EMERGENCY

PEDIATRIC

PICU Subdiv. Child Health Dept

Medical Faculty, University of Hasanuddin
Dr. Wahidin Sudirohusodo Hospital Makassar

DEHYDRATION
Causes :
1. Decrease water input (anorexia)
2. Increase water output:
a.
Excesssive water losses (hyperhidrosis)
b. Excessive renal losses cause by diuretic osmotic (Diabetic
Insipidus)
c.
Excess sodium losses (diuretic, adreno-cortical insufficiency)
d. Fluid translocation (burn, ascites, pleural effusion, dengue
fever)
e.
Losses of GIT (diarrhoea, vomiting, fistula)

DENGUE SHOCK
SYNDROME

ETIOLOGY

Dengue Virus (Den 1,Den 2, Den 3, Den 4)

PATHOGENESIS
Unclear
1.The Secondary Heterologous
Infection Hypothesis
2.Virulence viral theory

PATHOPHYSIOLOGY
1. Vascular damage
2.Plasma leakage
3.Diatesis haemorrhagic

DIAGNOSE
WHO ( 2 clinical symptoms + 2 laboratory)
Clinical symptom :

Fever : acute, high, continuously, 2-7 days

Bleeding manifestation

Liver enlargement

Shock

LABORATORY

Decrease platelet count (< 100.000/mm3)

Hemoconcentration (Ht acute-conv) > 20%

Ht conv

CLASSIFICATION
WHO CLASSIFICATION OF DHF (1975)

Grade I : fever, Tourniquet test (+)

Grade II : Grade I + spontaneous bleeding
Grade III : Grade II + Circulatory failure
(pulse pressure 20 mmHg, syst pressure 80
mmHg)
Grade IV : Profound shock (blood pressure
unmeasurable, pulse rate unpalpable)

Grade III & IV Dengue Shock Synd

MONITORING

Vital signs
Hematocryte , platelet count,
Haemoglobin

TREATMENT
GR. IV

GR. III

DENGUE FEVER GRADE III & IV

1.
2.

Oxygen 2-4 l/min

Bolus RA,RL,NaCl 0,9% 100-200 ml

Oxygen, Fluid replacement (isotonic cristaloid)

RL, RA, NaCl 0,9% 20 ml/kgbw/hour ( 1 hour)

Shock (-)
Councious
Pulse pressure > 20 mmHg
No dyspneu, cyanotic
Warm extremity
Vol. urine 1 ml/kgbw/h

Evaluate
Vital sign/15 min
Fluid Balance

Unconcious
Pulseless
Shock (+)
Pulse pressure 20mmHg
Resp distress/cyanotic
Cold extremity
Check blood glucose Fluid continue 20 cc/bw/h

Add colloid/plasma (Dextran/FFP)

10-20 (max 30) ccbw/h
Corrected acidosis
Evaluate 1 hour

RL/RA 10 ml/kgbw/hour (4-6 h)

Close monitoring
Vital sign,bleeding
Diuresis,Hb,Ht,platelet count

Shock (+)
Ht decrease

RL/RA 5 ml/kgbw/hour
Stabil condition in 24 h/Ht <40%

RL/RA 3 ml/bw/hour
IVFD stop

Ht increase

Shock (-)

Blood transfusion
10 cc/bw

Colloid 20 cc/bw/h

DIARRHEA WITH
DEHIDRATION

DEFINITION
Watery stool
Frequency 3X/ 24
hours.

PENYEBAB
1.
2.

3.

Viral >>> (rotavirus)

Bacteria : E.Coli, Shigella, salmonella, vibrio
cholera, campylobacter jejuni
Protozoa : amoebiasis, giardiasis

DEHYDRATION TYPES

Isotonic
Na+ concentration 130-150meq/L or 280
mosm/L
Hypertonic:
Na+ concentration > 150meq/L or 413
mosm/L
Hypotonic:
Na+ concentration <130meq/L or
200mosm/L

DEHYDRATION GRADE
1. Cumulative losses (pwl, cwl, nwl)
Mild : 5%
Moderate : 5-10%
Severe : >10%

2.Clinical manifestation ( scoring system)

Scoring
Examination

Good
Normal
Normal
20-30/min
Good
<120 / min

Fatigue/thirsty
Sunken
Dry
30-40/min
Return slowly
120-140/min

irritable/shock
Very sunken
Very dry
40-60/min
Very slowly
>140/min

score 6
Diarrhea without
dehydration

score 7-12
Diarrhea with
mild/moderate
dehydration

score 13
Diarrhea with
severe
dehydration

Clinical
manifestation
General condition
Eyes
Mouth
Respiratory
Skin pinch
Pulse rate
Dehydration grade

No dehydration (<5%BW)

Mild-Moderate
Dehydration (5-10% BW)

Severe Dehydration
(>10% BW)

Condition: good
Vital sign normal
No sunken fontanella, no
sunken eye, tear still
present, no dry mouth and
tongue
Skin turgor normal,
normal bowel movement
Warm extremity
Possible for homecare ,
except there are
complication (poor
drinking, frequent
vomiting or diarrhoe)

There are 2 major sign +

two/more additional sign
Condition: irritable/
restless
Fontanella a little sunken,
eye slightly sunken, Less
tear drop, mouth and
tongue a little dry
Skin turgor slightly
decrease
Warm extremity
Must hospitalized

There are 2 major sign +

two/more additional sign
Condtion: weak, letargi,
or comatous
Fontanella very shunken,
eye very shunken, no tear,
mouth and tongue very
dry
Skin turgor very decrease
Cold extremity
Must hospitalized

TREATMENT

Rehidration (Ringer Lactat or

Ringer Asetat)

Diitetic ( continue breastfeeding)

Zinc supplementation ( < 6
months:10 mg/day (1/2 tab), > 6
months : 20 mg/day (1 tab).

Give

10-14 days

Education
Antibiotic therapy bacterial infect

REHADRATION
Age
Diarrhoea
Infantile
- PWL 125 ml
- NWL 100 ml
- CWL 25 ml
250 ml
Cholera
PWL 100 ml/kg
PWL 100 ml/kg
WHO :
Baby < 12 months
Children 12 months

Administration of IV fluid
Initial

Maintanance

First 4 hours
60 ml/kg

Next 20 jam
190 ml/kg

First 1 hour
30 ml/kg

Next 7 hours
70 ml/kg

First 1 hour
30 ml/kg
First hour
30 ml/kg

Next 5 hours
70 ml/kg
Next 2 hours
70 ml/kg

IVFD :
2 years
: Asering/R. asetat 24 hours system
4 first hours : 5 drops/kgbw/minute
20 second hours : 3 drops/kgbw/minute
> 2 tahun
: Ringers lactat 8 hours system
1 first hour : 10 drops/kgbw/minute
7 second hours : 3 drops/kgbw/minute

Also give ORS (about 5 ml/kg/hour) as soon as the child can

drink; usually after 3-4 hours (infant) or 1-2hours (children)

If the IV line not available or cant be insert, start rehydration

by tube with ORS: 20 ml/kg/hour for 6 hour

Education : 4 rules of home treatment

1.

Give extra fluid (breast feeding or ORS)

2.

Give zinc supplementation

3.

Continue feeding

4.

When to return