Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Pharmaceutical Affairs

National Standard Treatment Guidelines for the Primary Level

may 2013 Contents Foreword...... ix Introduction...... xi Acknowledgments ...... xiii How to Use This Guideline ...... xix Acronyms and Abbreviations...... xxii Glossary...... xxv Chapter 1. Dental and Oral Conditions...... 41 Chapter 2. Digestive System Conditions...... 46 2.1. Diarrhea and Dehydration...... 46 2.1.1. Acute Diarrhea, without Blood, in Children Younger Than 5 Years...... 46 2.1.2. Acute Diarrhea, without Blood, in Children Older Than 5 Years and in Adults...... 53 2.1.3. Persistent Diarrhea, without Blood, in Children Younger Than 5 Years...... 54 2.1.4. Persistent Diarrhea in Children Older Than 5 Years and in Adults...... 56 2.1.5. Dysentery...... 56

Copyright ©2013 Ministry of Public Health, 2.1.5.1. Dysentery, Bacillary...... 56 General Directorate of Pharmaceutical Affairs 2.1.5.2. Dysentery, Amebic...... 58 2.1.6. Giardiasis...... 59 This publication is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID), 2.1.7. Cholera...... 60 under the terms of cooperative agreement number 306-A-00-11-00532-00. 2.2. Peptic Ulcer Disease...... 62 The contents are the responsibility of Ministry of Public Health of the Islamic Chapter 3. Respiratory System Conditions...... 65 Republic of Afghanistan with the technical support of Management Sciences for Health and the World Health Organization Eastern Mediterranean 3.1. Asthma...... 65 Regional Office and do not reflect necessarily the views of USAID or the 3.1.1. Asthma in Children...... 65 United States Government. 3.1.2. Asthma in Adults...... 68 About SPS 3.2. Common Cold and Flu...... 71 The Strengthening Pharmaceutical Systems (SPS) Program strives to build 3.3. Pneumonia in Children and Adults...... 73 capacity within developing countries to effectively manage all aspects of 3.3.1. Pneumonia in Children Younger Than 5 Years . . 74 pharmaceutical systems and services. SPS focuses on improving governance in the pharmaceutical sector, strengthening pharmaceutical management 3.3.2. Pneumonia in Children Older Than 5 Years systems and financing mechanisms, containing antimicrobial resistance, and and in Adults...... 78 enhancing access to the most efficacious, safe and cost-effective medicines 3.4. Chronic Obstructive Pulmonary Disease...... 81 and appropriate use of medicines.

National Standard Treatment Guidelines for the Primary Level iii Contents Contents

Chapter 4. Ear, Nose, and Throat Conditions...... 84 9.5. Abortion (Vaginal Bleeding in Early Pregnancy). . 156 4.1. Otitis Externa...... 84 9.6. Ectopic Pregnancy...... 163 4.2. Acute Otitis Media...... 87 9.7. Preterm Labor...... 164 4.2.1. Acute Otitis Media in Children Younger 9.8. Delivery and Postpartum Care...... 166 Than 5 Years ...... 88 9.9. Postpartum Hemorrhage ...... 172 4.2.2. Acute Otitis Media in Children Older Than 5 Years 9.10. Newborn Care ...... 176 and in Adults...... 90 9.11. Cracked Nipples during Breastfeeding...... 184 4.3. Chronic Otitis Media...... 91 9.12. Mastitis and Breast Abscess...... 187 4.4. Acute Sinusitis...... 92 9.12.1. Mastitis...... 187 4.5. Sore Throat...... 94 9.12.2. Breast Abscess ...... 188 4.5.1. Viral Pharyngitis...... 94 9.13. Dysmenorrhea...... 189 4.5.2. Bacterial Tonsillitis ...... 96 9.14. Abnormal Vaginal Bleeding...... 191 4.6. Rhinitis ...... 98 9.15. Postmenopausal Bleeding ...... 193 Chapter 5. Eye Conditions...... 100 9.16. Pelvic Inflammatory Disease...... 195 5.1. Conjunctivitis (Red Eye)...... 100 9.17. Infertility...... 198 5.2. Trachoma...... 103 Chapter 10. Nutritional and Blood Conditions. . . . .201 5.3. Glaucoma ...... 105 10.1. Anemia...... 201 Chapter 6. Cardiovascular System Conditions. . . . .107 10.2. Thalassemia...... 207 6.1. Systemic Hypertension...... 107 10.3. Malnutrition and Under-Nutrition...... 208 6.1.1. Chronic Hypertension...... 107 10.4. Vitamin A Deficiency...... 212 6.1.2. Hypertension Emergency...... 113 10.5. Vitamin D Deficiency and Rickets...... 217 6.2. Cardiac Failure...... 114 10.6. Iodine Deficiency...... 219 6.3. Rheumatic Fever...... 117 Chapter 11. Urinary Tract and Renal Conditions. . . . 220 6.4. Angina Pectoris...... 121 11.1. Urinary Tract Infection...... 220 6.5. Acute Myocardial Infarction...... 123 11.1.1. Acute Pyelonephritis ...... 220 Chapter 7. Central Nervous System Disorders. . . . .126 11.1.2. Cystitis and Urethritis...... 222 7.1. Epilepsy...... 126 11.2. Acute Glomerulonephritis...... 224 7.2. Encephalitis and Meningitis...... 130 Chapter 12. Endocrine System Disorders...... 226 Chapter 8. Mental Health Conditions...... 135 12.1. Diabetes Mellitus...... 226 12.2. Hyperglycemia and Ketoacidosis...... 231 Chapter 9. Obstetrics and Gynecological Conditions. .143 9.1. Pregnancy and Antenatal Care...... 143 Chapter 13. Skin Conditions ...... 234 9.2. Anemia in Pregnancy...... 149 13.1. Impetigo...... 234 9.3. Hypertension Disorders of Pregnancy...... 151 13.2. Fungal Skin Infection and Napkin (Diaper) Rash. 236 9.4. Antepartum Hemorrhage...... 154 13.3. Furunculosis...... 239

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13.4. Sycosis...... 241 16.2.2. Acute Appendicitis...... 330 13.5. Urticaria...... 243 16.2.3. Acute Cholecystitis...... 331 13.6. Pediculosis...... 245 16.2.4. Perforated Peptic Ulcer ...... 332 13.7. Scabies...... 247 16.2.5. Bowel Obstruction ...... 332 Chapter 14. Musculoskeletal Conditions ...... 251 16.2.6. Ruptured Ectopic Gestation ...... 333 14.1. Arthritis and Arthralgia...... 251 16.2.7. Ureteric Colic...... 334 14.2. Osteomyelitis...... 256 16.3. Animal and Human Bites...... 335 16.4. Insect Bites and Stings...... 340 Chapter 15. Infectious Diseases, Parasitic Diseases, and Helminthic Infestations...... 259 16.4.1. Wasp and Bee Stings...... 340 15.1. Pertussis (Whooping Cough)...... 259 16.4.2. Scorpion Stings...... 342 15.2. Diphtheria...... 261 16.4.3. Spider Bites...... 343 15.3. Tetanus ...... 263 16.5. Snake Bites...... 345 15.4. Poliomyelitis...... 267 16.6. Burns...... 348 15.5. Measles ...... 268 16.7. Eye Injuries (Trauma, Foreign Bodies, 15.6. Sepsis...... 272 and Burns)...... 355 15.7. Malaria...... 274 16.8. Hypoglycemia...... 360 15.7.1. First-Line Therapies...... 277 16.9. Shock...... 363 15.7.2. Second-Line Therapies...... 281 16.10. Dislocation...... 373 15.8. Hepatitis...... 284 16.11. Abscess ...... 373 15.9. Typhoid (Enteric) Fever...... 287 16.12. Poisoning...... 377 15.10. Tuberculosis...... 290 Chapter 17. Signs and Symptoms...... 390 15.11. Chickenpox...... 300 17.1. Febrile Convulsion...... 390 15.12. Rabies...... 302 17.2. Cough...... 394 15.13. Leishmaniasis...... 304 17.3. Fever...... 397 15.14. Ascariasis (Roundworm)...... 306 17.4. Headache and Migraine...... 401 15.15. Taenia Saginata and Hymenolepis Nana 17.4.1. Headache ...... 401 (Tapeworm)...... 308 17.4.2. Migraine...... 403 15.16. Anthrax...... 310 17.5. Jaundice...... 404 15.17. Brucellosis...... 311 17.6. Chest Pain...... 407 15.18. Mumps...... 313 17.7. Constipation...... 411 15.19. Sexually Transmitted Infections...... 315 17.8. Nausea and Vomiting...... 413 Chapter 16. Emergencies And Trauma...... 322 Chapter 18. Family Planning for Birth Spacing. . . . .417 16.1. Acute Pulmonary Edema ...... 322 18.1. Preparing to Use a Family Planning Method. . . . 417 16.2. Acute Abdominal Pain...... 323 18.2. Family Planning Options Available 16.2.1. Acute Peritonitis ...... 329 in Afghanistan...... 421 vi National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level vii Contents

18.2.1. Condoms (Male)...... 421 Foreword 18.2.2. Combined Oral Contraceptive Pills...... 422 18.2.3. Progestin-Only Pill...... 425 The Ministry of Public Health (MoPH) of the Islamic 18.2.4. Progestin-Only Injectables ...... 427 Republic of Afghanistan is very pleased to present the first 18.2.5. Intrauterine Device ...... 428 edition of the National Standard Treatment Guidelines 18.2.6. Lactational Amenorrhea Method...... 429 for Primary Level (NSTG-PL) 2013/1391. The NSTG-PL 18.2.7. Fertility Awareness Methods...... 430 reflects the recommended state-of-the-art treatments 18.2.8. Withdrawal Method (Coitus Interruptus). . .432 for the priority health conditions addressed by the Basic 18.2.9. Spermicides...... 433 Package of Health Services (BPHS). The BPHS continues Chapter 19. Immunization...... 435 to serve as the foundation of the Afghan health system and remains the key instrument in making sure that Chapter 20. HIV Infection and AIDS...... 439 the most important and effective health interventions Annexes...... 443 are made accessible to all Afghans. Afghanistan is a Annex A. Medicine Dosages and Regimens...... 443 country with limited resources, and the MoPH believes Annex B. Newborn Resuscitation...... 459 that by continuing to focus on a BPHS, it will be able Annex C. Partograph and Delivery Note...... 461 to concentrate its resources on reducing mortality Annex D. References...... 462 among its most vulnerable citizens, especially women of Annex E. Procedure to Apply for Modification of the reproductive age and children under five years of age. NSTG-PL by the MoPH of Afghanistan...... 466 Indexes...... 473 Providing essential medicines is a cornerstone of the BPHS, and the NSTG-PL will be a key instrument in guiding all health workers at the primary level to use the most efficient treatment for the conditions included in the guidelines, thus promoting the rational use of medicines. Where possible, the NSTG-PL refers to or uses standard treatment protocols previously developed by various MoPH programs. The first edition of the NSTG-PL is the result of the efforts and dedication of many. The MoPH, through the General Directorate of Pharmaceutical Affairs, conducted a medicines use study survey in 2009 and, based on the results, asked experts in the areas of pharmaceutical and clinical practice to form the Standard Treatment Guidelines (STG) Working Group. Based on the past experience of developing the essential drugs list, the

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STG Working Group consulted as widely as possible Introduction with departments in the MoPH, as well as with national and international experts. We would like to take this This national standard treatment guidelines (STGs) opportunity to thank all writers, technical reviewers, manual is designed for use at the first-level (i.e., primary) contributors, and editors who participated in the facilities delivering the Basic Package of Health Services tremendous effort of developing the NSTG-PL. Our special (BPHS). The guidelines can also be used by general appreciation goes to sustained technical and financial practitioners in their private practice. support provided by the Strengthening Pharmaceutical The set of conditions included is not exhaustive, but rather Systems project, funded by the United States Agency for is based on the conditions recommended for management International Development, and to technical support and treatment in the BPHS. Likewise, recommended provided by World Health Organization. pharmaceutical treatments are primarily limited to the This is a dynamic document that will regularly be updated medicines recommended in the BPHS (2010) and the to reflect the state of the art in treatment at the primary essential drug list (2007). level. We, therefore, welcome constructive comments on The elaboration of the manual was a participatory effort the usefulness and the acceptability of this first version, between the STG Working Group and various medical and which will guide us in keeping the guidelines updated with paramedical professionals who volunteered their time and the new developments in health care. expertise. We strongly encourage all health care providers in the The manual was conceived to address, in the most public and the private sectors to use the NSTG-PL, thus practical way possible, the problems faced by clinical staff promoting the access to affordable health care for all in at the first-level facilities. The references used are the Afghanistan. existing MoPH guidelines for specific conditions, WHO references when MoPH guidelines were insufficient, and specialized works when deemed necessary. (See annex D.) Despite all efforts, it is possible that certain errors have been overlooked, or some therapeutic approaches are Dr. Suraya Dalil incomplete, and the authors would be grateful to have any Minister of Public Health such error or incompleteness reported. To this end, an Kabul, Afghanistan example of an STG modification form has been included in annex E. See page xii for where to send changes. Although we hope the manual will be a useful guide to many prescribers, it is important to remember that, when in doubt, it remains the responsibility of the prescribing medical professional to ensure that the active substances and doses prescribed correspond with the therapeutic

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need of the patient and conform to the manufacturer’s Acknowledgments specifications. Please send any identified errors or other comments that may help improve future version of this The firstNational Standard Treatment Guideline for the manual to the following address: Primary Level in Afghanistan is the result of national Ministry of Public Health and international efforts coordinated by the Standard General Directorate of Pharmaceutical Affairs (GDPA) Treatment Guideline (STG) Working Group members STG Working Group from the Ministry of Public Health; Kabul Medical Kabul, Afghanistan University, Faculty of Pharmacy; the Afghanistan Physicians Association, the Strengthening Pharmaceutical An electronic copy of the STG modification form may be Systems (SPS) project funded by United States Agency for sent to the following e-mail addresses: International Development (USAID), the Health Sector E-mail: [email protected] Support Project (HSSP) funded by USAID, and World Phone: 0093 799 303 008 Health Organization. OR The development of these STGs would not have been E-mail: mailto:[email protected] possible without the full support of the Afghan health Phone: 0093 707 369 408 authorities and the many Afghan health professionals The manual is also available on the MoPH website: whose comments enriched this document. The STG www.moph.gov.af/. Users are encouraged to check the Working Group thanks the MoPH; Kabul Medical copy on the website for updates on this edition. University, Faculty of Pharmacy; WHO, the Afghanistan Physicians Association and all the writers, reviewers and contributors who have actively contributed to the production of this National Standard Treatment Guidelines for the Primary Level. Special appreciation Pharmacist Abdul Hafiz “Quraishi” goes to the Strengthening Pharmaceutical Systems (SPS) General Director of Pharmaceutical Affairs project funded by USAID for its technical and financial Ministry of Public Health support throughout the development process of this important guideline. STG Working Group nn Dr. M. Rafi Rahmani, MD, Professor in the Pharmacology Department, Kabul Medical University, Head of the Committee nn Abdul Zahir Siddiqui, Pharmaceutical Services and Field Coordination Program Manager, SPS nn Dr. Abdul Samad Omar, MD, Associate Professor and Surgeon, Aliabad Teaching Hospital

xii National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xiii Acknowledgments Acknowledgments nn Dr. M. Amin Asghari, MD, Clinical Professor and Head de Formation Specialisée Approfondie–Paris (AFSA of the Internal Medicine Ward, Wazir Akbar Khan Paris), Sardar M. Dawood Khan Hospital Hospital (WAKH) nn Dr. Ahmad Shah Wazir, MD, Chief of the Burn Center, nn Dr. Paul Ickx, MD, Senior Principal Technical Advisor, Isteqlal Hospital Center for Health Services (CHS), MSH nn Dr. Malali Alami, MD, Obstetrics/Gynecology Trainer nn Dr. M. Fayaz Safi, MD, Associate Professor, Afghanistan Specialist, Rabia Balkhi Hospital Physicians Association nn Dr. Bashir Ahmad Sarwari, MD, Psychiatrist and nn M. Hasan Frotan, Associate Professor and Lecturer, Director of Mental Health and Substances Abuse Faculty of Pharmacy, Kabul University Department, MoPH nn Haji M. Naimi, Professor and Lecturer, Faculty of nn Dr. Motawali Younusi MD, Integrated Management Pharmacy, Kabul University of Childhood Illness, Child and Adolescent Health nn Dr. Tawfiq Mashaal, MD, Director for Preventive and Department, MoPH Health Care, MoPH nn Dr. Najibullah Tawhidwal, MD, Ear Nose and Throat nn Dr. Ahmad Shah Pardis, MD, National Professional Trainer Specialist, Ibn-e -Sina Emergency Hospital Officer, WHO nn Dr. Sohaila Ziaee, MD, Reproductive Health nn Dr. Safiullah Nadeeb, MD, National Professional Officer, Department, MoPH WHO nn Dr. Nooria Atta, MD, Lecturer, Kabul Medical University nn Dr. Mohammad Alem Asem, MD, General Directorate of nn Dr. Hasibullah Mohammadi, MD, Internal Medicine the Health Care Unit, MoPH Specialist, WAKH nn Dr. Ahmad Shah Noorzada, MD, Training and nn Dr. Hamida Hamid, MD, National Malaria and Performance Manager, HSSP Leishmania Control Program, MoPH Writers nn Dr. Khalilullah Hamdard, MD, Internal Medicine Trainer Specialist, Isteqlal Hospital nn Dr. Katayon Sadat, MD, Obstetrics/Gynecology Specialist, Malalai Hospital nn Dr. Atiqullah Halimi, MD, Children Specialist, Indira Gandhi Child Health Hospital nn Dr. Homa Kabiri, MD, Obstetrics/Gynecology Specialist, Malalai Hospital nn Dr. Mirwais Saleh, MD, PGD, DO, Eye Specialist and Trainer, Eye Teaching Hospital nn Dr. Sultan Najib Dabiry, MD, Assistant Clinical Professor of Dermatology and Trainer Specialist, Ibn-e- nn Dr. Roqia Naser, MD, Expanded Programme on Sina Emergency Hospital Immunization Department, MoPH nn Dr. M. Najib Roshan, MD, Eye Specialist, Noor Eye nn Dr. M. Nazir Sherzai, MD, MS, Assistant Professor of Orthopedic and General Director, Sardar M. Dawood Hospital Khan Hospital nn Dr. Anisa Ezat, MD, Dental Surgeon Specialist, Stomatology Hospital nn Dr. Yaqub Noorzai, MD, MS, PGD, Professor of Urology and General Surgery Specialist, Attestation nn Dr. Ajmal Yadgari, MD, National Tuberculosis Control Program, MoPH

xiv National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xv Acknowledgments Acknowledgments  nn Dr. Assadullah Safi, MD, Neurosurgeon and Trainer, Technical Reviewers of Monographs Ibn-e-Sina Emergency Hospital nn Dr. M. Rafi Rahmani, MD, Professor in the nn Dr. Abdul Wali Wali, MD, Associate Professor of the Pharmacology Department, Kabul Medical University Pediatrics Department, Maiwand Teaching Hospital nn Dr. Abdul Samad Omar, MD, Associate Professor and nn Dr. M. Wali Karimi, MD, Ear Nose and Throat Specialist, Surgeon, Aliabad Teaching Hospital Maiwand Teaching Hospital nn Dr. M. Amin Asghari, MD, Clinical Professor and Head nn Dr. Abdul Hai Wali, MD, Dermatologist of Maiwand of the Internal Medicine Ward, WAKH Teaching Hospital nn Dr. William Holmes, SPS Consultant nn Dr. Samarudin, MD, HIV Department, MoPH nn Dr. Paul Ickx, MD, Senior Principal Technical Advisor, nn Dr. Shaista Koshan, MD, Nutrition Department, MoPH CHS, MSH nn Dr. Ruhullah Zaheer, MD, Clinical Professor, Internal Technical Reviewers of Final Draft (Quick Reviewers) Medicine Specialist, Isteqlal Hospital nn Mohammad. Nowrooz Haqmal, MD, DPH, MBA, District nn Dr. Zabiullah Azizi, MD, Internal Medicine Specialist, Health System Support Project Manager, MoPH Sardar M. Dawood Khan Hospital nn Dr. Hamidullah Habibi, MD, National Consultant to nn Dr. Sultan M. Naji, MD, Surgeon Specialist and Trainer, Provincial Liaison Directorate, MoPH Ibn-e-Sina Chest Hospital nn Dr. M. Yasin Rahimyar, Technical Deputy Director, Care nn Dr. Bismellah Nejrabi, MD, Professor of Orthopedic of Afghan Families Surgery and Lecturer, Kabul Medical University nn Dr. Jawid Omar Senior, Contract Consultant, Grant nn Dr. Gul Aqa Wader, MD, Internal Medicine Specialist Contract Management Unit and Trainer, Ibn-e-Sina Emergency Hospital nn Dr. Laurence Laumonier-Ickx, MD, Senior Principal nn Dr. M. Sadiq Naimi, MD, Internal Medicine Specialist, Technical Advisor, CHS, MSH Antani Hospital nn Yakoub Aden Abdi, MD, PhD, WHO nn Dr. Habibullah Raghbat, MD, Internal Medicine nn Professor, Dr. Ahmad Farid Danish, MD, Pharmacology Specialist, Ibn-e-Sina Chest Hospital Department, Kabul Medical University nn Dr. Seddiq Faizi, MD, Children Specialist, Indira Gandhi Child Health Hospital Contributors nn Mohammad Zafar Omari, SPS nn Dr. Mirwais Norani Safi, MD, Surgeon Specialist, Wazir n Akbar Khan Hospital (WAKH) n Pharmacist Aisha Noorzaee, General Directorate of Pharmaceutical Affairs (GDPA)/Avicenna Pharmacy nn Dr. Abdulhaq Qiam, MD, Internal Medicine Specialist, Diploma in Child Health, Ataturk Hospital Institute (API) nn Assistant Professor Jawid Onib, Faculty of Pharmacy nn Dr. M. Jawid Shahab, MD, Surgeon and Urology Specialist, Jamhoriat Hospital Kabul University nn Mark Morris, SPS nn Dr. Rafiullah Ahmadzai, MD, Children Specialist, Indira n Gandhi Child Health Hospital n Pharmacist Lutfullah Ehsaas, SPS nn Niranjan Konduri, SPS

xvi National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xvii Acknowledgments nn Dr. Nadir Arab, MoPH How to Use This Guideline nn Pharmacist Zakia Aadil, GDPA/API nn Pharmacist Fahima Habib, GDPA/API The National Standard Treatment Guidelines for the nn Dr. Bahram Sadat, Dental Specialist, Stomatology Hospital Primary Level serves as a reference treatment guide for nn Pharmacist Aziza Habib, WHO delivering the Basic Package of Health Services (BPHS) nn Terry Green, SPS in the primary health care facilities in Afghanistan. It is nn Dr. Ibne Amin Khalid, MoPH important that you become familiar with the content and nn Pharmacist Nahid Ayubi, SPS layout of the manual to use standard treatment guidelines nn Dr. Noor Safi, MoPH (STGs) effectively. nn Dr. Habibullah Habib, National Tuberculosis Control The conditions included in these STGs have been selected Program, MoPH among the BPHS and common diseases in Afghanistan nn Dr. Faridullah Omary, National Malaria Program, MoPH seen at the primary health care level facilities from nn Dr. Faiz M. Delawer, National Tuberculosis Control sub–health centers up to the district hospitals. The Program, MoPH medicines recommended for use are all included in the nn Dr. Nasir Orya, SPS essential drugs list for facilities of primary level. The 20 nn Pharmacist Khan Aqa Karim Ghazi, GDPA chapters are presented according to the organ systems nn Dr. William Holmes, SPS of the body; a common format has been adopted for each nn Dr. Khalid Amini, SPS condition: brief description; diagnosis with the common nn Pharmacist Shakila Amarkhil, GDPA/API signs and symptoms of the condition; management that nn Pharmacist Khalilullah Khakzad, GDPA/API includes objectives, nonpharmacologic management, and nn Pharmacist Nazir Haiderzad, GDPA pharmacologic management; prevention; and instructions Editorial Committee: to the patient. The instructions to the patient, especially in nn Dr. Laurence Laumonier-Ickx, MD, Senior Principal chronic conditions, aims at helping health care providers Technical Advisor, CHS, MSH to improve patient compliance and health generally. nn Dr. M. Rafi Rahmani, MD, Professor in the Pharmacology When appropriate, a guideline also makes provision for Department, Kabul Medical University referral of patients to higher level health facilities when nn Dr. Paul Ickx, MD, Senior Principal Technical Advisor, equipment, medicines available, and staff do not permit CHS, MSH proper treatment at the actual level. A distinction is made nn Abdul Zahir Siddiqui, Pharmaceutical Services and Field between the terms refer, which indicates routine referral, Coordination Program Manager, SPS and refer urgently, which designates conditions that Editors of the English Version: require immediate action; for the latter, the patient must be stabilized, and immediate transportation must be nn Laurie B. Hall, Managing Editor, Center for Pharmaceutical Management, MSH arranged. nn Marilyn K. Nelson, writer/editor

xviii National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xix How to Use This Guideline How to Use This Guideline

To find the relevant sections and conditions in the the appropriateness of the recommendations in the STG manual easily, you can use the indexes at the end of the for the individual patient. manual to find a specific condition and medicine name Comments that aim to improve this STG will be alphabetically. A glossary with brief definitions of the appreciated. See annex E for more details. The STG medical terminology used in the manual can be found as modification form must be submitted by mail or e-mail. well following the acronym and abbreviation list. A electronic copy of the form can be obtained from the This STG also contains five annexes: MoPH website, www.moph.gov.af/ nn Annex A lists the most common essential medicines Printed forms may be sent to the following address: used in the STG with their usual dosages for children and adults; the tables allow for easy dose calculation Ministry of Public Health based on per kilogram or age–weight, mode of General Directorate of Pharmaceutical Affairs (GDPA) medicine administration, dose frequency, duration of STG Working Group treatment, pharmaceutical strengths, and instructions Kabul, Afghanistan for preparing the medicine. An electronic copy may be sent to the following e-mail nn Annex B describes the procedure for newborn addresses: resuscitation. E-mail: [email protected] nn Annex C shows the partograph and delivery notes to Phone: 0093 799 303 008 use for deliveries. OR nn Annex D provides the references of MoPH policies E-mail: [email protected] documents, books, and articles used for developing the Phone: 0093 707 369 408 STGs. nn Annex E includes the procedures for requesting a modification to the STG. The STG promotes the rational use of medicines and the quality of health care service delivery at the primary care level. Where relevant, the manual is consistent with the existing case management and treatment protocols of the national programs. It is important to remember that the recommended treatments provided in this guideline are based on the assumption that prescribers are competent to handle patients’ health conditions presented at their facilities. It remains the responsibility of the health worker to evaluate

xx National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxi Acronyms and Abbreviations 

Acronyms and Abbreviations FAM fertility awareness methods FDC fixed-dose combination < less than FP family planning ≤ less than or equal to g/dl grams per deciliter > more than GDPA General Directorate of Pharmaceutical ≥ more than or equal to Affairs ACE angiotensin-converting enzyme H isoniazid AGN acute glomerulonephritis Hib Haemophilus influenzae type b vaccine AIDS acquired immunodeficiency syndrome HIV human immunodeficiency virus AMI acute myocardial infarction HPV human papilloma virus ANC antenatal care HSSP Health Sector Support Project APH antepartum hemorrhage HTN hypertension BCG bacillus Calmette-Guérin (TB vaccine) IM intramuscular BP blood pressure IMCI Integrated Management of Childhood BPHS Basic Package of Health Services Illness C Celsius IV intravenous CHC comprehensive health center IU international units CHS Center for Health Services IUD intrauterine device CNS central nervous system kg kilogram COC combined oral contraception LAM lactational amenorrhea method COPD chronic obstructive pulmonary disease mg milligram DH district hospital ml milliliter DMPA medroxyprogesterone acetate mmHg millimeters of mercury DPT diphtheria-pertussis-tetanus MoPH Ministry of Public Health DOTS internationally recommended strategy for MSH Management Sciences for Health tuberculosis control NaCl sodium chloride (table salt) E ethambutol NSAID nonsteroidal anti-inflammatory drug ECG electrocardiogram NSTG-PL national standard treatment guidelines for EDL essential drugs list the primary level EPHS Essential Package of Health Services OPV oral polio vaccine EPI Expanded Programme on Immunization ORS oral rehydration solution/salts [WHO]

xxii National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxiii  Acronyms and Abbreviations

PF Plasmodium falciparum Glossary PID pelvic inflammatory disease abruptio placentae a complication of pregnancy; PMB postmenopausal bleeding detachment of a normally located POP progesterone-only pills placenta before delivery of the fetus PPH postpartum hemorrhage acute cholecystitis a sudden inflammation of the PPHO provincial public health office gallbladder that causes severe PUD peptic ulcer disease abdominal pain PV Plasmodium vivax adnexa ovaries and fallopian tubes R rifampicin anaphylaxis a life-threatening allergic reaction RBC red blood cell/count angina pectoris chest pain due to one or more heart’s S streptomycin arteries being narrowed or blocked; SPS Strengthening Pharmaceutical Systems also called ischemia STG standard treatment guideline anicteric without jaundice STI sexually transmitted infection anorexia loss of appetite TB tuberculosis antenatal occurring before birth TT tetanus toxoid anterior chamber a fluid-filled space on the inside of UK United Kingdom the eye; the cornea lies in front of the anterior chamber, and the iris and USAID United States Agency for International the pupil are behind it Development apnea a potentially life-threatening WAKH Wazir Akbar Khan Hospital condition of breathing cessation WHO World Health Organization appendicitis inflammation of appendix, a small Z pyrazinamide tube-like organ attached to the beginning of the large intestine arrhythmia a problem with the rate and rhythm of heartbeat arthralgia joint pain arthritis inflammation and eventual destruction of the joint ascites accumulation of protein-containing (i.e., ascitic) fluid in the abdomen

xxiv National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxv Glossary Glossary birth spacing delaying first pregnancy until after convulsion a rapid and uncontrollable the age of 18 and ensuring an interval contraction of the voluntary of at least 36 months between muscles, it can be one manifestation pregnancies of seizures; see seizure booster dose a dose of an active immunizing corneal ulcer an open sore on the cornea (i.e., agent, like a vaccine or a toxoid, the clear front window of the usually smaller than the initial dose, eye) usually resulting from an eye and given to maintain immunity infection, a dry eye, or other eye breech presentation a positioning of the baby (i.e., fetus) disorder that will lead to a delivery in the Cushing’s syndrome hormonal disorder caused by long- birth canal in which the buttocks, term exposure to too much cortisol feet, or knees come out first with symptoms such as upper body bronchiectasis destruction and widening of the obesity, fragile skin and bones, large airways anxiety and depression, and in Brudzinski’s sign a demonstrable symptom of women, excessive body hair meningitis: severe neck stiffness that cyanosis condition in which lips, fingers, and causes a patient’s hips and knees to toes appear blue due to a low oxygen flex when the neck is flexed level in the blood cardiogenic shock sudden inability of the heart to pump cystitis inflammation of the bladder, often enough blood to meet the body’s but not always due to infection needs; often caused by a severe heart debridement the process of removing damaged, attack dead, or infected tissue cellulitis infection of the skin and the soft dehydration a condition resulting when the body tissues underneath the skin does not have enough fluid to work cervix the lower part of the uterus that properly opens into the vagina duodenal loop the upper small intestine chest indrawing inward movement of the lower chest dyslipidemia having lipid (i.e., cholesterol, wall (i.e., lower ribs) when inspiring triglyceride) levels in the blood that chronic bronchitis chronic inflammation of the are too high or too low bronchial tubes, the airways that dysmenorrhea painful menstrual periods carry air to the lungs dyspnea a breathing problem with shortness compromised condition in which the body loses its of breath immunity natural ability to fight infections

xxvi National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxvii Glossary Glossary eclampsia a seizure in a pregnant woman; epigastric region upper central region of the abdomen follows pre-eclampsia, which is a (i.e., epigastrium) serious complication of pregnancy epithelialization the process by which the skin repairs that includes high blood pressure itself after injury rapid and excessive weight gain; see erythema redness of the skin caused by pre-eclampsia hyperemia of the capillaries in the ectopic pregnancy a pregnancy that occurs outside the lower layers of the skin uterus Fallopian tubes very fine tubes leading from the edema swelling caused by excess fluid in ovaries into the uterus; also called body’s tissues salpinges embolism a clot that travels from the site where follicles a small spherical group of cells it formed to another location in the containing a cavity body glaucoma a condition generally caused by a emphysema damage to the air sacs (i.e., alveoli) in slow rise in the fluid pressure inside the lungs the eyes which damages the optic encephalitis inflammation of the brain due to nerve viral or bacterial infection glomerulonephritis kidney disease in which the part of endemic a disease that occurs frequently and the kidney that helps filter waste and at a predictable rate in a specific fluids from the blood is damaged location or population gout precipitation of crystals within the endocarditis inflammation of the heart’s inner joint causing acute onset of swelling, lining; most common type, bacterial pain, and often redness or heat in the endocarditis, occurs when germs involved joint enter the heart hematoma localized collection of blood outside endometrium The mucous membrane lining of the the blood vessels, usually in liquid uterus form within the tissue enuresis involuntary release of urine; hematuria presence of red blood cells in the sometimes used to indicate urine nocturnal enuresis (bedwetting), hemolytic related to the rupture of the red where urine is released during sleep. blood cells and the release of their envenomation a complication of massive poisoning contents into the blood plasma by venom hepatitis inflammation of the liver

xxviii National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxix Glossary Glossary hepatomegaly nonspecific medical sign of enlarged ileus an intestinal obstruction that liver prevents the contents of the Hirschprung disease of the large intestine (i.e., intestine from passing through disease colon and rectum) when all or part of infant a child under 1 year of age the large intestine has no nerves and insulin a peptide hormone, which is therefore cannot function causing produced by the beta cells of the severe constipation or intestinal pancreas and which regulates obstruction carbohydrate and fat metabolism; hydrophobia painful laryngeal spasms upon also diabetes medicine drinking iritis an inflammation of the iris (i.e., the hyperglycemia a condition in which an excessive colored ring of tissue surrounding amount of glucose circulates in the the pupil of the eye) blood ischemia decreased blood flow by a partial hypogastrium an area of the human body located or complete blockage of arteries, below the navel; also called reducing the oxygen supply hypogastric region, pubic region, and jejunum middle section of the small intestine lower abdomen between the duodenum and the hypoglycemia an abnormally diminished content of ileum glucose in the blood keratitis inflammation of the eye’s cornea (i.e., hypothermia a condition in which the body’s the front part of the eye) core temperature drops below the Kernig’s sign a physical symptom of meningitis: required temperature for normal inability to straighten the leg when metabolism and body functions; the hip is flexed to 90 degrees defined as 35.0°C (95.0°F) or lower left ventricular an enlargement of the muscle tissue hypovolemia a decrease in the volume of blood hypertrophy that makes up the wall of the heart’s plasma; loss of blood volume due to main pumping chamber (i.e., the left hemorrhaging or dehydration ventricle) hypoxia pathological condition in which lethargy fatigue with a feeling of weariness, the body or a region of the body is tiredness, or lack of energy deprived of an adequate oxygen lymph nodes oval-shaped organs of the immune supply system, widely distributed icteric related to jaundice throughout the body

xxx National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxxi Glossary Glossary lymphangitis inflammation or infection of the multipara a woman who has given birth two or lymphatic vessels; a common more times complication of certain bacterial myocardial commonly known as a heart attack; infections infarction results from the interruption of mania state of abnormally elevated or blood supply to a part of the heart, irritable mood, arousal, and/or causing heart cells to die; also called energy levels acute myocardial infarction (AMI) mastitis an inflammation or infection of the myocarditis inflammation of the heart muscle breast tissue myocardium the heart muscle mastoiditis an infection of the mastoid bone of nasogastric tube a medically inserted rubber or the skull (located just behind the ear) plastic flexible tube that carries Meckel’s a pouch on the wall of the lower part food and medicine to the stomach diverticulum of the intestinet present at birth (i.e., through the nose congenital); occurs in about 2% of neonate an infant in the first 28 days after the population birth meconium early feces (i.e., stool) passed by a nocturia the need to urinate at least twice newborn soon after birth, before the during the night baby has started to digest breast milk oliguria decreased urine output (i.e., or formula production of less than 500 ml of meningitis an inflammation of the thin tissue urine per 24 hours) that surrounds the brain and spinal ophthalmologic related to eye cord, called the meninges orthopedic related to musculoskeletal system metrorrhagia uterine bleeding at irregular osteomyelitis a serious infection of the bone intervals, particularly between the caused by bacteria expected menstrual periods otitis an inflammation or infection of the micronutrient any substance, such as a vitamin ear or trace element, essential for otitis externa an inflammation of the outer ear and healthy growth and development but ear canal (also called external ear required only in very small amounts infection) morbidity rate either the incidence rate or the otitis media an infection of the middle ear prevalence of a disease or medical pain reliever an analgesic; a medicine that reduces condition or relieves aches and pain mortality rate a measure of the number of deaths in pancreatitis an inflammation of the pancreas a given population xxxii National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxxiii Glossary Glossary parenteral the introduction of nutrition, a pneumothorax an abnormal collection of air or gas medication, or other substance in the pleural space that separate into the body via a route other than the lung from the chest wall; may the alimentary tract, especially via interfere with normal breathing infusion, injection, or implantation polyuria an excessive volume of urination paresthesia a burning or prickling sensation that (i.e., more than 2.5 liters per day) is usually felt in the hands, arms, postnatal period the period beginning immediately legs, or feet, but can also occur in after the birth of an infant and other parts of the body extending for 6 weeks; refers to the pepsin an enzyme released in the stomach infant that degrades food proteins into postpartum the period beginning immediately peptides period after the delivery and extending for pericardial an emergency condition due 6 weeks; refers to the mother; also tamponade to a pressure on the heart that called puerperium occurs when blood or fluid builds pouch of Douglas an extension of the peritoneal up in the space between the cavity between the rectum and the heart muscle (myocardium) and posterior wall of the uterus in the the outer covering sac of the heart female human body (pericardium) pre-eclampsia a sudden increase in blood pressure perinatal period the period covering 28 days before after the 20th week of pregnancy; and 28 days after the birth delivery can be life threatening for the peritonitis an acute, life-threatening condition, mother and the unborn baby caused by bacterial or chemical prevalence the proportion of a population found contamination of the peritoneal to have a condition cavity primipara a woman who has given birth once phonophobia a fear of loud sounds prodromal an early symptom (or set of photophobia an abnormal intolerance to the syndrome symptoms) that might indicate the visual perception of light start of a disease before specific placenta praevia an obstetric complication in which symptoms occur the placenta is attached partially or prophylaxis a medical or public health procedure wholly in lower uterine segment and whose purpose is to prevent, rather covers all or part of the opening of than treat or cure, a disease the cervix proteinuria the presence of an excess of serum proteins in the urine xxxiv National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxxv Glossary Glossary pruritus a sensation that causes the desire or schizophrenia a mental disorder characterized by reflex to scratch a breakdown of thought processes psychosis a generic psychiatric term for a and by a deficit of typical emotional mental state often described as responses involving a “loss of contact with seizure a sudden disruption of the reality” brain’s normal electrical pulmonary edema a life-threatening emergency activity accompanied by altered characterized by extreme consciousness and/or other breathlessness due to abnormal neurological and behavioral accumulation of fluid in the lungs manifestations. One manifestation pyelonephritis an ascending urinary tract infection can be convulsions; see convulsion. that has reached the pyelum (or sepsis an invasion of microbes or their pelvis) of the kidney toxins into the blood, organs, or other pyloric canal the opening between the stomach normally sterile parts of the body and the small intestine shock a life-threatening condition retinopathy an eye disorder caused by persistent caused by circulatory failure with or acute damage to the retina of the inadequate supply of blood flow to eye bring required oxygen and nutrients Reye’s syndrome a sudden and sometimes to the tissues and to remove toxic fatal disease of the brain with metabolites degeneration of the liver cause sinusitis an inflammation and infection of the unknown; studies have shown that sinuses taking aspirin increases the risk of stillbirth a birth that occurs after a fetus has occurrence; can lead to a coma and died in the uterus brain death; condition mostly seen stomatitis an inflammation of the mucous in children lining of any of the structures in rhinitis irritation and inflammation of the the mouth; may involve the cheeks, mucous membrane inside the nose gums, tongue, lips, throat, and roof or rhonchi coarse rattling sound somewhat like floor of the mouth snoring, usually caused by secretion stridor abnormal high-pitched noisy in bronchial airways breathing that occurs due to salpingitis an infection and inflammation in the obstructed air flow through a fallopian tubes narrowed airway; usually heard when the patient is taking in a breath

xxxvi National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxxvii Glossary Glossary stroke the rapid loss of brain function due vacuum extraction a procedure sometimes done, during to disturbance in the blood supply to the course of vaginal childbirth, to the brain the baby’s head to help guide the sublingual the pharmacological route of baby out of the birth canal administration by which medicines vaginitis the inflammation and infection of diffuse into the blood through tissues the vagina under the tongue valvular heart a disease process involving one or systemic affecting the whole body or at least disease more of the valves of the heart multiple organ systems volvulus the twisting of the intestine; causes tachycardia a heart rate that exceeds the normal an intestinal obstruction and may range cut off blood flow and damage part of tachypnea rapid breathing the intestine tonsillitis an inflammation of the tonsils vulva the external genital organs of the caused by viral or bacterial infection woman topical medicine a medication that is applied to body wheezing a high-pitched whistling sound made surfaces such as the skin or mucous while breathing, usually breathing membranes out (i.e., expiration); results from tympanic ear drum (i.e., the thin drum-like narrowed airways membrane tissue that separates the ear canal xerophthalmia a medical condition in which the eye from the middle ear) fails to produce tears; may be caused urethral meatus the point at which urine and, in by a deficiency in vitamin A males, semen exits the urethra Zollinger–Ellison a complex condition in which one or urethritis a swelling and irritation (i.e., syndrome more tumors form in the pancreas or inflammation) of the urethra (i.e., the the upper part of the small intestine tube that carries out urine from the (duodenum); the tumors secrete body) large amounts of the hormone uveitis a swelling and irritation of the uvea gastrin, which causes the stomach (i.e., the middle layer of the eye that to produce too much acid; the excess provides most of the blood supply to acid, in turn, leads to peptic ulcers the retina)

xxxviii National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level xxxix

1. Dental and Oral Conditions

Chapter 1. Dental and Oral Conditions DENTAL AND ORAL The five dental and oral conditions discussed in this chapter are dental caries, gingivitis, periodontitis, abscess, and oral candidiasis. Description The oral cavity is made up of specialized tissue comprised of oral mucosa, gingival mucosa, bones, teeth, and the surrounding structure of the teeth. Inflammation and infection of these tissues can lead to local and widespread destruction, cellulitis, and abscess, and loss of tooth and bone. nn Dental caries: Local destruction of the tooth enamel and dentine possibly leading to local infection and tooth loss nn Gingivitis: A chronic inflammatory process of the gum that may lead to separation of gum from tooth margin. Acute necrotizing gingivitis is noncontagious infection that can cause severe pain and rapid destruction of gingiva and surrounding tissue. nn Periodontitis: An infectious disease resulting in inflammation within the supporting tissue of the teeth that may cause progressive bone loss, tooth loosening, and tooth loss nn Abscess: A collection of pus that can be localized or spreading—with or without surrounding cellulitis. Most commonly, tooth decay and gum disease cause localized abscess. Occasionally, the infection spreads rapidly to surrounding tissue and the cervicofacial fascia and may be life-threatening. nn Oral candidiasis: A fungal infection most often caused by Candida albicans; can involve the tongue and mucosa of the oral cavity. It is most often seen in patients whose immunity is impaired because of

National Standard Treatment Guidelines for the Primary Level 41 1. Dental and Oral Conditions 1. Dental and Oral Conditions

underlying medical problem (e.g., diabetes, human nn Abscess

immunodeficiency virus [HIV], chronic disease), ll Deep space infection that may be localized— DENTAL AND ORAL malnutrition, or medication (e.g., systemic steroids or swelling, pus, or both surrounding involved tooth; long-term antibiotics). local pain and gum swelling Diagnosis ll May become generalized and spread uu Diffuse pain nn Dental caries uu Overlying skin and soft tissue swelling; possible ll Dental caries often begin as a sensitive white spot DENTAL AND ORAL DENTAL that progresses to a (black) hole in the tooth that is overlying cellulitis painful to direct touch or hot/cold foods. If the patient has spreading infection in the deep tissue can become a surgical emergency, refer. ll The destruction of the tooth can be complicated by surrounding abscess and infection in which case nn Oral candidiasis the patient may experience constant pain, localized ll Milky white patches attached to tongue and oral swelling of gum, and pus. mucosa that may be scraped away with moderate pressure, exposing erythematous base nn Gingivitis ll May cause mild pain or burning sensation of mouth ll Chronic, uncomplicated ll May lead to difficulties with eating or breastfeeding uu Slow onset uu May have mild pain of local or widespread area of Management gum The most important aspect of management of these five uu May have bleeding of gum—especially after conditions is to recognize a spreading infection that may brushing become a surgical emergency. The goals are to address uu Gums appear bright red (instead of normal light pain, eradicate infection, and treat any underlying or pink) and may separate from teeth causal condition. ll Acute or subacute nn Order an oral rinse 4 times per day for 5 days for all five uu Acute onset types of dental and oral conditions. uu Painful gums ll 2 pinches salt in 1 cup lukewarm (previously boiled) uu May have spontaneous bleeding of gums water uu May have grayish membrane covering the gums ll 0.2% chlorhexidine solution 15 ml uu May be localized or involve all gum area Limit to 5 days because it may cause darkening of uu May be associated with halitosis (bad breath) teeth. nn Periodontitis nn Advise use of an analgesic for pain. ll May be localized or generalized ll Paracetamol tablets. Refer to table A15 in annex A ll Deep red or purplish color of gum for standard dosages. ll Separation of tooth from gum with tooth loosening nn Prescribe antibiotics for infections including tooth ll May lead to loss of tooth and localized bone abscess, cellulitis, and acute gingivitis. destruction ll Phenoxymethylpenicillin (penicillin V) for 7 days.

42 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 43 1. Dental and Oral Conditions 1. Dental and Oral Conditions

Refer to table A16 in annex A for standard dosages. Prevention

uu Children: 10 mg/kg/dose every 6 hours nn Use good oral hygiene: Maswak (i.e., tooth stick) and DENTAL AND ORAL uu Adults: 500 mg every 6 hours tooth brushing, using a soft tooth brush and fluoride ll For penicillin-allergic patients, prescribe toothpaste, if possible, after meals. erythromycin PLUS metronidazole. Refer to tables nn Perform dental flossing, if possible. A12 and A14 in annex A for standard dosages. nn Eat a diet rich in fruits and vegetables. uu Children: Erythromycin 10–15 mg/kg/dose every nn Get routine dental care, if possible.

DENTAL AND ORAL DENTAL 6 hours PLUS metronidazole 7.5 mg/kg every nn Seek early evaluation of tooth or gum pain. 8 hours for 7 days nn Avoid the use of tobacco and mouth snuff. uu Adults: Erythromycin stearate or base tablet nn Limit intake of sugar, candy, and sweets. 500 mg every 6 hours PLUS metronidazole tablet Patient instructions 400 mg every 8 hours for 7 days nn Avoid using your teeth to break hard food or materials nn Prescribe an antifungal rinse for oral candidiasis (e.g., walnuts, almonds). (thrush). nn Avoid drinks that are too hot or too cold. ll Children: Nystatin drops (100,000 IU/ml)—0.5 ml nn Drink warm and sugar-free fluid after eating sweets or topically after each feeding for 10 days candies. ll Adults: Nystatin mouth lozenge—suck one lozenge every 6 hours for 10 days. Alternatively, apply nystatin drops (100,000 IU/ml)—3 ml topically to oral mucosa every 6 hours for 10 days. ll When nystatin is not available, apply gentian violet 0.5% aqueous solution topically every 8 hours for 7 days. Referral nn Evidence of local or spreading abscess for evaluation of drainage, tooth removal, or both nn Evidence of dental caries—for filling of hole or tooth removal nn No improvement,uncertain diagnosis, or both Spreading abscess and cellulitis of the face and neck can be a surgical emergency because of possible airway compromise and sepsis, and the condition requires urgent referral.

44 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 45 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

Chapter 2. ll Unable to drink or breastfeed ll Persistent vomiting Digestive System Conditions ll Convulsions ll Altered state of consciousness 2.1. Diarrhea and Dehydration ll Acute abdomen l Caution: Antidiarrheal medicine should not be used to l Severe malnutrition treat acute diarrhea. nn Assess degree of dehydration and classify (see table 2.1.1A) as— 2.1.1. Acute Diarrhea, without Blood, in Children ll Severe dehydration (C) Younger Than 5 Years ll Some dehydration (B) ll No dehydration (A) DIGESTIVE SYSTEM See also IMCI flipchart, “Child with Diarrhea.”

Note: if not available at the health facility, IMCI flipchart Table 2.1.1A. Classifying the Degree of Dehydration can be found at the Child and Adolescent Health department of MoPH. C = B = Severe Some Description Dehydration Dehydration A =

DIGESTIVE SYSTEM DIGESTIVE Signs to (At Least (At Least No Acute diarrhea is marked by a sudden change in Look for Two Signs) Two Signs) Dehydration consistency (liquid) and frequency of stools. It is most Level of Sleepy, Restless, Well and alert commonly caused by viruses, but also may be caused consciousness difficult to irritable, or by bacteria or parasites and can quickly become fatal in wake, or both newborns, undernourished children, and children showing unconscious other danger signs (see below and IMCI flipchart). Sunken eyes Eyes sunken Eyes sunken Eyes not sunken Diagnosis Ability to drink Drinks (sucks) Drinks (sucks) Drinks (sucks) nn Ask about— (suck) poorly or not eagerly, thirsty normally ll Frequency of stools at all ll Duration of diarrhea; if more than 2 weeks, see Skin pinch Skin pinch Skin pinch Skin pinch section 2.1.3 “Persistent Diarrhea.” takes 2 returns slower returns ll Blood in stools; if blood in stool, see section 2.1.5 seconds or to normal, but to normal more before in <2 seconds immediately “Dysentery.” returning to ll Cholera cases in neighborhood; if yes, suspect normal cholera and see section 2.1.7 “Cholera.” nn Inspect for danger signs and signs of severe illness— Note: All of these cases should receive IM antibiotic and be referred to hospital. ll Infant younger than 2 weeks old

46 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 47 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

Management Table 2.1.1B. nn In children, the main objective is to prevent or Severely Dehydrated Child: Administration of IV Fluid treat dehydration and exclude causative associated Give Then, give infections (e.g., malaria, pneumonia, otitis, urinary Age of the Child 30 ml/kg in 70 ml/kg in tract infection) and malnutrition. <12 months (infant) 1 houra 5 hours Nonpharmacologic 12 months to 5 years 30 minutesa 2½ hours nn In children who are breastfed, continue breastfeeding a If radial pulse is weak or undetectable, repeat this once. as much and as often as the child will take it until diarrhea stops. ll Refer urgently for IV treatment. nn In children who are no longer breastfeeding, continue ll If child can drink, provide ORS solution to the DIGESTIVE SYSTEM normal feeding and give extra fluids until diarrhea caretaker and show how to give frequent sips to the stops. child during the trip. Pharmacologic nn Plan C-3. If no IV treatment is available less than 30 Follow one of the plans below, according to the minutes away, and you know how to use a nasogastric classification of dehydration determined from table 2.1.1A. tube— DIGESTIVE SYSTEM DIGESTIVE Plan C. Treat child who has severe dehydration quickly. ll Place nasogastric tube, and give ORS at the rate of nn Plan C-1. If you have IV equipment and solutions at 20 ml/kg/hour for 6 hours. hand— ll Reassess every hour. ll Rapidly give IV Ringer’s lactate solution uu If repeated vomiting or abdominal distention, (Hartmann’s solution, or if not available, normal give ORS more slowly. saline 0.9%) as per table 2.1.1B. uu If no improvement after 3 hours, refer for IV ll Keep the child at the clinic, and check every hour. treatment. ll As soon as the child can drink, give ORS at the rate ll Reassess and reclassify dehydration after 6 hours of 5 ml/kg/hour. and adapt management plan. ll Reassess and reclassify: nn Plan C-4. If no IV treatment is available less than uu Infant (younger than 12 months old) after 6 hours 30 minutes away, and you do not know how to use a uu Child (12 months old or older) after 3 hours nasogastric tube, but child can drink something— uu Choose appropriate management plan (i.e., B or A) ll Give frequent sips of ORS at the rate of 20 ml/kg/ according to classification. hour for 6 hours. uu If still classified as C, refer to hospital while ll Reassess every hour. keeping IV drip going. uu If repeated vomiting or abdominal distention, nn Plan C-2. If you do not have IV equipment and give ORS more slowly. solutions at hand, but IV treatment is available less uu If no improvement after 3 hours, refer for IV than 30 minutes away— treatment.

48 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 49 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

ll Reassess and reclassify dehydration after 6 hours Table 2.1.1C. and adapt management plan. Child with Some Dehydration: Oral Rehydration nn Plan C-5. If no IV treatment available less than Age (If Weight Is Unknown)a 30 minutes away, you cannot place a nasogastric 4 to <12 1 to 2 to tube, and child does not drink—refer urgently to the <4 months months <2 years <5 years nearest hospital. Dosage Weight Plan B. Treat child who has some dehydration with ORS. 6 kg to 10 kg to nn Plan B-1. Treat the child with ORS in the health <6 kg <10 kg <12 kg 12–19 kg facility for 4 hours. Total ml 200–400 400–700 700–900 900– ll Rehydrate the child with ORS according to weight or in 4 hours ml ml ml 1,400 ml DIGESTIVE SYSTEM age as shown in table 2.1.1C. a Use the child’s age only when you do not know the weight. The appropriate amount ll If the child wants more ORS than shown in table of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75. 2.1.1C, give more. ll Show the caregiver how to give the ORS. uu 6 months old or older: 1 tablet a day dissolved in uu Give frequent small sips with spoon or cup. some clean water, for 10 days uu If child vomits, wait 10 minutes, then continue a DIGESTIVE SYSTEM DIGESTIVE l bit slower than before. l Tell the caregiver to continue feeding the child normally. uu Continue breastfeeding when the child wants. ll Tell the caregiver to return if child— ll Reassess and reclassify the child after 4 hours. uu Is not better uu Select the appropriate management plan (i.e., C, u B, or A). u Shows danger signs (see “Diagnosis” above) uu Has blood in stool uu Start feeding the child in clinic before sending home. Plan A. Treat child who has diarrhea without dehydration at nn Plan B-2. If the caregiver cannot stay for 4 hours at the home. Counsel the caregiver on the four principles of home clinic— care for diarrhea. ll Show the caregiver how to prepare and give ORS at nn Principle 1: Give extra fluids until diarrhea stops. home. (See plan B-1.) ll Give two packets of ORS, and teach the caregiver ll Explain how much ORS to give for the first 4 hours. how to prepare ORS. ll Give enough ORS packets for the first 4 hours. Give ll Instruct the mother to breastfeed as often as the two extra packs for continuing plan A after the first child will take. 4 hours. ll If child is exclusively breastfed (i.e., younger than ll Give zinc (20 mg) tablets: 6 months), tell mother to give ORS after each uu Younger than 6 months: tablet of 20 mg a day breastfeeding, as much as the child will take. dissolved in some breast milk or clean water, ll If child is not exclusively breastfed, tell her give ORS for 10 days and other liquids (e.g., soup, rice water, clean water).

50 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 51 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

ll Advise the caregiver to give frequent, small sips Referral using spoon or small cup. nn Severe dehydration with other complications ll If child vomits, instruct the caregiver to wait 10 nn Children younger than 12 months with blood in the minutes and continue giving small sips. stool ll Tell the mother or caregiver to offer ORS after each nn Malnourished children loose stool (10 ml/kg): nn Children with general danger signs (e.g., altered level uu 50–100 ml if child is younger than 2 years old of consciousness, convulsions, inability to feed or uu 100–200 ml if child is older than 2 years old drink, vomiting everything) ll She should continue extra fluids until the diarrhea nn Suspected acute abdominal problem that may require stops. surgery DIGESTIVE SYSTEM nn Principle 2: Continue feeding. Prevention ll Instruct the mother to breastfeed as often and as nn Individual hygiene (i.e., hand washing with soap before much as the child will take. handling food and after toilet use) ll If the child is more than 6 months, instruct the nn Safe latrines mother to give other foods as normal and encourage nn Exclusively breastfeeding for first 6 months of life liquid foods as much as the child will take. DIGESTIVE SYSTEM DIGESTIVE nn Principle 3: Give zinc to the child for 10 days, even 2.1.2. Acute Diarrhea, without Blood, in Children when diarrhea stops. Older Than 5 Years and in Adults ll Give 5 tablets of 20 mg if the child is younger than 6 months old. Description Acute diarrhea is marked by increased frequency and uu Each day, dissolve tablet in some breast milk or clean water. liquid stools for fewer than 2 weeks. It is usually self- limiting and managed by fluid replacement. ll Give 10 tablets of 20 mg if the child is older than than 6 months. Management uu Each day dissolve 1 tablet in some clean water nn Advise patient to continue taking foods normally and ll Instruct the mother or caregiver that zinc does not to increase fluids and liquid foods. replace ORS; it is in addition to ORS. nn Show patient or caregiver how to prepare ORS, and nn Principle 4: Return immediately to the health facility advise patient to drink one glass regularly, at least one if the child— after each loose stool. ll Does not get better or gets worse Referral ll Has blood in the stool nn Co-morbidity and severe dehydration or electrolytes ll Gets a fever disorder ll Starts feeding or drinking poorly nn Suspected acute abdominal problem that may require ll Has sunken eyes or slow skin pinch surgery

52 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 53 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

2.1.3. Persistent Diarrhea, without Blood, –– Give 2 extra meals a day. in Children Younger Than 5 Years –– Continue above diet for 4 weeks. ll Give supplements as follows: Description uu Oral zinc for 10 days Persistent diarrhea is any diarrhea that begins acutely and – Younger than 6 months old: tablet of 20 mg lasts for 14 days or longer is considered persistent. Signs of – a day dissolved in some breast milk or clean dehydration or general danger signs require hospitalization water of the child. (See section 2.1.2 “Acute Diarrhea, without – 6 months old or older: 1 tablet of 20 mg a day Blood, in Children Younger Than 5 Years.”) – dissolved in some clean water Diagnosis uu Oral folic acid—1 mg tablet, once a day for 14 days Assess for dehydration, malnutrition, and danger signs. uu Vitamin A—according to schedule in table 2.1.3 in DIGESTIVE SYSTEM Management a single dose nn If child is younger than 2 months, start rehydration ll Tell the mother to bring the child back in 5 days or according to classification (i.e., C, B, or A in table sooner if the child’s condition worsens. 2.1.1A), and refer to hospital. nn If dehydration or danger signs are present, start Table 2.1.3. Vitamin A Supplementation Schedule DIGESTIVE SYSTEM DIGESTIVE rehydration according to classification (i.e., C, B, A in Vitamin A Capsules table 2.1.1A), and refer to hospital. Age 200,000 IU 100,000 IU 50,000 IU nn If child has no dehydration— 6 to <12 months ½ capsule 1 capsule 2 capsules ll Adapt feeding as follows: uu If the child is exclusively breastfeeding, advise 1–5 years 1 capsule 2 capsules 4 capsules mother to breastfeed more frequently and for longer. Referral uu If the child is taking other milk, but no solid nn All children younger than 2 months who have diarrhea foods— for more than 14 days –– Replace other milk with breastfeeding. nn All children who have diarrhea for more than 14 days —OR— with dehydration or general danger signs –– Replace other milk with fermented milk such as nn All children who still have diarrhea when coming back yogurt. 5 days after initializing management of persistent —OR— diarrhea –– Replace half the other milk with semi-solid foods (e.g., eggs, pulses, cereals, and oil). uu If the child is taking other foods— –– Prepare foods appropriate to the age (e.g., shola, ash moqawi, mashawa, firni).

54 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 55 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

2.1.4. Persistent Diarrhea in Children Older ll Often abdominal cramps Than 5 Years and in Adults ll Possible general symptoms: toxic appearance, convulsions, lethargy Description nn Check for general danger signs and dehydration, Diarrhea for more than 14 days in children older than especially in children younger than 5 years old (see 5 years or in adults may indicate serious underlying causes. IMCI flipchart) Management nn Assess and classify degree of dehydration (see table If direct stool examination (three specimens) is possible, 2.1.1A) and nutritional status. determine the pathogen and treat accordingly. Management Referral Treat and prevent dehydration (see section 2.1.1 “Acute DIGESTIVE SYSTEM All cases with no or negative stool examination (after taking Diarrhea, without Blood, in Children Younger Than three specimens) 5 Years” and section 2.1.2 “Acute Diarrhea, without Blood, in Children Older Than 5 Years and in Adults”). 2.1.5. Dysentery nn In children younger than 5 years, prescribe oral zinc Description for 10 days: ll Younger than 6 months old: tablet of 20 mg a day DIGESTIVE SYSTEM DIGESTIVE Dysentery is diarrhea presenting with loose frequent stools containing blood and mucus. Most episodes are due to dissolved in some breast milk or clean water Shigella and nearly all require antibiotic treatment. When ll 6 months or older: 1 tablet of 20 mg a day dissolved there is no immediate access to a laboratory, start treatment in some clean water for bacillary dysentery (see section 2.1.5.1 “Dysentery, nn In all children and adults, prescribe an antibiotic for Bacillary”). If patient does not improve after 48 hours, start 5 days: treating for amebic dysentery (see section 2.1.5.2 “Dysentery, ll First-line: Amebic”), or refer for formal laboratory assessment. uu Ciprofloxacin tablet: 10 mg/kg/dose every 12 hours (see IMCI flipchart, “Give an Appropriate Referral Oral Antibiotic” section) Refer when patient has no response to empirical treatment. Caution: Ciprofloxacin is contraindicated 2.1.5.1. Dysentery, Bacillary in pregnant women and should be avoided in children when possible. Description —OR— Most bacillary dysentery is caused by Shigella. uu Co-trimoxazole. Refer to table A8 in annex A for Diagnosis standard dosages. nn Check for sudden onset of diarrhea with the following: —OR— ll Bloody stools ll Second-line: ll Mucus in stools uu Metronidazole. Refer to table A14 in annex A for ll Fever standard dosages.

56 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 57 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

Follow-Up nn Check for alternating constipation, flatulence, or both. Check patient after 48 hours. If he or she shows no nn Assess and classify dehydration (see table 2.1.1A). improvement (i.e., does not have fewer stools, less blood in nn If possible, a fresh stool examination (three the stool, or both; still has fever; does not have improved specimens) will confirm live forms or cysts. appetite), switch to the other first-line antibiotic or to Management metronidazole. nn Provide nutritional and fluid support. Referral nn Prescribe metronidazole. Refer to table A14 in annex A nn All children younger than 2 months old with bloody for standard dosages. diarrhea Referral Caution: refer urgently. nn Failure to respond to treatment DIGESTIVE SYSTEM nn All children younger than 5 years with bloody diarrhea nn For laboratory confirmation and any general danger sign, severe malnutrition, or nn Worsening condition severe dehydration Patient Instructions nn All cases with serious general symptoms, or not responsive to treatment after 48 hours Advise the use of good individual and general hygiene practices:

DIGESTIVE SYSTEM DIGESTIVE Prevention nn Hand washing with soap before handling food and Advise the use of good individual and general hygiene after toilet use practices: nn Hand washing with soap after handling sick babies and n n Hand washing with soap before handling food and children after toilet use nn Washing soiled garments and bed clothes with soap nn Hand washing with soap after handling sick babies and nn Using safe latrines children nn Exclusive breastfeeding for first 6 months of life nn Washing soiled garments and bed clothes with soap nn Using safe latrines 2.1.6. Giardiasis nn Exclusive breastfeeding for first 6 months of life Description 2.1.5.2. Dysentery, Amebic Giardiasis is a protozoal infection of the upper small intestinal causes by the flagellateGiardia lamblia. Cysts Description or trophozoites in stools are transmitted by fecal-oral Amebic dysentery is caused by Entamoeba histolytica. contamination. Diagnosis Diagnosis nn Check for diarrhea with— nn Giardiasis is often asymptomatic or has intermittent l l Blood and mucus signs such as the following: ll Unpleasant odor ll Can present as acute watery diarrhea, sometimes l l No fever (usually) prolonged for days to weeks

58 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 59 2.1. Diarrhea and Dehydration 2.1. Diarrhea and Dehydration

ll Can present with nausea, flatulence, epigastric pain, Diagnosis and abdominal cramps nn Acute watery diarrhea— ll Can present with malodorous and bulky stools ll Without blood or mucus nn If a laboratory test can be performed, diagnosis is ll No specific fecal odor traditionally made by the identification of trophozoites ll Often gray and turbid (so-called “rice water stool”) or cysts in stool (three specimens). nn Possible vomiting nn Assess and classify possible dehydration (see table nn Possible dehydration, which can have a rapid onset, 2.1.1A). can be severe, and is potentially fatal (see section 2.1.1 Management “Acute Diarrhea, without Blood, in Children Younger Than 5 Years” and section 2.1.2 “Acute Diarrhea, nn If diarrhea is present, treat and prevent dehydration DIGESTIVE SYSTEM (see section 2.1.1 “Acute Diarrhea, without Blood, in without Blood, in Children Older Than 5 Years and in Children Younger Than 5 Years” and section 2.1.2 Adults”) n “Acute Diarrhea, without Blood, in Children Older n Possible shock (see section 16.9 “Shock”) Than 5 Years and in Adults”) and malnutrition. Management nn Give oral metronidazole. Refer to table A14 in annex A nn Treat urgently to prevent dehydration and possible for standard dosages. shock. DIGESTIVE SYSTEM DIGESTIVE nn In pregnant women, prescribe furazolidone (100 mg nn At the primary level of care, antibiotic treatment is not orally every 6 hours for 7 days), if available. needed. n Referral n In children younger than 5 years, prescribe oral zinc for 10 days: nn All complicated cases ll Younger than 6 months old: tablet of 20 mg a day nn Cases without response to treatment dissolved in some breast milk or clean water Prevention ll 6 months old or older: 1 tablet of 20 mg a day nn Hand washing with soap before handling food and dissolved in some clean water after using toilet nn Always inform the PPHO of a suspected case. nn Boil water before use Prevention 2.1.7. Cholera Advise the use of good individual and general hygiene practices: Cholera is suspected when patients present with sudden nn Hand washing with soap before handling food and watery diarrhea and dehydration in an area where other after toilet use people have been confirmed cases. The main danger is nn Boil water before drinking rapid and severe dehydration. Always notify the PPHO of a nn Use of safe latrines suspected case.

60 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 61 2.2. Peptic Ulcer Disease 2.2. Peptic Ulcer Disease

2.2. Peptic Ulcer Disease ll Burning, dull, gnawing, or aching pain or a hungry feeling Description uu In a gastric ulcer, pain occurs soon after eating A peptic ulcer is a break in the gastric or duodenal mucosa (within 15–30 minutes); in a duodenal ulcer, pain that arises when the normal mucosal defensive factors occurs 90 minutes to 3 hours after eating and is are impaired or are overwhelmed by aggressive luminal often nocturnal. factors such as acid and pepsin. It may also occur in the uu Gastric ulcer pain is burning and made worse by esophagus, pyloric channel, duodenal loop, jejunum, or or unrelated to food intake; duodenal ulcer pain is Meckel’s diverticulum. A duodenal ulcer most commonly relieved by the absorption of food. occurs in patients between the ages of 35 and 55 years; uu Radiating pain indicates ulcer penetration or gastric ulcer is more common in patients between the ages perforation. DIGESTIVE SYSTEM of 55 and 70 years. nn Sign—The physical examination is often normal The causes of peptic ulcer disease (PUD) include the in uncomplicated PUD. Mild, localized epigastric following: tenderness to deep palpation may be present. In one nn Major causes third of patients, signs of anemia may be present. ll Bacteria Helicobacter pylori nn Differential diagnosis—Epigastric pain can also occur DIGESTIVE SYSTEM DIGESTIVE ll NSAIDs in ischemic heart disease, acute pancreatitis, or acute ll Acid hypersecretory conditions such as Zollinger- cholecystitis. Ellison syndrome Management nn Uncommon causes Nonpharmacologic ll Hereditary (increased parietal cell number) nn Advise patient to avoid— ll Blood group O (antigen may bind H. pylori) ll Smoking nn Unproven causes ll Prolonged treatment with NSAIDs or steroids ll Stress ll Alcohol ll Coffee ll Alcohol Pharmacologic Smoking is an important risk factor; it also decreases the nn To reduce acid production, prescribe ranitidine rate of healing and increases the risk of recurrence. tablets. ll Children and infants—2 to 4 mg/kg every 12 hours Diagnosis ll Adults: nn Symptoms uu 150 mg tablet every 12 hours for 6–8 weeks l l Epigastric pain and vague feeling of discomfort in —OR— the upper belly or abdomen (dyspepsia) during or uu 300 mg tablet at night for 6–8 weeks right after eating. These symptoms, however, are not sensitive or specific enough to serve as reliable diagnostic criteria for PUD.

62 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 63 2.2. Peptic Ulcer Disease 3.1. Asthma

nn To neutralize existing gastric acid, recommend antacid Chapter 3. Respiratory ll Children 1–12 years: to 15 ml oral suspension 1–3 hours after meals and at bedtime System Conditions ll Adults: 2 tablets every 8 hours, half an hour before meal for 10 days. 3.1. Asthma

Referral Asthma is a chronic inflammatory condition with nn Complication such as gastrointestinal bleeding or reversible airway obstruction. perforation nn No response to available medicines 3.1.1. Asthma in Children nn Suspected H. pylori or other pathology (cancer); endoscopy required Description Asthma in children is characterized by recurrent episodes Prevention of wheezing, often with cough or signs of pneumonia, nn Avoid alcohol use, smoking, and NSAIDs. which respond to bronchodilators. nn Do not consume expired foods. Diagnosis Patient Instructions The patient has a history of recurrent episodes of— DIGESTIVE SYSTEM DIGESTIVE nn Use good personal and environment hygiene (i.e., nn Wheezing; the sound of wheezing is most obvious hand washing after bathroom, eating healthy food, and when breathing out (exhaling), but may be heard when drinking safe water). taking a breath (inhaling) RESPIRATORY SYSTEM nn Avoid self-medication. nn Shortness of breath often with cough nn Return in 1 week for reevaluation. The patient may also report— nn Periods without symptoms between attacks nn Provoking factors, such as allergens, exercise, cold temperature, or respiratory infections Findings on examination may include— nn Prolonged expiration with audible wheeze is most common sign in children. nn Check for general danger signs, stridor and chest in-drawing, and if so, treat as severe pneumonia (see section 3.3 “Pneumonia in Children and Adults”). nn Check for fast breathing. Treat as pneumonia (see section 3.3). If the diagnosis is uncertain, give a dose of a rapid-acting bronchodilator. A child with asthma will improve rapidly,

64 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 65 3.1. Asthma 3.1. Asthma

showing signs such as a decrease in the respiratory rate and in chest wall in-drawing and less respiratory distress. A

child with severe asthma may require several doses before urgently a response is seen. Next Step Next ollow up inollow to hospital. Refer Refer F 2 days. Management None First, using table 3.1.1., exclude pneumonia. In a child classified with no pneumonia, manage asthma as follows: nn Prescribe an oral bronchodilator: salbutamol tablets

for 5 days. Refer to table A17 in annex A for standard a dosages. nn Steroids are not usually required for the first episode of wheezing. If a child has a severe acute attack of wheezing and a history of recurrent wheezing, give— ll Oral prednisolone 0.5 mg/kg/dose every 12 hours for 3 days. Prednisolone is available in DHs.

ll If the child remains very sick, continue the steroid to Prescribe Medication

treatment until improvement is seen. b RESPIRATORY SYSTEM nn

Prescribe aminophylline. US— ll If a child does not improve after 3 doses of nebulized US— ne dose of pre-referral antibiotic: pre-referral ne dose of (nebulized rapid-acting bronchodilator ne dose of Ampicillin Gentamicin l l O O salbutamol) is present. if wheeze co-trimoxazole of 5 days with wheeze salbutamol (if child presents oral of 5 days than 6 months old)and is more solution of salbutamol given at short intervals plus l l n n n n —P L —P L n n n n oral prednisolone— than 6 months old) salbutamol (if child is more oral of 5 days uu Slowly—over at least 20 minutes and preferably over 1 hour—give an IV injection of aminophylline.

RESPIRATORY SYSTEM RESPIRATORY Refer to table A2 in annex A for standard dosages. Caution: Weigh the child carefully and give the IV reat as severe as severe reat as reat reat as reat Action to Take Action T pneumonia. T pneumonia. dose according to exact weight. T no pneumonia. uu Followed by a maintenance IV injection dose. Refer again to table A2.

Caution: IV aminophylline can be dangerous in

an overdose or when given too rapidly. Do not give and aminophylline if the child has already received Pneumonia and Asthma between Differentiating any form of aminophylline or theophylline in the ast breathing ast breathing Symptoms Present Symptoms nly wheezing previous 24 hours. danger signs General Stridor —OR— Chest in-drawing W heezing F BUT danger general No signs and no stridor n n n n n n —OR— O n n n n n n ab l e 3.1.1. Refer to the tables in annex A for standard dosages: table A4 for ampicillin, table A8 for co-trimoxazole, table A13 for gentamicin, and table A17 for table A13 for co-trimoxazole, ampicillin, table A8 for dosages: table A4 for standard to the tables in annex A for Refer salbutamol. In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 in annex A for standard dosages. standard to table A12 in annex A for Refer use erythromycin. or sensitivity, penicillin allergy the case of In  T a b

66 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 67 3.1. Asthma 3.1. Asthma

Caution: Stop giving aminophylline immediately nn Signs if the child starts to vomit, has a pulse rate more ll Mild attack than 180/minute, develops a headache, or has a uu Slight tachycardia, tachypnea convulsion. uu Mild diffuse wheezing (rhonchi) nn Prescribe antibiotics only if pneumonia or severe ll Moderate attack pneumonia is suspected (see section 3.3 “Pneumonia uu Use of accessory muscle of respiration in Children and Adults”). uu Loud expiratory wheezing Referral and Follow-Up uu Retraction of intercostal muscle ll Severe attack nn Refer all patients who are not improved following acute-care treatment. uu Fatigue uu Pulses paradox nn After providing emergency treatment as outlined above, refer all patients who have life-threatening uu Inaudible breath sound (silent chest) with symptoms. diminished rhonchi uu Inability to maintain lying position nn Asthma is a chronic and recurrent condition; a long-term treatment plan must be made based on the uu Cyanosis frequency and severity of symptoms. Refer patient to a Management specialist for initiation of long-term treatment. Asthma medication is of two types: quick-relief and long- term control. RESPIRATORY SYSTEM 3.1.2. Asthma in Adults nn Quick relief medications are used for acute care. Description ll Give or prescribe salbutamol inhaler in acute Asthma in adults is characterized by paroxysmal attacks attack. Treatment in the clinic is 2 puffs and can of breathlessness, chest tightness, and wheezing, all of be repeated every 15 minutes for 1 hour in a severe which result from paroxysmal narrowing of the bronchial attack. airways due to muscle spasm, mucosal swelling, and viscid uu Inhaler may be substituted with nebulizer when available. Refer to table A17 in annex A for

RESPIRATORY SYSTEM RESPIRATORY bronchial secretions occurring as result of inflammatory reaction within the bronchial walls. Genetic and standard dosages. environmental factors are involved. uu Once the patient has improved sufficiently to be discharged home, give salbutamol tablets—1 tablet Diagnosis of 4 mg every 8 hours for 3 days. nn Symptoms ll Systemic corticosteroids ll Feeling of tightness in the chest uu Oral prednisolone—0.5 mg/kg/day every 12 hours ll Episode of dyspnea for 3–10 days. Prednisolone is available in DHs. ll Unproductive cough which aggravates the dyspnea uu In a severe attack that is not responsive to ll Expiratory wheeze bronchodilators and requires referral, give hydrocortisone IV 200 mg before transfer.

68 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 69 3.1. Asthma 3.2. Common Cold and Flu

ll In the case of a severe attack when salbutamol Prevention inhalant is not available or effective— nn Avoid causative allergens such as house dust, mites, uu Give slow injection IV of aminophylline—loading pets, grass pollens, and chemicals. dose 5 mg/kg slow IV injection in more than 20 nn Seek early treatment of chest infections. minutes and preferably with 100 ml IV solution; nn Avoid beta-blockers (e.g., propranolol, atenolol), maintenance dose: 0.7–0.9 mg/kg/h continuous angiotensin-converting enzyme (ACE) inhibitors (e.g., IV infusion. captopril), and NSAIDs. Caution: Patients with congestive heart failure Patient Instructions should receive 0.25 mg/kg/h continuous infusion nn Patient and caregiver education includes the following: only. ll Education on early recognition and management of Caution: Use above dosage only if the patient has acute attacks not taken aminophylline or theophylline within ll Diagnosis and natural course of condition 24 hours. ll Teaching and monitoring patient use of inhalers and uu Aminophylline is used for patients in status medicines asthmaticus who do not respond to maximal, ll Reassurance regarding safety and efficacy of inhaled bronchodilators and corticosteroids. treatment These patients will require referral to EPHS facility. 3.2. Common Cold and Flu

nn Long-term medications require a referral to a RESPIRATORY SYSTEM specialist for chronic and prophylactic treatment. Description ll Inhaled steroid therapy (beclomethasone) is the Colds and flu are common, self-limiting viral infections most potent and effective anti-inflammatory to that require only supportive care. They are contagious and decrease the frequency and severity of the attacks. spread by airborne droplets. Most episodes end within Its use requires the advice of a specialist for dosage, 14 days in adults and children. A child who has a cough or depending of type of asthma. difficult breathing but who has no general danger signs,

RESPIRATORY SYSTEM RESPIRATORY ll Systemic corticosteroids (oral and parenteral) are no chest in-drawing, no stridor when calm, and no fast most effective in asthma during exacerbation with breathing is classified as having a common cold or the flu. severe persistent asthma. A child who has a chronic cough (i.e., a cough lasting more Referral than 14 days), however, may have TB, asthma, whooping cough, or another problem. Malnourished children, nn After providing emergency treatment as outlined above, refer all patients who are not improved or who the elderly, and the debilitated are at greater risk of have life-threatening symptoms. complications. nn Refer patients who require chronic or prophylactic Diagnosis therapy—for increased diagnostic and treatment nn Cough options and to formulate a long-term treatment plan. nn Nasal congestion and discharge

70 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 71 3.2. Common Cold and Flu 3.3. Pneumonia in Children and Adults

nn Throat pain Prevention nn Headache, muscle pain, fever—more common with flu nn Use cough etiquette to avoid spreading of airborne nn May be complicated by otitis media, wheezing, droplets by infected person. sinusitis nn Practice good nutrition. Note: Malaria, measles, and pneumonia may begin with Patient Instructions flu-like symptoms nn Encourage fluids and feeding. n Management n Emphasize the need to keep nasal passages clear, particularly for infants who are obligatory nasal Nonpharmacologic breathers. nn Advise bed rest as needed. nn Advise the patient to— nn Encourage fluids to avoid dehydration and to keep ll Watch for fast or difficult breathing, and return mucous thin. immediately if either develops. nn Soothe the throat and relieve the cough with a ll Return if the child becomes sicker or is not able to traditional remedy, such as warm, sweet tea. drink or breastfeed. nn Clear secretions from the child’s nose before feedings ll Follow up in 5 days if not improving. using a cloth soaked in water, which has been twisted to form a pointed wick. 3.3. Pneumonia in Children and Adults Pharmacologic Pneumonia is an infection of the lung tissues. Pneumonia RESPIRATORY SYSTEM nn In an infant, use NaCl 0.9% drop into each nostril to is usually caused by viruses or bacteria or, less frequently, relieve congestion as needed. by fungus or parasites. Most serious episodes are caused nn Use paracetamol for high fever (38.5°C or higher) by bacteria. Determining the specific cause, however, is until fever subsides. Refer to table A15 in annex A for usually not possible by clinical features or chest X-ray standard dosages. Adults may take up to 1 g every 6 appearance. Based on clinical features, pneumonia is hours for high fever. classified as pneumonia and severe pneumonia, with nn Note: Avoid giving any of the following: specific treatment for each. Antibiotic therapy is needed in RESPIRATORY SYSTEM RESPIRATORY ll Antibiotics—not indicated since colds and the flu all pneumonia cases. are viral infections. Caution: Severe pneumonia requires additional ll Remedies containing atropine, codeine or codeine derivatives, or alcohol may be harmful. treatment, such as oxygen, and must urgently be referred to a hospital. ll Medicated nose drops Referral nn Severe complications (e.g., pneumonia, otitis media, sinusitis) nn Altered consciousness nn Inability to drink or feed

72 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 73 3.3. Pneumonia in Children and Adults 3.3. Pneumonia in Children and Adults

3.3.1. Pneumonia in Children Younger Than ll Chest in-drawing: the lower part of the chest goes in 5 Years when the child breathes in ll Hoarse noise when the child breathes in Description ll Refusal to drink or breastfeed Pneumonia is the leading cause of mortality and a common ll Abnormally sleepiness or difficulty in waking cause of morbidity in children younger than 5 years. ll Unconsciousness See also IMCI flipchart, “Child with Cough or Difficult ll Convulsions or recent convulsions Breathing.” ll Vomiting or recent persistent vomiting Diagnosis nn Check for signs of asthma, including the following: nn Suspect pneumonia in all children who present with ll Wheezing noise when child breathes out cough or difficult breathing and in children who seem ll Cough for more than14 days to be breathing faster than normal. nn Check for signs of possible TB or other diseases, nn High fever (38.5°C or higher) is often present, but not including the following: always. ll Cough for more than 14 days nn If the child is not calm, wait for the child to calm down nn In addition, other signs of pneumonia (on before examining. If the child is sleeping, first check auscultation) may be present: crackles, reduced breath respiratory rate and chest in-drawing before trying to sounds, or an area of bronchial breathing. Auscultation wake the child. is often difficult in a child. nn Check the respiratory rate during 1 full minute nn If none of the signs listed above are present, and you RESPIRATORY SYSTEM using a timer or watch with a second hand (a shorter have eliminated the possibility of asthma, TB, or other observation time may be misleading because the diseases, you may conclude the child has a common respiratory rate fluctuates slightly). Fast breathing is cold (see section 3.2 “Common Cold and Flu”). present if the child has— Management ll More than 60 breaths/minute in a child younger than 2 months of age Child with a very severe disease or severe pneumonia ll nn refer urgently RESPIRATORY SYSTEM RESPIRATORY More than 50 breaths/minute in a child 2–11 months Give first dose of treatment, and to of age hospital. ll More than 40 breaths/minute in a child 1–5 years of ll Give the first dose of antibiotics. Give the first dose age IM of ampicillin PLUS gentamicin antibiotic in nn Check for signs of severe pneumonia or very severe muscle on the front of the thigh according to age or disease (e.g., congenital heart diseases). General weight. danger signs of very severe disease and severe uu IM ampicillin. Refer to table A4 in annex A for pneumonia include the following: standard dosages. ll Fast breathing (60 breaths/minute or more) in a —PLUS— child younger than 2 months of age uu IM gentamicin. Refer to table A13 in annex A for standard dosages.

74 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 75 3.3. Pneumonia in Children and Adults 3.3. Pneumonia in Children and Adults

ll Treat wheeze, if present, with salbutamol nebulizer. Child with pneumonia Refer to table A17 in annex A for standard dosages. nn Treat the infection. Give or prescribe a 5-day course of ll Treat convulsions, if present. the appropriate (i.e., first- or second-line) antibiotic. Caution: Do not give this treatment if the child ll First-line antibiotic: co-trimoxazole. Refer to table has only a history of convulsions; treat present A8 in annex A for standard dosages. See also IMCI convulsions only. flipchart. uu Give diazepam rectally. Use a TB or insulin ll Second-line antibiotic: amoxicillin. If the child is syringe; draw the appropriate diazepam dose; allergic to co-trimoxazole or if the child has not take out the needle and insert the syringe 4–5 cm improved after 3 days of co-trimoxazole treatment, into rectum before emptying. Squeeze buttocks give or prescribe amoxicillin. Refer to table A3 in together for 2–3 minutes Refer to table A9 in annex A for standard dosages. annex A for standard dosages. nn Teach the mother or caregiver how to give the nn If not able to refer immediately to hospital— complete 5-day treatment at home. Show the mother ll Treat infection with IM antibiotics, and treat fever or caregiver how to crush the tablet if necessary. Have as appropriate. the mother or caregiver give the first dose in front of uu Give IM ampicillin PLUS gentamicin as above for you. 5 days. Refer to tables A4 and A13 in annex A for nn Treat high fever (if present) with paracetamol standard dosages. according to weight or age until fever subsides. Refer

uu If child responds well, complete treatment for 5 to table A15 in annex A for standard dosages. RESPIRATORY SYSTEM additional days at home or in the health facility nn Treat wheezing (if present) with salbutamol according with— to weight and age. Refer to table A17 in annex A for –– Oral amoxicillin. Refer to table A3 in annex A standard dosages. for standard dosages. In the case of penicillin Child with cough or common cold allergy or sensitivity, use erythromycin. Refer to nn See section 3.2 “Common Cold and Flu.” table A12 in annex A for standard dosages. Patient Instructions RESPIRATORY SYSTEM RESPIRATORY —PLUS— nn Encourage the mother or caregiver to continue feeding uu IM gentamicin. Refer to table A13 in annex A for standard dosages. the child. nn Advise mother to increase breastfeeding or increase ll Provide supportive care. fluids. uu If fever (higher than 39°C) appears to be causing n distress, give paracetamol. Refer to table A15 in n Remind mother or caregiver to continue vaccinations annex A for standard dosages. according to schedule. nn Determine whether caregiver has understood how and uu Encourage breastfeeding and oral fluids, and food intake. when to give the medicine. nn Advise mother or caregiver to bring the child back after 2 days for a check-up.

76 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 77 3.3. Pneumonia in Children and Adults 3.3. Pneumonia in Children and Adults

nn Advise mother or caregiver to bring the child back ll Unilateral chest pain immediately if the child— ll Shortness of breath or superficial breathing ll Gets sicker ll Fever. Fever with sudden onset (often high, 38.5°C ll Stops eating or breastfeeding or higher) is often present, but not always, especially ll Develops a high fever (38.5°C or higher) in elderly patients. ll Starts breathing faster or has difficulty breathing ll Fast breathing. Deep inhalation may be painful. nn When the child returns for the 2-day check-up— ll Crackles on auscultation; often present. ll If the breathing has improved (i.e., slowed), the fever Auscultation may have decreased breath sounds or is lower, and the child is eating better, complete the wheezing. last 3 days of antibiotic treatment (pneumonia). nn Check for signs of severe pneumonia. ll If the breathing rate, fever, or eating has not ll Respiratory distress (nasal flaring) improved, change to the second-line antibiotic, and ll Respiratory rate more than 30 breaths/minute advise the mother or caregiver to return again in 2 ll Confusion or drowsiness days. Ask if the child has had measles within the 3 ll Cyanosis (blue lips or nail beds) months before the pneumonia; if yes, refer to the ll Low blood pressure (systolic less than 90 mm HG; hospital. diastolic less than 60 mm HG) ll If the child has signs of severe pneumonia or very nn Check for asthma. severe disease, follow the IMCI flipchart treatment ll Wheezing noise when patient breathes out

instructions, “Child with a Very Severe Disease or nn Check for TB. RESPIRATORY SYSTEM Severe Pneumonia.” and refer urgently to hospital ll Patient has had a productive cough for 14 days or more 3.3.2. Pneumonia in Children Older Than 5 Years Management and in Adults Severe cases of pneumonia Description nn Treat the infection by giving the first dose of antibiotic. Infection of the lung tissues is pneumonia, and the ll

RESPIRATORY SYSTEM RESPIRATORY Start oral amoxicillin. Refer to table A3 in annex A causative agent is the same as for the children younger for standard dosages. than 5 years. Pneumonia is more dangerous in elderly —OR— persons and when chronic disease is associated (e.g., ll If patient cannot swallow, give ampicillin IM. Refer diabetes, human immunodeficiency virus [HIV], to table A4 in annex A for standard dosages. malnutrition, or chronic pulmonary disease). —OR— Diagnosis ll In the case of penicillin allergy or sensitivity, use nn Check for signs of pneumonia in all children older erythromycin. Refer to table A12 in annex A for than 5 years and in adults presenting the following standard dosages. complaints: —OR— ll Cough

78 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 79 3.3. Pneumonia in Children and Adults 3.4. Chronic Obstructive Pulmonary Disease

ll Give doxycycline. Refer to table A10 in annex A for nn Advise the patient to come back immediately if he or standard dosages. she— Caution: Do not use doxycycline for children ll Gets drowsy or confused younger than 8 years old or for pregnant or lactating ll Starts breathing with difficulty women. ll Starts breathing fast (more than 30 breaths/minute) nn Refer to hospital. ll Develops a high fever (38.5°C or higher) Nonsevere cases of pneumonia 3.4. Chronic Obstructive Pulmonary Disease nn Treat the infection by giving or prescribing a 5-day course of the appropriate antibiotic. Description ll First-line choice: co-trimoxazole. Refer to table A8 Chronic obstructive pulmonary disease (COPD) is a in annex A for standard dosages. disease state characterized by air flow obstruction due ll Second-line choice: amoxicillin. Refer to table to chronic bronchitis or emphysema. Cigarette smoking A3 in annex A for standard dosages. In the case of is the most important cause of COPD; air pollution, penicillin allergy or sensitivity, use erythromycin. occupational dusts and chemicals, airway infections, Refer to table A12 in annex A for standard dosages. familial disorders, and allergy are also responsible for Note: Use amoxicillin if the patient is allergic to chronic bronchitis. co-trimoxazole, if the patient is suspected to be pregnant, or if the patient has not improved after Although emphysema and chronic bronchitis must be three days of co-trimoxazole treatment. diagnosed and treated as specific diseases, most patients RESPIRATORY SYSTEM who have COPD have features of both conditions nn Treat high fever with paracetamol until fever subsides. Refer to table A15 in annex A for standard dosages. simultaneously. nn Chronic bronchitis is a clinical diagnosis most nn Advise the patient to come back after 2 days for check- up. commonly seen after 30–40 years of age, defined by excessive secretion of bronchial mucus, and ll If improved, continue treatment and urge patient to complete the course of antibiotics. manifested by daily productive cough for 3 months or RESPIRATORY SYSTEM RESPIRATORY more in at least 2 consecutive years. ll If not improved, switch to second-line choice for antibiotic, and check patient again after 48 hours. nn Emphysema is a pathologic diagnosis most commonly seen after 50 years of age that denotes abnormal ll If not improved at the second check-up, treat as severe pneumonia, and refer to hospital. permanent enlargement of air spaces distal to the terminal bronchiole with distraction of their walls and Patient Instructions without obvious fibrosis resulting in reduction of gas nn Encourage the patient to drink more than usual, to eat exchange. as usual, and to take the medicines appropriately. Diagnosis nn Advise the patient to come back after 2 days for check- up. nn History of smoking and exposure to pollution nn Cough (productive in chronic bronchitis)

80 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 81 3.4. Chronic Obstructive Pulmonary Disease 3.4. Chronic Obstructive Pulmonary Disease

nn Progressive dyspnea (more severe in emphysema) ll Co-trimoxazole. Refer to table A8 in annex A for nn Wheezing, often not responsive to bronchodilators standard dosages. nn Cyanosis in late stage of the disease —OR— nn Fever (when secondary acute respiratory tract ll Amoxicillin. Refer to table A3 in annex A for infections) standard dosages. nn Hemoglobin raised in chronic bronchitis —OR— Management In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 in annex A for Nonpharmacologic standard dosages. n n The most important aspect of management is to —OR— encourage smoking cessation. ll Doxycycline. Refer to table A10 in annex A for nn All cases of productive cough of more than 2 weeks standard dosages. duration should be tested for TB (see section 15.10 Caution: Do not use doxycycline for children “Tuberculosis”). younger than 8 years old or for pregnant or lactating Pharmacologic women. nn Give oxygen, when available, to patients who have Referral acute hypoxemia. nn Refer all exacerbated cases that are not responding to nn Give or prescribe bronchodilators for wheezing. Treat treatment.

with only one agent at a time. RESPIRATORY SYSTEM nn In the case of chronic wheezing following a 4-week ll Salbutamol. Refer to table A17 in annex A for trial of bronchodilators, refer patients to a DH for standard dosages. possible steroid therapy. uu Inhaler —OR— Prevention nn Advise patient to stop smoking uu Tablet n —OR— n Urge people who are exposed to chemicals, dusts,

RESPIRATORY SYSTEM RESPIRATORY pollen, and smoke to take precautions. ll Aminophylline. Refer to table A2 in annex A for standard dosages. nn Give or prescribe oral prednisolone 0.5 mg/kg/day for 14–21 days if patient— ll Has asthmatic bronchitis ll Experiences exacerbations or disabling symptoms ll Fails to respond to therapy with aminophylline Note: Prednisolone is available in DHs. nn Give or prescribe antibiotics to treat acute bronchitis and prevent acute exacerbation of chronic bronchitis.

82 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 83 4.1. Otitis Externa 4.1. Otitis Externa

Chapter 4. Ear, Nose, ll Eczematous otitis externa may have red, scaling patches visible with edema of the external auditory and Throat Conditions meatus. Note: The tympanic membrane appears normal in 4.1. Otitis Externa otitis externa.

Description Management Otitis externa is an inflammation or infection of the Nonpharmacologic external auditory meatus. The four major causes of otitis nn Remove any foreign body or debris. externa are— nn Keep the ear canal clean and dry by dry mopping the nn Furuncular otitis externa (ear boil)—caused by ear. Dry mopping is a time-consuming process for staff bacteria, most often staphylococcus and patient, but must be done for effective treatment. nn Diffuse otitis externa—inflammation that may be It should be carefully taught to the patient or caregiver, caused by a foreign body, contaminated water from and the patient or caregiver should then demonstrate bathing or swimming, or scratching the external that he or she can perform the task properly. Follow auditory meatus with dirty fingernails this procedure to dry mop the ear: nn Fungal otitis externa (otomycosis)—caused by fungal ll Roll a piece of clean absorbent cloth into a wick. infection of the external auditory meatus ll Carefully insert the wick into the ear with twisting nn Eczematous otitis externa—caused by eczema or action. dermatitis of the external auditory meatus ll Remove the wick, and replace it with a clean dry Diagnosis wick. ll Repeat this procedure until the wick is dry when nn In furuncular otitis externa (ear boil), severe pain spreads to the jaw or head. The tragus sign is positive removed. (i.e., pressure on the tragus is painful). ll Dry the ear by wicking 4 times daily at home until the wick stays dry. nn Diffuse otitis externa presents with pain or discomfort and hearing loss. ll If bleeding occurs, temporarily stop dry mopping the ear. nn Eczematous or fungus otitis externa presents with EAR, NOSE, AND THROATEAR, NOSE, irritation, itching, dull pain, and sometimes discharge. ll Do not leave anything in the ear between dry mopping treatments. nn The otoscopic examination may show the following: ll Do not instill anything in the ear. ll Furuncular otitis externa may have associated pustules of the external auditory meatus. ll Instruct the patient or caregiver to avoid getting the inside of the ear wet while swimming and bathing. ll Fungal otitis externa may have a “wet blotting paper” appearance within the external auditory ll Reassess weekly to be sure the patient or caregiver meatus and may have discharge. is dry mopping the ear correctly. EAR, NOSE, AND THROAT

84 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 85 4.1. Otitis Externa 4.2. Acute Otitis Media

Pharmacologic Patient Instructions Note: Otitis externa can usually be treated without oral nn Keep the ear clean and dry. antibiotics. nn Tell patient you need to review medications, the dry nn Apply gentian violet (1%) daily to the skin of the mopping technique, and application of topical agents. external auditory meatus with a cotton tip applicator for 10 days. 4.2. Acute Otitis Media nn Suggest paracetamol for pain until pain subsides. Refer to table A15 in annex A for standard dosages. Description Acute otitis media is a rapid-onset, short-duration nn If you suspect furuncular otitis externa (i.e., you find a pustule on examination of the external auditory infection of the middle ear caused by bacteria (e.g., meatus), prescribe— streptococcus, pneumococcus, H. influenza, Staphylococcus pyogenes) or virus. It is frequently associated with a ll Cloxacillin (500 mg capsules) when available common cold or pharyngitis because the middle ear is uu Children: 15 mg/kg/dose every 6 hours for 7 days connected to the throat via the eustachian tube. If left uu Adults: 1 capsule every 6 hours for 7 days —OR— untreated, there is some risk of chronic otitis media, deafness, or most significantly, mastoiditis (i.e., infection uu Erythromycin for 5 days for patients allergic to penicillin. Refer to table A12 in annex A for of the mastoid, the bony protrusion behind the ear), which standard dosages. can lead to meningitis and brain abscess—both of which —OR— require urgent referral to hospital. uu Chloramphenicol. Refer to table A5 in annex A for Diagnosis standard dosages. nn History nn If you suspect eczematous (allergic dermatitis) otitis ll Earache externa, using a cotton tip applicator — ll Recent pharyngitis or common cold ll Apply betamethasone (1%) cream ll Fever —PLUS— ll Vomiting or diarrhea ll Neomycin (0.5%) cream to the external auditory ll Crying and agitation meatus every 12 hours for 7 days. nn Otoscopic examination may demonstrate (depending EAR, NOSE, AND THROATEAR, NOSE, Referral on stage)— ll Redness and bulging of tympanic membrane nn Inability to properly examine the external auditory meatus and tympanic membrane ll Loss of light reflex of tympanic membrane ll Perforation, pus drainage, or both nn Failure to respond to treatment Prevention nn Avoid scratching or placing foreign body in the ear. nn Do not bath or swim in contaminated water. EAR, NOSE, AND THROAT nn Keep the ear clean and dry.

86 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 87 4.2. Acute Otitis Media 4.2. Acute Otitis Media

4.2.1. Acute Otitis Media in Children Younger nn If pus has been draining from the ear for fewer than14 Than 5 Years days OR if the child has ear pain and otoscopy reveals that the eardrum is red, inflamed, bulging, and opaque See also IMCI flipchart, “Child Has an Ear Problem.” or perforated with discharge, treat for acute otitis Management media: Nonpharmacologic uu Give co-trimoxazole for 5 days. Refer to table A8 nn Advise parent or caregiver that the child needs to— in annex A for standard dosages. ll Drink lots of fluids and avoid dehydration —OR— ll Avoid putting anything in the ear uu Amoxicillin for 5 days. Refer to table A3 in annex ll Avoid getting the ear wet A for standard dosages. In the case of penicillin nn Advise parent or caregiver to continue to feed the allergy or sensitivity, use erythromycin. Refer to child. table A12 in annex A for standard dosages. uu Give paracetamol until pain and fever subside. Pharmacologic Refer to table A15 in annex A for standard nn Ask if the child has ear pain. dosages. nn Look for discharge from ear. If yes, ask how long the uu If pus is draining from the ear, show the mother child has had discharge. or caregiver how to dry the ear by wicking or nn Feel for tender spot behind ear (sign of mastoiditis). dry mopping as described in section 4.1 “Otitis ll If the child has tender swelling behind ear, give the Externa.” Advise the mother or caregiver to wick first dose of treatment for mastoiditis, and refer 3 times per day until there is no more pus. Tell the urgently to hospital. mother or caregiver not to place anything in the uu Give first dose of IM ampicillin PLUS gentamicin ear between wicking treatments. Do not allow the according to weight or age. Refer to table A4 child to go swimming or get water in the ear. (ampicillin) and table A13 (gentamicin) in annex uu Ask the mother or caregiver to return with A for standard dosages. the child for follow-up in 5 days. If ear pain or uu Give first dose of paracetamol for pain. Refer to discharge persists, treat for 5 more days with the table A15 in annex A for standard dosages. same antibiotic and continue wicking the ear. uu If referral is not possible, repeat the dose of AND THROATEAR, NOSE, Then follow up again in 5 days. IM ampicillin every 6 hours PLUS the dose of IM gentamicin every 12 hours until child has improved. Then change to an appropriate oral antibiotic (amoxicillin or, if penicillin allergic, erythromycin) to complete a total of 10 days of treatment. Refer to tables A3 (amoxicillin) and A12 (erythromycin) in annex A for standard

EAR, NOSE, AND THROAT dosages.

88 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 89 4.2. Acute Otitis Media 4.3. Chronic Otitis Media

4.2.2. Acute Otitis Media in Children Older Than 4.3. Chronic Otitis Media 5 Years and in Adults Description Management Chronic otitis media is a persistent infection of the middle Pharmacologic ear with perforation of the tympanic membrane and nn Paracetamol for pain or fever as needed. Refer to table pus draining from ear for more than 14 days. Secondary A15 in annex A for standard dosages. infection with multiple organisms (e.g., streptococcus, nn Antibiotics pneumococcus, mixed gram-negative) may occur making ll Amoxicillin treatment with antibiotics difficult. It may be associated uu Adults: one 250–500 mg tablet every 8 hours for 7 with mastoiditis, intracranial infection, cholesteatoma, days, depending on the severity of the symptoms and deafness. —OR— Diagnosis uu In the case of penicillin allergy or sensitivity, use nn Condition is painless unless complicated by otitis erythromycin for 7 days. Refer to table A12 in externa or other conditions. annex A for standard dosages. nn Drainage is usually clear unless associated with Referral secondary infection. nn Bulging eardrum failing to improve within 48 hours of nn Otoscopy shows a perforation of tympanic membrane, treatment which is central, and may be dry or wet. nn Failure to improve after 7 days of treatment nn Hearing loss is possible. nn Signs of mastoiditis, intracranial complication, or nn In the case of complication, tinnitus, vertigo, and facial facial nerve palsy nerve palsy are possible. nn Perforation or drainage of pus Management nn Recurrent otitis media Nonpharmacologic Prevention Dry mopping is the most important intervention to dry the nn Ensure proper treatment of pharyngitis or upper ear and allow it to heal. See section 4.1 “Otitis Externa” for respiratory infection. a step-by-step description of the dry mopping procedure. nn Minimize risk factors such as allergies, second-hand AND THROATEAR, NOSE, smoke, and exposure to others with cold or flu. Pharmacologic nn Normally, antibiotics are not indicated for chronic Patient Instructions otitis media. nn Return for reevaluation in 7 days. nn If acute re-infection occurs with fever and pain despite local treatment, treat with antibiotics as for acute otitis media (see section 4.2 “Acute Otitis Media”). EAR, NOSE, AND THROAT

90 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 91 4.4. Acute Sinusitis 4.4. Acute Sinusitis

Referral nn Headache or sometimes toothache nn All children who are vomiting, drowsy, or otherwise nn Pain and tenderness over one or more sinuses showing symptoms of illness (forehead or around the eyes) nn Suspected mastoiditis—painful swelling behind the nn Possible fever ear Note: Check any common cold that does not resolve or gets n n Patients who have persistent discharge for more than worse after 5–6 days for sinusitis. 4 weeks after beginning therapy Management nn Suspected TB in patients who have persistent drainage despite therapy Nonpharmacologic nn Patients who have a large, central perforation or an nn Instruct the patient to maintain adequate hydration evident mass in the middle ear and drink plenty of fluids. Prevention nn Advise that steam inhalation may be effective at liquefying the mucus and removing nasal obstruction. nn Ensure proper treatment of acute otitis media. nn Check for dental source; refer for extraction if you nn Keep the ear dry. suspect a tooth source. nn Avoid putting any type of foreign body in the ear. Patient Instructions Pharmacologic nn Prescribe an antibiotic. nn Have patient or caregiver demonstrate his or her ability to dry mop the ear. ll Amoxicillin oral every 8 hours for 10 days. Refer to table A3 in annex A for standard dosages. nn Return weekly for evaluation. nn Watch for any sign of complication such as spreading —OR— infection, intracranial involvement, or mastoiditis; ll For patients who are allergic to penicillin, return at first sign. erythromycin oral every 6 hours for 5 days, before meals. Refer to table A12 in annex A for standard 4.4. Acute Sinusitis dosages. nn Recommend the use of nose drops. Description ll NaCl 0.9% (normal saline), as frequently as possible

Acute sinusitis is the inflammation and bacterial infection to clear discharge AND THROATEAR, NOSE, of one or more sinuses, usually after viral nasal infection, nn Prescribe an antihistamine. dental infection, or allergic rhinitis. It is uncommon in ll Chlorpheniramine oral every 8 hours per day, but no children younger than 5 years because their sinuses are longer than 5 days. Refer to table A7 in annex A for not yet developed. If not properly treated, acute sinusitis standard dosages. may result in chronic sinusitis in adults and older children. nn Recommend a pain and fever reliever. Diagnosis ll Paracetamol oral every 6 hours per day until pain, fever, or both subside. Refer to table A15 in annex A nn Nasal obstruction with loss of smell EAR, NOSE, AND THROAT for standard dosages. nn Persistent or intermittent purulent nasal discharge

92 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 93 4.5. Sore Throat 4.5. Sore Throat

Referral  . Sore throat decision tree nn Poor treatment response after 5 days nn Complications such as dental abscess, periorbital Diculty YES cellulitis, or facial edema swallowing liquids? Refer Unable to n n Fever lasting more than 2 days open mouth? nn Recurrent sinusitis NO 4.5. Sore Throat

Description Hoarseness YES Sore throat is a common symptom due to viral infections, for more than Refer  weeks? bacterial infections, and other sometimes serious conditions (i.e., mononucleosis, diphtheria, and sexually transmitted diseases such as gonorrhea, syphilis, acute human immunodeficiency virus [HIV]). NO Treat as Diagnosis and Management viral pharyngitis. See section
.€.‚. The decision tree in figure 4.5 outlines the procedure for diagnosing and managing patients who have sore throat. Red tonsils with YES Cough? YES 4.5.1. Viral Pharyngitis or without follicles Runny and fever? nose? Description Viral pharyngitis, a painful red throat without purulence, NO Treat as is most commonly due to respiratory viruses and thus bacterial tonsillitis. NO requires only symptomatic treatment. See section
.€.ƒ. Diagnosis nn Usually follows an episode of runny nose and cough nn Sore, red throat More than AND THROATEAR, NOSE,
episodes? nn Difficulty swallowing solid food Not responding YES Refer nn Fever to treatment? nn No purulent exudates Persisting cervical nodes? Note: In children younger than 5 years, check for and exclude danger signs (see IMCI flipchart). EAR, NOSE, AND THROAT

94 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 95 4.5. Sore Throat 4.5. Sore Throat

Management Management Nonpharmacologic Because of the rather frequent complications if not appropriately treated (see section 6.3 “Rheumatic Fever”), nn Recommend the use of a salt water gargle. Instruct patient to mix 1 teaspoon of salt in an 8-ounce (250 this is one condition for which injectable retard penicillin ml) glass of lukewarm water and to gargle with this is the medicine of choice to ensure full treatment and solution for 1 minute 4–6 times a day. eradication of the infection. nn First-line treatment—Give a single dose of IM nn Encourage increased fluid intake. benzathine benzylpenicillin, which can be used as Pharmacologic powder for injection 1.2 million IU in a vial of 5 ml: nn Do not give antibiotics. ll Children less than 30 kg: 2.5 ml deep IM injection nn Recommend paracetamol until fever, pain, or both ll Adults and children more than 30 kg: 5 ml deep IM subside. Refer to table A15 in annex A for standard injection dosages. —OR— nn Second-line treatment—Prescribe oral penicillin V 4.5.2. Bacterial Tonsillitis (phenoxymethylpenicillin), powder for oral liquid 250 Description mg/5 ml, or 250 mg tablet for 10 days: Bacterial tonsillitis is commonly due to beta-hemolytic ll Children younger than 5 years: 250 mg/dose every streptococci group A, especially in the 3- to 14-year 12 hours (1 tablet or 5 ml oral liquid) age group, requiring antibiotics to prevent serious ll Adults and children older than 5 years: 500 mg every complications. 12 hours (2 tablets 250 mg or 10 ml oral liquid) Diagnosis —OR— nn For patients who are allergic to penicillin, prescribe nn Sore throat erythromycin ethylsuccinate oral, powder for oral nn Usually no runny nose or cough liquid (125 mg/5 ml), or tablet 400 mg, before meals for nn Mostly enlarged cervical lymph nodes, painful when touched 5–7 days. (See also table A12 in annex A for standard dosages.) nn White patches, exudates, or follicles on the throat nn If patient has a high fever, give paracetamol until fever nn Fever, often with sudden onset AND THROATEAR, NOSE, subsides. Refer to table A15 in annex A for standard Caution: If not treated properly, streptococcal throat dosages. infection can lead to serious complications such as the following: Referral nn See figure 4.5. nn Acute glomerulonephritis (section 11.2) nn In severe cases, especially in cases of peritonsillar nn Acute rheumatic fever (section 6.3) abscesses, refer. nn Abscesses around the throat EAR, NOSE, AND THROAT

96 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 97 4.6. Rhinitis 4.6. Rhinitis

4.6. Rhinitis nn Associated conditions (rare) ll Asthma Description ll Sinusitis Rhinitis is defined as an inflammatory condition that ll Eczema affects the nasal mucosa in which histamine and other Management mediator release leads to sneezing, nasal stuffiness, nn Instruct the patient to maintain adequate hydration increased mucous production (“runny nose”), and and drink plenty of fluids associated symptoms. Causes of rhinitis include the nn Suggest a salt water (normal saline 0.9% solution) following: rinse of nose to decrease mucous and congestion 3 nn Allergic rhinitis—Allergens such as pollens (mostly times daily. seasonal), dust, molds, food, and animal fur and nn Prescribe a systemic medicine. dander trigger symptoms. Allergic rhinitis is the most ll Chlorpheniramine maleate. Refer to table A7 in common presentation of rhinitis. It is often seasonal annex A for standard dosages. and often runs in families. uu Children: as needed nn Nonallergic rhinitis—Medicines, hormones, weather uu Adults: 4 mg every 8 hours as needed and temperature change, smoke, fumes and chemicals (e.g., insecticides, bleaching powder, paints), and Referral other inhaled irritants trigger symptoms. It is often a nn Failure to improve after 1 week of treatment persistent form of rhinitis. nn Recurrent symptoms—for consideration of long-term nn Infectious rhinitis—Bacteria or viruses trigger use of pharmaceutical prophylaxis symptoms (section 3.2 “Common Cold and Flu”). Prevention and Patient Instructions Diagnosis nn Advise patient to avoid recognized triggering factors. nn Most common signs and symptoms nn Ensure that patient does not overuse or abuse topical ll Increased nasal discharge (i.e., runny nose) nasal decongestants (a common occurrence) to avoid ll Nasal congestion (i.e., stuffy nose) rebound rhinitis. ll Sneezing, itchy nose nn Chlorpheniramine and other antihistamines may nn cause drowsiness; advise patients to avoid driving or

Associated signs and symptoms AND THROATEAR, NOSE, ll Red, inflamed, teary, and swollen eyes and lids operating machinery when taking. (conjunctiva) nn Ask patient to return in 1 week if no improvement or ll Clogged ears; middle ear effusion condition worsens. ll Swollen nasal mucosa nn Suggest patient reduce mold, dust, and mite (a tiny ll Diminished sense of smell creature present in the dust of pillows, mattresses, ll Fatigue carpets) concentration in the home by frequent ll Cough, sore throat, headache—especially with cleaning and replacing old or soiled carpets and

EAR, NOSE, AND THROAT infectious rhinitis bedding.

98 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 99 5.1. Conjunctivitis (Red Eye) 5.1. Conjunctivitis (Red Eye)

Chapter 5. usually present with sudden onset, severe pain, reduced vision, and cloudy or gray patch on cornea, Eye Conditions may cause sudden blindness. They require immediate

referral. eye 5.1. Conjunctivitis (Red Eye) eye Management Description Nonpharmacologic Red eye is most commonly caused by conjunctivitis (i.e., nn Clean eyes with clean (i.e., boiled) slightly warm water inflammation of the membrane covering the inside of or sterile normal saline solution (0.9%) 4–6 times a eyelids and white part of eyeball). The causes may be day. bacterial, viral, or allergic or from an irritation, injury, nn Take away pus with a clean cloth or tissue, but never or foreign body. Untreated, conjunctivitis may lead to use the same cloth or tissue— keratitis (i.e., a serious infection of membrane covering ll Twice iris and pupil) and blindness. Infectious causes are easily ll For both eyes spread from person to person. ll On another person Diagnosis Pharmacologic nn In addition to redness, the patient may have mild pain, nn For purulent drainage, prescribe tetracycline 1% itching, and blurred vision. Usually the onset is gradual eye ointment to be applied twice a day (after eating and slow. breakfast and before going to sleep) for 7 days. Show nn Examine eye for the following: the patient how to apply a small amount of ointment ll Visual acuity correctly (see “Patient Instructions” below). ll Purulent discharge—usually seen with bacterial nn For severe itching, consider chlorpheniramine. Refer conjunctivitis to table A7 in annex A for standard dosages. l l Watery discharge—usually seen with viral or allergic Referral conjunctivitis nn All cases with change of vision ll Cornea—clear or cloudy nn All cases with clouding or ulcer of cornea ll Eyelid—swelling or foreign body. Check for evidence nn Suspicion of keratitis, iritis, glaucoma, corneal ulcer, of follicles (i.e., small white or yellow raised dots) or penetrating injury, or trachoma scarring on the inside of the eyelid because they may nn Failure to improve after 5 days of treatment with be a sign of trachoma (see section 5.2); if present, ointment refer. nn All cases of suspected conjunctivitis in the neonate ll Foreign body—Check for presence on the eye and under the eyelid. Prevention nn Improve personal hygiene. nn Differential diagnoses include corneal ulcer, keratitis, acute iritis, and glaucoma. These conditions, which nn Wash face and hands regularly.

100 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 101 5.1. Conjunctivitis (Red Eye) 5.2. Trachoma

nn Do not share towels. 5.2. Trachoma nn Do not touch or rub the eyes. Description Patient Instructions Trachoma is a transmittable and chronic inflammation nn Teach the patient (or the patient’s caregiver) how to eye of the conjunctiva caused by infection called Chlamydia eye correctly apply eye ointment when it is prescribed. trachomatis. Initial infection is usually contracted during Take the time to explain in detail how to apply the childhood through direct or indirect contact with dirty ointment, and have the patient (or the patient’s hands, dirty towels, or flies; it is self-limiting. Repeated caregiver) demonstrate competence to you. Instruct infections lead to scarring, deformity, and blindness in the patient to follow this procedure: adults. ll Wash your hands. ll Sit in front of a mirror so you can see what you are Diagnosis doing. nn Afghanistan is endemic for trachoma, so every case of ll Take the lid off the ointment. conjunctivitis should be suspected to be trachoma. nn ll Tip your head back. Turn both upper eyelids inside out and look for the ll Gently pull down your lower eyelid and look up. signs of trachoma as listed in table 5.2. nn ll Hold the tube above the eye and gently squeeze a Differential diagnoses include conjunctivitis, keratitis, 1 cm line of ointment along the inside of the lower corneal ulcer, iritis, and glaucoma. eyelid, taking care not to touch the eye or eyelashes with the tip of the tube. Table 5.2. Trachoma Diagnosis ll Blink your eyes to spread the ointment over the Stage Signs of Trachoma surface of the eyeball. 1 Five or more follicles (i.e., whitish, gray, or yellow raised ll Your vision may be blurred when you open your dots) can be seen on the inner surface of the eyelid. eyes, but do not rub your eyes. Keep blinking the eyes 2 Inflammation in addition to follicles is apparent. The until the blurring clears. eyelid is rough and thickened, and the normal blood vessels seen on the conjunctiva are masked by follicles ll Wipe away any excess ointment with a clean tissue. and thickening. ll Repeat this procedure for the other eye if both eyes need to be treated. 3 Scars replace the follicles, presenting as white lines, bands, or patches on the inner surface and edge of the ll Replace the lid of the tube. eyelid. ll Take care not to touch the tip of the tube with your 4 Deformity of the eyelid occurs from scarring. The fingers. deformity, which turns the eyelid inward, may cause nn Tell patient to come back if— corneal injury and ulceration. ll Viral or allergic conjunctivitis (watery discharge) 5 Clouding of the cornea from chronic injury develops and starts producing purulent secretions may progress to blindness. ll Sharp pain or photophobia develops ll No improvement after 4–5 days

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Management Patient Instructions Nonpharmacologic nn Teach the patient and family members how to correctly apply 1% tetracycline eye ointment. See nn Clean eyes and face several times each day.

“Patient Instructions” in section 5.1, “Conjunctivitis.” eye nn Limit the density of flies through proper waste nn Patients and their families should regularly wash their eye management. faces and hands at least daily with soap and clean Pharmacologic water. The patient should not share towels with other nn Treat follicles and inflammation (stages 1 and 2). family members. ll Prescribe 1% tetracycline eye ointment 2 times per day for 6 weeks. Treat not only the patient but 5.3. Glaucoma also all family members. Teach the patient(s) (or the patient’s caregiver) how to correctly apply eye Description ointment. See “Patient Instructions” in section 5.1, Glaucoma is an eye disease in which the optic nerve “Conjunctivitis.” is damaged. It is usually associated with increased ll If no improvement with tetracycline 1% eye intraocular pressure, which results in loss of vision. There ointment after 6 weeks, refer the patient to DH for are three type of glaucoma: acute, chronic, and congenital. treatment with azithromycin to take in a single dose: Diagnosis uu Children: 20 mg/kg nn Acute (closed angle) glaucoma uu Adults: 1 gram (can be given to pregnant women ll Progressive, unilateral visual loss and lactating women) ll Periocular pain (often severe) Referral ll Congestion (i.e., dull red all over the eye) nn Evidence of progressive disease or corneal scarring ll Watery discharge requires referral. ll Nausea and vomiting in severe cases nn For stages 3, 4, and 5, refer the patient to hospital for ll Cornea cloudiness and edema possible surgery. ll Patient may see colored haloes around lights (bright Prevention rings) ll Pupil may be fixed, semi-dilated, and oval-shaped nn Improve personal hygiene. ll Shallow anterior chamber nn Wash face and hands regularly, at least daily, with soap and clean water. Caution: Acute glaucoma is a sight-threatening emergency. Its onset may be sudden. nn Do not share towels. nn Chronic (open angle) glaucoma nn Secure sources of clean water. ll Typically both eyes affected (bilateral) nn Control flies by spraying and using proper waste management (i.e., keeping animals away from the ll Gradual vision loss house and using deep-covered toilets). ll Older patients (more than 40 years) ll Sluggish reaction of the pupil

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nn Congenital glaucoma ll Typically both eyes affected ll Gradual visual loss ll Corneal clouding ll Watery discharge eye ll Photophobia ll Involuntary spasmodic winking of the eyelid (blepharospasm) ll Buphthalmos (i.e., large eye with bluish appearance) Management nn Refer all patients who have suspected glaucoma. Caution: All cases of painful eye with loss of vision should be considered an ophthalmologic emergency and be referred to hospital. nn Keep patient in supine position during transport (when possible). Patient Instructions nn Ensure that patients and family keep referral appointments. nn Instruct patients and community regarding eye safety during use of machinery and at-risk activities.

106 National Standard Treatment Guidelines for the Primary Level 6.1. Systemic Hypertension

Chapter 6. Cardiovascular System Conditions

6.1. Systemic Hypertension

6.1.1. Chronic Hypertension Description Chronic elevation of blood pressure (BP) more than 140/90 mmHg is called hypertension (HTN). In 90–95% of CARDIOVASCULAR patients, etiology is unknown (essential HTN or primary HTN). In 5–10% the cause is known (secondary HTN). The objective of the treatment of chronic HTN is to prevent long-term complications (e.g., cardiac disease or stroke) from HTN. Diagnosis nn Determine the degree or classification in 3 different BP measurements, 2 days apart in a patient at rest in a sitting or reclined position. (See table 6.1.1A.) If BP is abnormal, take in both arms. nn Determine the patient’s other risk factors for HTN and cardiovascular disease that influence the long-term prognosis:

Table 6.1.1A. Classification of Hypertension

Systolic BP Diastolic BP BP Classification (mmHg) (mmHg) Normal <120 <80 Pre-HTN 120–139 80–89 Stage 1 HTN (mild) 140–159 90–99 Stage 2 HTN (moderate) 160–179 100–109 Severe HTN ≥180 ≥110

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ll Diabetes mellitus uu High BP maybe the only sign. BP is taken in both ll Obesity arms and at rest (preferably 3 measurements at ll Smoking rest, at least 2 days apart). Never decide a patient ll Blood lipid disorders (Dyslipidemia) has HTN based on one isolated elevated BP ll Family history of primary HTN or premature measurement. cardiovascular disease in men younger than 50 years uu In secondary HTN, symptoms of the primary and in women younger than 55 years disease may be noted (e.g., Cushing’s syndrome, ll Physical inactivity polycystic kidney). nn Determine the patient’s pre-existing diseases that affect uu In stroke patients who have neurological signs prognosis: and symptoms (e.g., weakness or paralysis of ll Left ventricular hypertrophy one side of the body) complications such as CARDIOVASCULAR ll Ischemic heart disease (angina or prior myocardial hypertensive heart disease may be present. infarction) uu Retina artery damage (grade I, II, III, IV) may also ll Heart failure indicate HTN. ll Transient ischemic attacks Management ll Stroke

CARDIOVASCULAR The goal is to achieve and maintain the target BP. (See ll Chronic renal impairment table 6.1.1B for a summary of nonpharmacologic and ll Retinopathy pharmacologic management of HTN.) ll Peripheral arterial disease nn In most cases, the target BP should be— nn Examine the patient for the symptoms and signs of HTN. ll Diastolic below 90 mmHg ll Symptoms ll Systolic below 140 mmHg uu Mild to moderate primary HTN is largely nn In special cases (e.g., diabetic patients or patients asymptomatic for many years. The most frequent who have cardiac or renal impairment), the target BP symptom is headache, which is nonspecific. should be— uu Severe HTN may be associated with somnolence, ll Diastolic below 80 mmHg confusion, visual disturbances, nausea, and ll Systolic below 130 mmHg vomiting and with palpitations, unstable angina, pulmonary edema, and renal failure. Nonpharmacologic Lifestyle changes for all patients who have HTN include uu Untreated chronic HTN often leads to left ventricular hypertrophy, which can present with the following: exertional dyspnea, paroxysmal nocturnal dyspnea, nn Restrict salt intake. and other symptoms of secondary causes. nn Lose weight, if overweight. nn Stop smoking. ll Signs nn Stop alcohol consumption. uu Duration, severity, and degree of effect on target organs are primary signs. nn Get regular physical exercise.

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Table 6.1.1B. Management of Hypertension Table 6.1.1B. Management of Hypertension (continued)

Classification Treatment Desired Effect Classification Treatment Desired Effect Step 1 Step 3

nn Diastolic BP Nonpharmacologic BP falls below nn Failure step 2 after Nonpharmacologic BP falls below 90–99 mmHg, treatment (see 140/90 mmHg 1 full month of treatment 140/90 mmHg systolic BP above) within 3 months of treatment —PLUS— within 1 month of 140–159 mmHg, starting treatment —OR— Oral starting treatment or both (i.e., controlled BP) nn Diastolic BP ≥110 hydrochlorothiazide (i.e., controlled BP) nn No major risk mmHg, systolic tablets, 12.5 mg in factors present BP ≥180 mmHg, the morning, daily nn No existing or both —PLUS—

concomitant Oral atenolol, 25 CARDIOVASCULAR disease present mg (up to 100 mg) once daily Step 2 Caution: See nn Diastolic BP Nonpharmacologic BP falls below contraindications 90–99 mmHg, treatment 140/90 mmHg above. systolic BP —PLUS— within 1 month of If BP has not been normalized after 1 month on treatment step 3, 140–159 mmHg, Oral starting treatment

CARDIOVASCULAR refer patient for further evaluation and therapeutic options. or both hydrochlorothiazide (i.e., controlled BP) nn No major risk tablets, 12.5 mg in factors present the morning, daily nn Restrict saturated fat intake (i.e., butter, animal fat). nn No existing Caution: See nn Increase unsaturated fat intake (i.e., olive oil, fruits, concomitant contraindications disease present above. vegetables). nn Failure of step 1 Pharmacologic after 3 months —OR— Use when lifestyle changes and nonpharmacologic nn Diastolic BP interventions are not successful. 90–99 mmHg, nn systolic BP First-line therapy—hydrochlorothiazide: 12.5–25 mg 140–159 mmHg, daily, in the morning or both Caution: Contraindicated in patients who are nn Major risk factors or existing pregnant or who have renal disease, gout, or severe concomitant liver disease. disease present nn Second-line therapy (if a 1-month trial of first-line —OR— therapy fails)—atenolol: 25–50 mg once daily (to a nn Diastolic BP 100–109 mmHg, maximum dose of 100 mg once daily) systolic BP Caution: Atenolol is absolutely contraindicated in 160–179 mmHg, or both patients who have asthma and chronic obstructive pulmonary disease and relatively contraindicated in

110 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 111 6.1. Systemic Hypertension 6.1. Systemic Hypertension

patients who have heart failure, bradycardia (less ll Patients not responding adequately to step 3 after than 50/minute), diabetes mellitus, and peripheral 1 month of treatment vascular disease. ll Patients showing signs of organ damage such as Further therapeutic options may include the following: angina pectoris, dyspnea, edema, or proteinuria ll Patients showing severe side effects of the nn A diuretic administered alone controls BP in 50% of patients who have mild to moderate HTN and medicines can be used effectively in combination with other Patient Instructions agents. Oral hydrochlorothiazide (12.5–50 mg daily nn Restrict salt intake. Do not add salt at the table. preferably in the mornings) may be prescribed if not nn Lose weight. contraindicated. nn Restrict fatty diet. CARDIOVASCULAR Note: If renal function was disturbed, furosemide nn Stop smoking. could be administered (initial dose: oral 40 mg in nn Stop consuming alcohol. morning; maintenance: 20–40 mg daily). Furosemide nn Take medication daily. is available in CHCs and DHs. nn Come back weekly for BP check until BP is well nn A beta-adrenergic blocking agent may be used. controlled; then every 2 months. Take the medication

CARDIOVASCULAR Atenolol is a beta-blocking agent; the initial the morning of the visit. treatment dose of 25 mg once daily can be increased nn Get regular, moderate physical exercise. to up to a maximum of 100 mg once daily if not nn Avoid stress and other risk factors (see above). contraindicated. Atenolol is available in CHCs and DHs. 6.1.2. Hypertension Emergency nn Angiotensin-converting enzyme (ACE) inhibitors Hypertension (HTN) with diastolic blood pressure (BP) may be prescribed. The starting dose for captopril more than or equal to 130, systolic BP more than or equal is 25 mg every 12 hours. Captopril is available in to 180, or both that is associated with any of the following regional hospitals. constitutes an emergency: nn Calcium channel blockers, such as amlodipine, may nn Unstable angina pectoris (see section 6.4 “Angina be prescribed at a dose of 5 mg once daily. Pectoris”) Referral nn Grade 3 or 4 hypertensive retinopathy nn Refer the following cases before initiating nn Neurological signs: severe headache, confusion, visual pharmacological treatment: disturbances, seizures, decreased consciousness, or ll Children and young adults (younger than 30 years) coma ll Pregnant women (see section 9.3 “Hypertension nn Pulmonary edema (see section 16.1 “Acute Pulmonary Disorders of Pregnancy”) Edema”) nn Refer all of the following for more specialized nn Renal failure investigation and care:

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Management nn Left-side failure—principally from fluid backing up in Treat patient and urgently refer. the lungs nn Treat emergency conditions: pulmonary edema, ll Dyspnea or tachypnea (may first appear when cardiac ischemia, and coma. patient assumes supine position) nn Give nifedipine: one tablet 10 mg. Repeat after 1 hour ll Cough—heart failure may be confused with for BP more than 180/130. respiratory infection, especially in infants and —OR— children nn Give captopril (if available) tablet 25–50 mg. ll Fatigue Referral ll Nocturia All HTN emergencies need immediate urgent referral. ll Crackles ll Tachycardia, gallop rhythm, or heart murmur— CARDIOVASCULAR 6.2. Cardiac Failure depending on underlying cause nn Right-side failure Description ll Peripheral edema Cardiac, or heart, failure is a condition in which the ll Hepatomegaly, ascites heart is unable to pump sufficient blood for metabolizing ll Fatigue, nocturia CARDIOVASCULAR tissues, or it is the inability of the heart to maintain ll Jugular-venous distension adequate cardiac output to meet the demands of the body. ll Tachycardia, gallop rhythm, or heart murmur— It can result from conditions that depress ventricular depending on underlying cause function (e.g., coronary artery disease, hypertension, nn Right- and left-side failure dilated cardiomyopathy, valvular heart disease, or ll Combination of above signs and symptoms congenital heart disease) and from conditions that ll Infants may demonstrate poor feeding and sleeping restrict ventricular filling (e.g., mitral stenosis, restrictive Chest X-ray (when available) may demonstrate cardiomyopathy, or pericardial disease). cardiomegaly with or without pulmonary congestion. Acute precipitating factors include the following: Management n n Increased sodium intake Nonpharmacologic nn Arrhythmia nn Advise bed rest to reduce the demand on the heart, and n n Infection to reduce lung congestion as well, the sitting position n n Anemia in bed is recommended. nn Thyrotoxicosis nn Encourage a low-salt diet (i.e., limit intake to no more n n Pregnancy than 2 g salt per day) and good general nutrition. Diagnosis nn Advise weight reduction if patient is obese. Signs and symptoms are related to whether the right, left, nn Instruct the patient to stop smoking. or both sides of the heart are affected: nn Encourage regular, moderate exercise within the limits imposed by the patient’s symptoms.

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Pharmacologic ll Initiate emergency care with oxygen and IV nn Correct reversible causes such as myocardial ischemia furosemide (1 mg/kg) when available. (see section 6.4 “Angina Pectoris”), hypertension (see ll Avoid giving IV fluids. section 6.1 “Systemic Hypertension”), arrhythmia, or nn All newly diagnosed heart failure cases must be cardiomyopathy. referred for further tests and therapeutic options. nn Prescribe diuretic therapy, which is the most effective nn New complications of heart failure (e.g., arrhythmia, means of providing symptomatic relief to patient who progression of disease, new signs and symptoms) must has moderate to severe cardiac failure. be referred. ll Prescribe hydrochlorothiazide 25–100 mg once (mild). Caution: Contraindicated in pregnancy, 6.3. Rheumatic Fever renal disease, gout, and severe liver disease. CARDIOVASCULAR —OR— Description Rheumatic fever is an acute systemic immune process ll Prescribe oral furosemide. occurring 1–3 weeks after a streptococcal throat infection, uu Initial dose: 20–80 mg per dose commonly in children 3–15 years old. Streptococcal skin uu Maintenance dose: 20–40 mg/dose every 6 to 8 hours to desired effect infections are not associated with rheumatic fever. The CARDIOVASCULAR —OR— best way to prevent rheumatic fever is to treat promptly and properly any episode of acute streptococcal infection ll Prescribe IV or IM furosemide injection. (see section 4.5.2 “Bacterial Tonsillitis”). uu 10 to 20 mg once over 1 to 2 minutes. uu A repeat dose similar to the initial dose may be Long-term prophylaxis treatment against further attacks given within 2 hours if response is inadequate. of rheumatic fever can decrease the long-term damage. u u Following the repeat dose, if response remains Diagnosis inadequate after another 2 hours, the last IV dose Rheumatic fever signs and symptoms may include the may be raised by 20–40 mg until effective diuresis following: is achieved. nn Fever nn Prescribe a combination of angiotensin-converting nn Painful and red, hot, swollen joints enzyme (ACE) inhibitor PLUS diuretics. All patients ll Most often the ankles, knees, elbows, or wrists; less who have heart failure should be on ACE-inhibitor often the shoulders, hips, hands, and feet unless contraindicated. ll May involve multiple joints or migrate from joint to Caution: Pregnancy is a contraindication. joint ll Prescribe captopril 6.25–12.5 mg every 8 hours. nn Cardiac disease Referral ll May include endocarditis, heart failure, valvular nn All severe cases of heart failure (e.g., pulmonary disease (heart murmur upon auscultation) edema; see section 16.1 “Acute Pulmonary Edema”) ll May include arrhythmia or a sensation of rapid, must be referred. Start treatment before referral: fluttering, or pounding heartbeats (palpitations)

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nn Small, painless nodules beneath the skin ll No rheumatic valvular disease. These patients need (subcutaneous nodules); infrequent 5 years of treatment or until the age of 21, whichever nn Fatigue is longer. nn Flat or slightly raised, painless rash with a ragged edge nn Prescribe the following medications for duration (erythema marginatum); infrequent according to the protocol above. nn Chorea: jerky, uncontrollable body movements ll First choice of treatment: benzathine (Sydenham’s chorea or Saint Vitus Dance); most often benzylpenicillin, powder for IM injection, 1.2 in the hands, feet, and face; rare. Unusual behavior, million IU in a vial of 5 ml. Give 1 IM injection every such as crying or inappropriate laughing; infrequent 4 weeks. For high-risk patients or patients who are Management still having recurrences of rheumatic fever, give the CARDIOVASCULAR Objectives: IM injection every 2 or 3 weeks. uu Children less than 30 kg: 2.5 ml deep IM (i.e., nn Prevent rheumatic fever disease by early and proper treatment of streptococcal throat infection. 600,000 IU) uu Adults and children more than 30 kg: 5 ml deep IM nn Limit damage or further damage by preventing recurrent attacks of rheumatic fever disease through a Caution: Avoid using IM injection for patients who are taking warfarin.

CARDIOVASCULAR prophylaxis treatment. nn Treat inflammation, heart disease, and other —OR— symptoms. ll When injections are contraindicated, give oral penicillin V (phenoxymethylpenicillin). Use powder Nonpharmacologic for oral liquid 250 mg/5 ml, or tablet 250 mg. Patient should be kept at strict bed rest until— uu Children younger than 5 years: 125 mg every 12 nn The temperature returns to normal hours (1/2 tablet or 2.5 ml) every day nn Resting pulse rate is normal (under 100/minute in uu Adults and children older than 5 years: 250 mg children) every 12 hours (1 tablet or 5 ml) every day Pharmacologic —OR— nn Initiate pharmacologic treatment for all patients who ll If patient is allergic to penicillin, give oral have confirmed rheumatic fever and— erythromycin. Use powder for oral liquid, 100 ll Carditis and persisting heart disease. These patients mg/5 ml, or 250 mg erythromycin stearate, base, need 10 years of treatment after the last episode or estolate tablet (which is equivalent to 400 mg of acute rheumatic fever, or until the age of 45, erythromycin ethylsuccinate tablet). whichever is longer. uu Children younger than 5 years: 125 mg every 12 ll Rheumatic valvular disease. These patients need hours (1/2 tablet or 2.5 ml) before meals, every day 10 years of treatment after the last episode of acute uu Adults and children older than 5 years: 250 mg rheumatic fever, or until the age of 25, whichever is every 12 hours (1 tablet or 5 ml) before meals, longer. every day

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nn Treat inflammation 6.4. Angina Pectoris ll Give oral acetylsalicylic acid (aspirin). Advise patient to take during meals to prevent gastric Description irritation. Angina pectoris can present as a stable or unstable form: nn uu Children older than 5 years: 10–20 mg/kg/dose Stable angina pectoris: Angina pectoris is a clinical every 6 hours for 2–4 weeks (until fever and joint syndrome characterized by paroxysmal chest pain swelling subside). Caution: Do not give aspirin to due to transient myocardial ischemia. Chest pain is children younger than 5 years because of the risk precipitated by stress or exertion and relieved rapidly of Reye’s syndrome. by rest or sublingual nitrate. The most common cause uu Adults: 500 mg every 6 hours for 2–4 weeks (until is atherosclerosis; however, angina may occur in aortic fever and joint swelling subside) stenosis and hypertrophic cardiomyopathy. CARDIOVASCULAR nn Unstable angina pectoris: Unstable angina is usually Referral characterized by new onset severe angina or sudden nn All suspected cases for confirmation worsening of previously stable angina and may not be nn All complicated cases suspected of heart disease for relieved by sublingual nitroglycerin. further investigation and treatment options nn Diagnosis

CARDIOVASCULAR Patients who have a poor response to treatment nn nn Patients who have no tolerance or for whom aspirin is Symptoms contraindicated ll Patient has chest pain, a sensation of tightness, nn Patients who have other complications (e.g., chorea) squeezing, burning, pressing, hooking, aching, or gas indigestion. The pain is located behind or slightly to Prevention the left of the mid sternum. nn Ensure prompt and appropriate antibiotic treatment ll Pain may radiate to the jaw or left shoulder and of streptococcal throat infection (see section 4.5.2 upper arm, and move down the inner arm to the “Bacterial Tonsillitis”). elbow, forearm, wrist, or four and fifth finger. The nn Continue prophylaxis treatment until age limits (see pain maybe associated with dizziness or fainting. above). ll Exclude other causes of chest pain. nn Inform patient of possible symptoms of complications nn Signs (e.g., heart disease, heart failure, and other symptoms ll During attack, patient looks anxious, dyspneic, and as described above). pale; cold sweats may also be present. ll ECG between attacks maybe normal; during attack, ECG shows ST segment depression and T wave inversion.

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Management Note: Unstable angina could be treated like Nonpharmacologic myocardial infarction. See following section on Acute Myocardial Infarction nn Do not smoke. nn Aim for ideal body weight. Referral nn Avoid vigorous exercise after heavy meal or in very Refer all patients who have recurrent or persistent cold weather, and stress. chest pain for additional investigation, including an Pharmacologic exercise tolerance test and coronary angiography, and for treatment. nn Prescribe sublingual nitroglycerin (0.5 mg sublingual tablet) to be repeated after 5 minutes if needed (not Patient Instructions

more than 3 times). Nitroglycerin causes coronary nn Do not smoke. CARDIOVASCULAR vasodilatation and acts in about 1–2 minutes. It is nn Restrict fatty diet (e.g., saturated fats, nuts). available at regional hospitals and district hospital. nn Avoid heavy exertion, heavy meals, and cold weather. nn Give an aspirin dose of 81–325 mg orally once a day nn Get regular exercise and activity. beginning as soon as unstable angina is diagnosed and continuing indefinitely. 6.5. Acute Myocardial Infarction

CARDIOVASCULAR nn Prescribe isosorbide dinitrate, which is available in DHs. Description Acute myocardial infarction (AMI) is acute ischemic ll In acute attack, give initial dose of 2.5 mg sublingual tablet once, and repeat as needed as soon as the necrosis of an area of myocardium caused by complete or tablet has dissolved. The dose may be doubled and partial occlusion of a coronary artery. titrated upward as tolerated. The onset of action is Diagnosis within 3 minutes. Note: Not all symptoms and signs need to be present, and ll In chronic angina and as maintenance dose, give 25% of AMIs do not give any clear clinical signs. 10-40 mg sustained release tablet every 12 hours. nn The primary clinical sign is severe chest pain similar Sustained release preparations, if available, are to angina: preferred for patient tolerance. ll Retrosternal or epigastric ll Prescribe atenolol 50–100 mg daily for chronic ll Crushing or burning angina. ll Radiating to the neck, the inner part of the left arm, Caution: Atenolol is absolutely contraindicated in or both patients who have asthma and chronic obstructive ll Persisting more than 30 minutes pulmonary disease and relatively contraindicated ll Occurring at rest in patients who have heart failure, bradycardia nn Other signs that may be present include the following: (fewer than 50 beats/minute), diabetes mellitus, and ll Paleness peripheral vascular disease. ll Sweating ll Irregular heartbeat

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ll Anxiety Referral ll Difficulty breathing, indicating cardiac failure (see Refer all AMI cases urgently. section 6.2 “Cardiac Failure” ) Patient Instructions Note: Rest and sublingual nitroglycerine will not nn Stop smoking. completely relieve chest pain. nn Stop consuming alcohol. n Management n Control blood pressure and blood sugar. n Prepare for referral. n Do not lift heavy weights. nn Reduce body weight. Nonpharmacologic nn Resume sexual intercourse after 6 weeks. nn Activity: nn Return to work after 6–8 weeks. ll Complete bed rest for the first 12 hours CARDIOVASCULAR nn Get regular follow-up care from physician. ll Sitting upright or in a chair within 24 hours if no hypotension nn Diet: ll Nothing by mouth or only clear liquids by mouth for the first 4–12 hours because of the risk of vomiting CARDIOVASCULAR and aspiration ll A bedside commode facility should be available; give laxative for constipation. Pharmacologic nn Give cardiopulmonary resuscitation, if necessary. nn To reduce blood clotting, give aspirin immediately: 325 mg orally. If a solid dose formulation is used, the first dose should be chewed, crushed, or sucked. nn For pain relief, give sublingual nitroglycerine tablet (available in regional and DHs): 0.5 mg every 5 minutes up to 3 doses. —OR— nn Give isosorbide dinitrate sublingual tablet (available in DHs): 5 mg every 5–10 minutes as needed for pain to a maximum of 5 tablets. nn If patient has no response to pain relievers, give morphine 4–8 mg slow (1 mg/minute) IV injection (0.4–0.8 ml of a vial of 10 mg/ml). nn Open an IV line, and refer urgently to hospital.

124 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 125 7.1. Epilepsy 7.1. Epilepsy

Chapter 7. Central Nervous ll Development during childhood ll Management of previous seizures System Disorders nn Take a social history to assess the patient’s supportive environment. 7.1. Epilepsy A careful physical examination will determine the Description following: The term epilepsy denotes any disorder characterized by nn Whether a treatable condition is present. Excluding recurrent seizures. A seizure is a transient disturbance any treatable condition that might be a provoking of cerebral function due to an abnormal paroxysmal factor of the present seizure (see the list of provoking neuronal discharge in the brain. Epilepsy, which is often factors above) is important. associated with social, psychological, legal, and cultural nn The classification of the seizure. Seizures may be misperceptions, has several forms and causes. classified as— ll Generalized (grand mal) or tonic-clonic: myoclonic nn Idiopathic epilepsy—No specific cause can be identified. jerking ll Absence (petit mal): brief loss of consciousness and nn Symptomatic epilepsy—Provoking factors, such as the following, can be identified: flaccid muscles ll Partial or focal: localized involvement to one part of ll Intracranial infection such as bacterial meningitis, injury, mass lesion, or stroke the body nn Associated events. A seizure may be associated with— ll Metabolic disorders such as uremia, hypoglycemia NERVOUS SYSTEM and hyperglycemia, hypocalcemia, liver failure, or ll Pre-seizure aura—a warning signal that a seizure is other disorders imminent (usually known by the patient); the aura may be visual or auditory, or it may be a taste, smell, ll Drug or alcohol use or withdrawal or somatic sensation Diagnosis ll Cyanosis, salivation, tongue biting, or loss of bowel Never diagnose epilepsy based on only 1 seizure; 10% of NERVOUS SYSTEM NERVOUS and bladder control all people have 1 seizure during their lifetimes. Key in ll Either rapid or slow recovery; patients may the diagnosis of epilepsy is that the patient has 2 or more rapidly recover or may have prolonged period of seizures without any clear cause (i.e., with none of the somnolence, confusion, or headache provoking factors listed above); 70% of patients who have ll Abnormal behavior or mood alteration (infrequent had 2 seizures will have a third one. association) Careful history-taking is important. nn Take a medical history to include the following: ll A detailed description of at least the 2 last seizures ll Family history of seizures ll Perinatal history

126 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 127 7.1. Epilepsy 7.1. Epilepsy

Management Referral Nonpharmacologic nn All new patients who are suspected of epilepsy for nn During the seizure— diagnosis and initiation of therapy by a doctor or ll Move the person away from danger (e.g., fire, water, specialist machinery). nn All new epileptic patients after first dose of diazepam ll Ensure that the airway is clear. as soon as possible nn nn After the seizure stops— Patients who have had an increase in the number or ll Turn the patient into the recovery position (i.e., frequency of seizures or changes in the seizure type semi-prone). nn All women who are known epileptics and who are nn Person may be drowsy and confused for 30–60 pregnant for possible adjustment in medication during minutes and should not be left alone until fully the pregnancy recovered. nn Patients who have developed neurologic signs or symptoms Pharmacologic nn Patients experiencing adverse drug reactions or nn Give oxygen (if available) to prevent cerebral hypoxia. suspected toxicity nn Give diazepam. nn Patients who have been seizure-free on therapy for 2 ll Children younger than 10 years years or longer—for review of therapy uu Give diazepam rectally. –– Use a TB or insulin syringe; draw the Note: When referring patients, always provide detailed information about the seizure: appropriate diazepam dose; take out the needle NERVOUS SYSTEM and insert the syringe 4–5 cm into rectum nn Number and frequency of seizures (per month or per before emptying. Squeeze buttocks together for year) 2–3 minutes. nn Date of first seizure ever and dates of most recent –– Refer to table A9 in annex A for standard seizures dosages. nn Classification of seizure NERVOUS SYSTEM NERVOUS —OR— nn Description of seizure ll uu Give IV diazepam (over 10 minutes). Refer to Specifically— table A9. uu Were most of the recent seizures preceded by ll Adults and children older than 10 years auras? uu uu Give IV anticonvulsant diazepam. Refer to table Was there complete loss of consciousness? A9 in annex A for standard dosages. uu What happened during the seizure (step by step)? Caution: Monitor for respiratory depression or ll Generally— arrest. uu How long do the patient’s seizures usually last? —OR— uu What does patient feel or do after the seizure? uu uu Injection can be IM (same initial dose) and How long does it take the patient to recover from repeated once in 3-4 hours if necessary. the seizure?

128 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 129 7.2. Encephalitis and Meningitis 7.2. Encephalitis and Meningitis

nn Family history of seizures nn Meningitis: Infection of the coverings of the brain or nn Medication or substance abuse history, including spinal cord alcohol and illicit drugs ll Most often from bacteria (Pneumococcus, nn Name and dosage of anti-epileptic medicines the Meningococcus, H. Influenza, mixed gram-negative patient takes and whether the patient adheres well to [neonates]), or virus treatment nn Encephalitis: Infection or inflammation of the brain Prevention itself; may be associated with complications such as intracerebral bleeding or ischemia nn Advise good adherence to anti-epileptic medicines. ll Often from virus (wide variety) or a post-virus nn Counsel the patient and his or her family about the disease to minimize social stigma and promote normal inflammation life. ll May be from bacteria, fungus, parasites (especially in immunosuppressed patient) nn Prevent and adequately treat conditions that may provoke seizures. Note: TB infection may involve any of the CNS structures Patient Instructions and typically presents less acutely. nn Keep a seizure diary to include the information listed Diagnosis in “Referral” above, and bring it to the clinic and Note: For children younger than 5 years, follow IMCI referral visits. flipchart. nn Return for recurrent seizures or new signs or Infections or inflammation of the CNS may present symptoms. slowly or very quickly—leading to life-threatening illness. NERVOUS SYSTEM nn Avoid driving, using heavy machinery, and alcohol or Meningitis typically presents the most acutely and drug use if taking anticonvulsants. dramatically, but there is a wide spectrum of symptoms and speed of onset of symptoms whenever CNS structures 7.2. Encephalitis and Meningitis are involved.

NERVOUS SYSTEM NERVOUS Description The spectrum of symptoms may include the following: Acute infection or inflammation of the central nervous nn Headache system (CNS) and meninges may be caused by bacteria, nn Fever or malaise viruses, fungus, parasitic organisms, or may be from a nn Seizure post-infection inflammation. Any patient who has the nn Focal or generalized weakness possibility of infection or inflammation of the CNS and nn Neck pain or stiffness— meninges should be considered to be a medical emergency ll Brudzinski’s sign: neck flexion in a supine patient that requires prompt and focused case evaluation and results in involuntary flexion of the knees and hips management and referral to hospital. ll Kernig’s sign: attempts to extend the knees are met Infections or inflammation may involve isolated or a with strong passive resistance, neck pain, or both combination of CNS structures.

130 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 131 7.2. Encephalitis and Meningitis 7.2. Encephalitis and Meningitis

nn Altered mental status. Patients presenting with dose of appropriate, available antibiotic, and referred to confusion or coma should be considered suspect for hospital. infection of the CNS until proven otherwise. Other nn Stabilize the patient. causes of altered mental status include the following: ll Give oxygen as needed, if available. ll Cerebral malaria—check smear and rapid test on ll Start IV line and begin hydration. patients ll Protect the patient from injury during seizures. ll Metabolic abnormalities ll Ensure airway is clear if the patient has a seizure. uu Hypoglycemia—check glucose on all patients. nn Provide seizure control. Give diazepam. uu Hyperglycemia or diabetic ketoacidosis—check ll Children younger than 10 years glucose. uu Give diazepam rectally. uu Hypertensive crisis—check blood pressure. –– Use a TB or insulin syringe; draw the uu Head injury or stroke—obtain history. appropriate diazepam dose; take out the needle uu Drug induced—obtain history including alcohol, and insert the syringe 4–5 cm into rectum opiate, or other drug use (including overdose). before emptying. Squeeze buttocks together for uu Renal or liver failure. Refer for laboratory tests if 2–3 minutes. suspect. –– Refer to table A9 in annex A for standard nn Purpura or petechia—associated with some cases of dosages. meningococcal meningitis —OR— nn In infants (i.e., children younger than 1 year) and uu Give IV diazepam (over 10 minutes). Refer to generally in children younger than 5 years, the table A9. NERVOUS SYSTEM symptoms are nonspecific and include the following: ll Adults and children older than 10 years ll Irritability uu Give IV anticonvulsant diazepam. Refer to table ll Refusal to eat, poor sucking, vomiting, diarrhea A9 in annex A for standard dosages. ll Drowsiness, weak cry Caution: Monitor for respiratory depression or ll Decreased muscle tone (i.e., hypotonia) arrest. NERVOUS SYSTEM NERVOUS ll Bulging fontanel when at rest —OR— ll Coma or seizures uu Injection can be IM (same initial dose) and Caution: Check for general danger signs, and if repeated once in 3-4 hours if necessary. present, treat as a “very severe disease” following nn Give emergency antibiotics: ampicillin PLUS the IMCI flipchart. gentamicin Management ll Children younger than 5 years Because treatment of infections of the CNS often requires uu Ampicillin IM. Refer to table A4 in annex A for medicines and other interventions not available at BPHS standard dosages. facilities, patients should be stabilized, treated with a first —PLUS—

132 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 133 7.2. Encephalitis and Meningitis 8. Mental Health Conditions

uu Gentamicin IM. Refer to table A13 in annex A for Chapter 8. standard dosages. ll Adults and children older than 5 years Mental Health Conditions uu Ampicillin IM or slow IV injection 500 mg up to 1 Description g vial every 6 hours Psychological and mental disorders are often much more —PLUS— common than is generally recognized—presenting as a uu Gentamicin IM or slow IV 2 mg/kg as loading consequence of a stressful or traumatic life event, as the dose (i.e., 3 ml to 4 ml of vial containing 80 mg, result of an imbalance of essential neurotransmitters, followed by maintenance dose 1–1.7 mg/kg per or both. Often patients who have mental health issues dose every 12 hours) present with somatic complaints. Equally, patients nn Control fever if it is 38.5°C or higher. who have underlying organic problems may manifest ll Give patient a tepid sponge bath. themselves with psychological symptoms—so it is ll Give paracetamol. Refer to table A15 in annex A for essential to exclude organic problems as a root cause of standard dosages. psychological symptoms. nn Prevent low blood sugar in children younger than 5 years. Feed child with breast milk or sugar water. Psychological disorders may be divided into disorders present with symptoms of— nn Treat for cerebral malaria if smear positive or n presence of danger signs of very severe febrile disease n Mood change (i.e., depression or mania) n for children younger than 5 years in malaria-endemic n Anxiety states (i.e., panic or fearful feelings that zone (see section 15.7 “Malaria”). disrupt normal life and behavior) nn Psychosis (i.e., delusions, hallucinations, and loss Prevention of touch with reality occasionally associated with Ensure all individuals have been properly immunized and aggressive behavior) enrolled in EPI. Diagnosis Patient Instructions Psychological disorders may be divided into two groups: NERVOUS SYSTEM NERVOUS nn Transfer patient accompanied by medical staff, if common disorders of mild to moderate severity that allow available. for continuation of normal life activities and relationships nn Review airway management and seizure management and disorders of severe symptomatology that prevent with caregivers assisting with transport. normal behavior and social interaction. MENTAL HEALTH nn Monitor family members and close contacts for nn Patient presentation symptoms of meningitis. ll Common mental disorders are mild or moderately severe disorders in which the patient is able to carry on his or her daily life and activities and include depression, anxiety disorders, unexplained somatic complaints, and conversion disorder.

134 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 135 8. Mental Health Conditions 8. Mental Health Conditions

uu Depression is a mental disorder that exhibits a (e.g., cannabis, opium), or medication—Patients central change in mood and affect characterized may present with confusion, aggression, or by sadness, gloominess, loss of pleasure, somnolence. feeling of worthlessness or guilt, poor energy, uu Epilepsy: a brain disorder characterized by indecisiveness, poor concentration, poor appetite, spontaneous, repetitive seizures—epilepsy is not psychomotor retardation, thoughts of death a mental disorder, but a neurological disorder or suicidal thinking, or any combination of the with frequent psychosocial problems and stigma. above. Occasionally epilepsy is confused with panic uu Anxiety disorders comprise a group of mental disorder in children. disorders characterized by excessive worry, nn Approach to the patient nervousness, apprehension, fear, panic attack, ll Exclude organic causes for psychological symptoms intrusive thoughts or images, or traumatization. uu Hyperthyroidism or hypothyroidism—change in There are several types of anxiety disorder: mood –– Generalized anxiety disorder uu Cardiac, hypertension, or respiratory disease— –– Panic disorder anxiety states –– Post-traumatic stress disorder uu Hypoglycemia or hyperglycemia—change in –– Phobia behavior –– Obsessive compulsive disorder uu Infections—change in behavior (encephalitis), ll Severe mental disorder or psychosis are general mood, or alertness terms used to describe a mental disorder in which uu Drug, alcohol, or medication use or withdrawal— a person has lost contact with reality. Severe changes in behavior, aggressiveness disturbances in thinking, emotion, and behavior are uu Metabolic disturbances (renal/liver failure)— evident. Psychosis severely disrupts a person’s life change in behavior or alertness relationships and work, and initiating self-care or Management maintaining relationships is difficult. Psychosis is The principles of patient care include monitoring of characterized by delusions; hallucinations; bizarre symptoms, ensuring patient safety, and providing effective thoughts, speech, and behavior; aggression; violence; pharmacological and psychosocial support and therapy or any combination of the above. Severe mental (including addressing significant psychosocial stressors). MENTAL HEALTH disorders include the following: The goals of intervention for patients presenting with uu Acute psychosis psychological disorders in the BPHS setting is to— uu Chronic psychosis or schizophrenia nn Prevent injury to the patient or others uu Mania nn Establish whether there may be any organic cause for uu Postpartum psychosis the patient’s symptoms (see “Diagnosis” above)

MENTAL HEALTH MENTAL ll Other disorders include the following: nn Provide basic counseling to the patient and family, and uu Intoxication or withdrawal from alcohol, drugs address social factors in a safe and confidential setting

136 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 137 8. Mental Health Conditions 8. Mental Health Conditions

nn Provide short-term, acute pharmacological therapy Additional situations where referral is highly for those presenting with common syndromes of mild recommended include the following: symptomatology (i.e., not interfering with daily life nn All patients who may be a threat to themselves or and activities) others nn Provide referral to a trained counselor and health nn Children, adolescents, and the elderly facility with appropriate personnel and interventions nn Patients who have underlying severe medical to address severe symptomatology (i.e., the illness conditions is preventing normal daily life activities and nn Pregnant and lactating women relationships), those at extremes of age (children and nn Patients who have recurring symptoms the elderly), and those who have underlying medical nn Patients who are not responding to initial therapy conditions or poor response to initial therapy nn Psychotic patients, both those having a first episode Nonpharmacologic and those experiencing failure of treatment of chronic Psychosocial counseling is a service provided by trained disease health staff or counselors to an individual, family, nn People who have poor social support or group for the purpose of improving psychosocial nn Patients exhibiting aggressive behavior or delirium well-being, alleviating distress, and enhancing coping nn Any person who has a bipolar disorder (manic- skills. Psychosocial counseling addresses emotional, depression) situational, and developmental stressors and is provided Prevention in a confidential setting to individuals, couples, groups, nn Educate the patient and the community to or families. The goal is to achieve positive outcomes communicate that mental health disorders are and optimal psychosocial development by reducing common and can be treated. identified risk factors. There are two types of psychosocial nn Begin intervention before symptoms become severe. counseling: basic counseling and professional counseling. nn Rely on social and family support mechanisms. Pharmacologic Patient Instructions The three broad categories of medication used to treat nn Advise patients that once pharmacological treatment common psychiatric disorders are outlined in table 8. has been initiated, they must take their medication as Referral directed to prevent dependence and to achieve optimal All patients being evaluated for the first time for result. MENTAL HEALTH psychiatric disorder should see a trained counselor or nn Instruct patients to— specialist, particularly if the patient presents with a severe ll Avoid drugs, alcohol, and caffeine. mental disorder (see above) that is disrupting normal ll Maintain proper sleep, diet, and exercise. work, personal relationships, and lifestyle. ll Visit the counselor in the case of social and family conflict (if available). MENTAL HEALTH MENTAL

138 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 139 8. Mental Health Conditions 8. Mental Health Conditions Adults Adults Dosages Dosages of 6 months initiated, a minimum of nce or severe agitation, may give 10 mg give agitation, may or severe in agitation: 5 mg IM; repeat or severe 5 mg twice daily for maximum of maximum of daily for 5 mg twice week 1 over then taper off 2 weeks; F in 60 minutes if necessary IM; repeat dose: 50 mg at night; may Initial 14 days 25 mg every dose by increase to a maximum dose effect desired for 150 mg nightly of O is typically therapy pharmaceutical of required with 25 mg at night; begin E lderly: maximum dose 100 mg nightly dose: 20 mg in the morning; after Initial may if no or partial response, 4 weeks to 40 mg increase start with 10 mg in the E lderly: if no or partial morning; after 4 weeks to 20 mg increase may response 12 hours; may dose: 2.5 mg every Initial to a maximum daily dose of increase symptoms 12.5 mg for F 60 minutes if necessary n n n n n n n n n n n n n n n n n n ) a Children Children Refer Refer Refer Refer continued ( 3 Mood Elevators Mood Antipsychotic Agents Antipsychotic Anxiolytics or Sedatives Use Use MENTAL HEALTH sed for treatment of anxiety disorders, anxiety disorders, of treatment sed for May be used for a short period (i.e., ≤ a short period (i.e., be used for May medicine dependency can because weeks) develop U insomnia, and agitation (with or without psychosis) mild to a clear diagnosis of be used for May depression moderate source the referral by be recommended May panic disorder for as treatment for source referral be initiated by May depression of treatment post- of limited use in treatment have May (with referral) disorder stress traumatic acute of be initiated in treatment May (referral conditions psychotic or chronic recommended) agitation of treatment be initiated for May or has not been effective when diazepam when delusional symptoms coexist n n n n n n n n n n n n n n n n

Medications to Treat Psychiatric Disorders Psychiatric to Treat Medications Disorders Psychiatric to Treat Medications MENTAL HEALTH MENTAL Medication Medication Amitriptyline Haloperidol— only available in DHs luoxetine— F luoxetine— only available in DHs Diazepam ab l e 8. ab l e 8. T T

140 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 141 8. Mental Health Conditions 9.1. Pregnancy and Antenatal Care

Chapter 9. Obstetrics and Gynecological Conditions OBSTETRICS / GYN

9.1. Pregnancy and Antenatal Care

Description

Adults Pregnancy is the maternal condition of having a developing fetus in the body. Pregnancy usually lasts 40 weeks and is divided into three trimesters, each lasting approximately Dosages 3 months. or severe agitation: 50 mg IM; may agitation: 50 mg IM; may or severe

Initial dose: 25 mg every 8 hours; may 8 hours; may dose: 25 mg every Initial symptoms dose for increase gradually 8 100 mg every to a maximum of to response, hours, adjusted according 75–300 dose of to usual maintenance mg daily F to a in 60 minutes if necessary repeat 8 hours maximum dose 50 mg every Antenatal care is the care a pregnant woman receives se extreme caution if you suspect patient has if you caution se extreme n n n n during the gestational period. nn Antenatal care (ANC) is organized to ensure that a woman goes through pregnancy, delivery, and the

) postnatal period in a healthy state, and that a healthy Children

Refer baby is born. nn ANC serves to provide a good history and examination

continued to identify any problems that are likely to occur with ( the pregnancy, delivery, or during the postnatal period. nn Identified problems are treated or referred to a higher level facility. nn Ideally ANC starts at the preconception stage, although most often it begins during the first trimester Use when the woman realizes she has missed a menstrual period. nn The aims of ANC are to— ll Provide education, reassurance, and support to the woman and her partner ll

May be initiated in treatment of acute of be initiated in treatment May (referral conditions psychotic or chronic recommended) agitation of treatment be initiated for May or has not been effective when diazepam when delusional symptoms coexist. Advise on minor problems and symptoms of n n n n pregnancy ll Provide prenatal screening and management of problems detected Medications to Treat Psychiatric Disorders Disorders Psychiatric to Treat Medications ll Assess maternal and fetal risk factors at the onset MENTAL HEALTH MENTAL of pregnancy and as they develop throughout Medication Antidepressant medication, particularly tricyclic antidepressants, may be fatal if taken as an overdose. U as an overdose. if taken be fatal may antidepressants, medication, particularly tricyclic Antidepressant suicidal thoughts. or epilepsy. glaucoma, heart disease, urinary retention, a history of in patients who have antidepressants tricyclic Avoid medication and should be started maintained on a smaller dose. to antidepressant sensitive more T he elderly are § § § § § § Caution: Chlorpromazine ab l e 8. a T pregnancy

142 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 143 9.1. Pregnancy and Antenatal Care 9.1. Pregnancy and Antenatal Care

ll Individualize care for women experiencing a high- Table 9.1. Summary of Routine ANC Visits during

risk pregnancy to refer them to the higher level Pregnancy OBSTETRICS / GYN ll Determine the timing, mode, and place of delivery Visits Interventions (i.e., design a delivery plan) First— nn Obtain a complete history. ll Determine any danger signs such as— during 1st nn Do a physical examination. uu Severe anemia trimester, nn Order laboratory (blood and urine) tests as before 16th needed. uu Severe headache week nn Record vital signs, height, and weight. OBSTETRICS / GYN OBSTETRICS uu Hypertension (HTN) nn Give information on diet and lifestyle uu Upper body edema considerations and pregnancy care to the woman and her family, including her husband. uu Vaginal bleeding or leakage nn Use Naegele’s rule to determine expected date uu Fever of delivery, as commonly used in Afghanistan: uu Convulsions ll Determine the first day of last menstruation period. uu Problems with the fetus ll Add 7 days. Diagnosis ll Subtract 3 months. ll Add 1 year. nn Pregnancy is suspected when a woman misses her nn Begin ferrous sulfate and folic acid normal menstrual period or demonstrates symptoms supplementation. of pregnancy that is confirmed with urine pregnancy nn Check urine for bacteria, glucose, and protein, if possible. test. nn Check blood type and Rh group, if possible. nn Symptoms of pregnancy may include the following: Second— nn Review the findings of first visit. Note if there is ll Missed menstrual period around the any change in the findings (e.g., edema, signs of ll Nausea 26th week of anemia or other diseases, or alarming signs). pregnancy nn Measure vital signs and uterine height. ll Breast tenderness nn Repeat urine examination (i.e., bacteria, protein, ll Fatigue glucose) if the test was abnormal at the first ll Frequent urination visit. nn Give information on diet and lifestyle ll Soft and palpably enlarged uterus considerations and pregnancy care to the ll Evident fetal heart sounds (140–160 normal) woman and her family, including her husband. ll Positive urine pregnancy test (but not in the first nn Advise the woman and her husband on the weeks) importance of immediate and exclusive breastfeeding for the newborn baby. ll Weight gain (normally 11–13 kg over the course of the pregnancy) Third— nn Perform all the tasks of the second visit. around the nn Record the fetal heart rate. n n According to WHO, a pregnant woman should have at 32nd week of nn Measure blood hemoglobin to identify severely least 4 ANC visits (see table 9.1). pregnancy anemic women. nn Discuss birth spacing methods with the woman and her husband. nn Perform a breast examination. nn Give a TT vaccination.

144 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 145 9.1. Pregnancy and Antenatal Care 9.1. Pregnancy and Antenatal Care

Table 9.1. Summary of Routine ANC Visits during uu Give first dose of TT at first ANC visit—0.5 ml IM.

Pregnancy (continued) uu Give second dose 4 weeks later. OBSTETRICS / GYN Visits Interventions uu Give third dose 6 months after the second dose Fourth— Perform all the tasks of the third visit. (even if it is after delivery) between the Evaluate the fetal position using a Leopold uu Give fourth dose 1 year after the third dose 36th and examination or other systematic evaluation. uu Give fifth dose 1 year after the fourth dose. 38th week of Look for evidence of a breech fetus or other ll pregnancy abnormal fetal position. If the pregnant woman is not fully immunized, OBSTETRICS / GYN OBSTETRICS Make a birth plan for the woman. All information ensure that she receives at least 2 TT vaccinations on what to do, who to call, and where to go when before delivery. labor starts or in the case of other symptoms uu should be given. If patient is not sure, ensure that she receives Advise the woman and her husband on the 2 TT vaccinations (at least 4 weeks apart) before importance of immediate and exclusive delivery. breastfeeding for the newborn baby. uu If she has already received 2 or more TT vaccinations, recommend a TT vaccination about Management 2 months before delivery. nn Prevent iron deficiency anemia. ll If she has documented evidence of having received ll Give all pregnant patients throughout the pregnancy 5 TT vaccinations and the last one is fewer than and until 3 months after delivery or abortion— 10 years ago, she does not need a TT vaccination. uu Ferrous sulfate PLUS folic acid (60 mg elemental nn Give mebendazole 500 mg (5 tablets of 100 mg at iron PLUS 0.4 mg folic acid)—1 tablet once daily once)—once in trimester 2 or in trimester 3, as (with meal or at night) recommended by WHO. ll Give patients who have hemoglobin less than 11 g/dl— Caution: Do not give in the first trimester of pregnancy. uu Double dose of ferrous sulfate PLUS folic acid (60 Referral mg elemental iron PLUS 0.4 mg folic acid)—1 tablet nn All women who have a previous history of significant every 12 hours for 3 months bleeding or retained placenta following delivery —THEN— nn Any woman who exhibits— uu Followed by 1 tablet daily for the rest of pregnancy ll Severe anemia (hemoglobin less than 7g/dl) and for 3 months after delivery ll Uterine size much bigger than gestational age with nn For pregnancy-induced nausea and vomiting, give one fetus present pyridoxine (vitamin B6)—1 tablet of 25 mg of vitamin B6 ll Large abdomen (multiple fetuses or every 8 hours per day for 3 days (available in DHs). polyhydramniosis) nn Give TT vaccine to women who have not been fully ll Abnormal fetal position, such a transverse lie or immunized (i.e., 5 recorded doses). breech ll If the pregnant woman has not been immunized and ll Protracted pregnancy—gestational age more than she is seen at the first ANC visit: give standard doses: 42 weeks

146 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 147 9.1. Pregnancy and Antenatal Care 9.2. Anemia in Pregnancy

ll Pre-eclampsia or eclampsia nn Do not take any medication unless prescribed by the

ll HTN (blood pressure more than 140/90 mmHg) health center. OBSTETRICS / GYN ll Evidence of any severe illness nn Stop using tobacco, alcohol, and drugs. nn Any woman with a history of— nn Make a plan regarding whom to call or where to go ll Previous stillbirth or intrauterine growth restriction in case of bleeding, abdominal pain, or any other (i.e., poor growth of the baby in utero; uterine size emergency. smaller than gestational age) nn Record when you feel the first fetal movement. OBSTETRICS / GYN OBSTETRICS ll Neonatal death within the first week of life nn Bring your partner (or a family member) so that they ll Previous instrumental delivery—vacuum extraction can learn how to support you through your pregnancy. or forceps delivery nn Note anything you want to mention about the next ll Previous Caesarean section visit. ll Previous uterine surgery (myomectomy) or nn Learn about breastfeeding and newborn care. perforation (postdelivery and Caesarean) nn Review goals of birth spacing. nn Any woman who has a family history of genetic disease Prevention 9.2. Anemia in Pregnancy Complications of pregnancy can best be avoided by having Description routine ANC and a partogram (see annex C). Hemoglobin of less than 11 g/dl, typically due to iron Patient Instructions deficiency, folate deficiency, or a combination of the two is nn Follow the advice and suggestions made during the anemia. Iron deficiency anemia is responsible for 95% of ANC visits. anemia during pregnancy because of increased demand. ll Take ferrous sulfate and folic acid as directed. Severe anemia may cause intrauterine growth retardation, ll Receive TT vaccine as directed. preterm labor, or both. ll Make a birth plan with the family for trying to Diagnosis deliver at a health facility. A birth plan is especially nn Pallor of conjunctiva, nail beds, tongue important if any problems have been identified nn Easy fatigability, dizziness during the ANC visits. Plan for the following as well: nn In severe anemia, headache, tachycardia, palpitations, uu Transport options for delivery—both for routine edema in the feet, breathing difficulty (more than 30 and emergency breaths per minute; breathlessness at rest) uu Family member who can donate blood if needed nn In long-standing anemia, inflammation of the corner during emergency of the mouth or the tongue, changes in the form of the nn Eat a regular diet (i.e., nuts, vegetables, dairy products, nails (“spoon nails”) meat, fish, fruits). nn In some cases of hemolytic anemia, jaundice nn Get enough rest and do not to do heavy work. nn Blood hemoglobin less than 11 g/dl nn Sleep under an insecticide-treated bednet if in a malaria-prone area.

148 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 149 9.2. Anemia in Pregnancy 9.3. Hypertension Disorders of Pregnancy

Management nn Evidence of heart failure

Nonpharmacologic nn Anemia of sudden onset OBSTETRICS / GYN nn Anemia and evidence of obstetric complication nn Measure blood hemoglobin at first antenatal visit. nn Evidence of chronic disease, TB, malaria nn Consider (and investigate, if indicated) the following causes of anemia other than iron deficiency: Prevention ll Hookworm nn Get routine antenatal care (ANC) including standard ll Malaria iron and folic acid supplementation (see above). OBSTETRICS / GYN OBSTETRICS ll Chronic disease nn Eat a balanced, iron-rich diet including fruits and ll Gastrointestinal blood loss green vegetables (e.g., meat, fish, oils, nuts, seeds, Pharmacologic cereals, beans, vegetables, cheese, milk). nn Use insecticide-treated bednets to avoid malaria. nn Prevent iron deficiency anemia. nn Avoid obstetrical complications. Make a delivery plan. ll Give all pregnant patients throughout the pregnancy and until 3 months after delivery or abortion— Patient Instructions uu Ferrous sulfate PLUS folic acid (60 mg elemental nn Encourage the patient to attend ANC appointments iron PLUS 0.4 mg folic acid)—1 tablet once daily and comply with recommendations. (with meal or at night). nn Urge patients to resist the urge to eat soil (pica). ll Give patients who have hemoglobin less than 11 g/ nn Discuss any incorrect perceptions about iron dl— treatment (e.g., it will make the bleeding worse or will uu Double dose of ferrous sulfate PLUS folic acid cause the baby to be too large). (60 mg elemental iron PLUS 0.4 mg folic acid)—1 nn Tell the patient how to take iron tablets (i.e., with tablet every 12 hours for 3 months meals or, if once daily, at night). —THEN— uu Followed by 1 tablet daily for the rest of pregnancy 9.3. Hypertension Disorders of Pregnancy and for 3 months after delivery The hypertension (HTN) disorders of pregnancy include nn Give mebendazole to every women once in 6 months— one dose of 500 mg (5 tablets of 100 mg) at once chronic HTN, gestational HTN, pre-eclampsia, and Caution: Do not give during the first trimester of eclampsia. pregnancy Description Referral HTN disorders of pregnancy may have serious consequences for both mother and baby. HTN is defined nn Hemoglobin less than 8 g/dl at any stage of pregnancy. This is severe anemia. Refer patient to an appropriate as systolic blood pressure (BP) more than140 mmHg facility where blood transfusing is available. and diastolic BP more than 90 mmHg. nn Chronic HTN is HTN present before pregnancy (see nn Hemoglobin less than 11 g/dl at more than 34 weeks of gestation section 6.1 “Systemic Hypertension”).

150 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 151 9.3. Hypertension Disorders of Pregnancy 9.3. Hypertension Disorders of Pregnancy

nn Pregnancy-induced HTN is HTN that begins after nn Women with proteinuria (pre-eclampsia) should have

20 weeks of gestation and is of 3 types: home rest and be monitored carefully once a week in OBSTETRICS / GYN ll Gestational HTN (without proteinuria) the health facility or by a health worker in the home. ll HTN with proteinuria, or pre-eclampsia Pharmacologic ll HTN with proteinuria and seizures, or eclampsia, nn For gestational HTN more than 150/100, checked at which is a life-threatening event with seizures and least two times, 4 hours apart— coma ll Give methyldopa tablet—250 mg. Begin with 250 OBSTETRICS / GYN OBSTETRICS Diagnosis mg (1 tablet) every 8 hours up to maximum dose of nn BP taken after 15 minutes of rest more than 150/100. 500 mg (2 tablets) every 6 hours if necessary Check BP at least two times, 4 hours apart. Prescribe nn For HTN and eclampsia, give urgently before medication for gestational HTN. referral— nn HTN and presence of proteinuria indicate pre- ll First dose of magnesium sulfate—5 g IM (1 ampoule eclampsia.. Determine if the proteinuria is of 500 mg/ml) in each buttock every 4 hours until accompanied by headache, change in vision, upper patient reaches referral center (available in CHCs abdominal pain, nausea and vomiting, dizziness, and and DHs) sudden gain of weight (i.e., 0.9 kg/week). Look for —PLUS— edema in face and hands as well, but this edema is not ll Hydralazine injection—5–10 mg slow IV injection; specific because it can be present in normal pregnancy. dilute with 10 ml NaCl 0.9% (available in DHs). nn HTN, proteinuria, and seizures indicate eclampsia. Referral Note: Ensure there is no other cause for seizure such nn When possible, refer all pregnant women who have as meningitis, malaria, or a history of epilepsy. HTN for further investigation and treatment. Note: Eclampsia may still occur in the postpartum nn To avoid complications, any pregnant woman who has period. The patient will need to be monitored. HTN should be referred at 38 weeks of gestation for Management admission and delivery to a health facility equipped to Nonpharmacologic treat eclampsia. nn Pregnant patients who have HTN should be monitored nn Refer women who have persistent HTN more than weekly to check: 150/100 despite maximum dose of methyldopa for ll BP control of BP. ll Maternal weight gain and presence of edema nn refer urgently all women who have eclampsia ll Fetal status and growth for admission to health facility that can perform ll Urine for protein Caesarean section. ll Priority birth plan (i.e., their plan for delivery in ll Transport woman on left side, accompanied by a facility and their emergency transport and options) health care worker, and with oxygen, when possible. nn All patients who have HTN should be on a low-salt ll For woman having seizure, keep airway open and diet. protect her from injury.

152 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 153 9.4. Antepartum Hemorrhage 9.4. Antepartum Hemorrhage

Prevention nn Nonobstetrical causes

The complications of HTN disorders of pregnancy may ll Cervical polyps, malignancy, infection, or trauma. OBSTETRICS / GYN be prevented with careful antenatal care and appropriate ll Blood-clotting disorder (i.e., coagulopathy) referral. Note: Identification of a nonobstetrical cause for Patient Instructions bleeding does not rule out the possibility of an obstetrical cause of bleeding in the pregnant patient. nn Instruct all women who have HTN about the signs and symptoms of pre-eclampsia and eclampsia and Diagnosis OBSTETRICS / GYN OBSTETRICS the need for immediate return and review at health nn Analyze vaginal bleeding of the pregnant woman facility. after the 22nd week of gestation. Prior bleeding may nn Review the patient’s birth plan to ensure emergency indicate abortion or ectopic pregnancy (see section 9.5 transport and referral options. “Abortion [Vaginal Bleeding in Early Pregnancy]” and section 9.6 “Ectopic Pregnancy”). 9.4. Antepartum Hemorrhage nn Examine the woman’s general condition. Rule out shock. Description nn Note that abdominal pain may be present and could Antepartum hemorrhage (APH) is defined as bleeding indicate a uterine rupture or an ectopic pregnancy. from the birth canal (leading from the uterus through nn Evaluate the abdomen for uterus size, shape, fetal the cervix, vagina, and vulva) after the 22nd week of position, and evidence of fetal heart sounds. pregnancy up to and including the time of labor. The cause ll May be normal—some cases of placenta previa and of bleeding may be related to the pregnancy or may stem abruptio placenta from a nonobstetrical cause. ll May be abnormal—uterine rupture, some cases of n n Obstetrical causes placenta previa and abruptio placenta ll Placenta previa—implantation of the baby’s Caution: Do not perform vaginal examination. In placenta partially or totally covers the mother’s the case of placenta previa, an examination may cervix (i.e., the doorway between the uterus and the cause more bleeding. vagina); bleeding may occur at any time during the pregnancy Management ll Abruptio placenta—detachment of a normally Nonpharmacologic located placenta before delivery of the fetus; nn If woman presents with shock, stabilize and refer bleeding occurs during labor urgently (see section 16.9 “Shock,” and table 16.9C). ll Ruptured uterus—bleeding during labor nn For all cases of APH, the best action is to refer the Caution: A ruptured uterus can occur without patient to a facility that can perform a Caesarean vaginal bleeding if the blood drains into the section if needed. If the patient cannot be referred abdominal cavity or the broad ligament, rather than safely, then deliver the baby as soon as possible. into the vagina.

154 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 155 9.5. Abortion (Vaginal Bleeding in Early Pregnancy) 9.5. Abortion (Vaginal Bleeding in Early Pregnancy)

Pharmacologic nn Inevitable—moderate bleeding, cervix open,

nn If forced to deliver the baby without being able to refer, abdominal cramping. The pregnancy is in the process OBSTETRICS / GYN induce labor with oxytocin (see section 9.8 “Delivery of terminating. and Postpartum Care”). nn Incomplete—bleeding, clots, or both; some parts of nn Continue to treat for shock with IV fluids until fetus and products of conception have already been bleeding has stopped. expelled; cervix open Referral nn Complete—bleeding, clots; fetus and all products of OBSTETRICS / GYN OBSTETRICS conception have been passed, and the bleeding has nn For all cases of APH, the preferred action is referral to a facility for more investigation and treatment. slowed or stopped; cervix closed and firm nn Missed—refers to fetal death in utero before 20 weeks nn It is best to transfer the patient with a health care worker and IV infusion when possible. gestation; reversal of symptoms of pregnancy; recurrent bloody vaginal discharge Prevention nn Septic—foul-smelling vaginal discharge, abdominal n n Any vaginal bleeding during pregnancy is abnormal pain or tenderness, and fever more than 38°C; fetus and should be taken seriously. Women who have a may or may not be retained; may be associated with history of even minor bleeding should be referred for uterine damage as a frequent complication of unsafe an ultrasound, which may detect placenta previa or abortion involving instrumentation. other problems. Caution: refer urgently to hospital. nn As part of the woman’s birth plan during her antenatal nn Ectopic pregnancy—2 or more of the following care visits, encourage her to identify options for— signs: abdominal pain, fainting, pallor, and extreme l l Emergency transport to a health facility weakness. ll Family member who can donate blood in case of Caution: refer urgently to hospital. emergency Diagnosis 9.5. Abortion (Vaginal Bleeding in Early nn Assess the patient’s history for missed menstrual Pregnancy) period and known pregnancy. nn If she has vaginal bleeding during the first half of Description pregnancy, consider— Abortion is the expulsion of the fetus and other products ll Abortion (see types above) of conception before the 28th week of pregnancy. It is ll Ectopic pregnancy—may be associated with typically associated with cramping, vaginal bleeding, open abdominal pain, adnexal mass, shock cervix, and partial or complete passage of fetus, products nn Check for evidence of shock and treat immediately if of conception, or both. present (see section 16.9 “Shock” and table 16.9C). Types of abortion include the following: nn Assess vagina looking for wounds or foreign bodies. nn Threatened—light vaginal bleeding, cervix closed. The nn Determine whether the cervix is open or closed. pregnancy may not necessarily terminate.

156 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 157 9.5. Abortion (Vaginal Bleeding in Early Pregnancy) 9.5. Abortion (Vaginal Bleeding in Early Pregnancy)

nn Assess the amount of bleeding, blood clots, or products ll Observe the bleeding for 4–6 hours at the clinic.

of conception. uu If the bleeding does not decrease, refer to hospital. OBSTETRICS / GYN ll “Light bleeding” takes more than 5 minutes to soak uu If the bleeding does decrease, let the woman go pad home and rest for a few days. ll “Heavy bleeding” takes less than 5 minutes to soak –– Advise her on the following hygiene practices: pad ¡¡ Change pads every 4–6 hours. nn Check for abdominal pain. ¡¡ Wash perineum daily. OBSTETRICS / GYN OBSTETRICS nn Measure fever if patient feels hot to the touch. ¡¡ Avoid sexual relations until bleeding stops. nn Assess (gently) the size of the uterus (appropriate for –– Advise her to return immediately if she has any dates) and adnexa. of the following danger signs: nn Perform laboratory tests. ¡¡ Increased bleeding ll Pregnancy test—if in doubt ¡¡ Continued bleeding for 2 days ll Hemoglobin ¡¡ Foul-smelling vaginal discharge ll Type and cross-match blood if there is a potential for ¡¡ Abdominal pain transfusion (i.e., shock or the possibility of shock). ¡¡ Fever and weakness Management ¡¡ Dizziness and fainting The top priority of management is to look for evidence of ll Advise the patient on the use of family planning shock and treat immediately (see section 16.9 “Shock,” methods. and table 16.9C). Always consider ectopic pregnancy for nn Complete abortion— a woman who has missed menstruation and is in shock ll Provide patient counseling on self-care (see (with or without abdominal pain and vaginal bleeding)— “Threatened abortion” above). see section 9.13 “Ectopic Pregnancy”. And always check for ll Check preventive measures such as TT septic abortion (i.e., abortion with uterine manipulation) immunization status. ll Prescribe iron and folate supplementation (see Goals of management: below). nn Ensure complete evacuation of the uterus. ll Advise the patient to return in 2 days for follow-up. nn Stop bleeding. nn Incomplete abortion— nn Prevent Rhesus isoimmunization. ll If the appropriate staff and facility are available, nn Provide psychological support (i.e., patient evacuate the retained products of conception. counseling). uu If bleeding is light to moderate and pregnancy Nonpharmacologic is less than 16 weeks, use your fingers to remove Focus on evaluation and treatment of shock, patient any products of conception that are protruding counseling, and evacuation of uterus if necessary (and if through the cervix. the appropriate staff and facility are available). uu If bleeding is heavy and pregnancy is less than 16 nn Threatened abortion— weeks, evacuate the uterus.

158 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 159 9.5. Abortion (Vaginal Bleeding in Early Pregnancy) 9.5. Abortion (Vaginal Bleeding in Early Pregnancy)

ll If the appropriate staff and facility arenot available ll Give oxytocin—

or if you do not have the ability to evacuate the uu 40 units in 1 liter of 0.9% NaCl and infuse at 30 OBSTETRICS / GYN uterus— drops/minutes uu Start IV fluid. —OR— uu Administer ergometrine 0.2 mg IM. uu To stopping bleeding (after all products of uu Refer the patient. conception expelled)—10 units IM (one vial of 1 nn Inevitable abortion— ml) OBSTETRICS / GYN OBSTETRICS ll Evacuate uterus after expulsion of fetus. ll If oxytocin fails to stop bleeding, give— ll Administer appropriate medication (see below). uu Ergometrine—0.2 mg IV nn Septic abortion— uu Refer. ll Treat for shock, if needed (see section 16.9 “Shock,” Caution: Avoid ergometrine in patients who have and table 16.9C). hypertension. ll Insert an IV line and give fluids. nn Prescribe iron and folic acid supplements. ll Give paracetamol for pain. Refer to table A15 in ll If the patient’s hemoglobin is more than11g/dl, annex A for standard dosages. prescribe— ll Give appropriate IM or IV antibiotics (see below). uu Ferrous sulfate PLUS folic acid (60 mg elemental ll refer urgently to hospital. iron PLUS 0.4 mg folic acid) 1 tablet daily for nn Ectopic pregnancy— 3 months ll Treat for shock if needed (see section 16.9 “Shock,” ll If the patient’s hemoglobin less than 11 g/dl, and table 16.9C). prescribe— ll Insert an IV line and give fluids. uu Ferrous sulfate PLUS folic acid (60 mg elemental ll refer urgently to hospital for surgery. iron PLUS 0.4 mg folic acid) 2 tablets daily for Pharmacologic 3 months Use when needed depending of the type of abortion (see nn Give antibiotics for septic abortion give initial dose above). then refer for evaluation or uterine evacuation under general anesthesia. nn Give an analgesic for severe pain. ll Ampicillin 2 g IV every 6 hours ll Tramadol—50 mg IM injection (available in CHCs and DHs) —OR— l —OR— l In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 in annex A for ll Paracetamol. Refer to table A15 in annex A for standard dosages. standard dosages. nn Use an oxytocic medicine when uterine contractions —PLUS— are needed to expel products of conception (i.e., in an ll Gentamicin 5 mg/kg body weight IV every 24 hours incomplete or inevitable abortion), to stop uterine —PLUS— bleeding, or both.

160 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 161 9.5. Abortion (Vaginal Bleeding in Early Pregnancy) 9.6. Ectopic Pregnancy

ll Metronidazole 500 mg IV every 8 hours (available in 9.6. Ectopic Pregnancy

CHCs and DHs) OBSTETRICS / GYN nn TT Description ll Check woman’s TT immunization status. Ectopic pregnancy occurs when a fertilized egg implants ll If needed or if unknown, give 0.5 ml TT IM in a location outside the endometrial lining of the uterus. in upper arm to be followed according to the The egg may implant in the fallopian tube or in the TT immunization schedule (see chapter 19 abdominal cavity. Ectopic pregnancy should be suspected OBSTETRICS / GYN OBSTETRICS “Immunization”). in any woman of reproductive age who has pelvic pain. The incidence of ectopic pregnancy is slightly increased in Referral women who have a history of previous ectopic pregnancy, nn Patients who have septic abortion—after giving initial pelvic inflammatory disease, intrauterine device use, tubal dose of antibiotics, starting IV infusion, and treating surgery, or infertility. for shock nn Patients requiring uterine evacuation when proper The major risk of ectopic pregnancy is rupture, which staff or facility are not available can lead to intra-abdominal bleeding, shock, and death. nn Suspicion of ectopic pregnancy—after starting IV Ruptured ectopic pregnancy is a surgical emergency. infusion and preparing to treat for shock Diagnosis nn Missed abortion nn Missed menstrual period nn Rh (D) negative women—for evaluation and nn Symptoms of early pregnancy administration of anti-D Rh immunoglobulin, within nn Positive pregnancy test 72 hours (available only in provincial and regional Note: A negative urine pregnancy test does not hospitals) necessarily rule out ectopic pregnancy. Prevention nn Pain in the lower abdomen Timely antenatal care as per national guideline nn Adnexal mass or cervical pain recommendations nn Vaginal bleeding (usually mild) Patient Instructions nn Shock (if ruptured)—weakness, pallor (paleness), nn Provide psychological support. Reassure patient that syncope, tachycardia, hypotension with a sudden her chances of normal pregnancy in future remain sharp and stabbing pain at the hypogastrium and good. shoulder rips pain on lying down. nn Discuss family planning. Advise the patient to avoid Management pregnancy for at least 6 months. Pharmacologic nn Instruct the patient to return if she has a fever or Monitor vital signs, start IV, and give fluid if you suspect a continued bleeding. ruptured ectopic pregnancy. Treat for shock if patient has nn In the case of anemia, advise the patient to continue tachycardia or hypotension (see section 16.9 “Shock” and to take the iron and folic acid supplement daily for table 16.9C), and refer. 3 months.

162 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 163 9.7. Preterm Labor 9.7. Preterm Labor

Referral treatment is to delay delivery long enough (about 48

refer urgently all cases of suspected ectopic pregnancy hours) so that steroids, which promote development OBSTETRICS / GYN for observation or surgery. of the baby’s lungs, can be given. These steroids are needed when pregnancy is at 24–34 weeks of 9.7. Preterm Labor gestation. Delaying preterm delivery also allows the woman to be transferred, if necessary, to a facility that Description can provide specialized care to a premature infant.

OBSTETRICS / GYN OBSTETRICS Preterm labor is defined as regular uterine contractions at ll Salbutamol tablets—give an initial dose of 2 to 5 mg, more than 20 weeks, but less than 37 weeks of gestation, and then give 2 mg every 8 hours for the next 48–72 with associated cervical shortening and effacement. hours. Preterm birth is the leading cause of neonatal mortality. —OR— Diagnosis ll Nifedipine (tablet 20 mg)—initial dose of 1 tablet Early diagnosis is key to effective management of preterm orally once, and then 10–20 mg every 6–8 hours for labor. Look for these danger signs: 24–48 hours, and refer. nn Palpable contractions (more than 4 per hour) Caution: Do not give nifedipine if you suspect nn Watery or bloody vaginal discharge infection of the upper genital tract or if patient’s nn Cervical dilation more than 2 cm blood pressure is less than 120/80. Nifedipine nn Effacement of the cervix more than 50 percent is contraindicated if the woman has cardiac Management disease and should be used with caution if she has diabetes or multiple pregnancy owing to the risk of Nonpharmacologic pulmonary edema. nn Allow labor to progress if— nn Give antibiotics to prevent infection in the case of l l Gestation is more than 36 weeks amniotic fluid leakage: ll Cervix is more than 3 cm dilated ll Oral erythromycin ethylsuccinate—400 mg every 8 l l There is active bleeding hours for 5–7 days ll The fetus is distressed or dead —OR— ll There is infection or pre-eclampsia ll Amoxicillin tablet—500 mg every 8 hours for 5–7 n n Prepare for possibility of premature birth. days nn If gestation is more than 26 weeks, refer with tocolytic —OR— medicine to inhibit uterine contractions. ll If the woman is not able to swallow—500 mg n n If gestation is less than 26 weeks, refer without ampicillin vial IM every 8 hours tocolytic medicine. Referral Pharmacologic All patients who have danger signs should be stabilized n n Give medication to stop labor (tocolysis) for pregnancy and then referred. at 26–36 weeks of gestation. The primary goal of

164 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 165 9.8. Delivery and Postpartum Care 9.8. Delivery and Postpartum Care

Prevention ll Active phase: cervix is dilated 4–10 cm. The term

Routine antenatal care (see section 9.1 “Pregnancy and regular contraction in the active phase refers to 3–4 OBSTETRICS / GYN Antenatal Care”) contractions of a 25- to 30-second duration each, Patient Instructions within 10 minutes. nn Second stage: From full (10 cm) dilatation of cervix to nn If medication is effective in preventing labor and stopping contractions, advise home rest until the end delivery of the baby. of the pregnancy, and convince the patient’s family to nn Third stage: From delivery of the baby to delivery of OBSTETRICS / GYN OBSTETRICS support her during this period. the placenta. nn Ensure that mother is well hydrated. Special Note: An incorrect diagnosis of labor can lead to care is needed during summer months to prevent unnecessary anxiety and intervention. dehydration. Management n n Advise the mother to return if contractions start again. All patients should have labor monitored with a n n Ensure that the mother has a birth plan to ensure partograph to avoid complications. See annex C. planning for transport and emergency care if needed during labor. Prepare for labor and delivery. nn Review the patient’s history and antenatal record. 9.8. Delivery and Postpartum Care nn Ensure that the environment, equipment are clean and sterile and that staff have followed proper delivery Description hygiene procedures. Normal delivery takes place between 36 and 40 weeks nn Let the women choose any position that she wants for of pregnancy. Healthy delivery is supported by proper comfort; encourage her to eat and drink as she wishes antenatal care visits. during labor. Diagnosis nn Encourage the woman to empty her bladder properly. Suspect labor when the pregnant woman has intermittent Assess the progress of labor. uterine contractions associated with cervical effacement nn The first stage: The time taken for cervical effacement and dilatation that is often accompanied with blood- and dilatation is slow until 3 cm (latent phase); after stained mucosal discharge (blood spotting). that (in the active phase) the minimum acceptable rate Normal delivery is divided into the three stages of labor: of dilation is 1 cm/hour (8–12 hours in a primipara and 6–8 hours in a multipara). nn First stage: From the onset of regular contractions up to 10 cm (i.e., full) dilatation of the cervix or ll Monitor the fetal heart rate with a fetoscope every effacement. Regular contractions happen when the 30 minutes. patient enters into the first stage of labor, which itself ll Check maternal pulse every 30 minutes, blood has two phases: pressure every 4 hours, and temperature every 2 hours. ll Latent phase: cervix is dilated 1–4 cm ll Assess contractions every 30 minutes. Check

166 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 167 9.8. Delivery and Postpartum Care 9.8. Delivery and Postpartum Care

for frequency (i.e., the number/10 minutes) and rounded or the cord lengthens, cord traction is

duration in seconds. applied with the right hand, while supporting the OBSTETRICS / GYN ll Perform a vaginal examination every 4 hours to fundus of the uterus (counter traction) with the left assess the rate of cervical dilatation and effacement, hand. To prevent tearing of the thin membranes, position, and station of presenting part, presence of hold the placenta in two hands and turn it until the caput and molding, and character of discharge. membranes are twisted, and then slowly pull. The nn The second stage: The duration of the second stage of placenta should be examined to ensure its removal OBSTETRICS / GYN OBSTETRICS labor in the primipara is 30 minutes to 3 hours and has been complete. 5–30 minutes in the multipara. In this stage, fetal ll After delivery of the placenta, examine the woman descent continues as the presenting part reaches the carefully, and repair the episiotomy or any tears, if pelvic floor. The woman may also begin to have the needed. urge to push. ll Perform uterine massage. Massage the fundus of ll Perform a vaginal examination to determine the the uterus through the woman’s abdomen until the descent of the fetus at least once every hour. uterus is contracted. Repeat uterine massage every ll Monitor the fetal heart rate after each contraction. 15 minutes for first 2 hours. Ensure that the uterus ll Provide support to the perineum during delivery does not become soft (relaxed) after you stop the of the head and shoulders to control delivery and massage. prevent perineal tears. Note: Oxytocin IV injection may be used in the case of ll Consider an episiotomy in cases of— unsatisfactory progress during first or second stage of uu Complicated vaginal delivery (i.e., breech labor (i.e., if the contractions are irregular or infrequent) presentation of the baby, vacuum extraction, large as follows: baby) nn Re-evaluate the condition of baby’s presentation and uu Fetal distress position to ensure normal findings. uu Previous scarring nn If a trained attendant is present, augment the labor nn The third stage: Separation of the placenta generally with 10 units oxytocin in 1,000 ml Ringer’s lactate or occurs within 2–10 minutes of the end of the second physiologic serum, and give IV at the rate of 8 drops/ stage, but it can take 30 minutes. Active management minute. To achieve optimal contraction (regular of this stage helps to prevent PPH and includes the contractions, i.e., 3 contractions in 10 minutes each following: lasting 30 seconds), you may increase the infusion rate ll Give oxytocin immediately after making sure there to a maximum of 8 drops per minute every 30 minutes are not multiple births. In the case of multiple births, until a good contraction pattern is established not to give immediately after delivery of the last baby. Give exceed a total of 50 drops/minutes. 10 units IM injection. Caution: Be careful when increasing the dose. ll Control the cord traction. Clamp the cord near to If hyperstimulation of the uterus occurs (i.e., the perineum. When the uterus becomes firm and contractions lasting longer than 60 seconds or more

168 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 169 9.8. Delivery and Postpartum Care 9.8. Delivery and Postpartum Care

than 4 contractions/10 minutes), stop the oxytocin nn Prolonged labor. If after 8 hours of labor contractions

infusion. are stronger and more frequent and there is no OBSTETRICS / GYN Postpartum Care progress in cervical dilatation with or without Postpartum care includes the first 6 weeks following the membranes rupture, refer urgently to hospital. delivery. The immediate postpartum period (first 2 hours nn Rupture of membranes without labor beginning following delivery) is critical both for mother and baby. nn Meconium staining During this period mother is monitored with frequent vital nn Vaginal bleeding during first or second stages of labor OBSTETRICS / GYN OBSTETRICS signs checks, and checked for vaginal bleeding and proper nn Signs of fetal distress (i.e., fetal heart rate fewer than uterine contraction. 120 or more than 180 beats/minute) nn Prolonged or excessive PPH (see section 9.9 nn Check vital signs every 15 minutes for first 2 hours. “Postpartum Hemorrhage”) nn Massage uterus every 15 minutes for first 2 hours. nn Incomplete delivery of the placenta nn Have the mother begin breastfeeding the baby immediately. nn Fever in the mother nn Visible tears in the vagina, painful swelling of vulva or nn Mother and baby may be discharged after 6 hours if doing well, with the following instructions to the perineum (hematoma), or both mother: nn Uterine inversion nn Any other serious complications noted for mother or ll Continue breastfeeding. baby ll Keep the baby warm. If making a referral, place IV infusion when ll Eat well and drink lots of fluid. Note: possible, have mother lie on her left side, and give ll Get enough rest oxygen when available. ll Begin using a family planning method. ll Return for mother and baby evaluation in 1 week Patient Instructions and again in 1 month. If after 8 hours of the first stage of labor there is no Referral increase in contractions, the membranes have not In many instances, you will not have enough time to make ruptured, and there is no progress in cervical dilatation, a referral once labor has begun, depending on distance and discharge the woman and advise her to return when accessibility to referral facility. If considering referral, do pain or discomfort increases, if she experiences vaginal it early. Conditions requiring consideration for referral bleeding, or if her membranes rupture. include the following: nn Extremely small woman or large baby nn Evidence of malpresentation or malposition of the baby nn Unsatisfactory progress of first or second stage of labor

170 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 171 9.9. Postpartum Hemorrhage 9.9. Postpartum Hemorrhage

9.9. Postpartum Hemorrhage Table 9.9. Diagnosing Vaginal Bleeding after Childbirth Symptoms Symptoms OBSTETRICS / GYN Description and Signs and Signs Probable PPH is defined as blood loss more than 500 ml during a Typically Present Sometimes Present Diagnosis

vaginal delivery or more than 1,000 ml with a Caesarean nn Immediate PPH nn Shock Atonic uterus delivery. The two types of PPH are— nn Uterus soft and not nn Early (primary) PPH contracted

OBSTETRICS / GYN OBSTETRICS ll Occurs within 24 hours of delivery nn Immediate PPH nn Complete placenta Tears of cervix, delivered vagina, or ll May be caused by retained placenta, atonic uterus, nn Uterus contracted perineum trauma of birth canal, and blood clotting disorder (i.e., coagulopathy) nn Placenta not nn Immediate PPH Retained delivered within nn Uterus contracted placenta nn Late (secondary) PPH 30 minutes after ll Occurs 24 hours to 6 weeks after delivery delivery

ll May be caused by retention of placenta or infection nn Portion of maternal nn Immediate PPH Retained surface of placenta nn Uterus contracted placenta Diagnosis missing fragments nn Take a complete history, record vital signs, and nn Torn membranes perform a physical examination. with vessels nn Look for causes and etiology of the bleeding, keeping nn Uterine fundus not nn Inverted uterus Inverted uterus in mind the “4 Ts” of PPH: tone, trauma, tissue, and felt on abdominal apparent at vulva palpation nn Immediate PPH thrombin (coagulopathy). See table 9.9. nn Slight or intense Management of Early (Primary) PPH pain nn Immediate PPH nn Shock Ruptured uterus Nonpharmacologic nn Intra-abdominal, nn Tender abdomen nn Obtain help. Urgently mobilize all available personnel. vaginal bleeding, or nn Rapid maternal nn If the placenta has not been expelled, control cord both pulse nn Severe abdominal traction. pain that may nn If the placenta has been expelled, massage the uterus. decrease after Note: If the placenta has been expelled and the uterus rupture is contracted, examine the patient in the lithotomic nn Late PPH; bleeding nn Bleeding is variable nn Retention of position (with good light) for evidence of tear of cervix, occurs >24 hours (light or heavy, placenta after delivery continual, or nn Infection vagina, or uterus. nn Uterus softer irregular) and nn Rapidly assess the mother’s general condition. and larger than foul-smelling expected for nn Anemia nn If shock is suspected, immediately begin treatment elapsed time since (see section 16.9 “Shock” and table 16.9C). delivery nn Send blood for hemoglobin check, and cross-match

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blood (2 units) for possible transfusion (if the facility Try to stop the bleeding, and treat the shock before

has the capacity to do this). transfer. OBSTETRICS / GYN nn If facilities for manual removal of retained placenta A health worker should accompany the patient and apply under anesthesia are not available, prepare patient aortic compression if necessary. for emergency transfer. A health care worker should accompany the patient to the hospital so the treatment Management of Late (Secondary) PPH for shock is uninterrupted. Nonpharmacologic OBSTETRICS / GYN OBSTETRICS Pharmacologic If the woman shows evidence of severe blood loss, check her hemoglobin and cross-match blood (2 units) for nn In the case of uterus atony, give oxytocin 20 units in 1,000 ml normal saline infused rapidly (60 drops/ possible transfusion (if the facility has the capacity to do minute). The continuing dose, if patient is still this). bleeding, is oxytocin 10 units in 1,000 ml normal saline Pharmacologic (30 drops/minute). Treat mild blood loss with oral antibiotics. Caution: Do not give more than 3 liters (3,000 ml) of nn Amoxicillin—500 mg every 8 hours for 7 days IV fluids containing oxytocin. —OR— —OR— nn In the case of penicillin allergy or sensitivity, use If IV fluids are not available, give IM or IV 10 units of erythromycin. Refer to table A12 in annex A for oxytocin. If heavy bleeding persists, repeat after 20 standard dosages. minutes. —PLUS— nn If oxytocin therapy is not successful, give ergometrine nn Metronidazole—500 mg every 8 hours for 7 days 0.2 mg slow IV or IM. If heavy bleeding persists, repeat Note: Women with excessive PPH should receive iron 0.2 mg ergometrine IM after 15 minutes to a maximum therapy for 3 months (60 mg iron and 0.4 mg folic acid of no more than 5 doses (total of 1 mg). tablet) 2 tablets daily. Caution: Avoid ergometrine in hypertensive patient Referral unless shock is present. nn Women requiring examination of the uterus under nn If shock is suspected, immediately begin treatment anesthesia or ultrasound (see section 16.9 “Shock” and table 16.9C). A second IV nn Women showing signs of severe infection line is required. nn Women showing signs of blood clotting disorder Referral (coagulopathy) When a referral facility is accessible and patient can be Prevention transferred safely, refer all of the following: Active management of the third stage of labor reduces the nn Patients requiring anesthesia or surgery for trauma or incidence of PPH retained placenta nn Use uterine massage. nn Patients requiring a blood transfusion to treat shock. nn Apply gentle cord traction when required.

174 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 175 9.10. Newborn Care 9.10. Newborn Care

nn Administer oxytocin—10 units IM after delivery of ll Jaundice

baby. ll Bleeding OBSTETRICS / GYN nn Ensure complete delivery of placenta and good uterine ll Feeding difficulties tone during stage 3 of labor and before the woman goes ll Congenital malformations home. Diagnosis Patient Instructions nn Neonatal care begins with a basic assessment at Advise the patient to return to health facility immediately delivery, and continues for the first 28 days of life. OBSTETRICS / GYN OBSTETRICS if she experiences abnormal bleeding. Determine which level of care the neonate requires: essential, extra, or emergency. 9.10. Newborn Care nn The top priority is to identify neonates requiring emergency care or resuscitation (see annex B), those Description with danger signs requiring immediate intervention, The newborn or neonatal period is defined as the first 28 and those who are at higher risk of developing days of life. The majority of infant (i.e., children younger complications in the first weeks of life, including— than 1 year) deaths occur during this neonatal period, ll Low birth weight neonates especially in the first 24 hours of life. Planning, care, and ll High birth weight neonates treatment of emergencies during the neonatal period can ll Neonates born to mothers with underlying illness, have a significant impact on childhood survival. complications of pregnancy (e.g., hypertension, Newborn care refers to those interventions required during diabetes, eclampsia, human immunodeficiency virus the first 28 days of life: [HIV]) nn Essential newborn care refers to procedures to be ll Neonates who experienced complications during followed for all neonates. delivery nn Extra newborn care refers to procedures to be followed nn Neonatal danger signs include the following: for at-risk neonates, including the following: ll Difficulty breathing (e.g., abnormal respirations, ll Low birth weight (less than 2,500 grams) neonates chest in-drawing, grunting on expiration, gasping) ll Neonates born to sick mothers Caution: A respiratory rate more than 60 breaths/ ll Neonates who have had difficult or complicated minute or fewer than 20 breaths/minute is of deliveries concern. nn Emergency newborn care refers to procedures to be ll Convulsions, spasms, or loss of consciousness followed for neonates identified with an illness or ll Cyanosis (blueness) complication such as the following most common ll Floppiness or stiffness complications: ll Fever (i.e., hyperthermia, or a body temperature ll Asphyxia of more than 37.5°C) or hypothermia (i.e., a body ll Hypothermia temperature of less than 36.5°C) ll Infection or sepsis ll Bleeding from stump

176 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 177 9.10. Newborn Care 9.10. Newborn Care

ll Abnormal jaundice, presenting at or before 2 days of uu Maintain a temperature of 25°C in the room

age and severe in nature where the baby is staying. OBSTETRICS / GYN ll Poor feeding ll Provide good cord care: ll Diarrhea uu Wash your hands before and after cord care. ll Continuous vomiting uu Put nothing on the stump. ll Pus or redness of the umbilicus extending to eyes uu Fold nappy (diaper) below stump. or skin (i.e., more than 10 skin pustules or bullae or uu Keep cord stump loosely covered with clean OBSTETRICS / GYN OBSTETRICS swelling, redness, hardness of skin) clothes. uu Evaluate for cord infection or neonatal tetanus uu If the stump is soiled, wash it with clean water and uu Evaluate for severe conjunctivitis (i.e., ophthalmia soap, and dry it thoroughly with clean cloth. neonatorum) ll Begin immediate, exclusive breastfeeding (within 1 ll Swollen limb or joint hour of delivery). ll Pallor or blue lips or tongue ll Encourage “rooming in” immediately (i.e., baby Management stays with mother). Provide basic assessment to— nn Provide extra newborn care to at-risk neonates as defined above. Provide extra support regarding clinical nn Ensure newborn well-being condition, feeding, and maintaining warmth. nn Identify special needs nn Provide emergency newborn care based on “The Eight nn Identify potential complications Components Requiring Emergency Newborn Care” nn Treat emergency conditions; transfer to higher level facility, when required in the National Standards for Reproductive Health, Newborn Care Services: Nonpharmacologic ll Identify of neonatal danger signs (see above). nn Provide essential care to all newborns. ll Provide quality emergency care of the sick baby. ll Dry newborn with clean towel. uu Provide neonatal resuscitation as required (see ll Provide adequate warmth. Use the “Kangaroo annex B.) method”—skin-to-skin contact with the mother. uu Assess for and treat hypoglycemia uu Check temperature regularly every 4 hours by –– Maintain constant breastfeeding feeding touching baby’s feet. Watch for the danger signs of schedule (i.e., at least 8 times per 24 hours and hypothermia: on demand). – Decreased activity or lethargy – –– Provide feeding support for sick or very low –– Floppiness birth weight newborns with a nasogastric tube. – Poor feeding – ll Watch for neonatal asphyxia. – Weak cry – ll Watch for severe neonatal infection. – Shallow respirations – uu Identify meningitis, sepsis, pneumonia, and –– Red skin or face severe conjunctivitis. uu Wait at least 24 hours to bath the newborn.

178 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 179 9.10. Newborn Care 9.10. Newborn Care

Caution: Premature labor is often associated with flipchart for young infant age birth to 2 months) IM:

maternal infection. Check newborn carefully. uu Ampicillin—50 mg/kg/dose, every 6 hours OBSTETRICS / GYN ll Watch for neonatal tetanus. —PLUS— ll Watch for neonatal jaundice. uu Gentamicin: uu Severe jaundice appears at 2 days of life and –– First week of life—2.5 mg/kg/dose, every 12 progresses. hours uu Physiologic jaundice typically is not noted until –– From 2 weeks to 2 months of life—2.5 mg/kg/ OBSTETRICS / GYN OBSTETRICS 3–4 days of life and is very mild. dose, every 8 hours ll Watch for severe bleeding in the neonate. ll If first-line antibiotic therapy is not available or is ll Examine neonate for birth defects and congenital ineffective, change to second-line antibiotic therapy malformations. if available (i.e., in DHs). Pharmacologic uu Ceftriaxone—50 mg to 100 mg/kg once daily ll Refer. If referral is not possible give antibiotics for at nn Provide essential care of newborns: least 5 days. ll Give normal weight neonates vitamin K (phytomenadione)—1 mg IM once. nn Treat skin pustules or umbilical infections. ll For 5 days, do the following 3 times daily: ll Provide eye care within 1 hour of delivery. uu Wash your hands with clean water and soap. uu Wipe eyes with dry and clean cloth and then irrigate with clean water. uu Gently wash off pus and crusts with boiled and cooled water and soap. uu Apply tetracycline eye ointment (1%) to each eye, one time. uu Dry the area with a clean cloth. u Note: Breast milk irrigation of the newborn eyes, u Paint the area with gentian violet. nose, and ears is not recommended. uu Wash your hands again. ll Reassess in 2 days. ll Initiate immunizations before discharge, if possible, and always within the first 2 weeks of life (see also uu If worse, refer. chapter 19 “Immunization”): uu If improved, tell mother to continue treatment at home. uu BCG nn Treat eye infection. uu OPV-0 ll For 5 days, do the following 6–8 times daily: uu Hepatitis B (if available) u Caution: Babies born to mothers who have TB u Wash your hands with clean water and soap. should not receive BCG; for further evaluation, uu Wet clean cloth with boiled and cooled water. refer mother and infant to TB center. uu Use the wet cloth to gently wash off pus from baby’s eyes. nn Treat suspected severe infections or complications: sepsis, pneumonia, meningitis, skin, or umbilical cord uu Apply 1% tetracycline eye ointment in each eye infections. every 8 hours. uu Wash your hands again. ll Initiate first-line antibiotic therapy (see IMCI

180 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 181 9.10. Newborn Care 9.10. Newborn Care

ll Reassess in 2 days. Prevention

uu If worse, refer. nn A healthy newborn state is directly linked to a healthy OBSTETRICS / GYN uu If improved, tell mother to continue treatment at maternal and pregnancy state: home. ll Ensure pre-pregnancy health with good nutrition, nn Treat suspected severe conjunctivitis (ophthalmia hygiene, and medical care. neonatorum). ll Ensure family planning and birth spacing are ll Apply tetracycline eye ointment (1%) every 8 hours. maintained between pregnancies. OBSTETRICS / GYN OBSTETRICS —PLUS— ll Ensure proper maternal ANC, including routine ll Prescribe systemic antibiotics: ampicillin PLUS visits: gentamicin (see treatment for infections above). uu Give ferrous-folate supplement. u Referral u Keep immunization status up to date. uu Develop an emergency birth plan (see section 9.1 nn All newborns who are exhibiting danger signs “Pregnancy and Antenatal Care”). ll Provide emergency treatment and stabilization u before referral. u Identify any complications of pregnancy (e.g., hypertension, anemia, eclampsia, critical fetal ll Transfer with a health worker, when possible. position). ll Provide support to keep newborn breathing, warm, n and feeding during transfer. n Ensure clean and safe delivery (see section 9.8 “Delivery and Postpartum Care”). nn All very low birth weight newborns (i.e., less than 1,750 n g) for feeding support and monitoring. n Ensure proper postpartum care to include general Note: Some newborns weighing between 1,750 and support, iron supplement, and vitamin A supplement 2,500 g will require referral depending on how well (see section 9.8). n they are feeding and maintaining body temperature. n Provide treatment of sexually transmitted infection to the mother, as needed, during pregnancy. nn Newborns who are bleeding, who require a blood n transfusion, or both n Provide antibiotics to the mother if she has either of the following: nn Newborns who have severe jaundice that may require l exchange transfusion l Prolonged rupture of membranes (more than 24 hours before delivery) nn Newborns who have suspected infections or sepsis l (e.g., tetanus, meningitis) l Preterm rupture of membranes (rupture before the 37th week of pregnancy) nn Newborns who have a congenital malformation for evaluation and treatment plan Patient Instructions Note: Non–life-threatening malformation (e.g., cleft nn Promote early, exclusive, and on-demand lip, club foot) may have elective referral. breastfeeding for all newborns. n Include a copy of antenatal care (ANC) and delivery record n Initiate vaccination regimen for all newborns (see with referral materials. EPI).

182 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 183 9.11. Cracked Nipples during Breastfeeding 9.11. Cracked Nipples during Breastfeeding

nn Review essential maintenance of body warmth, Management

hygiene (washing and bathing), infection prevention, Nonpharmacologic OBSTETRICS / GYN and cord care. nn Apply warm compresses on the breast. nn Advise the mother that the newborn should be nn Measure patient’s temperature, and ensure she has no examined at least at 6 hours, 6 days (preferably within fever. 2–3 days), and 4–6 weeks after birth. nn Encourage the mother to continue breastfeeding. nn Clean cord properly using the instructions outlined nn Observe mother breastfeeding. OBSTETRICS / GYN OBSTETRICS above. Discourage the use of traditional medicines and nn Teach the patient the correct positioning and techniques for cord care. attachment of the baby (see “Prevention and Patient nn Counsel complication readiness for all caretakers by Instructions” below). ensuring that they know how to— nn Instruct the mother to apply expressed breast milk to ll Recognize danger signs the nipples and let it dry between feedings. ll Make emergency decisions about when and where nn Instruct the mother to express breast milk manually to seek help before the feeding. If expressing milk or nursing the ll Plan for emergency funds and transport baby is too painful on the affected side, advise her to begin nursing on the other breast and to expose the 9.11. Cracked Nipples during Breastfeeding breast with the fissure to air to allow the initial let- Description down to occur. n Tenderness of the nipples is a common symptom during n On rare occasions, it may be necessary to stop nursing the first days of breastfeeding and generally begins when temporarily on the affected side and to empty the the baby starts to suck. As soon as milk begins to flow, breast either manually or by gentle pumping. nipple sensitivity usually subsides. It can be caused by Pharmacologic poor attachment of the baby to the breast or removing nn Advise use of an analgesic. the baby from the nipple before suction is over. Candida ll Paracetamol. Refer to table A15 in annex A for infection can cause chronic severe sore nipple without standard dosages. remarkable physical findings. ll Ibuprofen—200 mg every 8 hours as needed nn Prescribe a topical agent. Diagnosis ll Vitamin A and D ointment or hydrous lanolin (if nn Severe pain available), which do not have to be removed during nn Fissure—may prevent normal letdown of milk feeding the baby nn Local infection around the fissure may lead to mastitis ll If candidiasis is suspected, prescribe nystatin (see section 9.12 “Mastitis and Breast Abscess”) topical drops (100,000 IU/ml)—applied every 8 nn Tender, swollen, warm breast hours for 5 days ll During treatment, teach the mother how to express breast milk from the affected breast and feed the

184 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 185 9.11. Cracked Nipples during Breastfeeding 9.12. Mastitis and Breast Abscess

baby by cup; she should continue breastfeeding on nn Instruct the mother to continue to breastfeed unless

the healthy side. there is a clear reason to stop. OBSTETRICS / GYN Prevention and Patient Instructions 9.12. Mastitis and Breast Abscess nn Ensure that the positioning and attachment between infant and breast is correct. 9.12.1. Mastitis ll Show the mother how to hold her baby. She should— uu Ensure that the baby’s head and body are in a Description OBSTETRICS / GYN OBSTETRICS straight line Mastitis means that the breast is inflamed. It occurs most uu Ensure that the baby is facing the breast and that often in primiparas. Usually only one breast is affected. the baby’s nose is opposite her nipple Staphylococcus is the most common causative agent. uu Hold the baby’s body close to her body Diagnosis uu Support the baby’s whole body, not just the neck nn Breast swelling and shoulders nn Redness ll Show the mother how to help her baby to attach. She nn Tenderness should— nn Pain and fever uu Touch her baby’s lips with her nipple nn Cracked or bleeding nipples uu Wait until her baby’s mouth is opened wide Management uu Move her baby quickly onto her breast, aiming the infant’s lower lip well below the nipple Nonpharmacologic ll Tell the mother to look for signs of good attachment: nn Advise rest. uu More of areola is visible above the baby’s mouth nn Encourage the woman to breastfeed frequently on uu Baby’s mouth is wide open the affected side, and use a breast pump or hand uu Baby’s lower lip is turned outward expression to get the milk out. uu Baby’s chin is touching the breast nn Teach correct positioning and attachment of the baby ll Instruct the mother to look for signs of effective to the breast (see section 9.11 “Cracked Nipples during suckling (i.e., slow, deep sucks, sometimes pausing). Breastfeeding”). ll Advise the mother that if the attachment or suckling nn Support breasts with a binder. is not good, she should try again and then reassess. nn Apply cold compresses to the breasts between feedings ll If her breasts are engorged, tell the mother to to reduce swelling and pain. express a small amount of breast milk before Pharmacologic starting breastfeeding to soften nipple area so that it nn Treat with antibiotics: is easier for the baby to attach ll Cloxacillin—500 mg by mouth every 6 hours for 10 nn Advise the mother to observe good hygiene of nipples days (available in CHCs and DHs) to avoid infection and mastitis. —OR—

186 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 187 9.12. Mastitis and Breast Abscess 9.13. Dysmenorrhea

ll Erythromycin—250–500 mg by mouth every 6 hours Referral

for 10 days. All breast abscesses should be referred to hospital for OBSTETRICS / GYN nn Give analgesics for fever and pain drainage and antibiotic therapy. ll Paracetamol—500 mg by mouth every 4–6 hours for Prevention 3 days or as needed Early and frequent breastfeeding. nn Instruct patient to follow up 3 days after initiating management to ensure response to treatment. 9.13. Dysmenorrhea OBSTETRICS / GYN OBSTETRICS Note: Mastitis without infection (i.e., sore nipples) is mostly due to missed feedings or intervals between Description feedings that are too long, and there is no need for Dysmenorrhea refers to cyclic lower abdominal pain specific treatment. associated with menstruation (i.e., the pain or cramps Referral occur before or during menstruation). Dysmenorrhea may If no response to initial treatment or recurrent mastitis be— n diagnosed n Primary dysmenorrhea—no organic cause identified nn Secondary dysmenorrhea—organic cause identified Patient Instructions including the following: nn Practice early, regular, and frequent breastfeeding ll Cervical stenosis (including at night). ll Endometrial polyps nn Avoid compressing breasts. ll Pelvic inflammation ll Uterine fibroids 9.12.2. Breast Abscess ll Endometriosis Description ll Intrauterine device A breast abscess is a localized compartment of infection Diagnosis containing pus in the breast tissue. It is caused by a nn Take a careful medical history. bacterial attack through an irritated or cracked nipple in a nn Perform a physical examination, including a pelvic woman who has recently delivered. examination (when appropriate staff members are Diagnosis available). nn Red, hard, swollen, painful, warm breast ll In primary dysmenorrhea, the pelvic examination is nn Fever normal. nn Breast mass of variable shape and size (the mass is ll In secondary dysmenorrhea, an abnormality may be usually near or around the nipple) found on pelvic examination. nn There may be discharge from the mass or the nipple of nn Look for recurrent lower abdominal pain and cramps the affected breast. associated with menstruation. Symptoms may also include backache, nausea, vomiting, diarrhea, and headache.

188 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 189 9.13. Dysmenorrhea 9.14. Abnormal Vaginal Bleeding

nn Occasionally, pelvic ultrasound may identify an 9.14. Abnormal Vaginal Bleeding

organic cause. Refer patient for ultrasound, if possible. OBSTETRICS / GYN Description Management Bleeding that deviates from the normal pattern for a Nonpharmacologic woman’s age, menstrual cycle, or both in terms of amount, nn Advise low-level topical heat therapy (e.g., hot pad on duration, or interval is considered abnormal. The causes the lower abdomen). depend on the age of the patient and whether the woman is n OBSTETRICS / GYN OBSTETRICS n Provide emotional support and reassurance to the pregnant and include the following: patient. nn Infancy and childhood Pharmacologic ll Traumatic lesions of vulva or vagina (e.g., accidental, For primary dysmenorrhea: foreign body or instrumentation, rape) ll nn For mild cases, give— Vaginitis ll ll Give paracetamol tablet as needed for 2–3 days. Rarely, prolapse of urethral meatus, tumors Refer to table A15 in annex A for standard dosages. nn Women and adolescents of childbearing age —OR— ll Complications of pregnancy ll ll Acetylsalicylic acid (aspirin) tablet—500 mg every Complications of hormonal or intrauterine 8 hours, as needed for about 2–3 days (until pain contraception subsides) ll Trauma: coital lacerations, instrumentation, rape ll nn For moderate to severe cases, give— Infection or inflammation of the vagina, cervix, or ll Ibuprofen—200-400 mg every 8 hours for 2–3 pelvic inflammatory disease days to take with or after food to minimize gastric ll Tumors irritation uu Cancer of the cervix, endometrium, vagina, vulva, or ovaries; choriocarcinoma Referral uu Benign fibroids nn Women with identified cause of dysmenorrhea (i.e., ll Dysfunctional uterine bleeding (i.e., when the secondary dysmenorrhea) endometrium sloughs in a severe and irregular nn Women who do not obtain adequate relief from manner, often associated with anovulatory cycle). ibuprofen or cannot maintain normal activity Dysfunctional uterine bleeding occurs most Prevention commonly at the extremes of menstrual life, in nn A low-fat diet may help to decrease dysmenorrhea. adolescents, and women over 40 years. nn Moderate, regular exercise may help to decrease nn Postmenopausal women (defined as women who have dysmenorrhea. stopped having menstruation for 6 or more months) Patient Instructions ll Cancer of the cervix, endometrium, vagina, vulva, or Encourage the woman to try to continue with her normal ovaries activities. ll Withdrawing from estrogen therapy

190 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 191 9.14. Abnormal Vaginal Bleeding 9.15. Postmenopausal Bleeding

ll Atrophic vaginitis or endometritis ll During labor, before delivery of baby; bleeding more

ll Trauma: coital, foreign body or instrumentation, than 100 ml since labor began OBSTETRICS / GYN rape Caution: Do not do a vaginal examination. Diagnosis uu Insert IV line. uu Give fluids rapidly if bleeding is heavy or if the nn Take a history regarding menstrual cycles, pregnancy, trauma, and systemic symptoms. patient is in shock (see section 16.9 “Shock,” and table 16.9C). nn In woman of childbearing age, do a laboratory OBSTETRICS / GYN OBSTETRICS pregnancy test. uu refer urgently to hospital because the abnormal bleeding may indicate placenta praevia, abruptio Management placentae, or a ruptured uterus. nn Treat the immediate, identified cause and then refer. ll PPH (see section 9.9 “Postpartum Hemorrhage”) nn In pregnant patients, look for complications of pregnancy. Referral nn All cases of abnormal vaginal bleeding for further ll Early pregnancy (uterus not above umbilicus) investigation and treatment uu If bleeding is heavy (i.e., pad or cloth soaked in less than 5 minutes)— Note: Do not refer if bleeding is due to contraception. Advise patient to return if bleeding or symptoms do –– Insert an IV line, and give fluids rapidly. not improve over next menstrual cycle. –– Give 0.2 mg ergometrine IM. nn Complications of cancer, trauma, and metrorrhagia –– Repeat 0.2 mg ergometrine IM/IV if bleeding continues. (i.e., dysfunctional uterine bleeding) uu If you suspect a septic abortion, give appropriate Prevention AND Patient Instructions antibiotics (see section 9.5 “Abortion [Vaginal nn Advise routine antenatal care in pregnant women. Bleeding in Early Pregnancy]”). nn Instruct patient to return if bleeding increases or uu refer urgently to hospital because the abnormal symptoms do not improve over next menstrual cycle. bleeding may indicate abortion, menorrhagia, or ectopic pregnancy. 9.15. Postmenopausal Bleeding ll Late pregnancy (uterus above umbilicus) Description uu Any bleeding is dangerous. Caution: Do not do a vaginal examination. Menopause is the cessation of menstruation at about age 45–51. Postmenopause is the phase of life after uu Insert an IV line. menopause. No vaginal bleeding should occur after uu Give fluids rapidly if bleeding is heavy or if the patient is in shock (see section 16.9 “Shock,” and menopause. table 16.9C). PMB is the bleeding that occurs after 12 months of uu refer urgently to hospital because the abnormal amenorrhea in a middle-aged woman. PMB is more likely bleeding may indicate placenta praevia, abruptio to be caused by pathologic disease and must be always placentae, or a ruptured uterus. investigated seriously. PMB is not preventable.

192 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 193 9.15. Postmenopausal Bleeding 9.16. Pelvic Inflammatory Disease

PMB is classified in two categories: nn Because PMB can be the first sign of endometrial

nn Nongynecological causes such as exogenous hormones cancer, refer the patient without delay. OBSTETRICS / GYN or anticoagulants Patient Instructions nn Gynecological causes such as the following: nn Practice good reproductive tract hygiene. ll Vaginal atrophy with or without trauma nn Avoid obesity. Maintaining a healthy weight decreases ll Endometrial hyperplasia (most common in obese the chance of PMB. women) nn Eat fruits and vegetables in addition to other foods. OBSTETRICS / GYN OBSTETRICS ll Endometrial polyp nn Report any PMB. PMB must be seriously investigated, ll Endometrial cancer and other genital organ cancers no matter how minimal or insignificant the bleeding Diagnosis may appear. nn Careful history taking is vital. nn Occasionally hematuria (blood in the urine) or rectal 9.16. Pelvic Inflammatory Disease bleeding may mistakenly present as PMB. Description nn The clinical examination should include an abdominal examination, looking for abdominal masses. Pelvic inflammatory disease (PID) is a general term for female upper genital tract infections (i.e., of the uterus nn A speculum examination should be performed to allow assessment of atrophic vaginitis and to rule out cervical lining, fallopian tubes, ovaries, or other pelvic organs). polyps and tumors of the cervix, vagina, or vulva. It may be acute (i.e., acute onset of pelvic infection) or chronic (i.e., with pelvic pain, painful menstrual nn Thin tissue of the vagina and ecchymosis (patchy reddening) are sign of vaginal atrophy. Try to expose periods, and pain with intercourse). PID may be sexually any vaginal tear if it is present due to trauma (e.g., transmitted, caused by organisms that ascend from postcoital bleeding). the lower genital tract, or from a sexually transmitted infection (STI)–related organism (e.g., anaerobic bacteria, nn Remember that an atrophic vagina does not exclude other causes. Careful history will inform you, for gonorrhea, chlamydia), or arise after childbirth or example, about whether the patient has taken or is abortion. PID may be complicated by peritonitis, abscess, taking exogenous hormones (e.g., for treatment of septicemia, chronic pelvic pain, increased risk of ectopic osteoporosis). pregnancy, or infertility. If the cause was not exogenous hormones or atrophy of the Diagnosis vagina, refer. Many women who develop pelvic inflammatory disease either experience no signs or symptoms or do not seek Management treatment. Others may exhibit the following symptoms: nn Discontinue exogenous hormone. nn Pain or tenderness in the pelvis and lower abdomen nn For vaginal atrophy, prescribe a topical, vaginal that may be associated with fever, nausea, or vomiting. estrogen such as estradiol 0.625 mg per gram, in 42.5 g nn Vaginal or cervical discharge with abnormal color or tube (not in the EDL). odor

194 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 195 9.16. Pelvic Inflammatory Disease 9.16. Pelvic Inflammatory Disease

nn Menstrual cramping nn Give antibiotics.

nn Irregular menstrual bleeding ll Doxycycline (capsule 100 mg). Refer to table A10 in OBSTETRICS / GYN nn Difficult or painful urination annex A for standard dosages. nn Pain with sexual intercourse (dyspareunia) Caution: Do not give doxycycline to pregnant or Infection is probable when one or more of the above lactating women. symptoms are associated with— —PLUS— ll Metronidazole—400–500 mg every 8 hours for 10 nn Pain with movement of the cervix OBSTETRICS / GYN OBSTETRICS days nn Adnexal tenderness nn Give an antipyretic or analgesic, if needed. nn Adnexal or pelvic mass (tubo-ovarian abscess) ll Paracetamol. Refer to table A15 in annex A for PID should be ruled out when the patient has the following: standard dosages. nn Ruptured ectopic pregnancy (see section 9.6 “Ectopic Pregnancy”) Referral nn All pregnant (suspected), postpartum, or postabortion nn Intestinal inflammation or abscess patients nn Peritonitis nn Patients who have severe illness or who are unable to nn Appendicitis tolerate oral medication nn Torsion or rupture of ovarian cyst (see section 16.2 “Acute Abdominal Pain”) nn Patients who have abnormal vaginal bleeding nn Patients who have a high fever (more than 39°C) or Management septicemia Nonpharmacologic nn Suspicion of pelvic abscess or peritonitis—for surgical nn Be careful to screen for pregnancy. Check menstrual consult history; give urine pregnancy test. nn Progression of symptoms at any time, or failure to ll All pregnant patients who have pelvic pain should improve within 48 hours of beginning oral treatment be referred for complication of pregnancy or PID Prevention and Patient Instructions during pregnancy. nn Educate the patient regarding spread of STIs, and urge ll Postpartum patients may have retained placenta or condom use. other complication of delivery. nn Instruct the patient to return to the clinic for follow- nn If an intrauterine device is present, remove it. up. If no improvement after 48 hours on treatment, nn Provide hydration; prevent dehydration. refer. nn Evaluate for evidence of other STIs (e.g., candidiasis, nn Instruct the patient to return to the clinic at end of the vaginitis, or genital ulcers or warts) course of treatment to ensure resolution and 4 weeks Pharmacologic after therapy to ensure no relapse of infection. Treat mild cases with oral therapy. Treat severe cases with nn Advise the woman that her spouse should be treated. IV therapy, and refer. Give him—

196 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 197 9.17. Infertility 9.17. Infertility

ll Ciprofloxacin—500 mg as single dose (available in If you suspect abnormal monthly bleeding, refer the

CHCs and DHs) woman to a gynecologist for further investigation. OBSTETRICS / GYN —PLUS— nn If the woman complains of painful episodes during ll Doxycycline—100 mg every 12 hours for 7 days monthly periods, suspect endometriosis and refer to nn Counsel the patient regarding compliance of gynecologist. treatment, risk reduction of STIs, and complications of nn Ask about any past surgical interventions, both STIs and PID. gynecological and abdominal. OBSTETRICS / GYN OBSTETRICS nn Counsel the patient regarding personal and genital In the man— hygiene. nn Check for anatomical abnormalities of the urethra and testes. If any are found, refer for correction. 9.17. Infertility nn Check for dilated veins in the scrotum (varicocele). If Description found, refer for surgery. Infertility is the inability of a couple who want children, nn Check for infections of urethra, prostate, or both. Treat who are having regular intercourse, and who are not any suspected infection appropriately. Always treat using any form of contraception to conceive within 1 year both the man and the woman at the same time. of trying. Infertility is called primary when the couple nn Ask about past testicular mumps or past injury or any has never conceived and secondary when the couple has other inflammation to the testes. conceived in the past. Difficulty in conceiving can be due to In both— male factors, female factors, or a combination of both. nn Check for conditions that may negatively alter normal Diagnosis fertility such as age, stress, poor or unbalanced diet, Patients complain of not having conceived for 1 year. Any athletic training or heavy physical activity, being infertility complaint should be taken seriously, since some overweight or underweight, smoking, substance abuse, of the causes are easily treated if found early on. Always exposure to environmental toxins such as pesticides reassure the couple that many causes of infertility can and lead, certain medicines, or radiation treatment be cured, but that it may take some time (6–12 months) and chemotherapy for cancer. depending on the cause. nn Carefully try to find out if intercourse is happening in a way that allows for conception. If it is not, advise In the woman— the couple accordingly. In addition, check whether nn Check for abnormal vaginal discharge and possible intercourse happens during the fertile period for the pelvic inflammatory disease. Treat any suspected woman: 10–17 days after the first day of the last period. infection appropriately. Always treat both the man and the woman at the same time (see section 9.16 “Pelvic Management Inflammatory Disease”). Nonpharmacologic nn Determine if the woman is ovulating. Inquire about For both partners give general advice on healthy lifestyles: any history of abnormal or irregular monthly bleeding. nn Advise on correct intercourse if necessary.

198 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 199 9.17. Infertility 10.1. Anemia

nn Recommend that the couple— Chapter 10. Nutritional ll Avoid stressful situations and activities ll Abstain from using any unhealthy substances (e.g., and Blood Conditions tobacco, hashish, opium) ll Eat a balanced diet 10.1. Anemia ll Practice good hygiene Description Pharmacologic OBSTETRICS / GYN OBSTETRICS Anemia is defined as a low level of hemoglobin in the Treat all suspected infections appropriately (see section blood, as evidenced by a reduced quality or quantity of red 9.16 “Pelvic Inflammatory Disease”), and treat both

blood cells. A decreased number of red blood cells may be nutrition and BL partners at the same time. the result of the following: Referral nn Decreased production Refer all unsolved infertility problems to gynecologist and ll Nutritional deficiency of iron, folate, or both, andrologist (specialist of male reproductive system). and of vitamin B12, which are needed to produce Patient Instructions hemoglobin uu Malnutrition—nutrient deficiency is the most nn Regardless of treatment, advise the couple to follow OOD the above-mentioned nonpharmacological treatment, common cause of anemia u to continue regular intercourse, and to follow up on u Pregnancy (see section 9.2 “Anemia in your referral advice. Pregnancy”) uu Chronic systemic illness nn Reassure them that many infertile couples can get l treated, but that it may take time. l Decreased bone marrow production (leukemia or other diseases) nn If possible, advise family members to not stress the l couple over the problem. l Infection ll Malabsorption nn Increased destruction (hemolysis) ll Malaria ll Infections (viral, bacterial) ll Medicine reactions (e.g., cytotoxics, co-trimoxazole, primaquine, or nitrofuran derivatives) ll Hypersplenism, enzyme deficiency nn Blood loss ll Parasitic infection (e.g., hookworm, whipworm) ll Blood loss from heavy menstruation or delivery ll Chronic blood loss from, for example, peptic ulcer disease, hemorrhoids, or intestinal cancer

200 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 201 10.1. Anemia 10.1. Anemia

Diagnosis Management Signs and symptoms of anemia vary with degree of Nonpharmacologic severity and chronicity. nn Assess the child’s feeding, and counsel the mother or nn Mild anemia may be asymptomatic. Major findings caregiver on feeding. If the child has a feeding problem, may include the following: follow up in 5 days (see IMCI flipchart). ll Pallor—of conjunctiva, mucous membranes, nn Encourage a diet rich in iron. Meat, cereals, vegetables, nailbeds and fruit all contain iron, but heme iron is much more ll Fatigue, anorexia, cold intolerance easily absorbed than non-heme iron. (See table 10.1B.) ll Headache and dizziness

Pharmacologic nutrition and BL nn Severe anemia (Hb less than 7.0 g/dl) is associated with severe pallor of the palms. It may lead to nn Treat any underlying causes of anemia such as OOD shortness of breath and heart failure (see section 6.2 infection, worms, malaria, or chronic disease (refer to “Cardiac Failure”) IMCI flipchart for children younger than 5 years). nn Give iron supplementation: ferrous sulfate and folic nn Values defining anemia vary according to age and sex; generally less than 10 g/dl in children (corresponds acid.

to hematocrit of 28) and less than 12 g/dl in adults OOD Table 10.1B. Dietary Sources of Iron (corresponds to hematocrit of 32) define anemia. (See nutrition and BL table 10.1A.) Amount of Iron Sources of Iron (in mg per 100 g)

Table 10.1A. Hemoglobin Values Defining Anemia Sources of Heme Iron for Population Groups Liver 7–21

Hemoglobin Value Red meat 1–3.5 Age or Sex Group Defining Anemia (g/dl) Eggs 2 Children 6–59 months <10.0 Milk (dried, skimmed) 0.4 Children 5–11 years <11.5 Sources of Non-Heme Iron Children 12–14 years <12.0 Millet 3.8–8 Nonpregnant women >15 years <12.0 Pulses 1.9–14 Pregnant women <11.0 Dried fruit 1.6–6.8 Boys and men >5 years <13.0 Bread 1.7–2.5 Source: WHO, UNICEF, UNU (2001); values used in DHS Green leafy vegetables 0.4–18 Rice 0.5

202 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 203 10.1. Anemia 10.1. Anemia

ll Double the dose shown in table 10.1C, which is Table 10.1C. Dosage and Schedule for Iron the iron supplementation to prevent anemia. This Supplementation to Prevent Iron Deficiency Anemia doubled dose should be given for 3 months in Age Specifics Dosage Duration confirmed anemia. Low birth Universal Iron: 2 mg/kg 2–23 months ll In pregnant women and infants (i.e., children weight supplementation body weight/ of age younger than 1 year), this therapeutic infants day treatment should be followed by the preventive <2,500 g supplementation regimen as shown in table 10.1C. Children Where the diet Iron: 2 mg/kg 6–23 months from 6 to 23 does not include body weight/ of age ll If a child is severely malnourished, he or she should months of foods fortified day be assumed to be severely anemic; however, iron age; normal with iron or nutrition and BL supplementation should be delayed until the child weight where anemia OOD regains appetite and starts gaining weight, usually prevalence is >40% 14 days after the nutritional rehabilitation has begun. Children Where anemia Iron: 2 mg/kg 3 months 24–59 prevalence is body weight/ Referral months >40% day up to

30 mg OOD nn Unknown cause of anemia nn School-age Where anemia Iron: 3 months nutrition and BL Signs and symptoms of severe anemia (e.g., syncope, children (>60 prevalence is 60 mg/day palpitations, and shortness of breath) months) >40% Folic acid: nn Pregnant women more than 36 weeks gestation who 0.4 mg/day have severe anemia Women of Where anemia Iron: 3 months nn Evidence of cardiac failure (see section 6.2 “Cardiac childbearing prevalence is 60 mg/day Failure”) age >40% Folic acid: 0.4 mg/day nn Signs of chronic disease (e.g., TB) Pregnant Universal Iron: As soon as nn Anemia associated with enlargement of the liver, women supplementation 60 mg/day possible after spleen, or lymph nodes Folic acid: gestation nn Signs and symptoms of acute blood loss or bleeding 0.4 mg/day starts—no disorder later than the 3rd nn Repeated blood in stool (undefined cause) month—and nn No improvement despite correct treatment at the continuing week 4 follow-up visit (i.e., hemoglobin increased less for the rest of pregnancy than 2.0 g/dl over a 2–3 week period) Lactating Where anemia Iron: 3 months Prevention women prevalence is 60 mg/day postpartum nn Recommend a diet rich in iron. >40% Folic acid: 0.4 mg/day nn Provide an adequate quantity of iron supplement tablets to patient or caregiver at each follow-up visit. Source: UNICEF, United Nations University, WHO 2001

204 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 205 10.1. Anemia 10.2. Thalassemia

nn Distribute antihelmintics with vitamin A supplements. 10.2. Thalassemia Give 1 dose of mebendazole when children are more than or equal to 1 year and have had no mebendazole Description within the last 6 months. Thalassemia represents a spectrum of anemia that runs in nn 250 mg if child is younger than 2 years families (i.e., it is inherited) whereby there is abnormal and ll 500 mg if child is 2 years or older decreased globulin—the protein responsible for carrying ll Screen for severe anemia in growth-monitoring oxygen in red blood cells. Thalassemia is of two types: programs for young children and antenatal care nn Thalassemia major—patients have a serious illness visits for pregnant women. that includes severe anemia and shortened life

nn Establish nutrition programs. expectancy nutrition and BL nn Thalassemia minor (carrier state)—patients are often

OOD Patient Instructions asymptomatic; the diagnosis is made from family nn Follow recommendations for a diet rich in iron. history and evidence of microcytic (small) red blood nn If feeding problems persist after the caregiver has been cells on smear counseled on how to feed the child, assess whether the caregiver understands and ask him or her to return Diagnosis regularly to the clinic as needed. Consider thalassemia when— OOD nn nn There is a known family history of thalassemia nutrition and BL Tell the patient or caregiver that epigastric discomfort, nausea, diarrhea, or constipation may appear with a nn A child presents with hypochromic, microcytic anemia daily dose of iron 60 mg or more. If these symptoms that does not respond to iron (or folate) therapy occur, instruct the patient to take the supplement with nn A child presents with severe anemia leading to meals. exercise intolerance, failure to thrive, or an enlarged nn Tell the patient or caregiver that his or her feces may spleen turn black, which is not harmful. Treatment of iron nn A child with anemia presents with bony changes such should continue. as “bossing” (i.e., protuberant) frontal bone, depressed nn Advise the patient or caregiver that all iron nasal bone, and pathologic fractures preparations inhibit the absorption of tetracyclines, A blood smear test (if possible) may be needed for sulphonamides, and trimethoprim. Thus, iron should diagnosis. not be taken together with these agents. Caution: Complications of untreated thalassemia major Caution: Iron overdose can cause critical illness. Store may lead to heart failure, liver problems, and susceptibility medicine in a safe place away from children. to infections. Management Patients who have suspected thalassemia should be referred to hospital for further investigation and treatment.

206 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 207 10.3. Malnutrition and Under-Nutrition 10.3. Malnutrition and Under-Nutrition

10.3. Malnutrition and Under-Nutrition

Description Malnutrition is a clinical syndrome due to a significant Low weight weight Low age for low Very weight age for

imbalance between nutritional intake and individual IMCI flipchart body’s needs. It is most often caused by both quantitative

(number of kilocalories per day) and qualitative (vitamins Source: and minerals, etc.) deficiencies. Complications are 5th year frequent and potentially life-threatening. More than

50% of child deaths are associated with malnutrition; nutrition and BL

10% are associated with severe malnutrition. Moderate 4th year OOD 9 8 and mild malnutrition are by far the biggest killers of 22 21 20 19 18 17 16 15 14 13 12 11 10 children younger than 5 years. There are two classes of malnutrition: over-nutrition and under-nutrition. Only under-nutrition is discussed here.

Clinical manifestation of under-nutrition and its OOD

classifications are as follows (see also figure 10.3): year 3rd nutrition and BL

nn Moderate type (low weight)—weight-for-height (or in months Age length) is 70–79% 24 18 17 nn Severe malnutrition (very low weight) )—weight-for- 23 22

height (or length) is less than 70% 21 20

ll Marasmic type (muscle-wasting): significant loss 19 18

of muscle mass and subcutaneous fat result in a 17 16 2nd year skeletal appearance 15 14

ll Kwashiorkor (edematous form): bilateral edema of 13 12 16 15 14 the lower limbs/edema of the face, often associated 11 10

with cutaneous signs (shiny or cracked skin, burn- 9 8

like appearance; discolored and brittle hair) 7 6 l l Marasmo-Kwashiorkor: the 2 forms are associated— 5 Weight 1st year 4

upper limb wasted and lower limb edema 3 2

Causes of death from under-nutrition include 1 Weight for age chart age for Weight 9 8 7 6 5 4 3 2 hypothermia, hypoglycemia, electrolyte imbalance, 13 12 11 10

dehydration, infection (i.e., septic shock), and vitamin and Kilograms for age for for age for mineral deficiency. weight Very low Very Low weight Low F igure 10.3.

208 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 209 10.3. Malnutrition and Under-Nutrition 10.3. Malnutrition and Under-Nutrition

Diagnosis becomes sicker, fever develops, fast-breathing, nn Mild wasting (early upper limb, late lower limb) difficult breathing, blood in stool, drinking poorly) nn Edema in lower limb ll If infant is younger than 6 months: assess nn Miscellaneous breastfeeding practice: assess the proper nn Acute and persistent diarrhea attachment of the baby, ensure that breastfeeding ll Recurrent infections (chest infection, pneumonia); happens at least 8 times in 24 hours (including at sometimes difficult to identify due to absence of night), ask mother to reduce other foods or drinks fever and specific symptoms if she does and to increase breastfeeding. Propose ll Hypothermia (cold extremities) follow-up visits in 2 days and in 14 days.

ll Anorexia ll If you do not think that feeding will improve, or if nutrition and BL ll Anemia the child has lost weight at the follow-up visit, refer OOD Management the child nn Give 1 dose of mebendazole if child is 1 year old or Moderate malnutrition older and has had no mebendazole within last 6 nn Advise home-based management, or refer to months. supplementary feeding center if available. uu 250 mg if the child is younger than 2 years OOD nn Assess the child`s feeding, and counsel the mother or uu 500 mg if the child is 2 years old or older nutrition and BL caregiver on feeding : take the time to review with the nn Treat other possible causes (e.g., pneumonia, acute or mother or caregiver the “Feeding Recommendations persistent diarrhea, or hypoglycemia. Refer to specific During Sickness and Health” of the IMCI flipchart and condition. propose follow-up visits at 5 days and then 30 days to ensure that proper feeding instructions are followed Severe malnutrition at home. At day 30, weigh the child and congratulate nn All children who have severe malnutrition must be the mother or caregiver if the child is gaining weight, referred to a therapeutic feeding unit or hospital. and review again the feeding recommendations for nn Before referral— reinforcing new knowledge. At day 30, if the child is ll Give 1 dose of vitamin A (see section 10.4 “Vitamin A still very low weight for age, counsel the mother about Deficiency”). feeding problem found and ask the mother or caregiver ll Treat the child to prevent low blood sugar: to return every month to weigh the child. uu Make sugar water by dissolving 4 level teaspoons ll If child is sick (pneumonia, dysentery, persistent of sugar (20 g) in a 200-ml cup of clean water. diarrhea, acute or chronic ear infection, any other uu If the child is not able to swallow, give 50 ml of illness) advise mother or caregiver to increase milk or sugar water by nasogastric tube. fluid during illness and to maintain a sufficient ll Give first dose of antibiotic if the patient has signs feeding and ask her/him to return within 2- 5 days or symptoms of infection (e.g., amoxicillin, co- for a follow-up visit or immediately if condition is trimoxazole, or ampicillin), and refer (see IMCI worsening (not able to drink or breastfeed, child flipchart). See annex A for standard dosages of

210 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 211 10.4. Vitamin A Deficiency 10.4. Vitamin A Deficiency

antibiotics. In the case of penicillin allergy or 1–5 years old. Vitamin A deficiency may be combined with sensitivity, use erythromycin. Refer to table A12 in measles, diarrhea, or malnutrition, and can increase the annex A for standard dosages. mortality of these diseases. If left untreated, it is the most ll Prevent hypothermia during the transport: keep the common cause for blindness in children. child next to the mother’s body (kangaroo method) Diagnosis and provide blankets. nn Night blindness; often, the first complaints are that the Prevention patient fell or hit something at night or dusk nn Weigh systematically all children younger than 5 years. nn Eye changes nn Ensure birth spacing, antenatal care visits, and good ll White foamy patches on the eye (Bitot’s spots) nutrition and BL (and increased) nutrition for pregnant women. ll Dry eyes and eyelids

OOD nn Avoid young-age marriages. ll Cornea becoming wrinkled and cloudy nn Practice early, exclusive breastfeeding until infant ll Cornea becoming soft and bulging, leading to reaches 6 months age. Continue breastfeeding until irreversible blindness child is 2 years old, but introduce complementary food nn Skin changes at 6 months. ll Bumpy appearance OOD nn Introduce solid and semi-solid foods at the age of ll Rough, dry texture ll nutrition and BL 6 months. Increase the consistency, diversity, and Hair follicles become plugged with keratin frequency of feeding as the child grows up. Refer to nn Growth-related changes; in areas of the world where the “Feeding Recommendations During Sickness and vitamin A deficiency exists, poor growth follows Health” of the IMCI flipchart. Management nn Continue feeding sick children and increase fluids intakes. Nonpharmacologic nn Increase intake of foods rich in vitamin A (see table nn Promote full vaccination in children younger than 2 years according to EPI schedule (see chapter 19 10.4A).

“Immunization”). Table 10.4A. Important Sources of Vitamin A nn Seek health education from health facility or community health worker. Gather information about Mainly as Retinol As Carotene the complications of malnutrition and the importance nn Breast milk—colostrum, nn Red palm oil (the carotene in particular, is very rich in makes the oil red) of a balanced diet. vitamin A. nn Orange and yellow fruits and nn Liver from animals, birds, and mangoes 10.4. Vitamin A Deficiency fish, especially small fish that nn Orange vegetables such as are eaten whole with their carrots and pumpkins. Description livers nn Dark green leaves, for nn Kidney example, spinach and beans. Deficiency in vitamin A most often affects the skin, nn Eggs nn Yellow maize and banana mucosa, and the eyes, and it is most common in children nn Butter and animal ghee

212 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 213 10.4. Vitamin A Deficiency 10.4. Vitamin A Deficiency

Table 10.4B. Table 10.4C. Treatment Schedule for Diseases Causing Treatment Schedule of Xerophthalmia in Children Vitamin A Deficiency Timing Condition and When to Based on Vitamin A Age Group Doses Timing Dose Administer Different Ages Dosage Measles Age-specific dose on First Immediately <6 months of age 50,000 IU 6–12 months 100,000 IU day 1, day 2, and day on diagnosis >12 months to 5 years 200,000 IU 14 (total of 3 doses) 6–12 months of age 100,000 IU Severe malnutrition Age-specific dose on <6 months 50,000 IU day 1, day 2, and day >12 months of age 200,000 IU 6–12 months 100,000 IU

14 (total of 3 doses) nutrition and BL Second Next day The same age- >12 months to 5 years 200,000 IU specified dose OOD Chronic diarrheal disease Third 2 weeks later The same age- One dose as per age <6 months 50,000 IU specified dose specified 6–12 months 100,000 IU >12 months to 5 years 200,000 IU Pharmacologic

The treatment refers to all children who have not received OOD a child with an existing measles infection dramatically a vitamin A capsule during the National Immunization nutrition and BL lowers measles morbidity and mortality. Days (NIDs) campaign (i.e., within the last 30 days) and have developed the following conditions: Referral nn Xerophthalmia—cases of eye diseases that are related All patients who have eye symptoms, severe malnutrition, to acute vitamin A deficiency, such as night blindness, or other complications xerosis, keratomalacia, and corneal melting (see table Prevention 10.4B). All children older than 5 years should receive vitamin A nn Other specified high-risk illnesses—children with supplementation every 6 months as shown in table 10.4D, measles, severely malnourished children, children and postpartum women should receive it once. with chronic diarrhea (see table 10.4C). Patient Instructions Note: Always administer the vitamin A capsule in the nn All children younger than 5 years must follow the clinic. Do not give to be administered at home. Make sure national program of prevention of vitamin A deficiency children swallow. and follow the vitamin A supplementation preventive All children with measles, severe protein-energy program. malnutrition, and chronic diarrheal diseases have an nn All women who are postpartum should have a increased risk of vitamin A deficiency. These conditions postnatal visit. deplete the body’s store of vitamin A, put the child at risk nn To prevent vitamin A deficiency, eat foods rich in of vitamin A deficiency, and can increase the severity of vitamin A, and whenever any sign and symptom of subsequent infections. Vitamin A supplementation for vitamin A deficiency appears, consult a doctor.

214 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 215 10.4. Vitamin A Deficiency 10.5. Vitamin D Deficiency and Rickets

10.5. Vitamin D Deficiency and Rickets

Description Vitamin D is produced in the body in response to sunlight 2 capsules 4 capsules 4 capsules

50,000 IU 50,000 and certain food sources including fish, liver, oils, egg yolk, butter, some grains, and milk. Vitamin D is essential for strong bones since it plays an important role in the metabolism of calcium and phosphate. Deficiency in vitamin D may lead to poor mineralization of bone with calcium and contribute to the following: nutrition and BL 1 capsule 2 capsules 2 capsules nn 100,000 IU 100,000

OOD Rickets—a childhood disease characterized by “soft

Vitamin A Capsule Vitamin bones,” growth abnormalities, and deformity of the long bones nn Osteomalacia—a bone-thinning disorder that occurs in adults and is associated with proximal muscle

weakness and bone fragility OOD 1 capsule 1 capsule ½ capsule nn Osteoporosis—poor mineralization of developed bone, 200,000 IU 200,000 nutrition and BL associated with bone fragility (in elderly) Diagnosis

nn Symptoms are subtle and nonspecific until bone changes occur. Consider a diagnosis of vitamin D deficiency in young children who have growth 100,000 I U 100,000 200,000 I U 200,000 200,000 I U 200,000 disturbance or bony deformities—early treatment every 6 months every 6 months every

Vitamin A Dosage Vitamin prevents permanent disability. nn Rickets—seen most commonly at 6–24 months of age ll Craniotabes—softening of the membranous bone of the skull causing spherical indentations (“ping pong ball”), and bossing of frontal bones

Age ll Bone pain, deformity, and delayed growth ll Delay of tooth formation ll Skeletal abnormalities Preventive Dosage Schedule for Vitamin A Supplementation Vitamin Schedule for Dosage Preventive Postpartum—ideally Postpartum—ideally 48 hours after delivery, but at least within 6 Do after delivery. weeks after 42 days not give postpartum. >6–12 months >6–12 12 months to 5 years uu Curvature of legs (“bowlegs” or “knock knees”) uu Nodules of the ribs (“rachitic rosary”) uu Protruding sternum (“pigeon chest”) Dose Single

ab l e 10.4D. uu

T Spine curvature—kyphosis, scoliosis, or both

216 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 217 10.5. Vitamin D Deficiency and Rickets 10.6. Iodine Deficiency

uu X-ray may show wide epiphyseal plate or Prevention widening of bony ends (particularly distal radius Adequate dietary intake of vitamin D and calcium (see and ulna) above) nn Osteoporosis and osteomalacia—in adults Patient Instructions ll Poor mineralization on X-ray nn Review instructions (from referral facility) for proper ll Bone fragility—fractures occur with unusually small administration of supplements and therapy. stress nn Instruct the patient to return in 2 weeks if bony Management changes are not improving. Focus of treatment is adequate replacement of vitamin D, calcium, and phosphorous. 10.6. Iodine Deficiency nutrition and BL OOD Nonpharmacologic Description nn Splinting and physiotherapy may be helpful in Iodine deficiency disorders refer to the wide spectrum of advanced cases of rickets effects of iodine deficiency on growth and development. Note: Bone changes normalize rapidly with proper Endemic goiter, endemic cretinism, and impaired mental treatment during early phases of rickets. function in children and adults can be manifestations of OOD nn Diet supplement iodine deficiency. nutrition and BL ll Vitamin D (see below) Diagnosis ll Calcium from dairy products and green vegetables nn Lack of iodine in the mother may result in abortion nn Adequate exposure to sunlight and stillbirth. Pharmacologic nn Congenital anomalies, neurological and When available myxedematous cretinism (i.e., mental retardation, nn Give vitamin D. short stature, large tongue, dry skin, sparse hair, ll 500–1000 IU daily for 1 month protuberant abdomen), goiter, and psychomotor ll Then 400 IU daily as prophylactic defects appear during the neonatal period. nn Give a calcium supplement. nn In children, iodine deficiency may result in goiter, ll Micronutrient or multivitamin tablet daily juvenile hypothyroidism, impaired mental function, ll Dietary sources—dairy products and green and retardation of physical and sexual growth. vegetables Management and Prevention Referral Iodine deficiency can be prevented by the use of iodized All cases of suspected rickets or severe osteoporosis salt through national program. should be referred for laboratory testing, X-ray confirmation, and treatment.

218 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 219 11.1. Urinary Tract Infection 11.1. Urinary Tract Infection

Chapter 11. Urinary Tract —OR— In the case of penicillin allergy or sensitivity, use and Renal Conditions erythromycin. Refer to table A12 in annex A for standard dosages. 11.1. Urinary Tract Infection —PLUS— uu Gentamicin for 7 days. Refer to table A13 in annex 11.1.1. Acute Pyelonephritis A for standard dosages. Description —OR— Acute pyelonephritis is an infection of the kidney uu Alternatively, when available (i.e., in DHs), parenchyma and pelvis. It is most often the result of ceftriaxone—80 mg/kg once daily for 10 days an ascending infection of the urinary tract by gram- ll Adults negative bacteria (most common, E. coli) or gram-positive uu Ampicillin (vial 1 g)—1 g IV every 6 hours for 14 bacteria (Enterococcus, Staphylococcus). If not correctly days treated, it can be potentially life threatening from —OR— septicemia, peritonitis, or both. Patients who have acute In the case of penicillin allergy or sensitivity, use pyelonephritis must be referred. erythromycin. Refer to table A12 in annex A for standard dosages. Diagnosis —PLUS— nn Fever, chills, or both, usually with nausea and vomiting uu Gentamicin (ampoule 40 mg/ml) —60 mg (1.50 URINARY AND RENAL nn Flank pain (tenderness to percussion) ml) slow IV or IM every 8 hours for 7 days nn Burning and frequency of urination —OR— nn Cloudy or bloody urine—or may look normal uu Alternatively, when available (i.e., in DHs), ll Urine dipstick may show leukocytes and nitrates. ceftriaxone (vial of 500 mg)—1 g IM every 24 ll Urine microscopy may show white blood cells, red hours for 10 days blood cells, and bacteria. ll Pregnant women

URINARY AND RENAL URINARY Management uu Ceftriaxone as for other adult patients Nonpharmacologic Referral Encourage high fluid intake. nn Refer all patients who have suspected pyelonephritis Pharmacologic for management. nn For fever and pain, give paracetamol. Refer to table nn Give first dose of antibiotic treatmentbefore referral. A15 in annex A for standard dosages. Patient Instructions n n Give an antibiotic. nn Keep fluid intake high. l l Children nn Seek early treatment of urinary tract infections. u u Ampicillin for 10 days. Refer to table A4 in annex nn Follow referral advice as directed. A for standard dosages.

National Standard Treatment Guidelines for the Primary Level 221 11.1. Urinary Tract Infection 11.1. Urinary Tract Infection

nn Obtain ultrasound in the case of recurrent urinary nn Differential diagnoses to consider— tract or kidney infections to rule out stones or other ll Pelvic inflammatory disease or vaginitis in women abnormality. ll Prostatitis in men Management 11.1.2. Cystitis and Urethritis Nonpharmacologic Description Encourage high fluid intake. Cystitis and urethritis are infections of the urinary bladder and urethra, respectively. Uncomplicated cases of cystitis Pharmacologic and urethritis may be seen in menstruating women with nn Children a normal urinary tract. All other cases (i.e., men, children, ll Amoxicillin for 5 days. Refer to table A3 in annex A women with multiple recurrent infections) raise concern for standard dosages. for complicated urinary tract infection and require —OR— investigation. ll Co-trimoxazole for 5 days. Refer to table A8 in annex A for standard dosages. nn Most often from gram-negative bacteria or intestinal flora(E. coli) nn Adults ll Nitrofurantoin (tablet 100 mg)—100 mg every 8 nn May be from gram-positive bacteria hours for 5 days nn May be associated with— ll Bladder stones —OR— ll Amoxicillin for 5 days. Refer to table A3 in annex A URINARY AND RENAL ll Urinary retention for standard dosages. ll Enlarged prostate in adult males ll Urethral valves in children —OR— ll Co-trimoxazole for 5 days. Refer to table A8 in annex Diagnosis A for standard dosages. n n Pain or burning with urination —OR— nn Frequency of urination ll Ciprofloxacin—500 mg every 12 hours for 5 days nn URINARY AND RENAL URINARY In more severe cases, suprapubic pain or tenderness Caution: Ciprofloxacin is contraindicated in Note: Rule out pyelonephritis, pelvic inflammatory pregnant women. disease, or an abdominal source. Referral nn In children, a nonspecific illness (e.g., diarrhea, upper respiratory symptoms) nn Failure to respond to treatment nn Recurrent infections nn Turbid or bloody urine ll Urine dipstick should be positive for leukocytes. Prevention and Patient Instructions ll Urine dipstick may be positive for nitrates. nn Practice good hygiene of the anal-genital area. ll Urine microscopy should show leukocytes and may nn Keep fluid intake high. show bacteria.

222 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 223 11.2. Acute Glomerulonephritis 11.2. Acute Glomerulonephritis

11.2. Acute Glomerulonephritis polymorphonuclear leukocytes. RBC casts point toward glomerulonephritis. Description Acute glomerulonephritis (AGN) is an immunologic Acute complications of AGN result primarily from HTN syndrome in children and adults, usually secondary to and the retention of sodium and fluids. untreated streptococcal infection (e.g., impetigo, tonsillitis, nn HTN is seen in 60% of patients and may be associated or pharyngitis), which results in acute glomerular with hypertensive encephalopathy in 10% of cases. inflammation. The resulting retention of sodium and fluids nn Other potential complications include heart failure can be life threatening (i.e., from acute pulmonary edema with pulmonary edema and seizures due to cerebral or cerebral edema), but the outcome is usually favorable edema. with clinical signs subsiding over days and proteinuria Management and hematuria subsiding over weeks to months. Nonpharmacologic Diagnosis Diet changes must be recommended. The intake of protein, nn The onset of retention of salt and fluids is rapid, with sodium (salt), potassium (i.e., from bananas, tomatoes, and puffiness around the eyes and soft and painless pitting other food sources), and fluids should be restricted in the edema of the legs. case of HTN. nn Urine is characteristically cola-colored; dark urine is a Pharmacologic sign of hematuria. nn Treat any identified streptococcal infection of skin or nn Hypertension (HTN) is present when renal URINARY AND RENAL throat with penicillin or alternative. (See section 4.5.2 impairment is significant. “Bacterial Tonsillitis” and section 13.1 “Impetigo.”) nn Oliguria is present with concentrated urine. nn Treat recognized HTN. (See section 6.1 “Systemic Do not give increased fluids to patients who Caution: Hypertension.”) have oliguria until AGN has been excluded as cause of nn Treat AGN complications of pulmonary edema (see the oliguria. section 16.1 “Acute Pulmonary Edema”), heart failure nn AGN is most common in children 5–12 years and is (see section 6.2 “Cardiac Failure”), and seizure (see URINARY AND RENAL URINARY uncommon in children younger than 3 years. section 7.1 “Epilepsy”). nn The patient will often report a recent streptococcal throat infection or skin infection (pyoderma). Check Referral for active streptococcal throat infection or skin Refer all patients to hospital for further investigation and infection. treatment. nn Other specific symptoms include malaise, lethargy, Prevention abdominal or flank pain, and fever. Early detection, appropriate treatment, and follow-up of nn Urine examination shows presence of red streptococcal infections. blood cells (RBC), RBC casts, proteinuria, and

224 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 225 12.1. Diabetes Mellitus 12.1. Diabetes Mellitus

Chapter 12. ll Often requires insulin treatment to reverse this catabolic state Endocrine System Disorders nn Type II diabetes ll Typically presents in adults and adolescents (may 12.1. Diabetes Mellitus rarely be seen in children) ll Is often related to obesity, which may play a Description significant role in the severity of the disease Diabetes is a metabolic disorder characterized by ll Tends to present with more gradual initial persistently high blood glucose levels. Diabetes may be symptoms; often patients present with the chronic caused by a variety of environmental and genetic factors complications of diabetes before the disease is resulting in deficient secretion of insulin from the recognized pancreas, resistance to insulin, or a combination of the ll Is usually treated with diet changes, oral medication, two. or both Diabetes may lead to the following acute (emergency) nn Gestational diabetes—elevated blood glucose that is conditions with confusion, coma, and shock: detected during pregnancy n n Hyperglycemia (excess of sugar in the blood) with or ll Is often detected on antenatal exam (with check of without ketoacidosis (see section 12.2 “Hyperglycemia glucose) and Ketoacidosis”) ll Requires careful management by a team of medical nn Hypoglycemia (abnormal decrease of sugar in the doctors and obstetricians, so patient must be blood) (see section 16.8 “Hypoglycemia”) referred Diabetes may lead to the following chronic complications ll May persist after delivery or present again later in after many years: life nn Heart, kidney, or vascular disease Medications to treat diabetes mellitus are limited to EPHS nn Decreased immune function facilities. n n Chronic wounds nn All patients require referral. n n Blindness nn BPHS facilities may need to— Three common forms of diabetes are encountered. ll Treat diabetic emergencies (see section 12.2 ENDOCRINE SYSTEM nn Type I diabetes “Hyperglycemia and Ketoacidosis” and section 16.8 ll May occur at any age but is seen most commonly “Hypoglycemia”) in children and young adults with a peak incidence ll Assist or support the patient with chronic and before school age ongoing care initiated at EPHS facility ll Tends to present with the most severe initial Diagnosis symptoms (see “Diagnosis” below) nn Type I diabetes tends to present with the most

ENDOCRINE SYSTEM ll Is a catabolic disorder with circulating insulin dramatic and severe findings, although the common virtually absent and plasma glucagon elevated

226 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 227 12.1. Diabetes Mellitus 12.1. Diabetes Mellitus

signs and symptoms may be present in all forms of controlled diabetes may present with dehydration, diabetes: confusion, coma, or shock (see below) ll Polyuria—passing of frequent, large amounts of uu Patients who have long-term diabetes may be urine prone to heart disease, stroke, infection, or ll Thirst and excessive drinking of water blindness ll Nocturnal enuresis ll Hypoglycemia ll Weakness and fatigue uu Patients who have hypoglycemia from too much ll Unexplained weight loss or, in children, failure to insulin or oral medication may present with a gain weight or grow change in mood, confusion, or coma (see section ll Blurred vision 16.8 “Hypoglycemia”). ll Recurrent infections such as skin abscesses, urinary Management tract infections, vulvovaginitis or pruritus, and other Goals for BPHS staff are to— fungal infections nn Identify the disease and refer ll Evidence of chronic complications nn Treat diabetic emergencies and refer uu Peripheral neuropathy nn Provide chronic care support uu Evidence of vascular disease Nonpharmacologic uu Ischemic heart disease nn Ensure the patient is correctly taking the medications uu Strokes from the referral facility. uu Foot ulcers nn Assist with weight loss (for obese patients) and proper ll History of obstetric complications (gestational diabetes) diet. Advise the patient to— ll Avoid processed sugar uu Infertility ll Eat regular (i.e., 3 times a day), balanced meals uu Recurrent stillbirths ll Avoid alcohol use uu Large babies ll Get regular physical exercise nn Laboratory ll Avoid smoking ll Blood glucose (when available by test strip or glucometer) nn Prevent long-term complications. ll uu Monitor for infections. Fasting blood sugar (most reliable): If more than ENDOCRINE SYSTEM 126 mg/dl on more than one occasion, diabetes is ll Control blood pressure. confirmed ll Monitor for visual and eye problems. ll Assist skin care and hygiene; treat wounds uu Random blood sugar: more than 200 mg/dl aggressively. ll Urine dipstick: glucose more than ++ ll Avoid foot trauma. nn Emergency presentations associated with diabetes ll Hyperglycemia ENDOCRINE SYSTEM uu Patient who have undiagnosed or poorly

228 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 229 12.1. Diabetes Mellitus 12.2. Hyperglycemia and Ketoacidosis

Pharmacologic ll Prevention of infections nn Type I diabetes—insulin as initiated by EPHS facility uu Good hygiene nn Type II diabetes—diet control with or without oral uu Good skin, and especially foot, care agents, as initiated by EPHS facility uu Proper-fitting shoes to avoid local trauma n n Diabetic emergencies: confusion, coma, and Patient Instructions dehydration nn Review and observe patient taking medicine l l Suspected hyperglycemia plus ketoacidosis, give prescribed by the referral facility as instructed. fluid resuscitation, and refer. (See section 16.9 nn Review and observe patient performing self- “Shock” for a discussion of fluid resuscitation.) monitoring activities ordered by the referral facility as l l Suspected hypoglycemia, give oral or IV glucose, and instructed, such as use of glucometer and recognition refer. (See section 16.8 “Hypoglycemia” and section of symptoms of hypoglycemia and how to manage the 16.9 “Shock.”) symptoms. ll If patient presents in coma and glucose status is not nn Review and support dietary and exercise known, treat for hypoglycemia (i.e., give glucose), recommendations. and refer (see section 16.8 “Hypoglycemia”). nn Ask the patient to carry his or her patient card with Referral diagnosis, dose of insulin (if any), and name and nn All patients suspected of having diabetes should be telephone number of family doctor. referred to EPHS facility for appropriate laboratory nn Inform the patient that sometimes diabetes is seen in testing and appropriate treatment. families. Monitor for symptoms in family members. nn Patients who have gestational diabetes may benefit from special antenatal services (e.g., ultrasound) when 12.2. Hyperglycemia and Ketoacidosis available. Description nn Treat medical emergencies prior to referral, and transport with medical staff, if possible (see below and Diabetes ketoacidosis is a life-threatening medical see section 16.8 “Hypoglycemia”). emergency. Diabetes ketoacidosis may be the initial manifestation of type I diabetes and may result from an Prevention increased insulin requirement in type I diabetes patients nn Type II diabetes may be prevented or treated in some during the course of infection, trauma, myocardial ENDOCRINE SYSTEM patients using— infarction, or surgery. Patients with type II diabetes may l l Weight control (i.e., weight loss in obese patients) develop ketoacidosis under severe stress such as infection l l Proper diet or trauma. ll Regular physical exercise Diagnosis nn Complications of diabetes can be reduced or prevented with— The diagnosis of ketoacidosis relies on mild symptoms

ENDOCRINE SYSTEM before the emergency signs and symptoms appear. ll Good blood sugar control nn Mild symptoms

230 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 231 12.2. Hyperglycemia and Ketoacidosis 12.2. Hyperglycemia and Ketoacidosis

ll Polyuria (i.e., the passing of frequent, large amounts (available in provincial and regional hospitals). of urine) ll Do not delay treatment while waiting for glucose ll Thirst and excessive drinking of water result or referral. ll Nausea, vomiting ll If diagnosis between hyperglycemia and ll Leg cramps hypoglycemia is unclear, treat for hypoglycemia first ll Weakness and fatigue (see section 16.8 “Hypoglycemia”). ll Unexplained weight loss or, in children, the failure Caution: Low blood sugar presents the most to gain weight or grow immediate danger to life. ll Blurred vision nn Hyperglycemia and hyperosmolar state (with or ll Abdominal pain without ketoacidosis) is an emergency and requires nn Emergency signs and symptoms fluid resuscitation and urgent referral. ll Diabetic ketoacidosis—seen with type I diabetes, presenting with typical signs and symptoms of diabetes plus the following: uu Severe dehydration with sunken eyes, dry skin, and reduced skin turgor uu Hypotension (hypovolemia) uu Deep and fast breathing with smell of acetone uu Weak and rapid pulse uu Hypothermia uu Confusion uu Drowsiness, coma, or both uu Elevated blood glucose (hyperglycemia more than 11 mmol/L or more than 200 mg/dl) uu Urine dipstick glucose: ++ or more uu Urine dipstick ketones: ++ or more uu Acidosis with blood pH less than 7.3 ll Hyperosmolar nonketotic diabetic state, which is ENDOCRINE SYSTEM seen with type II diabetes; same signs and symptoms as diabetic ketoacidosis except ketones are absent on urine dipstick. Management nn The management of ketoacidosis is correction of

ENDOCRINE SYSTEM dehydration (see section 16.9 “Shock” and table 16.9C), and refer patient for administration of insulin

232 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 233 13.1. Impetigo 13.1. Impetigo

Chapter 13. ll Neomycin sulfate ointment —OR— SKIN co n d i t o ns Skin Conditions ll Neomycin and bacitracin ointment (available in DHs) 13.1. Impetigo nn Use systemic antimicrobial treatment for extensive impetigo (i.e., more than 3 lesions, multiple body areas Description affected, bullous disease, abscess, or fever): n d i t o ns SKIN co Impetigo is a highly contagious, superficial infection of ll First-line treatment is penicillin. the skin mostly due to Streptococci and Staphylococci. uu Give oral penicillin V (i.e., oral It is common in children, but may occur in adults. phenoxymethylpenicillin) for 7 days. Refer to It may complicate pre-existing pruritic dermatoses table A16 in annex A for standard dosages for (e.g., eczema, lice, chickenpox, and herpes). Rare children and adults. complications of impetigo are abscess, pyodermatitis, —OR— lymphangitis, septicemia, and post-streptococcal acute uu Penicillin benzyl procaine: deep IM injection daily glomerulonephritis. for 7 days. Diagnosis –– Children less than 30 kg: 600,000 U nn Small erosions (sores) with crust, often golden-yellow –– Adults and children more than 30 kg: nn Possible vesicles with yellow or slightly turbid fluid 1.2 million U nn Initial involvement on the face; spreading to neck, —OR— arms, and legs ll Second-line treatment is oral cloxacillin. nn Itching (sometimes) uu Children: 10–15 mg/kg/dose every 6 hours for 7 nn Painful sores days nn Lesions (may persist for days to weeks) uu Adults: 250–500 mg every 6 hours for 7 days Management —OR— ll For a penicillin-allergic patient, give oral Nonpharmacologic erythromycin ethylsuccinate for 7 days. nn Keep any skin lesions clean. uu Children: Refer to table A12 in annex A for n n Wash and soak sores in water with soap. Gently standard dosages. remove crusts before applying topical treatment. uu Adults: 800 mg (2 tablets of 400 mg) every 6 hours nn Wash hands with soap regularly. Referral Pharmacologic nn Blood in urine, protein in urine, or suspected n n For localized impetigo, apply topical treatment twice glomerulonephritis (see section 11.2 “Acute daily on lesions and nares: Glomerulonephritis”) ll Gentian violet 0.5% nn No improvement after 7 days of treatment —OR—

234 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 235 13.2. Fungal Skin Infection and Napkin (Diaper)(Diaper) RashRash 13.2. Fungal Skin Infection and Napkin (Diaper) Rash

Prevention Diagnosis

nn Clean any skin infection with clean water and soap. Presentation is similar for all forms of fungal infection: SKIN co n d i t o ns nn Keep fingernails short and clean, and resist scratching. nn Fungal infection of any region of the body typically nn Practice daily hygiene with clean water and soap. presents with pale red or whitish scales that may be nn Wash hands after applying topical cream on lesions. slightly raised and with itching or burning. nn Ringworm presents with the following: 13.2. Fungal Skin Infection and Napkin ll Often round lesions with thickened borders n d i t o ns SKIN co (Diaper) Rash ll Scalp ringworm that may be associated with bald spots Description nn Candida infections typically are more erythematous Fungal infection of the skin and scalp are most often (red) and may appear moist, raw, and shiny. caused by dermatophytes (tinea) and by Candida albicans. nn Vesicles may appear in inflammatory cases. All areas of the body can be affected, but regions with nn Secondary bacterial infection may be associated with prolonged exposure to moisture either because of local drainage and pus. anatomy (e.g., skin folds, between toes, groin areas) or environmental factors (e.g., humid climate, occlusive Management covering) are most often affected. Nonpharmacologic Napkin, or diaper, rash is an irritated dermatitis of the nn Keeping the involved area clean and dry is the most diaper area in infants (children under 1 year age) that may essential treatment intervention (especially in napkin be secondarily infected by fungus (most often Candida) rashes). or by bacteria. Types of fungal infection include the nn Tinea capitis (scalp ringworm) is assisted by shaving following: the hair from the involved area of the scalp. nn Tinea pedis: dermatophyte-type fungal infection of the Pharmacologic feet, typically between the toes nn Apply gentian violet twice daily for 3 weeks. This nn Tinea cruris: dermatophyte-type fungal infection of treatment is often effective for all types of fungal skin the groin infection—particularly if the areas are moist or oozing. nn Ringworm: dermatophyte (tinea)-type fungal infection —OR— of the skin nn Use benzoic acid PLUS salicylic acid (6% + 3%) topical nn Tinea capitis (scalp ringworm): dermatophyte-type cream. Apply twice daily for 3 weeks (effective for fungal infection of the scalp, most commonly affecting most fungal skin infections). children Caution: Avoid benzoic acid PLUS salicylic acid (6% nn Candidiasis: fungal infection most often affecting + 3%) ointment for infants who have napkin rash and areas of skin fold (e.g., groin, breast, trunk, mouth, and for everyone in areas of skin flexure because it may vagina) irritate. nn Fungal infection of the nails (occasionally) —PLUS—

236 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 237 13.2. Fungal Skin Infection and Napkin (Diaper) Rash 13.3. Furunculosis

nn Give nystatin for oral, esophageal, intestinal, vaginal, ll Wear open-toed shoes or sandals during hot

and cutaneous candidiasis. summer months SKIN co n d i t o ns Note: Nystatin topical cream (100,000 IU) may nn Avoid unnecessary use of antibiotics because their use be applied twice daily for 2 weeks for napkin rash may increase risk of fungal infections. that has not improved with gentian violet and Patient Instructions nonpharmacologic treatment. nn Emphasize the need for keeping affected areas clean ll Nystatin presentations include lozenge (100,000 and dry. n d i t o ns SKIN co IU), pessary (100,000 IU), tablet (100,000 IU or nn Change nappies (diapers) regularly, and expose area to 500,000 IU), and oral suspension (100,000 IU/ml). air and sunlight if possible. ll Nystatin dosages: nn Return in 3 weeks for follow-up (or sooner if condition uu For oral candidiasis, give children (more than worsens). 1 month old) and adults oral nystatin 100,000 IU after food every 6 hours usually for 7 days (or 13.3. Furunculosis continue for 48 hours after lesions have resolved). uu For vaginal candidiasis, give adults pessary Description nystatin. Instruct patient to insert 1–2 pessaries A furuncle, or boil, is a localized infection of the hair vaginally at night for at least 2 weeks. follicles and surrounding dermis, usually provoked by —OR— Staphylococcus aureus. A carbuncle is merely two or more nn Advise zinc oxide topical cream for napkin rash confluent furuncles, with separate heads sometimes (available in DHs). accompanied by fever and local adenopathy. Referral Diagnosis nn Condition worsening during treatment nn Patient has patches of round, red, and swollen skin that nn No improvement after 3 weeks of treatment is tender around the hair. nn Fever or frank pus nn Sites of predilection are the nape, axillae, and buttocks, nn Involvement of nails but furuncles may occur anywhere. Prevention nn Most boils evolve to small abscesses. They undergo central necrosis and rupture through the skin, nn The cornerstone for preventing fungal infection is to avoid prolonged moisture of the skin area. Advise discharging purulent, necrotic debris. patient to— nn Patient may exhibit general symptoms such as fever or swollen lymph nodes. ll Clean and dry the at-risk areas twice daily ll Dry at-risk areas when they become moist or Management exposed to water Nonpharmacologic ll Refrain from sharing clothes, towels, and toiletries nn Promote washing with soapy water. such as combs and brushes nn Apply warm compresses locally 3 times daily on

238 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 239 13.3. Furunculosis 13.4. Sycosis

inflamed sites to promote maturation. Continue until Patient Instructions

furuncle starts draining. Do not puncture or incise nn Never manipulate or apply pressure to a furuncle, SKIN co n d i t o ns until the furuncle is mature (i.e., it has become an especially on the face, because of the risk of spreading abscess). serious infection. nn Incise and drain the furuncle (abscess) yourself only nn Return for follow-up after 3 days or if condition if it is mature. Use sterile gauze to pack and drain worsens. the abscess cavity. Refer to section 16.11 “Abscess,” if nn When initially being treated, launder bedding and n d i t o ns SKIN co necessary. clothing daily. Pharmacologic 13.4. Sycosis nn When the lesions are incipient and acutely inflamed, avoid incision and employ moist heat. Description nn If generalized symptoms (i.e., fever, swollen lymph Sycosis vulgaris is a perifollicular, chronic, pustular nodes) are present or if boils are localized on upper lip, staphylococcal infection of the bearded region ear channel, or nose, use antibiotics: characterized by the presence of inflammatory papules ll Give oral erythromycin (tablets). Refer to table A12 and pustules. It occurs primarily in men and is rare in in annex A for standard dosages for children and women. The disease is stubborn and may take many weeks adults. or months to resolve, and it has a tendency to recur. —OR— Diagnosis ll Give oral cloxacillin (capsules). nn Begins with erythema and mild burning or itching, uu Children: 10–15 mg/kg/dose every 6 hours for 7 days usually on the upper lip near the nose. May involve bearded area of chin and, rarely, other hair regions. uu Adults: 250–500 mg every 6 hours for 7 days nn —PLUS— In a day or two, one or more pinhead-sized pustules, pierced by hairs, develop. nn For boils of the external auditory canal, upper lip, n and nose, apply antibiotic ointment in addition to n These pustules rupture after shaving or washing and the systemic antibiotics. Apply warm saline-solution leave an erythematous spot, which is later the site of compresses liberally. a fresh crop of pustules. In this manner, the infection persists and gradually spreads. Referral nn At times, the infection may extend deep into the nn Worsening symptoms follicles. A hairless, atrophic scar bordered by pustules nn Appearance of general symptoms during treatment and crusts may result. Prevention nn Marginal blepharitis with conjunctivitis may be nn Good hand washing and skin hygiene present in severe cases. nn Cleansing and care of wounds and breaks in the skin

240 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 241 13.4. Sycosis 13.5. Urticaria

Management Referral

Nonpharmacologic nn Worsening condition despite treatment. Note: Sycosis SKIN co n d i t o ns is often resistant to treatment. nn Advise the patient to— nn Deep abscess formation. Refer for surgical ll Clean the affected areas thoroughly using antibacterial soap (e.g., Dettol) and clean water 3 consultation for drainage. times a day. nn Associated systemic disease or suspicion of compromised immune status ll Allow superficial pustules to rupture and drain n d i t o ns SKIN co spontaneously. Prevention nn Surgically drain deep lesions of folliculitis and nn Ensure clean shaving instruments. identified abscesses if necessary (rare). nn Practice good skin hygiene. Pharmacologic Patient Instructions nn Treat topically using antiseptic cream, antibacterial nn Return if the condition worsens. cream, or both. Options depend on availability. nn Do not share shaving instruments with anyone. ll Prescribe silver sulfadiazine cream (available in DHs) to be applied to affected area 2 times daily. 13.5. Urticaria —OR— Description ll Give gentian violet (0.5%) to be applied to affected area daily. Urticaria is a vascular reaction of the skin characterized by itchy swelling and papules of the skin. It may be caused nn If the patient has any accompanying soft tissue infection or cellulitis, prescribe a short course of by medicines, foods, plant pollen, insect bites, and other systemic antibiotic therapy: irritants (see “Management, nonpharmacologic”). ll First-line treatment: cloxacillin—500 mg (if Diagnosis available) every 6 hours for 7 days nn Look for appearance of wheals, surrounded by a red ll Second-line treatment: halo or flare. uu Chloramphenicol—250 mg every 6 hours for 7 nn Patient may report severe itching, stinging, or pricking days sensations. —OR— nn Look for a clearing of the central region which may uu Ciprofloxacin—500 mg every 12 hours for 7 days occur and lesions may coalesce, producing an annular Caution: Ciprofloxacin is contraindicated or polycyclic pattern. in pregnant women and should be avoided in nn Ask patient about provoking factors (see children when possible. “Management, nonpharmacologic”). nn If the patient has eyelash or eyebrow involvement, nn Watch for anaphylaxis and hypotension (see section prescribe tetracycline eye ointment (1%) to be applied 16.9 “Shock”). 3 times daily for 7 days.

242 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 243 13.5. Urticaria 13.6. Pediculosis

Management Patient Instructions

Nonpharmacologic nn Avoid items and situation that provoke urticaria. SKIN co n d i t o ns nn Identify the cause carefully with patient, and advise nn Chlorpheniramine can cause dizziness, so avoid avoidance of all possible causative factors: driving a vehicle, operating machinery, or working in ll Medicines are probably the most frequent cause of the heat. acute urticaria, most often penicillin and related antibiotics and aspirin. 13.6. Pediculosis n d i t o ns SKIN co ll Foods are a frequent cause of acute urticaria. The Description most allergenic foods are chocolate, shellfish, nuts, Pediculosis is an infestation with lice in the hairy parts of peanuts, tomatoes, strawberries, melons, cheese, the body or the clothing. Head lice are common in children garlic, onions, eggs, milk, and spices. and are usually located on the scalp. Pubic lice are located ll Infections may be linked to urticaria. Acute urticaria in the pubic area. Body lice are found in the seams of may be associated with upper respiratory infections. clothing and come to the body to feed. Note: Body lice may Helminths may also cause urticaria (e.g., ascaris, carry typhus (fever). echinococcus). ll Emotional stress can cause cholinergic urticaria. Diagnosis ll Inhalants such as grass pollens, house dust mites, nn Patient reports intense itching of involved area. feathers, cotton seed, animal dander, cosmetics, or nn Nits (eggs)—small, white specs—may be identified aerosols can also bring on urticaria firmly attached to hair. nn Advise the patient to use cool compresses or tepid or nn Bite marks may be identified on the skin, particularly cold tub baths or showers to relieve itching. in the case of body lice. nn Excoriation (from scratching) and secondary infection Pharmacologic may complicate bites (secondary impetigo, swollen nn To relieve itching, use— lymph nodes found in the neck with head lice or in the ll Oral chlorphenamine maleate tablet. Refer to table groin with pubic lice). A7 in annex A for standard dosages for children and nn In the case of pubic lice, it is wise to rule out sexually adults. transmitted infections and advise the patient’s sexual —PLUS— contacts, if necessary, although transmission can ll Topical calamine lotion (available in DHs) for happen simply by sharing a bed or other close contact. symptomatic relief nn To treat severe reactions including anaphylaxis, see Management section 16.9 “Shock.” Nonpharmacologic Referral nn Shaving the head or infected hairy area will cure head nn Failure to improve in 24–48 hours and pubic lice because doing so gets rid of living lice nn Chronic urticaria and the eggs. nn Generalized symptoms

244 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 245 13.6. Pediculosis 13.7. Scabies

nn Using anti-lice shampoo produces a cure rate of about Referral

40% when used alone. nn Complicated cases SKIN co n d i t o ns Note: Combing with a fine-toothed metal or plastic nit nn Cases resistant to treatment comb is an important adjunctive measure. Prevention nn Washing clothing and bedclothes in hot water (60°C), nn Advise patient to wash his or her clothes as well as the and ironing or drying in bright sunlight kills body lice clothes of his or her contacts to prevent recurrence living in seams, and prevents recurrence or spread to (see above). n d i t o ns SKIN co contacts. nn Advise simple public health measures when epidemics nn In the case of pubic lice, treating the patient’s close of louse infestation occur in schools: contacts is necessary. ll Store hats, scarves, and jackets separately under Pharmacologic each child’s desk nn Use an anti-lice shampoo. ll Tell children not to share clothing. ll First-line treatment: permethrin cream rinse 1% ll Advise the school nurse to provide lice education ll Second-line treatment: Lindane topical lotion and inspections to facilitate targeted treatment of (United States Pharmacopeia [USP] 1%). Follow this infested individuals. procedure: Patient Instructions uu Shampoo the involved area (i.e., scalp or pubic nn For eyelash involvement, a thick coating of petrolatum area) with soap and water, and allow to fully dry. can be applied twice daily for 8 days, followed by uu Shampoo the same area with Lindane, and leave it mechanical removal of any remaining nits. in the hair area for 15 minutes. nn When using Lindane treatment, follow all procedures uu Rinse hair area thoroughly. strictly, and use measures of prevention. uu Comb hair to remove dead lice. Caution: Lindane has been associated with 13.7. Scabies seizure and other neurologic symptoms (rarely). Avoid using it in children younger than 2 years, Description pregnant women, and lactating women and people Scabies is caused by Sarcoptes scabiei, the itch mite. The with weakened immune systems. Avoid contact fertilized female burrows into the upper layer of skin, with mucous membranes or open skin. Use usually in skin folds, and deposits her eggs. Scabies is Lindane only as directed. Do not repeat treatment easily transmitted by direct contact or contaminated within 6 months to avoid risk of neurologic linens and clothing and usually affects more than one complication. person in the household. nn Treat secondary skin infections with antibiotics as Diagnosis needed (see section 13.3 “Furunculosis”). nn Patient complains of persistent itching, more severe at night.

246 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 247 13.7. Scabies 13.7. Scabies

nn Close inspection shows small burrows in areas where Pharmacologic

the skin is folded. Sites of predilection include the nn Prescribe a scabicide— SKIN co n d i t o ns finger webs, wrists, axillae, areolas, umbilicus, lower ll Lindane 1% topical lotion abdomen, genitals, and buttocks. In infants, lesions are —OR— commonly present over the entire cutaneous surface. ll Permethrin 5% cream, which is safe for children nn The burrows appear as slightly elevated, grayish, younger than 2 years and pregnant and lactating tortuous lines in the skin. A vesicle or pustule women n d i t o ns SKIN co containing the mite may be noted at the end of the nn Advise patient to follow this procedure to apply the burrow, especially in infants and children. scabicide: nn Scratching may provoke excoriations and secondary ll Wash body with mild soap and water; allow to dry infections. completely. nn To identify burrows, apply a drop of gentian violet to ll Thoroughly rub the scabicide into the skin from the infested area, and then remove it with alcohol; thin, below the neck to the feet (including soles), with threadlike burrows retain the ink. particular attention given to the creases, perianal nn Lichenification, impetigo, and furunculosis may be areas, umbilicus, and free nail edge and folds. present. ll Apply in the evening and wash off after 8 to 10 hours nn In women, itching of the nipples associated with a (i.e., the next morning). generalized pruritic papular eruption is characteristic. Cautions: Ensure that the scabicide is washed nn In men, itchy papules on the scrotum and penis are off within 12 hours to avoid toxicity. Donot apply equally typical. to neck and face. Avoid using Lindane in children Management younger than 2 years, women who are pregnant or nursing, or people with weakened immune systems. Nonpharmacologic Note: Itching may persist for 2–3 weeks after nn Treat all close contacts (e.g., household members) treatment with scabicides. simultaneously. nn Advise patient to— Referral ll Keep his or her fingernails trimmed and clean Severe secondary infection ll Wash bed linen and underclothes with very hot Prevention (60°C) water, if possible nn Isolate patients. ll Expose bedding to direct sunlight nn Wash the patient’s clothes in hot water and iron them. ll Wash his or her whole body with mild soap and nn Put the bed clothes in direct sunlight. water nn Treat all individuals who are in close contact with the ll Scrub the affected areas with brush or cloth, and dry patient. Delays in treating close contacts may result in with a clean cloth large numbers requiring treatment. ll Put on washed clean and dry clothes after applying nn Screen for sexually transmitted infections. treatment

248 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 249 13.7. Scabies 14.1. Arthritis and Arthralgia

Patient Instructions Chapter 14. nn Advise patients to— ll Wash and iron their clothes and bedclothes Musculoskeletal Conditions ll Avoid contact with eyes nn Advise patients not to apply scabicides to— 14.1. Arthritis and Arthralgia ll Sores or broken skin Description ll The neck or face n d i t o ns SKIN co Arthritis and arthralgia are joint disorders. nn Tell patients that affected family members need to be treated at the same time to prevent recurrence. nn Arthralgia refers to joint pain that may be related to minor trauma (i.e., simple strains or sprains) or nn Warn patients that scabicides are toxic if swallowed. overuse. It is not associated with swelling, redness, MUSCULOSKELETAL heat, or fever. nn Arthritis refers to inflammation and eventual destruction of the joint, which often begins with pain alone (“arthralgia”) but develops more signs over time. ll Osteoarthritis refers to arthritis that develops from gradual destruction of joint surfaces many years following trauma or from chronic wear and tear. uu It typically affects older patients. uu It often begins with simple pain in a single joint, but may progress to include loss of motion, swelling, deformity, and additional joint involvement over time. uu Large joints (e.g., knees, hips) are often affected, as well as distal finger joints. uu Osteoarthritis limits movement and causes morning stiffness that lasts usually for less than 30 minutes. ll Rheumatoid (autoimmune) arthritis is a chronic systemic inflammatory disease of fluctuating course that may involve many organs, but particularly joints. uu It often involves multiple joints, particularly the feet, elbows, wrists, and proximal finger joints. uu The disease begins with pain but often progresses

250 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 251 14.1. Arthritis and Arthralgia 14.1. Arthritis and Arthralgia

to include loss of motion, swelling, and deformity Usually the first metatarsal-phalangeal joint is over time (wrist deviation and ulnar deviation of involved. fingers is classic). Caution: Urgent referral is required to differentiate uu It may include extra-articular features or other gout or pseudo-gout from septic arthritis. components of autoimmune syndromes such as Rare other causes of diffuse joint pain include systemic muscle wasting, neuropathy, keratoconjunctivitis infection or inflammation (see section 15.7 “Brucellosis”). or scleritis, pericarditis, pleural effusion, or rheumatoid nodules. Diagnosis The goal of diagnosis is to establish whether the pain uu Morning stiffness lasts for longer than 30 minutes. is mild and chronic in nature so that treatment can be initiated at the health center, or whether it is acute and MUSCULOSKELETAL uu Although the disease affects both sexes and all age groups, it is most common in women by a ratio of severe in nature requiring referral. 3 to 1. nn Establish history of recent or distant trauma (including penetrating trauma to the joint space); uu It may run in families. speed of onset; and evidence of swelling, redness, heat. ll Septic arthritis refers to an infection of the joint by bacteria or TB. Typically (i.e., in 90% of cases), nn Consider rheumatic fever in children who have a MUSCULOSKELETAL septic arthritis involves only one joint. history of pharyngitis, pain, or both that progresses to involve multiple joints (see section 6.1 “Rheumatic uu Sudden onset of pain, which increases with motion, is associated with swelling, redness, and Fever”). warmth. nn Look for additional joint or extra-articular features as seen in rheumatoid and autoimmune arthritis as uu Up to 50% of cases are associated with history of minor trauma. described above. nn Establish whether signs and symptoms are suspicious uu Often patients do not have fever. for septic arthritis (see above); if so, begin emergency uu TB infection tends to develop more slowly and with less dramatic physical findings. treatment (see referral section) and initiate transfer to surgical facility. uu Septic arthritis may affect any age group. Be suspicious of septic arthritis or acute uu It may be associated with acute osteomyelitis, Note: particularly in children (see section 14.2 osteomyelitis in any child presenting with acute onset “Osteomyelitis”). of joint pain or limping. Caution: Septic arthritis is a surgical emergency. Management Suspicion of septic arthritis requires immediate The primary goal is to use the correct management for the referral. type of arthritis (see “Diagnosis”): ll Gout or pseudo-gout is a precipitation of crystals nn In the case of patients presenting with signs and within the joint causing acute onset of swelling, symptoms of septic arthritis or gout (or pseudo-gout), pain, and often redness or heat in the involved joint. refer urgently. (See “Referral” below.)

252 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 253 14.1. Arthritis and Arthralgia 14.1. Arthritis and Arthralgia

nn In the case of patients presenting with signs and –– Ampicillin (see also table A4 in annex A). In symptoms of mild osteoarthritis or rheumatoid the case of penicillin allergy or sensitivity, use arthritis, initiate comfort therapies at the clinic level. erythromycin. Refer to table A12 in annex A for The focus of care for these patients is to— standard dosages. ll Lessen pain ¡¡ Children: 50 mg/kg IM injection ll Reduce inflammation ¡¡ Adults: 1 g IM injection ll Improve or maintain function —PLUS— ll Prevent long-term joint damage –– Gentamicin ll Control systemic involvement ¡¡ Children: 5–7.5 mg/kg IM injection ¡¡ Adults: 320 mg IM injection

Nonpharmacologic MUSCULOSKELETAL nn Apply local heat for comfort. —OR— uu Second-line treatment (available in DHs): nn Suggest gentle range-of-motion and low-impact exercises to maintain mobility, except in osteoarthritis. ceftriaxone vial – Children: 80 mg/kg IM injection nn Advise the patient to avoid heavy stress to the joints. – –– Adults: 2 g IM injection Pharmacologic nn Refer patients for whom you suspect exposure to or a nn MUSCULOSKELETAL Give an analgesia or anti-inflammatory medicine. diagnosis of TB arthritis. ll First-line treatment: oral paracetamol (tablet). nn Refer patients for whom you suspect rheumatoid Refer to table A15 in annex A for standard dosages. (autoimmune) arthritis for specialist care. l l Second-line treatment: oral ibuprofen Caution: Some patients who have rheumatoid uu Children: 5–10 mg/kg/dose every 8 hours arthritis may have cervical spine involvement and uu Adults: 200 mg to 400 mg every 8 hours instability. Use care in transport. Limit dosage period to 1–2 weeks, when Note: nn Refer for further investigation and treatment options possible. patients who have new onset of disease, severe Caution: Avoid ibuprofen if the patient has deformities, or recurrent or incapacitating pain, or if a history of gastrointestinal bleeding, other you are doubtful about a diagnosis. gastrointestinal problems, kidney disease, or nn Refer patients who have multiple organ system bleeding disorders. involvement (see above). Referral nn Refer anyone who has chronic pain (i.e., lasting more nn Refer all patients for whom you suspect a diagnosis of than 1 week in children and more than 2 weeks in septic arthritis or gout (or pseudo-gout) for immediate adults). diagnosis and surgical management. Prevention ll Before transfer, give first dose of antibiotics. nn Advise weight reduction for obese patients who have uu First-line treatment: ampicillin PLUS gentamicin involvement of or pain in any weight-bearing joint.

254 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 255 14.2. Osteomyelitis 14.2. Osteomyelitis

nn Ensure proper treatment of fractures and dislocations ll An injury visible on the skin overlying the affected to reduce the incidence of posttraumatic arthritis. bone (sometimes) Patient Instructions ll Previous infection, often of the throat, or skin injury ll Active movement of neighboring joints usually nn Advise the patient to rely on nonpharmacologic treatment options to avoid chronic use of medications limited by pain; some passive painless movement and their side effects. Instruct him or her to use pain usually possible relief only when necessary. nn Think of chronic osteomyelitis if a patient presents the following: nn Review with the patient the proper way to take medications (e.g., take ibuprofen with meals to reduce ll Past history of pain and tenderness in the same bone accompanied by fever

gastritis). MUSCULOSKELETAL ll Absence of high fever nn Instruct the patient to return in 1 week after initiating therapy for review. Refer if the patient’s symptoms ll Swelling, pain, and tenderness of the bone affected increase rapidly over time or involve new joints. ll Abscess or draining pus; will often diminish swelling and pain 14.2. Osteomyelitis nn Differential diagnoses include septic arthritis (infected joint), cellulitis (infected skin), pyomyositis MUSCULOSKELETAL Description (infected muscle), and local trauma. Osteomyelitis, which is difficult to diagnose at the primary Management level, is a serious infection of the bone caused by bacteria and requires referral to hospital. Often the bacteria Nonpharmacologic are carried by the blood stream from an infection site. nn Immobilize the affected limb. Sometimes the bone is infected through injury of the nn refer all suspected cases of osteomyelitis to a nearby overlying skin. The disease starts with an acute phase, hospital as soon as possible. which if left untreated, will become chronic. Responsible Pharmacologic agents are commonly Staphylococcus aureus and Before referral, give the first dose of ampicillinPLUS Streptococcus haemolyticus. TB may be the cause with less gentamicin IM injection. rapid and severe signs and symptoms. The bones of the nn Ampicillin (refer also to table A4 in annex A): thigh and leg are most often affected. ll Children: 50 mg per kg per dose. Add 4.5 ml sterile Diagnosis water to a vial containing 500 mg powder (100 mg/ml) and inject in the front thigh muscle. Dose nn Think of acute osteomyelitis if a patient presents the following signs: according to age or weight. ll Adults: 1 g IV or IM every 6 hours (but refer after ll High fever with chills; can be absent, however, if the infection is due to injury of the overlying skin first dose) ll Localized pain and tenderness of a bone, often —OR— located at the metaphysis

256 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 257 14.2. Osteomyelitis 15.1. Pertussis (Whooping Cough)

In the case of penicillin allergy or sensitivity, use Chapter 15. Infectious erythromycin. Refer to table A12 in annex A for standard dosages. Diseases, Parasitic Diseases, —PLUS— and Helminthic Infestations nn Gentamicin (refer also to table A13 in annex A): ll Children: 5–7.5 mg/kg IV or IM once daily 15.1. Pertussis (Whooping Cough) ll Adults: 320 mg in IV or IM once daily Referral Description Refer all cases to the nearest hospital, for further Pertussis is an extremely contagious childhood illness investigation (e.g., X-ray and laboratory tests, if available), caused by the bacteria Bordetella pertussis and spread by IV therapy in the acute phase, surgical care of chronic airborne droplets. The hallmark of the infection is severe phase (e.g., drainage, debridement), and necessary coughing bouts. Pertussis can be prevented by vaccination. orthopedic treatment. Pertussis may be complicated by secondary infections (e.g., pneumonia, otitis, activation of latent TB), seizures, Prevention malnutrition, or death. nn Treat all bacterial infections (see section 4.2.2 Diagnosis

MUSCULOSKELETAL “Bacterial Tonsillitis”) with the appropriate antibiotic. Pertussis is commonly misdiagnosed as another nn Clean and disinfect all skin wounds. respiratory infection, so consider the diagnosis, especially nn Open fractures require urgent surgical irrigation and INFECTIOUS DISEASES debridement; refer immediately. in unimmunized children. Following an incubation period of 6–12 days, pertussis is typically divided into three Patient Instructions phases: nn Convince the patient to go to the nearest hospital as nn Catarrhal phase: 1–2 weeks in duration soon as possible. ll Nasal discharge (catarrh) nn Advise the patient that failure to treat osteomyelitis ll Fever appropriately may result in serious complications and ll Nonspecific cough permanent disability. nn Whooping phase: 3–4 weeks in duration ll Typical, paroxysmal coughing bouts (whooping cough) ll Characteristic cough may lead to vomiting, poor feeding, and malnutrition. ll Characteristic cough may also lead to bouts of cyanosis, hypoxia, and apnea (especially in young infants). nn Convalescent phase: 1–4 weeks

258 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 259 15.1. Pertussis (Whooping Cough) 15.2. Diphtheria

ll Sometimes the coughing phase is prolonged for patient who received antibiotic treatment should be many weeks. isolated during the first 5 days of treatment. Management Patient Instructions Nonpharmacologic nn Stress the importance of feeding supplements and prevention of malnutrition. Advise frequent, small nn Prevent malnutrition. Feed frequently between coughing spasms even though the child may not want quantities of food and a high protein diet. to eat. Continue to breastfeed infants. nn Stress the importance of continuing all immunizations, including DPT. nn Give extra fluids. Monitor for dehydration. nn Monitor for malnutrition during illness and for 1 Pharmacologic month following resolution of symptoms. nn Give oxygen for cyanosis (if needed and if available). nn Give antibiotic: erythromycin (ethylsuccinate) for 15.2. Diphtheria 2–4 weeks. Refer to table A12 in annex A for standard dosages. Description nn Give paracetamol for fever 38.5°C or higher. Refer to Diphtheria is a serious and acute infection of the pharynx table A15 in annex A for standard dosages. and respiratory tract caused by the toxin-producing nn If needed, give salbutamol nebulizer solution for 24– bacteria, Corynebacterium diphtheria. Transmission is by 48 hours. Refer to table A17 in annex A for standard airborne droplets from infected individuals. Diphtheria

dosages. has a high mortality rate but can be prevented by INFECTIOUS DISEASES Referral vaccination. nn Children younger than 1 year. Young infants are at high Diagnosis risk of apnea and need constant monitoring. Look for the following: nn Malnourished children or children with other nn Fever significant medical problems nn Headache, malaise nn Patients who have periods of cyanosis or apnea nn Tonsillitis, pharyngitis—may be mild or may be severe INFECTIOUS DISEASES INFECTIOUS Prevention and associated with characteristic grayish-white sticky patch on the throat nn DPT immunization for all children (see chapter 19 “Immunization”). Continue DPT immunization nn Rhinitis (often unilateral) schedule after recovery to prevent diphtheria and nn May be associated with signs of serious illness tetanus. ll Cervical edema and stridor ll Bleeding (purpura, gingival bleeding, epistaxis) nn Isolate patients who have pertussis from unimmunized people for 4 weeks after coughing begins ll Skin lesions (i.e., the period of communicability), if the patient ll Myocarditis—may be associated with arrhythmia has not received antibiotic treatment. Otherwise, the ll Rarely—pneumonia, oliguria, neuropathies

260 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 261 15.2. Diphtheria 15.3. Tetanus

Management nn Isolate patient for 1–7 days. Nonpharmacologic nn Monitor, and treat if necessary, contacts of the household for development of diphtheria. nn Monitor airway for signs of stridor or obstruction. nn Complete DPT vaccination after illness because the nn Ensure adequate nutrition and hydration. Occasionally patient may require nasogastric tube feeding because disease does not always induce antitoxin formation to of difficulties swallowing (dysphagia). protect patient from re-infection. nn Isolate patients from those who have not been immunized. 15.3. Tetanus Pharmacologic Description nn Administer diphtheria antitoxin (available in Tetanus is caused by a neurotoxin tetanospasmin, provincial and regional hospitals). produced by Clostridium tetani. In unvaccinated nn Give antibiotic therapy. individuals, any injury of the skin or mucous membranes ll Penicillin V (phenoxymethylpenicillin) for 7–10 (e.g., accidents, cuts, stings, surgery, childbirth, days circumcision, ulcers) carries the risk of infection if uu Children: Refer to table A16 in annex A for contaminated by C. tetani. C. tetani is found in soil and standard dosages. feces, and spores are resistant to many disinfectants. The uu Adults: 500 mg every 6 hours disease is completely preventable through vaccination —OR— and is included in the standard EPI protocol and antenatal INFECTIOUS DISEASES ll Erythromycin ethylsuccinate (for penicillin allergic vaccinations. patient) for 7–10 days Diagnosis uu Children: Refer to table A12 in annex A for nn A history of a skin defect in unclean circumstances standard dosages. may be present, but the patient has often forgotten the u u Adults: 400–800 mg every 6 hours incident. uu Give paracetamol for pain or fever. Refer to table nn The disease progression is as follows: A15 in annex A for standard dosages. INFECTIOUS DISEASES INFECTIOUS ll The first sign of tetanus is stiffness of the jaw Referral muscles, starting with difficulty in chewing followed All serious and complicated cases should be referred, by locked jaw (i.e., unable to open). especially children younger than 15 years who have ll Next, other facial muscles cramp, followed by pneumonia and myocarditis. throat and neck muscles, which provokes difficulty Prevention and Patient Instructions swallowing. ll Progression of the disease is from 2 days to 3 weeks. nn Ensure proper immunization of all children. The patient experiences prolonged and painful nn Verify vaccination status of contacts. Complete 3 vaccinations or give booster if more than 1 year since muscle spasms: stiff arched back, flexed arms, and last injection. extended legs. Very slight sensory stimuli provoke

262 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 263 15.3. Tetanus 15.3. Tetanus

recurrent paroxysmal spasms while the patient Pharmacologic is fully conscious. The patient remains in this nn Give first dose of antibiotic IV then refer to hospital: condition for several weeks (3 on average). ll Penicillin G (penicillin benzyl) nn In infants, the baby cannot suck and umbilicus is uu Children: 50,000 units/kg/dose every 6 hours for infected. The baby has a stiff body, irritability, spasms, 10 days constipation, and cyanotic episodes. Neonatal tetanus uu Adults: 2–4 million units/dose IV every 6 hours may enter the body via the umbilicus from unclean for 10 days instruments or dressings used on the cord. —OR— nn Death is provoked by complications: asphyxia due to ll If in a penicillin-allergic patient, metronidazole: spasms in larynx or thorax or inhalation of vomit with uu Children: 7.5 mg/kg/dose every 8 hours for 10 days aspiration pneumonia. Neonates die of the inability to uu Adults: 500 mg IV every 8 hours for 10 days feed. nn Give diazepam for sedation of spasms, if needed, Management during the transfer l Refer all patients for injection of antitetanus l Children: 0.5 mg/kg rectally; repeat every 6 hours if immunoglobulin (available in DHs) and support as early needed l as possible. Refer to table 15.3 for specific treatment l Adults: 5 mg orally or rectally; repeat every 6 hours measures to prevent tetanus in high- and low-risk wounds. if needed Caution: Monitor for respiratory distress. Nonpharmacologic Prevention INFECTIOUS DISEASES nn Maintain a clear airway. Tetanus is completely preventable by active immunization nn Provide adequate fluids and nutrition because tetanus spasms result in high metabolic demands and a and is part of the routine childhood immunizations of EPI: n catabolic state. Nutritional support will enhance n Encourage the complete immunization of all children, chances of survival. including sick or weak ones: ll Three vaccinations before the age of 1 nn Assess the wound. ll ll A booster 1 year after the third dose

INFECTIOUS DISEASES INFECTIOUS Low-risk wounds include most superficial wounds l that have limited tissue loss and that are not more l A second booster 5 years after the first booster l than 6 hours old. l A booster every 10 years nn Check the immunization status of all children ll High-risk wounds include war wounds, deep puncture wounds, wounds with substantial tissue presenting for any reason at the facility and vaccinate loss, extensive burns, foreign bodies, and necrosis as appropriate (see chapter 19 “Immunization”). n that are more than 6 hours old n Check the immunization status of all pregnant women and vaccinate as appropriate (see chapter 19 nn Promote proper wound care and tetanus prophylaxis. “Immunization”). ll Remove any foreign body from the wound. nn Ensure that all women of childbearing age have ll Clean, disinfect, and dress the wound. received at least 5 doses of tetanus vaccine.

264 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 265 15.3. Tetanus 15.4. Poliomyelitis

nn Promote delivery by skilled birth attendants at 15.4. Poliomyelitis facilities. If not possible, promote clean deliveries, in particular sanitary umbilical cord care. Description nn Promote proper wound care and tetanus prophylaxis. Poliomyelitis is an acute viral infection due to poliovirus. It (See table 15.3.) is most often recognized by weakness or flaccid paralysis especially in the legs of children. Table 15.3 nn Humans are the only reservoir of the virus, so direct Specific Measures to Prevent Tetanus Following a Wound and indirect transmission is via humans. ll Direct: fecal-oral route. The virus is excreted in the Wound Risk Assessment stool of infected people for 2 weeks before until 8 Patient’s weeks after onset of illness. Vaccination Status Low High ll Indirect: ingestion of contaminated food or water Patient has been nn The incubation period is 7–14 days. completely vaccinated (3 doses or more) and nn The disease is preventable by proper immunization last dose was given— (see chapter 19 “Immunization”). nn <5 years ago None Antibioticsa Diagnosis nn >5 but <10 years ago None Antibioticsa Most poliomyelitis infections are asymptomatic or have b Booster TT mild symptoms. Diagnosis is most often recognized by b nn >10 years ago Booster Antibioticsa asymmetric flaccid paralysis, which occurs in fewer than INFECTIOUS DISEASES b Booster TT 1% of patients who are infected. Symptoms of the two Tetanus immunoglobulinc types of the infection include the following: Refer. nn Nonparalytic form of poliomyelitis Patient has not been Begin or Antibioticsa ll Fever vaccinated, has been complete Begin or complete ll Headache incompletely vaccinated, vaccination vaccination ll or has an unknown Tetanus Neck stiffness INFECTIOUS DISEASES INFECTIOUS vaccination status immunoglobulinc ll Muscle pain Refer. nn Paralytic form of poliomyelitis a Antibiotic treatment is phenoxymethylpenicillin (penicillin V) oral. Refer to table ll Paralysis (occurring in a small proportion of A16 in annex A for specific dosages. In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 in annex A for standard dosages. patients), which may affect any skeletal muscle b Booster TT: Give 1 dose 0.5 ml of TT IM, in another site than the serum (see group, including respiratory muscles. Paralysis is below). Urge the patient to return to complete the vaccination and get boosters as indicated. asymmetric, most commonly affecting lower limbs c Serotherapy: Give tetanus immunoglobulin, 500 IU IM. Refer the patient because with ascending progression. the serum is available only in DHs. ll Progression of the paralysis uu Muscles softened uu Reflexes diminished

266 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 267 15.5. Measles 15.5. Measles

uu Sensation remaining intact Diagnosis Caution: Paralysis is life threatening if nn Check the patient’s history for contact with a measles respiratory muscles are involved. case 1–2 weeks before the onset of symptoms. n Management n First symptoms may be like a common cold or flu: mild No specific treatment is available for poliomyelitis since to moderate fever, often accompanied by a persistent it is a virus. Immediately register any patient suspected of cough, runny nose, inflamed eyes (i.e., conjunctivitis), having polio, inform the focal point person, and refer the and sore throat. n patient to the nearest polio center. n In the early stage, 2–3 days after first general symptoms, tiny white spots on erythematous base Prevention and Patient Instructions can be seen on the inner lining of the cheek (Koplik’s nn Immunization with 4 doses of OPV almost certainly spots). prevents infection. nn The typical rash, which appears 3–10 days after first ll Ensure proper vaccine schedule for all children symptoms, consists of small red spots, often slightly according to EPI (see chapter 19 “Immunization”). raised that tend to cluster giving the skin a blotchy red ll Report any suspect case. Initiate vaccination appearance. The rash starts at the hairline and moves campaign following the national protocol. to the face, neck, thorax, abdomen, and then the arms nn Ensure proper disposal of excreta. and legs. With the appearance of the rash, the patient nn Ensure safe drinking water and food sources. has high fever (38.5°C or higher), which disappears nn Review the health status of family members and close once rash reached the feet. INFECTIOUS DISEASES contacts for all suspect cases. nn Check all children younger than 5 years suspected of nn Instruct all patients to return promptly to the health measles for general danger signs: facility if they begin exhibiting flulike symptoms and ll Ask if the child— then develop weakness or paralysis. uu Is unable to drink or breastfeed uu Vomits everything 15.5. Measles uu Has had convulsions

INFECTIOUS DISEASES INFECTIOUS See also IMCI flipchart for children younger than 5 years. ll Assess whether the child is lethargic or unconscious Description or is convulsing now. Measles is a highly contagious viral disease with possible Caution: Measles can complicate to pneumonia, serious complications and high mortality in malnourished eye infection, otitis media, mouth ulcers, diarrhea or children or children who have other diseases. It is rare in dehydration, or severe malnutrition particularly in infants younger than 3 months. The disease occurs most children with poor nutrition or other concomitant often in children between 6 months and 3 years of age who conditions. have not been completely or successfully vaccinated.

268 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 269 15.5. Measles 15.5. Measles

Management ll Treat pneumonia (see section 3.3 “Pneumonia in Nonpharmacologic Children and Adults”) and otitis media (see section 4.2 “Acute Otitis Media”). nn Ensure continued feeding and drinking. Diet is an essential part of the management because children ll Treat convulsions (see section 17.1 “Febrile with measles can quickly become malnourished. Convulsion”). Weigh the child and record regularly. Track weight nn Give first dose of treatment before referral in case of changes. severe complicated measles (clouded cornea and deep mouth ulcers): nn Gently clean the eyes with clean (i.e., boiled and cooled) water or with normal saline solution (0.9%) 3 ll Give one dose of vitamin A times daily. ll And give first dose of ampicillinPLUS gentamicin (refer also to table A4 and A13 in annex A) Pharmacologic ll Apply tetracycline eye ointment if clouding of the n n Give a capsule of vitamin A if child has not received cornea or pus draining from the eye vitamin A within 3 months (see table 10.4C). Give first ll Advise the mother to continue feeding the child and dose at the clinic, and give doses for day 2 and day 14 to refer. the caregiver. Referral nn If the child has fever, pain, discomfort, or a history of febrile convulsions, give oral paracetamol up to 4 times nn Children who have danger signs and severe daily until fever subsides. Refer to table A15 in annex A complications INFECTIOUS DISEASES for standard dosages. nn Severe pneumonia (stridor, chest in-drawing) nn Severe dehydration nn If mouth ulcers develop, instruct the patient or caregiver to rinse the mouth 4 times daily with nn Known asthma patients solution of 1 cup clean water plus teaspoon (2–3 cc) nn Malnutrition or compromised immune status and salt. For severe ulceration, apply gentian violet (0.5%) associated diseases (e.g., human immunodeficiency 2 times daily until resolved. virus [HIV], TB) nn Advise the mother to continue feeding and hydrating Prevention and Patient Instructions INFECTIOUS DISEASES INFECTIOUS the child. nn Keep children who have measles isolated from others nn Instruct the mother or caregiver to bring the child back (i.e., from kindergarten, school) for a follow-up in 2 days. nn Present all children for measles vaccination (first nn Treat possible complications according to IMCI injection at 9 months and second injection at 18 flipchart before referral. months). ll Treat eye infection with tetracycline eye ointment nn Focus on mouth and eye hygiene. (see section 5.1 “Conjunctivitis [Red Eye]”). nn Return to the clinic in 2 days for follow-up. ll Treat and prevent dehydration (see section 2.1 nn Advise the mother or caregiver that good nutritional “Diarrhea and Dehydration”). status of children limits complications of measles. Note: Measles is a reportable disease.

270 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 271 15.6. Sepsis 15.6. Sepsis

15.6. Sepsis Pharmacologic nn Initiate broad-spectrum antibiotics prior to referral. Description Give ampicillin, gentamicin, and—if you suspect a Sepsis is an invasion of microbes or their toxins into the gastrointestinal or anaerobic source—metronidazole. blood, organs, or other normally sterile parts of the body. ll Ampicillin Causative agents are most commonly gram-negative uu Children: Refer to table A4 in annex A for bacteria. Sepsis encompasses a spectrum of illnesses standard dosages. ranging from minor flulike symptoms to life-threatening uu Adults: 1 g IV every 6 hours shock and organ failure. —OR— Diagnosis In the case of penicillin allergy or sensitivity, use nn History or evidence of recent or current infection erythromycin. Refer to table A12 in annex A for standard nn History of recent invasive medical procedure (e.g., dosages. dental and obstetric procedures) —PLUS— nn Spectrum of signs and symptoms from mild to severe ll Gentamicin ll Increased (38.3°C or higher) or decreased (less than uu Children: Refer to table A13 in annex A for 35.5°C) temperature standard dosages. ll Malaise uu Adults: 80 mg IV every 8 hours ll Chills —PLUS—

ll Increased respiration (more than 20/minute in an ll Metronidazole, if you suspect a gastrointestinal or INFECTIOUS DISEASES adult) anaerobic source, IV injection ll Increased heart rate (more than 90/minute in an uu Children: 7.5 mg/kg/ IV every 8 hours adult) uu Adults: 500 mg IV every 8 hours ll Decreased blood pressure Referral ll Shock nn Refer all severe cases of sepsis. nn Organ dysfunction and failure nn In the case of septic shock, treat shock before referral INFECTIOUS DISEASES INFECTIOUS Caution: Systemic inflammatory response syndrome is (see section 16.9 “Shock” for a discussion of septic a physiologic condition that mimics sepsis but may be shock). caused by a serious medical condition other than infection Prevention such as pancreatitis, severe burn, trauma, or malignancy. nn Treat the focus of infections early and appropriately to Management avoid progression to sepsis. nn Sepsis may be prevented by reducing the number of Nonpharmacologic invasive procedures undertaken and by limiting the Identify and remove any focal source of infection. use (and duration of use) of indwelling vascular and bladder catheters.

272 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 273 15.7. Malaria 15.7. Malaria

15.7. Malaria Diagnosis nn The classic picture of episodic fever, chills, and See also IMCI flipchart for children younger than 5 years. sweating with symptom-free periods in between is not Description reliable. If the patient lives in a malaria-prone area, Malaria is a parasitic disease caused by plasmodium. or has travelled through a malaria-prone area, always Malaria infection is transmitted by the bite of an infected suspect malaria in a patient complaining of or showing mosquito. Plasmodium vivax (PV) and Plasmodium the following signs: falciparum (PF) are the two most common species in ll Fever Afghanistan. ll Chills nn PV accounts for more than 90% of cases of malaria in ll Sweating Afghanistan and does not usually cause severe (i.e., ll Headache life-threatening) cases. Even after treatment, PV ll Muscular ache parasites may remain in the liver and provoke new ll Nausea attacks even without a new mosquito bite. nn Consider malaria in any patient who presents with nn PF is not common in Afghanistan but is much more fever that has no obvious other cause. likely to provoke severe attacks. nn If the patient is younger than 5 years, use the IMCI nn In Afghanistan, only some regions have significant risk flipchart “Child with Fever” to exclude danger signs of malaria (see table 15.7). Always suspect malaria in a and other illnesses.

patient with fever who lives in, or has traveled within nn Always check for signs of possible severe (i.e., life- INFECTIOUS DISEASES the last 4 weeks to, a malaria-prone area. threatening) malaria: ll Dehydration Table 15.7. Risk of Malaria in Afghanistan, by Province ll Impaired consciousness, drowsiness, delirium, or Stratum Risk Level Provinces unconsciousness First Medium to Badakhshan, Badghis, Balkh, ll Prostration (i.e., generalized weakness so that high risk for Faryab, Herat, Helmand, Kandahar, the patient is unable to walk or sit up without

INFECTIOUS DISEASES INFECTIOUS transmission Khost, Kunar, Kunduz, Laghman, assistance) Nangarhar, and Takhar ll Deep breathing, respiratory distress Second Low risk for Daikundi, Farah, Jawzjan, Kabul, ll Seizures transmission Kapisa, Logar, Nimruz, Oruzgan, Paktia, Paktika, Parwan, Samangan, ll Circulatory collapse or shock; systolic blood Sar-e Pul, Wardak, and Zabul pressure less than 70 mmHg in adults and less than Third Very low Central highlands of Baghlan, 50 mmHg in children risk for Bamyan, Ghazni, and Ghor. ll Jaundice transmission ll “Coca-cola color” (dark) urine, which may indicate blood or hemoglobin in the urine ll Abnormal spontaneous bleeding

274 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 275 15.7. Malaria 15.7. Malaria

nn Get laboratory confirmation. Whenever possible,all 15.7.1. First-Line Therapies suspected cases of malaria must be verified by rapid Confirmed (Laboratory) Cases of Malaria dipstick test, blood smear microscopy, or both before nn PV. If laboratory confirmation is positive for PV and treatment. the patient does not have life-threatening signs, treat ll Microscopy of blood smear remains the standard as “Uncomplicated, ConfirmedPlasmodium vivax” for laboratory confirmation and can potentially according to the National Guidelines (see table 15.7.1A detect all forms of malaria; accuracy depends on for children and table 15.7.1B for adults). For children technician’s experience. over 4 years and adults, give chloroquine (total dose of ll Rapid dipstick test strips for malaria are available in 25 mg/kg, maximum 1500 mg divided over 3 days) in 1 Afghanistan. dose daily over 3 days PLUS primaquine (0.25 mg/kg/ uu Most rapid dipstick test strips identify only PF day, maximum 15 mg) in 1 dose daily for 14 days (tablet malaria, so a patient with PV malaria will have of 15 mg are available in comprehensive health centers negative result by this kind of testing strip. and district hospitals). uu Some rapid dipstick test strips can identify PF malaria as well as other forms. Make sure the Caution: Primaquine should not be given to the following health worker knows which test is being used in patients: their laboratory. ll Pregnant women ll nn If no laboratory confirmation is feasible, treat the Lactating mothers, except under medical

patient based on clinical suspicion. supervision INFECTIOUS DISEASES ll Children younger than 4 years (see IMCI flipchart Management for malaria treatment) Nonpharmacologic ll Those suspected of having G6PD (glucose-6- nn Avoid dehydration. Encourage intake of liquids in phosphate dehydrogenase) deficiency adults and children and breastfeeding for infants. nn PF. If laboratory confirmation is positive for PF nn Reduce fever (if higher than 38.5°C) by removing and the patient does not have life-threatening signs,

INFECTIOUS DISEASES INFECTIOUS patient’s clothing and applying cool compresses. treat as “Uncomplicated, ConfirmedPlasmodium Pharmacologic falciparum” according to the National Guidelines nn Whenever possible, try to confirm diagnosis of malaria (see table 15.7.1C for children). For adults, give with laboratory verification (blood smear microscopy, sulfadoxine-pyrimethamine (Fansidar®) 25 mg/kg rapid dipstick test strip, or both). sulfa component, maximum of 3 tablets per day in a nn Remember: PV accounts for 90% of malaria cases in single dose PLUS artesunate (4 mg/kg, maximum 200 Afghanistan. mg/day) once daily for 3 days. nn nn For fever, give paracetamol. Refer to tables A15A and Mixed PF and PV. Treat as for patient with PF A15B in annex A for standard dosages. according to National Guidelines (see table 15.7.1C for children). For adults, give sulfadoxine-pyrimethamine

276 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 277 15.7. Malaria 15.7. Malaria

Table 15.7.1.B. Treatment of Adults with Chloroquine

Day 1 Day 2 Day 3

— — — 10 mg/kg initial dose 5 mg/kg 5 mg/kg Day 3: 1 Day Day 1: 1½ Day Day 2: 1½ Day 20–29 kg 20–29 —PLUS— (5–10 years) (5–10 5 mg/kg 6–8 hours later —OR—

— — — 10 mg/kg = 10 mg/kg = 5 mg/kg =

Day 3: 1 Day 4 tablets of 150 mg 4 tablets of 150 mg 2 tablets of 150 mg Day 1: 1½ Day Day 2: 1½ Day 15 to <20 kg (3 to <5 years) Table 15.7.1C. Treatment Sulfadoxine-Pyrimethamine Plus Artesunate in Children

Sulfadoxine- Artesunate Day 1: 1 Day Day 2: 1 Day

Day 3: ½ Day Pyrimethamine (50 mg tablet) Day 2: 15 ml Day Day 1: 15 ml Day Day 3: 10 ml Day 10 to <15 kg (500 mg + 25 mg (1 to <3 years) Age in Weight tablet) Day Day Day Years in kg 1 Day Only 1 2 3 <1 <10 ½ 1 1 1 1 to <3 10 to <14 1 1 1 1 INFECTIOUS DISEASES Day 1: ½ Day <1 year) Day 3: ½ Day Day 2: ½ Day 6 to <10 kg Day 2: 7.5 ml 2: 7.5 Day Day 1: 7.5 ml 1: 7.5 Day Day 3: 5.0 ml 3: 5.0 Day (3 months to 3 to <5 17–19 1 2 2 2 5–11 20–35 2 3 3 3 12+ 36+ 3 4 4 4 — — — 3 to <6 kg <3 months) Day 3: 2.5 ml Day Day 2: 5.0 ml 2: 5.0 Day (Neonate to (Neonate Day 1: 5.0 ml 1: 5.0 Day (25 mg/kg sulfa component, maximum of 3 tablets in a single dose) PLUS artesunate (4 mg/kg, maximum 200 INFECTIOUS DISEASES INFECTIOUS mg/day) once daily for 3 days. Unconfirmed Malaria If laboratory confirmation not possible, if clinical suspicion is high for malaria, or if both are the case, treat as “Unconfirmed Malaria” according to the National Treatment of Children with Chloroquine According to Age and Body Weight to Age According with Chloroquine Children of Treatment Guidelines. nn Give chloroquine (total dose of 25 mg/kg, maximum nce a day nce 1500 mg divided over 3 days) daily for 3 days (see table Dosage Form and Dosage Form Dosage orm: 150 mg tablet ral: O ral: F 3 days Duration: 1 and Dosage: 10 mg/kg on day 3 2, and 5 mg/kg on day day orm: 50 mg base/5 ml syrup orm: 50 mg base/5 n n n 15.7.1A for children and table 15.7.1B for adults). O F n n n ab l e 15.7.1A. T

278 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 279 15.7. Malaria 15.7. Malaria

nn Do not use primaquine for unconfirmed cases. Do not for 7 days PLUS clindamycin (100 mg) every 12 treat with primaquine unless PV has been confirmedby hours for 7 days. Note: Clindamycin is not part of laboratory test. If you suspect PV, refer the patient for BPHS/EDL, so the patient may require referral. diagnostic confirmation and follow-up care. ll First trimester with severe (life-threatening) Severe Malaria malaria: May need to receive quinine as an IV dose Severe, or life-threatening, malaria, whether it has been according to National Guidelines. confirmed or is merely suspected, should be referred when ll Second and third trimester: Give sulfadoxine- possible. If not possible or safe to refer, treat according to pyrimethamine PLUS artesunate, the same as for the National Guidelines. nonpregnant patients. Refer all pregnant women with malaria nn Give artemether (3.2 mg/kg, maximum 160 mg/day) by Caution: 1 IM injection on day 1, then 1.6 mg/kg (maximum 80 when possible. mg/day) in 1 IM injection daily for 5 days. Malaria in Children Younger than 5 Years —OR— Refer to IMCI flipchart. nn Once patient can tolerate oral treatment, or after at least 2 days of artemether, give a complete treatment 15.7.2. Second-Line Therapies oral course of artesunate PLUS sulfadoxine- Use second-line therapies only when parasitology has pyrimethamine. confirmed cases of PV or PF. Consider use of a second-line nn All pregnant women with severe malaria should be therapy in the following cases: INFECTIOUS DISEASES referred to hospital as soon as possible. nn Patients who show no improvement after 2 days on Malaria in Pregnancy first-line therapy nn Patients who have persistent or recurrent symptoms nn For confirmed PV or suspected,uncomplicated malaria, treat according to the National Guidelines, 3–28 days after treatment and refer for laboratory confirmation whenever nn Women in first trimester of pregnancy with PF possible. nn Children younger than 2 months (see IMCI flipchart ll treatment of malaria)

INFECTIOUS DISEASES INFECTIOUS Give chloroquine (total dose of 25 mg/kg, maximum 1500 mg divided over 3 days) over 3 (see table 15.7.1B nn Patients who have worsening symptoms at any time for adults).days during treatment n Caution: Do not give primaquine to pregnant n Patients who have a known allergy to sulfadoxine- women, lactating mothers, or children under 4 years, pyrimethamine and those suspected of having G6PD (glucose-6- phosphate dehydrogenase) deficiency. nn For confirmed PF malaria in pregnancy, treat according to the National Guidelines. ll First trimester: Give quinine (600 mg) every 8 hours

280 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 281 15.7. Malaria 15.7. Malaria

Management Physical Pharmacologic Prevent or eliminate breeding sites and, thus, the risk of Give the following for 7 days: mosquito bites: nn Wear protective clothing to avoid mosquito bites, nn Quinine (oral) 10 mg salt/kg (maximum 600 mg) every 8 hours especially during early evening when the malaria —PLUS— biting mosquito is most common. nn Remove or destroy breeding sites such as stagnant nn Doxycycline (3.5 mg/kg) daily Caution: Do not use doxycycline in pregnant women waters, cans, or drainage water. The aim is to remove or children younger than 8 years. water and to fill breeding sites with stone and soil. —OR— Patient Instructions nn Clindamycin (10 mg/kg) every 12 hours nn Clearly instruct the patient or caregiver how much Referral medicine to take daily according to the age or weight as listed in the tables above. Have the patient or caregiver nn Severe (i.e., life-threatening) cases of malaria, whenever possible repeat the instructions so you can check his or her understanding. ll Transport with health worker when possible. nn Witness or supervise the first dose of medicine. ll Give first dose of malaria treatment prior to transport. Monitor the patient for 30 minutes, and if the patient vomits the medicine, repeat the first dose. ll Give supportive care as needed before and during INFECTIOUS DISEASES transport (e.g., oxygen, IV fluid). nn Recommend to take primaquine tablets (if it has been prescribed) with food as it can provide abdominal nn Pregnant women with malaria whenever possible discomfort on an empty stomach. nn Patient requiring second-line therapy nn Treat fever higher than 38.5°C with paracetamol nn Treatment failures (10–15 mg/kg/dose every 6 hours until fever subsides) nn Patients not improving after 2 days of treatment and cool compresses. nn Patients who have worsening condition during treatment nn Avoid dehydration. Encourage intake of liquids in INFECTIOUS DISEASES INFECTIOUS adults and children; continue breastfeeding infants. nn Patients who have serious complications from malaria nn Instruct the family about danger signs of severe Prevention malaria, and advise them to return immediately if any Chemical occur. nn Use long-lasting insecticide treated nets or insecticide nn Instruct the family that the patient must return in 2 treated nets. days if he or she shows no improvement. nn Use indoor residual spraying. nn Use repellents, aerosol sprays, and mosquito coils as forms of personal protection.

282 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 283 15.8. Hepatitis 15.8. Hepatitis

15.8. Hepatitis

Description No No No No Y es Y es RNA Virus Hepatitis refers to inflammation or infection of the liver 21–63 from a variety of causes: E Hepatitis nn Viral (most common) ll Hepatitis A, B, C, D, E specific (hepatotropic) viruses No have been identified. These viruses are transmitted Y es Y es Y es Y es Y es RNA Virus by the fecal-oral route or by the parenteral or body- 21–42 Hepatitis D Hepatitis fluid route (see table 15.8). ll Other viruses may cause hepatic inflammation (e.g., herpes, cytomegalovirus, Epstein-Barr No Y es Y es Y es Rare Rare RNA Virus

virus [responsible for mononucleosis], varicella, 14–160

adenovirus, enterovirus, parvovirus). C Hepatitis nn Substances nn Antimalarials (chloroquine), paracetamol (overdose),

anesthetic agents No Y es Y es Y es Y es Y es DNA Virus ll Alcohol 60–180 Hepatitis B Hepatitis ll

Autoimmune disease INFECTIOUS DISEASES Hepatitis may be complicated by fulminant disease, as well as hepatocellular damage linked to cirrhosis, liver failure, No No No Y es Rare Rare RNA Virus and hepatocellular carcinoma. 15–40 Hepatitis A Hepatitis Diagnosis Although the severity of illness and complication rate of the various causes of viral hepatitis may differ, general INFECTIOUS DISEASES INFECTIOUS signs and symptoms of hepatitis are similar for all forms. Infection may be not be apparent (i.e., asymptomatic, normal liver enzymes), subclinical (i.e., asymptomatic, elevated liver enzymes), anicteric (i.e., symptomatic, no ecal-oral ulminant disease F Sexual Perinatal infection Chronic F jaundice), and icteric (i.e., jaundiced or appearing to be Parenteral Virology jaundiced). Common symptoms are the following:

nn Fatigue, fever, and flulike symptoms for 1 week to Hepatitis of Causes Viral Hepatotropic of Characteristics 1 month before jaundice, if any, appears nn Anorexia, nausea, vomiting ransmission Incubation (days) Incubation T ab l e 15.8. T

284 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 285 15.8. Hepatitis 15.9. Typhoid (Enteric) Fever

nn Right upper quadrant tenderness with or without nn All patients who have positive rapid screening tests for palpable liver HBV and HCV, for investigation nn Itching Prevention and Patient Instructions nn Jaundice may appear as disease progresses nn Ensure vaccination as indicated per EPI (hepatitis nn Rapid screening test for hepatitis B and C (for centers B as part of pentavalent vaccine) (see chapter 19 with blood banks) may indicate previous exposure to “Immunization”). those forms (i.e., identify presence of antibodies), but nn Advise frequent and thorough hand washing for all it does not confirm current or active disease. contacts. nn Severe complications such as the following may nn Advise condom use for suspected hepatitis carriers. indicate fulminant disease, cirrhosis, or liver nn Use single-use sterile syringes for injections and failure: encephalopathy, ascites, coma, bleeding, or sterilized instruments for any surgical interventions hypoglycemia. or endoscopies. (Chlorine solution should be used for Management sterilization.) Nonpharmacologic nn Instruct patient to return if his or her symptoms worsen. nn Instruct patient to return every 2 weeks until his or her nn There is no specific treatment for hepatitis A. Give supportive care. condition has improved. nn Lactating women may continue to breastfeed. nn Supportive treatment consists of the following: ll IV hydration is given as needed. 15.9. Typhoid (Enteric) Fever INFECTIOUS DISEASES ll Rest in bed is recommended until the transaminase level is high. Description ll Good nutrition with a diet rich in carbohydrates and Typhoid, or enteric, fever is caused by consumption (via with adequate protein should be given. the fecal-oral route) of food or water contaminated by ll Fat may be restricted but not necessarily eliminated. the bacteria Salmonella typhi. The bacteria invades the Pharmacologic intestinal wall and can spread through the bloodstream

INFECTIOUS DISEASES INFECTIOUS Avoid medication, if possible, during the acute phase to all organs. Typhoid often begins as nonspecific illness because the absorption rates for medicines may be altered and fever that can evolve to serious disease complicated or the medicines may aggravate the severity of liver disease. by peritonitis, encephalitis, or death. Consider typhoid in Referral patients who have a fever persisting for more than 7 days and for whom malaria has been excluded. nn All patients who have complications such as severe jaundice, encephalopathy, coma, bleeding, and Diagnosis hypoglycemia nn High, recurring fever which may start insidiously and nn Pregnant women who have known hepatitis B active persist for weeks disease, for consideration of newborn immunoglobulin nn Pulse rate may be lower than expected therapy immediately postdelivery nn Lethargy

286 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 287 15.9. Typhoid (Enteric) Fever 15.9. Typhoid (Enteric) Fever

nn Poor feeding uu Adults: 2 capsules 250 mg every 8 hours nn Constipation in early stage, diarrhea in later stage, —OR— vomiting ll Second line: amoxicillin for 14 days nn Cough (mostly dry) uu Children: Refer to table A3 in annex A for nn Abdominal pain and distention standard dosages. nn Headache uu Adults: 500 mg every 8 hours nn Stiff neck may occur Note: Amoxicillin is preferred for pregnant and nn Confusion and psychosis; convulsions may occur in lactating women children —OR— nn Rose spots on the abdominal wall in light-skinned ll Third line (for suspected resistance; may require children referral because it is available in CHCs and DHs): nn Hepatosplenomegaly ciprofloxacin for 14 days Complications include intestinal hemorrhage manifested uu Children: 15 mg/kg/dose every 12 hours by the dark or fresh blood in stool, intestinal perforation, uu Adults: 500 mg every 12 hours cholecystitis, nephritis, meningitis, myocarditis, arthritis, Caution: Ciprofloxacin is contraindicated and osteomyelitis. in pregnant women and should be avoided in children when possible. Management Referral

Nonpharmacologic INFECTIOUS DISEASES nn All seriously ill patients nn Isolate the patient. nn All patients who are at the extremes of age (i.e., very nn Hydrate to prevent dehydration (see section 2.1 young and very old) or pregnant “Diarrhea and Dehydration”). nn Complicated cases with suspicion of bowel perforation nn Continue adequate oral intake (i.e., simple, soft diet). or peritonitis nn Monitor for bleeding, anemia, peritonitis, convulsions, ll Refer early to surgical center where appropriate shock, or other known complications of typhoid fever. monitoring and treatment is available. INFECTIOUS DISEASES INFECTIOUS Pharmacologic ll Start IV line, hydrate, and give IV antibiotics prior nn Give an antipyretic daily until the fever subsides: to transfer. paracetamol. Refer to table A15 in annex A for Prevention and Patient Instructions standard dosages. nn Good hygiene and hand washing nn Give an antibiotic. nn Community hygiene and sanitation measures ll First line: chloramphenicol for 14 days uu Children: Refer to table A5 in annex A for standard dosages. Caution: Avoid chloramphenicol in premature infants, and refer.

288 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 289 15.10. Tuberculosis 15.10. Tuberculosis

15.10. Tuberculosis The keys to decreasing TB in Afghanistan are early diagnosis and treatment of those with active disease. All Description health care workers should consider TB in any patient TB is a bacterial infection caused by Mycobacterium who has had cough of more than 2 weeks. All patients in tuberculosis. Most people infected as a primary infection Afghanistan who have active TB should be treated under with the bacteria that causes TB never develop active TB. the DOTS program, which aims to ensure the continuous In a small percentage of people, the primary infection and regular uptake of the anti-TB medicines during the spreads and remains active in the lung causing illness length of treatment and to prevent anti-TB medicine and capable of spreading the disease to others. Infection resistance by avoiding interruptions in treatments. is usually spread by the airborne route from a coughing patient who has active pulmonary disease. Diagnosis Diagnosis of TB should be established by a qualified Most cases of TB involve infection of the lung (i.e., physician using the following criteria: pulmonary TB). Other much less common forms of the nn Clinical features (signs and symptoms) disease include infections of the bone (the spine is the nn Sputum smear microscopy (first priority) most common site), lymph nodes, joints, meninges, or nn Culture (if available) abdomen or a disseminated infection (i.e., miliary TB). When diagnosing extrapulmonary TB, the judgment of Patients who have weak immune systems because of physician is an important supplement to the clinical extremes of age, poor nutrition, or underlying medical features. problems, including human immunodeficiency virus INFECTIOUS DISEASES (HIV), are more likely to develop active TB. Sometimes Look for the following to diagnose and categorize TB. these patients will have activation of previously inactive nn Pulmonary TB should be suspected in any patient who disease. has had cough for more than 2 weeks. nn Other signs and symptoms of pulmonary TB may Active TB infection is classified as follows: include the following: nn SS+ is sputum (stain) positive for TB. It indicates ll Weight loss

INFECTIOUS DISEASES INFECTIOUS pulmonary TB and is very infectious until therapy has ll Fever (typically low-grade) been given for at least 2 weeks. ll Night sweats nn SS– is sputum (stain) negative for TB. It indicates ll Coughing up blood (hemoptysis) patients diagnosed with pulmonary TB by a physician ll Fatigue, loss of appetite because of symptoms, despite having negative sputum ll Chest pain stain 3 times. These patients may be less contagious, ll Shortness of breath but can still spread the disease until therapy has been nn Pulmonary TB in young children may be particularly given for at least 2 weeks. difficult to diagnose because they may not demonstrate nn Extrapulmonary TB is diagnosed by a physician and classical symptoms (especially malnourished indicates a patient who has active TB in a site outside children). Pulmonary TB should be suspected in all of the lung.

290 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 291 15.10. Tuberculosis 15.10. Tuberculosis

young children who have the following: ll Cough for more than 2 weeks ll Exposure to a household or close community contact who has active TB ll History of malnutrition not improving with dietary supplement ll History of poor growth or poor weight gain ll Chronic fever (rarely higher than 38°C), lassitude, anorexia Note: Vaccination with BCG may limit the chance and severity of TB in children, but it does not guarantee its prevention. Possible Extrapulmonary TB Diagnosis Extrapulmonary Possible n disease TB , also called Pott’s ertebral TB lymphadenitis TB Pleural TB Renal V the spine TB of the joint TB of n Physical examination is often normal in patients TB osteomyelitis Gastro-abdominal TB , the most common is TB peritonitis form TB meningitis or abscess who have TB; however, some findingsmay be present depending on the involved organ. ll Pulmonary TB—decreased breath sounds, tubular breath sounds, crackles ll Extra pulmonary TB—see table 15.10A

nn Laboratory tests can confirm a diagnosis. INFECTIOUS DISEASES ll Sputum for TB (acid fast bacilli) stain—3 specimens for all pulmonary TB suspects who are able to provide sputum ll Chest X-ray—when ordered by physician looking for SS– TB ll Other X-rays—when ordered by physician looking

INFECTIOUS DISEASES INFECTIOUS for extrapulmonary TB

ll Tissue biopsy—when ordered by physician looking Clinical Features for extrapulmonary TB Management Nonpharmacologic

nn All TB suspects should be entered in facility TB Extrapulmonary of the Types of Clinical Features register and TB monitoring records (i.e., facility and laboratory). nn

All patients who have positive sputum for TB should extremities the lower of or paralysis eakness yphosis (i.e., collapse of vertebral bodies forming an outward angle in the an outward bodies forming vertebral of collapse yphosis (i.e., ocal swelling or draining sinus from the long bones sinus from or draining ocal swelling nlarged or draining lymph nodes, especially in the neck; sometimes fistulae or draining E nlarged the skin) lymph nodes out through swollen fluid from of drainage (i.e., dyspnea Pleuritic chest pain, fever, hematuria or painless urination, dysuria, B ackache, frequent K a over to the spine, tenderness adjacent spine), back pain, swelling vertebral abscess “cold” or a para-vertebral body, vertebral W joint(s) Swollen L Abdominal swelling or mild pain, fever, night sweats, weight loss, diarrhea, loss, weight night sweats, or mild pain, fever, Abdominal swelling anal fistulae, ascites abdominal mass, fever, confusion, mental changes and and neck stiffness, Headache or lethargy somnolence ab l e 15.10A.

be referred for DOTS program. T

292 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 293 15.10. Tuberculosis 15.10. Tuberculosis

nn All patients suspected of possible TB without positive Table 15.10B. Category I: Adults and Children Older Than sputum should be referred for evaluation of negative 10 Years, Daily Dose of Fixed-Dose Combination (FDC) sputum TB by a physician. per kg of Body Weight nn All patients suspected of possible extrapulmonary TB Initial Phase Continuation Phase should be referred to a physician for evaluation. (2 months or 56 doses) (4 months or 112 doses) nn All patients should be encouraged to get adequate Daily under DOTS Daily under DOTS rest, eat a high protein diet, stay in a well-ventilated (except Fridays and (except Fridays and holidays) holidays) environment, and increase their exposure to sunlight. Patient nn Screen for TB among all household and close Body Dose FDC RHZE community contacts of the TB patient, especially Weight (150 mg + 75 mg + 400 Dose FDC RH (kg) mg + 275 mg) (150 mg + 75 mg) high-risk patients such as young children, the very old, the malnourished, or those who have chronic disease 30–39 2 2 (including HIV) because these patients are high risk 40–54 3 3 for acquiring active TB. 55–70 4 4 Pharmacologic 71 5 5 nn All patients diagnosed with TB should be treated under the DOTS program. initial phase with RHZE daily (56 doses), followed nn Anti-TB medicines by continuation phase of 4 months of RH daily INFECTIOUS DISEASES ll The most important medicines used to treat TB are (112 doses). isoniazid (H), rifampicin (R), pyrazinamide (Z), ll Category II: 2SRHZE/1RHZE/5RHE (see table streptomycin (S), and ethambutol (E). 15.10C) l l Some medicines are available in fixed-dose uu Category II is applied to all re-treatment cases combinations such as RH (rifampicin and isoniazid), (i.e., relapses, treatment after interruption with RHZE (rifampicin, isoniazid, pyrazinamide, and bacteriological positive, failure of treatment ethambutol), and RHE (rifampicin, isoniazid, and category I, and others). INFECTIOUS DISEASES INFECTIOUS ethambutol). uu The DOTS is mandatory for both phases of nn Principally, there are two types of TB treatment. treatment. l l Category I: 2RHZE/4RH (see table 15.10B) uu The duration of treatment is 8 months: initial uu This category applies to all new TB cases phase of 3 months of RHZE daily supplemented including children (i.e., pulmonary, in the first 2 months with streptomycin (S) daily, extrapulmonary, SS +, and SS–) who have not followed by continuation phase of 5 months of received any TB treatment within at least the RHE daily. previous month. uu DOTS is mandatory for both phases of treatment. uu The duration of treatment is 6 months: 2 months

294 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 295 15.10. Tuberculosis 15.10. Tuberculosis

Table 15.10C. Category II: Adults and Children Older Than Table 15.10D. Daily Dose per kg of Body Weight of 10 Years, Daily Dose of Fixed-Dose Combination (FDC) First-Line Anti-TB Medicines for Children and Adults per kg of Body Weight Recommended Dose Daily Initial Phase Dose and Range (3 months or 84 doses) (mg/kg Body RHZES + 56 doses of Continuation Phase Medicine Weight) Maximum (mg) Streptomycin (140 doses) Isoniazid 5 (4–6) 300 Months 1, 2, Months and 3 1 and 2 5 Months Rifampicin 10 (8–12) 600 Daily under Daily under Daily under DOTS Pyrazinamide 25 (20–30) — DOTS DOTS (except Fridays and Ethambutola 20 (15–25) — (except (except holidays) Fridays and Fridays and Streptomycin 15 (12–18) holidays holidays) a Ethambutol is safe in children at a dose of 20 mg/kg (range 15–25 mg/kg) daily. Dose FDC Dose Dose FDC RHE Patient RHZE Streptomycin (150 mg + 75 mg + Body (150 mg + injection (mg) 275 mg) multisystem TB or respiratory insufficiency) Weight 75 mg + 400 nn Are suspected of having relapse of TB or treatment (kg) mg + 275 mg) failure 30–39 2 500 2 nn Are being considered for chemoprophylaxis against TB

40–54 3 500 3 because of risk due to underlying medical condition INFECTIOUS DISEASES (e.g., HIV, malnutrition, or late-stage diabetes) 55–70 4 1 ga 4 nn Have a high risk of disease following exposure to a 71 5 1 ga 5 person with active TB (e.g., young children, the elderly, a 750 mg for patient over age 60 the malnourished, and those with chronic disease) nn Have serious adverse effects to anti-TB medicines Tables 15.10D and 15.10E are given below for your own information as all TB treatments must be given and Prevention INFECTIOUS DISEASES INFECTIOUS followed by a DOTS center. nn For the individual— ll BCG immunization of newborn or first contact may Referral decrease the rate and severity of TB, but it does not Refer all patients who— guarantee prevention. nn Have smear positive for DOTS therapy ll Chemoprophylaxis (INH) therapy for high-risk nn Are suspected of having smear negative TB for exposures evaluation by a physician, who may order special tests ll Early detection, diagnosis, and treatment such as X-ray and other laboratory tests nn For the community— nn Have extrapulmonary TB, including miliary TB ll Suspicion, early detection, and early treatment are or meningitis TB, or have complicated TB (e.g., the keys to decreasing TB in Afghanistan.

296 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 297 15.10. Tuberculosis 15.10. Tuberculosis

ll Increase awareness about TB within communities. ll Increase awareness of cough etiquette among patients and the community. 1 5 6 2 E ½ 3½ 2½ ll Examine and screen close contacts of active TB (100 mg) patients. ll Encourage good nutrition and hygiene. ll Try to keep TB suspects or newly diagnosed patients who have TB from exposing their household or

Continuation Phase Continuation community members, especially young children or 1 3 5 2 4 ½ 1½ RH those at high risk for acquiring TB.

(60/30 mg) ll Early treatment of TB patients—airborne spread is normally eliminated after 2 weeks of treatment Patient Instructions nn Remind patients that TB is a curable disease when

S medicine is taken correctly and for the full course. nn Enroll in DOTS and fully comply with taking all (1000 mg) 200 mg (1 ml) 275 mg (1.4 ml)275 100 mg (0.5 ml) 450 mg (2.3 ml) 50 mg (0.25 ml) 350 mg (1.75 ml)350 mg (1.75 150 mg (0.75 ml)150 mg (0.75 medicines for the full duration. nn Notify patients that the diagnosis and treatment of TB is free of charge. INFECTIOUS DISEASES nn Instruct patients to— 1 5 6 2 E ½ ll 3½ 2½ Cover the mouth and nose when they cough or

(100 mg) sneeze to avoid spreading the disease to others Initial Phase Initial ll Never spit on the ground, but rather use a disposable pot with a lid ll Maintain good nutrition INFECTIOUS DISEASES INFECTIOUS ll Get adequate sleep 1 3 5 2 4 ½ 1½ ll

RHZ Refrain from smoking nn Advise patients that TB treatment sometimes

(60/30/ 150 mg) produces side effects. Instruct them to inform the health center where they receive treatment immediately if they develop any of the following: Daily Dose per kg of Body Weight of Anti-TB Medicine for Children for Medicine Anti-TB of Body Weight Dose per kg of Daily ll Jaundice <4 7–9 4–6

(kg) ll 13–18 10–12

19–24 Skin disease 25–29 ll Hearing disturbances Body Weight Body Weight

ab l e 15.10E. ll Vision impairment T

298 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 299 15.11. Chickenpox 15.11. Chickenpox

15.11. Chickenpox Refer to table A7 in annex A for standard dosages. Caution: Do not give to premature infants and infants Description younger than 1 month Chickenpox is a common childhood communicable nn Give antibiotics only for secondary skin infection disease caused by the Varicella zoster virus. The infection (cellulitis or pus). is self-limiting with a duration of about 1 week. The ll Cloxacillin for 7 days (available in CHCs and DHs) infection presents 2–3 weeks after exposure. uu Children: 15 mg/kg/dose every 6 hours Diagnosis uu Adults: 500 mg every 6 hours Ask about possible exposure, and look for the following: —OR— nn Mild fever, headache, and malaise preceding the rash; ll For penicillin-allergic patients, erythromycin afebrile by the end of the first week ethylsuccinate for 7 days. Refer to table A12 in annex nn Characteristic rash and vesicles beginning on the A for standard dosages. trunk and face, later spreading to the arms and legs Referral ll Groups of macules, papules, and vesicles nn Immunocompromised patient who has severe disease ll Variety of blisters to crusting scabs in various stages nn Failure to improve in 7 days of development; the spectrum of lesions may all nn Severely ill patient exist at the same time nn Complication of pneumonia, encephalitis, or nn Itching meningitis INFECTIOUS DISEASES Chickenpox is most severe in young infants, adults, and nn Babies younger than 6 months the immune-compromised patients. Rare complications— nn Pregnant women more commonly in adults—are pneumonia, meningitis, or nn Recurrent chickenpox encephalitis. Prevention Management Isolate the patient from others during infective phase, which occurs 6 days after the lesions have appeared, or Nonpharmacologic

INFECTIOUS DISEASES INFECTIOUS until all of the lesions have crusted over. Ensure adequate hydration and nutrition Patient Instructions Pharmacologic nn Review medication instructions and have patient or nn Fever is usually low grade and can be treated with caregiver repeat them. paracetamol until fever subsides. Refer to table A15 in nn Advise the patient or caregiver to— annex A for standard dosages. ll Keep the skin clean. Bathe often with soap and Caution: Do not give aspirin to children younger than water. 5 years because of the risk of Reye’s syndrome. ll Cut the fingernails and avoid scratching the lesions, nn Calamine lotion may be applied on skin to relieve which can become infected. severe pruritus. ll Maintain general good hygiene measures. nn Give chlorphenamine maleate tablet for severe itching.

300 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 301 15.12. Rabies 15.12. Rabies

15.12. Rabies Management nn There is no treatment for clinical rabies: the patient Description will die. Postexposure treatment prevents rabies from Rabies is a viral (rhabdovirus) encephalitis transmitted developing and is vitally important. by saliva of infected animals. Transmission can occur Caution: For a high-risk case, infiltrate the wound through bites or if an infected animal licks a person’s with rabies immunoglobulin. abraded skin or mucous membranes. Infected animals nn Observe the animal to assess for signs of rabies. Hold are infectious to humans up to 14 days before the animal the animal for observation for 14 days, when possible. shows signs of infection. Unless treated immediately after nn Care for the wound. infection, rabies is uniformly fatal. ll Wash the site of the contact bite with soap and clean Diagnosis water. In Afghanistan, a bite from any animal (e.g., dog, cat, or ll Wash the site of the contact with antiseptic wild animal) should be treated as possible until it is proven (chlorhexidine plus cetrimide solution) for at least that the animal does not have rabies. If a suspect animal 15 minutes. (e.g., dog, cat, cow, sheep, goat) licks a person’s mucosa ll For benign bites, refer for vaccination immediately. or skin in an area where its integrity is compromised, the ll For serious bites, refer for rabies immunoglobulin contact should be treated as possible until proven that the immediately. animal does not have rabies. If possible, catch and keep the nn Update tetanus immunization: 0.5 ml TT IM injection

animal under surveillance for 15 days. (see chapter 19 “Immunization”). INFECTIOUS DISEASES nn The patient usually has a history of an animal bite, but nn Use postexposure rabies prophylaxis, which is the bite may not be recognized or remembered since essential to prevent fatal results of active rabies incubation is usually 3–12 weeks. infection. refer to EPHS facility for vaccine with or nn The prodromal syndrome consists of pain and without rabies immunoglobulin. paresthesia at the site of the bite in association with Referral fever, malaise, headache, nausea, and vomiting. This Refer all suspected bites and contacts to a center with INFECTIOUS DISEASES INFECTIOUS phase lasts for a few days. vaccine with or without immunoglobulin available. nn In the acute phase, the patient can show the following: Prevention ll Agitation nn Ensure adequate referral for postexposure treatment. ll Hyperexcitability (e.g., skin is sensitive to air nn Encourage community control of suspicious animals. currents) ll Painful laryngeal spasms upon drinking (i.e., Patient Instructions hydrophobia) nn Make sure patients understand that untreated rabies ll Hypersalivation is lethal and that strict adherence to full postexposure ll Ascending paralysis and seizures course of treatment is the only prevention. nn Encourage community control of suspicious animals.

302 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 303 15.13. Leishmaniasis 15.13. Leishmaniasis

15.13. Leishmaniasis nn Visceral leishmaniasis— ll Can be deadly if untreated Description ll Suspect visceral leishmaniasis in patients who Leishmaniasis is a group of diseases caused by parasites have fever, enlarged spleen, weight loss, or called Leishmania. The infection is transmitted by bites lymphadenopathy from sand flies. Leishmaniasis has three main clinical ll May exhibit other signs: bleeding, hepatomegaly, presentations and forms: anemia, and diarrhea nn Cutaneous leishmaniasis (common in Afghanistan) Management consists of single or multiple lesions on the uncovered parts of the body; often starts as a papule and then Nonpharmacologic forms a scabbed ulcer. Keep the ulcer clean. nn Visceral leishmaniasis or kala-azar (occasionally seen Pharmacologic in Afghanistan) may have systemic signs such as fever, Refer the patient to a leishmaniasis center for treatment. splenomegaly, weight loss, or lymphadenopathy. Referral nn Mucocutaneous leishmaniasis (not typically seen in Refer all patients suspected of cutaneous leishmaniasis to Afghanistan) occurs when lesions spread to mucosa a leishmaniasis center for evaluation and treatment. Insist and cause destruction and disfigurement. that the patient go to the center, and inform the patient Diagnosis that treatment will take time.

nn Cutaneous leishmaniasis— INFECTIOUS DISEASES Prevention ll Suspect if a patient shows any of having had the Prevention of cutaneous leishmaniasis is mainly through following for more than 14 days: limiting the exposure to sand fly bites, which tend to bite uu A red papule (i.e., a small round bump on the from sunset to the first hours of the night. Advise patients skin) usually on an uncovered part of the body. to— It is painless but sometimes itches. The papule nn Wear clothing that leaves little skin exposed when sun becomes larger and also deeper, and a reddish

INFECTIOUS DISEASES INFECTIOUS starts setting. circle spreads to a larger area, with thickening of nn Use fly screens in windows. the skin. nn Use insecticide-impregnated curtains, bed nets, and uu A dry sore, with a hard crust on a red swelling, up sheets. to 2–3 cm in size, with an irregular boundary nn Sleep under long-lasting insecticidal treated nets or uu A wet sore, with exudates, often larger and leaving insecticidal treated nets, which reduce exposure to deeper scars sand fly bites. ll Typically patient has no pain; sometimes there nn Ensure vector control and elimination of animal is itching. The sore will heal spontaneously over reservoir hosts. several months, but will leave a shallow scar, with normal skin color.

304 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 305 15.14. Ascariasis (Roundworm) 15.14. Ascariasis (Roundworm)

Early diagnosis and treatment of infected patients reduces nn Migration phase—as larva migrate from site of cross-contamination. exposure through the lungs Patient Instructions ll Initial phase after exposure; rare to see symptoms ll Allergic signs nn Convince all patients who have had a painless skin lesion for more than 14 days to go for a checkup to a uu Skin: pruritis, erythema, urticaria leishmaniasis diagnostic center. uu Pulmonary: – Dry cough, wheeze, asthma-like symptoms nn Insist that prompt diagnosis and treatment will – prevent extensive scarring and infection of family (Loeffler’s syndrome) members. –– Pulmonary infiltrates Management 15.14. Ascariasis (Roundworm) Nonpharmacologic Description Look for evidence of anemia or malnutrition. Ascariasis is very common parasitic disease which is often Pharmacologic asymptomatic. Transmission is by the fecal-oral route. nn Give oral mebendazole (100 mg tablet) for 3 days: Ascariasis may cause nutritional deficiency, abdominal ll Children 1–2 years: 50 mg/dose every 12 hours distension, or bowel obstruction. ll Adults and children older than 2 years: 100 mg/dose Diagnosis every 12 hours

nn Alternative treatment albendazole (available in DHs) INFECTIOUS DISEASES nn Gastrointestinal phase—from the presence of adult worms in the intestine ll Children 1–2 years: 200 mg as single dose ll Adults and children older than 2 years: 400 mg as ll Pain, discomfort, irritability single dose ll Distension Mebendazole and albendazole are not ll Diarrhea Caution: advised during first trimester of pregnancy or while ll Poor growth in children; nutritional deficiencies breastfeeding ll Visible worm, in part or whole, in stool INFECTIOUS DISEASES INFECTIOUS Do not treat ascariasis with medicine if ll Rarely, visible worm from mouth or nose or in vomit Caution: patient has evidence of bowel obstruction. Refer. ll Rarely, vomiting and frank bowel or biliary tract obstruction (with ascariasis) due to worm mass nn Treat anemia, if needed, with oral ferrous sulfate (60 mg iron tablet) for 30 days: ll Diagnosis is established by evidence of characteristic eggs or worm noted on stool ll Children younger than 12 years: 1.5 mg/kg/dose microscopy (where available). every 12 hours (not to exceed 60 mg daily) ll Adults: 1 (60 mg) tablet every 12 hours uu Stool eosinophilia may be prominent during the early migration phase (i.e., pulmonary ascariasis). Referral uu Ultrasound may identify adult worms in bowel or nn Failure to respond to therapy for further diagnostic pancreatic-biliary duct lumen. evaluation

306 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 307 15.15. Taenia Taenia Saginata Saginata and and Hymenolepis Hymenolepis Nana Nana (Tapeworm) 15.15. Taenia15.15. Saginata Taenia and Saginata Hymenolepis and Hymenolepis Nana (Tapeworm) Nana

nn Evidence of severe abdominal tenderness, intestinal Pharmacologic obstruction, or biliary obstruction Based on confirmed diagnosis, prescribe niclosamide (if Prevention and Patient Instructions available on the market, not presently in EDL): n Instruct patients to— n If T. saginata ll Children weighing 11–34 kg: 1 g chewed in 1 dose nn Practice good hand washing hygiene (i.e., with soap and water before eating and after toilet use) (treatment may be repeated once after 7 days if needed) nn Teach children good hand washing hygiene. ll Children weighing more than 34 kg: 1.5 g chewed in nn Improve sewage facilities (e.g., latrines). 1 dose (treatment may be repeated once after 7 days nn Practice good food preparation hygiene (i.e., wash and cook food thoroughly). if needed) ll Adults: 2 g chewed in 1 dose (treatment may be nn Keep fingernails short. repeated once after 7 days if needed) 15.15. Taenia Saginata and Hymenolepis Nana nn If H. nana (Tapeworm) ll Children weighing 11–34 kg: 1 g chewed on the first day, then 500 mg once a day for the next 6 days. Description Treatment may be repeated in 7–14 days, if needed. Humans are infected with Taenia saginata by eating ll Children weighing more than 34 kg: 1.5 g chewed on raw or undercooked infected beef. Hymenolepis nana is the first day, then 1 g chewed once a day for the next

transmitted between humans through fecal-oral contact. 6 days. Treatment may be repeated in 7–14 days, if INFECTIOUS DISEASES Diagnosis needed. l Most infected individuals are asymptomatic, but vague l Adults: 1 g chewed twice a day for 7 days. Treatment abdominal pain, diarrhea, and weight loss may be present. may be repeated in 7–14 days, if needed. Children may develop nonspecific complaints such as Prevention nausea, pain in abdomen, and diarrhea. Diagnosis is nn Ensure adequate cooking of beef. usually made based on the identification of characteristic nn Practice general preventive measures— INFECTIOUS DISEASES INFECTIOUS eggs or proglottids in the stool, which requires direct ll Inspect beef. observation of the stools or microscopic observation. ll Dispose of human feces properly. l Management l Do not use fresh human waste as fertilizer. Nonpharmacologic If patient has diarrhea, treat it first (see section 2.1 “Diarrhea and Dehydration”). Treat malnutrition. Avoid dehydration.

308 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 309 15.16. Anthrax 15.17. Brucellosis

15.16. Anthrax nn For children younger than 8, pregnant or lactating women, and patients with a penicillin allergy or Description sensitivity, give oral erythromycin. Refer to table A12 Anthrax is a toxic infection by Bacillus anthracis in annex A for standard dosages. of herbivores (e.g., sheep, cows, goats, swine). It is Referral transmitted to humans by contact with skin (cutaneous nn All patients who have lesions on head or neck anthrax), inhalation (pulmonary anthrax), or ingestion nn All patients who have generalized signs (intestinal anthrax). Cutaneous anthrax is common in nn Any patient you suspect has pulmonary or intestinal Afghanistan. Transmission is via spores, so even dead anthrax animals or their hides can transmit the disease. Prevention Diagnosis Bury or burn the carcasses of all animals that die of nn The initial lesion is an erythematous papule, which anthrax. becomes an itching vesicle, and then starts ulcerating giving a black eschar. Patient Instructions nn The eschar is painless, but surrounded by edema, nn Ensure that the patient understands that anthrax is lymphangitis, and swollen lymph nodes. potentially lethal and that it is important to take the nn Lesions are usually on exposed areas: hands, arms, complete antibiotic treatment. neck, head, feet, or legs. nn Evaluate livestock to identify disease and control its

nn Generalized signs (i.e., fever, malaise, lymphangitis, spread. INFECTIOUS DISEASES and swollen lymph nodes) appear. nn If not treated promptly, extensive edema and 15.17. Brucellosis septicemia may develop. Description Management Brucellosis is a systemic bacterial, gram-negative To treat simple cutaneous anthrax— infection that may become chronic. Transmission to nn Do not peel or excise the eschar. Clean and apply dry

INFECTIOUS DISEASES INFECTIOUS humans occurs by contact with infected meat (e.g., among dressings daily. slaughterhouse workers); ingestion of raw meat, milk, nn Give oral doxycycline for 10 days. Refer to table A10 in or cheese; or contact with infected material and animals annex A for standard dosages. through skin abrasions. Caution: Do not give doxycycline to children younger Diagnosis than 8 years or to pregnant or lactating women. nn Diagnosis is difficult because clinical signs are —OR— nonspecific and fluctuating. nn Give amoxicillin, oral. Refer to table A3 in annex A for nn Consider brucellosis under the following conditions: standard dosages. ll The patient has undulating fever (i.e., up and down) —OR— for more than 10 days, with night sweats, chills, or

310 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 311 15.17. Brucellosis 15.18. Mumps

general asthenia with or without joint and muscle nn For children younger than 8 years, give pain. A flulike syndrome that lasts for more than 1 ll Co-trimoxazole for 6 weeks. Refer to table A8 in week should make you think of brucellosis. annex A for standard dosages. ll In malaria-prone areas, think of brucellosis if a —PLUS— patient’s high fever persists in spite of correct ll Gentamicin injection once daily (7.5 mg/kg) for 2 antimalaria treatment. weeks. nn Look for complications of brucellosis: Note: Combination regimens of two or three ll If not treated, bone and joint pains become more medicines are most effective. prominent and meningo-encephalitis may occur. Referral Refer these patients. nn Because the diagnosis of brucellosis is difficult and the ll Brucellosis may become chronic with slowly treatment is prolonged, refer all patients for serologic developing bone and joint pain and involvement or confirmation whenever possible. neuro-meningeal signs. nn In addition, refer the following: nn Perform laboratory tests, if available. The diagnosis ll All complicated cases such as myocarditis, arthritis, often is made by serologic testing. Rising serologic osteomyelitis, and meningitis titers or an absolute agglutination titer of more than ll All pregnant women 1:160 supports the diagnosis. Prevention nn Differential diagnoses include the following, and may nn Avoid eating unpasteurized cheese, unboiled milk, or be difficult to determine without a serologic laboratory INFECTIOUS DISEASES test: undercooked (“red”) meat. nn Wash hands with soap after contact with animals or ll Typhoid fever animal products. ll TB ll Human immunodeficiency virus (HIV) infection 15.18. Mumps ll Malaria Management Description INFECTIOUS DISEASES INFECTIOUS Pharmacological Mumps is an acute, contagious viral disease characterized by painful enlargement of the salivary glands especially nn For patients older than 8 years, give the parotid gland located below the ear, at the angle of the ll Oral doxycycline (100 mg) every 12 hours for 6 weeks jaw. It may rarely involve the testes (orchitis) and lead to Caution: Do not give doxycycline to children sterility. younger than 8 years or to pregnant or lactating Diagnosis women. nn Incubation period is 14–24 days. —PLUS— nn Most patients exhibit few symptoms except swelling of ll Oral rifampicin (10 mg/kg) up to 600 mg once daily one of the salivary glands. for 6 weeks

312 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 313 15.18. Mumps 15.19. Sexually Transmitted Infections

nn Swelling is often quite painful. 15.19. Sexually Transmitted Infections nn Edema of soft palate and pharynx may be seen. nn The patient may have no or only low-grade fever. Description nn Within 3–7 days, the swelling gradually subsides. Sexually transmitted infections (STIs) are caused by a broad range of pathogens and have a high physical and Management psychosocial morbidity. Bacterial and viral STIs such as nn Treatment is generally supportive. gonorrhea, syphilis, human papilloma virus (HPV), human nn No specific antiviral treatment is available. immunodeficiency virus (HIV), and herpes simplex nn Encourage fluids. Avoid dehydration. virus-2 are the most common infections. nn A semi-solid or liquid diet may help avoid pain on chewing. Diagnosis nn nn Bed rest may be needed. HPV and external genital warts ll nn Local support (elevation) is also given in the case of Usually asymptomatic except for cosmetic orchitis. appearance ll nn Give paracetamol until fever or pain subsides. Refer to Itching, burning, bleeding, vaginal or urethral table A15 in annex A for standard dosages. discharge, dyspareunia ll Skin-colored, pink, red, brown Referral ll Sites of predilection— nn High fever uu Male: frenulum, corona, glans penis, prepuce, nn Severe headache shaft, scrotum INFECTIOUS DISEASES nn Abdominal pain uu Female: labia, clitoris, periurethral, anal canal, nn Painful testes or orchitis rectal area, urethral meatus, urethra, bladder, nn Suspected pancreatitis, encephalitis oropharynx. nn Failure to improve within 10 days nn Herpes simplex virus and genital herpes Prevention and Patient Instructions ll Primary genital herpes nn Isolate patient from others during infectious period uu Most individuals with primary infection are

INFECTIOUS DISEASES INFECTIOUS (i.e., 3 days before parotid swelling until 7 days after it asymptomatic. has started). uu Those who have symptoms report fever, headache, nn Advise bed rest during the febrile episodes. malaise, myalgia, peaking within the first 3–4 nn Children may return to school 1 week after initial days after onset of lesions, resolving during the swelling. subsequent 3–4 days. uu Depending on location, pain, itching, dysuria, lumbar radiculitis, vaginal or urethral discharge are common symptoms. uu Tender inguinal lymphadenopathy occurs during second and third weeks.

314 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 315 15.19. Sexually Transmitted Infections 15.19. Sexually Transmitted Infections

uu Mucocutaneous lesions appear: an erythematous ll Congenital syphilis plaque, followed soon by grouped vesicles, uu Early congenital syphilis: lesions occur during the erosion, and ulceration. first 2 years of life. ll Sites of predilection— –– Present at birth: low birth weight, abnormally uu Male: glans, scrotum, thighs, buttocks large placenta, hepatosplenomegaly, blisters uu Female: labia, perineum, inner thighs and erosions mainly on palms and soles nn Syphilis –– Developing in first months in untreated infants: ll Primary syphilis chronic runny nose, often bloody; central uu Dark red nodule develops to ulceration (chancre). nervous system disease; glomerulonephritis, uu Base is salmon-colored while periphery is more with nephrotic syndrome red. uu Late congenital syphilis: lesions occur after 2 uu Sites of predilection— years of life. –– Men: prepuce, glans; in homosexuals: perianal –– Interstitial keratitis region, rectum –– Sensory deafness –– Women: vagina or cervix, labia, clitoris, –– Neurosyphilis perianal region, rectum –– Saddle nose –– Both genders: Extra genital lesions: lips, tongue, –– Saber shins palate, finger –– Effusion into large joints

ll Secondary syphilis –– Gothic palate INFECTIOUS DISEASES uu An incredible number of exanthemas and –– Hutchinson teeth enanthems are associated with secondary nn Chancroid syphilis. The rashes of secondary syphilis usually ll Acute STI with painful genital ulcers and do not itch. lymphadenopathy caused by Haemophilus ducreyi. uu Systemic changes can include lymphadenopathy, ll Sites of predilection— glomerulonephritis, or meningitis. uu Men: glans penis, inner aspects of foreskin,

INFECTIOUS DISEASES INFECTIOUS ll Tertiary syphilis frenulum uu Tuberous syphilis: grouped red-brown papules uu Women: labia, perianal region, cervix and nodules occurring more often on the upper ll Lymphadenopathy: acute painful, usually unilateral; arms, back, or face. develops in 50% after 1–2 weeks. typically forms uu Complications include— abscesses that rupture forming fistulas –– Musculoskeletal disease ll Painful soft ulcer –– Cardiovascular disease nn Gonorrhea –– Central nervous system disease ll Males uu Urethral discharge ranging from scanty and clear to purulent and copious

316 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 317 15.19. Sexually Transmitted Infections 15.19. Sexually Transmitted Infections

uu Edema: meatus, prepuce, or penis ll Systemic symptoms during acute phase uu Deeper structures: prostatitis, epididymitis, include fever, headache, myalgia. Skin findings cystitis include erythema nodosum, enanthems, and ll Females photosensitivity. uu Periurethral edema, urethritis Management uu Purulent discharge from cervix but no vaginitis nn For HPV and herpes simplex virus, refer. uu In prepubescent females, vulvovaginitis, nn For syphilis— Bartholin’s abscess ll Early syphilis, give— uu Deeper structures: pelvic inflammatory disease, uu Benzathine penicillin injection (2.4 MU) IM endometritis single dose l l Anorectum: proctitis with pain and purulent —or— discharge In the case of penicillin allergy or sensitivity, use ll Pharynx: pharyngitis with erythema erythromycin for 2 weeks. Refer to table A12 in annex A for nn Granuloma inguinal (granuloma venereum) standard dosages. l l Painless, progressive, ulcerative lesions of the —OR— genital and perianal areas; lesions bleed easily on uu Doxycycline tablet (100 mg) every 12 hours for 2 contract. weeks l l Sites of predilection— Caution: Do not give doxycycline to children uu Males: prepuce or glans, penile shaft, scrotum younger than 8 years or to pregnant or lactating INFECTIOUS DISEASES uu Females: labia minora, mons veneris, fourchette women. uu Both genders: extra genital lesions: mouth, lips, ll Late syphilis, give— throat, face, gastrointestinal tract, and bone uu Benzathine penicillin injection (2.4 MU) IM on nn Lymphogranuloma venereum day 1, day 8, and day 15 l l Primary lesion is 5–8 mm painless erosion, which —OR— heals over days. uu Doxycycline tablet (100 mg) every 12 hours for 28 INFECTIOUS DISEASES INFECTIOUS ll Lymphadenopathy is prominent, bilateral, and both days. In the case of neurosyphilis, give doxycycline above and below inguinal ligament. Often rupture tablet (200 mg) every 12 hours for 28 days. with fistula formation. Without treatment, healing —OR— occurs in 2–3 months. uu During pregnancy, give erythromycin (500 mg) ll Rectal infection is more common in women and every 6 hours for 2 weeks. homosexual men. Bloody discharge with pain. ll Congenital syphilis, refer. ll Oral infection involves enlarged cervical nodes. nn For chancroid, give— Later, axillary and thoracic nodes are involved. ll Ceftriaxone (250 mg) IM single dose injection Differential diagnosis is lymphoma. —OR—

318 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 319 15.19. Sexually Transmitted Infections 15.19. Sexually Transmitted Infections

ll Erythromycin (oral) for 1 week. Refer to table A12 in nn Use protective gloves and clothing when there is risk annex A for standard dosages. of contact with blood or other potentially infected nn For gonorrhea, give— body fluids. ll Ceftriaxone (250 mg) IM in a single dose injection nn Employ safe handling methods, and dispose of waste —OR— materials, needles, and other sharp instruments ll Ciprofloxacin tablet (500 mg) in a single dose properly. (available only in CHCs and DHs; may need to refer) nn Ensure access to voluntary counseling and testing for nn For granuloma inguinal and lymphogranuloma all health care workers. venereum, give— nn Use of condoms for men protects against all STIs, ll Co-trimoxazole adult (480 mg), 2 tablets every 12 including HIV hours for 3 weeks —OR— ll For pregnant women, erythromycin (500 mg) tablet every 6 hours for 3 weeks Referral nn Patient with a new diagnosis of human immunodeficiency virus (HIV) (see chapter 20, “HIV Infection and AIDS”) INFECTIOUS DISEASES nn Patient with persistent, refractory, or recurrent STIs particularly when medicine resistance is suspected Prevention and Patient Instructions nn Report all cases to the local health authority. nn Isolate all newborn infants and pre-pubertal children who have gonococcal infection until

INFECTIOUS DISEASES INFECTIOUS effective parenteral antimicrobial therapy has been administered for 24 hours. nn Immunize or vaccinate. nn Investigate contacts and source of infection, and treat the contacts. nn Avoid nonessential blood transfusions. nn Carefully screen donors when recruiting to ensure a safe blood donor pool. nn Wash hands with soap and water, especially after contact with body fluids or wounds

320 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 321 16.1. Acute Pulmonary Edema 16.2. Acute Abdominal Pain

Chapter 16. nn Give furosemide IV injection immediately. ll Children: 1 mg/kg/dose Emergencies And Trauma Note: If there is no diuresis after 30 minutes and blood pressure is stable, give a repeat dose of 16.1. Acute Pulmonary Edema furosemide IV of 2 mg/kg. ll Adults: 40 mg/dose, and then monitor diuresis, Description which should follow in 15–20 minutes Acute pulmonary edema is a life-threatening emergency Note: If there is no diuresis after 30 minutes and characterized by extreme breathlessness due to abnormal blood pressure is stable, inject 80 mg furosemide IV. accumulation of fluid in the lungs. Acute myocardial nn If patient shows no improvement, give morphine slow infarction is a common cause (see section 6.5 “Acute IV injection of 2 mg (i.e., 1 mg in 1 minute). Morphine Myocardial Infarction”). is available in DHs. Diagnosis Caution: Do not give morphine to patients who have The patient presents with the following: asthma or hypotension. nn Difficulty breathing, usually with sudden onset and not nn If you suspect acute myocardial infarction (see section stress related 6.5 “Acute Myocardial Infarction”), give 1 aspirin (325 nn Rapid breathing mg) tablet and refer urgently to EPHS hospital where nn Rapid pulse following medicines are available. nn Signs of cyanosis ll For adults, give sublingual nitroglycerine (0.5 nn Usually, agitation and perspiring mg) tablet: 2–3 tablets every 4 hours (available in nn Distended neck veins or other signs of heart disease or regional hospitals). failure ll If patients have hypertensive crisis, captopril (25 nn Often, hypertension mg) tablet (available in regional hospitals) Auscultation often reveals rales (i.e., crackles) and Referral wheezing in both lungs. Refer all patients to hospital for exploration and treatment Note: Verify the patient’s history to exclude an acute of underlying cause. If possible, keep oxygen running asthma attack (see section 3.1 “Asthma”). during transfer.

Management 16.2. Acute Abdominal Pain EMERGENCIES Treat immediately to relieve acute symptoms, and then treat underlying cause. Refer. Description nn Ease the patient’s breathing by placing him or her in Abdominal pain is common, often self-limiting, and not sitting upright position. serious. Acute abdominal pain, or acute abdomen, however, EMERGENCIES nn If possible, administer oxygen by mask to achieve refers to sudden (less than 24 hours) severe abdominal PaO2 760 mmHg. pain, and many of its causes require urgent surgical

322 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 323 16.2. Acute Abdominal Pain 16.2. Acute Abdominal Pain

intervention. Acute abdominal pain in young children figure 16.2 Location of abdominal pain and possible causes and older patients is always an alarming symptom. Many diseases produce abdominal pain, so careful evaluation is Right or Left Upper Quadrant necessary to decide which cases to refer urgently. When Acute pancreatitis in doubt, refer the patient to the hospital for surgical Myocardial ischemia Pneumonia of lower lobe evaluation. Common surgical conditions that cause acute abdominal pain are addressed in sections 16.2.1 through 16.2.7 below. Right Upper Quadrant Live: Hepatitis, liver abscess, Left Upper Diagnosis congestive hepatomegaly Quadrant Gallbladder: cholecystitis, Abscess of spleen nn Look for signs of emergency. biliary colic Rupture of spleen ll Focus on life-threatening-emergencies first. Perforation of duodenal ulcer Gastritis ll Rule out pregnancy in women of childbearing age. ll Look for severe pain. ll Watch for signs of shock (e.g., tachycardia, hypotension, excessive sweating, and confusion). (See section 16.9 “Shock.”) ll Look for signs of peritonitis (e.g., sharp, constant pain, worsened by movement). nn Examine for abdominal distention. Take a careful history. Ask the following questions Right Lower Left Lower l l Where is the pain located? (See figure 16.2.) Quadrant Quadrant Caution: Children often cannot indicate the Appendicitis Sigmoid location precisely. Constipation diverticulitis ll What is the pain like? (Possible causes are in parentheses.) Right or Left Lower Quadrant uu Acute waves of sharp constricting pain that “takes Gynecological pelvic pain: PID, ectopic pregnancy, endometriosis, dysmenorrhea the breath away” (renal or biliary colic) Kidney stones, ureter colic, urinary tract uu Waves of dull pain with vomiting (intestinal infections obstruction) Inguinal hernia EMERGENCIES Inflammatory bowel disease uu Colicky pain that becomes steady (appendicitis, strangulating intestinal obstruction, mesenteric ischemia) Diffuse Abdominal Pain uu Gastronenteritis Acute pancreatitis EMERGENCIES Sharp, constant pain, worsened by movement Peritonitis Intestinal obstruction (peritonitis) Typhoid fever beginning appendicitis uu Tearing pain (dissecting aneurysm)

324 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 325 16.2. Acute Abdominal Pain 16.2. Acute Abdominal Pain

uu Dull ache (appendicitis, diverticulitis, no flatus (acute intestinal obstruction; the time pyelonephritis) period of delay increases with a more distal site of ll Have you had similar pain before? obstruction) uu If yes, that suggests recurrent problems such as uu Severe vomiting precedes intense epigastric, left ulcer disease, gallstone colic, diverticulitis, or chest, or shoulder pain (emetic perforation of the mittelschmerz (ovulatory or mid-cycle pain). intra-abdominal esophagus) ll Was the onset sudden? nn Perform a physical exam and look for the following. uu If yes—sudden, “like a light switching on”—that ll Determine the vital signs. suggests perforated ulcer, renal stone, ruptured uu Rapid respiration may indicate pneumonia. ectopic pregnancy, torsion of ovary or testis, or uu Tachycardia and hypotension indicate shock. sometimes a ruptured aneurysm. uu Temperature is elevated in gastrointestinal uu If no, consider most other causes. perforation and often normal in bowel ll How severe is the pain? obstruction. uu Severe pain (perforated viscus, kidney stone, ll In women, assume pregnancy until proven peritonitis, pancreatitis) otherwise. Perform a pregnancy test, when available. uu Pain out of proportion to physical findings ll Listen to the bowel sounds. (mesenteric ischemia) uu Absence of bowel sounds is a sign of peritonitis or ll What pain relief medicine did you take? ileus. uu Strong pain relief medicine may interfere with the uu A high-pitched tinkling indicates obstruction. evaluation of the severity of the pain, but not with ll Palpate the abdomen. signs of severe peritonitis. uu Start away from the site of tenderness. ll Does the pain travel to any other part of the body? uu Check for masses and tumor. uu Right scapula (gallbladder pain) uu Determine the site of maximum tenderness. uu Left shoulder region (ruptured spleen, uu Check for abdominal rigidity. pancreatitis) ll Always examine the following: uu Pubis or vagina (renal pain) uu Groin for incarcerated hernia uu Back (ruptured aortic aneurysm) uu Rectum for signs of trauma, abscess, ectopic ll What relieves the pain? pregnancy, or distended pouch of Douglas u u u Antacids (peptic ulcer disease) u Pelvis in women who have lower abdominal pain EMERGENCIES uu Lying as still as possible with bent knees (when attendant is present) (peritonitis) uu Any other system that might be relevant (e.g., ll What other symptoms occur with the pain? respiratory and cardiovascular) uu Vomiting precedes pain and is followed by ll Look for abdominal distension: percuss to EMERGENCIES diarrhea (gastroenteritis) differentiate gas from liquid. uu Delayed vomiting, absent bowel movement, and nn Order laboratory examinations, when available.

326 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 327 16.2. Acute Abdominal Pain 16.2. Acute Abdominal Pain

ll Blood count—raised in intra-abdominal —PLUS— inflammation uu Gentamicin: 320 mg in one IV injection daily ll Urine analysis—for glucose, ketones, and white nn Avoid analgesia when possible because it may mask blood count progressive symptoms. ll Pregnancy test in all women of childbearing age Referral Management nn Stabilize general condition of the patient Nonpharmacologic nn Refer for more investigation or eventual need for nn Keep patient nil by mouth. surgery. nn Consider passing a nasogastric tube if patient has Prevention severe vomiting or signs of intestinal obstruction Refer patients who have a suspected acute abdomen to or if he or she is extremely unwell and in danger of surgical facility early for evaluation and monitoring. aspiration. Patient Instructions Pharmacologic nn Avoid the use of an analgesic before diagnosis of acute nn Apply oxygen as appropriate. abdomen or without advice of doctor. nn Start IV fluid in the case of shock (see section 16.9, nn Avoid the use of traditional medicine in all cases of “Shock”); cross-match blood and perform other tests. abdominal pain. nn Give antibiotics if you suspect systemic sepsis, peritonitis, severe urinary tract infection, or 16.2.1. Acute Peritonitis pyelonephritis. Give first-line treatment: ampicillin PLUS gentamicin. Refer after giving the first dose. Description Peritonitis is an acute, life-threatening condition, caused ll Children: by chemical or bacterial contamination of the peritoneal uu Ampicillin: Refer to table A4 in annex A for standard dosages. cavity. The treatment of peritonitis is treatment of —OR— the underlying cause. Major causes of peritonitis are In the case of penicillin allergy or sensitivity, use appendicitis, perforated peptic ulcer, strangulation erythromycin. Refer to table A12 in annex A for of bowel, pancreatitis, cholecystitis, intra-abdominal standard dosages. abscess, typhoid perforation of bowel, salpingitis, or —PLUS— postpartum infection. EMERGENCIES uu Gentamicin: 5 mg/kg/dose in one injection daily Diagnosis ll Adults: nn Sharp abdominal pain, worsens on movement or uu Ampicillin: 1 g IV every 6 hours coughing —OR— nn Abdominal distension

EMERGENCIES In the case of penicillin allergy or sensitivity, use nn Abdominal tenderness and muscle guarding erythromycin. Refer to table A12 in annex A for nn Diminished or absent bowel sounds standard dosages.

328 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 329 16.2. Acute Abdominal Pain 16.2. Acute Abdominal Pain

nn Tenderness on rectal or vaginal examination (pelvic of the distance along the line drawn from anterior peritonitis) superior iliac spine to the umbilicus). Management nn Any movement including coughing and extending the right leg may increase pain. Nonpharmacologic nn Most patients’ laboratory blood examination reveals nn Withhold oral feeding or oral treatment. high white blood cell count with increased neutrophils nn Insert a nasogastric tube. (more than 75%). Pharmacologic Management nn Start IV hydration with Ringer’s lactate solution or Treatment is surgery. normal saline (0.9%) solution. nn Start IV antibiotics: 16.2.3. Acute Cholecystitis ll Ampicillin (2 g) —PLUS— Description Acute cholecystitis is most commonly associated with ll Gentamicin (5 mg/kg) —PLUS— gallbladder stone and caused by obstruction of the cystic duct by gallstone. ll Metronidazole (500 mg) (available in CHCs and DHs) Diagnosis nn Refer. nn An acute attack is often precipitated by a large or fatty Referral meal. Refer all patients after stabilizing general conditions nn An attack is characterized by the sudden appearance and giving first dose of antibiotics. Referral will allow for of steady pain localized to the epigastrium or right diagnosis of the underlying cause and surgical treatment. hypochondrium that radiates to the right upper quadrant. 16.2.2. Acute Appendicitis nn Fever, nausea, and vomiting are present. nn Right upper quadrant tenderness is almost always Description present and is usually associated with muscle guarding Acute appendicitis is the most common general surgical and rebound tenderness. emergency. Early surgical intervention improves outcome. Management Diagnosis Treatment of choice is either early surgical removal of EMERGENCIES nn Pain that starts around the umbilicus and shifts to the gallbladder (within 72 hours) or conservative treatment right lower quadrant after few hours plus late surgical removal of gallbladder (after 6–10 nn Nausea and anorexia weeks). nn Looks ill and lies still on the bed EMERGENCIES Conservative treatment: nn The site of maximal pain and tenderness is most commonly at McBurney’s point (located one third nn Withhold oral feeding.

330 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 331 16.2. Acute Abdominal Pain 16.2. Acute Abdominal Pain

nn Start IV fluid alimentation. Diagnosis nn Give IV antibiotic. nn Abdominal pain that may be colicky ll Ampicillin: 1–2 g every 6 hours for 10–14 days nn In small bowel obstruction—mid-abdominal pain —PLUS— nn In large bowel obstruction—pain below the umbilicus ll Metronidazole: 500 mg every 6 hours for 10–14 days nn Vomiting—the more severe the bowel obstruction, the nn Give morphine for pain (when available). more frequent the vomiting nn Constipation and obstipation (i.e., absence of bowel 16.2.4. Perforated Peptic Ulcer movement and flatus) n Description n Abdominal distension—the more distal the bowel A perforated ulcer is a serious condition in which digestive obstruction, the more distended the abdomen juices and food leech into the abdominal cavity. Bowel obstruction is a clinical diagnosis, but it is greatly Diagnosis aided by plain erect X-ray. Distended loops of small bowel with air fluid level indicate a small bowel obstruction; nn Sudden onset of severe abdominal pain distended bowel and haustral marking indicate a large nn Intense burning pain in the upper abdomen after acute episode bowel obstruction. nn Extreme pain with any movement Management nn Extremely tender, rigid abdomen nn Stop any oral feeding or treatment (i.e., give nothing by nn Absent or reduced bowel sounds mouth). nn Free gas in the abdominal cavity on X-ray nn Start IV fluid. nn Septic shock developing later nn Insert a nasogastric tube. n Management n Refer for more investigation or surgery. Treatment is emergency surgery. 16.2.6. Ruptured Ectopic Gestation 16.2.5. Bowel Obstruction Description Description Refer to section 9.6 “Ectopic Pregnancy” for a description. Bowel obstruction can be mechanical or nonmechanical The major risk of ectopic pregnancy is rupture, which (paralytic ileus). can lead to intra-abdominal bleeding, shock, and death. nn Mechanical obstruction can be caused by adhesion Ruptured ectopic pregnancy is a surgical emergency. EMERGENCIES bands, strangulated hernia, volvulus, cancer, Diagnosis intussusception (especially in children), or bowel nn History of amenorrhea ischemia. nn Hypogastrium: sudden sharp and stabbing pain nn EMERGENCIES Nonmechanical obstruction is caused by peritonitis, nn Fainting, collapse with vomiting in childbearing spinal injury, drugs or medicines, or hypokalemia. women

332 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 333 16.2. Acute Abdominal Pain 16.3. Animal and Human Bites

nn Pain in the shoulder when lying down. commonly used (see conditions). (See section 11.1.1 nn Blood pressure falls gradually if bleeding is not “Acute Pyelonephritis.”) stopped. nn Give an antispasmodic medicine. nn Pregnancy test is positive. Referral nn Ultrasound may show fluid in abdomen. nn Complicated cases (e.g., sepsis, not relieved with Management medications) Treatment is emergency surgery. nn Need for more investigation nn Need for surgery 16.2.7. Ureteric Colic Patient Instructions Description Never use an analgesic before diagnosis of acute abdomen Ureteric colic is a pain associated with the passage or without advice of doctor. of a stone. It can be quite severe and requires prompt treatment. 16.3. Animal and Human Bites Diagnosis Description nn Loin pain radiates to groin and testes or labium or Animal bites may be inflicted by domestic animals such inner side of the thigh. as dogs, cats, or horses; or by wild animals. Most animal nn Pain is excruciating, and the patient moves about to try bites are provoked. Animals that bite without provocation to obtain relief rather than lying still. may have a greater risk of carrying rabies. Human bites are nn Renal angle tenderness is present. most often inflicted during fighting, including closed fist nn Coughing does not cause pain. injuries against an open mouth, which present a high risk nn Frequency of urination may be present. for finger joint injury. nn Patient may give previous history of passing calculus Animal or human bites may result in the following: in the urine. nn Infection, especially bites to the hand or foot, which nn Urine microscopic picture shows red blood cells and are often mixed with aerobic and anaerobic infections pus cells. nn Injury to a vital structure, such as a tendon, nerve, nn KUB (X-ray of Kidney, Ureter and Bladder) shows blood vessel, or joint; or to the cranium hydronephrotic changes (or stone). nn Tetanus (see section 15.3 “Tetanus”) n n Ultrasound is helpful. EMERGENCIES nn Rabies (see section 15.12 “Rabies”) Management Diagnosis In suspected acute abdomen: nn Look for puncture wounds, crush injuries, lacerations, nn Give patient nil by mouth. injuries to vital structures, and the presence of foreign nn EMERGENCIES Start IV fluid. body. nn Give antibiotics if you suspect systemic sepsis or nn Assess the amount of contamination and any signs of severe urinary tract infection. IV antibiotics are early infection such as redness, warmth, or pus.

334 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 335 16.3. Animal and Human Bites 16.3. Animal and Human Bites

nn Assess the patient for risk of tetanus, depending on his ll For an unimmunized or not fully immunized patient, or her immunization status (see section 15.3 “Tetanus” give 500 IU human tetanus immunoglobulin (or and chapter 19 “Immunization”). tetanus antiserum) IM, if needed (requires referral nn Assess the patient for risk of rabies, depending on type to DH). and history of bite (see section 15.12 “Rabies”). nn Give prophylactic antibiotics for 3–5 days (see table Management 16.3A) for— ll Cat bites—in any location Nonpharmacologic ll Human or animal bites to the hand n n The highest priority of early management is irrigation Note: Patients seen more than 24 hours after a bite and cleansing of the wound to prevent infection. Do a without any signs of infection usually do not need generous, gentle wash and irrigation of the wound and prophylactic antibiotic treatment. surrounding skin with clean water or normal saline nn Give therapeutic antibiotics for signs of cellulitis or and iodine solution. abscess; for wounds that are infected, antibiotics are nn Remove any foreign bodies. clearly indicated and should be continued for at least nn Generally speaking, do not suture bites because 2–3 weeks. (See tables 16.3A and 16.3B.) suturing increases the likelihood of infection. Referral ll Consider suturing only for large, relatively clean lacerations in highly cosmetic areas such as the face. nn Possibility of bite by animal with rabies (for vaccination) ll Bites more than 8 hours old should be treated with delayed primary closure (i.e., sutured at day 3 if nn Patient with high fever, sepsis, and spreading cellulitis sutured at all). nn Suspicion of joint penetration, the risk of which is high in a closed fist injury; tendon laceration; bone fracture; ll Consideration for suturing is best left to experienced clinician or referral center. presence of foreign body; and severe hand or foot Caution: Never suture lacerations over joints of the injuries. hand because penetration of the bite into the joint Prevention space is likely. nn Observe domestic animals or captured wild animals nn Apply a clean dressing. for 14 days for signs of rabies. Pharmacologic nn Clean and irrigate all bite injuries as soon as possible n after the accident. n Give paracetamol for pain. Refer to table A15 in annex EMERGENCIES A for standard dosages. Patient Instructions nn Give tetanus immunization if patient is not up to nn Return for wound check and dressing change in 48 date (see section 15.3 “Tetanus” and chapter 19 hours or sooner if any signs of infection (e.g., redness, “Immunization”). increasing pain, warmth, fever, pus) appear. EMERGENCIES ll Give prophylaxis with a booster TT (0.5 ml) IM injection, if needed..

336 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 337 16.3. Animal and Human Bites 16.3. Animal and Human Bites every every a

a every every a every 12 hours every a every 12 hours every a every 8 hours every a every 8 hours every 12 hours every a a every 8 hours every 8 hours every a a Dose 1 year: 0.8 ml/kg every 8 hours 0.8 ml/kg every 1 year: 5 months: ½ teaspoon

Alternative in Penicillin-Allergic Patient in Penicillin-Allergic Alternative US— US— ne 480 mg tablet every 12 hours ne 480 mg tablet every Clindamycin: 150–300 mg orally every 6 hours every 150–300 mg orally Clindamycin: 2 tablets (480 mg) every E ither co-trimoxazole: 12 hours 12 hoursa every 500 mg orally Ciprofloxacin: 6 hours every 150–300 mg orally Clindamycin: 2 tablets (480 mg) every E ither co-trimoxazole: 12 hours 12 hoursa every 500 mg orally Ciprofloxacin: 6 hours every 500 mg orally E rythromycin: 12 hours every 500 mg orally Ciprofloxacin: and children Infants 1 teaspoon 1–6 years: Children 2 teaspoons years: 6–12 Children 8 hours a 625 mg tablet every of Half and children Infants 1 teaspoon 6 months to 1 year: Children 1 teaspoon 1–6 years: Children 2 teaspoon years: 6–12 Children 2–6 months: ½ teaspoon Children 1 teaspoon 6 months to 5 years: Children 2 teaspoon years: 6–12 Children O 12 hours 12 hours n n n n n n n n n n n n n n n n n n n n —P L —OR— —P L —OR— —OR— n n n n n n n n n n n n n n n n n n n n —OR— —OR— Refer these cases. Refer Refer these cases. Refer Antibiotic Preferred Antibiotic(s) Preferred ablet: 625 mg (500 ablet: 480 mg Suspension: 156 mg/5 ml (125 mgSuspension: acid)amoxicillin/31.25 mg clavulanic T acid)amoxicillin/125 mg clavulanic 6 hours every mg/kg/dose 10–15 200 mg per 5 ml Suspension: mg per 5 ml 240 Suspension: T n n n n n n Amoxicillin/clavulanate: 250–500 mg Amoxicillin/clavulanate: 8 hours every orally Co-trimoxazole (sulfamethoxazole + (sulfamethoxazole Co-trimoxazole trimethoprim) Amoxicillin/clavulanic acid Amoxicillin/clavulanic Amoxicillin/clavulanate: 250–500 mg Amoxicillin/clavulanate: 8 hours every orally 250–500 mg Amoxicillin/clavulanate: 8 hours every orally E rythromycin —OR— n n n n n n EMERGENCIES Management of Wound Infections in Adults Following Animal or Human Bite Animal or Human Following in Adults Infections Wound of Management Management of Wound Infections in Children Following Animal or Human Bite Animal or Human Following in Children Infections Wound of Management EMERGENCIES reatment is required for 2–3 weeks. for is required reatment 2–3 weeks. for is required reatment Biting Species Biting Species Biting T T ne teaspoon = 5 ml Dog Human, clenched-fist Human, Human, occlusional Human, Dog Cat occlusional Human, Cat clenched-fist Human, ab l e 16.3A. ab l e 16.3B. O Ciprofloxacin is contraindicated in pregnant women and should be avoided in children when possible. in children avoided women and should be in pregnant contraindicated is Ciprofloxacin T Note: a T Note: a

338 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 339 16.4. Insect Bites and Stings 16.4. Insect Bites and Stings

nn Take antibiotics as instructed for as long as instructed. nn Clean the site with soap, water, and a gentle nn Limit your risk of provoking animal attacks and disinfectant. fighting. Pharmacologic nn Do not put any type of herbal or traditional medicine nn Give an analgesic: paracetamol. Refer to table A15 in on the wounds. annex A for standard dosages. nn In the case of severe itching, give— 16.4. Insect Bites and Stings ll Calamine lotion (topical) Note: Do not use calamine lotion for multiple stings. 16.4.1. Wasp and Bee Stings ll Oral antihistamine: chlorpheniramine. Refer to Description table A7 in annex A for standard dosages. Injury is caused by local reaction, envenomation, and nn Large local reactions may require a short course of anaphylaxis. Anaphylactic reaction to a bite or sting is therapy with glucocorticoids systemic corticosteroids a more common cause of death than direct effects of (hydrocortisone vial of 100 mg), by slow IV injection envenomation. ll Children—Adjust according to response after initial dose. Diagnosis uu Infant younger than 1 year: initially 25 mg every 8 nn In nonallergic individuals, single stings usually hours produce only localized effects of pain, warmth, uu Child 1–5 years: initially 50 mg every 8 hours redness, and swelling. Local effects are dangerous uu Child 6–12 years: initially 100 mg every 8 hours only if the airway is obstructed by the swelling (e.g., uu Child 12–18 years: initially 200 mg every 8 hours following stings on the tongue). Fatal systemic toxicity ll Adults: 250 mg/dose every 6 hours followed by 2–4 can result if the patient has been stung many times doses if needed (typically, more than 10). Clinical features of massive nn Anaphylaxis is treated with subcutaneous or IM envenomation are hypotension, vomiting, diarrhea, injection of epinephrine (adrenaline hydrochloride headache, and coma. epinephrine 0.1% in 1 ml ampoule). For dosages, see nn In allergic individuals, systemic symptoms include table 16.9C. tingling scalp, flushing, dizziness, visual disturbances, Caution: Patients should be observed for 24 hours for syncope, urticaria, wheezing, abdominal colic, recurrent anaphylaxis.

diarrhea, and tachycardia, which may develop within EMERGENCIES a few minutes of the sting. After 15–20 minutes Referral anaphylactic shock may appear (see table 16.9C). nn All patients who have a history of hypersensitivity and anaphylactic reactions Management nn Cases with signs of systemic envenomation

EMERGENCIES Nonpharmacologic nn All patients who have multiple stings (more than 10) nn Remove the embedded stinger using clean forceps. nn All complicated cases

340 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 341 16.4. Insect Bites and Stings 16.4. Insect Bites and Stings

Patient Instructions nn Send home patients who have single stings and no nn Return to health facility if you develop any systemic systemic signs of envenomation. signs or symptoms. Pharmacologic nn Do not apply any herbal or traditional medicine to the nn Give paracetamol for mild pain. Refer to table A15 in sting. annex A for standard dosages. nn Do not provoke insects, especially the nests. nn Give a local injection of lidocaine 1% anesthetic without epinephrine (i.e., without adrenaline) around 16.4.2. Scorpion Stings the bite for severe pain. Description nn If hypertension is present, manage with amlodipine or Afghanistan has many scorpion species, and they often hydralazine, when available (see section 6.1 “Systemic reside in dark, covered places. A scorpion has a stinger in Hypertension”). its tail. Referral Diagnosis nn Any patient who has severe local or any generalized Local symptoms nn Patient who has any signs of anaphylaxis—must be nn Stings leave a single mark monitored by health staff and accompanied with nn May be excruciating painful epinephrine (adrenaline) injectable nn Local swelling, redness, blister, and necrosis may occur nn Patient who has Brady arrhythmia Systemic Prevention nn Avoid contact with scorpions. nn Initial systemic signs and symptoms may include abdominal pain, hypersalivation, abnormal eye nn Do not walk barefoot outside the house at night. movements, profuse sweating, hyperthermia, nn Do not put your hand in holes and spaces where you vomiting, and diarrhea cannot see. nn Late manifestations may include hypertension, Patient Instructions cardiac arrhythmia, muscle twitching and spasm, nn Return to the health facility if your condition worsens seizure, respiratory problems, and rarely, shock or if you develop any systemic symptoms. Management nn Do not use traditional therapies on the sting site. EMERGENCIES Nonpharmacologic 16.4.3. Spider Bites nn Gently clean the wound with soap, water, and a Description disinfectant. Most spiders are nonvenomous or mildly venomous. Two nn Reassure the patient. EMERGENCIES main clinical syndromes are neurotoxic and necrotic. nn Apply cold packs to the sting site to decrease the nn Neurotoxic: muscle pain, hypertension, nausea, absorption of venom. vomiting, headache, sweating

342 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 343 16.4. Insect Bites and Stings 16.5. Snake Bites

nn Necrotic (brown recluse spider): tissue necrosis and nn Return to the health facility if you develop— ulceration, fever, malaise, and rarely, hemolysis ll Signs or symptoms of systemic effects Diagnosis ll Signs of local infection (e.g., increasing pain, redness, warmth, or pus) nn Skin lesions, varying in severity from mild localized erythema and blistering to quite extensive tissue nn Use insecticide sprays. necrosis may be present. 16.5. Snake Bites nn Systemic signs and symptoms may include weakness, headache, nausea, vomiting, muscle pain, or rash. Description Management Venomous snakes, such as the viper, cobra, and krait, and Nonpharmacologic nonvenomous snakes, such as the python and rat snake, nn Clean the bite with soap, water, and a disinfectant. live in Afghanistan. Snake bites can damage soft tissue, Apply a sterile dressing if needed. and injection of venom may cause two major types of nn Elevate and loosely immobilize the affected limb for syndromes: comfort, as needed. nn Neurologic disorders (cobra) with possible coma, Pharmacologic muscle weakness, respiratory compromise nn Bleeding or coagulation disorders (viper) with nn Give an analgesic for pain: paracetamol. Refer to table A15 in annex A for standard dosages. bleeding of gums, nose, and intestines nn Give an antihistamine: chlorpheniramine maleate. Diagnosis Refer to table A7 in annex A for standard dosages. nn Take a rapid, detailed history of the incident and the nn Administer tetanus prophylaxis if the patient not up to type and description of the snake. This information is date on immunization: TT (0.5 ml) IM injection. important for the management of the patient. Referral nn Ask when the snake bite occurred. Lack of symptoms at 6–12 hours indicates nonpoisonous snake, or a bite nn Patients who have signs of systemic effects: heart rate, elevated blood pressure, muscle weakness or spasm, without injection of venom. breathing problems, seizures should be referred. nn Look for puncture wounds or teeth marks. Poisonous snake bites are usually indicated by one or two fang nn Patients who have severe tissue necrosis may need late surgical excision. marks on the skin; multiple teeth marks suggest that Caution: Immediate surgical excision is not indicated the snake is not poisonous. EMERGENCIES and may be harmful. nn Look signs that venom has been injected: ll Soft tissue swelling, local pain, and perhaps blisters nn Pregnant patients should be evaluated to ensure the baby does not have any problems. all indicate injection of venom. ll Bleeding from gums, nose, and intestine, which EMERGENCIES Patient Instructions also indicate venom injection. If there is bleeding, nn Avoid spider bites by monitoring for spiders at home, at work, and in toilet areas.

344 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 345 16.5. Snake Bites 16.5. Snake Bites

check the coagulation by collecting 2–5 ml of blood, nn If coagulation is abnormal, continue to monitor daily waiting 30 minutes, then examining: until return to normal. uu Complete coagulation means no hemorrhagic Caution: Do not do any of the following: syndrome. ll Do not give the patient alcoholic beverages or uu Incomplete coagulation or no coagulation means stimulants. hemorrhagic syndrome. ll Do not apply ice. ll Weakness, difficulty breathing, difficulty ll Do not apply a tourniquet. swallowing, ptosis, or double vision (i.e., neurologic ll Do not suction the bitten area. The trauma to disorder) also indicates venom has been injected. underlying structures resulting from incision nn Check for the effects of venom. If venom was injected, and suction performed by unskilled people is not the severity of injury depends on species of snake, justified in view of the small amount of venom that quantity of venom injected, location of injury (i.e., head can be recovered. and neck bites are more dangerous), size of the snake, Pharmacologic and age of the patient (i.e., bites are more serious in nn Give TT (0.5 ml) IM if patient has not been fully children). immunized. nn Assess the patient’s mental status. Confusion or nn Give paracetamol. Refer to table A15 in annex A for restlessness may indicate a poisonous bite. standard dosages. nn Examine the snake, if the patient or caregiver has nn Refer if antivenom is needed. killed it and brought to the health facility, to determine what type it is. Referral n Caution: Be careful when handling any snake brought n Refer all venomous or suspected venomous snake in with the patient for identification. Even dead snakes bite patients as soon as possible to nearest hospital and severed heads can have a bite reflex for up to an for specific antidote (antivenom), if available, and for hour. supportive care for shock, bleeding, tissue necrosis, weakness, or respiratory compromise. Management nn Summarize the detailed history of the incident Nonpharmacologic indicating the type of snake (and description) on the nn Clean the wound with a nonalcoholic solution (i.e., written referral note and send it with the patient. clean water) and mild soap. Prevention EMERGENCIES nn Avoid traditional treatments. Caution family members and the community about nn Immobilize the patient and the bitten part in a neutral avoiding contact with snakes. position. Use anything stiff as a splint to immobilize the area (e.g., cardboard or wood). Patient Instructions nn EMERGENCIES Typically, if the snake bite is 6–12 hours old, and the nn Avoid manipulation of the bitten area. patient does not have symptoms, either the snake was nn Support respiration and circulation if necessary. nonpoisonous or no venom was injected.

346 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 347 16.6. Burns 16.6. Burns

nn Nonvenomous snake bites can still become infected, so The severity of burns is evaluated on the basis of surface, the patient should return if he or she develops signs of depth, and location of the burn, and associated injuries, the swelling, redness, increased pain, or fever. patient’s pre-existing medical condition or health status, and the age of the patient. 16.6. Burns nn Mild (minor) ll Partial thickness: less than 15% in adults Description ll Partial thickness: less than 10% in children Burns are thermal injuries caused by tissue contact with ll Full thickness: less than 2% hot substances, flame, caustic chemicals, electricity, or nn Moderate radiation. Thermal injury may compromise the ability of ll Partial thickness: 15–25% burns in adults skin to serve as a barrier to injury and infection, and as a ll Partial thickness: 10–20% in children temperature and fluid regulator. ll Full thickness: 2–10% The depth of burn wound is classified by degree and by nn Major partial versus full thickness burn. ll Partial thickness: more than 25% in adults nn First degree—superficial, partial thickness ll Partial thickness: more than 20% in children ll The affected area is red, painful, and without ll Full thickness: more than 10% blisters. ll Burns involving face, eyes, ears, feet, hands, ll The burn heals rapidly, in 5–7 days, by perineum epithelialization without scarring. ll All inhalation and electrical burns nn Second degree—deep, partial thickness ll Burns associated with other major injury or pre- ll The affected area is mottled, red, painful, and with existing medical conditions blisters. Diagnosis ll The burn heals by epithelialization in 14–21 days nn Take a careful history paying attention to the time and causing pigmentation changes and some scarring. nature of the accident. Take note of— nn Third degree—full thickness ll Whether smoke was present ll The affected area is charred, parchment-like, ll Whether the accident occurred in an enclosed space painless and insensitive, with thrombosis of ll What kind of clothes were worn by the patient superficial vessels. ll What first aid was given l l A charred, denatured, insensitive, contracted full- EMERGENCIES nn Examine the patient, looking for signs of an inhalation thickness burn is called “eschar.” burn: ll These wounds must heal by re-epithelialization ll Soot or carbon around mouth or nose from wound edges or by skin grafting. ll Swelling of oral or pharyngeal tissues nn Fourth degree—complex, full thickness ll EMERGENCIES Respiratory difficulty or dyspnea ll The affected area involves injury to the underlying nn Record the extent and distribution of superficial and tissues, muscles, bones, or brain. full-thickness burns. The best guide to the depth of

348 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 349 16.6. Burns 16.6. Burns

Table 16.6. Rule of Nines (Wallace’s Rule of Nines) nn Examine the patient to exclude other injuries or pre- Body Part Adult Children Infants existing medical conditions. Head and neck 9% 18% 20% Management The goals of management are to— Front of chest 9 × 2 = 18% 18% 10 × 2 = 20% and abdominal nn Assess the severity of the burn, provide emergency wall treatment, and refer all but minor burn injuries (i.e., Back of chest 9 × 2 = 18% 18% 10 × 2 = 20% involving less than 5% of body surface that do not and abdominal include sensitive areas of hands, feet, face, perineum). wall nn Minimize the risk of infection of minor burns during Lower limb 18 × 2 = 36% 13.5 × 2 27% 10 × 2 = 20% healing process. Upper limb 9 × 2 = 18% 18% 10 × 2 = 20% Nonpharmacologic Perineum 1% 1% nn Take the patient away from the accident place. Total body 100% 100% 100% nn Check the patient’s airway, breathing, circulation, surface area disability, and extremities—the A-B-C-D-E protocol. nn Remove all the patient’s clothing, and check him or her the burn is found by taking of accurate history of the from head to toe. mechanism of the burn. nn Remove all the patient’s jewelry, particularly rings. ll Thermal burns with gases usually cause superficial nn If the extent of the burn is less than 20% of total body burns. surface and the injuries are less than 1 hour, pour ll Thermal burns with liquid usually cause deep clean, cool water on the burn injury for 20 minutes to dermal burns. Boiling water and fat can cause full- diminish extent of injury. thickness burns (especially in infants). nn Cover the patient in a clean and dry cloth. Monitor for ll Contact with hot solids and flames usually cause hypothermia. full-thickness burns nn After giving medication for pain control (see ll Electrical burns usually cause full-thickness skin “Pharmacologic” below), gently clean the burn with loss. soap and clean (i.e., boiled and cooled) water or saline ll Radiation burns are usually superficial solution. ll Chemical burns may be superficial or deep nn Keep small blisters. Remove large blisters that are EMERGENCIES nn Estimate the total body surface area of the burn likely to rupture. using the “rule of nines” as outlined in table 16.6. The nn Apply a thin layer of silver sulfadiazine 1% cream, with information given in the table about the percentage daily dressing. of body surface burned will guide the health care nn Give oxygen if an inhalation burn is suspected.

EMERGENCIES worker in the management of the burn (see below). Caution: Refer patients who have suspect inhalation For scattered burns, the palm of the hand represents burns. approximately 1% of body surface.

350 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 351 16.6. Burns 16.6. Burns

nn For major burn injuries (i.e., more than 20% second or nn Apply clean dressing daily for those patients who third degree), begin fluid resuscitation (as associated have small burn injuries that are being treated at the with severe fluid loss) before referral: primary health facility. ll Set-up a reliable IV line and start IV fluid (i.e., Pharmacologic Ringer’s lactate with 5% glucose, normal saline with nn Prescribe appropriate medication including— 5% glucose, or half normal saline with 5% glucose). ll Adequate analgesia ll Calculate fluid requirements by adding maintenance uu Give oral paracetamol. Refer to table A15 in annex fluid requirements (100 ml/kg for the first 10 kg, A for standard dosages. then 50 ml/kg for the next 10 kg, thereafter 25 —OR— ml/kg for each subsequent kg) additional PLUS uu Ibuprofen tablet resuscitation fluid requirements (volume equal to –– Children: 5–10 mg/kg/dose orally every 8 hours 4 ml/kg for every 1% of surface burned). Sample as needed calculations are as follows: –– Adults: 200–400 mg orally every 8 hours as uu A child of 20 kg with a 25% burn, for example, needed needs maintenance fluid (100 ml × 10 kg + 50 ml Caution: Burn injury may increase the risk × 10 kg = 1,500 ml) PLUS resuscitation fluid (4 of gastritis or stress ulcer. Give H2 receptor ml × 20 kg multiplied by 25% of burn injury body antagonist (e.g., ranitidine 150 mg every 12 surface = 2,000 ml) = 3,500 ml to be given during hours), which is available in CHCs and DHs. the first 24 hours; half of this volume (1,750 ml) in ll If tetanus prophylaxis is needed or if the patient’s the first 8 hours and the rest in the next 16 hours vaccination status is not current, give TT vaccine following severe burn injury. IM injection (0.5 ml). uu An adult of 70 kg, for example, with a total body nn Pruritus is a common complaint in patients who have surface area burned of 20% needs maintenance healing burn wounds, and severe pruritis is extremely fluid (100 ml × 10 kg + 50 ml ×10 kg + 25 ml × 50 difficult to treat. kg = 2,750 ml) resuscitation fluid (4 ml × 70 PLUS ll Chlorpheniramine may prove helpful for itching. kg multiplied by 20 = 5,600 ml) = 8,350 ml in first Refer to table A7 in annex A for standard 24 hours; half of this volume (4,175 ml) must be dosages. given in the first 8 hours and the rest in the next Caution: Do not give chlorpheniramine to 16 hours. premature and infants younger than 1 month. EMERGENCIES uu During the second 24 hours, give half to three- ll Using a moisturizing cream may also help to quarters of the fluid required during the first alleviate itching. day, and monitor pulse, respiratory rate, blood nn Do not give antibiotics for the burn prophylactically, pressure, and urine output.

EMERGENCIES but reserve them for use later after referral. n n Insert a Foley catheter and monitor urine output to Note: Systemic antibiotics are rarely indicated for assess adequacy of fluid resuscitation. the treatment of small burns and may predispose the

352 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 353 16.6. Burns 16.7. Eye Injuries (Trauma, Foreign Bodies, and Burns)

wound to later opportunistic infection with bacteria, minor burn wounds, since they have been shown to fungi, or viruses. delay wound healing. Referral nn Normally, follow-up is performed in the clinic every week until the burn is fully healed and the patient nn Moderate and major burns (see classification) shows no evidence of complication. If there is some nn All second or third degree burns involving more than 5% body surface or involving sensitive areas of hands, question regarding the extent or depth of the wound, or feet, face, perineum, or joints. Give analgesia and fluid the reliability of the patient or his or her family, follow- resuscitation during transfer. up may be performed daily. nn At follow-up visit and as the burn heals, evaluate nn All cases with inhalation whether the patient will require skin grafting or nn Complications of small burns such as infection or loss of motion. physical therapy. Prevention 16.7. Eye Injuries (Trauma, Foreign Bodies, nn More than 90% of all burns are preventable by using and Burns) common sense and taking ordinary precautions. nn All caustics (e.g., gas balloons, fuel equipment, Description Sandalies [coal stoves], electrical equipment, and Injuries to the eye and surrounding structures can lead to chemical) should be carefully handled and kept out of loss of vision, loss of movement, or total blindness. Injuries the reach of the children. Avoid bare feet in winter. have multiple causes: nn Take care with children around fires, boiling water, and nn Blunt trauma—most often from a road traffic accident Bukhari. or an assault with an object or by a fist Patient Instructions nn Penetrating trauma (with or without foreign body) ll Superficial—limited to coverings of globe (i.e., the nn Advise the patient to follow the basic principles of keeping the burn wound clean and protected while it conjunctiva, sclera, and cornea) heals. ll Deep—penetrating the globe nn Burn injury nn Follow-up care includes daily— ll Direct thermal injury (e.g., from boiling water or ll Washing of the wound with bland soap and clean (i.e., boiled and cooled) water flame) ll l Chemical exposure l Patting the wound dry with a clean towel EMERGENCIES uu Alkali agent—a common agent in cleaning ll Applying a thin layer of silver sulfadiazine (1%) cream when available materials. Alkali may continue to damage tissue for a long period after the initial exposure. nn Instruct the patient not to apply powerful topical chemotherapeutic agents such as mafenide acetate uu Acid—contained, for example, inside car batteries EMERGENCIES (Sulfamylon®) or povidone-iodine (Betadine®) to and used for industrial purposes

354 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 355 16.7. Eye Injuries (Trauma, Foreign Bodies, and Burns) 16.7. Eye Injuries (Trauma, Foreign Bodies, and Burns)

Diagnosis uu Blood in the front of the eye may be in the anterior Trauma to the eye may present with pain, tearing, redness, chamber (i.e., a hyphema) and can lead to loss of photophobia, blurred vision, or sense of a foreign body in vision; refer urgently. or an irritation of the eye. The priority for evaluating eye nn Examine the surrounding soft tissue: injuries is to try to minimize long-term damage. Examine ll Check the eye lids for laceration, swelling, or a all structures of the eye and surrounding tissue as follows: foreign body. nn Globe and coverings ll Check the ocular muscles for normal eye movement. ll Always check for visual acuity. Loss of vision or Loss of normal eye movement may indicate muscle blindness requires urgent referral. injury or a fracture of the orbit with possible muscle uu Use the Snellen (eye) chart, or have patient read entrapment. or identify numbers; compare results in each eye. nn Gently palpate the bony orbit—orbital rims and uu Check for diplopia (i.e., double vision). cheek—to check for fracture. ll Inspect the globe and anterior structures for signs Management of injury. The goal of treatment is to preserve vision and eye uu Clouding of the cornea may indicate severe injury movement. or burn and requires urgent referral. Nonpharmacologic uu Corneal ulceration indicates severe injury and Use irrigation to remove a chemical or foreign body from requires urgent referral. the eye. ll Gently palpate each globe and compare one to the nn Chemical injury of the eye, from either a liquid or other. powder, may continue to cause damage long after uu If the globe of one eye seems flaccid (i.e., soft), exposure, so immediate removal of the chemical is suspect a penetrating injury to the globe with loss most urgent. If you see evidence of chemical powder or of vitreous fluid, and referurgently . liquid inside or around the eye, use this procedure to uu If the globe of one eye seems tense, suspect acute remove it. glaucoma or bleeding inside of globe, and refer ll Gently wipe away any chemical around the eye with urgently. a clean cloth before beginning irrigation. ll Inspect for evidence of a foreign body (e.g., wood, ll Use gentle irrigation of the eye with saline solution metal, dirt, or liquid or powder chemical). u or clean, sterile water for all cases of suspected u Ask the patient about recent incidents. EMERGENCIES foreign body or chemical burn. uu Examine the conjunctiva, including on the eyelid Chemical burn requires irrigation for at surfaces, for injury or a foreign body. Caution: least 20 minutes; irrigate for at least 40 minutes if ll Examine for evidence of blood you suspect an alkali burn. Alkali burns (i.e., from uu A patch of blood on the white of the eye may EMERGENCIES cleaning products) continue to cause injury for be subconjunctival hemorrhage and is often long after initial exposure and require prolonged associated with fracture of the orbit. irrigation to minimize long-term damage.

356 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 357 16.7. Eye Injuries (Trauma, Foreign Bodies, and Burns) 16.7. Eye Injuries (Trauma, Foreign Bodies, and Burns)

uu Gently hold the patient’s eyelids open, and irrigate nn All patients you suspect of having a deep injury or all areas of the eye. acute glaucoma uu Instruct the patient to move the eye into different nn refer immediately if you— positions. ll Cannot easily remove a foreign body (e.g., deep uu Be sure to irrigate under the eyelids. foreign body) uu Be careful to keep the run-off out of the other eye. ll Find acute change in vision in either eye (6/12 or nn If a foreign body is identified and was not removed by less on the Snellen chart) irrigation, try gently to remove it with a swab stick. ll Diagnose double vision (diplopia) ll Be careful not to irritate the eye or cause abrasion ll See lid laceration or edema with the swab. ll Encounter extreme swelling that prevents adequate ll If you are unable to remove the foreign body easily, examination refer. ll See scleral or corneal laceration or perforation Pharmacologic ll Find blood in the anterior chamber or intraocular hemorrhage nn Patients who have a suspected superficial irritation or injury to the eye may benefit from antibiotic ointment. ll See evidence of continuing subconjunctival bleeding Give tetracycline 1% eye ointment. Apply every 8 hours ll Find posttraumatic dilatation or a deformed and for 7 days. Show patient’s family member how to apply, slowly reactive pupil using this technique: ll Note a corneal defect or corneal opacity ll Encounter limitation of eye movement ll Ask the patient to look upward. ll Diagnose enophthalmos (i.e., eyeball appears sunken ll Gently retract lower eyelid with your fingers. or depressed), which may indicate orbital floor ll Apply one strip of ointment into the lower fornix. fracture ll Instruct the patient to move the eye to spread the ointment. Prevention nn Some patients may feel more comfortable (i.e., because Practice safety measures to prevent eye injury: of photophobia) with gentle eye patching for several nn Wear seat belts in vehicles. days. Apply as follows: nn Keep all chemical in a safe, secure place—away from ll Ask the patient to close the eye gently. children—and label them properly. ll Apply the patch over the closed eye with enough nn Use protective eye wear when using machinery. EMERGENCIES gentle pressure to keep the eye closed, but not Patient Instructions enough to put increased pressure on the eye. Advise the patient to— nn Give paracetamol for pain as needed. Refer to table nn Apply eye ointment as instructed. Demonstrate proper A15 in annex A for standard dosages. use to the health worker.

EMERGENCIES Referral nn Return for follow-up in 2 days nn All patients who exhibit a decrease in visual acuity nn Return immediately if he or she experiences increased pain, swelling, or loss of vision.

358 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 359 16.8. Hypoglycemia 16.8. Hypoglycemia

nn Always use a clean cloth and clean hands when Diagnosis examining or applying medicine around the eye. Signs and symptoms correlate with severity of hypoglycemia. Mild symptoms appear when blood glucose 16.8. Hypoglycemia levels fall below 60 mg/dl. Clinical features include the following: Description nn Hunger, pallor, anxiety, nausea, and blurred vision Blood glucose below normal range (60 mg/dl) can present nn Impaired concentration, headache, irritability, with mild, moderate, or severe features of hypoglycemia abnormal behavior, confusion, and decreased that can rapidly lead to altered consciousness and coordination irreversible brain damage. Risk factors for hypoglycemia nn Sweating, trembling, tachycardia, and abdominal pain include the following: nn Seizures nn Diabetic patients on treatment who have— nn Coma ll Decreased food intake Symptoms may be diminished in— ll Increased exercise nn Elderly, malnourished, or very ill patients ll Faulty medication or insulin administration because n of— n Patients who have long-standing diabetes nn Patients taking beta blockers or other medicines that uu Deficient glucose counter regulation impair autonomic nervous system response uu Impaired awareness of hypoglycemia Note: Impaired awareness may lead to nocturnal Management hypoglycemia. Obtaining blood glucose level with glucometer or ll Neonates or premature infants dextrostix may be useful to document the event and ll Malnourished or sick children or those with hyper- improvement, but treatment should never be delayed parasitemia (e.g., malaria) while waiting for a blood glucose test result. Successful ll Septic patients treatment results in a prompt response with full recovery ll The elderly in 10–15 minutes and serves to confirm the diagnosis— ll Patients who have kidney or liver disease (hepatic even without knowing the blood glucose level. failure) Nonpharmacologic ll Convulsing patients, unconscious patients, or Conscious patients who have mild, recognized symptoms patients in shock may respond to food intake, particularly starch and sugars. EMERGENCIES ll Patients who consume excessive amounts of alcohol ll Breast feeding infants: breast milk ll Patients who have an unrecognized endocrine ll Adults and children: milk, cheese, crackers, rice, disorder (e.g., Addison’s disease) or a tumor sweet tea (insulinoma) EMERGENCIES

360 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 361 16.8. Hypoglycemia 16.9. Shock

Pharmacologic Note: In patients without IV access or if dextrose (or Conscious patients who have significant symptoms should glucose) solution is not available, you may need to attempt receive concentrated glucose source. Those with altered to administer glucose by— consciousness require IV glucose. nn Nasogastric tube: dissolve 4 level teaspoons of sugar nn Conscious patients (20 g) in a 200 ml cup of clean water or milk ll Children: 2 teaspoons granulated sugar or honey nn Placing small amount of sugar in buccal sulcus by mouth. Repeat in 10 minutes if there is no nn Giving sugar syrup or honey (30 ml) rectally; this improvement. method has been reported to be successful l l Adults: 3 teaspoons of granulated sugar or honey Referral by mouth. Repeat in 10 minutes if there is no nn All cases with new onset or unexplained hypoglycemia improvement. nn Patients who have continued impaired consciousness, nn Unconscious patients nn Patients who have other neurologic deficits ll Children: dextrose 10%, 5 ml/kg IV rapidly (see table nn Patients who have serious medical conditions 16.8), then dextrose 10%, 3 ml/kg/hour until the nn Patients requiring adjustment or reevaluation of patient able to eat normally diabetic regimen or medicines ll Adults: dextrose 50% (or glucose 50%), 50 ml over 3 minutes IV, then dextrose 10% (or glucose 10%) Prevention and Patient Instructions solution, 500 ml IV every 4 hours until patient able Ensure proper adjustment of antidiabetic agents. to eat normally nn Advise diabetic patients who are on medication always Note: Alcoholic patients should receive thiamine to carry a source of glucose (e.g., sugar tablets or sweet 100 mg (if available) IV along with the 50% dextrose juice) with them to allow for prompt treatment of infusion. hypoglycemia when symptoms first appear. nn Counsel diabetic patients regarding the disease, Table 16.8. Volume of Glucose 10% Solution per Age and medication use, proper diet, and an exercise regimen. Weight in Children with Hypoglycemia nn Ensure proper monitoring of glucose in patients who Volume of 10% Glucose are at risk. Solution to Give as Bolus Age (Weight) (5 ml/kg) 16.9. Shock <2 months (<4 kg) 15 ml Description EMERGENCIES 2 to <4 months (4 to <6 kg) 25 ml Shock is a life-threatening condition caused by circulatory 4 to <12 months (6 to <10 kg) 40 ml failure with inadequate supply of blood flow to bring 1 to <3 years (10 to <14 kg) 60 ml required oxygen and nutrients to the tissues and to remove

EMERGENCIES 3 to <5 years (14 to <19 kg) 80 ml toxic metabolites. If not diagnosed and treated early, inadequate perfusion (shock) leads to vital organ failure and death.

362 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 363 16.9. Shock 16.9. Shock

Major categories and etiologies of shock: ll Decreased urine output nn Hypovolemic shock ll Excessive sweating ll Decreased blood volume: trauma, gastrointestinal ll Obtundation, confusion, lethargy bleeding nn Other signs and symptoms are specific according to ll Severe dehydration: diarrhea, hyperglycemic the type of shock (see table 16.9A). ketoacidosis, severe burns Management nn Cardiogenic or obstructive shock The goal of shock management is to restore peripheral ll Inadequate myocardial function: myocardial tissue perfusion and oxygenation. In the essential workup, infarction, valve disease, heart failure, cardiac identify type and the underlying cause of shock. contusion, toxins, pulmonary embolism, pericardial nn Perform the following tasks for initial stabilization tamponade, tension pneumothorax and rapid fluid resuscitation: Ensure the airway and nn Septic shock ventilation are adequate, then— ll An initial infectious insult that overwhelms the ll Establish a large-bore IV access. immune system (i.e., biochemical messengers may Note: Start at least 2 large bore (16–18 gauge cause vessel dilatation and circulatory collapse) needles) IV lines. nn Neurogenic shock ll Perform fluid resuscitation for hypovolemia or ll Spinal cord insults that disrupt sympathetic hypotension in noncardiogenic shock patients after stimulation to vessels and cause vasodilatation and first excluding a cardiac cause of the shock. circulatory collapse uu Dosages nn Anaphylactic shock –– Children: Give bolus 20 ml/kg (see table 16.9B) l l An antigen that stimulates the allergic reaction; may of normal saline (0.9%) OR Ringer’s lactate as result in decreased systemic vascular resistance and rapidly as possible and reexamine. Look for circulatory collapse signs of improvement: pulse slows, systolic ll May also be associated with airway obstruction blood pressure increases, and urine output from tracheal edema normalizes. If there is no improvement, repeat Diagnosis up to 3 times and reexamine after each bolus. nn Generalized shock has the following signs and Caution: Correct the dose to 15 ml/kg in symptoms: a malnourished child (see section 10.3 ll Hypotension (systolic blood pressure less than 80 “Malnutrition”). EMERGENCIES mmHg) ¡¡ If the child improves with fluid resuscitation, ll Decreased peripheral pulses give the treatment for severe dehydration ll Pale extremities, often cyanotic with poor capillary with Ringer’s lactate solution or normal

EMERGENCIES refill (i.e., refill time is longer than 3 seconds) saline (0.9%): 70 ml/kg over 5 hours for ll Tachycardia infants younger than 12 months and over 2 ll Tachypnea hours for children 1–5 years.

364 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 365 16.9. Shock 16.9. Shock

Table 16.9B. Volume IV Fluids by Age and Body Weight in Fluid Resuscitation of Children without Severe Malnutrition

Volume of Ringer’s Lactate Other Signs oss of rectal rectal of oss

L tone or Normal Saline Solution Age (Weight) (20 ml/kg) 2 months (<4 kg) 75 ml 2 to <4 months (4 to <6 kg) 100 ml 4 to <12 months (6 to <10 kg) 150 ml

Chest Exam Chest 1 to <3 years (10 to <14 kg) 250 ml Respiration and Respiration 3 to <5 years (14–19 kg) 350 ml Dyspnea, orthopnea or Dyspnea, chest pain, pressure, dull wheezes, rales, lung bases, S3 gallops hroat tightness, T hroat wheezing hoarseness,

—PLUS— ¡¡ Give ORS solution (about 5 ml/kg/hour) as Pulse soon as the child can drink. Reassess after 6 achycardia Narrow Strong Strong T Hypotension Hypotension with possible bradycardia hours and reclassify dehydration and choose plan A, B, or C to continue treatment (see section 2.1 “Diarrhea and Dehydration”). –– Adults: Give bolus 1 liter normal saline (0.9%) OR Ringer’s lactate rapidly and reexamine. Neck Veins Neck F lattened Distended Look for signs of improvement: pulse slows, systolic blood pressure increases above 100 mmHg, and urine output normalizes. If there is no improvement, repeat up to 3 times and reexamine after each bolus. uu If the patient shows no sign of improvement after arm, flushed, arm, flushed, rash, arm, flushed, 4 boluses with crystalloid, give blood if available Skin and Extremities Pale, cold, clammy cold, Pale, Cold, clammy, sweaty Cold, clammy, W hyperthermia, purpura, hypothermia, or petechial rashes W urticaria laccid paralysis F laccid (20 ml/kg over 30 minutes). EMERGENCIES ll Control bleeding with direct pressure over the wound or finger pressure to a proximal vessel or

Specific Signs and Symptoms According to Type of Shock Type to According Symptoms Signs and Specific pulse. ll Provide oxygen therapy. EMERGENCIES ll Insert a Foley catheter to assess urine output. Type of Shock of Type ll Hypovolemic shock Hypovolemic Cardiogenic shock Cardiogenic Septic shock Anaphylactic shock Anaphylactic Neurogenic Elevate the patient’s legs. ab l e 16.9A. T

366 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 367 16.9. Shock 16.9. Shock

ll Keep the patient warm. ll Immobilize a fracture, if needed. uu Use a splint for a long bone. uu Use a pillow and sheet wrap for pelvic fracture. uu Use a firm, padded board with cervical collar,

pillows, or sand bag for spinal fracture. Remarks nn Refer to table 16.9C for management of the specific types of shock. ailure” and 6.5 “Acute and 6.5 “Acute ailure” he vast majority of patients majority of T he vast of in shock because are bleeding) (i.e., ortrauma dehydration). diarrhea (i.e., See sections 6.2 “Cardiac F Infarction.” Myocardial shock in cardiogenic Patients medications available require center. only at a referral Referral All patients who are in shock should be referred to a higher level facility after emergency care and stabilization to follow up the shock treatment and treat the underlying cause of the shock. Before transfer, do the following: ll Control hemorrhage. ll Give fluids. Caution: Do not give fluids if patient is in cardiogenic shock. ll Initiate antibiotics in septic shock. ll Stabilize fractures. nn Patients in cardiogenic shock require medications available only at a referral center. Treatment Prevention nn Minimize morbidity of shock by recognizing hypovolemia early. Note: A decrease in blood pressure does not occur until at least 20% volume depletion in most patients. n n Treat shock early and aggressively. for patients in cardiogenic resuscitation fluid Do not perform minimal fluid. Patient Instructions EMERGENCIES Instruct the patient’s family to assist in the monitoring shock. Identify the source of volume depletion. volume of the source Identify to or finger pressure the wound over pressure the bleeding with direct Stop or pulse. vessel a proximal and table 16.9 B ). resuscitation (see instructions above fluid Give treatment. definitive for patient rapidly Refer an I V line. Start Give Caution: refer urgently. n n n n n n n n and safe transport of the patient. n n n n n n n n Management of the Specific Types of Shock Types the Specific of Management EMERGENCIES Shock Type of of Type Cardiogenic Cardiogenic shock Hypovolemic Hypovolemic shock ab l e 16.9C. T

368 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 369 16.9. Shock 16.9. Shock reat reat Remarks Remarks In the setting of severe severe the setting of In See section 15.6 “Sepsis.” Note: spinal cord many trauma, in shock injury patients are injury and missed of because an internal bleeding from site. T additional trauma shock. as hypovolemic ) ) continued continued ( ( Treatment Treatment US— US— EMERGENCIES Subcutaneous injection: 0.01 ml/kg/dose (maximum 0.5 ml); ml/kg/dose injection: 0.01 may Subcutaneous if the pulse is <140 3 times at 10-minutes intervals repeat at 3 times if necessary repeat may ml/kg/dose; IM injection: 0.01 pulse, and respiratory depending on blood pressure, 5-minute intervals, functions —OR— ® ® ® ® Adults: >30 ml/hour to table A4 in annex A for infection—refer severe Ampicillin dose of dosages. standard to table A13 in annex A for infection—refer severe Gentamicin dose for dosages. standard to table Refer metronidazole. infection, suspect a gastrointestinal you If dosages. standard A14 in annex A for contains 0.1% 1:1000 solution (vial 1 ml of epinephrine (adrenaline) Give 1 mg epinephrine) I V injection of a slow is inadequate, give circulation the patient’s If 1 ml with 9 of dilute one vial 0.1% solution (i.e., epinephrine 1:10,000 ml/kg. 1 ml/minute). Dose is 0.1 of at a rate normal saline and give itrate fluid to urine output. itrate l l l l l l Start aggressive crystalloid fluid resuscitation (see instructions above and resuscitation (see instructions above fluid crystalloid aggressive Start table 16.9 B ). T ml/kg/hour 0.5–1 Children: and, infection Consider the origin site of therapy. early antimicrobial Start of— the first dose give referral, before Refer. therapy. supportive Provide the spine. Stabilize and table 16.9 B ). resuscitation (see instructions above fluid Give response. allergic the body’s Reduce l l l l l l n n n n n n n n n —P L —P L n n n n n n n n n Management of the Specific Types of Shock Types the Specific of Management of Shock Types the Specific of Management EMERGENCIES Shock Shock Type of of Type of Type Anaphylactic shock Septic shock Neurogenic shock ab l e 16.9C. ab l e 16.9C. T T

370 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 371 16.9. Shock 16.10. Dislocation

16.10. Dislocation

Description Dislocation is defined as the total loss of contact between the two ends of bones. The cause of dislocation is most often trauma, but it can be with other causes Remarks (e.g., congenital hip dislocation). All dislocations are If the patient has If emergencies and need prompt reduction and early

Note: symptoms, asthma-like salbutamol (2.5–5 mg)give nebulization O Rby (5 mg/kg)aminophylline by over (i.e., I V injection, slowly at least 20 minutes). treatment to prevent complication. Children have a remarkable ability to heal fractures if the bones are aligned

properly. Diagnosis nn History of trauma (e.g., road traffic accident)

) nn Pain, deformity, swelling, and loss of joint movement Management Nonpharmacologic continued ( nn If the dislocation is accompanied by an open fracture, close the injury with a clean dressing. nn Immobilize the affected part and refer. Pharmacologic Treatment For pain relief, give an analgesic (e.g., paracetamol). Refer to table A15 in annex A for standard dosages.

16.11. Abscess

Description An abscess is a localized collection of pus in the skin or

Infants and children: Refer to table A7 in annex A for standard standard to table A7 in annex A for Refer and children: Infants up to 4 times daily if necessary dosages. Dose can be repeated <1 and children infants hours for 0.4 ml in 24 (maximum dose of year). (maximum total dose 40 mg if required Adults: 10–20 mg, repeated hours) in 24 —P LU S— 25 mg <1 year: Children 50 mg 1–5 years: Children 100 mg years: 6–12 Children 100–300 mg >12 years: Adults and children soft tissue. It is commonly caused by Staphylococcus EMERGENCIES – – – – – – – Antihistamine, such as chlorphenamine (vial of 10 mg per ml),Antihistamine, such as chlorphenamine (vial of I V by – – – I V injection: slow by such as hydrocortisone, Corticosteroids, – – – – injection over 1 minute injection over ® ® ® ® Maintain an open airway. breathing. restricted for mask to help compensate by oxygen Give feet. raising the the patient flat and laying by blood pressure Restore by giving: breathing, and improve of the air passages inflammation Reduce and table (see instructions above hypovolemia for resuscitation fluid Give 16.9 B ). aureus. Patients who have a compromised immune system l l l l l Stabilize vital functions. Stabilize l l l l l n

n (i.e., from diabetes, human immunodeficiency virus [HIV], malnutrition, or cancer) may have a mixed infection Management of the Specific Types of Shock Types the Specific of Management (e.g., gram-positive, gram-negative, anaerobes). Complex

EMERGENCIES wounds (e.g., bites, severe contamination) may also have Shock Type of of Type a mixed infection. The three types of abscess are the Anaphylactic shock (continued) ab l e 16.9C.

T following:

372 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 373 16.11. Abscess 16.11. Abscess

nn Simple abscess—originating in the dermis, hair patient adequate anesthesia. A local anesthetic follicles, or superficial skin glands field block (e.g., 1% lidocaine) circumferentially nn Complex abscess—originating in deeper tissue, most infiltratinguninfected tissue surrounding the commonly the breast or the perianal region abscess is effective. nn Cold abscess—a localized TB infection of soft tissue ll Perform the preliminary aspiration using an Diagnosis 18-gauge or larger needle to confirm the presence of pus. nn Local signs are most obvious when the abscess is superficial: ll Make an incision over the most prominent part of the abscess, or use the needle to guide your incision. ll Pain or tenderness Make an adequate incision to provide complete and ll Local warmth or heat free drainage of the cavity. An incision that is too ll Redness small may lead to recurrence. ll Shiny appearance ll Introduce the tip of sterile artery forceps into the ll Fluctuant mass, in mature abscess abscess cavity and gently open the jaws. Explore the nn A deep or complex abscess may present only with throbbing pain and not the other typical signs. cavity with a gloved finger andgently break down all septa. nn A cold abscess may present as a painless, fluctuant swelling without other signs. ll Extend the incision if necessary for complete drainage, but do not open healthy tissue or tissue nn If in doubt about the diagnosis, confirm the presence of pus with a needle aspiration using an 18-gauge needle. planes beyond the abscess. l Caution: Use for a superficial mass only. Avoid l Irrigate the abscess cavity with saline and drain or puncturing into the chest or abdominal cavity. pack open. The objective is to prevent the wound edges from closing, allowing healing to occur nn In the case of a patient who has a history of recurrent abscesses, screen for diabetes or immunodeficiency. from the bottom of the cavity upward. To provide drainage, place a latex drain or gauze wick into the Management depth of the cavity. Fix the drain or wick to the edge Nonpharmacologic of the wound with suture and leave in place until the nn During the early indurated stage that precedes the drainage is minimal, typically 2–3 days. suppurative (i.e., fluctuant pus collection) stage, apply ll Apply a large dressing to avoid further

warm compresses to the involved area every 6 hours. contamination. Change this dressing daily at the EMERGENCIES Compresses may help to prevent pus formation, may health facility. cause spontaneous drainage, or both. Pharmacologic nn Incise and drain a mature abscess. This procedure is nn Give paracetamol for pain. Refer to table A15 in annex the cornerstone of treatment.

EMERGENCIES A for standard dosages. : Do not incise and drain a cold abscess. Refer. Caution nn Give antibiotics only under certain conditions. The ll Prepare the skin with an antiseptic, and give the treatment of common abscess relies on incision

374 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 375 16.11. Abscess 16.12. Poisoning

and drainage of the pus, and not antibiotics. Special 16.12. Poisoning indications for giving antibiotics include the following: ll In the early stage of induration, before fluctuance Description and pus have collected A poison is a substance that causes harm if it gets into ll If the patient has large surrounding area of cellulitis the body through ingestion (e.g., drugs and medicines, ll In the case of fever or other systemic signs of caustics, and other dangerous substances), skin contact infection (e.g., pesticides), or inhalation (e.g., vapors, fumes, spray). ll If the lymph nodes are tender or swollen or if you Most poisoning in children is accidental, and prevention diagnosis lymphangitis is key. Poisoning may be intentional, self-inflicted, or both. ll If the patient has a compromised immune status Review the patient’s history of psychiatric illness. Suspect nn Give antibiotics, when indicated, for 7 days. poisoning in any unexplained illness in previously healthy ll Penicillin V tablet. Refer to table A16 in annex A for individuals. standard dosages. Diagnosis —OR— nn Take the patient’s history of exposure to poisonous ll Erythromycin tablet (for penicillin-allergic agents via ingestion, inhalation, or skin contact. patients). Refer to table A12 in annex A for standard Investigate details of exposure: dosages. ll Determine the agent, quantity, time of ingestion, and —PLUS— other people exposed. ll If you suspect an anaerobic infection (e.g., perianal ll Attempt to establish the exact agent involved by abscess), metronidazole. Refer to table A14 in annex inspecting the container or label, if available, and A for standard dosages. questioning witnesses. Referral ll Obtain warning information and recommended nn All patients who have a suspected cold (i.e., TB) poison procedures from container or label, if abscess. Refer without drainage of abscess. available. ll nn Complex abscess in a deep or critical site (e.g., thorax, Refer to reference sources regarding the identified abdominal cavity, pharynx, perianal region) agent (e.g., textbooks, drug tables) to determine if it presents a danger and to ascertain specific antidotes. Prevention nn Examine for signs and symptoms, which are varied and Advise the patient to practice good hygiene, sanitation, depend on poisonous agent. EMERGENCIES and nutrition. ll Check for emergency signs (e.g., obstructed Patient Instructions breathing, severe respiratory distress, cyanosis, Advise the patient to— coma, convulsion, and signs of shock such as cold nn Return for daily dressing hands, weak or fast pulse, and capillary refill longer EMERGENCIES nn Keep the area from additional contamination than 3 seconds). nn Maintain good nutrition ll Check for hypoglycemia.

376 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 377 16.12. Poisoning 16.12. Poisoning

ll Inspect for burns of the skin or about mouth and nose, which may be present with corrosive agents. ll Check for respiratory difficulty, stridor, or changes in speech, which may indicate an inhaled or aspirated agent.

ll Check for neurologic changes, parasympathetic induce Never activation, or both, which may be seen following

exposure by ingestion, skin contact, or inhalation to of level an altered Has or other consciousness that he or she reason the airway cannot protect ingested caustic, Has or petroleum corrosive, agents burn of evidence Has the nose or mouth around Cautions and Remarks Cautions l l l Caution: gastric or perform vomiting in a patient who— lavage l l l n

organophosphorous and carbonate compounds as n found in pesticides. Look for— uu Increased salivation uu Sweating uu Lacrimation uu Slow pulse uu Small pupils uu Seizures uu Muscle weakness, twitching, or paralysis uu Pulmonary edema uu Respiratory depression nn Many ingested agents cause nausea, vomiting, changes in level of consciousness, or a combination of the three. Management

Nonpharmacologic Management Nonpharmacologic a corrosive or a petroleum derivative or a petroleum a corrosive Never use salt as an emetic agent. It can be very can be very use salt as an emetic agent. It Never

The presentation for those poisoned is extremely varied, not

depending on causative agent. Treatment options follow hours earlier as only a few as he staff are familiar with the procedure T he staff are it safely T he staff can perform to vomit T he patient unable or unsafe W threatening life Is W in case the patient is available a suction apparatus sure Make vomits. position. down the patient in left lateral/head Place the tube tube to be inserted and ensure the length of Measure is in the stomach. only if — only se gastric lavage if the ingestion— only se gastric lavage ollow these steps to perform gastric lavage: these steps to perform ollow – – – – – – – – – U – – – U – – – F – – –

recommendations outlined in reference sources regarding ® ® ® ® ® ® dangerous. Induce vomiting by stimulating the back of the pharynx with soft the pharynx with soft stimulating the back of by vomiting Induce spoon or spatula. Caution: gastric lavage Perform o remove or eliminate a caustic agent— or eliminate a caustic o remove l l l T l l l

the specific agent. The BPHS approach emphasizes n EMERGENCIES —OR— n removal, neutralization, or dilution of the causative agent, if it can be done safely and in a timely fashion (see table

16.12A), supportive care, and referral. in a Poisoning Agent the Causative or Eliminating Removing In the case of ingested poisons, gastric decontamination by EMERGENCIES induced vomiting or gastric lavage is generally helpful only of Type

if it is performed within 2 hours of the ingestion—ideally Agent Causative Ingested poisons Ingested ab l e 16.12A. T

378 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 379 16.12. Poisoning 16.12. Poisoning erosene and other erosene K petroleum-based products Most pesticides Acids and alkaline cleansers and solvents (bleach) B attery acid Cautions and Remarks Cautions and Remarks Cautions l l l l ) ) Identify the causative agent the causative Identify to induce proceeding before gastric or perform vomiting agents Corrosive lavage. include the following: l l l l n n continued continued ( (

se cautiously andse cautiously

Nonpharmacologic Management Nonpharmacologic Management Nonpharmacologic Perform lavage with 10 ml/kg body weight of warm normal warm of with 10 ml/kg body weight lavage Perform returned should fluid lavage of saline (0.9%). T he volume should L avage fluid given. to the amount of approximate solution is clear of lavage until the recovered be continued particulate matter. – – 1 g/kg body weight <1 year: Children 25–50 g years: 1–12 Children g >12: 25–100 Adults and children U nausea. cause may Caution: Charcoal or other agent with if the ingested agent is a caustic with care to vomiting. contraindication ® ® ® ® ® ® If giving by nasogastric tube, be particularly careful that the tube is tube, be particularly careful nasogastric giving by If in the stomach. divided dose otherwise by as single dose when possible, Give amounts in the charcoal 30 minutes apart. Mix the following charcoal: of per gram water of 8 cc of proportion o neutralize the ingested agent, give activated charcoal, if available, if available, charcoal, activated the ingested agent, give o neutralize l l if the staff is experienced with if the staff is experienced only charcoal activated Caution: Give the procedure. T tube. T his action is advised only if the mouth or nasogastric by ingestion, when it is not possible hours of within two patient arrives no other contraindications. are and there vomiting, to induce is not indicated neutralization or charcoal vomiting W hen induced to dilute the or milk orally the patient clean water give or possible, ingested agent. l l n n EMERGENCIES n n Removing or Eliminating the Causative Agent in a Poisoning in a Poisoning Agent the Causative or Eliminating Removing in a Poisoning Agent the Causative or Eliminating Removing EMERGENCIES Type of of Type of Type Causative Agent Causative Agent Causative Ingested poisons Ingested (continued) poisons Ingested (continued) ab l e 16.12A. ab l e 16.12A. T T

380 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 381 16.12. Poisoning 16.12. Poisoning

within 1 hour. Likewise, neutralization of the ingested agent is advised only if the patient arrives within 2 hours of the ingestion, when it is not possible to induce vomiting and there are no other contraindications. Note: Often it is not possible to eliminate or neutralize the causative agent because the patient arrives at the health facility more than 2 hours after the ingestion. Cautions and Remarks Cautions ) Pharmacologic Attending staff should Attending to protect care take secondary from themselves wearing by contamination and apron. gloves nn Give oxygen if the patient is short of breath, has change in level of consciousness, or has had carbon monoxide continued

( exposure. nn The specific antidote for the poison should be given yes Injuries Injuries yes

based on label or reference recommendation, if available. Most cases will require transfer to higher level facility for specific therapies not available at BPHS level. nn For pharmacologic management of specific poisons, see table 16.12B. Referral nn Refer all patients suspected of significant poisoning to be observed for at least 6 hours. Observation may extend to 24 hours, depending on the poison exposure, distance from health facility, and other factors. Nonpharmacologic Management Nonpharmacologic nn Patients who have ingested corrosives or petroleum oreign B odies, and urns].”) oreign products should not be sent home without observation se soap and water for oily substances. for se soap and water

Removed clothing and personal effects should be stored should be stored clothing and personal effects Removed for 6 hours. Corrosives can cause esophageal burns, ipe away any liquid or powder agent with a dry, clean cloth. agent with a dry, liquid or powder any ipe away rauma, F rauma, which may not be immediately apparent. Petroleum or eye exposure, rinse with clean water or normal saline for at or normal saline for rinse with clean water exposure, or eye T safely in a see-through plastic bag that can be sealed for later plastic bag that can be sealed for in a see-through safely cleansing or disposal. Remove all the patient’s clothing and personal effects. all the patient’s Remove Note: W of tepid copious amounts with flush all exposed areas T horoughly U water. alkali 20 minutes—longer for at least for with clean water Irrigate hours after many damage for to cause agents, which continue exposure. F that alkali agents), taking care 20 minutes (40 for least (See section 16.7 “ E eye. does not enter the other run-off [ and upper airway swelling cause irritant gases may of Inhalation pneumonia. and delayed obstruction, bronchospasm, be support may and ventilation bronchodilators, Intubation, required. n n n n n n n EMERGENCIES n n n n n n n products, if aspirated, can cause pulmonary edema that may take some hours to develop. nn Transfer the following patients to next level referral Removing or Eliminating the Causative Agent in a Poisoning in a Poisoning Agent the Causative or Eliminating Removing hospital, when appropriate and when it can be done safely: EMERGENCIES Type of of Type ll Unconscious patient or patient who has a

Causative Agent Causative deteriorating level of consciousness Skin or eye Skin or eye to exposure poisonous agent Inhaled poisonous Inhaled agents or caustic ab l e 16.12A. T

382 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 383 16.12. Poisoning 16.12. Poisoning

Note: Keep unconscious patients in recovery position. ll Patient who has burns to mouth and throat ll Patient in severe respiratory distress ll Patient who has circulatory compromise ll Patient who has a significant ocular injury nn Refer all patients who have ingested poison vomiting. induce use activated vomiting induce activated give deliberately or may have been given the poison not not not not Cautions and Remarks Cautions Do Do when corrosives charcoal been ingested because have further cause doing so may damage to the mouth, esophagus, airway, throat, and stomach. Do Do inhalation because charcoal respiratory can cause with hypoxemia distress due to pulmonary edema or pneumonia. also is a risk. E ncephalopathy n n n n n Caution: Caution: intentionally. n n n n n Prevention nn Keep medicines, drugs, and poisons in properly labeled and identified containers Caution: Keep these substances out of the reach of children. nn Patients who have psychiatric problems or suicide risk should have early, supportive intervention. Patient Instructions nn Review late findings and complications of specific poison. Return if you experience danger signs. nn Advise parents on first aid in case a poisoning happens again in the future.

ll Do not make the child vomit if— Method Pharmacologic uu He or she has swallowed corrosives, kerosene, petrol, or petrol-based products uu The child’s mouth and throat have been burned uu The child is drowsy ll If other medicines, drugs, or poisons have been to dilute the corrosive as soon possible milk or water Give agent. referral mouth and arrange the patient nothing by give Afterward, esophageal damage to check for review surgical for if necessary or rupture. n n Specific treatment includes oxygen therapy if patient exhibits therapy oxygen includes Specific treatment distress. respiratory taken, try to make the child vomit by stimulating the n n EMERGENCIES back of the throat. ll Take the child to a health facility as soon as possible,

together with detailed information about the Poisons Specific of Management Pharmacologic substance concerned (e.g., the container, label, Type of of Type EMERGENCIES sample of poisonous agent). Specific Poison Specific erosene leaches urpentine Sodium hydroxide hydroxide Potassium Acids B Disinfectants K T substitutes Petrol n n n n n n n n Corrosive compounds: Corrosive Petroleum Petroleum compounds: n n n n n n n n ab l e 16.12B. T

384 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 385 16.12. Poisoning 16.12. Poisoning induce not Do Cautions and Remarks Cautions and Remarks Cautions Caution: most because vomiting in petrol-based pesticides are solvents. does not charcoal Activated salts; therefore, bind to iron giving a gastricconsider if potentially toxic lavage taken were iron amounts of when patient cannot vomit recent. and ingestion was ). se

) ) continued continued ( ( Pharmacologic Method Pharmacologic Method Pharmacologic se nasogastric lavage or activated charcoal if charcoal or activated lavage se nasogastric Gastrointestinal features usually appear in the first 6 features Gastrointestinal Nausea, vomiting, abdominal pain, and diarrhea vomiting, Nausea, or stools or black vomit Gray drowsiness, hemorrhage, hypotension, Gastrointestinal poisoning and metabolic acidosis—in severe convulsions, Note: this time asymptomatic for hours. A patient who has remained antidote treatment. does not require probably or acidosis, hydrate to encourage high urine output. Refer to high urine output. Refer to encourage or acidosis, hydrate l l l hese agents can be absorbed through the skin, ingested, or T hese agents can be absorbed through inhaled. the skin as or washing irrigating the eye the poison by Remove appropriate. ingestion and within if poisoning is by charcoal activated Give the ingestion. 1 hour of (i.e., activation parasympathetic excess the child has signs of If gastric disturbance, urination, defecation, teary eyes, salivation, (vial): atropine mg/kg IM injection 0.015–0.05 and emesis), give (maximum 1 mg), when available. is It muscle weakness. for pralidoxime the patient to receive Refer a chemical or pesticide poisoning by used as an antidote to treat a muscle disorder. a medicine used to treat or by (insect) spray U vomiting. ingestion, induce patient seen within 1 hour of If cannot induce if you charcoal or activated lavage nasogastric vomiting. the antidote, methionine or patient to receive Refer failure. liver to prevent acetylcysteine, 150 mg/kg or of paracetamol a dose of ingestions of for Refer hospitals). (to regional more rapidly they because children T his agent can be serious in young the to suffer likely more consequently acidotic and are become Aspirin causes of toxicity. effects system nervous central severe and tinnitus. vomiting, breathing, acidotic-like U vomiting. Induce vomiting. cannot induce you F sodium bicarbonate, vitamin K (e.g., further therapy hospital for poisoning: iron of clinical features Check for ingestion. if <2 hours from vomiting Induce of consideration to hospital symptomatic patients for Refer antidote therapy. l l l n n n n n n n n n n n n n n n n n n n n n n n n n n n n EMERGENCIES Pharmacologic Management of Specific Poisons Specific of Management Pharmacologic Poisons Specific of Management Pharmacologic Type of of Type of Type EMERGENCIES rganophosphorous rganophosphorous Specific Poison Specific Poison Specific rganophosphorous rganophosphorous O malathion, (e.g., TE PP, parathion, mevinphos) Carbamates methiocarb (e.g., and carbaryl— pesticides) n n O and carbamate compounds: acidAcetylsalicylic (aspirin) and other salicylates Paracetamol Iron n n ab l e 16.12B. ab l e 16.12B. T T

386 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 387 16.12. Poisoning 16.12. Poisoning

Cautions and Remarks Cautions and Remarks Cautions Patient can look pink but still Patient be hypoxemic. Naloxone hydrochloride may may hydrochloride Naloxone in the same be administered IM or subcutaneousdoses by injection, but only if the I V IM and is not feasible. route a have subcutaneous routes action. onset of slower ) ) continued continued ( ( ial is 400 micrograms (=0.4 mg)ial is 400 micrograms Pharmacologic Method Pharmacologic Method Pharmacologic Mild intoxication is characterized by euphoria, drowsiness, and euphoria, drowsiness, by is characterized Mild intoxication pupils. constricted bradycardia, hypotension, cause may intoxication Severe and respiratory pulmonary edema, coma, seizures, hypothermia, or arrest. depression gastric of Death is usually due to apnea or pulmonary aspiration content. dose in 2 Repeat body weight. 10 micrograms/kg Children: minutes if no response. 2–3 minutes up to of at intervals Adults: 0.4–2 mg repeated 10 mg. Question the diagnosis if respiratory a maximum of function does not improve. l l l l l Check for clinical features of narcotic poisoning: narcotic of clinical features Check for ventilation. and assist oxygen, give the airway, Protect and administer activated stomach lavage), (or vomiting Induce if can be done safely. charcoal, a specific opioid antagonist, if naloxone, patient to receive Refer and higher). V (in DHs available I V injection: per ml. Dosages by l l l l l n n n n Give 100% oxygen to accelerate removal of carbon monoxide until carbon monoxide of removal to accelerate 100% oxygen Give disappear. hypoxia signs of lumazenil is a benzodiazepine receptor specific antagonist receptor is a benzodiazepine F lumazenil 2 minutes (to 0.2 mg/kg I V over and higher). Give in DHs (available 2 mg).a maximum dose of n n n n EMERGENCIES Pharmacologic Management of Specific Poisons Specific of Management Pharmacologic Poisons Specific of Management Pharmacologic Type of of Type of Type EMERGENCIES Specific Poison Specific Poison Specific Carbon monoxide Carbon monoxide poisoning opioids Narcotics: morphine, heroin, (e.g., tramadol, codeine, propoxyphene) opioids Narcotics: morphine, heroin, (e.g., tramadol, codeine, propoxyphene) [continued] B enzodiazepines ab l e 16.12B. ab l e 16.12B. T T

388 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 389 17.1. Febrile Convulsion 17.1. Febrile Convulsion

Diagnosis Chapter 17. SIGNS AND SYMPTOMS nn Always check the child younger than 5 years for danger Signs and Symptoms signs per IMCI flipchart. nn Look for a temperature 38.5°C or higher. 17.1. Febrile Convulsion nn Seizure is typically tonic-clonic and may be associated with loss of consciousness and bowel or bladder Description control. A febrile convulsion is a seizure triggered by a high fever nn Establish cause of fever and of seizure. SIGNS AND SYMPTOMS (38.5°C or higher). It typically occurs between the ages ll Viral infection (e.g., viral pharyngitis) of 3 months and 5 years in the absence of detectable ll Bacterial infection— central nervous system (CNS) infection. Generally, febrile uu Intracranial: meningo/encephalitis or brain convulsion has an excellent prognosis. abscess nn A febrile convulsion may be simple or complex. uu Extracranial: upper respiratory tract infection, ll Simple febrile convulsion acute otitis media, bacterial pharyngitis, or uu A single, generalized seizure usually occurs at urinary tract infection beginning of febrile condition. ll Metabolic: hypoglycemia uu Seizure lasts 2–3 minutes and always less than 15 ll Malaria minutes. uu No associated neurologic defect is found. Management uu Often the family has a history of febrile seizures. The goals of management are to maintain the airway, stop uu Typically, the convulsion does not recur, has a the seizure, control the fever, and identify and treat the good prognosis, and not associated with epilepsy. cause of the fever. ll Complex febrile convulsion Nonpharmacologic uu It may be focal, recurrent, or both. nn Maintain the airway. uu Seizures last more than 10 minutes. ll Turn the child on his or her side to avoid aspiration. uu Residual neurologic abnormality, subsequent ll If the lips or tongue are blue, open the child’s mouth epilepsy, or both are found. and ensure that airway is clear. Give oxygen. uu It is associated with intracranial infection or ll Clear secretions. other CNS problem. ll Do not give anything by mouth to patient while he or nn The problem is to differentiate the simple febrile she is convulsing. convulsion (due to fever) from the convulsion nn Protect from injury. associated with the following: ll Prevent from falling or local trauma. ll Serious intracranial disease (e.g., meningitis) ll Protect tongue from biting. ll Extracranial disease, such as pneumonia, viral nn Lower fever. disease, or malaria, or a specific infection such as ll Remove the child’s clothing. urinary tract infection and hypoglycemia

390 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 391 17.1. Febrile Convulsion 17.1. Febrile Convulsion

ll

Sponge with cool, damp cloth (i.e., give a tepid shows no improvement after 48 hours of treatment, SIGNS AND SYMPTOMS sponge bath). give the second choice: amoxicillin. Refer to table A3 nn Encourage fluids once the patient has recovered from in annex A for standard dosages. the seizure. —OR— Pharmacologic ll In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 in annex A for nn First priority: treat the seizure with diazepam. Caution: Treat only if the patient is still having standard dosages. nn Avoid or treat low blood sugar (hypoglycemia) with SIGNS AND SYMPTOMS seizure. If the seizure has stopped, control the fever. sugar water or breastfeeding in infants. ll Give diazepam: 0.5 mg/kg/dose, rectally. Repeat once in 10 minutes if seizure continues. Referral ll Follow this administration procedure: nn All first attack of convulsions and atypical types (e.g., uu Draw the appropriate amount of diazepam recurrent seizures, full consciousness not regained solution using a TB syringe or insulin syringe. after seizure) should be immediately referred to Refer to table A9 in annex A for standard dosages. hospital for more investigation. uu Take out the needle and insert the syringe 4–5 cm nn All children younger than 5 years who have suspected into rectum before emptying. meningitis or encephalitis, IMCI general danger uu Squeeze buttocks together for 2–3 minutes. signs, or signs of severe disease should be referred nn Second priority: treat the fever with paracetamol until after stabilization and initial dose of treatment of the fever subsides. Refer to table A15 in annex A for antibiotics: ampicillin PLUS gentamicin. (Refer standard dosages. to tables A4 and A13, respectively, in annex A for ll If the child is unable to eat, give the paracetamol standard dosages.) through nasogastric tube. Prevention Caution: Do not give aspirin to children younger Prevent high fever (38.5°C or higher) in children, than 5 years because of the risk of Reye’s syndrome. especially those with history of febrile convulsion, by nn Third priority: treat the infection, which is the cause giving a tepid sponge bath and paracetamol. of the high temperature. When a bacterial illness is suspected and there are no general danger signs Patient Instructions or signs of severe disease, appropriate antibiotic nn Encourage the mother or caregiver to continue feeding treatment should be given according to diagnosis. If the fully conscious child. you diagnose an upper respiratory tract infection or nn Avoid recurrent fever by giving a tepid sponge bath and urinary tract infection— paracetamol. nn Place patient in a warm but well-ventilated place. ll Give co-trimoxazole. Refer to table A8 in annex A for standard dosages. Remove patient’s excess clothing. Cover patient with —OR— only a sheet or other light covering. If the patient feels cold, then cover him or her lightly. ll If the patient has an allergy to co-trimoxazole or

392 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 393 17.2. Cough 17.2. Cough

nn ll

Advise the family to bring the child back after 2 days Convulsions of recent onset SIGNS AND SYMPTOMS for re-evaluation. ll Lethargy or loss of consciousness nn Advise the family to bring the child back immediately ll Chest in-drawing if new symptoms arise or the child’s condition ll Stridor in a calm child worsens. ll Pneumonia in an infant younger than 2 months nn Look for other respiratory findings: 17.2. Cough ll Dyspnea: an awareness of breathlessness ll Rapid breathing SIGNS AND SYMPTOMS Description uu Infants 0–2 months old: more than 60 or more Cough is a pulmonary reflex most often caused by breaths per/minute irritation of the respiratory system due to infection, uu Infants 2–11 months old: more than 50/minute foreign body, or chronic disease. Cough is a common uu Children 1–5 years old: more than 40/minute sign in children and adults. Cough is often mild and ll Cyanosis, grunting, nasal flaring, neck swelling, self-limiting (common cold). Cough may, however, be an stridor, lower chest wall in-drawing (children), or an indication of serious or life-threatening disease. Cough inability to feed may be a sign of an acute condition (e.g., acute respiratory nn Associated conditions include the following: infection, foreign body, pneumonia, asthma, or lung edema ll Common cold or flu from cardiac failure) or a sign of chronic condition (e.g., ll Pneumonia: fever, purulent sputum, crackles, TB, chronic obstructive pulmonary disease, or carcinoma). decreased breath sounds, dullness to percussion Diagnosis (consider pleural effusion or empyema) nn Take a history to determine duration of cough and ll Wheezing—may be associated with asthma, or as a associated findings: complication of pneumonia, bronchiolitis, croup, ll Investigate a persistent cough of more than 2 weeks. other pulmonary diseases, or the pulmonary phase ll Look for sputum production, fever, and vomiting. of worm or parasite infestation (i.e., Loeffler’s ll Assess the character of the cough (i.e., sporadic, syndrome) constant, paroxysmal “whooping cough”). ll Heart failure—fluid in the lungs may trigger cough ll Ask about the patient’s exposure to TB patient or ll Stridor—a harsh noise during inspiration due to person with other infectious disease. narrowing of major air passages caused by— ll Determine the patient’s immunization history. uu Foreign body aspiration or trauma nn Do an examination, especially in children younger uu Edema from: viruses (e.g., croup or measles), than 5 years. Refer to IMCI flipchart and look for diphtheria, pertussis, retropharyngeal abscess, or danger signs of severe disease and signs of severe anaphylaxis pneumonia such as the following: Management ll Inability to drink or breastfeed Determine cause of the cough and associated conditions. ll Uncontrolled vomiting Provide emergency care and referral for those presenting

394 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 395 17.2. Cough 17.3. Fever

Patient Instructions

with danger signs and signs of severe disease. Determine SIGNS AND SYMPTOMS risk for TB. Refer all patients who have had a cough for nn Practice good cough etiquette. more than 2 weeks for TB check. ll Turn head away from others. ll Note: Ensure there is no foreign body or laryngeal edema, Cough into clean cloth. n especially in patients who have stridor. n Maintain hydration and nutrition. nn Sip tea, warm water, or soup to help soothe the throat Nonpharmacologic and alleviate symptoms. nn Instruct the patient to maintain good hydration and nn Return in 5 days for check, or sooner if condition SIGNS AND SYMPTOMS nutrition; continue breastfeeding. worsens. nn Advise bed rest, as needed. nn Do not use cough suppressant or traditional medicine. Pharmacologic nn Give oxygen, as needed. 17.3. Fever nn Treat underlying diseases. Description Referral Fever is a frequent symptom, often linked to infection, but nn Pneumonia in infants younger than 2 months not always. Fever is defined as a body temperature higher nn All patients exhibiting danger signs or respiratory than 38°C (rectal) or 37.5°C (oral or axillary). Always distress; patients who have— look for signs of serious illness before trying to establish ll Severe pneumonia a diagnosis. Fever is a natural and sometimes useful ll Severe asthma response to infection. Fever alone is not a diagnosis. Fever ll Any condition that may be life-threatening (e.g., can cause pain, myalgia, arthralgia, headache, insomnia, foreign body) and convulsions in children. nn All suspects with exposure or symptoms of TB, particularly blood in sputum and cough more than Diagnosis n 2 weeks n Determine duration and pattern of fever. nn Determine whether the patient has any localizing signs nn Cough associated with loss of weight or growth faltering of infection to explain the fever. nn Carefully take the temperature. If you use a mercury nn Patients who have not improved with initial treatment thermometer, measurement should take at least 5 Prevention minutes. nn Isolate patients who have suspected pneumonia or nn If the patient is a child younger than 5 years, follow the other contagious disease. IMCI flipchart and look for signs of very severe disease nn Ensure proper immunization for all children (see (i.e., general danger signs are present). chapter 19 “Immunization”). ll Child refuses to drink or breastfeed. ll Child is abnormally sleepy or difficult to wake. ll Child is unconscious.

396 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 397 17.3. Fever 17.3. Fever

ll nn

Child has convulsions or has had convulsions. Consider causes that may not have localizing signs SIGNS AND SYMPTOMS ll Child vomits or has been vomiting persistently and ll Malaria—endemic area or travel in endemic area is at risk for dehydration. within the past 4 weeks, recurrent fever, jaundice, nn If the patient is a child younger than 5 years, follow the anemia (check malaria blood test) IMCI flipchart and look for signs of severe disease ll Septicemia—seriously and obviously ill with no ll Fast breathing (60 breaths/minute or more) in a apparent cause (purpura, petechia, shock in young child younger than 2 months of age infant, or severely malnourished child) ll Chest in-drawing: the lower part of the chest goes in ll TB SIGNS AND SYMPTOMS when the child breathes in ll Malignancy ll Hoarse noise when the child breathes in ll Endocarditis, rheumatic fever ll Lethargic, sunken eyes, unable to drink, skin pinch ll Brucellosis goes back very slowly nn Consider causes of fever that may be associated with ll Stiff neck a rash ll Clouded cornea or deep mouth ulcers ll Measles: typical rash ll Tender swelling behind ear ll Meningococcal infection: petechial or purpuric rash ll Visible severe wasting or edema of both feet ll Viral syndrome l l Severe palmar pallor Note: In neonates and the elderly, fever may be absent or nn Look for localizing signs to explain the fever and preceded by other symptoms such as confusion and failure diagnose problem. (Possible diagnoses are in to feed. parentheses.) Management ll Severe headache, stiff neck, coma (meningitis, sinusitis) All patients who have fever should be examined for signs and symptoms that will indicate the underlying cause of ll Severe throat pain (pharyngitis, abscess) the fever and should be treated accordingly. ll Ear or mastoid pain or pus (otitis media, mastoiditis) Nonpharmacologic ll Cough, lower chest wall in-drawing, fast breathing nn Place patient in a warm but well-ventilated place. (pneumonia) nn Remove patient’s excess clothing. ll Cough, cold (viral upper respiratory tract infection) nn Cover patient only with a sheet or other light covering. ll Abdominal pain, diarrhea, constipation nn Sponge the patient’s body with lukewarm water if the (gastrointestinal problem, peritonitis, typhoid) room temperature is higher than 40°C. ll Pain with urination, flank pain, or both (urinary nn If the patient feels cold and begins to shiver, then cover tract infection) him or her lightly. ll Pain of joint or limb (osteomyelitis, septic arthritis) nn Prevent dehydration. Encourage to increase oral fluid ll Localized pain, swelling, or fluctuance (cellulitis, intake or continue to breastfeed an infant. abscess)

398 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 399 17.3. Fever 17.4. Headache and Migraine

Pharmacologic Prevention SIGNS AND SYMPTOMS nn For children younger than 5 years presenting signs of nn Practice good hygiene and hand washing. very severe disease or severe disease, give the first dose nn Practice good cough etiquette (i.e., covering nose and of treatment as per IMCI flipchart, and referurgently mouth) to prevent possible airborne spread of diseases to hospital. such as upper respiratory infections, pneumonia, TB, nn Treat according to underlying cause (if identified). or measles. nn For a fever 38.5°C or higher, give paracetamol until Patient Instructions fever subsides. Refer to table A15 in annex A for nn SIGNS AND SYMPTOMS Check temperature regularly. standard dosages. nn Return to the clinic— Do not give aspirin to children younger than Caution: ll If new symptoms develop 5 years because of the risk of Reye’s syndrome. ll If the fever persists more than 3 days after beginning nn Give antibiotics, only if needed. of treatment ll Treat an identified cause of fever with appropriate nn If no underlying cause for the fever has been identified, antibiotic(s). return within 2 days. l l Do not treat an unidentified cause of fever with Note: Keep the patient close by for 48 hours if it is antibiotic(s). difficult for him or her to return. Referral nn All neonates 17.4. Headache and Migraine nn All children younger than 5 years who have signs of very severe or severe disease (IMCI). 17.4.1. Headache nn All patients who have signs of possible severe disease or fever combined with signs of meningitis, jaundice, Description coma, confusion, convulsion, or malignancies Headache can be benign or serious. Headache can have serious underlying causes including the following: nn Children without known cause of fever lasting more than 3 days nn Encephalitis and meningitis nn Hypertension emergencies nn Patients who have signs of severe pneumonia nn Stroke nn Patients who have signs of deeps space infection or abscess—may require surgical drainage nn Mastoiditis and otitis media nn Brain tumor nn Toxic patients (i.e., patients who look very sick or are becoming sicker) nn Anemia nn Fever that recurs (i.e., went down but comes back) Diagnosis nn Patients who have severe abdominal pain or guarding Headache due to a serious disease will often be associated (i.e., signs of peritonitis) with neurological symptoms and signs including the following: nn Impaired consciousness

400 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 401 17.4. Headache and Migraine 17.4. Headache and Migraine

nn nn

Mood change Prevent the patient from working, sleeping, or SIGNS AND SYMPTOMS nn Visual disturbances participating in normal activities nn Confusion nn Pupillary changes and difference in size 17.4.2. Migraine nn Focal paralysis Description nn Convulsions A classic migraine headache is a lateralized throbbing nn Neck stiffness headache that occurs episodically following its onset in nn Vomiting SIGNS AND SYMPTOMS adolescence or early adult life, although not all headaches nn Fever that are throbbing in character are of migrainous origin. Tension headache due to muscle spasm and migraine (see Patients often give a family history of migraine. Attacks section 17.4.2 “Migraine”) are common benign headaches. may be triggered by emotional or physical stress, lack Management or excess of sleep, missed meal, specific foods (e.g., The goals of management are to determine the cause chocolate), alcoholic beverages, menstruation, or use of and treat as well as to provide symptomatic support for oral contraceptives (see chapter 18 “Family Planning”). common benign headache: Diagnosis nn Teach relaxation techniques. nn Headache, usually pulsatile nn Advise patient to increase fluid intake. nn Nausea, vomiting, photophobia, and phonophobia nn Give oral paracetamol. Refer to table A15 in annex A nn May be transient neurologic symptoms (commonly for standard dosages. visual) Referral Management nn Suspected meningitis; refer immediately after initial treatment (see section 7.2 “Encephalitis and Nonpharmacologic Meningitis”) Advise the patient to avoid any precipitating factors. nn Headache in children lasting for 3 days Pharmacologic nn Headache with neurological manifestations Pharmacologic management encompasses both nn Newly developed headache persisting for more than 1 prophylactic treatment and treatment of acute attacks (i.e., week in an adult symptomatic treatment). Patient Instructions nn Treatment of an acute attack: Patient should consult the health facility when ll Aspirin 300–900 mg every 4–6 hours when headaches— necessary Do not give aspirin to children younger nn Occur more frequently than usual Caution: than 5 years because of the risk of Reye’s syndrome. nn Are more severe than usual nn Worsen or do not improve with appropriate use of —OR— paracetamol

402 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 403 17.5. Jaundice 17.5. Jaundice

ll

Paracetamol. Refer to table A15 in annex A for life, and all other causes have been excluded. All other SIGNS AND SYMPTOMS standard dosages. presentations of neonatal jaundice should be referred to —OR— prevent complication of kernicterus (i.e., hyperbilirubin ll Ibuprofen (tablet 400 mg): 1 tablet every 6 hours in of the brain), which may cause mental disorders or death. adults when necessary All cases of jaundice in children and adults are abnormal —PLUS— and should be referred for proper testing and treatment ll Treatment with extra-cranial vasoconstrictions: of possible causes: hepatitis, biliary tract obstruction or caffeine 100 mgPLUS ergotamine tartrate 1 mg: 1 disease, hemolysis, or severe infection. SIGNS AND SYMPTOMS or 2 tablets at the onset of headache, followed by 1 Diagnosis tablet every 30 minutes, if necessary, up to 6 tablets nn Physiologic neonatal jaundice occurs in more than per attack and 10 tablets per week (not available in 50% of normal newborns and more than 80% of BPHS facilities). premature babies. To diagnose physiologic and mild nn Prophylactic treatment: prophylactic treatment may jaundice look for the following evidence: be necessary if migraine headaches occur more than ll The condition presents 2–5 days after birth, is 2–3 times a month and disturb normal life. Treatment resolved by 14 days, and is very mild. will be given by a specialist, which will require referral. ll With your finger, gently compress the skin on the The following are typically prescribed: baby’s forehead. When you remove your finger, the ll Propranolol 80–240 mg (usual adult daily dose) imprint will be slightly yellowish instead of white. (available in DH) nn Nonphysiologic or abnormal neonatal jaundice will ll Amitriptyline 10–150 mg (available in CHCs and present with the following: DHs) ll Jaundice starts either in first 24 hours or after 13th ll Imipramine 10–150 mg (not available in BPHS day of life. facilities) ll Jaundice lasts for more than 2 weeks. ll Skin and eyes are a deep yellow. 17.5. Jaundice ll Yellow jaundice is obvious on the palms of the hands Description and soles of feet. Jaundice is a condition in which the skin, palms, and ll Convulsions or jitteriness in the newborn with eyes become yellow. It is the result of accumulation of jaundice may be an indication of bilirubin crossing bilirubin in the body tissue typically either from increased into the brain. production (hemolysis) or decreased processing (hepato- ll Evidence of infection, danger signs, or both may be biliary disease). Jaundice is not clinically recognizable present. until level of bilirubin is more than 3 mg/dl; normal is Caution: Jaundice is always abnormal in non- less than 1.2 mg/dl. Jaundice may be physiologic in the newborns, children, and adults. newborn when it presents in mild form at 2–5 days of

404 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 405 17.5. Jaundice 17.6. Chest Pain

Management nn

Abstain from alcohol consumption, which can lead to SIGNS AND SYMPTOMS Nonpharmacologic jaundice from hepatitis or cirrhosis in adults. Neonatal jaundice may benefit from phototherapy (i.e., Patient Instructions for physiologic jaundice) or exchange transfusion (i.e., for nn In newborns being treated at home, monitor closely for severe jaundice). Patients should be referred for diagnosis severity and complications. and treatment when possible. Normal breastfeeding nn Support breastfeeding, particularly for preterm should continue for infants. infants, who are at higher risk of developing jaundice

SIGNS AND SYMPTOMS Pharmacologic and of having complications of jaundice. nn Give antibiotics if you suspect neonatal infection. ll Treat as for sepsis (see section 15.6 “Sepsis”). 17.6. Chest Pain l l Refer. Description n n Give oral chlorpheniramine for itching if the diagnosis Chest pain (or chest discomfort) is a common symptom is known and there is no contraindication. that can occur as result of cardiovascular, pulmonary, l l Children: Refer to table A7 in annex A for standard pleural, esophageal, gastrointestinal, or musculoskeletal dosages. disorders; skin disease; or anxiety states. It may be l l Adults: 4 mg every 8 hours described as sharp, dull, or burning or as a sensation of Referral pressure. n n All adults and children for diagnosis and treatment The evaluation of the patient with chest discomfort must— options of jaundice nn Assess the safety of the immediate management plan nn All newborns with evidence of nonphysiologic nn Determine the diagnosis jaundice Diagnosis nn All newborns with evidence of physiologic jaundice, if possible, to assess bilirubin level and for full treatment To determine the cause of chest pain see table 17.6. options Management Prevention Nonpharmacologic nn Identify high-risk pregnancies for neonatal nn The most important issue is to eliminate a life- complication with proper antenatal care (see section threatening problem as the cause of the chest 9.1 “Pregnancy and Antenatal Care”) and deliver at pain, such as angina, myocardial infarction, or EPHS facility. pneumothorax. If one of those diagnoses seems nn Prevent complications of severe neonatal jaundice plausible, the patient requires urgent referral. with early referral of newborn. nn Otherwise, treatment of chest pain should be guided by nn Look for signs of sepsis and other causes of neonatal the underlying etiology. jaundice.

406 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 407 17.6. Chest Pain 17.6. Chest Pain

Pharmacologic SIGNS AND SYMPTOMS nn If angina or myocardial infarction is suspected, give acetylsalicylic acid (81–325 mg) prior to referral. Patient will need to go to hospital for evaluation and possible nitroglycerine therapy. nn If angina or myocardial infarction is suspected, and blood pressure is more than 160/100, give 1 tablet of Associated Features Associated nrelieved by rest and rest by nrelieved

captopril (25 mg) by mouth prior to referral, when ever SIGNS AND SYMPTOMS Precipitated by exertion, exertion, by Precipitated or stress to cold, exposure and rest by Relieved nitroglycerine U nitroglycerin with be associated May or heart failure of evidence arrhythmia Dyspnea Cough F crackles) (i.e., Rales Dyspnea sounds breath Decreased n n n n n n n n n n Relieved with food or with food Relieved antacids available. n n n n n n n n n n nn If esophagitis or peptic ulcer disease is suspected, give an antacid: aluminum hydroxide plus magnesium hydroxide, 2–4 chewable tablets by mouth. Referral nn All cases of suspected angina pectoris, myocardial ocation infarction, pneumothorax, or severe pneumonia L require urgent referral.

nn If you suspect myocardial infarction, transport with localized often nilateral, Retrosternal, often with often Retrosternal, to neck, jaw, radiation shoulders, or arms, frequently on the left health worker and oxygen, when possible. Similar to angina U the to the side of L ateral, pneumothorax E pigastric, substernal nn If treatment by antacid of a suspected esophagitis or peptic ulcer is not successful, refer for further investigation. Prevention

Often chest pain is the result of esophageal reflux or Quality disorder and may be helped by avoiding spicy and fatty food. Pressure, tightness, Pressure, heaviness, squeezing, burning lasting 2–10 minutes Similar to angina but often Similar to angina but often lasting often severe, more >30 minutes pain Sharp chest-wall respiration by aggravated onset; lasts several Sudden hours B urning Patient Instructions nn Patients who have mild symptoms should be lcer encouraged to document what activities seem to bring on the pain because the history is important in making the correct diagnosis. For example, are the symptoms associated with exertion, with food, or with coughing? Typical Clinical Features of Common Causes of Acute Chest Discomfort Chest Acute of Common Causes of Clinical Features Typical nn Patients who have mild and rare symptoms may have Condition trial of antacid therapy to see if it is helpful. Patients should return for reevaluation in all cases. Angina pectoris (see section 6.4) Acute myocardial infarction Acute myocardial (see section 6.5) Pneumonia (see section 3.3) Pneumothorax E sophageal or gastrointestinal U (see section 2.2 “Peptic Disease”) ab l e 17.6. T

408 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 409 17.6. Chest Pain 17.7. Constipation

17.7. Constipation SIGNS AND SYMPTOMS

Description Constipation may be defined as delay or difficulty of defecation. A stool frequency of fewer than 3 times per ) week at any age is abnormal. In children, constipation is most often functional (i.e., nonorganic). In some cases,

Associated Features Associated constipation is organic (e.g., anal stricture, Hirschprung SIGNS AND SYMPTOMS continued esicular rash in area of of in area esicular rash ( disease, hypothyroidism, cerebral palsy, or due to some V discomfort Aggravated by movement movement by Aggravated on pressure and localized examination May follow a meal, especially follow May meal a high-fat medicines, such as narcotics). Note: Be suspicious of new onset of constipation in adults; it may be sign of colon cancer. Diagnosis nn Take a history of the patient that includes the ocation L following: ll History of family, psychological profile, school

ariable performance, and medication Dermatomal distribution V E pigastric, right upper substernal quadrant, ll The age of onset of symptoms (e.g., the infant who fails to pass meconium within 48 hours may have Hirschprung disease) nn Perform a perineal and rectal examination to assess perineal sensation, anal tone, size of rectum, and presence of anal wink. Quality Management Nonpharmacologic Sharp or burning Aching B urning, pressure Patients should be reassured of the benign nature of simple constipation, and children should be helped to developed normal bowel habits. Advise the following: nn Increase fluid intake (at least 6–8 cups/day), nn Eat a high residue (i.e., high fiber) diet, high in whole wheat flour, fruits, and vegetables.

Typical Clinical Features of Common Causes of Acute Chest Discomfort Discomfort Chest Acute of Common Causes of Clinical Features Typical n Condition n Make appropriate behavior modifications to establish regular toilet habits. Children should be encouraged to use the toilet regularly without hurry or distraction. Herpes zoster—skin disease zoster—skin Herpes Musculoskeletal disease Musculoskeletal Gallbladder disease (see section 16.2.3) ab l e 17.6.

T Note: Excessive milk drinking may worsen constipation.

410 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 411 17.7. Constipation 17.8. Nausea and Vomiting

Pharmacologic 17.8. Nausea and Vomiting SIGNS AND SYMPTOMS If nonpharmacologic treatment is not successful, advise a trial of oral daily medication for 1 week. Give— Description nn Mineral oil Nausea is a vague, disagreeable sensation of sickness or —OR— queasiness. Vomiting often follows nausea and is a violent nn Magnesium hydroxide ejection of stomach contents via the mouth. Vomiting ll Children 5 years or younger: 5–15 ml of oral liquid may be self-limiting or associated with serious disease. once a day The approach to the patient who is vomiting involves SIGNS AND SYMPTOMS ll Children from 6–12 years: 15–30 ml oral liquid identifying cause or associated disease and treating ll Children 13–18 years: 6 chewable tablets at once dehydration rapidly, particularly in children younger than daily 5 years. ll Adults: 6–8 chewable tablets at once daily Diagnosis Caution: Avoid magnesium hydroxide in pregnant Establish the patient’s medical history and the sequence and breastfeeding women. of the illness. Assess degree of dehydration (see section 2.1 —OR— “Diarrhea and Dehydration”). Identify any associated signs ll Lactulose (15–30 ml at breakfast) or symptoms: —OR— nn If the patient has fever, consider infection including ll Bisacodyl tablet (5–10 mg at night adjusted the following: according to the response) in adults and children ll Meningitis—stiff neck, bulging fontanel (infants) older than 6 years (generally avoided in children ll Gastroenteritis younger than 6 years). Alleviation of constipation ll Pneumonia—cough, rales (i.e., crackles) should be expected within 8–12 hours if taken at ll Urinary tract infection—dysuria, flank pain bedtime. ll Hepatitis—enlarged, tender liver; jaundice ll For rectal disimpaction of the hard fecoliths, use ll Peritoneal irritation—abdominal tenderness, a saline enema, mineral oil enema, or glycerin guarding and rebound, diminished bowel sounds suppository until dissolved and evacuated. (e.g., appendicitis, cholecystitis, pancreatitis) Referral nn If the patient exhibits signs of central nervous system nn Patients who have no response to treatment should be disorder or raised intracranial pressure, consider referred for further investigation. meningitis, cerebral malaria, migraine, vertigo or inner nn Newborn infants with failure to produce stool should ear inflammation, closed head trauma, or tumor. be referred. nn If there is constipation, consider bowel obstruction and look for abdominal distension and hyperactive or Patient Instructions high-pitched bowel sounds. nn Eat a high residue (i.e., high fiber) diet. nn If there is diarrhea, consider gastroenteritis, parasite nn Drink lots of liquid. infestation, or systemic infection.

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nn uu

Evidence of systemic or metabolic disorders could Patient is not dehydrated, but is unable to take SIGNS AND SYMPTOMS indicate pregnancy, acidosis or diabetic ketoacidosis, liquids orally. or uremia. ll Maintain a balanced rate of hydration: maintenance nn In the case of bleeding (hematemesis), consider plus replacement of estimated ongoing losses from gastritis, ulcer, or a stomach or esophageal (i.e., vomiting or diarrhea. mucosal) tear. nn Give an antiemetic: metoclopramide. nn Ingestion of harmful substances such as medications, Caution: Remember, vomiting treatment should be alcohol, drugs, poisons, or food toxins can cause nausea based on the cause. SIGNS AND SYMPTOMS and vomiting. ll Children: 0.1–0.2 mg/kg IM injection Management —OR— Management should be based on the cause of vomiting; see 0.1–0.2 mg/kg orally every 8 hours until nausea or specific condition cited above for identified diagnosis. vomiting stops (maximum dose 10 mg/dose) ll Adults: 10 mg IM injection Nonpharmacologic —OR— n n Withhold food until you have established whether 10 mg orally every 8 hours until nausea or vomiting the patient has peritonitis, intestinal obstruction, or a stops severe illness requiring urgent referral. Referral nn When the patient is ready to begin a feeding trial, start with small, frequent quantities of clear liquids (e.g., Referral is indicated if— clean water, broth, tea, or soup) and dry foods (e.g., nn Patient has a possible surgical problem such as an soda crackers, bread, and rice). intestinal obstruction or peritonitis or is vomiting blood Pharmacologic nn Dehydration is moderate to severe, especially in nn Treat dehydration or the inability to take oral fluids: children younger than 5 years (see IMCI flipchart) ll Give ORS for those able to tolerate oral intake (see nn Patient shows evidence of severe illness or infection section 2.1 “Diarrhea and Dehydration” plan A). such as shock, septicemia, pneumonia, meningitis, ll Provide IV hydration if— central nervous system disturbance, jaundice, uu Patient is unable to tolerate oral intake, has a acidosis (diabetes or other metabolic disturbance), or decreased level of consciousness, or has a possible complications of pregnancy surgical condition. nn Symptoms have been present for more than 1 week uu Patient is dehydrated. Give Ringer‘s lactate nn The patient is an infant who has projectile vomiting solution (Hartmann’s solution), or if not available, nn You diagnose other complex or obvious causes give normal saline (0. 9%) solution (see section requiring treatment at a higher level facility 2.1 “Diarrhea and Dehydration” plan C or plan B, nn The symptoms persist or worsen after initiating based on estimated severity of dehydration). treatment

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Patient Instructions Chapter 18. Family Planning nn Reassure the patient that most cases of vomiting are self-limiting. for Birth Spacing nn Advise patient to increase his or her diet volume and complexity slowly as the symptoms improve. 18.1. Preparing to Use a Family Planning Method nn Instruct the patient to return in 48 hours if vomiting persists or sooner if he or she develops new symptoms Description or signs of dehydration. Family planning (FP) for birth spacing allows couples SIGNS AND SYMPTOMS to have children at a time where pregnancy, delivery, and breastfeeding entail the lowest risk for mothers and

children. Consecutive births should be spaced at least FAMILY PLANNING 3 years apart to avoid unnecessary risk for mothers and children. Management FP counseling primarily involves helping the couple decide on an FP method that is not only objectively safe and effective but also acceptable to them. (The available methods are outlined in table 18.1A.) nn The first step in FP counseling is to assess the couple’s needs. Listen carefully to what the couple says about their FP preferences. Make sure both partners understand the effectiveness of the available methods. Determining the Couple’s Pregnancy Status The next step in FP counseling is to rule out pregnancy. Table 18.1B will help you ask the right questions in the right order. Start with question 1 and if the answer is “No,” go to the next question until you get a “Yes” answer. If the woman answers “No” to all questions, assume she is pregnant. If you get one “Yes,” go to table 18.1C to explicitly rule out the symptoms and signs of pregnancy. With at least one “Yes” answer to the list in table 18.1B and no symptoms or signs of pregnancy from the list in table 18.1C, you can reasonably assume that the woman is not pregnant. You may proceed to table 18.1D and section 18.2, and give the couple the FP method they request.

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Table 18.1A. Available Contraceptive Methods and Table 18.1C. The Signs and Symptoms of Pregnancy Their Effectiveness Ask the woman if she is experiencing any of the following: Methods Effectiveness Refer to Section nn Nausea, especially in the nn Increased frequency of nn Intrauterine devices Most effective nn 18.2.5 morning urination (IUDs) nn Breast tenderness nn Increased sensitivity to odors nn Permanent methods nn Not covered in this standard nn Fatigue more than usual nn Unexplained mood changes treatment guideline nn Vomiting nn Weight gain

nn Injectable methods Very effective nn 18.2.4 nn Lactational amenorrhea nn 18.2.6 If pregnancy is not ruled out, however, and if a pregnancy method (LAM) FAMILY PLANNING nn Combined oral nn 18.2.2 test available, do urine pregnancy test. If the test is contraception (COC) negative, you may proceed to table 18.1D and section 18.2, nn Progesterone-only pills nn 18.2.3 and give the couple the FP method they request. (POP)

nn Condoms Effective if used nn 18.2.1 If pregnancy test is not available, but you (or a colleague) nn Fertility awareness correctly each nn 18.2.7 are capable of performing a bimanual pelvic examination,

FAMILY PLANNING FAMILY methods (FAMs) time do an examination and determine the following: nn Withdrawal Less effective nn 18.2.8 nn The date of last monthly bleeding nn Spermicides nn 18.2.9 nn The size of uterus for future comparison

Table 18.1B. Ruling Out Pregnancy Until you can be sure the woman is not pregnant, you Question Yes No cannot move on to table 18.1D and section 18.2. nn Tell couple that the only available method for them 1. Did you have a baby <6 months ago, and have you been fully or near-fully breastfeeding, and until they come back for check-up is condoms. If have you not had any monthly bleeding? condoms are unacceptable, less reliable methods (such 2. Did you abstain completely from sexual as withdrawal) or abstinence can be used. intercourse since your last monthly bleeding or nn Tell couple to come back after 4 weeks, or when the delivery? woman gets a monthly bleeding, whichever is first. 3. Have you had a baby <1 month ago? When the couple returns— 4. Did your last monthly bleeding start within ll If woman has monthly bleeding, you may proceed to the past 7 days (within past 12 days if IUD is table 18.1D and section 18.2, and give the couple the requested)? FP method they request. 5. Did you have a miscarriage or abortion within ll If woman has no monthly bleeding, conduct the past 7 days (within past 12 days if IUD is requested)? bimanual pelvic examination: uu If the uterus is larger than before, then the woman 6. Have you been using a reliable contraceptive method consistently and correctly? is pregnant. Advise her to start regular antenatal

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Table 18.1D. Rating of Routine Examinations and Tests nn B = contributes substantially to safe and effective use. for FP Prescribing Failing the test requires considering another method. The risk of not performing the test should be weighed against benefit of making the FP method available. nn C = does not contribute substantially to safe and effective use.

Routine Examination COC Injection POP IUD Condoms Spermicides Breast examination by provider C C C C C C 18.2. Family Planning Options Available in Blood pressure screening —a — — C C C Afghanistan Cervical cancer screening test C C C C C C FAMILY PLANNING Hemoglobin test C C C B C C 18.2.1. Condoms (Male) Pelvic/genital examination C C C C C C Description Most condoms are made of latex and packed in aluminum Routine laboratory tests C C C A C C foil, often lubricated. They work by forming a barrier that Sexually transmitted infection (STI) risk assessment (history and C C C A C C keeps sperm out of the vagina, preventing pregnancy. They

FAMILY PLANNING FAMILY physical examination) also keep infections residing in the semen, on the penis, or STI/human immunodeficiency in the vagina from infecting the other partner. C C C B C C virus (HIV) screening (laboratory) Effectiveness a — = desirable, but if not possible, method should not be denied if preferred Condoms require, first, correct use with every act of sex for greatest effectiveness and, second, both the male and visits (see section 9.1 “Pregnancy and Antenatal female partner’s cooperation. As commonly used in the Care”). first year, about 15% of couples will still have a pregnancy. uu If you find no change in uterus size and no signs or When correctly used with every act of sex, about 2% of symptoms of pregnancy, and if the couple has used couples will have a pregnancy. Condom use is the only an FP method consistently during the month, method that protects both against pregnancy and all STIs, consider the woman not to be pregnant, and give including HIV. FP method preferred by the couple (i.e., proceed Side Effects to table 18.1C and section 18.2). Side effects are extremely rare, although condoms cannot Performing Routine Examinations and Tests for FP Prescribing be used by people who have a latex allergy. In addition, Table 18.1D rates procedures often recommended, but not some men feel a condom interferes with sensation. always necessary. Rating is as follows: nn A = essential and mandatory for safe and effective use. If the test cannot be performed or if the client fails the test, an alternate FP method must be used.

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18.2.2. Combined Oral Contraceptive Pills Special Considerations Description Who Cannot Use COCs are the most commonly used modern FP method. Recommend other methods for the following women who One pill must be taken every day. COCs come in strips of want to use COC: 28 pills: 21 in one color containing low doses of combined nn Fully breastfeeding: not before 6 months after birth. estrogen and progestin (similar to the ones naturally nn Not breastfeeding, but has had a baby within the past present in the body) and 7 pills containing ferrous sulfate. 3 weeks: give COC and tell her to start 3 weeks after birth Effectiveness nn Age 35 or older and regularly smoking COC’s effectiveness depends on the user. As commonly nn Jaundice and serious liver disease or jaundice used, about 8% of couples using COCs during the first year FAMILY PLANNING previously while using COCs will have a pregnancy, mainly because pills are skipped or nn Hypertension (more than 140/90 mm Hg) confirmed forgotten. Risk of pregnancy diminishes to less than 1% of nn Diabetes for more than 20 years or organ damage due the couples if the pills are taken quite regularly (i.e., every to diabetes day at about the same time) for the first year. COCs donot nn Gallbladder disease presently or medically treated protect against STIs. nn

FAMILY PLANNING FAMILY Stroke, heart attack, deep vein thrombosis Side Effects nn Breast cancer or history of breast cancer COCs require sound counseling to the patient, particularly nn Migraine with aura at any age and without aura but about bleeding changes. Side effects are common, but not over 35 years all women have them, and they will become less or stop nn Taking barbiturates, carbamazepine, phenytoin, within the first months of using COCs. Advise the client topiramate, or rifampicin because these medications to keep taking COCs and not to skip pills. Side effects can reduce the effectiveness of COCs include the following: Correct Use nn Changes in bleeding patterns (e.g., less volume, A nonpregnant woman who qualifies can start at any time irregular, infrequent, none)—common but not harmful of the month, but in certain cases (e.g., if taking it more nn Headaches than 5 days after the start of her monthly bleeding), it is nn Dizziness advisable for the couple to use a back-up method for a nn Nausea short time (preferably condoms). nn Breast tenderness nn Weight change In All Cases nn Mood changes nn Explain the pill pack, where to start and where to end; nn Acne (can improve or worsen, but usually improves) remind her to start the new pack the very next day nn Blood pressure (BP) increases a few points (mm Hg). after a pack ends When increase is due to COCs, BP declines quickly nn Explain that she should take 1 pill each day, and help after use of COCs stops. her identify the best time to take it each day.

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nn Explain how to start the next pack: finish all the 28 18.2.3. Progestin-Only Pill pills in the first pack, then start next pack. Description nn Explain what she should do if she misses 1 or more POP, or the so-called mini-pill, comes in strips of 28 pills, pills and help her decide on a back-up method. containing a low dose of a progestin. The most commonly Missed Pills used one in Afghanistan contains 0.03 mg levonorgestrel. Explain the following, even if the couple does not ask Breastfeeding women can start taking this pill 6 weeks about it: after giving birth; smokers and women who have migraines nn If she missed 1 nonhormonal pill, it is not a problem; can also take this pill. she should take the missed pill as soon as possible and Effectiveness continue. As commonly used, about 3% of couples using POP for the FAMILY PLANNING nn If she missed 1 or 2 pills or started the next cycle 1 or first year will have a pregnancy, mainly because pills are 2 days late, it is not a problem; she should continue skipped or forgotten. Risk of pregnancy diminishes to less taking the pills. If she prefers, she can take 2 pills on than 1% if pills are taken quite regularly (i.e., every day at one day. about the same time). POP does not protect against STIs. nn If she missed 3 or more pills or started next cycle 3 or Side Effects

FAMILY PLANNING FAMILY more days late, she should— nn ll Take the next pill as soon as possible and continue Changes in bleeding patterns (less volume, irregular, as usual infrequent, prolonged no bleeding) nn ll Use a back-up method for 7 days Headaches nn nn If she vomited within 2 hours of taking hormonal pill, Dizziness she should take another one and continue nn Nausea nn nn If she vomited or had diarrhea for more than 2 days, Breast tenderness she should follow instructions for missing 3 or more nn Weight change pills. nn Mood changes nn Abdominal pain Prescribing Give the number of cycles convenient for the woman Special Considerations (average 6 months). You can start by giving 3 months, then Who Cannot Use 6 months. Recommend other methods for the following woman who wants to use POP: nn Breastfeeding: not before 6 weeks after birth nn Not breastfeeding, but had a baby within 3 weeks before: give POP and tell her to start 3 weeks after birth nn Jaundice, severe liver disease, or both

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nn Current deep vein thrombosis in legs or lungs and not 18.2.4. Progestin-Only Injectables on anticoagulant therapy Description nn Breast cancer or history of breast cancer The only injectable progestin promoted in Afghanistan nn Taking barbiturates, carbamazepine, phenytoin, is medroxyprogesterone acetate (DMPA) 150 mg in IM topiramate, or rifampicin because these medications injection every 3 months. It does not contain estrogen and reduce the effectiveness of POPs can be used throughout breastfeeding and by women who Correct Use cannot use methods that contain estrogen. A nonpregnant woman who qualifies can start at any time, Effectiveness but in certain cases it is advisable to use a back-up method As commonly used over the first year, about 3% of for a short time. couples normally using DMPA will still have a pregnancy, FAMILY PLANNING In All Cases mainly because injections are not given on time. Risk of nn Give the pills, up to 1 year’s supply. pregnancy diminishes to less than 1% if injections are nn Explain that the woman should take 1 pill each day at given on time. DMPA does not protect against STIs. the same time. Help her identify the best time to take Side Effects each day, and remind her that taking the pill a few Changes in bleeding patterns with DMPA include the FAMILY PLANNING FAMILY hours late increases the risk of pregnancy. following: nn Explain how to start the next pack: finish all the 28 nn First 3 months pills in the first pack, then start next pack. ll Irregular bleeding nn Explain what to do when missing 1 or more pills and ll Prolonged bleeding help her decide on back-up method. nn At 1 year Missed Pills ll No monthly bleeding Explain the following even if the couple does not ask about ll Infrequent bleeding it: ll Irregular bleeding nn If she takes a pill 3 hours late or forgets a pill, she nn Weight gain should take the missed pill immediately and then the nn Headaches other pills as planned (even if this means taking 2 pills nn Dizziness at once or on the same day). nn Abdominal bloating and discomfort nn If she has regular monthly bleedings, recommend nn Mood changes using a back-up method for 2 days; if she had nn Diminished sex drive (libido) intercourse the last 5 days, consider emergency nn Occasionally loss of bone density contraceptive pills. Special Considerations Prescribing Who Cannot Use Give the number of cycles convenient for the woman (up Recommend other methods for the following woman who to 12 months). wants to use DMPA:

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nn Breastfeeding: not before 6 weeks after birth Side Effects nn Not breastfeeding, but had a baby within 3 weeks Side effects include cramps and increased bleeding during before. Give DMPA and tell her to start 3 weeks after menstruation. Serious complications such as perforation birth. are rare if the insertion procedure is done correctly. nn Hypertension (systolic more than 160 mmHG, When To Use diastolic more than100 mmHG) The preferred time of insertion is within the first 12 days nn Jaundice, severe liver disease, or both after the onset of menstruation. During this period, the nn Diabetes for more than 20 years or organ damage due cervix is open allowing for easy insertion of the IUD. to diabetes nn Heart attack, stroke, or deep vein thrombosis in legs or 18.2.6. Lactational Amenorrhea Method lungs FAMILY PLANNING Description nn Breast cancer or history of breast cancer LAM is a temporary FP method based on the natural effect nn Unusual vaginal bleeding suggesting some underlying disease. Reevaluate after investigation and treatment. of breastfeeding on fertility, and works on the condition that the baby is fully (no supplement) or nearly fully Correct Use (occasional supplements) breastfed, is fed often, and is fed

FAMILY PLANNING FAMILY A nonpregnant woman who qualifies can start at any night and day for up to 6 months after birth. time. The preferred time of the injection is within 7 days after the onset of menstruation, but in certain cases it is Effectiveness advisable to use a back-up method for a short time. LAM’s effectiveness depends whether the woman can nearly fully breastfeed night and day. As commonly used, 18.2.5. Intrauterine Device 2% of couples using LAM in the first 6 months after birth will have a pregnancy. Risk of pregnancy diminishes to Description less than 1% if LAM is very strictly applied. LAM does not An IUD is a T-shaped device with copper wires on the protect against STIs. arms and vertical stem that when inserted into the uterus prevents pregnancy by interfering with the movement of Side Effects the sperm and preventing implantation of the embryo. No other side effects than those of breastfeeding Effectiveness Special Considerations IUDs are a very effective long-term contraceptive (99.2% Who Cannot Use effective), although their effectiveness depends on the Recommend other methods for the following woman who provider. They are cost-effective and can be used by wants to use LAM: breastfeeding women. IUDs do not protect against STIs nn Woman who— including human immunodeficiency virus/ acquired ll Has had her period after giving birth immunodeficiency syndrome (HIV/AIDS). ll Is regularly giving other foods to a baby younger than 6 months

428 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 429 18.2. Family Planning Options Available in Afghanistan 18.2. Family Planning Options Available in Afghanistan

ll Has a baby older than 6 months Effectiveness Caution: Advise another FP method, but encourage As commonly used in the first year, 25% of women using the woman to continue breastfeeding until the baby periodic abstinence will become pregnant. Using the is 2 years old for the baby’s health. standard days method correctly and consistently the first nn Woman who takes mood altering medicines, reserpine, year, 5% of women will become pregnant. ergotamine, anti-metabolites, cyclosporine, high Side Effects doses of corticosteroids, bromocriptine, radioactive None medicines, lithium, and certain anticoagulants Special Considerations nn Woman whose newborn has any condition that may interfere with normal breastfeeding, including being Who Cannot Use small-for-date or premature and needing intensive All women can use this method, but you need to carefully FAMILY PLANNING neonatal care; being unable to digest food normally; or consider the decrease of the effectiveness—and, thus, having deformities of the mouth, jaw, or palate increased risk for pregnancy—in the following cases: n Correct Use n If the woman’s menstrual cycles have just started or Always check: have become less frequent or stopped due to older age, nn identifying the fertile time may be difficult.

FAMILY PLANNING FAMILY Baby is younger than 6 months. nn If a woman has irregular bleeding, then identifying nn Woman is breastfeeding nearly exclusively. the fertile time may be difficult. If 2 cycles a year nn Woman did not have monthly bleeding after birth. are longer than 30 days or shorter than 26 days, the The method will work reliably only if these three criteria method will be less reliable. are met. If one is not true, recommend another method, nn Women who recently gave birth or are breastfeeding but encourage breastfeeding till the baby is 2 years old for should delay using this method until at least 3 the baby’s health. Plan a follow-up visit to help the woman regular cycles have taken place. Advise the woman switch to another method when the LAM criteria no to use another method (e.g., LAM or barrier) in the longer apply. meantime. nn Women who recently had an abortion or miscarriage 18.2.7. Fertility Awareness Methods should delay starting this method until the start of her Description next monthly bleeding. A fertility awareness method (FAM) is an FP method nn Women who take mood-altering medicines, certain based on the woman’s knowledge of the fertile time in her antibiotics, or NSAIDs should check for the exact menstrual cycle and on practicing abstinence or using influence of the medicine on her cycle. a barrier method during that period. There are several nn If the woman or the husband does not understand the ways a woman can know about her fertile period, and they fertile period, recommend another method. can be used in combination. The MoPH recommends the standard days method for use in Afghanistan.

430 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 431 18.2. Family Planning Options Available in Afghanistan 18.2. Family Planning Options Available in Afghanistan

Correct Use Side Effects Detailed counseling and instruction for the couple is None necessary. Special Considerations nn Assure that the woman’s cycle is not shorter than 26 days and not longer than 32 days. Who Cannot Use Every couple can use it. Recommend another method if nn Both the woman and the man must understand what the term “fertile period” means and agree to use the the couple is unsure about using it. method. Correct Use nn Always propose and provide condoms as a back-up nn Counsel the couple, both man and woman. method, and explain their use. nn Ensure that the clients understand the importance of nn Carefully instruct the client to follow this procedure: full withdrawal. FAMILY PLANNING ll Note that the first day of cycle is the first day of onset nn Provide condoms as a back-up method, and of bleeding or spotting; record that date. demonstrate the use of condoms. Ensure that the ll Count to the 8th day of the cycle. client has understood the use of condoms. ll Avoid sexual intercourse from the 8th day through nn Counsel and provide emergency contraception in case 19th day. the penis is not withdrawn before ejaculation. FAMILY PLANNING FAMILY ll If sexual intercourse cannot be avoided, use a condom. 18.2.9. Spermicides ll From day 20 until the 7th day of the next cycle, Description having intercourse is safe. Spermicides are sperm-killing substances inserted deep in nn Decide with the woman or couple what memory aid the vagina, near the cervix, before sexual intercourse. they will use for tracking the fertile period each month. Effectiveness 18.2.8. Withdrawal Method (Coitus Interruptus) Spermicides are one of the least effective FP methods. As commonly used during the first year, 29% of women Definition become pregnant. When used correctly with every act of Coitus interruptus is a method of FP in which the man sex 18% of women become pregnant. Spermicides do not completely withdraws his penis from the woman’s vagina protect against STIs. before he ejaculates, thus preventing sperm from reaching and fertilizing the ovum. Side Effects nn Irritation in or around vagina or penis, possible vaginal Effectiveness lesions Effectiveness is highly dependent on the user. On average nn May increase risk of HIV infection during the first year of use, 26% of women will become pregnant. When used consistently and exactly for each intercourse, 4% of women will become pregnant. It is considered the least effective method.

432 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 433 18.2. Family Planning Options Available in Afghanistan 19. Immunization

Special Considerations Chapter 19. Who Cannot Use Immunization nn Women at high risk for HIV infection nn Women who have HIV infection or AIDS Description Correct Use As part of the global effort to combat preventable childhood illnesses, the MoPH of Afghanistan participates nn Advise use anytime less than 1 hour before sex. actively in the global EPI. The objective of EPI in nn Caution the woman not to wash the vagina after sex. Afghanistan is to protect all children younger than 5 years against the following infectious diseases: nn TB nn Diphtheria nn Pertussis nn Tetanus nn Hepatitis B nn Haemophilus influenza type B nn

FAMILY PLANNING FAMILY Measles nn Poliomyelitis It is the responsibility of health workers to— nn Promote vaccination of target groups at the facility IMMUNIZATION ll Promote full routine immunization with the EPI vaccines to children younger than 1 year ll Promote full immunization with TT to women of childbearing age ll Offer a booster dose of measles vaccine to children at the age of 2 ll Participate in polio eradication campaigns nn Ensure proper temperature-controlled storage of the EPI vaccines nn Promote outreach and mobile vaccination for hard-to- reach areas and population groups nn Collaborate fully with the PPHO EPI team for organizing National Immunization Days

434 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 435 19. Immunization 19. Immunization

Management Women 15–45 Years nn All children younger than 2 years should be enrolled in Any woman in this age group presenting for any reason EPI. should be asked how many TT vaccinations she has nn All women of childbearing age should be fully received and when she received the last one. Check the vaccinated with TT. vaccination card if present. Administer the next TT Children Younger Than 2 Years vaccination when due, and remind the woman to come In practice, many parents will not bring the child for back for the next TT vaccination. (See table 19B.) vaccination at the exact age recommended by the Table 19B. TT Vaccination Schedule for Women of EPI program. Therefore, any child presenting for any Childbearing Age reason at the health facility should be fully checked for immunization (i.e., ask for the immunization card) and the When to Vaccinate Vaccine earliest vaccination due (and not yet administered) should As soon as possible after 15th birthday TT-1 be administered before the child leaves the health facility. At least 4 weeks after TT1 TT-2 (See table 19A.) At least 6 months after TT2 TT-3

Table 19A. Schedule of Routine Childhood Immunizations At least 1 year after TT3 TT-4 According to EPI At least 1 year after TT4 TT-5

Age Vaccine How to Give Note: Make sure all women of reproductive age have

Birth (as soon as BCG Intradermal IMMUNIZATION possible) injection received at least 2 TT vaccinations. If a woman is not sure, make sure she receives 2 TT vaccinations (at least 4 weeks Birth (from 0–14 days) OPV 0 Oral drops apart) before delivery. If she has already received 2 or At 6 weeks Pentavalent 1 IM injection more TT vaccinations, recommend a TT vaccination about (1.5 months, 45 days) OPV 1 Oral drops 2 months before delivery is due. If she has documented

IMMUNIZATION At 10 weeks Pentavalent 2 IM injection (2.5 months, 73 days) OPV 2 Oral drops evidence of having received 5 TT vaccinations and the last one is fewer than 10 years ago, she does not need a TT At 14 weeks Pentavalent 3 IM injection (3.5 months, 88 days) OPV 3 Oral drops vaccination. At 9 months Measles-1 Subcutaneous How to Vaccinate (270 days) OPV 4 injection nn Insert the vials sizes with the recommended syringes Oral drops and needles. At 18 months Measles-2 Subcutaneous nn For BCG and measles, use a diluent. Do not keep (1.5 years) injection reconstituted vaccine for longer than 6 hours. Notes: BCG protects against TB; OPV protects against poliomyelitis; pentavalent nn contains five vaccines (against diphtheria, pertussis, hepatitis-B, tetanus, and Use the DTP-HepB for diluting the Haemophilus H-influenza B). influenzae type b vaccine (Hib).

436 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 437 19. Immunization 20. HIV Infection and AIDS

Prevention Chapter 20. Be sure to check vaccination status of women of childbearing age and all children at every health provider HIV Infection and AIDS visit. Description Patient Instructions The human immunodeficiency virus (HIV) infection nn For children younger than 2 years, make sure that— causes illness by entering the host lymphocytes and ll The mother or caregiver understands that the progressively destroying the immune system until the vaccination card should be kept current and brought infected person is no longer able to fight infections— to every visit. leading to the most severe form of the infection, acquired ll The mother or caregiver repeats back your immunodeficiency syndrome (AIDS). instructions concerning when to return for the next nn The virus is transmitted through contamination with vaccination (even if the child is sick). infected body fluids. ll The mother or caregiver understands the need for ll It can be sexually transmitted via body fluid contact several vaccinations. with an infected person (i.e., semen or vaginal and ll The mother or caregiver understands that sick or mucosal fluid). weak children should also be vaccinated. ll Cross contamination of blood or other fluid can nn Carefully explain that side effects are normal after the occur from contact with an infected person: vaccinations and may include— uu Sharing needles (drug addicts) or injury from ll Some local redness, stiffness, pain, or swelling at the non-sterile needles or blood products (medical site of injection personnel) ll Low-grade fever, malaise, muscle pain, headache, or uu Use of contaminated (i.e., non-sterile) loss of appetite instruments (traditional medicine) nn For any other reactions, or a persistent normal side uu Mother-to-child transmission via placenta, effect, tell the mother or caregiver to bring the child during delivery, or from breast milk IMMUNIZATION back to the health facility. nn Studies have shown that HIV is not transmitted by everyday social contact such as hugging or kissing,

through food or water, or by mosquitoes or other biting HIV INFECTION AND AIDS insects. nn In some instances, HIV transmission can be limited by appropriately treating exposed people (e.g., exposed health workers, infants of HIV-positive mothers) with prophylactic therapy. nn A person infected with HIV may remain healthy for many years, but can still pass on the infection.

438 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 439 20. HIV Infection and AIDS 20. HIV Infection and AIDS

nn HIV can be controlled (leading to many healthy years), –– Generalized lymphadenopathy without by taking appropriate medication correctly for the life apparent cause of the patient. –– Repeated common infections (otitis media, Diagnosis pharyngitis) in infant with confirmed maternal WHO clinical staging and case definition (four stages) HIV infection continues to be modified and is based upon severity and Note: It may take as long as 6 months for seroconversion to number of symptoms along with confirmed positive HIV occur following infection with HIV (window period). test. Management nn Diagnosis is made by clinical suspicion and serologic Patients suspected of having HIV should be counseled testing. and referred to voluntary confidential counseling and ll Counseling and voluntary testing should be treatment center for testing and care. performed at a recognized center. Prevention ll Clinical signs that may reflect immunosuppression from HIV (or other causes such as cancer or Information and education should be provided at the malnutrition) commonly include the following: community level to develop awareness and reduce stigma. uu Major signs HIV infection can be prevented by limiting exposure to –– Weight loss (more than 10%) or failure to thrive infected body fluids of HIV positive person through the (children) following: –– Chronic diarrhea (more than 1 month) nn Follow safe sexual practices. –– Prolonged fever (more than 1 month constant nn Avoid blood-borne exposure. or intermittent) ll Avoid sharing needles (IV drug users). –– Evidence of opportunistic infection (infection ll Avoid body fluid exposure to skin wounds or mucous by a microorganism that normally does not membranes (health workers). cause disease but becomes pathogenic when uu Use universal precautions at all times including the body’s immune system is impaired and the following: unable to fight off infection, for example, TB, –– Gloves, eye protection, good hand washing

malaria, bacterial pneumonia, herpes zoster, –– Postexposure prophylaxis when available—per HIV INFECTION AND AIDS staphylococcal skin infections, and septicemia) protocol uu Minor signs ll Avoid mother-to-infant transmission. –– Persistent cough (more than 1 month) uu Diagnose and screen for HIV risk among mothers –– Generalized pruritic dermatitis and pregnant women. –– Recurrent herpes zoster or herpes simplex uu Treat HIV-positive mothers and pregnant women. infection uu Review indications for bottle feeding versus –– Oropharyngeal candidiasis breastfeeding of infants born to HIV-positive

HIV INFECTION AND AIDS HIV INFECTION mothers.

440 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 441 20. HIV Infection and AIDS

Patient Instructions ll Review prevention methods for infected and at risk people. ll Review major and minor signs of severity of disease with patient—seek early consultation for concerns. HIV INFECTION AND AIDS HIV INFECTION

442 National Standard Treatment Guidelines for the Primary Level Annex A

Annex A. Medicine Dosages and Regimens

Table A1. Weight, Height, and Gender annexes

Age Weight (kg) Height (cm) Full-term neonate 3.5 51 1 month 4.3 55 2 months 5.4 58 3 months 6.1 61 4 months 6.7 63 6 months 7.6 67 1 year 9 75 3 years 14 96 5 years 18 109 7 years 23 122 10 years 32 138 12 years 39 149 14 years (male) 49 163 14 years (female) 50 159 Adult male 68 176 Adult female 58 164 Source: United Kingdom–WHO growth charts 2009 and United Kingdom 1990 standard centile charts.

National Standard Treatment Guidelines for the Primary Level 443 Annex A Annex A

Table A2. Aminophylline

Children up to 10 years: nn Oral: 6 mg/kg/dose every 8 hours annexes nn IV: Calculate exact dose based on body weight where possible — — —

(weigh the child!). Use the following doses only where this is not 5 ml 15 ml 10 ml possible: Loading dose: IV: 5–6 mg/kg (max. 300 mg); slowly

over 20–60 minutes; followed by maintenance dose: IV: 5 mg/kg in Pneumonia annexes up to every 6 hours OR by continuous infusion 0.9 mg/kg/hour. Syrup (125 mg/5 ml)Syrup Caution: Avoid dosing by age; weigh the child carefully and dose by exact weight if at all possible. Adults (and children older than 10 years): nn Oral: Loading dose: 6.3 mg/kg orally once, followed by maintenance dose: 4 to 6 mg/kg/dose every 8 hours daily 1 tab 2 tab ½ tab 1½ tab 2½ tab (maximum dose per day 1,125 mg/day). Patient with congestive 2–4 tab heart failure: 2.5 mg/kg/dose every 8 hours daily (maximum dose in Pneumonia

per day 500 mg/day) (250 mg) Tablet nn IV: Loading dose: 6 mg/kg in 100 to 200 ml of IV fluid intravenously once over 20 to 30 minutes followed by maintenance dose 0.7 mg/kg/hour up to 0.9 mg/kg/hour continuous IV infusion. Patient with congestive heart failure: 0.25 mg/kg/hour continuous IV infusion. — — 5 ml 10 ml 7.5 ml 7.5 2.5 ml Syrup Syrup

Caution: Use above dosage only if patient has not taken to Body Weight Dose According aminophylline or theophylline within 24 hours. (125 mg/5 ml) Dose According to Body Weight Tablet Vial Weight (Age) 100 mg 250 mg/10 ml 3 – <6 kg ¼ 1 ml (neonate – <3 month) 1 tab ½ tab ¼ tab ¾ tab 1½ tab 1½ tab Tablet Tablet 250 mg 6 – <10 kg ½ 1.5 ml (3 month – <1 year) 10 – <15 kg ¾ 2.5 ml (1 year – <3 years) 12 hours daily). pneumonia: 25 mg/kg every 8 hours daily (for every 15 mg/kg/dose ral: 15 – <20 kg

1 3.5 ml

(3 years – <5 years)

20–29 kg 1½ 5 ml (5–10 years) >29 kg 3 – <6 kg 20–29 kg Amoxicillin 6 – <10 kg 10 – <15 kg 15 – <20 kg (5–10 years) (5–10

>29 kg (Age) Weight 2–3 10–15 ml (1 year – <3 years) (1 year In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 for standard dosages. standard to table A12 for Refer use erythromycin. or sensitivity, penicillin allergy the case of In (3 years – <5 years) (3 years (adults and children >10 years) (3 month – <1 year) (neonate – <3 month) O up to 10 years: Children In infections. dose is doubled in severe 8 hours daily; every 250 mg/dose older than 10 years): children (and Adults 8 hours daily. g every mouth, 500 mg –1 pneumonia, by Note: ab l e A3. (adults and children >10 years) (adults and children T

444 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 445 Annex A Annex A

Table A4. Ampicillin

Children up to 5 years: IM/IV: 50 mg/kg per dose every 6 hours daily. annexes Adult (and children older than 5 years): 500 mg/dose every 6 hours daily; dose is doubled in severe infections due to sensitive organisms, by IM injection or by slow IV injection or by IV infusion. . 5–10 ml 5–10 5–7.25 ml 5–7.25 annexes 2.5–3.5 ml

Note: In the case of penicillin allergy or sensitivity, use 1.5–2.25 ml 0.75–1.25 ml 0.75–1.25 3.75–4.75 ml 3.75–4.75

erythromycin. Refer to table A12 for standard dosages. 6 : 25 mg/kg every Vial of 1 g Mixed with 1 g Mixed of Vial Dose According to Body Weight to Water ml Sterile 9.2 Give 1 g/10Give ml in Meningitis Vial of 500 mg Mixed with 4.5 ml Sterile Water to Weight (Age) Give 100 mg/1 ml or meningitis I V 3 – <4 kg 1.5 ml = 150 mg (neonate to <2 months) 1 2 2 — — 4 – <6 kg 1½ 2 ml = 200 mg (2 months – <4 months)

6 – <8 kg Capsule 250 mg 3 ml = 300 mg (4 months – <9 months)

8 – <10 kg to Body Weight Dose According 4 ml = 400 mg (9 months – <12 months) 10 – <14 kg 5 ml = 500 mg (12 months – <3 years) 14–19 kg — 7 ml = 700 mg —

(3–5 years) 3–5 ml 6–9 ml 15–19 ml 15–19 10–14 ml 10–14 >19 kg 5 ml = 500 mg (Palmitate)

(adults and children >5 years) (to 10 ml = 1 g if severe infection) 125 mg/5 ml Syrup ral: 25 mg/kg/dose every 8 hours (maximum1g per dose). F every 25 mg/kg/dose ral:

>29 kg 3 – <6 kg 20–29 kg 6 – <10 kg 10 – <15 kg 15 – <20 kg Chloramphenicol (5–10 years) (5–10 Avoid chloramphenicol in premature infants. in premature chloramphenicol Avoid Weight (Age) Weight (1 year – <3 years) (1 year (3 years – <5 years) (3 years (3 months – <1 year) (neonate – <3 months) (adults and children >10 years) (adults and children hours (maximum 1g per dose). or I V oral 6 hours (maximum dose: 4 g/day) 12.5–25 mg/kg every older than 10 years): children (and Adults Caution: O up to 10 years: Children ab l e A5. T

446 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 447 Annex A Annex A

Table A7. Chlorphenamine (Chlorpheniramine)

Children up to 12 years: In allergic reactions, anaphylaxis — — —

10 ml (adjunct), IM/IV or subcutaneous: 0.25 mg/kg once (can be annexes Day 3 2.5 ml 5.0 ml 5.0 repeated up to 4 times in 24 hours to a maximum dose of 0.4 ml in 24 hours for children younger than 1 year). For symptomatic relief of allergy, oral: nn Children 2–6 years: 1 mg/dose every 4–6 hours per day annexes (maximum 6 mg daily) — — —

15 ml nn 7.5 ml 7.5 Day 2 5.0 ml 5.0 Children 6–12 years: 2 mg/dose every 4–6 hours per day (maximum 12 mg daily) Adults (and children older than 12 years): In allergic reaction,

Syrup 50 mg Base/5 ml 50 mg Base/5 Syrup anaphylaxis 10–20 mg in single dose, repeated if required (maximum total dose 40 mg in 24 hours). For symptomatic relief — — — 15 ml Day 1

7.5 ml 7.5 of allergy: oral 4 mg/dose every 4–6 hours (maximum, 24 mg daily). 5.0 ml 5.0 Caution: Do not give to premature infants and infants <1 month. Dose According to Body Weight 1 1 Ampoule 2 ½ ½ —

Day 3 10 mg in 1 ml (IM, IV, or Tablet: Subcutaneous) 4 mg (Oral) Dose According to Body Weight Dose According Allergic Symptomatic Weight (Age) Reaction Relief of Allergy 1 4 ½ — 1½ 1½ 4 – <6 kg Day 2 0.1 ml — (2 months – <3 months) Tablet 150 mg Tablet 6 – <10 kg 0.2 ml — (3 months – <1 year) 1 4 ½ — 10 – <15 kg 1½ 1½ 0.3 ml ¼ Day 1 (1 year – <3 years)

nce a day for 3 days: 10 mg/kg on days 1 and 2, 5 mg/kg on day 3. 1 and 2, 5 mg/kg on day 10 mg/kg on days 3 days: for a day nce 15 – <20 kg 0.5 ml ¼ (3 years – <5 years) ral: O ral: 20–29 kg 0.6 ml ½ (5–12 years)

>29 kg

10 mg/kg once on day 1 and day 2, followed by 5 mg/kg on day 3 (i.e., 4 tablets 150 mg day 1 and day 2 and 1 and day 4 tablets 150 mg day 3 (i.e., 5 mg/kg on day by 2, followed 1 and day on day 10 mg/kg once (adults and children 1 ml 1 >12 years) >29 kg 3 – <6 kg 20–29 kg 6 – <10 kg 10 – <15 kg Chloroquine 15 – <20 kg (5–10 years) (5–10 Weight (Age) Weight (1 year – <3 years) (1 year (3 months – 1 year) (3 years – <5 years) (3 years (neonate –<3 months) (adults and children >10 years) (adults and children O up to 10 years: Children 10 mg/kg followed by 5 mg/kg 6–8 hours later on day 1, then 5 mg/kg daily on day 1, then 5 mg/kg daily on day 5 mg/kg 6–8 hours later on day by 10 mg/kg followed older than 10 years): children (and Adults 3 OR 2 and day in the table below). 3 as shown tablets day ab l e A6. T

448 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 449 Annex A Annex A

Table A8. Co-trimoxazole Table A9. Diazepam

Children up to 10 years: Oral: 4 mg trimethoprim/kg +20 mg Children up to 10 years: If convulsions, rectal: 0.5 mg/kg/dose sulfamethoxazole/kg/dose every 12 hours daily slow IV: 0.2–0.3 mg/kg/dose. For sedation before procedures:

OR annexes Adults (and children older than 10 years): Oral two tablets adult 0.1–0.2 mg/kg/dose IV. 480 mg every 12 hours daily. Adults (and children older than 10 years): Convulsion, rectal: Caution: If child is younger than1 month, give co-trimoxazole 0.2 mg/kg OR 5 to 10 mg initial dose slow IV or IM to be repeated annexes (½ pediatric tablet or 1.25 ml syrup) every 12 hours daily. Avoid 10 minutes later if seizure continues. Anxiety, by mouth: 2 mg/ co-trimoxazole in neonates who are premature or jaundiced. dose every 8 hours daily (reduced to half the adult dose in the elderly and debilitated patients). Note: SMX = sulfamethoxazole; TMP = trimethoprim Dose According to Body Weight Dose According to Body Weight Syrup Ampoule Ampoule (40 mg TMP 10 mg/2 ml 10 mg/2 ml Slow + 200 mg Rectal IV or IM SMX per Weight (Age) Administration Administration Pediatric 5 ml) 3 – <6 kg 0.4 ml 0.25 ml Tablet (20 (A Regular Adult Tablet (neonate – <3 months) mg TMP+ Teaspoon (80 mg 6 – <10 kg 100 mg Contains 5 ml TMP+ 400 0.75 ml 0.4 ml Weight (Age) SMX) of Liquid) mg SMX) (3 months – <1 year) 10 – <15 kg 3 – <4 kg 1.2 ml 0.6 ml (neonate – ½ 1.25 ml — (1 year – <3 years) <1 month) 15 – <20 kg 1.7 ml 0.75 ml 3 – <6 kg (3 years – <5 years) (neonate – 1 2 ml ¼ 20–29 kg 2.5 ml 1.25 ml <3 months) (5–10 years) 6 – <10 kg >29 kg (3 months – 2 3.5 ml ½ (adults and children 10 ml 1–2 ml <1 year) >10 years) 10 – <15 kg 3 6 ml 1 (1 year – <3 years) Table A10. Doxycycline 15-<20 kg 3 8.5 ml 1 (3 – < 5 years) Only for adults and children over 8 years: Oral: one tablet 100 mg every 12 hours daily for 7–10 days 20–29 kg 4 — 1 Caution: Do not give to pregnant women and lactating women, (5–10 years) and children under 8 years old. >29 kg Capsule or Tablet: (adults and — — 2 Age 100 mg (Hydrochloride) children >10 years) 100 mg twice daily Adults and children >8 years for 7–10 days

450 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 451 Annex A Annex A

Table A12. Erythromycin Ethylsuccinate

Children up to 12 years: Oral: 7.5–12.5 mg/kg/dose every 6 hours daily. In severe infections, this dosage may be doubled ( maximum annexes dose is 4 g per day). Adult (and children older than 12 years): 400 mg erythromycin ethylsuccinate (one tablet 400 mg) OR 250 mg erythromycin of 10,000 I V of

annexes base or stearate (one tablet 250 mg) every 6 hours daily is the

5 ml usual dose. Dosage may be increased up to 4 g per day according 0.1 ml/kg 0.1 ml/kg 0.1 ml/kg 0.1 to the severity of the infection. Note: one tablet 400 mg erythromycin ethylsuccinate is equivalent to one tablet 250 mg erythromycin base or stearate. IV given over 5–10 minutes 5–10 over IV given

1 ml of 1 vial 0.1% to 9 ml of to 9 ml of 1 vial 0.1% 1 ml of Caution: Must not be given together with theophylline IV Shock: Slow Anaphylactic normal saline or 5% glucose) 0.1 ml/kg (maximum dose = 5 ml) 0.1 1:10,000 solution (1 mg = 10 ml)1:10,000 (aminophylline) due to risk of serious adverse reactions. (Make a 1:10,000 solution by adding solution by a 1:10,000 (Make Dose According to Weight Tablet Syrup 400 mg of Tablet 250 mg Weight 125 mg per Erythromycin Erythromycin (Age) 5 ml (base) Ethylsuccinate Base or Stearate

Dose According to Body Weight Dose According 3 – <4 kg 1.2–2 ml (neonate – = ¼–½ — — <2 months) teaspoona

0.05 ml 0.05 4 – <6 kg

(1 mg = 1 ml) 2 ml = ½ 0.5 mg = ml 0.30 mg = 0.3 ml Vial 0.1% in 1 ml 0.1% Vial (2 months – ¼ tab ¼ tab 0.12 mg = 0.12 ml mg = 0.12 0.12 0.25 mg = ml teaspoon <4 months) Allergic Reaction IM or Reaction Allergic 6 – <11 kg Subcutaneous 1:1000 Solution Subcutaneous 4 ml = ¾ (4 months – ¼ tab ¼ tab teaspoon <2 years ) 12–23 kg 8 ml = 1 ½ injection dose of 5 ml of a solution of 1:10,000. a solution of 5 ml of I V injection dose of (2 years – <7 ½ tab ½ tab teaspoon years) 23–45 kg (7 years – — ¾ tab ¾ tab <12 years) >45 kg >55 kg (Adults and — 1 tab 1 tab Weight (Age) Weight children

Epinephrine (Adrenaline) >12 years) 39–55 kg (12–18 years) 39–55 kg (12–18 a 20 kg – <39 kg (6–12 years) 20 kg – <39 (6–12 1 teaspoon = 5 ml 3 kg – <8 (under 6 months) (adults and adolescents >18 years) (adults and adolescents 8 kg – < 20 (6 months 6 years) Subcutaneous or IM in anaphylactic reaction: 0.01 ml/kg/dose (maximum 0.4 ml) a solution of ml/kg/dose 0.01 of reaction: or IM in anaphylactic Subcutaneous up to 18 years: Children not if symptoms have reaction after 10 minutes in allergic in 1 ml). be repeated 1:1000 solution epinephrine (vial 0.1% May in shock slow than 140). Alternatively shock (if pulse less or after 3–5 minutes in an anaphylactic improved, ml/kg. 0.1 solution, at the dose of be repeated 1:1000; may a solution of 0.5 ml of or IM dose of Subcutaneous than 18 years): more adolescents (and Adults minutes; in shock, slow 10–15 every ab l e A11. T

452 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 453 Annex A Annex A

Table A14. Metronidazole

Children up to 10 years: Oral: 7.5 mg/kg every 8 hours daily for 7 days. (For the treatment of giardiasis, the dose is 5 mg/kg/dose annexes every 8 hours daily for 5–10 days; for amoebiasis, 10 mg/kg/dose every 8 hours for 7–10 days.) — — — — —

. Adults (and children older than 10 years): Invasive amoebiasis,

annexes by mouth: 500–750 mg every 8 hours for 5–10 days. Giardiasis, Undiluted 2 ml = 80mg 2 ml = 80 mg by mouth: 400 mg every 8 hours daily for 5–7 days. In severe 1.25 ml = 50 mg infections: 7.5 mg/kg IV every 8 hours for 10–14 days. Vial Containing 80 mg Vial I V or IM initial loading dose

(Vial 40 mg/ml) 2 ml at of Dose According to Body Weight Tablet Tablet Suspension Weight (Age) 200 mg 400 mg 200 mg/5 ml 3 – <6 kg (neonate – <3 ¼ tab — 1–1.5 ml months) 6 – <10 kg ¼ tab — 1.5–2.5 ml (3 months – <1 year)

Dose According to Body Weight Dose According 10 – <15 kg ½ tab ¼ tab 2.5–4 ml — — (1 year – <3 years)

5 ml = 50 mg 15 – <20 kg 1.5 ml = 15 mg 3.0 ml = 30 mg 3.0

1.00 ml = 10 mg 1.00 1 tab ½ tab 5 ml 3.75 ml = 37.5 mg ml = 37.5 3.75 2.25 ml = 22.5 mg (3 years – <5 years) 20–29 kg 1 tab ½ tab — (5–10 years) Vial Containing 20 mg = 10 mg/ml Vial Vial Containing 80 mg = 10 mg/ml Vial 40 mg/ml) add 6 ml Sterile Water to 40 mg/ml) Water add 6 ml Sterile 10 mg/ml). Add 2 ml Sterile Water to 10 mg/ml). Water 2 ml Sterile Add Vial Containing 20 mg (VialVial 2 ml at of Vial Containing 80 mg (VialVial 2 ml at of >29 kg (adults and children — 1 tab — >10 years) Weight (Age) Weight Gentamicin 14–19 kg (3 years – <5 years) kg (3 years 14–19 10 – <14 kg (1 year – <3 years) 10 – <14 kg (1 year 20–29 kg (>5 years – 10 years) 20–29 kg (>5 years 3 – <4 kg (neonate <2 months) 6 – <8 kg (4 months <9 months) 4 – <6 kg (2 months <4 months) 8 – <10 kg (9 months <12 >29 kg (Adults and children >10 years) and children >29 kg (Adults slow slow infection, severe If 12 hours daily. every mg/kg/dose I V or IM: 3.75 up to 10 years: Children 7 mg/kg. referral: before I V injection (over slow IM injection or by 8 hours daily by every mg/kg/dose 1–1.7 older than 10 years): children (and Adults daily IM or I V once 5 mg/kg/dose infection: loading dose if severe I V infusion. Initial at least 3 minutes) or by ab l e A13. T

454 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 455 Annex A Annex A

Table A15. Paracetamol (Acetaminophen)

Neonates age 1 month or less: Oral 10–15 mg/kg/dose every 6 to 8 hours as needed. annexes Infants older than 1 month to children 10 years: Oral 10–15 mg/ kg/dose up to every 4–6 hours daily. — Adults (and children older than 10 years): 500 mg to 1 g every ½ to 1 tab annexes 6–8 hours (maximum 4 g daily). 125 mg = ¼ tab Tablet 500 mg Tablet Caution: Do not give aspirin in children because of risk of Reyes 250 mg = ½ tab (as Potassium Salt) Potassium (as syndrome. Dose According to Body Weight Syrup 120 mg/5 ml (Teaspoon = Tablet Tablet Weight (Age) 5 ml) 100 mg 500 mg 3 – <4 kg (neonate – ¼–½ ½ — 1 tab to 2 250 mg = 1 tab 125 mg = ½ tab Tablet: 250 mg Tablet: <1 month) 62.5 mg = ¼ tab 4 – <6 kg Salt) Potassium (as ½ 1 ¼ (2–3 months) Dose According to Body Weight Dose According 6 – <10 kg 1 1 ¼ (3 months – <1 year) 10 – <15 kg 1¼ 1 ¼ (1 year – <3 years) —

15 – <20 kg 6 hours daily. 250–500 mg every sual dose orally: 1½–2 1½–2 ½ (3 years – <5 years) 250 mg/5 ml 250 mg = 5 ml 125 mg = 2.5 ml

20–29 kg 62.5 mg = 1.25 ml

— 2–3 ½ Salt) Potassium (as (5–10 years) Powder for Oral L iquid: Oral for Powder >30 kg (adults and — — 1 children >10 years) ral: 10 mg/kg/dose every 6 hours usually. every 10 mg/kg/dose ral:

>39 kg 6–10 kg 6–10 Penicillin V (Phenoxymethylpenicillin) Penicillin 10–20 kg 20–39 kg Weight (Age) Weight (children 1–5 years) 1–5 years) (children In the case of penicillin allergy or sensitivity, use erythromycin. Refer to table A12 for standard dosages. standard to table A12 for Refer use erythromycin. or sensitivity, penicillin allergy the case of In (children 6–12 years) years) 6–12 (children (children up to 1 year) up to 1 year) (children (adults and children >12 years) (adults and children O up to 12 years: Children U older than 12 years): children (and Adults Note: ab l e A16. T

456 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 457 Annex A Annex B

Annex B. Newborn Resuscitation Start resuscitation using the procedure below within

1 minute of birth if baby is not breathing or is gasping annexes for breath. Observe universal precautions to prevent infection. sterile water 0.5 ml to 1 (Rapid Acting Acting (Rapid annexes

Bronchodilator): Bronchodilator): 1.

5 mg/ml Solution Keep the baby warm. 2.0 ml sterile water 2.0 2.0 ml sterile water 2.0 2.0 ml sterile water 2.0 2.0 ml sterile water 2.0 Nebulizer Solution Nebulizer 0.5 ml salbutamol plus 0.5 ml salbutamol plus 0.5 ml salbutamol plus salbutamol plus 2.0 mlsalbutamol plus 2.0 0.25 ml salbutamol plus ll Clamp and cut the cord if necessary. ll Transfer the baby to a dry, clean, and warm surface. ll Inform the mother that the baby has had difficulty initiating breathing and that you will help the baby — — None 1 puff to breathe. 1–2 puffs

with Spacer: with Spacer: ll Keep the baby wrapped and under a radiant heater if Aerosol Inhaler Inhaler Aerosol 0.1 mg per Dose 0.1 possible. 2. Open the airway. ll Position the head so it is slightly extended. 1 ¼ ½ ½ 4 mg None ll

Tablet: Tablet: Suction first the mouth and then the nose. ll Introduce the suction tube into the newborn’s

Dose According to Body Weight Dose According mouth 5 cm from lips and suck while withdrawing. ll Introduce the suction tube 3 cm into each nostril 1 1 ½

1–2 and suck while withdrawing until there is no mucus. 2 mg None Tablet: Tablet: ll Repeat each suction if necessary, but no more than

ral 2–4 mg every 6 or 8 hours daily. Relief of acute bronchospasm by aerosol aerosol by acute bronchospasm of Relief 6 or 8 hours daily. 2–4 mg every ral twice and for no more than 20 seconds in total. 3. If the baby is still not breathing, ventilate. ll Place the mask to cover the baby’s chin, mouth, and — 5 ml 5 ml None 2.5 ml Syrup: Syrup:

if child is older than 6 months. nose. 2 mg/5 ml ll Form a seal. ll Squeeze the bag attached to the mask with 2 fingers ral 0.1–0.4 mg/kg/dose every 8 hours during acute symptoms. every mg/kg/dose 0.1–0.4 ral

or whole hand (according to bag size) 2 or 3 times. ll

Watch for the chest to rise. If the chest is not rising—

uu Reposition head uu Check the mask seal >29 kg Salbutamol

4 – <7 kg uu 7 – <10 kg >10 years) 20 – 29 kg Squeeze the bag harder with whole hand 10 – <19 kg (5–10 years) (5–10 (2–6 months) Weight (Age) Weight ll (1 year – <5 year) (1 year Once the seal is good and the chest rising, ventilate (adults and children (adults and children (6 months – <1 year) at 40 squeezes per minute until the newborn starts O up to 10 years: Children O older than 10 years): children (and Adults of exercise-induced Prophylaxis 6 to 8 hours daily during acute symptoms. every mg–0.2 mg (1–2 puffs) inhalation, 0.1 up to 3–4 times daily. inhalation, 0.2 mg (2 puffs) aerosol by bronchospasm, salbutamol only oral Caution: Give ab l e A17.

T crying or breathing spontaneously.

458 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 459 Annex B Annex C

4. If the baby is breathing or crying, stop ventilating. Annex C. Partograph and Delivery Note ll Watch the chest for in-drawing. Forms for Partograph and Delivery Note are available on ll Count the breaths per minute. the website, www.moph.gov.af annexes ll If breathing is more than 30 breaths per minute and there is no severe chest in-drawing— Let’s make pregnancy and delivery safe in Afghanistan. uu Do not resume ventilating annexes Partograph and Delivery Note u u Put the baby in skin-to-skin contact on mother’s Name Gravida Para Hospital number Date of admission Time of admission Ruptured membranes hours

200 190 chest, and continue essential newborn care (see 180 170 160 150 Fetal 140 heart rate section 9.10 “Newborn Care”) 130 120 110 100 90 uu Monitor every 15 minutes for breathing and 80 Amniotic fluid Moulding 10 9 Cervix (cm) 8 warmth Alert Action [Plot X] 7 6 5 Descent 4 uu of head 3 SAMPLE Tell the mother that the baby will probably be well [Plot 0] 2 1 0 Hours 1 2 3 4 5 6 7 8 9 10 11 12 Caution: Do not leave the baby alone. Time 5 4 Contractions 3 per 10 mins 5. If the baby’s breathing is fewer than 30 breaths per 2 1

Oxytocin U/L minute or if there is severe chest in-drawing— drops /min Drugs given and IV fluids ll Continue ventilating 180 170 160 150 140 ll Pulse • 130 Arrange for immediate referral 120 and BP 110 100 90 ll 80 Explain to the mother what has happened, what you 70 60

Temp °C

protein are doing, and why Urine acetone volume ll Ventilate during referral Let’s make pregnancy and delivery safe in Afghanistan. ll Record the event on the referral form and labor

Delivery Note: Obstetric Section record Personal Information Patient’s name: Date of delivery: 6. If the baby is not breathing or gasping at all after Patient’s age: Time of delivery: Pregnancy period:

Method of Delivery (Check the method of delivery. In the case of Caesarean, fill in the blank to explain.) 20 minutes of ventilation— • Normal (vaginal) • Breach (delivery in foot) • Vacuum extraction • Forceps • Caesarean section Caesarean indication: ll Perineum Stop ventilating; the baby is dead Intact (normal)? • Yes • No Laceration episiotomy? • Yes • No

Third Phase ll Active plan? • Yes • No Placenta out by hand? • Yes • No Explain to the mother and give supportive care Placenta delivery time: Complete? • Yes • No Incomplete? • Yes • No Blood Loss Quantification (Circle the quantity of blood lost.) ll Record Mild (less than 250 ml) Moderate (250–500 ml) Severe (more than 500 ml) Delivery Note: UrgentSAMP Supervision after Delivery LE Vaginal Bleeding Notes: Time Uterus Status (mild, moderate, n If pulse is >110 and (after delivery) Blood Pressure Pulse (hard or soft) or severe) blood pressure <90/60, consider shock and manage appropriately.

n If uterus is soft and bleeding is moderate or severe, check for PPH

Delivery Note: Information about Neonate Neonate weight: Weight less than 2.5 kg? • Yes • No Gender: • Male • Female

Status/situation (APGAR check): 1° 5° Needs help? • Yes • No

Respiration normal? • Yes • No If no, describe resuscitation of the newborn:

Death delivery? • Yes • No If yes, • fresh or • old?

General status (Check one. Explain disorder or malformation in the blank.) • Healthy • Pale or unconscious • Organ disorder or malformation Explain:

Patient in discharge steps Mother Is uterus well contracted? • Yes • No How much blood loss? • Normal • Severe If severe, what steps did you take?

Neonate Mother feeding? • Good • Bad

Signature

460 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 461 Annex D Annex D

Annex D. References Salam, Ahmad Shah. 2009. Clinical Procedures for Primary Eye Care: An Essential Training Guide for Physicians. Kabul: National Eye Care Coordination Office, MoPH. I. Afghanistan MoPH Guidelines annexes Expanded Program of Immunization. 2006. EPI Guideline. II. WHO Guidelines Kabul: MoPH. annexes Integrated Management of Childhood Illness Department. Connolly, M.A. (ed.). 2005. Communicable Disease Control 2009. Assess and Classify the Sick Child Age 2 Months to in Emergencies: A Field Manual. (WHO Library 5 Years. Kabul: MoPH. Cataloguing-in-Publication Data, NLM classification: Mental Health Department. 2008. Introduction Mental WA 110.) Geneva: WHO. Disorders in BPHS. Kabul: MoPH. Cook, John, et al. 1991. Surgery at the District Hospital: Ministry of Public Health. 2010. A Basic Package of Health Obstetrics, Gynecology, Orthopaedic and Traumatology. Services for Afghanistan – 2010/1389. Kabul: MoPH (WHO Library Cataloguing-in-Publication Data, NLM National HIV/AIDS Control Program. 2006. Sexually classification: WO 100.) Geneva: WHO. Transmitted Disease and Other Sexual Route Disorders. Global Task Force on Cholera Control. 2004. Cholera Kabul: MoPH. Outbreak: Assessing the Outbreak Response and National HIV/AIDS Control Program. 2008. National Improving Preparedness. Geneva: WHO. Clinical Protocol on Anti-Retroviral Therapy (ART). United Nations Children’s Fund, United Nations Kabul: MoPH. University, and WHO. 2001. Iron Deficiency Anaemia National Malaria and Leishmania Control Program. 2009. Assessment, Prevention, and Control: A Guide for Guideline for Control and Prevention of Cutaneous Program Managers. Geneva: WHO. Leishmaniasis in Afghanistan. Kabul: MoPH. WHO. 2003. Malaria Control in Complex Emergencies. National Malaria and Leishmania Control Program. 2009. (WHO Library Cataloguing-in-Publication Data, NLM National Malaria Treatment Guideline. Kabul: MoPH. classification: WC 765.) Geneva: WHO. National Standards for Reproductive Health Services WHO. 2003. Surgical Care at the District Hospital. (WHO and Reproductive Health Task Force. 2003. Newborn Library Cataloguing-in-Publication Data, NLM Care Standards. Kabul: Department of Women and classification: WO 39.) Geneva: WHO. Reproductive Health, MoPH. WHO. 2005. Pocket Book of Hospital Care for Children: National Tuberculosis Control Program. 2009. TB Guidelines for the Management of Common Illnesses National Treatment Guideline. Kabul: MoPH. with Limited Resources. (WHO Library Cataloguing-in- Public Nutrition Department. 2006. Standard Operational Publication Data, NLM classification: WS 29.) Geneva: Guideline on Management of Severe Malnutrition. WHO. Kabul: MoPH. WHO. 2006. Guideline for the Treatment of Malaria. Reproductive Health Task Force. 2003. Family Planning (WHO Library Cataloguing-in-Publication Data, NLM for Birth Spacing. Kabul: Department of Women and classification: WC 770.) Geneva: WHO. Reproductive Health, MoPH.

462 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 463 Annex D Annex D

WHO. 2006. Pregnancy, Childbirth, Postpartum and Heymann, David L. 2004. Control of Communicable Newborn Care: A Guide for Essential Practice. Diseases Manual, An Official Report of the American Integrated Management of Pregnancy and Childbirth. Public Health Association (18th ed.). Washington, D.C.: annexes (WHO Library Cataloguing-in-Publication Data, NLM APHA. classification: WQ 170.) Geneva: WHO. Kanski, Jack J. 2007. Clinical Ophthalmology: A Systemic WHO. 2007. Managing Complications in Pregnancy Approach (6th ed.). Oxford: Butterworth-Heinemann. annexes and Childbirth: A Guide for Midwives and Doctors. Kliegman, Robert M., Jenson, Hal B., et al. 2007. Nelson Integrated Management of Pregnancy and Childbirth. Textbook of Pediatrics (18th ed.). Philadelphia: Saunders. (WHO Library Cataloguing-in-Publication Data, NLM Lalwani, Anil K. 2008. Current Diagnosis & Treatment of classification: WQ 240.) Geneva: WHO. Otolaryngology -Head & Neck Surgery (2nd ed.). New WHO. 2009. Pharmacological Treatment of Mental York: McGraw Hill Disorders in Primary Health Care. (WHO Library Longo, Dan L., Fausi, Anthony S. et al. 2012. Harrison’s Cataloguing-in-Publication Data, NLM classification: Principles of Internal Medicine (18th ed.). New York: QV 77.2.) Geneva: WHO. McGraw Hill. WHO in collaboration with the World Heart Federation McPhee, Stephen J. et al. 2010. Current Medical Diagnosis and the World Stroke Organization. 2011. and Treatment (49th ed.). .). New York: McGraw Hill. Cardiovascular Disease Prevention and Control. Mitchell, Laura, and Mitchell, David A. 2009. Oxford (WHO Library Cataloguing-in-Publication Data, NLM Handbook of Clinical Dentistry (5th ed.). Oxford: Oxford classification: WG 120.) Geneva: WHO. University Press. Reddy, Shantipriya. 2008. Essentials of Clinical III. Additional References Periodontology and Periodontics (2nd ed.). India: Brunicardi, F. Charles et al. 2010. Schwartz Principles of Jaypee Brothers Pub. Surgery (9th ed.). New York: McGraw Hill Medical. Scully, Crispian. 2004. Oral and Maxillo-Facial Medicine DeCherney, Alan, et al. 2006. Current Diagnosis and (The Basis of Diagnosis and Treatment) (2nd ed.). NY, Treatment Obstetrics and Gynecology (10th ed.).New NY: Elsevier. York: McGraw Hill Medical. Shafer, William G. 1983. Textbook of Oral Pathology (4th Desenclos J.C, et Al. 2007. Clinical Guideline: Diagnosis ed.). Philadelphia: Saunders. and Treatment Manual for Curative Programs in Sikri, Vimal K. 2005. Textbook of Operative Dentistry (1st Hospitals and Dispensaries: guidance for prescribing ed.). New Delhi: CBS Publishers and Distributors. (7th revised ed.). Paris: Médecins Sans Frontières. Townsend, Courtney M. et al. 2008. Sabiston Textbook Doherty, Gerard M. 2005. Current Surgery Diagnosis and of Surgery (The Biological Basis of Modern Surgical Treatment (12th ed.). New York: McGraw Hill Medical. Practice) (18th ed.). Philadelphia: Saunders. Ghai, O.P. 2008. Essential Pediatrics with Corrections Wood, Norman K., and Goaz, Paul W. 2007. Differential 2005. Delhi: CBS Publishers and Distributors. Diagnosis of Oral and Maxillofacial Lesions (5th ed.). New Delhi, India: Elsevier.

464 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 465 Annex E Annex E

Annex E. Procedure to Apply for Modification B. Submittal and Screening Process of the NSTG-PL by the MoPH of Afghanistan Applications are submitted to the STG secretariat by mail

or by e-mail: annexes A. General Ministry of Public Health The National Standard Treatment Guidelines for the General Directorate of Pharmaceutical Affairs (GDPA) annexes Primary Level (NSTG-PL) is a dynamic document STG Working Group and users are invited to submit any suggestions Kabul, Afghanistan for improvement using the procedure to apply for E-mail: [email protected] modification of the NSTG-PL outlined in this annex. Phone: 0093 799 303 008 Applications for modification of the NSTG-PL will be OR considered only if the application form has been fully E-mail: [email protected] completed for each condition for which a modification Phone: 0093 707 369 408 is proposed. One application form must be filled out for Applications are reviewed by the STG Secretariat at the each condition for which a modification is proposed. General Directorate of Pharmacy at the MoPH to ensure An application for inclusion in the NSTG-PL may be the following: submitted only for conditions explicitly included or 1. The applicant’s contact details are complete. clearly referred to in the BPHS. In summary, the necessary 2. The condition is clearly described. information required before an application for inclusion in 3. The references to the NSTG-PL or the BPHS are the NSTG-PL will be considered is as follows: clearly indicated. 1. The applicant’s contact details are complete. 4. The existing section that needs to be modified is 2. The condition is clearly described. explicitly stated. 3. The references to the NSTG-PL or the BPHS are 5. The proposed modification is given in detail. clearly indicated. 6. There is sufficient evidence provided to support the 4. The existing section that needs to be modified is proposed modification. explicitly stated. The STG Secretariat will send back incomplete 5. The proposed modification is given in detail. applications for completion by the applicant and will 6. There is sufficient evidence provided to support the schedule complete applications for review by the STG proposed modification. Working Group. The STG Working Group will review applications and decide whether to accept or reject the proposed modification. The applicant will be informed by the secretariat of the decision of the STG Working Group and its rationale. All reviewed applications will be kept on file

466 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 467 Annex E Annex E

with the STG Secretariat. Accepted modifications will be province. Both professional and private addresses are incorporated into the next version of the STG. acceptable. e. Phone: Phone number(s) at which the applicant can be annexes C. Detailed Description of the Data Elements contacted. of the Application Form f. E-mail: E-mail address where correspondence regarding the application can be sent. annexes The application submission form is divided into five sections. g. Facility ID: If applicable, the official MoPH facility code of the facility where the applicant works. If Section 1. Condition to Be Modified the applicant is a private practitioner working in a a. Name of condition: The name of the condition to be nonregistered facility, put the name of the facility. If modified. If the condition is already in the NSTG-PL, there is no name, put “NA”. use the exact name as mentioned in the NSTG-PL. b. NSTG-PL reference: Indicate the section and Section 3. Current NSTG-PL Information chapter number of the condition in the NSTG-PL. For the proposed condition, insert the text of the NSTG- If the condition is not in the NSTG-PL, indicate the PL to be modified. If a longer section is proposed for section number where the condition is proposed to be modification, indicate precisely the section by page included. number, paragraph, and lines. c. BPHS reference: When the application is for inclusion of a new condition, indicate the element and specific Section 4. Proposed Modification component of the BPHS where the condition fits. Write in detail exactly what is proposed to be inserted d. Submission date: The Shamsi calendar date on which into the NSTG-PL. If a longer piece is suggested, add the submission is filled out. on a separate page or pages, and indicate the number of additional pages on the form. Section 2. Applicant’s Details a. If needed, number of pages attached: When This section forms a vital link between the applicant and applicable, write the number of pages attached. the STG decision-making process. b. Evidence: Cite the reference used to propose the a. Title: Mr., Mrs., Dr., Pr., or other title. modification (exact reference of publication, or b. Name: Full name of the applicant. Do not abbreviate website page). (e.g., Mohammad, but not Mhd.; Sayyed, but not S.) c. Father’s name: Full name of the applicant’s father. Do not abbreviate (e.g., Mohammad, but not Mhd.; Sayyed, but not S.) d. Postal address: Full address where correspondence regarding the application should be sent: house number, street name, village of city nahia, district, and

468 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 469 Annex E Annex E

Section 5. For Use by STG Working Group Only Figure E1. The STG modification process This section is intended to ensure that the applications Applicant submits

follow the proper process. Dates of steps or decisions annexes application to will be noted as appropriate. The section will allow the STG Secretariat interested parties to quickly review the history of an

annexes application. a. Application number: Upon receipt, the serial number of the application is noted. It consists of the following: STG Secretariat STG Secretariat ll Number of the form checks completeness requests completion ll The four digits of the Shamsi year of submission of the application by applicant ll The serial number of submission in that year b. Date received: Date on which the application was received c. Date on which the STG Working Date reviewed: Relevant data in NO Group reviewed the application for modification of the sections ,,, condition are complete? d. Decision of the STG Working Group: Circle the appropriate decision YES e. Rationale for the decision: Brief summary of the reasons for acceptance or rejection STG Working f. Signature of STG Secretary: STG Secretary signs and Group reviews application dates the completed form g. Signature of STG Chairperson: STG Chairperson signs and dates the completed form The applicant will be informed in writing of the final Application NO decision. Figure E1 summarizes the modification process. Inform applicant accepted for of WG decision inclusion in STG?

YES

Include condition in STG

470 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 471 Annex E Index

Form for Application for Modification in STG is available Index on the website, www.moph.gov.af A Alkaline cleaners and solvents, 380 An electronic copy of the STG modification form may be A-B-C-D-E protocol, 351 Allergic dermatitis, 86 sent to the following e-mail addresses: Abdomen, acute, 323–324, 334–335 Allergic rhinitis, 98 Abdominal pain Altered mental status, 132 E-mail: [email protected] acute, 323–335 Amebic dysentery, 58–59 annexes Phone: 0093 799 303 008 severe, 400 Amenorrhea, lactational, 418, OR Abortion, 156–162, 219 429–430 Abruptio placenta, xxv, 154 Anaphylactic reaction, 340 E-mail: [email protected] Abscesses, 239–241, 373–376 Anaphylactic shock, 364 Phone: 0093 707 369 408 bites, 337 management of, 371–372 breast, 188–189 signs and symptoms of, 366 cold, 374 Anaphylaxis, xxv, 340, 341, 343 deep space, 400 ANC. See Antenatal care

furuncles, 239–241 Anemia, 201–206, 307 index

Islamic Republic of Afghanistan oral, 41, 43 iron deficiency anemia, 146, 149 Ministry of Public Health General Directorate of Pharmaceutical Affairs Acetylsalicylic acid (aspirin) in pregnancy, 149–151

Application for Modification in STG, Form no. overdose, 387 severe, 147, 150 SECTION 1 – Condition to be modified Acid hypersecretory conditions, 62 Aneurysm Name of the condition:

NSTG-PL reference: BPHS reference: Acidosis, 387 dissecting, 324 Submission date: diabetic ketoacidosis, 231, 232 ruptured aortic, 326 SECTION 2– Condition to be modified Title: Name: ketoacidosis, 230, 231–233 Angina pectoris, xxv, 121–123, 408 Father’s name: Postal address: Acids, 380 chest discomfort in, 409 Acquired immunodeficiency Animal bites, 302, 303, 335–340 Phone: SAMPE-mail: LE Facility ID and name: syndrome (AIDS), 420, 439–442 Antenatal care (ANC), 143–149, SECTION 3 – Current NSTG-PL information Acute abdomen, 323–324, 334–335 151, 212 Acute abdominal pain, 323–335 Antepartum hemorrhage, 154–156 Acute appendicitis, 330–331 Anterior chamber, xxv SECTION 4 – Proposed modification If needed, number of pages attached: pages Acute cholecystitis, xxv, 331–332 Anthrax, 310–311 Acute intestinal obstruction, Anxiety, 135 Evidence: 326–327 Anxiety disorders, 136 Acute myocardial infarction, Aortic aneurysm, ruptured, 326 SECTION 5 – For use by STG Working Group Only Application number: / /

Correspondence Date received: Correspondence Date reviewed: 123–125, 323 APH. See Antepartum hemorrhage Decision of STG Working Group: • Accept • Reject chest discomfort in, 409 Apnea, xxv Rationale for decision: See also Myocardial infarction Appendicitis, xxv, 324, 326 Acute necrotizing gingivitis, 41 acute, 330–331 Signature of STG Secretary: Signature of STG Chairperson: Acute peritonitis, 329–330 Arrhythmia, xxv Acute pulmonary edema, 322–323 Arthralgia, xxv, 251 Adnexa, xxv Arthritis, xxv, 251 Adolescents, childbearing age, 191 osteoarthritis, 251, 254 AIDS (acquired immunodeficiency rheumatoid (autoimmune), syndrome), 420, 439–442 251–255 Airway management, 459 septic, 252, 253, 254–255 Alcohol use, 137 TB, 255 Alcoholism, 362 Ascariasis (roundworm), 306–308

472 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 473 Index Index

Ascites, xxv Blindness. See Nightblindness Candidiasis (Candida infection), Partograph, 461 Aspirin (acetylsalicylic acid) Blood conditions 185, 236, 237 vaginal bleeding after, 173 overdose, 387 anemia, 201–206 cutaneous, 238 Children Asthma, 65–71 thalassemia, 207 oral, 41–42, 43, 238 abdominal pain in, 324, 328 severe, 396 Blood pressure screening, 420 vaginal, 238 abnormal vaginal bleeding in, 191 Asthma-like symptoms, 372 Blood sugar, low, 211 Carbamates, 386 acute abdominal pain in, 324 Asthmatic bronchitis, 82 Blood transfusion, 367 Carbon monoxide poisoning, 383, acute pulmonary edema in, 322 Aura, pre-seizure, 127 Blunt trauma, 355 388 acute pyelonephritis in, 220–221 Autoimmune (rheumatoid) Boils or furuncles, 239–241 Carbuncles, 239 anaphylactic shock in, 372 arthritis, 251–252, 254, 255 ear boils (furuncular otitis Cardiac disease, 137 anemia in, 204, 206, 307 externa), 84, 86 Cardiac failure, 114–117 animal or human bites in, 339 B Booster dose, xxvi Cardiac ischemia, 114 anthrax in, 310, 311 Bacillary dysentery, 56–58 Bowel (intestine) obstruction, 324, Cardiogenic shock, xxvi, 364, 368 arthritis and arthralgia in, 254, Bacille Calmette-Guérin (BCG) 326–327, 332–333 management of, 369 255 immunization Breast abscess, 188–189 signs and symptoms of, 366 ascariasis (roundworm) in, 307 how to vaccinate, 437 Breast examination by provider, 420 Cardiopulmonary resuscitation, asthma in, 65–68 newborn care, 180, 297 Breastfeeding 124 brucellosis in, 313 index schedule of routine childhood cracked nipples during, 184–187 Cardiovascular system conditions, burns in, 352, 353 immunizations, 436 newborn care, 179 107–125 constipation in, 411 index against TB, 297 for prevention of malnutrition, Carditis, 118 cystitis in, 222–223 Bacillus anthracis, 310 212 Carotene: sources of, 213 danger signs, 53 Bacterial tonsillitis, 96–97 Breathing Cat bites, 337, 338, 339 dehydration in, 48–50, 50–51, 53 Basic Package of Health Services fast, 74 Caustic agents, 382 diarrhea in, 51–52 (BPHS), ix rapid, 395 Cellulitis, xxvi, 242, 301, 337 diphtheria in, 262 Battery acid, 380 Breathing difficulty, 149, 177 Central nervous system disorders, febrile convulsions in, 393–394 Bedwetting (nocturnal enuresis), Breech presentation, xxvi, 147 126–134 fever in, 397–398, 400 xxviii Bronchiectasis, xxvi Cervical cancer, 191 fluid requirements (burns), 352 Bee stings, 340–342 Bronchitis Cervical cancer screening test, 420 fungal skin infections in, 238 Benzodiazepine overdose, 389 acute, 82–83 Cervical polyps, 194 furuncles or boils in, 240 Biliary colic, 324 asthmatic, 82 Cervix, xxvi gonococcal infection in, 320 Birth plan, 148 chronic, xxvi, 81, 82–83 tumors of, 194 hypoglycemia in, 361, 362 Birth spacing Brucellosis, 311–313 Chancroid, 317, 319–320 hypothermia in, 212 definition of, xxvi Brudzinski’s sign, xxvi, 131 Chemical burns, 350 immunizations for, 262, 436 family planning for, 417–434 Burns, 348–360 eye injuries, 355, 357–358 impetigo in, 234, 235 for prevention of malnutrition, chemical, 350, 355, 357–358 See also Burns jaundice in, 405, 406 212 esophageal, 383 Chemical or pesticide (insect) spray low blood sugar in, 211 Bites eye injuries, 355–360 poisoning, 386 malaria in, 274–279 animal bites, 302, 303, 335–340 in mouth and throat, 384 Chest discomfort, 407–410 malnutrition in, 211, 365 human bites, 335–340 Chest indrawing, xxvi medicine dosages and regimens insect bites and stings, 340–345 C Chest pain, 327, 407–410 for, 443–458 snake bites, 345–348 Calcium: dietary sources of, 218 Chickenpox, 300–301 osteomyelitis in, 257, 258 spider bites, 343–345 Cancer Childbirth pertussis (whooping cough), Bleeding cervical, 191, 420 birth plan, 148 259–261 dysfunctional uterine bleeding, endometrial, 191, 195 complicated vaginal delivery, pneumonia in, 73–80, 77 191 ovarian, 191 168 poisoning in, 380, 381, 384, 386, See also Hemorrhage; Vaginal vaginal, 191 delivery, 166–171 387, 389 bleeding vulvar, 191 Delivery Note, 461 pulmonary edema in, 323

474 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 475 Index Index

pulmonary TB in, 291–292 Circulatory compromise, 384 Cretinism, 219 for constipation, 411 pyelonephritis in, 220–221 Cobra bites, 345 Cushing’s syndrome, xxvii, 109 for dysmenorrhea, 190 schedule of routine See also Snake bites Cutaneous anthrax, 310–311 for heart failure, 115 immunizations for, 436 COC. See Combined oral Cutaneous candidiasis, 238 for hepatitis, 286 sepsis in, 273 contraception (COC) Cutaneous leishmaniasis, 304, 305 for measles, 270 severely dehydrated, 48–50 Coitus interruptus (withdrawal), Cyanosis, xxvii, 79, 177 for nausea and vomiting, 414 shock in, 365–367, 372 432–433 Cystitis, xxvii, 222–224 for postmenopausal bleeding, 195 tapeworm in, 309 Cold, common, 71–73 to prevent anemia, 204 tetanus in, 265 Cold abscess, 374 D for rickets, 218, 219 typhoid (enteric) fever in, 288, Colic, ureteric, 334–335 Debridement, xxvii, 258 sources of calcium, 218 289 Coma, 113, 114 Deep space infection, 400 sources of iron, 203 urethritis in, 222–223 Combined oral contraception Dehydration, xxvii, 46–61, 414–415 sources of vitamin A, 213 vitamin A deficiency in, 214–215 (COC), 418, 422–424 severe, 48–50, 53, 415 for vitamin A deficiency, 213, 215 vomiting, 415 Common cold, 71–73 Delivery, 166–171 for vitamin D deficiency, 218, 219 wasp and bee stings in, 341 Compromised immunity, xxvi, complicated vaginal delivery, 168 Difficulty breathing, 149, 177 wound infections in, 339 271, 373 Delivery Note: Obstetric Section, Digestive system conditions, 46–64 xerophthalmia in, 214 chickenpox in, 300 461 Diphtheria, 261–263 index See also Infants; Neonates Condoms (male), 287, 321, 418, Partograph and Delivery Note, 461 immunization against, 262, 263, Children older than 5 years 419, 421 Dental caries, 41, 42 435, 436 index acute diarrhea without blood Congestive heart failure, 70 Dental conditions, 41–45 schedule of routine childhood in, 53 Conjunctivitis (red eye), 100–102 Depression, 135, 136 immunizations against, 436 constipation in, 412 severe, 182 Dermatitis, allergic, 86 Dislocation, 373 diarrhea in, 53, 56 Consciousness Diabetes mellitus, 226–231, 363 Dissecting aneurysm, 324 medicine dosages and regimens change in level of, 383 gestational, 227 Diverticulitis, 326 for, 443–458 unconscious patients, 383–384 type I, 226–227, 230 Dog bites, 338, 339 otitis media in, 90 Constipation, 411–412 type II, 227, 230 Drug use, 137 persistent diarrhea in, 56 Convulsions, xxvii, 76 Diabetic ketoacidosis, 231, 232 Duodenal loop, xxvii, 62 pneumonia in, 78–81 febrile, 390–394 Diaper (napkin) rash, 236–239 Duodenal ulcers, 62 Children younger than 5 years in newborn with jaundice, 405 Diarrhea, 46–61 Dysentery, 56–59 acute diarrhea without blood in, COPD. See Chronic obstructive acute, 46–53 Dyslipidemia, xxvii, 108 46–53 pulmonary disease in children, 51–52 Dysmenorrhea, xxvii, 189–190 acute otitis media in, 88–89 Cord care, 179 in children older than 5 years, Dyspnea, xxvii, 115, 395 constipation in, 412 Corneal ulcers, xxvii, 101, 356 53, 56 diarrhea in, 46–53, 54–55 Corrosive agents, 380, 383, 385 in children younger than 5 years, E fever in, 398, 400 Corrosive compounds, 385 46–53, 54–55 Ear, nose, and throat conditions, immunization of, 436 Cough, 394–397 chronic, 215, 440 84–99 medicine dosages and regimens in chronic bronchitis, 81 in HIV infection and AIDS, 440 Ear boils (furuncular otitis for, 443–458 in HIV infection and AIDS, 440 home care for, 51–52 externa), 84, 86 persistent diarrhea in, 54–55 persistent, 440 persistent, 54–55, 56 Ear pain, 89 pneumonia in, 74–78 whooping cough (pertussis), Dietary measures Eclampsia, xxviii, 152, 153 Cholecystitis, acute, xxv, 331–332 259–261, 435, 436 for acute glomerulonephritis, Ectopic pregnancy, xxviii, 157, 160, Cholera, 60–61 Cough etiquette, 397, 401 225 163–164 Choriocarcinoma, 191 Counseling for acute myocardial infarction, ruptured, 333–334 Chronic bronchitis, xxvi, 81, 82–83 family planning, 417 124 Eczematous otitis externa, 84, Chronic diarrhea, 215, 440 psychosocial, 138 for anemia, 203, 204 85, 86 Chronic obstructive pulmonary Cracked nipples, 184–187 for anemia in pregnancy, 151 Edema, xxviii disease, 81–83 Craniotabes, 217 for angina pectoris, 123 with cough, 395

476 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 477 Index Index

pulmonary, xxxvi, 114, 116, Esophagus for prevention of malnutrition, G 322–323 emetic perforation of, 327 212 Gallbladder disease, 410 in sexually transmitted Essential newborn care, 176 See also Breastfeeding Gallbladder pain, 326 infections, 318 Exercise Fertility awareness methods Gastric lavage, 379–380 Electrical burns, 350 for angina pectoris, 123 (FAMs), 418, 430–432 Gastric ulcers, 62 See also Burns for dysmenorrhea, 190 Fetal distress, 171 Gastroenteritis, 326 Embolism, xxviii for heart failure, 115 Fever, 397–400 Gastroesophageal reflux, 409 Emergencies, 322–389 Expanded Programme on in chickenpox, 300 Gastrointestinal perforation, 327 Emergency newborn care, 176–177, Immunization (EPI), 265–266, definition of, 397 Genital herpes, 315–316 179–180 435, 436 febrile convulsion, 390–394 Genital warts, external, 315 indications for, 178 schedule of routine childhood high, 72, 76, 77, 78, 80 Gestational diabetes, 227 Emergency signs, 377 immunizations, 436 in malaria, 276, 283 Gestational hypertension, 152 of poisoning, 377 External ear infection. See Otitis persistent, 400 Giardiasis, 59–60 Emphysema, xxviii, 81 externa prolonged, 440 Gingivitis, 41, 42 Encephalitis, xxviii, 130–134 Extra newborn care, 176, 179 recurring, 400 Glaucoma, xxix, 101, 105–106 Endocarditis, xxviii Extrapulmonary tuberculosis, 290, rheumatic, 117–120 acute (closed angle), 105 Endocrine system disorders, 291, 292, 296 typhoid (enteric), 287–289 chronic (open angle), 105 index 226–233 clinical features of, 293 Flu, 71–73 congenital, 106 Endometrial cancer, 191, 195 Eye conditions, 100–106 Fluid requirements: for burns, Glomerulonephritis, xxix index Endometrial hyperplasia, 194 exposure to poisonous agents, 382 352 acute, 224–225 Endometriosis, 199 injuries, 100, 355–360 Fluid resuscitation Gonorrhea, 315, 317–318, 320 Endometrium, xxviii neonatal infections, 181–182 for anaphylactic shock, 372 Gout, xxix, 252–253, 254–255 Entamoeba histolytica, 58 penetrating trauma, 101, 355 for burns, 352, 354 Granuloma inguinal (granuloma Enteric (typhoid) fever, 287–289 vitamin A deficiency, 213, 214 for children, 367 venereum), 318, 320 Enuresis, xxviii Eye patching, 358 for hypovolemia, 371 Growth faltering, 396 Envenomation, xxviii for hypovolemic shock, 369 Growth restriction, intrauterine, scorpion stings, 342 F for neurogenic shock, 371 148 wasp and bee stings, 340, 341 Fallopian tubes, xxix for septic shock, 370 Guarding, 400 EPI (Expanded Programme on ectopic pregnancy in, 163 for shock, 365–367 Guidelines (Afghanistan MoPH), Immunization), 265–266, 435, infections in, 195 Follicles, xxix, 100, 103, 104 462–463 436 Family planning Food Guidelines (WHO), 463–464 schedule of routine childhood available options, 421–434 for hypoglycemia, 361 Gynecological conditions, 143–200 immunizations, 436 for birth spacing, 417–434 nutritional support, 264 Epigastric discomfort, 206 fertility awareness methods See also Dietary measures H Epigastric pain, 60, 123, 327 (FAMs), 418, 430–432 Food preparation hygiene, 308 Haemophilus influenzae type b Epigastric region, xxix lactational amenorrhea method Foreign bodies, 396 immunization against, 435, 436 Epigastric tenderness, 63 (LAM), 418, 429–430 eye injuries, 355, 358 schedule of routine childhood Epilepsy, 126–130, 137 preparing to use a method, FP. See Family planning immunizations against, 436 idiopathic, 126 417–421 Fungal infections, 237 Hand washing, 58, 59, 308 symptomatic, 126 tests for prescribing, 420–421 of nails, 236 Headache, 401–403 Episiotomy, 168 withdrawal method (coitus otitis externa, 84 migraine, 403–404 Epithelialization, xxix, 348 interruptus), 432–433 of skin, 236–239 Heart disease Erythema, xxix Family planning counseling, types of, 236 persisting, 118 Erythema marginatum, 118 417–421 See also specific infections by name rheumatic, 118 Esophageal burns, 383 Febrile convulsion, 390–394 Furuncular otitis externa (ear valvular, xxxix, 118 Esophageal reflux, 408, 409 Feeding boils), 84, 86 Heart failure, 114–117, 395 Esophagitis, 408 nasogastric tube, 262 Furunculosis, 239–241 congestive, 70

478 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 479 Index Index

Heat therapy, 190 psychological symptoms of, 137 Immunity, compromised, xxvi, napkin (diaper) rash, 236–239 Helminthic infestations, 306–309 Hyperosmolar state, 233 271, 373 pneumonia in, 396 See also specific infestations Hypertension, 343 chickenpox in, 300 premature, 288 Hematoma, xxix, 171 chronic, 107–113, 151 Immunization, 396, 435–438 projectile vomiting in, 415 Hematuria, xxix, 194, 224 classification of, 107 antenatal care, 146–147 shock in, 365, 372 Hemoglobin, 202, 420 definition of, 107, 151 of children, 262, 436 tetanus in, 264 Hemolytic, xxix essential, 107 for diphtheria, 262, 263, 435, 436 typhoid (enteric) fever in, 288 Hemorrhage gestational, 152, 153 Expanded Programme on vaginal bleeding in, 191 antepartum, 154–156 of pregnancy, 151–154 Immunization (EPI), 265–266, wasp and bee stings in, 341 postpartum, 172–176 pregnancy-induced, 152 435, 436 See also Neonates Hepatitis, xxix, 284–287 primary, 107 for hepatitis B, 435, 436 Infections associated signs and symptoms with proteinuria, 152 for Hib, 435, 436 in AIDS, 440, 441 of, 413 with proteinuria and seizures, 152 how to vaccinate, 437 deep space, 400 Hepatitis A, 284, 285, 286 psychological symptoms of, 137 for measles, 435 fungal, 236, 237, 238 Hepatitis B, 284, 285, 286 secondary, 107 National Immunization Days, 435 HIV infection, 439–442 immunization against, 435, 436 signs and symptoms of, 108–109 newborn care, 180, 435 meningococcal, 399 in pregnancy, 286 systemic, 107–114 for pertussis, 260, 435, 436 neonatal, 179–180, 180–181 index schedule of routine childhood Hypertension emergency, 113–114 for poliomyelitis, 268, 435, 436 opportunistic, 440 immunizations against, 436 Hypertensive crisis, 323 for prevention of malnutrition, psychological symptoms of, 137 index Hepatitis C, 284, 285, 286 Hypertensive retinopathy, 113 212 repeated, 441 Hepatitis D, 284, 285 Hyperthermia, 177 schedule of routine childhood sexually transmitted, 315–321 Hepatitis E, 284, 285 Hyperthyroidism, 137 immunizations, 436 soft tissue, 242 Hepatomegaly, xxx, 305 Hypogastric region. See for TB, 297, 435, 436 umbilical, 181 Herpes, genital, 315–316 Hypogastrium for tetanus, 265–266, 303, urinary tract, 220–224 Herpes simplex virus, 315–316, 319 Hypogastrium, xxx, 333 336–337, 435, 436, 437 wound infections, 338 Herpes simplex virus-2, 315 Hypoglycemia, xxx, 226, 229, Immunodeficiency.See AIDS See also specific infections by Herpes zoster, 410 360–363 (acquired immunodeficiency name Hirschprung disease, xxx, 411 management of, 230, 361–363 syndrome); HIV (human Infectious diseases, 259–321 History-taking, 126–127 neonatal, 179 immunodeficiency virus) See also specific diseases by HIV (human immunodeficiency psychological symptoms of, 137 infection name virus) infection, 315, 439–442 Hypotension, 364 Impetigo, 234–236 Infectious rhinitis, 98 screening for, 420 Hypothermia, xxx, 177 Infants Infertility, 198–200 Home care (diarrhea and in children, 212 abnormal vaginal bleeding in, Ingested poisons dehydration), 51–52 danger signs of, 178 191 removing or eliminating, 379–381 HPV (human papilloma virus), prevention of, 212 anaphylactic shock in, 372 See also Poisoning 315, 319 Hypothyroidism, 137 anemia in, 204 Inhalation burns, 351, 354 Human bites, 338, 339 Hypovolemia, xxx animal or human bites in, 339 See also Burns Human immunodeficiency virus Hypovolemic shock, 364 definition of, xxxi Inhaled poisonous or caustic (HIV) infection, 315, 439–442 management of, 369 encephalitis in, 132 agents, 382 screening for, 420 signs and symptoms of, 366 fever in, 399 See also Poisoning Human papilloma virus (HPV), Hypoxemia, acute, 82 gonococcal infection in, 320 Injectables, progestin-only, 315, 319 Hypoxia, xxx HIV infection and AIDS in, 441 427–428 Hydrophobia, xxx, 302 hypoglycemia in, 361 Injury, eye, 101, 355–360 Hymenolepis nana, 308–309 I malnutrition in, 211 Insect bites and stings, 340–345 Hyperglycemia, xxx, 226, 228–229, Ileus, 327 medicine dosages and regimens Insect (pesticide) spray poisoning, 231–233 definition of, xxxi for, 443–458 386 management of, 230, 233 paralytic, 332 meningitis in, 132 Insulin, xxxi, 226

480 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 481 Index Index

Insulin administration, 232–233 L in infants, 211 Metabolic disturbances, 137 faulty, 229, 360 Labor kwashiorkor, 208 Metrorrhagia, xxxii, 193 Insulinoma, 360 first stage, 166–167, 167–168 marasmic, 208 Micronutrient, xxxii Intestinal obstruction, 324 premature, 180 moderate, 208, 210–211 Migraine, 403–404 acute, 326–327 preterm, 164–166 prevention of, 260 Miliary tuberculosis, 296 strangulating, 324 prolonged, 171 severe, 208, 211–212, 215 Ministry of Public Health (MoPH) Intrauterine devices (IUDs), 418, second stage, 167, 168 Mania, xxxii, 135 guidelines, 462–463 428–429 stages of, 166–167 Marasmo-Kwashiorkor, 208 procedure to apply for Intrauterine growth restriction, third stage, 167, 168–169, 175–176 Mastitis, xxxii, 187–188 modification of the NSTG-PL, 148 vaginal bleeding during, 193 Mastoiditis, xxxii, 88, 92, 398 466–472 Iodine deficiency, 219 Laboratory tests, routine for FP, Maswak, 45 Mood changes, 135 Iritis, xxxi, 101 420 Measles, 268–271 Morbidity rate, xxxii Iron: dietary sources of, 203 Lactational amenorrhea method immunization against, 435 Mortality rate, xxxii Iron deficiency anemia (LAM), 418, 429–430 signs and symptoms of, 72, 269, Mucocutaneous leishmaniasis, in pregnancy, 149 Left chest pain, 327 399 304 prevention of, 146, 205 Left ventricular hypertrophy, xxxi, treatment schedule, 215 Multipara, xxxiii Iron overdose, 206, 387 108 Meckel’s diverticulum, xxxii, 62 Mumps, 313–314 index Ischemia Leishmaniasis, 304–306 Meconium, xxxii, 411 Muscle-wasting, 208 cardiac, 114 cutaneous, 304, 305 Medications Musculoskeletal conditions, index definition of, xxxi mucocutaneous, 304 dosages and regimens, 443–458 251–258 See also Angina pectoris visceral, 304, 305 for psychiatric disorders, chest discomfort in, 410 Itching Lethargy, xxxi, 178 140–142 Mycobacterium tuberculosis, 290 with burns, 353 Level of consciousness psychological symptoms of, 137 Myocardial infarction, xxxiii, 408 with wasp and bee stings, 341 change in, 383 sublingual administration of, acute, 123–125, 323, 409 IUDs (intrauterine devices), 418, unconscious patients, 383–384 xxxviii Myocarditis, xxxiii 428–429 Lice, 245–247 topical medicine, xxxviii Myocardium, xxxiii Loeffler’s syndrome, 395 See also Drugs Index J Low blood sugar Meningitis, xxxii, 130–134 N Jaundice, 404–407 in children, 211 signs and symptoms of, 131–132, Nails: fungal infection of, 236 abnormal, 178 See also Hypoglycemia 413 Napkin (diaper) rash, 236–239 neonatal, 180, 405, 406 Low weight, 208, 209 Meningitis TB, 296 Narcotic poisoning, 388–389 physiologic, 180, 406 Lower abdomen. See Hypogastrium Meningococcal infection, 399 Nasogastric lavage, 386, 387 physiologic neonatal jaundice, Lymph nodes, xxxi Menopause, 193 Nasogastric tube 405 swollen, 96, 204, 239, 240, 245, Men’s health for bowel obstruction, 333 Jejunum, xxxi, 62 310, 376 infertility, 199 definition of, xxxiii Lymphangitis, xxxii, 234, 310, 376 medicine dosages and regimens for dysphagia, 262 K Lymphogranuloma venereum, for, 443–458 for hypoglycemia, 363 Kala-azar, 304 318–319, 320 sexually transmitted infections, for peritonitis, 330 Kangaroo transport, 212 321 for removing or eliminating Kangaroo warming, 178 M Mental health conditions, 135–142 ingested poisons, 380 Keratitis, xxxi, 101 Malaria, 72, 274–283, 399 common mental disorders, National Immunization Days, 435 Kernig’s sign, xxxi, 131 in pregnancy, 280–281 135–136 National Standard Treatment Kerosene, 380 second-line therapies, 281–283 medications for psychiatric Guidelines for Primary Level Ketoacidosis, 230, 231–233 severe, 280 disorders, 140–142 (NSTG-PL), ix Kidney stone, 326 unconfirmed, 279–280 psychological disorders, 135, 137 modification process, 471 Kwashiorkor, 208 Malnutrition, 208–212 severe mental disorders, 136 procedure to apply for in children, 211, 365 Mesenteric ischemia, 324, 326 modification of, 466–472

482 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 483 Index Index

Nausea and vomiting, 413–416 Older patients: acute abdominal epigastric, 60, 123, 327 acute, 329–330 pregnancy-induced, 146 pain in, 324 gallbladder, 326 Pertussis (whooping cough), Necrotizing gingivitis, acute, 41 Oliguria, xxxiii, 224 mild, 343 259–261 Neonatal infection, severe, 179–180 Ophthalmia neonatorum, 182 pelvic, 163 immunization against, 260, 435, Neonatal jaundice, 180, 405, 406, Ophthalmologic, xxxiii renal, 326 436 407 Opioid overdose, 388–389 severe, 343 schedule of routine childhood nonphysiologic or abnormal, 405 Opportunistic infections, 440 shoulder, 327 immunizations against, 436 physiologic, 405 Oral candidiasis (thrush) Pain relievers, xxxiii Pesticides, 380, 386 Neonates description of, 41–42 See also Drugs Index Petechia, 132 danger signs in, 177–178 diagnosis of, 43 Pancreatitis, xxxiii, 326 Petroleum-based products, 380, definition of, xxxiii management of, 44, 238 Paracetamol poisoning, 386 383 fever in, 400 Oral cavity, 41 Paralysis, 267–268 Petroleum compounds, 385 medicine dosages and regimens Oral conditions, 41–45 Paralytic ileus, 332 Pharyngitis for, 443–458 Oral contraceptives. See Combined Parasitic diseases, 304–309 in HIV infection and AIDS, 441 newborn care, 176–184 oral contraception (COC) See also specific parasites by repeated, 441 Neurogenic shock, 364 Oral hygiene, 45 name viral, 94–96 management of, 371 Orchitis, 313 Parasympathetic activation, excess, Phonophobia, xxxiv, 403 index signs and symptoms of, 366 Organophosphorous, 386 386 Photophobia, xxxiv, 358 Neurosyphilis, 319 Orthopedic, xxxiii Paresthesia, xxxiv, 302 Physiologic jaundice, 180 index Newborn care, 176–184 Osteoarthritis, 251, 254 Partograph and Delivery Note, 461 PID. See Pelvic inflammatory emergency care, 176–177 Osteomalacia, 218 Patient instructions disease essential, 176 Osteomyelitis, xxxiii, 256–258 for antenatal care, 148–149 Placenta previa, xxxiv, 154 extra, 176 acute, 256–257 for breastfeeding, 186 Plasmodium falciparum (PF), 274, See also under Neonatal; chronic, 257 for how to apply eye ointment, 277–279, 281 Neonates Osteoporosis, 218 102 Plasmodium vivax (PV), 274, 276, Newborn resuscitation, 459–460 Otitis, xxxiii, 259 for how to take medications, 256 277–279, 280, 281 Nightblindness, 213 Otitis externa, xxxiii, 84–87 for nipple hygiene, 186–187 Pneumonia, 67, 68, 72, 73–80, 395, Nipple hygiene, 186–187 eczematous, 84, 85, 86 See also specific conditions by 396 Nipples, cracked, 184–187 fungal, 84 name chest discomfort in, 409 Nocturia, xxxiii furuncular (ear boils), 84, 86 Pediatrics. See Children; Infants; in children, 77 Nocturnal enuresis (bedwetting), Otitis media, xxxiii, 398 Neonates in children older than 5 years, xxviii acute, 87–90, 88–89, 90 Pediculosis, 245–247 78–81 Nose, runny, 98 in children older than 5 years, 90 Pelvic/genital examination, 420 in children younger than 5 years, Nutritional conditions, 201–219 in children younger than 5 years, Pelvic inflammatory disease, 74–78 Nutritional support 88–89 195–198 differential diagnosis of, 67 tetanus, 264 chronic, 91–92 Pelvic pain, 163 in infants, 396 See also Dietary measures in HIV infection and AIDS, 441 Penetrating injury, 101, 355 nonsevere, 80 recurrent, 90 Pepsin, xxxiv severe, 74–75, 75–76, 79–80, O repeated, 441 Peptic ulcer disease, 62–64, 326, 394–395, 396, 408 Obstetrics, 143–200 Otomycosis, 84 408 signs and symptoms of, 74–75, Delivery Note: Obstetric Section, Ovarian cancer, 191 chest discomfort in, 409 78–79, 413 461 perforated ulcers, 332 Pneumothorax, xxxv, 408, 409 Partograph and Delivery Note, 461 P Pericardial tamponade, xxxiv, 364 Poisoning, 377–389 Obstructive pulmonary disease, Pain Perinatal period, xxxiv pharmacologic management of chronic, 81–83 abdominal, 323–335, 400 Periodontitis, 41, 42 specific poisons, 385–389 Obstructive shock, 364 chest, 327, 407–410 Peritoneal irritation, 413 removing or eliminating Ocular injury, 384 chronic, 255 Peritonitis, xxxiv, 324, 326, 327, 328 causative agents in, 379–382

484 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 485 Index Index

Poliomyelitis, 267–268 protracted, 147 Pus, 301 Ruptured ectopic gestation, immunization against, 268, 435, routine ANC visits during, Pyelonephritis, xxxvi, 326, 328 333–334 436 145–146 acute, 220–222 Ruptured spleen, 326 schedule of routine childhood routine examinations, 420–421 Pyloric canal or channel, xxxvi, 62 immunizations against, 436 ruling out, 418 S Polyhydramnios, 147 signs and symptoms of, 144, 419 R Safety measures Polyps, cervical, 194 syphilis in, 319 Rabies, 302–303, 337 to prevent eye injury, 359 Polyuria, xxxv, 228 vaginal bleeding in, 156–162, Radiation burns, 350 sterilization, 287 Postmenopausal bleeding, 191–192, 192–193 See also Burns Saint Vitus dance, 118 193–195 Pregnancy-induced hypertension, Red eye (conjunctivitis), 100–102, Salicylates poisoning, 387 Postnatal period, xxxv 152 182 Salpingitis, xxxvi, 329 Postpartum care, 170, 183 Pregnancy-induced nausea and Reflux Scabies, 247–250 preventive dosage schedule for vomiting, 146 chest discomfort in, 409 Scalp ringworm (tinea capitis), vitamin A supplementation, 216 Premature infants, 288 esophageal, 408, 409 236, 237 Postpartum hemorrhage (PPH), Premature labor, 180 gastroesophageal, 409 Schizophrenia, xxxvii, 136 172–176 Preterm infants. See Premature Renal colic, 324 Scorpion stings, 342–343 early (primary), 172–174 infants Renal conditions, 220–225 Seizures, xxxvii index late (secondary), 172, 173, 175 Preterm labor, 164–166 Renal pain, 326 associated events, 127 Postpartum period, xxxv Preterm rupture of membranes, 183 Respiratory conditions, 65–83, 137 classification of, 127 index Pouch of Douglas, xxxv Primiparas, xxxv Respiratory distress, 384, 385 febrile convulsions, 390–394 distended, 327 Prodromal syndrome, xxxv Resuscitation focal, 127 PPH. See Postpartum hemorrhage of rabies, 302 cardiopulmonary, 124 generalized (grand mal), 127 Pre-eclampsia, xxxv, 152, 153 Progestin-only injectables, newborn, 459–460 grand mal (generalized), 127 Pregnancy, 143–149 427–428 See also Fluid resuscitation hypertension with, 152 abnormal vaginal bleeding in, Progestin-only pill, 425–426 Retinol: sources of, 213 partial, 127 192–193 Projectile vomiting, 415 Retinopathy, xxxvi recurrent, 126 anemia in, 149–151 Prolonged rupture of membranes, hypertensive, 113 tonic-clonic, 127 antenatal care (ANC), 143–149, 183 Reye’s syndrome, xxxvi, 300 Sepsis, xxxvii, 272–273 151 Prophylaxis, xxxv Rheumatic fever, 117–120 systemic, 328 danger signs, 144 Proteinuria, xxxv, 153 Rheumatic valvular disease, 118 Septic abortion, 157, 160, 161–162 delivery, 166–171 hypertension with, 152 Rheumatoid (autoimmune) Septic arthritis, 252, 253, 254–255 determining, 417–421 Pruritus, xxxvi arthritis, 251–252, 254, 255 Septic shock, 273, 364 early, 156–162, 192 in burns, 353 Rhinitis, xxxvi, 98–99 management of, 370 ectopic, xxviii, 157, 160, 163–164 in wasp and bee stings, 341 allergic, 98 signs and symptoms of, 366 granuloma inguinal in, 320 Pseudo-gout, 252–253, 254–255 infectious, 98 Septicemia, 399 hepatitis B in, 286 Psychiatric disorders, 140–142 Rhonchi, xxxvi, 69 Sexually transmitted infections hypertension disorders of, Psychological disorders, 135, 137 Rice-water stools, 61 (STIs), 315–321 151–154 Psychosis, xxxvi, 135, 136 Rickets, 217–218 laboratory screening, 420 late, 192 Psychosocial counseling, 138 Ringworm, 236, 237 risk assessment, 420 lymphogranuloma venereum Pubic region. See Hypogastrium Rooming in, 179 Shigella, 56 in, 320 Puerperium. See Postpartum period Roundworm (ascariasis), 306–308 Shock, xxxvii, 324, 327, 328, malaria in, 280–281 Pulmonary disease, chronic Rule of nines, 350 363–372 Partograph and Delivery Note, obstructive, 81–83 Runny nose, 98 anaphylactic, 364, 366, 371–372 461 Pulmonary edema, xxxvi, 114, 116 Rupture of membranes cardiogenic, xxvi, 364, 366, 368, postpartum care, 170, 183 acute, 322–323 preterm, 183 369 postpartum hemorrhage, 172–176 Pulmonary TB, 291–292 prolonged, 183 hypovolemic, 364, 366, 369 preterm labor, 164–166 Purpura, 132 Ruptured aortic aneurysm, 326 neurogenic, 364, 366, 371

486 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 487 Index Index

obstructive, 364 for animal and human bites, immunizations against, 436 after childbirth, 173 septic, 273 336–337 signs of, 75, 79 in early pregnancy, 156–162, 192 Shortness of breath, 383 for rabies, 303 Tuberculosis (TB) arthritis, 255 heavy bleeding, 158 Shoulder pain, 327 schedule for women, 437 Tumors, 191, 194 during labor, 193 Signs and symptoms, 390–416 schedule of routine childhood Tympanic membrane, xxxviii, 85, 87 in late pregnancy, 192 Sinusitis, xxxvii immunizations, 436 perforation of, 91 light bleeding, 158 acute, 92–94 Tetanus prophylaxis, 344 Typhoid (enteric) fever, 287–289 postmenopausal, 193–195 Skin conditions, 234–250 in burns, 353 Vaginal cancer, 191 chest discomfort in, 410 Thalassemia, 207 U Vaginal candidiasis, 238 exposure to poisonous agents, 382 Thalassemia major, 207 Ulcers Vaginal delivery, complicated, 168 fungal infections, 236–239 Thalassemia minor, 207 corneal, xxvii, 101, 356 Vaginal tumors, 194 neonatal pustules, 181 Thermal burns, 350 duodenal, 62 Vaginitis, xxxix, 191 vitamin A deficiency changes, 213 eye injuries, 355 gastric, 62 atrophic, 194 Snake bites, 345–348 See also Burns peptic, 62–64, 326, 332, 408, 409 Valvular heart disease, xxxix Soft tissue infections, 242 Throat, sore, 94–97 Umbilical cord care, 179, 184 rheumatic, 118 Sore throat, 94–97 Thrush (oral candidiasis) Umbilical cord control, 168–169 Vasoconstrictions, extra-cranial, Spermicides, 433–434 description of, 41–42 Umbilical infections, 181 404 index Spider bites, 343–345 diagnosis of, 43 Umbilicus: pus or redness of, 178 Venomous snakes, 345 Spinal cord injury, 371 management of, 44, 238 Unconscious patients, 383–384 See also Snake bites index Spleen, ruptured, 326 Tinea capitis (scalp ringworm), Under-nutrition, 208–212 Ventilation, newborn, 459, 460 Spoon nails, 149 236, 237 Universal precautions, 441 Very low weight, 208, 209, 210–211 Status asthmaticus, 70 Tinea cruris, 236 Ureteric colic, 334–335 Viper bites, 345 Stillbirth, xxxvii, 219 Tinea pedis, 236 Urethral meatus, xxxviii See also Snake bites Stings Tocolysis, 164–165 infection of, 315 Viral hepatitis, 284 insect stings, 340–345 Toilet habits, 411 prolapse of, 191 Viral pharyngitis, 94–96 scorpion stings, 342–343 Tonsillitis, xxxviii Urethritis, xxxviii, 222–224 Visceral leishmaniasis, 304, 305 wasp and bee stings, 340–342 bacterial, 96–97 Urinary tract conditions, 220–225 Vitamin A: sources of, 213 STIs. See Sexually transmitted Topical medicine, xxxviii Urinary tract infections, 220–222, Vitamin A deficiency, 212–216 infections Toxicity, 400 328 Vitamin D deficiency, 217–219 Stomatitis, xxxvii Trachoma, 101, 103–105 signs and symptoms of, 413 Volvulus, xxxix Stools, rice-water, 61 diagnosis of, 103 Urticaria, 243–245 Vomiting Stridor, xxxvii, 395 signs of, 100, 103 Uterine atony, 174 inducing, 379, 387 Stroke, xxxviii, 109 Trauma, 322–389 Uterine bleeding, dysfunctional, 191 nausea and vomiting, 146, Sublingual administration, xxxviii blunt, 355 Uterine contractions, regular, 167 413–416 Sycosis, 241–243 eye injuries, 355–360 Uterine massage, 169 pregnancy-induced, 146 Sydenham’s chorea, 118 penetrating, 355 Uterine rupture, 154, 155 projectile, 415 Syphilis, 315, 316–317, 319 vaginal, 191 Uveitis, xxxviii Vulva, xxxix, 191, 194 Tuberculosis (TB), 131, 290–299 T exposure to, 396 V W Tachycardia, xxxviii, 340 extrapulmonary, 290, 291, 292, Vaccinations Wallace’s Rule of Nines, 350 Tachypnea, xxxviii, 115 293, 296 how to vaccinate, 437 Warming, 178 Taenia saginata, 308–309 immunization against, 297, 435, TT schedule for women, 437 Warts, genital, 315 Tapeworm, 308–309 436 See also Immunization Wasp and bee stings, 340–342 TB. See Tuberculosis meningitis, 296 Vacuum extraction, xxxix Wasting, mild, 210 Tetanus, 263–266 miliary, 296 Vaginal atrophy, 194 Weigh for age chart, 209 Tetanus immunization, 265–266, pulmonary, 291 Vaginal bleeding Weight loss 435 schedule of routine childhood abnormal, 191–193 cough with, 396

488 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 489 Index Drugs Index

for diabetes mellitus, 229 medicine dosages and regimens for heart failure, 115 for, 443–458 Drugs Index in HIV infection and AIDS, 440 obstetrics, 143–200 A for urethritis, 223 low weight, 208 postmenopausal women, 191–192 Acetaminophen. See Paracetamol Amoxicillin/clavulanate, 338, 339 for obesity, 229, 255 TT vaccination schedule for, 437 Acetylcysteine, 386 Ampicillin very low weight, 208, 209, World Health Organization (WHO) Acetylsalicylic acid (aspirin). See for abdominal pain, 328 210–211 Expanded Programme on Aspirin for cholecystitis, 332 Wheezing, xxxix, 76, 77, 82, 395 Immunization (EPI), 265–266, Activated charcoal dosages and regimens, 446 chronic, 83 435, 436 cautions, 385 for encephalitis, 133–134 mild diffuse, 69 guidelines, 463–464 for iron poisoning, 387 for febrile convulsion, 393 WHO. See World Health Wound care, 264, 303 for poisoning, 380–381, 386 for gout (or pseudo-gout), Organization (WHO) in animal or human bites, 338, Adrenaline (epinephrine) 254–255 Whooping cough (pertussis), 339 for anaphylactic shock, 371 for infections in malnutrition, 259–261 in burns, 354 for anaphylaxis, 341, 343 211–212 immunization against, 260, 435, follow-up care, 354 dosages and regimens, 452 for measles, 271 436 high-risk wounds, 264 Albendazole: contraindications for meningitis, 133–134 schedule of routine childhood low-risk wounds, 264 to, 307 for neonatal infections, 181, 182 immunizations against, 436 Wound infections, 338, 339 Alcohol: contraindications to, 72 for osteomyelitis, 257 Withdrawal (coitus interruptus), index Aluminum hydroxide plus for otitis media, 88 X 432–433 magnesium hydroxide for peritonitis, 330 Women’s health Xerophthalmia, xxxix, 214 for esophagitis, 408 for pneumonia, 67, 75, 76, 79 gynecological conditions, for peptic ulcer disease, 408 for preterm labor infection, 165 Z 143–200 Aminophylline for pyelonephritis, 220, 221 immunization, 437 Zollinger-Ellison syndrome, xxxix, for asthma, 66, 70 for sepsis, 273 infertility, 198, 199 62 for asthma-like symptoms, 372 for septic abortion, 161 contraindications to, 66, 68 for septic arthritis, 254–255 drugs index dosages and regimens, 444 for septic shock, 370 for status asthmaticus, 70 Analgesics for wheezing, 82 contradictions to, 335 Amitriptyline for arthritis and arthralgia, 254 for migraine, 404 for burns, 353, 354 for psychiatric disorders, 140 for dental and oral conditions, 43 Amlodipine, 112, 343 for fever and pain in mastitis, 188 Amoxicillin for pain of cracked nipples, 185 for anthrax, 309 for pain of dislocation, 373 for bronchitis, 83 for pain of spider bites, 344 for cystitis, 223 for pelvic inflammatory disease, dosages and regimens, 445 197 for febrile convulsion, 393 for wasp and bee stings, 341 for infections in malnutrition, See also specific medicines by 211–212 name for otitis media, 88, 89, 90 Anesthetics for pneumonia, 76, 77, 79, 80 for scorpion stings, 343 for postpartum hemorrhage, 175 for severe pain, 343 for preterm labor, 165 Angiotensin-converting enzyme for sinusitis, 93 (ACE) inhibitors for typhoid (enteric) fever, 289 contraindications to, 71, 116

490 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 491 Drugs Index Drugs Index

for heart failure, 116 for postpartum hemorrhage, 175 Antimicrobials newborn care, 180, 297 for hypertension, 112 for preterm labor, 165 for impetigo, 235 schedule of routine childhood Antacids prophylactic, 337 for septic shock, 370 immunizations, 436 for esophagitis, 408 for pyelonephritis, 220–221 See also Antibiotics Beclomethasone, 70 for peptic ulcer disease, 64, 408 for secondary skin infections, Antipyretics Benzathine benzylpenicillin Antibacterial creams, 242 301 for pelvic inflammatory disease, for rheumatic fever, 119 Antibiotics for sepsis, 273 197 for syphilis, 319 for abdominal pain, 328 for septic abortion, 161–162, 192 for typhoid (enteric) fever, 288 for tonsillitis, 97 for abscesses, 337, 375–376 for septic arthritis, 254–255 See also specific medicines by Benzoic acid, 237 for acute abdomen, 334–335 for septic shock, 368, 370 name Beta-blockers for acute otitis media, 88, 90 for skin infections, 246 Antiseptic creams, 242 contraindications to, 71 for acute pyelonephritis, for sycosis, 242 Antiseptics for hypertension, 112 220–221 for tetanus, 265, 266 for sycosis, 242 Betadine® (povidone-iodine): for animal or human bites, 337, for typhoid (enteric) fever, wound care, 303 contraindications to, 354–355 338, 340 288–289 See also specific medicines by Betamethasone, 86 for bronchitis, 82 for wound infections, 338 name Bisacodyl tablet, 412 for burns, 353–354 See also specific medicines by Antispasmodic medicine, 335 Bronchodilators for cellulitis, 337 name Anti-TB medicines, 294, 335 for asthma, 65–66, 67 for cholecystitis, 332 Anticonvulsants daily dose, 297, 298 for wheezing, 82, 83 for chronic otitis media, 91 for epilepsy, 128 Antitetanus immunoglobulin, 264 contraindications to, 72, 239 for seizures, 133 Antivenom, 347 C for dental and oral infections, See also specific medicines by Artemether, 280 Caffeine, 404 43–44 name Artesunate, 277, 279, 280, 281 Calamine lotion, 244, 300, 341 for diphtheria, 262 Anti-D Rh immunoglobulin, 162 Aspirin (acetylsalicylic acid) Calcium supplements for dysentery, 57 Antidepressants for acute MI, 124, 323 for rickets, 218, 219 for encephalitis, 133–134 contraindications to, 142 for angina pectoris, 122, 408 for vitamin D deficiency, 218,

for febrile convulsion, 393 for psychiatric disorders, 142 contraindications to, 300, 392, 219 drugs index for furuncles or boils, 240 See also specific medicines by 400, 403 Captopril for gout (or pseudo-gout), name for dysmenorrhea pain, 188 for angina, 408 254–255 Antidiabetic agents, 363 for migraine, 403 contraindications to, 71 for impetigo, 235 Antidotes, 383 for myocardial infarction, 124, for heart failure, 116 for infections in malnutrition, Antiemetics, 415 323, 408 for hypertension, 112 drugs index drugs 211–212 Antifungal rinses, 44 for rheumatic fever, 120 for hypertension emergency, for mastitis, 187–188 Antihelmintics, 206 Atenolol 114 for meningitis, 133–134 Antihistamines for angina pectoris, 122 for hypertensive crisis, 323 for neonatal jaundice, 180–181, for anaphylactic shock, 372 contraindications to, 71, 111–112, for myocardial infarction, 408 182, 406 for rhinitis, 99 122 Ceftriaxone for osteomyelitis, 258 for sinusitis, 93 for hypertension, 111, 112 for acute pyelonephritis, 221 for otitis media, 88, 90, 91 for spider bites, 344 Atropine for chancroid, 319 for pelvic inflammatory disease, for wasp and bee stings, 341 contraindications to, 72 for gonorrhea, 320 197 See also specific medicines by for poisoning, 386 for gout (or pseudo-gout), 255 for peritonitis, 329 name Azithromycin, 104 for neonatal infections, 181 for pertussis (whooping cough), Anti-inflammatory medicines for septic arthritis, 255 260 for arthritis and arthralgia, 254 B Charcoal, activated for pneumonia, 67, 68, 75, 76, 77, See also specific medicines by Bacille Calmette-Guérin (BCG) cautions, 385 78, 79, 80 name vaccine for iron poisoning, 387 postpartum care, 183 Anti-lice shampoo, 246 how to vaccinate, 437 for poisoning, 380–381, 386

492 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 493 Drugs Index Drugs Index

Chloramphenicol for furuncles or boils, 240 Diphtheria antitoxin, 262 for chancroid, 320 for cellulitis, 242 for impetigo, 235 Diuretics for cystitis, 223 contraindications to, 288 for mastitis, 187 for heart failure, 116 for dental infections, 44 dosages and regimens, 447 for otitis externa, 86 for hypertension, 112 for diphtheria, 262 for otitis externa, 86 for soft tissue infections, 242 See also specific medicines by dosages and regimens, 453 for soft tissue infections, 242 Codeine: contraindications to, 72 name for febrile convulsion, 393 for typhoid (enteric) fever, Combined oral contraception Doxycycline for furuncles or boils, 240 288–289 (COC), 418, 422–424 for anthrax, 309 for granuloma inguinal, 320 Chlorhexidine plus cetrimide Condoms, 418, 421 for bronchitis, 83 for impetigo, 235 solution, 303 Corticosteroids for brucellosis, 312 for infections in malnutrition, Chlorhexidine solution, 43 for anaphylactic shock, 372 contraindications to, 83, 282, 312 212 Chloroquine for asthma, 69, 70 dosages and regimens, 451 for lymphogranuloma venereum, dosages and regimens, 448 for wasp and bee stings, 341 for malaria, 282 320 for malaria, 277, 278, 279–280 See also specific medicines by for neurosyphilis, 319 for mastitis, 188 Chlorphenamine name for pelvic inflammatory disease, for oral infections, 44 (chlorpheniramine) Co-trimoxazole (sulfamethoxazole 197, 198 for osteomyelitis, 258 for burns, 352 + trimethoprim) for pneumonia, 80 for otitis externa, 86 for conjunctivitis (red eye), 101 for animal or human bites, 338, for syphilis, 319 for otitis media, 88, 89, 90 contraindications to, 301, 353 339 DPT (diphtheria, pertussis, and for pertussis (whooping cough), dosages and regimens, 449 for bronchitis, 83 tetanus) 260 drowsiness with, 99 for brucellosis, 313 for diphtheria, 263 for pneumonia, 67, 76, 79, 80 for anaphylactic shock, 372 for cystitis, 223 for pertussis (whooping cough), for postpartum hemorrhage, 175 for itching, 101, 244, 300–301, dosages and regimens, 450 260 for preterm labor, 165 353, 406 for dysentery, 57 DTP-HepB, 437 for pyelonephritis, 221 for rhinitis, 99 for febrile convulsion, 392 for rheumatic fever, 119 for sinusitis, 93 for granuloma inguinal, 320 E for sepsis, 273

for spider bites, 344 for infections in malnutrition, Enemas, 412 for septic abortion, 161 drugs index for wasp and bee stings, 341 211–212 Epinephrine (adrenaline) for sinusitis, 93 Chlorpromazine, 142 for lymphogranuloma venereum, for anaphylactic shock, 371 for syphilis, 319 Ciprofloxacin 320 for anaphylaxis, 341, 343 for tetanus, 266 for animal or human bites, 338 for otitis media, 89 dosages and regimens, 452 for tonsillitis, 97 for cellulitis, 242 for pneumonia, 67, 77, 80 Ergometrine for typhoid (enteric) fever, 289 drugs index drugs contraindications to, 223, 242, for urethritis, 223 for incomplete abortion, 160 for ureteric colic, 334 289, 338 Crystalloids, 370 for postpartum hemorrhage, for urethritis, 223 for cystitis, 223 174 Estradiol, 194 for dysentery, 57 D for uterine bleeding, 161 Estrogen for gonorrhea, 320 Decongestants, 99 for vaginal bleeding, 192 combined oral contraceptive pills, for pelvic inflammatory disease, See also specific medicines by Ergotamine tartrate, 404 422–424 198 name Erythromycin (erythromycin for vaginal atrophy, 194 for soft tissue infections, 242 Dextrose solution, 362 ethylsuccinate) Ethambutol (E) for typhoid (enteric) fever, 289 Diazepam for abdominal pain, 328 daily dose, 297, 298 for urethritis, 223 for convulsions, 76 for abscess, 376 rifampicin, isoniazid, and Clindamycin dosages and regimens, 451 for animal or human bites, 338, ethambutol (RHE), 294, 295, for animal or human bites, 338 for epilepsy, 128 339 296 for malaria, 281, 282 for psychiatric disorders, 140 for anthrax, 310 rifampicin, isoniazid, Cloxacillin for seizures, 133, 392 for bronchitis, 83 pyrazinamide, and ethambutol for cellulitis or pus, 242, 301 for spasms, 265 for cellulitis or pus, 301 (RHZE), 294–295, 296

494 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 495 Drugs Index Drugs Index

streptomycin, rifampicin, Folic acid H rifampicin, isoniazid, and isoniazid, pyrazinamide, and for anemia, 150, 203 H2 receptor antagonists, 353 ethambutol (RHE), 294, 295, ethambutol (SRHZE), 295, 296 for diarrhea, 55 Haemophilus influenzae type b 296 for tuberculosis, 294 for iron deficiency anemia, 146, (Hib) vaccine, 437 rifampicin, isoniazid, and Eye patching, 358 205 Haloperidol, 141 pyrazinamide (RHZ), 298 for postpartum hemorrhage, 175 Hartmann’s solution, 48 rifampicin, isoniazid, F for uterine bleeding, 161 Hepatitis B vaccine, 180, 287 pyrazinamide, and ethambutol Fansidar® (sulfadoxine- Furazolidone, 60 Honey, 362, 363 (RHZE), 294–295, 296 pyrimethamine), 277 Furosemide Hydralazine rifampicin and isoniazid (RH), Ferrous sulfate for heart failure, 116, 117 for HTN and eclampsia, 153 294–295, 298 for anemia, 150, 203, 307 for hypertension, 112 for hypertension, 343 streptomycin, rifampicin, for iron deficiency anemia, 146 for pulmonary edema, 323 Hydrochlorothiazide isoniazid, pyrazinamide, and newborn care, 183 contraindications to, 111, 116 ethambutol (SRHZE), 295, 296 for uterine bleeding, 161 G for heart failure, 116 for tuberculosis, 294 Fluids Gentamicin for hypertension, 110, 111, 112 Isosorbide dinitrate for acute abdomen, 334 for abdominal pain, 328, 329, 330 Hydrocortisone for acute MI, 124 for anaphylactic shock, 372 for brucellosis, 313 for anaphylactic shock, 372 for angina pectoris, 122 for bowel obstruction, 333 dosages and regimens, 454 for asthma, 69 for burns, 352, 354 for encephalitis, 133–134 for wasp and bee stings, 341 L for cardiogenic shock, 369 for febrile convulsion, 393 I Lactulose, 412 for children, 367 for gout (or pseudo-gout), Ibuprofen Lanolin, 185 for cholecystitis, 332 254–255 for arthritis and arthralgia, 254 Levonorgestrel, 425–426 for constipation, 411 for measles, 271 for burn pain, 353 Lidocaine for dehydration, 49, 283, 414–415 for meningitis, 133–134 contraindications to, 254 for abscess, 375 for diarrhea, 51 for neonatal infections, 181, 182 for migraine, 404 for scorpion stings, 343 for febrile convulsion, 392 for osteomyelitis, 257, 258 for pain of cracked nipples, 185 for severe pain, 343

for hyperglycemia, 233 for otitis media, 88 for pain of dysmenorrhea, 190 Lindane drugs index for hypovolemia, 372 for peritonitis, 329 proper way to take medications, contraindications to, 246, 249 for hypovolemic shock, 369 for pneumonia, 67, 75, 76 256 patient instructions, 247 for incomplete abortion, 160 for pyelonephritis, 221 Imipramine, 404 for pediculosis (lice), 246 for iron deficiency anemia, 203 for sepsis, 273 Immunoglobulin (anti-D), 162 for scabies, 249 for neurogenic shock, 371 for septic abortion, 161 INH (chemoprophylaxis), 297 drugs index drugs for pertussis (whooping cough), for septic arthritis, 254–255 Insulin, 230–233 M 260 for septic shock, 370 Intrauterine devices (IUDs), 418, Mafenide acetate (Sulfamylon®), for resuscitation of children, 367 Gentian violet 428–429 354–355 for ruptured ectopic pregnancy, for fungal skin infection, 237 Iodized salt, 219 Magnesium hydroxide, 412 163 for impetigo, 234 Iron supplements Magnesium sulfate, 153 for septic abortion, 160 for mouth ulcers, 270 for abortion, 159 Measles vaccine for septic shock, 370 for otitis externa, 86 for anemia, 162, 203, 204, 206 how to vaccinate, 437 for shock, 156, 328, 365–367, 368 for sycosis, 242 cautions, 206 schedule of routine childhood for tetanus, 264 for umbilical infections, 181 for iron deficiency anemia, 150, immunizations, 436 for vaginal bleeding, 192, 193 Glucocorticoids, 341 205 Mebendazole Flumazenil, 389 Glucose solution for postpartum hemorrhage, 175 for anemia, 150, 206 Fluoxetine, 141 for burns, 352 postpartum care, 183 antenatal care, 147 Folate supplements for hypoglycemia, 362, 363 for uterine bleeding, 161 for ascariasis (roundworm), 307 for abortion, 159 Glycerin suppository, 412 Isoniazid (H) contraindications to, 307 newborn care, 183 daily dose, 297 for malnutrition, 211

496 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 497 Drugs Index Drugs Index

Medroxyprogesterone acetate Niclosamide, 309 for carbon monoxide poisoning, for migraine, 404 (DMPA), 427–428 Nifedipine 383, 388 for mild pain, 343 Methionine, 386 contraindications to, 165 for changed level of for oral pain, 43 Methyldopa, 153 for hypertension emergency, 114 consciousness, 383 for pain, 314, 336, 373, 375 Metoclopramide, 415 for preterm labor, 165 for cough, 396 for pain in eye, 358 Metronidazole Nitrofurantoin for cyanosis, 260 for pain in septic abortion, 160 for abscesses, 376 for cystitis, 223 for encephalitis, 133 for pain of cracked nipples, 185 for cholecystitis, 332 for urethritis, 223 for epilepsy, 128 for pain of sinusitis, 93 for dental infections, 44 Nitroglycerin for heart failure, 117 for pain of spider bites, 344 dosages and regimens, 455 for acute MI, 124, 323 for inhalation burns, 351 for pelvic inflammatory disease, for dysentery, 57, 59 for angina pectoris, 122 for meningitis, 133 197 for giardiasis, 60 Nonsteroidal anti-inflammatory for respiratory distress, 385 poisoning, 386 for oral infections, 44 drugs (NSAIDs), 71 for shock, 367 for snake bite, 347 for pelvic inflammatory disease, contraindications to, 71 for shortness of breath, 383 for typhoid (enteric) fever, 288 197 Nose drops, 93 Oxytocin for viral pharyngitis fever and for peritonitis, 330 NSAIDs (nonsteroidal anti- for abortion, 160–161 pain, 96 for postpartum hemorrhage, 175 inflammatory drugs), 71 for antepartum hemorrhage, 154 for wasp and bee sting pain, 341 for sepsis, 273 Nutritional support, 264 for labor, 168, 169–170, 176 Penicillin benzyl (penicillin G), for septic abortion, 162 Nystatin for postpartum hemorrhage, 174 265 for septic shock, 370 for candidiasis, 44, 185, 238 for uterine bleeding, 160–161 Penicillin benzyl procaine, 235 for tetanus, 265 dosages, 238 Penicillin G (penicillin benzyl), 265 Micronutrients presentations, 238 P Penicillin V for rickets, 218 Nystatin topical cream, 238 Paracetamol (acetaminophen) (phenoxymethylpenicillin) for vitamin D deficiency, 218 for arthritis and arthralgia, 254 for abscesses, 376 Mineral oil, 412 O for burn pain, 353 for acute glomerulonephritis, 225 Mineral oil enema, 412 OPV for dental pain, 43 for dental and oral infections,

Mini-pill, 425–426 newborn care, 180 dosages and regimens, 456 43–44 drugs index Morphine for poliomyelitis, 268 for dysmenorrhea, 188 for diphtheria, 262 for acute MI, 124 schedule of routine childhood for ear pain, 86, 88, 89, 90 dosages and regimens, 457 for acute pulmonary edema, 323 immunizations, 436 for fever, 72, 76, 80, 260, 276, 283, for impetigo, 235 for pain, 332 Oral rehydration solution (ORS) 314, 392, 393, 400 for rheumatic fever, 119 Multivitamins for dehydration, 48, 49, 50, 51–52, for fever, pain, discomfort, 270 for tetanus, 266 drugs index drugs for rickets, 218 414–415 for fever and pain, 96, 188 for tonsillitis, 97 for vitamin D deficiency, 218 for diarrhea, 51, 52, 53 for fever and pain in diphtheria, Pentavalent vaccine, 436 for fluid resuscitation of children, 262 Permethrin N 367 for fever and pain in measles, 270 for hair (rinse), 246 NaCl (sodium chloride) Oral rinse, 43 for fever in chickenpox, 300 for hair (cream), 249 for abortions in early pregnancy, ORS (oral rehydration solution) for fever in children, 77 Petrolatum, 247 161 for dehydration, 48, 49, 50, 51–52, for fever in encephalitis and Phenoxymethylpenicillin for congestion, 72 414–415 meningitis, 134 (penicillin V) for sinusitis, 93 for diarrhea, 51, 52, 53 for fever in otitis media, 89, 90 for abscesses, 376 Naloxone, 388, 389 for fluid resuscitation of children, for fever in sinusitis, 93 for dental and oral infections, Nasal decongestants, 99 367 for fever in tonsillitis, 97 43–44 Neomycin, 86 Oxygen for fever prevention, 393 for diphtheria, 262 Neomycin and bacitracin ointment, for acute abdominal pain, 328 for headache, 402 dosages and regimens, 457 235 for acute hypoxemia, 82 for high fever, 72, 76, 77, 80 for impetigo, 235 Neomycin sulfate ointment, 235 for acute pulmonary edema, 322 for mastitis, 188 for rheumatic fever, 119

498 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 499 Drugs Index Drugs Index

for tetanus, 266 daily dose, 295, 298 Saline enema, 412 Sulfadoxine-pyrimethamine for tonsillitis, 97 for tuberculosis, 294–295 Saline solution (Fansidar®), 277–279, 280, 281 Phytomenadione (vitamin K), 180 RHE (rifampicin, isoniazid, and for anaphylactic shock, 371 Sulfamethoxazole + trimethoprim Povidone-iodine (Betadine®), ethambutol) for burns, 352 (co-trimoxazole) 354–355 daily dose, 296 for dehydration, 48 for animal or human bites, 338, Pralidoxime, 386 for tuberculosis, 294, 295, 296 for eye exposure to poisonous 339 Prednisolone RHZ (rifampicin, isoniazid, and agents, 382 for bronchitis, 83 for asthma, 66, 69 pyrazinamide), 298 for eye trauma, 357 for brucellosis, 313 for asthmatic bronchitis, 82 RHZE (rifampicin, isoniazid, for fluid resuscitation, 367 for cystitis, 223 Primaquine pyrazinamide, and ethambutol) for gastric lavage, 380 dosages and regimens, 450 contraindications to, 277, 280 daily dose, 295, 296 for shock, 365 for dysentery, 57 for malaria, 277, 280, 283 for tuberculosis, 294–295 for sinusitis, 93 for febrile convulsion, 392 Progestin Rifampicin (R) Salt, iodized, 219 for granuloma inguinal, 320 combined oral contraceptive pills, for brucellosis, 312 Salt water gargle, 96, 270 for infections in malnutrition, 422–424 daily dose, 297 Scabicides, 249 211–212 progestin-only injectables, rifampicin, isoniazid, and Silver sulfadiazine cream for lymphogranuloma venereum, 427–428 ethambutol (RHE), 294, 295, for burns, 351 320 progestin-only pill (POP), 418, 296 for sycosis, 242 for otitis media, 89 425–426 rifampicin, isoniazid, and Sodium chloride (NaCl) for pneumonia, 67, 77, 80 Propranolol pyrazinamide (RHZ), 298 for abortion in early pregnancy, for urethritis, 223 contraindications to, 71 rifampicin, isoniazid, 161 Sulfamylon® (mafenide acetate), for migraine, 404 pyrazinamide, and ethambutol for congestion, 72 354–355 Pyrazinamide (Z) (RHZE), 294–295, 296 for sinusitis, 93 daily dose, 297 rifampicin and isoniazid (RH), Spermicides, 418, 433–434 T rifampicin, isoniazid, and 294–295, 298 SRHZE (streptomycin, rifampicin, Tetanus antiserum, 337 pyrazinamide (RHZ), 298 streptomycin, rifampicin, isoniazid, pyrazinamide, and Tetanus immunoglobulin

rifampicin, isoniazid, isoniazid, pyrazinamide, and ethambutol) for animal and human bites, 337 drugs index pyrazinamide, and ethambutol ethambutol (SRHZE), 295, daily dose, 296 for tetanus prevention, 266 (RHZE), 294–295, 296 296 for tuberculosis, 295, 296 Tetracycline eye ointment streptomycin, rifampicin, for tuberculosis, 294 Steroids for conjunctivitis (red eye), 101 isoniazid, pyrazinamide, and Ringer’s lactate for anaphylactic shock, 372 for eye infections, 270, 271 ethambutol (SRHZE), 295, 296 for burns, 352 for asthma, 66, 70 for eye injuries, 358 drugs index drugs for tuberculosis, 294 for dehydration, 48, 414 for wasp and bee stings, 341 for glaucoma, 105 Pyridoxine (vitamin B6), 146 for fluid resuscitation, 367 for wheezing, 83 for neonatal conjunctivitis for labor, 169–170 See also specific medicines by (ophthalmia neonatorum), Q for peritonitis, 330 name 182 Quinine for shock, 365 Streptomycin (S) for sycosis, 242 for malaria in pregnancy, S daily dose, 296, 297, 298 for trachoma, 104 280–281 Salbutamol streptomycin, rifampicin, Thiamine, 362 for malaria second-line therapy, for asthma, 66, 67, 69 isoniazid, pyrazinamide, and Tramadol, 160 282 for asthma-like symptoms, 372 ethambutol (SRHZE), 295, Tricyclic antidepressants dosages and regimens, 458 296 contraindications to, 142 R for pertussis (whooping cough), for tuberculosis, 294 See also specific medicines by Ranitidine 260 Sugar syrup, 362, 363 name for burn injury, 353 for preterm labor, 165 Sugar water TT (tetanus toxoid) for peptic ulcer disease, 63 for wheezing, 76, 77, 82 for hypoglycemia, 393 for animal and human bites, 336 RH (rifampicin and isoniazid) Salicylic acid, 237 for low blood sugar, 211 antenatal care, 142–143, 146–147

500 National Standard Treatment Guidelines for the Primary Level National Standard Treatment Guidelines for the Primary Level 501 Drugs Index

booster dose, 266 for vitamin A deficiency, 214, 215 for burns, 353 for xerophthalmia, 214 for rabies, 303 Vitamin A and D ointment, 185 schedule for women of Vitamin B6 (pyridoxine), 146 childbearing age, 437 Vitamin D for septic abortion, 162 for rickets, 218, 219 for snake bites, 347 for vitamin D deficiency, 218, for spider bites, 344 219 for tetanus, 266 Vitamin K (phytomenadione), for tetanus prevention, 266 180, 387

V W Vitamin A Warfarin for anemia, 206 contraindications to, 119 for children, 211, 214, 216 for diarrhea, 55, 215 Z dosage schedule, 216 Zinc for malnutrition, 211, 215 for cholera, 61 for measles, 215, 270, 271 for dehydration, 50–51 postpartum care, 183, 216 for diarrhea, 52, 55 supplementation schedule, 55, for dysentery, 57 216 Zinc oxide topical cream, 238 drugs index drugs

502 National Standard Treatment Guidelines for the Primary Level