A House Officers Approach to

Dengue
General
1. The patient should be seen on arrival to the ward immediately.
2. Assess if the patient is ill:
a. Shock (cold peripheries, low pulse volume)
i. Decompensated (SBP<110, MAP<65)
ii. Compensated (HR>100 or >10bpm/C above 37C
from baseline heart rate)
b. Warning signs:
i. Persistent vomiting and/or diarrhea (3/24hours)
ii. Lethargy, altered mental status, confused
iii. Abdominal pain/ tenderness
iv. Spontaneous bleeding tendencies
v. Tender liver
vi. Raised hematocrit with rapid drop in platelet
1. Female: 40
2. Male 60: 42
3. Male 60: 46
c. Dehydrated (dry mucosa, sunken eyes)
3. If the patient is ill treat immediately (set line, run drip), inform
the medical officer and then clerk the patient.
4. A patient that had compensated or decompensated shock in
the Emergency Department must be attended to immediately
even if the blood pressure and heart rate is now normal.
5. Make sure height and weight is taken.
6. Calculate ideal body weight and adjusted body weight:
a. Ideal body weight=(height-152.4cm)0.91+45.5kg (if
female) or 50kg (if male)
b. Adjusted body weight=Ideal body weight+0.4(actual
weight-ideal body weight)

Clerking
1. All clerking questions asked must be documented. If it is not
documented it is not done and will be held against the house
officer.
2. Past medical history:
a. Duration
b. Diagnosis (Who? Where? How?)
c. Follow-up
d. Medications
e. Compliance
f. Control
g. Complications

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3. Ask about the fever:

a. Duration (Write down the day and date it started with
the time of the day)
b. Onset (sudden, gradual)
c. Pattern (intermittent, persistent)
d. Severity (high-grade, low-grade)
e. Relieving factors (paracetamol)
f. Exacerbating factors
g. Associated symptoms (arthralgia, myalgia, retro-orbital
pain, headache, rash, mucosal bleed, oral intake,
lethargy)
4. Ask if there are recent persons with dengue or fogging in the
housing area or place or work.
5. Ask about warning signs:
i. Persistent vomiting and/or diarrhea (3/24hours)
ii. Lethargy, altered mental status, confused
iii. Abdominal pain/ tenderness
iv. Spontaneous bleeding tendencies
v. Tender liver
vi. Raised hematocrit with rapid drop in platelet
1. Female: 40
2. Male 60: 42
3. Male 60: 46
6. Ask about the number of visits to clinics and when was the
last visit.
7. Ask about history of:
a. Last paracetamol taken (time and date it was taken)
b. Last intramuscular injection.
c. Antibiotics intake
d. Non-steroidal anti-inflammatories
e. History if travel local and foreign.
8. Ask about oral intake and urine output.
9. Other differential diagnosis. Just because a patient is admitted
to the dengue ward it does not mean they cannot have other
illnesses.
a. Meningitis (headache, altered sensorium, neck stiffness,
rash)
b. Otitis media (otalgia, otorrhoea, tinnitus, reduced
hearing)
c. Sinusitis (nasal stuffiness and discharge, facial pain)
d. Tonsillitis (dysphagia, hoarseness, enlarged tonsils with
exudates)
e. Pneumonia (cough, productive sputum, pleuritic chest
pain)
f. Infective endocarditis (murmurs, stigmata of
endocarditis)
g. Cholecystitis/ cholangitis (jaundice, RUQ pain)
h. Urinary tract infection/ pyelonephritis (dysuria,
frequency, nocturia, flank pain)

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i.
j.
k.
l.

10.
11.
12.
13.

Infective gastroenteritis (diarrhea, dysentery, mucus)

Skin infections (cellulitis, abscess)
Septic arthritis (joint pain, reduced range of movement)
Leptospirosis (jungle trekking, waterfalls, sewage
worker, exposure to rats)
m. Melioidosis (diabetes mellitus, working with the soil)
n. Scrub typhus (tick bite, eschar, working in the estates)
Past surgical history.
Family history
Drugs and allergies
Social history:
a. Smoking (number of pack years)
b. Alcohol intake
c. Recreational drugs
d. Previous and current occupation

Examination
1. Vital signs:
a. Measure blood pressure manually on admission and if
blood pressure is low.
i. Look for narrowing pulse pressure (systolic
pressure-diastolic pressure)
ii. Postural hypotension (>20mmHg drop if the
patient stands up)
b. Heart rate
c. Respiratory rate
i. Early sign of hypoperfusion and tachypnea
stimulated by acidosis.
d. Urine output
i. At least 1cc/kg/h
ii. Ask when was the last time patient passed urine
iii. Make sure patient records his urine output
e. Oral intake:
i. Make sure records his oral intake
ii. Make sure he takes at least enough for
maintenance according to adjusted body weight.
1. 4cc/kg/h for first 10kg
2. 2cc/kg/h for second 10kg
3. 1cc/g/h for the rest
2. Peripheries:
a. Feel the hands. Is it warm, cool or cold?
b. See the capillary refill time the fingers. Is it <2s or >2s?
c. Feel the pulse.
i. Is the volume good, moderate or poor?
ii. Is the patient tachycardic?
d. Feel the feet. Is it as warm as the hands?
e. See the capillary refill time of the toes. Is it <2s or >2s?
f. Feel the dorsalis pedis artery.

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3. Look for dehydration:

a. Sunken eyes.
b. Coated tongue.
4. Face:
a. Pallor
b. Epistaxis and gum bleed
5. Body:
a. Rash
b. Isles of white in a sea of red is an indication the
patient is in recovery
c. Petechiae
6. Auscultate the heart.
7. Look for pleural effusion:
a. Stony dullness.
b. Reduced air entry.
c. Reduced vocal resonance.
8. Examine the abdomen:
a. Palpate for epigastric tenderness and suprapubic
tenderness.
b. Percuss for shifting dullness.
9. Pedal oedema.

Investigation
1. Admission bloods:
a. Full blood count
i. Look for falling white cell count.
ii. Look for falling platelet count
iii. Look for rising haematocrit
1. Female: 40
2. Male 60: 42
3. Male 60: 46
b. Venous blood gas
i. Look for lactate. High lactate can be caused by:
1. Bleeding
2. Sepsis
3. Liver failure
4. Hyperglycaemia
5. Tissue hypoxia/ fluid overload
ii. Metabolic acidosis
1. Anion gap=([Na+]+[K+])-([HCO3]+[Cl])
2. Normal is 16mmol/L
c. Alanine transaminase and aspartate transaminase to
look for hepatitis
d. Creatinine kinase to look for myocarditis
e. Dengue serology
i. ELISA for NS-1
ii. Dengue IgM
iii. Dengue IgG

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f. Blood film for malarial parasites if foreigner

2. Bloods for monitoring
a. Febrile phase: once daily or as clinically indicated
b. Critical phase:
i. FBC 6 hourly or after every bolus
ii. Lactate after every bolus
iii. VBG after every bolus
c. Recovery phase: once daily of as clinically indicated.
3. Blood post-bolus
a. Full blood count
b. Venous blood gas
i. Lactate clearance=
Initial lactatesubsequent lactate
100 . Aim for at
Initial lactate
least 20% improvement in 2 hours.
ii. pH
iii. [HCO3-]
c. Taken immediately after completion of bolus.
d. If the bolus is 5cc/kg/h then post bolus bloods FBC,
VBG, lactate must be repeated one hour after the start
of the bolus
e. If the bolus is 3cc/kg/h then post-bolus bloods must be
repeated after 2 hours from the start of the bolus.

Management
1. Daily maintenance drip
a. Calculate the amount needed.
i. 4cc/kg/h for first 10kg
ii. 2cc/kg/h for second 10kg
iii. 1cc/g/h for the rest
b. Give normal saline 0.9%
c. If patient is taking orally without warning signs the
amount of drip given is the maintenance drip minus the
oral intake.
d. During the critical phase, the amount of drip required
maybe 1.2 to 1.5 times of maintenance.
e. For example, maintenance is 2000cc. Oral intake is
1300. Therefore the drip should be 700cc/24hours
f. If the patient is taking as per usual. Please stop the drip.
2. Dengue fever with warning signs without shock
a. Give 5cc/kg/h for 1 to 2 hours
b. Repeat blood investigation after 1 to 2 hours.
c. If the patient is improving clinically then taper to
3cc/kg/h fro 2 to 4 hours.
d. If the patient is worsening i.e. haematocrit is rising, a
higher infusion rate should be given.
3. Compensated dengue shock
a. Give 10cc/kg/h of crystalloid over 1 hour.

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b. Repeat FBC, VBG, and lactate/

c. If the patients condition improves, taper in a step-wise
fashion as follows: 7cc/kg/h for 1 hour, 5cc/kg/h for 2
hours, and 3cc/kg/h for 2 hours.
d. If the patients condition worsens after reducing the drip
please increase the infusion to the previous one.
e. If the patient does not improve:
i. But haematocrit is the same: give another bolus
of 10cc/kg/h
ii. If the haematocrit falls: think of bleeding and send
for GSH.
4. Decompensated dengue shock
a. Give 20cc/kg/h of colloids over 15 to 30 minutes
b. If the patient responds then use crystalloid and taper
accordingly with 10cc/kg/h for 1 hour, 7cc/kg/h for 1
hour, 5cc/kg/h for 2 hours, and 3cc/kg/h for 2 hours.
c. If the patient worsens then taper up again.
d. If haematocrit goes up despite the 20cc/kg/h bolus then
repeat the bolus up until an additional 2 times.
e. If haematocrit goes down but the patient is still ill then
think of bleeding.
i. Give fresh whole blood
f. If the haematocrit is unchanged, think:
i. Septic shock: antibiotics and inotrope
ii. Cardiac dysfunction: inotropes
iii. Liver failure and metabolic acidosis: inotrope, KIV
CRRT
iv. Cytokine storm: inotrope, fluids
v. Bleeding and leaking at the same time: look for
bleed, blood products.
5. Others
a. Hyperglycaemia: Start IVI insulin 0.1/kg/h.
b. Haematoma: cold compress for 20 minutes every 4
hours.
c. Gum bleed: cold saline gargle
d. Nose bleed: cold compress and pressure if not
responding refer to ENT.
e. If temperature >40 can give PCM 1g except if hepatitis.
Check ALT and AST before giving.

Daily Review
1. The patient must the reviewed when the patients blood results
are back
a. So if the patient QID bloods then the patient should be
reviewed QID.
b. If the patient is OD bloods then review OD.
c. If the patient has boluses then the patient should be
reviewed when the post-bolus blood results come back

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2.
3.

4.

5.

6.

7.

d. Only MO and specialist can decide to reduce the number

of reviews.
Write the age, gender and the pre-morbids.
Write the full diagnosis:
a. Diagnosis? Severe dengue, dengue fever with or without
warning signs.
b. Day what of illness?
c. What phase? Febrile, critical or recovery.
i. Critical phase start roughly when plat <100 and
temperature<38 count from which ever is later.
d. What are the complications? Compensated shock,
decompensated shock, bleeding, carditis, hepatitis,
encephalitis.
e. For example: Severe dengue, day seven of illness in
critical phase with decompensated shock, carditis and
hepatitis.
Ask about symptoms.
a. If patient came in with vomiting, diarrhoea and fever
then make sure you ask whether it is still there or
resolved.
Ask about warning signs:
a. Persistent vomiting and/or diarrhea (3/24hours)
b. Lethargy, altered mental status, confused
c. Abdominal pain/ tenderness
d. Spontaneous bleeding tendencies.
Ask about 5 basic functions:
a. Bowel motion
b. Urine output: When was the last urine and how much?
i. Make sure patient chart their oral urine output.
Make sure patient have a measuring vessel, paper
and pencil.
ii. Ask when was the last passing of water and how
much.
iii. Make sure there is at least 1cc/kg/h for the last 4
hours
c. Eat
d. Drink
i. Ask how much has the patient taken.
ii. Make sure patient chart their oral intake. Make
sure patient have a measuring cup, paper and
pencil.
e. Sleep
Review the vital signs:
a. Don't just look at one reading in isolation
b. Determine the trends: upwards, downwards, static.
i. If it is falling, ask yourself Is the patient preshock and slowly moving to shock?
ii. Pick things up early and save yourself a whole
world of hurt.

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c. Determine the range of reading e.g. SBP 120-130 and

DBP 70 to 80.
8. Tubes and lines:
a. Answer the 3 questions:
i. Is it necessary?
ii. Can it be removed?
iii. Should it be removed?
b. Look at the intravenous lines.
i. Is there thrombophlebitis?
ii. Has it been there for more than 3 days?
c. Other tubes:
i. Continuous bladder drainage
ii. Oxygen
d. Other than that the patient should be seen at least 4
times a day.
9. TOUCH the patient.
a. Feel the peripheries: colour, warmth, capillary refill time,
pulse volume and rate. Do the same for the feet
b. Listen to lungs: vocal resonance and air entry
c. Abdominal examination: Epigastric tenderness and
shifting dullness
10.
Look at the blood investigation results.
a. Don't look at them in isolation.
b. Look for trends. Is it upwards, downward or static.
c. What are the ranges?

ICU referral
1. Respiratory distress.
2. High level of supplemental oxygen >50% to maintain more
than 90%.
3. CCF, CKD
4. Massive haemoptysis
5. Need for ventilation invasive and non-invasive.
6. Haemodynamic instability
7. Arrhythmias
8. Underlying heart disease
9. Seizures
10.
CNS depression
11.
Upper GI bleed
12.
Sever hepatitis
13.
Severe coagulopathy and bleeding.
14.
Acute kidney injury
15.
Rhabdomyolysis with renal impairment.

Summary
1. A dengue patient can deteriorate in a the blink of an eye.
2. Call your medical officer if:

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a. You are not sure.

b. You feel the patient is not well.
c. You have a gut feeling, sixth sense, or premonition that
the patient is not well.
3. You are the eyes, ears, hands and feet of the ward.

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