Treating severe malaria. Principles of treatment for severe malaria in children

Currently, chloroquine- sensitive Plasmodium falciparum strains are still found in the Middle East, Central America north of the Panama Canal, Haiti and the Dominican Republic. However, the situation can change at any time. Chloroquine remains the main treatment for tropical malaria caused by susceptible Plasmodium falciparum strains . If the sensitivity of the pathogen is questionable (for example, the patient came from an area where Plasmodium falciparum strains resistant to chloroquine are found ), quinine preparations are prescribed. If it is necessary to use drugs for intravenous administration, preference should be given to drugs of quinine or quinidine , even if the pathogen is sensitive to chloroquine . Malaria caused by Plasmodium vivax , Plasmodium ovale, or Plasmodium malariae is treated with chloroquine . Resistant to chloroquine strains of Plasmodium vivax is widely distributed in Oceania, but nowhere else. Plasmodium ovale and Plasmodium malariae are sensitive to chloroquine throughout the world. In malaria caused by Plasmodium vivax and Plasmodium ovale , a two-week course of primaquine is required to eliminate tissue schizonts and hypnozoites . However, before prescribing this drug, it is necessary to ensure that the patient is not severely deficient in G-6-PD. With it, primaquine is contraindicated, since it can cause hemolysis and methemoglobinemia . A child with tropical malaria urgently needs to be examined. It is required to assess the mental and neurological status, the presence and degree of dehydration, the severity of anemia, to determine the levels of glucose and electrolytes, acid-base ratio and kidney function. All children who do not have signs of liver failure should be prescribed antipyretics. For malaria, it is preferable to use paracetamol rather than aspirin. Hypovolemia is an indication for fluid therapy. Anemia with clinical manifestations (eg, heart failure) requires blood transfusion. The degree of anemia, which serves as an absolute indication for blood transfusion in children, has not been established, but it is usually recommended to carry out it at a hemoglobin level of 5 mg% and below. To normalize the glucose level, a 50% glucose solution is injected in a stream , in addition, all infusion solutions that are administered to children with severe malaria must contain at least 5% glucose. It is very important to eliminate hypoglycemia, but in most children, even with severe hypoglycemia, mental disorders do not disappear quickly.

Most experts believe that with lactic acidosis , the first step is to treat malaria itself, combat dehydration and, if necessary, carry out a blood transfusion. In many cases, this is sufficient to eliminate lactic acidosis . Sodium bicarbonate may paradoxically exacerbate acidosis and is generally not recommended, but some experts still use it at blood pH below 7.1. Preliminary studies suggest that dichloroacetate can reduce malaria lactic acidosis and mortality , but this data has yet to be confirmed by large clinical trials. The role of exchange transfusion in the treatment of malaria is not well understood. Studies that have shown its feasibility, for the most part, were carried out in non-immune individuals, and mostly among adults. There are no large controlled trials and probably will not be conducted, especially in non-immune patients. Recently, an abstract was published, which contained the following recommendations: if the necessary equipment is available, exchange transfusion is necessary if the patient is in serious condition and the level of parasitemia exceeds 15%; in addition, it may be appropriate when the level of parasitemia is 5-15% and the presence of other unfavorable prognostic signs. Prophylactic anticonvulsant therapy in adults is advisable, but it is not clear what drugs and in what doses are best for children. For epileptic seizures, diazepam or paraldehyde is prescribed (the latter is rarely used in the United States). If seizures recur, phenobarbital or phenytoin is given (as usual for status epilepticus). Severe malaria in children, although much less frequently than in adults, can be complicated by bacterial infections: pneumonia, sepsis, meningitis. With a sharp deterioration in the child’s condition, it is necessary to determine the concentration of glucose in the blood, make a blood culture and prescribe broad-spectrum antibiotics. The justification for the use of mannitol , deferoxamine , pentoxifylline , dextran, and antibodies to TNF in severe tropical malaria has not yet been established. Glucocorticoids , heparin, and cyclosporin are contraindicated in malaria because their use can be dangerous for the patient.

Treatment of a common cold (rhinitis) with otitis media. Preobrazhensky powder for rhinitis

With concomitant upper airway inflammation (which in most cases is the cause of otitis media), it is very important to treat appropriately. The swollen mucous membrane of the nose interferes with normal breathing and ventilation of the tympanic cavity through the Eustachian tube. This complicates the outflow of secretion from the tympanic cavity through the tube, especially since with rhinitis there is also swelling of the nasopharyngeal mucosa, in particular, the mouth of the Eustachian tube. To mitigate these phenomena, it is recommended to lubricate the turbinates 3-4 times a day with 1-2% solution of cocaine with adrenaline, which is an excellent vasoconstrictor: Sol Cocaini hydrochlorici 1-2% 10.0; Sol . Adrenalini 1: 1,000 gtt . X. In addition, you can insert cotton swabs moistened with this solution for 3-5 minutes into the lower nasal passages, and also apply an ointment of the following composition: Mentholi 0.1, Cocaini hydrochlorici 0.2; Sol . Adrenalini 1: 1,000 gtt . X; Vaselini 10.0. With a good effect, a 2-3% solution of ephedrine is also used in the form of nasal drops (4-5 drops) or lubrication.

In acute rhinitis, a good effect is obtained by the powder proposed by B.S.Preobrazhensky ( Streptocidi albi ; Sulfasoli ; Sulfidini aa 2.0. M. f pulv . Subtilis ). The powder is blown into the nasal cavity using an insufflator ; the patient may also suck it up the nose like a snuff of tobacco, but not very energetically. In the first days of acute rhinitis, oral administration of the following medicine often has a stopping effect: Rp . Codcini pliosphorici Papaverini hydrochlorici aa 0.015 Sacchari albi 0.2 M. fp D. td N. XII The patient should be prohibited from drawing mucus from the nose into the oral cavity, as well as strongly blowing his nose or blowing his nose, although not strongly, but simultaneously through both nostrils, since this leads to an increase in pressure in the nasopharynx, and possibly to the penetration of infected secretions from the nasal cavity through the Eustachian tube into the tympanic cavity. In the initial stage of otitis media, ear pains come to the fore, depending on irritation of the branches of the trigeminal nerve in the tympanic membrane, caused by pressure from the exudate; the general condition of the patient, an increase in temperature recede into the background. Anti-inflammatory therapy: heat in all forms (in particular, a warming compress), aspirin, pyramidon, salicylic drugs, sulfa drugs, etc., in most cases weakens the inflammatory process, and at the same time reduces the accumulation of exudate in the tympanic cavity and partly pain … Locally , drops are poured into the external auditory canal to relieve pain. The most effective 5% carbol- glycerin drops with the addition of cocaine (3 or 5%); applicable anhydrous glycerin ( Ac . carbolici 0.5; Cocaini hydrochlorici 0.3; Glycerini 10.0).

Gastrointestinal bleeding. Emergency care for ventricular bleeding.

The causes of gastrointestinal bleeding are many and varied. Classification of acute gastrointestinal bleeding: Ulcerative bleeding. Non-ulcer bleeding: of a tumor nature, erosive hemorrhagic gastritis, from the veins of the esophagus, mechanical damage to the mucous membrane, with systemic blood diseases, others. Medical history: age, what medications and foodstuffs he took (aspirin, NSAIDs, iron supplements, activated charcoal, spinach). General status: skin (pallor, low body temperature, decreased skin turgor); cardiovascular system (pulse rate, blood pressure), respiratory rate, signs of dehydration, symptoms of concomitant diseases (spider veins, ascites).

Vomit and stool: amount, color (coffee grounds for the upper gastrointestinal tract), composition. Stool – color (black – melena, chestnut – hematochez , bright red blood). An important sign of gastric bleeding (along with the general symptoms of acute anemia is bloody vomiting. Bloody vomiting usually does not occur immediately after the onset of bleeding, but only when the stomach is full of blood. With folded gastric bleeding, the release of blood is accompanied by vomiting; in the outflowing blood, residues are usually found food; the secreted blood is usually dark in color (sometimes dark brown), with clots.However, with heavy bleeding, the blood can also be scarlet, since it does not have time to be exposed to the action of gastric juice.In addition to vomiting, gastric bleeding appears (usually for 2 days) black stools, runny, mushy, sticky stools with a fetid odor Difficult to diagnose bleeding from the duodenum, as in these cases, bloody vomiting is usually absent Additional methods of examination for ventricular bleeding Digital rectal examination – rectal tumor, hemorrhoids, complicated bleeding, anal fissure. In the case of hematochezia proctosigmoid or colonoscopy is performed . X-ray research methods for ventricular bleeding: studies using barium in the presence or suspicion of perforation of the hollow organ are CONTRAINDICATED! EGD is the most sensitive and specific study to determine the source of bleeding from the upper gastrointestinal tract; it identifies an obvious or potential source of bleeding in more than 80% of cases. The severity of bleeding is determined by the following criteria.

Emergency measures for bleeding from the digestive tract General hemostatic conservative therapy. – The patient is assigned strict bed rest, food and water are prohibited, it is recommended to put an ice pack on the stomach: you should know that the ice pack does not give a vasoconstrictor effect, but it has a disciplining effect on the patient. Means with hemostatic and angioprotective properties: – Dicinon is administered intravenously 2-4 ml of 12.5% solution , then every 4-6 hours, 2 ml. It can be administered by intravenous drip , adding to the usual solutions for infusion . – 5% solution of epsilon-aminocaproic acid, 100 ml every 4 hours; 5-10% solution of ascorbic acid, 1-2 ml IV. – 10% solution of calcium chloride up to 50-60 ml / day IV. – 1% or 0.3% solution of vicasol, respectively 1-2 and 3-5 ml. – Intravenous administration of H2-blockers of histamine ( ranitidine ) 50 mg 3-4 times a day, famotidine ( quamatel ) 20 mg 2 times a day, proton pump inhibitors ( omeprozole 40 mg 1-2 times a day). The rest of the measures for the management and treatment of this group of patients is in the competence of surgeons.

Polycythemia vera – at a glance : – Myeloproliferative disease with all cell line damage , dominant erythroid proliferation, and therefore increased plasma volume and hematocritoma . – Presence of acrocyanosis aquagenic itching, rash and Sweet’s syndrome. – The diagnostic criteria are: 1) increased erythrocyte mass, 2) normal oxygen content in arterial blood, and 3) splenomegaly . – Treatment: simultaneous administration of aspirin and phlebotomy cytoreductive therapy with hydroxyurea narrow -beam ultraviolet B phototherapy of itching.

Characteristic skin symptoms in polycythemia vera are acrocyanosis (ruddy cyanosis) and plethora. Other skin symptoms are aquagenic pruritus, neutrophilic dermatosis, pyoderma gangrenosum, and purpura. Acrocyanosis is observed in conditions accompanied by an increased level of hemoglobin, when deoxygenated blood enters the dilated capillaries of the skin. The increase in erythrocyte mass is also a direct result of compensation for hypoxia or primary diseases such as polycythemia vera. These changes cause an increase in blood viscosity and vascular volume, which leads to a state of hypercoagulability and paradoxical bleeding due to erythrocyte dysfunction. Other symptoms include headache, paresthesia, and erythromelalgia Erythromelalgia is a syndrome of impaired peripheral reaction, manifested in the form of erythema and burning pain, especially when touching warm objects. In myeloproliferative diseases, this syndrome, as a rule, develops secondarily in response to abnormalities in the structure of platelets and can cause microvascular occlusion and foci of necrosis in the affected areas. If untreated, this can lead to acrocyanotic ischemia and even gangrene. Catastrophic symptoms include damage to arteries in the brain (stroke) or heart (myocardial infarction), and peripheral arterial occlusion. Polycythemia vera usually leads to an unusually high incidence of portal and hepatic vein thrombosis Budd-Chiari syndrome ), deep vein thrombosis of the lower extremities, leg ulcers, Raynaud’s phenomenon, and pulmonary embolism. Bleeding is thought to be the direct cause of platelet dysfunction or von Willebrand disease . Violation of primary hemostasis manifests itself in the form of ecchymosis , uterine, nosebleeds and bleeding of the gums, less often gastrointestinal bleeding. Risk factors for polycythemia vera include age over 60 years, a history of thrombosis, risk factors for cardiovascular diseases (hypertension, smoking, hypercholesterolemia , diabetes), hereditary and acquired thrombophilic conditions (hereditary deficiency of anticoagulants: antithrombin III, proteins C and S, hereditary Leiden factor V mutation, prothrombin G20210A, or methylenetetrahydrofolate reductase ) and acquired conditions ( anticardiolipin and / or lupus antibodies). Diagnosis of polycythemia vera has become much easier with the recent opportunity to screen for the mutation in JAK2617F, which is seen in more than 95% of patients. There is no specific therapy for polycythemia vera. Treatment is aimed at preventing thrombohemorrhagic episodes and progression to myelofibrosis or leukemia. Aspirin may provide minimal assistance in preventing thrombosis. In the event that aspirin does not bring a positive effect, as a rule, treatment with cytostatics is required to reduce the number of platelets ( hydroxyurea bisulfan , radioactive phosphorus, chlorambucil , interferon) or anagrelide to reduce platelet function. Phlebotomy is also used to control the mass of CCC, but it can aggravate thrombocytosis or leukocytosis.

local_offerevent_note November 26, 2020

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