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    IMCI Plan C 2013

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    Suhazeli Abdullah
    This document provides guidance on diagnosing and managing severe dehydration in children. It states that severe dehydration should be diagnosed if a child has two or more of the following signs: being drowsy or unconscious, having sunken eyes, not being able to drink or drinking poorly, and skin pinch returning very slowly at 2 seconds or more. It outlines management of severe dehydration as urgent referral to the hospital and starting IV fluid resuscitation. It also discusses options for managing severe dehydration in situations where IV lines cannot be placed or referral is not possible, such as oral rehydration with ORS or using a nasogastric tube.

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    IMCI Plan C 2013

    Uploaded by

    Suhazeli Abdullah
    233 views51 pages
    This document provides guidance on diagnosing and managing severe dehydration in children. It states that severe dehydration should be diagnosed if a child has two or more of the following signs: being drowsy or unconscious, having sunken eyes, not being able to drink or drinking poorly, and skin pinch returning very slowly at 2 seconds or more. It outlines management of severe dehydration as urgent referral to the hospital and starting IV fluid resuscitation. It also discusses options for managing severe dehydration in situations where IV lines cannot be placed or referral is not possible, such as oral rehydration with ORS or using a nasogastric tube.

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    Pre conference 1 17th Family Medicine Conference | 4 to 7 July 2013 | The Zenith Kuantan

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    This document provides guidance on diagnosing and managing severe dehydration in children. It states that severe dehydration should be diagnosed if a child has two or more of the following signs: being drowsy or unconscious, having sunken eyes, not being able to drink or drinking poorly, and skin pinch returning very slowly at 2 seconds or more. It outlines management of severe dehydration as urgent referral to the hospital and starting IV fluid resuscitation. It also discusses options for managing severe dehydration in situations where IV lines cannot be placed or referral is not possible, such as oral rehydration with ORS or using a nasogastric tube.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    233 views51 pages

    IMCI Plan C 2013

    Uploaded by

    Suhazeli Abdullah
    This document provides guidance on diagnosing and managing severe dehydration in children. It states that severe dehydration should be diagnosed if a child has two or more of the following signs: being drowsy or unconscious, having sunken eyes, not being able to drink or drinking poorly, and skin pinch returning very slowly at 2 seconds or more. It outlines management of severe dehydration as urgent referral to the hospital and starting IV fluid resuscitation. It also discusses options for managing severe dehydration in situations where IV lines cannot be placed or referral is not possible, such as oral rehydration with ORS or using a nasogastric tube.

    Copyright:

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    of 51

    Plan C Severe Dehydration

    Dr Nor Azmi bin Abdullah Pakar Pediatrik Hospital Pekan, Pahang

    Diagnosis of Severe Dehydration


    If any two of the following signs are present, severe dehydration should be diagnosed: drowsy or unconscious sunken eyes not able to drink or drinking poorly. skin pinch goes back very slowly (2 seconds or more)

    Skin pinch goes back very slowly

    Sunken eyes?

    Sunken eyes?

    Sunken eyes?

    Severe Drowsy or unconscious Dehydration: Sunken eyes 2 or more: Not able to drink or drinking poorly Skin pinch goes back very slowly
    Some Restless, irritable Dehydration Sunken eyes 2 or more: Drinks eagerly, thirsty Skin pinch goes back slowly No Not enough signs to classify as some Dehydration dehydration

    IMCI Indonesian version for comparison

    IMCI Indonesian version for comparison

    MANAJEMEN TERPADU BALITA SAKIT

    Management of severe dehydration: Refer urgently to hospital

    Management of severe dehydration: Refer urgently to hospital


    Most children will be referred to hospital for IV management and most likely IV line already inserted at KK Initial fluid resuscitation according to IMCI guidelines
    Later will be adjusted in hospital according to clinical condition and investigation results

    However in certain situations you may need to manage severe dehydration at primary care

    Senario
    Kanak-kanak severe dehydration Boleh minum ORS perlahan-lahan Tak boleh refer sebab banjir Tak boleh set IV line Apa nak buat

    Plan C Can you give IV drip?


    If YES Start IV fluid immediately while arranging transport to hospital If the child can drink, give ORS by mouth while setting drip Give 100ml/kg IV fluid (NS or Hartmann)
    First give 20ml/kg bolus Feel radial pulse after completion. If not detectable, repeat 20ml/kg

    AGE Infants < 12 months

    First give Then 80 20 ml/kg in ml/kg in 1 hour 5 hours

    Children 30min 12mo to 5yrs

    2 hours

    Refer urgently to hospital once transport available

    Continue IV fluids along the way

    Plan C IV fluid
    16-month-old (10 kg) child who is classified as having SEVERE DEHYDRATION. PPP was able to set IV line He followed Plan C. He gave the child 200 ml (20 ml x 10 kg) in the first 30 minutes. He gave 800 ml (80 ml x 10 kg) over the next 2.5 hours (320 ml per hour).

    Still unable to refer


    Continue plan C until complete. Review the child every 1 hour. Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 34 hours (infants) or 12 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A,B, or C) to continue treatment. Observe for at least 6 hours after rehydration.

    Which IV Fluid?

    What IV fluid is suitable?


    Recommended: Ringers lactate or Hartmann solution
    Contains sodium (Na), potassium (K) and lactate

    Normal saline (0.9% NaCl)


    Only has Na (in hospital, potassium and bicarbonate can be added to NS but requires some calculation)

    Another example

    Plan C severe dehydration unable to refer to hospital


    Ellen, A 10 month old, 9kg girl, diarrhoea with severe dehydration Not able to drink KK able to give IV treatment and has normal saline (0.9% NaCl) How to proceed?

    Ellen, 10 month, 9kg


    Give Ellen 180ml (20ml x 9kg) of Normal saline IV over 1 hour Then check radial pulse - detectable Over the following 5 hours, give her 720ml of IV fluid (80ml x 9) = 720. (720/5 =144 ml/hr) Assess hydration status every hour At 3 hours hydration status was improving

    Ellen, 10 month, 9kg


    After 4 hours of IV treatment, Ellen was able to drink. Give ORS 45ml (5ml/kg) per hour. After on IV fluid for 6 hours, Ellen was reassessed. She had improved and was classified as some dehydration. The health worker continued treatment with plan B. IV drip was stopped. Note: Still try to refer to hospital as soon as possible

    Plan C can you give IV drip? NO Can you put in NG tube? YES

    Senario
    Kanak-kanak severe dehydration Tak nak minum Tak boleh rujuk ke hospital Tak dapat line Anda terlatih dan yakin boleh insert ryles tube

    Plan C Can you give IV drip? No


    Are you trained to use NG tube (Ryles tube) for rehydration? YES Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1 hour: If there is repeated vomiting or increased abdominal distension, give the fluid more slowly. After 6 hours reassess the child. Observe at least 6 hours after rehydration to make sure mother can maintain hydration giving child ORS by mouth.

    Plan C Can you give IV drip? NO Can you put in NG? NO Can the child drink? YES

    Plan C Child able to drink ORS


    Start rehydration by mouth with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1 hour: If there is repeated vomiting or increased abdominal distension, give the fluid more slowly. After 6 hours reassess the child. Observe at least 6 hours after rehydration to make sure mother can maintain hydration giving child ORS by mouth. STILL TRY TO SEND TO HOSPITAL AS SOON AS POSSIBLE

    Senario
    An 18 month old boy (8kg) is brought to KD c/o diarrhoea He has sunken eyes. Skin pinch goes back very slowly. He was able to take small sips of drink when offered.

    18 month old boy, 8kg Severe dehydration


    You are not able to provide IV treatment at your KD. However, IV treatment is available at KK nearby (within 30 minutes) What should you do?

    18 month old boy, 8kg Severe dehydration


    Go with patient urgently to KK Give frequent sips of ORS during the journey Aim to finish 20ml x 8 = 160ml ORS in 1 hour (At KK, set line, IV fluids, refer to hospital)

    Example
    KD Mat Daling does not give IV or NG therapy. The nearest hospital is more than 2 hours away A 15 month old girl, Eleli (weight 7kg), was brought by her mother. Eleli appeared to be sleeping but was able to take small sips of drink when aroused. The health worker found that she had sunken eyes. A skin pinch goes back very slowly.

    Eleli 15 months old, 7kg


    What would you do?

    Eleli 15 months old, 7kg


    What would you do? Try to refer to hospital as soon as possible Start to rehydrate by mouth according to plan C

    Eleli 15 months old, 7kg


    Since Eleli weighed 7kg, the JM calculated that she needed 7x20= 140ml ORS per hour. She showed Elelis mother how much ORS to give in 1 hour. Each hour during the next 6 hours, the JM checked Eleli to make sure she was not vomiting and her abdomen was not distended. The JM also checked her hydration status.

    Reassess dehydration and choose the appropriate Treatment Plan


    After 6 hours of taking ORS solution by mouth, reassess the child for dehydration. Classify dehydration. Select the appropriate treatment plan (Plan A, B or C), and continue treatment. After the child is rehydrated, keep the child at the clinic for 6 more hours if possible. During this time, encourage mother to give fluid according to plan A. Check the child periodically to make sure that signs of dehydration do not return.

    Reminder Plan C - ORS


    Reassess the childs hydration status every 1 to 2 hours If childs hydration status is not improving after 3 hours, try very hard to urgently refer the child for IV treatment

    Pemantauan jika beri ORS plan C (Bahasa Indonesia)


    Periksa kembali anak setiap 1-2 jam: - Jika anak muntah terus menerus atau perut makin kembung, beri cairan lebih lambat. - Jika setelah 3 jam keadaan hidrasi tidak membaik, rujuk anak untuk pengobatan intravena Sesudah 6 jam, periksa kembali anak. Klasifikasikan dehidrasi. Kemudian tentukan rencana terapi yang sesuai (A, B, atau C) untuk melanjutkan penanganan.

    Severe dehydration cannot give IV or put in RT


    If a child with SEVERE DEHYDRATION comes to your clinic and you cannot give IV or NG treatment, find out if the child is able to drink. If he is able to drink, you can try to rehydrate the child orally. If the child is not able to drink, you must refer him urgently to the nearest clinic or hospital where IV or NG treatment is available. If this child does not receive fluids, he will die.

    Is there a situation when it may be harmful to give (too much) IV fluids?

    Acute diarrhoea and


    This 2 year old male child was brought to the KK c/o diarrhoea for 6 days. He had angular stomatitis, peri-anal ulceration, weighed 7.0 kg and has visible severe wasting

    His hands were cold, pulse weak and fast and skin pinch went back very slowly. However, he appeared to be fully conscious and was not lethargic.

    MALNUTRITION

    Some or Severe Dehydration plus another severe classification


    severe pneumonia, very severe febrile disease, severe malnutrition

    This child has severe malnutrition Even though the child has some dehydration, it may be harmful to give too much IV fluids Management: Refer urgently to hospital Give frequent sips of ORS on the way and continue breastfeeding if still breastfeeding

    Take home message


    PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

    Plan C: Refer to hospital Start IV fluid according to IMCI (100ml/kg)


    20ml/kg over or 1 hour 80ml/kg over 2 or 5 hours Give ORS 5ml/kg/hr during journey if child able to take orally

    If cannot set IV line and hospital is near


    Refer to hospital ORS during journey (aim for 20ml/kg in 1 hr)

    Take home message


    PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

    What to do if cannot set IV line and hospital is far


    Still refer ORS according to plan C (orally or NG tube) Stop at KK that can set IV

    Know how to treat and assess severe dehydration esp if referral is delayed or cannot refer

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