Ref. No.MS/DG/CRSF/10/87 To : All health wokers in Timoe-Leste : All multi and bilateral organization supporting the Ministry of Health Subject : Introduction to the East Timor Standart Treatment Guidelines Along with discussions to update the Essential Medecines List (EML) which was approved January 2010, we have now also been able to finalize the second edition of the Standart Treatment Guidelines (STGs). This time, STGs have been prepared both for Primary Care level and for referral hospitals. The first draft standard treatment guideline was prepared for Primary Care in 2002 and has been lying with us since then. Unfortunately, several subjects could not be finished in that edition, due to different opinions and frequent treatment changes. The first edition was compiled with the help of consultants, Dr. Rudiger Kilian (Clinical Pharmacist) and Dr. Ali Sallami (Pharmacologist) who compiled the first guideline Edition, from drafts prepared by the Ministry and/or by specialists in national programs such as IMCI, Malaria et cetera. The first draft edition of standard treatment guidelines have now been compared with the latest literature and evidence based medicine, and also adjusted to match existing diagnostic resources available in healthcare in Timor Leste. Updating and corrections of the first draft from 2002 has now been done with advice and assistance of Dr Sam Tornquist (Clinical Pharmacologist/infectious diseases). This revision has both used input from evidence based medicine and a thorough process of consensus-building through workshops with prescribers. This process has also created a mechanism for future revision of treatment guidelines in Timor Leste. Several anomalies have now been set straight and we are confident that the information now contained in this STG is up to date and also matching the reality in Timor Leste. A standart treatment guideline is not a fixed document for ever, since medical scientific knowledge changes over time. Still, once the STG have been formally approved and agreed, this is an important tool to ensure quality of care and good clinical practice. I therefore request that all clinicians, contributors and programs shall follow these guidelines. Future updates of Standard Treatment Guidelines will be organized and coordinated by the Ministry of Health to match important changes in international evidence based medicine. The next revision will be due in the next two years. SAMES has updated its catalog and adjusted the buying program in line with the new medecines. However, since the buying procedures are taking time, the new product might not arrive in country for some time yet. There is also considerable amount of money involved in the discontinued items. You are requested to use up these supplies before changing your prescribing habits to the new medecines. Your are also requested not to use suspensions and injections where those are not really required. Do not practice polypharmacy. I take this opportunity to thank all the contributors and the editors for their excellent work, and wish that the information in this book could guide your in your daily works of practicing medecines. CC : The Minister of Health of RDTL The Vice – Minister of Health of RDTL List of authors, clinical reviewers and referees: Baucau district referral hospital Family name Given name Specialty / position Dr Calvino Luis Ocana Orthopedics Dr Da Silva Nilton General Practitioner Dr De Rosa Abraham G General Practitioner Dr dos Santos Valentin Ob/Gyn Dr Estrada Delmis Doural Dermatology Dr Estrada Rene Oscare Dermatology Dr Gusmao dos Santos Celia A. Surgery Dr Hernandez Armando Anaesthetics Dr Laborde Barbara Ochra Paediatrics Dr Macaret Maria E Neonatology Dr Monsale Ancieto Internal Medicine Dr Mora Yaima General Practitioner Dr Murillo Rostico R. Ob/Gyn Dr Mwaura Phillip Surgery Dr Olivares Rene Luis E General surgery Dr Sanches M Angilberto Internal Medicine Dr Santana Jose Antonino Pediatric surgery Dr Sevilleno Edna Pediatric Dr Tornquist Sam Infectious diseases Mr Ferreira Delfim Pharmaceuticals Suai, Cova Lima district referral hospital Dr Cortez L Liodemis General Practitioner Dr De Carvalho Irene Hospital Director, General Practitioner Dr Fajarda Tamayo Annie YS General Practitioner Dr Magno Julia R.C. Clinical Director, General Practitioner Dr Perez Haritza Q Senior nurse Dr Pupo Paiper Imaelda Paediatrician Dr Rjaboshenko Oleksiy Obstetrics & Gynecol. Dr Tornquist Sam Infectious diseases Mr Ferreira Delfim Pharmaceuticals Maliana district referral hospital Dr Ajete Valdes Norgelis Mercedes Farmacology Dr Balenten Fournier Ernan Ob/Gyn Dr Cabriales Pedroso Yaneisy General Practitioner Dr Calderon Reynoso Irene Alicia Pediatrician Dr Cid Medina Lissette General Practitioner Dr Cuellar Prieto Dagoberto General Practitioner Dr Fernandez Muniz Adilia Otilia General Practitioner Dr Hernandez Suares Odalys Harina Radiologist Dr Pineda Chacon Roberto Internal medicine Dr Santana Santana Jose Antonio Surgery, Pediatrics Dr Tornquist Sam Infectious diseases and Clinical pharmacology Adviser to MOH * Dr Vittorino Bere Talo Hospital Director, General Practitioner Dr Zaldivar Reyes Jorge General Practitioner Mr Ferreira Delfim Pharmaceuticals Mobissi district referral hospital Dr Da Costa Dr.Horacio Sarmento General Practitioner Dr Pereira Gabriela da C.M General Practitioner Dr.Guitherez Francis Saison Ob/Gyn Dr.Uris Hernandez Ramirez MGI Dr.Feliz Alesandro Lafiilla del Tores MGI Dr.Custadia B. Florindo General Practitioner Dr.Gonzales Amaro Matilde Maza Pediatrician Dr. Raimundo Danilo Gyaecology Dr. Quiala Alberto Surgery Dr Tornquist Sam Infectious diseases and Clinical pharmacology Adviser to MOH * Dr. Hechararria Vidalina Internal medicine Dr. Ximenes Juliana Faria Internal medicine * Contact address to the Advisor in Clinical Pharmacology, E-mail, tornquists@gmail.com Table of Contents Acknowledgements 7 Introduction 7 Chapter 1 – National Program guidelines. 10 Chapter 2 – Reproductive Health 11 2.1 Antenatal care 11 2.1.1 Anaemia during pregnancy 12 2.1.2 Malaria in pregnancy 13 2.1.3 Hypertension in pregnancy 13 2.1.4 Pre-eclamptic toxaemia and Eclampsia 14 2.1.5 Diabetes in pregnancy 18 2.1.6 Infections in pregnancy 19 2.1.7 Immunisations during pregnancy 20 2.1.8 Nausea and vomiting in pregnancy 20 2.2 Delivery 21 2.2.1 Episiotomy 21 2.2.2 Retained placenta 21 2.3 Post delivery care 23 2.3.1 Postpartum haemorrhage 23 2.3.2 Puerperal Sepsis 25 2.4 Neonatal conjunctivitis (Ophthalmia neonatorum) 26 Chapter 3 – Pain control. 27 3.1 Pain control for adults 27 3.1.1 Mild pain in an adult 27 3.1.2 Moderate Pain in an adult 27 3.1.3 Severe pain in an adult 28 3.2 Pain control for children 29 3.2.1 Mild pain in a child 29 3.2.2 Moderate pain in a child 29 3.2.3 Severe pain in a child 30 Chapter 4 – Respiratory tract conditions 31 4.1 Common cold 31 4.2 Bronchitis 32 4.3 Pneumonia 33 4.4 Asthma 39 4.4.1 Acute severe (life-threatening) asthma episode 40 4.4.2 Asthma Maintenance therapy 43 Chapter 5 – Musculoskeletal conditions 46 5.1 Backpain 46 5.2 Arthritis 47 5.2.1 Rheumatoid arthritis 47 5.2.2 Septic arthritis 48 5.2.3 Osteoarthritis 50 5.3 Gout 51 5.3.1 Gout – acute 51 5.3.2 Gout – chronic 52 Chapter 6 – Cardiovascular conditions 53 6.1 Hypertension 54 6.2 Heart failure 57 6.3 Ischaemic heart disease 60 6.3.1 Angina 60 6.3.2 Myocardial Infarction 62 6.4 Arrhythmia 63 6.5 Rheumatic fever 64 Chapter 7 – Blood disorders 66 7.1 Anaemia 66 7.2 Bleeding disorders 68 Chapter 8 – Common skin conditions 71 8.1 Bacterial skin infections 71 8.1.1 Boils/Abscess 71 8.1.2 Impetigo 72 8.1.3 Cellulitis 73 8.2 Fungal skin infections 74 8.2.1 Ringworm (Tinea Corporis) 74 8.2.2 Athletes foot (Tinea pedis) 75 8.2.3 Pityriasis versicolor, (Tinea versicolor) 76 8.2.4 Scalp ringworm (Tinea capitis) 77 8.2.5 Candidiasis of the skin 77 8.3 Viral skin infections 78 8.3.1 Herpes simplex 78 8.3.2 Shingles (Herpes zoster ) 78 8.3.3 Chicken Pox (Varicella-zoster infection) 80 8.4 Parasitic infections 81 8.4.1 Scabies 81 8.4.2 Body lice (Pediculosis) 83 8.5 Eczema 84 8.6 Large chronic sores 85 8.7 Itching (Pruritus) 86 Chapter 9 – Ear, Nose and Throat 88 9.1 Sore throat (Pharyngitis and Tonsillitis) 88 9.2 Hay fever (Allergic rhinitis) 89 9.3 Ear conditions 90 9.4 Sinusitis 93 9.5 Nose bleeds (Epistaxis) 94 Chapter 10 – Endocrinological conditions 95 10.1 Diabetes 95 10.2 Diabetic emergencies 99 10.2.1 Hypoglycaemia 99 10.2.2 Diabetic ketoacidosis 101 10.3 Thyroid conditions 103 10.3.1 Goitre 103 10.3.2 Hypothyroidism 104 10.3.3 Hyperthyroidism (Thyrotoxicosis) 105 Chapter 11 – Gastrointestinal conditions 107 11.1 Oral conditions 107 11.1.1 Oral thrush (Candidiasis) 107 11.1.2 Gingivitis and Stomatitis 108 11.1.3 Dental abscess 109 11.2 Abdominal pain/dyspepsia 109 11.3 Diarrhoea 111 11.4 Nausea and vomiting 117 11.5 Helminthic infestation (Worms) 119 11.6 Constipation 123 11.7 Anal conditions 124 Chapter 12 – Immunisations 126 Immunisation Schedule 126 Chapter 13 – Neurological conditions 127 13.1 Headache 127 13.2 Seizures (convulsions) 131 13.2.1 Epilepsy 132 Chapter 14 – Conditions of the Eye 133 14.1. Eye Injuries 133 14.1.1. Foreign bodies 133 14.1.2. Corneal Abrasions: 134 14.1.3. Bleeding on the white of the eye (Subconjunctival hemorrhage) 134 14.1.4. Conjunctival Laceration: 135 14.1.5. Bleeding behind cornea (inside eye – “Hyphema”): 135 14.1.6. Ruptured eye: 136 14.1.7. Chemical Injury: 137 14.2. Eye Infections 137 14.2.1. Infectious conjunctivitis: 137 14.2.2. Post-infectious Corneal Scarring: 138 14.2.3. Keratitis (Corneal Infection): 138 14.2.4. Stye and Hordeolum (Nodule on eyelid) 138 14.2.5. Infection of the tear sac (Dacryocystitis) 139 14.2.6. Infection of the eyelids/eye socket (Preseptal/orbital cellulitis) 140 14.2.7. Half face rash, blisters (Herpes Zoster or Shingles): 141 14.2.8. Trachoma 141 14.2.9. Infectious conjunctivitis of newborn babies 142 14.3. General Eye diseases 143 14.3.1. Cataract: 143 14.3.2. Pseudoexfoliation: 143 14.3.3. Pterygium 144 14.3.4. Trichiasis – (eyelashes rub the surface of the eye) 144 14.3.5. Xerophthalmia (Vitamin A Deficiency) 145 Vitamin A dosage for prevention of xerophtalmia 145 14.3.6. Double Vision 145 14.3.7. Glaucoma: 146 14.3.8. Diabetes and the eye: 146 14.3.9. Inflammation inside the eye from the iris (Iritis) 147 14.3.10. Albinism 147 14.3.11. Corneal scar 147 14.3.12. Blind and painful eye 148 Chapter 15 – Renal conditions 149 15.1 Urinary tract infections (UTI) 149 15.2 Glomerulonephritis (Glomerular lesions) 151 15.3 Nephrotic syndrome 152 Chapter 16 – Infectious diseases 153 16.1 Yaws 153 16.2 Syphilis 154 16.3 Gonorrhoea 159 16.4 Chancroid 162 16.6 Chlamydial infections 163 16.7 Tuberculosis 166 16.8. Leprosy 167 16.9 Tetanus 168 16.10 Rabies 171 16.11 Pertussis (Whooping cough) 173 16.12 Meningitis 175 16.13 Measles 178 16.14 Dengue Infection 180 16.15 Malaria 184 Acknowledgements The development and revision of standard treatment guidelines has been funded through the HSSP SP program, with funding from the World Bank, European Commission, AusAID. Additional support has been provided from the WHO and from the Cuban medical Cadres, in the form of active participation in the revision work, and with translation. Special acknowledgement shall also be presented to all Timorese physicians and managers of district referral hospitals, for their active contribution to the guideline revision work. Introduction Standard treatment guidelines are currently used World-wide as a tool both to improve the uniform delivery of good quality care, and to optimize the effective and efficient use of resources. Evidence based medicine is the foundation for decision about what is most appropriate treatment approach to the most prevalent diseases for each level of healthcare. Standard treatment guidelines, or clinical practice guidelines are now in use in Europe, USA, Australia, through South East Asia and elsewhere in the World. A first edition of Standard treatment guidelines for primary care was launched in Timor Leste by the year 2004. That first 2004 edition of Standard Treatment Guidelines for primary care has now been revised. The revision has been carried out through a process of dialogue at district referral hospitals throughout Timor Leste. This review focused on a discussion of what is appropriate clinical practice and rational drug-use at district referral hospitals, with a focus on care for patients referred to hospitals from primary care. At the same time, the review also considered clinical practice and treatments in primary care. This was also based on experience from outreach from district hospitals in support to primary healthcare. This review has thus incorporated a high degree of practical clinical experience from daily healthcare in Timor Leste. We thank all physicians and other healthcare personnel who have provided their valuable contribution and shared their experience with us in this work. Treatment Guidelines and the Essential Medicines List. The medicines included in the Standard treatment guidelines and Essential Medicines List for East Timor has been selected based on the World Health Organization (WHO) essential medicines lists for adults and children. In addition, the medicine selection also matches the drug selection of national programs, such as IMCI. The selection only includes medicines that fit the key criteria: • Proven and documented efficacy and documeted safety / risk profile. Meaning that drugs with unknown risk, unknown safety and unknown ability to give medical benefit have not been included. • Relevance to the pattern of prevalent diseases. Meaning that the selected drugs shall be well documented as effective as as safe as possible, for treatment of common and commonly serious disease occuring in Timor Leste. • Preference for well known medicines. • Single compound medicines are preferred Generic names As Policy, the generic names for medicines shall be used. Every medicine has a name for the chemical active substance, an international non-proprietary name (INN). The INN or Generic name is the official name of the active substance in the medicine, regardless of who manufactures the medicine product. A so called Brand name is also chosen by each manufacturer to facilitate association of one particular product, with a particular company for the purpose of marketing. Many medicines are manufactured by several different companies and marketed under several different brand names. As example, there are more than 40 brand names of products containing the active substance amoxicillin in South East Asia. Since Timor Leste is procuring medicines by international competitive tenders, different brand name products of Amoxicillin may be used in Timor Leste during during different years. Consequently, it is important that all health workers systematically use the generic (INN) name of the medicine instead of using the brand-names. Reasons for this are also: • To prevent confusion about which medicine is being prescribed • Generic names are more informative than brand names and facilitate purchasing of products from multiple suppliers, whether as brand name or generic products. • Generic prescribing also facilitates product substitution whenever appropriate. It may take a little time to get used to the generic names for medicines however; once learned the generic name does not change – unlike the many brand names. Chapter 1 – National Program guidelines. Timor Leste has well established National programs, for priority areas of the healthcare delivery system. These national standard treatment guidelines focus on primary care, defining essential drugs and standard diagnosis and treatment protocols. The reader is therefore referred directly to each of the National Program Treatment Guidleines: National guidelines for • Integrated management of childhood illness (IMCI), • Maternal and Child Health (MCH), • Family planning and Reproductive health, • HIV/AIDS, • Mental Health, • Emergency Maternal Obstetric Care (EMOC), • Care of the Newborn, • Leprosy, • Filariasis, • Tuberculosis, • Malaria, • Nutrition, • Immunization. This treatment guidleine booklet does not duplicate what already is well defined in national guidelines, by respective national program. Updating and quality control responsibility for each national program treatment guideline is held by each respective national program team, under the leadership and management of each national program coordinator. Chapter 2 – Reproductive Health 2.1 Antenatal care The objective of antenatal care is to ensure that the woman goes through pregnancy, delivery and post delivery with maintained health, and that a healthy baby is born. A minimum of 5 antenatal visits is recommended. Antenatal care also aims to identify women with risk factors, who will need to be referred to specialists. Women with risk factors shall also be checked by more frequent antenatal visits and/or hospitalization. Summary/checklist of investigations for antenatal care. Investigation Action to be taken Collect urine specimen and use dipstick to check for albumin glucose Albumin present – Refer for further investigation. See Preeclampsia and Hypertension. Glucose present – refer for further investigation See Diabetes in pregnancy. Record weight. If no weight gain – advice about appropriate diet and refer for further investigation. Take Blood Pressure BP above 140/90 mmHg or 15 mmHg above normal BP. See Hypertension in pregnancy. Measure blood Hb See section Anaemia in pregnancy. Take malaria blood slide See National Guidelines for Malaria, section Malaria in pregnancy. Check for syphilis at first visit See section “Infections in pregnancy” Ask what Iron and Folic acid supplements the woman is taking See section “Anaemia in pregnancy”. Carry out physical examination Check for signs of STDs See Reproductive Health Guidelines and Infections in pregnancy. Measure height of fundus If no growth refer for further investigation. Listen to foetal heart and ask about movement of baby If no foetal heart or no foetal movement then refer for further investigation. Check immunisation status of woman See National Immunization Guidelines. 2.1.1 Anaemia during pregnancy Anaemia in pregnancy is a major health problem with serious risks for the pregnancy and childbirth. Anaemia requires careful management, active prophylaxis, and investigations to determine the cause. Analyze blood Hb levels in all pregnant women at the first antenatal visit and again at 28 weeks. • Hb < 10 gm/dl is considered anaemia • Hb between 4-7 gm/dl is considered severe anaemia • Hb < 4 gm/dl is very severe anaemia Always check for underlying cause of anaemia, do not forget malaria! Symptoms/signs The anaemic patient may experience dizziness, swelling of feet, general weakness, being easily tired, and may having palpitations. Even heart failure may develop in case of severe anaemia. Mucosal pallor is often present. Non-drug treatment Educate about appropriate iron and vitamin C rich diet and the need to avoid tea and coffee especially within 1 hour of a meal (shown to reduce the absorption of iron). The best sources of iron are liver, kidney, spleen, heart, blood, meat, chicken, and fish. But legumes and cereals also contain useful amounts of iron. Consider the need to treat against hookworm or malaria. Anaemia prophylaxis in pregnancy Iron and folic acid 1 tablet = 60 mg iron + 400 micrograms folic acid All women Women with anaemia 1 tablet 2 tablets In pregnancy Throughout pregnancy 3 months Postpartum 3 months 3 months If anaemia is suspected i.e. inner eyelids pale or if HB < 11 g/dl then increase (add to) iron supplementation as follows: Ferrous sulfate (60 mg iron), oral ADULT: 1 tablet twice daily for 3 months. If severe anaemia is suspected Palmar pallor, breathlessness, nail beds pale, inner eyelids very pale blood levels of Hb < 7gm/dl: Refer and admit the patient to hospital for further investigation and determine the cause of severe anaemia. Key points • Pregnant women with anaemia shall have assisted delivery and should also continue iron supplementation 4-6 months after delivery. • Iron preparations taken after food to avoids gastrointestinal irritation. • If vomiting occurs, reduce dose to that which can be tolerated. 2.1.2 Malaria in pregnancy See the National Malaria Guidelines. • Always check Hb and take malaria blood slide during antenatal visits. • Inform all pregnant women to seek medical attention at the very first sign of illness. 2.1.3 Hypertension in pregnancy Women who develop hypertension during pregnancy (later than 20 weeks) have pregnancy-induced hypertension (PIH) which is a potentially serious condition possibly requiring early or urgent delivery. Do not forget that pregnant women who have an essential hypertension, may also develop superimposed preeclampsia ! Symptoms/signs Blood pressure should be monitored at every antenatal visit. Make sure the patient has rested for 30 minutes before measuring the BP and if it is high then repeat the BP again in 1 hour (encourage the woman to rest during this time). Patient is hypertensive if BP is above 140/90 mmHg. Look for signs and symptoms which may indicate pre-eclampsia: Oedema, esp. over shinbones / legs and sacral area. Test for protein in urine. Treatment and referral of women with; • Hypertencion PLUS albuminuria with or without oedema: Refer urgently to hospital care for preeclampsia. • Oedema on the back of the hands and/or face: Refer urgently to hospital care for preeclampsia. • Hypertension above 150/100 mmHg. Or sudden rise in BP. • Decreased urinary output, <400 ml/24 hour. Small amounts of urine passed, dark in colour. Refer urgently to hospital for preeclampsia. Must be referred to a hospital immediately, for pre-eclampsia. Women with BP slightly raised; BP less than 150/100 mmHg but more than 140/90 mmHg (or 15 mmHg above normal), but no oedema or albuminuria present. Carefully monitor blood pressure if possible in 6 hours or the next day. Check for albuminuria and monitor foetal heart. If BP remains slightly raised, even if there is no oedema or albuminuria refer the patient for further investigation and management. If BP becomes normal again educate pregnant women and partner about warning signs of pre-eclampsia i.e. headaches, blurred vision, epigastric pain and sudden swelling of legs/back/face. If warning signs develop inform the woman to return to healthcare immediately, refer to hospital for investigation and management. Key points • Never lie a pregnant woman on her back. This may result in fainting and false reading of BP. Measure BP in sitting position or in left or right tilt of 15°. • Whenever your patient needs i.v. fluids, use normal saline, do not give dextrose 5%. 2.1.4 Pre-eclamptic toxaemia and Eclampsia Pre-eclampsia is a disease specifically associated with pregnancy. It usually occurs in the second half of pregnancy. It is characterised by the presence of two out of three major features: • Elevated blood pressure. • Oedema or excessive weight gain. • Protein in the urine (albuminuria). Eclampsia is an obstestric emergency. The blood pressure rises rapidly followed by eclamptic fits similar to tonic/ clonic epileptic seizures, repeated at frequent intervals. All cases of preeclampsia needs to be referred to hospital-care, since the disease always worsens over time, and the progress to severe stage can suddenly be very rapid. Symptoms and signs of mild pre-eclampsia The diastolic blood pressure is between 90 and 109 mm Hg. The systolic blood pressure is between 140 and 159 mm Hg. There is albuminuria. OBSERVE that also a “mild” eclampsia inevitably deteriorates. The condition may worsen suddenly and very fast go from “mild” to become severe. Admit all cases of preeclampsia to hospital as soon as possible. Symptoms and signs of severe pre-eclampsia: The diastolic blood pressure is 110 mm Hg or higher. The systolic blood pressure is 160 mm Hg or higher. There is albuminuria. Symptoms and signs of impending or imminent eclampsia: • Sharp rise in blood pressure. • Frontal headaches. • Vomiting. • Visual disturbances, double vision, blurred vision, flashes of light. • Epigastric pain with or without liver tenderness. • Decrease in urine production i.e. 400ml or less in 24 hours. • Increased tendon reflexes with or without clonus. Treatment for mild pre-eclampsia: All patient should be referred to specialist. Encourage patients to lie on the left side to avoid supine hypotension. Urine proteins must be determined daily. Record every 4 hourl BP on a chart. Weigh patient every day. Treatment for severe/imminent pre-eclampsia / eclampsia: Monitor progress by ¼ – ½ hourly BP until BP is reduced and the patient is stable. Then monitoring can be done by 2-4 hourly BP reading, daily weighing and urine protein examination. If diastolic blood pressure is >110 mmHg: Give: Hydralazine IV: 5 mg slowly every 5 minutes until Blood pressure is lowered. Repeat hourly as needed. OR: Hydralazine IM: 12.5 mg every 2 hours as needed. Magnesium sulfate is the drug of choice for preventing and treating convulsions in severe pre-eclampsia and eclampsia. Give: Magnesium sulfate, IV, IM Loading dose: Give: 4g of 20% magnesium sulfate solution IV over 5 minutes. Follow promptly with 10 g of 50% magnesium sulfate solution: Give: 5 g in each buttock as a deep IM injection with 1 ml of 2% lidocaine in the same syringe. Warn the woman that a feeling of warmth will be felt when injection is given. If convulsions recur after 15 minutes, give 2 g of 50% magnesium sulfate solution IV over 5 minutes. Maintenance dose Give 5 g of 50% magnesium sulfate solution with 1 ml of 2% lidocaine in the same syringe by deep IM injection into alternate buttocks every four hours. Continue treatment for 24 hours after delivery or the last convulsion. If 50% solution is not available, give 1 g of 20% magnesium sulfate solution IV every hour by continuous infusion. Toxicity to magnesium sulfate presents as slowing or arrest of the heartbeat and respiration and loss of deep tendon reflexes. Before administering next dose check if: • respiratory rate is more than 14 per minute, • urine output is more than 25ml/hour (100ml/4hours), • knee jerk or other deep tendon reflex are present. If any of these are not present do not give the next dose. If the respiratory rate is <14 per minute do not give next dose magnesium sulfate. Give Calcium gluconate 10% solution as antidote. Calcium gluconate 10 % solution, IV 10 ml slowly IV until calcium gluconate begins to antagonise the effects of magnesium sulfate and respiration begins. Patient should be kept on her side and turned every hour to prevent aspiration pneumonitis, she is likely to be unconscious or semiconscious (often they regain consciousness fairly early). Insert catheter to measure urinary output and albuminuria. It will also prevent the patient from being stimulated by a filling bladder. Before delivery, the woman needs to be stabilised. There should be no fits, no signs of pulmonary oedema, urinary output at least 25 ml/hour (100 ml/4hours), and BP under control. If after a few hours there are no further seizures, delivery should be by most appropriate method to ensure safety to both mother and baby. Treat convulsions/fits with: Give: Magnesium sulfate, IM 5 g (i.e. 10 ml of 50 % solution) in each buttock. Refer immediately to hospital. If magnesium sulfate is not available, give Diazepam Considering the average low bodyweight of women in Timor Leste: Give: Diazepam, IV, loading dose 5 mg IV slowly over 5 minutes, and if convulsions recur, repeat with 10 mg. Then continue with: Diazepam, IV, maintenance dose 40 mg mixed into 500 ml IV fluids (normal saline or Ringer-Lactate, but do NOT use dextrose 5%) titrated over 6 – 8 hours to keep the woman sedated but rousalbe. Stop maintenance dose if breathing <16 breaths/minute Assist ventilation if necessary with mask and bag, anaesthesia apparatus, intubation. Do not give more than 100 mg in 24 hours. If IV access is not possible (during convulsion), give diazepam rectally. Diazepam, rectally, loading dose Use diazepam vials. Give 20 mg (4 ml) in a 10 ml syringe (or urinary catheter): – Remove the needle, lubricate the barrel and insert the syringe into the rectum to half its length. – Discharge the contents and leave the syringe in place, holding the buttocks together for 10 minutes to prevent expulsion of the drug. If convulsions recur, repeat 10 mg. Diazepam, rectally, maintenance dose Give additional 10 mg (2 ml) every hour during transport. Be prepared to assist ventilation. The rectal route is suitable as satisfactory absorption is achieved within minutes and administration is much easier. Suppositories are not suitable because absorption is too slow. For management of hypertension in pregnancy: Give: Methyldopa, oral: Dose; 250 mg 2-3 times daily; if necessary, increase gradually at intervals of 2 or more days; (maximum 3 g daily). Side-effects of methyldopa are minimised if daily dose is under 1 g. Monitor foetal growth. 2.1.5 Diabetes in pregnancy Diabetes that develops during pregnancy is called gestational diabetes. Diabetes types 1 and 2 may have been present before the pregnancy. Pregnant women with glucosuria must be referred for further investigation and management. Diabetics planning pregnancy or already pregnant should be referred for counselling and pregnancy management planning. Good blood glucose control with the help of insulin and diet is essential since hypoglycaemics and hyperglycaemia may be teratogenic. Blood glucose should be kept strictly within the range 4-6 mmol/L (72-109 mg/dl) during pregnancy. Take regular blood glucose profiles. Admit and take 4 hourly blood glucose levels for 24 hours. Insulin requirements will increase as pregnancy progresses so profiles will be necessary at intervals of around 2 weeks Labour should be at a tertiary level hospital. 2.1.6 Infections in pregnancy Urinary tract infections during pregnancy Even asymptomatic bacteriuria is a high risk condition in pregnancy. This is due to the risk that a lower urinary tract infection ascends and infect kidneys, causing pyelonephritis with risk for urosepsis. See Chapter “Renal conditions”. Positive RPR or syphilis during pregnancy Both partners should be counselled and treated with: Benzathine penicillin, IM 2.4 million units = 1.8 g once only. Give as 2 IM injections at separate sites. Plan to treat newborn. Pregnant women allergic to penicillin give: Erythromycin, oral 500mg four times a day for 15 days Observe that if the pregnant woman has been treated with Erythromycin, the drug does not pass across the placenta and the fetus ewmaIns untreated. The newborn will then need to be treated for Syphilis. Vaginal discharge during pregnancy Often polymicrobial and requires a combination of drugs. Give: Give: Erythromycin, oral 500mg four times a day for 7 days PLUS: Metronidazole, oral 500 mg 2 times a day for 7 days PLUS: Clotrimazole 500 mg, pessary Single dose intravaginally. Caution: Avoid metronidazole in first trimester of pregnancy Pelvic inflammatory disease (PID) Gonorrhoea, chlamydia, mycoplasma, anaerobic bacteria and gram-negative organisms can cause acute PID. 2.1.7 Immunisations during pregnancy Pregnant women and women planning pregnancy should be immunised according to the national immunization program, with tetanus toxoid during antenatal care. Pregnant women and women of childbearing age without previous immunization should get the following schedule: Tetanus Toxoid Vaccine When administered? TT 1 At first contact or as early as possible during pregnancy TT 2 At least 4 weeks after TT 1 TT 3 At least 6 months after TT 2 TT 4 At least 1 year after TT 3 or during subsequent pregnancy TT 5 At least 1 year after TT 4 or during subsequent pregnancy Key points • An adult woman with a complete course of childhood immunisations including boosters need only one booster dose of tetanus toxoid vaccine (recommended at first pregnancy), to protect for life. 2.1.8 Nausea and vomiting in pregnancy Nausea and vomiting related to pregnancy occur during the first trimester and usually pass after 12 weeks of pregnancy. If not excessive, advise small frequent bland meals and drinks. Antacids may give symptomatic relief if gastritis is present. Give: Aluminium hydroxide tablets, 500 mg 1 or 2 to be chewed four times a day and at bedtime or as required OR: Aluminium hydroxide suspension 10ml four times a day and at bedtime or as required Key points • If vomiting persists always look for an underlying cause e.g. UTI, molar pregnancy, multiple pregnancy, malaria. 2.2 Delivery 2.2.1 Episiotomy Where there are signs of severe foetal distress and the foetal head is visible at the vulva, emergency episiotomy shall be carried out. Signs of foetal distress; foetal heart rate below 100 or above 170 or delay in return of foetal heart rate after contractions, or presence of meconium. Treatment Prepare sterile equipment. If lidocaine is available, it is diluted to 0.5%, which gives the maximum effect with the least risk for toxicity. Combine Lidocaine 2%, 1 part; Normal saline or sterile distilled water, 3 parts (do not use glucose solution. It increases the risk of infection). Caution: avoid injecting into a blood vessel! Draw back several times during the infiltration. Insert needle along the intended incision line. Withdraw plunger to check that the needle is not into a blood vessel. Make a slow instillation of anaesthetic and the same time withdraw the syringe slowly so the incision line is anaesthetised. 2.2.2 Retained placenta Bleeding which occurs before the full expulsion of the placenta and where the uterus is not contracted, is usually due to retained placenta. Bleeding after delivery of the placenta when the uterus is soft may also be due to retained parts of the placenta/membranes and the placenta and membranes should be re-examined for completeness. Treatment If the placenta fails to deliver after 1 hour following the birth of the baby or bleeding occurs whilst the placenta is retained, give: Oxytocin, IM, IV: 10 units. Ensure that the bladder is empty and wait for a contraction. Then try to deliver the placenta using controlled cord traction. Note: Do not give ergometrine for retained placenta because it causes tonic uterine contraction, which may delay expulsion. If placenta will not deliver with controlled cord traction and there is no haemorrhage then refer. Once uterus is empty repeat: Oxytocin, IM, IV: 10 units. If heavy bleeding after delivery of the placenta then: GIVE: Ergometrine, IM 0.2 mg PLUS: Oxytocin, IV infusion 20 units in 1 litre Ringer-Lactate solution. infuse fast. Note: Do not give ergometrine if eclampsia, pre-eclampsia, or hypertension. If manual removal of placenta is required, explain to woman what is about to happen and if available: Give: Morphine, IM: 10 mg, single dose for analgesia OR: Diazepam injection, IM, IV: 10mg (as a sedative) Note: slow IV injection into a large vein at a rate of no more than 5 mg/minute. If there are signs of infection: GIVE: Ampicillin, IV: 2g IV every 6 hours; PLUS: Gentamicin, IV: 7,5 mg/kg every 24 hours; PLUS: Metronidazole, IV: 500 mg IV every 8 hours. If allergy to Ampicillin Give: Erythromycin, IV, IM: 500 mg every 6 hours. If fever is still present 72 hours after starting antibiotics, revise diagnosis. Key points • If unsure that the entire placenta was removed or if haemorrhage is not controlled then refer immediately. 2.3 Post delivery care 2.3.1 Postpartum haemorrhage Bleeding from the vagina following complete birth of the baby of more than 500ml, or any amount that causes signs and symptoms of shock is considered postpartum haemorrhage. Primary postpartum haemorrhage Occurs within the first 24 hours of delivery. If uterus is not contracted rub or massage to contract: Give: Oxytocin, IM, IV Initial dose : 10 units IM, IV. Continuing dose: repeat 10 units IM,IV after 20 minutes if heavy bleeding persists. OR: Oxytocin IV infusion Initial dose: 20 units in 1 litre Ringer-Lactate solution at 60 drops/minute. Continuing dose: 10 units in 1 litre Ringer-Lactate solution at 30 drops/minute Note: not more than 3 litres of IV fluids containing oxytocin. Oxytocin and ergometrine can be given together or sequentially. Give: Ergometrine, IM, IV Intitial dose: 0.2 mg slowly Continuing dose: Repeat 0.2 mg IM after 15 minutes, if heavy bleeding persists. Note: not more than 5 doses (total 1.0 mg) Note: Do not give ergometrine if eclampsia, pre-eclampsia, hypertension. Monitor closely for signs and symptoms of shock. If shock is then: Give: Sodium chloride 0.9%, IV infusion Infuse at a high infusion rate until pulse becomes stronger, then reduce infusion rate. If ruptured uterus is suspected or shock, refer urgently! Secondary postpartum haemorrhage Excessive bleeding from the vagina or excessive lochia after 24 hours and up to 42 days following delivery is considered abnormal and requires prompt investigation and treatment. Monitor at risk women for at least the first 10 days after delivery – • Retained fragments of placenta and membranes • Prolonged labour • Instrumental or complicated deliveries • Breakdown of wound following caesarean section • Breakdown of wound following episiotomy If there are signs of infection give antibiotic treatment until the patient is fever-free for 48 hours: GIVE: Ampicillin, IV: 2g IV every 6 hours; PLUS: Gentamicin, IV: 7,5 mg/kg every 24 hours; PLUS: Metronidazole, IV: 500 mg IV every 8 hours. If allergy to Ampicillin Give: Erythromycin, IV, IM: 500 mg every 6 hours. Note: If the infection is not severe, Amoxicillin 500 mg can be given by mouth every 8 hours instead of Ampicillin. Metronidazole can be given by mouth instead of IV. If fever is still present after 72 hours after starting antibiotics, re-evaluate and revise diagnosis. Per Oral antibiotics are not necessary after stopping IV antibiotics. If signs and symptoms of shock present then start IV infusions with: Sodium chloride 0.9%, IV infusion Infuse at a high infusion rate until pulse becomes stronger; then reduce infusion rate. Refer the woman with her baby immediately Key points • Small volume blood loss may cause shock in an anaemic woman • Always treat shock and replace all fluid lost • Transfer woman along with a relative for blood donation • Give iron supplementation following any bleeding • Bleeding can start at any time after the baby’s birth • Ruptured uterus can occur in labour in which case all blood loss may not be revealed. • Retained fragments of placenta and membranes are the main cause of secondary PPH 2.3.2 Puerperal Sepsis Fever in a woman who has delivered or miscarried the previous 6 weeks may be due to puerperal sepsis. Symptoms/signs Observe for signs and symptoms or puerperal sepsis, which is diagnosed when 2 or more of the following conditions occur anytime between the onset of ruptured membranes and 42 days post delivery: Pelvic pain, fever, abnormal vaginal discharge, abnormal smell discharge, delay in the rate of reduction in the size of the uterus. Non-drug treatment If uterus tender or there is delay in reduction in the uterine size or there is vaginal bleeding – transfer the woman immediately Drug treatment Puerperal sepsis can fast deteriorate into a septic shock. Then start IV fluids and give antibiotics, immediate referral to hospital! If there are signs of infection give: GIVE: Ampicillin, IV: 2g IV every 6 hours; PLUS: Gentamicin, IV: 7,5 mg/kg every 24 hours; PLUS: Metronidazole, IV: 500 mg IV every 8 hours. If the patient has a history of allergy to penicillin, instead give Give: Erythromycin, IV, IM: 500 mg every 6 hours. If fever is still present after 72 hours after starting antibiotics, re-evaluate and revise diagnosis. Refer immediately to hospital care ! Key points • Fever plus abdominal pain may also be due to malaria. 2.4 Neonatal conjunctivitis (Ophthalmia neonatorum) Purulent conjunctivitis occurs in babies less than one month of age is known as ophthalmia neonatorum. It can be caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or it can be due to pathogens such as Streptococci, Staphylococci, Klebsiella or Escherichia. If not treated early and effectively, blindness can occur. Prevention Treat maternal infection before labour. Instil to the conjunctival sacs of all babies immediately after birth: Tetracycline 1%, eye ointment At birth after cleansing eyes with sterile gauze, give one application of ointment in each eye. Close the eyelids and massage gently, to aid the spread of ointment. If there is conjunctivitis with discharge then treat the baby and the parents with systemic antibiotics. Chapter 3 – Pain control. 3.1 Pain control for adults 3.1.1 Mild pain in an adult The drug of first choice for pain relief as well as antipyretic is: Paracetamol, oral: 0.5 – 1 g repeated every 4 to 6 hr, up to maximum 4 g per day. Cautions: hepatic and renal impairment, alcohol dependence. Side-effects: rare, but rashes, blood disorders. Important: liver damage following overdose. An alternative to paracetamol is aspirin (acetylsalicylic acid): Aspirin, oral: 300 – 900 mg every 4 – 6 hours when necessary. Maximum 4 g daily. Contraindications: children and adolescents under 16 years and in breast-feeding (Aspirin may cause Reye’s syndrome in children), previous or active peptic ulcer, haemophilia, never give in case of gout. Cautions: do not give to patient with history of asthma, dehydration; Do not treat children and young adolescents (Reye’s syndrome); pregnancy. Side-effects: high incidence of gastro-intestinal irritation with risk for bleeding if long lasting treatment, increased bleeding time for 2 weeks after a single dose, bronchospasm in hypersensitive patients. 3.1.2 Moderate Pain in an adult When mild pain management is inadequate then introduce in addition paracetamol (or aspirin) the following: Codeine phosphate, oral: 30 – 60 mg every 4 hours when necessary, to a maximum of 240 mg/day. 3.1.3 Severe pain in an adult When pain is acute and severe, codeine should be stopped, the mild pain relief must be continued (e.g. paracetamol) and morphine can be introduced. Morphine is the drug of choice. Morphine, injection, IM or subcutaneous: 10 mg every 4 hour. Note: when calculating the intramuscular (or subcutaneous) dose, use half of the existing or estimated oral dose. If giving by slow intravenous injection, give only quarter to half the corresponding intramuscular (or subcutaneous) dose. Side effects of morphine These are generally transient and treatable and should not contraindicate the continued use of morphine: Constipation – very common and patients should be encouraged to have high fibre diet and high fluid intake. Regular laxative use may be needed in addition. Respiratory depression and hypotension – may be produced by larger doses. The antidote naloxone is then indicated. Nausea and vomiting – May be beneficial to give an antiemetic for the first three days or more if problem continues. Give: Metoclopramide, oral: 10 mg (5 mg in young adults 15-19 years under 60 kg) three times daily as required; OR: Promethazine, oral: 12,5 mg to 25 mg, repeated at intervals not less than 4 hours (max, 100 mg in 24 hr) If vomiting is severe, administer parenterally or rectally. Drowsiness, dizziness or confusion – usually improves in 3 to 5 days. Call doctor but do not discontinue morphine. Allergy – very rare with morphine, however, an alternative is tramadol but it is less potent than morphine. Tramadol, per oral: 50 – 100 mg, not more often than every 4 hours; Total 400 mg per da by mouth as usual max required; Tramadol, IM injection, IV injection (over 2-3 minutes), IV infusion: 50 – 100 mg every 4 – 6 hours. Postoperative pain: 100 mg initially then 50 mg every 10 – 20 minutes if necessary during first hour to total maximum 250 mg (including initial dose) in first hour, then 50 – 100 mg every 4 – 6 hours; max 600 mg/day; Tramadol has less of the typical opioid side-effects (less risk for respiratory depression, less constipation and less addiction risk). Key points • Pain, acute or chronic should be graded mild, moderate or severe. • Anxiety, depression and fear should be assessed. If overlooked these conditions may aggravate pain, making control more difficult. • In chronic pain, long-term pain relief is required. Analgesics should be given per orally wherever possible at regular intervals to prevent breakthrough of pain. • Tolerance, addiction and respiratory depression are very unlikely if the morphine doses are adjusted to the needs of individual patients. • Long-term use of morphine should be restricted to cancer patients. 3.2 Pain control for children 3.2.1 Mild pain in a child Aspirin is contraindicated in children under 16 years of age. Instead use Paracetamol, oral or rectal CHILD: 10 -15 mg/kg up to 4 times a day, as required for analgesia. Always calculate the dose of Paracetamol according to the weight of the child. 3.2.2 Moderate pain in a child Continue the Paracetamol, but in addition under supervision of a doctor give: Codeine phosphate, oral CHILD 1 – 12 years: 3 mg/kg/day in divided doses. To prevent constipation increase fluid intake, additionally the high fibre diet of East Timor helps to prevent constipation. 3.2.3 Severe pain in a child Continue the Paracetamol, stop the Codeine but in addition give: Morphine, oral, IV, IM Oral: 0.2 – 0.4 mg/kg/dose every 4 – 6 hour; increase if necessary for management of severe pain. IM: 0.1 – 0.2 mg/kg/dose every 4 – 6 hour. IV: 0.05 – 0.1 mg/kg/dose every 4 – 6 hour OR: 0.005 – 0.01 mg/kg/hour by IV infusion. Calculate dose based on the weight of the child. Review the pain management after every 2 to 3 doses and adjust if necessary until pain is well controlled. Morphine should be prescribed by a doctor only. Patients with severe nausea and vomiting may benefit from: Metoclopramide, oral CHILD 1-3 years (10 -14 kg): 1 mg, 2 to 3 times/day CHILD 3-5 years (15 -19 kg): 2 mg, 2 to 3 times/day CHILD 5-9 years (20 – 29 kg): 2 mg, 3 times/day CHILD 9-14 years (30 kg and over): 5 mg, 3 times/day Note: Daily dose of metoclopramide should not normally exceed 0.5 mg/kg, particularly for children and young adults. Metoclopramide should not be used for children under 12 months because of the high incidence of dystonic reactions. Key points • Pain in children needs careful and regular assessment, as children may not complain of pain. Babies also experience pain and may require analgesics. Parents are good judges of their child’s pain. • When available and necessary suppositories should be used. • If the pain cannot be treated then refer for specialist management. Chapter 4 – Respiratory tract conditions 4.1 Common cold This is a common viral infection, which is contagious and is spread by airborne droplets (coughing and sneezing). It is self-limiting. Symptoms/signs Runny nose, blocked nose Slight fever Cough with the cold. Often starts with a sore throat that resolves quickly. Often in children this may be the first sign of influenza or measles that may also have an associated conjunctivitis. Otitis media may also be a complication. Non-drug treatment Encourage patients to drink plenty of water and / or tea, which will facilitate expectoration. Expectorants (cough mixtures) have no pharmacological activity, but may serve as useful placebos. To relieve sore throats – gargle with salt and warm water solution. To prevent cold causing earache – wipe nose, do not blow nose. Drug treatment To relieve the fever, headache and associated muscle pain: Give: Paracetamol, oral ADULT: 0.5 to 1 g every 4 to 6 hours to a maximum of 4 g daily, if required. Paracetamol, oral, rectal CHILD: 10 – 15 mg/kg every 4 – 6 hours (not more than 4 doses in 24 hours) OR: Aspirin, oral ADULT: 300 – 900 mg every 4 – 6 hours if necessary; maximum 4 g daily. Aspirin should never be given to children, due to risk for Reyes Syndrom. Colds are viral infections therefore: NO ANTIBIOTIC TREATMENT. Safe paediatric remedies for soothing and relief of cough: Breastfed infant up to 6 months. Sweet soy sauce or honey mixed with lime water. Key points • Do not give antibiotics or injections to a patient with a simple cold. It will not help and may cause harm. • If a cold lasts for more than a week or if the person has fever, coughs up a lot of phlegm (mucus with pus), has shallow fast breathing or chest pain bronchitis or pneumonia may be developing. • Colds are more likely to develop into pneumonia in old people, in those who already have lung problems (e.g. asthmatics), and people who cannot move much. • If the sore throat is accompanied by fever it may be caused by a bacterial infection and requires antibiotic treatment. 4.2 Bronchitis Infection of the bronchial mucosa, usually caused by virus. Symptoms/signs Initially dry cough, then it becomes productive with phlegm or mucus and can be very noisy Low-grade fever Normal respiration Non-drug treatment Bed rest Drink plenty of water The humid air of East Timor is helpful in this aspect. Drug treatment Treatment of children <5 years see IMCI Guidelines. Treat the fever: Give: Paracetamol, oral ADULT: 0.5 to 1 g every 4 to 6 hours to a maximum of 4 g daily, if required. Paracetamol, oral, rectal CHILD: 10 – 15 mg/kg every 4 – 6 hours (not more than 4 doses in 24 hours) OR: Aspirin, oral ADULT: 300 – 900 mg every 4 – 6 hours if necessary Most cases do not require antibiotics, but antibiotics should be considered if there is secondary infection. If phlegm present (thick, coloured mucus) Give: Amoxicillin, per oral ADULT: 250 mg every 8 hours, doubled in severe infections. CHILD: 15 mg/kg 3 times a day Duration: 5 days Key points • Be suspicious of chronic bronchitis i.e. patients with a productive cough that lasts for months or years. The person may have tuberculosis or asthma. Refer for further investigation. • Cough in a child >1 month needs investigation for TB; refer to doctor. • Patients who are (or have been) heavy smokers may also have chronic bronchitis. • People with chronic bronchitis will probably need antibiotics every time they have a cold or “flu”. 4.3 Pneumonia Pneumonia is an acute bacterial infection of the lungs. It can occur along with other illnesses such as measles, asthma, and flu and can complicate also other illnesses. Pneumonia can develop very rapidly in children and may be life threatening if severe. Symptoms/signs Children: All children should be assessed using the Integrated Management of Childhood Illness Guidelines (IMCI). Cough or difficulty breathing PLUS one of the danger signs indicates a severe pneumonia or very severe disease. Urgent action must be taken. Look for the danger signs: • Child is unable to drink or breast feed • Child vomits everything • Convulsions • Child is lethargic or unconscious • Chest indrawing • Stridor A diagnosis of “severe pneumonia or very severe disease” means urgent referral must be organised. See IMCI. A child with cough or difficulty breathing PLUS fast breathing must be diagnosed with pneumonia and treated with antibiotics. Fast/shallow breathing in children is defined as: Age of child Respiration rate <2 months ≥60 breaths per minute or more 2 months – 12 months ≥50 breaths per minute or more 12 months – 5 years ≥40 breaths per minute or more Adults: Fever – may be preceded by sudden chills Cough – Can be productive (yellowish/green or rusty) or non-productive. If cough persistent for 3 weeks or more refer for investigations for TB Chest pain Breathlessness Use of accessory muscles for respiration and flaring of the nasal margins Cyanosis – If the person cannot get enough air, the nails and lips may turn blue and neck veins may swell. Fast pulse rate Signs of consolidation (lobar or patchy) or effusion in the chest Consider admission if the patient is obviously unwell or in severe pain. Admission and monitoring is mandatory if: • Severe respiratory distress • Fast/shallow breathing • Severely cyanosed • Pulse > 125/min • Hypotensive (systolic<90mmHg) • Temperature > 40 C or < 35 C • Altered mental state Non-drug treatment Control fever and pain Drink plenty of water Drug treatment For age group 2 months up to 5 years, if the patient’s condition does not warrant hospital admission (see notes above), treat the infection with: Give: Amoxicillin, oral CHILD: 25 mg/kg 2 times a day. Duration: 5 – 10 days in uncomplicated cases. Or: Co-trimoxazole, oral ADULT: 960 mg (160 mg TMP + 800 mg SMX) = 2 tablets every 12 hours for 7 days. CHILD: 24 mg/kg (4 mg/kg TMP/20 mg/kg SMX) twice daily. The IMCI recommendation for the dose of per oral amoxicillin for non-severe pneumonia has changed. It is now recommended to give 25 mg/kg two times per day. Severe pneumonia is commonly pneumococcal CHILD: If pre-referral: give chloramphenicol, see IMCI. Admit or refer urgently for admission to hospital and give: Benzylpenicillin, injection, IV, IM ADULT: 1.2 g (= 2 million units) every 6 hours. Duration: 5 – 10 days CHILD: 50 000 units/kg (= 30 mg/kg) IM or IV every 6 hours for at least 3 days. When child improves, switch to: Amoxicillin, per oral: 25 mg/kg 2-3 times a day, for 5 days. Duration: total course of treatment 5 days. Updated IMCI recommendation: When referral of children with severe pneumonia is not possible and when injection treatment is not available, per oral amoxicillin shall be given at the higher dose level, of 45 mg/kg two times per day, for 5 days. If not improved within 48 hours review diagnosis, consider tuberculosis. Note: Intramuscular administration of benzylpenicillin can be painful. Still, give intramuscular injection if intravenous administration cannot be given. If the child does not improve within 48 hours or deteriorates, switch to: Chloramphenicol, IM, IV CHILD: 25 mg/kg every 6 hour IM or IV until the child has improved. Then continue orally for a total course of 10 days. If not improved within 48 hours review diagnosis. Consider tuberculosis if cough continues more than one month. Note: Intramuscular administration of benzylpenicillin can be painful, however, give intramuscular injection if intravenous administration cannot be given. If Staphylococcal infection is likely (associated skin lesions, pleural effusion / empyema) then replace penicillin with or add: Cloxacillin, IV, IM ADULT: Cloxacillin: 1 – 2 g/dose IV every 6 hours. PLUS: Gentamicin: 7,5 mg/kg every 24 hour. (2 mg/kg once a day in the elderly, and if there is renal impairment). Duration: 14 – 21 days. CHILD: Cloxacillin: 50 mg/kg IM or IV every 6 hours PLUS: Gentamicin: 7.5 mg/kg IM or IV once a day. When the child improves, continue Cloxacillin, oral: 4 times a day for a total course of 3 weeks. In case of penicillin allergy give: Clindamycin, IV ADULT: 300 – 600 mg/dose repeated every 8 hour for a period of 7 to 14 days NEONATE: 5 mg/kg/dose every 6 – 8 hours INFANT and CHILD: 10 mg/kg/dose every 6 – 8 hours. Duration: Give IV for at least 7 days of treatment, before to consider a change to per oral route. If suspected infection due to Gram-negative organisms. Give: Gentamicin, IV, IM ADULT: 7,5 mg/kg every 24 hour. (2 mg/kg every 24 hours in the elderly and if there is renal impairment) PLUS: Chloramphenicol, IV ADULT: 50 mg/kg daily in divided doses Duration: 10 to 14 days Or; Give: Gentamicin, IV, IM NEONATE “Single daily” dosing Term – week 1 of life: 5 mg/kg/dose repeated every 24 hr Term – week 2 – 4 of life: 7.5 mg/kg/dose repeated every 24 hr INFANT and CHILD to 10 years: 7.5 mg/kg/dose every 24 hours. CHILD over 10 years: 7,5 mg/kg/dose every 24 hours PLUS: Chloramphenicol, IV CHILD: 25 mg/kg every 8 hours. Duration: 10 to 14 days If Lung abscess suspected Postural drainage and Give: Benzylpenicillin, IV ADULT: 1.2 g ( = 2 million units) every 6 hours. PLUS: Metronidazole, oral ADULT: 400 – 500 mg every 8 hours Duration: 4 – 6 weeks* *Continue until patient no longer is toxic. Then complete treatment as outpatient with amoxicillin 500 mg every 8 hours for 4 to 6 weeks. If Empyema / pleural effusion Drain pleural space with a large intercostal tube and under water seal. And give antibiotic treatment. Give: Benzylpenicillin, IV ADULT: 1.2g (2 million units) every 6 hours. PLUS: Metronidazole, oral ADULT: 400 – 500 mg every 8 hours. Duration: 10 – 14 days*. *If still draining pus after two weeks refer for surgical opinion. If underlying lung disease is present give: Give: Ampicillin, IV ADULT: 1 g every 6 hours. PLUS: Metronidazole, oral ADULT: 400 – 500 mg every 8 hours. Duration: 10 – 14 days. If preceded by suspected staphylococcal pneumonia give: Give: Cloxacillin, IV ADULT: 1 g every 6 hours. PLUS: Metronidazole, oral ADULT: 500 mg every 8 hours for 10 to 14 days Duration: 10 – 14 days. For children give: Chloramphenicol, IM, IV CHILD: 25 mg/kg IM or IV every 8 hours until the child has improved. Then continue with Chloramphenicol, oral 3 times a day for a total of 4 weeks. If cause of infection is identified as Staphylococcus aureus, give: CHILD: Cloxacillin: 50 mg/kg IM or IV every 6 hours PLUS: Gentamicin: 7.5 mg/kg IM or IV once a day. When the child improves, continue Cloxacillin, oral: 4 times a day for a total course of 3 weeks. Key points Severe pneumonia in children may cause hypoxia and respiratory failure. Children with cough and/or fast / difficult breathing, cyanosis or any of the danger signs should be referred to hospital – see the IMCI guidelines. 4.4 Asthma A person with asthma has episodes of reversible airway obstruction. Asthma often begins in childhood and is often also associated with other allergies. Episodes are triggered by dust, drugs, air pollution. Symptoms/signs Cough, wheeze, rapid breathing and breathlessness / difficulty breathing (uses extra muscles to breathe). Patients can rapidly deteriorate into a severe attack of asthma and this may be life threatening. Features of a life-threatening attack are: • Difficulty to speak • Tachycardia • Rapid respiration > 40/min • Increasing difficulty to breath – increasing recessions / tachypnoea • Central cyanosis silent or increasingly quiet chest on auscultation. Wheezing may or may not be heard in a severe attack as little air is moving in / out due to severe obstruction. • Increasing agitation / irritability • Drowsiness or confusion Drug treatment There are two aspects to the management of asthma in adults and children to consider: • Treatment of an acute episode • Maintenance therapy which is used to prevent recurrent episodes 4.4.1 Acute severe (life-threatening) asthma episode (status asthmaticus) Urgent treatment is required at the health facility If oxygen is available, give oxygen in high concentration Initially, oxygen should be given at the highest concentration available (40-60%) with a high flow rate. Salbutamol nebuliser solution. Nebuliser driven by oxygen. ADULT: 2.5 – 5 mg every 20 minutes for 3 doses, then 2.5 – 10 mg every 1 – 4 hours as needed, or 10 – 15 mg/hour continuously. CHILD: 0.15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses, then 0.15 – 0.3 mg/kg up to 10 mg every 1 – 4 hours as needed, or 0.5 mg/kg/hour continuously (maximum dose 15 mg/hour) Metered-dose inhaler (100 µg/puff) ADULT: 4 – 8 puffs every 20 minutes up to 4 hours, then every 1 – 4 hours as needed. CHILD: give 3 puffs every 20 minutes continuously and reassess. If child improves after 3 puffs, give hourly and gradually increase interval between puffs. If no improvement and situation worsens salbutamol i.v. should be given. (Salbutamol infusion only in ICU setting). Salbutamol injection, IV, IM, subcutaneous ADULT: 500 micrograms, IM, subcutaneous, repeated every four hours if necessary OR: 250 micrograms by slow intravenous injection, repeated as needed. CHILD 1 month – 12 years: 0.1 – 1 microgram/kg/minute by continuous intravenous infusion via infusion pump. In addition give: Prednisolone, oral ADULT: 30-60 mg daily until attack improves then reduce as appropriate for the patient CHILD: 1 mg/kg/day orally, to a maximum of 50 mg daily, for 3 – 5 days then cease abruptly without tapering. Note: Initial daily dose of prednisolone should be continued until the patient is better. If the course of therapy is shorter than 14 days then stop prednisolone without tapering. If the course is longer than 14 days then reduce dose gradually by 5mg daily. Oral and parenteral corticosteroids are generally comparable in rapidity of onset and efficacy in asthma. However, parenteral administration is warranted if the patient is vomiting or unable to take corticosteroids by mouth. Hydrocortisone, IV ADULT: 100 mg, 6-hourly, then review. Hydrocortisone: 2-4 mg/kg/dose 6 hourly for 24 hours. For anaphylaxis or imminent cardio-respiratory arrest give: Adrenaline (Epinephrine) (1:1000) ADULT: 0.5 mg (0.5 ml of 1:1000 ampoule), subcutaneously, IM, or transtracheally OR: 0.5 mg (0.5 ml of 1:1000 ampoule) diluted to 10 ml total volume slowly intravenously. CHILD: 0.3 mg (0.3 ml of 1:1000 ampoule) subcutaneously or transtracheally. OR: 0.3 mg (0.3 ml of 1:1000 ampoule) diluted to 10 ml total volume slowly intravenously. As an alternative to Salbutamol, if the patient has NOT received any theophylline during the last 8 hours; then give a bolus dose (loading dose) of aminophylline: Aminophylline, slow IV injection over at least 20 minutes ADULT: 5 mg/kg CHILD: 10 mg/kg over 60 minutes Caution: Aminophylline intravenous bolus must be administered very slowly, over at least 20 minutes, or preferably over 1 hour. Observe the patient carefully for symptoms and signs of toxicity. If necessary continue with a maintenance dose: Aminophylline, IV ADULT: 0.5 mg/kg/hour (slow intravenous infusion) in dextrose 5% CHILD, 3 weeks to 12 months: 3 mg/kg every 8 hours as slow infusion over 60 minutes. CHILD, 1 – 9 years: 6 mg/kg every 6 hours as slow infusion over 60 minutes. CHILD, 10 – 16 years: 4 mg/kg every 6 hours as slow infusion over 60 minutes. Key points • It may take 4 to 24 hours to observe a good clinical response to the use of prednisolone. • Early intervention is key to avoid deterioration and to stop an asthma attack. Patients must be educated to recognise the early symptoms of deterioration and to take immediate action – not to “wait and see”. Wheezing is an unreliable indicator of the severity of an asthmatic attack. Wheezing may be absent in severe attacks. 4.4.2 Asthma Maintenance therapy Long-term treatment of asthma is based on the severity. Assessment of severity of long-term asthma is as follows: Assessment factor Mild Moderate Severe Wheeze, chest tightness, cough, dyspnoea Occasional Most days Everyday Symptoms at night None Less than once a week More than once a week Symptoms of asthma when waking None Less than once a week More than once a week Episodes of severe acute attacks None Not usually May have a history Use of Salbutamol Inhaler Less than twice a week Most days More than 3 or 4 times a day Forced expiry volume in 1 second (FEV1) > 80% 60-80% < 80% (at best) Morning peak flow on waking >90% (recent best) 80-90% (best) < 80% (best) Daily maintenance with Beclomethasone inhaler <400 mcg per day 400-1000 mcg per day >1000 mcg per day (or oral prednisolone) Note: the grade of severity may change with treatment. Inhalation is the preferred route of asthma-drug administration. Use a spacer devices for patients with poor inhalation technique, for children, for patients requiring higher doses, for nocturnal asthma, and for patients prone to candidiasis with inhaled corticosteroids. To manage mild asthma give: Salbutamol, inhaler ADULT: 100-200 micrograms (1 – 2 puffs) up to 3 – 4 times daily. CHILD: 100 micrograms (1 puff) 3 – 4 times daily, increased to 200 micrograms (2 puffs) 3 – 4 times daily if necessary. OR Salbutamol, tablet ADULT: 2 to 4 mg 3 or 4 times daily; in some patients up to 8 mg 3 – 4 times daily. CHILD under 2 years: 0.1 mg/kg 4 times daily, CHILD 2-6 years: 1 to 2 mg 3 to 4 times daily CHILD 6-12 years: 2 mg 3 to 4 times daily. OR Theophylline, tablet ADULT and CHILD over 12 years: 100 – 200 mg 3 – 4 times daily after food OR: 300 – 450 mg every 12 hours as modified-release tablets. CHILD 1 – 12 months: 3 mg/kg every 8 hours CHILD 1-9 years: 4 mg/kg every 4 – 6 hours. To manage moderate asthma Add to the regimen for mild asthma the following: Beclomethasone, inhaler ADULT: 200 micrograms twice a day regularly OR: 100 micrograms 3 – 4 times daily (in more severe cases 600 – 800 micrograms daily). CHILD: 50 – 100 micrograms 2-4 times daily OR: 100 – 200 micrograms twice daily. To manage severe asthma Add to the regimen for mild asthma the following: Give: Beclomethasone, inhaler ADULT: 50 micrograms/dose inhaler 200 micrograms (4 metered doses) twice a day OR: 100 micrograms (2 metered doses) 4 times / day OR: ADULT: 250 micrograms/dose inhaler 500 micrograms (2 metered doses) twice daily OR: 250 micrograms (1 metered dose) four times a day.Dose may be increased to 500 micrograms four times a day if needed. Note: A dose of 2000 micrograms should not be exceeded! CHILD: 50 micrograms/dose inhaler 50-100 microgram (1-2 metered doses) 2 – 4 times / day PLUS (if necessary): Prednisolone, oral ADULT: 2.5-10 mg once in the morning as required. CHILD: 1-2 mg/kg daily, to a maximum of 20 mg daily in children aged 1 to 5 years, or 40 mg daily in those aged 5 – 15 years. Give once in the morning until controlled; then reduce to the lowest effective dose on alternate days. Note: Beclomethasone inhalers should be used regularly to provide long-term prevention of an asthmatic episode. Long-term prednisolone should be avoided in children unless there is no alternative as it causes growth suppression. Key points • Aspirin, Ibuprofen and other non-steroidal anti-inflammatory drugs can provoke an asthmatic attack in some asthmatics. Asthmatics should generally avoid using these. • Inhalers are only effective if the patient uses the correct inhalation technique, which can be achieved by using a spacer device. A spacer device can be made by cutting a hole in the bottom of a 750-1000ml plastic bottle. Cut the hole to ensure that the inhaler fits tightly. Holding the spacer device horizontally, give one puff into the spacer and breath normally through the top of the bottle for at least 30 seconds. • To avoid oral thrush when using inhaled corticosteroids advise the patient to rinse mouth with water and spit out after inhalation. • The mainstay of severe asthma treatment is the regular use of beclomethasone this is in contrast to the intermittent use of the salbutamol inhaler. Educate patients about the importance of this. Chapter 5 – Musculoskeletal conditions 5.1 Backpain Backpain and lower back pain is a common presenting complaint especially among the elderly. It may be a mild, transient symptom or a chronic and disabling complaint. There are many causes of low back pain therefore it is important to take a good clinical history and physical examination. Some of the causes of back pain are: • Chronic upper back pain in a patient with cough and weight loss may be due to tuberculosis • Mid back pain in a child may be TB of the spine especially if the backbone has a hump or a lump (cold abscess, Potts disease) • Low back pain that is worse the day after lifting or straining may be due to a sprain or muscle strain. • Severe low back pain that comes when lifting or twisting may be a slipped disc, especially if one leg or foot becomes painful, numb, weak. This can result from a pinched nerve. • Standing or sitting wrongly with the shoulder drooped is a common cause of backache • In older people chronic back pain is often arthritis • Pain in the upper right back may be from a gallbladder problem • Acute or chronic pain in the lower back may be due to a urinary tract infection or urinary problem • Low backache is normal for some women during menstrual period or pregnancy • Very low back pain sometimes comes from problems in the uterus, ovaries or rectum. Bed rest initially may provide some comfort. But inactivity beyond 24-48 hours should be avoided. It increases the risk of chronic back pain. Light exercise to increase muscle strength and flexibility, and to reduce spasm should be started. Drug treatment To relieve the pain see chapter 3 Pain management, section on mild pain management OR give: Ibuprofen, per oral Initially 1.2 – 1.8 g in 3 – 4 divided doses preferably after food; increased if necessary to a maximum of 2.4 g daily; maintenance dose of 0.6 – 1.2 g may be adequate. Key points • Backpain can have many different causes therefore careful history taking and examination is vital. • When initiating drug treatment it is better to take the medicines regularly for a few days rather than on an as required basis. • Anti-inflammatories like ibuprofen can cause gastro-intestinal side effects and even ventricular ulcers. Elderly are more at risk for this than young persons. Ranitidin or Omeprazol can reduce this risk. 5.2 Arthritis 5.2.1 Rheumatoid arthritis Chronic inflammation of the joints Symptoms/signs • Pain, stiffness, swelling in small joints for several weeks. • Morning stiffness, weight loss, lethargy, depression • Symptoms can fluctuate • Limitation of movement and destruction of the joint often occurs • The patient may be anaemic, have rheumatoid nodules, muscle wasting and dry eyes Drug treatment To reduce the pain and swelling (in adults): Aspirin, oral ADULT: 0.3 – 1 g every 4 hours after food; maximum in acute conditions 8 g daily; CHILD, juvenile arthritis only: up to 80 mg/kg daily in 5 – 6 divided doses after food, increased in acute exacerbations to 130 mg/kg. Note: high doses of aspirin are very rarely required. OR: Ibuprofen, oral ADULT: initially 1.2 – 1.8 g in 3 – 4 divided doses; increase if necessary to a maximum of 2.4 g daily; maintenance dose of 0.6 – 1.2 g may be adequate. Juvenile rheumatoid arthritis CHILD over 7 kg: 30 – 40 mg/kg daily in 3 – 4 divided doses Key points • Anti-inflammatory medicines such as ibuprofen can cause gastric irritation, ventricular ulcers and bleeding from oong term use. Elderly are more at risk for this than young persons. Concomittant use of Ranitidin or Omeprazol in standard doses, reduces this risk. • Refer all suspected cases to specialist. Children with suspected juvenile rheumatoid arthritis (JCA) should be referred URGENTLY to a paediatrician, and access to potent treatment. • May occur at any age, some form of juvenile arthritis occur at 2-4 years of age and in young adults. Refer all cases to specialist. • Painful joints in young people and children can also be a sign of other serious illness e.g. rheumatic fever or tuberculosis. 5.2.2 Septic arthritis Septic arthritis is a serious infection, affecting one or more joints. The infection can be caused by a variety of different organisms, needing different treatment approaches. Consider Staphylococcus aureus, Gram negatives or Gonorrhoea, depending on age group . Symptoms/signs Pain, swinging fever Restriction of movement of affected limb/s Sudden onset with the large joints usually affected The affected joint is hot, tender and swollen Non-drug treatment Rest the affected joint and try splinting during the acute phase Drug treatment Septic arthritis can develop into a life threatening systemic sepsis. Adequate parenteral antibiotic treatment is needed. For the sexually active adult, also consider the possibility that septic arthritis is due to Neisseria gonorrhoea. Then give Ceftriaxone, 1 gram per each 24 hour period. Treat until there is improvement. Continue with intravenous Ceftriaxone for at least 24 hours after clinical improvement. Treatment can then be changed to per oral Cefixime 400 mg for a duration of 7 days. (WHO has revised the treatment for Gonorrhoea. Due to the widespread problem of resistance in the region, Ciprofloxacin is no longer recommended). Treatment of septic arthritis should be referred to specialist. If the infection is likely to be Gram negative, treatment can also be given with a third-generation cephalosporin. But observe that while there is good Gram negative effect of these drugs, there is far less activity of Ceftriaxone against Gram-positive bacteria such as Group A Streptococci and Staphylococci. Empirical treatment of septic arthritis (and osteomyelitis) in children under 5 years, on suspicion of infection due to Staph aureus, Give: Cloxacillin 50mg/kg up to 12g/day intravenously, 4- to 6-hourly for 4 to 6 days. If the child is not immunised against Haemophilus influenzae type b (Hib), it is also necessary to add treatment with Ceftriaxone 50 to 75mg/kg up to 1g intravenously, daily for 4 to 6 days. If the disease responds to treatment after 4 to 6 days, continue with per oral therapy with Cloxacillin 12.5mg/kg up to 500mg orally, 6-hourly for a total of at least 21 days. If Haemophilus influenzae type b (Hib) infection is considered as the most likely diagnosis, it is also effective to use; Amoxycillin+Clavulanic acid at a dose of 22.5mg/kg up to 875/125mg per orally, repeated every 12-hour for a total duration of at least 21 days. For adults and children over 5 years, Give: Cloxacillin 25 to 50mg/kg up to 2g intravenously, repeated every 6-hour for a duration of 4 to 6 days, then 25mg/kg up to 500mg per orally, every 6-hour for a total of at least 21 days. For adult patients and children over 5 years hypersensitive to penicillin Give: Clindamycin (child: 10mg/kg up to) 600mg then Clindamycin (child: 5mg/kg up to) 300mg per orally, 8-hourly. Treatment for septic arthritis and osteomyelitis when the infection is likely due to Methicillin-susceptible Staphylococcus aureus, Give: Cloxacillin (child: 50mg/kg up to) 2g intravenously, 6-hourly for 2 to 4 weeks in case of acute septic arthritis, and for a duration of 2 to 6 weeks in chronic bone or chronic joint infection. This is followed by per oral Cloxacillin (child: 25mg/kg up to) 1g orally, repeated every 6-hour for a total of at least 6 weeks in acute infection. Treatment may need to continue for several months in cas of chronic infection. This treatment is a specialist responsibility. To reduce the pain and swelling: Give: Aspirin, oral ADULT: 0.3 – 1 g every 4 hours after food; maximum in acute conditions 8 g daily. OR: Ibuprofen, oral ADULT: initially 1.2 – 1.8 g in 3 – 4 divided doses preferably after food; increased if necessary to max. 2.4 g daily; maintenance dose of 0.6 – 1.2 g may be adequate. Key points • Anti-inflammatory NSAIDs like ibuprofen can cause gastro-intestinal side effects and even ventricular ulcers. Elderly patients are more at risk than young persons. Ranitidin or Omeprazol can reduce the risk. • The infection can be caused by a number of organisms therefore it is important that if septic arthritis is suspected the patient is referred to hospital so the organism can be identified (usually by joint aspiration) and the appropriate antibiotic selected. 5.2.3 Osteoarthritis Degenerative joint disease, which affects weight-bearing joints e.g. hips, knees but can also affect joints in hands. Symptoms/signs Morning stiffness that improves with exercise. Pain when exercise is started. A reduction in the movement of the joint. Non-drug treatment Encourage weight reduction if the patient is overweight. This will reduce the load on the joint. Encourage light exercise to retain movement Weight supports e.g. crutches, walking sticks, may be needed Drug treatment To reduce the pain (in adults): ADULT: Give Aspirin, oral ADULT: 0.3 – 1 g every 4 hour maximum in acute conditions 8 g daily. CHILD: Give Paracetamol, oral, 10-15 mg/kg every 4 hours (not more than 4 doses in 24 hours) Always calculate dose of Paracetamol according the weight of the child. OR: Ibuprofen, oral ADULT: initially 1.2 – 1.8 g in 3 – 4 divided doses; increased if necessary to a maximum of 2.4 g daily; maintenance dose of 0.6 – 1.2 g may be adequate. CHILD: 5-10 mg/kg every 6 hour Key points • Anti-inflammatories like ibuprofen can cause gastro-intestinal side effects. Elderly patients are more at risk for NSAID indiced ulcers. • Long-term management of severe cases need referral to orthopaedic surgical specialists 5.3 Gout 5.3.1 Gout – acute A condition where uric acid crystals deposit in the joints and other tissues. Symptoms/signs • One joint becoming very hot, painful and red. • Uric acid deposits in and around the joints. • Deformity due to uric acid deposits may occur. • Renal disease – poor kidney function, uric acid kidney stones. • Blood levels of uric acid increased (above 0.5mmol/L). Dehydration, fasting, binge eating or drinking alcohol can cause an acute episode of gout. Non-drug treatment Patient should have bed rest and drink lots of water. Do NOT drink alcohol and do NOT take aspirin. Drug treatment Ibuprofen is unsuitable for the treatment of an acute attack. Diclofenac is recommended, after specialist consultation Diclofenac, oral ADULT: 75 – 150 mg daily in 2 – 3 divided doses. If the patient is already being treated for heart failure or is on anti-coagulants e.g. warfarin then treat an acute attack of gout with colchicine, which should be ordered on special request: Colchicine, oral 1mg initially, followed by 500 micrograms every 2-3 hours until relief of pain is obtained or vomiting or diarrhoea occurs, or until a total dose of 6 mg has been reached; the course should not be repeated within 3 days. 5.3.2 Gout – chronic Chronic gout involves: • Many acute attacks – more than 4 per year. • Bony destruction. • Tophi – uric acid deposits in and around joints and cartilages of extremities. • Kidney stones. • Poor renal function. • Serum uric acid over 0.5mmol/L. Non-drug treatment Check to see if a thiazide diuretic e.g. hydrochlorothiazide, is being taken by the patient and change to an alternative diuretic. Advise patient to avoid alcohol, aspirin, and some foods e.g. red meat. Drug treatment Allopurinol should never be started during an acute attack. Treatment is usually started 2 – 3 weeks after the attack has settled. Give: Allopurinol, per oral Initially 100 mg daily, preferably after food, then adjusted according to plasma or urinary uric acid concentration; usual maintenance dose in mild conditions 100-200 mg daily, in moderately severe conditions 300-600 mg daily, in severe conditions 700-900 mg daily; doses over 300 mg daily given in divided doses. The period of introduction of allopurinol should be covered by use of colchicine or diclofenac until normal serum uric acid levels have been achieved. Ibuprofen is unsuitable for the treatment of an acute attack. Diclofenac should be ordered on special request: Give: Diclofenac, per oral ADULT: 75 – 150 mg daily in 2 – 3 divided doses. OR: Colchicine, per oral 500 micrograms 2-3 times daily and continuing for at least 1 month after hyperuricaemia has been corrected, (usually about 3 months of prophylaxis). Key points • Always remember to also consider the possibility of septic arthritis • Allopurinol should not be given during or within 2 – 3 weeks of an acute attack. • In the elderly, or patients on diuretics or with impaired renal function, allopurinol should be started at 100mg daily and cautiously increased if necessary. • Colchicine is effective and specific for acute attacks of gout but is not easy to use because of the development of vomiting and diarrhoea. Chapter 6 – Cardiovascular conditions 6.1 Hypertension Blood pressure persistently elevated constitutes an increased risk for early death, stroke, heart attack, heart failure and kidney failure. Symptoms/signs Persistently high blood pressure of more than 140/90 mmHg on at least three different measurement occasions (different days) taken after the patient has rested for at least thirty minutes. Hypertensive patients may be without symptoms but may also complain of headache, palpitation, dizziness, and being tired easily. Some drugs may cause an increase in blood pressure e.g. sodium-retaining drugs: glucocorticoids, non-steroidal anti-inflammatory drugs, sympathomimetics, amphetamines, monoamine-oxidase inhibitors, aminophylline, cold cures, oral contraceptives. Treatment Treatment for control of hypertension need to be long-lasting and aims to reduce the risk of cardiovascular or renal complications by maintaining blood pressure at 140/90 or less, with a minimum of adverse effects. Non-drug treatment involving lifestyle changes must always be considered first as these will contribute significantly to reduction in raised blood pressure. Non drug treatment – lifestyle modification All patients with hypertension must modify their lifestyle with the aim of reducing their blood pressure and prevent deterioration. Patients should be motivated and educated to: • Reduce weight if above ideal weight • Regular physical exercise • Stop smoking • Restrict alcohol intake • Restrict salt intake • Restrict cholesterol intake Drug treatment • Start with one first line drug • Start with the lowest recommended dose • Wait for 3-4 weeks to assess if the drug is not effective or not well tolerated, then change drug or add a drug of different class. First line, drugs of first choice; Hydrochlorothiazide, per oral Give; 12.5 to maximum 25 mg per day, once per day as morning dose for long-term treatment. More than 25 mg per day does not increase antihypertensive effects, but doses above this level causes electrolyte- imbalance with hypokalemia. This in turn aggravates the risk for arrhythmia in any patient with ischemic heart disease. Higher doses also induces insulin resistant diabetes. The antihypertensive effect of thiazide diuretics takes at least a period of 2-3 weeks continuous daily treatment to be established. If the needed antihypertensive effect is not achieved after 3-4 weeks with 25 mg hydrochlorthiazide, add a beta blocker such as atenolol. Contraindicated in patients who suffer from gout. Atenolol, per oral 50mg once a day – long term, higher doses rarely necessary. Contraindicated in patients with heart failure, diabetes mellitus, asthma and chronic obstructive airways disease, peripheral vascular disease, pulse rate less than 50/minute. Second line medicines ACE inhibitors Captopril, per oral Used alone, initially 12.5 mg twice daily; in elderly, initially 6,25 mg twice daily (first dose at bedtime); usual maintenance dose 25 mg twice daily; maximum 50 mg twice daily (rarely 3 times daily in severe hypertension). Caution: concomitant potassium supplements or potassium retaining drugs should be avoided, or used only with careful monitoring of serum potassium. Contra-indicated in pregnancy. Calcium channel blockers Nifedipine, sustained release 20 mg every 12 hours, increase if necessary to 40 mg every 12 hours. Centrally acting Methyldopa, oral Initially 250 mg 2-3 times daily, increased gradually at intervals of 2 or more days, maximum 3 g daily. ELDERLY: initially 125 mg twice daily, increased gradually, maximum 2 g daily. Special cases of hypertension Hypertension in diabetics Thiazide diuretics are contraindicated in the diabetic patient, because the may impair glucose tolerance, exacerbate hyperglycaemia and hyperlipidaemia. Beta-blockers are contraindicated in the diabetic patient, because they can interfere with awareness of, and recovery from, hypoglycaemia in insulin dependent diabetics. Recommendations: ACE inhibitors, calcium channel blockers or alpha-blockers. In hypertensive patients with diabetic nephropathy ACE inhibitors have been found to be more effective in slowing the decline in renal function and are the agent of first choice. Pregnancy induced hypertension See chapter Reproductive Health Treatment resistant hypertension Poor compliance should always be considered in all treatment-resistant patients. Drug interactions should be considered (such as concurrent use of non-steroidal anti-inflammatories, aminophylline, cold cures etc) If control remains poor, refer to a specialist. Accelerated or very severe hypertension Accelerated (or malignant) hypertension or very severe hypertension (e.g. blood pressure >140 mmHg) requires urgent treatment in hospital, but is not an indication for parenteral antihypertensive therapy. Normally treatment should be by mouth with a beta-locker (atenolol) or a long-acting calcium-channel blocker (nifedipine, slow-release). Within the first 24 hours the diastolic blood pressure should be reduced to 100 -110 mmHg. Over the next 2 or 3 days blood pressure should be normalised by using beta-blockers, calcium-channel blockers, diuretics or ACE inhibitors. Too rapid reduction in blood pressure can reduce organ perfusion leading to cerebral infarction and blindness, deterioration in renal function, and myocardial ischaemia. Parenteral antihypertensive drugs are rarely necessary. Key points • Refer urgently – hypertensive emergencies diastolic > 120 mmHg, cases of severe hypertension > 170/100 mmHg, • Refer within the next week – children or young adults with high blood pressure, cases that cannot be controlled, diabetics with hypertension, when there are signs of end organ damage e.g. if the patient has oedema, proteinuria etc. • Hypertension is not a disease but an important risk factor for cardiovascular and cerebrovascular disease • Correct measurement of blood pressure is vital to ensure that only the true hypertensive receives treatment • Patients should be counselled that treatment and lifestyle changes are for life • There is no ideal antihypertensive drug that reduces blood pressure at a reasonable cost without causing side effects • It is important to match the antihypertensive medication to the patients other co-existing disease states to gain the most benefit • Initial follow-up should be every 2 to 4 weeks until blood pressure is satisfactory, then follow-up can be every 3 months. 6.2 Heart failure This is a condition in which the heart is not able to maintain adequate cardiac output. Left ventricular (left side) failure may cause pulmonary congestion. Right ventricular (right side) failure may cause peripheral and hepatic congestion. Both forms can occur together. Symptoms/signs Heart failure is mainly a disease of the elderly. It is a result of damage to the heart due to some other underlying disease. Usually presents with shortness of breath on exertion or at rest, swelling of ankles, ascites (accumulation of fluid in the abdomen) and easy fatigability. More specifically: Left heart failure – shortness of breath after exercise, discomfort when breathing (relieved if person sits or stands up), shortness of breath at night causing the patient to wake up, wheezing, cough with bloody sputum, tiredness, increased respiration rate, heart murmur, gallop rhythm, crackles may be heard in the lungs. Right heart failure – abdominal discomfort and fluid build up in the abdomen, peripheral oedema (fluid build up) often seen around the ankles, increased heart rate, gallop rhythm, enlargement of the liver. Non-drug treatment Restrict salt in diet. Advise patients not to add salt to their diet. Avoid alcohol and weight reduction. Encourage bed rest but patients should be encouraged to be active when symptoms are mild or absent. Drug treatment Patients presenting at a primary health facility should be referred to a doctor for further management. Initial therapy for all grades of heart failure is: Captopril (cardiac failure, adjunct) Initially 6.25-12.5 mg under close medical supervision; usual maintenance dose 25 mg 2-3 times daily; usual maximum dose 150 mg daily. There is a risk of first-dose hypotension but this can be minimised by starting with very low doses of captopril. If response to captopril is inadequate then add: Give: Furosemide, oral 20 – 40 mg daily (in the morning) OR: Hydrochlorothiazide, oral 25 – 50 mg daily in mild heart failure. Patients receiving captopril and furosemide or hydrochlorothiazide should have electrolytes and renal function monitored. Patients receiving frusemide or hydrochlorothiazide may experience hypokalaemia (low blood potassium levels) therefore these patients must be encouraged to eat potassium rich foods such as fruit (bananas). Note: Patients with renal impairment who are on captopril AND furosemide or hydrochlorothiazide do not usually need potassium supplements as these could cause life-threatening hyperkalaemia (high blood potassium levels). To control rapid ventricular rate (in atrial fibrillation) or with sinus rhythm then add in: Digoxin, oral To obtain a rapid effect in acute situations: ADULT: 1-1.5 mg in divided doses over 24 hours. In less urgent cases: 250-500 micrograms daily (higher dose may be divided). Maintenance: 62.5 – 500 micrograms daily (Higher doses may be split up, and given as two or more doses per day). Dose should ideally be is djusted to age, plasma creatinine and resulting digoxin levels. OR: Digoxin, intravenous Emergency loading dose by IV infusion 0.75 – 1 mg over at least 2 hours, then maintenance dose by mouth on the following day. Continue with oral maintenance dose. Note: the dose need to be reduced if digoxin or another cardiac glycoside has been given the preceding 2 weeks. Acute pulmonary oedema Prop up in bed. Give Oxygen by mask. Give: Furosemide, IV Initially slow intravenous injection of 40 mg, if no satisfactory response within one hour, the dose may be increased to 80 mg given slowly intravenously. If patient is in pain or apprehensive give Morphine, IV: 5-10mg slowly If there is fast atrial fibrillation give Digoxin, oral Monitor urine output Treatment resistant cardiac failure Refer to specialist 6.3 Ischaemic heart disease Pain occurs because there is a blockage or partial blockage in the blood vessels feeding the heart muscle. There are three main types to consider, stable angina, unstable angina (as a pre-stage to myocardial infarction) and Myocardial infarction. Spasm-angina is not addressed here. The main separation need to be done between (i) stable angina, and on the other hand (ii) unstable angina and (iii) myocardial infarction. In the second and third case, immediate action shall be taken with giving a loading dose of Aspirin, antiarrhythmic beta blocker (atenolol or metoprolol) if the patient is hemodynamically stable and Oxygen. Then as next step, urgent referral to hospital is essential. If angina however is appearing in direct relation to physical exercise or stress, it is likely a stable angina. This can often be handled well with a vasodilator. The mechanism behind stable angina is, when emotional stress or exercise creates a demand for more blood flow to the heart muscle, this cannot be achieved because of an obstruction in the blood vessel. In contrast, the mechanism behind unstable angina is due to rupture of atherogenic plaques, and as such it causes thrombosis and heart musle necrosis, and may progress to full myocardial infarction. Unstable angina occurs without any obvious causal link to physical exercise or stress factor. Aspirin is then essential to prevent risk for acute thrombosis, and beta blocker is essential to prevent risk for arrhythmia. 6.3.1 Angina This is a recurrent central chest pain often induced by exertion. It is the result of a partial obstruction of a coronary artery and the principal factors associated with this are smoking, hypertension, diabetes and high blood cholesterol levels. Symptoms/signs Central chest pain often radiates to the left arm, neck or jaw. Pain is relieved by rest. Angina is often worse on effort, cold weather or after meals. Non-drug treatment Reassurances that the condition is not rapidly fatal. Stop smoking. Reduce weight. Regular gentle exercise. Minimise stressful life style. Control of hypertension, and diabetes and reduction in blood cholesterol levels. Drug treatment Acute attack The patient should know to stop physical activities as soon as pain is felt: Give: Isosorbide dinitrate, sublingual 5 mg sublingually, repeat every 5 minutes if pain persists, up to a maximum of 3 tablets. Stable angina, attacks which occur related to physical exercise: Give: Aspirin, oral 100-150 mg once a day – long-term PLUS: Isosorbide dinitrate, sublingual Prophylaxis: ADULT: 30 – 120 mg/day, divided doses. Tolerance: Patients taking isosorbide dinitrate for the long-term management of angina may often develop tolerance to the antianginal effect. Tolerance can be avoided by giving the second of 2 daily doses of longer-acting oral presentations after an 8 hour rather than a 12-hour interval, thus ensuring a nitrate-free interval each day. Frequent attacks of angina: Give: Aspirin, oral 100-150 mg once a day – long-term PLUS: Isosorbide dinitrate, slow release, oral 30 – 120 mg daily in divided doses PLUS: Atenolol, oral ADULT: 50 mg once daily, increased if necessary to 50 mg twice daily or 100 mg once daily. Refer to hospital. General notes • Angina which occurs unrelated to physical or other stress, is likely a case of unstable angina. This is a high risk condition, with high risk to progress to myocardial infarction. These patients thus need urgent hospital-referral for correct management. Before sending these patients to hospital, give a dose of per oral 300 mg aspirin (taken with a big glass of water to speed up absorption). This aspirin dose helps to prevent thrombose-formation, with a proven significant decreased risk for 24-hour mortality, when given on suspicion of unstable angina, or on suspicion of myocard infarction. • Refer patients when the chest pain of uncertain cause. 6.3.2 Myocardial Infarction Symptoms/signs Chest pain very severe or mild may radiate to left arm, neck and jaw. Persists and is not relieved by rest or glyceryl trinitrate. Patient is restless, apprehensive and in severe pain. Nausea, vomiting, shortness of breath, collapse. Peripheral or central cyanosis. Pulse thready, fast and possibly irregular. Low blood pressure. Raised jugular venous pressure. Bilateral crackles in chest. Presence of third or fourth heart sound. Non-drug treatment Bed rest and reassurance. Monitor pulse rate, blood pressure and respiratory rate. Drug treatment Oxygen administration Set up an intravenous line (dextrose 5% or sodium chloride 0.9%) Avoid intramuscular injections where possible as this interferes with the measurement of cardiac enzymes and results in haematomas with thrombolytic agents. Give: Aspirin, oral 300 mg, as single start-dose, then continue with; 100-150 mg once/day in long term treatment. PLUS: Morphine, slow IV injection (2 mg/minute) 10 mg followed by a further 5-10 mg if ecessary; elderly or frail patients, reduce dose by half. PLUS: Isosorbide dinitrate, sublingual 5 mg sublingually, provided systolic BP above or equal to 95 mmHg PLUS: Atenolol, oral 25 -100mg once a day Key points • Refer urgently after initial management above. • Do not give Adrenaline, as it may cause extension of the infarction. 6.4 Arrhythmia Symptoms/signs Palpitations and dizziness Syncopal attacks (sudden attacks) Chest discomfort, dyspnoea (shortness of breath) and headache Pulse irregular. Missed beats either at regular or random intervals In complete heart block pulse is slow (30-40 beats/minute) and regular Drug treatment Refer immediately to a facility with a doctor and equipment to diagnose the type of arrhythmia. Key points • It is dangerous to use any antiarrhythmic drug without doing an appropriate ECG examination. Refer symptomatic patients to hospital immediately. Choice of drug depends on the type of arrhythmia and severity of symptoms. 6.5 Rheumatic fever This illness is a complication of a streptococcal infection of the throat. Fever plus inflammation mainly the joints and heart. It is a major cause of permanent damage to the heart. Symptoms/signs The onset of symptoms occurs 1-3 weeks after the throat infection. Persistent fever, pain moves from one joint to another (migratory arthritis) Tires easily and looks unwell Tenderness with or without swelling on any of the joints mentioned above Carditis – rapid heart rate and / or palpitations, murmur, heart failure, pericardial rub, breathlessness and chest pain. Non-drug treatment Bed rest until rheumatic activity subsides Drug treatment: Give: Benzathine penicillin, IM as a single dose ADULT and CHILD >30 kg: 900 mg = 1.2 million units CHILD <30 kg: 450 to 675 mg = 0.6 to 0.9 million units OR: Phenoxymethylpenicillin (Penicillin V), oral 10 mg/kg up to 500 mg every 12 hours. Duration: 10 days. OR, if patient allergic to penicillin Erythromycin, oral ADULT: 250 mg every 6 hours; CHILD: 12.5 mg/kg every 6 hours. Duration: 10 days. To suppress rheumatic activity give: Aspirin, oral ADULT: 0.3 – 1 g every 4 hours after food; maximum in acute conditions 8 g daily. CHILD, Aspirin only in juvenile arthritis: then up to 80 mg/kg daily in 5 – 6 divided doses after food, increased in acute exacerbations to 130 mg/kg Aspirin should be continued until fever, all signs of joint inflammation and the ESR have returned to normal. Then taper gradually over 2 weeks. If symptoms recur, full doses restarted. In severe carditis with increasing heart failure or failure of response to aspirin add: Prednisolone, oral 0.5 – 2mg/kg up to 60 mg/day, given every 6 or 12 hr. The fully suppressive oral dose of prednisolone should then be resumed until the ESR has remained normal for 1 week or more and is then tapered at the rate of 5 mg every 2 days. To prevent rebound, NSAIDs are begun simultaneously and continued until 2 weeks after the prednisolone has been stopped. Continual antibiotic prophylaxis against streptococci infection, for patients with history of rheumatic fever: Give: Benzathine penicillin, IM ADULT and CHILD 900 mg = 1.2 million IU once eve 450 mg = 0.6 million IU once every 3-4 weeks. OR: Phenoxymethylpenicill All ages: 250 mg every 12 hours OR: Erythromycin, oral (all ages) All ages: 250mg twice a day. Chapter 7 – Blood disorders 7.1 Anaemia The diagnosis of anaemia is defined when: Males – Hb levels lower than 13 g/dl Females – Hb levels lower than 12 g/dl Children 6 to14 years– Hb levels lower than 12 g/dl Children 6 months to 6 years – Hb levels lower than 11 g/dl Symptoms/signs The patient may complain of becoming tired easily, dizziness, shortness of breath when exercising, palpitations. The patient may have: • Pale or transparent skin, pale gums and tongue, palmar pallor. • Pale insides of eyelids and pale fingernails • Weakness and fatigue • The spleen may be palpable. • Signs of high output cardiac failure if anaemia is severe. Thorough examination is required to attempt to identify the underlying cause of the anaemia. Iron deficiency anaemia Iron deficiency is the most common cause of anaemia and occurs most commonly in young children and women of childbearing age. In pregnancy and immediately after delivery deficiency in folic acid and/or combined with iron deficiencies is common. Megaloblastic/macrocytic anaemia This is anaemia with large red blood cells and is commonly due to deficiency of Vitamin B12 and/or folic acid. Vitamin B12 deficiency is very rare in childhood. Non-drug treatment Advise on an iron rich diet e.g. meat, fish, and chicken are high in iron. Liver is especially high. Dark green leafy vegetables, beans, peas and lentils. Drug treatment Identify cause of anaemia and treat e.g. malaria, intestinal parasites/nematodes, dysentery. In every patient with anaemia, screen for parasites (worms in stools) or provide empirical deworming treatment. It is also important to screen and / or treat for malaria. Indication for blood transfusion in the treatment of anaemia: normally refer anaemic children for blood transfusion if a) Hb < 4g/dl or b) Hb < 6g/dl and has symptoms. Iron deficiency anaemia Restore the iron levels by giving: Ferrous sulfate (Iron), oral ADULT: 200 mg (= 65 mg iron) three times a day. CHILD: 6mg/kg/day elemental iron oral. Iron paediatric dosing chart IRON Treatment of anaemia: 6mg/kg/day elemental iron oral. Age or Weight Iron and Folate Tablet Ferrous sulfate 200 mg + Folate 400 micrograms (60 mg of elemental iron) IMCI Ferrous sulfate oral solution 25 mg elemental iron / ml WHO2004 Anemia Program Pelathihan Perawat Klinik Ferrous sulfate tablet 60 mg of elemental iron 6 –12 months (7 kg – <10kg) 1 = 60 mg 1.5 ml = 37.5 mg 1/2 – 1 = 30 – 60 mg 1 year – 5 years (10 kg – 19 kg) 1 ½ = 90 mg 3 ml = 75 mg 1 – 1 ½ = 60 – 90 mg 5 years – 15 years (20kg – 29 kg) 2 = 120 mg ——– 1 ½ – 2 = 90 – 120 mg Treatment should be given for 3 months. It takes 2 – 4 weeks to correct the anaemia and 1 – 3 months after the haemoglobin reverts to normal to build up iron stores. Caution – iron is very toxic in overdose. This is particularly dangerous in children. Megaloblastic/macrocytic anaemia Special investigations are required to confirm the diagnosis. If Vitamin B12 deficiency anaemia, then give parenteral: Hydroxocobalamin, IM Initially 1 mg 3 times a week for 2 weeks, then 1 mg every 3 months If folic acid deficiency give: Folic acid, oral ADULT: Initially, 5 mg daily for 4 months; Maintenance: 5 mg every 1-7 days, depending on underlying disease. NEONATE: 50 micrograms; CHILD under 4 years: 0.1 – 0.25 mg daily; CHILD over 4 years: 0.5 – 1 mg daily. Note: folic acid should never be given alone for pernicious anaemia and other vitamin B12-deficiency states (may precipitate subacute combined degeneration of the spinal cord). Key points Refer patients with: • Undiagnosed cause and type of anaemia • Symptoms of anaemia – fainting, palpitations, shortness of breath • Evidence of cardiac failure. • Symptoms or signs of acute blood loss • Blood in stool • Pregnant women • Children with HB<8g/dl and Adults with HB<7g/dl • No improvement after treatment with iron 7.2 Bleeding disorders May be present from birth or acquired later in life. There is Ooften Vitamin K deficiency in the newborn, with bleeding risk. Bleeding risk may also be due to Dengue haemorrhagic fever or in rarer causes (leukaemia, congenital disorders of coagulation. Or drug induced bleeding due to non-steroidal antiinflammatory drugs). Symptoms/signs Bleeding may be spontaneous or after trauma/surgery. It may occur into the skin, gastrointestinal tract, brain, joints and muscles, urine, from gums and nose. In newborns with Vitamin K deficiency spontaneous bleeding occurs from various sites – umbilical cord, gastrointestinal tract, scalp, brain and there is usually a history of failure to administer Vitamin K injection at birth. With a large bleed patients may be severely anaemic and in haemorrhagic shock. Non-drug treatment Apply pressure bandage to minimise bleeding where possible Identify underlying cause and treat e.g. Dengue fever. Stop any drugs thought to be responsible for bleeding or which may aggravate bleeding. Drug treatment It is very important to treat the underlying cause of bleeding appropriately first i.e. dengue etc. Treatment and prophylaxis of haemorrhagic disease of the newborn: Phytomenadione (Vitamin K) , IM, IV Treatment: 1mg and, if necessary, further doses may be given 8-hourly. Prophylaxis: 0.5 – 1 mg as a single dose intramuscularly (preferred route). In adults and older children the following measures will help to arrest bleeding depending on cause: Transfusion. Relatives can be asked to donate blood. In cases of liver disease and abnormal prothrombin time give Phytomenadione (Vitamin K), IM ADULT: 5 -10mg/day for 2 – 3 days CHILD: 0.3mg/kg (maximum 10mg) IM or IV over 1 hour. Key points • Refer all patients for further evaluation in hospital • Avoid intramuscular injections and unnecessary surgical procedures • Prophylactic administration of Vitamin K to all newborn. Chapter 8 – Common skin conditions 8.1 Bacterial skin infections 8.1.1 Boils/Abscess A boil/abscess is a bacterial infection of hair follicles of the skin. Usually painful, and most frequently caused by Staphylococcus aureus. Symptoms/signs Swellings with pus, red, warm and painful. If multiple or recurrent boils/abscesses occur, consider diabetes mellitus or immunodeficiency. Non drug treatment A boil/abscess will often develop into a swelling with a mass of pus in the centre. When “ripe” it will burst or can be incised and drained. Application of hot compresses placed over the boil/abscess three times daily may help to bring it to the stage when it will burst or can be incised and drained. 30 minutes before the incision, give antibiotic Cloxacillin to prevent systemic spread of infection. Drug treatment Consider antibiotics only if the boil/abscess causes swollen lymph nodes or fever. Cloxacillin, oral, at least 30 minutes before food ADULT: 250mg – 500mg 4 times a day for 7 days. CHILD – dose for treating abscesses: 15 mg/kg every 6 hours. If patients are allergic to penicillins then give: Erythromycin, oral ADULT and CHILD over 8 years: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours Duration: 5 – 7 days. Key points • Abscessae and boils can not be treated with antibiotic alone, because antibiotics cannot penetrate pus in a fluctuant boil/abscess. • All boils/abscesses in diabetic or immunocompromised patients requires referral for specialist management. 8.1.2 Impetigo Impetigo is a staphylococcal or streptococcal skin infection common in children. It is highly contagious. Symptoms/signs Blisters and pustules rapidly spread and turn into irregular pussy sores with shiny yellow weeping crusts. The sores are painful. May be associated with conditions such as scabies, eczema, lice infestation and herpes simplex infection or any condition where the skin is broken. Treatment is initiated to eliminate infection and to prevent transmission. Non drug treatment Prevent infection by keeping breaks in the skin clean. Cut fingernails and keep these clean. Bathe affected parts, soak off the crusts with soap and water or use: Chlorhexidine 0.5% solution Use to clean the wound at each dressing change. Dilute 10ml of Chlorhexidine 5% with 90 ml of water to make 100ml of 0.5% solution Avoid spreading to other parts of the body or to other people by keeping the infected areas clean and taking care with towels, clothes, bedding etc. Keep these clean and wash separately. Drug treatment Dress wounds with Povidone iodine 10% solution (undiluted) Apply three times a day. When likely Streptococcal, give Phenoxymethylpenicillin, Adult, 500 mg every 6 hour, child up to 1 year, 62,5 mg every 6 hour, child 1-5 years, 125 mg every 6 hour, child 6-12 years 250 mg every 6 hours, for 5-10 days Or: Amoxycillin, adult and child over 10 years, 250 mg every 8 hour if severe infections. Child up to 10 years, 125 mg every 8 hours, double in severe infection. When likely Staphylococcal, give Cloxacillin, oral, at least 30 minutes before food ADULT: 250mg – 500mg every 6 hours. CHILD: 25 – 50 mg/kg every 6 hours. Duration: 10 days When patient is allergic to penicillins the give: Erythromycin, oral ADULT and CHILD over 8 years: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours Duration: 10 days Key points • Impetigo is often due to a mix of bacteria. Cloxacillin is effective against one of the two most common bacteria, Staphylococcus aureus, but less effective agaoinst Streptococci. Mixed impetigo should therefore be treated with a combination, using both Clocaxillin and Phenoxymethylpenicillin, or Amoxycillin. 8.1.3 Cellulitis Streptococcal or staphylococcal infections, causing inflammation of the soft tissue under the skin. Often follows an infected wound or prick by a pin, nail or thorn or insect bite. Diabetes mellitus is predisposing. Symptoms/signs Pain, tender and erythematous swelling of the area, fever, malaise, inflamed nodes in that region. If severe may also cause septic shock (fever, chills, tachycardia, headache, hypotension and delirium). Requires immediate antibiotic drug treatment and referral. Drug treatment In mild cases give: Cloxacillin, oral, at least 30 minutes before food ADULT: 250mg – 500mg every 6 hours for 10 days. CHILD: 25 – 50 mg/kg every 6 hours. Duration: 10 – 14 days When patient is allergic to penicillins the give: Erythromycin, oral ADULT and CHILD over 8 years: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours Duration: 10 – 14 days. When severe, refer for admission to hospital; take swab for culture and sensitivity tests. For the pain also give an analgesic. Key points • Important to treat diabetic patients quickly and affectively to avoid ulceration, gangrene and amputation. • Refer if the cellulitis is associated with underlying conditions such as varicose ulcers of if it is acute, severe or has a very speedy onset with systemic symptoms. 8.2 Fungal skin infections 8.2.1 Ringworm (Tinea Corporis) Fungal infection of the body or face. Highly contagious Symptoms/signs Round expanding lesions with white, dust-like scales and distinct thickened raised edges. Patches slowly grow bigger, as the patch extends a clear area develops in the centre. Flexures of toes, fingers, armpits, groin, skin below the breasts as well as nails may be affected. Non-drug treatment Keep infected areas clean. Avoid sharing towels, clothes and bedding etc. Wash these separately and frequently. Wash skin well and dry carefully before applying treatment. Drug treatment The first line antifungal treatment is Whitfield’s ointment Benzoic acid 6% and salicylic acid 3%, ointment Apply twice daily until infected skin is shed (usually at least 4 weeks) If the infection is in the groin area or if the above treatment is unsuccessful then use second line antifungal treatment: Miconazole 2%, ointment/cream Apply twice daily to clean dry lesions, continuing for at least 10 days after the condition has cleared. If the fungal infection covers a large area of the body or involves the nails then give oral treatment with Griseofulvin, oral ADULT: 500 mg daily, in divided doses or as a single dose, in severe infection dose may be doubled, reducing when response occurs. CHILD: 10 mg/kg daily in divided doses or as a single dose. Note: Duration of treatment depends on thickness of the keratin layer: 2 to 6 weeks for infections of hair and skin, up to 6 months for infections of the fingernails, and 12 months or more for infections of the toenails. Key points • Advise the patient to continue with treatment for the recommended duration to ensure that the infection has been eliminated. Stopping treatment early may cause the infection to re-emerge. • Trim nails to remove infected areas during this time. • Refer if there is no response to the treatment 8.2.2 Athletes foot (Tinea pedis) This is a common fungal infection and is often the source of infection at other sites. Symptoms/signs Itchy, burning, stinging skin. Start between toes spreading to sole of the foot. Often wet or weepy, skin layers flaking off. Reinfection is common. Non-drug treatment Keep the area clean and dry as possible, dry between toes after washing or walking in water. Wash feet and dry before treatment application Drug treatment First line treatment is Whitfield’s ointment: Benzoic acid 6% and salicylic acid 3%, ointment Apply twice daily until infected skin is shed (usually 4 weeks) If first line treatment fails then use the second line treatment, which is: Miconazole 2%, ointment/cream Apply twice daily to clean dry lesions, continuing for at least 10 days after the condition has cleared. In very severe infection and involves the nails use oral therapy: Griseofulvin, oral ADULT: 500 mg daily, in divided doses or as a single dose, in severe infection dose may be doubled, reducing when response occurs. CHILD: 10 mg/kg daily in divided doses or as a single dose. Note: The duration of treatment depends on the thickness of the keratin layer: 2 to 6 weeks for infections of the hair and skin, up to 6 months for infections of the fingernails, and 12 months or more for infections of the toenails. Key points • Fungal infections of the feet commonly occur where the feet are often wet e.g. through not drying the feet carefully after bathing, sweat from having the feet in socks and closed shoes. Therefore, keep feet especially dry and clean between toes. 8.2.3 Pityriasis versicolor, (Tinea versicolor) Caused by fungi which produce depigmented diffusely scaly patches Symptoms/signs Hypopigmented (light coloured) patches of skin of varying size on chest, back, arms and occasionally neck and face. Drug treatment Treatment is initiated to eliminate the infection as well as to prevent transmission to others: Miconazole 2%, ointment/cream Apply two times / day onto clean dry lesions, continuing for at least 10 days after the symptoms have cleared. Key points • Griseofulvin is not effective as a treatment and therefore should not be prescribed. 8.2.4 Scalp ringworm (Tinea capitis) Caused by fungi which have grown into the hair follicle Symptoms/signs Bald patches of ringworm on scalp. Drug treatment Treat with the following: Griseofulvin, oral ADULT: 500 mg daily, in divided doses or as a single dose, in severe infection dose may be doubled, reducing when response occurs. CHILD: 10 mg/kg daily in divided doses or as a single dose. Note: The duration of treatment depends on the thickness of the keratin layer: 2 to 6 weeks for infections of the hair and skin, up to 6 months for infections of the fingernails, and 12 months or more for infections of the toenails. Key points • Topical treatment is likely to be ineffective because it cannot penetrate into the hair follicle therefore oral antifungal treatment must be taken. 8.2.5 Candidiasis of the skin An infection of the skin caused by Candida albicans. Symptoms/signs Moist, weepy lesions, red raw looking patches appear commonly under the breasts, axilla, groin, perineum, and nail folds. Infants in nappies frequently present with this infection in the nappy area. The rash is commonly present in the skin creases and there are often scattered “satellite” lesions Non-drug treatment Try to keep the area clean and dry. Wear cotton clothing. Change infants’ nappies frequently. Drug treatment Treat with Miconazole 2%, ointment/cream Apply twice daily to clean dry lesions, continuing for at least 10 days after the condition has cleared. Key points • Refer if the infection is not responding to the topical treatment. 8.3 Viral skin infections 8.3.1 Herpes simplex Commonly known as “cold sores”, with sores occurring around the lips and gums (but may occur elsewhere e.g. genitals). May reclapse. Symptoms/signs Small vesicles appear which then develop into a larger sore. The sores are painful. The first time the patient has cold sores (usually a small child) there may be a high fever and the mouth may be covered with small blisters and superficial sores. Non-drug treatment Keep the sores dry. Identify the reason for decreased well-being and treat this. Drug treatment Drugs like aciclovir are very expensive and treatment does not cure the patient and does not stop the infection coming back. Treatment of the lesions includes: Gentian violet paint 0.5%: Apply twice daily. Treat the pain and fever, if necessary, with an analgesic. Key points • Cold sores will heal up. However, they do recur during times of stress and will do throughout a person’s life. • Young infants and children with florid herpes simplex gingivitis (mouth ulcers) may need hospitalisation in order to ensure adequate fluid intake, if their mouths are too sore to drink. 8.3.2 Shingles (Herpes zoster ) Varicella zoster or herpes zoster or shingles is caused by a re-activation of the chickenpox or Varicella zoster virus in someone who has had chickenpox before. This can happen for no apparent reason, or when immunity is impaired e.g. old age, cancer, HIV infection. Symptoms/signs Painful blisters on any part of the body preceded a few days earlier by pains on the affected site. Pain at the site may continue for some months after the blisters have disappeared. Severe eye damage may occur if it affects the upper part of the face. Involvelemt of tip of the nose is a serious warning sign, necessitating aciclovir and referral to specialist. Suspect immunosuppression if the lesions are widespread or haemorrhagic e.g. HIV infection or malignancies. Drug treatment Aciclovir, oral ADULT: 800 mg per dose 5 times daily, usually for 7 days; CHILD under 2 years: 400 mg per dose, five times per day, for 7 days CHILD over 2 years: 800 mg per dose 5 times per day for 7 days Treatment of the lesions also includes: Gentian violet paint 0.5%: Apply twice daily. Pain relief must be provided with appropriate analgetic drug treatment. Refer patient to hospital if lesions are haemorrhagic, widespread, are located to the nose, face and eyes or if shingles recur. Postherpetic neuralgia (pain) This can occur after the rash has disappeared. Simple analgesics or ibuprofen may be sufficient for some patients, and is worth trying for a few days. If the relief is inadequate, tricyclic antidepressants are the most effective drugs for postherpetic neuralgia with response in 40 to 65 percent of the patients. This treatment must however be taken for 3 to 6 months after pain is reduced or abolished. Amitriptyline, oral ADULT: 10 to 50 mg at night. For elderly, a low initial dose of antidepressant should be prescribed and the dosage increased weekly until pain relief or unacceptable side effects occur. Maximal effect may take weeks to achieve. In a small subset of patients with lancinating pain, addition of Carbamazepine may be useful Carbamazepine, oral 100 mg twice daily initially, increasing the dose gradually until relief is obtained, to avoid drowsiness. Doses of 400 mg orally, twice a day may be required by some patients. Key points • The skin lesions are usually transient; keep clean to avoid bacterial super infection. • Shingles (herpes zoster infection) is very painful both preceding the outbreak of lesions and long time after lesions have disappeared. Pain relief may be needed for some months. 8.3.3 Chicken Pox (Varicella-zoster infection) This disease is caused by Varicella zoster virus. Symptoms/signs Mild headache, fever, malaise occurring about 2 weeks after exposure to an infected person, this occurs about 2-3 days before rash appears. (Incubation period is 12-21 days) Rash occurs first on trunk then spreads to face and scalp. Papules, vesicles and crusts which then develop are very itchy. Non-drug treatment Avoid scratching, in children keep nails clipped short and hands clean. To dry out lesions, bathe in saline solution (Measure roughly one handful of salt to 10 litres of water) Drug treatment In the nonhospitalised patient with a normal immune system and uncomplicated varicella, aciclovir is not recommended because the benefits are only marginal. For the itching use: Calamine lotion. Apply as frequently as needed for as long as required. Plus: Promethazine, oral ADULT: 25 mg at night, increased to 25 mg twice daily if necessary Or: 10-20 mg 2-3 times daily; CHILD under 2 years: not recommended CHILD 2-5 years: 5-15 mg daily in 1-2 divided doses, CHILD 5-10 years: 10-25 mg daily in 1-2 divided doses. Key points • In children it may not be so severe, but it may be very severe in adults and in immuno-compromised patients. • In children it is not usually a severe infection however infection may be very severe in adults, newborns of nonimmune mothers and in immuno-compromised patients. If there is secondary bacterial infection then treat this first with: ADULT: 250mg – 500mg every 6 hours for 10 days. CHILD: 25 – 50 mg/kg every 6 hours. Duration: 5 days When patient is allergic to penicillin: Give: Erythromycin, oral ADULT and CHILD over 8 years: Give: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours. Duration: 5 days 8.4 Parasitic infections 8.4.1 Scabies Caused by mites Sarcoptes scabiei transmitted by skin-to-skin contact, the lesion is a burrow (a whitish zigzag channel) the resting place of the female mite. Symptoms/signs Itchy rash (burrows) mainly between the fingers, on the wrists, in the axilla, around the naval, genitals and inner sides of feet. Because the mite-infection/rash is itchy, scratching may cause secondary bacterial infection. Frequently more than one household member is infected. Treatment All members of the household should be examined. Patients with scabies may often also develop mixed Streptococcal and Staphylococcal impetigo. Treat as impetigo. When the bacterial infection has healed then treat the scabies with Permethrin as first drug of choice: Permethrin Cream 5% ADULT: apply over whole body and wash off after 8-12 hours; CHILD: apply over whole body including face, neck, scalp and ears; if hands washed with soap within 8 hours of application, they should be treated again with cream. Note: Some manufacturers recommend application to the body but to exclude head and neck. However, application should be extended to the scalp, neck, face, and ears. If patient is allergic to Permethrin, use Benzyl benzoate: Benzyl benzoate 25% ADULT: Apply over whole body, repeat without bathing on following day, then wash off after further 24 hours later; a third application may be required in certain cases. Note: Dilution reduces efficacy. CHILD: dilute 1:1 with water (25ml with 25ml of water will provide enough lotion to treat a child) Infants: dilute 1:3 with water (5 – 10ml with 10 -20ml of water will provide more than enough to treat an infant) Wash the patient; apply the product all over the body, except for the face and the mucous membranes; leave the product on the body for 24 hours, wash and repeat treatment after 5 days. A third application may be necessary. The itching may continue for days or weeks afterward. This may be relieved with: Promethazine, oral ADULT: 25 mg at night, increased to 25 mg twice daily if necessary Or: 10-20 mg 2-3 times daily; CHILD under 2 years: not recommended CHILD 2-5 years: 5-15 mg daily in 1-2 divided doses, CHILD 5-10 years: 10-25 mg daily in 1-2 divided doses. Key points • All persons living in the same house should be treated. • In prepubertal children the lotion is washed off after 12 hours. • Hot baths and scrubbing should be avoided. • The drug is irritant: avoid contact with eyes, broken skin or sores and mucous membranes. • The itch may take days or weeks to disappear. • Refer if there is severe secondary infection, glands are swollen or if there is fever. 8.4.2 Body lice (Pediculosis) Symptoms/Signs Eggs (nits) appear as fixed white specks on the hair. Body lice live in the seams of clothing and only come to the skin to feed. Bite marks may be apparent and the skin will be itchy. Secondary eczema and bacterial skin infection may be present. Non-drug treatment Use a fine comb to comb out the eggs and dead lice after treatment. Treat the whole family as the conditions spreads easily. Drug treatment Benzyl benzoate 25% ADULT: Apply to affected area and wash off 24 hours later; further applications possibly needed after 7 and 14 days. Note: Dilution reduces efficacy. CHILD: dilute 1:1 with water Infants: dilute 1:3 with water Apply to the infected region; wash off after 24 hours. Repeat after 7 days. A more effective treatment option, is using Permethrin: Permethrin cream rinse Apply to clean humid hair, leave for 10 minutes before rinse. Do not apply to broken skin or sores. Avoid contact with eyes. 8.5 Eczema Itchy skin due to a number of factors: Allergic contact dermatitis: results from an acquired allergy after skin contact with particular chemicals or drugs. Atopic dermatitis/eczema: often a personal or family history of atopic disease e.g. asthma, hay fever. Cause is not known. Infantile eczema usually appears at 3 months with oozing and crusting affected the cheeks, forehead and scalp. Flexural eczema: affects flexor surfaces of elbows, knees, nape of neck. Symptoms/signs Itchy red rash or rough and dry skin appears on inner surfaces of elbows, knees and creases of the neck. Very itchy at night. Can become chronic and infected. Papules, blisters and oozing characterise acute lesions. There is thickening, prominent skin lines and scaling when chronic. Non-drug treatment Remove any obvious cause e.g. skin irritants or allergens. If eczema is weepy, wash with saline then pat dry. Drug treatment Use a soap substitute and moisturiser Benzoic acid 6% and salicylic acid 3%, ointment = Whitfield’s ointment If skin is scaling add a keratolytic preparation such as: Salicylic acid 2%, ointment Apply twice a day as needed OR Coal tar 5%, ointment in salicylic acid 2%, ointment Apply twice a day as needed. Topical steroids may be added: Hydrocortisone 1%, cream/ointment Apply twice a day for not more than 2 weeks, can also be used on delicate skin or face. OR Betamethasone 0.1%, ointment/cream Apply once or twice a day for not more than 2 weeks. Use only on body, not face or delicate skin Mainstay of treatment of children: CHILD: Moisturisers, e.g. glycerol or soft liquid paraffin, then topical steroids. Treat secondary infections: Cloxacillin, oral, at least 30 minutes before food ADULT: 250mg – 500mg every 6 hours. CHILD – dose per kg: 25 – 50 mg/kg every 6 hours. Duration: 7 days. When patient is allergic to penicillins, give: Erythromycin, oral ADULT and CHILD over 8 years: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours Duration: 7 days. Key points • Refer if no improvement after 2 weeks or the eczema is severe, acute and moist (weeping). • If lesions are wet use creams, if dry use ointments. • Betamethasone is more potent than hydrocortisone and should only be prescribed by a specialist. • Do not use corticosteroids on weepy skin. • Avoid soaps and rough drying (pat dry with towels) 8.6 Large chronic sores An ulcer or a sore is a breach in the continuity of the skin and the underlying tissue, caused by infections such as Tuberculosis, or a result of diseases such as diabetes, trauma or malignancies. Symptoms/signs The sore may be painful or painless, there may be discharge, which may be offensive, and the sore may cause disfigurement or disability. Some sores have sloping edges, undermined edges, punched out edges, raised everted edges and may cause deformity. There may be an underlying disease or cause of the sore or ulcer and investigations to identify these should be undertaken. These include – Hb and sickling test, fasting blood sugar, VDRL/RPR test, wound swab for culture and sensitivity, Biopsy, X-ray of underlying bone. If the patient has no sensation of pain in sore/ulcer, then suspect diabetes, leprosy and yaws or syphilis. Non-drug treatment Keep the wound clean with chlorhexidine solution. Change dressing every day Rest and elevate the affected limb as much as possible. Drug treatment Use topical antiseptics such as chlorhexidine Chlorhexidine 0.5% solution Use to clean the wound at each dressing change. Dilute 10ml of Chlorhexidine 5% with 90ml of water to make 100ml of 0.5% solution. After swab and culture use specific antimicrobial treatment as indicated by the results. Key points • Refer if the sore fails to show signs of healing. • It is very important that sores that fail to heal are treated or referred quickly as if the patient is diabetic, the sore may eventually cause the limb or part of limb to be amputated. 8.7 Itching (Pruritus) It is a sensation that the patient instinctively attempts to relieve by scratching. It may accompany a primary skin disease or may be a symptom of a systemic disease. Skin diseases causing itching include: • Scabies • Pediculosis (body lice) • Insect bites (fleas, bed bugs) • Dry skin (especially in the elderly) • Atopic eczema, dermatitis and contact dermatitis • Urticaria and prickly heat Systemic conditions causing itching include: • Obstructive liver disease • Uraemia (in renal failure) • Malignancies • Pregnancy – during the latter months pruritus may occur • Drugs e.g. chloroquine and other antimalarials • Psychogenic – that is no obvious cause but itching occurs from the patients mind. Non-drug treatment The cause of the itching should be identified which could be a skin condition or an underlying systemic condition. Avoid contact with substances known to cause itching. If itching is due to medicines, then inform the patient that the itching will stop once the treatment is completed or if possible review the treatment and if it is possible then change the drug treatment. Drug treatment The following may be useful: Calamine lotion Apply as frequently as needed for as long as required PLUS Promethazine, oral ADULT: 25 mg at night, increased to 25 mg twice daily if necessary OR: 10-20 mg 2-3 times daily; CHILD under 2 years: not recommended CHILD 2-5 years: 5-15 mg daily in 1-2 divided doses, CHILD 5-10 years: 10-25 mg daily in 1-2 divided doses. Key points • Important to identify the underlying cause of itching and where possible treat the cause. • In infants / young children should ensure fingernails are kept short and it is also helpful to bandage / glove the hands at night time and / or to cover the rash. Chapter 9 – Ear, Nose and Throat 9.1 Sore throat (Pharyngitis and Tonsillitis) Infection of the throat and tonsils. Caused either by bacteria or virus. When caused by streptococcal infection, must be treated with antibiotic to avoid risk for serious complications. Symptoms/signs Signs/symptoms of a viral infection: Fever, difficulty in swallowing, sore throat, often also running nose and cough. The throat looks red, tonsils may be enlarged and reddened and tonsillar lymph glands are palpable. Signs of a bacterial (streptococcal) infection include: Painful enlarged tonsillar lymph glands, with whitish exudate at the back of the throat and with whitish exudate (white patches) on the tonsils. Sustained high fever, occasionally also rash or scarlet fever. In patients with bacterial infection will not have the signs suggesting a viral infection e.g. running nose, cough and red eyes. Non drug treatment For all sore throats a homemade salt mouthwash may help: ½ teaspoon of salt in a glass of slightly warm water; gargle for 1 minute twice a day. Drink plenty of water. But if in doubt, at least in children under 6 years, give antibiotics (penicillin) for sore throat. The clinical signs to differentiate bacterial and viral infections are not that specific and rheumatic fever is common. Drug treatment For all sore throats give pain relief. When Streptococcal tonsillitis is suspected, treat with a per oral penicillin; Phenoxymethylpenicillin (Penicillin V), oral ADULT: 500 mg every 12 hours for 10 days. CHILD: 10 mg/kg (up to 500 mg) every 12 hour, 10 days. Rheumatic fever can be a complication of streptococcal throat infection in children. Patients who are unlikely to comply to prescribed per oral penicillin, can be treated with: Benzylpenicillin, injection, IV, IM ADULT: 0.6 – 1.2 g (1-2 million units) every 6 hour for 10 days. CHILD: 50 000 units = 60 mg/kg every 6 hours for 10 days. OR: Benzathine penicillin, IM ADULT and CHILD over 30kg: 900 mg = 1.2 million units, single dose CHILD under 30 kg: 450 – 675 mg = 0.6 – 0,9 million units, single dose In patients allergic to penicillin give: Erythromycin, oral ADULT and CHILD over 8 years: Give: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours Duration: 10 days. Key points • If bacterial infection is suspected, treat with penicillin as 1st choice. • Refer all patients to hospital, in case of retropharyngeal or peritonsillar abscess, recurrent tonsillitis or tonsillitis accompanied by severe swallowing problems, suspected acute rheumatic fever, history of previous rheumatic fever or rheumatic heart disease, heart murmurs not previously diagnosed., or suspected acute glomerulonephritis. 9.2 Hay fever (Allergic rhinitis) Inflammation of nasal mucosa due to hypersensitivity to allergens e.g. pollen, house dust, grasses, animal proteins and foodstuffs. Symptoms/signs Blocked stuffy nose, watery nasal discharge, frequent sneezing often with nasal itching and irritation, itchy/watery eyes. The discharge from eyes and nose is watery/clear. Non-drug treatment Try to avoid the allergens and irritants Drug treatment Give antihistamines to relieve the symptoms temporarily: Promethazine, oral ADULT: 25 mg at night, increased to 25 mg twice daily if necessary OR: 10-20 mg 2-3 times daily; CHILD under 2 years: do not treat with promethazine CHILD 2-5 years: 5-15 mg daily in 1-2 divided doses, CHILD 5-10 years: 10-25 mg daily in 1-2 divided doses. Key points • The main treatment is to find out what the patient is allergic to and to avoid this in the future. In practise this is very difficult to do. • Use of antihistamines provides some temporary relief of the symptoms of hay fever. 9.3 Ear conditions It is important to find and treat ear conditions correctly to prevent deafness, and to prevent serious systemic complications such as mastoiditis and also to prevent the more rare complications of meningitis and brain abscess. Symptoms/signs Children under 5 years of age should always be assessed using the Integrated Management of Childhood Illnesses guidelines (IMCI). In children, check for ear pain and for ear discharge. Ask how long the ear has been discharging. Look for pus draining from the ear, and feel for tender swelling behind the ear. If there is: Then diagnose: Tender swelling behind the ear Mastoiditis Pus is seen draining from the ear and discharge is reported for 14 days or less and/or Ear pain Acute ear infection (Acute otitis media) Pus is seen draining from the ear and discharge is reported for 14 days or more Chronic ear infection (Chronic otitis media) No ear pain and no pus seen draining from the ear No ear infection Adults: Impaired hearing, sudden and persistent earache, fever, pus discharging from the ear for less than 2 weeks (acute ear infection) or longer (chronic ear infection). Treatment Children: If diagnosis: Then treat with: Mastoiditis Give first dose of Co-trimoxazole (see below for dose). Give paracetamol for pain Refer urgently! Acute ear infection Give Co-trimoxazole or Amoxicillin (see below for dose) Give Paracetamol for pain Dry ear by wicking Follow-up in 5 days Chronic ear infection Dry ear by wicking Follow-up in 5 days Adults: Acute ear infection – treat with antibiotics and wicking Chronic ear infection – treat with wicking only. Non-drug treatment Drink lots of fluid and continue eating normally. Wicking – a discharging ear can only heal if it is dry. Drying the ear is time-consuming but is the effective treatment for otitis media. Demonstrate to the mother if a patient is a child. • Roll a piece of clean absorbent gauze/cloth or soft strong tissue paper into a wick and insert carefully into ear. Leave for one minute then remove and replace with a clean wick. • Repeat the process with a new wick each time until the wick is dry when removed. • Dry the ear at least 3 times a day. • Nothing should be left in the ear between wicking. • If bleeding occurs then drying (wicking) the ear should be stopped temporarily. • Avoid swimming or otherwise getting the inside of the ear wet. • Reassess after 5 days to ensure the patient (or mother) is drying the ear correctly and check for tender swelling behind the ear (mastoiditis). If this occurs then refer immediately. Drug treatment For acute ear infections give: Co-trimoxazole, oral ADULT: 960 mg (160 mg TMP + 800 mg SMX) = 2 tablets every 12 hours. CHILD: Dose per kg body weight: 24 mg/kg (4 mg/kg TMP + 20 mg/kg SMX) twice daily. Duration: 7 days. OR Amoxicillin, oral ADULT: 250-500mg every 8 hours CHILD: 15 mg/kg 3 times a day Duration: 7 days. Key points • Refer to hospital all children with suspected mastoiditis. Give the first dose of chloramphenicol and paracetamol before sending patient to hospital. • Refer patients to hospital-based specialist if there is no response after 10 days treatment for acute otitis media. • Ear drops are not effective, and should not be used. 9.4 Sinusitis Inflammation of the sinuses which can be caused by infection in the nose which can spread to sinuses. Symptoms/signs Bacterial sinusitis is characterised by: • Thick mucus or pus in the nose, perhaps with a bad smell. The nose is often stuffy. It may be from one nostril only. • Pain and tenderness over one or more of the sinuses. Hurts when you tap over the bones or when the person bends over. • There are in some cases fever, and some patients have toothache. Non-drug treatment Tell patient to wipe runny or stuffy nose but try not to blow it. Blowing the nose may lead to earache and make the sinus congestion worse. Make a solution of salt and water to wash through the nose. Drug treatment Give analgetic to relieve the pain. If bacterial infection is suspected: Give: Amoxicillin, oral ADULT: 250-500mg every 8 hours. CHILD: 15 mg/kg up to 500 mg every 8 hours. Or: Co-trimoxazole, oral ADULT: 2 tablets (160 mg TMP + 800 mg SMX) every 12 hr CHILD: 24 mg/kg (4 mg/kg TMP + 20 mg/kg SMX) twice daily Duration: acute sinusitis 7 days, chronic sinusitis 3 weeks. Key points • Spontaneous resolution of acute sinusitis occurs in 80% of patients after 2 weeks, whether antibiotics are given or not. • Refer patients with recurrent infections. 9.5 Nose bleeds (Epistaxis) Bleeding from the nose is commonly caused by picking of the nose, however, it can also occur as a result of trauma, hypertension and bleeding disorders such as dengue fever. In children nose bleeds may be spontaneous. Nosebleed due to nose-picking or nasal infection, no further investigation is necessary. Non-drug treatment – first aid Ask the patient to sit quietly. Sit the patient up and flex head to prevent blood running down throat. Wipe the nose gently to remove mucus and blood. Pinch the nose (patient must breathe through mouth). Apply ice pack to nose. Key points • Refer patients who have nosebleeds not due to nose-picking or nasal infection this could be dengue fever or hypertension and these need urgent medical attention. • Refer patients whose nosebleed cannot be stopped or when nosebleed occur frequently and may require a transfusion. Chapter 10 – Endocrinological conditions 10.1 Diabetes Diabetes is a chronic disease where a person has abnormally high levels of glucose (sugar) in the blood. Without correction the person can develop some very serious complications. There are three types of diabetes are encountered in practice: Type 1 diabetes – is where a person cannot produce enough of the hormone insulin. Insulin is required by the body in order to use the glucose obtained in the food people eat. When there is not enough insulin then glucose cannot be used and the blood levels increase. Usually occurs in young people (<30years). Type 2 diabetes – blood glucose levels rise because the systems within the body that regulate the use of glucose fail. Usually occurs in older people (>30years), often in obese or overweight people. Gestational diabetes – diabetes developing during pregnancy in previously non-diabetic patient. If diabetes is not diagnosed and treated, the patient is at risk of serious illness and even death from coronary heart disease, stroke, renal and eye problems etc. Symptoms/signs Often the disease may be diagnosed by accident or when the serious long-term complications start to develop. Early signs of diabetes are: • Always thirsty • Urinates often and a lot • Always tired • Always hungry • Weight loss Later, more serious signs are: • Itchy skin • Periods of blurred vision • Some loss of feeling in hands or feet • Frequent vaginal infections • Sores on feet or legs that do not heal • Loss of consciousness – in extreme cases ∗ Note: It is important to distinguish diabetes type 1 diabetes from diabetes type 2. Al patients should be referred to a health facility where further investigation can be undertaken. The diagnosis can be suspected by finding sugar in the urine however it must be confirmed by blood testing and preferably a glucose tolerance test. Non-drug treatment Both type 1 and type 2 diabetics must be encouraged and educated to adhere to a balanced diet. Type 2 diabetes can often be controlled by a balanced diet and exercise, without drug therapy. • Encourage patients to avoid sugar-containing foods and to eat small regular meals of starchy foods e.g. bread, rice, pasta. Reduce fried and fatty food, eat high fibre food. • Eat at least 5 portions of fruit, vegetables or pulses per day. • Exercise at least 20 minutes walking – 4 or more days a week. To prevent infection and injury to the skin, clean teeth after eating, keep the skin clean and always wear shoes to prevent foot injuries. For poor circulation in the feet, rest often with the feet up. Have regular checks of the patients eyesight. Drug treatment Diabetes type 1 This type of diabetes requires changes to diet and exercise and treatment with insulin. Types of insulin: Type of insulin Duration of action Onset of action (hours) Peak activity (hours) Duration (hours) Concentration Soluble Short acting 0.5 to 1 2 – 5 6 – 8 100 units/ml Isophane Intermediate Within 2 hours 4 – 12 Up to 24 100 units/ml Examples of Recommended Insulin Regimens • Short-acting insulin mixed with intermediate-acting insulin: twice daily (before meals). • Short-acting insulin mixed with intermediate-acting insulin: before breakfast Short-acting insulin: before evening meal, Intermediate-acting insulin: at bedtime. • Short-acting insulin: three times daily (before breakfast, midday, evening meal) Intermediate-acting insulin: at bedtime. • Intermediate-acting insulin with or without short-acting insulin: once daily either before breakfast or at bedtime suffices for some patients with type 2 diabetes who need insulin, sometimes in combination with oral hypoglycaemic drugs. Insulin requirements may be increased by infection, stress, accidental or surgical trauma, puberty, and during the second and third trimesters of pregnancy. Requirements may be decreased in patients with renal or hepatic impairment and in those with some endocrine disorders (e.g. Addison’s disease, hypopituitarism) or coeliac disease. During pregnancy it is important that insulin requirements are assessed frequently by an endocrinology-experienced physician. Diabetes type 2 Try 3 months with dietary and exercise changes only. If after this there is still poor blood glucose control then start drug therapy. If the patient is of normal weight then give: Glibenclamide, oral Dose: Initially 5 mg daily with or immediately after breakfast, adjusted according to response; maximum 15 mg daily. Note: Elderly or debilitated patients may respond to half the usual doses. But the long-acting glibenclamide is associated with a greater risk of hypoglycaemia and should therefore be avoided in the elderly. Gliclazide is a short-acting per oral antidiabetic and a mor esuitable alternative for the elderly and for patients with decreased renal function. Gliclazide, oral Dose: Initially, 40-80 mg daily, adjusted according to response; up to 160 mg as a single dose, with breakfast; higher doses divided; maximum dose 320 mg daily. If the patient is overweight and strict diet failed to control diabetes, give: Metformin, oral Dose: Initially 500 mg with breakfast for at least 1 week then 500 mg with breakfast and evening meal for at least 1 week then 500 mg with breakfast, lunch and evening meal; maximum 3 g daily in divided doses but most physicians limit this to 2 g daily. If appropriate, metformin may also be considered as an option in patients who are not overweight. Metformn is also used when diabetes is inadequately controlled with sulphonylurea treatment. Metformin has a different mode of action from sulphonylureas (glibenclamide, Gliclazide) and is not interchangeable with them. It exerts its effect mainly by decreasing gluconeogenesis and by increasing peripheral utilisation of glucose. Like the sulphonylureas it is only effective in the presence of endogenous insulin and therefore requires some residual functioning pancreatic islet cells. Type 2 diabetes with failed drug therapy, insulin therapy should be initiated. In the elderly this is usually given as a once daily dose of intermediate acting insulin. Key points • Suspect type 2 diabetes in all middle age or elderly with obesity, hypertension, ischaemic heart disease, peripheral vascular disease or cerebrovascular disease. • Blood glucose should be maintained in the range 3.5-10mmol/litre • Where blood glucose measurements are not available, urinary sugar levels give a guide to overall control • Stable patients should be reviewed at least every 3 months • Refer urgently patients who may be developing hyperglycaemia or any complications of diabetes e.g. blindness, gangrene of the feet, myocardial infarction etc • Refer patients who are not responding to oral drug therapy for commencement of insulin therapy. 10.2 Diabetic emergencies 10.2.1 Hypoglycaemia Occurs when blood glucose levels become so low that symptoms and signs occur. These can occur at any time of the day or night, caused by: • Inappropriately high doses of insulin or oral anti-diabetic drugs • Patients takes the treatment but forgets to eat or delay meals • Patient undertakes unplanned exercise or exercise that is unusual. • Alcohol intake Symptoms/signs There are two groups of symptoms of hypoglycaemia: • Mediated by the sympathetic nervous system: pale skin, sweating, shaking, palpitations, anxiety, dizziness, headaches, fast heart rate. • Mediated by altered brain function: hunger, inappropriate or abnormal behaviour, confusion, coma and seizures. Treatment Mild to moderate cases If patient is conscious and cooperative then give a sugar containing food e.g. sweets containing sugar or soft drink containing sugar (not “diet” drinks as these do not contain sugar) or glass of milk or fruit drink and a tablespoonful of honey. This must be followed by a meal or snack that contains carbohydrates e.g. sandwich or dried fruit etc. Severe cases, i.e. patient is unconscious or unable to drink. Give: Dextrose 20%, IV infusion ADULT: 50 ml may be given intravenously into a large vein through a large-gauge needle; care is required since this concentration is irritant especially if extravasation occurs. Dextrose 10%, IV CHILD: 2 ml/kg as a bolus over 3 minutes followed by 0.1 ml/kg/minute until the child is fully conscious and able to have oral intake. Note: The excessive use of dextrose 50% has caused deaths in children due to hyperosmolality thus dextrose 10% is recommended in children. Patients should wake within 4 to 5 minutes following IV dextrose. Hypoglycaemia due to a long-acting oral treatment can take prolonged treatment with IV dextrose. Key points • Educate patients about hypoglycaemic symptoms. Patients should be encouraged to carry sweets or sugar containing food for these emergencies. The patients close relatives and friends should be instructed in management of hypoglycaemic attacks. • If a diabetic is confused or losing consciousness there should be no hesitation in administering a trial injection of IV dextrose. • If the period of hypoglycaemia is prolonged or extremely severe and/or associated with a seizure complete recovery may take several hours even though blood glucose levels are restored to normal. 10.2.2 Diabetic ketoacidosis Diabetic ketoacidosis is common in newly diagnosed diabetics and can be fatal. It is caused by • Previously undiagnosed diabetes • Interruption of insulin therapy i.e. the patients stops the insulin therapy for various reasons • Stress of another illness e.g. infection, stroke etc This is a medical emergency, refer to hospital urgently. Symptoms/signs Passing excessive urine, drinking very large amounts of water. Nausea, vomiting and abdominal pain. Dehydration and deep and fast breathing. Signs of hypovolaemic shock: Low blood pressure, fast and weak pulse Confusion, stupor or unconsciousness. Treatment The principles of management are: • Replace the fluid losses • Replace the electrolyte losses and restore acid-base balance • Replace deficient insulin • Monitor blood or urine glucose and urine ketones regularly • Monitor vital signs and urine output regularly • Seek the underlying cause and treat Fluids Sodium chloride 0.9% is the fluid of choice. Adults as much as 3.5 to 7 litres of fluid may be required in 24 hours. Give: Sodium chloride 0.9% ADULT: 15-30 ml/kg/hour over the first 2 hours, then reduce to 7.5 ml/kg over the third and fourth hours, thereafter give according to further clinical assessment. Specialist care is needed when treating children. Rapid rehydration increases the risk for acute cerebral oedema. Needed volumen of replacement fluid is calculated according to body size and degree of dehydration. Referral to an expert in paediatric diabetes care is necessary. Electrolytes Patients are depleted in total body potassium. Ideally potassium therapy should not be initiated until serum potassium levels area known and adequate in- and output has been established. Initial therapy should commence with potassium 20mmol per hour at about the second hour. Then adjust the infusion rate according to the serum potassium level as follows: Potassium chloride solution, 1.5 mmol/ml < 3 mmol/l: give 39 mmol/hour 3-4 mmol/l: give 26 mmol/hour 4-5 mmol/l: give 13.4 mmol/hour > 5 mmol/l: stop infusion of potassium Insulin Only short acting insulin should be used in the treatment of diabetic ketoacidosis. The intravenous route is preferred if methods are available to regulate the infusion rate. Commence intravenous insulin therapy with an infusion rate of 2 – 6 units per hour. The intramuscular route can be equally successful with 8 -10 units given every hour. Monitoring Blood glucose levels should be monitored every hour. When blood glucose level approaches 12-15mmol/L (216 – 270 mg/dL) the rate of insulin infusion should be halved. Change to subcutaneous route if IM route has been used. Infusion fluid should be changed to dextrose 5%. Monitor potassium and acid-base status at 2 to 4 hourly intervals. Search thoroughly and treat the underlying causes. Key points • Sodium bicarbonate injection should be used only in extreme acidosis and if complete biochemical data are available (arterial pH less than 7 or bicarbonate less than 9mmol) • In the months after diagnosis insulin requirements may decline and the pancreas continues to produce some insulin. Eventually the insulin produced by the pancreas declines and injected requirements are increased. Explain this to the patient. 10.3 Thyroid conditions The thyroid produces hormones regulating the body’s metabolism. Abnormalities in the thyroid therefore cause changes in many systems including the skin, nervous system, muscles, and the gastrointestinal and cardiovascular systems. A reduction in production of thyroid hormones results in hypothyroidism, while excess results in thyrotoxicosis or hyperthyroidism. 10.3.1 Goitre A goitre is a swelling if the neck due to enlargement of the thyroid gland. Goitres may be due to a lack of iodine (iodine deficiency), due to insufficient content of iodine in the diet. Goitre can be caused by: Hypothyroidism Hyperthyroidism or thyrotoxicosis Thyroid neoplasms Simple non-toxic goitre (endemic goitre) Symptoms/signs A swelling in the neck – if very large can cause obstructive symptoms with problems in breathing and swallowing Hoarseness of voice. Symptoms of hypothyroidism. Symptoms of hyperthyroidism. Irregular thyroid swelling/diffuse or generalised thyroid swelling. Slow pulse (<60 per minute) – associated hypothyroidism is likely, look for other signs. Fast pulse (> 90 per minute) – associated thyrotoxicosis is likely, look for other signs. Special investigations are required to determine the type of abnormal thyroid function. Treatment Refer patients to specialist care. 10.3.2 Hypothyroidism There is a reduction in thyroid hormone production. This affects intellectual development and growth in infants and young children. In adults it may be the cause of heart disease and reversible dementia. It can be caused by iodine deficiency, antibody-related thyroid destruction or may be congenital. Symptoms/signs Neonates – persistent neonatal jaundice, excessive sleep, floppiness and feeding problems. Children – born with congenital hypothyroidism and are untreated may develop cretinism (mental sub-normality, short stature, large tongue, dry skin, sparse hair, protruding abdomen, umbilical hernia). Adults – slow pulse (usually < 60 per minute), dry coarse skin, puffy face, pallor, deep hoarse voice, slow relaxing deep tendon flexures, dementia, cold intolerance, heavy menstrual periods, lethargy, weight gain. Refer for thyroid function tests if available. Treatment Treatment of hypothyroidism Levothyroxine, oral ADULT: initially, 50-100 micrograms (50 micrograms for those over 50 years) daily, preferably before breakfast, adjusted in steps of 50 micrograms every 3-4 weeks until normal metabolism maintained (usually 100-200 micrograms daily); where there is cardiac disease, initially 25 micrograms daily or 50 micrograms on alternate days, adjusted in steps of 25 micrograms every 4 weeks. Treatment of congenital hypothyroidism and juvenile myxoedema Levothyroxine, oral CHILD up to 1 month: initially 5 – 10 micrograms/kg daily. CHILD over 1 month: initially 5 micrograms/kg daily adjusted in steps of 25 micrograms every 2 – 4 weeks until mild toxic symptoms appear, then reduce dose. Key points • Prevent iodine deficiency disorders by giving people iodine e.g. via iodised salt. • Replacement therapy takes at least 1 month to reach steady-state levels. • Dose changes should be considered only every 3 to 4 weeks. • Close monitoring of clinical response and thyroid function tests are essential • Treatment is usually required lifelong 10.3.3 Hyperthyroidism (Thyrotoxicosis) Excess thyroid hormone and the patient is in a high metabolic state. If left untreated significant weight loss and cardiac complications including heart failure may occur. It is caused by Grave’s disease or toxic nodular goitre. Symptoms/signs Weight loss despite increased appetite Excessive sweating and heat intolerance Tremors, nervousness and irritability Menstrual irregularity Protruding eyes Rapid pulse rate that may be irregular Heart failure Smooth and diffuse goitre (if Grave’s disease) Irregular goitre in toxic multi-nodular goitre Refer for further investigation. Treatment Early patient referral is important. The thyroid hormone levels may be reduced by anti-thyroid drugs, radio-iodine therapy or partial thyroidectomy. Treatment with propranolol can reverse clinical symptoms of thyrotoxicosis within 4 days. Propranolol, oral: 10 – 40 mg every 6 to 8 hours. This may be started before referral but is contraindicated in asthmatics. For severe thyrotoxicosis due to hormone over-production give: Propylthiouracil, oral ADULT: 200 – 400 mg/day. This dose is maintained until patient becomes euthyroid; dose may then be gradually reduced to a maintenance dose of 50-100 mg/day. There is a lag time of 2 weeks between the achievement of biochemical euthyroidism and clinical euthyroidism. Overtreatment can result in rapid development of hypothyroidism and should be avoided particularly during pregnancy because it can cause fetal goitre. An uncommon serious adverse reaction is agranulocytosis due to bone marrow depression. Warn patient to tell doctor immediately if sore throat, mouth ulcers, bruising, fever, malaise, or non-specific illness occurs. Key points • Thyrotoxic crisis (“thyroid storm”) requires emergency treatment. • Overtreatment with propylthiouracil can result in rapid development of hypothyroidism. • Patients treated with propylthiouracil should be instructed to report sore throat and fever. Chapter 11 – Gastrointestinal conditions 11.1 Oral conditions 11.1.1 Oral thrush (Candidiasis) A fungal infection of the buccal mucosa, caused by Candida albicans. It commonly affects the very young, the very old or those whose immunity is impaired and occurs more frequently in HIV/AIDS patients, the malnourished, diabetics, patients on long-term antibiotics and steroids. Symptoms/signs White patches on the tongue, cheeks or roof of the mouth Difficulties in eating, breastfed babies may refuse to suck Burning sensation in the mouth Drug treatment Nystatin, oral suspension or pastilles ADULT or CHILD: 100 000 units 4 times a day after food, usually for 7 days (continued for 48 hours after lesions have resolved). Prophylaxis NEONATE: 100 000 units once daily. Key points • Advise the patients and mothers of babies that the medicine is effective only while it is in the mouth. Once it is swallowed it will not be effective. Therefore mothers of babies should be shown how to wipe the medicine inside the mouth of the baby. • Mothers of breastfeeding babies also need to treat their breasts with topical antifungal creme • The treatment should be continued for at least 7 days • Identify the underlying cause and refer if necessary. 11.1.2 Gingivitis and Stomatitis Symptoms/signs Sore mouth, bleeding gums after brushing, cracks at the corners of the mouth, poor appetite, nausea, and ulcers present. Non-drug treatment Encourage a well-balanced diet, sores at the corner of the mouth are often due to vitamin- and iron deficiency. Encourage the patient to rinse mouth frequently with a saline mouthwash made at home using a pinch of salt (or ¼ teaspoon) in 140 ml water (roughly half a glass). Rinse every few hours and especially after meals. Drug treatment If the ulcers look infected give: Phenoxymethylpenicillin (Penicillin V), oral ADULT: 250 mg every 6 hours, doubled in severe infections. CHILD: 12.5 mg/kg (up to 500 mg) every 6 hours; OR, if patient is allergic to penicillins Erythromycin, oral ADULT and CHILD over 8 years: 250 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections. CHILD: 12.5 mg/kg every 6 hours. PLUS, in more severe and unresponsive cases Metronidazole, oral ADULT: 200-250 mg every 8 hours. CHILD: 7.5 mg/kg 3 times a day. Duration: 7 days. Key points • Sore mouth can be due to a fungal infection therefore it is important to try and identify the cause of the soreness. Fungal infections will be made much worse if the above drug treatment is incorrectly given. • Much improvement can often be seen with the saline mouthwashes alone and this should be strongly encouraged. 11.1.3 Dental abscess A collection of pus around the affected tooth, which may spread into the surrounding tissue. Symptoms/signs Fever, feeling unwell, constant throbbing pain in the affected tooth, swelling of the gum around the tooth which may also cause the face to look swollen, pus may be seen discharging from the gum around the affected tooth. Drug treatment Relieve pain with standard analgesic treatment, and treat infection with: Phenoxymethylpenicillin (Penicillin V), oral ADULT: 500 mg every 6 hours. CHILD: 12.5 mg/kg (up to 500 mg) every 6 hours; OR, if patient is allergic to penicillins Erythromycin, oral ADULT: 500 mg every 6 hours. CHILD: 12.5 mg/kg every 6 hours. PLUS, in more severe and unresponsive cases Metronidazole, oral ADULT: 400 mg every 12 hours. CHILD: 7.5 mg/kg 3 times a day. Duration: 5 days. Key points • Refer the patient to a dental surgeon as soon as possible. 11.2 Abdominal pain/dyspepsia Abdominal pain or dyspepsia is commonly caused by reflux oesophagitis, peptic ulceration or non-ulcer dyspepsia. Symptoms/signs Any abdominal discomfort must be assessed for the following features: • Duration, severity, location, type. • Accompanying clinical features e.g. nausea, vomiting, constipation, diarrhoea, tenderness, fever, tachycardia, distension • Activity level of patients with severe pain e.g. restlessness or inability to lie still, ongoing heartburn or indigestion are difficult diagnostic problems because they are often non-specific Perform a thorough physical examination to assess if referral is needed. Non-drug treatment Stop smoking, limit alcohol intake and eat small frequent meals. Stop intake of non-steroidal anti-inflammatory drugs e.g. ibuprofen or aspirin and elevate the head of the bed. Drug treatment Initiate drug therapy only after full assessment Patients with mild, intermittent symptoms. Give: Aluminium hydroxide, tablets 500mg 1 or 2 to be chewed four times a day and at bedtime or as required Or: Aluminium hydroxide suspension 10ml four times a day and at bedtime or as required Patients with moderate symptoms. If patients are experiencing symptoms on most days, give: Ranitidine, oral Give: 150 mg twice daily or 300 mg at night (benign gastric and duodenal ulceration) for 4-8 weeks, and up to 6 weeks in chronic episodic dyspepsia. Treat up to 8 weeks in NSAID-associated ulcera (in duodenal ulcer 300 mg can be given twice daily for 4 weeks to achieve a higher healing rate); maintenance, 150 mg at night. Patients not responding should be referred for further investigation. Key points • Ranitidine may mask the symptoms of gastric cancer; particular care is needed in those whose symptoms change and in those who are middle-aged or over. • Refer urgently patients with symptoms haemorrhage or perforation, weight loss, anorexia or dysphagia, undiagnosed dyspepsia after the age of 45 years. • Refer patients with past history of duodenal ulcer, recurrence of symptoms after 6 weeks on ranitidine or family history and/or patient fears of cancer. 11.3 Diarrhoea Diarrhoea is defined as an increased frequency of liquid or semi-liquid stools (>3 in 24 hours), caused by intestinal infections and infestations, a wide range of gastro-intestinal disorders, or as side effect of some drugs. The major concern with diarrhoea is a rapid loss of fluid and risk of dehydration. Dehydration, particularly in young children can be fatal and must be treated as quickly as possible. Symptoms/signs of diarrhoea and dehydration All children should be assessed using the Integrated Management of Childhood Illness guidelines (IMCI). If the child has diarrhoea Ask: For how long? Is there blood in the stool? Look: Is the child lethargic or unconscious? Is the child restless and irritable? Eyes sunken? Able to drink or drinking poorly? Drinking eagerly or thirsty? Pinch the skin of the abdomen: Does it go back very slowly (longer than 2 seconds) or slowly? All children with diarrhoea must be treated against risk for dehydration, the management of the child will depend on the degree of how dehydrated the child is. First choice of treatment always includes both Oral rehydration solution ORS and Zinc as oral solution or as tablets. Give: Oral Rehydration Solution (ORS), according to updated IMCI protocol: The new Oral Rehydration solution contains less sodium than the old standard solution. The new preparation contains 75 mmol/L, while the old preparation contained 90 mmol/L. This means that the new ORS has a lower osmolality, and it is therefore also called “Low Osmolality ORS”. The new preparation both reduces the amount of diarrhoea and vomiting, and reduces the proportion of children who will need parenteral (IV) fluid. The Low Osmolality ORS shall be used for all diarrhoea cases, except for children with diarrhoea who also are severely malnourished. They shall still be treated with the standard, high-osmolality ORS solution. All diarrhoea patients shall also be treated with Zinc sulphate. Zinc sulphate both increases the rate of survival, and reduces duration of the diarrhoea, and reduces the risk and probability for recurrent diarrhoea for a period of 3 months after treatment. Give: Zinc tablets 2 x10 mg, according to IMCI. The daily dose is 20 mg Zinc sulphate per day, for 10-14 days. Or: For children less than 6 months of age: 10 mg Zinc sulphate per day. See IMCI guidelines. If there is blood in the stool dysentery is diagnosed and antibiotic therapy with Ciprofloxacin should be initiated as well as rehydration. Bloody diarrhoea is the only indication for antibiotics. Adults and older children Look for: Presence of fever Urine output plus the colour of the urine Presence of vomiting Duration of illness Blood or mucus in the stool Other signs of severe dehydration in adults and older children are absent radial pulse and low blood pressure. Treatment of adults and older children The aim of treatment is to prevent dehydration, replace lost fluid, maintain nutrition and maintain personal hygiene. If there are any pathogens present then additionally there is an aim to eradicate these. Acute diarrhoea – is usually self-limiting and is managed by fluid replacement. (If there is a blood in the stool or a pathogen is identified then drug therapy may be needed) Chronic diarrhoea – lasts more than 2 weeks. It may be treatable or it may be a symptom of an underlying disease like bowel cancer or AIDS. Refer all cases of chronic diarrhoea for further investigation. Non-drug treatment 1. Prevent dehydration and replace lost fluid. Patients should make up fresh mixture of Oral Rehydration Solution (ORS) Mix 1L sachet with 1 litre of clean water, in case of smaller sachets use instruction on the packet. Boil and cool the water if the quality is uncertain. Give: Zinc tablets 20 mg per day for 10-14 days Or: For children under 6 months old, 10 mg per day. OR, if ORS not available, make Homemade Sugar and Salt Solution Homemade Sugar and Salt Solution 1/2 teaspoon of table salt 8 teaspoons of sugar 1 litre of clean water (boil and cool the water if the quality is uncertain). Adults should aim to drink 200-400 ml of solution after every loose stool. Children should aim to drink 200 ml after each loose stool. Taking small sips but continuously may be easier than trying to drink the whole amount. Children may find it easier drinking off a spoon. Continue for as long as diarrhoea and signs of dehydration continue. Return of urine flow is a sign of recovery. When the patient is severely dehydrated (e.g. with cholera) then IV fluids may need to be administered: Intravenous rehydration: Sodium chloride 0.9%, intravenous infusion OR Compound solution of sodium lactate, (Ringer-Lactate), intravenous infusion ADULT: In severe dehydration the first litre may be infused in 15-20 minutes. Thereafter the drip rate should be progressively slowed down. 6 or more litres may be required in the first 24 hours of which the first 3-4 litres will be a replacement fluid after which a maintenance regimen of approximately 3 litres/24 hours should be used. OLDER CHILD: Severely dehydrated children: Rehydrate at a maximum rate of 30ml/kg bodyweight/hour for the first hour. Then reduce the speed during the next few hours, down to 75ml/kg/24 hours. 2. Maintain nutrition Adults and children should continue to eat. Food should be easy to eat and digest e.g. soup, boiled rice. After diarrhoea is finished there is a need to have increased solids intake until the patient regained any lost weight. Also more fluids than normal should be taken. Breastfeeding should be continued. Check, if vitamin A supplements have been given together with measles immunisation – if not ensure patient should get either or both. 3. Hygiene Educate the patient about the faecal-hand-oral route of transmission and the need to wash hands after using the toilet and before preparing food. Diarrhoea with blood in young children may also be a sign of serious bowel obstruction (intussusception). All young children with bloody diarrhoea should be assessed to exclude intussusception. Gastro-enteritis (Food poisoning/viral infection) Antibiotics are not required. Bacillary Dysentery (bloody diarrhoea) For Shigella give as first line antibiotic: Ciprofloxacin, oral Give Ciprofloxacin, see IMCI: Adult: Ciprofloxacin tablets 500 mg morning and evening, for 5 days. Child: Ciprofloxacin tablets 15 mg/kg bid for 5 days. Duration: 5 days If ciprofloxacin is unavailable: Nalidixic acid, oral ADULT: 1 g every 6 hours. CHILD: 15 mg/kg 4 times a day. Duration: 5 days Cholera Rice water diarrhoea with or without vomiting causing severe dehydration or death. Patients can die in a few hours from the severe dehydration therefore rehydration is most important either orally in moderate cases or IV (Ringer-lactate) in more severe cases. Antibiotic therapy reduces the volume and duration of diarrhoea. Give: Doxycycline, oral ADULT: 300mg as a single dose CHILD >8 years: 100 mg as a single dose OR: Co-trimoxazole, oral ADULT: 960 mg (160 mg TMP + 800 mg SMX) = 2 tablets every 12 hours. CHILD: 24 mg (4 mg/kg TMP + 20 mg/kg SMX) twice daily Duration: 5 days. Note: doxycycline should not be given to children below 8 years. Amoebic dysentery Extra-intestinal amoebiasis (including liver abscess) and symptomless amoebic cyst passers: Metronidazole, oral ADULT: 600 mg every 8 hours for 6 to 10 days CHILD: 15 mg/kg (up to 600 mg) every 8 hr for 6 – 10 days. PLUS Diloxanide, oral * ADULT: 500 mg every 8 hours for 10 days CHILD over 25 kg: 7 mg/kg daily every 8 hours for 10 days. *to eradicate pathogenic cysts and prevent relapse. For patients with hepatic involvement, metronidazole treatment should be continued for 14 days and specialist advice should be sought. Giardiasis Treatment of people with asymptomatic passage of giardia cysts is unwarranted. For symptomatic patients, give: Metronidazole, oral ADULT: 2 g daily for 3 days or 400 mg 3 times daily for 5 days OR: 500 mg twice daily for 7-10 days. CHILD: 15 mg/kg every 8 hour for 3 days Key points • Treating or preventing dehydration is the main objective when managing diarrhoea. • For dysentery/cholera etc. investigate the source of contamination and inform environmental health authorities. • Diarrhoea lasting more than 2 weeks is termed persistent diarrhoea. It may have many causes and may be associated with development of malnutrition. Patients with persistent diarrhoea should be referred for further investigation. 11.4 Nausea and vomiting Occasionally people have simple vomiting that is not serious and clears up without treatment. But vomiting can also indicate serious problems. Vomiting often comes from a problem such as infection, poisoning, appendicitis or something blocking the gut. Sickness with high fever may cause vomiting e.g. malaria, hepatitis, tonsillitis, earache, meningitis, urinary infection, gall bladder pain or migraine infection. Vomiting can also be associated with diarrhoea, drugs e.g. iron preparations and digoxin, the sequence of illness e.g. migraine, motion sickness and also alcohol abuse. It is very important that all patients are thoroughly examined and that the reason for nausea and vomiting is discovered. Any young children with bile stained (green) vomitus need urgent referral to hospital for assessment to exclude a bowel obstruction. Treatment involves to prevent dehydration, symptom relief and identifying cases that need referral for further investigation of more serious illness. Non-drug treatment 1. Prevent dehydration and replace lost fluid. Encourage patients to make up fresh mixture of Oral Rehydration Solution (ORS) Mix 1L sachet with 1 litre of clean water. Read the instruction on the packet. Always boil and then cool the water. OR, if ORS are not available, make Homemade Sugar and Salt Solution Homemade Sugar and Salt Solution 1/2 teaspoon of table salt 8 teaspoons of sugar 1 litre of clean water (boil and cool the water if the quality is uncertain). Continue for as long as vomiting and signs of dehydration continue. Return of urine flow is a sign of recovery. If the patient is unable to tolerate ORS (i.e. continued vomiting even when small amounts are given frequently) or has bile stained vomiting should be treated with intravenous fluids. When the patient is severely dehydrated then IV fluids may need to be administered as follows: Sodium chloride 0.9% IV infusion OR Sodium lactate, (Ringer-Lactate), IV infusion ADULT: In severe dehydration the first litre may be infused in 15-20 minutes. Thereafter the drip rate should be progressively slowed down. Six or more litres may be required in the first 24 hours of which the first 3-4 litres will be a replacement fluid after which a maintenance regimen of approximately 3 litres/24 hours should be used. CHILD <12 months: 30 ml/kg over 1 hours then 70 ml/kg over 5 hours. CHILD >12 months: the same amount over 30 minutes and 2.5 hours respectively. If the IV route is unavailable, a nasogastric tube is also suitable for administration of ORS, at a rate of 20 ml/kg every hour. If the child vomits, the rate of administration of the oral solution should be reduced. 2. Maintain nutrition Adults and children should continue to eat. Food should be easy to eat and digest e.g. soup, boiled rice. Drug treatment Symptoms of nausea and vomiting can be reduced through the use of the following antiemetics: Promethazine, oral ADULT: 25 mg at night, increased to 25 mg twice daily if necessary or 10-20 mg 2-3 times daily; CHILD under 2 years: not recommended CHILD 2-5 years: 5-15 mg daily in 1-2 divided doses, CHILD 5-10 years: 10-25 mg daily in 1-2 divided doses. OR Metoclopramide, oral ADULT: 10 mg three times daily YOUNG ADULT (15-19 years, under 60 kg): 5 mg three times daily CHILD 1-3 years (10-14 kg): 1 mg 2 to 3 times daily CHILD 3-5 years (15-19 kg): 2 mg 2 to 3 times daily CHILD 5-9 years (20-29 kg): 2 mg 3 times daily CHILD9-14 years (30 kg and over): 5 mg 3 times daily Note: Daily dose of metoclopramide should not normally exceed 0.5 mg/kg, particularly for children and young adults. Antiemetics are not recommended in children under 12 months of age. There is a high risk for dystonic reactions to metoclopramide and promethazine may cause sedation, which is dangerous in vomiting. Key points • Refer patients immediately if severely dehydrated, in shock, septicaemic, or if digested or fresh whole blood is vomited, or if there is constant abdominal pain. • Refer immediately if the person cannot pass a stool. • Refer infants who are projectile vomiting immediately • Refer patients who have symptoms for more than 1 week. • Keep patients well hydrated 11.5 Helminthic infestation (Worms) Infestation with worms is very common and is usually due to poor hygiene or contact of bare skin with soil in which the worm or worm eggs live. Thus this is particularly common in babies and children who often play and crawl around in or play in the soil. There are many types of worms that can infest the intestines and cause diseases. Common worm infestation includes: Hookworm (Ancylostoma) – causing anaemia Roundworm (Ascaris) – cause malabsorption and obstruction Strongyloides – causing weakness, nutritional deficiency Tape worm (Hymenolepis, Taenia) – causing nutritional deficiency Symptoms/signs Itching – when larvae are in the bloodstream and also when eggs are just outside the anus (children may scratch especially at night), Dry cough and wheeze – when the larvae pass through the lungs, Abdominal discomfort and sometimes pain, General weakness and getting tired easily, Seeing a worm in the stool or coming through the nose or mouth. Large swollen abdomen in children, heavy loads of worms may even cause bowel obstruction in young children, Anaemia, wheezing, and poor physical growth of children. Non-drug treatment Many worms are spread by the faecal hand oral route; therefore educate patients and all family members about the importance of: • Washing hands with soap and water after going to the toilet and before working with food • Keep fingernails short • Teach children to use toilets and to wash hands • Do not pollute the soil with sewerage/dispose of faeces properly • Encourage people that all meat is well cooked, especially pork. Make sure that no parts in the centre of meat or cooked fish are still raw. Drug treatment Mebendazole should not be used in the first trimester of pregnancy or in children under 6 months of age. Albendazole should be avoided in pregnancy and in children under 6 months of age. Pyrantel pamoate can be used in pregnancy and in children under 6 months of age. IMCI GUIDELINES If child is aged 1 – 5 years and has not received a dose in previous 6 months, then give albendazole as single dose while the patient is in the clinic. If child is 4 – 12 months and worms are seen give pyrantel as single dose. AGE or WEIGHT PYRANTEL PAMOATE Syrup 250 mg/5 ml ALBENDAZOLE (400 mg tablet) 4 – 9 months 6 – <8 kg 1.5 ml (75 mg) 9 months – 1 year 8 – <10 kg 1.8 ml (90 mg) 1 – 2 years ½ (200 mg) 2 – 5 years 1 (400 mg) NOTE: all kids between 1 and 5 years should be regularly dewormed at 6 month intervals. Threadworms (pinworms, Enterobius vermicularis): Mebendazole, oral ADULT and CHILD over 6 months: 100 mg as single dose; if reinfection occurs second dose may be needed after 2-3 weeks. CHILD 10 kg or less: 50 mg as single dose. OR; Albendazole, oral ADULT and CHILD >10 kg: 400 mg as single dose. CHILD 10 kg or less: 200 mg as single dose. CHILD < 6 months: not yet recommended. Whipworms (Trichuris trichiura) Mebendazole, oral ADULT and CHILD over 6 months: 100 mg twice daily for 3 days. CHILD 10 kg and less: 50 mg twice daily for 3 days. OR; Albendazole, oral ADULT and CHILD >10 kg: 400 mg once daily for 3 days. CHILD 10 kg and less: 200 mg once daily for 3 days. CHILD < 6 months: not yet recommended. Roundworms (Ascaris lumbricoides): Mebendazole, oral ADULT and CHILD over 6 months: 100 mg twice daily for 3 days. CHILD 10 kg and less: 50 mg twice daily for 3 days: OR; Albendazole, oral ADULT and CHILD >10 kg: 400 mg as single dose. CHILD 10 kg and less: 200 mg as single dose. CHILD < 6 months: not yet recommended. For beef tapeworm (Taenia saginata) and pork tapeworm (Taenia solium): Praziquantel, oral 10 mg/kg as single dose after a light breakfast. Dwarf tapeworm (Hymenolepis nana). This parasite often causes only asymptomatic infection. In symptomatic patients with persisting infection, give: Praziquantel, oral 25 mg/kg as single dose after a light breakfast. For hookworms (Ancylostoma): Mebendazole, oral ADULT and CHILD over 6 months: 100 mg twice daily for 3 days. CHILD 10 kg and less: 50 mg twice daily for 3 days. OR; Albendazole, oral ADULT and CHILD >10 kg: 400 mg as single dose. CHILD 10 kg and less: 200 mg as single dose. CHILD < 6 months: not yet recommended. For strongyloides (Strongyloides stercoralis): Albendazole, oral ADULT and CHILD >10 kg: 400 mg daily for 3 days. CHILD 10 kg and less: 200 mg daily for 3 days. CHILD < 6 months: not yet recommended. Repeat after 7 days in complicated or disseminated infections. If the patient is anaemic then treat: As directed in Chapter 7 Blood disorders Key points • Refer patients with signs of abdominal tenderness, pain and vomiting, abdominal masses, seizures, severe headaches, nausea, vomiting, changes in their vision. If tapeworm is suspected, refer. 11.6 Constipation Constipation can have many causes some of which are more serious than others e.g. incorrect diet, lack of exercise, pregnancy, old age, certain drugs, chronic use of laxatives and enemas, cancer of the bowel, disobeying the call to defecate (maybe due to immobility), anal fissure and other painful perianal lesions, obstructions etc Symptoms/signs There is a wide variation of what is normal between individuals, and therefore there must be careful assessment of each individual. Bowel habits vary between individuals, therefore constipation can mean: • Their stools are too hard. • They do not pass stools often enough. • Passing stools causes straining. • There is a sense that the evacuation is incomplete. Non-drug treatment • Encourage regular exercise. • Encourage food rich in fibre e.g. fruit, vegetables, bran. • Encourage adequate amounts of fluid – 4 – 6 250ml glasses of water (or fluid) per day. • Encourage a regular time for bowel motion even if there is no urge. • Discourage continuous use of laxatives. Drug treatment To stimulate the bowel and increase intestinal motility: Bisacodyl, oral ADULT: 5 mg – 10mg at bedtime CHILD under 10 years: 5 mg If the constipation is resistant to the above treatment then re-evaluate the underlying cause. For rapid bowel evacuation use: Magnesium sulfate, oral 1-2 teaspoonfuls (5 – 10 g) in a glass of water once or twice daily (should cause a bowel evacuation within 2 to 4 hours) Note: Do not use magnesium salts in patients with impaired renal function. For the treatment of hepatic encephalopathy only (specialist): Lactulose solution (3.1-3.7 g/5 ml) 30-50 ml 3 times daily, subsequently adjusted to produce 2-3 soft stools daily Key points • Prolonged severe constipation may present with overflow diarrhoea • Refer patients with recent unexplained change in bowel habits. • Refer patients with faecal impaction • Refer where the cause of constipation is uncertain 11.7 Anal conditions The two common conditions found in the anal area are anal fissures (cracks) and haemorrhoids (varicose veins of the ano-rectal area, piles). Often they are found together. Symptoms/signs Painful small cracks just inside the anal margin often seen with piles (either internal or external). These may cause spasm of the anal sphincter. Piles or haemorrhoids are varicose veins or the anus or rectum that feel like little limps or balls. They may be painful and frequently appear during pregnancy and may disappear afterwards. Often these occur when a patient is constipated and is straining to pass a hard dry stool. Haemorrhoids may bleed. Non-drug treatment Educate the patient on how to ensure soft easily passed stools are formed through eating a high fibre diet and drinking plenty of water. Counsel against chronic laxative use and against straining to pass a stool. Careful anal hygiene and sitting in a bath of warm water or in a saline bath (salt and water) will aid healing (Measure roughly one handful of salt to 10 litres of water). Drug treatment To relieve the symptoms use: Antihaemorrhoidal, ointment or suppository Apply or insert 2 to 4 times a day as required (usually after passing a stool and at bedtime). Key points • Refer if the haemorrhoids cannot be reduced or if the area is severely painful, if the episodes are recurrent. • Refer if haemorrhoidal bleeding is severe. Chapter 12 – Immunisations Immunisation Schedule The Expanded Program on Immunisation is aimed at the following target groups: • All children under 1 year of age (0-11 months) • All women of childbearing age (including pregnant women) See further the national program guidelines; Expanded Program for Immunizations. The recommended vaccines are the following: BCG Bacillus of Calmette and Guerin OPV Oral Polio Vaccine DPT Diphtheria, Pertussis, Tetanus DT Diphtheria, Tetanus TT Tetanus Toxoid Measles Measles See further the National program for immunization Chapter 13 – Neurological conditions 13.1 Headache Headache is a very common symptom. It can have very serious underlying causes however; in most cases the cause is not serious. Causes of headaches; Tension headache –said to be due to stress or anxiety, which causes tension in the frontal or occipital muscle. Occasionally due to visual defects. Common in young to middle-aged women. Often gets worse as the day progresses and may progress to chronic daily headache. Chronic daily headache – Headache occurs on more days than not for a period of 3 months or more. Main cause is long-term use of analgesics and is sometimes termed “analgesic rebound headache” or “medication misuse headache” Infections – usually of gradual onset with fever and general debility. Malaria, Dengue and other infections cause moderate, generalized, pulsating constant headache. Meningitis causes a headache that radiates down the neck. Patient is usually acutely ill, febrile and may be confused. Patient may have a stiff neck and fail to raise straight leg. (See chapter 16 – Infectious diseases) Sinusitis – pain and tenderness around the sinuses (see chapter Ear, Nose and Throat) Migraine – Often there is a family history. Is a frontal and unilateral headache that may be associated with vomiting, photophobia and visual changes. There may be trigger factors e.g. foods, stress, missed meals, premenstrual etc. Often there is an aura stage where the patient may experience visual disturbances before the onset of the headache. Cluster headache – unilateral pain occurring from 30 minutes to 3 hours duration. Often occurs at night with 1-8 attacks per day for several weeks or months (usually with running nose, and eyes). More common in males. Drugs – Many drugs will cause headaches e.g. vasodilators like the nitrates. Oral contraceptives are a well-known cause of migrainous headaches. Temporal arteritis – this is a vascular disorder which typically produces severe throbbing pain over the temporal area, marked tenderness over the affected arteries and ischaemic pain in the jaws. Vision can be significantly impaired and treatment needs to be undertaken as an emergency to prevent permanent blindness. The condition is characterised by a marked rise in ESR. Subarachnoid haemorrhage – Sudden onset of severe occipital headache often associated with collapse, brief unconsciousness and confusion, stiff neck and elevated blood pressure. CT scan or lumbar puncture confirms diagnosis. Brain Tumour – The headache is usually occipital worsening in the morning and associated with vomiting. Slowly progressive weakness on one side, convulsions, visual changes, impaired speech, vomiting and mental changes may be associated with headache. Hypertension – throbbing, there is a history of cardiovascular or renal disease. BP is elevated on examination and there may be retinal changes. Chronic subdural haematoma – This usually follows a head injury, which is sometimes trivial and occurs particularly in the elderly. The clue to the diagnosis is the fluctuating symptoms and signs, which usually increase in severity over the course of weeks. Always take a thorough history and examine the patient. Action: Measure pulse, temperature and blood pressure Check for neck stiffness and positive Kernig’s sign (ability to raise straightened leg) Check for tenderness of the sinuses and temporal arteries Perform a complete neurological examination Ask: Is the headache of sudden onset and very acute – the first or worst headache (thunderclap headache)? Subarachnoid haemorrhage Meningitis Is the headache recurrent (associated with vomiting and visual phenomena)? Migraine Cluster headache Is the headache daily and progressive over some time? Worse on rising and may improve during the day (may be worse on coughing)? Brain tumour Chronic subdural haematoma Hypertension Constant or worse in the afternoon or evening? Tension headache Sinuses/dental Cervical spondylosis Viral or other infection Temporal arteritis Drugs Toxic fumes Note: Headache is rare in children. Look for an underlying cause. Non-drug treatment Try to avoid unnecessary stress, modify lifestyle, relaxation techniques Migraine – avoid factors that trigger migraine, rest in darkened room during an attack. Drug treatment For pain (but avoid prolonged frequent use) standard analgesic treatment, see STG section Pain Control. Migraine To treat an acute attack: See chapter 3 – Pain management PLUS to stop vomiting Metoclopramide, oral ADULT: single dose of 10-20 mg at first sign of attack preferably 10-15 minutes before antimigraine drug; ADOLESCENT: single dose of 5-10 mg, (5 mg if body weight less than 60 kg) OR Promethazine, oral 25mg, give intramuscularly if patients is vomiting already. Metoclopramide has the added advantage of promoting gastric emptying and normal peristalsis. If these measures have failed to relieve a previous attack the use: Ergotamine 1 mg + caffeine 100 mg (oral) ADULT: 1-2 tablets at onset; maximum dose 4 tablets in 24 hours; not to be repeated at intervals of less than 4 days; maximum dose 8 tablets in one week. Note: To avoid habituation the frequency of administration of ergotamine should be limited to no more than twice a month. It should never be prescribed prophylactically. Rebound headache may occur after ergotamine. Peripheral vasospasms: Warn patient to stop treatment immediately if numbness or tingling of extremities develops and to contact doctor. Prophylaxis of migraine If a patient experiences more than 2 acute attacks of migraine per month then regular prophylactic medication is necessary. Use: Aspirin, oral: 150mg once a day If this is ineffective, then use: Atenolol, oral: 50 -100mg daily If atenolol does not prevent attacks, use: Amitriptyline, oral 10 – 50 mg, at night, initially, gradually increasing the dose depending on the response and side effects, up to a maximum of 150 mg orally, at night. Cluster headache Can be relieved with Oxygen inhalation, for 10 minutes. If the patient does not respond to oxygen, treatment of an acute episode is the same as for severe migraine. Temporal arteritis If this is diagnosed then treatment must be initiated immediately to avoid blindness. Give: Prednisolone, oral Give: 60mg daily dose, and then reduce rapidly to 20-30mg daily when the ESR falls, usually within 3 months. Further gradual dose-reduction should be titrated against symptoms and the ESR. Treatment is often required for many months, and can be required for up to 5 years. Key points • Most headaches are tension headaches, and will be relieved with analgesics and changed lifestyle. • Always look for underlying cause of headache. • Refer patients immediately if subarachnoid haemorrhage, meningitis, malaria or tumour, abscess, haematoma, is suspected. • Refer temporal arteritis but first start iv cortison treatment • Refer severe hypertension. • Refer any headache not responding to treatment • Refer elderly patients with dementia and history of head injury. • Headache is rare in children – refer for paediatrician assessment. 13.2 Seizures (convulsions) These are sudden unintentional (involuntary) movements of the whole or part of the body; the event is of cerebral origin. If generalised (involving the whole body) the Patients may lose consciousness, may bite their tongue, become incontinent and may unintentionally injure themselves. After a convulsion a patient may sleep for some time. Common causes of seizures Fever – especially in children. Infections – e.g. cerebral malaria, meningitis, encephalitis, TB, HIV, abscesses in the brain Metabolic causes – hypoglycaemia, hypocalcaemia, hypernatraemia, hyperosmolar diabetic state Epilepsy – spontaneous recurrent seizures Eclampsia – See Reproductive Health Hypertensive encephalopathy – Tumour or cysts in the brain – Head injury or, in children, non-accidental injury Drugs and toxins – alcohol, antidepressants, metronidazole, drug and alcohol withdrawal. Vascular causes – malformations, bleeds, etc. Non-drug treatment Put the patient in the coma position in a safe place and on the floor. Turn the patient on the side with that leg bent and other leg straight Bend head back to keep airway open. Remove any secretions or vomitus from mouth or nose with a finger / wipe. Do not insert any sharp objects (e.g. spoon) into the mouth. Drug treatment If the patient is still convulsing after a minute or two give: Diazepam, IV ADULT: 10-20 mg at a rate of 0.5 ml (2.5 mg) per 60 seconds, repeated if necessary after 30-60 minutes. May be followed by intravenous infusion up to maximum 3mg/kg over 24 hours. CHILD: 0.1-0.4 mg/kg, slowly IV. If not possible intravenously then remove the needle and give same dose into the rectum. To give rectally insert nasogastric tube a couple of cms into the rectum – a syringe is attached to the NGT and the drug is syringed into the rectum. The rectal route is suitable as satisfactory absorption is achieved within minutes and administration is much easier. Suppositories are not suitable, because absorption is too slow. If a child has a fever with afit also give paracetamol against fever. Key points • It is important to find the cause of the convulsion and treat. • IMCI all children under 5 with convulsion, refer to hospital. 13.2.1 Epilepsy Epilepsy is a disorder of the central nervous system that is characterised by spontaneous recurrent seizures. We refer to the National Epilepsy Program, standard treatment guidelines with its flow charts. Chapter 14 – Conditions of the Eye 14.1. Eye Injuries 14.1.1. Foreign bodies Symptoms and signs: History of injury is usually given by the patient. Symptoms of pain, redness, tearing, redness, feeling of something foreign being in the eye. A torch or slit lamp exam can often identify the foreign body on the eye as a dark spot (with surrounding flourescein staining). If the foreign body is not on the cornea or conjunctiva, the underside of the eye lids should be examined as the foreign body may be stuck to the underside of the lid. Treatment Instill anesthetic and irrigate the eye with saline or water to try to flush the foreign body off of the eye. If the foreign body remains after the irrigation, try to remove it by gently rubbing across the foreign body with a cotton bud (The underside of the eyelid can be exposed by pulling on the lashes and bending the upper lid back over the stick end of a cotton bud). Eye care nurses may attempt to gently remove the foreign body with a forceps or blunt eye spatula after application of topical anesthetic drops (usually tetracaine used two drops every two minutes over five minutes before attempting). If you cannot remove the foreign body, apply antibiotics and patch for one day with tetracycline 1% ointment (1 cm). Continue Tetracycline 1% ointment four times a day or Chloramphenicol eye drops four times a day – each medication should be continued for five days or until the symptoms resolve, whichever takes longer. . The patient should be examined approximately every two to three days to ensure that the foreign body site heals well and does not develop an infection. If the foreign body remains, and especially if the eye becomes more irritated, refer to an ophthalmologist. 14.1.2. Corneal Abrasions: These may be caused by any type of injury to the eye, even hitting the eye with a finger, pillow, or clothing. Symptoms and signs: A painful red eye, with tearing, and sometimes a sensitivity to light. If a slit lamp is available, look for a rough area on the surface of the eye (if flourescein eye drops are available and instilled in the eye, a bright yellow-green stain will form over the abrasion). Look for foreign bodies in the abrasion or under the lids. Examine the eye to make sure it has normal anatomy and is filled with fluid and there is not a cut through the cornea leaking fluid. Treatment: Apply either tetracycline 1% ointment (1 cm) four times a day or Chloramphenicol eye drops four times a day for five days or until the symptoms resolve, whichever takes longer. Optional treatment includes the application of an eye pad to hold the lid closed and protect the eye from irritating wind or sunlight. Examine every one to three days to ensure that the abrasion does not develop an infection. 14.1.3. Bleeding on the white of the eye (Subconjunctival hemorrhage) This problem may occur after lifting heavy objects, coughing, or injury to the eye. The blood on the white of the eye comes from a break in a blood vessel on the eye. These areas are commonly seen in newborn babies Symptoms and Signs: A painless blood-red area on the white of the eye, without a conjunctival laceration. The red area may cover a small or a very large part of the white of the eye. Treatment: No treatment is needed if there are no other problems with the eye. 14.1.4. Conjunctival Laceration: Symptoms and signs: Reddened area with bleeding on the conjunctiva – the torn edge of the conjunctiva is often visible with a pen light and is very visible with a slit lamp. This problem usually results from a sharp object hitting the eye (like a finger or a tree branch). Examine closely to make sure the wall of the eye (sclera) is not lacerated (if the sclera is cut, you will see a deep cut, brown or black tissue, or a dark and thick red hemorrhage on the sclera). Treatment: Clear away any foreign bodies. Apply antibiotic ointment (Tetracycline or Chloramphenicol) and a patch. Apply more antibiotic four times a day for five days. 14.1.5. Bleeding behind cornea (inside eye – “Hyphema”): Symptoms and Signs: Blood behind the cornea usually from a bad injury to the eye or from surgery. The eye may be painful or have blurry vision. Determine how full the front of the eye is with blood (is it ½ full, or ¼, for example) Treatment: This is a serious problem. Blood in may raise the eye pressure very high (which would cause headaches, nausea, and dizziness symptoms), or the blood vessels that broke in the injury may continue to bleed and fill the eye with blood. If the eye is ½ full of blood or more, or the patient has bad eye pain, refer the patient to an eye doctor immediately. If an eye doctor is unavailable or the patient would have to travel down rough roads or walk much to get to an eye doctor, it may be best to try to treat the patient immediately. If the eye is ½ full, or less, and the patient is not in pain, try to treat the patient. Put a protective shield over the eye (a metal patch is best, but a bandage patch will work). The shield should be left on except for when the eye is examined or medicine drops are put in the eye. The patient should rest in bed until two days after the blood clears (except for visits to the doctor). Any work or movement may make the blood vessels in the eye bleed again. If you have medicated drops to treat glaucoma (e.g. Timolol or similar), use these drops two times a day. Use dilating drops four times a day (e.g. Atropine, Scopolamine, or Cyclopentolate is best, or Tropicamide is acceptable). If the cornea does not have a scratch or cut on it, use Prednisolone 1% drops four times a day until the blood is clear. If the eye pressure is elevated, or if eye pressure measurement is not available, and the patient is in pain, use Acetazolamide pills – use 250 – 500 mg two times a day until the blood is clear. Do not use aspirin or ibuprofen for pain treatment as these thin the blood. Acetaminophen or Paracetamol are good to use. The patient should be evaluated in the clinic every 1-3 days. 14.1.6. Ruptured eye: Symptoms and signs: History of trauma or fall. Pain, loss of vision, fluid or bleeding coming from the eye. On examination there may be an obvious cut in the wall of the eye, black material on the wall of the eye (coming from inside the eye), iris on outside of the eye, thick red blood under the conjunctiva, a shrunken, soft, and low pressure eye may also be noted. Limited eye movement may also be noted. Treatment: Put a shield over the eye to protect it from further injury, be careful not to press on the eye. The patient should remain in bed rest. Give antibiotics (Cefazolin – one gram intravenously three times a day or Ciprofloxacin – 400 mg orally or intravenously two times a day until the patient can be referred to an ophthalmologist. Also, the patient should receive tetanus toxoid – 0.5 ml in one dose (for adults). The patient should be referred to ophthalmologist for surgical repair. The patient should not eat for 12 hours prior to surgery. The healing from this type of injury is usually difficult with limited vision, unless the injury is small. Paracetamol or stronger medicines may be needed for pain control. 14.1.7. Chemical Injury: Symptoms and signs: Eye exposure to petroleum, battery acid, insect killer, or other chemical usually causes a painful reaction on the eye with a reddened conjunctiva and sometimes swollen lids. Treatment: Immediately flush the eye for 30 minutes with water or saline (or anything that you can drink will work to flush the eye). Usually a large syringe without the needle works well for flushing. Sometimes you may need to put in a speculum or put in an anesthetic drop like tetracaine to help the patient open their eye to let the water flush the eye. You should not wait more than a minute to check the vision before starting to flush the eye. Carefully examine the eye to remove any solid foreign bodies. You can use a cotton bud to wipe inside the lids to remove any foreign bodies. Put 2cm antibiotic ointment (tetracycline or Chloramphenicol), put in a dilating drop, and patch the eye. Use more antibiotic ointment four times a day. If the eye is very painful, dilating drops four times a day may help. Continue this treatment until the eye is healed (usually 5-10 days). Use Paracetamol for pain. Evaluate the patient daily. If the cornea is cloudy refer to an ophthalmologist 14.2. Eye Infections 14.2.1. Infectious conjunctivitis: Symptoms and Signs: A red eye with mucous or tearing, usually worsens over a few days and lasts one or two weeks. The cornea is usually clear, but may develop small (< 1 mm) white spots called infiltrates. The vision is usually only mildly reduced. Treatment: Clean eye of mucous with a warm wash rag or cotton bud. Inspect eye to make sure there are no foreign bodies. Use antibiotic (Tetracycline 1% ointment or Chloramphenicol) four times a day for a week. Prevent spread to other people by keeping the infected person from playing, going to school or work, or sharing towels. Patient should be told to wash their hands regularly. 14.2.2. Post-infectious Corneal Scarring: Symptoms and signs: Blurred vision and sometimes sensitivity to light after an episode of conjunctivitis. About one in ten cases of infectious conjunctivitis will get 1 mm white spots (scarring) on the cornea (up to 40 per eye that can often only be seen with a slit lamp). These usually develop after a few days of infection and stay from several weeks to several months and fade very slowly. Treatment: There is no medicine to help with this problem. The lesions clear with the body’s natural healing mechanisms. 14.2.3. Keratitis (Corneal Infection): Symptoms and signs: Usually a scratch or injury to the cornea that becomes white and sometimes hazy. The eye is red and tearing with mucous and a visible whitened area on the cornea. Treatment: Chloramphenicol drops every hour while awake and immediate referral to an ophthalmologist 14.2.4. Stye and Hordeolum (Nodule on eyelid) Symptoms and Signs: A painful and irritated lid for several days to several weeks. Usually effects only one eye. Mucous may be present as well as a nodule on the eyelid that can either be seen or palpated. If the stye is infected, an area of the lid or the whole lid may be red and swollen (this infection is called a hordeolum and its treatment is described below). Treatment of Stye Application of a warm compress to the eye for fifteen minutes three times a day usually causes the stye to drain and the condition to resolve. The stye may take several days to two weeks to drain. Tetracyline 1% eye ointment should be applied three times per day for up to two weeks so that the infected material draining from the stye won’t cause an infection on the eye surface. Sometimes the stye won’t drain. If the stye won’t drain, it will slowly clear up over 1-3 months by the body’s natural healing processes. Treatment of Hordeolum Initial treatment should include oral cephalexin at 250 mg four times a day for a week. Use tetracycline 1% ointment (1 cm) in the eye three times a day. As the lid redness and swelling decrease, warm compresses can be applied to help drain the stye that caused the infection (according to the stye treatment instructions above). Surgical drainage is also an option if other treatments do not work. 14.2.5. Infection of the tear sac (Dacryocystitis) Symptoms and signs: Redness, swelling, and pain of the skin between the eye and the nose (Also, sometimes the eyelids are swollen and red, the lower lid is usually worse). The eye waters and usually has mucous or pus discharge. Pus may flow onto the eye from the swollen tear sac when gentle finger pressure applied to the swollen area. The problem may have occurred before for the patient. Treatment: Cephalexin 250-500mg four times a day for ten to fourteen days orally. Alternative treatment is amoxicillin 500 mg three times a day orally for ten to fourteen days. Chloramphenicol antibiotic drops four times a day in the affected eye for two weeks. Patients should use warm compresses for ten minutes three times a day. Give Paracetamol against pain. If the swelling is not improving in one week or the patient has a fever, refer to an ophthalmologist. Examine eye for patterns of movement, vision, and pupil function. With any abnormality of the eye function, or other signs of systemic illness, refer to ophthalmologist and consider admitting to hospital of intravenous antibiotics (e.g. Cefazolin 1 gram three times a day). Consider incision and drainage if referral is not possible and infection is not improving 14.2.6. Infection of the eyelids/eye socket (Preseptal/orbital cellulitis) Symptoms and signs Red swollen eyelids that are painful. The eye may be red and teary. There may be an obvious cause (for example a chalazion). The symptoms usually worsen over 1-3 days. The eye should be examined for normal vision, normal movement, normal position, and normal pupil function. Treatment: If the eye is functioning normal (vision, movement, position, pupil) then assume the infection is in the lids only. Treat with Cephalexin 250-500 mg four times a day for one week. Antibiotic eye drops (Chloramphenicol, tetracycline 1%) may be used four times a day if the surface of the eye is red and irritated. If the eye is NOT functioning normally or the patient has a fever, then assume the infection is in the eye socket and give intravenous Ceftriaxone 1 to 2 grams two times a day and refer to an ophthalmologist immediately 14.2.7. Half face rash, blisters (Herpes Zoster or Shingles): Symptoms and Signs: A rash (sometimes with blisters or vesicles) that does NOT cross over the mid-line of the face (it stays only on either the right or the left side of the face). It usually affects either the forehead or the cheek area and develops over 1-3 days. The rash is usually very painful and usually happens in older or sick patients. Treatment: The eye ball is only involved (red or painful) 5% of the time. If the eye is involved, use antibiotic ointment (tetracycline or Chloramphenicol) three times a day for five days. The rash will clear over 1-3 weeks without medical treatment. Give oral Acyclovir 800 mg five times a day for one week if the symptoms started within 4 days of the clinic visit to shorten the severity of the rash. 14.2.8. Trachoma Trachoma is rare in Timor Leste according to data from a recent national eye health survey. The principles of treatment are included below to ensure basic treatment is guided for these unusual cases. Symptoms and signs: Slowly worsening red and watery eyes. This problem may last months or years. On the underside of the upper lid, small gray or pink bumps are presen and a patch of grayish white tissue may be evident with a slit lamp or other magnification. The upper lids may either not close or have the lashes turned back toward the surface of the eye, where they can rub on, irritate, and scar the cornea. Treatment: Use 1% tetracycline ointment (1 cm), two times a day for six weeks (apply to both eyes). This treatment is appropriate for both adults and children. For lashes rubbing on the eye (see trichiasis section) – you may pull out the individual lashes out to lessen the irritation. Use tetracycline ointment to lubricate the eyes two times a day. Refer for definitive treatment with an ophthalmologist (most patients need surgical repair of their eyelids to move the eyelashes away from the eye). 14.2.9. Infectious conjunctivitis of newborn babies Symptoms and signs: Red eyes with discharge and swollen lids within the first three weeks of life. Irritation and redness of the conjunctiva in the first day after birth is usually not an infection. Usually, these infections occur when the mother has vaginal Chlamydia or Gonorrhea infection and the baby has a lot of pus on the eyes. These infections often cause blindness and severe generalized illness for babies. Gonorrhea usually starts 3-4 days after birth. Chlamydia conjunctivitis usually starts from 7 -14 days after birth and may be associated with a cough or signs of pneumonia. Treatment: Usually it is hard to know which disease is the problem so treatment for both infections are given. For Gonorrhea: Ceftriaxone – 50 mg/kg as a single dose (125 mg maximum) intramuscular injection. For Chlamydia: Erythromycin – 50mg/per kilogram of body weight of Erythromycin syrup by mouth divided into four doses a day for two weeks plus erythromycin ointment four times a day for two weeks. If Erythromycin is not available, give Co-trimoxazole 240 mg (40 mg trimethoprim + 200 mg sulfamethoxazole) two times a day for three weeks. Both parents should be treated for these diseases also. Prevention: All newborn babies should be given one drop of 2.5% Povidone-Iodine (or tetracycline 1% ointment if Iodine is not available) within the first two hours after birth to prevent this kind of infection. Babies born to mothers with Gonorrhea or Chlamydia infections are at high risk of infection and should receive the antibiotic treatment above to prevent infection. 14.3. General Eye diseases 14.3.1. Cataract: Symptoms and signs: Slow worsening of vision in one or both eyes. Some patients may be sensitive to bright light. A cataract (clouding) lens in the pupil can sometimes be seen easily if it is so severe that it is white. A brown or less severe clouding of the lens can often be seen in the pupil with a torch or slit lamp in a dark room. Treatment: The only effective treatment for cataract is surgery by an ophthalmologist. If the vision is bad enough to cause major problems in usual day to day work (fishing, farm work, driving, reading, walking, caring for the house, etc.), refer the patient for surgery. 14.3.2. Pseudoexfoliation: Symptoms and signs: This is common in patients with cataract and high eye pressure. Small white cloudy material on the surface of the lens and on the edge of the pupil (can only be seen with a slit lamp and careful examination in a dark room). If a patient has a cataract, especially if the cataract is worse on one eye, this finding should be looked for carefully. Treatment: If psuedoexfoliation is identified, refer to an ophthalmologist as there is a high chance the eye pressure may be high in this eye and the patient may have glaucoma. 14.3.3. Pterygium Symptoms and Signs: A slowly worsening fleshy (white or red) growth across the white of the eye and onto the cornea. These are caused by exposure to the sun, wind, and dust and are common in fishermen, farmers, and people who raise cattle. Treatment: Sunglasses protect the eye from the causes of pterygium so may relieve the irritation and slow the growth of the pterygium. Lubricating drops or ointment may relieve irritation – these can be used several times a day. Pterygiums should be reevaluated once a year or when the patient notices they are getting bigger. Surgical: The pterygium should be removed surgically if it is chronically painful or is growing close to or across the pupil and worsening the vision. 14.3.4. Trichiasis – (eyelashes rub the surface of the eye) Symptoms: Chronic eye irritation, tearing, occasionally blurred vision may be present. Signs: Obvious eyelashes rubb on the surface of the eye. Sometimes, the lashes may only rub intermittently and the problem may be brought on by having the patient squeeze their eyelids tightly. The eye may be red and tearing, with flourescein staining the cornea may show bright areas where the cornea is rough or there is an abrasion. Treatment Lashes may be carefully pulled out with a forceps. They usually grow back in 1-2 month and can be pulled again then. Tetracycline 1% ointment can be used two times a day for lubrication to protect the cornea. If the cornea is becoming damaged, rough, or hazey, refer to an ophthalmologist. 14.3.5. Xerophthalmia (Vitamin A Deficiency) This is a condition common in children and is associated with inadequate intake of foods that contain Vitamin A. If it is not recognised and treated early then it can cause blindness in the child. Symptoms and Signs: Usually this disease worsens when a child is ill with another disease like diarrhea. At first the child cannot see as well in the dark as other people can. Then a “Dry eye” occurs, the white of the eyes loses it shine and begins to wrinkle. Patches of little grey bubbles (spots) may appear on the surface of the sclera. The cornea becomes dry and dull and may become soft, white, and bulge. Usually there is no pain but blindness may result from infection, scarring or other damage. Treatment Acute treatment for severe cases for babies over one year old: 200,000 units vitamin A on day one, 200,000 units Vitamin A on day two, and 200, 000 units on day 14. (Use 100,000 units for each dose instead of 200,000 units for babies less than one year old). Refer to an ophthalmologist for any problems affecting the cornea. Vitamin A dosage for prevention of xerophtalmia For prevention, give the following doses every six months Age Vitamin A CAPSULE 200 000 IU Vitamin A CAPSULE 50 000 IU Less than 12 months 1/2 capsule 2 capsules 12 months up to 5 years 1 capsule 4 capsules 14.3.6. Double Vision Symptoms and signs The patient complains of seeing two objects when only one is present. The eyes may be pointing in different directions or may look normal during examination. Treatment: The treatment of double vision depends on the cause of the problem, there are many possible causes. If the double vision is chronic or worsening or severe, the cause may be serious and the patient should be referred to an ophthalmologist. If the double vision is only present sometimes, it may be from weakness, dehydration, or malnutrition. If these possible causes are treated and the double vision remains, refer to an ophthalmologist. 14.3.7. Glaucoma: Symptoms and signs: Usually develops in only one eye in patients over 40 years old. The high eye pressure that causes glaucoma may cause slowly worsening vision without pain or quickly worsening eye pain, headache, nausea, and blurred vision. The eye pressure is high and the eye may feel hard, like a rock. May develop within a day (“acute glaucoma”) or over months or years (“chronic glaucoma”). Treatment: Referral to ophthalmologist. The eye pressure may be temporarily lowered by treatment with Timolol drops two times a day, Pilocarpine drops four times a day, or oral Acetazolamide 250 or 500 mg from two to four times per day. 14.3.8. Diabetes and the eye: Signs and symptoms: Worsening vision which may develop slowly or quickly. Bleeding, swelling, and closed blood vessels inside the eye are common causes of decreased vision in diabetic patients. The higher the blood sugar is and the longer the blood sugar is elevated, the more likely the patient is to have these problems. A slit lamp or torch and a dark room may allow the examiner to see a darkening of the usual bright orange reflex in the pupil. Treatment: Any patients with diabetes with decreased vision that cannot be improved to normal vision with spectacles should be referred to an ophthalmologist. 14.3.9. Inflammation inside the eye from the iris (Iritis) Symptoms and signs: Usually iritis occurs in one eye only and the pain, sensitivity to light, and eye redness may worsen quickly or slowly. The eye may be teary, but there is no pus or mucous discharge. Vision may be blurred. The pupil edge of the iris is often irregular instead of being round and circular. Slit lamp exam may show cells or debris in the anterior chamber of the eye. Treatment: Antibiotics do not help. Refer to an ophthalmologist 14.3.10. Albinism Symptoms and Signs: Obvious lightening of the hair, skin, and eyes. Best corrected vision is often decreased to the 6/12 to 6/60 range. Patients may be light sensitive. Also refractive error, eye misalignment, and rapid horizontal eye movements (nystagmus) are common. Treatment: Refer to an ophthalmologist if possible for initial evaluation. Refractive error should be treated as early in life as possible. Sunglasses and a hat may be helpful to lessen discomfort due to light exposure to eyes. 14.3.11. Corneal scar Symptoms and signs: Decreased vision, usually a chronic condition. Some patients may have light sensitivity and chronic irritation to the eye. A history of infection or injury is common. A white or hazy cornea is usually evident on torch exam, and is definitely obvious on slit lamp exam. Treatment: Corneal scars that result from a recent viral infection usually clear over several months. Most other corneal scars do not heal. Surgical repair of corneal scars is difficult, but can be helpful for some patients (an ophthalmologist will need to evaluate these patients to determine the best candidates for surgery). 14.3.12. Blind and painful eye Symptoms and signs: No light perception vision and pain in the eye. Vision loss may be from many causes. Examination findings often include white cornea, redness of the eye, either increased eye pressure (glaucoma) or a loss of eye pressure and shrinking of eye may occur. The internal anatomy of the eye (on slit lamp exam) may often be notable for scarring and distortion. Treatment: Antibiotic ointment (1cm of tetracycline 1%) one or two times a day may be helpful to lubricate the surface of the eye. Dilating drops (usually Atropine or Cyclogyl 2-4 times a day) may calm inflammatory reactions in the eye and relieve pain. An ophthalmologist may recommend Prednisolone drops up to four times a day may also calm the eye. If the eye pressure is elevated, refer to the glaucoma section for treatment options – the eye pressure should be kept below 40 to keep the eye pressure from causing pain and further damaging the eye. Chapter 15 – Renal conditions 15.1 Urinary tract infections (UTI) This refers to any bacterial infection of the urinary tract and usually presents as infection of the lower urinary tract (urethritis) and bladder (cystitis). Acute pyelonephritis is an acute infection of the kidney, with significant risk for urosepsis and serious damage to kidney fundcion; chronic pyelonephritis usually presents as chronic renal failure. UTIs are common in women due to the shortness of the urethra. UTIs in men can be associated with renal calculi (stones), prostatic hypertrophy or urethral stricture. While UTI often is treated with simple ampicillin or cotrimoxazol in the non-pregnant woman, UTI during pregnancy may need a more aggressive treatment. This is because of the fact that UTI in pregnancy has a high risk to ascend up and infect the kidneys (pyelonephritis) with risk for urosepsis. This is due to the physiological changes of the urinary tract during pregnancy. UTI is children may be associated with vesico-ureteric reflux or other urinary tract abnormality. Symptoms/signs Frequent painful urination or suprapubic pain after urination Occasionally haematuria (Blood in urine) Loin pain/tenderness Fever and lower back pain In children there may be resurgence of urinary incontinence, irritability, feeding problems, diarrhoea and failure to thrive Note: dysuria in men can indicate a sexually transmitted infection. Acute pyelonephritis is diagnosed when an UTI is accompanied by nausea, vomiting, fever, rigors and loin pain. Dysuria may be absent. This is a serious infection, which must be treated and referred urgently. Non-drug treatment Advise patient to drink plenty of water – 2 cupfuls every hour Avoid acidic fruit juices, coffee and tea. A teaspoonful of sodium bicarbonate (baking soda) in a glass of warm water may help to make the urine for alkali and ease the dysuria Good personal hygiene is important – always wipe away from urethra and wash the perianal area with mild soap and water after defecation. Dry with soft towel. Drug treatment In mild/moderate cases treat with first line therapy: Amoxicillin, oral ADULT: 250-500mg three times a day for 7 days (3 days may be adequate for infections in women) OR ADULT: 3 g repeated after 10-12 hours, for uncomplicated acute urinary-tract infection and fully sensitive bacteria. CHILD: 15 mg/kg 3 times a day for 5 to 10 days. Note: All cases of ascending urinary tract infection/pyelonephritis and men with UTIs require referral for treatment. Treatment should then use Ciprofloxacin, and treatment duration continue for 14 days. Second line therapy: Nitrofurantoin, oral For treatment of acute uncomplicated lower urinary tract infection: ADULT: 50 mg every 6 hours with food for 7 days. INFANT and CHILD: 1.5 mg/kg/dose every 6 hours For treatment of chronic recurrent infection: ADULT: 100 mg every 6 hours with food for 7 days (dose reduced or discontinued if severe nausea). Prophylaxis ADULT: 50 – 100 mg at night. CHILD: 1 – 2 mg/kg at night. Refer acutely ill patients for intravenous therapy. In acutely ill patients give intravenous antibiotics until the patient is apyrexial then change to oral therapy: Ampicillin, IV: 2g every 3 hours AND Gentamicin, IV, IM: ADULT: 7,5 mg/kg once every 24 hours; (2 mg/kg every 24 hours in the elderly and if there is renal impairment. Young infants or children may be quite unwell with a UTI and should be referred to specialist for treatment. UTI in young infants may be associated with septicaemia and/or pyelonephritis. All young infants with UTI, under 3 months, should be referred to specialist and treated with parenteral antibiotics (IM, IV) – ampicillin and gentamicin. Attention also needs to be paid to hydration – they may require intravenous or nasogastric hydration if intake is poor. Key points • If the patient still has symptoms after 3 days then refer for further investigation • Reduce dose of gentamicin or avoid use in renal failure. • Refer all children and men with UTI. • Refer patients with recurrent UTI and patients with persistent haematuria (blood in the urine). • Refer pregnant women with acute pyelonephritis • UTIs in women are more common when first becoming sexually active, in pregnancy and after the menopause 15.2 Glomerulonephritis (Glomerular lesions) Inflammation of the glomeruli due to deposits of immune complexes. Usually due to bacterial infection. Common causes include streptococcal infections hepatitis, dengue, malaria, systemic lupus erythematosus, systemic vasculitis, etc. In children it is most commonly related to a recent streptococcal infection. Symptoms/signs Oliguria (urine volumes < 400ml/day) Hypertension, haematuria (dark or “coca-cola” urine) Acute heart failure and coma in serious cases. Common signs in children are: History of preceding infection (e.g. sore throat or skin infection), generalized oedema most marked around the eyes, breathlessness (due to fluid retention), anorexia, fever, seizures (due to the hypertension), urinary abnormalities like oliguria, haematuria. Treatment Patients presenting to a Primary Health Care facility should be referred to hospital care immediately. 15.3 Nephrotic syndrome This is defined by severe proteinuria in excess of 3.3-3.5 g daily accompanied by hypoalbuminaemia, oedema, hyperlipidaemia and hypercoagulable state. Can be caused by infections (viral, bacterial and parasitic), primary glomerular disease, some systemic diseases (diabetes) or be caused by drugs (captopril, lithium). In children it is most commonly idiopathic. Symptoms/signs Oedema – generalised or local, pleural effusion, hypoalbuminaemia and proteinuria (>3gm/day) – makes frothy urine. May be complicated by infection Non-drug treatment Adequate protein diet – 0.8g/kg of high-class protein per day No added salt diet Weigh patient at each review Treatment Patients presenting to a Primary Health Care facility should be referred immediately to hospital care. Chapter 16 – Infectious diseases 16.1 Yaws Yaws is an infection with Treponema pertenue causing a contagious skin infection which is spread by direct skin-to-skin contact. Skin lesions occur and can result in patients having chronic sores. WHO has launched an eradication program with population-wide- penicillin treatment many decades ago. Unfortunately, in recent years, there outbreaks have been reported again, in far distant locations, especially in the Pacific region. Awareness is therefore in place. The infection can remain in the body for a long time without causing any visible problems. Symptoms/signs Commonly occurs in children younger than 15 years. There are 4 stages: Primary stage – lesion occurs at infection site on the skin. This will heal up by itself after 3-6 months. Secondary stage – many skin lesions appear as the infection spreads. These lesions may last as long as 6 months. During the primary and secondary stage the skin lesions are very contagious i.e. the infection is very easily spread to another person. Latent stage – may be no symptoms but also some lesions can appear. This stage may last as long as 5 years. Tertiary stage – deformities of the bone, joints and soft tissue can occur but usually 5-10 years after the first infection. During the latent and tertiary stages the skin is not contagious. Early yaws lesions are raised, have wavy borders and are creeping, sometimes scaly looking. There can be nodules and thickened skin on the palms of hands and soles of feet, lesions on bones and joints. Swollen lymph nodes can occur. Late yaws lesions present as nodular scars, thickened skin; there may be nodules next to joints. Swellings each side of the nose may occur. Make diagnosis based on what the sores looks like and patient history. Drug treatment If treatment is initiated in the early stages a rapid improvement can be seen: Benzathine penicillin, IM ADULT: 900 mg = 1.2 million units as a single dose by deep intramuscular injection CHILD: 450 mg = 0.6 million units as a single dose by deep intramuscular injection For patients allergic to penicillin give: Erythromycin, oral ADULT: 500 mg four times a day for 15 days INFANT and CHILD 12.5 mg/kg/dose four times daily for 15 days. Key points • After a single dose of benzathine penicillin early lesions become non-infectious after 24 hours and heal within 1-2 weeks. • Tissue damage occurring during the late stages of yaws is irreversible. Provide hygiene and health education to patients and community, to stop yaws being transmitted. 16.2 Syphilis Syphilis is a sexually transmitted disease caused by Treponema pallidum, which causes a sore where the organism enters the body. This sore heals without treatment. However, the bacteria spread all through the body and cause serious subacute and chronic disease of many organs. Previous infection with the similar yaws bacterium gives some immunity against syphilis. Symptoms and Signs Primary syphilis Syphilis causes a chancre and enlarged lymph glands and usually presents with: • Chancre, the lesion at the site of infection, first a painless lump develops, it soon ulcerates in the centre and clear fluid oozes from it. It usually heals after 2-6 weeks, even without treatment. It may look different if secondary bacterial infection occurs. • A female patient may not know she has a chancre if it occurs in the vagina or on the cervix. • The nearby lymph glands are usually hard but not tender. Secondary syphilis Usually about 6 weeks after the primary sore heals, but it can be earlier and much later. There may be any or all of these common lesions: • A skin rash with bilateral (on both sides) round, red, non-itchy flat patches 5-10 mm in diameter. • A skin rash with bilateral red, non-itchy lumps, which may become scaly or turn into pustules. • A skin rash called condylomata lata in warm moist areas such as the perineum, vulva, scrotum, inner thighs, under breasts, etc. The above lumps here get bigger and the surface skin comes off to produce large painless raised moist grey areas. However, secondary infection may occur and change the appearance. • Mucous patches are painless, shallow grey ulcers with a narrow red margin (or edge). They occur on the lips or mouth, vulva, vagina, scrotum and penis. • Painless enlargement of all lymph nodes of the body. • General symptoms and signs of infection, e.g. malaise, fever, loss of appetite, loss of weight. Tertiary syphilis Occurs many years later in one out of every two or three infected cases, if left untreated. “Gumma” is causing mostly non-inflamed ulcers on the skin as well as disease of the heart or disease of the brain can occur. Congenital syphilis A child may be infected through the placenta, if his mother has syphilis. The child may be born dead or develop any of the signs of secondary or tertiary syphilis. Symptoms and signs of congenital syphilis include: • Low birth weight, jaundice and rash (especially blistering and especially on hands and feet) but may vary. • Albuminuria, hepatomegaly, pneumonia and sepsis syndrome. • Abnormalities of the blood count (Hb, WCC and platelets). • Long bone abnormalities and pain in the limbs. • Neurological abnormalities including meningitis. • Rhinitis and snuffles, rashes around anus and mouth. Drug treatment Before giving treatment ask the patient about previous or present symptoms of gonorrhoea. If the patient has symptoms of gonorrhoea do tests and give treatment for gonorrhoea as well as for syphilis (which will not cure gonorrhoea). Early syphilis recommended treatment ( WHO ): Give: Benzathine benzylpenicillin, IM 1.8 g = 2.4 million units intramuscularly in a single session, usually given as 2 injections at separate sites OR: Procaine benzylpenicillin, IM 1.2 g = 1.2 million units intramuscularly daily for 10 consecutive days OR, for non-pregnant penicillin-allergic patients: Doxycycline, oral: 100 mg twice daily for 15 days OR, for pregnant women allergic to penicillin Erythromycin, oral: 500 mg 4 times daily for 15 days Late syphilis recommended treatment (WHO) Give: Benzathine benzylpenicillin, IM 1.8 g = 2.4 million units intramuscularly once weekly for 3 consecutive weeks, as 2 injections at 2 separate sites. OR: Procaine benzylpenicillin, IM 1.2 g = 1.2 million units once daily for 20 consecutive days OR, for non-pregnant penicillin-allergic patients Doxycycline, oral: 100 mg twice daily for 30 days OR, for pregnant penicillin-allergic patients Erythromycin, oral: 500 mg 4 times daily for 30 days Note: The effectiveness of erythromycin in all stages of syphilis and its ability to prevent the stigmata of congenital syphilis are highly questionable, and many failures have been reported. Neurosyphilis recommended treatment (WHO): Give: Benzylpenicillin, IV 1.2 g to 2.4 g = 2 to 4 million units every 4 hours for 14 days OR, alternative regimen Procaine benzylpenicillin, IM 1.2 g = 1.2 million units once daily for 10 – 14 days, PLUS: Probenecid 500 mg, oral: 4 times daily for 10 – 14 days. OR, for non-pregnant penicillin-allergic patients: Doxycycline, oral: 200 mg twice daily for 30 days Congenital syphilis recommended treatment (WHO) Recommended treatment regimens from WHO for early congenital syphilis in children up to 2 years of age and infants having abnormal cerebrospinal fluid: Benzylpenicillin, IV 30 mg = 50 000 units/ kg every 12 hours during first 7 days of life and every 8 hours thereafter for a total of 10 days OR, if no evidence of neurosyphilis (this requires a lumbar puncture to exclude) Procaine benzylpenicillin, IM 50 mg = 50.000 units/kg daily in a single dose for 10 days Treatment for congenital syphilis of 2 or more year duration: Benzylpenicillin, IV 30 mg = 50.000 units/kg every 4-6 hours for 10-14 days OR for penicillin-allergic patients after the first month of life Erythromycin, oral 7.5-12.5 mg/kg 4 times daily for 30 days Key points • Any genital ulcer is treated as syphilis no matter what it looks like. • Any wet skin lesions in groin, perineum, axilla, etc. must be suspected as being syphilis. • Treatment for syphilis needs only a low concentration of the antibiotic penicillin, but for a long time. • Treatment for gonorrhoea needs a high concentration of the antibiotic third generation cephalosporine, but only for a short time. • Treat also for chancroid • It is essential to detect and adequately treat infants / newborns with congenital syphilis as untreated congenital syphilis may result in either death or permanent neurological disability and other serious effects (e.g. bony and ocular abnormalities) 16.3 Gonorrhoea Gonorrhoea is a sexually transmitted disease caused by Neisseria Gonorrhoea (Gonococcus). It occurs predominantly as urethritis in men and cervicitis in women, and also as pharyngitis, proctitis or conjunctivitis. Systemic form may appear with skin pustles. It can spread within the genital organs causing more severe infections of them and through the blood to other parts of the body, causing serious disease there or septicaemia. The original host is an infected person. Some infected people have symptoms and signs; but some men and many women are carriers with no symptoms. Symptoms/Signs in the male Symptoms and signs usually develop within a week; but they can take longer or never develop. They usually present with: • urethral discharge which is usually white or yellow (pus) and often a large amount, • dysuria and urinary frequency. • The symptoms slowly improve over weeks or months, although a little white discharge may continue to be present each morning. But the infection does not go. Complications include • Abscess around urethra, inflammation of the epididymis and testis, • Sterility due to blocked epididymis and vas deferens, • Severe conjunctivitis and iritis (spread by fingers from the genitalia), •Bacteraemia, pustular skin rash, acute infective arthritis, septicaemia. These complications usually occur soon after infection. Sterility occurs later. Urethral stricture (narrowing of the urethra is due to scarring where there was a previous infection in/around the urethra) causes difficulty in passing urine and distends the bladder with time. Symptoms/Signs in the female Symptoms and signs usually develop within a week: but they can take longer or never develop and usually present with: • Dysuria and urinary frequency, and vaginal discharge, which is often mistaken for an urinary tract infection. • After treatment with sulphadimidine, which does not cure the infection, or after no treatment, the symptoms slowly improve over weeks or months. But the infection does not go. Complications include • Acute salpingitis, pelvic peritonitis, pelvic abscess, ectopic (tubal) pregnancies and/or sterility (due to blocked fallopian tubes). • Severe acute conjunctivitis and iritis (spread to the eyes by fingers), abscess in labia, bacteraemia with pustular skin rash, acute septic arthritis and septicaemia. Newborns may develop gonococcal ophthalmia if born to a mother with active gonorrhoea. Gonococcal ophthalmia neonatorum may result in a severe conjunctivitis which if untreated, may cause permanent blindness. Non-drug treatment Advise on the importance of good hygiene and the need to avoid sharing towels, clothing, bedclothes etc. Keep skin clean using soap and water. Drug treatment recommended by WHO Uncomplicated anogenital gonococcal infections in ADULTS WHO has changed the recommended treatment, and no longer recommends Ciprofloxacin for treatment of gonorrhoea. This change is due to widespread resistance against quinolones observed in Gonococci in the SE Asia region, including territories near Timor Leste. Cefixime per oral OR: Ceftriaxone, IM: 125 mg as a single dose OR: Azithromycin, oral: 2 g as a single dose Gonococcal eye infections in ADULTS Give: Ceftriaxone, IM: 125 mg as single dose Disseminated gonococcal infections in ADULTS Ceftriaxone, IM, IV: 1 g once daily for 7 days Gonococcal infections in INFANTS Infants born to mothers with gonorrhoea are at high risk of infection and require prophylactic treatment. Ceftriaxone, IM: 50 mg/ kg as a single dose (maximum 125 mg) Gonococcal ophthalmia in neonates Ceftriaxone, IV: 50 mg/kg daily for 7 days. Babies with ophthalmia neonatorum (severe and early neonatal conjunctivitis) needing treatment, often need referral to hospital as they require very frequent instillation of antibiotic drops and also regular cleansing and washouts of the eye when it is really swollen and infected and this cannot be done at home. Key points • Treat for gonorrhoea all clinical cases of gonorrhoea including: • all persons with urethral discharges, • all persons with “urinary tract infections” especially young adults if there is a possibility of gonorrhoea, • all persons with vaginal infections especially if cervicitis present and especially if the patient is a young woman and has had a recent change of sexual partner and especially if there is any other reason to suspect STI. • Note that 30% of patients will have both gonococcal and chlamydial infections. • Find out if there is or was also a sore on the genitalia or anus. If so, treat for syphilis too. • Treatment for syphilis is not adequate for gonorrhoea. 16.4 Chancroid Chancroid is a sexually transmitted disease caused by Haemophilus ducreyi. It is a frequent cause of genital ulceration and a risk factor in the transmission of HIV. Chancroid is much more common in males, suggesting a female carrier state. Symptoms/Signs • Between 3-7 days post-infection, a painful vesicular papules form and then rapidly develops into soft ulcers with undermined, ragged edges. • Ulcers are haemorrhagic and sticky (often secondarily infected). • If multiple, they may become confluent and they occur at sites of trauma during intercourse (extragenital is rare). • Commonly 7-14 days later, inguinal nodes become involved: painful, matted, tethered to erythematous skin = bubo. • A discharging sinus may develop and in time become a spreading ulcer. • The lesions heal slowly and commonly relapse. Non-drug treatment Advise on the importance of good hygiene and the need to avoid sharing towels, clothing, bedclothes etc. Keep skin clean using soap and water. Drug treatment Recommended treatment regimens of WHO: Give: Ciprofloxacin, oral: 500 mg twice daily for 3 days OR: Erythromycin, oral: 500 mg 4 times daily for 7 days OR: Azithromycin, oral: 1 g as a single dose OR, as alternative regimen Ceftriaxone, IM: 250 mg as a single dose Key points • Chancroid can be the commonest cause of genital ulcers. • By examination alone it is not possible to tell, if the condition is definitely due to chancroid or syphilis or due to other infection. • If the condition is not cured, consider an antibiotic resistant organism, HIV infection and other conditions and refer. 16.6 Chlamydial infections Chlamydia trachomatis, an intracellular bacterium, causes two sexually transmitted diseases in adults, depending on the serotype: 1. Infection of urethra, endocervix or rectum; 2. Lymphogranuloma venereum. Chlamydia trachomatis is also the cause of ocular trachoma, which is a major cause of blindness worldwide. 1. Urethritis / endocervicitis / proctitis Symptoms/Signs • Frequently coexisting with gonococcal infections. • In men commonest cause of non-gonoccal urethritis (NGU). • Complications include epididymitis and, in homosexual men, proctitis. • In women infection is often subclinical or non-specific, associated with cervicitis, salpingitis and endometriosis. • Major cause of female subfertility worldwide. 2. Lymphogranuloma venereum (Inguinal bubo) Symptoms/Signs • Usual signs: no ulcer on the genitalia but very enlarged inflamed inguinal lymph nodes with toxaemia and the ulceration of the inguinal lymph nodes. • 1-3 weeks after infection, a small blister or ulcer appears on the genitalia, and is usually not noticed. • About 2-6 weeks later the lymph nodes in the groin become enlarged and inflamed. Pus forms in the lymph nodes which then burst. • As more nodes are affected, many abscesses discharging whitish fluid develop. Abscesses can join to make large ulcers. • The area affected increases. Sometimes abscesses and ulcers form in the anal region. • During this time the patient may have general symptoms and signs of infection such as malaise, fever, etc. • After some months the ulcers usually get better. But there is often a lot of deformity left. There may be strictures (narrowing) of the rectum or urethra or vulva. There may also be chronic oedema of the genitalia. Non-drug treatment Advise on the importance of good hygiene and the need to avoid sharing towels, clothing, bedclothes etc. Keep skin clean using soap and water. Drug treatment Recommended treatment regimens from WHO Chlamydia trachomatis infections other than lymphogranuloma venereum: Uncomplicated urethral, endocervical, or rectal infection Give: Doxycycline, oral: 100 mg twice daily for 7 days OR: Azithromycin, oral: 1 g in a single dose Pregnant women Give: Erythromycin, oral: 500 mg 4 times daily for 7 days OR: Amoxicillin, oral: 500 mg 3 times daily for 7 days Recommended treatment regimens of WHO for Lymphogranuloma venereum Give: Doxycycline, oral: 100 mg twice daily for 14 days Pregnant women Erythromycin, oral: 500 mg 4 times daily for 14 days Children born to women with untreated Chlamydial infection They may develop severe conjunctivitis and blindness or pneumonia. Atypical pneumonia in young children and infants shows typically staccato cough and a pneumonia that doesn’t respond to antibiotics. Conjunctivitis typically starts in 2nd week of life and may be associated with pneumonia and cough. As well as the mother, the baby should be treated immediately as for gonococcal conjunctivitis or ophthalmia neonatorum and if there are still any eye symptoms or if the child develops pneumonia the following treatment is recommended: Give: Erythromycin, oral 50 mg/kg per day in 4 divided doses for 14 days*, OR, if erythromycin is not available: Co-trimoxazole: 240 mg (40 mg TMP + 200 mg SMX) twice daily for 3 weeks*. *Optimal duration of therapy has not yet been established. There is no evidence that additional treatment with a topical agent provides further benefit. If inclusion conjunctivitis recurs after treatment has been completed, erythromycin treatment should be reinstituted for 2 weeks. Babies with ophthalmia neonatorum (severe and early neonatal conjunctivitis) need treatment and need referral to hospital. They require very frequent instillation of antibiotic eyedrops and regular cleansing / washouts of the eye when it is swollen and infected. Key points • Chlamydia trachomatis is the commonest cause of non-gonoccal urethritis (NGU) in men. • Chlamydia trachomatis is the major cause of female subfertiliy worldwide. • Children born to women who have untreated Chlamydia trachomatis infection have to be treated immediately. • Gonococcal and chlamydial infections frequently occur together. Treatment for the two infections should be given concomitantly. Otherwise postgonococcal urethritis due to Chlamydia trachomatis may follow after the cure of the gonorrhoea. • Treatment of the sexual partner(s) is essential. 16.7 Tuberculosis This Guideline does not duplicate the contents of the national Tuberculosis guidelines. The reader is referred directly to the National Tuberculosis and DOTS guidelines for Timor Leste. Pulmonary TB (TB of the lungs) is the most common form of the disease and occurs in 80% of the cases. It is the only form of TB that may be infectious and may spread when the patient coughs. Extrapulmonary TB affects other body parts than the lungs, such as: • Spine (bone) • Skin and lymph nodes • Brain and meninges • Disseminated throughout the body (Miliary tuberculosis) TB can be cured! All children should have the BCG vaccination for protection at birth. Symptoms/signs Adults usually present with: • Cough that lasts for more than 3 weeks • Chest pain, shortness of breath • Loss of appetite, loss of weight • May cough up small amounts or a lot of bright red blood • Mild fever, general feeling of illness • Evening or night sweating Always suspect tuberculosis in a case of a productive cough of at least 3 weeks duration that is not resolving with antibiotic treatment. Children often present with symptoms that are mild but includes temperature slightly but persistently elevated (lasting 2 to 3 weeks) • Fatigue, irritability, malaise. • Late symptoms usually include chest pain and cough Chronic illness or malnutrition increases the risk for infection. Suspect tuberculosis in any child with severe malnutrition who is showing poor response to dietary treatment. It is important to confirm whether or not a patient has TB before treatment is started. Patients with suspected TB must be referred to a health facility where the diagnosis can be confirmed. Examining the sputum coughed up from the lungs can make confirmation. Three specimens must be collected: ♦ As soon as the patient is suspected of having TB at the first interview. ♦ The following morning, early, before the second interview. ♦ During the second interview another specimen is collected. Any patient who has TB microorganisms visible on microscopic examination of the sputum must be diagnosed with TB and classed as a case. This person is recorded as a smear positive case. Some cases may be treated for TB but may be smear negative. Drug treatment See the national Tuberculosis treatment guidelines. 16.8. Leprosy Leprosy is endemic in Timor Leste, disease caused by Mycobacterium leprae. It affects the peripheral nervous system, the skin, and some other tissues. It is transmitted from person-to-person, when bacilli are shed from the nose and skin lesions of infected patients. Most individuals are however naturally immune, and symptoms are suppressed. Clinical leprosy may be regarded as a consequence of deficient cell-mediated immunity in susceptible individuals. For the purpose of grouping patients for chemotherapy, leprosy may be classified as multibacillary of paucibacillary. • Multibacillary leprosy occurs when cellular immunity is largely deficient. • Paucibacillary leprosy results when cellular immunity is only partially deficient. For the purpose of treatment, WHO now classifies patients with more than 5 skin lesions as multibacillary, and those with 1 to 5 skin lesions as paucibacillary. It further classifies patients with only one skin lesion as having paucibacillary single-lesion leprosy. This clinical classification avoids the necessity to provide facilities for bacteriological examination of skin smears. Leprosy can be cured! Symptoms/Signs A leprosy patient is someone who has a skin patch or patches with a definite loss of sensation and has not completed a full course of treatment with multidrug therapy. Leprosy patches • can be pale or reddish or copper-coloured • can be flat or raised • do not itch • usually do not hurt • lack sensation to heat, touch or pain • can appear anywhere Signs, which are not leprosy: Skin patches present from birth (i.e. birth marks) and skin patches with normal feeling. Skin patches that itch, and skin patches that are white, black or dark red; Skin patches with scaling skin; and skin patches that appear or disappear suddenly and spread fast. Drug treatment See the National Program Treatment Guidelines for Leprosy. 16.9 Tetanus Tetanus is a very dangerous infection caused by Clostridium tetani a bacterium mainly living in the soil or faeces of animals. The bacterium produces a toxin that affects the muscles. Infection occurs easily through cuts or breaks in the skin. Tetanus of the newborn (neonatal tetanus) occurs when the infection enters through the umbilical cord when it has not been kept clean or if non-sterile instruments or dressings have been used. Symptoms/signs In infants: 3 to 10 days after birth the child begins to cry continuously and is unable to suck. Umbilicus may look infected. Stiff body, irritability and spasms. Constipation and tongue and lips become blue (cyanosed) during spasms. This condition is often fatal. Symptoms/signs in adults and older children: History of wound or trauma. Headache and muscular stiffness in the jaw (lockjaw) followed by neck stiffness, difficulty swallowing, rigidity or abdominal muscles, spasms and sweating. Painful convulsions of the jaw and finally of the whole body. Moving or touching the person may trigger sudden spasms like this. Noise and bright lights will also trigger muscle spasms. Patients often do not have any fever. Non-drug treatment Tetanus is a deadly disease and must be treated immediately. Arrange for immediate transfer to a health facility where antitetanus immunoglobulin (human) can be administered. Avoid noise, bright light and unnecessary touching of the body. Clean the infected umbilicus or wound with water and chlorhexidine solution: Chlorhexidine 0.5 %, solution Use to clean the wound at each dressing change Dilute 10 ml of Chlorhexidine 5 % with 90 ml of water to make 100 ml of 0.5 % solution Remove any foreign bodies. Maintain a clear airway. Ensure adequate hydration and nutrition. Drug treatment – Neonatal tetanus Give: Tetanus immunoglobulin, human, IV 250 units/kg IV as single dose. PLUS: Benzylpenicillin*, IV 50 mg/kg (≈ 83 000 units/kg/dose) every 6 hours IV, or, if not possible, IM, for 48 hours. If possible, continue with oral penicillin. If not possible continue benzylpenicillin. Phenoxymethylpenicillin (Penicillin V), oral 12.5 mg/kg every 6 hours Duration: 7 days. OR: Metronidazole, IV CHILD: 7.5 mg/kg every 8 hours Duration: 7 days. Different dosages of human tetanus immunoglobulins are recommended in literature; Ronald and Southall recommend 5000 to 10 000 units IV. As standard praxis, 250 units/kg IV are currently used in the National Hospital Guido Valadares. Spasms can usually be controlled by: Diazepam, IV 200 micrograms/kg every 3-6 hours by slow IV injection, If not possible intravenously then remove the needle and give same dose into the rectum. To give rectally insert nasogastric tube a couple of cms into the rectum – a syringe is attached to the NGT and the drug is syringed into the rectum. The rectal route is suitable as satisfactory absorption is achieved within minutes and administration is much easier. Suppositories are not suitable because absorption is too slow. Tetanus in adults and children Give : Tetanus immunoglobulin, IV ADULT: 8,000 units. Start with 1 ml/minute for about 15 minutes. If there is no adverse reaction, the rate can be increased up to 3-4 ml/min. CHILD up to 14/15 years: 4.000 units. Start with 1 ml/minute. If there is no adverse reaction, the rate can be increased to 3-4 ml/minute. PLUS: Metronidazole, IV CHILD: 15 mg/kg every 12 hours for 7-10 days OR: Benzylpenicillin, IV ADULT and CHILD >12 years: 2 million units (=1.2 g) 6 times daily. CHILD up to 3 years: 0,5 million units (= 0.3 g) 6 times daily. 0.5 ml once only (for active immunisation) To control muscle spasms: Give: Diazepam, IV ADULT and CHILD by IV injection: 0.1 – 0.3 mg/kg repeated every 1-4 hours. OR: by IV infusion (or by nasoduodenal tube): 3-10 mg/kg over 24 hours, adjusted according to response. Key points • Do not inject tetanus human immunoglobulin and tetanus toxoid using the same syringe or into the same site. • Vaccination is the key to prevention – both children and adults should be vaccinated against tetanus and this should be repeated every 10 years. (See national program guidelines for Immunisations) • Women should be vaccinated every time they are pregnant to prevent neonatal tetanus. • Wounds should be carefully washed and kept clean. Patients should be encouraged to go to the health facility to have wounds cleaned and dressed and to have vaccination against tetanus. • Sterilize instruments used to cut the umbilical cord, cut the cord short and keep the area clean and dry. • Refer all children and adults with tetanus to hospital. 16.10 Rabies Rabies is a virus that is carried by animals such as dogs, cats, bats etc. Saliva or central nervous tissue from the infected animal contains large numbers of the rabies virus and this is transferred to other animals or humans through a bite or wound to the skin. Symptoms/signs In the animals: Acts strangely, sometimes sad, restless or irritable Foaming at the mouth, cannot eat or drink Sometimes the animal goes wild (mad) and may bite anyone or anything The animal dies within 5 to 7 days In humans: After a bite or infection with the virus it may take 20-90 days (or longer) before any symptoms start to appear. Malaise, anorexia, headaches, fever, chills, sore throat, nausea, vomiting, anxiety, agitation, insomnia and depression. As the disease progresses the patient may become very agitated, restless, thrash about, bite, become confused and hallucinate. There may also be very quiet times. Eventually the patient will go into a coma and will die. Non-drug treatment This is a life-threatening infection. Try to find out if the animal has rabies. If the animal looks healthy, lock it up for 10 days. If it is still alive and well after 10 days, the animal did not have rabies and no immunisation of the patient is necessary. Clean the bite-wound well with soap and water and with chlorhexidine solution Chlorhexidine 0.5 %, solution Dilute 10 ml of Chlorhexidine 5 % with 90 ml of water to make 100 ml of 0.5 % solution Leave the wound open. Update tetanus immunisation, 0.5 ml tetanus vaccine (IM). If rabies is suspected then refer the person immediately to a health facility able to administer passive and active immunisation. i.e. human rabies immunoglobulin (passive immunity) and rabies vaccine (active immunity). Drug treatment – post-exposure prophylaxis Before onset of symptoms occurs both passive and active immunisations are effective in preventing full-blown rabies in unimmunised individuals or those whose prophylaxis is possibly incomplete. Give: ADULT and CHILD: Give human rabies immunoglobulin 20 units/kg, half by IM injection and half by infiltration around the original bite-wound. PLUS Rabies human diploid cell vaccine, IM or deep subcutaneous injection Deep or subcutaneous or intramuscular injection of 1 ml in the deltoid region (CHILD in antero-lateral region of the thigh muscle) on days 0,3,7,14, and 28. Do not inject in the glutaeal region. For post-exposure prophylaxis of fully immunised individuals (who have previously received pre-exposure or post-exposure prophylaxis with cell-derived rabies vaccine), 2 intramuscular doses of cell-derived vaccine, separated by 3-7 days, are likely to be sufficient. Rabies immunoglobulin is not necessary in such cases. Key points • It is important to observe the animal concerned in order to know if the person bitten is likely to be infected with rabies. • Stop the immunisations if the animal is confirmed as NOT having rabies i.e. the animal recovers. • If rabies is suspected it is vital that full immunisation (both passive and active) is completed before symptoms of the infection occur in the patient. 16.11 Pertussis (Whooping cough) Whooping cough occurs when the bacterium Bordetella pertussis gets into the respiratory tract and causes a bloody mucous to be formed. The patient coughs very hard and as he/she tries to take air into the lungs a whooping noise can be heard. It is a particularly serious infection in young, unimmunised, infants and may be fatal. Symptoms/signs Initially there is a cough, fever, running nose. Patient coughs many times without stopping (paroxysms of cough) to breathe eventually coughing up sticky / frothy mucous. Patient then takes a deep breath, which may sound like a “whoop”. During coughing the patients face, lips and fingers may turn blue (cyanosis). Vomiting may occur after coughing. Poor appetite and food refused. Young infants may have apnoea after coughing spasms Severe coughing may result in subconjunctival haemorrhages The symptoms last for weeks and sometimes even months Whooping cough may cause secondary complications such as: • Protein-calorie malnutrition • Secondary pneumonia • Chronic dilation of the bronchi or bronchioles (small airways in the lungs) – bronchiectasis • Convulsions and coma due to cerebral hypoxia (lack of oxygen in blood). • Secondary infections such as otitis media, pneumonia, activation of latent TB. • Apnoea and hypoxia may result in death in young babies Non-drug treatment If patient is healthy: Feed frequently between coughing spasms even though the child may not want to eat. Give extra fluids Drug treatment If patient is weak, malnourished or a child under one year of age: Admit to hospital Treat the following conditions if they occur – dehydration, fever, pneumonia, malnutrition. To prevent the disease from spreading to others give: Erythromycin, oral ADULT and CHILD over 8 years: 250-500 mg every 6 hours or 0.5-1 g every 12 hours; up to 4 g daily in severe infections; CHILD: 12.5 mg/kg every 6 hours. Duration: 7 days. Key points • Refer infants who have episodes of not breathing or turning blue. • Antibiotics will not influence the course of the illness but help to prevent others from getting the disease. • All children should be immunised with DPT (Diphtheria, Pertussis, Tetanus). • A child with pertussis should continue with DPT immunisation to prevent diphtheria and tetanus. 16.12 Meningitis This is a very severe infection of the coverings of the brain and is commonly caused by bacteria but can be caused by viral or fungal infection or be due to tuberculosis. Symptoms/signs Fever, severe headache, neck pains or stiff neck, abnormal conscious state and even coma, vomiting, convulsions, neurological abnormalities. All children should be assessed using the Integrated Management of Childhood Illness (IMCI) guidelines. For children less than 5 years the diagnosis of meningitis is encompassed under the top section of danger signs or the section relating to serious infection. The danger signs include: • Child is unable to drink or breast feed. • Child vomits everything. • Convulsions. • Child is lethargic or unconscious. • Child has a stiff neck. Fever plus any one of the danger signs indicates a very severe febrile disease and urgent action must be taken. A diagnosis of “very severe febrile disease” means the child may have meningitis and urgent referral must be organised – see RCM guidelines p.61 for management. Children over 5 years more commonly have the same signs / symptoms as do adults with meningitis Non-drug treatment This is a life threatening condition therefore urgent referral must be arranged. Take blood slide to check for malaria parasites. Keep the airway clear. Drug treatment Treatment must be started at once: ADULT regimens Chloramphenicol, IV ADULT: 50 mg/kg daily in 4 divided doses (exceptionally, can be doubled for severe infections such as meningitis, providing high doses reduced as soon as clinically indicated). OR Benzylpenicillin, IV ADULT: 2.4 g = 4 million units every 4 hours. Duration: at least 2 weeks or for 1 week after the fever stops – whichever is longer. Alternatively for all types of bacterial meningitis: Ceftriaxone, IV ADULT: 4 – 6 g/day, in 2-3 divided doses for 7 days. Chloramphenicol, IM, IV CHILD: 25 mg/kg IM (or IV) every 6 hours. PLUS Ampicillin, IM, IV CHILD: 50 mg/kg IM (or IV) every 6 hours. Duration: 10 days. OR Chloramphenicol, IV CHILD: 25 mg/kg IM (or IV) every 6 hours. PLUS Benzylpenicillin, IV CHILD: 60 mg/kg (100 000 units/kg) every 6 hours. Duration: 10 days. Review therapy when CSF results are available. If the diagnosis is confirmed, give treatment parenterally for at least 3 days. Once the child has improved, give chloramphenicol orally unless there is concern about oral absorption (e.g. in severely malnourished children or in those with diarrhoea), in which cases the full treatment should be given parenterally. The total duration of treatment is 10 days. Where there is known significant drug resistance of common organisms (e.g. Haemophilus influenzae or Pneumococcus) to these antibiotics, a third-generation cephalosporin can be given: Ceftriaxone, IV CHILD: 50 mg/kg IV, over 30 – 60 minutes every 12 hours. Duration: 10 days. Neonates (< 28days) should be treated with intravenous benzylpenicillin and gentamicin. Neonates with confirmed meningitis require treatment for 3-4 weeks. Older children should, in the unavailability of ceftriaxone, be treated with chloramphenicol. Chemoprophylaxis for close contacts (meningococcal meningitis) give: Ciprofloxacin, oral ADULT: 500 mg as a single dose CHILD 5-12 years: 250 mg OR Rifampicin, oral ADULT: 600 mg every 12 hours for 2 days CHILD: 10 mg/kg (under 1 year, 5 mg/kg) every 12 hours for 2 days Note: Do not use ciprofloxacin in children or pregnant women. If the patient experiences convulsions give: Diazepam, IV ADULT: 10 mg slowly over 3 minutes CHILD: 0.25 mg/kg slowly over 3 minutes Key points • All contacts of the patient should be advised to come to the clinic immediately at the first sign of fever, sore throat, rash or any symptoms of meningitis. 16.13 Measles An acute infectious disease caused by a virus transmitted by droplets produced by sneezing and coughing. Usually occurs in children between 6 months and 3 years who have not been successfully immunised. Very infectious from 7 days before to 2 days after the rash appears. Symptoms/signs All children should be assessed using the Integrated Management of Childhood Illness guidelines. Look for the danger signs: • Child is unable to drink or breast feed • Child vomits everything • Convulsions • Child is lethargic or unconscious • Clouding of the cornea • Deep or extensive mouth ulcers Fever plus any one of the danger signs indicates a severe complicated measles and urgent action must be taken. In case of diagnosis of “severe complicated measles”, urgent referral to hospital must be organised. General symptoms and signs of measles are: Fever before the rash appears. Runny nose. Cough. Conjunctivitis. Sore mouth. Rash starting with head and neck moving down over the body. Diarrhoea. Child is generally miserable. This infection is particularly dangerous in children who have TB or who are malnourished. Complications can occur quickly. Look for: Early complications Croup Bronchopneumonia Otitis media Diarrhoea Vitamin A deficiency leading to xerophthalmia and blindness Malnutrition Deafness from otitis media Activation of latent TB Measles cannot be treated but the complications arising from measles must be treated. Prevention Measles is preventable by vaccination. See Integrated Management of Childhood Illness Guidelines (IMCI) and EPI guidelines. Educate parents about immunisation and ensuring their child eats the correct food to remain healthy. Encourage breast-feeding and good weaning foods. Immunise children at 9 months of age or at any clinic visit after this age. If a measles case is suspected, notify the Department of Health and consider mass immunisation. Measles is a notifiable disease. Treatment Wash eyes with clean water Treat sores in and around mouth with gentian Violet paint and encourage oral hygiene Tepid sponge and for the fever give: Paracetamol, oral, rectal 10-15 mg/kg every 4 hours (not more than 4 doses in 24 hours) Always calculate the dose of Paracetamol according the weight of the child. Continue feeding. Vitamin A supplements are given as a routine: Age Vitamin A CAPSULE 200 000 IU Vitamin A CAPSULE 50 000 IU 6 months to 12 months 1/2 capsule 2 capsules 12 months up to 5 years 1 capsule 4 capsules Duration: 1 dose every 6 months. Warning: Too much Vitamin A is poisonous. Do not give more than the amounts advised here. If pus is draining from the eye(s) then: Tetracycline 1%, eye ointment Apply to the eye(s) three times a day until redness is gone and for 2 or 3 days afterwards. Children with complications Pneumonia – See chapter Respiratory conditions Otitis media – See Chapter Ear, Nose and Throat Xerophthalmia – See Chapter Eye conditions Diarrhoea – See chapter Gastrointestinal Key points • Refer immediately children with severe complicated measles. These are children with fever plus any one general danger sign (not able to drink or breastfeed, vomiting everything, convulsions, lethargy or unconsciousness), or if there is clouding of the cornea or deep extensive mouth ulcers. • Measles can be prevented by vaccination therefore take every opportunity to vaccinate children. 16.14 Dengue Infection This is an illness caused by a virus that is spread by mosquitoes. It is difficult to tell the difference between malaria and dengue fever during the early stages of the disease. Symptoms/signs Children All children should be assessed using the Integrated Management of Childhood Illness guidelines. Look for the danger signs: • Signs of shock. • Blood or “coffee ground” vomitus. • Tarry black stools. • Severe bleeding from nose or gums. • Positive tourniquet test or skin petechiae • Frequent vomiting and no diarrhoea. Fever plus any one of the danger signs indicates Dengue haemorrhagic fever and urgent action must be taken. A diagnosis of “Dengue haemorrhagic fever” means urgent referral must be organised – see IMCI guideline page 5 for management. Adults Fever lasting 2-7 days then a phase with no fever of about 2-3 days. In early stages headache, aching muscles and joints, rash, small haemorrhagic spots on the skin may (or may not) also be present. Following fever patient may or may not develop Dengue haemorrhagic fever (DHF) and Dengue shock syndrome (DSS). Check for Dengue haemorrhagic fever perform a Tourniquet test as follows: Tourniquet test Inflate a blood pressure cuff to a point midway between systolic and diastolic pressures for 5 minutes. Test is positive if 10 or more haemorrhagic spots per square inch (2.5 cm2) are seen. Dengue haemorrhagic fever (DHF) – patients may bleed from nose and gums, have black tarry stools (indicating internal bleeding), vomit blood. Dengue Shock Syndrome (DSS) – Patients with a history indicating dengue fever and presenting with rapid and weak pulse, narrow pulse pressure, hypotension, cold and clammy skin and restlessness. Dengue haemorrhagic fever and Dengue shock syndrome are life-threatening conditions and urgent referral must be arranged! Guidelines for Treatment of Dengue Fever and Dengue Haemorrhagic Fever in Small Hospitals, WHO. Grading the Severity of Dengue Infection DF/DHF Grade* Symptoms Laboratory DF Fever with 2 or more of the following signs: headache, retro-orbital pain, myalgia, arthralgia. Leukopenia occasionally. Thrombocytopenia may be present, no evidence of plasma loss DHF I Above signs plus positive tourniquet test Thrombocytopenia <100 000. Hematocrit rise ≥20% DHF II Above signs plus spontaneous bleeding Thrombocytopenia <100 000. Hematocrit rise ≥20% DHF III Above signs plus circulatory failure (weak pulse, hypotension, restlessness) Thrombocytopenia <100 000. Hematocrit rise ≥20% DHF IV Profound shock with undetectable blood pressure and pulse Thrombocytopenia <100 000. Hematocrit rise ≥20% *DHF Grade III and IV are also called Dengue Shock Syndrome (DSS) Treatment Febrile/afebrile phase – patient has fever (or previously had fever) but no other signs of serious illness During early febrile phase it is not possible to distinguish DF from DHF. There is risk of developing DHF or DSS. Fever may last from 2 to 7 days followed by a period of no fever for 2-3 days. Advise rest, and to help with the fever above 39º C give: Paracetamol, oral ADULT: 0.5 – 1 g every 4 to 6 hours to a maximum of 4 g daily. Paracetamol, oral or rectal CHILD: 10 -15 mg/kg every 4 -6 hours (not more than 4 doses in 24 hours) Ensure the patient keeps well hydrated by drinking oral rehydration solutions. Tell the patient to eat normally. Observe carefully for the following 2 – 3 days after recovery from fever. Tell patients and household members to watch for severe abdominal pain, black stools, bleeding gums, nose or bleeding into the skin, sweating and cold skin. Refer patient to hospital urgently if any of these occur! Dengue Haemorrhagic Fever – patient must be admitted to hospital. Immediately check haematocrit and platelet count to assess patients’ condition. If haematocrit rises >20% then: Initiate IV therapy – Volume Replacement. Dengue Shock Syndrome – patient must be admitted to hospital. Immediately check haematocrit and platelet count and vital signs to assess patient’s condition. Initiate IV therapy – Volume replacement. Signs of recovery Stable pulse, blood pressure and breathing rate, normal temperature, no evidence of external or internal bleeding, return of appetite, no vomiting, good urinary output, stable haematocrit, convalescent confluent petechiae rash. Key points • Hyperosmolar or Ringer-Lactate solution should not be used in cases of acidosis. • Avoid fluid overload, adjust rate of infusion after monitoring the haematocrit and vital signs. Volume of fluid replacement should be just sufficient to maintain effective circulation during period of plasma leakage. Excessive fluid will cause pleural effusion, ascites and pulmonary congestion/oedema. • Do not give aspirin or ibuprofen for the treatment of fever. • Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding. • Avoid giving blood transfusion unless indicated i.e. reduction in haematocrit or severe bleeding. • Avoid giving steroids. They do not show any benefit. • Do not use antibiotics. • Do not change the speed of fluid rapidly i.e. avoid rapidly increasing or rapidly slowing the speed of fluids. • Do not insert a nasogastric tube to determine concealed bleeding or to stop bleeding (by cold lavage) this is hazardous. 16.15 Malaria This treatment guideline booklet does not duplicate the instructions which are already given in the national treatment guidelines for Malaria. The reader is referred directly to the Timor Leste National Malaria Program standard treatment protocols. Index A Abdominal pain/dyspepsia 109 Accelerated or very severe hypertension 56 ACE inhibitors 55 Acetazolamide 141, 151 Aciclovir 79 Acknowledgements 7 Acute attack 61 Acute diarrhoea 113 Acute ear infection 91 Acute otitis media 91 Acute pulmonary oedema 59 Acute pyelonephritis 154 acute severe (life-threatening) asthma episode 40 Acyclovir 146 Adrenaline 41 Albendazole 120, 121, 122 ALBENDAZOLE 121 Albinism 152 Allopurinol 53 Aluminium hydroxide 20, 110 Aluminium hydroxide suspension 110 Aminophylline 41, 42 Amitriptyline 79, 130 Amoebic dysentery 116 amoxicillin 145 Amoxicillin 33, 35, 36, 91, 92, 93, 155, 169 Amoxycillin 49, 72 ampicillin 154 Ampicillin 22, 24, 25, 38, 156, 181 anaemia 66 Anaemia 66 Anaemia prophylaxis in pregnancy 12 Anal conditions 124 Angina 60 antenatal care 11 Antenatal care 11 Antihaemorrhoidal, ointment 125 area are anal fissures (cracks) 124 Arrhythmia 63 Arthritis 47 Aspirin 27, 31, 33, 50, 51, 61, 63, 65, 130 Asthma 39 Asthma Maintenance therapy 43 Atenolol 55, 62, 63, 130 Athletes foot (Tinea pedis) 75 Atropine 141, 153 Azithromycin 165, 167, 169 B Bacillary Dysentery (bloody diarrhoea) 115 Backpain 46 Bacterial skin infections 71 Beclomethasone 44 Benzathine benzylpenicillin 161, 162 Benzathine penicillin 19, 64, 65, 89, 159 Benzoic acid 74, 76, 84 Benzyl benzoate 82, 83 Benzylpenicillin 35, 38, 89, 162, 163, 174, 176, 181 Betamethasone 85 Bisacodyl 123 Bleeding 21 Bleeding behind the cornea 140 Bleeding disorders 69 Bleeding on the white of the eye 139 Blind and painful eye 153 Blood disorders 66 Bloody diarrhoea 112 Body lice (Pediculosis) 83 Boils/Abscess 71 Brain Tumour 128 Bronchitis 32 burrows 81 C Calamine lotion 87 Calamine lotion. 80 Calcium channel blockers 56 Calcium gluconate 17 Candida albicans 107 Captopril 55, 58 Carbamazepine 80, 135 Cardiovascular conditions 54 Cataract 148 Causes of headaches 127 Cefazolin 141, 145 Cefixime 165 Ceftriaxone 49, 145, 147, 165, 166, 167, 181, 182 Cellulitis 73 Cephalexin 145 Chancre 159 Chancroid 167 Chemical Injury 142 Chicken Pox (Varicella-zoster infection) 80 Children born to women with untreated Chlamydial infection 170 Chlamydia trachomatis 168 Chlamydia trachomatis infections other than lymphogranuloma venereum 169 Chlamydial infections 168 Chloramphenicol 36, 37, 38, 39, 140, 142, 143, 145, 146, 181 Chloramphenicol antibiotic drops 145 Chloramphenicol drops 143 Chlorhexidine 72, 86, 174, 177 Cholera 115 Chronic daily headache 127 Chronic diarrhoea 113 Chronic ear infection 91 Chronic otitis media 91 Chronic subdural haematoma 128 Ciprofloxacin 115, 141, 167, 182 Clavulanic acid 49 Clindamycin 37, 49 Clostridium tetani 173 Clotrimazole 20 Cloxacillin 36, 38, 39, 49, 50, 71, 73, 85 Cluster headache 127, 130 Coal tar 84 Codeine phosphate 27, 29 Colchicine 52, 53 Common cold 31 Compound solution of sodium lactate 114 Conditions of the Eye 138 Congenital syphilis 160 Congenital syphilis recommended treatment 163 Conjunctival Laceration 140 Constipation 123 Corneal Abrasions 139 Corneal scar 152 cotrimoxazol 154 Co-trimoxazole 35, 91, 92, 93, 115, 147, 170 Cyclogyl 153 Cyclopentolate 141 cystitis 154 D Dengue Infection 185 Dental abscess 109 Dextrose 100, 136 Diabetes 95 Diabetes and the eye 151 Diabetes in pregnancy 18 Diabetes type 1 96 Diabetes type 2 98 Diabetic emergencies 99 Diabetic ketoacidosis 101 Diarrhoea 111 Diazepam 17, 18, 22, 132, 136, 175, 176, 182 Diclofenac 52, 53 Digoxin 59, 60 Diloxanide 116 Disseminated gonococcal infections in ADULTS 166 Double Vision 150 Doxycycline 115, 161, 162, 169 Dwarf tapeworm (Hymenolepis nana). 122 E Ear conditions 90 Ear, Nose and Throat 88 Early syphilis recommended treatment 161 Eclampsia 14, 131 Eczema 84 Electrolytes 102 EMOC 10 endemic goitre 103 Endocrinological conditions 95 Enterobius vermicularis 121 Epilepsy 131, 132 Episiotomy 21 Ergometrine 22, 23 Ergotamine 130 Erythromycin 19, 22, 24, 25, 64, 65, 71, 74, 81, 85, 89, 108, 109, 147, 159, 161, 162, 163, 167, 169, 179 Essential Medicines List for 8 Extrapulmonary TB 171 Eye Infections 142 Eye Injuries 138 F Fast/shallow breathing in children 34 Febrile convulsions 137 Ferrous sulfate 13, 67 Folate 67 folic acid 12 Folic acid 68 Foreign bodies 138 Frequent attacks of angina 61 Fungal skin infections 74 Furosemide 58, 59 G Gastro-enteritis 115 Gastrointestinal conditions 107 General Eye diseases 148 Generalised seizure 137 Generalised seizures 133 Generic name 8 Generic names 8 Gentamicin 22, 24, 25, 36, 37, 39, 156 Gentian 78 Gentian violet 79 Giardiasis 116 Gingivitis and Stomatitis 108 glaucoma 153 Glaucoma 151 Glibenclamide 98 Gliclazide 98 Glomerulonephritis 156 Goitre 103 Gonococcal eye infections in ADULTS 166 Gonococcal infections in INFANTS 166 Gonococcal ophthalmia in neonates 166 Gonorrhoea 164 Gout 51 Gout – acute 51 Gout – chronic 52 Griseofulvin 75, 76, 77 H haemorrhoids (varicose veins of the ano-rectal area 124 Half face rash and blisters (Herpes Zoster or Shingles): 146 Hay fever (Allergic rhinitis) 89 Headache 127 Heart failure 57 Helminthic infestation (Worms) 119 Homemade Sugar and Salt Solution 113, 117 Hookworm (Ancylostoma) 119 human rabies immunoglobulin 178 Hydralazine 16 Hydrochlorothiazide 55, 58 Hydrocortisone 41, 84 Hydroxocobalamin 68 Hypertension 54 Hypertension in diabetics 56 Hypertension in pregnancy 13 Hypertensive encephalopathy 131 Hyperthyroidism 103 Hyperthyroidism (Thyrotoxicosis) 105 Hyphema 140 Hypoglycaemia 99 Hypothyroidism 103 I Ibuprofen 47, 48, 50, 51 If Empyema 38 IMCI 2, 10, 111 Immunisation Schedule 126 Immunisations 126 Impetigo 72 Infection of the eyelids/eye socket (Preseptal/orbital cellulitis) 145 Infection of the tear sac (Dacryocystitis) 144 Infection of urethra 168 Infections 127 Infectious conjunctivitis 142 Infectious conjunctivitis of newborn babies 147 Infectious diseases 158 Inflammation inside the eye from the iris (Iritis) 152 insulin 19, 95, 96 Insulin 19, 102 Integrated Management of Childhood Illness 111 Intermediate 97 Intermediate-acting insulin 97 international non-proprietary name 8 Introduction 2, 7 iron 12 Iron 12 Iron deficiency anaemia 66, 67 Iron paediatric dosing chart 67 Ischaemic heart disease 60 Isophane 97 Isosorbide dinitrate 61, 62, 63 Itching (Pruritus) 86 Itchy rash 81 J juvenile arthritis 47 Juvenile rheumatoid arthritis 48 juvenile rheumatoid arthritis (JCA) 48 K Keratitis (Corneal Infection): 143 L Lactulose solution 124 Large chronic sores 85 Late syphilis recommended treatment 162 Leprosy 172 Levothyroxine 104 lidocaine 16 Lidocaine 21 Lymphogranuloma venereum 168 Lymphogranuloma venereum (Inguinal bubo) 168 M magnesium sulfate 16 Magnesium sulfate 16, 17, 124 Malaria 2, 189 Malaria in pregnancy 13 Mastoiditis 91 MCH 10 Measles 183 Mebendazole 120, 121, 122 Mebendazole, 122 Megaloblastic/macrocytic anaemia 66 Meningitis 180 Metformin 98 Methyldopa 18, 56 Metoclopramide 28, 30, 118, 129 Metronidazole 20, 22, 24, 25, 38, 108, 109, 116, 175 Miconazole 75, 76 Migraine 127, 129 mild asthma 44 Mild pain 27, 29 Moderate pain 29 Moderate Pain 27 Morphine 22, 28, 30, 59, 63 Multibacillary leprosy 172 Musculoskeletal conditions 46 Myocardial Infarction 62 N Nalidixic acid 115 National guidelines for Emergency Maternal Obstetric Care 10 National guidelines for Filariasis 10 National guidelines for HIV/AIDS 10 National guidelines for Immunization 10 National guidelines for Malaria 10 National guidelines for Mental Health 10 National guidelines for Nutrition 10 National guidelines for Tuberculosis 10 National Guidleines for care of the Newborn 10 National Guidleines for Leprosy 10 National Program Treatment Guidelines for Leprosy. 173 Nausea and vomiting 20, 117 Nephrotic syndrome 157 Neurological conditions 127 Neurosyphilis recommended treatment 162 Nitrofurantoin 155 Nodule on eyelid 143 non-toxic goitre 103 Normal saline 21 Nose bleeds 94 Nystatin 107 O oral cephalexin 144 Oral conditions 107 Oral Rehydration Solution 113 Oral Rehydration Solution (ORS 112 Oral Rehydration Solution (ORS) 117 Oral thrush (Candidiasis) 107 ORS 113 Osteoarthritis 50 oxygen 136 Oxygen 133 Oxytocin 22, 23 Oxytocin IV 23 P Pain control for adults 27 Pain control for children 29 Paracetamol 27, 29, 31, 32, 33, 51, 91, 141, 184, 187 Parasitic infections 81 Partial or focal seizures 133 Paucibacillary leprosy 172 Penicillin V 175 Permethrin 82 Permethrin cream 83 Pertussis (Whooping cough) 178 Phenobarbital 134 Phenoxymethylpenicill 65 Phenoxymethylpenicillin 64, 72, 88, 108, 109, 175 Phenytoin 134 Phytomenadione 69 Phytomenadione (Vitamin K) 69 Pilocarpine 151 pinworms 121 Pityriasis versicolor 76 pleural effusion 38 Pneumonia 33 Postherpetic neuralgia (pain) 79 Post-infectious Corneal Scarring 143 Potassium chloride solution 102 Povidone iodine 72 Praziquantel 122 Prednisolone 41, 65, 130, 153 Prednisolone 1% 141 preeclampsia 14 pre-eclampsia 14 pre-eclampsia 15 Pre-eclamptic toxaemia 14 Prevent dehydration and replace lost fluid 117 Primary syphilis 159 Probenecid 162 Procaine benzylpenicillin 161, 162 Promethazine 28, 80, 82, 87, 90, 118, 129 Prophylaxis of migraine 130 Propranolol 105 Propylthiouracil 105 Pseudoexfoliation 148 Pterygium 149 Puerperal Sepsis 25 Pulmonary TB 171 pyelonephritis 154 PYRANTEL PAMOATE 121 R Rabies 176 Rabies human diploid cell vaccine 178 Ranitidine 110 Recommended treatment regimens of WHO for Lymphogranuloma venereum 169 renal calculi (stones), 154 Renal conditions 154 Reproductive Health 11 Respiratory tract conditions 31 Retained placenta 21 Rheumatic fever 64 Rheumatoid arthritis 47 Rifampicin 182 Ringer-Lactate 23, 114, 188 Ringer-Lactate solution 22 Ringworm (Tinea Corporis) 74 Roundworm (Ascaris) 119 Roundworms (Ascaris lumbricoides): 122 Ruptured eye 141 ruptured uterus 24 S Salbutamol 40, 44 Salicylic acid 84 salpingitis 165 Scabies 81 Scalp ringworm (Tinea capitis) 77 Scopolamine 141 Secondary postpartum haemorrhage 24 Secondary syphilis 160 seizures 131 Seizures (convulsions) 131 Septic arthritis 48 Severe pain 28, 30 Severe pneumonia 35 Shingles (Herpes zoster ) 78 Short acting 97 Short-acting insulin 97 Sinusitis 93, 127 skin conditions 71 Sodium chloride 24, 101, 114, 118 Sodium lactate 118 Sodium valproate 135 Soluble 97 Sore throat (Pharyngitis and Tonsillitis) 88 Stable angina, 61 Staphylococcal infection 36 status asthmaticus 40 Status epilepticus 133, 136 Strongyloides 119 strongyloides (Strongyloides stercoralis): 122 Stye and Hordeolum 143 Subarachnoid haemorrhage 128 Subconjunctival hemorrhage 139 Syphilis 159 syphilis during pregnancy 19 T Tape worm (Hymenolepis, Taenia) 119 Temporal arteritis 127, 130 Tension headache 127 Tertiary syphilis 160 Tetanus 173 tetanus immunisation 177 Tetanus immunoglobulin 174, 175 Tetanus in adults and children 175 Tetanus Toxoid Vaccine 20 tetanus vaccine 177 tetracycline 142, 144, 145, 146, 153 Tetracycline 140, 149, 185 Tetracycline 1% 143 tetracycline 1% ointment 138, 139 Tetracycline 1%, eye ointment 26 tetracycline ointment 146 Tetracyline 1% eye ointment 144 Theophylline 44 Threadworms 121 Thyroid conditions 103 Thyroid neoplasms 103 thyrotoxicosis 103 Timolol 140, 151 Tinea versicolor 76 Trachoma 146 Tramadol 28 Treatment for congenital syphilis of 2 or more year duration 163 Treatment resistant hypertension 56 Trichiasis 149 Tropicamide 141 Tuberculosis 171 Type 2 diabetes 98 Types of insulin 97 U ulcers 108 Uncomplicated anogenital gonococcal infections in ADULTS 165 urethritis 154 Urethritis / endocervicitis / proctitis 168 Urinary tract infections (UTI) 154 Urinary tract infections during pregnancy 19 urosepsis 154 V Vaginal discharge during pregnancy 19 Vitamin A 150 Vitamin B12 deficiency 68 vitamin C 12 Vitamin K 70 Vitamin K deficiency 69 W Wheezing 42 Whipworms (Trichuris trichiura) 121 X Xerophthalmia (Vitamin A Deficiency) 150 Y Yaws 158 Z Zinc tablets 112, 113