CHOLERA

Guidelines and Protocols for Management. Click to edit Master subtitle style

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Definition

Cholera is an acute diarrhoeal disease, which results from colonization of the small intestine by vibro.cholerae 01 (classical or EL Tor biotypes) The disease is characterized by the sudden onset of profuse, effortless watery diarrhea, followed by vomiting, rapid dehydration, muscle cramps and suppression of urine. 4/29/12

Important Information

Transmission: Oral faecal route through contaminated water, food or direct contact with the contaminated hands. Incubation Period is from few hours up to 6 days. Reservoir of infection is the human being that is cases or carriers. Cases range from in apparent infections to 4/29/12 severe ones.

Clinical Features

Diarrhoea and vomiting, classical forms come in 3 phases:

Evacuation phase: abrupt onset of watery or rice watery diarrhoea w or w/o vomiting. If untreated leads to the next stage: Collapse Phase: cold clammy skin, tachycardia, Low BP, Peripheral cyanosis, Sunken eyes, low urine output (less than 25mls per hour. Occasionally renal failure may occur, and in children convulsion from hypoglycaemia. Recovery Phase: If the patient survives collapse phase they start to recover gradually and this takes from 1 to 3 days.

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Diagnosis

Rapid Diagnosis using the dipsticks; not a confirmatory test Confirmation

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Management
Assess dehydration status and classify patient. DEHYDRATION MILD TO MODERATE SEVERE i) Patients Thirsty: alert restless appearance Normal rate and ii) Radial pulse volume iii) Skin elasticity Pinch retracts immediately or slowly (<2sec) iv) Tongue Moist v) Anterior fontanelle 4/29/12 Normal Drowsy; limp, cold, sweaty; may be sleepy, unconscious. Rapid, weak, sometimes not felt. Pinch retracts very slowly (more than 2 sec) Very dry Very sunken

Management (contd)
For suspected cases with no dehydration: Give ORS to maintain normal hydration, Monitor for 6 hours All suspected cases with mild or moderate dehydration: Give ORS as per chart below Note: Give more ORS if patient asks for it, if patient vomits wait 10 minutes Age continue slowly <4 months4-11 12-23 2-4 years 5-14 years >14 years and months months Weight <5kg 5-8 kg 8-11kg 11-16kg 16-30kg >30kg

ORS in ml 200-400 4/29/12

400-600

600-800

800-1200 1200-2200 2200-4000

R H D A IO P O O O F R A U T F W H R F R E Y R T N R T C LS O D L S LO C A T O S V R LYD H D A E P T N S EEE E Y R T D A IE T
G e1lit int efirst1 m ue iv re h 5 in t s A dM n o p lse n o it r u .

IsP ls >0 /m ? u e 1 0 in
Ye s N o

Give another 1 litre R L in 15 minutes Ch c p lserae v lu e. ek u t/ o m Isp ls v lu est o g r? u e o m r ne

YS E

G e1 reRL in4 iv lit 5 m ue in t s

N O
Re e t 1lit RL IVin1 pa re 5 m ue in t s Co t u m n o gp lse nin e o it rin u a dre id t n n h raio

G ea d io a 1lit in iv d it n l re 2-5h u o rs N T : O a ea e ase ee d h dae OE n vr g, v r ly e y r t d a u p t n n e s8 -1 lit e R p rd y d lt aie t e d 0 r s L e a. St rt O a t h sa et e r a RS t e m im ,o a so na t ep t n ca s o s h aie t n in e it g st .

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Intravenous in fusion schem for children below1year if not in e shock

Age

W eight

st 1 hour

Follow 5 ing hours

Continuation phase

New born

3 kg

90 m l 30 drops/m in

210 m l 14 drops/m in

18 m l/hour 6 drops/m in

6m onths

6 kg

180 m l 60 drops/m in

420 m l 28 drops/m in

36 m l/hours 12 drops/m in

9m onths

8kg

240 m l 80 drops/m in

560 m l 37 drops/m in

48 m l/hour 16 drops/m in

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I taeo si f so s hmf rc ide aoe ya i nti n vnu n i n c e eo h r n bv 1 er f o n r u l s ok hc

Ae g 1 er ya

Wgt eh i 9g k

Fs 3 m t 1 i t0 i o r n hu 3 m g or 0 lk / 20 luc u t b 7 m no n l ae

Fl o i g o w 2 12 hus7 l n / or 0 mg lk / 60 l= D p/ i 3 m 7 r sm 0 o n uc ut b no n l ae

C nnao pae ot ut n hs i i 5 m o r 1 do sm 4 lhus 8 r p/ i / n

2 er yas

1k 2g

30 luc u t b 6 m no n l ae

80 lu c u t b 4 m no n l ae

7 m o r2 do sm 2 lhu 4 r p/ i / n

5 er yas

1k 5g

40 luc u t b 5 m no n l ae

15 m u c ut b 00 l no n l ae

9 m or 0 lh u / 3 do sm 0 r p/ i n

1 yas 5 er

3k 0g

90 luc u t b 0 m no n l ae

2 lte . ir s 1 uc ut b no n l ae

1 0 lh u 8 m or / 6 do sm 0 r p/ i n

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If the child is in shock

If the patient is in shock First 15 minutes = 20 ml/kg.IV Next 4 hours = 50ml/kg. IV After initial 20ml/kg, pulse should be stronger. If not, continue 20ml/kg IV for another 15 min.

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The role of antibiotics

They are indicated only for very severe cases and after good IV rehydration, Antibiotics can reduce liquid losses and carriage time of vibrio, but can induce a false sense of security. Most patients are cured by good rehydration and do not need antibiotics. Remember that if not well rehydrated, the patient will die even if antibiotics are given.
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Monitoring Cases

The following must be checked regularly and assessment made to regulate therapy. *consciousness of the patient. *Pulse *Respiration air hunger ( Kussmals breathing) suggests acidosis. *Temperature : patient is usually

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Complete disappearance of dehydration sings

infusion in a cholera patient with IV treatment

Absence of vomiting during last 12 hours ORS started for 2 hours or more , while IV kept at slow rate.

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Criteria for discharging a cholera patient

Keep with only ORS and under observation for 6 hours Discharge when no more sings of dehydration and less than 3 liquid stools during 6 hours Advice the patient to come back to the health center immediately if
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Vomiting restarts

For all patients, after each stool despite the level of dehydration, the stools should be disinfected with chlorine before being disposed. All clothing should also be soaked in chlorine after use. Caretakers must wash hands and feet before leaving the room where patients are being managed.
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After discharge, patients are also to

PREVENTION FOR HEALTH CARE STAFF

1. Wash hands with water and disinfectant after attending each patient. 2. Leave items used there i.e. pens, gloves and gowns in the isolation wards 3. Wash hands after leaving the isolation ward 4. The isolation ward should be 4/29/12 disinfected with chlorine after