NEW: Cholera Treatment Workshop - Case Study (Answers) in English and French

Sunken eyesAbsent tears IrritabilityDepressed fontanelles (when palpating head)Dry mouthDrinks EagerlyModerate skin tenting

SOME, because the child is awake but irritable, has moderate skin tenting, and is able to drink. (Note that the scenes repeat once)

Because the child has SOME dehydration and is able to drink, he can be treated with oral rehydration solution. He needs observation and can be monitored in the observation area.

The child weighs 7 kg. Based on the guidelines table, he should receive 400 to 600 ml of ORS in the first four hours. The volume of ORS to be given in the first four hours can also be calculated by multiplying 7 kg by 75, which equals 525 ml. He should be reassessed after 1 hour of therapy, and then every 1-2 hours until rehydration is complete. Remember that these ORS amounts are guidelines, and that the quantity of ORS given can vary based on patient’s situation.

The child should also receive zinc supplementation (10-20 mg zinc per day by mouth) if available. This can reduce the severity and duration of diarrhea.

If he has been breast-fed, he should continue to receive breast-feeding.

As soon as the vomiting pauses, he should continue to receive oral rehydration solution. If the child continues to vomit and cannot drink sufficient ORS, he will need intravenous fluids.

Less irritabilityEyes no longer sunkenDrinks less eagerly, or is less thirstyStrong radial pulseUrine has been passedSkin pinch goes back quicklyMouth is moist

Feed the patient when vomiting has stopped. If he has been breast-fed, he should continue to receive breast-feeding.

Because the child has moderate dehydration, antibiotics should be considered if he is still passing large volumes of stool or if he is hospitalized.See the antibiotic table in the CDC/PAHO guidelines to choose an antibiotic. First choices in children <12 months old are Azithromycin, Erythromycin, and Doxycycline oral suspensions.A second choice is tetracycline oral suspension.After each loose stool, give 100 ml of ORS (for children less than 24 months old), though this amount can vary based on the amount of stool.Continue to reassess the patient for signs of dehydration at least every 4 hours to ensure that ORS solution is being taken appropriately, and to detect patients with profuse ongoing diarrhea who will require closer monitoring.Urine output decreases as dehydration develops, and may cease. It usually resumes within 6-8 hours after starting rehydration. Regular urinary output (every 3-4 hours) is a good sign that enough fluid is being given.Keep the patient under observation, if possible, until diarrhea stops, or is infrequent and little in volume. This is especially important for any patient who presented with severe dehydration.If a patient must be discharged before diarrhea has stopped, show the caretaker how to prepare and give ORS solution, and instruct the caretaker to continue to give ORS solution, as above. Also instruct the caretaker to bring the patient back if any signs of dehydration develop.

Assume that any patient with acute watery diarrhea has cholera in an area where there is an outbreak of cholera. If in an area here cholera has not been confirmed, can seek microbiological diagnosis with rapid diagnostic kit and culture.

Severe lethargy, near unconsciousWeak radial pulse (though note the nurse is checking the brachial pulse)Low blood pressureVery sunken eyesSkin pinch goes back very slowly (>3 seconds)Rapid breathing (from acidosis)Shriveled "washerwoman" hands

SEVERE, because of the severe lethargy, weak pulse, inability to drink.

The patient needs immediate intravenous (IV) hydration. Use Ringer’s lactate if available. Use Normal Saline if no Ringer’s Lactate available (though this will not help the acidosis)If he is able to drink, give ORS solution by mouth while the IV drip is set upStart with 1800 ml (30 ml/kg) IV fluid in the first 30 minutes. Repeat this step if the patient’s radial pulse is still weakThen give 4200 ml (70 ml/kg) IV fluids over the next 2.5 hours.Reassess the patient at least every 1-2 hoursThe patient may need 12,000 ml (200 ml/kg) or more in the first 24 hours of treatmentAlso give the patient ORS solution (5 ml/kg per hour) as soon as the patient can drinkPerform a full reassessment at 3 hours. Switch to ORS solution if hydration is improved and the patient can drinkBecomes more alertEyes no longer sunkenStrong radial pulseDrinks normallySkin pinch goes back quicklyUrine has been passed

When the patient is adequately hydrated and can drink ORS.

Because he has severe dehydration, he should receive an antibiotic. See antibiotic table from CDC/PAHO. For adults:
•   First choice is Doxycycline 300mg by mouth in one dose.
•   Second choices are azithromyin, tetracycline, ciprofloxacin, and erythromycin.
Give it after rehydration has begun, when able to take fluids by mouth

Hypoglycemia: This can occur after severe diarrhea. The best way to prevent this is to start feeding the patient as soon as possible.

Renal Failure (anuria): This rare complication occurs when shock is not rapidly corrected. Urine output normally resumes within 6 to 8 hours after starting rehydration. All patients should be urinating before discharge from a CTC.

Pulmonary Edema: Fluid in the lungs from overhydration due to excessive IV fluids. Young children, the elderly, and severely anemic patients are at highest risk. Signs of pulmonary edema include shortness of breath, dry cough, and crepitations or crackles on auscultation. Reduce the IV fluid rate, and sit the patient up.

Hypokalemia (low potassium): Suspect low potassium if repeated episodes of painful cramps occur. This may happen after the first 24 hours of IV rehydration if patients do not eat or drink ORS (ORS provides enough potassium).

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