© 2008 Federal Ministry of Health, Nigeria ACKNOWLEDGEMENTS

The first edition of the Nigerian Standard Treatment Guidelines is a product of the support, All rights reserved. No part of this publication may be reproduced, stored in retrieval recommendations and contributions of the following: system or transmitted in any form or by any means, electronic, mechanical, Federal Ministry Of Health photocopying, recording and/or otherwise, without prior written permission of the Prof. Eyitayo Lambo Federal Ministry of Health, Nigeria. Prof. Adenike Grange Mr. R.K. Omotayo mni Mr. J.E. B. Adagadzu

World Health Organization European Commission For all enquiries or comments, write to the publishers: Dr Peter Eriki For funding the programme Dr Mohammed Belhocine Dr. Olaokun Soyinka Dr Ogori Taylor The Honourable Minister, Federal Ministry of Health, Federal Secretariat Complex, Expert Committee Members International Network for Rational Use of Shehu Shagari Way, Prof. Abdu-Aguye, I. Drugs (INRUD) - Nigerian Core Group P.M.B. 080 Garki, Prof. Adelowo, F. Prof. Abdu-Aguye, I. Abuja. Prof. Bayeroju-Agbeja, A. Prof. Isah, A.O. Prof. Mabadeje, A.F.B. Prof. Borodo, M. Nigeria Dr. Abosede, O.A. Prof. Danbauchi, S.S Dr. Aina, B.A. Prof. Gureje, O. Dr. Akinyede, A. Printed in Nigeria. Prof. Idoko, J. Dr. Akoria, O.A. Prof. Isah, A.O. Dr. Asalu, A.F. Dr. Akinlekan, J. Prof. Mabadeje, A.F.B. Mr. Obiaga, G. Prof. Mbonu, O. Dr. Obodo, J.O. Prof. Ogisi, F. Mr. Okoko, O.O. Prof. Ohwovoriole, A. Dr. Oparah, A. Prof. Olumide, M. Dr. Olayemi, S.O. Dr. Oreagba, I. Prof. Ojogwu, L.I. Mr. Otahabru, B. Prof. Okonofua, F. Dr. Mero-Asagba, G. Prof. Oruamabo, R. Dr. Taylor, O. Prof. Oviawe, O Dr. Ameh, E. Editorial Team Prof. Abdu-Aguye, I. Dr. Abosede, Y. Prof. Isah, A.O. Dr. Akoria, O. Dr. Akoria, O.A. Dr. Irhibhogbe, P. Dr. Mero-Asagba, G. Dr. Kehinde, M. Mr. Obiaga, G.O. Dr. Mero-Asagba, G. Mrs. Okpeseyi, M.I. Mr. Fagbemiro, L.O. Dr. Okpapi, J.U. Mr. Otahabru, B. Dr. Savage, S. Dr. Olaokun Soyinka Dr. Taylor, O. Dr. Taylor, O. Mr. Obiaga, G.O. FOREWORD

I am indeed very pleased to write the foreword to this maiden edition of the Standard Treatment Guidelines (STG) for the Nigerian health care system. I am aware that the process of its production began in 2005 involving contributions and recommendations of various experts and stakeholders in the health care sector.

The STG is an important tool for the attainment of comprehensive and effective health care delivery services thereby achieving the goals of the National Drug Policy, which inter alia are: the availability of safe, efficacious and affordable medicines to satisfy the healthcare needs of the majority of the population and ensure the rational use of drugs. The fulfillment of the above mentioned goals is part of the strategic thrust of the Health Sector Reform Programme aimed at the reduction of disease burden and the improvement of access to quality health services. It is expected that the STG will become a major reference document for all health workers both in the public and private sectors.

It is instructive to note that the development of the STG followed due process with wide consultations and meetings involving various stakeholders and interest groups. The document that has come out of this process is a reflection of the quality of the inputs that went into its development. In my opinion, this maiden edition of the STG has been produced and serialized in such a way as to assist health care providers especially doctors in the effective discharge of their duties as prescribers. It will also ensure discipline as only those medicines recommended will be prescribed for patients within a given health facility.

I commend all those who worked tirelessly towards the completion of this maiden edition STG. Special mention and gratitude must go to the World Health Organization (WHO) for sponsoring and providing sustained technical support to the committee. Without this support, this STG would not have seen the light of the day.

Finally, let me quickly add that this STG must be widely circulated and disseminated. Everything possible must be done to ensure that practitioners maximize the benefit of such a useful document. If it has worked in other parts of the world, it should also work in Nigeria. It must also be subjected to regular reviews in view of the dynamic nature of health care management.

Dr. Hassan Muhammed Lawal, CON Supervising Minister of Health

PREFACE Standard Treatment Guidelines for Nigeria 2008

This first edition of Standard Treatment Guidelines (STG) for the Nigerian health TABLE OF CONTENTS practitioner is coming relatively later than those of many other countries. It is indeed a welcome development. SECTION A The standard of medical practice and the wage bill of health services are usually Chapter 1: Alimentary Tract remarkably improved by health personnel putting to use STG. This among other Gastrointestinal Disorders ...... 1 Chapter 4: Central Nervous System benefits can only lead to improved health of the community. Amoebiasis ...... 1 Non-psychiatric Disorders ...... 34 Bacillary Dysentry ...... 1 Dizziness ...... 34 In Nigeria our health indices are among the worst in the world. Our country Nigeria Cholera ...... 2 Headaches...... 35 Constipation ...... 2 Meningitis ...... 36 does not lack the manpower or the necessary infrastructure to turn things around. What Diarrhoea (acute) ...... 3 Migraine ...... 37 appears to be lacking is the organization of health services required to put both to Gastritis ...... 4 Parkinsonism...... 38 optimal use. Efforts such as the actualization of our own national STG and the various Giardiasis ...... 4 Seizures/epilepsies ...... 39 health reforms currently in progress will definitely improve our situation. Haemorrhoids ...... 5 Stroke ...... 41 Pancreatitis ...... 5 Syncope ...... 42 Peptic Ulcer Disease ...... 6 The Unconscious Patient ...... 42 It is therefore my pleasure and privilege to write the preface to this maiden edition of Upper Gastrointestinal Bleedin ...... 6 Psychiatric Disorders ...... 43 the STG. This is the outcome of a long journey that started several years ago. The Hepatic And Biliary Disorders ...... 7 Alcoholism (alcohol Dependence) ...... 43 previous chairmen of the National Formulary and Essential Drugs Review Committees Hepatitis...... 7 Anxiety Disorder ...... 44 made efforts to start the project but were unsuccessful due to lack of funds. Hepatic Encephalopathy ...... 8 Bipolar Disorders ...... 44 Jaundice ...... 9 Delirium...... 45 Liver Cirrhosis ...... 9 Depression ...... 46 The current committee had the luck of being assisted by the country office of the World Nutritional Disorders ...... 10 Insomnia...... 47 Health Organization (WHO) in not only this endeavor but in the preparation and Kwashiokor And Marasmus ...... 10 Panic Disorder...... 47 printing of the last edition of the Nigerian Essential Medicines List. The desk officer, Micronutrient Deficiencies ...... 10 Schizophrenia...... 48 Obesity...... 11 Dr Ogori Taylor showed great commitment to the project and the country owes a debt Chapter 5: Dental And Oral Disorders of gratitude to WHO. Chapter 2: Blood And Blood-forming Organs Acute Necrotizing Ulcerative Gingivitis...... 49 Anaemias ...... 13 Acute Periapical Abscess ...... 49 In preparing this document every effort was made to ensure that the stakeholders own Blood Transfusion ...... 14 Alveolar Osteitis ...... 50 Haemostasis And Bleeding Disorders ...... 16 Cellulitis...... 50 the project so that it is not seen as an imposition. Accordingly, the major contributions Leukaemias ...... 16 Dental Caries ...... 50 came from various practitioners and their associations as well as from many Lymphomas ...... 19 Gingivitis ...... 51 practitioners whose input were judged crucial to the success of the project. We also Sickle Cell Disease...... 20 Neoplasms Of The Oral Cavity ...... 51 adopted the acceptable practices in the field that were in use by special health projects Oral Thrush (candidiasis) ...... 51 Chapter 3: Cardiovascular System Pericoronitis ...... 52 such as HIV/AIDS, Malaria, TB/Leprosy programmes etc. The academia was also Angina Pectoris...... 23 Periodontitis...... 52 involved. There were several fora where the contributions were discussed openly with Cardiac Arrhythmias ...... 23 Pulpitis ...... 53 the stakeholders and consensus arrived at. Congenital Heart Disease ...... 24 Salivary Gland Diseases ...... 54 Deep Venous Thrombosis ...... 24 Temporo-mandibular Joint Disorders...... 54 Heart Failure ...... 25 It is my hope therefore that this document will be widely used by Nigerian health Hyperlipidaemia ...... 26 Chapter 6: Dermatology practitioners. I salute the contributors and those that helped in one way or the other. Hypertension ...... 26 Bacterial Infections ...... 56 The committee of course accepts responsibility for any lapses but also hopes that these Infective Endocarditis ...... 27 Cellulitis ...... 56 Myocardial Infarction...... 29 would be brought to our attention for correction in subsequent editions. Furunculosis (boils) ...... 56 Myocarditis ...... 30 Impetigo Contagiosa ...... 57 Paediatric Cardiac Disorders...... 30 Dermatitis And Eczema ...... 58 Pericarditis ...... 30 Atopic Dermatitis (atopic Eczema)...... 58 Pulmonary Embolism ...... 31 Contact Dermatitis ...... 59 Pulmonary Oedema ...... 32 Professor Ibrahim Abdu-Aguye,MBBS; FMCP;SFIAM; FIICA;D. Sc (Hon) Exfoliative Dermatitis (erythroderma)...... 59 Rheumatic Fever ...... 32 Chairman, National Formulary and Essential Drugs Review Committee. Parasitic Dermatoses ...... 60 Rheumatic Heart Disease ...... 33 Cutaneous Larva Migrans (creeping Eruption)...... 61

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Guinea Worm Disease (dracunculiasis)...... 61 The Red Eye ...... 104 Chapter 13: Obstetrics And Gynaecology Myiasis ...... 62 Trachoma...... 105 Abortion ...... 149 Onchocerciasis (river Blindness) ...... 62 Xerophthalmia ...... 105 Antenatal Care ...... 150 Pediculosis (lice) ...... 63 Anaemia In Pregnancy ...... 152 Section C Scabies ...... 64 Cancer Of The Cervix ...... 153 Papulosquamous Disorders ...... 65 Chapter 10: Genito-urinary System Cardiac Disease In Pregnancy ...... 154 Chapter 18: Emergencies Lichen Planus ...... 65 Nephrology ...... 106 Eclampsia ...... 156 Acute Left Ventricular Failure ...... 195 Pityriasis Rosea ...... 66 Acute Renal Failure...... 106 Ectopic Pregnancy ...... 158 Cardiac Arrest ...... 196 Psoriasis ...... 67 Chronic Kidney Disease ...... 106 Hyperemesis Gravidarum ...... 159 Drowning And Near-drowning ...... 197 Superficial Fungal Infections ...... 69 Nephrotic Syndrome ...... 107 Immunization Schedules ...... 160 Electrolyte Abnormalities ...... 198 Dermatophyte Infections (tinea) ...... 69 Sexually Transmitted Infections ...... 108 Jaundice In Pregnancy ...... 160 Hypertensive Emergencies ...... 200 Pityriasis Versicolor (tinea Versicolor ) ...... 70 Bacterial Vaginosis ...... 108 Pelvic Inflammatory Disease ...... 162 Hypoglycemia ...... 200 Viral Infections ...... 71 Chancroid (ulcus Molle, Soft Chancre) ...... 109 Rape ...... 163 Myxoedema Coma ...... 201 Herpes Zoster ...... 71 Chlamydial Infection ...... 110 Thyroid Storm (thyrotoxic Crisis) ...... 201 Molluscum Contagiosum ...... 72 Gonorrhoea ...... 111 Chapter 14: Respiratory System Poisoning ...... 202 Varicella (chickenpox) ...... 72 Granuloma Inguinale (donovanosis; Acute Epiglottitis ...... 165 Viral Warts (verrucae) ...... 73 Granuloma Venereum)...... 113 Acute Laryngo-tracheo-bronchitis (croup) ...... 165 Chapter 19: Therapeutics Miscellaneous Disorders ...... 74 Lymphogranuloma Venereum ...... 114 Acute Rhinitis (common Cold) ...... 166 Prescription Writing ...... 206 Acne Vulgaris (pimples) ...... 74 Syphilis ...... 115 Bronchial Asthma ...... 166 Adverse Drug Reactions ...... 208 Pruritus ...... 76 Trichomoniasis ...... 116 Bronchiectasis ...... 167 Urticaria And Angioedema ...... 78 Vulvo-vaginal Candidiasis ...... 117 Chest Pain ...... 168 Chapter 20: Notifiable Diseases ...... 209 Vitiligo ...... 80 Urology ...... 118 Chronic Obstructive Airways Disease(coad) ....168 Benign Prostatic Hyperplasia ...... 118 Cough ...... 169 Chapter .7: Ear, Nose And Throat Carcinoma Of The Prostate ...... 118 Dyspnoea ...... 170 Acute Otitis Media...... 81 Erectile Dysfunction (impotence) ...... 119 Lung Abscess ...... 170 Adenoid Disease ...... 82 Male Infertility ...... 120 Pneumonia ...... 171 APPENDICES Chronic Otitis Media ...... 82 Posterior Urethral Valves ...... 120 Pulmonary Embolism ...... 172 Epistaxis ...... 83 Priapism ...... 121 Appendix I Foreign Bodies In The Airways ...... 83 Prostatitis ...... 121 WHO clinical staging of HIV for infants and Foreign Bodies In The Ear ...... 84 Scrotal Masses ...... 122 Section B children with established HIV infection...... 211 Foreign Bodies In The Nose And Rhinoliths...... 84 Torsion Of The Testis ...... 122 Chapter 15: Injuries And Acute Trauma Mastoiditis...... 84 Urethral Stricture ...... 123 Bites And Stings ...... 173 Appendix II: Nasal Allergy ...... 85 Urinary Schistosomiasis ...... 123 Burns ...... 175 WHO new antenatal care model classifying Otitis Externa ...... 86 Urinary Tract Calculi ...... 124 Disaster Plan ...... 176 form 2001...... 212 Peritonsillar Abscess (quinsy) ...... 86 Head Injury ...... 177 Pharyngitis (sore Throat) ...... 86 Chapter 11: Infectious Diseases / Multiple Injuries ...... 180 Appendix III Sinusitis ...... 87 infestations Calculation of dosage requirements in Tonsillitis ...... 88 Fevers: Management Approach ...... 125 Chapter 16: Surgical Care And Associated children...... 214 Tracheostomy ...... 89 Food Poisoning ...... 125 Disorders Wax In The Ear ...... 89 Helminthiasis ...... 127 Acute Abdomen ...... 182 Human Immunodeficiency Virus Infection ...... 129 Appendix IV: Chapter 8: Endocrine System Antimicrobial Prophylaxis In Surgery ...... 184 Malaria ...... 135 Medicines with teratogenic potential...... 215 Diabetes Mellitus ...... 90 Intestinal Obstruction ...... 184 Rabies...... 137 Hyperthyroidism (thyrotoxicosis) ...... 97 Preoperative Evaluation and Tetanus ...... 138 Hypothyroidism (myxoedema) ...... 99 Postoperative Care ...... 186 Appendix V: Trypanosomiasis (sleeping Sickness) ...... 140 Use Of Blood Transfusion In Surgery ...... 189 Medicines that could cause harm when Tuberculosis ...... 140 administered to breastfeeding mothers...... 215 Chapter 9: Eye Disorders Typhoid Fever ...... 142 Chapter 17: Paediatric Perspectives Acute Anterior Uveitis (iritis) ...... 100 Measles (rubeola) ...... 190 Appendix VI: Acute Keratitis ...... 100 Chapter 12: Musculoskeletal System Poliomyelitis ...... 191 NAFDAC Adverse Drug Reaction Reporting Allergic Conjunctivitis ...... 101 Back Pain ...... 143 Vitamin A Deficiency ...... 193 Eye Injuries ...... 101 Gout ...... 144 form ...... 217 Foreign Bodies In The Eye ...... 102 Osteoarthritis ...... 145 Infective Conjunctivitis ...... 103 Rheumatoid Arthritis ...... 146 Ophthalmia Neonatorum ...... 103 Septic Arthritis ...... 147 Scleritis / Episcelitis ...... 104 Systemic Lupus Erythematosus ...... 148 Stye (hordeolum) ...... 104

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CHAPTER 1: ALIMENTARY TRACT Consult a surgeon. diarrhoeas resulting from bacterial infection are usually Or: SECTION A GASTROINTESTINAL DISORDERS Asymptomatic cyst carriers self-limiting. Appropriate systemic antibiotics are Doxycycline: Treat cyst carrier if patient is a food handler: however required when systemic infections occur. Adult: 200 mg orally once daily for 5 days AMOEBIASIS Diloxanide furoate - Amoxicillin 500 mg 8 hourly for 5 days Child: 12 - 18 years, 200 mg on first day, then 100 mg Introduction Adult: 500 mg every 8 hours for 10 days Or: daily A common parasitic infection of the gastrointestinal Child over 25 kg: 20 mg/kg orally every 8 hours for 10 - Cotrimoxazole 960 mg 12 hourly for 3-5 days - Severe infections, 200 mg orally daily system caused by the protozoan Entamoebahistolytica days Or: Erythromycin: Acquired through faeco-oral transmission. Notable adverse drug reactions, caution - Ciprofloxacin 500 mg - 1 g orally 12 hourly for 5 days Adult and child over 8 years: 250 - 500 mg orally every 6 Clinical features Metronidazole is contraindicated in pregnancy. - Azithromycin 500 mg daily for 3 days for resistant hours for 5 days or 500 mg -1 g every 12 hours It may present as: Avoid alcohol during treatment and at least 48 hours after strains Child up to 2 years: 125 mg every 6 hours;2-8years: 250 Amoebic dysentery treatment. Notable adverse drug reactions mg every 6 hours Persistent mucoid / bloody diarrhoea Prevention Ciprofloxacin may induce tendinitis especially in - Doses doubled in severe infection Abdominal pain Provision of safe drinking water children . Or: Fever/chills Sanitary disposal of faeces Precaution Sulfamethoxazole-trimethroprim (Co-trimoxazole) Amoebic abscess Regular examination of food handlers and appropriate Ciprofloxacin is not recommended for use in children Adult: 960 mg orally every 12 hours for 5 days This can occur in any of the following forms as a result of treatment where necessary. less than 18 years. Child: 6 weeks - 6 months 120 mg 12 hourly; 6 months - 6 spread via the blood stream: Antidiarrhoeal medicines are not advised. years 240 mg; 6 - 12 years 480 mg; 12 - 18 years 960 mg Liver abscess: swelling, pain in the right sub-costal area BACILLARY DYSENTRY Prevention orally every 12 hours for 5 days Intracranial space-occupying lesion Introduction Safe drinking water Supportive measures Lungs: cough and blood stained sputum An important cause of colonic diarrhoea in developing Sanitary disposal of human waste material Monitor fluid intake and output (vomitus, urine and Amoeboma: swelling anywhere in the abdomen countries. stool) Anal ulceration: may occur by direct extension from the Caused by pathogenic species of Shigella A-D Prevention intestinal infection ()dysenteri, flexneri, boydii and sonnei . CHOLERA Provide access to safe drinking water Chronic Carriers Transmitted via the faeco-oral route. Introduction Food hygiene Symptom-free Clinical features An acute severe diarrhoeal illness of worldwide Safe disposal of human waste Differential diagnoses Mucoid bloody diarrhoea associated with severe central importance; endemic in many developing countries. Cholera vaccine Bacillary dysentery and lower abdominal pain Caused byVibrio cholerae bacilli (classical and El Tor Any other cause of bloody diarrhoea Tenesmus species). Cancer of the liver Moderate-grade pyrexia Excessive secretion of fluid is mediated by the release CONSTIPATION Other causes of liver enlargement Sometimes only a mild, self-limiting diarrhoea lasting 2- of enterotoxin (released by the bacilli), which acts on the Introduction Complications 3 days enterocytes of the small intestine via cyclicAMP. A clinical condition characterized by infrequent bowel Rupture of abscess into the lungs, peritoneum Articular features occasionally Highly infectious; spread by faeco-oral route. opening and/or passage of hard stools. Space-occupying lesion in the brain Septicaemic spread with multi-system involvement Clinical features Aetiology Right inguinal mass occasionally. Mild watery diarrhoea Inadequate fibre in diet (simple constipation) Investigations Differential diagnoses Severe life-threatening diarrhoea leading to Drugs e.g. antidepressants, narcotic analgesics, etc Stool: microscopy for cysts and motile organisms Amoebic dysentery hypovolaemic shock if untreated Diseases of the anus, rectum and colon e.g. fissures, (amoebic dysentery) Idiopathic enterocolits (ulcerative) Occasionally, vomiting haemorrhoids, cancer Full Blood Count Campylobacter jejuni infection Complications Functional: irritable bowel syndrome Chest radiograph (in amoebic liver abscess) Colorectal cancer Hypovolaemic shock with multiple end organ failure Metabolic diseases e.g. hypothyroidism, hypercalcaemia Abdominal Ultrasound Scan Complications leading to death Clinical features Treatment objectives Septicaemia/bacteraemia Hypoglycaemia Stools are often hard Rehydrate adequately Severe rectal bleeding Paralytic ileus Abdominal bloating Eradicate the protozoa Intestinal perforation Investigations Excessive flatulence Drug treatment Reiter's syndrome Stool microscopy, culture and sensitivity Relevant associated history to determine aetiology Amoebic dysentery Investigations Full Blood Count should be vigorously pursued Correct dehydration (see section on rehydration) Stool microscopy, culture and sensitivity Urea, Electrolytes and Creatinine Physical examination should be thorough, and must Metronidazole Full Blood Count Treatment objectives include a rectal examination Adult: 800 mg 8 hourly for 5 days Urea, Electrolytes and Creatinine Rehydrate adequately and rapidly Complications Child: 30 mg/kg/day in 3 divided doses for 5 days Treatment objectives Eradicate the infective organism Megacolon Amoebic liver abscess Adequate rehydration Prevent spread of the infection Anal fissures/tears Metronidazole Eradicate bacterial pathogens Drug treatment Haemorrhoids Adult: 800 mg 8 hourly for 10 days Drug treatment Intravenous Ringer's lactate/Darrow's solutions Rectal bleeding Child: 50 mg/kg/day in 3 divided doses for 7-10 days Oral Rehydration Therapy (see rehydration under Oral Rehydration Therapy Non-drug treatment diarrhoea) Antibiotic therapy Investigations Aspiration is indicated to prevent spontaneous rupture of Parenteral hydration therapy (see rehydratrion under Tetracycline: Stool examination including microscopy abscesses. diarrhoea) Adult: 500 mg orally every 6 hours for 5 days Proctoscopy/sigmoidoscopy Antibacterial drugs are not usually necessary: even

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Barium enema Clinical features Personal hygiene: hand-washing, care in food-handling - Omeprazole 20 mg orallyevery 12 hours for 7 days Serum hormonal levels e.g. thyroxine, triiodotyronine, Watery diarrhoea of varying volumes, sometimes with Or: thyroid stimulating hormone to exclude hypothyroidism vomiting: this is the commonest presentation, and - Metronidazole 400 mg orally every 8 hours for 7 days Treatment objectives suggests pathology in the small intestine. GASTRITIS Plus: Identify and eliminate cause(s) Bloody mucoid stools: suggests disease in the colon Introduction - Amoxicillin 500 mg orally every 8 hours for 7 days Evacuate hard faecal matter Fever, abdominal pain and dehydration Inflammation of the gastric mucosa. Plus: Indications for use of laxatives Fast and small volume pulse with low blood pressure: Can be acute or chronic. - Omeprazole 20 mg orallyevery 12 hours for 7 days Situations where straining will exacerbate pre-existing indicates significant fluid loss The most important risk factors for acute gastritis Prevention medical/surgical conditions Complications include use of drugs (NSAIDs in particular) and alcohol. Avoid risk factors (NSAIDs, alcohol, etc) - Angina Hypovolaemic shock with multiple organ failure H.pylori infection is the most important risk factor for - Risk of rectal bleeding Septicaemia chronic gastritis. - Increased risk of anal tear Intestinal perforation All agents of gastritis work through the common path of GIARDIASIS Other indications Gastro-intestinal bleeding disrupting the protective mucosal barrier of the stomach. Introduction - Drug-induced constipation Paralytic ileus Acute gastritis may evoke pain that mimics peptic ulcer Aparasitic infection caused by Giardia lamblia. - To clear the alimentary tract before surgery or Differential diagnoses disease; chronic gastritis is a precursor of peptic ulcer Worldwide in distribution but more common in radiological procedures Non-infectious diarrhoea e.g. drug-induced disease (type B gastritis) and gastric cancer (type A developing countries. Non-drug treatment Gut allergy (e.g. gluten) gastritis). Spread by the faeco-oral route. Avoid precipitants Psychogenic stress Clinical features Pathogenesis High fibre diet (including fruits and vegetables) Metabolic and endocrine causes (e.g. thyrotoxicosis, Chronic gastritis is essentially asymptomatic Invasion of the upper small intestine by the parasite Adequate fluid intake uraemia, diabetes mellitus) Acute gastritis evokes acute abdominal pain that mimics evokes inflammation, leading to progressive villous Megacolon: Investigations peptic ulcer disease (see peptic ulcer disease) atrophy. Saline enema Stool examination including microscopy, culture and Occasionally acute gastritis may be haemorrhagic with Clinical features Surgical: resection of large bowel sensitivity melaenal stools or rarely haematemesis Acute disease: watery diarrhoea with abdominal Drug treatment Full Blood Count Complications bloating Stimulant laxatives Urea, Electrolytes and Creatinine Acute gastritis: haemorrhage Chronic disease: diarrhoea, steatorrhoea and weight - Senna 7.5 mg tablet (as sennoside B) Serology (e.g. Widal test) Chronic gastritis: peptic ulcer disease; gastric cancer loss from malabsorption syndrome- with lactose

Adult: 2 - 4 tablets at night Treatment objectives Differential diagnosis intolerance, xylose malabsorption and vitamin B12 Child6 - 12 years : 1 - 2 tablets at night (or in the morning Achieve adequate hydration Peptic ulcer disease (acute gastritis) deficiency if preferred) Eliminate infectious agent (where possible) Investigations Complications

12 - 18 years: 2 - 4 tablets at night Treat complications Endoscopy (macroscopic diagnosis) Diseases related to Vitamin B12 deficiency Or: Drug treatment Histology of gastric biopsy for definitive diagnosis Differential diagnoses Bisacodyl tablets 10 mg orally at night; suppositories Rehydrate with: Treatment objectives Other causes of upper gastrointestinal malabsorption 10 mg per rectum at night Oral Rehydration Therapy - ORT (low osmolarity) for Eliminate pain (acute gastritis) such as coeliac disease and tropical sprue Caution mild to moderate dehydration Prevent progression to peptic ulcer disease or gastric Investigations Laxatives should generally be avoided. Most times - 500 mLorally over 2 - 3 hours, 3 - 4 times daily cancer Full blood count these drugs are needed for only a few days Intravenous sodium chloride 0.9% Re-establish normal histology Stool microscopy and faecal fat assessment - 1 litre 2 - 6 hourly for moderate-to- severe dehydration Drug treatment Jejunal biopsy - Alternate with Darrow's solution depending on serum Acute Gastritis: Treatment objectives potassium Antacids Rehydrate adequately DIARRHOEA(Acute) Children: - Magnesium trisilicate 1 - 2 tablets or suspension 10 mL Eradicate parasite Introduction Use of zinc supplementation orally three times daily or as required Replace malabsorbed (deficient) nutrients A very common clinical problem the world over, - 20 mg per day for 10 - 14 days Or: Drug treatment particularly in developing countries. - Under 6 months old: 10 mg per day H2 receptor antagonist Metronidazole Accounts for significant morbidity and mortality, Specific anti-infective agents for infectious diarrhoeas - Ranitidine 150 mg orally once daily as required Adult: 2 g orally daily for 3 days or 400 mg 8 hourly for 5 especially in children. e.g. metronidazole for amoebiasis, giardiasis Or: days Infective agents are recognized in about 70% of cases Supportive measures Proton Pump Inhibitors Child: 1 - 3 years 500 mg orally daily; 3 - 7 years 600 - and are transmitted by the faeco-oral route. Monitor fluid intake/output - Omeprazole 20 mg orally once daily as required 800 mg daily; 7-10 years 1 g daily for 3 days Viruses (particularly Rotavirus) are responsible for Notable adverse drug reactions TypeAgastritis: Tinidazole over 70% of diarrhoeas in children below 2 years. Heart failure: from overhydration Endoscopic surveillance every 2 - 3 years for early Adult: 40 mg/kg orally as a single dose; repeat after 1 Many bacteria and some parasites are also important Initial increase in diarrhoea with ORT: this is self detection of cancer week aetiologic agents, particularly in adolescents and adults. limiting Type B gastritis: Child: 50 to 75 mg/kg as a single dose; repeat after 1 Endemic and epidemic presentations can occur. Hyperkalaemia: from excessive use of potassium- Eradication of H.pylori using triple therapy with week Contamination of food and water by bacterial toxins can containing fluids - Clarithromycin 500 mg orally twice daily for 7 days also lead to acute diarrhoea, sometimes with associated Prevention Plus: Supportive Provide access to safe drinking water vomiting (i.e. food poisoning). This is usually self- - Amoxicillin 1g orally every 12 hours for 7 days Vitamin B12 supplementation limiting. Sanitary disposal of human waste Plus: Avoidance of milk

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Notable adverse drug reactions acute or chronic. Nasogastric tube suctioning Drug treatment Metallic taste and vomiting from metronidazole Aetiology Decrease pancreatic inflammation Symptomatic treatment with antacids may be used prior Prevention Varied,but most important are: Prevent, identify and treat complications to confirming the diagnosis of peptic ulcer disease Good sanitary habits Gallstones Caution H. pylori eradication Uncontaminated water and food supplies Alcohol ingestion Avoid narcotic analgesics which may cause spasm of Triple therapy with: Abdominal trauma the sphincter of Oddi and worsen pancreatitis - Metronidazole 400 mg orally every 8 hours for 7 days Infections Prevention Plus: HAEMORRHOIDS Idiopathic in as many as 20-30% cases Control alcohol ingestion - Amoxicillin 500 mg orallyevery 8 hours for 7 days Introduction Occurrence is worldwide, but commoner in areas of the Plus: Enlarged or varicose veins of the tissues at the anus or world where gallstones and alcohol ingestion are - Omeprazole 20 mg orally every 12 hours for 7 days rectal outlet. common. PEPTIC ULCER DISEASE Or: Engorgement of the vascular complex or thrombus Pathophysiology Introduction - Clarithromycin 500 mg orallyevery 12 hours for 7 often leads to the symptoms of disease. Autolysis of pancreatic tissue by pancreatic enzymes as Caused by peptic ulceration that involves the stomach, days The pathophysiologic mechanisms are complex and a result of “secretory block” in the pancreatic bed (often duodenum and lower oesophagus. Plus: vary with the subject. caused by stones) . An increasingly common problem in developing - Amoxicillin 1g orallyevery 12 hours for 7 days May be external or internal. Clinical features countries. Plus: Clinical features Acute pancreatitis: Most ulcers are duodenal - Omeprazole 20 mg orallyevery 12 hours for 7 days Internal haemorrhoids: typically painless but present Epigastric pain: may radiate to the back in over 50% of Aetiology/Predisposing factors Adjunct therapy with bright red rectal bleeding cases H. pylori gut infection Magnesium trisilicate suspension 15 mL orally three May become thrombosed and protrude into the anal Nausea, vomiting, abdominal distension Use of NSAIDs times daily as required canal Severe abdominal tenderness with features of Smoking Supportive therapy External haemorrhoids when thrombosed cause acute hypovolaemia in severe cases Clinical features Regular meals perineal pain with or without necrosis and bleeding Differential diagnoses Recurrent epigastric pain Avoidance of provocative factors (NSAIDs, alcohol, Fibrosed external haemorrhoids present as anal tags Peptic ulcer disease - Often radiating to the back spicy foods etc.) Differential diagnoses Cholecystitis - Worse at night Notable adverse drug reactions Colorectal cancer Investigations - Improved by antacids Gastric irritation, diarrhoea from triple therapy Adenomatous polyps Serum amylase: raised in 80% of acute cases - May be made worse by some food types (generally Diarrhoea/constipation from adjunct therapy Inflammatory bowel disease Serum lipase: if raised is more specific than serum better with bland diet) Treatment of complications Complications amylase Complications Mild upper gastrointestinal bleeding Bleeding, necrosis, perineal sepsis, mucus discharge Alanine aminotransferase: a rise above 3-fold suggests Upper gastrointestinal bleeding Intravenous omeprazole 20 mg 12 hourly for 5 days then Investigations pancreatitis of gallstone origin Perforation standard triple therapy Anoscopy CT scan Penetration Severe upper gastrointestinal bleeding Full blood count including blood film Abdominal ultrasound: least useful in acute pancreatitis Gastric outlet obstruction Interventional endoscopic treatment Treatment objectives Complications Gastric cancer Blood transfusion Relieve pain Hypovolaemic shock Investigations Surgery Prevent complications Acute renal and respiratory failure Full Blood Count Perforation Non-drug treatment Phlegmos Liver Function Tests Surgery Increase fibre in foods Gastrointestinal bleeding Urea, Electrolytes and Creatinine Gastric outlet obstruction Increase fluid intake Electrolyte imbalance (hypo & hypercalcaemia) Occult blood test Rest the gut Avoid foods that cause constipation Pancreatic pseudocysts Stool microscopy Surgery Stool softeners Treatment objectives Endoscopy Regular exercise Relieve pain Double contrast barium meal Drug treatment Prevent complications Direct/indirect detection ofH. pylori (by CLO test or by UPPER GASTROINTESTINALBLEEDING Suppositories/ointments of preparations containing Non-drug treatment CO2 breath test) hydrocortisone acetate with or without lidocaine Renal failure: haemodialysis Differential diagnoses Introduction hydrochloride plus astringent(s) Respiratory failure: mechanical ventilation Gastritis Bleeding from the lower oesophagus, stomach or Surgery Gallstones: Endoscopic Retrograde Cholangio Duodenitis duodenum up to the level of ligament of Treitz. Elastic band ligation Pancreatography (ERCP) with sphincterotomy Non-Ulcer Dyspepsia Occurs worldwide and is responsible for significant Sclerosis, photocoagulaton, cryosurgery, excisional Pancreatic pseudocyst: surgery Gastro-duodenal malignancy mortality and morbidity. haemorrhoidectomy Drug treatment Oesophagitis Major causes include bleeding from: Caution Analgesics Gall bladder diseases - Peptic ulcer disease Each drug treatment course should not exceed 7 days Treat specific complications Treatment objectives - Oesophageal and gastric varices Relieve pain - Mallory-Weiss tear PANCREATITIS Supportive measures Promote healing of ulcers - NSAID-related mucosal bleeding Introduction Bed rest Eradicate H. pylori - Neoplasia A state of inflammation of the pancreas, which can be Monitor vital signs; fluid intaket/output Prevent/reduce recurrence Bleeding is either from rupture of engorged varices or from disruption of the oesophageal or gastro-duodenal

5 6 Chapter 1: Alimentary Tract Standard Treatment Guidelines for Nigeria 2008 mucosa with ulceration or erosion into an underlying - Injection therapy with epinephrine (1:10,000) up to Aetiology less than 65 kg; 400 mg in the morning and 600 mg in the vessel. 1mL Varies,depending on geographical region: evening for adults weighing 65-85 kg; 600 mg twice daily Clinical features Or: Viruses, alcohol and drugs are the commonest aetiologic for adults weighing over 85 kg Depends on whether the bleeding is acute or chronic, - Thermal coagulation with heat probe agents Hepatitis D mild or severe Or: Important risk factors Interferon alfa -2b: 3 million units subcutaneously 3 Variouspresentations - Laser therapy Family history times weekly for 4 months - Haemetemesis Bleeding varices Alcohol ingestion Plus: - Melaena Intravenous vasopressin 20 units over 20 minutes bolus Previous blood transfusion Lamivudine: 100 mg orally once daily for 4 months - Haematochezia then infusion of 0.1 - 0.5 units/min Contamination of food and water by sewage Hepatitis E - Hypovolaemia Plus: Drug ingestion Largely supportive - Iron deficiency anaemia (with its associated Intravenous nitroglycerin 40 microgram/min (titrated Sexual contact Notable adverse drug reactions symptoms) upward to maintain systolic blood pressure above 90 Clinical features Interferon alpha 2b and Ribavirin haematopoietic Differential diagnoses mmHg) Acute hepatitis: toxicity Black stools from ingestion of iron tablets Endoscopic treatment Mild-to-moderate jaundice Flu-like illness Haematemesis/melaena from previously swallowed Injection sclerotherapy: equal volume mixture of 3% Vagueupper quadrant discomfort Leucopenia blood (from the upper respiratory tract and oral cavity) sodium tetradecyl sulfate, 98% ethanol, sodium chloride With or without mild fever Psychiatric-like symptoms Complications 0.9% injection (2-5 mL/site; maximum 50 mL) There may be enlargement of the liver below the costal Development of early resistance if therepy exceeds 1 Hypovalaemic shock Varicealband ligation margin with varying consistency (depending on the stage year Congestive heart failure from chronic severe anaemia Radiologic therapy of the liver disease) Prevention Investigations Venousembolization Chronic hepatitis: Prevention of faecal contamination of food and water Upper gastrointestinal endoscopy: picks up lesions in Transjugular Intrahepatic Portosystemic Shunt (TIPS) Re-occurence of jaundice may suggest a chronic illness Screen blood and blood products for hepatotrophic 90% of cases Oesophageal transection and devascularization Differential diagnoses viruses Upper gastrointestinal barium radiography: 80% Liver transplant Liver abscess Immunization against hepatitisA, B detection rate Peptic ulcers/erosions/tumours Metabolic liver disease/disorder Reduction of drug misuse/abuse Selective mesenteric arteriography Surgical repair or resection as appropriate Complications Pre-exposure prophylaxis (as for NPI/EPI) Radio isotope scanning Supportive Fulminant hepatic failure Post-exposure prophylaxis Stool- occult blood test Monitor vital signs and urine output to detect early Bleeding tendencies Full Blood Count features of hypovolaemic shock Investigations Treatment objectives Look out for features of hepatic encephalopathy Liver Function Tests HEPATIC ENCEPHALOPATHY Restore and maintain haemodynamic status Notable adverse drug reactions Serologic markers of HepatitisA, B, C, D and E Introduction Control bleeding Vasopressin can cause abdominal cramps. It lowers Abdominal ultrasonography Astate of disturbed central nervous system function as a Prevent recurrence of bleeding blood pressure drastically and could worsen ischaemic Treatment objectives result of hepatic insufficiency Non-drug treatment heart disease Provide supportive measures Characterized by changes in personality, cognition, Carefully monitor vital signs (pulse, blood pressure, Prevention Prevent progression to chronic phase motor function, level of consciousness respiration and temperature) as frequently as Peptic ulcers/erosions related upper gastrointestinal Non-drug treatment One-year survival rate is 40% necessitated by the patient's condition bleeding High carbohydrate and low protein diet Nitrogenous substances, particularly ammonia, reach Insert a nasogastric tube to aspirate gastric contents Avoid NSAIDs. Discontinuation of hepatotoxic medication the brain via portosystemic shunts leading to alteration of and/or to introduce agents to constrict the blood vessels TreatH. pylori infection Bed rest neurotransmission Blood transfusion: whole blood (acute bleeding) or Oesophageal varices Drug treatment Predisposing factors packed cells (chronic) bleeding. Up to 5 - 6 pints of blood β blockers (propranolol 40 mg orally 12 hourly and HepatitisA Reduced blood supply to the liver may be needed in severe cases titrate up to 160 mg depending on the heart rate) Self-limiting disease. No specific drug treatment Infection of the liver - Plasma expanders in the absence of blood Maintenance sclerotherapy Hepatitis B Bleeding into the gut Continuous Central VenousPressure (CVP) monitoring Acute: Electrolyte imbalance (hypokalaemia and Drug treatment Self-limiting to fulminant hypomagnesaemia) Bleeding peptic ulcers/erosions Treatment is supportive Poor bowel evacuation Proton Pump Inhibitors HEPATICAND BILIARYDISORDERS Chronic: Clinical features - Omeprazole 20 mg orally once daily for 4 weeks Interferon alfa -2b: 10 million units subcutaneously Cognitive abnormalities: may be mild and recognizable Or: HEPATITIS three times weekly for 4 months only with psychometric testing but may be severe with - Omeprazole 40 mg by slow intravenous injection over Introduction Lamivudine: 100 mg orally daily for 1year frank confusion, altered level of consciousness and coma 5 minutes once daily until patient can take orally Inflammation of the liver that can be caused by Liver transplant Hyper-reflexia AntiHelicobacter pylori therapy set above. infective agents, drugs and other toxins Chronic Hepatitis C: Fetor hepaticus Endoscopic treatment for actively bleeding ulcer or The most predominant and important presentation of Interferon alfa -2b Insomnia visible non-bleeding vessel liver disease worldwide - 3 million units subcutaneously 3 times weekly for 4 Flapping tremor (asterixis) - Injection therapy with 98% alcohol (total volume less The suffixes acute, chronic, viral, autoimmune, months Differential diagnoses than 1mL) alcoholic etc. define the agents causing hepatic injury or Ribavirin Intracranial lesions (haemorrhage, tumour, abscess Or: their duration as the case may be - 400 mg orally twice daily for adults with body weight etc.)

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CNS infections (encephalitis, meningitis) Associated features of the underlying disease Hepato-renal syndrome High percentages in under-developed countries, Other metabolic encephalopathies (uraemia, Investigations Investigations especially sub-SaharanAfrica hyper/hypoglycaemia etc.) LFTs: determine levels and nature of bilirubin, liver LFTs Clinical features Hypertensive encephalopathy enzymes (AST,ALT,Alkaline phosphotase) PT, PTTK, Serum albumin Kwashiorkor: Alcohol intoxication Abdominal ultrasound scan: look out for canalicular Liver biopsy Growth retardation Drug toxicity e.g. sedatives, heavy metals dilatations, biliary stones Ultrasound examination of the liver Muscle wasting Investigations Treatment objectives Screening for aetiologic factors in chronic liver disease Anaemia As appropriate to identify possible precipitating factors Treat underlying cause e.g. viral markers for hepatotrophic viruses (e.g. Apathy Full Blood Count Prevent complications Hepatitis B & C) Moon face Urea, Electrolytes and Creatinine, Drug treatment Treatment objectives Lack-luster skin Blood sugar Specific treatment depends on the identified cause Prevent further liver damage Easily plucked hair Microscopy and culture of the stool and blood Colestyramine Prevent deterioration of liver function Pedal oedema Treatment objectives - 3-6gorally 6 hourly in severe obstructive jaundice Symptomatic relief from anaemia, fatigue and oedema Hypo-pigmented skin patches Reverse neuropsychiatric symptoms Phenobarbital in neonatal jaundice Non-drug treatment Exfoliation, Minimize nitrogenous substances - 5 - 8 mg/kg orally daily Encourage high fibre and low salt diet Diarrhoea Treat precipitating factors Notable adverse drug reactions Enhance opening of bowel Marasmus: Drug treatment Colestyramine: diarrhoea Correction of anaemia Thin; protruding bones Lactulose syrup (10 g/15 mL) Phenobarbital may cause dose-dependent respiratory Reduce oedema and ascites Hungry-looking - Initially 30 - 45 mL orally three times daily titrated to depression Drug treatment 'old-looking face’ either the resolution of symptoms or production of three Surgical treatment Ascites and pedal oedema Whimpering cry soft stools per day Obstructive jaundice Spironolactone tablets 25 - 100 mg orally 12 hourly Investigations Or: ERCPsphincterotomy with stone removal Furosemide 20 - 80 mg orally 12 hourly Full Blood Count, ESR - As rectal retention enema 300 mL in 1 litre water Stent insertion Salt-poor albumin for intractable ascites Stool microscopy retained for 1 hour; duration usually for days or weeks Pancreatic head/duodenal head realignment Prevention of variceal bleeding Urinalysis Or: Supportive measures Propranolol 40 - 80 mg orally daily Serum proteins Metronidazole 800 mg orally 12 hourly Reassurance and monitoring Replacement of damaged liver Chest radiograph Treat underlying cause(s) e.g hypokalaemia, anaemia, Phototherapy in neonatal jaundice Liver transplant Mantoux test infection Prevention of encephalopathy Non-drug treatment Supportive measures Lactulose 30 mLorally twice daily Nutritional counselling High carbohydrate, low protein diet LIVER CIRRHOSIS - Doses to be titrated upward until at least 3 bowel Adequate nutrient intake: may require assistance and Adequate hydration Introduction motions daily are achieved special preparations e.g. nasogastric feeding, etc. Rectal wash out An advanced stage of chronic liver disease associated Saline rectal enema Periodic growth monitoring Notable adverse drug reactions with permanent distortion of the liver architecture and Prevention Drug treatment Lactulose: excess gas, diarrheoa replacement of some destroyed hepatocytes with fibrous Immunization against hepatitis B, C May be indicated where there are specific Metronidazole: peripheral neuropathy, dysgeusia tissue Abstinence from alcohol infections/infestations Prevention Accompanied by some loss of liver function leading to Avoid precipitating factors certain recognized symptoms and signs Aetiology MICRONUTRIENT DEFICIENCIES Similar to some causes of acute liver diseases NUTRITIONALDISORDERS Definition No known aetiology in up to 30% of cases Deficiencies of minerals (iron, iodine, zinc, calcium, JAUNDICE Clinical features KWASHIOKORAND MARASMUS phosphorus, magnesium, copper, potassium, sodium, Introduction Varieswith the extent of liver damage: Introduction chloride, fluoride etc); folic acid and vitamins Acommon clinical state of varying aetiologies Fatigue Adequate nutrition is the intake and utilization of Aetiology Classified as haemolytic, hepatic or obstructive Ascites energy-giving and body building foods and nutrients, to Inadequate dietary intake Clinical jaundice occurs when the level of serum Pedal oedema maintain well-being, and productivity. Increased requirements bilirubin exceeds 2.5 mg/dL Haematemesis “Malnutrition” includes generalized malnutrition that Increased loss (e.g. worm infestation) The bilirubin may be conjugated, unconjugated or Liver may be shrunken or enlarged below the costal manifests as stunting, underweight, wasting Epidemiology mixed margin; it is typically firm (kwashiorkor and marasmus), obesity as well as Global; high percentages in under-developed countries, Important causes Differential diagnoses deficiencies of micronutrients. especially sub-SaharanAfrica Diseases of the liver and the biliary tract Granulomatous lesion of the liver Kwashiorkor is protein-energy malnutrition . Clinical features Conditions that cause excessive red cells haemolysis: Primary or secondary neoplasms of the liver Marasmus is malnutrition resulting from inadequate Iron: anaemia infections, haemoglobinopathies Complications calorie intake. Iodine: goitre Clinical features Intractable oedema Zinc, copper: manifestations of enzyme and insulin Discolouration of the sclerae and other mucus Upper gastrointestinal tract bleeding Obesity is a commonly nutritional disorder (results from deficiencies membranes Coagulopathy excessive intake of calories). Calcium: rickets, osteomalacia With or without pruritus (especially with cholestatic Hepatic encephalopathy Epidemiology Phosphorus and fluoride: teeth and bone abnormalities jaundice)

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Vitamins: The pattern of distribution of fat in the body (whether Prevent complications CHAPTER 2: BLOOD AND BLOOD-FORMING - A: keratomalacia, corneal xerosis, night blindness mostly peripheral or central) is assessed by the use of the Management ORGANS

- B1 (thiamine): beri-beri waist/hip ratio (WHR) Assess dietary intake, level of physical activity, BMI ANAEMIAS - B2 (riboflavin): scrotal and vulval dermatoses, angular Waist/Hip ratio=Waist circumference (in cm) divided by (total body fat) and waist circumference (abdominal fat) stomatitis, scars, magenta tongue, cheilosis Hip circumference (in cm) on presentation and at regular monitoring Introduction - B (niacin): scarlet and dry tongue, pellagra Waist circumference: measure midway between the Assess efficacy of weight loss measures Anaemia is a reduction in the haemoglobin 6 concentration in the peripheral blood below the normal - Ascorbic acid: scurvy, petechiae and musculo-skeletal lower rib margin and the iliac crests Integrate weight control measures into the overall range expected for the age and sex of an individual haemorrhages Hip circumference: the largest circumference of the hip management of diabetes mellitus and co-morbidities if The determination of haemoglobin concentration - D: rickets, epiphyseal enlargement, muscle wasting, Waist circumference better depicts central or upper - BMI is >25 should always take the state of hydration and altitude of bossing of skull bone, 'thoracic rosary', persistently open body obesity than waist/hip ratio - Waist circumference is more than 102 cm and 88 cm in residence of the individual into consideration anterior fontanelle, genu valgum or varum - Upper limits: 102 cm and 88 cm in men and women men and women respectively It can be classified on the basis of red cell morphology Investigations respectively Educate patients and other family members and aetiology/pathogenesis Blood, urine and stool tests Investigations Set realistic goals Morphological classification Other investigations as appropriate Non-specific Use a multi-disciplinary approach to weight control Macrocytic Treatment objectives - Always bear in mind the possibility of an underlying Dietary changes and increased level of physical activity Megaloblastic Correct nutrient deficiencies cause: although these may not be common, specific are the most economical means to loose weight - Folic acid deficiency Ensure adequate intake therapy may be available Maintain records of goals, instructions and weight - Vitamin B deficiency Prevent complications - Clinical presentation may therefore require specific progress charts 12 Treatment investigations to exclude conditions such as Surgical intervention may be required in extreme cases - Inherited disorders of DNAsynthesis Administration of specific nutrients (as concentrates in Hypothyroidism Non-megaloblastic foods) Hypercortisolism - Accelerated erythropoiesis Food supplementation Male hypogonadism - Increased membrane surface area Treat underlying diseases Insulinoma - Obscure Prevention CNS disease that affects hypothalamic function Hypochromic-microcytic Nutritional counselling Complications Iron deficiency Optimal breastfeeding and appropriate weaning Cardiovascular: Disorders of globin synthesis practices Coronary disease Other disorders of iron metabolism Adequate intake of locally available, nutritious foods Stroke Normochromic-normocytic Personal/food/water hygiene Congestive heart failure Recent blood loss Prophylactic therapies for malaria Pulmonary: Haemolytic anaemias Obstructive sleep apnoea Hypoplastic bone marrow 'Obesity hypoventilation syndrome' Infiltrated bone marrow OBESITY Endocrine: Endocrine abnormality Introduction Insulin resistance and type 2 diabetes mellitus Chronic disorders Amajor component of the metabolic syndrome. Hepatobiliary: - Renal disease Being overweight or obese significantly increases the Gall stones - Liver disease risk of morbidity and mortality from Type 2 diabetes and Reproductive: Classification based on aetiology and pathogenesis its co-morbidities. Male hypogonadism Blood Loss: Successful weight reduction has a positive impact on Menstrual abnormalities Acute morbidity and mortality outcomes. Infertility Chronic (leads to iron deficiency) Constititional obesity is a result largely of diet and Cancers: Increased red cell destruction (haemolytic anaemias): lifestyle. In males, higher mortality from cancer of the colon, Corpuscular defects (intracorpuscular or intrinsic Measurements for evaluation rectum and prostate abnormality) Body mass index (BMI): calculation for overall obesity In females, higher mortality from cancer of the gall Disorders of the membrane e.g elliptocytosis, Waist circumference: determination of central fat bladder, bile ducts, breasts, endometrium, cervix and spherocytosis distribution ovaries Disorders of metabolism e.g Glucose-6-Phosphate BMI is calculated as follows Bone, joint and cutaneous disease: Dehydrogenase deficiency 2 BMI = weight in kg divided by height in m , expressed as Osteoarthritis Haemoglobinopathy e.g sickle cell disease 2 kg/m Gout Paroxysmal Nocturnal Haemoglobinuria Classification of BMI Acanthosis nigricans Abnormal haemolytic mechanisms (extra-corpuscular or Underweight: <18.5 kg/ m2 Increased risk of fungal and yeast infections intrinsic abnormality): Normal weight: 18.5 - 24.9 kg/ m2 Venousstasis Autoimmune Overweight: 25 - 29.9 kg/ m2 Rhesus-incompatibility, mismatched transfusion Obesity (Class1): 30 - 34.9kg/m2 Treatment objectives Hypersplenism Obesity (Class 2): 35 - 39.9 kg/m2 To educate patient and care givers Infections e.g malaria, Clostridium welchii Extreme obesity (Class 3): > 40 kg/m2 Achieve an ideal body weight Drugs and toxins BMI represents overall adiposity

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Others e.g. burns Platelet count Not necessary unless there is intolerance to oral iron transfusion. Decreased red cell production: Erythrocyte sedimentation rate Indications for parenteral iron: Indication(s) must be clearly established. Nutritional (due to deficiencies of substances essential Blood film examination for morphology of cells Anaemia diagnosed in late pregnancy Transfusion of whole blood or red cell concentrates is for erythropoiesis) Thick and thin films for malaria parasites Correction of anaemia just before an operative important in the treatment of acute blood loss and of - Iron Urine analysis: procedure anaemia. - Folate Colour, pH, clarity, specific gravity Haemorrhage expected to continue unabated Red cells can be stored at 4ºC for 5 weeks in media that

- Vitamin B12 Microscopic examination of fresh urine specimen Iron preparations: are specially designed to maintain the physical and - Variousdeficiencies e.g. protein, ascorbic acid Protein Iron dextran given as “total dose" infusion biochemical integrity of the erythrocytes and which Bone marrow stem cell failure: Glucose Dose in mL (of 50 mg/mL preparations) = [Patient's wt. maintain their viability after transfusion. Primary (idiopathic): Occult blood in kg X (14 Hb in g/dL)]÷ 10 Citrate Phosphate Dextrose with Adenine (CPDA) is - Aplastic anaemia Stool: Notable adverse drug reactions, caution commonly used for collections of whole blood. - Pure red cell aplasia Colour, consistency Oral iron preparations: The use of whole blood as a therapeutic agent has been Secondary: Examination for ova and parasites Nausea, epigastric pain, diarrhoea, constipation, skin almost completely replaced by the use of blood - Drugs (phenylbutazone, cytotoxic agents, etc) Occult blood eruptions fractions. - Chemicals Plasma: Reduce dosage and frequency of administration to Types of blood transfusion - Irradiation Blood Urea Nitrogen (BUN) reduce these effects Autologous blood transfusion: Anaemias associated with systemic disorders: Total protein and albumin Parenteral iron: Transfusion of the patient's own blood to him /her Infection Bilirubin Local reactions: phlebitis and lymphadenopathy - Safest blood for patients Liver disease Creatinine (if BUN is abnormal) Systemic reactions: may be early or late- headache, The three main types are: Renal disease Others: fever, vomiting; general aches and pains, backache, - Pre- deposit autologous transfusion Connective tissue disease Coombs test for the presence of antibodies to red cells chest pain, dyspnoea, syncope; death from anaphylaxis - Immediate pre-operative phlebotomy with Cancer (including leukaemia) Ham's test (acidified serum test) A test dose should be administered: 25 mg haemodilution Marrow infiltration Bone marrow aspiration and trephine biopsy intramuscularly or by intravenous infusion over 5 to 10 - Intra-operative blood salvage Thyroid or pituitary disease Haemoglobin electrophoresis minutes Exchange transfusion: Clinical features Sickling test (metabisulphite and solubility) Total-dose infusion should be avoided in patients with To remove deleterious material from the blood, for Depend on the degree of anaemia, severity of the Family studies history of allergy example, in severe jaundice resulting from haemolytic causative disorder and age of the patient Treatment objectives Megaloblastic anaemia disease of the newborn The clinical effects of anaemia are due to anaemia itself Restore haemoglobin concentration to normal levels Response to therapy is satisfactory if administered Alternatives to red cell transfusion: and the disorder(s) causing it Prevent/treat complications dose is limited to the minimal daily requirement Perfluorochemicals such as Fluosol-DA

Common: Supportive measures Treatment with vitamin B12 (cobalamin) to replace Polymerised haemoglobin solutions with good Tiredness Bed rest in severe cases: initially necessary, especially body stores intravascular recovery Lassitude when cardiovascular symptoms are prominent - Six-1000 micrograms intramuscular injections of Indications for blood transfusion Weakness Treat cardiac failure by standard measures hydroxocobalamin given at 3 - 7 day intervals Symptomatic anaemias: Dyspnoea on exertion Balanced diet with adequate protein and vitamins Maintenance therapy: patients will need to take - Recurrent haemorrhage

Palpitations Correct dietary deficiencies (e.g. iron, folic acid) vitamin B12 for life - Haemolysis Pallor Blood transfusion: a very important measure in the - 1000 micrograms hydroxocobalamin intramuscularly - Bone stem cell failure Less common: treatment of anaemia, but should not be used as a once every 3 months - Pure red cell aplasia Angina of effort substitute for investigation, or specific treatment of the Notable adverse drug reactions, caution - Severe anaemia of chronic disorders Faintness cause Toxic reactions are very rare and are usually not due to - Haematological malignancies (e.g. leukaemia, Giddiness Arrest blood loss cobalamin itself lymphoma) Headache Treat any underlying systemic disorder Pharmacologic doses of folic acid produce - Chemotherapy complicated by anaemia Remove any toxic chemical agent or drug In neonates: Ringing in the ears haematological response in vitamin B12 -deficient High output state Correct anatomical gastro-intestinal abnormalities patients but worsen the neurological complications - Severe acute haemorrhage Congestive cardiac failure Drug treatment - Haemolytic disease of the new born Large doses of vitamin B12 also give haematological Differential diagnoses Haematinics e.g. iron, vitamin B12, folic acid response in folate-deficient patients - Septicaemia Cardiac failure The specific haematinic indicated should be given alone Prevention - Prematurity Respiratory failure Response to adequate treatment is important in Balanced diet Bleeding disorders: Complications confirming diagnosis Prompt treatment of all illnesses - Congenital e.g. haemophilia Cardiac failure Iron deficiency - Acquired e.g. disseminated intravascular coagulopathy Death Oral iron therapy: Prevention or treatment of shock: Investigations - Ferrous sulfate 200 mg (containing 65 mg of iron) 1 BLOOD TRANSFUSION - Clinical situations in which there is need to restore Haematologic: tablet 2-3 times daily Introduction and/or maintain circulatory volume e.g. trauma, Haematocrit; haemoglobin concentration Treat for 3- 6 months to correct deficits in haemoglobin Blood transfusion is the administration of blood for haemorrhage Red cell indices and in stores therapy. To maintain the circulation (as in extracorporeal or Reticulocyte count Parenteral therapy: It is potentially hazardous: blood should be given only cardiac by-pass shunts) Total leukocyte and differential counts if the dangers of not transfusing outweigh those of Whole blood preparations

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Should be limited to correction or prevention of - Febrile transfusion reactions Prompt treatment of illnesses that could be complictated Clinical features hypovolaemia in patients with severe acute blood loss - Post-transfusion purpura by anaemia General symptoms of anaemia Fresh Blood Reactions due to white cell and plasma protein Regular medical check-ups Bleeding Justified by the recognition that there is a relatively antibodies Infections rapid loss of platelets, leucocytes and some coagulation - Urticaria Anorexia factors with liquid storage. There is also progressive - Anaphylaxis Weight loss increase in the levels of undesirable products such as Non-immunological: HAEMOSTASIS AND BLEEDING DISORDERS - Lymphadenopathy (not common in AML except in the potassium, ammonia, and hydrogen ions Transmission of disease refer for specialist care monocytic variant) Erythrocyte preparations Reactions due to bacteria and bacterial pyrogens Skin : Four types are in common use: Circulatory overload LEUKAEMIAS Macules, papules, vesicles - Packed red blood cells Thrombophlebitis Introduction Pyoderma gangrenosum - Washed red blood cells Air embolism A heterogeneous group of diseases characterized by Neutrophilic dermatitis - Leucocyte-reduced red blood cells Transfusion haemosiderosis infiltration of the blood, bone marrow and other tissues Leukaemic cutis - Frozen red blood cells Complications of massive transfusion by neoplastic cells of the haematopoietic system Granulocytic sarcoma Washed red blood cells Testsof Compatibility Two main types Differential diagnoses Obtained from liquid-stored blood by saline washing A minimum of three major procedures must be carried - Myeloid leukaemia Septicaemia using a continuous-flow cell separator or from frozen out: - Lymphoid leukaemia Miliary tuberculosis erythrocytes extensively washed to remove the - Determine the recipient'sABO and Rhesus groups Each is further divided into acute and chronic Malignant histiocytosis cytoprotective agents - Select compatible donor blood Acute leukaemias are defined pathologically as blast Complications Leucocyte-reduced red blood cells - Cross-match donor cells against recipient's serum cell leukaemias or malignancies of immature Worsening ill- health Best prepared by passing whole blood or packed cells Donor blood should be screened for infective agents: haematopoietic cells. The bone marrow shows > 30% Investigations through specifically designed filters. HIV,hepatitis B, and C viruses blast cells Full blood count with ESR, reticulocyte count Three main reasons for the use of leucocyte-reduced Other investigations Two main groups of acute leukaemias Coomb's test red blood cells: Haemoglobin concentration - Acute myeloid leukaemia (AML) Bone marrow examination - To prevent non-haemolytic febrile reactions to white Haematocrit - Acute lymphoblastic leukaemia (ALL) Biochemical tests: serum electrolytes, urea, creatinine, cell and platelet antibodies in recipients exposed to Red cell indices: MCH, MCV,MCHC Childhood leukaemias: patients aged <15 years uric acid previous transfusions or pregnancies Total leucocyte and differential counts Adult leukaemias: patients aged >15 years Liver function tests - To prevent sensitization of patients with aplastic Reticulocyte count Leukaemias in adults aged > 60 years: an important Prothrombin time, partial thromboplasnime anaemia who may be candidates for bone marrow Erythrocyte sedimentation rate group because Human LeucocyteAntigen typing transplantation Platelet count - Their responses to current treatment protocols both for HIV I and II - To minimize risk of transmission of viruses such as Treatment objectives ALLandAMLare inferior Cytochemical tests HIV or cytomegalovirus To raise haemoglobin concentration and other blood - These patients are not usually considered for more - Peroxidase Transfusion therapy parameters to normal levels radical treatment approaches such as autologous or - Sudan Black B Informed consent should be obtained from patients To prevent blood transfusion complications allogeneic bone marrow transplantation - Non-specific esterase reaction e.g. alpha napthyl except in life-threatening emergencies Non-drug treatment 80% of adult cases:AML acetate esterase The risks and benefits of the proposed transfusion Transfusion of red blood cells, platelet concentrates or Epidemiology/predisposing conditions Bone marrow cultures therapy should be discussed with the patient and platelet rich plasma as required Acute lymphoblastic leukaemia (ALL) and Acute Cytogenetic studies documented in the patient's medical records Provision of fresh frozen plasma or other blood myeloid leukaemia (AML) Electron microscopy Blood for emergencies products as necessary More common in industrialized than rural areas Cell markers e.g. using a panel of antibodies combined There may be no time available to type, select and Drug treatment Environmental agents implicated in the induction of with flow cytometric analysis or the alkaline phosphase- cross-match compatible blood Furosemide 40 mg on administration of one unit of certain types of leukaemia: antialkaline phosphate (APAAP) technique to classify Arare occurrence, except for blood Ionising radiation: X-rays and other ionizing rays the blast cells into lymphoid or myeloid lineages - Trauma In the event of transfusion reactions, stop the transfusion Chemical carcinogens Abdominal ultrasound/CT scans - Unexpected intra-operative haemorrhage immediately and administer the following: - Benzene and other petroleum derivatives Immunological classification - Massive gastro-intestinal bleeding Promethazine 25 mg intramuscularly or intravenously - Alkylating agents Terminal deoxynucleotidyl transferase demonstration - Ruptured aneurysm Epinephrine 0.5 mL of 1:1000 solutions to be Host susceptibility e.g. genetic disorders: in nuclei of B and T lymphocytes Uncross-matched or partially cross-matched blood is administered subcutaneously Bloom's syndrome Treatment objectives administered; routine cross-match should be carried out Hydrocortisone sodium succinate 100 mg injection Fanconi's anaemia (AML) Induce remission to achieve complete remission retrospectively to identify any incompatibility Supportive measures Ataxia telangiectasia (ALL) Maintain disease-free state Complications of blood transfusion Appropriate nutrition Down's syndrome Non-drug treatment Immunological: Adequate hydration Blast transformation in pre-existing myeloproliferative Appropriate nutrition Sensitization to red cell antigens Notable adverse drug reactions, caution disoders: Adequate hydration (at least 3 litres/24 hours) Haemolytic transfusion reactions Furosemide: dehydration and hypersensitivity Aplastic anaemia (ALL) Erythrocyte transfusion as required - Immediate Promethazine: drowsiness, hypersensitivity Oncogenic viruses: Platelet concentrate transfusion as required - Delayed Prevention HTLV-1 (Human T-cell Lymphotropic virus 1): Maintain electrolyte balance Reactions due to white cell and platelet antibodies Avoid/prevent accidents implicated in adult T cell leukaemia /lymphoma

15 16 Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

Drug treatment for 7 days Clinical features cardiotoxicity Acute lymphoblastic leukaemia Prednisolone 40 mg/ m2 orally for 14 days Asymptomatic All are contraindicated in patients with history of Allopurinol 300 mg daily orally - Nervous system prophylaxis is not required Abdominal swelling/pain hypersensitivity reactions to the respective medicines DVPRegime - Assess for remission after 3 courses Lethargy Prevention Daunorubicin 30 mg/m2 intravenously on days 8, 15, 22 Maintenance Shortness of breath on exertion Avoid exposure to ionizing radiation and 29 COAPevery 6 weeks for 2 years Weight loss Early detection and treatment Vincristine 1.4 mg/m2 to a maximum of 2 mg Intrathecal treatment as forALL if there is CNS disease Unexplained haemorrhage at various sites e.g. gums, Chronic Lymphocytic Leukaemia intravenously on days 8, 15, 22 and 29 of the monocytic type intestinal/urinary tracts Neoplastic proliferations of mature lymphocytes Prednisolone 60 mg orally once daily from day 1 - 28 Chronic Myeloid Leukaemia (CML) Increased sweating The diseases involve the blood bone marrow and other L-asparaginase 1000 IU/m2 intravenously on days 12, Also Chronic Myelogenous Leukaemia; Chronic Visual disturbances tissues 15, 18, 21, 24, 27, 30 and 33 Granulocytic Leukaemia (CGL) Gout Characterized by accumulation of small mature-looking Or: A clonal disease that results from acquired genetic Priapism CD5+ B lymphocytes in the blood, marrow and COAPRegime change in a pluri-potential haematopoietic stem cell Splenomegaly lymphoid tissues Cyclophosphamide 650 mg/m2 intravenously on days 1 Altered stem cell proliferation generates a population of Anaemia B-cell disorders are more common and 8; 14 and 22 differented cells, and a greatly expanded total myeloid Haemorrhage B-cell CLLis more common in males than females Vincristine 1.4 mg/m2 intravenously to a maximum of 2 mass Fever - Accounts for 60% of cases mg: days 1 and 8; 14 and 22 Classification Lymphadenopathy (rare in chronic phase) - Rarely diagnosed below the age of 40 years Cytosine Arabinoside 50 mg/ m2 subcutaneously 12 Majority of patients have relatively homogenous Complications Clinical features hourly for 12 days or bolus intravenous injection 100 disease characterized by: Blastic transformation Asymptomatic (30% of cases) mg/m2 daily for 7 days - Splenomegaly Death Symptoms of anaemia Prednisolone 40 mg/m2 oral for 14 days - Leucocytosis Investigations Lymph node enlargement (painless) - Drugs are given every 28 days for 3 courses - Presence of Philadelphia (Ph) chromosone in all As above for acute leukaemia plus: Rare: pyrexia, sweating or weight loss Nervous system prophylaxis leukaemia cells Determination of Philadelphia chromosome Severe chest infection/pneumonia - Methotrexate 12.5 mg/m2 intrathecally twice weekly to Minority of patients have less typical disease (atypical Lactic dehydrogenase Splenomegaly (50% of cases) a maximum of 15 mg i.e. 5 doses over 3 weeks. CML) Serum calcium Hepatomegaly (not frequent) Consolidation - These variants lack Ph chromosome. Examples: Treatment objectives Differential diagnoses To be given on day 29 - Chronic myelomonocytic leukaemia Induce remission to achieve complete remission Low grade non-Hodgkin's lymphomas with frequent COAP regime to be given once provided WBC count is - Chronic neutrophilic leukeamia Maintain disease-free state blood and bone marrow involvement (leukaemia / 99 Achieve absence of Philadelphia chromosome = 1x10 /Land platelet count is = 100 x10 /L - Juvenile chronic myeloid leukaemia lymphoma syndromes) Non-drug treatment Maintenance Epidemiology, aetiology and natural history Tuberculosis 2 Rare below the age of 20 years but occurs in all age Appropriate nutrition 6-Mercaptopurine 75 mg/m orally daily Viral infections 2 groups Adequate hydration Methotrexate 20 mg/m orally weekly Toxoplasmosis Increased risk of developing CMLwith exposure to high Electrolyte balance - For 3 years if remission is maintained, otherwise re- Complications doses of irradiation Drug treatment assessment Richter transformation Abiphasic or triphasic disease, usually diagnosed in the Hydroxycarbamide (hydroxyurea) Pulse therapy (Intensification) Progression of disease initial “chronic”or stable phase Adult: 20-30 mg/kg orally daily or 80 mg/kg every third To be given every 3 months with Investigations 2 Distinguishing features between phases of CGL day Cell morphology: - Vincristine 1.4 mg/ m to a maximum of 2 mg weekly Chronic phase Child: Not recommended Size on days1 and 8 Untreated patient: Interferon alpha Nuclear: cytoplasmic (N:C) ratio Acute myeloblastic leukaemia - <12% blast cells in blood or marrow Adult: 9 million units subcutaneously or intravenously Regularity or irregularity of the nuclear outline Either TAD or COAPas shown below: Treated patient: thrice weekly for6-12months Characteristics of the cytoplasm (presence and length or TAD 2 - Normal or near-normal blood count without immature Or: absence of azurophil granules) Cytarabine 100 mg/m (continuous infusion) on days 1 2 granulocytes in peripheral blood Imatinib mesylate Degree of nuclear chromatin condensation and its and 2, and 100 mg/mevery 12 hours by intravenous Accelerated phase - 400 mg orally daily pattern infusion over 30 minutes on days3-8 - Tobe used strictly under specialist supervision 2 Rising leucocyte count despite treatment Prominence, frequency and localization of the Thioguanine 100 mg/mevery 12 hours orally on days Rapid leucocyte doubling time Notable adverse drug reactions, caution nucleolus 3-9 Immature granulocytes in blood The above drugs (except the steroids) all cause profound 2 Investigations Daunorubicin 60 mg/m by intravenous infusion over Blast cells >5% but <30% in marrow myelosuppression As for anaemia and other leukaemias one hour on days3-5 Anaemia (Hb <10 g/dL) not attributable to treatment Profound nausea, vomiting, diarrhoea and abdominal Treatment objectives Or: Thrombocytosis (>1000 x 109 /L) discomfort Induce remission to achieve complete remission COAP Acquisition of specific new cytogenetic abnormalities Secondary malignancies 2 Maintain disease-free state Cyclophosphamide 650 mg/m intravenously on days 1 Increasing marrow fibrosis Steroids: Cushing's syndrome, hypertension, diabetes Non-drug treatment and 8 Blastic transformation mellitus, immunosuppression, infections Appropriate nutrition 2 Vincristine 1.4 mg/m intravenously to a maximum of 2 More than 30% blasts Vincristine: neurotoxicity Adequate hydration mg on days 1 and 8 Or: Cylophosphamide: alopecia, haemorrhagic cystitis Maintenance of electrolyte balance 2 Cytarabine 50 mg/m subcutaneously every 12 hours Blasts plus promyelocytes in blood or bone marrow Daunorubicin: myelosuppression, alopecia, Bone marrow transplant

17 18 Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

Red cell and platelet concentrate transfusion as required - Vary widely according to histological subtype, Vincristine 1.4 mg/m2 (maximum 2 mg) on days 1 Sickle cell-ß+thalassaemia. Type III. (Sß+thal. Drug treatment stage and bulk of disease and 8 Type III) Chronic Lymphocytic Leukaemia Prednisolone 100 mg orally on days1-8 Sickle cell trait Allopurinol 100 mg orally every 8 hours Investigations Hodgkin's lymphoma Inheritance of one normal gene controlling Chlorambucil 5 mg/m2 orally on days 1 to 3 Mandatory MOPP formation of ß Haemoglobin (HbA), and a sickle Prednisolone 75 mg orally on day 1; 50 mg orally on Full Blood Count (i.e. haemoglobin, haematocrit, Mechlorethamine 6 mg/m2 intravenously on days 1 gene (HbS) day 2 and 25 mg orally on day 3 leucocyte and differential counts; red cell indices, and 8 Total haemoglobin Ais more than haemoglobin S - Repeat every 2 weeks reticulocyte count) Vincristine 1.4 mg/m2 (maximum 2 mg) Normal haemoglobin F Or: Erythrocyte sedimentation rate intravenously on days 1 and 8 Sickle cell disease Fludarabine 25 - 30 mg intravenously over 30 minutes Coombs test Procarbazine 100 mg/m2 orally on days 1 4 Inheritance of two abnormal allelemorphic genes on days 1-5 Bone marrow aspiration and needle biopsy Prednisolone 40 mg orally on days1-14 controlling formation of ß chains of haemoglobin, at - Repeat every 4 weeks Serum Urea, Electrolytes ChIVPP least one of which is the sickle gene Or: Serum Uric acid Chlorambucil 6 mg/m2 orally on days 1 and 14 Polymerization of the sickle haemoglobin may Liver Function Tests: transaminases-ALT, AST, 2 Combination chemotherapy Vinblastine 6 mg/m (maximum 10 mg) lead to vaso-occlusion 2 ALP; bilirubin; serum proteins - Cyclophosphamide 400 mg/m intravenously on days 1 and 18 Pathophysiology 2 HIV screening 2 - Vincristine 1.4 mg/m Procarbazine 100 mg/m orally on days 1 and 14 Red cells have reduced deformability and easily Immunoglobulins - Prednisolone 100 mg orally days1-5 Prednisolone 40 mg orally on days1-14 adhere to vascular endothelium, increasing the Chest X- ray Repeat every 3 weeks Supportive measures potential for decreased blood flow and vascular Optional Or: Appropriate nutrition obstruction. 2 Examination of post-nasal space Fludarabine 30 mg/m intravenously over 30 minutes Adequate hydration Abnormalities in coagulation, leucocytes, vascular Serum copper level ondays1-3 Notable adverse drug reactions, caution endothelium, and damage to the membranes of red 2 Neutrophil alkaline phosphatase Cyclophosphamide 250 - 300 mg/m intravenously All the drugs are contraindicated in patients with cells contribute to sickling Tomograms of lung or mediastinum over 30 minutes on days1-3 hypersensitivity reactions to the respective Haemolytic anaemia and vasculopathy are the Skeletal X-ray - Repeat every 4 weeks medicines result of the various pathophysiologic processes Abdominal ultrasound scans Supportive measures Profound nausea, vomiting, diarrhoea and Organ damage is on-going and is often silent until Intravenous pyelography Appropriate nutrition abdominal discomfort far advanced CT scans of chest and abdomen Adequate hydration Secondary malignancies The course of the disease is punctuated by episodes Supplementary node biopsy Notable adverse drug reactions, caution Myelosuppression (except the steroids) of pain Treatment objectives Same as for other leukaemias Steroids (prednisolone) may cause Cushing's Clinical features Induce remission Prevention syndrome, hypertension, diabetes mellitus, Varywidely from one patient to another: Restore patient to disease-free state Avoid chemicals on body (e.g benzene) suppression of immunity, infections Persistent anaemia/pallor Maintain state of well being Avoid ionizing radiation (X rays) Vincristine: neurotoxic Growth retardation (variable) Non-drug treatment Early detection and treatment Cyclophosphamide: alopecia and haemorrhagic Jaundice (variable) Appropriate nutrition cystitis Bone pains (recurrent) Adequate hydration Doxorubicin: cardiotoxic Prominent facial bones due to increased bone Red cell and platelet concentrate transfusions as LYMPHOMAS Prevention marrow activity required Introduction Avoid unnecessary exposure to irradiation and Leaner body build and less weight (on average) Drug treatment Solid neoplasms that originate in lymph nodes or chemicals Some fingers are shortened as a result of infarction Malaria prophylaxis: proguanil 200 mg orally daily other lymphatic tissues of the body (destruction due to blockage of blood supply) Antibiotics as indicated Aheterogeneous group of disorders Hand-foot syndrome (painful and swollen hands Allopurinol 300 mg orally daily (when uric acid is - Can arise at virtually any site and feet) in childhood high) - More often occurs in regions with large SICKLE CELLDISEASE Life span on average shorter than normal Non-Hodgkin's lymphomas concentrations of lymphoid tissues, e.g. lymph Introduction Sexual development is delayed in both sexes: CHOP (3 weekly): menarche occurs at a mean age of 15.5 years (range nodes, tonsils, spleen and bone marrow 2 Agroup of conditions with pathological processes Two main groups: Cyclophosphamide 750 mg/m intravenously on resulting from the presence of Haemoglobin S 12 - 20 years) compared to non-sicklers (mean day 1 Usually inherited from the parents who have 13.2years) - Hodgkin's disease 2 Doxorubicin 50 mg/m intravenously on day 1 themselves inherited haemoglobin S Impotence can occur from prolonged priapism - Non-Hodgkin's lymphomas 2 Hodgkin's disease is characterized by Reed- Vincristine 1.4 mg/m (maximum of 2 mg) The principal genotypes include: High foetal loss in pregnancy Sternberg cells (large binucleate cells with vesicular intravenously on day 1 - Homozygous sickle cell disease (SS) Sickle cell crises nuclei and prominent eosinophilic nucleoli) Prednisolone 100 mg orally on days1-5 - Sickle cell-haemoglobin C disease (SC) Patient has acute symptoms/signs attributable CHOP (4 weekly): - Sickle cell-ß thalassaemia (Sß thal) directly to sickle cell disease - Reed-Sternberg cells are occasionally found in 2 other clinical conditions e.g. hyperplastic or Cyclophosphamide 750 mg/m intravenously on Sickle cell-ß+ thalassaemia Type I (Sß+thal.Type Two main types: days 1 and 8 I) Pain (vaso-occlusive) crisis inflammatory lesions of lymph nodes 2 Non-Hodgkin's lymphomas: a heterogeneous Doxorubicin 25 mg/m intravenously on days 1 and Sickle cell-ß+thalassaemia. Type II. (Sß+thal. Anaemia crisis collection of lymphoproliferative malignancies 8 Type II) Vaso-occlusivecrises

19 20 Chapter 2: Blood and Blood-Forming Organs Standard Treatment Guidelines for Nigeria 2008

Painful - Pulmonary hypertension - Emotional stress Antimalarials Tender, swollen bones - Acute chest syndrome Adjunct treatment Artemisinin-based combination therapy (see Acute hepatopathy Investigations Blood transfusion (especially red cell transfusion) section on malaria) Acute chest syndrome Full Blood Count (haemoglobin, haematocrit, total Anti-pneumococcal vaccine Supportive measures Priapism leucocyte count and differential counts, platelet Drug treatment Counselling and health education counts) Steady state (when patient is well with no Membership of support group Painless Erythrocyte sedimentation rate complaints): Regular health checks Haematuria Red cell indices (MCH, MCHC, MCV) Proguanil Notable adverse drug reactions, caution and Cerebrovascular disease (accident) - in descending Reticulocyte count Adult: 200 mg orally daily contraindications order of prevalence Sickling tests: solubility test; metabisulphite test Child: under 1 year 25 mg daily; 1 - 4 years 50 mg; 5 - Paracetamol should be used with caution in - Thrombotic stroke Haemoglobin electrophoresis 8 years 100 mg; 9 - 14 years 150 mg orally daily patients with hepatic impairment - Seizures - Using cellulose acetate paper at pH 8.4 (alkaline) Plus: Opioid analgesics cause varying degrees of - Haemorrhage or citrate agar gel at pH 5.6 (acidic) Folic acid 5 mg orally daily respiratory depression and hypotension Retinopathy (commonest in SC patients) Serum Electrolytes, Urea and Creatinine Pain crises - They should be avoided when intracranial pressure Anaemic crises Liver function tests (transaminases, bilirubin, Mild pain is suspected to be raised Acute splenic (or hepatic) sequestration serum albumin, alkaline phosphatase and Paracetamol Prevention Hyper-haemolytic (e.g. precipitated by malaria) prothrombin time) Adult: 1 g, every 4 - 6 hours to a maximum of 4 g Advice on the risks involved in marriages between Megaloblastic (folic acid deficiency) Urinalysis; microscopy, culture and sensitivity: daily carriers, and between sicklers Hypoplastic (due to infection or renal failure) Sputum Child: 1 - 5 years 120 - 250 mg; 6 -12 years 250 - 500 Anti-pneumococcal vaccine Aplastic (e.g. due to epidemic parvo virus B19) - Acid Fast Bacilli mg; 12 -18 years 500 mg every 4 - 6 hours Differential diagnoses - Microscopy, culture and sensitivity (maximum 4 doses in 24 hours) Connective tissue disorders e.g. rheumatoid Stool: Or: arthritis - Ova and parasites Aspirin (acetylsalicylic acid) 600 mg orally every 8 Liver disease - Occult blood hours daily Other causes of failure to thrive Ultra sound scan: - Not recommended for children under 16 years Complications - Abdominal ultrasound scan Or: Kidneys: - Transcranial Doppler ultrasonography Ibuprofen 200 mg every 8 hours daily (or other - Hyposthenuria (reduced ability to concentrate Chest radiograph non-steroidal anti-inflammatory drugs) urine/conserve body fluids) Treatment objectives - Not recommended for children under 16 years - Haematuria Maintain (or restore) a steady state of health Moderate-to-severe painful crises - Albuminuria Prevent and treat complications Parenteral therapy: - Reduced kidney function Provide accurate diagnosis, relevant health Diclofenac sodium Leg ulcers: education and genetic counselling to patients, Adult: 75 mg or 100 mg intramuscularly (as - Occur around ankles relatives and heterozygotes necessary) - Heal slowly and tend to recur Improve quality of life - Not recommended for children Bones and Joints Provide a positive self-image in affected persons Oral therapy: - Osteomyelitis Treatment strategies Paracetamol - Avascular necrosis Counselling and health education Child: 1 - 5 years 20 mg/kg every 6 hours (maximum These may cause: Encouraging membership of support groups 90 mg/kg daily in divided doses) for 48 hours or - Hip pain Providing infection prophylaxis (antimalarial; anti- longer if necessary and if adverse effects are ruled - Limping gait pneumococcal, hepatitis B virus vaccines) out - Kyphoscoliosis when necrosis affects spinal Providing folate supplementation Then: vertebral bones Avoiding pain-inducing conditions 15 mg/kg every 6 hours (maintenance) Infections: Providing prompt treatment of symptoms 6 - 12 years: 20 mg/kg (maximum 1 g) 6 hourly - Salmonella osteomyelitis Advising on contraception (maximum 90 mg/kg daily in divided doses, not to - Pneumococcal pneumonia Supervising pregnancy/Labour exceed 4 g for 48 hours or longer if necessary and if - Pneumoccoccal meningitis (rare in adolescents Providing regular health checks adverse effects are ruled out and adults) Limiting family size Then: - Tonsillitis and pharyngitis Non-drug treatment 15 mg/kg every 6 hours (maximum 4 g daily) Brain and nerves: Balanced diet 12 - 18 years: 500 mg - 1g every 4 - 6 hours - Strokes, seizures (not common in adults) Adequate fluid intake (at least 3 litres/24 hours) (maximum 4 doses in 24 hours) - Meningitis (not common in adults) Avoidance of pain-inducing conditions Diclofenac potassium 50 mg every 12 hours daily - Cerebral haemorrhage - Strenous physical exertion or stress Or: - Mental neuropathy (rare) - Dehydration Diclofenac sodium 100 mg once daily Cardiovascular/respiratory: - Sudden exposure to extremes of temperature Or: - Heart failure - Infections e.g. malaria Morphine 15 mg every 8 - 12 hours daily

21 22 Chapter 3: Cardiovascular System Standard Treatment Guidelines for Nigeria 2008

CHAPTER 3: CARDIOVASCULAR SYSTEM Drug treatment Differential diagnoses Differential diagnoses ß blockers Sinus arrhythmias Rheumatic heart disease - Atenolol 50 - 100 mg daily Anxiety Endomyocardial fibrosis ANGINAPECTORIS Nitrates Complications Complications Introduction - Glyceryl trinitrate 0.3-1mgsublingually, repeated as Cardiac failure Embolic phenomena A symptom complex characterised by chest pain or required Stroke Cardiac failure discomfort caused by transient myocardial ischaemia Or: Peripheral embolic phenomena Investigations usually due to coronary heart disease - Isosorbide dinitrate 30 - 120 mg orally daily (up to 240 Sudden death Full Blood Count and differentials Less common in this environment though current mg) Investigations Urea, Electrolytes and Creatinine studies show increasing prevalence Calcium channel antagonists Electrocardiograph (resting, 24 hour Holter, 1 month Chest radiograph In 90% (or more) of cases there is a hereditary factor - Verapamil80 - 120 mg orally 8 hourly Holter monitoring) Electro cardiograhy Major risk factors: Anti-platelets Urea, Electrolytes and Creatinine Foetal echocardiography Hypertension - Aspirin (acetylsalicylic acid) 75 mg orally daily Echocardiography Angiography Diabetes mellitus Unstable angina Electrophysiology Treatment objectives Hypercholesterolemia Treat as for acute myocardial infarction Treatment objectives Relieve symptoms Smoking Other measures Abolish the arrhythmias Treat the definitive defect(s) Obesity Angioplasty (PTCA) Treat complications Non-drug treatment Male sex Coronary artery bypass graft (CABG) Prevent further arrhythmias Low salt diet Age Treat/reduce risk factors Non-drug treatment Drug treatment Clinical features Patient education (very important) Pacemaker insertion Treatment of cardiac failure if present Stable angina (chest discomfort on exertion and Notable adverse drug reactions, caution and Ablation (electrophysiology) - Digoxin, diuretics and potassium supplements relieved by rest) contraindications Cardioversion: acute arrhythmias Supportive measures Unstable angina (discomfort on exertion and at rest) ß blockers Drug treatment Oxygen Myocardial infarction (chest pain or discomfort that - Bradycardia Depends on the type of arrythmia Counselling lasts more than 30 minutes; may be associated with - Caution in asthmatics and patients with chronic Refer to a specialist for appropriate management Prevention symptoms of cardiac failure, shock, arrhythmias) obstructive airways disease because of Supportive measures Pre-conception nutrition education Differential diagnoses bronchoconstriction. Patient education Antenatal care Myalgia Nitrates: hypotension Efficient systems to facilitate patient recovery Genetic counselling Pericarditis Calcium channel antagonists: hypotension Notable adverse drug reactions Aortic dissection Aspirin, thrombolytics: bleeding All anti-arrhythmias are pro-arrhythmics themselves Pleurisy - Avoid in recent stroke and in upper gastrointestinal Cardiac failure (all anti-arrhythmics) Complications bleeding Blindness (amiodarone) DEEPVENOUS THROMBOSIS Cardiac failure Avoid concurrent use of ß-blockers with verapamil Prevention Introduction Myocardial infarction Prevention Prevention of conditions such as hypertension, Formation of blood clot(s) in the deep veins of the calf Arrhythmias Nutrition education rheumatic heart disease, diabetes mellitus, ischaemic muscles or pelvis Sudden death Address risk factors heart disease, congenital heart diseases etc It has the potential of being dislodged to the lungs, Investigations Healthy living causing pulmonary embolism Full Blood Count and differentials Brought about by: Urea, Electrolytes and Creatinine Hyper-coagulable states Fasting blood glucose CONGENITALHEART DISEASE Long periods of immobilization e.g. cardiac failure, Urinalysis; urine microscopy CARDIACARRHYTHMIAS Introduction following surgery, long-distance travel, etc Electrocardiograph: resting, treadmill exercise Introduction A heart defect that occurs during the formation of the Malignancies Echocardiography (resting/exercise) Conditions in which cardiac rhythms become abnormal heart in utero Clinical features Radio nuclide studies Usually complicate acquired and congenital heart Could be fatal (i.e. causes intrauterine death, or death at Could be asymptomatic Cardiac enzymes (CK-MB) diseases anytime afterwards) Pain and swelling of the leg (calf muscles) Coronary angiography - Abnormal arrangements of the cardiac impulse fibres - An important cause of perinatal morbidity/mortality Differential diagnoses Treatment objectives or fibrosis affect the conduction fibres Classified as Cellulitis Relieve discomfort Clinical features Cyanotic Infarctive crisis in sicklers Improve quality of life Mild arrhythmias might go unnoticed Acyanotic Abscess (myositis) Prevent complications May present with: Clinical features Complications Relieve the obstruction Palpitations Will depend on the type of the defect: Pulmonary embolism Address the risk factors present Sudden collapse Mild defects go unnoticed Investigations Non-drug treatment Dizziness Stunted growth Full Blood Count and differentials Dietary manipulation (low salt, low cholesterol diet) Syncope Cyanosis Prothrombine time Exercise Near-syncope Failure to thrive KCCT Stop smoking - May be complicated by cardiac failure, stroke, etc Heart murmurs Doppler of the leg/pelvic vessels (veins) Reduce alcohol consumption

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Echocardiography Chest: with or without crepitations - Warfarin: monitor INR 2 - 2.5 Serum proteins (total and differential) Electrocardiography Abdomen: hepatomegaly - Important in atrial fibrillation Treatment objectives Venography(pelvic or calf veins) Differential diagnoses Supportive measures Lower lipid levels Treatment objectives Bronchial asthma Pacemakers for arrythmias Prevent complications Lyse the clot Chronic obstructive airways disease (COAD) Ventricularassist devices Treat complications Prevent clot from being dislodged Renal failure Notable adverse drug reactions Non-drug treatment Relieve inflammation Liver failure Digoxin: arrhythmias Stop smoking Non-drug treatment Complications Potassium-sparing drugs: hyperkalaemia Reduce weight Avoid stasis Thrombo-embolic phenomena: stroke, pulmonary ACEIs: hypotension, hyperkalaemia Exercise moderately and regularly Drug treatment embolism Do not combine potassium supplements with potassium- Water soluble fibre: oat, bran AchieveAPTT of 1.5 to 2.5 of control: Pre-renal azotaemia sparing drugs Drug treatment Heparin 5000 - 10,000 units by intravenous injection Arrhythmias Precautions Fluvastatin followed by subcutaneous injection of 15,000 units every Investigations The dose and infusion rate for dopamine are critical - Initially 20 mg orally once daily at bedtime 12 hours or intravenous infusion at 15 - 25 units/kg/hour, Full Blood Count with differentials - Low dose infusion rates will cause excessive - Adjust dose at 4-week intervals as needed and tolerated with close laboratory monitoring Urea, Electrolytes and Creatinine hypotension - Maintenance 20 - 40 mg orally once daily in the Warfarin 1-5mgorally daily for6-12weeks Fasting blood glucose - Higher infusion rates will elevate the blood pressure evening Notable adverse drug reactions Urine micro-analysis The use ofβ blockers, atrial natriuretic peptide - A 40 mg daily dose may be split and taken every 12 Bleeding from heparin, warfarin Chest radiograph analogues and endothelin receptor antagonists should be hours Osteoporosis (heparin) Electrocardiography reserved for specialist care Notable adverse drug reactions, caution and Prevention Echocardiography Prevention contraindications Low molecular weight heparin 5000 units Treatment objectives Adequate treatment of hypertension and diabetes Caution in patients with history of liver disease, high subcutaneously every 12 hours Relieve symptoms mellitus alcohol intake Early mobilization Enhance quality of life Good sanitation and personal hygiene (to prevent Hypothyroidism should be adequately managed before Prevent complications rheumatic fever) starting treatment with a statin Prolong life Liver function tests mandatory before and within 1 - 3 Non-drug treatment months of starting treatment; thereafter at intervals of 6 HEART FAILURE Bed rest months for 1 year Introduction Low salt diet HYPERLIPIDAEMIA Statins may cause reversible myositis, headache, A clinical state (syndrome) in which the heart is unable Exercise (within limits of tolerance) Introduction diarrhoea, nausea, vomiting, constipation, flatulence, to generate enough cardiac output to meet up with the Drug treatment Aclinical syndrome in which there are high lipid levels: abdominal pain; insomnia metabolic demands of the body Digoxin cholesterol, or its fractions, or triglyceridaemia Prevention The commonest cause in Nigeria is hypertension - 125 - 250 micrograms daily (the elderly may require Can be primary (hereditary) or secondary - as a result of Dietary manipulation Other causes include dilated cardiomyopathy and 62.5 - 125 micrograms daily) other diseases Early identification of individuals at risk rheumatic heart disease Diuretics Incidence in Nigeria is thought to be low but recent Cardiac failure can be classified as: - Furosemide 40 - 80 mg intravenously or orally studies show increasing incidence in association with Left or right-sided Or: diabetes mellitus and hypertension Congestive - Bendroflumethiazide 5 mg orally daily Amajor risk factor for ischemia heart disease HYPERTENSION Acute Or: Clinical features Introduction Chronic - Spironolactone 25 - 100 mg once, every 8 - 12 hours Patients present with complications of hypertension, A persistent elevation of the blood pressure above - Chronic cardiac failure is the commonest syndrome daily ischaemic heart disease or the cause of secondary normal values (taken three times on at least two different encountered in our setting Potassium supplements hyperlipideaemia occasions with intervals of at least 24 hours) Clinical features - Potassium chloride 600 mg orally once, every 8 - 12 Signs include xanthomata, xanthelasmata, and corneal Blood pressure³ 140/90 mmHg irrespective of age is Difficulty with breathing on exertion hours daily depending on the serum levels of potassium arcus regarded as hypertension Paroxysmal nocturnal dyspnoea Vasodilators Differential diagnoses The commonest non-communicable disease in Nigeria Orthopnoea - Angiotensin converting enzyme inhibitors (ACEIs) Primary hyperlipidaemia The commonest cause of cardiac failure and stroke Cough productive of frothy sputum Captopril 6.25 - 25 mg every 12 hours Secondary hyperlipidaemia: diabetes mellitus, Hypertension may be: Leg swelling Or: nephrotic syndrome Diastolic and systolic Abdominal swelling Lisinopril 2.5 - 20 mg daily Complications Diastolic alone The prominence of particular symptoms will depend on Venodilators Ischaemic heart disease Isolated systolic which side is affected - Nitrates Peripheral vascular disease Clinical features Signs include: Glyceryl trinitrate 0.3-1mgsublingually and repeated as Stroke, hypertension Largely is asymptomatic until complicated (”silent Oedema required Investigations killer”) Tachycardia (about 100 beats per minute) Ionotropes Urea, Electrolytes and Creatinine Non-specific symptoms: headache, dizziness, Raised jugular venous pressure - Dopamine 2 - 5 microgram/kg/minute by intravenous Fasting blood glucose palpitations etc Displaced apex infusion Lipid profile Other symptoms and signs depending on the target S3 or S4 or both ( With or without murmurs) Anticoagulants Urine proteins organs affected e.g. cardiac or renal failure, stroke etc

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Differential diagnoses Or: The sub-acute form usually occurs on damaged valves Following bacteriological confirmation institute White coat hypertension Amlodipine 2.5 - 10 mg orally once daily (e.g. rheumatic heart disease, congenital heart disease), appropriate antimicrobial therapy Anxiety/fright/stress Angiotensin converting enzyme inhibitors: shunts, and atherosclerotic lesions Staphylococci: Complications Captopril 6.25 - 50 mg orally once or every 8 - 12 hours Causative organisms include staphylococci, Flucloxacillin Heart: Or: streptococci enterococci; haemophilus, actinobacillus, - 250 mg - 2 g intravenously every 6 hours for4-6 - Heart failure, ischaemic heart disease Lisinopril 2.5 - 20 mg orally once daily cardiobacterium, eikenella, and kingella species weeks Brain: Angiotensin receptor blockers: ('HACEK' organisms) Candida: - Stroke (ischaemic, hemorrhagic) Losartan 50 - 100 mg orally daily Clinical features Systemic antifungals Eye: Other vasodilators: Acute: Notable adverse drug reactions - Hypertensive retinopathy Hydralazine 25 - 100 mg orally once daily or every 12 High fever with rigors Penicillin: rashes, anaphylaxis Kidney: hours Delirium Gentamicin: nephropathy - Renal failure Or: Shock Prevention Large arteries: Prazosin 0.5-1mgorally daily Development of new murmurs Prophylactic antibiotics for patients at risk who are - Aortic aneurysm Centrally acting drugs: Severe cardiac failure undergoing: Investigations Alpha methyldopa 250 - 500 mg orally twice, three or Abscesses may form in many parts of the body (e.g. 1. Dental procedures Full Blood Count four times daily brain) Under local or no anaesthesia, for those who have NOT Urinalysis; urine microscopy Fixed combinations: Subacute: had endocarditis, and have NOT received more than a Urea, Electrolytes and Creatinine Reserpine plus dihydroergocristine plus clopamide Low-grade fever single dose of a penicillin in the last one month: Uric acid 0.25/0.5/5 mg one-two tablets orally daily Signs of carditis Amoxicillin Fasting blood glucose Or: Finger clubbing Adult: 3 g orally 1 hour before procedure Lipid profile Lisinopril plus hydrochlorothiazide 20/12.5 mg daily Arthralgia Child under 5 years: 750 mg orally 1 hour before Chest radiograph Hypertensive emergencies Splenonegaly procedure; 5- 10 years: 1.5 g Electrocardiography Treatment should be done by the experts Osler's nodules For penicillin-allergic patients or patients who have Echocardiography (not in all cases) Involves the administration of antihypertensives by the Janeway lesions received more than a single dose of a penicillin in the Abdominal ultrasound parenteral route (usually intravenous hydralazine or Roth spots previous one month: Renal angiography (not in all cases) sodium nitoprusside) Differential diagnoses Azithromycin Treatment objectives Supportive measures Myocarditis Adult: 500 mg orally one hour before procedure Educate patient about disease and need for treatment Patient/care giver education Rheumatic heart disease Child under 5 years: 200 mg orally; 5 - 10 years: 300 mg adherence Notable adverse drug reactions, caution and Complications Patients who have had endocarditis: Reduce blood pressure to acceptable levels contraindications Cardiac failure - Amoxicillin plus gentamicin intravenously as for Prevent complications (primary, secondary, tertiary) All antihypertensive drugs may themselves cause Destruction of heart valves procedures under general anaesthesia (see below) Rehabilitate hypotension Systemic embolism (could be infective) Dental procedures under general anaesthesia, and no Non-drug treatment (lifestyle modification) Angiotensin converting enzyme inhibitors, angiotensin Investigations special risk: Low salt diet receptor blockers: angioedema; cough withACEIs Full Blood Count and differentials; ESR Amoxicillin Achieve/maintain ideal body weight (BMI 18.5 - 24.9 Alpha methyldopa, thiazides (and potentially other anti- Urinalysis; urine microscopy Adult: 1 g intravenously at induction of anaesthesia; 500 kg/m2 ) hypertensive drugs): erectile dysfunction Blood cultures X 3 (the yield is higher at the time of mg orally 6 hours later Stop smoking SLE-like syndrome: hydralazine pyrexia) Child under 5 years: a quarter of adult dose; 5 - 10 years: Reduce alcohol intake Do not useβ blockers in asthmatics Echocardiography half adult dose Regular moderate exercise Prevention Treatment objectives Or: Reduce polysaturated fatty acid intake Weight reduction Stop the infection Adult: 3 g orally 4 hours before induction, then 3 g orally Drug treatment Exercise moderately and regularly Treat cardiac failure as soon as possible after the procedure Diuretics: Public education Prevent coagulation disorders Child under 5 years: a quarter of adult dose; 5 - 10 years: Thiazides Individual approach Non-drug treatment half adult dose - Bendroflumethiazide 2.5 - 10 mg orally daily Population approach Bed rest Special risk, e.g. previous infective endocarditis, or Or: Advocacy for the positive lifestyle change Low salt diet patients with prosthetic valves: - Hydrochlorothiazide 12.5 - 50 mg orally daily Drug treatment Amoxicillin plus gentamicin intravenously Or: Initiate therapy with: Adult: 1 g amoxicillin plus 120 mg gentamicin at - Hydrochlorothiazide/amiloride 25/2.5 mg daily Benzylpenicillin 7.2 g daily by slow intravenous induction Loop diuretics INFECTIVE ENDOCARDITIS injection or intravenous infusion in 6 divided doses for 4 - - Then oral amoxicillin 500 mg 6 hours after procedure - Furosemide 40 - 80 mg orally daily Introduction 6 weeks Child under 5 years: a quarter of adult dose of amoxicillin ß-blockers: Amicrobial infection of the endocardium and the valves - May be increased up to 14.4 g daily if necessary (e.g. in plus 2 mg/kg gentamicin intravenously at induction Propranolol 40 - 80 mg orally every 8 - 12 hours of the heart endocarditis) 5 - 10 years: half adult dose for amoxicillin; 2 mg/kg Or: May be acute or sub-acute Plus: gentamicin Atenolol 25 - 100 mg orally daily Some acute cases occur in normal valves or may be part Gentamicin 60 - 80 mg intravenously or intramuscularly Patients who are penicillin-allergic or have received more Calcium channel antagonists: of systemic illness every 8 hours for 2 weeks than a single dose of a penicillin in the last one month: Nifedipine retard 20 - 40 mg orally once or twice daily Vancomycin

27 28 Chapter 3: Cardiovascular System Standard Treatment Guidelines for Nigeria 2008

Adult: 1 g intravenously over at least 100 minutes Dietary control (low cholesterol) Notable adverse drug reactions, caution Treat the effect on the heart Plus Exercise (later) Heparin or streptokinase: bleeding (risk of bleeding in Treat complications Gentamicin Weight reduction (later) recent stroke, diabetic retinopathy, brain tumours, peptic Non-drug treatment Adult: 120 mg intravenously Stop smoking ulcer disease or surgery) Bed rest - Given at induction or 15 minutes before procedure Drug treatment - Laboratory monitoring is essential: preferably daily, Drug treatment Child under 10 years: Vancomycin 20 mg/kg; Aspirin (acetylsalicylic acid) 150 - 300 mg orally stat, and dose adjusted accordingly Treat underlying cause(s) gentamicin 2 mg/kg then 75 - 150mg daily Aspirin: dyspepsia Anti arrhythmics (depends on the type of arrhythmias) 2. Genito-urinary tract manipulation Morphine 10 mg by slow intravenous injection over 5 ß-blockers: bradycardia Anticoagulant: warfarin As for special risk patients undergoing dental minutes (i.e. 2 mg/minute) - Should be avoided in patients presenting with this Anti-cardiac failure: digoxin, diuretics, potassium procedures under general anaesthesia Unfractionated heparin symptom supplements 3.Obstetric s , gynaecological and gastrointestinal Adult: 5,000 - 10,000 units (75 units/kg) by intravenous Prevention Steroids: prednisolone (not in all cases) procedures injection as loading dose followed by continuous Treat hypertension, diabetes mellitus, and Multivitamins As for genitourinary tract manipulation infusion of 15 - 25 units/kg/hour hyperlipidaemia Anti-oxidants: ascorbic acid (vitamin C),vitamin E - 15,000 units 12 hours by subcutaneous injection Stop smoking Notable adverse drug reactions Small adult or child: lower loading dose, then 15 - Nutrition education Antiarrhythmics may be pro-arrhythmic MYOCARDIALINFARCTION 25/kg/hour by intravenous infusion, or 250 units/kg Anticoagulants: bleeding Introduction every 12 hours by subcutaneous injection Steroids: fluid retention, dyspepsia Occurs when an area of heart muscle is necrosed or Or: MYOCARDITIS Diuretics: dehydration, electrolyte imbalance permanently damaged because of an inadequate supply Lowmolecular weight heparin Introduction Prevention of oxygen (heart attack) - Enoxaparin: 30 mg intravenous bolus (optional) then 1 Inflammatory process affecting the myocardium Prevent infection (viral, bacterial, etc) Reported to be uncommon in Nigeria, although recent mg/kg subcutaneously every 12 hours for7-8days A common disorder; usually occurs in association with Prevent exposure to toxins reports suggest a rising incidence Thrombolytics endocarditis and pericarditis Nutrition education Clinical features - Streptokinase Possible causes: Precordial pain: discomfort, heaviness, tightening Adult: 1,500,000 units by intravenous infusion over 60 Infections: viral, bacterial, protozoal lasting 30 minutes or more minutes, then 250 units over 30 minutes according to Toxins e.g.scorpion sting PAEDIATRIC CARDIAC DISORDERS (Refer for Shortness of breath condition (with monitoring) Poisons e.g. alcohol Specialist Care) Palpitations Child: 1 month - 12 years, initially 2,500 - 4,000 units/kg Drugs e.g. chloroquine Cough productive of frothy sputum over 30 minutes followed by continuous infusion of 500- Allergy e.g. to penicillin Signs of right or left-sided cardiac failure and shock 1,000 units/kg/hour for up to 3 days until reperfusion Deficiencies e.g. thiamine PERICARDITIS Differential diagnoses occurs Physical agents e.g. radiation Introduction Pulmonary embolism - 12 - 18 years: initially 250,000 units intravenously Clinical features An inflammation of the pericardium which may arise Aortic dissection over 30 minutes, followed by intravenous infusion of Largely asymptomatic from viral, bacterial, fungal or protozoal infections Pericarditis 100,000 units/hour for up to 3 days until reperfusion A few may present with palpitations; symptoms of Other causes: metabolic, malignancy, connective tissue Complications occurs cardiac failure disease, radiation, trauma etc Cardiac failure Recombinant plasminogen activator (use by specialist Physical examination: May be acute or chronic Ventricularaneurysm physician) Arrhythmias Clinical features Arrhythmias: heart block, ventricular tachycardia, - Alteplase 15 mg intravenously over 1 - 2 minutes, Tachycardia Acute pericarditis: ventricular fibrillation, atrial fibrillation followed by intravenous infusion of 50 mg over 30 Raised JVP Chest pain Sudden death minutes then 35 mg over 60 minutes Cardiomegaly - Retrosternal Investigations (Total dose, 100 mg over 90 minutes; lower doses in S3 or S4 (with or without murmurs of regurgitation in - Sharp Full Blood Count; ESR patients less than 65 kg the mitral/tricuspid areas) - Radiating to the left shoulder Urea, Electrolytes and Creatinine ß blockers Differential diagnoses - Made worse by breathing or coughing Uric acid - Atenolol 50 - 100 mg orally daily Other forms of cardiac failure, e.g. peripartum cardiac - Relieved by the upright position Fasting blood glucose - Propranolol 180 - 240 mg orally in 2 - 4 divided doses failure Low grade fever Lipid profile daily Complications Pericardial friction rub Enzyme assays:AST, CK-MB, and LDH Angiotensin converting enzyme inhibitors Cardiac failure Chronic pericarditis: Electrocardiograph monitoring throughout admission - Captopril 6.25 - 50 mg orally once, twice or three times Arrhythmias - Insidious onset Coronary angiography (in case of secondary daily Thrombus formation There may be: angioplasty) - Lisinopril 2.5 - 10 mg daily Investigations - Dyspnoea on exertion Treatment objectives Maintenance anti-anginal therapy Full Blood Count and differentials - Leg and abdominal swelling Relieve pain (discomfort) Non-drug therapy Urea, Electrolytes and Creatinine Differential diagnoses Relieve obstruction Coronary artery bypass graft (CABG) Electrocardiography Endomyocardial fibrosis Treat complications Secondary or rescue PTCA Echocardiography Sarcodosis Prevent future episodes Supportive measures Myocardial biopsy Amyloidosis Non-drug treatment Treat arrhythmias Treatment objectives Complications Bed rest Oxygen: 100% at 5L/minute Eliminate/withdraw the offending agent(s) Pericardial tamponade

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Constrictive pericarditis Chest pain Streptokinase Bed rest Investigations Sweating - 250,000 units over 30 minutes, then 100,000 units Sit on bed with legs hanging down Electrocardiography Collapse (shock) every hour for 24 - 72 hours Drug treatment Full Blood Count and differentials Haemoptysis Or: Oxygen 3 - 5L/min Chest radiograph Signs: Recombinant plasminogen activator (alteplase) Morphine 10 mg stat Echocardiography Small volume pulse - 10 mg intravenously over 1 - 2 minutes, followed by Loop diuretics Treatment objectives Low blood pressure intravenous infusion of 90 mg over 2 hours - Furosemide 40 - 120 mg intravenously stat; Relieve distress from pain and tamponade Cyanosis Tobe used by a specialist physician maintenance with 40 - 500 mg daily in single or divided Relieve constriction Raised JVP Notable adverse drug reactions doses Treat the effect on the heart Cool, clammy skin Heparin, warfarin or streptokinase: bleeding Aminophylline 250 mg intravenously slowly over 10 - Treat complications Pallor Risk of bleeding in: 15 minutes Eradicate the organism (if cause is infection) Tachycardia - Recent stroke Treat underlying cause(s) Non-drug treatment Fever - Diabetic retinopathy Supportive measures Bed rest Pleural friction rubs - Brain tumours Nursing care (e.g.nurse in cardiac position) Drug treatment Loud P2 - Peptic ulcer disease Notable adverse drug reactions NSAIDs Differential diagnoses - Surgery Aminophylline, digoxin: arrhythmias - Indomthaem 50 mg orally every 8 hours Lobar pneumonia Prevention Diuretics,ACEIs: hypotension Or: Myalgia Low molecular weight heparin for immobilized patients Prevention - Ibuprofen 400 - 800 mg orally every 12 hours Pleuritis (pleurisy) Early mobilization of patients Treat cause(s) of cardiac failure or fluid overload (e.g. Steroids Complications Appropriate, moderate and frequent exercises renal failure) - Prednisolone 30 mg orally every 8 hours and tapered Right-sided cardiac failure Judicious administration of blood and intravenous Anti-tuberculous drugs or other antimicrobial agents (if Haemorrhagic pleural effusion fluids mycobacterium or other microbes are causative) Investigations PULMONARYOEDEMA Supportive measures Full Blood Count and differentials Introduction Pericardiocentesis Electrocardiograph Occurs when there is congestion of the lungs with fluid, RHEUMATIC FEVER Pericardiectomy - Sinus tachycardia usually in a scenario of left-sided cardiac failure Introduction Notable adverse drug reactions - New onset atrial fibrillation/flutter Results in stiffness of the lungs and flooding of the A result of abnormal reaction of antibodies developed NSAIDs/steroids: dyspepsia and upper GI bleeding - S wave in lead 1, Q wave in lead 3 and an inverted T alveoli, with difficulty in breathing against antigens of groupAß- haemolytic streptococcus Prevention wave in lead 3 May also follow inflammatory processes Infection is usually of the throat; occasionally the skin Avoid radiation - QRS axis >90º, quite often May be acute or chronic in a sensitized individual Prevent infection Chest radiograph Clinical features Antibodies damage the heart(endocardium, myocardium Blood gasses (arterial) Difficulty in breathing, with a sensation of drowning and pericardium) Ventilation/perfusionlung scanning Cough productive of frothy (sometimes pink) sputum Commonest streptococcal strains inAfrica are C and G PULMONARYEMBOLISM Pulmonary artery angiogram Central cyanosis Clinical features (Also see in Respiratory system) Treatment objectives Sweating, agitation etc Fever Introduction Relieve discomfort Other symptoms of left-sided cardiac failure Arthralgia Blockage of the pulmonary artery or one of its branches Relieve the obstruction(s) Examination: Abnormal movements of the hands (upper hands) by a blood clot, fat, air, or clumped tumour cells Prevent complications Wide-spread crepitations Diagnosis: Duckett-Jones' diagnostic criteria The most common form is thrombo-embolism; occurs Prevent further episodes Rhonchi (in severe cases) Major: when Non-drug treatment Other signs of left-sided cardiac failure Carditis - A blood clot (generally a venous thrombus) becomes Bed rest Differential diagnoses Sydenham's chorea dislodged from its site of formation and embolizes to the Mobilization Pulmonary embolism Erythema marginatum arterial blood supply of one of the lungs Drug treatment Pneumonia Subcuoeous nodules The calf veins (deep vein thrombosis) and right Heparin Complications Arthritis (migratory polyarthritis) ventricle are sources of embolism - 5000 - 10,000 units intravenously stat, followed by Hypoxaemia Minor: Some predisposing factors: 1000 - 2000 units per hour (APTT or INR 1.5 - 2.5 greater Coma Fever Congestive cardiac failure than normal) Investigations Leucocytosis Trauma Or: Blood gases Arthralgia Surgery Enoxaparin Urea, Electrolytes and Creatinine Raised ESR Prolonged immobilization - 1.5 mg/kg (150 units/kg) subcutaneously every 24 Echocardiography RaisedASO titre (> 200 IU) Malignancies hours, usually for at least 5 days (and until adequate oral Chest radiograph Previous history of rheumatic fever Stroke anticoagulation is established) Electrocardiography Diagnosis Clinical features Or: Treatment objectives 2 major criteria Depend on how massive the embolism is: Warfarin 1-5mg(INR 1.5 - 2) for6-12weeks (as Relieve oedema Or: No symptoms maintainance after initial parenteral anticoagulation) Relieve discomfort 1 majorplus 2 (or more) minor criteria Moderate-to-severe cases: Or: Treat underlying cause Difficulty in breathing Non-drug treatment

31 32 Chapter 3: Cardiovascular System Standard Treatment Guidelines for Nigeria 2008

Differential diagnoses weeks or months Investigations CHAPTER 4: CENTRAL NERVOUS SYSTEM Malaria - Maintenance 2.5 -15 mg orally daily Electrocardiography (resting/exercise) Viral infection Prophylaxis against infective endocarditis Lipid profile NON-PSYCHIATRIC DISORDERS Pyrexia of undetermined origin Benzathine penicillin 720 mg (1.2 million units) Echocardiography Connective tissue disease intramuscularly 3 - 4 weekly until the age of 25 years (or Chest radiograph Complications 10 years after the attack-whichever is longer) Coronary angiography DIZZINESS Rheumatic heart disease Notable adverse drug reactions Treatment objectives Introduction Arrhythmias Penicillin: anaphylactic reaction Relieve symptoms Simply means 'light-headedness' Cardiac failure Salicylates; steroids: peptic ulceration Prevent recurrence of rheumatic attack Usually due to impaired supply of blood, oxygen Investigations Cushingoid effects are increasingly likely with doses of Repair and replace affected valves and glucose to the brain Full Blood Count and differentials prednisolone above 7.5 mg daily Non-drug treatment May suggest some form of unsteadiness, or could ASO titre Prevention Bed rest precede a fainting spell ESR Good sanitation. Low salt diet Causes: Electrocardiograph School surveys - identify carriers of streptococcus and Drug treatment Side effects of medications, notably anti- Echocardiography treat Treat for heart failure if present hypertensives and sedatives Chest radiograph Secondary prevention and prophylaxis against Use anticoagulants if necessary Anaemia Throat swab for microscopy, culture and sensitivity endocarditis Prophylaxis against endocarditis (see Infective Arrhythmias Treatment objectives Endocarditis) Fever Relieve symptoms - Benzathine penicillin 720 mg (1.2 million units) intra Hypoglycaemia Treat the bacterial throat infection RHEUMATIC HEART DISEASE musculary monthly for life Brain stem lesions Reduce or abolish inflammatory process Introduction Other measures: Alcohol overdose Treat cardiac failure if present Acomplication of rheumatic fever - Valvereplacement Excessive blood loss Non-drug treatment Acommon cause of cardiac failure in Nigeria - Valverepair Prolonged standing Bed rest InAfrica manifests later compared to Caucasians - Treat endocarditis Autonomic neuropathy (especially in diabetic Drug treatment The mitral valve is most affected, followed by the aortic, Notable adverse drug reactions, caution patients) Antibiotics then the tricuspid Penicillin may cause hypersensitivity reaction / May be accompanied by vertigo (giddiness) in - Penicillin V The lesions can occur in various combinations of anaphylaxis some individuals Adult: 500 mg orally every 6 hours, increased up to 1g 6 stenosis and regurgitation - Caution in patients with a history of penicillin allergy May culminate in loss of consciousness hourly in severe infections Clinical features Prevention Clinical features Child:1 month - 1 year 62.5 mg orally every 6 hour s Shortness of breath on exertion Personal hygiene and good sanitation to prevent Light-headedness increased in severe infection to ensure at least 12.5 Paroxysmal nocturnal dyspnoea recurrence of rheumatic fever Feeling faint especially on attempting to stand or mg/kg/dose Orthopnoea after squatting 1 - 6 years: 125 mg every 6 hours increased in severe Leg and abdominal swelling Weakness infection to ensure at least 12.5 mg/kg/dose Cough with production of frothy sputum Differential diagnoses 6 - 12 years 250 mg every 6 hours, increased in severe Pedal and sacral oedema Benign positional vertigo infection to ensure at least 12.5 mg/kg/dose Small volume pulse which may be irregular Labyrinthine disorders 12 - 18 years 500 mg every 6 hours, increased in severe With or without tachycardia Hysteria infection up to 1 g/dose With or without hypotension Premonitory symptoms of epilepsy Or Raised JVP Migraine aura - Erythromycin Displaced apex Warning symptom of posterior circulation stroke Adult and child over 8 years: 250 - 500 mg orally every 6 Left ventricular hypertrophy (posterior inferior cerebellar artery) hoursor 500 mg - 1 g every 12 hours; up to 4 g daily in Right ventricular hypertrophy Cervical spondylosis with compression of vertebral severe infections Thrills artery Child: up to 2 years, 125 orally mg every 6 hours;2-8 Palpable P2 Brain tumour (acoustic neuroma) years 250 mg every 6 hours; doses doubled for severe Soft S1; loud P2 Complications infections S3 or S4 Falls with injury Salicylates-Aspirin (acetylsalicylic acid) Systolic/diastolic murmurs Stroke Adult: 300 mg - 1 g orally every 4 hours after food; Differential diagnoses If due to intracranial tumour: raised intracranial maximum dose in acute conditions 8 g daily Constrictive pericarditis pressure with coning Child: not recommended for use Endomyocardial fibrosis If due to other intracranial pathology: cranial nerve Steroids (if salicylates are ineffective) Dilated cardiomyopathy palsies - Prednisolone Complications Investigtions - Initially, up to 10 - 20 mg orally daily; up to 60 mg daily Arrhythmias e.g. atrial fibrillation, heart block Full Blood Count and differentials in severe disease (preferably taken in the morning Cardiac failure Electrocardiography after breakfast); dose can often be reduced within a Embolic phenomena Echocardiography few days, but may need to be continued for several Endocarditis Random blood glucose X-ray sinuses

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Neuro-imaging: CT scan, MRI, carotid Doppler etc in the head Secondary headaches Septicaemia with meningism Management Pain around the eyes and forehead Medical or surgical management of identified Complications Depends on the aetiological factor identified Redness of the eyes causes Cranial nerve palsies Treatment objectives Nasal stuffiness Antibiotics for infections like meningitis, sinusitis Subdural pus collection (empyema) Eliminate symptom Drooping of the eyelids Steroids for vasculitis Stroke Prevent recurrence Migraine headache Notable adverse drug reactions, caution Epilepsy Drug treatment will depend on underlying cause(s) - See below Aspirin and other NSAIDs: use with caution in Heat stroke Non-drug treatment Secondary headaches: presence of additional patients with history of dyspepsia, and asthma SyndroVme of Inappropriate Anti-Diuretic Stop all medicines suspected to be responsible symptoms Tricyclic antidepressants: use with caution in Hormone secretion (SIADH) Physiotherapy: pressure stockings Fever patients with cardiac symptoms Investigations Prevention Vomiting Tricyclic antidepressants: anticholinergic effects Lumbar puncture for CSF analysis Avoid precipitants Neck stiffness e.g urinary retention in the elderly - To demonstrate presence of inflammatory cells - These must be identified early for effective Alteration in level of consciousness Prevention (after exclusion of raised intracranial pressure by prevention Convulsions Reduce stress levels fundoscopy or CT scan) Cranial nerve deficits Prophylactic medications if attacks last more than Full Blood Count and differentials Limb weakness (hemiparesis, quadriparesis) 15 days a month, or are severely incapacitating (in Blood culture HEADACHES Papilloedema as evidence of raised intracranial the absence of other causes) Erythrocyte sedimentation rate Introduction pressure Early detection and correction of refractive errors, Random blood glucose The commonest neurological disease in Nigerian Evidence of disease in other organs sinusitis, oto-rhino-laryngologic and dental Electrolytes, Urea and Creatinine communities Evidence of drug or alcohol abuse problems. Chest radiograph Defined as pain or discomfort in the head and the Differential diagnoses Mantoux test (if tuberculosis is suspected) surrounding structures Meningitis HIV screening They may be: Hysteria MENINGITIS Treatment objectives Primary (idiopathic) Refractive error Introduction Eliminate the organism Secondary Cervical spondylosis An infection of the meninges with presence of pus Reduce raised intracranial pressure Primary headache types Brain tumour and inflammatory cells in the cerebrospinal fluid Correct metabolic derangements Tension type Haemorrhagic stroke A medical emergency, and associated with Treat complications (if any) Migraine with or without aura Complications considerable morbidity and mortality Non-drug treatment Cluster headache Depend on the cause and type May be bacterial (pneumococcus, meningococcus, Tepid-sponging Secondary causes Some are benign with no sequelae tubercle bacilli,Haemophilus ), viral, fungal, Attention to calories and fluid/electrolyte balance Intracranial space-occupying lesions like brain Coning (depending on cause) protozoal, neoplastic or chemical Physiotherapy (for passive muscle exercises) tumours, subdural haematoma Blindness (following temporal arteritis, unrelieved Organism may vary with age of the patient Nursing care (e.g. frequent turning and bladder Vascularlesions: strokes raised intracranial pressure) Epidemic meningitis is usually due to Neisseria care) to prevent decubitus ulcers and urinary tract Infections Investigations meningitidis infection Following generalized convulsions Neuro-imaging: skull X-ray, computerized Clinical features Drug treatment Metabolic derangements tomographic scan, MRI Fever Initial therapy will depend on the age of the patient Alcohol hangover Electroencephalography Headache (and causative agent) Drugs Cerebrospinal fluid examination for pressure, cells Vomiting Bacterial infections- third generation Irritation of sensory cranial nerves and chemistry Photophobia cephalosporins: Inflammation or diseases of structures/organs in Erythrocyte sedimentation rate Alteration in level of consciousness Ceftriaxone is the drug of first choice the head region: eyes, nose, sinuses, ears, cervical Treatment objectives Neck stiffness and positive Kernig's sign - 2-4gdaily by intravenous injection or by vertebrae Eliminate pain May present in epidemics intravenous infusion over 2 - 4 minutes Atypical headache Treat the precipitating factor or disease Other presentations: Or: Sleep disorders (hypoxia) Prevent recurrence Fever of unknown origin: chronic meningitis Penicillin V 2-4gbyslow intravenous injection Brain stem malformations Non-drug treatment Mass lesion with focal neurological deficits: every 4 hours HIV infection Psychotherapy tuberculoma, empyema Or: Clinical features Physiotherapy/biofeedback Stroke-like syndrome: resulting from inflammation Chloramphenicol 100 mg/kg intravenously every 6 Depend on the underlying type/cause(s): Drug treatment of blood vessels hours Tensiontype Primary headaches Seizures which may be uncontrolled and prolonged - May be useful forH. influenzae infection Heaviness in the head Simple analgesics and non-steroidal anti- (status epilepticus) Tuberculosis: Crawling sensation inflammatory agents Acute psychosis (Organic Brain Syndrome) Standard anti-tuberculous drugs (including “Peppery sensation” Tricyclic antidepressants Dementia pyrazinamide and isoniazid for their good Tight-band sensation - Amitriptyline 10 - 25 mg daily at night Differential diagnoses penetration of the blood-brain Poor sleep Anxiolytics Subarachnoid haemorrhage barrier) Disturbed concentration - Lorazepam 1 - 2.5 mg at night. Use lower doses Tetanus Anti-pyretics: Cluster type for the elderly patient Brain abscess Aspirin (acetylsalicylic acid) Recurrent, frequent, brief attacks of disturbing pain Cerebral malaria

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Adult: 300 mg - 1 g orally every 4 hours after food; thrombophlebitis Complications Notable adverse drug reactions, caution and maximum dose in acute conditions 8 g daily - Contraindicated in congestive cardiac failure and Stroke contraindications Child: not recommended for use pulmonary oedema Epilepsy Aspirin and other NSAIDs: use with caution in Diazepam (for seizures) Prevention Blindness patients with history of dyspepsia and in asthmatics Adult: 10 - 20 mg at a rate of 0.5 ml per 30 seconds, Immunize against communicable diseases Investigations Tricyclic antidepressants used with caution in repeated if necessary after 30 - 60 minutes; may be - Meningococcus, heamophilus, streptococcus Neuro-imaging patients with cardiac symptoms followed by intravenous infusion to a maximum of 3 (especially for sicklers). Computerized tomographic scan Ergotamine: use should not exceed 4-6mgper mg/kg over 24 hours Chemoprophylaxis (Rifampicin or ciprofloxacin) MRI attack Child: 300 - 400 micrograms/kg (maximum 20 mg) - As determined by national policy Electroencephalography - Caution in patients with vascular and renal by slow intravenous injection into a large vein for - For close contacts of clinical cases Treatment objectives disorders protracted or frequent recurrent convulsions Eliminate pain - Not recommended for children - Not required in single, short-lived convulsions Prevent recurrence Opiates: risk of addiction Acute cerebral decompression: Non-drug treatment ß-blockers: slow down cardiovascular function; Furosemide MIGRAINE Manage in a quiet (and dark) room Introduction reduce sensitivity to hypoglycaemia in diabetics Adult: 40 - 80 mg every 8 hours by slow intravenous Psychotherapy Prevention injection (for a maximum of 6 doses) Headache resulting from changes in the calibre of Physiotherapy/biofeedback certain blood vessels in the brain with resulting Avoid precipitants Child: neonate 0.5 - 1 mg/kg every 12 - 24 hours Drug treatment These must be identified for effective prevention (every 24 hours in neonates born before 31 weeks physical, autonomic and emotional disturbance Acute attack Can be very incapacitating Reduce stress levels as much as possible gestation) Aspirin (acetylsalicylic acid) tablets 300 - 900 mg Give prophylactic medicines if attacks last more 1 month - 12 years: 0.5 - 1 mg/kg (maximum 4 Affects more females than males, usually between every 4 - 6 hours when necessary maximum 4g daily. the ages of 15 and 50 years than 15 days a month, or are severely incapacitating mg/kg), repeated every 8 hours as necessary Child and adolescent - not recommend (risk of (in the absence of other causes) 12 - 18 years: 20 - 40 mg, repeated every 8 hours as Clinical features reye’s syndrome) necessary; higher doses may be required in resistant VascularHeadaches - With an anti-emetic agent (e.g. metoclopramide), cases Common migraine (or migraine without aura) or other non-steroidal anti-inflammatory agents plus PARKINSONISM Or: - Throbbing pain usually affecting one side of the metoclopramide Introduction Mannitol 20% solution head around the temples, associated nausea and Ergotamine preparations (useful only during the Synonyms: 'shaking palsy'; 'paralysis agitans'; Adult: 50 - 200 g by intravenous infusion over 24 vomiting aura phase) 'akinetic-rigid syndrome' hours, preceded by a test dose of 200 mg/kg by slow - Dislike of light and noise Adult: 1 - 2 mg orally at first sign of attack; A common neuro degenerative disease that results intravenous injection Classical migraine (or migraine with aura): maximum 4 mg in 24 hours from deficiency of dopamine in the striato-nigral Child: neonate 0.5 - 1 g/kg (2.5 - 5 ml/kg of 20% - Attacks of pain preceded by seeing flashes of light - Do not repeat at intervals of less than 4 days; pathway solution) repeated if necessary 1 - 2 times after 4 - 8 - Disturbances in the field of vision (scotomas) maximum 8 mg in any one week Causes:- hours - Visual hallucinations - Not to be used more than twice in any one month Drugs: 1 month - 18 years: 0.5 - 1.5 g/kg (2.5 - 7.5 ml/kg of Childhood periodic syndromes: Child: not recommended - Antipsychotics e.g. phenothiazines 20% solution); repeat if necessary 1 - 2 times after 48 - Abdominal pain and vomiting Prophylaxis - Antihypertensives: alpha methyl dopa, reserpine hours - Alternating hemiplegia Consider for patients who: Infections: Chemoprophylaxis - Benign positional vertigo Suffer at least 2 attacks a month - Encephalitis Treat contacts during meningococcal epidemics Basilary artery migraine - predominantly brain Suffer an increasing frequency of headaches - Typhoid fever with either ciprofloxacin or rifampicin stem symptoms Suffer significant disability inspite of suitable Vasculardiseases: - Rifampicin - Dysarthria treatment for acute attacks - Arteriosclerosis Adult: 600 mg orally every12 hours for 5 days - Vertigo Cannot take suitable treatment for acute attacks Neurotoxins Child: 10 mg/kg orallyevery12 hours for 5 days - Tinnitus Available options are: - Carbon monoxide Under 1 year: 5 mg/kg orallyevery12 hours for 5 - Decreased hearing Propanolol - Manganese days - Diplopia - 40 mg orally every 8 - 12 hours - Cyanide - Ciprofloxacin - Ataxia Tricyclic antidepressants, notably amitryptiline - Heroin analogues Adult: 500 mg orally as a single dose May coexist with tension-type headache - 10 mg orally at night, increased to a maintenance Head trauma as in boxing Child: 5 - 12 years 250 mg orally as a single dose May present without headache (migraine dose of 50 - 75 mg at night Tumours Notable adverse drug reactions, caution and equivalent) usually seen in psychiatry Sodium valproate Metabolic diseases (Wilson's disease) contraindications May present with complications: stroke-like - Initially 300 mg orally every 12 hours, increased if Idiopathic:- Parkinson's disease Diazepam manifestations necessary to 1.2 g daily in 2 divided doses Clinical features - Must be administered slowly intravenously to Ophthalmoplegia In refractory cases: Classical disease: avoid respiratory depression Status attacks: unrelieved, persistent headaches Cyproheptadine Rest tremors: coarse, distal tremors described as Chloramphenicol Differential diagnoses - An antihistamine with serotonin-antagonist and pill-rolling type - May cause aplastic anaemia Epilepsy calcium channel-blocking properties Rigidity Mannitol Hysteria 4 mg orally; a further 4 mg if necessary; Slowness of movement; loss of arm swinging when - May cause chills and fever Glaucoma maintainance 4 mg every 4 - 6 hours walking - Extravasation causes inflammation and Multiple sclerosis Retropulsion, propulsion, turning en bloc Brain tumours

37 38 Chapter 4: Central Nervous System Standard Treatment Guidelines for Nigeria 2008

Postural instability with frequent falls - Caution is advised to avoid falls Investigations Adult: 150 - 300 mg orally daily Gait changes: shuffling gait with flexed posturing Anticholinergic drugs: constipation; memory Electroencephalography Child: neonate- initial loading dose by slow intravenous Parkinsonism may occur in association with other problems Neuro-imaging: CT scan, MRI injection then 2 - 4 mg/kg by mouth every 12 hours neurodegenerative diseases - Contraindicated in the presence of glaucoma Random blood glucose adjusted according to response (usual maximum 7.5 Differential diagnoses Prevention Urea, Electrolytes and Creatinine mg/kg every 12 hours) Multi-infarct dementia Avoid identified causative agents where feasible Treatment objectives 1 month - 12 years: 1.5 - 2.5 mg/kg orally every 12 hours Alzheimer's disease Timely and appropriate treatment to prevent/reduce Arrest convulsions/attacks (usual maximum 7.5 mg/kg every 12 hours or 300 mg Normal pressure hydrocephalus complications Treat underlying cause if identified daily) Brain tumour Improve quality of life 12 - 18 years: initially 75 - 150 mg every 12 hours, Benign essential tremor Drug treatment adjusted according to response up to 150 - 200 mg every Depression SEIZURES/EPILEPSIES Parenteral drugs are recommended for acute 12 hours (usual maximum 300 mg every 12 hours) Creutfeldt-Jakob disease Introduction attacks/status epilepticus Sodium valproate Complications Aseizure results from abnormal excessive electrical Diazepam Adult: 600 mg daily in 2 divided doses Recurrent falls with attendant complications e.g. discharge of brain cells Adult: 10 - 20 mg by slow intravenous injection; Child: neonate, initially 20 mg/kg orally or per subdural haematoma Epilepsy is a condition characterized by recurrent repeat if necessary in 30 - 60 minutes rectum once daily; usual maintenance dose 10 mg/kg Dementia (³ 2) seizures unprovoked by any immediate Child: 200 - 300 micrograms/kgor 1 mg per year of twice daily Depression identifiable cause age 1 month - 12 years: initially 5-7.5 mg/kg every 12 Investigations May be idiopathic or could follow: Could be given per rectum as rectal solution in hours; maintenance 12.5 - 15 mg/kg every 12 hours Diagnosis is essentially clinical - Cerebral infections restless patients 12 - 18 years: usually 300 mg every 12 hours, Neuro-imaging: CT scan/MRI for exclusion of - Metabolic derangements (glucose, electrolytes, - 500 micrograms/kg (up to a maximum of 30 mg) increased in steps of 200 mg at 3-day intervals; usual possible differentials fluids) in adults and children over 10 kg maintenance 500 mg - 1 g twice daily (maximum Treatment objectives - Stroke Phenytoin 1.25 g twice daily) Replace dopamine - Tumours Adult:initially 15 mg/kg by slow intravenous Partial seizures Ensure mobility and avoidance of falls - Head trauma injection or infusion (with blood pressure and Carbamazepine Drug treatment - Birth injury/asphyxia Electrocardiograph monitoring) at a rate not more Adult: 100 - 200 mg orally 1-2 times daily L-dopa/carbidopa (dose expressed as levodopa) - Drug abuse/overdosage/withdrawal than 50 mg/minute; then 100 mg every 6-8 hours - Not recommended in pregnancy - 50 mg orally every 6 - 8 hours increased by 100 - Alcoholism Child: neonate- initial loading dose 20 mg/kg by slow Child 1 month - 12 years: initially 5 mg/kg orally at mg once or twice weekly depending on response - Neuro-degeneration intravenous injection, then 2 - 4 mg/kg orally every 12 night or 2.5 mg/kg twice daily, increased as Anti-cholinergic drugs for tremors Clinical features hours, adjusted according to response (usual maximum necessary by 2.5-5mg/kg every 3 - 7 days; usual - Trihexyphenidyl (benzhexol) 1 mg orally daily, Classical attack with sudden loss of consciousness, dose 7.5 mg/kg every 12 hours) maintenance 5 mg/kg every 8 - 12 hours increased gradually (usually 5 - 15 mg in 3 - 4 convulsions (tonic and/or clonic) 1 month - 12 years: initially 1.5 - 2.5 mg/kg every 12 12 - 18 years: initially 100 - 200 mg 1 - 2 times daily, divided doses up to a maximum of 20 mg) Abnormal sensation or perception hours, adjusted according to response to 2.5 - increased slowly to usual maintenance of 400-600 Dopamine receptor agonists Autonomic disturbances: epigastric discomfort, 5mg/kg every 12 hours (usual maximum dose 7.5 mg every 8 - 12 hours - Bromocriptine 1 - 1.25 mg orally nocte in the first sphincteric incontinence mg/kg every 12 hours or 300 mg daily) Absence attacks week; 2 - 2.25 mg nocte in the 2nd week; 2.5 mg twice Semi-purposive actions (automatisms) 12 - 18 years: initially 75 - 150 mg every 12 hours, Ethosuximide daily in the 3rd week, 2.5 mg three times daily in the Aura adjusted according to response to 150 - 200 mg 12 Adult: 500 mg daily initially; increase by 250 mg at 4th week, increasing by 2.5 mg every 1 - 2 weeks Loss of postural tone (sudden falls without hourly (usual maximum 300 mg every 12 hours) intervals of4-7days to doses of 1 - 1.5 g daily according to response (usual range is 10 - 40 mg convulsions) Paraldehyde (see important precaution below)? (maximum dose 2 g daily) daily) Limb paralysis (Todd's paralysis) usually after - Useful where facilities for rescucitation are poor Child over 6 years: same as adult dose - Ropinirole 1-3mgorally once daily (in resistant attacks - Causes little respiratory depression when given Up to 6 years: 250 mg daily; increase gradually to 20 cases) Differential diagnoses rectally mg/kg daily (maximum 1 g daily) Supportive measures Migraine headache - Administer 10 - 20 mLper rectum as an enema Non-drug treatment Physiotherapy for postural adjustments Syncope Child: neonate- 0.4 mL/kg (maximum 0.5 mL) as a single Psychotherapy Antidepressants Narcolepsy dose; up to 3 months: 0.5 mL; 3 - 6 months: 1 mL; 6 - 12 Health education to patients, relations and public - Amitryptiline for pain (which could be quite Panic attacks months: 1.5 mL; 1 - 2 years 2 mL; 3 - 5 years 3-4mL;6- Discourage harmful cultural practices e.g. burning, incapacitating) especially with dopamine- Catatonic schizophrenia 12 years 5-6mL(administered as a single dose per mutilation replacement drugs Transient ischaemic attacks rectum) per kg body weight Notable adverse drug reactions, caution and Notable adverse drug reactions, caution and Hysteria - Not recommended in pregnancy contraindications contraindications Ménière's disease Cerebral decompression with mannitol 20% Antiepileptics: foetal damage if used in pregnancy Dopamine replacement drugs: dyskinesia, pain Complications infusion or furosemide if indicated (see meningitis) - Serial measurements of alpha-fetoprotein and - Advisable to start with small doses and gradually Status epilepticus Maintenance therapy in day-to-day care ultrasound studies are necessary with close increase Cardiac arrhythmias Generalized epilepsies monitoring by an obstetrician - There is need for dosage and timing adjustments Renal failure from myoglobinuria Phenobarbital Phenytoin: gingival hypertrophy; may not be the when side effects manifest Cerebral hypoxia/anoxia resulting in brain damage Adult: 60 - 180 mg orally daily first choice in young children Dopa-agonists: postural hypotension; may cause Sudden death Child: 5-8 mg orally daily Phenobarbital: sedation and mental dullness and vomiting Phenytoin may affect school performance in children

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Most antiepileptics: skin rashes, especially Brain abscess administered slowly to avoid respiratory depression Investigations Stevens-Johnson syndrome; exfoliative dermatitis Meningitis/encephalitis and laryngeal spasm Electrocardiography Introduce drugs singly because of possible Cerebral malaria Prevention Echocardiography interaction between drugs Migraine headache Treat/control known risk factors Neuro-imaging: CT scan, MRI, carotid Doppler Doses must be gradually increased to avoid toxicity Multiple sclerosis - Hypertension Random blood sugar and other side effects Metabolic derangements e.g. hypoglycaemia, - Diabetes mellitus Management Do not use paraldehyde if it has a brownish colour hyperosmolar non-ketotic coma - Cardiac diseases Depends on the cause(s) or the odour of acetic acid Complications - Hyperlipidaemia Treatment objectives All antiepileptics must be withdrawn slowly so as Tentorial herniation with coning and death - Obesity Restore circulation and ensure brain perfusion not to precipitate status epilepticus Cardiac arrhythmias - Smoking Identify cause and treat accordingly Prevention Depression - Excessive alcohol consumption Prevent recurrence Prompt treatment of fever in children to avoid Epilepsy Give low dose aspirin (acetylsalicylic acid) to Non-drug treatment febrile convulsions Dementia patients at risk if tolerated Physiotherapy: pressure stockings Prevention of head injuries Parkinsonism Drug treatment Treat diseases of the brain early to avoid poor Hyperglycaemia Specific treatment for cardiac arrhythmias: refer to healing and death of brain cells Investigations SYNCOPE cardiologist Immunization of children against communicable Neuro-imaging with CT scan/MRI to determine Introduction If hypotensive, give pressor agents diseases stroke type and choice of management Loss of consciousness and postural tone as a result Notable adverse drug reactions, caution Address causative factors (see above) Lumbar puncture for CSF analysis in suspected of diminished cerebral blood flow Aspirin and other NSAIDs: use with caution in Avoid driving and swimming unattended, and subarachnoid haemorrhage May be due to: patients with history of dyspepsia, and in asthmatics operation of machinery Electrocardiography Vaso-vagalattack Prevention Echocardiography Cardiac causes Avoid prolonged standing Carotid Doppler ultrasound study Prolonged standing Treat underlying cardiac disease STROKE Cerebral angiography Severe emotional disturbance Avoid dehydration or excessive fluid loss Introduction Full Blood Count with differentials The more severe form is associated with various Give aspirin tablets as anti-platelet agent A condition resulting from disruption of blood Random blood glucose heart diseases: supply to brain cells with disability lasting more than Urea, Electrolytes and Creatinine Arrhythmias (especially complete heart block) 24 hours or resulting in death Chest radiograph Hypertrophic cardiomyopathy THE UNCONSCIOUS PATIENT Could result from: HIV screening 'Heart attack' (mycardial infarction ) Introduction Occlusion (ischaemic) Treatment objectives Atrial myxoma An unresponsive patient who may also have Rupture of blood vessels with bleeding into the Restore cerebral circulation Aortic stenosis breathing and circulatory problems brain substance or into the subarachnoid space Limit disability Dissecting aneurysm May be neurological or may result from other (haemorrhagic) Treat identified risk/predisposing factors Other causes: systemic diseases Clinical features Reduce raised intracranial pressure Pulmonary embolism An easy way of finding the cause is to think in terms Classical stroke: Treat complications (if any) Vertebro-basilarinsufficiency of the vowels - Sudden motor weakness, with/without speech, Non-drug treatment Subclavian steal syndrome AA: poplexy (stroke) visual and sensory impairment Attention to calories, fluid balance Carotid sinus pressure EE: pilepsy Subarachnoid haemorrhage : Physiotherapy for passive muscle exercises Migraine headache II: nfections e.g. meningo-encephalitis - Severe headache, neck stiffness and positive Nursing care (frequent turning and bladder care) to Clinical features OO: verdosing with drugs, alcohol intoxication, Kernig's sign prevent decubitus ulcers and urinary tract infection Sudden loss of consciousness toxins Stroke-in-evolution: Rehabilitation Cold extremities UU: raemia and other metabolic disorders - Gradual onset of deficit with progression Drug treatment Bluish discolouration of extremities ( cyanosis) Other causes include: Mass lesion: Cerebral decompression if there is evidence of Pulse irregularities (or pulselessness) Head injury - Sudden rise in intracranial pressure raised intracranial pressure Hypotension (or unrecordable blood pressure) Brain tumours (with complications) - Loss of consciousness, respiratory changes, - Furosemide 40 mg every 8 hours by slow Fainting induced by pressure on the neck Clinical features pupillary changes intravenous injection for 6 doses Fainting induced by coughing, micturition Varyinglevels of impaired consciousness: - Sudden death And/Or: Differential diagnoses Comatose: no response to stimulus, however painful Lacunar syndrome: - 20% mannitol 250 mL repeated every12 hours for Epilepsy Semi-comatose: some response to pain - Incomplete deficits: speech defects with clumsy 4 - 6 doses Myocardial infarction Stuporose: a state deeper than sleep; vigorous hand involvement Treat underlying conditions such as diabetes Stroke stimulation required to stimulate response - Pure motor and/or pure sensory deficits mellitus, hypertension, and thrombosis Aortic dissection Other features: Dementia: Notable adverse drug reactions, caution Hysteria Cessation of respiration or abnormal ventilatory - Arises from small, recurrent strokes resulting in Rebound cerebral oedema when mannitol is Complications patterns: Cheyne-Stokes, ataxic, apneustic, gasping cognitive impairment and functional dependence discontinued Cerebral hypoxia/anoxia resulting in brain damage etc Differential diagnoses Thrombolytic agents: bleeding tendencies Stroke Unresponsiveness or variable response to painful Brain tumour Diazepam by the intravenous route must be Sudden death stimuli Subdural haematoma

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Features of the underlying cause(s) prevent deep vein thrombosis (see Pulmonary Non-drug treatment - Stroke: may present with hemiparesis, facial Embolism) Psychosocial interventions Drug treatment asymmetry, crossed-eye defects, speech defects etc Notable adverse drug reactions Cognitive behavioural therapy Diazepam 10 - 20 mg orally daily - Epilepsy: frothing or tongue biting; abrasions of Diazepam, if required, should be administered Marital and family therapy Or: the extremities; positive past history slowly intravenously to avoid respiratory depression Group therapy Imipramine 50 - 150 mg orally daily - Infections: may present with fever, neck stiffness Prevention Drug treatment Or: - Drug overdosage/toxins: pin-point pupils; Accessible, efficient and effective health care Only occasionally required, and following careful Fluoxetine 20 - 60 mg orally daily respiratory problems; suggestive history service delivery assessment Supportive measures - Uraemia: characteristic fetor; skin rashes; oedema; Early reporting/detection of ill-health Note Relaxation techniques severe dehydration Adherence to medications and non-drug measures in - Detoxification is required for severe withdrawal Exercise - Head trauma: haematomas; subconjuctival managing disease states syndrome or delirium tremens Psychotherapy haemorrhages Public Health Education - This will involve the administration of a long- Notable adverse drug reaction, caution - Bleeding from orifices (if coma is due to trauma Promote awareness on avoidance of risk factors acting benzodiazepine and thiamine supplements The risk of dependence (and withdrawal syndromes) or bleeding diathesis) over 7 - 10 days limits the utility of benzodiazepines for treatments of Features of raised intracranial pressure: Supportive measures long duration Slow pulse (Cushing's reflex) PSYCHIATRIC DISORDERS Rehabilitation to Prevention Rising blood pressure - Sustain abstinence Avoid of undue and extreme stress Papilloedema ALCOHOLISM (Alcohol dependence) - Acquire an alcohol-free life style Avoid psycho-active substances Differential diagnoses Introduction - Prevent relapse Stroke A disorder characterized by a wide spectrum of Prevention Post-epilepsy state problems Health education (including school health BIPOLAR DISORDERS Syncope Central feature is the use of alcohol which takes an education, peer group education and self help group Introduction Mycardial infarction increasingly dominant place in the user's life in spite e.g .alcoholic anonymous) Atype of mood disorder in which there is (typically) Hysteria of experience of harm related to drinking Government regulation of alcohol use alternation of a depressive phase and a manic or Substance abuse Social and genetic factors are thought to be hypomanic phase Complication important in pathogenesis Experienced by about 1% of the adult population at Cerebral hypoxia/anoxia resulting in brain damage A life time prevalence of about 0.2 - 0.5% in ANXIETYDISORDER some point in their lifetime Investigations Nigerian adult males Introduction About equal incidence between males and females Neuro-imaging: CT scan, MRI Clinical features Generalized anxiety disorder (GAD) is May be precipitated by psychosocial stress; strong Random blood glucose Tolerance characterized by exaggerated worry and tension, genetic vulnerability often present Urea, Electrolytes and Creatinine Withdrawal episodes even when there is little or no cause for anxiety Clinical features Electroencephalography Compulsive desire to use alcohol A chronic disorder affecting about 2 - 3% of the Depressive phase: Cerebrospinal fluid analysis Associated physical, social, or occupational population - Low mood Drug levels/toxicology screen impairments Clinical features - Impaired appetite and sleep Full Blood Count Differential diagnoses Pre-occupations: often of diverse nature - Ideas of worthlessness or hopelessness Blood culture Dependence on (and withdrawal from) other Poor concentration - Suicidal ideation Treatment objectives substances Muscle aches and headaches - Other depressive symptoms and signs Clear airway and restore breathing Complications Irritability Manic or hypomanic phase: Maintain circulation Liver cirrhosis Sweating - Elation Eliminate the cause Damage to other organs (including the brain) Fatigue - Euphoria Prevent complications: decubitus ulcers, Accidents Insomnia - Irritability atelectasis, contractures etc Delirium tremens Shortness of breath - Expansive mood Correct metabolic derangements Increased mortality (reduce life expectancy) Differential diagnoses - Disturbed sleep Non-drug treatment Family, social and occupational disability Medical causes of suggestive symptoms and signs - Grandiosity Physiotherapy to prevent contractures/deep vein Investigations (e.g. hyperthyroidsm) - Disinhibition thrombosis, and for passive muscle exercises Full Blood Count and differentials Complications Differential diagnoses Nursing care (frequent turning and bladder care) to Liver function tests Chronicity Schizo-affective disorder prevent decubitus ulcers and infections Other investigations as indicated for Co-morbid depression Schizophrenia Drug treatment medical/physical complications Medical morbidity (e.g. hypertension) Organic mood/affective disorder (including effects Infections: appropriate antibacterial agent Investigations of drug abuse) Epilepsy: use effective parenteral anticonvulsant Treatment objectives To exclude medical/physical cause(s) Complications drugs; diazepam (see Epilepsy) Reduction in alcohol consumption as an interim Treatment objectives Social and personal consequences of inappropriate Renal failure: dialysis measure Achieve remission of symptoms behaviour (e.g. unplanned pregnancy, sexually- Appropriate treatment of other metabolic causes Abstinence as the desired goal Prevent relapse transmitted infections, etc) Supportive measures Rehabilitation Non-drug treatment Suicide Subcutaneous Low Molecular Weight heparin to Prevention of relapse Cognitive-behavioural therapy Increased risk of morbidity (reduce life expectancy) (e.g. trauma and accidents)

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Increased mortality maximum 10 mg daily Usually transient but may be associated with often (but not always) the triggers Investigations 12 - 18 years: initially 0.5-3mgdaily, adjusted increased morbidity (e.g. from falls) and mortality Strong genetic is vulnerability sometimes present Investigations as indicated to rule out according to response to lowest effective maintenance Investigations Occurs in about 2 - 5% of the population at any given organic/medical causes dose (as low as 5 -10 mg daily) Determined by any causal or contributing medical time and in about 10 - 25% in their lifetime Full Blood Count and renal function tests (to Supportive measures conditions Women are generally at an elevated risk determine suitability of mood stabilizers) Psychotherapy and social intervention for patient Treatment objectives Clinical features Treatment objectives and relatives/caregivers Identify and ameliorate any causal or contributing Sadness, unhappiness, feeling low Reduce risk to self and others Notable adverse drug reactions medical conditions Loss of interest in usual activities Normalize mood - More likely with doses above recommended upper Improve cognition Reduced energy Return to full functional status limits Normalize behaviour Disturbance of sleep and appetite Prevent recurrence Lithium Non-drug treatment Impaired concentration Non-drug treatment - Gastrointestinal disturbances Nurse in a quiet, well-lit environment Ideas of worthlessness, guilt, or failure Cognitive-behavioural therapy as sole treatment in - Tremors Support physical care, including food and fluid Morbid or suicidal rumination or ideation mild cases, and adjunct in all others - Confusion intake Somatic complaints of various types Electroconvulsive therapy (ECT) - Myoclonic twitches Provide orienting cues Differential diagnoses - An effective and essentially safe treatment for Carbamazepine: hypersensitivity reactions Physical restraint judiciously used when indicated Normal grief reaction severe and acute presentations Transient memory impairment is common Drug treatment Medical conditions causing lowering of mental and - Acourse of8-12treatments are usually needed following ECT High-potency antipsychotics in low dosages for physical activities (e.g. anaemia, hypothyroidism) Drug treatment Prevention sedation Infections (e.g. viral) Treat underlying causes No primary preventive measures are clearly - Haloperidol Complications Lithium delineated Adult:0.5-1mgorally or parenterally every 6 - 8 Worsening of co-morbid physical illness - 1st line drug following established diagnosis Adherence to therapy with mood stabilizers until hours Suicide Adult: initially 1 - 1.5 g daily discontinuation is considered prudent (this is Child 2 - 12 years: initially 12.5 - 25 micrograms/kg Recurrence (in 50% or more) Prophylaxis: initially 300 - 400 mg daily individually determined) orally twice daily, adjusted according to response to Investigations Child: not recommended maximum 10 mg daily; 12 - 18 years: initially 0.5-3mg Full Blood Count and differentials - Measure serum lithium concentration regularly (every daily, adjusted according to response to lowest effective Thyroid function test three months on established regimens) DELIRIUM maintenance dose (as low as 5 -10 mg daily) Indicative infection screen - Adjust dosage to achieve serum levels of 0.6 - 1.2 Introduction Benzodiazepines Treatment objectives mEq/L Atransient disorder of brain function - For severe agitation (i.e. life-threatening features) Normalize mood Sodium valproate Manifests as a global cognitive impairment and or patient seriously disrupting management Prevent suicide attempts Adult: 750mg-2gmgorally/day behavioural disturbance Supportive measures Return to active life Child: neonate, initially 20 mg/kg orally once daily; More common at the extremes of life though it can Give reassurance to patient and relatives/caregivers Prevent recurrence usual maintenance dose 10 mg/kg every 12 hours daily occur at any age - The transient nature of condition Non-drug treatment 1 month - 12 years: initially 5 - 7.5 mg/kg every 12 hours, Incidence up to 15% has been reported among - No risk of “madness” Cognitive-behavioural treatment usual maintenance dose 12.5 -15 mg/kg every 12 hours general medical inpatients; up to 40% among Caution Inter-personal psychotherapy (up to 30 mg/kg twice daily) acutely ill geriatric patients Close nursing care is required to prevent injuries Drug treatment 12 - 18 years: initially 300 mg every 12 hours, increased Poor detection and mis-diagnosis are common and falls Tricyclic antidepressants (TCAs) in steps of 200 mg daily at 3-day intervals; usual The most common causes are: Avoid over-medication, especially as - Amitriptyline in increasing doses up to 150 mg maintenance dose 0.5 - 1 g twice daily (maximum 1.5 g Trauma antipsychotics and sedatives used may worsen orally/day daily) Infections delirium - Fluoxetine 20 - 80 mg orally/day Carbamazepine Metabolic derangements Prevention Supportive measures Adult: 600 - 1,800 mg orally daily Side effects of drugs Early treatment of infective and metabolic Supportive psychotherapy for patients and Child: 1 month - 12 years: initially 5 mg/kg orally at Clinical features conditions family/caregivers night or 2.5 mg/kg twice daily, increased as necessary by Disturbance of consciousness Care with the use of drugs (especially Notable adverse drug reactions, caution 2.5 - 5 mg/kg every 3 - 7 days Disorientation anticholinergic medications) in the elderly Tricyclic antidepressants: - Maintenance dose 5 mg/kg 2 - 3 times daily, increased Memory deficits - Dryness of the mouth slowly to usual maintenance of 400 - 600mg 2-3times Language disturbances - Urinary retention daily Perceptual disturbances DEPRESSION - Constipation Antidepressants Rapid fluctuations Introduction - Blurring of vision - TCAs or SSRIs may be indicated in depressive Disruption of sleep-wake cycle A disorder of mood and affect in which the Selective Serotonin Reuptake Inhibitors (SSRIs) phase Psychomotor hyperactivity predominant emotion is sadness/unhappiness - Sleep disturbance Antipsychotics Mood alterations Can occur alone (unipolar depression) or as part of - Sexual dysfunction - Haloperidol 1.5 to 3 mg orally 2 - 3 times daily Differential diagnoses an alternation disorder in which elevation of mood - Serotonin syndrome (may be indicated in acute manic phase) Dementia also occurs (bipolar disorder) Cardiac toxicity, especially in overdose with TCAs Child 2 - 12 years: initially 12.5 - 25 micrograms/kg Acute (idiopathic) psychotic disorders Variesin severity from mild to severe and SSRIs orally twice daily, adjusted according to response to Complications Life events, especially those involving loss, are Increased suicidal ideation in adolescents

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- Should be used with caution in patients with than 2 - 3 weeks daily (maximum 80 mg) Non-drug treatment epilepsy, history of mania, cardiac disease, diabetes - For middle insomnia Elderly: 20 - 40 mg (maximum 60 mg for elderly) Psycho-social interventions as indicated (including mellitus, and bleeding disorders Supportive measures once daily social and occupational therapy) - Caution is also required in patients receiving Relaxation therapy: a useful adjunct for the most - Discontinue if no improvement within 10 weeks Psycho-education for patient and relatives / concurrent electroconvulsive therapy (reports of common forms of insomnia Child and adolescent under 18 years: not recommended caregivers prolonged seizures with fluoxetine) Notable adverse drug reactions Or: Supportive psychotherapy Prevention Benzodiazepines: dependence and rebound Amitryptiline 50 - 150 mg orally/day ECT (especially for catatonic forms) Recurrence is reduced by continuing medication for insomnia Supportive measures Drug treatment at least 6 months after acute symptoms resolve Prevention Psychotherapy Chlorpromazine Reduced stress exposure Relaxation techniques Adult: initially 25 mg orally every 8 hours (or 75 mg at Caution with alcohol and psychoactive substances, Notable adverse drug reactions night), adjusted according to response to usual INSOMNIA such as coffee, kolanut. Tricyclic antidepressants are cardiotoxic in maintenance dose of 75 - 300 mg daily Introduction Discourage of misuse of “sleeping pills” e.g. overdose - Elderly: a third to half adult doses Difficulty in falling asleep or staying asleep Bromazepam, diazepam Increased risk of suicidal attempts by patients with By deep intramuscular injection: 25 - 50 mg every 6 - 8 May be primary and unrelated to any physical or panic disorder hours mental disorder PANIC DISORDER Prevention Child: 1 - 5 years: 500 micrograms/kg orally every 6 - 8 May relate to a mental disorder, medical or physical Introduction No specific primary prevention measures hourly (maximum 40 mg daily); 6 - 12 years: a third to conditions A disorder characterized by episodic attacks of half adult dose (maximum 75 mg daily) May be an adverse effect of medication (or extreme fear, mostly unrelated to specific objects or SCHIZOPHRENIA Haloperidol psychoactive substances) situations Introduction Adult: initially 1.5-3mgevery 8 - 12 hours daily or 3 - Acommon, often chronic problem; tends to increase Associated with multiple somatic and cognitive A serious psychotic disorder characterized by 5mg every 8 - 12 hours in severely affected or resistant with age symptoms multiple impairments in emotional, behavioural, patients Clinical features Each attack lasts for about 5 - 30 minutes cognitive, social, and occupational domains (among - In resistant schizophrenia, up to 30 mg daily may be Early insomnia: difficulty in initiating sleep Often begins abruptly others) needed, adjusted according to response to the lowest Middle insomnia: difficulty in going back to sleep Affects about 0.5 - 1.0% of the population Affects about 1% of the population effective maintenance dose (as low as5-10mgdaily) after waking up at night Clinical features Onset usually in late adolescence or early adulthood Elderly, initially half adult dose Terminal insomnia: early awakening, commonly 2 Afeeling of choking Strong genetic component to its etiology; Child: initially 25 - 50 mg micrograms/kg daily in 2 hours or more before desiring to do so Pounding heart environmental factors, including pre-natal and divided doses (maximum 10 mg) Differential diagnoses Chest pressure or pain obstetric factors, also implicated Fluphenazine Useful to consider possible aetiological factors: Dizziness Clinical features Adult: initially 2 - 10 mg every 8 - 12 hours, adjusted medical, mental, situational, environmental Shortness of breadth Disorders of: according to response to 20 mg daily Pain is a common factor Trembling Thought - Doses above 20 mg daily (10 mg in elderly) only with Complications Sweating Perception special precaution Deteriorating physical and/or mental health Tingling or numbness in the hands or feet Speech Or: Decline in overall well-being and quality of life Hot flushes Cognition 25 - 100 mg intramuscularly fortnightly to monthly Investigations Differential diagnoses Behaviour Child: not recommended Mainly of the presumed underlying cause(s) Other causes of intense fear (phobias, obsessive- Motor function Supportive measures Treatment objectives compulsive disorders, etc) Differential diagnoses Supportive psychotherapy To improve sleep, especially sleep satisfaction Medical causes (e.g. hyperthyroid states, episodic Psychosis of other origin (including those due to Social and occupational therapy To remove underlying/associated factors hypoglycemia, etc) organic factors) Cognitive therapy (as adjunct in the treatment of Non-drug treatment Seizure disorders Affective psychosis persisting psychotic experience) Sleep hygiene Complications Epilepsy, especially of temporal lobe origin Rehabilitation Behavioural modifications to enhance relaxation Phobia Drug effect, e.g. amphetamine intoxication Notable adverse drug reactions Avoid habits and lifestyles that promote insomnia Depression Complications Extrapyramidal and Parkinsonian symptoms (may Improve environmental/sleeping conditions Suicide Chronicity require anticholinergic medication) Drug treatment Investigations Suicide Tardive dyskinesia General principles As indicated to exclude medical aetiologies Increased physical morbidity Weight gain Treat underlying cause(s) Treatment objectives Increased mortality Agranulocytosis (monitor blood counts in patients Avoid sedatives: use for only short periods when To reduce intensity and frequency of attacks Investigations on clozapine) indicated To reduce anticipatory anxiety To exclude organic causes of acute psychotic Prevention Short-acting benzodiazepines e.g. Non-drug treatment presentations No clear/specific scope for primary prevention at - Nitrazepam 5 -10 mg at night for short term use Cognitive-behavioural treatment Treatment objectives present - For the elderly, 2.5-5mg Drug treatment Relieve acute symptoms Secondary and tertiary: - For early insomnia Fluoxetine Return to full functional status - Early and effective treatment Or: Adult: initially 20 mg orally once daily, increased Rehabilitate - Rehabilitation to reduce disability Longer-acting benzodiazepines e.g. after two weeks (if necessary) to 20 - 60 mg once Prevent relapse - Diazepam at low doses: 2.5 - 10 mg for no more

47 48 Chapter 5: Dental and Oral Disorders Standard Treatment Guidelines for Nigeria 2008

CHAPTER 5: DENTAL AND ORAL DISORDERS Follow-up treatment ALVEOLAR OSTEITIS The fascial space infections may involve sublingual, Rehabilitation of the mouth Introduction submandibular and/or parapharyngeal spaces ACUTE NECROTIZING ULCERATIVE Once the acute phase has subsided, oral hygiene should The most frequent painful complication of extractions Ludwig's angina is bilateral cellulitis of the sublingual GINGIVITIS be brought to as high a standard as possible to lessen the Caused by destruction of the clot that normally fills the and submandibular spaces risk of recurrence socket Clinical features Definition Sequestrectomy Predisposing factors Diffuse, tense, painful swelling of the involved soft Apolymicrobial, endogenous infection Notable adverse drug reactions, caution Excessive extraction trauma tissues Aetiology Metronidazole: nausea, vomiting, unpleasant taste; Limited local blood supply Malaise Fusiform and spirochaete bacteria disulfiram-like effect with alcohol. Local anesthesia Elevated temperature Epidemiology Oral contraceptives Ludwig's angina causes airway obstruction which can In developing countries, seen almost exclusively in Osteosclerotic disease quickly result in asphyxia children Radiotherapy Suppuration and abscess formation may occur later if ACUTE PERIAPICALABSCESS Related to poverty and malnutrition Clinical features treatment is neglected or delayed Definition In industrialized countries, most common in young More common in women Complications Alocalized collection of pus in the periapical region of a adults with neglected mouths; smoking and stress have Pain delayed for few days up to a week after extraction Extension towards the eyes, and risk of cavernous sinus tooth been associated Deep seated, throbbing pain thrombosis: cellulitis affecting maxillary teeth Aetiology Clinical features Mucosa around socket is red and tender Respiratory difficulty: cellulitis affecting mandibular May develop either directly from acute periapical Crater ulcers striating at the tips of the interdental No clot in socket - bare whitish lamina dura exposed teeth periodontitis or more usually from a chronic periapical papillae Differential diagnosis Investigations granuloma Ulcers spread along gingival margins Osteomyelitis Culture (blood and swab) and sensitivity testing Generally the result of a mixed bacterial infection Gingival soreness and bleeding Complication Non-drug treatment Culture of the pus yields a wide range of different Foul breath Osteomyelitis Drainage of the swelling to reduce pressure (oral drain organisms Metallic taste Treatment objective may also be placed) - Strict anaerobes (e.g.prevotella , porphyromonas ) Increased salivation Keep open socket clean and protect exposed bone Secure the airway by tracheostomy if necessary usually predominante, but facultative anaerobes may be Cervical lymphadenopathy and fever in advanced Non-drug treatment Drug treatment found cases Irrigate with mild warm saline and antiseptic Aggressive antibiotic treatment Clinical features Differential diagnoses Fill with an obtudant dressing containing some non- - Intravenous co-amoxiclav (given over 3 to 4 minutes) Painful swelling at the root of tooth Primary herpetic gingivo-stomatitis irritant antiseptic in combination with intramuscular gentamicin for 5 days Sinus (may be present) HIV-associatedacute ulcerative gingivitis Warm saline mouth rinse Injection co-amoxiclavulanate Tooth is tender to biting or percussion Gingival ulceration in acute leukaemia or aplastic Drug treatment Adult: 1,000/200 mg intravenoulsly every 8 hours Tooth mobility anaemia Local anaesthesia Child: neonate and premature infants, 25 mg/kg every 12 Differential diagnoses Investigations - Lidocaine 2% (1in 80,000) hours; infants up to 3 months, 25 mg/kg every 8 hours, 3 Inflammatory radicular cyst Smears from ulcers show predominantly spirochaetes Co-amoxiclav months to 12 years, 25 mg/kg every 8 hours increased to Osteomyelitis and gram negative fusiform bacteria - Severe dental infection with spreading cellulitis 25 mg/kg every 6 hours in more severe infections Periodontal abscess Treatment objectives - 250/125 mg orally every 8 hours for 5 days (dose Injection gentamicin: Investigations Treat infection doubled in severe infections) Adult: 3 - 5 mg/kg daily in divided doses every 8 hours Radiographs (periapical) Restore oral health Chlorhexidene gluconate 2% Child: up to 2 weeks: 3 mg/kg every 12 hours; 2 weeks - Treatment objectives Non-drug treatment - 10 mLfor mouth washes three times daily 12 years: 2 mg/kg every 8 hours Remove source of infection e.g. fish-bone, other foreign Oral hygiene (debridement) is essential Prevention Precaution objects Drug treatment Minimal trauma during extractions Gentamicin may cause significant ototoxic and Drain abscess using local anaesthesia Metronidazole Immediately after extraction, squeeze socket edges nephrotoxic effects Treat residual infection Adult: 200 mg orally 8 hourly for 3 days firmly together and hold for a few minutes till clot has Prevention Non-drug treatment Child:1 - 3 years: 50 mg orally every 8 hour s for 3 days; formed Early treatment of carious teeth Extraction (or endodontic treatment) i.e. root canal 3 - 7 years: 100 mgevery 12 hour s ; 7 - 10 years: half adult Antibiotics if patients have had irradiation, or have therapy dose Paget's disease Drug treatment Supportive therapy DENTALCARIES Amoxicillin Ascorbic acid Definition Adult: 250 mg orally every 8 hours for 5 to 7 days Adult: not less than 250 mg orally daily (in divided CELLULITIS A progressive bacterial damage to teeth exposed to the Child: up to 10 years 125 mg every 8 hours, doubled in doses) Definition saliva severe infections Child: 1 month - 4 years: 125 - 250 mg in 1 - 2 divided A rapidly spreading, poorly localized inflammation of Classification Metronidazole doses the soft tissues particularly associated with streptococcal Enamel caries Adult: 200 mg orally every 8 hours for 3 days 4 - 12 years: 250 - 500 mg daily in 1 - 2 divided doses; 12 infection Dentine caries Child: 1 - 3 years: 50 mg orally 8 hourly for 3 days; 3 - 7 - 18 years 500 mg - 1 g daily in 1 - 2 divided doses Pathogenesis Root surface caries years: 100 mg every 12 hours;7-10years: half adult dose Ferrous sulfate Rapid spread is most likely related to release of large Aetiology Adult: 200 mg orally three times daily taken before food amounts of streptokinase and hyalurondinase which are Develops over time in the presence of certain interacting Child 6 - 12 years: half adult dose produced by most strains of streptococci variables

49 50 Chapter 5: Dental and Oral Disorders Standard Treatment Guidelines for Nigeria 2008

- Carbohydrate diet Scaling and polishing May be asymptomatic, or painful, with difficulty in PERICORONITIS - Viridans streptococci bacteria Antiseptic mouthwashes e.g. chlorhexidine gluconate swallowing Introduction - Susceptible tooth surface 2% three times daily for1-2weeks Predisposing factors An inflammatory condition of the gum/flap around a - Hexetidine mouthwashes to alternate with warm Denture wearing partially erupted tooth Pathogenesis saline mouthwashes Reduced salivation (e.g. drug induced) Common around the lower last molars or wisdom teeth Enamel caries progress in the following stages: Drug treatment Antibiotic therapy (especially broad spectrum) Upper canine may also be affected - Early (sub-microscopic) lesion Analgesics Poorly controlled diabetes mellitus Classification - Phase of non-bacterial enamel crystal destruction - Paracetamol Steroid therapy (chronic) Acute - Cavity formation Adult: 1 g orally every 8 hours for3-5days Salivary gland damage (e.g. post radiation) Chronic - Bacterial invasion of enamel Child: 1 - 5 years: 125 - 250 mg, 6 - 12 years 250 - 500 mg Malnutrition Acute-on-chronic Clinical features orally every 8 hours HIV infection Aetiology Cavity formation in affected tooth Antibiotics Leukaemia Food impaction and plaque accumulation under gum flap

- Starts as a white spot - Amoxicillin Iron, vitamin B2 , folic acid deficiency Trauma to gum flap from opposing tooth Pain Adult: 250 mg orallyevery 8 hours for 5 days Agranulocytosis Ulcerative gingivitis - On exposure of the cavity to thermal changes or food Child: 1 month - 1 year 62.5 mg orally every 8 hours; Investigations Reduced resistance particles dose doubled in severe infections Smear of the affected region and Gram staining or PAS Anaerobes in plaque Complications 1 - 5 years: 125 mgevery 8 hours ; 5 - 12 years: 250 mg 8 with or without potassium hydroxide to demonstrate Clinical features Pulpitis hourly; 12 - 18 years 500 mg 8 hourly; all doses doubled hyphae Soreness and tenderness around partially-erupted tooth - If not treated can cause apical periodontitis and in severe infections Swab sample for microscopy, culture and sensitivity Pain dentoalveolar abscess - Metronidazole Biopsy and histopathologic examination Swelling Investigations Adult: 200 mg orallyevery 8 hours for 5 days Identify predisposing factors (including Enlargement of regional lymph nodes Periapical radiographs Child: 1 - 3 years 50 mg orallyevery 8 hours ; 3 - 7 years: immunosuppresion) Fever Bitewing radiographs 100 mgevery 12 hour s ; 7 - 10 years: 100 mg every 8 Define extent of involvement Abscess formation Electric pulp testers hours Non-drug treatment Investigations Thermal test Notable adverse drug reactions, caution Manage any underlying predisposing factors Radiographs Non-drug treatment Metronidazole: nausea, vomiting and metallic taste Replace worn dentures - To establish the position of the affected tooth and its Depending on the stage of the lesion: Metronidazole is contraindicated in pregnancy Proper counselling of patients as to use of dentures relationship to the second molar Amalgam filling, Glass Ionomer Cement (GIC) Avoid alcohol during treatment with metronidazole, Diet modification and improvement - May show impacted third molar composite andAtraumatic Restorative Technique (ART) and for at least 48 hours after Chlorhexidine mouthwash three times daily for1-2 Non-drug treatment for enamel caries Prevention weeks When mouth opening is possible: careful irrigation under Amalgam filling, GIC for dentine caries Oral health education Drug treatment the gum flap to clear debris, using warm saline Root Canal Therapy, pulp capping pulpotomy, Scaling and polishing every six months Topical anti-fungal medication e.g mouthwash pulpectomy for pulpal involvement - Nystatin suspension - To be done frequently until stagnation area is removed Drug treatment Adult: 100,000 units/mL 4 times daily , after food Operculectomy Analgesics pre-operatively NEOPLASMS OF THE ORAL CAVITY refer to (usually for 7 days) Disimpaction of the third molar by surgical extraction - Paracetamol 1g4-6hourly orally to a maximum of 4 specialist care - Continue for 48 hours after lesions have resolved Occlusal reduction of opposing tooth g daily Child 1 month - 18 years, prophylaxis and treatment: Extraction of opposing tooth Prevention ORALTHRUSH (Candidiasis) 100,000 units 6 hourly after food for 7 days Drug treatment Oral health education Introduction - Continue for 48 hours after lesions have healed Appropriate antibiotics Regular scaling and polishing A clinical infection of mucous membranes due to the Immunocompromised children: Analgesics Systemic and topical fluoride application fungus species Candida - 500,000 units 6 hourly for 7 days Supportive therapy Fissure sealants Candida albicans is the most frequently isolated strain Or: Possible complications Routine dental check-ups Classification - Miconazole oral gel 2% Cellulitis Acute oral candidosis Adult: place 5 - 10 mL in the mouth after food and retain Ludwig's angina Chronic oral candidosis near lesions 4 times daily Osteomyelitis GINGIVITIS Denture association candidosis/denture stomatitis Child under 2 years: 2.5 mL twice daily; 2 - 6 years: 5 mL Introduction Pathogenesis/aetiology twice daily; 6 - 12 years: 5 mL4 times daily; 12 - 18 years: An inflammatory response of the gingivae to plaque Immunosupression results in theCandida albicans (a 5 - 10 mL4 times daily PERIODONTITIS bacteria normal oral commensal) becoming virulent - Leave in the mouth after food and retain near lesions Introduction The most common type is chronic gingivitis - It invades and proliferates in superficial epithelium Some patients may require systemic antimicrobial An inflammatory condition of the periodontium: Clinical features - Results in a thick plaque which is oedematous and not medicines periodontal ligament, cementum, alveolar bone, gingivae Chronic gingivitis is asymptomatic, low grade easily rubbed off - Fluconazole Classification inflammation of the gingivae Clinical features Adult: 50 mg orally daily for7-14days Acute periodontitis Gums become red and slightly swollen Acreamy/whitish, soft and friable slough located on the Child: 3 - 6 mg/kg on the first day, then 3 mg/kg daily Chronic periodontitis Non-drug treatment soft tissues of the oral cavity: tongue, palate, cheek, For neonates up to 2 weeks old: administer every 72 Juvenile periodontitis Oral hygiene instructions pharynx hours;2-4weeks old: administer every 48 hours Other sub-classifications

51 52 Chapter 5: Dental and Oral Disorders Standard Treatment Guidelines for Nigeria 2008

Acute periodontitis hours; 10 -18 years: 200 mg every 8 hours reversible pulpitis Sjogren's syndrome Relatively uncommon Plus: To remove the pulp in irreversible pulpitis - Presents with dryness of the eyes and mouth (primary Of short duration; may be due to trauma, abscess or Tetracycline 250 mg orally daily for up to 21 days Non-drug treatment type) ulceration Child under 12 years: metronidazole and amoxicillin (or Reversible: - In the secondary type, dryness occurs in association Characterized by pain erythromycin for those sensitive to penicillin) - Indirect pulp capping with rheumatoid arthritis or other connective tissue - May be associated with bleeding, fever, swelling and Precaution - Direct pulp capping disease redness of the mucosa, unpleasant taste in the mouth Tetracyclines should not be given to children under 12 - Conventional filling using amalgam, composite or Neoplasms of the salivary gland Chronic periodontitis years GIC The next most common neoplasms of the mouth after Asequela of chronic gingivitis - Desensitization with strontium chloride squamous cell carcinomas Symptoms are the same as in the acute type, but with Irreversible: Above 70% develop in the parotid gland less pain and longer history PULPITIS - Root canal therapy Over three-quarters are benign Clinical features Introduction - Extraction Women are slightly more frequently affected Inflammation Inflammation of the dental pulp Drug treatment Classification Destruction of the periodontal membrane fibres The single most important disease process affecting the Paracetamol The modified WHO classification (1972) includes: Resorption of the alveolar bone dental pulp Adult: 500 mg - 1 g orally every 4 - 6 hours (to a Epithelial tumours Migration of the epithelial attachment along root Accounts for virtually all pulpal disease of any clinical maximum of 4 g) for5-7days Adenomas: towards the apex significance Child over 50 kg: same as adult dosing - Pleomorphic adenoma ('mixed tumour') Pocket formation around the tooth Clinical features 6 - 12 years: 250 -500 mg; 1 - 5 years: 125 - 250 mg; 3 - Monomorphic adenomas Juvenile periodontitis Pain which is difficult to localize months - 1 year: 125 - 250 mg for 5 - 7days - Warthin's tumour, oxyphoitic adenoma An uncommon disease characterized by periodontal - May radiate to the adjacent jaw and occasionally to the NSAIDs may be required in some patients Carcinomas: destruction, often in the absence of overt gingival face, ear or neck Notable adverse drug reactions - Mucoepidermoid carcinoma inflammation May be triggered by: Aspirin and other NSAIDs - Acinic cell carcinoma Epidemiology - Cold or hot stimulants - Gastrointestinal haemorrhage, allergic reactions - Adenocarcinoma Prevalence 1:1000; male = female - Arecumbent position - Do not prescribe for patients with peptic ulcer disease - Epidermoid carcinoma Onset at puberty or earlier - Occasionally by mastication when food particles get - May exacerbate symptoms in asthmatics - Undifferentiated carcinoma Clinical features into a carious cavity Aspirin is contraindicated in children less than 16 years - Malignant mixed tumour Affects the first permanent molar and incisors Important to determine whether pulpitis is reversible or as it may precipitate Reye's syndrome Non-epithelial tumours Actinobacillus,Actinomycetes comitans has been irreversible Prevention - Lymphomas isolated from the affected sites Reversible pulpitis: Prevent dental caries (the most important cause of - Sarcomas Results in drifting and loss of the first permanent molar The pulp can recover with removal of stimulus pulpitis)s Clinical features and incisors Pain lasts for only a few moments after removal of the Seek prompt dental attention Benign tumours are generally asymptomatic Investigation initiating stimulus enlargements Radiology may reveal marked bone loss interdentally, Irreversible pulpitis: Malignant varieties are painful, irregular, ulcerative and inter-radicularly and apically The pulp cannot recover even after removal of stimulus SALIVARYGLAND DISEASES metastatic Complications Characterized by pain which lingers for at least one Introduction Investigations Tooth loss minute after removal of stimulus Awide spectrum of disorders Sialography Malocclusion May be spontaneous Diseases due to obstruction - Postero-anterior view of the skull Temporo-Mandibular Joint (TMJ) dysfunction Complications Salivary calculi - Oblique lateral view of the jaws syndrome The sequelae of untreated pulpitis (in the order in which Parotid papilla and duct strictures Management Non-drug treatment they occur) are: Salivary fistulae Benign and malignant lesions: surgical excision Control of plaque bacteria by use of antiseptic solution Reversible pulpitis Mucoceles and cysts Malignant lesions: radiotherapy and chemotherapy in Establishing a healthy gingival and periodontal Irreversible pulpitis Ranula addition to excision attachment Pulpal necrosis Sialadenitis Secondary bacterial infections: treat with antibiotics Oral hygiene instruction and motivation Apical periodontitis Diseases which result from inflammation of the salivary e.g. ampicillin/cloxacillin 250/250 mg every 6 hours for 5 Regular scaling and polishing Periapical abscess glands - 7 days Root planing Cellulitis - Mumps - Adjust doses as appropriate for children Splinting of mobile tooth Investigations - Suppurative parotitis Periodontal surgery Of primary importance is the use of a pulp tester to test - Chronic sialadenitis Bone regenerative techniques e.g using the vitality of the pulp Xerostomia TEMPORO-MANDIBULAR JOINT DISORDERS Polytetrafluoroethylene (PTFE) membranes, Bio-Oss, The following can be used: Dry mouth Introduction Bio-membrane - Electric pulp tester It can be caused by the following: These disorders can be grouped under the following Drug treatment - Cold or hot water bath - Sjogren's syndrome conditions: Metronidazole - Ethyl chloride spray - Irradiation Temporo-Mandibular Joint (TMJ) pain-dysfunction Adult: 200 mg orally every 8 hours for 5 days - Hot gutta percha sticks - Dehydration syndrome Child 1 - 3 years: 50 mg orally every 8 hours;3-7years: - Ice sticks - Psychogenic Osteoarthritis 100 mg every 12 hours;7-10years: 100 mg every 8 Treatment objectives - Drugs Rheumatoid arthritis To exclude the pulp from the stimulus (or stimuli) in

53 54 Chapter 5: Dental and Oral Disorders Standard Treatment Guidelines for Nigeria 2008

Trauma Usually begins in early adult life and affects females CHAPTER 6: DERMATOLOGY Child under 5 years: a quarter adult dose; 5 - 10 years: Developmental defects more frequently half adult dose Ankylosis Patients rarely complain of pain from TMJ but clinical BACTERIALINFECTIONS Ciprofloxacin Infection examination shows TMJ involvement in 50% of cases Adult: 250 - 750 mg orally every 12 hours for 5 - 7days Neoplasia Limitation of mouth opening; softness, crepitus, CELLULITIS Child: see note on caution referred pain, and tenderness on biting Introduction Ceftriaxone TMJ pain dysfunction syndrome Severe disability is unusual A suppurative bacterial infection of the skin and soft Adult: 1 g intravenously or intramuscularly daily for 3 The most common problem in or around the TMJ tissue, often with involvement of underlying structures: days Clinical features Trauma fascia, muscles and tendons Child: neonate, 20 - 50 mg/kg by intravenous infusion Equal frequency between genders, but five times as Clinical features include: Most often due to ß-haemolytic streptococci or over 60 minutes; 1 month - 12 years, body weight less many females seek treatment Condyle fracture or trauma arthritis Staphylococcus aureus than 50 kg: 50 mg/kg by deep intramuscular injection or Patients are usually between 15 and 40 years Pain and trismus of traumatic arthritis resolve after one Usually (but not always) follows some discernible intravenous injection over 2 - 4 minutes, or by Unilateral or bilateral dull pain within the TMJ and/or week wound intravenous infusion surrounding muscles, sometimes on waking or during Micro-trauma from parafunction may result in chronic Often a complication of immunosuppression like - Intramuscular injections over 1 g should be divided eating or speech symptoms diabetes and HIV/AIDS over more than 1 site TMJ may lock in the open or closed positions, Dislocation is usually a result of trauma and is rare; very Clinical features - Doses of 50 mg/kg and more should be given by occasionally rarely it occurs after yawning Areas of oedema; rapidly spreading intravenous infusion only TMJ sounds such as clicking, crunching or grating are Erythema (rapidly becomes intense and spreads) - Use only when there is significant resistance to other often described Developmental defects Tenderness and warmth drugs Associated headache is usually located in the temporal Aplasia of the condyle is extremely rare and may be - Often accompanied by fever, lymphangitis, regional Surgical treatment region unilateral or bilateral lymphadenitis May need incision and drainage or debridement Pain is cyclical and usually resolves, but may recur Hypoplasia of the condyle may be congenital or Systemic signs of toxicity Caution, contraindications May be associated with psychological stress acquired Area becomes infiltrated and pits on pressure Ciprofloxacin is contraindicated in growing adolescents Differential diagnoses Cause of congenital hypoplasia is not known; either one Sometimes the central part becomes nodular and and children below 12 years; also contraindicated in Migraine or both condyles may be involved surrounded by a vesicle that ruptures and discharges pus pregnancy Psychologic depression Acquired hypoplasia may be secondary to trauma, and necrotic material Prevention Treatment objectives infection or radiation Differential diagnoses Treat any wound promptly Most symptoms are self-limiting and do not require Hyperplasia of the mandibular condyle is rare and self- Erysipelas treatment limiting. Cause is unknown. It is generally unilateral with Deep vein thrombosis Treatment should be conservative and reversible resultant facial asymmetry, deviation of mandible to the Complications FURUNCULOSIS (Boils) Non-drug treatment opposite side and malocclusion - Unusual in immunocompetent adults; children and Introduction Educate patient about the condition, emphasizing its compromised adults are at higher risk immuno Infection of a hair follicle by staphylococcal organisms, frequency and self-limiting nature Ankylosis Septicaemia that leads to an inflammatory nodule, with a pustular Soft diet Follows trauma, infection or other inflammatory Gangrene centre Apply moist heat to painful muscles condition Metastatic abscesses Acarbuncle is merely two or more confluent furuncles, Physiotherapy Recurrent cellulitis may predispose to chronic with separate heads Drug treatment Infection lymphoedema Recalcitrant cases may occur with a background of Analgesics as appropriate Follows penetrating trauma to joint or spread from Investigations immune suppression Anxiolytics middle ear Blood culture - Alcoholism: - Diazepam 5 mg orally 1 hour before sleep, then 2 mg Full Blood Count with differentials - Malnutrition every 12 hours, for up to 10 days (maximum) Neoplasia Fasting blood glucose - Blood dyscrasias Supportive measures Primary neoplasms arising from the structures of the HIV screening - Disorders of neutrophil function Occlusal splints TMJ are extremely rare Wound swab for microscopy, culture and sensitivity - Diabetes Osteoarthritis Benign tumours such as chondromas and osteomas are Urinalysis - AIDS Rare more frequent than sarcomas arising from bone or Treatment objectives May occur in patients with atopic dermatitis Increasing incidence after 50 years synovial tissues Eradicate infection May be iatrogenic Joint crepitus denotes degenerative joint disease Others are secondary carcinomas Treat underlying immunosuppression Clinical features May be accompanied by pre-auricular pain, but not Prevent complications Can be found on all body sites where hairs are present involving the masticatory muscles Drug treatment Starts with a small, yellow creamy pustule that rapidly Radiographs (e.g. panoramic, trans-pharyngeal, trans- Ampicillin/cloxacillin evolves into a red nodule, often with a central yellow cranial, oblique, lateral, open and closed) show Adult: 500 mg - 1 g orally every 6 hours for5-7days plug degenerative joint disease Child under 5 years: a quarter adult dose; 5 - 10 years: As the lesion expands, it becomes: Rheumatoid arthritis half adult dose Painful and tense Adisease of unknown aetiology Or: Associated with local oedema, lymphangitis, regional Autoimmune mechanisms and immune complex Cloxacillin lymphadenopathy and fever formation have been implicated Adult: 500 mg orally every 6 hours for5-7days - Eventually, the central part of the nodule becomes soft

55 56 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008 and drains spontaneously Begins with a 2 mm erythematous macules which - Strict personal hygiene Suppress inflammation Healing occurs after about 1 - 2 weeks with scar quickly develop into vesicles or bullae Treat underlying skin disease(s) Reduce itching formation - Blisters are superficial and rupture easily, releasing a Notable adverse drug reactions Prevent complications Differential diagnoses thin straw-coloured seropurulent discharge Sulphonamide and co-trimoxazole: fixed drug eruption Drug treatment Folliculitis - The exudate dries to form loosely stratified golden Topical: Cutaneous myiasis yellow crusts Hydrocortisone 1% or betamethasone valerate 0.1% Acne inversa in the axilla or groin Auto-inoculation from fluid (from ruptured blister) DERMATITISAND ECZEMA - Apply twice a day until the skin improves then decrease Complications leads to multiple lesions to once a day or less frequently as needed Cellulitis As the lesions spread peripherally and the skin clears ATOPIC DERMATITIS (Atopic eczema) Systemic therapy: Septicaemia centrally, large circles are formed by fusion of the Introduction Steroids (only to control acute exacerbations) Carvenous sinus thrombosis when the lesions are on the spreading lesions to produce gyrate patterns Inflammation of the superficial dermis and epidermis, - Prednisolone head and neck Lesions heal without scarring, but may leave behind leading to disruption of the skin Adult: initially up to 10 - 20 mg orally daily Investigations erythema and hyperpigmentation Dermatitis and eczema are used interchangeably, - Preferably taken as a single dose in the morning after Wound swab for bacteriology and sensitivity Other pruritic dermatoses may become impetiginized although eczema was initially used to refer to blistering breakfast Full Blood Count with differentials (i.e.infected with the above organisms): dermatitis, being derived from a Greek term meaning 'to - In severe disease: up to 60 mg orally daily, as a short Fasting blood glucose - Scabies boil over' course for 5-10 days HIV screening - Pediculosis Atopic dermatits is a hereditary disorder characterised Or: Urinalysis - Papular urticaria by dry skin, the presence of eczema, and onset less than 2 - Triamcinolone acetonide 40 mg by deep intramuscular Treatment objectives - Atopic eczema years injection, into gluteal muscle Treat infection Differential diagnoses Clinical features Criteria for systemic steroid therapy Correct predisposing factors Ringworm Atopic dermatitis looks different at different ages and Failed maximal therapy; little improvement after Prevent complications Ecthyma in people of different races environmental changes Drug treatment Herpes simplex Essential features are: Chronic unbearable, unrelenting itch Topical antibiotics Complications Pruritic, exudative, or lichenified eruptions on face, Erythroderma without infections - Gentamicin 0.3% cream Regional lymphadenopathy neck, upper trunk, wrists and hands, and in the Social setting in which other modalities are impossible - Resistance may set in with prolonged use Cellulitis antecubital and popliteal folds Smallpox vaccination is absolutely contraindicated Systemic antibiotics Rarely: septicaemia Personal or family history (in about 70% of cases) of Guidelines for the use of potent topical steroids in infants Usually unnecessary except for head and neck lesions, or Rarely: acute glomerulonephritis, if nephritogenic strain - Allergic manifestations e.g. asthma, hay fever, allergic Do not use on the face, axillae, diaper area or flexures when the boil is accompanied by fever, chills, regional of streptococcoci is involved rhino-conjunctivitis, or eczema Do not use under occlusion lymphadenopathy, or a feeling of being unwell Investigations Chronic or chronically relapsing dermatitis Do not use for an area greater than about 25% of total - Co-trimoxazole Wound swab for bacteriology and sensitivity Dry skin body surface area Adult: 960 mg orally every 12 hours for5-10days Treatment objectives The age at which eczema ceases to be a problem varies Do not use for more than 2 weeks consecutively and do Child: 6 weeks - 5 months: 120 mg; 6 months - 5 years: Treat infection - Many children show a significant improvement by the not give refills 240 mg; 6 - 12 years: 480 mg taken orally every 12 hours Treat underlying pruritic dermatoses age of 5 years Do not dispense more than 50 g per week for5-10days Prevent complications - Most will have only occasional flare-ups by the time Always use sparingly - Erythromycin Non-drug treatment they are teenagers Adjunctive measures Adult and child over 8 years 250 - 500 mg orally every 6 Debrideor crusted lesions with soap and water - A few continue to have troublesome eczema in adult Exclusive breastfeeding; milk substitute if need be hours or -1g12hourly for 5-10 days desloughing antibacterial agents life, especially those children that suffer from hay fever Attention to cleanliness especially in the diaper region Child: up to 2 years: 125 mg orally every 6 hours;2-8 Dry weepy lesions with astringent such as potassium There is no “cure” for atopic eczema Avoid excessive bathing, vigorous rubbing, or chafing years: 250 mg every 6 hours for 5 - 10days permanganate, sodium chloride 0.9% solution, Differential diagnoses Avoid unduly heavy, tight, or soiled clothing Surgical treatment hydrogen perioxide Seborrhoeic dermatitis (especially in the infant) Treat local infections A small puncture wound often gives less of a scar than Drug treatment Irritant or allergic contact dermatitis Pat (rather than rub) skin dry after bath and immediately allowing spontaneous rupture; it also reduces the pain Erythromycin Nummular dermatitis lubricate skin with petroleum jelly or emulsifying Should be under antibiotic cover to prevent septicaemia Adult and child over 8 years: 250 - 500 mg orally every 6 Scabies ointment hoursor 500 mg - 1 g every 12 hours for5-10days Psoriasis (especially palmo-plantar) Showers should be warm to cool, not hot Child: up to 2 years: 125 mg orally every 6 hours;2-8 In infants certain immunodeficiency syndromes Tub soaking is good, if followed by adequate lubrication years: 250 mg every 6 hours Complications Avoid wool; its fibers are irritating IMPETIGO CONTAGIOSA Or: Bacterial infections of the skin Emotional stress leads to increased scratching Introduction Co-trimoxazole Eczema herpeticum In patients and parents of affected children, other A superficial, highly contagious, bullous skin disorder Adult: 960 mg orally every 12 hours for5-10days Complications of over treatment with steroids psychologic techniques may be useful caused by coagulase positive staphylococci and Child: 6 weeks - 5 months: 120 mg; 6 months - 5 years: Investigations Secondary skin infection with bacteria such as occasionallyb -haemolytic streptococci 240 mg; 6 - 12 years: 480 mg taken orally every 12 hours RAST or skin tests may suggest dust mite allergy Staphylococcus aureus may worsen the dermatitis and Clinical features for5-10days Eosinophilia and increased serum IgE levels may be itching Children are more commonly affected Supportive measures present but are nonspecific Patients must consciously be shielded from anyone Initial lesions are superficial vesicles, or bullae found Debride crusted lesions: Dislodging antibacterial agen Blinded food challenges: for diagnosing food allergy with varicella or herpes simplex around orifices: eyes, nose and ears Avoid auto-inoculation e.g. with fingers, shaving Treatment objectives Keep finger nails trimmed short brushes, handkerchiefs, or pillow cases

57 58 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008

Some kinds of soap may irritate and dehydrate the skin; - Hands: various chemicals handled at home, at work Moderate-to-gross generalized enlargement of lymph PARASITIC DERMATOSES use synthetic soap powders and at leisure hours nodes in the absence of an underlying malignant Reassure patients and/or anxious parents - Feet: shoes, socks, remedies for athletes' foot, etc lymphoma (dermatopathic lymphadenopathy) Use patient education handouts Differential diagnoses The nodes are rubbery in consistency CUTANEOUS LARVAMIGRANS (Creeping eruption) Allergy tests, restriction diets and environmental Atopic dermatitis The general picture is modified by the initial cause Introduction hypoallergenic changes will not cure eczema Seborrhoeic dermatitis Pruritus is often intense if due to atopic eczema or An infection of the skin by various nematode larvae Notable adverse drug reactions Psoriasis lymphoma which migrate, but never reach internal organs or Steroids Dermatophyte infection Differential diagnoses complete their life cycles - Increased susceptibility to and severity of infection Lichen planus All the causes of exfoliative dermatitis listed above Migration leads to twisting, winding linear skin lesions - Activation or exacerbation of tuberculosis, amoebiasis, Face: lupus erythematosus, pellagra, rosacea Complications produced by the burrowing of larvae strongyloidiasis Complications Hypothermia Victims are usually: - Risk of severe chickenpox in non-immune patients Impetiginization Hypoalbuminaemia People who go barefoot at the beaches - Nausea, dyspepsia, hiccups Secondary dissemination Dehydration Children playing in sandboxes and crawling on the bare - Hypersensitivity reactions Investigations High output cardiac failure ground - Atrophy of the skin; striae, telangiectasia, petechiae Patch test Septicaemia Carpenters and plumbers working under homes - Glaucoma, cataracts Occupational site assessment Enteropathy Gardeners - Cushingoid syndrome, adrenal/pituitary suppression, Treatment objectives Steatorrhoea The most common causes are cat and dog hookworm hyperglycaemia and diabetes mellitus Cure the dermatitis Anaemia - Ancylostoma braziliense - Suppression of growth in children Identify cause(s) and avoid further contact Investigations - Ancylostoma caninum - Menstrual irregularities Drug treatment Full Blood count and differentials; ESR - Necator americanus - Oedema As for atopic dermatitis Urea and Electrolytes - Gnathostoma spinigerum - Electrolyte imbalance Supportive measures Histopathology - Strongyloides stercoralis - Hypertension Counselling (after identifying the cause) Blood culture Clinical features - Pseudotumour cerebri Allergen replacement Treatment objectives Shortly after entering the skin: Restore the skin to normal The larvae elicit intense pruritus Treat underlying disease Tiny papules and even papulovesicles develop Prevent or treat complications As the larvae begin to migrate: CONTACT DERMATITIS EXFOLIATIVE DERMATITIS (Erythroderma) Drug treatment Intermittent stinging pain occurs Introduction Introduction Systemic steroids in high doses Thin red, tortuous and minimally elevated lines are An acute or chronic dermatitis that results from direct Refers to the involvement of all or most of the skin - Prednisolone 40 - 60 mg orally per day formed in the skin skin contact with chemicals or allergens surface by a scaly erythematous dermatitis Treat impetiginization and septicaemia as appropriate - Rate of migration varies with the species These agents could be Usually a secondary or reactive process to an (depending on results of culture and sensitivity) - Pruritus and excoriation promote secondary bacterial Chemicals underlying cutaneous or systemic disease Further treatment depends on the cause of exfoliative infections Animal or plant products Some causes: dermatitis Intestinal infections withStrongyloides stercoralis may Physical agents like heat, cold, ultraviolet rays or Contact dermatitis Adjuvant therapy be associated with perianal larva migrans syndrome ionizing radiation Atopic eczema Adequate hydration called' larva currens' because of the rapidity of larval Contact dermatitis is classified as : Seborrhoeic dermatitis Emolients for skin (seeAtopic eczema) migration (up to 10 cm/hr) Irritant dermatitis Drug eruptions Keep warm - Larva currens is an autoinfection caused by penetration - Acute irritant dermatitis Lichen planus and lichenoid eruptions Adequate nursing care of the perianal skin by Strongyloides stercoralis - Cumulative insult dermatitis Crusted scabies Appropriate nutrition and haematinics Differential diagnosis Allergic contact dermatitis Pediculosis corporis Prevention Ring worm Phototoxic dermatitis Dermatophytosis Avoid over-treatment of skin diseases and Complications Photo-allergic dermatitis Psoriasis polypharmacy, generally Secondary bacterial infection Clinical features Pemphigus foliaceus Do not abuse the skin with “medicated” soaps and FatalStrongyloides stercoralis hyperinfection in Acute phase Lymphomas and leukaemia herbal concoctions immunocompromised patients - Tiny vesicles, weepy and crusted lesions Ichthyosiform erythroderma Get appropriate management of skin disease(s) from Investigation Resolving or chronic contact dermatitis Pityriasis rubra pilaris qualified personnel None useful to management - Scaling, erythema, and possibly thickened (lichenified) Clinical features Treatment objectives skin May be acute or chronic Eradicate the larvae - Itching, burning, and stinging may be severe The irritating process is followed by a patchy erythema Eradicate gut Strongyloides Contact dermatitis is recognized by the distribution and which spreads rapidly within 24 hours Treat impetiginization configuration of the lesion which usually corresponds to Pyrexia, malaise and shivering Prevent re-infection the contactant e.g Scaling Drug treatment - Face: cosmetics Irritation and tightness Ivermectin - Photodermatitis: airborne allergens e.g. dust, fumes, Skin feels cold Adult: 150 microgram/kg orally as a single dose sprays The periorbital skin is inflamed and oedematous, Child over 5 years old: 200 micrograms/kg orally daily - Neck: nickel necklace, perfume, and collars of garments resulting in ectropion, with consequent epiphora

59 60 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008 for 2 days Oesteomyelitis MYIASIS Clinical features Or: Arthritis Introduction Interval from exposure to onset of symptoms can be as Albendazole Tetanus Invasion of mammalian tissue by fly larvae long as1-3years Adult: 400 mg orally twice daily for 2 days, repeated after Investigations Furuncular myiasis may be caused by Dermatobia Skin lesions 3 weeks if necessary Radiograph of the affected area hominisor the Tumbu fly Cordylobia anthropophaga - May be localized or cover large areas Child over 2 years: 400 mg once or twice daily for 3 days, - If osteomyelitis and arthritis (or calcified worms) are Larvae ofD. hominis are often transferred by Intense pruritus repeated after 3 weeks if necessary suspected mosquitoes - A cardinal symptom; may occur in the absence of the Antihistamines for pruritus Treatment objectives Usual host is cattle. People living near cattle-rearing skin lesions Antibiotics for secondary bacterial infections Resolve local inflammation to permit easier removal of areas are particularly vulnerable Dermatitis Prevention the worm Eggs, living larvae, or both are deposited on the skin or - Skin eventually becomes lichenified from chronic Avoid direct contact of skin with sand Extract the worm mucous membranes or on clothing scratching Prevent and treat complications - Eggs hatch and produce larvae that then burrow into - Post inflammatory confetti-like depigmentation on the Drug treatment the skin and cause mild or severe inflammatory changes skin (“leopard skins”) may occur in late onchodermatitis GUINEAWORM DISEASE (Dracunculiasis) Metronidazole Clinical features Onchocercomata Introduction Adult: 500 mg orally every 8 hours for 7 days Furuncular myiasis looks like a furuncle (boil) - Subcutaneous nodules which develop on various sites An infection by a very long nematode, Dracunculus Child: 7.5 mg/kg orally every 8 hours Key feature is the presence of a tiny hole in the of the body and contain myriad adult worms which can medinensis Or: inflammed erythematous papule live for up to 14 years. Contracted through drinking water contaminated with Mebendazole There may be a sensation of motion within the furuncle Firm, non-tender lymphadenopathy is a common water fleas (cyclops) infected with Dracunculus Adult: 400 - 800 mg orally daily for 6 days There may be intermittent stinging sensation finding in patients with chronically infected Except for remote villages in Rajastan desert of India Child over 1 year: usually 100 mg orally twice daily for 3 In accidental myiasis, there is a pre-existing lesion, onchocerciasis and Yemen the disease is now only seen in Africa, days usually a leg ulcer, wound or ulcerated basal cell - “Hanging groin” describes the pendulous loose, between the Sahara and Equator Or: carcinoma atrophic skin sac that contains these large nodes Nigeria is one of the few countries with reports of Ivermectin Differential diagnoses Microfilariae in the eye may lead to visual impairment >1,000 new cases a year Adult: 200 micrograms/kg orally as a single dose Furuncles and carbuncles and blindness Efforts are currently going on to eradicate the disease in Child: consult specialist companies Complications Differential diagnoses Nigeria Treat or prevent complications with antibiotics Secondary bacterial infection Scabies Pathophysiology Worm extraction Investigation Pediculosis In the stomach, the larvae penetrate into the mesentery, Traditionally: Nil Papular urticaria where they mature sexually in 10 weeks Extract the worm slowly by winding it about a match Treatment objectives Papulonecrotic tuberculids The female worm burrows to the cutaneous surface to stick or twig, removing 3-5cmdaily, with care not to Extract the maggot Pruritic papular eruption of HIV deposit her larvae, causing specific skin manifestations rupture it Treat or prevent bacterial infection Other causes of generalized pruritus without a rash When the parasite comes in contact with water, the - In the event of such an accident, the larvae escape into Non-drug treatment Other causes of subcutaneous nodules e.g worm rapidly discharges its larvae, which are ingested by the tissues and produce fulminating inflammation Apply petrolatum: the maggot crawls out to avoid - Sparganosis the cyclops - The process appears to be facilitated by placing the asphyxiation - Paragonimiasis Clinical features affected part in water several times a day Or: - Gnathostomiasis As the worm approaches the surface it may be felt as a Notable adverse drug reactions, caution and Extract the maggot by compressing simultaneously - Cysticercosis cordlike thickening contraindications from beneath on both sides with a pair of spatulae - Echinococcosis It forms an indurated cutaneous papule Metronidazole Drug treatment Complication Several hours before the head appears at the skin surface - Avoid high dose regimens in pregnancy Prevent bacterial infection with oral antibiotics if Blindness there is (at the point of emergence) - Avoid drinking alcohol during treatment and at least 48 lesions are multiple Investigations - Local erythema hours after Wound myiasis is flushed out surgically with Skin snips or punch biopsy for microfilariae - Burning sensation Ivermectin antiseptics: surgical debridement Excise nodule for adult worms - Pruritus - Oedema (face and limbs) Prevention Mazzotti test reaction - Tenderness - Fever, pruritus, lymphadenitis, malaise, hypotension Iron clothes that are dried in the open air Slit lamp eye examination Soon after, the papule blisters and a painful ulcer - Should not be used in the presence of concurrent L. loa Treatment objectives develops, usually on the leg infection: risk of encephalopatic reactions to dying L. loa Kill the microfilariae - Ulcer may occur on other parts of the body e.g the microfilariae ONCHOCERCIASIS (River blindness) Eliminate source of microfilarial release genitalia, buttocks, or arms - Should not be used in patients with central nervous Introduction Prevent blindness Differential diagnoses system diseases (e.g. meningitis): increased penetration A common chronic filarial disease in tropical regions Drug treatment Sickle cell ulcer of ivermectin into the CNS which frequently cause pruritus and blindness Ivermectin Stasis ulcer Caution in early pregnancy Causative organism is Onchocerca volvulus - As a single oral dose of 150 microgram/kg in adults Complications Prevention The microfilariae are transmitted by femaleSimulium , and children over 5 years Secondary infection Provide universal access to safe and portable water tiny blackflies which breed along small, rapidly moving - Repeat every 6 months for 2 years and yearly for 12 - Cellulitis In hyperendemic areas, treat the whole population twice streams 15 years or longer Erysipelas yearly with ivermectin Female worms release motile microfilariae into the Eye involvement Progressive lymphoedema skin, subcutaneous issues, lymphatics, and eyes - Prednisolone 1 mg/kg orally should be started several

61 62 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008 days before treatment with ivermectin and nodules, numerous excoriations, secondary - The cream is lathered through the hair, left on for 10 The phallus (especially in adults) Surgical infections and even lymphadenopathy minutes and thoroughly rinsed out. A fine-tooth comb General immune status and experience with S. scabiei Excise individual nodules (nodulectomy) The combination of excoriations, hyperpigmentation, should be used to remove adherent nits play a role Notable adverse drug reactions, caution and healed scars and secondary impetiginization is quite - Repeat treatment after a week In a normal host, the initial infection is asymptomatic contraindications typical and known as “vagabond's skin” P.corporis: for about 3 - 6 weeks during which time the individual is No food or alcohol should be taken for at least 2 hours Overcrowding and poor personal hygiene promote Treat dermatitis with antipruritics or corticosteroids capable of transmitting the disease before or after dosage infestation Treat secondary infection with oral antibiotics - All family or living unit members must therefore be Pregnant women should not receive ivermectin until Refugees, destitutes and vagrants are particularly Supportive measures treated, not just the itching ones after delivery vulnerable P.capitis: After a reinfestation, symptoms appear within 24 hours Breastfeeding mothers should not be treated until the Pediculosis pubis: All contact individuals should be examined and treated Crusted scabies (Norwegian scabies) infant is at least 1 week old Most often found in the pubic and axillary hairs as necessary An uncommon variant of scabies Prevention Occasionally may be found on abdominal or trunk hairs Pillow cases should be disinfested as for clothing. Patient fails to mount a resistance and the mites Use biodegradable insecticides to kill flies On rare occasions may be seen on the scalp, eyebrows P.corporis: proliferate dramatically Netting and repellents remain crucial. and even eyelashes Eradicate lice from clothing by laundering in hot water May be found among HIV/AIDS patients, Provide access to safe and portable water Pruritus is also a symptom or machine-drying at a high temperature, followed by institutionalized inmates like prisoners, refugees, and In hyperendemic areas, treat the whole population twice Classic clinical finding is the maculae cerulae ironing the seams psychiatric patients yearly with ivermectin - Indistinct blue-grey or slate-coloured macules ranging P.pubis: Differential diagnoses in size from several millimeters to several centimeters Treatment is the same as for pediculosis capitis, with Infantile acropustulosis - They result from the bite of the louse causing small the exception that pediculosis of the eyelashes should be Atopic dermatitis PEDICULOSIS (Lice) intracutaneous haemorrhages treated with an occlusive ophthalmic ointment applied to Papular acral dermatitis of childhood Introduction - The colour is due to blood whose haemoglobin has the eyelid margins for 10 days Dermatitis herpetiformis Diseases due to blood sucking lice been altered by the saliva - Affected persons' sexual contact(s) should be treated Complications Can be divided into three conditions: Differential diagnoses simultaneously Secondary bacterial infection leading to acute Pediculosis capitis (head lice): P.capitis: Notable adverse drug reactions, caution glomerulonephritis - Caused by Pediculus humanus var.capitis - Seborrhoeic dermatitis As stated under scabies Investigations Pediculosis corporis (body lice): - Pityriasis amiantacea Prevention Burrow scraping on to a glass slide for microscopy - Caused by P.humanus var.corporis - Peripilar keratin Improve personal hygiene Video dermatoscopy Phthiriasis pubis (pubic lice): - Hair casts Do not share hair combs, brushes, clothing, pants and Treatment objectives - Caused by Phthirus pubis - Piedra pillows Treat the infestation The arthropods are transmitted from human to human P.corporis : Treat secondary bacterial infection via: - Scabies Relieve pruritus Direct contact - Atopic dermatitis SCABIES Drug treatment Sharing of combs, brushes, towels (P.capitis ) - All pruritic dermatoses Introduction Scabicides: Sharing clothing (P.corporis ) P.pubis: An intensely pruritic infestation caused by human mite Permethrin 5% cream Shearing underwear - Scabies Sarcoptes scabiei Adult: apply over the whole body and wash off after 8-12 Sexual intercourse or any intimate personal contact (P. - Candidiasis Contracted by close contact and rarely via fomites hours pubis) - In the axillae trichomycosis axillaris Occurs commonly in children and inmates of Child: supervision required with application and rinsing Clinical features Complications overcrowded institutions such as prisons and boarding Or: Pediculosis capitis: Secondary bacterial infections houses Benzyl benzoate 25% in emulsion Generally the only complaint is pruritus: The body louse serves as a vector for diseases: Infection of households is common Adult: apply over the whole body; repeat without bathing Nits can easily be seen at the base of the hairs; careful Epidemic typhus (Rickettsia prowazekii ) Sexual intercourse is also another possible method of next day and wash off 24 hours later inspection may reveal the adult louse Trench fever (Bartonella quintana ) spread among adults - If necessary apply a third time Secondary impetiginization is common because of the Relapsing fever (Borrelia recurrentis ) Sharing a bed or using the same underwear will also Child: Benzyl benzoate is an irritant and should be itching Investigations suffice to contact the disease avoided in children - Cervical nodes may become enlarged P.capitis and pubis: Clinical features Or: Children and individuals with long hair are more likely - Examine louse or the nits on epilated hair strands Severe pruritus worse at night is characteristic Precipitated sulfur 5 - 10% in petroleum jelly to be affected (especially from behind the ears) under the microscope The typical lesion is the burrow Adult and child: apply over all the body daily for7-10 Homeless people and refugees are also vulnerable P.corporis : - It is hardly seen because of the marked excoriation and days No age or economic stratum is immune - Examine the seams of clothing for nits and lice secondary infection on the skin Antihelminthic: - School children who share school caps, hair brushes Treatment objectives Papulo-pustular eruptions with excoriation and Ivermectin and combs, pillow cases are particularly vulnerable Eradicate the lice impetiginized. Characteristic sites of predilection: Adult: Single 200 microgram/kg oral dose for crusted Pediculosis corporis : Prevent re-infection Interdigital spaces of the fingers scabies Pruritus may be the only symptom in some patients Treat complications Flexural surfaces of the wrist Child: over 5 years: 200 micrograms/kg daily for 2 days Chronic scratching may result in characteristic Drug treatment Extensor surfaces of the elbows and knees Antihistamine: hemorrhagic puncta and linear excoriations P.capitis: Anterior axilliary area Chlorphenamine Patient eventually develops intensely pruritic papules 1% permethrin cream rinse Nipples Adult: 4 mg orally every 4 - 6 hours; maximum 24 mg a

63 64 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008 day accompany, or follow the onset of skin lesions Systemic corticosteroids purpuric, follicular, lichenoid, and psoriasiform Child: 1 month - 2 years 1mg orally every 12 hours; 2 - 5 The hair follicles in the scalp may also be affected Prednisolone Avariant, inverse pityriasis rosea also occurs years: 1 mg every 4 - 6 hours; 6 - 12 years: 2 mg every 4 - (lichen planopilaris) with post-inflammatory scarring Adult: 20 - 40 mg orally daily for several weeks with - Believed to be commoner in blacks 6 hours alopecia reduction of dosage or switch to alternate-day therapy as - Affects the face, neck, distal extremities and the Topical antipruritic: Hepatitis C infection is found with greater frequency in soon as improvement is seen flexures Crotamiton cream (for residual itching) lichen planus than in controls Child: not recommended for children for this indication Use of ampicillin early in the course of the eruption Adult: apply every 8 - 12 hours Healing of the skin lesions leave post-inflammatory Or: causes an explosive exacerbation of eruptions which Child: less than 3 years: apply once daily only hyperpigmentation Triamcinolone acetonide 40 mg intramuscularly once become more inflammatory and urticarial Differential diagnoses or twice (at a 6-week interval) - Lesions may become impetiginized Consider other papulosquamous disorders: Or: The disease persists for about 6 weeks but may last for 3 PAPULOSQUAMOUS DISORDERS Psoriasis Ciclosporin - 4 months LICHEN PLANUS Pityriasis rosea Adult and child over 16 years: 2.5 mg/kg daily in two Healing may occur with postinflammatory Introduction Lupus erythematosus divided doses hyper/hypopigmentation Achronic, pruritic, papular skin disease Secondary syphilis - If good results not achieved within two weeks increase Recurrences are uncommon (about 1%) but the lesions The three cardinal features are: Lichen striatus rapidly to maximum 5 mg/kg daily are usually mild and localized Skin lesions Parap soriasis Notable adverse drug reactions Differential diagnoses Mucosal lesions Pityriasis rubra pilaris See Psoriasis Secondary syphilis Histopathologic features of band-like infiltration of Nummular eczema Prevention Exanthematic or pityriasis rosea-like drug eruptions lymphocytes and melanophages in the upper dermis Oral lesions:- Avoid precipitating drugs Lichen planus Some of the drugs known to cause lichen planus (LP): - Erosive lesions may mimic Guttate psoriasis Chloroquine Aphthous stomatitis and herpes simplex Tinea corporis Quinacrine - White plaques may be confused with PITYRIASIS ROSEA Tinea versicolor Quinidine Pre-malignant leukoplakia Introduction Seborrhoeic dermatitis Gold White sponge naevus Acommon, mild, inflammatory exanthem Viral exanthems Streptomycin Complications Tends to be seasonal Pityriasis lichenoides chronica Tetracycline 20-nail dystrophy - More common during the fall, winter and spring in Complications NSAIDs Rarely, squamous cell carcinoma of oral and temperate countries None Phenothiazines hypertrophic lichen planus - In Nigeria more common during the early part of the Investigations Hydrochlorothiazide Investigations rainy season (though cases are seen throughout the year) Non-specific Clinical features Histopathology Common among siblings or other family/household VDRL LP has been found in children, young and middle-aged Hepatitis C antigen members - If secondary syphilis is suspected (e.g. lesions on adults Treatment objectives The seasonal clustering and household concurrence are palms and soles with/without lymphadenopathy) The skin lesions are flat-topped polygonal papules with Relieve itching suggestive of an infective origin Treatment objectives a characteristic colour Clear lesions - Increasingly regarded as a delayed reaction to a viral To relieve symptoms (if any) - Violaceous in fair skinned people but slate-grey on Suppress inflammation infection (most likely Human Herpes Virus 7) Reassure patients about the harmless, self-limiting black skin Drug treatment Clinical features nature of the eruption Itching is mild-to-severe Topical corticosteroids: Largely a disease of adolescents and in young adults, Drug treatment Like psoriasis, lesions often occur on sites of trauma Beclomethasone dipropionate 0.1% cream but it has been described all age groups Topical: and scratch marks (Koebner's or isomorphic - Apply1-2times daily Rarely, there is an observable prodrome of pharyngitis, Urea cream phenomenon) - Not licensed for use in children under one year malaise and mild headache - Useful as a hydrating agent: apply twice daily Wickham's striae are fine white streaks present on the Bethamethasone valarate 0.1% cream and ointment The initial lesion in 20 - 80% of cases (“herald patch”) Systemic: tops of papules - Apply1-2times daily is often larger than the later lesions and precedes the Oral antihistamine The lesions are distributed mainly on: For isolated or hyperkeratotic lesions apply general eruption by1-30days - If pruritus is bothersome (see Urticaria) - Flexor surfaces of the wrist corticosteroids under occlusion or use intralesional - Often found on the trunk, but may appear on the face or Systemic corticosteroids: - Lumbar area triamcinolone (see Psoriasis) extremities - If complicated by ampicillin exanthematic eruption - The penis, tongue, buccal and vaginal mucous Scalp lesions: - Oval with a collarette of scales Triamcinolone acetonide 40 mg intramuscularly as a membranes Topical corticosteroids - May be diagnosed as “ringworm” before the other single dose On the buccal mucous membrane it may present as Clobetasol propionate 0.05% lotion lesions appear Antibiotics: white reticulate pattern or plaque which may after - Apply thinly 1 - 2 times daily for up to 4 weeks Other lesions consist of multiple erythematous macules If lesions are impetiginized several years transgress into squamous cell carcinoma Mouth lesions: progressing to small, red papules on the trunk Erythromycin 500 mg orally every 6 hours for 14 days The nails are also affected with: Triamcinolone acetonide 0.1% in adhesive base Sun-exposed areas are spared Notable adverse drug reactions, caution - Pitting, roughening and splitting (trachyonychia) - Apply a thin layer 2 - 4 times daily for a maximum of 5 Papules enlarge and become oval with long axes parallel Antihistamine; Triamcinolone: see Urticaria - Thickening (pachyonychia) days; do not rub in to each other, and following lines of cleavage: the so- Prevention - Encroachment of the nail fold on the nail plate Or: called “Christmas tree” pattern Unknown (pterygium ungium) Tretinoin 0.025% cream Pruritus is mild or absent PSORIASIS Total destruction of all 20 nails may precede, Adult and child: apply thinly 1 - 2 times daily Some lesions may be atypical: vesicular, crusted, Introduction

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A chronic inflammatory skin disease which is Intertriginous regions such as the gluteal cleft, groin, psoriasis) Fluocinolone acetonide 0.01% in oil characterized by penis, labia, axillae, beneath the breasts and between the - Initiate under medical supervision - Apply and leave under a shower cap at night and - Increased epidermal proliferation toes are involved (inverse psoriasis or psoriasis inversa) - Start with 0.1%; carefully apply to lesions only, leave shampoo in the morning - Epidermal thickening There could also be other organ involvement e.g. in contact for 30 minutes, then wash off thoroughly - After shampooing and while the hair is still wet, - Erythematous lesions with silvery white scales psoriatic arthritis - Repeat application daily, gradually increasing strength massage thoroughly into the scalp skin Affects people of all ages in all countries The disease runs a chronic and highly variable course to 2% and contact time to 60 minutes at weekly intervals - Attempting to remove scales by excessive brushing, Cause remains largely unknown but it has been (waxes and wanes) - Wash hands thoroughly after use scrubbing, or combing may result in sufficient trauma to variously attributed to genetic, climatic, nutritional, - New lesions may replace older, regressing ones - Avoid contact with eyes and healthy skin worsen psoriasis (Koebner's effect) ecological and immunological factors - Unstable lesions may evolve into psoriatic Coal tar solution (for chronic psoriasis) Ultraviolet light (UVL) Triggers include: erythroderma or generalized pustular psoriasis - Use either alone or in combination with exposure to - For psoriasis involving more than 30% of the body Streptococcal or viral infections HIV/AIDS can lead to the onset or worsening of ultraviolet light surface Emotional crises psoriasis - Apply1-4times daily, preferably starting with a lower 290 - 320 nm ultraviolet B (UVB) three times weekly Pregnancy and delivery Differential diagnoses strength preparation for 18 - 24 treatments Trauma (Köebner phenomenon) Guttate psoriasis: Coal tar bath - Lubricating the skin surface with mineral oil or Diet Pityriasis lichenoides et varioliformis acuta - Use 100 mL in bath of tepid water and soak for 10 - 20 petroleum jelly before UVL produces uniform Alcohol Pityriasis rosea minutes penetration by reducing the reflection of light from the Cigarette smoking Secondary syphilis (psoriasiform syphilis) - Use once daily, to once every 3 days for at least 10 - 20 disrupted skin surface Hypocalcemia Scalp, face, chest lesions: minutes, and for at least 10 baths PUVA(psoralen plus ultravioletA) Stress Seborrhoeic dermatitis - Often alternated with ultraviolet (UVB) rays, allowing - For patients who have not responded to standard UVB Infections e.g. streptococcal pharyngitis Lupus erythematosus at least 24 hours between exposure and treatment with treatment May occasionally be provoked or exacerbated by drugs: Chronic truncal psoriasis: coal tar Severe psoriasis unresponsive to outpatient UVL, may ACE inhibitors Nummular dermatitis - Urea 10% cream or ointment (for dry scaling and be treated in a day care centre with the Goeckerman Calcium channel blockers Lichen planus itching skin) - Use of crude coal tar for many hours and exposure to β- adrenoceptor antagonists Small plaque parapsoriasis - Apply twice daily, preferably to damp skin UVB light Chloroquine Tinea corporis Vitamin D analogue calcipotriol Systemic therapy: Lithium Pityriasis rubra pilaris - Suitable for childhood psoriasis Antibiotics to eliminate streptococcal pharyngitis Non-SteroidalAnti-inflammatory Drugs (NSAIDs) Intertriginous areas: Combination therapy with calcipotriol and high-potency Aciteritin Terbinafine Candidiasis (Class I) steroids may provide: Adult: Initially 25 - 30 mg orally daily for2-4weeks; Lipid lowering drugs Intertrigo - Greater response rates, fewer side effects, and steroid adjusted according to response. Usual range 25 - 50 mg Clinical features Hailey-Hailey disease sparing, allowing a shift to a less potent topical steroid or daily (maximum 75 mg) Lesions are characterized by: Nail: less frequent use of a Class I steroid - For pustular, erythrodermic and plaque types, and Sharp borders Tinea unguium Salicylic acid 3 - 5% in cold cream or hydrophilic psoriatic arthritis Erythema Lichen planus ointment (for thick scaling) Child: severe extensive psoriasis resistant to other forms Increased scales Trachyonychia Tazarotene 0.05% and 0.1% gels of therapy, palmo-plantar pustular psoriasis When scratched, scales fall off as tiny flakes that Complications - May be combined with topical steroids for mild- to- 1 month - 12 years: 500 micrograms/kg orally once daily resemble scrapings from a candle (Candle sign) Erythroderma moderate plaque psoriasis with food or milk; occasionally up to 1 mg/kg/day If the scales are removed (exposing the dermal papillae) Arthritis mutilans Tacrolimus ointment 0.1% or 0.03% To be administered under expert supervision in both punctate bleeding from the enlarged capillaries occur Investigations - For psoriasis in the flexures, face and penis, when adults and children (Auspitz sign) Histopathology potent steroids cannot be used and other agents are poorly Methotrexate Eruptive lesions may be intensely or mildly pruritic, or Treatment objectives tolerated Adult: 20 mg orally once weekly may be asymptomatic To retard epidermal proliferation Small lesions and nail psoriasis Child: not licensed for this indication All lesions begin as small scaly macules but may take Reduce inflammation Intra-lesional corticosteroid injections of triamcinolone Indicated for: divergent paths as they spread centrifugally Prevent complications are frequently used - Psoriatic erythroderma Patterns seen may be: Drug treatment - Triamcinolone acetonide suspension 10 mg/mL may - Moderate-to-severe psoriatic arthritis - Guttate Choice of treatment depends on the site, severity and be diluted with sterile saline to make a concentration of - Acute pustular psoriasis (von Zumbusch type) - Follicular duration of the disease, previous treatment, and the age 2.5 - 5 mg/mL - Involvement of more than 20% total body surface - Numular of the patient - For nail lesions inject triamcinolone in the region of - Localized pustular psoriasis that causes functional - Geographic Topical treatment: the matrix and the lateral nail fold impairment (e.g. hands) - Erythrodermic Corticosteroid ointment Scalp - Lack of response to phototherapy, PUVA,or retinoids - Annular - Hydrocortisone for the face and flexures Soften scales with salicylic acid 3% in mineral/olive Cyclosporine - Gyrate or serpenginous - Betamethasone or clobetasol for the scalp, hands and oil, massage in and leave on overnight - Induction therapy is 2.5 - 3.0 mg/kg given in a divided Favoured sites are feet - Then shampoo with a tar shampoo, and remove scales dose twice daily - Knees and elbows - Application is followed by an occlusive dressing of a mechanically with a comb and brush - Can be increased to 5.0 mg/kg/day until a clinical - Scalp polyethylene film, which may remain in place for 12 - 24 - Repeat daily until the scales are gone response is noted. The dose is then tapered - Palms and soles hours to augment effectiveness - If 3% is not very effective, use 6% salicylic acid - On discontinuation a severe flare-up may occur, - Nails Dithranol ointment 0.1% - 2% (for moderately severe Or: suggesting that an alternative treatment (e.g.

67 68 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008 phototherapy or acitretin) should be instituted as the Should be administered only by experienced Common in tropical climate (which is hot and humid) illness, or chronic use of topical steroid creams lesions cyclosporine dose is reduced dermatologists Infection could be spread by fomites may be very extensive and atypical in appearance (Tinea TNF inhibitors (Efaluzimab) Methotrexate: The mycoses caused by dermatophytes are called incognito) - Indicated for moderate-to-severe chronic plaque May cause blood disorders (bone marrow dermatophytosis, tinea, or ringworm Tinea cruris: psoriasis unresponsive to, or intolerant of other systemic suppression), liver damage, pulmonary toxicity, GIT On certain parts of the body they have distinctive features Occurs more commonly in adult men therapy or photochemotherapy disturbances characteristic of that particular site; therefore the tineas Leads to severe itching in the groins (crotch) - Initially 700 micrograms/kg by subcutaneous - If stomatitis and diarrhoea occur, stop treatment are divided into: Presents as slowly spreading erythematous patches with injection then 1 mg/kg weekly - Renal failure, skin reactions, alopecia, osteoporosis, Tinea capitis (scalp) scaly borders on the upper inner aspects of the thighs - Discontinue if inadequate response after 12 weeks arthalgia, myalgia, ocular irritation, may also occur Tinea barbae (beard) Treatment objectives - Not recommended for children and adolescents - May precipitate diabetes Tinea faciei (face) To clear lesions and prevent recurrence Adjuvant therapy - Monitor before and throughout treatment: blood Tinea corporis (trunk) Drug treatment Diet: fish oils rich inΩ- 3 polyunsaturated fatty acids counts and hepatic and renal function tests Tinea cruris (groin) Topical Patient education - Contraception during and for at least 6 months after Tinea manuum (hand) Ketoconazole Emotional support treatment for both males and females Tinea pedis (feet) - 2% cream apply twice daily Notable adverse drug reactions, caution and - Contraindicated in pregnancy and breast feeding. Tinea unguium or onychomycosis (nail) Miconzole contraindications Folic acid may be given to reduce toxicity Clinical features - 2% cream apply twice daily Coal tar: Cyclosporin: Varied:depending on the site of the body involved Systemic Contraindicated in inflammed, broken or infected skin Nephrotoxic: monitor kidney function Pruritis is a notable symptom Fluconazole - May cause irritation, photosensitivity reactions Other side effects- hypertrichosis, hyperuricaemia, Tinea capitis: Adult: 50 mg orally daily for 2 - 4 weeks; up to 6 weeks in Hypersensitivity thrombocytopenia, malignancies and Scalp involvement is seen predominantly in children tinea pedis Skin, hair, fabrics and bathtubs discoloured brown and lymphoproliferative disorders Lesions are varied in appearance: usually scaly, dry and Child: 1 month - 18 years 3 mg/kg (maximum 50 mg) smelly (similar to other immunosuppressive therapies) annular, with or without alopecia daily for2-4weeks; up to 6 weeks in tinia pedis Dithranol: Aciteritin: Some appear diffuse and scaly and may involve the Notable adverse drug reactions Irritant: avoid contact with eyes and healthy skin SeeAcne- isotretinoin whole of the scalp Fluconazole: numerous drug interactions Contraindicated in hypersensitivity; avoid use on face, Tacrolimus: Inflamed, pustular lesions (kerion) may develop when Hepatotoxicity during long-term daily therapy acute eruptions, and excessively inflamed areas SeeAtopic eczema infection is from animal to man Prevention - Discontinue use if excessive erythema occurs or Efalizumab: Pruritus usually leads to excoriation of lesions and Do not share combs, hair brushes, school caps, shoes, lesions spread Thrombocytopenia, hepatic and renal impairment. secondary bacterial infection socks or underwears Conjunctivitis following contact with eyes Monitor platelet count during initial herapy, then every 3 Hypersensitivity to the presence of the fungal elements Keep the feet dry; avoid tight-fitting covered shoes Staining of skin, hair, and fabrics brown months may occur at distant sites (“Id” reaction) Aerate the feet as often as possible

Vitamin D3 (calcipotriol): Contraindicated in immunodeficiency, severe infection, Tinea barbae: Use good antiseptic powder on the feet after bathing e.g. May irritate the skin (stinging) active tuberculosis; history of malignancy; pregnancy Ringworm of the beard is not a common disease Tolnaftate 1% powder Veryexpensive and breastfeeding Occurs chiefly among those in agricultural pursuits, Reduce perspiration and enhance evaporation from the Urea: May cause influenza-like symptoms, leucocytosis, especially those in contact with farm animals crural areas by wearing loose pants (e.g. boxer pants) Avoid application to face or broken skin; avoid contact arthralgia, paradoxical exacerbation of psoriasis or Lesions present as severe, deep folliculitis with made of absorbent cotton fabric with eyes development of variant forms including psoriatic erythema, nodular infiltrates, scales and pustules Apply plain talcum powder or antifungal powders in the May cause transient stinging and local irritation arthritis (discontinue treatment) Marked regional lymphadenopathy is the rule flexures e.g. armpits, under the breasts, in the groins Steroids: Expensive Tinea faciei: Avoid exposure to animals with ringworm (M. canis ) When extensive areas are treated or when there is Prevention Fungal infection of the face (apart from the beard) especially cats, dogs and (less commonly), horses and erythrodermic psoriasis, sufficient may be absorbed to Avoid exacerbating factors e.g. abrasions, scatches, - Frequently misdiagnosed, since the typical ringworm cattle cause adrenal suppression harsh fibre bathing sponges, and the drugs listed above not commonly seen on the face Excessive perspiration is the most common predisposing May induce tachyphylaxis Prevent streptococcal sore throat and treat promptly Erythematous, slightly scaling, indistinct borders are factor in adult T. corporis Rebound often occurs after stopping treatment, when it occurs usually seen - Avoid excessively hot, humid environments, or take a resulting in a more unstable form of psoriasis People who use corticosteroids such as cosmetic cold shower after sweating Intralesional injection may cause reversible atrophy at bleaching creams are prone to T. faciei the injection site SUPERFICIALFUNGALINFECTIONS The steroid effect makes the lesions atypical hence, Salicylic acid: T.incognito Widespread application may lead to salicylate toxicity DERMATOPHYTE INFECTIONS (Tinea) Tinea corporis: Ultraviolet light: Introduction One or more circular, sharply circumscribed, slightly PITYRIASIS VERSICOLOR() Tinea versicolor Burning of skin may cause Koebner's phenomenon Superficial fungal infection that affects keratinized erythematous, dry, scaly patches Introduction and an exacerbation tissues Lesions may be slightly elevated, particularly at the Superficial yeast infection of the skin caused by Increased risk of skin cancer particularly in persons Fungi that usually cause only superficial infections on borders, where they are more inflammed and scaly than at Malassezia furfur species (normal commensals on the with fair complexions and albinos. Examine the skin are called dermatophyte- classified in three the central parts skin) periodically genera: Progressive central clearing produces annular outlines Common in warm humid climates Use protective glasses to prevent cataracts Microsporum, Trichophyton and Epidermophyton that give them the name “ringworm” Predisposing factors: Causes premature ageing of the skin Can be acquired from humans, animals, soil or In the presence of immune suppression from underlying Occlusion of the skin with pomades and greases vegetable matter

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Immune suppression Introduction Adult: apply 3 - 4 times daily VARICELLA (Chickenpox) Hyperhidrosis A second infection with varicella-zoster virus (VZV), Child: may not be suitable for children because of its Introduction Heat usually in adults and limited to a dermatome irritant properties VaricellaZoster virus is Human Herpes Virus 3 Clinical features Synonyms: Topical local anaesthetics Transmission is by direct contact with the lesions and Usually asymptomatic (or just mild itching) Zoster, from the Greek “zostrix”, meaning belt - Helpful in some patients by the respiratory route May be generalized in the immuno-compromised Shingles, from the Latin “cingulus”, also meaning belt Notable adverse drug reactions, caution Initial replication occurs in the nasopharynx and Fine scaly, guttate or nummular patches, particularly on Clinical features Aciclovir conjunctivae young adults who perspire freely Vesicles arranged in one or more dermatomes - Ensure adequate hydration After the primary infection, the virus remains dormant Individual patches are dirty, yellowish/brownish/ unilaterally - Caution in pregnancy and breastfeeding in nervous tissue hypopigmented macules (hence the term versicolor) Initial pruritus, pain and paraesthesia - May cause nausea, vomiting, dizziness - Reactivation later in life is typically manifested as Larger irregular patches may evolve Multidermatomal and disseminated forms may occur - Fatigue pruritus and photosensitivity Herpes zoster Sometimes follicular tendency is marked; more in immuno-compromised states especially HIV infection Clinical features noticeable at the advancing edges of the irregular patches The early rash is vesicular, later becomes pustular and Incubation period is 10 - 21 days Sites of predilection: then ulcerates Vesicular eruptions consist of delicate “teardrop” - Sternal region The whole episode may last 2 weeks MOLLUSCUM CONTAGIOSUM vesicles on an erythematous base - Sides of the chest Differential diagnosis Introduction The eruption starts with faint macules that develop - Shoulders Chicken pox A common infection caused by a large epidermotropic rapidly into vesicles within 24 hours - Upper back Complications pox virus Successive fresh crops of vesicles appear for a few days, - Face Pain may persist long after rash has healed (post- Common in children mainly on the trunk, face, and oral mucosa Differential diagnoses herpetic neuralgia) Spread by direct human to human contact New lesions usually stop appearing by the fifth day; the Seborrhoeic dermatitis Dissemination of infection in the immunocompromised In adults it is often transmitted during sexual intercourse majority is crusted by the sixth day Pityriasis alba Hemorrhagic and necrotic lesions Clinical features - Most disappear in less than 20 days without a scar, Pityriasis rosea Ramsay-Hunt syndrome (Herpes zoster of the ear Individual lesions are smooth-surfaced, firm, dome- except larger and secondarily infected lesions Leprosy resulting in severe ear pain, hearing loss and vertigo) shaped, pearly papules; average diameter 3-5mm Low grade fever Complications Visual impairment due to corneal ulcers (Zoster Some “giant” lesions may be up to 1.5 cm in diameter Malaise None usually; only of cosmetic significance ophthalmicus-V1) Characteristic central umbilication Headaches M. furfur sepsis Investigations Spontaneous resolution is expected The severity of the disease is age-dependent - From contamination of the lipid-containing medium in HIV screening for all patients Host response plays an important role - Adults have more severe disease and a greater risk of immunocompromised patients receiving Full Blood Count with differentials Children with widespread molluscum contagiosum visceral disease hyperalimentation through tubes ESR usually have atopic dermatitis Differential diagnoses Investigations Exclude Hodgkin's disease and leukaemia Consider HIV in adults Variolaminor Skin scraping for KOH microscopy Treatment objectives Differential diagnoses Disseminated zoster in immunosuppressed patients Treatment objectives Provide symptomatic relief Viral warts Widespread papular urticaria Improve appearance of skin Treat secondary infection Giant molluscum contagiosum may mimic basal cell Coxsackie and ECHO viruses eruption Drug treatment Treat any identified predisposing factor epithelioma Complications Topical: Drug treatment Complications Secondary bacterial infection Selenuim sulphide shampoo Drying agents e.g. zinc oxide 5% (calamine) lotion Secondary bacterial infection Pneumonia - Apply on affected areas daily, leave on for 10 - 30 - Apply twice daily Investigations Cerebellar ataxia and encephalitis minutes minutes and wash off Aciclovir Histopathology of the expressed pasty core Reye's syndrome - Continue for 3 weeks Adult: 800 mg orally five times daily for5-7days Treatment objectives Investigations Ketoconazole shampoo - Continue for at least 3 days after complete healing Eradicate the skin lesions Tzanck smear - Use as above Child: 12 - 18 years: 5 mg/kg orally every 8 hours usually Non-drug treatment Direct fluorescent antibody (DFA) staining Miconazole cream for 5 days Light electrosurgery with a fine needle Polymerase Cham. Reaction (PCR) - For limited areas Or: Cryotherapy with trichloroacetic acid 35% - 100% Treatment objectives - Apply twice daily for 3 weeks Aciclovir cream 5% Curettage and paint with iodine Relieve itching and treat secondary bacterial infection Supportive measures Adult: apply five times daily for5-10days Reduce severity and scarring Deal with underlying predisposing factor(s) Child: not listed for this indication in children Drug treatment Drug treatment Prevention Oral antibiotics to treat or prevent secondary bacterial Cimetidine Aciclovir Avoid hot, humid environments or clothings that infection Adult: 40 mg/kg/day orally for 2 months Adult: 10 mg/kg intravenously three times daily for 7 promote perspiration Herpetic neuralgia Child: not licensed for use in children less than 1 year. 1 days in immunocompromised patients Take a cold shower after perspiration Amitriptyline month - 12 years: 5 - 10 mg/kg (maximum 400 mg) 4 Child: see Herpes zoster Use any of the above shampoo washes once a month if 10 - 25 mg orally initially, gradually increased to 75 mg times daily 12 - 18 years: 400 mg orally 4 times daily Antihistamine for pruritus predisposed daily Antibiotics Co-trimoxazole or erythromycin for secondary VIRALINFECTIONS Or: - To prevent or treat secondary infection infection Capsaicin 0.075% cream Prevention Notable adverse drug reactions, caution HERPES ZOSTER - For use after lesions have healed Avoid direct skin contact with an infected person Aciclovir

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- Ensure adequate hydration Plane warts Drug treatment Almost every individual has some degree of acne during - Caution in pregnancy and breastfeeding More common in children and young adult. Salicylic acid with lactic acid plaster puberty, with spontaneous resolution occurring in early - May cause nausea, vomiting, dizziness, fatigue pruritus Usually appear in groups as smooth, yellow-brown, - Apply carefully to wart; rub wart surface gently with adult life and photosensitivity small, flat papules; most frequently on the face file or pumice stone once weekly Occasionally, the disease persists into the fourth decade, Prevention Genital warts - May need to treat for as long as 3 months or even remains a life-long problem Isolate patients from non-immune persons Occur most often on warm, moist surfaces of the body Podophyllum resin Favoured sites are the face, upper back and upper chest In men, usual sites are the end and shaft of the penis, and - Apply weekly under supervision e.g. in genitourinary and shoulders below the foreskin (if uncircumcised) clinic There may be mild soreness, pain, or itching VIRALWARTS (Verrucae) In women, lesions occur on the vulva, vaginal wall, Imiquimod 5% cream May present differently in different age groups Introduction cervix, and skin surrounding the vaginal area - Apply thinly once daily on 3 alternate days per week - Pre-teens often present with comedones as their first Infections caused by human papilloma viruses (HPV); May develop in the perianal region or rectum until lesions resolve (maximum 16 weeks) lesions include more than 80 types - Especially in homosexual men, and in women who Notable adverse drug reactions, caution and - Teenage acne is invariably inflammatory and the lesions Transferred between humans, or from animals to engage in anal sex contraindications include firm red papules, pustules, abscesses, indurated humans Usually appear 1 - 6 months after infection as soft Salicylic acid plaster nodules, cysts and rarely interconnecting draining sinus Cause cutaneous tumours which tend to regress erythematous papules, which may be greyish if - Avoid broken skin tracts spontaneously but may rarely progress into cutaneous hyperkeratotic - Not suitable for anogenital region or large areas Inflammatory acne can be classified as mild, moderate, malignancies New lesions develop rapidly and all coalesce, producing Podophyllum or severe Clinical features a cauliflower-like picture - Avoid normal skin and open wounds Mild acne: Infection may be clinical, subclinical, or latent May grow rapidly in pregnant women, and - Keep away from face - Few-to-several inflammatory papules and pustules, but Clinical lesions are visible by gross inspection immunocompromised patients - Should not stay on treated skin for more than 6 hours no nodules Subclinical lesions may be seen only by aided Differential diagnoses before washing Moderate acne: examination (e.g. the use of acetic acid soaking) Common warts Prevention - Several-to-many papules, pustules, and a few to several Latent infection: Keratoacanthoma Women with genital HPV infection should have routine nodules - HPV virus or viral genome is present in apparently Squamous cell carcinoma cervical cytologic screening Severe acne (acne conglobata): normal skin Seborrhoeic keratosis - Pappanicolaou (PAP)smear to detect cervical dysplasia - Numerous fistulated comedones; extensive - Thought to be common, especially in genital warts, Hypertrophic lichen planus inflammatory papules; pustules; many cysts, abscesses, and explains in part the failure of destructive methods to Tuberculosis verrucosa cutis nodules, and draining sinuses eradicate warts Palmoplantar keratoderma MISCELLANEOUS DISORDERS - The lesions may be generalized, involving even the Incubation period is highly variable; from weeks to Arsenical keratoses buttocks years Plane warts ACNE VULGARIS (Pimples) - Excoriation of acne papules and microcomedones are Auto-inoculation is the rule Epidermodysplasia verruciformis Introduction common, and scarring may result Lesions may also occur on scratches (Koebner Syringomas One of the most common skin diseases - Usually, multiple shallow erosions or crusts are found phenomenon) Dermatosis papulosa nigra Adisorder of the pilosebaceous follicles Differential diagnoses Lesions are classified according to their positions and Lichen planus Typically first appears during puberty when androgenic Acne rosacea shape: Lichen nitidus stimulation triggers excessive production of sebum Dermatosis papulosa nigra Common warts Genital warts Many factors interact to produce acne in a given patient Steatocystoma multiplex Firm growths with rough surface; round or irregular, Condyloma lata - Genetics Syringoma greyish or brown Pemphigus vegetans - Sebum production Trichoepithelioma Generally appear on areas that are frequently injured, Complications - Hormones Warts such as the fingers, around the nails (periungual warts); Squamous cell carcinoma of the perianal skin - Bacteria Angiofibromas of tuberous sclerosis knees, face and scalp Cervical carcinoma from anogenital warts - Properties of the sebaceous follicle Molluscum contagiosum Plantar warts Obstructive laryngeal papillomatosis in babies infected - Immunologic Steroid acne from the use of systemic steroids or topical Develop on the soles of the feet, where they are usually through maternal birth canal Over-production of stratum corneum cells fluorinated steroids on the face (often as cosmetic skin flattened by the pressure of walking (hyperkeratosis) obstructs the hair follicles at the lightening creams) - Areactive callus forms around lesions Investigations follicular mouth producing open comedones, or Some drugs may produce acneiform eruptions Multiple warts may coalesce, resembling a tile or Histopathology if in doubt blackheads - Androgens mosaic floor (mosaic warts) Management Just beneath the follicular opening in the neck of the - Adrenocorticotropic hormone (ACTH) May be extremely tender Treatment depends on their location, type, and severity, sebaceous follicle it caues microcomedones (closed - Glucocorticoids Unlike corns and calluses, plantar warts tend to bleed as well as duration of lesions comedones, or whiteheads) - Hydantoins from many tiny spots, like pinpoints when pared down Treatment objectives There is an overgrowth of gram-positive bacteria in the - Isoniazid with a blade Eradicate the skin lesions obstructed follicle:Propionibacterium acnes or - Halogens Filiform warts Prevent complications Staphylococcus epidermidis; distally Pityrosporum Complications Long, thin, small growths that usually crop up on the Non-drug treatment ovale Psychosocial problems from cosmetic disfigurement eyelids, face, neck, or lips Liquid nitrogen freeze Rupture of the comedonal contents into the dermis Post-inflammatory pigmentary changes People who chronically use corticosteroids as cosmetic Electro-desiccation induces a foreign body reaction and inflammation Pitted scars bleaching creams are prone to multiple filiform warts Laser surgery Clinical features Keloids

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Acne fulminans (acute febrile ulcerative acne Doxycycline Comedone extraction therapy conglobata with polyarthritis and leukemoid reaction) Adult and child over 12 years: 100 mg orally every 12 Intralesional injection for deeper papules and - Check cholesterol and triglyceride levels every 2 - 4 Investigations hours occasional cysts weeks while on therapy Usually, none required Or: Dilute suspensions of triamcinolone acetonide - Dapsone at such high doses is likely to cause In the presence of unusual acne, hirsutism, premature Minocycline - 2.5 mg/mLor 0.05 mLper lesion methhaemoglobinemia pubarche, or androgenic alopecia (especially when Adult and child over 12 years: 50 - 100 mg orally every 12 Laser, dermabrasion for cosmetic improvement of scars - Where leprosy is still endemic (e.g. Nigeria), reserve associated with obesity and/or menstrual irregularities): hours Notable adverse drug reactions, caution and for treatment of leprosy Screen for hyperandrogenism Or: contraindications Prevention Blood levels of free testosterone, Erythromycin Topical preparations: Avoid dehydroepiandrosterone, and androstenedione Adult and child over 12 years: 500 mg - 1 g every 12 hours Creams and water-based gels are less irritating than - Oil-based cosmetics, hair styling mousse, face creams - If raised, test response of the hormones and cortisol to Infants requiring oral therapy: 250 mg once daily or 125 alcohol/acetone-based gels and hair sprays dexamethasone suppression mg every 12 hours - Always initiate treatment with lower strength and - Medicines that may induce acne Treatment objectives Or: increase as tolerance develops to initial irritant reaction Reduce severity of acne Clarithromycin 250 - 500 mg orally every 12 hours - Occasionally contact sensitivity may occur Prevent complications - In patients who do not tolerate any of the tetracyclines Benzoyl peroxide PRURITUS Drug treatment or who fail to improve - May bleach fabrics, hair and skin Introduction Comedonal acne Review patient in 6 weeks and 3 - 4 months later - Avoid contact with eyes, mouth, and mucous Commonly known as itching Topical treatment only: - If there is marked improvement, taper the dose by 250 membranes The most common unpleasant experience involving the Tretinoin cream mg for tetracycline every 6 - 8 weeks while treating with Antibiotic resistance may occur skin; provokes a desire to scratch Adult: 0.025%or 0.05% or 0.1% cream or gel applied topicals to arrive at the lowest systemic dose needed to - Avoid the use of different oral and topical antibiotics at May be elicited by many normally occurring stimuli e.g nightly maintain clearing the same time - Light touch Child: apply thinly 1 - 2 times daily Antibiotic-resistant acne - Vaginitis and perianal itching due to Candida may - Temperature change Or: Oral contraceptives containing a non-androgenic occur - Emotional stress Benzoyl peroxide progestin - Tetracyclines, minocycline and doxycycline are - Chemical, mechanical, thermal and electrical stimuli Adult: 2.5%or 5% water-based or alcohol-based gels, Co-cyprinidiol: contraindicated in pregnancy and in children less than 12 Mediated by the release of chemical substances e.g. applied twice daily - A mixture of cyproterone acetate and ethinylestradiol years histamine, kinins, and proteases Child 12-18 years: apply 1 - 2 times daily preferably 2000 parts to 35 parts - May reduce the effectiveness of oral contraceptives - Prostaglandin E lowers the threshold for histamine- after washing with soap and water - 1 tablet orally daily for 21 days starting on day 1 of - Often cause GIT symptoms induced pruritus, while enkephalins, pentapeptides - Start with lower strength preparations menstrual cycle and repeated after a 7-day interval, - Minocycline and doxycycline may cause which bind to opiate receptors in the brain modulate pain Infantile acne: usually for several months photodermatitis and itching centrally Child 1 month to 2 years; neonate: apply 1 - 2 times daily - Forwomen with severe acne refractory to prolonged - Erythromycin cannot be used in conjunction with Clinical features - Start with lower strength preparations antibiotic therapy astemizole or terfenadine, as serious cardiovascular At a low level, may merely be annoying Or: Or: complications may occur May actually torture the patient, interfere with sleep and Clindamycin or erythromycin gel or solution twice Spironolactone may be added as an antiandrogen Salicylic acid lead to less than optimal performance daily Adult: 50 - 200 mg orally daily - Significant absorbtion may occur from the skin in There are great variations from person to person Adult and child: apply twice daily Severe acne children - In the same person there may be variation in reactions Or: Start with systemic antibiotics as above Isotretinoin: to the same stimuli Azelaic acid 20% cream Oral isotretinoin (13-cis retinoic acid) Dry skin, lips and eyes In the elderly, senile pruritus due to dry skin may be Adult and child: apply twice daily; initially once daily Adult: 0.5 - 1 mg/kg/day for 20 weeks for a cumulative Decreased night vision particularly bothersome for sensitive skin dose of at least 120 mg/kg Epistaxis Psychologic trauma, stress, absence of distractions, - Suitable for acne patients with atopic dermatitis Child 12 - 18 years: 500 micrograms/kg once daily, Hypercholesterolaemia anxiety, and fear may all enhance itching Salicylic acid solution 2% increased if necessary to 1 mg/kg in 1 - 2 divided doses Hypertriglyceridaemia Adult and child: apply up to 3 times daily - Occasionally, acne does not respond or promptly recurs Pseudotumour cerebri and headaches Tends to be most severe at the time of undressing for - Tretinoin may be used at night and benzoyl peroxide after therapy, but may clear after a second course Depression bed or topical antibiotics in the morning because they have - At least a 4-month rest period from the drug is Musculoskeletal or bowel symptoms There are also regional variations different modes of action and are complementary recommended before a second treatment course is Thinning of hair - The ear canals, eyelids, nostrils, and perianal and - It may take 8 - 12 weeks before observable considered Bony hyperosteoses genital areas are especially susceptble to pruritus improvement occurs Acne fulminans Premature epiphyseal closure in children May be localized or generalized Mild inflammatory acne Prednisolone 1.0 mg/kg daily for7-10days then taper - Absolutely contraindicated during pregnancy May or may not be associated with skin lesions Treat as above off rapidly as isotretinoin is started (teratogenicity) Excoriations are typically linear and occur where the Moderate inflammatory acne Success has been reported with dapsone but only in toxic - Obtain informed consent before use; start oral patient can reach with his hands Topical and systemic drugs: doses (100 mg three or four times daily) contraceptives one month before commencing therapy - The middle of the back is typically spared except when Tetracycline Adjuvant measures and continue for another month after conclusion of the patient has used a back scratcher Adult and child over 12 years: 500 mg orally every 12 Use non-irritating cleansing agents to reduce facial therapy - The scratch is usually erythematous, with many tiny hours sheen and bacterial flora - Women of childbearing age are strongly advised to erosions scattered along it Or: Emotional support avoid pregnancy for up to 3 years following cessation of - Fresh marks are usually weepy or bloody; older ones

75 76 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008 crusted increased if necessary to 50 mg daily in divided doses Child: not recommended because of associated burning The activation of cutaneous mast cells and their release - Lesions may become impetiginized Over 6 years: initially 15 - 25 mg daily, increased if Or: of mediators is the unifying feature of most urticaria In addition to excoriations, some patients may have necessary to 50 - 100 mg daily in divided doses Urea 10% hydrocortisone cream 1 %, Mast cells are found in the immediate vicinity of blood smooth, shiny fingernails (the polished nails of chronic Aquagenic pruritus, mastocytosis, and pruritus of Adult and child: dilute with aqueous cream in first 1 week vessels pruritus) neurofibromatosis of use if stinging occurs - They release preformed mediators (histamine, heparin Pruritus without skin lesions suggests Sodium cromoglycate Or: and various enzymes) as well newly manufactured ones - Biliary obstruction Adult: 200 mg orally taken before bath and immediately Emulsifying ointment BP (prostaglandins, leukotrienes) - Diabetes mellitus after Adult and child: can be used as soap substitute; rub on A hive or urticarial lesion is the result of localized - Uraemia Child 2 - 14 years: 100 mg orally 4 times daily before skin before rinsing off completely oedema in the dermis - Lymphoma meals Or: Causes: - Hyperthyroidism - Dose may be increased after 2 - 3 weeks to a maximum - Doxepin hydrochloride Medications - Adverse reaction to medicines e.g. Histamine of 40 mg/kg daily, reduced according to response Adult: apply thinly 3 - 4 times daily (coverage should be Food liberators, opioids Or: less than 10% body surface area) Aero-allergens - Occult scabies Ketotifen Adverse drug reactions, caution and contraindications Latex; seminal fluid (contact urticaria) - Pediculosis Adult: 2 mg orally taken before bath (with food) Colestyramine: Insect antigens (bees, wasps or hornet toxins) - Onchodermatitis Child 3 years and over: 1 mg orally twice daily Counsel patients Infections and infestations (parasitic, fungal, bacterial - Dermatitis herpetiformis Depressed, itchy individuals Other drugs should be taken at least 1 hour before, or 4 - and viral) - Atopic eczema in remission Doxepin 6 hours after colestyramine to reduce possible Foreign proteins (antisera, vaccinations) - HIV/AIDS Adult: initially 75 mg orally daily in divided doses or as a interference with absorption Physical stimuli (pressure, heat, cold, cholinergic - Systemic mastocytosis single dose at bedtime May cause constipation and gastrointestinal discomfort stimuli, water, light and irradiations) Polycythaemia vera is a notable cause of pruritus; - Increased if necessary to a maximum of 300 mg daily Interferes with the absorption of fat-soluble vitamins Auto-immune disorders, enzyme defects (C1 esterase usually induced by temperature changes in 3 divided doses - Supplements of vitaminsA, D and K may be required inihibitor deficiency) Some patients complain of pruritus provoked by bath Up to 100 mg may be given as a single dose Activated charcoal: Psychosocial conflicts (stress, depression) or immediately post-bath Elderly: initially 10 - 50 mg daily; range of 30 - 50 mg Risk of aspiration in drowsy or comatose patients Excessive mast cells (mastocytoma, urticaria Factors include: daily may be adequate Risk of intestinal obstruction in patients with reduced pigmentosa) - Aquagenic pruritus Not recommended for children gastro-intestinal motility Pseudoallergy (mast cell degranulators e.g. NSAIDS; - Temperature-dependent pruritus due to cold/heat Pruritus associated with partial biliary obstruction and Black stools dyes, preservatives, contact urticaria) - Cholinergic pruritus (when the core temperature is primary biliary cirrhosis Soduim cromoglycate: Serum sickness increased and there is sweating) Colestyramine Occasional nausea, rashes, and joint pain Malignancies - Allergy to bath sponge or soap Adult: 4-8gorally daily in water (or other suitable Ketotifen: Idiopathic - Mechanical scrubbing of the skin with coarse sponge liquid) Drowsiness; dry mouth; slight dizziness; CNS Clinical features causing degranulation of mast cells Child 1 month - 1 year: 1 g orally once daily mixed with stimulation; weight gain May be acute or chronic: - A forceful jet of water from the shower may trigger water; 1 - 6 years: 2 g once daily; 6 - 12 years: 4 g once Driving, swimming and operating machines should be Acute urticaria is of sudden onset and lasts less than 6 pruritus in some cases. daily; 12 - 18 years: 4-8gdaily, adjusted according to avoided weeks Differential diagnoses response in all age groups Enhances the effects of alcohol Chronic urticaria persists for more than 6 weeks with All the above causes of pruritus Pruritus of renal failure Doxepin: either: Complications Activated charcoal Caution in patients with glaucoma, urinary retention, - Daily emergence of new wheals (chronic continuous) Sleep disturbance Adult: 50 g orally initially then 50 g every 4 hours. and severe liver impairment or Less than optimal performance at home, work or - Treat vomiting with an anti-emetic because it may May cause drowsiness, local burning, stinging, - Occasional hive-free periods (chronic recurrent) school reduce the efficacy of charcoal treatment irritation and dry mouth The typical urticarial reaction is similar to the triple Emotional disturbance In cases of intolerance reduce the dose and increase Prevention response of Lewis Suicidal ideation frequency of administration (e.g. 25 g every 2 hours or Use a cleansing bar (instead of soap) for baths - Initial erythema 12.5 g every hour). This may however compromise Pat rather than rub skin dry after bath and immediately - Next oedema (the hive) Investigations efficacy lubricate skin with petroleum jelly or emulsifying - Finally an erythematous ring surrounding the hive As suggested by meticulous history and physical Or: ointment Urticarial lesions may: examination Ultra Violet B therapy - Varyin size and shape over minutes to hours Treatment objectives Localized pruritus - Present an orange-skin appearance Suppress itch Corticosteroid creams for inflammatory skin disease URTICARIAANDANGIOEDEMA - Become bullous Identify and treat cause(s) Or: Introduction The pruritus associated with urticaria is usually extreme Improve quality of life Crotamiton cream 10% An eruption of evanescent wheals or hives which can Excoriations are extremely unusual because the lesions Prevent complications Adult: apply topically 2 - 3 times daily result from many different stimuli on an immunologic or are almost invariably rubbed, not scratched Drug treatment Child: apply once daily for child below 3 years; over 3 non-immunologic basis Dermographism is characterized by wheal and erythema Hydroxyzine hydrochloride years: apply 2 - 3 times daily The most common immunologic mechanism is after minor stroking of, or pressure on the skin Adult: initially 25 mg at night, increased if necessary to Or: hypersensitivity mediated by IgE - Commonly found under pressure areas e.g. the belt line 25 mg 3 - 4 times daily Capsaicin cream 0.75% - Another mechanism involves activation of the - May persist for years, but spontaneous regression Child: 6 months - 6 years: initially 5 - 15 mg daily, Adult: apply topically 3 - 4 times daily complement cascade. usually occurs within 2 years

77 78 Chapter 6: Dermatology Standard Treatment Guidelines for Nigeria 2008

Angioedema is the involvement of deeper vessels Child 2 - 6 years: 5 mg orally daily or 2.5 mg every 12 VITILIGO - Usually a good prognostic sign since it suggests an - Characterized by painless, deep, subcutaneous swelling hours Introduction effective immune reaction against the tumour cells - Often involves periorbital, circumoral and facial Or: A disease characterized by acquired loss of Segmental vitiligo affects only one part of the body regions; palms, soles and the genitalia Acrivastine melanocytes, leading to areas of depigmentation - It spreads rapidly in that area and then stabilizes - May target the gastrointestinal and respiratory tracts, Adult: 8 mg orally every 8 hours Sometimes associated with uveitis and other - It is not associated ith autoimmune diseases causing abdominal pain, coryza, asthma and respiratory Child under 12 yearsand elderly : not recommended autoimmune phenomena - Favoured sites are the trigeminal area or an intercostal problems Or: - Many autoantibodies can be demonstrated in vitiligo nerve distribution (zosteriform pattern) - Respiratory tract involvement may cause airway Loratadine patients; those against melanocytes may rarely be Just as with albinism, the interplay between the obstruction Adult and Child over 6 years: 10 mg orally daily demonstrable melanocytes of the eyes, ears, and skin is apparent - Anaphylaxis and hypotension may also occur Child 2 - 5 years 5 mg daily There is also a neural hypothesis The prototype is Vogt-Koyanagi-Haradasyndrome: Differential diagnoses If persistent and chronic urticaria - Vitiliginous patches often follow a dermatome Vitiligo of the face, eyelashes, and scalp hair in Gyrate erythemas Add Doxepin (oral form discontinued) - A neurochemical mediator responsible for destroying association with Urticarial vasculitis Adult: apply thinly 3 - 4 times daily; usual maximum 3 g the melanocytes has therefore been suggested - Uveitis Mastocytosis per application (total daily maximum 12 g) There is also an occupational vitiligo - Dysacoussis Pityriasis rosea (early lesions) Child: not recommended for children under 12 years - Due to chemically induced depigmentation - Alopecia areata Bullous lesions: Or: - Seen among workers who are in contact with para- Chemical vitiligo affects sites of contact with the Pemphygus (For symptomatic dermographism and chronic urticaria) phenolic compounds or hydroquinones (but this is chemicals Pemphygoid Add: considered a different disorder) - When the chemicals are inhaled or a substantial Erythema multiforme Ranitidine hydrochloride Clinical features quantity is absorbed through the skin, the distribution of Fixed drug eruption Adult: 150 mg orally every 12 hours or 300 mg at night All ages are affected the white patches may simulate the generalized Angioedema: - Not to be used alone for the treatment of urticaria The dermatomal type is more common in the paediatric autoimmune type “Calabar swelling” Refractory cases age Differential diagnoses Cellulitis Systemic corticosteroids The completely depigmented patches have distinct Post-burns depigmentation Idiopathic scrotal oedema of children - Prednisolone 0.5 to 1.0 mg/kg orally daily borders Tertiary stage of pinta Melkerson-Rosenthal syndrome Adjuvant measures - A few patients may have inflammatory vitiligo with Morphoea Cold uriticaria: To relieve itching: raised erythematous borders Lichen sclerosis Cryoglobulinemia Tepid or cold tub baths or showers - Some may have hypopigmented skin between the Pityriasis alba Immune complex diseases Add starch, or sodium bicarbonate, menthol, or depigmented and normal skin (trichrome vitiligo) Tinea versicolor Systemic lupus erythematosus and other collagen magnesium sulfate to bath water The distribution may be: Piebaldism vascular diseases Do not scrub the body with sponge (it promotes Generalized (autoimmune type) Hypomelanosis of Ito Macroglobulinemia degranulation of cutaneous mast cells) Segmental (dermatomal type) Complications Mycoplasma infections (cold hemagglutinins) Avoid medicines likely to cause urticaria/angioedema The hairs on the patches eventually turn white (acquired Emotional problems due to cosmetic disfigurement Syphilis Eliminate any suspected food poliosis) Investigations Familial cold urticaria Counselling The generalized type may be symmetrically distributed Exclude other autoimmune diseases if clinically Acquired cold urticaria Notable adverse drug reactions, caution and in the extremities suggestive Complications contraindications - Generalized vitiligo continues to spread while new See also notes on caution below Emotional distress in chronic cases Chlorphenamine maleate: lesions develop for years Treatment objectives Fatality Patients not to drive or operate machinery Spontaneous repigmentation may occur Re-pigmentation Investigations Ranitidine: Favoured sites are Improve cosmetic appearance Suggested by meticulous history and physical Tachycardia, agitation, visual disturbances, alopecia, - Extensor surfaces of the extremities Emotional support examination gynaecomastia and impotence - Face and peri-orificial surfaces (around the mouth, Topical Treatment objectives Caution in hepatic impairment, pregnancy and in breast eyes, nipples, umbilicus, penis, vulva, and anus) Corticosteroids To alleviate symptoms feeding Focal vitiligo may affect one non-dermatomal site e.g. - Hydrocortisone 1% or betamethasone valerate Eliminate and treat cause Cetirizine, loratadine, and acrivastine: lips, vulva or penis Adult: 0.1% apply once or every 12 hours (for focal or Drug treatment Headache, dry mouth, drowsiness, dizziness and nausea Universal vitiligo applies to cases where the entire body limited lesions) Chlorphenamine maleate Caution in the elderly especially if renal function is surface is depigmented Child: apply 1 - 2 times daily Adult: 4 mg orally every 4 - 6 hours (maximum 24 mg compromised Generalized vitiligo may be associated with Psoralens daily) Doxepin: - Hyperthyroidism - 8-methoxypsoralen (MOP) Child: under 1 year, not recommended Caution in cardiac disease - Hypothyroidism 0.05% - 0.1% in combination with ultraviolet-A 1 - 2 years: 1 mg every 12 hours;2-5years: 1mg every 4 - Contraindicated in recent myocardial infarction, - Pernicious anaemia radiation (PUVA)for focal or limited lesions 6 hours (maximum 6 mg daily); 6 - 12 years: 2 mg every 4 arrhythmias, glaucoma and severe liver disease - Diabetes mellitus Adult and child: apply twice weekly - 6 hours (maximum12 mg daily) May cause dry mouth, sedation, blurred vision, - Addison's disease Tacrolimus - If less sedation is required (e.g. day time) constipation, nausea, difficulty with micturition Local loss of pigment may occur around a naevus and 0.1% ointment twice daily for 24 weeks Cetirizine Prevention melanomas, the so-called halo phenomenon Topical depigmentation Adult and Child over 6 years: 10 mg orally daily or 5 mg Eliminate/avoid any identified/possible causal factor(s) Vitiligo-like leucoderma occurs in about 1% of - Monobenzyl ether of hydroquinone every 12hours melanoma patients 20%, apply twice daily for3-6months (if more then

79 80 Chapter 7: Ear, Nose and Throat Standard Treatment Guidelines for Nigeria 2008

50% of the body is affected) CHAPTER 7: EAR, NOSEAND THROAT months - 1 year: 125 - 250 mg for 5 - 7days - 5 years 2.5 mL Systemic Systemic decongestant Or: Systemic 8-methoxypsoralen (or 5-methoxypsoralen) ACUTE OTITIS MEDIA - Psuedoephedrine - Ephedrine nasal drops (0.5%) Adult: 0.5 mg/kg orally Introduction Adult: 60 mg orally every 4 - 6 hours (up to 4 times daily) Instil into nostrils twice daily and at night time The initial UVAdose is 1 or 2 J/cm2 , gradually increased Acute inflammation of the middle ear due to pyogenic Child: 6 - 12 years: 30 mg (5 mLof syrup) 3 times daily; 2 Antibiotic Two or three treatments are done per week for3-6 organisms - 5 years 15 mg, (2.5 mL) - Amoxicillin syrup 125 - 250 mg orally every 8 hours for months Usually secondary to upper respiratory infection Supportive measures 5 - 7 days Systemic corticosteroids spreading from nasopharynx Bed rest and adequate fluids - May occasionally be used to arrest the autoimmune Common in infants and young children; more frequent Notable adverse drug reactions, caution process during winter and rainy periods Many preparations of pseudoephedrine contain CHRONIC OTITIS MEDIA - Prednisolone tablets 0.5 - 1.0 mg/kg orally day Usual organisms are streptococcus pneumococcus and antihistamines and may cause drowsiness Introduction Surgical staphylococcus Avoid ear drops A chronic inflammatory condition of the middle ear Pigmented skin grafted onto vitiliginous patches Clinical features Prevention mucosa with recurrent ear discharge - Often the transferred melanocytes repigment the Main symptoms: Good general health and clean airy environment to - Often over a period of years depigmented areas Earache reduce incidence of upper respiratory infections (colds) Occurs in two clinical varieties The various techniques include: Fever - The more common simple type with a central eardrum - Suction blister grafts Deafness perforation - Mini-punch grafts Ear discharge ADENOID DISEASE - The much less common, serious type often associated - Transfer of either pure melanocyte cultures or mixed Malaise Introduction with the presence of cholesteatoma epidermal cultures to a prepared site In babies, irritability A manifestation of hyperplasia/hypertrophy of the Bacteriology is usually mixed, mostly gram negative Adjuvant measures Clinically increasing inflammation and redness of the adenoid tissue in the nasopharynx organisms (Proteus, Pseudomonas) Camouflage (cover-up cosmetics) eardrum Usually occurs in children aged 2 - 6 years Clinical features Patient education and emotional support Later, perforation and pulsating mucopurulent Excessively large adenoids may cause obstruction of the Main complaints: recurrent ear discharge and increasing Notable adverse drug reactions, caution and discharge nasopharyngeal airway with symptoms of nasal deafness contraindications Differential diagnoses obstruction Pain is uncommon Corticosteroids: Acute otitis externa Large adenoids may encroach on the Eustachian tube Discharge is mucoid in the simple type but thick and See Dermatitis and Eczema Referred otalgia openings causing secretory otitis media with deafness in foul-smelling in the serious variety 8-MOP: Complications the child Usually central eardrum perforation is of varying size Inadvertent sunburns with blistering Acute mastoiditis Chronic infection of adenoid tissue is also often present - Cholesteatoma and marginal or attic perforation is seen Systemic psoralen is contraindicated in: Facial nerve paralysis Symptoms usually subside spontaneously as adenoids in the serious type - Known photosensitivity Labyrinthitis regress physiologically and become atrophic with age Complications - Porphyria Intracranial Clinical features Generally more with the serious type: - Liver disease - Meningitis Nasal obstruction and mouth-breathing Intracranial suppuration - Systemic lupus erythematosus - Brain abscesses Snoring at night - Extradural abscess If systemic therapy is to be used the following should - Lateral sinus thrombosis Obstructive sleep apnoea - Meningitis be done before therapy Investigations Progressive deafness due to secretory otitis media - Brain abscess - Ophthalmological examination Ear swab for culture and sensitivity- swab taken Differential diagnoses Lateral sinus thrombosis - Full Blood Count properly without contamination Allergic rhinitis Facial nerve paralysis - Liver function tests Full Blood Count Sinusitis Labyrinthitis - AntinuclearAntibody Test Treatment objectives Otitis media Investigations Monobenzylether of hydroquinone: Control infection Complications Ear swab taken properly for microscopy, culture and Depigmentation at distant sites Restore normal hearing Sinusitis sensitivity Acquired ochronosis Non-drug treatment Recurrent otitis media Audiogram: conductive deafness PUVA therapy should be supervised by an experienced Ear toilet and antiseptic dressings Pneumonitis X-ray of the mastoids: shows sclerosis, dermatologist Myringotomy for persistent mucopurulent collection in Investigations hypopneumatization Prevention middle ear with bulging eardrum X-ray of nasopharynx Treatment objectives Unknown Drug treatment Xray sinuses and chest To give the patient a safe and dry ear Antibiotics Treatment objectives To preserve or restore hearing as much as possible - Amoxicillin To significantly improve nasopharyngeal airway and Non-drug treatment Adult: 500 mg -1 g orally every 8 hours for5-7days thereby improve nasal breathing Careful ear toilet and regular ear dressing with antiseptic Child: 40 mg/kg orally every 8 hours Analgesics Treat concurrent infection pack - Paracetamol Non-drug treatment With dry ear, persistent perforation may be closed Adult: 500 mg - 1 g orally every 4 - 6 hours (to a Adenoidectomy in severe cases surgically (myringoplasty) to protect middle ear and maximum of 4 g) for5-7days Drug treatment improve hearing Child over 50 kg: same as adult dosing Decongestants In the serious type with cholesteatoma not responding to 6 - 12 years: 250 -500 mg; 1 - 5 years: 125 - 250 mg; 3 - Psuedoephedrine syrup treatment, mastoid operation is done to clear out disease 6 - 12 years: 30 mg (5 mLof syrup) orally every 8 hours; 2 and prevent complications

81 82 Chapter 7: Ear, Nose and Throat Standard Treatment Guidelines for Nigeria 2008

Drug treatment Identify and treat aetiological factors In the lower airways objects may remain for long Treatment objectives Antibiotic Non-drug treatment periods, with unexplained chest symptoms Remove object expeditiously without damage to ear - Co-amoxiclav Pressure and compression of the nose between fingers Differential diagnoses structures or causing undue pain to patient Adult: 500/125 mg orally every 8 hours for acute to arrest bleeding Acute laryngitis Non-drug treatment exacerbations up to 14 days Cotton wool pack soaked in epinephrine 1:1000 may be Acute laryngeal oedema Removal by ear syringing Child: 6 - 12 years: 250 mg orally every 12 hours; under placed on bleeding area before compression to induce Bronchopneumonia Removal with appropriate hook, or alligator forceps 6 years: 125 mg every12 hours vasoconstriction Pulmonary tuberculosis Examination and removal under anaesthesia if difficult If infection does not settle with systemic antibiotics refer Nasal packing with lubricated ribbon gauze Complications in the clinic to specialist Arrest of posterior bleed with rubber tampon or Life-threatening asphyxia Prevention Supportive measures improvised Foley's catheter balloon Lung collapse and atelectasis Vigilant supervision of young children Protect ears from water with Vaseline/cotton wool Cauterization of bleeding point or dilated vessels in Investigations while bathing anterior nasal septum Radiograph of neck and chest Caution - Diathermy cautery (electrical) or chemical cautery Treatment objectives FOREIGN BODIES IN THE NOSE AND Topical treatment with ototoxic antibiotics is with silver nitrate stick To maintain the airway and adequate respiratory function RHINOLITHS contraindicated in the presence of a perforation Drug treatment Remove the foreign object as expeditiously as possible Introduction Treat underlying aetiologies Non-drug treatment Children often insert various objects into the nostrils Sedation if necessary Immediate removal under anaesthesia by direct while playing: pieces of plastic toys, rolled paper, foam, EPISTAXIS - Diazepam 5 mg orally twice daily for1-2days laryngoscopy or bronchoscopy as appropriate seeds, some metal objects, etc Introduction Antibiotics if infection is present Tracheostomy where necessary to maintain airway The objects may remain undetected for long periods, Acondition of bleeding from the nose - Amoxicillin Drug treatment particularly organic items, until they become infected Aclinical presentation rather than a disease entity on its Adult: 500 mg orally every 8 hours for5-7days Antibiotic prophylaxis if necessary (for 3 days) Typically result in foul smelling unilateral nasal own Child: 250 - 500 mg orally for5-7days - Amoxicillin discharge Bleeding is most often from ruptured vessels in the Other drugs depending on identified causative factors Child: 6 - 12 years: 250 mg orally every 12 hours; under 6 Some inorganic objects may (after long periods) become anterior nasal septum, sometimes from the posterior Supportive measures years: 125 mg orally every 12 hours coated by hard calcific deposits and become known as nose especially in the elderly Intravenous infusion, crystalloids and blood as Steroid rhinoliths Can arise from a wide variety of causes necessary - Hydrocortisone (for pneumonitis) Clinical features Local (in the nose) Bed rest Child 1 month - 1 year: initially 25 mg by intravenous or Often no indication or symptom Trauma Prevention intramuscular injection every 8 hours;1-6years: May be accidentally noticed by parent Inflammation of nose or sinuses Avoid/treat predisposing conditions initially 50 mg every 8 hours;6-12years: initially 100 Later, complaints of foul purulent unilateral nasal - Acute e.g. acute rhinitis/sinusitis mg every 8 hours; 12 - 18 years: initially 100 - 500 mg 3 discharge of unknown origin - Chronic e.g. tuberculosis, leprosy times daily, adjusted in all age groups according to Differential diagnoses Neoplasms FOREIGN BODIES IN THEAIRWAYS response Acute or chronic rhinitis Manifestation of systemic diseases Introduction Supportive measures Sinusitis Bleeding diatheses Children (most commonly) may aspirate pieces of play Oxygen Nasal growth/polyp Blood dyscrasias objects or food items accidentally into the airway Steam inhalation/nebulizer Complication Hypertension May present as serious emergencies with imminent Prevention Secondary infection: rhinosinusitis Clinical features asphyxia Vigilant supervision of young children Investigation Bleeding from nose; often spontaneous but may follow The object if arrested at laryngeal level causes acute Radiograph of nose: for metallic or radio-opaque objects obvious trauma or injury upper respiratory obstruction Treatment objectives Varying amounts of blood, from few drops to torrential Sharp objects such as fish bone or pins may be impacted FOREIGN BODIES IN THE EAR Remove object safely with little discomfort to patient life-threatening haemorrhage on the vocal cord and the resulting oedema causes Introduction Non-drug treatment Often intermittent; most bleeds stop spontaneously progressive obstruction Acommon presentation in ENT emergency practice Careful removal with appropriate hook or forceps Differential diagnoses Small objects such as seeds may traverse the larynx and Children usually involved as they insert various objects Removal under anaesthesia as necessary Various pathological conditions, both local and become arrested in the trachea or bronchus lower down into ears while playing: beads, plastic toys, seeds, etc Prevention systemic present with nasal bleeding Vegetables such as peanuts often cause severe reaction Live insects may also crawl into the ear in adults/children Vigilant supervision of young children Complications in the lungs with pneumonitis Clinical features Haemorrhagic shock Clinical features Symptoms are often absent MASTOIDITIS Fatality Difficulty in breathing with stridor occurs immediately Little pain (sometimes) Introduction Investigations or progressively Sensation of blockage may be reported by older children Develops as a complication of acute suppurative otitis Full Blood Count, including platelet count Initial dyspnoea and cough may subside if the object Object usually seen with good light in the ear canal media, mostly in children Bleeding and clotting time; partial thromboplastin time passes down. Symptoms gradually return later Differential diagnoses Follows acute otitis media (untreated or inadequately Urea and Electrolytes and Creatinine Severe cases: stridor and severe cyanosis with imminent Impacted wax treated), or due to particularly virulent organisms X-ray sinuses asphyxia requiring immediate intervention to prevent a Otitis externa Infection spreads from the tympanum posteriorly into CT scan fatal outcome Complications the mastoid antrum and aircells Treatment objectives Two-way stridor often occurs with tracheal foreign Otitis externa Colliquative necrosis of the air cells and suppuration in To arrest bleeding in actively bleeding cases bodies Perforation of tympanic membrane from inexpert the mastoid bone follows Replace significant blood losses and treat shock attempts at removal

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Asubperiosteal abscess forms behind the ear in a child NASALALLERGY daily if necessary or, 10 - 20 mg every 8 - 12 hours Urinalysis for glycosuria with a discharging ear Introduction Child: not recommended under 2 years Blood glucose estimation in cases of recurrent Clinical features Hypersensitivity of the nasal mucosa to various foreign 5 - 10 years: 10 - 25 mg orally daily in 1 - 2 divided doses; furunculosis to exclude diabetes mellitus Fever substances, of the atopic type 2 - 5 years: 5 - 15 mg daily in 1 - 2 divided doses Treatment objectives Pain behind the ear Manifests as recurrent episodes of sneezing, rhinorrhoea Topical steroid Control infection / inflammation Mucopurulent ear discharge and nasal obstruction whenever patient comes in contact - Beclomethasone nasal spray Relieve discomfort Progressive inflammatory swelling over the mastoid with the offending allergen Adult and child over 6 years: 100 micrograms (i.e. 2 Non-drug treatment region Symptoms are attributed to the effect of histamine and sprays) into each nostril twice daily Careful ear toilet to clear out debris Swelling is tender and fluctuant other chemical substances released from ruptured mast - Or 50 micrograms into each nostril every 8 hours Daily dressing with antiseptic gauze packed with Differential diagnosis cells in the nasal mucosa - Reduce dose to 50 micrograms into each nostril twice Acriflavin in spirit Suppurating post-aural lymphadenitis from otitis Common allergens are pollens of various plants, flowers daily when symptoms are controlled Furunculosis: dressing with magnesium sulfate wick or externa and trees; house-dust; hairs; some foods; fungi and Decongestant steroid and antibiotic ointment dressing Complications cosmetics - Psuedoephedrine Drug treatment Spread of infection into cranial cavity with: Acommon condition and affects all age groups Adult: 60 mg orally 4 - 6 hourly (up to 4 times daily) Antibiotics Extradural abscess May be familial, often associated with allergic asthma Child: 6 - 12 years: 30 mg (5 mL of syrup) orally every 8 - Amoxicillin Meningitis or dermatitis hours;2-5years: 2.5 mL Adult: 500 mg -1 g orally every 8 hours for5-7days Brain abscess Clinical features Notable adverse drug reactions, caution Child: 40 mg/kg orally in every 8 hours for5-7days Lateral sinus thrombophlebitis Repeated episodes of sneezing Drowsiness with antihistamine drugs - Neomycin/hydrocortisone ear drops Investigations Watery nasal discharge Avoid prolonged use of medications Adult and child: instil 2 - 3 drops 3 - 4 times daily Ear swab for microscopy, culture, culture and Nasal obstruction with itching and conjunctival Prevention Analgesics sensitivity irritation whenever patient is in contact with allergen Avoid known allergenic substances, inhalants, foods, etc - Paracetamol Radiographs of the mastoid Nasal mucosa may be congested or sometimes normal Adult: 500 mg -1 g orally every 4 - 6 hours (to a maximum Treatment objectives at the time of clinical examination of4g)for5-7days Control and eradicate infection Presentation may be seasonal as with pollen allergy, or OTITIS EXTERNA Child over 50 kg: same as adult dosing Prevent more serious complications perennial with allergy to house dust, etc Introduction 6 - 12 years: 250 - 500 mg; 3 months - 5 years: 125 - 250 Non-drug treatment Nasal polyps may develop Inflammation of the external ear mg taken orally every 4 - 6 hours Cortical mastoidectomy to open the mastoid Differential diagnoses May be: Supportive measures - Exenterate the infected air cells and drain the mastoid Chronic rhinitis from other causes Infective: bacteria or fungi Prevent water from entering ear for one month Drug treatment Vasomotorrhinitis Reaction of the canal skin to chemical irritant(s) Prevention Large doses of parenteral antibiotics Chronic sinusitis Part of a generalized dermatitis Avoid trauma to ear canal (especially scratching) - Amoxicillin Complications Localised otitis externa or furuncle (boil) is a Keep ears dry Adult: 500 mg -1 g intravenously every 6 - 8 hours for 7 Chronic sinusitis Staphylococcal infection of a hair follicle in the canal days Pharyngitis Diffuse otitis externa may be bacterial or fungal or Child: 50 - 100 mg/kg intravenously every 6 - 8 hours in Investigations reactive PERITONSILLARABSCESS (Quinsy) divided doses daily for 7 days Skin tests for allergens: intradermal or prick tests - May be acute or chronic Introduction - Ceftriaxone Smear of nasal secretions for eosinophilia Bacterial infection often follows trauma from scratching The main common local complication of acute Adult: 1 g every 12 hours intravenously for 7 days Serological tests: radio-immunoassay for IgE antibodies the canal skin tonsillitis Child: by intravenous infusion over 60 minutes Sinus X-ray Fungal otitis (otomycosis) commonly follows A virulent streptococcal infection; may spread beyond Neonates: 20 - 50 mg/kg once daily, by deep Treatment objectives swimming in the tropics, usually infection by Aspergillus the tonsillar capsule into the peri-tonsillar space, causing, intramuscular injection, intravenous injection over 2 - 4 Control or suppress the allergic symptoms niger first cellulitis, and later suppuration in the space minutes, or by intravenous infusion Prevent allergic reactions Clinical features More common in adults with tonsillitis 1 month - 12 years (body weight under 50 kg) 50 mg/kg Non-drug treatment Pain and itching Clinical features once daily, up to 80 mg/kg in severe infections Elimination of allergens Ear discharge Follows an attack of acute tonsillitis Analgesics Hyposensitisation by vaccination Sensation of blockage due to accumulated debris in Increasing pain, fever and dysphagia - Paracetamol Drug treatment canal Trismus- spread of oedema and infection to pterygoid Adult: 500 mg -1 g orally every 4 - 6 hours (to a Antihistamines Deafness is variable muscles maximum of 4 g) for5-7days - Chlorphenamine Canal is red and swollen, full of inflammatory debris Often referred pain to ipsilateral ear Child over 50 kg: same as adult dosing Adult: 4 mg orally every 4 - 6 hours; maximum 24 mg - In otomycosis whitish mass of debris with black spots Difficulty in opening mouth for examination; mouth 6 - 12 years: 250 - 500 mg; 3 months - 5 years: 125 - 250 daily Differential diagnoses full of saliva mg taken orally every 4 - 6 hours for5-7days Child: not recommended under 1 year Otitis media Affected tonsil displaced downwards and medially, Supportive measures 6 - 12 years: 2 mg orally every 4 - 6 hours; maximum 12 Acute mastoiditis with swelling above and lateral to it, all inflamed and Bed rest: in-patient care mg daily; 2 - 5 years: 1 mg every 4 - 6 hours; maximum 6 Complications oedematous Intravenous infusion as appropriate mg daily Acute perichondritis Uvula pushed to opposite side Prevention Or: Investigations Differential diagnoses Adequate and timely treatment of acute otitis media - Promethazine Ear swab, taken properly for microscopy, culture and Parapharyngeal abscess Adult: 25 mg orally at night, increased to 25 mg twice sensitivity Retropharyngeal abscess

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Tonsillar tumours Chronic exposure to irritants such as tobacco smoke - Mucopurulent postnasal discharge (“drip”) hours for 7 days for patients with severe or nosocomial Complications and alcohol Differential diagnoses disease Septicaemia Secondary infection from carious teeth Acute rhinitis (coryza) Child: by intravenous infusion over 60 minutes Parapharyngeal suppuration/abscess Clinical features Allergic rhinitis Neonates: 20 - 50 mg/kg once daily, by deep Investigations Persistent sore throat with no systemic upset or Vasomotorrhinitis intramuscular injection, intravenous injection over 2 - 4 Throat swab dysphagia Complications minutes, or by intravenous infusion Full Blood Count with differentials Sore throat is often worse in the mornings Orbital cellulitis (complicating ethmoidal sinusitis) 1 month - 12 years (body weight under 50 kg) 50 mg/kg Treatment objectives Differential diagnoses Cavernous sinus thrombosis (sphenoidal sinusitis) once daily, up to 80 mg/kg in severe infections Rapid control of infection Chronic tonsillitis Intracranial infection Decongestant Relief of pain and discomfort Pharyngeal or laryngeal tumour - Subdural abscess - Psuedoephedrine tablets Non-drug treatment Complications - Meningitis Adult: 60 mg orally twice daily until congestion improves Incision and drainage, preferably under local anaesthetic More often related to the primary sources of irritation or - Cerebral abscess Child 2-6 years: 15 mg orally 3 - 4 times daily; 6 - 12 when suppuration is definite infection - Dural vein thrombophlebitis years: 30 mg 3 - 4 times daily; 12 - 18 years: 60 mg 3 - 4 Drug treatment Investigations Osteomyelitis of frontal or maxillary bones times daily Antibiotics Throat swab: microscopy, culture and sensitivity Chronic pharyngotonsillitis Analgesic - Amoxicillin X-ray of paranasal sinuses Chronic laryngitis and bronchitis - Paracetamol Adult: 500 mg -1 g intravenously every 6 hours for 7 Treatment objectives Investigations Adult: 500 mg -1 g orally every 4 - 6 hours (to a maximum days Control symptoms by identifying and treating primary Nasal swab for microscopy, culture and sensitivity of4g)for5-7days Child: 50 - 100 mg/kg orally every 8 hours causes X-ray of sinuses: four-view Child over 50 kg: same as adult dosing Analgesics Non-drug treatment Antrum roof puncture/lavage: specimen for culture 6 - 12 years: 250 - 500 mg; 3 months - 5 years: 125 - 250 - Paracetamol Treat sinusitis CT scan in complicated cases mg taken orally every 4 - 6 hours for5-7days Adult: 500 mg - 1 g orally every 4 - 6 hours (to a Surgery for obstructive nasal conditions Treatment objectives Supportive measures maximum of 4 g) for5-7days Treat dental caries Control and eradicate infection Steam inhalations with menthol Child over 50 kg: same as adult dosing Drug treatment Restore adequate drainage of sinuses Treat contributory nasal pathology as appropriate 6 - 12 years: 250 - 500 mg; 3 months - 5 years: 125 - 250 Appropriate antibacterial agent if indicated Non-drug treatment - Allergy, nasal polyps, septal deviations, dental mg taken orally 4 - 6 hourly for5-7days Supportive measures Antrum wash-out/lavage pathology, etc Or: Reduction or avoidance of exposure to known irritants- Trephining of frontal sinus Notable adverse drug reactions - Aspirin (Acetysalicylic acid) tobacco, alcohol, etc Radical surgery for non-responsive cases Amoxicillin Adult: 300 - 900 mg orally every 4 - 6 hours when - Intranasal antrostomy - Minor gastrointestinal disturbance necessary; maximum 4 g - Caldwell-Luc operation Cotrimoxazole Not recommended in children (risk of Reye's syndrome) - Fronto-ethmoidectomy - Fixed drug eruption Supportive measures SINUSITIS Drug treatment - Nausea and vomiting Intravenous infusion Introduction Antibiotics - Erythema multiforme Bed rest Inflammation of the mucosal lining of the paranasal - Amoxicillin - Steven-Johnson syndrome Notable adverse drug reactions sinuses Adult: 500 mg - 1 g orally every 8 hours for5-7days Prevention Aspirin may cause gastrointestinal irritation May be acute or chronic and affect one or more of the Child: 40 mg/kg orally every 8 hours for5-7days Avoid airway irritants, smoking, and alcohol Prevention sinuses Or: Avoid air pollution Elective tonsillectomy is advised after an episode of - Most commonly the maxillary sinus or antrum (in very Amoxicillin/clavulanic acid Maintain good general health and nutrition quinsy to prevent further (more severe) attacks young children the ethmoidal sinuses) Adult: 500/125 mg orally every 12 hours Acute sinusitis is often sequel to acute rhinitis Child: 0.25 mL/kg of 125/31 mg suspension orally every - Common organisms are streptococcus, pneumococcus, 8 hours; dose doubled in severe infections PHARYNGITIS (Sore Throat) and haemophilus 1 - 6 years: 5 mL of 250/62 mg suspension every 8 hours; TONSILLITIS Introduction Chronic sinusitis is more insidious dose doubled in severe infections Introduction A common cause of persistent sore throat in young and - May be associated with chronic rhinitis and allergy but 6 - 12 years: 5 mL of 250/62 mg suspension every 8 An inflammatory condition of the palatine tonsils, most middle-aged adults, usually unaccompanied by other other factors such as air pollution, smoking, dental sepsis hours; dose doubled in severe infections common in children symptoms and poor general health may be contributory 12 - 18 years: one 250/125 mg strength tablet every 8 In half or more cases infection is by beta-haemolytic Often secondary to chronic nasal conditions with nasal Bacteriology is mixed: sometimes Gram negative and hours, daily increased in severe infection to one 500/125 streptococcus, in others viral obstruction e.g fungal organisms strength tablet every 8 hours daily Typically an acute infection - Vasomotorrhinitis Clinical features Or: Chronic tonsillitis presents usually as recurrent acute - Nasal polyps Rhinorrhoea Cotrimoxazole infection - Septal deviation Nasal obstruction Adult: 960 mg orally every 12 hours Essentially a disease of children but also occurs in Obstruction causes mouth breathing with dryness of the Fever with pain over affected sinus in acute cases Child 6 weeks to 5 months: 120 mg orally every 12 hours; young adults throat Less dramatic symptoms in chronic sinusitis 6 months - 5 years: 240 mg every 12 hours;6-12years: Clinical features Other causes: - Intermittent nasal obstruction and discharge over a 480 mg every 12 hours Fever Secondary inflammation from postnasal discharge of long period - Ceftriaxone Sore throat sinusitis - Little pain Adult: 1 g intravenously or intramuscularly every 12 Dysphagia

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Systemic upset and malaise TRACHEOSTOMY Clinical features CHAPTER 8: ENDOCRINE SYSTE Tonsils are swollen, inflamed and covered with Introduction Sensation of blockage and some degree of deafness are purulent exudates A surgical procedure in which an opening is created the most common complaints DIABETES MELLITUS Jugulo-digastric lymph nodes are enlarged and tender into the trachea from the outside, commonly to bypass an Sometimes, pain and irritation Introduction Differential diagnoses upper respiratory obstruction Ear discharge in some cases Agroup of metabolic diseases characterized by chronic Infectious mononucleosis May also be done to provide easier access for care of Quantity seen varies hyperglycaemia Vincent's angina the chest in some seriously ill patients - May be soft or hard Results from defects in insulin secretion, insulin action Agranulocytosis - Also for respiratory support and artificial ventilation - May be impacted in the deep meatus or both Complications in patients with respiratory insufficiency or paralysis Differential diagnoses It is associated with acute as well as long-term Quinsy : main common complication Most cases are done to by-pass upper airway Foreign bodies complications affecting the eyes, kidneys, feet, nerves, Parapharyngeal infection/abscess obstruction: Otitis externa brain, heart and blood vessels Rheumatic fever and nephritis following streptococcal - Acute infections of the larynx Complications Its classification has been revised by the WHO and is tonsillitis - Trauma Superimposed infection: otitis externa based on aetiology: Investigations - Foreign body aspiration Hearing impairment Type 1: Throat swab for microscopy, culture and sensitivity - Acute laryngeal oedema Treatment objectives - Results from destruction (usually autoimmune) of the Full Blood Count - Vocalcord paralysis Evacuate the wax and clear the ear pancreaticβ cells Treatment objectives - Tumours Non-drug treatment - Insulin is required for survival Control the infection Some cases are done as part of, or to facilitate major Removal with probe and cotton wool: for soft wax Type 2: Control pain head and neck surgery Ear syringing: for hard wax, often after preliminary - Characterized by insulin resistance and/or abnormal Prevent further episodes An appropriate-sized tracheostomy tube, portex or softening with oily drops insulin secretion (either may predominate); both are Non-drug treatment metal, is inserted to maintain the opening Occasionally, removal under anaesthesia if syringing is usually present Oral hydration Clinical features unsuccessful - It is the most common type of diabetes Salt/warm water gargle Acute presentation with clinical features of airway Drug treatment Other specific types of diabetes- less common, and Tonsillectomy in chronic cases with frequent recurrent obstruction, stridor and incipient asphyxia following Ear drops to soften and loosen wax include: tonsillitis trauma - Warm olive oil - Genetic disorders Drug treatment Acute inflammatory conditions of the larynx, which Or: - Infections Antibiotics would require the operation as an emergency Chlorobutanol 5% paradichlorobenzene 2%, arachis - Diseases of the exocrine pancreas - Amoxicillin Progressive lesions: may require less urgent (peanut) oil 57.3% - Endocrinopathies Adult: 250 - 500 mg orally every 8 hours for5-7days intervention in anticipation of likely obstruction - Drugs Child: 40 mg/kg orally every 8 hours for5-7days Cases with medical indications requiring respiratory Gestational diabetes: appears for the first time in The parenteral route may be required when there is support are usually done on a more elective basis pregnancy vomiting or severe dysphagia Complications Clinical features Or: Haemorrhage Type 1 diabetes: - Cotrimoxazole Infection: wound and chest Patients present at a young age (usually teens or Adult: 960 mg orally every 12 hours 5 - 7 days Damage to nerves and large vessels in the neck twenties); earlier presentation may also occur Child 6 weeks to 5 months: 120 mg orally every 12 Treatment objectives Rapid onset of severe symptoms: weight loss, thirst and hours; 6 months - 5 years: 240 mg every 12 hours;6-12 To secure the airway polyuria years: 480 mg every 12 hours Non-drug treatment Blood glucose levels are high and ketones are often Analgesic Postoperative care of tracheostomy preferably in an present in the urine - Paracetamol intensive care unit, with suction, humidification, stoma If treatment is delayed, ketoacidosis (DKA) and death Adult: 500 mg -1 g orally every 4 - 6 hours (to a care as appropriate may follow maximum of 4 g) for5-7days Drug treatment The response to insulin therapy is dramatic and Child over 50 kg: same as adult dosing Broad spectrum antibiotic cover gratifying 6 - 12 years: 250 - 500 mg; 3 months - 5 years: 125 - 250 Misclassification of patients as “Type 1” is relatively mg taken orally every 4 - 6 hours for5-7days common Supportive measures WAX IN THE EAR - Insulin-treatment is not the same as insulin-dependence Bed rest Introduction Type 2 diabetes: Intravenous infusion as necessary Wax (or cerumen) is a normal product of the human Most patients present with the classical symptoms Notable adverse drug reactions external ear including polyuria, polydipsia and polyphagia Cotrimoxazole - A dark brownish mixture of the secretions of the Some patients present with sepsis, diabetic coma - Fixed drug eruption ceruminous and sebaceous glands in the outer third of the (hyperosmolar non-ketotic states) - Nausea and vomiting external auditory canal A minority is asymptomatic and therefore identified at - Erythema multiforme Small quantities are produced continuously and function screening - Steven-Johnson syndrome to lubricate the canal The patients usually do not seek medical attention early Quantities produced and the consistencies vary because of the insidious nature of the disease - May be excessive in some people, causing deafness, Many present at diagnosis with features of diabetic ear ache, secondary infection and even vertigo

89 90 Chapter 8: Endocrine System Standard Treatment Guidelines for Nigeria 2008 complications with periodic re-testing until the diagnostic situation Management activity) should be the first step in the management of - Visual difficulties from retinopathy becomes clear Goals: newly diagnosed persons with Type 2 diabetes - Pain and/or tingling in the feet from neuropathy Take into consideration additional risk factors for Early diagnosis - Should be maintained throughout the course of diabetes - Foot ulcerations diabetes before deciding on a diagnostic or therapeutic Prevent and/or reduce short and long term morbidities management - Stroke course of action Prevent premature mortality Goals of dietary management of Type 2 diabetes mellitus Gestational diabetes (GDM): The diagnosis of diabetes must be confirmed Improve quality of life and productivity of affected To achieve an ideal body weight Diabetes which arises in pregnancy biochemically prior to initiation of any therapy persons - An appropriate diet should be prescribed along with an Must be distinguished from existing diabetes in women Symptoms of hyperglycaemia Promote self care practices and empowerment of people exercise regimen who become pregnant Plus: with diabetes - Caloric restrictions should be moderate and yet provide Of particular importance because it is associated with Random venous plasma glucose³ 11.1 mmol/L or Reduce the personal, family and societal burden of a balanced nutrition poor pregnancy outcomes, especially if not recognised fasting venous plasma glucose³ 7.0 mmol/L diabetes - Eat at least three meals a day. Binge eating should be and not treated - Confirms the diagnosis of diabetes Achievement of these goals is dependent on: avoided Particular problems associated with GDM: In asymptomatic subjects, a single abnormal blood Successful establishment of diabetes health care team, - Asnack between meals can be healthy for certain groups Foetal macrosomia glucose result is inadequate to make a diagnosis of and infrastructure to support it, including provision of of people Eclampsia diabetes education for health care professionals and for people - The diet should be individualized, based on traditional Intra-uterine growth retardation - Abnormal values must be confirmed at the earliest living with diabetes eating patterns, be palatable and affordable Birth difficulties possible date using any of the following Core components of diabetes care - Animal fat, salt, and so-called diabetic foods should be Neonatal hypoglycaemia - Two separate fasting or random blood samples Treatment of hyperglycaemia avoided Neonatal respiratory distress Or: Treatment of co-morbidities - Pure (simple sugars) in foods and drinks should be Diagnosis - A75 g oral glucose tolerance test Prevention and treatment of macrovascular and avoided Straightforward in the majority of cases microvascular complications - Eating plans should be high in carbohydrates and fibre, May pose a problem for those with a minor degree of Non-drug treatment vegetables and fruits should be encouraged hyperglycaemia, and in asymptomatic subjects Education - Dietary instructions should be written out, even if the - In these circumstances, two abnormal blood glucose The provision of knowledge and skills to people with person is illiterate: someone at home should be available results on separate occasions are needed to make the diabetes mellitus to interpret to him/her diagnosis - To empower them to render self-care in their - Food quantities should be measured in volumes using - If the results of point blood glucose testing are management available household items (e.g. cups), or be countable (e.g equivocal, an oral glucose tolerance test should be Priciples of Diabetes Education number of fruits or slices of yam or bread) performed Should be locally applicable, simple and effective - Weighing scales are generally unaffordable and/or - If diagnosis remains in doubt maintain surveillance All members of the diabetes care team should be trained difficult to understand to provide the education - Appetite suppressants generally yield poor and/or It must empower people with diabetes as well as their unsustainable weight reductions and are expensive families Physical activity - Provide them with adequate knowledge of diabetes and - One of the essentials in the prevention and management Valuesfor the Diagnosis of Categories of Hyperglycaemia its sequelae of Type 2 diabetes mellitus - Create the right attitudes and provide resources to Regular physical activity: provide appropriate self care Improves metabolic control Glucose ToleranceState Venousplasma (mmol/L) Venousplasma (mg/dL) The effectiveness of the programme must be evaluated Increases insulin sensitivity and modified as necessary Improves cardiovascular health Diabetes mellitus What people with diabetes need to know Helps weight loss Fasting³³ 7 126 Diabetes is serious but can be controlled Gives a sense of well-being 2 hour post-75 g glucose load³³ 11.1 200 Complications can be prevented Two main types of physical activity: That the cornerstones of therapy are education, diet and Aerobic or endurance exercise e.g. walking, running Impaired glucose tolerance exercise Anaerobic or resistance exercise (e.g. lifting weights) Fasting < 7.0 < 110 Their metabolic and blood pressure targets - Both types of activity may be prescribed to persons with AND How to look after their feet and thus prevent ulcers and type 2 diabetes mellitus; the aerobic form is usually 2 hour post-75 g glucose load³³ 7.8 and < 11.1 140 and < 200 amputations preferred How to avoid other long term complications General principles and recommendations Impaired fasting glycaemia That regular medical check ups are essential Detailed evaluation When to seek medical help - Cardiovascular, renal, neurological and foot Fasting³³ 6.1 and < 7.0 5.6 and < 6.1 Diet assessments - One of the cornerstones of diabetes management - Evaluation should be done before a formal exercise - Based on the principle of healthy eating in the context programme is commenced Unless there is unequivocal hyperglycaemia with acute metabolic decompensation or obvious symptoms, the of social, cultural and psychological influences on food - The presence of chronic complications excludes certain diagnosis of diabetes should always be confirmed by repeating the test on another day choices forms of exercises - Dietary modification (and increasing level of physical Prescribed physical activity programmes should be

91 92 Chapter 8: Endocrine System Standard Treatment Guidelines for Nigeria 2008 appropriate for: - (In some cases) at the first presentation of diabetes (i.e. Sulphonylureas and biguanides are the agents most Secondary failure of OGLAs is said to be common (5 - - The age fasting blood glucose more than 11 mmol/L or random widely available 10% of patients annually) although no reports from - Socio-economic status blood glucose more than 15 mmol/L) - Stocking these agents would meet the diabetes care Africa are available - State of physical fitness May be used as monotherapy or in combination therapy, needs of most diabetes facilities Insulin Therapy in Type 2 Diabetes - Lifestyle targeting different aspects in the pathogenesis of The choice of OGLAs should be informed by: Insulin is increasingly being used - Level of control hyperglycaemia in Type 2 diabetes mellitus - Lifestyle - In combination with OGLAs or as monotherapy in the Exercise generally improves metabolic control, but can - i.e. increasing insulin production and release, - Degree of control management of Type 2 diabetes to achieve optimum precipitate acute complications like hypoglycaemia and decreasing insulin resistance and/or decreasing hepatic - Access to medicines targets hyperglycaemia glucose production - Economic status - Hyperglycaemic emergencies Physical activity should : Sulphonylureas - Mutual agreement between the doctor and the person - Peri-operatively, especially major or emergency - Be regular (about 3 days/week) Initial monotherapy in non-obese patients with diabetes surgeries - Last at least 20 - 30 minutes per session Add-on as combination therapy Monotherapy with any of the drugs should be the initial - Organ failure: renal, liver, heart etc - Be at least of moderate activity Adult: Glibenclamide 1.25 - 10 mg orally twice daily choice - Pregnancy Activities like walking, climbing steps (instead of Child 12 - 18 years: initially 2.5 mg orally daily with, or - Use of stepped-care approach is recommended - LatentAutoimmune Diabetes ofAdults (LADA) taking lifts) should be encouraged immediately after breakfast, adjusted according to If overweight (BMI > 25 kg/m2 ) or if insulin resistance - Sensitivity to OGLAs For sedentary persons with diabetes, a gradual response; maximum 15 mg daily is the major abnormality Regimen and dose of insulin therapy will vary from introduction using a low intensity activity like walking is - Indicated for Type 2 diabetes, maturity-onset diabetes - Metformin should be the first choice patient to patient mandatory of the young, under specialist care - If metformin is contraindicated thiazolidinediones may Two forms of insulin therapy are often used in Avoid exercising if : Notable adverse drug reactions be used combination with OGLAtherapy - Ambient glycaemia is > 250 mg/dLblood glucose Weight gain Avoid metformin and long acting sulphonylureas in - Intermediate/long-or- acting insulin plus OGLA pre - Patient has ketonuria Hypoglycaemia elderly patients mixed insulin - Blood glucose is less than 80 mg/dL Syndrome of inappropriateADH secretion - Instead, use short acting sulphonylureas and/or glinides Referral to an endocrinologist should be considered if To avoid exercise-induced hypoglycaemia in patients Blood dyscrasias or glitazones more than 30 units of insulin are required per day on insulin Heart burn Combination therapy using OGLAs with different - Increase peri-exercise carbohydrate intake Abdominal pain mechanisms of action is indicated if monotherapy with - Reduce insulin dose Contraindications one of the agents has failed - Adjust injection site (avoid exercising muscles site) Allergy to sulpha drugs The rapid acting secretagogues (glinides) and the alpha For persons with type 2 diabetes mellitus on long acting Liver impairment glucosidase inhibitors make for flexibility in the insulin secretagogues Severe renal failure glycaemic management of Type 2 diabetes mellitus but - Extra carbohydrate should be taken before and after the Pregnancy are relatively very expensive exercise Age > 80 years When oral combination therapy fails, insulin should be In those on short acting secretagogues (e.g. glipizide, Biguanides added to the treatment regimen or should replace the repaglinide) the post exercise dose should be omitted Indicated in: OGLAs Glycaemia should be monitored (using strips and Monotherapy in obese Type 2 diabetes mellitus meters) before and after planned physical activity Combination therapy - Delayed hypoglycaemia may occur Metabolic syndrome Proper foot wear must always be worn during exercise Allergy to sulphonylureas For a prescribed formal activity, the exercise session Adult: Metformin 500 mg - 1 g orally twice or three times Time Course ofAction of Insulin Preparations should consist of: daily - Awarm-up period of5-10minutes Child 10 - 18 years: initially 500 mg orally once daily, Insulin Preparation Onset ofAction PeakAction Duration ofAction Injections per day - The activity proper: 20 - 60 minutes adjusted according to response at intervals of not less - Acool-down period of5-10minutes than 1 week; maximum 2 g daily in 2-3 divided doses Veryrapid acting In most parts of Africa, prescribing formal exercise in - Under specialist supervision ONLY (insulin analogues) 10 min 1 h 3 h Immediately gyms or requiring special equipment is a recipe for non- - Not licensed for use in children less than 10 years old before meals adherence to the exercise regimen Notable adverse drug reactions Patients should be encouraged to integrate increased Gastrointestinal upset/nausea/loose bowel motions Short-acting 30 min 2-5h 5-8h 30minbefore physical activity into their daily routine Metallic taste meals - The programme should impose minimum (if any) extra Lactic acidosis financial outlay in new equipment and materials Contraindications Intermediate-acting Drug treatment Impaired hepatic and renal function (NPH or lente) 1-3h 6-12h 16-24h Once or twice daily Oral hypoglycaemic agents: Congestive cardiac failure - For Type 2 diabetes mellitus Contrast studies Biphasic mixtures Indicated : Chronic obstructive airways disease (30/70; premixed) 30 min 2 - 12 h 16 - 24 h Once or twice daily - When individualized targets are not met by the Alcoholism combination of dietary modifications and physical Important notes on Oral Glucose Lowering Agents activity/exercise (OGLAs)

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Monitoring glycaemic control - Between 24 and 28 weeks of gestation treatment with insulin and intravenous fluids - 100% oxygen by intermittent positive pressure Clinical and laboratory methods are employed Who: Women with Blood ketones (acetoacetate and 3-hydroxbutyrate) ventilation HbA1c tests are desirable standard tests but are - High risk for GDM concentration > 5 mmol/L Intravenous dexamethasone, mannitol for cerebral unavailable in most of the primary and secondary health - BMI³ 25 kg/m2 Carries a high mortality inAfrica oedema (see cerebral oedema) facilities inAfrica - Previous history of GDM - Through late presentation, delayed diagnosis and Treat specific thromboembolic complications if they Fasting plasma glucose performed in the laboratory in - Glycosuria inadequate treatment occur place of HbA1c is the best alternative - Previous large baby (> 4 kg) Presents at any age although there is a well defined peak - Its average for repeated measurements gives a reliable - Poor obstetric history at puberty Diabetic non-ketotic hyperosmolar state indication of the control - Family history of diabetes Causes include: Introduction Glycosuria is a poor means of assessment of control - Known IGT / IFG Infection Characterized by the insidious development of: Self Blood Glucose Monitoring (SBGM) should be Management Management errors Marked hyperglycaemia (usually > 50 mmol/L) encouraged Combined health care team- obstetrician, diabetologist, New cases of diabetes (treatment not commenced) Dehydration Results of self urine testing or blood glucose tests diabetes educator, and paediatrician/neonatologist No obvious cause in about 40% of cases Pre-renal uraemia should be recorded in a logbook Initial therapy is dietary modification Indications for immediate hospital admission - Significant hyperketonaemia does not develop Clinic protocols should set out in some detail, the - Spread carbohydrate over 3 small to moderate sized Repeated vomiting or inability to take adequate oral Two-thirds of cases occur in previously undiagnosed parameters to be monitored at the initial visits, at regular meals and 2 - 3 snacks/day fluids cases of diabetes follow-up visits, and at annual reviews - Consider an evening snack to prevent starvation ketosis Hyperventilation Usually affects middle- aged or elderly patients and At the initiation of insulin therapy, appropriate advice - Energy intake should provide for desirable weight gain Any disturbance of consciousness carries a mortality of over 30% on SBGM and diet should be given during pregnancy Persistent ketonuria Precipitating factors include: Treatment of co-morbidities - For obese women a 30 - 33% calorie restriction is Presence of infections Infections Examples are obesity, hypertension and dyslipidaemias advised Initial treatment plan for Diabetic Ketoacidosis in adults Diuretic treatment - See relevant chapters Daily SBGM (urine glucose monitoring) is not useful Fluids and electrolytes Drinking glucose-rich beverages Diabetic foot problems in pregnancy - One litre per hour for 3 hours; thereafter according to Treatment Introduction Initiate insulin therapy if: need Rehydration People with diabetes are at increased risk of foot ulcers - Fasting plasma glucose is > 5.8 mmol/L - Sodium chloride 0.9% injection Insulin therapy and amputations which are major causes of morbidity - 1 hour post-prandial glucose is > 8.6 mmol/L - Hypotonic (half-normal) saline: 75 mmol/L if plasma Electrolyte replacement and disability - 2 hour post-prandial plasma glucose is >7.5 mmol/L sodium exceeds 150 mmol/L - In a manner similar to that used for diabetic ketoacidosis Both foot ulcers and amputations can be prevented by Modify insulin regimen to achieve above targets - Glucose 5% when blood glucose level falls below14 education, anticipation, early recognition and prompt Regular assessment of maternal wellbeing should mmol/L management include blood pressure and urine protein Plus: Hypoglycaemia The most common predisposing factors for ulcers and Regular surveillance for foetal well-being Potassium (K+ ) replacement Introduction amputations are: Delivery at 38 weeks gestation recommended - To be added into each litre of fluid Affects over 70% of patients on insulin therapy Peripheral neuropathy with loss of sensation Withdraw therapy for diabetes after birth Plasma K+ less than 3.5 mmol/L: Common causes of hypoglycaemia in persons with Poor foot hygiene Re-assess classification of maternal status at 6 weeks Add 40 mmol KCl diabetes mellitus Peripheral vascular disease post partum Plasma K+ 3.5 - 5.5 mmol/L: Engaging in more exercise than usual Deformities and abnormal biomechanics Add 20 mmol KCl Delay or omission of a snack or main meal Unsuitable or no footwear Acute metabolic complications of diabetes mellitus Plasma K+ greater than 5.5mmol/L: Administration of too much insulin Cornerstones of management These are: Do not add KCl Eating insufficient carbohydrate Regular inspection and examination of the foot at risk Diabetic ketoacidosis Plus: Overindulgence in alcohol Identify the at-risk foot Non-ketotic hyperosmolar states Insulin Overdosing with sulphonylureas Education of healthworkers, people with diabetes and Hypoglycaemia - To be added into intravenous fluid for rehydration In the presence of low blood glucose (< 2 mmol/L) their families Lactic acidosis - Initially,5-10units/hour; by continuous intravenous characteristic symptoms and signs include: Appropriate footwear - Acute hyperglycaemic complications may present infusion Light headedness Early treatment of non-ulcerative and ulcerative foot with coma or altered levels of consciousness in people - Maintenance 2 - 4 units/hour, titrated against blood Headaches problems with diabetes glucose levels (until able to eat) Tremulousness Differential diagnoses Intramuscular injections: Palpitations Diabetes in pregnancy Stroke - 20 units immediately, then 5 - 10 units/hour, titrated Sweating Introduction Seizures against blood glucose levels Feeling of hunger Gestational diabetes mellitus (GDM) is any degree of Trauma Other measures: Tachycardia glucose intolerancefirst recognised in pregnancy Drug overdose Treat precipitating cause (e.g. infection, myocardial Hypertension (usually systolic) If inadequately managed, GDM is associated with Ethanol intoxication infarction) Stroke-like presentations increased risk of perinatal morbidity and mortality Correct hypotension (should respond to adequate fluid Coma Diagnosis and prompt institution of therapy reduce the replacement) Acute management risks of poor outcomes Diabetic ketoacidosis Pass nasogastric tube if consciousness is impaired Oral glucose if patient is conscious Screening for GDM Introduction Ventilateif adult respiratory distress syndrome develops If patient is unconsious: When: Severe uncontrolled diabetes requiring emergency

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Some important features of the main types of diabetic emergencies are shown below: Aetiology Cardiac failure Grave's disease (80% of patients) Loss of visual acuity Diabetic Ketoacidosis Hyperosmolar non-ketotic Hypoglycaemic coma Lactic acidosis Multinodular goitre Infertility state Autoimmune functioning solitary thyroid nodule Periodic paralysis Thryroiditis (sub-acute or postpartum) Investigations Hyperventilation No hyperventilation Normal breathing Hyperventilation Iodine induced- drugs such as : Specific: Dehydration Tachypnoea; Dehydration more severe No dehydration Absence of acetone odour - Amiodarone Serum T34 , T and TSH levels Kaussmaul breathing Marked polydipsia and Absence of acetone breath Common in those taking 131 Acetone breath polyuria May occur in all categories of biguanides - Radiographic contrast media Measurement of I intake by the thyroid gland More common in insulin- Absence of acetone breath persons with diabetes Diagnosis made only - Iodine prophylaxis programmes Non-specific: dependent persons; may occur Usually seen in Type 2 Cold, clammy skin; profuse when other causes of Extra-thyroidal sources of thyroid hormone excess Liver function tests in Type 2 diabetes Warm skin diabetes sweating metabolic acidosis have - Factitious hyperthyroidism - Slightly raised concentrations of bilirubin, alanine Normal or low blood pressure Normal, low or elevated blood Systolic hypertension may been excluded - Struma ovarii aminotransferase Hyperglycaemia and pressure precede coma Blood lactate levels not TSH-induced: Serum calcium glycosuria Hyperglycaemia more marked Low blood glucose commonly measured - Inappropriate TSH secretion by the pituitary Hyperketonaemia and Absence of ketones in blood Absence of ketones in blood - Mild hypercalcaemia ketonuria and urine and urine - Choriocarcinoma Fasting blood glucose Fall in blood pH No change in blood pH No change in pH - Hydatiform mole - Glycosuria may be present Increased free fatty acid Normal fatty acid levels Follicular carcinoma of the thyroid with metastasis Treatment objectives Levels in blood Clinical features Achieve normal metabolic rates

Agoit may or may not be present Obtain normal serum T34 , T and TSH Levels - May be diffuse or nodular Prevent complications Dermatological: Drug treatment Increased sweating and pruritus Antithyroid drugs Intravenous glucose Onset of diabetes can be delayed in people at high risk Pretibial myxoedema - Carbimazole - 50% glucose given as a bolus of 40 - 50 mL by active lifestyle modification Pigmentation, vitiligo Adult: starting dose 30 - 60 mg orally in divided doses Or: - Lifestyle modification should be the cornerstone of Palmar erythema. daily - 20% glucose 100 - 150 mL followed by 8 - 10% glucose preventative strategies in the following categories of Cardiorespiratory: Maintenance: 10 - 15 mg oral daily infusion if necessary people: Dyspnoea on exertion Child: neonate, initially 250 micrograms/kg orally every Or: Age > 45years Angina and cardiac failure 8 hours until euthyroid then adjust as necessary 2 Injectable glucagon Overweight and obesity (BMI > 25 kg/m ) Increased pulse pressure 1 month - 12 years: initially 250 micrograms/kg - 1 mg intramuscularly stat Physical inactivity Exacerbation of asthma (maximum 10 mg every 8 hours) until euthyroid then If hypoglycaemia is due to long acting sulphonylureas, or First degree relatives with diabetes Gastrointestinal: adjusted as necessary long and intermediate acting insulin or alcohol Previous gestational diabetes Weight loss despite increased appetite 12 - 18 years: initially 10 mg every 8 hours until Prolonged intravenous glucose infusion (5 - 10% for 12 Previously identified IGT or IFG Diarrhoea euthyroid then adjusted as necessary - 24 hours; even longer) may be necessary Dyslipidaemia Steatorrhoea - Higher initial doses occasionally required, particularly If intravenous access is impossible: Hypertension Neuromuscular: in thyrotoxic crisis Consider nasogastric or rectal glucose The components of lifestyle modification should include Tremors, nervousness, irritability, emotional lability Child and carers to inform doctor immediately if sore Or: (but not be limited to) the following: and psychosis throat, mouth ulcers,bruising, fever, malaise or non- Give glucagon 1 mg intramuscularly - Lose 5 - 10% weight Muscle weakness and proximal myopathy specific illness develops As a last resort: - Reduce fat intake (< 30% of total daily calories) Reproductive: Propylthiouracil Administer epinephrine (adrenaline) - Reduce saturated fat intake (< 10% of total daily Loss of libido, impotence Adult: starting dose 300 - 450 mg orally in divided doses - 1 mLof 1 in 1,000 strength, subcutaneously stat calories) Amenorrhoea/oligomenorrhoea daily On recovery: - Increase fibre intake to > 15 g/1000 kcal Infertility and spontaneous abortions Maintenance: 100 - 150 mg orally in 2 or 3 divided doses Give a long acting carbohydrate snack - TraditionalAfrican diets are high in fibre content Ocular: daily Attempt to identify the cause of hypoglycaemia and - Increase levels of physical activity e.g.brisk walking Lid lag lid retraction Child: neonate, initially 2.5 - 5 mg/kg orally every 12 correct it producing a heart rate >150/min Grittiness, excessive lacrimation hours until euthyroid, then adjusted as necessary Assess the type of insulin used, injection sites and - Exercise should last for at least 30 minutes and should Exophthalmos diplopia 1 month - 1 year: initially 2.5 mg/kg every 8 hours until injection techniques be undertaken at least three times a week Papilloedema euthyroid; 1 - 5 years: 20 mg/kg 8 hourly until euthyroid; - Lipohypertophy can alter the rate of absorption - Reduce high alcohol intake Others: 5 - 12 years: initially 50 mg every 8 hours until euthyroid; Enquire into, and correct inappropriate habits of eating, Increased thirst 12 - 18 years: initially 100 mg every 8 hours until exercise and alcohol consumption HYPERTHYROIDISM (Thyrotoxicosis) Fatigue and apathy euthyroid Review other drug therapy and renal function Introduction Differential diagnosis - Higher doses occasionally required particularly in Adjust insulin or OGLAdosages as appropriate Aclinical syndrome which results from exposure of the Simple goitre thyrotoxic crisis Prevention of diabetes body to excess levels of the thyroid hormones, Malignant tumours of the thyroid - Duration of treatment usually is 18 - 24 months Complications Generalised obesity, central obesity and physical Thyroxine (T43 ) and Tri-iodothyronine (T ) β- adrenergic blocking drugs inactivity are the major modifiable risk factors, and More females are affected than males (usually in the Hyperthyroid crisis (thyroid storm) - Propranolol 80 - 160 mg orally daily in divided doses should be avoided/corrected ratio of 5:1) Compression of the trachea - Symptoms and signs of hyperthyroidism due to

97 98 Chapter 8: Endocrine System Standard Treatment Guidelines for Nigeria 2008 adrenergic stimulation may respond to these agents May be primary or secondary Child 1 month - 2 years: initially 15 micrograms/kg CHAPTER 9: EYE DISORDERS Iodine Primary hypothyroidism more common orally once daily, adjusted in steps of 25 micrograms Used in: - Probably an autoimmune disease; may occur as a daily every 2 - 4 weeks until metabolism normalizes ACUTEANTERIOR UVEITIS (Iritis) - The emergency management of thyroid storm sequel to Hashimoto's thyroiditis 2 - 12 years: initially 5 - 10 micrograms/kg once daily Introduction - Thyrotoxic patients undergoing emergency surgery - Post therapeutic hypothyroidism (medical or adjusted in steps of 25 micrograms daily every 2 - 4 Inflammation of the iris (with or without the cilliary - For the preoperative preparation of thyrotoxic patients surgical) weeks until metabolism normalizes body) selected for subtotal thyroidectomy Secondary hypothyroidism: 12 - 18 years: initially 50 - 100 micrograms once daily, Usually occurs without any associated systemic Aqueous iodide oral solution (Lugol's solution): Occurs when there is failure of the hypothalamic- adjusted in steps of 50 micrograms daily every 3 - 4 inflammation - Iodine 5%, potassium iodide 10% in purified water; pituitary axis due to weeks until metabolism normalizes (usual dose 100 - 200 Tends to recur total iodine 130 mg/mL - Deficient secretion of TRH from the hypothalamus micrograms daily Clinical features Adult: 2 - 3 drops of saturated potassium iodide solution Or: Or: Eyeball is tender orally 3 or 4 times daily (300 - 600 mg/day) - Lack of secretion of TSH from the pituitary Liothyronine sodium (1-tri-iodothyronine sodium) Phoptophobia due to cilliary spasms Child: neonate 0.1 - 0.3 mLorally every 8 hours; 1 month Clinical features Adult: initially 10 - 20 micrograms orally daily, gradually Exudation into anterior chamber - 18 years: 0.1 - 0.3 mLevery 8 hours Generally in striking contrast to those of increased to 60 micrograms daily in2-3divided doses Flare and cells Thyrotoxic crisis: hyperthyroidism; may be quite subtle, with an insidious - Small initial doses in the elderly Keratic precipitates onset In hypothyroid coma: Hypopion Child 1 month - 1 year: 0.2 - 0.3 mL8 hourly In adults: - 5 - 20 micrograms by slow intravenous injection, Posterior synechiae - Dilute with milk or water Dull facial expression, slow speech and poor memory repeated every 12 hours (as often as every 4 hours if Miosis due to spasm of sphincter pupillae Radioactive sodium iodine (I131 ) Puffiness of the hands, feet and face necessary)Alternatively: Differential diagnoses - Used in patients who are past child bearing age Lethargy and fatigue - 50 micrograms by slow intravenous injection initially Infective conjunctivitis - Dosage difficult to gauge; the response of the gland is Thinning, dryness and loss of hair then 25 micrograms every 8 hours, reducing to 25 Acute iritis unpredictable Hypothermia micrograms daily Acute glaucoma - Up to 25% of patients given enough radioactive iodine Bradycardia Child 12 - 18 years: 10 - 20 micrograms orally daily, Complications to achieve euthyroidism may develop hypothyroidism Reduced systolic and increased diastolic blood gradually increased to 60 micrograms daily in 2 - 3 Secondary glaucoma within one year pressure divided doses Cataracts - High incidence of recurrence of hyperthyroidism if Weight gain In hypothyroid coma: Investigations smaller doses are used Decreased reflexes 1 month - 12 years: 2 - 10 micrograms by slow Chest radiograph to exclude sarcoidosis and tuberculosis Surgery Constipation intravenous injection every 8 hours (up to every 4 hours Spinal X-ray (especially lumbrosacral segment) to Indications include: Menstrual abnormalities if necessary); exclude ankylosing spondilytis Patients < 21 years who should not receive radio iodine In infants: - Reduce to 1 - 5 micrograms in patients with Treatment Persons who cannot tolerate other agents because of Mental and physical retardation cardiovascular disease Corticosteroid drops for treatment of inflammation: hypersensitivity, or for other reasons - If not corrected, cretinism 12 - 18 years: 5 - 20 micrograms, repeated every 12 hours Betamethasone sodium phosphate 0.1% Patients with very large goiters, having compressive Differential diagnoses (up to every 4 hours if necessary) - Apply eye drops every 1 - 2 hours until inflammation is symptoms or signs Endogenous depression - Reduce to 10 - 20 micrograms in patients with controlled then reduce frequency Some patients with toxic adenoma and multinodular Reactive depression cardiovascular disease - Subconjunctival injection of steroid if severe goitres Complications Supportive measures Atropine sulfate 0.5% or 1% Supportive measures Myxoedema coma Treat anaemia, constipation and other complications as - 1 drop up to 4 times daily Appropriate care of any system affected e.g eye care, Cretinism in the young appropriate Caution treatment of heart failure Investigations Immediate mechanical ventilation in myxoedema Avoid atropine drops if there is risk of acute glaucoma

Thyroid storm would require judicious intravenous Total serum T34 and T levels coma Prevention fluid use, corticosteroids and treatment of the TSH stimulation test Notable adverse drug reactions, caution No real preventive measures precipitating cause TRH test - T3 should not be used alone for long term replacement Notable adverse drug reactions, caution and Treatment objectives therapy contraindications Establish cause - Monitor serum levels of hormones to ensure that ACUTE KERATITIS Carbimazole and propylthiouracil Establish the severity of hypothyroidism patients are not exposed to cardiac risks Introduction - May cause severe bone marrow suppression Restore normal body functions Prevention Infection or inflammation of the cornea (including pancytopemia and agranulocytosis) Prevent complications Iodinated salt to prevent iodine deficiency Could be secondary to trauma - They are contraindicated in breastfeeding mothers Drug treatment Sometimes associated with infective conjunctivitis Replacement therapy Could occur de novo - Levothyroxine sodium (thyroxine sodium) Clinical features HYPOTHYROIDISM (Myxoedema) Adult: initially 20 - 100 micrograms (50 micrograms Irritation, pain Introduction for those over 50 years) orally daily, preferably before Red eye (conjunctival congestion) Refers to subnormal amounts of thyroid hormones in breakfast Eye discharge: watery; purulent if bacterial the circulation, and the clinical features associated with - Adjusted in steps of 50 micrograms every 3 - 4 weeks Photophobia this until metabolism normalizes (usually 100 - 200 Visual impairment, depending on the site and size of Aetiology micrograms daily) ulcer and if interstitial

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Hypopion, if associated with uveitis (no hypopion if - May be associated with itchy ears and throat, or Chemicals e.g., alkali or acid ruptured globe, or if infection not settling on antibiotics viral) sinusitis Clinical features Chemical burns Ulceration of cornea, which stains with fluorescene; no Brownish discolouration of the conjunctiva Blunt injury Copious rinsing of eyeball and fornices with sodium ulcer in interstitial keratitis Eyelid oedema Eyelids: peri-orbital haematoma and oedema chloride 0.9% or clean water at site Aetiology Red eyes occasionally, with watering when acute Conjunctivae: subconjunctival haemorrhage and In hospital, copious rinsing again, to dilute offending Exogenous Follicles on the bulbar conjunctiva especially at the chemosis agent - Marginal ulcers secondary to bacterial conjunctivitis limbus Cornea: abrasion or oedema Remove particles from eye e.g. lime or cement ()S. aureus Papillae on the tarsal conjunctiva (seen on eversion of Anterior chamber: hyphaema from tears of the iris or Antibiotic ointment - Central ulcers (Pneumococcus,Herpes simplex , fungi) the eyelid) cilliary body Rodding of fornices with ointment to prevent Keratomalacia (VitaminAdeficiency) Phlycten in tuberculosis- appears as a yellow nodule Iris: traumatic mydriasis symblepharon Exposure (7th cranial nerve palsy or dysthyroid eye with surrounding leash of engorged vessels Traumatic uveitis Topical steroids for uveitis once cornea is re-epithelized disease) Aetiology Angle recession Vitamin C (ascorbic acid) Endogenous Exogenous allergens Lens: dislocation into anterior or posterior chambers; Caution and contraindications - Interstitial keratitis of congenital syphilis - Topical drugs - atropine, penicillin cataract Avoid the use of topical steroids in active corneal - Interstitial keratitis of Herpes zoster - Cosmetics Vitreous haemorrhage ulceration Differential diagnoses - Pollen from plants and flowers (hay fever or spring Retina: peripheral tear leading to retinal detachment; Avoid the use of harmful traditional eye medications; Infective conjunctivitis catarrh) oedema with haemorrhage (Commotio Retinae) may cause more complications Acute iritis - House dust mite and animals Choroid: tear with haemorrhage Prevention Acute glaucoma Endogenous allergens Rupture of the eyeball, usually posteriorly (rare) Wearing of appropriate protective eye goggles for sports, Complications Phlyctenular conjunctivitis caused by tuberculo-protein Optic nerve: avulsion welding and when working with chemicals Corneal perforation Differential diagnoses Blow out fracture of the orbital wall Investigations Trachoma Sharp Injury Corneal scraping for microscopy, culture and sensitivity Other forms of conjunctivitis Lacerations of eyelids, conjunctivae, cornea, sclerae, or Drug treatment Complications corneo-sclera FOREIGN BODIES IN THE EYE Antibiotic drops (if bacterial) Pannus formation Uveal prolapse with or without lens extrusion Introduction - Chloramphenicol eye drops 0.5% Keratoconus Intraocular foreign body Foreign bodies are usually in the form of small particles - Apply 1 drop at least every 2 hours, and then reduce Corneal plaques Endophthalmitis of metal, vegetable matter or insects which embed on the frequency as infection is controlled and continue for 48 Investigation Chemical burns surface of the eye hours after healing Skin sensitivity test to detect allergen Acids coagulate surface proteins Occasionally a high velocity material, usually a metal Atropine drops Drug treatment Alkalis penetrate into the anterior chamber causing could be propelled into the eye - 1 drop up to 4 times daily Antiinflammatory preparations uveitis Clinical features Antivirals (if dendritic ulcer) -Antazoline sulfate 0.5%, xylometazoline hydrochloride - Symblepharon: adhesions between bulbar and tarsal May be embedded on the tarsal or bulbar conjunctiva, - Idoxuridine 5% in dimethylsulfoxide 0.05% conjunctivae the cornea or inside the eye Adult and child over 12 years: apply to lesions 4 times Adult and child over 5 years: apply 2 - 3 times daily Differential diagnoses - Intraocular foreign body (IOFB) daily for 4 days, starting at first sign of attack - Sodium cromoglycate eye drops Conjuctivitis IOFBs may be in the anterior chamber, iris, lens or Child under 12 years: not recommended Adult and child: apply four times daily Endophthalmitis vitreous; on the retina or even behind the eyeball after Topical steroids - Diclofenac sodium 0.1% eye drops Orbital cellulitis doubly perforating the eye - Only for interstitial keratitis where there is no active Adult and child: apply once daily Complications Differential diagnoses ulcer Phlyctenular conjuntivitits: Ruptured globe Corneal abrasion Non-drug measures Treat for tuberculosis using standard regimen Endophthalmitis Endophthalmitis Lateral tarsorrhaphy for exposure keratopathy Caution Reversible blindness (compression of optic nerve by Complications Caution and contraindications to treatment Xylometazoline is a sympathomimetic; use with caution orbital haematoma) Perforation of the eye Never use topical steroids in the presence of an active in patients susceptible to angle closure glaucoma Irreversible blindness (optic nerve avulsion) Endophthalmitis ulcer Systemic absorption of antazoline and xylometazoline Corneal opacity/scarring Retinal toxicity from a metallic IOFB Prevention may result in interactions with other drugs Investigations Investigation Treat initial infection or trauma promptly to avoid Prevention Orbital radiographs Radiograph of the orbit with a localizing ring progression to keratitis Avoid allergen(s) as much as possible in cases where Orbital ultrasound Management it/they have been identified Management Removal of subtarsal, conjunctival or corneal foreign Blunt injuries body under magnification e.g. slit lamp microscope Treat individual injury Caution ALLERGIC CONJUNCTIVITIS EYE INJURIES Sharp injuries Ultrasound should be avoided in an eye with a Introduction Introduction Suture lacerations perforating wound Could occur on it own or in association with Injuries to the eye could be caused by blunt or sharp Remove foreign bodies with magnet if possible, or by Prevention generalized atopy (asthma, eczema, spring catarrh) objects or chemicals vitrectomy Appropriate protective goggles for sports, welding, Clinical features Aetiology Parenteral antibiotics, if infected game hunting etc Itching of the eyes with grittiness Blunt injuries e.g. a fist or a ball hitting the eye Evisceration (removal of the contents of the eyeball) if Sharp injuries e.g. glass, metal, broom stick, etc

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INFECTIVE CONJUNCTIVITIS intramuscular injection, intravenous injection over 2 - 4 Apply 1 drop at least every 2 hours, and then reduce Treat arthritis if active Introduction minutes, or by intravenous infusion frequency as infection is controlled Caution The commonest cause of a red eye is infective 1 month - 12 years (body weight under 50 kg) 50 mg/kg Or: Avoid prolonged use of steroids conjunctivitis which could be caused by bacteria or once daily, up to 80 mg/kg in severe infections Ofloxacin 0.3% eye drops Prevention viruses Chlamydia Apply twice daily. (not to be used for more than 10 days) No real preventive measures available Clinical features - Systemic erythromycin Or: Red eye (generalized) Adult and child over 8 years: 250 - 500 mg orally every 6 Tetracycline 1% eye ointment Eye discharge: purulent or catarrhal, worse on waking hours (or 500 mg - 1 g every 12 hours) Apply 3 times daily for one week or more, depending on from sleep 1 month - 2 years: 125 mg orally every 6 hours; dose the severity of the condition STYE (HORDEOLUM) Eye discomfort: grittiness doubled in severe infections Plus Introduction Photophobia: mild 2 - 8 years: 250 mg 6 hourly; 8 - 18 years: 250 - 500 mg 6 Ciprofloxacin 10 mg/kg per dose intramuscularly 12 External stye Swollen eyelids in ophthalmia neonatorum hourly; dose doubled in severe infections hourly for 2 days - Infection of the lash follicle and its associated gland of Aetiology Caution and contraindications Or: Zeis or Moll Staphylococcus aureus Steroid drops are absolutely contraindicated Ceftriaxone 100 mg/kg by deep intramuscular injection Internal stye (chalazion) Pneumococcus Prevention or intravenous injection over 2 - 4 minutes every 24 hours - Infection of the meibomian gland Haemophillus influenzae Wash hands thoroughly after any unhygienic procedure - By intravenous infusion: 1 g daily,2-4ginsevere Clinical features Gonococcus: ophthalmia neonatorum Avoid sharing towels used for cleaning face infections Painful lump growing on the eyelid Use of infected urine to treat a red eye Child: neonate, infuse over 60 minutes, 20 - 50 mg/kg Red swollen area on the eyelid (like a boil) TRIC agent (chlamydia) daily (maximum 50 mg/kg daily) Pain in the affected area of the eyelid Adenovirus: Epidemic keratoconjunctivitis ('Apollo') OPHTHALMIANEONATORUM Child under 50 kg: 20 - 50 mg/kg daily by deep Chalazion: firm, painless lump on the eyelid, usually the Differential diagnoses Introduction intramuscular injection or by intravenous injection over 2 upper lid Allergic conjunctivitis Infection in both eyes of a newborn baby in the first one - 4 minutes, or by intravenous infusion; up to 80 mg/kg Differential diagnoses Acute keratitis month of life, without obstruction of the nasolacrimal daily in severe infections Variouseyelid cysts and tumours Acute iritis/uveitis ducts Caution Complications Acute glaucoma Clinical features Do not use steroids eyedrops Pre-septal cellulitis Complications Swollen eyelids: Penicillin drops are not effective in the treatment of Orbital cellulitis Corneal affectation which could lead to perforation - It may be impossible to see the baby's eye because of opthalmia neonatorum Cavernous sinus thrombosis Endophthalmitis the swelling Prevention Investigations Investigation Red eyes: Apply tetracycline eye ointment or silver nitrate drops If recurrent, screen for diabetes Conjunctival swab for microscopy, culture and - The conjunctivae are less inflamed in chlamydial in both eyes of neonates immediately after delivery Non-drug measures sensitivity infection Proper antenatal care for early detection of infection in Apply warm wet pads for 15 minutes 4 times daily until Non-drug measures Pus: mothers the stye drains Dark glasses for photophobia - Oozes out when the eyelids are opened Incision and curettage (if there is still a chalazion lump), Drug treatment Fever: as soon as the infection settles Antibiotic eyedrops or ointments - May or may not be present Drug treatment - Chloramphenicol 0.5% Aetiology SCLERITIS / EPISCELITIS Antibiotic eye ointment to stop infection - Apply one drop at least every 2 hours until infection is Bacterial: Introduction - Chloramphenicol ointment apply 4 times daily for 2 controlled then reduce frequency and continue for 48 - EspeciallyNeisseria gonorrhoea : starts within 3 days Inflammation of the sclera and episclera weeks hours after healing after birth Usually self-limiting but relapses may occur Systemic antibiotics Inclusion conjunctivitis - Chlamydia ( usually starts 1 week after birth) Usually unilateral and associated with collagen disorders - Amoxicillin 250 - 500 mg orally every 8 hours for5-7 Sulphonamide drops or tetracycline drops or ointment Chemicals: Clinical features days Epidermic keratoconjunctivitis Others Dull, deep-seated pain in the eye Caution Antibiotic drops to prevent secondary bacterial Differential diagnosis Localized conjunctival congestion Discourage the use of traditional eye medication infection Lid oedema following prolonged difficult labour Differential diagnoses Prevention - Chloramphenicol 0.5% drops Complications Pterygium Clean eyelids regularly and thoroughly Adult and child over 2 years: apply every 4 hours for no Corneal perforation Phlyctenular conjunctivitis For recurrent styes, use baby shampoo to clean the more than 5 days Endophthalmitis Trauma to the eye eyelashes regularly Ophthalmia Neonatorum Investigation Complications - Gentamicin sulfate 0.3% applied as stated above Conjunctival swab for microscopy, culture and Thinning of the sclera Or: sensitivity Anterior staphyloma - Ofloxacin 0.3% solution applied as stated above Non-drug measures Scleral perforation THE RED EYE Plus: Copious irrigation to wash pus from the eyes with cooled Investigations Causes - Asystemic cephalosporin e.g. ceftriaxone boiled water or sodium chloride 0.9% Investigate for collagen diseases Infective conjunctivitis including ophthalmia Adult: 1 g every 12 hours intravenously for 7 days Drug treatment neonatorum Child: by intravenous infusion over 60 minutes Topical antibiotics Management Allergic conjunctivitis Neonates: 20 - 50 mg/kg once daily, by deep - Gentamicin 0.3% eye drops Topical steroids or NSAIDs for the duration of symptoms Keratitis

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Scleritis/episcleritis - 35 kg: 300 mg once daily for 3 days; body weight 36 - 45 CHAPTER 10: GENITO-URINARY SYSTEM Treatment objectives Trauma to the eye kg: 400 mg once daily for 3 days Correct primary haemodynamic abnormality See relevant sections Surgical treatment NEPHROLOGY Correct biochemical abnormalities Indicated for the treatment of trichiasis, entropion, Prevent further renal damage corneal scarring Non-drug treatment Corneal graft, but entropion must be corrected first ACUTE RENALFAILURE Fluid challenge (where indicated) TRACHOMA Caution and contraindications Introduction Low potassium, low salt, low protein diet Introduction Systemic tetracycline is contraindicated in young Asyndrome characterized by rapid decline in glomerular Avoid or discontinue nephrotoxic drugs Caused byChlamydia trachomatis , an organism children filtration rate with retention of nitrogenous waste Drug treatment midway between a bacterium and virus Prevention products, disturbance of extracellular fluid volume, Antihypertensive drugs (see treatment of hypertension) The organism is found in the conjunctival as well as Improve personal and public hygiene electrolytes and acid-base homeostasis Loop diuretics corneal epithelium and is responsible for two different Treat the whole community with topical or systemic Classification/aetiology Furosemide: conditions: antibiotics Pre-renalAcute Renal Failure - Initially 250 mg by intravenous infusion over 1 hour at - Trachoma (a severe disease) Prompt surgery for trichiasis and entropion to prevent Hypovolaemia (e.g. from haemorrhage, severe a rate not exceeding 4 mg/minute - Inclusion conjunctivitis (milder) blindness from corneal scarring diarrhoea and vomiting etc) - Give another 500 mg by intravenous infusion over 2 Trachoma is commonly associated with poverty and Low cardiac output (e.g myocarditis) hours if urine output is satisfactory unhygienic living conditions Renal hypoperfusion (e.g. from use of angiotensin - Effective dose can be repeated every 24 hours Clinical features converting enzyme inhibitors) - If no response, dialysis is probably required Acute phase: XEROPHTHALMIA Systemic vasodilatation (e.g. sepsis) Supportive therapy Irritable red eye Introduction Hyperviscosity syndromes (e.g polycythaemia) Regular intermittent haemodialysis Mucopurulent discharge The spectrum of eye diseases under Vitamin A Intrinsic renal failure Peritoneal dialysis Eyelid oedema, pain, photophobia in severe cases deficiency Renovascular obstruction (e.g. renal vein thrombosis) Prevention Chronic phase: Ranges from night blindness to conjunctival xerosis, to Glomerular disease e.g. glomerulonephritis Close attention to cardiovascular function and Follicles on tarsal conjunctivae Bitot's spots, corneal xerosis and finally keratomalacia Acute tubular necrosis (e.g. from ischemia) intravascular volume in high risk patients, especially Papillae Clinical features Interstitial nephritis (e.g. infections, allergic, from those with pre-existing renal insufficiency Superficial punctate keratitis Night blindness antimicrobials like rifampicin) Avoid hypovolaemia (especially in patients on Pannus formation on superior cornea Dryness of the conjunctiva and cornea (xerosis) Intratubular deposition and obstruction (e.g. uric acid, nephrotoxic drugs) End stage: Tearing oxalate stones) Adequate hydration and sodium loading in patients to Eyelid scarring with trichiasis, entropion Bitot's spots Renal allograft rejection be exposed to radiocontrast dye investigations (for Conjunctival scarring Corneal degeneration (keratomalacia) Post renalAcute Renal Failure example) Limbal scarring with Herbert's pits Differential diagnosis Ureteric obstruction (from calculi, blood clots etc) Corneal scarring Measles keratoconjunctivitis Bladder neck obstruction from prostate hypertrophy Differential diagnoses Complications Urethral obstruction (e.g. from strictures, congenital Other forms of infective conjunctivitis (especially viral) Corneal perforation urethral valves) CHRONIC KIDNEYDISEASE Allergic/vernal conjunctivitis Corneal scarring Clinical features Also chronic renal failure Corneal scarring from other diseases Blindness Thirst, dizziness, hypotension, tachycardia in pre-renal Complications Investigations ARF Introduction Trichiasis Conjunctival impression cytology (where available) Oliguria (not invariable) A progressive and persistent deterioration in kidney Entropion Serum VitaminAlevels Oedema, hypertension structure and function ultimately resulting in Corneal scarring Non-drug treatment Flank pain, hesitancy, nocturia, in post-renalARF accumulation of nitrogenous waste products and Investigations Nutrition education Complications disruption of acid-base homeostasis. Conjunctival scraping for microscopy Drug treatment Volumeoverload - Also associated with derangement in the kidney's - Immunofluorescence or Eliza test VitaminAcapsules 200,000 IU orally daily for two days, Hyperkalaemia osmoregulatory, metabolic and endocrine function Giemsa staining for trachoma inclusion bodies then one capsule after one week Metabolic acidosis Aetiology Drug treatment Topical antibiotics and antivirals where applicable Uraemic encephalopathy Hypertension Topical: Padding the eye (for active corneal ulceration) Hypertension Diabetes mellitus Tetracycline ointment applied 4 times a day for 6 weeks Caution Differential diagnoses Chronic glomerulonephritis Systemic: Avoid the use of harmful traditional eye medication Acute-on-chronic renal failure Systemic lupus erythematosus Erythromycin, tetracycline (not recommended for Prevention Chronic renal failure Chronic pyelonephritis young children) or the newer antibiotics e.g. Distribution of massive dose capsules of vitamin A to Investigations Genetic e.g. adult polycystic kidney disease, Alport's azithromycin as appropriate affected communities Urine microscopy: casts (granular, hyaline) syndrome - Azithromycin Nutrition and health education Urinalysis: proteinuria, haemauria Clinical features Adult: 500 mg orally once daily for 3 days Fortification of foods with vitaminA Serum Electrolytes, Urea and Creatinine Nocturia Child over 6 months: 10 mg/kg (maximum 500 mg) Full Blood Count with differentials Oliguria orally once daily for 3 days; over 6 months (body weight Abdominal ultrasound scan Bleeding tendencies 15 - 25 kg) 200 mg once daily for 3 days; body weight 26 Anaemia Hypertension (not invariable)

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Body swelling Child: 1 month - 1 year: 120 mg 3 - 4 times daily with Membranous glomerulopathy understood Pruritus feeds; 1 - 6 years: 300 mg; 6 - 12 years: 600 mg; 12 - 18 Mebrano- proliferative glomerulonephritis The associated malodour is due to the release of amines Bone pains years: 1.25 g; all 3 - 4 times daily prior to, or with meals Mesangio-proliferative glomerulonephritis produced by anaerobic bacteria that decarboxylate lysine Complications and adjusted as necessary Clinical features to caverdine, and arginine to putrescine Hyperkalaemia Aluminium hydroxide: Generalized body swelling Predisposing factors are the use of antiseptic/antibiotic Severe anaemia Adult: 300 - 600 mg orally 3 times a day with meals Passage of frothy urine vaginal preparations or vaginal douching Hypertensive heart disease Child 5 - 12 years: 1 - 2 capsules orally 3 - 4 times daily; Complications Clinical features Atherosclerosis 12 - 18 years: 1 - 5 capsules 3 - 4 times daily; adjusted as Peripheral arterial or venous thrombosis Malodorous and increased white vaginal discharge that Uraemic pericarditis necessary Acceleration of atherosclerosis is homogenous, low in viscosity, and uniformly coats the Renal osteodystrophy Supportive measures Protein malnutrition vaginal walls Metabolic acidosis Haemodialysis Vitamin D deficiency The fishy-smelling discharge is particularly noticeable Investigations Peritoneal dialysis Increased susceptibility to infections after sexual intercourse; usually no pruritus or inflamed Urine Definitive treatment is renal transplantation Iron-resistant microcytic hypochromic anaemia vulvae - Urinalysis Notable adverse drug reactions, caution and Differential diagnoses Differential diagnoses - Urine microscopy, culture and sensitivity contraindications Other causes of body swelling Other causes of vaginal discharge: see Gonorrhoea Blood See furosemide - Congestive heart failure Complications - Serum Electrolytes, Urea and Creatinine Potential for adverse drug reactions with drugs - Decompensated chronic liver disease Acute salpingitis - Creatinine clearance eliminated primarily by the kidneys e.g. aminoglycoside - Protein losing enteropathy Premature rupture of membranes - Full Blood Count; ESR antibiotics, NSAIDs, metformin, etc Investigations Preterm delivery and low birth weight - Serum lipids Calcium-containing phosphate-binding agents are Blood: Investigations - Serum proteins preferred in children but are contraindicated in - Serum proteins Homogeneous milky discharge with pH > 4.5 (pH > 6.0 - Serum calcium and phosphate hypercalcaemia or hypercalciuria - Serum lipids highly suggestive) Abdominal ultrasound scan Prevention Urine: Fishy odour from the biogenic amines; altered by Treatment objectives Appropriate management of known causes of chronic - Urinalysis addition of 10% KOH (Sniff test) Slow down rate of decline of GFR renal failure e.g. hypertension and diabetes mellitus - 24 hour urine collection for protein estimation Clue cells on a wet mount Manage hypertension Cautious use of nephrotoxic agents: avoid their use in - Abdominal ultrasound scan - Clue cells are normal vaginal epithelial cells studded Control hypertension patients with low renal reserves - Renal biopsy with bacteria, giving the cells a granular Provide renal replacement therapy (if in end stage) Early detection and treatment of renal disease when Treatment objectives appearance Non-drug treatment renal function is still adequate Reduce proteinuria Treatment objective Diet: low salt, low protein, low potassium Eradicate peripheral oedema To eliminate the organisms Avoid nephrotoxic agents Drug treatment Drug therapy Drug Treatment Diuretics e.g. loop diuretics like furosemide Recommended regimen: Anthypertensive agents (see treatment of hypertension) NEPHROTIC SYNDROME Glucocorticoids (e.g. prednisolone) - Metronidazole 400 mg orally, every12 hous for 7 days Diuretics (furosemide at doses appropriate for clinical Introduction - If renal biopsy and histology reveal a steroid-responsive Alternative regimen: condition) Aclinical complex characterized by cause of the nephrotic syndrome - Metronidazole 2 g orally, as a single dose Vitamin D and calcium supplements - Proteinuria of³ 3.5 g per 24 hours Cytotoxic drugs (e.g.cyclophosphamide) in some Or: Erythropoietin - Hypoalbuminaemia steroid-resistant cases - Metronidazole 0.75% gel 5 g intravaginally, twice daily - Initially 50 units/kg 3 times weekly; adjusted according - Generalized oedema Prevention for 7 days to response in steps of 25 units/kg 3 times weekly at - Hyperlipidaemia; lipiduria Avoid nephrotoxins Notable adverse drug reactions, caution intervals of at least 4 weeks - Hypercoagulability Treat bites and stings to prevent β haemolytic Metronidazole: see Trichomoniasis - Maintenance dose (when Hb concentration 10 -12 Aetiology streptococcal infection Advise to return if symptoms persist as re-treatment may g/100 mLis achieved) Idiopathic in a significant proportion of cases be needed - Total 75 - 300 units/kg weekly, as a single dose or in Known causes include: Recommended regimen for pregnant women divided doses Inflammatory diseases of the glomeruli SEXUALLY TRANSMITTED INFECTIONS Metronidazole 200 orally, every 8 hours for 7 days, after Iron supplements (glomerulopathies) the first trimester - Ferrous sulphate - Viral infections e.g.Hepatitis B, HIV Or: Adult: 200 mg orally 3 times daily - Immunologic disorders e.g. SLE BACTERIALVAGINOSIS 2 g orally, as a single dose Child: 6 - 18 years: prophylactic 1 tablet (200 mg) daily; Allergies: insect bites, poisonous plants Introduction If treatment is imperative in the first trimester of therapeutic 200 mg 2 - 3 times daily Intravenous drugs e.g. heroin A clinical syndrome resulting from replacement of the pregnancy Treat hyperkalaemia (see chapter on hyperkalaemia) Others: normal hydrogen peroxide-producingLactobacillus sp. - Give metronidazole 2 g orally as a single dose Phosphate binding agents - Diabetes mellitus in the vagina by high concentrations of anaerobic Notable adverse reactions, caution and Calcium carbonate: - Carcinomas bacteria, such as contraindications Adult: 500 mg - 1.25 g orally - Amyloid deposition Gardnerella vaginalis Metronidazole: - Starting dose usually 500 mg - 1 g orally 2 times daily Histologic types Mycoplasma hominis Causes a disulfiram-like reaction with alcohol after meals Minimal change disease Mobiluncus curtisii Avoid high doses in pregnancy and breast feeding Focal segmental glomerulosclerosis The cause of the microbial alteration is not fully May cause nausea, vomiting, unpleasant taste, furred

107 108 Chapter 10: Genito-Urinary System Standard Treatment Guidelines for Nigeria 2008 tongue, and gastro-intestinal disturbances healed Enzyme-linked immunoassay Generally not recommended for use in the first trimester Atypical lesions have been reported in HIV-infected - Patients should therefore be followed up weekly until DNAprobe test of pregnancy individuals there is clear evidence of improvement Ligase chain reaction (LCR) Prevention - More extensive, or multiple lesions sometimes Notable adverse drug reactions, caution and Treatment objectives Reduce or eliminate predisposing factors such as accompanied by systemic manifestations such as fever contraindications Same as for gonococcal infection antiseptic/antibiotic vaginal preparations or vaginal and chills Ciprofloxacin and ceftriaxone (see gonorrhoea) Drug therapy douching Complications Erythromycin and azithromycin (see chlamydia) Recommended regimen: Treat symptomatic pregnant women Progressive ulceration and amputation of the phallus, Prevention Doxycycline 100 mg orally, every 12 hours for 7 days Screen pregnant women with a history of previous pre- particularly in HIV patients CCCounselling, ompliance, ondom use and C ontact Or: term delivery to detect asymptomatic infections Differential diagnoses treatment Azithromycin 1 g orally, in a single dose Retreat pregnant women with recurrence of symptoms Other causes of genital ulcers: Chlamydial infection during pregnancy CCCounselling, ompliance, ondom use and C ontact Syphilis Recommended regimen: treatment Herpes CHLAMYDIALINFECTION Erythromycin 500 mg orally every 6 hours for 7 days Granuloma inguinale (Other than Lymphogranuloma venereum) Or: Lymphogranuloma venereum Introduction Amoxycillin 500 mg orally every 8 hours for 7 days Fixed drug eruption The chlamydiae occupy a special place between bacteria Neonatal chlamydial conjunctivitis CHANCROID (Ulcus Molle, Soft Chancre) Erythema multiforme and viruses Typically has an incubation period of 10 - 14 days Introduction Behcet's disease - They are a large group of obligate intracellular compared to 2 - 3 days for gonococcal opthalmia An infectious disease caused byHaemophilus ducreyi , Trauma organisms Recommended regimen: a small gram-negative bacillus Tuberculous chancre Chlamydia trachomatis has a number of serovars and Erythromycin syrup 50 mg/kg per day orally, every 6 Common in the tropics, especially in Africa, the Far Cancers causes many different human infections hours for 14 days East, and the Caribbean Investigations - Eye: trachoma; inclusion conjunctivitis Alternative regimen: Persons may present with chancroid outside endemic Microscopy, culture and sensitivity of discharge from - Genital tract: lymphogranuloma venereum, non- Trimethoprim 40 mg with sulfamethoxazole 200 mg regions; sporadic outbreaks of infection occur in Europe ulcer gonococcal urethritis, cervicitis, salpingitis orally, every 12 hours for 14 days and NorthAmerica Serological tests e.g. complement fixation (CF); - Respiratory tract: pneumonia Note Clinical features microimmuno-fluorescence (MIF) test; PCR C. trachomatis immunotypes D - K are isolated in about There is no evidence that additional therapy with a Incubation period is about 3 - 7 days Treatment objectives 50% of cases of non-gonococcal urethritis and cervicitis topical agent provides further benefit Begins as a small, tender papule, changing into a Same as for Gonorrhoea by appropriate techniques If inclusion conjunctivitis recurs after therapy has been pustule which rapidly progresses to a painful ulcer with a Drug therapy Clinical features completed, erythromycin treatment should be reinstituted bright red areola Recommended regimen: Infections are asymptomatic, but when an incubation for 2 weeks Neither the edge nor base of the ulcer is indurated Ciprofloxacin period can be determined, it is usually about 10 - 20 days It is important to treat the mother and her sexual partner (unlike syphilis) 500 mg orally every 12 hours for 3 days Co-infection with gonococci and chlamydiae is common Notable adverse drug reactions, caution and - The ulcer feels soft, hence the name 'soft sore' (ulcus Or: C. trachomatis is an important cause of non-gonococcal contraindications molle) Erythromycin 500 mg orally every 6 hours for 7 days urethritis in males, and in females cervicitis, salpingitis, Doxycycline and tetracycline With superimposed bacterial infection it often feels Or: or pelvic inflammatory disease - Caution in patients with hepatic impairment, systemic indurated Azithromycin 1 g orally as a single dose Urethral or cervical discharge tends to be less painful, lupus erythematosus and myasthenia gravis The ulcers may be multiple due to auto-inoculation Alternative regimen: less purulent, and watery in chlamydial compared with - Antacids, aluminium, calcium, iron, magnesium and Sites of predilection in men are the prepuce, frenulum, Ceftriaxone, 250 mg by intramuscular injection, as a gonococcal infection zinc salts, and milk decrease the absorption of glans or shaft of the penis single dose On physical examination, the cervix may show contact tetracyclines In women the labia, fourchette, vestibule, clitoris, Adjuvant therapy bleeding in addition to the discharge - Deposition of tetracyclines in growing bones and teeth cervix, or perineum are favored sites Keep ulcerative lesions clean A patient with urethritis or cervicitis and absence of (by binding to calcium) causes staining and occasionally Lesions may cause dyspareunia, pain on voiding or Aspirate fluctuant lymph nodes through the gram-negative diplococci on Gram stain and of N. dental hypoplasia defaecation and vaginal discharge surrounding healthy skin, preferably from a superior gonorrhoeae on culture is assumed to have chlamydial - Should not be given to children under 12 years, or to Women may be asymptomatic carriers approach to prevent persistent dripping and sinus infection pregnant or breast-feeding women About7-14days after the appearance of the ulcer, a formation Complications - With the exception of doxycycline and minocycline, bubo appears Incision and drainage, or excision of nodes may delay Epididymo-orchitis and sterility in males tetracyclines may exacerbate renal failure and should not - Amass of glands matted together, often adherent to the healing and is not recommended Pelvic inflammatory disease (PID) and infertility in be given to patients with kidney disease overlying skin Follow-up females - May cause nausea, vomiting and diarrhoea; The glands above the inguinal ligament are usually All patients should be followed up until there is clear Adverse pregnancy outcomes hypersensitivity reactions. Headache and visual affected, and often there is a unilateral enlargement evidence of improvement or cure Conjunctivitis and pneumonia in the newborn disturbances may indicate benign intracranial Central softening is often found and if untreated the In patients infected with HIV, treatment may appear to Differential diagnoses hypertension bubo may rupture and discharge through a fistula be less effective, but this may be a result of co-infection Other causes of urethral and vaginal discharge (see - Candidal superinfection with prolonged therapy The combination of a painful genital ulcer and with genital herpes or syphilis Gonorrhoea) Azithromycin and Erythromycin suppurative inguinal adenopathy is almost Chancroid and HIV infection are closely associated Investigations - Erythromycin estolate is contraindicated during pathognomonic of chancroid and therapeutic failure is likely to be seen with increasing Microscopy, culture and sensitivity (of discharge) pregnancy because of drug-related hepato-toxicity; only Patient may present with bubo, the initial ulcer having frequency Direct immunofluorescence assay erythromycin base or erythromycin ethylsuccinate should

109 110 Chapter 10: Genito-Urinary System Standard Treatment Guidelines for Nigeria 2008 be used Littré abscess involving periurethral glands is the commonest presentation in women Investigations - Erythromycin should not be taken on an empty Paraurethral abscesses Urethritis: the urethra becomes the most common site in Endocervical swab (through a vaginal speculum) for stomach Proximal urethral involvement with frequency and women who have had hysterectomy microscopy, culture and sensitivity - Caution in persons with arrhythmias terminal haematuria The most frequent complaint is discharge, often Gonorrhoea in children - Infants should be followed up for symptoms and signs accompanied with burning on urination of infantile hypertrophic pyloric stenosis (has been Cowper's gland abscess involving the bulbourethral Over 50% of infected women are asymptomatic Clinical features reported in infants less than 6 weeks exposed to this glands, producing a swelling behind the base of the Oropharyngeal gonorrhoea from orogenital sex (fellatio) Sexual abuse is a common cause of gonorrhoea in drug) scrotum that can produce a proximal or Cowper's may present as sore throat young girls Ofloxacin stricture Complications Usually symptomatic in young girls See ciprofloxacin- Gonorrhoea Prostatitis Local: Pruritus and dysuria are common complaints Amoxicillin Proctitis Infections of Skene's periurethral glands and Bartholin's Discharge may cause irritant dermatitis of the upper - Caution where there is a history of allergy Urethral stricture leading to hydroureters and labial glands; a Bartholin's gland abscess may cause pain thighs - Erythematous rashes common in glandular fever, hydronephrosis on sitting or walking Differential diagnoses cytomegalovirus infection, acute or chroni Chronic epididymo-orchitis leading to sterility Vulvitis Other causes of vaginal discharge in young girls: lymphocytic Contaminated fingers or other fomites can also lead to Ascending infection to the endometrium, fallopian tubes, Avaginal foreign body such as a small toy, bead, or leukaemia with pityriasis rosea, and allopurinol use infection of the eyes- gonococcal conjunctivitis ovaries and peritoneum (pelvic inflammatory disease) even a piece of food Prevention - Haematogenous spread leading to meningitis, arthritis Ectopic pregnancy Other infections caused byT. vaginalis , and C. albicans CCCounselling, ompliance, ondom use and C ontact etc Infertility Intestinal bacteria or pin worms due to inadequate treatment Differential diagnoses Perihepatic abscess (Fitz-Hugh-Curtis syndrome) cleaning after defeacation Urethral discharge: Risk of disseminated gonococcal infection during Ophthalmia neonatorum Spermatorrhoea/prostatorrhoea (sexual arousal) pregnancy and menstruation Gonococcal conjunctivitis in the neonate can be GONORRHOEA - Trichomonas vaginalisand Candida albicans can also Risk to the newborn infant: acquired perinatally Introduction give rise to urethral discharge and balanitis - Premature rupture of membranes Purulent conjunctivitis; the lids swell; eyes are red and Caused byNeisseria gonorrhoeae, a gram-negative Ascending infections: - Premature labour tender aerobic diplococcus Escherichia coli, a common cause in the insertive male - Chorioamnionitis If not treated promptly, the cornea may be eroded and It prefers the columnar epithelium of the urethra, the homosexuals - Septic abortion perforated, leading to secondary glaucoma, cervical canal, the rectum and the conjunctivae. - Other organisms may be transmitted non-sexually - Ophthalmia neonatorum conophthalmus and blindness The keratinizing epithelium of the adult vagina is quite following genitourinary infections, surgery and - Oropharyngeal gonorrhoea About 30% of babies infected will also have resistant toN. gonorrhoeae, but that of the pre-pubertal instrumentation (including catheterization) Differential diagnoses oropharyngeal gonorrhoea girls, pregnant women and the elderly is more easily Scrotal swelling (epididymo-orchitis): Other causes of vaginal discharge: Differential diagnoses colonized In older men, where there may have been no risk of STIs, Accentuation of physiological discharge The silver nitrate prophylaxis can produce a chemical OccasionallyN. Gonorrhoeae reaches the bloodstream other general infections may be responsible, e.g. - Premenstrually conjunctivitis, usually appearing 6 - 8 hours after causing sepsis Escherichia coli, Klebsiellaspp. or Pseudomonas - At the time of ovulation treatment and resolving over 24 hours Gonorrhoea in males aeruginosa - In pregnancy The most common cause of neonatal conjunctivitis in Clinical features Tuberculous epididymo-orchitis, secondary to lesions - Use of contraceptive pills or an intrauterine device most countries isC. trachomatis . Presents as foul-smelling urethral discharge of pus elsewhere, especially in the lungs or bones Infective causes: -E. coli, staphylococci, streptococci and Pseudomonas with dysuria 2 - 6 days after exposure Brucellosis, caused by Brucella melitensis or Brucella - Candidiasis sp. can also cause conjunctivitis in the neonate Some patients have a scanty discharge that cannot be abortus - Trichomoniasis Treatment objectives distinguished from non-gonococcal urethritis - Orchitis is usually clinically more evident than an - Bacterial vaginosis Eliminate the organism in the patient and sexual Often asymptomatic during the day but there may be epididymitis - Chlamydia partner(s) a drop of discharge in the morning In pre-pubertal children the usual aetiology is coliform, - Cervical herpes genitalis Prevent re-infection Urethral orifice is usually inflamed; there may be pseudomonas infection or mumps virus - Cervical warts Prevent complications balanitis because of the irritation from the discharge and Non-infectious causes of scrotal swelling: - Syphilitic chancre Counsel and screen for possible co-infection with HIV secondary infection Trauma (haematocoele) - Toxic shock syndrome (Staphylococcus aureus) so that appropriate management can be instituted About half of infected males are asymptomatic Testicular torsion -β -haemolytic streptococcal infection, Mycoplasma Drug therapy Ascending infection is common and may lead to Tumour infection Recommended regimen: inflammation of the epididymis (epididymitis) Hydrocoele of the tunica vaginalis Non-infective causes: Ciprofloxacin 500 mg orally, as a single dose Epididymitis usually manifests by acute onset of Cyst of epididymis - Cervical ectropion Or: unilateral testicular pain and swelling, often with Varicocoele - Cervical polyp(s) Ceftriaxone 125 mg by intramuscular injection, as a tenderness of the epididymis and vas deferens Inguinoscrotal hernia - Neoplasia e.g. cancer of the cervix single dose - Occasionally there is erythema and oedema of the Investigations - Retained products (tampon, post-abortion, post-natal) Neonatal gonococcal conjunctivitis overlying skin Urethral swab for microscopy and culture and - Trauma Recommended regimen: - The adjacent testis is often also inflamed (orchitis), sensitivity - Semen (post-coital) Ceftriaxone 50 mg/kg by intramuscular injection, as a giving rise to epididymo-orchitis Gonorrhoea in women - Contact irritants and sensitizers e.g. from douches or single dose, to a maximum of 125 mg Complications Clinical features feminine hygiene sprays Or: Local complications (now uncommon): Inflammation of the cervix and cervical canal (cervicitis) - Bullous diseases of the mucous membranes Spectinomycin 25 mg/kg by intramuscular injection as

111 112 Chapter 10: Genito-Urinary System Standard Treatment Guidelines for Nigeria 2008 a single dose, to a maximum of 75 mg/kg Incubation period ranges from 10 - 40 days All treatment should be for a minimum of 14 days Secondary stage Note The early lesion is a papule or nodule which soon Note About 3 - 6 weeks post-contact a uni-or bilateral massive Single-dose ceftriaxone and kanamycin are of proven becomes ulcerated and has an offensive discharge The addition of a parenteral aminoglycoside such as inguinal lymphadenopathy (bubo) appears efficacy The floor of the ulcer may be covered with a dirty grey gentamicin should be carefully considered for treating The glands elongate along the Poupart's ligament to material; its walls may be overhanging, or a HIV-infectedpatients become sausage shaped The addition of tetracycline eye ointment to these papillomatous fungating mass may arise from the growth Follow-up Buboes progress to involve the glands above and below regimens is of no documented benefit of vegetations Patients should be followed up clinically until signs and the ligament, so that the depression formed by the Adjunctive therapy for gonococcal ophthalmia Progressive indolent, serpiginous ulceration of the symptoms have resolved ligament which separates these two groups of glands - Systemic therapy, as well as local irrigation with groins, pubis, genitals and anus may form. Pain on Notable adverse drug reactions, caution and gives the “sign of the groove” saline or other appropriate solution walking may be excrutiating contraindications Pain in the gland is usual, and as the glands are matted - Irrigation is particularly important when the Persisting sinuses and hypertrophic depigmented Sulfamethoxazole/trimethoprim together, the overlying skin develops an erythematous or recommended therapeutic regimens are not available scars are fairly characteristic - Contraindicated in persons with hypersensitivity to violaceous hue - Careful hand washing by personnel caring for infected Regional lymph nodes are not enlarged but with sulfonamides or trimethoprim; porphyria The glands eventually become fluctuant, break down patients is essential cicatrisation, the lymph channels may be blocked - Caution required in renal impairment (avoid if severe); and discharge Follow-up causing pseudoelephantiasis of the genitalia hepatic impairment (avoid if severe); maintain adequate Inguinal lymphadenopathy occurs in only 20 - 30% of Review patients after 48 hours Both the fibrotic scarring and elephantiasis-like lesion fluid intake (to avoid crystalluria) women with LGV Notable adverse drug reactions, caution and could cause obstructed labour - May cause nausea, vomiting, diarrhoea, headache, There is primary involvement of the rectum, vagina, contraindications Subcutaneous extension and abscesses may occur and hypersensitivity reactions, including fixed drug eruption, cervix, or posterior urethra, which drain to the deep iliac Ciprofloxacin form a pseudo-bubo in the inguinal region pruritus, photo-sensitivity reactions, exfoliative or perirectal nodes - Avoid in pregnancy and breast feeding; children Healing is unlikely without treatment; the locally dermatitis, and erythema nodosum - This may produce symptoms of lower abdominal or below 12 years destructive lesion may eventually involve the groins, Others back pain - Reduce dose in renal impairment pubis and anus - See Chlamydia Systemic symptoms usually present with: Ceftriaxone A squamous cell carcinoma may arise from chronic Prevention - Fever - Caution in persons with known sensitivity to beta- lesions. CCCounselling, ompliance, ondom use and C ontact - Malaise lactam antibiotics Differential diagnoses treatment - Arthritis - May cause diarrhoea (and rarely antibiotic-associated Syphilis - Loss of weight colitis); nausea, vomiting and abdominal discomfort Chancroid Skin manifestations (erythema nodosum, papulo- Spectinomycin Lymphogranuloma venereum pustular lesions and photodermatosis) - Nausea, dizziness, fever and urticaria Lupus vulgaris LYMPHOGRANULOMAVENEREUM - Raised ESR Prevention Deep mycosis (Climatic bubo; lymphogranuloma inguinale; Late stage CCCounselling, ompliance, ondom use and C ontact Amoebic ulcer lymphopathia venereal; Durand-Nicolas-Favre Spontaneous remission is common, though some patients treatment Pyoderma gangrenosum Disease) enter the late stage Ocular prophylaxis provides poor protection against C. Squamous cell and basal cell carcinoma Introduction Characterized by disfiguring and destructive sequelae trachomatis conjunctivitis Complications A chronic disease caused by Chlamydia trachomatis Impairment of the lymphatic drainage from fibrotic Prevention of ophthalmia neonatorum Obstructed labour (serotypes L1, L2, L3), an obligate intracellular scarring leads to distant oedema and gross elephantiasis Clean the eyes carefully immediately after birth Squamous cell carcinoma microorganism of the genitalia The application of 1% silver nitrate solution or 1% Investigations Most common inAsia,Africa, and SouthAmerica - There could be associated anorectal and vaginal tetracycline ointment to the eyesof all infants at the time Direct microscopy In Europe and North America, it is most prevalent strictures of delivery is strongly recommended as a prophylactic Treatment objectives among homosexuals, immigrants from endemic areas Complications measure Same as for gonococcal infection and people returning from endemic areas, such as Systemic spread ofC. trachomatis in the secondary Infants born to mothers with gonococcal infection Drug therapy soldiers, seamen, and vacationers stage resulting in arthritis, pneumonia, hepatitis or rarely should receive additional antibiotic treatment (as those Recommended regimen: Clinical features perihepatitis with clinical neonatal conjunctivitis) Azithromycin A chronic granulomatous, locally destructive disease Other rare systemic complications include pulmonary - 1 g orally on first day, then 500 mg orally, once a day that is characterized by progressive, indolent, infection, cardiac involvement, aseptic meningitis, and Or: serpiginous ulceration of the groins, pubes, genitals and ocular inflammatory disease Doxycycline anus The late stage may be complicated by the genito- GRANULOMA INGUINALE (Donovanosis; - 100 mg orally every 12 hours May be classified into primary, secondary, and late anorectal syndrome Granuloma venereum) Therapy should be continued until the lesions have stages - Reported more in homosexual men, and women who Introduction completely epithelialized Primary stage engage in receptive anal intercourse A mildly contagious disease caused by Klebsiella Alternative regimen: After an incubation period of7-15days, a papule or Patients may also complain of fever, pain, and tenesmus. granulomatis Erythromycin small non-indurated painless ulcer appears Obstructed labour from elephantiasis of the vulva Currently rare in several parts ofAfrica - 500 mg orally every 6 hours - Usually goes unnoticed Differential diagnoses Endemic in Southeast Asia, Southern India, the Or: Extra-genital lesions (rectal, oral) have also been Buboes: Caribbean and SouthAmerica Tetracycline 500 mg orally every 6 hours described - Chancroid Clinical features Or: Women probably act as asymptomatic carriers - Infections of the lower limbs A chronic mildly contagious disease with a potentially Trimethoprim 80 mg/sulfamethoxazole 400 mg, 2 Patients are very rarely seen at the primary stage - Hodgkins disease and other lymphomas progressive and destructive character tablets orally, 12 hourly

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- Plague Secondary syphilis: skin rash, condyloma lata, Prevent complications TRICHOMONIASIS - Tularemia mucocutaneous lesions and generalized Counsel and screen for possible co-infection with HIV Introduction Late stage: lymphadenopathy so that appropriate management can be instituted Caused by the flagellated protozoan, Trichomonas - Tuberculosis Late syphilis: late latent syphilis, gummatous, Drug therapy vaginalis - Deep mycosis of the genitalia neurological and cardiovascular syphilis Recommended regimen: An extremely common infection, almost always - Squamous cell or basal cell carcinoma This section is only on primary syphilis Benzathine benzylpenicillin transmitted via sexual contact Investigations Clinical features - 4 g (2.4 million units) by intramuscular injection, at a Women are far more frequently affected and more likely Culture and cell typing of the isolate from an aspirate of After an incubation period of2-4weeks (full range 90 single session to have symptoms involved lymph node days) the first lesion of syphilis may appear at the site of - Because of the volume involved, this dose is usually Men are more likely to be asymptomatic and serve as Serological tests e.g. CFT and MIF; PCR exposure, most commonly, the genitals given as two injections at separate sites carriers Treatment objectives Chancres may also be located on the lips or tongue; ano- Alternative regimen: Clinical features Same as for gonorrhoea rectal chancres frequently seen in male homosexuals Procaine benzylpenicillin Vaginal discharge: a white-yellow frothy discharge is Drug treatment - Begins as a small, dusky-red macule which soon - 2 g (1.2 million units) by intramuscular injection, characteristic Recommended regimen: develops into a papule daily for 10 consecutive days Burning sensation Doxycycline The surface of the papule erodes to form an ulcer which Alternative regimen for penicillin-allergic (non Dysuria - 100 mg orally every 12 hours for 14 days is typically round and painless with a clean surface and -pregnant) patients Dyspareunia Or: exudes a scanty yellow serous discharge teeming with Doxycycline The liabia are often swollen Erythromycin spirochaetes - 100 mg orally, every 12 hours for 14 days The cervix may have punctuated haemorrhages - 500 mg orally every 6 hours for 14 days Lesion is indurated and feels firm or hard on palpation; Or: producing a strawberry-like surface when viewed with a Alternative regimen: surrounding skin is oedematous - Tetracycline 500 mg orally, every 6 hours for 14 days colposcope Tetracycline Regional inguinal (or generalized) lymphadenopathy Alternative regimen for penicillin-allergic pregnant Some men may have dysuria or a minimal urethral - 500 mg orally every 6 hours for 14 days follows patients discharge and balanoposthitis Adjuvant measures The glands are painless, moderately enlarged (not Erythromycin Co-infection withN. gonorrhoeae is common Aspirate fluctuant lymph nodes through healthy skin buboes), discrete and never suppurate - 500 mg orally, every 6 hours for 14 days Differential diagnoses Incision and drainage or excision of nodes may delay Atypical lesions may be seen for various reasons e.g. Notable adverse drug reactions, caution and Other causes of vaginal discharge or urethral discharge: healing and is not recommended bacterial superinfection, trauma or co-infection with contraindications see Gonorrhoea Some patients with advanced disease may require chancroid. Benzylpenicillin (Penicillin G) Complications treatment for longer than 14 days, and sequelae such as Even without treatment, the primary lesion(s) gradually - Caution in patients with history of allergy; atopic Acute salpingitis strictures and/or fistulae may require surgery heals up and will disappear after approximately 3 - 8 patients; in severe renal impairment, neurotoxicity; high Adverse pregnancy outcomes, particularly premature Notable adverse drug reactions, caution and weeks, sometimes leaving a thin atrophic scar which is doses may cause convulsions rupture of membranes, pre-term delivery and low birth contraindications easily overlooked - Contraindicated in penicillin hypersensitivity weight See Chlamydia Differential diagnoses - May cause hypersensitivity reactions including Investigations Prevention Other causes of genital ulcers: urticaria, fever, joint pains, rashes, angioedema, Microscopy and culture of vaginal discharge CCCounselling, ompliance, ondom use and C ontact Chancroid anaphylaxis, serum Treatment objectives treatment Herpes sickness-like reaction, rarely intestitial nephritis, Eliminate the organism in the patient and sexual Lymphogranuloma venerum haemolytic anaemia, leucopaenia, thrombocytopaenia partner(s) Granuloma inguinale and coagulation disorders Prevent re-infection Trauma Other antibiotics Prevent complications SYPHILIS Fixed drug eruption - See Chlamydia Counsel and screen for possible co-infection with HIV Introduction Behcet's disease Prevention so that appropriate management can be instituted Infection caused by the spirochaete Treponema Erythema multiforme CCCounselling, ompliance, ondom use and C ontact Drug treatment pallidum Tuberculous ulcer treatment Recommended regimen: Occurs worldwide Amoebic ulcer All infants born to seropositive mothers should be Metronidazole Can be classified as: Cancer treated with a single intramuscular dose of benzathine - 2 g orally in a single dose Congenital (transmitted from mother to childin utero ) Complications penicillin Or: Acquired (through sex or blood transfusion) Phimosis and paraphimosis - 50,000 units/kg, whether or not the mothers were Tinidazole Acquired syphilis may be early or late Late syphilis: gummatous, neurological and treated during pregnancy (with or without penicillin) - 2 g orally in a single dose Primary syphilis is characterized by an ulcer or chancre cardiovascular syphilis Prevention of congenital syphilis is feasible Alternative regimen: at the site of infection or inoculation Investigations - Programmes should implement effective screening Metronidazole Manifestations of secondary syphilis include a skin Dark field examination and direct fluorescent antibody strategies for syphilis in pregnant women - 400 mg or 500 mg orally every 12 hours for 7 days rash, condyloma lata, mucocutaneous lesions and tests of lesion exudates or tissue Screening for syphilis should be conducted at the first Or: generalized lymphadenopathy VDRL; RPR prenatal visit Tinidazole Early syphilis: primary, secondary and early latent Treatment objectives Some programmes have found it beneficial to repeat the - 500 mg orally every 12 hours for 5 days stages Eliminate the organism in the patient and sexual tests at 28 weeks of pregnancy and at delivery in Note Primary syphilis: an ulcer or chancre at the site of partner(s) populations with a high incidence of congenital syphilis Other 5-nitroimidazoles are also effective, both in single infection or inoculation Prevent re-infection and in multiple dose regimens

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Asymptomatic women with trichomoniasis should be Clinical examination: invasive or systemic) treated with the same regimen as symptomatic women Vulval erythema (redness) or excoriations from Prevention Serum Urea, Electrolytes and Creatinine Recommended regimens for male urethral infections: scratching Reduce or eliminate predisposing factors Prostate SpecificAntigen (PSA) same as for women Vulval oedema After defecation cleaning should be done backwards to Trans-rectal ultrasound Patients not cured with the repeated course of Erosions and crusting on the adjacent intertriginous skin prevent faecal contamination of the vulva and vagina Abdominal ultrasound scan metronidazole may be treated with a regimen consisting Although treatment of sexual partners is not Full Blood Count of metronidazole 2 g orally daily, together with 500 mg recommended, it may be considered for women who applied intravaginally each night for3-7days have recurrent infections Treatment objectives Vaginal preparations of metronidazole are available in A minority of male partners may have balanitis, which UROLOGY Relieve obstruction many parts of the world, but are only recommended for is characterized by erythema of the glans penis or Treat or prevent complications the treatment of refractory infections, not for the primary inflammation of the glans penis and foreskin BENIGN PROSTATIC HYPERPLASIA Non-drug treatment therapy of trichomoniasis (balanoposthitis) Introduction Surgery: open prostatectomy or transurethral resection Recommended regimen for neonatal infections Differential diagnoses A common cause of lower urinary tract obstruction Minimally invasive procedures Metronidazole Other causes of vaginal discharge: see Gonorrhoea in among elderly males High intensity focused ultrasound - 5 mg/kg orally, every 8 hours for 5 days women Non-cancerous increase in size of the prostate gland Transurethral balloon dilatation Infants with asymptomatic trichomoniasis, or urogenital Complications Increase in size impacts on the urethra and partially or Intraurethral stent colonization persisting past the fourth month of life Emotional problems because of the recurrent nature of totally obstructs urine outflow Transurethral vaporization of the prostate should be treated with metronidazole the infection, and dyspareunia Occurs after the age of 40 years; cause is uncertain Intermittent self-catheterization Notable adverse drug reactions, caution and Very serious emotional problems in a non-sexually Symptoms are due to mechanical obstruction or spasms Drug treatment contraindications active person wrongly “accused” by parents, spouse or of the smooth muscles around the bladder neck and Alpha adrenergic blockers Metronidazole health care providers prostate - Prazosin, doxazosin, tamsulosin Causes a disulfiram-like reaction with alcohol Investigations Clinical features Doses are titrated from 1 -10 mg depending on - Avoid high doses in pregnancy and breast feeding Positive KOH examination Lower urinary tract symptoms individual response - May cause nausea, vomiting, unpleasant taste, furred Culture of vaginal discharges Irritative symptoms: - 400 microgram orally daily as single dose for tongue, and gastro-intestinal disturbances Treatment objectives Frequency tamsulosin - Generally not recommended for use in the first trimester Cure the infection Urgency 5-Alpha reductase inhibitors of pregnancy Prevent recurrence Nocturia - Finasteride 5 mg orally daily Prevention Drug therapy Urge incontinence Notable adverse drug reactions, caution CCCounselling, ompliance, ondom use and C ontact Recommended regimen: Obstructive symptoms: Alpha-adrenergic blockers: dizziness, syncopal attacks, treatment Clotrimazole 1 % vaginal cream Poor stream tachycardia - Insert 5 g at night as a single dose; may be repeated Hesitancy - Should therefore to be taken at night before going to once if necessary Straining bed 5- Alpha reductase inhibitors: loss of libido, erectile VULVO-VAGINALCANDIDIASIS Or: Intermittency dysfunction, gynaecomastia Introduction Miconazole 2% intravaginal cream Retention of urine Inflammation of the vagina and vulva, usually evolving - Insert 5 g applicator once daily for 10 - 14 days or twice Haematuria from vaginal discharge and secondary external irritation daily for 7 days Recurrent urinary tract infections Candida albicans is the commonest cause of candidal Or: Progressive renal failure CARCINOMAOF THE PROSTATE vulvo-vaginitis;Candida glabrata has also been - Clotrimazole 500 mg intravaginally, as a single dose Digital rectal examination: Introduction identified Or: Enlarged prostate; firm and symmetrical The most commonly diagnosed malignancy affecting Candidal vaginitis is most common in : - Fluconazole 150 mg orally, as a single dose Differential diagnoses men beyond the middle age - Pregnancy Recommended topical regimen for balanoposthitis Prostate cancer The commonest malignancy of the genitourinary tract - Patients with diabetes mellitus - Clotrimazole 1% cream apply twice daily for 7 days Bladder cancer Exact cause is not known - Those on long-term antibiotic therapy or oral Or: Bladder calculi About 90% are adenocarcinomas contraceptives - Miconazole 2% cream twice daily for 7 days Urethral stricture Risks factors - Conditions associated with immunosuppression - Notable adverse drug reactions, caution and Prostatitis Increasing age Corticosteroid use contraindications Neurogenic bladder Familial and genetic factors Usually not acquired through sexual intercourse Fluconazole: Complications High levels of testosterone and dihydrotestosterone Because of the close proximity between the anus and - Caution in patients with renal impairment Acute or chronic urine retention Clinical features female genitalia, re-infections may occur from the - Avoid in pregnancy and breastfeeding Recurrent urinary tract infections Lower urinary tract symptoms gastrointestinal tract - Monitor liver function Bladder calculi Frequency Clinical features - Discontinue if signs or symptoms of hepatic disease Haematuria Urgency Up to 20% of women with the infection may be develop (risk of hepatic necrosis) Hydroureter/hydronephrosis Nocturia asymptomatic - May cause nausea, abdominal discomfort, diarrhoea, Progressive renal failure Poor stream If symptoms occur, they usually consist of vulval flatulence, headache, skin rash and Steven-Johnson Investigations Straining itching, soreness and a non-offensive vaginal discharge syndrome Urinalysis Terminal dribbling which may be curdy - Discontinue treatment or monitor closely if infection is Urine microscopy, culture and sensitivity

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Haematuria with orchidectomy Androgen replacement in those with androgen Hormone profile (LH, FSH, testosterone, and prolactin) Features of metastasis Or: deficiency: Scrotal ultrasound Low back pain Flutamide 250 mg orally three times daily Testosterone enanthate Trans-rectal ultrasound Paraplegia Or: - 250 mg intramuscularly every 2-4 weeks Testicular biopsy Pathological fractures Diethyl stilbestrol 3 mg orally daily Or: Vasography Pedal oedema Cytotoxic chemotherapy: Oral methyl testosterone or fluoxymesterone Azotaemia Docetaxel 75 mg/m2 every 3 weeks 120 - 160 mg daily for2-3weeks; maintenance 40 - 120 Treatment objectives Weight loss Notable adverse drug reactions, caution and mg daily To improve semen quality and restore reproductive Rectal Examination: hard, nodular, asymmetrical contraindications Intra-corporal administration of: capability prostate Anti-androgens: Prostaglandin E1 Non-drug treatment Differential diagnoses - Loss of libido - 5 - 15 microgram Surgical options: Benign prostatic hyperplasia - Gynaecomastia 5-Phosphodiesterase inhibitors: Varicocoelectomy Chronic prostatitis - Impotence Sildenafil citrate Vasovasotomy Bladder cancer/calculi Diethyl stilbestrol: - 25 - 100 mg one hour before intercourse Epididymo-vasotomy Prostatic calculi - Fluid retention Notable adverse drug reactions, caution and Transurethral resection of obstructed ejaculatory duct Urethral stricture - Hypertension contraindications Assisted reproductive techniques: Complications - Thrombo-embolic disease Androgens Intra-uterine insemination Urinary retention - Loss of libido - Not to be given to patients with prostate carcinoma In vitro fertilization Urinary tract infection - Gynaecomastia Phosphodiesterase inhibitors Gamete intra-fallopian tube transfer Hydroureter/hydronephrosis - Contraindicated in patients with cardiovascular - Altered vision, headache, dizziness and nasal Intra-cytoplasmic sperm injection Progressive renal failure diseases congestion Paraplegia - Contraindicated in patients taking nitrates Pathological fractures - Should be used with caution in patients with ischaemic Lymphoedema heart disease POSTERIOR URETHRALVALVES Investigations ERECTILE DYSFUNCTION (Impotence) Introduction Prostate Specific Antigen Introduction Congenital mucosal folds situated in the Prostate biopsy Persistent inability to obtain and sustain an erection prostatic/membranous urethra, causing urine outflow Trans-rectal ultrasound sufficient for sexual intercourse MALE INFERTILITY obstruction Abdominal ultrasound May be non-organic (psychogenic) or organic, Introduction Occurs in males CT scan resulting from physical causes Failure to achieve conception after one year of regular, - The most common mechanical cause of renal Liver function tests - Vascular, neurologic or endocrine dysfunction unprotected sexual intercourse in a couple trying to deterioration in children Chest radiograph Other causes include drugs and trauma achieve pregnancy Clinical features Serum Urea, Electrolytes and Creatinine Clinical features Primary : Obstructive urinary symptoms Full Blood Count Inability to obtain or sustain erection - When the man has never impregnated a woman Urinary retention Treatment objectives History suggestive of possible causes e.g. drugs, Secondary: Failure to thrive Aim at cure for early disease systemic disease like hypertension, diabetes mellitus - When the man had impregnated a woman in the past Distended bladder with palpable kidneys Palliation for advanced disease With or without gynaecomastia Male factor is responsible for about 50% of infertile Differential diagnoses Non-drug treatment With or without penile deformity, plaques or impaired unions Anterior urethral valves Watchful waiting sensation Clinical features Congenital bladder neck hypertrophy Radical prostatectomy Complications Vital points in the history: Congenital urethral stricture Radiotherapy (brachytherapy or external beam Psychological disturbances Duration of infertility Meatal stenosis radiation) Infertility Ability to have erection, penetration and ejaculation Posterior urethral polyp Bilateral orchidectomy Investigations Family history of infertility Complications Cryoablation therapy Full Blood Count History of systemic disease e.g. diabetes mellitus, Recurrent urinary tract infections Laser therapy Hormonal assay (LH, FSH, testosterone, prolactin) hypertension, chronic liver disease and tuberculosis Septicaemia Drug treatment Serum Urea, Electrolytes and Creatinine History of sexually transmitted infections and urinary Bladder dysfunction LHRH agonist: Blood glucose tract infections Bladder stones Goserelin acetate Nocturnal penile tumescence test History of genital trauma Hydroureter/hydronephrosis - 3.6 mg by subcutaneous injection into the anterior Treatment objective History of surgery: herniorraphy, orchidopexy, urethral Progressive renal impairment abdominal wall every 28 weeks To obtain and sustain erection surgeries, etc Failure to thrive Anti-androgens: Non-drug treatment Examination: Investigations Cyproterone acetate Psychotherapy Gynaecomastia Urinalysis - 100 mg orally twice daily for long term palliative Use of vacuum suction devices Penis: epispadias, hypospadias, penile deformities Urine microscopy, culture and sensitivity therapy Placement of intracorporal prosthesis Scrotum: absence of testis, small sized testis, Full Blood Count Or: Microsurgical vascular anastomosis varicocoeles, hard and irregular epididymis Serum Urea, Electrolytes and Creatinine Bicalutamide 50 mg orally daily in advanced cases, Drug treatment Investigations Abdominal ultrasound Semen analysis x 3

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Micturating cysto-urethrogram Supportive measures Perineal pain Atrophic testis Urethrocystoscopy Adequate hydration Haemospermia Surgical removal (for treatment of other conditions) Treatment objectives Pain relief Painful ejaculation Undescended testis To relieve obstruction Prevention Rectal examination: enlarged, tender, firm prostate The testis is arrested in its normal path of descent Treat any complications Avoid causative drugs Differential diagnoses Unilateral arrest is more common than bilateral arrest Non-drug treatment Benign prostatic hypertrophy Incidence at birth is about 3% in full term infants, 30% Valveresection with endoscopes Cystitis in preterm infants and 1% in adulthood Valveavulsion with valvotomes Urethral stricture Clinical features Drug treatment PROSTATITIS Prostate cancer Absence of one or both testes from the scrotum None Introduction Complications Pain from trauma to the testis Supportive measures An inflammation of the prostate or pain in the prostate, Prostatic abscess Infertility (in adulthood) Correct dehydration and electrolyte imbalance similar to that caused by an inflammation Prostatic calculi Atrophic testis Treat infection with appropriate antibiotics Accounts for 2% of prostatic pathology Infertility The testis, if palpable cannot be manipulated into the Urinary diversion: vesicostomy Classified into: Septicaemia scrotum Prevention Acute bacterial prostatitis Investigations Inguinal hernia may be present on the affected side Not applicable Chronic bacterial prostatitis Urinalysis Complications Chronic non-bacterial prostatitis Urine microscopy, culture and sensitivity Torsion of the spermatic cord Prostatodynia Prostatic massage: microscopy, culture and sensitivity Trauma to the testis Risk factors: (chronic prostatitis only) Malignancy PRIAPISM Ductile reflux Trans-rectal ultrasound Infertility Introduction Urinary tract infection Biopsy: culture and histology Investigations Persistent penile erection that continues beyond, or is Indwelling urethral catheterization Urethrocystoscopy (chronic prostatitis only) Urinary 17-ketosteroids, gonadotropins not related to sexual stimulation Penetrating anal sex Full Blood Count; ESR Serum testosterone Predisposing factors: Sexually transmitted infections Treatment objectives Ultrasonography Thromboembolic disorders e.g. sickle cell disease, Acute bacterial prostatitis To eradicate causative organisms Computed tomography leukaemia Results from direct spread of ascending urethral Control pain Laparoscopy Spinal injuries infection or reflux of infected urine into the prostatic Drug treatment Magnetic Resonance Imaging Perineal and genital trauma ducts Antibiotics (based on local sensivity Management Drugs e.g. chlorpromazine, prazosin and prostaglandins -E. coli is the main causative organism. Others are - Ciprofloxacin 500 mg orally every 12 hours for 28 days Hormone therapy: Clinical features klebsiella, pseudomonas, Streptococcus faecalis and Or: Human chorionic gonadotropin Persistent painful erection lasting several hours Staph aureus - Cotrimoxazole 960 mg orally every 12 hours for 28 - 1,500 units/week intramuscularly, for a total of 9 Penis is rigid and tender but the glans penis and corpus Chronic bacterial prostatitis days injections spongiosum are soft Caused byE. coli , Klebsiella, Mycoplasma and Anti-inflammatory drugs - Applicable only to special cases Complication Chlamydia - Non-steroidal e.g. diclofenac, ibuprofen etc Surgical treatment: Erectile dysfunction Non-bacterial prostatitis - Steroids e.g. prednisolone, dexamethasone In those with undescended testes Investigations An inflammation of indeterminate cause Alpha blockers e.g. prazocin, doxazocin - Bring testis down and fix it in the scrotum Full Blood Count Clinical features Hormonal therapy e.g. finasteride, cyproterone Haemoglobin electrophoresis Acute prostatitis Non-drug treatment Colour Doppler/duplex ultrasound Systemic features Prostatic massage (chronic prostatitis only) Treatment objectives - Fever Physiotherapy TORSION OF THE TESTIS To increase venous drainage from the corpora cavernosa - Chills Sitz baths Introduction Decrease arterial inflow in high flow priapism - Malaise Twisting of the spermatic cord with compromise of the Treat the primary cause(s) - Nausea blood supply to the testis Non-drug treatment Local features An uncommon affliction that is most commonly seen in Shunting procedures - Dysuria SCROTALMASSES adolescent males.Afew cases occur in infancy - Caverno-glandular shunt - Frequency Clinical features - Caverno-spongiosum shunt - Haematuria The empty scrotum Pain in one testicle: of sudden onset, severe in intensity - Caverno-saphenous shunt - Urethral discharge Introduction and radiates to the lower abdomen Spinal or epidural anaesthesia Rectal examination: Aclinical situation in which the testis is absent from the Nausea and vomiting Drug treatment - Hot boggy, swollen and very tender prostate scrotum Swollen, high lying testis with reddening of the scrotal Intracavernosal injection of alpha adrenergic agonist: Chronic prostatitis May be bilateral or unilateral skin Phenylephrine Voiding symptoms: dysuria, frequency, urgency, Causes include: Tenderness. Pain can be increased by lifting the testicle - 250 - 500 microgram haematuria Undescended testis up Or: Poor stream Ectopic testis Absence of the cremasteric reflex Ephedrine Urethral discharge Retractile testis Abnormal lie of the testis on the opposite side - 50 - 100 mg Low back pain Absent (vanishing) testis

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Differential diagnoses Dribbling Six - 24 months later: Obstruction to urine outflow Acute epididymo-orchitis Examination of the external genitalia may reveal: Intermittent, painless terminal haematuria (may be Infection in the urinary tract Mumps orchitis Urethral indurations total) Crystallization on foreign bodies Trauma to the testis Periurethral or perineal abscess Symptoms of bladder irritability: dysuria, frequency, Dehydration Strangulated inguinal hernia Urinary fistula urgency, strangury Change in pH Insect bites Differential diagnoses Differential diagnoses In-born errors of metabolism Inflammatory vasculitis (Henoch-Schönlein purpura) Benign prostatic hypertrophy Tuberculous cystitis Clinical features Idiopathic scrotal oedema Prostate cancer Abacterial cystitis Renal and ureteric stones: Testicular tumour Bladder calculi Bladder carcinoma Sudden onset loin pain radiating to the groin Fournier's gangrene Bladder neck stenosis Complications Haematuria Complications Complications Bladder fibrosis and contracture Nausea and vomiting Testicular atrophy Urinary tract infections Ureteral stricture Stones in the bladder: Sympathetic orchidopathy Urethral/bladder calculi Urethral stricture Frequency Abnormal sperm count Urinary retention Bladder calculi Urgency Infertility Fournier's gangrene Bladder cancer Difficulty in passing urine Investigations Perineal urinary fistulae Investigations Stones in the urethra: Colour Doppler sonography Progressive renal failure Urine examination for schistosomal ova Urinary retention - An absence of arterial flow is typical Investigations Cystoscopy: tubercles, sandy patches, nodules, ulcers Differential diagnoses Radionuclide scan using Tc-99m pertechnetate Urinalysis Plain abdominal radiograph (KUB) Acute pyelonephritis - The twisted testis is avascular Urine microscopy, culture and sensitivity Intravenous urogram Renal tumour Treatment objectives Urethroscopy Serological tests Acute appendicitis Detorsion Urethrogram Full Blood Count Other causes of urinary obstruction e.g. enlarged Fixation of the testis to prevent recurrence Uroflowmetry Treament objectives prostate, urethral strictures Treatment Abdominal ultrasound To eradicate the fluke and ova Complications Fixation on the affected side and prophylactic fixation Serum Urea, Electrolytes and Creatinine Prevent complications Recurrent and intractable urinary tract infection on the opposite side Full Blood Count Drug treatment Secondary hydronephrosis Treatment objective Praziquantel Progressive renal failure To restore urethral patency - The schistosomicide with the most attractive Periurethral abscess/urethral fistula Drug treatment combination of effectiveness, broad-spectrum activity Investigations URETHRALSTRICTURE None and low toxicity Urinalysis Introduction Non-drug treatment Adult: Single oral dose of 50 mg/kg Urine culture An abnormal narrowing or loss of distensibility of any Serial dilatation/bouginage Child over 4 years: 20 mg/kg orally, repeated after 4 - 6 Serum calcium, phosphate and albumin part of the urethra, as a result of fibrosis Endoscopic direct visual urethrotomy hours Intravenous urography (IVU) One of the commonest causes of urine retention in Urethroplasty: excision and end-to-end anastomosis - InS.japonicum infection, 20 mg/kg 3 times daily for Ultrasonography tropicalAfrica Substitution urethroplasty one day after initial dose Computerized tomography (non-contrast enhanced) Veryrare in females. Prevention Or: Treatment objectives May result from trauma or inflammation; may be Ensure prevention of sexually transmitted infections Metrifonate Relieve symptoms iatrogenic Prompt and appropriate treatment of sexually Adult: 10 mg/kg orally, fortnightly for three doses Remove stones Traumatic causes: transmitted infections Notable adverse drug reactions, caution Prevent recurrence Penetrating or blunt injury to the urethra Care and attention to asepsis during instrumention Nausea, epigastric pain, pruritus, headache, dizziness Non-drug treatment - From pelvic fractures or falling astride an object procedures involving the urethra Prevention Increased fluid intake Infective causes: Provision of and access to pipe-borne water Endoscopic Short Wave Lithotripsy (ESWL) Gonococcal urethritis or non-gonococcal urethritis Improvement in socio-economic conditions Endoscopic removal of stones from chlamydia, tuberculosis or schistosomiasis Mass chemotherapy in endemic areas Open surgical removal Iatrogenic causes: URINARYSCHISTOSOMIASIS Eradicating the intermediate hosts (water snails) Drug treatment Urethral instrumentations e.g. catheterization and 1ntroduction Analgesics urethroscopy Acommon parasitic infection of the urinary tract caused Antibiotics to treat infections May be congenital by a body fluke, Schistosoma haematobium URINARYTRACT CALCULI Drugs used to prevent recurrence: May be complete or partial, single or multiple Acquired while bathing/wading in infected water Introduction Thiazide diuretics Can affect any part of the urethra, anterior or posterior Endemic in many parts ofAfrica Occurrence of stone(s) in the kidney, ureter, bladder or - Hydrochorothiazide 5 mg orally daily Clinical features Gets to the urinary tract through the blood vessels after urethra Or: Dysuria penetrating the skin Incidence in Nigeria is7-34per100,000 Potassium citrate Frequency Clinical features Stones are different wih respect to their composition - 60 mEq orally daily Urgency Soon after penetration of the skin: - Oxalate stones, phosphate stones, uric acid stones and Or: Poor stream Pricking sensation and itching (cercarial dermatitis) cystine stones Allopurinol 100 mg orally daily Straining Four weeks later: Factors promoting stone formation: Hesitancy Intermittent fever, malaise, urticaria and cough

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CHAPTER 11: INFECTIOUS Other investigations as may be indicated in the clinical - Food is contaminated byS.aureus when prepared Not a major cause of sporadic diarrhoea DISEASES/INFESTATIONS cirmcumstances unhygienically by individuals who are carriers Norwalk virus food poisoning: Complications - Subsequent growth ofS.aureus in the food and Abrupt onset of nausea and abdominal cramps FEVERS: MANAGEMENTAPPROACH Heat stroke in adults enterotoxin production occurs if the food is not cooked at followed by vomiting and/or diarrhoea Introduction Febrile convulsions in children temperatures sufficient to kill the bacteria, or is not HepatitisAvirus food poisoning: Aleading cause for seeking medical care Complications associated with underlying cause(s) of refrigerated May cause large outbreaks of diarrhoea and vomiting In health, temperature is controlled within limits (in fever Food-borne botulism from contaminated food, water, milk and shellfish adults at a mean of 36.8° C) with diurnal variations of Treatment objectives Non-typhoidal Salmonellosis - Intrafamily and intrainstitutional spread common about 0.5° C To lower the temperature Shigellosis Diagnosis 'Fever' is elevation of body temperature that exceeds the To treat underlying causes E. coli food poisoning Essentially clinical normal daily variation and occurs in conjunction with an Non-drug treatment Campylobacter food poisoning Laboratory confirmation of the specific microbe(s) increase in hypothalamic set point Tepid sponging Listeria monocytogenes food poisoning involved In children younger than 5 years of age: Liberal oral sips of water (if clinical state is not a Yersiniaenterocolitica food poisoning Differential diagnoses Arectal temperature greater than 38° C contraindication) Norwalk virus food poisoning Other causes of acute onset diarrhoea, nausea, Oral temperature above 37.8° C Drug treatment HepatitisAvirus food poisoning abdominal cramps and vomiting with or without Axillary temperature above 37.2° C Paracetamol Giardiasis systemic manifestations Important points in the history are: Adult: 500 mg - 1 g orally every 4 - 6 hours; maximum 4 g Helminthic parasitic food poisoning Complications Chronology of symptoms daily Clinical features Fluid and electrolyte derangements Occupational history Child: 3 months - 1 year: 60 - 125 mg; 1 - 5 years: 120 - Staphylococcal food poisoning: Others Travel history 250 mg; 6 - 12 years: 250 - 500 mg; repeated every 4 - 6 Nausea - By no means limited to the stated organisms Geographic region hours if necessary to a maximum of 4 doses in 24 hours Diarrhoea 2 - 6 hours after eating food contaminated by Shigellosis: Family history - Infants under 3 months should not be given paracetamol enterotoxin Dehydration Physical examination: unless advised by a doctor Food-borne botulism: Rectal prolapse Vital signs (axillary temperatures are unreliable) Aspirin: (acetylsalicylic acid) Incubation period is 18 - 36 hours, but depending on Protein-losing enteropathy Skin, lymph nodes, eyes, nail beds, CNS, chest, Adult: 300 - 900 mg orally (with or without food) very 4 - toxin dose, can extend from a few hours to several days Malnutrition abdomen, cardiovascular, musculo-skeletal and nervous 6 hours if necessary; maximum 4g daily Symmetric descending paralysis Haemolytic-uraemic syndrome systems Treat the identified (or suspected) cause of fever Diplopia Toxic megacolon Rectal examination is imperative Child: under 16 years, not recommended because of the Dysarthria/dysphagia Perforation The penis, prostate, scrotum and testes (for men) risk of Reye's syndrome Nausea, vomiting and abdominal pain may precede or Campylobacter food poisoning: Pelvic examination (for women) Notable adverse drug reactions, caution follow the onset of paralysis Bacteraemia Investigations Paracetamol: Non-typhoidal Salmonellosis: Cholecystitis The number of investigations will depend on the clinical Liver damage (and less frequently, renal damage) Diarrhoea Pancreatitis circumstances. On occasions, patients may need to be following over dosage Nausea Cystitis extensively investigated Aspirin Vomiting Meningitis General: Gastrointestinal discomfort, nausea Abdominal cramps Endocarditis Full Blood Count Ulceration with occult bleeding Fever Arthritis Differential white blood cell count Hearing disturbances such as tinnitus (rarely deafness) Headache Peritonitis Urinalysis with examination of the urinary sediment Use with caution in the following clinical conditions: Myalgia Cellulitis Examination of any abnormal fluid collection Asthma Shigellosis: Septic abortion Microbiology: Allergic disease Fever Treatment objectives Smears and culture of specimens from the throat, Impaired renal or hepatic function Self-limiting watery diarrhoea Restore fluid and electrolyte balance urethra, anus, cervix, and vagina (as indicated) Pregnancy Bloody diarrhoea Neutralize toxin Sputum smears; culture Breastfeeding Dysentry Eradicate microbe Blood culture Elderly - Frequent passage, 10 - 30 times/day of small volume Non-drug measures Urine microscopy, culture and sensitivity Dehydration stools containing blood, mucus and pus Gastric lavage in food-borne botulism Cerebrospinal fluid examination Abdominal cramps Drug treatment Abnormal fluid collection: specimens for microscopy, Tenesmus Appropriate fluid and electrolyte replacement culture and sensitivity testing FOOD POISONING Campylobacter food poisoning: Trivalent (types A, B, and E) equine anti-toxin should Chemistry: Introduction A prodrome with fever, headache, myalgia and/or be administered as soon as possible after specimens are Urine examination Aspectrum of disorders arising from: malaise obtained for laboratory analysis for food-borne botulism Serum urea, electrolytes and creatinine Infections acquired by eating contaminated food 12 - 48 hours later: Emetics in food-borne botulism Blood glucose Clinical problems that result from eating food Diarrhoea and abdominal pain Administer appropriate medicines Liver function tests contaminated with toxins E.coli food poisoning: Shigellosis Cerebrospinal fluid examination Clinical sequelae from inherently poisonous animals, Watery diarrhoea accompanied by cramps Oral Rehydration Therapy Radiology: plants or mushrooms L. monocytogenes food poisoning: Plus: Chest radiograph Clinical forms: Common source of outbreaks of acute gastritis Adult: Amoxicillin 50 - 100 mg/kg/day orally every 8 Staphylococcal food poisoning:

125 126 Chapter 11: Infectious Diseases/Infestations Standard Treatment Guidelines for Nigeria 2008 hours; up to 2 g/day HELMINTHIASIS Abdominal pain presentation Child up to 10 years: 125 mg every 8 hours, doubled in Introduction Weight loss Investigations severe infections Parasitic worm infestations can arise from different Vulvo-vaginitis Stool examination for ova and parasites Or: groups: Pelvic/perineal granulomas Urine examination: microscopy Trimethoprim/sulfamethoxazole (co-trimoxazole) Nematodes (round worms) Trichuriasis Haematology: eosinophilia and anaemia may be present Adult: 960 mg orally every 12 hours for 5 days Ascaris Abdominal pain Serology and CT scan may be required in some Child weeks to 5 months: 120 mg orally; 6 months - 5 Ancylostoma (hookworm) Anorexia instances years: 240 mg; 6 - 12 years: 480 mg given every 12 hours Enterobius (pinworm) Bloody or mucoid diarrhoea Drug Treatment for 5 days Trichiuris (whipworm) Rectal prolapse Hookworm Or: Cestodes (flat worms/tapeworms) Growth retardation Mebendazole Ceftriaxone: -Taeniasolium and T. saginata Strongyloidiasis Adult and child: 100 mg orally every 12 hours for 3 days Adult: 1 g intravenously slowly Trematodes (flukes) Distinguished by its ability to replicate in the human Iron supplementation may be given if anaemia is Child: 50 mg/kg/day intravenously for 5 days -Schistosoma haematobium and S. mansoni host present Campylobacter food poisoning Round worm infestations are associated with rural - Can thus persist for decades without further exposure of Ascaris Fluid and electrolyte replacement living and poor hygiene the host to exogenous infective larvae Mebendazole Plus: - Prevalent among school children and young adults Recurrent urticaria: buttocks and wrists Adult and child: 100 mg orally every 12 hours for 3 days Erythromycin - Acquired through soil and faeco-oral contamination Pruritic raised erythematous skin lesions: advance as Or: Adult: 250 mg orally every 6 hours for5-7days Flat worms and tape worms are acquired by eating rapidly as 10 cm/hour along the course of larval Piperazine phosphate Child: 30-50 mg/kg orally every 6 hours for5-7days under-cooked contaminated meat or fish migration Adult: 4 g (i.e. the contents of one satchet) stirred into E. coli food poisoning Bladder worms (S. haematobium ) are acquired by - The pathognomonic serpiginous eruption water or milk and taken at bedtime Ciprofloxacin wading through streams and ponds contaminated with Mid-epigastric abdominal pain - Reapeat after 14 days Adult: 500 - 750 mg orally every 12 hours the vector snails Nausea Child: 1 - 6 years: 750 mg (i.e. 5 mL) orally in the Or: Clinical features Diarrhoea morning, repeated after 14 days 200 - 400 mg 12 hourly by intravenous infection over 30 - Depend on the infecting helminth: Gastrointestinal bleeding Infants 3 months - 1 year: 2.5 mL orally in the morning, 60 minutes Ascariasis Mild chronic colitis repeated after 14 days Child and adolescent: not recommended Lung phase: Weight loss - Repeated treatments may be necessary L.monocyogenes food poisoning Irritating, non-productive cough Small bowel obstruction Trichiuris Amoxicillin Burning substernal discomfort, aggravated by coughing Disseminated strongyloidiasis in patients with Mebandazole Plus: or deep inspiration unsuspected infection who are given glucocorticoids Adult and child: 100 mg orallyevery 12 hours for 3 days Gentamicin Dyspnoea can be fatal Enterobius Treat specific complications as appropriate e.g Blood-tinged sputum Trichinellosis Pyrantel embonate - Antibiotic-unresponsive toxic megacolon: colectomy Intestinal phase: In the first week after infection (gut invasion): Adult and child: 10 mg/kg orally once - Haemolytic-uraemic syndrome: dialysis Usually no symptoms Diarrhoea - Repeat dose 2 weeks later; several treatments may be - Malnutrition from protein-losing enteropathy: Pain Abdominal necessary nutritional support; optimal nutritional management Features of small bowel obstruction Pain Trematodes Prevention Features of perforation Constipation Praziquantel Appropriate environmental and personal hygiene Intussusception Nausea Adult: 40 mg/kg given orally at once - Hand washing with soap and water Volvulus Vomiting - Provides up to 80% cure rates - Decontamination of water supplies Biliary tree occlusion: biliary colic, cholecystitis, In the second week after infection (muscle invasion): Child over 4 years: 20 mg/kg followed after 4 - 6 hours by - Use of sanitay latrines or toilets cholangitis, pancreatitis, intrahepatic abscess Fever a further dose of 20 mg/kg Identify and treat chronic carriers among food handlers Effects of migration of an adult worm up the oesophagus: Periorbital and facial oedema Praziquantel is effective in all human cases caused by all Hygienic preparation and storage of food Coughing Haemorrhages (subconjunctival, retinal and nail bed) schistosomes Ensure that food is cooked at temperatures sufficient to Oral expulsion of the worm Maculopapular rash Cestodes kill bacteria Hookworm Headache Praziquantel Refrigerate food whenever possible Most are asymptomatic Cough Adult: 40 mg/kg given orally at once Encourage exclusive breastfeeding Maculo-papular dermatitis Dyspnoea Or: Encourage measures measures to reduce the burden of Mild transient pneumonitis Dysphagia - 20 mg/kg followed by another 20 mg/kg after 4 - 6 malnutrition (with its attendant predisposition to severe Epigastric pain, often with post-prandial accentuation Tachyarrhythmias hours infections) Diarrhoea Heart failure Child over 4 years: 20 mg/kg followed after 4 - 6 hours by Administer a pentavalent vaccine (A, B, C, D, and E) Weakness Encephalitis a further dose of 20 mg/kg (20 mg/kg 3 times daily for one for persons at high of botulism Shortness of breath Pneumonitis day forS.japonicum infections) Report new cases to public health authorities Skin depigmentation Schistosomiasis Notable adverse drug reactions, caution and Enterobiasis - See Urology contraindications Perianal pruritus, worse at night owing to the nocturnal Differential diagnoses Avoid mebendazole in pregnant women migration of the female worms Other causes of acute-onset diarrhoea and/or vomiting Side effects of praziquantel include abdominal pain, Skin excoriation and bacterial superinfection -Other conditions depending on the predominant clinical headache, dizziness and skin rashes

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Prevention cryptosporidium, cryptocooccocus. 2: Clinical findings of disabling cognitive and/or motor Good personal and food hygiene Systemic fungal infections dysfunction interfering with activities of daily living, Access to safe and potable water Other cancers (lymphomas, cervical cancer, etc.) progression over weeks or months in absence of Regular deworming Staging of HIV/AIDS concurrent illness or condition other than HIV infection Adequate cooking of food and meats WHO Staging System for HIV Infection and Disease in that could explain the finding Adults andAdolescents Clinical Stage I: Asymptomatic HUMAN IMMUNODEFICIENCY VIRUS Generalised lymphadenopathy INFECTION Performance scale 1: asymptomatic, normal activity Introduction Clinical Stage II: Human Immunodeficiency Virus (HIV) is a retrovirus Weight loss < 10% of body weight WHO Improved Clinical Staging which infects primarily CD4 T cells (T helper cells) Minor mucocutaneous manifestations (seborrhoeic Infection leads to a progressive destruction of the dermatitis, prurigo, fungal nail infections, recurrent oral Laboratory indices Clinical stage immune system with a consequent myriad of ulcerations, angular cheilitis) opportunistic infections and the development of certain Herpes zoster within the last five years Recurrent upper respiratory tract infections (i.e. malignancies Lymphocytes CD4 Stage 1 Stage 2 Stage 3 Stage 4 Acquired Immuno Deficiency Syndrome (AIDS) is bacterial sinusitis) defined as the presence of an AIDS-defining illness (see And/or performance scale 2: symptomatic, normal Asym.PGL Early HIV Intermed. LateAIDS table 1) with a positive antibody test for HIV activity HIV transmission Clinical Stage III: (ARC) Sexual transmission through vaginal and anal sex is the Weight loss > 10% of body weight commonest route globally and in Nigeria, accounting for Unexplained chronic diarrhoea, > 1 month A > 2000 > 500 1A 2A 3A 4A about 80% Unexplained prolonged fever (intermittent or constant) Transfusion of infected blood and blood products > 1 month B 1000 - 2000 200 - 500 1B 2B 3B 4B Use of contaminated instruments; sharing needles, Oral candidiasis (thrush) tattooing and occupational exposures Oral hairy leucoplakia C < 1000 < 200 1C 2C 3C 4C Mother-to-child transmission of HIV: from an infected Pulmonary tuberculosis within the past year mother to her baby during pregnancy, at delivery and, Severe bacterial infections (i.e. pneumonia, after birth through breast-feeding pyomyositis) Clinical features And/or performance scale 3: bedridden < 50% of the Transient early acute symptoms: commonly “flu” -like day during last month illness, often not recognized in the first 2 - 3 weeks of Clinical Stage IV: CDC classification HIV infection: HIV wasting syndrome1 Generalized lymphadenopathy Pneumocystic carinii pneumonia CD4 StageA Stage B Stage C Sore throat Toxoplasmosis of the brain Asym. Symp. AIDS indicator Fever Cryptosporidiosis with diarrhoea > 1 month PGL notAor C condition Skin rash Cryptococcosis, extrapulmonary Asymptmatic period: Cytomegalovirus disease of an organ other than liver, > 500 A1 B1 C1 The individual feels well despite on-going viral spleen or lymph node (e.g. retinitis) replication Herpes simplex virus infection, mucocutaneous 200 - 500 A2 B2 C2 Initial symptoms: (>1month) or visceral Generalized lymphadenopathy Progressive multifocal leucoencephalopathy < 200 A3 B3 C3 Wasting syndrome/fever/night sweats Any disseminated endemic mycosis Neurologic disease Candidiasis of oesophagus, trachea, bronchi Early immune failure Atypical mycobacteriosis, disseminated or lungs Oral thrush Non-typhoid salmonella septicaemia Herpes zoster Extrapulmonary tuberculosis Hairy leukoplakia Lymphoma AIDS (opportunistic infections) Kaposi sarcoma 2 Differential diagnoses Recurrent bacterial pneumonias HIV encephalopathy Tuberculosis Pulmonary and extrapulmonary tuberculosis And/or performance scale 4: bedridden > 50% of the Malignancies Pneumocytis carinii infection day during last month Diabetes mellitus Kaposi sarcoma 1: Weight loss of > 10% plus either unexplained Other wasting syndromes Viral infections including cytomegalo virus chronic diarrhoea > 1 month, or chronic weakness and Other protozoan infections including unexplained prolonged fever > 1 month.

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3 Diagnosis of HIV has to be made by identifying HIV Didanosine (ddI) CD4 count (cells/mm ) Infectious complications Non-infectious complications DNAusing PCR - 400 mg orally once daily HIV-seropositivechildren aged <18 months - If weight < 60 kg or combined with TDF: 250 mg once > 500 Acute HIV, candidal vaginitis PGL, Guillain-Barre syndrome, myopathy, aseptic meningitis If HIV status is virologically-proven ART is daily recommended when the child has: Tenofovir (TDF) WHO Paediatric Stage III disease irrespective of CD4 - 300 mg once daily 200 - 500 Pneumococcal and other bacterial Cervical cancer, anaemia, lymphomas pneumonias, pulmonary TB, Herpes % Abacavir (ABC) zoster, oropharyngeal candidiasis, oral WHO Paediatric Stage II disease, with consideration of - 300 mg orally twice daily hairy leukoplakia, Kaposi sarcoma using CD4 <20% to assist in decision making Indinavir (IDV) Or: - 800 mg orally three times daily WHO Paediatric Stage I (asymptomatic) and CD4 Nelfinavir (NFV) < 200 Milliary/extrapulmonary TB, Wasting, peripheral neuropathy, pneumocystis carinii pneumonia (PCP), progressive polyradiculopathy, HIV- <20% - 1.25 g orally twice daily disseminated histoplasmosis and associated dementia, cardiomyopathy - If HIV-seropositive status is not virologically proven Or: coccidiomycosis, progressive multifocal but CD4 cell assays are available, ART can be initiated - 750 mg three times daily leukoencephalopathy (PML) when the child has : Lopinavir/Ritonavir (LPV/r) WHO Stage II or III disease and CD4 <20% - 3 capsules (498 mg) orally twice daily - In such cases, HIV antibody testing must be repeated at Saquinavir (SQV) < 100 Disseminated herpes simplex, toxoplasmosis, crytococcosis, age 18 months to definitively confirm that the child is - 1.2 g orally three times daily cryptosporidium, chronic HIV infected Amprenavir (AMP) microsporidiosis, and oesophageal - Only children with confirmed infection should have - 1.2 g twice daily candidiasis ARVtherapy continued Ritonavir (RTV) HIV-seropositivechildren aged >18 months - 100 mg orally twice daily ART can be initiated when child has: Atazanavir (ATV) <50 Disseminated cytomegalovirus (CMV), Central nervous system lymphomas disseminated Mycobacterium avium WHO Paediatric Stage III disease (e.g. clinical AIDS) - 400 mg orally once daily complex (MAC) irrespective of CD4 count Children WHO Paediatric Stage II disease with CD4 <15% Preferred first line regimen Or: - d4T or ZDV/ 3TC / NVPor EFV WHO Paediatric Stage I disease (e.g. asymptomatic- - EFV for age 3 years and above; avoid liquid appendix I) and CD4 <15% (Appendix I) formulations For children > 8 years adult criteria for initiation of Alternative first line regimens therapy are applicable - ddI/3TC/NVPor EFV Complications count testing Drug treatment - EFV for age 3 years and above, avoid liquid If CD4 testing is available: Preferred first line regimen (adults and adolescents) formulations Investigations WHO Stage IV disease irrespective of CD4 cell count 3 - d4T / 3TC / NVPor EFZ Alternative first line drugs for special category of Full Blood Count and differentials WHO Stage III disease with CD4 cell counts < 350/mm Alternative first line regimens children VDRL(or RPR) WHO Stage I or II disease with CD4 cell counts ³ - TDF/3TC/NVPor EFZ Children with tuberculosis require rifampicin-containing 3 Tuberculin test (PPD) 200/mm Or: regimen for TB treatment Sputum smears for TB If CD4 testing is unavailable: - ABC/3TC/NVPor EFZ - D4Tor ZDV/3TC/EFV (3 years and above) Electrolytes, Urea and Creatinine WHO Stage IV disease irrespective of total lymphocyte Alternative first line drugs for special category of adults Age less than 3 years: please refer to paediatric HIV Blood glucose 3 count (TLC) Pregnant women with CD4 count <250 cells/mm or consultant Liver function tests WHO Stage III disease irrespective of TLC women who are likely to become pregnant First line recommendations for HIV/TB patients Lipid studies (fasting trigycerides, LDL, HDL) 3 WHO Stage II disease with a TLC³ 1200/mm - ZDV / 3TC / NVP Adults/Adolescents and Pregnant Women: HBV,HCV serology 3 ATLC of³ 1200/mm does not predict a CD4 cell count Adult dosages - (ZDV or dT4) + 3TC + NVP during non-rifampicin- Cervical (PAP)smears 3 of³ 200/mm in asymptomatic patients Nevirapine (NVP) containing continuation phase CD4 T cell counts ³ 3 - 200 mg orally once daily for 2 weeks; then 200 mg Or: HIV RNAlevel (viral load) TLC of 1200/mm may not be used as criterion for the twice daily - (ZDV or dT4) +3TC + EFV during rifampicin- HIV DNA(paediatric diagnosis <18 months of age) initiation of therapy in asymptomatic patients (WHO Efavirenz (EFV) containing intensive or continuation phase Genotype and phenotype assays for resistance testing Stage 1 disease) - 600 mg orally once daily; 800 mg once daily when Management of virological treatment failure Treatment objectives Children using anti-tuberculosis drug Treatment failure due to resistance Clinical: prevent disease progression Children are monitored using CD4 percentage (CD4 %) Zidovudine (ZDV) The three drugs reserved for the first line regimens are Immunological: restore immunity i.e. percentage of lymphocytes that are CD4 cells - 250 - 300 mg orally twice daily replaced with three totally new drugs-second line Virological: control or suppress viral replication CD4% of an HIV-negativechild is around 40% Stavudine (d4T) regimens Public health: reduce infectivity Diagnosis depends on the age of the child and - 40 mg orally twice daily - If resistance testing cannot be done (see second line Criteria for initiating ART based on Nigerian ART availability of virological testing - If weight <60 kg: 30 mg twice daily treatment regimens) guidelines Children < 18 months Lamivudine (3TC) Where resistance testing is available, the failing drug Adults andAdolescents Serological diagnosis is unreliable as maternally- - 150 mg orally twice daily may be identified and replaced Initiation of therapy depends on availability of CD4 cell derived antibodies may persist for up to 15 - 18 months

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- Hallucinations reactions: Recommended second line regimens - Insomnia - Gastrointestinal Adults and adolescents - Abnormal dreams - Hepatic transaminitis especially in patients with chronic First line Second line - Somnolence hepatitis B or C d4T or ZDV/3TC/NVPor EFV TDF/FTC/IDV/r or SQV/r or LPV/r - Amnesia - Hyperlipidaemia Or: - Abnormal thinking - Fat accumulation ABC/ddI/IDV/r or SQV/r or LPV/r - Confusion Saquinavir (SQV) Or: - Euphoria GIT intolerance in 5 - 30% leading to: TDF/FTC/NVPor EFV ZDV/3TC or ddI/IDV/r or SQV/r or LPV/r For these reasons, EFV is contraindicated in patients - Nausea Or: who already have psychiatric manifestations - Abdominal pain ABC/3TC/NVPor EFV TDF/FTC/IDV/r or SQV/r or LPV/r - Foetal abnormalities observed in animal models; - Diarrhoea efavirenz should not be used in pregnant women or Amprenavir (AMP) Note women who might become pregnant while on therapy - Class adverse effects The dose of ddI should be reduced from 400 mg to 250 mg when co-administering with TDF in an adult > 60 kg Zidovudine (ZDV) - GIT intolerance; oral paraesthesia in 28% of patients Reduce dose to 125 mg in adult < 60 kg - Bone marrow suppression resulting in: Oral solution contains propylene glycol which may IDV/r, LPV/r and SQV/r require secure cold chain for storage - Anaemia with macrocytosis precipitate: Co-formulations of the medications above may be used to reduce the pill burden - Thrombocytopaenia - Seizures - Leucocytopaenia - Stupor Children - Gastro-intestinal intolerance is fairly common: - Tachycardia First line Second line hypersalivation, nausea, abdominal discomfort - Hyperosmolality d4T or ZDV/3TC/NVPor EFV d4T or ZDV/3TC/ABC/LPV/r (preferred) or NFV Stavudine (d4T) - Lactic acidosis Or: Or: - Peripheral neuropathy presenting with painful - Renal failure ddI/3TC/NVPor EFV ZDV/3TC/LPV/r (preferred) or NFV sensations in the lower limbs more than the upper limbs - Haemolysis LPV/r requires secure cold chain - Lactic acidosis with hepatic steatosis Oral solution is contraindicated in children below 4 All treatment failures at first and second level health facilities should be referred to a paediatric consultant - Stop treatment or switch to a drug less toxic to years; should be changed to capsules as soon as possible mitochondria (worse when d4T is used in combination Ritonavir (RTV) with ddI) - Class side effects - Peripheral fat atrophy - Perversion of taste - Ascending motor weakness resembling Guillain- Child dosages - <4 years: not used - Circumoral and peripheral paraesthesia 2 Barre syndrome - Hepatotoxicity Didanosine (ddI) - 4 - 17 years: 500 mg/m orally twice daily; (maximum 2 Lamivudine (3TC) - Aesthenia - 2 weeks - 8 months: 100 mg/m orally twice daily 800 mg) three times daily 2 - No major side effect but class side effects may occur Atazanavir (ATV) - > 8 months: 120 mg/m twice daily Nelfinavir (NFV) Didanosine (ddI) - Unconjugated hyperbilirubinaemia Lamivudine (3TC) - <1 year: 40 - 50 mg/kg orally three times daily; or 65 - - Dose-related pancreatitis; worse when combined with - Gastrointestinal effects - <1 month: 2 mg/kg orally twice daily 75 mg/kg twice daily hydroxycarbamide (hydroxyurea) - No effect on lipids - >1 month: 4 mg/kg orally twice daily - 1 - 13 years: 55 - 65 mg/kg twice daily - Peripheral neuropathy; worse if combined with d4T Note - Adolescents < 50 kg: 2 mg/kg orally twice daily Lopinavir/rotinavir (Lop/r) - Lactic acidosis (a class adverse effect) Refer to standard texts for possible drug-drug Stavudine (d4T) - 7 kg to <15 kg: lopinavir 12 mg/kg, rotinavir 3 mg/kg Tenofovir (TDF) interactions in all cases - 1mg/kg orally twice daily up to a maximum of 40 mg orally twice daily with food - Infrequent; not more than what is observed in placebos Prevention per dose - 15 - 40 kg: lopinavir 10 mg/kg, rotinavir 2.5 mg/kg in controlled trials Mechanisms with established merit: Zalcitabine (ddC) orally twice daily with food - Renal insufficiency and bone demineralization Prevention of mother-to-child transmission (PMTCT) - Not available - >40 kg lopinavir 400 mg, rotinavir 100 mg orally Abacavir (ABC) ProphylacticAZT/NVPor HAART Zidovudine (ZDV) twice daily with food - Life-threatening hypersensitivity in 3 - 9% of patients Caesarian section 2 Notable adverse drug reactions, caution and - 160 mg/m orally every 8hours - Lactic acidosis with or without hepatic steatosis Infant feeding choices (Exclusive Formula) Contraindications Efavirenz (EFZ) Indinavir (IDV) Safer sex (condom use) Nevirapine (NVP) - Taken orally once daily - Class-specific events Post exposure prophylaxis among healthworkers - Life-threatening skin rash (Stevens-Johnson - 10 to <15 kg: 200 mg; 15 to < 20 kg 250 mg; 20 to <25 - Nephrolithiasis with or without haematuria in 10 - Treatment of STIs syndrome); occurs in < 5% of patients, usually within 8 kg 300 mg; 25 to <32.5 kg 350 mg; 32.5 to <40 kg 400 28% of patients; (fluid intake should be increased) Voluntarycounselling and testing (VCT) weeks of treatment mg; >40 kg 600 mg - Alopecia Needle exchange programmes for IVUs - DRESS syndrome (dr rug ash, e osinophilia and Nevirapine (NVP) Nelfinavir (NFV) Mechanisms with anticipated (potential) merit: ssystemic ymptoms): manifests as fever, athralgia, etc - 15 - 30 days: 5 mg/kg orally once daily for 14 days, then - Diarrhoea: 10 - 30% of patients; (should be managed Reduction of viral load with HAART 22- Hepatitis and jaundice reported 120 mg/m twice daily for 14 days, and 200 mg/m twice with agents such as loperamide) Post exposure prophylaxis following sexual exposure Efavirenz (EFV) daily - Fat accumulation (rape) 2 - Morbilliform rash may appear; usually not life- - 1month - 13 years: 120 mg/m twice daily for 14 days, - Hyperlipidaemia Sexual risk reduction 2 threatening then 200 mg/m twice daily Lopinavir/ritonavir (LPV/r) Promotion of safer sex and low-risk behaviour - CNS side effects in about 50% of patients (usually Indinavir (IDV) Well tolerated except for occasional class adverse A: Abstinence self-limiting)

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B: Be faithful (mutual fidelity to infected partner) Repeated vomiting White cell count with differentials Adult: 20 mg/kg of salt to a maximum of 1.2 g loading C: Consistent and correct use of male and female Prostration Blood sugar dose intravenously, diluted in 10 ml/kg isotonic fluid condoms Impaired consciousness Urinalysis over 4 hours D: Delay onset of sexual activity Severe anaemia Electrolytes and Urea; Creatinine - 8 hours after start of the loading dose: 10 mg/kg salt to E: Examine yourself Circulatory collapse Stool microscopy for ova; occult blood a maximum of 600 mg over 4 hours, every 8 hours until F: Find out your status Hypoglycaemia Chest radiograph the patient is able to take orally Screening and treatment of sexually transmitted Pulmonary oedema Cerebrospinal fluid biochemistry; microscopy, culture - Then change to tablets 10 mg/kg 8 hourly for 7 days or infections Abnormal bleeding and sensitivity give full dose of artemether-lumefantrine Encourage Partner Disclosure and Voluntary Jaundice Treatment objectives Child: 20 mg/kg of salt as loading dose diluted in 10 Confidential Couple Counselling (VCCCT) Haemoglobinuria Eradicate parasitaemia mL/kg of 4.3% glucose in 0.18% saline or in 5% glucose Promote the rights and protection of children and Febrile seizures Prevent severe malaria over 4 hours 12 hours later, give 10 mg salt/kg as infusion women Renal failure Attend to the immediate threats of life over 4 hours, and every 8 hours until patient is able to take Hyperparasitaemia Prevent complications orally MALARIA Cerebral malaria Provide personal protection against malaria Change to tablets 10 mg/kg every 8 hours to complete a Introduction Asevere form of malaria Provide chemoprophylaxis in susceptible groups total of 7 days An infectious protozoan disease transmitted by the Occurs usually in children and in non-immune adults Drug treatment Or: femaleAnopheles mosquito Manifests with diffuse and symmetric encephalopathy; Uncomplicated malaria - Where intravenous access is not possible, give quinine Amajor public and private health problem and indeed a focal neurologic signs are unusual It is vital to prevent severe disease, therefore as soon as a dihydrochloride 20 mg/kg salt as loading dose, diluted to cause and consequence of national underdevelopment Requires prompt and effective therapy to avoid fatality presumptive diagnosis of malaria is made: 60 -100 mg/ml intramuscularly in different sites Four species of the parasite cause the disease in Diagnosis of malaria Insert artesunate suppository per rectum as a single - 8 hours after loading dose, give 10 mg/kg 8 hourly humans:Plasmodium falciparum , vivax , ovale and Absence of fever does not exclude a diagnosis of dose until patient is able to take orally malariae malaria Re-insert if expelled; in young children the buttocks - Thereafter, change to tablets 10 mg/kg 8 hourly for 7 P.falciparum accounts for 98% of all cases of malaria Microscopic diagnosis should not delay appropriate may need to be held or taped together for 10 minutes to days or give a full dose of artemether-lumefantrine in Nigeria and is responsible for the severe form of the treatment if there is a clinical suspicion of severe malaria ensure retention of the rectal dose Or: disease Differential diagnoses Artemisin-based combination therapy is the treatment of - Artesunate Principal mode of spread: bites from infected female Typhoid fever choice Adult: 2.4 mg/kg intravenous bolus; repeat 1.2 mg/kg Anopheles mosquito Meningitis Adult and child over 16 years < 40 kg: 10 mg/kg; 40 - 59 after 12 hours then 1.2 mg/kg daily for 7 days Peak feeding times are usually dusk and dawn, but also Encephalitis kg: 400 mg (one 400 mg suppository); 60 - 80 kg: 800 mg Child: intravenous use reserved for specialists throughout the night Septicaemia (two 400 mg suppositories); >80 kg: 1,200 mg (three 400 - Once patient can tolerate oral medication give a full Other uncommon modes are: Other causes of fever mg suppositories) dose of artemether-lumefantrine Blood transfusion Complications Child: 30 - 39 kg: 300 mg (three 100 mg suppositories); Or: Mother-to-child transmission Early 20 - 29 kg: 200 mg (two 100 mg suppositories); 9 - 19 kg: - Artemether Classification Hypoglycaemia 100 mg (one 100 mg suppository); 5 - 8.9 kg: 50 mg (one - 3.2 mg/kg intramuscular loading dose followed by 1.6 Uncomplicated Lactic acidosis 50 mg suppository) mg/kg daily for 6 days There are no life-threatening manifestations Haematological abnormalities - Dose should be given ONCE and followed as soon as Alternatively: Complicated Liver dysfunction possible by definitive therapy for malaria - Once patient can tolerate oral medication, give full P.falciparum asexual parasitaemia, with the presence Pneumonia Definitive treatment dose of artemether-lumefantrine of clinical and/or laboratory life-threatening features Septicaemia Artemisin-based combination therapy is recommended In all cases, patient's progress should be monitored and Clinical features Non-cardiogenic pulmonary oedema Monotherapy with dihydroartemisin or other artemisinin management changed as deemed necessary These are non-specific: Cerebral malaria derivatives is not recommended Supportive measures Fever 'Blackwater' fever Artemether-lumefantrine (20 mg/120 mg) Paracetamol (oral/rectal) for symptomatic relief of fever Chills Acute tubular necrosis Adult and child over 14 years: 4 standard tablets orally If temperature is >38.5°C, wipe with wet towel, and fan Headache In pregnancy every 12 hours to lower the temperature Malaise Anaemia Child: 9 - 14 years: 3 tablets twice daily for 3 days; 4 - 8 Pulmonary oedema Aches and body pain Preterm contractions/preterm labour years 2 tablets every 12 hours for 3 days - Nurse in cardiac position Weakness Abortions 6 months - 3 years: 1 tablet every 12 hours for 3 days - Give oxygen Tiredness Low birth weight - Not recommended for children under 3 months or <5 kg - Furosemide 2 - 4 mg/kg intravenously Pallor Intrauterine deaths Or: - Exclude anaemia as the cause of heart of the heart Anorexia Congenital malaria Artesunate-amodiaquine (4 mg/10 mg base) failure Vomiting Late Adult: 4 standard tablets every 12 hours Renal failure Bitterness in the mouth Hyperreactive malaria splenomegaly Child: 1 - 2 standard tablets orally every 12 hours, - Give fluids if patient is dehydrated: 20 ml/kg of sodium Excessive sweating Quartan malaria nephropathy adjusted according to age or body weight chloride injection 0.9%, and challenge with furosemide 1 Pallor Possibly, Burkitt's lymphoma Severe malaria - 2 mg/kg Hepatosplenomegaly Investigations Quinine or artemisinin derivatives given parenterally are - Catheterize to monitor urinary output Jaundice Blood smear for malaria parasites the drugs of choice - If no urine within the next 24 hours, refer for peritoneal Malaria is severe when there is: Packed cell volume; haemoglobin concentration - Quinine: or haemodialysis

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Profuse bleeding There are four stages: antiserum Certain port officials - Transfuse with screened fresh whole blood Anon-specific prodrome of1-4days consisting of Provide active immunization with the vaccine Bat handlers - Give pre-referral treatment and refer urgently - Fever If meningitis is suspected, and can not be excluded - Headache Non-drug treatment Persons living in (or travelling to) areas where rabies is immediately by lumbar puncture, give appropriate - Malaise Wound care enzootic and/or where there is limited access to prompt antibiotics - Myalgia The wound or site of exposure should be: medical care Other severe diseases should be treated accordingly - Anorexia Cleansed under running water Those caring for patients caring for patients with rabies Treatments not recommended - Nausea Washed for several minutes with soapy water - Although there is no proven evidence of human-human Corticosteroids and other anti-inflammatory agents; - Vomiting Disinfected and dressed simply transmission agents used for cerebral oedema e.g. urea, adrenaline, - Sore throat It should not be sutured immediately Pregnancy is not a contraindication: if there is substantial heparin - Cough Drug treatment risk of exposure, and rapid access to post-exposure - Have no role in the treatment of severe malaria - Paraesthesia Unimmunized persons or those whose prophylaxis is prophylaxis is limited, give pre-exposure prophylaxis Prevention An acute encephalitic stage probably incomplete Rabies vaccine: Personal protection - Excitement - Rabies (cell mediated) vaccine - 1 ml by deep subcutaneous or intramuscular injection in - Reduce the frequency of mosquito bites by avoiding - Agitation Adult: 1 ml by deep subcutaneous or intramuscular the deltoid region on days 0, 7 and 28 exposure to mosquitoes at their peak feeding times - Confusion injection in the deltoid region on days 0, 3,7,14 and 30 Booster doses every 2 - 3 years for those at continued risk - Use insect repellants - Hallucinations Plus: - Put on suitable clothing - Combativeness Rabies immunoglobulin given on day 0 - Use insecticide-impregnated bed nets (ITN) - Bizarre aberrations of thought Child: same as for adult TETANUS Chemoprohylaxis- - Muscle spasms For fully immunized persons: Introduction - Indicated for: - Meningismus - Rabies (cell mediated) vaccine A common, infectious disease affecting individuals of - Children born to non-immune mothers in endemic areas - Seizures Adult: 1 ml by deep subcutaneous or intramuscular all ages and sexes, particularly the socio-economically - Pregnant women (see section on antenatal care) - Focal paralysis injection in the deltoid region on days 1 and 3 deprived - Travellers to endemic areas - Hydrophobia Child: same as for adult Aneurologic disorder characterized by increased muscle Mefloquine 5 mg base/kg weekly, giving an adult dose Brainstem dysfunction Post-exposure prophylaxis (PEP) tone and spasm that is caused by tetanospasmin, a of 250 mg base/week - Diplopia Should be initiated as soon as possible after exposure powerful protein toxin elaborated by Clostridium tetani Or: - Facial paralysis The decision to initiate PEPshould include: The bacteria are found in the soil, inanimate environment, 1.5 mg of salt/kg administered daily (100 mg of salt - Optic neuritis Whether the individual came into physical contact with animal faeces and occasionally in human faeces daily) - Difficulty with deglutition saliva or another substance likely to contain rabies virus Portals of entry: - If tablets are available, an appropriate fraction can be - Priapism Whether rabies is known or suspected in the species and Umbilical stump given to child aged 8 - 13 years - Spontaneous ejaculation area associated with the exposure Female genital mutilation (FGM) - Contraindicated in children <8 years and in pregnant - Coma The circumstances surrounding the exposure e.g. Male circumcision women Death or recovery whether the bite was provoked or unprovoked Abortion sites - Commence one week before departure and continue Differential diagnoses - Consider the use of rabies vaccine whenever a patient Penetrative wounds (e.g. nail puncture or intramuscular until 4 weeks after leaving the region Gullain-Barré syndrome has been attacked by an animal in an environment where injection) Chemoprophylaxis is not recommended for Other causes of viral encephalitis rabies is enzootic, even if there is no direct evidence of Head injury; scalp wounds individuals living with areas of intense transmission Poliomyelitis rabies in the attacking animal Traditional scarification (e.g. for tribal identity) People with sickle cell anaemia should have regular Allergic encephalomyelitis - Pregnancy not a contraindication Trado-medical incisions chemoprophylaxis (see Sickle Cell Diseases) Complications Supportive measures Post-operative surgical sites Inappropriate secretion ofADH Allay anxiety: reassure Chronic otitis media Diabetes insipidus Other measures as appropriate for clinical situation Clinical forms: RABIES Cardiac arrythmias Notable adverse drug reactions, caution Generalized tetanus Introduction Adult Respiratory Distress Syndrome (ARDS) Concomitant chloroquine administration interferes with Neonatal tetanus An acute disease of the CNS caused by a bullet-shaped Gastro Intestinal (GI) bleeding antibody response to rabies vaccine Localized tetanus rhabdovirus that affects all mammals Thrombocytopenia There are no specific contraindications Cephalic tetanus The virus is a single-stranded RNA virus found in Paralytic ileus Prevention Clinical features animals, in all regions as urban rabies or sylvatic rabies Investigations Pre-exposure prophylaxis Generalized tetanus Transmitted by infected secretions, usually saliva Full Blood Count and differentials Should be offered to persons at high risk of exposure Lock jaw Most exposures are through bites of an infected animal; Urea and Electrolytes and/or contact with rabies virus: Dysphagia ocassionally contact with a virus-containing aerosol or Culture of secretions Veterinnarians Stiffness or pain in the neck, shoulder and back muscles the ingestion or transplant of infected tissues may initiate Cerebro Spinal Fluid (C SF) analysis Cave explorers Rigid abdomen and stiff proximal limb muscles the disease process Serology Laboratory workers who handle the rabies virus The hands and feet are relatively spared Human infection is through contact with un- Pulmonary Chain Reaction (PCR) Animal handlers Neonatal tetanus immunized domestic animals Treatment objectives Workers in quarantine stations Poor feeding Dogs are the most important vectors worldwide Disinfect wound; avoid early suturing Field workers who are likely to be bitten by infected Rigidity Clinical features Provide passive immunization with antirabies wild animals Spasms

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Localized tetanus Provide intubation or tracheostomy for hypoventilation Treat intercurrent infections Differential diagnsoses Increased tone; spasms are restricted to the muscles near Physiotherapy Notable adverse drug reactions, caution and Malaria fever the wound Monitor bowel, bladder and renal function contrainndications Meningitis Prognosis is excellent Prevent decubitus ulcers Diazepam is adsorbed from plastics of infusion bags Viral infections involving the CNS Cephalic tetanus Drug treatment and giving sets; causes drowsiness and light headedness; Treatment Follows head injury or ear infection Antibiotics hypotension Early stage Trismus - Benzylpenicillin (Penicillin G) Benzyl penicillin: hypersensitivity reactions Suramin Dysfunction of one or more cranial nerves, often the 7th Adult: 0.6 - 2.4 g daily by slow intravenous injection or Metronidazole: taste disturbances Adult and child: 5 mg/kg on day 1, 10 mg/kg on day 3, nerve infusion in 2 - 4 divided doses; higher doses in severe Phenobarbital: caution in renal and hepatic impairment and 20 mg/kg on days 5, 11, 17, 23 and 30 Mortality is high infections - May cause paradoxical excitement, restlessness and Late stage Diagnosis Child: 1 month - 18 years, 100 mg/kg in 4 divided doses confusion in the elderly; hyperkinesia in children Melarsoprol Entirely clinical ,every 6 hours; dose doubled in severe infections Prevention Adult: 2.0 - 3.6 mg/kg intravenously in 3 divided doses Differential diagnoses (maximum 2.4 g ,every 4 hours) Active immunization of all partially or un-immunized for 3 days, followed 1 week later with 3.6 mg/kg Alveolar abscess 1 - 4 weeks: 75 mg/kg daily in 3 divided doses, every 86 adults, those recovering from tetanus, all pregnant intravenously in 3 divided doses for 3 days Strychnine poisoning hours; dose doubled in severe infection women, infants and un-immunized (missed) children 10 - 21 days later: 3.6 mg/kg intravenously in 3 divided Dystonic drug reactions Preterm neonate and neonate under 7 days: 25 mg/kg Health education doses for 3 days Hypocalcaemic tetani ,every 12 hours; dose doubled in severe infection Improvement in socio-economic status Caution Meningitis/encephalitis Or: Urine should be examined for casts and protein before Acute abdomen - Metronidazole and after treatment treatment with suramin Complications Adult: 500 mg intravenously ,every 6 hours for 10 days TRYPANOSOMIASIS (Sleeping sickness) Lumbar puncture follow-up for at least 1 year after Autonomic dysfunction Child: neonate, initially 15 mg/kg by intravenous Introduction treatment with melasoprol is required - Labile or sustained hypertension infusion then 7.5 mg/kg twice daily; 1 month - 12 years: African trypanosomiasis is an acute or chronic disease Prevention - Tachycardia 7.5 mg/kg (maximum 400 mg) every 8 hours; 12 - 18 caused byTrypanosoma brucei namely Surveillance and treatment - Dysarrhythmias years: 400 mg every 8 hours T. brucei rhodesiense (EastAfrica) Chemoprophylaxis - Hyperpyrexia Antitoxin T. brucei gambiense (WestAfrica) Vector control by selective clearing of vegetation and - Profuse sweating - Human tetanus immune globulin (TIG) Clinical features use of insecticides - Peripheral vasoconstriction Adult: 250 units by intramuscular injection, increased to (Gambian Sleeping Sickness) - Cardiac arrest 500 units if: Two clinical stages: Aspiration pneumonia - The wound is older than 12 hours Early stage TUBERCULOSIS Fractures - There is risk of heavy contamination CNS stage Introduction Muscle rupture - Patient weighs more than 90 kg Early stage: One of the oldest diseases known to affect humans, Deep vein thrombophlebitis A second dose of 250 units should be given after 3 - 4 Anodule or chancre following a bite globally Pulmonary emboli weeks if patient immunosuppressed or if active Fever Nearly one third of the global population (i.e. 2 billion) Decubitus ulcers immunization with tetanus vaccine is contraindicated Headache people are infected with Mycobacterium tuberculosis Rhabdomyolysis - Administer antitoxin before manipulating the wound Dizziness and at risk of developing the disease Investigations Control of muscle spasm Weakness More than 8 million people develop active tuberculosis Wound swab for microscopy, culture and sensitivity - Diazepam Significant posterior cervical (Winterbottom sign) and (TB) every year; about 2 million die Cerebrospinal fluid for biochemistry; microscopy, Adult: 20 mg intravenously slowly stat and titrate up to supraclavicular lymphadenopathy More than 90% of global TB cases and deaths occur in culture and sensitivity 250 mg/day in infusion Splenomegaly the developing world where 75% of cases are in the most Full Blood Count; ESR Child: 1 month - 18 years: 100 - 300 micrograms/kg CNS stage: economically productive age group (15 - 54 years) Urinalysis; urine microscopy, culture and sensitivity repeated every 1 - 4 hours by slow intravenous injection Occurs six months to several years later M. tuberculosis usually affects the lungs although in up Blood glucose - Could also be administered by intravenous infusion or Characterized by behavioural changes with to one third of cases other organs are involved Electrocardiography by nasoduodenal tube as follows hallucinations, delusions, and disturbances of sleep with If properly treated, TB caused by drug-susceptible Serum Electrolytes, Urea and Creatinine 3 - 10 mg/kg over 24 hours, adjusted according to drowsiness during the day and terminating with stupor strains is curable in virtually all cases; however if Electromyography response Investigations untreated it may be fatal within 5 years in more than half Treatment objectives Or: Peripheral blood film for the detection of of cases Eliminate the source of toxin Phenobarbital (dilute injection, 1 in 10 with water for trypanosomes Transmission usually takes place through the airborne Neutralize unbound toxin injection) Rapid Card Agglutination Trypanosomiasis Test spread of droplet nuclei produced by patients with Prevent muscle spasms Adult: 10 mg/kg intravenously at a rate of not more than (CATT)for antibody detection infectious pulmonary TB and aerosolized by coughing Monitor the patient's condition and provide support 100 mg/minute, up to maximum total dose of 1g Diagnosis - As many as 3,000 infectious nuclei per cough can be (especially respiratory support) until recovery Child: 5 - 10mg/kg at a rate not more than 30 mg/minute Presumptive produced Non-drug treatment Treat autonomic dysfunction with - Based on the clinical suspicion and history of - Droplet nuclei could also by spread by sneezing and Admit patient to a quiet room - Vasopressors,chronotropic agents if necessary exposure to the tsetse fly speaking Protect airway Hydration A finding of the trypanosome in peripheral blood, Poverty and widening gap between rich and poor, Explore wounds - To control insensitive and other fluid losses lymph node aspirate or CSF is confirmatory hunger, neglect of the disease, the collapse of health Cleanse and thoroughly debride the wound Enteral or parenteral nutrition infrastructure plus the impact of HIV pandemic - As determined by clinical situation

139 140 Chapter 11: Infectious Diseases/Infestations Standard Treatment Guidelines for Nigeria 2008 contribute to the worsening global burden of TB TB of the upper airways pulmonary TB; a history of contact with a smear positive Incidence of chronic carriage is higher among women Determinants of transmission: from exposure to Nearly always a complication of advanced cavitatory pulmonary TB case, respiratory symptoms for more than and persons with biliary abnormalities: gall stones, infection (exogenous factors) pulmonary TB 2-3 weeks not responding to broad spectrum antibiotics, carcinoma of the gall bladder; also higher in persons with The probability of contact with a case of TB May involve the laynx, pharynx and epiglottis and weight loss, failure to thrive may suggest TB gastrointestinal malignancies The intimacy and duration of that contact Hoarseness Differential diagnoses Clinical features Degree of infectiousness of the case Dysphagia Incubation period ranges from 3 - 21 days Will vary depending on the system affected: °° The shared environment of the contact (crowding in Dysphonia Asthma Prolonged fever (38.8 C to 40.5 C) poorly ventilated rooms) Chronic productive cough Bronchiectasis Aprodrome of non-specific symptoms: Determinants of developing TB: from infection to Genitourinary TB Whooping cough - Chills disease (endogenous factors) Urinary frequency Inhaled foreign body - Headache Innate susceptibility to disease Dysuria Cardiac disease - Anorexia Level of function of the individual's cell mediated Haematuria Carcinomas - Cough immunity Flank pain Intracranial space-occupying lesions - Weakness Age Skeletal TB Osteoarthritis, etc - Sore throat - Incidence highest during late adolescence and early Weight bearing joints are affected: spine, hips and knees Investigations - Dizziness childhood, women aged 25 - 34 years and the elderly Spinal TB (Pott's disease) Sputum forAAFB, microscopy, culture and sensitivity - Muscle pains Other diseases Paraparesis Tuberculin skin test Gastro-intestinal: The outcome of infection by M.tuberculosis is affected Paraplegia Chest radiograph Diarrhoea or constipation by the presence of: TB meningitis Full Blood Count; ESR Abdominal pain HIV co- infection Headache HIV screening Rash (rose spots) Silicosis Mental changes Urinalysis; microscopy, culture and sensitivity Hepato-splenomegaly Lymphoma Confusion CSF microscopy, culture, sensitivity; chemistry Epistaxis Leukaemia Lethargy Nucleic acid amplication Relative bradycardia Chronic renal failure and haemodialysis Altered sensorium Drug susceptibility testing Complications Insulin dependent diabetes mellitus Neck rigidity Others: IVP,bone biopsy, etc as indicated Neuropsychiatric symptoms Immunosuppressive treatment Ocular nerve paresis Complications Intestinal perforation Malnutrition Hydrocephalus Lung abscess Gastro-intestinal haemorrhage Old, self-healed fibrotic TB lesions Gastrointestinal TB Destroyed lung syndrome Pancreatitis Clinical features Commonly affects the terminal ileum and caecum Pressure effects from enlarged lymph nodes Hepatitis Generally non-specific: Abdominal pain (may be similar to that of appendicitis) Obstructive uropathy Splenic abscesses Fever (low grade and intermittent) Diarrhoea Chronic kidney disease Meningitis Night sweats Intestinal obstruction Infertility Nephritis Wasting Haematochezia Skeletal deformities (varum and valgus; kyphosis, Pneumonia Anorexia Palpable mass scoliosis) Osteomyelitis General malaise Fever Treatment objectives Chronic carrier state Weakness Weight loss Cure the disease Investigations Cough (initially non-productive, subsequently Night sweats Prevent death from active TB or its late effects A positive culture is the 'gold standard' for the diagnosis productive of purulent and/or blood streaked sputum) TB peritonitis Prevent relapse of TB of typhoid fever Haemoptysis Pericardial TB Decrease transmission of TB Specimens for culture may be obtained from the blood, Chest pain Fever Prevent the development of acquired drug resistance stool, urine, bone marrow; gastric and intestinal Dyspnoea Dull retrosternal pain Treatment secretions Adult respiratory distress syndrome (ARDS) Friction rub Regimen should include at least 4 drugs in the initiation There are no diagnostic tests other than positive cultures Pallor Cardiac tamponade phase Non-specific Finger clubbing Military TB Standardized regimens are the choice in settings where Full Blood Count Extrapulmonary TB Fever susceptibility testing of reserve drugs is not available - Leucopenia, neutropenia, leucocytosis can develop Lymph node TB Night sweats early, especially in children; late if complicated by Painless swelling of lymph nodes (usually cervical and Anorexia intestinal perforation or secondary infection supracervical sites Weakness Liver function tests - Usually discrete in early disease; may become inflamed Weight loss TYPHOID FEVER - Valuesmay be elevated and have a fistulous tract draining caseous material) Cough Introduction Electrocardiography Pleural TB Hepatomegaly A systemic disease characterized by fever and - ST and T wave abnormalities may be present Fever Splenomegaly abdominal pain, caused by dissemination of Salmonella Serological tests Pleuritic chest pain Lymphadenopathy typhior S. paratyphi . - Widal test gives high rates of false positives and Dyspnoea Choroidal tubercles (pathognomonic) Transmitted only through close contact with acutely negatives Dullness to percussion Meningitis infected individuals or chronic carriers (from ingestion Treatment objectives Absence of breath sounds There are no clinical findings specific for a diagnosis of of contaminated food or water) EliminateS. typhi and S. paratyphi

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Prevent complications CHAPTER 12: MUSCULOSKELETAL SYSTEM Full Blood Counts; ESR or knee Prevent chronic carrier status C-Reactive Protein May also present as arthritis in the big toe: podagra Drug treatment BACK PAIN Calcium, phosphate, alkaline phosphatase levels Arthritis may be recurrent before attention is sought Ceftriaxone Introduction Radiograph of the lumbosacral spine, myelogram Affected joint is exquisitely warm to touch, painful and Adult: 1 g daily by deep intramuscular injection or by A common complaint which most adults will have had CT Scan swollen intravenous injection over at least 2 - 4 minutes; 2-4g at one time or the other MR1 There may be a skin reaction over the affected joint daily in severe infection Defined as any pain of the back, at any site between the Bone densitometry The attack may be accompanied by fever and other - May also be given by intravenous infusion neck and the buttocks Treatment objectives constitutional symptoms Child: neonate, 20 - 50 mg/kg daily by intravenous Low back pain is the commonest; involves essentially Treat underlying cause If untreated, subsequent attacks may be polyarticular or injection over 60 minutes; infant and child under 50 kg: the lumbosacral/coccygeal spine Relieve pain more painful 20 - 50 mg/kg daily; up to 80 mg/kg in severe infection; Most cases result from mechanical causes and usually Treat complications Complications over 50 kg: adult dose last less than six weeks Drug treatment Joint-destruction if untreated Doses of 50 mg/kg and above should be given by Causes include: Paracetamol Nephrolithiasis and renal failure intravenous infusion only Spondylosis - 1 g orally every 8 hours Septic arthritis Intramuscular doses over 1 g should be divided between Intra-spinal abscess NSAIDs Differential diagnoses more than one site; single intravenous doses above 1 g Tumours (primary or secondary) - Ibuprofen 1.2 - 1.8 g orally in 3 - 4 divided doses daily Septic arthritis should be given by intravenous infusion only Osteoporosis Narcotic analgesics Osteoarhritis Or: Osteomyelitis - Morphine 10 mg orally every 4 hours (if necessary) Cellulitis Ciprofloxacin Trauma Antidepressants Gonococcal arthritis Adult: 500 - 750 mg orally every 12 hours Pregnancy - Amitriptyline initially 25 mg orally daily Traumatic synovitis Or: Clinical features Non-drug treatment Investigations 200 - 400 mg every 12 hours by intravenous infection Patients will complain of aches, pains, or sometimes Physical therapy Serum uric acid over 30 - 60 minutes peppery sensation Acupuncture - Normal: 2 - 6 mg/100 mL in females; 2 - 7 mg/100 mL Child and adolescent: not recommended Pain is usually worsened on bending forward if due to a Surgery in males Parenteral fluid administration disc pathology Notable adverse effects, caution and contraindications - Normal during acute attacks in 20% of patients Treat complications -Worsened when the intra-abdominal pressure is NSAIDs - Always elevated in chronic tophaceous gout Notable adverse drug reactions, caution increased as in sneezing and coughing - Individuals vary in their responses Synovial fluid analysis and examination under Ciprofloxacin: Worsened on extension of the back if it is due to - Should not be taken on empty stomach because of polarized light microscopy for intracellular crystals of Diarrhoea, nausea, vomiting, abdominal discomfort, apophyseal lesion increased risk of gastric erosions and bleeding uric acid headache (which are themselves features of the disease) - Most back pains are from mechanical causes and are - Particular caution in the elderly; paracetamol is very 24 hour-urine for uric acid Should be given with caution in pregnancy and during self-limiting useful in treating pain of mild to moderate severity Radiographs of affected joints breastfeeding There are danger or 'red flag' features that indicate more - Combinations of different NSAIDs increases gastro- Treatment objectives - Not recommended for children or adolescents serious causes as infections, or malignanacy toxicity without conferring any advantage Lower serum uric acid if above 9 mg/100mL in acute Non-drug treatment - Starting for the first time in persons aged 50 years and - Interaction with antihypertensive medicines may lead attacks Nursing care above to poor blood pressure control Lower the serum uric acid level in chronic tophaceous Enteral or parenteral nutrition - Worsened at night - Interaction with warfarin: increased risk of bleeding gout Prevention - Worse on lying supine Morphine Prevent joint deformity Eliminate Salmonella by effective treatment of cases, - Associated with constitutional disturbances such as - Nausea and vomiting; constipation; drowsiness; Non-drug treatment improved sewage management, improved water fever, loss of weight, anorexia, anaemia difficulty with micturition; biliary spasm; hypotension Dietary control: restrict purine intake by avoiding red treatment and improved food hygiene (production, - Associated with radicular pain - Dependence meat, alcohol, offals of animals, salmon and sardines transit, storage and utilization) - Associated with structural abnormalities such as Weight reduction Typhoid immunization is recommended for those at risk kyphosis or scoliosis GOUT Physical exercise - Not a substitute for scrupulous personal and Differential diagnoses Introduction Avoid using inflammed joint(s) during acute attacks environmental hygiene Pancreatic or gall bladder, stomach, or intestinal Arises from a disorder of uric acid metabolism Avoid operating on tophi deposits Identify, and treat chronic carriers with amoxicillin or disorders with referred pain Deposition of uric acid crystals in joints results in Drug treatment ciprofloxacin daily for4-6weeks Retro-peritoneal tumours recurrent episodes of arthritis, usually in one joint Non SteroidalAnti-inflammatory Drugs (NSAIDs): - In patients with urolithiasis and schistosomiasis Alcoholic gastritis Deposition of uric acid crystals in tissues and joint Indomethacin appropriate treatment should be instituted Aortic aneurysms destruction may occur if untreated - 50 mg orally three or four times daily Correct anatomic abnormalities associated with the Tumours or inflammation of the pleura, pericardium Clinical features Or: disease surgically Metastatic bone disease Acute presentation: acute gout Ibuprofen - Cholecystectomy may be required in some cases Psychosomatic disorders Chronic tophaceous gout: there is deposition of uric acid - 1.2 - 1.8 g orally daily in 3 - 4 divided doses Pelvic inflammatory disease in tissues such as skin and kidneys Or: Complications Most common in men aged 30 years and over Naproxen Complications of underlying cause(s) or pressure It has also been seen in post-menopausal women, - 500 mg orally three times daily for 3 days then 500 mg effects on the spinal cord and nerve roots especially those on diuretic therapy twice daily thereafter Investigations Sudden onset of pain in a joint: usually the ankles, foot, Or:

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Diclofenac sodium injuries should be looked for - See Gout Fibromyalgia syndrome - 75 mg orally twice daily Affects mostly weight-bearing joints such as knees, Hyaluronate Sjogren's syndrome Oral corticosteroids: ankles. Other joints such as hips (especially in sickle cell - Injected into the joint (usually the knee), results in pain Osteoarthritis Prednisolone disease), hands and spine may be affected relief in 1 - 6 months, but increases inflammation in the Hepatitis B - 40 mg in divided doses for 3 days, tapered over 2 Presenting features are: short term Complications weeks - Pain Glucosamine/chondroitin (triple strength i.e. 750/600 Chronic pain Intra-articular steroids: - Morning stiffness of short duration mg) one tablet orally every 12 hours Joint instability and deformity Triamcinolone - Swelling Indications for surgery Pulmonary fibrosis - 5 - 40 mg by intra-articular/intradermal injection - Creakiness while walking Intractable pain Ischaemic heart disease according to patient's size (maximum 80 mg); may be - Loss of function and deformity Deformity Eye involvement repeated when relapse occurs Complications Disability Malignancies: lymphoma Or: Joint deformity Alternative therapies Investigations Methylprednisolone Septic arthritis Acupuncture Full Blood Count; ESR - 4 - 80 mg (depending on patient's size) intra- Differential diagnoses Osteopathy Rheumatoid factor articularly; may be repeated at intervals of7-35days Rheumatoid arthritis Transcutaneous Electrical Nerve Stimulation (TENS) Synovial fluid analysis Uricosuric agents: Gouty arthritis Notable adverse drug reactions, caution and Radiographs of affected joints Allopurinol Benign Hypermobility Syndrome contraindications Treatment objectives - Initially 100 mg orally once daily then maintenance Bursitis NSAIDs Reduce pain and disability 300 - 400 mg/day Psoriatic arthritis - Gastro-intestinal side effects which may be mild (e.g. Limit joint damage Or: Investigations dyspepsia, nausea, constipation and diarrhoea) or serious Improve quality of life Probenecid None diagnostic: (e.g. perforation, ulceration, bleeding and stenosis) There is no cure - 250 mg orally twice daily for 1 week, then 500 mg Radiographs of affected joints - May also cause pruritus, rashes, fixed drug eruptions; Non- drug treatment twice daily Investigations to exclude other differentials dizziness and drowsiness; renal insufficiency/renal Education - Increase up to 3 g/day Treatment objectives failure, especially in the elderly Physiotherapy Notable adverse drug reactions, caution and Reduce pain Prevention - Improve mobility contraindications Enhance mobility Reduce weight - Increase muscle power Allopurinol Prevent deformity Regular exercise - Reduce pain and disability - Hypersensitivity rashes Non-drug treatment Treat early Drug treatment - Reduce dose in renal insufficiency Patient education - Paracetamol Probenecid Exercise Adult: 500 mg orally three times daily - Blood dyscrasias Physiotherapy RHEUMATOIDARTHRITIS Child 1 - 5 years: 120 - 250 mg; 6 -12 years: 250 - 500 NSAIDs Hydrotherapy Introduction mg; 12 - 18 years: 500 mg every 4 - 6 hours (maximum 4 - Risk of peptic ulceration, bleeding, perforation, renal Occupational therapy Achronic inflammatory disease of unknown cause doses in 24 hours) insufficiency, cardiac decompensaton Intra-articular lavage Possibly occurs as a result of auto-immunity Non-steroidal anti-inflammatory drugs Uricosuric agents Drug treatment Affects primarily the peripheral joints in a symmetric - Ibuprofen - Not to be used during acute gout: arthritis may worsen Paracetamol pattern; may affect other organs Adult: 400 - 800 mg orally every 8 hours or evolve into polyarticular disease - 500 mg -1 g orally every 8 hours Clinical features Child 1-3 months: (and body weight >5 kg), 5 mg/kg Prevention NSAIDs Clinical manifestations are usually preceeded by orally3 - 4 times daily preferably after food; in severe Avoid alcohol - Orally or local application constitutional symptoms such as fatigue, malaise, fever, conditions and weight >5 kg, maximum 30 mg/kg in 3 - 4 Prevent/treat obesity - Ibuprofen weight loss, loss of appetite divided doses Avoid drugs that elevate serum uric acid Adult: 400 - 800 mg orally every 8 hours Joint involvements are characterized, serially or 3 months - 1 year and body weight >5 kg: 50 mg 3 - 4 - Naproxen simultaneously, by the following times daily; in severe conditions up to 30 mg/kg in 3 - 4 Adult: 500 mg orally every 12 hours Significant joint morning stiftness divided doses - Diclofenac sodium Polyarthritis 1 - 4 years: 100 mg every 6 - 8 hours daily; in severe OSTEOARTHRITIS Adult: 75 - 150 mg orally in 2-3 divided doses daily Arthritis of joints of the hands conditions up to 30 mg/kg in 3 - 4 divided doses Introduction Narcotic analgesics Bilaterally symmetrical arthritis 4 - 7 years: 150 mg every 8 hours; in severe conditions up A heterogenous group of diseases manifesting with - Morphine - Any joint could be affected but mostly the knees, to 30 mg/kg in 3 - 4 divided doses, maximum 2.4 g daily symptoms and signs in the synovial joints, attributable to Adult: 5 - 20 mg orally every 4 hours ankles, hips, shoulders, elbows; not joints of the back 7 - 10 years: 200 mg every 8 hours; in severe conditions dysfunction of the articular cartilage and subchondral Anti-depressants for night pain Other clinical features up to 30 mg/kg in 3 - 4 divided doses, maximum 2.4 g bone - Amitriptyline Rheumatoid nodules daily It is the end result of all forms of diseases in the joints Adult: 25 - 75 mg orally daily in divided doses or as a Lymph glands enlargement 10 - 12 years: 300 mg every 8 hours; in severe conditions - When such changes occur in the intervertebral disc, it single dose at bedtime Anaemia up to 30 mg/kg in 3 - 4 divided doses, maximum 2.4 g is called spondylosis Capsaicin cream Hepatosplenomegaly daily Clinical features 0.075% cream, apply small amounts up to 3 - 4 times Differential diagnoses 12 - 18 years: 300 - 400 mg very 6 - 8 hours daily, Affects mostly females 40 years and above. If less than daily Systemic Lupus Erythematosus preferably after food, increased if necessary to maximum 40 years, underlying causes e.g. trauma or repetitive Intra-articular steroids Polyarticular gout 2.4 g daily

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- Diclofenac potassium Rare, but may cause a lot of illness and early joint 500 mg orally twice a day for another 1 week Rheumatoid arthritis Adult: 25 - 50 mg orally every 8 hours destruction or deformity Surgical measures Typhoid fever Child 14-18 years: 75-100 mg daily in 2-3 divided doses Septic arthritis is broadly categorized as: Needle aspiration Hepatitis Corticosteroids Gonococcal Arthroscopic drainage and lavage Fibromyalgia syndrome - Prednisolone: low dose, up to 15 mg orally daily Non-gonococcal Open drainage and lavage Scleroderma - Triamcinolone and methylprednisolone into joints S. aureus, streptococci, candida species, M.tuberculosis , Prevention Mixed connective tissue disease (See Gout) HIV,hepatitis B virus Effective treatment of the primary infective agents and Benign hypermobility syndrome Disease ModifyingAnti-Rheumatic Drugs (DMARDs) Clinical features other predisposing disease states e.g. sickle cell disease, Drug-induced SLE - Methotrexate Frequency in most studies is about 2 - 10 cases per complicated fractures Complications Adult: 10 - 25 mg orally once weekly 100,000 Attention to asepsis in joint manipulation procedures Opportunistic infections Child 1 month - 18 years: 10 - 15 mg/m2 once weekly, May occur on its own, or in association with other forms and during intra-articular diagnostic/therapeutic Avascular necrosis increased if necessary to a maximum of 25 mg/m2 once of arthritis such as gout, rheumatoid arthritis and interventions Premature atherosclerotic disease weekly: by oral, subcutaneous or intramuscular route osteoarthritis Myocardial infarction - Azathioprine Causative organisms are mostlyS.aureus , and Investigations Adult: 50 - 150 mg orally daily streptococci. Other organisms include H.influenzae, SYSTEMIC LUPUS ERYTHEMATOSUS Full Blood Count: leucopaenia, thrombocytopaenia, Child 1 month - 18 years: initially 1 mg/kg daily, adjusted Neisseria gonorrhoeae Introduction anaemia according to response to a maximum of 3 mg/kg daily Typical presentations: A chronic, multisystemic, auto-immune inflammatory ESR, CRP (Consider withdrawal if no improvement within 3 Fever disease that affects virtually any organ in the body Urine analysis and microscopy: albuminuria, casts, months) Hot, painful and distended joint with pus Typically runs a relapsing and remitting course haematuria - Hydroxychloroquine sulphate Markedly decreased range of motion Affects mainly women of child-bearing age Urea, Electrolytes and Creatinine Adult: initially 400 mg orally daily in divided doses; Occasionally, septic arthritis may present with a Particularly common among Blacks and Asians, in LE cell test maintenance 200 - 400 mg (but not exceeding 400 mg) migratory polyarthralgia and dermatitis, especially with whom it runs a more devastating course Serology:ANA,Anti-ds DNA,Anti-SM daily or gonococcal infection Clinical features Ro/Ssa; La/SSB,Anti-Cardiolipin antibody Child 1 month - 18 years: 5 - 6.5 mg/kg orally (maximum Constitutional symptoms such as nausea, vomiting, Affects one or more organs simultaneously Radiographs of affected joints 400 mg) once daily headaches, loss of weight, loss of appetite may also be Skin and joints most affected but may also affect the Echocardiogram Or: seen central nervous system and kidneys MRI - Chloroquine base Differential diagnoses Onset usually preceded by constitutional symptoms: Treatment objectives Adult: 150 mg orally daily (maximum 2.5 mg/kg daily) Malaria fever Fever Reduce pain Child: up to 3 mg/kg orally daily Acute gouty arthritis Marked weight loss Improve mobility - To be administered on expert advice Osteoarthritis Loss of appetite Prevent such organ involvement as kidney and brain In unresponsive cases, refer for specialist care Rheumatoid arthritis Aches and pains all over the body There is no cure for the disease Notable adverse drug reactions, caution and Complications Typical characteristics are seen serially or Non-drug treatment contraindications Irreversible joint destruction simultaneously: Patient education NSAIDs Degenerative joint disease Joint pains Physiotherapy - May cause severe gastrointestinal side effects e.g. Osteomyelitis Malar rash Occupational therapy peptic ulceration, bleeding, perforation Soft tissue injury Discoid skin rash Adequate nutrition - Renal and cardiac failure especially in elderly persons Investigations Photosensitivity Exercise to prevent contractures (should be used with caution) Full Blood Count and differentials Mouth or pharyngeal ulcers Drug treatment DMARDs ESR Pleurisy Non-SteroidalAnti-inflammatory drugs (NSAIDs) - Bone marrow suppression Blood cultures Pericarditis - See above - May also cause lymphoma Urethral, cervical and rectal cultures Renal failure Anti-malarials Methotrexate Synovial fluid analysis Nephritis - Hydroxychloroquine - Pulmonary fibrosis, hepatotoxicity Main radiographs of affected regions Nephritic syndrome Adult: 200 mg orally daily - Regular Full Blood Count including differentials, Ultrasonography Seizures Child 1 month - 18 years: 5 - 6.5 mg/kg orally (maximum renal and liver function tests are required Treatment objectives Psychosis 400 mg) once daily - Concomitant administration of folic acid may reduce Initiate appropriate antibiotics therapy early to prevent Peripheral neuropathy Or: mucosal and gastrointestinal side effects joint damage Transverse myelitis Chloroquine Prevent septicaemia arising from the joint Eye involvement Adult: 150 - 300 mg base daily Drug treatment Recurrent abortions Child: up to 3 mg/kg orally daily Antibiotic choice (based on culture report) Complications Corticosteroids SEPTICARTHRITIS - Cefriaxone 1 g intravenously every 24 hours Opportunistic infections - Pulse methylprednisolone Introduction Treatment may be continued for 4 weeks Avascular necrosis Adult: 1 g/day intravenously for 3 days An inflammation of synovial tissues by bacteria, with - There can be a change to oral antibiotics after the first Premature atherosclerotic disease - Used for organs or life-threatening exarcerbations production of pus into the joint space week Myocardial infarction Or: Also variously called suppurative, purulent or infective Joints infected withN. gonorrhoeae respond to 1 week Differential diagnoses - Prednisolone arthritis of intravenous ceftriaxone followed by ciprofloxacillin Malaria Adult: 0.5 mg - 1 mg/kg orally daily

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Immunosuppressives Chapter 13: OBSTETRICS AND - Aborted ectopic pregnancy, the pregnancy having Review existing laws on abortion with a view to - Methotrexate GYNAECOLOGY originated in the fallopian tube promoting and protecting the overall wellbeing of mother Adult: 7.5 mg - 15 mg orally weekly Septic abortion: and unborn child Child 1 month - 18 years: 10 - 15 mg/m2 once weekly, ABORTION Complicated by fever, endometritis and parametritis increased if necessary to a maximum of 25 mg/m2 once Introduction Differential diagnoses weekly: by oral, subcutaneous or intramuscular route Expulsion from the mother's uterus of a growing and Antepartum haemorrhage Or: developing embryo or foetus prior to the stage of viability Ectopic pregnancy ANTENATAL CARE (ANC) - Azathioprine (about 20 weeks), with foetal weight less than 50 g Hydatidiform mole Introduction Adult: 2.3 mg/kg orally daily One of the leading causes of maternal mortality and Carcinoma of the cervix ANC is clinical assessment of mother and foetus, Child 1 month - 18 years: initially 1 mg/kg daily, adjusted morbidity in Nigeria Rape with an overall goal of obtaining the best possible according to response to a maximum of 3 mg/kg daily May be: Investigations outcomes for both Or: Spontaneous Pelvic ultrasound scan An excellent example of preventive health care, as it - Cyclophosphamide - Occurring from natural causes Abdominal radiograph deals mainly with normal individuals with an emphasis Adult: 500 - 750 mg/m2 intramuscularly or intravenously Induced Chest radiograph on the practice of health promotion monthly - Brought about purposefully by drugs or mechanical Microscopy, culture and sensitivity test of vaginal Availability, accessibility and utilization of ANC Child: not listed for this indication means discharge remain poor in Nigeria as in many other developing Notable adverse drug reactions Accidental Urinalysis; urine microscopy, culture and sensitivity nations NSAIDs: - Due to a fall, blow or other injury Full Blood Count Aims of antenatal care - Gastrointestinal side effects: perforation, bleeding, Complete Blood Group Assessment and management of maternal risk and ulceration - With complete expulsion or extraction from the mother Complications symptoms - Renal failure of a foetus or embryo, and of any other products of Endometritis Assessment and management of foetal risk - Cardiac failure conception Parametritis Prenatal diagnosis and management of foetal - Hepatotoxicity Incomplete Peritomitis abnormality - CNS involvement - Parts of the products of conception have been expelled Haemorhage Diagnosis and management of perinatal Methotrexate but some (usually the placenta) remain in the uterus HIV infection complications - Pulmonary fibrosis Illegal (criminal) Secondary infertility Decisions regarding timing and mode of delivery - Hepatocellular damage - Termination of a pregnancy without legal justification Perforation of the uterus and/or intestines Parental education regarding pregnancy and - Immune suppression Legal Rupture of the bladder childbirth Azathioprine - With or without medical justification but done in a Treatment objectives Parental education regarding child-rearing - Risk of neoplasia manner that is legal Restore haemostasis Providers of antenatal care - Hepatocellular damage Solitary Prevent/treat complications Community care, supervised predominantly by the - Bone marrow suppression - Asingle experience of an abortion Provide health education midwife Cyclophosphamide Habitual Non-drug treatment Shared care between the woman's general practitioner, - Haemorrhagic cystitis - When a woman has had three or more consecutive, Nursing care midwife and obstetrician, with visits interspersed - Ovarian failure spontaneous abortions Psychological support between all health professionals concerned- basic care - Bone marrow suppression Clinical features Personal hygiene component - Bladder malignancy Threatened abortion: Drug treatment - 75% of pregnant women usually qualify for this Prevention Cramp like pains Treat infection(s) Hospital-only No primary prevention Slight show of blood Replace fluid, electrolyte, and blood losses care: Relapses can be prevented by: May or may not be followed by the expulsion of the Complete incomplete abortion - In cases where there is increased risk to the mother, Avoiding ultraviolet light exposure to sun foetus Surgical correction of complication(s) foetus, or both- specialized care component Anti-malarial therapy Occurs during the first 20 weeks of intrauterine life ('pre Prevention - A critical 25% of women will usually fall under this Treating hypertension adequately viability' period) Promote personal and family understanding of basic category Correcting dyslipidaemia Imminent /incipient/impending abortion: reproductive health Schedule of visits during pregnancy ACE inhibitors (to limit renal damage) Copious vaginal bleeding - Universal basic education Previously, antenatal visits were: Uterine contractions - Girl child education - Monthly until 28 weeks gestation, then fortnightly until Cervical dilatation - Moral instruction 36 weeks, and weekly thereafter until delivery, resulting Inevitable abortion: Protect vulnerable groups (young females) from undue in up to 14 hospital visits during pregnancy Rupture of the membranes in the presence of cervical exposure to their male folks Best available evidence indicates that there is no dilatation in a pre-viable pregnancy - At home difference in outcome between a four-visit schedule Ampular/tubal abortion: - In school and a twelve-visit schedule - Abortion of pregnancy in the ampulla of the fallopian - Within peer groups -Current trends favour fewer visits, while tube or the tube itself Legislation against street hawking for vulnerable groups establishing clearly defined objectives to be - Rupture of an oviduct, the seat of ectopic pregnancy Provide access to Primary Health Care and referral to achieved at each visit - Extrusion of the products of pregnancy through the efficient and effective higher levels of care Pre-conception visit st fimbriated end of the oviduct Enforce existing laws on the criminality of abortion 1 ANC visit

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- Best before, and not later than the 12th week Maintain complete clinic records of all transactions Iron countries a haemoglobin concentration of 10 g/dLor 2nd ANC visit of the visit Folic acid haematocrit of 30% is taken as cut off nd - Scheduled around the 26th week 2nd ANC visit Tetanus toxoid (2 injection) - Below these levels there may be adverse foetal and 3rd ANC visit Should be close to, or at 26th week Antimalarials maternal outcomes - Scheduled around the 32nd week Expected to take about 20 minutes Maintain complete records: clinic as well as ANC Classification th Activities during the visit should include: card records Mild 4 ANC visit th - Between the 36th and 38 th week Review of history for any changes 4 ANC visit - PCV 25 - 29% Assessment of adherence to routineANC medicines The final visit before labour or delivery Moderate Postnatal visit- scheduled within 1 week postnatally th th This model is suited for the basic care component; Assess for referral Should take place about or between the 36 - 38 - PCV 20 - 24% the specialized care component is better managed - Update the risk status and refer if the need arises weeks Severe with the 12-visit schedule Physical examination Activities during the visit include: PCV < 20% Activities during each visit - General examination: pallor, oedema Review history for any changes Clinical presentation Pre-conception visit - Blood pressure Assessment of adherence to routineANC medicines Varies;depends on the severity Assess the general health and well-being of the - SFH Physical examination - May be asymptomatic or symptomatic patient Investigations - General examination Symptoms Take appropriate action based on the outcome Urinalysis for bacteriuria, proteinuria - Blood pressure Generalised weakness assessment For nulliparous women and those with a history of - Abdomen: SFH, foetal lie and presentation; Lassitude General advice regarding nutrition and life style hypertension or pre-eclampsia/eclampsia presence of multiple gestations Easy fatigability st Haemoglobin concentration/packed cell volume - Advise on the concept of prolonged pregnancy and Headaches 1 ANC visit st Should be in the 1st trimester, preferably before the only if there is evidence of anaemia the need to present if still not in labour by the 41 Dyspnoea on mild exertion 12th week Interventions week Ankle swelling Should last between 30 - 40 minutes Iron Investigations Signs Key objective is to obtain the patient's medical and Folic acid Urine: proteinuria; only in nullipara, hypertension, Pallor obstetric history: Malaria prophylaxis pre-eclampsia/eclampsia Jaundice may or may not be present - Assess the woman's eligibility to follow the basic - Intermittent treatment with sufadoxine / Assess for referral Pedal oedema pyrimethamine Interventions Tachypnoea component of the new WHO model using the nd rd classifying form which contains 18 sets of questions - One full treatment dose in the 2 and 3 trimesters Iron Tachycardia Activities during the visit should include: - Last dose not later than 1 month before the Folic acid Haemic murmurs Physical examination Expected Date of Delivery Malaria prophylaxis Pseudo-toxaemia - General examination including height and weight Or: Advice, questions and answers; scheduling next - Systolic hypertension, oedema and albuminuria - Blood pressure - Proguanil 100 - 200 mg orally daily appointment There may, or may not be clinical evidence of - Chest and heart auscultation Maintain complete clinic records as well as ANC Maintain complete records: clinic as well as ANC causative pathology - SFH and abdominal palpation card records card records - Sickle cell facies, urinary tract symptoms, etc 3rd ANC visit Malaria treatment for breakthrough episodes Hepatomegaly: not invariable - Vaginal examination; specifically for PAP smear nd if the woman has not done one in the past 2 years; Should be around the 32 week Quinine is safe and can be used in all trimesters Splenomegaly: not invariable Expected to take about 20 minutes Artemisinin-based combinations are safe in the 2nd Anaemic heart failure in extreme cases also for women with past history suggestive of rd cervical incompetence Activities during the visit: and 3 trimesters Differential diagnoses Assessment for referral Review history for any changes - Artemether-lumefantrine is considered safe Nutritional deficiencies - Any medical or obstetric conditions that require Assess adherence to routineANC medicines Postnatal visit - Iron, folic acid, protein, vitamin C; trace elements, and rarely vitamin B specialized care Extra attention to advice on Should hold within 1 week postpartum 12 Investigations - What to do if labour occurs Offer contraception Physiological demands of pregnancy -Urinalysis for bacteriuria, proteinuria and - What to do if membranes rupture Complete tetanus prophylaxis with tetanus toxoid Excessive red cell haemolysis as in malaria, glycosuria - Birth spacing and counselling on contraception Continue interventions: iron, folic acid and malaria haemoglobinopathies - Haemoglobin genotype Assess for referral prophylaxis Infections: urinary tract infection, HIV/AIDS - Blood group Physical examination Hookworm infestation - HIV screening - General examination: pallor, oedema, dyspnoea Excessive sweating in the tropics - VDRL - Breast examination ANAEMIAIN PREGNANCY Antepartum haemorrhage - Haemoglobin concentration/packed cell volume - Blood pressure Introduction Bone marrow pathologies Interventions - Abdomen: SFH palpation for twin gestation Anaemia is the most common complication of Miscellaneous: e.g. bleeding duodenal ulcer Iron Investigations pregnancy in Sub-SaharanAfrica Complications Folate - Haemoglobin concentration or packed cell volume It is a diminution below normal of the total Maternal Tetanus toxoid- 1st injection compulsory for all in this visit circulating haemoglobin mass Abortion Treat for syphilis if VDRLis positive - Urinalysis: bacteriuria, proteinuria; for nullipara World Health Organization definition of anaemia Cardiac failure Refer if other investigation results so require and those with hypertension, pre- - Haemoglobin concentration less than 11 g/dL or a Reduced ability to tolerate blood loss at delivery Allow time for advice, questions and answers, and eclampsia/eclampsia haematocrit less than 33% in peripheral blood Reduced ability to tolerate anaesthesia scheduling of next appointment Interventions For practical purposes in developing and tropical Diminished resistance to infection

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Preterm labour Intramuscular injection Low socio-economic status Intravenous urography Precipitate labour - 250 mg daily; after a negative test dose of 25 mg Smoking Principles of management Death Intravenous Micronutrient deficiency Examination UnderAnaesthesia Foetal - If the total calculated dose of iron dextran is less Oral contraceptive usage - Staging and Biopsy Abortion than 1,500 mg it can be given over 8 hours in one litre Poor sexual hygiene Treatment of invasive carcinoma of the cervix Intrauterine growth restriction of sodium chloride 0.9% Clinical features - Surgery Intrauterine foetal death - If greater than 1,500 mg, it should be given in Two age groups with highest incidence: 35 - 40 - Radiotherapy Still birth divided doses daily, not exceeding 1,500 mg/day years; 45 - 55 years - Surgery plus radiotherapy Prematurity Antihistamine (chlorphenamine injection), May be asymptomatic - Chemo-radiation Risk of developing anaemia within 2 - 3 months of epinephrine and hydrocortisone injection must be - Picked up in the early stage by routine PAP smear Treatment options will depend on birth if mother suffered iron deficiency anaemia available: iron dextran could cause severe screening The skill of the surgeon Investigations anaphylaxis Abnormal vaginal bleeding Availability of facilities Haematocrit Blood transfusion - Postcoital The stage of the disease Haemoglobin concentration - Consider as from the 37th week for mild anaemia - Contact Age of the patient White blood cell count and differentials and from the 32nd week for moderate anaemia - Spontaneous Ability of available personnel to manage untoward Blood picture - Usually, packed cells under furosemide cover - Inter-menstrual effects of the modality of treatment chosen Reticulocyte count Indications: - Post-menopausal Stages I to IIA Blood smear Severe anaemia irrespective of gestational age Vaginaldischarge Surgery or radiotherapy (as primary modes of treatment Midstream urine: microscopy, culture and Cardiac failure - Becomes offensive in advanced disease respectively) sensitivity Moderate anaemia detected in labour or during an Pyometria with uterine enlargement - Radiotherapy can be used as primary mode of Stool analysis: ova, cysts, parasites, occult blood abortion, or co-existing with other conditions such as Haemorrhagic, ulcerative or fungating lesion on treatment in all stages of the disease Group and cross-match blood sepsis, renal failure, haemorrhage or eclampsia the cervix, with extension on to the vagina wall in Follow up Haemoglobin genotype Prevention advanced stages This is for life Blood Group Counselling on contraception; adequate spacing of Vesico-vaginalfistula in advanced stages Regular cytology of vault smears for early VDRL pregnancies Recto-vaginal fistula in advanced stages detection and prompt treatment of recurrence HIV screening Malaria prophylaxis in pregnancy Cachexia Prevention Urinalysis Chemoprophylaxis against helminthiasis - The presence of a lesion on the cervix Adequate screening programmes: Ultrasound scan (e.g. of abdomen, pelvis) Prompt and appropriate treatment of febrile Presumptive Diagnosis Papanicolaou smear Bone marrow biopsy if bone marrow involvement illnesses in pregnancy Based on : Visual inspection of the cervix after acetic acid is suspected Improvement in the socioeconomic status of the - Typical history of risk factors lavage (VIA) Treatment objectives people - Histological confirmation of malignancy Testing for the human papilloma virus DNA Correct haematocrit Provision of accessible and affordable maternity Differential diagnoses Specific programmes targeted at eliminating or Treat underlying cause(s) care facilities Endometrial cancer mitigating the effects of recognized risk factors - See differential diagnoses Endometrial hyperplasia Foetal surveillance Endometrial polyps - Of growth and wellbeing for IUGR and Endometritis: particularly atrophic CARDIAC DISEASE IN PREGNANCY intrauterine asphyxia CANCER OF THE CERVIX Choriocarcinoma Introduction Correction of haematocrit Introduction Cervicitis Arare but potentially serious clinical entity Oral haematinics The second most common malignancy and the Cervical polyps Occurs in about 1% of all pregnancies - For mild and moderate anaemia leading cause of death among women in developing Cervical erosion Incidence and prevalence of all heart disease varies Ferrous sulfate countries Vaginallesions: vaginitis, vaginal malignancy from place to place - 200 mg daily and folic acid 5 mg daily - 75% of the patients present in advanced stages; lack of Functioning tumours of the ovary leading to - Rheumatic heart disease is more commonly found in Vitamin C (ascorbic acid) organized screening programmes for detection of the pre- endometrial hyperplasia and vaginal bleeding less affluent societies while congenital heart disease now - 100 mg three times daily clinical stages in many countries Iatrogenic: hormonal drugs and IUCD in-situ accounts for approximately 50% of cardiac diseases in Parenteral iron: indicated in Blood disorders: bleeding dyscrasias, leukaemia pregnancy in the UK - Mild to moderate anaemia, near term Aetiology/risk factors Types of cardiac diseases in pregnancy - Malabsorption of oral iron, or when it causes Aetiology not known but several risk factors have Investigations Acquired serious gastroenteritis been implicated: Packed cell volume; haemoglobin concentration Rheumatic heart diseases Administration: Early sexual exposure Urinalysis - Mitral >Aortic > Tricuspid > Pulmonary Calculate haemoglobin deficit Multiple sexual partners Blood Group Cardiomyopathies For each 1 g/dL deficit, 250 mg of iron dextran Apromiscuous male partner White cell count, differentials - Particularly peripartum cardiomyopathy which injection is required History of sexually transmitted infections Electrolytes and Urea could be either congestive or obstructive Additionally, 50% of the total calculated is added particularly Human Papilloma Virus infection; Liver function tests Pre-existing hypertensive heart disease onto the deficit value to take care of the iron stores Herpes simplex type 2; chlamydiae Midstream urine specimen for microscopy, culture Ischaemic heart disease Administer by deep intramuscular injection into Early first child birth and sensitivity Congenital the gluteal muscle, by slow intravenous injection or High parity Chest radiograph Acyanotic heart disease by intravenous Infusion (after a negative test dose) HIV screening

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- Atrial septal defect, ventricular septal defect, suspected) Foetal surveillance: Clinical features patent ductus arteriosus, etc Chest radiograph is better avoided in pregnancy - Ultrasound scan particularly for cardiac anomaly at Generalized tonic-clonic seizures, usually heralded Cyanotic heart disease Management 22 weeks by: - Tetralogy of Fallot, Eisenmenger's syndrome Pre-pregnancy Delivery: - Headaches Acquired forms of cardiac disease appear to be more Fully evaluate patient in conjunction with a - Either for maternal or foetal indications - Dizziness and blurring of vision lethal in association with pregnancy, in women aged 25 cardiologist Cardiac surgery in pregnancy if indicated - Nausea and vomiting years or more, and in third or later pregnancies Surgically correct any defect that is amenable Management of labour in women with cardiac disease - Epigastric pain Congenital malformations are more prevalent in Counsel on the following points: Avoid induction of labour if possible - Rapidly progressive oedema younger women and in those of lower parity - Risk of maternal death Prophylactic antibiotics to prevent bacterial Exaggerated tendon reflexes Clinical features - Possible reduction of maternal life expectancy endocarditis Oliguria Severity of heart disease in pregnancy - Risk of foetus developing congenital heart disease; Careful fluid balance Hypertension The New York Heart Association Guidelines (1965) foetal growth restriction Avoid the supine position Worsening proteinuria is used. - Possibility of pre-term labour Epidural anesthesia by a senior anesthetist Complications - Relies on the cardiac response to physical activity; - Need for frequent hospital attendance; possibly Shorten 2nd stage with low cavity forceps delivery Maternal may not bear any relationship to the extent of the lesion admission Oxytocin for third stage; ergometrine is Cerebral haemorrhage present - Need for intensive maternal and foetal monitoring in contraindicated Disseminated intravascular coagulopathy Classs 1 labour Oxygen should be available and used if needed Renal failure - No limitation of physical activity Antenatal Care Complications Cardiopulmonary failure Class 2 Joint management with the cardiologist Maternal Liver dysfunction (as in HELLPsyndrome) - Slight to moderate limitation of physical activity: Extreme vigilance: most features of cardiac failure are Mortality: Fatality ordinary day-to-day activities cause dyspnoea present in pregnancy - 25 - 50% in Eisenmenger's syndrome; 5% in Foetal Class 3 Watch out for respiratory tract infection or urinary tract tetralogy of Fallot; 1% in rheumatic heart disease Prematurity - Marked limitation of activity. Minimal exertion infection and treat aggressively Congestive cardiac failure: Intrauterine growth restriction causes dyspnoea Watch out for anaemia, obesity and multiple - Greatest risk in the immediate post-partum period Intrauterine foetal death Class 4 gestations for intensive care. Intensive care also Foetal Brain damage - Symptoms at rest; unable to carry out any required when other medical or psychological Rheumatic heart disease: Death physical activity without dyspnoea; orthopnoea conditions co-exist Intrauterine growth restriction; pre-term delivery Differential diagnoses may be present Examination: Cyanotic congenital heart disease: Idiopathic epilepsy: sometimes accompanied by Other symptoms - Ankle and sacral oedema Poor outcomes; up 40% foetal loss transient proteinuria Palpitations - Pulse rate and rhythm Uncorrected coarctation of aorta: Cerebral malaria: sometimes accompanied by Nasal stuffiness - Blood pressure Foetal growth restriction in > 10% of cases hypertension and albuminuria Dizziness; light headedness; syncope - Jugular venous pressure Pre-maturity Pneumococcal meningitis Epigastric or subxiphoid pain; bloating, heartburn - Basal crepitations Small for gestation age Hyper and/or hypo-glycaemia, particularly among Heat intolerance, sweating and flushing - Symphysio-fundal height (SFH) measurement Intrauterine growth restriction diabetics Signs Competent dental care: Intrauterine foetal death Terminal phase of severe anaemia Plethoric facies - Full inspection 10 - 15% chance of baby having congenital heart Terminal phase of hepatic failure Odema (legs; occasionally hands and face) - Advise on oral hygiene disease Severe infections and septicaemia Varicoseveins - Dental treatment e.g. tooth extraction should be done Others: Bounding pulses and capillary pulsations under antibiotic cover to prevent infective endocarditis - Uraemia Capillary telangiectasia Admission - Brain tumours or abscesses Prominent jugular venous pulsations - Individualised; usually when complications or ECLAMPSIA - Cerebral haemorrhage Lateral displacement of cardiac apex intercurrent illnesses occur Introduction - Poisoning (accidental or intentional) Sinus tachycardia; ectopic beats Supportive measures The occurrence of generalized convulsions, - Hysteria Third heart sound Elastic stockings or tights to prevent pooling of blood associated with signs of pre-eclampsia during Investigations in the veins of the lower limb pregnancy, labour, or within 7 days of delivery; not Haemoglobin concentration/haematocrit Widely split S12 and S heart sounds Anticoagulation caused by epilepsy or other convulsive disorders Bedside crude clotting time Murmurs - Indicated for example in patients with congenital Referred to as atypical eclampsia if it occurs Haemoglobin genotype Crepitations heart disease, with pulmonary hypertension; artificial - In the absence of high blood pressure Platelet count Investigations valve - After 7 days post-partum Blood Group Full Blood Count replacements; those with atrial fibrillation Incidence is widely variable. Worldwide range reported Serum Urea and Electrolytes; Creatinine Serum Electrolytes, Urea and Creatinine - Heparin safer in pregnancy; warfarin is teratogenic tobe1in100-1in3,448 pregnancies Liver function tests Urinalysis Termination of pregnancy and sterilization In Nigeria, it is commoner among unbooked patients Urinalysis Blood Glucose - Best option in severe debilitating cases Aetiology Management Echocardiography (Doppler) Congestive Cardiac Failure Not exactly known. Its precursor is pre-eclampsia Manage in conjunction with the physician Electrocardiography Manage as if non-pregnant (in conjunction with a A disease of primigravidae, or multigravidae with Treatment objectives Serial blood cultures (if infective endocarditis is cardiologist) pregnancy for a new consort Stabilise the patient

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Deliver foetus by the safest and most expeditious hours on intravenous therapy hours after delivery (or after last seizure), whichever ultrasound for another pelvic pathology route Magnesium toxicity comes first Complications Prevent complications Absent patellar reflexes: Prevention Shock Stabilization Stop magnesium sulfate treatment Adequate antenatal, intrapartum and postpartum care Sterility (with the loss of both tubes) Control (and prevent further) fits Administer oxygen by face mask Early detection of pregnancy-induced hypertension Often requires blood transfusion (with its attendant cost Control blood pressure 1 g calcium gluconate by slow intravenous injection Aggressive management and risk of blood-borne infections) Maintain the airway If respiratory rate is abnormal: This is the 'gold standard' towards achieving good 5 - 20% risk of having another ectopic gestation Ensure adequate urinary output Stop further magnesium sulfate foetal and maternal outcomes Fatality Monitor If there are no respiratory abnormalities or abnormal Re-occurence Diagnosis Controlling fits patellar reflexes: - Occurs in 15.6% of cases Requires a high index of suspicion particularly in the Intravenous diazepam Reduce the dose by half - Adequate counselling on the need for early booking, case of atypical, slow-leaking or chronic ectopic - 10mg stat to abort seizures or prevent fits during Respiratory arrest: regular antenatal clinic attendance and hospital delivery gestation where diagnosis could be difficult examination; then Stop magnesium sulfate treatment in subsequent deliveries required Differential diagnoses - Intravenous infusion of glucose 5% in water with 40 Intubate and ensure ventilation (manage with the For unruptured ectopic pregnancy: mg of diazepam added, and titrated against the patient's anaesthetist) Acute pelvic inflammatory disease level of consciousness Calcium gluconate 1 g by slow intravenous injection ECTOPIC PREGNANCY Adnexial torsion Magnesium sulfate (see details below) Control of blood pressure Introduction Incomplete abortion Treatment packs are contained in cardboard boxes Intravenous hydralazine Pregnancy in which the conceptus implants either Endometriosis containing magnesium sulfate for the loading dose, 24- - 5 mg bolus slowly over 15 minutes, stat. Further outside the uterus (fallopian tube, ovary or abdominal Degenerating uterine fibroid hour maintenance therapy and treatment of one boluses can be given every 20 - 30 minutes as long as cavity) or in an abnormal position within the uterus Acute appendicitis (recurrent) convulsion. Syringes, swabs, drip sets and diastolic blood (cornua, cervix, angular and rudimentary horn) Accidented ovarian cysts fluids also contained in treatment packs; pressure is 110 mg and above The most common surgical emergency in women in Investigations - Calcium gluconate should always be available to Or: many developing countries Haemoglobin concentration/packed cell volume manage toxicity Labetalol Asubstantial cause of maternal mortality Blood grouping and cross matching Intravenous infusion of magnesium sulfate - 20 mg intravenously as a bolus - Rapidity with which haemorrhage and shock occur Urinalysis - Loading dose: 4 g by slow intravenous injection over - Repeat after 15 - 20 minutes (if need be, increasing - Pre-rupture diagnosis is elusive, with consequent delay Ultrasound scan of the pelvis/abdomen a period not less than 5 minutes (preferably over 10 - 15 the doses) in surgical management Serum ß-hCG (where available) especially in silent minutes) The airway Clinical features cases - Maintenance: 10 g in 1litre of sodium chloride 0.9%, Intermittent suction of the nostrils and oropharynx The clinical subsets include: Paracentesis abdominis (should be considered) given by intravenous infusion at a rate of 1g per hour Insert an airway Acute ectopic gestation Laparoscopy The intramuscular magnesium sulfate (Pritchard) Urinary output - 25% or less of cases - Final arbiter when the diagnosis is in doubt regimen Indwelling Foley's catheter for strict fluid input and Sub-acute ectopic gestation Treatment objectives - Loading dose: 4 g by slow intravenous injection over output monitoring - 75% of cases Depend on the clinical subset a period not less than 5 minutes, then 10 g Monitoring “Silent” ectopic/chronic ectopic gestation Preserve maternal life intramuscularly,5gbydeep intramuscular injection - Quarter-hourly vital signs Acute Ectopic Gestation Acute ectopic into each buttock - Record any further fits Amenorrhoea Immediate resuscitation (fluids/blood) - Maintenance therapy: 5 g by deep intramuscular Delivery Features of acute abdomen particularly lower Stop haemorrhage: by surgery injection, 2.5 g in each buttock every 4 hours Induction of labour abdominal pain Replace lost blood Continue for 24 hours after last convulsion, or - Is the first option if the cervix is favourable, Vaginalbleeding or brownish discharge General principles and treatment modalities delivery. particularly if the patient is not yet in established labour Severe pallor Surgery Recurrent convulsions - Can be done by the use of escalating doses of oxytocin Shoulder tip pain - Salpingectomy (total or partial) for ruptured ectopic Magnesium sulfate infusion or with misoprostol tablets Difficulty with sitting on hard surfaces pregnancy - 2-4gintravenously over 5 minutes Elective forceps delivery Features of shock with cardiovascular collapse: - Partial salpingectomy if the remaining segment of the - Give lower dose (2 g) if the patient is small and/or - Should be done if patient is in the second stage to hypotension and tachycardia tube is about 4 cm long; this could be used for weight is less than 70 kg reduce the stress and cardiovascular changes, especially The uterus is slightly enlarged with tenderness on one reconstructive surgery subsequently Monitoring during magnesium sulfate therapy peaks of elevated blood pressure that accompany side - Salpingostomy for unruptured cases Continue with intravenous infusion or give the next expulsive efforts at this stage in labour - Some advise that examination should be avoided if Non-surgical options intramuscular doseonly if Emergency Caesarean section is indicated when: there is a strong suspicion of an ectopic pregnancy - Used in unruptured cases: expectant management and - Patellar reflexes are normal - Cervix is unfavourable for induction Positive cervical excitation tenderness medical agents - Respiratory rate is > 16 cycles/minute - There is foetal distress Sub-acute Ectopic Gestation Expectant management - Urine output is > 25 mL/hour (or > 100 mLin 4 hours) - Patient is unconscious (unless delivery is imminent) Slow-leaking ectopic prior to rupture, with most of the - Monitor pregnancy by -hCG levels Consider reducing the dose if - Vaginaldelivery is unlikely within 6 - 8 hours from the signs and symptoms of acute ectopic gestation but in the - Vaginal scans: spontaneous resorption can occur - Renal function is impaired onset of the first eclamptic fit and there is an obstetric mildest form provided gestation sac is<4cmandhCGis<1,500 IU - Respiratory depression occurs indication for a Caesarean section “Silent”/Chronic Ectopic Gestation Medical treatment - Urine output is < 100 mLin 4 hours Post partum Asymptomatic - Methotrexate More frequent monitoring is required in the first two Continue parenteral anticonvulsant for another 24 - May just be picked up during a pelvic examination in Administered systemically or locally to induce the course of booking or antenatal clinic, or found on

157 158 Chapter 13: Obstetrics and Gynaecology Standard Treatment Guidelines for Nigeria 2008 dissolution of trophoblastic tissue (Ru 486 ) Acute polyhydramnios - Hyperosmolar glucose solution, potassium chloride - Commonly associated with monozygotic twinning IMMUNIZATION SCHEDULES and prostaglandins can also been used and diabetic pregnancies Introduction Auto transfusion Pre-eclampsia Tetanus immunization for the pregnant woman is geared towards protecting the mother (and baby) against tetanus - During surgery for ectopic gestation; very important Accidents to ovarian cysts in developing countries - Torsion, haemorrhage, infection and rupture TetanusImmunization Schedule in Pregnancy - Inadequate blood banking services Red degeneration in a fibroid - The risks of transfusion with donated blood are Complications TIMING OF IMMUNIZATION PROTECTION OFFERED avoided Biochemical abnormalities - Use only fresh blood - Usually sequel to vomiting, starvation and st st On discharge: dehydration 1 dose at booking or on 1 contact Confers no protection - Counsel for contraception and advise to report - Ketosis, electrolyte imbalance (alkalosis and immediately to the hospital if a pregnancy is suspected hypokalaemia); vitamin deficiencies 2nd dose at 4 weeks after 1 st dose so that its site can be confirmed In neglected or poorly managed cases: Confers protection for 3years

Severe weight loss rd nd HYPEREMESIS GRAVIDARUM Tachycardia 3 dose at 6 months after 2 dose Confers protection for 5years Introduction Hypotension Aclinical situation in which vomiting in early pregnancy Oliguria 4th dose at 1 year after 3 rd dose or in next considered to be physiological becomes persistent or Neurologic disorders from vitamin B deficiency 1 pregnancy Confers protection for 10 severe enough to disturb the patient's health and/or Retinal haemorrhages years require hospitalization Jaundice (from hepatic necrosis) Occurs in approximately a third to 50% of women Oesophageal tears and spontaneous rupture of the 5th dose at 1 year after 4 th dose or in next - Often the first sign of pregnancy, beginning at oesophagus Confers protection for life th pregnancy about the 6 week and stops spontaneously before Mendelson's syndrome th the 14 week Foetal loss Generally limited to the early morning but may Maternal mortality occur at other times of the day Investigations Cause is essentially unknown, but hypotheses Full Blood Count with differentials Immunization andVitaminASchedule include Urea, Electrolytes and Creatinine Hormonal: Liver function tests - Increased sensitivity to placental hormones such Midstream urine for microscopy, culture and At Delivery Vitamin A to Mother as hCG, estrogen or progesterone sensitivity Psychogenic : Urinalysis for ketones At Birth BCG; POLIO01 ; HBV - The woman thinks she should have early morning Blood film for malaria parasites sickness because generations before her have had it Ultrasound scan of the pelvis/abdomen 6 Weeks Clinical features Management DPT112 ; POLIO ; HBV Persistent and severe vomiting that leads to Admit electrolyte and nutritional derangements Strict intake-output monitoring 10 Weeks Differential diagnoses Intravenous fluid therapy to: DPT22 ; POLIO It is a diagnosis of exclusion. Concerted effort must be - Correct electrolyte disturbances made to exclude the under listed causes of pathological - Provide calories 14 Weeks vomiting: - Rehydrate the patient DPT333 ; POLIO ; HBV Multiple gestations Anti-emetics Hydatidiform mole Those which have been proven not to be teratogenic: 9 Months st Malaria in pregnancy - Meclozine 25 mg orally MEASLES; YELLOW FEVER; 1 Gastrointestinal disorders: Or: Dose Vitamin A1 Heartburn due to hiatus hernia: a common cause of - Cyclizine 50 mg orally vomiting in late pregnancy Or: 15 Months Enteritis - Promethazine 25 mg orally Vitamin A2 Appendicitis All of these are taken three times daily Peptic ulcer disease Total parenteral nutrition JAUNDICE IN PREGNANCY Many indicators of liver disease in the non-pregnant Hepatitis - In severe cases Introduction State are normal findings in pregnancy. These Acute fatty liver of pregnancy In persistent and intractable cases with significant Usually indicates a liver/biliary disorder and becomes include: Pancreatitis maternal complications, termination of pregnancy may clinically apparent when the serum bilirubin exceeds 2 - - Spider naevi Cholescystitis be considered Urinary tract disorders: pyelonephritis 2.5 mg/dL - Decreased plasma albumin - Increased alkaline phosphatase

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- Increased serum lipids Disseminated intravascular coagulopathy decrease itching and normalize liver function and well-being (CTG) monitoring Prothrombin time, transaminases and bilirubin are Hypotension Adult: 10 - 15 mg/kg daily in 2 - 4 divided doses If all is well, induce at 38 weeks unaltered in normal pregnancy Significant risk of maternal and foetal death due to: Child 1 month - 18 years: 10 - 15 mg/kg twice daily; total Management of pruritus Jaundice occurs in about 1 in 1,500 - 2,000 pregnancies Maternal liver failure dose may be given in 3 divided doses - See Cholestasis of pregnancy Aetiology Metabolic disturbance Recurrence Recurrence Aetiology peculiar to pregnancy Encephalopathy Quite high Risk of recurrence is 50% Hyperemesis gravidarum Overwhelming haemorrhage associated with clotting Prognosis Can be precipitated by oestrogen-containing oral Pre-eclampsia and eclampsia as seen with HELLP defects Good contraceptive pills syndrome Prognosis - Complete recovery in days to weeks Acute yellow atrophy (acute fatty liver in pregnancy; Good Viral hepatitis acute hepatic failure) Post-natally, liver function returns to normal over a few Dubin-Johnson syndrome The most common cause of jaundice in pregnancy, Intra-hepatic cholestasis of pregnancy weeks and there is no evidence of long-term liver Intermittent bilirubinaemia (conjugated) accounting for about 40% of the causes Cholestasis in pregnancy dysfunction Often chronic and familial Incidence during pregnancy is probably no more than Gallstones No itching, usually asymptomatic in the normal population Aetiology not peculiar to pregnancy Cholestasis of pregnancy Cause is unknown Pregnancy does not alter the course of the disease Viral hepatitis Uncommon, in the order of 1: 2,000 pregnancies Treatment HepatitisAvirus does not affect the foetus Haemolytic jaundice Common in certain southern American countries None is required - Unlike other hepatotrophic viral infections, which Adverse reactions to drugs e.g. chlorpromazine, particularly Chile carry a significant risk of vertical transmission tetracycline Presents commonly in late third trimester, after Intra-hepatic cholestasis of pregnancy (particularly in the third trimester) Cogenital hyperbilirubinaemias such as Dubin- 36weeks Also termed 'recurrent obstructive jaundice' or Asevere attack may influence foetal outcome Johnson syndrome Clinically significant because of its association with 'idiopathic cholestasis' - Slight increase in premature labour and stillbirths (as Liver cirrhosis IUGR and IUFD (mechanism unclear) Thought to be due to the effect of high estrogen levels seen in any severe medical illness) Clinical features It is not as a rule associated with maternal on the liver, which results in decreased conjugation of Treatment Acute yellow atrophy complications bilirubin Avoid any further damage to the liver by drugs A rare and serious disorder associated with high Clinical features Arare condition Bed rest mortality Generalized pruritus - Incidence of 1:500 pregnancies Adequate nutrition Occurs in the order of 1: 10,000 pregnancies Decreased foetal movements More commonly seen in Scandinavians If hepatitis B is present then the infant requires Unknown aetiology Upper abdominal pain Its exact etiology is unknown protection with immunoglobulins against HBsAg Typically noted in primigravidae, occurring after the Dark urine Clinical features - Hepatitis B immunoglobulin by intramuscular 30th week or few days after birth Steatorrhea Intense pruritus due to retention of bile salts injection The jaundice is classically obstructive Occasionally there is jaundice (particularly in the later The most common presenting symptom and may occur Neonate: 200 units as soon as possible after birth Onset usually sudden with stages of the disease) in the absence of other symptoms Child 1 month - 5 years: 200 units; 5 - 10 years: 300 - Abdominal pain (right upper quadrant) Investigations Onset of symptoms usually in the third trimester units; 10 - 18 years: 500 units - Headaches Liver function tests: Jaundice is not often seen Avoid breastfeeding - Nausea and vomiting - Mildly deranged Investigations Delivery room personnel must exercise great care in - Progressive jaundice - Serum bilirubin and bile salts may be elevated Bilirubinuria dealing with these patients, as all their body fluids are - Encephalopathy Differential diagnoses Elevated bile acids highly infectious - Hypertension is not uncommon Viral hepatitis Elevated alkaline phosphatase Immediate delivery if hepatitis becomes fulminant Histology Early HELLPsyndrome Elevated liver transferase enzymes Perilobular fatty infiltration of the liver cells Acute fatty liver Prothrombin time There is no place for liver biopsy because of bleeding Management Always exclude viral disease, gallstones and treatment PELVIC INFLAMMATORYDISEASE complications Careful maternal follow-up with LFTs with chlorpromazine Introduction Management Foetal surveillance: by growth (serial USS biometry) Complications Ascending pelvic infection involving the upper genital Early diagnosis is mandatory and wellbeing (CTG) monitoring Maternal tract - Clinical features with evidence of deranged LFTs and If all is well induce at 38 weeks Haemorrhage Usually involves sexually transmitted organisms of renal failure Management of associated pruritus Preterm labour e.g.Neisseria gonorrhoeae and Chlamydia trachomatis The management it requires a combined team of (Difficult to manage) Steatorrhea - It may also be caused by organisms endogenous to the obstetrician, physician and anesthetist Topical agents offer little help Foetal lower genital tract Definitive treatment Colestyramine Foetal distress In severe cases, organisms may migrate via the Deliver the baby as soon as possible (frequently by - To bind bile salts Still-birth peritoneum to the upper abdomen causing perihepatic Caesarean section) Vitamin K Perinatal death adhesions: the so- called “violin strings” (Fitz-Hugh- Supportive measures - To decrease bleeding tendencies Prematurity and its problems Curtis syndrome) Transfusion with blood, fresh frozen plasma, platelets - (Colestyramine binds fat soluble vitamins) Meconium staining of the liquor Responsible for significant morbidity in women, as indicated Antihistamines Management accounting for about 30% of all gynaecological Dialysis - May offer brief respite Careful maternal follow-up with LFTs admissions in sub-SaharanAfrica Complications Ursodeoxycholic acid and colestyramine (orally) Foetal surveillance: by growth (serial USS biometry) It is thought that 3% of women have Pelvic

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Inflammatory Disease (PID) during their lifetime Uncertain diagnosis duress, intimidation or without legal consent (as with a infections and pregnancy Risk factors Intolerance of oral medication or non-response to minor) It is important to document clinical findings Age: outpatient therapy A growing social disorder afflicting the poor and rich, Non-drug measures - Peak incidence between 15 - 25 years Presence of a pelvic mass alike, with devastating and longstanding emotional Reassure patient Sexual activity: Presence of an intrauterine device consequences for the afflicted, family and society at Provide information about legal services - Multiplicity of sexual partners Upper abdominal pain large Drug treatment Use of intrauterine contraceptive devices : Non-adherence to therapy An enormous societal problem that appears to be poorly Treat physical injury (as appropriate) - Usually within the first 4 months of use Pregnancy recognized and grossly under-reported Treat STIs, UTI (as appropriate) Previous episode(s) of PID Nulliparity An average of one in five adult women may have Treat HIV infection (if detected); Post-exposure Clinical features Treatment objectives experienced sexual assault during her lifetime prophylaxis if clinical situation so requires Major criteria (the Westrom triad): Rehydrate adequately Adult women are much more likely to be raped by a - See section on HIV infection Lower abdominal pain and tenderness Eradicate the infecting organism(s) spouse, ex-spouse, or acquaintance than by a stranger Manage pregnancy (as appropriate) Cervical excitation tenderness Prevent complications The girl-child is much more likely to be raped by her Treat depression (if present) Adnexial tenderness Drug treatment close male associates (non-strangers), not excluding her Prevention Minor criteria Appropriate antibiotics for an adequate period father, uncle, brother, cousin, neighbour, school teacher, Promote Basic Education forAll Fever ( 380 C) - The antibiotic chosen should cover all possible family driver, security personnel, and even faith-based Reduce adult illiteracy Leucocytosis causative organisms while awaiting culture/sensitivity instructor Promote family/community moral values Purulent vaginal discharge results Mental illness, alcohol and drug abuse appear to be Promote Basic Health Education Adnexial mass Out patient therapy while awaiting culture results: predisposing factors; neglect and inattentiveness to the Promote safe shelter and neighbourhoods Diagnosis Ceftriaxone (or equivalent cephalosporin) needs of the girl-child also contribute Enforce existing laws on rape Based on the presence of the Westrom triad of - 1 g intramuscularly stat Clinical features Legislate for new laws to deter potential rapists and symptomatologyplus one of the minor criteria Plus: Indirect presentation protect females Confirmation by demonstration of causative Doxycycline Vaguesymptoms Promote socio-economic well-being for all organism(s) on microscopy, culture and sensitivity - 100 mg orally every 12 hours for 14 days Physical features: testing Plus or minus: - Perineal pain Differential diagnoses Metronidazole - Bleeding per vaginam Acute appendicitis - 400 mg orally every 12 hours for 14 days - Bruised face/body Ovarian cyst accident If no response in 48 - 72 hours - Arthritis Endometriosis - Admit, re-evaluate and give appropriate intravenous - Disordered gait Urinary tract infections therapy Psychological symptoms/disorders Renal disorders (e.g. nephrolithiasis) Inpatient triple therapy - Sadness Pelvic adhesions - Ceftriaxone/doxycycline/metronidazole - Depression Lower lobe pneumonia Or: - Refusal to respond to simple questions Ectopic gestation - Clindamycin/gentamicin/metronidazole - Avoidance of eye contact Complications Triple antibiotic regimen to be continued for 48 hours - School/work absenteeism Pelvic abscess after the patient improves clinically Differential diagnoses Septicaemia Subsequently, the patient should continue therapy with Vaginitis Chronic pelvic pain Doxycycline Threatened abortion Ectopic gestation - 100 mg orally every 12 hours Domestic violence Infertility Plus: Alcoholism Fitz-Hugh-Curtis syndrome Metronidazole Drug abuse Recurrence (about 25% rates) - 400 mg orally every 8 hours for 10-14 days Depression Investigations Prevention Investigations Packed cell volume Encourage the use of barrier contraceptive with Early Haemoglobin genotype spermicides Vaginal/perineal swab for microscopy, culture and Blood Group Modify risky sexual behaviour: avoid multiplicity of sensitivity White Blood Cell count sexual partners Semen: DNAanalysis Electrolytes and Urea Contact tracing: to break the existing chain of infection Late Midstream urine microscopy, culture and sensitivity and prevent recurrence Urinalysis; urine microscopy, culture and sensitivity Endocervical swab Prompt diagnosis and treatment to prevent long term Pregnancy test (blood) High vaginal swab culture: to exclude trichomoniasis, complications HIV screening bacterial vaginosis Treatment objectives Urethral swab Evaluate safety of the patient Ultrasound scan: to exclude cyesis, ectopic gestation, RAPE Assess and treat physical injuries adnexial mass (e.g. ovarian mass) Introduction Provide emotional support Indications for admission Performance of the act of sexual intercourse by force, Assess and deal with the risk of sexually transmitted

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daily in severe infections Caution Manifests physiologically by wide-spread airway CHAPTER 14: RESPIRATORY SYSTEM Supportive measures Effects of nebulized epinephrine last 2 - 3 hours; the narrowing and clinically by paroxysmal attacks of Oxygen child should be monitored carefully for recurrence of the dyspnoea, cough and wheezing ACUTE EPIGLOTTITIS Steam inhalation obstruction Acute episodes are interspersed with symptom-free Introduction Nasotracheal intubation may be required periods A life threatening, rapidly progressive cellulitis of the Maintain adequate caloric intake and hydration Clinical features epiglottis that may cause complete airway obstruction Notable adverse drug reactions, caution ACUTE RHINITIS (Common cold) Episodic dyspnoea Most common in children, in whom Haemophilus Cefuroxime: avoid in pregnancy and in patients with Introduction Cough: unproductive, or productive of scanty sputum influenzae is the most common pathogen renal impairment Inflammation of the mucosal surface of the nose, most Wheezing In adults, is often caused byStrept. pneumoniae and Ceftriaxone: rashes, fever, gastrointestinal disturbances commonly due to infection with respiratory viruses Tachypnoea groupAstreptococcus - Dose reduction in the elderly Clinical features Tachycardia Clinical features Prevention Tickling sensation in the nose associated with itching Pulsus paradoxus in severe attacks Fulminant presentation in children with: Haemophilus influenzae vaccine of the nose and palate Mildly raised blood pressure Fever Child 2 months - 18 years: 0.5 mL Watery nasal discharge (rhinorrhoea), which may later Rhonchi: inspiratory and expiratory Irritability - Should be available as part of childhood immunization become purulent Prolonged expiration Cough Sneezing Silent chest (an ominous sign) Dysphonia Headaches Differential diagnoses Airway occlusion ACUTE LARYNGO-TRACHEO-BRONCHITIS Nasal obstruction (usually alternating) Chronic bronchitis Dysphagia (Croup) Differential diagnoses Left ventricular failure Dyspnoea Introduction Allergic rhinitis Glottic dysfunction with respiratory obstruction Drooling An infection of the upper and lower respiratory tract Vasomotorrhinitis Recurrent pulmonary emboli Stridor affecting children 2 - 3 years of age Bacterial rhinitis (often supervenes after the viral onset) Eosinophilic pneumonia Adults' symptoms are less fulminant, presenting with: Causes significant sub-glottic oedema Complications Carcinoid tumour Sore throat Most common aetiology is parainfluenza virus Superimposed bacterial rhinitis Complications Dysphagia infection preceded by an upper respiratory tract - Suspect this if symptoms last longer than 7 - 10 days Spontaneous pneumothorax Dyspnoea infection Sinusitis Pneumo-mediastinum Absence of hoarseness distinguishes acute epiglottitis Clinical features Lower respiratory infection Atelectasis from acute laryngitis Fever Otitis media Investigations Differential diagnoses Hoarseness Obstruction of internal auditory meatus: may cause Diagnosis is based on: Acute laryngitis 'Bovine cough' deafness Airway reversibility to inh aled β adrenergic agonist Laryngo-tracheo-bronchitis (Croup) Inspiratory stridor Treatment objectives Isocapnoeic response to hyperventilation of cold air Complications Differential diagnosis Relieve nasal mucosal oedema and obstruction Sputum eosinophilia Complete airways obstruction and asphyxiation Acute epiglottitis Relieve pain/discomfort Chest radiograph: hyperinflation Investigations Complication Treat complications Treatment objectives Lateral X-ray of the neck Respiratory obstruction Drug treatment Arrest and reverse acute episodes “Thumb sign” appearance of the enlarged epiglottis Investigations Analgesics Prevent (or at least reduce) frequencies of asthmatic Blood culture Radiograph of the neck (postero-anterior view) - Paracetamol attacks Do not view the epiglottis using a tongue depressor: this Treatment objectives Adult: 1 g orally three times daily to relieve headaches or Achieve a stable asymptomatic state may cause laryngospasm, with complete respiratory Prevent asphyxiation fever Maintain the best pulmonary function possible obstruction Treat inflammatory oedema Child 1 - 5 years: 120 - 250 mg; 6 -12 years: 250 - 500 Drug treatment Treatment objectives Supportive measures mg; 12 - 18 years: 500 mg 4 - 6 hourly (maximum 4 doses Acute asthma episodes: Safeguard the airway Humidification in 24 hours) Nebulised salbutamol Control infection Hospitalization may be necessary Antibiotics Adult and child over 18 months: 2.5 mg repeated up to 4 Drug treatment Drug treatment - Only if secondary bacterial infection occurs times daily; may be increased to 5 mg if necessary Cefuroxime Nebulized epinephrine Supportive measures Child under 18 months: 1.25 - 2.5 mg up to 4 times daily Adult: 250 mg orally every 12 hours for5-10days Child: 400 micrograms/kg (maximum 5 mg) Steam inhalation with a drop of eucalyptus oil - More frequent administration may be needed in severe Child: 125 mg orally every 12 hours for5-10days - Repeat after 30 minutes if necessary Notable adverse drug reactions cases Or: Glucocorticoids Paracetamol: raised liver enzymes, renal papillary Intravenous aminophylline Ceftriaxone - Dexamethasone necrosis Adult: 250 - 500 mg slowly (with close monitoring) over Adult: 250 - 500 mg intramuscularly or intravenously Child 1 month - 18 years:10 - 100 micrograms/kg orally 20 minutes for5-10days daily in 1 - 2 divided doses, adju sted according to Child 1 month - 18 years: by intravenous injection Child: neonate, infuse over 60 minutes, 20 - 50 mg/kg response up to 300 micrograms/kg daily especially in BRONCHIALASTHMA 5mg/kg (maximum 500 mg), and then by intravenous daily (maximum 50 mg/kg daily) emergencies Introduction infusion Child under 50 kg: 20 - 50 mg/kg daily by deep - Give parenterally in more severe cases A chronic inflammatory disease of the airways that is Intravenous steroids intramuscular injection or by intravenous injection over - May repeat dose after 12 hours if necessary characterized by hyper-responsiveness of the tracheo- Adequate hydration 2 - 4 minutes, or by intravenous infusion; up to 80 mg/kg bronchial tree to a multiplicity of stimuli Oxygen

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Chronic management is based on severity: Supplemental oxygen bronchial dilatations effusion Intermittent symptoms Hydration CT scan (of the chest) Central chest pain precipitated by a dry harking cough: Inhaled salbutamol on as-needed basis Education on care and precipitating factors Bronchoscopy: biopsy of endobronchial lesion suggestive of tracheitis or tracheobronchitis Mild persistent asthma Notable adverse reactions, caution Sputum microscopy, culture; Ziehl Nielson microscopy Central chest discomfort/pain with sensation of Inhaled salbutamol In all cases, prescribers/dispensers should consult Ventilatoryfunction test: obstructive pattern heaviness or chest compression: suggestive of Adult: 100 - 200 micrograms for persistent symptoms product literature to confirm the strengths of various Treatment objectives myocardial ischaemia up, to 4 times daily aerosol prepartations Eliminate underlying pathology Lateral burning chest pain associated with tenderness Child 1 month - 18 years: 100 - 200 micrograms (1 - 2 Aminophylline Improve mucus clearance on physical contact: Bornholm's disease puffs) up to 4 times daily (for occasional use only) - Do not exceed 500 mg in 24 hours because of the risk Control infection Investigations Plus: of cardiac arrhythmias Reverse airflow obstruction Chest radiography Inhaled corticosteroid - May cause CNS stimulation with insomnia and Drug treatment Electrocardiography - Beclomethasone dipropionate 100 microgram 3 - 4 convulsions Empirical antibiotics in acute exacerbations Echocardiography times daily Steroids - Amoxicillin Treatment objectives Moderate persistent asthma - Immunosuppression, metabolic derangements, etc Adult: 500 mg -1 g orally every 8 hours for5-7days Treat primary cause Inhaled salbutamol - Care should be taken in withdrawing steroids Child: 40 mg/kg orally in 3 divided doses daily Relieve pain Adult: 100 - 200 micrograms for persistent symptoms Prevention - Cotrimoxazole Drug treatment up to 4 times daily Avoid precipitating factors Adult: 960 mg orally every 12 hours for5-7days Non narcotic analgesics Child 1 month - 18 years: 100 - 200 micrograms (1 - 2 Appropriate use of medicines Child: 6 weeks to 5 months: 120 mg orally; 6 months - 5 - Paracetamol puffs) up to 4 times daily (for occasional use only) Training of patients in the techniques of the proper use years: 240 mg; 6 - 12 years: 480 mg Adult: 1 g orally every 8 hours Plus: of aerosols/spacer devices is important Appropriate antibiotics as soon as culture results are Child 1 - 3 months: 30 - 60 mg every 8 hours;3-12 Inhaled corticosteroid available months: up to 120 mg every 4 - 6 hours;1-5years: 120 - - Beclomethasone dipropionate Bronchodilators 250 mg every 4 - 6 hours;6-12years: 250 - 500 mg Adult: 100 microgram 3 - 4 times daily BRONCHIECTASIS - Salmeterol xinafoate every 4 - 6 hours; 12 - 18 years: 500 mg every 4 - 6 hours Child under 2 years: 50 micrograms every 12 hours; 2 - Introduction Adult: 2 puffs (50 micrograms) twice daily Non-steroidal analgesics 5 years: 100 - 200 micrograms every 12 hours;5-12 Abnormal and permanent dilatation of medium sized - Can be doubled in severe airway obstruction - Diclofenac sodium years: 100 -200 micrograms every 12 hours; 12 - 18 bronchi Child: same as adult dose (for children > 4 years) Adult: 25 - 50 mg orally three times (daily depending on years: 100 - 400 micrograms every 12 hours Aconsequence of inflammation and destruction of the - Salbutamol severity) Plus: structural components of the bronchial wall, caused by Adult: 1 - 2 puffs (100 - 200 micrograms) 3 - 4 times Child 6 months - 18 years:0 . 3 1 mg/kg by mouth or by bacterial or viral infections daily Long- acting ß2 agonist rectum 3 times daily (maximum total dose 150 mg daily) - Salmeterol May be focal or diffuse Child: usually 100 microgram (1 puff) may be increased Pain of more serious aetiology e.g.pain of lower or Adult: 50 micrograms twice daily, up to 100 Clinical features to 200 microgram with more severe symptoms upper respiratory tract infection, or pain of myocardial micrograms Persistent or recurrent cough Supportive measures ischaemia Child 2 - 4 years: 25 micrograms (1 puff) every 12 Purrulent fetid sputum Supplemental oxygen - Refer to an appropriate specialist hours;4-12years: 50 micrograms (2 puffs) every 12 Haemoptysis Postural drainage or suction hours; 12 - 18 years 50 - 100 micrograms (2 - 4 puffs) Pleuritic chest pain Cessation of cigarette smoking every 12 hours With or without a history of preceding pneumonic Notable adverse drug reactions, caution CHRONIC OBSTRUCTIVEAIRWAYS DISEASE Severe persistent asthma illness Prescribers/dispensers should consult product Introduction Inhaled salbutamol Digital clubbing. literature to confirm the strength of various aerosol Apulmonary disorder of adults characterized by chronic Adult and child up over 18 months: nebulizer 2.5 mg Crepitations, rhonchi and wheezes prepartations airflow limitation in the small airways repeated up to 4 times daily; may be increased to 5 mg if Cor pulmunale and right ventricular failure in Salbutamol: palpitations, tremors, nervous tension, Complicates chronic bronchitis and emphysema necessary chronically hypoxic patients muscle cramps, sleep disturbances, tachycardia, Obstruction to air flow is only partially reversible with Child under 18 months: 1.25 - 2.5 mg up to 4 times daily Differential diagnoses peripheral vasodilation, hypotension bronchodilator therapy - Repeated administration may be required in severe Pulmonary tuberculosis Prevention Two extreme types of COAD are recognized although cases Lung abscess Avoidance of smoking there is a lot of overlap Chronic bronchitis Timely and effective treatment of bacterial infections Long- acting ß2 agonist Clinical features Adult: 50 micrograms twice daily up to 100 micrograms Bullous emphysema Respiratory care during childhood measles Depending on the predominant syndromes, could be Child 2 - 4 years: 25 micrograms (1 puff) every 12 Complications described as follows: hours;4-12years: 50 micrograms (2 puffs) every 12 Massive haemoptysis Pink puffers hours; 12 - 18 years 50 - 100 micrograms (2 - 4 puffs) Lung abscess CHEST PAIN Slowly progressive dyspnoea every 12 hours Mycotic brain abscess Introduction Cough with scanty sputum Oral corticosteroid Pulmonary amyloidosis Acommon clinical symptom that may or may not have Aesthenic features - Prednisolone Ventilatory failure significant clinical implications Barrel-shaped chest Adult: 40 - 50 mg orally daily for a few days, and then Cor pulmunale and right ventricular failure Clinical features(with differential diagnoses ) Wheeze reduce gradually Investigations Sharp, lancinating lateral chest pain, worse with These patients mainly have emphysema Child: 1 - 2 mg/kg orally once daily for3-5days Chest radiograph: cystic spaces with air-fluid levels breathing and coughing: pleurisy Blue bloaters Supportive measures Bronchography: saccular, cylindrical or varicose Dull aching lateral chest pain: chest wall pain, pleural Prolonged periods of cough and copious sputum

167 168 Chapter 14: Respiratory System Standard Treatment Guidelines for Nigeria 2008 production Exclude tuberculosis if cough is chronic underlying/precipitating cause Dyspnoea Supportive measures Sputum cytology for malignant cells Frequent respiratory infections Assisted ventilation Chest radiograph where indicated Central cyanosis Hydration HIV screen if history and clinical features are LUNGABSCESS These patients mainly have chronic bronchitis Pulmonary physiotherapy suggestive Introduction Differential diagnoses Prevention Treatment objectives Suppuration of the lung parenchyma Chronic persistent asthma Avoidance of cigarette smoking Identify and treat the underlying cause(s) May be due to: Cystic fibrosis Avoid / remove atmospheric pollutants Abolish cough Infection by aspirated oro-pharyngeal anaerobes Complications Non-drug measures Inadequately treated pneumonia caused by Respiratory failure Adequate rehydration to prevent inspissation Staphylococcus aureus, Mycobacterium tuberculosis Recurrent bronchial infections with Haemophilus COUGH Encourage expectoration for productive cough Bronchial obstruction. influenzaeand Streptococcus pneumooniae Introduction Do not use antitussives unless cough is dry, Clinical features Cor pulmonale The explosive expiration that clears the tracheo- unproductive and distressing Symptoms are indolent lasting several weeks: Left ventricular failure bronchial tree of secretions and foreign particles or Drug treatment Cough, with purulent offensive sputum Pulmonary thromboembolism noxious gaseous materials Cough suppressants: for dry, unproductive cough Fever, chills Investigations Adefensive reflex reaction - Codeine cough linctus Night sweats Chest radiograph: hyperinflation, pulmonary Comes to medical attention only when it becomes Adult: 5 - 10 mL3 - 4 times daily Weight loss hypertension troublesome, affects life style and/or when there is - Not recommended in children Pleurtic chest pain Ventricularfunction tests: FEV1 /FVC ratio concern about its cause Appropriate antibiotics for bacterial infections Signs: Blood gas analysis Clinical features Notable adverse drug reactons, caution Digital clubbing Blood pH Cough may be: Codeine cough linctus: sedation, constipation Crepitations Haematocrit Acute or chronic Pleural friction rub Sputum microscopy and culture (during symptom Seasonal Differential diagnoses exacerbation) Associated with breathlessness and or wheezing Localized bronchiectasis Electrocardiogram Productive of sputum: note colour, smell; haemoptysis DYSPNOEA Pneumonia Airways reversibility test Associated with fever Introduction Tuberculosis Treatment objectives Associated with chest pain: note location and character An abnormal and uncomfortable awareness of Complications Maintain optimal level of oxygenation and ventilation of pain breathing Cerebral abscess - Supplemental oxygen, at 24 - 28% or1-2litres/minute Associated with risk factors, e.g. cigarette smoking Effort of breathing is out of proportion with exertion Empyema Treat infections Associated with the use of drugs for other illnesses needs Pulmonary amyloid Reverse airways obstruction Associated with other constitutional symptoms Patients often have difficulties in describing the Investigations Clear airways secretions Differential diagnoses discomfort of dyspnoea Sputum: Gram stain and culture Drug treatment Triggers of cough may rise from the upper or lower Clinical features Bronchoscopy Will depend on the underlying cause(s) of dyspnoea Long acting ß2 - agonist airways, or lung parenchyma Transthoracic aspiration - See bronchial asthma Upper airways: Differential diagnoses Blood culture Theophylline - Inhaled irritants: dust, fumes, smoke Pulmonary: Chest radiograph - Aminophylline (see bronchial asthma) - Upper airways secretion -Obstructive airways disease: asthma, chronic Treatment objectives Antibiotics (when necessary to control infection) - Gastric reflux bronchitis, emphysema Eradicate bacterial cause - Erythromycin Lower airways: -Parenchymal lung disease: pneumonia, Drain abscess Adult and child over 8 years: 250 - 500 mg orally every 6 - Inflammation pneumoconiosis, pulmonary fibrosis Preserve normal lung function hours, or 500 mg - 1 g every 12 hours (up to 4 g daily in - Viral bronchitis - Pulmonary vascular obstruction: pulmonary emboli Non-drug treatment severe infections) - Bronchiectaesis - Chest wall disorders: respiratory muscle paralysis, Hydration Child: 2 - 8 years: 250 mg orally every 6 hours - Bacterial infection kyphoscoliosis Pain relief Up to 2 years: 125 mg every 6 hours - Bronchial asthma Cardiogenic: Physiotherapy - Co-amoxiclavulanate - Endobronchial tuberculosis - Congestive cardiac failure Drug treatment Adult: 500/125 mg orally every 12 hours - Bronchial infiltration/compression - Left ventricular failure Antibiotics Child 1 month -1 year: 0.25 mL/kg of 125/31 mg Parenchymal lung disease Metabolic: - Metronidazole suspension orally every 8 hours; dose doubled in severe - Pneumonia - Diabetic ketoacidosis Adult: 500 mg orally every 8 hours infections - Lung abscess Neurogenic: Child: neonate, initially 15 mg/kg orally then 7.5 mg/kg 1 - 6 years: 5 mLof 250/62 mg suspension every 8 hours; - Interstitial or endobronchial oedema due to heart - Anxiety neurosis every 12 hours; 1 month - 12 years: 7.5 mg/kg dose doubled in severe infections disease Treatment objectives (maximum 400 mg) every 8 hours; 12 - 18 years: 400 6 - 12 years: 5 mL of 250/62 mg suspension every 8 Drugs: Treat cause(s) of dyspnoea mg every 8 hours hours; dose doubled in severe infections - ACE inhibitors Restore normal respiration Plus: 12 - 18 years: one 250/125 mg strength tablet every 8 Investigations Non-drug treatment Amoxicillin hours, daily increased in severe infection to one 500/125 Macroscopic and microscopic examination of sputum Oxygen in appropriate concentration Adult: 500 mg orally every 8 hours for7-10days strength tablet every 8 hours daily Sputum culture Other treatment will depend on the Child less than 5 years: a quarter adult dose; 5 - 10

169 170 Chapter 14: Respiratory System Standard Treatment Guidelines for Nigeria 2008 years: half adult dose Pleural effusion headaches - Focal oligaemia Or: Empyema thoracis - Rarely, antibiotic-associated colitis - Pleural effusion Amoxicillin/clavulanic acid Septicaemia Prevention - Wedge-shaped opacity (Hampton's hump) Adult: 1 g/200 mg orally every 8 hours for7-10days Endocarditis Pneumococcal vaccine Ventilation/perfusionscan (Definitive antibiotic therapy should be based on culture Meningitis Haemophilus influenzae vaccine Arterial blood gas analysis: hypoxaemia, respiratory and sensitivity results) Investigations alkalosis Prevention Sputum examination Full Blood Count: leucocytosis Good dental care Haematological evaluation Raised ESR Adequate treatment of acute pneumonia Sputum culture PULMONARYEMBOLISM Raised LDH levels Prevent pneumonia with vaccination in persons at risk Chest radiograph Introduction Treatment objectives - HIV infected patients who are still capable of Blood cultures Occurs when a venous thrombus is dislodged from its Prevent fatality responding to a vaccine challenge Serologic studies site of formation (thrombotic embolus) or a fat globule Restore normal lung perfusion - Patients with recurrent sinopulmonary infection Treatment objectives from a long bone fracture or crush tissue injury or even a Non-drug treatment - Patients with or acquired hypogammaglobulinaemia Eliminate the infection tumour fragment (non-thrombotic embolism), is carried Primary measures: Return to normal lung function in the blood stream to the pulmonary arterial circulation Embolectomy Drug treatment causing obstruction to alveolar perfusion Supplemental oxygen PNEUMONIA Antibiotics Clinical features Psychological support Introduction - Co-amoxiclavulanate Massive embolus in main pulmonary artery: Drug treatment An inflammation of the lung parenchyma Adult: 1 g/200 mg orally every 12 hours for 5 -7 days Sudden death Anticoagulants Various bacterial species, fungi and viruses may cause Child: neonate and premature infants, 25 mg/kg every Sudden onset dyspnoea - Heparin pneumonia 12 hours; infants up to 3 months, 25 mg/kg every 8 Tachypnoea Adult: 5,000 units (10,000 in severe pulmonary The setting in which infection is acquired could be a hours, 3 months to 12 years, 25 mg/kg every 8 hours Tachycardia embolism) loading dose then continuous infusion at a predictor of the infecting pathogen increased to 25 mg/kg every 6 hours in more severe Small volume pulse rate of 15 - 25 units/kg/hour Streptococcus pneumoniae is the most common infections Hypotension Child: neonate, initially 75 units/kg (50 units/kg if under pathogen in community-acquired pneumonia Or: Circulatory collapse 35 weeks post-menstrual age), then 25 units/kg/hour by Other causative organisms: - Benzyl penicillin Raised jugular venous pressure intravenous injection, adjusted according toAPTT Haemophilus influenzae Adult: initially 1.2 g (2 million units) intravenously Small-to-moderate embolus: 1 month - 1 year: same as for neonate Mycoplasma pneumoniae every 6 hours Cough 1 year - 18 years: initially 75 units/kg by intravenous Pseudomonas aeruginosa (usually implicated in Child: preterm and neonate under 7 days, 25 mg/kg by Pleurtic chest pain injection, then 20 units/kg/hour by continuous nosocomial pneumonia) intramuscular injection or by slow intravenous injection Haemoptysis intravenous infusion, adjusted according toAPTT Clinical features or infusion every 12 hours; dose doubled in severe Tachycardia Or: Typical pneumonia: infection Left parasternal heave - Enoxaparin Sudden onset fever, chills and rigors Neonate 7 - 28 days: 25 mg/kg every 8 hours; dose Loud pulmonary component of second heart sound Adult: 1.5 mg/kg (or 150 units/kg) by subcutaneous Cough with purulent sputum production doubled in severe infection Fever injection every 24 hours, for at least 5 days (until Pleuritic chest pain 1 month - 18 years: 25 mg/kg every 4 - 6 hours, increased Signs of lung consolidation adequate oral anticoagulation is established) Breathlessness with short inspiratory efforts to 50 mg/kg every 4 - 6 hours (maximum 2.4 g every 4 Pleural friction rubs Child: neonate, 1.5 - 2 mg/kg by subcutaneous injection Signs: hours) in severe infection Differential diagnoses twice daily; 1 - 2 months: 1.5 mg/kg twice daily; 2 Fever - Commence oral therapy as soon as practicable Myocardial infarction months - 18 years: 1 mg/kg twice daily Herpes labialis Or: Unstable angina - Warfarin Tachypnoea - Cefuroxime axetil Pericarditis Adult: initially 10 mg orally daily for 2 days Signs of lung consolidation Adult: 500 mg orally every 8 hours for5-7days Exacerbation of chronic bronchitis Child: neonate (under specialist advice), 200 Pleural friction rubs Child 3 months - 2 years: 10 mg/kg (maximum 125 mg) Congestive cardiac failure micrograms/kg once daily as a single dose on first day, Atypical pneumonia: orally every 12 hours;2-12years: 15 mg/kg (maximum Pneumothorax then on the following 2 days Gradual onset 250 mg) every 12 hours daily; 12 - 18 years: 250 mg Complications 1 month - 18 years: 200 micrograms/kg (maximum 10 Dry cough every 12 hours; dose doubled in severe infection Sudden death mg) as a single dose on first day, reduced to 100 Prominent extra-pulmonary symptoms Supportive measures Pulmonary infarction micrograms/kg (maximum 5 mg) once daily for Headache Analgesics Lung abscess following 2 days Sore throat Hospitalization may be necessary in severe infection Investigations - Usual maintenance dose: 100 - 300 micrograms/kg Fatigue Adequate hydration. Electrocardiography once daily Myalgia Supplemental oxygen if cyanosis is present - Sinus tachycardia - Subsequent doses depend on prothrombin time (INR) Chest crackles or rales Notable adverse drug reactions, caution and - Atrial fibrillation Thrombolytic agents Differential diagnoses contraindications - Right bundle branch block - Recombinant tissue plasminogen activator Pulmonary embolism Co-amoxiclavulanate: nausea, diarrhoea, skin rashes - Right axis deviation <90° Adult: 10 mg by intravenous injection given over 1 - 2 Septicaemia - Contra indicated in penicillin-hypersensitive - T wave inversion minutes; then intravenous infusion of 90 mg given over Complications individuals - Q waves in leads III,AVF,V3 2 hours Lung abscess Cefuroxime: nausea, vomiting, abdominal discomfort, Chest radiograph - Not exceeding 1.5 mg/kg in persons less than 65 kg May be normal or show:

171 172 Chapter 15: Injuries and Acute Trauma Standard Treatment Guidelines for Nigeria 2008

Notable adverse drug reactions, caution and CHAPTER 15: INJURIES AND ACUTE Myalgias Inhibition of peripheral nerve impulses contraindications TRAUMA Headaches Multisystem effects Heparin: Severe migratory arthralgia Rhabdomyolysis - Thrombocytopaenia and haemorrhage Amaculopapular rash involving the palms and soles Haemolysis - Osteopaenia BITESAND STINGS Human bites Blood vessel damage - Osteoporosis Introduction May be: Elapidae - Pathologic fractures Bites occur from: Self-inflicted Neurotoxic effects - May cause hyperkalaemia (inhibition of aldosterone Humans Sustained by medical personnel caring for patients Snake bite wounds may become secondarily infected secretion) Domestic animals such as cats and dogs Sustained during fights, rapes or during sexual activity with: - Contraindicated after recent surgery or trauma, in Wild animals e.g. snakes, sharks and crocodiles May become infected more than bites from other - Clostridium tetani, causing tetanus haemophilia and other bleeding disorders, peptic ulcer, Stings often occur from: animals - Clostridium welchi, causing gas gangrene severe liver disease, acute bacterial endocarditis Bees, wasps and other insects The oral microflora include multiple species of Indications for antivenom treatment Enoxaparin : Marine invertebrates such as the jellyfish, corals, aerobic and anaerobic bacteria Hypotension - Haemorrhage scorpions and anemones Those of hospitalized and debilitated patients often Vomiting - May cause hyperkalaemia (inhibition of aldosterone The microbiology of bite wound infections reflects the include Enterobacteriacae Hand or foot bite swellings extending beyond the wrist secretion) oro-pharyngeal flora of the biting animal HIV,HBV have been reported due to human bites or ankle within 4 hours of the bite Warfarin: - Organisms from the soil, skin of the animal and Snake bites Electrocardiograph abnormalities - Haemorrhage victims, animal feaces may also be present InAfrica, often occur among farmers who walk unshod Sharks and crocodiles - Skin necrosis Clinical features Occasionally occur around homes when snakes are Cause death by: - Avoid during pregnancy Depend on the type of injury, and the delay before accidentally stepped upon Tissue destruction Recombinant tissue plasminogen activator presentation in hospital Poisonous snakes belong to the families of: Crush syndrome - Intracranial haemorrhage Bites from common domestic animals usually result in Viperidae : Haemorrhage Prevention bruises, lacerations and haemorrhage; - Subfamily viperinae (the Old World vipers) Infection Prophylactic warfarin or heparin in patients at risk Rabies may complicate dog bites - Crotalinae (the New World vipers,Asian pit vipers) Bees and wasps Inferior vena cava filters, when anticoagulation cannot Dog bites Elapidae (e. g. cobras) Are the most common causes of stings be undertaken because of active bleeding Responsible for 80% of bite wounds Colubridae (e. g. boomslang) They leave their stinging apparatus behind in the skin Bacteriology usually mixed - A large group; only a few species are dangerously The symptoms that follow bee stings are those due to - Alpha haemolytic streptococci, pasteurella species, toxic to humans anaphylaxis to their venom staphylococci, Eikenella chorrodeus, actinomyces, Hydrophidae (sea snakes) Marine invertebrates fusobacterium, prevotella, pophyomonas species, InAfrica the vipers are responsible for most snake bites. Have specialized organelles called nematocysts for Capnocytophaga canimorsus Clinical features poisoning and capturing prey 15 - 20 % of wounds become infected - Depend on the type of snake, location of bite and May cause serious ill health and death Lower limbs are most commonly affected promptness of intervention Initial assessement Infections occur 8 - 24 hours after bite and may manifest Local effects: Careful history as: Pain Contact local authorities to determine if the specie is - Pain Swelling rabid; if possible locate animal for observation - Fever Bruising Antibiotic allergy, immunization of patient and other - Lymphadenopathy Tender enlargement of regional lymph nodes morbid condition(s) should be documented - Cellulitis Systemic effects: Inspect wound for evidence of infection. If the canine tooth penetrates synovium or bone: Early anaphylactoid symptoms Conduct general physical examination, including vital - Septic arthritis Transient hypotension with syncope signs - Osteomyelitis Angioedema Investigations Cat bites Urticaria Depend on the type of injury, the clinical presentation Less common Abdominal colic and the onset/type of complications: More than 50% result in infection Diarrhoea Full Blood Count Females are more affected than males Vomiting Electrolytes and Urea The hands and arms are more commonly affected Late persistent or recurrent hypotension Blood clotting profile Usual organisms includeP. mutocida and those ones Electrocardiograph abnormalities Arterial blood gas estimations following dog bites Spontaneous systemic bleeding Chest radiographs Rats, mice, gerbils and animals that prey on them Coagulopathy Wound and blood cultures May transmitStreptobacillus moniliformis or Spirillus Adult respiratory distress syndrome Treatment objectives minor Acute renal failure Neutralize envenomation Usually affect hunters or laboratory handlers of rats Viperidae and crotalidae Limit systemic effects Manifests as: Local and systemic bleeding Local wound care Fever Impairment of organ function Prevent onset of complications Chills Reduction of cardiac output

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Prevent specific infections such as rabies in high risk Adrenaline (epinephrine), hydrocortisone must be Wound swab for microscopy, culture and sensitivity Commence prophylaxis against deep venous cases immediately on hand for the treatment of anaphylaxis Blood culture thrombosis Non-drug measures if it occurs Intracompartmental pressure monitoring Physiotherapy Limb splinting (and rest the limb) Prevention Treatment objectives Decide whether patient should go to a burns unit or Use of venom detection kit (if available) Appropriate clothing and footwear while outdoors At the scene: to stop the burning process or remove burns centre following standard criteria Application of pressure bandage Attention and care to observe general safety measures victim from the burn situation Drug treatment Control/care of the airway Transfer the patient to hospital as soon as possible Oxygen Incision is discouraged; the mouth should not be used to In the hospital identify life threatening injuries and Tetanus toxoid suction BURNS treat Anti tetanus serum, antitetanus globulin as appropriate Identification of the snake would help in the choice of Introduction Perform a detailed survey Narcotic analgesics e. g. morphine, pethidine, tramadol antivenom (where specific antivenoms are available) Acommon form of trauma in our environment Restore patient's physiology as much as possible Nonsteroidal anti inflammatory analgesics e. g. Wound debridement and fasciotomy for compartment Involves coagulative necrosis of tissue cells following Promote wound healing diclofenac syndrome may become necessary varied insults Prevent complications H2 receptor antagonists e. g ranitidine Drug treatment - Flames Rehabilitation Prophylactic antibiotics e. g cephalosporins Administration of high flow oxygen - Chemicals Treatment Topical wound dressing agents e. g with zinc oxide Intravenous fluid administration to maintain - Electricity Copiously irrigate the wound with cold water (not ice based creams, antibiotic-containing dressings circulation: use colloids or cystalloids as clinically - Friction cold) for 10 - 15 minutes Prevention appropriate - Cold or hot fluids Avoid hypothermia and the use of agents such as raw Health education to promote healthy life style and

Treatment of anaphylaxis with antihistamines (H1 The various types occur with varying frequencies in eggs and palm oil avoidance of risky behaviour blockers), epinephrine (adrenaline) and corticosteroids various segments of the population - They are not useful and may promote wound sepsis Installation of fire warning systems such as smoke Analgesia - For example scalds occur with great frequency in In hospital perform a quick primary survey detectors in buildings Prophylactic antibiotics as appropriate children while flame burns occur commonly in young Check: Control of petroleum products Tetanus prophylaxis adults -A irway An efficient fire service For animal bites in which rabies is considered a Clinical features() and complications -B reathing Fire protocols in all establishments significant risk it is imperative that anti-rabies Extensive skin loss with dehydration -C irculation prophylaxis be instituted Airway burns leading to dyspnoea, tachypnoea, stridor, -D isability - If the patient is not previously vaccinated local wound hypoxia, hypercarbia, airway obstruction and death -E xposure DISASTER PLAN cleansing should be done, rabies immune globulin Breathing difficulties from circumferential chest burns Correct problems identified Introduction administered and the vaccine given Acute respiratory distress syndrome, acute lung injury Give patient 100% oxygen A disaster is an event which causes serious disruption Antirabies prophylaxis and pulmonary oedema Pass an endotracheal tube if there is risk of airway to community life, threatens or causes death or injury in Rabies immune globulin Massive fluid losses from evaporation and interstitial obstruction that community, and/or damage to property Adult and child: 20 units/kg body weight by infiltration fluid shifts leading to hypovolaemic shock Obtain specimens for investigations as detailed above It is beyond the day-to-day capacity of the prescribed in and around the cleansed wound; if whole volume not Acute renal failure from pre renal failure, acute tubular Determine percentage total body surface area (TBSA) statutory authorities and requires special resources other exhausted, give remainder by intramuscular injection necrosis, and the crush syndrome burned than those normally available to those authorities into anterior-lateral thigh (distant from vaccine site) Electrolyte abnormalities: hyper or hypokalaemia with - Wallace rule of nines is recommended in adults Could arise from natural causes cyclones, earthquakes - Half of the dose is infiltrated around the wound and cardiac dysrhythmias and/or arrest - In children there are several charts e. g Lund and and tsunamis or from man-made situations such as plane the rest given intramuscularly into the gluteal muscles Anaemia from destruction of red cells.Also nutritional Browder charts crashes and wars Human Diploid Cell Vaccine (HDCV) or Rabies anaemia Calculate the total fluid requirement in the first 24 Occur with little or no warning VaccineAdsorbed (RVA) Hypothermia hours using appropriate formulae - Only well-prepared systems will be able to limit the - 1 mL is given into the deltoid on days 0, 3, 7, 14, and Immune dysfunction - We recommend the Parkland's damages and losses that follow disasters 28 Burns wound sepsis and septicaemia Determine burn depth The effectiveness and quality of response to a disaster - Should not be administered in the gluteal area Tetanus Apply burns dressing is highly dependent on the level of preparation - If the patient has previously been vaccinated clean the Acute gastric dilatation Pass all relevant tubes and gadgets An ill-prepared system will lead to an ineffective and wound and give the vaccine given on days 0 and 3 only Stress ulcerations in the gastrointestinal system - Nasogastric tube, urethral catheter, etc uncoordinated response Indications for anti-snake venom treatment Limb compartment syndrome Perform a detailed secondary survey (especially if Apart from an effective response, other advantages of Symptoms or signs of systemic envenoming: Crush syndrome combined with other trauma) preparation include cost savings and an improved and hypotension, angioedema, urticaria, diarrhoea and Deep vein thrombosis - Obtain theAMPLE history alert system vomiting, spontaneous bleeding, adult respiratory Systemic Inflammatory Response Syndrome (SIRS) Allergies, There are four phases of disaster management: distress syndrome, acute renal failure, etc Multiple Organ Dysfunction Syndrome (MODS) Medications, Prevention Electrocardiograph abnormalities Investigations Past medical history, pregnancy, Preparation Marked local envenoming e.g. swelling extending Full Blood Count Last meal Response beyond wrist within 4 hours of bite on hand, or beyond Electrolytes and Urea Environment (including details of the incident) Recovery ankle after bite on foot Grouping and cross-matching Adult and child: contents of the antivenom vial diluted Arterial blood gases Administer tetanus prophylaxis depending on immune Prevention in sodium chloride 0.9% intravenous infusion, and Chest radiograph status Essentially the evolution and implementation of infused intravenously over 30 minutes Electrocardiogram Apply relevant splintage strategies to prevent or mitigate the impact of disasters

175 176 Chapter 15: Injuries and Acute Trauma Standard Treatment Guidelines for Nigeria 2008 if/when they arise e.g. designing tsunami warning Ensure management commitment to disaster 13 - 15: mild - This is associated with hypertension and bradycardia systems or fire alarm systems management 9 - 12: moderate (Cushing's reflex) Preparation Committee composition 8 or less: severe - Sequentially apnoea, arrythmias, hypotension and Involves system upgrade, overhaul, protocol design, The committee should be composed of the following: Morphology: death ensue implementation and quality assessment for disaster The Hospital Trauma Director Skull fractures Clinical features management The Emergency Department Chief Intracranial lesions These patients may present with: Response The Head of Surgery - Skull fractures could involve the vault or base of the Features of multisystem trauma Involves the interaction of the various emergency The Head ofAnaesthesia skull Altered level of consciousness response agencies to the disaster to save as many The Chief of Nursing services - Vault fractures may be linear, stellate, depressed or Skull fractures and mass effect from intracranial lesions casualties as possible; quick transfer to hospitals, The Head of Security non-depressed; open or closed Features of raised intracranial pressure coordination of the hospitals and creation of temporary The Head of Stores - Basilar fractures may be with or without CSF leaks - Headaches shelters The Head of Pharmacy and also with or without facial nerve palsy - Nausea Recovery Arepresentative of the Hospital Manager - Intracranial lesions may be focal or diffuse. - Projectile vomiting A phase that involves rebuilding, reconstruction and The disaster protocol in the hospital should address the - Focal lesions include epidural, subdural and - Drowsiness rehabilitation, with a goal to restoring the community to following principal issues: intracerebral haematomas - Papilloedema its pre-event state or as close to it as possible Who activates the disaster protocol? - Diffuse lesions include concussions and diffuse axonal Complications of TBI: For a disaster plan to be effective it needs to involve all What are the criteria for activation? injury (DAI) Alucid interval (often occurs in extradural haematoma) the stake holders in its design Information relay to critical departments: laboratories, Pathophysiology - Post injury, the patients maintain a satisfactory level Disaster plan is necessary at various levels of health blood bank, theatres, ICU, radiology, anaesthesia, The brain is covered by the meninges: dura, arachnoid of consciousness until suddenly consciousness is lost care and political terrain: national, regional, state and Emergency Department (ED) Management, Hospital and pia mater with the subdural and the subarachnoid Extradural haematoma local government levels Management, Portage and Security spaces Rare; overall, occurs in less than 1% of head injuries There should be disaster plans within organizations Pattern of staff call up to the Emergency Department CSF is produced in the lateral ventricles More common in young patients such as the hospitals, fire service, Army, Air force and in a disaster situation - The normal circulating volume of CSF is 140 mL Often results from torn middle meningeal vessels Navy; the Ministries of health, the police and the Method of staff call The brain normally regulates its blood flow by a process CT shows a biconvex or lenticular opacity Emergency Medical Service (EMS) Pre-determined plan for Emergency Department of autoregulation, which is for the most time Subdural haematoma There is need for a coordinating agency such as the evacuation undisturbed in TBI More common National Emergency ManagementAgency (NEMA) to Information centre constitution for distressed relatives Normal CBF is 800 mL/min or 20% of total cardiac Occurs in 20 - 30% of severe head injuries, more supervise, monitor and coordinate inter-agency Departmental disaster procedures output commonly in the elderly (due to brain atrophy) procedures, protocols, joint training sessions and drills Logistic issues in a disaster situation - CBF = CPP/CVR = 50 mL/100 g of brain tissue/min Results from torn bridging veins Personnel in all the relevant response agencies must be “Standing down” criteria and procedure - CPPis the Cerebral Perfusion Pressure The opacity on CT follows the contour of the brain familiar with the policies, protocols and procedures to - CVR is Cerebral VascularResistance Basal skull fracture be implemented following a disaster - CPP= MAP- ICP May be suggested by: Training and retraining is essential HEAD INJURY - MAPis MeanArterial Pressure Periorbital ecchymosis (racoon eyes) The hospital disaster plan Introduction - ICPis Intracranial Pressure Retroauricular ecchymosis (Battle sign)

There should be a Disaster Committee in the hospital The term refers to any injury to the head The normal ICPis 10 mmHg (136 mm H2 O) CSF leaks which should: - Includes bruises and lacerations to the scalp - Changes in intracranial volume result in compensation, Facial nerve palsy Design a disaster plan for the hospital For practical purposes it is preferable to talk of: with alterations in CSF volume and blood volume within Complications of TBI Put in place procedures and protocols to be Traumatic brain injury (TBI) the cranium but with minimal change in intracranial Early: implemented in a disaster situation Craniocerebral injury pressure Coma Supervise staff training for disaster management Craniofaciocerebral injury At some point minimal changes in volume result in Post concussion headaches Be engaged in capacity building - This section will focus on TBI geometric increases in ICP (The Monro-Kellie Post traumatic amnesia Promote staff awareness regarding disaster prevention TBI is common in trauma patients doctrine), and decompensation occurs Retrograde amnesia and preparation - Present in up to 50% of multiply injured patients An expanding intracranial mass (such as a subdural Abnormalities of salt and water metabolism such as Promote inter-departmental interaction regarding Isolated TBI is uncommon haematoma) leads to : diabetes insipidus and syndrome of inappropriateADH disaster management In up to 50% of cases of severe TBI there is - Uncal herniation through the incisura in the tentorium Anterior pituitary dysfunction such as ACTH Determine staff competency levels in disaster multisystem trauma with compression of the oculomotor nerve and the motor abnormalities and poor cortisol stress response management Classification tracts in the mid brain Late: Allocate staff roles in disaster management Can be considered from the point of view of : - This leads to ipsilateral pupllary dilatation and Chronic subdural haematoma Ensure regular drills, seminars, tabletop exercises, Mechanism of injury contralateral hemiparesis or hemiplegia Infections such as meningitis and brain abscess computer simulations and interactions on disasters Severity of injury In the Kernohan's notch syndrome which occasionally Hydrocephalus Ensure stockpile of drugs and equipment to be Morphology occurs there isipsilateral papillary dilatation and Epilepsy mobilized in disaster situation Mechanism: hemiparesis. CSF leaks Ensure quality assurance and audit Blunt or penetrating Carotico-cavernous fistulae Promote inter-hospital and inter-agency interaction Severity: With progressive expansion of an intracranial mass the Traumatic aneurysms within the municipality with regard to disaster - Depends on the patient's position on the Glasgow cerebellar tonsils eventually herniate through the Chronic headaches management Coma Scale (GCS). foramen magnum (coning) Personality changes

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Treatment objectives haematomas and skull fractures Vasopressors e.g. noradrenaline, dobutamine if there - Relayed in theMIST format, preferably before the Identify life threatening injuries and treat In trauma it is advisable to do a non-contrast CT scan is hypotension, and in collaboration with a physician patient's arrival to enable adequate preparation to be Limit primary injury Indications for CT scan Prevention made before hand Prevent secondary brain injury GCS of 14 or less Measures aimed at reducing accidents in transportation M: Mechanism of injury Provide critical care GCS of 15 with: (especially road traffic accidents), in homes and in I: Injuries sustained Rehabilitate - Loss of consciousness > 5minutes factories: S: Prehospital vital signs: pulse, blood pressure, Primary survey - Amnesia for injury - Motorbike crash helmet laws and enforcement respiratory rate, oxygen saturation, temperature Assess airway and maintain patency - Focal neurological deficit - Alcohol laws T: Treatment given e. g cervical collar, intravenous - Suctioning and manoeuvers to elevate the tongue (jaw - Signs of calvarial or basal skull fracture - Speed limits fluids etc thrust and chin lift) may be useful Intracranial pressure monitoring - Better motor licensing rules Primary Survey - A patent airway is important in optimizing outcome Best done through a ventriculostomy catheter, with or - Health education - Quick survey to identify life threatening injuries and in TBI without concomitant intraparenchymal transducer - Better motor engineering treat Ventilationis next addressed Indications for ICPmonitoring in TBI - Good road designs Airway - Administer 100% oxygen Patients with post resuscitation GCS of 8 or less - Safety procedures at work and a good EMS and trauma - Talking? Assume airway is alright. If not suction, - Hypoxia is one of the causes of secondary head injury Intubated patients in ICU system Guedel's airways and must be avoided Patients with intracranial haematomas but are - Careful with airway manoeuvers such as the jaw thrust - Conduct a quick chest examination to identify tension adjudged not to need surgery and chin lift pneumothorax, pneumothorax, haemothorax, flail chest Emergency management of raised intracranial pressure MULTIPLE INJURIES - Always protect the cervical spine etc Endotracheal intubation Introduction - Apply rigid cervical collar

- Institute urgent treatment as may be indicated Controlled ventilation to a pCO2 of 35 mmHg The multiply injured patient is that patient with injury - May need endotracheal intubation. Maintenance of the circulation Volumeresuscitation to more than one organ system Breathing - Equally important in optimizing outcomes Maintain normal blood pressure Often victims of motor vehicle crashes, motor bike - Check the breathing, respiratory rate, oxygen - Hypotension is a cause of secondary brain injury and Narcotic sedation accidents, pedestrians hit by cars, or falls from heights saturation must be avoided Neuromuscular blockade Present a challenge to the managing team in terms of Examine the chest: - Intravenous lines should be set up; administer Bolus mannitol (1 g/kg) priority of medical intervention - Tension pneumothorax? Haemothorax? Flail chest? crystalloids - See Meningitis - If the priorities are not well ordered the results can be Chest tube decompression? Asses the GCS and the state of the pupils Head up tilt at 30 degrees catastrophic - Always obtain a chest radiograph before Expose the patient to perform a quick general Controlled hypothermia Difficult to outline clinical features for these patients decompression if possible examination but avoid hypothermia. Surgery in TBI as virtually any injury is possible - Perform arterial blood gas estimations Secondary Survey: Often indicated in head injury for the evacuation of Treatment objectives Circulation: (See section on multiple injuries) intracranial haematomas or elevation of depressed skull Identify life threatening injuries and treat - Check the pulse, blood pressure, capillary refill Secondary brain injury fractures Identify all injuries, institute primary management - Listen to the heart sounds Neuronal injury that is not present at the time of the Indications may depend on the centre and the and limit progress of injuries and further tissue damage - Apply electrocardiograph leads primary insult but develops in response to subsequent neurosurgeon, but all agree that an intracranial Restore patient's physiology paying special attention - Set up an intravenous line with a large bore cannula intracranial or extracranial events haematoma causing significant mass effect should be to the triad ofhypothermia , acidosis and coagulopathy size 14 or 16 FG Extracranial causes: removed Format a prioritized plan of definitive treatment and - Collect blood for investigations: ABGs, FBC, Hypoxia A midline shift of more than 5 mm is considered rehabilitation electrolytes and urea, grouping and cross matching; Hypotension significant Management pregnancy tests Seizures Indications for surgery will depend on: Advanced trauma life support (ATLS) principles - Focused Assessment using Sonography in Trauma Hyperthermia - The neurological status of the patient should apply (FAST) Hyponatraemia - Findings on CT Patient should be received by a trauma team Disability and Neurology Hypernatraemia - Extent of intracranial injury consisting of at least : - Assess patient's level of consciousness using the Hypoglycaemia - Intracranial pressure. - Atrauma team leader Glasgow coma scale Hyperglycaemia The procedures include: - An airway and a procedure doctor - Check the state of the pupils and their reaction to light Intracranial causes: Burr holes - Two nurses in similar capacity - Expose the patient to perform a quick general Extradural haematoma Craniotomy - Aradiographer examination but prevent hypothermia Subdural haematoma Craniectomy - Ascrub nurse - Cover with warm blanket or put on artificial warmer if Intracerebral haematoma Elevation of depressed skull fractures - Asocial worker available Cerebral oedema Drugs in TBI It is important that hospitals which regularly manage - Record core temperature Cerebral contusion Diuretics to reduce intracranial pressure e.g. mannitol trauma patients should maintain a standing trauma team The trauma series of radiographs is part of the primary Hydrocephalus (see Meningitis) on a 24- hour basis survey. These are Meningitis Sedatives e.g. diazepam (see Tetanus) - This helps to optimize outcomes in patient - A-Pchest view Brain abscess Muscle relaxants e.g. diazepam, suxamethonium management - A-Ppelvic view CT scan in TBI Anticonvulsants e.g. phenytoin, phenobarbital (see Prehospital information - Lateral cervical view Has revolutionalized the management of traumatic Epilepsy) The trauma team needs this information from the - (In the above order) brain injury as it can readily diagnose intracranial Antibiotics as appropriate prehospital team

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Secondary survey urethrocystogram to confirm urethral rupture CHAPTER 16: SURGICAL CARE AND Metabolic disorders: This is a total body examination to detect injuries - If not contraindicated pass an indwelling urethral ASSOCIATED DISORDERS - Diabetes mellitus sustained catheter to monitor urinary output and tissue perfusion - Porphyria Involves obtaining theAMPLE history (allergies, - Haematuria is suggestive of bladder or kidney injury ACUTEABDOMEN Haematologic conditions: medications, past medical history, pregnancy, last Perform a vaginal examination, checking for bleeding Introduction - Sickle cell disease meal, environment including details of the accident) and lacerations An abdominal condition of sudden onset requiring - Leukaemia Head: Lower limb examination: immediate (urgent) attention Infections and infestations: - Check for scalp haematomas, lacerations, skull - Check for obvious lacerations, deformity, fractures Acommon surgical emergency - Lower lobe pneumonia fractures, CSF leaks (rhinorrhoea, otorhoea); facial and dislocations Aetiology - Gastroenteritis fractures, raccoon eyes - Undertake an appropriate neurovascular assessment Surgical: - Malaria - Remove contact lenses; examine pupils, oral - Assess muscle power in each limb Inflammatory/infective conditions: - Parasitic infestations examination; Battle sign Upper limb examination: - Acute appendicitis: the commonest cause of acute Clinical features Neck: - Same as for lower limb abdomen Acute abdominal pain - Perform a careful neck examination 'LOG ROLL' - Acute salpingitis: a common cause in sexually active Note the following: - Leave in collar if there is a high index of suspicion for - The patient is now log rolled by four persons so as to young females - Location cervical injury examine the back - Acute cholecystitis - Onset and progression Chest: - The spine is examined from the occiput to the coccyx - Acute pancreatitis - Nature and character - Inspect for dyspnoea, tachypnoea, chest movements, checking for deformity, swellings, steppings, and - Acute diverticulitis: not very common in this - Aggravating and relieving factors flail chest, open pneumothorax or obvious penetration tenderness environment - Abdominal distension - Palpate for chest expansion, crepitus (subcutaneous - While still in this position perform a digital rectal These conditions usually begin with a localized - Apast history of similar pain suggests complication of emphysema) and rib fractures examination to assess anal tone, presence of blood in the peritonitis which progresses to generalized peritonitis if an underlying condition - Assess position of the trachea and determine any rectum and the position of the prostate left untreated. - In typhoid perforation, fever precedes abdominal tracheal shift - Ahigh riding prostate is suggestive of urethral rupture Perforation of hollow viscera: pain, while the reverse is true for acute appendicitis - Determine percussion notes in both lung fields (dull - Return patient to the supine position - Perforated chronic duodenal ulcer Nausea and vomiting: in haemothorax and hyperresonant in pneumothorax) Neurological examination: - Perforated typhoid ileitis: a common cause in this - Afrequent finding - Auscultate for breath sounds and air entry - Perform a detailed neurological examination as environment - Common in intestinal obstruction Abdomen: indicated - Traumatic gastrointestinal perforation Altered bowel habits - Examination findings often unreliable in the multiply The trauma team should now note all the observed - Perforated gastrointestinal malignancies - Diarrhoea may suggest an infective/inflammatory injured patient injuries and format a plan for: Intestinal obstruction: condition - This may be as a result of altered sensorium due to - The further management of the patient - Strangulated external and internal hernias - Constipation occurs in intestinal obstruction and late head injury, inebriation or drugs, neurological injury, or - Removal from the emergency department and - Intussusception in peritonitis distracting injury - Definitive management of the patient under the - Peritoneal adhesions and bands (congenital or - The presence or absence of blood, mucus in stool - There is need to augment examination with bedside appropriate surgical units and consultants acquired) should be ascertained investigations like FAST and DPL (Diagnostic - Gastrointestinal tumours Fever: Peritoneal Lavage) if indicated Intra-abdominal haemorrhage - An early feature in inflammatory/infective conditions - In the haemodynamically stable patient the best - Trauma (injury to solid viscera e.g. spleen and liver) - Alate feature in most other causes of acute abdomen imaging modality is the CT scan with contrast - Ruptured abdominal aortic aneurysm Gynaecologic history: -Inspect for seat belt marks, lacerations, abdominal - Haemorrhage from tumours (e.g. primary liver cell - In every female, the following should be ascertained contour and movements with respiration carcinoma) - Last menstrual period: this will help in the suspicion -Palpate for tenderness, rebound tenderness and Obstruction to urinary/biliary tract: of ectopic gestation and bleeding Graffian follicle rigidity These usually present as colics due to stones - Vaginaldischarge: salpingitis -Percuss if indicated - Ureteric colic Urinary symptoms: -Auscultate for bowel sounds - Biliary colic - Ascertain the presence or absence of the following - Pass a nasogastric tube Gynaecologic (outside those listed above) - Pain on micturition Pelvis: - Bleeding Graffian follicle - Pus in urine or cloudy urine - Perform anteroposterior and lateral compression tests - Twisted ovarian cyst - Urethral discharge to check for pelvic fractures - Ectopic pregnancy - Loin pain - If fracture is suspected, apply a pelvic girdle or pelvic - Salpingitis Past medical history: sheet to decrease pelvic volume, improve tamponade - Degenerating fibroids - Diabetes mellitus and decrease pelvic haemorrhage Non-specific abdominal pain: - Sickle cell disease Examine the perineum: - Includes a variety of conditions that do not come Physical examination: - Check for perineal bruising, bogginess, scrotal under the above causes General examination haematomas, and blood at the tip of the penis Medical: - Dehydration - If there is blood at the tip of the penis it is inadvisable These should always be borne in mind so as to avoid - Temperature (the exact temperature should be taken to pass a urethral catheter: a partial urethral rupture may unnecessary surgery with a thermometer: oral, axillary or rectal temperature) be converted to a complete rupture. Do an - Pallor

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- Jaundice - May identify injured solid organ in trauma - Central venous pressure - Many surgeons prefer to give at the time of induction - Foetor (as in diabetic ketoacidosis etc.) Diagnostic peritoneal lavage: - Pulmonary capillary wedge pressure of anaesthesia Haemodynamic status: - Useful in abdominal trauma to identify - Urine output, volume, colour Should be repeated intraoperatively if the surgery lasts - Pulse rate: >100/minute is abnormal haemoperitoneum and leakage of gastrointestinal - Hydration status for >3 hours - Blood pressure: <100 mmHg systolic and <60 mmHg contents and secretions of other organs into the - Skin turgor Not more than 2 - 3 doses (not longer than 24 hours) diastolic pressures indicate hypotension in an adult peritoneal cavity - Sensorium should be given after surgery Chest: Biochemical tests: Ascertain level of consciousness Antibiotics should be reinstituted if infection occurs - Examine carefully for evidence of chest infection - Urinalysis: test the urine for sugar, protein, ketones, Evidence of adequate resuscitation Choice of antibiotics Abdomen: etc - Pulse rate begins to fall towards, or below 100 Should depend on the known prevalent bacteria in the - Distension - Random blood sugar to exclude diabetes mellitus beats/minute part of the body - Presence of scars of previous surgery or bruising in - Serum electrolytes and urea; correction may be needed - Blood pressure: begins to towards normal Broad spectrum antibiotics are preferred trauma - Serum amylase to exclude acute pancreatitis - Urine output: 50 - 100mL/hr (1 - 2 mL/kg/hr); clear or Combination of antibiotics (with synergistic actions) is - Visible peristalsis (suggests intestinal obstruction) Haematological tests: amber preferred to a single antibiotic - General peritonitis: there may be no movement with - Haemogram to exclude anaemia Definitive treatment Should be used only when scientific evidence shows respiration - Packed cell volume may not be reliable because of Surgical conditions: benefit Ascertain the site of tenderness haemoconcentration from dehydration Most of the surgical conditions will require urgent Indications for antibiotic prophylaxis Localized: - If there is suspicion of sickle cell disease, the laparotomy after adequate resuscitation Where endogenous contamination is expected - Right iliac fossa (appendicitis, gynaecologic haemoglobin genotype should be obtained - Evacuation of pus, blood and all infected material (breaching of hollow organs): conditions etc.) - A complete blood count may show evidence of acute - Meticulous examination of all organs and recesses Oesophageal surgery - Right hypochondrium (cholecystitis) infection (leucocytosis, neutrophilia) - Identify primary pathology Hepatobiliary surgery Generalised: varied causes - Blood should be grouped, and compatible blood - Identify other associated/coexisting pathology Colorectal surgery As much as possible any palpable mass should be cross-matched and made ready - Treat identified pathologies on their merits Urinary tract surgery and procedures characterized Other investigations: - Cleanse peritoneal cavity with large volumes of warm Vaginaland uterine surgery If tenderness is not too marked, ascertain the presence - Computed tomography may be needed when there is sodium chloride 0.9% Patients with valvular heart disease of free fluid in the peritoneal cavity by shifting dullness diagnostic confusion Medical conditions: Use of prostheses and implants or fluid thrill (ascites) - Cultures: any suspicious fluid and materials should be Consult a physician as appropriate, to treat the Orthopaedic implants Listen for bowel sounds obtained and sent for microbiology and culture (e.g. condition accordingly Neurosurgical implants - Diminished or absent in peritonitis; exaggerated in vaginal discharge, peritoneal fluid) Prognosis Patients with cardiac prostheses early stages of intestinal obstruction Differential diagnoses Outcome and survival depends on: Other prostheses Rectal examination: Follow a detailed evaluation (as above) and make a Early presentation and diagnosis Immunocompromised patients: - Look for perianal soilage reasonable (probable) list of not more than 3 - 5 Prompt and adequate resuscitation before surgery HIV/AIDS - Presence or absence of faeces in rectum differential diagnoses Appropriate and meticulous surgery and other Diabetes mellitus - Palpate rectovesical pouch or rectouterine pouch (of General measures treatments as indicated Cancer; patients on cytotoxic chemotherapy Douglas) for bogginess and tenderness indicating a Resuscitation Patients on steroids pelvic collection of pus or blood Rehydration and correction of electrolyte Severely malnourished patients Examine the faeces on the examining finger for blood, derangements ANTIMICROBIALPROPHYLAXIS IN SURGERY Others: mucus Correct shock by giving crystalloids (sodium chloride Introduction Patients with peripheral vascular disease undergoing Vaginalexamination: 0.9%, Ringer's lactate) or colloid (e.g. dextran) Postoperative surgical site infection (wound infection) surgery on that limb - May be necessary to exclude gynaecological Maintenance fluids are calculated based on degree of is a rather common, but undesirable occurence in this Complications conditions dehydration environment Antibiotic misuse Investigations Correct electrolyte deficits (especially potassium) Surgical site infection tends to increase postoperative Antibiotic resistance Plain radiography Nasogastric decompression: the largest possible size of morbidity and may lead to mortality Complications of antibiotics (e.g. pseudomembranous Abdomen: tube for patient Efforts therefore need to be made to prevent surgical colitis) - Supine and upright films to identify features of Aspirate intermittently using low pressure suction or site infection False sense of surgical security intestinal obstruction (dilated bowel loops and multiple large syringe Antibiotic prophylaxis is not a substitute for adherence Antibiotic prophylaxis should be effective and efficient fluid levels) Urethral catheterization (to monitor urine output) to basic principles of surgical asepsis and meticulous - A radio-opaque shadow may be seen in the region of Correct anaemia (by blood transfusion) attention to technical details the urinary tract in ureteric colic Commence broad spectrum, intravenous antibiotics Objective of antibiotic prophylaxis Chest: effective against likely microorganisms To prevent postoperative infection in susceptible INTESTINALOBSTRUCTION - An upright film may identify gas under the diaphragm - Do not give aminoglycosides until urine output is patients Introduction in gastrointestinal perforation adequate Principles of antibiotic prophylaxis A condition in which there is failure of onward - Chest infection should also be looked for Monitor the following parameters to ensure adequate Should be used only where there is a high risk of propulsion of intestinal contents Abdomino-pelvic ultrasonography: rehydration: bacterial contamination Acommon surgical emergency Should help to ascertain the cause of pain in a proportion - Cardio-respiratory stability Intravenous route is preferred to achieve optimum Aetiology of the patients (e.g. cholecystitis, gynaecologic - Pulse rate effect Mechanical (dynamic): conditions, urinary calculi, and degenerating masses) - Blood pressure Should be given not >2 hours before surgical incision Extra-luminal (compression from outside the intestinal wall)

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- Strangulated external hernias (e.g. inguinal hernia), Vomiting: usually bilious and occurs early in small Haematological: adequate preoperative assessment internal hernias intestinal obstruction - Haemogram In the emergency situation, all efforts must be made to - Volvulus - Alate symptom in large intestinal obstruction - Complete blood count (leucocytosis and neutrophilia ensure that the patient can withstand anaesthesia and the - Peritoneal adhesions and bands - May be faeculent in advanced obstruction suggest strangulation) surgical procedure - Intra-abdominal masses (e.g. lymph nodes, tumours) Constipation: occurs early in large intestinal obstruction - Group and cross match blood and store appropriately Occasionally (e.g. with severe on-going haemorrhage, Intramural (due to causes within the wall of the and late in small intestinal obstruction Ultrasonography airway obstruction) resuscitation, anaesthesia and intestine): Obstipation (non-passage of faeces or flatus) signifies - Useful in intussusception, suspected intra-abdominal surgery may commence simultaneously - Intussusception complete obstruction tumours Objectives of preoperative evaluation - Intestinal atresia and stenosis Stools may be blood-stained (intussusception, Laparoscopy: To detect any fluid and electrolyte derangements - Strictures volvulus, strangulation) - May be helpful in some instances to identify the cause To detect any haematological derangements (e.g. - Hirschsprung's disease Diarrhoea: may be present in the face of obstruction of obstruction anaemia, bleeding diathesis, sickle cell disease) - Intestinal tumours (spurious diarrhoea) In difficult cases, other investigations may be necessary To detect any coexisting medical conditions that may Intraluminal (due to causes within the lumen of the Fever: signifies strangulation or perforation depending on the presentation and clinical suspicion adversely affect the outcome of anaesthesia and surgery intestine): Signs: - Avoid contrast studies (as much as possible) in acute - All patients scheduled to have surgery should be in a - Impacted faeces General: intestinal obstruction haemodynamically stable condition before surgery - Impacted worms (e.g. ascaris lumbricoides) Dehydration General measures The above may not always be possible, but efforts must - Foreign bodies Pyrexia Resuscitate: be made to improve cardiopulmonary and renal function - Pedunculated polyps Pallor - Rehydrate and correct electrolyte deficits (especially Correct any detected abnormality Non-mechanical (adynamic, paralytic ileus): Cardiorespiratory: assess the following potassium) Patient evaluation and correction of abnormalities may Electrolyte derangements - Lung fields - Nasogastric decompression using a wide bore need to be done in conjunction with others: the - Hypokalaemia - Pulse rate nasogastric tube anaesthetist, physician, paediatrician etc Septicaemia (especially in neonates and infants) - Blood pressure Urethral catheterization to monitor urine output Clinical evaluation Diabetes mellitus Abdomen: Broad-spectrum intravenous antibiotics (anaerobes, Efforts should be made to identify the following by Other metabolic conditions e.g. uraemia - Distension: usually marked in large intestinal gram negatives, gram positives) history and physical examination: Pathophysiology obstruction Correct anaemia by blood transfusion Cardiopulmonary disorders: Simple obstruction - Visible peristalsis Definitive treatment Cough Only the intestinal lumen is affected; there is no - Tenderness Should only be embarked upon after adequate Chest infection evidence of strangulation - Tympanitic percussion notes resuscitation Bronchial asthma Strangulated obstruction - Bowel sounds: increased, diminished or absent Mechanical obstruction Chronic obstructive airways disease Vascular compromise has occurred and may progress Rectal examination Most of the causes will require laparotomy Hypertension to gangrene and/or perforation - Perianal soilage Treat identified cause on its merits: Cardiac failure Closed loop obstruction - Empty or full rectum Gangrenous or perforated bowel: resect Metabolic disorders: Asegment of intestine is blocked at 2 ends (e.g. colonic - Any palpable mass Small intestine: Diabetes mellitus obstruction with competent ileocaecal valve, intestinal - Examine finger for faeces, blood, mucus Re-anastomose if patient is fit Haematologic disorders: volvulus) Complications Bring ends out as stomas if patient is too ill Sickle cell disease - Dangerous because the risk of perforation is high Fluid and electrolyte derangements (especially Large intestine: Allergy: Irrespective of the cause or type of obstruction, the hypokalaemia) Re-anastomose if on right side Drug allergies (e.g. penicillins, talc, elastoplast, symptoms, signs and physiologic consequences are the Intestinal gangrene Bring ends out as stomas if on left side antiseptics etc.) result of the following Intestinal perforation Evacuate any peritoneal collection Drug history: - Stasis proximal to the level of obstruction (gases, fluid) Peritonitis Suspicious lesions: take specimens for histopathology Propranolol, diuretics, steroids and other hormonal - Dilatation above level of obstruction Septicaemia and septic shock Non-mechanical (adynamic) obstruction agents; prednisolone, oral contraceptives; tricyclic - Increased secretion from the involved segment(s) Investigations Treat accordingly antidepressants - Compression of the veins and later arteries leading to Plain radiographs Surgery is not required Social habits: ischaemia, gangrene, necrosis and perforation - Abdomen Cigarette smoking, alcohol use The end results are: Supine: Previous anaesthetic experience: - Dehydration Dilated bowel loops How long ago, type of anaesthesia - Electrolyte derangements Should identify affected bowel (jejunum, ileum, large PREOPERATIVE EVALUATION and Investigations - Anaemia intestine) POSTOPERATIVE CARE Cardiopulmonary: - Peritonitis Upright (erect): Chest radiograph: especially for patients 60 years and - Septicaemia Multiple fluid levels Preoperative Evaluation above, and those with chest infection Clinical features - Chest Introduction - Look for evidence of chest infection and cardiomegaly Symptoms: To identify gas under diaphragm (suggests perforation) The assessment of a patient before surgery to ensure Electrocardiogram: especially for patients over 60 Colicky abdominal pain: not a prominent symptom in and chest infection that the patient is in optimal physiologic state and fitness years and those with heart disease or hypertension adynamic obstruction Biochemical tests; for the surgical procedure Pulmonary function tests may be necessary in patients Abdominal distension - Electrolytes and urea Amost important aspect of the care of a surgical patient with obstructive airways disease - Blood Glucose No elective operation should be carried out without an Metabolic:

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Urine sugar to exclude diabetes mellitus Any associated medical condition should be treated / effects of anaesthesia Choose an appropriate fluid to provide enough calories - All adults and patients with history suggestive of controlled before embarking on surgery The cardiopulmonary status (pulse rate, blood pressure, and electrolytes diabetes mellitus - This should be done in conjunction with the physician respiration) needs to be monitored very closely (every 15 Glucose 5% in sodium chloride 0.9% or lactated Ringer's Serum Electrolytes and Urea as much as possible minutes) in order to promptly detect any abnormality solution is appropriate for most adults Haematologic: Patients who require nutritional rehabilitation Where available, electronic monitors with an alarm After the 48 hours, the daily requirement of potassium Haemogram/packed cell volume - If surgery is elective reschedule it, and give adequate system should be used should be provided if oral intake is still prohibited, Haemoglobin genotype time to achieve improved nutritional status, otherwise Airways management especially if nasogastric drainage is ongoing Clotting profile (prothrombin time and kaolin cephalin morbidity and mortality may be increased The patient may still be under some effect of anaesthesia - This should be in form of potassium chloride added to clotting time) where there is suspicion of bleeding High- risk patients: - Airways need to be kept patent intravenous fluids diathesis e.g. in jaundiced patients - At high risk of developing postoperative complications Prevent the tongue from falling backwards by positioning Assess fluid and electrolyte balance on a daily basis and Others: - Deliberate and meticulous efforts should always be patient in the left lateral position correct deficits Other investigations as may be indicated by individual made to adequately evaluate them and ensure optimal The neck should be prevented from falling on itself as All intake (intravenous fluids, drugs, blood etc.) and clinical circumstances fitness for surgery this can occlude the airway output (urine, nasogastric drainage, other tubes, etc.) as Correction of abnormalities and preparation for - Elderly patients (age >60 years): - risk of deep vein Secretions should also be cleared using a low-pressure well as insensible losses should be carefully recorded surgery thrombosis, atelectasis suction Nutrition Cardiopulmonary: - Obesity- risk of deep vein thrombosis, atelectasis Nursing position Following major surgery, adequate nutrition should be Rehydrate patient adequately, using appropriate fluids - Cancer-risk of deep vein thrombosis, atelectasis, Different operations require specific positioning in the provided for the patient, particularly if oral intake is going Control blood pressure haemorrhage postoperative period to reduce venous pressures, keep to be prohibited for more than 48 - 72 hours Treat/control chest infections with appropriate - Women on oral contraceptive pills-risk of deep vein airways patent, enhance drainage etc - This can be done in the form of parenteral nutrition antibiotics thrombosis The surgeon should be conversant with the specific Chest physiotherapy Control obstructive airways disease - Co-existing chronic medical conditions-risk of wide positions and give appropriate instructions Bed-ridden patients and patients who have had chest or Metabolic conditions and derangements: ranging complications Analgesia upper abdominal surgery are prone to basal atelectasis and Correct electrolyte deficits, especially hypokalaemia - Sickle cell anaemia-risk of sickling crises, deep vein Pain is a most undesirable effect of surgery hypostatic pneumonia. Acidosis is usually corrected by adequate rehydration thrombosis Patients should not be allowed to suffer from pain unduly - These should be prevented by appropriate chest (provided the patient has no renal disease) Consent for surgery The appropriate analgesic technique should be chosen physiotherapy Diabetes should be controlled Details of the surgery should always be explained to the for the nature of surgical procedure performed - Ensure adequate analgesia to enhance chest excursion - Patients already controlled will need their therapy to be patient (or relatives) in very simple language before Adequate analgesia will ensure early ambulation and - Encourage coughing and expectoration, with a hand converted to soluble insulin for long surgical procedures surgery help to limit atelectasis supporting any abdominal wound (this should be done in conjuction with the physician and Should include a mention of the possible/common Minor/moderate surgery - Periodic chest percussion to loosen bronchial secretions anaesthetist) complications Patient taking orally: - Ambulate as early as possible Haematological: A signed consent should be obtained, in the presence of Paracetamol Mobilization and ambulation Correct anaemia a witness (usually a nurse) Non steroidal antiinflammatory drugs Mobilize and ambulate patients as early as is practicable - Cause(s) of anaemia should be identified and treated Obtaining consent should be done by the surgeon himself Patient not taking orally: to avoid the complications of prolonged recumbency - The minimum haemogram for a patient undergoing Injectable nonsteroidal antiinflammatory drugs (e.g. Ambulation should be gradual: prop up in bed, sit out of elective surgery should be 10 g/dL diclofenac sodium) bed, short walks etc.) - Haemogram 6 - 9 g/dL: correction may be achieved by Postoperative Care Major surgery: Early ambulation should help prevent hypostatic haematinics; reschedule surgery Introduction Parenteral analgesics pneumonia and deep vein thrombosis (very important in - Haemogram <6 g/dL: correction may require blood Meticulous and efficient care in the postoperative - Narcotic analgesics (e.g. morphine) obese and elderly patients) transfusion period is paramount for adequate patient recovery and - NSAIDs (e.g. diclofenac sodium) Antibiotics - Emergency surgery: correct anaemia by blood success of surgery Nasogastric decompression Appropriate antibiotics as indicated transfusion A well-planned and supervised postoperative care The stomach may need to be kept decompressed for 24 - Irrational or indiscriminate use is not to be encouraged Blood transfusion should be avoided as much as ensures a smooth recovery, and helps to prevent or limit 48 hours, particularly following gastrointestinal surgery Wound care practicable. postoperative morbidity and mortality Decompression prevents abdominal distension and Specific surgical wounds are cared for in different ways - Patient with sickle cell anaemia: haemogram should be Preoperative, intraoperative and postoperative care is a tension on abdominal fascial closure Clean surgeries: do not open wound (unless indicated) brought up to 8 g/dL continuum and interlinked It also prevents splinting of the diaphragm and atelectasis until day 5 - 7 - These patients must be adequately hydrated to avoid - Many of the instructions and therapy started in the The widest possible bore of nasogastric tube for patient's Inspect wounds immediately if there are features sickling and sludging within the bloodstream preoperative period may need to be continued into the age should be chosen suggestive of surgical site (wound) infection - Short day case procedure: imperative to admit the postoperative period The nasogastric tube should be removed as soon as it is no - Undue pain patient with sickle cell anaemia at least a day before The surgeon himself must be involved in the longer needed, evidenced by: - Undue swelling surgery to achieve adequate hydration postoperative care and not leave it to others, who may not - Progressively diminishing effluent (<500 mL/24 hours - Discharge of serosanguinous fluid or pus Suspected bleeding diathesis have much ideas or information about the surgery in an adult) Infected wounds: - Intramuscular vitamin K (10 mg daily), at least 48 - 72 Initial recovery - Change from bilious colour to clear colour of gastric Wound swab for microbiological culture and sensitivity hours before surgery Close monitoring and observation: juice tests - For major surgery, blood should be grouped, cross- The first 4 - 6 hours after a major surgery and general Fluid and electrolyte balance Adequate local wound care matched and stored anaesthesia are critical Ensure that the patient receives adequate amounts of Appropriate antibiotics Other disorders: - The patient is still drowsy and recovering from the intravenous fluids if oral intake is prohibited If there are systemic features (e.g. fever, anorexia)

187 188 Chapter 16: Surgical Care and Associated Disorders Standard Treatment Guidelines for Nigeria 2008 systemic treatment with antibiotics may be necessary Complications - Appropriate for patients undergoing laparotomy or CHAPTER 17: PAEDIATRIC PERSPECTIVES Care of indwelling tubes, catheters and drains Early complications: thoracotomy for haemorrhage into these cavities (e.g. All indwelling catheters, tubes and drains should be Immune reactions traumatic haemothorax, splenic injury, ectopic gestation) monitored and appropriately managed to avoid infection, ABO incompatibility - The blood is collected in an appropriate blood bag and MEASLES (Rubeola) dislodgement/displacement Rhesus incompatibility then transfused using a blood giving set with filter Introduction They should be removed as soon as they have served Febrile reactions - Special salvage equipment may be available sometimes An acute viral infection caused by an RNA virus of the their purpose(s) Allergic reactions - Contaminated blood must not be transfused genus Morbillivirus in the family Paramyxoviridae General complications in the post-operative period Reactions to plasma proteins Contraindications to autologous transfusion - Only one serotype is known Look out for general complications and treat accordingly Biochemical complications: Pregnancy Endemic through out the world Postoperative pyrexia may be due to: Hyperkalaemia Chronic medical conditions 30 - 40 million cases and 745,000 deaths for the year - Malaria Citrate toxicity (hypocalcaemia) Cancer 2001 - Atelectasis and hypostatic pneumonia Haemoglobinaemia Situations where the blood may have become - 50 - 60% of estimated deaths due to vaccine- - Wound infection Infective complications: contaminated (this is for intraoperative blood salvage) preventable diseases - Urinary tract infection Bacteraemia Children: Also a major cause of preventable blindness - Deep vein thrombosis Transfusion of parasites (e.g. malaria) Other sources of blood Transmission is by droplet infection during the - Wound infection Transfusion of viruses (HIV,Hepatitis B, C, D) Umbilical cord blood prodromal stage Physical complications: Alternatives to blood transfusion Incubation period: 9 - 11 days Volumeoverload Since blood transfusion is attended by several untoward Time of exposure to appearance of rash: about 14 days Air embolism effects and complications, efforts are continuously being Clinical features Hypothermia made to identify alternatives to transfusion The essential lesion is found on the skin, mucous USE OF BLOOD TRANSFUSION IN SURGERY Complications of massive blood transfusion - Most of these are experimental at the moment and are membranes of the nasopharynx, bronchi, intestinal tract Introduction Massive transfusion refers to the single transfusion of not practicable in the clinical setting and conjunctivae Blood transfusion is the introduction of whole blood or 50 - 100% of the equivalent of an individual's blood Three stages: blood components into the blood stream of an individual volume in less than 24 hours Incubation period Should be used appropriately because its use is not - 2.5 - 5 litres in adults and 40 - 80 mL/kg body weight in Prodromal stage with an enanthem without complications and untoward effects children Final stage Blood and its commonly used components: The complications are related to: Incubation period: Whole blood Volumeoverload Mild fever; 10 - 11 days Packed red cells Transfusion of old blood Prodromal stage: Fresh frozen plasma Electrolyte derangements (especially potassium and 3 - 5 days Clotting factor concentrates calcium) Low grade to moderate fever Platelet concentrate Transmission of infections Dry cough Basic principles of blood transfusion: Delayed complications: Coryza Appropriate use Haemosiderosis Conjunctivitis Adequate evaluation before transfusion to ascertain the Post transfusion purpura Koplik spots indication, amount and component required Autologous transfusion Photophobia Screening for communicable diseases (HIV, hepatitis, Transfusion of the patients' own blood Final stage: etc.) before transfusion Advantages Temperature rises abruptly as the rash appears Adequate grouping and cross-matching before Reduced risk of transmitting communicable diseases Rash begins from the upper lateral part of the neck, transfusion Overcomes the problem of shortage of blood behind the ears, along the hairline and posterior parts of Store under at appropriate temperature Types and methods the cheek then spreads to the rest of the body Use blood fractions whenever possible to avoid wastage Pre-deposit blood Rash fades in the same pattern in 3 - 4 days Use autologous blood whenever possible to minimize - Usually best done in conjunction with haematology Associated lymphadenopathy risk of transfusing communicable diseases staff Differential diagnoses Transfusion is not a substitute for meticulous and - The patient donates one unit of blood at a time (e.g. Rubella appropriate surgical techniques weekly) several weeks before the elective surgery Roseola infantum Indications for blood transfusion - Following donation, the patient is given haematinics, Infections from Echovirus, Coxsackie Virus and To replace lost blood volume and sometimes erythropoietin to enhance bone marrow Adenovirus - Haemorrhage from trauma and other forms of blood function; the blood is stored for later use Infectious mononucleosis loss Pre-operative isovolaemic haemodilution Toxoplasmosis - Operative haemorrhage - Just before elective surgery,1-2units of blood are Meningococcaemia To improve oxygen carrying capacity taken from the patient and replaced by volume expanders Scarlet fever - Varioustypes of anaemias such as Ringer's lactate, sodium chloride 0.9%, or colloid Rickettsial diseases To replace clotting factors - The blood taken is transfused intraoperatively after all Kawasaki disease - Some liver diseases haemostasis has been secured Serum sickness - Deficiency states Intraoperative blood salvage Drug rashes

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Complications POLIOMYELITIS Progresses to paralysis Pulmonary embolism Diarrhoea Introduction - Location of paralysis depends on region affected Paralysis of limbs, muscles of respiration and swallowing Otitis media An acute infectious disease of humans (particularly Abnormal sensation which can be fatal Pneumonia children) caused by any of three serotypes of poliovirus Hyperaesthesia Investigations Laryngo-tracheobronchitis P1, P2, and P3 Difficulty in initiating micturition Viral isolation from stool, pharynx or cerebrospinal fluid Encephalitis Immunity to one serotype does not confer immunity to Constipation If the virus is isolated from a person with acute flaccid Seizures others Bloated abdomen paralysis, it must be tested further, using fingerprinting or Blindness Occurs in many regions of the developing world Dysphagia genomic sequencing to determine if it is the wild type or Subacute sclerosing panencephalitis The global polio eradication initiative was launched in Muscle spasms vaccine type Investigations 1988 Drooling Serology: a fourfold rise in antibody may be Isolation of the virus by tissue culture - In 15 years, the number of cases has fallen by 99% and Dyspnoea demonstrated ELISA: first IgM and later IgG response the number of infected countries reduced from 125 to 7 Irritability Cerebrospinal fluid examination: Demonstration of Warthin Finkeldy giant cells in - There was an increase in global cases as a result of an Positive Babinski's sign - Raised white cell count, 10 - 200 cells/mm3 (primarily smears of the nasal mucosa epidemic in India, and increase in cases in Nigeria Complications lymphocytes) Full Blood Count: low white blood cell count with Pathogenesis Multiple intestinal erosions - Mild increase in protein: 40 - 50 mg/mL relative lymphocytosis Entry into mouth (via faecally-contaminated Acute gastric dilatation Treatment objectives Lumbar puncture: increase in CSF protein; and small food/water) Hypertension Allay fear increase in lymphocytes, normal glucose level Replication in pharynx, gastrointestinal tract, local Hypercalcaemia Minimize ensuing skeletal deformities Treatment objectives lymphatics Nephrocalcinosis Anticipate and treat complications Relieve symptoms Haematologic spread to lymphatics and central nervous Vascularlesions Prepare the child and family for a prolonged management Hydrate adequately system Myocarditis of permanent disability if it seems likely Treat secondary bacterial infection Viral spread along nerve fibres Pulmonary oedema Non-drug treatment Prevent complications Destruction of motor neurons Pulmonary embolism Bed rest Non-drug treatment Clinical features Paralysis of limbs, muscles of respiration and Avoidance of exertion Humidification of the room for those with croup Incubation period: 6 - 20 days, with a range of 3 - 35 swallowing which can be fatal Application of hot packs Protection from strong light for those with days Differential diagnoses Lying on a firm bed photophobia Asymptomatic infection: 95% Guillain- Barré syndrome Hospitalization for those with paralytic disease Nutrition Minor non-specific symptoms: 4 - 8% Lead toxicity Suitable body alignment to avoid excessive skeletal Fluids Symptoms occur in less than 2 % Cranial nerve Herpes zoster deformity Drug treatment - Slight fever Post-diphtheric neuropathy Active and passive motions as soon as pain disappears No specific drugs - Headache Arthropod borne viral encephalitis Manual compression of the bladder Some children require supplemental vitaminA - Malaise Rabies Adequate dietary and fluid intake - 100,000 IU stat for age 6 months - 1 year - Sore throat Tetanus Review by orthopaedist and psychiatrist - 200,000 IU stat for age above 1year - Vomiting Botulism Gravity drainage of accumulated secretions - Repeat on days 2 and 14 for those with ophthalmologic Non-paralytic polio (1-2%) Encephalomyelitis: demyelinating type Tracheostomy in case of vocal cord paralysis evidence of vitaminAdeficiency - Symptoms last 1- 2 weeks Neoplasms in and around the spinal cord Drug treatment Specific treatment of complications Moderate fever Familial periodic paralysis Bethanicol 5 - 10 mg orallyor 2.5 - 5 mg subcutaneously Notable adverse drug reactions Headache Myasthenia gravis for bladder paralysis VitaminAmay cause features of pseudotumour cerebri Vomiting Acute porphyrias Analgesics - Nausea, vomiting, drowsiness, bulging fontanelle, Diarrhoea Hysteria and malingering - Avoid opiates if there is impairment of ventilation diplopia, papilloedema and cranial nerve palsies Fatigue Conditions causing pseudoparalysis Treat urinary tract infecton with appropriate antibiotics Prevention Irritability Unrecognized trauma Prevention Isolation precaution from the 5th day of exposure until Pain or stiffness of the back, arms, legs, abdomen Transient toxic synovitis Hygienic practices 5days after appearance of the rash Muscle tenderness and spasms in any part of the body Acute osteomyelitis - To prevent / limit contamination of food and water by Measles vaccine at 9 months Neck pain and stiffness Acute rheumatic fever the virus - Vaccine may be given at 6 months for measles post- Skin rash Scurvy Vaccination exposure, and in outbreak prophylaxis Paralytic polio Congenital syphilis: pseudoparalysis of Parrot - The only effective method of prevention Post-exposure prophylaxis 3 types depending on the level of involvement Complications Oral Polio Vaccine - Passive immunization with immune globulin within 6 - Spinal polio: 79% Multiple intestinal erosions Given at: days of exposure - Bulbar polio: 2% Acute gastric dilatation Birth - Bulbospinal: polio 19% Hypertension 6 weeks Fever 5 - 7 days before other symptoms Hypercalcaemia 10 weeks Headache Nephrocalcinosis 14 weeks Stiff neck and back Vascular lesions - Highly effective Assymmetric muscle weakness Myocarditis - 50% immune after 1 dose Rapid onset Pulmonary oedema - >95% immune after 3 doses

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- Confers herd immunity the United States, but it is more prevalent in developing Inadequate intake Iron panel - Immunity probably life long countries. Measles infection - Useful because iron deficiency can affect the - Limits spread of wild polio virus Among the first signs of vitaminAdeficiency (VAD)are: Increased risk of deficiency in: metabolism of vitaminA Inactivated Polio Vaccine Abnormal dark adaptation Fat malabsorption Serum albumin Given at: Dry skin and dry hair Cystic fibrosis - Levels are indirect measures of levels of vitaminA 2 months Broken fingernails Tropical sprue Full Blood Count with differentials 4 months Decreased resistance to infections Pancreatic insufficiency - If anaemia, infection, or sepsis is a possibility 12 months Epidemiology Inflammatory bowel disease Serum electrolytes - Highly effective An estimated 250 million children in developing Cholestasis Liver function tests - >90% immune after 2 doses countries are at risk for vitamin deficiency syndromes Small bowel bypass surgery - To evaluate nutritional status - >99% immune after 3 doses The most widely affected group includes up to 10 Vegans Radiographs of the long bones - Duration of immunity not known with certainty million malnourished children who develop Refugees - To evaluate bone growth and excessive deposition of Notable adverse drug reactions, caution and xerophthalmia and have an increased risk of Recent immigrants periosteal bone contraindications complications and death from measles Alcoholism Clinical testing for dark-adaptation threshold Oral polio vaccine: Each year 250,000 - 500,000 children become blind Toddlers and pre-school children living below the Treatment objectives - Paralytic poliomyelitis because of VAD poverty line Reduce morbidity - Should not be administered to persons who are Improving the vitaminAstatus of children (aged 6 - 59 Clinical features Prevent complications immunocompromised (it is a live vaccine) months) with deficiencies can reduce rates of death from VAD may be asymptomatic Treat complications Contra indicated in : measles by 50%; from diarrhoea by 33%, and from of all Increased risk of respiratory and diarrhoeal infections Non-drug treatment - Persons with history of severe allergic reaction to a causes of mortality by 23% Decreased growth rate Eat foods rich in vitaminA vaccine component or following prior dose Pathophysiology Retarded bone development - Liver - Moderate or severe acute illness VitaminAdeficiency may be secondary to: Increased fatigue as a manifestation of VAD anaemia - Beef Inactivated vaccine may be used in Decreased ingestion Bitot spots - Chicken immunocompromised persons Defective absorption and altered metabolism Poor dark adaptation (nyctalopia) - Eggs - It may (rarely) cause local reactions Increased requirements Dry skin - Whole milk; fortified milk An adult liver can store up to a year's reserve of vitamin Dry hair - Carrots A, whereas a child's liver may have enough stores to last Pruritus - Mangoes only several weeks Broken fingernails - Orange fruits VITAMINADEFICIENCY Serum retinol concentration reflects an individual's Keratomalacia - Sweet potatoes Introduction vitaminAstatus Xerophthalmia - Spinach Vitamin A was the first fat-soluble vitamin to be Because serum retinol is homeostatically controlled, Follicular hyperkeratosis (phrynoderma) from blockage - Green vegetables discovered its levels do not drop until the body's stores are of hair follicles with plugs of keratin At least 5 servings of fruits and vegetables per day is It comprises a family of compounds called the retinoids significantly limited Excessive deposition of periosteal bone secondary to recommended to provide a comprehensive distribution of In nature, the active retinoids occur in 3 forms The serum concentration of retinol is affected by several reduced osteoclastic activity carotenoids - Alcohol (retinol), aldehyde (retinal or retinaldehyde) factors: Anaemia Drug treatment and acid (retinoic acid) - Synthesis of Retinol Binding Protein in the liver Keratinization of mucous membranes Daily oral supplements of vitaminA In the human body, retinol is the predominant form, - Infection Differential diagnoses Child: and 11-cis-retinol is the active form - Nutritional status Cataract Less than, or 3 years Retinol-binding protein (RBP) binds vitamin A and - Adequate levels of other nutrients such as zinc and Refractive errors - 600 microgram (2,000 IU) orally once daily regulates its absorption and metabolism iron Zinc deficiency 4 - 8 years VitaminAis essential for: Recommended DailyAllowance Complications - 900 microgram (3,000 IU) orally once daily Vision (especially dark adaptation) Infant (1 year or younger) Blindness 9 - 13 years Immune response - 375 micrograms Corneal ulceration - 1,700 microgram (5,665 IU) orally once daily Epithelial cell growth and repair Child 1 - 3 years Investigations 14 - 18 years Bone growth - 400 micrograms Serum retinol - 2,800 microgram (9,335 IU) orally once daily Reproduction Child 4 - 6 years - Costly but is a direct measure Adult: all ages 3,000 microgram (10,000 IU) orally once Maintenance of the surface linings of the eyes - 500 micrograms - A value of less than 0.7 mg/L in children younger than daily Epithelial integrity of respiratory, urinary, and intestinal Child 7 - 10 years 12 years is considered low Severe disease tracts - 700 micrograms Serum RBP - 60,000 microgram (200,000 IU) orally for a minimum Embryonic development All males older than 10 years - Easier and less expensive to perform than retinol of 2 days Regulation of adult genes - 1000 micrograms - Less accurate because levels are affected by serum - Has been shown to reduce child mortality rates by 35 - It functions as an activator of gene expression by All females older than 10 years protein concentrations; types of RBP cannot be 70% retinoid alpha-receptor transcription factor and ligand- - 800 micrograms differentiated Notable adverse drug reactions, caution dependent transcription factor Aetiology Serum zinc Risk of teratogenicity increases in pregnant women at Deficiency of vitamin A is found among malnourished Malnutrition - Useful because zinc deficiency interferes with RBP doses >800 micrograms/day (not recommended at these children, the elderly, and chronically ill populations in - The commonest cause of VAD in this part of the world production doses)

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Contraindicated in CHAPTER 18: EMERGENCIES repeated every 8 hours as necessary Inflammatory, infiltrative, neoplastic and degenerative - Documented hypersensitivity 12 - 18 years: 20 - 40 mg every 8 hours; higher doses may processes - Hypervitaminosis A be necessary in resistant cases Fluids and electrolyte imbalances Parenteral vitamin A in infants of low birth weight may ACUTE LEFT VENTRICULAR FAILURE Angiotensin converting enzyme inhibitors Drugs and other substances of abuse be associated with: Introduction - Captopril Sudden infant death syndrome Thrombocytopenia Sudden diminution in the function of the left ventricle Adult: 6.25 - 12.5 mg daily orally, then 25 mg in divided Miscellaneous Renal dysfunction Pulmonary capillary and venous pressure increase doses daily (maximum 150 mg daily) for maintenance Clinical features Hepatomegaly beyond plasma oncotic pressure Child: not licensed for use in children Usually sudden collapse Cholestasis There is resultant accumulation of oedema fluid in the Or: Unrecordable blood pressure Ascites pulmonary interstitial spaces and alveoli - Lisinopril Loss of peripheral pulses Hypotension Aetiology Adult: 2.5 mg orally daily; 5 - 20 mg daily for Cessation of respiration Metabolic acidosis (E-Ferol syndrome) Insipient left ventricular failure secondary to maintenance May be asymptomatic Prevention hypertension Child: neonate, initially 10 micrograms/kg orally once Complaints may be non-specific Eat foods rich in vitaminA, in adequate amounts Arhythmias daily; monitor blood pressure carefully for 1 - 2 hours, Presentation may be that of underlying cause Family and community health education Myocardial infarction increased as necessary up to 500 micrograms/kg daily in Differential diagnoses Clinical features 1 - 3 divided doses Syncope Dyspnoea 1 month - 12 years: initially 100 micrograms/kg orally Seizures Orthoponea once daily, monitor blood pressure carefully for1-2 Complications Paroxysmal nocturnal dyspnoea hours, increased as necessary up to a maximum of 1 Death Cough mg/kg daily in 1 - 2 divided doses Sequelae involving the vital organs Heamoptysis 12 - 18 years: initially 2.5 mg daily, monitor blood - Acute renal failure Restlessness pressure carefully for1-2hours; usual maintenance dose - Myocardial infarction Wheezes 10 - 20 mg daily in 1 - 2 divided doses (maximum 40 mg - Cerebrovascular accident Hypoxia daily if body weight is >50 kg) Investigations (after the initial rapid assessment and Differential diagnoses May require morphine resuscitation) Pulmonary thromboembolism Adult: 5 - 10 mg orally, subcutaneously or Electrocardiography Bronchial asthma intramuscularly (usually a single initial dose) Echocardiography Pulmonary tuberculosis Child: not listed for this indication Urea, Electrolytes and Creatinine Cardiac tamponade Digoxin Lipid profile Complications Adult: 125 - 250 micrograms orally daily may be required Blood gases Right-sided heart failure Aminophylline Chest radiograph Acute renal failure Adult: up to 250 mg by slow intravenous injection stat Treatment objectives Myocardial infarction Supportive measures Prompt restoration of cardiac and respiratory function Investigations Oxygen Monitoring of impact of cardiac arrest on the various Electrocardiography Nurse in cardiac position associated organs Plain chest radiograph Notable adverse drug reactions, caution and Intervention to restore normal functions Echocardiography contraindications Formulation of a broader and more comprehensive Cardiac catheterization Use ACE inhibitors, and aminophylline and digoxin diagnostic and treatment plan Pulmonary function tests with caution Eliminate/control aetiological factor(s) in order to Arterial blood gasses - Monitor potassium levels closely reduce morbidity/prevent mortality Electrolyte, Urea and Creatinine - Monitor fluid input and output Non- drug treatment Treatment objectives Prevention Ensure clear airway by tilting the head backwards, lifting To improve pump performance of the failing ventricle Adequate control of hypertension the chin and exploring to remove foreign bodies/dentures To reduce the cardiac workload Remove wears/ornaments which may negate the above To control salt and water retention Basic life support (CPR) Non-drug treatment CARDIAC ARREST Ensure that patient is lying on a firm/hard surface As in hypertension Introduction Cardiac massage (80 - 100 per minute) Drug treatment Sudden cessation of cardiac pump function Assisted ventilation using a masked ambu bag Diuretics If there is no spontaneous reversal or resuscitatory - Twice in succession for every 15 cardiac massages - Furosemide measure, death results (once every 5th massage when 2 people are in attendance) Adult: 40 - 80 mg by slow intravenous injection stat Commonest cause of cardiovascular deaths among - Watch out for spontaneous respiration during this - Then 40 - 160 mg orally or intravenously daily in 1or 2 caucasions exercise divided doses for maintenance Peaks between ages 0 - 6 months and 45 - 75 years Advanced life support Child: neonate, 0.5 - 1 mg/kg by slow intravenous Aetiology Intubation with an endotracheal tube injection every 12 - 24 hours (every 24 hours if post- Congenital and acquired structural defects of the heart Defibrillation/cardioversion for patients with menstrual age is under 31 weeks) Abnormal electrical activities of the heart ventricular fibrillation/ventricular tachycardia 1 month - 12 years: 0.5 - 1 mg/kg (maximum 4 mg/kg),

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- Defibrillate with 200 J shock. Additional shock up to of the alveoli, resulting in right-to-left shunting of un- Treat cerebral oedema The measures are aimed at: 360 J may be required oxygenated blood - Hyperventilation Promoting potassium loss Epinephrine (adrenaline) 1mg intravenously after Absorption of hypertonic salt water results in alveolar - Intravenous mannitol (1 - 2 g/kg every 4 hours) Limiting exogenous potassium intake failed defibrillation oedema, but the overall effects are the same for both Appropriate management of pulmonary oedema Discontinuation of anti-kaliuretic drugs Repeat defibrillation inhalation of fresh and salt water Prevention Shifting potassium into cells Insert intravenous line Infection may develop subsequently and is more likely Teach the unskilled to stay away from water Drug treatment Monitor arterial blood gases when contaminated water is inhaled Teach persons not to swim beyond skill level Calcium gluconate Drug treatment Clinical features Parental/caregiver supervision of children - 10 ml of 10% solution intravenously over 2 - 3 minutes Sodium bicarbonate If alive, patient is unconscious and not breathing Diving only under suitable conditions Insulin plus glucose infusion - 1 milliequivalent/kg Hypoxemia and tissue hypoxia Education/public awareness - 10 - 20 units of regular insulin plus 25 - 50 g of glucose - Additional 50% of this dose every 10 to 15 minutes as Acidosis Isolation fences around outdoor pools, and locked doors given as 10 units in 100 ml of 50% glucose deemed clinically appropriate Hypothermia for indoor pools Other alternatives to cause influx of potassium: Lidocaine 1 mg/kg intravenously if there is unstable Pneumonia Locked safety covers for spas and hot tubs Sodium bicarbonate (134mmoles/L) if there is metabolic cardiac electrical activity. Repeat as required Acute renal failure acidosis Other antiarhythmic drugs if necessary Hemolysis - See CardiacAarrest For cardiac arrest secondary to bradyarrhythmias or Complications of near-drowning ELECTROLYTE ABNORMALITIES Or: asystole: Hypoxic brain injury with cerebral oedema (which may Introduction Parenteral/nebulised salbutamol (see Bronchial asthma) Continue CPR occur within 24 hours) Detection of deranged electrolytes and fluid balance Removal of potassium with diuretics (loop plus thiazide Insert intravenous line Cardiac arrhythmias does not constitute a diagnosis diuretics in combination) Prevention Dehydration Efforts should be made to determine the underlying Sodium polysterene sulphonate (a cation exchange Family and community basic support education Acute Respiratory Distress Syndrome (ARDS) causes in every case resin) Acute renal failure Hyperkalaemia - Administered as a retention enema of 50 g of resin and Disseminated Intravascular Coagulopathy Plasma K concentration > 5 mmoles/L 50 ml of 70% sorbitol mixed in 150 ml of tap water DROWNINGAND NEAR-DROWNING Investigations Aetiology Haemodialysis Introduction Full Blood Count; ESR Usually occurs as a result of potassium release from - The most rapid and effective way of lowering plasma Refers to death by suffocation due to immersion in Chest radiograph cells potassium concentration water Electrolytes, Urea and Creatinine Decreased renal excretion of K as in renal failure - Reserved for patients in renal failure and those with May be classified as “wet”- where the victim has Liver function tests Decreased potassium secretion: severe hyperkalaemia unresponsive to more conservative inhaled water or “dry”- a less common condition, but one Acid base status evaluation Impaired sodium reabsorption in measures that involves the closing of the airway due to spasms Arterial blood gases - Primary hypoaldosteronism induced by water Skull and spine radiographs - Adrenal insufficiency Hypernatraemia Wet drowning could occur by either fresh or salt water CT Scan (if available) - Secondary hypoaldosteronism Introduction Drowning typically accounts for a small but significant Treatment objectives - Medications such as ACE inhibitors, NSAIDs and Defined as plasma sodium > 145 mmoles/Litre percentage of accidental deaths Immediate resuscitation and stabilization to prevent or heparin Majority of cases result from water loss in the absence of Near-drowning episodes refer to instances where minimize complications Enhanced chloride reabsorption (chloride shunt) as seen sodium loss, when the thirst mechanism is impaired, or rescue was successful and death prevented Non-drug measures in Gordon's syndrome (infrequently) due to primary sodium gain Near-drowning can be associated with considerable Airway management Clinical features Clinical features disability e.g. head injury, paralysis, and respiratory Immobilize the cervical spine, as trauma may be Weakness, flaccid paralysis, metabolic acidosis Mainly neurologic: complications present ECG changes Altered mental status Contributory factors Treat hypothermia vigorously - Increased T wave amplitude Weakness Swimming in deep waters Endotracheal intubation with mechanical ventilation - Peaked T waves Neuromuscular irritability Falling unexpectedly into water and Positive End-Expiratory Pressure if patient is apneic - Prolonged PR intervals, QRS duration Focal neurological deficits Not being able to swim or in severe respiratory distress or has oxygen-resistant - Atrioventricular conduction delays Occasionally coma and seizures Breath-holding swimming and diving hypoxemia - Loss of Pwaves As in hyponatraemia severity of the clinical features are Alcohol consumption Admission for observation for at least 24 hours if any of - Ventricularfibrillation or asystole related to the rapidity of onset and the magnitude of the High water temperatures the complications are observed even if briefly Investigations rise in plasma sodium concentration Easy, illicit access to pools Drug treatment Serum Urea, Electrolytes and Creatinine Treatment objectives Inadequate pool and spa covers Ventilatewith 100% oxygen Other renal function tests Correct water deficit Muscle cramps or epileptic attacks developing during Establish an intravenous infusion with 0.9% saline or Acid base balance Stop on-going water loss swimming lactated Ringer's solution Treatment objectives Calculation of water deficit Manage pulmonary complications with the Correction of hyperkalaemia Deficit=-Xor (Plasma Na+ 140)/140 0.5(males) 0.4 administration of 100% oxygen initially, titrated Preservation of cardiac function (females)X body weight in kg Pathophysiology thereafter reviewing arterial blood gases Treatment of underlying cause(s) Water replacement in glomerulo nephropathy Inhalation of water results in ventilation-perfusion Bronchodilators if bronchospasm is present Management Mineralocorticoid excess (primary deficit should be imbalance with hypoxaemia and pulmonary oedema Manage metabolic acidosis: give NaHCO3 if pH is Depends on the degree of hyperkalaemia, associated corrected slowly over 48 - 72 hours to prevent cerebral Absorption of hypotonic fresh water results in collapse persistently less than 7.2 physical features and ECG changes oedema

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Water replacement can be given by mouth or status Mild hyponatraemia with ECF volume contraction: Treatment objectives nasogastric tube Intravenous potassium (given in an infusion) Sodium releption with isotonic saline infusion Prompt but gradual reduction in mean arterial pressure - Glucose 5% injection is also suitable for water - Do not exceed 20 mmoles/L Hyponatraemia associated oedematous states: by not more than 25% within the first 2 hours replacement, being a hypotonic fluid Calculation of potassium requirement Restriction of both sodium and water intake Further reduction of BPto (not less than) 160/100 mmHg Deficit body weight (kg) 0.3 Promotion of water loss in excess of sodium by use of a within 2 to 6 hours Hypokalaemia - Add daily requirement of potassium and correct over 3 loop diuretic - Lower pressures may be indicated for patients with Introduction days For severe cases which are symptomatic (plasma sodium aortic dissection Plasma potassium less than 3.5 mmol/Litre Caution concentration <115 mmoles/L): Initiate/re-initiate long term therapy to normotensive Mostly associated with increase in potassium loss Oral potassium supplements should be taken in an Hypertonic saline to raise sodium concentration by 1 - 2 levels Increased renal loss: erect position or sitting upright and with plenty of water mmol/L/hour for the first 3 hours, but not more than 12 Drug treatment Diuretics and salt-waste and secondary to avoid oesophageal erosions mmoles/Lduring the first 24 hours Sodium niprusside hyperaldosteronism Hyponatraemia Calculation of the total amount of sodium to administer - 0.3 micrograms/kg/min intravenously initially, 0.5 - 6 Increased distal delivery of non-reabsorbable anions Plasma Na+ < 135mmol/L Amount of sodium = (desired concentration -- actual micrograms/kg/min maintenance (maximum of 6 (vomiting, DKA, renal tubular acidosis) Different types with varied aetiologies concentration) X body weight X 0.6 micrograms/kg/min) Amphotericin B Pseudo-hyponatraemia: Notable adverse drug reactions, caution Cushing’s syndrome, Bartter's syndrome With normal plasma osmolality as seen in Stop infusion if response is unsatisfactory after 10 Increased non-renal loss: hyperlipidaemia or hyper-proteinaemia HYPERTENSIVE EMERGENCIES minutes at maximum dose GIT loss (diarrhoea, integumentary sweat) With increased plasma osmolality as seen in Introduction Lower doses in patients already on anti-hypertensives Redistribution into cells: hyperglycaemia, infusion of mannitol Severely elevated blood pressure (>200/120 mmHg) with Hypotension may occur Metabolic alkalosis Hypo-osmolar hyponatraemia: evidence of target organ damage such as: Monitor blood cyanide and thiocyanate concentrations Drugs Due to a primary water gain and secondary sodium Neurologic (e.g. altered consciousness) Discontinue if adverse drug reaction to metabolites Insulin loss, or a primary sodium loss and secondary water gain Cardiovascular (myocardial ischeamia, left ventricular develop: tachycardia, sweating, hyperventilation, β adrenergic agonists Integumentary loss: sweating, burns failure) arrhythmias, acidosis) α adrenergic antagonists Loss from the GIT: vomiting, tube drainage, fistula Renal deterioration Reduce infusion over 15 - 30 minutes to avoid rebound Decreased intake: Renal loss: diuretics, hypoaldosteronism, salt wasting Fundoscopic abnormalities effect when stopping therapy Starvation neuropathy, obstructive diuresis Presentations include: Use sodium nitroprusside with caution in ischaemic Clinical features Primary polydypsia Aortic dissection heart disease, renal impairment, raised intracranial - Vary between patients and depend on the level of Cardiac failure Hypertensive encephalopathy pressure and impaired pulmonary function potassium loss Hepatic cirrhosis Eclampsia Serum K <3mmoles/Litre: Nephritic syndrome Malignant hypertension Fatigue Decreased solute intake: Aetiology HYPOGLYCEMIA Myalgia SIADH Improperly managed hypertension Introduction Weakness of the lower extremities Glucocorticoid deficiency Renal vascular disease Blood glucose level less than 2.5 mmol/L(45 mg/dL) More severe hypokalaemia results in Hypothyroidism Pheochromocytoma May occur in a fasting state or may be post-prandial - Progressive weakness Chronic renal insufficiency Accelerated essential hypertension Aetiology - Hypoventilation Clinical features Clinical features Most commonly iatrogenic - Complete paralysis Cerebral oedema Severely elevated blood pressure (>200/120mmHg) Antidiabetic drugs ECG changes are due to ventricular depolarisation and May be asymptomatic Headaches, malaise, vomiting, dizziness, blurred vision, Associated with quinine, salicylates and sulphonamide do not correlate with the plasma potassium levels Otherwise nausea, malaise, headache, lethargy, chest pain, palpitations, dyspnoea, oliguria use - Flattening/inversion of the T wave confusion, and altered consciousness Fundoscopic changes After overnight fast - Aprominent U wave Coma when plasma sodium is less than 120 millimoles Evidence of left ventricular failure Missed meal(s) - ST segment depression per litre Changes in level of consciousness During exercise - Prolonged QT interval Differential diagnoses Complications Can be due to intensive insulin therapy - Severe depletion results in prolonged PR interval Congestive cardiac failure Target organ damage May follow weight loss - Decreased voltage and widening of the QRS complex Hepatic cirrhosis Cerebrovascular accident May follow alcohol ingestion Investigations Nephritic syndrome Myocardial infarction Reduced insulin clearance Electrocardiography Investigations Cardiac failure Sepsis Electrolytes, Urea and Creatinine Directed at establishing the cause and severity of Renal failure Secondary to non-ß cell tumours/insulinoma Acid-base status hyponatraemia Death Clinical features Identifying the underlying disease Treatment objectives Investigations The two types are neuroglycopenic and neurogenic Treatment objectives To correct plasma sodium concentration by restricting Plain chest radiograph Neurogenic manifestations: Correction of potassium deficit water intake and promoting water loss Echocardiography Palpitations Minimize/stop on-going loss To correct the underlying disorder Full Blood Count Tremors Drug treatment (oral route preferred) Management Urea, Electrolytes and Creatinine Anxiety Potassium chloride Mild asymptomatic hyponatraemia requires no Urinalysis Sweating - Doses depend on deficits, on-going losses and renal treatment Echocardiography Hunger

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Paresthesia CO2 retention and respiratory depression due to Other tests to identify precipitating factors Practitioners are advised to seek advice from experts, Neuroglycopenic manifestations: decreased cerebral blood flow Management standard texts in medicine and toxicology, in the absence Confusion Differential diagnoses Requires intensive monitoring of a Poison Information Centre Fatigue Coma due to CNS depressants Supportive care Principles of management of poisoning Seizures Adrenal insufficiency Identification and treatment of precipitating cause(s) Verify, validate or confirm all of the events related to the Loss of consciousness Morbid depression Treatment objectives poisoning

Death Complications Reduction in T3 synthesis/action and restoration to Take good clinical history Diagnosis Cardiac failure normal values - Information from relatives, friends, emergency services The Whipples's triad provides a framework for diagnosis Respiratory failure Treatment of identified precipitating factors personnel may be very useful especially where the patient of hypoglycaemia: Death Prevention of complications is unwilling or unable to provide useful information Symptoms of hypoglycaemia Investigations Drug treatment Emergency stabilization

Low plasma glucose concentration (<2.5 mmole/L) T34, , T TSH assay Propylthiouracil Quick clinical evaluation Alleviation of hypoglycemic symptoms after glucose Treatment objectives Adult: 600 mg loading dose; 200 - 300 mg orally every 6 Elimination of the poison or decontamination administration To restore normal body metabolism hours by nasogastric tube or per rectum Enhancing systemic clearance Differential diagnoses To prevent death Child 5 - 12 years: Initially 50 mg orally 3 times daily Administration of antidotes Other causes of acute confusional state Drug treatment until euthyroid then adjusted as necessary Supportive measures Investigations Triiodothyronine 12 - 18 years: initially 100 mg 3 times daily administered Observation Random blood sugar on presentation - 20 micrograms intravenously stat, then 20 micrograms until euthyroid then adjusted as necessary; higher doses Disposition Other tests to confirm the cause of hypoglycaemia every 8 hours until there is sustained clinical sometimes required Emergency stabilization Treatment objectives improvement Saturated Solution of Potassium Iodide (SSKI) Life-saving measures take priority over all other Prompt restoration of normal blood glucose level May also require hydrocortisone 100 mg intravenously Adult: 5 drops every 6 hours; to be commenced 1 hour decontamination techniques Prevention of rebound or recurrent hypoglycaemia every 8 hours after the first dose of propylthiouracil The followingABC approach is recommended: Prevention of occurrence of neural damage or death Maintain therapy with oral thyroxine in a dose of 50 Child 1 month - 1 year: 0.2 - 0.3 mLorally 3 times daily AAEstablish a clear irway Treatment micrograms per day - Dilute well with milk and water BBEnsure adequate reathing and ventilation Urgent treatment must be given if irreversible Treat precipitating factor(s) Propranolol CCEnsure adequate irculation complications are to be avoided Precaution Adult: 40 - 60 mg orally every 4 hours or 2 mg DDAddress rug-induced depression of the Oral glucose tablets or glucose drinks if tolerated (and Patients should not be re-warmed rapidly because of intravenously every 4 hours central nervous and respiratory systems if patient is conscious) risk of cardiac arrhythmias Child: neonate, initially 250 - 500 micrograms/kg every 6 EECorrect any lectrolyte and metabolic If there is neuroglycopaenia preventing the use of oral - 8 hours, adjusted according to response abnormalities glucose, give 50% glucose (dextrose) 1 month - 18 years: initially 250 - 500 micrograms/kg Clinical evaluation - 50 ml/25 g in double dilution intravenously followed THYROID STORM (THYROTOXIC CRISIS) every 6 - 8 hours, adjusted according to response; doses Aquick clinical evaluation should be carried to: by 5 - 10% glucose (dextrose) for at least 48 hours in Rare but life-threatening up to 1 mg/kg may be required; maximum 40 mg every 8 Obtain a good history of the drug ingestion/exposure hypoglycaemia secondary to sulphonylurea therapy Mortality rate is up to 30% even with treatment hours - Amount, time, etc Intravenous glucagon 1mg stat (give subcutaneously Causes of death include cardiac failure, arrythmias and Dexamethasone - Circumstances surrounding the event (from the patient, or intramuscularly if intravenous route is impractical) hyperthermia - 2 mg intravenously every 6 hours relations and other eyewitnesses) Supportive measures Precipitants include the following: Antibiotics (if infection is present) The patient may have no symptoms when seen early in Discontinue or reduce the dosage of causative drugs Infections Supportive measures the course of the poisoning Treat identified underlying cause(s) Trauma Adequate hydration with intravenous fluids and cooling A thorough physical examination may further provide Precaution Surgery clues on the drug class causing toxicity e.g pinpoint pupils Glucagon is not effective in glycogen-depleted Stroke with opioid overdose individuals e.g. those with alcohol induced- Diabetic ketoacidosis - The absence of a significant sign does not negate the hypoglycaemia Radio iodine treatment of patients with partially treated POISONING diagnosis or untreated hyperthyroidism Introduction Clinical laboratory patient data e.g. urine drug screens Clinical features The ingestion by, or exposure of a patient to excessive - Useful in patients with coma of unknown aetiology MYXOEDEMACOMA Fever doses of a medicine or other substances may cause harm Elimination of poisons (or Decontamination) Introduction Diarrhoea This may be: The removal of the offending substance from the patient Alife-threatening complication of hypothyroidism Vomiting Self poisoning (may be suicidal) The presumption is that both the dose and duration of Follows a background of long-standing Jaundice Accidental exposure are determinants of toxicity, and limiting hypothyroidism Seizures Homicidal continued exposure is beneficial Clinical features Coma Clinical presentation Remove the patient from the toxic environment May be precipitated by exposure to cold, infection, Complications Determined (amongst others) by: Provide fresh air and oxygen (respiratory trauma and CNS suppressants Cardiac failure Type of drug decontamination) Coma with extreme hypothermia, temperatures 24 - Arrythmias Inherent toxicity Flushing the areas (e.g. skin and eyes) with large 32o C Hyperthermias Dose and duration following exposure volumes of fluid to remove the toxic substance Seizures Investigations Concurrent therapy Gastrointestinal decontamination: Areflexia Thyroid function tests Co-existing disease states etc Emesis or lavage to evacuate the gastric contents This guideline provides only a brief overview.

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Administer activated charcoal as an absorbent to bind Haemorrhage the respiratory centre, incomplete oxidative CNS neurons the toxic substance in the gastrointestinal tract Hypoglycaemia phosphorylation and increased rate of metabolism Clinical features Use cathartics or whole bowel irrigation to increase the Cerebral oedema Clinical features Mainly CNS depression occuring within 30 minutes of rectal elimination of unabsorbed drugs Death Initial manifestations (occur 3 - 6 hours after an overdose acute overdose A combination of the above methods may be used. These symptoms are maximal in 3 - 4 days of >150 mg/kg): Respiratory depression Enhancing systemic clearance Poor prognostic indices: Vomiting Coma, especially when benzodiazepines are combined Clearance of the toxic substances may be enhanced by: Encephalopathy or hepatic failure Sweating with other CNS depressants Manipulation of urine pH Greater than two fold prolongation of Prothrombin Tachycardia Paradoxical excitement may occur early in the course of Haemodialysis time Hyperventilation poisoning Haemo perfusion Serum bilirubin > 68 micromol/L(4 mg/dL) Tinnitus Treatment objectives Antidotes Serum creatinine > 3.3 Fever As for paracetamol poisoning An antidote is a drug that antagonizes the toxicity of Chronic poisoning is usually similar but alcoholics may Lethargy Non-drug treatment another substance in a specific manner present with a syndrome of severe combined hepatic and Confusion Respiratory support Examples: renal insufficiency Respiratory alkalosis Drug treatment - Naloxone for opioids Investigations Impaired renal function Activated charcoal: method of choice for gastrointestinal - N-acetylcysteine for paracetamol LFTs including prothrombin time and serum proteins Increased anion gap decontamination Looked out for, and address the peculiarities related to Urea, Electrolytes and Creatinine. Metabolic acidosis may result - See Paracetamol poisoning specific poisonings Blood sugar estimation Severe poisoning: Flumazenil, a competitive benzodiazepine receptor - Important where multiple drugs are involved Blood levels of paracetamol (where facility is available) Coma antagonist, can reverse CNS and respiratory depression The pattern of poisoning is influenced by age and Laboratory evidence of hepatotoxicity includes: Respiratory depression - Give 0.1 mg intravenously at 1 minute intervals until gender Prolongation of prothrombin time Seizures desired effect is achieved Common substances causing poisoning in the Nigeria Elevation of serum bilirubin and transaminase activity Cardiovascular collapse Notable adverse drug reactions include (but are not limited to): Renal function may also be impaired Cerebral and pulmonary oedema Flumazenil with tricyclic antidepressants can cause Pharmaceuticals Treatment objectives Investigations seizures - Analgesics, hypnosedatives, antidepressants, alcohol To prevent or reduce damage to organs FBC, ESR Activated charcoal colours stools black Petroleum distillates To restore normal metabolic functions Electrolytes, Urea and serum Creatinine Prevention of Drug Poisoning Industrial chemicals Drug treatment Random Blood Glucose - Keep all medicine out of reach when not needed Agrochemicals Activated charcoal, especially within 4 hours of LFTs including prothrombin time - Label all medicines appropriately Household products ingestion Blood aspirin levels - Kerosene poisoning prevention Natural toxins Adult: 50 g orally, repeated if necessary Treatment objectives Keep kerosene and other hydrocarbons away from Toiletries Child: under 12 years, 25 g (50g in severe poisoning) As for paracetamol poisoning children Acetylcysteine Non-drug treatment Use dedicate on tenants kerosene and other hydrocarbon SPECIFIC POISONS Adult and child: initially 50 mg/kg by intravenous Gastric lavage and whole bowel irrigation Co-poison prevention Paracetamol infusion over 15 minutes, then 50 mg/kg over 4 hours and Drug treatment (1) Keep working generator safely away from explosions Toxicity often occurs following an acute ingestion then 100 mg/kg over 16 hours Activated charcoal can be used up to 12 - 24 hours after (2) Do not run mobile engine/vehicles within explosions (within 24 hours) of =10 - 15 g (20 - 30 tablets) or 150 - Diluted 3:1 with a non-alcoholic, non-dairy beverage ingestion (see Paracetamol poisoning) (3) Enact and enforce laws for safe engine/generator mg/kg - Loading dose is 140 mg/kg; maintenance dose 70 Intravenous infusion of sodium chloride 0.9% purchasing and use

It could also in conditions with enhanced P450 enzyme mg/kg every 4 hours for 17 doses (preferably with glucose) activity (e.g. on-going use of anticonvulsants, - Treatment is effective if started within 8 - 10 hours - To correct dehydration and produce brisk urine flow Carbon monoxide poisoning rifampicin) Alternatively: (saline diuresis) Usually due to inhalation of smoke, car or generator Less often hepatotoxicity occurs following chronic Methionine Supplemental oxygen exhaust fumes caused by incomplete combustion in a ingestion of therapeutic or slightly greater amounts in Adult and child over 6 years: 2.5 g orally followed by a Supplemental glucose confined space conditions with decreased gluthatione reserve further dose of 2.5 g every 4 hours Intravenous vitamin K 10 mg daily for coagulopathy Carbon monoxide binds to haemoglobin, myoglobin

- Acute starvation Child under 6 years: initially 1 g followed by 3 further Intravenous NaHCO3 to alkalinize urine (see Cardiac and to mitochondria, inhibiting cellular respiration - Alcoholism doses of 1g every 4 hours Arrest for administration) Toxic effects of carbon monoxide are related to hypoxia - Childhood Supportive measures Correction of other electrolyte derangements Clinical features - Chronic malnutrition As for all cases of acute poisonings Haemodialysis for severe salicylate poisoning Dyspnoea Clinical features Notable adverse drug reactions, caution and Indications for haemodialysis Tachypnoea Early manifestations are non-nspecific and also non- contraindications Severe clinical toxicity Headache predictive of subsequent hepatotoxicity. They include: Acetylcysteine may cause nausea, vomiting and Aspirin (acetylsalicylic acid) levels = 7 mmol/L (100 Emotional lability Nausea and vomiting epigastric discomfort. Antiemetics (metoclopramide) mg/dL) Confusion Excessive sweating may be required Contraindications, failure of other treatment modalities Impaired judgement Onset of hepatotoxicity is heralded by right upper Methionine may cause nausea, vomiting, drowsiness, Clumsiness quandrant tenderness and hepatomegaly irritability Benzodiazepines Syncope Features of liver damage include: Aspirin: Most commonly involves diaazepam and bromazepam Nausea, vomiting and diarrhoea may occur Encephalopathy Toxic doses are associated with increased sensitivity of These drugs potentiate the inhibitory effect of GABAon Cardiovascular manifestations:

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Ischaemic chest pain, arrhythmias, heart failure and Glucocorticoids are ineffective severity of poisoning, every 5 - 10 minutes until the skin CHAPTER 19: THERAPEUTICS hypotension becomes flushed and dry, pupils dilate and tachycardia In severe poisoning: Organophosphate/insecticide poisoning develops Cerebral oedema Introduction - Effective for muscarinic symptoms Pulmonary oedema These substances irreversibly inhibit Plus: PRESCRIPTION WRITING Respiratory depression acetylcholinesterase and cause accumulation of Pralidoxine Introduction Coma may be seen in severe poisoning acetylcholine at muscarinic and nicotinic synapses and in - Diluted to 10 - 15 mL with water for injection and The writing of a prescription is the culmination of a Cherry-red colour of skin and mucus the CNS administered by slow intravenous injection over 5 - 10 clinical encounter with a patient Rarely cyanosis Organophosphates are absorbed through the skin, lungs, minutes The decision to issue a prescription follows a complex Investigations and gastrointestinal tract and are distributed widely in Adult: 1-2g;canberepeated in 30 minutes process of professional analysis and must be based on the To identify complications and establish a diagnosis tissues Child: initially 30 mg/kg, then either 30 mg/kg every 4 following considerations: - Full Blood Count and ESR Elimination is slow- by hepatic metabolism hours or by intravenous infusion, 8 - 10 mg/kg/hour Knowledge of the patient's clinical state - Serum Urea, Electrolytes and Creatinine Clinical features (usual maximum 12 g in 24 hours) Factors likely to influence the drug's pharmacokinetics - Liver function tests Onset from exposure to toxicity is between 30 minutes - Treat seizures with intravenous diazepam 10 mg stat and pharmacodynamics; the efficacy, safety and cost of - Acid-base status 2 hours the drug - Blood gases Muscarinic effects: Rational prescribing entails the following process with Non-drug treatment Nausea various steps: Remove from carbon monoxide exposure; move to Vomiting Step 1: fresh air Abdominal cramps - Define the patient's problem Drug treatment Increased urinary frequency; urinary and fecal Step 2: Oxygen administration - face mask in conscious incontinence - Specify the therapeutic objectives patients and endotracheal intubation in comatose Increased bronchial secretions Step 3: patients after clearing the airways Cough - Verify whether your proposed treatment is suitable for Treat hypotension and arrhythmia Dyspnoea this patient Mannitol Sweating Step 4: - 10 - 20%; 250 mL intravenously over 30 minutes. Salivation - Start the treatment Repeat every 8 hours Miosis Issuing a prescription is not conclusive treatment. Two Blurred vision further steps must be considered: Kerosene poisoning Lacrimation Step 5: Similar to poisoning by other petroleum distillates Bradycardia, hypotension, and pulmonary oedema may - Give information, instructions and warnings Petroleum distillate hydrocarbons are poorly absorbed occur Step 6: following ingestion but can be aspirated, causing Nicotinic effects: - Monitor (and/or stop) the treatment significant toxicity to the airways Twitching Details of this process will be found in the WHO's “Guide More common in children Weakness to Good Prescribing” Clinical features Hypertension Aprescription order should specify: CNS excitation in low doses; depression in high doses Tachycardia What is to be administered Rarely coma and seizures Paralysis in severe cases To whom Other effects: nausea, vomiting, abdominal pain and CNS effects: By whom prescribed diarrhoea Anxiety It should clearly indicate: Aspiration may occur and cause aspiration pneumonia Restlessness How much should be taken (the amount e.g. in Investigations Tremor milligrams, grams) Electrolytes, Urea and serum Creatinine Confusion How often (frequency) Liver function tests Weakness The route of administration Chest radiograph Seizure And: Electrocardiography Coma Duration of therapy Non-drug treatment Non-drug treatment Apart from its use in therapy, a prescription order is Gastric lavage and decongestion are contraindicated Remove contaminated clothing important as a medico-legal document because of the risk of aspiration Wash skin with soap and water Essential elements of a prescription order Supportive measures Ventilatorysupport Identity of prescriber : Oxygen administration Drug treatment - Name Respiratory support Oxygen administration - Address/institution of prescriber Monitoring liver, renal and myocardial function Atropine - Telephone number Correct metabolic abnormalities Adult: 0.5-2mgintravenously every 5 - 15 minutes until Date of prescription: Drug treatment bronchial and other secretions have dried - Near top/beginning of left margin of a chart order Antibiotics for aspiration pneumonitis Child: 20 micrograms/kg (maximum 2 mg) Identity of patient: intramuscularly or intravenously depending on the - Name

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- Age (especially in children) Prescription for special cases Pregnancy and Lactation Report any suspected adverse response to a drug to - Gender Special precaution should be taken in children Changes in fluid and tissue composition occur during the hospitals'Adverse Reaction Registry or directly to - Address of patient (especially neonates and infants), and the elderly when pregnancy the National Agency for Food and Drug - Hospital number considering drug therapy Reduced gastrointestinal motility delays gastric Administration and Control (NAFDAC),Abuja Elements specifying medication: - There are differences in drug handling emptying and may delay drug absorption after oral Asample of theYellowForm is shown inAppendix VI - Name of medication (generic name) (pharmacokinetics) and sensitivity in drug response administration Analysis of such reports enables appropriate decisions - Strength(metric units) and quantity (pharmacodynamics) in the different age groups Vasodilation may result in enhanced absorption to ensure safe and judicious use of medicines - Dosage Particular care should also be taken when prescribing following drug administration by the intramuscular route In the text a number of known adverse reactions are - Frequency for pregnant women There is increased volume of distribution, increased listed for medicines used for the treatment of the stated - Duration Precaution should also be taken in clinical states hepatic metabolism and increased elimination of drugs diseases - Directions for use (drug- and patient- specific) associated with organ system failure (renal, hepatic) Extreme care must be taken when administering drugs - This list is by no means complete or comprehensive - Refill instructions where dosage adjustment may be required with teratogenic potential to women in the reproductive - There may be unknown adverse reactions peculiar to - Waiver of requirements for child-proof containers Children (including neonates and infants) age group (See appendix IV) our population - Additional labelling instructions There are notable differences in the proportions and Some drugs may cause harm to infants when Prescriber's signature and other identification data e.g constituents of body fluids between adults and children administered to nursing mothers (see appendix V) code. Prescriptions may be hand written or computer- The immature enzyme systems result in poor oxidation Other drugs e.g bromocripine inhibit lactation issued: and conjugation and may cause adverse effects Drugs excreted significantly in milk and likely to cause - Hand written prescriptions should be written in - Grey Baby syndrome with chloramphenicol is an toxicity are shown in appendix V indelible ink and the hand writing should be legible example (important, to avoid medication errors) Drugs predominantly excreted by the kidneys e.g - Any alteration(s) made in a computer-issued aminoglycosides, penicillins may require dose reduction ADVERSE DRUG REACTIONS prescription should be duly endorsed Use appropriate formulations for various routes e.g Introduction Abbreviations rectal route (for diazepam, theophylline) in the The use of medicines is inextricably linked to Only standard, official abbreviations should be used. uncooperative child unintended responses The following are some notable abbreviations (See appendix IV for calculation of dose requirements for The safe use of medicines is therefore an important a.c ante cibum (before food) children) consideration in therapy b.d bis die (twice daily) The Elderly In this text the following WHO definitions will apply o.d omni die (every day) Persons 65 years or over: a growing segment of the Adverse drug reaction o.m omni mane ( every morning) Nigerian population A response to a medicine which is noxious and p.c post cibum (after food) A number of factors interplay to increase the incidence unintended p.r.n pro re nata (when required) of adverse drug reactions in this group of patients - Occurs at doses normally used in man for the q.d.s quarter die sumendum (to be taken four - Bodily changes affecting drug handling and tissue prophylaxis, diagnosis or therapy of disease, or for the times daily) response modification of physiologic function q.q.h quarter quaque hora (every four hours) - The increasing number of medicines prescribed to Adverse drug event stat immediately treat multiple diseases, each with a potential to cause an Any untoward medical occurrence that may present t.d.s ter die sumendum (to be taken three times adverse drug reaction as well as a drug-drug interaction during treatment with a pharmaceutical product, but daily) - Poor adherence to therapy due to factors inherent in the which does not necessarily have a causal relationship t.i.d ter in die (three times daily) elderly with the treatment NOTE Dosage reduction may be required for some drugs Aserious adverse event (experience, or reaction) Avoid abbreviations of drug names because of Any untoward medical occurrence that at any dose Doses should be written in the metric system or in - Changes in volume of distribution - Results in death international units (IU) when metric doses are not - Reduced metabolism - Is life-threatening practicable - Reduced renal elimination - Requires patient hospitalization or prolongs existing If a drug is to be administered 'as required', specify the Particular care is necessary in administration of drugs hospitalization minimum dose interval and the total amount of drug to be where sensitivity in the elderly is increased e.g: - Results in persistent or significant disability/incapacity administered - Hypno-sedatives - Causes a congenital anomaly or birth defect Avoid unnecessary use of decimal points - Neuroleptics - Requires an intervention to prevent permanent 1 mg not 1.0 mg - Diuretics impairment or damage If >1 g state as g Where no drug is needed avoid unnecessary Side effect If<1gstate as milligram e.g. 500 mg not 0.5 g prescriptions. Any unintended effect of a pharmaceutical product If<1mgstate as microgram: 100 microgram not 0.1 mg Relevant drugs should be prescribed in the appropriate occurring at doses normally used in humans If the decimal point is unavoidable, insert zero (0) in dose and monitored closely front of the point e.g 0.5 mLnot .5 mL Consideration should be given to the formulation that is - Is related to the pharmacological properties of the drug Microgram and nanogram should not be abbreviated most appropriate in the clinical circumstances There is need to have a high index of suspicion during Millilitre (mL) should be used for volume and not The possibility of drug-drug interactions should therapy so as to recognize and adequately manage cubic centimetre, c.c or cm3 always be borne in mind adverse effects

207 208 Chapter 20: Notifiable Diseases Standard Treatment Guidelines for Nigeria 2008

CHAPTER 20: NOTIFIABLE DISEASES List of Notifiable diseases 1. AIDS 2. Anthrax (human) 3. Brucellosis (human) 4. Cerebro-spinal meningitis 5. Chicken pox 6. Cholera 7. Diarrhoea (simple without blood) 8. Diarrhoea with blood (dysentery) 9. Diphtheria 10. Dracuncolasis 11. Filariasis 12. Food poisoning 13. Gonorrhoea 14. Hepatitis 15. Lassa Fever 16. Leprosy 17. Louse-borne typhus fever 18. Malaria 19. Measles 20. Onchocerciasis (River blindness) 21. Ophthalmia neonatorum 22. Pertussis (Whooping cough) 23. Plague 24. Pneumonia 25. Poliomyelitis 26. Rabies (human) 27. Schistosomiasis 28. Smallpox 29. Syphilis 30. Other sexually transmitted diseases (STD) 31. Tetanus (other) 33. Tetanus (neonatal) 33. Trachoma 34. Trypanosomiasis (sleeping sickness) 35. Tuberculosis 36. Typhoid and paratyphoid fevers 37. Viral influenza 38. Yaws 39. Yellowfever

List of emergency and immediate notifiable disease 1. AIDS (Acquired Immune Deficiency syndrome) 2. Acute Flaccid Paralysis 3. Anthrax 4. Cerebro-spinal Meningitis (CSM) 5. Cholera 6. Lassa fever 7. Plague 8. Rabies (human) 9. Small pox 10. Typhoid and paratyphoid fevers 11. Yellowfever

209 210 Appendices Standard Treatment Guidelines for Nigeria 2008

APPENDIX 1 cutaneous of more than one month's duration, or APPENDIX II: visceral at any site WHO CLINICAL STAGING OF HIV FOR INFANTS Extrapulmonary tuberculosis WHO NEW ANTENATAL CARE MODEL CLASSIFYING FORM 2001 AND CHILDREN WITH ESTABLISHED HIV Kaposi sarcoma INFECTION Oesophageal candidiasis (or Candida of trachea, bronchi or lungs) Clinical Stage 1 Cytomegalovirus infection; retinitis or Asymptomatic cytomegalovirus infection affecting another organ, Persistent generalized lymphadenopathy with onset at age over 1 month Central nervous system toxoplasmosis (after the Clinical Stage 2 (I) neonatal period) Extrapulmonary cryptococcossis (including Unexplained persistent hepatosplenomegaly meningitis) Papular pruritic eruptions HIV encephalopathy Fungal nail infections Disseminated endemic mycosis (extrapulmonary Angular cheilitis histoplamosis, coccidiomycosis) Lineal gingival erythema Chronic cryptosporidiosis (with diarrhoea) Extensive wart virus infection Chronic isosporiasis Extensive molluscum contagiosum Disseminated non-tuberculous mycobacteria Recurrent oral ulceration infection Unexplained persistent parotid enlargement Cerebral or B cell non-Hodgkin lymphoma Herpes zoster Progressive multifocal leukoencephalopathy Recurrent or chronic upper respiratory tract HIV-associated cardiomyopathy or nephropathy infections (otitis media, otorrhoea, sinusitis, tonsillitis) (I) Unexplained refers to where the condition is not explained by other causes Clinical Stage 3 (I) (Ii) Some additional specific conditions can be included Unexplained moderate malnutrition or wasting not in regional classifications (e.g. Disseminated adequately responding to standard therapy Penicilliosis in Asia, HIV-associated rectovaginal Unexplained persistent diarrhoea (14 days or fistula in Africa), and reactivation of American more) trypanosomiasis Unexplained persistent fever (above 37.6 °C, intermittent or constant, for longer than one month) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis or periodontitis Lymph node tuberculosis Pulmonary tuberculosis Severe recurrent bacterial pneumonia Symptomatic lymphoid interstitial pneumonitis Chronic HIV-associated lung disease including bronchiectasis Unexplained anaemia (<8.0 g/dl), neutropaenia (<0.5 x 109/L3) and or chronic thrombocytopenia

Clinical stage 4 (i) (ii)

Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy Pneumocystis pneumonia Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia) Chronic herpes simplex infection; (orolabial or

211 212 Appendices Standard Treatment Guidelines for Nigeria 2008

APPENDIX III in adults Body Surface Area (BSA) estimates are more accurate fo CALCULATION OF DOSAGE REQUIREMENTS IN calculation of paediatric doses- Many physiological CHILDREN phenomena correlate better to BSA For most medicines the adult maximum dose should not Introduction exceeded Medicine doses are generally based on body weight (in For example if the dose is stated as 4 mg/kg (max. 180 kilogram) or the following age ranges: mg), a child weighing 10 kg should receive 40 mg but a First one month (neonate) child weighing 50 kg should receive 180 mg and not Up to 1 year (infant) 200mg 1 - 5 years 6 - 12 years Young children may require higher doses per kilogram th Unless the age is specified, the term child includes adults because of their higher metabolic rate persons aged 12 years and below Calculation by body weight in an overweight child may Dose Calculation result in much higher doses being administered than Calculated based on body weight (in kilogram) or the necessary. Such doses should be calculated based on idea body surface area (in m2). Use this rather than body weight in relation to height and age. attempting to calculate doses on the basis of doses used See table below.

Age Ideal body-weight Height Body Surface Kg lb cm Inch /m2

Newborn* 3.5 7.7 50 20 0.23 1 Month* 4.2 9 55 22 0.26 3 Month* 5.6 12 59 23 0.32 6 Month 7.7 17 67 26 0.40 1 year 10 22 76 30 0.47 3 years 15 33 94 37 0.62 5 years 18 40 108 42 0.73 7 years 23 51 120 47 0.88 12 years 39 86 148 58 1.25

* The figures relate to full term and not preterm infants who may need reduced dosage according to their clinical condition

213 214 Appendices Standard Treatment Guidelines for Nigeria 2008

APPENDIX IV: Medicines that could cause harm when administered to breastfeeding mothers contd. Medicine Comment MEDICINES WITH TERATOGENIC POTENTIAL Antipsychotics Avoid unless absolutely necessary Apomorphine Manufacturer advises avoid Medicine Comment Atenolol Toxicity due to bet-blockage. Avoid or use with caution (monitor infant) Antiepileptics Risk of teratogenicity greater if more than one medicine used Atropine Manufacturer advises caution Bleomycin Avoid (teratogenic and carcinogenic in animal studies) Azithromycin Present in milk; manufacturer advises use only if no suitable alternative Busulfan Avoid (teratogenic in animals) Barbiturates Avoid if possible. Large doses may produce drowsiness Carboplatin Avoid (teratogenic and embryotoxic in animal studies) Benzodiazepines Avoid if possible Cisplatin Avoid (teratogenic and embryotoxic in animal studies) Beta-blockers Monitor infant; possible toxicity due to beta-blokade Co-trimoxazole Teratogenic risk (trimethoprim -a folate antagonist) Caffeine Regular intake of large amounts can affect infant Cytarabine Avoid (teratogenic in animal studies) Captopril Manufacturers advise avoid Dactinomycin Avoid (teratogenic in animal studies) Carbimazole Use lowest effective dose Daunorubicin Avoid (teratogenic and carcinogenic in animal studies) Ceftriaxone Present in milk in low concentrations Doxorubicin Avoid (teratogenic and toxic in animal studies) Cefuroxime Present in milk in low concentrations Sulfadoxine/pyrimethamine Possible teratogenic risk (pyrimethamine is a folate antagonist) Chloramphenicol Use another antibiotic; may cause bone marrow toxicity in infant Griseofulvin Avoid (fetotoxicity and teratogenicity in animal studies) Chlorpromazine Drowsiness in infant reported Hydroxocarbamide(hydroxyurea) Avoid (teratogenic in animal studies) Ciprofloxacin Manufacturer advises avoid Idoxuridine Teratogenic in animal studies Contraceptives, oral Avoid until weaning or for 6 months after birth (adverse effects on Isotretinoiin Teratogenic lactation) Lithium salts Avoid if possible (risk of teratogenicity) Corticosteroids Avoid maternal dose of prednisolone beyond 40 mg daily Phenytoin Congenital malformation (screening advised) Co-trimoxazole Risk of kernicterus in jaundiced infants and of haemolysis in G6PD- Trenitoin Teratogenic deficient infants Trimethoprim Teratogenic risk (folate antagonist) Cyclophosphamide Discontinue breastfeeding during and for 36 hours after stopping Vinblastine Avoid (limited experience suggest fetal harm; teratogenic in animal studies) treatment Vincristine Avoid (teratogenicity and fetal loss in animal studies) Dapsone Haemolytic anaemia; although significant amount in milk, risk to infant very small unless infant is G6PD deficient Desferroxamine Use only if potential benefit outweighs risk APPENDIX V: Enoxaparin Irritability and disturbed sleep reported MEDICINES THAT COULD CAUSE HARM WHEN ADMINISTERED TO BREASTFEEDING MOTHERS Ergotamine Avoid Furosemide May inhibit lactation Medicine Comment Ibuprofen Manufacturer advises avoid Abacavir Breastfeeding not advised in HIV infection Indometacin Manufacturers advise avoid Acetazolamide Amount too small to be harmful Iodine and iodides Stop breastfeeding; danger of neonatal hypothyroidism and goitre Alcohol Large amounts may affect infant and reduce milk consumption Lisinopril Manufacturers advise avoid Amantadine Avoid; present in milk; toxicity in infants reported Morphine Withdrawal symptoms in infants of dependent mothers; breastfeeding not Amiloride Manufacturer advises avoid best method of treating dependence in offspring Aminophylline Present in milk- irritability in infants reported Nicotinic acid Avoid Amitryptilline Manufacturers advise avoid Nifedipine Manufacturers advise avoid Amlodipine Manufacturers advise avoid Oestrogens Avoid Amoxicillin Trace amounts in milk Phenobarbital Avoid when possible Amphetamines Significant amount in milk Phenytoin Manufacturer advises avoid Amprenavir Breast feeding not advised in HIV infection Progesterone Manufacturers advise avoid Aspirin Avoid- possible risk of Reye's syndrome; regular use of high doses could Statins Manufacturers advise avoid impair platelet function and produce hypoprothrombinaemia in infants if neonatal Tetracycline Avoid vitamin K stores low Theophylline Irritability in infants reported Androgens Avoid. May cause masculinization in the female infant or precocious Thiamine Severely thiamine-deficient mothers should avoid breastfeeding as toxic development in the male infant; high doses suppress lactation methyl-glyoxal present in milk Anticoagulants, oral Risk of haemorrhage; increased by Vitamin K deficiency; Tinidazole Avoid breastfeeding during and for 3 days after stopping treatment warfarin appears safe but phenindione should be avoided Vitamin A Theoretical risk of toxicity in infants of mothers taking large doses Antihistamines Significant amounts of some antihistamines present in milk, although not Vitamin D Caution with systemic doses; may cause hypercalcaemia in infant. known to be harmful Manufacturers advise avoid

215 216 Appendices Standard Treatment Guidelines for Nigeria 2008

217 218 Appendices Standard Treatment Guidelines for Nigeria 2008