PARTNERS Suggested Citation: Standard Treatment Workﬂows of India, 2019 Edition, Vol

Department of Health Research Ministry of Health and Family Welfare, Government of India

PARTNERS Suggested Citation: Standard Treatment Workﬂows of India, 2019 Edition, Vol. 1, New Delhi, Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India

Printed in India

Department of Health Research Ministry of Health and Family Welfare, Government of India

These STWs have been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Department of Health Research Ministry of Health and Family Welfare, Government of India

• INTRODUCTION

CARDIOLOGY ATRIAL FIBRILIATION BRADYARRTHYMIAS HEART FAILURE STABLE ANGINA STEMI UNSTABLE ANGINA/ NSTEMI

ENT ACUTE RHINOSINUSITIS CHRONIC RHINOSINUSITIS EPISTAXIS HEARING IMPAIRMENT IN PEDIATRIC AGE GROUP NECK SPACE INFECTION OTORRHOEA PHARYNGITIS AND SORE THROAT

NEPHROLOGY ACUTE KIDNEY INJURY CHRONIC KIDNEY DISEASE GLOMERULONEPHRITIS URINARY TRACT INFECTION

NEUROLOGY APPROACH TO ACUTE PARALYSIS DEMENTIA EPILEPSY HEADACHE NEUROINFECTIONS STROKE

OBG ANTENATAL MANAGEMENT DILATATION AND CURETTAGE HEAVY MENSTRUAL BLEEDING HYSTERECTOMY POSTPARTUM HAEMORRHAGE UTERINE FIBROIDS AND POLYPS

PAEDIATRICS ACUTE ENCEPHALITIS SYNDROME ACUTE DIARRHEA DENGUE FEVER FEVER IN CHILDREN SEPSIS AND SEPTIC SHOCK IN CHILDREN SEVERE ACUTE MALNUTRITION SEVERE PNEUMONIA IN CHILDREN

PSYCHIATRY ALCOHOL USE DISORDERS ANXIETY DISORDERS CHILDHOOD BEHAVIOURAL DISORDERS CHILDHOOD EMOTIONAL DISORDERS CHILDREN WITH DEVELOPMENTAL DISORDERS DEPRESSION PSYCHOSIS SOMATOFORM DISORDERS

PULMONOLOGY ACUTE RESPIRATORY INFECTION ASTHMA CHRONIC OBSTRUCTIVE PULMONORY DISORDER RESPIRATORY FAILURE

UROLOGY ACUTE URINARY RETENTION IN MEN GROSS HAEMATURIA MALE INFERTILITY RENAL AND URETRIC STONES SCROTAL SWELLING

• CONTRIBUTORS Department of Health Research INTRODUCTION Ministry of Health and Family Welfare, Government of India

GOAL To empower the primary, secondary and tertiary care physicians/ surgeons towards achieving the overall goal of Universal Health Coverage with disease management protocols and pre-deﬁned referral mechanisms by decoding complex guidelines

OBJECTIVES

Primary Objective: To formulate clinical decision making protocols for common and serious medical/ surgical conditions for both OPD and IPD management at primary, secondary and tertiary levels of healthcare system for equitable access and delivery of health services which are locally contextual

Secondary Objective: To facilitate PMJAY arm of Ayushman Bharat with secondary and tertiary level management of all surgical and medical conditions covered under the scheme.

METHODOLOGY

ADVISORY COMMITTEE

STW SECRETARIAT EDITORIAL BOARD DESIGN TEAM

EXPERT GROUPS COMMITTEES

PROCESS OVERVIEW

• 100 Meetings 650 hours

Consultations

DEVELOP STWS & (5200 person hours) CONVERT THEM • Participation also from INTO INFOGRAPHICS Public Health Specialists TOPIC Search Strategists PRIORITIZATION Clinical Scientists Graphic Designers

• Prevalence studies • Global burden of REVIEW OF • Review by Editorial Board CURRENT diseases studies • Approval by Advisory GUIDELINES & • HBP of AB-PMJAY FEASIBILITY AS Committee PER HEALTH • Public Comments SYSTEM

Harrison’s Textbook Oxford Handbook CARDIOLOGY October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of ATRIAL FIBRILLATION ICD-10-I48.91

SYMPTOMS LOOK FOR PRECIPITATING CATEGORIZE AF - Rapid rate palpitations with or without FACTORS: • General fatigue or weakness or • Paroxysmal AF: Episodes of AF for exhaustion • Post (cardiac) surgery less than 7 days • Dizziness, near syncope or syncope • Alcoholism or binge drinking • Persistent AF: AF lasing from 7 days • Shortness of breath • Myo-pericarditis or ACS to 1 year WHEN TO • Chest pain • Pneumonitis or pulmonary • Long standing persistent AF: AF - More marked on exertion SUSPECT ? embolism lasting for > 1 year • Sepsis, hyperthyroidism • Permanent AF: AF with heart rate control as only option SIGNS - Irregularly irregular pulse MANAGEMENT PRINCIPLES: - Variable heart sound • Categorize AF LOOK FOR IMMEDIATE INTERVENTION LOOK FOR RISK FACTORS • Look for immediate intervention INDICATORS: • Prior valvular heart disease or indicators CHF or MI • Assess stroke risk & need for • Systolic BP 90 mmHg, HR > 150 or • Prior TIA or stroke or embolic anti-coagulation <50/min episode • Assess bleeding risk • Ongoing Angina • Hypertension, DM, COPD,CKD, • Need for rate control • CHF or TIA or stroke Obesity • Consideration for rhythm control • Major bleed on Oral Anti-coagulants

STROKE RISK SCORE BLEEDING RISK SCORE CHOICE OF ANTI-COAGULATION: • Vitamin K antagonist CHA2DS2-VASC SCORE HAS-BLED SCORE • Aim for INR 2-3 - Congestive heart failure/LV dysfunction 1 - Hypertension i.e. uncontrolled BP 1 • Assess risk of bleeding - Hypertension 1 - Abnormal renal/ liver function 1 or 2 • Take measures to reduce/ modify risk of bleeding - Aged > 75 years 2 - Stroke 1 • Dietary modiﬁcation & regular monitoring - Diabetes mellitus 1 - Bleeding tendency or 1 - Stroke/ TIA/ TE 2 predisposition 1 - Vascular disease [prior MI, PAD or aortic 1 - Labile INR 1 MEASURES TO REDUCE HIGH BLEEDING RISK: plaque] - Age (e.g. >65) • Control SBP to less than 140 mmHg - Aged 65-74 years 1 1 • Avoid dietary indiscretions - Drugs (e.g. concomitant aspirin or • Avoid concomitant aspirin, anti platelets, NSAIDs - Sex category [i.e. female gender] 1 NSAIDSs or alcohol • Avoid alcohol Maximum Score 9 9 • Correct anemia OAC if score >1 in men and >2 in women Bleeding Risk High in score >3 HEART RATE CONTROL

In all patients except hemodynamic Beta blocker or calcium blocker or BB + digoxin in HF Rate aim to be less than 110/ min instability combination CONVERSION TO NSR Uncontrolled symptoms despite HR Unacceptable rate control drug side Hemodynamic instability Patients’ preference control effects MANAGEMENT INVESTIGATIONS WHAT TO LOOK FOR IN ECG ? AT PHC/ CHC: BASIC INVESTIGATIONS: • Ventricular rate • Detailed clinical evaluation • Chamber enlargement • Hemograms • Basic investigations • Pre-excitation • Blood sugar, Creatinine • Careful ECG evaluation • Prior MI • Electrolytes • Start OAC if indicated (based on Stroke risk) • Bundle branch block • 12 lead ECG • Start Metoprolol if HR >110/ min & no evidence of CHF • QT interval • Refer if indicators for early intervention RHYTHM CONTROL AT DISTRICT HOSPITAL: DESIRABLE INVESTIGATIONS: • Admit if indicators of early interventions • Plain X-ray chest Pharmacological Cardioversion • Immediate cardioversion after heparinization,if • Thyroid evaluation hemodynamic instability • Liver function test CHF • Manage precipitating factors if any Normal Heart • Troponins CAD • Assess stroke, bleeding risk & coagulation parameters • Prothrombin time, INR (Coagulation Abnormal LVH • Detailed echocardiogram proﬁle) • Start OAC, maintain INR around 2-3 Flecainide Pill in pocket • Echocardiography • Control HR by single drug or combination of BB & Ca Ibutilide (Flecainide OR Blocker Amiodarone Propafenone Propafenone) OPTIONAL INVESTIGATIONS: Refer HR uncontrolled or CHF or angina Long Term Rhythm Control AT TERTIARY CENTRE: • Prolonged ECG monitoring • Trans-esophagial echocardiography • Re-assess clinical status, adequacy of AC CHF Normal Heart CAD, LVH • Exercise Stress Test • Consider need of NOAC • CT scan • Optimise management of underlying cardiac disease • MRI • Stress life style and AF risk factor modiﬁcation Amiodarone Flecainide Amiodarone • EP study • Assess need for rhythm control and discuss pros & cons Propafenone Sotalol • Coronary angiography • Consider RFA in select patient Sotalol

MANAGEMENT ALGORITHM Sign/ symptoms suugestive of AF Conﬁrm by 12 channel rhythm strip Hemodynamic Instability

No Yes No Very rapid HR >130/ min Yes Yes No Symptomatic Drug version CHF

Successful Yes No Yes No

No Yes HR control Aim <110/min Clinical Careful BB/Dig BB or Ca Block Follow-up Anti-coagulants in all Except DC version Continue drug Amiodarone or combine • Reversible HR > 110/ min • Score <1 (men) ; <2 (women) Consider DC version

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of BRADYARRTHYMIAS IN SYMPTOMATIC PATIENTS ICD-10-R00.1

Syncope/ presyncope/ dizziness

WHEN TO SUSPECT

Patient with any of the Lethargy/ fatigue following symptoms, AND a pulse rate < 50bpm: (persistent)

Breathlessness/ chest pain on exertion

BASIC EVALUATION

HISTORY EXAMINATION TESTS TO BE DONE • Syncope/ presyncope: frequency, associated fall/ injury/ incontinence • Drowsiness/ impaired Patient presenting to PHC/CHC: • Exertional angina or known coronary artery disease consciousness • 12-lead ECG • Known hypothyroidism or kidney disease • BP, heart rate • Blood urea, serum creatinine • On beta-blockers, Calcium Channel Blockers or digoxin • Electrolytes • Patient with an implanted pacemaker or other device • Blood sugar • Yellow oleander poisoning

EVALUATION AND TREATMENT OF UNSTABLE PATIENTS EVALUATION AND MANAGEMENT OF STABLE PATIENTS

1. TREATMENT OF ASSOCIATED CONDITIONS Findings on 12-lead ECG - Hyperkalemia - Suspected drug (BB or CCB) overdose: • Atrioventricular block i. Withhold the drug • Sinus node dysfunction ii. iv insulin (1 U/kg bolus followed by 0.5 U/kg/h) with glucose monitoring(or) iv • Other conduction disorders with 1:1 AV glucagon if available conduction 2. TEMPORARY PACEMAKER INSERTION • Non-diagnostic ECG (iv dopamine or adrenaline may be given till the time TPI can be placed)

INDICATIONS FOR URGENT TREATMENT/REFERRAL GENERAL APPROACH TO PATIENTS WITH SYMPTOMATIC BRADYCARDIA

• Hypotension (SBP <90 mmHg), impaired consciousness or 1. Rule out associated conditions ongoing chest pain - Renal dysfunction, hyperkalemia • Recurrent or ongoing syncope/presyncope - Drug toxicity (BB, CCB, clonidine, Lithium) • Associated headache with or without neurologic deﬁcit (suspect - Sleep apnea (clinical scoring systems such as Epworth intracranial event) Sleepiness Scale may be used for initial assessment) • Patient with a pre-existing device • If ECG available, evidence of any of the following 2. Transthoracic echocardiography - Complete heart block - Sinus node disease with pauses >3 s long - Bradycardia (HR < 50 bpm) (with or without hyperkalemia, serum K > 5 mEq/L)

INDICATIONS FOR PERMANENT PACING

AV NODAL DISEASE SINUS NODE DYSFUNCTION OTHER CONDUCTION DISORDERS WITH 1:1 AV CONDUCTION • Complete heart block, advanced AV block, • Symptomatic patients with sinus or Mobitz Type II block pauses > 3 s long with symptom • Symptomatic patients with HV ≥100 ms on EPS • Symptomatic patients with AV block other correlation • Others (alternating BBB, inﬁltrative/ neuromuscular than above • Asymptomatic patients with sinus disease) • Associated neuromuscular disease pauses > 6 s long

RECOMMENDED PACING MODES ADDITIONAL TESTING

1. SND with intact AV conduction 1. Advanced imaging (cMRI) may be needed if inﬁltrative disease - Atrial-based single or dual chamber pacing is suspected - VVI pacing is reasonable if symptoms are 2. Ambulatory ECG may be needed infrequent - In patients with ﬁrst or second degree AV block for 2. AV node disease symptom correlation - VVI/Dual chamber pacing in patients with - In patients with suspected sinus node disease for LVEF >50% detection of pauses and symptom correlation - CRT (or HBP) in patients with LVEF - In symptomatic patients with LBBB or bifascicular block 36-50% and requiring ventricular pacing 3. Implantable Loop Recorder and EPS (consult published society >40% of the time guidelines) - CRT (or HBP) if LVD <35%

ECG: SINUS BRADYCARDIA ECG: THIRD DEGREE HEART BLOCK

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of HEART FAILURE: A BREATHLESS PATIENT ICD-10-I50.9

ADDITIONAL INFORMATION SYMPTOMS Raised JVP • Prior history of respiratory illness like asthma or COPD 1. Dyspnea/ orthopnea/ PND Pulmonary Cardiomegaly • Known patient of CHF/ similar illness in 2. Pink frothy sputum Oedema past with response to therapy 3. Dependent pedal edema • Prior history of RHD, CAD, pregnancy, 4. Recent weight gain cancer chemotherapy 5. Easy fatiguability Pleural • Risk factors: HT, DM, smoking, 6. H/o CHF/ MI Effusions hyperlipidemia or premature CAD in ﬁrst degree relatives

Ascites

COMMON ETIOLOGY AND INDICATORS SIGNS 1. Ischemic cardiomyopathy: past MI 1. Tachypnoea Hepatomegaly 2. Diabetic cardiomyopathy 2. Tachycardia or irregular 3. RHD: existing valvular disease 4. Post-viral: acute onset pulse breathlessness within last 3 months 3. Basal crepitations 5. Peri-partum cardiomyopathy-onset 4. Cardiomegaly in last trimester or after delivery 5. Presence of murmurs Pitting 6. Idiopathic cardiomyopathy 6. Systemic desaturation Oedema 7. Post-cancer chemotherapy

MANAGEMENT AT PHC MANAGEMENT AT CHC • Admit and stabilize • Rule out respiratory cause: Breathlessness REFER TO • Send for routine investigations with fever, cough and expectoration or COMMUNITY • ECG: Rule out acute ST-Elevation MI known patient of asthma or COPD HEALTH CENTRE • X-ray chest: Rule out respiratory etiology • Likely CHF: Decongest with furosemide • Decongest with intravenous furosemide • O2 therapy if systemic saturation < 90% REFER IF FOLLOWING: • Start enalapril and spironolactone orally • BP < 90 mmHg or > 200 mmHg • Consider carvedilol after decongestion • Heart rate < 50/min or > 120/min • Respiratory rate > 30/min or cyanosis • Oliguria • Altered sensorium KEEP WATCHING 1. Respiratory distress REFER TO A and oxygen saturation MANAGEMENT AT DISTRICT HOSPITAL DISTRICT 2. BP and heart rate HOSPITAL 3. Electrolytes and renal • Admit and re-assess parameters • Optimise therapy with furosemide/ enalapril/ spironolactone/ O2 and stabilize • Consider non-invasive ventilation if marked respiratory MANAGEMENT AT TERTIARY HOSPITAL distress and O2 saturation < 90% 1. Re-assess and confirm diagnosis of HF • Echocardiography: confirm diagnosis of HFrEF: LV 2. Categorize acute (< 3 months) vs chronic (> 3 months) and HFrEF ejection fraction < 35% (EF 35%) vs HFpEF (EF 35-50%) • Search for etiological diagnosis 3. Optimize therapy with furosemide, enalapril, carvedilol, • Consider carvedilol after decongestion spironolactone and O2 • Refer back to CHC/ PHC after stabilization 4. Consider ARNI and ivabradine 5. Pneumococcal and influenza vaccines 6. Investigate for etiology and manage 7. Consider non-pharmacological invasive therapy REFER TO TERTIARY CARE IF a. ICD: In selected patients (Ref Arrhythmia STW) • CHF uncontrolled, b. BiV: Consider in NYHA class II/ III Symptomatic patient , • Unstable hemodynamics EF <35%, QRS >150msec in sinus rhythm with LBBB • Suspected ongoing ischemia morphology and optimal medical therapy of >3 months • Abnormal electrolytes 8. Etiology based Interventions • Abnormal renal functions a. PCI • Structural heart disease b. Valve replacement • Unclear etiology c. CABG

CONSIDER AT ALL LEVELS Secondary CVD prevention Smoking Salt Physical Weight Control of DM/ Moderation with aspirin and statins Cessation restriction activity Reduction of alcohol HTN/ Lipids

INVESTIGATIONS: BASIC INVESTIGATIONS WHAT TO LOOK FOR IN WHAT TO LOOK FOR IN AN ECG? DESIRABLE OPTIONAL INVESTIGATION • Hemogram, ESR X RAY • Pathological Q wave INVESTIGATIONS • Prolonged ECG monitoring • Blood sugar • Conduction abnormalities, • 2D Echocardiography • Coronary angiography • Cardiomegaly • Urine examination especially LBBB • BNP/NT pro-BNP • Radionuclide imaging • Pulmonary venous • Urea/ Creatinine • Chamber enlargement • Troponin • CT scan congestion • Sodium/ Potassium • Atrial fibrillation • Lipid profile • MRI • Pneumonia or other • ECG Note: If ST elevation present, manage as • Thyroid function test • PET lung pathology • Chest X-ray PA view STEMI • Iron profile • Myocardial biopsy • Electrophysiological study COMMON DRUGS AND DOSAGE FOR CHF FUROSEMIDE CARVEDILOL ENALAPRIL • Dose 20-80 mg daily PO • Dose 3.125 to 25 mg twice daily PO • Dose 2.5 to 10 mg twice daily PO • Intravenous 10-40 mg SOS in acute stage • Start after decongestion with low dose • Start with low dose with BP >100 • Change to oral when symptoms subside with BP > 100 mmHg and HR >60/ min mmHg, normal electrolyte and • Monitor serum electrolytes, creatinine and uric acid • Uptitrate dose 1-2 weekly till maximum creatinine less than 2.5 mg/dl on therapy tolerable dose • Uptitrate dose 1-2 weekly till maximum • Keep watch on BP, heart rate and tolerable dose SPIRONOLACTONE recipitation of CHF symptoms • Keep watch on BP and electrolytes • Dose 25-50 mg once daily PO • Increase diuretics and reduce carvedilol before every increment and on • Keep watch on serum potassium and creatinine to manage reappearance of CHF follow-up every 2-4 weekly KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES PCI: Percutaneous Coronary Intervention HFrEF: Heart Failure with reduced Ejection Fraction ABBREVIATIONS CABG: Coronary Artery Bypass Graft HFpEF: Heart Failure with preserved Ejection Fraction ICD: Implantable Cardioverter defibrillator CVD: Cardiovascular Diseases STEMI: ST elevation Myocardial Infarction BiV: Bi-Ventricular Pacing RHD: Rheumatic Heart Disease LV: Left Ventricle PND: Paroxysmal Nocturnal Dyspnea CAD: Coronary Artery Disease COPD: Chronic Obstructive Pulmonary Disease REFERENCES 1. Management Protocols for Chronic Heart Failure in India. Mishra S, Mohan JC, Nair T et al. Indian Heart J.2018;70:105-127, 2. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Ponikowski P, Voors AA. Anker SD et al. European Heart Journal. 2016;37:2129–2200 3. Chronic heart failure in adults: diagnosis and management. NICE guideline [NG106] Published date: September 2018 4. 2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Yancy CW, Jessup M, Bozkurt B. J Am Coll Cardiol. 2013;62-16: e150-e210

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of STABLE ANGINA ICD-10-I20.9

PATIENT PRESENTING CONSIDER ANGINA IF WITH CHEST PAIN • Diffuse retrosternal pain, ACUTE CORONARY SYNDROME heaviness or constriction, • Angina at rest or lasting more than 20 minutes radiating to arms or neck • Recent worsening of stable angina (crescendo) to or back CCS class III • Associated with sweating • New onset effort angina of less than 1 month in • Easily reproduced with CCS class II/ III post-meal exertion • Post infarction angina • Consider atypical presentation: Exertional For management: refer to STEMI/ NSTEMI STW fatigue or breathlessness or profuse sweating or

epigastric discomfort CATEGORIZE ANGINA

Likelihood more if known patient of CAD STABLE ANGINA Any effort related pain ﬁtting in previous category, relieved by rest or NTG in 1-2 min ANGINA UNLIKELY IF

• Variable location or characteristic • Long lasting (hours to days) or short lasting (less than a STABLE ANGINA: GENERAL MANAGEMENT minute) • Restricted to areas above jaw 1. Manage factors potentaiting angina or below epigastrium - Anemia, Thyrotoxicosis, Pregnancy, febrille illness • Localized to a point - Hypertension, Ventricular hypertrophy, CHF • Pricking or piercing or - Tachy or brady-arrhythmia stabbing type of pain - Drugs : bronchodilators, steroids • Precipitated by movement of 2. Risk factor control neck or arms or respiration 3. Other atherosclerotic CV disease : PVD, stroke 4. Secondary prevention : Statins, BB, ACE-I

INVESTIGATIONS

ESSENTIAL INVESTIGATIONS DESIRABLE INVESTIGATIONS OPTIONAL INVESTIGATIONS

1. Hemogram 1. Echocardiography 1. Stress radionuclide/ echocardiographic imaging 2. Urea, Creatinine, Electrolytes 2. Exercise Treadmill Test 2. CT scan including multi-slice coronary angiography 3. Sugar, HbA1C 3. Thyroid Function Test 3. Coronary Angiography 4. Lipids 4. Iron proﬁle 4. Coronary Fractional Flow Reserve 5. Liver function test 5. Uric acid 5. Intra-vascular Ultrasound/ OCT 6. ECG 7. Plain X-ray chest MANAGEMENT

MANAGEMENT AT PHC/ CHC MANAGEMENT AT DISTRICT HOSPITAL LEVEL MANAGEMENT AT TERTIARY LEVEL LEVEL 1. Optimise anti-anginal treatment 1. Reassess and optimise drug therapy: If 1. Control angina : 2. Echocardiography for LV function or structural heart uncontrolled choose from trimetazidine, Metoprolol disease nicorandil ranolazine and ivabid Add nitrates if symptoms 3. Risk stratify by exercise treadmill test in low, intermediate 2. Risk stratify with exercise treadmill test if not not controlled or high risk (DUKE risk score) for cardio-vascular events , if already done 2. ECG for Q waves, ST - T patient is ambulatory and ECG is interpretable 3. Stress imaging if following: changes, BBB or chamber 4. Refer to tertiary centres if: • Non ambulatory patient enlargement • Angina uncontrolled on optimal medical therapy • Abnormal or uninterpretable baseline 3. Aspirin & high intensity • Echo reveals abnormality ECG statins • Non-ambulatory patient or un-interpretable ECG • Exercise treadmill test result is 4. Refer to higher centre • High risk on exercise stress test for possible equivocal electively re-vascularization • Compromised LV function

RISK CATEGORIZATION A. Very high: B. High Risk: -Acute LVF -GRACE score > 140 or TIMI score >4 -Hypotension C. Intermediate Risk: Based on clinical features, -GRACE score 109-140 or TIMI score 2-3 -Uncontrolled Ventricular arrhythmia D. Low Risk: GRACE score & TIMI score -Severe MR -Grace score <108 or TIMI score 0-1

RISK CATEGORY MANAGEMENT REVASCULARIZATION 1. Revascularize if anatomy is suitable Low/ Intermediate Risk High Risk Group 2. Prefer CABG over PCI in DM with Group 1. Discuss pros and cons of possible multivessel disease or left main disease 1. Optimal anti-anginal therapy revascularization and dual anti-platelet therapy 3. Complete re-vascularization is preferable 2. Follow up 3-6 monthly at 2. Angiography, if any of following 4. Use invasive functional and imaging primary/ secondary care - Angina not controlled on optimal medical modalities (FFR, IVUS, OCT) when centre therapy indicated 3. Refer to tertiary centre when - High risk on non-invasive testing 5. Stress on continuing dual anti-platelets change in symptomatic status - Cardiac arrest survivor or documented VT (aspirin and clopidogrel) after PCI

DRUGS & DOSAGE Anti-platelets Anti-ischemic: 1. Aspirin 75 mg OD 1. Metoprolol: 2. Clopidogrel 75 mg OD (if intolerant to aspirin) Short acting: 25-100 mg BD Long acting: 25 -100 mg OD Statins: 2. Nitrates: Atorvastatin: 40-80 mg OD Isosorbide mono-nitare: 20 to 60 mg in 2 devided dose Rosuvastatin: 20-40 mg OD Nitroglycerine sustained release: 2.6 to 6.5 mg BD 3. Calcium channel blockers: Ace-inhibitor Verapamil 40-80 mg TDS Ramipril: 2.5-10 mg OD Diltiazem 30 to 90 mg TDS Enalapril: 2.5-10 mg BD 4. Nicorandil: 5-10 mg BD 5. Ranolazine: 500 -1000 mg BD 6. Trimetazidine: 20 mg mg TDS

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES : STRENGTHEN SECONDARY PREVENTION WITH STATINS, BB & ACE-I

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of ST ELEVATION MYOCARDIAL INFARCTION STEMI ICD-10-I21.3

CONSIDER ANGINA IF ACUTE CORONARY SYNDROME: • Diffuse retrosternal pain, heaviness or constriction 1. Angina at rest or lasting more than 20 minutes • Radiation to arms or neck or back 2. Recent worsening of stable angina (crescendo) to CCS • Associated with sweating • Easily reproduced with post-meal exertion class III • Consider atypical presentation: Exertional 3. New onset effort angina of less than 1 month in CCS class II/ fatigue or breathlessness or profuse III sweating or epigastric discomfort/ syncope 4. Post infarction angina More likelihood if known patient of CAD/ ECG: If ST Elevation: Follow ST Elevation MI (STEMI) protocol multiple risk factors If no ST Elavation: UA/NSTEMI

ANGINA UNLIKELY IF: Variable Long lasting (hours to Restricted to areas Localized Pricking or piercing Precipitated by movement location or days) or short lasting above jaw or to a point or stabbing type of of neck or arms or characteristic (less than a minute) below epigatrium pain respiration

PATIENT WITH STEMI WITHIN 12 HOURS

ECG REVEALS ST ELEVATION MI* GENERAL MEASURES

Refer to primary angioplasty/ 1. Admit in ICU equipped with continuous ECG monitoring & deﬁbrillation thrombolysis capable hospital 2. Routine bio-chemistry and serial cardiac enzymes (troponin) 3. Pain relief by opioid 4. O2 if saturation less than 90% *Includes new onset LBBB 5. Aspirin 325 mg, Clopidogrel 300 mg and Atorvastatin 80 mg 6. Echocardiography, particularly for mechanical complication

PCI CAPABLE HOSPITAL PCI INCAPABLE CENTRE A. Tranfer to PCI capable hospital if PCI can be performed within 120 min 1. Proceed for PCI 2. Radial route preferred B. If Transfer to PCI capable hospital not feasible 3. Preferably within 90 minutes THROMBOLYSE 1. Within 12 hours of symptom onset, if no contra-indication DURING PROCEDURE 2. Preferably with fibrin specific agent Tenecteplase/ TPA/ Reteplase or Streptokinase, if fibrin-specific are unavailable 1. Use unfractionated heparin 3. Therapy to be started within 10 min preferably 2. No routine thrombosuction 3. Tackle culprit artery only unless shock POST THROMBOLYSIS 1. ECG to be done at 60-90 min after starting thrombolysis to assess whether thrombolysis 4. DES to be preferred is successful ( >50% ST settlement with pain relief) or not 2. If successful, transfer patient for PCI within 3-24 hours POST PROCEDURE 3. If thrombolysis failed, transfer patient immediately for PCI capable hospital 4. Enoxaparin (preferred over unfractionated heparin) to be continued till PCI OR discharge 1. Continue dual antiplatelets for at least 1 year

LOOK FOR OTHER Unequal or absent peripheral pulses Dissection of Aorta CAUSES OF CHEST Respiratory evaluation Pleuritis/ Pneumonitis/ embolism/ pneumothorax PAIN (ONGOING OR WITHIN 12 HRS) Pericardial rub

Neuralgia or herpes

PATIENT WITH STEMI IN 12-24 HOURS

Transfer to PCI capable hospital immediately If ongoing pain, thrombolysis and transfer immediately

PATIENT WITH STEMI AFTER 24 HOURS Angiography with a view to PCI only if any of following/ Contra indications of angiography:

Recurrent anginal Mecahnical Dynamic ST-T Life threatening Cardiogenic shock Acute LVF pain not controlled complication changes ventricular by medical therapy arrhythmias

ABSOLUTE CONTRA-INDICATIONS TO THROMBOLYIC THERAPY:

Previous intra- Known bleeding Severe cerebral Ischemic stroke CNS neoplasm or Recent (within 1 Recent (within 1 tendency (except Aortic dissection uncontrolled hemorrhage or stroke of in last 6 AV malformation month) major month) major GI menstrual bleed) hypertension unknown months trauma/ surgey/ bleed etiology head injury DRUGS & DOSAGE STEMI DIAGNOSIS* Anti-platelets Anti thrombotics: 1. Aspirin: Loading dose 325 mg followed by 75 mg OD 1. Unfractionated heparin: Bolus of 2. Clopidogrel: Loading dose 300 mg followed 75 mg OD 60 U/Kg (maximum 5000 U) EMS or non 3. Prasugrel: Loading dose 60 mg followed by 10 mg OD followed by 12 U/Kg hourly Primary-PCI primary-PCI 4. Ticagralor: Loading dose 180 mg followed by 90 mg BD infusion to maintain APTT at capable centre capable centre Anti-ischemic: 50-70 sec Metoprolol: 2. Enoxaparin: 1 mg/Kg SC 12 hrly Preferably PCI possible Short acting: 25-100 mg BD <60 mins <120 mins? Long acting: 25 -100 mg OD Thrombolyic Therapy: Immediate Nitrates: Tenecteplase transfer to PCI centre Isosorbide mono-nitare 20 to 60 mg in 2 divided dose 35 mg IV bolus if 60-70 Kg Primary PCI Yes No Nitroglycerine sustained release 2.6 to 6.5 mg BD 40 mg IV bolus if 70-80 Kg Preferably <90mins (<60 mins) in Nitroglycerine IV 5-25 mcg/ min infusion 45 mg IV bolus if more than early presenters Statins: 80 Kg Rescue PCI High dose Atorvastatin 80 mg OD Reteplase Preferably within Ace-inhibitor 10 mg IV bolus, repeat after 30 30 mins

Ramipril 2.5 -10 mg OD min Immediately Enalapril 2.5 -10mg BD Alteplase Oxygen: 15 mg IV bolus followed by If oxygen saturation below 90% 0.75 mg/Kg over 30 min upto No Successful Immediate ﬁbrinolysis ﬁbrinolysis Morphine: 50 Kg weight, then 0.5 mg/Kg Yes Immediate transfer to Titrated in a dose of 2-4 mg IV every 15 minutes over 60 min up to 35 mg PCI centre

Beta-blocker: Streptokinase Preferably Oral beta-blocker if LVEF is less than 40% 1.5 million units IV over 60 min 3-24 hours *The time point the diagnosis is conﬁrmed with patient history & ECG ideally within 10mins from Coronary the First Medical Contract (FMC). angiography All delays are related to FMC.

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of UNSTABLE ANGINA NSTEMI ICD-10-I20.0

CONSIDER ANGINA IF ACUTE CORONARY SYNDROME: • Diffuse retrosternal pain, heaviness or 1.Angina at rest or lasting more than 20 minutes constriction. Radiation to arms or neck or back 2.Recent worsening of stable angina (crescendo) to • Associated with sweating CCS class III • Easily reproduced with post-meal exertion 3.New onset effort angina of less than 1 month in • Consider atypical presentation: Exertional CCS class II/ III fatigue or breathlessness or profuse sweating 4.Post infarction angina or epigastric discomfort ECG: More likelihood if known patient of CAD/ multiple - If ST Elevation: Follow ST Elevation MI (STEMI) risk factors STW - If no ST Elavation: UA/NSTEMI

• Pain lasting for more than 20 minutes • Associated breathlessness, profuse sweating or syncope • Recurrent or ongoing pain or rest pain • Hemodynamic instability RED FLAG SIGNS Refer as emergency to nearest Primary PCI/Thrombolysis capable centre Rest pain beyond 24hrs or without above features may be referred early for further evaluation

LOOK FOR OTHER Dissection of aorta Respiratory Evaluation: Pleuritis/ pneumonitis/ Pericardial Neuralgia or CAUSES OF PROLONGED (unequal/ absent peripheral herpes CHEST PAIN pulses) embolism/ pneumothorax rub

ANGINA UNLIKELY IF: Variable Long lasting (hours to Restricted to areas Localized Pricking or piercing Precipitated by location or days) or short lasting above jaw or to a point or stabbing type of movement of neck or characteristic (less than a minute) below epigatrium pain arms or respiration

MANAGEMENT PHC/ CHC LEVEL DISTRICT HOSPITAL TERTIARY CENTRE 1, ECG, Troponin. 1.Admit in ICU equipped with 1. Admit, reassess clinically and monitor in ICCU 2. Start ECG monitoring and 2. Continue aspirin and heparin -Aspirin, Clopidogrel defibrillator 3. Load with clopidogrel or prasugrel or ticagralor if not already done -Heparin/ LMWH 2.Troponin & bio-chemistry if 4. Optimal medical therapy to continue (BB, high dose atorvastatin, ACE-inhibitors, -High dose atorvastatin not done intra-venous nitrates if ongoing pain, severe MR or LVF) -Metoprolol 3.Serial ECG & 5. Detailed echocardiography 3. Risk stratify GRACE score or echocardiography 6. Low risk patients may undergo non-invasive risk stratification with exercise stress TIMI score 4.Continue Aspirin, test, CT coronary angiography or stress imaging - Refer High/ Intermediate risk Clopidogrel, Heparin & 7. Very high risk, high risk and intermediate risk patients may be subjected to to Metoprolol coronary revascularization PCI capable centre 5.Add nitrates if needed - Refer Low risk for further 6.Management for different Revascularization: evaluation to DH risk categories: 1. Discuss pros & cons of re-vascularization and prolonged dual anti-platelet therapy 4. Refer to PCI capable centre if: -Very high,High or 2. Revascularize if anatomy is suitable - Acute LVF Intermediate risk 3. Prefer CABG over PCI in DM with multivessel disease or left main disease - Hypotension or LVEF <40%: Refer for - Systolic murmur revascularization Revascularization strategy: - Arrythmia -Low risk patients: 1. Very High risk: Urgent re-vacsularization (within few hours) after loading preferably Conservative management with Ticagrelor or prasugrel if PCI is planned Life style modification 2. High risk patients: Early revascularization (within 24 hours) Risk factor control 3. Intermeditae risk patients: Revascularization (within 72 hours) Secondary prevention 4. Continue Dual anti-platelets in patients undergoing PCI for atleast 12 months in DES and for 3 months in BMS 1. GRACE SCORE: 2. TIMI SCORE:

Killip SBP1 Heart rate Creatinine One point for each of following Points Points Points Age. y Points Points Class mm Hg Beats/ min Level, mg/ dL 1. Age >65 yrs 2. More than 3 risk factors I 0 <80 58 <50 0 <30 0 0-0.39 1 3. Known CAD (>50% lesion) II 20 80-99 53 50-69 3 30-39 8 0.40-0.79 4 4. Recurrence of angina in 24 hrs III 39 100-119 43 70-89 9 40-49 25 0.80-1.19 7 5. Aspirin use within 7 days IV 59 120-139 34 90-109 15 50-59 41 1.20-1.59 10 6. ST deviation >0.5 mV 140-159 24 110-149 24 60-69 58 1.60-1.99 13 7. Raised cardiac markerss 160-199 10 150-199 38 70-79 75 2.00-3.99 21 >200 0 >200 46 80-89 91 >4.0 28 Sum total = TIMI score of patient >90 100

UNSTABLE ANGINA OR NSTEMI DIAGNOSIS Other risk factors Points

Cardiac arrest at admission 39 Very high risk High risk Intermediate risk Low risk ST-Segment Deviation 28 Clinical instability GRACE > 140, TIMI >4 GRACE 109-140, TIMI2-3 GRACE <109, TIMI <1 Elevated Cardiac Enzyme Levels 14 Immediate invasive Early invasive Delayed invasive Medical/ non-invasive Sum Total= GRACE score of patient <2 h 2-24 h 25-72 h strategy

If at non-PCI-capable hospital Clinical instability. rise in Very high risk: Immediate transfer to cTn, or ECG changes INVESTIGATIONS PCI-capable hospital High risk: same-day transfer ESSENTIAL INVESTIGATIONS Intermediate risk: transfer for PCI withing 72 h + Non-invasive 1. Hemogram Low risk: transfer if pursuing invasive Invasive evaluation ischaemic testing 2. Creatinine treatment 3. Sugar, HbA1C UA/NSTEMI: RISK CATEGORIZATION: UA/NSTEMI: RISK CATEGORY MANAGEMENT: 4. Fasting lipids 6. ECG Based on clinical features, GRACE score & TIMI score A)Low risk: 7. Troponin T/ Troponin I A).Very high risk: 1.Conservative management: Aspirin, clopidogrel, BB 8. Plain X-ray chest -Acute LVF and statin -Hypotension 2.TMT if ambulatory patient within a week to risk DESIRABLE INVESTIGATIONS -Uncontrolled Ventricular arrhythmia stratify 1. Echocardiography -Severe MR 3.Refer low risk for re-vascularization if 2. Exercise Treadmill Test B. High Risk: -Recurrent pain 3. C reactive protein -GRACE score > 140 or TIMI score >4 -Hemodynamic deterioration 4. B-Natriuretic Peptide C. Intermediate Risk: -New ECG change -GRACE score 109-140 or TIMI score 2-3 5. D dimer D. Low Risk: B. Intermediate/ Very High/ High risk: Re-vascularization 6. Bleeding and coagulation profile -Grace score <108 or TIMI score 0-1 7. Liver function test 8. Coronary Angiography DRUGS & DOSAGE Anti-platelets Anti-ischemic: OPTIONAL INVESTIGATIONS 1. Aspirin: Loading dose 325 mg followed by 75 mg OD 1. Metoprolol: 1. Stress Radionuclide/ 2. Clopidogrel: Loading dose 300 mg followed 75 mg OD Short acting 25-100 mg BD echocardiographic 3. Prasugrel: Loading dose 60 mg followed by 10 mg OD Long acting 25 -100 mg OD imaging 4. Ticagralor: Loading dose 180 mg followed by 90 mg BD 2. Nitrates: Anti thrombotics: Isosorbide mono-nitare 20 to 60 mg in 2 devided 2. CT scan including 1. Enoxaparin: 1 mg/Kg SC 12 hrly dose coronary angiography 2. Unfractionated heparin: Bolus of 60 U/Kg (maximum Nitroglycerine sustained release 2.6 to 6.5 mg BD 3. MRI 5000 U) followed by 12 U/Kg hourly infusion to Nitroglycerine IV 5-25 mcg/ min infusion 4. Coronary Fractional Flow maintain APTT at 50-70 sec Statins: Reserve High dose Atorvastatin 80 mg OD Ace-inhibitor 5. Intra-vascular Ultrasound Ramipril 2.5 -10 mg OD 6. VQ scan Enalapril 2.5-10 mg BD KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURE This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. ENT October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of ACUTE RHINOSINUSITIS ICD 10 J01.90 RELATED CLINICAL SCENARIOS

Recurrent acute sinusitis is episodes of acute sinusitis interspersed with symptom free intervals of more than 3 months in duration.

WHEN TO SUSPECT?

Symptoms with duration less than 7 days are treated as viral Usually a sequela of viral upper respiratory infection. infection which causes ciliary impairment and bacterial superinfection

Diagnosis- persistence of nasal blockage/ nasal discharge and facial pain/ hyposmia beyond 7 days Invasive fungal sinusitis is suspected if in addition to above symptoms (maximum upto 3 months) the following are present: facial hyposthesia, facial skin/palatal/ turbinate discoloration and proptosis/ diplopia/ reduced or loss of vision

Children may present with acute febrile illness/cough associated with these symptoms.

ALTERNATIVE CLINICAL SCENARIOS ∙ Consider alternate diagnosis if: Unilateral symptoms/ Bleeding/ Crusting/ Cacosmia (foul smell) ∙ Rule out other contributory factors: Allergy/ upper alveolar dental caries/ DNS/ LPR/ smoking. ∙ Rhinorrhoea and nasal congestion in second trimester of pregnancy is considered hormonal in etiology and is to be managed with saline irrigation/ drops

RED FLAGS FOR REFERRAL TO DISTRICT HOSPITAL

∙ Known diabetic/ immunocompromised ∙ Suspicion of complications viz. (A) Orbital involvement (Periorbital edema/ erythema, displaced globe, ophthalmoplegia, visual disturbance); (B) Meningitis/ altered sensorium; (C) Frontal fullness. ∙ Non-resolution with oral antibiotics for ten days ∙ Pointers of invasive fungal sinusitis (Facial hypoesthesia, facial skin/palatal/turbinate discoloration)

CLINICAL EXAMINATION LABORATORY INVESTIGATIONS

PRELIMINARY Desirable in non-resolving/worsening cases despite antibiotic therapy ∙ Anterior rhinoscopy: Discharge, bleeding, crusting, polyposis ∙ Oral examination: Dental caries, post nasal drip, palatal discolouration ∙ Assess for contributory factors listed above ∙ Endoscopy- for guided nasal swabs/ KOH smear ∙ CT PNS (for suspected complications / non-resolving cases on antibiotics for 14 days) DESIRABLE ∙ Screen for Diabetes / Immunodeﬁciency ∙ Nasal endoscopy

MANAGEMENT

PHC / PRIMARY LEVEL Duration of treatment 7-14 days INDICATIONS OF PARENTERAL ANTIBIOTIC THERAPY ∙ Oral antibiotics- Amoxycillin/ Co-amoxyclav for 7-10 days. Levoﬂoxacin and Azithromycin can be opted for patients intolerant/ sensitive to penicillins. ∙ Orbital/ intracranial ∙ Topical budesonide/ mometasone nasal spray once/twice a day for 2 weeks provides earlier complications symptomatic relief. ∙ Non-resolution of symptoms ∙ Normal saline nasal washes help in clearing secretions and improved effect of topical with atleast 7 days of oral medications antibiotics ∙ Topical/ oral decongestant (Oxymetazline/ pseudoephedrine) for 3-5 days relieves symptoms. ∙ Worsening of symptoms while ∙ Adequate hydration and steam inhation. on oral antibiotics ∙ Antihistaminics (patients with co-existing allergy).

DISTRICT HOSPITAL TERTIARY LEVEL • Surgical interventions to manage: Underlying anatomical conditions causing recurrent acute Cases of acute invasive fungal sinusitis/ sinusitis like- DNS/ adenoid hypertrophy/ anatomical variations seen on CT complicated acute bacterial sinusitis • Ophthalmology referral for suspected intraorbital complications and patients with • Dental deferral for suspected dental origin infection. immunocompromised status may be • Invasive fungal sinusitis- start antifungal medications, control underlying referred for management. immunocompromising co-morbidity and consider debridement.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

CT: Computerized Tomogram DNS: Deviated Nasal Septum ABBREVIATIONS PHC: Primary Health Center LPR: Laryngo Pharyngeal Reﬂux

REFERENCES 1. Indian Council of Medical Research. Treatment Guidelines for Antimicrobial Use in Common Syndromes. New Delhi, India, 2017. 2. Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298. 3. Sharma V, Saxena RK, Sharma S, Sharma G, Dhasmana DC, Mishra KC. Comparative Eﬃcacy and safety of various anti-microbials in patients of acute rhinosinusitis at tertiary-care hospital in Uttarakhand. Indian Jour Otol Head & Neck Surg, 2011, Oct ; 63 (4): 364 - 9 4. Blomgren K, Eliander L, Hytönen M, Ylinen S, Laitio M, Virkkula P. How patients experience antral irrigation. Clin Med Insights Ear Nose Throat. 2015;8:13-7.

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of CHRONIC RHINOSINUSITIS ICD 10 - J32.9

EXAMINE THE NOSE FOR NASAL POLYPI RULE OUT FOLLOWING TWO PHENOTYPES PRECIPITATING/ • Chronic sinusitis with nasal polypi (CRSwNP) EXACERBATING CONDITIONS • Chronic sinusitis without nasal polypi (CRSsNP) • Occupational exposure to irritants/ pollutants (refer to hyperlink) Signs of meningitis/ • Allergic rhinitis, aspirin intracranial sensitivity, asthma, Frontal complications laryngopharyngeal swelling WHEN TO SUSPECT? a. Fever with headache If symptoms persist for reﬂux, smoking b. Neck stiffness more than 12 weeks: • Adenoid hypertrophy, c. Photophobia bottle feeding, passive d. Altered sensorium nasal obstruction/ smoking in children e. Vomiting nasal discharge and • Medications and Orbital symptoms facial pain/ reduced RED hormones associated a. Periorbital edema/ erythema sense of smell FLAG with nasal congestion b. Displaced globe c. Double or reduced vision (loss of (NSAIDS, green-red color differentiation may antihypertensive, be the ﬁrst sign) psychotropic drugs, d. Ophthalmoplegia prolonged use of Known diabetic/ AIDS/ topical nasal immunosuppressive decongestants) medications (suspect invasive fungal sinusitis)

TREATMENT OF CRS

• Mild/ moderate symptoms (no signiﬁcant congestion/ discharge/ IN ALL PATIENTS, polypi/complications) ESPECIALLY IN THE 1. Address etiology and exacerbating factors. PRESENCE OF NASAL 2. For allergic rhinitis, antihistamines and nasal steroid spray to be POLYPI, RULE OUT given. 3. Saline nasal wash ALLERGY/ALLERGIC 4. Steam inhalation RHINITIS 5. Stretching exercises and yoga are very effective for nasal congestion 1. Consider allergen 6. Topical (oxymetazoline/ xylometazoline) and oral decongestants are avoidance associated with cardiovascular risks and rebound phenomenon. 2. Skin prick test Hence, careful patient selection and short course treatment to be 3. Co-existing bronchial followed. asthma needs to be 7. Intra nasal steroid sprays for 6-8weeks (Fluticasone proprionate/ treated Fluticasone furoate/ Mometasone) after discussing risk - beneﬁt - 4. Consider AIT if indicated. cost issues with patient regarding steroid sprays If no symptomatic relief to above treatment, perform nasal endoscopy and consider NCCT of paranasal sinuses

In presence of nasal purulent discharge 1. Culture directed antibiotics to be considered HYPERLINK 2. If culture is negative, empirical antibiotics (Amoxycillin/ (https://www.dovemed.c Co-amoxyclav/ Fluoroquinolone/ Roxithromycin) to be given for at om/diseases-conditions/ least 2weeks. airborne-irritant-induce 3. Upper dental (particularly 1st molar) infection may cause maxillary d-sinusitis/) sinusitis which is to be treated with metronidazole.

• In the presence of nasal polypi, initial nasal steroid spray and subsequent endoscopic surgery is to be planned. 1. Short course of oral steroid (Prednisolone 0.5 mg/kg for 5 - 10 days) provides temporary relief in nasal obstruction in extensive polypi. 2. Steroid therapy is not a replacement for surgery.

Always rule out Prolonged use of Identiﬁcation of Ensure adherence Educate patients DNS/ nasal polypi topical nasal precipitating or to nasal saline on correct 1 2 in CRS, as surgical 3 4 5 decongestant beyond exacerbating washes / regular technique of using treatment may be 5-7 days may cause factors is the key physical activity / steroid nasal sprays necessary for rebound congestion to successful medications. and nasal irrigation. complete and rhinitis treatment resolution of medicamentosa and to outcome. symptoms. be strongly discouraged.

ABBREVIATIONS

CT: Computerized Tomogram AIT: Allergen Immuno Therapy DNS: Deviated Nasal Septum

REFERENCES • Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298. • Cain RB, Lal D. Update on the management of chronic rhinosinusitis. Infect Drug Resist. 2013;6:1-14. • Ah-See KL, MacKenzie JM, As-See KW. Management of chronicrhinosinusitis. BMJ. 2012;345:e7054. • Slovick A, Long J, Hopkins C: Updates in the management of chronic rhinosinusitis. Clin Pract. 2014;11(6):649–63. 10.2217/cpr.14.71

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of EPISTAXIS ICD-10-R04.0

Acute bleeding from the ESSENTIAL CLINICAL EXAMINATION nose after physical trauma/ barotrauma/ nose picking/ physical exertion. ESSENTIAL

• Local examination by anterior rhinoscopy/ endoscopy to look for source of bleeding (scanty/moderate). Acute bleeding from the • Little’s area bleeder/clot/congestion CLINICAL nose in hypertensive / • Sharp septal spur SCENARIOS hematological disorders. • Congested nasal mucosa as in URTI • General physical examination to evaluate other systems (Cardiovascular/Lower Respiratory/Neurological) clinically.

Acute bleeding from the SYSTEMIC ASSESSMENT nose without any obvious cause. Screen for coagulation disorders/ anticoagulant medications/ hematological malignancies

MANAGEMENT

STEP-WISE MANAGEMENT PRINCIPLE Trotter’s Position 1. Ensure patent airway/ avoid aspiration by head down/lateral positioning 2. Restore hemodynamic stability by intravenous ﬂuid replacement/ transfusion 3. Control bleeding/bleeder by • Bidigital compression of nose for 10 minutes in Trotter’s position (cotton pledgets soaked in 4% xylocaine with adrenaline may be used) • Short term tab labetalol will take care of uncontrolled hypertension • Chemical/electrocauterization of bleeder in Little’s area 4. Tamponade of bleeders by anterior nasal packing/ epistaxis balloon 5. Posterior nasal packing if bleeding is not controlled with above measures 6. Antibiotic prophylaxis and hospitalizarion is recommended after nasal packing 7. H2blockers/ PPI to be given in case of blood aspiration to avoid gastritis 8. Persisting bleeding despite nasal packing > consider arterial ligation (sphenopalatine / anterior ethmoidal artery). 9. Selective embolization is an alternative to surgery 10. Address identiﬁed etiology, if any

INVESTIGATIONS Features suggestive of neoplasia ESSENTIAL . Unilateral bleeding . Nasal obstruction 1. Hemoglobin level .Visual/orbital symptoms Altered blood counts/ coagulation 2. Coagulation proﬁle . Obvious mass lesion 3. Complete blood count proﬁle Persistent bleeding despite nasal packing Recurrent profuse bleeding - Consider JNA in teenage boys DESIRABLE - Aneurysmal bleeding (specially following trauma) to be ruled out CT scan with contrast in cases with no by DSA - To be managed by appropriate obvious cause// suspected benign or treatment at tertiary level malignant lesion RED FLAG SIGNS

FOLLOW UP SERVICES QUALITY ASSESSMENT PARAMETERS

1. Continued nasal lubrication for 2 weeks with liquid 1. Recurrence of episodes parafﬁn 2. Improvement in hemoglobin level over a period of 2. Repeat anterior rhinoscopy/ endoscopy to time. know/conﬁm the cause of bleeding 3. Oral hematinics to be considered if needed

POINTS TO PONDER WHILE MANAGING EPISTAXIS

1. Epistaxis in children is almost always anterior and from Little’s area, consequent to mucosal drying by dry air. 2. Epistaxis in adults is often related to hypertension and arises posteriorly from the posterior end of inferior turbinate 3. Initial non-invasive methods may sufﬁce in a large majority of patients.

ABBREVIATIONS

JNA: Juvenile Nasopharyngeal Angioﬁbroma CT: Computerized Tomograms DSA: Digital Subtraction Angiography URTI: Upper Respiratory Tract Infection

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of HEARING IMPAIRMENT IN PEDIATRIC AGE GROUP 0 12 YEARS ICD 10 H90.5

Disabling hearing impairment (31 or more dB HL in better ear) may affect language development and learning outcomes and hence needs urgent intervention

WHEN TO SUSPECT IN CHILDREN UNIVERSAL HEARING SCREENING FOR 1. Parental concern about delayed speech, language, and CONGENITAL DEAFNESS developmental delay (refer to red ﬂags) • Community based hearing screening: 2. Family history of Hearing Loss (HL). i. May be co-ordinated with 3. Exposure to ototoxic drugs/ hyperbilirubinemia requiring immunization schedule exchange transfusion/ Neonatal ICU stay for > 3days. ii. By primary health care workers. 4. In-utero infections (CMV/ rubella/ syphilis/ herpes/ iii. Using calibrated noisemakers/ toxoplasmosis) toys 5. Syndromes (NF) Or neurodegenerative disorders (Hunter syndrome, FA) associated with HL. • All children who fail preliminary 6. Post-natal infection known to cause HL (Meningitis) screen to undergo detailed evaluation 7. Head Trauma at health care facility. 8. Recurrent/ persistent (>/=3 months) middle ear disease 9. Chemo/ Radiotherapy to head and neck

EVALUATION COMMON CAUSES OF HL ESSENTIAL 1. Impacted wax 1. Clinical examination to look for ear canal deformities, tympanic membrane and 2. Middle ear ﬂuid assciated with middle ear status by otoscopy/ otoendoscopy. adenoid hypertrophy/ cold climate 2. Age appropriate audiological/ behavioral observation tests in a soundproof room by 3. Tympanic membrane perforation audiologist/ ENT specialist. 4. Sensorineural Hearing loss (SNHL) due 3. Tympanic membrane mobility test/ tympanometry. to various causes as indicated earlier

RED FLAGS POINTING FOR URGENT HEARING EVALUATION

- 6months- no head turning to the side of calling - 1yr- no babbling/ speech like sound production - 1.5yrs- not saying mama/papa/dada or other names - 2yrs-not pointing to pictures/ body parts when named or speaking less than 10 words - 3 yrs- does not understand action words or not asking for things by names or not speaking small sentences. - At any age- has regressed or lost previously acquired speech/ language milestones

MANAGEMENT

GUIDING PRINCIPLES

CONDUCTIVE HL SNHL Middle ear fluid (OME) may be Wax removal under direct associated with adenotonsillar disease Appropriate vision by ENT specialist which needs to be treated. Initially amplification, relieves hearing impairement medical treatment and surgery to be preferential seating in Screening for considered for OME persisting for more classroom developmental Appropriate surgery is to than 3months/ earlier in the presence of delay by be planned for tympanic speech and language delay pediatrician/ membrane perforation Periodic evaluation psychologist For non-surgical condidates/ delayed for hearing aid users surgical management, amplification for mould fitting by hearing aid to be reinforced in and amplification bilateral CHL. settings

DIVISION OF RESPONSIBILITIES PHC LEVEL DH LEVEL

1. Audiometric evaluation by Audiologist/ Otolaryngologist • Suspect HL 2. Hearing aid dispensing (mould ﬁtting and HA programming) • Initial evaluation 3. Rehabilitation by speech therapist • Referral if initial evaluation is suggestive of HL 4. Appropriate surgery for CHL • Follow up of rehabilitated/ treated patients with HL 5. Training programme for parents of hearing impaired children • Prevention of HL to enhance pre-school language development

QUALITY ASSESSMENT PARAMETERS TERTIARY LEVEL • Short term: Quality of ampliﬁcation using • Surgical intervention options : Cochlear implant / BAHA (as per ADIP electroacoustic objective measures and culturally guidelines) appropriate subjective questionnaire tools • Interdisciplinary team based interventions in children with multiple • Long term (Desirable) : Use CBR matrix based disabilities. measurement for ensuring holistic rehabilitation

FOLLOW UP SERVICES

1. Home visits by Health Worker/ASHA to ensure utilization of assistive devices and support parents to enhance language development. 2. School visits to educate teachers and normally hearing children to include their peers with hearing disability in the school environment 3. Home/ school visit by social worker for evaluation of social/ educational/ livelihood/ justice and empowerment domains of the child

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

ADIP : Assistance to disabled BAHA : Bone Anchored Hearing Aid FA : Friedreich Ataxia ABBREVIATIONS persons for purchase/ ﬁtting of CBR : Community Based Rehabilitation NF : NeuroFibromatosis aids and appliances CMV : Cyto Megalo Virus OME : Otitis Media with Effusion REFERENCES • Indian Council of Medical Research. Audiological evaluation protocols. Task force project on prevalence and etiology of hearing impairment, New Delhi. 2015 • Ramesh A, Jagdish C, Suman Rao PN et al. Low cost calibrated mechanical noisemaker for hearing screening in resource constrained settings. Indian Journal of Medical Research. 2012, 135: 170 - 176. • Rathna.B.Shetty. Manual for training parents of hearing impaired children (Kannada : Kivudu makkalige kalisuva vidhana). Parents association of deaf children. Mysore. • Chapal Mkhasnabis, Karen Heinicke Motsch (eds.) Towards community based inclusive development. World Health Organisation: 2010. • Margaret Lavina Fernandes. Guidelines to establish a community based rehabilitation program for hearing impaired children in medically underserved areas. St. John’s Medical Journal, 2018 (1), 5 : 14 - 27 • ADIP Guidelines : http://disabilityaﬀairs.gov.in/content/page/adip-scheme.php

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of NECK SPACE INFECTION ICD-10-J36, J39.0, K 12.2, J39.1

Rapidly progressive bacterial infections which spread along facial planes and spaces of head and neck region. They may be fatal unless emergently treated. Most of these infections are secondary to dental infection.

The typical presentation is with acute onset of pain and swelling in the neck with fever, malaise, trismus and dysphagia.

Extension along spaces to involve multiple deep neck spaces is frequent and may extend to parotid space, masticator space, temporal space, visceral vascular CLINICAL SCENARIOS (carotid) space.

They usually present as • Ludwig’s angina (submandibular space infection) • Peritonsillar abscess Cervical space infection may spread inferiorly to the anterior mediastinum and • Parapharyngeal abscess posteriorly along prevertebral space. • Retropharyngeal abscess

Tubercular cold abscess involves the same anatomical spaces but would not display inﬂammatory signs or rapid progression.

SYSTEMIC ASSESSMENT

Screen for diabetes mellitus, HIV infection, agranulocytosis and immunosuppressive therapy or chemotherapy. Signs of inﬂammation may be less marked and disease course may be more rapidly progressive in immunocompromised patients.

CLINICAL EXAMINATION

• Airway assessment to rule out stridor or respiratory compromise RED FLAGS FOR REFERRAL TO DISTRICT HOSPITAL • Look for signs of dehydration • Monitor temperature, heart rate, respiratory rate, BP, and signs • Breathing difficulty of sepsis/ septic shock. • Trismus • Oral cavity examination to check jaw opening, condition of teeth • Torticollis/ neck stiffness and floor of mouth • Subcutaneous crepitus and skin discolouration • Oropharyngeal examination to check for inflammed medially or blisters suggest necrotizing fibrofascitis. displaced tonsil & uvula and bulge in lateral pharyngeal wall • Toxaemia • Palpation of neck for lymph nodes, cellulitis, abscess or • Lower cranial nerve palsy subcutaneous crepitus • Facial puffiness suggestive of venous • Cranial nerve examination to rule out lower cranial nerve palsies thrombosis • Mediastinal extension

INVESTIGATIONS

ESSENTIAL INVESTIGATIONS

1. Contrast enhanced CT scan of head and neck is the standard in evaluation of neck space infections. If CT Scan facility is not available, following should be done:- a. Lateral x-ray neck: Prevertebral soft tissue thickening >7 mm at the level of C2 or > 2/3rd of the width of the vertebral body at C6 is highly suggestive of retropharyngeal abscess. It may also demonstrate foreign bodies, subcutaneous air, air ﬂuid levels and erosion of vertebrae. b. Ultrasound neck can suggest abscess and guide aspiration attempts. 2. Blood: Total and differential leukocyte count, blood sugar, urea 3. Abscess Cultures with Gram stain to direct antimicrobial therapy. Anaerobic culture, when available.

MANAGEMENT

PHC/PRIMARY LEVEL DISTRICT HOSPITAL INDICATIONS FOR I&D 1. Cautiously assess the 1. Hospitalization: As an emergency for close watch and intensive airway. If found management. • Necrotizing fibrofascitis compromised, do 2. Airway management: In progressive disease, in view of impending • Abscess formation endotracheal intubation/ airway compromise, consider securing the airway early. During acute • No response to antibiotics over consider tracheotomy respiratory difficulty, tracheostomy should be done if intubation is 48-72 hours 2. Immediately gain an IV difficult • Deterioration despite antibiotics access for hydration, broad 3. Correction of fluid and electrolyte imbalance over 24 hours spectrum antibiotics and 4. Antibiotics: Early and aggressive IV antibiotic therapy with a • Airway compromise or impending pain killers. combination of Crystalline Penicillin, Aminoglycoside and airway compromise 3. Transfer the patient to Metronidazole or Clindamycin is preferred. • Mediastinal spread hospital with facility for 5. Incision and drainage: Peritonsillar abscess is drained intraorally. All • Vascular complication like venous surgical drainage other abscesses are drained via an external approach thrombosis

QUALITY ASSESSMENT PARAMETERS FOLLOW UP SERVICES

Complete resolution of infection and follow up to ensure no recurrence; Consider cold tonsillectomy for patients with history of multiple treatment of initial cause of infection in tooth or tonsil. episodes of tonsillar abscess

ABBREVIATIONS CT – Computerized Tomography MRI – Magnetic Resonance Imaging

REFERENCES 1. Smith II JL, Hsu JM, Chang J (2006) Predicting deep neck space abscess using computed tomography. Am J Otolaryngol 27: 244-247. 2. Mayor GP, Millán JMS, Martínez VA (2001) Is conservative treatment of deep neck space infections appropriate? Head And Neck 23: 126-133. 3. Bottin R, Marioni G, Rinaldi R, Boninsegna M, Salvadori L, et al. (2003) Deep neck infection: A present day complication. A retrospective review of 83 cases. Eur Arch Otorhinolaryngol 260: 576-579.

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of OTORRHOEA ICD-10-H92.10

CLINICAL SCENARIOS

DISEASES OF EXTERNAL EAR

• Serous/purulent discharge with signiﬁcant tenderness of external ear amidst edema (localized-pus: furunculosis or generalized: Acute otitis Fig 1 externa denoting Staph/ Pseudomonas infection)

Fig 2 • Thick discharge with itching usually in hot/ humid climate: Otomycosis (Candida- white spores; Aspergillus- black spores) [Fig 2]

• Scanty serous discharge & itching with desquamated debris in ear canal Eczematous otitis externa (EAC) Fig 3

FIGURES Fig 4A 1: Furunculosis DISEASES OF MIDDLE EAR 2: Otomycosis • URI with severe ear pain (manifested in children as inconsolable 3: Resolving AOM crying and ear tugging), relieved with episode of mucopurulent blood 4A: Safe CSOM (central perforation) stained otorrhoea: Resolving AOM [Fig 3] 4B: Safe CSOM (subtotal Fig 4B perforation) • Mucopurulent discharge > 12 weeks : CSOM 5A: Unsafe CSOM (cholesteatoma) • Active : otorrohoea in last 12 weeks 5B: Unsafe CSOM (granulation) • Inactive : no otorrohoea in last 12 weeks 6: Traumatic Perforation • Safe type : central perforation [Fig 4A] and total perforation [Fig 4B] • Unsafe type : cholesteatoma [Fig 5A] and granulation [Fig 5B]

Fig 5A • Recurrent painless profuse mucopurulent discharge with pale granulations/ multiple perforations unresponsive to antibiotics: Tubercular otitis media should be suspected and needs biopsy conﬁrmation Fig 5B • Bloody otorrhoea following Trauma: Traumatic perforation

Fig 6 • Acute onset bloody discharge with neural deﬁcits/ neck nodes: Neoplasia

• Watery otorrhoea (may be associated with trauma) : CSF Otorrhoea

CLINICAL EXAMINATIONS INVESTIGATIONS RED FLAGS FOR REFERRAL TO DISTRICT LEVEL

• Otoscopy as a part of Complete • Pure tone audiometry • Periaural abscess or cellulitis ENT examination by primary • Routine hemogram including blood • High grade fever, dizziness and toxic appearance physician (Tele-otoscopy sugar (fasting and postprandial) • Severe headache with neck stiffness/ vomiting / interpreted by physician) • CT/ MRI in suspected complications altered sensorium. • Hearing evaluation by (refer to red ﬂags) • Facial palsy/ Neurological defecits conversation/ whisper/ Tuning • Soft tissue x ray nasopharynx (To • Diabetic with severe deep seated ear pain / neural forks tests examine adenoid enlargement in defecits (Skull base osteomyelitis) • General and systemic clinical children) • Physical trauma with bloody/ watery discharge (suspected CSF leak) examination • Culture & sensitivity of aural secretions. • Suspected tuberculosis/ neoplasm

MANAGEMENT

PHC / PRIMARY LEVEL DISTRICT HOSPITAL

• Acute otitis externa: Oral Ciprofloxacin/ Amoxycillin clavulanic acid combination for 7-10 days (2 weeks • Surgical interventions except maximum) and analgesics. Ichthammol gycerine (1:9) packing of EAC in moderate to severe edema. Refer neurosurgical interventions (eg I&D, pus pointing furuncle to DH tympanoplasty, mastoidectomy) • Otomycosis: Cleaning and Clotrimazole ear drops • Biopsy in suspected neoplasm • Eczematous otitis externa: Ciprofloxacin ear drops with steroid combination. • Medical management of medical • AOM / Resolving AOM: Oral amoxicillin / Erythromycin / Clarithromycin for 10 days. With no response in 3 co-morbidities such as diabetes, days start Amoxycillin clavulanic acid combination for 10 days. Refer to DH if no resolution tuberculosis, meningismus/ • Inactive CSOM: Referral to DH for surgery. meningitis • Active CSOM: Ciprofloxacin ear drops with dry mopping & referral to DH for surgery. A course of oral antibiotics maybe prescribed in ase of persistant otorrhoea after topical antibiotics TERTIARY LEVEL • Traumatic perforation: Topical antibiotics for otorrhoea if any and maintain ear dry till healing complete Surgical management particularly • In case of suspicion of complications start intravenous Amoxycillin clavulanic acid combination and refer to of intracranial complications DH including neurosurgical interventions

• Patient to be educated for proper technique of ear mopping, contralateral lie (10 min) following instillation of drops & avoiding water entry e.g ear-plugs during bathing • To ensure adequate immunization (measles/ H.Inﬂuenza/ Pneumococcus) in recurrent AOM and to adopt correct posture during breastfeeding while avoiding bottle feeding • Pus culture sensitivity to guide antibiotic regime in recurrent/ complicated cases Patient education to refrain from indigenous (oil/ hot water/ acid etc) ear treatments

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

CT: Computerized Tomogram AOM: Acute Otitis Media EAC: External Auditory Canal ABBREVIATIONS MRI: Magnetic Resonance Imaging CSOM: Chronic Suppurative Otitis Media URI: Upper Respiratory Infection REFERENCES • Otitis media (acute): antimicrobial prescribing. NICE guideline. Published: 28 March 2018. nice.org.uk/guidance/ng91 • Primary ear and hearing care training resource, Student’s workbook: intermediate level. Chronic disease prevention and management. WHO 2006 • Primary ear and hearing care training resource, advanced level. Chronic disease prevention and management. WHO 2006 • Treatment Guidelines for antimicrobial use in common syndromes. ICMR. Department of Health Research. 2017 • Sagar P, Thakar A, Samant S. Otorhinolaryngology. In Paul VK, Bagga A. eds. Ghai Essential Pediatrics, 9th ed. New Delhi: CBS Publishers & Distributors; 2019. p.357-370

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Oct o ber/ 2 01 9

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of PHARYNGITIS AND SORE THROAT ICD-10-J02

Acute onset of throat pain with or without – Fever, tonsillo-pharyngeal exudates, odynophagia and tender cervical lymphadenopathy is typically seen in bacterial pharyngitis. Streptococcal (GABHS) pharyngitis is the commonest cause of bacterial pharyngitis

Rhinitis, conjunctivitis, skin or mucosal rashes point towards a viral etiology. Pharyngitis and sore throat may be the initial symptoms in epidemics of ﬂu

CLINICAL SCENARIOS

Acute pharyngitis Sore throat followed by high grade fever, cough, drooling, lymphadenopathy, may include a breathing difﬁculty suggest Epiglottitis or Laryngotracheobronchitis, spectrum of disease especially in pediatric patients varying from simple viral pharyngitis to dreaded neck space infection. An adherent membrane extending beyond the tonsillar conﬁnes with toxaemia suggests Diphtheria

Pharyngitis with generalized lymphadenopathy is consistent with Infectious Mononucleosis (IM)

Smoking and GERD are common causes of non-infective pharyngitis

CLINICAL EXAMINATION

PRELIMINARY • Temperature chart: fever is usually absent or low-grade in viral pharyngitis DESIRABLE RED FLAGS • Check for vitals/ signs of dehydration due to compromised oral intake due to odynophagia • Generalized • Complete oral and oropharyngeal examination with tongue depressor Assess Centor lymphadenopathy • Palpate for cervical and generalized lymphadenopathy • Cardiac murmurs • Rheumatic fever and acute glomerulonephritis are potential systemic complications of criteria and • Purulent streptococcal pharyngitis productive cough ascertain • Hepatosplenomegaly can be found in IM with tachypnea • A sandpapery scarlatiniform rash may be seen in GABHS infection whereas maculopapular its suggestive of LRTI rashes are seen with various viral infections and with IM empirically treated with penicillin score • Hot potato voice • Unilateral tonsillar enlargement CENTOR UNLIKELY TO HAVE LIKELY TO HAVE REQUIRE LAB TESTS TO • Tonsillar CLINICAL FEATURES membrane going SCORE GABHS GABHS CONFIRM GABHS INFECTION beyond its Fever 1 conﬁnes • Agranulocyosis Anterior cervical 1 lymphadenopathy Score = 0-1 Score = 4 Score = 2-3 • Epidemic of ﬂu Tonsillar exudate 1 Absence of cough 1

INVESTIGATIONS

ESSENTIAL OPTIONAL DESIRABLE

Throat swab for culture, routine hemogram including GABHS rapid antigen detection test (RADT) Lab tests to rule out EB Virus, Coxsackie virus, total and differential leukocyte counts and peripheral Herpes virus, fungal or Gonococcal pharyngitis smear to look for atypical lymphocytes (seen in IM).

MANAGEMENT

PHC / PRIMARY LEVEL DISTRICT HOSPITAL

1. Assess the patient for signs of toxicity, epiglottitis or oropharyngeal abscess 2. Ensure vitals/ hydration of the patient 3. Saltwater gargle, warm liquids, and rest may be helpful in relieving symptoms Management of 4. Ibuprofen or Paracetamol is recommended for analgesia complication 5. Antibiotic therapy: e.g. a. Patients positive for all 4 Centor criteria to be treated with antibiotics without waiting for antigen testing or cultures • Deep neck b. Patients with Centor score of 2&3 to be treated with antibiotics only if antigen testing or throat swab culture is positive space infection c. Patients with Centor score of only 1 not to be treated with antibiotics • Diphtheria d. Amoxicillin (50 mg/kg/d in 2-3 doses orally) for 10 days is the ﬁrst choice for GABHS infection. For patients who are • Epiglottitis sensitive for penicillin group, Erythromycin or Azithromycin is the antibiotic of choice • Croup 6. Parenteral antibiotics (Ceftriaxone/ cefotaxime) and steroids are to be started when the airway is compromised due to suspected epiglottis/ Croup. FOLLOW UP SERVICES

Recurrent (more than 7 episodes in previuos year or 5/year in last two years or 3/year in last 3 years) tonsillitis episodes need to be evaluated for tonsillectomy.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

GABHS: Group A Beta Hemolyticus Streptococcus EB: Epstein Barr GERD: Gastro Esophageal Reﬂux Disease ABBREVIATIONS RADT: Rapid Antigen Detection Test LRTI: Lower Respiratory Tract Infection REFERENCES

Cochrane Database Syst Rev. 21. CD004872. This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. NEPHROLOGY October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of ACUTE KIDNEY INJURY ICD-10-N17.9

SYMPTOMS PRELIMINARY ACTIONS • Reduced urine output • Monitor urine volume & body weight • Dark, concentrated urine • Identify and treat life-threatening complications • Correct hydration status • Swelling over feet/face • Stop nephrotoxic drugs • Breathlessness • Exclude urinary outlet obstruction • Stabilize blood pressure • Treat infection • Assess for dialysis need

LOOK OUT FOR AKI IN THE PRESENCE OF DESIRABLE ACTIONS/INVESTIGATIONS • Hypotension • Stage AKI (KDIGO criteria*) • Volume loss (eg: vomiting, • Check electrolytes, acid-base status diarrhea, bleeding); heat • Urinalysis exposure or heat stroke • Rule out pre-existing kidney disease WHAT IS AKI? • Ultrasound of KUB region Increase in Serum • Pregnancy-related • Assessment for infection creatinine by >0.3 complications • Laboratory investigation for speciﬁc cause mg/dl in 48 hours • Multiple organ failure AND/OR Urine • Nephrotoxic medication use output <0.5 ml/kg/h for 6–12 hours • In neonates - oligohydramnios/ birth asphyxia, respiratory AKI IN SPECIFIC SETTINGS distress • Neonatal - refer to paediatrician • Pregnancy - manage complications • Envenomations - antivenin, hemodynamic correction • Poisoning - speciﬁc antidote when available • Systemic disease - refer for investigations • Kidney transplant recipient - refer to PRINCIPLES OF ASSESSMENT nephrologist • Determine whether pre-renal, renal or post-renal • Identify and correct reversible factors TREATMENT OF HYPERKALEMIA • Look out for occult causes (e.g. • Calcium gluconate 1000 mg slow IV under ECG envenomations, poisoning) monitoring, can be repeated upto 3 times • Determine severity of AKI • Salbutamol : 10 to 20 mg in 4 mL of saline by • Identify complications nebulization • Insulin-dextrose: 10 to 20 units of regular insulin • Decide need for dialysis in 100 ml 25% or 50% dextrose

MANAGEMENT

PRIMARY CARE SECONDARY CARE TERTIARY CARE • Detailed history and physical • Detailed history and physical • Detailed history and physical examination examination examination • Identify and correct volume deficit • Identify and correct volume deficit • Identify and correct volume deficit • Stop nephrotoxic agents • Stop nephrotoxic agents • Stop nephrotoxic agents • Identify and correct urinary tract obstruction (USG, CT • Identify and correct bladder outlet • Identify and treat hyperkalemia, scan) obstruction metabolic acidosis and pulmonary • Identify and treat hyperkalemia, metabolic acidosis • Give anti-snake venom if indicated edema and pulmonary oedema • Identify hyperkalemia and start • Identify and correct urinary tract • Detailed investigation for infections treatment obstruction (USG, CT) • Manage pregnancy complications- deliver if indicated • Identify pulmonary edema- start • Detailed investigation for infections • Look for underlying CKD intravenous furosemide and • Manage pregnancy complications - • Investigations for specific cause (including imaging, oxygen deliver if indicated genetic tests) • PD if indicated • Look for underlying CKD • Kidney biopsy • Timely referral after stabilisation • Dialysis (PD or HD) • Dialysis (PD or HD)

RED FLAGS FOR URGENT INDICATIONS FOR DIALYSIS FOLLOW-UP OF AKI REFERRAL • Fluid overload • UO > 1L, stable or falling creatinine, no symptoms: stop • Pericarditis dialysis • Hyperkalemia • Not resolving for >2 weeks: CECT to exclude cortical • Indications for dialysis • Severe metabolic acidosis necrosis; kidney biopsy as indicated • Unexplained AKI • Encephalopathy • Look for systemic diseases (e.g. vasculitis, myeloma, • Involvement of other organs • Severe uraemia TMA) • Sepsis • To create space for ﬂuids or blood • Serum creatinine and urine protein q 6-12 months for • Systemic disease products life • Complicated pregnancy

ABBREVIATIONS

AKI: Acute Kidney Injury PD: Peritoneal dialysis CKD: Chronic Kidney Disease UO: Urine output CECT: Contrast-enhanced CT scan TMA: Thrombitic microangiopathy HD: Hemodialysis USG: Ultrasonography

REFERENCE

*KIDNEY DISEASE: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int, Suppl. 2012; 2: 1–138

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of CHRONIC KIDNEY DISEASE CKD ICD-10-N18.3

WHEN TO LOOK FOR CKD BP CONTROL • History of long-standing nocturia, or constitutional symptoms ( TARGET <130/80, • Edema, hematuria, proteinuria or renal stones 120/80 IF PROTEINURIA) • Long-term intake of painkillers or herbal medicines • Restrict dietary salt to < 5 g/day • Family history of kidney disease • Use any anti-HT available in local • Growth retardation, rickets, or proximal myopathy pharmacy • Unexplained hypertension or anemia • Diuretics - eGFR > 45 : thiazide, • Longstanding diabetes, hypertension, CVD, stroke, PVD <45 ml/min: furosemide; <30 • Systemic diseases (e.g. connective tissue disease) ml/min: do not use potassium sparing agents EVALUATION OF NEWLY DIAGNOSED PATIENT • ACEI/ARB preferred* for WITH CKD proteinuric patients (> 1 g/d) • Serum creatinine, electrolytes, bicarbonate *caution/do not use if eGFR <30 • Estimate glomerular filtration rate using CKD-EPI ml/min, or Potassium >5.5 mEq/L equation • Urinalysis (examine sediment, proteinuria quantitation) VACCINATION SCHEDULE FOR WHAT IS CKD? • Ultrasound of kidneys and urinary tract NEWLY DIAGNOSED CKD • Calcium, phosphate, alkaline phoshatase, albumin PATIENT Abnormalities of • CBC including peripheral blood film • If HBV -ve: 20 µg IM in each kidney structure or • Iron profile - Serum iron, TIBC, TSAT deltoid at 0,1,2 and 6 months function, present for >3 • HBsAg, anti-HCV • In children - complete primary months, with vaccination schedule implications for health INITIAL ASSESSMENT FOR • Confirmation of CKD diagnosis (repeat tests after ANEMIA MANAGEMENT 3 months) • Establish iron replete state • Staging and progression rate • If not iron replete, give oral iron • Establishing cause of kidney disease • Consider IV iron for dialysis patients • Identify and treat reversible factors (hypertension, and those not tolerating orally volume loss, obstruction, infection) • If Hb still <8 g/dl – start erythropoietin, • Look for complications (anemia, bone disease, titrate to Hb 10-11 g/dl dyselectrolytemias, CVD) MANAGEMENT OF HYPERPHOSPHATEMIA (PO4>5.5) LIFESTYLE MEASURES FOR ALL CKD PATIENTS: • Start with Ca-containing binders • Weight control/ weight gain monitoring in children • Non Ca-binders can be used if • Regular physical activity serum Ca >9 mg/dl, vascular • Reduce dietary salt intake to < 5 g/day calcification or low iPTH • Stop tobacco use in all forms • Stop/moderate alcohol use • Stop using unproven health supplements DIABETES CONTROL (TARGET • Do not use NSAIDS HBA1C <7%) • Avoid untested indigenous medicines • Do not use metformin if eFGR <30

NUTRITION VITAMIN D THERAPY LOW POTASSIUM FRUITS/ • Salt restriction < 5g/d. Protein 0.6-0.8 g/kg/day. VEGETABLES: • Supplement 60,000 • DO NOT restrict proteins unless documented high protein units cholecalciferol user (dairy, white meat are good protein sources, mix Apple, pineapple, papaya, pear, q2W different types of dal). tangerine, watermelon, grape, • Correction of acidosis • Restrict green leafy vegetables if eGFR <30 ml/min plum, cabbage, carrot, cauliﬂower, with oral sodium • Avoid fruit juices, coconut water and carbonated beverages onion, radish, peppers, chillies, bicarbonate • For children: ensure adequate protein intake appropriate brinjal, cucumber, green beans, • Activated vitamin D if for age. peas, rice, bread hyperparathyroidism

MANAGEMENT PRIMARY CARE INDICATIONS FOR REFERRAL • Detailed history and physical examination • Initial evaluation of all newly diagnosed cases • Identify and correct reversible factors • Rapid disease progression • Stop nephrotoxic agents • New complication • Referral after stabilization • Discussion for Renal Replacement Therapy (RRT)

ADMISSION CRITERIA DISTRICT HOSPITAL • Initial evaluation or when patient presents with speciﬁc • Detailed history and physical examination problems – like acute worsening, development of a new • Investigate to ascertain cause of CKD complication • Tailor treatment to cause • For creation of vascular access • Identify and manage complications • For PD catheter placement or initiation • Vaccination • Initiation on HD and for kidney transplant • Identify and correct acute factors • Counseling: nutrition, lifestyle, pregnancy in women of child-bearing age • Discussion regarding RRT • Vascular access creation or PD Catheter insertion TERTIARY CARE • Send patient back to community with treatment plan • Detailed history and physical examination • Investigate to ascertain cause of CKD (imaging/biopsy/genetic studies) PREPARATION FOR RENAL REPLACEMENT THERAPY • Tailor treatment to cause • eGFR < 30 : Preserve veins in the non-dominant arm for AV Fistula • Identify and manage complications • eGFR < 30 : discuss RRT options. • Vaccination • eGFR < 15 : May need dialysis soon, counsel for AV ﬁstula, list for transplant • Counseling: nutrition, lifestyle, pregnancy in • Dialysis start : depends on symptoms or eGFR <5 ml/min women of child-bearing age • Look for contraindications to HD or PD : discuss choice in those suitable for either • Discussion regarding RRT • Vascular access creation/PD catheter insertion • Work-up for transplantation CONSERVATIVE CARE • Send patient back to community with • If life expectancy limited, multiple comorbidities/personal preference treatment plan • Decision-making should be shared with patient/family

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of GLOMERULONEPHRITIS ICD-10-N05.9

IDENTIFY THE PRESENTING EVALUATION OF A PATIENT WITH GN CLINICAL SYNDROME • Full history and clinical examination • Urinalysis: urine routine exam, microscopy Acute nephritic • proteinuria quantitation: 24 h UP; ACR/PCR for follow up syndrome: Sudden WHAT IS GN? • Assess eGFR using age-appropriate formula onset, hematuria, • Renal imaging oliguria, edema, • Serologic testing Glomerulonephritis hypertension, reduced refers to an • Kidney biopsy eGFR inﬂammation of the glomerulus hence it is not strictly a single Nephrotic syndrome: KIDNEY BIOPSY disease, its proteinuria (>3.5 • Age <1 y or >12 y presentation depends g/1.73m2/d; 50 mg/kg/d in • Steroid resistant state on the speciﬁc children), edema, • Family history of kidney disease disease entity. It may hypoalbuminemia, • Features suggestive of systemic disease present as hyperlipidemia • Diagnosis unclear, therapeutic uncertainty symptomatic urinary • Doubling of serum creatinine over days-weeks abnormalities/ nephrotic syndrome/ Asymptomatic urinary nephritic syndrome/ abnormalities: proteinuria, SEROLOGY AKI/ CKD hematuria • ASO • HBsAg, anti-HCV • HIV (high risk) • C3 RPGN: doubling of serum • ANA • ANCA creatinine over days to • Anti-GBM antibody • SPEP (>50 y) weeks • Anti-PLA2R

TREATMENT IN CHILDREN <12 Y WITH NEPHROTIC SYNDROME DO NOT Lifestyle modiﬁcations Avoid nephrotoxic agents • Give any vaccine while on steroids or within 3 months of stopping BP control (<130/80 mm Hg • Prescribe bed rest unless indicated Sodium restriction (not in children) in adults, <95th centile for • Restrict salt in children with nephrotic syndrome age in children) • Restrict ﬂuids • Use ACE inhibition in children with renal dysfunction, Diuretics - loop needed, ACE inhibition (see reverse edema slowly exceptions under DO NOT) or in steroid sensitive nephrotic syndrome

RECOMMENDED PHARMACOLOGICAL TREATMENT ADULTS BEFORE STARTING STEROIDS IN CHILDREN, CHILDREN • Prednisolone 2 • Treatment Depends on diagnosis (biopsy, REMEMBER TO mg/kg x 6 w serology) • Look for latent TB (Mantoux test, Chest X-ray) followed by 1.5 • Therapeutic choices include • Start 6 months INH therapy (5mg/kg day) if mg/kg A/D x 6w • Corticosteroid (Prednisolone, IV asymptomatic Mantoux +ve methylprednisolone) • Be on the lookout for common infections (e.g. • In case of relapse- • CNIs (cyclosporine/tacrolimus) peritonitis, pneumonia and skin infections) Prednisolone 2 • Cyclophosphamide mg/kg x 2w • Azathioprine followed by 1.5 • Mycophenolate mofetil CAUTION mg/kg A/D x 4w • Levamisole • Rituximab • Non-nephrotic proteinuria: rule out orthostatic cases • Isolated hematuria: rule out urological causes

THROMBOSIS PROPHYLAXIS LOOK FOR COMPLICATIONS • Malnutrition • Hypovolemia • AKI Evaluate bleeding risk: S alb <2 + non-ambulatory: • Thromboembolism Do not use if risk high start aspirin, OAC if high risk • Infections

MANAGEMENT PHC/CHC INDICATIONS FOR REFERRAL DISTRICT HOSPITALS • Detailed history and • All cases >12 years old and less than 1 year old • Detailed history and clinical examination clinical examination • In children: • 24-hr urinary protein estimation • Urine dipstick test • Frequent relapses (=>3 per year) • Serum creatinine, electrolytes, serum albumin, lipid proﬁle • Serum creatinine, • Steroid dependent or resistant state • Imaging of kidneys • Evaluate for secondary causes electrolytes • Recent rise in serum creatinine • Look for and treat complications • Stabilize • Appearance of complications related to disease • Start general treatment • Start or treatment • Can treat antihypertensives • Pregnancy • Uncomplicated NS in 1-12 y old and diuretics if • Persistent asymptomatic urinary abnormalities • Infrequent relapses needed (>6 months) • Prepare treatment plan and refer back to primary care

ADMISSION CRITERIA: Initial evaluation, kidney biopsy, or management of complications

RED FLAG SIGNS

TERTIARY CARE HOSPITALS Cold Peripheries Accelerated hypertension

• Detailed history and clinical examination • 24-hr urinary protein estimation DO NOT USE DIURETICS • Serum creatinine, electrolytes, serum albumin, lipid proﬁle ALBUMIN can be given in Seizures • Imaging of kidneys • Evaluate for secondary causes severe Hypoalbuminemia • Look for and treat complications • Start antihypertensives and diuretics Increased capillary ﬁlling • Kidney biopsy Altered Sensorium time • Prepare treatment plan and refer back to primary care

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of URINARY TRACT INFECTIONS ICD-10-N39.0

DETERMINE UTI TYPE MANAGEMENT PRIMARY/ SECONDARY LEVEL

SIMPLE CYSTITIS/ LOWER UTI PRIMARY CARE INITIAL ASSESSMENT • Dysuria, urgency, frequency • History and Examination • History • Look for red flag signs and • Symptoms PYELONEPHRITIS/ UPPER UTI refer • Recurrent UTI WHAT IS UTI? • Fever • Refer special groups • Diabetes At least 3 Symptoms • Chills and rigors • Treatment in primary care • Congenital (dysuria, frequency, • Loin pain, pelvic pain • Acute cystitis females malformations urgency, suprapubic • Renal angle tenderness • Acute cystitis males • Stones pain) • Toxic and sick appearance • Treatment • Immunosuppression OR • Nitrofurantoin • Examination Dipstick +ve for COMPLICATED UTI • Trimethoprim • Temperature, renal leucocyte esterase and • History of stones, congenital sulphamethoxazole angle tenderness, nitrite if <3 symptoms anomalies, obstruction • Symptomatic relief genital exam OR • Diabetes • CUE >10 WBC/HPF in • Immunosuppression MALE UTI CYSTITIS/UTI IN FEMALES uncentrifuged urine + Acute cystitis/ simple UTI • Empirical RX (only • Urine culture WHEN TO DO URINE CULTURE? • Rx Men for 7 days symptoms no tests • Nitrofurantoin* 100 mg PO BD x 7d >105 CFU of single • Complicated UTI needed) • TMP/SMX 1 DS tab PO BD x 7d species/ml in Mid stream • Pyelonephritis • Nitrofurantoin* 100 urine (multiple species • Ciprofloxacin 500 mg BD x 7 days • Special situations • Levofloxacin 750 mg OD x 5 day mg indicate contamination) • All males (except simple • Acute cystitis is not to be referred PO BD x 5d cystitis) ALL OTHER UTI IN MALES-REFER • TMP/SMX 1 DS tab • Children • Pyelonephritis or complicated UTI PO BD x 3d • Pregnancy • Pelvic/perineal pain (prostatitis) • If no response refer • Recurrent UTI (> 2 to higher centre episodes/ 6 months) • Catheter associated UTI *Avoid if GFR <45,caution in elderly

SYMPTOMATIC TREATMENT Plenty of Urine alkalinizer recommended eg citrate Phenazopyridine Local Estrogen creams for recurrent Paracetamol Cranberry water - Avoid if patient on nitrofurantoin 200mg tid for 2 days UTI in post menopausal women for pain can be used

RED FLAG SIGNS - REFER • Pyelonephritis • Special situations (Children, pregnancy, • Non response within 3 days of AB • Complicated UTI males except simple cystitis, catheter UTI) • Recurrent UTI

TERTIARY LEVEL • Send for culture Rx Rx Rx all male UTI Rx Rx • Imaging if no response to antibiotics in 48 hrs Pyelonephritis/ pregnancy including recurrent non-resolving • Urology services if obstruction complicated UTI UTI prostatitis UTI UTI PYELONEPHRITIS PREGNANCY UTI CATHETER UTI MALES WITH PROSTATITIS RECURRENT UTI

Empiric Outpatient: • Urine culture at 1st • Rx of asymptomatic • UTI symptoms+ pelvic • Uncomplicated • Urine c/s antenatal visit CAUTI NOT pain/ fever RUTI • Consider initial dose of a parenteral • For asymptomatic recommended • Refer - post coital voiding agent bacteriuria/acute cystitis: • Urinary catheters • Urine culture & MSU and post coital - Ceftriaxone 1-2 g IV/IM x 1 - Nitrofurantoin 100 mg PO should be removed as • Digital rectal exam- antibiotic - Gentamicin 5 mg/kg IV/IM x 1 BD x 5-7 d (avoid near- soon as not required tender prostate - Low dose • Followed by term ) • If indwelling catheter • Older >35 yrs- nitrofurantoin 50 - Ciprofloxacin 500 mg PO BD x 7d - Cephalexin 500 mg PO for >2 weeks and is still - Septran DS BD mgX 6 months - Levofloxacin 750 mg PO OD x 5 d QID x 5-7 d indicated, replacing - Levofloxacin 500mg OD, - Single strength - Cefuroxime 500 mg PO BD x10-14d - TMP/SMX 1 DS tab PO BD x the catheter is ciproflox 500 mg BD septran x 6 - Amoxy clav x10-14 days 5-7 d (avoid in 1st trimester & recommended - Avoid nitrofurantoin months - TMP-SMX 1 DS BD x 7-10 days near term; supplement with • Symptomatic CAUTI • Young males- - Or norflox 200mg, Empiric Inpatient : multivitamin containing - (Fever, back pain, new - Doxy 100mg bd /azithro 1 ciproflox200mg , • Ceftriaxone 1-2 g IV once daily+ /-AMP folic acid) onset delirium, rigors) gm / oflox 300mg BD for cephalexin 250mg • Gentamicin +/-AMP • Check repeat urine c/s 7days - Send culture chlamydia + Single dose - Vaginal cream in • Others as per c/s- Carbapenem, after Rx to confirm clearing - Rx as complicated of Ceftrioxone 250mg IM post menopausal Piperacillin Tazo • Repeat urine culture in each UTI for gonorrhoea • Complicated RUTI antenatal visit • No role of routine • Rx- 6 weeks - Urology referral IV therapy required until afebrile x • If recurrent- Antibiotic antibiotic prophylaxis • Imaging to rule out - Cystoscopy, 48 hrs, then switch to PO If no prophylaxis till term for prevention abscess urodynamics (post response in 3 days imaging menopausal)

ASYMPTOMATIC BACTERIURIA CHILDREN • No symptoms • Bacteria in urine culture SYMPTOMS FIRST URINARY TRACT INFECTION* >105CFU/ml • Neonates and Infants < 1yr - Fever,vomiting, diarrhoea, jaundice, Poor • No treatment required stream - Older children same as adults • Exceptions when you TREATMENT should treat - Infants <3months as upper UTI (PN) with Age <1 yr Age >5 yr - Pregnancy IV antibiotics • Ultrasound - Before any urological - Urinary bladder catheterisation for infants • Ultrasound • MCU If ultrasound intervention with upper tract UTI • DMSA renal scan abnormal: - Older children MCU and DMSA • Upper UTI- IV antibiotics scan gentamicin, amikacin, ceftriax * Pregnancy UTI, one Age 1-5 yr Catheter UTI may also be • Lower UTI- oral cefixime, oflox, • Ultrasound managed at secondary ciproflox, amoxyclav level. • Duration of Rx • DMSA scan - Upper UTI- 10-14 days MCU if ultrasound or - Lower UTI 7-10 days DMSA scan is abnormal LONG TERM CONSEQUENCES - Adolescents 3-5 days • Renal scars REFER All patients with recurrent UTI need • Hypertension Upper UTI(PN), infants UTI, recurrent UTI detailed evaluation with • CKD PREVENTION ultrasonography DMSA scan and MCU • Poor quality of life Avoid constipation, clean washrooms

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. NEUROLOGY October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the APPROACH TO ACUTE PARALYSIS ICD 10 G82, G83

PRESENTATION WITH ACUTE ONSET (WITHIN HOURS TO DAYS) PARAPLEGIA OR QUADRIPLEGIA

Are There Any Signs Of Upper Motor Neuron (UMN) Involvement?

• Brisk reﬂexes • Extensor plantar • Increased tone • Sensory level • Bladder or bowel incontinence

NO YES

Is the weakness predominantly proximal or distal? Likely to be : ∙ Acute myelopathy like tuberculosis ∙ Trauma WEAKNESS WEAKNESS ∙ Tumor ∙ Transverse myelitis PROXIMAL DISTAL ∙ Epidural abscess ∙ Spinal cord stroke

Presence of Lower Motor Neuron (LMN) signs like wasting, absent reﬂexes and sensory impairment

REFLEXES REFLEXES MANAGEMENT Likely to be : ABSENT PRESENT Acute onset peripheral neuropathy • Check pulse, BP and respiration (due to toxin/drug) • If retention of urine present then catheterize • Transfer/ refer to nearest district Likely to be : MANAGEMENT hospital/ medical college with • Guillain Barre Syndrome (GBS) or • Transfer/ refer to nearest district MRI facility • Hypokalemic periodic paralysis. hospital/ medical college with • Treatment will depend on MRI NCS and EMG facilities. and other investigation • CSF for cells and biochemistry • After treatment follow up at • Treatment as per diagnosis CHC for medications and MANAGEMENT • After treatment follow up at CHC rehabilitation • Check pulse, BP and respiration for medications and • Check serum K+ levels rehabilitation • Intubate if unable to complete sentences, single breath count low and breath holding time low and chest expansion poor • Transfer/ refer to nearest District Hospital/ medical college with facility for doing plasma exchange or giving IVIg and presence of ventilator. • After treatment follow up at CHC for medications and rehabilitation

ADMISSION CRITERIA If the weakness is fatigable If no sensory impairment and or • Any progressive weakness normal extra ocular movements • Unable to walk If extra ocular movements are • Unable to swallow or choking while drinking affected water • Evidence of respiratory distress like unable to complete sentences, falling serial single breath count, respiratory rate >20 or SaO2 levels < 95% Likely to be : Likely to be : • Persistent tachycardia >100 • Myasthenia gravis or • Myopathy (eg polymyositis) • Fever • Snake bite • Bowel and bladder involvement

DISCHARGE CRITERIA MANAGEMENT MANAGEMENT

• Cause of acute paralysis established • Check pulse, BP and respiration • Check pulse, BP and respiration • Progression of weakness has stopped • Intubate if unable to complete • Check serum electrolytes, creatine • Able to breathe on his own sentences, single breath count low kinase • If present care of tracheostomy taught to and breath holding time low and • Transfer/ refer to nearest district care giver chest expansion poor hospital/ medical college with • If not swallowing- Ryles tube in place and • Transfer/ refer to nearest district facility for NCS & EMG care giver has been taught feeding hospital/ medical college with • After treatment follow up at CHC • Care of urinary catheter and constant facility for doing NCS, plasma for medications and rehabilitation turning taught to the patient exchange or giving IVIg and • Caregiver trained for physiotherapy at presence of ventilator. home • After treatment follow up at CHC for medications and rehabilitation

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of DEMENTIA ICD 10 - F02,F03,G30

Impaired memory Anxiety Hallucinations Incontinence

CLINICAL Forgetting learned Apathy Agression Mood ﬂuctuations FEATURES OF activities DEMENTIA

Depression Sleep disturbances Personality change

IMPORTANT POINTS TO CONSIDER • Dementia is a complex and variable condition • No single test will deﬁnitively diagnose dementia • The clinical features if present, should be a change from baseline normal functioning in a middle aged to old person • Assessment should aim at gathering information about changed behaviours, functional capacity, psychosocial support and medical comorbidities • History should be taken from a close caregiver, staying with the patient for a longer duration than the appearance of symptoms

EVALUATION OF DEMENTIA

No No dementia

History and Cognitive decline in examination more than one domain ASHA Lab investigation PHC Yes Suspected dementia TSH,Vit B12, vit D CHC Yes LFT/RFT/FBS Treat Delirium or Depression? DH Yes No No Neuropsychiatry Functional decline Follow up and Re-evaluation testing Yes Medical college Dementia Tertiary level centre

Optional tests No Yes based on clinical Typical clinical proﬁle (age, progression, no focal signs) Probable AD features

CT scan/MRI VD/ mixed dementia

Lab investigation Other causes TSH, vit. B12

FOLLOW UP OF DIAGNOSED & TREATED PATIENTS INTERVENTION MATRIX FOR DEMENTIA ACROSS PLATFORMS OF CARE DISTRICT HOSPITAL (SPECIALIST- PHYSICIAN/ PRIMARY HEALTH CENTRE (MEDICAL OFFICER) REASONS FOR GERIATRIC SPECIALIST/ NEUROLOGIST/ REFERRAL PSYCHIATRIST) • Diagnose dementia after detailed history • Not responding to • Screening for: adequate dose and - Treatable causes of dementia - thyroid disorders, B-12 • Careful evaluation of all the referral patients of dementia • Screening for treatable causes for dementia including duration of deficiency, subdural hemorrhage. prescribed - Depression. normal pressure hydrocephalus, B12 deficiency, hypothyroidism, chronic meningitis medications - Vascular risk factors • Presence of red flags • Lab investigations- CBC, biochemistry, liver function • Neuroimaging CT/MRI- to rule out subdural hematoma/ Folic Acid 5 mg/day to be added along with AEDs in all women of child bearing age. Polytherapy and valproate to be avoided in women with epilepsy tests, hemogram, lipid profile, TFT, VDRL, vit B12 level, vit tumors/ NPH(surgically remediable causes of rapid D level cognitive decline) • Referrals for MRI/CT • Lab investigations- CBC, liver function tests, biochemistry, hemogram, lipd profile, vit D levels, TFT, VDRL, retrovirus • Initiation of treatment/drugs; treatment for co-morbid RED FLAGS conditions (including depression, vision, hearing deficits after counselling (whenever feasible and high index of suspicion) and gait problems), thyroid, arthritis. • Fever • Initiate therapy for vascular risk factors • All the points mentioned in PHC to be followed if patient presents to a DH • Rapid progression • Encourage healthy lifestyle • Seizures • Assess for palliative care • Upward referral linkages with tertiary care and downward referral with PHC. • Recent head • Learn and share facts about dementia to provide injury immediate need to the person with severe dementia • Encouraging patient and caregiver participation in an ongoing support program for them. • Alcoholism and • Follow up and monitor for side effects of drugs/ red flags falls in patient/ signs of danger • Avoid antipsychotics until necessary • Follow-up of difficult patients under the guidance of • Interaction with, training of MOs at PHC/UPHC and higher centre. ongoing clinical support and supervision

MEDICATIONS RECOMMENDED FOR USE FOR ALZHIEMERS DEMENTIA FOR COGNITION FOR DEPRESSION FOR AGITATION • Donepezil: 5 mg once after breakfast x 1 month, then 10 mg after breakfast to continue • Identiﬁcation of If any side effect/ not tolerating: Rivastigmine to be used start dose 1.5 mg BD / 1 month then 3 • Escitalopram 10 mg triggers mg BD x 1 month, then 4.5 mg BD x 1 month, then 6 mg twice after meals only x 1 month. • Non • Memantine: in moderate to severe dementia 5 mg BD x 1 month, then 10 mg BD to continue. pharmacological • Galantamine: 8 mg BD if not tolerating 1 interventions

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of EPILEPSY ICD 10 - G40

Abnormal jerky Loss of Episodes could be single Episodic, few Blank movements consciousness/ with high risk of secs-mins staring awareness recurrence. Prolonged motor convulsion of > 5 CLINICAL mins with loss of FEATURES Sudden consciousness - STATUS With or without urine/ Bizzare activity Any other episode drops/ falls, EPILEPTICUS (SE) - stool incontinence, out of context lasting for few mins brief jerks tongue bite, drooling (usually<5 mins) MEDICAL EMERGENCY

PRIMARY HEALTH CENTRE (MEDICAL OFFICER) REASONS FOR REFERRAL DISTRICT HOSPITALS

• Clinical diagnosis of epilepsy: detailed history from an eyewitness (centres with specialists like • Careful evaluation of all • Differentiate between provoked seizures and epilepsy (provoked due to fever, paediatrician, referral patients, provide acute CNS insult, antibiotics, and metabolic causes) neurologist) specialized management • Laboratory investigations: CBC, liver function tests, routine biochemistry, for patients and refer hemogram, lipid profile, vit D levels, TFT (whichever feasible) • Redflag Signs back to PHC for follow up • Initiation of treatment: • Progressive problems, rapid of management - Treat the patient if patient has epilepsy (2 or more episodes of unprovoked seizures) appearance of new symptoms • Maintain communication, - Treat a single seizure if risk of recurrence is high as in patients with focal • Recent injury ongoing clinical support seizures,mentally retarded, neurological deficits having family history of • Symptoms appearing after and supervision of MOs at seizures abnormalEEG, neuroimaging alcohol binge PHC - Anti Epileptic Drug (AED broad spectrum, low dose, start low go slow, except • Status epilepticus after • Laboratory investigation status epilepticus) stabilization - CBC, liver function - Emergency medical care of status epilepticus • Non response to adequate tests, antiepileptic drug • Treatment counselling: side effects/toxicities of drugs, red flags, importance of dose and duration of levels, routine adherence, maintaining treatment diary medication biochemistry, • Advice on prevention of seizures: regular medication, sleep 7-8 hrs, avoid excess • Serious side effects hemogram, lipid profile, TV/mobile/ photic stimulation, regular diet, lifestyle choices(avoid alcohol) • Neuroimaging vit D levels, TFT, CT • Evaluate any possibility of superimposed non-epileptic seizure brain (when necesary) • Training of MLP/ANM/ASHA on epilepsy • Monitor side effects of • For excessive alcohol use, refer to ANM/MLP where psychosocial interventions are RED FLAG SIGNS AED carried out for substance use disorders • Clinical Psychologist: • Follow up visits for treatment monitoring & difficult patients under neurologist at • Fever STC centre counselling health • Headache services for persons with • Basic management of co-morbidities (behaviour, cognition, reproductive health, • Vomiting bone health) epilepsy or upon referral • Alert to signs of abuse and neglect • Altered Sensorium from PHC/UPHC • Maintain upward referrals with paediatrician/physician at DH • Severe Giddiness • Loss of function of body

AED– BROAD SPECTRUM (GENERALIZED SEIZURES) DOSE (MAINTENANCE: MG/D) ADVERSE EFFECTS

Sodium Valproate (avoid in women of child Starting dose :200mg TDS Anorexia, wt gain, nausea, vomiting, tremors, bearing age unless non responsive to other drugs) Maintenance Dose: 600-2400 hair loss, PCOS, thrombocytopenia

Starting dose: 25mg HS (Lower dose with VPA) Sedation, ataxia, dizziness, skin rash, SJS (lower Lamotrigine Maintenance Dose: 100-300 risk with slow titration)

Starting dose: 250mg BD Somnolence, dizziness, cognitive slowing, Levetiracetam Maintenance Dose: 1000-3000 psychosis Sedation, somnolence, cognitive problems, Starting dose: 25mg OD Topiramate weight loss, word ﬁnding difﬁculty, renal Maintenance Dose: 100-400 stones, seizure worsening AED (focal seizures) Sedation, dizziness, ataxia, skin rash, SJS, Starting dose: 100mg BD Carbamazepine hyponatremia, seizure worsening in some Maintenance dose: 400-1200 situations Oxcarbazepine Starting dose: 150mg BD Sedation, dizziness, ataxia, headache, Maintenance dose: 600 to 1800 hyponateremia, skin rash Phenobarbitone Starting dose: 30mg HS Sedation, ataxia, depression, memory Can be used for generalized also Maintenance dose: 60-180 problems, hyperactivity in children, skin rash Ataxia, sedation, gum hyperplasia, coarsening Starting dose: 200mg HS Phenytoin of facial features, hirsutism, memory Maintenance dose:200-400 problems, osteomalacia & bone loss, skin rash Folic Acid 5 mg/day to be added along with AEDs in all women of child bearing age. Polytherapy and valproate to be avoided in women with epilepsy IMPENDING SE ESTABLISHED SE REFRACTORY SE 5 MIN 30 MIN 60 MIN 2 IV drugs fail (Benzo + IV AED) FIRST ABCS TO BE DONE FROM WHEN YOU SEE PATIENT SIMULTANEOUSLY WITH MEDICATION

Out of Hospital/home : Buccal/Intranasal IMDZ with acute repititive seizures/status (0.3-0.5 mg/kg) ICU IV Midazolam loading 0.2 mg/kg EMERGENCY ROOM OR CIV 0.05-0.5 mg/kg/hr (can go up to 2 mg/kg/hr) IV Lorazepam up to 0.1 mg/kg @ 2mg/min Taper gradually after seizure stops OR (preferably as evidenced by EEG) IV Midazolam 0.1-0.2 mg/kg bolus or 0.05-0.5 mg/kg/hr in CIV OR Thiopental 5-7 mg/kg IV bolus IV Diazepam upto 0.25-0.4 mg/kg over 2-3 min further 50 mg until seizures controlled 3-5 mg/kg/hr for only 48 hours Phenytoin @50 mg/min 20 mg/kg repeat • OR Propofol IV loading 2-5 mg/kg plus 10 mg/kg if seizures do not stop in 15-20 min CIV 1-15 MG/KG/HR • If seizures not controlled or contra indiction (CI) to PHT OR Pentobarbital IV upto 10 mg/kg Intravenous Valproate 25-40 mg/kg @3-6 mg/kg/min @ <0.2-0.4 mg/kg/min CIV 0.5-2 mg/kg/h • If CI to above two; Phenobarbitone 20 mg/kg IV @ less than 5-60 mg/min but be OR Ketamine bolus 1.5 mg/kg prepared to Intubate and ventilate CIV 0.01-0.05 mg/kg/h max 10mg/kg/hr * to be EEG Monitoring Levetiracetam 20-30 mg/kg IV at 5 mg/kg/min (max 3g) or Levetiracetam 1500-3000 mg via NGT or Super refractory Lacosamide 200-400 mg IV at 40-80 mg/min > 24hr no control Topiramate 150-800 mg bid via NGT Airway, blood pressure, temperature, intravenous access, electrocardiography, CBC, glucose, electrolytes, AED levels, ABG, oximetry, tox screen, central line If alcoholic- thiamine & glucose, if diabetic GLUCOTEST/blood sugar & glucose IV. MUST INFORM CONSULTANT ON CALL KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of HEADACHE ICD-10-G43-44

CONTINUOUS HEADACHES • CT with CT • Progressive headache of acute or subacute Referred Angiogram/ MRI onset persisting more than 1 week to with MR angiogram • Possibilities: Cerebral Venous Thrombosis, higher • Lumbar puncture Intra Cranial Space Occupying Lesion, centre • Refer to tertiary care Meningitis, Brain abscess centre

CHRONIC TENSION HEADACHE Start Amitriptyline Brain imaging Continuous bilateral headache for many years with (10mg HS) and if atypical signiﬁcant insomnia and psychosomatic complaints. advice on lifestyle features exist

MIGRAINE Frequency > 2 /month - TREATMENT FLOWCHART Side Start prophylaxis trial for 2 months alternating, • Propranolol 40 mg OD Brain LEGEND/ INDEX/ KEY associated • Flunarizine 10 mg OD imaging visual aura, Acute management if photo-phono • Analgesics( Paracetamol 650 mg, or there are Type of phobia, Indomethacin 50 mg) and atypical Headache nausea, • Antiemetics ( Prochlorperazine 10mg). relieved by Life style changes symptoms sleep or • Good sleep at least 6 hrs, food habit Management analgesics modiﬁcation, avoiding triggers of migraine. at PHC

ATYPICAL MIGRAINE Analgesics for pain • CT/ MRI with MR angiogram or CT Management at Hemiplegia, visual Refer to higher angiogram if required district hospital impairment, centre with • Migraine prophylaxis after ruling out vertigo imaging facility stroke and other diseases

TRIGEMINAL AUTONOMIC CEPHALGIAS Indomethacin Refer to Rapid onset peri orbital and temporal (25mg TID) for tertiary care pain with autonomic features 7 days centre

CLUSTER HEADACHE, PAROXYSMAL HEMICRANIAS, SHORT Refer to Refer to LASTING UNILATERAL NEURALGIFORM PAIN WITH tertiary tertiary CONJUNCTIVAL INJECTION AND TEARING SYNDOME (SUNCT) care centre care centre

• First or worst • Headache with fever, change in • Rapid onset with strenuous exercise REASONS FOR REFERRAL headache of the personality, mental status, level of • Sudden onset (maximal intensity patient’s life consciousness occurs within seconds to minutes, • Non responding • Focal neurologic signs • Fever, neck stiffness or meningism thunderclap headache) headaches (not typical aura) • New onset of severe headache in • New headache type in a patient • Headaches with danger • Severe headache pregnancy or postpartum or while with malignancy or signs should be awakening from sleep on hormone treatment immunosuppression immediately referred and investigated for potentially dangerous RED FLAG SIGNS conditions

TREATMENT OF MAJOR CATASTROPHIC HEADACHES AT TERTIARY CENTRE

Headache with fever, Progressive Sudden Severe headache, Progressive personality change, headache with First or Worst headache of life headache altered sensorium, seizure or focal neck stifffness deﬁcit

CT with CT Angiogram/ MR venogram CT scan followed CT/MRI with MRI with MR angiogram by CSF study contrast

SUBARACHNOID INTRACEREBRAL CEREBRAL VENOUS MENINGIOENCEPHALITIS BRAIN TUMORS HEMORRHAGE HEMORRHAGE THROMBOSIS

Folic Acid 5 mg/day to be added along with AEDs in all women of child bearing age. Polytherapy and valproate to be avoided in women with epilepsy Intravenous UFH / Angiogram, Stroke unit Surgery, subcutaneous Antibiotics/ clipping/ admission and radiation, heparin/LMWH antivirals coiling of neurosurgery for chemotherapy aneurysm cortical (to prevent hemorrhages or rebleed) large hemorrhage with herniation

INDICATIONS FOR ADMISSION CRITERIA FOR DISCHARGE FOLLOW UP OF HEADACHE PATIENTS

• Patient with unrelenting • Primary headache disorders- CAUSES OF HEADACHE TREATMENT OF HEADACHE headache symptomatically improved severe • Immunosuppressed patients episode of headache due to primary Intra cerebral hemorrhage Good control of blood pressure headache disorder can be discharged with continuous headache, Seizures Antiepileptic medications • First ever headache with worsening intensity, • Secondary headache disorders- Cerebral venous sinus thrombosis Follow up of anticoagulation • Progressive headache with secondary headache disorders with other systemic disease essential work up, diagnosis and Give prophylaxis for • Severe symptomatic primary treatment as per individual case can Migraine adequate duration of time headache disorders be discharged and taper after remission

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES REFERENCES 1. Hainer BL, Matheson EM. Approach to acute headache in adults. American family physician. 2013 May 15;87(10). 2. https://www.uptodate.com/contents/evaluation-of-headache-in-adults ABBREVIATIONS CSF: Cerobrospinal Fluid, UFH: Unfractionated Heparin, LMWH: Low Molecular Weight Heparin

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of NEUROINFECTIONS ICD-10-G03.9

DIFFERENTIAL Acute onset-hours to days DIAGNOSIS DIFFERENTIAL

Vascular-ischemic/hemorrhagicDIAGNOSIS stroke

SYMPTOMS Infections Alteration in sensorium viral/bacterial/fungal/protozoal meningoencephalits/brain abscess

Metabolic encephalopathies

Seizures/postictal state With/ without fever/ headache/vomiting/seizures

Intoxications-drugs/toxins

AT PRIMARY CARE LEVEL ESSENTIAL NOT Check Airway/Breathing/Circulation RECOMMENDED • Stomach wash Rule out circulatory shock, ongoing convulsions and hyperthermia/hyperpyrexia(core temperature > 40.5°C • Inj Mannitol or hypothermia(< 36.5°C) • Inj Steroids

Establish IV access-urgent blood for hemogram/sugar/electrolytes/malaria testing-peripheral smear/rapid CRITERIA FOR antigen detection REFERRAL

Altered Correct hypoglycemia (blood sugar 50 mg/dl) with IV 100ml of 25% dextrose solution sensorium/seizures /focal If seizing- IV/IM Lorazepam 0.1 mg/kg followed by loading with Phenytoin 20 mg/kg weight at a rate of deﬁcits/hemodyna 50 mg/minute mic instability –where imaging When IV access not available-intra nasal or buccal Midazolam 0.2 mg/kg /intra rectal Diazepam 0.3-0.4 mg/kg and ICU management are Urgent referral to higher centres with intensive care facilities required.

AT SECONDARY CARE LEVEL( TALUK, DISTRICT) HEADQUARTERS HOSPITAL

In addition to all the steps given above : ESSENTIAL DESIRABLE • Neuroimaging-CT with contrast -to rule out Establish and maintain airway: Intubate if GCS<8, impaired airway reflexes, abnormal hemorrhage/infarcts/focal edema or lesions respiratory pattern, signs of raised ICP, oxygen saturation <92% despite high flow oxygen, • Blood cultures aerobic/anaerobic and fluid refractory shock • First dose of empirical treatment of pyogenic meningitis-Inj Ceftriaxone 2 g + Inj Vancomycin Inj Thiamine 100 mg IV 500 mg. Add Inj Ampicillin 2 g if older than 50 years / Stomach wash/activated charcoal administration-if history or suspicion of drug overdose/ immunocompromised along with Inj non corrosive poison intake Dexamethasone 8 mg • Fundus examination,CSF study to rule out Start treatment for cerebral malaria-first dose of IV Artesunate 2.4 mg/kg OR meningoencephalitis-if imaging rules out any Quinine 20 mg/kg bolus mass lesions/herniations. • Urgent referral to higher centres with Intensive Emergency CT/referral to centre with 24 hour CT facilities care facilities

CRITERIA FOR REFERRAL • Altered sensorium/seizures/focal deﬁcits/hemodynamic instability –where imaging and ICU management are required. • If no deﬁnite diagnosis achieved after preliminary investigations

AT TERTIARY CARE HOSPITALS-SELECTED DISTRICT HOSPITALS/MEDICAL COLLEGES

• Neuroimaging-MRI/CT with contrast to rule out abscess/herniations. If abscess-emergency neurosurgical consultation for favour of aspiration –open/stereotactic • Blood cultures-aerobic/anaerobic • CSF analysis-biocehmistry/cytology/gram staining/culture-bacterial , AFB and fungal/viral PCR/TB-PCR/fungal antigen

Empirical antibiotic (within 30 minutes of arrival) Viral-Herpes Cerebral malaria • If suspecting pyogenic meningitis-Inj Ceftriaxone 2 g+ Inj simplex/Zoster Inj Artesunate 2.4 mg/kg IM or IV 3 doses Vancomycin 500 mg+ Inj Ampicillin 2 g if older than 50 years or 12 hours apart and then OD / immunocompromised+ Inj Dexamethasone 8 mg IV • Inj Acyclovir Inj Quinine 20 mg/kg IV stat followed by 10mg/kg • Continue empirical treatment till culture yields causative 500 mg IV TDS till patient can take orally,then organism,then tailor treatment as per sensitivity reports for 10-14 8 hourly for oral Artesunate+Pyrimethamine /Sulphadoxine for days. 10 days 3 days OR oral Quinine 10 mg/kg TDS for total 7 • Steroids to be stopped after 48 hours,unless any other compelling days + Doxycycline 3 mg/kg OD for 7 days. indications-adrenal insufﬁciency/TBM

COMPLICATIONS

Raised ICP SIADH Vasculitis Hydrocephalus

*If uncomplicated-back referral to Secondary care centre for completing treatment regimen/monitoring. CRITERIA FOR DISCHARGE

Afebrile,hemodynamically stable,seizure Diagnosis and treatment plan made and Continuation of treatment with monitoring can free >48 hours initiated. be ensured for the prescribed duration.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of STROKE ICD-10-I63, I64

SYMPTOMS WARNING SIGNS (BEFAST) • Numbness or weakness, especially on one side of • BALANCE : Loss of balance or the body coordination • Loss of consciousness or altered consciousness WHAT IS STROKE? • EYES : Sudden blurred or double vision/ • Decreased vision in one or both eyes An episode of sudden, persistent vision trouble • Language difficulties, either in speaking or neurological • FACE : Deviation at the angle of the dysfunction caused by understanding mouth focal cerebral, spinal, or • Difficulty walking; loss of balance or coordination retinal infarction or • ARM : Arm Drift • Confusion or loss of memory haemorrhage • SPEECH : Slurred speech or the inability • Swallowing difficulties to speak or understand • Paralysis of any part of the body, including face • TIME : Act fast • Sudden, severe headache with no known cause • Sudden new onset of headache or loss of • Neck pain consciousness • Nausea and vomiting • Sudden giddiness, vomiting and imbalance

TYPES OF STROKE

Intracerebral haemorrhage Transient Ischemic Attack Focal collection of blood (TIA) Ischemic stroke Subarachnoid haemorrhage Cerebral venous within the brain Transient episode of Focal cerebral, spinal, or Bleeding into the thrombosis Thrombosis of parenchyma or ventricular neurologic dysfunction caused retinal infarction subarachnoid space a cerebral venous system that is not caused by by focal cerebral, spinal cord, structure trauma or retinal ischemia, without acute infarction

PRELIMINARY MANAGEMENT INVESTIGATIONS

• Assess and manage ABCs • Initiate cardiac monitoring ESSENTIAL DESIRABLE OPTIONAL • Maintain O2 saturation >94% • Establish IV access • CT Scan head • CTA • MRI/MRA • Determine blood glucose and treat accordingly • ECG • Echocardiogram • Holter monitoring • Determine time of symptom onset or last known normal, and obtain family • Blood Sugar contact information, preferably a cell phone • Lipids • Triage and RAPID TRANSFER of patient to nearest district hospital with CT • Renal parameter Scan facility or Stroke center with facility for thrombolysis • Referal hospital to be notiﬁed to handle the referred patient with stroke

MANAGEMENT

ISCHEMIC: * HAEMORRHAGIC: IV tPA (0-4.5 hrs) or • Dysphagia assessment, STROKE ONSET TIME: <4.5 HOURS endovascular treatment • Blood pressure/blood sugar monitoring and IV ﬂuids. according to eligibility • Prevention of Pneumonia and availability • Prophylaxis for deep venous thrombosis etc, monitor and record ECG

* RECOMMENDED DIAGNOSTIC STUDIES

ALL PATIENTS SELECTED PATIENTS

• Noncontrast brain CT or brain MRI • TT and/or ECT if it is suspected the patient is taking direct thrombin • Blood glucose inhibitors or direct factor Xa inhibitors • Oxygen saturation • Liver function tests • Serum electrolytes/renal function tests • Toxicology screen • Complete blood count, including platelet count • Blood alcohol level • Markers of cardiac ischemia • Pregnancy test • BT, CT, Prothrombin time/INR • Arterial blood gas test (if hypoxia is suspected) • Activated partial thromboplastin time • Chest radiography (if lung disease is suspected) • ECG • Lumbar puncture (if subarachnoid hemorrhage is suspected and CT • FLP and carotid doppler (ischemic stroke) scan is negative for blood) • Electroencephalogram (if seizures are suspected)

Rapid Assessment, CODE Stroke, Blood pressure and Blood Sugar monitoring, NIHSS, Intravenous lines STROKE ONSET TIME: >4.5 HOURS Endovascular treatment with Mechanical thrombectomy using stent retriever (4.5 hrs to 24hrs) according to eligibility

SECONDARY PREVENTION DISCHARGE PLANNING REHABILITATION (checklist : drugs, diet, compliance, Aspirin (in ischemic stroke) Physiotherapy exercises, health education) Antihypertensives Speech Therapy Antidiabetics Occupational Therapy at 2nd week, 1st month, 3rd Lipid lowering agents Vocational training FOLLOW UP month and 6th month

STROKE UNIT MANAGEMENT

· Medical and Nursing staff : control of blood pressure; control of diabetes; swallow assessment; DVT prophylaxis; antiplatelet drugs · Rehabilitation staff: » Acute phase: basic bed mobility, transfer techniques, communication training, prevention of complications » Subacute and chronic phase: mobility, gait and balance training, training of activities of daily living (grooming, eating, dressing etc), bowel/bladder training, perceptual and cognitive rehabilitation, provision of assistive devices.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. OBG October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW) for ANTE-NATAL MANAGEMENT OF NORMAL PREGNANCY FIRST VISIT (PREFERABLY IN FIRST TRIMESTER) ASK EXAMINE INVESTIGATIONS DO • Age • Height, weight ESSENTIAL TESTS • UPT if in doubt • LMP • Calculate BMI • Hemoglobin • Fill up MCH • Parity & obstetric history • Pallor, Jaundice, Pedal edema • Urine R & M protection card or • Any complaints especially excessive • Pulse, BP, RR, temperature • ABO & Rh grouping ANC card, make entry nausea & vomiting/ bleeding PV • Thyroid DESIRABLE TESTS on RCH portal & • H/o medical illness : diabetes, • Breast • VDRL/ RPR generate RCH hypertension, cardiac problem, • Respiratory and CVS exam - • HIV number (in public epilepsy or any other chronic illness ination • HBsAg sector) • Consanguinity, multiple pregnancy • P/A examination, P/S and P/V • WHO OGTT/ DIPSI test for diagnosis of • Give filled MCH • H/o blood transfusion and H/o prior examination GDM protection card & safe surgical intervention # If woman presents with • TSH in high risk cases (BOH, goiter, obesity motherhood booklet • Personal history : tobacco/ alcohol bleeding per vaginum do P/A or residing in iodine deficiency prone to woman intake & P/S to confirm amount of areas) • Give Tab Folic Acid • Family history : diabetes, hypertension, bleeding & rule out local OPTIONAL TESTS* daily genetic disorders/ congenital causes. All such cases to be Aneuploidy screen* by USG & double • Give first dose of problems, multiple pregnancy, referred to CHC or higher marker tetanus toxoid infections including tuberculosis centre SECOND VISIT (SECOND TRIMESTER) ASK EXAMINE INVESTIGATIONS DO ESSENTIAL TESTS • IFA tablet one (if Hb >11g%) or twice ( if Hb • Any com- • Weight • Hemoglobin <11g%) daily with water or lemon juice plaints since • Pallor • Urine albumin • Calcium carbonate 500 mg with vitamin D last visit • Pedal edema DESIRABLE TESTS 250 mcg tablet twice daily with meals. • Quickening • Pulse, BP in • USG ( Level II between 18-20 weeks for gross congenital • Calcium Carbonate and IFA not to be given and/ or fetal sitting malformations) together movements position • WHO OGTT/ DIPSI test if >24weeks & at least 4 weeks have • Single dose of Albendazole 400mg • Adherence to • P/A elapsed after 1st test • Ensure compliance for investigations and medications examination OPTIONAL TESTS* treatment

for fundal Quadruple test as per availability • Discuss birth preparedness height • Give second dose Tetanus Toxoid at least four *Should be performed only if adequate counselling facilities are available weeks after ﬁrst dose THIRD (28 – 34 WEEKS) AND FOURTH VISIT (36 - 40 WEEKS)

ASK EXAMINE DO • Same as above INVESTIGATIONS • Continue IFA and calcium tablets and ensure compliance Same as • Auscultate FHS • Hemoglobin • If non compliant or Hb < 9g% give parenteral iron sucrose therapy (not > 200mg above • Measurement of • Urine albumin at one time & not > 3 times a week) and refer patient with Hb < 7g% to higher abdominal girth • Optional USG for fetal centre and Symphysiofundal growth and liquor • Refer to higher centre if any discrepancy between fundal height and period of Height gestation

DANGER SIGNALS FOR PATIENT TO REPORT TO HEALTH HIGH RISK PREGNANCY FACILITY • Any H/o medical illness, previous caesarean section, past obstetric • Fever mishap or congenital malformation • Persistent vomiting • Past H/o PPH • Abnormal vaginal discharge • Age > 35 years or < 19 years or parity > 4 • Palpitations, easy fatigability and breathlessness at rest and/ or on • Malnourished (BMI < 18.5 kg/m 2 or > 30 kg/m 2) mild exertion. • Hemoglobin < 7g% • BP > 140/90mm Hg on 2 occasions 6 hours apart • Vaginal bleeding • APH • Decreased or absent fetal movements at > 28 weeks gestation • Discrepancy between fundal height and period of gestation > 4 weeks • Leaking of watery ﬂuid per vaginum (P/V) • GDM/ overt DM * High risk pregnancy to be • Severe headache/ blurring of vision/ convulsion • Multiple pregnancy • Passing lesser amounts of urine and/ or burning sensation during delivered at district • Malpresentation at term hospital/medical college micturition • Previous uterine surgery • Itching all over the body * Preferably to have antenatal care also at these centres

COUNSELLING AT ALL LEVELS FOR : BIRTH PREPAREDNESS MUST INCLUDE • Timing and place of next ANC visit based on presence or absence of risk factor • Rest, nutrition, balanced diet and exercise IDENTIFICATION OF THE FOLLOWING : • Counselling for HIV testing • Facility for delivery • Danger signs • Support persons • Institutional delivery • Birth companion ∙ Birth preparedness • Means of transport in emergency ∙ Early & exclusive breastfeeding for six months • Blood donors (if required in emergency) • Post partum contraception

ASSESSMENT OF FUNDAL HEIGHT & ITS CORRELATION WITH GESTATIONAL AGE

At 12 th week : Just palpable above the symphysis pubis

At 16 th week : At lower one-third of the distance between the symphysis pubis and umbilicus

At 20th week : At two-thirds of the distance between symphysis pubis and umbilicus

At 24 th week : At the level of umbilicus UMBILICUS At 28th week : At lower one-third of the distance between the umbilicus and • xiphisternum

At 32 nd week : At two-thirds of the distance between the umbilicus and xiphisternum

At 36 th week : At the level of xiphisternum

At 40th week : Sinks back to the level of the 32 nd week, but the ﬂanks are full, unlike that in the 32 nd week

COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for DILATATION AND CURETTAGE (D&C)

• Mostly done for gynaecological indications, but may also be considered in early pregnancy complications • traditional D&C in gynaecological cases, it still has a place when other modalities are not available or do not yield adequate tissue

GYNAECOLOGICAL GYNAECOLOGICAL PROCEDURES Abnormal uterine bleeding in appropriate cases (refer to HMB STW) Endometrial Aspiration Biopsy [EA]

Post menopausal bleeding OR (ECC with D&C) D & C

Infertility (to rule out TB) Differential curettage (Endocervical Amenorrhoea curettage [ECC] with EA)

As a haemostatic measure in women with excessive / prolonged vaginal PROCEDURES FOR INDICATIONS : bleeding EARLY PREGNANCY COMPLICATIONSDIFFERENTIAL

sampling Dilatation and Evacuation [D & E]

OR D & C EARLY PREGNANCY COMPLICATIONS OR

Retained products of conception- as a Evacuation (with or without suction) treatment of inevitable, incomplete, missed, septic or induced abortion.

CONTRAINDICATION

Molar pregnancy Acute pelvic and vaginal infections

WHERE CAN IT BE PERFORMED? • In secondary or tertiary healthcare centres preferably where facilities for anaesthesia and operation theatre are available to deal with procedure related complications, if any. • Endometrial aspiration biopsy is usually done as an outpatient procedure in non pregnant cases.

ALL TISSUE REMOVED MUST BE SENT FOR HISTOPATHOLOGICAL EXAMINATION

PRE- OPERATIVE REQUISITES Presence of a valid indication General medical ﬁtness & no contraindication A written informed consent

ANESTHESIA (ANY OF THE FOLLOWING) • General anesthesia • Regional anesthesia • Paracervical block with 1% xylocaine • IV sedation • IM/ oral analgesia

Strict asepsis to be maintained. Antibiotics to be used judiciously and decided as per need of individual case.

POST PROCEDURE CARE & FOLLOW UP COMPLICATIONS DOʼS DONTʼS • Observe the patient for minimum two • Excessive bleeding • Evacuation of urinary bladder • Over abduction of legs hours after the procedure for haemorrhage • Cervical laceration before procedure. • No sounding in cases or any other symptoms or signs of • Perforation of the uterus • Safety checklist of pregnant uterus. complications prior to discharge • Injury to bowel and • Dorsal/lithotomy position • No forceful insertion of • Patient can be discharged as soon as she is bladder • Bimanual pelvic examination any instrument comfortable and alert. • Pelvic infection prior to the procedure • Abandon the • Most common side effect is abdominal • Post-operative intra • Sounding to measure procedure in case of cramps which can be managed by oral uterine adhesions uterocervical length ONLY in suspected perforation analgesics. non pregnant women. and refer to higher • Warning signals to report backare to be • Sample to be sent for centre. explained at the time of discharge - severe histopathology and • Insertion of the dilator pain, bleeding, foul smelling discharge or microbiology (where should be just beyond fever. indicated) the internal os and • Follow up is done after a week with • REFER in case of a NOT till the fundus histopathology report for further advice. complication

D&C is a blind procedure and may miss the pathology in some cases. In cases where focal pathology is suspected, tissue should be obtained under hysteroscopic visualization.

COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of HEAVY MENSTRUAL BLEEDING (HMB) ICD-10-H90.5 TO DO AT ALL LEVELS HISTORY EXAMINATION SUPPORTIVE TREATMENT • General • Age Evaluate pallor • Parity Calculate BMI • Detailed menstrual history including irregularities • Reassurance • Other medical illness: thyroid disorder, • Hematinics • Systemic coagulopathy, jaundice etc • Tranexamic acid during episode of CVS, RS and hepatosplenomegaly • IUCD use heavy bleeding • Lactation • Local examination (where indicated and • Drug intake feasible) P/S and P/V

MANAGEMENT OF HMB AT PRIMARY LEVEL HISTORY AND EXAMINATION

Abnormality No Abnormality

Adolescents Women of Reproductive Age Age > 40 years Refer to R/o pregnancy* INVESTIGATIONS Higher centre Any Refer to higher Supportive Speculum examination Abnormality centre • Hemoglobin Treatment Pelvic examination • Complete Blood Count (CBC) with No abnormality -Tranexamic acid peripheral smear - OC Pills • Bleeding time / Contraception Contraception not Clotting time desired desired No Relief (BT/CT) OC Pills - NSAIDs Refer to higher - Tranexamic acid centre No Relief - Progestogens**

* R/o Pregnancy in doubt especially in all women of reproductive age group after appropriate consent ** Amongst progestogens Norethisterone provides the best hemostasis MANAGEMENT OF HMB AT SECONDARY LEVEL (CHC)

HISTORY AND EXAMINATION

Adolescents Married <40 years Married >40 years Post Menopausal

Supportive treatment Do USG Refer to higher centre ET>12mm or Endometrial thickness Do endometrial sampling and send High Risk for endometrial -Tranexamic acid < 12 mm for histopathological examination - OC Pills cancer*

Secretory/ Non Secretory Hyperplasia without No Relief Hyperplasia with atypia/ endometrium without hyperplasia atypia malignancy

- NSAIDS Refer to higher - Progestogens Refer to higher - Tranexamic acid centre - Levonorgestrel- centre - Combined OC Pills releasing intrauterine - Progestogens system (LNG IUS) - LNG IUS INVESTIGATIONS Hormonal therapy to • Hemoglobin continue for 6 months HIGH RISK FOR ENDOMETRIAL • CBC with peripheral smear If no relief, CANCER • BT / CT Refer to higher centre If no relief or recurrence Patient having: • ABO and Rh typing Refer to higher centre - Obesity • Thyroid function test - Diabetes • USG of Abdomen & Pelvis - Hypertension - PCOD MANAGEMENT OF HMB AT TERTIARY LEVEL

HISTORY, EXAMINATION AND ULTRASONOGRAPHY TREATMENT FOR ACUTE BLEEDING EPISODE No structural abnormality Structural abnormality - IV Tranexamic acid 1g stat slowly followed by oral Tranexamic acid 0.5-1g, Refer to Adolescents < 40 years > 40 years Thickened Fibroids & 6-8 hourly for 5 days endometrium polyps, Fibroid & - Blood transfusion if Polyps STW Treat underlying cause - NSAIDS and indicated adenomyosis if present - Tranexamic Acid Endometrial sampling - D&C/ (thyroid disorders, - OC Pills Hysteroscopic guided HORMONE THERAPY jaundice, coagulopathy - Progestogens etc) - LNG IUS No hyperplasia or Atypical - Norethisterone (max daily - Ormeloxifene benign hyperplasia Hyperplasia dose 40 mg) In absence of obvious - Ablative Techniques OR cause Conservative modalities Hysterectomy - Medroxyprogesterone - NSAIDS If no relief - Tranexamic Acid acetate (max daily dose - Tranexamic Acid - Progestogens 40 mg) - OC Pills Hysterectomy - LNG IUS Hormone therapy should - Progestogens (Preferably after If no relief - Ormeloxifene be given orally daily in second opinion) - Ablative divided doses from the ﬁfth day of the cycle for INVESTIGATIONS techniques three weeks and repeated • Hemoglobin • ABO and Rh typing in a cyclical manner for • CBC with peripheral • TSH total of 4-6 cycles of smear • USG of Abdomen & Pelvis treatment • BT / CT

COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for HYSTERECTOMY FOR BENIGN GYNAECOLOGICAL CONDITIONS

IN WOMEN AGED LESS THAN 40 AND/OR LOW PARITY IT IS MANDATORY TO HAVE A SECOND OPINION FROM A QUALIFIED GYNAECOLOGIST

HYSTERECTOMY TO BE CONSIDERED ONLY WHEN CHILD BEARING IS COMPLETED & RARELY IN YOUNGER PATIENTS

• Symptomatic fibroids especially if not responding to medical management • Asymptomatic fibroids greater than or equal to 14 weeks LEIOMYOMA uterine size • Fibroid causing hydroureteronephrosis • Rapidly enlarging fibroids • Submucus myoma greater than 4cm

HEAVY MENSTRUAL Failed medical treatment BLEEDING ROUTES OF HYSTERECTOMY

• Failed medical treatment • ABDOMINAL • Causing hydroureteronephrosis ENDOMETRIOSIS • Recurrence after failed medical/ conservative • VAGINAL surgical management INDICATIONS : • Pelvic organ prolapse • Non descent PROLAPSE Third or fourth degree utero vaginal prolapse hysterectomy

• LAPAROSCOPIC

• Endometrial hyperplasia without atypia with failed • In appropriately medical treatment PRE - INVASIVE selected • Endometrial hyperplasia with atypia. DISEASES patients • CIN II with poor compliance or CIN III

• Adnexal masses : Need for hysterectomy to be individualised OTHERS and justiﬁed • Recurrent post-menopausal bleeding (even in the absence of malignancy)

Simple ovarian cysts less than 5 cm in size and without other signiﬁcant/ suspicious features should be kept on observation and reviewed after 6 months

HYSTERECTOMY SHOULD NOT BE DONE FOR Fibroids which are Minor degree of small (less than 5 cm) Simple ovarian cyst White discharge Non speciﬁc utero vaginal or less than or equal to per vaginum Cervicitis abdominal or pelvic prolapse Asymptomatic 5 cm pain (less than12 weeks size uterus)

COMPONENTS OF PRE OPERATIVE COUNSELLING INVESTIGATIONS AND INFORMED CONSENT ∙ Complete Blood Count • Blood grouping & cross matching ∙ Need for hysterectomy ∙ Fasting Blood Sugar & Post Prandial Blood Sugar ∙ Alternative treatment options ∙ Renal Function Test ∙ Risks and beneﬁts ∙ Liver Function Test ∙ Potential complications of the procedure ∙ Urine Routine & Microscopy ∙ Removal/ conservation of ovaries & tubes ∙ Electrocardiogram ∙ Route of hysterectomy ∙ X ray chest ∙ Possible need for post operative Hormone therapy in selected cases ∙ Others as indicated

COMPLICATIONS TO BE EXPLAINED FOLLOW UP

• Risk of Infection • Discharge summary with operative details • Bleeding (primary/ reactionary/ secondary) • Review for histopathology report • Injury to bladder/ bowel/ ureter • Report if there is fever, bleeding or any other symptoms • Pain • Avoid lifting heavy weight for 8 weeks • Fever • Abstinence for eight weeks • Hernia (rare and late complication) • Adequate iron and calcium & Vitamin D3 supplements • Evaluate need for hormones in very selected patients

• Ovaries should be preserved in most pre-menopausal women unless diseased or removal speciﬁcally indicated • While doing hysterectomy for benign gynaecological conditions in pre-menopausal women, it is recommended to combine it with bilateral salpingectomy with a view to minimise the risk of subsequent development of ovarian malignancy 1,2

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of

ICD O72

More than 500 ml of blood loss or any amount of bleeding which causes derangement of vital parameters is PPH

• Call for help RED FLAG SIGN: SUPPORTIVE MANAGEMENT • Rapid Initial Assessment - evaluate vital signs: PR, BP, RR and Temperature ∙ PR > 120/min • Establish two IV lines with wide bore cannula (16-18 gauge) • Monitoring of vitals ∙ Systolic BP < 100 mm Hg • Draw blood for grouping and cross matching • Measurement of ∙ Tachypnea < 95% • Start RL/ NS, infuse 1 L in 15-20 minutes * input and output • Give Oxygen @ 6-8 L /minute by mask, • Give blood ∙ SpO2 < 95% ∙ Deterioration of • Insert indwelling Catheter and connect to urobag transfusion as sensorium • Check vitals and blood loss frequently - at least every 15 minutes indicated • Monitor input and output

• Give Inj. Oxytocin 10 IU IM (if not given after delivery) • Start Oxytocin infusion : 20 IU in 500 ml RL/NS @ 40-60 drops per minute • IV bolus of oxytocin should NOT be given • Check to see if placenta has been delivered.

PLACENTA NOT DELIVERED PLACENTA DELIVERED

• Continue Oxytocin drip • Fundal Massage of the uterus • Palpate uterus • Inspect placenta for completeness • Attempt controlled cord • Explore uterus for any retained traction if uterus is placental bits/ membranes/ clots contracted and evacuate

PLACENTA DELIVERED PLACENTA NOT Uterus well contracted but Uterus • Continue oxytocin and DELIVERED ﬂabby uterine massage Shift for manual bleeding continuing • Check for completeness of removal of placenta placenta and membranes (MRP) TRAUMATIC PPH ATONIC PPH

• Explore for cervical/ vaginal/ perineal tears. Repair if Bimanual present If bleeding continues compression and • If bleeding persists despite repair of above, suspect pharmacotherapy without any apparent cause inadequate repair, rupture uterus or scar dehiscence. check for coagulopathy as per details • Shift to OT for exploration under GA and/or below laparotomy

* Arrange for blood / blood product at the earliest 3 ml of crystalloid solution should be used to replace every ml of blood lost during the initial part of the acute bleeding phase

MANAGEMENT OF ATONIC PPH

PHARMACOTHERAPY ANY OF THE FOLLOWING OPTIONS CAN BE USED EITHER ALONE OR COMBINATION AS PER AVAILABILITY

Inj Methyl Ergometrine 0.2 mg IM or IV slowly ∙ Contraindicated in hypertension, severe Inj Carboprost (PGF2 alpha) 250 µg IM Or Tab Misoprostol (PGE1) 800 µg Or • Contraindicated in asthma anemia, heart disease Per rectal or sublingual • Can be repeated every 20 minutes ∙ Can be repeated after 15 minutes to a to a maximum of 8 doses (2 mg) maximum of 5 doses (1mg)

Bleeding not controlled Bleeding controlled

Explore uterus for retained bits • Repeat uterine massage every 15 minutes for ﬁrst two hours • Monitor vitals every 10 minutes for 30 minutes , every 15 minutes for next 30 minutes and every 30 minutes for next 3-6 hours or Continue bimanual compression & Oxytocin infusion @10-20 units /hr until stable • Continue Oxytocin infusion @5-10 units /hr Bleeding not controlled (total Oxytocin not to exceed 100 IU in 24 hours)

• Check for coagulation defects Intra uterine balloon tamponade Tranexamic Acid (1g slow IV) has recently been • If present give blood and blood using condom catheter recommended as an adjunctive treatment for PPH components to be used as early as possible irrespective of cause Bleeding still not controlled but deﬁnitely within three hours of delivery. It can be repeated after 30 minutes if bleeding persists. Surgical intervention Standard treatment for PPH must continue • Uterine compression sutures meanwhile 1, 2 • Systematic uterine devascularisation by doing Uterine Ovarian Internal Iliac artery ligation 1 The WOMAN trial, The Lancet, 2017 • Hysterectomy 2 WHO update on Tranexamic Acid, 2017

Timely Referral to a higher centre must be considered if facilities for blood transfusion or exploration and surgical intervention are not available. Patient must be transported with I/V fluids containing oxytocin on flow and preferably with uterine/vaginal tamponade in situ. • Aortic compression may be used as a short time measure to reduce blood loss while awaiting definitive steps. • Non- pneumatic anti-shock garment (NASG) should be used during transport if available • Uterine artery embolization may be offered in selected patients if facilities are available

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of UTERINE FIBROIDS AND POLYPS ICD-10-D25 & N84

Heavy menstrual/ irregular bleeding EXAMINATION GPE: Specially check for pallor

Urinary pressure symptoms Abdominal examination: Check for any suprapubic mass or lump

P/S: Inspect cervix for local abnormalities Heaviness and pain in abdomen, dysmenorrhoea P/V: Assess for uterine size (enlarged and/or irregular uterus) SYMPTOMS:

Mass in lower abdomen INVESTIGATIONS Hemoglobin Infertility Complete blood count

Asymptomatic Thyroid function test

USG

ASYMPTOMATIC FIBROIDS <5CM DO NOT NEED TO BE TREATED

FIBROIDS & POLYPS

Endometrial polyps / sub Fibroids Fibroid Polyps mucus ﬁbroids

Thin pedicle Thick pedicle

Polypectomy Individualized management at tertiary centre

Small Fibroids (<5cm) Hysteroscopic removal Asymptomatic Symptomatic

• Endometrial polyps Medical • Select appropriate Management : Large Fibroids patient with Observation - Tranexamic acid (Uterine size >12 weeks) submucus ﬁbroids - Levonorgestrel-releasing intrauterine (selection should be system (if uterine cavity normal) based on size and - Progestogenic agents* proportion of the ﬁbroid projecting into the uterine No Relief cavity)

Discuss treatment option based on age and parity

Non surgical Surgical

Uterine artery Myomectomy Hysterectomy embolization (younger age (to be avoided in &/ or young patients low parity) aged <35 years as far as possible)

*Norethisterone (max daily dose 40 mg) OR Medroxyprogesterone acetate (max daily dose 40 mg). Any hormone should be given orally daily in divided doses for a duration of three weeks and repeated in a cyclical manner for total of 4-6 cycles of treatment

ALL THERAPUTIC OPTIONS NEED TO BE EXPLAINED TO THE PATIENT INCLUDING JUST KEEPING THE PATIENT ON OBSERVATION. ALL PATIENTS OF FIBROID UTERUS DO NOT NECESSARILY NEED HYSTERECTOMY.

COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. PAEDIATRICS October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of ACUTE ENCEPHALITIS SYNDROME AES IN CHILDREN ICD-10-G04

SYMPTOMS ADDITIONAL INFORMATION (HISTORY OF)

Fever, headache, vomiting, lethargy, unconsciousness

Acute onset of fever • Rash, vesicles, past history of chicken pox (

EXAMINATION

VITAL SIGNS GENERAL EXAMINATION NEUROLOGICAL EXAMINATION • Level of consciousness by Glasgow Coma Scale (GCS) • Temperature • Pallor • Abnormal posturing: decerebrate, decorticate • Pulse rate • Petechieae • Active seizures • Respiratory rate • Rash • Cranial nerves: pupil size and reaction, doll’s eye movements, squint, facial deviation • Blood pressure • Icterus • Focal neurological deﬁcits • Meningeal signs INVESTIGATIONS ESSENTIAL DESIRABLE OPTIONAL CBC, LFT, KFT, blood sugar, CECT Brain, MRI Brain, CSF PCR for Herpes CSF Neurovirology panel, anti-NMDA receptor antibody CSF examination* (cytology, biochemistry, culture, simplex encephalitis, JE testing, PCR viral testing of other samples (throat swab, AFB staining, Gene Xpert), peripheral smear for serology, EEG, Dengue nasopharyngeal aspirates, stool etc), Blood Tandem Mass malarial parasite, Rapid Malarial Antigen Test serology and NS1 testing, HIV Spectrometry and urine gas chromatography, antinuclear testing antibodies *Lumbar puncture is contra-indicated or neuroimaging must be obtained before lumbar puncture 1.Fundus: papilledema 2. Platelet count < 50,000 3. Focal neurological deﬁcits 4. Asymmetric/unreactive pupils 5.Decerebrate/decorticate posturing MANAGEMENT

All patients need to be admitted. If any of the following signs are present, the child should be referred to tertiary care facility with PICU and facilities for mechanical ventilation: • Glasgow Coma Scale < 8 • Abnormal breathing pattern • Shock not responding to ﬂuid bolus • Decerebrate or decorticate posturing • Seizures persisting despite benzodiazepine and phenytoin

Step I: Rapid assessment and stabilization Step II: History, Examination and Investigations as given above • Establish and maintain airway: Intubate if GCS<8, impaired airway reflexes, abnormal respiratory pattern, signs of raised intracranial pressure, SpO2 <92% despite Step III: Empirical Treatment (must be started if CSF cannot be high flow oxygen and fluid refractory shock done/ report will take time and patient sick) • Ventilation, oxygenation • Ceftriaxone: 100 mg/kg/day in 2 divided doses X 10-14 days • Circulation: Establish IV access, take samples for • Acyclovir (use in all suspected sporadic viral encephalitis): relevant investigations, fluid bolus if in circulatory failure 3 mo to 12 y: 500mg/m2 8 hourly (min 21 days) (20 mL/kg NS), inotropes if required >12 y: 10mg/Kg 8 hourly (14-21 days in confirmed cases)** • Identify signs of cerebral herniation or raised ICP • Artesunate combination therapy (stop if peripheral smear and RDT are • Temperature: treat fever and hypothermia negative) : 3mg/kg in child <20 kg, and 2.4mg/kg in child > 20kg IV/IM at 0,12 • Treat ongoing seizures- Benzodiazepine, followed by and 24 hours, followed by once daily parental/oral X 3-7 days phenytoin loading **If therapy was started empirically stop acyclovir, in case an alternative diagnosis is confirmed, or HSV PCR of CSF is negative on two occasions (24-48 h apart) and MRI imaging not suggestive of Herpes Simplex Encephalitis

Step V: Prevention/treatment of complications and rehabilitation Step IV: Supportive care and treatment • Physiotherapy, posture change, prevent bed sores and • Maintain euglycemia, hydration and control fever exposure keratitis • Treat raised intracranial pressure#, mild head-end elevation–15-30° • Complications: aspiration pneumonia, nosocomial • Treat seizures##; Give anticonvulsant if: history of seizures / GCS <8 / infections, coagulation disturbances child has features of raised ICP • Nutrition: early feeding • Steroids: Pulse steroids (methylprednisolone) to be given in children with • Psychological support to patient and family suspected acute disseminated encephalomyelitis or autoimmune encephalitis

#Management of raised intracranial pressure ##Treatment of seizures • Intubate if: GCS <8 / evidence of herniation / irregular respirations and inability to 1st Line: IV Lorazepam 0.1mg/kg or Midazolam 0.2 mg/kg maintain airway orDiazepam 0.3 mg/kg). • Signs of impending herniation: patient to be hyperventilated to a target PaCO2 of If no IV access: IM Midazolam 0.2 mg/kg 30-35 mmHg 2nd Line: Inj. Phenytoin 20 mg/kg (in Normal saline • Initial bolus of Mannitol(0.25 g/kg), then 0.25 g/kg q 6 h as per requirement, up to 48 1mg/kg/min) hours. If seizures still persist: • In the presence of hypotension, hypovolemia, and renal failure: hypertonic (3%) saline Refractory status: Transfer to PICU -> midazolam infusion (preferable to mannitol) 0.1–1 mL/kg/hr by infusion; serum sodium to be targeted to (1-18 microgram/kg/min) 145-155 meq/L If ICU facilities not available: sodium valproate (20 mg/kg) or • Adequate sedation and analgesia levetiracetam (20-40 mg/kg) or phenobarbitone (20mg/kg) • Avoid noxious stimuli • Administer nebulized lignocaine prior to endotracheal tube suctioning

DISCHARGE CRITERIA

Parents have been explained the Improvement in Has started eating Seizures have Hemodynamically Afebrile supportive care and physiotherapy consciousness and drinking orally subsided stable to be continued at home KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES REFERENCES 1. World Health Oraganisation. Acute Encephalitis Syndrome. Japanese encephalitis surveillance standards.January 2006. From WHO-recommended standards for surveillance of selected vaccine-preventable diseases. WHO/V&B/03.01. Available from: http://www. who. int/vaccines-documents/ DocsPDF06/843.pdf 2. National Program for Prevention and Control of Japanese Encephalitis/Acute Encephalitis Syndrome 2014. Government of India Ministry of Health & Family Welfare Directorate General of Health Services National Vector Borne Disease Control Programme. 3. Sharma S, Mishra D, Aneja S, Kumar R, Jain A, Vashishtha VM. Consensus guidelines on evaluation and management of suspected acute viral encephalitis in children in India. Indian Pediatr. Nov 2012;49(11):897-910. 4. Sankhyan N, Vykunta Raju KN, Sharma S, Gulati S. Management of raised intracranial pressure. Indian J Pediatr. 2010 Dec;77(12):1409-16. This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of ACUTE DIARRHEA ICD-10-R19.7

ASK FOR SKIN PINCH TEST REFER TO HOSPITAL • Duration • Locate the area on the child’s • Severe malnutrition/ HIV • Blood in stool abdomen halfway between the • Severe dehydration • Vomiting, fever, cough, recent umbilicus and the side of the • Hypernatremic (Na >145mmol/L) / measles, HIV status (if known) abdomen. hyponatremic dehydration (Na • Immunization status and pre • Use thumb and first finger to pinch <135 mmol/L) DIARRHEA IS and not finger tips. • Dysentery with age <1 yr/ measles • >3 loose or watery illness feeding practices • The fold of the skin should be in a line in past 6 weeks/ dehydration/ sick stools/ day • Fluids/ food/ drugs and other up and down the child’s body. • Dysentery with no improvement • Acute Diarrhea <14 remedies taken during illness • Firmly pick up all layers of the skin and on antibiotics days tissue under them. • Persistent diarrhea with • Persistent diarrhea • Pinch the skin for one second and then dehydration >14 days EXAMINATION release it. Look to see if the skin pinch • Persistent diarrhea with serious • Dysentery – blood • General condition of child goes back: systemic infection such as in stools • Nutritional status (weight/ • Very slowly (longer than 2 seconds) pneumonia, sepsis, infants <4 weight for height / MUAC) • Slowly (skin stays up even for a months of age, or when there is • Classify malnutrition if any brief instant) no improvement with treatment • Signs of dehydration & • Immediately (normal) over 5 days classify dehydration

MANAGEMENT CLASSIFY DEHYDRATION

2 of following: 2 of following: Not enough signs to a) Restless , irritable a) Lethargy / unconscious classify some or severe b) Sunken eyes b) Sunken eyes dehydration c) Drinks eagerly, thirsty c) Not able to drink/ drinking poorly d) Skin pinch - goes back very slowly d) Skin pinch - goes back slowly

NO DEHYDRATION: PLAN A SOME DEHYDRATION: PLAN B SEVERE DEHYDRATION: PLAN C • Fluids • Manage in clinic /daycare facility with recommended • Urgent referral to hospital • Give extra fluids (as much as child amount of ORS (75ml /kg) over 4 hour period • Mother to continue rehydration by giving will take) until diarrhea stops. • If weight is not known frequent sips of ORS during transport or use • Use WHO ORS after each loose NG tube when possible in patients with stool (in addition to usual fluid < 4 4 -11 12 -23 2 – 4 5-14 15 years poor drinking AGE months months months years years or older intake) NO • Upto 2 yrs → 50 -100 ml 5 – 7.9 8 - 10.9 11 – 16 – 30 kg or WEIGHT <5kg kg kg 15.9 kg 29.9 kg more CAN YOU GIVE INTRAVENOUS • 2 yrs or more → 100 -200ml 200 - 400 - 600 - 800 - 1200 - 2200 - (IV) FLUIDS IMMEDIATELY? • On ORS packet check whether IN mL 400 600 800 1200 2200 4000 200ml or 1 litre of clean water is NO needed • After 4 hours reassess the child, classify dehydration • Start IV fluid immediately • Frequent small sips with spoon or and select appropriate plan (A /B/C) • Ideal fluid is Ringer lactate solution / Normal cup. • Give extra fluids, zinc supplement, feeding advise and saline (DNS in malnourished) • If child vomits, wait 10 minutes counselling regarding danger signs* as in plan A FIRST GIVE THEN GIVE 70 then continue slowly. AGE • Follow up in 5 days if no improvement 30 ML/KG IN ML/KG IN • Homemade fluids- salted rice Infant (< 12 1 hour 5 hours water, salted yogurt drink, months) vegetable or chicken soup with salt Older 30 minutes 2.5 hours and clean water, unsweetened fresh PATIENT EDUCATION fruit juice and coconut water • Danger signs* • If child can drink, give ORS by mouth while • Unsuitable fluids - carbonated • Hygiene practices the drip is set up beverages, commercial fruit juice, • Hand washing , proper disposal of excreta • Assess heart rate/ respiratory rate/ BP/ CFT/ sweetened tea & coffee, other • Safe drinking water consciousness and recognize early shock medicinal teas / infusions. • Appropriate feeding practices • Refer for hospitalization • Zinc supplement (Zinc sulphate/ • Vaccination as per IAP guidelines • If prevalance of cholera – carbonate / acetate) Doxycycline single dose 300mg or • 2-6 months → 10mg/day x 2 weeks Tetracycline 12.5mg/kg 4 times a day x 3 days. For young children Erythromycin 12.5mg/kg • >6 months → 20mg/day x 2 weeks INVESTIGATIONS • Counsel Mother/ Attender • Some dehydration: 4 times a day x 3 days • Feeding advise Preferable Tests- electrolytes • Associated vomitings – Ondanstetron 0.15 mg/kg/dose IV/oral in • Infants on breast feed, to • Severe dehydration: addition to rehydration therapy continue more frequent breast Essential tests- CBC, electrolytes • Reassess every 15-30 minutes till a strong feeding than usual. Preferable Tests- Renal Function Tests, VBG radial pulse is present and then every hour • Those not on breast feed to • In suspected cholera cases: If hydration status is not improving, give IV continue their usual milk feed/ Preferable tests- stool for hanging drop and drip more rapidly formula at least once in 3 hours. stool culture • Give age appropriate foods to >6 • After 6 hours (infants) and 3 hours (older • Dysentery: (no response to antibiotic in 2 months old based on their pre patients) - evaluate for dehydration and days) Preferable test- stool culture & stool illness feeding pattern choose the appropriate plan (A, B, or C) to routine for trophozoites of Ameoba continue treatment • Persistent diarrhea: • Give ORS (about 5 ml/kg/hour) as soon as • Danger signs (return immediately) Preferable test- stool routine microscopy, the child can drink: usually after 3-4 hours • Passing many watery stools urine routine microscopy, urine culture , (infants) or 1-2 hours (children) • Repeated vomitings / very thirsty sepsis screen • Observe for 6 hours after the child has been • Eating / drinking poorly fully rehydrated. • Develops fever / blood in stools • In hypernatremic and hyponatremic WHEN CONSIDERING ALTERNATIVE DIAGNOSIS OF dehydration child appears relatively less ill / • Follow up in 5 days if no improvement PERSISTENT DIARRHEA AND DYSENTRY more ill respectively and needs to be referred for hospitalization DISCHARGE CRITERIA PERSISTENT DIARRHEA • Suffcient rehydration (indicated by wt gain • Appropriate fluids to prevent or treat dehydration &/or clinical status) • Nutrition: • IV fluids no longer needed • If breastfeeding, give more frequent, longer breastfeeds, day and night. • Oral intake = / > losses • Other milk: replace with increased breastfeeding, or with fermented milk • Medical f/u available products, such as yogurt, or half the milk with nutrient-rich semi-solid food. • For other foods, follow feeding recommendations for the child’s age: give small, frequent meals (at least 6 times a day), and avoid very sweet foods or drinks. DYSENTERY • Treat dehydration according to assessment. • Zinc for 14 days • Supplement vitamins / minerals • Ciprofloxacin 15mg/kg twice a day and reassess • Antimicrobial to treat diagnosed infection after 2 days. A) Intestinal infection: Improvement: 3 days of treatment • If blood in stool: Treat like dysentery • No improvement → Cefixime 10 mg//kg/d, 2 div • If stool routine suggestive of Amoebiasis: Treat for it doses. Reassess after 2 days. If better complete • If stool suggestive of cyst/ Trophozoite of Giardia: Give Metronidazole 3 -5 days of treatment. 5mg/kg/dose x 8hrly x 5 -7 days • If stool routine positive for Ameobiasis : B) Treat Non intestinal such as UTI / Otitis Media Metronidazole 10mg/kg/dose 8 hourly x 7 • Follow up in 5 days days (10 days in severe cases) • Refer to hospital (See box) • Refer to hospital (See box)

REFERENCES 1. IMCI (WHO) module on Diarrhea 2014. 2. WHO Treatment for Diarrhea - A manual for physicians and other senior health workers 2005. 3. WHO GLOBAL TASK FORCE ON CHOLERA CONTROL 2010. KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of DENGUE FEVER ICD-10-A90

SYMPTOMS WARNING SIGNS Fever and two of the following • Abdominal pain or tenderness criteria: • Persistent vomiting 1. Nausea Live in / • Clinical ﬂuid accumulation – pleural effusion, 2. Vomiting travel to ascites. WHEN TO 3. Rash dengue • Mucosal bleed – malena, epistaxis, gum bleed 4. Myalgia endemic SUSPECT? • Liver enlargement > 2 cms 5. Headache area • Shock (DSS) – weak rapid pulse, pulse 6. Retro orbital pain pressure < 20mm Hg hypotension, cold 7. Arthralgia clammy skin, restlessness. 8. Hemorrhagic manifestations

Dengue without Dengue with Severe ASSESSMENT warning signs warning signs dengue

TREATMENT OF PROBABLE DENGUE SEVERE REASONS FOR REFERRAL WITHOUT WARNING SIGNS DENGUE • Cold extremities, restlessness • Fluid accumulation with • Symptomatic ambulatory • Acute abdominal pain respiratory distress • Decreased urine output treatment • Bleeding and • Paracetamol for fever: avoid NSAIDs • Severe bleeding hemoconcentration • Daily monitoring: clinical, PCV, • Rising PCV & platelets • Impaired consciousness thrombocytopenia without clinical symptopms

INVESTIGATIONS ESSENTIAL DESIRABLE OPTIONAL • Echocardiography • Hb, TLC, DLC, Platelets, PCV • Chest X-ray • LFT, RFT, • PCR - dengue • Positive tourniquet test • CPK, albumin • CVP monitoring • NS1 antigen (ELISA method) • USG abdomen • USG guided measurement of collapsibility of • Dengue IgM IVC for monitoring hypovolemia SHOCK

Assess airway, breathing, circulation & start oxygen inhalation

COMPENSATED SHOCK HYPOTENSIVE SHOCK (tachypnea, tachycardia, normotensive) (tachypnea, tachycardia, hypotension, peripheral pulses not palpable) Ringer’s Lactate/ NS 10 ml/kg/hr 20 ml/ kg crystalloid or colloid in 15 minutes

Assess after every hour by checking HR, Assessment of Shock RR, BP, CVP and PCV (monitor HR, RR, BP, PCV and CVP)

No Improvement Improvement No Improvement Improvement

RL 10-15ml/kg/hr RL 5-7ml/kg/ 1-2hr Gradually decrease PCV Increased PCV Decreased infusion rate Assessment at second hour Further Improvement 10ml/kg/hr 1-2 hr No Improvement Colloids 10-20ml/kg Blood Transfusion 7ml/kg for 2-3 hrs RL 3-5ml/kg/hr 5ml/kg for 2-4 hrs RL 15ml/kg/hr 3ml/kg for 2-4 hrs Continue IV ﬂuids till Assessment Stop at 48 hours Assessment at third hour stable for 24 hours No Improvement Improvement Colloids 10ml/kg/hr Once stable, observe for 24 hours, then discharge Look for blood loss, acidosis if the discharge criteria is No Improvement cardiac dysfunction and treat fulﬁlled accordingly

Look for anemia, acidosis, myocardial dysfunction and In case of shock, start bolus and arrange for urgent referral with continuous monitoring treat accordingly by a health professional to facilities with a PICU.

INDICATION FOR PLATELET TRANSFUSION & PACKED RED CELLS

PACKED RED CELLS PLATELETS FRESH FROZEN PLASMA/ • Loss of blood (overt blood) 10% or • Prolonged shock CRYOPRECIPITATE more of total blood volume. • Prophylactic platelet transfusion (PLT <10.000/cumm) Coagulopathy with • Refractory shock • Fluid overload • Systemic massive bleeding bleeding

DISCHARGE CRITERIA (ALL OF THE FOLLOWING CONDITIONS MUST BE PRESENT) CLINICAL LABORATORY • No fever for 48 hours • Increasing trend of platelet count • Improvement in clinical status (check for general well-being, appetite, haemodynamic status, • Stable haematocrit without intravenous ﬂuids urine output, respiratory distress)

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of FEVER IN CHILDREN ICD-10-R50

FEVER IS Core (rectal) temperature ≥ 38.0ºC (100.4ºF) or axillary temperature > 37.5ºC (100.4ºF).

EXAMINATION CLUES TO A SPECIFIC DIAGNOSIS

Vital signs: Temp, HR, RR, BP, CFT Fever + respiratory symptoms: Fever duration • Cough, runny nose: URTI • Membrane over tonsils/pharynx: Diphtheria Appearance: Sick, toxic, lethargic, irritable, • Paroxysmal cough: Pertussis like illness inconsolable, dehydrated • Barking cough: Localizing symptoms of: RTI, UTI, GI Laryngotracheobronchitis/ croup tract infection, CNS infection General Examination: • Ear, nose, throat Fever + rash • Rash (petechieae, macules, papules, vesicles, • Red maculopapular rash: Measles, Rash, joint symptoms, skin/ soft Rubella, Dengue. WHAT nodules, polymorphic) tissue swelling or redness • Fine generalized maculopapular rash TO ASK? • Lymphadenopathy with systemic dysfunction/shock: • Skin (pustules, pyoderma, impetigo, Meningococcemia. cellulitis) • Itchy erythematous macules evolving to clear vesicles: Varicella Vaccination within 24 hours, • Joints drug/ toxin exposure • Genitalia (for erythema, tenderness, edema) • Bones Fever + other symptoms: • Parotid gland swelling: Mumps Family/ neighbourhood • Arthritis: Consider Chikungunya, acute history of similar illness Systemic Examination rheumatic fever, JIA • Strawberry red tongue, skin peeling, • Chest auscultation, abdominal palpation, lymphadenopathy, conjunctival CNS, CVS injection: Kawasaki disease

INVESTIGATION OF THE FEBRILE CHILD (Consider if one or more of the following are warranted. Perform investigations only where result impacts management)

<7 DAYS FEVER ALONE <7 DAYS AND LOCALIZING <7 DAYS AND NON >7 DAYS AND FEVER ALONE >7 DAYS AND LOCALIZING SYMPTOMS PRESENT SPECIFIC SYMPTOMS OR WITHOUT LOCALIZING SYMPTOMS PRESENT SYMPTOMS ESSENTIAL: ESSENTIAL: As given in the ESSENTIAL: As given before ESSENTIAL: All mentioned in ESSENTIAL: All investigations If fever <72 hours and first box Essential & Desirable list in the mentioned in the prior child not looking sick: No DESIRABLE: As given prior boxes. Additionally boxes investigations before. Additionally consider Widal test. All If fever >72 hours, DESIRABLE: As given in consider: serology for DESIRABLE: DESIRABLE: Consider Mantoux investigations mentioned in consider: TLC, DLC, P.S for the first box + consider: specific viral infection, test, ultrasonography the prior boxes. Additionally leukocyte (Clean-catch) urine rapid antigen test for consider: serology for morphology, malarial microscopy & culture, malaria, NS1 antigen and Brucella, CMV, Herpes, parasite & platelet count chest Xray, CSF analysis dengue IgM antibody, OPTIONAL: As given before. Japanese encephalitis. CT blood culture, serology Additionally consider: scan in deep seated abscess DESIRABLE: Rapid for scrub typhus Ultrasonography of abdomen, or lung abscess, Bone antigen test for malaria, OPTIONAL: As given in the chest, pericardium, joint(s), marrow examination, ANA NS1 antigen and dengue first box + consider: abscess, lymph node clusters, profile, HIV serology, PET IgM antibody, blood ultrasonography, throat/ OPTIONAL: As given before parotid gland etc, for scan. culture pharyngeal swab, pus microscopy, Xpert MTB RIF assay, Mycobacterial culture. Consider: aspiration. OPTIONAL: All bone marrow, ANA-profile, HIV OPTIONAL: C reactive investigations mentioned in serology, echocardiography, CT protein, procalcitonin the prior boxes PET scan.

MANAGEMENT

STEP1 STEP2 STEP3 STEP4 STEP5

INITIAL ASSESSMENT AND CONSIDER HOSPITALIZATION CONSIDER REFERRAL TO EMPIRIC MANAGEMENT CONSIDER DISCHARGE WHEN STABILIZATION FOR OBSERVATION/ TERTIARY CARE CENTRE MANAGEMENT IN

Manage urgent issues • All neonates (after appropriate • Consider based on • Afebrile > 48 hours or • Decrease body • Young infants with toxic stabilization and/or likely diagnosis, fever is showing temperature with appearance. initial management) : sickness status, and defervescence Paracetamol (15mg/kg • Severe malnutrition, toxic • Need for intensive care availability of • Feeding well by any route) and/or appearance, inability to • Complex multi-system investigation facilities. • Presenting symptoms (in hydrotherapy. feed, lethargy, irritability, disease. • Empiric treatment addition to fever) • Manage any dehydration, etc. • Confirmed should be tailored resolved/resolving life-threatening issue. • >14 days illness without complications of the based on • Physician is satisfied that • Consider first dose diagnosis. primary illness subsequently available further care can be antibiotic in suspected • Any reason deemed by investigation reports & continued on meningitis, severe the treating physician. local antimicrobial ambulatory basis pneumonia, or severe sensitivity. • Duration of i.v antibiotic malnutrition. • Anti tuberculosis therapy is completed • Consider anti-malarial in treatment (ATT) suspected malaria should not be started on empiric basis except in suspected TBM

ABBREVIATIONS ANA: Anti-nuclear antibody CSF: Cerebro-spinal uid HR: Heart rate RTI: Respiratory tract infection BP: Blood pressure CT: Computed tomography JIA: Juvenile idiopathic arthritis TLC: Total leukocyte count CFT: Capillary lling time DLC: Di erential leukocyte count PET: Positron emission tomography URTI: Upper respiratory tract infection CMV: Cytomegalovirus CVS: Cardiovascular system PS: Peripheral smear UTI: Urinary tract infection CNS: Central nervous system GI: Gastro-intestinal RR: Respiratory rate KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES REFERENCES 1. World Health Organization. Integrated Management of Childhood Illness: distance learning course. http://apps.who.int/iris/bitstream/handle/10665/104772/9789241506823_Module-5_eng.pdf;jsessionid=942F89F89671BA396EC7F46C9B5C1158?sequence=7 2. Mahajan P, et al. Consensus Guidelines on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India. Indian Pediatr 2017; 54: 652-60. 3. World Health Organization 2015. Government of India National Guidelines for Clinical Management of Dengue Fever. 4. Kliegman RM (ed). Nelson Textbook of Pediatrics 20th edition, 2016. This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of SEPSIS AND SEPTIC SHOCK IN CHILDREN ICD-A41.9, R65.21

WHEN TO SUSPECT (2-59 MONTHS)? CHECK FOR HISTORY OF Sepsis to be suspected: Decreased Prior treatment Poor Feeding Lethargy Unconsciousness in children with any responsiveness Previous recurrent infections infections (fever with Cold/ Rapid or or without rashes/ Chest bluish shallow Stridor Prior hospitalisation pneumonia/ peripheries breathing in drawing diarrhoea) and they Chronic systemic illness are at risk of life Excessive (congenital or acquired) Decreased Convulsions Stiff neck threatening organ vomiting urine output dysfunction Immunization (age appropriate)

EXAMINATION GENERAL PHYSICAL EXAMINATION VITAL SIGNS SYSTEMIC EXAMINATION

Lethargy Petechial rash Pulse volume (High volume as Heart rate and Respiratory: Signs of respiratory well as low volume/feeble respiratory rate distress – retraction, nasal ﬂaring, Decreased alertness Mucosal bleeding pulse) (outside the age range) grunting ,crepitation on auscultation Activity Rapid breathing CVS: Murmur, gallop rhythm Capillary reﬁlling time > 3 Pulse oximetry Per abdomen: Abdominal distension Pallor Chest in drawing seconds (saturation <95%) CNS: *AVPU scale, signs of meningitis, >1 year child if seizures Cyanosis Cold peripheries Blood pressure* Skin: Rashes (Systolic blood Pressure systolic BP < 70+ Age Bone & joints: Swelling, redness, Skin mottling Assess nutritional < 70 in <1 year) (yrs) x2) or ( lower status than age range) tenderness

SIGNS OF SEVERE DEHYDRATION Diarrhoea plus any two of these: Lethargy or unconscious, not able to drink or drinks poorly, Sunken eyes, skin pinch goes back very slowly

INVESTIGATIONS- (Based on symptoms and available facility) Essential – Complete blood counts, peripheral blood Desirable - Blood culture, blood gas, relevant cultures (based on Optional- PCT , USG film, urine routine, blood sugar, CRP, serum symptoms), chest X-ray, specific illness- Malaria – rapid malarial to guide the fluids electrolytes, renal function test, liver function test antigen test, Dengue- dengue NS1, IgM, CSF study

MANAGEMENT DIAGNOSTIC ALGORITHM

CHILD (2-59 MONTHS OF AGE WITH FEBRILE ILLNESS (WITH WARNING SIGNS)

GOOD PERIPHERAL PERFUSION POOR PERIPHERAL PERFUSION** Admit or initiate treatment as per IMNCI guidelines2 With fast pulse, cold peripheries, poor pulse volume, CRT >3 seconds (Fast pulse: HR> 180 in < 12 month old child, HR >120 in >12 month old child)

Admit, initiate treatment, refer to centre with facility of ICU, ventilation, 24 hour monitoring (if required) **If there is improvement after 1st bolus and history of diarrhea present then: Start O with face mask @ 4-6 lit/min, or hood @8-10 Give 70 ml/kg over 5 hours in infants and 2 lit if not available nasal prongs 1-2 lit/min to main- over 2 ½ hours in a child with hypovolemic tain SpO >95%, Insert two IV cannulas, give first shock. Give additional ﬂuids if losses 2 dose of antibiotics within first one hour continue.

Start maintenance ﬂuid in case of other illness Give 20 ml/kg of normal saline fluid bolus over 20- 30 Antibiotics minutes. 1. >3 months Inj Ceftriaxone 100mg/kg/day ( 2 Reassess for decreases in heart divided doses) rate, improvement in pulse 2. <3 month Inj Cefotaxime 200mg/kg (divided volume and warm peripheries 6-8hrly), Inj Gentamicin 5-7.5 mg/kg single dose /day If no improvement 3. If soft tissue infection: consider Inj Cloxacillin Repeat bolus of 20 ml/kg over 30 minutes, with careful 200mg/kg divided monitoring for hepatomegaly, oxygen saturation, crepitation’s 6 hourly or Inj Amoxicillin- Clavulanic acid 30 in chest (if any of above appears then stop fluids) mg/kg/dose 8hrly)

Inj Adrenaline- 0.3x body weight in mg in 50 ml NS or 5% dextrose at 1 ml/hr will give 0.1 If shock persists microgram/kg/min Start Inj Adrenaline infusion @0.1 microgram/kg/min and refer to higher centre

#For severe acute malnutrition – consider SAM STW #For suspected Dengue follow Dengue Fever STW

When to refer When to Suspect Cardiac Failure Complications • Shock does not improve after 2nd • History of underlying heart disease • Respiratory failure ( excessive increase in the respiratory fluid bolus • History of forehead sweating/ suck rest suck cycle rates and inability to maintain saturation> 94% with • Signs of fluid overload • Murmur oxygen) -non-invasive (CPAP/BIPAP) or invasive • No facility for continuous • Hepatomegaly or basilar crept ventilation monitoring. • Congestive heart failure- Dobutamine / Milrinone • Before referral counsel the parents If it is suspected be careful in giving fluid bolus infusion and Furosemide and inform referring facility • Infections on other sites- explore and treat accordingly DISCHARGE CRITERIA Completion of antibiotics Afebrile for 48 hours Vitals within normal limit Good oral intake Adequate urine output as per culture sensitivity for age >1ml/kg/hr

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

*DISABILITY (AVPU SCALE) A Is the child Alert? If not; V Is the child responding to Voice? If not; P Is the child responding to Pain?; U The child who is Unresponsive to voice (or being shaken) AND to pain is Unconscious *Anything below A should be classify as danger sign

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of SEVERE ACUTE MALNUTRITION WITH COMPLICATIONS ICD-10-E43

COMMON PRESENTATION DIAGNOSTIC CRITERIA FOR EXAMINE FOR • Faulty feeding SAM & MAM • Vital signs: PR, RR, CRT • Not exclusively breastfed • Lethargy/ irritability for 6 months 0-6 months • Loss of subcutaneous fat • Consider SAM if MUAC <11.0 cm • Muscle wasting • Bottle feeding • Pallor • Delayed/Inadequate 6-59 months • Signs of Vitamin B, K and A deﬁciencies complementary feeding • Respiratory distress • Consider SAM if MUAC <11.5 cm • Dehydration • Poor appetite or WHZ <-3 SD or bilateral • Not gaining weight pitting oedema • Lethargic • Consider MAM if MUAC is TRIAGE • Disinterested in surroundings between 11.5- 12.4 cm or WHZ is SAM + GOOD APPETITE + NO MEDICAL • Delayed development between -2 to -3 SD COMPLICATION WHEN TO Home based treatment + oral amoxicillin Additional symptoms of >5 years 50 mg/kg/dose twice a day for 7-10 days SUSPECT? complications • Consider SAM if BMI ≤ 3SD • Loose motions (severe thinness) • Jaundice SAM + COMPLICATIONS/ POOR APPETITE/ FAILED • Consider MAM if BMI ≤ 2 SD • Seizures HOME TREATMENT (thinness) Inter-current infections: Hospitalize • Pneumonia • Diarrhea INVESTIGATIONS • Sepsis ESSENTIAL DESIRABLE OPTIONAL • Skin infections Hemogram, RBS, LFT, ECG, Stool pH, Stool Blood Culture, Blood • Severe dehydration KFT, Chest X-Ray, microscopic, Urine culture, • Untreated tuberculosis gases, Ultrasound RDT-HIV, Gastric Serum electrolytes (Na, K, • HIV aspirate for (inferior vena cava to • Social challenges Cal), Serum B12, Serum CBNAAT/AFB Folate levels ascending aorta ratio)

TREATMENT A. STABILISATION PHASE: Monitor vitals, urine frequency, stool/vomitus volumes INTAKE: IVF (DNS) 4 ml/kg/hr for 2-3 days with early/concomitant initiation of oral feeds (130 ml/kg/day) CONDITION PLACE OF TREATMENT TREATMENT

Facilities for supportive • Inj.. Ampicillin – 50 mg/kg/iv or im X 6hrly Plus inj. Gentamicin- 7.5 mg/kg iv or im, OD for 7-10 days INFECTIONS monitoring, • If no response within 48 hrs or critically ill give inj. Ceftriaxone 50 mg/kg, OD for 7-10 days (empirically) investigations and IVF • When accepting orally, switch to oral amoxicillin 40-45 mg/kg/dose twice a day for 7 days • If prolonged diarrhea (>7 days): Metronidazole 10-12 mg/kg, 8 hrly for 7-10 days (inj.ectable or oral)

Facilities for supportive monitoring, investigations Conscious: 50 ml of 10% Dextrose or 1 tsf sugar in 3 tsf water orally HYPOGLYCEMIA and IVF (RBS <54mg/dL) Transfer to intensive care Unconscious: 5 ml/kg of 10% Dextrose IV facility to manage shock NO IMPROVEMENT treat as shock

Facilities for supportive Skin to skin care with mother (infants) monitoring, investigations and Warming under warmer, incandescent lamp or warmer HYPOTHERMIA IVF. Plus warmer (<35.5 ºC or 96 ºF) Intensive care facility to NO IMPROVEMENT treat as shock manage shock Facilities for supportive monitoring, investigations Conscious: 50 ml of 10% Dextrose or 1 tsf sugar in 3 tsf water orally SEVERE and IVF DEHYDRATION Transfer to intensive care Unconscious: 5 ml/kg of 10% Dextrose IV facility to manage shock NO IMPROVEMENT treat as shock

ELECTROLYTE Facilities for supportive Potassium: 3-4 mmol/kg/D, orally for 2 wks monitoring, investigations IMBALANCE Magnesium: 0.4-0.6 mmol/kg/D1 IM followed by oral for 2 wks (emperically) and IVF

Facilities for supportive Whole blood /PRBC transfusion (10 ml/kg over 3 hrs) : if Hb <4 gm/dL or Hb 4-6.5 gm/dL with respiratory monitoring, ANEMIA distress with close monitoring and hy. Furosemide (1 mg/kg) at start of transfusion investigations and IVF

B. REHABILITATION PHASE (Transfer to NRC when child meets criteria for discharge* & accepts home available foods) FEEDING ELECTROLYTES VITAMINS Place of treatment: Facilities for supportive monitoring Place of treatment: Facilities for supportive Place of treatment: Nutritional rehabilitation center (NRC) Treatment: monitoring a. 6 months and above: F75 at least 5 times/day gradually Treatment: increasing to give 150-200 kCal/kg/day (usually 2-3 days) then Treatment: a. Zinc: 2 mg/kg/day X 2wks orally switch to F100 for next 5-7days with introduction of home a. Vitamin A: >12 months- 2 lac iu, 6-12 available food b. Copper: 0.3 mg/kg/day X 2 wks orally months: 1 lac iu, <6 months: 0.5 lac b. Below 6 months: same as above with return to exclusive c. Iron: 3 mg/kg/day once weight gain iu if food not fortiﬁed breastfeeding where ever possible has started orally for 6 weeks b. Vitamin D, A, B Complex: RDA

*CRITERIA FOR DISCHARGE FROM HOSPITAL TO OUTPATIENT CARE: Clinically well and alert; no or resolving medical complications; no or resolving oedema (if present); satisfactory oral intake has a good appetite (taking at least 75% of target calorie intake of 150- 200 kcal/kg/day & 0-6 months old have weight gain of 3-5 gm/kg/day for three days). PRIMARY FAILURE OF TREATMENT: (a.) Failure to regain appetite by day 4 (b.) Failure to lose oedema by day 4 (c.) Oedema still present Day 10 (d.) Failure to gain at least 5g/Kg/day for 3 consecutive days on catchup diet. Look for unrecognized congenital abnormality, inborn errors of metabolism, immune deﬁciency, other major organ dysfunction, and malignancy.

APPETITE TEST: Passed if, a child not fed for last 2 hours, when fed by mother in a quiet place consumes HOW TO PREPARE F75 AND F100 F75 F100 in 1 hour: • 7-12 months: of ≥ 25 ml/kg of F100 FRESH WHOLE CREAM MILK 300 ml 900 ml • > 12 months: of locally prepared ready to eat food ** SUGAR 100 gm 75 gm AMOUNT TO BE GIVEN: 15 gms or more if < 4 kg; 25 gms or more if 4 – 7 kg; 35 gms or more if 7-10 kg **[ Mixture of Roasted groundnut 1000 gm , Milk powder 1200 gms, Sugar 1120 gms, Coconut oil 600 VEGETABLE OIL 20 ml 20 ml gms. To be kept refrigerated for not more than 1 week.] ADD WATER TO GET TOTAL VOLUME OF 1 Litre 1 Litre

ABBREVIATIONS WHZ: Weight for Height Z-score MUAC: Mid-upper Arm Circumference MAM: Moderate Acute Malnutrition SAM: Severe Acute Malnutrition SD: Standard Deviation (from median) BMI: Body Mass Index

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES REFERENCES 1. The WHO growth standards. Available at http://www.who.int/childgrowth/standards/en/ 2. Management of severe acute malnutrition in children 6–59 months of age with oedema. Available at http://www.who.int/elena/titles/oedema_sam/en/ 3. Operational guidelines on Facility Based Management of Children with Severe Acute Malnutrition.Available at http://nhm.gov.in/nrhm-components/rmnch-a/child-health-immunization/child-health/guidelines.html 4. Kumar R, Kumar P, Aneja S, Kumar V, Rehan HS. Safety and Efﬁcacy of Low-osmolarity ORS vs. Modiﬁed Rehydration Solution for Malnourished Children for Treatment of Children with Severe Acute Malnutrition and Diarrhea: A Randomized Controlled Trial. J Trop Pediatr. 2015 Dec;61(6):435-41.

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of SEVERE PNEUMONIA IN CHILDREN ICD10-J18.9

ADDITIONAL INFORMATION Cough, cold, with or without CHECK FOR HISTORY OF fever, difficulty in breathing (that includes fast breathing and chest indrawing) of less than 2 weeks duration. Similar illness in past, if yes, history of improvement with nebulized medications to Asthma/allergy in family. consider asthma. PRESENTING GENERAL DANGER SIGNS SYMPTOMS Not able to drink, persistent vomiting, convulsions, lethargic /WHEN TO or unconscious, stridor in a SUSPECT? calm child or severe malnutrition. Influenza like illness in Immunization (age family over past 2 weeks: appropriate specifically to consider treatment for vaccination included in influenza. SUSPICION OF FOREIGN BODY ASPIRATION national schedule and Sudden onset choking and Pneumococcus, breathlessness. Influenza).

EXAMINATION FOR VITAL SIGNS NUTRITIONAL AUSCULTATION OF FOLLOWING SIGNS STATUS CHEST Respiratory rates, heart Chest indrawing, state of rate, temperature, capillary Specifically for defining Breath sounds, crepitation, alertness, cyanosis, clubbing, refill time, pulse oximetry. Severe Acute Malnutrition rhonchi. stridor, grunting. (SAM).

DIAGNOSTIC ALGORITHM Child age 2–59 months RED FLAG SIGNS with cough and/or Irregular or gasping respiration, difﬁcult breathing. cold extremities, altered sensorium, cyanosis.

Fast breathing (2-12 Fast breathing (2-12months>50; 1-5 years>40 ;>5 Cough and cold, months >50; 1-5 years >20 ) and/or chest indrawing with any of the no breathing years>40; >5 years >20 ) general danger signs (not able to drink, persistent difﬁculty. and/or chest indrawing vomiting, convulsions, lethargic or unconscious, oxygen saturation>92%. stridor in a calm child or severe malnutrition).

NO PNEUMONIA PNEUMONIA SEVERE PNEUMONIA Red flag signs positive No red flag signs Admit or refer to facility with following: Admit or refer to a facility with Ambulatory treatment Appropriate: ventilation facility, ICU, round Home care following: oxygen by mask or with oral Amoxicillin the clock monitoring advice. hood, pulse oxymeter, IV fluids, and follow up. If plan to refer: Give first dose of oxygen, clinical supervision, X ray antibiotics, arrange transport and inform film (desirable). to the referral centre.

INVESTIGATIONS TREATMENT COMPLICATIONS AND THEIR TREATMENT ESSENTIAL: OXYGEN INHALATION: by mask (1-2 L/min) or hood (4-6 L/Minute) to Hemogram, random maintain oxygen saturation> 95%. NON RESPONDERS: persistence blood sugar, CRP, IV ANTIBIOTICS: of symptoms and/or signs chest X-ray. • For children 2-59 months: Ampicillin 100-200mg/kg in four divided doses + 48-72 hours after initiation of Blood DESIRABLE: Gentamicin +- 5-7.5 mg/kg as single dose daily. appropriate culture, pleural tap, • For children >5 years: Ampicillin/Amoxicillin, add macrolide treatment-change serum electrolytes, (Azythromycin/Erythromycin) if atypical pneumonia is suspected. antimicrobials. renal and liver • If suspected Staphylococcal pneumonia in any age (Pneumatocele on PLEURAL EFFUSION: diagnostic function tests. CXR, post measles, infected scabies or pyoderma) add Cloxacillin/ aspiration. OPTIONAL: ABG, lung Amoxiclavulanic acid. EMPYEMA: drainage with ICD. ultrasound, PCT, SUPPORTIVE CARE: Paracetamol for fever, IV ﬂuid, bronchodilators LUNG ABSCESS: change tracheal aspirate (inhaled) as needed. antibiotics for longer duration (gram stain with WHEN AND WHAT TO SWITCH TO ORAL AND DURATION: (4-6 weeks). culture), • Child is afebrile, RR has returned to below age speciﬁc cutoffs, no chest PNEUMOTHORAX: Intercostal bronchoscopy/BAL, indrawing and accepting orally: switch to oral Amoxicillin to complete a drainage. microbiology total of 5-7 days duration (include duration of IV also in it). RESPIRATORY FAILURE: consider culture, • If getting Doxacillin/Amoxyclav: continue oral Cloxacillin or Amoxclav for 2 ventilation. investigations for weeks. INFECTION IN OTHER SITES: atypical organisms, • Start feeding as soon as possible when child shows improvement. identify and treat PCR for viral etiology. IF ASSOCIATED SAM: follow treatment guidelines for SAM. appropriately.

ADDITIONAL First and second line FIRST LINE ALTERNATE FIRST LINE SECOND LINE antibiotics for severe Amoxiclav Cefuroxime INFORMATION pneumonia: Ampicillin First gen Cephalosporins Cefotaxime/ Ceftrioxone WHEN TO REFER TO WHEN TO SUSPECT WHEN TO SUSPECT ACUTE WHEN TO SUSPECT WHEN TO SUSPECT CHRONIC HIGHER CENTERS? INFECTION WITH H1N1 BRONCHIOLITIS? ASTHMA? RESPIRATORY PROBLEM? VIRUS? Facilities (as described A child below 2 years of A child of age >3 years Child has any of the above) for treatment or Child with cold, cough, age fulfilling case with history of recurrent following: severe complications (if fever with similar illness definition of first episode cough, cold, wheezing malnutrition, clubbing, develops) are not in any family members, of severe pneumonia with or without fever with feeding difficulty, family available, suspecting consider H1N1 infection. with predominant good response to history of sibling death due chronic respiratory Start Oseltamivir (as per finding of wheezing on bronchodilator and to pneumonia, multi site problems. national guideline). auscultation. personal or family history infections (diarrhea, ear of asthma. discharge oral thrush). Discharge when child is switched to oral medications, accepting oral for 24 to 48 hours

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES REFERENCES 1. Integrated Management of Childhood Illness (IMCI) (revised). Geneva, World Health Organization/The United Nation Children’s Fund (UNICEF), 2014 (http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/). 2. Revised WHO classiﬁcation and treatment of childhood pneumonia at health facilities. http://apps.who.int/iris/bitstream/handle/10665/137319/9789241507813_eng.pdf;jsessionid=8BF6F1C94BD7BA81B8F464D4CBA40249?sequence=1 3. Bradley JS, Byington CL, Shah SS, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53:617-30. 4. Lodha R, Kabra SK, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev. 2013 Jun 4;(6):CD004874

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. PSCHIATRY October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of ALCOHOL USE DISORDERS ICD10-F10

ASSESSMENT (DETAILED HISTORY) Special attention to: (AUDIT can be used • Age at initiation, quantity, frequency and progression (daily use and/or morning drinking) for screening) • Time of last alcohol use and amount • Binge drinking ( men: 5 drinks over 2 hours; women: 4 drinks over 2 hours) • Withdrawal state: insomnia, restlessness, anxiety, tremors. Use of alcohol (or benzodiazepines) to relieve or avoid withdrawal symptoms. H/ o head injury • Tolerance: increased doses of alcohol taken to achieve effects produced by earlier intake • Craving Appearing under • Difficulty in controlling duration of drinking or amount of use Universal influence of alcohol screening for • Preoccupation with alcohol use with neglect of alternative pleasures or interests • Increased time spent to obtain/ take alcohol/ recover from its effects every patient H/ o impaired • Continued use despite patient being aware of evidence of harmful consequences that have attending any social, occurred healthcare occupational • Abstinence and treatment attempts in past and reasons for relapse functioning facility • Co-morbid medical illness or psychiatric illness and their treatment • Complications: Daily alcohol • Physical- gastritis, peripheral neuropathy, hepatic dysfunction, accidents/injuries consumption • Psychosocial - loss of work, fights at home, financial, legal problems

Drinking in large EXAMINATION quantities (men: 5 or more VITALS WITHDRAWAL SIGNS SIGNS OF HEPATIC DYSFUNCTION NEUROLOGICAL SIGNS drinks/ day; • BP • Cerebellar signs women: 4 or • Tremor • Enlarged liver • Pulse Rate • Sweating • Icterus • Peripheral neuropathy more drinks/ day) • Temperature • Tachycardia • Abdominal swelling • Confusion

DIAGNOSIS

Hazardous or Harmful use Alcohol dependence (three of the following six criteria to be present for at least one month)

• Involvement in risky behaviours such as 1) A strong desire or sense of compulsion to take alcohol binge drinking, driving under the 2) Difﬁculty in controlling alcohol use inﬂuence of alcohol 3) Withdrawal state when alcohol use has stopped or been reduced or use of the alcohol (or benzodiazepines) to relieve or avoid withdrawal symptoms • It should have resulted in harmful 4) Evidence of tolerance physical or psychosocial consequences 5) Preoccupation with alcohol use 6) Alcohol use persisting despite clear evidence of harmful consequences

INVESTIGATIONS

CBC Liver function test Blood sugar Electrolytes CT head (in case of seizure/ delirium tremens)

MANAGEMENT

PRIMARY CARE • Alcohol Hazardous/ Harmful users - Brief Intervention* to reduce/stop consumption • Alcohol Dependent users – Advice to stop use and motivate for treatment using Brief • H/ o withdrawal intervention* seizures/ hallucinations REFER TO • Additional psychiatric SECONDARY disorder CARE IF SECONDARY CARE • Recurrent failed • Treatment of withdrawal symptoms attempts at treatment • Managment of withdrawal seizure • Inpatient management with benzodiazepines (diazepam or lorazepam) • Frequent titration of medication. Higher dosage may be required. • Closer monitoring and nursing care • Treatment of additional psychiatric disorder or substance use disorder

TERTIARY CARE • Treatment of delirium tremens • R/ o head injury, hepatic encephalopathy, Wernicke’s encephalopathy • H/ o delirium • R/ o other causes of delirium tremens • Manage on similar lines as withdrawal seizures REFER TO • Major medical • Management in ICU setting when indicated TERTIARY problems • Consult with other medical specialists (like gastroenterology or medicine for CARE IF • Additional substance use hematemesis). • Management for suicidality or violence when emergent threat

*BRIEF INTERVENTION WITHDRAWAL MANAGEMENT RELAPSE PREVENTION (Long term goals- abstinence and socio-occupational Inquire using open ended questions in a • Tab Diazepam integration) non-judgmental manner. Help patient to evaluate the (20-40mg/day in divided risks versus the perceived benefits and to arrive at a doses) based on severity • Disulfiram (250 mg OD) decision to reduce or stop alcohol use. of withdrawals. Pre-requisites: Includes (FRAMES) : • Monitor and titrate dose. • Motivated patient • Feedback about alcohol related problems • If patient comfortable, • Patient’s written consent • Responsibility – acknowledging that the patient is reduce dose of • Under supervision of family members. responsible for making the decision about their alcohol medication by 10% to • Inform patient and family about unpleasant, use 20% per day, taper potentially serious reaction with even small • Advice regarding the harms associated with continued within 7 to 10 days amounts of alcohol (flushing, headache, vomiting, use • Thiamine 100 mg OD reduction of blood pressure, arrhythmias) • Menu of alternative change options (includes identifying • Significant liver • Ability of health personnel in the area to handle a alternative activities such as hobbies, involving the dysfunction: potential reaction family in treatment) Lorazepam (2 mg • Relapse prevention counselling: • Empathetic attitude Lorazepam equal to 5 • Identify cues leading to craving (like person, place, • Self efficacy - to encourage patients’ confidence that mg Diazepam) situation etc) they can make changes in their alcohol use and lifestyle • Develop strategies to deal with them effectively

INDICATIONS FOR ADMISSION

H/o withdrawal seizures/ delirium Co-morbid signiﬁcant medical Failure of outpatient treatment tremens illness and/or psychiatric illness Poly-substance use

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of ANXIETY DISORDERS ICD-10-F40-F42

Tension, anxiety, apprehension, fear, worrying

Sadness, lack of interest, uncontrolled negative thoughts

Unexplained physical symptoms like chest pain, abdominal pain, muscular tension, headache, nausea

Episodes of palpitations, difﬁculty in breathing, feelings of choking, light headededness, dizziness, fainting, trembling

Attacks of fear, losing control or going “crazy”, fear of dying

Repetitive unwanted thoughts and behaviours

DIAGNOSIS Panic Disorder: Recurrent unexpected attacks of intense fear/ anxiety along with ASSESSMENT Generalized Anxiety Disorder physical symptoms (palpitations, feelings of (GAD): Chronic feeling of tension, “choking”, trembling, chest pain feeling • Duration of anxiety apprehension, anxiety or worrying dizzy/faint etc.) • Degree of distress, and about a number of events or impairment of activities that involve every day day-to-day functioning routine life circumstances (e.g., work, Social Phobia: Marked fear and avoidance of • Symptoms of school, health, ﬁnance, household social situations (e.g., interaction with chores etc.) depression strangers, meeting unfamiliar people, • Substance and alcohol performing in front of others) misuse • Physical disorders: Agoraphobia: Fear of going out thyrotoxicosis, of home alone, being in enclosed Obsessive-compulsive disorder (OCD): pheochromocytoma spaces (e.g., malls, cinemas etc.), Recurrent and persistent unwanted and hypoglycaemia thoughts (e.g., unwanted sexual and open spaces (e.g., bridges, vast • Psychosocial factors: blasphemous thoughts, fear of harming self playgrounds etc.), using public ongoing stress and or others, fear of contamination, doubts transportation (e.g., trains, buses, other issues pertaining planes etc.) about daily activities etc.) and repetitive behaviours (e.g., excessive washing / to work, family cleaning, checking, ordering etc.)

MANAGEMENT

PRIMARY CARE LEVEL SECONDARY CARE LEVEL TERTIARY CENTRE (MEDICAL COLLEGE, (DISTRICT HOSPITAL) REGIONAL MEDICAL CENTRE, PSYCHIATRIC Psychoeducation HOSPITAL) • Reassurance • Review diagnosis and treatment • Explain symptoms are of anxiety/ fear and mimic history if there is no improvement • Evaluate reasons for treatment resistance like symptoms of physical illnesses (e.g., heart attack) with a trial of Escitalopram. • Wrong diagnosis • Do not investigate excessively. Few investigations • Check whether the patient has • Inadequate drug treatment, like ECG, ECHO maybe necessary in some patients taken medication at prescribed • Poor adherence to treatment • Discourage doctor shopping dose and on a regular basis • Inadequate CBT, • Do not avoid triggers of panic attacks (e.g., physical • Presence of comorbid conditions such as exertion, agoraphobic situations) and fear (e.g., • Second SSRI personality disorders and organicity travelling by public transport). (either of them for about 2-3 • Emphasize avoidance maintains fears and phobias. months): • Panic disorder: evaluate any medical • OCD: Educate that the unwanted thoughts are a • Sertraline upto 200 mg/day, conditions that mimic panic disorder part of illness, and not a reﬂection of character or • Fluoxetine upto 60 mg/day, (hyperthyroidism, hyperparathyroidism, hidden intentions. • Paroxetine upto 50 mg/day, pheochromocytoma, vestibular diseases, seizures, arrhythmias, etc.). • Fluvoxamine upto 300 mg/day Pharmacological treatment • OCD: Trial of third SSRI or clomipramine • Mild illness: Spending time, reassurance, and • Treatment resistant OCD: inpatient treatment • No response to second SSRI: psychoeducation. May not need any medications. for intensive therapist-assisted daily CBT and cognitive behaviour therapy (CBT) • No improvement (few weeks): Escitalopram 5mg / for rationalization of medication regimen. if trained therapists available. day at night, with increase to 10 mg/d in a week. No • Other anxiety disorders: Trial of non-SSRIs • Refer to tertiary centre if satisfactory improvement in 4-6 weeks, may (e.g., venlafaxine, duloxetine, pregabalin etc.) unsatisfactory response after increase to 20 mg / day. If there is no signiﬁcant and tricyclic antidepressants improvement in another 4-6 weeks, refer to a second SSRI and / or addition of CBT. specialist. • If response to medications is poor or • If referral to tertiary centre is not • Severe and unbearable anxiety: Diazepam (5 -10 unsatisfactory: feasible, psychiatrists may try mg) may be given at night. Do not continue for > 1 • CBT is the preferred mode of treatment other strategies (other than Deep month. Taper and stop over 2 weeks. Long-term alone or in combination with medications. Brain Stimulation and surgery for treatment with benzodiazepines to be avoided • Treat comorbid psychiatric disorders (e.g., OCD) mentioned under the • Escitalopram to be continued for at least 1-2 years personality disorders) “tertiary care” at the secondary after remission • Pharmacological augmenting strategies if level itself. • Side-effects (sexual dysfunction, sedation, weight antidepressants and CBT do not provide gain) : monitor and address periodically relief.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of CHILDHOOD BEHAVIORAL DISORDERS ICD10- F90-98

OPPOSITIONAL DEFIANT DISORDER (ODD) DIAGNOSIS • Doesn’t obey or listen, back-answers, rude behaviors • Demanding, stubborn, throws tantrums when demands are not met • Symptoms are present and persistent over CONDUCT DISORDER • Aggressive – angry, abusive, ﬁghts, hits or hurts several months people, bullies other children, damages articles • Attempt further • Stealing, lying, threatening or misbehaving with classiﬁcation into ADHD, people, truant (keeps away from school without ODD and CD (ADHD may parents’ knowledge), runs away from home, bad be present with or company, cruelty to animals without ODD and CD CLINICAL PRESENTATION ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) • Restless, always on the move / running, can’t sit in a CAUTION place,talkative • Abrupt onset • Can’t focus attention on a task, poor concentration, gets easily distracted, disorganized, does not • Recent onset (few weeks complete school work to few months) • Too mischievous, can’t be left alone, troubles • Sudden increase in people or damages things, or gets injured severity (consider another • Impatient, always in a hurry, can’t wait for his turn, psychiatric disorder such does not care for danger, acts without thinking as bipolar affective disorder, hypomanic or ALL 3 DISORDERS Poor or erratic school performance and / or manic episode -> follow complaints about behaviour from school the relevant STW)

ASSESSMENT (History From Multiple Sources) PARENT INTERVIEW FAMILY SITUATION SCHOOLING CHILD INTERVIEW • Symptoms- onset, duration, • Health (including mental health) and • Attendance • Develop rapport( discuss neutral topics; avoid direct type(ODD, Conduct, ADHD-as wellbeing of family members • Performance tackling of misbehaviors) above) and severity • Cohesion, mutual understanding and • Learning • Observe: • Developmental problems, harmony in the family problems, - Features of ADHD (restless, ﬁdgety, easily distracted, emotional disturbances and • Parenting and childrearing practices: • Classroom attention keeps shifting) stress caring and disciplining, criticism, unfair behaviors - Speech and language ability, intelligence, academic • Alcohol and substance use comparison and physical punishments, • Recent changes skills and mood /misuse mutual blaming of parents for child’s in syllabus and/or • Enquire about any stress or difﬁculties child is facing at • Impact on child and family problem school home, school, and with peers and anger control MANAGEMENT

WORK WITH FAMILY WORK WITH THE CHILD WORK WITH THE • PSYCHOEDUCATION SCHOOL - Explain the child’s behaviours are not intentional • Avoid advice • Feedback to school - Not child’s fault, do not blame the child • Anger management ( count regarding child’s - Multifactorial causes-lack of self-regulation, and adverse environment from 10 -1 backwards, move - Can be improved with proper management condition away from situation, deep - Parents can directly contribute to the child’s improvement • Teachers to give extra breaths, relax, self-talk to • Help parents deal with their own worries and stress (listening, giving space to attention, help and cool down) ventilate, validate and empathize their difﬁculties, reassure) support for the child • Children with ADHD: • Recognize and manage mental health problems such as depression and alcohol • Extra coaching, if “stop-think-act” or “halt and problem in parents needed in case of proceed” technique • Parent management training* learning problems

*PARENT MANAGEMENT TRAINING MEDICATION (AVOID BEFORE 5 YEARS) • Analyse the problem behaviors and understand patterns : time of occurance, triggers, • Severe and persistant aggression: duration and consequencies - T. Risperidone under close supervision (starting • Engage with child in mutually enjoyable, pleasurable activities (playing games, dose-0.25 mg, single daily morning dose after discussing interesting things or doing activities together) breakfast. Based on response, increase by 0.25 mg • Set clear do’s and don’ts and explain to child in clear, simple, short instructions the weekly up to 1 mg single daily dose). consequencies (like withholding privileges following misbehavior; use star-charting Not to exceed 1 mg/day (contingency management) and rewards based on number of stars earned - Response + : continue 3 months f/b slow taper • In children with ADHD, develop clear daily routines, supervise activities and appreciate - Response - : 4 weeks trial, then refer on completion of taks - Monitor adverse effects: weight gain, • Limit screen time/ monitor use of electronic devices extra-pyramidal symptoms (EPS) [if EPS : add I mg Trihexyphenidyl OD morning] • Dos • Don’ts • Severe hyperactivity and impulsivety: – Consistency in enforcing rules – Bribe - T. Clonidine (starting dose-25 µg single daily – Catch the child being good and praise – False promises and threats dose before sleep, increase by 25 µg weekly up – Ignore negative behaviours – Harsh punishments to100 µg per day in 2-3 divided doses – Child can be put in a boring place till he/ – Excessive criticism and blaming she becomes quiet for a few minutes especially in front of others - Monitor BP and drowsiness (time-out) – Unfair comparison - Advise against sudden discontinuation – Encourage age appropriate responsibilities – Yielding to unreasonable demands

REASONS FOR REFERRAL Severe, complicated presentation Lack of response to treatment Severe aggression Highly dysfunctional family Alcohol and substance abuse SECONDARY CARE (DISTRICT HOSPITAL) TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE) • Review and reassess diagnosis (clinical evaluation • Evaluate and manage severe behavior disorders – severe ADHD, ODD, and CD, if necessary on using Rutter’s multi-axial system) and all the short-term inpatient basis pointers given above • Multi-modal management with clear individualized plan • If failed trial of Clonidine/ Moderate ADHD: • Trial of Methylphenidate in moderate / severe ADHD under expert supervision T. Atomoxetine (starting dose-10 mg single daily • Recognize and treat comorbid disorders such as bipolar disorder, substance use disorder, and morning dose after breakfast. Increase up to internalizing disorders and manage 1mg/ kg/day under close supervision). • Pharmacological management of older children / adolescents with severe aggression / Monitor adverse effects and response impulsivity with Risperidone and/or Lithium • Systematic parent management training / • Family therapy for dysfunctional / discordant families, contributing to child’s condition behavioral management and individual therapy • Management of children in difﬁcult circumstances with mental health issues (children in need of (as given above) care and protection; children in conﬂict with law)

REFERENCES • World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO. 2016. • Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2007 Jul 1;46(7):894-921. • Steiner H, Remsing L. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2007 Jan 1;46(1):126-41. KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of CHILDHOOD EMOTIONAL DISORDERS

DIAGNOSIS SOMATIC (PHYSICALLY UNEXPLAINED) SYMPTOMS • Weakness and tiredness • Persistent symptoms of • Aches and pains emotional disturbance • Headache for several weeks, • Non-epileptic attacks of fainting signiﬁcantly affecting • Chest pain and stomach pain the child’s life • Hyperventilation- often triggered by stress or distress • Unexplained by medical condition such as SYMPTOMS OF DEPRESSION hypothyroidism • Loss of interest in usual activities • Depression and anxiety • Recent deterioration in school performance symptoms can co-occur • Wanting to be alone, withdrawn, not interacting • Depression more with people common in CLINICAL • Looks unhappy, “off mood”, crying for trivial or no adolescents, may have PRESENTATION - features similar to adult Recent Onset reason, irritable, sensitive to any criticism onset depression Behavioral • Decreased sleep, loss of appetite and weight loss Changes • Talking about death and dying, self harm (eg. self-cutting) or suicidal attempt CAUTION • Assessment of suicidal risk SYMPTOMS OF ANXIETY and a plan of action is • Always worrying, tense important in children with • Exam tension, performance anxiety, worries about emotional disorders, marks and ranks especially depression (refer ? • Excessive fear and avoidance of some objects or to appropriate STW) • Elicit h/o hypomania/mania situations (insects, animals, ghosts) in children with moderate • Reluctance or refusal to go to school to severe depression • Very shy, avoids social situations, scared of talking or (consider diagnosis of interacting with strangers, bipolar disorder) • Clinging to mother, scared of being separated from • Physical conditions can cause similar symptoms mother (anemia and thyroid disturbance)

ASSESSMENT PARENT INTERVIEW AND HISTORY TAKING CHILD INTERVIEW PHYSICAL EXAMINATION • Onset, duration, severity and full range of • Develop rapport (Rule out) symptoms • Ask subjective distress (low mood, irritability, sadness, lack of • Post-viral syndrome • Home environment, family life and enjoyment of activities, worries, fears, tensions, autonomic symptoms) • Recurrent attacks of relationships, parenting practices and • Stressful events (loss, death in the family, separation, frightening malaria stressors experiences, traumatic abusive or shocking events, humiliating • Chronic infections, chronic • Information (from paretns and school) about experiences, bullying in school, academic stress) and interpersonal physical illness, anaemia, school performance, behavior, school refusal, difficulties PCOD or thyroid bullying experiences, peer relations and any • Explore parent-child relations and interactions and any undue disturbance recent change punishment or criticism MANAGEMENT WORK WITH PARENTS WORK WITH THE CHILD WORK WITH SCHOOL • PSYCHOEDUCATION: • Psycho-education of the child- explain they are • Give feedback to the school about - Child is emotionally disturbed and not able to suffering from an emotional problem and it is not their child’s condition and stress, need function well fault and they will get better with proper treatment for support, encouragement and - Not the child’s fault • Anxiety management and emotional regulation skills school’s cooperation. - Avoid undue criticism, over expectation, unfair - Muscle relaxation • If school refusal, graded return to comparison, scolding and punishment - Deep breathing exercises school: encourage child to return - Parents’ support, encouragement and - Praanaayaama / yoga to school gradually with the understanding is important - Substituting distressing thoughts with more support of family and cooperation • Counsel about suicidal risk in depression and to be comforting thoughts of school (e.g. initially for a few alert to pointers to suicidality • Counsel the child to confide any distressing thoughts, minutes in school compound, • Evaluation and management of the mental health including thoughts of death and dying later for 1 period in school and issues in parents • Encourage the child to gradually return to the usual moving on to longer duration • Discuss about specific steps to reduce undue stress life and activities in a step-by step manner with the child is facing parental support and encouragement

MEDICATION (MODERATE CASE OF DEPRESSION OR ANXIETY IN ADOLESCENTS) • Frequent expression of suicidal ideation/ • Tab Fluoxetine - start at 10 mg OD morning, increase to 20 mg OD after 2 attempted suicide / self-harm behavior weeks depending on response such as self-cutting • Inform adverse effects: behavioral activation (marked restlessness and REASONS FOR • Severe symptoms irritability), onset of hypomanic symptoms, and worsening of suicidal ideas. REFERRAL • Complicated picture, or features of Stop drug if they are troublesome obsessive compulsive disorder (OCD) • Avoid benzodiazepines (except as temporary measure for few weeks in • No response to interventions in 4-6 weeks severe anxiety attacks or panic attacks - Clonazepam 0.25- 1 mg /day)

SECONDARY CARE (DISTRICT HOSPITAL) TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL • Review and reassess diagnosis through detailed clinical examination using Rutter’s CENTRE) multi-axial system • Thorough diagnostic evaluation • Review the treatment received and plan multi-modal treatment. • Manage severe mental disorders – psychoses, recurrent • Reconsider medications, and augmentation strategies mood disorders, adolescents with severe depression, & • Review child’s and family’s awareness of the illness and do psycho-education treatment resistant cases, persistent suicidality, • Ascertain the presence of psychosocial factors : disturbed home environment, recurrent self-cutting, if necessary in inpatient setting parent-child relationships and severe stressors • Family therapy for dysfunctional / discordant families • Screen parents for mental health problems and manage accordingly contributing to child’s condition • Individual therapy focussing on identifying and challenging negative thoughts, • Cognitive behavior therapy for older children with anxiety management and coping with stress, helping them face difﬁcult situations severe OCD, depression, and anxiety disorders in small steps, improving interpersonal relationships • ECT on case to case basis (older adolescents with • Parent counselling to address family issues, communication and interaction severe depression, mania, psychosis or catatonia patterns unresponsive to adequate pharmacological • Collaborate with school wherever necessary (get school report; explain problem in management) simple terms, and suggest ways by which school can help) • Appropriate psycho-social steps if there is abuse, • Recognize and manage less common problems such as obsessive compulsive maltreatment or neglect disorder, psychoses and bipolar disorders • Neurology referral in suspected cases of epilepsy and • Manage adolescents with mild / moderate suicidal risk organicity

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are basedThis on STW expert has opinionsbeen prepared and available by national scientiﬁc experts evidence. of India KEEP There with A feasibilitymayHIGH be THRESHOLDvariations considerations in the FOR management for INVASIVEvarious levels of PROCEDURES an of individualhealthcare patient system based in the oncountry. his/her Kindly speciﬁc visit condition, the website as decided of DHR forby the treatingmore physician. information: There https://dhr.gov.in/ will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian© Department Council of of Medical Health ResearchResearch, andMinistry Department of Health of & Health Family Research, Welfare, Government Ministry of Health of India. & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of CHILDREN WITH DEVELOPMENTAL PROBLEMS ICD10-F70-89

DIAGNOSIS Speciﬁc speech delay – Only lagging in speech with normal Intellectual disability intelligence, hearing and Slow in development / (mental retardation)* - non-verbal communication delayed milestones of global developmental development delay + impairment compared to peers in Autism Spectrum Disorder (ASD) marked impairment in CLINICAL Poor speech, intellectual functioning and adaptive skills verbal and non-verbal social PRESENTATION self-care, learning interactions (being solitary or and memory “in his own world”, poor Speciﬁc Learning response to name call and poor Less intelligent Disorder (SLD)- Average eye-to-eye contact) and compared to other intelligence with poor stereotyped behaviors *in children academic skills (reading, children under 5 years, avoid writing, spelling and diagnosis of ID, name it as maths inspite of global developmental delay adequate schooling) and start intervention

ASSESSMENT

DETAILED DEVELOPMENTAL PHYSICAL EXAMINATION: BEHAVIOURAL PROBLEMS: OTHERS: ASSESSMENT: • Height and weight, • Hyperactive • Family situation • Assess if child is lagging behind • Head circumference, • Impulsive behaviors • Parents’ awareness of in developmental attainments • Vision and hearing • Sleeping and feeding problems the child’s problems compared to same-age children • Any noticeable physical anomalies • Aggression • Quality of attention • Ask mother to estimate the (club-foot) or unusual facial appearance and care being given mental age of child • Motor abnormalities (stiffness / spasticity or EMOTIONAL PROBLEMS: to the child, • Ascertain if delay is global (all weakness of limbs, unsteady gait) • Excessive crying • Past consultations and milestones) or restricted to one • Any other problems (heart murmurs, • Irritability treatment area (motor or speech) organomegaly) • Shyness and fears educational history

MANAGEMENT

PSYCHO-EDUCATION OF PARENTS EARLY INTERVENTION / SENSORY-MOTOR STIMULATION FOR HOME-BASED PARENT MEDIATED SKILLS TRAINING YOUNG CHILDREN – UNDER 3 YEARS • Normal – reassure parents • Create opportunities for the child to learn with • Develop and maintain regular, stimulating daily • Mild delay (“at risk”) – early interset and attention routines intervention and follow-up •Engaging and spending time with child in activities • Teach parent to teach child : simple imitation, • Explain causation due to some • Offer appreciation pointing, pretend-play; self-help skills (eating, damage to brain before, during or • Engage the child to use eyes and ears (different toilet training, bathing, dressing), doing simple after birth types of sounds and sights), touch (eg., tickling, household chores (washing utensils, helping in • No medication can improve stroking, gentle massaging), movements (gentle cleaning house), social skills – skills of interaction, intelligence movement of limbs, gentle bouncing, range of simple academic skills, simple vocational skills, Teaching and training to improve movement exercises) and improving hand functions helping in kitchen under supervision, skills and gaining independence (taking, holding, giving, pushing, pulling) self-protection • Systematic, persistent and repetitive • Use play materials–rattles, paper balls, rubber balls, • Find current level of adaptive abilities of the child training as per the child’s ability clay, soft dough, water play, soap bubbles, and choose a target skill • Treatment of associated problems vegetables. • Tell and show how to do things (modelling), (vitamin or mineral deﬁciency or • Parallel vocalization to improve utterances (making make the tasks simpler, break activities in simple epilepsy, ADHD, vision/ hearing the same sound as the child immediately). steps and teach one step at a time, notice and issues,) – refer to appropriate STW • Improve conceptual skills by classifying, arranging, praise even minor efforts and improvements • Avoid overprotection, sorting, and recognizing and naming activities (for (rewarding or reinforcing), using hand-on-hand overindulgence and eg., vegetable sorting, grain sorting, arranging techniques (keeping your hand on the child’s understimulation vessels by their size and shape) hand and making them do the activity)

EDUCATION AND TRAINING SOCIAL WELFARE / LIAISON MEASURES • Liaise with schools and ensure child attends school that is most appropriate • IQ testing and certiﬁcation for social welfare beneﬁts • Assist in enrolment to special school • Help parents to link with other agencies/ services that deal with • Consider training in vocational skills (informal and formal) for older adolescents such children such as CBR programs or parent associations

• Severe or multiple developmental • Co-occuring severe behavioral or problems emotional problems • History of regression ( loss of acquired REASONS • Suspected case of ASD skills) FOR • Suspected SLD • Deﬁnite family history of REFERRAL • Genetic counselling developmental problems (h/o similar • Speech therapy or physiotherapy problem in the sibling)

SECONDARY CARE (DISTRICT HOSPITAL) • Psychological testing for ID, SLD and diagnosis of ASD • Basic management of ASD – home-based parent-mediated training in social, communicative, and self-help skills • Appropriate management of behavior problems with medication / psychosocial or behavioral intervention (see relevant STW’s) • Help parents access relevant services such as District Early intervention centres (DEIC’s), parent organizations, and beneﬁts

TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE) • Evaluate and manage children with severe IDD, ASD, multiple disabilities, and those with severe comorbid disorders such as ADHD, aggression, bipolar disorder, and psychotic disorders through multi-disciplinary approach • Investigate for the cause – review tests already done; imaging, genetic tests, metabolic tests (as per requirement) ;arrange for genetic counselling • Manage treatable disorders (like hypothyroidism and inherited metabolic disorders) • Manage comorbid physical health problems (like epilepsy, visual /hearing impairment, locomotor/ orthopaedic problems) • Assessment and management for SLD – psychoeducation of the child and parents, liaison with school, teaching basic remediation techniques to parents, helping parents access relevant organizations, issue of exemption certiﬁcates, and decisions about further schooling such as open schooling REFERENCES

• World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO. 2016. • Szymanski L, King BH. Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 1999 Dec 1;38(12):5S-31S. • Girimaji SC.(2008) Clinical Practice Guidelines for the Diagnosis and Management of Children With Mental Retardation. Retrieved from www.indianjpsychiatry.org/cpg/cpg2008/CPG-CAP_05.pdf

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES TThis STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Octo be r / 2 019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of DEPRESSION ICD10-F45 CORE SYMPTOMS CLINICAL ASSESSMENT

Assessment Depressed Loss of Easy Cognition 1 2 3 of 1 mood 1 interest 1 fatigability/ • Hopelessness (about future) Depressive • Helplessness (about others) and diminished Cognition enjoyment activity • Worthlessness (about self)

Assess ADDITIONAL SYMPTOMS Assessment of Suicide Risk friend • Reduced concentration and attention • Suicidal thoughts and • Reduced self-esteem and self-conﬁdence • Suicidal idea family • Ideas of guilt and unworthiness • Suicidal intent support • Immediate risk for attempt • Bleak and pessimistic views of the future CLINICAL • Ideas or acts of self-harm or suicide DIAGNOSIS OF • Disturbed sleep • Diminished appetite INVESTIGATION DEPRESSION • Haemogram To make a diagnosis of depression, • Thyroid function tests symptoms must present for at least 2 weeks. • Electro Cardiogram Severity of Core Additional • Electrolytes (Sodium) depression symptoms symptoms • Rule out secondary medical cause of depression Mild depression 2 2 or more ? • Rule out use of anticancer drugs Moderate depression 2 3 or more (Cyclophoshamide) / anti retroviral drugs Severe (Efavirenz, Zidovudine)/ Antibiotics (Dapsone , depression 3 4 or more Ethambutol)/ Anabolic Steroids/ Propanolol • Rule out associated comorbid medical condition – Diabetes, Stroke, Epilepsy, Cancer, Coronary Artery Rule out Bipolar Disorder / Grief / Adjustment Disorder Disease and Auto Immune disorder

AT PRIMARY CARE MILD DEPRESSION MODERATE / SEVERE DEPRESSION • Advise Behavioral Activation to patients • Tab Escitalopram 10 mg-20 mg /day or • Practicing activity monitoring - write down your activities / rate your depression / schedule activities that Cap. Fluoxetine 20mg -40mg /day make you feel good / make a to do list/ set clear and speciﬁc goals • Tab. Clonazepam 0.25mg – 0.5mg /day for • Focusing on your value categories – make time for your family / friends / set clear goals at work / contribute sleep disturbance / anxiety symptoms to community • Reccomend yoga & mediatation and consider taper and stop after 2 • Handling daily task - monitor sleep /diet and practice good personal hygiene weeks. • Supportive psychotherapy / Brief Counselling • If patient responds to SSRI in 2 to 4 • Validate the problems and ensure frequent follow-up weeks, then continue treatment for 6 to 9 • If no improvement in 4 to 6 weeks, consider pharmacotherapy months and taper and stop

REFERRAL TO SECONDARY CARE BROAD MANAGEMENT PLANS AT SECONDARY CARE

• Difficulty in making diagnosis • Selective Serotonin Reuptake Inhibiters (SSRI) are • Confirm Diagnosis and Suicide risk • No improvement after 4 to 6 usually first choice (watch for GI bleed and drug assessment weeks of treatment with first interaction) • Assess for other Medical • Improvement starts in in 2nd week and expect Comorbidities line medications adequate response by 6 weeks • Investigations – Haemoglobin,Thyroid • Depression in special • Duration of treatment typically lasts 6-9 months Function Test, Electrocardiogram population: Elderly / and Gradual tapering of medication advised for first • Non Responder - Switch over to SNRI Pregnancy / Lactation / episode (Venlafaxine 75 – 150 mg, Mirtazapine Children / Adolescents • Restart SSRI , In case of resurgence and recurrence 30 mg) or TCA (Amitriptyline 75 - • Comorbid medical illness / of depressive symptoms 225mg / Imipramine 75 -225mg) Substance use • Observe for switch / activation with Antidepressants • Cognitive Behavioral Therapy / • Suicidal risk assessment • Watch for risk of overdose with TCA (Amitriptyline / Problem Solving Therapy Imipramine) and Mirtazapine • Add on Yoga Therapy / Meditation

REFERRAL TO TERTIARY CARE SPECIAL POPULATION AT TERTIARY CARE

• No improvement in 2nd • Pregnancy / Lactation period - • Reconﬁrm Diagnosis line treatment Pre Conception counselling and • Assess other psychiatric comorbidities • Immediate risk for preferred drug is • Partial Responder - Optimise the SNRI /TCA or Augment suicidal attempt / Tab. Sertraline 50 mg – use with Tab. Lithium 300 to 600mg /per day or Tab. Thyroxine thought lowest possible dose 25 - 50 ug per day. • Needing intense • Elderly - • Non Responder – Add Tab. Sertraline 100mg or counselling/ Tab. Escitalopram 10 -20 mg or Tab. Bupropion 300mg to existing Venlafaxine 150mg / Tab. psychotherapy Tab. Sertraline 100 mg Mirtazapine 30mg / Amitriptyline 225mg / Imipramine • Co Morbid Substance - (monitor for hyponatremia) 225mg. Cannabis / Poly • Avoid TCAs like Amitriptyline / • Add on Electro Convulsive Therapy for Catatonia / Suicidality substance Imipramine in Elderly (due to • Add on Cognitive Behavioural Therapy/ Inter Personal anticholinergic side effects) Therapy / Problem Solving Therapy • Adolescents- Cap. Fluoxetine • Add on low dose antipsychotic treatment (Risperidone 2 -4 20 -40 mg /day ( observe for mg / Tab. Olanzapine 5 – 10 mg) for psychotic symptoms switch / activation/ suicidality)

REFERENCES

• Avasthi A, Grover S. Clinical practice guidelines for management of depression in elderly. Indian J Psychiatry 2018;60, Suppl S3:341-62

• mhGAP Intervention Guide - Version 2.0 for mental, neurological and substance use disorders in non-specialized health settings. World Health Organisation, 2016

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of PSYCHOSIS ICD10-F20-29

Presence of Hallucinations delusions (talking, Disorganized Social and (suspiciousness DIAGNOSIS smiling or behaviour & occupational and fear without laughing to poor self-care dysfunction ? obvious self) explanation)

PRIMARY CARE LEVEL

WELLNESS CENTERS PHC Identify, educate and refer to PHC INITIATE TREATMENT: FOLLOW UP: REASONS FOR REFERRAL TO TALUK / DISTRICT LEVEL:

If immediate threat to self/ others, • T. Risperidone • 2 weeks after initial contact: Check for changes • Diagnostic confusion / suspicion of refer to Taluk / District center 2mg HSx1 week f/b in symptoms and adverse effects (excess sleep, organic condition 3 – 4 mg HS + extrapyramidal symptoms (EPS), tiredness) • Substantial risk of harm to self or others FOLLOW-UP AND REHABILITATION: Trihexyphenidyl adjust the dose of risperidone and THP and catatonic symptoms • Monitor & manage challenges in (THP) 2mg(morning) accordingly; address questions if any; advise • Comorbid substance use, treatment continuation • Psychoeducation: gradual return to work/school; give specific depression/anxiety, intellectual disability • If unsatisfactory outcome despite - medical model of follow-up date; liaise with wellness center for • Poor symptom-control or functioning regular treatment: psychosis ensuring continuity of care despite regular treatment or poor - Liaise with higher centers for - address • Once in 1 – 2 months: Check for symptoms, treatment adherence optimal outcome misconceptions & functioning and adverse effects (EPS, • Significant adverse effects: weight-gain, - Liaise with social welfare build hope weight-gain, menstrual/sexual dysfunction); metabolic adverse effects, tardive department for disability - inform about adjust the dose of Risperidone (range: 2 – 8 dyskinesia certification & welfare benefits if possible adverse mg/day) and THP (range 2 – 6 mg/day); liaise • Questions regarding marriage, pregnancy, continued poor outcomes effects of with wellness center for ensuring continuity of sexual dysfunction medications care SECONDARY CARE (TALUK/DISTRICT HOSPITALS) # Intolerance Poor INDICATION Diagnostic Poor response Comorbid Challenging Rehabilitation to adherence to Pregnancy FOR REFERRAL confusion to Risperidone conditions situations needs FROM PHC Risperidone treatment Follow • Assessment • Depression/ • Suicidality: • Assess disability & counsel • Proactively MANAGEMENT Clarify Positive symptoms: algorithm of factors anxiety: -Inpatient about welfare benefits address #Encourage diagnosis; Follow algorithm causing poor Brief care, sexual and follow up in neuroimaging adherence & psychological -Crisis • Rehabilitation endocrine primary care if organicity is Negative specific intervention; management, counseling problems after suspected symptoms: manage- consider SSRIs* -Management - Family intervention for when addressing • Rule out or manage ment • Substance of expressed emotions and relevant referral issues depression/ anxiety • Consider use: comorbidity; attitudes & behaviors • Educate * Watch for and extrapyramidal depot anti- Detoxification -Consider ECT interfering with about risk of adverse symptoms; psychotics and brief functioning obstetric effects as • Family counseling if • Liaise with interventions • Violence: - Brief interventions for outcomes, SSRIs may understimulated/ primary care (see SUD -Verbal cognitive & social-skill risk of increase over-protected for assertive module) de-escalation deficits relapse & serum levels • Consider follow up • -IV sedation, - Address vocational/ risk of of less-sedating Developmenta -Brief educational challenges psychosis in antipsychotics antipsychotics and adding SSRIs* l disabilities: inpatient care involving governmental/ the Behavioral non-governmental offspring TERTIARY CARE CENTERS

INTERVENTION CONTEXT IN WHICH USEFUL Referral to tertiary care if Psychoeducation Poor adherence; high family expressed emotions Family therapy High family expressed emotions; family discord Cognitive remediation Poor neuro and social cognitive functions 1. Diagnostic confusion: Cognitive behavior therapy Depression, anxiety, obsessions, persistent Inpatient observation for clariﬁcation psychotic symptoms of history, thorough neurological / mental status examination, Social skills training Poor social skills diagnostic psychometry, brain CT Vocational rehabilitation and Poor occupational functioning, challenges in Scan or MRI, neurology consultation supported education studying or getting / pursuing gainful occupation and urine toxicology screen Day care with interventions including Negative symptoms, poor socio-occupational vocational training, recreational functioning, combination of other symptoms 2. Poor outcome: activities, living-skill training, etc. listed in the table Hazardous use of substance or substance use +Following psychosocial Interventions for substance-use interventions may be offered in disorder isolation or in combination Pre-pregnancy, pregnancy and post-partum depending on the context in Pregnancy – puerperium services advise and interventions Pre-pregnancy, inpatient, outpatient or pregnancy and post-partum advise and day-boarding settings interventions

ALGORITHM FOR CHOOSING ANTIPSYCHOTIC MEDICATION (AP) FOR TREATMENT OF SCHIZOPHRENIA

Good response without intolerable side effects At any point, consider electroconvulsive Risperidone* Stabilization phase: For 6 months: same therapy if: dose of AP; 1. Serious suicidal risk 2. Catatonia not responding to Lorazepam Maintenance phase: Attempt to reduce 3. Refusal of food / ﬂuids Intolerable side effects dose to minimum possible dose. or inadequate effect 4. Severe aggression / violence 1st episode: About 2 years. 5. Refractory / intolerance to clozapine 1+ episodes: indeﬁnite period

Choose different AP*#^ Investigate for No cause medical/ found or poor * Treat with adequate dose as shown in table-1 for 6 – 8 Intolerable side effects Inadequate effect neurological response causes of despite weeks to assess efﬁcacy or inadequate effect for 2+ APs #While choosing alternative AP, consider adverse effect non-response and treatment of proﬁle and cost treat them the cause ^ At any point, if there is medication non-adherence, consider long-acting preparations in addition to other measures for managing non-adherence CLOZAPINE

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of SOMATOFORM DISORDER SD ICD10-F45

Repeated subjective experience CHALLENGES FACED BY THE DOCTOR of physical symptoms which are not explained by any recognizable physical disease ∙ Repeated request for investigations – despite negative Bodily complaints are often ﬁndings and reassurance the most common reason for ∙ Doctor shopping and not SOMATIZATION consultation with health satisﬁed with repeated DISORDER/ professionals reassurance MEDICALLY UNEXPLAINED SYMPTOMS

Pain at Fatigue and Signiﬁcant distress and multiple sites exhaustion impairment PRESENTION TO A DOCTOR Functional disturbance of Focus of patient is on symptom relief different organ systems rather than cause of illness

DIAGNOSTIC CRITERIA

INITIAL ASSESSMENT PSYCHOSOCIAL ASSESSMENT

∙ Detailed clinical examination – to rule out any medical illnesses ∙ Encourage to talk about psychosocial stressors if any which might explain the symptoms ∙ Individual factors – poor copying skills, anxiety, life events, health anxiety, ∙ Complete history of the onset of all symptoms, exacerbating and medical illnesses relieving factors ∙ Family related factors – Substance use in family, interpersonal relationship ∙ Assessment for any other psychiatric illness such as depression or with family, ﬁnancial status anxiety disorders ∙ Environmental factors – support system, peer relationship, work environment

DIAGNOSTIC CRITERIA

A. One or more somatic symptoms that are distressing or result in significant disruption of Following list include the commonest daily life. symptoms B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated 1. Pain symptoms at multiple sites (such as health concerns as manifested by at least one of the following: abdominal, back, chest, dysmenorrhea, 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms dysuria, extremity, head, joint, rectal) is often 2. Persistently high level of anxiety about health or symptoms present 3. Excessive time and energy devoted to these symptoms or health concerns 2. Gastrointestinal sensations (pain, belching, C. Although only one somatic symptom may not be continuously present, the state of regurgitation, vomiting, nausea) being symptomatic is persistent (typically more than 6 months) 3. Abnormal skin sensations (itching, burning, A persistent course is characterized by severe symptoms, marked impairment, and long tingling, numbness, soreness) and duration (more than 6 months) blotchiness Severity: 4. Sexual and menstrual complaints Mild – only one of the symptoms specified in criterion B is fulfilled (ejaculatory or erectile dysfunction, Moderate – Two or more of the symptoms specified in criterion B is fulfilled hyperemesis of pregnancy, irregular menses, Severe – Two or more of the symptoms specified in criterion B are fulfilled, plus there are multiple menorrhagia, sexual indifference) are also somatic symptoms (or one very severe somatic symptom) common

MANAGEMENT

PRIMARY CARE 1. Difficulty in making diagnosis ∙ Detailed physical examination 2. No improvement after 4 weeks of ∙ Management of anemia and nutritional deficiencies REFER TO treatment with first line medications ∙ Avoid irrational use of pain medications SECONDARY 3. Comorbid medical illness ∙ Low dose of antidepressant medications – Amitriptyline 12.5 mg to 50 CARE IF 4. Suicidal risk mg (max) night dose 5. Comorbid psychiatric illness ∙ Explain that onset of medication effect will take 2-3 weeks ∙ Validate the somatic symptoms ∙ Advise to engage in routine activities, physical exercise and relaxation SECONDARY CARE techniques like deep breathing ∙ Investigations – to rule out any medical illnesses that ∙ Discuss with family members that the symptom, distress and might explain the symptoms disability are genuine ∙ Complete history with behavioural observation ∙ Strengthen supports ∙ Use 2nd line medications – SSRIs (Escitalopram 10-20 mg, ∙ Regular follow up Sertraline 50-100 mg, Fluoxetine 20 mg) and SNRIs (Venlafaxine 75 – 150 mg, Duloxetine 30- 60 mg) ∙ Combination of two psychotropic medications (might be TERTIARY CARE required if poor response to single medication) ∙ Inpatient care if needed ∙ Brief counselling ∙ Combination of two psychotropic medications (when required) ∙ Psycho education – focusing on relationship between ∙ Add on second and third line medications – Duloxetine, Mirtazapine, stress and physical symptoms anticonvulsants ( Lamotrigine, Pregabalin). Use of Gabapentin, ∙ Relaxation training, regular exercise, yoga and meditation Carbamazepine if chronic pain symptom predominates ∙ Structured Cognitive Behavioural Therapy, Cognitive restructuring, Mindfulness and acceptance based approach 1. No improvement in 2nd line ∙ Use of alternative medicine approach – Yoga treatment REFER TO ∙ Collaborative approach – involve Physician, Neurology team and Pain 2. High suicidal risk Clinic referral (where indicated) 3. Needing intense counselling/ TERTIARY ∙ Vocational rehabilitation if needed psychotherapy CARE IF ∙ Physical therapies – guided exercise and physiotherapy 4. Difficult patients

REFERENCES ∙ Desai G & Chaturvedi SK. Medically Unexplained Somatic Symptoms & Chronic Pain – assessment & management. A primer for Healthcare professionals. 1st Edition 2017. Paras medical publisher, Hyderabad, India. ∙ World Health Organization. (2017). mhGAP training manuals for the mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings - version 2.0 (for field testing). World Health Organization. http://www.who.int/iris/handle/10665/259161. ∙ Agarwal V, Srivastava C & Sitholey P. Clinical Practice Guidelines for the Management of Paediatric Somatoform disorders. Indian Psychiatric Society – Practice guidelines 2018. ∙ Guidance for health professionals on medically unexplained symptoms (MUS) - https://www.rcpsych.ac.uk/pdf/CHECKED%20MUS%20Guidance_A4_4pp_6.pdf ∙ Jacob KS. A simple protocol to manage patients with unexplained somatic symptoms in medical practice. Natl. Med. J. India. 2004; 17: 326-8 KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. PULMONOLOGY Oct o ber/ 201 9

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for Management of ACUTE RESPIRATORY INFECTION IN ADULTS ICD-10-J09-J18; J00-06; J40 Signs of respiratory failure: 1. Vital RR> 30/ min, Abdomin • Cough with othoracic paradox, cyanosis, parameters: speaks in short sentences. yellow/rusty sputum Sensorium, Pulse, • Breathlessness Refer Respiratory Failure Blood pressure, STW. • Pleuritic chest pain • Malaise, myalgia, Respiratory rate, Temperature, arthralgia 2. Systemic

SYMPTOMS • Extra pulmonary Oxygen saturation examination: WHEN TO symptoms a. Upper respiratory SUSPECT tract: nose & paranasal

PAST HISTORY sinuses (frontal and • TB maxillary sinus tenderness), throat • Pneumonia examination ( pharynx and tonsils) • Airway disease b. Lower respiratory tract: breath • sounds (type, intensity), added sounds (crackles, wheeze, pleural • Diabetes rub) CLINICAL • Chronic steroid use Frank haemoptysis, may suggest EXAMINATION Pulmonary TB or malignancy

PROCEED FOR FURTHER ASSESSMENT

• Fever, tachycardia, pharyngitis, • Fever, tachycardia • Fever, tachycardia, tachypnea suffusion of eyes, rhinitis, hoarse • Respiratory system exam: Wheeze • Respiratory system exam: Crackles/ bronchial voice * Consider acute exacerbation of breath sounds • Respiratory system asthma/ COPD if there is a history of * Consider acute exacerbation of asthma/ COPD examination: Normal any of these 2 illnesses is there is a history of any of these 2 illnesses

PATHWAYS BASED ON INITIAL ASSESSMENT FINDINGS PATHWAY 1: ACUTE URI (RESPIRATORY CATARRH) PATHWAY 2: ACUTE BRONCHITIS PATHWAY 3: COMMUNITY ACQUIRED PNEUMONIA

LABORATORY INVESTIGATION: LABORATORY INVESTIGATION: SEVERITY ASSESSMENT • Total and differential count in suspected flu. • Total and differential count if sputum is • X-ray TREATMENT purulent, • Use CRB-65* score for mortality risk assessment in primary care • Symptomatic treatment for fever, myalgia • X-ray chest PA view CRB-65 SCORE (Paracetamol or other NSAID), TREATMENT • Rest, Oral fluids (plenty) • Symptomatic treatment for fever SCORE RISK CLASS SITE OF CARE • Oral antihistamines (Tab. CPM 4mg BD) for (Paracetamol or other NSAID), Oral fluids Low Risk severe runny nose or sneezing (plenty) OP Intermediate • Antibiotics in acute follicular tonsillitis: • Inhaled bronchodilators: Salbutamol IP Amoxicillin/ Ampicillin 500mg tid X 5 days nebulization (5mg/ 2.5ml ) 6-8 hourly Risk In penicillin sensitive individuals: • Antibiotics if there is purulent sputum and High Risk ICU Erythromycin estolate 250mg q 6 hrly X 5 polymorphonuclear leukocytosis days with food • Amoxicillin 500mg tidX 5 days *65 in the scoring mnemonic refers to age> 65 Suspect epidemic flu • In penicillin sensitive individuals: H/ o recent travel, symptoms of upper Erythromycin estolate 250mg q 6 hrly Give 1 point for each of the following Prognostic features: respiratory infection, diarrhoea, myalgia, X5 days with food • Confusion breathlessness Refer to higher centre for • If asthma is suspected refer to asthma STW • Respiratory rate ≥30/ min diagnosis, notification and treatment. • Low BP (DBP ≤60 mm Hg or SBP ≤90 mm Hg) • Age ≥65 years

OUT-PATIENT BASED CARE OF CAP (CRB-65 SCORE 0-1)

INVESTIGATIONS TREATMENT

Preliminary 1. Targeted towards Streptococcus pneumoniae Chest radiogram 2. Oral antibiotics after checking for comorbidities* (Diabetes, CVDs, CKD, CLD, Hepatic PULMONOLOGY Repeat if: Pathology, Cancer, Alcohol Abuse, H/ o antibiotics within last 3 months.) i. Patient is not improving/ worsening a. Without comorbidities: Cap. Amoxicillin (500 mg TDS) / Tab. Erythromycin clinically 250mg QID/ Tab. Doxycycline 100mg BD ii. Suspected underlying malignancy b. With comorbidities: Cap. Amoxicillin 500mg TDS + Tab.Azithromycin 500 mg OD Desirable 3. Duration: 5 days in (A); extend to a 7-10 days course if there is no response within 3 days of 1. Pulse oximetry in outpatients starting treatment and in (B). 2. Sputum microbiology: In suspected 4. Do not give: PTB & non-response after 48 hours of a. Corticosteroids: unless other medical indications present antibiotics b. Fluoroquinolones: as they have anti-tubercular activity.

INPATIENT MANAGEMENT OF CAP

ANTIBIOTIC THERAPY IN THE HOSPITALIZED NON-ICU SETTING ADJUNCTIVE THERAPIES FOR THE MANAGEMENT OF CAP a. Single agent IV β-lactam a. Steroids are not recommended for use in non-severe CAP b. If suspected atypical pathogens, other end organ disease, diabetes, malignancy, b. Non-invasive ventilation may be used in patients with severe CAP, use of antibiotics in past 3 months: Combination of IV β-lactam CAP and acute respiratory failure (Cefotaxime 2 grams TID/ IV Ceftriaxone 1gram BD/ Amoxicillin–Clavulanic acid 1.2 CONTRA INDICATIONS FOR NON-INVASIVE VENTILATION grams TID ) + ORAL macrolide (Tab Azithromycin 500 mg PO OD/ Tab a. Cardiorespiratory arrest Clarithromycin 500 mg PO BD) b. Presence of severe upper airway inflammation & edema ANTIBIOTIC THERAPY IN THE HOSPITALIZED ICU SETTING c. Severe haemodynamic instability - hypotension i. Patients without risk factors for Pseudomonas aeruginosa: Manage as above d. Eu-capnic (normal PaCO2) coma ii. Suspected P. aeruginosa (diabetes, chronic lung disease like bronchiectasis, e. Multiple organ dysfunction or severe psychomotor chronic steroid therapy): agitation IV Cefepime (1G BD)/ IV Ceftazidime (2G TID)/ Piperacillin–tazobactam(4.5 G QID)/ DISCHARGE CRITERIA IV Cefoperazone–sulbactam 1.5G IV TID/ IV Meropenem 1g TID; Accepting orally, Afebrile and Hemodynamically stable for a Combination therapy : Aminoglycosides(IV Amikacin)/ Antipseudomonal period of at least 48 h fluoroquinolones(Levofloxacin/ Moxifloxacin)

REFERRAL TO A HIGHER CENTRE : CLINICAL CRITERIA 1. Frank hemoptysis and /or Signs of respiratory failure [listed POINTS TO NOTE WHILE SHIFTING under in the history and evaluation sections] 1. If referring to a higher center, give the ﬁrst dose of 2. CRB-65 score > 1 antibiotic (oral and if available, parenteral), secure an IV line 3. Oxygen saturation by pulse oximetry ≤ 92% (patients ≤ 50 and start 0.9% Normal saline and oxygen supplementation yrs) OR <90% (patients > 50 yrs) through face mask at 4-6 litres per minute during shift 4. Multi-lobar consolidation on chest X-ray 2. If the patient is drowsy, has copious secretions, consider 5. Confusion/disorientation calling for help from the SUB-DISTRICT/ DISTRICT hospital 6. Hypothermia (core temperature<360C) for endotracheal intubation and shifting on a transport ventilator

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Oct o ber/ 201 9

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of ASTHMA ICD-10-J45

Classic symptoms TRY AND RULE OUT APPROACH TO DIAGNOSIS • Recurrent/ episodic wheezing • Other obstructive airway • Clinical assessment is • Breathlessness disorders – see Table 1 for the mainstay • Cough and/ or chest tightness features that favour asthma • Airway obstruction, and over COPD bronchodilator SYMPTOMS Supportive features • Other mimics – presence of reversibility, on • History of atopy, family history fever, constitutional symptoms, spirometry (if available) of asthma, presence of triggers, purulent sputum, hemoptysis, may support diagnosis presence of rhonchi on chest focal chest signs on physical • Refer patients for further auscultation examination, foreign body work-up if diagnosis is in • No alternative explanation for aspiration, abnormal chest doubt these symptoms radiograph, etc.

INITIATION AND MODULATION OF TABLE 1. DIFFERENTIATING BETWEEN ASTHMA AND CHRONIC OBSTRUCTIVE ASTHMA PHARMACOTHERAPY AIRWAY DISEASE (COPD) Asthma COPD Usually later in life Age of Onset More often in childhood or Levosalbutamol early adulthood; variable (4th or 5th decade) (50ug) Infrequent & Course Episodic Progressive OR Intermittent Salbutamol Smoking, other exposures Uncommon Common symptoms (100 ug), Nasal Symptoms, Atopy Common Rare 2 puffs sos Family History Often Uncommon Poor Good Triggers Often Identiﬁed None Control Control Prominent and almost May or may not be Wheeze Regular Budesonide universal present Symptoms (100µg) 2 puffs (<2 per week BD plus TABLE 2. LEVEL OF CURRENT ASTHMA CONTROL (OVER THE but >2 per Levosabutamol PRECEDING FOUR WEEKS) month) (50µg) 2 puffs sos Inadequately Adequately controlled Components controlled (all should be present) Poor Good (any one) Control Control Daytime symptoms Regular Formoterol/ More than twice a Twice or less in a or use of rescue Symptoms (>2 Budesonide week week per week) or (6/ 200µg) as a medication exacerbation single inhaler Night-time in past one 2 puffs BD symptoms/ Any None year and sos awakening

Limitation of Poor Good Any None Control Control activities FEV1 <80% of FEV1 >80% of Add tiotropium Pulmonary function predicted or PEF predicted or PEF (9µg) 2 puffs OD (if available) <80% of personal >80% of personal and low dose best best oral FEV1 Forced Expiratory Volume in first second, PEF Peak Expiratory Flow methylxanthine GUIDING PRINCIPLES • Mainstay of pharmacotherapy: Inhaled drugs Refer Poor • Frequency of symptoms determine treatment initiation (see figure 1 for details) Control • Reassess at 3-4 weeks – good response: in favour of asthma diagnosis • Patient education for compliance, warning signs, triggers, inhaler technique, PEF monitoring Add low dose • Inhaler technique to be monitored oral • Follow-up at 4-12 weeks, assess diseases control by clinical parameters (see Table 2) corticosteroids • Step-up or step-down treatment as per level of asthma control (see figure 1) • Follow up three-monthly and modulate treatment as needed • Refer for further evaluation and management if asthma remains poorly controlled DISEASE EXACERBATION

WHEN TO SUSPECT EXACERBATION SEVERE ACUTE ASTHMA (PATIENT TO BE ADMITTED) • Suspect if acute symptomatic worsening, or reduction in • Inability to complete sentences, agitation, use of accessory muscles, respiratory rate >30/ min, heart rate >110/ min, pulsus paradoxus >25 mm Hg, silent chest, PEF to below 80% of personal best, while on continued and/ or room air sPo2 <92% treatment • Take two additional puffs of the inhaler used if • Oxygen supplementation to maintain spO2 92-95% symptoms persist, and repeat if needed • Nebulized levosalbutamol/ ipratropium (1.25 mg/ 0.5 mg) three doses at • If no response after 24 hours, or symptomatic worsening, 20-minute interval, then 4-6 hourly or as needed or further reduction in PEF, contact physician • Injection hydrocortisone 200 mg intravenously, then oral prednisolone 0.5 mg/ kg • Physician to assess severity of exacerbation and manage daily for five days accordingly • Refer if no improvement • Discharge only when symptoms improve, wheezing absent or significantly reduced, heart rate <100 bpm, respiratory rate <30/ min, room air sPo2 >94% LIFE-THREATENING EXACERBATION • Schedule follow-up outpatient visit at one week Altered sensorium, orthopnea, cyanosis, NON-SEVERE ACUTE ASTHMA paradoxical breathing, hypotension, and/ or • If none of the above features present – manage on outpatient basis bradycardia (heart rate <60 bpm) – immediately • Continue additional inhaler doses as needed refer to higher centre with ICU facility • Oral prednisolone 0.5 mg/ kg daily for five days • Schedule follow-up outpatient visit at one week

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

REFERENCES 1. Agarwal R, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/ NCCP(I) recommendations. Lung India 2015;32(Suppl 1):S3-S42. 2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2018. 3. National Institute for Health and Care Excellence (NICE). Asthma: diagnosis, monitoring and chronic asthma management. 2017.

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Oct o ber/ 201 9

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of CHRONIC OBSTRUCTIVE PULMONARY DISEASE ICD-10-J44.9 TRY AND RULE OUT Symptoms – chronic cough, progressively worsening breathlessness Other obstructive airway disorders – Refer Asthma STW Risk factors – tobacco (Table 1) for features that favor smoking, use of solid fuels COPD over asthma for cooking, occupational exposures, Age - >35 years Pulmonary tuberculosis – WHEN TO Supportive features: Barrel sputum AFB examination in case SUSPECT? shaped chest, hyperresonant of cough ( >2 weeks) note , diminished breath sounds and rhonchi on chest auscultation, forced expiratory Consider alternative diagnosis/- time > 6 seconds, features of cor pulmonale (loud P2, complication– presence of fever, elevated JVP, edema) in hemoptysis, orthopnea, chest advanced cases pain, signiﬁcant weight loss, No other alternative focal chest signs on physical explanation for these examination, abnormal chest symptoms radiograph, etc.

Airway obstruction should be documented on Assess severity based on spirometry, severity DIAGNOSIS spirometry on all patients provisionally of dyspnea (mMRC scale, diagnosed as having COPD – refer if necessary, & Table 1), exacerbation frequency and Post-bronchodilator FEV1/ FVC <0.70 deﬁnes SEVERITY presence of complications (see Table 2) ASSESSMENT airﬂow obstruction

TREATMENT • Advice smoking cessation and counsel for other risk factors Disease progression • Inhaled drugs are the mainstay • Treatment based on severity Moderate assessment (See adjacent ﬁgure) Mild COPD Severe COPD COPD • Follow up: Mild to moderate disease - 3 to 6 Months; Severe Levosalbutamol (50 µg) 2 Formoterol/Budesonide (6/200 µg) disease - 1-3 months Tiotropium (9 µg) 2 puffs OD plus puffs prn Levosalbutamol (50 µg) 2 puffs prn as a single inhaler 2 puffs BD plus • Ensure compliance and proper Levosalbutamol (50 µg) 2 puffs prn inhaler technique at each visit. • If uncotrolled/ complications develop, refer to higher center Persistent Symptoms Persistent Symptoms Persistent Symptoms

DISEASE EXACERBATION Three cardinal symptoms: Add Tiotropium (9 µg) Add low dose Add Tiotropium (9 µg) 2 puffs OD • Increase in dyspnea 2 puffs OD methylxanthines and/or low dose methylxanthines • Increase in sputum volume and/or • Increse in sputum purulence Refer if inadequate response, onset of new complications, or suspicion of alternative diagnosis

Classify As:

• Mild Exacerbation TABLE 1. GRADING OF BREATHLESSNESS USING MODIFIED MEDICAL RESEARCH COUNCIL (MMRC) SCALE. • Severe Exacerbation GRADE DESCRIPTION OF BREATHLESSNESS Features Of Severe Exacerbation: I only get breathless with strenuous exercise. • Cyanosis I get short of breath when hurrying on level ground or walking up a slight hill. • Respiratory rate >30/ min • Heart rate >110/min On level ground, I walk slower than people of the same age because of breathlessness • Systolic blood pressure <90 mm or have to stop for breath when walking at my own pace. Hg I stop for breath after walking about 100 yards or after a few minutes on level ground. • SpO2 <90% • Paradoxical respiratory I am too breathless to leave the house or I am breathless when dressing. movements • Altered sensorium TABLE 2. SEVERITY CLASSIFICATION FOR COPD • Asterixis • Presence of severe co-morbid POSTBRONCHODILATOR DYSPNEA (MMRC EXACERBATIONS IN SEVERITY COMPLICATIONS* conditions (e.g. heart failure, FEV1 (% PREDICTED) GRADE) LAST ONE YEAR arrhythmia) MILD > 80 <2 <2 NO 50-79 > 2 <2 NO MILD EXACERBATION MODERATE • Increase dose and/ or frequency SEVERE <50 > 2 > 2 YES of levosalbutamol and/ or The category with the worst value should be used for severity classiﬁcation ipratropium inhalation, or *Complications include respiratory failure, cor pulmonale, and secondary polycythemia nebulized levosalbutamol/ ipratropium (1.25 mg/ 0.5 mg), repeated as needed at 20-minute interval RED FLAG SIGNS FOR PEOPLE HAVING EXCERBATION ADMISSION CRITERIA • Amoxycillin 500 mg TDS/ • Altered sensorium 1. Severe symptoms; sudden worsening of resting dyspnea, Azithromycin 500 mg OD/ • spO2 <88% despite therapy • Heart rate >110 bpm 2. Fall in oxygen saturation, cyanosis, Doxycycline 100 mg OD (BD on confusion, drowsiness. day 1) X 5 Days • Systolic blood pressure <90 mm Hg 3. Failure of an exacerbation to respond to • Oral prednisolone 30 mg daily X • High risk comorbid conditions (arrhythmia, initial medical management. 5 days congestive cardiac failure, poorly controlled 4. Presence of serious comorbidities (heart diabetes, renal or liver failure) failure, newly occurring arrhythmias, etc.) SEVERE EXACERBATION Treatment as under Mild Refer to higher centre for further management, DISCHARGE CRITERIA Exacerbation and ensure continued supplemental oxygen and 1. Normalization of clinical and laboratory + nebulization during transfer data to pre-admission levels Supplement oxygen with target 2. Patient able to follow maintenance therapy spO2 of 92% (if spO2 monetoring SCHEDULE FOLLOW UP VISIT ONE WEEK AFTER DISCHARGE 3. Completion of acute medications available) 4. Adequate control of comorbidities

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

REFERENCES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Oct o ber/ 201 9

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of RESPIRATORY FAILURE ICD 10 : J96.0

Shortness of Chest SYMPTOMS Cough 1 1 Wheezing 1 breath tightness

Tachycardia Restlessness Anxiety 1 Confusion SIGNS

Seizure Cyanosis Asterexis 1 Arrhythmia

Look for underlying causes in hypercapnia, headache, bounding pulse, tremor/ﬂap, papilloedema, coma.

HYPOXIA (SPO2 <90%) HEART FAILURE PNEUMONIA/ LRTI PULMONARY EMBOLISM

SYMPTOMS SIGNS SYMPTOMS SIGNS SYMPTOMS SIGNS • Dyspnea or • Tachycardia • Cough with or • Tachypnea • Sudden Shortness • Syncope exertion or rest • Pulsus Alterans without Sputum • Tachycardia of Breath • Arrhythmia • Chest Pain • Weak Rapid Thready Pulse • Chest Pain • Crackles and Rhonchi • Chest Pain • Tachycardia • Wheezing • Pink Frothy Sputum • Fever with Chills, • Hypoxemia • Calf Pain & or • Fatigue • Cyanosis Fatigue, Malaise • Pleuritic Chest Pain Swelling • Pallor • Hemoptysis • Distended Neck Veins

AIRWAY DISEASE ACUTE ASTHMA AE OF COPD BRONCHIOLITIS SYMPTOMS SIGNS SYMPTOMS SIGNS SYMPTOMS SIGNS • Wheeze • Tachypnea • Worsening of • Tachypnea • Cough • Cyanosis • Shortness of • Tachycardia Dyspnea • Hypoxemia • Shortness of • Nasal Flares Breath • Fall in SPO2 • Increase in • Hypercarbia Breath • Tachypnea • Chest Tightness • Use of Accessory Sputum • Confusion • Wheezing • Paradoxical Breathing • Cough Muscle Production • Drowsy (children) • Increased Cough • Peripheral Edema • Crackles and or Rattling sounds in Lung

INVESTIGATIONS

ABG, CRP, FBC, U&E Chest Xray Sputum culture, Blood culture (if febrile) Spirometry(COPD, Neuromuscular disease

TREATMENT Heart Acute Severe AE COPD ARI Pneumonia Pulmonary DIAGNOSIS failure Asthma LRTI embolism

Start oxygen therapy at SpO2 < 90% OXYGEN Monitor SpO2 during oxygen therapy to titrate ﬂow rate: target SpO2 < 96% Oxygen delivery usign Nasal cannulae/ Simple face mask/ Venturi mask/ Non re-breathing mask (Note: for patients with AECOPD, keep lower target SpO2 = 88-92%)

SABA ± SAMA (Salbutamol ± SABA + SAMA (Salbutamol neb SABA + BRONCHODILATORS SOS Ipratropium neb SOS SOS q20 min X 1 hr hourly + Ipratropi- SAMA then prn) um neb 4 hourly)

Yes (IV Furosemide SOS SOS SOS SOS SOS DIURETICS 40 mg or Torsemide 20 mg)

No risk factor Mild/ Mod cases: Pseudomonas: Ceftriaxone Amoxycillin PO/ IV or or levofloxacin or Ceftriaxone IV moxifloxacin Severe Cases: Pseudomonas risk factor: ------Amoxycillin IV or --- ANTIBIOTICS levofloxacin or piperacillin tazobactam or ceftazidime Ceftriaxone IV or cefepime Atypical pneumonia: Influenza suspect: Azithromycin IV/ PO or Oseltamivir Doxycycline IV/ PO

Severe CAP (ﬁO2 > 0.5 Yes Yes AND pH <7.3 OR lactate (Methylpredniolone (Methylprednisolone Yes >4 mmolL-1 OR CRP > STEROIDS --- IV 40 to 60 mg or IV 60 to 125 mg IV --- 150 mgL-1): Prednisolone PO q6-12 hourly) Methylprednisolone IV 60 mg) 0.5 mg/ kg q12h

If high suspicion with low risk of Prophylactic, Prophylactic, Prophylactic, Prophylactic, LMWH Prophylactic, bleeding: UFH (if if indicated if indicated if indicated if indicated if indicated thrombolysis anticipated), OR LMWH No relief OR Need for mechanical ventilation OR life threatening features: REFERRAL Stabilize CAB, transfer to higher center ABBREVIATIONS • LRTI : Lower Respiratory Tract Infection • SABA : Short Acting Beta Agonist • CAP: Community Acquired Pneumonia • LMWH: Low Molecular Weight Heparin • SAMA: Short Acting Muscarinic Antagonist • UFH : Unfractionated Heparin

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. PULMONOLOGY UROLOGY October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of ACUTE URINARY RETENTION IN MEN AUR ICD-10-R33.9

• Nature and duration of urinary symptoms prior to AUR • Associated symptoms like fever, weight loss, sensory loss or weakness of lower limbs • Past history of retentions HISTORY • Rule out precipitating causes like diabetes mellitus, alcohol DEFINITION: consumption, recent surgery, UTI, constipation, cold exposure, Emergency prolonged travel and neurological conditions condition • Medication history characterized • Look for risk factors by a sudden and painful inability to void voluntarily • Fever despite having a • Enlarged tender palpable bladder dull on percussion full bladder • Phimosis, meatal stenosis, urethral induration, stone, urethral discharge EXAMINATION • DRE for estimating prostatic size, consistency, tenderness ; exclude fecal impaction • Focused neurological examination-anal tone, perianal sensation and bulbocavernous reflex

RISK FACTORS OF SPONTANEOUS AUR DUE TO BPH RISK FACTORS OF PRECIPITATED AUR

• Old age • Surgical procedure with general or • Severe lower urinary tract symptoms (LUTS) loco-regional anaesthesia • Low peak ﬂow rate • Bladder over-distension (eg prolonged journey) • High postvoid residual urine (PVR) • Exposure to cold • Enlarged prostate or large median lobe • Medications with sympathomimetic or • High serum PSA anticholinergic effects, diuretics, alcohol intake • Symptom worsening • Feacal impaction • Increasing PVR during medical therapy

CAUSES

THAT BLOCK Urethral Urethral Acute Vesical Faecal BPH Ca Prostate THE PASSAGE Calculus Stricture Prostatitis Calculus impaction

THAT PARALYSE Neurological diseases e.g. spinal cord compression, Drug induced eg. opiods, anticholinergics, DETRUSOR transverse myelitis, stroke, head injury anti-histaminics, anti-diarrhoeals, flavoxate

INVESTIGATIONS

As AUR is an acute emergency, no investigation is required before catheterization to relieve symptoms. The volume of urine drained should be documented.

DESIRABLE OPTIONAL (ONLY BY SPECIALISTS) CBC, S. Glucose,S. Creatinine and Electrolytes, USG KUB Urine NOT TO BE DONE ROUTINELY analysis& Urine culture of the drained urine • Cystoscopy,CT / MRI,RGU + MCU,Urodynamic studies MANAGEMENT ALGORITHM

FOR CATHETERIZATION Attempt gentle urethral catheterization - Use a 14 or 12 Fr Foley urethral catheter - Do not remove catheter earlier Catheterization successful Catheterization fails than a day

Suprapubic cystostomy if Keep catheter adequately trained 1-3 days* COMPLICATIONS DUE TO AUR OR Refer to urologist • Urinary tract infection • Acute kidney injury Precipitated AUR Spontaneous AUR due to due to BPH COMPLICATIONS DUE TO CATHETERIZATION Drugs No prior history • Post obstructive diuresis with Diabetes No prior history of dys-electrolytemia Neurological disturbances r/c acute retention α blockers for • Transient decompression Urethral stricture ± severe 2-4 days hematuria Pelvic and Perineal Surgery obstructive lower • Urethral injury during Fecal impaction urinary tract catheterization Urinary/ peri anal Infection symptoms T.W.O.C

Treat the cause Surgery Succeeds Fails INDICATIONS FOR HOSPITALIZATION

Trial without catheter • Patients of AUR with Continue Surgery significant comorbidities If fails, medical • Patient of AUR with refer to urologist management complications listed above

ABBREVIATIONS

BPH: Benign Prostatic IPSS: International Prostate TWOC: Trial Without Catheter WW: Watchful waiting Hyperplasia Symptom Score KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India

Standard Treatment Workﬂow (STW) for the Management of GROSS HAEMATURIA ICD-10-R31.0

PERFORM THOROUGH CLINICAL EVALUATION

• Blood in urine - red coloured or dark coloured EXAMINATION • May be associated with pain: • Pulse, blood pressure • Pain during voiding (urethra) • Check for pallor • Pain in suprapubic region (bladder) • Check for anasarca • Pain in ﬂank (kidney) • Per abdomen • Acute retention of urine due to clots examination: Palpable • Haematuria associated with clots (severe) bladder, ﬂank mass • Digital rectal examination: Enlarged prostate, hard nodular/ smooth surfaced prostate • Rule out vaginal causes SYMPTOMS of bleeding

RED URINE BUT NOT HAEMATURIA • Foods: beetroot, blackberry, rhubarb • Medicines: rifampicin, pyridium

Even single episode of haematuria warrants complete evaluation

MAKE A CLINICAL HOW TO INVESTIGATE OPTIONAL DIAGNOSIS: IS HAEMATURIA • Urine culture ESSENTIAL • Urine for active • Urine examination - routine, microscopy sediments(if • Hemoglobin estimation INITIAL nephrotic/ • Kidney function tests (KFT) • Urethra: stone, urethritis, stricture nephritic • Ultrasonography of kidney urinary syndrome • Prostate: inﬂammation, benign bladder and prostate region hyperplasia, malignancy suspected) • PT/INR (if bleeding disorder TOTAL DESIRABLE suspected) • Kidney: stone, malignancy (renal parenchyma, • Contrast enhanced computed • Serum prostate speciﬁc antigen pelvis/ ureter), genito-urinary tuberculosis tomography of kidney urinary bladder (if required) • Ureter: stone, malignancy, genitourinary region/ intravenous pyelography (if KFT normal) • Urine for acid fast tuberculosis • Magnetic resonance imaging of Kidney bacilli - 3 samples • Bladder: infection, genitourinary tuberculosis, urinary bladder region (if KFT deranged) (if tuberculosis stone, malignancy • Urine cytology if > 40yrs or smoker suspected) • Cystoscopy if > 40 years or smoker

TERMINAL • Bladder: stone, tumor at bladder neck • Deranged kidney functions • Suspecting malignancy • Prostate: inﬂammation, benign WHEN TO REFER • Haematuria with hypertension / hyperplasia, malignancy (WARNING SIGNS) albuminuria • Persistent severe haematuria

HOW TO TREAT

GENERAL SPECIFIC • Haematuria should be considered as a symptom of genitourinary malignancy in patients >40years old until • Start intravenous ﬂuids proven otherwise if required (primary • Suspected nephrotic/nephritic syndrome: cola coloured urine, proteinuria, anasarca, hypertension - Refer to level) nephrologist (tertiary level) • If Anaemia - may trans- • Suspect urinary tract infection : presents with dysuria, increased frequency of voiding and other irritative lower fuse blood as required urinary tract symptoms with/ without fever- treat with broad spectrum oral antibiotics (primary level) (primary level) • Manage clot colic / ﬂank pain with analge- DIFFERENTIAL DIAGNOSIS FOR CHRONIC CONDITIONS LEADING TO HAEMATURIA sics (primary level) Stones Renal cell cancer Bladder tumor Genito-urinary tuberculosis • If Acute urinary retention - catheterise with Flank pain Flank mass Haematuria Dysuria 20/22Fr 3 way Foley and Symptoms Ureteric colic Flank pain Urinary retention Frequency may start continuous Recurrent urinary tract infection Haematuria Nocturia irrigation with normal Haemturia Haematuria saline (Primary level) Ultrasonography Urine analysis • Cystoscopic clot evacu- Ultrasonography Ultrasonography Computed Urine acid fast bacilli ation may be per- Xray KUB Computed Investiga- tomography Urine tuberculosis culture formed if feasible (ter- Intravenous pyelography or tomography tions Urine cytology Gene expert (optional) tiary level) Computed tomography Intravenous pyelography or • If basic evaluation and Computed tomography management facilities Mostly surgical Mostly surgical are unavailable - refer >5mm or symptomatic - Oral Antitubercular treat- Treatment treatment - refer treatment - refer to (tertiary level) refer to urologist ment - 6months, refer to a to urologist urologist urologist, close follow up

REFERENCES

1. Standard treatment guidelines in urology: Ministry of Health and Family selfare

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workflow (STW) for the Management of MALE INFERTILITY ICD-10-N46.9 HOW TO PROCEED? AIM HISTORY • To ascertain contributory male • Age of partners and duration of Both partners factor infertility. examined • Identify potentially correctable • Use of contraception and simultaneously* conditions lubricants. • Identify incorrectable condtions • Knowledge of sexual cycle, WHEN TO SUSPECT? that may or may not be amenable technique, frequency. Ensure to Assisted Reproductive • Sexual and ejaculatory dysfunction, Inability to conceive marriage is Technique (ART) volume of ejaculate even after one year of consummated, • Identify underlying medical • Medical illness: STD, diabetes, recent fever, chronic bronchitis and regular unprotected couple has conditions responsible for infertility any debilitating medical conditions intercourse. frequent • H/o Chemotherapy, Radiotherapy timed • Congenital anomalies, Evaluation earlier intercourse cryptorchidism, hypospadias, Chordee than one year if with the PHYSICAL EXAMINATION female age is >35yrs, • Testicular torsion, drug history, knowledge of • Body habitus (obesity, trauma and swelling family history of ovulatary cycle. Klinefelter’s). Secondary sexual • H/o past surgeries( hernia repair, infertility or very characters, gynecomastia orchiopexy, retroperitoneal anxious couples. • Penis: hypospadias, surgery) epispadiasis, chordee, Infertility Incidence is • Family history *Male factor is an under • Testes: volume, consistency, (infertility,consanguinity,genetic 10-15%. Male factor- recognised problem and the masses, contours failure to recognise often disorders), contributory in 50% leads to social and • Epididymis: flat, turgid, • Exposure to environmental toxins cases. psychological adverse nodularity. Vas deferens (pesticides,herbicides, chronic heat effects. Often the male is –present/absent thickened or and radiation (sauna bath, tight evaluated once the female beaded non cotton undergarments, laptops has been examined • Cords-presence of varicocele. & mobile) thoroughly and this delays Inguinal or scrotal scar. • Partner history: Any menstrual the treatment . Greater the • Rectal examination: cyst, dilated duration of infertility lesser abnormality, infertility evaluation the chance of success. seminal vesicles. till date

INVESTIGATIONS SEMEN ANALYSIS (ESSENTIAL) • At least two- samples 1-2 months apart ; Abstinence of 1-3 days.; Collected in sterile, medical grade plastic wide mouth containers. • Provided within the lab or transported within an hour at room temperature and examined immediately • WHO 2010 criteria for normal report. Volume: >1.5, ml, Sperm conc.: >15 million/ ml, Sperm motility: >40% , Progressive > 32%, Sperm morphology: >4% normal forms, Leukocyte density: <1 million/mL

DIAGNOSTIC CATEGORIES ACCORDING TO SEMEN ANALYSIS REPORT Normal Semen Analysis: Low volume semen: Incomplete • Azoospermia: • Oligo-astheno-teratospermia: Isolated Asthenospermia: Rule out sexual Collection, Retrograde Obstructive Antisperm antibodies, Sperm structural defect, Hypogonadism dysfunctions, Anatomic ejaculation, Ejac. duct (Epididymal,vasal) • Multiple defects: Varicocele, Cryptorchidism, Genital tract abnormalities, Female obstruction, Cong. Absence of • Nonobstructive: (Genetic, infection, Systemic illness, Prolonged abstinence, Drugs factor and unexplained VasDeferens, Hypogonadism Chromosomal, Hormonal, (Sulfasalazine, NFT, Colchicine, Chemotherapy, GnRh analogs, CT/RT, Post torsion testes, Spironolactone, Ketokonazole, Anabolic steroids, cocaine, alcohol. Note: If a patient is unable to produce semen consider retrograde orchitis, Cryptorchidism, Chemicals: heavy metals, herbicides, organic solvents, fungicides, ejaculation and anejaculation. Need further evaluation. Idiopathic) pesticides) OPTIONAL INVESTIGATIONS • Hormonal assay: Serum FSH, LH, Prolactin, Testosterone, Estradiol, T/E ratio • Culture: Urine, Semen, Prostatic ﬂuid, Antisperm antibodies, Viability assay, Sperm function tests, Scrotal USG & doppler, TRUS, Genetic studies, • Testicular biopsy (Multiple bilateral preferable) MANAGEMENT PHC/CHC DISTRICT HOSPITAL • History and Physical examination( PE) • Hormonal assay and Testicular biopsy • Proper Semen analysis • Management of sexual and ejaculatory dysfunction Normal Semen report: (Rule out unconsummation, sexual dysfunction, anatomic abnormailities) • Management of Varicocele and Hypogonadotropic Abnormal Semen report: hypogonadism • Refer to Urologist/ infertility centre • ART: AIH/AID and counselling for adoption. • Preventive measures: Avoid gonadotoxins, gonadotoxic drugs, smoking, tobacco, chronic heat , excess use of mobiles; Encouraging healthy life style: Nutritious diet, regular physical exercise, TERTIARY LEVEL avoid stress, use of antioxidants and vitamins( Vit. C, Vit E , Zinc) • Additional testing:TRUS, Genetic, ASA, Sperm • Female partner to be evaluated by gynecologist function tests • Management of reversible nonsurgical causes (Infections etc.) and surgical cause i.e. varicocoele if • Advanced surgery: Microsurgical VVA,VEA, surgeon available. Varicocelectomy, TURED, Sperm retreival techniques, Cryopreservation and sperm banking • For further evaluation refer to district/ tertiary hospital. • Advanced ART: IVF-ET/IVF ICSI

TREATMENT ALGORITHM

AZOOSPERMIA AZOOSPERMIA (Low volume, ↓pH, Fructose -ve) (Normal volume, Fructose +ve) Retrograde Clinical Examination & FSH ejaculation ruled out Examine Vas Obstructive Equivocal P.T.F. (FSH-N, Epid, (N-FSH, N-testes) (Testes small, FSH>2N) turgid) Not palpable Palpable Normal testes B/L Multiple testicular biopsy Discuss options CABVD E.D.O. Exploration, check DI/ Considering vasal patency Normal No Focal CFTR DI/ Adoption TRUS Sperms Sperms Adoption ICSI Needle biopsy (if VEA/ Gene Genetic study required) ICSI DI/ TESE-ICSI Mutation Cystic SV & ED Fibrous Counselling Adoption Multiple testicular biopsy Microsurgical ICSI Non-operable TURED VEA Sperms Sperms present Vasography guided absent TRUS guided PESA + ICSI Cryo preservation ICSI

OLIGO-ASTHENO-TERATOSPERMIA (↓ count, ↓ motility, poor morphology)

↑ FSH ↑ASA Varicocele Infection Idiopathic Severe Germ epith damage Steroids + Varicocelectomy Antibiotics Empirical Medical Rx Refer for Assisted Reproductive Technique (IUI/IVF/ICSI) KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

ABBREVIATIONS PTF: Primary Testicular Failure DI: Donor Insemination ART: Assited Reproductive Technique FSH: Follicle Stimulating Hormone VEA: Vasoepididymal Anastomosis TESE: Testicular Sperm Extraction AIH: Artiﬁcial Insemination Husband EDO: Ejaculatory Duct Obstruction TRUS: Trans Rectal Ultrasonography SV & ED: Seminal Vesicle & Ejaculatory AID: Artiﬁcial Insemination Donor CABVD: Congenital Absence of Bilateral Vas PESA: Percutaneous Epididymal Duct ICSI: Intra Cytoplasmic Sperm Injection deferens Sperm Aspiration TURED: Trans Urethral Resection of IVF-ET: Invitro Fertiliztion - Embryo Transfer VVA: Vaso Vasostomy ASA: Anti Sperm Antibodies Ejaculatory Duct GUTB: Genito Urinary Tuberculosis

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of RENAL AND URETERIC STONES ICD N20.0

HOW WILL YOUR PATIENT PRESENT AND WHAT TO SUSPECT

CLINICAL SCENARIO SUSPECT

Flank pain Renal Stone

Colicky pain starting Upper ureteric from back stone and radiating to front

SYMPTOMS Renal Pelvic Stone Colicky pain starting from back Mid ureteric & radiating upto groin stone

Upper Ureteric Stone Colicky pain starting from Lower ureteric back & radiating to upper stone thigh & scrotum/ vulva

History of site & type of pain, associated • Haematuria may be present with • Colics may be associated with symptoms hint towards stone at any location nausea and vomiting possible site of stones. • Lower ureteric stones may also • Can present as anuria in bilateral Remember to take past present with difﬁculty in passing ureteric stones, ureteric stone in a history of stone diseases, solitary kidney medications, family urine history etc

INVESTIGATION RADIOLOGY

NAME ADVANTAGES AND DISADVANTAGES TIPS FOR ORDERING INVESTIGATIONS Readily available, inexpensive, minimal radiation but needs preparation hence may DISTRICT HOSPITAL X-KUB • Order X-KUB and Ultrasound in all patients of • Hormonal assay and Testicular biopsy not be the preferred test in emergency settings suspected renal stones (90% of renal stones are • Management of sexual and ejaculatory dysfunction radio-opaque). USG Readily available, no radiation, safe test in pregnancy, detects • Management of Varicocele and Hypogonadotropic radiolucent stones, high sensitivity for hydronephrosis. Can miss a ureteric calulus • In acute colic NCCT should be preferred if hypogonadism available Anatomical and functional imaging, aids in planning surgery but high radiation • ART: AIH/AID and counselling for adoption. IVP • Once the stone is detected, get Intravenous and needs preparation. Not useful in poor renal function pyelography if stone is seen on X-ray No contrast required, highly sensitive and speciﬁc, detect radiolucent stones, • CT urography if stone is radiolucent to aid further CT Scan detect other causes of ﬂank pain, but risks higher radiation and cost treatment

METABOLIC EVALUATION

Initial biochemical evaluation To be done in recurrent stone former, stone in in all stone formers children, bilateral stones, family history of stone, Extended history of gut surgery, solitary kidney and cysteine Evaluation Urine analysis, serum creatinine, stones. Typically to be done at 3-4 weeks after stone electrolytes namely calcium, clearance phosphorous and uric acid. Intact parathyroid hormone and stone Should include initial metabolic evaluation plus 24-hour analysis are preferrable. urinary levels of calcium,uric acid, and creatinine. Preferable to do urinary oxalate and citrate levels too.

MANAGEMENT ALGORITHM

Warning signs for Analgesics Flank Pain, ∙ Increase daily ﬂuid immediate referral Hydration Hematuria intake to ensure a ∙ Anuria urine output >2 ∙ Fever with chills and lit/day rigors • Restrict extra salt Fevers with Empiric ∙ Suspected renal failure intake and chills & rigors/ Antibiotic/ ∙ Persistent haematuria increase dietary

Anuria hydration HIGHER CENTRE REFERRAL ﬁbre. • Do not restrict calcium intake. Medical Expulsive • Increase citrate X- Ray KUB Urine Analysis Therapy (MET) rich food such as USG Abdomen + Initial Metabolic ∙ Alpha blockers such as lemon, orange IVP/ CT Scan screen Tamsulosin(0.4mg/day); juice etc. Alfuzocin(10mg/day); • Decrease Doxazocin(4mg/day); consumption of Silodocin(8mg/day) food rich in ∙ MET should be offered oxalates like ∙ In Ureteric stones Single Stone > 5mm, Renal Stone <1cm Kidney/ ureteric spinach, nuts, beet <10mm Baseline Uteric Stone >5mm stone >1cm root, potato chips, investigation normal <1cm ∙ In the absence of French fries. infection, obstruction • Avoid purine rich or deranged renal foods like animal Counsel the patient Medical expulsive therapy function. protein, alcoholic for future preventive Alpha Blockers ∙ MET can be tried for drinks like beer strategies Potaasium Nitrate upto 4 weeks

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientiﬁc evidence. There may be variations in the management of an individual patient based on his/her speciﬁc condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. October/ 2019

Department of Health Research Ministry of Health and Family Welfare, Government of India Standard Treatment Workﬂow (STW) for the Management of SCROTAL SWELLING ICD-10-N50.89

HOW TO MAKE A CLINICAL DIAGNOSIS?

Are you able to reach Scrotal wall AS PER SITE DIAGNOSE THE SITE YES Scrotal swelling OF SWELLING? above the swelling? involved in swelling NO PARIETAL INGUINOSCROTAL SWELLING SWELLING Scrotal wall normal & can be A swelling, pinched off the swelling clinical or on USG, arising Testis palpated INTRASCROTAL SWELLING Testis not palpable from any of separately normally the scrotal Swelling located Swelling located just structures: above &/or behind testis scrotal wall &/ well above testis or intrascrotal SPERMATIC CORD SWELLING EPIDIDYMAL SWELLING contents

AS PER NATURE DIAGNOSE THE NATURE PAINFUL Fever Present Acute infection TESTICULAR OF SWELLING? SWELLING Fever Absent • Traumatic PAINLESS • Ischaemic (e.g. torsion)

Cystic Fluid accumulation, (e.g. Hydrocele,epididymal cyst)

Solid • Ch. inﬂammatory, (e.g. Filariasis, TB) • Tumors

MAKE A CINICAL DIAGNOSIS PARIETAL (SCROTAL WALL) SWELLINGS INTRASCROTAL SWELLINGS

BILATERAL UNILATERAL Testicular Epididymal Spermatic cord • Reactionary to • Cellulitis • Epididymal cyst Ac. Inflammation epididymo- orchitis Cystic Hydrocele Varicocele • Fournier gangrene • Furuncle Abscess • Spermatocele Traumatic Contusional Blunt trauma Painless Painless Painless Ch. Inflammation Filarial Elephantiasis • Testicular • Ch. Filarial Solid • Lipoma cord • Edema in anasarca, tumor epididymitis Fluid IVC thrombosis • Ch. Tuberculous Accumulation Scrotal wall cysts Painful Painful Epididymitis • Urinary extravasation • Funiculitis • Torsion testis • Adenomatoid tumor Melanoma, Scrotal • Orchitis Painful Neoplasm Carcinoma • Ac. Epididymitis Dermatofibroma; RED FLAG SIGNS

PAINFUL SWELLING CONFIRM BY • Sudden onset TORTION TESTIS • Scrotal doppler • O/E tender enlarged testis, pain (More common in REFER URGENTLY FOR increases on elevating testis adolescents) ATTEMPT EXPERT CONSULTATION • Severe pain • Manual detorsion if patient • Vomiting reports early • No fever

PAINLESS SWELLING CONFIRM BY TORTION TESTIS REFER ALL CASES FOR • Solid testicular swelling is felt • Scrotal USG (Testicular Tumor) • Serum tumor markers EXPERT CONSULTATION

INVESTIGATIONS

SUSPECTING AC. INFLAM SUSPECTING CH. SUSPECTING TESTICULAR SUSPECTING SUSPECTING DISEASE INFLAMMATORY DIS. TUMOR TORSION VARICOCELE Essential Desirable Essential Desirable Essential Desirable Essential Desirable Essential Desirable • TLC/DLC • Anti ﬁlarial • TLC/DLC • Anti ﬁlarial Ab • Beta hCG • Scrotal USG • TLC/DLC • Scrotal • TLC/DLC • Scrotal • Blood sugar antibody • ESR • TB Gold test • Alfa feto • Abdomino - doppler doppler • Scrotal USG protein Pelvic CECT • Serum LDH Scan

HOW TO TREAT COMMON CONDITIONS? PARIETAL SWELLINGS INTRASCROTAL SWELLINGS FURUNCLE/ABSCESS AC. EPIDIDYMO-ORCHITIS CHRONIC EPIDIDYMO-ORCHITIS • Broad Spectrum Antibiotic • If patient had a urinary tract • Mostly filarial in origin but if - Amoxy + Clavulinic acid instrumentation or dysuria - - Patient has had H/O UTI or urethral • Consider drainage if suspect bacterial type, catheterization, suspect bacterial fluctuations+ or impending treat by - antibiotic and support - Patient has H/O TB, suspect rupture tuberculosis REFER REFER If no response in 48 hrs • Treat by DEC 100 mg • If abscess appears part of • Treat all other cases as filarial by - DEC 100 TDS + Doxycycline 100 mg BD for 20 underlying disease mg x TDS x20 days days • Nonresponders • Doxycycline 100 mg x BD x 20 days REFER if • Immunocompromised • Give anti inflammatory drugs to all • No response to treatment patient • Epididymal abscess or local sinus HYDROCELE discharging syrup like pus FILARIAL ELEPHANTIASIS • Small size - no treatment • DEC 100 mg TDS x 20 days • Moderate to large -Do VARICOCELE • Doxycycline 100 mg BD x 20 hydrocelectomy • Counsel for semen analysis (2-3 times) days • Aspiration can be performed REFER if ‘discrepancy in size of testis’ • Scrotal Elevation/support under asceptic precautions in select cases and/or ‘abnormal semen parameters REFER present’ • Non responders REFER if not trained to do the surgery • Rest all cases be given symptomatic • Huge size treatment KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Department of Health Research CONTRIBUTORS Ministry of Health and Family Welfare, Government of India

ADVISORY COMMITTEE

Dr. Balram Bhargava, Secretary, DHR and DG, ICMR - Chairman Dr. Nikhil Tandon, Dept. of Endocrinology, AIIMS, New Delhi. - Vice Chairman WHO India Country Office Representative – Member, Ex officio Director General Health Services / Representative- Member, Ex officio Additional Secretary & MD (NHM), MoHFW – Member, Ex officio Joint Secretary, DHR - Member Secretary, Ex officio Dr. Pramod Garg, Dept. of Gastroenterology, AIIMS, New Delhi - Member Dr. Sanjay Jain, Dept. of Internal Medicine, PGIMER, Chandigarh - Member Dr. T. Sunderraman, School of Health System Studies, TISS, Mumbai - Member Dr. J.V. Peter, Dept. of ICU and Trauma, CMC, Vellore - Member Dr. Ashok Deorari, Dept. of Paediatrics, AIIMS, New Delhi - Member Dr. Naveet Wig, Dept. of Medicine, AIIMS, New Delhi - Member Dr. C. H. Arun Kumar, Dept. of Orthopaedics, RIMS, Imphal – Member Brig. Shakti Vardhan, Dept. of Gyanecology/Oncology, AFMC, Pune - Member Dr. Sudeep Gupta, Dept. of Medical Oncology, TATA Memorial, Mumbai - Member Dr. S.K. Dwivedi, Dept. of Cardiology, KGMU, Lucknow - Member Dr. Jeyaraj Durai Pandian, Dept. of Neurology, CMC, Ludhiana - Member Dr. Vivekanand Jha, Nephrologist, The George Institute for Global H ealth, Delhi – Member Dr. Rajdeep Singh, Dept. of Surgery, MAMC, Delhi – Member Dr. Reva Tripathi, Formerly Dept of ObGyn, MAMC, New Delhi- Member. Dr. S. S. Kale, Dept. of Neurosurgery, AIIMS New Delhi- Member Dr. Peush Sahni, Dept. of G.I. Surgery, AIIMS, New Delhi- Member. Dr. Binod Khaitan, Dept. of Dermatology, AIIMS, New Delhi- Member Dr. Amlesh Seth, Dept. of Urology, AIIMS, New Delhi- Member Dr. Shally Avasthi, Dept. of Paediatrics, KGMC, Lucknow- Member Dr. B.N. Gangadhar, NIMHANS Bangalore – Member. Dr. Anil Bhansali, Dept. of Endocrinology, PGIMER, Chandigarh- Member. Dr. Shiv Chaudhary, Dept. of CTVS, AIIMS New Delhi- Member Dr. Surinder Lal Jindal, Formerly Dept.of Pulmonology, PGIMER, Chandigarh-Member. Dr. Lalit Kumar, Dept. of Medical Oncology, AIIMS, New Delhi- Member Dr. Radhika Tandon, Dept. of Ophthalmology, AIIMS, New Delhi- Member Dr. Alok Thakar, Dept. of Otorhinolaryngology, AIIMS , New Delhi-Member Dr. Prakash Kotwal, Foremerly Dept. of Orthopaedics, AIIMS, NewDelhi- Member.

SPECIAL GUESTS Dr. V. K. Paul, Member, NITI Aayog Dr. Indu Bhushan, CEO, National Health Authority Dr. Sudhir Gupta, D.G.H.S. Dr. Anil Kumar, MoHFW.

EDITORIAL BOARD

CHAIR Prof. Pramod Garg, Dept. of Gastroente rology, AIIMS, New Delhi

MEMBERS Prof. Rajdeep Singh,, Dept. of Surgery, MAMC, New Delhi. Prof. Sanjay Jain, Dept. of Medicine, PGIMER, Chandigarh.

Prof. S.K. Dwivedi, Dept. of Cardiology, KGMC, Lucknow. Prof. Sushil Kabra, Dept. ofPaediatrics, AIIMS, New Delhi. Prof. Vivekanand Jha, Executive Director, The George Institute for Public Health, New Delhi

MEMBER SECRETARY Dr. Deepika Saraf, Scientist E, ICMR. EXPERT GROUPS

NAME AND AFFILIATED INSTITUTE ROLE Department of Health Research Ministry of Health and Family Welfare, Government of India PAEDIATRICS

Dr. Shally Awasthi, KGMC, Lucknow Chair

Dr. Sushil Kabra, AIIMS, New Delhi Co-Chair

Dr. Neelam Mohan, Medanta, Gurgaon Co-Chair

Dr. Pushpa Kini - KMC, Manipal Member

Dr. Suvasini Sharma, LHMC,New Delhi Member

Dr. Joseph Mathew- PGIMER, Chandigarh Member

Dr. Surjit Singh, PGIMER, Chandigarh Member

Dr. Kuldeep Singh, AIIMS, Jodhpur Member

Dr. Himanshu Chaturvedi, Balrampur Hospital, LKO Member

Dr. Shinjini Bhatnagar, THSTI, Faridabad Member

UROLOGY

Dr. Amlesh Seth, AIIMS, New Delhi Chair

Dr. Anup Kumar, Safdarjung,New Delhi Co-Chair

Dr. Rakesh Kapoor, SGPGI, Lucknow Member

Dr. Dorairajan Narayanan, JIPMER, Pondycherry Member

Dr. Santosh Kumar, CMC, Vellore Member

Dr. Divakar Dalela, Ex KGMC, Lucknow Member

Dr. Anil Mandhani, Medanta, Gurugram Member

Dr. Shivam Priyadarshi, SMS Jaipur Member

Dr. Ravi Mohan Mavuduru,PGIMER Chandigarh Member

Dr. T P Rajeev, Guhawati Medical College Member

NEUROLOGY

Dr. Jeyaraj Pandiyan, CMC, Ludhiana Chair

Dr. Manjari Tripathi, AIIMS,New Delhi Co-Chair

Dr. Salil Gupta, R & R Hospital, New Delhi Member

Dr. Shefali Gulati, AIIMS,New Delhi Member

Dr. Sylaja PN, SCTIMST, Trivandrum Member

Dr. Vivek Nambiar, AIMS, Kochi Member

Dr. Karamvir Goyal, Ludhiana Member

Dr. P K Misra, Lucknow District Hospital Member

Dr. Sapna Erat Sreedharan, SCTIMST, Trivandrum Member

NEPHROLOGY

Dr. Vivekanand Jha, The George Inst of Global Health Chair

Dr. Sandeep Mahajan, AIIMS, New Delhi Co-Chair

Dr. Manisha Sahay, Osmania Medical College, Hyderabad Member

Dr. Arpana Iyengar, St John’s Medical College, Bangalore Member

Dr. Vijay Kher, Medanta, Gurgaon Member

Dr. Gopesh Modi, Samarpan Noble Hospital, Bhopal Member

Dr. Swaranjeet Kaur Gill, Bathinda Member

Dr. Anant Kumar Jha, Civil Surgeon, Godda Member

Dr. Vikram Singh, Dehradun Member

Dr. Ranjeet Nair, R&R Army Hospital, New Delhi Member

Dr. Vivek Kumar, PGIMER, Chandigarh Member

Dr. Vishal Golay, Anandalok Hospital, Siliguri Member

Dr. Mukta Mantan, MAMC, New Delhi Member

Dr. Natarajan Ramakrishnan Member

Dr. Narayan Prasad, SGPGI, Lucknow Member

Dr. Ramesh Chandrababu Member Member Dr. R.K. Sharma, SGPGI, Lucknow Department of Health Research Ministry of Health and Family Welfare, Government of India Dr. George Abraham, JIPMER, Pondycherry. Member

CARDIOLOGY

Dr. S. K. Dwivedi, KGMC, Lucknow Chair

Dr. George Joseph, CMC, Vellore Co-Chair

Dr. Aditya Kapoor, SGPGI, Lucknow Member

Dr. G.Karthikeyan, AIIMS, New Delhi. Member

Dr. Paul V George, CMC Vellore Member

Dr. Santhosh Satheesh, JIPMER, Pondycherry Member

Dr. Saurabh Mehrotra, PGIMER, Chandigarh Member

Dr. Praveen Chandra, Medanta, Gurgaon Member

Dr. Amit M Vora, Reliance, Mumbai. Member

Dr. Calambur Narasinhan, CARE, Hyderabad Member

Dr. Paul V George, CMC Vellore Member

Dr. Praveen Chandra, Medanta, Gurgaon Member

Dr. Reva Tripathi, MAMC Delhi Chair

Dr. Vinita Das, KGMC, Lucknow Co-Chair

Dr. Anjoo Agarwal, KGMC, Lucknow Member

Dr. Manju Puri, LHMC, New Delhi Member

Dr. Radhika, UCMS, New Delhi Member

Dr. Neelam Aggarwal, PGIMER, Chandigarh Member

Dr. Asmita Rathore, MAMC, New Delhi. Member

Dr. Aruna Kekre, CMC, Vellore Member

Dr. Dasari Papa, JIPMER, Pondycherry Member

Dr. Usha Rani, IOG Member

Dr. Manika Khanna , NRIGS Member

Dr. Neerja Bhatla, AIIMS, New Delhi Member

Dr. Seema Saran, GMC, Badaun Member

ENT

Dr. Alok Thakar, AIIMS, Delhi Chair

Dr. Anupam Mishra, KGMC, Lucknow Co-Chair

Dr. A Ramesh, St John’s Medical College, Bangalore Member

Dr. Harpreet Kochar , Private Practice, Greater Noida Member

Col Dr. B. K. Prasad, Command Hospital, Lucknow Member

Dr. Anuja Bhargava, Ira Medical College, Lucknow Member

Dr. Prem Sagar, AIIMS Delhi Member

PULMONOLOGY

Dr. Surinder Jindal, PGIMER, Chandigarh Chair

Dr. G.C. Khilnani, AIIMS, New Delhi. Co-Chair

Dr. Ashutosh Aggarwal, PGIMER, Chandigarh Member

Dr. Anant Mohan, AIIMS, New Delhi Member

Dr. Raj Kumar, VPCI, Delhi Member

Dr. Alok Nath, SGPGI, Lucknow Member

Dr. Dhruv Chaudhary, PGIMS, Rohtak Member

Dr. Uma Mohan, St John’s Medical College, Bengalluru Member

Dr. DJ Christopher, CMC, Vellore Member

Dr. Deepak Talwar, Metro Hospital, Noida Member

PSYCHIATRY

Dr. BN Gangadhar, Director, NIMHANS Member Dr. Pratap Sharan, AIIMS, New Delihi. Co-Chair Department of Health Research Ministry of Health and Family Welfare, Government of India Dr. Jagadisha Thirthalli, NIMHANS, Bengaluru Member

Dr. Subho Chakrabarti, PGIMER, Chandigarh Member

Dr. Prabha Chandra, NIMHANS, Bengaluru Member

Dr. Janardhan Reddy, NIMHANS, Bengaluru Member

Dr. Anju Dhawan, AIIMS, New Delhi Member

Dr. Satish Girimaji, NIMHANS, Bangalore Member

Dr. L Vijayakumar, Sneha, Chennai Member

Dr. KS Jacob, CMC, Vellore Member

Dr. Rajesh Sagar, AIIMS, New Delhi. Member

ADMINISTRATIVE SUPPORT Mr. V. K. Gauba, Jt. Secretary, Dept. of Health Research, MoHFW, Govt. of India

Mrs. Anu Nagar, Jt. Secretary, Dept. of Health Research, MoHFW, Govt. of India

Dr. Reeta Rasaily, Scientist G, ICMR, New Delhi

Dr. Ashoo Grover, Scientist F, ICMR, New Delhi

Dr. Kavitha Rajshekhar, Scientist E, ICMR, New Delhi

STW SECRETARIAT

Dr. Deepika Saraf, Scientist E & Team Lead, ICMR, New Delhi

Dr. JerinJose Cherian, Scientist D, ICMR, New Delhi

Dr. Ashis John, Scientist, C, ICMR, New Delhi

Dr. Deeksha Elwadhi, Scientist, C, ICMR, New Delhi

Mr. Parth Garg, Graphic Designer, ICMR, New Delhi

Ms. Anika Gupta, Graphic Designer, ICMR, New Delhi Ms. Surabhi Singh, Graphic Designer, ICMR, New Delhi Ms. Sugandha Singh, Graphic Designer, ICMR, New Delhi Er. Amitesh Kumar Sharma, Scientist B, ICMR, New Delhi Mr. Sandeep Suman, Logistics Support, ICMR, New Delhi Department of Health Research Ministry of Health and Family Welfare, Government of India

STANDARD TREATMENT WORKFLOWS

PARTNERS

2019 EDITION

VOLUME I