Current diagnosis and

management of dengue infection

DIVISI INFEKSI DAN PEDIATRI TROPIS

FKUI - RSCM
Guideline of Diagnosis and therapy of
Dengue Infection in Children

Pedoman
Diagnosis dan Tata laksana
Written by
Infeksi Dengue pada Anak Infection & Tropical Pediatric Group
Indonesian Pediatric Society

Published by
Badan Penerbit
Penyunting
Sri Rezeki Hadinegoro
Ismoedijanto P Moedjito

Indonesian Pediatric Society

Alex Chairulfatah

Jakarta, 2014
UKK Infeksi dan Pediatri Tropis IDAI
 Dengue Classification

Source: Comprehensive guideline for prevention and control of dengue and dengue haemorrhagic fever.
Revised and expanded edition. Regional office for South-East Asia, New Delhi, India 2011.
 Dengue Shock Syndrome

Compensated Decompensated
Profound shock
shock shock
• Tachycardia • Tachycardia • Unpalpable pulse,
• Tachypnea • Hypotensive • Undetectable blood
• Pulse rate <20 mmHg • Narrow of pulse rate pressure
• Capillary refill time > 2 sec
• Hyperpnea or
• Cold skin Kussmaul
• Decreased urine output
• Cyanosis
• Restless
• Cold and clamp skin
 Compensated Dengue Shock Syndrome
• Give oxygen 2-4L/minute
• Check hematocrit
•Crystalloid RL/RA 10-20ml/kg.BW within 60 minutes

Yes Shock recovered No

IVFD 10ml/kg.BW, 1-2 hours Check Ht, blood gas, blood glucose,
calcium, bleeding (ABCS)
Correction soon for acidosis,
Stabile, hypoglycemia, hypocalcaemia
Decreased IVFD gradually
7, 5, 3 , and 1,5 Ht increased Ht decreased
ml/kg.BW/hour
2nd bolus for crystalloid
Or colloid 10-20ml/kg.BW Bleeding
within 10-20 minutes Unclear
Stop IVFD
maximal 48 hours
after shock recover Colloid 10-20ml/kg.BB
within 10-20menit, if shock
Blood transfusion
persist suggested blood
transfusion UKK IPT 2014, WHO 2011
 Fluid management in dengue infection

Dengue fever DHF non-shock DHF shock

Oral or maintenance Maintenance + Loading crystalloid of

(Dextrose 5%:NS=3:1) deficit 5-10% 20 ml/kgBW,followed
(crystalloid) by colloid if
necessary, then
reduce by titration

Adequate fluid therapy gives good response without inotropics

Dyspnea in children
a clinical approach

Darmawan B Setyanto
Yapnas SUDDHAPRANA Jakarta
The sensation of abnormal or uncomfortable breathing
in the context of what is normal for a person according
to his/her level of fitness and exertional threshold for
breathless
Am Fam Phys, Evaluation of Dyspnea, 1998
Other terminologies:
 Shortness of breath  Labored breathing
 Breathlessness  Troubled breathing
 Difficult breathing  Getting winded
 Breathing difficulties  Constriction
 Breathing discomfort  Uncomfortable breathing
 Chest tightness  Unusual awareness of breathing
 Breath stops  Increased breathing effort
 Air hunger  Increased muscular effort to breath
 The need to breath more
 Patient with dyspnea

• what’s come in mind first? 

PNEUMONIA !
• what should we do ?  give O2!
• NOT THAT SIMPLE !
 Pulmonary  Mix cardio-pulmonary
Asthma, COPD  COPD with PH
Pneumonia, bronchiolitis  Chronic pulmonary emboli
Restrictive lung disorders  Deconditioning
 Trauma
Hereditary lung disease
Pneumothorax
Cardiac  Non cardio-pulmonary
 Metabolic conditions
Congestive heart failure
 Pain
Coronary artery disease
 Neuromuscular disorders
Myocardial infarction
 Otorhinolaryngeal disorders
Cardiomyopathy
 Functional (anxiety, panic
Pericarditis disorders
Arrhythmias
Am Fam Phys, Evaluation of Dyspnea, 1998

 need to be memorized  create

new way how to SEE dyspnea
Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Extra-thorax FLOW disorders
Obstruction of proximal / larger airways
 rhinitis with nasal obstruction, nasal polyp
 cranio-facial malformation
 OSAS
tonsil-adenoid hypertrophy
 laringo-tracheo-malacia
 larynx papilloma
 diphtheria
 croup, epiglottitis

• clinical: inspiratory stridor

• age : infant – below five
Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Intra-thorax FLOW disorders
Obstruction of distal / smaller airways
 asthma
 bronchiolitis
 thymus hypertrophy
 vascular ring
 solid foreign body aspiration
 lymph node enlargement pressure

• clinical: expiratory effort

• age: infants, below five age – bronchiolitis
Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Intra-thorax VOLUME disorders Lung
parenchyma disorders

 pneumonia (infection, aspiration)

 atelectasis
 pulmonary edema
 near drowning
 sepsis

clinical: inspiratory effort

Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Intra-thorax VOLUME disorders
Extra-pulmonary disorders
 pneumothorax, pneumomediastinum
 cardiomegaly, heart failure (perfusion)
 pleural effusion (incl’ empyema, hematothorax)
 hernia diaphragmatica
 diaphragmatica eventration
 intra-thorax mass (non pulmonary)
 chest trauma (rib fracture, lung contusion)
 thorax deformity (pectus excavatum, scoliosis)

klinis : inspiratory effort

Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Extra-thorax VOLUME disorders Lung
compliance disorders
 neuromuscular disorders (CP, GBS, MG)
 gastritis, peptic ulcer
 extreme obesity
 peritonitis, appendicitis, acute abdomen
 aerophagia, meteorismus
 ascites
 hepato-splenomegali
 abdominal solid tumor

clinical: inspiratory constraint

Dyspnea classification
pathophysiology, anatomic, disorders
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Extra-thorax VOLUME disorders
Respiratory center disorders

 anemia
 metabolic acidosis
 CNS infections: meningitis, encephalitis
 encephalopathy (typhoid, DHF, metabolic)
 psychologic (anxiety, usually adolescent)
 poisoning: salycylate, alcohol
 trauma capitis
 CNS disease sequelae

clinical: deep rapid breathing

Clinical approach

symptomatolo dyspn
gy ea
pathophysiolo evaluatio
gy n
pathology etiolog
y
treatme treatment ~
nt etiology
Dyspnea clinical approach - 1
first step : ANAMNESIS
 identity: age, sex, etc
 dyspnea:
 acute, chronic, recurrent
 degree of dyspnea
 how long has been dyspneic
 timing of dyspnea: at rest, at activity, day or night
 triggers, factors make worse / better
 response to therapy
 underlying cardiopulmonary / neuromuscular
disease
 associated symptoms: chest pain, cough, wheezing
 other signs & symptoms
 80% of cases can be diagnosed
Dyspnea clinical approach - 2

next step : PHYSICAL EXAMINATION

 inspiratory : nasal flaring, retraction (supra
sternal, intercostal, subcostal, epigastrium),
chest indrawing (retraksi arkus kosta)
 expiratory : prolonged expirium, wheezing,
abdominal muscle contraction

 respiratory examination: respiratory rate;

stridor, symmetry of breath sound & on
percussion; rales; sign of heart failure
 other holistic examination
Dyspnea clinical approach - 3

further step : SUPPORTING EXAMINATION

 Routine blood examination

 Pulse oximetry
 Imaging diagnostic: CXR, ultrasound,
 Blood gas analysis
 Pulmonary function test
 Electrocardiography, echocardiography
 Rhinoscopy, laryngoscopy, bronchoscopy
Dyspnea clinical approach - 4

last step : TREATMENT

 based on etiology
 first aid: give O2, before we can identify
the etiology; since most cases need it
 other cases, does not need O2 (see next)
Dyspnea classification maybe
oxygen is not needed
EXTRA Obstruction of proximal / larger
thorax airway
FLOW
disorders
INTRA Obstruction of distal / smaller
thorax airway

Lung parenchyma disorders

INTRA
thorax
VOLUME Extra-pulmonary disorders
disorders
Lung compliance disorders
EXTRA
thorax
Respiratory center disorders
Definition:
 *Oxygen therapy is the administration of
oxygen at concentrations greater than
ambient air(21%)

 *With the intent of treating or preventing

the symptoms and manifestations of
hypoxia(a deficiency of oxygen reaching
the tissues of the body)
 Indications
 1)PaO2 <60mmHg or SaO2 <90%, or as ordered by the
MD for a specific clinical situation.
 PaO2=partial pressure of oxygen as measured in the
arterial blood, SaO2=hemoglobin’s saturation
 of oxygen in the arterial blood
 2)Acute situation where hypoxemia is suspected
 3)Severe trauma
 4)Acute myocardial infarction
 5)Short term, post operative
 Contraindications & Precautions

 1)with PaO2>60, patients with chronic CO2

elevations may experience ventilatory
depression
 2)With FiO2>.50, oxygen toxicity, absorption
atelectasis, or depression of ciliary and/or
leukocytic function
 3)Administer with caution to patients receiving
bleomycin cancer therapy
 4)Fire hazard is increased in the presence of
oxygen concentration.
Delivery Systems
 Nasal Cannula
 Simple Mask
 Venturi Mask
 Aerosol Devices
 Non Rebreather Masks

1/18/2018 35
 Reference Chart
Method FiO2 Flowrate
(Approximate) (L/min)
Non rebreather Mask 60-80% 10-15
Venti Mask 24% 3
26% 3
28% 6
31% 6
35% 9
40% 12
50% 15
Simple Face Mask 35-55% 5-10lpm
Nasal Cannula 24% 1
28% 2
32% 3
36% 4
40% 5
44% 6

1/18/2018 36
 Irawan Mangunatmadja

Departemen Ilmu Kesehatan Anak

FKUI-RSCM Jakarta
38
 Riwayat klinis
Pemeriksaan fisis – neurologis
Skala koma Glasgow Tanda vital - Pola napas
Ukuran pupil - gerak bola mata Respon motorik

1/18/2018 39
Riwayat klinis
 Awal – penanganan kedaruratan:
The ABC emergency sampai stabil
 Riwayat klinis - Etiologi
 Sakit kepala hebat – tak sadar – AVM pecah
 Tertabrak mobil – Trauma kepala
 Panas tinggi, mengigau, kejang – Ensefalitis
 Muntah-muntah – Sindrom Reye
 Kesadaran menurun perlahan –
Ensefalopati
 dll
Clin Ped Emerg Med 2003; 4:171-8
Textbook Clinical Neurology 2003.h. 3-18
1/18/2018 40
Pemeriksaan fisis - neurologis
 ABC – jalan napas, pernapasan, sirkulasi
 Derajat kesadaran – Skala koma Glasgow
 Sistemik: tanda vital, irama jantung, pola napas
 Pemeriksaan Saraf Otak, gerakan bola mata,
respon pupil, funduskopi
 Pemeriksaan motorik: kelumpuhan

Crit Care Med 2006; 34: 31-41

1/18/2018 41
Skala koma Glasgow
 Dinilai: Buka mata (E4), motorik (M6) dan
lisan (V5)
 Skala berkisar 3 – 15
 Skala 12 – 14: ggn kesadaran ringan
 Skala 9 -11: ggn kesadaran sedang
 Skala < 8: ggn kesadaran berat - koma

Current Management in Child Neurology 2005.h.551-62

Crit Care Med 2006: 34:31-41

1/18/2018 42
Skala koma Glasgow
 Buka mata (E)  Respons motorik (M)
 Spontan 4  Spontan 6
 Rangsang bicara 3  Menarik tangan dng
 Rangsang nyeri 2 rangsang 5
 Tidak ada respons 1  Menarik tangan dengan
nyeri 4
 Respons Verbal (V)  Fleksi akibat nyeri 3
 Ekstensi akibat nyeri 2
 Senyum sosial 5
 Tidak ada respons 1
 Menangis 4
 Menangis terus 3
 Agitasi / lemah 2
 Tidak ada respons 1

1/18/2018 43
Tekanan darah – irama jantung
(Etiologi)
 Tekanan darah tinggi  Irama jantung tak teratur
 Peningkatan TIK  Amfetamin
 Perdarahan  Digitalis
 Intoksikasi  Antikolinergik

 Tekanan darah rendah  Bradikardi

 Syok spinal  Narkotika
 Obat Beta bloker
 Keracunan
 Takikardi
 Alkohol
 Amfetamin

Principles of Child Neurology 1996. h.303-15

1/18/2018 44
Pola Napas
(Letak lesi)
 Cheyne Stokes
 Pola napas apnue – hiperpnue
 Ggn serebral bilateral, diensefalon, herniasi
 Hiperventilasi
 Pola napas cepat – dalam (kelainan midbrain)
 Asidosis metabolik, hipoksia,keracunan
 Apneuristik
 Berhentinya inpirasi (kelainan di pons – kaudal pontin)
 Ataksik
 Tidak ada pola napas (kerusakan medula)

Crit Care Med 2006; 34: 31-41

1/18/2018 45
Pola napas

1/18/2018 46
Reaksi pupil
(letak lesi)
 Reaksi pupil
 Midriasis –saraf simpatis
 Miosis – saraf parasimpatis

 Reaksi pupil
 Lesi di diensefalon: miosis, bereaksi thd cahaya
 Lesi midbrain: pupil dilatasi, terfiksasi di tengah,
tidak bereaksi thd cahaya
 Lesi di pons: pupil pinpoint

Principles of Child Neurology 1996. h.303-15

1/18/2018 47
Letak lesi – reaksi pupil

1/18/2018 Plum dan Posner (1982) 48

Jaras konyugasi gerak bola mata

1/18/2018 49
 Doll’s eye movement
(tingkat lesi)

1/18/2018 50
Kelumpuhan motorik
 Hemiparesis
 Lesi kontralateral, refleks meningkat
 Dekortikasi – lengan fleksi + tertarik ke dada
 Kerusakan traktus spinalis di atas red nukleus
 Deserebrasi – lengan ekstensi dan rotasi interna
 Lesi di dekat traktus vestibulospinalis
 Opistotonus – kepala + tl belakang melengkung
 Kerusakan berat kedua hemisfer kortek

Principle of Cild Neurology 1996. h.303-15

1/18/2018 51
Pemeriksaan Penunjang
 Darah lengkap, elektrolit, glukosa, fungsi hati –
ginjal dll,
 Pem. khusus: laktat, kreatinin kinase, EKG dll
 Infeksi SSP – Pungsi lumbal
 CT scan atau MRI
 Perdarahan, trauma kepala – CT scan
 Batang otak, mielinisasi -- MRI

Pediatric Neurology 2006.h.1378-400

Crit Care Med 2006: 34:31-41
1/18/2018 52
Penyebab tersering
 Infeksi – inflamasi
 Ensefalitis, meningitis,
 Struktural
 Trauma, abses, tumor, perdarahan, hidrosefalus
 Metabolik
 Syok, ketoasidosis, uremia, koma hepatik,
ensefalopati

Current Management in Child Neurology 2005.h.551-62

Current therapy in neurologic disease 2002. h. 1-8

1/18/2018 53
TATALAKSANA Jalan napas – intubasi bila SKG < 8
ANAK TDAK Pernapasan – SaO2 > 80%
SADAR Sirkulasi – tekanan arteri > 70

Pem Lab: darah tepi, analisa gas darah, fungsi hati dll

PEM. NEUROLOGIS

Hiperventilasi – Manitol 0,5 – 1 gram/kgBB/kali

Glukosa darah < 60 mg% - 25 gram glukosa
Gangguan elektrolit – koreksi
Keracunan narkotika - naloxon

CT scan atau MRI kepala

Riwayat lengkap, pemeriksaan sistemik

Pungsi Lumbal, EEG Crit Care Med 2006;

34: 31-41
1/18/2018 54
ASPEK AKUT ASMA

• Nastiti Kaswandani
 Saluran napas anak asma • sangat rentan
• Sangat sensitif
• Mudah goncang/mengkerut
Pencetus
(debu, bulu binatang, kapuk, dll)

Tidak timbul serangan Timbul serangan

•Otot saluran napas mengkerut

•Saluran napas menebal/membengkak
•Lendir lebih banyak dan kental/lengket

Bronkus Bronkus
Kapan curiga asma
 BATUK dan/atau MENGI:
Berulang
Malam hari
Musiman
Aktivitas
Hilang sendiri dengan atau tanpa obat
Riwayat alergi baik pada pasien atau
keluarga
 ANAK

Batuk&/mengi:
Episodik, nokturnal,
musiman, pascaaktivitas,
atopi

ASMA

Serangan Di luar serangan

Ringan Sedang Berat AEJ AES AP

INHAL INHAL INHAL --- INHAL INHAL

 Asma
Pencetus

• Debu rumah
Kegagalan terapi • Tungau
jangka panjang • Asap
• Makanan

Serangan
Pathophysiology of asthma
attacks Triggers

b.constriction, oedema, secretion 

Airway obstruction

ununiform
pulmonary
ventilation
hyperinflation

atelectasis mismatch
compliance
ventilation-perfution
abnormality

 surfactant alv.hypoventilation 
Resp.rate
acidosis

pulmonary
v.constriction
 PaCO2
Michael Sly. Nelson Textbook
 PaO2 of Pediatric, 1996
Assessment of severity asthma attacks
Mild Moderate Severe Respiratory
arrest
imminent
Breathless Walking Talking At rest
Can lie down Infant-softer Infant stops
Shorter cry feeding
Difficult Hunched
feeding forward
Prefers
sitting
Talks in Sentences Phrases Words

Allertness Maybe Usually Usually Drowsy or

agitated agitated agitated confused

Respiratory Increased Increased Often

rate >30x/min
 Normal rates of breathing in awake children:
Age Normal rates
<2 months <60/min
2-12 months <50/min
1-5 years <40/min
6-8 years <30/min
Accessory Usually not Usually Usually Paradoxial
muscles and thoraco-
suprasternal abdominal
retractions movement
Wheeze Moderate, Loud Usually loud Absence of
often only end wheeze
expiratory
Pulse/min <100 100-200 >120 Bradycardia

Infants 2-12 months <160/min

Preschool age 1-2 years <120/min
School age 2-8 years <110/min
PEF after Over 80% Approx. 60- <60% predicted
initial 80% or personal
bronchodilat best or
or response lasts
%predicted <2 hrs
or %
personal
best
PaO2 (on air) Normal >60 mmHg <60 mmHg
Test not possible
and/or usually cyanosis
PaCO2 necessary <45 mmHg
<45 mmHg >45 mmHg
SaO2% >95% 91-95% <90%
 Asthma attacks algorithms

Emergency room
Assess severity of attacks

Early treatment
• nebulized -agonist 3x, interval 20 min
• 3rd nebulized + anticholinergic

Mild attacks Severe attacks

(nebulized 1x, Moderate attacks
(nebulized 2-3x, (nebulized 3x,
good response) poor response)
partial response)
• observe 1-2 jam, • O2 • O2
discharge • reassessment  mode- • IV line
• symptoms (+)  rate ODC • reassessment 
moderate attack • IV line severe,
 admission
• Chest X-ray
 One Day Care (ODC) Admission room
Discharge • Oxygen therapy • Oxygen therapy
• give -agonist • Oral steroid • Treat dehydration and
(inhaled/oral) • Nebulized / 2 hour acidosis
• routine drugs • Observe 8-12 hours, • Steroid IV / 6-8 hours
• viral infection: if stable discharge • Nebulized / 1-2 hours
oral steroid • Poor response in 12 hrs, • Initial aminophylline IV,
• Outpatient clinic in  admission then maintenance
24-48 hours • Nebulized 4-6x 
good response per 4-6 h
• If stable in 24 hours 
discharge
• Poor response  ICU
Notes:
• In severe attack, directly use -agonist + anticholinergic
• If nebulizers not available, use adrenalin SC 0.01 ml/kg/times
with maximal dose 0.3 ml/times
•Oxygen therapy 2-4 l/min should be early treatment in moderate
and severe attack
Early management
 Initial assessment of severity asthma
attacks
 Nebulized ß2-agonist, interval 20 minute
 3rd nebulization: anticholinergic agent
 Severe attacks: directly with
anticholinergic agent
 If nebulizer not available:
 MDI with Spacer
 Adrenalin SC National guidelines for childhood asthma,
2004
Mild attacks

 Good response post nebulization

 Observe: 1-2 hours
 Discharge if good response
 Treat as moderate attacks if symptoms still
remain
 Use routine drugs
 Out patient clinics
Moderate attacks
 Partial response post nebulization
 ODC admission
 Oxygen therapy
 Oral steroid
 IV line
 Repeated nebulization
 Good response: discharge
 Poor response: admission
Why is not response?
 Dehydration
 Metabolic acidosis
 Atelectasis
Severe attacks
 Poor response postnebulization
 Oxygen therapy
 IV line: rehydration and treat acidosis
 Corticosteroids (IV)
 Initial Aminophylline (IV), then
maintenance
 Repeated nebulization
 Chest X-ray
 Good response : Discharge
 Poor response : Intensive care
Oxygen therapy
 Reduce hypoxemia
 To achieve saturation > 95%
 Should be titrated according to oximetry
Inhalations (severe atacks)
 β2 agonist and ipratropium bromide Vs
β2 agonist alone:
 Hospitalization 
 Symptoms score 
 Lung function 
 Duration of action: 
 Mucolytics: worsen

Schuh et al. J Pediatr 1995; 126:639-45.

IVFD
 Replacement therapy for dehydration
 Intake  because dyspnea
 Vomiting
 Treat acid-base and electrolyte
imbalance
 Parenteral medications
Steroids
 Intravenous or oral
 Antiinflamations
 Inhaled steroids: controversial
Aminophylline
 Initial: 6-8 mg/kgBW IV in 10-20 minute
 Maintenance dose 0.5 - 1
mg/kgBW/hour
 Monitoring: aminophylline
 Narrow safety margin

National guidelines for childhood asthma,

2004
 MANAGEMENT OF ASTHMA ATTACKS

MILD
Nebulization
Observe 1-2 hours MODERATE

DISCHARGE ODC SEVERE

Oxygen •O2, steroid
• Nebulization
Nebulization • Hydration
IVFD •Aminophylline
• Rö
Oral steroid •ICU (?)
TERIMA KASIH