ADULT DENGUE INFECTION 1ST ENCOUNTER: IDENTIFICATION, RISK STRATIFICATION

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ADULT DENGUE INFECTION 1ST ENCOUNTER
IDENTIFICATION, RISK STRATIFICATION MANAGEMENT

• Dr Ho Bee Kiau
• / Dr Faizal Salikin

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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

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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

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STEP 1 - OVERALL ASSESSMENT

• 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

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WARNING SIGNS

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

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STEP 1 - OVERALL ASSESSMENT

• 2. Physical examination
• i. Assess mental state GCS
• ii. Assess hydration
• iii. Assess haemodynamic
• Skin colour
• Cold/ warm extremities
• Capillary filling time (normal lt 2 sec)
• Pulse rate pulse volume
• BP pulse pressure

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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)

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TOURNIQUET TEST

• 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 (lt 3 days)
  esp. when the platelet count is still normal

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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 gt40 in female adults and gt46 in male
  adults should raise the suspicion of plasma
  leakage

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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)

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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

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DIFFERENTIAL DIAGNOSES DURING FEBRILE PHASE
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DIFFERENTIAL DIAGNOSES DURING CRITICAL PHASE
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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

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STEP 3 PLAN OF MANAGEMENT

• Notify the district health office via phone
  followed by disease notification form
• To determine whether the patient requires
  admission

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IF ADMISSION NOT INDICATED WHAT NEXT?

• Daily or more frequent f/u from day 3 of illness
  until afebrile for at least 2448 hours
• Provide Dengue monitoring record Home Care
  Advice Leaflet
• Advise patient to return to hospital as soon as
  the warning signs arise

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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 !

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HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS
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CRITERIA FOR HOSPITAL REFERRAL / ADMISSION

• 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

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CONSIDER EARLY ADMISSION

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

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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 patients 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

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COMMON ERRORS AT OPD AE 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 Hesss test

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Common Errors at OPD AE 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)