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Diarrhoea Case II
2.
3. 4. 5. 6. 7.
Differential diagnoses
Main diagnosis
Triage
Emergency signs (Ref. p. 2,6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns
Emergency treatment
Airway management? Oxygen? Intravenous fluids? Anticonvulsants?
Immediate investigations?
Emergency treatment
How do you treat signs of shock?
Give IV fluids (Ref. Chart 7, p. 13)
Insert an IV line (and draw blood for immediate investigations such as: haemoglobin, blood sugar) Attach Ringer's lactate or normal saline (0.9% NaCl) make sure the infusion is running well Infuse 20ml/kg as rapidly as possible Reassess child after appropriate volume has run in Do not use 5% Glucose alone or solutions containing only 0.18% NaCl
Femoral venous access (Ref. p. 342) Intraosseus needle, if not available use 19 or 21 G needle
History
Chandra had been well 5 days ago, but then he began to have loose watery stools 6-8 times a day. His mother reduced his intake of fluids and feed as he was having diarrhoea and she thought this might make this worse. On the second day he was taken to a local medical shop where he received a syrupy medicine and a packet of oral rehydration solution.
His diarrhoea did not improve, still 6-8 times each day. He started vomiting on the third day. He was then taken to the district hospital, as he had become lethargic and had stopped eating and drinking altogether. There was no blood or pus in the diarrhoeal stool.
Severe dehydration
Two or more of the following signs: lethargy/unconsciousness sunken eyes unable to drink or drinking poorly skin pinch goes back very slowly (>2 seconds) Two or more of the following signs: restlessness, irritability sunken eyes drinks eagerly, thirsty skin pinch goes back slowly
Some dehydration
No dehydration
(Ref. p. 128)
(Ref. p. 127)
Differential diagnoses
List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm (Ref. p. 127)
Local reports of cholera outbreak Recent antibiotic or other drug treatment Attacks of crying with pallor in an infant
Diagnosis
Summary of findings: Examination: lethargy, sunken eyes, decreased skin tugor, unable to drink History: 4 day of profuse diarrhoea and vomiting everything for 2 days.
Acute diarrhoea with severe dehydration
Treatment
Diarrhoea treatment Plan C (Ref. Chart 13, p. 131)
Antibiotic treatment is rarely necessary (Ref. p. 126)
Only for: Dysentery (mostly Shigella) Cholera Neonates with diarrhoea and fever
Antidiarrhoeal agents Never necessary and often harmful
Supportive Care
All children should start to receive some ORS (about 5ml/kh/hour) by cup when they can drink without difficulty If the child is normally breastfed, encourage the mother to continue breastfeeding frequently When severe dehydration is corrected, prescribe zinc
Monitoring
Reassess every 15-30 minutes until strong radial pulse is present (Ref. Chart 13 p. 131) Reassess skin pinch, capillary refill, consciousness, ability to drink - hourly If signs of severe dehydration are still present, repeat IV fluid infusion as outlined earlier If the child is improving but still shows signs of some dehydration, discontinue IV treatment and give ORS for 4 hours (Treatment Plan B) If there are no signs of dehydration, follow Treatment Plan A
Summary
Chandra was rehydrated with intravenous fluids followed by oral rehydration solution. He was discharged when he was alert, able to drink and eat, and had less frequent episodes of diarrhoea.
At the time of discharge his mother was given advice on how to give extra fluid, to continue feeding and to return for follow up.
She was also given a Mothers card containing this information and two packets of oral rehydration solution.