Chapter 5

Diarrhoea Case II

Case study: Chandra

Chandra, 2 year old presented from health clinic with 4 day history of profuse diarrhoea. Vomiting everything for 2 days. Lethargic and not able to drink for 1 day.

What are the stages in the management of any sick child?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

What emergency and priority signs have you noticed?

Temperature: 37.2C, pulse: 145/min, weak and thready, RR: 50/ min, capillary refill time: 3-4 seconds; mouth: dry mucus membranes; eyes: sunken, dry, no tears; skin pinch goes back very slowly

Triage
Emergency signs (Ref. p. 2,6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

What emergency treatment does Chandra need?

Emergency treatment
Airway management? Oxygen? Intravenous fluids? Anticonvulsants?

Immediate investigations?

Emergency treatment
How do you treat signs of shock?
Give IV fluids (Ref. Chart 7, p. 13)
Insert an IV line (and draw blood for immediate investigations such as: haemoglobin, blood sugar) Attach Ringer's lactate or normal saline (0.9% NaCl) make sure the infusion is running well Infuse 20ml/kg as rapidly as possible Reassess child after appropriate volume has run in Do not use 5% Glucose alone or solutions containing only 0.18% NaCl

If peripheral vein access cant be obtained

Intraosseus (Ref. p. 340)

Femoral venous access (Ref. p. 342) Intraosseus needle, if not available use 19 or 21 G needle

Emergency treatment (continued)

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

Give emergency treatment until the patient is stable

History
Chandra had been well 5 days ago, but then he began to have loose watery stools 6-8 times a day. His mother reduced his intake of fluids and feed as he was having diarrhoea and she thought this might make this worse. On the second day he was taken to a local medical shop where he received a syrupy medicine and a packet of oral rehydration solution.

His diarrhoea did not improve, still 6-8 times each day. He started vomiting on the third day. He was then taken to the district hospital, as he had become lethargic and had stopped eating and drinking altogether. There was no blood or pus in the diarrhoeal stool.

Examination after stabilisation

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

Classification of the severity of dehydration in children with diarrhoea

Rapid assessment of hydration status and classification of severity of dehydration in children with diarrhoea:
Classification Signs or symptoms

Severe dehydration

Two or more of the following signs: lethargy/unconsciousness sunken eyes unable to drink or drinking poorly skin pinch goes back very slowly (>2 seconds) Two or more of the following signs: restlessness, irritability sunken eyes drinks eagerly, thirsty skin pinch goes back slowly

Some dehydration

No dehydration

Not enough signs to classify as some or severe dehydration

(Ref. Table 12, p. 128)

Poor skin turgor

(Ref. p. 128)

(Ref. p. 127)

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

Differential diagnoses (continued)

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

Additional questions on history

Diarrhoea
frequency of stools number of days blood in stools

Local reports of cholera outbreak Recent antibiotic or other drug treatment Attacks of crying with pallor in an infant

Further examination based on differential diagnoses

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

What investigations would you like to do to make your diagnosis ?

At this stage no additional investigations are necessary

Diagnosis
Summary of findings: Examination: lethargy, sunken eyes, decreased skin tugor, unable to drink History: 4 day of profuse diarrhoea and vomiting everything for 2 days.
Acute diarrhoea with severe dehydration

How would you treat Chandra after stabilisation?

Treatment
Diarrhoea treatment Plan C (Ref. Chart 13, p. 131)
Antibiotic treatment is rarely necessary (Ref. p. 126)

Only for: Dysentery (mostly Shigella) Cholera Neonates with diarrhoea and fever
Antidiarrhoeal agents Never necessary and often harmful

What supportive care and monitoring are required?

Supportive Care
All children should start to receive some ORS (about 5ml/kh/hour) by cup when they can drink without difficulty If the child is normally breastfed, encourage the mother to continue breastfeeding frequently When severe dehydration is corrected, prescribe zinc

Monitoring
Reassess every 15-30 minutes until strong radial pulse is present (Ref. Chart 13 p. 131) Reassess skin pinch, capillary refill, consciousness, ability to drink - hourly If signs of severe dehydration are still present, repeat IV fluid infusion as outlined earlier If the child is improving but still shows signs of some dehydration, discontinue IV treatment and give ORS for 4 hours (Treatment Plan B) If there are no signs of dehydration, follow Treatment Plan A

Summary
Chandra was rehydrated with intravenous fluids followed by oral rehydration solution. He was discharged when he was alert, able to drink and eat, and had less frequent episodes of diarrhoea.

At the time of discharge his mother was given advice on how to give extra fluid, to continue feeding and to return for follow up.
She was also given a Mothers card containing this information and two packets of oral rehydration solution.