ADULT DENGUE INFECTION 1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION & MANAGEMENT

1. ADULT DENGUE INFECTION1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION & MANAGEMENT Dr Ho Bee Kiau / Dr Faizal Salikin

2. OBJECTIVES: TO IDENTIFY AND MANAGE DENGUE INFECTION AT 1ST ENCOUNTER • Outpatient management & monitoring • Stepwise approach • Diagnostic challenges • Triaging at ED & OPD • Indication for referrals / admission

3. OUTPATIENT MANAGEMENT & MONITORING • Symptomatic and supportive • Should be assessed with stepwise approach • Focus of management - 3 phases of the clinical course • Frequent monitoring to recognise plasma leakage and shock early • Dengue monitoring record as an outpatient monitoring tool • Refer if no immediate HCT facilities

4. 1.History • Onset of fever • Oral intake Diarrhoea • Urine output Assess for warning signs Other important history: a. Neighbourhood history of dengue b. Travelling/ jungle trekking/ swimming in waterfall d. Recent unprotected sex or IVDU e. Co-morbidities STEP 1 - OVERALL ASSESSMENT

5. WARNING SIGNS • Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation (pleural effusion, ascites) • Mucosal bleed • Restlessness or lethargy • Liver enlargement > 2 cm • Laboratory : Increase in HCT with rapid decrease in platelet

6. 2. Physical examination i. Assess mental state & GCS ii. Assess hydration iii. Assess haemodynamic • Skin colour • Cold/ warm extremities • Capillary filling time (normal < 2 sec) • Pulse rate & pulse volume • BP & pulse pressure STEP 1 - OVERALL ASSESSMENT

7. STEP 1 - OVERALL ASSESSMENT 2. Physical examination iv. Look out for tachypnoea/ acidotic breathing/ pleural effusion v. Check for abdominal tenderness/ hepatomegaly/ ascites vi.Examine for bleeding manifestation vii.Tourniquet test (repeat if previously negative)

8. How to perform? Inflate the BP cuff on the upper arm to a point midway between the SBP & DBP for 5 min. A positive test : ≥20 petechiae per 6.25 cm2 (1 inch2) Note: Helpful in the early febrile phase (< 3 days) esp. when the platelet count is still normal TOURNIQUET TEST

9. STEP 1 - OVERALL ASSESSMENT 3. Investigation i. Serial FBC and HCT ii. Dengue serology • Leucopaenia followed by progressive thrombocytopaenia (dengue infection) • Rising HCT accompanying progressive thrombocytopaenia (DHF) • In the absence of a baseline HCT level, a HCT value of >40% in female adults and >46% in male adults should raise the suspicion of plasma leakage

10. STEP 2: DIAGNOSIS, DISEASE STAGING AND SEVERITY ASSESSMENT a) Dengue diagnosis (provisional) b) The phase of dengue illness (febrile/critical/recovery) c) The hydration and haemodynamic status (in shock or not) d) If admission indicated (triage)

11. DIAGNOSTIC CHALLENGES • Clinical features of dengue infection are rather non-specific and can mimic many other diseases • A high index of suspicion and appropriate history taking (e.g. dengue hotspots) are useful • May have co-infection • Syndromic approach - helpful

12. DIFFERENTIAL DIAGNOSES DURING FEBRILE PHASE

13. DIFFERENTIAL DIAGNOSES DURING CRITICAL PHASE

14. TRIAGING AT ED & OPD • To determine whether urgent attention required • Look out for warning signs of shock • Triage Checklist 1. History of fever 2. Abdominal Pain 3. Vomiting 4. Dizziness/ fainting 5. Bleeding • Vital parameters to be taken: • Mental state, BP, pulse, temp., cold or warm peripheries

15. STEP 3: PLAN OF MANAGEMENT • Notify the district health office via phone followed by disease notification form • To determine whether the patient requires admission

16. IF ADMISSION NOT INDICATED WHAT NEXT? • Daily or more frequent f/u from day 3 of illness until afebrile for at least 24–48 hours • Provide Dengue monitoring record & Home Care Advice Leaflet • Advise patient to return to hospital as soon as the warning signsarise

18. HOME CARE ADVICE LEAFLET • Encourage adequate intake of fluids • eg: fruit juice/barley water/isotonic drink/milk • Ensure patient pass urine every 4-6 hours • PCM/ tepid sponging for fever • Avoid NSAIDs !

19. HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS

20. Symptoms: 1. Warning signs 2. Bleeding manifestations 3. Inability to tolerate oral fluids 4. Reduced urine output 5. Seizure Signs: 1. Dehydration 2. Shock 3. Bleeding 4. Any organ failure CRITERIA FOR HOSPITAL REFERRAL / ADMISSION

21. CONSIDER EARLY ADMISSION • Co-morbidity e.g. DM, HPT, IHD, • Coagulopathies, Morbid Obesity, Renal • failure, Chronic Liver disease, COPD • Elderly > 65 • Pregnancy • Social factors: living far, living alone etc • Lab. criteria • Rising HCT with reducing platelet count

22. REFERRAL FROM HOSP. WITHOUT SPECIALIST TO HOSP. WITH SPECIALISTS • Early consultation with the nearest physician for ALL DHF or DF with organ dysfunction/ bleeding Prerequisites for transfer • Optimise the patient’s condition before & during transfer • The ED/ Medical Department of the receiving hospital must be informed • Adequate information to be sent together e.g. fluid chart, monitoring chart & investigation results

23. COMMON ERRORS AT OPD & A&E DEPARTMENT (1) • Failure to recognise dengue infection in a febrile patient • In febrile phase, always have high index of suspicion in • febrile patients coming from dengue areas • patients with symptoms of dengue • patients with positive Hess’s test

24. Common Errors at OPD & A&E Department (2) • Failure to recognise dengue shock in an afebrile patient • In the afebrile patient, always have high index of suspicion for • Nausea, vomiting, abdominal pain & warning signs • Manifestations of compensated and decompensated shock • Changing HCT (rather than platelet count)