Standard Treatment Workflows

Department of Health Research
Ministry of Health and Family Welfare, Government of India
PARTNERS
Suggested Citation: Standard Treatment Workflows of
India, 2019 Edition, Vol. 1, New Delhi, Indian Council of
Medical Research, Department of Health Research,
Ministry of Health and Family Welfare, Government of
India
© DHR and ICMR

Diary No. 17206/2019-CO/L
All rights reserved. No part of these workflows may be

transmitted or reproduced in any form or by any
means without prior permission from the
organization.
Printed in India
These STWs have been prepared by national experts of India with

feasibility considerations for various levels of healthcare system in
the country. These broad guidelines are advisory, and are based on
expert opinions and available scientific evidence. There may be
variations in the management of an individual patient based on
his/her specific condition, as decided by the treating physician.
There will be no indemnity for direct or indirect consequences.
Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health
Research, Ministry of Health & Family Welfare, Government of India.
• INTRODUCTION
CARDIOLOGY
ATRIAL FIBRILIATION
BRADYARRTHYMIAS
HEART FAILURE
STABLE ANGINA
STEMI
UNSTABLE ANGINA/ NSTEMI
ENT
ACUTE RHINOSINUSITIS
CHRONIC RHINOSINUSITIS
EPISTAXIS
HEARING IMPAIRMENT IN PEDIATRIC AGE GROUP
NECK SPACE INFECTION
OTORRHOEA
PHARYNGITIS AND SORE THROAT
NEPHROLOGY
ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
GLOMERULONEPHRITIS
URINARY TRACT INFECTION
NEUROLOGY
APPROACH TO ACUTE PARALYSIS
DEMENTIA
EPILEPSY
HEADACHE
NEUROINFECTIONS
STROKE
OBG
ANTENATAL MANAGEMENT
DILATATION AND CURETTAGE
HEAVY MENSTRUAL BLEEDING
HYSTERECTOMY
POSTPARTUM HAEMORRHAGE
UTERINE FIBROIDS AND POLYPS
PAEDIATRICS
ACUTE ENCEPHALITIS SYNDROME
ACUTE DIARRHEA
DENGUE FEVER
FEVER IN CHILDREN
SEPSIS AND SEPTIC SHOCK IN CHILDREN
SEVERE ACUTE MALNUTRITION
SEVERE PNEUMONIA IN CHILDREN
PSYCHIATRY
ALCOHOL USE DISORDERS
ANXIETY DISORDERS
CHILDHOOD BEHAVIOURAL DISORDERS
CHILDHOOD EMOTIONAL DISORDERS
CHILDREN WITH DEVELOPMENTAL DISORDERS
DEPRESSION
PSYCHOSIS
SOMATOFORM DISORDERS
PULMONOLOGY
ACUTE RESPIRATORY INFECTION
ASTHMA
CHRONIC OBSTRUCTIVE PULMONORY DISORDER
RESPIRATORY FAILURE
UROLOGY
ACUTE URINARY RETENTION IN MEN
GROSS HAEMATURIA
MALE INFERTILITY
RENAL AND URETRIC STONES
SCROTAL SWELLING
• CONTRIBUTORS
INTRODUCTION Department of Health Research
GOAL
To empower the primary, secondary and tertiary care physicians/ surgeons towards
achieving the overall goal of Universal Health Coverage with disease management
protocols and pre-defined referral mechanisms by decoding complex guidelines
OBJECTIVES
Primary Objective:
To formulate clinical decision making protocols for common and serious medical/
surgical conditions for both OPD and IPD management at primary, secondary and
tertiary levels of healthcare system for equitable access and delivery of health
services which are locally contextual
Secondary Objective:
To facilitate PMJAY arm of Ayushman Bharat with secondary and tertiary level
management of all surgical and medical conditions covered under the scheme.
METHODOLOGY
ADVISORY
COMMITTEE
STW SECRETARIAT EDITORIAL BOARD DESIGN TEAM
EXPERT GROUPS COMMITTEES
PROCESS OVERVIEW
• 100 Meetings 650 hours
Consultations
DEVELOP STWS & (5200 person hours)

CONVERT THEM
• Participation also from
INTO
INFOGRAPHICS Public Health Specialists
TOPIC Search Strategists
PRIORITIZATION
Clinical Scientists
Graphic Designers
• Prevalence studies
• Global burden of REVIEW OF • Review by Editorial Board
CURRENT
diseases studies • Approval by Advisory
GUIDELINES &
• HBP of AB-PMJAY FEASIBILITY AS Committee
PER HEALTH • Public Comments
SYSTEM
Harrison’s Textbook
Oxford Handbook
CARDIOLOGY
October/ 2019

Standard Treatment Workflow (STW) for the Management of

ATRIAL FIBRILLATION
ICD-10-I48.91
SYMPTOMS LOOK FOR PRECIPITATING CATEGORIZE AF

- Rapid rate palpitations with or without FACTORS:
• General fatigue or weakness or • Paroxysmal AF: Episodes of AF for
exhaustion • Post (cardiac) surgery less than 7 days
• Dizziness, near syncope or syncope • Alcoholism or binge drinking • Persistent AF: AF lasing from 7 days
• Shortness of breath • Myo-pericarditis or ACS to 1 year
• Chest pain • Pneumonitis or pulmonary
WHEN TO • Long standing persistent AF: AF
- More marked on exertion embolism lasting for > 1 year
SUSPECT ?
• Sepsis, hyperthyroidism • Permanent AF: AF with heart rate
SIGNS control as only option
- Irregularly irregular pulse MANAGEMENT PRINCIPLES:
- Variable heart sound
• Categorize AF LOOK FOR IMMEDIATE INTERVENTION
LOOK FOR RISK FACTORS • Look for immediate intervention INDICATORS:
• Prior valvular heart disease or indicators
CHF or MI • Assess stroke risk & need for • Systolic BP 90 mmHg, HR > 150 or
• Prior TIA or stroke or embolic anti-coagulation <50/min
episode • Assess bleeding risk • Ongoing Angina
• Hypertension, DM, COPD,CKD, • Need for rate control • CHF or TIA or stroke
Obesity • Consideration for rhythm control • Major bleed on Oral Anti-coagulants
STROKE RISK SCORE BLEEDING RISK SCORE

CHOICE OF ANTI-COAGULATION:
CHA2DS2-VASC SCORE HAS-BLED SCORE • Vitamin K antagonist
• Aim for INR 2-3
- Congestive heart failure/LV dysfunction 1 - Hypertension i.e. uncontrolled BP 1 • Assess risk of bleeding
- Hypertension 1 - Abnormal renal/ liver function 1 or 2 • Take measures to reduce/ modify risk of bleeding
- Aged > 75 years 2 - Stroke 1 • Dietary modification & regular monitoring
- Diabetes mellitus 1 - Bleeding tendency or 1
- Stroke/ TIA/ TE 2 predisposition 1
- Vascular disease [prior MI, PAD or aortic 1 - Labile INR 1 MEASURES TO REDUCE HIGH BLEEDING RISK:
plaque] - Age (e.g. >65) • Control SBP to less than 140 mmHg
- Aged 65-74 years 1 1 • Avoid dietary indiscretions
- Drugs (e.g. concomitant aspirin or • Avoid concomitant aspirin, anti platelets, NSAIDs
- Sex category [i.e. female gender] 1 NSAIDSs or alcohol • Avoid alcohol
Maximum Score 9 9 • Correct anemia
OAC if score >1 in men and >2 in women Bleeding Risk High in score >3
HEART RATE CONTROL

In all patients except hemodynamic Beta blocker or calcium blocker or BB + digoxin in HF Rate aim to be less than 110/ min
instability combination
CONVERSION TO NSR
Uncontrolled symptoms despite HR Unacceptable rate control drug side
Hemodynamic instability Patients’ preference
control effects
MANAGEMENT INVESTIGATIONS
WHAT TO LOOK FOR IN ECG ?
AT PHC/ CHC: BASIC INVESTIGATIONS: • Ventricular rate
• Detailed clinical evaluation • Chamber enlargement
• Hemograms • Pre-excitation
• Basic investigations
• Blood sugar, Creatinine • Prior MI
• Careful ECG evaluation
• Electrolytes • Bundle branch block
• Start OAC if indicated (based on Stroke risk)
• 12 lead ECG • QT interval
• Start Metoprolol if HR >110/ min & no evidence of CHF
• Refer if indicators for early intervention
AT DISTRICT HOSPITAL: RHYTHM CONTROL

DESIRABLE INVESTIGATIONS:
• Admit if indicators of early interventions Pharmacological Cardioversion
• Plain X-ray chest
• Immediate cardioversion after heparinization,if
• Thyroid evaluation
hemodynamic instability CHF
• Liver function test Normal Heart
• Manage precipitating factors if any CAD
• Troponins
• Assess stroke, bleeding risk & coagulation parameters Abnormal LVH
• Prothrombin time, INR (Coagulation
• Detailed echocardiogram
profile) Flecainide Pill in pocket
• Start OAC, maintain INR around 2-3
• Echocardiography Ibutilide (Flecainide OR
• Control HR by single drug or combination of BB & Ca
Blocker Amiodarone Propafenone Propafenone)
Refer HR uncontrolled or CHF or angina OPTIONAL INVESTIGATIONS:

Long Term Rhythm Control
AT TERTIARY CENTRE: • Prolonged ECG monitoring
• Trans-esophagial echocardiography CHF Normal Heart CAD, LVH
• Re-assess clinical status, adequacy of AC
• Exercise Stress Test
• Consider need of NOAC
• CT scan
• Optimise management of underlying cardiac disease
• MRI Amiodarone Flecainide Amiodarone
• Stress life style and AF risk factor modification
• EP study Propafenone Sotalol
• Assess need for rhythm control and discuss pros & cons
• Coronary angiography Sotalol
• Consider RFA in select patient
MANAGEMENT ALGORITHM
Sign/ symptoms suugestive of AF
Confirm by 12 channel rhythm strip
Hemodynamic Instability
No
Yes
No
Very rapid HR >130/ min
Yes
Yes No
CHF Symptomatic
Drug version
Successful Yes No Yes No

HR control
No Yes Aim <110/min Clinical
Careful BB/Dig BB or Ca Block Follow-up Anti-coagulants in all Except
DC version Continue drug Amiodarone or combine
• Reversible
HR > 110/ min
• Score <1 (men) ; <2 (women)
Consider DC version
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are
based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the
treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019


BRADYARRTHYMIAS IN SYMPTOMATIC PATIENTS
ICD-10-R00.1
Syncope/ presyncope/ dizziness
WHEN TO
SUSPECT
Patient with
any of the Lethargy/ fatigue
following
symptoms,
AND a pulse
rate < 50bpm:
(persistent)
Breathlessness/ chest pain on

exertion
BASIC EVALUATION
HISTORY EXAMINATION TESTS TO BE DONE
• Syncope/ presyncope: frequency, associated fall/ injury/ incontinence • Drowsiness/ impaired Patient presenting to PHC/CHC:
• Exertional angina or known coronary artery disease consciousness • 12-lead ECG
• Known hypothyroidism or kidney disease • BP, heart rate • Blood urea, serum creatinine
• On beta-blockers, Calcium Channel Blockers or digoxin • Electrolytes
• Patient with an implanted pacemaker or other device • Blood sugar
• Yellow oleander poisoning
EVALUATION AND TREATMENT OF UNSTABLE PATIENTS EVALUATION AND MANAGEMENT OF STABLE PATIENTS
1. TREATMENT OF ASSOCIATED CONDITIONS Findings on 12-lead ECG

- Hyperkalemia
- Suspected drug (BB or CCB) overdose: • Atrioventricular block
i. Withhold the drug • Sinus node dysfunction
ii. iv insulin (1 U/kg bolus followed by 0.5 U/kg/h) with glucose monitoring(or) iv • Other conduction disorders with 1:1 AV
glucagon if available conduction
2. TEMPORARY PACEMAKER INSERTION • Non-diagnostic ECG
(iv dopamine or adrenaline may be given till the time TPI can be placed)
INDICATIONS FOR URGENT TREATMENT/REFERRAL GENERAL APPROACH TO PATIENTS WITH SYMPTOMATIC BRADYCARDIA
• Hypotension (SBP <90 mmHg), impaired consciousness or 1. Rule out associated conditions
ongoing chest pain - Renal dysfunction, hyperkalemia
• Recurrent or ongoing syncope/presyncope - Drug toxicity (BB, CCB, clonidine, Lithium)
• Associated headache with or without neurologic deficit (suspect - Sleep apnea (clinical scoring systems such as Epworth
intracranial event) Sleepiness Scale may be used for initial assessment)
• Patient with a pre-existing device
• If ECG available, evidence of any of the following 2. Transthoracic echocardiography
- Complete heart block
- Sinus node disease with pauses >3 s long
- Bradycardia (HR < 50 bpm)
(with or without hyperkalemia, serum K > 5 mEq/L)
INDICATIONS FOR PERMANENT PACING
AV NODAL DISEASE SINUS NODE DYSFUNCTION OTHER CONDUCTION DISORDERS WITH 1:1 AV
CONDUCTION
• Complete heart block, advanced AV block, • Symptomatic patients with sinus
or Mobitz Type II block pauses > 3 s long with symptom • Symptomatic patients with HV ≥100 ms on EPS
• Symptomatic patients with AV block other correlation • Others (alternating BBB, infiltrative/ neuromuscular
than above • Asymptomatic patients with sinus disease)
• Associated neuromuscular disease pauses > 6 s long
RECOMMENDED PACING MODES ADDITIONAL TESTING
1. SND with intact AV conduction 1. Advanced imaging (cMRI) may be needed if infiltrative disease
- Atrial-based single or dual chamber pacing is suspected
- VVI pacing is reasonable if symptoms are 2. Ambulatory ECG may be needed
infrequent - In patients with first or second degree AV block for
2. AV node disease symptom correlation
- VVI/Dual chamber pacing in patients with - In patients with suspected sinus node disease for
LVEF >50% detection of pauses and symptom correlation
- CRT (or HBP) in patients with LVEF - In symptomatic patients with LBBB or bifascicular block
36-50% and requiring ventricular pacing 3. Implantable Loop Recorder and EPS (consult published society
>40% of the time guidelines)
- CRT (or HBP) if LVD <35%
ECG: SINUS BRADYCARDIA ECG: THIRD DEGREE HEART BLOCK
October/ 2019


HEART FAILURE: A BREATHLESS PATIENT
ICD-10-I50.9
ADDITIONAL INFORMATION
SYMPTOMS Raised JVP • Prior history of respiratory illness like
asthma or COPD
1. Dyspnea/ orthopnea/ PND Pulmonary Cardiomegaly • Known patient of CHF/ similar illness in
2. Pink frothy sputum Oedema past with response to therapy
3. Dependent pedal edema • Prior history of RHD, CAD, pregnancy,
4. Recent weight gain cancer chemotherapy
5. Easy fatiguability Pleural • Risk factors: HT, DM, smoking,
6. H/o CHF/ MI Effusions hyperlipidemia or premature CAD in
first degree relatives
Ascites
COMMON ETIOLOGY AND INDICATORS

SIGNS 1. Ischemic cardiomyopathy: past MI
1. Tachypnoea Hepatomegaly 2. Diabetic cardiomyopathy
3. RHD: existing valvular disease
2. Tachycardia or irregular
4. Post-viral: acute onset
pulse breathlessness within last 3 months
3. Basal crepitations 5. Peri-partum cardiomyopathy-onset
4. Cardiomegaly in last trimester or after delivery
5. Presence of murmurs Pitting 6. Idiopathic cardiomyopathy
6. Systemic desaturation Oedema 7. Post-cancer chemotherapy
MANAGEMENT AT PHC MANAGEMENT AT CHC

• Admit and stabilize
• Rule out respiratory cause: Breathlessness REFER TO • Send for routine investigations
with fever, cough and expectoration or COMMUNITY • ECG: Rule out acute ST-Elevation MI
known patient of asthma or COPD
HEALTH CENTRE • X-ray chest: Rule out respiratory etiology
• Likely CHF: Decongest with furosemide
• Decongest with intravenous furosemide
• O2 therapy if systemic saturation < 90%
REFER IF FOLLOWING:
• Start enalapril and spironolactone orally
• BP < 90 mmHg or > 200 mmHg
• Consider carvedilol after decongestion
• Heart rate < 50/min or > 120/min
• Respiratory rate > 30/min or cyanosis
• Oliguria
• Altered sensorium KEEP WATCHING
1. Respiratory distress
REFER TO A
and oxygen saturation
MANAGEMENT AT DISTRICT HOSPITAL DISTRICT 2. BP and heart rate
HOSPITAL 3. Electrolytes and renal
• Admit and re-assess parameters
• Optimise therapy with furosemide/ enalapril/
spironolactone/ O2 and stabilize
• Consider non-invasive ventilation if marked respiratory MANAGEMENT AT TERTIARY HOSPITAL
distress and O2 saturation < 90% 1. Re-assess and confirm diagnosis of HF
• Echocardiography: confirm diagnosis of HFrEF: LV 2. Categorize acute (< 3 months) vs chronic (> 3 months) and HFrEF
ejection fraction < 35% (EF 35%) vs HFpEF (EF 35-50%)
• Search for etiological diagnosis 3. Optimize therapy with furosemide, enalapril, carvedilol,
• Consider carvedilol after decongestion spironolactone and O2
• Refer back to CHC/ PHC after stabilization 4. Consider ARNI and ivabradine
5. Pneumococcal and influenza vaccines
6. Investigate for etiology and manage
7. Consider non-pharmacological invasive therapy
REFER TO TERTIARY CARE IF a. ICD: In selected patients (Ref Arrhythmia STW)
• CHF uncontrolled,
b. BiV: Consider in NYHA class II/ III Symptomatic patient ,
• Unstable hemodynamics
EF <35%, QRS >150msec in sinus rhythm with LBBB
• Suspected ongoing ischemia
morphology and optimal medical therapy of >3 months
• Abnormal electrolytes
8. Etiology based Interventions
• Abnormal renal functions
a. PCI
• Structural heart disease
b. Valve replacement
• Unclear etiology
c. CABG
CONSIDER AT ALL LEVELS

Secondary CVD prevention
Smoking Salt Physical Weight Moderation Control of DM/
with aspirin and statins
Cessation restriction activity Reduction of alcohol HTN/ Lipids
INVESTIGATIONS:
BASIC INVESTIGATIONS WHAT TO LOOK FOR IN WHAT TO LOOK FOR IN AN ECG? DESIRABLE OPTIONAL INVESTIGATION
• Hemogram, ESR X RAY INVESTIGATIONS • Prolonged ECG monitoring
• Pathological Q wave
• Blood sugar • Conduction abnormalities, • 2D Echocardiography • Coronary angiography
• Urine examination • Cardiomegaly • BNP/NT pro-BNP • Radionuclide imaging
especially LBBB
• Urea/ Creatinine • Pulmonary venous • Troponin • CT scan
• Chamber enlargement
• Sodium/ Potassium congestion • Lipid profile • MRI
• Atrial fibrillation
• ECG • Pneumonia or other • Thyroid function test • PET
Note: If ST elevation present, manage as
• Chest X-ray PA view lung pathology • Iron profile • Myocardial biopsy
STEMI
• Electrophysiological study
COMMON DRUGS AND DOSAGE FOR CHF

FUROSEMIDE CARVEDILOL ENALAPRIL
• Dose 20-80 mg daily PO • Dose 3.125 to 25 mg twice daily PO • Dose 2.5 to 10 mg twice daily PO
• Intravenous 10-40 mg SOS in acute stage • Start after decongestion with low dose • Start with low dose with BP >100
• Change to oral when symptoms subside with BP > 100 mmHg and HR >60/ min mmHg, normal electrolyte and
• Monitor serum electrolytes, creatinine and uric acid • Uptitrate dose 1-2 weekly till maximum creatinine less than 2.5 mg/dl
on therapy tolerable dose • Uptitrate dose 1-2 weekly till maximum
• Keep watch on BP, heart rate and tolerable dose
SPIRONOLACTONE recipitation of CHF symptoms • Keep watch on BP and electrolytes
• Dose 25-50 mg once daily PO • Increase diuretics and reduce carvedilol before every increment and on
• Keep watch on serum potassium and creatinine to manage reappearance of CHF follow-up
every 2-4 weekly

PCI: Percutaneous Coronary Intervention HFrEF: Heart Failure with reduced Ejection Fraction
ABBREVIATIONS CABG: Coronary Artery Bypass Graft HFpEF: Heart Failure with preserved Ejection Fraction
ICD: Implantable Cardioverter defibrillator CVD: Cardiovascular Diseases STEMI: ST elevation Myocardial Infarction
BiV: Bi-Ventricular Pacing RHD: Rheumatic Heart Disease LV: Left Ventricle
PND: Paroxysmal Nocturnal Dyspnea CAD: Coronary Artery Disease COPD: Chronic Obstructive Pulmonary Disease
REFERENCES
1. Management Protocols for Chronic Heart Failure in India. Mishra S, Mohan JC, Nair T et al. Indian Heart J.2018;70:105-127,
2. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC).
Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Ponikowski P, Voors AA. Anker SD et al. European Heart Journal. 2016;37:2129–2200
3. Chronic heart failure in adults: diagnosis and management. NICE guideline [NG106] Published date: September 2018
4. 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Yancy CW, Jessup M,
Bozkurt B. J Am Coll Cardiol. 2013;62-16: e150-e210
October/ 2019


STABLE ANGINA
ICD-10-I20.9
PATIENT PRESENTING CONSIDER ANGINA IF
WITH CHEST PAIN • Diffuse retrosternal pain, ACUTE CORONARY SYNDROME
heaviness or constriction, • Angina at rest or lasting more than 20 minutes
radiating to arms or neck • Recent worsening of stable angina (crescendo) to
or back CCS class III
CATEGORIZE ANGINA
• Associated with sweating • New onset effort angina of less than 1 month in
• Easily reproduced with CCS class II/ III
post-meal exertion • Post infarction angina
• Consider atypical
presentation: Exertional For management: refer to STEMI/ NSTEMI STW
fatigue or breathlessness
or profuse sweating or
epigastric discomfort
Likelihood more if known

patient of CAD STABLE ANGINA
Any effort related pain fitting in previous category,
relieved by rest or NTG in 1-2 min
ANGINA UNLIKELY IF
• Variable location or
characteristic
• Long lasting (hours to days)
or short lasting (less than a STABLE ANGINA: GENERAL MANAGEMENT
minute)
• Restricted to areas above jaw 1. Manage factors potentaiting angina
or below epigastrium - Anemia, Thyrotoxicosis, Pregnancy, febrille illness
• Localized to a point - Hypertension, Ventricular hypertrophy, CHF
• Pricking or piercing or - Tachy or brady-arrhythmia
stabbing type of pain - Drugs : bronchodilators, steroids
• Precipitated by movement of 2. Risk factor control
neck or arms or respiration 3. Other atherosclerotic CV disease : PVD, stroke
4. Secondary prevention : Statins, BB, ACE-I
INVESTIGATIONS
ESSENTIAL INVESTIGATIONS DESIRABLE INVESTIGATIONS OPTIONAL INVESTIGATIONS
1. Hemogram 1. Echocardiography 1. Stress radionuclide/ echocardiographic imaging

2. Urea, Creatinine, Electrolytes 2. Exercise Treadmill Test 2. CT scan including multi-slice coronary angiography
3. Sugar, HbA1C 3. Thyroid Function Test 3. Coronary Angiography
4. Lipids 4. Iron profile 4. Coronary Fractional Flow Reserve
5. Liver function test 5. Uric acid 5. Intra-vascular Ultrasound/ OCT
6. ECG
7. Plain X-ray chest
MANAGEMENT
MANAGEMENT AT PHC/ CHC MANAGEMENT AT DISTRICT HOSPITAL LEVEL MANAGEMENT AT TERTIARY LEVEL
LEVEL
1. Optimise anti-anginal treatment 1. Reassess and optimise drug therapy: If
1. Control angina : 2. Echocardiography for LV function or structural heart uncontrolled choose from trimetazidine,
Metoprolol disease nicorandil ranolazine and ivabid
Add nitrates if symptoms 3. Risk stratify by exercise treadmill test in low, intermediate 2. Risk stratify with exercise treadmill test if not
not controlled or high risk (DUKE risk score) for cardio-vascular events , if already done
2. ECG for Q waves, ST - T patient is ambulatory and ECG is interpretable 3. Stress imaging if following:
changes, BBB or chamber 4. Refer to tertiary centres if: • Non ambulatory patient
enlargement • Angina uncontrolled on optimal medical therapy • Abnormal or uninterpretable baseline
3. Aspirin & high intensity • Echo reveals abnormality ECG
statins • Non-ambulatory patient or un-interpretable ECG • Exercise treadmill test result is
4. Refer to higher centre • High risk on exercise stress test for possible equivocal
electively re-vascularization • Compromised LV function
RISK CATEGORIZATION A. Very high: B. High Risk:

-GRACE score > 140 or TIMI score >4
-Acute LVF
-Hypotension C. Intermediate Risk:
Based on clinical features, -GRACE score 109-140 or TIMI score 2-3
-Uncontrolled Ventricular arrhythmia D. Low Risk:
GRACE score & TIMI score -Severe MR -Grace score <108 or TIMI score 0-1
RISK CATEGORY MANAGEMENT

REVASCULARIZATION
1. Revascularize if anatomy is suitable
Low/ Intermediate Risk High Risk Group 2. Prefer CABG over PCI in DM with
Group 1. Discuss pros and cons of possible multivessel disease or left main disease
1. Optimal anti-anginal therapy revascularization and dual anti-platelet therapy 3. Complete re-vascularization is preferable
2. Follow up 3-6 monthly at 2. Angiography, if any of following 4. Use invasive functional and imaging
primary/ secondary care - Angina not controlled on optimal medical modalities (FFR, IVUS, OCT) when
centre therapy indicated
3. Refer to tertiary centre when - High risk on non-invasive testing 5. Stress on continuing dual anti-platelets
change in symptomatic status - Cardiac arrest survivor or documented VT (aspirin and clopidogrel) after PCI
DRUGS & DOSAGE

Anti-platelets Anti-ischemic:
1. Aspirin 75 mg OD 1. Metoprolol:
2. Clopidogrel 75 mg OD (if intolerant to aspirin) Short acting: 25-100 mg BD
Long acting: 25 -100 mg OD
Statins: 2. Nitrates:
Atorvastatin: 40-80 mg OD Isosorbide mono-nitare: 20 to 60 mg in 2 devided dose
Rosuvastatin: 20-40 mg OD Nitroglycerine sustained release: 2.6 to 6.5 mg BD
3. Calcium channel blockers:
Ace-inhibitor Verapamil 40-80 mg TDS
Ramipril: 2.5-10 mg OD Diltiazem 30 to 90 mg TDS
Enalapril: 2.5-10 mg BD 4. Nicorandil: 5-10 mg BD
5. Ranolazine: 500 -1000 mg BD
6. Trimetazidine: 20 mg mg TDS
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES : STRENGTHEN SECONDARY PREVENTION WITH STATINS, BB & ACE-I
October/ 2019


ST ELEVATION MYOCARDIAL INFARCTION (STEMI)
ICD-10-I21.3
CONSIDER ANGINA IF ACUTE CORONARY SYNDROME:
• Diffuse retrosternal pain, heaviness or
constriction 1. Angina at rest or lasting more than 20 minutes
• Radiation to arms or neck or back 2. Recent worsening of stable angina (crescendo) to CCS
• Associated with sweating class III
• Easily reproduced with post-meal exertion
• Consider atypical presentation: Exertional 3. New onset effort angina of less than 1 month in CCS class II/
fatigue or breathlessness or profuse III
sweating or epigastric discomfort/ syncope 4. Post infarction angina
More likelihood if known patient of CAD/ ECG: If ST Elevation: Follow ST Elevation MI (STEMI) protocol
multiple risk factors If no ST Elavation: UA/NSTEMI
ANGINA UNLIKELY IF:

Variable Long lasting (hours to Restricted to areas Localized Pricking or piercing Precipitated by movement
location or days) or short lasting above jaw or to a point or stabbing type of of neck or arms or
characteristic (less than a minute) below epigatrium pain respiration
PATIENT WITH STEMI WITHIN 12 HOURS

ECG REVEALS ST ELEVATION MI* GENERAL MEASURES
Refer to primary angioplasty/ 1. Admit in ICU equipped with continuous ECG monitoring & defibrillation
thrombolysis capable hospital 2. Routine bio-chemistry and serial cardiac enzymes (troponin)
3. Pain relief by opioid
4. O2 if saturation less than 90%
*Includes new onset LBBB 5. Aspirin 325 mg, Clopidogrel 300 mg and Atorvastatin 80 mg
6. Echocardiography, particularly for mechanical complication
PCI CAPABLE HOSPITAL PCI INCAPABLE CENTRE

A. Tranfer to PCI capable hospital if PCI can be performed within 120 min
1. Proceed for PCI
2. Radial route preferred B. If Transfer to PCI capable hospital not feasible
3. Preferably within 90 minutes THROMBOLYSE
1. Within 12 hours of symptom onset, if no contra-indication
DURING PROCEDURE 2. Preferably with fibrin specific agent Tenecteplase/ TPA/ Reteplase or Streptokinase,
if fibrin-specific are unavailable
1. Use unfractionated heparin 3. Therapy to be started within 10 min preferably
2. No routine thrombosuction
3. Tackle culprit artery only unless shock
POST THROMBOLYSIS
1. ECG to be done at 60-90 min after starting thrombolysis to assess whether thrombolysis
4. DES to be preferred
is successful ( >50% ST settlement with pain relief) or not
2. If successful, transfer patient for PCI within 3-24 hours
POST PROCEDURE
3. If thrombolysis failed, transfer patient immediately for PCI capable hospital
4. Enoxaparin (preferred over unfractionated heparin) to be continued till PCI OR discharge
1. Continue dual antiplatelets for at least 1 year
LOOK FOR OTHER Unequal or absent peripheral pulses Dissection of Aorta

CAUSES OF CHEST
Respiratory evaluation Pleuritis/ Pneumonitis/ embolism/ pneumothorax
PAIN (ONGOING OR
WITHIN 12 HRS) Pericardial rub
Neuralgia or herpes
PATIENT WITH STEMI IN 12-24 HOURS
Transfer to PCI capable hospital immediately If ongoing pain, thrombolysis and transfer immediately
PATIENT WITH STEMI AFTER 24 HOURS

Angiography with a view to PCI only if any of following/ Contra indications of angiography:
Recurrent anginal Mecahnical Dynamic ST-T Life threatening

pain not controlled Cardiogenic shock Acute LVF ventricular
complication changes
by medical therapy arrhythmias
ABSOLUTE CONTRA-INDICATIONS TO THROMBOLYIC THERAPY:

Previous intra-
Ischemic stroke Recent (within 1 Recent (within 1 Known bleeding Severe
cerebral CNS neoplasm or Aortic dissection
in last 6 month) major month) major GI tendency (except uncontrolled
hemorrhage or stroke of AV malformation
months trauma/ surgey/ bleed menstrual bleed) hypertension
unknown
etiology head injury
DRUGS & DOSAGE STEMI DIAGNOSIS*

Anti-platelets Anti thrombotics:
1. Aspirin: Loading dose 325 mg followed by 75 mg OD 1. Unfractionated heparin: Bolus of
2. Clopidogrel: Loading dose 300 mg followed 75 mg OD 60 U/Kg (maximum 5000 U)
EMS or non
3. Prasugrel: Loading dose 60 mg followed by 10 mg OD followed by 12 U/Kg hourly Primary-PCI primary-PCI
4. Ticagralor: Loading dose 180 mg followed by 90 mg BD infusion to maintain APTT at capable centre capable centre
Anti-ischemic: 50-70 sec
Metoprolol: 2. Enoxaparin: 1 mg/Kg SC 12 hrly
Short acting: 25-100 mg BD
Preferably
<60 mins PCI possible
<120 mins?
Long acting: 25 -100 mg OD Thrombolyic Therapy:
Tenecteplase
Immediate
Nitrates: transfer to
PCI centre
Isosorbide mono-nitare 20 to 60 mg in 2 divided dose 35 mg IV bolus if 60-70 Kg Primary PCI Yes No
Nitroglycerine sustained release 2.6 to 6.5 mg BD 40 mg IV bolus if 70-80 Kg Preferably
<90mins
Nitroglycerine IV 5-25 mcg/ min infusion 45 mg IV bolus if more than (<60 mins) in
early
Statins: 80 Kg Rescue PCI
presenters
High dose Atorvastatin 80 mg OD Reteplase Preferably

within
Ace-inhibitor 10 mg IV bolus, repeat after 30 30 mins
Ramipril 2.5 -10 mg OD min Immediately
Enalapril 2.5 -10mg BD Alteplase

Oxygen: 15 mg IV bolus followed by
If oxygen saturation below 90% 0.75 mg/Kg over 30 min upto No Successful Immediate
fibrinolysis fibrinolysis
Morphine: 50 Kg weight, then 0.5 mg/Kg Yes Immediate
transfer to
Titrated in a dose of 2-4 mg IV every 15 minutes over 60 min up to 35 mg PCI centre
Beta-blocker: Streptokinase Preferably

Oral beta-blocker if LVEF is less than 40% 1.5 million units IV over 60 min 3-24 hours
*The time point the diagnosis is
confirmed with patient history &
ECG ideally within 10mins from
Coronary the First Medical Contract (FMC).
angiography All delays are related to FMC.

October/ 2019


UNSTABLE ANGINA/ NSTEMI
ICD-10-I20.0
CONSIDER ANGINA IF ACUTE CORONARY SYNDROME:
• Diffuse retrosternal pain, heaviness or 1.Angina at rest or lasting more than 20 minutes
constriction. Radiation to arms or neck or back 2.Recent worsening of stable angina (crescendo) to
• Associated with sweating CCS class III
• Easily reproduced with post-meal exertion 3.New onset effort angina of less than 1 month in
• Consider atypical presentation: Exertional CCS class II/ III
fatigue or breathlessness or profuse sweating 4.Post infarction angina
or epigastric discomfort
ECG:
More likelihood if known patient of CAD/ multiple - If ST Elevation: Follow ST Elevation MI (STEMI)
risk factors STW
- If no ST Elavation: UA/NSTEMI
• Pain lasting for more than 20 minutes • Associated breathlessness, profuse sweating or syncope
• Recurrent or ongoing pain or rest pain • Hemodynamic instability
RED FLAG
SIGNS Refer as emergency to nearest Primary PCI/Thrombolysis capable centre
Rest pain beyond 24hrs or without above features may be referred early for further evaluation
LOOK FOR OTHER Dissection of aorta Respiratory Evaluation:

Pleuritis/ pneumonitis/ Pericardial Neuralgia or
CAUSES OF PROLONGED (unequal/ absent peripheral herpes
CHEST PAIN pulses) embolism/ pneumothorax rub
ANGINA UNLIKELY IF:

Variable Long lasting (hours to Restricted to areas Localized Pricking or piercing Precipitated by
location or days) or short lasting above jaw or to a point or stabbing type of movement of neck or
characteristic (less than a minute) below epigatrium pain arms or respiration
MANAGEMENT
PHC/ CHC LEVEL DISTRICT HOSPITAL TERTIARY CENTRE
1, ECG, Troponin. 1.Admit in ICU equipped with 1. Admit, reassess clinically and monitor in ICCU
2. Start ECG monitoring and 2. Continue aspirin and heparin
-Aspirin, Clopidogrel defibrillator 3. Load with clopidogrel or prasugrel or ticagralor if not already done
-Heparin/ LMWH 2.Troponin & bio-chemistry if 4. Optimal medical therapy to continue (BB, high dose atorvastatin, ACE-inhibitors,
-High dose atorvastatin not done intra-venous nitrates if ongoing pain, severe MR or LVF)
-Metoprolol 3.Serial ECG & 5. Detailed echocardiography
3. Risk stratify GRACE score or echocardiography 6. Low risk patients may undergo non-invasive risk stratification with exercise stress
TIMI score 4.Continue Aspirin, test, CT coronary angiography or stress imaging
- Refer High/ Intermediate risk Clopidogrel, Heparin & 7. Very high risk, high risk and intermediate risk patients may be subjected to
to Metoprolol coronary revascularization
PCI capable centre 5.Add nitrates if needed
- Refer Low risk for further 6.Management for different Revascularization:
evaluation to DH risk categories: 1. Discuss pros & cons of re-vascularization and prolonged dual anti-platelet therapy
4. Refer to PCI capable centre if: -Very high,High or 2. Revascularize if anatomy is suitable
- Acute LVF Intermediate risk 3. Prefer CABG over PCI in DM with multivessel disease or left main disease
- Hypotension or LVEF <40%: Refer for
- Systolic murmur revascularization Revascularization strategy:
- Arrythmia -Low risk patients: 1. Very High risk: Urgent re-vacsularization (within few hours) after loading preferably
Conservative management with Ticagrelor or prasugrel if PCI is planned
Life style modification 2. High risk patients: Early revascularization (within 24 hours)
Risk factor control 3. Intermeditae risk patients: Revascularization (within 72 hours)
Secondary prevention 4. Continue Dual anti-platelets in patients undergoing PCI for atleast 12 months in
DES and for 3 months in BMS
1. GRACE SCORE: 2. TIMI SCORE:
Killip Points SBP1 Heart rate Creatinine One point for each of following
Points Points Age. y Points
Class mm Hg Beats/ min Level, mg/ dL Points 1. Age >65 yrs
2. More than 3 risk factors
I 0 <80 58 <50 0 <30 0 0-0.39 1 3. Known CAD (>50% lesion)
II 20 80-99 53 50-69 3 30-39 8 0.40-0.79 4 4. Recurrence of angina in 24 hrs
III 39 100-119 43 70-89 9 40-49 25 0.80-1.19 7 5. Aspirin use within 7 days
IV 59 120-139 34 90-109 15 50-59 41 1.20-1.59 10 6. ST deviation >0.5 mV
140-159 24 110-149 24 60-69 58 1.60-1.99 13 7. Raised cardiac markerss
160-199 10 150-199 38 70-79 75 2.00-3.99 21
>200 0 >200 46 80-89 91 >4.0 28 Sum total = TIMI score of patient
>90 100
UNSTABLE ANGINA OR NSTEMI DIAGNOSIS

Other risk factors Points
Cardiac arrest at admission 39 Very high risk High risk Intermediate risk Low risk
ST-Segment Deviation 28 Clinical instability GRACE > 140, TIMI >4 GRACE 109-140, TIMI2-3 GRACE <109, TIMI <1
Elevated Cardiac Enzyme Levels 14
Immediate invasive Early invasive Delayed invasive Medical/ non-invasive
Sum Total= GRACE score of patient <2 h 2-24 h 25-72 h strategy
If at non-PCI-capable hospital Clinical instability. rise in
Very high risk: Immediate transfer to cTn, or ECG changes
INVESTIGATIONS PCI-capable hospital
High risk: same-day transfer
ESSENTIAL INVESTIGATIONS Intermediate risk: transfer for PCI withing 72 h Non-invasive
+
1. Hemogram Low risk: transfer if pursuing invasive Invasive evaluation ischaemic testing
2. Creatinine treatment
3. Sugar, HbA1C
UA/NSTEMI: RISK CATEGORIZATION: UA/NSTEMI: RISK CATEGORY MANAGEMENT:
4. Fasting lipids
6. ECG Based on clinical features, GRACE score & TIMI score A)Low risk:
7. Troponin T/ Troponin I A).Very high risk: 1.Conservative management: Aspirin, clopidogrel, BB
8. Plain X-ray chest -Acute LVF and statin
-Hypotension 2.TMT if ambulatory patient within a week to risk
DESIRABLE INVESTIGATIONS -Uncontrolled Ventricular arrhythmia stratify
1. Echocardiography -Severe MR 3.Refer low risk for re-vascularization if
2. Exercise Treadmill Test B. High Risk: -Recurrent pain
3. C reactive protein -GRACE score > 140 or TIMI score >4 -Hemodynamic deterioration
4. B-Natriuretic Peptide C. Intermediate Risk: -New ECG change
-GRACE score 109-140 or TIMI score 2-3
5. D dimer D. Low Risk: B. Intermediate/ Very High/ High risk: Re-vascularization
6. Bleeding and coagulation profile -Grace score <108 or TIMI score 0-1
7. Liver function test
8. Coronary Angiography DRUGS & DOSAGE
Anti-platelets Anti-ischemic:
OPTIONAL INVESTIGATIONS 1. Aspirin: Loading dose 325 mg followed by 75 mg OD 1. Metoprolol:
1. Stress Radionuclide/ 2. Clopidogrel: Loading dose 300 mg followed 75 mg OD Short acting 25-100 mg BD
echocardiographic 3. Prasugrel: Loading dose 60 mg followed by 10 mg OD Long acting 25 -100 mg OD
4. Ticagralor: Loading dose 180 mg followed by 90 mg BD 2. Nitrates:
imaging
Anti thrombotics: Isosorbide mono-nitare 20 to 60 mg in 2 devided
2. CT scan including 1. Enoxaparin: 1 mg/Kg SC 12 hrly dose
coronary angiography 2. Unfractionated heparin: Bolus of 60 U/Kg (maximum Nitroglycerine sustained release 2.6 to 6.5 mg BD
3. MRI 5000 U) followed by 12 U/Kg hourly infusion to Nitroglycerine IV 5-25 mcg/ min infusion
4. Coronary Fractional Flow maintain APTT at 50-70 sec Statins:
High dose Atorvastatin 80 mg OD
Reserve
Ace-inhibitor
5. Intra-vascular Ultrasound Ramipril 2.5 -10 mg OD
6. VQ scan Enalapril 2.5-10 mg BD
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURE

ENT
October/ 2019


ACUTE RHINOSINUSITIS
ICD 10 J01.90
RELATED CLINICAL SCENARIOS
Recurrent acute sinusitis is episodes of acute sinusitis interspersed

with symptom free intervals of more than 3 months in duration.
WHEN TO SUSPECT?
Symptoms with duration less than 7 days are treated as viral

Usually a sequela of viral upper respiratory infection.
infection which causes
ciliary impairment and
bacterial superinfection
Diagnosis- persistence of
nasal blockage/ nasal
discharge and facial pain/
hyposmia beyond 7 days Invasive fungal sinusitis is suspected if in addition to above symptoms
(maximum upto 3 months) the following are present: facial hyposthesia, facial skin/palatal/ turbinate
discoloration and proptosis/ diplopia/ reduced or loss of vision
Children may present with acute febrile illness/cough

associated with these symptoms.
ALTERNATIVE CLINICAL SCENARIOS

∙ Consider alternate diagnosis if: Unilateral symptoms/ Bleeding/ Crusting/ Cacosmia (foul smell)
∙ Rule out other contributory factors: Allergy/ upper alveolar dental caries/ DNS/ LPR/ smoking.
∙ Rhinorrhoea and nasal congestion in second trimester of pregnancy is considered hormonal in etiology and is to be managed with
saline irrigation/ drops
RED FLAGS FOR REFERRAL TO DISTRICT HOSPITAL
∙ Known diabetic/ immunocompromised

∙ Suspicion of complications viz. (A) Orbital involvement (Periorbital edema/ erythema, displaced globe,
ophthalmoplegia, visual disturbance); (B) Meningitis/ altered sensorium; (C) Frontal fullness.
∙ Non-resolution with oral antibiotics for ten days
∙ Pointers of invasive fungal sinusitis (Facial hypoesthesia, facial skin/palatal/turbinate discoloration)
CLINICAL EXAMINATION LABORATORY INVESTIGATIONS
PRELIMINARY Desirable in non-resolving/worsening cases despite antibiotic

therapy
∙ Anterior rhinoscopy: Discharge, bleeding, crusting, polyposis
∙ Oral examination: Dental caries, post nasal drip, palatal discolouration
∙ Assess for contributory factors listed above ∙ Endoscopy- for guided nasal swabs/ KOH smear
∙ CT PNS (for suspected complications / non-resolving cases on
antibiotics for 14 days)
DESIRABLE
∙ Screen for Diabetes / Immunodeficiency
∙ Nasal endoscopy
MANAGEMENT
PHC / PRIMARY LEVEL

Duration of treatment 7-14 days INDICATIONS OF PARENTERAL
ANTIBIOTIC THERAPY
∙ Oral antibiotics- Amoxycillin/ Co-amoxyclav for 7-10 days. Levofloxacin and Azithromycin can be
opted for patients intolerant/ sensitive to penicillins. ∙ Orbital/ intracranial
∙ Topical budesonide/ mometasone nasal spray once/twice a day for 2 weeks provides earlier complications
symptomatic relief. ∙ Non-resolution of symptoms
∙ Normal saline nasal washes help in clearing secretions and improved effect of topical with atleast 7 days of oral
medications antibiotics
∙ Topical/ oral decongestant (Oxymetazline/ pseudoephedrine) for 3-5 days relieves symptoms. ∙ Worsening of symptoms while
∙ Adequate hydration and steam inhation. on oral antibiotics
∙ Antihistaminics (patients with co-existing allergy).
DISTRICT HOSPITAL
TERTIARY LEVEL
• Surgical interventions to manage: Underlying anatomical conditions causing recurrent acute
Cases of acute invasive fungal sinusitis/
sinusitis like- DNS/ adenoid hypertrophy/ anatomical variations seen on CT
complicated acute bacterial sinusitis
• Ophthalmology referral for suspected intraorbital complications
and patients with
• Dental deferral for suspected dental origin infection.
immunocompromised status may be
• Invasive fungal sinusitis- start antifungal medications, control underlying
referred for management.
immunocompromising co-morbidity and consider debridement.
CT: Computerized Tomogram DNS: Deviated Nasal Septum

ABBREVIATIONS PHC: Primary Health Center LPR: Laryngo Pharyngeal Reflux
REFERENCES
1. Indian Council of Medical Research. Treatment Guidelines for Antimicrobial Use in Common Syndromes. New Delhi, India, 2017.
2. Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298.
3. Sharma V, Saxena RK, Sharma S, Sharma G, Dhasmana DC, Mishra KC. Comparative Efficacy and safety of various anti-microbials in patients of acute rhinosinusitis at tertiary-care hospital in Uttarakhand. Indian
Jour Otol Head & Neck Surg, 2011, Oct ; 63 (4): 364 - 9
4. Blomgren K, Eliander L, Hytönen M, Ylinen S, Laitio M, Virkkula P. How patients experience antral irrigation. Clin Med Insights Ear Nose Throat. 2015;8:13-7.
October/ 2019


CHRONIC RHINOSINUSITIS
ICD 10 - J32.9
EXAMINE THE NOSE FOR NASAL POLYPI

RULE OUT FOLLOWING TWO PHENOTYPES
PRECIPITATING/ • Chronic sinusitis with nasal polypi (CRSwNP)
EXACERBATING CONDITIONS • Chronic sinusitis without nasal polypi (CRSsNP)
• Occupational exposure
to irritants/ pollutants
(refer to hyperlink)
Signs of meningitis/
• Allergic rhinitis, aspirin
Frontal intracranial
sensitivity, asthma,
swelling complications
WHEN TO SUSPECT? laryngopharyngeal a. Fever with headache
If symptoms persist for reflux, smoking b. Neck stiffness
more than 12 weeks: • Adenoid hypertrophy, c. Photophobia
bottle feeding, passive d. Altered sensorium
nasal obstruction/ smoking in children e. Vomiting
nasal discharge and • Medications and Orbital symptoms
facial pain/ reduced RED a. Periorbital edema/ erythema
hormones associated
sense of smell FLAG b. Displaced globe
with nasal congestion
c. Double or reduced vision (loss of
(NSAIDS, green-red color differentiation may
antihypertensive, be the first sign)
psychotropic drugs, d. Ophthalmoplegia
prolonged use of Known diabetic/ AIDS/
topical nasal immunosuppressive
decongestants) medications (suspect
invasive fungal sinusitis)
TREATMENT OF CRS
IN ALL PATIENTS,
• Mild/ moderate symptoms (no significant congestion/ discharge/
polypi/complications) ESPECIALLY IN THE
1. Address etiology and exacerbating factors. PRESENCE OF NASAL
2. For allergic rhinitis, antihistamines and nasal steroid spray to be POLYPI, RULE OUT
given.
3. Saline nasal wash ALLERGY/ALLERGIC
4. Steam inhalation RHINITIS
5. Stretching exercises and yoga are very effective for nasal congestion 1. Consider allergen
6. Topical (oxymetazoline/ xylometazoline) and oral decongestants are avoidance
associated with cardiovascular risks and rebound phenomenon. 2. Skin prick test
Hence, careful patient selection and short course treatment to be 3. Co-existing bronchial
followed. asthma needs to be
7. Intra nasal steroid sprays for 6-8weeks (Fluticasone proprionate/ treated
Fluticasone furoate/ Mometasone) after discussing risk - benefit - 4. Consider AIT if indicated.
cost issues with patient regarding steroid sprays
If no symptomatic relief to above treatment, perform nasal endoscopy
and consider NCCT of paranasal sinuses
In presence of nasal purulent discharge

1. Culture directed antibiotics to be considered HYPERLINK
2. If culture is negative, empirical antibiotics (Amoxycillin/ (https://www.dovemed.c
Co-amoxyclav/ Fluoroquinolone/ Roxithromycin) to be given for at om/diseases-conditions/
least 2weeks. airborne-irritant-induce
3. Upper dental (particularly 1st molar) infection may cause maxillary d-sinusitis/)
sinusitis which is to be treated with metronidazole.
• In the presence of nasal polypi, initial nasal steroid spray and subsequent
endoscopic surgery is to be planned.
1. Short course of oral steroid (Prednisolone 0.5 mg/kg for 5 - 10 days)
provides temporary relief in nasal obstruction in extensive polypi.
2. Steroid therapy is not a replacement for surgery.
Always rule out Prolonged use of

Identification of Ensure adherence Educate patients topical nasal
DNS/ nasal polypi
1 precipitating or 2 in CRS, as surgical 3 to nasal saline
4 on correct 5 decongestant beyond
exacerbating washes / regular technique of using 5-7 days may cause
treatment may be physical activity / steroid nasal sprays
factors is the key rebound congestion
necessary for medications. and nasal irrigation.
to successful and rhinitis
complete
treatment medicamentosa and to
resolution of
outcome. be strongly
symptoms.
discouraged.
ABBREVIATIONS
CT: Computerized Tomogram AIT: Allergen Immuno Therapy DNS: Deviated Nasal Septum
REFERENCES
• Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298.
• Cain RB, Lal D. Update on the management of chronic rhinosinusitis. Infect Drug Resist. 2013;6:1-14.
• Ah-See KL, MacKenzie JM, As-See KW. Management of chronicrhinosinusitis. BMJ. 2012;345:e7054.
• Slovick A, Long J, Hopkins C: Updates in the management of chronic rhinosinusitis. Clin Pract. 2014;11(6):649–63. 10.2217/cpr.14.71
October/ 2019


EPISTAXIS
ICD-10-R04.0
Acute bleeding from the ESSENTIAL CLINICAL EXAMINATION

nose after physical
trauma/ barotrauma/ nose
picking/ physical exertion.
ESSENTIAL
• Local examination by anterior rhinoscopy/ endoscopy to look for

source of bleeding (scanty/moderate).
Acute bleeding from the
CLINICAL • Little’s area bleeder/clot/congestion
nose in hypertensive /
SCENARIOS • Sharp septal spur
hematological disorders.
• Congested nasal mucosa as in URTI
• General physical examination to evaluate other systems
(Cardiovascular/Lower Respiratory/Neurological) clinically.
Acute bleeding from the SYSTEMIC ASSESSMENT

nose without any obvious
cause. Screen for coagulation disorders/ anticoagulant medications/
hematological malignancies
MANAGEMENT
STEP-WISE MANAGEMENT PRINCIPLE Trotter’s

Position
1. Ensure patent airway/ avoid aspiration by head down/lateral positioning
2. Restore hemodynamic stability by intravenous fluid replacement/ transfusion
3. Control bleeding/bleeder by
• Bidigital compression of nose for 10 minutes in Trotter’s position (cotton pledgets soaked
in 4% xylocaine with adrenaline may be used)
• Short term tab labetalol will take care of uncontrolled hypertension
• Chemical/electrocauterization of bleeder in Little’s area
4. Tamponade of bleeders by anterior nasal packing/ epistaxis balloon
5. Posterior nasal packing if bleeding is not controlled with above measures
6. Antibiotic prophylaxis and hospitalizarion is recommended after nasal packing
7. H2blockers/ PPI to be given in case of blood aspiration to avoid gastritis
8. Persisting bleeding despite nasal packing > consider arterial ligation (sphenopalatine /
anterior ethmoidal artery).
9. Selective embolization is an alternative to surgery
10. Address identified etiology, if any
INVESTIGATIONS
Features suggestive of
neoplasia
ESSENTIAL
. Unilateral bleeding
. Nasal obstruction
1. Hemoglobin level .Visual/orbital symptoms
2. Coagulation profile Altered blood counts/ coagulation
. Obvious mass lesion
profile
3. Complete blood count
Persistent bleeding despite
nasal packing Recurrent profuse bleeding
- Consider JNA in teenage boys
DESIRABLE - Aneurysmal bleeding (specially
following trauma) to be ruled out
by DSA
CT scan with contrast in cases with no
- To be managed by appropriate
obvious cause// suspected benign or treatment at tertiary level
malignant lesion
RED FLAG SIGNS
FOLLOW UP SERVICES QUALITY ASSESSMENT PARAMETERS
1. Continued nasal lubrication for 2 weeks with liquid 1. Recurrence of episodes

paraffin 2. Improvement in hemoglobin level over a period of
2. Repeat anterior rhinoscopy/ endoscopy to time.
know/confim the cause of bleeding
3. Oral hematinics to be considered if needed
POINTS TO PONDER WHILE MANAGING EPISTAXIS
1. Epistaxis in children is almost always anterior and from Little’s area, consequent to mucosal drying by dry air.
2. Epistaxis in adults is often related to hypertension and arises posteriorly from the posterior end of inferior turbinate
3. Initial non-invasive methods may suffice in a large majority of patients.
ABBREVIATIONS
JNA: Juvenile Nasopharyngeal Angiofibroma CT: Computerized Tomograms
DSA: Digital Subtraction Angiography URTI: Upper Respiratory Tract Infection
October/ 2019

Standard Treatment Workflow (STW) for the

Management of HEARING IMPAIRMENT IN
PEDIATRIC AGE GROUP (0 - 12 YEARS)
ICD 10 H90.5
Disabling hearing impairment (31 or more dB HL in better ear) may affect language development and learning outcomes and
hence needs urgent intervention
WHEN TO SUSPECT IN CHILDREN

UNIVERSAL HEARING SCREENING FOR
1. Parental concern about delayed speech, language, and CONGENITAL DEAFNESS
developmental delay (refer to red flags) • Community based hearing screening:
2. Family history of Hearing Loss (HL). i. May be co-ordinated with
3. Exposure to ototoxic drugs/ hyperbilirubinemia requiring immunization schedule
exchange transfusion/ Neonatal ICU stay for > 3days. ii. By primary health care workers.
4. In-utero infections (CMV/ rubella/ syphilis/ herpes/ iii. Using calibrated noisemakers/
toxoplasmosis) toys
5. Syndromes (NF) Or neurodegenerative disorders (Hunter
syndrome, FA) associated with HL. • All children who fail preliminary
6. Post-natal infection known to cause HL (Meningitis) screen to undergo detailed evaluation
7. Head Trauma at health care facility.
8. Recurrent/ persistent (>/=3 months) middle ear disease
9. Chemo/ Radiotherapy to head and neck
EVALUATION COMMON CAUSES OF HL

ESSENTIAL
1. Impacted wax
1. Clinical examination to look for ear canal deformities, tympanic membrane and 2. Middle ear fluid assciated with
middle ear status by otoscopy/ otoendoscopy. adenoid hypertrophy/ cold climate
2. Age appropriate audiological/ behavioral observation tests in a soundproof room by 3. Tympanic membrane perforation
audiologist/ ENT specialist. 4. Sensorineural Hearing loss (SNHL) due
3. Tympanic membrane mobility test/ tympanometry. to various causes as indicated earlier
RED FLAGS POINTING FOR URGENT HEARING EVALUATION
- 6months- no head turning to the side of calling

- 1yr- no babbling/ speech like sound production
- 1.5yrs- not saying mama/papa/dada or other names
- 2yrs-not pointing to pictures/ body parts when named or speaking less than 10 words
- 3 yrs- does not understand action words or not asking for things by names or not speaking small sentences.
- At any age- has regressed or lost previously acquired speech/ language milestones
MANAGEMENT
GUIDING PRINCIPLES
CONDUCTIVE HL SNHL
Middle ear fluid (OME) may be
Wax removal under direct associated with adenotonsillar disease Appropriate
vision by ENT specialist which needs to be treated. Initially amplification,
relieves hearing impairement medical treatment and surgery to be preferential seating in Screening for
considered for OME persisting for more classroom developmental
Appropriate surgery is to than 3months/ earlier in the presence of delay by
be planned for tympanic speech and language delay pediatrician/
membrane perforation Periodic evaluation psychologist
For non-surgical condidates/ delayed for hearing aid users
surgical management, amplification for mould fitting
by hearing aid to be reinforced in and amplification
bilateral CHL. settings
DIVISION OF RESPONSIBILITIES
PHC LEVEL DH LEVEL
1. Audiometric evaluation by Audiologist/ Otolaryngologist

• Suspect HL 2. Hearing aid dispensing (mould fitting and HA programming)
• Initial evaluation 3. Rehabilitation by speech therapist
• Referral if initial evaluation is suggestive of HL 4. Appropriate surgery for CHL
• Follow up of rehabilitated/ treated patients with HL 5. Training programme for parents of hearing impaired children
• Prevention of HL to enhance pre-school language development
QUALITY ASSESSMENT PARAMETERS

TERTIARY LEVEL
• Short term: Quality of amplification using
• Surgical intervention options : Cochlear implant / BAHA (as per ADIP electroacoustic objective measures and culturally
guidelines) appropriate subjective questionnaire tools
• Interdisciplinary team based interventions in children with multiple • Long term (Desirable) : Use CBR matrix based
disabilities. measurement for ensuring holistic rehabilitation
FOLLOW UP SERVICES
1. Home visits by Health Worker/ASHA to ensure utilization of assistive devices and support parents to enhance language development.
2. School visits to educate teachers and normally hearing children to include their peers with hearing disability in the school environment
3. Home/ school visit by social worker for evaluation of social/ educational/ livelihood/ justice and empowerment domains of the child
ADIP : Assistance to disabled BAHA : Bone Anchored Hearing Aid FA : Friedreich Ataxia
ABBREVIATIONS persons for purchase/ fitting of CBR : Community Based Rehabilitation NF : NeuroFibromatosis
aids and appliances CMV : Cyto Megalo Virus OME : Otitis Media with Effusion
REFERENCES
• Indian Council of Medical Research. Audiological evaluation protocols. Task force project on prevalence and etiology of hearing impairment, New Delhi. 2015
• Ramesh A, Jagdish C, Suman Rao PN et al. Low cost calibrated mechanical noisemaker for hearing screening in resource constrained settings. Indian Journal of Medical Research. 2012, 135: 170 - 176.
• Rathna.B.Shetty. Manual for training parents of hearing impaired children (Kannada : Kivudu makkalige kalisuva vidhana). Parents association of deaf children. Mysore.
• Chapal Mkhasnabis, Karen Heinicke Motsch (eds.) Towards community based inclusive development. World Health Organisation: 2010.
• Margaret Lavina Fernandes. Guidelines to establish a community based rehabilitation program for hearing impaired children in medically underserved areas. St. John’s Medical Journal, 2018 (1), 5 : 14 - 27
• ADIP Guidelines : http://disabilityaffairs.gov.in/content/page/adip-scheme.php
October/ 2019


NECK SPACE INFECTION
ICD-10-J36, J39.0, K 12.2, J39.1
Rapidly progressive bacterial infections which spread along facial planes and spaces of head and neck region. They may be fatal unless
emergently treated. Most of these infections are secondary to dental infection.
The typical presentation is with acute onset of pain and swelling in the neck with fever,
malaise, trismus and dysphagia.
Extension along spaces to involve multiple deep neck spaces is frequent and may
extend to parotid space, masticator space, temporal space, visceral vascular
CLINICAL SCENARIOS (carotid) space.
They usually present as

• Ludwig’s angina
(submandibular space infection)
• Peritonsillar abscess Cervical space infection may spread inferiorly to the anterior mediastinum and
• Parapharyngeal abscess posteriorly along prevertebral space.
• Retropharyngeal abscess
Tubercular cold abscess involves the same anatomical spaces but would not
display inflammatory signs or rapid progression.
SYSTEMIC ASSESSMENT
Screen for diabetes mellitus, HIV infection, agranulocytosis and immunosuppressive therapy or chemotherapy.
Signs of inflammation may be less marked and disease course may be more rapidly progressive in immunocompromised patients.
CLINICAL EXAMINATION
• Airway assessment to rule out stridor or respiratory compromise

RED FLAGS FOR REFERRAL TO DISTRICT HOSPITAL
• Look for signs of dehydration
• Monitor temperature, heart rate, respiratory rate, BP, and signs
• Breathing difficulty
of sepsis/ septic shock.
• Trismus
• Oral cavity examination to check jaw opening, condition of teeth
• Torticollis/ neck stiffness
and floor of mouth
• Subcutaneous crepitus and skin discolouration
• Oropharyngeal examination to check for inflammed medially
or blisters suggest necrotizing fibrofascitis.
displaced tonsil & uvula and bulge in lateral pharyngeal wall
• Toxaemia
• Palpation of neck for lymph nodes, cellulitis, abscess or
• Lower cranial nerve palsy
subcutaneous crepitus
• Facial puffiness suggestive of venous
• Cranial nerve examination to rule out lower cranial nerve palsies
thrombosis
• Mediastinal extension
INVESTIGATIONS
ESSENTIAL INVESTIGATIONS
1. Contrast enhanced CT scan of head and neck is the standard in evaluation of neck space infections. If CT Scan facility is not available, following
should be done:-
a. Lateral x-ray neck: Prevertebral soft tissue thickening >7 mm at the level of C2 or > 2/3rd of the width of the vertebral body at C6 is highly
suggestive of retropharyngeal abscess. It may also demonstrate foreign bodies, subcutaneous air, air fluid levels and erosion of vertebrae.
b. Ultrasound neck can suggest abscess and guide aspiration attempts.
2. Blood: Total and differential leukocyte count, blood sugar, urea
3. Abscess Cultures with Gram stain to direct antimicrobial therapy. Anaerobic culture, when available.
MANAGEMENT
PHC/PRIMARY LEVEL DISTRICT HOSPITAL

INDICATIONS FOR I&D
1. Cautiously assess the 1. Hospitalization: As an emergency for close watch and intensive
airway. If found management. • Necrotizing fibrofascitis
compromised, do 2. Airway management: In progressive disease, in view of impending • Abscess formation
endotracheal intubation/ airway compromise, consider securing the airway early. During acute • No response to antibiotics over
consider tracheotomy respiratory difficulty, tracheostomy should be done if intubation is 48-72 hours
2. Immediately gain an IV difficult • Deterioration despite antibiotics
access for hydration, broad 3. Correction of fluid and electrolyte imbalance over 24 hours
spectrum antibiotics and 4. Antibiotics: Early and aggressive IV antibiotic therapy with a • Airway compromise or impending
pain killers. combination of Crystalline Penicillin, Aminoglycoside and airway compromise
3. Transfer the patient to Metronidazole or Clindamycin is preferred. • Mediastinal spread
hospital with facility for 5. Incision and drainage: Peritonsillar abscess is drained intraorally. All • Vascular complication like venous
surgical drainage other abscesses are drained via an external approach thrombosis
QUALITY ASSESSMENT PARAMETERS FOLLOW UP SERVICES
Complete resolution of infection and follow up to ensure no recurrence; Consider cold tonsillectomy for patients with history of multiple
treatment of initial cause of infection in tooth or tonsil. episodes of tonsillar abscess
ABBREVIATIONS
CT – Computerized Tomography MRI – Magnetic Resonance Imaging
REFERENCES
1. Smith II JL, Hsu JM, Chang J (2006) Predicting deep neck space abscess using computed tomography. Am J Otolaryngol 27: 244-247.
2. Mayor GP, Millán JMS, Martínez VA (2001) Is conservative treatment of deep neck space infections appropriate? Head And Neck 23: 126-133.
3. Bottin R, Marioni G, Rinaldi R, Boninsegna M, Salvadori L, et al. (2003) Deep neck infection: A present day complication. A retrospective review of 83 cases. Eur Arch Otorhinolaryngol 260: 576-579.
October/ 2019


OTORRHOEA
ICD-10-H92.10
CLINICAL SCENARIOS
DISEASES OF EXTERNAL EAR
• Serous/purulent discharge with significant tenderness of external ear

amidst edema (localized-pus: furunculosis or generalized: Acute otitis
Fig 1
externa denoting Staph/ Pseudomonas infection)
Fig 2 • Thick discharge with itching usually in hot/ humid climate:

Otomycosis (Candida- white spores; Aspergillus- black spores) [Fig 2]
• Scanty serous discharge & itching with desquamated debris in ear

canal Eczematous otitis externa (EAC)
Fig 3
FIGURES
Fig 4A
DISEASES OF MIDDLE EAR
1: Furunculosis
2: Otomycosis
• URI with severe ear pain (manifested in children as inconsolable
3: Resolving AOM
crying and ear tugging), relieved with episode of mucopurulent blood
4A: Safe CSOM (central perforation)
Fig 4B stained otorrhoea: Resolving AOM [Fig 3]
4B: Safe CSOM (subtotal
perforation)
• Mucopurulent discharge > 12 weeks : CSOM
5A: Unsafe CSOM (cholesteatoma)
• Active : otorrohoea in last 12 weeks
5B: Unsafe CSOM (granulation)
• Inactive : no otorrohoea in last 12 weeks
6: Traumatic Perforation
• Safe type : central perforation [Fig 4A] and total perforation [Fig 4B]
• Unsafe type : cholesteatoma [Fig 5A] and granulation [Fig 5B]
Fig 5A • Recurrent painless profuse mucopurulent discharge with pale

granulations/ multiple perforations unresponsive to antibiotics:
Tubercular otitis media should be suspected and needs biopsy
confirmation
Fig 5B
• Bloody otorrhoea following Trauma: Traumatic perforation
Fig 6 • Acute onset bloody discharge with neural deficits/ neck nodes:
Neoplasia
• Watery otorrhoea (may be associated with trauma) : CSF Otorrhoea
CLINICAL EXAMINATIONS INVESTIGATIONS RED FLAGS FOR REFERRAL TO DISTRICT LEVEL
• Otoscopy as a part of Complete • Pure tone audiometry • Periaural abscess or cellulitis

ENT examination by primary • Routine hemogram including blood • High grade fever, dizziness and toxic appearance
physician (Tele-otoscopy sugar (fasting and postprandial) • Severe headache with neck stiffness/ vomiting /
interpreted by physician) • CT/ MRI in suspected complications altered sensorium.
• Hearing evaluation by (refer to red flags) • Facial palsy/ Neurological defecits
conversation/ whisper/ Tuning • Soft tissue x ray nasopharynx (To • Diabetic with severe deep seated ear pain / neural
forks tests examine adenoid enlargement in defecits (Skull base osteomyelitis)
• General and systemic clinical children) • Physical trauma with bloody/ watery discharge
• Culture & sensitivity of aural secretions. (suspected CSF leak)
examination
• Suspected tuberculosis/ neoplasm
MANAGEMENT
PHC / PRIMARY LEVEL DISTRICT HOSPITAL
• Acute otitis externa: Oral Ciprofloxacin/ Amoxycillin clavulanic acid combination for 7-10 days (2 weeks • Surgical interventions except
maximum) and analgesics. Ichthammol gycerine (1:9) packing of EAC in moderate to severe edema. Refer neurosurgical interventions (eg I&D,
pus pointing furuncle to DH tympanoplasty, mastoidectomy)
• Otomycosis: Cleaning and Clotrimazole ear drops • Biopsy in suspected neoplasm
• Eczematous otitis externa: Ciprofloxacin ear drops with steroid combination. • Medical management of medical
• AOM / Resolving AOM: Oral amoxicillin / Erythromycin / Clarithromycin for 10 days. With no response in 3 co-morbidities such as diabetes,
days start Amoxycillin clavulanic acid combination for 10 days. Refer to DH if no resolution tuberculosis, meningismus/
• Inactive CSOM: Referral to DH for surgery. meningitis
• Active CSOM: Ciprofloxacin ear drops with dry mopping & referral to DH for surgery. A course of oral
antibiotics maybe prescribed in ase of persistant otorrhoea after topical antibiotics TERTIARY LEVEL
• Traumatic perforation: Topical antibiotics for otorrhoea if any and maintain ear dry till healing complete Surgical management particularly
• In case of suspicion of complications start intravenous Amoxycillin clavulanic acid combination and refer to of intracranial complications
DH including neurosurgical
interventions
• Patient to be educated for proper technique of ear mopping, contralateral lie (10 min) following instillation of drops & avoiding water
entry e.g ear-plugs during bathing
• To ensure adequate immunization (measles/ H.Influenza/ Pneumococcus) in recurrent AOM and to adopt correct posture during
breastfeeding while avoiding bottle feeding
• Pus culture sensitivity to guide antibiotic regime in recurrent/ complicated cases
Patient education to refrain from indigenous (oil/ hot water/ acid etc) ear treatments

CT: Computerized Tomogram AOM: Acute Otitis Media EAC: External Auditory Canal
ABBREVIATIONS CSOM: Chronic Suppurative Otitis Media URI: Upper Respiratory Infection
MRI: Magnetic Resonance Imaging
REFERENCES
• Otitis media (acute): antimicrobial prescribing. NICE guideline. Published: 28 March 2018. nice.org.uk/guidance/ng91
• Primary ear and hearing care training resource, Student’s workbook: intermediate level. Chronic disease prevention and management. WHO 2006
• Primary ear and hearing care training resource, advanced level. Chronic disease prevention and management. WHO 2006
• Treatment Guidelines for antimicrobial use in common syndromes. ICMR. Department of Health Research. 2017
• Sagar P, Thakar A, Samant S. Otorhinolaryngology. In Paul VK, Bagga A. eds. Ghai Essential Pediatrics, 9th ed. New Delhi: CBS Publishers & Distributors; 2019. p.357-370
October/ 2019


PHARYNGITIS AND SORE THROAT
ICD-10-J02
Acute onset of throat pain with or without – Fever, tonsillo-pharyngeal exudates, odynophagia
and tender cervical lymphadenopathy is typically seen in bacterial pharyngitis.
Streptococcal (GABHS) pharyngitis is the commonest cause of bacterial pharyngitis
Rhinitis, conjunctivitis, skin or mucosal rashes point towards a viral etiology.

Pharyngitis and sore throat may be the initial symptoms in epidemics of flu
CLINICAL SCENARIOS
Acute pharyngitis Sore throat followed by high grade fever, cough, drooling, lymphadenopathy,
may include a breathing difficulty suggest Epiglottitis or Laryngotracheobronchitis,
spectrum of disease especially in pediatric patients
varying from simple
viral pharyngitis to
dreaded neck space
infection. An adherent membrane extending beyond the tonsillar confines with
toxaemia suggests Diphtheria
Pharyngitis with generalized lymphadenopathy is consistent with Infectious

Mononucleosis(IM)
Smoking and GERD are common causes of non-infective pharyngitis
CLINICAL EXAMINATION
PRELIMINARY
• Temperature chart: fever is usually absent or low-grade in viral pharyngitis DESIRABLE RED FLAGS
• Check for vitals/ signs of dehydration due to compromised oral intake due to odynophagia
Assess • Generalized
• Complete oral and oropharyngeal examination with tongue depressor
Centor lymphadenopathy
• Palpate for cervical and generalized lymphadenopathy • Cardiac murmurs
• Rheumatic fever and acute glomerulonephritis are potential systemic complications of criteria
and • Purulent
streptococcal pharyngitis productive cough
• Hepatosplenomegaly can be found in IM ascertain
with tachypnea
• A sandpapery scarlatiniform rash may be seen in GABHS infection whereas maculopapular its suggestive of LRTI
rashes are seen with various viral infections and with IM empirically treated with penicillin score • Hot potato voice
• Unilateral tonsillar
enlargement
CENTOR UNLIKELY TO HAVE LIKELY TO HAVE REQUIRE LAB TESTS TO • Tonsillar
CLINICAL FEATURES membrane going
SCORE GABHS GABHS CONFIRM GABHS INFECTION
beyond its
Fever 1 confines
Anterior cervical • Agranulocyosis
1 • Epidemic of flu
lymphadenopathy Score = 0-1 Score = 4 Score = 2-3
Tonsillar exudate 1
Absence of cough 1
INVESTIGATIONS
ESSENTIAL OPTIONAL DESIRABLE
Throat swab for culture, routine hemogram including GABHS rapid antigen detection test (RADT) Lab tests to rule out EB Virus, Coxsackie virus,
total and differential leukocyte counts and peripheral Herpes virus, fungal or Gonococcal pharyngitis
smear to look for atypical lymphocytes (seen in IM).
MANAGEMENT
PHC / PRIMARY LEVEL DISTRICT HOSPITAL
1. Assess the patient for signs of toxicity, epiglottitis or oropharyngeal abscess

2. Ensure vitals/ hydration of the patient
3. Saltwater gargle, warm liquids, and rest may be helpful in relieving symptoms Management of
4. Ibuprofen or Paracetamol is recommended for analgesia complication
5. Antibiotic therapy: e.g.
a. Patients positive for all 4 Centor criteria to be treated with antibiotics without waiting for antigen testing or cultures • Deep neck
b. Patients with Centor score of 2&3 to be treated with antibiotics only if antigen testing or throat swab culture is positive space infection
c. Patients with Centor score of only 1 not to be treated with antibiotics • Diphtheria
d. Amoxicillin (50 mg/kg/d in 2-3 doses orally) for 10 days is the first choice for GABHS infection. For patients who are • Epiglottitis
sensitive for penicillin group, Erythromycin or Azithromycin is the antibiotic of choice • Croup
6. Parenteral antibiotics (Ceftriaxone/ cefotaxime) and steroids are to be started when the airway is compromised due to suspected
epiglottis/ Croup.
FOLLOW UP SERVICES
Recurrent (more than 7 episodes in previuos year or 5/year in last two years or 3/year in last 3 years) tonsillitis episodes need to be evaluated for
tonsillectomy.

GABHS: Group A Beta Hemolyticus Streptococcus EB: Epstein Barr
ABBREVIATIONS GERD: Gastro Esophageal Reflux Disease RADT: Rapid Antigen Detection Test
LRTI: Lower Respiratory Tract Infection
REFERENCES
Cochrane Database Syst Rev. 21. CD004872.

NEPHROLOGY
October/ 2019


ACUTE KIDNEY INJURY
ICD-10-N17.9
SYMPTOMS PRELIMINARY ACTIONS

• Reduced urine output • Monitor urine volume & body weight
• Dark, concentrated urine • Identify and treat life-threatening complications
• Correct hydration status
• Swelling over feet/face
• Stop nephrotoxic drugs
• Breathlessness • Exclude urinary outlet obstruction
• Stabilize blood pressure
• Treat infection
• Assess for dialysis need
LOOK OUT FOR AKI IN THE

PRESENCE OF DESIRABLE ACTIONS/INVESTIGATIONS
• Hypotension • Stage AKI (KDIGO criteria*)
• Volume loss (eg: vomiting, • Check electrolytes, acid-base status
diarrhea, bleeding); heat • Urinalysis
• Rule out pre-existing kidney disease
WHAT IS AKI? exposure or heat stroke
• Ultrasound of KUB region
Increase in Serum • Pregnancy-related
• Assessment for infection
creatinine by >0.3 complications • Laboratory investigation for specific cause
mg/dl in 48 hours • Multiple organ failure
AND/OR Urine
• Nephrotoxic medication use
output <0.5 ml/kg/h
for 6–12 hours • In neonates - oligohydramnios/
birth asphyxia, respiratory AKI IN SPECIFIC SETTINGS
distress • Neonatal - refer to paediatrician
• Pregnancy - manage complications
• Envenomations - antivenin, hemodynamic
correction
• Poisoning - specific antidote when available
• Systemic disease - refer for investigations
• Kidney transplant recipient - refer to
PRINCIPLES OF ASSESSMENT nephrologist
• Determine whether pre-renal,
renal or post-renal
• Identify and correct reversible
factors TREATMENT OF HYPERKALEMIA
• Look out for occult causes (e.g. • Calcium gluconate 1000 mg slow IV under ECG
envenomations, poisoning) monitoring, can be repeated upto 3 times
• Determine severity of AKI • Salbutamol : 10 to 20 mg in 4 mL of saline by
• Identify complications nebulization
• Insulin-dextrose: 10 to 20 units of regular insulin
• Decide need for dialysis
in 100 ml 25% or 50% dextrose
MANAGEMENT
PRIMARY CARE SECONDARY CARE TERTIARY CARE
• Detailed history and physical • Detailed history and physical • Detailed history and physical examination
examination examination • Identify and correct volume deficit
• Identify and correct volume deficit • Identify and correct volume deficit • Stop nephrotoxic agents
• Stop nephrotoxic agents • Stop nephrotoxic agents • Identify and correct urinary tract obstruction (USG, CT
• Identify and correct bladder outlet • Identify and treat hyperkalemia, scan)
obstruction metabolic acidosis and pulmonary • Identify and treat hyperkalemia, metabolic acidosis
• Give anti-snake venom if indicated edema and pulmonary oedema
• Identify hyperkalemia and start • Identify and correct urinary tract • Detailed investigation for infections
treatment obstruction (USG, CT) • Manage pregnancy complications- deliver if indicated
• Identify pulmonary edema- start • Detailed investigation for infections • Look for underlying CKD
intravenous furosemide and • Manage pregnancy complications - • Investigations for specific cause (including imaging,
oxygen deliver if indicated genetic tests)
• PD if indicated • Look for underlying CKD • Kidney biopsy
• Timely referral after stabilisation • Dialysis (PD or HD) • Dialysis (PD or HD)
RED FLAGS FOR URGENT INDICATIONS FOR DIALYSIS FOLLOW-UP OF AKI

REFERRAL • Fluid overload • UO > 1L, stable or falling creatinine, no symptoms: stop
• Pericarditis dialysis
• Hyperkalemia • Not resolving for >2 weeks: CECT to exclude cortical
• Indications for dialysis • Severe metabolic acidosis necrosis; kidney biopsy as indicated
• Unexplained AKI • Encephalopathy • Look for systemic diseases (e.g. vasculitis, myeloma,
• Involvement of other organs • Severe uraemia TMA)
• Sepsis • To create space for fluids or blood • Serum creatinine and urine protein q 6-12 months for
• Systemic disease products life
• Complicated pregnancy
ABBREVIATIONS
AKI: Acute Kidney Injury PD: Peritoneal dialysis CKD: Chronic Kidney Disease UO: Urine output
CECT: Contrast-enhanced CT scan TMA: Thrombitic microangiopathy HD: Hemodialysis USG: Ultrasonography
REFERENCE
*KIDNEY DISEASE: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury.
Kidney Int, Suppl. 2012; 2: 1–138

October/ 2019


CHRONIC KIDNEY DISEASE (CKD)
ICD-10-N18.3
WHEN TO LOOK FOR CKD BP CONTROL

• History of long-standing nocturia, or constitutional symptoms ( TARGET <130/80,
• Edema, hematuria, proteinuria or renal stones 120/80 IF PROTEINURIA)
• Long-term intake of painkillers or herbal medicines • Restrict dietary salt to < 5 g/day
• Family history of kidney disease • Use any anti-HT available in local
• Growth retardation, rickets, or proximal myopathy pharmacy
• Unexplained hypertension or anemia • Diuretics - eGFR > 45 : thiazide,
• Longstanding diabetes, hypertension, CVD, stroke, PVD <45 ml/min: furosemide; <30
• Systemic diseases (e.g. connective tissue disease) ml/min: do not use potassium
sparing agents
EVALUATION OF NEWLY DIAGNOSED PATIENT • ACEI/ARB preferred* for
proteinuric patients (> 1 g/d)
WITH CKD
• Serum creatinine, electrolytes, bicarbonate
*caution/do not use if eGFR <30
• Estimate glomerular filtration rate using CKD-EPI ml/min, or Potassium >5.5 mEq/L
equation
• Urinalysis (examine sediment, proteinuria
quantitation) VACCINATION SCHEDULE FOR
WHAT IS CKD? • Ultrasound of kidneys and urinary tract NEWLY DIAGNOSED CKD
• Calcium, phosphate, alkaline phoshatase, albumin PATIENT
Abnormalities of • CBC including peripheral blood film • If HBV -ve: 20 µg IM in each
kidney structure or • Iron profile - Serum iron, TIBC, TSAT deltoid at 0,1,2 and 6 months
function, present for >3 • HBsAg, anti-HCV • In children - complete primary
months, with vaccination schedule
implications for health
INITIAL ASSESSMENT FOR
• Confirmation of CKD diagnosis (repeat tests after ANEMIA MANAGEMENT
3 months) • Establish iron replete state
• Staging and progression rate • If not iron replete, give oral iron
• Establishing cause of kidney disease • Consider IV iron for dialysis patients
• Identify and treat reversible factors (hypertension, and those not tolerating orally
volume loss, obstruction, infection) • If Hb still <8 g/dl – start erythropoietin,
• Look for complications (anemia, bone disease, titrate to Hb 10-11 g/dl
dyselectrolytemias, CVD)
MANAGEMENT OF
HYPERPHOSPHATEMIA (PO4>5.5)
LIFESTYLE MEASURES FOR ALL CKD PATIENTS: • Start with Ca-containing binders
• Weight control/ weight gain monitoring in children • Non Ca-binders can be used if
• Regular physical activity serum Ca >9 mg/dl, vascular
• Reduce dietary salt intake to < 5 g/day calcification or low iPTH
• Stop tobacco use in all forms
• Stop/moderate alcohol use
• Stop using unproven health supplements DIABETES CONTROL (TARGET
• Do not use NSAIDS HBA1C <7%)
• Avoid untested indigenous medicines • Do not use metformin if eFGR <30
NUTRITION VITAMIN D THERAPY

LOW POTASSIUM FRUITS/
• Salt restriction < 5g/d. Protein 0.6-0.8 g/kg/day. VEGETABLES: • Supplement 60,000
• DO NOT restrict proteins unless documented high protein units cholecalciferol
user (dairy, white meat are good protein sources, mix Apple, pineapple, papaya, pear, q2W
different types of dal). tangerine, watermelon, grape, • Correction of acidosis
• Restrict green leafy vegetables if eGFR <30 ml/min plum, cabbage, carrot, cauliflower, with oral sodium
• Avoid fruit juices, coconut water and carbonated beverages onion, radish, peppers, chillies, bicarbonate
• For children: ensure adequate protein intake appropriate brinjal, cucumber, green beans, • Activated vitamin D if
for age. peas, rice, bread hyperparathyroidism
MANAGEMENT
PRIMARY CARE INDICATIONS FOR REFERRAL
• Detailed history and physical examination • Initial evaluation of all newly diagnosed cases
• Identify and correct reversible factors • Rapid disease progression
• Stop nephrotoxic agents • New complication
• Referral after stabilization • Discussion for Renal Replacement Therapy (RRT)
ADMISSION CRITERIA DISTRICT HOSPITAL

• Initial evaluation or when patient presents with specific • Detailed history and physical examination
problems – like acute worsening, development of a new • Investigate to ascertain cause of CKD
complication • Tailor treatment to cause
• For creation of vascular access • Identify and manage complications
• For PD catheter placement or initiation • Vaccination
• Initiation on HD and for kidney transplant • Identify and correct acute factors
• Counseling: nutrition, lifestyle, pregnancy in women of child-bearing age
• Discussion regarding RRT
• Vascular access creation or PD Catheter insertion
TERTIARY CARE • Send patient back to community with treatment plan
• Detailed history and physical examination
• Investigate to ascertain cause of CKD
(imaging/biopsy/genetic studies) PREPARATION FOR RENAL REPLACEMENT THERAPY
• Tailor treatment to cause • eGFR < 30 : Preserve veins in the non-dominant arm for AV Fistula
• Identify and manage complications • eGFR < 30 : discuss RRT options.
• Vaccination • eGFR < 15 : May need dialysis soon, counsel for AV fistula, list for transplant
• Counseling: nutrition, lifestyle, pregnancy in • Dialysis start : depends on symptoms or eGFR <5 ml/min
women of child-bearing age • Look for contraindications to HD or PD : discuss choice in those suitable for either
• Discussion regarding RRT
• Vascular access creation/PD catheter insertion
• Work-up for transplantation CONSERVATIVE CARE
• Send patient back to community with • If life expectancy limited, multiple comorbidities/personal preference
treatment plan • Decision-making should be shared with patient/family

October/ 2019


GLOMERULONEPHRITIS
ICD-10-N05.9
IDENTIFY THE PRESENTING EVALUATION OF A PATIENT WITH GN
CLINICAL SYNDROME • Full history and clinical examination
• Urinalysis: urine routine exam, microscopy
Acute nephritic • proteinuria quantitation: 24 h UP; ACR/PCR for follow up
syndrome: Sudden • Assess eGFR using age-appropriate formula
WHAT IS GN? onset, hematuria, • Renal imaging
oliguria, edema, • Serologic testing
Glomerulonephritis hypertension, reduced
refers to an • Kidney biopsy
eGFR
inflammation of the
glomerulus hence it is
not strictly a single Nephrotic syndrome: KIDNEY BIOPSY
disease, its proteinuria (>3.5 • Age <1 y or >12 y
presentation depends g/1.73m2/d; 50 mg/kg/d in • Steroid resistant state
on the specific children), edema, • Family history of kidney disease
disease entity. It may hypoalbuminemia, • Features suggestive of systemic disease
present as hyperlipidemia • Diagnosis unclear, therapeutic uncertainty
symptomatic urinary • Doubling of serum creatinine over days-weeks
abnormalities/
nephrotic syndrome/ Asymptomatic urinary
nephritic syndrome/ abnormalities: proteinuria, SEROLOGY
AKI/ CKD hematuria • ASO • HBsAg, anti-HCV
• HIV (high risk) • C3
RPGN: doubling of serum • ANA • ANCA
creatinine over days to • Anti-GBM antibody • SPEP (>50 y)
weeks • Anti-PLA2R
TREATMENT
IN CHILDREN <12 Y WITH NEPHROTIC SYNDROME
DO NOT Lifestyle modifications Avoid nephrotoxic agents
• Give any vaccine while on steroids or within 3 months
of stopping
Sodium restriction (not BP control (<130/80 mm Hg
• Prescribe bed rest unless indicated in adults, <95th centile for
in children)
• Restrict salt in children with nephrotic syndrome age in children)
• Restrict fluids
• Use ACE inhibition in children with renal dysfunction, Diuretics - loop needed, ACE inhibition (see
reverse edema slowly exceptions under DO NOT)
or in steroid sensitive nephrotic syndrome
RECOMMENDED PHARMACOLOGICAL TREATMENT

CHILDREN ADULTS
BEFORE STARTING STEROIDS IN CHILDREN, • Treatment Depends on diagnosis (biopsy,
• Prednisolone 2
REMEMBER TO mg/kg x 6 w serology)
• Look for latent TB (Mantoux test, Chest X-ray) followed by 1.5 • Therapeutic choices include
• Start 6 months INH therapy (5mg/kg day) if mg/kg A/D x 6w • Corticosteroid (Prednisolone, IV
asymptomatic Mantoux +ve methylprednisolone)
• Be on the lookout for common infections (e.g. • In case of relapse- • CNIs (cyclosporine/tacrolimus)
peritonitis, pneumonia and skin infections) Prednisolone 2 • Cyclophosphamide
mg/kg x 2w • Azathioprine
followed by 1.5 • Mycophenolate mofetil
mg/kg A/D x 4w • Levamisole
CAUTION
• Rituximab
• Non-nephrotic proteinuria: rule out orthostatic cases
• Isolated hematuria: rule out urological causes
THROMBOSIS PROPHYLAXIS
LOOK FOR COMPLICATIONS
• Malnutrition
• Hypovolemia
• AKI Evaluate bleeding risk: S alb <2 + non-ambulatory:
• Thromboembolism Do not use if risk high start aspirin, OAC if high risk
• Infections
MANAGEMENT
PHC/CHC INDICATIONS FOR REFERRAL DISTRICT HOSPITALS
• Detailed history and • All cases >12 years old and less than 1 year old • Detailed history and clinical examination
clinical examination • In children: • 24-hr urinary protein estimation
• Urine dipstick test • Frequent relapses (=>3 per year) • Serum creatinine, electrolytes, serum albumin, lipid profile
• Serum creatinine, • Steroid dependent or resistant state • Imaging of kidneys
• Evaluate for secondary causes
electrolytes • Recent rise in serum creatinine • Look for and treat complications
• Stabilize • Appearance of complications related to disease • Start general treatment
• Start or treatment • Can treat
antihypertensives • Pregnancy • Uncomplicated NS in 1-12 y old
and diuretics if • Persistent asymptomatic urinary abnormalities • Infrequent relapses
needed (>6 months) • Prepare treatment plan and refer back to primary care
ADMISSION CRITERIA: Initial evaluation, kidney biopsy, or management of complications
RED FLAG SIGNS
TERTIARY CARE HOSPITALS Cold Peripheries Accelerated hypertension
• Detailed history and clinical examination

• 24-hr urinary protein estimation DO NOT USE DIURETICS
• Serum creatinine, electrolytes, serum albumin, lipid profile ALBUMIN can be given in Seizures
• Imaging of kidneys
• Evaluate for secondary causes severe Hypoalbuminemia
• Look for and treat complications
• Start antihypertensives and diuretics
Increased capillary filling Altered Sensorium
• Kidney biopsy
time
• Prepare treatment plan and refer back to primary care

October/ 2019


URINARY TRACT INFECTIONS
ICD-10-N39.0
DETERMINE UTI TYPE MANAGEMENT PRIMARY/ SECONDARY LEVEL
SIMPLE CYSTITIS/ LOWER UTI PRIMARY CARE INITIAL ASSESSMENT

• Dysuria, urgency, frequency • History and Examination • History
• Look for red flag signs and • Symptoms
PYELONEPHRITIS/ UPPER UTI refer • Recurrent UTI
WHAT IS UTI? • Fever • Refer special groups • Diabetes
At least 3 Symptoms • Chills and rigors • Treatment in primary care • Congenital
(dysuria, frequency, • Loin pain, pelvic pain • Acute cystitis females malformations
urgency, suprapubic • Renal angle tenderness • Acute cystitis males • Stones
pain) • Toxic and sick appearance • Treatment • Immunosuppression
OR • Nitrofurantoin • Examination
Dipstick +ve for COMPLICATED UTI • Trimethoprim • Temperature, renal
leucocyte esterase and • History of stones, congenital sulphamethoxazole angle tenderness,
nitrite if <3 symptoms anomalies, obstruction • Symptomatic relief genital exam
OR • Diabetes
• CUE >10 WBC/HPF in • Immunosuppression MALE UTI CYSTITIS/UTI IN FEMALES
uncentrifuged urine + Acute cystitis/ simple UTI • Empirical RX (only
• Urine culture WHEN TO DO URINE CULTURE? • Rx Men for 7 days symptoms no tests
>105 CFU of single • Complicated UTI • Nitrofurantoin* 100 mg PO BD x 7d
needed)
species/ml in Mid stream • TMP/SMX 1 DS tab PO BD x 7d
• Pyelonephritis • Nitrofurantoin* 100
urine (multiple species • Ciprofloxacin 500 mg BD x 7 days
• Special situations • Levofloxacin 750 mg OD x 5 day mg
indicate contamination) • All males (except simple • Acute cystitis is not to be referred PO BD x 5d
cystitis) ALL OTHER UTI IN MALES-REFER • TMP/SMX 1 DS tab
• Children • Pyelonephritis or complicated UTI PO BD x 3d
• Pregnancy • Pelvic/perineal pain (prostatitis) • If no response refer
• Recurrent UTI (> 2 to higher centre
episodes/ 6 months)
• Catheter associated UTI *Avoid if GFR <45,caution in elderly
SYMPTOMATIC TREATMENT
Plenty of Urine alkalinizer recommended eg citrate Phenazopyridine Local Estrogen creams for recurrent Paracetamol Cranberry
water - Avoid if patient on nitrofurantoin 200mg tid for 2 days UTI in post menopausal women for pain can be used
RED FLAG SIGNS - REFER

• Pyelonephritis • Special situations (Children, pregnancy, • Non response within 3 days of AB
• Complicated UTI males except simple cystitis, catheter UTI) • Recurrent UTI
TERTIARY LEVEL
• Send for culture Rx Rx Rx all male UTI Rx Rx
• Imaging if no response to antibiotics in 48 hrs Pyelonephritis/ pregnancy including recurrent non-resolving
• Urology services if obstruction complicated UTI UTI prostatitis UTI UTI
PYELONEPHRITIS PREGNANCY UTI CATHETER UTI MALES WITH PROSTATITIS RECURRENT UTI
Empiric Outpatient: • Urine culture at 1st • Rx of asymptomatic • UTI symptoms+ pelvic • Uncomplicated
• Urine c/s antenatal visit CAUTI NOT pain/ fever RUTI
• Consider initial dose of a parenteral • For asymptomatic recommended • Refer - post coital voiding
agent bacteriuria/acute cystitis: • Urinary catheters • Urine culture & MSU and post coital
- Ceftriaxone 1-2 g IV/IM x 1 - Nitrofurantoin 100 mg PO should be removed as • Digital rectal exam- antibiotic
- Gentamicin 5 mg/kg IV/IM x 1 BD x 5-7 d (avoid near- soon as not required tender prostate - Low dose
• Followed by term ) • If indwelling catheter • Older >35 yrs- nitrofurantoin 50
- Ciprofloxacin 500 mg PO BD x 7d - Cephalexin 500 mg PO for >2 weeks and is still - Septran DS BD mgX 6 months
- Levofloxacin 750 mg PO OD x 5 d QID x 5-7 d indicated, replacing - Levofloxacin 500mg OD, - Single strength
- Cefuroxime 500 mg PO BD x10-14d - TMP/SMX 1 DS tab PO BD x the catheter is ciproflox 500 mg BD septran x 6
- Amoxy clav x10-14 days 5-7 d (avoid in 1st trimester & recommended - Avoid nitrofurantoin months
- TMP-SMX 1 DS BD x 7-10 days near term; supplement with • Symptomatic CAUTI • Young males- - Or norflox 200mg,
Empiric Inpatient : multivitamin containing - (Fever, back pain, new - Doxy 100mg bd /azithro 1 ciproflox200mg ,
• Ceftriaxone 1-2 g IV once daily+ /-AMP folic acid) onset delirium, rigors) gm / oflox 300mg BD for cephalexin 250mg
• Gentamicin +/-AMP • Check repeat urine c/s 7days - Send culture chlamydia + Single dose - Vaginal cream in
• Others as per c/s- Carbapenem, after Rx to confirm clearing - Rx as complicated of Ceftrioxone 250mg IM post menopausal
Piperacillin Tazo • Repeat urine culture in each UTI for gonorrhoea • Complicated RUTI
antenatal visit • No role of routine • Rx- 6 weeks - Urology referral
IV therapy required until afebrile x • If recurrent- Antibiotic antibiotic prophylaxis • Imaging to rule out - Cystoscopy,
48 hrs, then switch to PO If no prophylaxis till term for prevention abscess urodynamics (post
response in 3 days imaging menopausal)
ASYMPTOMATIC BACTERIURIA CHILDREN

• No symptoms
• Bacteria in urine culture SYMPTOMS
• Neonates and Infants < 1yr FIRST URINARY TRACT INFECTION*
>105CFU/ml
- Fever,vomiting, diarrhoea, jaundice, Poor
• No treatment required
stream
- Older children same as adults
• Exceptions when you TREATMENT
should treat - Infants <3months as upper UTI (PN) with
Age <1 yr Age >5 yr
- Pregnancy IV antibiotics • Ultrasound
- Before any urological - Urinary bladder catheterisation for infants • Ultrasound
• MCU If ultrasound
intervention with upper tract UTI abnormal:
- Older children • DMSA renal scan
MCU and DMSA
• Upper UTI- IV antibiotics scan
gentamicin, amikacin, ceftriax
* Pregnancy UTI, one
Catheter UTI may also be Age 1-5 yr
• Lower UTI- oral cefixime, oflox,
managed at secondary • Ultrasound
ciproflox, amoxyclav
level. • Duration of Rx • DMSA scan
- Upper UTI- 10-14 days MCU if ultrasound or
- Lower UTI 7-10 days DMSA scan is abnormal
LONG TERM CONSEQUENCES - Adolescents 3-5 days
• Renal scars REFER
Upper UTI(PN), infants UTI, recurrent UTI All patients with recurrent UTI need
• Hypertension
PREVENTION detailed evaluation with
• CKD
Avoid constipation, clean washrooms ultrasonography DMSA scan and MCU
• Poor quality of life

NEUROLOGY
October/ 2019

Standard Treatment Workflow (STW) for the

APPROACH TO ACUTE PARALYSIS
ICD 10 G82, G83
PRESENTATION WITH ACUTE ONSET (WITHIN HOURS TO DAYS) PARAPLEGIA OR QUADRIPLEGIA
Are There Any Signs Of Upper Motor Neuron (UMN)

Involvement?
• Brisk reflexes
• Extensor plantar
• Increased tone
• Sensory level
• Bladder or bowel incontinence
NO YES
Is the weakness predominantly

proximal or distal?
Likely to be :
∙ Acute myelopathy like
tuberculosis
∙ Trauma
WEAKNESS ∙ Tumor
WEAKNESS
∙ Transverse myelitis
PROXIMAL DISTAL ∙ Epidural abscess
∙ Spinal cord stroke
Presence of Lower Motor Neuron

(LMN) signs like wasting, absent
reflexes and sensory impairment
REFLEXES REFLEXES MANAGEMENT
Likely to be :
ABSENT PRESENT Acute onset peripheral neuropathy • Check pulse, BP and respiration
(due to toxin/drug) • If retention of urine present
then catheterize
• Transfer/ refer to nearest district
Likely to be : MANAGEMENT hospital/ medical college with
• Guillain Barre Syndrome (GBS) or • Transfer/ refer to nearest district MRI facility
• Hypokalemic periodic paralysis. hospital/ medical college with • Treatment will depend on MRI
NCS and EMG facilities. and other investigation
• CSF for cells and biochemistry • After treatment follow up at
• Treatment as per diagnosis CHC for medications and
MANAGEMENT • After treatment follow up at CHC rehabilitation
• Check pulse, BP and respiration for medications and
• Check serum K+ levels rehabilitation
• Intubate if unable to complete
sentences, single breath count low
and breath holding time low and
chest expansion poor
• Transfer/ refer to nearest District
Hospital/ medical college with
facility for doing plasma exchange
or giving IVIg and presence of
ventilator.
• After treatment follow up at CHC
for medications and rehabilitation
ADMISSION CRITERIA
If the weakness is fatigable
If no sensory impairment and
• Any progressive weakness or
normal extra ocular movements
• Unable to walk If extra ocular movements are
• Unable to swallow or choking while drinking affected
water
• Evidence of respiratory distress like unable
to complete sentences, falling serial single
breath count, respiratory rate >20 or SaO2
levels < 95% Likely to be : Likely to be :
• Persistent tachycardia >100 • Myasthenia gravis or • Myopathy (eg polymyositis)
• Fever • Snake bite
• Bowel and bladder involvement
DISCHARGE CRITERIA MANAGEMENT MANAGEMENT
• Cause of acute paralysis established • Check pulse, BP and respiration • Check pulse, BP and respiration
• Progression of weakness has stopped • Intubate if unable to complete • Check serum electrolytes, creatine
• Able to breathe on his own sentences, single breath count low kinase
• If present care of tracheostomy taught to and breath holding time low and • Transfer/ refer to nearest district
care giver chest expansion poor hospital/ medical college with
• If not swallowing- Ryles tube in place and • Transfer/ refer to nearest district facility for NCS & EMG
care giver has been taught feeding hospital/ medical college with • After treatment follow up at CHC
• Care of urinary catheter and constant facility for doing NCS, plasma for medications and rehabilitation
turning taught to the patient exchange or giving IVIg and
• Caregiver trained for physiotherapy at presence of ventilator.
home • After treatment follow up at CHC for
medications and rehabilitation

October/ 2019


DEMENTIA
ICD 10 - F02,F03,G30
Impaired memory Anxiety Hallucinations Incontinence
CLINICAL
Forgetting learned
FEATURES OF Apathy Agression Mood fluctuations
activities
DEMENTIA
Depression Sleep disturbances Personality change
IMPORTANT POINTS TO CONSIDER

• Dementia is a complex and variable condition
• No single test will definitively diagnose dementia
• The clinical features if present, should be a change from baseline normal functioning in a middle aged to old person
• Assessment should aim at gathering information about changed behaviours, functional capacity, psychosocial support and medical
comorbidities
• History should be taken from a close caregiver, staying with the patient for a longer duration than the appearance of symptoms
EVALUATION OF DEMENTIA
No
No dementia
History and Cognitive decline in

examination more than one
domain
ASHA
Lab investigation
Yes PHC
Suspected dementia TSH,Vit B12, vit D
CHC
Yes LFT/RFT/FBS
Treat Delirium or Depression? DH
Yes
No
No Neuropsychiatry
Functional decline Follow up and Re-evaluation
testing
Yes
Medical college
Dementia
Tertiary level centre
Optional tests Yes

No
based on clinical Typical clinical profile (age, progression, no focal signs) Probable AD
features
CT scan/MRI VD/ mixed dementia
Lab investigation
Other causes TSH, vit. B12
FOLLOW UP OF DIAGNOSED & TREATED PATIENTS INTERVENTION MATRIX FOR DEMENTIA ACROSS PLATFORMS OF CARE
DISTRICT HOSPITAL (SPECIALIST- PHYSICIAN/ REASONS FOR
PRIMARY HEALTH CENTRE (MEDICAL OFFICER) GERIATRIC SPECIALIST/ NEUROLOGIST/ REFERRAL
• Diagnose dementia after detailed history PSYCHIATRIST)
• Not responding to
• Screening for: adequate dose and
- Treatable causes of dementia - thyroid disorders, B-12 • Careful evaluation of all the referral patients of dementia
• Screening for treatable causes for dementia including duration of
deficiency, subdural hemorrhage. prescribed
- Depression. normal pressure hydrocephalus, B12 deficiency,
hypothyroidism, chronic meningitis medications
- Vascular risk factors • Presence of red flags
• Lab investigations- CBC, biochemistry, liver function • Neuroimaging CT/MRI- to rule out subdural hematoma/
tests, hemogram, lipid profile, TFT, VDRL, vit B12 level, vit tumors/ NPH(surgically remediable causes of rapid
D level cognitive decline)
• Referrals for MRI/CT • Lab investigations- CBC, liver function tests, biochemistry,
• Initiation of treatment/drugs; treatment for co-morbid hemogram, lipd profile, vit D levels, TFT, VDRL, retrovirus
after counselling (whenever feasible and high index of
RED FLAGS
conditions (including depression, vision, hearing deficits
and gait problems), thyroid, arthritis. suspicion)
• All the points mentioned in PHC to be followed if patient • Fever
• Initiate therapy for vascular risk factors • Rapid progression
• Encourage healthy lifestyle presents to a DH
• Upward referral linkages with tertiary care and • Seizures
• Assess for palliative care • Recent head
• Learn and share facts about dementia to provide downward referral with PHC.
• Encouraging patient and caregiver participation in an injury
immediate need to the person with severe dementia • Alcoholism and
• Follow up and monitor for side effects of drugs/ red flags ongoing support program for them.
• Avoid antipsychotics until necessary falls
in patient/ signs of danger
• Follow-up of difficult patients under the guidance of • Interaction with, training of MOs at PHC/UPHC and
higher centre. ongoing clinical support and supervision
MEDICATIONS RECOMMENDED FOR USE FOR ALZHIEMERS DEMENTIA

FOR COGNITION FOR AGITATION
FOR DEPRESSION
• Donepezil: 5 mg once after breakfast x 1 month, then 10 mg after breakfast to continue
• Escitalopram 10 mg • Identification of
If any side effect/ not tolerating: Rivastigmine to be used start dose 1.5 mg BD / 1 month then 3
triggers
mg BD x 1 month, then 4.5 mg BD x 1 month, then 6 mg twice after meals only x 1 month.
• Non
• Memantine: in moderate to severe dementia 5 mg BD x 1 month, then 10 mg BD to continue.
pharmacological
• Galantamine: 8 mg BD if not tolerating 1
interventions
October/ 2019


EPILEPSY
ICD 10 - G40
Abnormal jerky Loss of Episodes could be single

Episodic, few Blank
movements consciousness/ with high risk of
secs-mins staring
awareness recurrence. Prolonged
motor convulsion of > 5
CLINICAL mins with loss of
FEATURES Sudden consciousness - STATUS
With or without urine/ Bizzare activity Any other episode
drops/ falls, stool incontinence, lasting for few mins EPILEPTICUS (SE) -
out of context
brief jerks tongue bite, drooling (usually<5 mins) MEDICAL EMERGENCY
PRIMARY HEALTH CENTRE (MEDICAL OFFICER) REASONS FOR REFERRAL DISTRICT HOSPITALS
• Clinical diagnosis of epilepsy: detailed history from an eyewitness (centres with specialists like • Careful evaluation of all
• Differentiate between provoked seizures and epilepsy (provoked due to fever, paediatrician, referral patients, provide
acute CNS insult, antibiotics, and metabolic causes) neurologist) specialized management
• Laboratory investigations: CBC, liver function tests, routine biochemistry, for patients and refer
hemogram, lipid profile, vit D levels, TFT (whichever feasible) • Redflag Signs back to PHC for follow up
• Initiation of treatment:
• Progressive problems, rapid of management
- Treat the patient if patient has epilepsy (2 or more episodes of unprovoked
seizures) appearance of new symptoms • Maintain communication,
- Treat a single seizure if risk of recurrence is high as in patients with focal • Recent injury ongoing clinical support
seizures,mentally retarded, neurological deficits having family history of • Symptoms appearing after and supervision of MOs at
seizures abnormalEEG, neuroimaging alcohol binge PHC
- Anti Epileptic Drug (AED broad spectrum, low dose, start low go slow, except • Status epilepticus after • Laboratory investigation
status epilepticus) stabilization - CBC, liver function
- Emergency medical care of status epilepticus • Non response to adequate tests, antiepileptic drug
• Treatment counselling: side effects/toxicities of drugs, red flags, importance of dose and duration of levels, routine
adherence, maintaining treatment diary medication biochemistry,
• Advice on prevention of seizures: regular medication, sleep 7-8 hrs, avoid excess • Serious side effects hemogram, lipid profile,
TV/mobile/ photic stimulation, regular diet, lifestyle choices(avoid alcohol) • Neuroimaging vit D levels, TFT, CT
• Evaluate any possibility of superimposed non-epileptic seizure brain (when necesary)
• Training of MLP/ANM/ASHA on epilepsy • Monitor side effects of
• For excessive alcohol use, refer to ANM/MLP where psychosocial interventions are RED FLAG SIGNS
AED
carried out for substance use disorders
• Follow up visits for treatment monitoring & difficult patients under neurologist at • Clinical Psychologist:
• Fever counselling health
STC centre • Headache
• Basic management of co-morbidities (behaviour, cognition, reproductive health, services for persons with
• Vomiting epilepsy or upon referral
bone health)
• Alert to signs of abuse and neglect • Altered Sensorium from PHC/UPHC
• Maintain upward referrals with paediatrician/physician at DH • Severe Giddiness
• Loss of function of body
AED– BROAD SPECTRUM (GENERALIZED SEIZURES) DOSE (MAINTENANCE: MG/D) ADVERSE EFFECTS
Sodium Valproate (avoid in women of child Starting dose :200mg TDS Anorexia, wt gain, nausea, vomiting, tremors,
bearing age unless non responsive to other drugs) Maintenance Dose: 600-2400 hair loss, PCOS, thrombocytopenia
Starting dose: 25mg HS (Lower dose with VPA) Sedation, ataxia, dizziness, skin rash, SJS (lower
Lamotrigine
Maintenance Dose: 100-300 risk with slow titration)
Starting dose: 250mg BD Somnolence, dizziness, cognitive slowing,

Levetiracetam psychosis
Maintenance Dose: 1000-3000
Sedation, somnolence, cognitive problems,
Topiramate Starting dose: 25mg OD
weight loss, word finding difficulty, renal
Maintenance Dose: 100-400
stones, seizure worsening
AED (focal seizures)
Sedation, dizziness, ataxia, skin rash, SJS,
Starting dose: 100mg BD
Carbamazepine hyponatremia, seizure worsening in some
Maintenance dose: 400-1200
situations
Oxcarbazepine Starting dose: 150mg BD Sedation, dizziness, ataxia, headache,
Maintenance dose: 600 to 1800 hyponateremia, skin rash
Phenobarbitone Starting dose: 30mg HS Sedation, ataxia, depression, memory
Can be used for generalized also Maintenance dose: 60-180 problems, hyperactivity in children, skin rash
Ataxia, sedation, gum hyperplasia, coarsening
Starting dose: 200mg HS
Phenytoin of facial features, hirsutism, memory
Maintenance dose:200-400
problems, osteomalacia & bone loss, skin rash
Folic Acid 5 mg/day to be added along with AEDs in all women of child bearing age. Polytherapy and valproate to be avoided in women with epilepsy
IMPENDING SE ESTABLISHED SE REFRACTORY SE

5 MIN 30 MIN 60 MIN 2 IV drugs fail (Benzo + IV AED)
FIRST ABCS TO BE DONE FROM WHEN YOU SEE PATIENT SIMULTANEOUSLY WITH MEDICATION
Out of Hospital/home : Buccal/Intranasal IMDZ with acute repititive seizures/status (0.3-0.5 mg/kg) ICU
IV Midazolam loading 0.2 mg/kg
EMERGENCY ROOM OR CIV 0.05-0.5 mg/kg/hr
(can go up to 2 mg/kg/hr)
IV Lorazepam up to 0.1 mg/kg @ 2mg/min Taper gradually after seizure stops
OR (preferably as evidenced by EEG)
IV Midazolam 0.1-0.2 mg/kg bolus or 0.05-0.5 mg/kg/hr in CIV
OR Thiopental 5-7 mg/kg IV bolus
IV Diazepam upto 0.25-0.4 mg/kg over 2-3 min further 50 mg until seizures controlled
3-5 mg/kg/hr for only 48 hours
• Phenytoin @50 mg/min 20 mg/kg repeat OR Propofol IV loading 2-5 mg/kg

plus 10 mg/kg if seizures do not stop in 15-20 min CIV 1-15 MG/KG/HR
• If seizures not controlled or contra indiction (CI) to PHT OR Pentobarbital IV upto 10 mg/kg
Intravenous Valproate 25-40 mg/kg @3-6 mg/kg/min @ <0.2-0.4 mg/kg/min CIV 0.5-2 mg/kg/h
• CI to above two; Phenobarbitone 20 mg/kg IV @ less than 5-60 mg/min but be
If OR Ketamine bolus 1.5 mg/kg
prepared to Intubate and ventilate CIV 0.01-0.05 mg/kg/h max 10mg/kg/hr * to be
EEG Monitoring
Levetiracetam 20-30 mg/kg IV at 5 mg/kg/min (max 3g) or
Levetiracetam 1500-3000 mg via NGT or Super refractory
Lacosamide 200-400 mg IV at 40-80 mg/min > 24hr no control
Topiramate 150-800 mg bid via NGT
Airway, blood pressure, temperature, intravenous access, electrocardiography, CBC, glucose, electrolytes, AED levels, ABG, oximetry, tox screen, central line
If alcoholic- thiamine & glucose, if diabetic GLUCOTEST/blood sugar & glucose IV. MUST INFORM CONSULTANT ON CALL
October/ 2019


HEADACHE
ICD-10-G43-44
CONTINUOUS HEADACHES • CT with CT

• Progressive headache of acute or subacute Referred Angiogram/ MRI
onset persisting more than 1 week to with MR angiogram
• Possibilities: Cerebral Venous Thrombosis, higher • Lumbar puncture
Intra Cranial Space Occupying Lesion, centre • Refer to tertiary care
Meningitis, Brain abscess centre
CHRONIC TENSION HEADACHE Start Amitriptyline Brain imaging

Continuous bilateral headache for many years with (10mg HS) and if atypical
significant insomnia and psychosomatic complaints. advice on lifestyle features exist
MIGRAINE Frequency > 2 /month -

TREATMENT FLOWCHART Side Start prophylaxis trial for 2 months
alternating, • Propranolol 40 mg OD Brain
LEGEND/ INDEX/ KEY associated • Flunarizine 10 mg OD imaging
visual aura, Acute management if
photo-phono • Analgesics( Paracetamol 650 mg, or there
Type of phobia, Indomethacin 50 mg) and are
Headache nausea, • Antiemetics ( Prochlorperazine 10mg). atypical
relieved by Life style changes symptoms
sleep or • Good sleep at least 6 hrs, food habit
Management analgesics modification, avoiding triggers of migraine.
at PHC
ATYPICAL MIGRAINE Analgesics for pain • CT/ MRI with MR angiogram or CT

Management at Hemiplegia, visual Refer to higher angiogram if required
district hospital impairment, centre with • Migraine prophylaxis after ruling out
vertigo imaging facility stroke and other diseases
TRIGEMINAL AUTONOMIC CEPHALGIAS Indomethacin Refer to

Rapid onset peri orbital and temporal (25mg TID) for tertiary care
pain with autonomic features 7 days centre
CLUSTER HEADACHE, PAROXYSMAL HEMICRANIAS, SHORT Refer to Refer to

LASTING UNILATERAL NEURALGIFORM PAIN WITH tertiary tertiary
CONJUNCTIVAL INJECTION AND TEARING SYNDOME (SUNCT) care centre care centre
• First or worst • Headache with fever, change in • Rapid onset with strenuous exercise REASONS FOR REFERRAL
headache of the personality, mental status, level of • Sudden onset (maximal intensity
patient’s life consciousness occurs within seconds to minutes, • Non responding
• Focal neurologic signs • Fever, neck stiffness or meningism thunderclap headache) headaches
(not typical aura) • New onset of severe headache in • New headache type in a patient • Headaches with danger
• Severe headache pregnancy or postpartum or while with malignancy or signs should be
awakening from sleep on hormone treatment immunosuppression immediately referred and
investigated for
potentially dangerous
RED FLAG SIGNS conditions
TREATMENT OF MAJOR CATASTROPHIC HEADACHES AT TERTIARY CENTRE
Headache with fever, Progressive

Sudden Severe headache, Progressive personality change, headache with
First or Worst headache of life headache altered sensorium, seizure or focal
neck stifffness deficit
CT with CT Angiogram/ MR venogram CT scan followed CT/MRI with

MRI with MR angiogram by CSF study contrast
SUBARACHNOID INTRACEREBRAL CEREBRAL VENOUS

THROMBOSIS MENINGIOENCEPHALITIS BRAIN TUMORS
HEMORRHAGE HEMORRHAGE
Angiogram, Stroke unit Intravenous UFH /

subcutaneous Surgery,
clipping/ admission and Antibiotics/
heparin/LMWH radiation,
coiling of neurosurgery for antivirals
chemotherapy
aneurysm cortical
(to prevent hemorrhages or
rebleed) large
hemorrhage
with herniation
INDICATIONS FOR ADMISSION CRITERIA FOR DISCHARGE FOLLOW UP OF HEADACHE PATIENTS
• Patient with unrelenting • Primary headache disorders- CAUSES OF HEADACHE TREATMENT OF HEADACHE
headache symptomatically improved severe
• Immunosuppressed patients episode of headache due to primary Intra cerebral hemorrhage Good control of blood pressure
with continuous headache, headache disorder can be discharged
Seizures Antiepileptic medications
• First ever headache with
worsening intensity, • Secondary headache disorders- Cerebral venous sinus thrombosis Follow up of anticoagulation
• Progressive headache with secondary headache disorders with
other systemic disease essential work up, diagnosis and Give prophylaxis for
• Severe symptomatic primary treatment as per individual case can Migraine adequate duration of time
headache disorders be discharged and taper after remission

REFERENCES
1. Hainer BL, Matheson EM. Approach to acute headache in adults. American family physician. 2013 May 15;87(10).
2. https://www.uptodate.com/contents/evaluation-of-headache-in-adults
ABBREVIATIONS
CSF: Cerobrospinal Fluid, UFH: Unfractionated Heparin, LMWH: Low Molecular Weight Heparin
October/ 2019


NEUROINFECTIONS
ICD-10-G03.9
DIFFERENTIAL
Acute onset-hours to days DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
Vascular-ischemic/hemorrhagic
stroke
SYMPTOMS Infections
Alteration in sensorium viral/bacterial/fungal/protozoal
meningoencephalits/brain abscess
Metabolic encephalopathies
Seizures/postictal state
With/ without fever/
headache/vomiting/seizures
Intoxications-drugs/toxins
AT PRIMARY CARE LEVEL

ESSENTIAL NOT
Check Airway/Breathing/Circulation
RECOMMENDED
• Stomach wash
Rule out circulatory shock, ongoing convulsions and hyperthermia/hyperpyrexia(core temperature > 40.5°C • Inj Mannitol
or hypothermia(< 36.5°C) • Inj Steroids
Establish IV access-urgent blood for hemogram/sugar/electrolytes/malaria testing-peripheral smear/rapid CRITERIA FOR

antigen detection REFERRAL
Altered
Correct hypoglycemia (blood sugar 50 mg/dl) with IV 100ml of 25% dextrose solution
sensorium/seizures
/focal
If seizing- IV/IM Lorazepam 0.1 mg/kg followed by loading with Phenytoin 20 mg/kg weight at a rate of deficits/hemodyna
50 mg/minute mic instability
–where imaging
When IV access not available-intra nasal or buccal Midazolam 0.2 mg/kg /intra rectal Diazepam 0.3-0.4 mg/kg and ICU
management are
Urgent referral to higher centres with intensive care facilities required.
AT SECONDARY CARE LEVEL( TALUK, DISTRICT) HEADQUARTERS HOSPITAL
In addition to all the steps given above :

ESSENTIAL DESIRABLE
• Neuroimaging-CT with contrast -to rule out
Establish and maintain airway: Intubate if GCS<8, impaired airway reflexes, abnormal hemorrhage/infarcts/focal edema or lesions
respiratory pattern, signs of raised ICP, oxygen saturation <92% despite high flow oxygen, • Blood cultures aerobic/anaerobic
and fluid refractory shock • First dose of empirical treatment of pyogenic
meningitis-Inj Ceftriaxone 2 g + Inj Vancomycin
Inj Thiamine 100 mg IV 500 mg.
Add Inj Ampicillin 2 g if older than 50 years /
Stomach wash/activated charcoal administration-if history or suspicion of drug overdose/
immunocompromised along with Inj
non corrosive poison intake
Dexamethasone 8 mg
• Fundus examination,CSF study to rule out
Start treatment for cerebral malaria-first dose of IV Artesunate 2.4 mg/kg OR
meningoencephalitis-if imaging rules out any
Quinine 20 mg/kg bolus
mass lesions/herniations.
• Urgent referral to higher centres with Intensive
Emergency CT/referral to centre with 24 hour CT facilities care facilities
CRITERIA FOR REFERRAL

• Altered sensorium/seizures/focal deficits/hemodynamic instability –where imaging and ICU management are required.
• If no definite diagnosis achieved after preliminary investigations
AT TERTIARY CARE HOSPITALS-SELECTED DISTRICT HOSPITALS/MEDICAL COLLEGES

• Neuroimaging-MRI/CT with contrast to rule out abscess/herniations.
If abscess-emergency neurosurgical consultation for favour of aspiration –open/stereotactic
• Blood cultures-aerobic/anaerobic
• CSF analysis-biocehmistry/cytology/gram staining/culture-bacterial , AFB and fungal/viral PCR/TB-PCR/fungal antigen
Empirical antibiotic (within 30 minutes of arrival) Viral-Herpes Cerebral malaria

• If suspecting pyogenic meningitis-Inj Ceftriaxone 2 g+ Inj simplex/Zoster Inj Artesunate 2.4 mg/kg IM or IV 3 doses
Vancomycin 500 mg+ Inj Ampicillin 2 g if older than 50 years or 12 hours apart and then OD /
immunocompromised+ Inj Dexamethasone 8 mg IV • Inj Acyclovir Inj Quinine 20 mg/kg IV stat followed by 10mg/kg
• Continue empirical treatment till culture yields causative 500 mg IV TDS till patient can take orally,then
organism,then tailor treatment as per sensitivity reports for 10-14 8 hourly for oral Artesunate+Pyrimethamine /Sulphadoxine for
days. 10 days 3 days OR oral Quinine 10 mg/kg TDS for total 7
• Steroids to be stopped after 48 hours,unless any other compelling days + Doxycycline 3 mg/kg OD for 7 days.
indications-adrenal insufficiency/TBM
COMPLICATIONS
Raised ICP SIADH Vasculitis Hydrocephalus
*If uncomplicated-back referral to Secondary care centre for completing treatment regimen/monitoring.
CRITERIA FOR DISCHARGE
Afebrile,hemodynamically stable,seizure Diagnosis and treatment plan made and Continuation of treatment with monitoring can
free >48 hours initiated. be ensured for the prescribed duration.

October/ 2019


STROKE
ICD-10-I63, I64
SYMPTOMS
WARNING SIGNS (BEFAST)
• Numbness or weakness, especially on one side of
• BALANCE : Loss of balance or
the body
coordination
WHAT IS STROKE? • Loss of consciousness or altered consciousness
• EYES : Sudden blurred or double vision/
• Decreased vision in one or both eyes
An episode of sudden, persistent vision trouble
• Language difficulties, either in speaking or
neurological • FACE : Deviation at the angle of the
dysfunction caused by understanding
mouth
focal cerebral, spinal, or • Difficulty walking; loss of balance or coordination
retinal infarction or • ARM : Arm Drift
haemorrhage • Confusion or loss of memory
• SPEECH : Slurred speech or the inability
• Swallowing difficulties
to speak or understand
• Paralysis of any part of the body, including face
• TIME : Act fast
• Sudden, severe headache with no known cause
• Sudden new onset of headache or loss of
• Neck pain
consciousness
• Nausea and vomiting
• Sudden giddiness, vomiting and
imbalance
TYPES OF STROKE
Intracerebral haemorrhage Transient Ischemic Attack

Focal collection of blood (TIA)
Ischemic stroke Subarachnoid haemorrhage Cerebral venous Transient episode of
within the brain
Focal cerebral, spinal, or Bleeding into the thrombosis Thrombosis of neurologic dysfunction caused
parenchyma or ventricular subarachnoid space
retinal infarction a cerebral venous by focal cerebral, spinal cord,
system that is not caused by
structure or retinal ischemia, without
trauma
acute infarction
PRELIMINARY MANAGEMENT INVESTIGATIONS
• Assess and manage ABCs

• Initiate cardiac monitoring ESSENTIAL DESIRABLE OPTIONAL
• Maintain O2 saturation >94%
• Establish IV access • CT Scan head • CTA • MRI/MRA
• Determine blood glucose and treat accordingly • ECG • Echocardiogram • Holter monitoring
• Determine time of symptom onset or last known normal, and obtain family • Blood Sugar
contact information, preferably a cell phone • Lipids
• Triage and RAPID TRANSFER of patient to nearest district hospital with CT • Renal parameter
Scan facility or Stroke center with facility for thrombolysis
• Referal hospital to be notified to handle the referred patient with stroke
MANAGEMENT
ISCHEMIC: * HAEMORRHAGIC:
IV tPA (0-4.5 hrs) or • Dysphagia assessment,
STROKE ONSET TIME: <4.5 HOURS endovascular treatment • Blood pressure/blood sugar monitoring and IV fluids.
according to eligibility • Prevention of Pneumonia
and availability • Prophylaxis for deep venous thrombosis etc, monitor and record ECG
* RECOMMENDED DIAGNOSTIC STUDIES
ALL PATIENTS SELECTED PATIENTS
• Noncontrast brain CT or brain MRI • TT and/or ECT if it is suspected the patient is taking direct thrombin
• Blood glucose inhibitors or direct factor Xa inhibitors
• Oxygen saturation • Liver function tests
• Serum electrolytes/renal function tests • Toxicology screen
• Complete blood count, including platelet count • Blood alcohol level
• Markers of cardiac ischemia • Pregnancy test
• BT, CT, Prothrombin time/INR • Arterial blood gas test (if hypoxia is suspected)
• Activated partial thromboplastin time • Chest radiography (if lung disease is suspected)
• ECG • Lumbar puncture (if subarachnoid hemorrhage is suspected and CT
• FLP and carotid doppler (ischemic stroke) scan is negative for blood)
• Electroencephalogram (if seizures are suspected)
Rapid Assessment, CODE Stroke, Blood pressure and Blood Sugar monitoring, NIHSS, Intravenous lines
STROKE ONSET TIME: >4.5 HOURS Endovascular treatment with Mechanical thrombectomy using stent retriever (4.5 hrs to 24hrs) according to
eligibility
SECONDARY PREVENTION DISCHARGE PLANNING

REHABILITATION (checklist : drugs, diet, compliance,
Aspirin (in ischemic stroke) Physiotherapy
Antihypertensives exercises, health education)
Speech Therapy
Antidiabetics Occupational Therapy
Lipid lowering agents FOLLOW UP at 2nd week, 1st month, 3rd
Vocational training
month and 6th month
STROKE UNIT MANAGEMENT

· Medical and Nursing staff : control of blood pressure; control of diabetes; swallow assessment; DVT prophylaxis; antiplatelet drugs
· Rehabilitation staff:
» Acute phase: basic bed mobility, transfer techniques, communication training, prevention of complications
» Subacute and chronic phase: mobility, gait and balance training, training of activities of daily living (grooming, eating, dressing etc), bowel/bladder
training, perceptual and cognitive rehabilitation, provision of assistive devices.

OBG
October/ 2019

Standard Treatment Workflow (STW) for

ANTE-NATAL MANAGEMENT OF NORMAL PREGNANCY
FIRST VISIT (PREFERABLY IN FIRST TRIMESTER)
ASK EXAMINE INVESTIGATIONS DO
• Age • Height, weight ESSENTIAL TESTS • UPT if in doubt
• LMP • Calculate BMI • Hemoglobin • Fill up MCH
• Parity & obstetric history • Pallor, Jaundice, Pedal edema • Urine R & M protection card or
• Any complaints especially excessive • Pulse, BP, RR, temperature • ABO & Rh grouping ANC card, make entry
nausea & vomiting/ bleeding PV • Thyroid DESIRABLE TESTS on RCH portal &
• H/o medical illness : diabetes, • Breast • VDRL/ RPR generate RCH
hypertension, cardiac problem, • Respiratory and CVS exam - • HIV number (in public
epilepsy or any other chronic illness ination • HBsAg sector)
• Consanguinity, multiple pregnancy • P/A examination, P/S and P/V • WHO OGTT/ DIPSI test for diagnosis of • Give filled MCH
• H/o blood transfusion and H/o prior examination GDM protection card & safe
surgical intervention # If woman presents with • TSH in high risk cases (BOH, goiter, obesity motherhood booklet
• Personal history : tobacco/ alcohol bleeding per vaginum do P/A or residing in iodine deficiency prone to woman
intake & P/S to confirm amount of areas) • Give Tab Folic Acid
• Family history : diabetes, hypertension, bleeding & rule out local OPTIONAL TESTS* daily
genetic disorders/ congenital causes. All such cases to be Aneuploidy screen* by USG & double • Give first dose of
problems, multiple pregnancy, referred to CHC or higher marker tetanus toxoid
infections including tuberculosis centre
SECOND VISIT (SECOND TRIMESTER)

ESSENTIAL TESTS • IFA tablet one (if Hb >11g%) or twice ( if Hb
• Any com- • Weight • Hemoglobin <11g%) daily with water or lemon juice
plaints since • Pallor • Urine albumin • Calcium carbonate 500 mg with vitamin D
last visit • Pedal edema DESIRABLE TESTS 250 mcg tablet twice daily with meals.
• Quickening • Pulse, BP in • USG ( Level II between 18-20 weeks for gross congenital • Calcium Carbonate and IFA not to be given
and/ or fetal sitting malformations) together
movements position • WHO OGTT/ DIPSI test if >24weeks & at least 4 weeks have • Single dose of Albendazole 400mg
• Adherence to • P/A elapsed after 1st test • Ensure compliance for investigations and
medications examination OPTIONAL TESTS* treatment
for fundal Quadruple test as per availability • Discuss birth preparedness
height • Give second dose Tetanus Toxoid at least four
*Should be performed only if adequate counselling facilities are available weeks after first dose
THIRD (28 – 34 WEEKS) AND FOURTH VISIT (36 - 40 WEEKS)

• Same as above • Continue IFA and calcium tablets and ensure compliance
Same as • Auscultate FHS • Hemoglobin • If non compliant or Hb < 9g% give parenteral iron sucrose therapy (not > 200mg
above • Measurement of • Urine albumin at one time & not > 3 times a week) and refer patient with Hb < 7g% to higher
abdominal girth • Optional USG for fetal centre
and Symphysiofundal growth and liquor • Refer to higher centre if any discrepancy between fundal height and period of
Height gestation
DANGER SIGNALS FOR PATIENT TO REPORT TO HEALTH HIGH RISK PREGNANCY

FACILITY • Any H/o medical illness, previous caesarean section, past obstetric
• Fever mishap or congenital malformation
• Persistent vomiting • Past H/o PPH
• Abnormal vaginal discharge • Age > 35 years or < 19 years or parity > 4
• Palpitations, easy fatigability and breathlessness at rest and/ or on • Malnourished (BMI < 18.5 kg/m 2 or > 30 kg/m 2)
mild exertion. • Hemoglobin < 7g%
• BP > 140/90mm Hg on 2 occasions 6 hours apart
• Vaginal bleeding • APH
• Decreased or absent fetal movements at > 28 weeks gestation • Discrepancy between fundal height and period of gestation > 4 weeks
• Leaking of watery fluid per vaginum (P/V) • GDM/ overt DM
• Severe headache/ blurring of vision/ convulsion * High risk pregnancy to be
• Multiple pregnancy delivered at district
• Passing lesser amounts of urine and/ or burning sensation during • Malpresentation at term hospital/medical college
micturition • Previous uterine surgery
• Itching all over the body * Preferably to have antenatal
care also at these centres
COUNSELLING AT ALL LEVELS FOR :

BIRTH PREPAREDNESS MUST INCLUDE
• Timing and place of next ANC visit based on presence or absence of risk factor
• Rest, nutrition, balanced diet and exercise IDENTIFICATION OF THE FOLLOWING :
• Counselling for HIV testing • Facility for delivery
• Danger signs • Support persons
• Institutional delivery • Birth companion
∙ Birth preparedness • Means of transport in emergency
∙ Early & exclusive breastfeeding for six months • Blood donors (if required in emergency)
• Post partum contraception
ASSESSMENT OF FUNDAL HEIGHT & ITS CORRELATION WITH

GESTATIONAL AGE
At 12 th
week : Just palpable above the symphysis pubis
At 16 th week : At lower one-third of the distance between the symphysis pubis and
umbilicus
At 20th week : At two-thirds of the distance between symphysis pubis and umbilicus
At 24 th week : At the level of umbilicus
At 28 th week : At lower one-third of the distance between the umbilicus and • UMBILICUS
xiphisternum
At 32 nd week : At two-thirds of the distance between the umbilicus and xiphisternum
At 36 th week : At the level of xiphisternum
At 40th week : Sinks back to the level of the 32 nd

week, but the flanks are full, unlike
that in the 32 nd week
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT

October/ 2019


DILATATION AND CURETTAGE (D&C)
• Mostly done for gynaecological indications, but may also be considered in early pregnancy complications
•
traditional D&C in gynaecological cases, it still has a place when other modalities are not available or do not yield adequate tissue
GYNAECOLOGICAL
GYNAECOLOGICAL
PROCEDURES
Abnormal uterine bleeding in
appropriate cases (refer to HMB STW)
Endometrial Aspiration Biopsy [EA]
Post menopausal bleeding OR

(ECC with D&C) D&C
OR
Infertility (to rule out TB)

Differential curettage (Endocervical
Amenorrhoea
curettage [ECC] with EA)
As a haemostatic measure in women

with excessive / prolonged vaginal PROCEDURES FOR
INDICATIONS : bleeding EARLY PREGNANCY
COMPLICATIONS
DIFFERENTIAL
sampling Dilatation and Evacuation [D & E]
OR
D&C
EARLY PREGNANCY COMPLICATIONS
OR
Retained products of conception- as a Evacuation (with or without suction)

treatment of inevitable, incomplete,
missed, septic or induced abortion.
CONTRAINDICATION
Molar pregnancy Acute pelvic and vaginal infections
WHERE CAN IT BE PERFORMED?

• In secondary or tertiary healthcare centres preferably where facilities for anaesthesia and operation theatre are available to deal
with procedure related complications, if any.
• Endometrial aspiration biopsy is usually done as an outpatient procedure in non pregnant cases.
ALL TISSUE REMOVED MUST BE SENT FOR HISTOPATHOLOGICAL EXAMINATION
PRE- OPERATIVE REQUISITES

Presence of a valid indication General medical fitness & no contraindication A written informed consent
ANESTHESIA (ANY OF THE FOLLOWING)

• General anesthesia • Regional anesthesia • Paracervical block with 1% xylocaine • IV sedation • IM/ oral analgesia
Strict asepsis to be maintained. Antibiotics to be used judiciously and decided as per need of individual case.
POST PROCEDURE CARE & FOLLOW UP COMPLICATIONS DOʼS DONTʼS

• Observe the patient for minimum two • Excessive bleeding • Evacuation of urinary bladder • Over abduction of legs
hours after the procedure for haemorrhage • Cervical laceration before procedure. • No sounding in cases
or any other symptoms or signs of • Perforation of the uterus • Safety checklist of pregnant uterus.
complications prior to discharge • Injury to bowel and • Dorsal/lithotomy position • No forceful insertion of
• Patient can be discharged as soon as she is bladder • Bimanual pelvic examination any instrument
comfortable and alert. • Pelvic infection prior to the procedure • Abandon the
• Most common side effect is abdominal • Post-operative intra • Sounding to measure procedure in case of
cramps which can be managed by oral uterine adhesions uterocervical length ONLY in suspected perforation
analgesics. non pregnant women. and refer to higher
• Warning signals to report backare to be • Sample to be sent for centre.
explained at the time of discharge - severe histopathology and • Insertion of the dilator
pain, bleeding, foul smelling discharge or microbiology (where should be just beyond
fever. indicated) the internal os and
• Follow up is done after a week with • REFER in case of a NOT till the fundus
histopathology report for further advice. complication
D&C is a blind procedure and may miss the pathology in some cases. In cases where focal pathology is suspected, tissue should be
obtained under hysteroscopic visualization.

October/ 2019


HEAVY MENSTRUAL BLEEDING (HMB)
ICD-10-H90.5
TO DO AT ALL LEVELS
HISTORY EXAMINATION SUPPORTIVE TREATMENT
• General
• Age
Evaluate pallor
• Parity
Calculate BMI • Reassurance
• Detailed menstrual history including irregularities
• Other medical illness: thyroid disorder, • Hematinics
• Systemic • Tranexamic acid during episode of
coagulopathy, jaundice etc
CVS, RS and hepatosplenomegaly heavy bleeding
• IUCD use
• Lactation • Local examination (where indicated and
• Drug intake feasible) P/S and P/V
MANAGEMENT OF HMB AT PRIMARY LEVEL

HISTORY AND EXAMINATION
Abnormality No Abnormality
Adolescents Women of Reproductive Age Age > 40 years

Refer to
Higher centre R/o pregnancy* Any
INVESTIGATIONS Supportive Refer to higher
Speculum examination Abnormality
• Hemoglobin Treatment centre
Pelvic examination
• Complete Blood
Count (CBC) with No abnormality
-Tranexamic acid
peripheral smear
- OC Pills
• Bleeding time / Contraception Contraception not
Clotting time desired desired
No Relief
(BT/CT)
OC Pills - NSAIDs
Refer to higher - Tranexamic acid
centre No Relief - Progestogens**
* R/o Pregnancy in doubt especially in all women of reproductive age group after appropriate consent
** Amongst progestogens Norethisterone provides the best hemostasis
MANAGEMENT OF HMB AT SECONDARY LEVEL (CHC)

HISTORY AND EXAMINATION
Adolescents Married <40 years Married >40 years Post Menopausal
Supportive treatment Do USG Refer to higher

centre
ET>12mm or Do endometrial sampling and send
Endometrial thickness
-Tranexamic acid High Risk for endometrial for histopathological examination
< 12 mm
- OC Pills cancer*
Secretory/ Non Secretory Hyperplasia without Hyperplasia with atypia/

No Relief
endometrium without hyperplasia atypia malignancy
Refer to higher - NSAIDS - Progestogens Refer to higher

centre - Tranexamic acid - Levonorgestrel- centre
- Combined OC Pills releasing intrauterine
- Progestogens system (LNG IUS)
- LNG IUS Hormonal therapy to
INVESTIGATIONS
continue for 6 months HIGH RISK FOR ENDOMETRIAL
• Hemoglobin
If no relief, CANCER
• CBC with peripheral smear
• BT / CT Refer to higher centre
If no relief or recurrence Patient having:
• ABO and Rh typing - Obesity
Refer to higher centre
• Thyroid function test - Diabetes
• USG of Abdomen & Pelvis - Hypertension
- PCOD
MANAGEMENT OF HMB AT TERTIARY LEVEL

HISTORY, EXAMINATION AND ULTRASONOGRAPHY
TREATMENT FOR ACUTE
BLEEDING EPISODE
No structural abnormality Structural abnormality
- IV Tranexamic acid 1g stat
slowly followed by oral
Tranexamic acid 0.5-1g,
Thickened Fibroids & Refer to 6-8 hourly for 5 days
Adolescents < 40 years > 40 years
endometrium polyps, Fibroid & - Blood transfusion if
and Polyps STW indicated
Treat underlying cause - NSAIDS
if present - Tranexamic Acid adenomyosis
Endometrial sampling - D&C/
(thyroid disorders, - OC Pills Hysteroscopic guided HORMONE THERAPY
jaundice, coagulopathy - Progestogens
etc) - LNG IUS Atypical - Norethisterone (max daily
No hyperplasia or
- Ormeloxifene Hyperplasia dose 40 mg)
benign hyperplasia
In absence of obvious - Ablative Techniques OR
cause Hysterectomy - Medroxyprogesterone
If no relief Conservative modalities
- NSAIDS acetate (max daily dose
- Tranexamic Acid
- Tranexamic Acid 40 mg)
- Progestogens
- OC Pills Hysterectomy Hormone therapy should
- LNG IUS
- Progestogens (Preferably after If no relief be given orally daily in
- Ormeloxifene
second opinion) divided doses from the
- Ablative
techniques fifth day of the cycle for
INVESTIGATIONS
three weeks and repeated
• Hemoglobin
• ABO and Rh typing in a cyclical manner for
• CBC with peripheral
• TSH total of 4-6 cycles of
smear
• USG of Abdomen & Pelvis treatment
• BT / CT

October/ 2019


HYSTERECTOMY FOR BENIGN GYNAECOLOGICAL CONDITIONS
IN WOMEN AGED LESS THAN 40 AND/OR LOW PARITY IT IS MANDATORY TO HAVE A SECOND
OPINION FROM A QUALIFIED GYNAECOLOGIST
HYSTERECTOMY TO BE CONSIDERED ONLY WHEN CHILD BEARING IS COMPLETED & RARELY IN YOUNGER PATIENTS
• Symptomatic fibroids especially if not responding to medical

management
• Asymptomatic fibroids greater than or equal to 14 weeks
LEIOMYOMA uterine size
• Fibroid causing hydroureteronephrosis
• Rapidly enlarging fibroids
• Submucus myoma greater than 4cm
HEAVY MENSTRUAL Failed medical treatment

BLEEDING
ROUTES OF
HYSTERECTOMY
• Failed medical treatment • ABDOMINAL

ENDOMETRIOSIS • Causing hydroureteronephrosis
• Recurrence after failed medical/ conservative • VAGINAL
surgical management
INDICATIONS : • Pelvic organ
prolapse
• Non descent
PROLAPSE Third or fourth degree utero vaginal prolapse hysterectomy
• LAPAROSCOPIC
• Endometrial hyperplasia without atypia with failed
• In appropriately
PRE - INVASIVE medical treatment
selected
DISEASES • Endometrial hyperplasia with atypia.
patients
• CIN II with poor compliance or CIN III
• Adnexal masses : Need for hysterectomy to be individualised

OTHERS and justified
• Recurrent post-menopausal bleeding (even in the absence
of malignancy)
Simple ovarian cysts less than 5 cm in size and without other significant/ suspicious features
should be kept on observation and reviewed after 6 months
HYSTERECTOMY SHOULD NOT BE DONE FOR

Fibroids which are
Minor degree of small (less than 5 cm) Simple ovarian cyst
White discharge Non specific or
Cervicitis utero vaginal less than or equal to
per vaginum abdominal or pelvic Asymptomatic
prolapse 5 cm
pain (less than12 weeks size
uterus)
COMPONENTS OF PRE OPERATIVE COUNSELLING INVESTIGATIONS

AND INFORMED CONSENT ∙ Complete Blood Count
• Blood grouping & cross matching
∙ Need for hysterectomy ∙ Fasting Blood Sugar & Post Prandial Blood Sugar
∙ Alternative treatment options ∙ Renal Function Test
∙ Risks and benefits ∙ Liver Function Test
∙ Potential complications of the procedure ∙ Urine Routine & Microscopy
∙ Removal/ conservation of ovaries & tubes ∙ Electrocardiogram
∙ Route of hysterectomy ∙ X ray chest
∙ Possible need for post operative Hormone therapy in selected cases ∙ Others as indicated
COMPLICATIONS TO BE EXPLAINED FOLLOW UP
• Risk of Infection • Discharge summary with operative details

• Bleeding (primary/ reactionary/ secondary) • Review for histopathology report
• Injury to bladder/ bowel/ ureter • Report if there is fever, bleeding or any other symptoms
• Pain • Avoid lifting heavy weight for 8 weeks
• Fever • Abstinence for eight weeks
• Hernia (rare and late complication) • Adequate iron and calcium & Vitamin D3 supplements
• Evaluate need for hormones in very selected patients
• Ovaries should be preserved in most pre-menopausal women unless diseased or removal specifically indicated
• While doing hysterectomy for benign gynaecological conditions in pre-menopausal women, it is recommended to combine it with
bilateral salpingectomy with a view to minimise the risk of subsequent development of ovarian malignancy 1,2

October/ 2019

ICD O72
More than 500 ml of blood loss or any amount of bleeding which causes
derangement of vital parameters is PPH
RED FLAG SIGN: • Call for help

SUPPORTIVE MANAGEMENT
• Rapid Initial Assessment - evaluate vital signs: PR, BP, RR and Temperature
∙ PR > 120/min • Establish two IV lines with wide bore cannula (16-18 gauge) • Monitoring of vitals
∙ Systolic BP < 100 mm Hg • Draw blood for grouping and cross matching • Measurement of
∙ Tachypnea < 95% • Start RL/ NS, infuse 1 L in 15-20 minutes * input and output
∙ SpO2 < 95% • Give Oxygen @ 6-8 L /minute by mask, • Give blood
∙ Deterioration of • Insert indwelling Catheter and connect to urobag transfusion as
sensorium • Check vitals and blood loss frequently - at least every 15 minutes indicated
• Monitor input and output
• Give Inj. Oxytocin 10 IU IM (if not given after delivery)

• Start Oxytocin infusion : 20 IU in 500 ml RL/NS @ 40-60 drops per minute
• IV bolus of oxytocin should NOT be given
• Check to see if placenta has been delivered.
PLACENTA NOT DELIVERED PLACENTA DELIVERED
• Continue Oxytocin drip • Fundal Massage of the uterus

• Palpate uterus • Inspect placenta for completeness
• Attempt controlled cord • Explore uterus for any retained
traction if uterus is placental bits/ membranes/ clots
contracted and evacuate
PLACENTA DELIVERED PLACENTA NOT Uterus well

contracted but Uterus
• Continue oxytocin and DELIVERED flabby
uterine massage Shift for manual bleeding continuing
• Check for completeness of removal of placenta
placenta and membranes (MRP)
TRAUMATIC PPH ATONIC PPH
• Explore for cervical/ vaginal/ perineal tears. Repair if Bimanual

present compression and
If bleeding continues • If bleeding persists despite repair of above, suspect
without any apparent cause pharmacotherapy
inadequate repair, rupture uterus or scar dehiscence. as per details
check for coagulopathy • Shift to OT for exploration under GA and/or below
laparotomy
* Arrange for blood / blood product at the earliest

3 ml of crystalloid solution should be used to replace every ml of blood lost during the initial part of the acute bleeding phase
MANAGEMENT OF ATONIC PPH
PHARMACOTHERAPY
ANY OF THE FOLLOWING OPTIONS CAN BE USED EITHER ALONE OR COMBINATION AS PER AVAILABILITY
Inj Methyl Ergometrine 0.2 mg IM or IV slowly

∙ Contraindicated in hypertension, severe Inj Carboprost (PGF2 alpha) 250 µg IM
Or Tab Misoprostol (PGE1) 800 µg Or • Contraindicated in asthma
anemia, heart disease
Per rectal or sublingual • Can be repeated every 20 minutes
∙ Can be repeated after 15 minutes to a
to a maximum of 8 doses (2 mg)
maximum of 5 doses (1mg)
Bleeding not controlled Bleeding controlled
Explore uterus for retained bits • Repeat uterine massage every 15 minutes for first two hours
• Monitor vitals every 10 minutes for 30 minutes , every 15 minutes
for next 30 minutes and every 30 minutes for next 3-6 hours or
Continue bimanual compression & Oxytocin infusion @10-20 units /hr until stable
• Continue Oxytocin infusion @5-10 units /hr
Bleeding not controlled (total Oxytocin not to exceed 100 IU in 24 hours)
• Check for coagulation defects Intra uterine balloon tamponade Tranexamic Acid (1g slow IV) has recently been
• If present give blood and blood using condom catheter recommended as an adjunctive treatment for PPH
components
to be used as early as possible irrespective of cause
Bleeding still not controlled but definitely within three hours of delivery. It can
be repeated after 30 minutes if bleeding persists.
Surgical intervention Standard treatment for PPH must continue
• Uterine compression sutures meanwhile 1, 2
• Systematic uterine devascularisation by doing
1 The WOMAN trial, The Lancet, 2017
Uterine Ovarian Internal Iliac artery ligation
2 WHO update on Tranexamic Acid, 2017
• Hysterectomy
Timely Referral to a higher centre must be considered if facilities for blood transfusion or exploration and surgical intervention are not available.
Patient must be transported with I/V fluids containing oxytocin on flow and preferably with uterine/vaginal tamponade in situ.
• Aortic compression may be used as a short time measure to reduce blood loss while awaiting definitive steps.
• Non- pneumatic anti-shock garment (NASG) should be used during transport if available
• Uterine artery embolization may be offered in selected patients if facilities are available

October/ 2019


UTERINE FIBROIDS AND POLYPS
ICD-10-D25 & N84
Heavy menstrual/ irregular

bleeding EXAMINATION
GPE: Specially check for pallor
Urinary pressure symptoms Abdominal examination: Check for any

suprapubic mass or lump
P/S: Inspect cervix for local abnormalities

Heaviness and pain in
abdomen, dysmenorrhoea P/V: Assess for uterine size (enlarged
and/or irregular uterus)
SYMPTOMS:
Mass in lower abdomen
INVESTIGATIONS
Hemoglobin
Infertility
Complete blood count
Asymptomatic Thyroid function test
USG
ASYMPTOMATIC FIBROIDS <5CM DO NOT NEED TO BE TREATED
FIBROIDS & POLYPS
Endometrial polyps / sub Fibroids Fibroid Polyps

mucus fibroids
Thin pedicle Thick pedicle
Polypectomy Individualized management

at tertiary centre
Small Fibroids
(<5cm)
Hysteroscopic removal Asymptomatic Symptomatic
• Endometrial polyps Medical

• Select appropriate Management : Large Fibroids
patient with Observation - Tranexamic acid (Uterine size >12 weeks)
submucus fibroids - Levonorgestrel-releasing intrauterine
(selection should be system (if uterine cavity normal)
based on size and - Progestogenic agents*
proportion of the
fibroid projecting
into the uterine No Relief
cavity)
Discuss treatment
option based on
age and parity
Non surgical Surgical
Uterine artery Myomectomy Hysterectomy

embolization (younger age (to be avoided in
&/ or young patients
low parity) aged <35 years as
far as possible)
*Norethisterone (max daily dose 40 mg) OR Medroxyprogesterone acetate (max daily dose 40 mg). Any hormone should be given orally daily
in divided doses for a duration of three weeks and repeated in a cyclical manner for total of 4-6 cycles of treatment
ALL THERAPUTIC OPTIONS NEED TO BE EXPLAINED TO THE PATIENT INCLUDING JUST KEEPING THE PATIENT ON OBSERVATION.
ALL PATIENTS OF FIBROID UTERUS DO NOT NECESSARILY NEED HYSTERECTOMY.
PAEDIATRICS
October/ 2019


ACUTE ENCEPHALITIS SYNDROME (AES) IN CHILDREN
ICD-10-G04
SYMPTOMS
ADDITIONAL INFORMATION (HISTORY OF)
Fever, headache, vomiting,
lethargy, unconsciousness
Acute onset of fever • Rash, vesicles, past history of chicken pox

( </= 5-7 days) with • Residence of child: rural/urban, endemic for cerebral malaria, any
altered sensorium epidemic of AES in neighborhood
Seizures
and/or new onset of • Animal contact, insect bite, dog bite
seizures • Drug or toxin exposure: enquire for presence of any drugs at home
(excluding simple • Recent travel
febrile seizures) • Trauma
• Seizures
Abnormal posturing
• Recent immunizations
• Recurrent episodes of encephalopathy
• Past or concurrent systemic illness
• Pre-morbid developmental/ neurological status of the child
Paucity of limb movements
EXAMINATION
VITAL SIGNS GENERAL EXAMINATION NEUROLOGICAL EXAMINATION

• Level of consciousness by Glasgow Coma Scale (GCS)
• Temperature • Pallor • Abnormal posturing: decerebrate, decorticate
• Pulse rate • Petechieae • Active seizures
• Respiratory rate • Rash • Cranial nerves: pupil size and reaction, doll’s eye movements, squint, facial deviation
• Blood pressure • Icterus • Focal neurological deficits
• Meningeal signs
INVESTIGATIONS
ESSENTIAL DESIRABLE OPTIONAL
CBC, LFT, KFT, blood sugar, CECT Brain, MRI Brain, CSF PCR for Herpes CSF Neurovirology panel, anti-NMDA receptor antibody
CSF examination* (cytology, biochemistry, culture, simplex encephalitis, JE testing, PCR viral testing of other samples (throat swab,
AFB staining, Gene Xpert), peripheral smear for serology, EEG, Dengue nasopharyngeal aspirates, stool etc), Blood Tandem Mass
malarial parasite, Rapid Malarial Antigen Test serology and NS1 testing, HIV Spectrometry and urine gas chromatography, antinuclear
testing antibodies
*Lumbar puncture is contra-indicated or neuroimaging must be obtained before lumbar puncture

1.Fundus: papilledema 2. Platelet count < 50,000 3. Focal neurological deficits 4. Asymmetric/unreactive pupils 5.Decerebrate/decorticate posturing
MANAGEMENT
All patients need to be admitted.

If any of the following signs are present, the child should be referred to tertiary care facility with PICU and facilities for mechanical ventilation:
• Glasgow Coma Scale < 8 • Abnormal breathing pattern • Shock not responding to fluid bolus • Decerebrate or decorticate posturing
• Seizures persisting despite benzodiazepine and phenytoin
Step I: Rapid assessment and stabilization Step II: History, Examination and Investigations as given above
• Establish and maintain airway: Intubate if GCS<8,
impaired airway reflexes, abnormal respiratory pattern,
signs of raised intracranial pressure, SpO2 <92% despite
Step III: Empirical Treatment (must be started if CSF cannot be
high flow oxygen and fluid refractory shock
done/ report will take time and patient sick)
• Ventilation, oxygenation
• Ceftriaxone: 100 mg/kg/day in 2 divided doses X 10-14 days
• Circulation: Establish IV access, take samples for
• Acyclovir (use in all suspected sporadic viral encephalitis):
relevant investigations, fluid bolus if in circulatory failure
3 mo to 12 y: 500mg/m2 8 hourly (min 21 days)
(20 mL/kg NS), inotropes if required
>12 y: 10mg/Kg 8 hourly (14-21 days in confirmed cases)**
• Identify signs of cerebral herniation or raised ICP
• Artesunate combination therapy (stop if peripheral smear and RDT are
• Temperature: treat fever and hypothermia
negative) : 3mg/kg in child <20 kg, and 2.4mg/kg in child > 20kg IV/IM at 0,12
• Treat ongoing seizures- Benzodiazepine, followed by
and 24 hours, followed by once daily parental/oral X 3-7 days
phenytoin loading
**If therapy was started empirically stop acyclovir, in case an alternative diagnosis is
confirmed, or HSV PCR of CSF is negative on two occasions (24-48 h apart) and MRI
imaging not suggestive of Herpes Simplex Encephalitis
Step V: Prevention/treatment of complications and

rehabilitation Step IV: Supportive care and treatment
• Physiotherapy, posture change, prevent bed sores and • Maintain euglycemia, hydration and control fever
exposure keratitis • Treat raised intracranial pressure#, mild head-end elevation–15-30°
• Complications: aspiration pneumonia, nosocomial • Treat seizures##; Give anticonvulsant if: history of seizures / GCS <8 /
infections, coagulation disturbances child has features of raised ICP
• Nutrition: early feeding • Steroids: Pulse steroids (methylprednisolone) to be given in children with
• Psychological support to patient and family suspected acute disseminated encephalomyelitis or autoimmune
encephalitis
#Management of raised intracranial pressure ##Treatment of seizures

• Intubate if: GCS <8 / evidence of herniation / irregular respirations and inability to 1st Line: IV Lorazepam 0.1mg/kg or Midazolam 0.2 mg/kg
maintain airway orDiazepam 0.3 mg/kg).
• Signs of impending herniation: patient to be hyperventilated to a target PaCO2 of If no IV access: IM Midazolam 0.2 mg/kg
30-35 mmHg 2nd Line: Inj. Phenytoin 20 mg/kg (in Normal saline
• Initial bolus of Mannitol(0.25 g/kg), then 0.25 g/kg q 6 h as per requirement, up to 48 1mg/kg/min)
hours. If seizures still persist:
• In the presence of hypotension, hypovolemia, and renal failure: hypertonic (3%) saline Refractory status: Transfer to PICU -> midazolam infusion
(preferable to mannitol) 0.1–1 mL/kg/hr by infusion; serum sodium to be targeted to (1-18 microgram/kg/min)
145-155 meq/L If ICU facilities not available: sodium valproate (20 mg/kg) or
• Adequate sedation and analgesia levetiracetam (20-40 mg/kg) or phenobarbitone (20mg/kg)
• Avoid noxious stimuli
• Administer nebulized lignocaine prior to endotracheal tube suctioning
DISCHARGE CRITERIA
Parents have been explained the
Hemodynamically Improvement in Has started eating Seizures have
Afebrile supportive care and physiotherapy
stable consciousness and drinking orally subsided
to be continued at home

REFERENCES
1. World Health Oraganisation. Acute Encephalitis Syndrome. Japanese encephalitis surveillance standards.January 2006. From WHO-recommended standards for surveillance of selected vaccine-preventable diseases.
WHO/V&B/03.01. Available from: http://www. who. int/vaccines-documents/ DocsPDF06/843.pdf
2. National Program for Prevention and Control of Japanese Encephalitis/Acute Encephalitis Syndrome 2014. Government of India Ministry of Health & Family Welfare Directorate General of Health Services National Vector
Borne Disease Control Programme.
3. Sharma S, Mishra D, Aneja S, Kumar R, Jain A, Vashishtha VM. Consensus guidelines on evaluation and management of suspected acute viral encephalitis in children in India. Indian Pediatr. Nov 2012;49(11):897-910.
4. Sankhyan N, Vykunta Raju KN, Sharma S, Gulati S. Management of raised intracranial pressure. Indian J Pediatr. 2010 Dec;77(12):1409-16.
October/ 2019


ACUTE DIARRHEA
ICD-10-R19.7
ASK FOR SKIN PINCH TEST REFER TO HOSPITAL
• Duration • Locate the area on the child’s • Severe malnutrition/ HIV
• Blood in stool abdomen halfway between the • Severe dehydration
• Vomiting, fever, cough, recent umbilicus and the side of the • Hypernatremic (Na >145mmol/L) /
measles, HIV status (if known) abdomen. hyponatremic dehydration (Na
• Immunization status and pre • Use thumb and first finger to pinch <135 mmol/L)
DIARRHEA IS
illness feeding practices and not finger tips. • Dysentery with age <1 yr/ measles
• >3 loose or watery
• Fluids/ food/ drugs and other • The fold of the skin should be in a line in past 6 weeks/ dehydration/ sick
stools/ day
remedies taken during illness up and down the child’s body. • Dysentery with no improvement
• Acute Diarrhea <14
• Firmly pick up all layers of the skin and on antibiotics
days
tissue under them. • Persistent diarrhea with
• Persistent diarrhea
• Pinch the skin for one second and then dehydration
>14 days EXAMINATION release it. Look to see if the skin pinch • Persistent diarrhea with serious
• Dysentery – blood • General condition of child goes back: systemic infection such as
in stools • Nutritional status (weight/ • Very slowly (longer than 2 seconds) pneumonia, sepsis, infants <4
weight for height / MUAC) • Slowly (skin stays up even for a months of age, or when there is
• Classify malnutrition if any brief instant) no improvement with treatment
• Signs of dehydration & • Immediately (normal) over 5 days
classify dehydration
MANAGEMENT
CLASSIFY DEHYDRATION
2 of following: 2 of following:
Not enough signs to a) Restless , irritable a) Lethargy / unconscious
classify some or severe b) Sunken eyes b) Sunken eyes
dehydration c) Drinks eagerly, thirsty c) Not able to drink/ drinking poorly
d) Skin pinch - goes back very slowly d) Skin pinch - goes back slowly
NO DEHYDRATION: PLAN A SOME DEHYDRATION: PLAN B SEVERE DEHYDRATION: PLAN C

• Fluids • Manage in clinic /daycare facility with recommended • Urgent referral to hospital
• Give extra fluids (as much as child amount of ORS (75ml /kg) over 4 hour period • Mother to continue rehydration by giving
will take) until diarrhea stops. • If weight is not known frequent sips of ORS during transport or use
• Use WHO ORS after each loose NG tube when possible in patients with
stool (in addition to usual fluid AGE
<4 4 -11 12 -23 2–4 5-14 15 years poor drinking
months months months years years or older
intake) NO
• Upto 2 yrs → 50 -100 ml 5 – 7.9 8 - 10.9 11 – 16 – 30 kg or
WEIGHT <5kg kg kg 15.9 kg 29.9 kg more CAN YOU GIVE INTRAVENOUS
• 2 yrs or more → 100 -200ml (IV) FLUIDS IMMEDIATELY?
200 - 400 - 600 - 800 - 1200 - 2200 -
• On ORS packet check whether IN mL 400 600 800 1200 2200 4000
200ml or 1 litre of clean water is NO
needed • After 4 hours reassess the child, classify dehydration • Start IV fluid immediately
• Frequent small sips with spoon or and select appropriate plan (A /B/C) • Ideal fluid is Ringer lactate solution / Normal
cup. • Give extra fluids, zinc supplement, feeding advise and saline (DNS in malnourished)
• If child vomits, wait 10 minutes counselling regarding danger signs* as in plan A FIRST GIVE THEN GIVE 70
then continue slowly. • Follow up in 5 days if no improvement AGE
30 ML/KG IN ML/KG IN
• Homemade fluids- salted rice
Infant (< 12 1 hour 5 hours
water, salted yogurt drink, months)
vegetable or chicken soup with salt Older 30 minutes 2.5 hours
PATIENT EDUCATION
and clean water, unsweetened fresh
fruit juice and coconut water • Danger signs* • If child can drink, give ORS by mouth while
• Unsuitable fluids - carbonated • Hygiene practices the drip is set up
beverages, commercial fruit juice, • Hand washing , proper disposal of excreta • Assess heart rate/ respiratory rate/ BP/ CFT/
sweetened tea & coffee, other • Safe drinking water consciousness and recognize early shock
medicinal teas / infusions. • Appropriate feeding practices • Refer for hospitalization
• Zinc supplement (Zinc sulphate/ • Vaccination as per IAP guidelines • If prevalance of cholera –
carbonate / acetate) Doxycycline single dose 300mg or
• 2-6 months → 10mg/day x 2 weeks Tetracycline 12.5mg/kg 4 times a day x 3 days.
• >6 months → 20mg/day x 2 weeks INVESTIGATIONS For young children Erythromycin 12.5mg/kg
• Counsel Mother/ Attender • Some dehydration: 4 times a day x 3 days
• Feeding advise Preferable Tests- electrolytes • Associated vomitings –
• Infants on breast feed, to Ondanstetron 0.15 mg/kg/dose IV/oral in
• Severe dehydration:
continue more frequent breast addition to rehydration therapy
Essential tests- CBC, electrolytes
feeding than usual. • Reassess every 15-30 minutes till a strong
Preferable Tests- Renal Function Tests, VBG
• Those not on breast feed to radial pulse is present and then every hour
• In suspected cholera cases:
continue their usual milk feed/ If hydration status is not improving, give IV
Preferable tests- stool for hanging drop and
formula at least once in 3 hours. drip more rapidly
stool culture
• Give age appropriate foods to >6 • After 6 hours (infants) and 3 hours (older
• Dysentery: (no response to antibiotic in 2
months old based on their pre patients) - evaluate for dehydration and
days) Preferable test- stool culture & stool choose the appropriate plan (A, B, or C) to
illness feeding pattern
routine for trophozoites of Ameoba continue treatment
• Persistent diarrhea: • Give ORS (about 5 ml/kg/hour) as soon as
• Danger signs (return immediately) Preferable test- stool routine microscopy, the child can drink: usually after 3-4 hours
• Passing many watery stools urine routine microscopy, urine culture , (infants) or 1-2 hours (children)
• Repeated vomitings / very thirsty sepsis screen • Observe for 6 hours after the child has been
• Eating / drinking poorly
fully rehydrated.
• Develops fever / blood in stools
• In hypernatremic and hyponatremic
WHEN CONSIDERING ALTERNATIVE DIAGNOSIS OF dehydration child appears relatively less ill /
• Follow up in 5 days if no improvement PERSISTENT DIARRHEA AND DYSENTRY more ill respectively and needs to be
referred for hospitalization
DISCHARGE CRITERIA
PERSISTENT DIARRHEA • Suffcient rehydration (indicated by wt gain
• Appropriate fluids to prevent or treat dehydration &/or clinical status)
• Nutrition: • IV fluids no longer needed
• If breastfeeding, give more frequent, longer breastfeeds, day and night. • Oral intake = / > losses
• Other milk: replace with increased breastfeeding, or with fermented milk • Medical f/u available
products, such as yogurt, or half the milk with nutrient-rich semi-solid food.
• For other foods, follow feeding recommendations for the child’s age: give
small, frequent meals (at least 6 times a day), and avoid very sweet foods or DYSENTERY
drinks.
• Treat dehydration according to assessment.
• Zinc for 14 days
• Supplement vitamins / minerals • Ciprofloxacin 15mg/kg twice a day and reassess
• Antimicrobial to treat diagnosed infection after 2 days.
A) Intestinal infection: Improvement: 3 days of treatment
• If blood in stool: Treat like dysentery • No improvement → Cefixime 10 mg//kg/d, 2 div
• If stool routine suggestive of Amoebiasis: Treat for it doses. Reassess after 2 days. If better complete
• If stool suggestive of cyst/ Trophozoite of Giardia: Give Metronidazole 3 -5 days of treatment.
5mg/kg/dose x 8hrly x 5 -7 days • If stool routine positive for Ameobiasis :
B) Treat Non intestinal such as UTI / Otitis Media Metronidazole 10mg/kg/dose 8 hourly x 7
• Follow up in 5 days days (10 days in severe cases)
• Refer to hospital (See box) • Refer to hospital (See box)
REFERENCES
1. IMCI (WHO) module on Diarrhea 2014.
2. WHO Treatment for Diarrhea - A manual for physicians and other senior health workers 2005.
3. WHO GLOBAL TASK FORCE ON CHOLERA CONTROL 2010.
October/ 2019


DENGUE FEVER
ICD-10-A90
SYMPTOMS WARNING SIGNS

Fever and two of the following
• Abdominal pain or tenderness
criteria:
• Persistent vomiting
1. Nausea Live in /
• Clinical fluid accumulation – pleural effusion,
2. Vomiting travel to
WHEN TO 3. Rash dengue
ascites.
• Mucosal bleed – malena, epistaxis, gum bleed
SUSPECT? 4. Myalgia endemic
• Liver enlargement > 2 cms
5. Headache area
• Shock (DSS) – weak rapid pulse, pulse
6. Retro orbital pain
pressure < 20mm Hg hypotension, cold
7. Arthralgia
clammy skin, restlessness.
8. Hemorrhagic manifestations
Dengue without Dengue with Severe

ASSESSMENT warning signs warning signs dengue
TREATMENT OF PROBABLE DENGUE SEVERE REASONS FOR REFERRAL

WITHOUT WARNING SIGNS DENGUE
• Cold extremities,
restlessness
• Fluid accumulation with • Acute abdominal pain
• Symptomatic ambulatory respiratory distress • Decreased urine output
treatment
• Bleeding and
• Paracetamol for fever: avoid NSAIDs • Severe bleeding hemoconcentration
• Daily monitoring: clinical, PCV, • Rising PCV &
platelets • Impaired consciousness thrombocytopenia without
clinical symptopms
INVESTIGATIONS
ESSENTIAL DESIRABLE OPTIONAL
• Chest X-ray • Echocardiography
• Hb, TLC, DLC, Platelets, PCV • PCR - dengue
• LFT, RFT,
• Positive tourniquet test • CPK, albumin • CVP monitoring
• NS1 antigen (ELISA method) • USG abdomen • USG guided measurement of collapsibility of
• Dengue IgM IVC for monitoring hypovolemia
SHOCK
Assess airway, breathing, circulation & start oxygen inhalation
COMPENSATED SHOCK HYPOTENSIVE SHOCK

(tachypnea, tachycardia, normotensive) (tachypnea, tachycardia, hypotension, peripheral pulses not palpable)
Ringer’s Lactate/ NS 10 ml/kg/hr 20 ml/ kg crystalloid or colloid in 15 minutes
Assess after every hour by checking HR, Assessment of Shock

RR, BP, CVP and PCV (monitor HR, RR, BP, PCV and CVP)
No Improvement Improvement
RL 10-15ml/kg/hr RL 5-7ml/kg/ 1-2hr

Gradually decrease
PCV Increased PCV Decreased infusion rate
Assessment at second hour
Further Improvement 10ml/kg/hr 1-2 hr
No Improvement Colloids 10-20ml/kg Blood Transfusion 7ml/kg for 2-3 hrs
RL 3-5ml/kg/hr 5ml/kg for 2-4 hrs
RL 15ml/kg/hr 3ml/kg for 2-4 hrs
Continue IV fluids till Assessment Stop at 48 hours
Assessment at third hour stable for 24 hours
Colloids 10ml/kg/hr
Once stable, observe for
24 hours, then discharge
Look for blood loss, acidosis
No Improvement if the discharge criteria is
cardiac dysfunction and treat
fulfilled
accordingly
Look for anemia, acidosis,

myocardial dysfunction and In case of shock, start bolus and arrange for urgent referral with continuous monitoring
treat accordingly by a health professional to facilities with a PICU.
INDICATION FOR PLATELET TRANSFUSION & PACKED RED CELLS
PACKED RED CELLS PLATELETS FRESH FROZEN PLASMA/

• Loss of blood (overt blood) 10% or • Prolonged shock CRYOPRECIPITATE
more of total blood volume.
• Prophylactic platelet transfusion (PLT <10.000/cumm) Coagulopathy with
• Refractory shock
• Fluid overload • Systemic massive bleeding bleeding
DISCHARGE CRITERIA (ALL OF THE FOLLOWING CONDITIONS MUST BE PRESENT)

CLINICAL LABORATORY
• No fever for 48 hours • Increasing trend of platelet count
• Improvement in clinical status (check for general well-being, appetite, haemodynamic status, • Stable haematocrit without intravenous fluids
urine output, respiratory distress)

October/ 2019


FEVER IN CHILDREN
ICD-10-R50
FEVER IS Core (rectal) temperature ≥ 38.0ºC (100.4ºF) or axillary temperature > 37.5ºC (100.4ºF).
EXAMINATION CLUES TO A SPECIFIC DIAGNOSIS
Vital signs: Temp, HR, RR, BP, CFT Fever + respiratory symptoms:
Fever duration • Cough, runny nose: URTI
• Membrane over tonsils/pharynx:
Diphtheria
Appearance: Sick, toxic, lethargic, irritable, • Paroxysmal cough: Pertussis like illness
inconsolable, dehydrated • Barking cough:
Localizing symptoms of: RTI, UTI, GI Laryngotracheobronchitis/ croup
tract infection, CNS infection
General Examination:
• Ear, nose, throat Fever + rash
• Rash (petechieae, macules, papules, vesicles, • Red maculopapular rash: Measles,
WHAT Rash, joint symptoms, skin/ soft
nodules, polymorphic)
Rubella, Dengue.
• Fine generalized maculopapular rash
TO ASK? tissue swelling or redness
• Lymphadenopathy with systemic dysfunction/shock:
• Skin (pustules, pyoderma, impetigo, Meningococcemia.
cellulitis) • Itchy erythematous macules evolving
to clear vesicles: Varicella
Vaccination within 24 hours, • Joints
drug/ toxin exposure • Genitalia (for erythema, tenderness, edema)
• Bones Fever + other symptoms:
• Parotid gland swelling: Mumps
Family/ neighbourhood • Arthritis: Consider Chikungunya, acute
history of similar illness Systemic Examination rheumatic fever, JIA
• Strawberry red tongue, skin peeling,
• Chest auscultation, abdominal palpation, lymphadenopathy, conjunctival
CNS, CVS injection: Kawasaki disease
INVESTIGATION OF THE FEBRILE CHILD

(Consider if one or more of the following are warranted. Perform investigations only where result impacts management)
<7 DAYS FEVER ALONE <7 DAYS AND LOCALIZING <7 DAYS AND NON >7 DAYS AND FEVER ALONE >7 DAYS AND LOCALIZING
SYMPTOMS PRESENT SPECIFIC SYMPTOMS OR WITHOUT LOCALIZING SYMPTOMS PRESENT
SYMPTOMS
ESSENTIAL: ESSENTIAL: As given in the ESSENTIAL: As given before ESSENTIAL: All mentioned in ESSENTIAL: All investigations
If fever <72 hours and first box Essential & Desirable list in the mentioned in the prior
child not looking sick: No DESIRABLE: As given prior boxes. Additionally boxes
investigations before. Additionally consider Widal test.
If fever >72 hours, DESIRABLE: As given in consider: serology for
DESIRABLE: All
DESIRABLE: Consider Mantoux investigations mentioned in
consider: TLC, DLC, P.S for the first box + consider: specific viral infection, test, ultrasonography
leukocyte (Clean-catch) urine the prior boxes. Additionally
rapid antigen test for
morphology, malarial microscopy & culture, consider: serology for
malaria, NS1 antigen and
Brucella, CMV, Herpes,
parasite & platelet count chest Xray, CSF analysis dengue IgM antibody, OPTIONAL: As given before.
Additionally consider: Japanese encephalitis. CT
blood culture, serology
scan in deep seated abscess
DESIRABLE: Rapid for scrub typhus Ultrasonography of abdomen,
OPTIONAL: As given in the chest, pericardium, joint(s), or lung abscess, Bone
antigen test for malaria,
first box + consider: abscess, lymph node clusters, marrow examination, ANA
NS1 antigen and dengue
IgM antibody, blood ultrasonography, throat/ OPTIONAL: As given before parotid gland etc, for profile, HIV serology, PET
pharyngeal swab, pus microscopy, Xpert MTB RIF assay, scan.
culture
Mycobacterial culture. Consider:
aspiration. OPTIONAL: All
OPTIONAL: C reactive bone marrow, ANA-profile, HIV
investigations mentioned in
protein, procalcitonin serology, echocardiography, CT
PET scan.
the prior boxes
MANAGEMENT
STEP1 STEP2 STEP3 STEP4 STEP5
INITIAL ASSESSMENT AND CONSIDER HOSPITALIZATION CONSIDER REFERRAL TO

FOR OBSERVATION/ EMPIRIC MANAGEMENT CONSIDER DISCHARGE WHEN
STABILIZATION TERTIARY CARE CENTRE
MANAGEMENT IN
Manage urgent issues • All neonates (after appropriate • Consider based on • Afebrile > 48 hours or
• Decrease body • Young infants with toxic stabilization and/or likely diagnosis, fever is showing
temperature with appearance. initial management) : sickness status, and defervescence
Paracetamol (15mg/kg • Severe malnutrition, toxic • Need for intensive care availability of • Feeding well
by any route) and/or appearance, inability to • Complex multi-system investigation facilities. • Presenting symptoms (in
hydrotherapy. feed, lethargy, irritability, disease. • Empiric treatment addition to fever)
• Manage any dehydration, etc. • Confirmed should be tailored resolved/resolving
life-threatening issue. • >14 days illness without complications of the based on • Physician is satisfied that
• Consider first dose diagnosis. primary illness subsequently available further care can be
antibiotic in suspected • Any reason deemed by investigation reports & continued on
meningitis, severe the treating physician. local antimicrobial ambulatory basis
pneumonia, or severe sensitivity. • Duration of i.v antibiotic
malnutrition. • Anti tuberculosis therapy is completed
• Consider anti-malarial in treatment (ATT)
suspected malaria should not be started
on empiric basis
except in suspected
TBM
ABBREVIATIONS
ANA: Anti-nuclear antibody CSF: Cerebro-spinal fluid HR: Heart rate RTI: Respiratory tract infection
BP: Blood pressure CT: Computed tomography JIA: Juvenile idiopathic arthritis TLC: Total leukocyte count
CFT: Capillary filling time DLC: Differential leukocyte count PET: Positron emission tomography URTI: Upper respiratory tract infection
CMV: Cytomegalovirus CVS: Cardiovascular system PS: Peripheral smear UTI: Urinary tract infection
CNS: Central nervous system GI: Gastro-intestinal RR: Respiratory rate
REFERENCES
1. World Health Organization. Integrated Management of Childhood Illness: distance learning course.
http://apps.who.int/iris/bitstream/handle/10665/104772/9789241506823_Module-5_eng.pdf;jsessionid=942F89F89671BA396EC7F46C9B5C1158?sequence=7
2. Mahajan P, et al. Consensus Guidelines on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India. Indian Pediatr 2017; 54: 652-60.
3. World Health Organization 2015. Government of India National Guidelines for Clinical Management of Dengue Fever.
4. Kliegman RM (ed). Nelson Textbook of Pediatrics 20th edition, 2016.
October/ 2019


SEPSIS AND SEPTIC SHOCK IN CHILDREN
ICD-A41.9, R65.21
WHEN TO SUSPECT (2-59 MONTHS)? CHECK FOR HISTORY OF
Sepsis
to be suspected: Decreased Prior treatment
Poor Feeding Lethargy Unconsciousness
in children with any responsiveness
Previous recurrent infections
infections (fever with
or without rashes/ Cold/ Rapid or
bluish shallow Chest Prior hospitalisation
pneumonia/ in drawing Stridor
peripheries breathing
diarrhoea) and they Chronic systemic illness
are at risk of life Excessive Decreased (congenital or acquired)
threatening organ Convulsions Stiff neck
vomiting urine output Immunization (age appropriate)
dysfunction
EXAMINATION
GENERAL PHYSICAL EXAMINATION VITAL SIGNS SYSTEMIC EXAMINATION
Lethargy Petechial rash Pulse volume (High volume as Heart rate and Respiratory: Signs of respiratory
well as low volume/feeble respiratory rate distress – retraction, nasal flaring,
Decreased alertness Mucosal bleeding (outside the age range) grunting ,crepitation on auscultation
pulse)
Activity Rapid breathing CVS: Murmur, gallop rhythm
Capillary refilling time > 3 Pulse oximetry Per abdomen: Abdominal distension
Pallor Chest in drawing seconds (saturation <95%) CNS: *AVPU scale, signs of meningitis,
>1 year child if seizures
Cyanosis Cold peripheries Blood pressure*
systolic BP < 70+ Age Skin: Rashes
(Systolic blood Pressure
Skin mottling Assess nutritional (yrs) x2) or ( lower Bone & joints: Swelling, redness,
< 70 in <1 year)
status than age range) tenderness
SIGNS OF SEVERE DEHYDRATION

Diarrhoea plus any two of these: Lethargy or unconscious, not able to drink or drinks poorly, Sunken eyes, skin pinch goes back very slowly
INVESTIGATIONS- (Based on symptoms and available facility)

Essential – Complete blood counts, peripheral blood Desirable - Blood culture, blood gas, relevant cultures (based on Optional- PCT , USG
film, urine routine, blood sugar, CRP, serum symptoms), chest X-ray, specific illness- Malaria – rapid malarial to guide the fluids
electrolytes, renal function test, liver function test antigen test, Dengue- dengue NS1, IgM, CSF study
MANAGEMENT
DIAGNOSTIC ALGORITHM
CHILD (2-59 MONTHS OF AGE WITH FEBRILE ILLNESS (WITH WARNING SIGNS)
GOOD PERIPHERAL PERFUSION POOR PERIPHERAL PERFUSION**

Admit or initiate treatment as per IMNCI guidelines 2 With fast pulse, cold peripheries, poor pulse volume, CRT >3 seconds
(Fast pulse: HR> 180 in < 12 month old child,
HR >120 in >12 month old child)
Admit, initiate treatment, refer to centre with facility of ICU,

ventilation, 24 hour monitoring (if required)
**If there is improvement after 1st bolus and
history of diarrhea present then:
Start O2 with face mask @ 4-6 lit/min, or hood @8-10
Give 70 ml/kg over 5 hours in infants and
lit if not available nasal prongs 1-2 lit/min to main-
over 2 ½ hours in a child with hypovolemic
tain SpO2 >95%, Insert two IV cannulas, give first
shock. Give additional fluids if losses
dose of antibiotics within first one hour
continue.
Start maintenance fluid in case of other

illness
Give 20 ml/kg of normal saline fluid bolus over 20- 30
Antibiotics minutes.
1. >3 months Inj Ceftriaxone 100mg/kg/day ( 2 Reassess for decreases in heart
divided doses) rate, improvement in pulse
volume and warm peripheries
2. <3 month Inj Cefotaxime 200mg/kg (divided
6-8hrly),
Inj Gentamicin 5-7.5 mg/kg single dose /day If no improvement
3. If soft tissue infection: consider Inj Cloxacillin Repeat bolus of 20 ml/kg over 30 minutes, with careful
200mg/kg divided monitoring for hepatomegaly, oxygen saturation, crepitation’s
6 hourly or Inj Amoxicillin- Clavulanic acid 30 in chest (if any of above appears then stop fluids)
mg/kg/dose 8hrly)
Inj Adrenaline- 0.3x body weight in mg in 50

ml NS or 5% dextrose at 1 ml/hr will give 0.1 If shock persists
microgram/kg/min Start Inj Adrenaline infusion
@0.1 microgram/kg/min and refer to higher centre
#For severe acute malnutrition – consider SAM STW

#For suspected Dengue follow Dengue Fever STW
When to refer When to Suspect Cardiac Failure Complications

• Shock does not improve after 2nd • History of underlying heart disease • Respiratory failure ( excessive increase in the respiratory
fluid bolus • History of forehead sweating/ suck rest suck cycle rates and inability to maintain saturation> 94% with
• Signs of fluid overload • Murmur oxygen) -non-invasive (CPAP/BIPAP) or invasive
• No facility for continuous • Hepatomegaly or basilar crept ventilation
monitoring. • Congestive heart failure- Dobutamine / Milrinone
• Before referral counsel the parents If it is suspected be careful in giving fluid bolus infusion and Furosemide
and inform referring facility • Infections on other sites- explore and treat accordingly
DISCHARGE CRITERIA
Completion of antibiotics Vitals within normal limit Adequate urine output
Afebrile for 48 hours Good oral intake
as per culture sensitivity for age >1ml/kg/hr

*DISABILITY (AVPU SCALE) A Is the child Alert? If not; V Is the child responding to Voice? If not; P Is the child responding to Pain?; U The child who is Unresponsive to voice (or being
shaken) AND to pain is Unconscious *Anything below A should be classify as danger sign
October/ 2019


SEVERE ACUTE MALNUTRITION WITH COMPLICATIONS
ICD-10-E43
COMMON PRESENTATION DIAGNOSTIC CRITERIA FOR EXAMINE FOR
• Faulty feeding SAM & MAM • Vital signs: PR, RR, CRT
• Not exclusively breastfed • Lethargy/ irritability
for 6 months 0-6 months • Loss of subcutaneous fat
• Consider SAM if MUAC <11.0 cm • Muscle wasting
• Bottle feeding • Pallor
• Delayed/Inadequate 6-59 months • Signs of Vitamin B, K and A deficiencies
complementary feeding • Respiratory distress
• Consider SAM if MUAC <11.5 cm • Dehydration
• Poor appetite or WHZ <-3 SD or bilateral
• Not gaining weight pitting oedema
• Lethargic • Consider MAM if MUAC is TRIAGE
• Disinterested in surroundings between 11.5- 12.4 cm or WHZ is SAM + GOOD APPETITE + NO MEDICAL
• Delayed development between -2 to -3 SD COMPLICATION
WHEN TO Home based treatment + oral amoxicillin
Additional symptoms of >5 years
SUSPECT? complications • Consider SAM if BMI ≤ 3SD
50 mg/kg/dose twice a day for 7-10 days
• Loose motions (severe thinness)
• Jaundice SAM + COMPLICATIONS/ POOR APPETITE/ FAILED
• Consider MAM if BMI ≤ 2 SD HOME TREATMENT
• Seizures
Inter-current infections:
(thinness) Hospitalize
• Pneumonia
• Diarrhea INVESTIGATIONS
• Sepsis ESSENTIAL DESIRABLE OPTIONAL
• Skin infections Hemogram, RBS, LFT, ECG, Stool pH, Stool
• Severe dehydration Blood Culture, Blood
KFT, Chest X-Ray, microscopic, Urine culture,
• Untreated tuberculosis RDT-HIV, Gastric gases, Ultrasound
Serum electrolytes (Na, K,
• HIV aspirate for (inferior vena cava to
• Social challenges Cal), Serum B12, Serum
CBNAAT/AFB Folate levels ascending aorta ratio)
TREATMENT
A. STABILISATION PHASE: Monitor vitals, urine frequency, stool/vomitus volumes
INTAKE: IVF (DNS) 4 ml/kg/hr for 2-3 days with early/concomitant initiation of oral feeds (130 ml/kg/day)
CONDITION PLACE OF TREATMENT TREATMENT
Facilities for supportive • Inj.. Ampicillin – 50 mg/kg/iv or im X 6hrly Plus inj. Gentamicin- 7.5 mg/kg iv or im, OD for 7-10 days
INFECTIONS monitoring, • If no response within 48 hrs or critically ill give inj. Ceftriaxone 50 mg/kg, OD for 7-10 days
(empirically) investigations and IVF • When accepting orally, switch to oral amoxicillin 40-45 mg/kg/dose twice a day for 7 days
• If prolonged diarrhea (>7 days): Metronidazole 10-12 mg/kg, 8 hrly for 7-10 days (inj.ectable or oral)
Facilities for supportive

monitoring, investigations Conscious: 50 ml of 10% Dextrose or 1 tsf sugar in 3 tsf water orally
HYPOGLYCEMIA and IVF
(RBS <54mg/dL) Transfer to intensive care Unconscious: 5 ml/kg of 10% Dextrose IV
facility to manage shock NO IMPROVEMENT treat as shock

Skin to skin care with mother (infants)
monitoring, investigations and
Warming under warmer, incandescent lamp or warmer
HYPOTHERMIA IVF. Plus warmer
(<35.5 ºC or 96 ºF) Intensive care facility to
NO IMPROVEMENT treat as shock
manage shock
monitoring, investigations Conscious: 50 ml of 10% Dextrose or 1 tsf sugar in 3 tsf water orally
SEVERE and IVF
DEHYDRATION Transfer to intensive care Unconscious: 5 ml/kg of 10% Dextrose IV
facility to manage shock NO IMPROVEMENT treat as shock
ELECTROLYTE Facilities for supportive

Potassium: 3-4 mmol/kg/D, orally for 2 wks
IMBALANCE monitoring, investigations
Magnesium: 0.4-0.6 mmol/kg/D1 IM followed by oral for 2 wks
(emperically) and IVF

Whole blood /PRBC transfusion (10 ml/kg over 3 hrs) : if Hb <4 gm/dL or Hb 4-6.5 gm/dL with respiratory
ANEMIA monitoring,
distress with close monitoring and hy. Furosemide (1 mg/kg) at start of transfusion
investigations and IVF
B. REHABILITATION PHASE (Transfer to NRC when child meets criteria for discharge* & accepts home available foods)
FEEDING ELECTROLYTES VITAMINS
Place of treatment: Facilities for supportive monitoring Place of treatment: Facilities for supportive Place of treatment: Nutritional
Treatment: monitoring rehabilitation center (NRC)
a. 6 months and above: F75 at least 5 times/day gradually Treatment:
increasing to give 150-200 kCal/kg/day (usually 2-3 days) then Treatment:
a. Zinc: 2 mg/kg/day X 2wks orally a. Vitamin A: >12 months- 2 lac iu, 6-12
switch to F100 for next 5-7days with introduction of home
available food b. Copper: 0.3 mg/kg/day X 2 wks orally months: 1 lac iu, <6 months: 0.5 lac
b. Below 6 months: same as above with return to exclusive c. Iron: 3 mg/kg/day once weight gain iu if food not fortified
breastfeeding where ever possible has started orally for 6 weeks b. Vitamin D, A, B Complex: RDA
*CRITERIA FOR DISCHARGE FROM HOSPITAL TO OUTPATIENT CARE: Clinically well and alert; no or resolving medical complications; no or resolving oedema (if present); satisfactory oral intake
has a good appetite (taking at least 75% of target calorie intake of 150- 200 kcal/kg/day & 0-6 months old have weight gain of 3-5 gm/kg/day for three days).
PRIMARY FAILURE OF TREATMENT: (a.) Failure to regain appetite by day 4 (b.) Failure to lose oedema by day 4 (c.) Oedema still present Day 10 (d.) Failure to gain at least 5g/Kg/day for 3
consecutive days on catchup diet. Look for unrecognized congenital abnormality, inborn errors of metabolism, immune deficiency, other major organ dysfunction, and malignancy.
APPETITE TEST: Passed if, a child not fed for last 2 hours, when fed by mother in a quiet place consumes HOW TO PREPARE F75 AND F100 F75 F100
in 1 hour:
• 7-12 months: of ≥ 25 ml/kg of F100 FRESH WHOLE CREAM MILK 300 ml 900 ml
• > 12 months: of locally prepared ready to eat food **
SUGAR 100 gm 75 gm
AMOUNT TO BE GIVEN: 15 gms or more if < 4 kg; 25 gms or more if 4 – 7 kg; 35 gms or more if 7-10 kg
**[ Mixture of Roasted groundnut 1000 gm , Milk powder 1200 gms, Sugar 1120 gms, Coconut oil 600 VEGETABLE OIL 20 ml 20 ml
gms. To be kept refrigerated for not more than 1 week.]
ADD WATER TO GET TOTAL VOLUME OF 1 Litre 1 Litre
ABBREVIATIONS
WHZ: Weight for Height Z-score MUAC: Mid-upper Arm Circumference MAM: Moderate Acute Malnutrition
SAM: Severe Acute Malnutrition SD: Standard Deviation (from median) BMI: Body Mass Index

REFERENCES
1. The WHO growth standards. Available at http://www.who.int/childgrowth/standards/en/
2. Management of severe acute malnutrition in children 6–59 months of age with oedema. Available at http://www.who.int/elena/titles/oedema_sam/en/
3. Operational guidelines on Facility Based Management of Children with Severe Acute Malnutrition.Available at
http://nhm.gov.in/nrhm-components/rmnch-a/child-health-immunization/child-health/guidelines.html
4. Kumar R, Kumar P, Aneja S, Kumar V, Rehan HS. Safety and Efficacy of Low-osmolarity ORS vs. Modified Rehydration Solution for Malnourished Children
for Treatment of Children with Severe Acute Malnutrition and Diarrhea: A Randomized Controlled Trial. J Trop Pediatr. 2015 Dec;61(6):435-41.
October/ 2019


SEVERE PNEUMONIA IN CHILDREN
ICD10-J18.9
ADDITIONAL INFORMATION
Cough, cold, with or without CHECK FOR HISTORY OF
fever, difficulty in breathing
(that includes fast breathing
and chest indrawing) of less
than 2 weeks duration. Similar illness in past, if
yes, history of
improvement with
nebulized medications to
Asthma/allergy in family.
GENERAL DANGER SIGNS consider asthma.
PRESENTING
SYMPTOMS Not able to drink, persistent
vomiting, convulsions, lethargic
/WHEN TO or unconscious, stridor in a
SUSPECT? calm child or severe
malnutrition. Influenza like illness in
Immunization (age
family over past 2 weeks:
appropriate specifically
to consider treatment for
vaccination included in
influenza.
SUSPICION OF FOREIGN BODY ASPIRATION national schedule and
Sudden onset choking and Pneumococcus,
breathlessness. Influenza).
EXAMINATION FOR VITAL SIGNS NUTRITIONAL AUSCULTATION OF

FOLLOWING SIGNS STATUS CHEST
Respiratory rates, heart
Chest indrawing, state of rate, temperature, capillary Specifically for defining Breath sounds, crepitation,
alertness, cyanosis, clubbing, refill time, pulse oximetry. Severe Acute Malnutrition rhonchi.
stridor, grunting. (SAM).
DIAGNOSTIC ALGORITHM Child age 2–59 months RED FLAG SIGNS

with cough and/or Irregular or gasping respiration,
difficult breathing. cold extremities, altered
sensorium, cyanosis.
Fast breathing (2-12 Fast breathing (2-12months>50; 1-5 years>40 ;>5

Cough and cold, months >50; 1-5 years >20 ) and/or chest indrawing with any of the
no breathing years>40; >5 years >20 ) general danger signs (not able to drink, persistent
difficulty. and/or chest indrawing vomiting, convulsions, lethargic or unconscious,
oxygen saturation>92%. stridor in a calm child or severe malnutrition).
NO PNEUMONIA PNEUMONIA SEVERE PNEUMONIA

Red flag signs positive
No red flag signs
Admit or refer to facility with following:
Ambulatory treatment Admit or refer to a facility with
Home care Appropriate: ventilation facility, ICU, round
with oral Amoxicillin following: oxygen by mask or
advice. the clock monitoring
and follow up. hood, pulse oxymeter, IV fluids,
If plan to refer: Give first dose of
oxygen, clinical supervision, X ray
antibiotics, arrange transport and inform
film (desirable).
to the referral centre.
INVESTIGATIONS TREATMENT COMPLICATIONS AND THEIR

TREATMENT
ESSENTIAL: OXYGEN INHALATION: by mask (1-2 L/min) or hood (4-6 L/Minute) to
Hemogram, random maintain oxygen saturation> 95%. NON RESPONDERS: persistence
blood sugar, CRP, IV ANTIBIOTICS: of symptoms and/or signs
chest X-ray. • For children 2-59 months: Ampicillin 100-200mg/kg in four divided doses + 48-72 hours after initiation of
DESIRABLE: Blood Gentamicin +5-7.5 mg/kg as single dose daily. appropriate
-
culture, pleural tap, • For children >5 years: Ampicillin/Amoxicillin, add macrolide treatment-change
serum electrolytes, (Azythromycin/Erythromycin) if atypical pneumonia is suspected. antimicrobials.
renal and liver • If suspected Staphylococcal pneumonia in any age (Pneumatocele on PLEURAL EFFUSION: diagnostic
function tests. CXR, post measles, infected scabies or pyoderma) add Cloxacillin/ aspiration.
OPTIONAL: ABG, lung Amoxiclavulanic acid. EMPYEMA: drainage with ICD.
ultrasound, PCT, SUPPORTIVE CARE: Paracetamol for fever, IV fluid, bronchodilators LUNG ABSCESS: change
tracheal aspirate (inhaled) as needed. antibiotics for longer duration
(gram stain with WHEN AND WHAT TO SWITCH TO ORAL AND DURATION: (4-6 weeks).
culture), • Child is afebrile, RR has returned to below age specific cutoffs, no chest PNEUMOTHORAX: Intercostal
bronchoscopy/BAL, indrawing and accepting orally: switch to oral Amoxicillin to complete a drainage.
microbiology total of 5-7 days duration (include duration of IV also in it). RESPIRATORY FAILURE: consider
culture, • If getting Doxacillin/Amoxyclav: continue oral Cloxacillin or Amoxclav for 2 ventilation.
investigations for weeks. INFECTION IN OTHER SITES:
atypical organisms, • Start feeding as soon as possible when child shows improvement. identify and treat
PCR for viral etiology. IF ASSOCIATED SAM: follow treatment guidelines for SAM. appropriately.
ADDITIONAL First and second line FIRST LINE ALTERNATE FIRST LINE SECOND LINE
antibiotics for severe
INFORMATION Amoxiclav Cefuroxime
pneumonia: Ampicillin First gen Cephalosporins Cefotaxime/ Ceftrioxone
WHEN TO REFER TO WHEN TO SUSPECT WHEN TO SUSPECT ACUTE WHEN TO SUSPECT WHEN TO SUSPECT CHRONIC
HIGHER CENTERS? INFECTION WITH H1N1 BRONCHIOLITIS? ASTHMA? RESPIRATORY PROBLEM?
VIRUS?
Facilities (as described A child below 2 years of A child of age >3 years Child has any of the
above) for treatment or Child with cold, cough, age fulfilling case with history of recurrent following: severe
complications (if fever with similar illness definition of first episode cough, cold, wheezing malnutrition, clubbing,
develops) are not in any family members, of severe pneumonia with or without fever with feeding difficulty, family
available, suspecting consider H1N1 infection. with predominant good response to history of sibling death due
chronic respiratory Start Oseltamivir (as per finding of wheezing on bronchodilator and to pneumonia, multi site
problems. national guideline). auscultation. personal or family history infections (diarrhea, ear
of asthma. discharge oral thrush).
Discharge when child is switched to oral medications, accepting oral for 24 to 48 hours

REFERENCES
1. Integrated Management of Childhood Illness (IMCI) (revised). Geneva, World Health Organization/The United Nation Children’s Fund (UNICEF), 2014
(http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/).
2. Revised WHO classification and treatment of childhood pneumonia at health facilities.
http://apps.who.int/iris/bitstream/handle/10665/137319/9789241507813_eng.pdf;jsessionid=8BF6F1C94BD7BA81B8F464D4CBA40249?sequence=1
3. Bradley JS, Byington CL, Shah SS, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric
Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53:617-30.
4. Lodha R, Kabra SK, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev. 2013 Jun 4;(6):CD004874
PSCHIATRY
October/ 2019


ALCOHOL USE DISORDERS
ICD10-F10
ASSESSMENT (DETAILED HISTORY)
Special attention to:
(AUDIT can be used • Age at initiation, quantity, frequency and progression (daily use and/or morning drinking)
for screening) • Time of last alcohol use and amount
• Binge drinking ( men: 5 drinks over 2 hours; women: 4 drinks over 2 hours)
• Withdrawal state: insomnia, restlessness, anxiety, tremors. Use of alcohol (or
benzodiazepines) to relieve or avoid withdrawal symptoms.
H/ o head injury
• Tolerance: increased doses of alcohol taken to achieve effects produced by earlier intake
• Craving
Appearing under
Universal influence of alcohol
• Difficulty in controlling duration of drinking or amount of use
screening for • Preoccupation with alcohol use with neglect of alternative pleasures or interests
• Increased time spent to obtain/ take alcohol/ recover from its effects
every patient H/ o impaired • Continued use despite patient being aware of evidence of harmful consequences that have
attending any social, occurred
healthcare occupational • Abstinence and treatment attempts in past and reasons for relapse
functioning
facility • Co-morbid medical illness or psychiatric illness and their treatment
• Complications:
Daily alcohol • Physical- gastritis, peripheral neuropathy, hepatic dysfunction, accidents/injuries
consumption • Psychosocial - loss of work, fights at home, financial, legal problems
Drinking in large EXAMINATION

quantities
(men: 5 or more VITALS WITHDRAWAL SIGNS SIGNS OF HEPATIC DYSFUNCTION NEUROLOGICAL SIGNS
drinks/ day;
• BP • Tremor • Enlarged liver • Cerebellar signs
women: 4 or • Pulse Rate • Peripheral neuropathy
• Sweating • Icterus
more drinks/ day) • Temperature • Tachycardia • Abdominal swelling • Confusion
DIAGNOSIS
Hazardous or Harmful use Alcohol dependence (three of the following six criteria to be present for at least one month)
• Involvement in risky behaviours such as 1) A strong desire or sense of compulsion to take alcohol
binge drinking, driving under the 2) Difficulty in controlling alcohol use
influence of alcohol 3) Withdrawal state when alcohol use has stopped or been reduced or use of the alcohol (or
benzodiazepines) to relieve or avoid withdrawal symptoms
• It should have resulted in harmful 4) Evidence of tolerance
physical or psychosocial consequences 5) Preoccupation with alcohol use
6) Alcohol use persisting despite clear evidence of harmful consequences
INVESTIGATIONS
CBC Liver function test Blood sugar Electrolytes CT head (in case of seizure/ delirium tremens)
MANAGEMENT
PRIMARY CARE
• Alcohol Hazardous/ Harmful users - Brief
Intervention* to reduce/stop consumption
• Alcohol Dependent users – Advice to stop use
and motivate for treatment using Brief • H/ o withdrawal
intervention* seizures/
hallucinations REFER TO
• Additional psychiatric SECONDARY
disorder
• Recurrent failed CARE IF
SECONDARY CARE
• Treatment of withdrawal symptoms attempts at treatment
• Managment of withdrawal seizure
• Inpatient management with benzodiazepines (diazepam or lorazepam)
• Frequent titration of medication. Higher dosage may be required.
• Closer monitoring and nursing care
• Treatment of additional psychiatric disorder or substance use disorder
TERTIARY CARE
• Treatment of delirium tremens
• R/ o head injury, hepatic encephalopathy, Wernicke’s encephalopathy
• H/ o delirium • R/ o other causes of delirium
tremens • Manage on similar lines as withdrawal seizures
REFER TO
• Major medical • Management in ICU setting when indicated
TERTIARY problems • Consult with other medical specialists (like gastroenterology or medicine for
CARE IF • Additional substance
use hematemesis).
• Management for suicidality or violence when emergent threat
*BRIEF INTERVENTION WITHDRAWAL MANAGEMENT RELAPSE PREVENTION

(Long term goals- abstinence and socio-occupational
Inquire using open ended questions in a • Tab Diazepam integration)
non-judgmental manner. Help patient to evaluate the (20-40mg/day in divided
risks versus the perceived benefits and to arrive at a doses) based on severity • Disulfiram (250 mg OD)
decision to reduce or stop alcohol use. of withdrawals. Pre-requisites:
Includes (FRAMES) : • Monitor and titrate dose. • Motivated patient
• Feedback about alcohol related problems • If patient comfortable, • Patient’s written consent
• Responsibility – acknowledging that the patient is reduce dose of • Under supervision of family members.
responsible for making the decision about their alcohol medication by 10% to • Inform patient and family about unpleasant,
use 20% per day, taper potentially serious reaction with even small
• Advice regarding the harms associated with continued within 7 to 10 days amounts of alcohol (flushing, headache, vomiting,
use • Thiamine 100 mg OD reduction of blood pressure, arrhythmias)
• Menu of alternative change options (includes identifying • Significant liver • Ability of health personnel in the area to handle a
alternative activities such as hobbies, involving the dysfunction: potential reaction
family in treatment) Lorazepam (2 mg • Relapse prevention counselling:
• Empathetic attitude Lorazepam equal to 5 • Identify cues leading to craving (like person, place,
• Self efficacy - to encourage patients’ confidence that mg Diazepam) situation etc)
they can make changes in their alcohol use and lifestyle • Develop strategies to deal with them effectively
INDICATIONS FOR ADMISSION

H/o withdrawal seizures/ delirium Co-morbid significant medical
Failure of outpatient treatment illness and/or psychiatric illness Poly-substance use
tremens

October/ 2019


ANXIETY DISORDERS
ICD-10-F40-F42
Tension, anxiety,
apprehension, fear,
worrying
Sadness, lack of interest,

uncontrolled negative
thoughts
Unexplained physical symptoms

like chest pain, abdominal pain,
muscular tension, headache,
nausea
Episodes of palpitations, difficulty in

breathing, feelings of choking, light
headededness, dizziness, fainting,
trembling
Attacks of fear, losing

control or going “crazy”, fear
of dying
Repetitive unwanted
thoughts and
behaviours
DIAGNOSIS
Panic Disorder: Recurrent unexpected
attacks of intense fear/ anxiety along with ASSESSMENT
Generalized Anxiety Disorder physical symptoms (palpitations, feelings of
(GAD): Chronic feeling of tension, “choking”, trembling, chest pain feeling • Duration of anxiety
apprehension, anxiety or worrying dizzy/faint etc.) • Degree of distress, and
about a number of events or impairment of
activities that involve every day
day-to-day functioning
routine life circumstances (e.g., work, Social Phobia: Marked fear and avoidance of • Symptoms of
school, health, finance, household social situations (e.g., interaction with
chores etc.) depression
strangers, meeting unfamiliar people, • Substance and alcohol
performing in front of others)
misuse
• Physical disorders:
Agoraphobia: Fear of going out thyrotoxicosis,
of home alone, being in enclosed Obsessive-compulsive disorder (OCD): pheochromocytoma
spaces (e.g., malls, cinemas etc.), Recurrent and persistent unwanted and hypoglycaemia
open spaces (e.g., bridges, vast thoughts (e.g., unwanted sexual and
• Psychosocial factors:
playgrounds etc.), using public blasphemous thoughts, fear of harming self
ongoing stress and
transportation (e.g., trains, buses, or others, fear of contamination, doubts
other issues pertaining
planes etc.) about daily activities etc.) and repetitive
behaviours (e.g., excessive washing / to work, family
cleaning, checking, ordering etc.)
MANAGEMENT
PRIMARY CARE LEVEL SECONDARY CARE LEVEL TERTIARY CENTRE (MEDICAL COLLEGE,
(DISTRICT HOSPITAL) REGIONAL MEDICAL CENTRE, PSYCHIATRIC
Psychoeducation HOSPITAL)
• Reassurance • Review diagnosis and treatment
• Explain symptoms are of anxiety/ fear and mimic history if there is no improvement • Evaluate reasons for treatment resistance like
symptoms of physical illnesses (e.g., heart attack) with a trial of Escitalopram. • Wrong diagnosis
• Do not investigate excessively. Few investigations • Check whether the patient has • Inadequate drug treatment,
like ECG, ECHO maybe necessary in some patients taken medication at prescribed • Poor adherence to treatment
• Discourage doctor shopping dose and on a regular basis • Inadequate CBT,
• Do not avoid triggers of panic attacks (e.g., physical • Presence of comorbid conditions such as
exertion, agoraphobic situations) and fear (e.g., • Second SSRI personality disorders and organicity
travelling by public transport). (either of them for about 2-3
• Emphasize avoidance maintains fears and phobias. months): • Panic disorder: evaluate any medical
• OCD: Educate that the unwanted thoughts are a • Sertraline upto 200 mg/day, conditions that mimic panic disorder
part of illness, and not a reflection of character or (hyperthyroidism, hyperparathyroidism,
• Fluoxetine upto 60 mg/day,
hidden intentions. pheochromocytoma, vestibular diseases,
• Paroxetine upto 50 mg/day,
seizures, arrhythmias, etc.).
Pharmacological treatment • Fluvoxamine upto 300 mg/day
• OCD: Trial of third SSRI or clomipramine
• Mild illness: Spending time, reassurance, and • Treatment resistant OCD: inpatient treatment
psychoeducation. May not need any medications. • No response to second SSRI:
for intensive therapist-assisted daily CBT and
• No improvement (few weeks): Escitalopram 5mg / cognitive behaviour therapy (CBT)
for rationalization of medication regimen.
day at night, with increase to 10 mg/d in a week. No if trained therapists available.
• Other anxiety disorders: Trial of non-SSRIs
satisfactory improvement in 4-6 weeks, may • Refer to tertiary centre if
(e.g., venlafaxine, duloxetine, pregabalin etc.)
increase to 20 mg / day. If there is no significant unsatisfactory response after
and tricyclic antidepressants
improvement in another 4-6 weeks, refer to a second SSRI and / or addition of
specialist. CBT.
• If response to medications is poor or
• Severe and unbearable anxiety: Diazepam (5 -10 • If referral to tertiary centre is not
unsatisfactory:
mg) may be given at night. Do not continue for > 1 feasible, psychiatrists may try
• CBT is the preferred mode of treatment
month. Taper and stop over 2 weeks. Long-term other strategies (other than Deep
alone or in combination with medications.
treatment with benzodiazepines to be avoided Brain Stimulation and surgery for
• Treat comorbid psychiatric disorders (e.g.,
• Escitalopram to be continued for at least 1-2 years OCD) mentioned under the
personality disorders)
after remission “tertiary care” at the secondary
• Pharmacological augmenting strategies if
• Side-effects (sexual dysfunction, sedation, weight level itself.
antidepressants and CBT do not provide
gain) : monitor and address periodically relief.

October/ 2019


CHILDHOOD BEHAVIORAL DISORDERS
ICD10- F90-98
OPPOSITIONAL DEFIANT DISORDER (ODD) DIAGNOSIS
• Doesn’t obey or listen, back-answers, rude behaviors
• Demanding, stubborn, throws tantrums when
demands are not met • Symptoms are present
CONDUCT DISORDER and persistent over
• Aggressive – angry, abusive, fights, hits or hurts several months
people, bullies other children, damages articles • Attempt further
• Stealing, lying, threatening or misbehaving with classification into ADHD,
people, truant (keeps away from school without ODD and CD (ADHD may
parents’ knowledge), runs away from home, bad be present with or
company, cruelty to animals without ODD and CD
CLINICAL
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
PRESENTATION • Restless, always on the move / running, can’t sit in a
CAUTION
place,talkative
• Abrupt onset
• Can’t focus attention on a task, poor concentration,
gets easily distracted, disorganized, does not • Recent onset (few weeks
complete school work to few months)
• Too mischievous, can’t be left alone, troubles • Sudden increase in
people or damages things, or gets injured severity (consider another
• Impatient, always in a hurry, can’t wait for his turn, psychiatric disorder such
does not care for danger, acts without thinking as bipolar affective
disorder, hypomanic or
ALL 3 DISORDERS
Poor or erratic school performance and / or manic episode -> follow
complaints about behaviour from school the relevant STW)
ASSESSMENT (History From Multiple Sources)
PARENT INTERVIEW FAMILY SITUATION SCHOOLING CHILD INTERVIEW

• Symptoms- onset, duration, • Health (including mental health) and • Attendance • Develop rapport( discuss neutral topics; avoid direct
type(ODD, Conduct, ADHD-as wellbeing of family members • Performance tackling of misbehaviors)
above) and severity • Cohesion, mutual understanding and • Learning • Observe:
• Developmental problems, harmony in the family problems, - Features of ADHD (restless, fidgety, easily distracted,
emotional disturbances and • Parenting and childrearing practices: • Classroom attention keeps shifting)
stress caring and disciplining, criticism, unfair behaviors - Speech and language ability, intelligence, academic
• Alcohol and substance use comparison and physical punishments, • Recent changes skills and mood
/misuse mutual blaming of parents for child’s in syllabus and/or • Enquire about any stress or difficulties child is facing at
• Impact on child and family problem school home, school, and with peers and anger control
MANAGEMENT
WORK WITH FAMILY WORK WITH THE CHILD WORK WITH THE
• PSYCHOEDUCATION
SCHOOL
- Explain the child’s behaviours are not intentional • Avoid advice
- Not child’s fault, do not blame the child • Feedback to school
• Anger management ( count
- Multifactorial causes-lack of self-regulation, and adverse environment regarding child’s
from 10 -1 backwards, move
- Can be improved with proper management condition
away from situation, deep
- Parents can directly contribute to the child’s improvement • Teachers to give extra
breaths, relax, self-talk to
• Help parents deal with their own worries and stress (listening, giving space to attention, help and
ventilate, validate and empathize their difficulties, reassure) cool down)
support for the child
• Recognize and manage mental health problems such as depression and alcohol • Children with ADHD:
• Extra coaching, if
problem in parents “stop-think-act” or “halt and
needed in case of
• Parent management training* proceed” technique
learning problems
*PARENT MANAGEMENT TRAINING MEDICATION (AVOID BEFORE 5 YEARS)

• Analyse the problem behaviors and understand patterns : time of occurance, triggers, • Severe and persistant aggression:
duration and consequencies - T. Risperidone under close supervision (starting
• Engage with child in mutually enjoyable, pleasurable activities (playing games, dose-0.25 mg, single daily morning dose after
discussing interesting things or doing activities together) breakfast. Based on response, increase by 0.25 mg
• Set clear do’s and don’ts and explain to child in clear, simple, short instructions the weekly up to 1 mg single daily dose).
consequencies (like withholding privileges following misbehavior; use star-charting Not to exceed 1 mg/day
(contingency management) and rewards based on number of stars earned - Response + : continue 3 months f/b slow taper
• In children with ADHD, develop clear daily routines, supervise activities and appreciate - Response - : 4 weeks trial, then refer
on completion of taks - Monitor adverse effects: weight gain,
• Limit screen time/ monitor use of electronic devices extra-pyramidal symptoms (EPS)
[if EPS : add I mg Trihexyphenidyl OD morning]
• Dos • Don’ts • Severe hyperactivity and impulsivety:
– Consistency in enforcing rules – Bribe - T. Clonidine (starting dose-25 µg single daily
– Catch the child being good and praise – False promises and threats
dose before sleep, increase by 25 µg weekly up
– Ignore negative behaviours – Harsh punishments
to100 µg per day in 2-3 divided doses
– Child can be put in a boring place till he/ – Excessive criticism and blaming
she becomes quiet for a few minutes especially in front of others - Monitor BP and drowsiness
(time-out) – Unfair comparison - Advise against sudden discontinuation
– Encourage age appropriate responsibilities – Yielding to unreasonable demands
REASONS FOR REFERRAL

Severe, complicated presentation Lack of response to treatment Severe aggression Highly dysfunctional family Alcohol and substance abuse
SECONDARY CARE (DISTRICT HOSPITAL) TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE)
• Review and reassess diagnosis (clinical evaluation • Evaluate and manage severe behavior disorders – severe ADHD, ODD, and CD, if necessary on
using Rutter’s multi-axial system) and all the short-term inpatient basis
pointers given above • Multi-modal management with clear individualized plan
• If failed trial of Clonidine/ Moderate ADHD: • Trial of Methylphenidate in moderate / severe ADHD under expert supervision
T. Atomoxetine (starting dose-10 mg single daily • Recognize and treat comorbid disorders such as bipolar disorder, substance use disorder, and
morning dose after breakfast. Increase up to internalizing disorders and manage
1mg/ kg/day under close supervision). • Pharmacological management of older children / adolescents with severe aggression /
Monitor adverse effects and response impulsivity with Risperidone and/or Lithium
• Systematic parent management training / • Family therapy for dysfunctional / discordant families, contributing to child’s condition
behavioral management and individual therapy • Management of children in difficult circumstances with mental health issues (children in need of
(as given above) care and protection; children in conflict with law)
REFERENCES
• World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO. 2016.
• Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American
Academy of Child & Adolescent Psychiatry. 2007 Jul 1;46(7):894-921.
• Steiner H, Remsing L. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child & Adolescent Psychiatry.
2007 Jan 1;46(1):126-41.

October/ 2019


CHILDHOOD EMOTIONAL DISORDERS
DIAGNOSIS
SOMATIC (PHYSICALLY UNEXPLAINED) SYMPTOMS
• Weakness and tiredness • Persistent symptoms of
• Aches and pains emotional disturbance
• Headache for several weeks,
• Non-epileptic attacks of fainting significantly affecting
• Chest pain and stomach pain the child’s life
• Hyperventilation- often triggered by stress or distress • Unexplained by medical
condition such as
SYMPTOMS OF DEPRESSION hypothyroidism
• Loss of interest in usual activities • Depression and anxiety
• Recent deterioration in school performance symptoms can co-occur
• Wanting to be alone, withdrawn, not interacting • Depression more
with people common in
CLINICAL adolescents, may have
PRESENTATION - • Looks unhappy, “off mood”, crying for trivial or no
features similar to adult
Recent Onset reason, irritable, sensitive to any criticism onset depression
Behavioral • Decreased sleep, loss of appetite and weight loss
Changes • Talking about death and dying, self harm (eg.
self-cutting) or suicidal attempt
CAUTION
• Assessment of suicidal risk
SYMPTOMS OF ANXIETY and a plan of action is
• Always worrying, tense important in children with
• Exam tension, performance anxiety, worries about emotional disorders,
marks and ranks especially depression (refer
? to appropriate STW)
• Excessive fear and avoidance of some objects or
• Elicit h/o hypomania/mania
situations (insects, animals, ghosts) in children with moderate
• Reluctance or refusal to go to school to severe depression
• Very shy, avoids social situations, scared of talking or (consider diagnosis of
interacting with strangers, bipolar disorder)
• Clinging to mother, scared of being separated from • Physical conditions can
cause similar symptoms
mother (anemia and thyroid
disturbance)
ASSESSMENT
PARENT INTERVIEW AND HISTORY TAKING CHILD INTERVIEW PHYSICAL EXAMINATION
• Onset, duration, severity and full range of • Develop rapport (Rule out)
symptoms • Ask subjective distress (low mood, irritability, sadness, lack of
enjoyment of activities, worries, fears, tensions, autonomic • Post-viral syndrome
• Home environment, family life and
symptoms) • Recurrent attacks of
relationships, parenting practices and
• Stressful events (loss, death in the family, separation, frightening malaria
stressors
experiences, traumatic abusive or shocking events, humiliating • Chronic infections, chronic
• Information (from paretns and school) about
experiences, bullying in school, academic stress) and interpersonal physical illness, anaemia,
school performance, behavior, school refusal, difficulties PCOD or thyroid
bullying experiences, peer relations and any • Explore parent-child relations and interactions and any undue disturbance
recent change punishment or criticism
MANAGEMENT
WORK WITH PARENTS WORK WITH THE CHILD WORK WITH SCHOOL
• PSYCHOEDUCATION: • Psycho-education of the child- explain they are • Give feedback to the school about
- Child is emotionally disturbed and not able to suffering from an emotional problem and it is not their child’s condition and stress, need
function well fault and they will get better with proper treatment for support, encouragement and
- Not the child’s fault • Anxiety management and emotional regulation skills school’s cooperation.
- Avoid undue criticism, over expectation, unfair - Muscle relaxation • If school refusal, graded return to
comparison, scolding and punishment - Deep breathing exercises school: encourage child to return
- Parents’ support, encouragement and - Praanaayaama / yoga to school gradually with the
understanding is important - Substituting distressing thoughts with more support of family and cooperation
• Counsel about suicidal risk in depression and to be comforting thoughts of school (e.g. initially for a few
alert to pointers to suicidality • Counsel the child to confide any distressing thoughts, minutes in school compound,
• Evaluation and management of the mental health including thoughts of death and dying later for 1 period in school and
issues in parents • Encourage the child to gradually return to the usual moving on to longer duration
• Discuss about specific steps to reduce undue stress life and activities in a step-by step manner with
the child is facing parental support and encouragement
MEDICATION (MODERATE CASE OF DEPRESSION OR ANXIETY IN ADOLESCENTS)

• Frequent expression of suicidal ideation/
• Tab Fluoxetine - start at 10 mg OD morning, increase to 20 mg OD after 2 attempted suicide / self-harm behavior
weeks depending on response such as self-cutting
• Inform adverse effects: behavioral activation (marked restlessness and REASONS FOR • Severe symptoms
irritability), onset of hypomanic symptoms, and worsening of suicidal ideas. REFERRAL • Complicated picture, or features of
Stop drug if they are troublesome obsessive compulsive disorder (OCD)
• Avoid benzodiazepines (except as temporary measure for few weeks in • No response to interventions in 4-6 weeks
severe anxiety attacks or panic attacks - Clonazepam 0.25- 1 mg /day)
SECONDARY CARE (DISTRICT HOSPITAL) TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL
• Review and reassess diagnosis through detailed clinical examination using Rutter’s CENTRE)
multi-axial system • Thorough diagnostic evaluation
• Review the treatment received and plan multi-modal treatment. • Manage severe mental disorders – psychoses, recurrent
• Reconsider medications, and augmentation strategies mood disorders, adolescents with severe depression, &
• Review child’s and family’s awareness of the illness and do psycho-education treatment resistant cases, persistent suicidality,
• Ascertain the presence of psychosocial factors : disturbed home environment, recurrent self-cutting, if necessary in inpatient setting
parent-child relationships and severe stressors • Family therapy for dysfunctional / discordant families
• Screen parents for mental health problems and manage accordingly contributing to child’s condition
• Individual therapy focussing on identifying and challenging negative thoughts, • Cognitive behavior therapy for older children with
anxiety management and coping with stress, helping them face difficult situations severe OCD, depression, and anxiety disorders
in small steps, improving interpersonal relationships • ECT on case to case basis (older adolescents with
• Parent counselling to address family issues, communication and interaction severe depression, mania, psychosis or catatonia
patterns unresponsive to adequate pharmacological
• Collaborate with school wherever necessary (get school report; explain problem in management)
simple terms, and suggest ways by which school can help) • Appropriate psycho-social steps if there is abuse,
• Recognize and manage less common problems such as obsessive compulsive maltreatment or neglect
disorder, psychoses and bipolar disorders • Neurology referral in suspected cases of epilepsy and
• Manage adolescents with mild / moderate suicidal risk organicity

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October/ 2019


CHILDREN WITH DEVELOPMENTAL PROBLEMS
ICD10-F70-89
DIAGNOSIS
Specific speech delay – Only
lagging in speech with normal
Intellectual disability intelligence, hearing and
Slow in development / (mental retardation)* - non-verbal communication
delayed milestones of global developmental
development delay + impairment
compared to peers in Autism Spectrum Disorder
intellectual functioning (ASD) marked impairment in
CLINICAL Poor speech, verbal and non-verbal social
self-care, learning and adaptive skills
PRESENTATION interactions (being solitary or
and memory “in his own world”, poor
Specific Learning response to name call and poor
Less intelligent Disorder (SLD)- Average eye-to-eye contact) and
compared to other intelligence with poor stereotyped behaviors *in
children academic skills (reading, children under 5 years, avoid
writing, spelling and diagnosis of ID, name it as
maths inspite of global developmental delay
adequate schooling) and start intervention
ASSESSMENT
DETAILED DEVELOPMENTAL PHYSICAL EXAMINATION: BEHAVIOURAL PROBLEMS: OTHERS:
ASSESSMENT: • Height and weight, • Hyperactive • Family situation
• Assess if child is lagging behind • Head circumference, • Impulsive behaviors • Parents’ awareness of
in developmental attainments • Vision and hearing • Sleeping and feeding problems the child’s problems
compared to same-age children • Any noticeable physical anomalies • Aggression • Quality of attention
• Ask mother to estimate the (club-foot) or unusual facial appearance and care being given
mental age of child • Motor abnormalities (stiffness / spasticity or EMOTIONAL PROBLEMS: to the child,
• Ascertain if delay is global (all weakness of limbs, unsteady gait) • Excessive crying • Past consultations and
milestones) or restricted to one • Any other problems (heart murmurs, • Irritability treatment
area (motor or speech) organomegaly) • Shyness and fears educational history
MANAGEMENT
PSYCHO-EDUCATION OF PARENTS EARLY INTERVENTION / SENSORY-MOTOR STIMULATION FOR HOME-BASED PARENT MEDIATED SKILLS TRAINING
YOUNG CHILDREN – UNDER 3 YEARS
• Normal – reassure parents • Create opportunities for the child to learn with • Develop and maintain regular, stimulating daily
• Mild delay (“at risk”) – early interset and attention routines
intervention and follow-up •Engaging and spending time with child in activities • Teach parent to teach child : simple imitation,
• Explain causation due to some • Offer appreciation pointing, pretend-play; self-help skills (eating,
damage to brain before, during or • Engage the child to use eyes and ears (different toilet training, bathing, dressing), doing simple
after birth types of sounds and sights), touch (eg., tickling, household chores (washing utensils, helping in
• No medication can improve stroking, gentle massaging), movements (gentle cleaning house), social skills – skills of interaction,
intelligence movement of limbs, gentle bouncing, range of simple academic skills, simple vocational skills,
Teaching and training to improve movement exercises) and improving hand functions helping in kitchen under supervision,
skills and gaining independence (taking, holding, giving, pushing, pulling) self-protection
• Systematic, persistent and repetitive • Use play materials–rattles, paper balls, rubber balls, • Find current level of adaptive abilities of the child
training as per the child’s ability clay, soft dough, water play, soap bubbles, and choose a target skill
• Treatment of associated problems vegetables. • Tell and show how to do things (modelling),
(vitamin or mineral deficiency or • Parallel vocalization to improve utterances (making make the tasks simpler, break activities in simple
epilepsy, ADHD, vision/ hearing the same sound as the child immediately). steps and teach one step at a time, notice and
issues,) – refer to appropriate STW • Improve conceptual skills by classifying, arranging, praise even minor efforts and improvements
• Avoid overprotection, sorting, and recognizing and naming activities (for (rewarding or reinforcing), using hand-on-hand
overindulgence and eg., vegetable sorting, grain sorting, arranging techniques (keeping your hand on the child’s
understimulation vessels by their size and shape) hand and making them do the activity)
EDUCATION AND TRAINING SOCIAL WELFARE / LIAISON MEASURES

• Liaise with schools and ensure child attends school that is most appropriate • IQ testing and certification for social welfare benefits
• Assist in enrolment to special school • Help parents to link with other agencies/ services that deal with
• Consider training in vocational skills (informal and formal) for older adolescents such children such as CBR programs or parent associations
• Severe or multiple developmental

• Co-occuring severe behavioral or
problems
emotional problems
• History of regression ( loss of acquired REASONS • Suspected case of ASD
skills) FOR • Suspected SLD
• Definite family history of
REFERRAL • Genetic counselling
developmental problems (h/o similar
• Speech therapy or physiotherapy
problem in the sibling)
SECONDARY CARE (DISTRICT HOSPITAL)

• Psychological testing for ID, SLD and diagnosis of ASD
• Basic management of ASD – home-based parent-mediated training in social, communicative, and self-help skills
• Appropriate management of behavior problems with medication / psychosocial or behavioral intervention (see relevant STW’s)
• Help parents access relevant services such as District Early intervention centres (DEIC’s), parent organizations, and benefits
TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE)

• Evaluate and manage children with severe IDD, ASD, multiple disabilities, and those with severe comorbid disorders such as ADHD, aggression,
bipolar disorder, and psychotic disorders through multi-disciplinary approach
• Investigate for the cause – review tests already done; imaging, genetic tests, metabolic tests (as per requirement) ;arrange for genetic counselling
• Manage treatable disorders (like hypothyroidism and inherited metabolic disorders)
• Manage comorbid physical health problems (like epilepsy, visual /hearing impairment, locomotor/ orthopaedic problems)
• Assessment and management for SLD – psychoeducation of the child and parents, liaison with school, teaching basic remediation techniques to
parents, helping parents access relevant organizations, issue of exemption certificates, and decisions about further schooling such as open
schooling
REFERENCES
• World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO.
2016.
• Szymanski L, King BH. Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders.
Journal of the American Academy of Child & Adolescent Psychiatry. 1999 Dec 1;38(12):5S-31S.
• Girimaji SC.(2008) Clinical Practice Guidelines for the Diagnosis and Management of Children With Mental Retardation. Retrieved from
www.indianjpsychiatry.org/cpg/cpg2008/CPG-CAP_05.pdf

TThis STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
October/ 2019


DEPRESSION
ICD10-F45
CORE SYMPTOMS CLINICAL ASSESSMENT
Depressed Loss of Easy Assessment

11 Cognition
21 31 of
mood interest fatigability/ • Hopelessness (about future)
Depressive
and diminished • Helplessness (about others)
Cognition
enjoyment activity • Worthlessness (about self)
Assess
ADDITIONAL SYMPTOMS Assessment of Suicide Risk friend
• Reduced concentration and attention • Suicidal thoughts and
• Reduced self-esteem and self-confidence • Suicidal idea family
• Ideas of guilt and unworthiness • Suicidal intent support
• Immediate risk for attempt
• Bleak and pessimistic views of the future
CLINICAL • Ideas or acts of self-harm or suicide
DIAGNOSIS OF • Disturbed sleep
INVESTIGATION
• Diminished appetite
DEPRESSION • Haemogram
To make a diagnosis of depression,
• Thyroid function tests
symptoms must present for at least 2 weeks.
• Electro Cardiogram
Severity of Core Additional • Electrolytes (Sodium)
depression symptoms symptoms • Rule out secondary medical cause of depression
Mild
depression 2 2 or more
? • Rule out use of anticancer drugs
Moderate
depression 2 3 or more (Cyclophoshamide) / anti retroviral drugs
Severe (Efavirenz, Zidovudine)/ Antibiotics (Dapsone ,
depression 3 4 or more Ethambutol)/ Anabolic Steroids/ Propanolol
• Rule out associated comorbid medical condition –
Diabetes, Stroke, Epilepsy, Cancer, Coronary Artery
Rule out Bipolar Disorder / Grief / Adjustment
Disorder Disease and Auto Immune disorder
AT PRIMARY CARE
MILD DEPRESSION MODERATE / SEVERE DEPRESSION
• Advise Behavioral Activation to patients • Tab Escitalopram 10 mg-20 mg /day or
• Practicing activity monitoring - write down your activities / rate your depression / schedule activities that
Cap. Fluoxetine 20mg -40mg /day
make you feel good / make a to do list/ set clear and specific goals
• Tab. Clonazepam 0.25mg – 0.5mg /day for
• Focusing on your value categories – make time for your family / friends / set clear goals at work / contribute
sleep disturbance / anxiety symptoms
to community
• Reccomend yoga & mediatation and consider taper and stop after 2
• Handling daily task - monitor sleep /diet and practice good personal hygiene weeks.
• Supportive psychotherapy / Brief Counselling • If patient responds to SSRI in 2 to 4
• Validate the problems and ensure frequent follow-up weeks, then continue treatment for 6 to 9
• If no improvement in 4 to 6 weeks, consider pharmacotherapy months and taper and stop
REFERRAL TO SECONDARY CARE BROAD MANAGEMENT PLANS AT SECONDARY CARE
• Difficulty in making diagnosis • Selective Serotonin Reuptake Inhibiters (SSRI) are • Confirm Diagnosis and Suicide risk
• No improvement after 4 to 6 usually first choice (watch for GI bleed and drug assessment
weeks of treatment with first interaction) • Assess for other Medical
• Improvement starts in in 2nd week and expect Comorbidities
line medications
adequate response by 6 weeks • Investigations – Haemoglobin,Thyroid
• Depression in special
• Duration of treatment typically lasts 6-9 months Function Test, Electrocardiogram
population: Elderly /
and Gradual tapering of medication advised for first • Non Responder - Switch over to SNRI
Pregnancy / Lactation / episode (Venlafaxine 75 – 150 mg, Mirtazapine
Children / Adolescents • Restart SSRI , In case of resurgence and recurrence 30 mg) or TCA (Amitriptyline 75 -
• Comorbid medical illness / of depressive symptoms 225mg / Imipramine 75 -225mg)
Substance use • Observe for switch / activation with Antidepressants • Cognitive Behavioral Therapy /
• Suicidal risk assessment • Watch for risk of overdose with TCA (Amitriptyline / Problem Solving Therapy
Imipramine) and Mirtazapine • Add on Yoga Therapy / Meditation
REFERRAL TO TERTIARY CARE SPECIAL POPULATION AT TERTIARY CARE
• No improvement in 2nd • Pregnancy / Lactation period - • Reconfirm Diagnosis

line treatment Pre Conception counselling and • Assess other psychiatric comorbidities
• Immediate risk for preferred drug is • Partial Responder - Optimise the SNRI /TCA or Augment
suicidal attempt / Tab. Sertraline 50 mg – use with Tab. Lithium 300 to 600mg /per day or Tab. Thyroxine
thought lowest possible dose 25 - 50 ug per day.
• Needing intense • Elderly - • Non Responder – Add Tab. Sertraline 100mg or
counselling/ Tab. Escitalopram 10 -20 mg or Tab. Bupropion 300mg to existing Venlafaxine 150mg / Tab.
psychotherapy Tab. Sertraline 100 mg Mirtazapine 30mg / Amitriptyline 225mg / Imipramine
• Co Morbid Substance - (monitor for hyponatremia) 225mg.
Cannabis / Poly • Avoid TCAs like Amitriptyline / • Add on Electro Convulsive Therapy for Catatonia / Suicidality
substance Imipramine in Elderly (due to • Add on Cognitive Behavioural Therapy/ Inter Personal
anticholinergic side effects) Therapy / Problem Solving Therapy
• Adolescents- Cap. Fluoxetine • Add on low dose antipsychotic treatment (Risperidone 2 -4
20 -40 mg /day ( observe for mg / Tab. Olanzapine 5 – 10 mg) for psychotic symptoms
switch / activation/ suicidality)
REFERENCES
• Avasthi A, Grover S. Clinical practice guidelines for management of depression in elderly. Indian J Psychiatry 2018;60, Suppl S3:341-62
• mhGAP Intervention Guide - Version 2.0 for mental, neurological and substance use disorders in non-specialized health settings. World Health Organisation, 2016
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory,
and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as
decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
October/ 2019


PSYCHOSIS
ICD10-F20-29
Presence of
Hallucinations
delusions Disorganized Social and
(talking,
(suspiciousness
DIAGNOSIS smiling or behaviour & occupational
and fear without poor self-care dysfunction
laughing to
?
obvious
self)
explanation)
PRIMARY CARE LEVEL
WELLNESS CENTERS PHC

Identify, educate and refer to PHC INITIATE TREATMENT: FOLLOW UP: REASONS FOR REFERRAL TO TALUK / DISTRICT LEVEL:
If immediate threat to self/ others, • T. Risperidone • 2 weeks after initial contact: Check for changes • Diagnostic confusion / suspicion of
refer to Taluk / District center 2mg HSx1 week f/b in symptoms and adverse effects (excess sleep, organic condition
3 – 4 mg HS + extrapyramidal symptoms (EPS), tiredness) • Substantial risk of harm to self or others
FOLLOW-UP AND REHABILITATION: Trihexyphenidyl adjust the dose of risperidone and THP and catatonic symptoms
• Monitor & manage challenges in (THP) 2mg(morning) accordingly; address questions if any; advise • Comorbid substance use,
treatment continuation • Psychoeducation: gradual return to work/school; give specific depression/anxiety, intellectual disability
• If unsatisfactory outcome despite - medical model of follow-up date; liaise with wellness center for • Poor symptom-control or functioning
regular treatment: psychosis ensuring continuity of care despite regular treatment or poor
- Liaise with higher centers for - address • Once in 1 – 2 months: Check for symptoms, treatment adherence
optimal outcome misconceptions & functioning and adverse effects (EPS, • Significant adverse effects: weight-gain,
- Liaise with social welfare build hope weight-gain, menstrual/sexual dysfunction); metabolic adverse effects, tardive
department for disability - inform about adjust the dose of Risperidone (range: 2 – 8 dyskinesia
certification & welfare benefits if possible adverse mg/day) and THP (range 2 – 6 mg/day); liaise • Questions regarding marriage, pregnancy,
continued poor outcomes effects of with wellness center for ensuring continuity of sexual dysfunction
medications care
SECONDARY CARE (TALUK/DISTRICT HOSPITALS) #
INDICATION Intolerance Poor
Diagnostic Poor response Comorbid Challenging Rehabilitation
FOR REFERRAL to adherence to Pregnancy
confusion to Risperidone conditions situations needs
FROM PHC Risperidone treatment
MANAGEMENT Clarify Positive symptoms: Follow • Assessment • Depression/ • Suicidality: • Assess disability & counsel • Proactively
diagnosis; Follow algorithm algorithm of factors anxiety: -Inpatient about welfare benefits address
#Encourage
neuroimaging causing poor Brief care, sexual and
follow up in
if organicity is Negative adherence & psychological -Crisis • Rehabilitation endocrine
primary care
suspected symptoms: specific intervention; management, counseling problems
after
• Rule out or manage manage- consider SSRIs* -Management - Family intervention for when
addressing
depression/ anxiety ment • Substance of expressed emotions and relevant
referral issues
and extrapyramidal • Consider use: comorbidity; attitudes & behaviors • Educate
* Watch for
symptoms; depot anti- Detoxification -Consider ECT interfering with about risk of
adverse
• Family counseling if psychotics and brief functioning obstetric
effects as
understimulated/ • Liaise with interventions • Violence: - Brief interventions for outcomes,
SSRIs may
over-protected primary care (see SUD -Verbal cognitive & social-skill risk of
increase
• Consider for assertive module) de-escalation deficits relapse &
serum levels
less-sedating follow up • -IV sedation, - Address vocational/ risk of
of
antipsychotics and Developmenta -Brief educational challenges psychosis in
antipsychotics
adding SSRIs* l disabilities: inpatient care involving governmental/ the
Behavioral non-governmental offspring
TERTIARY CARE CENTERS

INTERVENTION CONTEXT IN WHICH USEFUL
Referral to tertiary care if
Psychoeducation Poor adherence; high family expressed emotions
Family therapy High family expressed emotions; family discord
Cognitive remediation Poor neuro and social cognitive functions
1. Diagnostic confusion: Depression, anxiety, obsessions, persistent
Inpatient observation for clarification Cognitive behavior therapy
psychotic symptoms
of history, thorough neurological /
mental status examination, Social skills training Poor social skills
diagnostic psychometry, brain CT Vocational rehabilitation and Poor occupational functioning, challenges in
Scan or MRI, neurology consultation supported education studying or getting / pursuing gainful occupation
and urine toxicology screen Day care with interventions including Negative symptoms, poor socio-occupational
vocational training, recreational functioning, combination of other symptoms
2. Poor outcome: activities, living-skill training, etc. listed in the table
+Following psychosocial Hazardous use of substance or substance use
Interventions for substance-use
interventions may be offered in disorder
isolation or in combination Pre-pregnancy, pregnancy and post-partum
depending on the context in Pregnancy – puerperium services advise and interventions Pre-pregnancy,
inpatient, outpatient or pregnancy and post-partum advise and
day-boarding settings interventions
ALGORITHM FOR CHOOSING ANTIPSYCHOTIC MEDICATION (AP) FOR TREATMENT OF SCHIZOPHRENIA
Good response without

intolerable side effects At any point, consider electroconvulsive
Risperidone* Stabilization phase: For 6 months: same therapy if:
dose of AP; 1. Serious suicidal risk
2. Catatonia not responding to Lorazepam
Maintenance phase: Attempt to reduce 3. Refusal of food / fluids
Intolerable side effects dose to minimum possible dose.
or inadequate effect 4. Severe aggression / violence
1st episode: About 2 years. 5. Refractory / intolerance to clozapine
1+ episodes: indefinite period
Choose different AP*#^ Investigate for No cause
medical/ found or poor
Intolerable side effects Inadequate effect neurological response * Treat with adequate dose as shown in table-1 for 6 – 8
causes of despite weeks to assess efficacy
or inadequate effect for 2+ APs #While choosing alternative AP, consider adverse effect
non-response and treatment of profile and cost
treat them the cause ^ At any point, if there is medication non-adherence,
consider long-acting preparations in addition to other
measures for managing non-adherence
CLOZAPINE

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
October/ 2019


SOMATOFORM DISORDER (SD)
ICD10-F45
CHALLENGES FACED BY THE DOCTOR

Repeated subjective experience
of physical symptoms which are
not explained by any
recognizable physical disease ∙ Repeated request for
investigations – despite negative
Bodily complaints are often findings and reassurance
the most common reason for ∙ Doctor shopping and not
SOMATIZATION consultation with health satisfied with repeated
DISORDER/ professionals reassurance
MEDICALLY
UNEXPLAINED
SYMPTOMS
Pain at Fatigue and Significant distress and

multiple sites exhaustion impairment
PRESENTION
TO A
DOCTOR Functional disturbance of Focus of patient is on symptom relief
different organ systems rather than cause of illness
DIAGNOSTIC CRITERIA
INITIAL ASSESSMENT PSYCHOSOCIAL ASSESSMENT
∙ Detailed clinical examination – to rule out any medical illnesses ∙ Encourage to talk about psychosocial stressors if any
which might explain the symptoms ∙ Individual factors – poor copying skills, anxiety, life events, health anxiety,
∙ Complete history of the onset of all symptoms, exacerbating and medical illnesses
relieving factors ∙ Family related factors – Substance use in family, interpersonal relationship
∙ Assessment for any other psychiatric illness such as depression or with family, financial status
anxiety disorders ∙ Environmental factors – support system, peer relationship, work environment
DIAGNOSTIC CRITERIA
A. One or more somatic symptoms that are distressing or result in significant disruption of Following list include the commonest
daily life. symptoms
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated 1. Pain symptoms at multiple sites (such as
health concerns as manifested by at least one of the following: abdominal, back, chest, dysmenorrhea,
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms dysuria, extremity, head, joint, rectal) is often
2. Persistently high level of anxiety about health or symptoms present
3. Excessive time and energy devoted to these symptoms or health concerns 2. Gastrointestinal sensations (pain, belching,
C. Although only one somatic symptom may not be continuously present, the state of regurgitation, vomiting, nausea)
being symptomatic is persistent (typically more than 6 months) 3. Abnormal skin sensations (itching, burning,
A persistent course is characterized by severe symptoms, marked impairment, and long tingling, numbness, soreness) and
duration (more than 6 months) blotchiness
Severity: 4. Sexual and menstrual complaints
Mild – only one of the symptoms specified in criterion B is fulfilled (ejaculatory or erectile dysfunction,
Moderate – Two or more of the symptoms specified in criterion B is fulfilled hyperemesis of pregnancy, irregular menses,
Severe – Two or more of the symptoms specified in criterion B are fulfilled, plus there are multiple menorrhagia, sexual indifference) are also
somatic symptoms (or one very severe somatic symptom) common
MANAGEMENT
PRIMARY CARE 1. Difficulty in making diagnosis

∙ Detailed physical examination 2. No improvement after 4 weeks of
∙ Management of anemia and nutritional deficiencies REFER TO treatment with first line medications
∙ Avoid irrational use of pain medications SECONDARY 3. Comorbid medical illness
∙ Low dose of antidepressant medications – Amitriptyline 12.5 mg to 50 CARE IF 4. Suicidal risk
mg (max) night dose 5. Comorbid psychiatric illness
∙ Explain that onset of medication effect will take 2-3 weeks
∙ Validate the somatic symptoms
∙ Advise to engage in routine activities, physical exercise and relaxation SECONDARY CARE
techniques like deep breathing ∙ Investigations – to rule out any medical illnesses that
∙ Discuss with family members that the symptom, distress and might explain the symptoms
disability are genuine ∙ Complete history with behavioural observation
∙ Strengthen supports ∙ Use 2nd line medications – SSRIs (Escitalopram 10-20 mg,
∙ Regular follow up Sertraline 50-100 mg, Fluoxetine 20 mg) and SNRIs
(Venlafaxine 75 – 150 mg, Duloxetine 30- 60 mg)
∙ Combination of two psychotropic medications (might be
TERTIARY CARE required if poor response to single medication)
∙ Inpatient care if needed ∙ Brief counselling
∙ Combination of two psychotropic medications (when required) ∙ Psycho education – focusing on relationship between
∙ Add on second and third line medications – Duloxetine, Mirtazapine, stress and physical symptoms
anticonvulsants ( Lamotrigine, Pregabalin). Use of Gabapentin, ∙ Relaxation training, regular exercise, yoga and meditation
Carbamazepine if chronic pain symptom predominates
∙ Structured Cognitive Behavioural Therapy, Cognitive restructuring,
Mindfulness and acceptance based approach 1. No improvement in 2nd line
∙ Use of alternative medicine approach – Yoga treatment
2. High suicidal risk REFER TO
∙ Collaborative approach – involve Physician, Neurology team and Pain
3. Needing intense counselling/ TERTIARY
Clinic referral (where indicated)
∙ Vocational rehabilitation if needed psychotherapy CARE IF
∙ Physical therapies – guided exercise and physiotherapy 4. Difficult patients
REFERENCES
∙ Desai G & Chaturvedi SK. Medically Unexplained Somatic Symptoms & Chronic Pain – assessment & management. A primer for Healthcare professionals. 1st Edition 2017. Paras medical publisher, Hyderabad,
India.
∙ World Health Organization. ( 2017) . mhGAP training manuals for the mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings - version 2.0 ( for field
testing) . World Health Organization. http://www.who.int/iris/handle/10665/259161.
∙ Agarwal V, Srivastava C & Sitholey P. Clinical Practice Guidelines for the Management of Paediatric Somatoform disorders. Indian Psychiatric Society – Practice guidelines 2018.
∙ Guidance for health professionals on medically unexplained symptoms (MUS) - https://www.rcpsych.ac.uk/pdf/CHECKED%20MUS%20Guidance_A4_4pp_6.pdf
∙ Jacob KS. A simple protocol to manage patients with unexplained somatic symptoms in medical practice. Natl. Med. J. India. 2004; 17: 326-8

PULMONOLOGY
October/ 2019

Standard Treatment Workflow (STW) for Management of

ACUTE RESPIRATORY INFECTION IN ADULTS
ICD-10-J09-J18; J00-06; J40
Signs of respiratory failure:
1. Vital RR> 30/ min, Abdomin
• Cough with othoracic paradox, cyanosis,
parameters: speaks in short sentences.
yellow/rusty sputum Sensorium, Pulse,
SYMPTOMS • Breathlessness Refer Respiratory Failure
Blood pressure, STW.
• Pleuritic chest pain
• Malaise, myalgia, Respiratory rate,
arthralgia Temperature,
2. Systemic
• Extra pulmonary Oxygen saturation examination:
WHEN TO symptoms a. Upper respiratory
SUSPECT tract: nose & paranasal
sinuses (frontal and
• TB maxillary sinus tenderness), throat
PAST HISTORY
EXAMINATION
• Pneumonia examination ( pharynx and tonsils)
b. Lower respiratory tract: breath
CLINICAL
• Airway disease
• sounds (type, intensity), added
sounds (crackles, wheeze, pleural
• Diabetes rub)
• Chronic steroid use Frank haemoptysis, may suggest
Pulmonary TB or malignancy
PROCEED FOR FURTHER ASSESSMENT
• Fever, tachycardia, pharyngitis, • Fever, tachycardia • Fever, tachycardia, tachypnea

suffusion of eyes, rhinitis, hoarse • Respiratory system exam: Wheeze • Respiratory system exam: Crackles/ bronchial
voice * Consider acute exacerbation of breath sounds
• Respiratory system asthma/ COPD if there is a history of * Consider acute exacerbation of asthma/ COPD
examination: Normal any of these 2 illnesses is there is a history of any of these 2 illnesses
PATHWAYS BASED ON INITIAL ASSESSMENT FINDINGS

PATHWAY 1: ACUTE URI (RESPIRATORY CATARRH) PATHWAY 2: ACUTE BRONCHITIS PATHWAY 3: COMMUNITY ACQUIRED PNEUMONIA
LABORATORY INVESTIGATION: LABORATORY INVESTIGATION: SEVERITY ASSESSMENT

• Total and differential count in suspected flu. • Total and differential count if sputum is • X-ray
TREATMENT purulent, • Use CRB-65* score for mortality risk assessment in primary care
• Symptomatic treatment for fever, myalgia • X-ray chest PA view CRB-65 SCORE
(Paracetamol or other NSAID), TREATMENT
• Rest, Oral fluids (plenty) • Symptomatic treatment for fever SCORE RISK CLASS SITE OF CARE
• Oral antihistamines (Tab. CPM 4mg BD) for (Paracetamol or other NSAID), Oral fluids
severe runny nose or sneezing (plenty)
Low Risk OP
• Antibiotics in acute follicular tonsillitis: • Inhaled bronchodilators: Salbutamol Intermediate
Risk
IP
Amoxicillin/ Ampicillin 500mg tid X 5 days nebulization (5mg/ 2.5ml ) 6-8 hourly
In penicillin sensitive individuals: • Antibiotics if there is purulent sputum and High Risk ICU
Erythromycin estolate 250mg q 6 hrly X 5 polymorphonuclear leukocytosis
days with food • Amoxicillin 500mg tidX 5 days *65 in the scoring mnemonic refers to age> 65
Suspect epidemic flu • In penicillin sensitive individuals:
H/ o recent travel, symptoms of upper Erythromycin estolate 250mg q 6 hrly Give 1 point for each of the following Prognostic features:
respiratory infection, diarrhoea, myalgia, X5 days with food • Confusion
breathlessness Refer to higher centre for • If asthma is suspected refer to asthma STW • Respiratory rate ≥30/ min
diagnosis, notification and treatment. • Low BP (DBP ≤60 mm Hg or SBP ≤90 mm Hg)
• Age ≥65 years
OUT-PATIENT BASED CARE OF CAP (CRB-65 SCORE 0-1)

INVESTIGATIONS TREATMENT
Preliminary 1. Targeted towards Streptococcus pneumoniae

Chest radiogram 2. Oral antibiotics after checking for comorbidities* (Diabetes, CVDs, CKD, CLD, Hepatic
Repeat if: Pathology, Cancer, Alcohol Abuse, H/ o antibiotics within last 3 months.)
i. Patient is not improving/ worsening a. Without comorbidities: Cap. Amoxicillin (500 mg TDS) / Tab. Erythromycin
clinically 250mg QID/ Tab. Doxycycline 100mg BD
ii. Suspected underlying malignancy b. With comorbidities: Cap. Amoxicillin 500mg TDS + Tab.Azithromycin 500 mg OD
Desirable 3. Duration: 5 days in (A); extend to a 7-10 days course if there is no response within 3 days of
1. Pulse oximetry in outpatients starting treatment and in (B).
2. Sputum microbiology: In suspected 4. Do not give:
PTB & non-response after 48 hours of a. Corticosteroids: unless other medical indications present
antibiotics b. Fluoroquinolones: as they have anti-tubercular activity.
INPATIENT MANAGEMENT OF CAP
ANTIBIOTIC THERAPY IN THE HOSPITALIZED NON-ICU SETTING ADJUNCTIVE THERAPIES FOR THE MANAGEMENT OF CAP
a. Single agent IV β-lactam a. Steroids are not recommended for use in non-severe CAP
b. If suspected atypical pathogens, other end organ disease, diabetes, malignancy, b. Non-invasive ventilation may be used in patients with
severe CAP, use of antibiotics in past 3 months: Combination of IV β-lactam CAP and acute respiratory failure
(Cefotaxime 2 grams TID/ IV Ceftriaxone 1gram BD/ Amoxicillin–Clavulanic acid 1.2 CONTRA INDICATIONS FOR NON-INVASIVE VENTILATION
grams TID ) + ORAL macrolide (Tab Azithromycin 500 mg PO OD/ Tab a. Cardiorespiratory arrest
Clarithromycin 500 mg PO BD) b. Presence of severe upper airway inflammation & edema
ANTIBIOTIC THERAPY IN THE HOSPITALIZED ICU SETTING c. Severe haemodynamic instability - hypotension
i. Patients without risk factors for Pseudomonas aeruginosa: Manage as above d. Eu-capnic (normal PaCO2) coma
ii. Suspected P. aeruginosa (diabetes, chronic lung disease like bronchiectasis, e. Multiple organ dysfunction or severe psychomotor
chronic steroid therapy): agitation
IV Cefepime (1G BD)/ IV Ceftazidime (2G TID)/ Piperacillin–tazobactam(4.5 G QID)/ DISCHARGE CRITERIA
IV Cefoperazone–sulbactam 1.5G IV TID/ IV Meropenem 1g TID; Accepting orally, Afebrile and Hemodynamically stable for a
Combination therapy : Aminoglycosides(IV Amikacin)/ Antipseudomonal period of at least 48 h
fluoroquinolones(Levofloxacin/ Moxifloxacin)
REFERRAL TO A HIGHER CENTRE : CLINICAL CRITERIA

1. Frank hemoptysis and /or Signs of respiratory failure [listed POINTS TO NOTE WHILE SHIFTING
under in the history and evaluation sections] 1. If referring to a higher center, give the first dose of
2. CRB-65 score > 1 antibiotic (oral and if available, parenteral), secure an IV line
3. Oxygen saturation by pulse oximetry ≤ 92% (patients ≤ 50 and start 0.9% Normal saline and oxygen supplementation
yrs) OR <90% (patients > 50 yrs) through face mask at 4-6 litres per minute during shift
4. Multi-lobar consolidation on chest X-ray 2. If the patient is drowsy, has copious secretions, consider
5. Confusion/disorientation calling for help from the SUB-DISTRICT/ DISTRICT hospital
6. Hypothermia (core temperature<360C) for endotracheal intubation and shifting on a transport
ventilator

the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information.
October/ 2019


ASTHMA
ICD-10-J45
Classic symptoms TRY AND RULE OUT APPROACH TO DIAGNOSIS

• Recurrent/ episodic wheezing • Other obstructive airway • Clinical assessment is
• Breathlessness disorders – see Table 1 for the mainstay
• Cough and/ or chest tightness features that favour asthma • Airway obstruction, and
over COPD bronchodilator
SYMPTOMS Supportive features • Other mimics – presence of reversibility, on
• History of atopy, family history fever, constitutional symptoms, spirometry (if available)
of asthma, presence of triggers, purulent sputum, hemoptysis, may support diagnosis
presence of rhonchi on chest focal chest signs on physical • Refer patients for further
auscultation examination, foreign body work-up if diagnosis is in
• No alternative explanation for aspiration, abnormal chest doubt
these symptoms radiograph, etc.
INITIATION AND MODULATION OF TABLE 1. DIFFERENTIATING BETWEEN ASTHMA AND CHRONIC OBSTRUCTIVE
ASTHMA PHARMACOTHERAPY AIRWAY DISEASE (COPD)
Asthma COPD
More often in childhood or Usually later in life

Levosalbutamol Age of Onset
early adulthood; variable (4th or 5th decade)
(50ug)
Infrequent & Course Episodic Progressive
OR
Intermittent Smoking, other exposures
Salbutamol Uncommon Common
symptoms
(100 ug),
Nasal Symptoms, Atopy Common Rare
2 puffs sos
Family History Often Uncommon
Poor Good Triggers Often Identified None
Control Control
Prominent and almost May or may not be
Budesonide Wheeze
Regular universal present
Symptoms (100µg) 2 puffs
(<2 per week BD plus TABLE 2. LEVEL OF CURRENT ASTHMA CONTROL (OVER THE
but >2 per Levosabutamol PRECEDING FOUR WEEKS)
month) (50µg) 2 puffs
sos
Inadequately
Adequately controlled
Components controlled
Good
(all should be present)
Poor (any one)
Control Control
Regular Formoterol/ Daytime symptoms Twice or less in a

More than twice a
Symptoms (>2 Budesonide or use of rescue week
week
per week) or medication
(6/ 200µg) as a
exacerbation single inhaler Night-time
in past one 2 puffs BD symptoms/ None
Any
year and sos awakening
Good Limitation of
Poor Any None
Control Control activities
FEV1 <80% of FEV1 >80% of
Add tiotropium Pulmonary function predicted or PEF predicted or PEF
(9µg) 2 puffs OD (if available) <80% of personal >80% of personal
and low dose best best
oral FEV1 Forced Expiratory Volume in first second, PEF Peak Expiratory Flow
methylxanthine
GUIDING PRINCIPLES
• Mainstay of pharmacotherapy: Inhaled drugs
Refer Poor • Frequency of symptoms determine treatment initiation (see figure 1 for details)
Control • Reassess at 3-4 weeks – good response: in favour of asthma diagnosis
• Patient education for compliance, warning signs, triggers, inhaler technique, PEF
monitoring
Add low dose • Inhaler technique to be monitored
oral • Follow-up at 4-12 weeks, assess diseases control by clinical parameters (see Table
2)
corticosteroids • Step-up or step-down treatment as per level of asthma control (see figure 1)
• Follow up three-monthly and modulate treatment as needed
• Refer for further evaluation and management if asthma remains poorly controlled
DISEASE EXACERBATION
WHEN TO SUSPECT EXACERBATION SEVERE ACUTE ASTHMA (PATIENT TO BE ADMITTED)
• Suspect if acute symptomatic worsening, or reduction in • Inability to complete sentences, agitation, use of accessory muscles, respiratory
rate >30/ min, heart rate >110/ min, pulsus paradoxus >25 mm Hg, silent chest,
PEF to below 80% of personal best, while on continued
and/ or room air sPo2 <92%
treatment
• Take two additional puffs of the inhaler used if
• Oxygen supplementation to maintain spO2 92-95%
symptoms persist, and repeat if needed
• Nebulized levosalbutamol/ ipratropium (1.25 mg/ 0.5 mg) three doses at
• If no response after 24 hours, or symptomatic worsening, 20-minute interval, then 4-6 hourly or as needed
or further reduction in PEF, contact physician • Injection hydrocortisone 200 mg intravenously, then oral prednisolone 0.5 mg/ kg
• Physician to assess severity of exacerbation and manage daily for five days
accordingly • Refer if no improvement
• Discharge only when symptoms improve, wheezing absent or significantly
reduced, heart rate <100 bpm, respiratory rate <30/ min, room air sPo2 >94%
LIFE-THREATENING EXACERBATION • Schedule follow-up outpatient visit at one week
Altered sensorium, orthopnea, cyanosis,
NON-SEVERE ACUTE ASTHMA
paradoxical breathing, hypotension, and/ or • If none of the above features present – manage on outpatient basis
bradycardia (heart rate <60 bpm) – immediately • Continue additional inhaler doses as needed
refer to higher centre with ICU facility • Oral prednisolone 0.5 mg/ kg daily for five days
• Schedule follow-up outpatient visit at one week

REFERENCES
1. Agarwal R, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/ NCCP(I) recommendations. Lung India 2015;32(Suppl 1):S3-S42.
2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2018.
3. National Institute for Health and Care Excellence (NICE). Asthma: diagnosis, monitoring and chronic asthma management. 2017.
October/ 2019


CHRONIC OBSTRUCTIVE PULMONARY DISEASE
ICD-10-J44.9
TRY AND RULE OUT
Symptoms – chronic
cough, progressively
worsening breathlessness Other obstructive airway
disorders – Refer Asthma STW
Risk factors – tobacco (Table 1) for features that favor
smoking, use of solid fuels COPD over asthma
for cooking, occupational
exposures, Age - >35 years
Pulmonary tuberculosis –
WHEN TO
Supportive features: Barrel sputum AFB examination in case
SUSPECT? of cough ( >2 weeks)
shaped chest, hyperresonant
note , diminished breath
sounds and rhonchi on chest
auscultation, forced expiratory Consider alternative diagnosis/-
time > 6 seconds, features of
cor pulmonale (loud P2, complication– presence of fever,
elevated JVP, edema) in hemoptysis, orthopnea, chest
advanced cases pain, significant weight loss,
No other alternative focal chest signs on physical
explanation for these examination, abnormal chest
symptoms radiograph, etc.
Airway obstruction should be documented on

DIAGNOSIS spirometry on all patients provisionally
Assess severity based on spirometry, severity
of dyspnea (mMRC scale,
& diagnosed as having COPD – refer if necessary,
Table 1), exacerbation frequency and
SEVERITY Post-bronchodilator FEV1/ FVC <0.70 defines
presence of complications (see Table 2)
airflow obstruction
ASSESSMENT
TREATMENT
• Advice smoking cessation and
counsel for other risk factors Disease progression
• Inhaled drugs are the mainstay
• Treatment based on severity
Mild COPD Moderate Severe COPD
assessment (See adjacent figure)
COPD
• Follow up: Mild to moderate
disease - 3 to 6 Months; Severe Levosalbutamol (50 µg) 2 Formoterol/Budesonide (6/200 µg)
disease - 1-3 months Tiotropium (9 µg) 2 puffs OD plus
puffs prn Levosalbutamol (50 µg) 2 puffs prn as a single inhaler 2 puffs BD plus
• Ensure compliance and proper Levosalbutamol (50 µg) 2 puffs prn
inhaler technique at each visit.
• If uncotrolled/ complications
develop, refer to higher center Persistent Symptoms Persistent Symptoms Persistent Symptoms
DISEASE EXACERBATION
Three cardinal symptoms: Add Tiotropium (9 µg) Add low dose Add Tiotropium (9 µg) 2 puffs OD
• Increase in dyspnea 2 puffs OD methylxanthines and/or low dose methylxanthines
• Increase in sputum volume
and/or
• Increse in sputum purulence Refer if inadequate response, onset of new complications, or suspicion of alternative diagnosis
Classify As:
• Mild Exacerbation TABLE 1. GRADING OF BREATHLESSNESS USING MODIFIED MEDICAL RESEARCH COUNCIL (MMRC) SCALE.
• Severe Exacerbation
GRADE DESCRIPTION OF BREATHLESSNESS
Features Of Severe Exacerbation: I only get breathless with strenuous exercise.
• Cyanosis
I get short of breath when hurrying on level ground or walking up a slight hill.
• Respiratory rate >30/ min
• Heart rate >110/min On level ground, I walk slower than people of the same age because of breathlessness
• Systolic blood pressure <90 mm or have to stop for breath when walking at my own pace.
Hg I stop for breath after walking about 100 yards or after a few minutes on level ground.
• SpO2 <90%
• Paradoxical respiratory I am too breathless to leave the house or I am breathless when dressing.
movements
• Altered sensorium TABLE 2. SEVERITY CLASSIFICATION FOR COPD
• Asterixis
• Presence of severe co-morbid POSTBRONCHODILATOR DYSPNEA (MMRC EXACERBATIONS IN
SEVERITY COMPLICATIONS*
conditions (e.g. heart failure, FEV1 (% PREDICTED) GRADE) LAST ONE YEAR
arrhythmia) MILD > 80 <2 <2 NO
MODERATE 50-79 >2 <2 NO
MILD EXACERBATION
• Increase dose and/ or frequency SEVERE <50 >2 >2 YES
of levosalbutamol and/ or
The category with the worst value should be used for severity classification
ipratropium inhalation, or
*Complications include respiratory failure, cor pulmonale, and secondary polycythemia
nebulized levosalbutamol/
ipratropium (1.25 mg/ 0.5 mg),
repeated as needed at
20-minute interval RED FLAG SIGNS FOR PEOPLE HAVING EXCERBATION ADMISSION CRITERIA
• Amoxycillin 500 mg TDS/ • Altered sensorium 1. Severe symptoms; sudden worsening of
• spO2 <88% despite therapy resting dyspnea,
Azithromycin 500 mg OD/
• Heart rate >110 bpm 2. Fall in oxygen saturation, cyanosis,
Doxycycline 100 mg OD (BD on confusion, drowsiness.
day 1) X 5 Days • Systolic blood pressure <90 mm Hg 3. Failure of an exacerbation to respond to
• Oral prednisolone 30 mg daily X • High risk comorbid conditions (arrhythmia, initial medical management.
5 days congestive cardiac failure, poorly controlled 4. Presence of serious comorbidities (heart
diabetes, renal or liver failure) failure, newly occurring arrhythmias, etc.)
SEVERE EXACERBATION
Treatment as under Mild Refer to higher centre for further management, DISCHARGE CRITERIA
Exacerbation and ensure continued supplemental oxygen and 1. Normalization of clinical and laboratory
+ nebulization during transfer data to pre-admission levels
Supplement oxygen with target 2. Patient able to follow maintenance therapy
spO2 of 92% (if spO2 monetoring SCHEDULE FOLLOW UP VISIT ONE WEEK AFTER DISCHARGE 3. Completion of acute medications
available) 4. Adequate control of comorbidities
REFERENCES
October/ 2019


RESPIRATORY FAILURE
ICD 10 : J96.0
SYMPTOMS Shortness of Chest

Cough 1 1 Wheezing 1 tightness
breath
Tachycardia Restlessness Anxiety 1 Confusion
SIGNS
Seizure Cyanosis Asterexis 1 Arrhythmia
Look for underlying causes in hypercapnia, headache, bounding pulse, tremor/flap, papilloedema, coma.
HYPOXIA (SPO2 <90%)

HEART FAILURE PNEUMONIA/ LRTI PULMONARY EMBOLISM
SYMPTOMS SIGNS SYMPTOMS SIGNS SYMPTOMS SIGNS
• Dyspnea or • Tachycardia • Cough with or • Tachypnea • Sudden Shortness • Syncope
exertion or rest • Pulsus Alterans without Sputum • Tachycardia of Breath • Arrhythmia
• Chest Pain • Weak Rapid Thready Pulse • Chest Pain • Crackles and Rhonchi • Chest Pain • Tachycardia
• Wheezing • Pink Frothy Sputum • Fever with Chills, • Hypoxemia • Calf Pain & or
• Fatigue • Cyanosis Fatigue, Malaise • Pleuritic Chest Pain Swelling
• Pallor • Hemoptysis
• Distended Neck Veins
AIRWAY DISEASE
ACUTE ASTHMA AE OF COPD BRONCHIOLITIS
SYMPTOMS SIGNS SYMPTOMS SIGNS SYMPTOMS SIGNS
• Wheeze • Tachypnea • Worsening of • Tachypnea • Cough • Cyanosis
• Shortness of • Tachycardia Dyspnea • Hypoxemia • Shortness of • Nasal Flares
Breath • Fall in SPO2 • Increase in • Hypercarbia Breath • Tachypnea
• Chest Tightness • Use of Accessory Sputum • Confusion • Wheezing • Paradoxical Breathing
• Cough Muscle Production • Drowsy (children)
• Increased Cough • Peripheral Edema • Crackles and or Rattling
sounds in Lung
INVESTIGATIONS
ABG, CRP, FBC, U&E Chest Xray Sputum culture, Blood culture (if febrile) Spirometry(COPD, Neuromuscular disease
TREATMENT
Heart Acute Severe Pneumonia Pulmonary
DIAGNOSIS failure Asthma
AE COPD ARI
LRTI embolism
Start oxygen therapy at SpO2 < 90%

OXYGEN Monitor SpO2 during oxygen therapy to titrate flow rate: target SpO2 < 96% Oxygen delivery usign Nasal cannulae/
Simple face mask/ Venturi mask/ Non re-breathing mask
(Note: for patients with AECOPD, keep lower target SpO2 = 88-92%)
SABA ± SAMA
(Salbutamol ± SABA + SAMA
(Salbutamol neb SABA +
BRONCHODILATORS SOS Ipratropium neb SOS SOS
q20 min X 1 hr hourly + Ipratropi- SAMA
then prn) um neb 4 hourly)
Yes
(IV
Furosemide SOS SOS SOS SOS
DIURETICS SOS
40 mg or
Torsemide
20 mg)
No risk factor Mild/ Mod cases:

Pseudomonas: Ceftriaxone Amoxycillin PO/ IV or
or levofloxacin or Ceftriaxone IV
moxifloxacin Severe Cases:
--- --- Pseudomonas risk factor: --- ---
Amoxycillin IV or
ANTIBIOTICS levofloxacin or piperacillin
Ceftriaxone IV
tazobactam or ceftazidime
or cefepime Atypical pneumonia:
Influenza suspect: Azithromycin IV/ PO or
Oseltamivir Doxycycline IV/ PO
Severe CAP (fiO2 > 0.5

Yes Yes
AND pH <7.3 OR lactate
(Methylpredniolone (Methylprednisolone Yes
STEROIDS >4 mmolL-1 OR CRP >
--- IV 40 to 60 mg or IV 60 to 125 mg IV ---
150 mgL-1):
Prednisolone PO q6-12 hourly)
Methylprednisolone IV
60 mg)
0.5 mg/ kg q12h
If high suspicion
Prophylactic, with low risk of
LMWH Prophylactic, Prophylactic, Prophylactic, Prophylactic,
if indicated bleeding: UFH (if
if indicated if indicated if indicated if indicated
thrombolysis
anticipated), OR
LMWH
No relief OR Need for mechanical ventilation OR life threatening features:
REFERRAL Stabilize CAB, transfer to higher center
ABBREVIATIONS
• LRTI : Lower Respiratory Tract Infection • SABA : Short Acting Beta Agonist • CAP: Community Acquired Pneumonia
• LMWH: Low Molecular Weight Heparin • SAMA: Short Acting Muscarinic Antagonist • UFH : Unfractionated Heparin

UROLOGY
October/ 2019


ACUTE URINARY RETENTION IN MEN (AUR)
ICD-10-R33.9
• Nature and duration of urinary symptoms prior to AUR

• Associated symptoms like fever, weight loss, sensory loss or weakness
of lower limbs
• Past history of retentions
HISTORY • Rule out precipitating causes like diabetes mellitus, alcohol
DEFINITION: consumption, recent surgery, UTI, constipation, cold exposure,
Emergency prolonged travel and neurological conditions
condition • Medication history
characterized • Look for risk factors
by a sudden and
painful inability
to void
voluntarily • Fever
despite having a • Enlarged tender palpable bladder dull on percussion
full bladder • Phimosis, meatal stenosis, urethral induration, stone, urethral
discharge
EXAMINATION • DRE for estimating prostatic size, consistency, tenderness ; exclude
fecal impaction
• Focused neurological examination-anal tone, perianal sensation
and bulbocavernous reflex
RISK FACTORS OF SPONTANEOUS AUR DUE TO BPH RISK FACTORS OF PRECIPITATED AUR
• Old age
• Surgical procedure with general or
• Severe lower urinary tract symptoms (LUTS)
loco-regional anaesthesia
• Low peak flow rate
• Bladder over-distension (eg prolonged journey)
• High postvoid residual urine (PVR)
• Exposure to cold
• Enlarged prostate or large median lobe
• Medications with sympathomimetic or
• High serum PSA
anticholinergic effects, diuretics, alcohol intake
• Symptom worsening
• Feacal impaction
• Increasing PVR during medical therapy
CAUSES
THAT BLOCK Urethral Urethral Acute Vesical Faecal
BPH Ca Prostate
THE PASSAGE Calculus Stricture Prostatitis Calculus impaction
THAT PARALYSE Neurological diseases e.g. spinal cord compression, Drug induced eg. opiods, anticholinergics,
DETRUSOR transverse myelitis, stroke, head injury anti-histaminics, anti-diarrhoeals, flavoxate
INVESTIGATIONS
As AUR is an acute emergency, no investigation is required before catheterization to relieve symptoms. The volume of urine
drained should be documented.
DESIRABLE OPTIONAL (ONLY BY SPECIALISTS)
CBC, S. Glucose,S. Creatinine and Electrolytes, USG KUB Urine NOT TO BE DONE ROUTINELY
analysis& Urine culture of the drained urine • Cystoscopy,CT / MRI,RGU + MCU,Urodynamic studies
FOR CATHETERIZATION
Attempt gentle urethral catheterization
- Use a 14 or 12 Fr Foley
urethral catheter
- Do not remove catheter earlier
Catheterization successful Catheterization fails than a day
Suprapubic cystostomy if
Keep catheter adequately trained
1-3 days*
COMPLICATIONS DUE TO AUR
OR
Refer to urologist • Urinary tract infection
• Acute kidney injury
Precipitated AUR
Spontaneous AUR
due to
due to BPH COMPLICATIONS DUE TO
CATHETERIZATION
Drugs
No prior history • Post obstructive diuresis with
Diabetes No prior history of
Neurological disturbances dys-electrolytemia
r/c acute retention
Urethral stricture α blockers for • Transient decompression
± severe
Pelvic and Perineal Surgery 2-4 days hematuria
obstructive lower
Fecal impaction • Urethral injury during
urinary tract
Urinary/ peri anal Infection T.W.O.C catheterization
symptoms
Treat the cause Surgery

Succeeds Fails INDICATIONS FOR HOSPITALIZATION
Trial without catheter • Patients of AUR with
Continue Surgery significant comorbidities
If fails, medical • Patient of AUR with
refer to urologist management complications listed above
ABBREVIATIONS
BPH: Benign Prostatic IPSS: International Prostate TWOC: Trial Without Catheter WW: Watchful waiting
Hyperplasia Symptom Score

October/ 2019


GROSS HAEMATURIA
ICD-10-R31.0
PERFORM THOROUGH CLINICAL EVALUATION
• Blood in urine - red coloured or dark coloured EXAMINATION

• May be associated with pain: • Pulse, blood pressure
• Pain during voiding (urethra) • Check for pallor
• Pain in suprapubic region (bladder) • Check for anasarca
• Pain in flank (kidney) • Per abdomen
• Acute retention of urine due to clots examination: Palpable
• Haematuria associated with clots (severe) bladder, flank mass
• Digital rectal
examination: Enlarged
prostate, hard nodular/
smooth surfaced
prostate
• Rule out vaginal causes
SYMPTOMS of bleeding
RED URINE BUT NOT

HAEMATURIA
• Foods: beetroot,
blackberry,
rhubarb
• Medicines:
rifampicin,
pyridium
Even single episode of

haematuria warrants
complete evaluation
MAKE A CLINICAL HOW TO INVESTIGATE OPTIONAL

DIAGNOSIS: IS HAEMATURIA ESSENTIAL
• Urine culture
• Urine for active
• Urine examination - routine, microscopy sediments(if
• Hemoglobin estimation nephrotic/
INITIAL
• Kidney function tests (KFT) nephritic
• Urethra: stone, urethritis, stricture
• Ultrasonography of kidney urinary syndrome
• Prostate: inflammation, benign bladder and prostate region
hyperplasia, malignancy suspected)
• PT/INR (if
bleeding disorder
TOTAL DESIRABLE suspected)
• Kidney: stone, malignancy (renal parenchyma, • Contrast enhanced computed • Serum prostate
tomography of kidney urinary bladder specific antigen
pelvis/ ureter), genito-urinary tuberculosis
region/ intravenous pyelography (if KFT (if required)
• Ureter: stone, malignancy, genitourinary
normal) • Urine for acid fast
tuberculosis bacilli - 3 samples
• Magnetic resonance imaging of Kidney
• Bladder: infection, genitourinary tuberculosis, (if tuberculosis
urinary bladder region (if KFT deranged)
stone, malignancy • Urine cytology if > 40yrs or smoker suspected)
• Cystoscopy if > 40 years or smoker
TERMINAL
• Bladder: stone, tumor at bladder neck • Deranged kidney functions
• Prostate: inflammation, benign • Suspecting malignancy
WHEN TO REFER
hyperplasia, malignancy • Haematuria with hypertension /
(WARNING SIGNS)
albuminuria
• Persistent severe haematuria
HOW TO TREAT
GENERAL SPECIFIC
• Haematuria should be considered as a symptom of genitourinary malignancy in patients >40years old until
• Start intravenous fluids proven otherwise
if required (primary • Suspected nephrotic/nephritic syndrome: cola coloured urine, proteinuria, anasarca, hypertension - Refer to
level) nephrologist (tertiary level)
• If Anaemia - may trans- • Suspect urinary tract infection : presents with dysuria, increased frequency of voiding and other irritative lower
fuse blood as required urinary tract symptoms with/ without fever- treat with broad spectrum oral antibiotics (primary level)
(primary level)
• Manage clot colic /
flank pain with analge- DIFFERENTIAL DIAGNOSIS FOR CHRONIC CONDITIONS LEADING TO HAEMATURIA
sics (primary level) Stones Renal cell cancer Bladder tumor Genito-urinary tuberculosis
• If Acute urinary reten-
tion - catheterise with Flank pain Flank mass Dysuria
Haematuria
20/22Fr 3 way Foley and Frequency
Symptoms Ureteric colic Flank pain Urinary retention
may start continuous Recurrent urinary tract infection Haematuria Nocturia
irrigation with normal Haemturia Haematuria
saline (Primary level) Urine analysis
• Cystoscopic clot evacu- Ultrasonography
Ultrasonography Ultrasonography Urine acid fast bacilli
ation may be per- Computed
Investiga- Xray KUB Computed Urine tuberculosis culture
formed if feasible (ter- tomography
tions Intravenous pyelography or tomography Gene expert (optional)
tiary level) Urine cytology
Computed tomography Intravenous pyelography or
• If basic evaluation and Computed tomography
management facilities
Mostly surgical Mostly surgical Oral Antitubercular treat-
are unavailable - refer >5mm or symptomatic -
Treatment treatment - refer treatment - refer to ment - 6months, refer to a
(tertiary level) refer to urologist
to urologist urologist urologist, close follow up
REFERENCES
1. Standard treatment guidelines in urology: Ministry of Health and Family selfare

October/ 2019


MALE INFERTILITY
ICD-10-N46.9
HOW TO PROCEED? HISTORY
AIM
• To ascertain contributory male • Age of partners and duration of
Both partners factor infertility.
examined • Identify potentially correctable • Use of contraception and
simultaneously* conditions lubricants.
• Identify incorrectable condtions • Knowledge of sexual cycle,
WHEN TO SUSPECT? that may or may not be amenable technique, frequency.
Ensure to Assisted Reproductive • Sexual and ejaculatory dysfunction,
Inability to conceive marriage is Technique (ART) volume of ejaculate
even after one year of consummated, • Identify underlying medical • Medical illness: STD, diabetes,
regular unprotected conditions responsible for recent fever, chronic bronchitis and
couple has any debilitating medical conditions
intercourse. infertility
frequent • H/o Chemotherapy, Radiotherapy
timed • Congenital anomalies,
Evaluation earlier intercourse cryptorchidism, hypospadias,
than one year if Chordee
with the PHYSICAL EXAMINATION • Testicular torsion, drug history,
female age is >35yrs, knowledge of • Body habitus (obesity, trauma and swelling
family history of ovulatary cycle. Klinefelter’s). Secondary sexual • H/o past surgeries( hernia repair,
infertility or very characters, gynecomastia orchiopexy, retroperitoneal
anxious couples. • Penis: hypospadias, surgery)
epispadiasis, chordee,
Infertility Incidence is * Male factor is an under • Testes: volume, consistency,
• Family history
(infertility,consanguinity,genetic
10-15%. Male factor- recognised problem and the
masses, contours
failure to recognise often disorders),
contributory in 50% leads to social and • Epididymis: flat, turgid, • Exposure to environmental toxins
cases. psychological adverse nodularity. Vas deferens (pesticides,herbicides, chronic heat
effects. Often the male is –present/absent thickened or and radiation (sauna bath, tight
evaluated once the female beaded non cotton undergarments, laptops
has been examined • Cords-presence of varicocele.
thoroughly and this delays
& mobile)
Inguinal or scrotal scar. • Partner history: Any menstrual
the treatment . Greater the
duration of infertility lesser
• Rectal examination: cyst, dilated abnormality, infertility evaluation
the chance of success. seminal vesicles. till date
INVESTIGATIONS
SEMEN ANALYSIS (ESSENTIAL)
• At least two- samples 1-2 months apart ; Abstinence of 1-3 days.; Collected in sterile, medical grade plastic wide mouth containers.
• Provided within the lab or transported within an hour at room temperature and examined immediately
• WHO 2010 criteria for normal report. Volume: >1.5, ml, Sperm conc.: >15 million/ ml, Sperm motility: >40% , Progressive > 32%, Sperm morphology: >4% normal
forms, Leukocyte density: <1 million/mL
DIAGNOSTIC CATEGORIES ACCORDING TO SEMEN ANALYSIS REPORT

Normal Semen Analysis: Low volume semen: Incomplete • Azoospermia: • Oligo-astheno-teratospermia: Isolated Asthenospermia:
Rule out sexual Collection, Retrograde Obstructive Antisperm antibodies, Sperm structural defect, Hypogonadism
dysfunctions, Anatomic ejaculation, Ejac. duct (Epididymal,vasal) • Multiple defects: Varicocele, Cryptorchidism, Genital tract
abnormalities, Female obstruction, Cong. Absence of • Nonobstructive: (Genetic, infection, Systemic illness, Prolonged abstinence, Drugs
factor and unexplained VasDeferens, Hypogonadism Chromosomal, Hormonal, (Sulfasalazine, NFT, Colchicine, Chemotherapy, GnRh analogs,
CT/RT, Post torsion testes, Spironolactone, Ketokonazole, Anabolic steroids, cocaine, alcohol.
Note: If a patient is unable to produce semen consider retrograde orchitis, Cryptorchidism, Chemicals: heavy metals, herbicides, organic solvents, fungicides,
ejaculation and anejaculation. Need further evaluation. Idiopathic) pesticides)
OPTIONAL INVESTIGATIONS
• Hormonal assay: Serum FSH, LH, Prolactin, Testosterone, Estradiol, T/E ratio
• Culture: Urine, Semen, Prostatic fluid, Antisperm antibodies, Viability assay, Sperm function tests, Scrotal USG & doppler, TRUS, Genetic studies,
• Testicular biopsy (Multiple bilateral preferable)
MANAGEMENT
PHC/CHC DISTRICT HOSPITAL
• History and Physical examination( PE) • Hormonal assay and Testicular biopsy
• Proper Semen analysis • Management of sexual and ejaculatory dysfunction
Normal Semen report: (Rule out unconsummation, sexual dysfunction, anatomic abnormailities) • Management of Varicocele and Hypogonadotropic
Abnormal Semen report: hypogonadism
• Refer to Urologist/ infertility centre • ART: AIH/AID and counselling for adoption.
• Preventive measures: Avoid gonadotoxins, gonadotoxic drugs, smoking, tobacco, chronic heat ,
excess use of mobiles; Encouraging healthy life style: Nutritious diet, regular physical exercise, TERTIARY LEVEL
avoid stress, use of antioxidants and vitamins( Vit. C, Vit E , Zinc) • Additional testing:TRUS, Genetic, ASA, Sperm
• Female partner to be evaluated by gynecologist function tests
• Management of reversible nonsurgical causes (Infections etc.) and surgical cause i.e. varicocoele if • Advanced surgery: Microsurgical VVA,VEA,
surgeon available. Varicocelectomy, TURED, Sperm retreival
techniques, Cryopreservation and sperm banking
• For further evaluation refer to district/ tertiary hospital.
• Advanced ART: IVF-ET/IVF ICSI
TREATMENT ALGORITHM
AZOOSPERMIA AZOOSPERMIA
(Low volume, ↓pH, Fructose -ve) (Normal volume, Fructose +ve)
Retrograde Clinical Examination & FSH
ejaculation ruled out
Examine Vas Obstructive Equivocal P.T.F.
(FSH-N, Epid, (N-FSH, N-testes) (Testes small, FSH>2N)
turgid)
Not palpable Palpable Normal testes B/L Multiple testicular biopsy Discuss
options
CABVD E.D.O.
Exploration, check
Normal No Focal DI/ Considering
TRUS vasal patency Sperms Sperms Adoption ICSI
CFTR DI/ Adoption Needle biopsy (if
Gene VEA/
required) ICSI TESE-ICSI Genetic study
Mutation Fibrous DI/
Counselling Cystic SV & ED Adoption Multiple testicular biopsy
Microsurgical
ICSI TURED Non-operable
VEA Sperms Sperms present
Vasography guided absent
TRUS guided PESA + ICSI Cryo preservation
ICSI
OLIGO-ASTHENO-TERATOSPERMIA
(↓ count, ↓ motility, poor morphology)
↑ FSH
↑ASA Varicocele Infection Idiopathic
Severe Germ epith damage
Steroids + Varicocelectomy Antibiotics Empirical Medical Rx
Refer for Assisted Reproductive
Technique (IUI/IVF/ICSI)

ABBREVIATIONS PTF: Primary Testicular Failure DI: Donor Insemination ART: Assited Reproductive Technique
FSH: Follicle Stimulating Hormone VEA: Vasoepididymal Anastomosis TESE: Testicular Sperm Extraction AIH: Artificial Insemination Husband
EDO: Ejaculatory Duct Obstruction TRUS: Trans Rectal Ultrasonography SV & ED: Seminal Vesicle & Ejaculatory AID: Artificial Insemination Donor
CABVD: Congenital Absence of Bilateral Vas PESA: Percutaneous Epididymal Duct ICSI: Intra Cytoplasmic Sperm Injection
deferens Sperm Aspiration TURED: Trans Urethral Resection of IVF-ET: Invitro Fertiliztion - Embryo Transfer
VVA: Vaso Vasostomy ASA: Anti Sperm Antibodies Ejaculatory Duct GUTB: Genito Urinary Tuberculosis
October/ 2019


RENAL AND URETERIC STONES
ICD N20.0
HOW WILL YOUR PATIENT PRESENT AND WHAT TO SUSPECT
CLINICAL SCENARIO SUSPECT
Flank pain Renal Stone
Colicky pain starting

Upper ureteric
from back
stone
and radiating to front
SYMPTOMS Renal Pelvic

Stone
Colicky pain starting
from back Mid ureteric
& radiating upto groin stone
Upper
Ureteric
Stone
Colicky pain starting from
Lower ureteric
back & radiating to upper
stone
thigh & scrotum/ vulva
History of site & type of

pain, associated
• Haematuria may be present with • Colics may be associated with symptoms hint towards
stone at any location nausea and vomiting possible site of stones.
• Lower ureteric stones may also • Can present as anuria in bilateral Remember to take past
present with difficulty in passing ureteric stones, ureteric stone in a history of stone diseases,
solitary kidney medications, family
urine history etc
INVESTIGATION
RADIOLOGY
NAME ADVANTAGES AND DISADVANTAGES TIPS FOR ORDERING INVESTIGATIONS
Readily available, inexpensive, minimal radiation but needs preparation hence may • Order X-KUB and Ultrasound in all patients of
X-KUB
not be the preferred test in emergency settings suspected renal stones (90% of renal stones are
Readily available, no radiation, safe test in pregnancy, detects radio-opaque).
USG
radiolucent stones, high sensitivity for hydronephrosis. Can miss a ureteric calulus • In acute colic NCCT should be preferred if
available
Anatomical and functional imaging, aids in planning surgery but high radiation • Once the stone is detected, get Intravenous
IVP
and needs preparation. Not useful in poor renal function pyelography if stone is seen on X-ray
No contrast required, highly sensitive and specific, detect radiolucent stones, • CT urography if stone is radiolucent to aid further
CT Scan treatment
detect other causes of flank pain, but risks higher radiation and cost
METABOLIC EVALUATION
Initial biochemical evaluation To be done in recurrent stone former, stone in

in all stone formers children, bilateral stones, family history of stone,
Extended
history of gut surgery, solitary kidney and cysteine
Urine analysis, serum creatinine, Evaluation
stones. Typically to be done at 3-4 weeks after stone
electrolytes namely calcium, clearance
phosphorous and uric acid. Intact
parathyroid hormone and stone Should include initial metabolic evaluation plus 24-hour
analysis are preferrable. urinary levels of calcium,uric acid, and creatinine.
Preferable to do urinary oxalate and citrate levels too.
Warning signs for
∙ Increase daily fluid Analgesics Flank Pain,
immediate referral
intake to ensure a Hydration Hematuria
∙ Anuria
urine output >2 ∙ Fever with chills and
lit/day rigors
• Restrict extra salt Fevers with Empiric ∙ Suspected renal failure
intake and chills & rigors/ Antibiotic/ ∙ Persistent haematuria
increase dietary Anuria hydration
fibre.
HIGHER
• Do not restrict
calcium intake. Medical Expulsive
• Increase citrate X- Ray KUB Urine Analysis Therapy (MET)
+
CENTRE
rich food such as USG Abdomen Initial Metabolic ∙ Alpha blockers such as
lemon, orange IVP/ CT Scan screen Tamsulosin(0.4mg/day);
juice etc. Alfuzocin(10mg/day);
• Decrease Doxazocin(4mg/day);
REFERRAL
consumption of Silodocin(8mg/day)
food rich in ∙ MET should be offered
oxalates like Single Stone > 5mm, Renal Stone <1cm ∙ In Ureteric stones
Kidney/ ureteric
spinach, nuts, beet Baseline Uteric Stone >5mm <10mm
stone >1cm
root, potato chips, investigation normal <1cm ∙ In the absence of
French fries. infection, obstruction
• Avoid purine rich or deranged renal
foods like animal Counsel the patient Medical expulsive therapy function.
protein, alcoholic for future preventive Alpha Blockers ∙ MET can be tried for
drinks like beer strategies Potaasium Nitrate upto 4 weeks

October/ 2019


SCROTAL SWELLING
ICD-10-N50.89
HOW TO MAKE A CLINICAL DIAGNOSIS?
DIAGNOSE THE SITE Are you able to reach Scrotal wall
AS PER SITE YES Scrotal swelling
OF SWELLING? above the swelling? involved in
swelling
NO
PARIETAL
INGUINOSCROTAL SWELLING SWELLING
Scrotal wall normal & can be
A swelling, pinched off the swelling
clinical or on
USG, arising Testis palpated INTRASCROTAL SWELLING Testis not palpable
from any of separately normally
the scrotal Swelling located just
structures: Swelling located
well above testis above &/or behind testis
scrotal wall &/
or intrascrotal EPIDIDYMAL SWELLING
SPERMATIC CORD SWELLING
contents
AS PER NATURE DIAGNOSE THE NATURE PAINFUL Fever Present Acute infection TESTICULAR
OF SWELLING? SWELLING
Fever Absent • Traumatic
PAINLESS • Ischaemic
(e.g. torsion)
Cystic Fluid accumulation, (e.g. Hydrocele,epididymal cyst)
Solid • Ch. inflammatory, (e.g. Filariasis, TB)

• Tumors
MAKE A CINICAL DIAGNOSIS

PARIETAL (SCROTAL WALL) SWELLINGS INTRASCROTAL SWELLINGS
BILATERAL UNILATERAL Testicular Epididymal Spermatic cord
• Reactionary to
• Cellulitis epididymo- orchitis Cystic • Epididymal cyst
Ac. Inflammation Hydrocele Varicocele
• Fournier gangrene • Furuncle Abscess • Spermatocele
Traumatic Contusional Blunt trauma
Painless Painless
Ch. Inflammation Filarial Elephantiasis • Ch. Filarial Painless
Solid • Testicular
epididymitis • Lipoma cord
• Edema in anasarca, tumor
Fluid • Ch. Tuberculous
IVC thrombosis Scrotal wall cysts Painful
Accumulation Epididymitis
• Urinary extravasation Painful
• Adenomatoid tumor • Funiculitis
• Torsion testis
Melanoma, Scrotal Painful
• Orchitis
Neoplasm Carcinoma • Ac. Epididymitis
Dermatofibroma;
RED FLAG SIGNS
PAINFUL SWELLING
CONFIRM BY
• Sudden onset TORTION TESTIS • Scrotal doppler
• O/E tender enlarged testis, pain (More common in REFER URGENTLY FOR
increases on elevating testis adolescents)
• Severe pain
ATTEMPT EXPERT CONSULTATION
• Manual detorsion if patient
• Vomiting reports early
• No fever
PAINLESS SWELLING CONFIRM BY

TORTION TESTIS • Scrotal USG
REFER ALL CASES FOR
• Solid testicular swelling is felt (Testicular Tumor) • Serum tumor markers EXPERT CONSULTATION
INVESTIGATIONS
SUSPECTING AC. INFLAM SUSPECTING CH. SUSPECTING TESTICULAR SUSPECTING SUSPECTING
DISEASE INFLAMMATORY DIS. TUMOR TORSION VARICOCELE
Essential Desirable Essential Desirable Essential Desirable Essential Desirable Essential Desirable
• TLC/DLC • Anti filarial • TLC/DLC • Anti filarial Ab • Beta hCG • Scrotal USG • TLC/DLC • Scrotal • TLC/DLC • Scrotal
• Blood sugar antibody • ESR • TB Gold test • Alfa feto • Abdomino - doppler doppler
• Scrotal USG protein Pelvic CECT
• Serum LDH Scan
HOW TO TREAT COMMON CONDITIONS?

PARIETAL SWELLINGS INTRASCROTAL SWELLINGS
FURUNCLE/ABSCESS AC. EPIDIDYMO-ORCHITIS CHRONIC EPIDIDYMO-ORCHITIS
• Broad Spectrum Antibiotic • If patient had a urinary tract • Mostly filarial in origin but if -
Amoxy + Clavulinic acid instrumentation or dysuria - - Patient has had H/O UTI or urethral
• Consider drainage if suspect bacterial type, catheterization, suspect bacterial
fluctuations+ or impending treat by - antibiotic and support - Patient has H/O TB, suspect
rupture tuberculosis
REFER REFER If no response in 48 hrs • Treat by DEC 100 mg
• If abscess appears part of • Treat all other cases as filarial by - DEC 100 TDS + Doxycycline 100 mg BD for 20
underlying disease mg x TDS x20 days days
• Nonresponders • Doxycycline 100 mg x BD x 20 days REFER if
• Immunocompromised • Give anti inflammatory drugs to all • No response to treatment
patient • Epididymal abscess or local sinus
HYDROCELE discharging syrup like pus
FILARIAL ELEPHANTIASIS • Small size - no treatment
• DEC 100 mg TDS x 20 days • Moderate to large -Do VARICOCELE
• Doxycycline 100 mg BD x 20 hydrocelectomy • Counsel for semen analysis (2-3 times)
days • Aspiration can be performed REFER if ‘discrepancy in size of testis’
• Scrotal Elevation/support under asceptic precautions in select cases and/or ‘abnormal semen parameters
REFER present’
• Non responders REFER if not trained to do the surgery • Rest all cases be given symptomatic
• Huge size treatment
CONTRIBUTORS Department of Health Research
ADVISORY COMMITTEE
Dr. Balram Bhargava, Secretary, DHR and DG, ICMR - Chairman

Dr. Nikhil Tandon, Dept. of Endocrinology, AIIMS, New Delhi. - Vice Chairman
WHO India Country Office Representative – Member, Ex officio

Director General Health Services / Representative- Member, Ex officio
Additional Secretary & MD (NHM), MoHFW – Member, Ex officio
Joint Secretary, DHR - Member Secretary, Ex officio
Dr. Pramod Garg, Dept. of Gastroenterology, AIIMS, New Delhi - Member

Dr. Sanjay Jain, Dept. of Internal Medicine, PGIMER, Chandigarh - Member
Dr. T. Sunderraman, School of Health System Studies, TISS, Mumbai - Member
Dr. J.V. Peter, Dept. of ICU and Trauma, CMC, Vellore - Member
Dr. Ashok Deorari, Dept. of Paediatrics, AIIMS, New Delhi - Member

Dr. Naveet Wig, Dept. of Medicine, AIIMS, New Delhi - Member
Dr. C. H. Arun Kumar, Dept. of Orthopaedics, RIMS, Imphal – Member
Brig. Shakti Vardhan, Dept. of Gyanecology/Oncology, AFMC, Pune - Member
Dr. Sudeep Gupta, Dept. of Medical Oncology, TATA Memorial, Mumbai - Member
Dr. S.K. Dwivedi, Dept. of Cardiology, KGMU, Lucknow - Member
Dr. Jeyaraj Durai Pandian, Dept. of Neurology, CMC, Ludhiana - Member
Dr. Vivekanand Jha, Nephrologist, The George Institute for Global Health, Delhi – Member
Dr. Rajdeep Singh, Dept. of Surgery, MAMC, Delhi – Member
Dr. Reva Tripathi, Formerly Dept of ObGyn, MAMC, New Delhi- Member.
Dr. S. S. Kale, Dept. of Neurosurgery, AIIMS New Delhi- Member
Dr. Peush Sahni, Dept. of G.I. Surgery, AIIMS, New Delhi- Member.
Dr. Binod Khaitan, Dept. of Dermatology, AIIMS, New Delhi- Member
Dr. Amlesh Seth, Dept. of Urology, AIIMS, New Delhi- Member
Dr. Shally Avasthi, Dept. of Paediatrics, KGMC, Lucknow- Member

Dr. B.N. Gangadhar, NIMHANS Bangalore – Member.
Dr. Anil Bhansali, Dept. of Endocrinology, PGIMER, Chandigarh- Member.
Dr. Shiv Chaudhary, Dept. of CTVS, AIIMS New Delhi- Member

Dr. Surinder Lal Jindal, Formerly Dept.of Pulmonology, PGIMER, Chandigarh-Member.
Dr. Lalit Kumar, Dept. of Medical Oncology, AIIMS, New Delhi- Member
Dr. Radhika Tandon, Dept. of Ophthalmology, AIIMS, New Delhi- Member

Dr. Alok Thakar, Dept. of Otorhinolaryngology, AIIMS , New Delhi-Member
Dr. Prakash Kotwal, Foremerly Dept. of Orthopaedics, AIIMS, NewDelhi- Member.
SPECIAL GUESTS
Dr. V. K. Paul, Member, NITI Aayog

Dr. Indu Bhushan, CEO, National Health Authority
Dr. Sudhir Gupta, D.G.H.S.

Dr. Anil Kumar, MoHFW.
EDITORIAL BOARD
CHAIR
Prof. Pramod Garg, Dept. of Gastroenterology, AIIMS, New Delhi
MEMBERS
Prof. Rajdeep Singh,, Dept. of Surgery, MAMC, New Delhi.
Prof. Sanjay Jain, Dept. of Medicine, PGIMER, Chandigarh.

Prof. S.K. Dwivedi, Dept. of Cardiology, KGMC, Lucknow.
Prof. Sushil Kabra, Dept. ofPaediatrics, AIIMS, New Delhi.
Prof. Vivekanand Jha, Executive Director, The George Institute for Public Health, New Delhi
MEMBER SECRETARY
Dr. Deepika Saraf, Scientist E, ICMR.
EXPERT GROUPS
NAME AND AFFILIATED INSTITUTE ROLE Department of Health Research

PAEDIATRICS
Dr. Shally Awasthi, KGMC, Lucknow Chair
Dr. Sushil Kabra, AIIMS, New Delhi Co-Chair
Dr. Neelam Mohan, Medanta, Gurgaon Co-Chair
Dr. Pushpa Kini - KMC, Manipal Member
Dr. Suvasini Sharma, LHMC,New Delhi Member
Dr. Joseph Mathew- PGIMER, Chandigarh Member
Dr. Surjit Singh, PGIMER, Chandigarh Member
Dr. Kuldeep Singh, AIIMS, Jodhpur Member
Dr. Himanshu Chaturvedi, Balrampur Hospital, LKO Member
Dr. Shinjini Bhatnagar, THSTI, Faridabad Member
UROLOGY
Dr. Amlesh Seth, AIIMS, New Delhi Chair
Dr. Anup Kumar, Safdarjung,New Delhi Co-Chair
Dr. Rakesh Kapoor, SGPGI, Lucknow Member
Dr. Dorairajan Narayanan, JIPMER, Pondycherry Member
Dr. Santosh Kumar, CMC, Vellore Member
Dr. Divakar Dalela, Ex KGMC, Lucknow Member
Dr. Anil Mandhani, Medanta, Gurugram Member
Dr. Shivam Priyadarshi, SMS Jaipur Member
Dr. Ravi Mohan Mavuduru,PGIMER Chandigarh Member
Dr. T P Rajeev, Guhawati Medical College Member
NEUROLOGY
Dr. Jeyaraj Pandiyan, CMC, Ludhiana Chair
Dr. Manjari Tripathi, AIIMS,New Delhi Co-Chair
Dr. Salil Gupta, R & R Hospital, New Delhi Member
Dr. Shefali Gulati, AIIMS,New Delhi Member
Dr. Sylaja PN, SCTIMST, Trivandrum Member
Dr. Vivek Nambiar, AIMS, Kochi Member
Dr. Karamvir Goyal, Ludhiana Member
Dr. P K Misra, Lucknow District Hospital Member
Dr. Sapna Erat Sreedharan, SCTIMST, Trivandrum Member
NEPHROLOGY
Dr. Vivekanand Jha, The George Inst of Global Health Chair
Dr. Sandeep Mahajan, AIIMS, New Delhi Co-Chair
Dr. Manisha Sahay, Osmania Medical College, Hyderabad Member
Dr. Arpana Iyengar, St John’s Medical College, Bangalore Member
Dr. Vijay Kher, Medanta, Gurgaon Member
Dr. Gopesh Modi, Samarpan Noble Hospital, Bhopal Member
Dr. Swaranjeet Kaur Gill, Bathinda Member
Dr. Anant Kumar Jha, Civil Surgeon, Godda Member
Dr. Vikram Singh, Dehradun Member
Dr. Ranjeet Nair, R&R Army Hospital, New Delhi Member
Dr. Vivek Kumar, PGIMER, Chandigarh Member
Dr. Vishal Golay, Anandalok Hospital, Siliguri Member
Dr. Mukta Mantan, MAMC, New Delhi Member
Dr. Natarajan Ramakrishnan Member
Dr. Narayan Prasad, SGPGI, Lucknow Member
Dr. Ramesh Chandrababu Member

Dr. R.K. Sharma, SGPGI, Lucknow Member Department of Health Research
Dr. George Abraham, JIPMER, Pondycherry. Member
CARDIOLOGY
Dr. S. K. Dwivedi, KGMC, Lucknow Chair
Dr. George Joseph, CMC, Vellore Co-Chair
Dr. Aditya Kapoor, SGPGI, Lucknow Member
Dr. G.Karthikeyan, AIIMS, New Delhi. Member
Dr. Paul V George, CMC Vellore Member
Dr. Santhosh Satheesh, JIPMER, Pondycherry Member
Dr. Saurabh Mehrotra, PGIMER, Chandigarh Member
Dr. Praveen Chandra, Medanta, Gurgaon Member
Dr. Amit M Vora, Reliance, Mumbai. Member
Dr. Calambur Narasinhan, CARE, Hyderabad Member
Dr. Paul V George, CMC Vellore Member
Dr. Praveen Chandra, Medanta, Gurgaon Member
Dr. Reva Tripathi, MAMC Delhi Chair
Dr. Vinita Das, KGMC, Lucknow Co-Chair
Dr. Anjoo Agarwal, KGMC, Lucknow Member
Dr. Manju Puri, LHMC, New Delhi Member
Dr. Radhika, UCMS, New Delhi Member
Dr. Neelam Aggarwal, PGIMER, Chandigarh Member
Dr. Asmita Rathore, MAMC, New Delhi. Member
Dr. Aruna Kekre, CMC, Vellore Member
Dr. Dasari Papa, JIPMER, Pondycherry Member
Dr. Usha Rani, IOG Member
Dr. Manika Khanna , NRIGS Member
Dr. Neerja Bhatla, AIIMS, New Delhi Member
Dr. Seema Saran, GMC, Badaun Member
ENT
Dr. Alok Thakar, AIIMS, Delhi Chair
Dr. Anupam Mishra, KGMC, Lucknow Co-Chair
Dr. A Ramesh, St John’s Medical College, Bangalore Member
Dr. Harpreet Kochar, Private Practice, Greater Noida Member
Col Dr. B. K. Prasad, Command Hospital, Lucknow Member
Dr. Anuja Bhargava, Ira Medical College, Lucknow Member
Dr. Prem Sagar, AIIMS Delhi Member
PULMONOLOGY
Dr. Surinder Jindal, PGIMER, Chandigarh Chair
Dr. G.C. Khilnani, AIIMS, New Delhi. Co-Chair
Dr. Ashutosh Aggarwal, PGIMER, Chandigarh Member
Dr. Anant Mohan, AIIMS, New Delhi Member
Dr. Raj Kumar, VPCI, Delhi Member
Dr. Alok Nath, SGPGI, Lucknow Member
Dr. Dhruv Chaudhary, PGIMS, Rohtak Member
Dr. Uma Mohan, St John’s Medical College, Bengalluru Member
Dr. DJ Christopher, CMC, Vellore Member
Dr. Deepak Talwar, Metro Hospital, Noida Member
PSYCHIATRY
Dr. BN Gangadhar, Director, NIMHANS Member

Dr. Pratap Sharan, AIIMS, New Delihi. Co-Chair Department of Health Research
Dr. Jagadisha Thirthalli, NIMHANS, Bengaluru Member
Dr. Subho Chakrabarti, PGIMER, Chandigarh Member
Dr. Prabha Chandra, NIMHANS, Bengaluru Member
Dr. Janardhan Reddy, NIMHANS, Bengaluru Member
Dr. Anju Dhawan, AIIMS, New Delhi Member
Dr. Satish Girimaji, NIMHANS, Bangalore Member
Dr. L Vijayakumar, Sneha, Chennai Member
Dr. KS Jacob, CMC, Vellore Member
Dr. Rajesh Sagar, AIIMS, New Delhi. Member
ADMINISTRATIVE SUPPORT
Mr. V. K. Gauba, Jt. Secretary, Dept. of Health Research, MoHFW, Govt. of India
Mrs. Anu Nagar, Jt. Secretary, Dept. of Health Research, MoHFW, Govt. of India
Dr. Reeta Rasaily, Scientist G, ICMR, New Delhi
Dr. Ashoo Grover, Scientist F, ICMR, New Delhi
Dr. Kavitha Rajshekhar, Scientist E, ICMR, New Delhi
STW SECRETARIAT
Dr. Deepika Saraf, Scientist E & Team Lead, ICMR, New Delhi
Dr. JerinJose Cherian, Scientist D, ICMR, New Delhi
Dr. Ashis John, Scientist, C, ICMR, New Delhi
Dr. Deeksha Elwadhi, Scientist, C, ICMR, New Delhi
Mr. Parth Garg, Graphic Designer, ICMR, New Delhi

Ms. Anika Gupta, Graphic Designer, ICMR, New Delhi
Ms. Surabhi Singh, Graphic Designer, ICMR, New Delhi

Ms. Sugandha Singh, Graphic Designer, ICMR, New Delhi
Er. Amitesh Kumar Sharma, Scientist B, ICMR, New Delhi
Mr. Sandeep Suman, Logistics Support, ICMR, New Delhi

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