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Group AMay be sent home Group BReferred for in-hospital care Group CRequire emergency treatmentGroup criteria

Patients who do not have warningsigns

ANDwho are able:

o To tolerate adequate volumes

of oral fluids

o To pass urine 3-4 times per day

Group criteria

Patients with any of t he following features:

o Existing warning signs OR o Co-existing conditions such aspregnancy, infancy, o ld age, diabetes

mellitus, renal failureo Social circumstances such as l iving

alone, living far from hospital

Group criteria

Patients with any of the following features.o Severe plasma leakage with shock and/or fluid

accumulation with respiratory distress

o Severe bleeding

o Severe organ impairment

Laboratory tests

o Full blood Count (FBC)o Haematocrit (Hct)

Laboratory tests

o Full blood Count (FBC)o Haematocrit (Hct)

Laboratory tests

o Full blood Count (FBC)o Haematocrit (Hct)

Treatment

Advice for:o Adequate bed rest

o Adequate fluid intake

o Paracetamol, 4 gram max. per

day

Patients with stable Hct can be sent

home

Treatment

o Obtain reference Hct before fluid therapyo Give isotonic solutions such as 0,95 saline, Ringer

lactate, start with 5-7 ml/kg/hr for 1-2 hours, then

reduce to 2-3 ml/kg/hr or less according to clinical

response

Reassess clinical status and repeat Hcto

If Hct remains the same or rises only minimally ->

continue with 2-3 ml/kg/hr for another 2 -4 hours

o If worsening of vital signs and rapidly rising Hct - >

increase rate to 5-10 ml/kg/hr for 1-2 hoursReassess clinical status, repeat Hct and review fluid

infusion rates accordingly

o Reduce i ntravenous fluids gradually when the rate

of plasma leakage decreases towards the end of thecritical phase.

This is indicated by:

o Adequate urine output and/or fluid intake

o Hct deceases below the baseline value in a stablepatient

Treatment

o Encouragement for oral fluidso If not tolerated, start intravenous

fluid therapy 0,9% saline or

Ringer Lactate at maintenance rate

Treatment of shock:

o Start intravenous fluid resuscitation with isotoniccrystalloid solutions at 5-10 ml/kg/hr

o Reassess patients s condition,

If patient improves:

o Intravenous fluids should be reduced gradually to 3-

5 ml/kg/hr, then to 2 -3 ml/kg/hr and then dependingon haemodynamic status

o Can be maintained for up to 24 - 48 hours

If patient still unstable:

o Check Hct after first boluso If Hct increases/ still high (>50%), repeat a second

bolus of crystalloid solution at 10-20 ml/kg/hr.

o If improvement after second bolus, reduce rate to 7-

10 ml/kg/hr, continue to reduce as aboveo If Hct decreases, this indicates bleeding and n eed to

cross-match and transfuse blood as soon as possible

Treatment of hypotensive shock

Monitoring

o Daily review for warning signs

(until out of critical period)

o Advice for immediate return tohospital if development of any

warning signs

o Written advice of management

(e.g. home card for dengue)

Monitoring

o Vital signs and peripheral perfusion (1-4 hourly

until patient is out of critical phase

o Urine output (4-6 hourly)o Hct (before and after fluid replacement, then 6-12

hourly)

o Blood glucose ( before f luid replacement and repeat

as indicatedo Other organ functions (renale profile, liver profile,

coagulation profile, before fluid replacement and as

indicated)

Monitoring

o Temperature pattern

o Volume of fluid intake and losses

o Urine output volume andfrequency

o Warning signs

o Hct, white blood cell and platelet

counts

o Initiate IV fluid resuscitation with crystalloid or

colloid solution at 20 ml/kg as a bolus for 15 min

If patient improves

o Give a crystalloid / c olloid solution of 10 ml/kg/hr,them reduce gradually

If patient still unstable

o Check Hct after the first bolus

o

If Hct increases/ still h igh (>50%), change IV fluidsto colloid solutions at 10 ml/kg/hr, then reduce to 7-

10 ml/kg/h, then change back to crystalloid solution

and reduce rate as above

o If HCT decreases, this indicates bleeding, see a bove

Treatment of haemorrhagic complications:

o Give 5-10 ml/kg of fresh packed red cells or 10-20

ml/kg of fresh whole blood

Dengue Case Management

Classification

Assessment

Presumptive Diagnosis:

Neighbourhood dengue/travel to endemic area plus

Fever and two of the following: Anorexia and nausea Rash Aches and pains +/- warning signs Leucopenia

Tourniquet test +/-

Warning signs: Abdominal pain or tenderness

Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy; restlessness Liver enlargement >2cm Laboratory: Increase in HCT concurrent with rapiddecrease of platelet count

negative positive

Co-existing conditionsSocial circumstances

negative

positive

Dengue withoutwarning signs

Dengue withwarning signs

Severe Dengue

Management

Lab.confirmed dengue(important when no signof plasma leakage)

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Dengue case classification by severity

Without

with

warningsigns

1.Severe plasma

leakage

2.Severehaemorrhage

3.Severe organimpairment

Severe dengueDengue warningsigns

Probable dengue

Live in/travel todengue endemicarea. Fever and 2 ofthe following criteria:

Nausea, vomiting Rash

Aches and pains Tourniquet testpositive Leucopenia

Any warning signLaboratoryconfirmed dengue(important when no sign of

plasma leakage)

Warning signs*

Abdominal pain ortenderness Persistent vomiting Clinical fluid

accumulation Mucosal bleed

Lethargy;restlessness Liver enlargement>2cm

Laboratory:

Increase in HCTconcurrent with rapiddecrease in plateletcount

* Requiring strict observationand medical intervention

1. Severe plasma

leakage leading to: Shock (DSS) Fluid accumulationwith

respiratory distress

2. Severe bleedingas evaluated by

clinician

3. Severe organinvolvement

Liver: AST orALT>=1000 CNS: Impaired

consciousness Heart and other

organs

Criteria for dengue warning signs Criteria for severe dengue

WHO/TDR200

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