Department of Health Research

Ministry of Health and Family Welfare, Government of India
PARTNERS

Suggested Citation: Standard Treatment Workflows of India, 2019 Edition, Vol. 1, New Delhi, Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India
© DHR and ICMR Diary No. 17206/2019-CO/L
All rights reserved. No part of these workflows may be transmitted or reproduced in any form or by any means without prior permission from the organization.
Printed in India

Department of Health Research
Ministry of Health and Family Welfare, Government of India
These STWs have been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information. © Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Department of Health Research
Ministry of Health and Family Welfare, Government of India
• INTRODUCTION
CARDIOLOGY
ATRIAL FIBRILIATION BRADYARRTHYMIAS HEART FAILURE STABLE ANGINA STEMI
UNSTABLE ANGINA/ NSTEMI
ENT
ACUTE RHINOSINUSITIS
CHRONIC RHINOSINUSITIS
EPISTAXIS
HEARING IMPAIRMENT IN PEDIATRIC AGE GROUP NECK SPACE INFECTION
OTORRHOEA
PHARYNGITIS AND SORE THROAT
NEPHROLOGY
ACUTE KIDNEY INJURY CHRONIC KIDNEY DISEASE GLOMERULONEPHRITIS URINARY TRACT INFECTION
NEUROLOGY
APPROACH TO ACUTE PARALYSIS DEMENTIA
EPILEPSY
HEADACHE
NEUROINFECTIONS STROKE
OBG
ANTENATAL MANAGEMENT DILATATION AND CURETTAGE HEAVY MENSTRUAL BLEEDING HYSTERECTOMY
POSTPARTUM HAEMORRHAGE UTERINE FIBROIDS AND POLYPS
PAEDIATRICS
ACUTE ENCEPHALITIS SYNDROME ACUTE DIARRHEA
DENGUE FEVER
FEVER IN CHILDREN
SEPSIS AND SEPTIC SHOCK IN CHILDREN SEVERE ACUTE MALNUTRITION
SEVERE PNEUMONIA IN CHILDREN
PSYCHIATRY
ALCOHOL USE DISORDERS
ANXIETY DISORDERS
CHILDHOOD BEHAVIOURAL DISORDERS CHILDHOOD EMOTIONAL DISORDERS CHILDREN WITH DEVELOPMENTAL DISORDERS DEPRESSION
PSYCHOSIS
SOMATOFORM DISORDERS
PULMONOLOGY
ACUTE RESPIRATORY INFECTION
ASTHMA
CHRONIC OBSTRUCTIVE PULMONORY DISORDER RESPIRATORY FAILURE
UROLOGY
ACUTE URINARY RETENTION IN MEN GROSS HAEMATURIA
MALE INFERTILITY
RENAL AND URETRIC STONES SCROTAL SWELLING
• CONTRIBUTORS

INTRODUCTION

GOAL
To empower the primary, secondary and tertiary care physicians/ surgeons towards achieving the overall goal of Universal Health Coverage with disease management protocols and pre-defined referral mechanisms by decoding complex guidelines
OBJECTIVES
Primary Objective:
To formulate clinical decision making protocols for common and serious medical/ surgical conditions for both OPD and IPD management at primary, secondary and tertiary levels of healthcare system for equitable access and delivery of health services which are locally contextual
Secondary Objective:
To facilitate PMJAY arm of Ayushman Bharat with secondary and tertiary level management of all surgical and medical conditions covered under the scheme.
Department of Health Research
Ministry of Health and Family Welfare, Government of India
METHODOLOGY
ADVISORY
COMMITTEE
EDITORIAL BOARD
STW SECRETARIAT
EXPERT GROUPS COMMITTEES
DESIGN TEAM
PROCESS OVERVIEW
TOPIC PRIORITIZATION
• Prevalence studies • Global burden of
diseases studies
• HBP of AB-PMJAY
Harrison’s Textbook Oxford Handbook
DEVELOP STWS & CONVERT THEM
INTO INFOGRAPHICS
• 100 Meetings 650 hours Consultations
(5200 person hours)
• Participation also from Public Health Specialists Search Strategists Clinical Scientists Graphic Designers
REVIEW OF CURRENT GUIDELINES &
FEASIBILITY AS PER HEALTH
SYSTEM
• Review by Editorial Board • Approval by Advisory
Committee
• Public Comments

CARDIOLOGY

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ATRIAL FIBRILLATION
WHEN TO SUSPECT ?
ICD-10-I48.91
LOOK FOR PRECIPITATING FACTORS:
• Post (cardiac) surgery
• Alcoholism or binge drinking • Myo-pericarditis or ACS
• Pneumonitis or pulmonary
embolism
• Sepsis, hyperthyroidism
MANAGEMENT PRINCIPLES:
• Categorize AF
• Look for immediate intervention
indicators
• Assess stroke risk & need for
anti-coagulation
• Assess bleeding risk
• Need for rate control
• Consideration for rhythm control
CATEGORIZE AF
• Paroxysmal AF: Episodes of AF for less than 7 days
• Persistent AF: AF lasing from 7 days to 1 year
• Long standing persistent AF: AF lasting for > 1 year
• Permanent AF: AF with heart rate control as only option
LOOK FOR IMMEDIATE INTERVENTION INDICATORS:
• Systolic BP 90 mmHg, HR > 150 or <50/min
• Ongoing Angina
• CHF or TIA or stroke
• Major bleed on Oral Anti-coagulants
SYMPTOMS

Rapid rate palpitations with or without • General fatigue or weakness or
exhaustion
• Dizziness, near syncope or syncope • Shortness of breath
• Chest pain
More marked on exertion
SIGNS
Irregularly irregular pulse – Variable heart sound
STROKE RISK SCORE
OAC if score >1 in men and >2 in women
BLEEDING RISK SCORE
CHOICE OF ANTI-COAGULATION:
• Vitamin K antagonist
• Aim for INR 2-3
• Assess risk of bleeding
• Take measures to reduce/ modify risk of bleeding • Dietary modification & regular monitoring
MEASURES TO REDUCE HIGH BLEEDING RISK:
• Control SBP to less than 140 mmHg
• Avoid dietary indiscretions
• Avoid concomitant aspirin, anti platelets, NSAIDs • Avoid alcohol
• Correct anemia
LOOK FOR RISK FACTORS
• Prior valvular heart disease or CHF or MI
• Prior TIA or stroke or embolic episode
• Hypertension, DM, COPD,CKD, Obesity
CHA2DS2-VASC
SCORE
SCORE
HAS-BLED
- Congestive heart failure/LV dysfunction – Hypertension
Aged > 75 years
Diabetes mellitus
Stroke/ TIA/ TE
Vascular disease [prior MI, PAD or aortic
plaque]
Aged 65-74 years
Sex category [i.e. female gender]
1 1 2 1 2 1
1 1
Hypertension i.e. uncontrolled BP – Abnormal renal/ liver function
Stroke
Bleeding tendency or
predisposition – Labile INR
Age (e.g. >65)
Drugs (e.g. concomitant aspirin or NSAIDSs or alcohol
1
1 or 2 1
1
1
1
1
Maximum Score
99 Bleeding Risk High in score >3
HEART RATE CONTROL
In all patients except hemodynamic instability
Beta blocker or calcium blocker or combination
BB + digoxin in HF
Rate aim to be less than 110/ min
CONVERSION TO NSR
Hemodynamic instability
• Detailed clinical evaluation
• Basic investigations
• Careful ECG evaluation
• Start OAC if indicated (based on Stroke risk)
• Start Metoprolol if HR >110/ min & no evidence of CHF • Refer if indicators for early intervention
Uncontrolled symptoms despite HR control
Unacceptable rate control drug side effects
INVESTIGATIONS
Patients’ preference
MANAGEMENT
WHAT TO LOOK FOR IN ECG ?
• Ventricular rate
• Chamber enlargement • Pre-excitation
• Prior MI
• Bundle branch block
• QT interval
AT PHC/ CHC:
BASIC INVESTIGATIONS:
• Hemograms
• Blood sugar, Creatinine • Electrolytes
• 12 lead ECG
DESIRABLE INVESTIGATIONS:
• Plain X-ray chest
• Thyroid evaluation
• Liver function test
• Troponins
• Prothrombin time, INR (Coagulation
profile)
• Echocardiography
RHYTHM CONTROL
AT DISTRICT HOSPITAL:
• Admit if indicators of early interventions
• Immediate cardioversion after heparinization,if
hemodynamic instability
• Manage precipitating factors if any
• Assess stroke, bleeding risk & coagulation parameters • Detailed echocardiogram
• Start OAC, maintain INR around 2-3
• Control HR by single drug or combination of BB & Ca
Blocker
Refer HR uncontrolled or CHF or angina
OPTIONAL INVESTIGATIONS:
• Prolonged ECG monitoring
• Trans-esophagial echocardiography • Exercise Stress Test
• CT scan
• MRI
• EP study
• Coronary angiography
AT TERTIARY CENTRE:
• Re-assess clinical status, adequacy of AC
• Consider need of NOAC
• Optimise management of underlying cardiac disease
• Stress life style and AF risk factor modification
• Assess need for rhythm control and discuss pros & cons • Consider RFA in select patient
Sign/ symptoms suugestive of AF Confirm by 12 channel rhythm strip
Hemodynamic Instability
Yes CHF
Yes
HR control Aim <110/min Careful BB/Dig BB or Ca Block Amiodarone or combine HR > 110/ min Consider DC version
MANAGEMENT ALGORITHM
Yes
No
No
Very rapid HR >130/ min
No Symptomatic
Yes No
Clinical Follow-up
No DC version
Yes
Continue drug
Yes
Drug version Successful
No
Anti-coagulants in all Except
• Reversible
• Score <1 (men) ; <2 (women)
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019
CHF
CAD Abnormal LVH
Pharmacological Cardioversion Normal Heart
Flecainide Pill in pocket
Ibutilide (Flecainide OR Amiodarone Propafenone Propafenone)
Long Term Rhythm Control
CHF Normal Heart
Amiodarone Flecainide Propafenone
Sotalol
CAD, LVH
Amiodarone Sotalol Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
BRADYARRTHYMIAS IN SYMPTOMATIC PATIENTS
ICD-10-R00.1
WHEN TO SUSPECT
Patient with any of the following symptoms, AND a pulse rate < 50bpm: (persistent)
Syncope/ presyncope/ dizziness
Lethargy/ fatigue
Breathlessness/ chest pain on exertion
BASIC EVALUATION
HISTORY
• Syncope/ presyncope: frequency, associated fall/ injury/ incontinence • Exertional angina or known coronary artery disease
• Known hypothyroidism or kidney disease
• On beta-blockers, Calcium Channel Blockers or digoxin
• Patient with an implanted pacemaker or other device • Yellow oleander poisoning
EXAMINATION
• Drowsiness/ impaired consciousness
• BP, heart rate
TESTS TO BE DONE
Patient presenting to PHC/CHC:
• 12-lead ECG
• Blood urea, serum creatinine
• Electrolytes
• Blood sugar
EVALUATION AND TREATMENT OF UNSTABLE PATIENTS EVALUATION AND MANAGEMENT OF STABLE PATIENTS

TREATMENT OF ASSOCIATED CONDITIONS

Hyperkalemia
Suspected drug (BB or CCB) overdose:
i. Withhold the drug
ii. iv insulin (1 U/kg bolus followed by 0.5 U/kg/h) with glucose monitoring(or) iv
glucagon if available

TEMPORARY PACEMAKER INSERTION
(iv dopamine or adrenaline may be given till the time TPI can be placed)
Findings on 12-lead ECG
• Atrioventricular block
• Sinus node dysfunction
• Other conduction disorders with 1:1 AV
conduction
• Non-diagnostic ECG
INDICATIONS FOR URGENT TREATMENT/REFERRAL GENERAL APPROACH TO PATIENTS WITH SYMPTOMATIC BRADYCARDIA
• Hypotension (SBP <90 mmHg), impaired consciousness or ongoing chest pain
• Recurrent or ongoing syncope/presyncope
• Associated headache with or without neurologic deficit (suspect
intracranial event)
• Patient with a pre-existing device
• If ECG available, evidence of any of the following

Complete heart block
Sinus node disease with pauses >3 s long
Bradycardia (HR < 50 bpm) (with or without hyperkalemia, serum K > 5 mEq/L)

Rule out associated conditions

Renal dysfunction, hyperkalemia
Drug toxicity (BB, CCB, clonidine, Lithium)
Sleep apnea (clinical scoring systems such as Epworth
Sleepiness Scale may be used for initial assessment) 2. Transthoracic echocardiography
INDICATIONS FOR PERMANENT PACING
AV NODAL DISEASE
• Complete heart block, advanced AV block, or Mobitz Type II block
• Symptomatic patients with AV block other than above
• Associated neuromuscular disease
SINUS NODE DYSFUNCTION
• Symptomatic patients with sinus pauses > 3 s long with symptom correlation
• Asymptomatic patients with sinus pauses > 6 s long
OTHER CONDUCTION DISORDERS WITH 1:1 AV CONDUCTION
• Symptomatic patients with HV ≥100 ms on EPS
• Others (alternating BBB, infiltrative/ neuromuscular
disease)
RECOMMENDED PACING MODES

SND with intact AV conduction

Atrial-based single or dual chamber pacing – VVI pacing is reasonable if symptoms are
infrequent 2. AV node disease
VVI/Dual chamber pacing in patients with LVEF >50%
CRT (or HBP) in patients with LVEF 36-50% and requiring ventricular pacing >40% of the time
CRT (or HBP) if LVD <35%
ECG: SINUS BRADYCARDIA
ADDITIONAL TESTING

Advanced imaging (cMRI) may be needed if infiltrative disease is suspected
Ambulatory ECG may be needed

In patients with first or second degree AV block for symptom correlation
In patients with suspected sinus node disease for detection of pauses and symptom correlation
In symptomatic patients with LBBB or bifascicular block

Implantable Loop Recorder and EPS (consult published society guidelines)
ECG: THIRD DEGREE HEART BLOCK
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
HEART FAILURE: A BREATHLESS PATIENT
ICD-10-I50.9
SYMPTOMS
Dyspnea/ orthopnea/ PND 2. Pink frothy sputum
Dependent pedal edema 4. Recent weight gain
Easy fatiguability 6. H/o CHF/ MI
SIGNS
Tachypnoea
Tachycardia or irregular
pulse
Basal crepitations
Cardiomegaly
Presence of murmurs 6. Systemic desaturation
MANAGEMENT AT PHC
• Rule out respiratory cause: Breathlessness with fever, cough and expectoration or known patient of asthma or COPD
• Likely CHF: Decongest with furosemide
REFER IF FOLLOWING:
• BP < 90 mmHg or > 200 mmHg
• Heart rate < 50/min or > 120/min
• Respiratory rate > 30/min or cyanosis • Oliguria
• Altered sensorium
MANAGEMENT AT DISTRICT HOSPITAL
• Admit and re-assess
• Optimise therapy with furosemide/ enalapril/
spironolactone/ O2 and stabilize
• Consider non-invasive ventilation if marked respiratory
distress and O2 saturation < 90%
• Echocardiography: confirm diagnosis of HFrEF: LV
ejection fraction < 35%
• Search for etiological diagnosis
• Consider carvedilol after decongestion
• Refer back to CHC/ PHC after stabilization
ADDITIONAL INFORMATION
• Prior history of respiratory illness like asthma or COPD
• Known patient of CHF/ similar illness in past with response to therapy
• Prior history of RHD, CAD, pregnancy, cancer chemotherapy
• Risk factors: HT, DM, smoking, hyperlipidemia or premature CAD in first degree relatives
COMMON ETIOLOGY AND INDICATORS
Ischemic cardiomyopathy: past MI 2. Diabetic cardiomyopathy
RHD: existing valvular disease
Post-viral: acute onset
breathlessness within last 3 months 5. Peri-partum cardiomyopathy-onset
in last trimester or after delivery 6. Idiopathic cardiomyopathy
Post-cancer chemotherapy
Raised JVP
Pulmonary Oedema
Pleural Effusions
Hepatomegaly
Cardiomegaly
Ascites
Pitting Oedema
REFER TO COMMUNITY HEALTH CENTRE
MANAGEMENT AT CHC
• Admit and stabilize
• Send for routine investigations
• ECG: Rule out acute ST-Elevation MI
• X-ray chest: Rule out respiratory etiology • Decongest with intravenous furosemide • O2 therapy if systemic saturation < 90% • Start enalapril and spironolactone orally • Consider carvedilol after decongestion
REFER TO A DISTRICT HOSPITAL
MANAGEMENT AT TERTIARY HOSPITAL
KEEP WATCHING
Respiratory distress and oxygen saturation
BP and heart rate
Electrolytes and renal
parameters
REFER TO TERTIARY CARE IF
• CHF uncontrolled,
• Unstable hemodynamics
• Suspected ongoing ischemia • Abnormal electrolytes
• Abnormal renal functions
• Structural heart disease
• Unclear etiology
Re-assess and confirm diagnosis of HF
Categorize acute (< 3 months) vs chronic (> 3 months) and HFrEF
(EF 35%) vs HFpEF (EF 35-50%)
Optimize therapy with furosemide, enalapril, carvedilol,
spironolactone and O2
Consider ARNI and ivabradine
Pneumococcal and influenza vaccines
Investigate for etiology and manage
Consider non-pharmacological invasive therapy
a. ICD: In selected patients (Ref Arrhythmia STW)
b. BiV: Consider in NYHA class II/ III Symptomatic patient ,
EF <35%, QRS >150msec in sinus rhythm with LBBB
morphology and optimal medical therapy of >3 months 8. Etiology based Interventions
a. PCI
b. Valve replacement c. CABG
Smoking Cessation
BASIC INVESTIGATIONS
• Hemogram, ESR
• Blood sugar
• Urine examination
• Urea/ Creatinine
• Sodium/ Potassium • ECG
• Chest X-ray PA view
FUROSEMIDE
Salt restriction
Physical activity
CONSIDER AT ALL LEVELS
Weight Moderation Reduction of alcohol
INVESTIGATIONS:
WHAT TO LOOK FOR IN AN ECG?
• Pathological Q wave
• Conduction abnormalities,
especially LBBB
• Chamber enlargement
• Atrial fibrillation
Note: If ST elevation present, manage as STEMI
Control of DM/ HTN/ Lipids
Secondary CVD prevention with aspirin and statins
• Dose 20-80 mg daily PO
• Intravenous 10-40 mg SOS in acute stage
• Change to oral when symptoms subside
• Monitor serum electrolytes, creatinine and uric acid
on therapy
SPIRONOLACTONE
• Dose 25-50 mg once daily PO
• Keep watch on serum potassium and creatinine
every 2-4 weekly
ABBREVIATIONS
ICD: Implantable Cardioverter defibrillator BiV: Bi-Ventricular Pacing
PND: Paroxysmal Nocturnal Dyspnea
• Dose 2.5 to 10 mg twice daily PO • Start with low dose with BP >100
mmHg, normal electrolyte and
creatinine less than 2.5 mg/dl
• Uptitrate dose 1-2 weekly till maximum
tolerable dose
• Keep watch on BP and electrolytes
before every increment and on follow-up
WHAT TO LOOK FOR IN X RAY
• Cardiomegaly
• Pulmonary venous
congestion
• Pneumonia or other
lung pathology
DESIRABLE INVESTIGATIONS
• 2D Echocardiography • BNP/NT pro-BNP
• Troponin
• Lipid profile
• Thyroid function test • Iron profile
OPTIONAL INVESTIGATION
• Prolonged ECG monitoring • Coronary angiography
• Radionuclide imaging
• CT scan
• MRI
• PET
• Myocardial biopsy
• Electrophysiological study
COMMON DRUGS AND DOSAGE FOR CHF CARVEDILOL
• Dose 3.125 to 25 mg twice daily PO
• Start after decongestion with low dose with BP > 100 mmHg and HR >60/ min
• Uptitrate dose 1-2 weekly till maximum tolerable dose
• Keep watch on BP, heart rate and recipitation of CHF symptoms
• Increase diuretics and reduce carvedilol to manage reappearance of CHF
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
ENALAPRIL
PCI: Percutaneous Coronary Intervention CABG: Coronary Artery Bypass Graft CVD: Cardiovascular Diseases
RHD: Rheumatic Heart Disease
CAD: Coronary Artery Disease
REFERENCES
HFrEF: Heart Failure with reduced Ejection Fraction HFpEF: Heart Failure with preserved Ejection Fraction STEMI: ST elevation Myocardial Infarction
LV: Left Ventricle
COPD: Chronic Obstructive Pulmonary Disease
Management Protocols for Chronic Heart Failure in India. Mishra S, Mohan JC, Nair T et al. Indian Heart J.2018;70:105-127,
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC).
Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Ponikowski P, Voors AA. Anker SD et al. European Heart Journal. 2016;37:2129–2200
Chronic heart failure in adults: diagnosis and management. NICE guideline [NG106] Published date: September 2018
2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Yancy CW, Jessup M,
Bozkurt B. J Am Coll Cardiol. 2013;62-16: e150-e210
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
STABLE ANGINA
ICD-10-I20.9
PATIENT PRESENTING WITH CHEST PAIN
CONSIDER ANGINA IF
• Diffuse retrosternal pain, heaviness or constriction, radiating to arms or neck or back
• Associated with sweating
• Easily reproduced with
post-meal exertion
• Consider atypical
presentation: Exertional fatigue or breathlessness or profuse sweating or epigastric discomfort
Likelihood more if known patient of CAD
ANGINA UNLIKELY IF
• Variable location or characteristic
• Long lasting (hours to days) or short lasting (less than a minute)
• Restricted to areas above jaw or below epigastrium
•Localizedtoapoint •Prickingorpiercingor stabbing type of pain
• Precipitated by movement of neck or arms or respiration
ACUTE CORONARY SYNDROME
• Angina at rest or lasting more than 20 minutes
• Recent worsening of stable angina (crescendo) to
CCS class III
• New onset effort angina of less than 1 month in
CCS class II/ III
• Post infarction angina
For management: refer to STEMI/ NSTEMI STW
STABLE ANGINA
Any effort related pain fitting in previous category, relieved by rest or NTG in 1-2 min
STABLE ANGINA: GENERAL MANAGEMENT
Manage factors potentaiting angina

Anemia, Thyrotoxicosis, Pregnancy, febrille illness – Hypertension,Ventricularhypertrophy,CHF
Tachyorbrady-arrhythmia
Drugs : bronchodilators, steroids

Risk factor control
Other atherosclerotic CV disease : PVD, stroke 4. Secondary prevention : Statins, BB, ACE-I
INVESTIGATIONS
ESSENTIAL INVESTIGATIONS
Hemogram
Urea, Creatinine, Electrolytes 3. Sugar, HbA1C
Lipids
Liver function test
ECG
Plain X-ray chest
DESIRABLE INVESTIGATIONS
Echocardiography
Exercise Treadmill Test 3. Thyroid Function Test 4. Iron profile
Uric acid
OPTIONAL INVESTIGATIONS
Stress radionuclide/ echocardiographic imaging
CT scan including multi-slice coronary angiography 3. Coronary Angiography
Coronary Fractional Flow Reserve
Intra-vascular Ultrasound/ OCT
MANAGEMENT
MANAGEMENT AT PHC/ CHC LEVEL
Control angina : Metoprolol
Add nitrates if symptoms not controlled
ECG for Q waves, ST – T changes, BBB or chamber enlargement
Aspirin & high intensity statins
Refer to higher centre electively
MANAGEMENT AT DISTRICT HOSPITAL LEVEL
Optimise anti-anginal treatment
Echocardiography for LV function or structural heart
disease
Risk stratify by exercise treadmill test in low, intermediate
or high risk (DUKE risk score) for cardio-vascular events , if
patient is ambulatory and ECG is interpretable 4. Refer to tertiary centres if:
• Angina uncontrolled on optimal medical therapy • Echo reveals abnormality
• Non-ambulatory patient or un-interpretable ECG • High risk on exercise stress test for possible
re-vascularization
MANAGEMENT AT TERTIARY LEVEL
Reassess and optimise drug therapy: If uncontrolled choose from trimetazidine, nicorandil ranolazine and ivabid
Risk stratify with exercise treadmill test if not already done
Stress imaging if following:
• Non ambulatory patient
• Abnormal or uninterpretable baseline
ECG
• Exercise treadmill test result is
equivocal
• Compromised LV function
RISK CATEGORIZATION
Based on clinical features, GRACE score & TIMI score
A. Very high: B.
High Risk:
-GRACE score > 140 or TIMI score >4
Intermediate Risk:
-GRACE score 109-140 or TIMI score 2-3
Low Risk:
-Grace score <108 or TIMI score 0-1
REVASCULARIZATION
Revascularize if anatomy is suitable 2. Prefer CABG over PCI in DM with
multivessel disease or left main disease 3. Complete re-vascularization is preferable 4. Use invasive functional and imaging
modalities (FFR, IVUS, OCT) when
indicated
Stress on continuing dual anti-platelets
(aspirin and clopidogrel) after PCI
RISK CATEGORY MANAGEMENT
-Acute LVF
-Hypotension
-Uncontrolled Ventricular arrhythmia -Severe MR
C. D.
Low/ Intermediate Risk Group
Optimal anti-anginal therapy 2. Follow up 3-6 monthly at
primary/ secondary care
centre
Refer to tertiary centre when
change in symptomatic status
High Risk Group
Discuss pros and cons of possible revascularization and dual anti-platelet therapy
Angiography, if any of following

Angina not controlled on optimal medical
therapy
High risk on non-invasive testing
Cardiac arrest survivor or documented VT
DRUGS & DOSAGE
Anti-platelets

Aspirin 75 mg OD
Clopidogrel 75 mg OD (if intolerant to aspirin)
Statins:
Atorvastatin: 40-80 mg OD Rosuvastatin: 20-40 mg OD
Ace-inhibitor
Ramipril: 2.5-10 mg OD Enalapril: 2.5-10 mg BD
Anti-ischemic:
Metoprolol:
Short acting: 25-100 mg BD Long acting: 25 -100 mg OD
Nitrates:
Isosorbide mono-nitare: 20 to 60 mg in 2 devided dose Nitroglycerine sustained release: 2.6 to 6.5 mg BD
Calcium channel blockers: Verapamil 40-80 mg TDS Diltiazem 30 to 90 mg TDS
Nicorandil: 5-10 mg BD
Ranolazine: 500 -1000 mg BD 6. Trimetazidine: 20 mg mg TDS
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES : STRENGTHEN SECONDARY PREVENTION WITH STATINS, BB & ACE-I
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019
CATEGORIZE ANGINA Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ST ELEVATION MYOCARDIAL INFARCTION (STEMI)
ICD-10-I21.3
CONSIDER ANGINA IF
• Radiation to arms or neck or back
• Associated with sweating
• Easily reproduced with post-meal exertion
• Consider atypical presentation: Exertional
More likelihood if known patient of CAD/ multiple risk factors
• Diffuse retrosternal pain, heaviness or constriction
ACUTE CORONARY SYNDROME:
Angina at rest or lasting more than 20 minutes
Recent worsening of stable angina (crescendo) to CCS
class III
New onset effort angina of less than 1 month in CCS class II/
III
Post infarction angina
ECG: If ST Elevation: Follow ST Elevation MI (STEMI) protocol If no ST Elavation: UA/NSTEMI
fatigue or breathlessness or profuse sweating or epigastric discomfort/ syncope
ANGINA UNLIKELY IF:
Variable location or
characteristic
Long lasting (hours to days) or short lasting (less than a minute)
Restricted to areas above jaw or below epigatrium
Localized to a point
Pricking or piercing or stabbing type of pain
Precipitated by movement of neck or arms or respiration
ECG REVEALS ST ELEVATION MI*
Refer to primary angioplasty/ thrombolysis capable hospital
*Includes new onset LBBB
PATIENT WITH STEMI WITHIN 12 HOURS
GENERAL MEASURES
Admit in ICU equipped with continuous ECG monitoring & defibrillation 2. Routine bio-chemistry and serial cardiac enzymes (troponin)
Pain relief by opioid
O2 if saturation less than 90%
Aspirin 325 mg, Clopidogrel 300 mg and Atorvastatin 80 mg 6. Echocardiography, particularly for mechanical complication
PCI CAPABLE HOSPITAL
Proceed for PCI
Radial route preferred
Preferably within 90 minutes
DURING PROCEDURE
Use unfractionated heparin
No routine thrombosuction
Tackle culprit artery only unless shock 4. DES to be preferred
POST PROCEDURE
Continue dual antiplatelets for at least 1 year
PCI INCAPABLE CENTRE
A. Tranfer to PCI capable hospital if PCI can be performed within 120 min
B. If Transfer to PCI capable hospital not feasible
THROMBOLYSE
Within 12 hours of symptom onset, if no contra-indication
Preferably with fibrin specific agent Tenecteplase/ TPA/ Reteplase or Streptokinase,
if fibrin-specific are unavailable
Therapy to be started within 10 min preferably
POST THROMBOLYSIS
ECG to be done at 60-90 min after starting thrombolysis to assess whether thrombolysis is successful ( >50% ST settlement with pain relief) or not
If successful, transfer patient for PCI within 3-24 hours
If thrombolysis failed, transfer patient immediately for PCI capable hospital
Enoxaparin (preferred over unfractionated heparin) to be continued till PCI OR discharge
LOOK FOR OTHER CAUSES OF CHEST PAIN (ONGOING OR WITHIN 12 HRS)
Unequal or absent peripheral pulses Respiratory evaluation
Dissection of Aorta
Pleuritis/ Pneumonitis/ embolism/ pneumothorax
Pericardial rub Neuralgia or herpes
PATIENT WITH STEMI IN 12-24 HOURS
Transfer to PCI capable hospital immediately
PATIENT WITH STEMI AFTER 24 HOURS
Angiography with a view to PCI only if any of following/ Contra indications of angiography:
If ongoing pain, thrombolysis and transfer immediately
Recurrent anginal pain not controlled by medical therapy
Cardiogenic shock
Acute LVF
Mecahnical complication
Dynamic ST-T changes
Life threatening ventricular arrhythmias
ABSOLUTE CONTRA-INDICATIONS TO THROMBOLYIC THERAPY:
Previous intra- cerebral hemorrhage or stroke of unknown etiology
Ischemic stroke in last 6 months
CNS neoplasm or AV malformation
Recent (within 1 month) major trauma/ surgey/ head injury
Recent (within 1 month) major GI bleed
Known bleeding tendency (except menstrual bleed)
Aortic dissection
Severe uncontrolled hypertension
DRUGS & DOSAGE
STEMI DIAGNOSIS*
Anti-platelets
Aspirin: Loading dose 325 mg followed by 75 mg OD
Clopidogrel: Loading dose 300 mg followed 75 mg OD 3. Prasugrel: Loading dose 60 mg followed by 10 mg OD 4. Ticagralor: Loading dose 180 mg followed by 90 mg BD
Anti-ischemic:
Metoprolol:
Short acting: 25-100 mg BD Long acting: 25 -100 mg OD
Nitrates:
Isosorbide mono-nitare 20 to 60 mg in 2 divided dose Nitroglycerine sustained release 2.6 to 6.5 mg BD Nitroglycerine IV 5-25 mcg/ min infusion
Statins:
High dose Atorvastatin 80 mg OD
Ace-inhibitor
Ramipril 2.5 -10 mg OD
Enalapril 2.5 -10mg BD
Oxygen:
If oxygen saturation below 90%
Morphine:
Titrated in a dose of 2-4 mg IV every 15 minutes
Beta-blocker:
Oral beta-blocker if LVEF is less than 40%
Anti thrombotics:
Unfractionated heparin: Bolus of 60 U/Kg (maximum 5000 U) followed by 12 U/Kg hourly infusion to maintain APTT at 50-70 sec
Enoxaparin: 1 mg/Kg SC 12 hrly
Thrombolyic Therapy: Tenecteplase
35 mg IV bolus if 60-70 Kg 40 mg IV bolus if 70-80 Kg 45 mg IV bolus if more than
80 Kg
Reteplase
10 mg IV bolus, repeat after 30 min
Alteplase
15 mg IV bolus followed by 0.75 mg/Kg over 30 min upto 50 Kg weight, then 0.5 mg/Kg over 60 min up to 35 mg
Streptokinase
1.5 million units IV over 60 min
Primary-PCI capable centre
Preferably <60 mins
Primary PCI
Rescue PCI Immediately
Immediate transfer to PCI centre
Preferably <90mins (<60 mins) in early presenters
EMS or non primary-PCI capable centre
PCI possible <120 mins?
Yes No
Preferably within 30 mins
Immediate fibrinolysis
No Yes
Coronary angiography
Preferably 3-24 hours
*The time point the diagnosis is confirmed with patient history & ECG ideally within 10mins from the First Medical Contract (FMC).
All delays are related to FMC.
Successful fibrinolysis
Immediate transfer to PCI centre
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
UNSTABLE ANGINA/ NSTEMI
ICD-10-I20.0
• Associated with sweating
• Easily reproduced with post-meal exertion • Consider atypical presentation: Exertional
More likelihood if known patient of CAD/ multiple risk factors
CONSIDER ANGINA IF
ACUTE CORONARY SYNDROME:
• Diffuse retrosternal pain, heaviness or constriction. Radiation to arms or neck or back
1.Angina at rest or lasting more than 20 minutes 2.Recent worsening of stable angina (crescendo) to
fatigue or breathlessness or profuse sweating or epigastric discomfort
CCS class II/ III
4.Post infarction angina
CCS class III
3.New onset effort angina of less than 1 month in
ECG:

If ST Elevation: Follow ST Elevation MI (STEMI)
STW
If no ST Elavation: UA/NSTEMI
RED FLAG SIGNS
• Pain lasting for more than 20 minutes • Recurrent or ongoing pain or rest pain
• Associated breathlessness, profuse sweating or syncope • Hemodynamic instability
Refer as emergency to nearest Primary PCI/Thrombolysis capable centre
Rest pain beyond 24hrs or without above features may be referred early for further evaluation
LOOK FOR OTHER CAUSES OF PROLONGED CHEST PAIN
Dissection of aorta (unequal/ absent peripheral pulses)
Respiratory Evaluation:
Pleuritis/ pneumonitis/ embolism/ pneumothorax
Pericardial rub
Neuralgia or herpes
ANGINA UNLIKELY IF:
Variable location or
characteristic
Long lasting (hours to days) or short lasting (less than a minute)
MANAGEMENT
Restricted to areas above jaw or below epigatrium
Localized to a point
Pricking or piercing or stabbing type of pain
Precipitated by movement of neck or arms or respiration
PHC/ CHC LEVEL
1, ECG, Troponin. 2. Start
-Aspirin, Clopidogrel -Heparin/ LMWH
-High dose atorvastatin -Metoprolol

Risk stratify GRACE score or TIMI score

Refer High/ Intermediate risk to
PCI capable centre
Refer Low risk for further
evaluation to DH

Refer to PCI capable centre if:

Acute LVF
Hypotension
Systolic murmur – Arrythmia

GRACE SCORE:
TIMI SCORE:
One point for each of following 1. Age >65 yrs
More than 3 risk factors
Known CAD (>50% lesion)
Recurrence of angina in 24 hrs 5. Aspirin use within 7 days
ST deviation >0.5 mV
Raised cardiac markerss
Sum total = TIMI score of patient
UNSTABLE ANGINA OR NSTEMI DIAGNOSIS
DISTRICT HOSPITAL
1.Admit in ICU equipped with ECG monitoring and defibrillator
2.Troponin & bio-chemistry if not done
3.Serial ECG & echocardiography
4.Continue Aspirin, Clopidogrel, Heparin & Metoprolol
5.Add nitrates if needed 6.Management for different
risk categories: -Very high,High or Intermediate risk
or LVEF <40%: Refer for
revascularization -Low risk patients:
Conservative management Life style modification
Risk factor control Secondary prevention
TERTIARY CENTRE
Admit, reassess clinically and monitor in ICCU
Continue aspirin and heparin
Load with clopidogrel or prasugrel or ticagralor if not already done
Optimal medical therapy to continue (BB, high dose atorvastatin, ACE-inhibitors,
intra-venous nitrates if ongoing pain, severe MR or LVF)
Detailed echocardiography
Low risk patients may undergo non-invasive risk stratification with exercise stress
test, CT coronary angiography or stress imaging
Very high risk, high risk and intermediate risk patients may be subjected to
coronary revascularization
Revascularization:
Discuss pros & cons of re-vascularization and prolonged dual anti-platelet therapy 2. Revascularize if anatomy is suitable
Prefer CABG over PCI in DM with multivessel disease or left main disease
Revascularization strategy:
Very High risk: Urgent re-vacsularization (within few hours) after loading preferably
with Ticagrelor or prasugrel if PCI is planned
High risk patients: Early revascularization (within 24 hours)
Intermeditae risk patients: Revascularization (within 72 hours)
Continue Dual anti-platelets in patients undergoing PCI for atleast 12 months in
DES and for 3 months in BMS
Killip Class
Points
SBP1 mm Hg
Points
Heart rate Beats/ min
Points
Age. y Points
Creatinine Points Level, mg/ dL
I0 II 20 III 39
IV 59
<80 58 80-99 53 100-119 43 120-139 34 140-159 24 160-199 10

200 0
<50 0 50-69 3 70-89 9 90-109 15 110-149 24 150-199 38 >200 46
<30 0 30-39 8 40-49 25 50-59 41 60-69 58 70-79 75 80-89 91 90 100 0-0.39 1 0.40-0.79 4 0.80-1.19 7 1.20-1.59 10 1.60-1.99 13 2.00-3.99 21 >4.0 28
Other risk factors Points
Cardiac arrest at admission 39 ST-Segment Deviation 28 Elevated Cardiac Enzyme Levels 14
Sum Total= GRACE score of patient
INVESTIGATIONS
ESSENTIAL INVESTIGATIONS

Hemogram
Creatinine
Sugar, HbA1C
Fasting lipids
ECG
Troponin T/ Troponin I 8. Plain X-ray chest
DESIRABLE INVESTIGATIONS
Echocardiography
Exercise Treadmill Test
C reactive protein
B-Natriuretic Peptide
D dimer
Bleeding and coagulation profile 7. Liver function test
Coronary Angiography
Very high risk Clinical instability
If at non-PCI-capable hospital
Very high risk: Immediate transfer to PCI-capable hospital
High risk: same-day transfer
Intermediate risk: transfer for PCI withing 72 h Low risk: transfer if pursuing invasive treatment
Clinical instability. rise in cTn, or ECG changes
+
UA/NSTEMI: RISK CATEGORIZATION:
Based on clinical features, GRACE score & TIMI score A).Very high risk:
Anti-platelets
Aspirin: Loading dose 325 mg followed by 75 mg OD
Clopidogrel: Loading dose 300 mg followed 75 mg OD 3. Prasugrel: Loading dose 60 mg followed by 10 mg OD 4. Ticagralor: Loading dose 180 mg followed by 90 mg BD
Anti thrombotics:
Enoxaparin: 1 mg/Kg SC 12 hrly
Unfractionated heparin: Bolus of 60 U/Kg (maximum
5000 U) followed by 12 U/Kg hourly infusion to maintain APTT at 50-70 sec
High risk
GRACE > 140, TIMI >4
Early invasive 2-24 h
Intermediate risk GRACE 109-140, TIMI2-3
Low risk
GRACE <109, TIMI <1 Immediate invasive <2 h Delayed invasive 25-72 h Medical/ non-invasive strategy DRUGS & DOSAGE Invasive evaluation UA/NSTEMI: RISK CATEGORY MANAGEMENT: A)Low risk: 1.Conservative management: Aspirin, clopidogrel, BB and statin 2.TMT if ambulatory patient within a week to risk stratify 3.Refer low risk for re-vascularization if -Recurrent pain -Hemodynamic deterioration -New ECG change B. Intermediate/ Very High/ High risk: Re-vascularization Non-invasive ischaemic testing B. C. D. -Acute LVF -Hypotension -Uncontrolled Ventricular arrhythmia -Severe MR High Risk: -GRACE score > 140 or TIMI score >4
Intermediate Risk:
-GRACE score 109-140 or TIMI score 2-3
Low Risk:
-Grace score <108 or TIMI score 0-1
Anti-ischemic:
Metoprolol:
Short acting 25-100 mg BD Long acting 25 -100 mg OD
Nitrates:
Isosorbide mono-nitare 20 to 60 mg in 2 devided dose
Nitroglycerine sustained release 2.6 to 6.5 mg BD Nitroglycerine IV 5-25 mcg/ min infusion
Statins:
High dose Atorvastatin 80 mg OD
Ace-inhibitor
Ramipril 2.5 -10 mg OD Enalapril 2.5-10 mg BD
OPTIONAL INVESTIGATIONS
Stress Radionuclide/ echocardiographic imaging
CT scan including coronary angiography
MRI
Coronary Fractional Flow
Reserve
Intra-vascular Ultrasound 6. VQ scan
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURE
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

ENT

WHEN TO SUSPECT?

Usually a sequela of viral infection which causes ciliary impairment and bacterial superinfection
Diagnosis- persistence of nasal blockage/ nasal discharge and facial pain/ hyposmia beyond 7 days (maximum upto 3 months)
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of ACUTE RHINOSINUSITIS
ICD 10 J01.90
RELATED CLINICAL SCENARIOS
Recurrent acute sinusitis is episodes of acute sinusitis interspersed with symptom free intervals of more than 3 months in duration.
Symptoms with duration less than 7 days are treated as viral upper respiratory infection.
Invasive fungal sinusitis is suspected if in addition to above symptoms the following are present: facial hyposthesia, facial skin/palatal/ turbinate discoloration and proptosis/ diplopia/ reduced or loss of vision
Children may present with acute febrile illness/cough associated with these symptoms.
ALTERNATIVE CLINICAL SCENARIOS
∙ Consider alternate diagnosis if: Unilateral symptoms/ Bleeding/ Crusting/ Cacosmia (foul smell)
∙ Rule out other contributory factors: Allergy/ upper alveolar dental caries/ DNS/ LPR/ smoking.
∙ Rhinorrhoea and nasal congestion in second trimester of pregnancy is considered hormonal in etiology and is to be managed with
saline irrigation/ drops
RED FLAGS FOR REFERRAL TO DISTRICT HOSPITAL
∙ Known diabetic/ immunocompromised
∙ Suspicion of complications viz. (A) Orbital involvement (Periorbital edema/ erythema, displaced globe,
ophthalmoplegia, visual disturbance); (B) Meningitis/ altered sensorium; (C) Frontal fullness.
∙ Non-resolution with oral antibiotics for ten days
∙ Pointers of invasive fungal sinusitis (Facial hypoesthesia, facial skin/palatal/turbinate discoloration)
CLINICAL EXAMINATION
LABORATORY INVESTIGATIONS
PRELIMINARY
∙ Anterior rhinoscopy: Discharge, bleeding, crusting, polyposis
∙ Oral examination: Dental caries, post nasal drip, palatal discolouration ∙ Assess for contributory factors listed above
Desirable in non-resolving/worsening cases despite antibiotic therapy
∙ Endoscopy- for guided nasal swabs/ KOH smear
∙ CT PNS (for suspected complications / non-resolving cases on
antibiotics for 14 days)
∙ Screen for Diabetes / Immunodeficiency
∙ Nasal endoscopy
DESIRABLE
MANAGEMENT
Duration of treatment 7-14 days PHC / PRIMARY LEVEL
∙ Oral antibiotics- Amoxycillin/ Co-amoxyclav for 7-10 days. Levofloxacin and Azithromycin can be opted for patients intolerant/ sensitive to penicillins.
∙ Topical budesonide/ mometasone nasal spray once/twice a day for 2 weeks provides earlier symptomatic relief.
∙ Normal saline nasal washes help in clearing secretions and improved effect of topical medications
∙ Topical/ oral decongestant (Oxymetazline/ pseudoephedrine) for 3-5 days relieves symptoms.
∙ Adequate hydration and steam inhation.
∙ Antihistaminics (patients with co-existing allergy).
INDICATIONS OF PARENTERAL ANTIBIOTIC THERAPY
∙ Orbital/ intracranial complications
∙ Non-resolution of symptoms with atleast 7 days of oral antibiotics
∙ Worsening of symptoms while on oral antibiotics
DISTRICT HOSPITAL
• Surgical interventions to manage: Underlying anatomical conditions causing recurrent acute sinusitis like- DNS/ adenoid hypertrophy/ anatomical variations seen on CT
• Ophthalmology referral for suspected intraorbital complications
• Dental deferral for suspected dental origin infection.
• Invasive fungal sinusitis- start antifungal medications, control underlying
immunocompromising co-morbidity and consider debridement.
TERTIARY LEVEL
Cases of acute invasive fungal sinusitis/ complicated acute bacterial sinusitis and patients with immunocompromised status may be referred for management.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
ABBREVIATIONS
CT: Computerized Tomogram DNS: Deviated Nasal Septum PHC: Primary Health Center LPR: Laryngo Pharyngeal Reflux
REFERENCES

Indian Council of Medical Research. Treatment Guidelines for Antimicrobial Use in Common Syndromes. New Delhi, India, 2017.
Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298.
Sharma V, Saxena RK, Sharma S, Sharma G, Dhasmana DC, Mishra KC. Comparative Efficacy and safety of various anti-microbials in patients of acute rhinosinusitis at tertiary-care hospital in Uttarakhand. Indian Jour Otol Head & Neck Surg, 2011, Oct ; 63 (4): 364 – 9
Blomgren K, Eliander L, Hytönen M, Ylinen S, Laitio M, Virkkula P. How patients experience antral irrigation. Clin Med Insights Ear Nose Throat. 2015;8:13-7.
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of CHRONIC RHINOSINUSITIS
ICD 10 – J32.9
RULE OUT FOLLOWING PRECIPITATING/ EXACERBATING CONDITIONS
• Occupational exposure to irritants/ pollutants (refer to hyperlink)
• Allergic rhinitis, aspirin sensitivity, asthma, laryngopharyngeal reflux, smoking
• Adenoid hypertrophy, bottle feeding, passive smoking in children
• Medications and hormones associated with nasal congestion (NSAIDS, antihypertensive, psychotropic drugs, prolonged use of topical nasal decongestants)
WHEN TO SUSPECT?
If symptoms persist for more than 12 weeks:
nasal obstruction/ nasal discharge and facial pain/ reduced sense of smell
Frontal swelling
Orbital symptoms
Signs of meningitis/ intracranial complications
a. Fever with headache b. Neck stiffness
c. Photophobia
d. Altered sensorium e. Vomiting
TREATMENT OF CRS
• Mild/ moderate symptoms (no significant congestion/ discharge/ polypi/complications)
Address etiology and exacerbating factors.
For allergic rhinitis, antihistamines and nasal steroid spray to be
given.
Saline nasal wash
Steam inhalation
Stretching exercises and yoga are very effective for nasal congestion 6. Topical (oxymetazoline/ xylometazoline) and oral decongestants are
associated with cardiovascular risks and rebound phenomenon. Hence, careful patient selection and short course treatment to be followed.
Intra nasal steroid sprays for 6-8weeks (Fluticasone proprionate/ Fluticasone furoate/ Mometasone) after discussing risk – benefit – cost issues with patient regarding steroid sprays
If no symptomatic relief to above treatment, perform nasal endoscopy and consider NCCT of paranasal sinuses
In presence of nasal purulent discharge
Culture directed antibiotics to be considered
If culture is negative, empirical antibiotics (Amoxycillin/
Co-amoxyclav/ Fluoroquinolone/ Roxithromycin) to be given for at
least 2weeks.
Upper dental (particularly 1st molar) infection may cause maxillary
sinusitis which is to be treated with metronidazole.
• In the presence of nasal polypi, initial nasal steroid spray and subsequent endoscopic surgery is to be planned.
RED FLAG
a. Periorbital edema/ erythema
b. Displaced globe
c. Double or reduced vision (loss of
green-red color differentiation may be the first sign)
EXAMINE THE NOSE FOR NASAL POLYPI TWO PHENOTYPES
• Chronic sinusitis with nasal polypi (CRSwNP)
• Chronic sinusitis without nasal polypi (CRSsNP)
d. Ophthalmoplegia
Known diabetic/ AIDS/ immunosuppressive medications (suspect invasive fungal sinusitis)
IN ALL PATIENTS, ESPECIALLY IN THE PRESENCE OF NASAL POLYPI, RULE OUT ALLERGY/ALLERGIC
RHINITIS
Consider allergen avoidance
Skin prick test
Co-existing bronchial
asthma needs to be
treated
Consider AIT if indicated.
HYPERLINK
(https://www.dovemed.c om/diseases-conditions/ airborne-irritant-induce d-sinusitis/)
1. Short course of oral steroid (Prednisolone 0.5 mg/kg for 5 – 10 days) provides temporary relief in nasal obstruction in extensive polypi.
Steroid therapy is not a replacement for surgery.
1
Identification of precipitating or exacerbating factors is the key to successful treatment outcome.
2
Always rule out DNS/ nasal polypi in CRS, as surgical treatment may be necessary for complete resolution of symptoms.
Ensure adherence 3 to nasal saline
washes / regular physical activity / medications.
4
Educate patients
on correct 5
technique of using steroid nasal sprays and nasal irrigation.
Prolonged use of topical nasal decongestant beyond 5-7 days may cause rebound congestion and rhinitis medicamentosa and to be strongly discouraged.
ABBREVIATIONS
CT: Computerized Tomogram AIT: Allergen Immuno Therapy DNS: Deviated Nasal Septum
REFERENCES
• Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298. • Cain RB, Lal D. Update on the management of chronic rhinosinusitis. Infect Drug Resist. 2013;6:1-14.
• Ah-See KL, MacKenzie JM, As-See KW. Management of chronicrhinosinusitis. BMJ. 2012;345:e7054.
• Slovick A, Long J, Hopkins C: Updates in the management of chronic rhinosinusitis. Clin Pract. 2014;11(6):649–63. 10.2217/cpr.14.71
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of EPISTAXIS
ICD-10-R04.0
Acute bleeding from the nose after physical trauma/ barotrauma/ nose picking/ physical exertion.
Acute bleeding from the nose in hypertensive / hematological disorders.
Acute bleeding from the nose without any obvious cause.
CLINICAL SCENARIOS
ESSENTIAL CLINICAL EXAMINATION
ESSENTIAL
• Local examination by anterior rhinoscopy/ endoscopy to look for source of bleeding (scanty/moderate).
• Little’s area bleeder/clot/congestion • Sharp septal spur
• Congested nasal mucosa as in URTI
• General physical examination to evaluate other systems (Cardiovascular/Lower Respiratory/Neurological) clinically.
SYSTEMIC ASSESSMENT
Screen for coagulation disorders/ anticoagulant medications/ hematological malignancies
MANAGEMENT
STEP-WISE MANAGEMENT PRINCIPLE
Ensure patent airway/ avoid aspiration by head down/lateral positioning
Restore hemodynamic stability by intravenous fluid replacement/ transfusion 3. Control bleeding/bleeder by
• Bidigital compression of nose for 10 minutes in Trotter’s position (cotton pledgets soaked in 4% xylocaine with adrenaline may be used)
• Short term tab labetalol will take care of uncontrolled hypertension
• Chemical/electrocauterization of bleeder in Little’s area
Tamponade of bleeders by anterior nasal packing/ epistaxis balloon
Posterior nasal packing if bleeding is not controlled with above measures
Antibiotic prophylaxis and hospitalizarion is recommended after nasal packing
H2blockers/ PPI to be given in case of blood aspiration to avoid gastritis
Persisting bleeding despite nasal packing > consider arterial ligation (sphenopalatine /
anterior ethmoidal artery).
Selective embolization is an alternative to surgery
Address identified etiology, if any
Trotter’s Position
INVESTIGATIONS
ESSENTIAL
Hemoglobin level
Coagulation profile
Complete blood count
DESIRABLE
CT scan with contrast in cases with no obvious cause// suspected benign or malignant lesion
FOLLOW UP SERVICES
Continued nasal lubrication for 2 weeks with liquid paraffin
Repeat anterior rhinoscopy/ endoscopy to know/confim the cause of bleeding
Oral hematinics to be considered if needed
Features suggestive of neoplasia
. Unilateral bleeding . Nasal obstruction
.Visual/orbital symptoms . Obvious mass lesion
Persistent bleeding despite nasal packing
Altered blood counts/ coagulation profile
Recurrent profuse bleeding

Consider JNA in teenage boys
Aneurysmal bleeding (specially
following trauma) to be ruled out
by DSA
To be managed by appropriate
treatment at tertiary level
RED FLAG SIGNS
QUALITY ASSESSMENT PARAMETERS

Recurrence of episodes
Improvement in hemoglobin level over a period of
time.
POINTS TO PONDER WHILE MANAGING EPISTAXIS
Epistaxis in children is almost always anterior and from Little’s area, consequent to mucosal drying by dry air.
Epistaxis in adults is often related to hypertension and arises posteriorly from the posterior end of inferior turbinate 3. Initial non-invasive methods may suffice in a large majority of patients.
ABBREVIATIONS
JNA: Juvenile Nasopharyngeal Angiofibroma DSA: Digital Subtraction Angiography
CT: Computerized Tomograms
URTI: Upper Respiratory Tract Infection
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of HEARING IMPAIRMENT IN
PEDIATRIC AGE GROUP (0 – 12 YEARS)
ICD 10 H90.5
Disabling hearing impairment (31 or more dB HL in better ear) may affect language development and learning outcomes and hence needs urgent intervention
WHEN TO SUSPECT IN CHILDREN
Parental concern about delayed speech, language, and developmental delay (refer to red flags)
Family history of Hearing Loss (HL).
Exposure to ototoxic drugs/ hyperbilirubinemia requiring
exchange transfusion/ Neonatal ICU stay for > 3days. 4. In-utero infections (CMV/ rubella/ syphilis/ herpes/
toxoplasmosis)
Syndromes (NF) Or neurodegenerative disorders (Hunter
syndrome, FA) associated with HL.
Post-natal infection known to cause HL (Meningitis)
Head Trauma
Recurrent/ persistent (>/=3 months) middle ear disease 9. Chemo/ Radiotherapy to head and neck
EVALUATION
ESSENTIAL
Clinical examination to look for ear canal deformities, tympanic membrane and middle ear status by otoscopy/ otoendoscopy.
Age appropriate audiological/ behavioral observation tests in a soundproof room by audiologist/ ENT specialist.
Tympanic membrane mobility test/ tympanometry.
RED FLAGS POINTING FOR URGENT HEARING EVALUATION
UNIVERSAL HEARING SCREENING FOR CONGENITAL DEAFNESS
• Community based hearing screening: i. May be co-ordinated with
immunization schedule
ii. By primary health care workers.
iii. Using calibrated noisemakers/ toys
• All children who fail preliminary screen to undergo detailed evaluation at health care facility.
COMMON CAUSES OF HL
Impacted wax
Middle ear fluid assciated with
adenoid hypertrophy/ cold climate
Tympanic membrane perforation
Sensorineural Hearing loss (SNHL) due
to various causes as indicated earlier
- 6months- no head turning to the side of calling

1yr- no babbling/ speech like sound production
1.5yrs- not saying mama/papa/dada or other names
2yrs-not pointing to pictures/ body parts when named or speaking less than 10 words
3 yrs- does not understand action words or not asking for things by names or not speaking small sentences. – At any age- has regressed or lost previously acquired speech/ language milestones
MANAGEMENT
CONDUCTIVE HL
SNHL
GUIDING PRINCIPLES
Middle ear fluid (OME) may be associated with adenotonsillar disease which needs to be treated. Initially medical treatment and surgery to be considered for OME persisting for more than 3months/ earlier in the presence of speech and language delay
Wax removal under direct vision by ENT specialist relieves hearing impairement
Appropriate amplification, preferential seating in classroom
Screening for developmental delay by pediatrician/ psychologist
Appropriate surgery is to be planned for tympanic membrane perforation
Periodic evaluation for hearing aid users for mould fitting and amplification settings
For non-surgical condidates/ delayed surgical management, amplification by hearing aid to be reinforced in bilateral CHL.
DIVISION OF RESPONSIBILITIES
PHC LEVEL
• Suspect HL
• Initial evaluation
• Referral if initial evaluation is suggestive of HL
• Follow up of rehabilitated/ treated patients with HL • Prevention of HL
DH LEVEL

Audiometric evaluation by Audiologist/ Otolaryngologist
Hearing aid dispensing (mould fitting and HA programming) 3. Rehabilitation by speech therapist
Appropriate surgery for CHL
Training programme for parents of hearing impaired children
to enhance pre-school language development
TERTIARY LEVEL
• Surgical intervention options : Cochlear implant / BAHA (as per ADIP guidelines)
• Interdisciplinary team based interventions in children with multiple disabilities.
QUALITY ASSESSMENT PARAMETERS
• Short term: Quality of amplification using electroacoustic objective measures and culturally appropriate subjective questionnaire tools
• Long term (Desirable) : Use CBR matrix based measurement for ensuring holistic rehabilitation
FOLLOW UP SERVICES
Home visits by Health Worker/ASHA to ensure utilization of assistive devices and support parents to enhance language development.
School visits to educate teachers and normally hearing children to include their peers with hearing disability in the school environment 3. Home/ school visit by social worker for evaluation of social/ educational/ livelihood/ justice and empowerment domains of the child
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
ADIP : Assistance to disabled ABBREVIATIONS persons for purchase/ fitting of
aids and appliances
BAHA : Bone Anchored Hearing Aid CBR : Community Based Rehabilitation CMV : Cyto Megalo Virus
FA : Friedreich Ataxia
NF : NeuroFibromatosis
OME : Otitis Media with Effusion
REFERENCES
• Indian Council of Medical Research. Audiological evaluation protocols. Task force project on prevalence and etiology of hearing impairment, New Delhi. 2015
• Ramesh A, Jagdish C, Suman Rao PN et al. Low cost calibrated mechanical noisemaker for hearing screening in resource constrained settings. Indian Journal of Medical Research. 2012, 135: 170 – 176.
• Rathna.B.Shetty. Manual for training parents of hearing impaired children (Kannada : Kivudu makkalige kalisuva vidhana). Parents association of deaf children. Mysore.
• Chapal Mkhasnabis, Karen Heinicke Motsch (eds.) Towards community based inclusive development. World Health Organisation: 2010.
• Margaret Lavina Fernandes. Guidelines to establish a community based rehabilitation program for hearing impaired children in medically underserved areas. St. John’s Medical Journal, 2018 (1), 5 : 14 – 27 • ADIP Guidelines : http://disabilityaffairs.gov.in/content/page/adip-scheme.php
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of NECK SPACE INFECTION
ICD-10-J36, J39.0, K 12.2, J39.1
Rapidly progressive bacterial infections which spread along facial planes and spaces of head and neck region. They may be fatal unless emergently treated. Most of these infections are secondary to dental infection.
CLINICAL SCENARIOS
They usually present as • Ludwig’sangina
(submandibular space infection) • Peritonsillarabscess
• Parapharyngealabscess
• Retropharyngealabscess
The typical presentation is with acute onset of pain and swelling in the neck with fever, malaise, trismus and dysphagia.
Extension along spaces to involve multiple deep neck spaces is frequent and may extend to parotid space, masticator space, temporal space, visceral vascular (carotid) space.
Cervical space infection may spread inferiorly to the anterior mediastinum and posteriorly along prevertebral space.
Tubercular cold abscess involves the same anatomical spaces but would not display inflammatory signs or rapid progression.
SYSTEMIC ASSESSMENT
Screen for diabetes mellitus, HIV infection, agranulocytosis and immunosuppressive therapy or chemotherapy.
Signs of inflammation may be less marked and disease course may be more rapidly progressive in immunocompromised patients.
CLINICAL EXAMINATION
• Airway assessment to rule out stridor or respiratory compromise • Look for signs of dehydration
• Monitor temperature, heart rate, respiratory rate, BP, and signs
of sepsis/ septic shock.
• Oral cavity examination to check jaw opening, condition of teeth
and floor of mouth
• Oropharyngeal examination to check for inflammed medially
displaced tonsil & uvula and bulge in lateral pharyngeal wall • Palpation of neck for lymph nodes, cellulitis, abscess or
subcutaneous crepitus
• Cranial nerve examination to rule out lower cranial nerve palsies
RED FLAGS FOR REFERRAL TO DISTRICT HOSPITAL
• Breathing difficulty
• Trismus
• Torticollis/ neck stiffness
• Subcutaneous crepitus and skin discolouration
or blisters suggest necrotizing fibrofascitis. • Toxaemia
• Lower cranial nerve palsy
• Facial puffiness suggestive of venous
thrombosis
• Mediastinal extension
INVESTIGATIONS
ESSENTIAL INVESTIGATIONS
Contrast enhanced CT scan of head and neck is the standard in evaluation of neck space infections. If CT Scan facility is not available, following should be done:-
a. Lateral x-ray neck: Prevertebral soft tissue thickening >7 mm at the level of C2 or > 2/3rd of the width of the vertebral body at C6 is highly suggestive of retropharyngeal abscess. It may also demonstrate foreign bodies, subcutaneous air, air fluid levels and erosion of vertebrae.
b. Ultrasound neck can suggest abscess and guide aspiration attempts.
Blood: Total and differential leukocyte count, blood sugar, urea
Abscess Cultures with Gram stain to direct antimicrobial therapy. Anaerobic culture, when available.
MANAGEMENT
PHC/PRIMARY LEVEL
Cautiously assess the airway. If found compromised, do endotracheal intubation/ consider tracheotomy
Immediately gain an IV access for hydration, broad spectrum antibiotics and pain killers.
Transfer the patient to hospital with facility for surgical drainage
DISTRICT HOSPITAL
Hospitalization: As an emergency for close watch and intensive management.
Airway management: In progressive disease, in view of impending airway compromise, consider securing the airway early. During acute respiratory difficulty, tracheostomy should be done if intubation is difficult
Correction of fluid and electrolyte imbalance
Antibiotics: Early and aggressive IV antibiotic therapy with a
combination of Crystalline Penicillin, Aminoglycoside and
Metronidazole or Clindamycin is preferred.
Incision and drainage: Peritonsillar abscess is drained intraorally. All
other abscesses are drained via an external approach
INDICATIONS FOR I&D
• Necrotizing fibrofascitis
• Abscess formation
• No response to antibiotics over
48-72 hours
• Deterioration despite antibiotics
over 24 hours
• Airway compromise or impending
airway compromise
• Mediastinal spread
• Vascular complication like venous
thrombosis
QUALITY ASSESSMENT PARAMETERS FOLLOW UP SERVICES
Complete resolution of infection and follow up to ensure no recurrence; treatment of initial cause of infection in tooth or tonsil.
Consider cold tonsillectomy for patients with history of multiple episodes of tonsillar abscess
CT – Computerized Tomography
MRI – Magnetic Resonance Imaging
ABBREVIATIONS
REFERENCES
Smith II JL, Hsu JM, Chang J (2006) Predicting deep neck space abscess using computed tomography. Am J Otolaryngol 27: 244-247.
Mayor GP, Millán JMS, Martínez VA (2001) Is conservative treatment of deep neck space infections appropriate? Head And Neck 23: 126-133.
Bottin R, Marioni G, Rinaldi R, Boninsegna M, Salvadori L, et al. (2003) Deep neck infection: A present day complication. A retrospective review of 83 cases. Eur Arch Otorhinolaryngol 260: 576-579.
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
OTORRHOEA
ICD-10-H92.10
CLINICAL SCENARIOS
Fig 1
DISEASES OF EXTERNAL EAR
• Serous/purulent discharge with significant tenderness of external ear amidst edema (localized-pus: furunculosis or generalized: Acute otitis externa denoting Staph/ Pseudomonas infection)
• Thick discharge with itching usually in hot/ humid climate: Otomycosis (Candida- white spores; Aspergillus- black spores) [Fig 2]
• Scanty serous discharge & itching with desquamated debris in ear canal Eczematous otitis externa (EAC)
DISEASES OF MIDDLE EAR
• URI with severe ear pain (manifested in children as inconsolable crying and ear tugging), relieved with episode of mucopurulent blood stained otorrhoea: Resolving AOM [Fig 3]
• Mucopurulent discharge > 12 weeks : CSOM
• Active : otorrohoea in last 12 weeks
• Inactive : no otorrohoea in last 12 weeks
• Safe type : central perforation [Fig 4A] and total perforation [Fig 4B] • Unsafe type : cholesteatoma [Fig 5A] and granulation [Fig 5B]
• Recurrent painless profuse mucopurulent discharge with pale granulations/ multiple perforations unresponsive to antibiotics: Tubercular otitis media should be suspected and needs biopsy confirmation
• Bloody otorrhoea following Trauma: Traumatic perforation
• Acute onset bloody discharge with neural deficits/ neck nodes:
Neoplasia
• Watery otorrhoea (may be associated with trauma) : CSF Otorrhoea
Fig 2
FIGURES
Fig 3
Fig 4A
Fig 4B
Fig 5A
1: Furunculosis
2: Otomycosis
3: Resolving AOM
4A: Safe CSOM (central perforation) 4B: Safe CSOM (subtotal
perforation)
5A: Unsafe CSOM (cholesteatoma) 5B: Unsafe CSOM (granulation)
6: Traumatic Perforation
Fig 5B Fig 6
CLINICAL EXAMINATIONS
INVESTIGATIONS RED FLAGS FOR REFERRAL TO DISTRICT LEVEL
• Otoscopy as a part of Complete ENT examination by primary physician (Tele-otoscopy interpreted by physician)
• Hearing evaluation by conversation/ whisper/ Tuning forks tests
• General and systemic clinical examination
• Pure tone audiometry
• Routine hemogram including blood
sugar (fasting and postprandial)
• CT/ MRI in suspected complications
(refer to red flags)
• Soft tissue x ray nasopharynx (To
examine adenoid enlargement in
children)
• Culture & sensitivity of aural secretions.
• Periaural abscess or cellulitis
• High grade fever, dizziness and toxic appearance • Severe headache with neck stiffness/ vomiting /
altered sensorium.
• Facial palsy/ Neurological defecits
• Diabetic with severe deep seated ear pain / neural
defecits (Skull base osteomyelitis)
• Physical trauma with bloody/ watery discharge
(suspected CSF leak)
• Suspected tuberculosis/ neoplasm
MANAGEMENT
PHC / PRIMARY LEVEL
• Acute otitis externa: Oral Ciprofloxacin/ Amoxycillin clavulanic acid combination for 7-10 days (2 weeks maximum) and analgesics. Ichthammol gycerine (1:9) packing of EAC in moderate to severe edema. Refer pus pointing furuncle to DH
• Otomycosis: Cleaning and Clotrimazole ear drops
• Eczematous otitis externa: Ciprofloxacin ear drops with steroid combination.
• AOM / Resolving AOM: Oral amoxicillin / Erythromycin / Clarithromycin for 10 days. With no response in 3
days start Amoxycillin clavulanic acid combination for 10 days. Refer to DH if no resolution
• Inactive CSOM: Referral to DH for surgery.
• Active CSOM: Ciprofloxacin ear drops with dry mopping & referral to DH for surgery. A course of oral
antibiotics maybe prescribed in ase of persistant otorrhoea after topical antibiotics
• Traumatic perforation: Topical antibiotics for otorrhoea if any and maintain ear dry till healing complete
• In case of suspicion of complications start intravenous Amoxycillin clavulanic acid combination and refer to
DH
DISTRICT HOSPITAL
• Surgical interventions except neurosurgical interventions (eg I&D, tympanoplasty, mastoidectomy)
• Biopsy in suspected neoplasm
• Medical management of medical
co-morbidities such as diabetes, tuberculosis, meningismus/ meningitis
TERTIARY LEVEL
Surgical management particularly of intracranial complications including neurosurgical interventions
• Patient to be educated for proper technique of ear mopping, contralateral lie (10 min) following instillation of drops & avoiding water entry e.g ear-plugs during bathing
• To ensure adequate immunization (measles/ H.Influenza/ Pneumococcus) in recurrent AOM and to adopt correct posture during breastfeeding while avoiding bottle feeding
• Pus culture sensitivity to guide antibiotic regime in recurrent/ complicated cases
Patient education to refrain from indigenous (oil/ hot water/ acid etc) ear treatments
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
ABBREVIATIONS
CT: Computerized Tomogram MRI: Magnetic Resonance Imaging
AOM: Acute Otitis Media EAC: External Auditory Canal CSOM: Chronic Suppurative Otitis Media URI: Upper Respiratory Infection
REFERENCES
• Otitis media (acute): antimicrobial prescribing. NICE guideline. Published: 28 March 2018. nice.org.uk/guidance/ng91
• Primary ear and hearing care training resource, Student’s workbook: intermediate level. Chronic disease prevention and management. WHO 2006
• Primary ear and hearing care training resource, advanced level. Chronic disease prevention and management. WHO 2006
• Treatment Guidelines for antimicrobial use in common syndromes. ICMR. Department of Health Research. 2017
• Sagar P, Thakar A, Samant S. Otorhinolaryngology. In Paul VK, Bagga A. eds. Ghai Essential Pediatrics, 9th ed. New Delhi: CBS Publishers & Distributors; 2019. p.357-370
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 October/ 2019
CLINICAL SCENARIOS
Acute pharyngitis may include a spectrum of disease varying from simple viral pharyngitis to dreaded neck space infection.
ICD-10-J02
Acute onset of throat pain with or without – Fever, tonsillo-pharyngeal exudates, odynophagia and tender cervical lymphadenopathy is typically seen in bacterial pharyngitis.
Streptococcal (GABHS) pharyngitis is the commonest cause of bacterial pharyngitis
Rhinitis, conjunctivitis, skin or mucosal rashes point towards a viral etiology. Pharyngitis and sore throat may be the initial symptoms in epidemics of flu
Sore throat followed by high grade fever, cough, drooling, lymphadenopathy, breathing difficulty suggest Epiglottitis or Laryngotracheobronchitis,
especially in pediatric patients
An adherent membrane extending beyond the tonsillar confines with toxaemia suggests Diphtheria
Pharyngitis with generalized lymphadenopathy is consistent with Infectious Mononucleosis(IM)
CLINICAL FEATURES
Fever
Anterior cervical lymphadenopathy
REQUIRE LAB TESTS TO CONFIRM GABHS INFECTION
Score = 2-3
Tonsillar exudate
Absence of cough 1
ESSENTIAL
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of PHARYNGITIS AND SORE THROAT
Throat swab for culture, routine hemogram including total and differential leukocyte counts and peripheral smear to look for atypical lymphocytes (seen in IM).
GABHS rapid antigen detection test (RADT)
MANAGEMENT
PHC / PRIMARY LEVEL
CENTOR SCORE
1 1 1
UNLIKELY TO HAVE GABHS
Score = 0-1
LIKELY TO HAVE GABHS
Score = 4
INVESTIGATIONS
OPTIONAL
CLINICAL EXAMINATION
PRELIMINARY
RED FLAGS
• Generalized lymphadenopathy
• Cardiac murmurs • Purulent
productive cough with tachypnea suggestive of LRTI
• Hot potato voice
• Unilateral tonsillar
enlargement • Tonsillar
membrane going beyond its
confines
• Agranulocyosis • Epidemic of flu
DESIRABLE
Lab tests to rule out EB Virus, Coxsackie virus, Herpes virus, fungal or Gonococcal pharyngitis
• Temperature chart: fever is usually absent or low-grade in viral pharyngitis
• Check for vitals/ signs of dehydration due to compromised oral intake due to odynophagia
• Complete oral and oropharyngeal examination with tongue depressor
• Palpate for cervical and generalized lymphadenopathy
• Rheumatic fever and acute glomerulonephritis are potential systemic complications of
streptococcal pharyngitis
• Hepatosplenomegaly can be found in IM
• A sandpapery scarlatiniform rash may be seen in GABHS infection whereas maculopapular
rashes are seen with various viral infections and with IM empirically treated with penicillin
DESIRABLE
Assess Centor criteria and ascertain its
score
Assess the patient for signs of toxicity, epiglottitis or oropharyngeal abscess
Ensure vitals/ hydration of the patient
Saltwater gargle, warm liquids, and rest may be helpful in relieving symptoms 4. Ibuprofen or Paracetamol is recommended for analgesia
Antibiotic therapy:
a. Patients positive for all 4 Centor criteria to be treated with antibiotics without waiting for antigen testing or cultures
b. Patients with Centor score of 2&3 to be treated with antibiotics only if antigen testing or throat swab culture is positive c. Patients with Centor score of only 1 not to be treated with antibiotics
d. Amoxicillin (50 mg/kg/d in 2-3 doses orally) for 10 days is the first choice for GABHS infection. For patients who are
sensitive for penicillin group, Erythromycin or Azithromycin is the antibiotic of choice
Parenteral antibiotics (Ceftriaxone/ cefotaxime) and steroids are to be started when the airway is compromised due to suspected epiglottis/ Croup.
FOLLOW UP SERVICES
DISTRICT HOSPITAL
Management of complication e.g.
• Deep neck space infection
• Diphtheria • Epiglottitis • Croup
Smoking and GERD are common causes of non-infective pharyngitis
Recurrent (more than 7 episodes in previuos year or 5/year in last two years or 3/year in last 3 years) tonsillitis episodes need to be evaluated for tonsillectomy.
ABBREVIATIONS
Cochrane Database Syst Rev. 21. CD004872.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
GABHS: Group A Beta Hemolyticus Streptococcus GERD: Gastro Esophageal Reflux Disease
LRTI: Lower Respiratory Tract Infection
REFERENCES
EB: Epstein Barr
RADT: Rapid Antigen Detection Test
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. NEPHROLOGY Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
PRELIMINARY ACTIONS
• Monitor urine volume & body weight
• Identify and treat life-threatening complications • Correct hydration status
• Stop nephrotoxic drugs
• Exclude urinary outlet obstruction
• Stabilize blood pressure
• Treat infection
• Assess for dialysis need
WHAT IS AKI?
Increase in Serum creatinine by >0.3 mg/dl in 48 hours AND/OR Urine output <0.5 ml/kg/h for 6–12 hours ACUTE KIDNEY INJURY ICD-10-N17.9 SYMPTOMS • Reduced urine output • Dark, concentrated urine • Swelling over feet/face • Breathlessness LOOK OUT FOR AKI IN THE PRESENCE OF • Hypotension • Volume loss (eg: vomiting, diarrhea, bleeding); heat exposure or heat stroke • Pregnancy-related complications • Multiple organ failure • Nephrotoxic medication use • In neonates – oligohydramnios/ birth asphyxia, respiratory distress PRINCIPLES OF ASSESSMENT • Determine whether pre-renal, renal or post-renal • Identify and correct reversible factors • Look out for occult causes (e.g. envenomations, poisoning) • Determine severity of AKI • Identify complications • Decide need for dialysis DESIRABLE ACTIONS/INVESTIGATIONS • Stage AKI (KDIGO criteria*) • Check electrolytes, acid-base status • Urinalysis • Rule out pre-existing kidney disease • Ultrasound of KUB region • Assessment for infection • Laboratory investigation for specific cause AKI IN SPECIFIC SETTINGS • Neonatal – refer to paediatrician • Pregnancy – manage complications • Envenomations – antivenin, hemodynamic correction • Poisoning – specific antidote when available • Systemic disease – refer for investigations • Kidney transplant recipient – refer to nephrologist TREATMENT OF HYPERKALEMIA • Calcium gluconate 1000 mg slow IV under ECG monitoring, can be repeated upto 3 times • Salbutamol : 10 to 20 mg in 4 mL of saline by nebulization • Insulin-dextrose: 10 to 20 units of regular insulin in 100 ml 25% or 50% dextrose MANAGEMENT PRIMARY CARE • Detailed history and physical examination • Identify and correct volume deficit • Stop nephrotoxic agents • Identify and correct bladder outlet obstruction • Give anti-snake venom if indicated • Identify hyperkalemia and start treatment • Identify pulmonary edema- start intravenous furosemide and oxygen • PD if indicated • Timely referral after stabilisation SECONDARY CARE • Detailed history and physical examination • Identify and correct volume deficit • Stop nephrotoxic agents • Identify and treat hyperkalemia, metabolic acidosis and pulmonary edema • Identify and correct urinary tract obstruction (USG, CT) • Detailed investigation for infections • Manage pregnancy complications – deliver if indicated • Look for underlying CKD • Dialysis (PD or HD) TERTIARY CARE • Detailed history and physical examination • Identify and correct volume deficit • Stop nephrotoxic agents • Identify and correct urinary tract obstruction (USG, CT scan) • Identify and treat hyperkalemia, metabolic acidosis and pulmonary oedema • Detailed investigation for infections • Manage pregnancy complications- deliver if indicated • Look for underlying CKD • Investigations for specific cause (including imaging, genetic tests) • Kidney biopsy • Dialysis (PD or HD) RED FLAGS FOR URGENT REFERRAL • Indications for dialysis • Unexplained AKI • Involvement of other organs • Sepsis • Systemic disease • Complicated pregnancy INDICATIONS FOR DIALYSIS • Fluid overload • Pericarditis • Hyperkalemia • Severe metabolic acidosis • Encephalopathy • Severe uraemia • To create space for fluids or blood products FOLLOW-UP OF AKI • UO > 1L, stable or falling creatinine, no symptoms: stop dialysis
• Not resolving for >2 weeks: CECT to exclude cortical necrosis; kidney biopsy as indicated
• Look for systemic diseases (e.g. vasculitis, myeloma, TMA)
• Serum creatinine and urine protein q 6-12 months for life
ABBREVIATIONS
AKI: Acute Kidney Injury PD: Peritoneal dialysis CKD: Chronic Kidney Disease UO: Urine output CECT: Contrast-enhanced CT scan TMA: Thrombitic microangiopathy HD: Hemodialysis USG: Ultrasonography
REFERENCE
*KIDNEY DISEASE: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int, Suppl. 2012; 2: 1–138
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
CHRONIC KIDNEY DISEASE (CKD)
ICD-10-N18.3
WHEN TO LOOK FOR CKD
• History of long-standing nocturia, or constitutional symptoms • Edema, hematuria, proteinuria or renal stones
• Long-term intake of painkillers or herbal medicines
• Family history of kidney disease
• Growth retardation, rickets, or proximal myopathy
• Unexplained hypertension or anemia
• Longstanding diabetes, hypertension, CVD, stroke, PVD • Systemic diseases (e.g. connective tissue disease)
EVALUATION OF NEWLY DIAGNOSED PATIENT
WITH CKD
• Serum creatinine, electrolytes, bicarbonate
• Estimate glomerular filtration rate using CKD-EPI
equation
• Urinalysis (examine sediment, proteinuria
quantitation)
• Ultrasound of kidneys and urinary tract
• Calcium, phosphate, alkaline phoshatase, albumin • CBC including peripheral blood film
• Iron profile – Serum iron, TIBC, TSAT
• HBsAg, anti-HCV
INITIAL ASSESSMENT FOR
• Confirmation of CKD diagnosis (repeat tests after 3 months)
• Staging and progression rate
• Establishing cause of kidney disease
• Identify and treat reversible factors (hypertension,
volume loss, obstruction, infection)
• Look for complications (anemia, bone disease,
dyselectrolytemias, CVD)
LIFESTYLE MEASURES FOR ALL CKD PATIENTS:
• Weight control/ weight gain monitoring in children • Regular physical activity
• Reduce dietary salt intake to < 5 g/day • Stop tobacco use in all forms • Stop/moderate alcohol use • Stop using unproven health supplements • Do not use NSAIDS • Avoid untested indigenous medicines WHAT IS CKD? Abnormalities of kidney structure or function, present for >3 months, with implications for health
BP CONTROL
( TARGET <130/80, 120/80 IF PROTEINURIA) • Restrict dietary salt to < 5 g/day • Use any anti-HT available in local pharmacy • Diuretics – eGFR > 45 : thiazide,
<45 ml/min: furosemide; <30 ml/min: do not use potassium sparing agents • ACEI/ARB preferred* for proteinuric patients (> 1 g/d)
*caution/do not use if eGFR <30 ml/min, or Potassium >5.5 mEq/L
VACCINATION SCHEDULE FOR
NEWLY DIAGNOSED CKD
PATIENT
• If HBV -ve: 20 μg IM in each deltoid at 0,1,2 and 6 months
• In children – complete primary vaccination schedule
ANEMIA MANAGEMENT
• Establish iron replete state
• If not iron replete, give oral iron
• Consider IV iron for dialysis patients
and those not tolerating orally
• If Hb still <8 g/dl – start erythropoietin, titrate to Hb 10-11 g/dl MANAGEMENT OF HYPERPHOSPHATEMIA (PO4>5.5)
• Start with Ca-containing binders • Non Ca-binders can be used if
serum Ca >9 mg/dl, vascular calcification or low iPTH
DIABETES CONTROL (TARGET HBA1C <7%)
• Do not use metformin if eFGR <30
VITAMIN D THERAPY
• Supplement 60,000 units cholecalciferol q2W
• Correction of acidosis with oral sodium bicarbonate
• Activated vitamin D if hyperparathyroidism
NUTRITION
• Salt restriction < 5g/d. Protein 0.6-0.8 g/kg/day.
• DO NOT restrict proteins unless documented high protein
user (dairy, white meat are good protein sources, mix
different types of dal).
• Restrict green leafy vegetables if eGFR <30 ml/min
• Avoid fruit juices, coconut water and carbonated beverages • For children: ensure adequate protein intake appropriate
for age.
LOW POTASSIUM FRUITS/ VEGETABLES:
Apple, pineapple, papaya, pear, tangerine, watermelon, grape, plum, cabbage, carrot, cauliflower, onion, radish, peppers, chillies, brinjal, cucumber, green beans, peas, rice, bread
MANAGEMENT
PRIMARY CARE
• Detailed history and physical examination • Identify and correct reversible factors
• Stop nephrotoxic agents
• Referral after stabilization
INDICATIONS FOR REFERRAL
• Initial evaluation of all newly diagnosed cases
• Rapid disease progression
• New complication
• Discussion for Renal Replacement Therapy (RRT)
ADMISSION CRITERIA
• Initial evaluation or when patient presents with specific problems – like acute worsening, development of a new complication
• For creation of vascular access
• For PD catheter placement or initiation
• Initiation on HD and for kidney transplant
DISTRICT HOSPITAL
• Detailed history and physical examination • Investigate to ascertain cause of CKD
• Tailor treatment to cause
• Identify and manage complications
• Vaccination
• Identify and correct acute factors
• Counseling: nutrition, lifestyle, pregnancy in women of child-bearing age • Discussion regarding RRT
• Vascular access creation or PD Catheter insertion
• Send patient back to community with treatment plan
TERTIARY CARE
• Detailed history and physical examination • Investigate to ascertain cause of CKD
(imaging/biopsy/genetic studies)
• Tailor treatment to cause
• Identify and manage complications
• Vaccination
• Counseling: nutrition, lifestyle, pregnancy in
women of child-bearing age
• Discussion regarding RRT
• Vascular access creation/PD catheter insertion • Work-up for transplantation
• Send patient back to community with
treatment plan
PREPARATION FOR RENAL REPLACEMENT THERAPY
• eGFR < 30 : Preserve veins in the non-dominant arm for AV Fistula
• eGFR < 30 : discuss RRT options.
• eGFR < 15 : May need dialysis soon, counsel for AV fistula, list for transplant
• Dialysis start : depends on symptoms or eGFR <5 ml/min
• Look for contraindications to HD or PD : discuss choice in those suitable for either
CONSERVATIVE CARE
• If life expectancy limited, multiple comorbidities/personal preference • Decision-making should be shared with patient/family
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
GLOMERULONEPHRITIS
ICD-10-N05.9
IDENTIFY THE PRESENTING CLINICAL SYNDROME
WHAT IS GN?
Glomerulonephritis refers to an inflammation of the glomerulus hence it is not strictly a single disease, its presentation depends on the specific disease entity. It may present as symptomatic urinary abnormalities/ nephrotic syndrome/ nephritic syndrome/ AKI/ CKD
EVALUATION OF A PATIENT WITH GN
• Full history and clinical examination
• Urinalysis: urine routine exam, microscopy
• proteinuria quantitation: 24 h UP; ACR/PCR for follow up • Assess eGFR using age-appropriate formula
• Renal imaging
• Serologic testing
• Kidney biopsy
KIDNEY BIOPSY
• Age <1 y or >12 y
• Steroid resistant state
• Family history of kidney disease
• Features suggestive of systemic disease
• Diagnosis unclear, therapeutic uncertainty
• Doubling of serum creatinine over days-weeks
SEROLOGY
Acute nephritic syndrome: Sudden onset, hematuria, oliguria, edema, hypertension, reduced eGFR
Nephrotic syndrome: proteinuria (>3.5 g/1.73m2/d; 50 mg/kg/d in children), edema, hypoalbuminemia, hyperlipidemia
Asymptomatic urinary abnormalities: proteinuria, hematuria
• ASO
• HIV (high risk)
• ANA
• Anti-GBM antibody
• Anti-PLA2R
TREATMENT
• HBsAg, anti-HCV • C3
• ANCA
• SPEP (>50 y)
Avoid nephrotoxic agents
BP control (<130/80 mm Hg in adults, <95th centile for age in children) ACE inhibition (see exceptions under DO NOT) RPGN: doubling of serum creatinine over days to weeks IN CHILDREN <12 Y WITH NEPHROTIC SYNDROME DO NOT • Give any vaccine while on steroids or within 3 months of stopping • Prescribe bed rest unless indicated • Restrict salt in children with nephrotic syndrome • Restrict fluids • Use ACE inhibition in children with renal dysfunction, or in steroid sensitive nephrotic syndrome Lifestyle modifications Sodium restriction (not in children) Diuretics – loop needed, reverse edema slowly RECOMMENDED PHARMACOLOGICAL TREATMENT CHILDREN • Prednisolone 2 mg/kg x 6 w followed by 1.5 mg/kg A/D x 6w • In case of relapse- Prednisolone 2 mg/kg x 2w followed by 1.5 mg/kg A/D x 4w ADULTS • Treatment Depends on diagnosis (biopsy, serology) • Therapeutic choices include • Corticosteroid (Prednisolone, IV methylprednisolone) • CNIs (cyclosporine/tacrolimus) • Cyclophosphamide • Azathioprine • Mycophenolate mofetil • Levamisole • Rituximab BEFORE STARTING STEROIDS IN CHILDREN, REMEMBER TO • Look for latent TB (Mantoux test, Chest X-ray) • Start 6 months INH therapy (5mg/kg day) if asymptomatic Mantoux +ve • Be on the lookout for common infections (e.g. peritonitis, pneumonia and skin infections) CAUTION • Non-nephrotic proteinuria: rule out orthostatic cases • Isolated hematuria: rule out urological causes LOOK FOR COMPLICATIONS • Malnutrition • Hypovolemia • AKI • Thromboembolism • Infections THROMBOSIS PROPHYLAXIS Evaluate bleeding risk: Do not use if risk high S alb <2 + non-ambulatory: start aspirin, OAC if high risk MANAGEMENT PHC/CHC • Detailed history and clinical examination • Urine dipstick test • Serum creatinine, electrolytes • Stabilize • Start antihypertensives and diuretics if needed INDICATIONS FOR REFERRAL • All cases >12 years old and less than 1 year old
• In children:
• Frequent relapses (=>3 per year)
• Steroid dependent or resistant state
• Recent rise in serum creatinine
• Appearance of complications related to disease or treatment
• Pregnancy
• Persistent asymptomatic urinary abnormalities
(>6 months)
DISTRICT HOSPITALS
• Detailed history and clinical examination
• 24-hr urinary protein estimation
• Serum creatinine, electrolytes, serum albumin, lipid profile
• Imaging of kidneys
• Evaluate for secondary causes
• Look for and treat complications
• Start general treatment
• Can treat
• Uncomplicated NS in 1-12 y old
• Infrequent relapses
• Prepare treatment plan and refer back to primary care
TERTIARY CARE HOSPITALS
• Detailed history and clinical examination
• 24-hr urinary protein estimation
• Serum creatinine, electrolytes, serum albumin, lipid profile
• Imaging of kidneys
• Evaluate for secondary causes
• Look for and treat complications
• Start antihypertensives and diuretics
• Kidney biopsy
• Prepare treatment plan and refer back to primary care
ADMISSION CRITERIA: Initial evaluation, kidney biopsy, or management of complications
RED FLAG SIGNS
Cold Peripheries Accelerated hypertension
Seizures
DO NOT USE DIURETICS
ALBUMIN can be given in severe Hypoalbuminemia
Increased capillary filling time
Altered Sensorium
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
ICD-10-N39.0
DETERMINE UTI TYPE
SIMPLE CYSTITIS/ LOWER UTI
• Dysuria, urgency, frequency
PYELONEPHRITIS/ UPPER UTI
• Fever
• Chills and rigors
• Loin pain, pelvic pain
• Renal angle tenderness
• Toxic and sick appearance
COMPLICATED UTI
• History of stones, congenital anomalies, obstruction
• Diabetes
• Immunosuppression
WHEN TO DO URINE CULTURE?
• Complicated UTI • Pyelonephritis
• Special situations
• All males (except simple cystitis)
• Children
• Pregnancy
• Recurrent UTI (> 2
episodes/ 6 months)
• Catheter associated UTI
Standard Treatment Workflow (STW) for the Management of
URINARY TRACT INFECTIONS
MANAGEMENT
PRIMARY/ SECONDARY LEVEL
PRIMARY CARE
• History and Examination
• Look for red flag signs and
refer
• Refer special groups
• Treatment in primary care
• Acute cystitis females
• Acute cystitis males
• Treatment
• Nitrofurantoin • Trimethoprim
sulphamethoxazole
• Symptomatic relief
INITIAL ASSESSMENT
• History
• Symptoms
• Recurrent UTI • Diabetes
• Congenital
malformations
• Stones
• Immunosuppression
• Examination
• Temperature, renal
angle tenderness, genital exam
WHAT IS UTI?
At least 3 Symptoms (dysuria, frequency, urgency, suprapubic pain)
OR
Dipstick +ve for leucocyte esterase and nitrite if ❤ symptoms OR • CUE >10 WBC/HPF in uncentrifuged urine +
• Urine culture

105 CFU of single species/ml in Mid stream urine (multiple species indicate contamination)
MALE UTI
Acute cystitis/ simple UTI •RxMenfor7days
• Nitrofurantoin* 100 mg PO BD x 7d •TMP/SMX1DStabPOBDx7d
• Ciprofloxacin 500 mg BD x 7 days • Levofloxacin 750 mg OD x 5 day
• Acute cystitis is not to be referred ALL OTHER UTI IN MALES-REFER
• Pyelonephritis or complicated UTI • Pelvic/perineal pain (prostatitis)
CYSTITIS/UTI IN FEMALES
• Empirical RX (only symptoms no tests needed)
• Nitrofurantoin* 100 mg
PO BD x 5d
• TMP/SMX 1 DS tab
PO BD x 3d
• If no response refer
to higher centre
*Avoid if GFR <45,caution in elderly
SYMPTOMATIC TREATMENT
Plenty of water
Urine alkalinizer recommended eg citrate – Avoid if patient on nitrofurantoin
Phenazopyridine 200mg tid for 2 days
Local Estrogen creams for recurrent UTI in post menopausal women
Paracetamol for pain
Cranberry can be used
RED FLAG SIGNS – REFER
• Pyelonephritis • Special situations (Children, pregnancy, • Non response within 3 days of AB • Complicated UTI males except simple cystitis, catheter UTI) • Recurrent UTI
TERTIARY LEVEL
• Send for culture
• Imaging if no response to antibiotics in 48 hrs • Urology services if obstruction
Rx Pyelonephritis/ complicated UTI
Rx pregnancy UTI
Rx all male UTI including prostatitis
Rx recurrent UTI
Rx non-resolving UTI
PYELONEPHRITIS PREGNANCY UTI CATHETER UTI MALES WITH PROSTATITIS RECURRENT UTI
Empiric Outpatient: • Urine c/s
• Consider initial dose of a parenteral
agent

Ceftriaxone 1-2 g IV/IM x 1
Gentamicin 5 mg/kg IV/IM x 1
• Followed by
Ciprofloxacin 500 mg PO BD x 7d
Levofloxacin 750 mg PO OD x 5 d
Cefuroxime 500 mg PO BD x10-14d – Amoxy clav x10-14 days
TMP-SMX 1 DS BD x 7-10 days
Empiric Inpatient :
• Ceftriaxone 1-2 g IV once daily+ /-AMP • Gentamicin +/-AMP
• Others as per c/s- Carbapenem,
Piperacillin Tazo
IV therapy required until afebrile x 48 hrs, then switch to PO If no response in 3 days imaging
• Urine culture at 1st antenatal visit
• For asymptomatic bacteriuria/acute cystitis:
Nitrofurantoin 100 mg PO BD x 5-7 d (avoid near- term )
Cephalexin 500 mg PO QID x 5-7 d
TMP/SMX 1 DS tab PO BD x 5-7 d (avoid in 1st trimester & near term; supplement with multivitamin containing folic acid)
• Check repeat urine c/s 7days after Rx to confirm clearing
• Repeat urine culture in each
antenatal visit
• If recurrent- Antibiotic
prophylaxis till term
• Rx of asymptomatic CAUTI NOT recommended
• Urinary catheters should be removed as soon as not required
• If indwelling catheter for >2 weeks and is still indicated, replacing the catheter is recommended
• Symptomatic CAUTI
(Fever, back pain, new
onset delirium, rigors) – Send culture
Rx as complicated
UTI
• No role of routine
antibiotic prophylaxis for prevention
• UTI symptoms+ pelvic pain/ fever
• Refer
• Urine culture & MSU • Digital rectal exam-
tender prostate
• Older >35 yrs-
Septran DS BD
Levofloxacin 500mg OD,
ciproflox 500 mg BD – Avoid nitrofurantoin
• Young males-
Doxy 100mg bd /azithro 1
gm / oflox 300mg BD for chlamydia + Single dose of Ceftrioxone 250mg IM for gonorrhoea
• Rx- 6 weeks
• Imaging to rule out
abscess
• Uncomplicated RUTI
post coital voiding and post coital antibiotic
Low dose nitrofurantoin 50 mgX 6 months
Single strength septran x 6 months
Or norflox 200mg, ciproflox200mg , cephalexin 250mg
Vaginal cream in post menopausal
• Complicated RUTI – Urology referral
Cystoscopy,
urodynamics (post menopausal)
ASYMPTOMATIC BACTERIURIA
• No symptoms
• Bacteria in urine culture
105CFU/ml
• No treatment required
• Exceptions when you should treat
Pregnancy
Before any urological
intervention
Pregnancy UTI, Catheter UTI may also be managed at secondary level.
LONG TERM CONSEQUENCES
• Renal scars
• Hypertension
• CKD
• Poor quality of life
CHILDREN
SYMPTOMS
• Neonates and Infants < 1yr
Fever,vomiting, diarrhoea, jaundice, Poor
stream
Older children same as adults
TREATMENT
Infants <3months as upper UTI (PN) with
IV antibiotics
Urinary bladder catheterisation for infants with upper tract UTI
Older children
• Upper UTI- IV antibiotics
gentamicin, amikacin, ceftriax
one
• Lower UTI- oral cefixime, oflox,
ciproflox, amoxyclav • Duration of Rx
Upper UTI- 10-14 days – Lower UTI 7-10 days
Adolescents 3-5 days REFER
Upper UTI(PN), infants UTI, recurrent UTI
PREVENTION
Avoid constipation, clean washrooms
FIRST URINARY TRACT INFECTION*
Age <1 yr • Ultrasound • MCU • DMSA renal scan Age 1-5 yr Age >5 yr
• Ultrasound
If ultrasound abnormal:
MCU and DMSA scan
• Ultrasound
• DMSA scan
MCU if ultrasound or DMSA scan is abnormal
All patients with recurrent UTI need detailed evaluation with ultrasonography DMSA scan and MCU
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

     NEUROLOGY

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the
APPROACH TO ACUTE PARALYSIS
ICD 10 G82, G83
PRESENTATION WITH ACUTE ONSET (WITHIN HOURS TO DAYS) PARAPLEGIA OR QUADRIPLEGIA
WEAKNESS PROXIMAL
REFLEXES ABSENT
WEAKNESS DISTAL
Are There Any Signs Of Upper Motor Neuron (UMN) Involvement?
• Brisk reflexes
• Extensor plantar
• Increased tone
• Sensory level
• Bladder or bowel incontinence
NO
REFLEXES PRESENT
YES
Is the weakness predominantly proximal or distal?
Presence of Lower Motor Neuron (LMN) signs like wasting, absent reflexes and sensory impairment
Likely to be :
Acute onset peripheral neuropathy (due to toxin/drug)
Likely to be :
∙ Acute myelopathy like
tuberculosis
∙ Trauma
∙ Tumor
∙ Transverse myelitis
∙ Epidural abscess
∙ Spinal cord stroke
MANAGEMENT
• Check pulse, BP and respiration • If retention of urine present
then catheterize
• Transfer/ refer to nearest district
hospital/ medical college with
MRI facility
• Treatment will depend on MRI
and other investigation
• After treatment follow up at
CHC for medications and rehabilitation
Likely to be :
• Guillain Barre Syndrome (GBS) or • Hypokalemic periodic paralysis.
MANAGEMENT
• Check pulse, BP and respiration • Check serum K+ levels
• Intubate if unable to complete
sentences, single breath count low and breath holding time low and chest expansion poor
• Transfer/ refer to nearest District Hospital/ medical college with facility for doing plasma exchange or giving IVIg and presence of ventilator.
• After treatment follow up at CHC for medications and rehabilitation
MANAGEMENT
• Transfer/ refer to nearest district hospital/ medical college with NCS and EMG facilities.
• CSF for cells and biochemistry
• Treatment as per diagnosis
• After treatment follow up at CHC
for medications and rehabilitation
ADMISSION CRITERIA
• Any progressive weakness
• Unable to walk
• Unable to swallow or choking while drinking
water
• Evidence of respiratory distress like unable
to complete sentences, falling serial single breath count, respiratory rate >20 or SaO2 levels < 95% • Persistent tachycardia >100
• Fever
• Bowel and bladder involvement
If the weakness is fatigable or
If extra ocular movements are affected
If no sensory impairment and normal extra ocular movements
Likely to be :
• Myasthenia gravis or • Snake bite
Likely to be :
• Myopathy (eg polymyositis)
DISCHARGE CRITERIA
• Cause of acute paralysis established
• Progression of weakness has stopped
• Able to breathe on his own
• If present care of tracheostomy taught to
care giver
• If not swallowing- Ryles tube in place and
care giver has been taught feeding
• Care of urinary catheter and constant
turning taught to the patient
• Caregiver trained for physiotherapy at
home
MANAGEMENT
• Check pulse, BP and respiration • Intubate if unable to complete
sentences, single breath count low and breath holding time low and chest expansion poor
• Transfer/ refer to nearest district hospital/ medical college with facility for doing NCS, plasma exchange or giving IVIg and presence of ventilator.
• After treatment follow up at CHC for medications and rehabilitation
MANAGEMENT
• Check pulse, BP and respiration
• Check serum electrolytes, creatine
kinase
• Transfer/ refer to nearest district
hospital/ medical college with
facility for NCS & EMG
• After treatment follow up at CHC
for medications and rehabilitation
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

  CLINICAL FEATURES OF

DEMENTIA
Impaired memory
Apathy
Depression
DEMENTIA
ICD 10 – F02,F03,G30
Anxiety
Agression
Sleep disturbances
Hallucinations
Mood fluctuations
Personality change
Incontinence
Forgetting learned activities
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
IMPORTANT POINTS TO CONSIDER
• Dementia is a complex and variable condition
• No single test will definitively diagnose dementia
• The clinical features if present, should be a change from baseline normal functioning in a middle aged to old person
• Assessment should aim at gathering information about changed behaviours, functional capacity, psychosocial support and medical
comorbidities
• History should be taken from a close caregiver, staying with the patient for a longer duration than the appearance of symptoms
EVALUATION OF DEMENTIA
History and examination
No
No
No dementia
Suspected dementia
Cognitive decline in more than one domain
Yes Yes
No Yes
Lab investigation TSH,Vit B12, vit D
LFT/RFT/FBS
Delirium or Depression?
Yes
Neuropsychiatry testing
Functional decline
Dementia
Follow up and Re-evaluation
Medical college Tertiary level centre
Optional tests based on clinical features
Other causes
No
Yes
CT scan/MRI
Lab investigation TSH, vit. B12
Typical clinical profile (age, progression, no focal signs)
Probable AD
ASHA PHC CHC DH
Treat
VD/ mixed dementia
FOLLOW UP OF DIAGNOSED & TREATED PATIENTS INTERVENTION MATRIX FOR DEMENTIA ACROSS PLATFORMS OF CARE
PRIMARY HEALTH CENTRE (MEDICAL OFFICER)
• Diagnose dementia after detailed history
• Screening for:

Treatable causes of dementia – thyroid disorders, B-12 deficiency, subdural hemorrhage.
Depression.
Vascular risk factors
• Lab investigations- CBC, biochemistry, liver function
tests, hemogram, lipid profile, TFT, VDRL, vit B12 level, vit
D level
• Referrals for MRI/CT
• Initiation of treatment/drugs; treatment for co-morbid
conditions (including depression, vision, hearing deficits
and gait problems), thyroid, arthritis.
• Initiate therapy for vascular risk factors
• Encourage healthy lifestyle
• Assess for palliative care
• Learn and share facts about dementia to provide
immediate need to the person with severe dementia
• Follow up and monitor for side effects of drugs/ red flags
in patient/ signs of danger
• Follow-up of difficult patients under the guidance of
higher centre.
DISTRICT HOSPITAL (SPECIALIST- PHYSICIAN/ GERIATRIC SPECIALIST/ NEUROLOGIST/
PSYCHIATRIST)
• Careful evaluation of all the referral patients of dementia • Screening for treatable causes for dementia including
normal pressure hydrocephalus, B12 deficiency,
hypothyroidism, chronic meningitis
• Neuroimaging CT/MRI- to rule out subdural hematoma/
tumors/ NPH(surgically remediable causes of rapid
cognitive decline)
• Lab investigations- CBC, liver function tests, biochemistry,
hemogram, lipd profile, vit D levels, TFT, VDRL, retrovirus after counselling (whenever feasible and high index of suspicion)
• All the points mentioned in PHC to be followed if patient presents to a DH
• Upward referral linkages with tertiary care and downward referral with PHC.
• Encouraging patient and caregiver participation in an ongoing support program for them.
• Avoid antipsychotics until necessary
• Interaction with, training of MOs at PHC/UPHC and
ongoing clinical support and supervision
REASONS FOR REFERRAL
• Not responding to adequate dose and duration of prescribed
medications
• Presence of red flags
RED FLAGS
• Fever
• Rapid progression • Seizures
• Recent head
injury
• Alcoholism and
falls
MEDICATIONS RECOMMENDED FOR USE FOR ALZHIEMERS DEMENTIA
FOR COGNITION
• Donepezil: 5 mg once after breakfast x 1 month, then 10 mg after breakfast to continue
If any side effect/ not tolerating: Rivastigmine to be used start dose 1.5 mg BD / 1 month then 3
mg BD x 1 month, then 4.5 mg BD x 1 month, then 6 mg twice after meals only x 1 month.
• Memantine: in moderate to severe dementia 5 mg BD x 1 month, then 10 mg BD to continue. • Galantamine: 8 mg BD if not tolerating 1
FOR DEPRESSION
• Escitalopram 10 mg
FOR AGITATION
• Identification of triggers
• Non pharmacological interventions
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
EPILEPSY
ICD 10 – G40
CLINICAL FEATURES
Episodic, few secs-mins
Sudden drops/ falls, brief jerks
Blank staring
Any other episode lasting for few mins (usually<5 mins) REASONS FOR REFERRAL (centres with specialists like paediatrician, neurologist) • Redflag Signs • Progressive problems, rapid appearance of new symptoms • Recent injury • Symptoms appearing after alcohol binge • Status epilepticus after stabilization • Non response to adequate dose and duration of medication • Serious side effects • Neuroimaging RED FLAG SIGNS • Fever • Headache • Vomiting • Altered Sensorium • Severe Giddiness • Loss of function of body Abnormal jerky movements With or without urine/ stool incontinence, tongue bite, drooling Loss of consciousness/ awareness Bizzare activity out of context Episodes could be single with high risk of recurrence. Prolonged motor convulsion of > 5 mins with loss of consciousness – STATUS EPILEPTICUS (SE) – MEDICAL EMERGENCY
DISTRICT HOSPITALS
• Careful evaluation of all referral patients, provide specialized management for patients and refer back to PHC for follow up of management
• Maintain communication, ongoing clinical support and supervision of MOs at PHC
• Laboratory investigation – CBC, liver function
tests, antiepileptic drug levels, routine biochemistry, hemogram, lipid profile, vit D levels, TFT, CT brain (when necesary)
• Monitor side effects of AED
• Clinical Psychologist: counselling health services for persons with epilepsy or upon referral from PHC/UPHC
ADVERSE EFFECTS
Anorexia, wt gain, nausea, vomiting, tremors, hair loss, PCOS, thrombocytopenia
Sedation, ataxia, dizziness, skin rash, SJS (lower risk with slow titration)
Somnolence, dizziness, cognitive slowing, psychosis
Sedation, somnolence, cognitive problems, weight loss, word finding difficulty, renal stones, seizure worsening
Sedation, dizziness, ataxia, skin rash, SJS, hyponatremia, seizure worsening in some situations
Sedation, dizziness, ataxia, headache, hyponateremia, skin rash
Sedation, ataxia, depression, memory problems, hyperactivity in children, skin rash
Ataxia, sedation, gum hyperplasia, coarsening of facial features, hirsutism, memory problems, osteomalacia & bone loss, skin rash
PRIMARY HEALTH CENTRE (MEDICAL OFFICER)
• Clinical diagnosis of epilepsy: detailed history from an eyewitness
• Differentiate between provoked seizures and epilepsy (provoked due to fever,
acute CNS insult, antibiotics, and metabolic causes)
• Laboratory investigations: CBC, liver function tests, routine biochemistry,
hemogram, lipid profile, vit D levels, TFT (whichever feasible) • Initiation of treatment:
Treat the patient if patient has epilepsy (2 or more episodes of unprovoked seizures)
Treat a single seizure if risk of recurrence is high as in patients with focal seizures,mentally retarded, neurological deficits having family history of
seizures abnormalEEG, neuroimaging
Anti Epileptic Drug (AED broad spectrum, low dose, start low go slow, except
status epilepticus)
Emergency medical care of status epilepticus
• Treatment counselling: side effects/toxicities of drugs, red flags, importance of adherence, maintaining treatment diary
• Advice on prevention of seizures: regular medication, sleep 7-8 hrs, avoid excess TV/mobile/ photic stimulation, regular diet, lifestyle choices(avoid alcohol)
• Evaluate any possibility of superimposed non-epileptic seizure
• Training of MLP/ANM/ASHA on epilepsy
• For excessive alcohol use, refer to ANM/MLP where psychosocial interventions are
carried out for substance use disorders
• Follow up visits for treatment monitoring & difficult patients under neurologist at
STC centre
• Basic management of co-morbidities (behaviour, cognition, reproductive health,
bone health)
• Alert to signs of abuse and neglect
• Maintain upward referrals with paediatrician/physician at DH
AED– BROAD SPECTRUM (GENERALIZED SEIZURES)
Sodium Valproate (avoid in women of child bearing age unless non responsive to other drugs)
Lamotrigine
Levetiracetam
Topiramate
AED (focal seizures)
Carbamazepine
Oxcarbazepine
Phenobarbitone
Can be used for generalized also
Phenytoin
DOSE (MAINTENANCE: MG/D)
Starting dose :200mg TDS Maintenance Dose: 600-2400
Starting dose: 25mg HS (Lower dose with VPA) Maintenance Dose: 100-300
Starting dose: 250mg BD Maintenance Dose: 1000-3000
Starting dose: 25mg OD Maintenance Dose: 100-400
Starting dose: 100mg BD Maintenance dose: 400-1200
Starting dose: 150mg BD Maintenance dose: 600 to 1800
Starting dose: 30mg HS Maintenance dose: 60-180
Starting dose: 200mg HS Maintenance dose:200-400
Folic Acid 5 mg/day to be added along with AEDs in all women of child bearing age. Polytherapy and valproate to be avoided in women with epilepsy
IMPENDING SE ESTABLISHED SE REFRACTORY SE
5 MIN 30 MIN 60 MIN 2 IV drugs fail (Benzo + IV AED)
FIRST ABCS TO BE DONE FROM WHEN YOU SEE PATIENT SIMULTANEOUSLY WITH MEDICATION
Out of Hospital/home : Buccal/Intranasal IMDZ with acute repititive seizures/status (0.3-0.5 mg/kg) ICU
EMERGENCY ROOM
IV Lorazepam up to 0.1 mg/kg @ 2mg/min OR
IV Midazolam 0.1-0.2 mg/kg bolus or 0.05-0.5 mg/kg/hr in CIV OR
IV Diazepam upto 0.25-0.4 mg/kg over 2-3 min
• Phenytoin @50 mg/min 20 mg/kg repeat
plus 10 mg/kg if seizures do not stop in 15-20 min
• If seizures not controlled or contra indiction (CI) to PHT Intravenous Valproate 25-40 mg/kg @3-6 mg/kg/min
• If CI to above two; Phenobarbitone 20 mg/kg IV @ less than 5-60 mg/min but be prepared to Intubate and ventilate
Levetiracetam 20-30 mg/kg IV at 5 mg/kg/min (max 3g) or Levetiracetam 1500-3000 mg via NGT or
Lacosamide 200-400 mg IV at 40-80 mg/min
Topiramate 150-800 mg bid via NGT
IV Midazolam loading 0.2 mg/kg OR CIV 0.05-0.5 mg/kg/hr
(can go up to 2 mg/kg/hr)
Taper gradually after seizure stops (preferably as evidenced by EEG)
Thiopental 5-7 mg/kg IV bolus
further 50 mg until seizures controlled 3-5 mg/kg/hr for only 48 hours
OR Propofol IV loading 2-5 mg/kg
CIV 1-15 MG/KG/HR
OR Pentobarbital IV upto 10 mg/kg
@ <0.2-0.4 mg/kg/min CIV 0.5-2 mg/kg/h OR Ketamine bolus 1.5 mg/kg CIV 0.01-0.05 mg/kg/h max 10mg/kg/hr * to be EEG Monitoring Super refractory > 24hr no control
Airway, blood pressure, temperature, intravenous access, electrocardiography, CBC, glucose, electrolytes, AED levels, ABG, oximetry, tox screen, central line If alcoholic- thiamine & glucose, if diabetic GLUCOTEST/blood sugar & glucose IV. MUST INFORM CONSULTANT ON CALL
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
HEADACHE
CONTINUOUS HEADACHES
• Progressive headache of acute or subacute onset persisting more than 1 week
• Possibilities: Cerebral Venous Thrombosis, Intra Cranial Space Occupying Lesion, Meningitis, Brain abscess
CHRONIC TENSION HEADACHE
Continuous bilateral headache for many years with significant insomnia and psychosomatic complaints.
ICD-10-G43-44
Referred to higher centre
• CT with CT Angiogram/ MRI with MR angiogram
• Lumbar puncture
• Refer to tertiary care
centre
TREATMENT FLOWCHART
LEGEND/ INDEX/ KEY
Type of Headache
Management at PHC
Management at district hospital
• First or worst headache of the patient’s life
• Focal neurologic signs (not typical aura)
• Severe headache awakening from sleep
RED FLAG SIGNS
MIGRAINE
Side alternating, associated visual aura, photo-phono phobia, nausea, relieved by sleep or analgesics
ATYPICAL MIGRAINE
Hemiplegia, visual impairment, vertigo
Frequency > 2 /month –
Start prophylaxis trial for 2 months
• Propranolol 40 mg OD
• Flunarizine 10 mg OD
Acute management
• Analgesics( Paracetamol 650 mg, or
Indomethacin 50 mg) and
• Antiemetics ( Prochlorperazine 10mg).
Life style changes
• Good sleep at least 6 hrs, food habit
modification, avoiding triggers of migraine.
Start Amitriptyline (10mg HS) and advice on lifestyle
Brain imaging if atypical features exist
Brain imaging if there are atypical symptoms
Analgesics for pain Refer to higher centre with
imaging facility
• CT/ MRI with MR angiogram or CT angiogram if required
• Migraine prophylaxis after ruling out stroke and other diseases
TRIGEMINAL AUTONOMIC CEPHALGIAS
Rapid onset peri orbital and temporal pain with autonomic features
CLUSTER HEADACHE, PAROXYSMAL HEMICRANIAS, SHORT LASTING UNILATERAL NEURALGIFORM PAIN WITH CONJUNCTIVAL INJECTION AND TEARING SYNDOME (SUNCT)
Indomethacin (25mg TID) for 7 days
Refer to tertiary care centre
Refer to tertiary care centre
Refer to tertiary care centre
REASONS FOR REFERRAL
• Non responding headaches
• Headaches with danger signs should be immediately referred and investigated for potentially dangerous conditions
Progressive headache with seizure or focal deficit
CT/MRI with contrast
BRAIN TUMORS
Surgery, radiation, chemotherapy
• Headache with fever, change in personality, mental status, level of consciousness
• Fever, neck stiffness or meningism • New onset of severe headache in
pregnancy or postpartum or while on hormone treatment
• Rapid onset with strenuous exercise • Sudden onset (maximal intensity
occurs within seconds to minutes,
thunderclap headache)
• New headache type in a patient
with malignancy or immunosuppression
Sudden Severe headache, First or Worst headache of life
CT with CT Angiogram/ MRI with MR angiogram
Progressive headache
MR venogram
CEREBRAL VENOUS THROMBOSIS
Intravenous UFH / subcutaneous heparin/LMWH
CRITERIA FOR DISCHARGE
Headache with fever, personality change, altered sensorium, neck stifffness
CT scan followed by CSF study
MENINGIOENCEPHALITIS
Antibiotics/ antivirals
TREATMENT OF MAJOR CATASTROPHIC HEADACHES AT TERTIARY CENTRE
SUBARACHNOID HEMORRHAGE
Angiogram, clipping/ coiling of aneurysm
(to prevent rebleed)
INTRACEREBRAL HEMORRHAGE
Stroke unit admission and neurosurgery for cortical hemorrhages or large hemorrhage with herniation
INDICATIONS FOR ADMISSION
FOLLOW UP OF HEADACHE PATIENTS
CAUSES OF HEADACHE
TREATMENT OF HEADACHE
Intra cerebral hemorrhage
Good control of blood pressure
Seizures
Antiepileptic medications
Cerebral venous sinus thrombosis
Follow up of anticoagulation
Migraine
Give prophylaxis for adequate duration of time and taper after remission
• Patient with unrelenting headache
• Immunosuppressed patients with continuous headache,
• First ever headache with worsening intensity,
• Progressive headache with other systemic disease
• Severe symptomatic primary headache disorders
• Primary headache disorders- symptomatically improved severe episode of headache due to primary headache disorder can be discharged
• Secondary headache disorders- secondary headache disorders with essential work up, diagnosis and treatment as per individual case can be discharged
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
REFERENCES

Hainer BL, Matheson EM. Approach to acute headache in adults. American family physician. 2013 May 15;87(10). 2. https://www.uptodate.com/contents/evaluation-of-headache-in-adults
ABBREVIATIONS
CSF: Cerobrospinal Fluid, UFH: Unfractionated Heparin, LMWH: Low Molecular Weight Heparin
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
In addition to all the steps given above :
ESSENTIAL
NEUROINFECTIONS
ICD-10-G03.9
SYMPTOMS
DIFFERENTIAL
Acute onset-hours to days
DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
Vascular-ischemic/hemorrhagic stroke
Alteration in sensorium
Infections viral/bacterial/fungal/protozoal meningoencephalits/brain abscess
Metabolic encephalopathies
With/ without fever/ headache/vomiting/seizures
ESSENTIAL
Seizures/postictal state
Intoxications-drugs/toxins
AT PRIMARY CARE LEVEL
NOT RECOMMENDED
• Stomach wash • Inj Mannitol
• Inj Steroids
CRITERIA FOR REFERRAL
Altered sensorium/seizures /focal deficits/hemodyna mic instability –where imaging and ICU management are required.
Check Airway/Breathing/Circulation
Rule out circulatory shock, ongoing convulsions and hyperthermia/hyperpyrexia(core temperature > 40.5°C or hypothermia(< 36.5°C) Establish IV access-urgent blood for hemogram/sugar/electrolytes/malaria testing-peripheral smear/rapid antigen detection Correct hypoglycemia (blood sugar 50 mg/dl) with IV 100ml of 25% dextrose solution If seizing- IV/IM Lorazepam 0.1 mg/kg followed by loading with Phenytoin 20 mg/kg weight at a rate of 50 mg/minute When IV access not available-intra nasal or buccal Midazolam 0.2 mg/kg /intra rectal Diazepam 0.3-0.4 mg/kg Urgent referral to higher centres with intensive care facilities AT SECONDARY CARE LEVEL( TALUK, DISTRICT) HEADQUARTERS HOSPITAL DESIRABLE • Neuroimaging-CT with contrast -to rule out hemorrhage/infarcts/focal edema or lesions • Blood cultures aerobic/anaerobic • First dose of empirical treatment of pyogenic meningitis-Inj Ceftriaxone 2 g + Inj Vancomycin 500 mg. Add Inj Ampicillin 2 g if older than 50 years / immunocompromised along with Inj Dexamethasone 8 mg • Fundus examination,CSF study to rule out meningoencephalitis-if imaging rules out any mass lesions/herniations. • Urgent referral to higher centres with Intensive care facilities Establish and maintain airway: Intubate if GCS<8, impaired airway reflexes, abnormal respiratory pattern, signs of raised ICP, oxygen saturation <92% despite high flow oxygen, and fluid refractory shock Inj Thiamine 100 mg IV Stomach wash/activated charcoal administration-if history or suspicion of drug overdose/ non corrosive poison intake Start treatment for cerebral malaria-first dose of IV Artesunate 2.4 mg/kg OR Quinine 20 mg/kg bolus Emergency CT/referral to centre with 24 hour CT facilities CRITERIA FOR REFERRAL • Altered sensorium/seizures/focal deficits/hemodynamic instability –where imaging and ICU management are required. • If no definite diagnosis achieved after preliminary investigations AT TERTIARY CARE HOSPITALS-SELECTED DISTRICT HOSPITALS/MEDICAL COLLEGES • Neuroimaging-MRI/CT with contrast to rule out abscess/herniations. If abscess-emergency neurosurgical consultation for favour of aspiration –open/stereotactic • Blood cultures-aerobic/anaerobic • CSF analysis-biocehmistry/cytology/gram staining/culture-bacterial , AFB and fungal/viral PCR/TB-PCR/fungal antigen Empirical antibiotic (within 30 minutes of arrival) • If suspecting pyogenic meningitis-Inj Ceftriaxone 2 g+ Inj Vancomycin 500 mg+ Inj Ampicillin 2 g if older than 50 years or immunocompromised+ Inj Dexamethasone 8 mg IV • Continue empirical treatment till culture yields causative organism,then tailor treatment as per sensitivity reports for 10-14 days. • Steroids to be stopped after 48 hours,unless any other compelling indications-adrenal insufficiency/TBM COMPLICATIONS Viral-Herpes simplex/Zoster • Inj Acyclovir 500 mg IV 8 hourly for 10 days Cerebral malaria Inj Artesunate 2.4 mg/kg IM or IV 3 doses 12 hours apart and then OD / Inj Quinine 20 mg/kg IV stat followed by 10mg/kg TDS till patient can take orally,then oral Artesunate+Pyrimethamine /Sulphadoxine for 3 days OR oral Quinine 10 mg/kg TDS for total 7 days + Doxycycline 3 mg/kg OD for 7 days. Raised ICP SIADH *If uncomplicated-back referral to Secondary care centre for completing treatment regimen/monitoring. Vasculitis Hydrocephalus CRITERIA FOR DISCHARGE Afebrile,hemodynamically stable,seizure free >48 hours
Diagnosis and treatment plan made and initiated.
Continuation of treatment with monitoring can be ensured for the prescribed duration.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 WHAT IS STROKE?
An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction or haemorrhage
• Numbness or weakness, especially on one side of the body
• Loss of consciousness or altered consciousness • Decreased vision in one or both eyes
• Language difficulties, either in speaking or
understanding
• Difficulty walking; loss of balance or coordination • Confusion or loss of memory
• Swallowing difficulties
• Paralysis of any part of the body, including face
• Sudden, severe headache with no known cause
• Neck pain
• Nausea and vomiting
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
SYMPTOMS
WARNING SIGNS (BEFAST)
• BALANCE : Loss of balance or coordination
• EYES : Sudden blurred or double vision/ sudden, persistent vision trouble
• FACE : Deviation at the angle of the mouth
• ARM : Arm Drift
• SPEECH : Slurred speech or the inability
to speak or understand
• TIME : Act fast
• Sudden new onset of headache or loss of
consciousness
• Sudden giddiness, vomiting and
imbalance
STROKE
ICD-10-I63, I64
TYPES OF STROKE
Ischemic stroke
Focal cerebral, spinal, or retinal infarction
Intracerebral haemorrhage
Focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma
Subarachnoid haemorrhage
Bleeding into the subarachnoid space
Cerebral venous thrombosis Thrombosis of a cerebral venous structure
Transient Ischemic Attack (TIA)
Transient episode of neurologic dysfunction caused by focal cerebral, spinal cord, or retinal ischemia, without acute infarction
PRELIMINARY MANAGEMENT
INVESTIGATIONS
• Assess and manage ABCs
• Initiate cardiac monitoring
• Maintain O2 saturation >94%
• Establish IV access
• Determine blood glucose and treat accordingly
• Determine time of symptom onset or last known normal, and obtain family
contact information, preferably a cell phone
• Triage and RAPID TRANSFER of patient to nearest district hospital with CT
Scan facility or Stroke center with facility for thrombolysis
• Referal hospital to be notified to handle the referred patient with stroke
ESSENTIAL
• CT Scan head • ECG
• Blood Sugar
• Lipids
• Renal parameter
DESIRABLE
• CTA
• Echocardiogram
OPTIONAL
• MRI/MRA
• Holter monitoring
MANAGEMENT
STROKE ONSET TIME: <4.5 HOURS
ISCHEMIC: *
IV tPA (0-4.5 hrs) or endovascular treatment according to eligibility and availability
HAEMORRHAGIC:
• Dysphagia assessment,
• Blood pressure/blood sugar monitoring and IV fluids.
• Prevention of Pneumonia
• Prophylaxis for deep venous thrombosis etc, monitor and record ECG

RECOMMENDED DIAGNOSTIC STUDIES
ALL PATIENTS SELECTED PATIENTS
• Noncontrast brain CT or brain MRI
• Blood glucose
• Oxygen saturation
• Serum electrolytes/renal function tests
• Complete blood count, including platelet count • Markers of cardiac ischemia
• BT, CT, Prothrombin time/INR
• Activated partial thromboplastin time
• ECG
• FLP and carotid doppler (ischemic stroke)
• TT and/or ECT if it is suspected the patient is taking direct thrombin inhibitors or direct factor Xa inhibitors
• Liver function tests • Toxicology screen
• Blood alcohol level • Pregnancy test
• Arterial blood gas test (if hypoxia is suspected)
• Chest radiography (if lung disease is suspected)
• Lumbar puncture (if subarachnoid hemorrhage is suspected and CT
scan is negative for blood)
• Electroencephalogram (if seizures are suspected)
Rapid Assessment, CODE Stroke, Blood pressure and Blood Sugar monitoring, NIHSS, Intravenous lines Endovascular treatment with Mechanical thrombectomy using stent retriever (4.5 hrs to 24hrs) according to eligibility
STROKE ONSET TIME: >4.5 HOURS
SECONDARY PREVENTION
Aspirin (in ischemic stroke) Antihypertensives Antidiabetics
Lipid lowering agents
REHABILITATION
Physiotherapy Speech Therapy Occupational Therapy Vocational training
STROKE UNIT MANAGEMENT
DISCHARGE PLANNING
(checklist : drugs, diet, compliance, exercises, health education)
FOLLOW UP at 2nd week, 1st month, 3rd month and 6th month
· Medical and Nursing staff : control of blood pressure; control of diabetes; swallow assessment; DVT prophylaxis; antiplatelet drugs · Rehabilitation staff:
» Acute phase: basic bed mobility, transfer techniques, communication training, prevention of complications
» Subacute and chronic phase: mobility, gait and balance training, training of activities of daily living (grooming, eating, dressing etc), bowel/bladder
training, perceptual and cognitive rehabilitation, provision of assistive devices.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 OBG Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for
ANTE-NATAL MANAGEMENT OF NORMAL PREGNANCY
FIRST VISIT (PREFERABLY IN FIRST TRIMESTER)
ASK
• Age
• LMP
• Parity & obstetric history
• Any complaints especially excessive
nausea & vomiting/ bleeding PV • H/o medical illness : diabetes,
hypertension, cardiac problem,
epilepsy or any other chronic illness • Consanguinity, multiple pregnancy • H/o blood transfusion and H/o prior
surgical intervention
• Personal history : tobacco/ alcohol
intake
• Family history : diabetes, hypertension,
genetic disorders/ congenital problems, multiple pregnancy, infections including tuberculosis
EXAMINE
• Height, weight
• Calculate BMI
• Pallor, Jaundice, Pedal edema • Pulse, BP, RR, temperature
• Thyroid
• Breast
• Respiratory and CVS exam –
ination
• P/A examination, P/S and P/V
examination

If woman presents with

bleeding per vaginum do P/A & P/S to confirm amount of bleeding & rule out local causes. All such cases to be referred to CHC or higher centre
INVESTIGATIONS
ESSENTIAL TESTS
• Hemoglobin
• Urine R & M
• ABO & Rh grouping
DESIRABLE TESTS
• VDRL/ RPR
• HIV
• HBsAg
• WHO OGTT/ DIPSI test for diagnosis of
GDM
• TSH in high risk cases (BOH, goiter, obesity
or residing in iodine deficiency prone areas)
OPTIONAL TESTS*
Aneuploidy screen* by USG & double marker
DO
• UPT if in doubt • Fill up MCH
protection card or ANC card, make entry on RCH portal & generate RCH number (in public sector)
• Give filled MCH protection card & safe motherhood booklet to woman
• Give Tab Folic Acid daily
• Give first dose of tetanus toxoid
SECOND VISIT (SECOND TRIMESTER)
ASK
• Any com- plaints since last visit
• Quickening and/ or fetal movements
• Adherence to medications
EXAMINE
• Weight
• Pallor
• Pedal edema • Pulse, BP in
sitting
position • P/A
examination for fundal height
ESSENTIAL TESTS
• Hemoglobin
• Urine albumin DESIRABLE TESTS
INVESTIGATIONS
• USG ( Level II between 18-20 weeks for gross congenital malformations)
• WHO OGTT/ DIPSI test if >24weeks & at least 4 weeks have elapsed after 1st test
OPTIONAL TESTS*
Quadruple test as per availability
*Should be performed only if adequate counselling facilities are available
DO
• IFA tablet one (if Hb >11g%) or twice ( if Hb <11g%) daily with water or lemon juice • Calcium carbonate 500 mg with vitamin D 250 mcg tablet twice daily with meals. • Calcium Carbonate and IFA not to be given together • Single dose of Albendazole 400mg • Ensure compliance for investigations and treatment • Discuss birth preparedness • Give second dose Tetanus Toxoid at least four weeks after first dose THIRD (28 – 34 WEEKS) AND FOURTH VISIT (36 – 40 WEEKS) ASK Same as above EXAMINE • Same as above • Auscultate FHS • Measurement of abdominal girth and Symphysiofundal Height INVESTIGATIONS • Hemoglobin • Urine albumin • Optional USG for fetal growth and liquor DO • Continue IFA and calcium tablets and ensure compliance • If non compliant or Hb < 9g% give parenteral iron sucrose therapy (not > 200mg
at one time & not > 3 times a week) and refer patient with Hb < 7g% to higher centre • Refer to higher centre if any discrepancy between fundal height and period of gestation DANGER SIGNALS FOR PATIENT TO REPORT TO HEALTH FACILITY • Fever • Persistent vomiting • Abnormal vaginal discharge • Palpitations, easy fatigability and breathlessness at rest and/ or on mild exertion. • Vaginal bleeding • Decreased or absent fetal movements at > 28 weeks gestation
• Leaking of watery fluid per vaginum (P/V)
• Severe headache/ blurring of vision/ convulsion
• Passing lesser amounts of urine and/ or burning sensation during
micturition
• Itching all over the body
HIGH RISK PREGNANCY
• Any H/o medical illness, previous caesarean section, past obstetric mishap or congenital malformation
• Past H/o PPH
• Age > 35 years or < 19 years or parity > 4
• Malnourished (BMI < 18.5 kg/m 2 or > 30 kg/m 2)
• Hemoglobin < 7g% • BP > 140/90mm Hg on 2 occasions 6 hours apart
• APH
• Discrepancy between fundal height and period of gestation > 4 weeks • GDM/ overt DM
• Multiple pregnancy
• Malpresentation at term
• Previous uterine surgery

High risk pregnancy to be delivered at district hospital/medical college
Preferably to have antenatal care also at these centres
COUNSELLING AT ALL LEVELS FOR :
• Timing and place of next ANC visit based on presence or absence of risk factor •
•
•
• ∙
∙ •
Rest, nutrition, balanced diet and exercise Counselling for HIV testing
Danger signs
Institutional delivery Birth preparedness
Early & exclusive breastfeeding for six months Post partum contraception
ASSESSMENT OF FUNDAL HEIGHT & ITS CORRELATION WITH
GESTATIONAL AGE
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT
BIRTH PREPAREDNESS MUST INCLUDE IDENTIFICATION OF THE FOLLOWING :
• Facility for delivery
• Support persons
• Birth companion
• Means of transport in emergency
• Blood donors (if required in emergency)
At 12 th week : Just palpable above the symphysis pubis
At 16 th week : At lower one-third of the distance between the symphysis pubis and umbilicus
At 20th week : At two-thirds of the distance between symphysis pubis and umbilicus
At 24th week : At the level of umbilicus
At 28th week : At lower one-third of the distance between the umbilicus and xiphisternum
At 32 nd week : At two-thirds of the distance between the umbilicus and xiphisternum
At 36 th week : At the level of xiphisternum
At 40th week : Sinks back to the level of the 32 nd week, but the flanks are full, unlike that in the 32 nd week
•
UMBILICUS
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for
DILATATION AND CURETTAGE (D&C)
• Mostly done for gynaecological indications, but may also be considered in early pregnancy complications •
traditional D&C in gynaecological cases, it still has a place when other modalities are not available or do not yield adequate tissue
INDICATIONS :
GYNAECOLOGICAL
Abnormal uterine bleeding in appropriate cases (refer to HMB STW)
Post menopausal bleeding (ECC with D&C)
Infertility (to rule out TB) Amenorrhoea
As a haemostatic measure in women with excessive / prolonged vaginal
bleeding
sampling
EARLY PREGNANCY COMPLICATIONS
Retained products of conception- as a treatment of inevitable, incomplete, missed, septic or induced abortion.
Molar pregnancy
OR OR
OR OR
CONTRAINDICATION
Acute pelvic and vaginal infections
WHERE CAN IT BE PERFORMED?
• In secondary or tertiary healthcare centres preferably where facilities for anaesthesia and operation theatre are available to deal with procedure related complications, if any.
• Endometrial aspiration biopsy is usually done as an outpatient procedure in non pregnant cases.
GYNAECOLOGICAL PROCEDURES
Endometrial Aspiration Biopsy [EA]
D& C
Differential curettage (Endocervical curettage [ECC] with EA)
PROCEDURES FOR
EARLY PREGNANCY
COMPLICATIONS
DIFFERENTIAL
Dilatation and Evacuation [D & E]
D& C
Evacuation (with or without suction)
ALL TISSUE REMOVED MUST BE SENT FOR HISTOPATHOLOGICAL EXAMINATION
PRE- OPERATIVE REQUISITES
Presence of a valid indication
General medical fitness & no contraindication
A written informed consent
ANESTHESIA (ANY OF THE FOLLOWING)
• General anesthesia • Regional anesthesia • Paracervical block with 1% xylocaine • IV sedation • IM/ oral analgesia
Strict asepsis to be maintained. Antibiotics to be used judiciously and decided as per need of individual case.
POST PROCEDURE CARE & FOLLOW UP
• Observe the patient for minimum two hours after the procedure for haemorrhage or any other symptoms or signs of complications prior to discharge
• Patient can be discharged as soon as she is comfortable and alert.
• Most common side effect is abdominal cramps which can be managed by oral analgesics.
• Warning signals to report backare to be explained at the time of discharge – severe pain, bleeding, foul smelling discharge or fever.
• Follow up is done after a week with histopathology report for further advice.
COMPLICATIONS
• Excessive bleeding
• Cervical laceration
• Perforation of the uterus • Injury to bowel and
bladder
• Pelvic infection
• Post-operative intra
uterine adhesions
DOʼS
• Evacuation of urinary bladder before procedure.
• Safety checklist
• Dorsal/lithotomy position
• Bimanual pelvic examination
prior to the procedure • Sounding to measure
uterocervical length ONLY in
non pregnant women. • Sample to be sent for
histopathology and microbiology (where indicated)
• REFER in case of a complication
DONTʼS
• Over abduction of legs • No sounding in cases
of pregnant uterus.
• No forceful insertion of
any instrument • Abandon the
procedure in case of suspected perforation and refer to higher centre.
• Insertion of the dilator should be just beyond the internal os and NOT till the fundus
D&C is a blind procedure and may miss the pathology in some cases. In cases where focal pathology is suspected, tissue should be obtained under hysteroscopic visualization.
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
HEAVY MENSTRUAL BLEEDING (HMB)
ICD-10-H90.5
TO DO AT ALL LEVELS
HISTORY EXAMINATION SUPPORTIVE TREATMENT
• Age
• Parity
• Detailed menstrual history including irregularities • Other medical illness: thyroid disorder,
coagulopathy, jaundice etc • IUCD use
• Lactation
• Drug intake
• Reassurance
• Hematinics
• Tranexamic acid during episode of
heavy bleeding
Abnormality
Refer to Higher centre
Adolescents
Supportive Treatment
-Tranexamic acid – OC Pills
No Relief
Refer to higher centre
No Abnormality
Women of Reproductive Age Age > 40 years
INVESTIGATIONS
• Hemoglobin
• Complete Blood
Count (CBC) with
peripheral smear • Bleeding time /
Clotting time (BT/CT)
R/o pregnancy* Speculum examination Pelvic examination
No abnormality
Contraception desired
OC Pills No Relief
Any Abnormality
Contraception not desired
NSAIDs
Tranexamic acid – Progestogens**
Refer to higher centre
R/o Pregnancy in doubt especially in all women of reproductive age group after appropriate consent ** Amongst progestogens Norethisterone provides the best hemostasis
MANAGEMENT OF HMB AT SECONDARY LEVEL (CHC)
Adolescents
Supportive treatment
-Tranexamic acid – OC Pills
No Relief
Refer to higher centre
INVESTIGATIONS
• Hemoglobin
• CBC with peripheral smear • BT / CT
• ABO and Rh typing
• Thyroid function test
• USG of Abdomen & Pelvis
HISTORY AND EXAMINATION
Married <40 years Married >40 years
Post Menopausal
Refer to higher centre
Do USG
Endometrial thickness < 12 mm ET>12mm or
High Risk for endometrial cancer*
Do endometrial sampling and send for histopathological examination
Secretory/ Non Secretory endometrium without hyperplasia
NSAIDS
Tranexamic acid
Combined OC Pills – Progestogens
LNG IUS
If no relief, Refer to higher centre
Hyperplasia without atypia
Progestogens
Levonorgestrel-
releasing intrauterine
system (LNG IUS) Hormonal therapy to continue for 6 months
If no relief or recurrence Refer to higher centre
Hyperplasia with atypia/ malignancy
Refer to higher centre
• Hemoglobin
• CBC with peripheral
smear • BT / CT
• ABO and Rh typing
• TSH
• USG of Abdomen & Pelvis
INVESTIGATIONS
• General
Evaluate pallor Calculate BMI
• Systemic
CVS, RS and hepatosplenomegaly
• Local examination (where indicated and feasible) P/S and P/V
MANAGEMENT OF HMB AT PRIMARY LEVEL
HISTORY AND EXAMINATION
MANAGEMENT OF HMB AT TERTIARY LEVEL
HISTORY, EXAMINATION AND ULTRASONOGRAPHY
No structural abnormality
Structural abnormality
Adolescents
Treat underlying cause if present (thyroid disorders, jaundice, coagulopathy etc)
In absence of obvious cause
NSAIDS
Tranexamic Acid – OC Pills
Progestogens
< 40 years

40 years
Thickened endometrium
Fibroids & polyps, and
adenomyosis
Atypical Hyperplasia
Hysterectomy If no relief
Refer to Fibroid & Polyps STW

NSAIDS
Tranexamic Acid
OC Pills
Progestogens
LNG IUS
Ormeloxifene
Ablative Techniques
If no relief Hysterectomy
(Preferably after second opinion)
Endometrial sampling – D&C/ Hysteroscopic guided
No hyperplasia or benign hyperplasia
Conservative modalities – Tranexamic Acid
Progestogens
LNG IUS
Ormeloxifene – Ablative
techniques
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT
HIGH RISK FOR ENDOMETRIAL CANCER
Patient having:
Obesity
Diabetes
Hypertension
PCOD
TREATMENT FOR ACUTE BLEEDING EPISODE
IV Tranexamic acid 1g stat slowly followed by oral Tranexamic acid 0.5-1g,
6-8 hourly for 5 days – Blood transfusion if
indicated
HORMONE THERAPY
Norethisterone (max daily dose 40 mg)
OR
Medroxyprogesterone
acetate (max daily dose 40 mg)
Hormone therapy should be given orally daily in divided doses from the fifth day of the cycle for three weeks and repeated in a cyclical manner for total of 4-6 cycles of treatment
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

October/ 2019
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for
HYSTERECTOMY FOR BENIGN GYNAECOLOGICAL CONDITIONS
IN WOMEN AGED LESS THAN 40 AND/OR LOW PARITY IT IS MANDATORY TO HAVE A SECOND OPINION FROM A QUALIFIED GYNAECOLOGIST
HYSTERECTOMY TO BE CONSIDERED ONLY WHEN CHILD BEARING IS COMPLETED & RARELY IN YOUNGER PATIENTS
INDICATIONS :
HEAVY MENSTRUAL BLEEDING
ENDOMETRIOSIS
PROLAPSE
PRE – INVASIVE DISEASES
Failed medical treatment
• Failed medical treatment
• Causing hydroureteronephrosis
• Recurrence after failed medical/ conservative
surgical management
Third or fourth degree utero vaginal prolapse
• Endometrial hyperplasia without atypia with failed medical treatment
• Endometrial hyperplasia with atypia. • CIN II with poor compliance or CIN III
ROUTES OF HYSTERECTOMY
• ABDOMINAL • VAGINAL
• Pelvic organ prolapse
• Non descent hysterectomy
• LAPAROSCOPIC
• Inappropriately selected
patients
White discharge per vaginum
Cervicitis
Non specific abdominal or pelvic pain
Minor degree of utero vaginal prolapse
Fibroids which are small (less than 5 cm) or
Simple ovarian cyst less than or equal to 5 cm
LEIOMYOMA
• Symptomatic fibroids especially if not responding to medical management
• Asymptomatic fibroids greater than or equal to 14 weeks uterine size
• Fibroid causing hydroureteronephrosis
• Rapidly enlarging fibroids
• Submucus myoma greater than 4cm
OTHERS
• Adnexal masses : Need for hysterectomy to be individualised and justified
• Recurrent post-menopausal bleeding (even in the absence of malignancy)
Simple ovarian cysts less than 5 cm in size and without other significant/ suspicious features should be kept on observation and reviewed after 6 months
HYSTERECTOMY SHOULD NOT BE DONE FOR
COMPONENTS OF PRE OPERATIVE COUNSELLING AND INFORMED CONSENT
∙ Need for hysterectomy
∙ Alternative treatment options
∙ Risks and benefits
∙ Potential complications of the procedure
∙ Removal/ conservation of ovaries & tubes
∙ Route of hysterectomy
∙ Possible need for post operative Hormone therapy in selected cases
COMPLICATIONS TO BE EXPLAINED
• Risk of Infection
• Bleeding (primary/ reactionary/ secondary) • Injury to bladder/ bowel/ ureter
• Pain
• Fever
• Hernia (rare and late complication)
Asymptomatic (less than12 weeks size
uterus)
INVESTIGATIONS
• Ovaries should be preserved in most pre-menopausal women unless diseased or removal specifically indicated
• While doing hysterectomy for benign gynaecological conditions in pre-menopausal women, it is recommended to combine it with bilateral salpingectomy with a view to minimise the risk of subsequent development of ovarian malignancy 1,2
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
∙ Complete Blood Count
• Blood grouping & cross matching
∙ Fasting Blood Sugar & Post Prandial Blood Sugar ∙ Renal Function Test
∙ Liver Function Test
∙ Urine Routine & Microscopy
∙ Electrocardiogram
∙ X ray chest
∙ Others as indicated
FOLLOW UP
• Discharge summary with operative details
• Review for histopathology report
• Report if there is fever, bleeding or any other symptoms • Avoid lifting heavy weight for 8 weeks
• Abstinence for eight weeks
• Adequate iron and calcium & Vitamin D3 supplements
• Evaluate need for hormones in very selected patients

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ICD O72
• Call for help
• Rapid Initial Assessment – evaluate vital signs: PR, BP, RR and Temperature • Establish two IV lines with wide bore cannula (16-18 gauge)
• Draw blood for grouping and cross matching
• Start RL/ NS, infuse 1 L in 15-20 minutes *
• Give Oxygen @ 6-8 L /minute by mask,
• Insert indwelling Catheter and connect to urobag
• Check vitals and blood loss frequently – at least every 15 minutes
• Monitor input and output
• Give Inj. Oxytocin 10 IU IM (if not given after delivery)
• Start Oxytocin infusion : 20 IU in 500 ml RL/NS @ 40-60 drops per minute • IV bolus of oxytocin should NOT be given
• Check to see if placenta has been delivered.
RED FLAG SIGN:
∙ PR > 120/min
∙ Systolic BP < 100 mm Hg ∙ Tachypnea < 95%
∙ SpO2 < 95%
∙ Deterioration of
sensorium
SUPPORTIVE MANAGEMENT
• Monitoring of vitals • Measurement of
input and output • Give blood
transfusion as indicated
PLACENTA NOT DELIVERED
• Continue Oxytocin drip
• Palpate uterus
• Attempt controlled cord
traction if uterus is contracted
PLACENTA DELIVERED
• Fundal Massage of the uterus
• Inspect placenta for completeness • Explore uterus for any retained
placental bits/ membranes/ clots and evacuate
PLACENTA DELIVERED
PLACENTA NOT DELIVERED
Shift for manual removal of placenta (MRP)
Uterus well contracted but bleeding continuing
TRAUMATIC PPH
Uterus flabby
ATONIC PPH
Bimanual compression and pharmacotherapy as per details below
• Continue oxytocin and uterine massage
• Check for completeness of placenta and membranes
If bleeding continues without any apparent cause check for coagulopathy
• Explore for cervical/ vaginal/ perineal tears. Repair if present
• If bleeding persists despite repair of above, suspect inadequate repair, rupture uterus or scar dehiscence.
• Shift to OT for exploration under GA and/or laparotomy
More than 500 ml of blood loss or any amount of bleeding which causes derangement of vital parameters is PPH
* Arrange for blood / blood product at the earliest
3 ml of crystalloid solution should be used to replace every ml of blood lost during the initial part of the acute bleeding phase
MANAGEMENT OF ATONIC PPH
Inj Methyl Ergometrine 0.2 mg IM or IV slowly ∙ Contraindicated in hypertension, severe
anemia, heart disease
∙ Can be repeated after 15 minutes to a
maximum of 5 doses (1mg)
Or
Tab Misoprostol (PGE1) 800 μg Per rectal or sublingual
Inj Carboprost (PGF2 alpha) 250 μg IM Or • Contraindicated in asthma
• Can be repeated every 20 minutes to a maximum of 8 doses (2 mg)
PHARMACOTHERAPY
ANY OF THE FOLLOWING OPTIONS CAN BE USED EITHER ALONE OR COMBINATION AS PER AVAILABILITY
Bleeding not controlled Explore uterus for retained bits
Continue bimanual compression & Oxytocin infusion @10-20 units /hr Bleeding not controlled
Bleeding still not controlled
Bleeding controlled
Tranexamic Acid (1g slow IV) has recently been recommended as an adjunctive treatment for PPH to be used as early as possible irrespective of cause but definitely within three hours of delivery. It can be repeated after 30 minutes if bleeding persists. Standard treatment for PPH must continue
meanwhile 1, 2
1 The WOMAN trial, The Lancet, 2017
2 WHO update on Tranexamic Acid, 2017
• Check for coagulation defects
• If present give blood and blood
components
Intra uterine balloon tamponade using condom catheter
Surgical intervention
• Uterine compression sutures
• Systematic uterine devascularisation by doing
Uterine Ovarian Internal Iliac artery ligation
• Hysterectomy
Timely Referral to a higher centre must be considered if facilities for blood transfusion or exploration and surgical intervention are not available. Patient must be transported with I/V fluids containing oxytocin on flow and preferably with uterine/vaginal tamponade in situ.
• Aortic compression may be used as a short time measure to reduce blood loss while awaiting definitive steps. • Non- pneumatic anti-shock garment (NASG) should be used during transport if available
• Uterine artery embolization may be offered in selected patients if facilities are available
• Repeat uterine massage every 15 minutes for first two hours
• Monitor vitals every 10 minutes for 30 minutes , every 15 minutes
for next 30 minutes and every 30 minutes for next 3-6 hours or
until stable
• Continue Oxytocin infusion @5-10 units /hr
(total Oxytocin not to exceed 100 IU in 24 hours)
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

SYMPTOMS:
EXAMINATION
GPE: Specially check for pallor Abdominal examination:Check for any
suprapubic mass or lump
P/S: Inspect cervix for local abnormalities
P/V: Assess for uterine size (enlarged and/or irregular uterus)
INVESTIGATIONS
Hemoglobin Complete blood count
Thyroid function test USG
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
UTERINE FIBROIDS AND POLYPS
ICD-10-D25 & N84
Heavy menstrual/ irregular bleeding
Urinary pressure symptoms
Heaviness and pain in abdomen, dysmenorrhoea
Mass in lower abdomen
Infertility
Asymptomatic
ASYMPTOMATIC FIBROIDS <5CM DO NOT NEED TO BE TREATED FIBROIDS & POLYPS Endometrial polyps / sub mucus fibroids Hysteroscopic removal • Endometrial polyps • Select appropriate patient with submucus fibroids (selection should be based on size and proportion of the fibroid projecting into the uterine cavity) Fibroids Symptomatic Fibroid Polyps Thick pedicle Individualized management at tertiary centre Large Fibroids (Uterine size >12 weeks)
Surgical
Hysterectomy (to be avoided in young patients aged <35 years as far as possible)
Thin pedicle Polypectomy
Small Fibroids (<5cm)
Asymptomatic
Observation
Medical
Management :

Tranexamic acid
Levonorgestrel-releasing intrauterine system (if uterine cavity normal)
Progestogenic agents*
No Relief
Discuss treatment option based on age and parity
Non surgical
Uterine artery embolization
Myomectomy (younger age &/ or
low parity)
*Norethisterone (max daily dose 40 mg) OR Medroxyprogesterone acetate (max daily dose 40 mg). Any hormone should be given orally daily in divided doses for a duration of three weeks and repeated in a cyclical manner for total of 4-6 cycles of treatment
ALL THERAPUTIC OPTIONS NEED TO BE EXPLAINED TO THE PATIENT INCLUDING JUST KEEPING THE PATIENT ON OBSERVATION. ALL PATIENTS OF FIBROID UTERUS DO NOT NECESSARILY NEED HYSTERECTOMY.
COUNSELLING IS AN IMPORTANT ADJUNCT TO MANAGEMENT
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 PAEDIATRICS Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ACUTE ENCEPHALITIS SYNDROME (AES) IN CHILDREN
ICD-10-G04
SYMPTOMS
ADDITIONAL INFORMATION (HISTORY OF)
Fever, headache, vomiting, lethargy, unconsciousness
Acute onset of fever ( </= 5-7 days) with altered sensorium
and/or new onset of seizures (excluding simple febrile seizures)
• Rash, vesicles, past history of chicken pox
• Residence of child: rural/urban, endemic for cerebral malaria, any
epidemic of AES in neighborhood
• Animal contact, insect bite, dog bite
• Drug or toxin exposure: enquire for presence of any drugs at home • Recent travel
• Trauma
• Seizures
• Recent immunizations
• Recurrent episodes of encephalopathy
• Past or concurrent systemic illness
• Pre-morbid developmental/ neurological status of the child
Seizures
Abnormal posturing
Paucity of limb movements
EXAMINATION
VITAL SIGNS
• Temperature
• Pulse rate
• Respiratory rate • Blood pressure
GENERAL EXAMINATION
• Pallor
• Petechieae • Rash
• Icterus
NEUROLOGICAL EXAMINATION
• Level of consciousness by Glasgow Coma Scale (GCS)
• Abnormal posturing: decerebrate, decorticate
• Active seizures
• Cranial nerves: pupil size and reaction, doll’s eye movements, squint, facial deviation • Focal neurological deficits
• Meningeal signs
INVESTIGATIONS
ESSENTIAL
CBC, LFT, KFT, blood sugar, CECT Brain,
CSF examination* (cytology, biochemistry, culture, AFB staining, Gene Xpert), peripheral smear for malarial parasite, Rapid Malarial Antigen Test
DESIRABLE
MRI Brain, CSF PCR for Herpes simplex encephalitis, JE serology, EEG, Dengue serology and NS1 testing, HIV testing
OPTIONAL
CSF Neurovirology panel, anti-NMDA receptor antibody testing, PCR viral testing of other samples (throat swab, nasopharyngeal aspirates, stool etc), Blood Tandem Mass Spectrometry and urine gas chromatography, antinuclear antibodies
*Lumbar puncture is contra-indicated or neuroimaging must be obtained before lumbar puncture
1.Fundus: papilledema 2. Platelet count < 50,000 3. Focal neurological deficits 4. Asymmetric/unreactive pupils 5.Decerebrate/decorticate posturing
MANAGEMENT
All patients need to be admitted.
If any of the following signs are present, the child should be referred to tertiary care facility with PICU and facilities for mechanical ventilation:
• Glasgow Coma Scale < 8 • Abnormal breathing pattern • Shock not responding to fluid bolus • Decerebrate or decorticate posturing • Seizures persisting despite benzodiazepine and phenytoin
Step I: Rapid assessment and stabilization
• Establish and maintain airway: Intubate if GCS<8, impaired airway reflexes, abnormal respiratory pattern, signs of raised intracranial pressure, SpO2 <92% despite high flow oxygen and fluid refractory shock
• Ventilation, oxygenation
• Circulation: Establish IV access, take samples for
relevant investigations, fluid bolus if in circulatory failure
(20 mL/kg NS), inotropes if required
• Identify signs of cerebral herniation or raised ICP
• Temperature: treat fever and hypothermia
• Treat ongoing seizures- Benzodiazepine, followed by
phenytoin loading
Step V: Prevention/treatment of complications and rehabilitation
• Physiotherapy, posture change, prevent bed sores and exposure keratitis
• Complications: aspiration pneumonia, nosocomial infections, coagulation disturbances
• Nutrition: early feeding
• Psychological support to patient and family
Step II: History, Examination and Investigations as given above
Step III: Empirical Treatment (must be started if CSF cannot be done/ report will take time and patient sick)
• Ceftriaxone: 100 mg/kg/day in 2 divided doses X 10-14 days • Acyclovir (use in all suspected sporadic viral encephalitis):
3 mo to 12 y: 500mg/m2 8 hourly (min 21 days)

12 y: 10mg/Kg 8 hourly (14-21 days in confirmed cases)**
• Artesunate combination therapy (stop if peripheral smear and RDT are
negative) : 3mg/kg in child <20 kg, and 2.4mg/kg in child > 20kg IV/IM at 0,12 and 24 hours, followed by once daily parental/oral X 3-7 days
**If therapy was started empirically stop acyclovir, in case an alternative diagnosis is confirmed, or HSV PCR of CSF is negative on two occasions (24-48 h apart) and MRI imaging not suggestive of Herpes Simplex Encephalitis
Step IV: Supportive care and treatment
• Maintain euglycemia, hydration and control fever
• Treat raised intracranial pressure#, mild head-end elevation–15-30°
• Treat seizures##; Give anticonvulsant if: history of seizures / GCS <8 / child has features of raised ICP • Steroids: Pulse steroids (methylprednisolone) to be given in children with suspected acute disseminated encephalomyelitis or autoimmune encephalitis #Management of raised intracranial pressure • Intubate if: GCS <8 / evidence of herniation / irregular respirations and inability to maintain airway • Signs of impending herniation: patient to be hyperventilated to a target PaCO2 of 30-35 mmHg • Initial bolus of Mannitol(0.25 g/kg), then 0.25 g/kg q 6 h as per requirement, up to 48 hours. • In the presence of hypotension, hypovolemia, and renal failure: hypertonic (3%) saline (preferable to mannitol) 0.1–1 mL/kg/hr by infusion; serum sodium to be targeted to 145-155 meq/L • Adequate sedation and analgesia • Avoid noxious stimuli • Administer nebulized lignocaine prior to endotracheal tube suctioning ##Treatment of seizures 1st Line: IV Lorazepam 0.1mg/kg or Midazolam 0.2 mg/kg orDiazepam 0.3 mg/kg). If no IV access: IM Midazolam 0.2 mg/kg 2nd Line: Inj. Phenytoin 20 mg/kg (in Normal saline 1mg/kg/min) If seizures still persist: Refractory status: Transfer to PICU -> midazolam infusion (1-18 microgram/kg/min)
If ICU facilities not available: sodium valproate (20 mg/kg) or levetiracetam (20-40 mg/kg) or phenobarbitone (20mg/kg)
DISCHARGE CRITERIA
Hemodynamically stable
Improvement in consciousness
Afebrile
Has started eating and drinking orally
Seizures have subsided
Parents have been explained the supportive care and physiotherapy to be continued at home
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
REFERENCES

World Health Oraganisation. Acute Encephalitis Syndrome. Japanese encephalitis surveillance standards.January 2006. From WHO-recommended standards for surveillance of selected vaccine-preventable diseases. WHO/V&B/03.01. Available from: http://www. who. int/vaccines-documents/ DocsPDF06/843.pdf
National Program for Prevention and Control of Japanese Encephalitis/Acute Encephalitis Syndrome 2014. Government of India Ministry of Health & Family Welfare Directorate General of Health Services National Vector Borne Disease Control Programme.
Sharma S, Mishra D, Aneja S, Kumar R, Jain A, Vashishtha VM. Consensus guidelines on evaluation and management of suspected acute viral encephalitis in children in India. Indian Pediatr. Nov 2012;49(11):897-910. 4. Sankhyan N, Vykunta Raju KN, Sharma S, Gulati S. Management of raised intracranial pressure. Indian J Pediatr. 2010 Dec;77(12):1409-16.
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ACUTE DIARRHEA
ASK FOR
ICD-10-R19.7
SKIN PINCH TEST
• Locate the area on the child’s abdomen halfway between the umbilicus and the side of the abdomen.
• Use thumb and first finger to pinch and not finger tips.
• The fold of the skin should be in a line up and down the child’s body.
• Firmly pick up all layers of the skin and tissue under them.
• Pinch the skin for one second and then release it. Look to see if the skin pinch goes back:
• Very slowly (longer than 2 seconds) • Slowly (skin stays up even for a
brief instant)
• Immediately (normal)
REFER TO HOSPITAL
• Severe malnutrition/ HIV
• Severe dehydration
• Hypernatremic (Na >145mmol/L) /
hyponatremic dehydration (Na
<135 mmol/L) • Dysentery with age <1 yr/ measles in past 6 weeks/ dehydration/ sick • Dysentery with no improvement on antibiotics • Persistent diarrhea with dehydration • Persistent diarrhea with serious systemic infection such as pneumonia, sepsis, infants <4 months of age, or when there is no improvement with treatment over 5 days DIARRHEA IS • >3 loose or watery stools/ day
• Acute Diarrhea <14 days • Persistent diarrhea >14 days
• Dysentery – blood in stools
• Duration
• Blood in stool
• Vomiting, fever, cough, recent
measles, HIV status (if known) • Immunization status and pre
illness feeding practices
• Fluids/ food/ drugs and other
remedies taken during illness
EXAMINATION
• General condition of child • Nutritional status (weight/ weight for height / MUAC)
• Classify malnutrition if any • Signs of dehydration &
classify dehydration
MANAGEMENT
Not enough signs to classify some or severe dehydration
CLASSIFY DEHYDRATION
2 of following:
a) Restless , irritable
b) Sunken eyes
c) Drinks eagerly, thirsty
d) Skin pinch – goes back very slowly
2 of following:
a) Lethargy / unconscious
b) Sunken eyes
c) Not able to drink/ drinking poorly d) Skin pinch – goes back slowly
• FluidsNO DEHYDRATION: PLAN A
• Give extra fluids (as much as child will take) until diarrhea stops.
• Use WHO ORS after each loose stool (in addition to usual fluid intake)
•Upto2yrs→50-100ml
•2yrsormore→100-200ml
• On ORS packet check whether
200ml or 1 litre of clean water is
needed
• Frequent small sips with spoon or
cup.
• If child vomits, wait 10 minutes
then continue slowly.
• Homemade fluids- salted rice
water, salted yogurt drink, vegetable or chicken soup with salt and clean water, unsweetened fresh fruit juice and coconut water
• Unsuitable fluids – carbonated beverages, commercial fruit juice, sweetened tea & coffee, other medicinal teas / infusions.
• Zinc supplement (Zinc sulphate/ carbonate / acetate)
• 2-6 months → 10mg/day x 2 weeks
• >6 months → 20mg/day x 2 weeks • Counsel Mother/ Attender
• Feeding advise
• Infants on breast feed, to continue more frequent breast feeding than usual.
• Those not on breast feed to continue their usual milk feed/ formula at least once in 3 hours.
• Give age appropriate foods to >6 months old based on their pre illness feeding pattern
• Danger signs (return immediately)
• Passing many watery stools
• Repeated vomitings / very thirsty • Eating / drinking poorly
• Develops fever / blood in stools
• Follow up in 5 days if no improvement
SOME DEHYDRATION: PLAN B
• Manage in clinic /daycare facility with recommended amount of ORS (75ml /kg) over 4 hour period
• If weight is not known
• After 4 hours reassess the child, classify dehydration and select appropriate plan (A /B/C)
• Give extra fluids, zinc supplement, feeding advise and counselling regarding danger signs* as in plan A
• Follow up in 5 days if no improvement
AGE
< 4 4 -11 12 -23 2 – 4 5-14 15 years months months months years years or older WEIGHT <5kg 5 – 7.9 8 – 10.9 11 – 16 – 30 kg or kg kg 15.9 kg 29.9 kg more IN mL 200 – 400 – 600 – 800 – 1200 – 2200 – 400 600 800 1200 2200 4000 SEVERE DEHYDRATION: PLAN C • Urgent referral to hospital • Mother to continue rehydration by giving frequent sips of ORS during transport or use NG tube when possible in patients with poor drinking NO CAN YOU GIVE INTRAVENOUS (IV) FLUIDS IMMEDIATELY? NO • Start IV fluid immediately • Ideal fluid is Ringer lactate solution / Normal saline (DNS in malnourished) • Ifchildcandrink,giveORSbymouthwhile the drip is set up • Assessheartrate/respiratoryrate/BP/CFT/ consciousness and recognize early shock • Referforhospitalization • Ifprevalanceofcholera– Doxycycline single dose 300mg or Tetracycline 12.5mg/kg 4 times a day x 3 days. For young children Erythromycin 12.5mg/kg 4timesadayx3days • Associatedvomitings– Ondanstetron 0.15 mg/kg/dose IV/oral in addition to rehydration therapy • Reassess every 15-30 minutes till a strong radial pulse is present and then every hour If hydration status is not improving, give IV drip more rapidly • After 6 hours (infants) and 3 hours (older patients) – evaluate for dehydration and choose the appropriate plan (A, B, or C) to continue treatment • GiveORS(about5ml/kg/hour)assoonas the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children) • Observefor6hoursafterthechildhasbeen fully rehydrated. • In hypernatremic and hyponatremic dehydration child appears relatively less ill / more ill respectively and needs to be referred for hospitalization DISCHARGE CRITERIA • Suffcientrehydration(indicatedbywtgain &/or clinical status) • IVfluidsnolongerneeded • Oralintake=/>losses
• Medicalf/uavailable
AGE
FIRST GIVE THEN GIVE 70 30 ML/KG IN ML/KG IN
Infant (< 12 months)
1 hour 5 hours
Older 30 minutes 2.5 hours
PATIENT EDUCATION
• Danger signs*
• Hygiene practices
• Hand washing , proper disposal of excreta • Safe drinking water
• Appropriate feeding practices
• Vaccination as per IAP guidelines
INVESTIGATIONS
• Some dehydration: Preferable Tests- electrolytes
• Severe dehydration:
Essential tests- CBC, electrolytes Preferable Tests- Renal Function Tests, VBG
• In suspected cholera cases:
Preferable tests- stool for hanging drop and stool culture
• Dysentery: (no response to antibiotic in 2 days) Preferable test- stool culture & stool routine for trophozoites of Ameoba
• Persistent diarrhea:
Preferable test- stool routine microscopy, urine routine microscopy, urine culture , sepsis screen
WHEN CONSIDERING ALTERNATIVE DIAGNOSIS OF PERSISTENT DIARRHEA AND DYSENTRY
PERSISTENT DIARRHEA
• Appropriate fluids to prevent or treat dehydration • Nutrition:
• If breastfeeding, give more frequent, longer breastfeeds, day and night.
• Other milk: replace with increased breastfeeding, or with fermented milk
products, such as yogurt, or half the milk with nutrient-rich semi-solid food. • For other foods, follow feeding recommendations for the child’s age: give
small, frequent meals (at least 6 times a day), and avoid very sweet foods or
drinks.
• Zinc for 14 days
• Supplement vitamins / minerals
• Antimicrobial to treat diagnosed infection
A) Intestinal infection:
• If blood in stool: Treat like dysentery
• If stool routine suggestive of Amoebiasis: Treat for it
• If stool suggestive of cyst/ Trophozoite of Giardia: Give Metronidazole
5mg/kg/dose x 8hrly x 5 -7 days
B) Treat Non intestinal such as UTI / Otitis Media
• Follow up in 5 days
• Refer to hospital (See box)
DYSENTERY
• Treat dehydration according to assessment.
• Ciprofloxacin 15mg/kg twice a day and reassess
after 2 days.
Improvement: 3 days of treatment
• No improvement → Cefixime 10 mg//kg/d, 2 div
doses. Reassess after 2 days. If better complete 3 -5 days of treatment.
• If stool routine positive for Ameobiasis : Metronidazole 10mg/kg/dose 8 hourly x 7 days (10 days in severe cases)
• Refer to hospital (See box)
REFERENCES

IMCI (WHO) module on Diarrhea 2014.
WHO Treatment for Diarrhea – A manual for physicians and other senior health workers 2005. 3. WHO GLOBAL TASK FORCE ON CHOLERA CONTROL 2010.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
WHEN TO SUSPECT?
TREATMENT OF PROBABLE DENGUE WITHOUT WARNING SIGNS
• Symptomatic ambulatory treatment
• Paracetamol for fever: avoid NSAIDs • Daily monitoring: clinical, PCV,
platelets
WARNING SIGNS
• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation – pleural effusion,
ascites.
• Mucosal bleed – malena, epistaxis, gum bleed
• Liver enlargement > 2 cms
• Shock (DSS) – weak rapid pulse, pulse
pressure < 20mm Hg hypotension, cold clammy skin, restlessness.
REASONS FOR REFERRAL
• Cold extremities, restlessness
• Acute abdominal pain
• Decreased urine output • Bleeding and
hemoconcentration • Rising PCV &
thrombocytopenia without clinical symptopms
DENGUE FEVER
ICD-10-A90
SYMPTOMS
Fever and two of the following criteria:
Nausea
Vomiting
Rash
Myalgia
Headache
Retro orbital pain
Arthralgia
Hemorrhagic manifestations
Live in / travel to dengue endemic area
Dengue without warning signs
Dengue with warning signs
Severe dengue
ASSESSMENT
SEVERE DENGUE
• Fluid accumulation with respiratory distress
• Severe bleeding
• Impaired consciousness
INVESTIGATIONS
ESSENTIAL
• Hb, TLC, DLC, Platelets, PCV • Positive tourniquet test
• NS1 antigen (ELISA method)
DESIRABLE
• Chest X-ray
• LFT, RFT,
• CPK, albumin • USG abdomen • Dengue IgM
• Echocardiography OPTIONAL
• PCR – dengue
• CVP monitoring
• USG guided measurement of collapsibility of
IVC for monitoring hypovolemia
SHOCK
COMPENSATED SHOCK
(tachypnea, tachycardia, normotensive)
No Improvement
RL 10-15ml/kg/hr Assessment at second hour
No Improvement RL 15ml/kg/hr
Assessment at third hour Colloids 10ml/kg/hr
No Improvement
Look for anemia, acidosis, myocardial dysfunction and treat accordingly
PACKED RED CELLS
• Loss of blood (overt blood) 10% or more of total blood volume.
• Refractory shock • Fluid overload
No Improvement
Improvement
Gradually decrease infusion rate
10ml/kg/hr 1-2 hr 7ml/kg for 2-3 hrs 5ml/kg for 2-4 hrs 3ml/kg for 2-4 hrs Stop at 48 hours
Assess airway, breathing, circulation & start oxygen inhalation
HYPOTENSIVE SHOCK
(tachypnea, tachycardia, hypotension, peripheral pulses not palpable)
20 ml/ kg crystalloid or colloid in 15 minutes
Ringer’s Lactate/ NS 10 ml/kg/hr
Assess after every hour by checking HR, RR, BP, CVP and PCV
Assessment of Shock (monitor HR, RR, BP, PCV and CVP)
Improvement RL 5-7ml/kg/ 1-2hr
Further Improvement
RL 3-5ml/kg/hr
Continue IV fluids till stable for 24 hours
Once stable, observe for 24 hours, then discharge if the discharge criteria is fulfilled
PCV Increased Colloids 10-20ml/kg
PCV Decreased Blood Transfusion
Assessment
No Improvement
Improvement
Look for blood loss, acidosis cardiac dysfunction and treat accordingly
In case of shock, start bolus and arrange for urgent referral with continuous monitoring by a health professional to facilities with a PICU.
INDICATION FOR PLATELET TRANSFUSION & PACKED RED CELLS
PLATELETS
• Prolonged shock
• Prophylactic platelet transfusion (PLT <10.000/cumm) • Systemic massive bleeding
FRESH FROZEN PLASMA/ CRYOPRECIPITATE Coagulopathy with bleeding
DISCHARGE CRITERIA (ALL OF THE FOLLOWING CONDITIONS MUST BE PRESENT)
CLINICAL
• No fever for 48 hours
• Improvement in clinical status (check for general well-being, appetite, haemodynamic status,
urine output, respiratory distress)
LABORATORY
• Increasing trend of platelet count
• Stable haematocrit without intravenous fluids
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
FEVER IS
Fever duration
FEVER IN CHILDREN
ICD-10-R50
Core (rectal) temperature ≥ 38.0oC (100.4oF) or axillary temperature > 37.5oC (100.4oF).
EXAMINATION
Vital signs: Temp, HR, RR, BP, CFT
CLUES TO A SPECIFIC DIAGNOSIS
Fever + respiratory symptoms:
• Cough, runny nose: URTI
• Membrane over tonsils/pharynx:
Diphtheria
• Paroxysmal cough: Pertussis like illness • Barking cough:
Laryngotracheobronchitis/ croup
Fever + rash
• Red maculopapular rash: Measles, Rubella, Dengue.
• Fine generalized maculopapular rash with systemic dysfunction/shock: Meningococcemia.
• Itchy erythematous macules evolving to clear vesicles: Varicella
Fever + other symptoms:
• Parotid gland swelling: Mumps
• Arthritis: Consider Chikungunya, acute
rheumatic fever, JIA
• Strawberry red tongue, skin peeling,
lymphadenopathy, conjunctival injection: Kawasaki disease
Appearance: Sick, toxic, lethargic, irritable, inconsolable, dehydrated
Localizing symptoms of: RTI, UTI, GI tract infection, CNS infection
General Examination:
• Ear, nose, throat
• Rash (petechieae, macules, papules, vesicles,
nodules, polymorphic)
• Lymphadenopathy
• Skin (pustules, pyoderma, impetigo,
cellulitis)
• Joints
• Genitalia (for erythema, tenderness, edema) • Bones
WHAT TO ASK?
Rash, joint symptoms, skin/ soft tissue swelling or redness
STEP1
INITIAL ASSESSMENT AND STABILIZATION
Manage urgent issues
• Decrease body temperature with Paracetamol (15mg/kg by any route) and/or hydrotherapy.
• Manage any life-threatening issue.
• Consider first dose antibiotic in suspected meningitis, severe pneumonia, or severe malnutrition.
• Consider anti-malarial in suspected malaria
ANA: Anti-nuclear antibody BP: Blood pressure
CFT: Capillary filling time CMV: Cytomegalovirus
CNS: Central nervous system
CSF: Cerebro-spinal fluid
CT: Computed tomography
DLC: Differential leukocyte count CVS: Cardiovascular system
GI: Gastro-intestinal
HR: Heart rate
JIA: Juvenile idiopathic arthritis PET: Positron emission tomography PS: Peripheral smear
RR: Respiratory rate
RTI: Respiratory tract infection
TLC: Total leukocyte count
URTI: Upper respiratory tract infection UTI: Urinary tract infection
Vaccination within 24 hours, drug/ toxin exposure
Family/ neighbourhood history of similar illness
STEP2
CONSIDER HOSPITALIZATION FOR OBSERVATION/
MANAGEMENT IN
• All neonates
• Young infants with toxic
appearance.
• Severe malnutrition, toxic
appearance, inability to feed, lethargy, irritability, dehydration, etc.
• >14 days illness without diagnosis.
• Any reason deemed by the treating physician.
Systemic Examination
• Chest auscultation, abdominal palpation, CNS, CVS
INVESTIGATION OF THE FEBRILE CHILD
(Consider if one or more of the following are warranted. Perform investigations only where result impacts management)
<7 DAYS FEVER ALONE ESSENTIAL: If fever <72 hours and child not looking sick: No investigations If fever >72 hours, consider: TLC, DLC, P.S for leukocyte
morphology, malarial parasite & platelet count
DESIRABLE: Rapid antigen test for malaria, NS1 antigen and dengue IgM antibody, blood culture
OPTIONAL: C reactive protein, procalcitonin
<7 DAYS AND LOCALIZING SYMPTOMS PRESENT
ESSENTIAL: As given in the first box
DESIRABLE: As given in the first box + consider: (Clean-catch) urine microscopy & culture, chest Xray, CSF analysis
OPTIONAL: As given in the first box + consider: ultrasonography, throat/ pharyngeal swab, pus aspiration.
<7 DAYS AND NON SPECIFIC SYMPTOMS
ESSENTIAL: As given before
DESIRABLE: As given before. Additionally consider: serology for specific viral infection, rapid antigen test for malaria, NS1 antigen and dengue IgM antibody, blood culture, serology for scrub typhus
OPTIONAL: As given before
CONSIDER REFERRAL TO TERTIARY CARE CENTRE
(after appropriate stabilization and/or initial management) :
• Need for intensive care • Complex multi-system
disease.
• Confirmed
complications of the primary illness

7 DAYS AND FEVER ALONE OR WITHOUT LOCALIZING SYMPTOMS
ESSENTIAL: All mentioned in Essential & Desirable list in the prior boxes. Additionally consider Widal test.
DESIRABLE: Consider Mantoux test, ultrasonography
OPTIONAL: As given before. Additionally consider: Ultrasonography of abdomen, chest, pericardium, joint(s), abscess, lymph node clusters, parotid gland etc, for microscopy, Xpert MTB RIF assay, Mycobacterial culture. Consider: bone marrow, ANA-profile, HIV serology, echocardiography, CT PET scan.
STEP4
EMPIRIC MANAGEMENT
• Consider based on likely diagnosis, sickness status, and availability of investigation facilities.
• Empiric treatment should be tailored based on subsequently available investigation reports & local antimicrobial sensitivity.
• Anti tuberculosis treatment (ATT) should not be started on empiric basis except in suspected TBM
7 DAYS AND LOCALIZING SYMPTOMS PRESENT
ESSENTIAL: All investigations mentioned in the prior boxes
DESIRABLE: All investigations mentioned in the prior boxes. Additionally consider: serology for Brucella, CMV, Herpes, Japanese encephalitis. CT scan in deep seated abscess or lung abscess, Bone marrow examination, ANA profile, HIV serology, PET scan.
OPTIONAL: All investigations mentioned in the prior boxes
MANAGEMENT
STEP3
STEP5
CONSIDER DISCHARGE WHEN
• Afebrile > 48 hours or fever is showing defervescence
• Feeding well
• Presenting symptoms (in
addition to fever)
resolved/resolving
• Physician is satisfied that
further care can be continued on ambulatory basis
• Duration of i.v antibiotic therapy is completed
ABBREVIATIONS
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
REFERENCES

World Health Organization. Integrated Management of Childhood Illness: distance learning course. http://apps.who.int/iris/bitstream/handle/10665/104772/9789241506823_Module-5_eng.pdf;jsessionid=942F89F89671BA396EC7F46C9B5C1158?sequence=7
Mahajan P, et al. Consensus Guidelines on Evaluation and Management of the Febrile Child Presenting to the Emergency Department in India. Indian Pediatr 2017; 54: 652-60. 3. World Health Organization 2015. Government of India National Guidelines for Clinical Management of Dengue Fever.
Kliegman RM (ed). Nelson Textbook of Pediatrics 20th edition, 2016.
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
Sepsis
to be suspected: in children with any infections (fever with or without rashes/ pneumonia/ diarrhoea) and they are at risk of life threatening organ dysfunction
ICD-A41.9, R65.21
WHEN TO SUSPECT (2-59 MONTHS)?
CHECK FOR HISTORY OF
SEPSIS AND SEPTIC SHOCK IN CHILDREN
Poor Feeding
Lethargy
Decreased responsiveness
Unconsciousness
Cold/ bluish peripheries
Rapid or shallow breathing
Chest
in drawing
Stridor
Excessive vomiting
Decreased urine output
Convulsions
Stiff neck
Prior treatment
Previous recurrent infections
Prior hospitalisation
Chronic systemic illness (congenital or acquired)
Immunization (age appropriate)
EXAMINATION
GENERAL PHYSICAL EXAMINATION VITAL SIGNS SYSTEMIC EXAMINATION
Pulse volume (High volume as well as low volume/feeble pulse)
Heart rate and respiratory rate (outside the age range)
Respiratory: Signs of respiratory distress – retraction, nasal flaring, grunting ,crepitation on auscultation CVS: Murmur, gallop rhythm
Per abdomen: Abdominal distension CNS: AVPU scale, signs of meningitis, seizures Skin: Rashes Bone & joints: Swelling, redness, tenderness Lethargy Petechial rash Decreased alertness Mucosal bleeding Activity Rapid breathing Capillary refilling time > 3 seconds Pulse oximetry (saturation <95%) Pallor Chest in drawing Cyanosis Cold peripheries Blood pressure (Systolic blood Pressure < 70 in <1 year)

1 year child if systolic BP < 70+ Age (yrs) x2) or ( lower than age range)
Skin mottling
Essential – Complete blood counts, peripheral blood film, urine routine, blood sugar, CRP, serum electrolytes, renal function test, liver function test
Assess nutritional status
SIGNS OF SEVERE DEHYDRATION
Diarrhoea plus any two of these: Lethargy or unconscious, not able to drink or drinks poorly, Sunken eyes, skin pinch goes back very slowly
INVESTIGATIONS- (Based on symptoms and available facility)
Desirable – Blood culture, blood gas, relevant cultures (based on symptoms), chest X-ray, specific illness- Malaria – rapid malarial antigen test, Dengue- dengue NS1, IgM, CSF study
MANAGEMENT
DIAGNOSTIC ALGORITHM
CHILD (2-59 MONTHS OF AGE WITH FEBRILE ILLNESS (WITH WARNING SIGNS)
Optional- PCT , USG to guide the fluids
GOOD PERIPHERAL PERFUSION
Admit or initiate treatment as per IMNCI guidelines2
**If there is improvement after 1st bolus and history of diarrhea present then:
Give 70 ml/kg over 5 hours in infants and over 2 1⁄2 hours in a child with hypovolemic shock. Give additional fluids if losses continue.
Start maintenance fluid in case of other illness
Antibiotics

>3 months Inj Ceftriaxone 100mg/kg/day ( 2 divided doses)
❤ month Inj Cefotaxime 200mg/kg (divided 6-8hrly), Inj Gentamicin 5-7.5 mg/kg single dose /day 3. If soft tissue infection: consider Inj Cloxacillin 200mg/kg divided 6 hourly or Inj Amoxicillin- Clavulanic acid 30 mg/kg/dose 8hrly) Inj Adrenaline- 0.3x body weight in mg in 50 ml NS or 5% dextrose at 1 ml/hr will give 0.1 microgram/kg/min POOR PERIPHERAL PERFUSION** With fast pulse, cold peripheries, poor pulse volume, CRT >3 seconds (Fast pulse: HR> 180 in < 12 month old child, HR >120 in >12 month old child)
Admit, initiate treatment, refer to centre with facility of ICU, ventilation, 24 hour monitoring (if required)
Start O2 with face mask @ 4-6 lit/min, or hood @8-10 lit if not available nasal prongs 1-2 lit/min to main- tain SpO2 >95%, Insert two IV cannulas, give first dose of antibiotics within first one hour
Give 20 ml/kg of normal saline fluid bolus over 20- 30 minutes.
Reassess for decreases in heart rate, improvement in pulse volume and warm peripheries
If no improvement
Repeat bolus of 20 ml/kg over 30 minutes, with careful monitoring for hepatomegaly, oxygen saturation, crepitation’s in chest (if any of above appears then stop fluids)
If shock persists
Start Inj Adrenaline infusion
@0.1 microgram/kg/min and refer to higher centre

For severe acute malnutrition – consider SAM STW #For suspected Dengue follow Dengue Fever STW

When to refer
• Shock does not improve after 2nd fluid bolus
• Signs of fluid overload
• No facility for continuous
monitoring.
• Before referral counsel the parents
and inform referring facility
When to Suspect Cardiac Failure
• History of underlying heart disease
• History of forehead sweating/ suck rest suck cycle • Murmur
• Hepatomegaly or basilar crept
If it is suspected be careful in giving fluid bolus
Complications
• Respiratory failure ( excessive increase in the respiratory rates and inability to maintain saturation> 94% with oxygen) -non-invasive (CPAP/BIPAP) or invasive ventilation
• Congestive heart failure- Dobutamine / Milrinone infusion and Furosemide
• Infections on other sites- explore and treat accordingly
DISCHARGE CRITERIA
Completion of antibiotics as per culture sensitivity
Afebrile for 48 hours
Vitals within normal limit for age
Good oral intake
Adequate urine output >1ml/kg/hr
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
*DISABILITY (AVPU SCALE)
A Is the child Alert? If not; V Is the child responding to Voice? If not; P Is the child responding to Pain?; U The child who is Unresponsive to voice (or being shaken) AND to pain is Unconscious *Anything below A should be classify as danger sign
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
SEVERE ACUTE MALNUTRITION WITH COMPLICATIONS
ICD-10-E43
COMMON PRESENTATION
• Faulty feeding
• Not exclusively breastfed
for 6 months
• Bottle feeding
• Delayed/Inadequate
complementary feeding • Poor appetite
• Not gaining weight
• Lethargic
• Disinterested in surroundings • Delayed development
Additional symptoms of complications
• Loose motions
• Jaundice
• Seizures
Inter-current infections: • Pneumonia
• Diarrhea
• Sepsis
• Skin infections
• Severe dehydration
• Untreated tuberculosis • HIV
• Social challenges
DIAGNOSTIC CRITERIA FOR SAM & MAM
0-6 months
• Consider SAM if MUAC <11.0 cm
6-59 months
• Consider SAM if MUAC <11.5 cm or WHZ <-3 SD or bilateral pitting oedema
• Consider MAM if MUAC is between 11.5- 12.4 cm or WHZ is between -2 to -3 SD

5 years
• Consider SAM if BMI ≤ 3SD (severe thinness)
•ConsiderMAMif BMI≤2SD (thinness)
WHEN TO SUSPECT?
EXAMINE FOR
• Vital signs: PR, RR, CRT
• Lethargy/ irritability
• Loss of subcutaneous fat
• Muscle wasting
• Pallor
• Signs of Vitamin B, K and A deficiencies • Respiratory distress
• Dehydration
TRIAGE
SAM + GOOD APPETITE + NO MEDICAL COMPLICATION
Home based treatment + oral amoxicillin 50 mg/kg/dose twice a day for 7-10 days
SAM + COMPLICATIONS/ POOR APPETITE/ FAILED HOME TREATMENT
Hospitalize
INVESTIGATIONS
ESSENTIAL
Hemogram, RBS, LFT, KFT, Chest X-Ray, RDT-HIV, Gastric aspirate for CBNAAT/AFB
DESIRABLE
ECG, Stool pH, Stool microscopic, Urine culture, Serum electrolytes (Na, K, Cal), Serum B12, Serum Folate levels
OPTIONAL
Blood Culture, Blood gases, Ultrasound (inferior vena cava to ascending aorta ratio)
TREATMENT
A. STABILISATION PHASE: Monitor vitals, urine frequency, stool/vomitus volumes
INTAKE: IVF (DNS) 4 ml/kg/hr for 2-3 days with early/concomitant initiation of oral feeds (130 ml/kg/day)
CONDITION PLACE OF TREATMENT TREATMENT
Facilities for supportive INFECTIONS monitoring,
(empirically) investigations and IVF
• Inj.. Ampicillin – 50 mg/kg/iv or im X 6hrly Plus inj. Gentamicin- 7.5 mg/kg iv or im, OD for 7-10 days • If no response within 48 hrs or critically ill give inj. Ceftriaxone 50 mg/kg, OD for 7-10 days
• When accepting orally, switch to oral amoxicillin 40-45 mg/kg/dose twice a day for 7 days
• If prolonged diarrhea (>7 days): Metronidazole 10-12 mg/kg, 8 hrly for 7-10 days (inj.ectable or oral)
HYPOGLYCEMIA
(RBS <54mg/dL) Facilities for supportive monitoring, investigations and IVF Conscious: 50 ml of 10% Dextrose or 1 tsf sugar in 3 tsf water orally Transfer to intensive care facility to manage shock Unconscious: 5 ml/kg of 10% Dextrose IV NO IMPROVEMENT treat as shock HYPOTHERMIA (<35.5 oC or 96 oF) Facilities for supportive monitoring, investigations and IVF. Plus warmer Skin to skin care with mother (infants) Warming under warmer, incandescent lamp or warmer Intensive care facility to manage shock NO IMPROVEMENT treat as shock SEVERE DEHYDRATION Facilities for supportive monitoring, investigations and IVF Conscious: 50 ml of 10% Dextrose or 1 tsf sugar in 3 tsf water orally Transfer to intensive care facility to manage shock Unconscious: 5 ml/kg of 10% Dextrose IV NO IMPROVEMENT treat as shock ELECTROLYTE IMBALANCE (emperically) Facilities for supportive monitoring, investigations and IVF Potassium: 3-4 mmol/kg/D, orally for 2 wks Magnesium: 0.4-0.6 mmol/kg/D1 IM followed by oral for 2 wks ANEMIA Facilities for supportive monitoring, investigations and IVF Whole blood /PRBC transfusion (10 ml/kg over 3 hrs) : if Hb <4 gm/dL or Hb 4-6.5 gm/dL with respiratory distress with close monitoring and hy. Furosemide (1 mg/kg) at start of transfusion B. REHABILITATION PHASE (Transfer to NRC when child meets criteria for discharge* & accepts home available foods) FEEDING Place of treatment: Facilities for supportive monitoring Treatment: a. 6 months and above: F75 at least 5 times/day gradually increasing to give 150-200 kCal/kg/day (usually 2-3 days) then switch to F100 for next 5-7days with introduction of home available food b. Below 6 months: same as above with return to exclusive breastfeeding where ever possible ELECTROLYTES Place of treatment: Facilities for supportive monitoring Treatment: a. Zinc: 2 mg/kg/day X 2wks orally b. Copper: 0.3 mg/kg/day X 2 wks orally c. Iron: 3 mg/kg/day once weight gain has started orally for 6 weeks VITAMINS Place of treatment: Nutritional rehabilitation center (NRC) Treatment: a. Vitamin A: >12 months- 2 lac iu, 6-12 months: 1 lac iu, <6 months: 0.5 lac iu if food not fortified b. Vitamin D, A, B Complex: RDA *CRITERIA FOR DISCHARGE FROM HOSPITAL TO OUTPATIENT CARE: Clinically well and alert; no or resolving medical complications; no or resolving oedema (if present); satisfactory oral intake has a good appetite (taking at least 75% of target calorie intake of 150- 200 kcal/kg/day & 0-6 months old have weight gain of 3-5 gm/kg/day for three days). PRIMARY FAILURE OF TREATMENT: (a.) Failure to regain appetite by day 4 (b.) Failure to lose oedema by day 4 (c.) Oedema still present Day 10 (d.) Failure to gain at least 5g/Kg/day for 3 consecutive days on catchup diet. Look for unrecognized congenital abnormality, inborn errors of metabolism, immune deficiency, other major organ dysfunction, and malignancy. APPETITE TEST: Passed if, a child not fed for last 2 hours, when fed by mother in a quiet place consumes in 1 hour: • 7-12 months: of ≥ 25 ml/kg of F100 • > 12 months: of locally prepared ready to eat food **
AMOUNT TO BE GIVEN: 15 gms or more if < 4 kg; 25 gms or more if 4 – 7 kg; 35 gms or more if 7-10 kg
**[ Mixture of Roasted groundnut 1000 gm , Milk powder 1200 gms, Sugar 1120 gms, Coconut oil 600 gms. To be kept refrigerated for not more than 1 week.]
HOW TO PREPARE F75 AND F100
F75
F100
FRESH WHOLE CREAM MILK
300 ml
900 ml
SUGAR
100 gm
75 gm
VEGETABLE OIL
20 ml
20 ml
ADD WATER TO GET TOTAL VOLUME OF
1 Litre
1 Litre
ABBREVIATIONS
WHZ: Weight for Height Z-score MUAC: Mid-upper Arm Circumference MAM: Moderate Acute Malnutrition SAM: Severe Acute Malnutrition SD: Standard Deviation (from median) BMI: Body Mass Index
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
REFERENCES

The WHO growth standards. Available at http://www.who.int/childgrowth/standards/en/
Management of severe acute malnutrition in children 6–59 months of age with oedema. Available at http://www.who.int/elena/titles/oedema_sam/en/ 3. Operational guidelines on Facility Based Management of Children with Severe Acute Malnutrition.Available at
http://nhm.gov.in/nrhm-components/rmnch-a/child-health-immunization/child-health/guidelines.html
KumarR,KumarP,AnejaS,KumarV,RehanHS.SafetyandEfficacyofLow-osmolarityORSvs.ModifiedRehydrationSolutionforMalnourishedChildren
for Treatment of Children with Severe Acute Malnutrition and Diarrhea: A Randomized Controlled Trial. J Trop Pediatr. 2015 Dec;61(6):435-41.
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

Department of Health Research
Ministry of Health and Family Welfare, Government of India
ICD10-J18.9
GENERAL DANGER SIGNS
Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition.
SUSPICION OF FOREIGN BODY ASPIRATION
Sudden onset choking and breathlessness.
Standard Treatment Workflow (STW) for the Management of
SEVERE PNEUMONIA IN CHILDREN
ADDITIONAL INFORMATION
CHECK FOR HISTORY OF
Cough, cold, with or without fever, difficulty in breathing (that includes fast breathing and chest indrawing) of less than 2 weeks duration.
Similar illness in past, if yes, history of improvement with nebulized medications to consider asthma.
PRESENTING SYMPTOMS /WHEN TO SUSPECT?
Asthma/allergy in family.
Influenza like illness in family over past 2 weeks: to consider treatment for influenza.
Immunization (age appropriate specifically vaccination included in national schedule and Pneumococcus, Influenza).
EXAMINATION FOR FOLLOWING SIGNS
Chest indrawing, state of alertness, cyanosis, clubbing, stridor, grunting.
VITAL SIGNS
Respiratory rates, heart rate, temperature, capillary refill time, pulse oximetry.
NUTRITIONAL STATUS
Specifically for defining Severe Acute Malnutrition (SAM).
AUSCULTATION OF CHEST
Breath sounds, crepitation, rhonchi.
DIAGNOSTIC ALGORITHM
Cough and cold, no breathing difficulty.
NO PNEUMONIA
Home care advice.
Child age 2–59 months with cough and/or difficult breathing.
RED FLAG SIGNS
Irregular or gasping respiration, cold extremities, altered sensorium, cyanosis.
Fast breathing (2-12 months >50; 1-5 years>40; >5 years >20 ) and/or chest indrawing oxygen saturation>92%.
PNEUMONIA
Ambulatory treatment with oral Amoxicillin and follow up.
Fast breathing (2-12months>50; 1-5 years>40 ;>5 years >20 ) and/or chest indrawing with any of the general danger signs (not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition).
No red flag signs
Admit or refer to a facility with following: oxygen by mask or hood, pulse oxymeter, IV fluids, oxygen, clinical supervision, X ray film (desirable).
Red flag signs positive
Admit or refer to facility with following: Appropriate: ventilation facility, ICU, round the clock monitoring
If plan to refer: Give first dose of antibiotics, arrange transport and inform to the referral centre.
SEVERE PNEUMONIA
INVESTIGATIONS
ESSENTIAL:
Hemogram, random blood sugar, CRP, chest X-ray. DESIRABLE: Blood culture, pleural tap, serum electrolytes, renal and liver function tests. OPTIONAL: ABG, lung ultrasound, PCT, tracheal aspirate (gram stain with culture), bronchoscopy/BAL, microbiology culture, investigations for atypical organisms, PCR for viral etiology.
TREATMENT
OXYGEN INHALATION: by mask (1-2 L/min) or hood (4-6 L/Minute) to maintain oxygen saturation> 95%.
IV ANTIBIOTICS:
• For children 2-59 months: Ampicillin 100-200mg/kg in four divided doses + Gentamicin +-5-7.5 mg/kg as single dose daily.
• For children >5 years: Ampicillin/Amoxicillin, add macrolide (Azythromycin/Erythromycin) if atypical pneumonia is suspected.
• If suspected Staphylococcal pneumonia in any age (Pneumatocele on CXR, post measles, infected scabies or pyoderma) add Cloxacillin/ Amoxiclavulanic acid.
SUPPORTIVE CARE: Paracetamol for fever, IV fluid, bronchodilators (inhaled) as needed.
WHEN AND WHAT TO SWITCH TO ORAL AND DURATION:
• Child is afebrile, RR has returned to below age specific cutoffs, no chest indrawing and accepting orally: switch to oral Amoxicillin to complete a total of 5-7 days duration (include duration of IV also in it).
• If getting Doxacillin/Amoxyclav: continue oral Cloxacillin or Amoxclav for 2 weeks.
• Start feeding as soon as possible when child shows improvement.
IF ASSOCIATED SAM: follow treatment guidelines for SAM.
COMPLICATIONS AND THEIR TREATMENT
NON RESPONDERS: persistence of symptoms and/or signs 48-72 hours after initiation of appropriate treatment-change antimicrobials.
PLEURAL EFFUSION: diagnostic aspiration.
EMPYEMA: drainage with ICD. LUNG ABSCESS: change antibiotics for longer duration (4-6 weeks).
PNEUMOTHORAX: Intercostal drainage.
RESPIRATORY FAILURE: consider ventilation.
INFECTION IN OTHER SITES:
identify and treat appropriately.
ADDITIONAL INFORMATION
First and second line FIRST LINE antibiotics for severe
pneumonia: Ampicillin
ALTERNATE FIRST LINE
First gen Cephalosporins
SECOND LINE
Amoxiclav Cefuroxime Cefotaxime/ Ceftrioxone
WHEN TO REFER TO HIGHER CENTERS?
Facilities (as described above) for treatment or complications (if develops) are not available, suspecting chronic respiratory problems.
WHEN TO SUSPECT INFECTION WITH H1N1 VIRUS?
Child with cold, cough, fever with similar illness in any family members, consider H1N1 infection. Start Oseltamivir (as per national guideline).
WHEN TO SUSPECT ACUTE BRONCHIOLITIS?
A child below 2 years of age fulfilling case definition of first episode of severe pneumonia with predominant finding of wheezing on auscultation.
WHEN TO SUSPECT ASTHMA?
A child of age >3 years with history of recurrent cough, cold, wheezing with or without fever with good response to bronchodilator and personal or family history of asthma.
WHEN TO SUSPECT CHRONIC RESPIRATORY PROBLEM?
Child has any of the following: severe malnutrition, clubbing, feeding difficulty, family history of sibling death due to pneumonia, multi site infections (diarrhea, ear discharge oral thrush).
Discharge when child is switched to oral medications, accepting oral for 24 to 48 hours
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
REFERENCES

Integrated Management of Childhood Illness (IMCI) (revised). Geneva, World Health Organization/The United Nation Children’s Fund (UNICEF), 2014 (http://www.who.int/maternal_child_adolescent/documents/IMCI_chartbooklet/en/).
Revised WHO classification and treatment of childhood pneumonia at health facilities. http://apps.who.int/iris/bitstream/handle/10665/137319/9789241507813_eng.pdf;jsessionid=8BF6F1C94BD7BA81B8F464D4CBA40249?sequence=1
Bradley JS, Byington CL, Shah SS, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53:617-30.
Lodha R, Kabra SK, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database Syst Rev. 2013 Jun 4;(6):CD004874
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 PSCHIATRY October/ 2019
Universal screening for every patient attending any healthcare facility
Special attention to: (AUDIT can be used for screening)
H/ o head injury
Appearing under influence of alcohol
H/ o impaired social, occupational functioning
Daily alcohol consumption
Drinking in large quantities
(men: 5 or more drinks/ day; women: 4 or
more drinks/ day)
ICD10-F10
ASSESSMENT (DETAILED HISTORY)
• Age at initiation, quantity, frequency and progression (daily use and/or morning drinking)
• Time of last alcohol use and amount
• Binge drinking ( men: 5 drinks over 2 hours; women: 4 drinks over 2 hours)
• Withdrawal state: insomnia, restlessness, anxiety, tremors. Use of alcohol (or
benzodiazepines) to relieve or avoid withdrawal symptoms.
• Tolerance: increased doses of alcohol taken to achieve effects produced by earlier intake
• Craving
• Difficulty in controlling duration of drinking or amount of use
• Preoccupation with alcohol use with neglect of alternative pleasures or interests
• Increased time spent to obtain/ take alcohol/ recover from its effects
• Continued use despite patient being aware of evidence of harmful consequences that have
occurred
• Abstinence and treatment attempts in past and reasons for relapse
• Co-morbid medical illness or psychiatric illness and their treatment
• Complications:
• Physical- gastritis, peripheral neuropathy, hepatic dysfunction, accidents/injuries • Psychosocial – loss of work, fights at home, financial, legal problems
Hazardous or Harmful use
Alcohol dependence (three of the following six criteria to be present for at least one month)
1) A strong desire or sense of compulsion to take alcohol
2) Difficulty in controlling alcohol use
3) Withdrawal state when alcohol use has stopped or been reduced or use of the alcohol (or
benzodiazepines) to relieve or avoid withdrawal symptoms
4) Evidence of tolerance
5) Preoccupation with alcohol use
6) Alcohol use persisting despite clear evidence of harmful consequences
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
• Involvement in risky behaviours such as binge drinking, driving under the influence of alcohol
• It should have resulted in harmful physical or psychosocial consequences
CBC Liver function test
PRIMARY CARE
Blood sugar
INVESTIGATIONS
Electrolytes
MANAGEMENT
CT head (in case of seizure/ delirium tremens)
• Alcohol Hazardous/ Harmful users – Brief Intervention* to reduce/stop consumption
• Alcohol Dependent users – Advice to stop use and motivate for treatment using Brief intervention*
SECONDARY CARE
• Treatment of withdrawal symptoms • Managment of withdrawal seizure
• H/ o withdrawal seizures/ hallucinations
• Additional psychiatric disorder
• Recurrent failed attempts at treatment
TERTIARY CARE
REFER TO SECONDARY CARE IF
ALCOHOL USE DISORDERS
• Inpatient management with benzodiazepines (diazepam or lorazepam)
• Frequent titration of medication. Higher dosage may be required.
• Closer monitoring and nursing care
• Treatment of additional psychiatric disorder or substance use disorder
REFER TO TERTIARY CARE IF
• H/ o delirium tremens
• Major medical problems
• Additional substance use
*BRIEF INTERVENTION
• Treatment of delirium tremens
• R/ o head injury, hepatic encephalopathy, Wernicke’s encephalopathy • R/ o other causes of delirium
• Manage on similar lines as withdrawal seizures
• Management in ICU setting when indicated
• Consult with other medical specialists (like gastroenterology or medicine for hematemesis).
• Management for suicidality or violence when emergent threat
Inquire using open ended questions in a non-judgmental manner. Help patient to evaluate the risks versus the perceived benefits and to arrive at a decision to reduce or stop alcohol use.
Includes (FRAMES) :
• Feedback about alcohol related problems
• Responsibility – acknowledging that the patient is
responsible for making the decision about their alcohol
use
• Advice regarding the harms associated with continued
use
• Menu of alternative change options (includes identifying
alternative activities such as hobbies, involving the
family in treatment)
• Empathetic attitude
• Self efficacy – to encourage patients’ confidence that
they can make changes in their alcohol use and lifestyle
WITHDRAWAL MANAGEMENT
• Tab Diazepam (20-40mg/day in divided doses) based on severity of withdrawals.
• Monitor and titrate dose. • If patient comfortable,
reduce dose of medication by 10% to 20% per day, taper within 7 to 10 days
• Thiamine 100 mg OD • Significant liver
dysfunction: Lorazepam (2 mg Lorazepam equal to 5 mg Diazepam)
RELAPSE PREVENTION
(Long term goals- abstinence and socio-occupational integration)
• Disulfiram (250 mg OD)
Pre-requisites:
• Motivated patient
• Patient’s written consent
• Under supervision of family members.
• Inform patient and family about unpleasant,
potentially serious reaction with even small amounts of alcohol (flushing, headache, vomiting, reduction of blood pressure, arrhythmias)
• Ability of health personnel in the area to handle a potential reaction
• Relapse prevention counselling:
• Identify cues leading to craving (like person, place,
situation etc)
• Develop strategies to deal with them effectively
Failure of outpatient treatment
H/o withdrawal seizures/ delirium tremens
Co-morbid significant medical illness and/or psychiatric illness
Poly-substance use
VITALS
• BP
• Pulse Rate
• Temperature
WITHDRAWAL SIGNS
• Tremor
• Sweating
• Tachycardia
DIAGNOSIS
EXAMINATION
SIGNS OF HEPATIC DYSFUNCTION
• Enlarged liver
• Icterus
• Abdominal swelling
NEUROLOGICAL SIGNS
• Cerebellar signs
• Peripheral neuropathy • Confusion
INDICATIONS FOR ADMISSION
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India. Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ANXIETY DISORDERS
ICD-10-F40-F42
Tension, anxiety, apprehension, fear, worrying
Sadness, lack of interest, uncontrolled negative thoughts
Unexplained physical symptoms like chest pain, abdominal pain, muscular tension, headache, nausea
Episodes of palpitations, difficulty in breathing, feelings of choking, light headededness, dizziness, fainting, trembling
Attacks of fear, losing control or going “crazy”, fear of dying
Repetitive unwanted thoughts and behaviours
DIAGNOSIS
Panic Disorder: Recurrent unexpected attacks of intense fear/ anxiety along with physical symptoms (palpitations, feelings of “choking”, trembling, chest pain feeling dizzy/faint etc.)
ASSESSMENT
• Duration of anxiety
• Degree of distress, and
impairment of
day-to-day functioning • Symptoms of
depression
• Substance and alcohol
misuse
• Physical disorders:
thyrotoxicosis, pheochromocytoma and hypoglycaemia
• Psychosocial factors: ongoing stress and other issues pertaining to work, family
Generalized Anxiety Disorder (GAD): Chronic feeling of tension, apprehension, anxiety or worrying about a number of events or activities that involve every day routine life circumstances (e.g., work, school, health, finance, household chores etc.)
Agoraphobia: Fear of going out of home alone, being in enclosed spaces (e.g., malls, cinemas etc.), open spaces (e.g., bridges, vast playgrounds etc.), using public transportation (e.g., trains, buses, planes etc.)
Social Phobia: Marked fear and avoidance of social situations (e.g., interaction with strangers, meeting unfamiliar people, performing in front of others)
Obsessive-compulsive disorder (OCD):
Recurrent and persistent unwanted
thoughts (e.g., unwanted sexual and blasphemous thoughts, fear of harming self or others, fear of contamination, doubts about daily activities etc.) and repetitive behaviours (e.g., excessive washing / cleaning, checking, ordering etc.)
MANAGEMENT
PRIMARY CARE LEVEL
Psychoeducation
• Reassurance
• Explain symptoms are of anxiety/ fear and mimic
symptoms of physical illnesses (e.g., heart attack) • Do not investigate excessively. Few investigations
like ECG, ECHO maybe necessary in some patients • Discourage doctor shopping
• Do not avoid triggers of panic attacks (e.g., physical
exertion, agoraphobic situations) and fear (e.g.,
travelling by public transport).
• Emphasize avoidance maintains fears and phobias. • OCD: Educate that the unwanted thoughts are a
part of illness, and not a reflection of character or hidden intentions.
Pharmacological treatment
• Mild illness: Spending time, reassurance, and psychoeducation. May not need any medications.
• No improvement (few weeks): Escitalopram 5mg / day at night, with increase to 10 mg/d in a week. No satisfactory improvement in 4-6 weeks, may increase to 20 mg / day. If there is no significant improvement in another 4-6 weeks, refer to a specialist.
• Severe and unbearable anxiety: Diazepam (5 -10 mg) may be given at night. Do not continue for > 1 month. Taper and stop over 2 weeks. Long-term treatment with benzodiazepines to be avoided
• Escitalopram to be continued for at least 1-2 years after remission
• Side-effects (sexual dysfunction, sedation, weight gain) : monitor and address periodically
SECONDARY CARE LEVEL (DISTRICT HOSPITAL)
• Review diagnosis and treatment history if there is no improvement with a trial of Escitalopram.
• Check whether the patient has taken medication at prescribed dose and on a regular basis
• Second SSRI
(either of them for about 2-3
months):
• Sertraline upto 200 mg/day,
• Fluoxetine upto 60 mg/day,
• Paroxetine upto 50 mg/day,
• Fluvoxamine upto 300 mg/day
• No response to second SSRI: cognitive behaviour therapy (CBT) if trained therapists available.
• Refer to tertiary centre if unsatisfactory response after second SSRI and / or addition of CBT.
• If referral to tertiary centre is not feasible, psychiatrists may try other strategies (other than Deep Brain Stimulation and surgery for OCD) mentioned under the “tertiary care” at the secondary level itself.
TERTIARY CENTRE (MEDICAL COLLEGE, REGIONAL MEDICAL CENTRE, PSYCHIATRIC
HOSPITAL)
• Evaluate reasons for treatment resistance like • Wrong diagnosis
• Inadequate drug treatment,
• Poor adherence to treatment
• Inadequate CBT,
• Presence of comorbid conditions such as
personality disorders and organicity
• Panic disorder: evaluate any medical conditions that mimic panic disorder (hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular diseases, seizures, arrhythmias, etc.).
• OCD: Trial of third SSRI or clomipramine
• Treatment resistant OCD: inpatient treatment
for intensive therapist-assisted daily CBT and
for rationalization of medication regimen. • Other anxiety disorders: Trial of non-SSRIs
(e.g., venlafaxine, duloxetine, pregabalin etc.) and tricyclic antidepressants
• If response to medications is poor or unsatisfactory:
• CBT is the preferred mode of treatment alone or in combination with medications.
• Treat comorbid psychiatric disorders (e.g., personality disorders)
• Pharmacological augmenting strategies if antidepressants and CBT do not provide relief.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
CLINICAL PRESENTATION
ICD10- F90-98
OPPOSITIONAL DEFIANT DISORDER (ODD)
• Doesn’t obey or listen, back-answers, rude behaviors • Demanding, stubborn, throws tantrums when
demands are not met
CONDUCT DISORDER
• Aggressive – angry, abusive, fights, hits or hurts people, bullies other children, damages articles
• Stealing, lying, threatening or misbehaving with people, truant (keeps away from school without parents’ knowledge), runs away from home, bad company, cruelty to animals
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
• Restless, always on the move / running, can’t sit in a place,talkative
• Can’t focus attention on a task, poor concentration, gets easily distracted, disorganized, does not complete school work
• Too mischievous, can’t be left alone, troubles people or damages things, or gets injured
• Impatient, always in a hurry, can’t wait for his turn, does not care for danger, acts without thinking
ALL 3 DISORDERS
Poor or erratic school performance and / or complaints about behaviour from school
DIAGNOSIS
• Symptoms are present and persistent over several months
• Attempt further classification into ADHD, ODD and CD (ADHD may be present with or without ODD and CD
CAUTION
• Abrupt onset
• Recent onset (few weeks
to few months)
• Sudden increase in
severity (consider another psychiatric disorder such as bipolar affective disorder, hypomanic or manic episode -> follow the relevant STW)
CHILDHOOD BEHAVIORAL DISORDERS
ASSESSMENT (History From Multiple Sources)
PARENT INTERVIEW
• Symptoms- onset, duration, type(ODD, Conduct, ADHD-as above) and severity
• Developmental problems, emotional disturbances and stress
• Alcohol and substance use /misuse
• Impact on child and family
FAMILY SITUATION
• Health (including mental health) and wellbeing of family members
• Cohesion, mutual understanding and harmony in the family
• Parenting and childrearing practices: caring and disciplining, criticism, unfair comparison and physical punishments, mutual blaming of parents for child’s problem
SCHOOLING
• Attendance
• Performance
• Learning
problems,
• Classroom
behaviors
• Recent changes
in syllabus and/or school
CHILD INTERVIEW
• Develop rapport( discuss neutral topics; avoid direct tackling of misbehaviors)
• Observe:

Features of ADHD (restless, fidgety, easily distracted,
attention keeps shifting)
Speech and language ability, intelligence, academic
skills and mood
• Enquire about any stress or difficulties child is facing at
home, school, and with peers and anger control
MANAGEMENT
• PSYCHOEDUCATION WORK WITH FAMILY
Explain the child’s behaviours are not intentional
Not child’s fault, do not blame the child
Multifactorial causes-lack of self-regulation, and adverse environment – Can be improved with proper management
Parents can directly contribute to the child’s improvement
• Help parents deal with their own worries and stress (listening, giving space to ventilate, validate and empathize their difficulties, reassure)
• Recognize and manage mental health problems such as depression and alcohol problem in parents
• Parent management training*
*PARENT MANAGEMENT TRAINING
• Analyse the problem behaviors and understand patterns : time of occurance, triggers, duration and consequencies
• Engage with child in mutually enjoyable, pleasurable activities (playing games, discussing interesting things or doing activities together)
• Set clear do’s and don’ts and explain to child in clear, simple, short instructions the consequencies (like withholding privileges following misbehavior; use star-charting (contingency management) and rewards based on number of stars earned
• In children with ADHD, develop clear daily routines, supervise activities and appreciate on completion of taks
• Limit screen time/ monitor use of electronic devices
WORK WITH THE CHILD
• Avoid advice
• Anger management ( count
from 10 -1 backwards, move away from situation, deep breaths, relax, self-talk to cool down)
• Children with ADHD: “stop-think-act” or “halt and proceed” technique
WORK WITH THE SCHOOL
• Feedback to school regarding child’s condition
• Teachers to give extra attention, help and support for the child
• Extra coaching, if needed in case of learning problems
• Dos
– Consistency in enforcing rules
– Catch the child being good and praise
– Ignore negative behaviours
– Child can be put in a boring place till he/
she becomes quiet for a few minutes
(time-out)
– Encourage age appropriate responsibilities
• Don’ts
– Bribe
– False promises and threats
– Harsh punishments
– Excessive criticism and blaming
especially in front of others
– Unfair comparison
– Yielding to unreasonable demands
MEDICATION (AVOID BEFORE 5 YEARS)
• Severe and persistant aggression:
T. Risperidone under close supervision (starting dose-0.25 mg, single daily morning dose after breakfast. Based on response, increase by 0.25 mg weekly up to 1 mg single daily dose).
Not to exceed 1 mg/day
Response + : continue 3 months f/b slow taper – Response – : 4 weeks trial, then refer
Monitor adverse effects: weight gain, extra-pyramidal symptoms (EPS)
[if EPS : add I mg Trihexyphenidyl OD morning]
• Severe hyperactivity and impulsivety:
T. Clonidine (starting dose-25 μg single daily dose before sleep, increase by 25 μg weekly up to100 μg per day in 2-3 divided doses
Monitor BP and drowsiness
Advise against sudden discontinuation
REASONS FOR REFERRAL
Severe, complicated presentation
Lack of response to treatment
Severe aggression
Highly dysfunctional family
Alcohol and substance abuse
SECONDARY CARE (DISTRICT HOSPITAL) TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE)
• Review and reassess diagnosis (clinical evaluation using Rutter’s multi-axial system) and all the pointers given above
• If failed trial of Clonidine/ Moderate ADHD:
T. Atomoxetine (starting dose-10 mg single daily morning dose after breakfast. Increase up to 1mg/ kg/day under close supervision).
Monitor adverse effects and response
• Systematic parent management training / behavioral management and individual therapy (as given above)
• Evaluate and manage severe behavior disorders – severe ADHD, ODD, and CD, if necessary on short-term inpatient basis
• Multi-modal management with clear individualized plan
• Trial of Methylphenidate in moderate / severe ADHD under expert supervision
• Recognize and treat comorbid disorders such as bipolar disorder, substance use disorder, and
internalizing disorders and manage
• Pharmacological management of older children / adolescents with severe aggression /
impulsivity with Risperidone and/or Lithium
• Family therapy for dysfunctional / discordant families, contributing to child’s condition
• Management of children in difficult circumstances with mental health issues (children in need of
care and protection; children in conflict with law)
REFERENCES
• World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO. 2016.
• Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American
Academy of Child & Adolescent Psychiatry. 2007 Jul 1;46(7):894-921.
• Steiner H, Remsing L. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child & Adolescent Psychiatry.
2007 Jan 1;46(1):126-41.
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
CHILDHOOD EMOTIONAL DISORDERS
CLINICAL PRESENTATION – Recent Onset Behavioral Changes
SOMATIC (PHYSICALLY UNEXPLAINED) SYMPTOMS
• Weakness and tiredness
• Aches and pains
• Headache
• Non-epileptic attacks of fainting • Chest pain and stomach pain
• Hyperventilation- often triggered by stress or distress
SYMPTOMS OF DEPRESSION
• Loss of interest in usual activities
• Recent deterioration in school performance
• Wanting to be alone, withdrawn, not interacting
with people
• Looks unhappy, “off mood”, crying for trivial or no
reason, irritable, sensitive to any criticism
• Decreased sleep, loss of appetite and weight loss • Talking about death and dying, self harm (eg.
self-cutting) or suicidal attempt
SYMPTOMS OF ANXIETY
• Always worrying, tense
• Exam tension, performance anxiety, worries about
marks and ranks
• Excessive fear and avoidance of some objects or
situations (insects, animals, ghosts)
• Reluctance or refusal to go to school
• Very shy, avoids social situations, scared of talking or
interacting with strangers,
• Clinging to mother, scared of being separated from
mother
DIAGNOSIS
• Persistent symptoms of emotional disturbance for several weeks, significantly affecting the child’s life
• Unexplained by medical condition such as hypothyroidism
• Depression and anxiety symptoms can co-occur
• Depression more common in adolescents, may have features similar to adult onset depression
CAUTION
• Assessment of suicidal risk and a plan of action is important in children with emotional disorders, especially depression (refer to appropriate STW)
• Elicit h/o hypomania/mania in children with moderate to severe depression (consider diagnosis of bipolar disorder)
• Physical conditions can cause similar symptoms (anemia and thyroid disturbance)
?
ASSESSMENT
PARENT INTERVIEW AND HISTORY TAKING
• Onset, duration, severity and full range of symptoms
• Home environment, family life and relationships, parenting practices and stressors
• Information (from paretns and school) about school performance, behavior, school refusal, bullying experiences, peer relations and any recent change
CHILD INTERVIEW
• Develop rapport
• Ask subjective distress (low mood, irritability, sadness, lack of
enjoyment of activities, worries, fears, tensions, autonomic
symptoms)
• Stressful events (loss, death in the family, separation, frightening
experiences, traumatic abusive or shocking events, humiliating experiences, bullying in school, academic stress) and interpersonal difficulties
• Explore parent-child relations and interactions and any undue punishment or criticism
PHYSICAL EXAMINATION
(Rule out)
• Post-viral syndrome
• Recurrent attacks of
malaria
• Chronic infections, chronic
physical illness, anaemia, PCOD or thyroid disturbance
MANAGEMENT
WORK WITH PARENTS
• PSYCHOEDUCATION:
Child is emotionally disturbed and not able to
function well
Not the child’s fault
Avoid undue criticism, over expectation, unfair
comparison, scolding and punishment – Parents’ support, encouragement and
understanding is important
• Counsel about suicidal risk in depression and to be
alert to pointers to suicidality
• Evaluation and management of the mental health
issues in parents
• Discuss about specific steps to reduce undue stress
the child is facing
WORK WITH THE CHILD
• Psycho-education of the child- explain they are suffering from an emotional problem and it is not their fault and they will get better with proper treatment
• Anxiety management and emotional regulation skills – Muscle relaxation
Deep breathing exercises
Praanaayaama / yoga
Substituting distressing thoughts with more comforting thoughts
• Counsel the child to confide any distressing thoughts, including thoughts of death and dying
• Encourage the child to gradually return to the usual life and activities in a step-by step manner with parental support and encouragement
WORK WITH SCHOOL
• Give feedback to the school about child’s condition and stress, need for support, encouragement and school’s cooperation.
• If school refusal, graded return to school: encourage child to return to school gradually with the support of family and cooperation of school (e.g. initially for a few minutes in school compound, later for 1 period in school and moving on to longer duration
MEDICATION (MODERATE CASE OF DEPRESSION OR ANXIETY IN ADOLESCENTS)
• Tab Fluoxetine – start at 10 mg OD morning, increase to 20 mg OD after 2 weeks depending on response
• Inform adverse effects: behavioral activation (marked restlessness and irritability), onset of hypomanic symptoms, and worsening of suicidal ideas. Stop drug if they are troublesome
• Avoid benzodiazepines (except as temporary measure for few weeks in severe anxiety attacks or panic attacks – Clonazepam 0.25- 1 mg /day)
SECONDARY CARE (DISTRICT HOSPITAL)
• Review and reassess diagnosis through detailed clinical examination using Rutter’s multi-axial system
• Review the treatment received and plan multi-modal treatment.
• Reconsider medications, and augmentation strategies
• Review child’s and family’s awareness of the illness and do psycho-education
• Ascertain the presence of psychosocial factors : disturbed home environment,
parent-child relationships and severe stressors
• Screen parents for mental health problems and manage accordingly
• Individual therapy focussing on identifying and challenging negative thoughts,
anxiety management and coping with stress, helping them face difficult situations
in small steps, improving interpersonal relationships
• Parent counselling to address family issues, communication and interaction
patterns
• Collaborate with school wherever necessary (get school report; explain problem in
simple terms, and suggest ways by which school can help)
• Recognize and manage less common problems such as obsessive compulsive
disorder, psychoses and bipolar disorders
• Manage adolescents with mild / moderate suicidal risk
REASONS FOR REFERRAL
• Frequent expression of suicidal ideation/ attempted suicide / self-harm behavior such as self-cutting
• Severe symptoms
• Complicated picture, or features of
obsessive compulsive disorder (OCD)
• No response to interventions in 4-6 weeks
TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL
CENTRE)
• Thorough diagnostic evaluation
• Manage severe mental disorders – psychoses, recurrent
mood disorders, adolescents with severe depression, & treatment resistant cases, persistent suicidality, recurrent self-cutting, if necessary in inpatient setting
• Family therapy for dysfunctional / discordant families contributing to child’s condition
• Cognitive behavior therapy for older children with severe OCD, depression, and anxiety disorders
• ECT on case to case basis (older adolescents with severe depression, mania, psychosis or catatonia unresponsive to adequate pharmacological management)
• Appropriate psycho-social steps if there is abuse, maltreatment or neglect
• Neurology referral in suspected cases of epilepsy and organicity
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. Kindly visit the website of DHR for
based on expert opinions and available scientific evidencKeE. EThPerAe mHaIGy bHe TvHarRiaEtiSoHnsOiLnDthFeOmRanIaNgVeAmSeInVt EofPaRn OinCdEivDidUuRalEpSatient based on his/her specific condition, as decided by the more information: https://dhr.gov.in/
treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Department of Health Research, Ministry of Health & Family Welfare, Government of India.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 October/ 2019
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
CHILDREN WITH DEVELOPMENTAL PROBLEMS
CLINICAL PRESENTATION
DETAILED DEVELOPMENTAL ASSESSMENT:
• Assess if child is lagging behind
in developmental attainments
compared to same-age children • Ask mother to estimate the
mental age of child
• Ascertain if delay is global (all
milestones) or restricted to one area (motor or speech)
PSYCHO-EDUCATION OF PARENTS
• Normal – reassure parents • Mild delay (“at risk”) – early intervention and follow-up
• Explain causation due to some damage to brain before, during or after birth
• No medication can improve intelligence
Teaching and training to improve skills and gaining independence
• Systematic, persistent and repetitive training as per the child’s ability
• Treatment of associated problems (vitamin or mineral deficiency or epilepsy, ADHD, vision/ hearing issues,) – refer to appropriate STW
• Avoid overprotection, overindulgence and understimulation
EDUCATION AND TRAINING
• Liaise with schools and ensure child attends school that is most appropriate
• Assist in enrolment to special school
• Consider training in vocational skills (informal and formal) for older adolescents
• Severe or multiple developmental problems
• History of regression ( loss of acquired skills)
• Definite family history of developmental problems (h/o similar problem in the sibling)
REASONS FOR REFERRAL
SECONDARY CARE (DISTRICT HOSPITAL)
• Co-occuring severe behavioral or emotional problems
• Suspected case of ASD
• Suspected SLD
• Genetic counselling
• Speech therapy or physiotherapy
Slow in development / delayed milestones of development
Poor speech, self-care, learning and memory
Less intelligent compared to other children
DIAGNOSIS
Intellectual disability (mental retardation)* – global developmental delay + impairment compared to peers in intellectual functioning and adaptive skills
Specific Learning Disorder (SLD)- Average intelligence with poor academic skills (reading, writing, spelling and maths inspite of adequate schooling)
Specific speech delay – Only lagging in speech with normal intelligence, hearing and non-verbal communication
Autism Spectrum Disorder (ASD) marked impairment in verbal and non-verbal social interactions (being solitary or “in his own world”, poor response to name call and poor eye-to-eye contact) and stereotyped behaviors *in children under 5 years, avoid diagnosis of ID, name it as global developmental delay and start intervention
PHYSICAL EXAMINATION:
BEHAVIOURAL PROBLEMS:
• Hyperactive
• Impulsive behaviors
• Sleeping and feeding problems • Aggression
EMOTIONAL PROBLEMS:
• Excessive crying
• Irritability
• Shyness and fears
OTHERS:
• Family situation
• Parents’ awareness of
the child’s problems • Quality of attention
and care being given
to the child,
• Past consultations and
treatment educational history
ICD10-F70-89
ASSESSMENT
• Height and weight,
• Head circumference,
• Vision and hearing
• Any noticeable physical anomalies
(club-foot) or unusual facial appearance
• Motor abnormalities (stiffness / spasticity or
weakness of limbs, unsteady gait)
• Any other problems (heart murmurs,
organomegaly)
MANAGEMENT
EARLY INTERVENTION / SENSORY-MOTOR STIMULATION FOR YOUNG CHILDREN – UNDER 3 YEARS
• Create opportunities for the child to learn with
interset and attention
•Engaging and spending time with child in activities
• Offer appreciation
• Engage the child to use eyes and ears (different
types of sounds and sights), touch (eg., tickling, stroking, gentle massaging), movements (gentle movement of limbs, gentle bouncing, range of movement exercises) and improving hand functions (taking, holding, giving, pushing, pulling)
• Use play materials–rattles, paper balls, rubber balls, clay, soft dough, water play, soap bubbles, vegetables.
• Parallel vocalization to improve utterances (making the same sound as the child immediately).
• Improve conceptual skills by classifying, arranging, sorting, and recognizing and naming activities (for eg., vegetable sorting, grain sorting, arranging vessels by their size and shape)
HOME-BASED PARENT MEDIATED SKILLS TRAINING
• Develop and maintain regular, stimulating daily routines
• Teach parent to teach child : simple imitation, pointing, pretend-play; self-help skills (eating, toilet training, bathing, dressing), doing simple household chores (washing utensils, helping in cleaning house), social skills – skills of interaction, simple academic skills, simple vocational skills, helping in kitchen under supervision, self-protection
• Find current level of adaptive abilities of the child and choose a target skill
• Tell and show how to do things (modelling), make the tasks simpler, break activities in simple steps and teach one step at a time, notice and praise even minor efforts and improvements (rewarding or reinforcing), using hand-on-hand techniques (keeping your hand on the child’s hand and making them do the activity)
• Psychological testing for ID, SLD and diagnosis of ASD
• Basic management of ASD – home-based parent-mediated training in social, communicative, and self-help skills
• Appropriate management of behavior problems with medication / psychosocial or behavioral intervention (see relevant STW’s) • Help parents access relevant services such as District Early intervention centres (DEIC’s), parent organizations, and benefits
TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE)
• Evaluate and manage children with severe IDD, ASD, multiple disabilities, and those with severe comorbid disorders such as ADHD, aggression, bipolar disorder, and psychotic disorders through multi-disciplinary approach
• Investigate for the cause – review tests already done; imaging, genetic tests, metabolic tests (as per requirement) ;arrange for genetic counselling • Manage treatable disorders (like hypothyroidism and inherited metabolic disorders)
• Manage comorbid physical health problems (like epilepsy, visual /hearing impairment, locomotor/ orthopaedic problems)
• Assessment and management for SLD – psychoeducation of the child and parents, liaison with school, teaching basic remediation techniques to
parents, helping parents access relevant organizations, issue of exemption certificates, and decisions about further schooling such as open schooling
REFERENCES
• World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO. 2016.
• Szymanski L, King BH. Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 1999 Dec 1;38(12):5S-31S.
• Girimaji SC.(2008) Clinical Practice Guidelines for the Diagnosis and Management of Children With Mental Retardation. Retrieved from http://www.indianjpsychiatry.org/cpg/cpg2008/CPG-CAP_05.pdf
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
TThis STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
SOCIAL WELFARE / LIAISON MEASURES
• IQ testing and certification for social welfare benefits
• Help parents to link with other agencies/ services that deal with
such children such as CBR programs or parent associations Department of Health Research
Ministry of Health and Family Welfare, Government of India
ICD10-F45
Standard Treatment Workflow (STW) for the Management of
DEPRESSION
CORE SYMPTOMS
CLINICAL ASSESSMENT
Cognition
• Hopelessness (about future) • Helplessness (about others) • Worthlessness (about self)
Assessment of Suicide Risk • Suicidal thoughts
• Suicidal idea
• Suicidal intent
• Immediate risk for attempt
1 Depressed 111
Easy fatigability/ diminished activity
Assessment of Depressive Cognition
Assess friend and family support
2 Loss of mood interest
and enjoyment
3
CLINICAL DIAGNOSIS OF DEPRESSION
ADDITIONAL SYMPTOMS
• Reduced concentration and attention
• Reduced self-esteem and self-confidence
• Ideas of guilt and unworthiness
• Bleak and pessimistic views of the future
• Ideas or acts of self-harm or suicide
• Disturbed sleep
• Diminished appetite
To make a diagnosis of depression, symptoms must present for at least 2 weeks.
INVESTIGATION
• Haemogram
• Thyroid function tests
• Electro Cardiogram
• Electrolytes (Sodium)
• Rule out secondary medical cause of depression
• Rule out use of anticancer drugs (Cyclophoshamide) / anti retroviral drugs (Efavirenz, Zidovudine)/ Antibiotics (Dapsone , Ethambutol)/ Anabolic Steroids/ Propanolol
• Rule out associated comorbid medical condition – Diabetes, Stroke, Epilepsy, Cancer, Coronary Artery Disease and Auto Immune disorder
Severity of depression
Core symptoms
Additional symptoms
Mild depression
2
2 or more
Moderate depression
2
3 or more
Severe depression
3
4 or more
?
Rule out Bipolar Disorder / Grief / Adjustment Disorder
AT PRIMARY CARE
MILD DEPRESSION
• Advise Behavioral Activation to patients
• Practicing activity monitoring – write down your activities / rate your depression / schedule activities that
make you feel good / make a to do list/ set clear and specific goals
• Focusing on your value categories – make time for your family / friends / set clear goals at work / contribute
to community
• Reccomend yoga & mediatation
• Handling daily task – monitor sleep /diet and practice good personal hygiene
• Supportive psychotherapy / Brief Counselling
• Validate the problems and ensure frequent follow-up
• If no improvement in 4 to 6 weeks, consider pharmacotherapy
MODERATE / SEVERE DEPRESSION
• Tab Escitalopram 10 mg-20 mg /day or Cap. Fluoxetine 20mg -40mg /day
• Tab. Clonazepam 0.25mg – 0.5mg /day for sleep disturbance / anxiety symptoms and consider taper and stop after 2 weeks.
• If patient responds to SSRI in 2 to 4 weeks, then continue treatment for 6 to 9 months and taper and stop
REFERRAL TO SECONDARY CARE BROAD MANAGEMENT PLANS AT SECONDARY CARE
• Difficulty in making diagnosis
• No improvement after 4 to 6
weeks of treatment with first
line medications
• Depression in special
population: Elderly / Pregnancy / Lactation / Children / Adolescents
• Comorbid medical illness / Substance use
• Suicidal risk assessment
• Selective Serotonin Reuptake Inhibiters (SSRI) are usually first choice (watch for GI bleed and drug interaction)
• Improvement starts in in 2nd week and expect adequate response by 6 weeks
• Duration of treatment typically lasts 6-9 months and Gradual tapering of medication advised for first episode
• Restart SSRI , In case of resurgence and recurrence of depressive symptoms
• Observe for switch / activation with Antidepressants
• Watch for risk of overdose with TCA (Amitriptyline /
Imipramine) and Mirtazapine
• Confirm Diagnosis and Suicide risk assessment
• Assess for other Medical Comorbidities
• Investigations – Haemoglobin,Thyroid Function Test, Electrocardiogram
• Non Responder – Switch over to SNRI (Venlafaxine 75 – 150 mg, Mirtazapine 30 mg) or TCA (Amitriptyline 75 – 225mg / Imipramine 75 -225mg)
• Cognitive Behavioral Therapy / Problem Solving Therapy
• Add on Yoga Therapy / Meditation
REFERRAL TO TERTIARY CARE SPECIAL POPULATION AT TERTIARY CARE
• No improvement in 2nd line treatment
• Immediate risk for suicidal attempt / thought
• Needing intense counselling/ psychotherapy
• Co Morbid Substance – Cannabis / Poly substance
• Pregnancy / Lactation period – Pre Conception counselling and preferred drug is
Tab. Sertraline 50 mg – use lowest possible dose
• Elderly –
Tab. Escitalopram 10 -20 mg or Tab. Sertraline 100 mg (monitor for hyponatremia)
• Avoid TCAs like Amitriptyline / Imipramine in Elderly (due to anticholinergic side effects)
• Adolescents- Cap. Fluoxetine 20 -40 mg /day ( observe for switch / activation/ suicidality)
• Reconfirm Diagnosis
• Assess other psychiatric comorbidities
• Partial Responder – Optimise the SNRI /TCA or Augment
with Tab. Lithium 300 to 600mg /per day or Tab. Thyroxine
25 – 50 ug per day.
• Non Responder – Add Tab. Sertraline 100mg or
Tab. Bupropion 300mg to existing Venlafaxine 150mg / Tab. Mirtazapine 30mg / Amitriptyline 225mg / Imipramine 225mg.
• Add on Electro Convulsive Therapy for Catatonia / Suicidality
• Add on Cognitive Behavioural Therapy/ Inter Personal
Therapy / Problem Solving Therapy
• Add on low dose antipsychotic treatment (Risperidone 2 -4
mg / Tab. Olanzapine 5 – 10 mg) for psychotic symptoms
REFERENCES
• Avasthi A, Grover S. Clinical practice guidelines for management of depression in elderly. Indian J Psychiatry 2018;60, Suppl S3:341-62
• mhGAP Intervention Guide – Version 2.0 for mental, neurological and substance use disorders in non-specialized health settings. World Health Organisation, 2016
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
PSYCHOSIS
ICD10-F20-29
DIAGNOSIS
Presence of delusions (suspiciousness and fear without obvious explanation)
Hallucinations (talking, smiling or laughing to self)
PRIMARY CARE LEVEL
Disorganized behaviour & poor self-care
Social and occupational dysfunction
?
WELLNESS CENTERS
Identify, educate and refer to PHC
If immediate threat to self/ others, refer to Taluk / District center
FOLLOW-UP AND REHABILITATION:
• Monitor & manage challenges in treatment continuation
• If unsatisfactory outcome despite regular treatment:
Liaise with higher centers for optimal outcome
Liaise with social welfare department for disability
certification & welfare benefits if continued poor outcomes
INITIATE TREATMENT:
• T. Risperidone
2mg HSx1 week f/b
3 – 4 mg HS + Trihexyphenidyl (THP) 2mg(morning)
• Psychoeducation: – medical model of
psychosis – address
misconceptions &
build hope
inform about
possible adverse effects of medications
FOLLOW UP:
• 2 weeks after initial contact: Check for changes in symptoms and adverse effects (excess sleep, extrapyramidal symptoms (EPS), tiredness) adjust the dose of risperidone and THP accordingly; address questions if any; advise gradual return to work/school; give specific follow-up date; liaise with wellness center for ensuring continuity of care
• Once in 1 – 2 months: Check for symptoms, functioning and adverse effects (EPS, weight-gain, menstrual/sexual dysfunction); adjust the dose of Risperidone (range: 2 – 8 mg/day) and THP (range 2 – 6 mg/day); liaise with wellness center for ensuring continuity of care
REASONS FOR REFERRAL TO TALUK / DISTRICT LEVEL:
• Diagnostic confusion / suspicion of organic condition
• Substantial risk of harm to self or others and catatonic symptoms
• Comorbid substance use, depression/anxiety, intellectual disability
• Poor symptom-control or functioning despite regular treatment or poor treatment adherence
• Significant adverse effects: weight-gain, metabolic adverse effects, tardive dyskinesia
• Questions regarding marriage, pregnancy, sexual dysfunction
PHC
SECONDARY CARE (TALUK/DISTRICT HOSPITALS) #
INDICATION FOR REFERRAL FROM PHC
Diagnostic confusion
Poor response to Risperidone
Intolerance to Risperidone
Poor Comorbid Challenging Rehabilitation
adherence to conditions situations needs Pregnancy treatment
MANAGEMENT

Encourage follow up in primary care after addressing referral issues * Watch for adverse effects as SSRIs may increase serum levels of antipsychotics

Clarify diagnosis; neuroimaging if organicity is suspected
Positive symptoms:
Follow algorithm
Negative
symptoms:
• Rule out or manage depression/ anxiety and extrapyramidal symptoms;
• Family counseling if understimulated/ over-protected
• Consider less-sedating antipsychotics and adding SSRIs*
Follow algorithm
• Assessment of factors causing poor adherence & specific manage- ment
• Consider depot anti- psychotics
• Liaise with primary care for assertive follow up
• Depression/ anxiety:
Brief psychological intervention; consider SSRIs*
• Substance use:
Detoxification and brief interventions (see SUD module)
•
Developmenta l disabilities: Behavioral
• Suicidality: -Inpatient care,
-Crisis management, -Management of comorbidity; -Consider ECT
• Violence: -Verbal de-escalation -IV sedation, -Brief inpatient care
• Assess disability & counsel about welfare benefits
• Rehabilitation counseling

Family intervention for expressed emotions and attitudes & behaviors interfering with functioning
Brief interventions for cognitive & social-skill deficits
Address vocational/ educational challenges involving governmental/ non-governmental
• Proactively address sexual and endocrine problems when relevant
• Educate about risk of obstetric outcomes, risk of relapse & risk of psychosis in the offspring
TERTIARY CARE CENTERS
INTERVENTION
CONTEXT IN WHICH USEFUL
Psychoeducation
Poor adherence; high family expressed emotions
Family therapy
High family expressed emotions; family discord
Cognitive remediation
Poor neuro and social cognitive functions
Cognitive behavior therapy
Depression, anxiety, obsessions, persistent psychotic symptoms
Social skills training
Poor social skills
Vocational rehabilitation and supported education
Poor occupational functioning, challenges in studying or getting / pursuing gainful occupation
Day care with interventions including vocational training, recreational activities, living-skill training, etc.
Negative symptoms, poor socio-occupational functioning, combination of other symptoms listed in the table
Interventions for substance-use
Hazardous use of substance or substance use disorder
Pregnancy – puerperium services
Pre-pregnancy, pregnancy and post-partum advise and interventions Pre-pregnancy, pregnancy and post-partum advise and interventions
Referral to tertiary care if

Diagnostic confusion:
Inpatient observation for clarification
of history, thorough neurological / mental status examination, diagnostic psychometry, brain CT Scan or MRI, neurology consultation and urine toxicology screen
Poor outcome: +Following psychosocial
interventions may be offered in isolation or in combination depending on the context in inpatient, outpatient or day-boarding settings
ALGORITHM FOR CHOOSING ANTIPSYCHOTIC MEDICATION (AP) FOR TREATMENT OF SCHIZOPHRENIA
Good response without intolerable side effects
At any point, consider electroconvulsive
therapy if:
Serious suicidal risk
Catatonia not responding to Lorazepam 3. Refusal of food / fluids
Severe aggression / violence
Refractory / intolerance to clozapine

Treat with adequate dose as shown in table-1 for 6 – 8 weeks to assess efficacy

While choosing alternative AP, consider adverse effect profile and cost

^ At any point, if there is medication non-adherence, consider long-acting preparations in addition to other measures for managing non-adherence
Stabilization phase: For 6 months: same dose of AP;
Maintenance phase: Attempt to reduce dose to minimum possible dose.
1st episode: About 2 years.
1+ episodes: indefinite period
Risperidone*
Intolerable side effects or inadequate effect
Choose different AP*#^
Investigate for medical/ neurological causes of non-response and treat them
No cause found or poor response despite treatment of the cause
Intolerable side effects or inadequate effect
Inadequate effect for 2+ APs
CLOZAPINE
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

October/ 2019
SOMATIZATION DISORDER/ MEDICALLY UNEXPLAINED SYMPTOMS
Bodily complaints are often the most common reason for consultation with health professionals
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
INITIAL ASSESSMENT
Focus of patient is on symptom relief rather than cause of illness
PSYCHOSOCIAL ASSESSMENT
∙ Encourage to talk about psychosocial stressors if any
∙ Individual factors – poor copying skills, anxiety, life events, health anxiety,
medical illnesses
∙ Family related factors – Substance use in family, interpersonal relationship
with family, financial status
∙ Environmental factors – support system, peer relationship, work environment
∙ Detailed clinical examination – to rule out any medical illnesses which might explain the symptoms
∙ Complete history of the onset of all symptoms, exacerbating and relieving factors
∙ Assessment for any other psychiatric illness such as depression or anxiety disorders
SOMATOFORM DISORDER (SD)
PRESENTION TO A DOCTOR
Functional disturbance of different organ systems
DIAGNOSTIC CRITERIA
DIAGNOSTIC CRITERIA
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

Disproportionate and persistent thoughts about the seriousness of one’s symptoms 2. Persistently high level of anxiety about health or symptoms
Excessive time and energy devoted to these symptoms or health concerns
C. Although only one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)
A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months)
Severity:
Mild – only one of the symptoms specified in criterion B is fulfilled
Moderate – Two or more of the symptoms specified in criterion B is fulfilled
Severe – Two or more of the symptoms specified in criterion B are fulfilled, plus there are multiple
Following list include the commonest symptoms
Pain symptoms at multiple sites (such as abdominal, back, chest, dysmenorrhea, dysuria, extremity, head, joint, rectal) is often present
Gastrointestinal sensations (pain, belching, regurgitation, vomiting, nausea)
Abnormal skin sensations (itching, burning, tingling, numbness, soreness) and blotchiness
Sexual and menstrual complaints (ejaculatory or erectile dysfunction, hyperemesis of pregnancy, irregular menses, menorrhagia, sexual indifference) are also common
Difficulty in making diagnosis
No improvement after 4 weeks of
treatment with first line medications 3. Comorbid medical illness
Suicidal risk
Comorbid psychiatric illness
somatic symptoms (or one very severe somatic symptom)
PRIMARY CARE
MANAGEMENT
ICD10-F45
Repeated subjective experience of physical symptoms which are not explained by any recognizable physical disease
CHALLENGES FACED BY THE DOCTOR
∙ Repeated request for investigations – despite negative findings and reassurance
∙ Doctor shopping and not satisfied with repeated reassurance
Significant distress and impairment
Pain at multiple sites
Fatigue and exhaustion
∙ Detailed physical examination
∙ Management of anemia and nutritional deficiencies
∙ Avoid irrational use of pain medications
∙ Low dose of antidepressant medications – Amitriptyline 12.5 mg to 50
mg (max) night dose
∙ Explain that onset of medication effect will take 2-3 weeks
∙ Validate the somatic symptoms
∙ Advise to engage in routine activities, physical exercise and relaxation
techniques like deep breathing
∙ Discuss with family members that the symptom, distress and
disability are genuine ∙ Strengthen supports ∙ Regular follow up
TERTIARY CARE
∙ Inpatient care if needed
∙ Combination of two psychotropic medications (when required)
∙ Add on second and third line medications – Duloxetine, Mirtazapine,
anticonvulsants ( Lamotrigine, Pregabalin). Use of Gabapentin,
Carbamazepine if chronic pain symptom predominates
∙ Structured Cognitive Behavioural Therapy, Cognitive restructuring,
Mindfulness and acceptance based approach
∙ Use of alternative medicine approach – Yoga
∙ Collaborative approach – involve Physician, Neurology team and Pain
Clinic referral (where indicated)
∙ Vocational rehabilitation if needed
∙ Physical therapies – guided exercise and physiotherapy
REFERENCES
∙ Desai G & Chaturvedi SK. Medically Unexplained Somatic Symptoms & Chronic Pain – assessment & management. A primer for Healthcare professionals. 1st Edition 2017. Paras medical publisher, Hyderabad, India.
∙ World Health Organization. (2017). mhGAP training manuals for the mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings – version 2.0 (for field testing). World Health Organization. http://www.who.int/iris/handle/10665/259161.
∙ Agarwal V, Srivastava C & Sitholey P. Clinical Practice Guidelines for the Management of Paediatric Somatoform disorders. Indian Psychiatric Society – Practice guidelines 2018. ∙ Guidance for health professionals on medically unexplained symptoms (MUS) – https://www.rcpsych.ac.uk/pdf/CHECKED%20MUS%20Guidance_A4_4pp_6.pdf
∙ Jacob KS. A simple protocol to manage patients with unexplained somatic symptoms in medical practice. Natl. Med. J. India. 2004; 17: 326-8
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
REFER TO SECONDARY CARE IF
SECONDARY CARE
∙ Investigations – to rule out any medical illnesses that might explain the symptoms
∙ Complete history with behavioural observation
∙ Use 2nd line medications – SSRIs (Escitalopram 10-20 mg,
Sertraline 50-100 mg, Fluoxetine 20 mg) and SNRIs
(Venlafaxine 75 – 150 mg, Duloxetine 30- 60 mg)
∙ Combination of two psychotropic medications (might be
required if poor response to single medication)
∙ Brief counselling
∙ Psycho education – focusing on relationship between
stress and physical symptoms
∙ Relaxation training, regular exercise, yoga and meditation
No improvement in 2nd line treatment
High suicidal risk
Needing intense counselling/
psychotherapy 4. Difficult patients
REFER TO TERTIARY CARE IF PULMONOLOG
Y Department of Health Research Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for Management of
ACUTE RESPIRATORY INFECTION IN ADULTS
ICD-10-J09-J18; J00-06; J40
WHEN TO SUSPECT
• Cough with yellow/rusty sputum
• Breathlessness
• Pleuritic chest pain • Malaise, myalgia,
arthralgia
• Extra pulmonary
symptoms
• TB
• Pneumonia
• Airway disease •
• Diabetes
• Chronic steroid use
Vital parameters: Sensorium, Pulse, Blood pressure, Respiratory rate, Temperature, Oxygen saturation
Signs of respiratory failure: RR> 30/ min, Abdomin othoracic paradox, cyanosis, speaks in short sentences. Refer Respiratory Failure STW.
Systemic examination:
a. Upper respiratory tract: nose & paranasal sinuses (frontal and
maxillary sinus tenderness), throat examination ( pharynx and tonsils) b. Lower respiratory tract: breath sounds (type, intensity), added sounds (crackles, wheeze, pleural rub)
Frank haemoptysis, may suggest Pulmonary TB or malignancy
PROCEED FOR FURTHER ASSESSMENT
• Fever, tachycardia, pharyngitis, suffusion of eyes, rhinitis, hoarse voice
• Respiratory system examination: Normal
• Fever, tachycardia
• Respiratory system exam: Wheeze * Consider acute exacerbation of
asthma/ COPD if there is a history of any of these 2 illnesses
• Fever, tachycardia, tachypnea
• Respiratory system exam: Crackles/ bronchial
breath sounds

Consider acute exacerbation of asthma/ COPD
is there is a history of any of these 2 illnesses
PATHWAYS BASED ON INITIAL ASSESSMENT FINDINGS
PATHWAY 1: ACUTE URI (RESPIRATORY CATARRH) PATHWAY 2: ACUTE BRONCHITIS PATHWAY 3: COMMUNITY ACQUIRED PNEUMONIA
LABORATORY INVESTIGATION:
• Total and differential count in suspected flu.
TREATMENT
• Symptomatic treatment for fever, myalgia (Paracetamol or other NSAID),
• Rest, Oral fluids (plenty)
• Oral antihistamines (Tab. CPM 4mg BD) for
severe runny nose or sneezing
• Antibiotics in acute follicular tonsillitis:
Amoxicillin/ Ampicillin 500mg tid X 5 days In penicillin sensitive individuals:
Erythromycin estolate 250mg q 6 hrly X 5 days with food
Suspect epidemic flu
H/ o recent travel, symptoms of upper respiratory infection, diarrhoea, myalgia, breathlessness Refer to higher centre for diagnosis, notification and treatment.
LABORATORY INVESTIGATION:
• Total and differential count if sputum is purulent,
•X-ray chestPAview
TREATMENT
• Symptomatic treatment for fever (Paracetamol or other NSAID), Oral fluids (plenty)
• Inhaled bronchodilators: Salbutamol nebulization (5mg/ 2.5ml ) 6-8 hourly
• Antibiotics if there is purulent sputum and polymorphonuclear leukocytosis
• Amoxicillin 500mg tidX 5 days
• In penicillin sensitive individuals:
Erythromycin estolate 250mg q 6 hrly
X5 days with food
• If asthma is suspected refer to asthma STW
SEVERITY ASSESSMENT
• X-ray
• Use CRB-65* score for mortality risk assessment in primary care
CRB-65 SCORE
*65 in the scoring mnemonic refers to age> 65
Give 1 point for each of the following Prognostic features: • Confusion
• Respiratory rate ≥30/ min
• Low BP (DBP ≤60 mm Hg or SBP ≤90 mm Hg)
• Age ≥65 years
SCORE
RISK CLASS
SITE OF CARE
Low Risk
OP
Intermediate Risk
IP
High Risk
ICU
OUT-PATIENT BASED CARE OF CAP (CRB-65 SCORE 0-1)
Preliminary
INVESTIGATIONS
TREATMENT

TargetedtowardsStreptococcuspneumoniae
Oral antibiotics after checking for comorbidities* (Diabetes, CVDs, CKD, CLD, Hepatic
Pathology, Cancer, Alcohol Abuse, H/ o antibiotics within last 3 months.)
a. Without comorbidities: Cap. Amoxicillin (500 mg TDS) / Tab. Erythromycin
250mg QID/ Tab. Doxycycline 100mg BD
b. With comorbidities: Cap. Amoxicillin 500mg TDS + Tab.Azithromycin 500 mg OD
Duration: 5 days in (A); extend to a 7-10 days course if there is no response within 3 days of startingtreatmentandin(B).
Do not give: a.Corticosteroids:unlessothermedicalindicationspresent b. Fluoroquinolones: as they have anti-tubercular activity.
Chest radiogram
Repeat if:
i. Patient is not improving/ worsening
clinically
ii. Suspected underlying malignancy Desirable
1.Pulseoximetryin outpatients
Sputum microbiology: In suspected
PTB& non-responseafter48hoursof antibiotics
INPATIENT MANAGEMENT OF CAP
ANTIBIOTIC THERAPY IN THE HOSPITALIZED NON-ICU SETTING
a. Single agent IV β-lactam
b. If suspected atypical pathogens, other end organ disease, diabetes, malignancy, severe CAP, use of antibiotics in past 3 months: Combination of IV β-lactam (Cefotaxime 2 grams TID/ IV Ceftriaxone 1gram BD/ Amoxicillin–Clavulanic acid 1.2 grams TID ) + ORAL macrolide (Tab Azithromycin 500 mg PO OD/ Tab Clarithromycin 500 mg PO BD)
ANTIBIOTIC THERAPY IN THE HOSPITALIZED ICU SETTING
i. Patients without risk factors for Pseudomonas aeruginosa: Manage as above
ii. Suspected P. aeruginosa (diabetes, chronic lung disease like bronchiectasis, chronic steroid therapy):
IV Cefepime (1G BD)/ IV Ceftazidime (2G TID)/ Piperacillin–tazobactam(4.5 G QID)/ IV Cefoperazone–sulbactam 1.5G IV TID/ IV Meropenem 1g TID;
Combination therapy : Aminoglycosides(IV Amikacin)/ Antipseudomonal fluoroquinolones(Levofloxacin/ Moxifloxacin)
REFERRAL TO A HIGHER CENTRE : CLINICAL CRITERIA
Frank hemoptysis and /or Signs of respiratory failure [listed underinthehistoryand evaluationsections]
CRB-65 score > 1
Oxygen saturation by pulse oximetry ≤ 92% (patients ≤ 50
yrs) OR <90% (patients > 50 yrs)
Multi-lobar consolidation on chest X-ray 5. Confusion/disorientation
Hypothermia (core temperature<360C)
ADJUNCTIVE THERAPIES FOR THE MANAGEMENT OF CAP
a. Steroids are not recommended for use in non-severe CAP b. Non-invasive ventilation may be used in patients with CAP and acute respiratory failure
CONTRA INDICATIONS FOR NON-INVASIVE VENTILATION
a. Cardiorespiratory arrest
b. Presence of severe upper airway inflammation & edema c. Severe haemodynamic instability – hypotension
d. Eu-capnic (normal PaCO2) coma
e. Multiple organ dysfunction or severe psychomotor agitation
DISCHARGE CRITERIA
Accepting orally, Afebrile and Hemodynamically stable for a period of at least 48 h
POINTS TO NOTE WHILE SHIFTING
1.Ifreferringtoahighercenter,givethefirstdoseof antibiotic (oral and if available, parenteral), secure an IV line and start 0.9% Normal saline and oxygen supplementation through face mask at 4-6 litres per minute during shift
If the patient is drowsy, has copious secretions, consider calling for help from the SUB-DISTRICT/ DISTRICT hospital for endotracheal intubation and shifting on a transport ventilator
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
CLINICAL EXAMINATION
SYMPTOMS
October/ 2019
PAST HISTORY Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
Classic symptoms
ASTHMA
ICD-10-J45
TRY AND RULE OUT
• Other obstructive airway disorders – see Table 1 for features that favour asthma over COPD
• Other mimics – presence of fever, constitutional symptoms, purulent sputum, hemoptysis, focal chest signs on physical examination, foreign body aspiration, abnormal chest radiograph, etc.
APPROACH TO DIAGNOSIS
• Clinical assessment is the mainstay
• Airway obstruction, and bronchodilator reversibility, on spirometry (if available) may support diagnosis
• Refer patients for further work-up if diagnosis is in doubt
SYMPTOMS
• Recurrent/ episodic wheezing • Breathlessness
• Cough and/ or chest tightness
Supportive features
• Historyofatopy,familyhistory of asthma, presence of triggers, presence of rhonchi on chest auscultation
• Noalternativeexplanationfor these symptoms
INITIATION AND MODULATION OF ASTHMA PHARMACOTHERAPY
TABLE 1. DIFFERENTIATING BETWEEN ASTHMA AND CHRONIC OBSTRUCTIVE AIRWAY DISEASE (COPD)
Infrequent & Intermittent symptoms
Poor Control
Good Control
Levosalbutamol (50ug)
OR Salbutamol
(100 ug), 2 puffs sos
Age of Onset
Course Smoking, other exposures
Nasal Symptoms, Atopy
Family History Triggers
Wheeze
Asthma
More often in childhood or early adulthood; variable
Episodic Uncommon
Common Often
Often Identified
Prominent and almost universal
COPD
Usually later in life (4th or 5th decade)
Progressive Common Rare Uncommon
None
May or may not be present
Regular Symptoms (<2 per week but >2 per month)
Regular Symptoms (>2 per week) or exacerbation in past one year
Refer
Budesonide (100μg) 2 puffs BD plus
Levosabutamol (50μg) 2 puffs sos
TABLE 2. LEVEL OF CURRENT ASTHMA CONTROL (OVER THE PRECEDING FOUR WEEKS)
Poor Control
Poor Control
Good Control
Good Control
Budesonide (6/ 200μg) as a single inhaler 2 puffs BD and sos
Components
Daytime symptoms or use of rescue medication
Night-time symptoms/ awakening
Limitation of activities
Pulmonary function (if available)
Inadequately controlled (any one)
More than twice a week
Any
Any
FEV1 <80% of predicted or PEF <80% of personal best Adequately controlled (all should be present) Twice or less in a week None None FEV1 >80% of predicted or PEF >80% of personal best
Formoterol/
Add tiotropium (9μg) 2 puffs OD and low dose
oral methylxanthine
Poor Control
Add low dose oral corticosteroids
FEV1 Forced Expiratory Volume in first second, PEF Peak Expiratory Flow
GUIDING PRINCIPLES
• Mainstay of pharmacotherapy: Inhaled drugs
• Frequency of symptoms determine treatment initiation (see figure 1 for details)
• Reassess at 3-4 weeks – good response: in favour of asthma diagnosis
• Patient education for compliance, warning signs, triggers, inhaler technique, PEF
monitoring
• Inhaler technique to be monitored
• Follow-up at 4-12 weeks, assess diseases control by clinical parameters (see Table
2)
• Step-up or step-down treatment as per level of asthma control (see figure 1)
• Follow up three-monthly and modulate treatment as needed
• Refer for further evaluation and management if asthma remains poorly controlled
DISEASE EXACERBATION
SEVERE ACUTE ASTHMA (PATIENT TO BE ADMITTED)
• Inability to complete sentences, agitation, use of accessory muscles, respiratory rate >30/ min, heart rate >110/ min, pulsus paradoxus >25 mm Hg, silent chest, and/ or room air sPo2 <92% • Oxygen supplementation to maintain spO2 92-95% • Nebulized levosalbutamol/ ipratropium (1.25 mg/ 0.5 mg) three doses at 20-minute interval, then 4-6 hourly or as needed • Injection hydrocortisone 200 mg intravenously, then oral prednisolone 0.5 mg/ kg daily for five days • Refer if no improvement • Dischargeonly when symptoms improve, wheezing absent or significantly reduced, heart rate <100 bpm, respiratory rate <30/ min, room air sPo2 >94% • Schedule follow-up outpatient visit at one week
NON-SEVERE ACUTE ASTHMA
• If none of the above features present – manage on outpatient basis • Continue additional inhaler doses as needed
• Oral prednisolone 0.5 mg/ kg daily for five days
• Schedule follow-up outpatient visit at one week
WHEN TO SUSPECT EXACERBATION
• Suspect if acute symptomatic worsening, or reduction in PEF to below 80% of personal best, while on continued treatment
• Take two additional puffs of the inhaler used if symptoms persist, and repeat if needed
• If no response after 24 hours, or symptomatic worsening, or further reduction in PEF, contact physician
• Physician to assess severity of exacerbation and manage accordingly
LIFE-THREATENING EXACERBATION
Altered sensorium, orthopnea, cyanosis, paradoxical breathing, hypotension, and/ or bradycardia (heart rate <60 bpm) – immediately refer to higher centre with ICU facility
REFERENCES
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
Agarwal R, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/ NCCP(I) recommendations. Lung India 2015;32(Suppl 1):S3-S42. 2. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2018.
National Institute for Health and Care Excellence (NICE). Asthma: diagnosis, monitoring and chronic asthma management. 2017.
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 October/ 2019
WHEN TO SUSPECT?
DIAGNOSIS &
SEVERITY ASSESSMENT
TREATMENT
• Advice smoking cessation and counsel for other risk factors
• Inhaled drugs are the mainstay
• Treatment based on severity
assessment (See adjacent figure)
• Follow up: Mild to moderate
disease – 3 to 6 Months; Severe
disease – 1-3 months
• Ensure compliance and proper
inhaler technique at each visit.
• If uncotrolled/ complications
develop, refer to higher center
DISEASE EXACERBATION
Three cardinal symptoms:
• Increase in dyspnea
• Increase in sputum volume
and/or
• Increse in sputum purulence
Classify As:
• Mild Exacerbation
• Severe Exacerbation
Features Of Severe Exacerbation:
• Cyanosis
• Respiratory rate >30/ min
• Heart rate >110/min
• Systolic blood pressure <90 mm Hg • SpO2 <90% • Paradoxical respiratory movements • Altered sensorium • Asterixis • Presence of severe co-morbid conditions (e.g. heart failure, arrhythmia) MILD EXACERBATION • Increase dose and/ or frequency of levosalbutamol and/ or ipratropium inhalation, or nebulized levosalbutamol/ ipratropium (1.25 mg/ 0.5 mg), repeated as needed at 20-minute interval • Amoxycillin 500 mg TDS/ Azithromycin 500 mg OD/ Doxycycline 100 mg OD (BD on day 1) X 5 Days • Oral prednisolone 30 mg daily X 5 days SEVERE EXACERBATION Treatment as under Mild Exacerbation + Supplement oxygen with target spO2 of 92% (if spO2 monetoring available) TRY AND RULE OUT Other obstructive airway disorders – Refer Asthma STW (Table 1) for features that favor COPD over asthma Pulmonary tuberculosis – sputum AFB examination in case of cough ( >2 weeks)
Consider alternative diagnosis/- complication– presence of fever, hemoptysis, orthopnea, chest pain, significant weight loss, focal chest signs on physical examination, abnormal chest radiograph, etc.
Assess severity based on spirometry, severity of dyspnea (mMRC scale,
Table 1), exacerbation frequency and presence of complications (see Table 2)
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
ICD-10-J44.9
Symptoms – chronic cough, progressively worsening breathlessness
Risk factors – tobacco smoking, use of solid fuels for cooking, occupational exposures, Age – >35 years
Supportive features:Barrel shaped chest, hyperresonant note , diminished breath sounds and rhonchi on chest auscultation, forced expiratory time > 6 seconds, features of cor pulmonale (loud P2, elevated JVP, edema) in advanced cases
No other alternative explanation for these symptoms
Airway obstruction should be documented on spirometry on all patients provisionally diagnosed as having COPD – refer if necessary, Post-bronchodilator FEV1/ FVC <0.70 defines airflow obstruction
Mild COPD
Levosalbutamol (50 μg) 2 puffs prn
Persistent Symptoms
Add Tiotropium (9 μg) 2 puffs OD
Disease progression
Moderate COPD
Tiotropium (9 μg) 2 puffs OD plus Levosalbutamol (50 μg) 2 puffs prn
Persistent Symptoms
Add low dose methylxanthines
Severe COPD
Formoterol/Budesonide (6/200 μg) as a single inhaler 2 puffs BD plus Levosalbutamol (50 μg) 2 puffs prn
Persistent Symptoms
Add Tiotropium (9 μg) 2 puffs OD and/or low dose methylxanthines
Refer if inadequate response, onset of new complications, or suspicion of alternative diagnosis
GRADE
SEVERITY
MILD MODERATE SEVERE
TABLE 2. SEVERITY CLASSIFICATION FOR COPD
TABLE 1. GRADING OF BREATHLESSNESS USING MODIFIED MEDICAL RESEARCH COUNCIL (MMRC) SCALE.
DESCRIPTION OF BREATHLESSNESS
I only get breathless with strenuous exercise.
I get short of breath when hurrying on level ground or walking up a slight hill.
On level ground, I walk slower than people of the same age because of breathlessness or have to stop for breath when walking at my own pace.
I stop for breath after walking about 100 yards or after a few minutes on level ground. I am too breathless to leave the house or I am breathless when dressing.
POSTBRONCHODILATOR FEV1 (% PREDICTED)

80 50-79
<50 DYSPNEA (MMRC GRADE) <2 2 > 2
EXACERBATIONS IN LAST ONE YEAR
COMPLICATIONS*
The category with the worst value should be used for severity classification *Complications include respiratory failure, cor pulmonale, and secondary polycythemia
RED FLAG SIGNS FOR PEOPLE HAVING EXCERBATION
• Altered sensorium
• spO2 <88% despite therapy • Heart rate >110 bpm
• Systolic blood pressure <90 mm Hg
• High risk comorbid conditions (arrhythmia, congestive cardiac failure, poorly controlled diabetes, renal or liver failure)
Refer to higher centre for further management, and ensure continued supplemental oxygen and nebulization during transfer
SCHEDULE FOLLOW UP VISIT ONE WEEK AFTER DISCHARGE
ADMISSION CRITERIA

Severe symptoms; sudden worsening of resting dyspnea,
Fall in oxygen saturation, cyanosis, confusion, drowsiness.
Failure of an exacerbation to respond to initial medical management.
Presence of serious comorbidities (heart failure, newly occurring arrhythmias, etc.)
DISCHARGE CRITERIA
Normalization of clinical and laboratory data to pre-admission levels
Patient able to follow maintenance therapy 3. Completion of acute medications
Adequate control of comorbidities
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
REFERENCES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
<2 NO <2 NO > 2 YES

SYMPTOMS
• Wheeze
• Shortness of
Breath
• Chest Tightness • Cough
SIGNS
• Tachypnea
• Tachycardia
• Fall in SPO2
• Use of Accessory
Muscle
ACUTE ASTHMA
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
RESPIRATORY FAILURE
SYMPTOMS
• Worsening of Dyspnea
• Increase in Sputum Production
• Increased Cough
SIGNS
• Tachypnea
• Hypoxemia
• Hypercarbia
• Confusion
• Drowsy
• Peripheral Edema
ICD 10 : J96.0
SYMPTOMS
SIGNS
Cough
Tachycardia
1
Shortness of breath
1
Wheezing 1 Anxiety 1
Chest tightness
Restlessness Cyanosis
Confusion Arrhythmia
Asterexis 1
Look for underlying causes in hypercapnia, headache, bounding pulse, tremor/flap, papilloedema, coma.
Seizure
SYMPTOMS
• Dyspnea or exertion or rest
• Chest Pain
• Wheezing
• Fatigue
SIGNS
• Tachycardia
• Pulsus Alterans
• Weak Rapid Thready Pulse • Pink Frothy Sputum
• Cyanosis
• Pallor
• Distended Neck Veins
HYPOXIA (SPO2 <90%)
HEART FAILURE PNEUMONIA/ LRTI PULMONARY EMBOLISM
SYMPTOMS
• Cough with or without Sputum
• Chest Pain
• Fever with Chills,
Fatigue, Malaise
SIGNS
• Tachypnea
• Tachycardia
• Crackles and Rhonchi • Hypoxemia
• Pleuritic Chest Pain
SYMPTOMS
• Cough
• Shortness of
Breath
• Wheezing
SIGNS
• Cyanosis
• Nasal Flares
• Tachypnea
• Paradoxical Breathing
(children)
• Crackles and or Rattling
sounds in Lung
SYMPTOMS
• Sudden Shortness of Breath
• Chest Pain
• Calf Pain & or
Swelling
• Hemoptysis
SIGNS
• Syncope
• Arrhythmia • Tachycardia
AIRWAY DISEASE
AE OF COPD
BRONCHIOLITIS
INVESTIGATIONS
ABG, CRP, FBC, U&E
Chest Xray
Sputum culture, Blood culture (if febrile)
Spirometry(COPD, Neuromuscular disease
TREATMENT
DIAGNOSIS
Heart Acute Severe failure Asthma
AE COPD ARI
Pneumonia Pulmonary LRTI embolism
OXYGEN
Start oxygen therapy at SpO2 < 90%
Monitor SpO2 during oxygen therapy to titrate flow rate: target SpO2 < 96% Oxygen delivery usign Nasal cannulae/ Simple face mask/ Venturi mask/ Non re-breathing mask
(Note: for patients with AECOPD, keep lower target SpO2 = 88-92%)
BRONCHODILATORS
ANTIBIOTICS
SABA ± SAMA
(Salbutamol ± SOS Ipratropium neb
q20 min X 1 hr then prn)
SABA + SAMA
(Salbutamol neb SABA +
Yes
(IV Furosemide 40 mg or Torsemide 20 mg)
SOS SOS
SOS SOS SOS
hourly + Ipratropi- SAMA SOS SOS um neb 4 hourly)
DIURETICS

No risk factor
Pseudomonas: Ceftriaxone
or levofloxacin or
moxifloxacin
Pseudomonas risk factor: — levofloxacin or piperacillin tazobactam or ceftazidime
or cefepime
Influenza suspect:
Oseltamivir
Mild/ Mod cases: Amoxycillin PO/ IV or Ceftriaxone IV Severe Cases:
Amoxycillin IV or — Ceftriaxone IV
Atypical pneumonia: Azithromycin IV/ PO or Doxycycline IV/ PO
STEROIDS
LMWH
Methylprednisolone IV 0.5 mg/ kg q12h
Prophylactic, if indicated
If high suspicion with low risk of bleeding: UFH (if thrombolysis anticipated), OR LMWH

REFERRAL

Prophylactic, if indicated
Yes (Methylpredniolone IV40to60mgor PrednisolonePO 60mg)
Prophylactic, if indicated
Yes (Methylprednisolone
IV60to125mgIV q6-12hourly)
Prophylactic, if indicated
Yes
Prophylactic, if indicated
Severe CAP (fiO2 > 0.5 AND pH <7.3 OR lactate

4 mmolL-1 OR CRP > — 150 mgL-1):
No relief OR Need for mechanical ventilation OR life threatening features: Stabilize CAB, transfer to higher center
ABBREVIATIONS
• LRTI : Lower Respiratory Tract Infection • SABA : Short Acting Beta Agonist • CAP: Community Acquired Pneumonia • LMWH:Low Molecular Weight Heparin • SAMA: Short Acting Muscarinic Antagonist • UFH : Unfractionated Heparin
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal ( stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

UROLOGY

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
ACUTE URINARY RETENTION IN MEN (AUR)
ICD-10-R33.9
• Nature and duration of urinary symptoms prior to AUR
• Associated symptoms like fever, weight loss, sensory loss or weakness
of lower limbs
• Past history of retentions
• Rule out precipitating causes like diabetes mellitus, alcohol
consumption, recent surgery, UTI, constipation, cold exposure,
DEFINITION:
Emergency condition characterized by a sudden and painful inability to void voluntarily despite having a full bladder
HISTORY
EXAMINATION
prolonged travel and neurological conditions • Medication history
• Look for risk factors
• Fever
• Enlarged tender palpable bladder dull on percussion
• Phimosis, meatal stenosis, urethral induration, stone, urethral
discharge •DREforestimatingprostaticsize,consistency,tenderness;exclude
fecal impaction
• Focused neurological examination-anal tone, perianal sensation
and bulbocavernous reflex
RISK FACTORS OF PRECIPITATED AUR
RISK FACTORS OF SPONTANEOUS AUR DUE TO BPH
• Old age
• Severe lower urinary tract symptoms (LUTS) • Low peak flow rate
• High postvoid residual urine (PVR)
• Enlarged prostate or large median lobe
• High serum PSA
• Symptom worsening
• Increasing PVR during medical therapy
• Surgical procedure with general or loco-regional anaesthesia
• Bladder over-distension (eg prolonged journey)
• Exposure to cold
• Medications with sympathomimetic or
anticholinergic effects, diuretics, alcohol intake
• Feacal impaction
CAUSES
THAT BLOCK THE PASSAGE
THAT PARALYSE DETRUSOR
BPH Urethral Urethral Acute Calculus Stricture Prostatitis
Neurological diseases e.g. spinal cord compression, transverse myelitis, stroke, head injury
Ca Prostate Vesical Faecal Calculus impaction
Drug induced eg. opiods, anticholinergics, anti-histaminics, anti-diarrhoeals, flavoxate
INVESTIGATIONS
As AUR is an acute emergency, no investigation is required before catheterization to relieve symptoms. The volume of urine drained should be documented.
DESIRABLE
CBC, S. Glucose,S. Creatinine and Electrolytes, USG KUB Urine analysis& Urine culture of the drained urine
OPTIONAL (ONLY BY SPECIALISTS)
NOT TO BE DONE ROUTINELY
• Cystoscopy,CT / MRI,RGU + MCU,Urodynamic studies
MANAGEMENT ALGORITHM
Attempt gentle urethral catheterization
FOR CATHETERIZATION

Use a 14 or 12 Fr Foley urethral catheter
Do not remove catheter earlier than a day
COMPLICATIONS DUE TO AUR
• Urinary tract infection • Acute kidney injury
COMPLICATIONS DUE TO CATHETERIZATION
• Post obstructive diuresis with dys-electrolytemia
• Transient decompression hematuria
• Urethral injury during catheterization
INDICATIONS FOR HOSPITALIZATION
• Patients of AUR with significant comorbidities
• Patient of AUR with complications listed above
Catheterization successful
Catheterization fails
Keep catheter 1-3 days*
Precipitated AUR due to
Suprapubic cystostomy if adequately trained
OR
Refer to urologist
Drugs
Diabetes
Neurological disturbances Urethral stricture
Pelvic and Perineal Surgery Fecal impaction
Urinary/ peri anal Infection
Spontaneous AUR due to BPH
No prior history of r/c acute retention ± severe obstructive lower urinary tract symptoms
No prior history
α blockers for 2-4 days
T.W.O.C
Treat the cause
Surgery
Succeeds
Fails
Surgery
Trial without catheter
Continue medical management
If fails,
refer to urologist
ABBREVIATIONS
BPH: Benign Prostatic IPSS: International Prostate TWOC: Trial Without Catheter Hyperplasia Symptom Score
WW: Watchful waiting
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
GROSS HAEMATURIA
ICD-10-R31.0
PERFORM THOROUGH CLINICAL EVALUATION
SYMPTOMS
• Blood in urine – red coloured or dark coloured • May be associated with pain:
• Pain during voiding (urethra)
• Pain in suprapubic region (bladder) • Pain in flank (kidney)
• Acute retention of urine due to clots
• Haematuria associated with clots (severe)
HOW TO INVESTIGATE
EXAMINATION
• Pulse, blood pressure • Check for pallor
• Check for anasarca
• Per abdomen
examination: Palpable
bladder, flank mass • Digital rectal
examination: Enlarged prostate, hard nodular/ smooth surfaced prostate
• Rule out vaginal causes of bleeding
RED URINE BUT NOT
HAEMATURIA
• Foods: beetroot, blackberry, rhubarb
• Medicines: rifampicin, pyridium
Even single episode of haematuria warrants complete evaluation
MAKE A CLINICAL DIAGNOSIS: IS HAEMATURIA
ESSENTIAL
• Urine examination – routine, microscopy • Hemoglobin estimation
• Kidney function tests (KFT)
• Ultrasonography of kidney urinary
bladder and prostate region
OPTIONAL
• Urine culture
• Urine for active
sediments(if nephrotic/ nephritic syndrome suspected)
• PT/INR (if bleeding disorder suspected)
• Serum prostate specific antigen (if required)
• Urine for acid fast bacilli – 3 samples (if tuberculosis suspected)
INITIAL
• Urethra: stone, urethritis, stricture • Prostate: inflammation, benign
hyperplasia, malignancy
TOTAL
• Kidney: stone, malignancy (renal parenchyma, pelvis/ ureter), genito-urinary tuberculosis
• Ureter: stone, malignancy, genito- urinary tuberculosis
• Bladder: infection, genitourinary tuberculosis, stone, malignancy
TERMINAL
• Bladder: stone, tumor at bladder neck • Prostate: inflammation, benign
hyperplasia, malignancy
WHEN TO REFER (WARNING SIGNS)
• Deranged kidney functions
• Suspecting malignancy
• Haematuria with hypertension /
albuminuria
• Persistent severe haematuria
DESIRABLE
• Contrast enhanced computed tomography of kidney urinary bladder region/ intravenous pyelography (if KFT normal)
• Magnetic resonance imaging of Kidney urinary bladder region (if KFT deranged)
• Urine cytology if > 40yrs or smoker • Cystoscopy if > 40 years or smoker
HOW TO TREAT
GENERAL
• Start intravenous fluids if required (primary level)
• If Anaemia – may trans- fuse blood as required (primary level)
• Manage clot colic / flank pain with analge- sics (primary level)
• If Acute urinary reten- tion – catheterise with 20/22Fr 3 way Foley and may start continuous irrigation with normal saline (Primary level)
• Cystoscopic clot evacu- ation may be per- formed if feasible (ter- tiary level)
• If basic evaluation and management facilities are unavailable – refer (tertiary level)
SPECIFIC
• Haematuria should be considered as a symptom of genitourinary malignancy in patients >40years old until proven otherwise
• Suspected nephrotic/nephritic syndrome: cola coloured urine, proteinuria, anasarca, hypertension – Refer to nephrologist (tertiary level)
• Suspect urinary tract infection : presents with dysuria, increased frequency of voiding and other irritative lower urinary tract symptoms with/ without fever- treat with broad spectrum oral antibiotics (primary level)
DIFFERENTIAL DIAGNOSIS FOR CHRONIC CONDITIONS LEADING TO HAEMATURIA
Stones
Renal cell cancer
Bladder tumor
Genito-urinary tuberculosis
Symptoms
Flank pain
Ureteric colic
Recurrent urinary tract infection Haemturia
Flank mass Flank pain Haematuria
Haematuria Urinary retention
Dysuria Frequency Nocturia Haematuria
Investiga- tions
Ultrasonography
Xray KUB
Intravenous pyelography or Computed tomography
Ultrasonography Computed tomography
Ultrasonography Computed tomography Urine cytology
Urine analysis
Urine acid fast bacilli
Urine tuberculosis culture Gene expert (optional) Intravenous pyelography or Computed tomography
Treatment

5mm or symptomatic – refer to urologist
Mostly surgical treatment – refer to urologist
Mostly surgical treatment – refer to urologist
Oral Antitubercular treat- ment – 6months, refer to a urologist, close follow up
REFERENCES

Standard treatment guidelines in urology: Ministry of Health and Family selfare
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
MALE INFERTILITY
ICD-10-N46.9
AIM
• To ascertain contributory male factor
• Identify potentially correctable conditions
• Identify incorrectable condtions that may or may not be amenable to Assisted Reproductive Technique (ART)
• Identify underlying medical conditions responsible for infertility
HISTORY
• Age of partners and duration of infertility.
• Use of contraception and lubricants.
• Knowledge of sexual cycle, technique, frequency.
• Sexual and ejaculatory dysfunction, volume of ejaculate
• Medical illness: STD, diabetes, recent fever, chronic bronchitis and any debilitating medical conditions
• H/o Chemotherapy, Radiotherapy
• Congenital anomalies,
cryptorchidism, hypospadias,
Chordee
• Testicular torsion, drug history,
trauma and swelling
• H/o past surgeries( hernia repair,
orchiopexy, retroperitoneal
surgery)
• Family history
(infertility,consanguinity,genetic
disorders),
• Exposure to environmental toxins
(pesticides,herbicides, chronic heat and radiation (sauna bath, tight non cotton undergarments, laptops & mobile)
• Partner history: Any menstrual abnormality, infertility evaluation till date
WHEN TO SUSPECT?
Inability to conceive even after one year of regular unprotected intercourse.
Evaluation earlier than one year if female age is >35yrs, family history of infertility or very anxious couples. Infertility Incidence is 10-15%. Male factor- contributory in 50% cases.
HOW TO PROCEED?
Both partners examined simultaneously*
Ensure marriage is consummated, couple has frequent timed intercourse with the knowledge of ovulatary cycle.
*Male factor is an under recognised problem and the failure to recognise often leads to social and psychological adverse effects. Often the male is evaluated once the female has been examined thoroughly and this delays the treatment . Greater the duration of infertility lesser the chance of success.
PHYSICAL EXAMINATION
• Body habitus (obesity, Klinefelter’s). Secondary sexual characters, gynecomastia
• Penis: hypospadias, epispadiasis, chordee,
• Testes: volume, consistency, masses, contours
• Epididymis: flat, turgid, nodularity. Vas deferens –present/absent thickened or beaded
• Cords-presence of varicocele. Inguinal or scrotal scar.
• Rectal examination: cyst, dilated seminal vesicles.
INVESTIGATIONS
SEMEN ANALYSIS (ESSENTIAL)
• At least two- samples 1-2 months apart ; Abstinence of 1-3 days.; Collected in sterile, medical grade plastic wide mouth containers.
• Provided within the lab or transported within an hour at room temperature and examined immediately
• WHO 2010 criteria for normal report. Volume: >1.5, ml, Sperm conc.: >15 million/ ml, Sperm motility: >40% , Progressive > 32%, Sperm morphology: >4% normal
forms, Leukocyte density: <1 million/mL Normal Semen Analysis: Rule out sexual dysfunctions, Anatomic abnormalities, Female factorandunexplained Low volume semen: Incomplete Collection, Retrograde ejaculation, Ejac. duct obstruction, Cong. Absence of VasDeferens,Hypogonadism • Azoospermia: Obstructive (Epididymal,vasal) • Nonobstructive: (Genetic, Chromosomal,Hormonal, CT/RT, Post torsion testes, orchitis, Cryptorchidism, Idiopathic) • Oligo-astheno-teratospermia: Isolated Asthenospermia: Antisperm antibodies, Sperm structural defect, Hypogonadism • Multiple defects: Varicocele, Cryptorchidism, Genital tract infection, Systemic illness, Prolonged abstinence, Drugs (Sulfasalazine,NFT, Colchicine,Chemotherapy,GnRhanalogs, Spironolactone, Ketokonazole, Anabolic steroids, cocaine, alcohol. Chemicals: heavy metals, herbicides, organic solvents, fungicides, pesticides) DIAGNOSTIC CATEGORIES ACCORDING TO SEMEN ANALYSIS REPORT Note: If a patient is unable to produce semen consider retrograde ejaculation and anejaculation. Need further evaluation. OPTIONAL INVESTIGATIONS • Hormonal assay: Serum FSH, LH, Prolactin, Testosterone, Estradiol, T/E ratio • Culture: Urine, Semen, Prostatic fluid, Antisperm antibodies, Viability assay, Sperm function tests, Scrotal USG & doppler, TRUS, Genetic studies, • Testicular biopsy (Multiple bilateral preferable) MANAGEMENT PHC/CHC Normal Semen report: (Rule out unconsummation, sexual dysfunction, anatomic abnormailities) Abnormal Semen report: • Refer to Urologist/ infertility centre •Preventivemeasures:Avoidgonadotoxins,gonadotoxicdrugs, smoking,tobacco,chronicheat, excess use of mobiles; Encouraging healthy life style: Nutritious diet, regular physical exercise, avoid stress, use of antioxidants and vitamins( Vit. C, Vit E , Zinc) • Female partner to be evaluated by gynecologist • Management of reversible nonsurgical causes (Infections etc.) and surgical cause i.e. varicocoele if surgeon available. • For further evaluation refer to district/ tertiary hospital. DISTRICT HOSPITAL • Hormonal assay and Testicular biopsy • Management of sexual and ejaculatory dysfunction • Management of Varicocele and Hypogonadotropic hypogonadism • ART: AIH/AID and counselling for adoption. TERTIARY LEVEL • Additional testing:TRUS, Genetic, ASA, Sperm function tests • Advanced surgery: Microsurgical VVA,VEA, Varicocelectomy, TURED, Sperm retreival techniques, Cryopreservation and sperm banking • Advanced ART: IVF-ET/IVF ICSI • History and Physical examination( PE) • Proper Semen analysis TREATMENT ALGORITHM CFTR Gene Mutation ICSI DI/ Adoption Counselling Cystic SV & ED TURED Vasography guided TRUS guided Fibrous Non-operable PESA + ICSI Not palpable CABVD Palpable E.D.O. TRUS AZOOSPERMIA (Low volume, ↓pH, Fructose -ve) Retrograde ejaculation ruled out Examine Vas Obstructive (FSH-N, Epid, turgid) Normal testes Exploration, check vasal patency Needle biopsy (if required) Microsurgical VEA AZOOSPERMIA (Normal volume, Fructose +ve) Clinical Examination & FSH Equivocal (N-FSH, N-testes) B/L Multiple testicular biopsy Focal Sperms TESE-ICSI P.T.F. (Testes small, FSH>2N)
Normal No
DI/ Adoption
Discuss options
Considering ICSI
VEA/
ICSI DI/
Adoption
Genetic study Multipletesticularbiopsy
Sperms
Sperms absent
Sperms present Cryo preservation
ICSI
↑ FSH
Severe Germ epith damage
↑ASA Steroids +
OLIGO-ASTHENO-TERATOSPERMIA
(↓ count, ↓ motility, poor morphology) Varicocele
Varicocelectomy
Refer for Assisted Reproductive Technique (IUI/IVF/ICSI)
Infection Antibiotics
Idiopathic Empirical Medical Rx
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
ABBREVIATIONS
FSH: Follicle Stimulating Hormone
EDO: Ejaculatory Duct Obstruction CABVD: Congenital Absence of Bilateral Vas deferens
VVA: Vaso Vasostomy
PTF: Primary Testicular Failure VEA: Vasoepididymal Anastomosis TRUS: Trans Rectal Ultrasonography PESA: Percutaneous Epididymal Sperm Aspiration
ASA: Anti Sperm Antibodies
DI: Donor Insemination
TESE: Testicular Sperm Extraction
SV & ED: Seminal Vesicle & Ejaculatory Duct
TURED: Trans Urethral Resection of Ejaculatory Duct
ART: Assited Reproductive Technique
AIH: Artificial Insemination Husband
AID: Artificial Insemination Donor
ICSI: Intra Cytoplasmic Sperm Injection IVF-ET: Invitro Fertiliztion – Embryo Transfer GUTB: Genito Urinary Tuberculosis
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
RENAL AND URETERIC STONES
ICD N20.0
HOW WILL YOUR PATIENT PRESENT AND WHAT TO SUSPECT
CLINICAL SCENARIO
Flank pain
Colicky pain starting from back
and radiating to front
Colicky pain starting from back
& radiating upto groin
Colicky pain starting from back & radiating to upper thigh & scrotum/ vulva
• Haematuria may be present with stone at any location
• Lower ureteric stones may also present with difficulty in passing urine
SUSPECT
Renal Stone
Upper ureteric stone
SYMPTOMS
Renal Pelvic Stone
Upper Ureteric Stone
Lower ureteric stone
• Colics may be associated with nausea and vomiting
• Can present as anuria in bilateral ureteric stones, ureteric stone in a solitary kidney
History of site & type of pain, associated symptoms hint towards possible site of stones.
Remember to take past history of stone diseases,
medications, family history etc
RADIOLOGY
Mid ureteric stone
INVESTIGATION
NAME
ADVANTAGES AND DISADVANTAGES
X-KUB
Readily available, inexpensive, minimal radiation but needs preparation hence may not be the preferred test in emergency settings
USG
Readily available, no radiation, safe test in pregnancy, detects radiolucent stones, high sensitivity for hydronephrosis. Can miss a ureteric calulus
IVP
Anatomical and functional imaging, aids in planning surgery but high radiation and needs preparation. Not useful in poor renal function
CT Scan
No contrast required, highly sensitive and specific, detect radiolucent stones, detect other causes of flank pain, but risks higher radiation and cost
METABOLIC EVALUATION
TIPS FOR ORDERING INVESTIGATIONS
• Order X-KUB and Ultrasound in all patients of suspected renal stones (90% of renal stones are radio-opaque).
• In acute colic NCCT should be preferred if available
• Once the stone is detected, get Intravenous pyelography if stone is seen on X-ray
• CT urography if stone is radiolucent to aid further treatment
Initial biochemical evaluation in all stone formers
Urine analysis, serum creatinine, electrolytes namely calcium,
phosphorous and uric acid. Intact parathyroid hormone and stone analysis are preferrable.
Extended Evaluation
To be done in recurrent stone former, stone in children, bilateral stones, family history of stone, history of gut surgery, solitary kidney and cysteine stones. Typically to be done at 3-4 weeks after stone clearance
MANAGEMENT ALGORITHM
Should include initial metabolic evaluation plus 24-hour urinary levels of calcium,uric acid, and creatinine. Preferable to do urinary oxalate and citrate levels too.
∙ Increase daily fluid intake to ensure a urine output >2 lit/day
• Restrict extra salt intake and increase dietary fibre.
• Do not restrict calcium intake. • Increase citrate
rich food such as lemon, orange juice etc.
• Decrease consumption of food rich in oxalates like spinach, nuts, beet root, potato chips, French fries.
• Avoid purine rich foods like animal protein, alcoholic drinks like beer
Analgesics Hydration
Flank Pain, Hematuria
+
Fevers with chills & rigors/ Anuria
Empiric Antibiotic/
hydration
Warning signs for immediate referral
∙ Anuria
∙ Fever with chills and
rigors
∙ Suspected renal failure
∙ Persistent haematuria
X- Ray KUB USG Abdomen IVP/ CT Scan
Urine Analysis Initial Metabolic screen
Single Stone > 5mm, Baseline
investigation normal
Counsel the patient for future preventive strategies
Renal Stone <1cm Uteric Stone >5mm
<1cm Medical expulsive therapy Alpha Blockers Potaasium Nitrate Kidney/ ureteric stone >1cm
Medical Expulsive Therapy (MET)
∙ Alpha blockers such as Tamsulosin(0.4mg/day);
Alfuzocin(10mg/day); Doxazocin(4mg/day);
Silodocin(8mg/day)
∙ MET should be offered
∙ In Ureteric stones <10mm
∙ In the absence of infection, obstruction or deranged renal function.
∙ MET can be tried for upto 4 weeks
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019
HIGHER CENTRE REFERRAL

Department of Health Research
Ministry of Health and Family Welfare, Government of India
Standard Treatment Workflow (STW) for the Management of
SCROTAL SWELLING
ICD-10-N50.89
HOW TO MAKE A CLINICAL DIAGNOSIS?
AS PER SITE
DIAGNOSE THE SITE Are you able to reach YES
Scrotal swelling
Scrotal wall involved in swelling
PARIETAL SWELLING
A swelling, clinical or on USG, arising from any of the scrotal structures: scrotal wall &/ or intrascrotal contents
OF SWELLING?
Testis palpated separately
Swelling located well above testis
above the swelling? NO
INGUINOSCROTAL SWELLING
Scrotal wall normal & can be pinched off the swelling
INTRASCROTAL SWELLING
PAINFUL
Fever Present Fever Absent
Acute infection
• Traumatic • Ischaemic (e.g. torsion)
TESTICULAR SWELLING
Testis not palpable normally
Swelling located just above &/or behind testis
SPERMATIC CORD SWELLING
DIAGNOSE THE NATURE OF SWELLING?
PAINLESS
Cystic Solid
EPIDIDYMAL SWELLING
AS PER NATURE
Fluid accumulation, (e.g. Hydrocele,epididymal cyst)
• Ch. inflammatory, (e.g. Filariasis, TB) • Tumors
MAKE A CINICAL DIAGNOSIS
PARIETAL (SCROTAL WALL) SWELLINGS INTRASCROTAL SWELLINGS
BILATERAL UNILATERAL
Ac. Inflammation
• Cellulitis
• Fournier gangrene
• Reactionary to epididymo- orchitis
• Furuncle Abscess
Traumatic
Contusional
Blunt trauma
Ch. Inflammation
Filarial Elephantiasis
Fluid Accumulation
• Edema in anasarca, IVC thrombosis
• Urinary extravasation
Scrotal wall cysts
Neoplasm
Melanoma, Scrotal Carcinoma
Dermatofibroma;
Testicular
Epididymal Spermatic cord
Cystic
Hydrocele
• Epididymal cyst • Spermatocele
Varicocele
Solid
Painless
• Testicular tumor
Painful
• Torsion testis • Orchitis
Painless
• Ch. Filarial epididymitis
• Ch. Tuberculous Epididymitis
• Adenomatoid tumor
Painful
• Ac. Epididymitis
Painless
• Lipoma cord
Painful
• Funiculitis
RED FLAG SIGNS
PAINFUL SWELLING
• Sudden onset
• O/E tender enlarged testis, pain
increases on elevating testis • Severe pain
• Vomiting
• No fever
PAINLESS SWELLING
• Solid testicular swelling is felt
TORTION TESTIS
(More common in adolescents)
TORTION TESTIS
(Testicular Tumor)
CONFIRM BY
• Scrotal doppler
ATTEMPT
• Manual detorsion if patient reports early
CONFIRM BY
• Scrotal USG
• Serum tumor markers
REFER URGENTLY FOR EXPERT CONSULTATION
REFER ALL CASES FOR EXPERT CONSULTATION
INVESTIGATIONS
SUSPECTING AC. INFLAM DISEASE
Essential
• TLC/DLC
• Blood sugar
Desirable
• Anti filarial antibody
SUSPECTING CH. INFLAMMATORY DIS.
Essential
• TLC/DLC • ESR
Desirable
• Anti filarial Ab • TB Gold test
• Scrotal USG
SUSPECTING TESTICULAR TUMOR
Essential
• Beta hCG • Alfa feto
protein
• Serum LDH
Desirable
• Scrotal USG • Abdomino – Pelvic CECT
Scan
SUSPECTING
TORSION
Essential Desirable
• TLC/DLC • Scrotal doppler
SUSPECTING
VARICOCELE
Essential Desirable
• TLC/DLC • Scrotal doppler
HOW TO TREAT COMMON CONDITIONS?
PARIETAL SWELLINGS
FURUNCLE/ABSCESS
• Broad Spectrum Antibiotic Amoxy + Clavulinic acid
• Consider drainage if fluctuations+ or impending rupture
REFER
• If abscess appears part of underlying disease
• Nonresponders
• Immunocompromised
patient
FILARIAL ELEPHANTIASIS
• DEC 100 mg TDS x 20 days
• Doxycycline 100 mg BD x 20
days
• Scrotal Elevation/support
REFER
• Non responders • Huge size
AC. EPIDIDYMO-ORCHITIS
• If patient had a urinary tract instrumentation or dysuria – suspect bacterial type,
treat by – antibiotic and support
REFER If no response in 48 hrs
• Treat all other cases as filarial by – DEC 100
mg x TDS x20 days
• Doxycycline 100 mg x BD x 20 days
• Give anti inflammatory drugs to all
HYDROCELE
• Small size – no treatment
• Moderate to large -Do
hydrocelectomy
• Aspiration can be performed
under asceptic precautions in select cases REFER if not trained to do the surgery
CHRONIC EPIDIDYMO-ORCHITIS
• Mostly filarial in origin but if –

Patient has had H/O UTI or urethral
catheterization, suspect bacterial – Patient has H/O TB, suspect
tuberculosis
• Treat by DEC 100 mg
TDS + Doxycycline 100 mg BD for 20 days
REFER if
• No response to treatment
• Epididymal abscess or local sinus
discharging syrup like pus
VARICOCELE
• Counsel for semen analysis (2-3 times) REFER if ‘discrepancy in size of testis’ and/or ‘abnormal semen parameters present’
• Rest all cases be given symptomatic treatment
INTRASCROTAL SWELLINGS
KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.
October/ 2019 CONTRIBUTORS
ADVISORY COMMITTEE
Dr. Balram Bhargava, Secretary, DHR and DG, ICMR – Chairman
Dr. Nikhil Tandon, Dept. of Endocrinology, AIIMS, New Delhi. – Vice Chairman
WHO India Country Office Representative – Member, Ex officio
Director General Health Services / Representative- Member, Ex officio
Additional Secretary & MD (NHM), MoHFW – Member, Ex officio
Joint Secretary, DHR – Member Secretary, Ex officio
Dr. Pramod Garg, Dept. of Gastroenterology, AIIMS, New Delhi – Member
Dr. Sanjay Jain, Dept. of Internal Medicine, PGIMER, Chandigarh – Member
Dr. T. Sunderraman, School of Health System Studies, TISS, Mumbai – Member
Dr. J.V. Peter, Dept. of ICU and Trauma, CMC, Vellore – Member
Dr. Ashok Deorari, Dept. of Paediatrics, AIIMS, New Delhi – Member
Dr. Naveet Wig, Dept. of Medicine, AIIMS, New Delhi – Member
Dr. C. H. Arun Kumar, Dept. of Orthopaedics, RIMS, Imphal – Member
Brig. Shakti Vardhan, Dept. of Gyanecology/Oncology, AFMC, Pune – Member
Dr. Sudeep Gupta, Dept. of Medical Oncology, TATA Memorial, Mumbai – Member
Dr. S.K. Dwivedi, Dept. of Cardiology, KGMU, Lucknow – Member
Dr. Jeyaraj Durai Pandian, Dept. of Neurology, CMC, Ludhiana – Member
Dr. Vivekanand Jha, Nephrologist, The George Institute for Global Health, Delhi – Member Dr. Rajdeep Singh, Dept. of Surgery, MAMC, Delhi – Member
Dr. Reva Tripathi, Formerly Dept of ObGyn, MAMC, New Delhi- Member.
Dr. S. S. Kale, Dept. of Neurosurgery, AIIMS New Delhi- Member
Dr. Peush Sahni, Dept. of G.I. Surgery, AIIMS, New Delhi- Member.
Dr. Binod Khaitan, Dept. of Dermatology, AIIMS, New Delhi- Member
Dr. Amlesh Seth, Dept. of Urology, AIIMS, New Delhi- Member
Dr. Shally Avasthi, Dept. of Paediatrics, KGMC, Lucknow- Member
Dr. B.N. Gangadhar, NIMHANS Bangalore – Member.
Dr. Anil Bhansali, Dept. of Endocrinology, PGIMER, Chandigarh- Member.
Dr. Shiv Chaudhary, Dept. of CTVS, AIIMS New Delhi- Member
Dr. Surinder Lal Jindal, Formerly Dept.of Pulmonology, PGIMER, Chandigarh-Member.
Dr. Lalit Kumar, Dept. of Medical Oncology, AIIMS, New Delhi- Member
Dr. Radhika Tandon, Dept. of Ophthalmology, AIIMS, New Delhi- Member
Dr. Alok Thakar, Dept. of Otorhinolaryngology, AIIMS , New Delhi-Member
Dr. Prakash Kotwal, Foremerly Dept. of Orthopaedics, AIIMS, NewDelhi- Member.
SPECIAL GUESTS
Dr. V. K. Paul, Member, NITI Aayog
Dr. Indu Bhushan, CEO, National Health Authority Dr. Sudhir Gupta, D.G.H.S.
Dr. Anil Kumar, MoHFW.
EDITORIAL BOARD
CHAIR
Prof. Pramod Garg, Dept. of Gastroenterology, AIIMS, New Delhi
MEMBERS
Prof. Rajdeep Singh,, Dept. of Surgery, MAMC, New Delhi.
Prof. Sanjay Jain, Dept. of Medicine, PGIMER, Chandigarh.
Prof. S.K. Dwivedi, Dept. of Cardiology, KGMC, Lucknow.
Prof. Sushil Kabra, Dept. ofPaediatrics, AIIMS, New Delhi.
Prof. Vivekanand Jha, Executive Director, The George Institute for Public Health, New Delhi
MEMBER SECRETARY
Dr. Deepika Saraf, Scientist E, ICMR.
Department of Health Research
Ministry of Health and Family Welfare, Government of India EXPERT GROUPS
NAME AND AFFILIATED INSTITUTE ROLE
UROLOGY
Department of Health Research
Ministry of Health and Family Welfare, Government of India
PAEDIATRICS
Dr. Shally Awasthi, KGMC, Lucknow Chair
Dr. Sushil Kabra, AIIMS, New Delhi Co-Chair
Dr. Neelam Mohan, Medanta, Gurgaon Co-Chair
Dr. Pushpa Kini – KMC, Manipal Member
Dr. Suvasini Sharma, LHMC,New Delhi Member
Dr. Joseph Mathew- PGIMER, Chandigarh Member
Dr. Surjit Singh, PGIMER, Chandigarh Member
Dr. Kuldeep Singh, AIIMS, Jodhpur Member
Dr. Himanshu Chaturvedi, Balrampur Hospital, LKO Member
Dr. Shinjini Bhatnagar, THSTI, Faridabad Member
Dr. Amlesh Seth, AIIMS, New Delhi Chair
Dr. Anup Kumar, Safdarjung,New Delhi Co-Chair
Dr. Rakesh Kapoor, SGPGI, Lucknow Member
Dr. Dorairajan Narayanan, JIPMER, Pondycherry Member
Dr. Santosh Kumar, CMC, Vellore Member
Dr. Divakar Dalela, Ex KGMC, Lucknow Member
Dr. Anil Mandhani, Medanta, Gurugram Member
Dr. Shivam Priyadarshi, SMS Jaipur Member
Dr. Ravi Mohan Mavuduru,PGIMER Chandigarh Member
Dr. T P Rajeev, Guhawati Medical College Member
NEUROLOGY
Dr. Jeyaraj Pandiyan, CMC, Ludhiana Chair
Dr. Manjari Tripathi, AIIMS,New Delhi Co-Chair
Dr. Salil Gupta, R & R Hospital, New Delhi Member
Dr. Shefali Gulati, AIIMS,New Delhi Member
Dr. Sylaja PN, SCTIMST, Trivandrum Member
Dr. Vivek Nambiar, AIMS, Kochi Member
Dr. Karamvir Goyal, Ludhiana Member
Dr. P K Misra, Lucknow District Hospital Member
Dr. Sapna Erat Sreedharan, SCTIMST, Trivandrum Member
NEPHROLOGY
Dr. Vivekanand Jha, The George Inst of Global Health Chair
Dr. Sandeep Mahajan, AIIMS, New Delhi Co-Chair
Dr. Manisha Sahay, Osmania Medical College, Hyderabad Member
Dr. Arpana Iyengar, St John’s Medical College, Bangalore Member
Dr. Vijay Kher, Medanta, Gurgaon Member
Dr. Gopesh Modi, Samarpan Noble Hospital, Bhopal Member
Dr. Swaranjeet Kaur Gill, Bathinda Member
Dr. Anant Kumar Jha, Civil Surgeon, Godda Member
Dr. Vikram Singh, Dehradun Member
Dr. Ranjeet Nair, R&R Army Hospital, New Delhi Member
Dr. Vivek Kumar, PGIMER, Chandigarh Member
Dr. Vishal Golay, Anandalok Hospital, Siliguri Member
Dr. Mukta Mantan, MAMC, New Delhi Member
Dr. Natarajan Ramakrishnan Member
Dr. Narayan Prasad, SGPGI, Lucknow Member
Dr. Ramesh Chandrababu Member Dr. R.K. Sharma, SGPGI, Lucknow Member
Dr. George Abraham, JIPMER, Pondycherry. Member
CARDIOLOGY
Department of Health Research
Ministry of Health and Family Welfare, Government of India
Dr. S. K. Dwivedi, KGMC, Lucknow Chair
Dr. George Joseph, CMC, Vellore Co-Chair
Dr. Aditya Kapoor, SGPGI, Lucknow Member
Dr. G.Karthikeyan, AIIMS, New Delhi. Member
Dr. Paul V George, CMC Vellore Member
Dr. Santhosh Satheesh, JIPMER, Pondycherry Member
Dr. Saurabh Mehrotra, PGIMER, Chandigarh Member
Dr. Praveen Chandra, Medanta, Gurgaon Member
Dr. Amit M Vora, Reliance, Mumbai. Member
Dr. Calambur Narasinhan, CARE, Hyderabad Member
Dr. Paul V George, CMC Vellore Member
Dr. Praveen Chandra, Medanta, Gurgaon Member
Dr. Reva Tripathi, MAMC Delhi Chair
Dr. Vinita Das, KGMC, Lucknow Co-Chair
Dr. Anjoo Agarwal, KGMC, Lucknow Member
Dr. Manju Puri, LHMC, New Delhi Member
Dr. Radhika, UCMS, New Delhi Member
Dr. Neelam Aggarwal, PGIMER, Chandigarh Member
Dr. Asmita Rathore, MAMC, New Delhi. Member
Dr. Aruna Kekre, CMC, Vellore Member
Dr. Dasari Papa, JIPMER, Pondycherry Member
Dr. Usha Rani, IOG Member
Dr. Manika Khanna , NRIGS Member
Dr. Neerja Bhatla, AIIMS, New Delhi Member
Dr. Seema Saran, GMC, Badaun Member
ENT
PULMONOLOGY
Dr. Alok Thakar, AIIMS, Delhi Chair
Dr. Anupam Mishra, KGMC, Lucknow Co-Chair
Dr. A Ramesh, St John’s Medical College, Bangalore Member
Dr. Harpreet Kochar, Private Practice, Greater Noida Member
Col Dr. B. K. Prasad, Command Hospital, Lucknow Member
Dr. Anuja Bhargava, Ira Medical College, Lucknow Member
Dr. Prem Sagar, AIIMS Delhi Member
Dr. Surinder Jindal, PGIMER, Chandigarh Chair
Dr. G.C. Khilnani, AIIMS, New Delhi. Co-Chair
Dr. Ashutosh Aggarwal, PGIMER, Chandigarh Member
Dr. Anant Mohan, AIIMS, New Delhi Member
Dr. Raj Kumar, VPCI, Delhi Member
Dr. Alok Nath, SGPGI, Lucknow Member
Dr. Dhruv Chaudhary, PGIMS, Rohtak Member
Dr. Uma Mohan, St John’s Medical College, Bengalluru Member
Dr. DJ Christopher, CMC, Vellore Member
Dr. Deepak Talwar, Metro Hospital, Noida Member
PSYCHIATRY
Dr. BN Gangadhar, Director, NIMHANS Member Dr. Pratap Sharan, AIIMS, New Delihi.
Co-Chair
Dr. Jagadisha Thirthalli, NIMHANS, Bengaluru
Member
Dr. Subho Chakrabarti, PGIMER, Chandigarh
Member
Dr. Prabha Chandra, NIMHANS, Bengaluru
Member
Dr. Janardhan Reddy, NIMHANS, Bengaluru
Member
Dr. Anju Dhawan, AIIMS, New Delhi
Member
Dr. Satish Girimaji, NIMHANS, Bangalore
Member
Dr. L Vijayakumar, Sneha, Chennai
Member
Dr. KS Jacob, CMC, Vellore
Member
Dr. Rajesh Sagar, AIIMS, New Delhi.
Member
ADMINISTRATIVE SUPPORT
Mr. V. K. Gauba, Jt. Secretary, Dept. of Health Research, MoHFW, Govt. of India Mrs. Anu Nagar, Jt. Secretary, Dept. of Health Research, MoHFW, Govt. of India Dr. Reeta Rasaily, Scientist G, ICMR, New Delhi
Dr. Ashoo Grover, Scientist F, ICMR, New Delhi
Dr. Kavitha Rajshekhar, Scientist E, ICMR, New Delhi
STW SECRETARIAT
Dr. Deepika Saraf, Scientist E & Team Lead, ICMR, New Delhi Dr. JerinJose Cherian, Scientist D, ICMR, New Delhi
Dr. Ashis John, Scientist, C, ICMR, New Delhi
Dr. Deeksha Elwadhi, Scientist, C, ICMR, New Delhi
Mr. Parth Garg, Graphic Designer, ICMR, New Delhi
Ms. Anika Gupta, Graphic Designer, ICMR, New Delhi
Ms. Surabhi Singh, Graphic Designer, ICMR, New Delhi Ms. Sugandha Singh, Graphic Designer, ICMR, New Delhi Er. Amitesh Kumar Sharma, Scientist B, ICMR, New Delhi Mr. Sandeep Suman, Logistics Support, ICMR, New Delhi
Department of Health Research
Ministry of Health and Family Welfare, Government of India Department of Health Research
Ministry of Health and Family Welfare, Government of India
STANDARD TREATMENT WORKFLOWS
PARTNERS
2019 EDITION VOLUME I