EDLU Condition

EDLU Condition

Condition Name Condition Description

Elephantiasis

Lymphatic Filariasis (Elephantiasis)

Case Definition: Hydrocoele, lymphoedema, elephantiasis or chyluria in a resident of an endemic area for which other causes of these findings have been excluded. Causative organisms: 

Lymphatic filariasis is caused by the following nematodes

  1. Wuchereria Bancrofti (most common)
  2. Brugia Malayi
  3. Brugia Timori

 

The infection is transmitted by mosquitoes of the anopheles and culicine species. The disease is prevalent in 39 of 63 districts in Zimbabwe which will require MDA.

Clinical Manifestations:

There are three stages of the disease:

 

Early stage: 

Due to infective larvae comprising a triad of eosinophilia, lymphadenopathy and a positive intradermal test. Some patients may be asymptomatic.

 

Acute Filarial Manifestation: patients have fever, lymphangitis, lymphadenitis and relapsing lymphoedema of various body parts e.g. epididymo-orchitis in males.

 

Chronic stage: gross persistent lymphoedema of limbs, scrotum, breast or vulva in females. 

 

Diagnosis: this is based on a combination of a clinico-epidemiological information and sometimes demonstration of microfilariae in a blood or fluid smear.

Treatment of the acute phase involves use of Diethylcarbamazine (DEC). 

 

Patients should be referred for specialist management.

Drug therapy for chronic elephantiasis does not alter the eventual clinical outcome. Surgery for hydrocoele is indicated with local care of the limbs through daily cleaning/hygiene, elevation, exercise and use of foot ware.

Lymphatic Filariasis (Elephantiasis)

Case Definition: Hydrocoele, lymphoedema, elephantiasis or chyluria in a resident of an endemic area for which other causes of these findings have been excluded. Causative organisms: 

Lymphatic filariasis is caused by the following nematodes

  1. Wuchereria Bancrofti (most common)
  2. Brugia Malayi
  3. Brugia Timori

 

The infection is transmitted by mosquitoes of the anopheles and culicine species. The disease is prevalent in 39 of 63 districts in Zimbabwe which will require MDA.

Clinical Manifestations:

There are three stages of the disease:

 

Early stage: 

Due to infective larvae comprising a triad of eosinophilia, lymphadenopathy and a positive intradermal test. Some patients may be asymptomatic.

 

Acute Filarial Manifestation: patients have fever, lymphangitis, lymphadenitis and relapsing lymphoedema of various body parts e.g. epididymo-orchitis in males.

 

Chronic stage: gross persistent lymphoedema of limbs, scrotum, breast or vulva in females. 

 

Diagnosis: this is based on a combination of a clinico-epidemiological information and sometimes demonstration of microfilariae in a blood or fluid smear.

Treatment of the acute phase involves use of Diethylcarbamazine (DEC). 

 

Patients should be referred for specialist management.

Drug therapy for chronic elephantiasis does not alter the eventual clinical outcome. Surgery for hydrocoele is indicated with local care of the limbs through daily cleaning/hygiene, elevation, exercise and use of foot ware.

Cardiac Failure

Usually presents with shortness of breath on exertion or at rest, swelling of ankles, ascites and easy fatigueability.

General guidelines

i.Precipitating factors should be sought and treated e.g: hypertension

ii.Infections such as sub-acute bacterial endocarditis, chest infection arrhythmias,hypokalaemia,anaemia ,medicines, eg. digoxin overdose,NSAID‘s, beta-blockers ,pulmonary embolism ,thyrotoxicosis ,myocardial infarction

iii.Daily weights and fluid balance (intake/output) should be recorded as a simple measure of response to treatment. Ideal weight loss should be 1 kg per day.

iv.Restrict salt in diet.

v.Encourage bed rest.

vi.Check blood pressure daily.

vii.Potassium supplements are to be stopped and levels monitored regularly when using ACE inhibitors (e.g.captopril and enalapril).

Viii,Monitor serum potassium levels.

ix.Digoxin toxicity may be a problem especially in the elderly and in patients with hypokalaemia and hypomagnesaemia.

The role of digoxin in systolic heart failure patient who are in sinus rhythm (as compared to atrial fibrillation) has diminished over the years. Digoxin does not improve mortality in such patients, and be harmful in some patients and should therefore be used with great care

Low dose aspirin should be considered in most patients with severe systolic heart failure (very low ejection fraction) who have not had a stroke

Medicine Management:

Chronic heart failure management (heart failure secondary to left ventricular systolic dysfunction)

Frusemide po 40-80mg once or twice daily

Enalapril po 5-20mg once daily

Metoprolol succinate XI 12.5-200mg once daily or Carvedilol 3.125-25mg twice daily or Bisoprolol 1.25-10mg daily

Spironolactone 25-50mg once daily

Potassium chloride po 600mg-1.2g once daily

Digoxin po 0.25-0.5mg 3times a day first 24 hours then 0.125-0.25mg once a day( Paed=0.01mg/kg)

Notes

give intravenous treatment for severely oedematous patients

if using ACE inhibitors, losartan or spironolactone discontinue or use cautiously

ACE inhibitors are of benefit in all stages of heart failure

Selected beta blockers such as carvedilol, metoprolol succinate XL or bisoprolol  are of benefit in all stages of heart failure

For oedematous and bed-ridden patients:

Add Enoxaparin 40mg once a day

         Heparin 5000unites 3 times a day

Acute Pulmonary Oedema

Prop up in Bed Give 40% Oxygen by Mask(2-4L/min)

Morphine iv 5-10 mg slowly over 1-2mins and repeat every 15mins if required plus procloperazine 12.5mg for vomitting if required plus frusemide iv 40-80mg as required

Subsequent treatment includes ACE inhibitors as for heart failure.

Beta blockers should not be introduced in patients with acute heart failure which has not been stabilized (in contrast, patients with acutely decompensated heart heart who are already taking a beta blocker should be continued on their current dose – dose escalation should be deferred until the acute episode has been controlled)

Resistant cardiac failure

Exclude advanced renal failure as a cause of resistant heart failure. 

A progressive increase of frusemide is valuable. A single daily dose, at first, up to 160mg.Then hydrochlorothiazide 50mg may be added to advantage. After which the frusemide can be further increased up to 240mg. A second dose of frusemide before 4.00pm may be useful for nocturnal breathlessness.

The use of IV frusemide confers little advantage over the oral preparation. If still unsatisfactory consider referral for further management under specialist care.

 

Aim to optimize medical therapy, i.e. maximum tolerated doses of ACE inibitors (or ARBs), spironolactone or beta blockers in addition to diuretic therapy titrated to severity of symptoms

 

Refractory cardiac failure due to documented systolic heart failure, may represent end stage‘disease medical therapy is only palliative, with a goal of relieving symptoms and quality of life rather than prolonging life

 

Heart failure due to specific causes such as rheumatic heart disease needs to be considered separately, and patients should be referred for surgical intervention as early as possible

 

Cor Pulmonale

Treat as above but ACE inhibitors are not recommended.

Care should be taken with higher doses of diuretics as patients with cor pulmonale are prone to overdiuresis and subsequent pre-renal azotaemia Anticoagulation  should be considered in patients with cor pulmonale, pulmonary venous thromboembolic disease should be sought if the cause of the cor pulmonale is not obvious

 

Thyroid Disease

Thyroid Disease

Goitre

Compulsory iodisation of all salt for human consumption was commenced in 1995.  As a result the iodine intake of the population has increased tenfold or more and iodine deficiency has been eliminated in Zimbabwe.  Goitre is much less common than in the past, and can no longer be assumed to be due to iodine deficiency, although long standing cases will only resolve slowly if at all.  Iodine therapy is now rarely indicated.

Points in Management

  • Exclude hyper/hypo-thyroidism by careful clinical examination and thyroid function testing if necessary.
  • Thyroid cancer should be considered in patients with nodular goitre, or a single thyroid nodule, if there are suspicious features. (Rapid growth, fixation, unusual firmness, enlarged lymph nodes, hoarse voice: refer)
  • Otherwise treatment is not necessary, but if the goitre causes cosmetic embarrassment or pressure symptoms, thyroxine 100mcg daily should be given for an initial period of at least 6 months and response observed.  In severe or unresponsive cases, consider surgery.
  • After subtotal thyroidectomy, thyroxine 100mcg should be administered indefinitely. The dose should be adjusted according to tests of thyroid function.
  • Iodine is unlikely to be of benefit unless the subject does not have access to iodised salt.  Supplemental iodine is contra-indicated in those with nodular goitre due to the risk of hyperthyroidism.

Hyperthyroidism

  • Accurate diagnosis and identification of the underlying cause is essential; if not possible, refer. In clinically obvious cases either refer or start treatment while awaiting laboratory results.  
  • In severe cases refer early for possible radio-iodine.  In all cases hyperthyroid symptoms may be relieved by propranolol unless contraindicated (e.g. by asthma):

Propranolol po  40 – 240mg 3 times a day

Graves disease

Carbimazole 20-60mg daily until euthyroid then reduce to 5-20mg

CAUTION: May induce bone marrow suppression; advise patient to report sore throat or other signs of infection. Stop medicine immediately if neutropenic.  Minor rashes are not an indication to stop treatment.

Check thyroid function at 5-6 weeks and if normalised, gradually reduce the dose to the lowest that will maintain euthyroidism. Continue carbimazole for one year from time of stabilisation. If poor response, relapse or clinically very severe, refer for radio-iodine or surgery.

NB: after radio-iodine therapy for Graves disease, long-term follow up is essential to detect late hypothyroidism that might otherwise remain neglected and untreated.

Toxic Nodular Goitre [including toxic adenoma]

  • Carbimazole should normally be given only for short-term treatment prior to surgery or radioiodine. Give as for Graves‘ Disease, but higher doses may be needed.  
  • Radioiodine is recommended, particularly in older patients and those with other medical problems. Radio-iodine (I-131) treatment is available at the Radiotherapy Centres at Parirenyatwa and Mpilo Central Hospitals.
  • Surgery is particularly suitable for those with a large goitre.  As radioiodine may take three months or longer to produce a clinical effect, propranolol may be continued uninterrupted and carbimazole may be restarted. Patients must be rendered euthyroid prior to thyroidectomy by use of anti-thyroid medicines
  • Aqueous iodine oral solution may be administered for 10-14 days before thyroidectomy:

Iodine Solution (Lugol’s Iodine) 0.1-0.3ml 3 times a day for 10-14 days before surgery

 

 

 

 

 

Hypothyroidism

Except in iodine deficient areas, this is treated by thyroid hormone replacement whatever the cause:

Thyroxine po 50-100mcg once a day for 4weeks then increase by 25-50mcg every 4weeks as necessary until euthyroid

  • Start at 25mcg/day in the elderly or those with heart disease.
  • Typical adult replacement dose is 2mcg/kg/day [i.e. 150mcg daily].
  • Larger doses are needed in infancy [10 - 15mcg/kg/day] and childhood [4mcg/kg/day].
  • Close monitoring of clinical response and thyroid function tests (T4, TSH) is essential.

Cardiac Disease In Pregnancy

Types of cardiac disease:

  1. rheumatic heart disease accounts for over 95% of conditions
  2. hypertension
  3. puerperal cardiomyopathy
  4. congenital heart disease
  5. post-operative cardiac patients

Antenatal Management

The woman should be managed by a specialist obstetrician and physician together, and should be seen more frequently than usual.

In the antenatal period avoid fluid overload, anaemia and infection. Any infection should be treated aggressively with the appropriate antibiotics.

Treatment:

General guidelines

i.Precipitating factors should be sought and treated e.g: hypertension

ii.Infections such as sub-acute bacterial endocarditis, chest infection arrhythmias,hypokalaemia,anaemia ,medicines, eg. digoxin overdose,NSAID‘s, beta-blockers ,pulmonary embolism ,thyrotoxicosis ,myocardial infarction

iii.Daily weights and fluid balance (intake/output) should be recorded as a simple measure of response to treatment. Ideal weight loss should be 1 kg per day.

iv.Restrict salt in diet.

v.Encourage bed rest.

vi.Check blood pressure daily.

vii.Potassium supplements are to be stopped and levels monitored regularly when using ACE inhibitors (e.g.captopril and enalapril).

Viii,Monitor serum potassium levels.

ix.Digoxin toxicity may be a problem especially in the elderly and in patients with hypokalaemia and hypomagnesaemia.

The role of digoxin in systolic heart failure patient who are in sinus rhythm (as compared to atrial fibrillation) has diminished over the years. Digoxin does not improve mortality in such patients, and be harmful in some patients and should therefore be used with great care

Low dose aspirin should be considered in most patients with severe systolic heart failure (very low ejection fraction) who have not had a stroke

Medicine Management:

Chronic heart failure management (heart failure secondary to left ventricular systolic dysfunction)

Frusemide po 40-80mg once or twice daily

Enalapril po 5-20mg once daily

Metoprolol succinate XI 12.5-200mg once daily or Carvedilol 3.125-25mg twice daily or Bisoprolol 1.25-10mg daily

Spironolactone 25-50mg once daily

Potassium chloride po 600mg-1.2g once daily

Digoxin po 0.25-0.5mg 3times a day first 24 hours then 0.125-0.25mg once a day( Paed=0.01mg/kg)

Notes

give intravenous treatment for severely oedematous patients

if using ACE inhibitors, losartan or spironolactone discontinue or use cautiously

ACE inhibitors are of benefit in all stages of heart failure

Selected beta blockers such as carvedilol, metoprolol succinate XL or bisoprolol  are of benefit in all stages of heart failure

For oedematous and bed-ridden patients:

Add Enoxaparin 40mg once a day

         Heparin 5000unites 3 times a day

Acute Pulmonary Oedema

Prop up in Bed Give 40% Oxygen by Mask(2-4L/min)

Morphine iv 5-10 mg slowly over 1-2mins and repeat every 15mins if required plus procloperazine 12.5mg for vomitting if required plus frusemide iv 40-80mg as required

Subsequent treatment includes ACE inhibitors as for heart failure.

Beta blockers should not be introduced in patients with acute heart failure which has not been stabilized (in contrast, patients with acutely decompensated heart heart who are already taking a beta blocker should be continued on their current dose – dose escalation should be deferred until the acute episode has been controlled) 

Heart failure due to specific causes such as rheumatic heart disease needs to be considered separately, and patients should be referred for surgical intervention as early as possible

Anticoagulants for patients on long term anticoagulation (e.g. valve replacement) - warfarin should be avoided in the first trimester. Use heparin or low molecular weight heparin for the first 13 weeks, and change back to warfarin between weeks 13 – 37. After 37 weeks change back to heparin until after delivery. Warfarin can be commenced 24hrs after delivery.

Labour in cardiac patients

Cardiac disease patients should not be induced – they usually have easy vaginal deliveries, which can be assisted by forceps delivery or vacuum extraction to avoid stress. 

Give a single dose of ampicillin at the onset of labour: Ampicillin 1g IV once only

  • Keep the resuscitation trolley at hand.
  • Nurse in a propped up position
  • Do not give ergometrine. Use oxytocin (10 units oxytocin once at delivery of anterior shoulder
  • Post-natally keep the woman in high care for 24 hours.
  • Contraception:

    At 6 weeks after delivery, use the progesterone only oral contraceptive or injectable medroxyprogesterone acetate.

Guidelines on Antimicrobial Treatment And Prophylaxis 

General guidelines

Antimicrobials ares the most over-used class of medicines worldwide and in Zimbabwe. Apart from the unnecessary cost and risk to the patient, overuse encourages development of resistant organisms, a problem that has proven serious and expensive in many countries. Antimicrobials should be used only in patients with likely bacterial illness requiring systemic therapy. In many cases anti-microbial medicines will initially be given ?blind? or ?empirically?, the choice being based on clinical suspicion without microbiological confirmation. Positive identification of the pathogen and anti-microbial susceptibility testing should be sought wherever possible as this will result in better and more cost-effective treatment.

Principles of antimicrobial use

  1. Choice of agent should be based on factors such as spectrum of activity, anticipated efficacy, safety, previous clinical experience, cost, and potential for resistance. These will be influenced by the severity of illness and whether the medicine is to be used for prophylaxis, empirical therapy or therapy directed by identification of one or more pathogens.
  2. Prophylactic therapy should be restricted to the use of a limited range of agents of proven efficacy in invasive procedures with a high risk of infection or where the consequences of infection are disastrous. Most surgical prophylaxis should be parenteral and commence just before the procedure, continuing for no more than one or two doses after the end of the operation. The aim is to achieve high plasma and tissue levels at the time that contamination is most likely i.e. during the operation.
  3. Empirical therapy should be based on local epidemiological data on potential pathogens and their patterns of antibiotic susceptibility. Appropriate specimens for Gram stain, culture and sensitivity testing should be obtained before commencing antimicrobial therapy. Maintain a database of susceptibility profile in order to guide intelligent choice of empirical antibiotic therapy at regional and national patterns.
  4. Directed antimicrobial therapy for proven pathogens should include the most effective, least toxic, narrowest spectrum agent available. This practice reduces the problems associated with broad-spectrum therapy, that is, selection of resistant microorganisms and superinfection.

Choice of route should be determined by the site and severity of infection. It is important that topical antimicrobial therapy be restricted to a few proven indications, for example, eye infections because of the capacity of most agents

  1. to select resistant microorganisms and to cause sensitisation; topical antiseptics are preferred in most situations.
  2. Antimicrobial combinations have few indications. These include:
    • to extend the spectrum of cover, for example, in empirical therapy or in mixed infections,
    • to achieve a more rapid and complete bactericidal effect, for example, in enterococcal endocarditis,
    • to prevent the emergence of resistant micro-organisms, for example in the therapy of tuberculosis.

Note: Doses given are for a 70kg adult with normal hepatic and renal function. Paediatric doses are given in the chapter on Paediatric Conditions. In the elderly, as a general rule, doses given could be lower than the recommended adult dose (see Chapter on Medicines and the Elderly).

Notes on Specific Antimicrobials

Note that some antibiotics are becoming ineffective because microorganisms are generally resistant to them. Antimicrobial susceptibility testing should therefore be sought where possible. Patients should be counselled to complete courses even when they feel better.

Oral amoxicillin should be used in preference to oral ampicillin because of its better absorption, efficacy and lower cost. However, the same is not true of the injectable preparations that have similar efficacy.

Chloramphenicol must be limited to serious infection such as typhoid, Klebsiella pneumonia, Haemophilus influenzae infections, difficult to treat pelvic inflammatory disease and brain abscesses and not used indiscriminately in the treatment of fever. An exception to this is when a broad-spectrum antibiotic is required and there is a problem with availability. Furthermore, the oral preparation should be used judiciously as it is more prone to cause aplastic anaemia than the injectable formulation.

Dosage      of      gentamicin,      streptomycin,      and     kanamycin

(aminoglycosides) must be carefully adjusted for weight and renal function. Except for duration less than 3 days use or when lower doses are used, as with TB therapy, they require peak and trough serum levels (where available), careful monitoring of serum urea and/or creatinine, and checking for complaints of auditory or vestibular symptoms (adverse effects).

Patients with true penicillin allergy (that is, a pruritic rash, angioedema or anaphylaxis) must not be given penicillin. Rashes occurring after 48 hours are rarely due to allergy and are not a contraindication to further use. Note that, penicillins have crossreactivities with other medicines including cephalosporins and such newer medicines as imipenem. Macrolides are suitable alternatives. Persons with a history of co-trimoxazole allergy may be offered desensitisation (see Chapter on HIV infections).

Pyrexia/Fever of Unknown Origin

Fever is a common presenting symptom at all ages, but in adults there will usually be some localising symptoms or signs, which point to a likely focus of infection. If after careful examination no clear focus of infection is identified, the following should be considered in a previously healthy patient admitted from the community with fever of less than two weeks‘ duration:

  • Viral infections (frequently resolve after 4-5 days, or may be the prodromal phase, for example, hepatitis)
  • Malaria
  • Typhoid
  • Urinary tract infection
  • Bacteraemia
  • HIV related causes of fever

If HIV infection is suspected see guidelines in the chapter on HIV Related Diseases.

  • If the patient‘s general condition is satisfactory, it is reasonable to withhold antibiotics while carrying out a few basic investigations: that is urinalysis (dip-stick), urine microscopy, haemoglobin, white cell count and differential and malarial parasites which are all within the capabilities of a district hospital laboratory. If possible, send a blood culture to the nearest reference laboratory. Liver function tests and urine testing for bile products are appropriate if hepatitis is suspected.
  • If no improvement occurs after 3-4 days, and there is still no identifiable focus of infection, and there is no evidence of malaria (at least two negative blood films), the subsequent management of the patient should be guided by the results of the investigations.
  • In those patients who present very ill or toxic, or whose condition deteriorates, antibiotic therapy should be initiated on the basis of clinical suspicion (typhoid - chloramphenicol, staphylococcal septicaemia - cloxacillin, etc), anaerobes (metronidazole).
  • Recommended „blind? therapy for septicaemia with no identifiable source is as follows: 

  • -Ampicillin 2g IV four times a day review, and Gentamycin 4-5mg/kg IV once daily for a maximum of 2 weeks

  • Alternatively:  

  • -Chloramphenicol 1g IV four times a day review, and Gentamycin 4-5mg/kg once daily for a maximum of 2 weeks.

  • The use of antimicrobials for prophylaxis of infection

    There are some instances where the use of prophylactic antibiotics is well established. However, the use of antibiotics for prophylaxis of infection often consumes a disproportionate amount of all antibiotics used in the hospital setting and consideration to their appropriate use must be given. Prophylactic antibiotic use must be within accepted principles and guidelines.

    General Recommendations:

  • use the appropriate medicine (see below)
  • give as a single dose where possible
  • repeat when the procedure lasts longer than 3-4 hours
  • give intravenously 10-15 minutes before incision, or orally 1-2 hours before incision.

    Specific indications:

    Surgical prophylaxis 

  • Vaginal Operations- Chloramphenicol 1g IV single dose

  • Caesarian Section- Ceftriaxone 1g IV single dose

  • Hysterectomy or Colorectal Surgery- Ceftriaxone 1g IV single dose and Gentamycin 4-5mg/kg IV single dose. If signs of infection after operation, give: Amoxycillin 500mg po tds and Metronidazole 400mg po tds for 7 days.

  • Urinary Tract Surgery- Ciprofloxacilin 500mg po single dose

    Other prophylaxis

  • Skull base fracture with liquorrhoea (rhino/otorrhoea): Chloramphenicol 1g IV single dose
  • Meningococcal Meningitis Contacts: Ceftriaxone 250mg im single dose

Basic Infection Prevention And Control Measures

General Notes

 

(See National Infection Control Guidelines)

Transmission of infections in healthcare facilities can be prevented and controlled through the application of basic infection control prevention and control practices. The 2 tiers or categories of infection control prevention and practices are A) standard precautions and B) transmission based precautions.  The goal of this two- tier/category system is to minimise risk of infection and maximise safety level within our healthcare facilities.

  • Educate healthcare workers not only on what to do but why it is important to do it.
  • Emphasising outcomes helps healthcare workers see how their routine job duties interact with the infection control system.

Categories of Infection Control Practices:

  1. Standard Precautions (previously known as Universal Precautions) - must be applied to all patients at all times, regardless of diagnosis or infectious status.
  2. Transmission based precautions - are specific to modes of transmission e.g. airborne, droplet or contact. 

 

A) Standard Precautions

Treating all patients in the healthcare facility with the same basic level of ?standard? precautions involves work practices that are essential to provide a high level of protection to patients, healthcare workers and visitors.

These precautions include the following:

  • Hand hygiene (hand washing, hand antisepsis)
  • Use of personal protective equipment when handling blood substances excretions and secretions.
  • Appropriate handling of patient care equipment and soiled linen.
  • Prevention of needle stick/sharp injuries.
  • Environmental cleaning and spills management.
  • Appropriate handling of waste.
  • Hand Hygiene

    Appropriate hand washing can minimise micro-organisms acquired on the hands by contact with body fluids and contaminated surfaces. Hand washing breaks the chain of infection transmission and reduces person to person transmission.

     

    NB:  Hand washing or hand antisepsis is the simplest and most cost- effective way of preventing the transmission of infection and thus reducing the incidence of healthcare associated infections.

     

    Types of Hand Hygiene

     

  • Hand washing is usually limited to hands and wrists, the hands are washed for a minimum 10-18 seconds with hand washing soap and water.
  • Hand antisepsis/Decontamination
  • Decontaminate hands with a waterless alcohol based hand gel or rub for 15-30 seconds.
  • This is appropriate for hands that are not visibly soiled.

  • Surgical hand antisepsis
    • This removes or destroys transient micro-organisms and confers a prolonged effect. The hands and forearms are washed thoroughly with an antiseptic soap for a minimum 2-3 minutes and dried with a sterile towel. This is required before performing invasive procedures.
  • NB: Hands should be dried with disposable paper towels.

     

    Use of Personal Protective Equipment.

    Types:

    • Scrub Suit or Gowns
    • Plastic Aprons 
    • Boots or shoes covers
    • Caps 
    • Protective eye wear
    • Gloves
  •  

    • Gloves
  • Reduce the incidence of hand contamination with infective material which in turn reduces the opportunity for personnel to become infected and/or the organisms to spread to other personnel and /or patients.
  • Gloves however should not replace hand washing.
  •  

    Gloves are to be worn when touching the following:

  • Blood
  • All body fluids
  • All body secretions
  • All body excretions
  • Gloves should be removed before touching clean items (e.g. phone, door knobs or patients‘ charts.) After removing gloves, wash hands thoroughly.

     

    A. Important points to remember when using gloves. 

  • Use gloves when there is potential exposure to blood, body fluids, excretions or secretions.
  • Change gloves between patients, between procedures on the same patient when they become soiled.
  • Remove gloves before leaving the patient‘s bedside and decontaminate hands immediately with 70% alcohol hand rub solution.
  • Discard gloves after attending to each patient.
  •  

  • Boots/shoe covers ? These are used to protect the wearer from splashes of blood, body fluids, secretions and excretions.
  •      Shoe covers should be disposable and waterproof. ?            Waterproof boots should be washable.
  •  

    C. Caps

  •      Disposable and waterproof caps that completely cover the hair are used when splashes of blood and body fluids are expected.
  •  

    D. Masks

  • A surgical mask protects healthcare providers from inhaling respiratory pathogens transmitted by the droplet routes. It prevents the spread of infectious diseases such as varicella (Chicken pox) and meningococcal diseases (meningococcal meningitis.)
  • A N95 mask protects healthcare providers from inhaling respiratory pathogens that are transmitted via the airborne route. This helps to prevent the spread of infectious diseases such as TB, or MDR TB.
  • NB: In order to prevent the spread of infection, the appropriate mask should be worn by healthcare providers and visitors when attending to a patient suffering from a communicable disease that is spread via the airborne or droplet route.

     

    The patient with a communicable disease via the droplet or airborne route should wear a surgical mask when being transferred to other departments or hospitals or in isolation room to prevent spread of infection.

    Disposable masks are for single use only and should only be discarded after 4-6 hours use.

    Precautions

  • Masks should not be worn around the neck
  • Masks cannot be worn with beards or unshaven faces.
  • Masks should completely seal the face at all times to ensure effective filtering of micro-organisms.
  •  

    E. Gowns

  • Gowns made of impervious material are worn to protect the wearer‘s clothing/uniform from possible contamination with micro-organisms and exposure to blood, body fluids, secretions and excretions.
  • Use gown once for one patient and discard.
  • Healthcare workers should remove gowns before leaving the unit.
  • Recommendations for use of gowns

  • Lab coats or scrub suits should not be viewed as an effective barrier to blood or other body fluids.
  • Use of fluid resistant gowns, impervious gowns or plastic aprons, if soiling of clothes with blood or other potentially infectious material is likely, is highly recommended.  
  •  

  • Plastic Aprons ? A plastic apron protects the wearers‘ uniform from contact with contaminated body fluids.
  • The inside of the apron is considered clean, the outside is considered contaminated. The neck of the apron is clean because that part is not touched with contaminated hands.
  • Wash hands thoroughly after removing apron.
  •  

    Protective eyewear/Goggles

  • Should be worn at all times during patient contact where there is a possibility that  patients‘ body fluids may splash or spray onto the care giver‘s face/eyes (e.g. during suctioning, intubation, endoscopy and cleaning of instruments used for these procedures)
  • During all dental, surgical, laboratory and post mortem procedures.
  • Full face shields may also be used to protect the eyes and mouth of the healthcare worker in high risk situations.
  •  

  • Re-usable goggles should be washed and decontaminated after removal and in-between use.
  • Please note:  All protective equipment should be removed prior to leaving work area.

     

    G. Needles, sharp instruments and other devices.

    All equipment contaminated with blood or other body fluids should be handled with special care. Keep in mind these recommendations:

  • Never recap needles
  • Never bend or break needles
  • Never remove needles from disposable syringes
  •  

  • Immediately dispose of all disposable syringes and needles, scalpel blades and other sharp instruments, after use, in a colour-coded or labelled leak-proof puncture resistant container.
  • B) Transmission based precautions.

    These are designed to supplement standard precautions or protocols and must always be used in conjunction with Standard Precautions isolation techniques. Transmission based precautions provide extra safety by facilitating a concerted effort to control the spread of specific types of bacteria. Whilst mostly used for diagnosed infection, they are useful when a specific diagnosis is suspected. Transmission based precautions are divided into 3 basic categories:

    • Contact
    • Droplet
    • Airborne
  •  Contact Precautions:

  • Reduces the risk of transmission of organisms from infected or colonised patient through direct or indirect contact.(e.g. Herpes Simplex, Haemorrhagic Fever Virus e.g. Ebola, multi-drug resistant bacteria)
  • Precautions include: Hand gloving/Patient placement /Hand washing/Use of aprons and gowns/Patient care equipment/Patient transport
  •  Droplet Precautions:

  • Reduces the risk of nosocomial transmission of pathogens spread by large droplets particles usually within a metre (e.g. Mumps, Diptheria, Haemophilus and Influenza.) ? Droplets may be expelled during: Sneezing/Coughing/Talking
  • Teach cough hygiene i.e. cover mouth when coughing
  • Precautions include: Patient Placement/Respiratory protection/Patient transportation.
  •  
  • Airborne Precautions:
  • Designed to provide protection from extremely tiny airborne bacteria or dust particles which may be suspended in the air for an extended period of time.
  • Used in addition to Standard Precautions for patients known or suspected to be infected with micro-organisms transmitted by airborne route e.g. TB, chicken pox/measles.
  • Precautions include: Respiratory Protection/Patient placement/Patient transportation

Pelvic Inflammatory Disease

Acute PID refers to the acute syndrome attributed to the ascent of microorganisms, not related to pregnancy or surgery, from the vagina and cervix to the endometrium, fallopian tubes and adnexal structures.      Gonorrhoea, chlamydia,  mycoplasma, anaerobic bacteria and gram-negative organisms can cause acute PID.

Mild / Moderate Pelvic Inflammatory Disease

First line: Amoxyl 500mg po three times a day and Doxycycline 100mg po twice daily and Metronidazole 400mg po three times daily, all for 7 days

Second Line: Norfloxacin 800mg po single dose and Doxycycline 100mg po twicw daily and Metronidazole 400mg po three times daily for 7 days

In patients with peniccilin allergies, give Erythromycin 500mg four times daily for 10 days.

Severe pelvic inflammatory disease

Temperature greater than 38oC with marked abdominal tenderness. Patients need IV fluids and IV medicines.

 Benzyl Penicillin 2,5MU IV 6 hourly for 48-72 hourly

Chloramphenicol 500mgIV 6 hourly for 48-72 hours

and Metronidazole 1g PR 12 hourly for 72 hours

ALTERNATIVELY

Ampicillin 500mg IV 6 hourly for 48-72 hours

Gentamycin 160mg im 12 hourly for 48-72 hours

and Metronidazole 1g PR 12 hourly for 72 hours

* Note: Duration as determined by patient?s response. Switch to oral after review. 

If no response within 48 hours suspect pelvic abscess: may need laparotomy or referral. Change to oral administration after temperature has settled.

Hypertension In Pregnancy

Women who develop hypertension during pregnancy (after 20 weeks) have pregnancy-induced hypertension (PIH) which is a potentially serious condition possibly requiring early or urgent delivery (see below). 

Pregnant women who have essential hypertension may also develop superimposed PIH and merit the same treatment. Methyldopa is the recommended anti-hypertensive throughout pregnancy. 

CAUTION: Avoid diuretic medicines during pregnancy.

Essential Hypertension

Monitor for development of proteinuria. Give

Methyldopa po 250-500mg po 3-4 times a day and Nifedipine 20mg po twice daily then review

Pregnancy Induced Hypertension 

  • Monitor closely and check urine for protein (exclude urinary tract infection). Manage as high-risk antenatal patient.
  • Any pregnant woman (especially primigravida) with a rise of diastolic pressure > 15 mm may have severe pregnancy induced hypertension, even with a BP < 140/90.

Mild Pregnancy Induced Hypertension Diastolic 90-100 mm Hg; no proteinuria.

  1. Bed rest at home. 
  2. Weekly antenatal visits. 
  3. Admit if there is a past history of foetal loss or eclampsia

Moderate Pregnancy Induced Hypertension  Diastolic 100-110 mm Hg; no proteinuria.

              §    Admit, monitor blood pressure 4 hourly, and give:

Methyldopa po 250-500mg po 3-4 times a day and Nifedipine 20mg po twice daily then review

At gestation > 37 weeks, plan delivery.

Severe Pregnancy induced hypertension

Diastolic > 110mm Hg; in first 20 weeks of pregnancy -this is likely to be essential hypertension.  Severe PIH in the second half of pregnancy needs careful monitoring for proteinuric PIH. Manage as for moderate pregnancy induced hypertension. If not controlled add hydralazine as follows:

Methyldopa po 250-500mg po 3-4 times a day and Nifedipine 20mg po twice daily plus hydralazine 10mg 1m every 4 hours then review

Severe Pre-Eclampsia(Proteinuric pregnancy-induced hypertension)

Manage as an inpatient. Plan to deliver at 37 weeks or before. 

  1. Monitor blood pressure 4 hourly. 
  2. Check urine for protein daily (exclude urinary tract infection). 
  3. Watch for signs of eclampsia.
  4. If diastolic > 110 mmHg check blood pressure hourly and continue giving medicines as for severe PIH (above).

 

Imminent Eclampsia

Proteinuric pregnancy induced hypertension with symptoms of visual disturbance or epigastric pain and/or signs of brisk reflexes:

  • Plan urgent delivery. Prevent convulsions with: Magnesium Sulphate - 4 gm iv in 20mls of Normal Saline over 20 minutes plus 5 gm in each buttock as the loading dose, followed by 5gm in alternate buttocks every four hrs until 24 hours after delivery
  • Check blood pressure at least hourly. If diastolic pressure > 110 mmHg give anti-hypertensives as for severe PIH (above).
  •  

    Eclampsia

    This is pregnancy-induced hypertension with epileptiform fits.

  • Ensure clear airway.
  • Stop convulsions with: Magnesium Sulphate  -4 gm iv in 20mls of Normal Saline over 20 minutes plus 5 gm in each buttock as the loading dose, followed by 5gm in alternate buttocks every four hrs until 24 hours after delivery, or 24 hrs after the last fit whichever is the later.
  • Plan urgent delivery, within 6 hours.
  • Monitor carefully:
    1. Patellar reflex
    2. Respiration (respiratory rate must not be less than 16/min) n                                                Urine output > 100mls in 4 hours
    3. All nurses, midwives and doctors attending to pregnant women should familiarise themselves with the magnesium sulphate regimen. Once competence is achieved in its administration, the regimen should be used at all levels. At the primary level, the intravenous component of the loading dose may be omitted, but the intramuscular component (10 grams) should always be given.
    4. Check blood pressure at least hourly. If diastolic pressure >110mmHg give: 
    5. Hydralazine iM  10mg    once

 

Acute Kidney Injury

What is causing the kidney injury? Try and classify by cause. The majority of cases of acute renal failure (or acute kidney injury) are due to ischaemic or toxic injury to the kidney and are reversible if treatment is instituted promptly i.e. within hours not days.

Pre-Renal Cases

Most common cause of acute kidney injury and most amenable to therapy. Usually have a history of hypovolaemia or hypotension e.g. bleeding, vomiting, diarrhoea and are usually oliguric.  Rapid recovery of renal failure is to be expected with prompt treatment.  

 

Acute Renal Failure 

Consider sepsis, malaria, acute glomerulonephritis, acute tubular necrosis, myeloma, nephrotoxic medicines such as gentamicin and NSAID‘s, and other causes such as acute -on-chronic renal failure.  As a minimum, get urine microscopy and an ultrasound of the kidneys for size. Are the kidneys normal sized, small, enlarged or obstructed?

Obstructive Uropathy

Continuous bladder catheterisation is required until the obstruction is relieved.  Relief of obstruction can result in polyuria.  Therefore, rehydrate with IV fluids.  Aim to keep up with the urine output.  Sodium and potassium supplements may be required. Scan kidneys to exclude hydronephrosis. Refer to a urologist for definitive management.

Exclude prostatic enlargement in males and cancer of the cervix in women.

Management of Renal Failure
  1. First line: Exclude dehydration in all cases. Give adequate rehydration. Try fluid challenge with sodium chloride 0.9%. Should show response within hours (not days). Aim for a visible jugular venous pressure (JVP) first and then consider giving IV frusemide to encourage diuresis.
  2. Second line: If the patient fails to respond to adequate rehydration and fluid challenge with sodium chloride 0.9% [not dextrose 5%] within 24 hours and condition is deteriorating, referral for dialysis is indicated.  If this is not possible, then aim to support patient until the kidneys recover [may take up to 6-8 weeks or more].  Monitor fluid (input and output charting) carefully. Check electrolytes regularly and maintain nutrition. Watch for infections.
  3. Third line: Start dialysis or consult dialysis team sooner rather than later so that they can help monitor the patient. Late referrals contribute to the mortality of acute kidney injury (acute renal failure) and endstage renal disease. Selection criteria are applied for the chronic dialysis programme and hence, each individual patient should be discussed with the dialysis team.  

 

Fluid balance: Daily weights before breakfast.  Aim for no weight gain. 

Previous day‘s losses (urine, vomit etc) +500mls =day‘s fluid intake. Electrolytes:  Ideally measure urea and electrolytes at least on alternate days.  Monitor potassium levels. 

 

To lower potassium levels in acute hyperkalaemia, give:

10ml of 10% Calcium gluconate/chloride over 10 minutes plus 50ml of 50% glucose over 10 minutes plus 10 units of short acting insulin OR

Salbutamol Nebulised 10gm two times a day review plus 50ml of 50% glucose over 10 minutes plus 10 units of short acting insulin OR 

Calcium Resonium 45mg as enema, keep enema in for as long as possible

General measures in the management of acute renal failure

  1. Catheter: Insert a urinary catheter but remove it once sustained diuresis has occurred or if oliguria persists and the patient is started on dialysis or conservative treatment. Avoid long catheterisation periods.
  2. Urine: Ward urinalysis test - check for haematuria, proteinuria and glycosuria. Send urine for microscopy (for cells, casts), culture and sensitivity.
  3. Diet: High calorie and normal or high protein diet with low sodium and low potassium. Ask for dietician‘s help. For low potassium diet, avoid e.g. oranges, bananas, mangoes.
  4. Anaemia: If oliguric do not transfuse unless there is significant bleeding, as there is a high risk of fluid overload. Wait to transfuse until patient is on dialysis.
  5. Monitor  BP regularly( e.g. 4 hourly) n                                   
  6.   Monitor fluid input/output strictly.
  7.  Avoid nephrotoxic medicines such as gentamicin and NSAIDs
  8.  Watch for and treat underlying infections.
  9. Check weight gain

 

 

Nephrotic Syndrome

Diagnosed where there is generalised oedema, hypoalbuminaemia and proteinuria (>3gm/day).  Dipstick should show at least protein ++.  To quantify the proteinuria, you can request a urine albumin: creatinine ratio. Estimate the GFR (creatinine clearance). See section on ART for calculation of GFR.. Check urine microscopy and U&Es.  Weigh patient at each review.  Exclude SLE, HIV and Hepatitis B or C or even diabetes. 

n Promote diuresis using

-Frusemide 40-80mg po once daily for 5 days

-If no response 40-200mg po/IV twice daily until resolution

Caution: Excessive use of frusemide may precipitate renal failure and large doses of frusemide may cause hearing loss. Therefore, check U&Es regularly.

Measure urea and electrolytes. Restrict fluid to 1 litre per day until diuresis occurs. If oedema is gross and no response, consider adding: prednisolone as a trial particularly if the urine sediment is benign (i.e. no red cells or casts). 

Predisolone 1mg/kg po once daily for 2 months

plus Enalapril 5-10mg po once daily review

-Aim to tail off dose to zero during the 3rd month.  Stopping early may result in a relapse.

-Give an ACEI for the proteinuria even if BP is normal e.g. a small dose of enalapril early unless contraindicated.This may be increased as the condiction allows.

-Refer if there is failure to reduce oedema within two weeks on high dose steroids.

-Anticoagulate if immobile: 

Heparin 5000units sc three times a day until mobile

Search for underlying cause -e.g. Diabetes, SLE, Hepatitis B/C, HIV, syphilis.

Restrict dietary salt intake, but leave on normal protein intake.

If oedema is not resolving after 2 weeks of treatment, refer to Central Hospital/Specialist.

 

Gout (Urate crystal synovitis)

Acute gout

The possibility of septic arthritis should always be considered. Allopurinol should not be given during or within three weeks following an acute attack unless if patient is currently on it. Aspirin should be avoided

Use: Indomethacin 50mg po four times a day for the first 24 hours, then reduce by 25mg po three times daily review 

OR Colchicine 0,5-1mg po upto 6 times a day for 2 days

 

Chronic gout

Treat acute attacks as they occur. Stop thiazide diuretics, avoid dehydration. 

Allopurinol 300mg po once daily continual

Note: 300 mg allopurinol orally once daily is the average dose but some patients need more to reduce the serum uric acid to normal levels.

  • In the elderly patients, those on diuretics, or those with impaired renal function, allopurinol should be started at the lower daily dose of 100 mg and increased cautiously if necessary.
  • Allopurinol should not be introduced during or immediately after an acute attack. 
  • During the period when allopurinol is being introduced an active drug for acute gout, like colchicine or NSAIDs, should be used until a normal level of uric acid is attained:Colchine 0,5mg po three times a day for 7 days OR Indomethacin 25mg po three times daily for 7 days
  • Concurrent anti-inflammatory therapy should be given for the first 3 months of allopurinol therapy: Indomethacin 25-50mg po three times day for 3 months

Dietary management of gout

Choice of foods aims to control the amount of purine in the diet.

  • Reduce weight (limit fats and refined carbohydrates).
  • Alcohol should be avoided or reduced drastically
  • Avoid dehydration.

These foods should be avoided:

  • offals, red meat especially goat meat.

These foods are permissible:

  • eggs, milk products, carbohydrates, fruit, vegetables, chicken and fish.

 

Rheumatoid Arthritis and Juvenile Chronic Arthritis </

To avert the erosive damage of progressive rheumatoid arthritis, early diagnosis and initiation of treatment with NSAIDs, Disease Modifying AntiRheumatic Medicines (DMARDs) (chloroquine, methotrexate and sulphasalazine), and low dose steroids in the presence of severe inflammation or vasculitis is necessary. Disease modifying medicines are the mainstay of treatment to minimise erosions and deformities

General Guidelines
  • The first line treatment for most of these conditions is a non-steroidal anti-inflammatory drug (NSAID). This group includes aspirin, indomethacin, diclofenac and ibuprofen, but does NOT include paracetamol.
  • NSAID‘s should be used cautiously in pregnancy, the elderly, and in patients with asthma
  • NSAID‘s should be avoided in patients with a history of peptic ulcer disease. 
  • Refer patients with serious rheumatic disease and peptic ulceration for specialist help. 
  • Indomethacin, used as a bed time suppository, may be very useful to alleviate morning stiffness.
  • NSAIDS should be taken with food.
  • If dyspeptic symptoms develop in a patient on NSAIDs, try adding magnesium trisilicate mixture. If dyspepsia persists and NSAID use is considered essential, refer for specialist help.  Addition of paracetamol for control of pain especially in the elderly is useful.
  • Physiotherapy or occupational therapy is a useful adjunct treatment especially after acute inflammation has subsided.

 Manage with:

-Asprin 600mg (paeds 12,5-50mg/kg) po four times a day review OR

-Indomethacin 25-50mg po three times a day review (+/- a night dose of 75mg po) OR

-Ibuprofen 200-400mg (paeds 7-14mg/kg) po three times a day review OR

-Diclofenac 25-50mg po three times aday review

Notes: A high dose of aspirin may cause tinnitus in an adult and Reye?s Syndrome in children. Maximum daily dose for indomethacin = 200mg, for ibuprofen = 2.4g

n Disease modifying anti-rheumatic medicines should be started early:

-Methotraxate 5-25mg po once a week review OR

-Chloroquine 150mg po once daily continual/ review

Referral to an ophthalmologist is strongly advised after 9 months of continuous treatment with chloroquine. Such continuous treatment should never exceed 2 years.  Treatment should be discontinued if a patient complains of visual disturbance on chloroquine. Methotrexate should be monitored with FBC and LFTs at 3 monthly intervals.

n Oral, low maintenance dose prednisolone can be added where indicated for a limited period:

Predinisolone 2,5-10mg poonce daily for a limited period

Note: Best results are achieved with combination of medicines.

 

Systemic Lupus Erythematosus 

Refer to a higher level for diagnosis and initial treatment. Sun-exposure should be avoided as much as possible particularly with the use of broadbrimmed hats and umbrellas. 

Manage with aspirin or indomethacin as for Rheumatoid arthritis as below:

Asprin 600mg(12,5-25mg/kg) po four times daily review

Indomethacin 25-50mg po three times a day review

-If severe skin or joint lesions, add:

Chloroquine 150mg po once daily continual

In severe disease with complications e.g. renal, neurological, vascular or haematological add prednisolone in high doses as well as immunosuppressive medicines:

Predinisolone 1mg/kg po once daily review and reduce

Reduce dose after crisis is over to smaller maintenance dose, enough to suppress activity.  Steroids should be started early and closely monitored for side effects.

Additionally azathioprine can be used to spare the high dose of prednisolone. It requires specialist monitoring for side effects, especially haematological ones. Refer for specialist care.

 

Diabetis Mellitus

There are two main types of diabetes mellitus:

Type 1

  • Usually under 30 years but can present at any age, present acutely, with weight loss and ketonuria: treated with diet and insulin. Type 2
  • Usually over 30 years, insidious onset, frequently obese: treated with diet and oral anti-diabetic agents. 40% will eventually require insulin treatment. Weight reduction is crucial.

Dietary control and weight loss plays an important part in the management of diabetes mellitus. Many type 2 diabetics are overweight. Reducing body weight through careful control of energy intake and physical activity like walking helps to control the symptoms of diabetes.

Most people with diabetes who are properly informed and managed soon become experts in their own care. 

General Insulin dosage guidance and monitoring:

  • In Type I diabetes, when initiating treatment the starting dose of insulin is 0.5-1.0units /kg/day. In most patients this was being as a combination of soluble and isophane insulin given twice daily, giving 2/3 of the total daily dose in the morning and 1/3 in the evening. 2/3 of the insulin dose should be isophane and 1/3 soluble. Doses should be given about 30 minutes before meals. 
  • Ideally a “basal/bolus” regimen should be used where basal (intermediate acting) insulin is taken at bedtime and 6-8u of soluble insulin (bolus) taken 3 times a day before meals. This regimen allows more flexibility with meals as the soluble insulin dose can be varied according to what is to be eaten and can be given at different times.  
  • Self monitoring of blood glucose is recommended and the patient can be taught to adjust doses appropriately based on results.
  • A physiologic insulin regimen can be conceptualized as having 3 separate components: basal insulin, nutritional (or prandial/meal/bolus) insulin and a correctional dose or supplementary insulin. A patient‘s total daily dose (TDD) of insulin is a sum of these, and represents the sum of insulin a patient needs. Roughly 50% of TDD is made up of Basal Insulin and the other 50% makes up Prandial or Bolus insulin. If the nutritional intake is interrupted, or severely reduced, this portion of insulin (prandial/meal/bolus) must be proportionately reduced. The correctional dose or supplementary dose is what needs to be added to the patient‘s calculated pre-meal insulin boluses based on the glucose readings(see Correction doses Table below)
  •  

    Basal Insulin (50% of TDDI):

  • Long acting insulin subcutaneously once at bedtime or morning § Or Intermediate acting insulin subcutaneously twice a day (50%/50% or 2/3 am and 1/3 pm)  
  • Nutritional Insulin (Prandial/Meal/Bolus): (50% of TDDI) 

    Can use the rapid acting or regular type insulins:

  • Rapid acting insulin before breakfast, lunch and dinner
  • Regular  insulin 30- 45 mins before breakfast and dinner +/- lunch  
  • In insulin treated type II diabetes, the total daily dose of insulin is 0.2units/kg/day. In the elderly, this is usually given as a once daily dose of an intermediate acting insulin.
  • Biphasic [pre-mixed] insulin is available. It is simple to give and is recommended for most type 1 diabetic patients. These preparations contain a fixed mixture of soluble and isophane insulin. 
  • Additional management guides:

  • Insulin treatment often leads to weight gain. 
  • Combined treatment of insulin + metformin can improve glycemic control in type 2 diabetes. 
  • Do not change dietary and medicine regimens simultaneously.
  • Select an insulin schedule best suited to the individual patient‘s eating pattern, physical activity and general lifestyle.
  • Insulin doses should be adjusted according to blood glucose levels (where available), and to avoid recurrent episodes of symptomatic hypoglycaemia.
  • Ideally, blood sugar should be maintained in the range 5-7mmol/litre.
  • Where blood glucose measurements are not available, urinary sugar levels give a guide to overall glycaemic control.
  • When stable, review at a minimum every 3 months.
  • Oral anti-diabetic agents

    See flow chart below for treatment approach. Apparent treatment failure is frequently due to poor compliance with diet: Monitor as for Type I diabetes but less strict glycaemic control is expected, especially in the elderly. Caution:

  • Oral anti-diabetics must not be used in pregnancy.
  • Glibenclamide can accumulate in the elderly and cause prolonged hypoglycaemia
  • Do not use metformin if renal failure, severe heart failure or liver failure (increased risk of lactic acidosis)
  • Obese Type 2 diabetic:
  • Mertfomin 500-1000mg po twice daily, gradually increase to upto 2g a day
  • If poorly controlled with strict adherence to diet then add
  • Glibenclamide 5-10mg po once to twice daily      OR
  • Gliclazide 80-160mg po once to twice daily 
  • *if poorly controlled despite diet: change to insulin or add a daily dose of intermediate acting insulin to the oral hypoglycaemics. Please discontinue sulphonylureas (glibenclamide and gliclazide) before adding insulin.
  • if poorly controlled despite diet and oral hypoglycaemics, change to insulin or add insulin to current therapy.

    Diabetic Diet

    Ideally a dietician should calculate dietary requirements for individual patients.

    Aim of diet: to reduce the blood sugar to normal and to maintain a constant blood sugar level.

  • 45-50% of energy intake should be in the form of carbohydrates; the amount of carbohydrates should be consistent from day to day.
  • Complex carbohydrates are preferable to simple sugars.
  • Carbohydrates and calories should be evenly distributed through the day. Meals must not be missed. A diabetic on insulin may have snacks between meals.
  • An adequate intake of fibre is important.
  • Alcohol is NOT RECOMMENDED in Diabetics.
  • Sugar and sugar-containing food/drinks should be totally avoided. The only exceptions are when a patient feels faint, or is ill and cannot eat normally.
  • Exercise should be encouraged. A snack should be taken before and after playing sport.
  • Unrefined carbohydrate, e.g. Roller Meal, wholemeal flour, is preferable to refined starches.
  • Special preparations for diabetics are safe but not ?diet? drinks. 100% fruit juices and diet sodas should be totally avoided in Diabetics.
  • General Advice for Diabetics

    All diabetic patients should have a "medic-alert" bracelet or necklace, and should be advised to join the Zimbabwe Diabetic Association.

    Syringes / Insulin Storage:

  • Reuse 1ml disposable syringes for 2-3 weeks. 
  • Store syringes dry.
  • Sterilisation is not necessary.
  • Change the needle when blunt.
  • Insulin should be stored in a cool place.
  • Injection technique

  • Clean and dry skin. Inject subcutaneously not intradermally.
  • The site of injection should be varied (abdomen and thighs are the most suitable sites).
  • Foot Care for Diabetics:

  • Advice about foot care is important: keep feet clean and dry, wear well-fitting shoes, and take care to avoid burns. Healthcare service provider to screen for diabetic foot at each review visit.
  • Ophthalmological Examinations:

  • At least annually from time of diagnosis; monitor and record acuities (each eye separately). If acuity drops, look for cataracts. Refer to eye hospital.
  • Blood pressure control:

  • Good BP control is essential and is more effective at preventing complications than good glycaemic control. Use combinations of medicines, preferably including an ACEI, target BP <140/80
  • To all diabetics with hypertension and any with documented vascular disease, add:
  • Aspirin and diabetes

  • Asprin 75mg po once daily

  • For those who are allergic or intolerant to asprin, give: Clopidogrel 75mg po once daily

  • Lipid control

  • Early and aggressive management of hyperlipidemia is desirable. For primary prevention treat if 10 year risk >30%. For secondary prevention following any vascular event aim for total cholesterol <4.8 mmol/l. Smoking
  • Patients with diabetes should stop smoking.
  • Sexual Dysfunction: 

  • Patients (Males and Females) MUST always be asked about sexual dysfunction and referred accordingly, since it is a marker of vascular disease.
  •  

     

     

    Oral Care: 

  • Good oral Hygiene should always be encouraged and patients should have annual dental check ups.
  • Gastrointestinal upset:

  • e.g. vomiting diarrhoea or constipation must be sought as they are an indicator of complications.
  • Are useful to focus care even at District Hospital level. Six monthly reviews should include eye checks, checking for peripheral neuropathy, checking for foot problems, oral care, sexual dysfunction and BP.
  • Special Problems in Diabetics

    Pregnancy 

  • Oral anti-diabetic agents should not be used and very strict glycaemic control is necessary. See the chapter on Obstetric and Gynaecological conditions.
  • Infections and Other Major Illnesses

  • Both types of diabetics (Type I and Type II) may need to be given an increased dose of infusion or Basal Bolus Insulin (see insulin therapy in adults). In Type 1 diabetes NEVER stop insulin, even if the patient is unable to eat.
  • Insulin is the anti-hyperglycaemic agent of choice in patients admitted to Hospital. Insulin acts rapidly, responds in a timely fashion to dose titrations, & can be used effectively in all patients and clinical situations. However clinically stable patients with normal nutritional intake; normal blood glucose and stable renal and cardiac function may continue oral antidiabetic medications. 
  • Diabetic Clinics

  • Are useful to focus care even at District Hospital level. Six monthly reviews should include eye checks, checking for peripheral neuropathy, checking for foot problems, oral care, sexual dysfunction and BP.
  • Special Problems in Diabetics

    Pregnancy 

  • Oral anti-diabetic agents should not be used and very strict glycaemic control is necessary. See the chapter on Obstetric and Gynaecological conditions.
  • Infections and Other Major Illnesses

  • Both types of diabetics (Type I and Type II) may need to be given an increased dose of infusion or Basal Bolus Insulin (see insulin therapy in adults). In Type 1 diabetes NEVER stop insulin, even if the patient is unable to eat.
  • Insulin is the anti-hyperglycaemic agent of choice in patients admitted to Hospital. Insulin acts rapidly, responds in a timely fashion to dose titrations, & can be used effectively in all patients and clinical situations. However clinically stable patients with normal nutritional intake; normal blood glucose and stable renal and cardiac function may continue oral antidiabetic medications. 
Hypoglycaemia and Hypoglycaemic Coma
  • Educate patients about hypoglycaemic symptoms (hunger, sweating, irritability, etc). 

Clinical presentation:

Adrenergic features:

  • Sweating, pallor, palpitations and tachycardia, hunger

Neuroglycopaenic features

  • Confusion, Seizures & Coma
  • Patients on oral hypoglycaemic agents and insulin must carry sweets or glucose tablets.  The patient‘s close relatives must also be instructed in management of hypoglycaemic attacks. Metformin cannot cause hypoglycamia.

Definition of hypoglycaemia

Venous plasma glucose < 3.0 mmol/L

Management of hypoglycaemia:

 

50% dextrose: if normal awake, give 25 mL by bolus intravenous injection (preferably through a large bore cannula). If level of consciousness is depressed, give 50 mL of 50% dextrose by bolus intravenous injection. Check blood glucose every 20 minutes. Repeat 25 mL of 50% dextrose intravenously, every 20 minutes until blood glucose is > 3.3 mmol/L.

 

5% dextrose: infused slowly (50-60 mL per hour) after injection of 50% dextrose and titrated according to capillary plasma glucose levels. Sulphonylurea-induced hypoglycaemia may be prolonged and glucose infusions may be needed for 2-3 days. The patient should take oral carbohydrate as soon as possible after the initial management with 20% dextrose.

  • In the event of confusion or coma in a diabetic on treatment and in the absence of reliable blood sugar readings, there should be no hesitation in administering a trial injection of intravenous dextrose.
  • If the above are unavailable, small quantities of sugar or preferably glucose, may be placed inside the cheeks and will be eventually swallowed or absorbed through the buccal mucosa.

Hyperglycaemic Coma

Pass a nasogastric tube and allow free drainage in the unconscious or semiconscious patient. Search for and treat infections promptly.

Fluid Replacement (Adults)

  • Sodium chloride 0.9% is the recommended fluid; as much as 8 litres may be required in 24 hours: Normal Saline infusion-1L over the first hour, 1L over the 2 hours, 1L over 4 hours, 1L over 6 hours, 1L over 8 hours(This schedule is a guide, be flexible)
  • Give subsequent litres of sodium chloride 0.9% every 8 hours.  Monitor closely during the period of infusion and modify accordingly, e.g. take into account skin turgor, peripheral perfusion and urine output. 

    CAUTION: Fluid overload is dangerous in elderly patients.

  • The above regimen may need to be modified depending on the state of hydration or the cardiovascular status of the patient. 
  • Beware of hypernatraemia by monitoring electrolytes and be prepared to change to a hypotonic solution, e.g. 5% dextrose if appropriate, or half sodium chloride 0, 9% (prepared by diluting normal saline by 50% with water for injection).  
  • When blood sugar falls to 13mmol/L change to dextrose 5% (or if urinary ketones can be measured), set up 5% dextrose infusion if ketones moderate or strong and blood sugars <13mmol/L.
  • Potassium Replacement

  • In conditions where blood potassium levels cannot be determined, add to intravenous fluid: 
  • Add potassium chloride infusion 20mmol with every litre after the first litre. Increase to 40mmol / litre given over 8hrs.
  • Where serum potassium levels are available start replacement:
  • Add potassium chloride infusion 20mmol / litre as soon as insulin has been started.
  • Assess serum potassium regularly and adjust replacement as needed to maintain potassium at 4.0-5.0mmol/per litre.
  • Continue with oral replacement for one week if not in renal failure:
  • Potassium Chloride 600-1200mg po twice daily for 7 days

    Insulin Therapy (Adults)

    Patients preferentially to be managed with protocol 1 in a High Care ward, with appropriate monitoring. 

    PROTOCOL 1:- continuous intravenous infusion: 

  • Give a bolus intravenous injection of 0.15 units/kg rapid acting or short acting (regular) insulin followed by a continuous intravenous infusion. This initial bolus should not be given to patients < 20 years of age
  • Mix 50 units rapid or short acting (regular) insulin in 200 mL isotonic saline - thus 4 mL solution contains 1 unit of insulin
  • Initial infusion: 0.1 unit/kg/hr (usually 5-7 units per hour: 20-28 mL/hr)
  • If plasma glucose does not fall by 3 mmol/L in the first hour, the insulin infusion may be doubled (hourly) until a steady reduction of plasma glucose (at 3.0 to 4.0 mmol/L per hour), is achieved
  • When plasma glucose < 14 mmol/L, reduce the insulin infusion rate to 0.05 units/kg/hr and adjust subsequently according to hourly bedside capillary glucose level (Glucometer)
  • NOTE:  Ketonaemia takes longer to clear than hyperglycaemia and combined insulin and glucose (and K+) are needed to ensure clearance of ketonaemia. Avoid focusing on glycaemia alone! 

    PROTOCOL 2 :- hourly intramuscular or subcutaneous bolus injections:

  • Loading dose: 0.4 – 0.6 units rapid or short acting insulin/kg (half the dose is given as an intravenous bolus injection and half is given intramuscularly)
  • Subsequent hourly doses: 0.1 unit/kg either by intramuscular or subcutaneous injection and titrated against the bedside capillary glucose level
  •  

    PROTOCOL 3:

  • Initially give by intramuscular injection (be careful not to inject into subcutaneous fat, use intramuscular needles and in very obese patients use the deltoid region), see below:
  • Soluble insulin 10mg im immediately then 5mg im hourly until blood sugar goes down to 14mmol
  • When the blood sugar is 14mmol/L or less and the clinical condition shows clear improvement, change to subcutaneous administration(per slididing scale) but continue to monitor blood sugar hourly until the level ceases to fall (the intramuscular injection may continue to act for some hours through a depot effect).Then give insulin according to Basal Bolus and correctional dose regimen. 
  •  

    Common problems with using the Sliding Scale Only:

    1. Is reactive rather than proactive
    2. Often mismatched with changes in patient‘s insulin sensitivity
    3. It does not meet the physiologic needs of   the patient

Leads to insulin stacking

Hyperglycaemic Coma and Pre-coma (Children)

Priorities:

Fluid replacement

Electrolyte / acid-base monitoring

Insulin therapy

Blood glucose monitoring

 

Fluid Replacement                                                                                       

Approximately 200 ml/kg in 24 hours is required for rehydration.

Start with rapid infusion of: 20ml/kg of Normal Saline fast then half the remaining fluid in 8 hours and the remaining half over 16 hours plus

Potassium chloride infusion add 20mmol/L after the initial 20mg/kg fast infusion

Monitor glucose levels hourly: when the blood sugar is less than 15mmol/l change to:

Half darrows with 5% dextrose infusion and potassium chloride 20mmol per litre

* Half darrows is made up by adding 50mls of 50% dextrose to 1 litre ½ Darrows with 2.5% dextrose.

  • Monitor U/E 2-4 hourly watching the potassium levels.

Insulin Therapy (Children)

Soluble insulin infusion 0,1units/kg/hour until blood sugar is less than 15mmol then o0,05units/kg/hour until condition stabilises then soluble insulin subcut 0,75-1 unit/kg/day in 3 devided doses before meals then apply the rule of thirds afterwards(2/3 of the dose in the morning and 1/3 in the evening of soluble insulin +isophane).

Honeymoon period

In the months after initial diagnosis insulin requirements may decline to less than 0.5 unit/kg/day as the pancreas continues to produce some endogenous insulin. Requirements invariably revert to higher doses as endogenous insulin levels decline.  Explain the concept to the patient or relatives.

Note: Diet is important in children but attempts at too rigid control may prove to be counter-productive. The diabetic child should be allowed to indulge in normal activities at school. Teachers need to be informed about the condition.

Meningitis

Management of suspected meningitis (fever +headache+ neck stiffness) at District level (or higher):

  1. Urgent lumbar puncture (18G cannula adequate in adults if spinal needle unavailable) , measure opening pressure using an IV giving set if manometer unavailable. If pressure greater than 20cm, remove CSF until less than 15cm.
  2. Blood slide for malaria parasites.
  3. If diagnosis is in doubt DO NOT perform a lumbar puncture. Refer to a higher level.
  4. Contraindications to lumbar puncture: deeply unconscious + focal signs; one pupil large and unresponsive; papilloedema (if fundoscopy available); rapidly falling level of consciousness. These are indications for referral to a tertiary care centre. 
  5. Lumbar puncture should be considered mandatory, and, preferably, when the condition is first suspected since Cryptococcal meningitis must always be excluded.
  6. Tuberculous meningitis should always be remembered. It may have no special distinguishing features, and can present acutely.
  7. If symptoms present less than one week: 

    Chloramphenicol 500mg IV 6hourly 

  8. Spinal fluid microscopy, (protein, glucose; Gram stain India ink stain, Ziehl-Neelsen stain and cultures if possible) and blood glucose.
  9.  

    Treatment for bacterial meningitis:

  10. Benzylpenicillin 3g IV 6 hourly for 14 days AND Chlorampenicol 500mg IV 6 hourly for 14 days OR Ceftriaxone 1g IV twice daily

  11. In patients who can swallow, and are fully cooperative, chloramphenicol can be given orally after 5 days, and amoxicillin 750mg 8 hourly can replace benzylpenicillin

    Chemoprophylaxis for close contacts (meningococcal meningitis only): 

  12. Give as soon as diagnosis made in index case: Ceftriaxone 500mg im single dose

    Further management

    The combination of fever and focal neurological signs is an indication for referral to a central hospital and CT scan of the head. 

    The differential diagnosis includes cerebral abscess, cryptococcal meningitis tuberculoma, toxoplasma encephalitis, and other parasitic infection.

    If a focal contrast-enhancing lesion or multiple lesions are present on scan and the patient is known to be HIV infected or is suspected to be infected on clinical grounds, start treatment for toxoplasmosis:

  13. Sulphadiazine 2g po four times a day for 6 weeks and Pyrimethamine 200mg po loading dose then 50mg po once daily for 6 weeks.

  14. OR

  15. Clindamycin 600mg po four times daily for 6 weeks and Pyrimethamine 200mg po loading dose then 50mg po once daily for 6 weeks.

  16. OR

  17. Cotrimoxazole 1920mg po three times a day for 6 weeks

If there is no response (clinically and on CT scan), in two weeks, or if lesion appears atypical, consider antituberculous treatment and neurosurgical intervention. (May need biopsy)

  1.  

Headache

This may be primary or secondary:

  • In secondary headache or facial pain treat specifically for the underlying cause (e.g. meningitis, sinusitis, malaria) and use aspirin 600mg every 4 hours as analgesic.
  • Primary headache is either of tension type (muscle contraction headache), migraine, or a combination or atypical.
Treatment of primary headache 

 

Tension

Bilateral; dull; band-like, worse as the day wears on; no nausea; frontal or occipital in site; often daily; can continue activities

Asprin 600mg po 4 hourly prn( not longer than 1 week continuously, risk ofanlgesic rebound headache)

  1. Social circumstances may precipitate these headaches; counselling in relaxation therapy (muscle relaxation) will help. Lifestyle changes may help (lunchtime rest, more sleep), and physiotherapy if local muscle spasm and tenderness.
  2. Avoid opiates (e.g. codeine compounds) and benzodiazepines as they particularly can cause rebound headache and habituation. 

If headache persists for more than six weeks, add Amytriptilline 25-150mg po nocte for 3 months.

Migraine

Unilateral; (occasionally bilateral); throbbing attacks; last hours to days; with nausea ± vomiting; photophobia, sometimes preceeded by visual aura; often have to lie down.

Asprin 600mg po 4 hourly PRN OR

Paracetamol 1g po 6 hourly PRN and Metochlopramide 10mg po at onset(one dose)

If Ineffective:

Metochlopramide 10mg po at onset and ergotamine 1mg po at onset, repeat once only after 1hr if needed

Ergotamine is contraindicated in complicated migraines (these include hemiplegia as an aura symptom). 

  1. Look for and avoid precipitating factors: Not enough sleep, alcohol, cheese, chocolate, menarche, menstrual cycle, oral contraceptive pills may all influence migraine frequency.
  2. If two or more disabling migraines a month (leave work, off school);
  3. Propranolol 20mg 3 times a day minimum 3 months If ineffective increase gradually to a max of 120mg 3 times a day, if side effects allow  OR
  4. Amytryptilline 25mg po nocte minimum 3 months

    Note: propranolol contraindicated in asthma – use amitriptyline.

    Cluster Headaches

    This is a sub-group of migraine with characteristic features of hemicrania, and periodicity (occurring about the same time for days or weeks). It shows a predilection for males.

    Combination

    A variable mixture of above two types of headache is common. Treat both.

    As prophylaxis, amitriptyline 25mg at night may be a good choice. 

    General Notes

  5. Ergotamine should not be taken more than twice in 24 hours, with a minimum of two days before the next dose, and not as a prophylactic treatment (excess ergotamine causes ergotism – severe headache, vomiting, gangrene of extremities and rebound headache). It should be avoided in pregnancy.
  6. Patients commonly abuse analgesics: headache diaries with a record of the daily number of tablets consumed will reveal this.
  7. Paracetamol 5OOmg 4-hourly should be used in children aged 7-12 years instead of aspirin.
  8. Ergotamine should not be used in children under 12 years Propranolol doses in children should be half of adult doses.

Epilepsy

This is defined as a tendency to recurrent (unprovoked) seizures. A single seizure is NOT epilepsy. One or more seizures in the presence of fever, brain infection, medicine intoxication (including alcohol), at the time of trauma and during an episode of metabolic derangement (hypoglycaemia, uraemia, liver failure) is not epilepsy, although the brain damage caused by some of the above may lead to epilepsy. Look for provoking factors like the ones listed above when faced with a patient with a first seizure.

Seizures are distinguished from other transient neurological episodes by the history, especially the description provided by an eyewitness. Do not start anticonvulsant treatment without an eyewitness description of a seizure. 

A typical generalised seizure has a sudden onset with abrupt loss of consciousness. There are often involuntary movements of the limbs, urinary incontinence or tongue biting. Afterwards the patient is often confused, sleepy and complains of headache. Partial seizures do not involve loss of consciousness but present as recurrent twitching or abnormal sensations in one body part. Complex partial seizures include reduced awareness, aimless movements and memory loss for the event afterwards.

First line treatment

Health workers who have undergone training in the recognition and management of epilepsy may initiate treatment at primary care (C) level. Otherwise refer to District level.

  • If two or more typical seizures in the past 12 months in a patient over 2 years

plus

  • normal physical examination, no neurological signs, start: Phenobarbitone 120mg (paeds 5mg/kg) once a day at night for 2 weeks until review

    Review after 2 weeks. Check compliance and side effects (very sleepy, loss of balance, rash, poor concentration, hyperactive). If side-effects, reduce phenobarbitone dose by 30mg. Review again after 4 weeks.

    Second line treatment

    For the patient with persistent seizures despite phenobarbitone check the diagnosis, compliance, medicine interactions, and intercurrent illness.

  • Phenobarbitone 120mg po nocte for 4 weeks then review

  • If seizures persist(one or more in 4 weeks), Add Phenytoin 300mg po nocte

  • If seizures persist,Carbamazepine 400mg(paeds 10mg/kg) po twice daily for 4 weeks then review

  • Review in 4 weeks
  • If seizures persist, intolerable side effects, patient maintained on more than one anticonvulsant: refer for tertiary level care or specialist care.
  • Other indications for referral to tertiary level / specialist care: neonatal epilepsy, progressive neurological deficit, absence seizures
  • Adults:

    Management at primary level:

  • Protect the airway and give oxygen if available, 
  • Give 50ml bolus of dextrose 50% intravenously (children: 10-20ml)                                          
  • While making arrangements to transfer the patient to a hospital, give:
  • (momentary loss of consciousness without involuntary movements)

    Tertiary/Specialist care 

    Decisions will include whether further investigations (EEG, CT scan) are indicated, and the use of phenytoin sodium, sodium valproate, ethosuximide, diazepam or clonazepam.

    Status epilepticus

    A seizure or a series of seizures continuing for more than 30 minutes, or recurrent seizures without regaining consciousness in-between, for more than 30 minutes. Many cases do not occur in known epileptic patients – always consider possible underlying causes such as stroke or brain abscess.

    The above description should be strictly adhered to. The practice of prescribing diazepam 10mg i.v. every time a seizure occurs should be resisted. It is preferable to use a regular anti-convulsant during the inpatient stay. 

    Adults:

    Management at primary level:

  • Protect the airway and give oxygen if available, 
  • Give 50ml bolus of dextrose 50% intravenously (children: 10-20ml)                                         
  • While making arrangements to transfer the patient to a hospital, give:
  • Diazepam 10mg slow IV infusion /PR over 2-3 minutes, may be repeated once after 5 min

    Management at district level:

  • Diazepam as above may be repeated twice (max dose 40 mg) if seizures persist, but watch for respiratory depression (ambu-bag must be available).
  • If seizures persist after 30 minutes, give: Phenobarbitone 10-15mg/kg 30-50mg per minute infusion IV over 10min
  • Commence oral medicines as soon as fully conscious: by naso-gastric tube if unrousable for more than 6hrs. 
  • If seizures persist, transfer to provincial or central level for:
  • Phenytoin 15-20mg/kg then 100mg at a rate of 50mg/minute infusion IV 6 hourly
  •  If seizures still persist after 30 minutes, and ICU facilities and anaesthetist available, give: Sodium Thiopentone IV 7mg/kg assess and review , Suxamethonium Chloride 100mg IV assess and review
  • intubate and ventilate; consider thiopentone infusion.
  • Children:

  • Protect the airway and give oxygen if available. 
  • At primary level (C) give: Dextrose 50% IV 10-20 ml once a day and Diazepam 5mg PR may be repeated once
  • Further management at district (B) level: Diazepam 1mg/year age, may be repeated once
  • Febrile convulsions should be treated with tepid sponging, paracetamol and diazepam as above if necessary. They do not require long-term anticonvulsants unless recurrent and with neurological deficit.

  •  

Acute Confusional State

Cardinal features are disorientation, short-term memory loss and fluctuating lowered level of consciousness. In delirium there are also hallucinations ? illusions. This indicates organic brain dysfunction and NOT a psychiatric condition.

  • Possible causes include: meningitis, encephalitis, malaria, pneumonia, septicaemia. Less commonly: HIV (seroconversion), typhoid, intracranial bleeding, metabolic disorder, liver or other organ (especially renal) failure and medicine abuse (e.g. alcohol withdrawal).
  • Management should focus on identification and treatment of the underlying cause, usually by looking for infections e.g. malaria and treating empirically (see section on antibiotics).
  • If sedation is required give:
  • Chlopromazine 25-50mg im 4 hourly as required

Stroke

Acute management in Zimbabwe focuses on prevention of complications.

Fibrinolysis is not practical. Prevent complications such as:

  1. chest infection (especially aspiration of vomitus or food because of dysphagia)
  2. urinary tract infection
  3. deep venous thrombosis and pulmonary embolus 
  4. pressure sores

Rehabilitation:

  1. physiotherapy from the day of admission. 
  2. occupational therapy and speech therapy (if available) is required n                             vocational training 

Manage precipitating causes:

  1. treat hypertension, but only start 2 weeks after the stroke, or if diastolic BP is >120. Use small doses of hydrochlorothiazide (avoid nifedipine).
  2. stop smoking
  3. treat arrhythmias, e.g. atrial fibrillation
  4. treat cardiac failure
  5. treatment of cerebral oedema may at times be necessary. Use mannitol (if available), 20mg IV frusemide, and 30 degree head tilt.

Prevention of stroke recurrence:

Thromboembolic stroke is difficult to differentiate from intracranial haemorrhage clinically without a CT scan. 

For thromboembolic stroke shown on scan, or if no CT scan but stable stroke, start after 2-4 weeks:

Asprin 150mg po once daily long term

For patients with atrial fibrillation who have access to facilities for regular blood monitoring (weekly INR for 1month, then monthly):

Warfarin 10mg po 2 times a day for 2 days then adjust for INR 

Refer the following patients to tertiary level:

  1. aged under 50 years
  2. diagnosis in doubt
  3. progressive deterioration

Psychosis

People with psychoses may present with hallucinations, delusions, loss of contact with reality. They may be violent; some may be withdrawn and mute. 

Non-organic psychosis 

  • This refers to conditions where there are problems in functioning of the brain. Major psychiatry conditions that may present with psychoses include schizophrenia group of disorders such as brief psychotic disorders, schizophreniform disorders and schizophrenia, mood disorders such as bipolar affective disorder and major depression, substance induced psychoses from substances such as cannabis, Zed, cough mixtures such as bronchleer, heroine, cocaince, inhalants and alcohol related disorders.Keep the patient in a safe place: prevent harm to self or others. If uncooperative or difficult to manage, refer to a psychiatric institution.  
  • Give anti-psychotic medicines: In all cases start at lower dose and increase gradually.
  • For a first episode of psychosis the first line medicines should be used. For a patient who has previously been stabilised on an alternative medicine may be continued on the same.

Rapid Tranquillisation

For the violent or agitated patient there may be a need for rapid tranquillisation. The following is recommended:

Chlopromazine 50-100mg im initially, can be repeated after 6 hours until calm and or can be given oral medicines OR

Haloperidol 2-6mg im initially, can be repeated after 6 hours(max 18mg daily) until calm and or can be given oral medications OR

Diazepam 5-10mg im/IV initially then can be repeated 6 hours until calm and or can be given oral medication OR 

Lorazepam 1-2mg iminitially, can be repeated after 6 hours until calm and or can be given oral medication

When giving Lorazepam, or any other Benzodiazepine, by IMI or IVI, resuscitation equipment and facilities for cardio-respiratory support should be available 

NB: Chlorpromanize should not be given IVI under what ever circumistance.

First line medicines

Chlopromazine 50-200mg po two to three times a day continual OR

Haloperidol 1,25-5mg po two to three times a day continual OR 

Sulpiride 50-200mg po two to three times a day continual

 

Second Line therapy 

Trifluoperazine 5-10mg po twice daily continual OR 

Olanzapine 5-10mg po twice daily continual OR

Risperidone 1-3mg po twice daily continual OR 

Clonapine 50-100mg po one to two times a day continual

Note: The First Line Medicines, chlorpromazine may cause postural hypotension. Use of Chlorpromazine should be avoided in Epilepsy. Olanzapine is associated with metabolic syndrome and Clonapine is associated with reduction in white cell count, so FBC should be done regularly.

In general poly-pharmacy i.e. the use of two or more antipsychotics should be avoided. However there may be a place for an additional sedative medicine at night.

Caution: Use chlorpromazine with caution as it lowers seizure threshold in organic pyschosis. 

 

Organic Psychosis

 

HIV/AIDS

  • Psychosis in HIV/AIDS may be caused by virus, ART and OIs.
  • Patients who are HIV infected are more susceptible to antipsychotic side effects therefore, use lower doses and observe for the side effects.

Other causes of organic psychosis

  • Infections such as malaria, syphilis,tuberculosis and others ?    Traumatic Brain Injury and tumours.
  • Systemic, Endocrine and Metabolic Conditions such as kidney diseases, thyroid disease, diabetes mellitus, electrolyte imbalance and others.

HIV infected patient preferably require use of atypical antipsychotic medicines such as risperidone.

Identify the cause and treat whenever possible. Use lower doses of antipsychotics as patients with organic psychosis are generally more prone to side effects

Depot Medications 

Adequate health education should be given to the patient on the importance of compliance and adherence. Where patients have difficulty in adherence, they should be offered the choice of depot preparations.

Risperidone 5mg po as a test dose then after monthly continual OR 

Fluphenazine Decanoate 12,5mg im as a test dose followed by 25-50mg im once every 4 weeks continual OR 

Flupentixol Decanoate 20mg im as a test dose then 20-40mg im every 2-4 weeks depending on response

Duration of therapy:

First or single psychotic episode

Most patients have to be maintained on a reduced dose of medication for 12 months after disappearance of psychotic symptoms. Then the medicine should be gradually tapered off. The patient must be reviewed regularly by medical staff and relatives for signs of relapse such as social withdrawal or strange behaviour.

Repeated relapses of psychoses

These patients require long term maintenance medication to prevent future relapses. Search for the cause of relapses [for example, continuing stress or non-compliance] and remedy if possible.

Side effects and adverse reactions of anti-psychotic medicines Early side effects:

  • Chlorpromazine and sulpiride may cause drowsiness, dizziness, postural hypotension, dry mouth, blurred vision and galactoria: usually in early stages of treatment and may be self-limiting. These should be discussed with patients and a change to a first line medicine considered if such side effects are limiting compliance and adherence.

Extra pyramidial side effects which include acute dystonia [common features are body stiffness, tongue protrusion, grimacing, writhing, twisting of neck or body, torticollis, and oculogyric crisis], Parkinsonism and akathesia. 

Treat with:

Ophernadrine 50mg po once daily for a week OR

Benzhexol 5mg po one to two times daily for a week OR

Diazepam 5 -10mg po one to two times daily for a week

If severe give:

Biperidine 2-4mg IV/im once only

And then continue with benzhexol as above. Reduce the dose of the antipsychotic therapy

Note: Avoid long-term use of benzhexol because there is a risk of developing dependence.

Avoid benzhexol in the elderly, use orphenadrine.

Hypothermia: keep the patient warm; refer to next level as medical emergency if body temperature cannot be raised.

Photosensitivity i.e. being more prone to skin damage from sunlight is common. Advice should be given on hats and sun block creams.

Appetite increase and weight gain are common. Consider regular monitoring of blood glucose to detect early diabetes Long term side effects:

Tardive dyskinesia: reduce medicine gradually and eventually stop and refer for specialist opinion. Use benzodiazepine and switch to atypical antipsychotics.

Clonazepam 0,25-0,5mg po in devided doses upto 1mg/day continual

Neuroleptic Malignant Syndrome is characterized by hyperthermia, fluctuating level of consciousness, muscle rigidity and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating and urinary incontinence.

This is a rare but potentially fatal side effect. Discontinuation of the antipsychotic is essential and an emergency referral made to a physician at a central hospital. During the transferring of patient, there is need to take care of rehydration of the patient, nutritional and fever control. Renal failure, hypoxia and acidosis should be managed at a referral centre. Bromocriptine may be use in doses of 2-3mg/kg body weight maximum 40mg/day and not for more than 10days.

 

 

 

Bipolar Affective Disorder

It is a condition characterised by elation (mania) and low mood (depression).

 Treatment is as for other psychoses i.e. with antipsychotics but add mood stabilisers.

 Use: 

Carbamazepine 100-400mg po three times daily continual OR 

Sodium Valproate 200-500mg po twice daily continual OR 

Lithum Carbonate 250mg-1g po at night continual OR 

Lamotrigine 50-200mg po twice daily continual

*For HIV patients, use Sodium Valproate,avoid carbamazepine

In manic patients with psychoses, Olanzapine 2,5-5mg po twice daily continual ,Quletiapine 50-200mg po once daily continual

 

HIV Induced Mood Disorders

For rapid tranquilisation, avoid chlorpromazine, use benzodiazepines 

Diazepam 5-10mg IV/im initially then repeat after 6 hours until calm

Lorazepam 1-2mg im initially then repeat after 6 hours until calm

Blood tests for FBC, U&E, Thyroid function and Pregnancy test are essential before commencing mood stabilizers. These medicines should be used with caution during pregnancy especially within the first trimester. Lithium levels are mandatory for pregnant patients.

 Carbamazepine may induce liver enzymes and hence causing more rapid metabolism, and therefore reduced efficiency of co-administered medicines e.g. ARV‘s and Oral Contraceptives.

 Lamotrigine is associated with skin rashes- discontinue treatment if this occurs.

Lithium toxicity can occur with dehydration, diarrhoea and vomiting. Hence the need to discontinue. At toxic levels this may cause tremor, incoordination, ataxia, coma and death. If toxicity occurs Lithium should be stopped immediately and a saline drip started – 1 litre fast then 4 hourly - and the patient should be referred to a central hospital

Depression

Assess severity and duration, identify stressoers, and carry out risk assessment for suicide.

§         Depressive Episode (Mild)

Counsel, follow up and help individual to deal with stressors. Commence on antidepressants preferably with Selective Serotonin Re-uptake Inhibitors (SSRIs).

  •      Major Depression

As for depressive episodeUse of anti-depressants and admission very important to allow monitoring of the patient. 

 

First Line Medicines:

Amitryptyline 50mg po, increase by 25mg every 2 nights upto 150mg once at night, an hour before sleeping. Assess progress after 2 weeks.

Imipramine 50mg po, increase by 25mg every 2 nights upto 150mg once at night, an hour before sleeping. Assess progress after 2 weeks.

Second line Medicines

Fluoxetine 20-80mg po once daily in the morning with food. Assess response after 2 weeks

Citalopram 10-40mg po once daily in the morning. Assess response after 2 weeks

Third Line Medicines:

Venlafaxine 75mg po once in the morning with food, continual OR 

Duloxetine 30mg po once in the morning with food, continual OR

Mianserin 15-40mg po once at bedtime continual

 

Caution: History of Epilepsy, history of Mania, cardiac disease, Diabetes Mellitus, close angle glaucoma, bleeding tendency or anticoagulant therapy, hepatic or renal impairment and breast feeding.

Side Effects: ?First flood effect? with increased restlessness or agitation (This may be managed by reduced dosage or with short term usage of a Benzodiazepine.

Gastro-intestinal upsets and appetite reduction. Reduced Libido. Some patients may have a hypersensitivity reaction with skin rash and, in general, medicine should be stopped if this occurs.

?Serotonin Syndrome? is a toxic over-activity of serotonin which may rarely occur with therapeutic dosage of an SSRI but occurs more commonly as a result of usage of more than one medicine acting on the serotonin system. Symptoms of varying severity include:

Autonomic effects – shivering, sweating, raised temperature, high blood pressure, tachycardia, nausea and diarrhoea.

Motor effects – myoclonus or muscle twitching, brisk tendon reflexes and tremor.

Cognitive effects – restlessness, hypomania, agitation, headache and coma.

Management involves immediate cessation of the offending medicine/s, usage of a Benzodiazepine for agitation and supportive care.

Medicines may cause reduced libido.

SSRIs cause insomnia - always take the dose in the morning; where there is sleep disturbance, limited use of benzodiazepines like clonazepam 1- 2mg at night or lorazepam 0.5 – 1mg can be given at night for a maximum of 2 weeks.

 Patients with Bipolar Affective Disorder in the depressive phase may need both an antidepressant and a mood stabiliser 

 For depression with psychomotor agitation give Amitryptyline and for depression with psychomotor retardation give Fluoxetine

Do not issue large quantities of antidepressant medicines; tricyclic antidepressants can be fatal in overdose!  

 

CAUTIONS: Avoid both amitriptyline and imipramine in patients with history of heart disease, urinary retention; glaucoma and epilepsy [refer such patients to a specialist]. In elderly patients, start with 25-50 mg/day. Imipramine is less sedating than amitriptyline.

 Side effects: Common side effects include dry mouth, blurring of vision, postural hypotension, appetite increase and constipation.

With Venlafaxine usage an EEG is recommended prior to initiating the medicine and blood pressure needs careful monitoring.

Ophthalmia Neonatorum

This is defined as conjunctivitis with discharge occurring in a neonate within the first month of life. The condition is commonly caused by gonococcal, chlamydial and bacterial infection and the new born acquires this infection from an infected birth canal during delivery. The condition is preventable by detecting and treating maternal and partner gonococcal and chlamydial infection during pregnancy and by swabbing with normal saline wet cotton swab both eyes as soon as the baby‘s head is out followed by instilling 1% tetracycline eye ointment (Crede Prophylaxis) carefully into the conjunctival sacs of every new born baby as soon as possible after birth.

Ophthalmia Neonatorum is treated as follows:

  • Collect pus swab for culture and sensitive before

initiation of antibiotic treatment

  • Eye(s) Irrigation with with warm Normal Saline until all the pus is removed and intermittently as long as pus is still present.

Instilling  Antibiotic Eye Drops ( Ofloxacillin / Fortified Gentamicin 0.3% ) hourly  as long as the eye are still discharging and red during the day and 1% Tetracycline eye ointment at night until infection is cleared.

Treatment:

Kanamycin 25mg/kg im single dose AND 

Erythromycin 16mg/kg po 6 hourly for 14 days

Treat the parents and the baby for gonococcal and chlamydial infection as described above. Also provide healtheducation and counselling to the parents.

Traumatic Eye Injuries

Penetrating Injury 

Treatment: Put on eye shield and ensure NO pressure. Refer urgently to an eye hospital.

Administer the following medicines before referral: 

Tetanus toxoid im  0.5mls once single dose AND

Paracetamol po C E 500mg 4 times a day if required AND

Amoxicillin po C V 500mg  3 times a day 5 days

 

Corneal Foreign Bodies

Gently attempt removal of foreign body with cotton wool tipped orange stick.If unsuccessful – refer to eye hospital.

Tetracycline 1% eye C V apply under 3 times a 1 ointment an eye pad day for 24hrs OR

Chloramphenicol 1% eye ointment may be used instead of tetracycline eye ointment above.

If worse after 24 hours – refer to eye hospital.

 
Corneal Abrasion

Apply an eye pad with tetracycline eye ointment or chloramphenicol 1% eye ointment stat and advise bed rest for 24 hours, then review.If worse, refer to eye hospital If improving, continue with:

Tetracycline 1% eye C V apply under 3 times a 1 ointment an eye pad day for 4 days OR

Chloramphenicol 1% eye ointment 4 times a day for 5 days

 

Chemical Burns 

Refer after doing the following:

Consider this to be a medical emergency - prompt action can save vision.

Irrigate the eye and surrounding areas thoroughly using tap water and a 10ml syringe (without the needle) for 30 minutes. Remove any debris or foreign bodies from the eye if present.  Then:

 tetracycline 1% eye C V apply under 3 times a 1 ointment an eye pad day for 24hrs AND

Chloramphenicol 1% eye ointment, apply eye pad and refer

 

Iritis/ Uveitis

Refer to eye specialist.

 
Corneal Ulcers

(Refer) NB: corneal sensation must always be tested with a cotton tip to exclude herpetic cause of corneal ulcer which would be treated with antiviral drugs like acyclovir Treatment:

Tetracycline 1% eye C V apply under 3 times a 1 ointment an eye pad day for 5-7 days OR

Chloramphenicol 1% eye ointment 4 times a day for 5 days

Otitis Media

Acute Otitis Media (AOM)

Patient presents with fever, chills and irritability. Most common under 2 years of age. Examination shows irritable child, tympanic membrane inflamed and bulging.

Natural history

  • 60% resolve in 24hrs
  • 80% by 48hrs
  • 88%  4-7 days
  • OME 63% resolve after  2 weeks 40%  remaining after one month
  • 20%  remaining by 3 months

Organisms that are involved in Acute Otitis Media 

Streptococcus pneumonia (35%), Haemophilus influenza (23%), Moraxella catarrhalis (14%) form the majority.

 

Treatment

  • Avoid risk factors-breastfeed more than 6 months; prevent parental smoking, encourage vaccination, provide good nutrition and encourage early attendance to day care.
  • Analgesia and supportive care

Indications for giving antibiotics

  • AOM under 6 months
  • Severe AOM-temperature (axillary) > 39.5ºC 
  • Associated comorbidity-malnutrition, HIV , Failure of resolution of symptoms in 48-72 hrs.
  • Patients who might not return to hospital

First line medicine

Amoxycillin 500mg(40mg/kg in paeds)  po three times a day

Caution: Use erythromycin in patients with penicillin allergy, patients who received amoxicillin in the last thirty days (mov second line as the risk of resistance is high)

 

Second line medicine

Amoxycillin 80mg/kg po twice a day AND

Clavulinic Acid 6,4mg/kg po twice daily for 10 days

 

Otitis Media with Effusion

  • Follows AOM or can present without any history of AOM
  • Hearing loss most common presentation and aural fullness 
  • 5-7 years most common age group affected
  • Otoscopy reveals brownish fluid behind intact tympanic membrane. Retraction of bulging of tympanic membrane with no signs of acute inflammation.

Otitis media with effusion in an adult needs referral to an ENT specialist for exclusion of nasopharyngeal carcinoma.

 

Organisms that are involved in Otitis Media Effusion

Otitis Externa

Presentations vary depending on cause

Itchiness of canal, ulcers on the externa auditory canal, inflamed canal, occasional discharge from canal

Otoscopy to assess the canal and tympanic membrane.

Inflamed external ear (auricle and external auditory canal)

 

Bacterial otitis externa

Aural toilet with boric acid and acetic acid

Ciprofloxacin and Dexamethasone Ear Drops 3 drops twice daily for 7 days OR

Chloramphenicol and Dexamethasone Ear Drops 3 drops twice daily for 7 das OR

Boric Acid 1% Ear Drops twice daily for 7 days OR 

Acetic Acid Ear Drops 3 drops twice daily for 7 days

 

Systemic Antibiotics are required for severe otitis externa-

Amoxycillin 500mg po three times a day for 7-10 days

Ciprofloxacin 500mg po twice daily for 7-10 days

 

Malignant Otitis Externa

This is a necrotising infection of the ear canal in patients who are immunosuppressed. Often the first presentation and should alert the physician of immunosuppression from any cause e.g. diabetes, HIV etc.

Initiate IV antibiotics with a penicillin as above 

Ciprofloxacillin 500mg po twice daily for 12 weeks

Add: Intravenous fluids

Debridement

REFER immediately 

 

Fungal otitis externa

After routine ear toilet as above

Cotrimoxazole Ear Drops once daily for 7 days

Acidifying agents like boric acid and acetic acid can be used as well

 

Allergic Otitis Externa

1% Hydrocortisone cream apply once daily for 7 days

 

Rhinosinusitis

Acute Rhinosinusitis

Clinical presentation
  • Nasal blockage, rhinorrhoea, anosmia facial pressure/pain are common symptoms
  • Examination reveals clear nasal discharge initially and discharge turns mucopurulent when bacterial superinfection occurs.
  • Majority are caused by viral infections such as rhinovirus, Adenovirus, respiratory syncytial virus, Para influenza virus
Treatment
  • Observation and supportive care
  • Analgesia and plenty of oral fluids
Indications of antibiotics
  • Failure of resolution of symptoms in 48-72 hrs.
  • Discharge turns mucopurulent
  • Patients with comorbidities e.g. malnutrition, immunosuppression

Amoxycillin 500mg po three times daily for 7 days

 

Chronic Rhinosinusitis

If above symptoms persist for 90 days.

REFER

 

Allergic Rhinosinusitis

Presentation
  • Acute rhinorrhoea- clear nasal discharge, Nasal obstruction, and anosmia

Treatment 

  • Avoid allergens

First Line

Fluticasone Diproprionate Nasal Spray one puff 1-2 times a day for 1 month

Fluticasone Furcate Nasal Spray one puff once a day for 1 month

 

Second Line

Chlopheniramine 4mg po three times a day for 7 days 

*Side Effects-Cause sedation, prostatism and should be used with caution in patients with glaucoma. They cause dryness of secretions and tachyphylaxis. Medications should not be taken for more than seven days without referral 

Second generation antihistamines Cetrizine 10mg po nocte for 7 days

NB: They do not have CNS penetration hence do not cause sedation and tachyphylaxis. 

Patients with persistent symptoms despite nasal steroids need referral for further investigations

 

Fungal Rhinosinusitis-Invasive

  • Invasive fungal sinusitis-common in immunosuppressed such as diabetic (uncontrolled, Ketoacidosis).
  • This is an aggressive soft tissue infection with high mortality rate and needs a high index of suspicion.  Early referral to Ear Nose and Throat Surgeon is required
  • Presentation- nasal blockage, necrosis of mucosa of nasal cavity. Orbital signs include proptosis and opthalmoplegia.

Patients also present with intracranial extension Management-Refer for:

  • Correct underlying cause
  • Aggressive surgical debridement 
  • Microscopy and culture to identify the fungal
  • Systemic antifungal treatment

 

Non Invasive fungal Rhinosinusitis

Refer 

 

Bacterial Infection

Impetigo

A superficial bacterial infection causing rapidly spreading blisters and pustules. It occurs commonly in children, usually starting on the face, especially around the mouth or nose. Often due to Staphylococcus aureus.

Keep infected areas clean and prevent spread to others (care with towels, clothes, bedding; change frequently and wash clothes separately). Bathe affected parts/soak off the crusts with soap and water,  If severe, or systemic symptoms present use:

Erythromycin 250-500mg(125-150mg for paeds) po four times a day for 7-10 days OR

Cloxacillin 250-500mg(125-150mg for paeds) po four times a day for 7-10 days

 

Folliculitis

Superficial infection causing small pustules, each localised around a hair. Deep follicular inflammation often occurs in hairy areas. 

Bath and remove crusts using soap and water,   Treat as for impetigo, above.

 

Furunculosis

These are painful boils, most frequently caused by Staphylococcus aureus.Usually resolves on its own, but improved by placing frequent hot compresses over the boil until it breaks. 

Review after 2 days; if not improving, consider surgical incision and drainage.  If the boil causes swollen lymph nodes and fever, consider systemic antibiotics:

Cloxacillin 250-500mg(125-250mg for paeds) po for 5-7 days

 

Erysipelas

A superficial cellulitis with lymphatic vessel involvement, due to streptococcal infection.

Begins at a small break in the skin or umbilical stump (children). Area affected has a growing area of redness and swelling, accompanied by high fever and pains.

Treat with:

Erythromycin 250-500mg(125-250mg for paeds) po four times a day for 7 days

Erysipelas has a tendency to recur in the same area. If recurrent episode, increase duration of antibiotic to 10-14 days.   

 
Acute Cellulitis

Inflammation of the deeper, subcutaneous tissue most commonly caused by Streptococci or Staphylococci.

Acute cellulitis [indistinct borders] should be differentiated from erysipelas [raised, sharply demarcated margins from uninvolved skin]. Give antibiotics:

Cloxacillin 250-500 mg(125-250mg for paeds) po four times a day for 5-7 days

 

Paronychia

Painful red swellings of the nailfolds which may be due to bacteria or yeast.

Acute Paronychia

Tenderness and presence of pus indicates systemic treatment with antibiotics is required:

Erythromycin 250-500mg(125-250mg for paeds) po four times a day for 5 days OR

Cloxacillin 250-500 mg(125-250mg for paeds) po four times a day for 5-7 days

 

Chronic Paronychia

Often fungal - due to candida. Avoid excessive contact with water, protect from trauma and apply:   

Treat secondary infection with antibiotics as above.

For both acute and chronic, incision and drainage may be needed.

 

Acne 

Comedones, papulopustules and eventually nodular lesions on the face, chest and back.

Seek underlying cause if any e.g. overuse of oils on skin, stress, anticonvulsant   medicines, and  use of  topical  steroids. Topical hydrocortisone or betamethasone must not be used.

Use ordinary soap and water 2-3 times a day.  In cases with many pustules, use:

Benzoyl Peroxide 5% gel, apply every night review

In severe cases use oral antibiotics

Doxycycline 100mg po once daily for 2-4 months

 

 

Fungal Infections

Body Ringworm (Tinea Corporis)

Round, expanding lesions with white, dust-like scales and distinct borders; on the body or face.

n  Responds to any of the topical antifungal agents.

 First line:

Miconazole Cream 2% apply 2-3 times a day for 7 days after resolved

OR

Clotrimazole Cream 1% apply 2-3 times a day for 7 days after resolved

 

Tinea Pedis (Fungal / Athlete's Foot)

This is a very common fungal infection and is often the source of infection at other sites. Keep the feet as dry as possible, and as far as possible avoid wearing socks / closed-in shoes.

Treat any bacterial superinfection first: 

Miconazole Cream 2% apply 2-3 times a day for 7 days after resolved

OR

Clotrimazole Cream 1% apply 2-3 times a day for 7 days after resolved

In severe cases use:

Griseofulvin 500mg(10mg/kg for paeds) po  once daily for 8 weeks

OR 

Terbinafine Cream apply twice a day for 6-8 weeks

Take with food or milk. Do not crush tablet tablets.

 

Pityriasis  Versicolor (Tinea Versicolor)

Common fungal infection caused by a yeast. Hypopigmented patches of varying size on the chest, back, arms and occasionally neck and face. Griseofulvin is not effective. Apply:

Selenium Sulphide 2,5% apply once daily for 5 days

 

Scalp Ringworm (Tinea Capitis)

In this case the fungus has grown down into the hair follicle.

Topical antifungal therapy may work but if ineffective; treat with:

Griseofulvin 500mg(10mg/kg for paeds) po  once daily for 14 days

Take with food or milk. Do not crush tablet tablets.

 

 

 

 

Scabies

Caused by mites, transmitted by skin-to-skin contact. The lesion is a “burrow” (a whitish ziz-zag channel), the resting place of the female mite.

Main sites: between the fingers, on the wrists, in the axilla, around the navel, genitals and inner sides of feet.

Treat all close contacts, especially children in the same household. Wash clothing and bedding and leave in the sun to dry. After normal bathing, apply: 

Permethrin Cream 5% apply once only from neck down, wash after 8-12 hours

OR 

Gamma Benzene Hexachloride 1% apply once only from neck down, wash after 24 hours

*CAUTION: In prepubertal children the gamma benzene hexachloride is washed off after 12 hours. Hot baths and scrubbing should be avoided to prevent systemic absorption. 

 Alternative in pregnancy, lactating mothers or children < 6 months:

Sulphur Ointment apply as needed

OR

Benzyl Benzoate 25% Emulsion apply every night from neck down for 3 nights, repeat within 10 days if necessary

*Dilute with one part water (1:1) for children. *Dilute with three parts water (1:3) for children

If there is secondary bacterial infection (?septic sores?), treat as for impetigo for 4-5 days. Only apply scabicide once lesions are closed.

Advise that the itch may continue for several weeks. This can be relieved by applying: 

Chlopheniramine 4mg po three times a day for 3 days

AND

Calamine Lotion apply as needed

 

Eczema

An inflammatory condition of the skin whose feature include redness, itching weeping (oozing) vesicular lessions which become scaly,crusted or hardened and may sometimes become secondarily infected. 

Allergic Contact Dermatitis 

Results from an acquired allergy after skin contact with particular chemicals (dyes, perfumes, rubber, chromium, nickel) or medicines (skin preparations containing lanolin, iodine, antihistamines, neomycin, vioform etc).

Atopic Dermatitis / Eczema 

Often a personal or family history of atopic disease (asthma, hay fever or atopic dermatitis). Cause not known. These persons are also more susceptible to herpes simplex and vaccinia (but not varicella-zoster).

The clinical form may differ according to age.

Infantile eczema / cradle cap

Usually appears at 3 months with oozing and crusting affecting the cheeks, forehead and scalp.

IMPORTANT: If generalised exfoliative dermatitis develops, refer to a specialist at once.

Flexural eczema

Affects the flexor surfaces of elbows, knees and nape of neck. In adults any part or the whole of the skin may be affected with intense itching, particularly at night. 

 

Management of Eczema

Remove any obvious cause e.g. skin irritants or allergens. As a soap substitute use:

Emulsifying Ointment as a soap substitute

OR 

Aqueous Cream as a soap substitute

**1% Hydrocortisone in an ointment for dry eczema and as a cream for ?weepy‘ eczema

Second Line

Use soap substitute as above and add Betamethasone) 0.1% in an ointment base for dry eczema and a s a cream for weepy eczema. If this fails refer for specialist management.

Treat itching with an oral antihistamine. Never use topical antihistamines: 

Chlopheniramine 4mg(0,1mg/kg for paeds) po three times a day for 3 days

OR

Promethazine 25-50mg at night as needed

* Not to be used in children under the age of 2 yrs. Promethazine causes drownsiness which may be aggravated by simultaneous intake of alcohol

Treat any infection. Choice of skin preparations depends on whether lesions are wet (use cream) or dry (use ointment)

 Where large areas are involved give a course of systemic antibiotics:

Erythromycin 250-500mg(125-150mg for paeds) po four times a day for 7-10 days

OR

Cloxacillin 250-500mg(125-150mg for paeds) po four times a day for 7-10 days

After the lesions have healed, apply a bland preparation such as aqueous cream or emulsifying ointment to moisturise the skin.

CAUTIONS: Never use corticosteroid preparations stronger than 1% hydrocortisone on the face. Systemic Steroids should be avoided except in severe conditions under specialist supervision.

 

Urticaria

Urticaria is the result of leakage of plasma from the dermal vasculature, presenting with itchy raised patches of skin (wheals) due to dermal oedema. These wheals are sometimes known as ‘hives’, and are usually a sign of an allergic reaction. Hives can be rounded or flat-topped but are always elevated above the surrounding skin.

Allergic urticaria may be caused by: medicines (e.g. penicillin) infection, contact with plants, pollen, insect bites, or foodstuffs (e.g. fish, eggs, citrus fruits, nuts, strawberries, tomatoes.)

Physical urticaria may be caused by mechanical irritation, cold, heat, sweating.

Exclude medicine reaction (e.g. penicillin), or infection (bacterial, viral or fungal).

Give antihistamine by mouth [never use topical antihistamines]:

Chlopheniramine 4mg(0,1mg/kg) po three times a day as required OR

Promethazine 25mg po at night as required OR

Cetirizine 10mg po once daily as required

* Not to be used in children under the age of 2 yrs. Promethazine causes drownsiness which may be aggravated by simultaneous intake of alcohol

If no improvement after 1 month or chronic problem, refer. 

Burns

Assessment

Burns caused by heat

Immediate cooling by immersion in water at approximately 25°C for 15mins to 30mins; then apply simple dry dressings (remove clothing if not adherent to burn and wrap in a clean cloth).

Chemical Burns

If there is dry powder present brush off the excess and then wash preferably with running water in large amounts for at least 20 minutes. Seal with soft paraffin (Vaseline) only what cannot be extracted with water.

Remove contaminated clothing, shoes, socks, and jewellery as the wash is applied. Avoid contaminating skin that has not been in contact with the chemical.

For burns due to sulphur or phosphorus a copper sulphate solution can be used to neutralise the chemicals.

Electrical Burns

Cool burns as above. A patient unconscious from electrical or lightning burns will need urgent cardiac assessment and resuscitation. Defibrillation or external cardiac massage may be lifesaving.  

Smoke Inhalation Burns  

If occurred in an enclosed area - may need 100 % oxygen.

 Resuscitation takes first precedence over any other management. This is followed by a quick history of the burn and then an estimation of the extent of the burn. Obtain information as to time of occurrence and circumstances of the burn. Other injuries are often seen with burns and may need management.

Evaluation of Burnt Surface Area 

Resuscitation is initially based on surface area burned. 

§In children use the Lund & Browder chart  

§In adults use the rule of nine‘s   

In children the head, thigh and legs account for different percentages according to the age of the child. Use the table below.  Estimating the Body Surface Area for Burns in Children (modified Lund & Browder)

Note: 

The Wallace Rule of Nines (fig. 25.2) is inaccurate in children.

Children compensate for shock very well, but then collapse rapidly – beware the restless, irritable child.  

Do not over-estimate burn size – this will lead to over-hydration

Note: In adults, the outstretched palm and fingers approximates to 1% of body surface area. If the burned area is small, find out how many times the „hand? covers the area. (Hand Rule)

Severity of burn is determined by the area of body surface burned and the depth of the burn.

Burns are either deep or superficial. Superficial burns (partial skin thickness) are sensitive all over. With deep burns (full thickness) there is sensation at the edges only.  Depth of burn influences later treatment in particular. 

NB: Pain is a poor guide to burn depth in children.

General Management Guidelines 

Depends upon extent and nature of burn. Any burn affecting greater than 10% of the body surface area is considered extensive and serious because of fluid loss, catabolism, anaemia and the risk of secondary infection.

Hospital admission is required for:

  • Adults with 10% burns or more 
  • Children with 8-10% burns or more.
  • Burns of special regions: face, neck, hands and feet, perineum and joints.
  • Circumferential burns (right around / both sides of a limb /region)
  • Electrical, lightning, and chemical burns
  • Lesser burns associated with inhalation injury, concomitant mechanical trauma, or significant pre-existing medical disorders (e.g. epilepsy, diabetes, malnutrition).
  • Very young/very old patients, psychiatric patients/ para-suicidal, suspected abuse.

Transferring burns patients

Severe burns will require long term special care and should be managed in a suitable hospital (burns unit). Always endeavour to transfer the above cases within 24hrs of the burn. Transfer with the following precautions:

  • Short, easy journey - commence resuscitation, make clear summary of records and send with medical attendant.
  • Prolonged or delayed journey - resuscitate and transfer when patient stable. Keep the patient warm and covered during journey and continue management already started.

Management of Moderate Burns

Small Surface Area Burns

Reassurance. 1st to 2nd degree burns are the most painful.  Give adequate analgesia

Paracetamol 500mg-1g(10mg/kg)po 4-6 hourly as required +/-

Codeine Phosphate 1560mg po 4 hourly as required

Give an anti-tetanus booster

Tetanus Toxoid 0,5ml im one dose only

Apply simple dry or non-adherent dressings,Elevate the burned part.

Follow up as outpatient. Expect healing within 10-14 days if clean. Any burn unhealed within 21-28 days needs reassessment.

Antibiotics are indicated for contaminated burns and inhalation burns. 

Benzylpenicillin 0,5MU/kg IV 6 hourly, reassess after culture OR

Erythromycin 500mg(12,5mg/kg for paeds) po 6 hourly, reassess after culture

Follow up as outpatient. Expect healing within 10-14 days if clean. Any burn unhealed within 21-28 days needs reassessment.

Change regimen if indicated by culture and sensitivity tests. Gram negative organisms are usually implicated later on, and a more appropriate blind therapy before results are obtained.

Large Surface Area Burns

Emergency Measures

Reassurance is an essential part of therapy.

Establish IV line. For all adults with burns greater than 15% and children with burns greater than 10%, start:

Ringers Lactate IV 10mls /kg/ hr for 12hrs, then reduce to 8mls /kg /hr.

Analgesia. Do not use oral or intra-muscular route in first 36hrs unless peripheral circulation is re-established.

Analgesia in adults:

Morphine IV slow 2,5-5mg every 4 hours as required OR 

Pethidine 1mg/kg im/IV every 4 hours as required

Analgesia in children:

Morphine 0,05-0,06mg/kg per hour continuous IV infusion OR

Morphine IV bolus 0,1mg every 2 hours as required

 

Use nasogastric tube to empty stomach in large burns; the tube may later be used for feeding if not possible orally after 48 hours. 

Resuscitation of Large Surface Area Burns: Adults

Fluid required in the first 24 hours:

*Total amount (ml) = 4 x weight in kg x area of burn % (Parkland Formular)

Resuscitation of Large Surface Area Burns: Children

For the child in shock or with large burns:Start Ringers Lactate IV 15-25ml/kg over 1-2 hours

then calculate:

*Total amount in mls = 3.5 x weight in kg x area of burn %

dextrose 2.5%           on IV fluids)

Example: for a 9 Kg child with 20% burn, initially give 135-225 ml (9 X 15-25 ml) plus the first 24 hour requirement by calculation, using the formula: 

3.5 X Weight (kg) x BSA burn (%) = volume required

3.5 X 9 X 20 = 630 ml Ringer Lactate

Plus NDR at 100ml/Kg = 900 ml half DD  Total requirement = 1530 ml 

Give 210 ml Ringer Lactate every 8 hours.

Give 900 ml half Darrows/Dextrose continuously over 24 hours.

NOTE: In calculating replacement fluid, do not exceed BSA (burned) of 45% for adults and 35% for children.  However, to prevent over (or under) transfusion the best guide is ?Monitoring? (see below).

General Notes:

If isolation facilities are available, then nurse trunk, face and neck exposed, reapplying a thin layer of burn cream (see below) as often as needed. Exposed patients lose heat rapidly, so ensure that the room is kept warm (above 28°C, preferably 31-32°C); this helps conserve calories and protein.

If forced to use a crowded ward, dress whole burn area. Cover loosely with a bandage.  Do not wrap limbs; allow movement, especially at the flexures, to prevent contractures. Unless infection ensues, the first dressing should be left undisturbed for 3 days (review daily).

Preferably never mix ?old and ?new burns cases.

Cleaning - small burns

  • Normal saline/ sitz baths
  • Povidone solution
  • Sitz baths with Povidone 

Cleaning - large burns  depending upon facilities and resources:

  • shower
  • sitz bath or
  • sitz bath and povidone iodine solution Apply to the burns: 

Silver Sulphadiazine 1% apply cream daily(not to the face) OR 

Povodine Iodine 5% apply daily

Give antitetanus booster:

Tetanus Toxoid 0,5ml im single dose

Give antitetanus booster:

Magnesium Trisillicate 20ml po 6 hourly review

Antibiotics are required only if/when wounds contaminated. Gram positive organisms (notably B-haemolytic streptococcus) predominate early on (first 5 days):  

Benzylpenicillin 2,5MU IV 6hourly then switsh to oral Amoxyl 500mg po three times daily review

Change regimen if indicated by culture and sensitivity tests. Gram negative organisms are usually implicated later on, and a more appropriate blind therapy before results are obtained is 

Benzyl Penicillin2,5MU IV 6 hourly review AND 

Gentamycin 80mg IV 8 hourly based on c/s

Monitoring

  • Basic observations and clear records including input/output are essential.
  • Mental responsiveness of patient (confusion can correspond to fluid imbalance).
  • Pulse, BP (if possible), temperature.
  • Breathing rate/depth; colour of nail beds and mucous membranes.
  • ECG after electric shock or lightning injury
  • Urine: colour, volume (should be at least 1ml/minute) and specific gravity; catheterise only if essential (predisposes to infection).

Later investigations:

  • full blood count and haematocrit;
  • electrolytes plus serum proteins;
  • urine electrolytes;

Nutrition

  • High protein, high energy diet, burns drink as per patient‘s weight.  §             
  • Give vitamin supplementation, high dose (dietary) Vitamin C:

Multivitamins 4 tablets 3 times a day review

NB: This does not apply in first 48 hours for large burns or non-motile GI tract (start feeding when bowel sounds return). 

Physiotherapy

It is very important to prevent disability and disfigurement. Physiotherapy also serves to prevent hypostatic pneumonia. Start physiotherapy early.

 

 

Intestinal Obstruction

History and examination is of paramount importance. While the different causes and types of obstruction are beyond the scope of the EDLIZ the important symptoms to look for are colicky abdominal pain, vomiting, abdominal distension and absolute constipation or obstipation (not passing stool and flatus). These symptoms are present in different degrees depending on the cause and level of obstruction. Remember to exclude previous abdominal surgery which makes adhesions the likely cause of obstruction and assess the potential hernia sites to exclude obstructed hernia.

Aggressive resuscitation and monitoring is important once intestinal obstruction is suspected or confirmed. Initial FBC, U+Es and possible X-match is important. IV fluids in the form of Normal saline and Ringers lactate are given as guided by degree of dehydration but aiming to achieve a urine output of 1ml/kg/hr as guided by the urine output monitoring with a urinary catheter. NGT insertion and monitoring of the effluent type and amounts is vital. The NGT losses should be replaced ml per ml with Normal Saline in addition to the normal daily requirements estimated at 40mls/kg/24hrs.

Antibiotic use in intestinal obstruction is necessary where bacterial translocation is suspected especially with longer history of obstruction or where a closed loop obstruction with possible gangrene/perforation of bowel is suspected e.g. in sigmoid volvulus or at surgery where unprepared bowel is opened.

FIRST LINE

Benzyl Penicillin 2,5MU IV four times a day AND

Gentamycin 120mg IV once a day AND

Metronidazole 500mg IV three times a day

SECOND LINE

Ceftriaxone 1g IV twice daily AND 

Metronidazole 1g IV three times a day

NB. Gentamicin should not be used where renal impairment is likely or confirmed.

Acute Abdomen

This is defined as severe sudden onset of pain of less than 7 to 10 days duration. The causes of an acute abdomen can be localized to the abdomen but sometimes can be from a systemic non-surgical cause. It is very important to be able to quickly assess and decide whether it is a surgical acute abdomen or medical acute abdomen.

 The usual presentation of a surgical acute abdomen is sudden abdominal pain (colicky or sharp piercing) associated with vomiting and/or constipation. Other features might include abdominal distension and failure to pass flatus. The main causes of a surgical acute abdomen are acute appendicitis, acute perforated duodenal ulcers, acute intestinal obstruction, acute cholecystitis, pancreatitis, ectopic pregnancy and ovarian torsion. Non abdominal causes of pain that mimic an acute abdomen are numerous and may include myocardial infarction, pericarditis, pneumonia or pleurisy.

 EVALUATION                  

  • History and physical examination will help narrow down the differential diagnoses and also determine whether the patient requires emergency surgery. Special attention should be paid to the nature of pain, location, onset, duration, intensity, recurrent nature, aggravating and alleviating factors.
  • Physical exam should note the general state of the patient, abdominal distension, surgical scars, tenderness, guarding, rebound tenderness, presence of a mass, rectal, cervical or adnexal tenderness.
  • Initial tests might include an FBC, U&Es, amylase, lipase, pregnancy test, urinalysis and LFTs. ? Imaging studies may be necessary:

Plain abdominal x-rays may reveal obstruction, perforation (free air under the diaphragm) and other pathology.

Ultrasound is indicated especially for biliary tract disease, pelvic and urinary system pathology.

             TREATMENT 

  • Haemodynamically unstable patients might need immediate resuscitation with Normal saline or Ringers lactate, possible transfusion, nasogastric tube for obstruction or persistent vomiting, urinary catheter for monitoring output, broad spectrum empirical antibiotic for peritonitis, suspected perforated viscus or intra-abdominal injection.
  • Direct treatment towards the specific condition should be instituted by the specialist after diagnostic workup.

Cholecystitis

Acute cholecystitis is a condition which is becoming more frequent in our population as major lifestyle changes occur with dietary shifts towards a western diet. This has increased the incidence of cholesterol related illness of which gallstone

disease is one. Calculous cholecystitis (gallstone-related cholecystitis) is the commonest indication for cholecystectomy in Zimbabwe. In young patients exclusion of haemolytic anaemia especially sickle cell anaemia is important.

While the definitive treatment for cholecystitis is surgery i.e. open cholecystectomy or laparascopic cholecystectomy it is necessary to give antibiotics for acute cholecystitis. While acute cholecystitis typically presents in a forty year old, fat, fertile, flatulent and fair female it can also occur in males, in a younger or older age group. The symptoms are mainly acute right upper quadrant pain usually at night after a fatty meal with some milder previous episodes of colicky upper abdominal pains. On examination tender right upper quadrant   is typical with a positive Murphy sign (catch of breath on inspiration while the palpating hand is advancing up from the right iliac fossa to the right costal margin).

TREAMENT OF ACUTE CHOLECYSTITIS

Antibiotics and analgesia are important.

FIRST LINE

Ampicillin 500mg IV four times a day AND

Metronidazole 500mg IV three times a day

*If Ampicillin is not available use benzyl penicillin 2,5MU iv 4 times daily

SECOND LINE

Ceftriaxone 1g IV twice daily AND

Metronidazole 500mg IV three times daily

Patients are managed as above and if symptoms and signs improve can be discharged on oral, amoxicillin 500mg tds x for 7 days and scheduled for elective cholecystectomy after six weeks.

Advances in laparascopic surgery have however made it possible to do early or ?hot cholecystectomy when certain criteria are met based on expertise of the surgeon. 

Perforated Duodenal Ulcer

Peptic ulcer disease is generally a medical condition where advances in diagnosis and treatment have made surgical intervention only reserved for its complications. Perforated duodenal ulcers remain a feared and relatively common complication.

While a reasonable number of patients who present with acute perforated duodenal ulcer have had a diagnosis of peptic ulcers before, the majority have no prior diagnosis or investigations done. Presentation is usually of sudden severe epigastric pain which rapidly spreads to the whole abdomen associated with fear of movement. Examination findings are typically those of generalized tenderness with board-like rigidity of the abdomen and rebound tenderness. The erect chest X-ray shows free air under the diaphragm in 75% of cases.

This is surgical emergency but resuscitation with Normal Saline, NGT insertion, analgesia and urinary catheterization should be done. FBC and U+Es are done in preparation for surgery. The prognosis is poor if surgery is delayed. The adage of ?the sun should not rise and set‘ before surgery is done is appropriate for this condition. IV antibiotics should be given as soon as signs of peritonitis are picked.

 FIRST LINE

Benzyl Penicillin 2,5MU IV four times a day AND

Gentamycin 120mg IV once a day AND

Metronidazole 500mg IV three times a day

SECOND LINE

Ceftriaxone 1g IV twice daily AND

Metronidazole 500mg three times daily

Breast Abscess

While the breast can be affected by many conditions practitioners should take all efforts to exclude malignancy. History and examination is of value in this regard. Common breast conditions are:

  • Breast abscess especially in breastfeeding or pregnant women
  • Mastitis
  • Breast fibroadenomas especially in young women age (1535years).
  • Breast cancer especially above the age of 35.
  • Ductal papilloma
  • Duct ectasia
  • Nipple/ breast eczema
  • Paget‘s disease of the breast

Breast Abcess typically occurs in a young lactating or pregnant women who has pain and swelling of the breast with an area of maximal tenderness or fluctuancy. Once the diagnosis is made, incision and drainage in theatre under general anaesthesia should be done as they are generally deep abscesses and adequate drainage is advisable under general anaesthesia. Analgesia and antibiotics should be instituted once diagnosis is made.

Preferred therapy:

Cloxacillin 500mg IV four times daily for 2 days THEN

Cloxacillin 500mg po four times daily for 5 days

Alternative therapy:

Clindamycin 300-600mg IV three times a day for 2 days THEN 

Clindamycin 300-600mg po three times a day for 5 days

The wound should be cleaned with saline or povidone iodine and packed or dressed with glycerin and ichthamol daily until healing occurs. The mother should be advised to continue breastfeeding or to express the breast frequently.

Appendicitis

This is the commonest acute abdominal surgical emergency. Typical symptoms are shifting abdominal pain (starting as vague periumbilical pain then shifting to the right iliac fossa) associated with nausea and occasional vomiting. On evaluation, uncomplicated appendicitis has right iliac tenderness ellicited maximally at McBurney‘s point with possible positive Rovsing sign. The white blood count may be elevated. The diagnosis of appendicitis should be made on clinical grounds but other investigations especially ultrasound scan and CT scan might be necessary in females and where the history is not typical. The other tests are especially useful to exclude other pathologies that might mimic appendicitis. Straightforward appendicitis needs emergency surgery as delays are associated with complications and poor outcome. The treatment of appendicitis is surgical. Laparascopic appendicectomy is now popular among surgeons with special interest and is particularly useful in females where the advantage of visualising pelvic viscera is important. The cosmetic advantages are additional to the less pain, reduced hospital stay and earlier recovery noted with laparascopic surgery.

The use of antibiotics in appendicitis and its complications can be summarized as below:

CONDITION TREATMENT

  • Acute appendicitis: Emergency appendicectomy and prophylaxis:

Ceftriaxone 1g IV once only AND

Metronidazole 500mg IV once only

Appendiceal Abcess:Clinical Assessment of mass and institution of IV antibiotics and analgesia

Benzyl Penicillin 2,5MU IV four times a day AND 

Gentamycin 120mg IV once daily AND 

Metronidazole 500mg IV three times a day

  • Alternatively

Ceftriaxone 1g IV 2 times a day AND

Metronidazole 500mg IV three times a day

This can be done while serial examinations (daily) for clinical improvement of size of mass. are instituted Serial FBC and USS monitoring for improvement is also important. Failure to improve or deterioration in condition might warrant surgical intervention. If the patient improves elective surgery (six weeks after initial presentation) is advised as operating early is fraught with higher risk of complications.

  • Appendiceal abscess. Emergency incision and drainage (with or without appendicectomy) or  USS guided pus drainage plus antibiotics as follows:

    Benzyl Penicillin 2,5MU IV four times a day AND 

    Gentamycin 120mg IV once daily

  • Alternatively

  • Ceftriaxone 1g IV 2 times a day AND

    Metronidazole 500mg IV three times a day

These treatments are continued till clinical improvement is satisfactory. Interval elective appendicectomy might or might not be necessary.

  • Appendiceal rupture/perforation. Generalised peritonitis is typical and prognosis is poor. Aggressive fluid resuscitation, IV antibiotics and urgent laparatomy are all necessary. The IV antibiotic regime is as for appendiceal abscess above.

 

 

 

 

Snake Bite

First Aid for Snake Bite

  • Calm and reassure the patient. Get them to lie down.
  • If venom has been spat in the eye, wash liberally with water for at least 15 minutes.
  • Apply a pressure bandage (not a tourniquet) firmly around the limb, starting from the bite site and moving upwards. This allows blood flow to the limb but prevents lymph return and absorption of poison.
  • Splint the limb to prevent movement that would increase absorption of poison.
  • Get the patient to a hospital with facilities to give antivenom. Reassure them on the way and be prepared to give artificial respiration if required.
  • Do NOT:
    • cut the wound
    • use a tourniquet
    • give electric shock to the site
    • rub or massage the wound site.

In hospital

  • Remove the pressure bandage
  • Give analgesia and: 
  • If no signs of envenomation, observe for 24 hours (5 days if boomslang bite) then discharge.
  • Only if signs of  envenomation (bleeding, signs  of neurotoxicity) give antivenom:

*Caution: Antivenom wrongly used can be more dangerous than snake bite.

  • Polyvalent antivenom covers all the main venomous snakes found in Zimbabwe except the boomslang, for which specific antivenom is necessary. Antivenom can prevent tissue

necrosis after adder bites, but only if given early: it will have no effect once gangrene has set in.

  • The decision to use antivenom should be based on the 20WBCT (20 minute Whole Blood Clotting Test. I.e. A few millilitres of blood taken by venepuncture is placed in a new, clean, dry, glass vessel, left undisturbed at room temperature for 20 minutes; then tipped once to see if the blood has clotted or not. The vessel must be glass rather plastic in order to activate blood coagulation via Hageman factor (FX11). Glass vessels may not activate coagulation if they have been cleaned with detergent or are wet.

Skin Ulcers

Chronic ulcers are a common condition. Unless the cause of the ulcer is known exclusion of malignancy is important. Exclusion of malignancy should be done by taking a biopsy for histological analysis. The common cutaneous malignancies are squamous cell carcinoma, malignant melanoma and basal cell carcinoma. These malignancies are more common in albinos who are sun exposed without ultraviolet protection. Use of sun protective clothes and sunscreen lotions is important in this group of people. However everyone is prone to developing skin cancers. Chronic non-healing ulcers (eg after burns) can develop squamous cell carcinoma, referred to as a Marjolin ulcer. Malignant melanoma of the acral lentiginous type is common on the soles of the feet in Zimbabwe and all suspicious lesions should be biopsied and referred to the general surgeon for further management.

 

Where malignancy has been ruled out or is not suspected exclusion of peripheral vascular disease, diabetes mellitus and venous stasis (eg in varicose veins) is also important. The management of nonmalignant chronic ulcers involves different disciplines. The guiding principle, however, is reducing inflammation on the wound by avoiding irritating substances on the wound and limiting frequent change of dressings. In this regard simple normal saline or equivalent salt solution would be preferred for cleaning the wound and then applying long staying dressings (which can be changed less often eg once every third day). Wound care products are varied and the state of the wound would guide the most appropriate product to use. In the absence of these specialized products cleaning the wound with simple saline and dressing it with glycerine and icthamol solution would suffice.

Anaphylaxis

 General Notes

Severe anaphylaxis is a life threatening immunological response to a substance to which an individual is sensitised. It is a medical emergency (life and death situation) in which seconds count. Prompt treatment is required for acute airway obstruction, bronchospasm and hypotension.

Triggers 

Common triggers of anaphylaxis are medicines, (notably: antibiotics, non-steroidal anti-inflammatory medicines, antiarrhythmics, heparin, parenteral iron, desensitising preparations and vaccines), blood transfusions, bee and other insect stings, anaesthetic medicines and certain foods. Latex allergy may be delayed in onset, taking up to 60minutes to manifest. Some anaesthetic medicines are also associated with anaphylactoid reactions (urticaria, flushing and mild hypotension). Food allergen triggers may have a delayed onset. Such as nuts may have a delayed onset and are commonly associated with urticaria.

Clinical Presentation of Anaphylaxis

Anaphylactoid reactions range from minor to life-threatening. The major presenting features are commonly cardiovascular. It is important to recognise and address the following:

Cardiovascular (hypotension, tachycardia, arrhythmias, ECG may show ischaemic changes even cardiac arrest)

Respiratory system (oedema of the glottis, tongue and airways, stridor and airway obstruction and bronchospasm)

Gastrointenstinal (abdominal pain, diarrhoea or vomiting)

Cutaneous (flushing, erythema, urticaria)

Note: It is imperative to establish a causative allergen source and it is essentially that the patient is advised in writing of the allergy and advised to wear a medic-alert bracelet indicating the sensitivity: repeat exposure may be fatal.

Treatment 

Discontinue administration of any suspect agent (for example medicine, blood, diagnostic agent) Lay the patient flat and elevate the legs.

Follow the ABC of resuscitation 

A- Airway

  • Give Adrenaline im 0.5- 1mg (0.5 – 1ml of 1:1000 solution) repeated each ten minutes as required
  • Ensure a clear airway; give 100% oxygen, if available. B- Breathing 
  • Ensure adequate breathing (intubate and ventilate as required)
  • Nebulised bronchodilators (for example, 5mg salbutamol) or iv aminophylline may be required if bronchospasm is refractory (loading dose of 5mg/kg followed by

0.5mg/kg/hr). 

C- Circulation

  • Monitor pulse, blood pressure, bronchospasm and general response/condition every 3-5 minutes.
  • Start CPR if cardiac arrest has occurred  Give:

Adrenaline 1 in 1000 im 0,5-1 ml (0,1-0,5ml in children <5 years)repeat every 10 minutes when necessary until improved

In severe allergic reaction give:

Adrenaline 1 in 10000 IV 1ml(0,1ml/kg in paeds)repeat every minute until satisfactory response

 Start IV volume expansion with normal saline (or Ringer lactate) adjusting rate according to blood pressure:

Normal Saline IV first litre in the first 15-20 minutes then review ADD

Promethazine 25-50mg(5mg for paeds) slow IV 8 hourly upto 48 hours OR

Chopheniramine in 6-12 years 10mg-12,5mg IV slowly AND

Hydrocortisone 200mg(25-100mg in paeds) 6 hourly as required

Monitor pulse, blood pressure, bronchospasm and general response/condition every two minutes.

If no improvement, the following may be necessary:

Aminophylline slow IV bolus 6mg/kg over 20 minutes(unless the patient has taken aminophylline in the past 8 hours)

Aminophylline in 5% dextrose IV 12mg/kg over 24 hours

Ventilation and/or tracheostomy

If after 20 minutes of treatment, acidosis is severe (arterial pH<7.2):

Sodium Bicarbonate 8,4% IV 50mmlo as required(15-30 minute intervals)