Malaria

Body weight (kg)

AL dosage (mg), 2x/day for 3 days (first day 8 hr. apart and then 12 hr. apart)

Number of tablets

< 15

20 + 120

1

15 to < 25

40 + 240

2

25 to < 35

60 + 360

3

≥ 35

80 + 480

4

Manifestation/ complication

Management

Evaluation/investigation

Coma (cerebral malaria): impaired consciousness (or a Glasgow coma score < 11 in adults or a Blantyre coma score < 3 in children)

• Maintain airway; intubate, if necessary
• Place the patient on their side.
• Check for hypoglycemia and manage it if present.
• Give recommended empirical parental antibiotic for bacterial meningitis.
• Ensure proper nursing care to prevent aspiration and bed sores.
• Catheterize and record fluid input and urine output.

• Blood slide, random blood sugar, full blood count, serum urea/bicarbonate +/- LP
• Glasgow and Blantyre coma score monitoring

Convulsions (multiple convulsions): more than two episodes in 24 hr.

Maintain airway

In children:

• Treat promptly with diazepam (0.3 mg/ kg by IV or 0.5 mg/kg rectally), which can be repeated twice, and then shift to phenobarbitone
• Administer phenobarbitone (20 mg/kg IM loading dose over 20 min.) with respiratory support; if convulsions persist, give a maintenance dose of 5 mg/kg/day in two divided doses. Commence maintenance dose 24 hours after loading dose.

In adults:

• Give a slow bolus of IV diazepam 5–10 mg
• If convulsions continue, give a second dose.
• If they persist, give phenobarbitone 20 mg/ kg (IM or IV) over 20 min. as a loading dose (max. 100 mg); if convulsions persist, repeat phenobarbitone at 6 mg/kg after a 20-min. interval.
• For both children and adults, ensure the patient has received glucose and that body temperature is controlled

• Fit chart
• Urine for urinalysis to rule out eclampsia in pregnant women

Severe malarial anemia: hemoglobin concentration ≤5 g/dL or a hematocrit of ≤ 15% in children under 12 years old (< 7 g/dL and < 20%, respectively, in adults), with a parasite count > 10,000/μ

• Administer oxygen (2.5 L/mm) to improve oxygen delivery
• Prop up the patient with pillows or clothing
• Collect blood for cross match and hemoglobin estimations and transfuse, as appropriate
• Give packed cells at l0 ml/kg and whole blood at 20 ml/kg in cases of hypovolemic shock; give
• IV start (bolus) dose of a loop diuretic (e.g., furosemide) at 1–2 mg/kg (provided the blood pressure is not low) during blood transfusion to avoid circulatory overload

Monitoring for transfusion reactions

Pulmonary edema: radiologically confirmed or oxygen saturation < 92% on room air with a respiratory rate > 30/min, often with chest indrawing and crepitation’s on auscultation

• Prop up the patient and administer oxygen
• Give a diuretic (furosemide at 1 mg/kg IV bolus in children and 40 mg IV stat in adults)
• Stop IV fluids
• Intubate, where necessary

• Monitoring oxygen saturation, respiratory rate, and breathing difficulties
• Catheterization and monitoring of fluid input and urine output
• Chest x-ray

Acute kidney injury: urine output < 400 ml / 24 hr. (< 1 ml/kg in children) with a plasma or serum creatinine > 265 μmol/L (3 mg/dL) or blood urea > 20mmol/L

• Check for and correct dehydration
• Exclude heart failure
• Avoid herbal medication and nonsteroidal anti-inflammatory and nephrotoxic drugs (e.g., Gentamicin)
• Quickly refer patient to next level

• Blood draw for urea and creatinine
• Monitoring of fluid input and urine output

Hypoglycemia: blood glucose < 2.2 mmol/L or < 40 mg/dL

• Check blood glucose
• Correct hypoglycemia (≤ 3 mmol/L) with glucose (IV or oral); ensure adequate caloric intake (nutritional support) thereafter Immediately give 5 ml/kg of 10% dextrose through a peripheral line
• Continue with a slow IV infusion of 5 ml/kg/hr of 10% dextrose or 10 ml/kg/hr of 5% dextrose to prevent the recurrence of hypoglycemia

Monitoring of blood sugar levels and general condition

Shock: compensated (capillary refill ≥ 3 sec. or temperature gradient on leg [mid to proximal limb] but no hypotension) or decompensated (systolic blood pressure < 70 mm Hg in children or < 90 mm Hg in adults, with evidence of impaired perfusion [cool peripheries or prolonged capillary refill])

• Administer IV saline or Ringer’s lactate solution if serum lactate is normal
• Administer blood transfusion if the patient has associated anemia
• Give a third-generation cephalosporin or benzyl penicillin with Gentamicin to cover for bacteremia

• Monitoring of the central venous pressure while infusing the fluids, keeping it at 0–5 cm of H2O to avoid fluid overload
• Blood samples for culture

Spontaneous bleeding and coagulopathy

• Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen plasma, and platelets, if available)
• Give vitamin K injection (1 mg IM stat in children, 30 mg IM stat in adults)

Monitoring for bleeding and transfusion reactions

Metabolic acidosis: symptomology of rapid, deep, labored breathing with a base deficit of > 8 mEq/L or a plasma bicarbonate level of < 15 mmol/L or venous plasma lactate of ≥ 5 mmol/L or pH of < 7.35

• Exclude or treat hypoglycemia. Correct hypovolemia
• Treat septicemia with a third-generation cephalosporin
• If severe, consider hemofiltration or hemodialysis, or refer if these facilities are not available

• Close monitoring of vitals
• Blood samples for random blood sugar, culture, lactate, and bicarbonate

Hemoglobinuria: passing of dark, cola- colored urine

• Continue appropriate antimalarial treatment. Transfuse screened fresh blood, if necessary
• If oliguria develops and blood urea and serum creatinine levels rise (i.e., if acute renal injury occurs), consider renal replacement therapy
• If possible, refer the patient to a dialysis unit or center

• Monitoring of input and output
• Full blood count, urea, creatinine, and electrolytes
• Blood group match/save