Chapter 5 Diarrhoea Case II

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Chapter 5DiarrhoeaCase II
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Case study Chandra
Chandra, 2 year old presented from health clinic
with 4 day history of profuse diarrhoea. Vomiting
everything for 2 days. Lethargic and not able to
drink for 1 day.
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• What are the stages in the management of any sick
  child?

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Stages in the management of a sick child (Ref.
Chart 1, p. xxii)

• Triage
• Emergency treatment
• History and examination
• Laboratory investigations, if required
• Main diagnosis and other diagnoses
• Treatment
• Supportive care
• Monitoring
• Discharge planning
• Follow-up

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What emergency and priority signs have you
noticed?
Temperature 37.2C, pulse 145/min, weak and
thready, RR 50/ min, capillary refill time 3-4
seconds mouth dry mucus membranes eyes
sunken, dry, no tears skin pinch goes back very
slowly
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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

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What emergency treatment does Chandra need?
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Emergency treatment

• Airway management?
• Oxygen?
• Intravenous fluids?
• Anticonvulsants?
• Immediate investigations?

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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

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If peripheral vein access cant be obtained
Intraosseus (Ref. p. 340)
Femoral venous access (Ref. p. 342)
Intraosseus needle, if not available use 19 or 21
G needle
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Emergency treatment (continued)

• Reassess after the first infusion of 20ml/kg
  (Ref. Chart 7, p. 13)
• If no improvement, repeat 20ml/kg as rapidly as
  possible
• Reassess the child after second infusion
• If no improvement, repeat 20ml/kg as rapidly as
  possible
• ?After the second reassess Chandra's pulse became
  slower and his capillary refill faster

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Emergency treatment (continued)

• Switch to following treatment if child's pulse
  becomes
• slower or the capillary refill faster (Ref. Chart
  11, p. 17)
• Give 70ml/kg Ringer's lactate solution (or normal
  saline) over 2,5 hours
• Total volume for Chandra 850ml (340ml/h)
• Reassess the child every 1-2 hours
• Give ORS as soon as the child can drink
• Reassess the child after 3 hours and classify
  dehydration

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• Give emergency treatment until the patient is
  stable

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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.
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Examination after stabilisation
Chandra was ill-looking and floppy. He was still
unable to drink. Vital signs temperature
37.2C, pulse 120/min, RR 40/min Weight 11
kg Capillary refill time 2 seconds Mouth dry
mucus membranes Eyes still sunken, dry, no
tears Skin decreased skin turgor (skin pinch
goes back in 3 seconds) Chest air entry was good
bilaterally and there were no added
sounds Abdomen scaphoid, soft, bowel sounds were
active and there was no organomegaly Neurology
lethargic, floppy, there was no neck stiffness
and no other focal signs
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Classification of the severity of dehydration in
children with diarrhoea

• Rapid assessment of hydration status and
  classification of severity of dehydration in
  children with diarrhoea

Classification Signs or symptoms
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 (gt2 seconds)
Some dehydration Two or more of the following signs restlessness, irritability sunken eyes drinks eagerly, thirsty skin pinch goes back slowly
No dehydration Not enough signs to classify as some or severe dehydration
(Ref. Table 12, p. 128)
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Poor skin turgor
(Ref. p. 128)
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(Ref. p. 127)
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Differential diagnoses

• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p. 127)

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Differential diagnoses (continued)

• Acute (watery) diarrhoea
• Cholera
• Dysentery
• Persistent diarrhoea
• Diarrhoea with severe malnutrition
• Diarrhoea associated with recent antibiotic use
• Intussusception

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Additional questions on history

• Diarrhoea
• frequency of stools
• number of days
• blood in stools
• Local reports of cholera outbreak
• Recent antibiotic or other drug treatment
• Attacks of crying with pallor in an infant

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Further examination based on differential
diagnoses

• Look for
• Blood in stool
• Severe malnutrition
• Abdominal mass
• Abdominal distension

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What investigations would you like to do to make
your diagnosis ?
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At this stage no additional investigations are
necessary
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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

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How would you treat Chandra after stabilisation?
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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

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What supportive care and monitoring are required?
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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

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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

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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.