Dengue

Rebojo, Jonah Claudine

Barol, Alexander Angelo
Bella, Elena

MHAM-CM Senior Clerk

Group 7A
 Den󰈇󰉉󰇵 Ca󰈼󰈩

01 Cli󰈝󰈎󰇸󰇽l Hi󰈻󰉄󰈡r󰉘 04 Ad󰈚i󰉅󰈎󰈞g O󰈸󰇶er󰈻

02 Ph󰉘󰈼ic󰈀󰈗 E󰉖󰇽mi󰈝󰈀󰉄󰈏on 05 Cas󰈩 󰉍󰈏󰈻󰇸us󰈻󰈎󰈢󰈞

Diff󰈩r󰇵󰈝󰉄i󰈀l D󰈏a󰈇󰈞󰈡s󰈏󰈻
03 Ad󰈚i󰉅󰈎󰈞g D󰈏a󰈇󰈞󰈡s󰈏󰈻
 PE
flow

Physical exam
(include growth
parameters: Ht
for age, Wt for
age, Wt for
height, BMI for
age,
interpretation)

(Include symptomatology & clinical manifestation)

Admitting orders (include diagnostic

modalities needed for the case,
venoclysis, fluid and at what rate,
therapeutic modalities, supportive
nursing care, and monitoring)
CASE

Gen󰈩󰈸󰇽󰈘 da󰉃󰈀
5 years-old, male, from Cordova Cebu

Chi󰈩󰇾 󰇸󰈢m󰈥󰈘a󰈎n󰉃
Fever of 5 days duration
 History of present illness

5 da󰉘󰈼 2 da󰉘󰈼 1 da󰉘

P󰈜A P󰈜A P󰈜A

● Diffuse abdominal pain

● Fever over epigastric area
○ ● Irritable,
○ moderate to gnawing pain
○ unconsolable by the
high-grade ○ exacerbated by food parents
○ intermittent intake
● Brought to ER for
○ Tmax: 41 C ● Assoc with onset of rashes
both upper extremities consult and possible
● Assoc with throat pain ○
○ pinpoint admission.
upon swallowing of food
maculopapular rash
● No medications taken
○ non-blanching of
● No consults done pressure
● Condition was tolerated ○ non pruritic
and persisted ● Brought to a local doctor and
diagnosed with measles
● Given cetirizine intake
Past medical history

● Patient was swab at a private

physicians office for COVID-19
RT-PCR
○ Result: COVID-19 negative

● Previous vaccinations:
Dengvaxia (2020)
Physical examination HR 154 bpm

RR 62 cpm

Temp 41.2 C

BP 60/40
Vit󰈀󰈗
Sig󰈝󰈼 Weight 25 kg

Length 98 cm

BMI 26 kg/m2

O2 sat 98%
Physical examination
flushed, rashes in both lower and upper extremities
Ski󰈝 (erythematous, pinpoint, pinkish to evanescent, non-pruritic,
non-blanching in pressure), good turgor and mobility

anicteric sclera, pink palpebral conjunctiva, (+) nasal

discharges (watery, non-mucoid), (+) tonsillopharyngeal
HE󰉋󰈰󰈙 congestion (grade 2)
Neck: supple, (+) lymphadenopathy, no neck vein
engorgement

Che󰈻󰉄 & equal chest expansion, tachypneic, with occasional fine rales
over both lung field, occasional wheezing over both lower lung
Lun󰈇󰈼
fields
Physical examination
Adynamic precordium, distinct heart sounds, tachycardic,
C󰈐󰈟 regular rhythm, no murmurs

globular, soft, normoactive bowel sounds, (+) direct

Ab󰇷o󰈛󰈩n tenderness (epigastric area), (+) hepatomegaly 5
finger breadths below the right subcostal margin, (+)
fluid wave test

Ex󰉃󰈹em󰈎󰉃󰈏e󰈼 cool to touch, non palpable peripheral and central

pulses, CRT= 5 seconds

Ne󰉉r󰈢󰈗o󰈈󰈎c lethargic, difficult to awake, irritable if awake, awake

status: unsustained
 Pertinent positives Pertinent negatives
● 5 years old
● Intermittent high-grade ● No nausea and
● BP: 60/40
fever = 41.2 C vomiting
● Non palpable pulses
● Throat pain and ● No cough
● Skin flushed
tonsillopharyngeal ● No conjunctivitis
● Cold extremities, with
congestion grade 2 ● No petechiae,
CRT of 5 seconds
● Tachycardia mucosal bleed and
● Tachypneic bleeding

● Pinpoint maculopapular
● fine rales over both lung
rash in upper and lower
field
extremities
● occasional wheezing over
● Lymphadenopathy
both lower lung field
● Liver enlargement
● Lethargic
● Direct tenderness in
● COVID-19 negative
epigastric area, (+)
● Previous dengvaxia
hepatomegaly, (+) fluid
vaccination
wave
 Differential Diagnosis
Dengue Measles Malaria Scarlet fever

5 years old Any age group Before 15 yrs old Any age group Any age group

high-grade fever (41 C)

+ + + +
Pinpoint maculopapular
rash in upper and lower
+ + - -
(reddish brown, koplik uncommon (erythematous
extremities
spots) sandpaper-like rash)

Tachycardia
+ +/- - -
Tachypneic
+ +/- +/- -
BP: 60/40
Non palpable pulses, Skin
+ +/- - +
flushed, cold extremities,
with CRT of 5 seconds

Previous dengvaxia
vaccination
+ - - -
 Differential Diagnosis
Dengue Measles Malaria Scarlet fever

Throat pain and

tonsillopharyngeal
congestion grade 2, + + - +
watery non-mucoid
nasal discharge

Cervical
lymphadenopathy
+ rare
- +
fine rales,
occasional wheezing
+ +/- - +

Direct tenderness in
epigastric area, (+) fluid
+ - + -
wave, liver enlargement

Lethargic, difficult to
awake
+ + + +/-
COVID-19 negative
+ + + +
Hemodynamic assessment

✔
✔
✔

✔
WHO 2012
Handbook for
Clinical
Management of
Dengue
2009 WHO DENGUE CLASSIFICATION AND LEVEL OF SEVERITY

WHO 2009
Course of illness

Critical Phase
● Warning signs mark the onset
of this phase as a result of
plasma leakage
● Weak pulses, cold clammy
extremities, and prolong
capillary refill time
● Easy bruising and bleeding
● Shock may result in metabolic
acidosis, progressive organ
impairment and DIC
● Progressive leukopenia
followed by thrombocytopenia
& inc hematocrit
(hemoconcentration)
 Ad󰈚i󰉅󰈎󰈞g
Di󰈀g󰈝󰈢󰈼is
Hy󰈥o󰉄󰈩n󰈻󰈏󰉐e Sh󰈡󰇹󰈕 s󰇵󰇹o󰈞d󰈀󰈸󰉙 t󰈢
Sev󰈩󰈸󰇵 De󰈞g󰉉󰇵, C󰈸i󰉄󰈎c󰇽󰈗 P󰈋as󰈩,
CO󰈐󰈾󰉌-19 Neg󰈀󰉃󰈏󰉐e
●
Admitting orders
● Admit the Patient ● Insert Foley Bag Catheter
● Monitor Urine output q 1 hr
● Secure Pt. Consent
● Hematology Lab evaluation -FBC, blood
● Obtain HCT level before fluid Rescuscitation typing, cross matching

● Give IV bolus of pNSS 500mL push-pull method Monitor q 15 mins until stable
over 15 mins. - alertness and comfort levels, vital
signs, peripheral perfusion

● Once bolus is done, inform and if with Monitor HCT level after rescuscitaion until
improvement proceed to D5LR 250 cc x 1 hour stable

Monitor q 30 mins until stable

- blood glucose,
● Medication - arterial or venous or capillary blood gas
Give: - Lactate
- Paracetamol 375 mg/kg for fever of 41 C - Total CO2/HCO3
- Renal, Liver, Coagulation Profile
 Admitting orders

● Diet: No dark colored foods, chocolates, red meat

● Give O2 support

● Watch out for signs of bleeding: Gums, Rectal,

Nose

WHO 2012: Handbook for Clinical Management of Dengue

 Case Discussion
● Is a mosquito-borne viral
infection
● Leading cause of serious
illness and death in some
Asian and Latin American
● benign syndrome caused by
several arthropod-borne Den󰈇󰉉󰇵 countries.
viruses
● Characterized by
○ biphasic fever
○ myalgia or arthralgia
○ Rash
○ leukopenia
○ Lymphadenopathy
Den󰈇󰉉󰇵 He󰈛󰈡r󰈸󰈋󰇽gi󰇹 󰇿󰈩v󰇵󰈸
● Philippine, Thai, Singapore
● hemorrhagic fever, hemorrhagic dengue, acute
thrombocytopenic purpura
○ Severe, often fatal, febrile diseases
○ Caused by one of four dengue viruses
○ Characterized by:
■ Capillary permeability
■ Abnormalities of hemostasis
■ protein -losing shock syndrome
(Dengue shock syndrome)
 Sev󰈩󰈸󰇵 De󰈞g󰉉󰇵
● Cases accompanied by:
○ Fluid loss leading to shock
○ Fluid loss with respiratory distress
○ Liver damage (elevations of ALT or AST
to >1000 U/L)
○ Severe bleeding
○ Altered consciousness
○ Significant heart problems
●
 Etiology
Aed󰈩󰈻 󰈛󰈢s󰈫u󰈎󰉄󰈢es,
Den󰈇󰉉󰇵 Vi󰈹󰉉s p󰈸i󰈞c󰈎󰈥󰇽󰈘l󰉘 Ae. 󰉝󰈩g󰉘󰈦t󰈏
● Small single stranded RNA virus
● Four distinct serotypes (DEN-1 ● Daytime biting mosquitoes and
to -4) the principal vector
● Genus Flavivirus ● Immature stages are found in
● Family Flaviviridae water-filled habitats, mostly in
artificial containers closely
associated with human dwellings

Aed󰈩󰈻 󰇽󰈘bo󰈥󰈎󰇸t󰉊󰈻, Ae󰇶󰈩s ● Caused outbreaks

species breed in water trapped in
po󰈗󰉙n󰈩󰈻󰈏e󰈞s󰈎󰈻 & 󰈼pe󰇹󰈎󰇵󰈼 of 󰉃󰈋󰈩 ●
vegetation
Aed󰈩󰈻 󰈼c󰉊󰉃e󰈘l󰈀󰈸󰈏󰈼 co󰈚󰈦l󰈩󰉕 ● found outside (forested areas, bush,
jungle)
 EPIDEMIOLOGY

● World Health Organization (WHO)

○ Endemic in more than 100 countries, most commonly
affected:
■ Africa
■ America
■ Eastern mediterranean
■ Southeast asia
■ Western pacific regions
○ Actual numbers of dengue cases are unreported and
many cases are misclassified
○ 390 million dengue infections occur every year
○ 96 million manifest clinically
○ 3.9 billion people in 128 countries (at risk of infection)
 EPIDEMIOLOGY IN THE PHILIPPINES
2020
2019
 Transmission
Mod󰈩 󰈢󰇾 In󰇹u󰇻󰈀t󰈏o󰈝 P󰈩󰈹󰈏od
Tra󰈝󰈼m󰈎󰈻󰈼󰈏on
1-7 days
Bite of infected Aedes aegypti

Per󰈎󰈢󰇷 o󰇿 Pat󰈊󰈡󰈦h󰉘󰈼󰈏ol󰈡󰈇󰉙
co󰈚󰈛󰉉n󰈏󰇹a󰇻󰈎l󰈏󰉃󰉙 ○ Virus replication leads to viremia
and formation of Ag-Ab complex
In the mosquito: DENV ○ Triggers the complement cascade
REPLICATION for 8-12 days ○ Activation of hageman factor
and remains infectious for life ○ Increased vascular permeability
○ shock
 Transmission cycle of dengue virus
1 3 5 Virus Replicates
in the mosquito 7 Infects mosquito’s
salivary gland
INFECTED MOSQUITO Viremia midgut
BITE (virus is
inoculated to humans)

2 4 6 8
Virus localizes and Mosquito ingests Virus in the Mosquito
multiplies (lymph blood containing mosquito escapes bites another
nodes and liver) virus in the body cavity human
 PATHOGENESIS
● PRIMARY INFECTION
○ Lifelong protective immunity (infecting
serotype)
○ Protected with 2-3 months
○ No long term cross protective immunity
○ Severe dengue observed during 1°
infection in infants born to
dengue-immune mothers
 INOCULATION OF VIRUS VIA SKIN

VIRUS INFECTS IMMATURE DENDRITIC CELLS

MIGRATION TO THE LYMPH NODES

MONOCYTE AND MACROPHAGES RECRUITMENT

MONOCYTES AND MACROPHAGES GET INFECTED

PRODUCTION OF LARGE AMOUNTS OF CYTOKINES (IL-6, IL-8, TNF)

INFLAMMATORY RESPONSE

Non-specific symptoms
 MONOCYTES AND MACROPHAGES RECRUITMENT

INCREASE VIRAL LOAD

DISSEMINATION AND VIREMIA

BONE MARROW PRECURSOR CELL DESTRUCTION CELLULAR DESTRUCTION HEPATOCYTE DAMAGE ENDOTHELIAL CELL DAMAGE
 PATHOGENESIS
● SECONDARY INFECTION
○ Increased number of infected cells= high
viral burden
○ Inflammatory cytokines and mediators
○ Capillary leakage
○ Viremia levels predict disease severity
 RECOVERY FROM PREVIOUS INFECTION

FORMED ANTIBODIES

INFECTION WITH ANOTHER DENV SEROTYPE

BIND WITH SURFACE PROTEIN OF DENV

MACROPHAGES AND MONOCYTES BIND TO AB

 MACROPHAGES ARE UNABLE TO NEUTRALIZE WITH VIRUS

FORMATION OF ANTIGEN ANTIBODY COMPLEXES

VIRUS WILL CONTINUE TO PROLIFERATE

PRODUCTION OF LARGE AMOUNT OF CYTOKINES AND COMPLEMENT

ACTIVATION

VASCULAR EFFECT
ANTIBODY DEPENDENT ENHANCEMENT (ADE)
 INCREASED VASCULAR PERMEABILITY

PLASMA LEAKAGE

● Pleural
THROMBOCYTOPENIA effusion
ascites
● Tachycardia
● Weak and
undetectable
BREAK IN THE BLOOD VESSELS
pulses
● BP

DECREASE IN THE BLOOD VOLUME

METABOLIC ACIDOSIS

ORGAIN IMPAIRMENT
 Course of DENGUE illness
Day of illness

Temperature

PHASES
Potential clinical issues 1. Febrile Phase
2. Critical Phase
3. Recovery Phase
Laboratory changes

Serology & Virology

COURSE OF DENGUE ILLNESS

 Febrile phase

Man󰈎󰇾󰇵󰈼ta󰉃󰈎󰈢󰈞 Com󰈥󰈘󰈎c󰇽󰉃i󰈡󰈞 Last 2-7

days

● Sudden high-grade fever ● Dehydration

● Anorexia, nausea and vomiting ● High fever may cause
● Facial flushing, skin erythema, neurological disturbances
generalized rash and febrile seizures in
● Generalized body ache, myalgia, young children
arthralgia (“back-break fever” or
“breakbone fever”
● Retroorbital eye pain,
photophobia, headache
● Petechiae, mucosal membrane,
easy bruising, and bleeding
● Enlarged and tender liver
● Leukopenia on CBC
 critical phase

24-48 hrs after

Man󰈎󰇾󰇵󰈼ta󰉃󰈎󰈢󰈞 Com󰈥󰈘󰈎c󰇽󰉃i󰈡󰈞 fever defervescence

● Not all pass through this phase ● Shock from plasma

● Warning signs mark the onset of leakage
this phase as a result of plasma ● Severe hemorrhage
leakage ● Organ impairment
● Weak pulses, cold clammy
extremities, and prolong capillary
refill time
● Easy bruising and bleeding
● Shock may result in metabolic
acidosis, progressive organ
impairment and DIC
● Progressive leukopenia followed by
thrombocytopenia & inc
hematocrit (hemoconcentration)
 Recovery phase

Man󰈎󰇾󰇵󰈼ta󰉃󰈎󰈢󰈞 Com󰈥󰈘󰈎c󰇽󰉃i󰈡󰈞

● Gradual reabsorption of ● Hypervolemia and acute

extravascular compartment fluid pulmonary edema (if IV
● May have bradycardia, stabilization fluid therapy was
of hematocrit, or hemodilution excessive or extended into
● Improvement of well-being & a period
return of appetite
● Hemodynamic status stabilized &
diuresis ensues
● Hermann’s rash (“isles of white in a
sea of red”) & many have
generalized pruritus
Hermans Sign
 Criteria for Admission

Sig󰈝󰈼 & Sy󰈚󰈦to󰈚󰈼

War󰈝󰈎󰈞g 󰈻󰈏󰈈n󰈻 Ble󰈩󰇷󰈏󰈞g
re󰈗󰈀󰉄󰇵d 󰉃o 󰈋y󰈥󰈡󰉄󰇵n󰈻i󰈡󰈞

● Abdominal pain or tenderness,

● persistent vomiting, ● Dehydrated patient, unable to tolerate
● lethargy, restlessness, oral fluids
● mucosal bleed, ● Dizziness or postural hypotension
● liver enlargement >2cm or tender ● Profuse perspiration, fainting, ● Spontaneous bleeding, independent of
enlarged liver, clinical fluid prostration during defervescence the platelet count
accumulation ● Hypotension or cold extremities
● increase hematocrit level ● Difficulty in breathing/shortness of
concurrent with dec in platelet breath (deep sighing breaths)
count
 Criteria for Admission
Or󰈇a󰈞 ● renal , hepatic, neurological or cardiac
○ Enlarged tender liver, although not yet in shock
im󰈥󰈀󰈏󰈹me󰈝󰉄 ○ Chest pain or respiratory distress, cyanosis

Fin󰇷󰈎󰈞g󰈻
t󰈊󰈹o󰉉g󰈊 󰇿󰉊r󰉃󰈋er ● Rising hematocrit
● Pleural effusion, ascites or asymptomatic gallbladder thickening
in󰉏󰈩󰈼t󰈏󰈇a󰉄󰈎󰈢n󰈻

● Pregnancy
Co-󰈩x󰈏󰈻󰉄in󰈇 ● Comorbid conditions:DM, hypertension, peptic ulcer, hemolytic
co󰈝󰇶󰈎t󰈏o󰈝󰈼 anemia, & others
● Overweight or ovese, infancy and old age

Soc󰈎󰇽󰈗 ● Living alone, living far from health facility

Cir󰇹󰉉󰈛s󰉃󰇽󰈞ce󰈻 ● Without reliable means of transport
2009 WHO DENGUE CLASSIFICATION AND LEVEL OF SEVERITY
2011 WHO CLASSIFICATION OF DENGUE INFECTIONS
& GRADING OF SEVERITY
 Laboratory work-up

1 2 3

Com󰈥󰈘󰈩t󰇵 󰇼󰈘o󰈡d 󰇹󰈢u󰈞t Den󰈇󰉉󰇵 N󰈠1 An󰉃i󰈈󰈩n Ser󰈡󰈗󰈢󰈈y (De󰈝󰈈󰉉󰇵 IgM/IgG)

Leukopenia, then thrombocytopenia, Viral nonstructural protein Method of choice: end of the acute
or with hemoconcentration (inc in released by infected cells into the phase of infection
hct) circulation; Dengue IgM: sample collected not
earlier than 5 days nor later than 6
↓WBC = febrile phase Detected in acute phase samples weeks after onset
↑ Hct = beginning of critical of phase Primary Infection: IgG is detectable in
↓↓ WBC followed by ↓ platelet = Useful from day 1 until day 3 of low titers at end of 1st week
critical phase (plasma leakage) illness Secondary infection: IgG detected even
↑Hct = recovery phase, dilution effect in the acute phase & persists
of fluid
 Laboratory work-up

4 5 6

P󰈜/AP󰈜󰈙 Blo󰈡󰇷 󰉑󰈋󰇵mi󰈻󰉄r󰉘 Che󰈻󰉄 󰈤󰈀d󰈏o󰈇󰈹󰈀p󰈊

DF: Normal PT, and plasma Liver function test (AST/ALT): Pleural effusion may be present (DSS)
fibrinogen Elevation of serum transaminase

DHF: Prolonged BT; Moderately ↓ ABG & electrolytes: Metabolic

prothrombin level acidosis with hyponatremia,
Hypochloremia,

kidney function test: elevated BUN,

and hypoalbuminemia (occasionally)
 Laboratory work-up

7 8

Ul󰉃󰈹as󰈡󰉊󰈝󰇶 To󰉉r󰈝󰈏󰈬u󰈩t T󰇵󰈻󰉄

Serosal effusions of the thorax or Take patient BP → Inflate cuff to
abdomen point midway between SBP and DB,
and maintain for 5 mins → deflate →
observe and count for petechiae

(+) >10 petechiae per 1 square inch

Tourniquet test
 The “abcs” of dengue
● Seen in profound shock
A Aci󰇷󰈡󰈼󰈏s BLOOD GAS ● Work up for organ impairment: liver function, BUN,
Crea

● Inc hematocrit = hemoconcentration

B Ble󰈩󰇷󰈏󰈞g HEMATOCRIT
● Dec hematocrit = improving condition
● Drop in hct = worsening clinical condition suggest occult
bleeding

C Cal󰇹󰈎󰉊󰈛 ELECTROLYTE (Ca2+)

● Hypocalcemia = almost all cases of DHF
● Usually asymptomatic

S Sug󰈀󰈸 BLOOD SUGAR(Ca2+) ● Hypoglycemia = due to decrease intake, vomiting,

hepatic impairment
 TREATMENT/management

WHO 2012: Handbook for Clinical Management of Dengue

 TREATMENT/management

WHO 2012: Handbook for Clinical Management of Dengue

 TREATMENT/management

WHO 2012: Handbook for Clinical Management of Dengue

 TREATMENT/management

WHO 2012: Handbook for Clinical Management of Dengue

 May be sent home

● Advice for:
- Adequate bed rest
- Adequate fluid intake
- Paracetamol, 4 gram max. Per day in
adults and accordingly in Children

Gro󰉉󰈥 A Patients with stable Hct can be sent home

Monitoring:
● Daily review for disease progression
● Decreasing WBC
● Defervescence
● Warning Sign (until out of critical period)
● Advice for immediate return to hospital if
development of any warning signs
● Written advice of mgt (home care card for
dengue)
CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon, and infographics
& images by Freepik and illustrations by Stories
 Referred for in-hospital care

Gro󰉉󰈥 󰉗
 Require emergency treatment

Gro󰉉󰈥 󰉑
✔

✔
✔
✔
Treatment of compensated shock

WHO 2012: Handbook for Clinical Management of Dengue

Treatment of hypotensive shock

WHO 2012: Handbook for Clinical Management of Dengue

Treatment of hemorrhagic complications

● If possible, attempts should be made to stop bleeding if the source of

bleeding is identified

● give aliquots of 5−10 ml/kg of fresh -packed red cells or 10−20 ml/kg of
fresh or fairly fresh whole blood (FWB) at an appropriate rate and observe
the clinical response.

● is important that fresh whole blood or fresh red cells are given.
Treatment of hemorrhagic complications

● Consider repeating the blood transfusion if there is further overt blood

loss or no appropriate rise in haematocrit

● In gastrointestinal bleeding, H-2 antagonist and proton pump inhibitors

have been used

● It is essential to remember that blood transfusion is only indicated in

dengue patients with severe bleeding.
Supportive care and adjuvant therapy
Supportive care and adjuvant therapy may be necessary in severe
dengue and includes:

● Vasopressor and inotropic therapy

The use of vasopressor and inotropic therapy should be limited to the

following clinical situations:
- As a temporary measure to prevent life-threatening hypotension in
dengue shock and during induction for intubation, while correction
of intravascular volume is being vigorously carried out.

- dopamine which should be titrated to maintain mean arterial BP of

65 mmHg in adults.

- Evidence of cardiogenic shock due to myocarditis or ischemic

heart disease. Dobutamine is the recommended choice.
● Central venous pressure monitoring

● The use of central venous pressure (CVP) to guide fluid

therapy in severe dengue with profound or prolonged shock.

● Risks of severe bleeding and pneumothorax due to

placement of the central venous line could be minimized
with the use of ultrasound guidance.

● more reliable method - Echocardiography

Ren󰈀󰈗 󰈹󰇵p󰈗a󰇸󰈩m󰇵󰈝󰉄 t󰈊e󰈹󰈀p󰉘
● Renal replacement therapy may be indicated in
acute kidney injury.
● It should be commenced after haemodynamic
stability.
● The preferred choice of renal replacement
therapy is continuous veno-venous
haemodialysis (CVVH)
● When renal replacement therapy is not available
or cannot be performed yet, the ensuing
hyperuricaemia, hyperkalaemia and
hyperphosphataemia should be managed with
allopurinol, Resonium A and calcium carbonate
respectively.
 Ot󰈊e󰈹 󰈮r󰈇󰈀󰈞 󰈏m󰈥a󰈎󰈹m󰇵󰈝󰉄

● Drug toxicity resulting from the use of paracetamol or acetaminophen should be

suspected if liver enzymes have increased disproportionate to the severity of shock

● Paracetamol should be discontinued in patients with liver enlargement or raised liver

enzymes.

● The most critical issue for recovery is stabilization of the haemodynamic state; without
this there can be no recovery of any organ.

● Once the critical period is over and stability of the haemodynamic state attained, it is
essential to stop or reduce intravenous fluids to the minimum and to maintain
euglycaemia.
 ✓ Afebrile for at least 24 – 48 hours

✓ Improved appetite and Good well being

C󰈤I󰈙󰉋R󰈽A 󰉇󰈮󰈣 ✓ Stable hematocrit without IVF & Increasing

Platelet trend
DI󰈠󰉎H󰉝󰈤󰉁󰉈 ✓ At least 2 – 3 Days from the last episode of
shock

✓ Adequate urine output

✓ No respiratory distress
 PREVENTION

MARS

4S
In Fighting Dengue
 PREVENTION
DE󰈰󰉁󰈖󰉈 VA󰉑󰉎󰈾N󰉈 – 󰉍E󰈯G󰈐󰉝󰈅󰈽A

● Indicated for the prevention of dengue

disease caused by dengue virus serotypes
1, 2, 3, and 4.

● DENGVAXIA is approved for use in

individuals 9 through 16 years of age with
laboratory-confirmed previous dengue
infection and living in endemic areas.
 PREVENTION
DE󰈰󰉁󰈖󰉈 VA󰉑󰉎󰈾N󰉈 – 󰉍E󰈯G󰈐󰉝󰈅󰈽A

DOSAGE AND ADMINISTRATION CONTRAINDICATIONS

For subcutaneous use only. Do not administer DENGVAXIA to individuals:
● Hypersensitivity
Dose ● Immunocompromised Individuals
Three doses (0.5 mL each) 6 months apart (at
month 0, 6, and 12).

Administration
After reconstitution, withdraw 0.5 mL of DENGVAXIA and administer subcutaneously immediately
or store refrigerated at 2°C to 8°C (36°F to 46°F) and use within 30 minutes. Do not administer
DENGVAXIA by intramuscular injection.
 Prognosis
Dengue Fever Dengue Hemorrhagic Fever
The prognosis is good. Care
should be taken to avoid
● The prognosis of dengue hemorrhagic fever is
use of drugs that suppress adversely affected by late diagnosis and delayed
platelet activity. or improper treatment.
● Death has occurred in 40-50% of patients with
shock
● adequate intensive care, deaths = <1% of
cases.
● Residual brain damage as a consequence of
prolonged shock or occasionally of intracranial
hemorrhage.
● Many fatalities are caused by overhydration.
CONTENTS OF THIS TEMPLATE

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Abo󰉉󰉃 󰉄h󰇵
di󰈻󰈩󰇽󰈼e
The planet’s name has nothing to
do with the liquid metal since it
was named after the Roman
messenger god, Mercury
01
Sy󰈚󰈦to󰈚󰈼
an󰇷 󰇶󰈎s󰇵a󰈻󰈩
You can enter a subtitle here if you need it
 INTRODUCTION

Mercury is the closest planet to

the Sun and the smallest one in
the Solar System—it’s only a bit
larger than the Moon
 About the
01 Disease
You could enter a subtitle
here if you need it
 ABOUT THE DISEASE

Mars Jupiter Saturn

Despite being red, It’s a gas giant and Yes, this is the
Mars is actually a the biggest planet ringed one. It’s a
cold place in the Solar System gas giant
A PICTURE IS
WORTH A
THOUSAND WORDS
 ABOUT THE DISEASE

Mercury is the closest Despite being red, Mars is

planet to the Sun actually a cold place

Venus has a beautiful Jupiter is the biggest

name, but it’s hot planet in the Solar System
 REFERENCES

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
● AUTHOR (YEAR). Title of the publication. Publisher
228.000.000
Cases of malaria in the world
 ABOUT THE DISEASE

10% 30% 25% 50%

Mercury is the Venus has a Mars is actually Neptune is the

smallest planet beautiful name a cold place farthest planet
 SYMPTOMS OF THE DISEASE

SATURN JUPITER
Saturn is the Jupiter is the
ringed one biggest planet

MARS NEPTUNE
Despite being Neptune is the
red, it’s cold farthest planet
 CONCEPTS AND TYPOLOGIES

type 1 type 2 type 3

Describe here your Describe here your Describe here your
concepts concepts concepts

Describe here your Describe here your Describe here your

concepts concepts concepts

Describe here your Describe here your Describe here your

concepts concepts concepts
 Prognosis
Venus Mars

To modify this graph, click

on it, follow the link, change
the data and paste the
resulting graph here,
replacing this one
 KEY NUMBERS

2018 2017
228 millions 231 millions
Mercury is the closest Venus is the second
planet to the Sun planet from the Sun
“This is a quote, Words full of
wisdom that someone
important said and can make
the reader get inspired.”
—Someone Famous
02 DIAGNOSIS
You could enter a subtitle
here if you need it
 DIAGNOSIS

MERCURY VENUS MARS

Mercury is the closest Venus is the second Despite being red, Mars
planet to the Sun planet from the Sun is actually a cold place

JUPITER SATURN NEPTUNE

It’s the biggest planet in Saturn is composed of Neptune is the farthest
the Solar System hydrogen and helium planet from the Sun
 RECOMMENDATIONs

WHAT to avoid What to do

● You can describe what the ● You can describe what the
patient shouldn’t do here patient should do here
● You can describe what the ● You can describe what the
patient shouldn’t do here patient should do here
● You can describe what the ● You can describe what the
patient shouldn’t do here patient should do here
PREVALENCE

SATURN
Saturn is the
ringed planet

JUPITER
Jupiter is the
biggest planet
CONCLUSIONS

Research conclusions
Mercury is the closest planet to the Sun
and the smallest one in the Solar
System—it’s larger than the Moon
 OUR TEAM

DR. JENNA DOE DR. JOHN JAMES DR. RICHARD ROE

You can replace the You can replace the You can replace the
image on the screen image on the screen image on the screen
 KEY NUMBERS

50,000 Venus has a beautiful

name, but it’s hot

20,000 Saturn is a gas giant

and has several rings

5,500 Neptune is far away

from Earth
 THANKS!
Do you have any questions?
[email protected]
+91 620 421 838
yourcompany.com

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