Module 6 Skill station: Diarrhea and Dehydration. Objectives of the module

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1 Module 6 Skill station: Diarrhea and Dehydration Objectives of the module Section I- Diarrheal disease Describe the management of acute diarrhea. Identify the clinical indications for antibiotic therapy for diarrheal illness in an acute emergency setting. Identify the clinical features of dysentery, the most frequent causative pathogens, and the antibiotics that can be used to treat the infection. Use the Integrated Management of Childhood Illness (IMCI) guidelines in the treatment of children with diarrhea. Section II- Diarrhea in infants 0 to 2 months of age Identify the different types of diarrhea. Define treatment for infants 0 to 2 months of age with diarrhea. Section III- Dehydration Describe and identify the different types of dehydration. Assess the degree of dehydration. Describe the physiological basis of oral rehydration therapy (ORT). Explain the characteristics and routes of administration of ORT solutions. List the advantages of ORT. Define when ORT has failed and when ORT is contraindicated. Describe how to give ORT to children with severe dehydration. Outline a strategy for setting up an ORT unit at the site of a disaster. Objectives of the station Use the IMCI guidelines in children with diarrhea, with and without dehydration. Identify the clinical findings used in the assessment of the severity of diarrheal diseases. Manage different types of diarrheal disease. Select appropriate rehydration plans for the different degrees of dehydration. Mix oral rehydration solutions (ORS) based on ingredients available in the context of disasters. 1

2 Give appropriate therapy for severe dehydration with resources available in disaster situations. Presentation format Case resolution in role-playing format, in which the facilitator or instructor performs as mother/adult, offering the required information for the resolution of the case. Duration 60 minutes Material Classroom or meeting area with a sufficient number of chairs in a semicircular arrangement. Sheets of paper and pens or pencils. Desk and chairs for role-playing (if possible, examination table). Scenario / clinical cases (with whole script and solution) for the facilitator. Scenario / clinical cases for participants. Optional : - Utensils needed for preparing ORS (bottles or other water containers, spoon, jar, cups, OMS ORS). - Various solutions (D5W, normal saline, local commercially available solutions, KCl, NaCl) for IV rehydration. - Infants scale. - Equipment for vascular access simulation. - Infant mannequin. Cases The initial scenario is common for all cases that will be discussed in this small group session. In each case one student is asked to perform the role of physician and to establish a diagnosis, based on history and physical findings, and initiate the appropriate management. Each case resolution should be supported by the student in a discussion with the rest of the group. Notes for the instructor 2

3 Before you begin the activity with each group of students be sure that all required elements are readily available. Review all the educational objectives for the skills station. Throughout the activity fill the information asked in the evaluation control list. The facilitator performing as the mother/adult bringing the child should know all data needed for the resolution of each case. In addition, it is recommended that he uses local typical language and figures of speech, and show attitudes and mannerisms frequently seen in the country or region where the course is taking place. In each case one of the students is asked to perform the role of physician and to establish a diagnosis, based on history and physical findings, and initiate the appropriate management. He must obtain all relevant history data and ask for the presence of physical findings expected according to each case. The instructor should encourage the participation of all the students in the group during the interview and physical exam. The same should be done when discussing the evidence supporting the diagnosis and the management suggested by the students. The instructor should also make a final review of each case stressing the key points involved in it. 3

4 Initial scenario Late on summer, great storms with heavy rains have caused floodings in the northern region of Argentina. Tartagal, a city in San Martín county in the province of Salta, has been severely affected. Many houses built in the banks of the nearby river have been washed away by the rushing water. This has resulted in the evacuation of more than 1800 families, including approximately 5000 individuals. Some of them have been placed in public buildings, and others in tents. For the latter, sanitation services are provided by chemical baths, and safe water is delivered by truck. The road bridge connecting San Martín county with the provincial Capital City has been destroyed by river erosion caused by the increased flow of river Seco. Tartagal has a general hospital, with 40 beds. Five days after the evacuation of the river side area, you are sent by public health authorities to take charge of a camp health facility, near to where 3000 people have been temporarily placed in tents. You have 100 liters of safe drinking water, 60 envelopes of WHO oral rehydration salts (1 liter of oral rehydration solution [ORS} per envelope), several catheters for IV fluid administration, various IV solutions (D5W, normal saline, KCl, NaCL, NaHCO 3 ), and some syringes. You also have a small refrigerator, various metered containers, 1 liter plastic bottles, an infant scale, 3 thermometers, 1 sphygmomanometer, and plastic spoons and cups. Two health agents, recently trained in the Integrated Management of Childhood Illness (IMCI), have been sent to assist you in the health post. Previous health information shows that, as usual during the summer, there were many cases of diarrheal diseases in the area. Case 1 A young woman brings her 3 children to the health center. You evaluate the eldest, a 4- years-old boy, while your assistants examine his two brothers. The mother says that her son has passed loose stools for the last 3 days. Stools are watery, with no blood. The boy drank water without any problem, and ate rice with good appetite. There have been no vomiting, or fever. Urine output is normal. Physical findings 4

5 Temperature (T ) is 37.2 C; heart rate (HR) is 100 bpm; blood pressure (BP) is 95/60 mmhg; and weight is 14 kg. The boy is alert, but irritable, and cries during the examination. Abdomen is soft, with no tenderness. Bowel sounds are slightly increased. Mucous membranes are moist, and skin turgor and capillary refill are normal. Diarrheal disease, with no general danger sings. Normal hydration or mild subclinic dehydration. Management No medication needed. Increase fluid uptake (broth, soup, rice water), according to tolerability. ORT Plan A. Show the mother how to prepare the ORS (if material is available, the student performing as physician should show how to prepare the ORS). Give 200 ml of ORS after each defecation, until stools return to normal. Offer usual food. If no improvement is noted after 3-5 days, make a second visit. If the child vomits, bloody stools are noted, or there is any change in the general appearance of the child (danger signs), come immediately to the health post. Acute diarrhea, with no blood in stools. Use of medications, particularly antibiotics and antispasmodics, in acute diarrhea. Likely pathogens. Vital signs are normal, and there are no findings suggesting dehydration or severe illness. Fluid and food tolerability is preserved, as well as urine output. Discuss ORT Plan A. Emphasize normal feeding for children with diarrhea, particularly breast-feeding. Review danger signs that should be given to the mother. Case 2 One of the assistants asks you to evaluate the 2-years-old sister of your first patient. She also has had diarrhea for 4 days. 5

6 The girl has vomited several times today, although she drank rice water yesterday with good tolerability. Vomitus is clear, without bile, and she has tolerated very small amounts of water. She has refused to drink anything since yesterday. Urine output is decreased and urine looks darker than usual. Physical findings T C is 37.2 C; HR is 120 bpm; BP is 90/50 mmhg; weight is 10 kg. Normal pulse pressure. The girl is alert, looks frightened, and cries without tears during the examination. Skinfold sign is positive, and the skin is mildly pale. Capillary refill time is < 3 sec. Other findings: semi-dry or dry mucous membranes; sunken eyes. Abdomen is soft and not tender, intestinal sounds are normal. Diarrheal disease, without blood. Moderate dehydration. Management Start immediately ORT Plan B. (If material is available, the student performing as physician should show how to prepare the ORS): ORS, ml in 4 hours. Continued monitoring of clinical status. Show the mother how to give ORS in small sips or with a small spoon. Do not give more than 200 ml in 20 minutes. Case 2 (cont.) Four hours later the girl has drank 900 ml of ORS. What is the appropriate next step in the management of this patient? Re-evaluate the girl. Determine weight and vital signs. Look for findings suggesting dehydration. The girl looks playful. Weight is 10,900 kg. There are no signs suggesting dehydration. What is the appropriate next step in the management of this patient? The girl is normohydrated. Give ORT Plan A. Show the mother how to prepare the ORS. Give 200 ml of ORS after each defecation, until stools return to normal. Offer solid food progressively according to oral tolerability. If still breast-fed, encourage the mother to continue doing so. If vomiting or bloody stools are noted, or there is any 6

7 change in the general appearance of the child (danger signs), come immediately to the health post. Follow-up visit in not more than 24 hours. History of vomiting is not a contraindication for ORT. Non-bilious vomiting and normal abdominal findings rule-out ileus. Review all causes of contraindication for ORT. Review appropriate steps when patients vomit during rehydration: Stop rehydration for a short period of time minutes, then give cold ORS in smaller volumes. If emesis persists, place a nasogastric tube and give ORS. If vomiting still persists, initiate IV fluid therapy. Case 3 Now you are asked to see the youngest brother. He is 6-months-old, and also has diarrhea. In this case the disease began 5 days before. Watery stools, without blood, persistent emesis. The mother tells you that she has not been able to breast-feed the infant since last night, because he refuses to do it. In addition, she is unable to wake him up completely. There has been no urine in the diapers since yesterday. Physical findings T C is 37.2 C; HR 160 bpm; BP 60/40 mmhg; weight 5 kg. Very weak, thready pulses; lethargy, extremely sunken eyes, depressed anterior fontanelle. Positive skinfold sign; mottled and cold skin. Capillary refill > 5. Dry mucous membranes. Acute diarrheal disease, without blood. Severe dehydration. Management Volume resuscitation with IV fluid therapy with isotonic crystalloids (normal saline solution): 100 ml (20 ml/kg) in 1 hour. Re-assessment. If hemodynamic failure persists, repeat volume expansion. If normal hemodynaic status is recovered, try ORT Plan B to 7

8 complete rehydration. If the infant does not tolerate oral fluids, refer immediately to the hospital for continued IV fluid therapy. Case 3 (Cont.) After 4 hours HR is 110 bpm; BP is 95/60 mmhg; weight 5,700 kg. The infant passed 2 watery stools, but oral tolerability is good. There are no findings suggesting dehydration. He is alert. What is the next step in the management of this patient? ORT plan A; continued breast-feeding; review danger signs with the mother; follow-up in hours. Review pathophysiology and findings associated with hypovolemic shock. Discuss ORT Plan C. If material is available practice IV access. Case 4 Three days later, you have sent one of the medical assistants to the hospital to ask for medical supplies. He has left with the only available vehicle capable to drive through the muddy roads. You have no equipment for IV therapy left. A 6-years-old boy is rushed into the health post in the arms of her mother. The mother tells you that her son has passed more than 8 watery stools in the last 6 hours. Stools are completely liquid, with no blood. No vomits. The child drinks water avidly. He has not voided in the last 6 hours. His father has been with diarrhea for the last 48 hours, with frequent, watery stools. Physical findings T C is 37.6 C; HR is 130 bpm; BP is 80/40 mmhg. The child is lethargic, but he can talk and describes no abdominal pain. There are marked sunken eyes; pale and cold skin, with positive skinfold sign. Capillary refill > 5. Weak, thready peripheral pulses. Soft and not tender abdomen, with increased intestinal sounds. Acute diarrheal disease, without blood. Severe dehydration. Suspected cholera. 8

9 Management With no material for IV fluid therapy and no transportation available, place a NG tube and start ORS 20/ml/kg per hour. Monitor vital signs and urine output. Check for emesis and abdominal distension. Continue until referral to the hospital is possible. Case 4 (Cont.) The child vomits 2-3 times. What is the next step in the management of this patient? Reduce the rhythm of ORS administration. At this time the medical assistant arrives with the elements required for IV fluid therapy. What do you do now? Initiate IV fluid therapy, according to ORT Plan C. If normal hydration is not achieved, send the child to the hospital. If normal hydration is achieved, give ORT Plan A, normal feeding, and start antibiotic therapy for suspected cholera (TMP-SMX; doxicycline), review danger signs with the mother; follow-up in hours. As cholera is suspected take a fecal specimen for culture. Report the suspected case to Public Health authorities. Discuss findings suggesting epidemic cholera, including age of patient with severe diarrhea and rapid dehydration, with shock. Favorable epidemiological context for V. cholerae dissemination. Contact with likely infected adult. Active investigation of suspected cases, particularly among adults, and epidemiological surveillance should be initiated if etiology is confirmed. Strengthen sanitary practices (e.g., hand-washing, use of chemical baths, safe cooking), as well as provision of safe water and uncontaminated food. Case 5 You are re-assessing a 4-years-old girl in a follow-up visit 5 days after her initial presentation. At that visit she had non-bloody diarrhea, with mild dehydration. She received rehydration with ORT Plan B. She tolerated the therapy well and was sent home with indications for the management of her diarrheal illness and ORT Plan A. Diarrhea persists, and the girl complains of fever and continued abdominal pain. Stools have been bloody in the last 48 hours. Oral tolerability is good, but she has no appetite and has ill appearance. Urine output is normal. 9

10 Physical findings T C is 38.9 C; HR is 90 bpm; BP is 95/65 mmhg. The girl is alert, but uncomfortable, although she allows herself to be examined. Mucous membranes are humid; skinfold sign is negative. The girl cries with tears. Capillary refill < 3. Abdomen slightly tense and tender. Bloody diarrhea (dysentery), without dehydration. Management Antibiotic therapy: azithromycin o ceftriaxone (amoxicillin or TMP-SMX, if first line agents are not available) if local antimicrobial resistance information is not known. If possible, send fecal specimens for culture. ORT Plan A; review danger signs with the mother; follow-up in 48 hours. If after 48 hours diarrhea persists and there is no amelioration of the clinical status, refer the patient to the hospital. Obtain culture and antibiotic sensitivity testing to guide antibiotic therapy. If the clinical picture is improved, continue antibiotic therapy for 5 days. If no improvement is noted after 2 antibiotic therapy series and no cultures are available, give anti-amebic therapy with metronidazole (if possible, try to confirm diagnosis with stool examination). The presence of blood in the stools makes dysentery the most likely diagnosis. Initially the most likely etiology is bacterial (Shigella sp., in most cases) if there are no findings (e.g., hepatomegaly) associated with amebic dysentery. Review most appropriate agents and timing for antibiotic therapy. Antimicrobial resistance. Use of antimicrobials should be cautious in uremic-hemolytic syndrome endemic regions because of the risk of toxin liberation in the intestine. Discuss likely local parasitosis, with emphasis in amebic disease, and their management. Case 6 There is an outbreak of diarrheal disease in the area, affecting a great number of displaced people. You have used all your ORT supplies. You expect to receive more in 10

11 several hours. You do have IV solutions. A 2-years-old girl with 3 days history of diarrhea presents to your health facility. The girl had some vomiting at the onset of her illness, but today she has accepted oral liquids at her shelter. There is no blood in the stools, and she refers no abdominal pain. Urine output is slightly decreased, but she voided once this morning. Physical findings TºC is 36.8; HR is 120 bpm; BP is 100/50 mmhg; weight: 10 Kg. She cries with no tears during physical examination. Abdomen is soft and not tender. Intestine sounds are slightly decreased. Dry mucosus membranes, positive skinfold sign. Capillary refill < 3. Acute diarrheal disease, without blood. Moderate dehydration. Management ORT Plan B. Since WHO ORS is not available, mix IV solutions to obtain ORS. Alternatively use tea with salt and sugar, or prepare rice water. Case 6 (Cont.) The girl has tolerated the ORT and her hydration is normal after 3 hours. You only have 1 metered container left. What is the appropriate next step in the management of this patient? Prepare enough ORS for 24 hours according to ORT Plan A. Give this ORS to the mother in a clean bottle. Review alarm findings with the mother; follow-up in 24 hours if diarrhea persists. Emphasize the importance of field expedient forms of ORS. Discuss appropriate proportions of various IV solutions and the use of locally available ingredients in the preparation of ORS. Case 7 11

12 The same girl you have assisted in case 6 returns 15 days after her first visit. The mother says that diarrhea has persisted throughout this time. The girl is eating and drinking well, without vomiting. Stools are somewhat liquid, fatty, with no blood. She has no abdominal pain, but complains of flatulence. She has been afebrile and urine output is normal. Physical findings T C is 36.8 C; HR is 95 bpm; BP is 100/60 mmhg. Mucosus membranes are moist negative skinfold sign. Capillary refill < 3. Abdomen is soft and not tender. Persistent diarrhea, without dehydration. Management ORT Plan A. Give metronidazole if has not received therapy previously. Review diet. Investigate parasites in stools, if possible. Follow-up in 5 days Emphasize the importance of Giardia lamblia as cause of persistent diarrhea in children. Review patohysiological and clinical features of persistent diarrhea. Note the importance of good sanitarian practices, as well as safe water and food in the context of disasters. 12

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