ansar
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(If its acute diarrhoea then it is infectious diarrhoea until proven otherwise. Most infectuois diarrhoea is self limited.)... kaplan.
My question is if I suspect acute infectious diarhhoea then what should be the first thing to do as a management ...
Thanks in advance.
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| miky
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if I suspect acute infectious diarhhoea then what should be the first thing to do as a management ...
Asnar,
The first thing you should do is to order a micro exam of the stools. If you see neutrophils, that's probably an invasive agent. This is an indication of ABs, especially if the pt. is a child or an elderly person , a pregnant woman or an immunosuppressed.
On the other hand, always look first for vitals - if severe dehydration, first hydrate well (actually follow ABcs of EM), then give ABs (if you give ABs in a severely dehydrated person, you may cause renal shutdown, particularly if the AB is excreted renally).
So, here's a useful algorithm (you may use it if you wish):
1st: vitals - look for S/S of dehydration, shock, septic shock
resuscitate with iv fluids (use Ringer Lactate / Normal saline
depending on the gravity of fluid loss) - always check Na, K,
bicarbonate, PH to see if severe Hyponatremia or metabolic acidosis is present. If you find electrolyte or volemia disturbances, correct them first. Also use drugs to maintain BP at normal levels, if necessary.
next: check temperature; if elevated (be careful in a child - may develop fever if severe dehydrated and consequently seizures) and BP low, think of sepsis - give ABs just in case.
next: Microscopy of stool sample - look for neutrophil presence; also ask for a GS & culture; if neutrophils found, consider an invasive agent; ABS are usually necessary; if no neutrophils found, the tx is generally supportive.
Also consider the type of diarrhea - volume, frequency, consistency, presence of blood / pus and symptoms and signs:
onset - acute vs progressive
frequency of stools and their consistence
S/S: abdominal pain, cramping, peritoneal irritation, trismus, neurologic S/S (esp paralysis, fear of water)
food ingested (rice - Bacillus cereus)
age of the pt.
underlying diseases
immune status
other drugs taken
and many others (consult a medical textbook for a more detailed discussion).
However, the algorithm is the one I forementioned.
Hope it helped.
___________________
always happy and ready to serve and help my friends and patients as well.
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| ansar
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thanks..Miky.
So if i make a short precise way of your reply..then we can say like this ..
Acute diarrhoea-----check vital signs----support it accordingly-----stool test for leukocyte----if + give antibiotic/ if negative then no antibiotic but just counselling .
Am I right Miky?
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| miky
Forum Senior
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yap, you've got it right.
However, you must always obtain a detailed history and a pertinent physical exam that will give you more clues to the possible etiology.
But remember - check vitals first - it's no use to give ABs if infection is suspected if there is severe hypovolemia (as I previously told you, that will place the pt. at a considerably increased risk or acute renal failure). If the BP is low, check Na levels and bicarbonate next. Always resuscitate and correct volemia and electrolyte disturbances before any further therapeutical intervention. The pt. may easily sucumb in a matter of mins before you can actually do sth. useful for him.
Once you stabilize pt., you may proceed with the mentioned investigations;
Hope it helped.
___________________
always happy and ready to serve and help my friends and patients as well.
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| miky
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Sth. more:
Be very careful if you see diarrhea in an immunocompromised individual (esp HIV/AIDS). Never assume its being benign. Always keep a high index of suspicion for a severe cause. It's actually one of the greatest emergencies in EM.
Also, be extracareful how you approach a child with diarrhea - children can easily become severely dehydrated, which is accompanied in most cases by fevers, which in turn can generate seizures. According to latest medical researches, it's no longer necessary to give an anticonvulsant agent prophilactically, unless the pt. is developing a seizure in front of your eyes or the body temps are too high (above 40 C). In this case, Lorazepam or Phenobarbital may be used. Also be ready to intubate.
Next, be very careful with pregnant women who develop diarrhea - severe dehydration is often catastrophical to the fetus (you know the possible consequences) - that's an emergency too. Aggressively but carefully resuscitate unless fetal problems / demise may occur.
Elderly patients are also prone to developing severe complications caused by dehydration. Most of them have heart, renal or liver problems, so hypovolemia may aggravate their underlying conditions.
I've told you all these because I have encounted many similar cases in my daily medical practice. I hope that I did not bore you to death with my explanations.
Hope it helped.
___________________
always happy and ready to serve and help my friends and patients as well.
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| ansar
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Thanks a lot Miky, for your great input .
Best of luck.
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