Clinical Guidelines

THIS DOCUMENT was produced with the support of the World Health Organization (WHO) Kenya Country Office, and all reasonable precautions have been taken to verify the information it contains. The published material does not imply the expression of any opinion whatsoever on the part of the World Health Organization, and is being distributed without warranty of any kind – either expressed or implied. The responsibility for interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Any part of this document may be freely reviewed, quoted, reproduced, or translated in full or in part, provided the source is acknowledged. It may not be sold or used in conjunction with commercial purposes or for profit.

The Ministry welcomes comments and queries from users of this publication. Please send feedback to:

Office of the Director of Medical Services Afya House

PO Box 3469 – City Square Nairobi 00200, Kenya

Clinical Management and Referral Guidelines – Volume III:

Clinical Guidelines for Management and Referral of Common Conditions at Levels 4–6: Hospitals

Published by: Ministry of Medical Services and Ministry of Public Health and Sanitation

Afya House

PO Box 3469 – City Square Nairobi 00200, Kenya http://www.health.go.ke

Email: dms@health.go.ke; dps@health.go.ke

Designed and Printed by: Soloh Worldwide Inter-Enterprises Ltd. P.O. Box 1868 00100

Tel: 22247191/317871

Email: soloworld@wananchi.com

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List of Tables

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57.2: Recommended emergency abortion care activities by level of health care

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Level 1 – Community

Contributors to This Volume

CONTRIBUTORS

Prof. Ezekiel M. Wafula, MB.ChB (Nairobi), M.Med (Nairobi), Associate Professor and Consultant Paediatrician, Department of Paediatric and Child Health, University of Nairobi, project editor

Prof. Nicholas A. Othieno Abinya, MB.ChB (Nairobi), M.Med (Nairobi), Associate Professor, Department of Medicine, Section of Oncology, Aga Khan University Hospital

Prof. Joseph G. Karanja, MB.ChB (Nairobi), M.Med (Nairobi), Associate Professor and Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, University of Nairobi

Prof. Dan C.O. Kaseje, MB.ChB (Nairobi), MPH, PhD, Professor of Community Health, Great Lakes University, Kisumu

Prof. Rachel Musoke, MB.ChB (East Africa), M.Med (Makerere), FABM,

Associate Professor and Consultant Paediatrician and Neonatologist, Department of Paediatrics and Child Health, University of Nairobi

Prof. Stephen W.O. Ogendo, MB.ChB (Nairobi), M.Med (Nairobi), FCS (ECSA), Associate Professor and Consultant Cardiothoracic Surgeon, Department of Surgery, University of Nairobi

REVIEWERS

Dr. Kirtida Acharya, Endocrinologist (Diabetes), MP Shah Hospital Dr. John Aduda, Kenya Medical Supply Agency

Dr. Maureen Ambetsa, Med Sup, Nakuru

Dr. Dianne Amojong, Machakos Level 5

Dr. K. Chesang, WHO

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Dr. Sarah Chuchu, Provincial Pharmacist – Nairobi Province

Dr. Samuel Gatere, MOMS – Mathari Hospital

Dr. Esther Getambo, Ministry of Medical Services (MOMS)

Dr. Michael M. Gichangi, MOMS

Dr. Evans Imbuki, New Nyanza Provincial General Hospital Dr. Anne Indalo University of Nairobi Pharmacy Department Dr. Alice Inyangala, MOMS/Pharmacy

Prof. Francis D. Juma, UON-Faculty of Medicine

Mr. John Kabanya, Clinical Officer, Clinical Officers Council Dr. Charles Kamotho, Thika District Hospital

Mrs. Lydia Karimuria, Ministry of Public Health and Sanitation (MOPHS), Division of Child and Adolescent Health

Mrs. Mercy Kasina, Ministry of Health, Department of Nursing

Dr. Harrison Kiambati, Head Technical Planning, MOMS

Dr. Humphrey Karamagi, Technical Officer, Health System Development, WHO Kenya

Dr. David Kiima, Diretor of Mental Health, MOMS, Division of Mental Health Mr. Titus M. Kilika, MOMS

Dr. Kilonzo, head of surgery, Machakos level 5 hospital

Dr. Sylvester J.N. Kimaiyo, Moi Teaching and Referral Hospital (MTRH) Dr. Francis M. Kimani, Director of Medical Services, MOMS

Dr. Maureen Kamene Kimenye, Ministry of Health, NASCOP / PASCOs

Mr. Julius Kimitei

Mr. Michael Kisoo, Chief Clinical Officer, MOMS

Mr. Alex K. Kisyanga, Ministry of Medical Services

Dr. Ndinda Kusu, Clinical Pharmacist, Management Sciences for Health/ Strengthening Pharmaceutical Systems

Dr. William K. Maina, Ministry of Health, Division of Non Communicable Diseases (DNCD)

Dr. Beth Maina, Paediatrician, Embu Level 5 Dr. John Jao Majimbo, Clinical Pharmacist, KPA

Dr. Wekesa Masasabi, Head, MOMS, Dept. of Surgery

Dr. Johnson Masese, Clinical Pharmacist, Provincial General Hospital – Kakamega

Dr. Jane Masiga, Clinical Pharmacist, Medical Equipment & Drug Supplies

Dr. Chris Masila, Programme Pharmacist, MOPHS/Division of Leprosy, Tuberculosis and Lung Diseases (DLTLD)

Dr. Josephine Maundu, Clinical Pharmacist, Management Sciences for Health/ Strengthening Pharmaceutical Systems

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Level 4– 6 Hospitals

Dr. Regina Mbindyo, National Professional Officer, Essential Drugs & Medicines, WHO

Bernard M. Mbogoh, Ministry of Health, Department of Environmental Health Dr. Josphat N. Mbuva, Head, Essential Med Mgt, MOMS/Pharmacy

Dr. Tom Menge, Toxicologist, Kenyatta National Hospital

Dr. Njeri Mucheru, Head Policy Dev & Review, MOMS/Pharmacy

Dr. Simon W. Mueke, MOMS Division of Obstetric and Gynaecology, Dept of Medicine

Dr. Joseph Wahome Mukundi, Pharmacist, Meru District Hospital

Dr. Stephen Muleshe, MOMS Dept of Standards and Regulatory Services

Mr. Stephen M. Muneene, Ministry of Health, Curative & Rehabilitative Health Services

Dr. Assumpta Muriithi, National Professional Officer, Child and Adolescent Health

Prof. Rachel Musoke, University of Nairobi

Mr. James Botela Muthui, Ministry of Medical Services

Dr. Robert Mwangi, Clinical Pharmacist, Provincial General Hospital – Nyeri Dr. Jonah Mwangi, Med Sup – Thika

Dr. Hilda Nderitu, Embu Level 5 - Clinical Pharmacist

Dr. Jacky Ndinda, Clinical Pharmacist, Rift Valley Provincial General Hospital

Mrs. Florence Ng’ang’a, Ministry of Health, Curative & Rehabilitative Health Services

Dr. George Ngatiri, Provincial Medical Officer, Central Province Dr. Bibiana Njue, MOMS – Pharmacy and Poisons Board

Dr. Andrew J. Nyandigisi, Ministry of Public Health and Sanitation, Division of Malaria Control

Dr. Mary A. Ochola, Dentist, Chair, Medicines and Therapeutic Committee, Port Reitz District Hospital

Mr. Alfred J.B. Odhiambo, Chief Clinical Officer, Ministry of Health

Dr. Isaaq Odongo, Head, Internal Medicine, MOMS Department of Medicine Dr. Margaret Oluka, Pharmacologist, UON-School of Pharmacy

Dr. Victor Ombeka, Ministry of Health, Division of Leprosy, Tuberculosis and Lung Diseases (DLTLD)

Dr. Elizabeth Ominde-Ogaja, Department of Pharmacy, Ministry of Medical Services

Dr. Enoch Omonge, Clinical Pharmacologist, Kenya Medical Association Dr. Joab Omondi Osumba, Machakos Level 5

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Dr. Geoffrey Otumu, ENT Surgeon, Chair, Medicines and Therapeutic Committee, Kisii Level 5

Dr. Charles Ouma, Management Sciences for Health/Strengthening Pharmaceutical Systems

Dr. George Owiti, Chair, Medicines and Therapeutic Committee, Moi Teaching and Referral Hospital

Chris Rakuom, Chief Nursing Officer, MOMS

Dr. Nelly Rangara, Head Clinical Pharmacy Services, MOMS/Pharmacy Dr. Gunturu Rivathi, Microbiologist, Aga Khan Hospital

Dr. Hardika Shah, Clinical Pharmacist, Pharmaceutical Society of Kenya Dr. Ahmed Tawakal, Deputy Chief Pharmacist, Mater Hospital

Mary Wachira, Ministry of Health, Nutrition – NASCOP

Dr. Lois Wagana, Internal Medicine, Nyeri Level 5

Dr. Annah Wamae, Ministry of Health, Division of Child Health

Dr. Wandegu, Meru District Hospital

Mrs. Belina Wasike, Ministry of Health

Dr. Herman Weyenga, MOPHS, Division of Leprosy, Tuberculosis and Lung Diseases (DLTLD)

COORDINATORS

Persons responsible for coordinating the elaboration of the guidelines Dr. Francis M. Kimani, Director of Medical Services

Dr. S. Sharif, Director of Public Health and Sanitation

Dr. Humphrey Karamagi, Technical Officer, Health Systems Development, WHO Kenya

Dr. Harrison M. Kiambati, Head, Sector Planning, Ministry of Medical Services

Dr. Elizabeth Ominde-Ogaja, Deputy Pharmacist, Head Appropriate Medicine Use Department of Pharmacy, Ministry of Medical Services

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Foreword

Following the articulation of the 1994 National Health Policy Framework, the Ministry of Health published the National Drug Policy, the Essential Drug List, and Clinical Guidelines and Referral Strategy. All these are important

building blocks of the elaboration of the Kenya Essential Package for Health (KEPH) subsequently mooted in the second National Health Sector Strategic Plan (NHSSP II – 2005–2010). This volume is one of a three-volume set that comprises the latest edition of the Clinical Guidelines.

Intended as neither prescriptive nor restrictive, the guidelines are facilitative, enabling, and foundational. They provide a firm base for the attainment of equity and high standards in health care and the development of rational procurement and use of drugs by all prescribers, dispensers, hospital managers, and patients.

The guidelines are for the use of all clinicians and nurses who have the primary responsibility for diagnosis, management, and referral of outpatients and inpatients. They are also very useful to interns, medical students, clinical officers, pharmacists, and nurses in training – and generally to health professionals working in the clinical setting and especially those in rural health services where it might be the only reference book.

The revision has been widely consultative, incorporating recent advances in disease management and emerging medical challenges of the 21st century. Efforts have been made to include the most recent recommendations of the Ministry of Medical Services (MOMS) and the Ministry of Public Health and Sanitation (MOPHS) with inputs from specialized disease programmes, community health and the World Health Organization (WHO).

On behalf of the Ministry of Medical Services and the Ministry of Public health and Sanitation, many thanks are accorded to WHO, and to all contributors, reviewers, and the editors who have worked so hard to make the third edition of the guidelines a reality. We would like to acknowledge the technical guidance

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provided by WHO in compiling these revised clinical and management guidelines, and the financial support for the process from the EC/ACP/WHO

partnership USAID-MSH/SPS (Management Sciences for Health/Strengthening Pharmaceutical Systems) on meeting the health targets of the Millennium Development Goals (MDGs).

The regular and consistent use of the guidelines by clinicians, nurses and other health proffessionals countrywide can be expected to improve health care in Kenya and encourage the rational use of available drugs and thus contribute albeit in a modest way towards the realization of Vision 2030 of “creating an enabling environment for the provision of sustainable quality health care that is cost effective and accessible to all Kenyans”.

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The clinical guidelines the sector has been utilizing were developed in 2002. Since then, the sector has put in place a strategy to respond to declining trends in health impact observed over the previous decade. This updated

edition of the guidelines represents part of that strategy, in particular by taking cognisance of the changes introduced by the Kenya Essential Package for Health (KEPH), with its emphasis on distinct levels of care – including the community – to be provided to defined cohorts of the human life-cycle. The new edition thus addresses key shortcomings in the previous versions that limited the ability of clinicians to provide a comprehensive package of effective health care.

Specifically, the guidelines have been updated in relation to:

Defining care protocols by level of service delivery, recognizing the fact that the skills and facilities for care differ at the different levels of health care.

Making available a clear, separate volume for management of conditions at the community level, in recognition of the fact that good health is nurtured – or destroyed – primarily at individual and household levels, rather than at the health facilities.

Providing greater elaboration of the identification and preparation for referral of clients in case the presenting condition or state doesn’t allow for management at the level where the client has presented.

Updating management protocols to address current existing conditions and potential threats to the health of Kenyans.

Including a process for monitoring and reviewing the guidelines.

For ease of reference and use, the guidelines are presented in 3 volumes: Volume 1: Management Guidelines for Level 1 (Community)

Volume 2: Management Guidelines for Levels 2 and 3 (Primary Care)

Volume 3: Management Guidelines for Levels 4–6 (Hospitals)

It is the hope of the sector that these guidelines will serve the users well as a

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guide for the appropriate care expected to be delivered at each respective level in the health system, thus facilitating the realization of the Kenya Essential Package for Health at all levels. Any information that could be of use in improving the management protocols is welcome, and can be provided directly to the Office of the Director of Medical Services in the Ministry of Medical Services.

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Kenya’s health sector aims to prevent ill health, and where this cannot be done, to address the medical and social implications of the resulting ill health. Clinical management relates to this by ensuring efficient and

effective management of the implications of ill health. It complements the public health services by ensuring that a specified quality of essential medical care is made available as needed, when needed, and in appropriate amounts.

Rationale for Revision of Clinical Guidelines

The sector last issued revised clinical guidelines in 2002. The guidelines defined management approaches for the key conditions that were expected to be afflicting the Kenyan population at that time. The guidelines had a number of weaknesses, however, including the following:

The health sector lacked a clear, comprehensive, evidence-based approach to service delivery. Such an approach is important as it provides the overall guidance for the services the sector intends to provide, plus the process for delivering the services.

The mechanism for monitoring and updating the clinical guidelines was not clear. As a result, the new management protocols that have come up since the guidelines were developed have not been incorporated, such as for avian influenza, management of multi-drug resistant tuberculosis (MDR/XDR TB), use of artemesinin combination treatment (ACT) for management of malaria, use of anti-retroviral drugs (ARVs) in HIV management, non-communicable diseases, and injuries/violence management, among others.

Guidelines for preparation and management of clients for physical referral were not included.

Besides these more or less innate shortcomings, the clinical guidelines predated the approach to service delivery grounded in the framework of 6 life-cycle cohorts and 6 levels of care, as set out in the second National Health Sector

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Strategic Plan ((NHSSP II – 2005–2010).1 Thus they did not take into consideration the new approach that calls for different capacities and different functions at the different service levels in the country. Significantly, there was no guidance on management of services at the community level, and the lack of a referral framework is a drawback that has become more apparent as the care level approach has become institutionalized. These updated guidelines attempt to address these shortcomings. In addition, they are aligned to the comprehensive multilevel service delivery approach defined by the Essential Package for Health (KEPH).2

Comprehensive Service Delivery Approach

The review of the 1st National Health Sector Strategic Plan (NHSSP I) in 2004 highlighted, amongst other issues, evidence of stagnating or downward trends in health indicators, especially in the key areas of maternal, newborn, and child health. To respond to this worrying trend, the health sector in Kenya initiated an accelerated reform process to halt, and then reverse, this trend.

The reform process is enshrined in NHSSP II, which states the midterm goal of the health sector as “To reduce health inequalities and reverse the downward trends in health-related outcome and impact indicators”. The plan’s defined strategic objectives are to:

Increase equitable access to health services;

Improve the quality and the responsiveness of services in the sector; Improve the efficiency and effectiveness of service delivery; Foster partnerships in improving health and delivering services; and Improve financing of the health sector.

As part of the reform process, the sector elaborated clear operational approach- es to enable it to achieve its strategic objectives, as well as health service norms and standards.3 Investment plans now guide multi-year investment priorities for different key areas of the sector. 4 The comprehensive service delivery approach is one of these operational approaches (refer to Figure A).

A comprehensive service delivery approach is based on provision of guidance – at community, dispensary/health centre, and hospital levels of care – on services to be provided, service standards to be attained, service inputs (human resource,

1Ministry of Health, Reversing the Trends – The Second National Health Sector Strategic Plan of Kenya: NHSSP II – 2005–2010, Nairobi, Kenya, 2005.

2Ministry of Health, Reversing the Trends: The Second National Health Sector Strategic Plan of Kenya – The Kenya Essential Package for Health, Nairobi, Kenya, 2007.

3Ministry of Health, Reversing the Trends: The Second National Health Sector Strategic Plan – Norms and Standards for Health Service Delivery in Kenya, Nairobi, Kenya, 2006.

4Ministry of Medical Services Strategic Plan 2008–2012, Ministry of Medical Services, Nairobi, Kenya, July 2008; Ministry of Public Health and Sanitation Strategic Plan 2008–2012, Ministry of Public Health and Sanitation, Nairobi, Kenya, December 2008.

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infrastructure, equipment) to be applied, and cross linkages of services. This comprehensive approach guides not only the investment priorities for service delivery at the administrative level, but also the form and content of clinical management.

The services to be provided for each level of care are defined in the Kenya KEPH). A particular focus of the package is the community level.5 The service linkages are defined in the Sector’s Referral Strategy. These documents together describe the overall strategic approach for the sector, and are further elaborated.

The Kenya Essential Package for Health

KEPH is a life-cohort based approach to the delivery of health care services. Its main focus is to define the priority services that will ensure a healthy population at 6 distinct levels of the health system – from the community level up to tertiary

5Ministry of Health, Taking the Kenya Essential Package for Health to the Community: A Strategy for the Delivery of Level One Services, Nairobi, Kenya, 2006.

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Figure B: The KEPH system

hospitals – for each of 6 defined life cohorts. As a result, it defines in a comprehensive manner, the services the sector is to prioritize so as to maintain health at all the different stages of life.

The diagram in Figure B illustrates the 6 life-cycle cohorts defined by KEPH: pregnancy and the newborn (up to 2 weeks); early childhood (to 5 years); late childhood (6–12 years); adolescence and youth (13–24 years); adulthood (25–59 years); and the elderly (60+ years). The diagram also illustrates the linkages of the 6 levels of care that KEPH defines:

Level 1: Community: Village/households/families/individuals

Level 2: Dispensaries/clinics

Level 3: Health centres, maternities, nursing homes

Level 4: Primary hospitals – District and subdistrict hospitals

Level 5: Secondary hospitals – Provincial hospitals

Level 6: Tertiary hospitals – National hospitals

The expected services to be provided are described in Table A. The KEPH has the following key characteristics:

The package puts emphasis on health (rather than disease), on rights (rather than needs), and on community empowerment to exercise their rights.

It identifies and redefines 6 distinct functional levels of care. The community level is recognized as the first level of care where major decisions are made and interventions are done that have an immediate impact. The focus at the community level is on the promotion of family practices that preserve and promote health.

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Cohort 2: Early childhood (0–5 years)

INTRODUCTION

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Table A, continued

system to ensure quality assurance

Cohort 4: Adolescence and youth (13–24 years)

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Its overall thrust is on revitalizing health promotion and preventive care at the first 3 KEPH levels.

It defines health needs at each level of human development – from birth to old age – and identifies comprehensive and cost-effective interventions required at each stage of the human life cycle.

It recognizes the packages of health care services per level of care to be rendered by both public and private health service providers.

KEPH is expected to improve the quality of services at levels 1–4 so that clients have confidence in these levels of care, thus resulting in increased client utilization of the lower level health facilities. KEPH is also expected to improve the networking of providers and facilities at the different levels of the health system thereby ensuring continuity of care for those who need the services provided at the higher levels of the system.

Sector Norms and Standards

Norms and standards defined to guide the provision of KEPH services are a statement of the human resource, infrastructure, equipment, and financing inputs necessary to ensure efficient and effective delivery of health care services to the population in Kenya. Service delivery standards relate to the expectations of each level of care with regard to service delivery and the types of human resources needed to provide these expectations. Service delivery norms define the quantities of these resource inputs needed to efficiently, effectively, and sustainably offer the service delivery package. These norms and standards are defined on the basis of the following principles:

Units of service delivery: The focus is on the function, as opposed to the physical level, as the function may also be provided by a higher level facility.

Equity in access and utilization: All inhabitants of the country and its respective districts have equal right not only to access health services, but also to use them equally for equal need.

Relevance and acceptability: Health care needs to be rooted in the cultural and social reality of the communities and to include user satisfaction in the health care delivery equation.

Continuity of care: Care should be viewed in a continuum, from the start of the illness or the risk episode until its resolution irrespective of the level at which care is sought. This means that a functional referral and counter-referral system should exist to make sure that services are availed.

Integration of care: Every contact is used to ensure that a comprehensive set of defined services is made available.

A comprehensive/holistic approach: Health services need to consider all the dimensions of the persons and their environment, and maintain a permanent interaction and dialogue with clients.

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specialist from each of these areas was in charge of coordinating the internal consultation process in each of these areas. In addition, pharmacy specialists were involved to review and guide the definition of the medicines and medical products included in the management protocols, ensuring that the management protocols are harmonized with the Essential Medicines List.

Four stakeholder consultations were held over the 3 years, to ensure that the management protocols being defined were in line with the overall policy direction from the programme and Ministry levels, and that their implementation is feasible. These involved management and technical specialists in each of the respective areas, from the public and non public sectors.

Description of the Revised Clinical Management Guidelines

In line with the process described above, this new addition of the clinical management guidelines is based on the latest orientation for each condition expected to afflict the population in Kenya. These are both for conditions in existence, plus conditions that are recognized as threats to the population.

Management descriptions are comprehensive, based on the expected capacity at each level of care. Descriptions of each condition are set out in terms of how it presents, physical and laboratory investigations for diagnosis, and the appropriate management, including when referral is to be made.

The referral management includes:

Identifying signs during client management that indicate referral should be considered.

Preparing the client for referral.

Arranging the required logistics for referral at the referring and receiving facility, plus during transport.

Ensuring the receipt and emergency management of the client who has been referred.

Managing the referred client by the referring facility when they return.

For relevance, alignment with the service delivery approach, and ease of use, the guidelines are presented in 3 volumes representing the major levels of care:

Volume I: Clinical Management and Referral Guidelines for Community Care – Corresponding to level 1 of the health care system

Volume II: Clinical Management and Referral Guidelines for Primary Care – Corresponding to levels 2 and 3 of the health care system

Volume II: Clinical Management and Referral Guidelines for Hospital Care – Corresponding to levels 4–6 of the health care system

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Levels 4–6 – Hospitals

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Management

Airway:

Clear airway immediately.

Aspirate vomitus and secretions or remove with fingers or handkerchief.

Ventilation: Inflate lungs with air or oxygen by: Mouth-to-mouth OR

Mouth-to-nose insufflation OR

By bag and mask devices (ensure thoracoabdominal motion).

Circulation:

Cardiac massage: Carry out external cardiac massage (compressions) by applying appropriate pressure over the sternum. One breath should be interposed between every 4 to 5 cardiac compressions.

Defibrillation: Use standard defibrillators delivering 200–360 J and biphasic defibrillators delivering 150–200 J.

Drugs

Intravenous adrenaline 1mg bolus, repeated every 3 to 5 minutes, OR Vassopressin 40 IU by intravenous push, or amiodarone 300mg in 20–30ml normal saline.

Thorough investigation and treatment of the underlying cause should be undertaken.

Admit

Defibrillation:

•Standard defibrillators delivering 200–360 J.

•Biphasic defibrillators delivering 150–200 J.

•Intravenous epinephrine 1mg push, repeated every 3 to 5 minutes, OR vassopressin 40 IU by intravenous push, OR amiodarone 300mg in 20–

30ml normal saline.

Thorough investigation and treatment of the underlying cause should be undertaken.

1.3 Shock

This is circulatory insufficiency and becomes irreversible if not promptly corrected.

1.3.1HYPOVOLAEMIC SHOCK

This is due to loss of intravascular fluid volume. It results from blood and/or fluid loss and is due to decreased circulating blood volume leading to decreased diastolic filling pressure and volumes.

Causes

Haemorrhage

Severe burns:

•Rapid plasma loss from damaged tissues when over 25% BSA is burnt

•Endotoxaemia makes matters worse

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Complications

Pulmonary oedema

Renal failure

Disseminated intravascular coagulopathy (DIC)

Investigations and Diagnosis at Levels 4–6

Hb, WBC, platelets

Urea and electrolytes, creatinine

Blood sugar

Culture and sensitivity (blood and body fluids)

Management – General

Resuscitate with normal saline or dextran 70. Large volumes may be required but watch for heart failure. An CVP line is useful at levels 4 and above. In addition:

Monitor pulse and BP hourly.

Catheterize and monitor urine output hourly – if less than 20ml/hour after adequate fluid replacement then give frusemide 80mg IV STAT.

Give oxygen via face mask. Determine and definitively treat cause.

Management – Pharmacological

Start empirically on:

•Ceftriaxone 1 gm IV once daily OR benzyl penicillin 4 mega units IV every 6 hours and gentamicin 80mg 12 hourly with adequate fluid replacement and close monitoring of urea and electrolytes.

•Metronidazole 500mg IV 8 hourly; hydrocortisone 200mg 8 hourly for 24–48 hours.

•Vasopressor (dobutamine, dopamine and adrenaline) as and where

indicated.

Commence oral medication once the required course of IV antibiotics is completed. Choice of antibiotics depends on the source of infection and culture and sensitivity results.

Commence resuscitation measures immediately the patient is seen.

Refer from level 4 to levels 5 and 6 if complicated, especially if urinary output starts falling, serum urea, creatinine and potassium start rising, or if there is evidence of any other organ failure despite attention to adequate hydration with brisk electrolyte balancing, and antimicrobial administration.

Always anticipate the onset of disseminated intravascular coagulopathy.

1.4 Stings and Bites

1.4.1BEE STING

Bee sting causes sharp pain followed by intense itching. Signs subside within a few hours. In hypersensitive individuals, anaphylaxis may occur (see Section 1.1, anaphylaxis). Some patients may experience delayed reactions usually after 0–14 days.

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Post exposure prophylaxis:

•Passive immunization: Human rabies immunoglobulin is given as a dose of 20 IU/kg of body weight infiltrated around the wound and 20 IU/kg given IM in gluteal region followed by a course of rabies vaccine.

•Intradermal schedule: 1 dose (0.1ml) should be given at each of two sites, either the forearm or the upper arm, on days 0, 3, and 7 and one dose at one site on days 30 and 90.

•Intramuscular schedule: 1 dose (1ml) should be administered on days 0, 3, 7, 14 and 28. All IM injections should be given into the deltoid region or in small children into the anterolateral area of the thigh muscle.

1.5 Poisoning

Can be acute or chronic. Acute poisoning is often life threatening and should always be treated as an emergency even if the immediate threat to life does not appear real. Refer to Table 5.1 for treatment summary.

Clinical Monitoring

Blood pressure measurement

Urine output (1–2ml/kg/hour) catheterize

Nasogastric suction in abdominal conditions

Blood glucose levels

Hb or PCV daily and correct appropriately

Treat renal complications appropriately, and more importantly treat the cause of the hypovolaemia to pre-empt these complications. Remember to consult in this very dire emergency.

Prevention

Public education about farm or household chemicals known to cause accidental, para-suicidal, or suicidal poisoning.

2.AIDS and Sexually Transmitted Infections

2.1 HIV/AIDS

HIV infection is caused by one of two related retroviruses, HIV-1 and HIV-2, resulting in a wide range of clinical manifestations. Transmission requires contact with body fluids containing infected cells or plasma. The virus progressively destroys the body’s immune functions leading to opportunistic infections and tumours. It is these opportunistic infections and tumours that give the manifestations of this disease.

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