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Upper airway obstruction occurs for up to 30% of burn patients and may occur as early as 4 hours or as late as 24 hours after exposure  discount 50mg cytoxan otc symptoms testicular cancer. The production of upper airway edema is because of a variety of factors generic cytoxan 50mg free shipping symptoms 89 nissan pickup pcv valve bad, including direct mucosal damage and ulceration from heat and superheated steam order cytoxan no prescription medications zoloft side effects, the release of inflammatory mediators from the damaged mucosa buy cytoxan with american express symptoms genital warts, and the production of oxygen free radicals from toxic chemicals on the surface of smoke particles. Rarely, thermal injury can produce circumferential, constricting eschars, or scarring of the upper airway after the acute edema resolves. Particles less than 3 μm in diameter travel to the distal portions of the respiratory tract and can cause small airways and alveolar injury. Lower airway penetration by small smoke particulates can cause irritation, inflammation, and bronchoconstriction. Individuals with preexisting asthma or chronic obstructive pulmonary disease may experience exacerbations, but bronchoconstriction can also occur in individuals with no prior history of airway disease. Small smoke particles can also cause alveolar-capillary injury in the lung parenchyma by direct oxidative damage from adsorbed irritants and by oxygen free radicals and inflammatory mediators released by neutrophils that migrate to areas of irritant damage. Rarely, pulmonary edema can occur as a consequence of alveolar-capillary injury and may occur hours to days after smoke inhalation. Although pulmonary edema occurs among far less than 10% of smoke inhalation victims, it has a high mortality rate . Airway injury, whether it is tracheobronchitis or small airway bronchoconstriction, can cause sloughing of necrotic tissue into the lower airways that can lead to mucous plugging, bronchial obstruction, atelectasis, hyperinflation, and altered mucociliary clearance. Secondary bacterial pneumonia can develop in obstructed lung segments or as a result of alveolar damage adversely affecting local immunodefenses. In this study, of the 144 patients who reached the emergency room alive, 12 had blood cyanide concentrations exceeding 1. Diagnosis and Management of Irritant Toxic Gases, Including Smoke Inhalation the most important factors for the diagnosis of toxic inhalational injury are a history of circumstances that caused the exposure, identification of the specific toxic gas to which an individual has been exposed, and an estimate of the exposure concentration. Exposure duration is based not only on exposure time but also on the patient’s minute ventilation during that time. Chemical analyses of material at the site of exposure, if available, can be particularly helpful in identifying the offending toxicant and estimating its exposure concentration. The relative solubility of a toxic gas can be helpful in determining the areas of the respiratory tract where irritant injuries are most likely to occur, and obviously patients with preexisting pulmonary disease are most at risk. When the irritant toxic gases are in the setting of smoke inhalation, the exposure will be to multiple gases and particulates. Facial burns, singed eyebrows, soot in the upper airway, and carbonaceous sputum make smoke inhalation highly likely. All contaminated clothing should be removed to prevent further inhalation and percutaneous absorption of the toxic substance. Superficial burns should be treated conservatively with a topical antibiotic such as silver sulfadiazine. Victims with mild inhalation exposures may be treated and released if they are (i) asymptomatic with normal mental status and absent of confusion; (ii) no burns, carbon material, or edema in the upper airway; (iii) normal pulmonary examination without signs of respiratory distress, stridor, or wheeze; and (iv) if available a pulse oximeter and noninvasive carboxyhemoglobin reading that are normal or at baseline. Upon release, patients should be advised to seek medical attention if symptoms occur or reoccur, because the clinical manifestations of inhalation injury may take 4 to 24 hours to develop . It is for this reason that borderline patients or patients with significant comorbidity should be observed rather than released whenever possible. The medical evaluation after any exposure to potentially toxic irritant gases should focus on assessing the nature and extent of upper and lower respiratory tract injury, the adequacy of oxygenation, cardiac function, and the hemodynamic stability of the patient. Typical patient complaints include eye irritation, headaches, confusion, sore throat, cough, chest tightness, and difficulty breathing. Common physical findings include irritation of the eyes, skin and other exposed mucosal surfaces, tachypnea, cough, stridor, wheezing, and rhonchi. Serum lactate concentration should be measured, and the magnitude of metabolic acidosis should be assessed. Although chest radiographs may be normal shortly after acute exposure, serial radiographs are useful for detecting the development of pulmonary edema and secondary bacterial pneumonia in hypoxemic individuals. An electrocardiogram should be obtained to detect the presence of myocardial ischemia and cardiac dysrhythmias. This will help improve the oxygen-carrying capacity of hemoglobin when high levels of carboxyhemoglobin or methemoglobin are present. High levels of methemoglobin are unusual but, if present, can be treated with intravenous methylene blue. The fraction of inspired oxygen can be titrated down to maintain a PaO greater than 60 mm Hg once2 carboxyhemoglobin and methemoglobin levels have returned to normal. In addition, all smoke inhalation victims found in cardiac arrest receive hydroxocobalamin during cardiac resuscitation. Inhaled amyl nitrite and intravenous sodium nitrite should be avoided because they generate methemoglobin that can further impair the oxygen-carrying capacity of blood hemoglobin if high levels of carboxyhemoglobin or methemoglobin are already present. The Paris Fire Brigade routinely administers hydroxocobalamin to smoke inhalation patients and published their experience in 2006 . Of the 29 patients in cardiac arrest, 18 (62%) recovered with cardiac resuscitation and hydroxocobalamin treatment. The average time between hydroxocobalamin administration and recovery of spontaneous cardiac activity was 19 minutes. In 15 hemodynamically unstable patients not in cardiac arrest, 12 (80%) showed hemodynamic improvement (blood pressure >90 mm Hg) after hydroxocobalamin. The average time for hemodynamic improvement was 49 minutes from the start of and 29 minutes from the end of hydroxocobalamin infusion. Irritant, toxic gases can also cause tachypnea, stridor, and hoarseness as a result of upper and lower airway disease. Patients are at risk for developing progressive laryngeal edema with complete obstruction of the upper airway. Patients with laryngeal edema can be difficult to intubate and, if intubation is delayed, may require an emergency tracheostomy. Immediate intubation should be considered if there is evidence of significant upper airway edema or blisters. All patients with upper airway edema should be treated with nebulized racemic epinephrine and systemic corticosteroids. An inhaled mixture of helium and oxygen can also improve upper airway airflow by reducing turbulence as a result of its low density. If the clinical decision is not for immediate or early intubation , then patients with upper airway edema should be admitted to the hospital and closely monitored for signs of edema progression and the need for emergent intubation at a later time. Lower airway involvement from irritant gas or smoke inhalation is typically diagnosed by history and physical examination. However, additional diagnostic evidence can be provided by laryngoscopic or bronchoscopic demonstration of edema, hemorrhage, or carbonaceous material distal to the vocal cords.
Otherwise generic 50mg cytoxan with amex treatment ulcerative colitis, there was no past medical history of note and no surgical or gynaecological history either buy generic cytoxan 50mg online treatment 1st degree heart block. However order cytoxan 50mg fast delivery treatment zoster, on further examination small pete- chial bruises were present on the arms and legs cheap cytoxan line medications for factor 8, particularly over exposed areas. This patient has presented with bleeding and bruising problems, and has a plate- let count of 4 × 109/L, which is significantly thrombocytopenic. Investigation of profound thrombocytopenia should include a thorough history and examination, a repeat full blood count to rule out sampling error and a blood film to look for any signs of a haematological malignancy that might be present. In this case, as the remainder of the full blood count is normal, it is unlikely that this thrombocytopenia is secondary to an underlying haematological malignancy, such as acute leukaemia or myelodysplastic syndrome. As she denies any regular drug use, drug-induced thrombocy- topenia is unlikely, but it is always worthwhile questioning her further about any over-the-counter, illicit or herbal medicines used. Finally, she reports feeling generally well, so glandular fever or other acute viral infections would be unlikely. Initial therapy is aimed at suppressing the immune response that is causing immune destruction of the patient’s own platelets. The immunosup- pressant of choice is usually high-dose prednisolone (1 mg/kg daily), but may also include immune modulatory doses of intravenous immunoglobulins. Response to this treatment is usually rapid and platelet counts can improve significantly after only 24 hours, but failure of treatment is not usually determined until no response has been achieved after 2–3 weeks’ treatment. A number of other immunosuppres- sant drugs, monoclonal antibodies, other treatment modalities and even splenec- tomy are options for those patients failing or relapsing after first-line therapy. Platelet transfusion is rarely used, as antibodies for autologous platelets will destroy any transfused platelets just as rapidly as they destroy the patient’s own platelets. Differential diagnosis • Immune thrombocytopenic purpura • Drug-induced thrombocytopenia • Acute viral infection (e. It was present upon waking one morning, and despite walking around and taking simple analgesia, the pain and swelling has not set- tled. She is 32 weeks’ pregnant in her first pregnancy, with no current concerns from her midwife according to her maternity notes. Her past medical history includes an admission at the age of 16 for a paracetamol over- dose and a couple of other A&E attendances for minor injuries. She has no known drug allergies and has been taking paracetamol for her leg pain and Gaviscon for indigestion as needed. She has no family history of note, although she does not know her parents well, having been adopted at an early age. She smokes 20 cigarettes a day and has managed to cut down her alcohol intake to about 8 units a week while pregnant. On direct questioning, she denies any increased shortness of breath, palpitations, dizzi- ness or chest pain. The remainder of her systemic examination is unremarkable with a clear chest, normal heart sounds, but for a mammary soufflé. These risks are all increased in pregnancy, but also in situations such as prolonged immobility and surgery. It is a safe, non-invasive test, involves no ionizing radiation and is therefore the best investigation both in pregnancy and in the general population. Warfarin is contraindicated in the first trimester of pregnancy and is used with caution in the sec- ond and third trimesters. This monitoring should normally be performed by your hospital’s anticoagulation service or directly through the haematology clinic. Testing for a heritable thrombophilia would not change your manage- ment of this patient either acutely, or in the long term, and is therefore not current- ly recommended. Further information about testing for heritable thrombophilias is available from the British Committee for Standards in Haematology website (www. As a result, she is no longer able to give you a coherent history and the remainder of the information is obtained from her husband. He tells you that up to yesterday she had been feeling well, except for some long- standing tiredness. However, since yesterday evening she has become increasingly tired and weak and went to bed early last night. The husband informs you that his wife has been undergoing chemotherapy for non- Hodgkin lymphoma and had her second cycle just over a week ago. She has an allergy to non-steroidal anti- inflammatory drugs and takes allopurinol, lansoprazole, metoclopramide, metformin, gliclazide, losartan and levothyroxine. Auscultation of the chest reveals no wheeze or crepitations and pulse oximetry is 96 per cent on high flow oxygen. This woman is suffering from neutropenic sepsis as defined by signs of sepsis (hypotension, tachycardia, fever, peripheral shut-down) and neutropenia (neutro- phils <1. The major morbidity and mortality of neutropenic sepsis results from the patient’s inability to mount an immune response to a bacterial pathogen. People most at risk of profound neutropenia are those with lower bone marrow reserve, such as the elderly and those who have had many previous courses of chemotherapy. Early signs of neutropenic sepsis include a fever of greater than 38°C, tachycardia, hypotension, shivers/rigors and diarrhoea. These may progress to include restless- ness, clamminess, confusion, hypothermia, severe hypotension and tachypnoea. The management of neutropenic sepsis involves the early administration of high doses of broad-spectrum antibiotics to those thought to be at risk from neutropenia, often even before a full blood count has been performed to confirm the neutrope- nia. Broad-spectrum antibiotic usage will depend on local protocols, and depends on patient allergies, but often includes piperacillin/tazobactam (tazocin) with or without gentamicin/ciprofloxacin. If you are involved in the initial management of patients with neutropenic sepsis, it would be beneficial to familiarize yourself with local policies. After gaining venous access and taking blood cultures – including cultures from any indwelling central line – administration of antibiotics is the first priority. Further investigations, including urine and sputum culture, should be performed when possible and a chest radiograph should be taken. Neutropenic patients often display no localizing signs because, for example, the production of sputum/chest crepitations requires the presence of neutrophils to migrate to the site of infection and these are absent in neutropenic patients. It is often only when a patient’s neutrophil count is recovering that it becomes clear exactly from where the offending infection has arisen. As with other acutely ill patients, neutropenic sepsis patients require supportive treatment varying from fluid resuscitation to inotrope administration, depending on the clinical scenario, and should always be nursed in areas with expertise in neu- tropenic sepsis, and areas where higher nurse:patient ratios are available. It is rec- ommended that intensive care or high dependency units, where available, are made aware of these patients early as deterioration can be rapid and unpredictable. This is a condition where chemotherapy agents cause rapid destruction of large numbers of tumour cells resulting in intracellular proteins and metabolites entering the circulation in concentrations that overcome normal physiological clearance mechanisms. Allopurinol is therefore used prophy- lactically to help prevent uric acid build up in patients either undergoing or about to undergo chemotherapy, such as in this case. As part of the medical team on call, the orthopaedics team have contacted you because her platelet count has been consist- ently dropping, and they are now concerned that it is too low for her to continue with the heparin infusion that she is currently receiving for her metallic heart valve, which was started 6 days ago.
Among the women in the 24-day group purchase cytoxan 50mg on line treatment zoster ophthalmicus, those who switched from another oral contraceptive had a lower mean number of bleeding days compared to new users buy generic cytoxan 50 mg line symptoms with twins, probably refecting suppression of endometrial growth by the previous use buy cytoxan master card symptoms e coli. Each cycle with the 24-day product demonstrated a shorter duration of withdrawal bleeding (bleeding beginning afer the last day of active drug intake) purchase cytoxan 50 mg amex symptoms 5 weeks pregnant, achieving statistical signifcance in the second cycle. Combining breakthrough bleeding and withdrawal bleeding, the total num- ber of days over the entire six treatment cycles with bleeding was signif- cantly less in the 24-day group: 18. A reasonable concern with extending the days of active treatment is the resulting increase in overall hormone exposure. A 21-day product has been compared with extending the schedule to 23 days, using 75 mg gestodene/20 mg ethinyl estradiol. The 23-day regimen was associated with shorter withdrawal bleeding periods compared with the 21-day schedule. Oral Contraception Ovarian activity was compared in a group of women using 60 mg gestodene/ethinyl estradiol 15 mg for 24 days compared to a group using the same product on the standard 21-day regimen. Breakthrough bleeding was more prevalent with the 24-day schedule; however, the number of treatment cycles in this small study was not large enough to assess bleeding control. A larger study compared the 24-day regimen of 60 mg gestodene/ethinyl estradiol 15 mg with a 21-day regimen using 150 mg desogestrel/ethinyl estradiol 20 mg and reported a greater incidence of breakthrough bleeding with the 24-day regi- men; however, the length of bleeding was shorter and the intensity of bleed- ing was reduced. Diminished ovarian follicular activity is responsible for less fuctuation in endogenous estrogen levels, resulting in a more quiescent and stable endo- metrium. Extended (and continuous dosing) regimens compared with the standard 21-day regimen are associated with a decrease in menstrual dis- comfort, headaches, and bloating. Randomized studies that extended the pill-free interval by 2 or 3 days observed that women taking a 20-mg ethinyl estradiol for- mulation had a greater increase in follicular activity compared with women using a 35-mg ethinyl estradiol product. In one study, a greater proportion of women on a 20-mg product, around 30%, achieved follicular diameters of 15 mm or greater, compared with a 35-mg formulation when the pill-free interval was extended from 7 to 9 days. Not only does the 24-day product allow a day or two grace period, but the extended hormone exposure suppresses gonadotropin and follicular activity to a greater degree. Tus, even in patients with good compliance, a greater reduction in follicular activity can reduce the possibility of breakthrough ovulations and contraceptive failure. This would be difcult and expensive to document because it would require a clinical trial with a very large num- ber of patients. A regimen is available that supplies a package containing the number of pills required for 84 days of daily administration, a reduction of men- strual frequency to 4 per year. Eforts to improve steroid contracep- tion are now focusing on maximizing adherence to treatment and minimizing pregnancies from contraceptive failures. The 24-day regimen ofers clinicians and patients the important advantage of reduced bleeding and the possible advantage of greater efcacy because of better compliance as well as a reduc- tion in ovarian activity. Continuous Dosing More and more women are embracing the idea that fewer menstrual periods provide a welcome relief from bleeding and menstrual symptoms. Clini- cians for years have prescribed unlimited daily oral contraceptives to treat conditions such as endometriosis, bleeding disorders, menstrual seizures, and menstrual migraine headaches, even to avoid bleeding in athletes and busy individuals. Many women do not require the periodic experience of vaginal bleeding to assure themselves they are not pregnant. And of course, modern society is long past the notion that menstrual bleeding is a cleans- ing event, a detoxifcation. Any com- bination oral contraceptive can be used on a daily basis; even the lowest estrogen dose formulations provide excellent bleeding and side efect pro- fles in a continuous regimen. Continuous dosing can also be achieved with the contraceptive vaginal ring and the contraceptive patch. The return of ovula- tion and achievement of pregnancy are not delayed afer discontinuation of continuous dosing. Tese products are less expensive, marketed by pharmaceutical companies afer patent expiration of the original drug. Generic oral contraceptives need only meet the test of bioequivalence; studies to demonstrate efcacy, side efects, and safety are not required. Meeting the test of bioequivalence requires demonstration in a small number of subjects that absorption, con- centrations, and time curves are comparable to the reference drug. The generic product will be approved if the bioequivalence testing ranges from 80% to 125% of the values for the reference drug (diferences no >20% lower or 25% higher). Approved, patented products must not vary more than ±10%; therefore, a generic oral contraceptive could contain only 70% of the standard dose. However, we should hasten to point out that there has been no evi- dence or even anecdotal suggestions that generic oral contraceptives have reduced efcacy or cause more side efects such as breakthrough bleeding. Oﬀ-Label Uses of Steroid Contraception Steroid contraception is ofen used for noncontraceptive purposes. The list is long, including treatment of acne, dysmenorrhea, heavy or irregular vaginal bleeding, menses-associated mood changes, the polycystic ovary syndrome, and endometriosis. For most of the oral contraceptive’s 50-year history, all of these have been “of-label” applications, but recently pharma- ceutical companies have conducted trials to obtain label “indications” to use in advertising directed to both clinicians and consumers. Because these trials usually compare a product to a placebo or just to another contraceptive formulation, the studies do not reveal whether the product receiving approval for an “indication” is really better than others. Prices and formularies restrict patient access to the full range of oral contraceptives96; therefore, clinicians must make judgments by comparing fndings from unrelated studies and experience to decide which A Clinical Guide for Contraception pill to use for a specifc purpose in an individual patient. In most cases, as we will emphasize, it is unlikely that there are major diferences among similar products. Potency For many years, clinicians, scientists, medical writers, and even the phar- maceutical industry attempted to assign potency values to the various progestational components of oral contraceptives. In the past, animal assays, such as the Clauberg test (endometrial change in the rabbit) and the rat ventral prostate assay, were used to determine progestin potency. Although these were considered acceptable methods at the time, a better understanding of steroid hor- mone action and metabolism and a recognition that animal and human responses difer have led to greater reliance on data collected from human studies. Historically, this has been a confusing issue because publications and experts used potency ranking to provide clinical advice. Oral contraceptive progestin potency is no longer a consideration when it comes to prescribing oral contraception, because the potency of the various progestins has been accounted for by appropri- ate adjustments of dose. In other words, the biologic efect (in this case the clinical efect) of the various progestational components in current low-dose oral contraceptives is approximately the same. The potency of a drug does not determine its efcacy or safety, only the amount of a drug required to achieve an efect. Clinical advice based on potency ranking is an artifcial exercise that has not stood the test of time. Tere is no clinical evidence that a particu- lar progestin is better or worse in terms of particular side efects or clinical responses. Tus, oral contraceptives should be judged by their clinical char- acteristics: efcacy, side efects, risks, and benefts. Our progress in lowering the doses of the steroids contained in oral contraceptives has yielded prod- ucts with little serious diferences. Mechanism of Action The combination pill, consisting of estrogen and progestin components, prevents ovulation by inhibiting gonadotropin secretion via an efect on both pituitary and hypothalamic centers. It provides stability to the endometrium so that irregular shedding and unwanted breakthrough bleeding can be minimized; and the presence of estrogen is required to potentiate the action of the progestational agents. The mechanism for this action is probably estrogen’s efect in increasing the con- centration of intracellular progestational receptors.
During fever purchase cytoxan with a visa symptoms migraine, whole body disease associated with organ involvement like hepatitis generic cytoxan 50mg visa medications memory loss, is invariably covered with bloachable erythematous flush encephalitis and myocarditis cheap generic cytoxan canada medicine 79. Anorexia discount cytoxan 50mg with amex medicine lake, nausea and vomiting be possible to distinguish dengue from non-dengue febrile are not uncommon and usually lead to dehydration. A positive tourniquet test in this phase increases hemorrhagic manifestations like petechiae. Presence of these warning signs of dengue fever patients makes a smooth and complete should alert clinician for regular monitoring and prompt recovery; however in a small number of patients disease fluid therapy to improve patient outcome. Unfortunately initial clinical features critical Phase are indistinguishable between severe and non-severe Around the time of defervescence, in some of the patients dengue cases; hence it is imperative that patient should an increase in capillary permeability sets in. Extravasations of be frequently monitored for warning signs for recognizing plasma through these leaky capillaries result in progressive progression to the critical phase. A parallel drop in platelets and progressive leukopenia usually precedes plasma leakage. Dengue with Warning Signs Together these changes mark the beginning of the critical Cases destined to pass into critical phase may display the phase. Patients in this phase would display many of the following warning signs: persistent vomiting, abdominal above mentioned warning signs. According to new classification these with progressive thrombocytopenia, mucosal bleeding patients should be classified as “dengue with warning 232 (epistaxis, hematemesis, gum bleeding, metromenorrhagia signs”. A sudden fall in otherwise elevated bleeding are few of the commonly encountered serious hematocrit during critical phase should alert clinician for manifestations of a dengue illness. Category has three types of patients: recovery Phase • Patients with severe plasma leakage: After 2–3 days, leak stops and plasma which had extra- – Shock [cold clammy peripheries, prolonged capillary vasated during the leaky phase, returns back to circulation. Typically – Patients with neurological involvement effusions are slow to resolve and may take a few more days – Patients with cardiac involvement. Dengue Shock Respiratory Distress Patients with prolonged and prolific leak would deteriorate. Patients with profound leak usually need massive resu- These deteriorating patients will manifest signs of scitative fluid therapy during critical phase. Massive pleural effusion primarily into serous cavities like peritoneum, pleura, and ascites (s 5. This phase generally lasts for 12–24 effusion are clinically detectable, however small effusions hours and needs intense observation. Patient may need would need chest X-ray and abdominal ultrasound for oxygen support and decongestive (diuretics) therapy to demonstration. Convalescence Poorly managed patients may progressively pass Termination of the illness is swift and is usually marked into hypovolemia, hypotension and shock. The disease is self-limiting, but some patients may have unduly severe hepatitis with markedly elevated transaminases, frank hemorrhages and hepatic failure which could culminate in death. Importantly these cases may not always have pathognomonic dengue vascular leak and could occur during febrile phase of the disease. Neurological Complications Dengue infections can cause variety of neurological manifestations; prominent among them are convulsions, ure 5. In some cases there are small round areas of clear skin giving it a name of annular Cardiac Complications petechial rash. Hepatomegaly and liver impairment in the form of elevated Proper dengue management has following principles: 234 transaminases is common occurrence in dengue illnesses. Serum transaminases, creatinine and electrolytes febrile illness; it is difficult to recognize dengue unless are some of the useful additional tests. A decubitus measly look and bloachable erythematous flush, presenting X-ray chest used to be employed by past clinicians for particularly during rainy season should immediately demonstrating mild pleural effusion. Respiratory viruses has made the things convenient; can demonstrate smallest prevailing during rainy season could also present with amount of extravasated in any of the serous cavity. Gall- similar erythematous flush; however a significant catarrh bladder edema is one of the unexplained yet a consistent differentiates them from dengue illnesses. Signs urine, giddiness, restlessness, anxiety, severe abdominal of pleural and peritoneal effusion (dull percussion note, pain and cold extremities. Abnormal pulses, narrowing of pulse pressure, and fall in blood mentation, impaired consciousness and convulsions may pressure. Patient with these symptoms need immediate suggest early neurological dysfunction. However, • In dengue illnesses crucial pathophysiology starts with diligent search is needed to find out petechiae, purpura and defervescence; hence any child deteriorating or failing ecchymoses. A tourniquet test should always be performed; to improve with subsidence of fever should be carefully positive test suggests underlying bleeding tendency and assessed for progression to critical phase. Hematocrit deterioration around the time of defervescence, severe test in the early febrile phase establishes the patient’s abdominal pain, persistent vomiting, cold and clammy own baseline value which serves as reference figure for extremities, lethargy or irritability/restlessness, bleeding any change occurring during further course of disease. These parameters exhibit a unique time-bound tolerate oral fluids; however patients with anorexia, nausea relationship with the disease. Normal saline 235 or Ringer’s lactate given at maintenance rate in general management Plan suffices. Switch over to oral fluids as soon as patients Dengue with Warning Signs tolerate. Patients should remain under close medical supervision at least for 2–3 days beyond defervescence. Patients exhibiting signs of severe dengue or warning signs Initial values serve as reference for future changes. Patients may need 5–7 mL/kg/hour for 1–2 hours for In majority of the dengue illnesses, intravenous fluid initial hemodynamic stabilization. In mild cases plasma leakage is small and less according to the clinical response. Use minimum intra- transient, and patients recover spontaneously or shortly after venous fluid volume required to maintain good perfusion. If the hematocrit remains the the mainstay for the treatment of this type of severe dengue. Bolus of 5–10 mL/kg/hour may fluid overload, and it was felt that dengue vascular leak be given for 1–2 hours then modify fluid infusion rates as could be managed with lesser fluid therapy. However at least 1–4 hourly solutions offer some advantages over crystalloid solutions, watch on vital signs and 4–6 hourly monitoring of urine as they provide volume expansion over and above the actual output are absolute must. The colloid molecules increase plasma assessments every 6–12 hourly and additionally before and oncotic pressure and reverse the net flux of fluid out of the after every bolus fluid replacement. Moreover pathophysiological studies indicate that there is preferential leakage of relatively Severe Dengue small plasma proteins (e. IgG), which implies that resuscitation Patients with severe dengue need urgent hospitalization with colloid preparations of larger molecular weights may and emergency treatment. Currently fluid therapy is were transient and no significant advantage was found over separated as fluid resuscitation and fluid replacement.