Management Protocol for suspected cases of Chikungunya

Transcription

1 Management Protocol for suspected cases of Chikungunya Prepared jointly by IMA Kerala State & Government epidemic Cell I. Medical Management First contact with the doctor Case definition Classification of cases Need for referral Acute cases Fever persisting with arthralgia / Fever screened by the doctor with arthralgia/arthritis/rashes Suspected case - sudden onset with fever and arthralgia Confirmed case - same as suspected with IgM ELISA +ve.(in case of outbreaks 5-10% of cases need be confirmed by the laboratory) Acute less than 7 days Sub acute more than 7-14 days Chronic - more than 14 days Haemodynamic instability Altered sensorium Bleeding manifestation Persistent vomiting Oliguria / Anuria / jaundice / any other organ dysfunction Fever persisting for more than 7 days 3rd trimester pregnancy Fever beyond 3 days with Extremes of age o co-morbidities o first and second trimester pregnancies Fever - complete rest Paracetamol - 2 to 3 g/24 hours x 3 days + adequate hydration Paracetamol injection preferably to be avoided Movement and mild exercise during pain free period to improve stiffness Avoid heavy exercise Avoid Aspirin Routine use of Steroids may be avoided Note: though a potent anti-inflammatory drug steroid, can not be given for mass treatment because of major side effects and chance of misuse Give NSAIDS 1

2 arthritis Other NSAIDS indicated in cases where there is pain not responding to Paracetamol NSAIDS to be selected judiciously depending on patients tolerance, availability and cost factors. Drugs used Indomethacin mg tid Naproxin mg tid Mefenamic acid mg tid Ibuprofen mg tid Diclofenac 50 mg tid Aceclofenac 100mg BD Etoricoxib mg OD Duration of treatment depends upon Decrease in arthralgia / arthritis the clinical response Fever subsides During the course of treatment, evaluate the patient clinically and look for complications. Alternative to NSAIDS- H2 blockers / proton pump inhibitors In pregnancy First Trimester Third Trimester Tramadol mg 4-6 hourly maximum 400mg /day Hydroxy Chloroquin 200mg once daily is preferred in prolonged arthralgia / arthritis cases (theoretically it has less chance of retinal damage when compared to Chloroquin). Gastro protective agents to be used with NSAIDS. Pantoprazole Omeprazole Rabiprazole Commonly used drugs are; Paracetamol Mefenamic acid Risk of miscarriage, but no malformations documented Fetal distress and pre-mature labour NSAIDS may be avoided Atypical presentations Fever with thrombocytopenia - not very severe as in dengue 2. Dermatological Manifestations and Management in Chikungunya Dermatitis involving seborrhoeic areas of the body Pruritus Erythematous Rashes of Body/Limbs Scrotal Dermatitis / Scrotal ulcers Lichenified tender lesions involving legs Central part of face with hyper pigmentation V areas of Body Axilla and Groin Localised Generalized Macular Maculo papular 2

3 Central part of face with hyper pigmentation Zinc Oxide cream Pruritis Antihistamines. Erythematous rashes of body / limbs Scrotal ulcers If symptomatic Lotiocalamine locally and Oral Antihistamines Cleansing measures Saline compress Topical antibiotics Systemic antibiotics, if necessary esp. Broad Spectrum Antibiotics. 3. Musculoskeletal manifestations and Management Arthropathy Enthesopathy/ Tendinitis Functional & Ambulation Limitations - Ankle and Foot, Knee, Spine, Wrist, Shoulder, Phalanges, - Tendo Achilles, Hamstrings, Evertors of foot, Extensor Pollicis Brevis & Abductor Pollicis Longus, Rotator Cuff. Bathing, Grooming & Dressing were the most common Activities Daily Living (ADL) affected Washing clothes & Grinding masala were the most common Instrumental Activities Daily Living (IADL) affected Average workday lost days, range from 2 wks 60 days Proposed functional classification (after one month of following fever) Grade I Grade II Grade III Active Mobile Independent Management Strategies Not active Mobile Independent 3 Dependent for ADLs Bedridden. Grade I Grade II Grade III Paracetamol Analgesics Ice/Cold compress 5 min BD to Enthesopathy region NSAIDs Cold compress Oral Steroid (short course tapering) Concomitant proton pump/h2 blockers NSAIDs Pain Killers-short term Oral steroids-short course tapering Ice for inflamed tendons Rest in sub acute period & Exercise in chronic phase Pulsed Ultra Sound Therapy (UST) if enthesitis localized Local steroid infiltration in tendon sheath

4 Monitoring of follow up of Functional & Musculoskeletal sequalae Cold Compresses Contra- indications Joint Count Total number of inflamed joints Enthesis Count Total No: of inflamed / tender tendons or ligaments ESR CRP Application of Functional Grading & Return to activity Can squat/climb step/walk without difficulty/ needs assistance Must be non-weight bearing, low repetition, slow and taken through the full range, either done actively or active assisted as tolerated? Eg:- 1. Slowly trying to touch the occiput (back of head) with the palm of your hand in the lying down position. 2. Slowly bending the knee towards the chest as tolerated. 3. Slow and ankle exercise (move up and down and clock wise) 4. Slowly trying to touch the low back with the dorsum of the hand 5. Pulley assisted exercises if shoulder and rotator cuff is involved only slow flexion exercises advised. Cloth soaked in ice cold water is applied or small ice cubes rubbed over the inflamed tendons and joints for five minutes twice daily. All standard contra indications for exercises like heart disease etc, apply All standard contra indications for steroids apply like uncontrolled diabetes reduced immunity and TB All standard contra indications for ice and apply eg: peripheral vascular disease etc. Short course steroids are used with caution only for musculo skeletal sequalae after the acute phase is over, that is more than 2 weeks since the fever has come down. 4. Neuro psychiatric problems- management guidelines 1. Functional overlay Persistent Somatoform Pain Disorder Persistent Somatoform Pain Disorder- Management guidelines Persistent, severe & distressing pain not fully explained by physical illness Never NEGLECT symptoms Therapeutic dialogue (Communication-verbal & non-verbal listening and touch, Address FEAR, emotional conflicts, psychosocial problems) 4

5 Encourage gradual re-entry into routine work 2. Adjustment disorder Subjective distress & emotional disturbance interfering with social functioning, arising in a period of adaptation to a serious physical illness -media-scare 3. Depression Mostly women Communicate essential information (stress can produce emotional and physical symptom) Emotional support, encourage return to routine Sadness of mood, lack of interest, easy fatigability, insomnia, loss of appetite, hopelessness, worthlessness, suicidal ideas lasting for more than two weeks Responds well to antidepressants 4. Insomnia Common symptom in acute phase Lasts for 2-3day to a week Management of pain and reassurance alone needed in most of the cases 5. Delirium Acute onset of confusion, clouded thinking or disorientation Children and elderly Hydration, management of fever If not responding, REFER to physician or neurologist 5