj ;k fdlh [kkl vax esa ydok ekj nsuk ;k gkFk iSj dk vdM+ tkukA

5- cPps dk 'kkjhfjd larqyu Bhd ugha gksukA

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gks ldsA

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3- ;fn cPpk csgks'k ugha gS rc lkQ ikuh esa vks vkj ,l dk ?kksy cukdj fiyk;saA *

4- csgks'kh@fexhZ dh voLFkk esa cPps dks goknkj LFkku ij j[ksaA

5- cPps ds 'kjhj ls diM+s gVk ysa ,oa Nk;knkj txg esa mls fyVk;sa ,oa xnZu lh/kk j[ksaA

6- ;fn ejht ds eqg ls >kx ;k ykj ckj&ckj o T;knk fudy jgk gS rks lkQ iV~Vh ;k diM+s ls ejht dk eqg lkQ djrs jgsaA

7- ejht dks ;fn >Vds vk jgs gksa rks mlds nkarks ds chp lkQ diM+ksa dk ,d xksyk cukdj j[ksa] ftlls thHk dVus ls cp ldsA

* cPps ds csgks'k gksus dh fLFkfr esa bls vkek'k; esa uyh Mky dj fn;k tk ldrk gSA

xko Lrj ij ,-,u-,e-] vk'kk] vkxuckM+h lsfodk ,oa Lo;a lgk;rk lewg (SHG) }kjk efLr"d Toj rFkk

bl rjg ds y{k.k lewg ds ejhtksa dk mipkj

Contd....

10

pedh vkus dh fLFkfr esa %

C ejht dks djoV ;k isV ds cy fyVk;saA

C 'kjhj ds diM+s

11

ejht dks utnhdh izkFkfed LokLF; dsUnz esa Hkstus ds e esa fuEu lko/kkuh cjrsa %

C ;fn cq[kkj rst gks rks ikuh ls cnu iksNasA

C ;fn IV ykbu yx lds rks IV Fluid yxk dj HkstsaA

C mYVh gksus dh n'kk esa IV Fluid ukeZy lsykbu ek=k 1 fdyksxzke otu ds fy;s 20 feyh ,d ?k.Vs esa yxk;sa mlds ckn IV Fluid ukeZy lsykbu yxk dj Hkstsa ek=k 15 fdykxzke otu ds fy;s 10&12 cwn izfr feuV

C pedh vkus dh n'kk esa] ejht dks ck,W ;k nk, djoV esa fyVkdj ys tk,aA

C vius MkWDVj ;k izk Lok dsUnz ds MkDVj ls lEidZ dj vko';d funsZ'k izkIr djsaA

C csgks'k @fof{kIr@>Vds dh voLFkk esa cPps ds eqg esa nok] ikuh] twl] nw/k ;k Hkkstu ugha MkysaA

vfoyac cPps dks utnhd ds izkFkfed Lok dsUnz@jsQjy vLirky@vuqeaMyh; vLirky@lnj vLirky@esfMdy dkWyst ds f'k'kq jksx foHkkx esa bZykt gsrq ykosaA blds fy, 102@108 ,Ecqysal *lsok dk mi;ksx djsaA

efLr"d Toj ds ejhtksa dh igpku gksus ij D;k ugha djuk pkfg, %

C cPps dks dEcy ;k xeZ diM+ksa esa u yisVsaA

C cPps dh ukd can u djsaA

C csgks'kh@fexhZ dh voLFkk esa cPps ds eqg esas dqN Hkh u nsaA

C cPps dh xnZu >qdh u jgsA

C pwafd ;g nSfod izdksi ugh gS cfYd vR;f/kd xehZ ,oa ueh ds dkj.k gksus okyh chekjh gS vr% cPps ds bZykt esa vks>k xq.kh esa le; u"V u djsaA

,Ecqysal pkyd dks bl ckr dk /;ku j[kuk pkfg, fd ,0bZ0,l0 ejht dks ykus ds nkSjku

fdlh izdkj dk 'kksj tSls lk;ju] gkuZ] vf/kd rst eksckbZy fjax Vksu] jsfM;ks bR;kfn dk iz;ksx u gksA

Contd....

LokLF; laca/kh rRdky bejtsUlh lsok] vkdfLed ,oa

vfregRoiw.kZ f'kdk;r gsrq VkWy h uacj Mk;y

djus ds ckjs esa turk dks voxr djk,A104

108 102/108*

* dsoy iVuk 'kgjh {ks= esa ,Ecqysal dh VkWy h lsok gsrq 108 uEcj ij MkW;y djsaA

12

efLr"d Toj ls cpko gsrq mik; ,oa lko/kkfu;k %

C vius cPps dks ts-bZ- dk Vhdk vo'; yxok;saA

C [kku&s ihu s e as mcy s g,q ikuh dk mi;kxs lfq uf'pr dj as vFkok

ihu s d s ikuh d s fy, bafM;k ekdZ& II/III gSaM iEi dk i;z kxs

djAas vko';drk iMu+ s ij Dykjs hu dh xkfs y;k a vFkok

Cyhfpxa ikmMj dk i;z kxs djAas

C uy ds pkjksa vksj dahV dk pcqrjk ,oa de&ls&de 10

ehVj nwj ikuh dk fudkl lqfuf'pr djus ds fy,

fudkl ukyh dk fuekZ.k djk;saA

C 40 QhV ls de xgjkbZ ds gSaM iEiksa dk ikuh u fi;saA

C rkykc ;k iks[kjs ds ikuh dks ugkus ;k eqg /kksus ds fy,

Hkh iz;ksx u djsaA

C gSaM iEi ds pkjksa rjQ ikuh bdV~Bk u gksus nsa rFkk ty

L=ksr ds pkjksa rjQ iznw"k.k QSykus okyh xfrfof/k;k tSls%

ey&ew=] ty teko] diM+s ;k crZu /kksuk] tkuojksa dks

/kksuk bR;kfn u djsaA

C yky jax ls jaxs gq, pkikdy dk ikuh ihus /;ku j[ksa&

;ksX; ugha gSA

C ;fn ihus dk ikuh bDV~Bk dj ds j[krs gS rks mlesa dHkh

Hkh gkFk u Mkysa] cfYd mls fudkyus ds fy, LoPN

gS.My yxs ex dk iz;ksx djsaA

C ekulwu ds iwoZ ,oa ekulwu ds i'pkr~ PHED dss pkikdy

ds ikuh dh xq.kokk dh fu%'kqYd tkp ftyk ty tkp

iz;ksx'kkyk* ls vo'; djok;saA

C tkuojksa dks vius jgus dh txg ls FkksM+k nwj ,oa

lkQ&lqFkjk j[ksaA

C 'kkjhfjd LoPNrk dk iwjk /;ku j[ksa ,oa ey foltZu

leqfpr ,oa lqjf{kr 'kkSpky;ksa esa gh djsaA

C [kkus ls iwoZ ,oa 'kkSp ds ckn lkcqu ls gkFk vo'; /kks,A

C fcLrj ij ePNjnkuh dk iz;ksx djuk pkfg,A

C ifjokj d s jgu s oky s dejk as e as ePNj Hkxku s okyh vxjcRrh ;k nlw jh nokb;k as dk mi;kxs djuk pkfg,A

Contd....

bafM;k ekdZ& II/III gSaM iEi

13

Contd....

C iwjs 'kjhj dks kfM+;ksa dh lkQ&lQkbZ djrs jguk pkfg,A

C tyh; i{kh tSls & lkjl] cxqyk] ck[k bR;kfn ds ek/;e ls Hkh efLr"d Toj QSyrk gSA vr% o"kkZ ds

fnuksa esa /kku ds [ksrksa esa tes gq, ikuh esa] iks[kj@rkykcksa ds utnhd vius cPpksa dks ugha Hkstuk

pkfg,A

C cxhps esa fxjs gq, twBs Qyksa dks cPpksa dks ugha [kkus nsuk pkfg,A

C xehZ ds fnuksa esa cPpksa dks ORS dk ?kksy fiykuk pkfg, ;fn ORS dk ?kksy ugha feys rks uhcw ikuh

vo'; fiykuk pfkg,A

C rst jkS'kuh ls cpkus ds fy, ejht dh vkW[kksa dks iV~Vh ;k diM+s ls kx fudy jgk gks rks lkQ diM+s ls iksNas] ftlls fd lkal ysus esa dksbZ fnDdr

uk gksA

vks-vkj-,l- ?kksy cukus dh fof/k %

C lkQ crZu esa ,d yhVj ikuh lk/kkj.k Xykl ls ikp fxykl esa vks-vkj-,l- dk ,d iwjk iSdsV ?kksy nsaA

C vxj cPpk gks'k esa gks rks rS;kj fd;s x, vks-vkj-,l ds ?kksy dks dqN&dqN varjky ij pEep ls nsrs jgsa rFkk cuk;s x;s ?kksy dks 24 ?kaVs ds ckn mi;ksx u djsaA

C vks-vkj-,l- dk iSdsV fudVre ljdkjh vLirky@LokLF; midsUnz@vk'kk ds ikl miyC/k gSA

C lwvjksa dk ePNjksa ls cpko o lwvjckM+ksa esa lq/kkj %

iDds lwvjckM+ksa ls cpko dk fuekZ.k] f[kM+dh ,oa njokts ij ePNj tkyh dh O;oLFkk rFkk ikuh ,oa lQkbZ dh leqfpr O;oLFkkA

lwvjckM+ksa esa VsfDudy eykfFk;kWu QkWfxax dh O;oLFkkA

lwvjksa ds ey&ew=ksa ds fy, lw[ks o

14

lwvjksa ds gj txg fopj.k dks jksdus ds fy, f'k{kk ,oa fn'kk funsZ'kA

lwvj dkVus ds LFkku dk fu/kkZj.k ,oa lQkbZA

lqjf{kr lwvjckM+ksa dk fuekZ.k cfLr;ksa ls nwj gksuk pkfg,A

lwvj ikydks dks ;g tkudkjh nsus dh vko';drk gS fd vxj lwvj ds cPpkssa esa vpkud chekjh gks ;k e`R;q gks ;k e`r xHkZikr gks rks os bldh lwpuk vius xko ds eqf[k;k dks nsaA

oSKkfudksa dk ekuuk gS fd flQZ lwvjckM+ksa dks ePNjjks/kh lwvjckM+k cukus ls ykHk ugha gksxk vxj lwvjksa ds ?kweus ij vadq'k ugha yxsA

C tkikuh balsQykbfVl ds ejht izfrosfnr gksus ij dsoy izHkkfor xkoksa esa VsfDudy ekWykfFk;kWu ds QkWfxax djkus gsrq izHkkjh fpfdRlk inkf/kdkjh ls laiZd LFkkfir djuk pkfg,A

C fofnr gks tkikuh balsQykbfVl fu;a=.kkFkZ VsfDudy ekWykfFk;kWu dk QkWfxax lw;kZLr ds mijkar fd;k tkrk gS] tcfd Msaxw fu;a=.kkFkZ QkWfxax lw;ksZn; ds i'pkr ,oa lw;kZLr ls igys fd;k tkrk gSA ;g vR;ar egRoiw.kZ gSA

C efLr"d Toj ds ejht bZykt ds ckn ;fn viax ik, tk,sa rks vfoyEc bldh lwpuk izHkkjh fpfdRlk inkf/kdkjh dks nh tk,A

C chekjh dk 'kq: esa irk py tkus ls vkSj mipkj tYnh 'kq: gks tkus ls jksxh dh tku cpkbZ tk ldrh gSA

C ,-,u+-,e- vk'kk ,oa vkaxuokM+h lsfodkvksa dks pkfg, fd bl chekjh ds ckjs esa vke turk dks tkx:d djsaA

C fo'ks"k ifjfLFkfr esa fu%'kqYd fpfdRlk gsrq izkFkfed LokLF; dsUnz esa cPpksa dks Hkstuk pkfg,A

izksRlkgu jkf'k dk izko/kku &

tSiuht balsQykbfVl vFkok efLr"d Toj AES-Unknown Cause) ds ejhtksa dk fpfdRlk inkf/kdkjh }kjk lR;kiu fd, tkus ds i'pkr gh vk'kk dk;ZdrkZ dks : 300@& rhu lkS :i;s ek= izR;sd ejht dh nj ls izksRlkgu jkf'k fn, tkus dk izko/kku gSA fo'ks"k tkudkjh gsrq vius izkFkfed LokLF; dsUnz ds izHkkjh fpfdRlk inkf/kdkjh vFkok ftys ds osDVj tfur jksx fu;a=.k inkf/kdkjh ls laidZ fd;k tk ldrk gSA

15

C fcgkj ds yhph iSnkokj okys ftyksa esa izfrosfnr efLr"d Toj vU; ftyksa ls vyx D;ksa gS \

fcgkj ds yhph iSnkokj okys ftyksa esa efLr"d Toj Acute Encephalopathy dh rjg yf{kr gksrk

gSA

bl chekjh es ejhtksa ds efLr"d esa lwtu gks tkrk gSA ;g mu txgksa ij ik;k tkrk gS tgk yhph

ds cxku ik, tkrs gSaA

lkekU; efLr"d Toj ds ejhtksa esa tks y{k.k ik;s tkrs gS yxHkx ogh y{k.k yhph iSnkokj okys

ftyksa ds izfrosfnr ejhtksa esa Hkh ik;s x, gSaA

ysfdu yhph iSnkokj okys ftyksa esa bl rjg ds ejhtksa esa mi;qZDr y{k.k lqcg 3 cts ls fn[kus

yxrs gSaA bu ejhtksa ds [kwu esa phuh dh ek=k ,dk,d de gks tkrh gS ,oa ejht dkQh xaHkhj gks

tkrs gSaA

dqN ejhtksa es ;g Hkh ik;k x;k gS fd mUgsa cq[kkj ugha Fkk] lksus ls igys cPps ,d ne LoLF; utj

vk jgs Fks vkSj lqcg esa mudh rfc;r vpkud [kjkc ikbZ xbZA

bl chekjh ls izHkkfor ejht dk le; ij bZykt ugha gksus ij tku Hkh tk ldrh gSA

C bl chekjh esa yhph dh D;k Hkwfedk gS\

'kks/k esa ik;k x;k gS fd yhph ds cht] v/kids ,oa ids yhph ds Qy esa ,d ,slk gkfudkjd

jlk;u gS tks [kwu esa phuh ds Lrj dks ,dk,d de dj nsrk gS ,oa ejht xaHkhj voLFkk esa pyk

tkrk gSA bl rjg dk gkfudkjd jlk;u iwjs ids gq, yhph ds Qy esa de ek=k esa ik;k x;k gSA

ejhtksa esa mi;ZqDr y{k.k yhph ds Qy esa ik;s x, gkfudkjd jlk;u ds dkj.k gksrk gSA

C ;g chekjh dc gksrh gS \

veweu bl chekjh ds ejht yhph ds ekSle vFkkZr~ vizSy ekg ds var ls twu ekg ds var rd ik,

tkrs gSaA cjlkr ds lkFk bl chekjh ds y{k.k yxHkx lekIr gks tkrs gSaA

C ;g chekjh fdl dks gks ldrh gS \

1 ls 15 o"kZ ds dqiksf"kr cPpksa dksA

oSls ifjokj tks yhph ds cxkuksa ds vkl&ikl jgrs gksa ,oa yhph dk lsou izk;% djrs gksaA

oSls dqiksf"kr cPps tks v/kids vFkok ids gq, yhph dk lsou djrs gksaA

yhph iSnkokj okys ftyksa ds fy, efLr"d Toj dh jksdFkke ,oa izca/ku gsrq ekxZnf'kZdk

Contd....

16

oSls dqiksf"kr cPps tks isV Hkjus ds fy, dsoy yhph dk gh lsou djrs gksaA

oSls cPps tks yhph [kkus ds ckn fcuk HkjisV Hkkstu fd;s jkr esas lks tkrs gksaA

oSls cPps tks xehZ ds fnuksa esa fcuk [kkuk ikuh dh ijokg fd;s /kwi esa [ksyrs gksaA

mi;ZqDr cPpksa esa bl chekjh ds gksus dh laHkkouk T;knk gksrh gSA

C bu ejhstksa dk mipkj fdl rjg ls fd;k tkuk pkfg,\

lkekU; efLr"d Toj ds ejhtksa dh Hkkafr gh bu ejhtksa dk mipkj fd;k tkuk pkfg,A

C bl chekjh dh jksd&Fkke esa vk'kk] vkaxuckM+h lsfodk ,oa ANM dh D;k Hkwfedk gS\

ekxZnf'kZdk esa ftl rjg efLr"d Toj ds ejhtksa ds lkFk D;k djuk pkfg, ,oa D;k ugha djuk

pkfg, dk mYys[k gS Bhd oSls dh AES ds ejhtks ds lkFk djuk pkfg,A

loZizFke ejht dks ;fn csgks'k u gks rks mls ORS vFkok phuh ;k Xywdkst dk ikuh fiyk;saA

;fn vk'kk vFkok ANM ds ikl XywdksehVj gks rc ejht ds [kwu esa phuh dh ek=k dh tkp vo';

djk;saA

ikjklhVkeksy dh nok mez ds fglkc ls f[kyk,A

Ambulance gsrq VkWy h la[;k 102@108 uEcj ij Qksu djsaA*

fudVre PHC, Referral vFkok ftyk vLirky dks ejht ds vkus dh iwoZ lwpuk nsaA

leqnk; esa chekjh dh igpku ,oa jksd&Fkke gsrq leqnk; esa tkx:drk QSyk,A

ejht dks fp= esa fn[kk;s x;s voLFkk esa fuEufyf[kr lko/kkfu;ksa ds lkFk fyVk dj utnhdh

LokLF; dsUnz esa Hkstsa&

lkal dh uyh [kqyk j[kus ds fy, jksxh dks ,d rjQ fyVk,WA

Bqh dks mBk dj j[ks vkSj ,d gkFk xky ds uhps j[k nsaA

'kjhj dh fLFkfr dks fLFkj j[kus ds fy, ,d iSj eksM+ nsaA

Contd....* dsoy iVuk 'kgjh {ks= esa ,Ecqysal dh VkWy h lsok gsrq 108 uEcj ij MkW;y djsaA

17

C bl chekjh ls cpko ds fy, D;k lko/kkfu;k cjruh pkfg,\

xehZ ds ekSle esa cPpksa dks HkjisV [kkuk ,oa ikuh vFkok ORS ;k Xywdkst ;k phuh dk ?kksy

fiykdj gh ?kj ls ckgj fudyus nsaA

vizSy ds vafre lIrkg ls twu ds vafre lIrkg rd vk'kk] vkaxuckM+h ,oa ANM }kjk mu ifjokjksa

ds ?kjksa dk vo'; Hkze.k fd;k tk, tgk 15 lky ls de mez ds cPps vius ifjokj ds lkFk yhph

ds ckxkuksa ds vkl&ikl jgrs gksaA

,sls lHkh ifjokjksa dks yhph ls gksus okys uqdlku ds ckjs esa ckj&ckj voxr djk;k tk,A

v/kids vFkok dPps yhph ds lsou ls cpk tk,A

ekrk&firk dks ;g vo'; lykg nh

tk, dh cPpksa dks jkr esa lksus ls

igys HkjisV [kkuk f[kyk;k tk,A

vkyw] 'kdjdan] Tokj cktjs dh

jksfV;ksa esa dkckZsagkbZMsM rRo T;knk

gksrs gSa tks jDr essa 'kqxj dh ek=k dks

de ugha gksus nsrs gSaA vr% [kkus esa

bldks t:j 'kkfey fd;k tk;sA

vxj cPps us fnu esa yhph dk lsou

fd;k gks rks mls vk/kh jkr esa Hkh

mBkdj [kkuk vo'; f[kyk;k tk;s

ftlls cPps ds [kwu esa 'kqxj dk

lgh Lrj cuk jgsA

yhph dk lsou oftZr ugha gSA mi;qZDr lko/kkfu;ksa ds lkFk yhph dk lsou fd;k

tk ldrk gSA

vxj cPpksa dks pedh vk jgh gks rks eqg esa dqN u MkysaA ;fn cPpk dqN ihus dh fLFkfr esa gks rHkh

mls ORS vFkok phuh ;k Xywdkst dk ikuh fiyk;saA

;g vko';d gS fd vk'kk] vkaxuckM+h lsfodk ,oa ANM ds ikl utnhd ds PHC, Referral

Hospital ,oa Ambulance dk eksckbZy u gks ftls t:jr iM+us ij bLrseky fd;k tk ldsA

bl chekjh ds dkj.kksa] y{k.kksa] D;k djuk pkfg, (Do's) rFkk D;k ugha djuk pkfg, (Don'ts) ds

laca/k esa leqnk; dks tkx:d djuk pkfg,A

18

lkcqu ls gkFk /kksus dk lgh rjhdk

gkFkksa dks lkcqu ls vPNh rjg /kksus ls ge cgqr lh chekfj;ksa ls cp ldrs gSaA

19

Practical Aspect of

Initial Management (at PHC level)

AES patient

Put I.V Line

Proper positioning of patient and suction

Give Diazepam @0.3mg/kg and @not more than 1mg/min (if convulsion)

Start Ringer Lactate @70-100ml/kg (according to degree of dehydration)

Apply Glucometer

Hypoglycemia

Give 5ml/kg of 10% Dextrose IV bolus.

Monitor for danger signs and plan for referral

ALERT- Never start with dextrose infusion, follow the above protocol and

Treat fever as per protocol

20

Fever

Tap water sponging

Paracetamol

Convulsions

Anti convulsants

Secretion

Suction

Nil orally

Position of patient prone/semiprone with head on one side

Oxygen if required

I/V line -I/V fluids

Correction of blood sugar - 5ml/kg of 10% Dextrose

I/V anti convulsant if convulsions are not controlled

Use of Ambu bag to assist respiration if necessary

Catheterization if required

Use of Inj. Mannitol 20%

Fluid intake/output chart

Pulse, respiratory rate, temperature and B.P. monitoring 4 hourly.

DANGER SIGNS

Needing referral to Sadar Hospital

Fever with any one of the following :

Lethargy

Unconsciousness

Convulsions

Other findings eg. paralysis, rash

Hepato-splenomegaly

For Laboratory investigation according to the type of facilities refer to page no. 36

At PHC/Referral/Sub Divisional Hospital

Management of AES

21

Fever

Tap water sponging

Paracetamol

Convulsions

Anti convulsants

Secretion

Suction

Nil orally

Position of patient prone/semiprone with head on one side

Oxygen if required

I/V line-I/V fluids

Correction of blood sugar - 5ml/kg of 10% Dextrose

I/V anti convulsant if convulsions are not controlled

Use of Ambu bag or ventilatory respiratory assistance if required

Catheterization if required

Use of Inj. Mannitol 20%

Fluid intake/output chart

Pulse, Respiratory rate, temperature and B.P. monitoring every 4 hourly

Management of unconscious patients

Management of other related ailments

DANGER SIGNS

Needing referral to nearest Medical College Hospital

Shock/low BP/rapid & thready pulse

Need of ventilator-poor respiratory efforts, cyanosis not managed by oxygen

At District Level (Sadar Hospital)

Management of AES

22

Fever

Tap water sponging

Paracetamol

Convulsions

Anti convulsants

Secretion

Suction

Nil orally

Position of patient prone/semiprone with head on one side

Oxygen if required

I/V line-I/V fluids

Correction of blood sugar - 5ml/kg of 10% Dextrose

I/V anti convulsant if convulsions are not controlled

Use of Ambu bag or ventilatory respiratory assistance if required

Catheterization if required

Use of Inj. Mannitol 20%

Fluid intake/output chart

Pulse, respiratory rate, temperature and B.P. monitoring every 4 hourly

Management of unconscious Patients

Management of shock and other complications if any

Management of AESAt Medical College

23

Management of Airway and Breathing

Assessment of Airway and Breathing

Clear Airways

No oral feed

Nurse in semi prone and prone position

Give oxygen if needed

Obstructed breathing/ severe respiratory distress

Clear Secretions from mouth

Wiping oral cavity

Suction of mouth turning head on one side

Give oxygen

Ventilate with Bag and Mask/Endo Tracheal Tube if breathing is labored.

Refer the case to tertiary care centre for ventilatory support if needed

Position of the Patient

Turn the Patient on the Prone or Semiprone side to reduce

risk of aspiration

Keep the neck slightly extended and stabilize by placing

one hand below cheek

Bend one leg to stabilize the body position.

24

Management of Circulation

Establish IV line. Look for signs and symptoms of shock Capillary refill > 3 secs Cold extremities Weak and rapid pulse

Assess pediatric patient for dehydration

No dehydration Symptomatic Management Look for signs of referral 2/3rd of maintenance fluid by

intravenous route.

Grade dehydration as some/severe dehydration

Severe dehydration. IV fluid Ringer lactate/ Normal Saline as per WHO guideline.

S o m e d e h y d r a t i o n I V f l u i d - R i n g e r Lactate/Normal Saline.

Shock present-IV fluid NS/ Ringer Lactate 20ml/kg in first hr

(Repeat 3 times if shock persists)

Reassess

NS/Ringer Lactate-20ml/kg. if shock improves and child is euvolemic, give maintenance fluid.if shock persists- Inotrope Dopamine drip in maintenance fluid 5 mcg/kg/minute then again increase Dopamine upto 20 mcg/kg/minute and similarly.Dobutamine start with 5 mcg/kg/minute & increase upto 20 mcg/kg/minute (till BP stabilizes)

Improvement : Continue maintenance IV fluid.No improvement : Refer to higher centre

NB : 1. These are broad guidelines; ultimate decision regarding management will depend upon the attending physician.

2. Management of Circulation - 3% NS 3 -5ml / kg over 1-2 hours if hyponatremia is symptomatic and documented.

Maintenance fluidMaintenance fluid administered at the following rate :

Weight (kg)

1-10

11-20

21-40

Fluid Volume/Day

100 ml/kg

1000 ml + 50ml/kg over & above 10kg

1500 ml + 20 ml/kg over & above 20 kg

(Fluid and Electrolyte Management)

25

Some Dehydration :

IV fluid Ringer lactate/normal saline 75ml/kg to be given over 4 hrs.

Where the facility for IV fluids is not available administer ORS 75 ml/kg 4 hrs through nasogastric tube.

Reassess :

If there is improvement continue with maintenance IV fluid/if no improvement is detected, switch to treatment for severe dehydration.

Severe Dehydration :

IV fluid Ringer lactate 100ml/kg is given as per the table below :

Rate of Fluid (Ringer Lactate)

< 1yr

> 1yr

30ml/kg

1hrs

1/2 hrs

70ml/kg

5hrs

2 hrs

Reassess :

If there is improvement switch to maintenance/ if no Improvement is detected or deterioration is observed infuse IV fluid more rapidly.

Management of Dehydration

26

Control of Convulsions For Convulsing Child :

Good for control & as maintenance

Sl. NoName of

Drugs Doses Available asRoute of

AdministrationIndication

Limitation/side effects

1

2

4

3

5

6

Diazepam

Lorazepam

Midazolam

Phenytoin Sodium

Phenobarbitone

Sod. Valporate

0.1-0.3mg/kg (0.5mg/kg for rectal use)

0.05-0.1 mg/kg

0.2 mg/kg

15-20 mg/kg

20mg/kg as loading dose (upto total 40mg/kg in increment of 10mg/kg)

20-40mg/kg

10mg/2ml rectal-2.5mg/2.5ml

2mg/ml

1mg/ml in 5ml & 10 ml vials Intra nasal spray

100mg/2ml amp.

200mg/ml ampule

100mg/1ml 400mg/4ml 1000mg/10ml Amp.

I/V Slowly/Suppository/(P/R)

I/V Slowly

IV, Intra Nasal, Sublingual

I/V Slowly after dilution in normal saline

I/V slowly after dilution in normal saline

IV

Uncontrolled convulsions

Uncontrolled convulsion

(Safe in infants)

Uncontrolled convulsion

Convulsion in all age groups

Convulsion in infants can be used in all age groups

All age group

May cause respiratory arrest in newborns & infants. short acting

Tachycardia, Depression, Confusion, Blurred vision

Short acting

Good drug for control of seizure & as maintenance

Good drug controlling seizure & long term use.

Note: After the control of convulsions by either Diazepam or Lorazepam or Midazolam, loading dose of Phenytoin should be given to prevent recurrence of seizures in the next 24 to 48 hours till the maintenance dose of drugs are given.

Maintenance Dose :

Phenobarbitone 3-5 mg/kg/day (Q-12 Hrs.) I/V or oral

Phenytion 5-8 mg/kg/day (Q-12 to 24 Hrs.) I/V or oral

Sodium valproate 20-60 mg/kg/day (Q-8 to 12 Hrs.) Oral

Total duration of anti convulsants to be decided by individual causes.

27

C Mannitol 20% I/V - 5ml/kg in 30 minutes as first dose then 2 ml/kg at 8 hrs. interval upto 48 hours (maximum 8 doses)

C+ 3% NS- 3-5ml/kg over 1-2 hrs. if hyponatremia co-exists (Target serum Na

around 150-155)

C Injection Lasix I/V - 1mg/kg upto 40 mg can be given

C Glycerol solution : Oral - 0.5 ml/kg mixed with fruit juice can be given by nasogastric tube (3 times a day)

C Steroids are not indicated in Viral Encephalitis including JE

C Mechanical Ventilation- Target PaCO 30mmHg2

C Head should be kept in neutral position with elevation of the head end of the bed upto 30 degree

*Recognised clinically by :

Abnormal tonic posturing

Pupillary dilatation specially if unilateral or non reacting

Periodic or Irregular respirations or Hyperventilation.

Bradycardia /Hypertensionth

Squint due to 6 nerve Palsy.

Management of Increased Intracranial Pressure*(Only after correction of Dehydration & Stabilization of Blood pressure)

28

Control of TemperatureC If No Rigors :

Tap Water Sponging : Not only on forehead, palms or soles but whole body to be wet with tap water and fan (ceiling/table/manual) should be on (Cold sponging is harmful).

Oral Paracetamol : 15mg/kg maximum upto 600mg (or by Nasogastric tube).

Injection Paracetamol : 5mg/kg by IV drip (infusion) SOS or deep intra muscular at either lateral side of thigh or upper outer Quadrant of hip.

If Injection is not available give paracetamol Suppository.

Other antipyretic medicines e.g.- Nimesulide/Brufen/Meftal/Aspirin etc are not advisable, specially in children.

C If Chills or Rigors present:

Don't cover patients

Don't do water sponging

Use Paracetamol I.M injection or syrup through nasogastric tube or parecetamol suppository as per advise.

Only for Heat Stroke, Paracetamol may not be effective therefore cold 0sponging should be continued till temperature is brought down (100 - 102 F).

29

During CNS infections with convulsion and hyperpyrexia state, calories specially

glucose requirement is increased and it should be given in form of 10% Dextrose which

may be given to the patient in a bolus dose of 5ml/kg body weight followed by a series

of maintenance doses after stabilization. All IV fluids with Dextrose should be

continued till patient is stabilized, convulsions are controlled and there is no vomiting

and distension of abdomen. At this time, intra gastric feeding may be added and slowly

IV fluids are replaced by total nasogastric feeding.

Calories/Nutrition

30

Suction :

Frequent suction (side effect- ICT) either by mucus sucker or suction machine is to be done on an unconscious patient, so that secretion may not collect in mouth to avoid aspiration and for the maintenance of the patency of airways. Avoid touching posterior part of throat (Pharynx), it may increase ICT or cause bardycardia.

Nasogastric Aspiration :

Nil orally, place a nasogastric / Ryles' Tube into stomach and do a frequent suction to avoid any vomiting and aspiration. It will also help in decompression of stomach and will decrease intra abdominal pressure. Thus, it will help in respiration.

Care of Eye, Bowel, Bladder & Back :

C Eyes to be covered by wet gauge

C An antibiotic eye ointment may be applied twice a day or liquid paraffin may be put in eyes to avoid drying of Cornea

C If child does not pass stool, put a glycerine enema

C Bed should be well maintained, to prevent formation of bed sore. Spirit & powder may be applied on back and on all pressure points

C Frequent changing of patient's position

C Catheterize the patient to avoid soiling of beds

C Physiotherapy once patient is stabilized

C Other General Nursing Care

C Treat secondary infections by appropriate Antibiotics

C Treat underlying other pathology. e.g. Anemia, Malnutrition, etc.

C Assessment of consciousness status

C AVPU Scale (A-Alert; V-Voice; P-Pain; U-Unresponsive)

General Management

31

Deteriorating General Condition

Very shallow respiration/severe respiratory distress/feeble heart sounds

Capillary Refill Time > 3 secs

Dusky colour of body/cyanosis

Need of continuous bag and mask (Ambu) ventilation

ABG parameters showing acidosis, hypoxia & hypercarbia

*For District Level Doctors if ventilator is not available they can hand ventilate by Ambu Bag

Indications of Ventilatory Support*

32

Herpes- Acyclovir- 10mg/kg/dose, I/V slowly over a period of one hour, 8 hourly x 21 days.

Varicella Zoster- Acyclovir-10mg/kg/dose 8 hourly, I/V slowly over a period of one hour x 7-10 days.

Malaria- Artesunate- 2.4mg/kg stat, then at 12 hour and 24 hour, then once a day for 7 days

(Change to oral, once patient can tolerate orally). or I/V Quinine- 20mg/kg in 5% Dextrose slowly over a period of 1 hour then 10

mg/kg 8 hourly. Monitor blood sugar and blood pressure.

Meningitis (Pyogenic)- Start with I/V inj. Ampicillin 200-400 mg/kg/day 6 hourly upto 12 gm/day+I/V inj. Ceftriaxone 100-150mg/kg as stat dose then in two divided doses 12 hourly+steroids. Change antibiotics according to culture & sensitivity report and response.

TBM- Anti Tubercular Drugs (INH, PZA, Rifampicin + Ethambutol + Steroids)

Neurocysticercosis- Albendazole oral 15mg/kg (upto 800mg)/day for 7 days. Premedicate with steroid (Prednisolone 2mg/kg or 0.15mg/kg of Dexamethasone) either concurrent with Albendazole or starting Albendazole on the 3rd day of corticosteroid.

In case of suspected Mycoplasma/Rickettsial infection, injection Azithromycin 10 mg / kg slowly IV drip/infusion once daily for 7 to 10 days.

Treatment of Specific Cause if any

Protocol for empirical therapy :

(Till definite diagnosis is established)

1. Ceftriaxone 100-150mg/kg as stat dose then in two divided doses 12 hourly.

2. Artesunate- 2.4mg/kg stat, then at 12 hour and 24 hour.

3. Acyclovir-10mg/kg/dose, I/V slowly over a period of one hour thrice daily.

33

C Myocarditis and heart Failure:

Bed rest

Fluid restriction (70%)

BP monitoring

Furosemide 1-2 mg/kg/IV 8 hrly

Enalapril 0.1mg/kg/day in 2 divided doses

IVIG 400mg/kg/day for 5 days (those who can afford)

Dexamethasone 0.5mg/kg/day for 5 days (those who can not afford IVIG)

for Neurocysticercosis or complications such as

Myocarditis and Heart failure

Dopamine and of Dobutamine may be used at any stage as per requirement

C Renal insufficiency:

Input/output charting

Daily weighing2 IV fluids 10% Dextrose 400ml/m /day

5% Dextrose in N/5 saline (to replace urinary output)

Correction of electrolyte imbalance

C Anemia:

Hb < 5 gm% - Packed cell (RBC) 10 ml/kg

Hb > 5 gm% - Oral Iron (4-6 mg/kg/day) and folic acid supplementation

C Thrombocytopenia:3 Platelets count < 20000/mm or severe bleeding-Platelets transfusion

Treatment of other associated complications

Contd....

34

Contd....

C GI Haemorrhage:

R/T suction of gastric content

Blood transfusion

I.V. fluids

Ranitidine 2-3mg/kg/day

Sucralfate syrup 0.5ml/kg/dose 6 hrly

Injection Vit. K 10mg stat

C Pulmonary oedema:

Furosemide 1mg/kg/IV 8 hrly

Fluid intake

35

C Disability Limitation:

Bed rest

Frequent change of postures-(every 2 hr)

Change bed sheets-Daily

Condom connection and catheterization (to every incontinent/unconscius child)

Control of cerebral oedema

Control of seizures

Control of fluid and electrolyte imbalance

Eyes (fundoscopy for papiloedema, optic neuritis and atrophy)

Pulmonary oedema

GIT Haemorrhage

Secondary bacterial infections

C Feeding:

Unresponsive

Breathing and circulation unstable

Secretions in airways

Responsive

Respiration and circulation stabilized

Coughing, swallowing absent

Conscious (biting, chewing and swallowing)

-R/T Feeding-Oral Feeding}

-Nil orally -R/T suction of gastric contents -I.V. Fluids

}

36

A. Investigations :

Complete Blood Count.

Antigen based RDT or Microslide for Malaria Parasite

Blood glucose

Peripheral blood smear

Serum electrolytes.

CSF and blood for serology- IgM ELISA/virus identification, cells, sugar, protein & JE/Typhus/Mycoplasma status

CSF is preferred since by the time patient presents with CNS manifestations the level of viremia in blood has decreased and there is cross reaction with other flaviviruses.

Other test if necessary - LFT (SGOT, SGPT, serum bilirubin etc)/KFT (Blood urea, Serum creatinine etc) blood culture/x-ray/ultra-sound/CT/MRI/ECHO/ any specific test-enzyme/ECG/EEG/HBsAg/serum protein/prothrombin time/ suspected etiology at appropriate facilities.

Blood test for suspected Leptospirosis

Virus identification is possible only in Apex Referral Laboratories (also at RMRI- Patna, NIV- Pune/Gorakhpur, KGMU- Lucknow) for selected cases if decided by investigating team.

LP to be done if needed at district level.

B. Specimen Collection :

Blood (serum) and CSF specimen are to be collected. Blood specimen should be collected within 4 days after onset of illness for identification of virus and at least 5 days after onset of illness for detection of IgM antibodies. A second convalescent serum sample should be collected 10-14 days after the first sample or at the time of discharge/death if possible/permitted.

Blood/Serum-

Equipment required :

5ml vacutainer tube (non-heparinized) with 23 gauze needle/5ml syringe with needle

Investigations, Sample Collection & Transportation

Contd....

Man

dat

ory

at P

HC

lev

el

37

5 ml blood collection tube if syringe and needle are used for blood collection Disposable gloves and face mask Tourniquet Sterilized swabs Sterile serum storage vial Specimen labels, marker pen Band aid Zip lock plastic bags Lab request form Cold box (vaccine carrier) with ice pack First-aid kit

Collection Procedure :

Collect 5 ml blood in a sterile tube labelled with patient identification and date of collection

Keep at room temperature till clot retracts from serum0 Blood can be stored at 4-8 C for 24 hrs before serum is separated, do not freeze

whole blood

Transport whole clotted blood specimen to laboratory on ice if it can reach lab in 24 hrs/centrifuge at 1000 rpm for 10 mins to separate the serum or if centrifuge is not available carefully remove serum with a pipette and transfer

0serum to a sterile vial and store at 4-8 C for 2 days

C. Transportation :

Specimen Should be transported to laboratory as soon as possible, do not wait for collection of additional specimen.

Put specimen in zip pouch/plastic bag with absorbent material (cotton/tissue).

Use vaccine carrier/thermos flask for transportation. In vaccine carrier use frozen packs along the sides and place specimen in the center. Transport in reverse cold chain.

Place lab request form in a plastic bag and tape to inside of carrier.

Inform the lab about the time and manner of transportation.

Transport the serum in vaccine carriers with four ice packs within 48 hrs or it 0can be stored at 4-8 C for 2 days.

0 If a delay is anticipated sera should be frozen at -20 C and transported on frozen ice packs. Repeated freezing and thawing should be avoided as it affects

the stabilityof IgM.

38

All attempts should be made to collect CSF specimens for confirmation of diagnosis.

Collection :

Lumbar puncture is the most commonly used means of collecting specimen

Patient is positioned on his side with knees curled up to his abdomen,

occasionally it is performed with the patient sitting or bent forward, fluid is

collected (usually 2-3 ml).

Skin is scrubbed and local anesthetic is injected over lower spine. Spinal

needle is inserted usually between L3 and L4 vertebrae.

Once the needle is in sub-arachnoid space pressure can be measured and

fluid is collected in a sterile screw capped bottle.

After sample is collected, the needle is removed and area is cleaned.

Patient is advised to lie flat for 6-8 hrs.

Perform physical examination of CSF, indicate the findings on the laboratory

requisition form and transport to the laboratory as soon as possible. Store at 04 C if delay in processing is anticipated.

Storage and Transportation :0

Store at 4 C as soon as possible after collection and dispatch at the earliest

with four ice packs in vaccine carrier/thermo flask.

For PCR-transport specimen on dry ice.

A designated person should be responsible for storage, packing and

transportation as per guidelines on previous page.

Lumbar Puncture & CSF Examination

Note: Lumbar puncture should be done in the facilities with laboratory service after stabilization of patient because there is chance of herniation

39

C Physiotherapy/PMR

C Advice of pediatric neurologist

C Correction to fix deformity by orthopaedic surgeon

C Child psychologist advice

C Various prosthesis

C Artificial appliances

C Eye and Ear check-up

Rehabilitation

40

Annexure-AReporting of Case

Case Investigation FormTo be filled up by Medical Officer at time of first contact with Health Facility and be to kept with BHT

ACUTE ENCEPHALITIC SYNDROME / JE CASE INVESTIGATION FORM

Registration Number : AES-

Reporting Information

Date of Case Reported

Date of Case Investigated

Patient Information

Patient's Name: Date of Birth:

Father's Name:

Village/Mohallah:

District:

Notified by

Investigated by

Sex:

Age: Years

Religion: Muslim/Hindu/ Other:

Landmark:

Block/Urban Area:

State:

Months

- - -

/ /

/ /

Travel History over Two weeks from Onset of First Symptoms

Date FromDate toAddress

Block

District and State

Immunization History

JE Immunization Yes/No/Partial/Unknown Date of last JE Immunization / /

Signs and Symptoms

Date of onset of first symptoms

Change in mental status Yes/No/ Unknown

Fever Yes/No/ Unknown

Headache Yes/No/UnknownParalysis Yes/No/Unknown

Unconsciousness Yes/No/Unknown

Neck rigidity Yes/No/ Unknown

Sample Collection, tracking and results

Date Collection

Date Sent

Date Result Condition*

Laboratory Result (Circle)

CSF

Serum 1

Serum 2

Positive UnknownNot-tested Negative

Positive UnknownNot-tested Negative

Positive UnknownNot-tested Negative

Diagnosis and final classification

Final Classification

Clinical Diagnosis

Discharge Status

Status of Patient Death/Discharge/Referral/LAMA

If Alive status of recovery Recovered completely/ Recovered with disability

If died, date of death:

Laboratory Confirmed JE / Known AES / Unknown AES

Date

(Name & Signature)Designation

Seizure Yes/No/ Unknown

*Condition is adequate if specimen is transported in reverse cold chain

/ /

/ /

/ /

Mob.No.

Address:

321

41

Annexure-BReporting of Case

Laboratory Request FormTo be filled at time of first contact with Health Facility by Medical Officer

JAPANESE ENCEPHALITIS LABORATORY REQUEST AND REPORT FORM

If sample is bad specifyAdd in the following information:Fever at onset Y N Duration .........Seizures : Y NAltered level of consciousness : Y NNeck rigidity: Y N

(Name and Signature) Designation

*Sample is good if:

There is no leakage

Of adequate quantity

Brought in cold chain

Documentation is complete

Patient Registration Number: Date:Patient name:Age:

Province:Town/village:

DistrictName of health facility:

Number of doses of Japanese Encephalitis vaccine: Date of last dose:

Date of onset of illness

Name & address of treating doctors:

Clinical Feature:

Specimen Type

(1)

(2)

(3)

Specimen ID Date of Collection Date of Shipment

Name of person to whom laboratory results should be sent:

Address:

Telephone/Mob.No.: E-mail:

For use by the receiving laboratory:

Name of laboratory:

Name of Person receiving the specimen:

Specimen condition*

Specimen Type

Date ofReceived in

LabDate Result Test Type Test Result

Date of Result to Program

/SenderRemarks

Name of Parent or guardian:

/ /

Any other informationSource : WHO Draft document operational guidelines

42

1. Essential equipments at the PHC/Referral/Sub Divisional Hospital level:

Glucometer with strip

Air way sizes 0 and 1

Mucus sucker

Rubber feeding tube of various size (10,12,14)

5 ml & 2 ml syringes with needles

Thermometer

Adhesive tape

Enema set

Oxygen

IV cannula, 22 to 24 gauze

Ambu bag

Foley's catheters of various sizes

2. Essential equipments at the Sadar Hospital/Medical College level:

Glucometer with strip

Air way sizes 0 and 1

Mucus Sucker

Rubber feeding tube of various size (10,12,14)

5 ml & 2 ml syringes with needles

Thermometer

Adhesive tape

Enema set

Oxygen

IV cannula, 22 to 24 gauze

Ambu Bag

Foley's catheters of various sizes

Lumbar puncture sets

Provision for cerebrospinal fluid analysis

Essential Equipments at the PHC/Referral/Sub Divisional Hospital/Sadar Hospital/Medical College

Annexure-C

(for Management of AES)

43

C Tablet/Syrup/Injection Paracetamol

C ORS

C Inj. Adrenaline

C Inj. Diazepam

C Inj. Phenytoin

C Inj. Dexamethasone/or Hydrocortisome

C Inj. Mannitol 20%

C Inj. Phenobarbitone

C Inj. Ceftriaxone

C Inj. Artesunate

C Diazepam rectal/Diazapam Suppository.

C IV fluids N/2 saline, Isolyte - P, 10% Dextrose, 3% Hypertonic saline.

C Normal saline

C Ringer Lactate

C Tab/Inj. Frusemide

C Oral Glycerol

C Glucose Powder

C Suspension Valproate

C Vitamins

C Midazolam- Intra Nasal Spray

C Lorazepam

Annexure-D

Essential Drugs at the PHC/Referral/Sub Divisional Hospital

(for Management of AES)

44

C Tablet/Syrup/Injection Paracetamol

C ORS

C Inj. Adrenaline

C Inj. Diazepam

C Inj. Phenytoin

C Inj. Dexamethasone/or Hydrocortisome

C Inj. Mannitol 20%

C Inj. Phenobarbitone

C Inj. Ceftriaxone

C Inj. Artesunate

C Diazepam rectal/Diazapam Suppository.

C IV fluids N/2 saline, Isolyte - P, 10% Dextrose, 3% Hypertonic saline.

C Normal saline

C Ringer Lactate

C Tab/Inj. Frusemide

C Oral Glycerol

C Glucose Powder

C Suspension Valproate

C Vitamins

C Midazolam- Intra Nasal Spray

C Lorazepam

C Inj. Dopamine

C Inj. Acyclovir

C Inj. Paraldehyde

C Inj. Ampicillin

C Syrup Chloral hydrate

C Syrup/Tab Haloperidol

C Inj. Chloramphenicol

C Inj. Azithromycin

C Capsule Doxycycline

C Dobutamine

Annexure-E

Essential Drugs at the Sadar Hospital/Medical College Hospitals

(for Management of AES)

45

Components of Paediatric Intensive Care Unit (PICU) *

Equipment Quantity/ies

1.1 ICU Beds 10

1.2 Bed Side Monitors (with facility to measure and display following parameters);

Heart rate/Respiratory rate/Temp.Non-invasive Blood Pressure (NIBP)Oxygen Saturation (SpO2)

ECG1.3 Central Monitoring Station1.4 Defibrillator 11.5 Central Gas Pipeline (Oxygen, compressed air,

vaccum)(2 pts. for O and 1 for vacuum and 2compressed air)

1

1.6 Paediatric Ventilators 5

1.7 ABG Analyzer 1

1.8 Syringe Pumps 201.9 Misc. Instruments/Equipment1.9.1 Nebulizer 11.9.2 X-ray View Box 11.9.3 Transport Ventilator 11.9.4 Transport Monitors 11.9.5 Over Head Warmers 21.9.6 Recovery Trolley 11.9.7 B type O Cylinder 2 1

1.9.8 Ambu Bag with Mask (Paediatric and adult size) 5 (each size)

1.9.9 Suction Machine 11.9.10 Laryngoscope 5 (of different size)

1.9.11 Endotracheal Tube with cuff and without cuff

12

1

Note: The estimated total cost of equipments has been decided by the Government. The

implementing authorities in the respective states may be requested to adjust the additional

cost of the equipment within the allocated budget. Any additional expenditure on equipment

would have to be managed from state resources only.

Annexure-F

*As per GoI guideline

46

Annexure-G

List of Equipment/Furniture required for PMR Department*1. Wards (Special requirements):

Paraplegia beds-steel plate base with 3 components - 10

Dunlop mattress- 10cm thick - 10

Bedside tables - 10

Trolleys - 02

Water mattresses - 10

Tricycles (2-hand operated, 2 motorized) - 04

Wheel chairs - 10

Adjustable dining/reading tables - 05

Pillows-6 per bed - 60

Quantity

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

One

2. Physiotherapy

Exercise Therapy

Sl No.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

Physiotherapy Equipment

Electrotherapy

Short wave diathermy

Ultrasound

Muscle stimulator

TENS

Traction-Lumbar & CervicalWax therapy

LASERInterferential therapy

Infra-Red Lamp (IRL)

CPM Apparatus (Continuous Passive Motion)

Shoulder wheelShoulder pulley bracket-wall mounting

Shoulder abduction ladder

Wrist circumductor

Wall barGrip exercise with six springs

Weight cuffs (1/2-3kgs)

Parallel bar

Dumbells ironMedicine ball (1kg, 2kg, 3kg, 5kg)

Quadriceps table

Contd....*As per GoI guideline

47

3. Equipments Required for Occupational Therapy:

4. Specialized requirements:

Gait and urodynamic laboratory

oneoneoneoneoneoneone

Optional

twotwotwotwo

Optionaltwotwotwo

twotwotwo

Sl. No.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Occupational therapy equipments

Bed with mattress-double bed with pillows

Mirror (adjustable & per table)

Cogni toys

Finger ladder

U.E. sling

Shoulder wheelSuspension U.E

Supra board

Nuts & bolts boardHand exercise tableStool with casterBolsters big

U.E. cycle

Sanding boards bilateral & reciprocal

Coordination pig board with adjustable height

Post office box

Quantity

Two

One

One set

One

One

One

One

One

One

Two

One

One

One + One

One

One

One

2324252627282930

3132333435363738

394041

Treatment Equipments

Mobility Aids

Stair Case-Corner typeCouch for suspensionMulti exercise therapy unitAnkle and leg exerciseStatic cycleExercise matPostural training mirrorAnkle exerciser

Wheel chairWalker adultWalker pediatricProne crawlerWalking frame

Crutch foreamAluminum stick

Examination couch wooden (Foam padded)Tilt tableActivity mattress

Crutch axillary

48

VERBAL AUTOPSY SAMPLE QUESTIONNAIRE

for

AES/JE (AES Unknown & JE Confirm) DEATH CASE

To be filled up by members of the committee at the time of Verbal Autopsy

(To be used at all government health facilities)

Reporting Information

Date of Case Reported :................................ Notified by :......................................................................................................................................

Date of Case Investigated :............................ Investigated by :...............................................................................................................................

Patient Information

Patient's Name :............................................................................................... Sex :........... Date of Birth :................. Age-Years....... Months........

Father's Name :.................................................................................................................................. Religion- Muslim/Hindu/ Other :....................

Address :......................................................................................................... Village/Mohallah :............................. Landmark :.............................

Block/Urban Area :........................................... District :....................................... State :.......................... Mob.No. :..........................................

Travel History over Two weeks from Onset of First Symptoms

Date from: 1 ...................................................... 2 ...................................................... 3 .....................................................

Date to: 1 ...................................................... 2 ...................................................... 3 .....................................................

Address :......................................................................................................... Village/Mohallah :............................. Landmark :.............................

Block/Urban Area :............................................ District :....................................... State :........................ Mob.No. :...........................................

Immunization History :....................................... JE Immunization- Yes / No / Partial / Unknown Date of last JE Immunization :..............................

Signs and Symptoms

Date of onset of first symptoms :................................. Headache Yes/No/Unknown :..................... Change in mental status- Yes/No/Unknown

Paralysis Yes/No/Unknown :...................................... Fever Yes/No/ Unknown :............................ Unconsciousness- Yes / No / Unknown

Seizure- Yes / No / Unknown Neck rigidity- Yes / No / Unknown Date of death :.............................

C Probable cause of death :

C Were the drugs and equipments as per Standard Operating Procedure Module available in health facility at the time of visit of team? Please elaborate.

C Was the patient treated at the health facility as per Standard Operating Procedure guidelines ?If yes please give details.(Use extra sheet if need be)

C Final opinion of Verbal Autopsy Team:

(Name, Signature & Designation of members of the committee with date)

Note- The audit team will carry a copy of Standard Operating Procedure for reference on spot.

District level committee- Chairperson- Civil Surgeon of concerned district

Committee members- ACMO, DIO and District VBD Control Officer

Medical College level committee- Chairperson- Principal of concerned Medical College

Committee members- HoD of concerned Department & two Senior Medical Officers

Verbal Autopsy Committee Members

Annexure-H

The Verbal Autopsy Format & Standard Operating Procedure are available on Health Deptt. GoB web portal as- www.health.bih.nic.in on its Operational Guidelines section.

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