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TABLE OF CONTENTS
Page
Editorial Board . . .

. . . . . . . . . . . . . . . . .

. . . . . . . . . . .

Foreword . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

ii

Introduction . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

iii

Acknowledgment . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

iv

How to Use this Manual . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

vi

. . . . . . . . . . .

vii

Glossary of Terms . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

viii

Acronym Guide . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

xiii

Measles . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

Rubella (German Measles)

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . . . . . . . .

. . . . . . . . . . .

Disclaimer

. . . . . . . . . . . . . . . . . . . .

Common Diseases in Evacuation Centers During Disasters


Section I. Viral Exanthems

Varicella

Section II. Respiratory Diseases


Upper Respiratory Tract Infection (Common Colds and Cough) .

. . . . . . . . .

. . . . . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . . . . . . . .

. . . . . . . . . . .

Pneumonia - Adult . . . . . . . . . . . . . .

. . . . . . . . . . .

Pneumonia - Pedia . . . . . . . . . . . . . .

. . . . . . . . . . .

Bronchial Asthma
Influenza

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Section III. Systemic Diseases


Dengue . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

Leptospirosis . . . . . . . . . . . . . . . .

. . . . . . . . . . .

10

Malaria . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

11

Mumps . . . . . . . . . . . . . . . . . .

. . . . . . . . . . .

12

. . . . . . . . .

. . . . . . . . . . .

13

. . . . . . . . . . . . . . .

. . . . . . . . . . .

14

. . . . . . . . . . . . . .

. . . . . . . . . . .

15

Conjunctivitis . . . . . . . . . . . . . . . .

. . . . . . . . . . .

16

Hypertension . .

. . . . . . . . . . .

17

Section IV. Gastro-intestinal Diseases


Acute Gastroenteritis (Diarrhea)
Typhoid Fever
Viral Hepatitis A
Section V. Other Diseases

. . . . . . . . . . . . .

Skin Diseases
Contact Dermatitis . . . . . . . . . . . . .

. . . . . . . . . .

18

Tinea Corporis (Body ringworm)

. . . . . . . .

. . . . . . . . . .

19

Tinea Pedis (Athletes foot) . . . . . . . . . .

. . . . . . . . . .

20

. . . . . . . . . . .

21

. . . . . . . . . . .

. . . . . . . . . . .

22

. . . . . . . . . . . . . . . . .

. . . . . . . . . . .

23

Tinea Versicolor (Tinea Flava) . . . . . . . .


Tetanus Non-Neonatorum
Wounds

Dog/ Cat Bite . . . . . . . . . . . . . . .

. . . . . . . . . .

24

Snake Bite . . . . . . . . . . . . . . . .

. . . . . . . . . .

25

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Annexes
1a

Assessment Table for Dehydration in Acute Gastroenteritis (Diarrhea) . . . . . . . .

26

1b

Treatment Plan A & B for Acute Gastroenteritis (Diarrhea) . . . . . . . . . . . .

27

1c

Hospital Management Protocol for Acute Gastroenteritis (Diarrhea) . . . . . . . . .

28

Hospital Management Protocol for Bronchial Asthma

. . . . . . . . . . . . .

31

Hospital Management Protocol for Dengue . . . . . . . . . . . . . . . . .

34

4a

Table of Oral Anti-Hypertensive Drugs

. . . . . . . . . . . . . . . . . .

38

4b

Hospital Management Protocol for Hypertensive Emergency . . . . . . . . . . .

39

Hospital Management Protocol for Influenza

. . . . . . . . . . . . . . . .

43

6a

Hospital Management Protocol for Leptospirosis . . . . . . . . . . . . . . .

46

6b

Management of Oliguria-Anuria in Leptospiral Acute Renal Failure . . . . .

. . .

49

Hospital Management Protocol for Malaria . . . . . . . . . . . . . . . . .

51

Hospital Management Protocol for Measles . . . . . . . . . . . . . . . . .

57

Hospital Management Protocol for Mumps . . . . . . . . . . . . . . . . .

59

10

Hospital Management Protocol for Pneumonia-Adult

. . . . . . . . . . . . .

60

11a Clinical Diagnosis of Pneumonia for Specific Pediatric Age Groups . . . . . . . . .

63

11b Hospital Management Protocol for Pneumonia-Pedia

64

. . . . . . . . . . . . .

12

Hospital Management Protocol for Rubella (German Measles)

. . . . . . . . . .

67

13

Hospital Management Protocol for Snakebite

. . . . . . . . . . . . . . . .

68

14

Hospital Management Protocol for Tetanus Non-Neonatorum . . . . . . . . . . .

71

15

Hospital Management Protocol for Typhoid Fever . . . . . . . . . . . . . . .

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16

Hospital Management Protocol for Varicella

. . . . . . . . . . . . . . . .

79

17

Hospital Management Protocol for Viral Hepatitis A . . . . . . . . . . . . . .

81

18a Local Wound Management

. . . . . . . . . . . . . . . . . . . . . .

84

18b Management Protocol for Dog/ Cat bite . . . . . . . . . . . . . . . . . .

86

19

Management Protocol of Shock . . . . . . . . . . . . . . . . . . . . .

92

20

Management Protocol for Cardiopulmonary Resuscitation (CPR) . . . . . . . . . .

93

21

Immunization Schedule for Children

. . . . . . . . . . . . . . . . . . .

94

22

Immunization Schedule for Adults . . . . . . . . . . . . . . . . . . . .

95

Bibliography

. . . . . . . . . . . . . . . . . .

. .

. . . . . . . . .

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EDITORIAL BOARD
CHAIRPERSON
CARMENCITA A. BANATIN, MD, MHA
Director III
Health Emergency Management Staff
Department of Health

MEMBERS
JOSE BENITO R. VILLARAMA, MD, MPH
Chief Medical Professional Staff
San Lazaro Hospital
EUMELIA P. SALVA, MD, DTMH, MPH, FPSMID
Head, Public Health Service
San Lazaro Hospital
EFREN M. DIMAANO, MD, FPSMID
Head, Clinical Division
San Lazaro Hospital
FERDINAND S. DE GUZMAN, MD, FPSVi
Head, Family Medicine Infectious Disease
& Tropical Medicine Department
San Lazaro Hospital
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INTRODUCTION
One of the risks brought about by health emergencies and disasters is the occurrence of diseases, communicable and non communicable. The
synergism between poor environmental sanitation, delayed medical services, and inadequate resources including food and water can give rise to
diseases with epidemic potential and other opportunistic infections. Records review revealed that there are diseases that commonly affect the
population at the evacuation centers and at the disaster site.
Immediate and definitive treatment and management of diseases during emergencies and disasters is a norm in order to prevent outbreak and
possible episodes of debilitation among the sick and the injured. The Department of Health has developed several treatment protocols for
specific diseases, especially to those who have its corresponding program like Dengue, Diarrhea, Acute Respiratory Infection and others.
Predicament lies in those diseases that do not have an attached program.
Experiences at the evacuation centers revealed that many of the health personnel had difficulty in extending immediate management in some of
the diseases and they clamor for treatment protocols that are presented in flow chart algorithm that are easily accessible and can be effortlessly
followed.
This Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments during Emergencies and Disasters was
conceptualized in order to address the need of the health responders in managing diseases that commonly exist at the community level, at the
impact site, evacuation centers and during transport to a health facility.
The Health Emergency Management Staff through the financial assistance from the World Health Organization has commissioned the
San Lazaro Hospital Medical Staff Association, Incorporated to develop a treatment protocol of the common diseases that exist at the above
mentioned sites. The development process entails consultation with the different medical societies and specialty hospitals that caters to specific
diseases. Comprehensibility test was also administered to the end user to ensure that the manual will cater to the needs of the target user.
It is with great confidence that this manual will enable the health responders in giving immediate and definite care and management to their
patient in order to alleviate their illness and their health needs during the times they need it most.

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ACKNOWLEDGMENT
The Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments during Emergencies and Disasters is
made possible and available to the Medical Community in the Philippines because of the support and participation of the different organizations,
institutions, hospitals and committees.
The Health Emergency Management Staff would like to thank the following:
For contributing their technical expertise, our gratitude to Dr. Dominga Padilla-Lopez, Philippine Academy of Ophthalmology, Inc.; Dr. Maria
Nanette A. Pamatian, Philippine Academy of Family Physicians, Inc.; Dr. Ma. Encarnita B. Limpin, Philippine College of Physicians;
Dr. Epifania S. Simbul, Philippine Pediatric Society; Dr. Lita C. Vizconde, Philippine Society for Microbiology and Infectious Diseases; Dr.
Susan C. Lee, San Lazaro Hospital; Dr. Albert G. Lu, San Lazaro Hospital; Dr. Jerome Laceda, San Lazaro Hospital; Dr. Rosario Jessica T.
Abrenica, San Lazaro Hospital; Dr. Lester A. Deniega, University of Santo Tomas Hospital; Dr. Emmanuel F. Montaa, Jr., Jose R. Reyes
Memorial Medical Center; Dr. Joseph T. Juico, Jose R. Reyes Memorial Medical Center; Dr. Cecilia C. Dizon, National Childrens Hospital;
Dr. Mary Antonnette C. Madrid, Philippine Childrens Medical Center; Dr. Regina Berba, Philippine General Hospital; Dr. Beatriz P.
Quiambao, Research Institute for Tropical Medicine; Dr. Gerard Belimac, NCDPC-DOH; Dr. Eric A. Tayag, NEC-DOH; Mr. Noel T. Orosco,
NEC-DOH and Dr. Marilyn Go, DOH-HEMS.
For their untiring assistance during the conduct of the comprehensibility assessment, we would like to extend our deep gratitude to Director
Nestor Santiago, Dr. Virgilio Ludovice, Dr. Juancho Torres, Dr. Alan Lucaas, Dr. Aurora M. Daluro and Mr. Camilo H. Aquino of the Center
for Health Development V.
For their active participation through the comments and suggestions given during the focus group discussion during the pre-testing, we would
like to give our gratitude to Dr. Anna Lynda Bellen, ICP Consultant and Ms. Rosario G. Coralde, Nurse IV of BRTTH; Mr. Noel B. Pitapit and
Ms. Emerly D. Ostonuse, Nurses of JBDMDH; Dr. Shiela M. Cao, Municipal Officer III of ZMNH, Tabaco City; Dr. Ma. Crispa L. Florece,
MHO, Ms. Gisela Buiza, PHN and Ms. Arlyn S. Obispo, RHM of Camalig-RHU; Ms. Dolores T. Adornado, PHN and Ms. Mardi G. Aragon,
RHM of Daraga-RHU; Dr. Joann M. Limos, MHO, Ms. Gloria P. Oringo, PHN and Ms. Hospicia P. Morta, RHM of Guinobatan-RHU;
Dr. Rosa Maria B. Rempillo, MHO and Ms. Rosemarie M. Nacion, Nurse II of Sto. Domingo-RHU.
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The manual would not have reached its realization if not for the prudence and indefatigable efforts of the officers and members of the San
Lazaro Hospital Medical Staff Association Incorporated namely Dr. Jose Benito R. Villarama, Chief of Clinics; Dr. Eumelia P. Salva, Head,
Public Health Service; Dr. Efren M. Dimaano, Head, Clinical Division; Dr. Ferdinand S. de Guzman, President, SLH-MSA, Inc. and Dr. Alexis
Q. Dimapilis, SLH-HEMS Coordinator that comprises the Core Group.
Indebtedness is likewise given to the members of the Technical Group from the different Medical Department of San Lazaro Hospital namely
the Adult Infectious Disease and Tropical Medicine composed of Dr. Emilio S. Pandong Team Coordinator, Dr. Ma. Luisa Nallica; Family
Medicine Infectious Disease and Tropical Medicine composed of Dr. Shane D. Marte Team Coordinator, Dr. Harold A. Sosa, Dr. Ricardo H.
Tandingan, Jr., Dr. Sharonda G. Abriam and the Pediatrics Infectious Disease and Tropical Medicine composed of Dr. Ethel C. Dao Team
Coordinator, Dr. Philip A. Morales, Dr. Farah Josefa Nerves, and Dr. Marco Ferdinand W. Torres.
And last but not the least, we are commending the invaluable patience of the secretarial staff Ms. Ma. Lourdes Carina D. Lacuata and
Ms. Delma R. Eliserio.
Special gratitude is given to Ms. Susana G. Juangco, who had generously shared her time and effort in finalizing this manual.
Finally, our indebtedness to the World Health Organization, Philippines (WHO) for providing the financial assistance in the development and
production of this Manual of Treatment Protocol.

HEALTH EMERGENCY MANAGEMENT STAFF

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HOW TO USE THE MANUAL


The Manual on Treatment Protocols of Common Communicable Diseases and Other Ailments during Emergencies and Disasters covers
a wide range of illnesses frequently encountered by health worker/s during emergencies and disasters. This guidebook consist of management
algorithms which illustrate general signs and symptoms (green box) of a specific disease for easy detection, trailed by local measures (blue
box) that can be done in evacuation areas, warning signs (yellow box) of said diseases, and the corresponding emergency measures (blue box)
that can be performed before or during transport of patient to the hospital. It also contains hospital management protocols to guide health
worker/s in the hospital where the patient is referred.
A format known as the management flow-chart algorithm is used in presenting this manual. It is constructed in such a way that clinical
manifestations (general signs and symptoms/ warning signs) are shown as top boxes and the courses of action (local measures/ emergency
measures) in bottom boxes. It is hoped that health worker/s will find the flow chart easy to follow and understand.
The broad orange arrow pointing to the right warns health worker/s on worsening condition of the patient that warrants referral to the hospital
or medical specialists (red box). The broad orange curved line connecting the top box to the bottom box defines the appropriate courses of
action to be undertaken by the health worker/s.
The Acronym Guide provides the list of abbreviations while the Glossary of Terms defines the medical terminologies used in this manual to
assist health worker/s in easily understanding its contents.
Annexes in the guidebook include further details that are too lengthy to be contained in the box/es and management of patient in a hospital setup. These are vital to the algorithm to expand details and clarify the courses of action (treatment guidelines).

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DISCLAIMER
The Manual contains management guidelines which is authored and approved for publication by various medical organizations and institutions.
Thus, the treatment protocols published herein represent the collective knowledge, experience and skills of participating medical practitioners as
well as latest consensus guidelines. Although every effort has been made in compiling and checking the information contained in this guidebook
to ensure that they are accurate and valid up to the time of publishing, there is no absolute claim or certainty for this treatment guidelines to work
and/or be effective at all times.
This manual is intended to guide health worker/s (physicians, nurses and midwives under the supervision of physicians) in evacuation
areas/centers and hospitals in an emergency or disaster setting where urgency is the key. The inclusion or exclusion of any medical procedure
does not mean to advocate or reject its use either generally or in any particular field of circumstances. Thus, the management guidelines should
not be regarded as absolute rules since nuances and peculiarities in individual cases or particular disaster areas may entail differences in the
specific approach. In the end, the recommendations should supplement, and not replace sound clinical judgment.

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GLOSSARY OF TERMS
ammonia - a nitrogenous waste product of protein/amino acids breakdown
anaphylaxis - exaggerated allergic reaction to a foreign protein resulting from previous exposure to it
ancillary - supplementary test
antihistamine - a drug that neutralize/ inhibit the effect of histamine in the body, used in the treatment of allergic disorders
antiseptic solution - antimicrobial substance that are apply in the skin and living tissues to reduce the occurrence of infections
anti-toxin - a substance formed in the body that counteracts a specific toxin or antibody formed in immunization with a given toxin,
used in treating or immunizing against infectious diseases
anti-venin - an antitoxic serum obtained from the blood of an animal following repeated injections of venom
anuria - urine output less than 100 ml/day
aspiration - the act of inhaling fluid or a foreign body into the bronchi and lungs, often after vomiting
atri- ventricular block - a disorder in conduction in which the sino-atrial impulse are not conducted to the heart ventricle
avulsion - complete or incomplete tearing of body parts
body mass index - a measure of body fat based on height and weight
bolus - large dose of drug given IV for the purpose of rapidly achieving the needed therapeutic concentration in blood stream
booster dose (booster shot) - a dose of an immunizing substance given to maintain or enhance the effect of a previous one
bradycardia - heart rate below60 beats per minute
bronchodilator - a substance that dilate constricted bronchial tubes to aid breathing, used especially for relief of asthma
calf muscle - muscular structure at the posterior aspect of the leg
carcass - the dead body of an animal
catecholamine - any of a group of chemically related neurotransmitters such as epinephrine and dopamine, that have similar effects on
the sympathetic nervous system
cerebral edema - swelling of the brain
central venous pressure - venous pressure as measured at the right atrium
chemoprophylaxis - prevention of disease by means of chemical agents or drugs or food nutrients
chest in-drawing (retraction) - a definite inward motion of the lower chest wall on breathing in
cholestyramine - ion-bonding resin that form insoluble complex with bile acid
clotting factors - plasma proteins involved in blood coagulation
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coagulopathy - a condition characterized by abnormality in blood clotting


co-morbid illness - co-existing illness
complement fixation - demonstration of specific antibody based on fixing of known quantity of complement to the antigen the
binding of complement to immune complexes or to certain foreign surfaces, as those of invading microorganisms
crackles - short, sharp or rough sounds heard with a stethoscope over the chest, most often heard in pleurisy with fibrinous exudates
cryoprecipitate blood component - rich in factor VIII and fibrinogen
cyanosis - bluish coloration of the skin, mucous membranes, and nail-beds, resulting from a lack of oxygenated hemoglobin in the blood
defervescence - period of abatement of fever
dehydration - an abnormal loss of water from the body, especially from illness or physical exertion
desensitization - the elimination or reduction of natural or acquired reactivity or sensitivity to an external stimulus, as an allergen.
diastolic pressure - arterial pressure during myocardial relaxation
disseminated intravascular coagulation - a hemorrhagic syndrome that occurs following uncontrolled activation of clotting factors
and fibrinolytic enzymes
down syndrome - chromosomal dysgenesis caused by translocation of chromosome 21
droplet transmission - contact involving conjunctivae or mucous membranes of the nose or mouth of a susceptible person with large
droplet (larger than 5 um in size) particle containing microorganisms
dyslipidemia - abnormal level of lipid & lipoprotein in the blood
dysphonia - difficulty in voice production due to laryngeal/ pharyngeal diseases or anatomical abnormality
eclampsia - a form of toxemia of pregnancy, characterized by albuminuria, hypertension, and convulsions
electrolyte - any inorganic compounds (sodium, potassium, magnesium, calcium, chloride, and bicarbonate), that dissociate in biological
fluids as ions capable of conducting electrical currents that constitute a major force in controlling fluid balance in the body
endemicity - presence of the disease in a particular geographic area, prevailing continually in an area
envenomation - injection of poisonous material (venom) by an animal bite
epiphora - overflow of tears due to obstruction of lacrimal duct
exudates - fluid with high content of protein and cellular debris which has escaped from blood vessel as a result of inflammation
fluorescent antibody technique (rabies) - immuno-staining assay using fluorescein-labeled marker coupled with anti-immunoglobulin
hemagglutination - inhibition-test to detect the amount of specific antigen in the blood/serum
hematocrit - percentage of the volume of a blood sample occupied by cell
hematuria - presence of blood cell and blood in urine
hemoculture - blood culture
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hemoglobinopathy - a genetic defect resulting in abnormal structure of one of the globin chains of the hemoglobin molecule
hemolysis - liberation and separation of hemoglobin from the red cells and its appearance in the plasma
hepatic encephalopathy - complication of liver failure resulting from accumulation of toxic substances
high caloric diet - food having high energy producing value
homeostasis - state of balance in the body with respect to various function and chemical composition of the fluid and tissues
hydration - fluid treatment/ replacement
hypertensive encephalopathy - transient neurologic symptoms associated with severe elevation in blood pressure
hyperventilate - to breathe rapidly & deeply
ICT/Opti-Mal-ParaSight F, ICT-Malaria Pf, OptiMAL - dipstick antigen tests useful in confirming malarial infection (P. falcifarum)
incubation period - development of disease from the time of exposure to development of clinical signs and symptoms
isotonic solution - same salt concentration as in normal cell and blood
jaundice - yellowish discoloration of skin & mucus membrane
kawasaki syndrome - an acute illness of unknown cause, occurring primarily in children, characterized by high fever, swollen lymph
glands, rash, redness in mouth and throat, and joint pain
koplik spots - small, white spots (often on a reddened background) occuring on the inside of the cheeks early in the course of measles
Kulantro (Tag.); uan-suy (Tag.); coriander (Engl.) - medicinal plant use for various ailments like erythema and colic
loss of skin turgor - persistence of skin fold in the skin after pinching with the thumb and index finger
malaise - a vague feeling of discomfort
malignancy - neoplastic growth having the properties to be locally invasive and able to metastasize
malnutrition - condition caused by improper nutrition or insufficient diet
mean arterial pressure - mean pressure during the entire cardiac cycle
measles IgM - antibody assay for acute measles
metabolic acidosis - a disturbance in which acid-base status shifts toward acidic body condition because of loss of base or retention of
non-carbonic or fixed acids
metabolic encephalopathy - temporary or permanent damage to brain that occurs when body metabolic process is seriously impaired
microscopic agglutination test (MAT) - gold standard serological assay for leptospirosis antibody detection using 23 leptospire antigens
myalgia - muscle pain
myocardial ischemia - tissue hypoperfusion due to obstruction of inflow of arterial blood in the heart
myoglobinuria - presence of myoglobin in urine
myotoxic - destructive to muscle tissue
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nasal prong - tubular plastic with a prong used in the delivery of oxygen
nasogastric - intubation of stomach by way of nasal passage
neurotoxic - poisonous to nervous system
non-neonatal - refers to more than 28 days old infants
oliguria - urine output less than 400 cc/24 hours
otitis media - inflammation of the middle ear
papule - small circumscribed solid elevation in the skin
parasitemia - presence of parasite (malaria)in the blood
parenteral - intravenous injection
paresis - weakness
passive immunization - transfer of preformed antibody to non-immuned individuals
peak expiratory flow rate - measurement tool to assess the severity of asthma and response to treatment
period of onset - the time when the first symtom manifested
petechiae - raised < 3 mm in diameter lesion due to inflammation of vessel wall with subsequent hemorrhage
portal hypertension - hypertension of portal system due to venous obstruction/ occlusion causing splenomegaly
post-auricular lymph node - circumscribed swelling at the back of the ear
preeclampsia - a form of toxemia of pregnancy, characterized by hypertension, fluid retention, and albuminuria, sometimes
progressing to eclampsia
pressure bandage - elastic bandage or any cloth use to immobilize the bitten limb as in snake bite
primigravid - first pregnancy
pro re nata (prn) - as needed
pruritus - itchiness
pulsus paradoxus - an exaggerated drop (> 10mm Hg) in the systolic arterial blood pressure upon inspiration wherein the drop is
larger than the decrease that normally occurs upon inspiration
pyrethroid - any of various synthetic compounds that are related to the pyrethrins that contain insecticidal properties
rabid - suffering from rabies
rhonhi - snoring sound when airway channels are partly obstructed
rose spot - erythematous maculo-papular rash on the trunk
salmonella EIA - immunoassay for the diagnosis of Typhoid Fever using monoclonal antibody
sardonic smile - sustained contraction of facial muscle
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seizure - transient disturbance of brain function that maybe manifested as episodic impairment or loss of consciousness, abnormal motor
and sensory phenomena
sensorium - ability of the brain to receive and interpret sensory stimuli
serum sickness - hypersensitivity response to the injection of anti-serum caused by formation of soluble immune complex
soluset - a tubular plastic calibrated devise used as a second infuser in the administration of intravenous medications
stage I hypertension - based on BP reading > 140 159 SBP, DBP> 90 99 mmHg
stage II hypertension - based on BP reading > 160 SBP, DBP > 100 mmHg
standard precautions - used to reduce the risk of transmission of microorganisms for both recognized and unrecognized sources of
infection in the hospitals
stat - without delay
stridor - a high-pitched, noisy respiration denoting respiratory obstruction, especially in the trachea or larynx
subcutaneous - injection of drug into fatty tissue (below dermis & epidermis)
sub-lingual - administration of drug under the tongue
sub-occupital - located below the occiput
sympathetic crisis - excess level of cathecolamines
systolic pressure - maximum arterial pressure during cardio/ myocardial contraction
tongue guard - flat thin wooden instrument use to protect tongue
torniquet test - a procedure to test capillary fragility by inflating a BP cuff placed above the ante-cubital area for five minutes at mean
blood pressure (obtained by getting the systolic blood pressure plus diastolic blood pressure divided by two). The test is positive
if there are more than 20 petechiae (a small red or purple spot in the body) per square inch
Trendelenburg position - a supine position in which the pelvis is higher than the head
tubex TF - rapid diagnostic test for Typhoid Fever that detects O9 antigen of Salmonella typhi
vasculotoxic - destructive to blood vessels
venom - poisonous fluid secreted by snake
viper - venomous (poisonous) snake belonging to species Vipera
wheezes - continuous whistling sounds produced in narrowed or obstructive airways

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ACRONYM GUIDE
ABC
ABG
AIDS
ALT
ANST
antiHAV IgM
(A)PTT
AST
ATS
BUN
BID
BP
bpm
BT
o
C
CAD
CAP
CBC
cc
CDD
COPD
CP
CPR
CPK
CQ+SP
CR
CSF

.....
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. .......
.....
....
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....
.....
.....
.....
.....
.....
.....
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.....
.....
.....
.....
.....
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.....
.....
.....
.....
.....
.....
.....

Airway Breathing Circulation


Arterial Blood Gas
Acquired Immunodeficiency Syndrome
Alanine Aminotransferase
After Negative Skin Test
anti-Hepatitis A Immunoglobulin M
(Activated) Partial Thromboplastin Time
Aspartate Aminotransferase
Anti-Tetanus Serum
Blood Urea Nitrogen
twice a day
Blood Pressure
breaths per minute
Bleeding Time
degrees Celcius
Coronary Artery Disease
Community Acquired Pneumonia
Complete Blood Count
cubic centimeter
Control of Diarrheal Diseases
Chronic Obstructive Pulmonary Disease
Cardio-pulmonary
Cardio-Pulmonary Resuscitation
Creatinine Phosphokinase
Chloroquine + Sulfadoxine + Phyrimethamine
Cardiac Rate
Cerebrospinal Fluid
xiii

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CT
cv
CVP
CXR
dl
DM
DPT
D5 W
D5LRS
D5IMB / D5NM
D5 0.3% NaCl
D5 0.9% NaCl
EIA
ff
FFP
FWB
gm
HBsAg
Hct
Hib
hr/ hrs
HTN
I.U.
ICU
IFAT
Ig M
IM
IV
IVP
IVT

.....
.....
. .......
. ...
. .......
.....
.....
. .......
.
.
. ...
.
. ...
. ...
.....
.
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....

Clotting Time
cardio-vascular
Central Venous Pressure
Chest X-ray
deciliter
Diabetes Mellitus
Diphtheria, Pertussis, Tetanus
5% Dextrose in Water
Dextrose in lactated ringers solution
Balance Multiple Maintenance Solution with Dextrose
Dextrose in 0.3% Sodium Chloride
Dextrose in 0.9% Sodium Chloride
Enzyme Immunoassay
following
Fresh Frozen Plasma
Fresh Whole Blood
gram
Hepatitis B antigen
Hematocrit
Hemophilus influenza type B
hour/ hours
Hypertension
International Units
Intensive Care Unit
Immune Fluorescent Antibody Test
Immunoglobulin M
Intramuscular
Intravenous
Intravenous Push
Intravenous Therapy/Transfusion
xiv

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JVP
K+
KBW
kg
KVO
LBM
LD
LR
max
MD
mg
min
mkBW
mkd
mkD
ml
mos
MMR
MU
Na +
NGT
NSS
NT
O2
OB
OD
ORS
Pa02
PaC02
po

.....
.....
.....
.....
.....
. .......
.....
.....
.....
.....
.....
. .......
.....
.....
.....
.....
.....
.....
.....
.........
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....

Jugular Venous Pressure


potassium
Kilogram Body Weight
kilogram
Keep Vein Open
Loose Bowel Movement
Loading Dose
Lactated Ringers
maximum
Maintenance Dose
milligram
minute/s
milligram per kilogram body weight
milligram per kilo gram body weight per dose
milligram per kilo gram body weight per day
milliliter
month/s
Measles, Mumps, Rubella
Million Units
sodium
Nasogastric Tube
Normal Saline Solution
Nose and Throat
Oxygen
Obstetrician
once a day
Oral Rehydrating Solution
partial arterial oxygen tension
partial arterial carbon dioxide tension
per orem
xv

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PEFR
PEP
PET
Plain LR
Plain NSS
prn
PT
q
QID
RBC
RFFIT
RIG
RR
SC
sec
To
TB
TID
TIG
TMP
TPA/G
Tsp
TT
TU
U
UDV
ug
URTI
y/o

.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
.....
. .......
.....
.....
.....
.....
.....
. .......
. .......
.....
.....
.....
.....
.....
.....
.....

Peak Expiratory Flow Rate


Post-Exposure Prophylaxis
Post-Exposure Treatment
Lactated Ringers Solution
Normal Saline Solution
as needed
Prothrombin Time
every
four times a day
Red Blood Cell(s)
Rapid Fluorescent Flocculation Inhibition Test
Rabies Immuneglobulin
Respiratory Rate
subcutaneous
second/s
temperature
Total Bilirubin
three times a day
Tetanus Immune Globulin (human)
Trimethoprim
Total Protein Albumin/Globulin
teaspoon
Tetanus Toxoid
Thousand Units
Units
unit dose vial
microgram
Upper Respiratory Tract Infection
years old

xvi

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SECTION I
VIRAL EXANTHEMS
MEASLES
RUBELLA (GERMAN MEASLES)
VARICELLA (CHICKEN POX)

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MEASLES
General Signs & Symptoms
Fever
Maculopapular rash
(starts from face spreads
to body and extremities)
3 Cs (cough, colds,
conjunctivitis)
May have Koplik spots
on the buccal mucosa

Warning Signs
Tachypnea and/or difficulty of
breathing
Seizure or changes in sensorium
Dehydration
Immunocompromised status
(malignancy, AIDS, Asthma,
Downs syndrome),
Grossly malnourish
History of coriander (kulantro,
uan-suy) intake or inappropriate
application

Local Measures

Emergency Measures

Isolate patient
Give Paracetamol (10-15 mkd)
for fever
Give Vitamin A* as follows:
>12 mos: 200,000 units
6-12 mos:100,000 units
Repeat dose next day and 4
weeks after for patients with
ophthalmologic evidence of
Vitamin A deficiency
Do measles IgM determination
(c/o NEC)
Observe for warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest (see annex 20)
Start IV line [Plain LR/Plain NSS if
with shock (see annex 1c);D5 0.3% NaCl
(<12 y/o); D5 NM (>12y/o)]
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
and cyanosis
Give Salbutamol inhalation (2 puffs)
or nebulization (1/2-1 neb) q 20 min for
wheezes until arrival at the hospital
Give Diazepam (0.2-0.4 mkd, max
10mg) for seizure
Refer to hospital with referral note

For Hospital
Management
(see annex 8)

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RUBELLA (GERMAN MEASLES)


General Signs & Symptoms

Fever
Malaise/ anorexia
Maculopapular rash
Swelling of lymph nodes
on sub-occipital and
post-auricular area

Local Measures
Isolate patient
Give Paracetamol
(10-15 mkd) for fever
Do Measles IgM
determination (c/o NEC)
Observe for warning signs

Warning Signs
Seizure or changes in
sensorium (encephalitis)
Immunocompromised/
special conditions
malignancy/ AIDS/
Diabetes / chronic
debilititating diseases
Pregnancy

Emergency Measures
Assess ABC and monitor vital
signs
Do CPR for CP arrest
(see annex 20)
Start IV line [D5 0.3% NaCl
(<12 y/o); D5NM (>12 y/o)]
Give Diazepam (0.2-0.4 mkd,
max 10mg) for seizure
Refer to hospital with referral
note

Hospital
Management
(see annex 12)

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VARICELLA (CHICKEN POX)


General Signs & Symptoms
Fever
Generalized papulovesicular eruption (starts
from trunk and face then
spreads to the extremities)

Warning Signs
Seizure or changes in sensorium
Difficulty of breathing
Bleeding from any site including
skin
Immunocompromised/
special conditions
malignancy/ AIDS/ Diabetes/
chronic debilititating diseases
Pregnancy/ newborns/
persons > 50 y/o

Local Measures

Emergency Measures

Strict isolation precaution


Give Paracetamol (10-15 mkd)
for fever. Do not give Aspirin
May give anti-viral (see annex for
indications)
Give Cloxacillin (50-100 mkD) for
7 days for secondary bacterial
skin infections
Give Diphenhydramine (1 mkd)
for pruritus
Advise personal hygiene
Observe for warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest (see annex 20)
Start IV line [D5 0.3% NaCl (<12 y/o);
D5NM (>12y/o)]
Give O2 (2-4L/min by nasal prong)
inhalation for difficulty of breathing
and cyanosis
Give Salbutamol inhalation (2 puffs)
or nebulization (1 neb) q 20 min for
wheezes until arrival at the hospital
Give Diazepam (0.2-0.4mkd, max
10mg) for seizure
Refer to hospital with referral note

For Hospital
Management
(see annex 16)

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SECTION II
RESPIRATORY DISEASES
UPPER RESPIRATORY TRACT INFECTION
(COMMON COLDS AND COUGH)

BRONCHIAL ASTHMA
INFLUENZA
PNEUMONIA - ADULT
PNEUMONIA - PEDIA

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UPPER RESPIRATORY TRACT INFECTIONS


(COMMON COLDS & COUGH)
General Signs & Symptoms
Cough/ colds
With any of the following:
Fever/ headache
Cough-induced
abdominal/ chest pains
Nausea/ vomiting
Body malaise/ weakness
Sore throat
Ear/ nasal and postnasal/
eye discharge

Warning Signs
Difficulty of breathing/ chest
indrawing/ retractions/ alar
flaring/ cyanosis
Wheezing/ stridor w/ or w/o
drooling/ dysphonia
Poor feeding/ unable to
drink
Seizure/ decrease level of
consciousness
Irritability/ restlessness

Local Measures

Emergency Measures

Give Paracetamol (10-15 mkd) for fever or


pain every 4 hours
Give Amoxicillin (30-50 mkd TID for 7-10
days) if symptoms persist > 10 days
May give oral Phenylpropanolamine w/ or
w/o Chlorpheniramine (syrup/drops) q 6hrs
7 y/o
12 y/o
1 tsp.
3 y/o
6 y/o
tsp.
>12 mos 2 y/o
1 ml
7 mos
12 mos. 0.75 ml
4 mos
6 mos. 0.50 ml
1 mo.
3 mos. 0.25 ml
Advise adequate fluids/ nutrition
Reassess patient after 3 days
Observe for warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest (see annex 20)
Start IV line [D5 0.3% NaCl (<12 y/o);
D5NM (>12y/o)]
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
and cyanosis
Give Salbutamol inhalation (2 puffs)
or nebulization (1 neb) q 20 min for
wheezes until arrival at the hospital
Give Diazepam (0.2-0.4mkd, max 10
mg) for seizure
Refer to hospital with referral note

See Annex for


Management of
Specific
Complications

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BRONCHIAL ASTHMA
General Signs & Symptoms
Difficulty of breathing with any of the ff:
cough and/or wheeze
chest tightness
breathlessness
gurgly chest (halak)
exertional difficulty of
breathing/ talks in sentence or
phrases/ may be agitated
Associated with any of precipitating
factors:
Exercise
Seasonal change
Exposure to allergens
(Dust, Odors, Pollens, Pets)

Warning Signs
Breathless at rest/ agitated to drowsy or
confused/ increase RR at
> 60 bpm for less than 2 mos old
> 50 bpm for 2 to 12 mos old
> 40 bpm for >12mos to 5 y/o
> 30 bpm for >5 to 13 y/o
Loud to absence of wheezes
Severe tachycardia to bradycardia at
160 bpm or < 110 bpm for 2-12 mos
120 bpm or < 90 bpm for >1-2 y/o
>110 bpm or < 60 bpm for >2 y/o
Cyanosis
History of severe asthma requiring
hospitalization
Poor response to therapy after 1 hour
treatment

Local Measures

Emergency Measures

Give Salbutamol by inhaler (2 puffs)


or nebulization (1 nebule) 3 x in 1 hr
Reassess patient, if with good
response (improved air entry) and
sustained for 4 hours, may send home
give oral/ inhaled Salbutamol
every 4-6 hours for 3-5 days
give oral Prednisone (1 mkD) for
5 days as prescribed by physician
Advise adequate fluid intake/
nutrition
Start asthma education (see annex 2)
Observe for warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest (see annex 20)
Start IV line [D5 0.3% NaCl (<12 y/o);
D5NM (>12y/o)]
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
and cyanosis
Give Salbutamol inhalation (2 puffs) or
nebulization (1 neb) q 20 min for
wheezes until arrival at the hospital
Give Hydrocortisone 10 mg/kg (max
250 mg) as IV bolus then maintain at
5-10 mkD (max 100 mg) given in 4
divided doses
Refer to hospital with referral note

For Hospital
Management
(see annex 2)

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INFLUENZA
General Signs & Symptoms

Warning Signs

Fever and chills of < 5


days duration
Body malaise/ myalgia/
headache
Plus any of the following:
Non-productive cough
Colds
Sore throat
Nausea and vomiting

Difficulty of breathing
Seizures and/ or changes in
sensorium
Poor feeding and activity
Chest pains/ irregular heart
beat
Dehydration
Immunocompromised status/
chronic debilitating illnesses
(malignancy, grossly
malnourish, elderly > 60 y/o)

Local Measures

Emergency Measures

Isolate patient
Give Paracetamol (10-15
mkd) q 4 hrs for fever,
headache, and body pains.
Do not give Aspirin.
Increase oral fluid intake
Maintain adequate nutrition
Avoid strenuous physical
activities
Observe for warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest (see annex 20)
Start IV line[D5 0.3% NaCl (<12 y/o);
D5NM (>12y/o)]
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
and cyanosis
Give Salbutamol inhalation (2 puffs)
or nebulization (1 neb) q 20 min for
wheezes until arrival at the hospital
Give Diazepam (0.2-0.4mkd, max 10
mg) for seizure
Refer to hospital with referral note

For Hospital
Management
(see annex 5)

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PNEUMONIA - ADULT
7

General Signs & Symptoms


Cough
Any abnormal vital sign:
tachypnea (RR > 20 breaths/
minutes)
tachycardia (CR > 100/
minutes)
fever (To > 37.8 C)
With at least one abnormal chest
finding:
diminished breath sounds
rhonchi
crackles
wheeze

Local Measures

Warning Signs

Worsening vital signs (RR > 30 breaths/


min, CR > 125 beats/min , T <35C or >
40C) or no improvement of condition for
3 days
Respiratory failure (RR < 12 breaths/min
or cyanosis)
Suspected aspiration
Hypotension/ altered mental state
Extra pulmonary evidence of sepsis
(bleeding/ jaundice)
Co-morbid /debilitating conditions
(diabetes mellitus, malignancies, neurologic
disease, heart diseases, on prolonged
steroid use, renal failure, COPD)
Inability to take in food or medicine
Severe malnutrition

Emergency Measures

Isolate patient and observe proper bed-spacing


Give oral antibiotic therapy

Antimicrobial Therapy for Low Risk CAP


Drugs of choice:
Amoxycillin 1 gm po q 8 hrs x 7 days
Alternative drugs:
Azithromycin 500 mg po OD x 3-5 days
Clarithromycin 500 mg po BID x 7 days
Roxithromycin 150 mg BID po or 300 mg
po OD x 7 days
Cotrimoxazole 160/800 mg po BID x 7 days

Give Salbutamol 2 mg tablet 3-4x/day for wheezing


Give Paracetamol 500 mg tablet q 4 hrs for fever
Increase oral fluid intake
Advise balanced nutrition & regular exercise
Observe for warning signs

Assess ABC and monitor vital


signs
Do CPR for CP arrest
(see annex 20)
Start IV line with D5LRS
Give O2 (2-4L/min by nasal
prong) inhalation for difficulty
of breathing and cyanosis
Place patient on moderate
high back rest
Refer to hospital with referral
note

For Hospital
Management
(see annex 10)

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PNEUMONIA - PEDIA
General Signs & Symptoms
Cough
May have fever
Rapid breathing
> 50 bpm for 2 - 12 mos old
> 40 bpm for >12mos - 5 y/o
> 30 bpm for >5 13 y/o
Any of the following abnormal
lung sounds:
Diminished breath sounds
Rhonchi (snoring sound)
Crackles (short, sharp, rough
sounds)

Warning Signs
Chest in-drawing/stridor (noisy
breathing)/wheezing in < 2 months
old/alar flaring/head lagging/
cyanosis
Rapid breathing (RR > 60 breaths/
min) for less than 2 mos old
Irritability/ restlessness
Seizure/ decreasing level of
consciousness
Poor feeding/ unable to drink
Dehydration/ persistent vomiting
Grossly malnourish
No improvement or worsening of
condition

Local Measures

Emergency Measures

Give Paracetamol (10-15 mkd) q 4 hrs


for fever
Advise adequate fluid intake and
nutrition
Give oral antibiotics:
Co-trimoxazole (TMP 5mg/kg) BID
for 5 days or
Amoxicillin (4050 mkd) TID for 5
days
Give oral Salbutamol (0.15 mkd) for
wheezes
Instruct caregiver to follow-up after 2
days and to observe for warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest
(see annex 20)
Start IV line [D5 0.3% NaCl
(<12 y/o); D5NM (>12y/o)]
Give O2 (2-4L/min by nasal prong)
inhalation for difficulty of
breathing & cyanosis
Give Salbutamol nebulization
(1 nebule) for wheezes
Give Diazepam (0.2-0.4 mkd,
max 10mg) for seizures
Refer to hospital with referral note

For Hospital
Management
(see annex 11b)

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SECTION III
SYSTEMIC DISEASES
DENGUE
LEPTOSPIROSIS
MALARIA
MUMPS

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DENGUE
General Signs & Symptoms
Fever of 2-7 days
With 2 or more of the ff:
Headache/ eyepains
Arthralgia/ myalgia/
generalized body malaise
Generalized flushing of
the skin/rash
Positive tourniquet test
( > 20 petechiae per
square inch)

Local Measures
Give Paracetamol (10-15 mkd)
for fever. Do not give Aspirin
Give ORS by mouth at
3cc/kg/hr
Assess patient daily until 3
days without fever
Request for CBC, platelet
count and monitor hct and
platelet count daily, if feasible
Observe for warning signs

Warning Signs

Spontaneous bleeding
Pallor/ cyanosis/ difficulty of breathing
Hypotension and weak pulses/ frequent
dizziness and faintings (for >5 y/o)
cold, clammy skin
Plasma leakage: cherry red lips, pleural
effusion, ascites
Restlessness/ listlessness/ seizure
Severe persistent abdominal pains/
severe tenderness
Signs of dehydration secondary to
persistent vomiting, diarrhea or poor
intake especially of fluids
Jaundice/ tea-colored urine
Platelet count of <100,000 cells/ul

Emergency Measures
Assess ABC & monitor vital signs
Do CPR for CP arrest (see annex 20)
Start IV line [Plain LR/Plain NSS if
with shock (see annex 3); D5LR if w/o
shock]
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
and cyanosis
Give Diazepam (0.2-0.4 mkd max 10
mg) for seizure
Do nasal packing for nose bleeding, or
use Epinephrine-soaked nasal pack in
severe bleeding
Refer to hospital with referral note

For Hospital
Management
(see annex 3)

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LEPTOSPIROSIS
General Signs & Symptoms

Warning Signs

Fever (TO > 38 OC) and


headache/ body malaise/
abdominal discomfort in patient
With any of the following:
Red eyes (conjunctival suffusion)
Yellow skin
Muscle tenderness/ pain
(esp. calf muscle)

Hypotension
Cold, clammy skin
Difficulty of breathing/
cyanosis
Seizure or changes in
sensorium
Decrease or no urine output
Bleeding manifestations

history of exposure to
contaminated water (flood/
ponds/sewage) or infected urine
droplets in a rat-infested areas/
farms

Emergency Measures
Assess ABC & monitor vital signs
Do CPR for CP arrest
(see annex 20)
Start IV line [Plain LR/Plain NSS
if with shock (see annex 19);
D5NSS if w/o shock]
Give O2 (2-4 L/min by nasal
prong) inhalation for difficulty of
breathing and cyanosis
Give Diazepam (0.2-0.4 mkd max.
10 mg) for seizure
Refer to hospital with referral note

For Hospital
Management
(see annex 6)

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MALARIA
General Signs & Symptoms*
Cyclical pattern of chills, fever
and sweating
Other signs as follows:
headache
generalized body weakness
abdominal pain

* strongly consider in a patient


who had recent travel/exposure
in an area endemic for malaria

Warning Signs
Changes in sensorium, seizures,
very severe headache and
signs of motor deficit
Decreased BP, abnormal heart rate
Cyanosis, difficulty of breathing
Yellowish discoloration of skin and
sclera
Decreased urine output/tea colored
urine
Severe dehydration
Bleeding tendencies (e.g. nose/gum
bleeding, black tarry stool )
Marked pallor or < 7 mg/dl Hgb
5% parasetemia or > 100,000 count
Special conditions: pregnancy, infancy

Local Measures

Emergency Measures

Give Paracetamol (10-15 mkd)


q 4 hrs for fever or pain
Do CBC
Do daily malarial smear for
3 days
Give anti-malarial treatment
for uncomplicated malaria
(see annex 7)
Observe for warning signs

Assess ABC & monitor vital


signs
Do CPR for CP arrest
(see annex 20)
Start IV line [[Plain LR/Plain
NSS if with shock (see annex19);
D5LR if w/o shock]
Give O2 (2-4 L/min) inhalation
for difficulty of breathing and
cyanosis
Start oral Quinine po/ NGT
Refer to hospital w/ referral note

For Hospital
Management
(see annex 7)

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MUMPS
General Signs & Symptoms

Warning Signs

Fever
Swelling and tenderness
of submandibular and/
or pre-auricular area
(involvement of one or
more of the salivary
glands)

Testicular swelling and


pain (orchitis)
Seizure/ changes of
sensorium (encephalitis)
Severe abdominal pain
& vomiting (pancreatitis)
Chest pains (myocarditis)

Local Measures

Emergency Measures

Isolate patient
Give Paracetamol (10-15mkd)
q 4 hrs for fever or pain
Advise soft diet
Advise not to apply indigo dye
Observe for warning signs

Assess ABC & monitor vital


signs
Do CPR for CP arrest
(see annex 20)
Start IV line [D5 0.3% NaCl
(<12 y/o); D5NM (>12y/o)]
Give O2 (2-4 L/min by nasal
prong) inhalation for difficulty
of breathing and cyanosis
Give Diazepam (0.2-0.4mkd,
max 10 mg) for seizure
Refer to hospital with referral note

For Hospital
Management
(see annex 9)

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SECTION IV
GASTRO-INTESTINAL DISEASES
ACUTE GASTROENTERITIS
(DIARRHEA)
TYPHOID FEVER

VIRAL HEPATITIS A

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ACUTE GASTROENTERITIS (DIARRHEA)


General Signs & Symptoms
Passage of > 3 liquid stools in 24
hrs
With any of the following:
Fever
Vomiting
Abdominal pain
Poor appetite
Signs of some dehydration
o thirst/irritability/
sunken eyeballs/
poor skin turgor

Local Measures
Give home fluids (soup, rice gruel)
Give ORS (see annex 1b)
Continue feeding or increase frequency
of breastfeeding
Do not give anti-diarrheal or antispasmodic
drugs
20
Give Zinc supplementation to children
at 20 mg/day for 10-14 days (10 mg/day
for infants < 6mos old)
Give Paracetamol (10-15 mkd) for fever
every 4 hours
Do rectal swab (c/o NEC)
Advise good personal hygiene
Observe for warning signs

Warning Signs

Signs of severe dehydration


Lethargic or unconscious/ floppy infant/
sunken eyes/ unable to drink/drinks
poorly/ poor skin elasticity
Cold clammy extremities/pallor/ weak pulse
Difficulty of breathing
Seizure
Absent or decrease urine output
Persistent vomiting
Persistent diarrhea of > 14 days w/
dehydration
Bloody stools/ rice watery voluminous stools
Abdominal distention
Muscle cramps
Grossly malnourished
No clinical improvement after 4-6 hrs of ORS

Emergency Measures
Assess ABC and monitor vital signs
Do CPR for CP arrest (see annex 20)
Start IV line [Plain LR/ Plain NSS using
large bore needle (gauge 21 for adult &
gauge 22-24 for pedia), see annex 1c]
Start 2 IV lines for patients w/ possible
cholera
Give ORS by NGT (20ml/kg for 6 hrs) if
IV therapy is not feasible for patients who
cannot drink (see annex 1c)
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
Give Diazepam (0.2-0.4 mkd, max 10 mg)
for seizure
Refer to hospital with referral note

For Hospital
Management
(see annex 1c)

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TYPHOID FEVER
General Signs & Symptoms

Warning Signs

Persistent fever ( > 7 days)


Abdominal manifestations
(abdominal pain, vomiting,
bloatedness, constipation, soft
stools)
With any of the following:
Weakness
Poor appetite
Enlarged liver and spleen
Rose spots (transient macular
rash) on chest/ abdomen
Relative bradycardia

Dehydration/ exhaustion
Unable to feed/ take oral
medications
Bloody/ black tarry stool
Severe abdominal pain/
abdominal rigidity/ absence of
bowel sounds
Cold, clammy skin with
hypotension
Pallor
Behavioral change (typhoid
psychosis)

Local Measures
Give Paracetamol (10-15 mkd) q 4 hrs for fever
Give oral antibiotics
ANTIBIOTICS
CHLORAMPHENICOL

ADULT
3-4 gm/day in
3-4 divided
doses x 14 days

PREGNANT
not
recommended

CHILDREN
75-100 mkBW in
4 divided doses x
14 days

AMOXICILLIN

3 gm/day in 3
divided doses
for 14 days
800/160 mg 1
tab BID for 14
days

3 gm/day in 3
divided doses
for 14 days
not
recommended

75-100 mg/kg/day
in 3 divided doses
for 14 days
8 mg/kg/day of
TMP in 2 divided
doses x 14 days

COTRIMOXAZOLE

Increase fluid intake if tolerated


Advise good personal hygiene
Wash hands after using bathroom and before handling food
& eating
Proper waste disposal
Limit close contact with susceptible individual during acute
phase of infection

Emergency Measures
Assess ABC and monitor
vital signs
Do CPR for CP arrest
(see annex 20)
Start IV line [Plain LR/
Plain NSS if with shock
(see annex19);D5 0.3% NaCl
(<12 y/o); D5NM (>12y/o)
if w/o shock]
Refer to hospital with
referral note

For Hospital
Management
(see annex 15)

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VIRAL HEPATITIS A
General Signs & Symptoms
Yellow eyes and/or skin
Fever/malaise/muscle aches/
abdominal discomfort
Plus any of the following
Loss of appetite
Nausea/vomiting
Loose stools
Dark or tea-colored
urine

Local Measures
Advise high-caloric diet
Increase oral fluid intake,
avoid alcoholic beverages
Advise to limit physical
activities
Advise good personal hygiene
Wash hands after using
bathroom and before handling
food and eating
Refrain from eating uncooked
shellfish/ vegetables & fruits
that are not peeled

Warning Signs
Persistent vomiting or
dehydration
Changes in sensorium
Deepening/persistent
jaundice
Special Conditions
Elderly/pregnancy/
patient with serious
underlying medical
conditions

Emergency Measures
Assess ABC and monitor
vital signs
Do CPR for CP arrest
(see annex 20)
Start IV line [D5 0.3% NaCl
(<12 y/o); D5NM (>12y/o)]
Refer to hospital with
referral note

For Hospital
Management
(see annex 17)

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SECTION V
OTHER DISEASES
CONJUNCTIVITIS
HYPERTENSION
SKIN DISEASES
CONTACT DERMATITIS
TINEA CORPORIS
TINEA PEDIS
TINEA VERSICOLOR
TETANUS NON-NEONATORUM
WOUNDS
DOG/CAT BITE
SNAKE BITE

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CONJUNCTIVITIS
General Signs & Symptoms
Itchiness/ redness/ foreign
body sensation in one or both
eyes
Eye discharge*/ tearing
Abundant exudates suggests
bacterial inflammation;
stringy, sparse exudates
suggests an allergy, and
watery discharge or epiphora
suggests adenoviral infection
(with some exceptions)

Warning Signs
Blurring/loss of vision
Significant pain in the
affected eye
Presence of eye
complications (ulceration,
blood-shot eyes)
Newborns
Signs and symptoms that do
not improve after 7 days

LocaI Measures

Instill eyedrops (Erythromycin or Gentamycin) q 3-4 hrs to affected eye for at least
7 days for bacterial infection
Use eyedrops with antihistamines, decongestants, steroids or anti-inflammatory
drops for allergic conjunctivitis
Use artificial tears or compress to relieve symptoms of viral/allergic conjunctivitis
Keep affected eye clean
Wipe crust gently by using cotton dipped in clean water or
use a solution containing 1 part of baby shampoo in 10 parts of clean water
Apply cool compress to the affected eye using a clean washcloth or dipped in a bowl
of cold water for 5-10 mins 3-4 x a day
Practice good personal hygiene
Wash hands thoroughly and frequently
Avoid touching eyes with bare hands; instead use clean cloth/tissue
Avoid sharing towel/pillowcase and change frequently
Avoid using eye cosmetics
Protect eyes with sunglasses

Refer to an
Ophthalmologist

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HYPERTENSION
General Signs & Symptoms

BP* of >140 systole and/or


diastole of >90 mm Hg
BP* of >130 systole and/or
> 80 diastole among
diabetics and renal patients

based on average of 2 or
more BP readings taken at 2 or
more consultations after initial
screening

Warning Signs
Hypertensive Emergency BP of
> 180 systole or >120 diastole
Any of the following:
Headache, pre-syncope/
syncope, altered sensorium,
neurologic deficit, blurring of
vision, shortness of breath,
chest pain, vomiting, nose
bleed, muscle tremors,
oliguria, anuria and hematuria
Uncontrolled persistent
elevation of blood pressure

Local Measures*

Emergency Measures

Administer oral anti-HTN drugs


(see annex 4a for class of drugs,
dosages & indications)
Low-dose thiazide diuretics
Beta-blockers
ACE inhibitors
Advise lifestyle modification
(see annex 4b)
Refer to Internist/Cardiologist for
uncontrolled hypertension

Assess ABC and monitor vital signs


Do CPR for CP arrest (see annex 20)
Start IV line with D5W
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of breathing
Give any short-acting anti-HTN drug
Clonidine at 0.1-0.2 mg po followed
by 0.1 mg/hr q hr or 2 hrs
(max 7 mg)
Captopril at 12.5-25 mg po, may
repeat at intervals of 30-60 mins
Furosemide at 20-40 mg IV
Refer to hospital with referral note

All cases should be seen by a


physician

For Hospital
Management
(see annex 4b)

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CONTACT DERMATITIS
General Signs & Symptoms

Warning Signs

Acute lesions at site of


contact:
itchy raised red patches/
wheals
vesicles/exuding punctuate
erosions and crusts
Chronic lesions at site of
contact:
dry, thick and scaly with
pigmentation

Severe, persistent itching


Worsening of skin lesions
Secondary bacterial
infection

Local Measures
Thoroughly clean skin with mild
soap and water
Apply Betamethasone cream
(for wet lesion) or ointment (for
dry lesion) to affected areas 2-3x
a day
Give Loratadine at 5-10 mg/day
for itching and redness

All cases should be seen by a


physician

Refer to
Dermatologist

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TINEA CORPORIS (BODY RINGWORM)


General Signs & Symptoms

Warning Signs

Itchy, round, scaly lesions


with central clearing and
elevated reddened edges
with sharp margins found
on trunk, extremities or
face

Severe, persistent itching


Widespread infection

Local Measures
Apply any of the following topical
antifungal agents on affected areas:
Tolnaftate 1% cream/ ointment 2x
daily for 2-3 weeks or
Terbinafine 1% cream once daily for
one week
Advise patient on the following:
keep skin dry
wear loose clothing of cotton materials
avoid sharing garments
practice personal hygiene
avoid application of irritants (kerosene,
battery liquid) to skin lesions

All cases should be seen by a physician

Refer to
Dermatologist

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TINEA PEDIS (ATHLETES FOOT)


General Signs & Symptoms

Warning Signs

Maceration, scaling,
fissuring of toe webs with
red underlying skin
Sole of foot if affected,
covered with fine silvery
scales
Itching or burning
sensation of affected area

Worsening of skin lesions


Failure of topical
treatment
Severe secondary
bacterial infection

Local Measures
Apply any of the following topical
antifungal agents on affected areas:
Clotrimazole 1% cream 2x a day for
2 weeks or
Tolnaftate 1% cream 2x a day for
2-3 weeks
Advise patient on the following:
keep feet dry
wear cotton socks and change socks
daily
wear open-toed shoes or sandals
avoid walking barefoot
practice good personal hygiene

All cases should be seen by a physician

Refer to
Dermatologist

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TINEA VERSICOLOR (TINEA FLAVA)


General Signs & Symptoms
Mild itchy pigmentation
of skin either tan, pink,
white or brown on face,
neck, arms, chest and/or
back with fine scales

Local Measures
Apply any of the following topical
antifungal agents on affected
areas:
selenium sulfide (2.5%) lotion or
shampoo for 10-15 mins once a
day followed by a shower, for 1
week or
Terbinafine 1% cream once or
twice daily for 2 weeks
Advise good personal hygiene

All cases should be seen by a


physician

Warning Signs
Persistence or worsening
of skin lesions despite
adequate treatment

Refer to
Dermatologist

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TETANUS NON-NEONATORUM
General Signs & Symptoms
Spasms/ stiffening in any parts of
the body (eg. jaw, neck,
extremities, back)
Manifested as any of the ff:
o Lock jaw
o Sardonic smile
o Abdominal rigidity
o Difficulty in swallowing

Warning Signs
Persistent and frequent
spasms
Difficulty of breathing
Cyanosis

History of wound exposure to


contaminated materials,
dental carries/ otitis media

Emergency
Warning
Signs Measures
Assess ABC & monitor vital signs
Do CPR for CP arrest
(see annex 20)
Start IV line [D5 0.3% NaCl
(<12 y/o); D5NM (>12y/o)]
Give O2 (2-4 L/min by nasal prong)
inhalation for difficulty of
breathing and cyanosis
Give Diazepam (0.2-0.4mkd, max
10mg) for seizure
Insert tongue guard
Refer to hospital with referral note

For Hospital
Management
(see annex 14)

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WOUNDS
General Signs & Symptoms

Warning Signs

Lacerations, abrasions,
puncture (single/
multiple) with or
without bleeding
resulting from any
trauma

Hypotension, cold clammy


extremities, cyanosis,
restlessness
Any deep extensive wound
like hacking, avulsion or
penetrating
Severe and/or uncontrolled
bleeding
Embedded foreign object in
the wound

Local Measures

Emergency Measures

Examine wounds and remove dirt


and foreign objects
Clean wound and apply antiseptics
and dressing
Apply direct pressure to any
bleeding wound
Appose gaping wound by suturing
or use of adhesive plaster, when
feasible
Give appropriate oral antibiotics
and pain reliever (see annex)
Give tetanus prophylaxis (see annex
18a)
Observe warning signs

Assess ABC & monitor vital signs


Do CPR for CP arrest
(see annex 20)
Start IV line [Plain LR/Plain NSS
if w/ shock (see annex 19); D5LR if
w/o shock]
Give O2 (2-4 L/min by nasal
prong) inhalation for difficulty
of breathing and cyanosis
Apply pressure bandage for severe
bleeding
Elevate the affected extremity
Refer to hospital with referral note

For Hospital
Management
(Refer to Surgeon)

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DOG/CAT BITE
General Signs & Symptoms
Any skin break (punctured,
abrasions, scratches)
resulting from bite of dog/ cat

Warning Signs
Gaping wound/ avulsion
with or without vessel
injury

(Refer to Surgeon)

non-bite exposure (licking of


mucous membrane and open
wounds, eating carcass, and
aerosol exposure)

Local Measures
Wash wound thoroughly and immediately
with soap and running water
Remove foreign materials (dirt, broken
teeth)
Apply antiseptic solution (Povidone iodine)
Give Mefenamic acid (25 mkD) and
antibiotic (see annex 18a)
Do not suture wound
Give the following instructions:
Observe biting animal for 14 days for
signs of rabies
Do not use garlic, stones (tandok),
tourniquet nor induce bleeding on the
wound
For other animal bites (see annex 18b)
Refer to animal bite center for
immunization (see annex 18b)

For Hospital
Management

Emergency Measures
Control bleeding by
direct/ pressure dressing
Bring avulsed body part
wrapped in clean plastic
and place in a container
with ice
Refer to hospital for
surgical management

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Warnin
g Signs

SNAKE BITE

Persi

General Signs & Symptoms


History of snakebite
with or without signs
of envenomation

Warning Signs
Seizures or changes in sensorium (lethargy)
Loss of consciousness
Cold skin, dilated pupils, insensitive to light
Circulatory failure (hypotension,
bradycardia, rapid feeble pulse)
Cyanosis
Signs of respiratory failure
Spreading paralysis causing difficulty in
speaking and breathing
Muscle weakness
Increase salivation, vomiting, frothing
around mouth
Burning pain, redness, swelling, superficial
necrosis, bleeding on site of bite, numbness
on site of bite
Abnormal bleeding

Emergency Measures
Assess ABC and monitor vital signs
Do CPR for CP arrest (see annex 20)
Start IV line [Plain NSS/ Plain LR if with
shock (see annex 19); D5LR if w/o shock]
Give O2 (2-4 L/min by nasal prong) inhalation
for difficulty of breathing and cyanosis
Apply pressure bandage to control bleeding
Use of tourniquet is no longer recommended
Refer to hospital with referral note
Precautionary Measures
Do not place any cooling materials on the site
of bite
Do not elevate bitten extremity above the
level of the heart
Do not incise nor suck the wound

For Hospital
Management
(see annex 13)

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ANNEXES

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Annex 1a
ASSESSMENT TABLE FOR DEGREE OF DEHYDRATION
IN DIARRHEA

Assessment Criteria

Well, alert

Restless, irritable*

Lethargic or Unconscious

Eyes

Normal

Sunken

Thirst

Drinks normally,
Not thirsty

Thirsty,
Drinks eagerly

Goes back quickly

Goes back slowly

Floppy*
sunken
Drinks poorly
Unable to drink*
Goes back very slowly
(>2 seconds)*

No Signs of dehydration
Not enough to classify as some/
severe dehydration

Some dehydration
If patient has at least 2 or more of
the above criteria

Severe dehydration
If patient has 2 or more of the
above criteria

Use Treatment Plan A

Weigh patient and


use Treatment Plan B

Weigh patient and


use Treatment Plan C

1. General Appearance

2. Skin Elasticity
(Abdominal skin pinch)
3. Degree of Dehydration

4. Treatment

Legend: * major signs of severe dehydration

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Annex 1b
TREATMENT PLAN A and B FOR DIARRHEA
A. TREATMENT PLAN A FOR NO SIGNS OF DEHYDRATION
AGE

AMOUNT OF ORS AFTER EACH LBM

AMOUNT OF ORS FOR USE AT HOME

< 24 months old

50 100 ml

500 ml

2 10 years old
10 years old or older

100 200 ml
As much as wanted

1000 ml/day
2000 ml/day

1. If patient shows no signs of dehydration after 6 hrs of observation, patient may be sent home with instructions and health
teachings.
2. If after 6 hrs of rehydration, patient still shows signs and symptoms of some dehydration with persistent vomiting (3- 4
episodes/hr) or condition has progressed to severe dehydration, said patient should be admitted to a hospital.

B. TREATMENT PLAN B FOR SOME SIGNS OF DEHYDRATION


AGE
WT.
Amt. in ml (ORS)

< 1 mo
< 5 kg
200-400

1-11 mos
5-7.9 kg
400-600

12-23 mos
8-10 kg
600-800

2-4 yrs.
11-15.9 kg
800-1200

5-14 yrs.
16-29.9 kg
1200-2200

> 15 yrs.
> 30 kg
2200-4000

1. Patients age should be used only when weight is unknown. The approximate amount of ORS required in 1 ml can also be
calculated by multiplying patients weight in grams times 0.75.
2. Patient should be observed and checked from time to time to see if there are problems such as vomiting and eyelids
puffiness. After 4 hours, patient should be reassessed using the Assessment Table to select the appropriate Treatment
Plan (A, B, or C).
3. If after 4 hours of rehydration, patient still shows signs/symptoms of some dehydration, the amount of ORS to be given
within 4 hours can be repeated until patient is rehydrated. But if theres persistent vomiting and condition has progressed
to severe dehydration, said patient should be admitted to a hospital.
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Annex 1c
HOSPITAL MANAGEMENT PROTOCOL FOR ACUTE GASTROENTERITIS
(DIARRHEA)
I.

Routine Laboratory Examination


-

Fecalysis

Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. TREATMENT PLAN C FOR SEVERE DEHYDRATION
1. Start IV fluids immediately by giving Ringers Lactate Solution at 100 ml/kg divided as follows:
AGE
Infants (< 12 months old)
Older
a.
b.
c.
d.
e.

First give 30 ml/kg


1 hour
30 minutes

Then give 70 ml/kg


5 hours
2 hours

Give ORS by mouth while the drip is being set up if patient can drink.
Repeat above rehydration course if radial pulse is still very weak or not detectable.
Reassess patient every 1 2 hrs. If hydration is not improving, give the IV drip more rapidly.
Give ORS (5 ml/kg/hr) as soon as patient can drink, usually after 34 hrs for infants or 1-2 hrs for older patients.
Evaluate patient using the Assessment Table after 6 hours of rehydration for infants or 3 hrs for older patients.
Then choose the appropriate plan (A, B, or C) to continue treatment.

2. If IV therapy is not feasible, start rehydration by NGT with ORS at 20 ml/kg/hr for 6 hrs (total of 120 ml/kg).
a. Reassess patient q 12 hrs. If there is repeated vomiting or increasing abdominal distention, give the fluid more
slowly.
b. After 6 hrs, reassess the patient and choose the appropriate treatment plan (A,B or C)
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B. Antimicrobial Therapy
Antibiotic is not essential for successful treatment of diarrhea, but it shortens the duration of illness and period of
excretion of organisms in severe cases.
Table on Antimicrobial Agents in the Treatment of Specific Diarrheal Diseases
Disease

CHOLERA

Antibiotics of Choice

Alternative(s)

Children:
Tetracycline 12.5 mkBW 4x a day x 3days

Children:
Furazolidone 1.25 mkBW 4x a day x 3 days
Co-trimoxazole (TMP 5 mkd) 2x a day for 5days

Adults:
Tetracycline 500 mg 4x a day x 3 days

Adults:
Furazolidone 100 mg 4x a day x 3 days
Doxycycline: 300 mg single dose
Ciprofloxacin 500 mg single dose
Co-trimoxazole 160/800 mg 1 tab 2x a day
for 3 days
Children:
Ciprofloxacin 10 mkBW 2x a day for 3 days

Pregnant:
Furazolidone: 100 mg 4x a day x 3 days
Children:
Co-trimoxazole (TMP 5 mkd) 2x a day x 5 days
SHIGELLA DYSENTERY

SALMONELLOSIS
Antimicrobials are given only
in patients with increased risk
of invasive disease:
1.
2.
3.
4.

infants <3months old


persons with malignancy
hemoglobinopathies
HIV infection/ other
immunosuppressive
illness or therapy
5. chronic gastrointestinal
disease/ severe colitis

Adults:
Co-trimoxazole (160/800 mg) 1tab 2x a day for 5 days
Infants < 3months:
Ampicillin 50 100 mkd at 6 hourly interval by IV or
IM x 3-5 days

Adults:
Ciprofloxacin 500 mg po BID x 3 days

Infants > 3months and children:


Children:
Ampicillin 50 100 mkd at 6 hourly interval by IV or Ceftriaxone 7580 mkd single dose x 3-5 days
IM x 3-5 days
or
Co-trimoxazole (TMP 5 mkd) 2x a day x 5 days
Adults:
Ciprofloxacin 500 mg po BID X 3-5 days
or
Ofloxacin 200 mg po BID x 3-5 days

Adults:
Co-trimoxazole 160 mg/ 800 mg BID x 5 days
Ceftriaxone: 3 4 gms/ IV single dose daily
for 5-7days

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C. Symptomatic and Supportive Treatment


1. Correct electrolyte disturbances: If after 4 hrs of initial rehydration, patient still shows manifestations like convulsive
seizure (hypernatremia), lethargy (hyponatremia), muscle weakness/ ileus/ abdominal disturbances (hypokalemia),
perform serum electrolytes determination and correct accordingly. Repeat serum electrolytes determination 24 48
hrs after correction.
2. Give Paracetamol at 10 15 mg/kg q 4 hours, but not > 6 times daily for fever.
3. Give 1.0 ml/kg of 50% glucose solution or 2.5 ml/kg of 20% glucose solution intravenously over 5 mins for
hypoglycemia.
4. Give Zinc supplementation as soon as child can drink and after initial hydration as follows: 20mg/day for > 6 months
old and 10mg/day for < 6 months old for 2 weeks.

III.

Guidelines for Patients Discharge


A. Criteria for Discharge: Patient properly and adequately rehydrated or clinically improved/ recovered
B. Follow-up Advice: Patient/ mothers/ relatives are given 2 sachets/ packs of ORS and to follow-up 2 days after discharge
at health center. Home treatment of diarrhea and Three Rules for Treating Diarrhea at Home is explained as follows:
1. Give child more fluids than usual to prevent dehydration.
2. Give child plenty of food to prevent undernutrition.
3. Instruct guardian to bring child to Health Center if child develop any of the following:
- watery stools > 3x/day
- repeated vomiting
- marked thirst
- eats or drinks poorly
- fever
- blood in the stools

IV.

Preventive Measures
Educate mother/ guardian/ relatives on:
1. Hygienic Practices:
a. Hand washing before eating or after toilet use.
b. Proper or sanitary disposal of stools.
c. Drinking water or eating food only from safe sources or boiling of drinking water from doubtful sources.
d. Proper practices in cooking and storage of food
2. Correct weaning practices
3. Environmental sanitation
4. Importance of measles immunization and breastfeeding till 4-6 months of age
5. Rotavirus vaccine for infants < 6months old. (see annex 21a on Immunization Schedule for Children)
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Annex 2
HOSPITAL MANAGEMENT PROTOCOL FOR BRONCHIAL ASTHMA
I. Routine Laboratory Examinations
1. CBC
2. ABG/ Oxygen saturation
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


Cases with poor response (PEFR <40% baseline, increase heart rate, increase RR, pulsus paradoxus 15 mmHg, inspiratory
and expiratory wheezing on auscultation, moderate to severe usage of accessory muscles, moderate to severe dyspnea, O2
saturation at > 91% after initial aggressive management) to therapy requires hospital admission.
A. Ward Management
*Criteria for Ward Admission:
PEFR >30% baseline and/or PaCO2 <40mmHg, O2 saturation 90%
Auscultation: moderate wheezing (entire expiration)
Accessory muscles; moderate usage
Dyspnea: moderate (one sentence)
Pulsus paradoxus: 15 mmHg
1. Give oxygen to keep O2 saturation at > 93%
2. Nebulize with Salbutamol or Terbutaline at 1 neb q 1-2 hrs or may use Salbutamol with Ipratropium at 1 UDV
3. Give Oral or IV Methylprednisolone at 1-2 mkd (max 150mg) or Hydrocortisone at 250 mg then 100mg q 6 hr
(pediatric: 10 mkBW LD, then 5-10 mkD MD), shift to oral if oral medication is tolerated to complete 5 days
therapy.
4. Give Paracetamol (10 15 mg/kg q 4 hours) for fever
5. Hydrate patient

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6. Reassess condition of patient q 1-2 hours


a. No Improvement of Condition (PEFR < 30% baseline and paCO2 > 40mmHg & other parameters
worsening)
1) Admit patient to ICU
2) Refer to Pulmonologist
b. With Improvement of Condition
1) Decrease aerosol frequency as tolerated
2) Continue steroids
B. Intensive Care Unit Management
*Criteria for ICU Admission:
PEFR <30% baseline and/or PaCO2 >40mmHg, O 2 sataturation < 90%
Auscultation: severe wheezing (inspiratory and expiratory)
Accessory muscles: severe usage
Dyspnea: severe (1-2 words)
Pulsus paradoxus: > 15 mmHg
1.
2.
3.
4.

5.
6.
7.
8.
9.

Consult Pulmonologist
Give oxygen to keep O2 saturation >93%
Continue nebulization with Salbutamol
Consider giving any of the following:
a. SC Epinephrine at 0.01mkd (0.3mg max dose)
b. SC Terbutaline at 0.005 0.01mkd q 15 20 min x 2 doses
c. Inhaled Ipratropium
Give Methylprednisolone at 1-2 mkd q 6 hr or Hydrocortisone at 250 mg then 100 mg q 6 hr (pediatrics: 10
mkBW LD, then 5-10 mkD MD), shift to oral if oral medication is tolerated to complete 5 days therapy
Give Aminophylline drip at 250 mg in 250 ml D5W with a LD of 5 mkBW in a soluset for 4- 6 hrs then MD of
0.4-0.8 ml/ kg/hour
Give Paracetamol (10 15 mg/kg q 4 hours) for fever
Hydrate patient
Re-assess condition of patient frequently (if PaCO2 is 55mmHg or rising at 5-10mmHg/hr, increasing dyspnea
and fatigue with accessory muscle use, pulsus paradoxus > 30mmHg, acidosis and O2 desaturation
a. Continue medications
b. Consider mechanical ventilation
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III.

Guidelines For Patients Discharge


A. Criteria for Discharge
Improved condition of patient as follows:
1.
2.
3.
4.

Patient able to walk comfortably


Patient not waking up at night or early morning needing a bronchodilator
Use of short acting inhaled B2-agonist at no more than every 4 hours
Clinical examination is normal or near normal (PEFR >90% baseline, heart and respiratory rate: normal,
auscultation: minimal to no wheezing, no accessory muscle use, no dyspnea, pulsus paradoxus: 5mmHg, O2
saturation: 94%)

B. Follow-up Advice
1. advise patient to use inhaler devices other than nebulizers
2. educate patient on medications and follow-up plan

IV.

Preventive Measures
Patients/ guardians/ relatives should be given Asthma Education as follows:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Keep home free of dust and pet hair.


Change air filters at least twice a year.
Keep childs room fabric-free as possible using wood furniture and window shades.
Do not allow anyone to smoke in the house or around the child.
Avoid use of hair spray, powder, perfume or make-up around the child.
Find out what foods trigger an asthma attack in the child and remove these foods from diet.
Keep child indoors when pollution levels are high by not letting the child play near streets or parking lots.
Avoid exposure of child from sudden extreme temperature changes.
Encourage open communication and keep child calm if stress triggers childs attacks and let child understand that the
situation is best handled by remaining cool, calm, and collected.

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Annex 3
HOSPITAL MANAGEMENT PROTOCOL FOR DENGUE
I. Laboratory Procedures
A. Routine Examinations
1. Baseline CBC, platelet count with blood typing
2. Serial hematocrit* depending on patients condition, platelet count**
* A drop of 20% in hct indicates signs of plasma leakage, thus, search for concealed hemorrhage.
** Platelet count may be requested at least daily until increasing trend is noted.
3. Serologic test to confirm diagnosis may be any of the following:
a. HI test
b. Dengue Duo
c. Dengue IgM
d. Dengue blot
B. Ancillary Examinations
These tests are requested when there are signs of bleeding and impending shock or in shock.

Ancillary Test
Protime
Partial Thromboplastin Time

Indication/s
For patients presenting with hemorrhagic manifestations in any form not responsive to usual
treatment

Serum albumin, ALT, AST,


Total and direct bilirubin

For assessment of patients with liver dysfunction which is not unusual in DHF

Urinalysis, Serum Creatinine

For patients in shock who require assessment of renal function

Chest x-ray

For patients in respiratory failure whether due to effusion or pneumonia/ pulmonary edema

Thoracic/ abdominal ultrasound

For evaluation of patients with lung problems/ effusion/ organomegaly/ ascites

ECG 12 leads

For evaluation of patients with possible myocarditis

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II. Treatment Guidelines


A. Specific Therapy: None
B. Symptomatic and Supportive Treatment
1. Intravenous Fluid (IVF) Therapy
a. Protocol for fluid correction with no shock:
1) Give IVF crystalloids Start IVF, preferably D5LR or D5 0.9 NaCl or Plain LR at 5-7 ml/kg/hr.
2) If there is improvement reduce IVF to 3 ml/kg/hr (up to 2-3 L/day in adults) and maintain at same rate for first
to second hospital day using D5LR alternating with D5MB (<2 y/o) or D5 0.3NaCl (>2 y/o).
3) If there is no improvement, increase IVF rate by 3-5 ml/KBW/hr increments up to 15 ml/KBW/hr then adjust
accordingly as above.
b. Protocol for fluid correction with shock:
1) Give IVF crystalloids - Plain LR or Plain 0.9 NSS at 20ml/KBW IV bolus in < 20minutes (20/20 rule) in
<20 minutes, may repeat twice if no improvement. If there is still no improvement, follow-up with colloids
(Dextran, Haemacel, Haesteril) at 10 ml/kg bolus in <20 minutes, may repeat if no improvement.
2) If there is still no improvement with colloids, may give Fresh Frozen Plasma at 15cc/kg in 2 hrs and start
inotropes (Dopamine at 7-15ug/kg/min).

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2. Blood/Blood Products Transfusion

Blood/ Blood Products

Indication/s and Dosage

Platelet Concentrate

Give platelet concentrate at 1 unit/5-7 kg if platelet count is <50,000 among patients with
significant bleeding or if platelet count is <20,000 even if there is no significant bleeding.

Cryoprecipitate

Give at 1 unit/5 kg if with prolonged PTT (>50 sec or 10 sec more than the upper limit of
normal or 20 sec more than the control) or with signs of DIC

Fresh Frozen Plasma

Fresh Whole Blood

Packed Red Blood Cells

Give in normotensive patient with prolonged PT (2 times the control) at 15 ml/kg x 2-4 hrs plus
Furosemide at 1-2 mg/kg given at mid-transfusion or if patient is in impending shock despite
crystalloid solution and in the absence of colloids.
Give at 20 cc/kg if with significant active/ gross bleeding or blood loss is 25% or more of blood
volume or if hct falls by 20% (>10% blood loss in adults or 25% blood loss in pediatrics of total
blood volume of 80 ml/kg). Calcium gluconate can be given if FWB is given more than 4 6
units/bags. However, it is essential to check for patients calcium level prior to administration.
Give at 10 cc/kg in 4 hours when blood loss is <25% or if there is no more active bleeding but
with low hct and hemoglobin (<8 gm/dL or 80 gm/L).

3. Other Symptomatic Treatment


a. Give Paracetamol (10 15 mg/kg q 4 hours) for febrile episodes. Do not use Aspirin.
b. Give Sucralfate as cytoprotector of the gastric mucosa, at 1 gm q 6 hrs for adults and 40-80 mkD q 6 hrs for
pediatric.
c. Give H2 blockers (Ranitidine at 1-2mkd) to patients with severe epigastric pain and/or gastric bleeding.
d. Do gastric lavage with cold saline after NGT insertion for patients with gastric bleeding.
e. Give Albumin infusion for hypoalbuminemia (<26mg/dl)
f. Place in Trendelenberg position patient with circulatory failure.
g. Do nasal packing with Epinephrine for epistaxis.
h. Give O2 (2-4L/min via nasal prong) inhalation for difficulty of breathing/ cyanosis/ shock
i. Use mechanical ventilation when necessary
j. Monitor vital signs as often as necessary
k. Monitor urine output and level of consciousness
*All Dengue patients must not be given with medications through intramuscular injections.
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III.

Guidelines for Patients Discharge


A. Criteria for Discharge: Improved clinical and laboratory status as follows:
1. Afebrile and stable vital signs for 3 days and with good appetite.
2. Resolution of complications such as encephalopathy, seizures, bleeding, arrhythmias, pneumonia, ascites, hematuria,
and/or oliguria.
3. Normal laboratory examinations: platelet count (increasing trend); PT (Control 70-120%); PTT (control 30-45 sec); hct
(0.38-0.45); Creatinine (54-133 mmol/L).
B. Followup Advice: Advise patient to follow-up at any health care facility 1 week after discharge.

IV.

Preventive Measures
Educate patient/ guardian/ parent/ relatives on:
1. Environmental sanitation and destruction of mosquito breeding places such as clogged gutters, old tires, cans, uncovered
water containers.
2. Personal protection by use of repellants and mosquito nets or wearing of long trousers and long sleeved shirts/ blouses.

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Annex 4a

Table of Oral Anti-Hypertensive Drugs


Class of Anti-Hypertensives
Ace Inhibitors
Imidapril 5-10 mg OD
Quinapril 5-10 mg OD
Angiotensin II antagonists
Losartan 50 mg OD
Beta blockers
Metoprolol 50,100 mg BID
Propanolol 10-40 mg TID
Carvedilol 12.5-25 mg OD-BID
Calcium Antagonists
Felodipine 2.5, 5, 10 mg OD
Diltiazem 30, 60mg,120 mg OD BID
Diuretics
Thiazide
HCTZ(Hytaz)12.5-25 mg/day

Indications
Stage I hypertension
diabetes mellitus, post-myocardial infarction,
heart failure, chronic renal disease
Stage I hypertension
diabetes mellitus, post-myocardial infarction,
heart failure, chronic renal disease
Prior myocardial infarction, Stage I
hypertension, coronary artery disease (preferred
therapy),
diabetes mellitus without nephropathy
Stage I hypertension (alternative therapy)
peripheral vascular disease,
coronary artery disease
Systolic hypertension (Felodipine)
Stage I hypertension, uncomplicated
hypertension, Systolic hypertension in elderly
(preferred therapy),
for older patients without nephropathy

Contraindications
Bilateral renal vascular disease
Creatinine >2mg/dl
Bilateral renal vascular disease
Creatinine > 2mg/dl
Asthma, severe peripheral arterial disease,
acute decompensated heart failure,
advanced heart block
Congestive heart failure,
heart block (Diltiazem)

Gout, dyslipidemia

Two drug combination for most cases


(Thiazide and ACE or ARB or BB or CCB) Stage II hypertension
Losartan 50 mg + thiazide 12.5 mg
(Combizaar) OD
Metoprolol 50 mg-100 mg BID +
Thiazide 6.25-25 mg OD

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Annex 4b

HOSPITAL MANAGEMENT PROTOCOL


FOR HYPERTENSIVE EMERGENCY
I. Treatment Guidelines
Immediate control of BP using IV antihypertensive drugs is essential to terminate on-going target organ damage by:
1. Reduce the mean arterial pressure by approximately 20-25% or reduce diastolic pressure to 100-110 mmHg in one hour.
2. Admit patients to ICU with intra-arterial BP monitoring.
Anti-hypertensive Therapy (Parenteral)

1. May use any of the following anti-hypertensive agents alone or in combination depending on the clinical
situation or presence of co-morbid illness (see Table 1).

Table 1: Clinical Conditions and Anti-Hypertensive Drugs of Choice


Conditions

Intracerebral
Hemorrhage

First Line Drug/s

Nitroprusside
infusion
(treat only if
diastolic pressure is
>130mmHg)

Dosages

Initial Dose: 0.25-0.3 mcg/kg/min IV


infusion. Gradually titrate up every
few min until BP is controlled.

Uncontrolled Hypertension
Despite Initial Treatment
Max dose: 10mcg/kg/min

Usual dose range: 0.25-10 mcg/


kg/min IV

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Conditions

Myocardial Ischemia

First Line Drug/s

Nitroglycerin infusion

PLUS
Labetalol

OR
Esmolol

Congestive Heart
Failure

Nitroprusside infusion

PLUS
Nitroglycerin infusion

PLUS
Loop diuretic
(Furosemide)

Dosages
Initial Dose: 5-10mcg/ min IV
infusion. Increase by 5mcg/min every
3-5 min until some response is noted.
Usual Dose: 5-100mcg/min IV
infusion. Once a partial response is
obtained, increases in dose increments
Loading dose: 20mg IV over 2 min..
Follow by: Boluses of 20-80mg
IVevery 10. OR
IV infusion: Starting at 2mg/min IV
titrated to desired response

Uncontrolled Hypertension
Despite Initial Treatment
If there is still no response
at 20mcg/min: May increase
at increments of
10mcg/min& later if
required, 20mcg/min
increments can be used
Max cumulative dose:
300mg/24 hr. min.(max
300mg)

Loading dose= 250mcg IV over 1


min.Follow by: 50-100 mcg/min.IV
over 4 min

If necessary, repeat the


loading dose or IV infusion
rate maybe increased to 300
mcg/kg/min as tolerated

Initial Dose: 0.25-0.3mcg/kg/min IV


infusion. Gradually titrate up every
few min until BP is controlled.
Usual dose range: 0.2510mcg/kg/min IV

Max dose: 10mcg/kg/min

Initial Dose: 5-10mcg/ min IV


infusion. Increase by 5mcg/min every
3-5 min until some response is noted.
Usual Dose: 5-100mcg/min IV
infusion.Once a partial response is
obtained, increases in dose increments

If there is still no response


at 20mcg/min: May increase
at increments of
10mcg/min& later if
required, 20mcg/min
increments can be used

Concentration=1mg/ml
Drip of 5-30ugtts/min is equivalent to
5-30mg/hour

Continuous IV
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Conditions
Acute Renal Failure/
Microangiopathic
Anemia
Acute Aortic Dissection
IV antihypertensive
therapy should be
started as soon as
aortic dissection is
suspected

First Line Drug/s

Nicardipine

Labetalol

OR
Nitroprusside

Surgical CV
consult is needed

PLUS

Esmolol

Labetalol

Antihypertensive
withdrawal

OR
Phentolamine

Sympathetic Crisis

Preeclampsia/Eclampsia

Nicardipine

Hydralazine

Dosages
IV infusion: 5mg/hr IV titrated to
desired effect. May increase dose by
2.5mg/hr IV every 5 min
Loading dose: 20mg IV over 2 min..
Follow by: Boluses of 20-80mg
IVevery 10. OR
IV infusion: Starting at 2mg/min IV
titrated to desired response
Initial Dose: 0.25-0.3mcg/kg/min IV
infusion. Gradually titrate up every
few min until BP is controlled.
Usual dose range: 0.2510mcg/kg/min IV
Loading dose= 250mcg IV over 1
min.Follow by: 50-100 mcg/min.IV
over 4 min
Loading dose: 20mg IV over 2 min..
Follow by: Boluses of 20-80mg
IVevery 10. OR
IV infusion: Starting at 2mg/min IV
titrated to desired response
Hypertensive crisis associated with
excess circulating cathecolamines:
5-15mg IV bolus
IV infusion: 5mg/hr IV titrated to
desired effect. May increase dose by
2.5mg/hr IV every 5 min
5-20mg IV (10-50mg IM) Dose (Use
the lower range doses initially for BP
control)

Uncontrolled Hypertension
Despite Initial Treatment
Max dose: 15mg/hr

Max cumulative dose:


300mg/24 hr.
min.(max=300mg)

Max dose: 10mcg/kg/min

If necessary, repeat the


loading dose or IV infusion
rate maybe increased to 300
mcg/kg/min as tolerated
Max cumulative dose:
300mg/24 hr.
min.(max=300mg)

Continuous IV
Max dose: 15mg/hr

may be increased & repeated


every 20-30 min as required
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2. Monitor patient closely and watch out for sudden drop of BP within a few minutes particularly in patients with the
following conditions with desired BP goals:
a. Diabetes and kidney disease at not < 130/80 mmHg
b. Without cardiovascular risk factors at not <140/90mmHg

II. Measures to Prevent Cardiovascular Events in Hypertensive Patients


Advise hypertensive patients to:
1.
2.
3.
4.
5.
6.
7.
8.

Stop smoking
Control blood sugar if diabetic
Treat dyslipidemia
Reduce intake of sodium and diet rich in fat
Consume a diet rich in vegetables, fruit and low fat dairy products.
Maintain a body mass index of (BMI) between 18.5-24.9kg/m2
Engage in regular aerobic exercise or engage in brisk walking at least 30 minutes a day once BP is controlled
Limit alcohol intake to less than 1 oz./day of ethanol (24 oz of beer, 8 oz of wine or 2 oz 80-proof whiskey)

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Annex 5
HOSPITAL MANAGEMENT PROTOCOL FOR INFLUENZA
I. Routine Laboratory Examination
-

CBC

Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Specific therapy
May give anti-viral drugs within 48 hrs of onset of illness for 3-5 days or 1-2 days after the disappearance of symptoms in
the following cases:
a. immuno-compromised status/ chronic debilitating illnesses (AIDS, malignancy, severe malnutrition, elderly > 60
y/o)
b. severe co-morbid illnesses (Kawasaki)
c. those with special environmental, family, or social situations, such as examinations in school, athletic
competitions, and those with high-risk family members.
1. OSELTAMIVIR for both influenza A and B.
Dose:
Children and Adults : 75 mg capsule po BID for 5 days
For 1- 12y/o
: 2mg/kg max 75mg po BID
2. AMANTADINE HCL (decreases the severity of Influenza A if given)
Dose:
1 9 y/o
: 5 mkd, max 75mg po BID
10 65y/o
: 100 mg po BID
> 65y/o
: 100mg po q 24 hr (adjust for decrease renal function)

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B. Symptomatic or Supportive Therapy


1.
2.
3.
4.

Give Paracetamol for fever at 10-15 mkd q 4-6 hr and avoid Aspirin.
Manage encephalitis accordingly.
Give antibiotics for secondary bacterial infection.
Hydrate patient adequately.

III. Guidelines for Patients Discharge


A. Criteria for Discharge
1. Afebrile and active for at least 2 days
2. Resolution of other symptoms or complications such as dyspnea and seizure.

IV. Preventive Measures


1. Isolate patients
a. Standard and droplet precautions are recommended for the whole duration of the illness.
b. Respiratory tract secretions should be considered infectious, and strict hand washing procedures should be used.
2. Give Chemoprophylaxis (Amantadine/Oseltamivir) in the following:
a. For > 1y/o at high risk who were immunized after circulation of Influenza A in the community has begun.
Beneficial during the interval before a vaccine response.
b. Unimmmunized persons providing care to high-risk persons
c. Immunodeficient persons whose antibody response to vaccine is likely to be poor.
d. Persons at high risk for whom vaccine is contraindicated as in anaphylactic hypersensitivity to egg protein who do
not receive desensitization.
e. Any healthy child with age-appropriate development for whom prevention of influenza is considered desirable.
Dosages for chemoprophylaxis:

Amantadine
Oseltamivir (for >12yo)

: same dose as for treatment


: 75 mg OD for the duration flu epidemic

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3. Give yearly vaccination before the start of influenza season, February to June. (see annex 21a and 21b on
Immunization Schedule for Children and Adults, respectively)
Priority should be given to targeted high-risk group:
a. Children and adolescents with the following high-risk factors:
1) Chronic cardiovascular disease (congenital heart disease, valvular heart disease)
2) Chronic lung disease (asthma)
3) Chronic metabolic disorders (diabetes)
4) Renal disorders and hemoglobinopathies
5) Condition requiring long term aspirin treatment (Kawasaki, rheumatoid arthritis)
6) On immunosuppressive therapy
7) HIV infection
b. Close contacts of high risk patients
1) All health care personnel in contact with pediatric patients in hospital and outpatient care settings.
2) Household contacts, including siblings and primary caregivers of high-risk children.
3) Children who are members of households with high-risk adults, including those with symptomatic HIV
infection.
4) Providers of home care to children and adolescents in high-risk groups.
c. Pregnant women in second/ third trimester of pregnancy since pregnancy increase the risk of complications
and hospitalizations from influenza.
d. Persons traveling to foreign areas where influenza outbreaks may be occurring.

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Annex 6a

HOSPITAL MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS


I. Routine Laboratory Examinations
1.
2.
3.
4.
5.
6.
7.
8.
9.

CBC with platelet count


Clotting time, bleeding time with blood typing
APTT, Protime for patients with hemorrhages and initial thrombocytopenia
BUN, Creatinine, Uric acid, CPK
AST, ALT, Alk phosphatase
TB, B1, B2, TPAG
Serum electrolytes
Serologic test (EIA, MAT- LAAT) to confirm diagnosis
Urinalysis

Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Antimicrobial Therapy
The maximum benefit of shortening the clinical course of the disease is achieved if antibiotic therapy is started before the
onset of the immune phase.

Antibiotics
Drug of Choice
PENICILLIN G

Dosage
Adult
1.5-2 MU IV q 6hrs for 7-10
days

Pregnant
1.5-2MU IV q 6hrs for 7-10 days

Children
200,000 U/kg/day IV in 4 divided
doses for 7-10 days
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Antibiotics
Alternative Drug
CEFTRIAXONE

Adult
2 gm/day IV OD for 7 days

Dosage
Pregnant
2 gm/day IV OD for 7 days

DOXYCYCLINE

100 mg BID for 7-10 days

Not recommended

TETRACYCLINE

500 mg q 6 hrs for 7-10 days

Not recommended

Children
100 mg/kg IV OD for 7 days
Not recommended below 8 yrs old
3 mkD in 2 divided doses for 7-10
days
Not recommended below 8 y/o
20-40 mkD in 4 divided doses

ERYTHROMYCIN 500 mg q 6 hrs for 7-10 days

500 mg q 6 hrs for 7-10 days

40-50 mkD in 4 divided doses for


7-10 days

AMOXICILLIN

3 gm/day in 3 divided doses for 7-10


days

50 mkD in 3 divided doses for


7-10 days

3 gm/day in 3 divided doses for


7-10 days

B. Symptomatic and Supportive Therapy


1. Give Paracetamol (10-20 mkd (IV), max of 300 mg) for fever. Do not use aspirin.
Pedia: Paracetamol at 5-10 mkd q 4 hr po.
Adult: Paracetamol at 500 mg q 4 hr po.
2. Maintain adequate hydration with isotonic solution.
3. Apply Povidone Iodine solution/ Mupirocin cream or ointment for wound care.
4. Correct fluid & electrolytes for gastrointestinal disturbances
5. Correct deranged hematologic functions for bleeding
a. use the protocol on use of platelet concentrate/fresh frozen plasma/cryoprecipitate
b. give Vitamin K at 10 mg STAT dose.
6. Use Dobutamine (4-20ug/KBW/min) or Norepinephrine (4-12 ug/min) as cardiac support to maintain MAP above
65mmHg or maintain systolic BP 110-120mmHg.
7. Correct acid base imbalance for metabolic encephalopathy
8. Give the following for massive proteinuria / hypoalbuminemia
a. Albumin: 0.5-1 g/kg/dose to be given in 2-4 hours period
b. Furosemide: 0.5-1 mkd to be given mid-way the infusion of albumin
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9. Use the Management Guidelines of Oliguria-Anuria (see annex 6b) and monitor patients response to fluid
challenge by:
a. Insertion of CVP line
b. Monitoring of input & output

III. Guidelines for Patients Discharge


A. Criteria for Discharge
Improved clinical and laboratory status as follows:
1. Resolution of signs and symptoms such as fever, jaundice, hypoalbuminemia.
2. Normal laboratory examination: BUN, creatinine
3. Urine output of at least 1 cc/kg/hour

B. Follow-up Advice: Advise patient to follow-up 1 week after discharge at health center.
IV. Preventive Measures
1. Educate patients/ guardians on the disease emphasizing the mode of transmission, to avoid swimming or wading in
potentially contaminated waters, and use protective gears when work requires such exposure or when exposure cannot be
avoided.
2. May give chemoprophylaxis using Doxycyline at:
a. 200 mg once a week in high risk groups with short term exposure
b. 100 mg BID for 3-5 days for persons whose wounds are exposed to potentially contaminated environment.

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Annex 6b
MANAGEMENT OF OLIGURIA-ANURIA
IN LEPTOSPIRAL ACUTE RENAL FAILURE
I. Additional Laboratory Examinations
1.
2.
3.
4.

Chest x-ray (PA view)


ABG (for correction of metabolic acidosis to improve cardiac contractility)
Electrolytes (for correction of hypokalemia/ hyperkalemia, and hypocalcemia)
TPA/G (for correction of low albumin in septic patient)

II. Treatment Guidelines


A. Group A Patient:
[With signs of volume depletion (dehydrated, positive thirst, dry axilla, flat neck veins, JVP of <5cm, no rales, tachycardic)
plus urine output of < 400 ml/day with normal systolic BP (>90mmHg)]
1. Institute fluid resuscitation by hydrating with normal saline or half saline (0.45%) NSS for elderly patients with
cardiovascular abnormality
2. Diuretics is not indicated when there is adequate diuresis (urine output of >30 cc/hr and increasing) in 2-4 hours after
fluid hydration
B. Group B Patient:
[With signs of volume depletion (dehydrated, positive thirst, dry axilla, flat neck veins, JVP of <5cm, CVP<10 cm, no rales,
tachycardic) plus urine output of < 400 ml/day with low systolic BP ( <90mmHg)]
1. Insert central venous catheter if feasible for CVP reading (guide for fluid challenge to target CVP reading of 10-12 cm)
2. Institute fluid resuscitation by hydrating with normal saline or half saline (0.45%) NSS for elderly patients with
cardiovascular abnormality.
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3. Give diuretics as indicated below, if there is no response to fluid hydration in 2-4 hours
a. Give Hydrochlorothiazide( Hytaz)* at 25mg to 50 mg tablet OD-BID plus any loop diuretics as follows:
1) Furosemide: doubling dose at 20mg-40-80-160 mg IV q 2 hr or initial dose of 100mg-200mg q 2 hr
2) Bumetanide: doubling dose at 1mg-2-4-8 mg
b. or may give loop diuretics as infusion in D5Water, 250cc + 240 mg Furosemide or 12 mg Bumetanide in 24
hours
*Give Hydrochlorothiazide 1 hour earlier before giving intravenous (IV) loop diurectics
4. May give Vasopressors (Dobutamine at 4-20 ug/KBW/min, Norepinehrine at 4-12 ug/min) to support BP after
hydration if patient remain hypotensive and need to challenge with diuretics
5. May consider to combine Albumin 25% as fast drip at 1 vial OD-BID plus loop diuretics
Target Urine Output: 30cc/hr or 700-800cc/day and increasing
6. Refer to Nephrologist for dialysis
*Indications for Dialysis: uremic manifestations
unresponsiveness to medical treatment, persistent hyperkalemia,
intractable metabolic acidosis, worsening pulmonary congestion
C. Group C Patient:
[With signs of volume excess (engorged neck veins, pulmonary rales, tachycardiac, edema) plus urine output of <400cc/day
and borderline unstable BP with CVP reading of >10 cm (>15 cm or frank fluid overload)]
1. Give fluids using D5Water as KVO
2. Support BP with vasoppressors (Dobutamine at 4-20 ug/kg/min, Norepinephrine at 4-12 ug/min) to maintain BP at
110-120 mmHg systolic
3. Give loop diuretics as bolus using Furosemide at 80-100mg, and if still has no response, then may give another
Furosemide at 200mg IV after 2 hours or Bumetanide at 2-4 mg then another 8 mg
4. Refer to Nephrologist if patient remain unresponsive (no urine output or inadequate urine output) for dialysis

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Annex 7
HOSPITAL MANAGEMENT PROTOCOL FOR MALARIA
I. Routine Laboratory Examinations
1. malaria blood film (thick and thin smears) upon admission and q 12 hrs thereafter for the first 48 hrs, daily for the next 5
days or until negative for asexual forms of parasites
2. CBC, platelet count, blood typing
3. urinalysis and urine urobilinogen
4. CT, BT, APTT
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Anti-Malaria Therapy
1. For Uncomplicated Malaria
a. For probable malaria and confirmed P. falciparum cases, except for pregnant women, use Chloroquine (CQ) plus
Sulfadoxine/Pyrimethamine (SP) and Primaquine as follows:

Table 1. Dose and Schedule of CQ + SP and Primaquine


Age (yrs)

0-4 mos.
5-11 mos.
1-3 yrs.
4-6 yrs.
7-11 yrs.
12-15 yrs.
16 yrs. & above

No. of Chloroquine Tablet


(150 mg base/tablet)
Day 1 10mg base/kg body weight
Day 2 10mg base/kg body weight
Day 3 5 mg base/ kg body weight
Day 1
Day 2
Day 3

1
1

1
1
1
2
2
1
3
3
1
4
4
2

Sulfadoxine/Pyrimethamine
(500 mg/25 mg/tab)

Primaquine
(15 mg/tablet)

No. of Tablet
Single dose only
Day 1

1
1
1
2
3

No. of Tablet
Single dose only
Day 4
Not indicated
Not indicated

1
2
3
3
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b. For confirmed P. vivax cases, administer orally CQ and Primaquine as follows:

Table 2. Dose and Schedule of CQ and Primaquine

Age (yrs)

Primaquine*
(15 mg/tablet)

No. of Chloroquine Tablet


(150 mg base/tablet)
Day 1 10mg base/kg body weight
Day 2 10mg base/kg body weight
Day 3 5 mg base/ kg body weight
Day 1
Day 2

1
1
1
1
2
2
3
3
4
4

1-14 days treatment


Day 3

0-4 mos.

Not indicated
5-11 mos.

Not indicated
1-3 yrs.

daily
4-6 yrs.
1
daily
7-11 yrs.
1
daily
12-15 yrs.
1
1 daily
16 yrs. &
2
1 daily
above
* contraindicated in pregnant women but may be given after the termination of pregnancy
c. For cases with mixed P. falciparum and P. vivax infection, except for pregnant women, give CQ+SP and
Primaquine as follows:

Table 3. Dose and Schedule of CQ +SP and Primaquine


Age (yrs)

0-4 mos.
5-11 mos.
1-3 yrs.
4-6 yrs.
7-11 yrs.
12-15 yrs.
16 yrs. & above

No. of Chloroquine Tablet


(150 mg base/tablet)
Day 1 10mg base/kg body weight
Day 2 10mg base/kg body weight
Day 3 5 mg base/ kg body weight
Day 1
Day 2
Day 3

1
1

1
1
1
2
2
1
3
3
1
4
4
2

Sulfadoxine/Pyrimethamine
(500 mg/25 mg/tab)
No. of Tablet
Single dose only
Day 1

1
1
1
2
3

Primaquine
(15 mg/tablet)

No. of Tablet
For 14 days
Not indicated
Not indicated
daily

1
1
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d. Assessment of Uncomplicated Malaria Response to CQ+SP Anti-Malarial Regimen


Evaluate the adequacy of clinical and parasitological response among patients with uncomplicated malaria treated with
CQ+SP anti-malarial regimen, using the table below.

Table 4. Grading of Clinical and Parasitological Response to CQ+SP Treatment


Clinical and Parasitological Response to Treatment
Absence of parasitemia on D28 irrespective of temperature; not treatment failure
1. Presence of any of signs of severe symptoms plus repeated vomiting in the
presence of parasitemia from Day 1, Day 2, or Day 3
2. Parasitemia on Day 3
3. Parasitemia on Day 2 higher than Day 0 count
4. Parasitemia on Day 3 > or = to 25% of count on Day 1
5. Development of signs of severe malaria plus repeated vomiting after Day 3 in
the presence of parasitemia
6. Presence of parasitemia and axillary temperature >37.5C on any day between
Day 4 to Day 28 without previously meeting any of the criteria of ETF
Presence of parasitemia on any of the scheduled return on Day 7, Day 14, Day 21 or
Day 28, and axillary temperature <37.5C without previously meeting of any of the
criteria of ETF

Level of Clinical Response


Adequate Clinical Response (ACR)
Early treatment failure (ETF)

Late clinic-parasitological failure (LCF)

Late parasitological failure (LPF)

2. Complicated Malaria
a. For cases with multi-drug resistant P. falciparum, give Artemether 20 mg/Lumefantrine 120 mg Combination Tablet
(Co-Artem) as the drug of choice as follows:

Table 5. Dose and Schedule of Artemether 20 mg/Lumefantrine 120 mg Combination Tablet (Co-Artem)*
Schedule

Adults and
children above 13 years
Day 1
4 tabs
8 hrs after 4 tabs
Day 2
4 tabs BID
Day 3
4 tabs BID
Day 4
Give primaquine as in Table1
*Contraindicated in infants < 1 year old

9 to 13 years
3 tabs
3 tabs
3 tabs BID
3 tabs BID
Give primaquine as in Table1

Pediatrics
4 to 8 years
2 tabs
2 tabs
2 tabs BID
1 tab BID
Give primaquine as in Table1

1 to 3 years
1 tab
1 tab
1 tab BID
1 tab BID

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b. For treatment failure or in the absence of Co-Artem and for pregnant women, give Quinine-plus as follows:

Table 6. Dose and Schedule for Quinine-plus


Plus any of the three drugs below:
Primaquine

Age group/
Condition

Quinine sulfate
(300 or 600 mg per
tablet)

Doxycycline

Tetracycline

Clindamycin

Adults

10 mg/kg/dose q
8 hrs x 7 days

3 mg/kg OD
x 3 days

250 mg QID
x 7 days

10 mg/kg BID
x 3 days

Table 1

Children > 8
years old

As above

As above

As above

As above

Table 1

Children < 8
years old

As above

Contraindicated

Contraindicated

As above

Table 1

Pregnant

As above

Contraindicated

Contraindicated

As above

At termination of pregnancy

c. For severe form of malaria, use Quinine dihydrochloride as shown in the table below:

Table 7. Dose and Schedule of Quinine for Severe Malaria


Quinine diHCl (600 mg/2 ml)
Age group
Adult

Loading dose

Tetracycline

Clindamycin

500 mg QID x
7 days

10 mg/kg BID x
3 days

Maintenance Dose

20 mg salt/kg in 10 ml/kg 0.9 10 mg salt/kg in 10 ml/kg 0.9 NaCl


NaCl or D5W x 4 hrs. IV drip or D5W IV drip x 4 hrs. every 8
hours
(Total not to exceed 2,000 mg)

Children
8-16 y/o

15 mg salt/kg IV drip x 4 hrs.

10 mg. salt/kg IV drip x 4


hrs.every 8 hrs.

4 mg/kg QID not to


exceed 250 mg/dose

As above

Children
7 y/o and below

10 mg salt/kg in IV drip x 4
hrs.

10 mg. salt/kg IV drip every 12


hrs.

Contraindicated

As above

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B. Supportive Management
1. Replace fluid losses following CDD guidelines.
2. Give IV Paracetamol for fever.
3. Control seizures with any of the following:
a. Diazepam - 10mg IV(adult) 0.3mg/kg IV (Pedia)
b. Phenobarbital - LD 10-20mg/kg slow IV divided into 2-4 doses at 30-60min interval, MD 1-5 mg/kg/day (Adult)
- LD 15-20mg/kg slow IV push in single or divided dose, MD 5-7mg/kg/day IV in 2-4 divided doses
(Pedia)
c. Phenytoin
- LD 13-18mg/kg, MD 3-5mg/kg/day (Adult)
- LD 15-20mg/kg slow IV push, MD 5 mg/kg IV in 2 divided dose (Pedia)
4. Transfuse blood/blood products in the following conditions:
a. for severe anemia (<8 mg/dl Hgb)
1) Packed RBC (10cc/kg) infuse at 2-3 mg/kg/hr in high output failure otherwise 1 ml/kg/hr
2) Fresh whole Blood 20cc/kg at 10mg/kg/hr
b. for thrombocytopenia with platelet count below 60,000 in adults and 30,000 in children
1) Platelet concentrate at 1 unit/7 kg body weight
5. Assess renal status of patient based on the following parameters:

Table 8. Assessment Parameters for Renal Failure


Renal Failure
Adults
Parameters

Children

Infants
< 1.0 ml/kg/hr

elevated

2. Urine specific gravity

< 1.015

< 300 ml/m2/24 hrs or


< 1 ml/kg/hr
<1.010

3. serum creatinine

elevated

elevated

1. Urine output

< 1 ml/kg/hr

a. Give Furosemide at 1mg/kg or Dopamine at renal dose (2-5ug/kg/min.)


b. Refer to Nephrologist when patient failed to respond to fluid management.
6. Assess for the presence of acute pulmonary edema and when present refer to pulmonologist.
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III. Preventive Measures


A. Chemoprophylaxis
This is recommended for persons who are at high risk for severe and complicated malaria, particularly non-immune
travelers to endemic areas and primigravids during entire pregnancy and who reside in endemic cases. Chloroquine as a
chemoprophylactic drug is generally safe and has little teratogenic risk. It is administered from the second trimester of
pregnancy to six weeks after delivery.

Table 9. Dose and Schedule for Anti-Malaria Chemoprophylaxis


Drug Schedule
Adult dose
Doxycycline tablet (100 mg); start two to three 100 mg daily (contraindicated
days prior to travel; continue up to four weeks pregnant and lactating women)
upon leaving the area

Pediatric dose
in 2 mg/kg up to 100 mg daily (not
recommended for seven years and
younger)

Mefloquine tablet (250 mg base); start one 250 mg weekly


week before travel; continue up to four weeks
upon leaving the area

> 45 kg = 250 mg
< 45 kg = 5 mg/kg up to maximum of
250 mg

Table 10. Dose and Schedule for Anti-Malaria Chemoprophylaxis Among Pregnant Women
Stage of pregnancy
First trimester

Chemoprophylactic drug
Standby treatment
Chloroquine tablets at two tablets weekly two weeks before Quinine alone as in Table 6
travel, during stay, and until four weeks after leaving the
area.

Second and third trimesters

Pyrimethamine-sulfadoxine (as in Table 1) for each trimester


of stay

Chemoprophylaxis alone does not give 100% protection against infection with the Plasmodium parasite and personal protective
measures are just as important.
B. Personal Protective Measures in Areas Endemic for Malaria
1. Wear light-colored, long-sleeved clothing and trousers when going out at night.
2. Screen doors and windows or otherwise windows and doors should be closed at night.
3. Use mosquito net, preferably impregnated with permethrin or deltamethrin in endemic areas.
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Annex 8
HOSPITAL MANAGEMENT PROTOCOL FOR MEASLES
I.

Routine Laboratory Examinations


1. CBC
2. Measles IgM determination (as per DOHs Measles Elimination Campaign)
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Specific therapy: None
B. Symptomatic and Supportive Therapy
1. Give Vitamin A using the following dosages:
a. For infants less than one year
b. For children > one year

: 100,000 I.U.
: 200,000 I.U.

Dose should be repeated the next day and 4 weeks later if with ophthalmologic evidence of Vitamin A deficiency.
2. Give Paracetamol at 10-15 mg/kg/BW q 4 to 6 hr for fever.
3. Give oral bronchodilator to patients with wheezes or acute respiratory distress if tolerated. However, if unresponsive shift
to nebulization (0.5 ml Salbutamol plus 2 ml sterile water) q 2 - 4 hours. As the severity of the attack decreases, change
from nebulization to oral Salbutamol using the following dosages:

4.
5.
6.
7.

a. 2-12 months (<10kg)


: tab (2mg tab) or tab (4 mg tab)
b. >12 months
: 1 tab (2mg tab) or tab (4 mg tab)
Give oxygen if child is cyanotic or unable to drink, restless and with chest in-drawing.
Suction secretions if necessary for airway clearance.
Advise complete bed rest until temperature returns to normal.
Encourage breast-feeding /frequent meals and increase fluid intake.
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B. Management of Complications
1.
2.
3.
4.
5.

Pneumonia: follow management guidelines for Pneumonia


Meningitis/Encephalitis: follow management guidelines for Meningitis/ Encephalitis
Severe dehydration: follow CDD guidelines
Otitis Media: give Procaine Penicilllin at 300,000 - 600,000 U IM 2 x a week for 2 weeks then shift to oral medications
Stomatitis (Oral Thrush): give Nystatin at 25,000 - 250,000 U 3 x a day for 3 - 5 days

III. Guidelines for Patients Discharge


A. Criteria for Discharge
1. Afebrile for 2 days
2. Normal RR
3. Able to feed and drink
B. Follow-up Advice: Advise patient/ parent to follow-up 1 week after discharge at any health care facility.
IV. Preventive Measures
1. Educate parents/guardian/ relatives on the importance of measles vaccination.
2. Give measles immunization (see annex 21a on Immunization Schedule for Children)
a. Live measles vaccine if given within 72 hours of exposure may be protective in some cases.
b. May give passive immunization (Measles IG) at a dose of 0.25 mkBW, 0.5ml/kg for immuno-compromised patient
(max 15ml) within 6 days of exposure to prevent or modify measles.

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Annex 9
HOSPITAL MANAGEMENT PROTOCOL FOR MUMPS
I. Routine Laboratory Examination
- CBC
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Specific Therapy: none
B. Supportive and Symptomatic therapy
1. Give Paracetamol (10-15mkd q 4-6 hr) for fever.
2. May give analgesic for pain.
3. Manage complications:
a. Encephalitis: follow management guidelines for Encephalitis
b. Pancreatitis: follow management guidelines for Pancreatitis
c. Orchitis: follow management guidelines for Orchitis

III. Guidelines For Patients Discharge


A. Criteria for Discharge
1. Afebrile and active for at least 2 days
2. Resolution of other symptoms or complications

IV. Preventive Measures


1. Isolate patient and observe droplet precautions until 9 days after onset of parotid swelling
2. Mumps vaccine as part of MMR (see annex 21a and 21b on Immunization Schedule)

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Annex 10
HOSPITAL MANAGEMENT PROTOCOL FOR PNEUMONIA - ADULT
I. Routine Laboratory Examinations
1. CBC
2. Blood culture and sensitivity
3. Chest x-ray
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Antibiotic Therapy
1. For Moderate Risk CAP: (Unstable vital signs, unstable co-morbid condition, evidence of extrapulmonary sepsis,
suspected aspiration, CXR findings of multilobar infiltrates, pleural effusion or abscess,
progression of findings to > 50% in 24 hours)
Etiology: S. pneumoniae, M. pneumoniae, C. pneumoniae, H. influenzae, M. catarrhalis, L. pneumophilia, Enteric gram
negative bacilli and Anaerobes (in patients with risk of aspiration)
Antibiotics
Dosages
Drugs of Choice
Co-Amoxiclav IV
1.2 g every 8 hours
Ampicillin-Sulbactam IV

1.5 g every 8 hours

Plus any of the following


Azithromycin p.o. or IV

500 mg OD x 3 days

Clarithromycin p.o. or IV

500 mg BID x 7 days

Roxithromycin p.o.

150 mg BID or 300 mg OD x 7 days


Alternative Drugs

Levofloxacin p.o. or IV

500 mg every 24 hours

Moxifloxacin p.o. or IV

400 mg every 24 hours


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2. For High Risk CAP: [With any of the clinical features of Moderate Risk CAP plus any of the following: shock or signs
of hypoperfusion (hypotension, altered mental state, urine output <30 ml/hr), hypoxia (PaO2 <60
mm Hg) or acute hypercapnea (PaCO2 >50 mm Hg), CXR as in moderate risk CAP]
Etiology: same as Moderate risk CAP III plus P. aeruginosa and S. aureus

High Risk CAP No Risk for P. aeruginosa


Drugs of Choice

Dosages

High Risk CAP With Risk for P. aeruginosa


Drugs of Choice

Dosages

Ceftriaxone IV

3-4 g OD

Ceftazidime IV

2 g every 8 hours

Ampicillin-Sulbactam IV

1.5 g every 6-8 hours

Cefepime IV

2 g every 8-12 hours

Piperacillin-Tazobactam IV

2.25-4.5 g every 6-8 hours

Plus any of the following:


Azithromycin IV

500 mg OD

Sulbactam-Cefoperazone IV

1.5 g every 12 hours

Clarithromycin IV

500 mg BID

Imipenem IV

500 mg every 6 hours

Meropenem IV

1-2 g every 8 hours

Alternative Drugs:
Levofloxacin IV

500 mg every 24 hours

Moxifloxacin IV

400 mg every 24 hours

Plus any of the following:


Azithromycin IV

500 mg OD

Clarithromycin IV

500 mg BID

Levofloxacin IV

500 mg every 24 hours

Moxifloxacin IV

400 mg every 24 hours

With or without any of the following


Amikacin IV

10-15 mg/kg every 24 hours

Gentamicin IV

3-5 mg/kg every 24 hours

Netilmicin IV

5-7 mg/kg every 24 hours

Ciprofloxacin IV

400 mg every 12 hours

3. Duration of antibiotic therapy: 7-10 days


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4. May step-down IV to oral after 3-4days if patient is afebrile for > 24 hours, resolution of symptoms, etiology is not a
highly virulent pathogen, no unstable co-morbid condition and can tolerate oral medications.
B. Symptomatic and Supportive Therapy
1. Give IV Fluids
2. Give Paracetamol (500 mg q 4 hrs) prn for fever (To > 38 oC).
3. Start nebulization with Salbutamol 2 ml q 4 hrs for dyspnea and wheezes. As the severity of the attack decreases shift to
oral salbutamol (2mg/tablet) at 2 tablets 3 x a day. May give Aminophylline 250 mg ampule in 250 cc D5W to run at
0.4 -0.8 mkd via soluset for 4-6 hours
4. Give O2 inhalation for dyspnea

III. Guidelines for Patients Discharge


A. Criteria for Discharge
1. temperature of 36-37.5C
2. pulse < 100/min
3. RR between 16-24/min
4. systolic BP > 90 mm Hg
5. blood oxygen saturation > 90%
B. Follow-up Advice
1. Advise patient to complete duration of treatment regimen and follow-up 1 week after discharge to any health care
facility.
2. Advise a repeat chest x-ray 4 to 6 weeks after hospital discharge to establish a new radiographic baseline and to exclude
the possibility of malignancy associated with CAP, particularly in old smokers.

IV. Preventive Measures


1. Educate patient to improve/ maintain body resistance by proper nutrition and healthy lifestyle
2. Advise Pneumococcal vaccination (see annex 21b on Immunization Schedule for Adults) for > 60 years old , with chronic
illness, immunosuppression and residents of nursing homes and other long-term care facilities
3. Advise Influenza vaccination (see annex on Immunization Schedule for Adults) for persons aged > 50 yrs, with chronic
illness, immunosuppression, residents of nursing homes and other long-term care facilities, pregnant women on their 2nd or
3rd trimester, health care workers, household contacts and caregivers of persons with medical conditions, person who provide
essential and emergency community services or in institutional settings
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Annex 11a

CLINICAL DIAGNOSIS OF PNEUMONIA


FOR SPECIFIC PEDIATRIC AGE GROUPS
I. For > 5-13 years old
with fever, cough, signs of respiratory distress/ crackles on auscultation.
II. For 2 months-5 years old
A. Very Severe Pneumonia
with fever, cough, tachypnea/ retractions plus 1 or more of the following danger signs:
1. unable to drink
2. cyanosis
3. convulsion
4. abnormally sleepy
5. severe under nutrition
6. dehydration
B. Severe Pneumonia
with fever, cough, tachypnea with chest in-drawing without the danger signs.
C. Pneumonia
with fever, cough with fast breathing without chest in-drawing.
III. For < 2 months old
A. Very Severe Pneumonia
with fever or hypothermia, RR of > 60/ minute, central cyanosis and severe chest in-drawing plus one or more of
the following:
1. poor feeding
2. convulsion
3. stridor in a calm child
4. abnormally sleepy
5. wheezing
B. Severe Pneumonia
with fever or hypothermia, sustained RR of > 60/ minute and severe chest in-drawing.
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Annex 11b

HOSPITAL MANAGEMENT PROTOCOL FOR PNEUMONIA - PEDIA


I. Routine Laboratory Examinations
1. Chest x-ray
2. CBC with differential count
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Antimicrobial Therapy:
1. For 2 months to > 5 years old
a. For severe pneumonia: Benzyl Penicillin 50,000 U/KBW/dose IM (ANST) q 6 hrs for 4 days; when child improves,
shift to oral Amoxycillin to complete 7 days course of treatment. If no improvement within 72 hours after proper
assessment, treat as very severe pneumonia.
b. For very severe pneunomia: Chloramphenicol 25 mkd IM or IV q 6 hours for 4 days; when child improves, shift to
oral chloramphenicol to complete 10 days course of treatment.
c. If no improvement in 24 - 48 hours, suspect staphylococcal pneumonia especially if patient has been on antibiotic
therapy for quite a time. If patient deteriorates within 24 hours, add Cloxacillin/oxacillin 25 mkBW IM or IV q 6 hrs
plus Gentamycin or Netilmycin at 2.5 mkd IM ANST q 8 hrs.
d. If patient is still unresponsive after proper assessment, may shift to other antimicrobials based on culture and
sensitivity results and treat co-morbidity.
2. Infant less than 2 months old
a. Very Severe Pneumonia/Severe Pneumonia:
1) Benzyl Penicillin at 50,000 U/ KBW/dose IM (ANST) q 12 hrs for infants < 1 week old and q 6 hrs for > 1
week old plus any of the following aminoglycoside:
Gentamycin at 3-5 mkD or Netilmycin at 5-7 mkD or Amikacin at 10-15 mkD OD
2) Alternative Antibiotic Therapy:
a) Chloramphenicol at 25 mg/ KBW every 12 hours in young infants > 1 week old. Do not give to
premature infants.
b) Streptomycin 1.25 mg/kg every 12 hours can be substituted if gentamicin, Netilmicin, Kanamycin or
Amikacin is not available. Streptomycin should be reserved for treatment of TB, if possible.
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c) If aminoglycoside is unavailable, give Benzyl penicillin plus cotrimoxazole. Do not give cotrimoxazole
if neonate is jaundiced or premature.
b. For > 1 month old, step-down from parenteral to oral antibiotics may be initiated 48-72 hours after defervescence and
infant can tolerate oral medications.
B. Symptomatic and Supportive Therapy
1. Paracetamol for To > 38oC at 10-15 mkBW q 4-6 hrs and give tepid sponge bath. Chilling should be avoided since it
increases O2 consumption and CO2 production that will precipitates respiratory failure.
2. Determine the cause of wheezing and treat accordingly.
a. If wheezing is due to asthma give bronchodilator.
1) Start patient on inhaled bronchodilator (Salbutamol 1 nebule) every 30 minutes (max 3 doses) then assess and
reduce frequency as necessary. As the severity of the attack decreases change from nebulization to oral
salbutamol using the following dosages:
a) for < 10 kg child : tab (2mg tab) or tab (4 mg tab)
b) for > 10 kg child : 1 tab (2mg tab) or tab (4 mg tab)
2) May give Aminophylline if there is no improvement at a LD of 3-6 mg/kg, given IV over 20-30 minutes. Give IV
maintenance dosage as mg/kg/hour as follows:
a) Infants (<12 mos.) : 0.008/kg/hour
b) 1-9 y/o
: 0.8/kg/hour
c) 10-12 y/o
: 0.7/kg/hour
d) 13-16 y/o
: 0.5/kg/hour
b. For status asthmaticus, give Hydrocortisone at a LD of 10 mkd then maintain at a dose of 5-10 mkD q 6 hrs.
c. If wheezing is due to respiratory secretions, do chest tapping.
3. Give oxygen if child is cyanotic or unable to drink/feed, restless and with severe chest in-drawing. Consider ventilation/
intubation if there is no response to O2 inhalation.
4. Suction secretions if necessary for airway clearance.
5. Continue breast-feeding and/ or give frequent small feedings with aspiration precautions.
6. Hydrate patient adequately.

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C. Special Supportive Care for Infants


1. Maintain a good thermal environment.
a. Infant should be kept in a warm room (To = 25oC) because they lose heat rapidly especially when they are wet. Thus,
infants need to be kept dry and well wrapped or held close to mothers body. A hat or bonnet is valuable to prevent
heat loss from the head.
b. Avoid use of heat lamp (the bulb may break) or radiant warmer unless a nurse can be at bedside. Incubator is
hazardous unless it is functioning correctly and electric supply is constant.
c. Hands and feet should be warm and rectal temperature should be between 36.50C to 37.50C.
2. Careful fluid management.
a. Continue frequent breastfeeding unless child is in respiratory distress
b. If infant is unable to drink for >2 days, give 20 ml of milk by NGT 6 times a day (total 120 ml/kg/day). Expressed
breast milk is best.

III. Guidelines for Patients Discharge


A. Criteria for Discharge
1. afebrile
2. absence of difficulty of breathing (normal RR, no chest in-drawing) for 2-3 days
3. able to eat and drink
B. Follow-up Advice: Parents are advised to continue and complete medication of child, follow-up 1 week after discharge at
any health care facility

IV. Preventive Measures


Educate or inform parents on:
1. importance of primary immunization against diphtheria, pertussis, measles, Haemophilus influezae (Hib), invasive
pneumococcal disease (IPD) and tuberculosis (see annex 21a on Immunization Schedule for Children)
2. importance of breastfeeding/ proper feeding practices
3. proper sanitation and hygiene
4. timely consultation for illness at health centers or hospitals.

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Annex 12
HOSPITAL MANAGEMENT PROTOCOL FOR RUBELLA (GERMAN MEASLES)
I.

Routine Laboratory Examinations


1. CBC
2. Measles IgM determination (as per DOHs Measles Elimination Campaign)
Other examinations may be requested depending on co-morbid conditions/ complications

II.

Treatment Guidelines
A. Specific Therapy: none
B. Symptomatic and Supportive Therapy
1.
2.
3.
4.
5.
6.

III.

Give Paracetamol (10-15mg/kg/dose q 4-6 hr) for fever


Give pain relievers for arthritis/ arthralgia
Manage encephalitis if present
May give Immune Globulin to susceptible pregnant women within 1st week of exposure
Refer pregnant women to Obstetrician if with labor pains
Advise bed rest and keep patient warm and comfortable

Guidelines for Patients Discharge


A. Criteria for Discharge
1. afebrile for 2 days
2. good appetite and activity
3. resolution of complications
B. Follow-up Advice: Instruct patient to follow-up one week after discharge to any health care facility.

IV.

Preventive Measures
1. Isolate patient until 7 days from onset of rash and practice standard and droplet precautions.
2. Give Rubella vaccine (see annex 21a and 21b on Immunization Schedule for Children and Adults, respectively).
Contraindicated in the following conditions:
a. with Immunodeficiency diseases
b. ongoing suppressive therapy for malignancy or on prolonged steroid use
c. pregnancy or those who plan to get pregnant in next 3 months
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Annex 13

HOSPITAL MANAGEMENT PROTOCOL FOR SNAKE BITE


I.

Routine Laboratory Examinations


1. CBC with platelet count
2. Urinalysis
Other examinations may be requested depending on co-morbid conditions/ complications

II.

Treatment Guidelines
Table on Types and Signs of Envenomation and Implicated Snake

Type of
Envenomation

Local Effect

Systematic Effects

Snake

NEUROTOXIC

Slow swelling, then


necrosis

cobra

MYOTOXIC

None

VASCULOTOXIC

Rapid swelling, then


necrosis

ptosis, glossopharyngeal palsy, respiratory paralysis,


cardiac effect, effect such as hypotension,
bradycardia, arrhythmias or an abnormal ECG
myalgia on moving, paresis, myoglobinuria,
hyperkalemia
abnormal bleeding, non-clotting blood, shock

sea snake
vipers

A. Anti-venin Therapy
1. Observe patients without signs of envenomation for 24 hours for development of signs of envenomation (see above
table).
2. Give anti-venin therapy for those with signs of envenomation.
a.

Anti-venin should be used with extreme caution and only in life-threatening situation as in Neurotoxic and
Myotoxic envenomation.
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b. The therapy is contraindicated in patients with known allergic history to horse serum. If anti-venin must be used,
patients should be pre-treated with:

Pre-Treatment

Dosage

Drugs

Adult

Pedia

Epinephrine (1:1,000)

0.5 mg SQ

0.01 mg/kg SQ

OR
Diphenhydramine

25-50 mg/dose IM

1-2 mg/kg IM

AND
Hydrocortisone

250 mg IV initially, then 100 mg q 6 hr for 3 doses

5 mg/kg q 6 hr IV

c. Late serum sickness type of reactions to anti-venin may occur 5-24 days after anti-venin treatment in about
75% of patients.
d. It is never too late to give anti-venin if indicated. There is no standard dose for anti-venin because it is difficult to
determine the amount of venom to be neutralized. In children, the same or larger dose than adults may be given
because the same volume of venom is injected which is distributed in a smaller body fluid volume.
e. The dosage of Philippine Cobra antivenin is based on the toxic symptoms present in patients as follows:
1)

Mild envenomation
(local signs/symptoms, no systemic symptoms)
2) Moderate envenomation
(swelling spread beyond the bite, mild systemic and/or hematological symptoms)
3) Severe envenomation
(marked local and systemic effects, evidence of abnormal bleeding or hemolysis)

2 - 5 ampules
6 - 10 ampules
11 - 15 ampules

f. Antivenin should always be given by intravenous infusion, which is the safest and most effective route.
Depending on the severity of poisoning, 2-5 ampules diluted in 500 cc of isotonic fluid should be given by
intravenous infusion over 1-2 hours. It is repeated every 1- 2 hours until the neurologic signs are resolved.
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B. Prostigmine
1. Use Prostigmine at 50-100 ug/kg/dose q 8 hr by IV infusion over 4 hours in the absence of anti-venin.
2. Administer Atropine at 0.6 mg/dose q 6-8 hr IV push or infusion by titration using a different syringe or infusion
bag from Prostigmine to counteract the side effects of Prostigmine, particularly increased secretions, abdominal
pain, and loose bowel movement.
C. Antimicrobial Therapy
Give antibiotics to patients with infected snakebite wound only. May use any of the following:
1. Sulbactam/Ampicillin at 750 mg/dose/IVT x 3 days then shift to oral preparation for 4 more days
2. Coamoxiclav 600 mg/dose/IVT q 8 hr x 3 days then shift to oral preparation for 4 more days
D. Blood Transfusions
Transfuse blood and blood products to patients with vasculotoxic envenomation to correct defects in homeostasis
including coagulopathies and to replace destroyed RBC in patients with active bleeding as follows:
1. Whole Blood at 20 cc/KBW if with active bleeding/ shock.
2. Frozen plasma at 10 -15 ml/KBW given at 10ml/ minute if with prolonged PTT & PT, normal platelet & BT.
3. Platelets at 1 unit/7 kg given at 5 ml/ min if with platelet <100,000/mm3, prolonged BT & normal PTT & PT.
4. Cryoprecipitate at 1 unit/ 5kg given at 10 ml/minute if with prolonged PTT and normal PT, Platelet, and BT.
E. Symptomatic and Supportive Therapy
Give IV fluids (Lactated Ringers solution or Normal Saline) to run at KVO.

III. Guidelines for Patients Discharge


A. Criteria for Discharge
1. No signs of envenomation after 24 hours of observation.
2. Twenty-four hours after complete resolution of signs of envenomation.
B. Follow-up Advice: Patient should be advised to follow-up one week after discharge particularly those who had signs of
envenomation.

IV. Preventive Measures


Educate the patient to wear protective clothing and/or to carry light when walking in grass fields especially at night.
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Annex 14
HOSPITAL MANAGEMENT PROTOCOL FOR TETANUS NON-NEONATORUM
I. Routine Laboratory Examination
-

CBC

Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


Classify tetanus by clinical stages using the table below:

Clinical Stages of Tetanus


CRITERIA

STAGE I
(Mild)

STAGE II
(Moderate)

Incubation period
Period of onset
Trismus (difficulty in opening the mouth)
Dysphagia (difficulty of swallowing)
Muscular rigidity
Paroxysmal spasm

> 11 days
> 7 days
mild or absent
absent
mild or localized
absent

8-10 days
4-6 days
moderate
present
pronounced
mild and short

Sympathetic overactivity

absent

absent or mild hypotension

Dyspnea or cyanosis

absent

absent

STAGE III
(Severe)
< 7 days
< 3 days
severe
present
severe, boardlike
frequent, violent, prolonged &
asphyxial
unstable BP (hypertension/
paroxysmal tachycardia & other
cardiac arhythmias
present
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A. Antitoxin Administration
1. Use Anti-Tetanus Serum (ATS) after negative skin test; if skin test is positive, give Tetanus Immune Globulin (TIG)
using the following dose:
Adult, infant, and children

ATS: 40,000 IU given at IM, IV


TIG: 3,000 IU, IV drip or IM

2. Give the whole dose of antitoxin on the day of admission. Serum intended for intramuscular route should be warmed
prior to injection to facilitate absorption.
3. If TIG is given by IV drip, administer at a high dilution (at least 1:20) and give very slowly (15 drops/minute) while the
patient is kept under close clinical supervision. If any signs of intolerance occur such as hypotension, the intravenous
treatment must be stopped immediately and the patient is kept under close observation for the next 4-6 hours.
B. Tetanus Toxoid (TT) Administration
1. Give TT as follows:
TT 1
TT 2
TT 3
TT 4
TT 5

on discharge
at least a month after TT 1
6 months after TT 2
1 year after TT 3
1 year after TT 4

2. For children < 7 yrs old, may add Pertussis and Diphtheria toxoid to TT as a combination (DPT).

C. Antimicrobial Therapy
1. For Uncomplicated Tetanus

Antibiotics
Drug of Choice
Metronidazole
Penicillin G Sodium
Chloramphenicol

Dosage
Adult
500 mg IV infusion q 8 hr x 10 days
Alternative Drugs
2-3 MU q 4 hr IV x 10-14 days
500 mg to 1 gm IV q 6 hr

Children
30 mkD (4 divided doses) x 10 days
200,000 U/kg/dose x 10-14 days
250 mg IV q 6 hr
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2. With Concomitant Sepsis/ Pneumonia


Add any one in group A antibiotics and +/- any of the group B antibiotics:

Antibiotics

Dosage
Adult

Ceftazidime
PiperacillinTazobactam
Imipenem
Meropenem
Amikacin
Netilmycin
Gentamycin

Group A
3-6 gm/day (divided into 3 doses) x 7-10
days
2.25 to 4.5 mkd q 6-8 hr x 7-10 days

Children
100 mg/kg/day in 3 divided doses x 7-10 days

500 mg q 6-8 hr x 7-10 days


500 mg q 8 hr x 7-10 days

100-200 mkD (Piperacillin) in 4 divided doses x


7-10 days
60 mkD in 4 divided doses x 7-10 days
60 mkD in 3 divided doses x 7-10 days

Group B
10-15 mg/kg OD IV
5-7 mg/kg OD IV
3-5 mg/kg OD IV (max 160 mg/day)

10-15 mg/kg OD
5-7 mg/kg OD IV
3-5 mg/kg OD IV

D. Control of Spasms
1. Give Diazepam as follows:
a. In stage I and II, Diazepam should be given by IV bolus at 0.2-0.4 mkd, max 10 mg q 4-6 hrs.
b. In stage III cases (severe), Diazepam is given by continuous IV drip and IV bolus as follows:
1) Adults: 60 mg/500 cc D5W to run in 8 to 12 hrs plus 5-10 mg/ IVP q 2-4 hr then reduce frequency
accordingly (q 46 hr) as soon as spasms lessen in frequency and intensity (see example). Some adults tolerate
the maximum dose of 300 mg/24 hours.
2) Pedia: Increase IVP q 2-4 hr then reduce frequency accordingly (q 3-4 hr) as soon as spasms lessen in
frequency and intensity (see example).
a) Diazepam/IV push should be used with caution in patients with respiratory problems.
b) Shift to oral Diazepam or other muscle relaxant as soon as the spasm is controlled (see example below).

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Step-Down Approach in Diazepam Administration in Tetanus Management


For Example: if patient presents spasm with: frequency of > 24/day and duration of > 60 second/attack
May give Diazepam as follows:
Total dose: 240 mg-300 mg
60 mg q 8 hr IV (in D5W) drip to run for 8 hrs (max dose 180 mg)
10 mg q 2-4 hr IV bolus (60-120 mg)
After 48-72 hours, may start to taper Diazepam, if spasm with: frequency of 12-24/day & duration of 30-60
second/attack
Suggested Diazepam dose as follows:
60 mg q 12 hr IV drip to run for 12 hrs
10 mg q 3-4 hr IV bolus

Total dose: 180 mg-200 mg

May further taper Diazepam if spasm with: frequency of < 12/day and duration of < 30 seconds
Give Diazepam at the following dose:
80 mg OD IV drip or 40 mg IV q 12 hrs to run for 12 hrs
10 mg q 4-6 hr IV bolus

Total dose: 120 mg-140 mg

Then give Diazepam as follows:


40 mg OD IV drip to run for 24 hrs
10 mg q 4-6 hr IV bolus

Total dose: 80-100 mg

Further taper Diazepam if spasm with: frequency of < 6/day and duration of < 10 seconds
Discontinue IV drip
Continue with 10 mg q 4-6 hr IV bolus

Total dose: 40-60 mg

May shift Diazepam IV to po in the absence of spasm and taper dose in 5 to 7 days

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2. Add either Chlorpromazine (Thorazine) or Phenobarbital for Spasms not controlled by Diazepam alone
a. Chlorpromazine for Adult and Children
Chlorpromazine and Diazepam should be given alternately at an interval of 6 hours. The doses are staggered so
that the patient receives one of the two drugs q 3 hrs to ensure an adequate level of both drugs throughout but
prevents a toxic level of either. However, close monitoring is essential for possible respiratory and circulatory
depression.
Example: Chlorpromazine*: 0.5 mkBW IVP q 6 hr (check IV line before IVP, the drug is irritating to
tissues)
Time: 9 3 9 3 oclock
Diazepam*

: 5-10 mg IV push q 6 hr
Time: 6 12 6 12 oclock

* Reduce to about the dose of each drug as spasm lessens in frequency or intensity.
b. Phenobarbital
Children
Adult

: LD of 10-15 mg/kg then maintained at 5mkD slow IV in 3 divided doses


: 130 mg every 6 hours

E. Symptomatic and Supportive Therapy


1.
2.
3.
4.

Minimize unnecessary maneuvers/manipulations that will stimulate tetanospasms.


Perform wound debridement after the patient has received optimal sedation and relaxation.
Monitor closely input and output, and vital signs
May start NGT feeding as soon as tolerated.

*May do Tracheostomy/ intubation to patients who have respiratory distress/ impending respiratory failure

IV.

Guidelines for Patients Discharge


1. Criteria for Discharge
a. Ability to open the mouth and swallow liquid/solid foods.
b. No spasms for 7 days.

2. Follow-up advice
a. All children < 7 y/o are advised to complete the DPT immunization.
b. Patients are advised to follow-up a week after discharge to evaluate if home medications needs to be continued.
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IV. Preventive Measures


Educate on proper wound management as follows:
1. All wounds must be thoroughly cleansed, foreign materials removed and necrotic tissues debrided. Povidone-iodine is
the most effective agent for skin decontamination.
2. Antimicrobials may be given to deal with wound infection or to kill the vegetative forms of Clostridium tetani.
a. Active and passive anti-Tetanus immunization. (see annex 18a on anti-Tetanus immunization)
b. Practice universal precautions.
c. Educate patient and the public on the necessity of completing immunization, the kind of injury prone to tetanus,
and proper wound care.

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Annex 15
HOSPITAL MANAGEMENT PROTOCOL FOR TYPHOID FEVER
I. Routine Laboratory Examinations
1.
2.
3.
4.

CBC, platelet count


Blood culture and sensitivity test before antibiotic therapy
Stool/ urine culture and sensitivity test - 2nd to 3rd week
Serologic test (Salmonella EIA, Tubex TF)

Other examinations may be requested depending on co-morbid conditions/ complications


II.

Treatment Guidelines
A. Antimicrobial therapy
1. For Uncomplicated Typhoid Fever
Give any of the following antibiotics of choice and switch parenteral to oral treatment within 48 hours after
resolution of fever and if patient can tolerate oral medications.

Antibiotics
Adult
3-4 gm/day in 3-4
divided
doses for 2
weeks
AMOXICILLIN Oral
3 gm/day in 3 divided
doses for 2 weeks
COTRIMOXAZOLE Oral 800/160mg 1 tab BID for 2
weeks
CHLORAMPHENICOL
IV/ Oral

Dosage
Pregnant
NOT RECOMMENDED

3 gm/day in 3 divided
doses for 2 weeks
NOT RECOMMENDED

Children
75-100 mkBW in
4 divided doses for 2
weeks
75-100 mkD in 3 divided
doses for 2 weeks
8 mkD of TMP in 2
divided doses for 2
weeks
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2.

For Complicated / Suspected Drug Resistant Typhoid Fever


Give any of the following antibiotics of choice and switch parenteral to oral treatment, within 48 hours
after resolution of fever and if patient can tolerate oral medications.

Antibiotics
Drugs of Choice
CEFTRIAXONE

Dosage
Adult
3-4 IV gm/day for 5-7
days

Pregnant
3-4 IV gm/day for 5-7 days

OFLOXACIN*

200-400 mg IV q 12 hrs NOT RECOMMENDED


for 7-10 days
CIPROFLOXACIN*
200-400 mg IV q 12 hrs NOT RECOMMENDED
for 7-10 days
Alternative Drugs
AZITHROMYCIN
1 gm initially then
1 gm initially then 500 mg
500mg OD for 7 days
OD for 7 days
CEFIXIME
400 mg BID for 7-14
400 mg BID for 7-14 days
days
*Not recommended in patients <18 years

Children
Ceftriaxone 80-100 mkBW
for 5-7 days
NOT RECOMMENDED
NOT RECOMMENDED

8-10 mkd OD for 7 days


15-20 mkD for 7-14 days

B. Supportive and Symptomatic Treatment of Typhoid Fever


1. Give soft diet
2. Hydrate patient adequately with IV fluids and correct any electrolyte imbalance
3. Give Paracetamol and tepid sponge bath for fever
4. Ambulate patients in gradual manner
C. Management of Complications
1. Give high-dose dexamethasone at 3 mkd IV LD followed by 8 doses of 1 mg/kg q 6 hrs for typhoid toxemia
2. Transfuse appropriate blood components for the following conditions:
a. Give FWB at 10-15 ml/KBW for significant blood loss
b. Give FFP at 10 ml/KBW for adult & 15 ml/KBW for cases of DIC and prolong Pro-time
c. Give platelet concentrate at 1 unit/ 7-10 KBW for platelet count <10,000
3. Refer severe intestinal bleeding or bowel perforation for surgical evaluation

III. Preventive Measures


Advice personal hygiene and proper environmental sanitation
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Annex 16
HOSPITAL MANAGEMENT PROTOCOL FOR VARICELLA (CHICKEN POX)
I. Routine Laboratory Examination
-

CBC

Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Anti-viral Therapy*
1. Give oral Acyclovir at 20 mkd (max 800 mg/dose) 5 x a day for 5 days within 24-48 hrs from onset of rash in the
following cases:
a. > 12 years old
b. with chronic cutaneous or pulmonary disorder
c. on long term salicylate therapy or on short/intermittent/aerosolized courses of corticosteroid
d. adult secondary household cases
e. pregnancy during the second and third trimester
* Alternative anti-viral drugs for adults and adolescence: Valacyclovir 1 gram TID for 5days
2. Give IV acyclovir at 10-15 mkd as 1 hr infusion q 8 hrs for at least 5 days in immuno-compromised cases (including
newborns).

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B. Symptomatic and Supportive Therapy


1.
2.
3.
4.

Give Paracetamol (10-15 mkBW q 4-6 hr) for fever. Avoid aspirin.
Apply NSS or aluminum acetate compression on lesions.
Give anti-histamine for itchiness.
Give antibiotics if with secondary bacterial infections.

C. Management of Complications
Give IV Acyclovir at 10-15 mkd as 1 hr infusion q 8 hrs for at least 5 days if with the following complications:
1. Pneumonia: follow management guidelines for Pneumonia
2. Meningitis/Encephalitis: follow management guidelines for Meningitis/ Encephalitis
3. Varicella with hemorrhagic rashes/ bleeding complications:
a. Transfuse blood if bleeding is severe to replace blood loss
b. Correct abnormal bleeding parameters.

III. Guidelines for Patients Discharge


A. Criteria for Discharge
1. Afebrile for 2 days
2. All lesions have crusted
3. Constitutional signs & symptoms have resolved
B. Follow-up Advice: Instruct patient to follow-up one week after discharge at any health care facility.

IV. Preventive Measures


1. Isolate patient using standard precaution (airborne and contact).
2. Recommend Varicella Zoster immune globulin prophylaxis at 1 vial/10 KBW given within 48 hrs after exposure for
high-risk individuals (immunocompromised children, pregnant women, newborn infants exposed to maternal
varicella).
3. May initiate active immunization among contacts with Live Varicella vaccine (see annex 21a and 21b on
Immunization Schedule for Children and Adults, respectively)

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Annex 17

HOSPITAL MANAGEMENT PROTOCOL FOR VIRAL HEPATITIS A


I. Routine Laboratory Examinations
1. CBC, platelet
2. urinalysis
3. fecalysis
4. ALT/ALT, alkaline phosphatase, total bilirubin, direct and indirect bilirubin
5. Anti-HAV IgM
Other examinations may be requested depending on co-morbid conditions/ complications

II. Treatment Guidelines


A. Specific Treatment: None
B. Symptomatic and Supportive Treatment
1. Give Cholestyramine at 8 gm po OD/BID or Hydroxyzine at 10-25 mg (pedia 0.6mgkd) BID for pruritus
2. Give Hyoscine N-Butyl Bromide at 1 ampule IV q hr prn as pain reliever
3. Give high caloric diet
4. Provide adequate hydration
5. Advise bed rest for the very ill
C. Management of Complications
1. Hepatic Encephalopathy
a. Restrict protein intake (0.5g/KBW/day) for a limited period of time
b. Institute gut-cleansing and ammonia-lowering measures as follows:
1) Give Lactulose at 15 to 60 ml/dose orally or nasogastrically.
2) Give Neomycin at 1 gm q 6 hrs po or Metronidazole at 250 mg 1 tab q 6 hr po (max of 2 weeks)
3) Give L-ornithine L-aspartate at 4-8 ampules (0.5 gm/ml)/day

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2. Cerebral Edema
a. Administer Mannitol IV at 100 cc IV drip q 4-6 hrs
b. Give Phenytoin at 100 mg q 8-12 hrs for convulsion/seizure (not indicated for first episode of seizure)
c. Hyperventilate patient
3. Bleeding Secondary to Decreased Clotting Factors
a. Give phytomenadione at 10 mg/ml SQ/IV OD for three days
b. Transfuse blood and blood products for active bleeding and for those undergoing invasive procedures
4. Gastrointestinal Bleeding
Give Proton-pump inhibitor (Omeprazole) at 40 mg IV OD or H 2 receptor antagonist (Ranitidine, Famotidine) at 50
mg IV q 8-12 hrs with Sucralfate at 1 gm 1 tablet q 4-6 hrs
5. Portal Hypertension
Give Propanolol at 10 mg TID or Isosorbide dinitrate 10-20 mg BID
6. Ascites and Edema
a. Limit fluid intake to 1.0 to 1.4 liter/day for patient with moderate to massive ascites
b. Give Furosemide at 20-40 mg OD/BID &/or Spironolactone 25 mg BID/QID
c. Do serial paracentesis for very tense ascites
d. Give Albumin 25% infusion for hypoalbuminemia
7. Hypoglycemia
a. Give 50% ml Dextrose solution IV over a period of 5 min, then follow with continuous infusion of D5W or D10W
b. Monitor hemoglucotest as frequently needed

III . Guidelines for Patients Discharge


A. Criteria for Discharge
1. Improved condition
a. afebrile for 72 hours
b. resolutions of signs and symptoms
2. Improved laboratory status
At least 50% improvement in values of monitored laboratory parameters or less than 10 fold increase
B. Follow-up Advice: Advise the patient to follow-up one week after discharge to any health care facility.
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IV. Preventive Measures


1. Educate on good personal hygiene
2. May give vaccination as follows:
a. Inactivated Hepatitis A vaccine (see annex 21b on Immunization Schedule for Adults) in the following individuals:
1) Travelers to areas or countries with highly endemic Hepatitis A
2) Persons in prostitution (PIP)
3) Intravenous drug users
4) Persons with clotting disorders
5) People with chronic liver disease
b. Immune globulin as pre-exposure and post-exposure prophylaxis at 0.06 mL/kg IM

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Annex 18a
LOCAL WOUND MANAGEMENT
I. Treatment Guidelines
A. Antimicrobial Therapy for Local Measures
Oral Antibiotic for 3-7 days
Cloxacillin
Amoxicillin
Co-amoxiclav

Adult
500 mg 1cap q 6 hr
500 mg 1 cap q 8 hr
625 mg 1 tab q 12 hr

Pedia
50-100 mkD in 4 divided doses
30-50 mkD in 3 divided doses
30-50 mkD in 2 divided doses

B. Supportive Therapy
Pain Reliever

Adult

Pedia

Mefenamic acid

500 mg 1 cap q 8 hr

25 mkD in 3-4 doses

Ibuprofen

200-400 mg 1 cap q 6-8 hr

5-10 mkd q 6-8 hr

C. Anti-Tetanus Immunization
Anti-Tetanus immunization should be based on patients immunization status and type of wound by exposure.

Immunization Status

Dirty Wound Anti-Tetanus


Immunization

Active
Passive
Unknown or < 3doses*
TIG or ATS
TT 1,2,3
3 doses* not more than 5 years
None
None
3 doses* more than 5 to 10 years
None
Booster dose (1 TT)
3 doses* more than 10 years
Booster dose (1 TT)
TIG or ATS
*completed 3 doses of tetanus immunization (DPT1, 2, 3/TT 1, 2, 3)

Clean Wound Anti-Tetanus


Immunization
Active
TT 1,2,3
None
None
Booster Dose (1 TT)

Passive
None
None
None
None
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Types of Wound by Exposure


Clinical Features
Duration of wound
Configuration
Depth
Mechanism of entry
Devitalized Tissue
Contamination (dirt, saliva, etc.)

Dirty Wound
> 6 hours
stellate, avulsion
> 1 cm
missile, crush, burn
present
present

Clean Wound
6 hours
linear
1 cm
sharp surface (glass, knife)
absent
absent

D. Recommendation on Anti-Tetanus Immunization


1. Give Tetanus Toxoid (TT) 0.5 ml intramuscularly as follows:
TT 1 upon consult
TT 2 a month after TT 1
TT 3 6 months after TT 2
a. one booster dose of TT every 10 years
b. should be administered on the deltoid area and must be opposite the TIG or ATS injection site
2. Give Tetanus Immune Globulin (TIG) 250 IU intramuscularly* regardless of age/weight or Anti-Tetanus Serum (ATS)
intramuscularly after negative skin test as follows:
Pediatric Dose by age:
< 5 yrs. old - 1500 IU
5-13 yrs old - 3000 IU
>13 yrs old - 4500 IU

Adult Dose by weight:


weight < 50 kg 4,500 IU
weight > 50 kg 6,000 IU

* preferred injection site for pediatric patients is the anterolateral aspect of the thigh

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Annex 18b

MANAGEMENT PROTOCOL OF DOG/CAT BITE


I. Post-Exposure Treatment (PET)
1. Do not delay initiation of PET for any reason regardless of interval between exposure and consultation as it increases the
risk of rabies and it is associated with treatment failure.
2. Assess and classify according to the three categories of exposure and follow its corresponding management as shown in the
following table:
Table 1. Management Based on Categories of Exposure to Rabid Animal or Animal Suspected to be Rabid
Category of Exposure
Management
CATEGORY I
1) feeding/touching an animal
1) Wash exposed skin immediately with soap and water
2) licking of intact skin (with reliable history and thorough 2) 2. No vaccine or RIG needed
physical examination)
CATEGORY II
1) nibbling/nipping of uncovered skin with bruising
2) minor scratches/abrasions without bleeding**
3) licks on broken skin
** includes wounds that are induced to bleed

Start active immunization immediately and depending on the


condition of the biting animal:
1) give complete vaccination regimen until day 90 if:
a) animal is rabid, killed, died or unavailable for 14-day observation
b) animal under observation died within 14 days and had signs of
rabies IFAT is positive or no IFAT testing was done
2) give complete vaccination regimen until day 30 if:
a) animal is alive and remains healthy after 14-day observation
period
b) animal under observation died within 14 days but had no signs of
rabies and IFAT negative
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CATEGORY III

Start active and passive immunization (RIG) immediately and


depending on condition of the biting animal:

1) single or multiple transdermal bites or scratches (include


puncture wounds, lacerations, avulsions)
2) contamination of mucous membrane with saliva (ie. licks)
3) exposure to a rabies patient through bites, contamination of
mucous membranes or open skin lesions with body fluids
(except blood/feces) through splattering, mouth-to-mouth
resuscitation, licks of eyes, lips, vulva, sexual activity,
exchanging kisses on the mouth or other direct mucous
membrane contact with saliva
4) handling of infected carcass or ingestion of raw infected
meat
5) all Category II exposures on head and neck area

1) give complete vaccination regimen until day 90 if:


a) animal is rabid/ killed/ died or unavailable for 14-day
observation
b) animal under observation died within 14 days and had signs of
rabies
IFAT positive or no IFAT testing was done
2) give complete vaccination regimen until day 30 if:
a) animal is alive and remains healthy after 14-day observation
period
b) animal under observation died within 14 days but had no signs
of rabies and IFAT negative

A. Immunization
1. Active Treatment Regimen
a. Use the Thai Red Cross Intradermal (ID) Regimen (see Table 2) in the following situations:
1) when two or more cases are seen at a time (within 8 hours) in the health facility
2) presence of trained personnel on intradermal injection
+

Table 2. Thai Red Cross Intradermal (ID) Regimen


Schedule of
Immunization
Day 0

Types and Dose of


Active Anti-Rabies Vaccine
PVRV
PCECV
0.1 ml
0.2 ml

Left and right deltoids or anterolateral thighs in infants

Day 3
Day 7
Day 14

0.1 ml
0.1 ml
None

0.2 ml
0.2 ml
None

Left and right deltoids or anterolateral thighs in infants


Left and right deltoids or anterolateral thighs in infants
None

Day 30

0.1 ml

0.2 ml

One deltoid or anterolateral thigh in infants

Day 90

0.1 ml

0.2 ml

One deltoid or anterolateral thigh in infants

Site of injection

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b. Use the Zagreb Intramuscular (IM) Regimen (see Table 3) in the following situations:
1) when only one case is seen at a time (within 8 hours) in the health facility
2) among patients under treatment with choloroquine, anti-epileptic drugs and systemic steroids
3) immunocompromised individuals (such as those with HIV infections, cancer/transplant patients on
immunosuppressive therapy, etc.)
Table 3. Zagreb Intramuscular (IM) Regimen
Schedule of
Immunization
Day 0
Day 7
Day 21

Types and Dose of Active Anti-Rabies Vaccine


PVRV
PCECV
0.5 ml
1.0 ml
0.5 ml
1.0 ml
0.5 ml
1.0 ml

Site of Injection
Left and right deltoids or antero-lateral thigh in infants
One deltoid or antero-lateral thigh in infants
One deltoid or antero-lateral thigh in infants

2. Passive Treatment Regimen


a. Give Rabies immune globulins (RIG) once only at the bite site by infiltration. If the computed amount is not
anatomically feasible for single infiltration, the remaining RIG is given by deep IM at a site distant from the
vaccine injection.
Table 4. Types, Preparation and Dose of Rabies immune globulins
Rabies Immune globulins
Human rabies immune globulin (HRIG)
Equine rabies immune globulin (ERIG)*
*After negative skin test. If positive, give HRIG.

Preparation
150 IU/ml in 2 ml vial
200 IU/ml in 5 ml vial

Dose
20 IU/kg
40 IU/kg

b. Administer RIG as follows:


1) RIG should be administered ideally at the same time with the first dose of vaccine (day 0) or within 7 days
from day 0.
2) RIG should not exceed the computed dose. If the computed volume is insufficient to infiltrate all bite
wounds, it may be diluted with sterile saline 2 or 3 fold for thorough infiltration of all wounds.
3) Use a gauge 23 or 24 needle, 1 inch length for infiltration. Multiple needle injections into the same wound
should be avoided.
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4) Give HRIG in patients with the following conditions:


a) Positive skin test to ERIG or history of hypersensitivity to equine sera
b) Multiple severe exposures (especially where dog is sick or suspected of being rabid)
c) Symptomatic HIV infected patients
B. Local Wound Treatment
1.
2.
3.
4.
5.

Wash wounds immediately and vigorously and flush with soap and water preferably for 10 minutes.
Apply povidone iodine or any antiseptic.
Suture wounds only if absolutely necessary, and after RIG infiltration.
Do not apply garlic or use tandok/tawak on the bite site.
Give anti-tetanus immunization, if indicated. (see annex 18a on anti-Tetanus Immunization Schedule)

C. Antimicrobial Treatment
1. Antimicrobials are recommended for the following conditions:
a. All frankly infected wounds
b. All category III cat bites
c. All other category III bites that are either deep, penetrating, multiple or extensive or located on the
hand/face/genital area
2. Use any of the following antibiotics:
Table 5. Dose and Schedule of Antibiotics for Dog/Cat Bite
Dosage
Antibiotic
Amoxicillin
Co-amoxiclav

Adult
500 mg 1 cap q 8 hr
625 mg 1 tab q 12 hr

Pedia
30-50 mkD in 3 divided doses
30-50 mkD in 2 divided doses

II. Post-Exposure Treatment under Special Conditions


1. Exposed persons who present for evaluation or treatment weeks or months after the bite should be treated as if exposure
has occurred recently. However, if the biting animal has remained healthy and alive until 14 days after the bite, no
treatment is needed.
2. Bites by rodents, rabbits and domestic animals other than dogs and cats do not require rabies PET unless the animal
is proven rabid. Anti-tetanus prophylaxis should be given.
3. Patients bitten by monkeys and other wild animals should be managed similarly as patients bitten by dogs and cats.
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III. Post-Exposure Treatment of Previously Immunized Animal Bite Patients


1. Local wound treatment should always be carried out.
2. Persons with a second exposure after having previously received full course of PET should be vaccinated as follows:
Table 6. PET Schedule for Previously Immunized Patients
Time interval
< than 3 months
No booster dose

Treatment Dose and Schedule

3 months - 1 year
1 year to 3 years

1 booster dose (D0) given ID at 0.1 ml for PVRV or 0.2 ml for PCEC or IM at 1 vial of PVRV or PCEC
Two booster doses (D0, D3) given ID at 0.1 ml. for PVRV or PCEC or IM at 1 vial of PVRV or PCEC

> than 3 years

Full course of active immunization, no RIG

IV. Post-Exposure Treatment for Patients with PEP with First Exposure
1. Persons with first exposure after having received PEP should be vaccinated as follows:
Table 7: PET for Patients with PEP (for Category II & III) with First Exposure
PEP Status

Complete Primary Vaccination


(no booster yet)

Time Interval
(from the last dose of PEP)
< 2 years
> 2 years
< 2 years

Complete Primary
Vaccination with booster
shots

> 2 years but < 3 years


* > 3 years

Treatment
2 Booster doses (D0, D3)
no RIG
Full active immunization
no RIG
1 Booster dose (D0)
no RIG
2 Booster Doses (D0, D3)
no RIG
Full active immunization
no RIG

* Advise RFFIT to determine level of neutralization antibody titer (adequate level: 0.5 IU)
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V.

Pre-Exposure Prophylaxis (PEP)


May give pre-exposure prophylaxis (see Table 8) for non-bite exposures such as:
1. contact with rabies patients thru sharing of eating/drinking utensils
2. casual contact to patient with signs and symptoms of rabies
Table 8. Schedule, Dose and Route of Anti-Rabies Vaccine for Pre-Exposure Prophylaxis
Route
of
Administration
Intradermal
Intramuscular

Schedule and Dose


Day 0
0.1 ml
1 vial
(0.5 ml)

PVRV
Day 7
0.1 ml
1 vial
(0.5 ml)

Day 21/28
0.1 ml
1 vial
(0.5 ml)

Day 0
0.1 ml
1 vial
(1.0 ml)

PCECV
Day 7
0.1 ml
1 vial
(1.0 ml)

Day 21/28
0.1 ml
1 vial
(1.0 ml)

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Annex 19

MANAGEMENT PROTOCOL OF SHOCK


Treatment Guidelines
1. Secure airway of the patient. Give O2 inhalation or intubate patient if necessary and monitor vital signs.
2. Start double intravenous lines with large bore needles (gauge 16 or 18 for adults, gauge 22 for pediatrics and gauge 24 for
infants).
3. Give an initial bolus of Plain LRS/NSS at 1-2 L in an adult or 10-20 cc/kg for pediatrics, and then assess patients response.
This may be repeated up to 3 cycles. May use D5NSS/D5LRS if Plain LRS/NSS are not available.
4. Start Dopamine drip (7-15 ug/kg/min) and/or Dobutamine drip (10-20 ug/kg/min) for persistent hypotension after fluid
resuscitation with Plain LRS/NSS.
5. Transfuse whole blood for severe blood loss.

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Annex 20

MANAGEMENT PROTOCOL FOR


CARDIOPULMONARY RESUSCITATION (CPR)
After assessing the ABC (airway, breathing and circulation) and patients is noted to have no pulse or cardiac rate, do the following:
1. Feel for the patients substernal notch. Place the middle finger in the substernal notch and the index finger on the lower end
of the sternum. Then place the heel of the hand beside the index finger. Then place the hand used for measuring the notch
on the top of the other hand and interlace the fingers and start the compression with locked elbows. Do effective 4-5 cms
sternal compressions at 30 compressions: 2 ventilations x 5 cycles in 2 minutes.
2. If patient is cyanotic or not breathing, check airway and do the following:
a. ambubagging with tight face mask. Give 100% Oxygen. Make sure ambubag is connected to the oxygen tank. Suction
secretions. Hyperventilate initially. Intubate patient if necessary. Continue CPR.
b. if no portable oxygen is available, open the patients airway (head tilt, chin lift maneuver) then give two slow breaths
(1 breath 1.5 to 2 seconds). Continue CPR.
3. Ensure that the IV access is patent.
4. If with asystole, give Epinephrine (1 mg/amp) 1-2 ampules IV stat every 3-5 minutes continuously until there is a cardiac
rhythm or until CPR is stopped. May give Epinephrine 1 mg ampule in 10 ml NSS via ET tube every 3-5 minutes if no IV
line is inserted yet.
5. If still pulse-less, give Epinephrine and continue CPR. Consider Bicarbonate 1 ampule (1 meq/kg) if more than 15 minutes
have elapsed since the heart has stopped.
6. Stop chest compressions every 1-2 minutes to check the cardiac rhythm. Check pulses throughout the duration of the CPR.
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