Treatment protocols managment guidelines for major communicable and nc ds
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Transcript of Treatment protocols managment guidelines for major communicable and nc ds
DEHYDRADEHYDRADEHYDRADEHYDRADEHYDRATION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTS(As per revised managementguidelines of GOl)
DEPARTMENT OF HEALTH AND FAMILY WELFAREGOVERNMENT OF KERALA
ASSESSMENT OF SEVERITY OF DEHYDRATION
Two of thefollowing signs Use
Two of thefollowing signs Use
• Lethargy or uncon-scious
• Sunken eyes• Not able to drink or
drink poorly• Skin pinch goes back
very slowly
SEVEREDEHYDRATION
PLANC
• Restless, irritable• Sunken eyes• Drinks eagerly, thirsty• Skin pinch goes back
slowly
Not enough signs to clas-sify as some or severedehyoration
SOMEDEHYDRATION
PLANB
NODEHYDRATION
PLANA
TREATMENT
PLAN A: Prevention of dehydration / Prevention of ongoing losses to prevent dehydration
Show the mother how much ORS to give after each stool and give her enough packets for two days
ORS for prevention of dehydration
Age Amount of ORS to giveafter each loose stool
Amount of ORS to provide foruse at home
Less than 24 months2 years to 10 years10 years or more
50- 100 ml100- 200 ml
As much as wanted
500ml/day1000ml/day2000ml/day
ORS is appropriate for both prevention and treatment of dehydration
Show the mother how to give ORS Show the mother how to mix the ORS• Give a teaspoonful every 1-2 minutes for a child under 2 years. • Give frequent sips from a cup for an older child.
• If the child vomits, wait for 10 minutes. Then give the solution more slowly (a spoonful every 2-3 minutes).• If diarrhoea continues after the ORS packets are used up, tell the mother to give other fluids or return for more
ORS. • The mother should be asked to continue feeding the child with diarrhoea
PLAN B: Patient with Physical signs of Dehydration
Guideline for deficit replacement/ rehydration therapy
75 ml /kg of ORS in the first 4 hours (patient’s age to be used only when the weight is not known)should be started immediately.
Approximate fluid estimates for deficit replacement are given in page 7
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DEHYDRADEHYDRADEHYDRADEHYDRADEHYDRATION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTSTION MANAGEMNT - KEY POINTS(As per revised managementguidelines of GOl)
DEPARTMENT OF HEALTH AND FAMILY WELFAREGOVERNMENT OF KERALA
Guideline for treating patient with some (but not severe) dehydration when body weight is not known
Approximate amount of ORS solution to be given in the first 4 hours*
Approx local measure (glass)
Age Upto 4 mths
4 mths to12 mths
12 mths to2 yrs
2 yrs to5 yrs
5 yrs to14 yrs
More than 14 yrs
Approx wt in kg
ORS in ml
<6 6-10 10-12 12-19 20-30 >30
200-400
1-2
400-700 700-900 900-1400 1500-2200 2200-4000
2-3 3-4 4-6 6-11 12-20• More ORS should be offered if the child wants it • 100-200 ml clean water should be given during this period forinfants upto 6 months who are not breast fed. • Breast feeding should be encouraged and continued whenever the
child wants • If the child vomits, wait for 10 minutes, then continue, but more slowly
Guidelines for maintaining fluid therapy
How much ORS to give for replacement ofongoing stool losses to maintain hydration
Age After each liquid stool,offer
Less than or equal to6 months Quarter glass (50 ml)
7 months to less than 2 years
Quarter to half glass(50-100ml)
2 years - 10 years Half to one glass(100-200ml)
Other children and adults As much as desiredPlan C: Children with severe dehydration should be
given rapid intravenous rehydrationIV fluids should be started immediately. While the drip isbeing set up, ORS solution should be given if the child candrink.The best IV fluid solution is Ringer’s Lactate solution. IfRinger’s Lactate is not available, normal saline solution (0.9%NaCI) can be used. Dextrose on its own is not effective.
100mllkg ofthe chosen solution should bedivided as follows:First give30ml/kg in
Then give70ml/kg in
<12 months 1 hour * 5 hoursOlder children ½ hour * 2 ½ hours
ZINC IN DIARRHOEA MANAGEMENT
Zn as an adjunct to ORT indiarrhoea management in children.
2 months to 6 months 10 mg/day x 14 days
Children 6 monthsand above 20 mg/day x 14 days
Suspect CHOLERA in all cases ofsevere dehydration in adults.
Send Stool samples for ‘Hanging Drop’ todistrict lab and for vibrio to Medical College.
Repeat again if the radial pulse is still very weakor not detectable
All children should be started on ORS solution (about 5ml/kg/h) when they can drink without difficulty during thetime they are getting IV fluids (usually within 3-4 hoursfor infants or 1-2 hour for older children.)
If one is unable to give IV fluids, rehydration with ORSusing naso gastric tube at 20ml/kg/h should be startedimmdiately. The child should be reasssessed every 1-2hours; if there is repeated vomitting or abdominal disten-sion, the fluids should be given more slowly. If there is noimprovement in hydration after 3 hours, IV fluids shouldbe started as early as possible.
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MALARIA TREATMENT ALGORITHM
Suspected Malaria Case
Do Blood Smear Microscopy/Blood test with Bivalent RDT
RDT / Microscopy+ve for P. vivax
Treat with CQ 25mg/kgbody wight divided
over 3 days + PQ 0.25mg/kg body weight
daily for 14 days
Note: PQ is contra indicated in pregnancy, in children under 1 year and individuals with G6PD Deficiency.
RDT / Microscopy+ve for P falciparum
Northe East- Treat with agespecific ACT- AL for 3 days +PQ 0.75 mg / kg body weightsingle doze on the second day
Other States- use ACT-SPinstead of ACT-AL
(Use SP on day 1 only)
RDT/ Microscopy+ve for Mixed Infection
North East- Treat withage spacific ACT- AL for3days + PQ 0.25 mg/
kg body weight daily for14 days
Other States- Use ACT-SP instead of ACT-AL
RDT Negative
However, if malaria issuspected,cross check
microscopy.If microscopy also
negative, no antimalariatreatment. Treat as per
clinical diagnosis
DEPARTMENT OFHEALTH AND FAMILY WELFARE
GOVERNMENT OF KERALA
Age Specific Dosage Chart for Malaria Plasmodium vivax Malaria (Common for all States)
Age Day 1 Day2 Day3 Day 4-14
CQ PQ CQ PQ CQ PQ PQ
150mgbase*
2.5 mg 150mgbase*
2.5 mg 150mgbase*
2.5 mg 2.5 mg
Less than 1 yr
1-4 yrs
5-8 yrs
9-14 yrs
15 yrs & more
Pregnancy
0
1
2
4
6
0
½
1
2
3
4
4
½
1
2
3
4
4
0
1
2
4
6
0
¼
½
1
1½
2
2
0
1
2
4
6
0
0
1
2
4
6
0
9
* 250 mg chloroquine phosphate tab = 150 mg chloroquine base
Mixed (vivax & falciparum) Malaria (From North Eastern States)Age Day 1 Day 2 Day 3
ACT - AL(Artemether +Lumefantrine)
(20mg + 120mg)
ACT - AL(Artemether +Lumefantrine)
(20mg + 120mg)
PQ *(2.5mg)
(Extra to ACT-AL Kit))
ACT - AL(Artemether +Lumefantrine)
(20mg + 120mg)
PQ*(2.5mg)
(Extra to ACT-AL Kit))
5m-2 Yrs (5-14kg)(Yellow blister)
1 Tablet twice daily(1 - 0 - 1)
1 Tablet twice daily(1 - 0 - 1)
5m - < 1yr : 0>1yr - < 2 yr : 1
1 Tablettwice daily(1 - 0 - 1)
5m - < 1yr : 0>1yr - < 2 yr : 1
3-8 Yrs (15-24kg) 2 Tablet twice daily(2 - 0 - 2)
2 Tablet twice daily(2 - 0 - 2)
>2yr - < 5 yr : 1>5yr -< 9 yr : 2
2 Tablet twice daily(2 - 0 - 2)
>2yr - < 5 yr : 1>5yr -< 9 yr : 2
9-14 Yrs(25-35kg)
3 Tablet twice daily(3 - 0 - 3)
3 Tablet twice daily(3 - 0 - 3) 4 43 Tablet twice daily
(3 - 0 - 3)
15 yrs and more(More than 35 kg)
4 Tablet twice daily(4 - 0 - 4)
4 Tablet twice daily(4 - 0 - 4) 6
4 Tablet twice daily(4 - 0 - 4) 6
PQ* : O.25 mg per kg body weight daily for 14 days
ACT -AL : Not recommended during the 1st trimester of pregnancy and for children weighing < 5 kg
Mixed (vivax & falciparum) Malaria (from States other than NE)Age Day 1 Day 2 Day 3
PQ* : O.25 mg per kg body weight daily for 14 days
PQ*(2.5mg)
(Extra to ACT-SP Kit))
Day 4 to 15
AS SP AS ASPQ*
(2.5mg)(Extra to ACT-SP Kit))
PQ*(2.5mg)
(Extra to ACT-SP Kit))Less than 1 year
(Pink blister)1
( 25mg) 1 (250+12.5mg)1
( 25mg) 01
( 25mg) 0 0
1-4 yrs(Yellow Blister)
1 (50mg)
1(500+25mg)
1 (50mg) 1
1 (50mg) 1 1
5-8 yrs(Green Blister)
1 (100 mg) 1 (750+37.5mg)
1 (100 mg)
2 1 (100 mg)
2 2
9-14 yrs(Red Blister)
1 (150mg)
2 (500+25mg)
1 (150mg) 4
1 (150mg) 4 4
15 yrs and more(White Blister)
1 (200mg)
2 (750+37.5mg)or
3 (500+25mg)
1 (200mg)
6 1 (200mg)
6 6
Plasmodium falciparum Malaria (From North Eastern States)Age Day 1 Day 2 Day 3
PQ* : 0.75mg per kg body weight on day 2
ACT - AL(Artemether + Lumefantrine)
(20mg + 120mg)
ACT - AL(Artemether + Lumefantrine)
(20mg + 120mg)
PQ*(7.5mg)
(Extra to ACT-AL Kit))
ACT - AL(Artemether + Lumefantrine)
(20mg + 120mg)
5m-2 Yrs (5-14kg)(Yellow blister)
1 Tablettwice daily(1 - 0 - 1)
1 Tablettwice daily(1 - 0 - 1)
5m - < 1yr : 0>1yr - < 2 yr : 1
1 Tablettwice daily(1 - 0 - 1)
3-8 Yrs (15-24kg)2 Tablet twice daily
(2 - 0 - 2)2 Tablet twice daily
(2 - 0 - 2)2 2 Tablet twice daily
(2 - 0 - 2)9-14 Yrs
(25-35kg)3 Tablet twice daily
(3 - 0 - 3)3 Tablet twice daily
(3 - 0 - 3)4 3 Tablet twice daily
(3 - 0 - 3)15 yrs and
more (More than35 kg
4 Tablet twice daily(4 - 0 - 4)
4 Tablet twice daily(4 - 0 - 4) 6
4 Tablet twice daily(4 - 0 - 4)
ACT -AL : Not recommended during the 1st trimester of pregnancy and for children weighing < 5 kg
Plasmodium falciparum Malaria (from States other than NE)Age Day 1 Day 2 Day 3
AS SP AS
PQ*(7.5mg)
(Extra to ACT-SP Kit)Less than 1 year
(Pink blister)1
( 25mg) 1 (250+12.5mg) 1(25mg) 0
AS
1( 25mg)
1-4 yrs(Yellow Blister)
1( 50mg) 1 (500+25mg) 1
(50mg) 1 1( 50mg)
5-8 yrs(Green Blister)
1( 100mg) 1 (750+37.5mg) 1
(100mg)
4
1( 100mg)
9-14 yrs(Red Blister)
1( 150mg) 2 (500+25mg) 1
(150mg)
2
1( 150mg)
15 yrs and more(White Blister)
1( 200mg)
2 (750+37.5mg)or
3 (500+25mg)
1(200mg) 6 1
( 200mg)
PQ* : 0.75mg per kg body weight on day 2
10
PQ*(2.5mg)
(Extra to ACT-AL Kit))
5m - < 1yr : 0>1yr - < 2 yr : 1
>2yr - < 5 yr : 1>5yr -< 9 yr : 2
4
6
Day 4-15
VIRAL HEPATITIS- MANAGEMENT GUIDELINECase Definition
Patient with Sudden onset of fever with mlaise, anorexia, vomiting, ab-dominal discomfort following jaun-dice within few days occurrence ofsimilar cases from a locality in-creases the suspision of feco orallytransmitted infection. History ofhigh risk sexual behaviour or con-tact with blood or blood productsindicates parentally translitted infec-tion
Patient with history of symptoms of the sus-pected case, along with the laboratory find-ings suggestive of altered liver function:a) altered serum bilirubin: Normal
level<1mg/dljaundice usually becomes aparant at lev-els over >2mg/dl
b) Elevated amino transferace:i) Aspartate amino transferace (AST)-
Normal level for adults 10-35 U/Litii) Alanine amino transferace (ALT) nor-
mal level for adults- 10- 45U/lit
Probable caseSupect Case Confirmed case
A patient with hystory, symp-toms, and laboratory findingsof the suspected case alongwith serologic evidenceagainst specific hepatitis vi-ruses or detection of viralparticiles.
Specific DiagnosisTypes of Healtitis Specific tests for confirmatory case
Hepatis A IgM (Anti- HAV)Hepatis B
specific Antigen HBsAg (surface Antigen), HBcAg (Core Antigen), HBeAgspecific Antibody IgM (Anti- HBc)
Hepatis C Anti- HCV/ HCV RNA in serumHepatis D Anti- HDV/ HDV RNA in serumHepatis E Anti- HEV/ HEV RNA in serum
Level clinical Features Investigations Management Referral criteria
Primary care facility-PHC/ CHC/ singledoctor/ few doctorclinic
Spcialty Hospitals-THQH/FRU/ MajorHospitals
Ter tiary Carecentres- MCH/Majorprivate Hospitals
Sudden onset of fever withmlaise, anorexia, vomiting,abdominal discomfor tfollowing jaundice withinfew days
Signs of hepaticencephalopathy, deepjaundice, intractablevomiting posing risk ofdehydration
In advanced stage of illness,or with complications;hepatitis already confirmed;
BRE, SerumBilirubin, LFT
SerumBilirubin, LFT,HBsAg
LFT, Specificdiagnosis (SeeTable 2), Liverbiopsy
Bed rest till jaundice is completely resolved;most drugs are to be avoided during acutehepatitis but antipyretics and anti emiticsmay be used till patient is symptomaticwith: paracetamol 10-15mg/kg for childrenand 0.5-1g X three time a day,metachlopromide, 0.2 mg/kg for children,10mg for adults 3-4 times per day
Essentially supportive; IV Fluids,
Constant close monitoring of liver functionparameters; ICU care with absolute bed rest,low protein diet, enemas to cleanse bowel,oral neomycin, all sedatives contra indicated, watchfor GI bleeding, monitor level of coma
Signs of hepaticencepha lopa thy,deep jaundice,pregnancy in thirdtrimester, intractablevomiting posing riskof dehydration
In case of no sign ofimprovement in 2-3days
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Cardinals signs
1. Anesthetic Patch,2. Thickened Peripheral Nerve,3. Smear Positive
Diagnostic Criteria
Symptoms Paucibacillary (PB) Multi Bacillary (MB)
Anesthetic Patch 1 - 5 numbers Above 5 numbers
Thickness and Tenderness No or only one nerve involved More than one nerve involved
Smear Examination Negative in all patches Positive in anyone or more patch/ nerve
* Positive for any one of the three criteria for MB will be treated as MB
Treatment Protocol
Age Paucibacillary (PB)(duration- 6 months)
Multi Bacillary (MB)(duration 12 months)
Rifampicin Dapsone Rifampicin Dapsone Clofazimine
more than14 years
10-14 years
Less than 10 years
600 mg 100 mg 600 mg 100 mg 300mg - once in a month50mg daily
450 mg 50 mg 450 mg 50 mg 150mg - once in a month50mg alternate days
300 mg 25 mg 300 mg 25 mg 100mg - once in a month50mg twice a week
DEPARTMENT OFHEALTH AND FAMILY WELFARE
GOVERNMENT OF KERALA
LEPROSY- TREATMENTGUIDELINE
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TUBERCULOSIS (RNTCP) TREATMENT REGIMEN
Cat I: This category is generally prescribed to new sputum smear positive cases.
Cat II: This category is generally prescribed to patients who have previous anti tuberculartreatment.
Paediatric TB: This category is for treating children who are infected with mycobacteriumtuberculosis.
Cat IV/MDR TB: This category is for treating patients who are infected with specific form ofdrug resistant mycobacterium tuberculosis.
Category of treatment Type of Patient Regimen
Category INew sputum smear-positive sputumsmear-negative extra-pulmonary
2(HRZE)3+4(HR)3
Category II
Sputum smear-positive relapseSputum smear-positive failure Sputumsmear-positive treat-ment after defaultothers. EP.Pul –neg.
2(HRZES)3+1(HRZE)35(HRE)3
Medication Dose(thrice a week) Number of pills in combipack
Isoniazid 600 mg (300x2)
Rifampicin 450 mg (450x1)
Pyrazinamide 1500 mg (750x2)
Ethambutol 1200 mg (600x2)
Streptomycin 0.75 g
Treatment Regimens
Information of the dosage is shown on the chart given bellow.
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In Paediatric case the regimen is same but dosage is adjusted according to the weight of patient.
Pediatric regimen
Suggested paediatric dosage for intermittent therapyDrugs Dosage(Thrice a week)
Isoniazid 10-15 mg/kgRifampicin 10mg/kgPyrazinamide 30-35 mg/kgEthambutol 30 mg/kgStreptomycin 15 mg/kg
Regimen for MDR –TBThis regime comprises of 6 drugs- Kanamycin, Levofloxacin, Ethionamide, Pyrazinamide, Ethambutol and Cycloserineduring 6-9 months of intensive phase and 4 drugs Levoflox,Ethionamide,Ethambutol and cycloserine during the 18months of the continuation phase.Pyridoxin should be administered to all patients on regime for MDR TB.
Regimen for MDR TB drugs and band recommendationsSL No Drugs 16-25 Kgs 26-45 Kgs >45 Kgs
1 Kanamycin 500 mg 500 mg 750 mg2 Levofloxacin 250 mg 750 mg 1000 mg3 Ethionamide 375 mg 500 mg 750 mg4 Ethamvuton 400 mg 800 mg 1200 mg5 Pyrazinamide 500 mg 1250 mg 1500 mg6 Cycloserane 250 mg 500 mg 750 mg7 Pyridoxine 50 mg 100 mg 100 mg
Na-PAS(80% weight/volume)2 5 gm 10 gm 10 gmMoxifloxacin 400mg 400mg 400mgCapreomycin 500mg 750mg 1000mg
Drug Daily Dosage-mg/kg body wtkanamycin 15-30Levofloxacin 7.5-10Ethionamide 15-20Cycloserane 15-20Ethamvuton 25Pyrazinamide 30-40Na-PAS 150
Drug regimen for MDR Paediatric age group less than 16 kg
For more details and latest updates please visit the web site www.tbcindia.nic.in
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TREATMENT PROTOCOL FOR DIABETES MELLITUS
• Assess habits - Tobacco use, Alcohol use, Diet and Exercise• Check height, weight and calculate BMI• Check BP and RBS
If RBS < 200 mg%
Reassess when develops diabeticsymptoms or every 2 years
If RBS > 200 mg% check FBS and PPBS
If FBS < 126 mg% and PPBS <200 mg% Advise LSM
If FBS> 126 mg% and orPPBS > 200 mg%
Advise LSM and refer to MO
If BMI < 23 & no highrisk behaviour reassess
every 6 months
If BMI >23 or have highrisk behaviour reassess
every 3 months
Tab Metformin 500 mg OD or BIDReassess monthly and may increase upto 2000 mg per day in 2 divided doses
Monitor abnormal value monthly
If no complication recheck after one month If complications1. Foot ulcer2. Nephropathy3. Retinopathy4. Neuropathy5. Sepsis
If undercontrolcontinue andreassess every3 months
If not under control addone second drug1. Glibenclamide 2.5 mg to 10 mg2. Glypizide 2.5 mg to 5 mg BID3. Glimepride 1 mg to 4 mg Refer to Physician
If not under control refer toHospital/Physician to start Insulin
If under control continueand reassess 3 months
State NCD DivisionGovernment of Kerala
LSMLife Style Modification
• Restrict sugar and sweets• Restrict fatty and fried
foods• Increase fibre rich food
(leafy vegetables)• Substitute as much starch
(rice, wheat, tubers) withvegetables
• Brisk walking for 20 - 30min• 5 to 6 days a week• 5 minutes warm up• 5 minutes cool down
• Avoid tobacco &alcohol use
BMI
18.5-22.9: Normal23.0-24.9: Overweight
>25.0: Obese
Screen all individuals of age above 30 years
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