Download - 8951863 Acute Gastroenteritis

8/2/2019 8951863 Acute Gastroenteritis

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by

Harold Rugnao

DIARRHEA


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ESSENTIAL CONCEPTS OF DIARRHEA DIARRHEA

passage of unusually loose or watery stools, at least 3x ina 24 hr period

CLINICAL TYPES OF DIARRHEA

Acute watery diarrhea

Acute bloody diarrhea

Persistent diarrhea Diarrhea with severe malnutrition


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ESSENTIAL CONCEPTS OF DIARRHEA Dehydration

Deficit of water and electrolyte

Malnutrition Zinc Deficiency

Use of antimicrobials and anti-diarrheal drugs


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Important Microbial Causes of Acute Diarrhea

in Infants and Children Rotavirus

Escherichia Coli

Enterotoxigenic

Localized adherent

Diffuse Adherent

Enteroinvasive

Enterohemorrhagic

Shigella

Campylobacter jejuni

Vibrio cholerae 01 and0139

Salmonella

Giardia duodenalis

Entamoeba histolytica

Cryptosporidium


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ASSESSMENT OF CHILD WITH DIARRHEA1. History

2. Physical Exam

3. Determine Degree of Dehydration and selecttreatment plan

4. Diagnose other important problems


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ASSESSMENT OF DIARRHEA PATIENTS FOR

DEHYDRATION

A B C

LOOK AT: CONDITION

EYES

THIRST

Well, alert

Normal

Drinksnormally, notthirsty

Restless, irritable

Sunken

Drinks eagerly,thirsty

Lethargic orunconscious

Sunken

Drinks Poorly or not

able to drink

FEEL: SKIN PINCH Goes backquickly

goes back slowly goes back very slowly

DECIDE NO SIGNS

OFDEHYDRA-TION

SOME SIGNS OF

DEHYDRATION

SEVERE SIGNS OF

DEHYDRATION

TREAT Usetreatment

plan A

Weigh the patient,use Treatment

Plan B

Weigh the patient, useTreatment Plan C

URGENTLY


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ESTIMATED FLUID DEFICIT

Assessment Fluid deficit as%of body wt

Fluid deficit inml/kg body wt

No signs of

dehydration

10% >100 ml/kg


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Management of Acute Diarrhea (without

blood) Objectives:

Prevent dehydration, if there are no signs of dehydration

Treat dehydration, when it is present Prevent nutritional damage

Reduce the duration and severity of diarrhea and theoccurrence of future episodes


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Plan A

Treat Diarrhea at Home1. GIVE EXTRA FLUID TELL THE MOTHER

Breastfeed frequently and for longer at each feed

If the child is exclusively breastfed, give ORS or clean waterin addition to breastmilk

If the child is not exclusively breastfed give one or more ofthe following: ORS, food base fluids, or clean water

TEACH THE MOTHER HOW TO MIX ORS

Home made solution: 3g/l of table salt (one level tspful)and 18g/l of common sugar


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SHOW THE MOTHER HOW MUCH FLUID TO GIVE INADDITION TO THE USUAL FLUID INTAKE

Up to 2 years 50 to 100ml after each loose

stool

2 years or more 100 to 200 ml after each loose

stool

Oldre children as much fluid as they want

Tell the mother to

give frequent small sips from a cup

If the child vomits, wait 10 mins. Then continue, but more slowly

Continue giving extra fluid until the diarrhea stops


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2. GIVE SUPPLEMENTAL ZINC- 10 20mg to the child everyday for 10 14 days

3. CONTINUE FEEDING- To prevent malnutrition

4. TAKE THE CHILD TO A HEALTH WORKER IF

THERE ARE SIGNS OF DEHYDRATION OROTHER PROBLEMS- Starts to pass many watery stools- Repeated vomiting- Becomes very thirsty

- Eating or drinking poorly- Develops fever- Blood in the stool- Child does not get better in 3 days


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Plan B

Treat Some Dehydration with ORSGive in clinic recommended amount of ORS over 4-hour period

DETERMINE AMOUNT OF ORS TO GIVE

DURING FIRST 4 HOURS*AGE Up to 4 mos 4 mos up to

12 mos12 mos to 2yrs

2 yrs to 5yrs

WT < 6 kg 6 < 10 kg 10


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AMOUNT OF ORS TO GIVE DURING FIRST 4HOURS

*AGE Up to 4mos

4 mos upto 11mos

12 mosto 23mos

2 yrs to 4yrs

5 14yrs

15 yrs orolder

WT < 5 kg 5 7.9kg

8 10.9kg

11 15.9kg

16 29.9kg

30 kg ormore

In ml 200

400

400

700

700

900

900

1400

1200

2200

2200

4000


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*Use the childs age only when you do not know the weight. Theapproximate amount of ORS required (in ml) can also becalculated by multiplying the childs weight (in kg) times 75

for infants under 6 mos who are not breatfed, if using the oldWHO ORS solution containing 90mmol/L of sodium also give100-200ml clean water during this period. However if using thenew reduced (low) osmolarity ORS solution contining

75mmol/L of sodium, this is not necessary For infants under 6 mos who are not breastfed, also give 100

200 ml of clean water during this period

If the child wants more ORS than shown, give more

Note: during initial stages of therapy, while still dehydratedadults can consume upto 750ml/hr if necessagry, children up to20ml/kg/hr


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SHOW THE MOTHER HOW TO GIVE ORSSOLUTION

AFTER 4 HOURS

Reassess the child and classify the child for dehydration

Select the appropriate plan

Begin feeding the child

MEET NORMAL FLUID NEEDS


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IF THE MOTHER MUST LEAVE BEFORECOMPLETING TREATMENT

Show her how to prepare ORS Show her how much ORS to give to finish the 4-hour

treatment at home

Give her enough ORS packets to complete hydration

Explain the 3 rules of HOME TREATMENT1. Give extra fluid

2. Continue feeding

3. When to return


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WHEN ORAL REHYDRATION FAILS

Continuing rapid stool loss (>1520 ml/kg/hr)

Insufficient intake of ORS owing to fatigue or lethargy Frequent, severe vomiting

GIVING ZINC

GIVING FOOD


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Treatment Plan C for patients with severe

dehydration1. GUIDELINES FOR INTRAVENOUSREHYDRATION

Give 100ml/kg Ringers Lactate Solutiona divided asfollows:

Age First give 30ml/kg in: Then give 70ml/kg in:

Infants (under12 months)

1 hourb 5 hours

Older 30 minutesb

2 hoursReassess the patient every 1 2 hrs. If hydration is not improving, give the IV dripmore rapidlyAfter 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessmentchart. Then choose the appropriate Treatment Plana

if Ringers Lactate Solution is not available, nomal saline may be usedb Repeat once if radial pulse is still very weak or not detectable


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2. MONITOR THE PROGRESS OF INTRAVENOUSREHYDRATION

3. ELECTROLYTE DISTURBANCES Hypernatremia

Serum Na > 150mmol/L

Can cause convulsions

Hyponatremia Serum Na < 130mmol/L

Lethargy, less often, seizures

Hypokalemia

Serum K+


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Management of Suspected

Cholera Cholera differs from acute diarrhea of other causes in 3ways: It occurs in large epidemics that involve both children

and adults

Voluminous watery diarrhea may occur, leading rapidlyto sever dehydration with hypovolemic shock

For cases with sever dehydration appropriate antibioticsmay shorten the duration of the illness

Antimicrobial Therapy


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Management of Acute Bloody Diarrhea

(Dysentery) Shigella is the most common cause of bloody diarrhea

Ciprofloxacin for 3 days


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Out Patient Management of Bloody Diarrhea

CHILD WITH LOOSE STOOLSWITH BLOOD

SEVERELY MALNOURISHED?

GIVE ANTIMICROBIAL FORSHIGELLA

BETTER IN 2 DAYS?

No

No

REFER TO

HOSPITALYes

COMPLETE 3DAYSTREATMENTYes


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INITIALLY DEHYDRATEDAGE< 1Y/O OR MEASLES

IN PAST 6 WEEKS

CHANGE TO SECONDANTIMICROBIAL FORSHIGELLA b

BETTER IN 2 DAYS?

No

COMPLETE 3DAYS

TREATMENTYes

REFER TOHOSPITALYes

REFER TO HOSPITAL ORTREAT FOR AMOEBIASIS


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Management of Persistent

Diarrhea Persistent Diarrhea Diarrhea, with or without blood, that begins acutely and lasts at

leat 14 days.

Usually associated with weight loss, and often, with seriousnon-intestinal infections

Objective of treatment is to restore weight gain and

normal intestinal function by: Appropriate fluids to prevent or treat dehydration

A nutritious diet that does not cause diarrhea to worsen

Supplementaryvitamins and minerals

Antimicrobials to treat diagnosed infections


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Treat in the Hospital:

Children with serious systemic infection

Children with signs of dehydration

Infants below 4 months of age

Prevent or treat dehydration

Identify and treat specific infections

Give a nutritious diet

Give supplementary multivitamins and minerals

Monitor response to treatment


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Management of Diarrhea with Severe

MalnutritionAssess for Dehydration

Manage Dehydration

Feeding Use of antimicrobials


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Prevention of Diarrhea Breastfeeding

Improved feeding practices

Use of safe water Handwashing

Food safety

Use of latrines and safe disposal of stools

Measles immunization


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