Clinical Guidelines - Diagnosis and Treatment Manual PDF

Exported on: 04/04/2024 Clinical guidelines - Diagnosis and treatment manual For curative programmes in hospitals and dispensaries Guidance for prescribing © Médecins Sans Frontières All rights reserved for all countries. No reproduction, translation and adaptation may be done without the prior pe...

Exported on: 04/04/2024 Clinical guidelines - Diagnosis and treatment manual For curative programmes in hospitals and dispensaries Guidance for prescribing © Médecins Sans Frontières All rights reserved for all countries. No reproduction, translation and adaptation may be done without the prior permission of the Copyright owner. Page 1 / 394 Médecins Sans Frontières. Clinical guidelines - Diagnosis and treatment manual. March 2024 ISBN 978-2-37585-253-8 Page 2 / 394 Table of contents Authors/Contributors Preface Abbreviations and acronyms Chapter 1: A few symptoms and syndromes Chapter 2: Respiratory diseases Chapter 3: Gastrointestinal disorders Chapter 4: Skin diseases Chapter 5: Eye diseases Chapter 6: Parasitic diseases Chapter 7: Bacterial diseases Chapter 8: Viral diseases Chapter 9: Genito-urinary diseases Chapter 10: Medical and minor surgical procedures Chapter 11: Mental disorders in adults Chapter 12: Other conditions Appendices Main references Page 3 / 394 Authors/Contributors T he Clinical guidelines has been developed by Médecins Sans Frontières. MSF would like to express its sincere gratitude to everyone who has contributed to developing these guidelines. Co-authors: Grace Dubois, Blandine Vasseur-Binachon, Cedric Yoshimoto Contributors: Gabriel Alcoba, Beatriz Alonso, Mohana Amirtharajah, Haydar Alwash, Catherine Bachy, Roberta Caboclo, Severine Caluwaerts, Cristina Carreno, Arlene Chua, Kate Clezy, Anne-Sophie Coutin, Marcio da Fonseca, Martin De Smet, Eva Deplecker, Carolina Echeverri, Sylvie Fagard-Sultan, Roopan Gill, Sonia Guinovart, Jarred Halton, Kerstin Hanson, Christian Heck, Caroline Henry-Ostian, Cathy Hewison, Yves-Laurent Jackson, Carolina Jimenez, John Johnson, Rupa Kanapathipillai, Mohamad Khalife, Nadia Lafferty, Amin Lamrous, James Lee, Helen McColl, Natasha Mlakar, Juno Min, Miguel Palma, Isabella Panunzi, Roberta Petrucci, Nicolas Peyraud, Ernestina Repetto, Jean Rigal, Koert Ritmeijer, Julia Sander, Raghda Sleit, Erin Stratta, Alex Telnov, Malcolm Townsend, Clara Van Gulik. Specific support has been given by the International Guidelines Publication team: Editor: Véronique Grouzard Language editors: Mohamed Elsonbaty Ramadan, Carolina López, Anna Romero Lay-out designer: Evelyne Laissu Page 4 / 394 Preface T his guide is designed for use by medical professionals involved in curative care at the dispensary and primary hospital. We have tried to respond in the simplest and most practical way possible to the questions and problems faced by field medical staff, using the accumulated field experience of Médecins Sans Frontières, the recommendations of reference organizations such as the World Health Organization (WHO) and specialized works in each field. T his edition touches on the curative and, to a lesser extent, the preventive aspects of the main diseases encountered in the field. T he list is incomplete, but covers the essential needs. T his guide is used not only in programmes supported by Médecins Sans Frontières, but also in other programmes and in other contexts. It is notably an integral part of the WHO Emergency Health Kit. Médecins Sans Frontières has also issued French, Spanish and Arabic editions. Editions in other languages have also been produced in the field. T his guide is a collaborative effort of medical professionals from many disciplines, all with field experience. Despite all efforts, it is possible that certain errors may have been overlooked in this guide. Please inform the authors of any errors detected. It is important to remember, that if in doubt, it is the responsibility of the prescribing medical professional to ensure that the doses indicated in this manual conform to the manufacturer ’s specifications. To ensure that this guide continues to evolve while remaining adapted to field realities, please send any comments or suggestions. As treatment protocols are regularly revised, please check the monthly updates. Page 5 / 394 Abbreviations and acronyms Last update: October 2023 Page 6 / 394 ACE angiotensin converting enzyme ACT artemisinin-based combination therapy AFB acid-fast bacillus ALT alanine aminotransferase ARV antiretroviral AST aspartate aminotransferase BCG bacillus Calmette-Guérin BMI body mass index BP blood pressure °C degree Celsius co-amoxiclav amoxicillin + clavulanic acid co-trimoxazole sulfamethoxazole + trimethoprim CRT capillary refill time CSF cerebrospinal fluid CMV cytomegalovirus D1 (D2, D3, etc.) Day 1 or first day (Day 2 or 2nd day, Day 3 or 3rd day, etc.) dl decilitre (e)FAST (extended) focused assessment with sonography for trauma FBC full blood count g gram HBP high blood pressure (hypertension) HF heart failure HIV human immunodeficiency virus HR heart rate Page 7 / 394 Ig immunoglobulin IM intramuscular IO intraosseous IU international unit IV intravenous kcal kilocalorie kg kilogram LP lumbar puncture mg milligram MIU million international units ml millilitre mmHg millimetre of mercury mmol millimole MSF Médecins Sans Frontières NSAID nonsteroidal anti-inflammatory drug ORS oral rehydration solution or salts PCP pneumocystosis PCR polymerase chain reaction PO per os – oral administration POCUS point-of-care ultrasound PRBC packed-red blood cells RR respiratory rate SAM severe acute malnutrition SC subcutaneous SMX sulfamethoxazole Page 8 / 394 SMX + T MP sulfamethoxazole + trimethoprim = co-trimoxazole SpO2 arterial blood oxygen saturation measured by pulse oximetry tab tablet TB tuberculosis T MP trimethoprim WHO World Health Organization Page 9 / 394 Chapter 1: A few symptoms and syndromes Shock Seizures Hypoglycaemia Fever Pain Anaemia Dehydration Severe acute malnutrition Page 10 / 394 Shock Last updated: September 2023 Shock is a condition of widespread reduced tissue perfusion and inadequate oxygen delivery. Prolonged shock can result in cellular dysfunction and irreversible organ failure. Mortality is high without early diagnosis and treatment. Clinical features Shock should be suspected in patients with: Sign(s) of hypotension: weak pulse, low or declining blood pressure (BP) a , narrow pulse pressure Acute onset of signs of tissue hypoperfusion: Skin: pallor, mottled skin, sweating, cold extremities or lower limb temperature gradient b , capillary refill time (CRT ) ≥ 3 seconds Lungs: tachypnea, dyspnoea Heart: tachycardia, which often occurs before BP decreases Kidney: oliguria (urine output < 0.5 to 1 ml/kg/hour) or anuria Brain: thirst, anxiety, agitation, confusional state, apathy, altered mental status In children, accurate BP measurement is difficult, and hypotension is a very late sign of shock. T herefore, critically ill childrenc should be treated for shock if they present at least one of the following signs: lower limb temperature gradient b , CRT ≥ 3 seconds, weak radial pulse or severe tachycardia d. Clinical features may vary according to the type of shock : Page 11 / 394  Type Specific clinical features Risk factors Anaphylaxis: likely when either of the following 2 Recent exposure to an allergen (e.g. food, sting, medicine) or criteria develop within minutes to hours : Involvement of skin and/or mucous membranes (e.g. history of anaphylaxis generalised urticaria, itching, flushing, swollen lips/tongue/uvula) AND ≥ 1 of the following: respiratory symptoms (wheeze, dyspnoea); Distributive low BP or symptoms of end-organ dysfunction Severe vasodilation (hypotonia, incontinence); and increased capillary severe gastrointestinal symptoms (abdominal permeability resulting pain, repetitive vomiting). in maldistribution of Hypotension, bronchospasm or laryngeal blood flow involvement (stridor, vocal changes, odynophagia) after exposure to known or probable allergen for that patient. Septic shock: signs of infection, fever or Infection, recent surgery, hypothermia, altered mental status, dyspnoea, immunodeficiency persisting hypotension despite fluid resuscitation Ischaemia: chest pain, dyspnoea History of cardiac disease, Arrhythmia advanced age Cardiogenic Murmur of valvular heart disease Cardiac pump failure Acute heart failure: see Heart failure in adults, Chapter History of cardiac disease, viral 12. illness, immunodeficiency Hypovolaemic Haemorrhagic: external bleeding, signs and symptoms Trauma, recent surgery, obstetric Direct blood/fluid loss (a) haemorrhage of internal bleeding, hypotension or fluid sequestration into the extravascular Non-haemorrhagic: dry mouth, absence of tears, Profuse diarrhoea and/or space resulting in sunken eyes/fontanelle, low jugular venous pressure vomiting, intestinal obstruction decreased (JVP), altered mental status intravascular volume Pulmonary embolism (PE): chest pain, tachycardia, Recent surgery or immobilisation, tachypnoea, hypoxia cancer, history of PE or DVT Deep vein thrombosis (DVT ): leg pain, swelling, warmth Obstructive Obstruction to blood Tension pneumothorax: decreased breath sounds, Trauma, invasive medical flow to, or from, the raised JVP, weak radial pulse, tracheal deviation procedure heart or great vessels Cardiac tamponade: pulsus paradoxus (b) , raised JVP, Trauma, immunodeficiency narrow pulse pressure, muffled heart sounds (a) In children and young adult s wit h hypovolaemic shock, BP may be maint ained init ially, but subsequent ly declines rapidly if fluid loss is not replaced. Page 12 / 394 (b) Pulsus paradoxus is measured by t aking t he pat ient 's BP during bot h expirat ion and inspirat ion. It is defined as a decrease of > 10 mmHg in t he SBP during inspirat ion compared wit h expirat ion. Management Attend to the patient immediately even if the type of shock is not known. Call for help. Move to critical care unit if possible. Assess and manage A (airway), B (breathing), and C (circulation) according to Basic Life Support (see below). If anaphylaxis is suspected, immediately go to specific management. Take a rapid history to try to determine underlying cause. Monitor: urine output hourly (insert a urinary catheter) HR, RR, BP, temperature, CRT, SpO2, and level of consciousness Perform the following tests: haemoglobin and blood glucose level malaria rapid diagnostic test in endemic area: see Malaria, Chapter 6 blood culture (if available) and blood group In children, administer ceftriaxone IV e : one dose of 80 mg/kg. Reassess need for further antibiotic treatment according to underlying cause. Treat pain: see Pain, Chapter 1. Primary objective of shock management is to restore adequate tissue perfusion, demonstrated by: Returning vital signs, CRT, SpO2, mental status, etc. to normal. Maintaining mean arterial pressure (MAP) f > 65 mmHg in adults (or higher if patient has pre-existing hypertension). Maintaining urine output > 0.5 to 1 ml/kg/hour. After initial management: Take a more detailed history. Perform a comprehensive physical examination. In case of dehydration: see Dehydration, Chapter 1. In case of blunt thoracic or abdominal trauma, perform POCUS g : (e)FAST exam to evaluate for pneumothorax or free fluid in pleural, pericardial and/or peritoneal spaces. Refer to surgeon as required. On-going care: Re-evaluate patient’s condition and response to treatment every 10 minutes until patient is stable. Perform a second comprehensive physical examination. Initiate nutritional support adapted to patient's needs as soon as possible and reassess regularly. Patients have high protein and energy requirements. Enteral route is preferred. Basic Life Support 1) Manage airways and breathing Lay the patient on their back. However: if spinal trauma is suspected, do not move the patient; in case of anaphylaxis, the patient may prefer a sitting position. In case of altered mental status: be prepared with mask and bag if needed for ventilation; remove any airway obstruction (e.g. secretions, foreign body); open airway: stand at head of bed, place one hand on the forehead and gently tilt the head back. Simultaneously, place the fingertips of the other hand under the chin and lift the chin. If suspicion of spinal trauma, do not move the neck. Instead, place heels of both hands on patient’s parietal areas, and use index and middle fingers of both hands to push the angle of mandible anteriorly (jaw thrust) Page 13 / 394  if needed, insert an oropharyngeal airway. Auscultate lungs to assess ventilation. Administer 10 to 15 litres/minute of oxygen with mask to maintain SpO2 > 94%. If SpO2 remains ≤ 94% with oxygen, see If resources allow. 2) Maintain circulation Control bleeding: apply direct manual pressure and/or compression/haemostatic dressing to the wound; in case of massive life-threatening bleeding from an extremity (e.g. leg) not controlled by direct pressure: apply a windlass tourniquet h. Insert 2 peripheral IV lines (catheters 20-22G in children and 14-18G in adults) or an intraosseous (IO) needle. Administer Ringer lactate (RL) i , glucose 5%-Ringer lactate (G5%-RL) j , and/or blood, following specific management described below. Reassess before giving additional fluid therapy. Monitor for fluid overload k , especially in patients at risk, e.g. severely malnourished children; patients with severe malaria, heart disease, severe anaemia; older patients. Maintain normal body temperature. If unable to maintain BP, see If resources allow. Anaphylaxis Remove exposure to causal agent. Administer epinephrine (adrenaline) IM into the mid-anterolateral thigh. Use undiluted solution and a 1 ml syringe graduated in 0.01 ml : Children under 6 months: 0.1 to 0.15 ml Children 6 months to 5 years: 0.15 ml Children 6 to 12 years: 0.3 ml Children over 12 years l and adults: 0.5 ml Repeat after 5 minutes if no or poor clinical improvement (up to a total of 3 IM injections). Monitor HR, BP, CRT and clinical response. In case of stridor, administer nebulized epinephrine: 0.5 mg/kg/dose (max. 5 mg) in 5 ml of 0.9% sodium chloride over 10 to 15 minutes If SpO2 is < 94%, ventilate with bag mask. Administer a bolus of RL: Children: 10 ml/kg as quickly as possible Adults: 500 ml as quickly as possible Repeat bolus once if signs of poor perfusion persist after 15 minutes. If shock persists after 3 IM injections of epinephrine, in particular if unable to maintain BP, see If ressources allow. After initial treatment with epinephrine and IV fluids, some patients (e.g. patients requiring continuing treatment after 2 doses of epinephrine IM or patients with ongoing asthma or shock) may benefit from a short course of corticosteroid therapy. When the patient is stable, prednisolone PO : 1 to 2 mg/kg (max. 50 mg) once daily in the morning for 3 to 5 days. Use an IV corticosteroid only if the patient cannot take oral treatment. Septic shock Look for source of infection. If possible, take specimens for culture before starting antibiotic treatment. Fluid therapy: Children and adolescents under 15 years: G5%-RL solution as maintenance fluids (see Appendix 1) Adolescents 15 years and over and adults: one bolus of 250 to 500 ml of RL as quickly as possible Antibiotic treatment: Start antibiotics according to the suspected origin of infection within 1 hour of presentation (see tables below). Page 14 / 394  If source is unknown, administer a broad-spectrum antibiotic to cover gram-positive, gram-negative, and anaerobic bacteria. If possible, take into account local epidemiology (rates and types of resistance). Differentiate community acquired sepsis and nosocomial sepsis as pathogens and rates of resistance may be different. Simplify the antibiotic treatment (to narrower spectrum) whenever possible. Reassess treatment daily: If culture results are available: adapt treatment accordingly. If improvement after 24 to 48 hours: change to oral route, however some foci (e.g. meningitis) require prolonged IV treatment. If no improvement after 48 to 96 hours: consider resistant pathogenm , in particular in patients with immunodeficiency or recent (in the last month) hospitalisation or antibiotic use and adapt treatment accordingly. Other measures to control infection: If suspected catheter-related infection, insert a new catheter in another site and remove the suspected catheter. Drain soft-tissue abscess (see Cutaneous abscess, Chapter 10); irrigate and debride traumatic wounds. Refer to surgeon if needed for debridement, drainage, relieving obstruction, etc. Treatment of fever: see Fever, Chapter 1. Page 15 / 394  Origin Antibiotics Alternatives (c) cloxacillin cefazolin(f) Cutaneous (+ vancomycin if risk factors (or vancomycin if risk factors for staphylococci, streptococci(d) for MRSA (e) ) MRSA (e) ) ceftriaxone + azithromycin clindamycin + ciprofloxacin + Pulmonary (+ gentamicin if risk factors doxycyline pneumococci, H. influenzae for MDR gram negative bacteria (g) ) ceftriaxone + clindamycin + ciprofloxacin metronidazole Intestinal or biliary (+ gentamicin if risk factors enterobacteria, anaerobic bacteria, for MDR gram negative enterococci bacteria (g) ) (+ ampicillin if biliary source) Gynaecological ceftriaxone + clindamycin + gentamicin + streptococci, gonococci, anaerobic metronidazole + azithromycin bacteria, E. coli azithromycin ceftriaxone meropenem Urinary (+ amikacin if risk factors (+ amikacin if risk factors for enterobacteria, enterococci (h) for pseudomonas ) pseudomonas (h) ) Central nervous system See Bacterial meningitis, Chapter 7. ampicillin + gentamicin in ceftriaxone children or cloxacillin + amikacin in children Other or undetermined ceftriaxone clindamycin + ciprofloxacin in adults (+ amikacin if risk factors for pseudomonas (h) ) in adults (c) Only if first -line ant ibiot ic is not available or in allergic pat ient s. (d) For necrot ising inf ect ions, see Necrot ising inf ect ion of skin and sof t t issues, Chapt er 10. (e) Risk f act ors f or MRSA: prior MRSA inf ect ion, recent hospit alisat ion or ant ibiot ic use, recurrent skin inf ect ion, chronic wounds, invasive device, set t ings wit h high rat es of MRSA. (f ) Do not administ er if severe bet a-lact am allergy (g) Risk f act ors f or mult iresist ant (MDR) gram negat ive bact eria: recent hospit alisat ion in int ensive care unit or ant ibiot ic use. (h) Risk f act ors f or pseudomonas: immunodeficiency, recent hospit alisat ion or ant ibiot ic use, burns or presence of invasive device. Page 16 / 394  Antibiotics Children over 1 month Adults amikacin IM or slow IV injection 15 mg/kg (max. 1.5 g) once daily 15 mg/kg once daily over 3 minutes ampicillin IV infusion over 50 mg/kg (max. 2 g) every 8 hours 2 g every 6 to 8 hours 30 minutes (2 g every 4 hours for meningitis) azithromycin PO (by NGT ) 10 to 20 mg/kg (max. 500 mg) once 500 mg to 1 g once daily daily cefazolin slow IV injection over 3 25 mg/kg (max. 3 g) every 12 hours 2 g every 8 hours minutes or IV infusion over 30 minutes ceftriaxone slow IV injection 80 mg/kg (max. 4 g) once daily (100 2 g once daily (2 g every 12 hours for over 3 minutes or IV infusion over mg/kg, max. 4 g, once daily for meningitis) 30 minutes meningitis) ciprofloxacin PO (by NGT ) 15 to 20 mg/kg (max. 750 mg) every 500 to 750 mg every 12 hours 12 hours ciprofloxacin IV infusion over 10 mg/kg (max. 400 mg) every 8 400 mg every 8 to 12 hours 60 minutes hours clindamycin IV infusion over 10 mg/kg (max. 600 mg) every 8 600 to 900 mg every 8 hours 30 minutes hours cloxacillin IV infusion over 25 to 50 mg/kg (max. 2 g) every 6 2 g every 6 hours 60 minutes hours doxycycline PO (by NGT ) 4.4 mg/kg (max. 200 mg) on D1 then 200 mg on D1 then 100 mg every 12 2.2 mg/kg (max. 100 mg) every 12 hours hours gentamicin IM or slow IV 7.5 mg/kg once daily 5 mg/kg once daily injection over 3 minutes meropenem IV infusion over 20 mg/kg (max. 2 g) every 8 hours 2 g every 8 hours 15 or 30 minutes metronidazole PO (by NGT ) 10 mg/kg (max. 500 mg) every 8 500 mg every 8 hours hours metronidazole IV infusion 10 mg/kg (max. 500 mg) every 8 500 mg every 8 hours over 30 minutes hours vancomycin IV infusion over 15 mg/kg (max. 500 mg) every 6 15 to 20 mg/kg (max. 2 g) every 12 hours Page 17 / 394  60 to 240 minutes hours Cardiogenic shock Administer RL with extreme caution and monitor closely for signs of fluid overload: Adults: 100 to 250 ml over 30 minutes Subsequent fluid administration should be based on thorough patient assessment, including urinary output, mental status and SpO2. Vasopressors are often required to maintain BP, see If resources allow. In case of acute heart failure, see Heart failure in adults, Chapter 12. Arrhythmias should be managed according to Advanced Life Support techniques as appropriate and where available. Hypovolemic non-haemorrhagic shock Administer RL: Children under 1 year: 30 ml/kg over 1 hour then 70 ml/kg over 5 hours Children/adolescents 1 to 14 years: 30 ml/kg over 30 minutes then 70 ml/kg over 2.5 hours Adolescents 15 years and over and adults: 250 to 500 ml as quickly as possible (to be repeated once if required) then adjusted to patient’s condition, providing up to 70 ml/kg over 2.5 hours Hypovolaemic haemorrhagic shock In order to prevent the “lethal trauma triad” of hypothermia, acidosis and coagulopathy: Determine blood group and if needed transfuse, as quickly as possible: Children under 20 kg: 20 ml/kg of whole blood Children 20 kg and over and adults: an adult unit of whole blood Repeat if needed. If blood is not immediately available, administer a bolus of RL with caution (i.e. minimize the use of RL) while waiting for blood: Children: 20 ml/kg as quickly as possible Adults: 250 to 500 ml as quickly as possible When blood is available, stop RL and administer blood only. Warm the patient (blankets, warm room, warm IV fluids). In case of trauma presenting within 3 hours, administer tranexamic acid slow IV (over 10 minutes): Children: 15 mg/kg (max. 1 g) Adults: 1 g T hen immediately start a second dose, administered by IV infusion over 8 hours. In case of postpartum haemorrhage, refer to the guide Essential obstetric and newborn care, MSF. Refer to surgery if needed. Obstructive shock T he management described up to this point will provide only temporary stabilization. Treat the cause or refer for aetiological treatment: Pulmonary embolism: anticoagulation +/- thrombolysis. Tension pneumothorax: needle decompression/finger thoracostomy, followed by insertion of chest tube. Cardiac tamponade: pericardial tap. f Page 18 / 394 If ressources allow: Manage airways and breathing: complete airway obstruction: endotracheal intubation or cricothyroidotomy respiratory failure: non-invasive or invasive mechanical ventilation Maintain circulation: If unable to achieve management objectives (in particular BP) using fluid therapy (and no signs of fluid overload are present) or, in the case of anaphylaxis, if shock persists after 3 IM epinephrine injections, vasopressors-inotropes (see below) can be used in the following conditions: close monitoring in a critical care unit; a large peripheral IV catheter n (proximal forearm or above), a central venous catheter or an IO line dedicated to the infusion; use of an electric syringe or pump to control flow rate o ; intensive monitoring of drug administration, particularly during syringe changes. All infused volumes must be accounted for when recording fluid balance. T hese protocols are for peripheral IV administration. T itrate according to patient's clinical situation. Refer to management objectives (including BP) under Management. Norepinephrine (NEP) tartrate (i) Epinephrine (EPN) (adrenaline) Children: 2nd choice Children: 1st choice Indication Adults: 1st choice Adults: 2nd choice Children: Children: Add 1 ml (2 mg) of NEP tartrate to 39 ml Add 2 ml (2 mg) of EPN to 38 ml of 0.9% NaCl of 0.9% NaCl to obtain a 0.05 mg/ml (50 to obtain a 0.05 mg/ml (50 micrograms/ml) Preparation micrograms/ml) solution. solution. of diluted Adults: Adults: solution (j) Add 2 ml (4 mg) of NEP tartrate to 38 ml Add 4 ml (4 mg) of EPN to 36 ml of 0.9% NaCl of 0.9% NaCl to obtain a 0.1 mg/ml (100 to obtain a 0.1 mg/ml (100 micrograms/ml) micrograms/ml) solution. solution. Starting 0.1 microgram/kg/minute rate (k) Rate for Increase by 0.05 micrograms/kg/minute every 10 minutes for the first hour, then every hour. (k) Max. 1 microgram/kg/minute. increasing Rate for Taper down doses when management objectives are attained. Do not stop abruptly. (k) Decrease by 0.05 micrograms/kg/minute every hour. decreasing (i) 2 mg of NEP t art rat e = 1 mg of NEP base. (j) 0.9% sodium chloride or 5% glucose or RL can be used f or dilut ion. (k) The inf usion rat e is calculat ed as f ollows: [desired dose (microgram/kg/min) x weight (kg) x 60 min] ÷ concent rat ion (microgram/ml). Ongoing care: measure serum potassium, magnesium, calcium and phosphate levels and correct any abnormalities. Additional investigations (e.g. X-rays, other laboratory tests) may be indicated, depending on aetiology suspected. Page 19 / 394 Footnotes (a) Hypot ension is based on syst olic blood pressure (SBP) in adult s: SBP < 90 mmHg or decrease in SBP ≥ 40 mmHg f rom baseline or mean art erial pressure MAP < 65 mmHg. Shock is of t en accompanied by hypot ension but may also occur wit h normal or elevat ed BP. (b) Run t he back of t he hand f rom t he t oe t o t he knee. A not able t emperat ure change f rom t he cold f oot t o t he warm knee is a posit ive t emperat ure gradient , indicat ing dist al hypoperf usion. (c) Crit ically ill-appearing child: weak grunt ing or crying, drowsy and dif ficult t o arouse, does not smile, disconjugat e or anxious gaze, pallor or cyanosis, general hypot onia. (d) Children under 1 year: > 180 bpm; Children 1 t o 5 years: > 160 bpm; Children 5 years and over: > 140 bpm. (e) For IV administ rat ion of cef t riaxone, dissolve only in wat er f or inject ion. (f ) MAP = diast olic BP (DBP) + 1/3 (SBP-DBP). A pat ient wit h BP 90/60 has a MAP = 60 + 1/3 (90-60) = 70. (g) POCUS should only be perf ormed and int erpret ed by t rained clinicians. (h) The pat ient should receive surgery wit hin 1 hour of t he applicat ion of a windlass t ourniquet. Af t er 1 hour, t here is a risk of ischaemic injury of t he limb. If surgery is not possible and t he t ourniquet is required t o save t he pat ient ’s lif e, it should be lef t in place. Any t ourniquet t hat has been applied f or more t han 6 hours should be lef t in place unt il arrival at a f acilit y capable of providing definit ive surgical care. (i) Cryst alloids should be used. Colloids (e.g. modified fluid gelat in, albumin) are not recommended. (j) Remove 50 ml of RL f rom a 500 ml RL bot t le or bag, t hen add 50 ml of 50% glucose t o t he remaining 450 ml of RL t o obt ain 500 ml of 5% glucose-RL solut ion. (k) In case of fluid overload: sit t he pat ient up, reduce t he inf usion rat e t o a minimum and administ er furosemide IV (0.5 mg/kg in children; 40 mg in adult s). Monit or t he pat ient closely over 30 minut es and assess f or underlying cardiorespirat ory or renal disease. Once t he pat ient is st abilised, reassess t he necessit y of cont inuing IV fluids. If IV fluids are st ill required, re-st art at half t he previous inf usion rat e and monit or closely. (l) If small or prepubert al children, administ er 0.3 ml of epinephrine. (m) For example: met hicillin-resist ant Staphylococcus aureus (MRSA), pseudomonas species, and gram-negat ive bact eria wit h ext ended-spect rum bet a-lact amase (ESBL) act ivit y. (n) When using a peripheral vein, monit or inf usion sit e closely f or signs of ext ravasat ion, in part icular in young children. (o) If no syst em t o cont rol volume delivery and flow rat e (e.g. syringe pump), an inf usion using an inf usion bag and st andard paediat ric giving set can be considered in ext reme sit uat ions as a t emporary measure. However, it is import ant t o consider t he risks relat ed t o t his t ype of administ rat ion (accident al bolus or insuf ficient dose). The inf usion must be const ant ly monit ored t o prevent any, even small, change f rom t he prescribed rat e. References 1. Houst on KA, George EC, Mait land K. Implicat ions f or paediat ric shock management in resource-limit ed set t ings: a perspect ive f rom t he FEAST t rial. Crit Care. 2018;22(1):119. ht t ps://doi.org/10.1186/s13054-018-1966-4 2. Cecconi M, De Backer D, Ant onelli M, et al. Consensus on circulat ory shock and hemodynamic monit oring. Task f orce of t he European Societ y of Int ensive Care Medicine. Intensive Care Med. 2014;40(12):1795-1815. ht t ps://doi.org/10.1007/s00134-014-3525-z 3. Cardona V, Ansot egui IJ, Ebisawa M, et al. World allergy organizat ion anaphylaxis guidance 2020. World Allergy Organ J. Page 20 / 394  2020;13(10):100472. Published 2020 Oct 30. ht t ps://doi.org/10.1016/j.waojou.2020.100472 4. Singer M, Deut schman CS, Seymour CW, et al. The Third Int ernat ional Consensus Definit ions f or Sepsis and Sept ic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. ht t ps://doi.org/10.1001/jama.2016.0288 5. Richey SL. Tourniquet s f or t he cont rol of t raumat ic hemorrhage: a review of t he lit erat ure. World J Emerg Surg. 2007;2:28. Published 2007 Oct 24. ht t ps://doi.org/10.1186/1749-7922-2-28 6. Emergency t reat ment of anaphylaxis. Guidelines f or healt hcare providers. Rescuscit at ion Council UK. Updat ed 2021 [Accessed May 31 2023]. ht t ps://www.resus.org.uk/sit es/def ault /files/2021- 05/Emergency%20Treat ment %20of %20Anaphylaxis%20May%202021_0.pdf 7. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: int ernat ional guidelines f or management of sepsis and sept ic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. ht t ps://doi.org/10.1007/s00134-021-06506-y Page 21 / 394 Seizures Involuntary movements of cerebral origin (stiffness followed by clonic movements), accompanied by a loss of consciousness, and often urinary incontinence (generalized tonic-clonic seizures). In pregnant women, eclamptic seizures require specific medical and obstetrical care. Refer to the guide Essential obstetric and newborn care, MSF. Initial treatment During a seizure Protect from trauma, maintain airway, place patient in ‘recovery position’, loosen clothing. Most seizures are quickly self-limited. Immediate administration of an anticonvulsant is not systematic. If generalized seizure lasts more than 5 minutes, use diazepam to stop it: diazepam Children: 0.5 mg/kg preferably rectally a without exceeding 10 mg IV administration is possible (0.3 mg/kg over 2 or 3 minutes), only if means of ventilation are available (Ambu bag and mask). Adults: 10 mg rectally or by slow IV In all cases: If seizure continues, repeat dose once after 10 minutes. In infants and elderly patients, monitor respiratory rate and blood pressure. If seizure continues after the second dose, treat as status epilepticus. The patient is no longer seizing Look for the cause of the seizure and evaluate the risk of recurrence. Keep diazepam and glucose available in case the patient starts seizing again. Status epilepticus Several distinct seizures without complete restoration of consciousness in between or an uninterrupted seizure lasting more than 30 minutes. Protect from trauma, loosen clothing, maintain airway and administer oxygen as required. Insert an intravenous or intraosseus line. Treat for hypoglycaemia (see Hypoglycaemia, Chapter 1). If 2 doses of diazepam have not stopped the seizures, use phenytoin or phenobarbital if phenytoin is not available or if seizures persist despite phenytoin. T here is a high risk of hypotension, bradycardia and respiratory depression, especially in children and elderly patients. Never administer these drugs by rapid IV injection. Monitor heart rate, blood pressure and respiratory rate every 15 minutes during and after administration. Reduce the infusion rate in the event of a drop in blood pressure or bradycardia. Ensure that respiratory support (Ambu bag via face mask or intubation, etc.) and IV solutions for fluid replacement are ready at hand. Page 22 / 394  phenytoin Children 1 month and over and adults: one dose of 15 to 20 mg/kg administered over 20 minutes slow IV minimum and 60 minutes maximum infusion T he concentration of the diluted solution should be between 5 and 10 mg/ml. T he infusion rate 250 mg in 5 ml should not exceed 1 mg/kg/minute or 50 mg/minute (25 mg/minute in elderly patients or patients ampoule with cardiac disorders). (50 mg/ml) For example: Child weighing 8 kg: 160 mg (20 mg x 8 kg), i.e. 3.2 ml of phenytoin in 17 ml of 0.9% sodium chloride over 30 minutes Adult weighing 50 kg: 1 g (20 mg x 50 kg), i.e. 20 ml of phenytoin in a bag of 100 ml of 0.9% sodium chloride over 30 minutes Do not dilute phenytoin in glucose. Do not administer via a line used for glucose solution administration. Use a large catheter. Check the insertion site and for blood backflow (risk of necrosis in the event of extravasation). After each infusion, rinse with 0.9% sodium chloride to limit local venous irritation. phenobarbital Children 1 month to < 12 years: one dose of 15 to 20 mg/kg (max. 1 g) administered over 20 slow IV minutes minimum infusion If necessary, a second dose of 10 mg/kg may be administered 15 to 30 minutes after the first 200 mg in 1 ml dose. ampoule Children ≥ 12 years and adults: one dose of 10 mg/kg (max. 1 g) administered over 20 minutes (200 mg/ml) minimum If necessary, a second dose of 5 to 10 mg/kg may be administered 15 to 30 minutes after the first dose. Do not administer more than 1 mg/kg/minute. For example: Child weighing 8 kg: 120 mg (15 mg x 8 kg), i.e. 0.6 ml of phenobarbital in 20 ml of 0.9% sodium chloride over 20 minutes Adult weighing 50 kg: 500 mg (10 mg x 50 kg), i.e. 2.5 ml of phenobarbital in a bag of 100 ml of 0.9% sodium chloride over 20 minutes For doses less than 1 ml, use a 1 ml syringe graduated 0.01 ml to draw the phenobarbital. Further treatment Febrile seizures Determine the cause of the fever. Give paracetamol (see Fever, Chapter 1). In children under 3 years, there is usually no risk of later complications after simple febrile seizures and no treatment is required after the crisis. For further febrile episodes, give paracetamol PO. Infectious causes Severe malaria (Chapter 6), meningitis (Chapter 7), meningo-encephalitis, cerebral toxoplasmosis (HIV infection and AIDS, Chapter 8), cysticercosis (Cestodes, Chapter 6), etc. Metabolic causes Page 23 / 394 Hypoglycaemia: administer glucose by slow IV injection to all patients who do not regain consciousness, to patients with severe malaria and to newborns and malnourished children. When possible, confirm hypoglycaemia (reagent strip test). Iatrogenic causes Withdrawal of antiepileptic therapy in a patient being treated for epilepsy should be managed over a period of 4-6 months with progressive reduction of the doses. An abrupt stop of treatment may provoke severe recurrent seizures. Epilepsy A first brief seizure does not need further protective treatment. Only patients with chronic repetitive seizures require further regular protective treatment with an antiepileptic drug, usually over several years. Once a diagnosis is made, abstention from treatment may be recommended due to the risks associated with treatment. However, these risks must be balanced with the risks of aggravation of the epilepsy, ensuing seizure- induced cerebral damage and other injury if the patient is not treated. It is always preferable to start with monotherapy. T he effective dose must be reached progressively and symptoms and drug tolerance evaluated every 15 to 20 days. An abrupt interruption of treatment may provoke status epilepticus. T he rate of dose reduction varies according to the length of treatment; the longer the treatment period, the longer the reduction period (see Iatrogenic causes). In the same way, a change from one antiepileptic drug to another must be made progressively with an overlap period of a few weeks. First line treatments for generalised tonic-clonic seizures in children under 2 years are carbamazepine or phenobarbital, in older children and adults sodium valproate or carbamazepine. For information: sodium valproate PO Adults: initial dose of 300 mg 2 times daily; increase by 200 mg every 3 days if necessary until the optimal dose has been reached (usually 500 mg to 1 g 2 times daily). Children over 20 kg: initial dose of 200 mg 2 times daily irrespective of weight; increase the dose progressively if necessary until the optimal dose has been reached (usually 10 to 15 mg/kg 2 times daily). carbamazepine PO Adults: initial dose of 100 to 200 mg once or 2 times daily; increase the dose every week by 100 to 200 mg, up to 400 mg 2 to 3 times daily (max. 1600 mg daily) Children 1 month and over: initial dose of 5 mg/kg once daily or 2.5 mg/kg 2 times daily; increase the dose every week by 2.5 to 5 mg/kg, up to 5 mg/kg 2 to 3 times daily (max. 20 mg/kg daily) phenobarbital PO Adults: initial dose of 2 mg/kg once daily (max. 100 mg); increase the dose progressively up to 6 mg/kg daily if necessary Children: initial dose of 3 to 4 mg/kg once daily at bedtime; increase the dose progressively up to 8 mg/kg daily if necessary Footnotes (a) For rect al administ rat ion, use a syringe wit hout a needle, or cut a nasogast ric t ube, CH8, t o a lengt h of 2-3 cm and at t ach it t o t he t ip of t he syringe. Page 24 / 394 Hypoglycaemia Last update: November 2023 Hypoglycaemia is an abnormally low concentration of blood glucose. Severe hypoglycaemia can be fatal or lead to irreversible neurological damage. Blood glucose levels should be measured whenever possible in patients presenting symptoms of hypoglycaemia. If hypoglycaemia is suspected but blood glucose measurement is not available, glucose (or another available sugar) should be given empirically. Always consider hypoglycaemia in patients presenting impaired consciousness (lethargy, coma) or seizures. For diagnosis and treatment of hypoglycaemia in neonates, refer to the guide Essential obstetric and newborn care, MSF. Clinical features Rapid onset of non-specific signs, mild to severe depending on the degree of the hypoglycaemia: sensation of hunger and fatigue, tremors, tachycardia, pallor, sweats, anxiety, blurred vision, difficulty speaking, confusion, convulsions, lethargy, coma. Diagnosis Capillary blood glucose concentration (reagent strip test): Non-diabetic patients: Hypoglycaemia: < 3.3 mmol/litre (< 60 mg/dl) Severe hypoglycaemia: < 2.2 mmol/litre (< 40 mg/dl) Diabetic patients on home treatment: < 3.9 mmol/litre (< 70 mg/dl) If blood glucose measurement is not available, diagnosis is confirmed when symptoms resolve after the administration of sugar or glucose. Symptomatic treatment Conscious patients: Children: a teaspoon of powdered sugar in a few ml of water or 50 ml of fruit juice, maternal or therapeutic milk or 10 ml/kg of 10% glucose by oral route or nasogastric tube. Adults: 15 to 20 g of sugar (3 or 4 cubes) or sugar water, fruit juice, soda, etc. Symptoms improve approximately 15 minutes after taking sugar by oral route. Patients with impaired consciousness or prolonged convulsions: Children: 2 ml/kg of 10% glucose by slow IV (2 to 3 minutes) a Adults: 1 ml/kg of 50% glucose by slow IV (3 to 5 minutes) Neurological symptoms improve a few minutes after the injection. Check blood glucose after 15 minutes. If it is still low, re-administer glucose by IV route or sugar by oral route according to the patient’s clinical condition. If there is no clinical improvement, differential diagnoses should be considered: e.g. serious infection (severe malaria, meningitis, etc.), epilepsy, unintentional alcohol intoxication or adrenal insufficiency in children. In all cases, after stabilisation, give a meal or snack rich in complex carbohydrates and monitor the patients for a few hours. Page 25 / 394 If patient does not return to full alertness after an episode of severe hypoglycaemia, monitor blood glucose levels regularly. Aetiological treatment Other than diabetes: Treat severe acute malnutrition, neonatal sepsis, severe malaria, acute alcohol intoxication, etc. End prolonged fast. Replace drugs inducing hypoglycaemia (e.g. quinine IV, pentamidine, ciprofloxacin, enalapril, beta-blockers, high- dose aspirin, tramadol), or anticipate hypoglycaemia (e.g. administer quinine IV in a glucose infusion). In diabetic patients: Avoid missing meals, increase intake of carbohydrates if necessary. Adjust dosage of insulin according to blood glucose levels and physical activity. Adjust dosage of oral antidiabetics, taking into account possible drug interactions. Footnotes (a) If ready-made 10% glucose solut ion is not available: remove 100 ml of 5% glucose f rom a 500 ml bot t le or bag, t hen add 50 ml of 50% glucose t o t he remaining 400 ml of 5% glucose t o obt ain 450 ml of 10% glucose solut ion. References 1. American Diabet es Associat ion. St andards of Care in Diabet es—2023 Abridged f or Primary Care Providers. Clinical Diabetes. 2022;41(1):4-31. ht t ps://doi.org/10.2337/cd23-as01 Page 26 / 394 Fever Last updated: December 2023 Fever is defined as an axillary temperature higher than 37.5 °C. Fever is frequently due to infection. In a febrile patient, first look for signs of serious illness then, try to establish a diagnosis. Signs of severity Petechial or purpuric rash, meningeal signs, heart murmur, severe abdominal pain, dehydration. Signs of severe bacterial infection or sepsis: critically ill appearance a , hypothermia, altered level of consciousness, severe tachycardia, hypotension, tachypnoea, respiratory distress, seizures; a bulging fontanel in young children. Signs of circulatory impairment or shock: see Shock, Chapter 1. Infectious causes of fever according to signs and symptoms Page 27 / 394  Signs or symptoms Possible aetiology Meningeal signs, seizures Meningitis/meningoencephalitis/severe malaria Abdominal pain or peritoneal signs Appendicitis/peritonitis/enteric fevers/amaebic liver abscess Diarrhoea, vomiting Gastroenteritis/enteric fevers Jaundice, enlarged liver Viral hepatitis Cough Pneumonia/measles/tuberculosis if persistent Eyelid erythema, eye pain and oedema Orbital cellulitis Ear pain, red tympanic membrane Otitis media Tender swelling behind the ear Mastoiditis Sore throat, enlarged lymph nodes Streptococcal pharyngitis/diphtheria/retropharyngeal or tonsillar abscess/epiglotittis Multiple vesicles on the oral mucosa and lips Oral herpes Dysuria, urinary frequency, back pain Urinary tract infection Red, warm, painful skin Erysipelas/cellulitis/necrotising infections of the skin and soft tissues/abscess Limp, difficulty walking Osteomyelitis/septic arthritis Rash Measles/dengue/viral haemorrhagic fevers/chikungunya Bleeding (petechiae, epistaxis, etc.) Dengue/viral haemorrhagic fevers/severe malaria Joint pain Rheumatic fever/chikungunya/dengue If the patient is ill appearing a and has a persistent fever, consider HIV infection and tuberculosis, according to clinical presentation. Laboratory and other examinations Malaria rapid diagnostic test in endemic areas. In case of circulatory impairment or shock: see Shock, Chapter 1. Children 1 to 3 months with fever without a focus: urine dipstick and urine culture, if available; blood culture, if available; full blood count (FBC), if available; Page 28 / 394  lumbar puncture (LP) if meningeal signs or signs of severe bacterial infection or sepsis, or failure of prior antibiotic treatment; chest x-ray, if available, in case of signs of respiratory disease or severe infection or sepsis. Children > 3 months to 2 years with fever without a focus: urine dipstick and urine culture, if available; LP if meningeal signs or signs of severe bacterial infection or sepsis; chest x-ray, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis; blood culture, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis; FBC, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis; other: according to clinical presentation. Children over 2 years with fever without a focus: urine dipstick and urine culture, if available, if history of urinary tract infection or fever > 72 hours or signs of severe bacterial infection or sepsis; LP if meningeal signs or signs of severe bacterial infection or sepsis; chest x-ray, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis; blood culture, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis; FBC, if available, if fever > 72 hours or signs of severe bacterial infection or sepsis; other: according to clinical presentation. Adults: according to clinical presentation. Aetiological treatment Treat patients with a positive malaria test: see Malaria, Chapter 6. If the source of infection has been found: administer antibiotic treatment accordingly. If severe infection, sepsis, circulatory impairment or shock: hospitalise and immediately administer an empiric antibiotic treatment (see Shock, Chapter 1). Continue this treatment until the source of infection is found and adapt antibiotic treatment accordingly. If no source of infection is found, and there are no signs of severe infection, sepsis, circulatory impairment or shock, hospitalise for further investigations and monitoring: Children 1 to 3 months; Children > 3 months to < 2 years with negative urine dipstick (and negative urine culture if available). For malnourished children, see Severe acute malnutrition, Chapter 1. For patients with sickle cell disease, see Sickle cell disease, Chapter 12. Symptomatic treatment Undress the patient. Do not wrap children in wet towels or cloths (not effective, increases discomfort, risk of hypothermia). Antipyretics may increase the patient’s comfort but they do not prevent febrile convulsions. Do not treat for more than 3 days with antipyretics. paracetamol PO Children 1 month and over: 15 mg/kg 3 to 4 times daily (max. 60 mg/kg daily) Adults: 1 g 3 to 4 times daily (max. 4 g daily) or ibuprofen PO Children over 3 months and < 12 years: 5 to 10 mg/kg 3 to 4 times daily (max. 30 mg/kg daily) Children 12 years and over and adults: 200 to 400 mg 3 to 4 times daily (max. 1200 mg daily) or acetylsalicylic acid (ASA) PO Children over 16 years and adults: 500 mg to 1 g 3 to 4 times daily (max. 4 g daily) Page 29 / 394 Prevention of complications Encourage oral hydration. Continue frequent breastfeeding in infants. Look for signs of dehydration. Monitor urine output. Notes: In pregnant or breast-feeding women use paracetamol only. In case of viral haemorrhagic fevers and dengue: acetylsalicylic acid and ibuprofen are contraindicated; use paracetamol with caution in the presence of hepatic dysfunction. Footnotes (a) Crit ically ill appearing child: weak grunt ing or crying, drowsiness, dif ficult t o arrouse, does not smile, disconjugat e or anxious gaze, pallor or cyanosis, general hypot onia. Page 30 / 394 Pain Pain results from a variety of pathological processes. It is expressed differently by each patient depending on cultural background, age, etc. It is a subjective experience meaning that only the individual is able to assess his/her level of pain. Regular assessment of the intensity of pain is indispensable in establishing effective treatment. Clinical features Pain assessment Intensity: use a simple verbal scale in children over 5 years and adults, and NFCS or FLACC scales in children less than 5 years (see Pain evaluation scales). Pattern: sudden, intermittent, chronic; at rest, at night, on movement, during care procedures, etc. Character: burning, cramping, spasmodic, radiating, etc. Aggravating or relieving factors, etc. Clinical examination Of the organ or area where the pain is located. Specific signs of underlying disease (e.g. bone or osteoarticular pain may be caused by a vitamin C deficiency) and review of all systems. Associated signs (fever, weight loss, etc.). Synthesis T he synthesis of information gathered during history taking and clinical examination allows aetiological diagnosis and orients treatment. It is important to distinguish: Nociceptive pain: it presents most often as acute pain and the cause-effect relationship is usually obvious (e.g. acute post-operative pain, burns, trauma, renal colic, etc.). T he pain may be present in different forms, but neurological exam is normal. Treatment is relatively well standardized. Neuropathic pain, due to a nerve lesion (section, stretching, ischaemia): most often chronic pain. On a background of constant, more or less localized pain, such as paraesthesia or burning, there are recurrent acute attacks such as electric shock-like pain, frequently associated with disordered sensation (anaesthesia, hypo or hyperaesthesia). T his type of pain is linked to viral infections directly affecting the CNS (herpes simplex, herpes zoster), neural compression by tumors, post- amputation pain, paraplegia, etc. Mixed pain (cancer, HIV) for which management requires a broader approach. Pain evaluation scales Self-evaluation scale - Children over 5 years and adults Simple verbal scale (SVS) Intensity No Mild Moderate Severe pain of pain pain pain pain Scoring 0 1 2 3 Write down 0 + ++ +++ Page 31 / 394 Observational evaluation scale - Children 2 months-5 years FLACC scale (Face Limb Activity Cry Consolability) Scoring Items 0 1 2 Face No particular Occasional grimace or frown, withdrawn, Frequent to constant frown, expression or smile disinterested clenched jaw, quivering chin Legs Normal position or Uneasy, restless, tense Kicking, or legs drawn up relaxed Activity Lying quietly, normal Squirming, shifting back and forth, tense Arched, rigid or jerking position, moves easily Cry No cry (awake or Moans or whimpers, occasional Crying steadily, screams or asleep) complaint sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, Difficult to console or comfort hugging or being talked to, distractible Each category is scored from 0 to 2, giving a final score between 0 and 10. 0 to 3: mild pain, 4 to 7: moderate pain, 7 to 10: severe pain Observational evaluation scale - Children under 2 months NFCS scale (Neonatal Facial Coding System) Scoring Items 0 1 Brow bulge no yes Eye squeeze no yes Nasolabial furrow no yes Open lips no yes A score of 2 or more signifies significant pain, requiring analgesic treatment. Treatment Treatment depends on the type and intensity of the pain. It may be both aetiological and symptomatic if a treatable cause is identified. Treatment is symptomatic only in other cases (no cause found, non-curable disease). Page 32 / 394 Nociceptive pain T he WHO classifies analgesics used for this type of pain on a three-step ladder: Step 1: non-opioid analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs). Step 2: weak opioid analgesics such as codeine and tramadol. T heir combination with one or two Step 1 analgesics is recommended. Step 3: strong opioid analgesics, first and foremost morphine. T heir combination with one or two Step 1 analgesics is recommended. T he treatment of pain is based on a few fundamental concepts: Pain can only be treated correctly if it is correctly evaluated. T he only person who can evaluate the intensity of pain is the patient himself. T he use of pain assessment scales is invaluable. T he pain evaluation observations should be recorded in the patient chart in the same fashion as other vital signs. Treatment of pain should be as prompt as possible. It is recommended to administer analgesics in advance when appropriate (e.g. before painful care procedures). Analgesics should be prescribed and administered at fixed time intervals (not on demand). Oral forms should be used whenever possible. T he combination of different analgesic drugs (multimodal analgesia) is advantageous. Start with an analgesic from the level presumed most effective: e.g., in the event of a fractured femur, start with a Step 3 analgesic. T he treatment and dose chosen are guided by the assessment of pain intensity, but also by the patient’s response which may vary significantly from one person to another. Treatment of acute pain Mild pain Paracetamol + /- NSAID Moderate pain Paracetamol + /- NSAID + tramadol or codeine Severe pain Paracetamol + /- NSAID + morphine Page 33 / 394  Adults (except Analgesics Children pregnant/breast-feeding Remarks women) Level paracetamol < 1 month: 10 mg/kg 1 g every 6 to 8 hours (max. T he efficacy of IV paracetamol 1 PO every 6 to 8 hours (max. 4 g daily) is not superior to the efficacy of 40 mg/kg daily) oral paracetamol; the IV route is ≥ 1 month: 15 mg/kg restricted to situations where every 6 to 8 hours (max. oral administration is impossible. 60 mg/kg daily) paracetamol < 1 month: 7.5 mg/kg < 50 kg: 15 mg/kg every 6 IV every 6 hours (max. 30 hours (max. 60 mg/kg daily) mg/kg daily) ≥ 50 kg: 1 g every 6 hours ≥ 1 month and < 10 kg: 10 (max. 4 g daily) mg/kg every 6 hours (max. 30 mg/kg daily) ≥ 10 kg: 15 mg/kg every 6 hours (max. 60 mg/kg daily) acetylsalicylic – 300 mg to 1 g every 4 to 6 Avoid in children less than 16 acid (aspirin) hours (max. 4 g daily) years. PO diclofenac IM – 75 mg once daily Treatment must be as short as possible. ibuprofen PO > 3 months: 5 to 10 mg/kg 200 to 400 mg every 6 to 8 Respect contra-indications. every 6 to 8 hours (max. hours (max. 1200 mg daily) 30 mg/kg daily) > 12 years: as for adults Level codeine PO > 12 years: 30 to 60 mg 30 to 60 mg every 4 to 6 Add a laxative if treatment > 48 2 every 4 to 6 hours (max. hours (max. 240 mg daily) hours. 240 mg daily) tramadol PO > 12 years: 50 to 100 mg 50 to 100 mg every 4 to 6 every 4 to 6 hours (max. hours (max. 400 mg daily) 25 to 50 mg every 12 hours in 400 mg daily) elderly patients and in patients with severe renal or hepatic tramadol IM, > 12 years: 50 to 100 mg 50 to 100 mg every 4 to 6 impairment. slow IV or every 4 to 6 hours (max. hours (max. 600 mg daily) infusion 600 mg daily) Level morphine PO > 6 months: 0.15 mg/kg 10 mg every 4 hours, to be Reduce the dose by half in 3 immediate every 4 hours, to be ajusted in relation to pain elderly patients and patients release (MIR) ajusted in relation to pain intensity with renal or hepatic impairment. intensity Page 34 / 394  Add a laxative if treatment > 48 hours. morphine PO T he daily dose is T he daily dose is Do not initiate treatment with sustained determined during the determined during the initial the MSR in elderly patients and release (MSR) initial treatment with treatment with immediate patients with renal or hepatic immediate release release morphine (MIR). impairment. Begin treatment morphine (MIR). If treatment is initiated with MIR. If treatment is initiated directly with MSR: Add a laxative if treatment > directly with MSR: 30 mg every 12 hours, to 48 hours. > 6 months: 0.5 mg/kg be ajusted in relation to every 12 hours, to be pain intensity ajusted in relation to pain intensity morphine SC, > 6 months: 0.1 to 0.2 0.1 to 0.2 mg/kg every 4 Reduce doses by half and IM mg/kg every 4 hours hours administer less frequently, according to clinical response, in morphine IV > 6 months: 0.1 mg/kg 0.1 mg/kg administered in elderly patients and patients administered in fractionated doses (0.05 with severe renal or hepatic fractionated doses (0.05 mg/kg every 10 minutes) impairment. mg/kg every 10 minutes) every 4 hours if necessary Add a laxative if treatment > every 4 hours if necessary 48 hours. Notes on the use of morphine and derivatives: Morphine is an effective treatment for many types of severe pain. Its analgesic effect is dosedependent. Its adverse effects have often been exaggerated and should not be an obstacle to its use. T he most serious adverse effect of morphine is respiratory depression, which may be fatal. T his adverse effect results from overdose. It is, therefore, important to increase doses gradually. Respiratory depression is preceded by drowsiness, which is a warning to monitor respiratory rate (RR). T he RR should remain equal to or greater than the thresholds indicated below: Children 1 to 12 months RR ≥ 25 respirations/minute Children 1 to 2 years RR ≥ 20 respirations/minute Children 2 to 5 years RR ≥ 15 respirations/minute Children > 5 years and adults RR ≥ 10 respirations/minute Respiratory depression must be identified and treated quickly: verbal and physical stimulation of the patient; administration of oxygen; respiratory support (bag and mask) if necessary. If no improvement, administer naloxone (antagonist of morphine) in bolus to be repeated every minute until RR normalises and the excessive drowsiness resolves: 5 micrograms/kg in children and 1 to 3 micrograms/kg in adults. Morphine and codeine always cause constipation. A laxative should be prescribed if the opioid treatment continues more than 48 hours. Lactulose PO is the drug of choice: children < 1 year: 5 ml daily; children 1-6 years: 5 to 10 ml daily; children 7-14 years: 10 to 15 ml daily; adults: 15 to 45 ml daily. Page 35 / 394  If the patient’s stools are soft, a stimulant laxative (bisacodyl PO: children > 3 years: 5 to 10 mg once daily; adults: 10 to 15 mg once daily) is preferred. Nausea and vomiting are common at the beginning of treatment. Children: ondansetron PO: 0.15 mg/kg (max. 4 mg per dose) up to 3 times daily Do not use metoclopramide in children. Adults: haloperidol PO (2 mg/ml oral solution): 1 to 2 mg up to 6 times daily or metoclopramide PO: 5 to 10 mg 3 times daily with an interval of at least 6 hours between each dose Do not combine haloperidol and metoclopramide. For chronic pain in late stage disease (cancer, AIDS etc.), morphine PO is the drug of choice. It may be necessary to increase doses over time according to pain assessment. Do not hesitate to give sufficient and effective doses. Morphine, tramadol and codeine have similar modes of action and should not be combined. Buprenorphine, nalbuphine and pentazocine must not be combined with morphine, pethidine, tramadol or codeine because they have competitive action. Treatment of nociceptive pain in pregnant and breast-feeding women Pregnancy Breast-feeding Analgesics 0-5 From 6th month months paracetamol first first choice first choice Level choice 1 aspirin avoid contra-indicated avoid ibuprofen avoid contra-indicated possible codeine possible T he neonate may develop withdrawal Use with caution, for a short period symptoms, respiratory depression and (2-3 days), at the lowest effective drowsiness in the event of prolonged dose. Monitor the mother and the Level administration of large doses at the child: in the event of excessive 2 end of the thirdtrimester. Closely drowsiness, stop treatment. monitor the neonate. tramadol possible T he child may develop drowsiness when the mother receives tramadol at the end of the thirdtrimester and during breast-feeding. Administer with caution, for a short period, at the lowest effective dose, and monitor the child. morphine possible T he child may develop withdrawal symptoms, respiratory depression and Level drowsiness when the mother receives morphine at the end of the third trimester 3 and during breast-feeding. Administer with caution, for a short period, at the lowest effective dose, and monitor the child. Neuropathic pain Page 36 / 394 Commonly used analgesics are often ineffective in treating this type of pain. Treatment of neuropathic pain is based on a combination of two centrally acting drugs: amitriptyline PO Adults: 25 mg once daily at bedtime (Week 1); 50 mg once daily at bedtime (Week 2); 75 mg once daily at bedtime (as of Week 3); max.150 mg daily. Reduce the dose by half in elderly patients. carbamazepine PO Adults: 200 mg once daily at bedtime (Week 1); 200 mg 2 times daily (Week 2); 200 mg 3 times daily (as of Week 3) Given its teratogenic risk, carbamazepine should only be used in women of childbearing age when covered by effective contraception (intrauterine device or injectable progestogen). It is not recommended in pregnant women. Mixed pain In mixed pain with a significant component of nociceptive pain, such as in cancer or AIDS, morphine is combined with antidepressants and antiepileptics. Chronic pain In contrast to acute pain, medical treatment alone is not always sufficient in controlling chronic pain. A multidisciplinary approach including medical treatment, physiotherapy, psychotherapy and nursing is often necessary to allow good pain relief and encourage patient selfmanagement. Co-analgesics T he combination of certain drugs may be useful or even essential in the treatment of pain: antispasmodics, muscle relaxants, anxiolytics, corticosteroids, local anaesthesia, etc. Page 37 / 394 Anaemia Last updated: January 2024 Anaemia is defined as a haemoglobin (Hb) level below reference values , which vary depending on age, sex, and pregnancy status (see Table 2). Anaemia may be caused by: Decreased production of red blood cells: iron deficiency, nutritional deficiencies (folic acid, vitamin B 12, vitamin A), depressed bone marrow function, certain infections (HIV, visceral leishmaniasis), renal failure; Loss of red blood cells: acute or chronic haemorrhage (gastrointestinal ulcer, ancylostomiasis, schistosomiasis, etc.); Increased destruction of red blood cells (haemolysis): parasitic (malaria), bacterial and viral (HIV) infections; haemoglobinopathies (sickle cell disease, thalassaemia); intolerance to certain drugs (primaquine, dapsone, co- trimoxazole, nitrofurantoin, etc.) in patients with G6PD deficiency. T he causes of anaemia are often interlinked. Clinical features Common signs: pallor of the conjunctivae, mucous membranes, palms of hands and soles of feet; fatigue, dizziness, dyspnoea, tachycardia, heart murmur. Signs of decompensation: cold extremities, altered mental status, oedema in the lower limbs, respiratory distress, elevated jugular venous pressure, cardiac/coronary failure, shock. Significant signs: cheilosis and glossitis (nutritional deficiency), jaundice, hepatosplenomegaly, dark coloured urine (haemolysis), bleeding (maelena, haematuria, etc.), signs of malaria (Chapter 6), etc. Laboratory Hb levels Rapid diagnostic test or thick and thin blood films in areas where malaria is endemic. Urinary dipstick: check for haemoglobinuria or haematuria. If sickle cell disease is suspected (to be done before blood transfusion): rapid diagnostic test (Sickle SCAN®) or, if not available, Emmel test. Full blood count (FBC) if available to guide diagnosis. Table 1 - Possible diagnoses with FBC Page 38 / 394  Characteristics Main diagnoses Macrocytic Deficiency (folic acid, vitamin B 12), chronic alcoholism Microcytic Iron deficiency (malnutrition, chronic haemorrhage), chronic inflammation (HIV infection, cancer), thalassaemia Normocytic Acute haemorrhage, renal failure, haemolysis Reduced number of Deficiency (iron, folic acid, vitamin B 12), spinal tumour, renal failure reticulocytes Increased or normal number of Haemolysis, sickle cell disease, thalassaemia reticulocytes Eosinophilia Ancylostomiasis, trichuriasis, schistosomiasis, HIV infection, malignant haemopathies Aetiological treatment Anaemia in itself is not an indication for transfusion. Most anaemias are well tolerated and can be corrected with simple aetiological treatment. Aetiological treatment may be given alone or together with transfusion. Iron deficiency ferrous salts/folic acid PO, or if not available, ferrous salts PO, for 3 months Doses are expressed in elemental irona : Children 1 month to < 6 years: 1.5 to 3 mg/kg 2 times daily Children 6 to < 12 years: 65 mg 2 times daily Children ≥ 12 years and adults: 65 mg 2 to 3 times daily Treatment Age Weight 45 mg/5 ml syrup 60 or 65 mg tablet 1 month to < 1 year 4 to < 10 kg 1.5 ml x 2 – 1 to < 6 years 10 to < 20 kg 2.5 ml x 2 – 6 to < 12 years 20 to < 40 kg – 1 tab x 2 ≥ 12 years and adults ≥ 40 kg 1 tab x 2 or 3 Helminthic infections: see Schistosomiasis and Nematode infections (Chapter 6). Folic acid deficiency (rarely isolated) folic acid PO for 4 months: Children under 1 year: 0.5 mg/kg once daily Children 1 year and over and adults: 5 mg once daily Page 39 / 394  Malaria: see Malaria (Chapter 6). In the event of associated iron deficiency, wait 4 weeks after malaria treatment before prescribing iron supplements. Suspected haemolytic anaemia: stop any drug that causes haemolysis in patients with (or that may possibly have) G6PD deficiency. Blood transfusion Indications To decide whether to transfuse, several parameters should be taken into account: Clinical tolerance of anaemia Underlying conditions (cardiovascular disease, infection, etc.) Rate at which anaemia develops. Hb levels If transfusion is indicated, it should be carried out without delay b. For transfusion thresholds, see Table 2. Volume to be transfused If presence of haemorrhagic shock: see Shock, Chapter 1. Otherwise: Children : Transfusion volume is based on presence or absence of fever at any point from the time of ordering blood to the time of transfusion: If no fever (axillary temperature ≤ 37.5 °C) c : administer either 15 ml/kg of packed red blood cells (PRBC) over 3 hours or 30 ml/kg of whole blood over 4 hours If fever (axillary temperature > 37.5 °C) c : administer either 10 ml/kg of PRBC over 3 hours or 20 ml/kg of whole blood over 4 hours Adolescents and adults: start with an adult unit of PRBC or whole blood; do not exceed a transfusion rate of 5 ml/kg/hour. Repeat if necessary, depending on clinical condition. Monitoring Monitor the patient’s condition and vital signs (heart rate, blood pressure, respiratory rate, temperature): During the transfusion: 5 minutes after the start of transfusion, then every 15 minutes during the first hour, then every 30 minutes until the end of the transfusion. After the transfusion: 4 to 6 hours after the end of the transfusion. Pay attention to signs of transfusion reaction, fluid overload, decompensation or continuing blood loss. For children: measure Hb once between 8 and 24 hours after the end of the transfusion or if signs of decompensation or continuing blood loss. If signs of circulatory overload appear: Stop temporarily the transfusion. Sit the patient in an upright position. Administer oxygen. Administer furosemide by slow IV injection: Children: 0.5 to 1 mg/kg Adults: 20 to 40 mg Repeat the injection (same dose) after 2 hours if necessary. Once the patient has been stabilised, start the transfusion again after 30 minutes. Page 40 / 394 Prevention Iron (and folic acid) deficiency: Drug supplements: ferrous salts/folic acid PO, or if not available, ferrous salts PO, as long as the risk of deficiency persists (e.g. pregnancy , malnutrition). Doses are expressed in elemental irona : Children 1 month to < 12 years: 1 to 2 mg/kg once daily (max. 65 mg daily) Children ≥ 12 years and adults: 65 mg once daily Prevention Age Weight 45 mg/5 ml syrup 60 or 65 mg tablet 1 month to < 1 year 4 to < 10 kg 1 ml – 1 to < 6 years 10 to < 20 kg 2.5 ml – 6 to < 12 years 20 to < 40 kg 5 ml – ≥ 12 years and adults ≥ 40 kg – 1 tab Nutritional supplements (if the basic diet is insufficient). In the event of sickle cell anaemia: see Sickle cell disease (Chapter 12). Early treatment of malaria, helminthic infections, etc. Table 2 - Definition of anaemia and transfusion thresholds Page 41 / 394  Hb levels defining Patients Transfusion thresholds anaemia Children 2-6 months < 9.5 g/dl Hb < 4 g/dl, even if there are no signs of decompensation Children 6 months-4 years < 11 g/dl Hb ≥ 4 g/dl and < 6 g/dl if there are signs of decompensation or ongoing blood loss or severe Children 5-11 years < 11.5 g/dl malaria or serious bacterial infection or pre-existing heart disease (a) Children 12-14 years < 12 g/dl Men (≥ 15 years) < 13 g/dl Hb < 7 g/dl if there are signs of decompensation or ongoing blood loss or severe malaria or serious bacterial Women (≥ 15 years) < 12 g/dl infection or pre-existing heart disease Pregnant women < 11 g/dl < 36 weeks st rd (1 and 3 trimester) Hb ≤ 5 g/dl, even if there are no signs of decompensation < 10.5 g/dl (2nd trimester) Hb > 5 g/dl and < 7 g/dl if there are signs of decompensation or sickle cell disease or severe malaria or serious bacterial infection or pre-existing heart disease ≥ 36 weeks Hb ≤ 6 g/dl, even if there are no signs of decompensation Hb > 6 g/dl and < 8 g/dl if there are signs of decompensation or sickle cell disease or severe malaria or serious bacterial infection or pre-existing heart disease (a) Immediat e t ransf usion is not required in children 2 mont hs t o 12 years wit h Hb ≥ 4 g/dl and < 6 g/dl and no sign of decompensat ion or ongoing blood loss, provided t hat : t hey are closely monit ored (including Hb measurement s at 8, 24 and 48 hours), and t ransf usion preparat ion (blood grouping, et c.) is carried out wit hout delay in case t he child needs t o be t ransf used lat er on. Footnotes (a) A cof ormulat ed t ablet of f errous salt s/f olic acid cont ains 185 mg of f errous f umarat e or sulf at e (equivalent t o 60 mg of element al iron) and 400 micrograms of f olic acid. A 200 mg t ablet of f errous f umarat e or sulf at e cont ains 65 mg of element al iron. A 140 mg/5 ml syrup of f errous f umarat e cont ains 45 mg/5 ml of element al iron. (b) Bef ore t ransf using: det ermine t he recipient ’s and pot ent ial donors’ blood groups/rhesus and carry out screening t est s on t he donor’s blood f or HIV-1 and 2, hepat it is B and C, syphilis and, in endemic areas, malaria and Chagas disease. (c) Axillary t emperat ure should be t aken at t he t ime of ordering blood and immediat ely prior t o t ransf usion. References Page 42 / 394 1. World Healt h Organizat ion. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. World Healt h Organizat ion; 2011. [Accessed June 26, 2023] ht t ps://apps.who.int /iris/handle/10665/85839 2. World Healt h Organizat ion. Educational Modules on Clinical Use of Blood. World Healt h Organizat ion; 2021. [Accessed June 26, 2023] ht t ps://apps.who.int /iris/handle/10665/350246 3. Mait land K, Olupot -Olupot P, Kiguli S, et al. Transf usion Volume f or Children wit h Severe Anemia in Af rica. N Engl J Med. 2019;381(5):420-431. ht t ps://doi.org/10.1056/NEJMoa1900100 4. Word Healt h Organizat ion. Daily iron and folic acid supplementation in pregnant women. Word Healt h Organizat ion. Geneva, 2012. [Accessed June 26, 2023] ht t ps://apps.who.int /iris/handle/10665/77770 Page 43 / 394 Dehydration Dehydration results from excessive loss of water and electrolytes from the body. If prolonged, dehydration can compromise organ perfusion, resulting in shock. It is principally caused by diarrhoea, vomiting and severe burns. Children are particularly susceptible to dehydration due to frequent episodes of gastroenteritis, high surface area to volume ratio and inability to fully communicate, or independently meet their fluid needs. T he protocols below are focused on treatment of dehydration caused by diarrhoea and vomiting. Alternative treatment protocols should be used for children with malnutrition (see Severe acute malnutrition, Chapter 1) or in patients with severe burns (see Burns, Chapter 10). Clinical features and assessment History of diarrhoea and/or vomiting and concomitant reduced urine output. Clinical features depend on the degree of dehydration (see table below). Features such as dry mouth, absence of tears may also be noted. Patients with severe dehydration should be assessed for shock (tachycardia, low blood pressure and delayed capillary refill time etc.). Electrolyte disorders may cause tachypnoea, muscle cramps or weakness, cardiac arrhythmia (irregular heart rate, palpitation), confusion and/or seizures. Classification of degree of dehydration (adapted from the WHO) Severe dehydration Some dehydration No dehydration At least 2 of the At least 2 No signs of "severe" following signs: of the following signs: or "some" dehydration. Lethargic or Mental status Restless or irritable Normal unconscious Radial pulse Weak or absent Palpable Easily palpable Eyes (a) Sunken Sunken Normal Goes back very slowly Goes back slowly Goes back quickly Skin pinch (b) (> 2 seconds) (< 2 seconds) (< 1 second) Drinks poorly T hirst, No thirst, Thirst or not able to drink drinks quickly drinks normally (a) Sunken eyes may be a normal f eat ure in some children. Ask t he mot her if t he child's eyes are t he same as usual or if t hey are more sunken t han usual. (b) Skin pinch is assessed by pinching t he skin of t he abdomen bet ween t he t humb and f orefinger wit hout t wist ing. In older people t his sign is not reliable as normal aging diminishes skin elast icit y. Treatment of dehydration Page 44 / 394 Severe dehydration Treat shock if present (see Shock, Chapter 1). If able to drink, administer oral rehydration solution (ORS) PO whilst obtaining IV access. according to WHO Treatment Plan C, monitoring infusion rate closely: Insert peripheral IV line using large caliber catheter (22-24G in children or 18G in adults) or intraosseous needle. Administer Ringer lactate (RL) a WHO Treatment Plan C Age First, give 30 ml/kg over (c) : Then, give 70 ml/kg over: Children < 1 year 1 hour 5 hours Children ≥ 1 year and adults 30 minutes 2 ½ hours (c) Repeat once if radial pulse remains weak or absent af t er first bolus. In case of suspected severe anaemia, measure haemoglobin and treat accordingly (see Anaemia, Chapter 1). b As soon as the patient is able to drink safely (often within 2 hours), provide ORS as the patient tolerates. ORS contains glucose and electrolytes which prevent development of complications. Monitor ongoing losses closely. Assess clinical condition and degree of dehydration at regular intervals to ensure continuation of appropriate treatment. If over the course of treatment the patient: remains or becomes lethargic: measure blood glucose level and/or treat hypoglycaemia (see Hypoglycaemia, Chapter 1). develops muscle cramps/weakness and abdominal distention: treat for moderate hypokalaemia with 7.5% potassium chloride syrup (1 mmol of K+/ml) PO for 2 days: Children under 45 kg: 2 mmol/kg (2 ml/kg) daily (according to weight, the daily dose is divided into 2 or 3 doses) Children 45 kg and over and adults: 30 mmol (30 ml) 3 times daily T his treatment should only be given as an inpatient c. develops peri-orbital or peripheral oedema: reduce the infusion rate to a minimum, auscultate the lungs, re- evaluate the stage of dehydration and the necessity of continuing IV rehydration. If IV rehydration is still required, continue the infusion at a slower rate and observe the patient closely. If IV rehydration is no longer required, change to oral treatment with ORS. develops dyspnoea, cough and bibasal crepitations are heard on auscultation of the lungs: sit the patient up, reduce the infusion rate to a minimum and administer one dose of furosemide IV (1 mg/kg in children; 40 mg in adults). Monitor the patient closely over 30 minutes and assess for underlying cardiorespiratory or renal disease. Once the patient is stabilised, reassess the degree of dehydration and the necessity of continuing IV rehydration. If IV rehydration is still required, re-start at half the previous infusion rate and monitor closely. If IV rehydration is no longer required, change to oral treatment with ORS. Some dehydration Administer ORS according to WHO Treatment Plan B which equates to 75 ml/kg ORS given over 4 hours. WHO Treatment Plan B d Page 45 / 394  10 years and adults at least 250 ml (at least 1 glass) Treatment of diarrhoea In addition to the WHO treatment plan corresponding to patient's degree of dehydration: Administer aetiologic treatment if required. Administer zinc sulfate to children under 5 years (see Acute diarrhoea, Chapter 3). Footnotes (a) If RL not available, 0.9% sodium chloride can be used. (b) If t ransf usion is required, it should be provided in parallel t o IV fluids, using a separat e IV line. The blood volume administ ered should be deduct ed f rom t he t ot al volume of Plan C. (c) If available, t ake blood t est s t o monit or urea and elect rolyt e levels. (d) For more det ailed inf ormat ion on ORS recommendat ions by age and weight , ref er t o t he guide Management of a cholera epidemic, MSF. Page 46 / 394 References 1. World Healt h Organizat ion. The t reat ment of diarrhoea : a manual f or physicians and ot her