Southafrica3 Law

STANDARD TREATMENT GUIDELINES
AND
ESSENTIAL DRUGS LIST
FOR
SOUTH AFRICA
PRIMARY HEALTH CARE
1998 EDITION
Copies may be obtained from:
The Directorate: Pharmaceutical Programmes and Planning
Private Bag X828
Pretoria
0001
Publisher's notes:
Text was prepared in Corel Word Perfect 8.
Copyright 1998, The National Department of Health
Any part of this material may be reproduced, copied or adapted to meet local needs,
without permission from the committee or the Department of Health, provided that
the parts reproduced are distributed free of charge or at cost - not for profit.
First printed 1996.
Published by:
The National Department of Health, Pretoria, South Africa
NOTE
The information presented in these guidelines conforms to current medical,
nursing and pharmaceutical practice. It is provided in good faith.
Contributors and editors cannot be held responsible for errors, individual
responses to drugs and other consequences.
South African Standard Treatment Guidelines and Essential Drugs List for
Primary Health Care, 1998 Edition
Compiled by:
The National Essential Drugs List Committee
National Essential Drugs List Committee
Mrs S Buekes
Dr MH Cassimjee
Prof HM Coovadia
Dr JE Doevendans
Prof AGS Gous
Prof BB Hoek
Dr JP Jooste
Prof WJ Kalk
Prof KP Klugman
Dr B Luke
Mr AT Masango, alternative Dr MH Smit
Ms MP Matsoso
Prof L Mazwai
Prof AM Meyers
Prof KP Mokhobo
Ms H Mller
Prof JJ Moodley
Prof S Rataemane
Dr SM Risenga
Prof H Seftel
Prof JR Snyman
Mr GS Steel
Prof RS Summers
Ms L Turner
Dr BW van de Wal
Dr B Vos (deceased)
Prof L Wagstaff
Review for Primary Health Care Expert Committee
Prof JD Baqwa
Dr S Beja
Prof V Gathiram
Prof B Maharaj
Dr L Makubalo
Prof KP Mokhobo
Ms H Mller
Ms S Naude
Dr P Onyebujoh
Prof H Seftel
Mr GS Steel
Ms F Suleman
Dr BW van de Wal
Editorial task team
Dr W Bannenberg
Ms A Labuschagne
Prof W Loening
Prof B Maharaj
Prof KP Mokhobo
Ms SM Naude
Ms V Pinkney-Atkinson
Mr GS Steel
Editors
Ms A Labuschagne
Ms S Naude
Ms V Pinkney-Atkinson
Secretariat
Mrs J Ludick
Mrs DPM Phillips
Ms LN Peteni
Mrs M Van Rooyen
Prof KP Mokhobo:
Chairperson: National EDL Committee and Review for PHC Expert Committee
Mr OMB Pharasi/Prof RS Summers :
Deputy-Chairpersons: National EDL Committee
Ms MP Matsoso: Director: Pharmaceutical Programmes and Planning
Ms LN Peteni: Essential Drugs Programme Manager
Acknowledgements
The second edition of the Standard Treatment Guidelines and Essential Drugs List for
Primary Health Care which appear in this booklet are the result of a lengthy consultative
process. They include material from many sources and recommendations and advice
from numerous individuals and groups. The groups included professional societies and
organisations, expert committees and institutions.
We offer sincere thanks to all those who contributed appropriate and relevant
information, members of the National Essential Drugs List Committee for the 1996-1999
period, the Review for Primary Health Care Expert Committee, the different task teams,
the editorial groups, and the editors. We also thank WHO/DAP in Geneva for their
technical support and the British government for financial assistance whenever it was
needed.
Special thanks go to:
Prof KP Mokhobo, Dr BW van de Wal, Prof B Maharaj, Ms F Suleman, Prof Gathiram,
Mr GS Steel, Ms H Mller, Ms S Naude and Dr W Bannenberg, without whose
dedication to the process this publication might not have been possible.
Table of Contents
Foreword ............................................................................................................................. i
Introduction......................................................................................................................... ii
The Essential Drugs Concept ............................................................................................iii
How to use this book.......................................................................................................... v
Motivation to amend the national essential drugs list/treatment guidelines ......................vii
Disease notification procedures ........................................................................................ ix
A guide to patient education in chronic conditions .......................................................... xiii
How to use a flow diagram.............................................................................................. xvii
Flow diagrams:
Acute abdominal pain without fever .............................................................................1
Adult with generalised oedema ....................................................................................2
Chest pain.....................................................................................................................3
Earache.........................................................................................................................4
Headache .....................................................................................................................5
Sexually transmitted diseases - male............................................................................6
Sexually transmitted diseases - female.........................................................................7
Sore throat ....................................................................................................................8
Vaginal bleeding ...........................................................................................................9
Chapter 1 - Cardiovascular conditions.............................................................................10
1.01 Acute pulmonary oedema(See Chapter 19 - Trauma and Emergencies) ......10
1.02 Cardiac arrest - cardio-pulmonary resuscitation(See Chapter 19 - Trauma and
Emergencies)........................................................................................................10
1.03 Hypertension .....................................................................................................10
1.04 Ischaemic heart disease, angina pectoris (See Acute myocardial infarction
(AMI), Chapter 19 - Trauma and Emergencies) ..................................................14
1.05 Acute myocardial Infarction (AMI)(See Chapter 19 - Trauma and Emergencies)
..............................................................................................................................14
1.06 Acute rheumatic fever ......................................................................................15
1.07 Valvular heart disease .......................................................................................15
Chapter 2 - Central nervous system conditions...............................................................17
2.01 Epilepsy .............................................................................................................17
2.02 Febrile convulsions (See Chapter 18 - Signs and symptoms) .........................20
2.03 Meningitis...........................................................................................................20
2.03.1 Meningitis, acute.......................................................................................20
2.03.2 Meningitis meningococcal, prophylaxis....................................................21
2.04 Status epilepticus (see Chapter 19 - Trauma and emergencies) .....................21
Chapter 3 - Dental and oral conditions ............................................................................22
3.01 Candidiasis, oral (thrush)...................................................................................22
3.02 Dental abscess and caries ................................................................................23
3.02.1 Dental abscess.........................................................................................23
3.02.2 Dental caries/toothache............................................................................24
3.03 Gingivitis.............................................................................................................25
3.03.1 Gingivitis, uncomplicated..........................................................................25
3.03.2 Acute necrotising ulcerative gingivitis.......................................................26
3.04 Herpes stomatitis/cold sore/fever blister............................................................27
3.05 Mouth ulcers......................................................................................................28
3.06 Periodontitis.......................................................................................................28
Chapter 4 - Ear, nose and throat .....................................................................................30
4.01 Allergic rhinitis (hay fever)..................................................................................30
4.02 Tonsillitis ............................................................................................................31
4.02.1 Pharyngitis, viral........................................................................................31
4.02.2 Tonsillitis, bacterial....................................................................................31
4.03 Otitis externa......................................................................................................32
4.04 Otitis media, acute.............................................................................................34
4.05 Otitis media, chronic suppurative......................................................................35
4.06 Sinusitis, acute...................................................................................................36
4.07 Epistaxis (See Chapter 19 - Trauma and Emergencies) ..................................37
Chapter 5 - Endocrine system..........................................................................................38
5.01 Diabetes mellitus................................................................................................38
5.01.1 Diabetes mellitus type 1............................................................................38
5.02 Diabetes mellitus type 2.....................................................................................38
Chapter 6 - Eye conditions...............................................................................................46
6.01 Conjunctivitis .....................................................................................................46
6.01.1 Conjunctivitis, allergic ...............................................................................46
6.01.2 Conjunctivitis, bacterial .............................................................................47
6.01.3 Conjunctivitis, viral and epidemic viral ......................................................47
6.02 Conjunctivitis of the newborn (ophthalmia neonatorum)..................................48
6.03 Eye, chemical burn (See Chapter 19 - Trauma and Emergencies) .................49
6.04 Eye injury, foreign body (See Chapter 19 - Trauma and Emergencies) ..........49
6.05 Glaucoma, acute...............................................................................................49
6.06 Trachoma ..........................................................................................................50
Chapter 7 - Family planning .............................................................................................52
7.01 Contraception, barrier methods ........................................................................52
7.02 Contraception, vaginal.......................................................................................52
7.03 Contraception, intrauterine contraceptive device (IUCD) .................................52
7.04 Contraception, hormonal...................................................................................53
7.04.1 Injectable contraceptives..........................................................................53
7.04.2 Oral contraceptives...................................................................................53
7.05 Post-coital contraception...................................................................................53
Chapter 8 - Gastro-intestinal conditions...........................................................................54
8.01 Abdominal pain/dyspepsia/heartburn/indigestion.............................................54
8.02 Amoebic dysentery............................................................................................56
8.03 Anal conditions..................................................................................................56
8.03.1 Anal fissures .............................................................................................56
8.03.2 Haemorrhoids...........................................................................................57
8.04 Appendicitis .......................................................................................................57
8.05 Bacillary dysentery (shigellosis) .........................................................................58
8.05 Cholera..............................................................................................................58
8.06 Constipation.......................................................................................................59
8.07 Diarrhoea, acute................................................................................................61
8.07.1 Acute diarrhoea in children ......................................................................61
8.07.2 Acute diarrhoea without blood in adults...................................................62
8.07.3 Chronic diarrhoea in adults ......................................................................63
8.08 Giardiasis...........................................................................................................63
8.09 Helminthic infestation - excluding tapeworm.....................................................64
8.10 Helminthic infestation (tapeworm).....................................................................65
8.11 Nausea and vomiting, non-specific...................................................................66
8.12 Typhoid fever .....................................................................................................68
Chapter 9 - Gynaecology and obstetrics..........................................................................69
9.01 Abortion.............................................................................................................69
9.01.1 Abortion, incomplete/spontaneous ..........................................................69
9.02 Anaemia in pregnancy.......................................................................................70
9.03 Antepartum haemorrhage.................................................................................71
9.04 Cracked nipples during breastfeeding ..............................................................71
9.05 Delivery, normal .................................................................................................72
9.06 Dysmenorrhoea.................................................................................................74
9.07 Ectopic pregnancy.............................................................................................74
9.08 Vaginal bleeding................................................................................................75
9.08.1 Abnormal vaginal bleeding during fertile years ........................................75
9.08.2 Post-menopausal bleeding.......................................................................75
9.09 Pregnancy-induced hypertension (PIH)............................................................75
9.10 Vaginal discharge/lower abdominal pain in women(STD Protocols 2 and 4) ..77
9.11 Vaginal ulcers (See Chapter 11 - Infections) ....................................................79
Chapter 10 - Immunisation...............................................................................................80
10.1 Dosage and administration ...............................................................................80
10.3 Immunisation schedule......................................................................................84
10.4 Additional vaccines and target groups..............................................................85
10.5 Immunisation by injection..................................................................................85
10.6 The cold chain...................................................................................................86
Chapter 11 - Infections (selected) and related conditions ...............................................89
11.01 Amoebic dysentery (See Chapter 8 - Gastrointestinal conditions).................89
11.02 Bacillary dysentery (See Chapter 8 - Gastrointestinal conditions)..................89
11.03 Bilharzia...........................................................................................................90
11.04 Chickenpox......................................................................................................91
11.05 Cholera (See Chapter 8 - Gastrointestinal conditions) ....................................92
11.06 Giardiasis (See Chapter 8 - Gastrointestinal conditions) .................................92
11.07 HIV...................................................................................................................92
11.08 Infection control: the use of antiseptics and disinfectants ..............................94
11.09 Malaria.............................................................................................................95
11.10 Measles ...........................................................................................................98
11.11 Meningitis (See Chapter 2 - Central Nervous System) ...................................99
11.12 Mumps...........................................................................................................100
11.13 Rubella (German measles) ...........................................................................100
11.14 Sexually transmitted diseases (STD) ............................................................101
Protocol 1: Urethral discharge/burning micturition in men................................102
Protocol 2 and 4: Vaginal discharge in women/lower abdominal pain
in women (see Chapter 9 - Gynaecology and Obstetrics) .................................102
Protocol 3: Genital ulceration in men and women .............................................102
Protocol 5: Inguinal swelling/bubo - no ulcer present in men and women........103
Protocol 6: Balanitis/balanoposthitis in men.......................................................103
Protocol 7: Painful scrotal swelling in men.........................................................104
Protocol 8: Interpretation of syphilis serology - RPR/VDRL...............................104
11.14.1 Genital warts.........................................................................................106
11.14.2 Pubic lice ..............................................................................................106
11.14.3 Genital scabies .....................................................................................106
11.14.4 Molluscum contagiosum......................................................................106
11.14.5 Gonorrhoea neonatorum.....................................................................107
11.15 Tick-bite fever ................................................................................................107
11.16 Typhoid fever (See Chapter 8 - Gastrointestinal conditions)........................107
11.17 Tuberculosis (See Chapter 16 - Respiratory conditions)..............................107
Chapter 12 - Musculoskeletal conditions .......................................................................108
12.01 Arthralgia (See Chapter 18 - Signs and Symptoms) ....................................108
12.02 Gout...............................................................................................................108
12.02.1 Gout, acute...........................................................................................108
12.02.2 Gout, chronic........................................................................................109
12.03 Osteoarthritis ..................................................................................................110
12.04 Rheumatoid arthritis ......................................................................................110
12.05 Septic arthritis................................................................................................110
Chapter 13 - Nutritional and blood conditions ...............................................................111
13.01 Anaemia ........................................................................................................111
13.01.1 Anaemia, iron deficiency ......................................................................112
13.01.2 Megaloblastic/Macrocytic anaemia ......................................................113
13.01.3 Folate deficiency (See chapter on pregnancy (section 9.02)).............113
13.02 Vitamin deficiencies.......................................................................................113
13.02.1 Vitamin A deficiency .............................................................................113
13.02.2 Pyridoxine (Vitamin B6) deficiency........................................................114
13.02.3 Pellagra (nicotinamide deficiency)........................................................115
13.02.4 Thiamine deficiency (Wernickes encephalopathy and beriberi) .........116
13.03 Failure to thrive (FTT)....................................................................................116
13.03.1 Protein energy malnutrition (PEM).......................................................117
13.04 Vitamin B deficiencies ...................................................................................118
Chapter 14 - Psychiatric illness ......................................................................................120
14.01 Delirium - acutely confused, aggressive patient(See Chapter 19 - Trauma and
emergencies) ......................................................................................................120
14.02 Depression ....................................................................................................120
14.03 Psychosis, acute ...........................................................................................122
Chapter 15 - Renal and urinary tract conditions ............................................................126
15.01 Urinary tract infection, uncomplicated (acute uncomplicated cystitis) ..........126
15.02 Acute pyelonephritis......................................................................................127
Chapter 16 - Respiratory conditions...............................................................................128
16.01 Asthma ..........................................................................................................128
16.01.1 Asthma, chronic ...................................................................................128
16.01.2 Chronic bronchitis and emphysema ....................................................132
16.01.3 Acute bronchospasm associated with asthma and chronic
obstructive bronchitis..........................................................................................133
16.02 Bronchitis, acute............................................................................................136
16.03 Common cold and influenza.........................................................................137
16.04 Cough (See Chapter 18 - Symptoms and signs) .........................................138
16.05 Croup (laryngotracheobronchitis) .................................................................138
16.06 Pneumonia....................................................................................................140
16.07 Tuberculosis..................................................................................................142
Chapter 17 - Skin conditions..........................................................................................150
17.01 Acne vulgaris.................................................................................................150
17.02 Bacterial infections of the skin.......................................................................151
17.02.1 Boil, abscess ........................................................................................151
17.02.2 Impetigo................................................................................................152
17.03 Cellulitis..........................................................................................................153
17.04 Eczema..........................................................................................................154
17.04.1 Eczema, atopic.....................................................................................154
17.04.2 Seborrhoeic eczema............................................................................155
17.04.3 Acute, moist or weeping eczema.........................................................155
17.05 Fungal infections of the skin .........................................................................156
17.05.1 Athlete's foot - tinea pedis ....................................................................156
17.05.2 Candidiasis, skin...................................................................................157
17.05.3 Napkin rash (candida) ..........................................................................158
17.05.4 Ringworm.............................................................................................158
17.06 Parasitic infections of the skin.......................................................................159
17.06.1 Lice (pediculosis)..................................................................................159
17.06.2 Scabies.................................................................................................160
17.07 Napkin rash, non-fungal................................................................................161
17.08 Sandworm.....................................................................................................162
17.09 Urticaria .........................................................................................................162
Chapter 18 - Signs and symptoms.................................................................................164
18.01 Arthralgia .......................................................................................................164
18.02 Cough............................................................................................................165
18.03 Febrile convulsions........................................................................................166
18.04 Fever..............................................................................................................167
18.05 Headache, mild, non-specific........................................................................169
18.06 Insomnia........................................................................................................170
18.07 Itching (pruritus) ............................................................................................171
18.08 Pain control ...................................................................................................172
18.08.1 Chronic pain control in advanced or incurable cancer ........................173
18.09 Jaundice........................................................................................................175
Chapter 19 - Trauma and emergencies.........................................................................176
19.01 Acute myocardial infarction (AMI) .................................................................177
19.02 Acute pulmonary oedema.............................................................................178
19.03 Anaphylactic shock .......................................................................................179
19.04 Bites and stings .............................................................................................180
19.04.1 Animal and human bites.......................................................................180
19.04.2 Insect bites and stings .........................................................................183
19.04.3 Snakebite..............................................................................................184
19.05 Burns .............................................................................................................186
19.06 Cardiac arrest - cardio-pulmonary resuscitation...........................................188
19.06.1 Cardiac arrest - adults ..........................................................................188
19.06.2 Cardiac arrest - children.......................................................................190
19.07 Delirium with acute confusion and aggression.............................................193
19.08 Nose bleed (epistaxis) ...................................................................................195
19.09 Eye, chemical burn........................................................................................195
19.10 Eye injury, foreign body.................................................................................196
19.11 Exposure to poisonous substances..............................................................197
19.12 Injuries ...........................................................................................................199
19.13 Shock ............................................................................................................201
19.14 Sprains and strains........................................................................................202
19.15 Status epilepticus ..........................................................................................203
19.16 Hypoglycaemia and hypoglycaemic coma....................................................204
Abbreviations ..................................................................................................................206
Essential drugs list ..........................................................................................................207
Index of diseases and conditions ...................................................................................216
Index of drugs.................................................................................................................221
i
Foreword
It is gratifying progress that the revised edition of the standard treatment guidelines and
essential drugs list is completed two years after the first publication. This edition is the
product of selfless contributions by several experts and is a highly commendable job
done in updating the treatment guidelines and essential drugs list to ensure acceptability
at primary health care level. The product has also enjoyed wider participation by health
workers than before, which has been a very important step for them to understand and
embrace the processes involved.
A truly national, enabling and facilitating document now exists that is suitable for
continuous improvement of practice and promotion of effective prescribing and rational
dispensing at primary health care level.
This revised edition has been completed at the time that the first of the treatment
guidelines on common conditions at hospital level have been completed. An important
milestone has thus been reached in the implementation of the objectives of the National
Drug Policy and Essential Drugs Programme. This second phase in the further
development and refinement of the EDL/STGs has seen tremendous progress from a
mere series of reactions to current problems, to a positive concept which is embraced
worldwide.
The experiences learnt thus far and the outcome of the surveys conducted are indicative
of a comprehensive approach needed to tackle the medicine-related problems that still
exist which result in non-availability of medicines when needed. This initiative should
then translate into an achievement of optimal availability and use of medicines which can
only be achieved if a common framework is established, that of the National Drug Policy.
All the stakeholders and contributors are to be congratulated and thanked on this
magnificent achievement. It now remains for the health authorities and all health care
providers at all levels, to commit themselves in ensuring that the medicines are available,
their rational use is promoted by prescribers and consumers, and the culture of cost-
effective and efficient management of drug supplies is developed.
Dr Nkosazana C Dlamini-Zuma
Minister of Health
ii
Introduction
The National Review Expert Committee for the Primary Health Care Standard Treatment
Guidelines and Essential Drug List set about its task professionally and expeditiously.
The first green book provided valuable experience and useful basic material. In this
same period of two years, the documents on adult and paediatric treatment guidelines
for hospitals were prepared. The various expert committees have ensured
concordance between the primary health care and secondary (hospital) treatment
guidelines.
South Africa is thus poised to realise the objectives of the National Drug Policy - a
historic stage. The implementation of the Essential Drugs Programme requires a
comprehensive strategy, including supply, distribution, education, training, information,
informed decision-making and appropriate human resource development. The year
1998 ushers in an important milestone in the process.
The EDL Committee tasked with the compilation of the treatment guidelines and
essential drugs lists, based on WHO guidelines and those from other countries,
employed sound principles. The common major health problems were identified,
competency based treatment guidelines were carefully prepared, categories of
prescribers were defined and linked to the level of care. Medicines were listed using their
generic names only. In the process, evidence-based data were used regarding efficacy,
safety, risk-benefit ratio, and acceptable quality.
As the pharmaceutical industry introduces new medicines, these will be critically
considered in terms of, inter alia, their potential to improve safety and efficacy, better
cost advantage, best researched, better pharmacokinetic properties, reliable supply,
best patient compliance and other drug qualities. Future additions, deletions and/or
replacements on the EDL shall be motivated based on scientific data accompanied by
appropriate references.
The development of standard treatment guidelines and essential drugs list will be an
ongoing process subject to regular updates, quality assurance and promotion of patient
compliance and rational use of drugs.
Professor K P Mokhobo
Chairperson
iii
The Essential Drugs Concept
Effective health care requires a judicious balance of preventive and curative services. A
crucial and often deficient element in curative services is an adequate supply of
appropriate medicines. The government of South Africa clearly outlines its commitment
to ensuring availability and accessibility of medicines for all people in the health
objectives of the National Drug Policy. They are as follows:
To ensure the availability and accessibility of essential medicines to all citizens.
To ensure the safety, efficacy and quality of drugs.
To ensure good prescribing and dispensing practice.
To promote the rational use of drugs by prescribers, dispensers and patients
through provision of the necessary training, education and information.
To promote the concept of individual responsibility for health, preventive care and
informed decision-making.
Achieving these objectives requires a comprehensive strategy that not only includes
improved supply and distribution, but also appropriate and extensive human resource
development. The implementation of an Essential Drugs Programme (EDP) forms an
integral part of this strategy, with rationalisation of the wide variety of medicines available
in the public sector as a first priority. The private sector is encouraged to use these
guidelines and the drug list wherever appropriate.
The working principles used by the National Essential Drugs List (EDL) Committee to
draft the EDL/STGs for primary care were:
conditions to be included are those which comprise the majority of contacts at the
primary level, i.e. at the point of first contact with the health service. Prevalence and
severity were factors also considered;
treatment for the conditions will be initiated at primary level, will be competency-
based and not restricted to specific occupations;
treatment will follow recommended standard treatment guidelines, which will specify
both treatment and referral details;
drug legislation will reflect and facilitate practice, i.e. scheduling will enable health
workers at primary level access to recommended drugs.
The criteria for the selection of essential drugs for Primary Health Care in South Africa
were based on the WHO guidelines for drawing up a national EDL. They include the
following points:
any drug included must meet the needs of the majority of the population
sufficient proven scientific data regarding effectiveness must be available
any drug included in the EDL should have a substantial safety and risk/benefit ratio
all products must be of an acceptable quality, and must be tested on a continuous
basis
the aim, as a rule, is to include only products containing single pharmacologically
active ingredients
combination products, as an exception, will be included where patient compliance
iv
becomes an important factor, or two pharmacologically active ingredients are
synergistically active in a product
products will be listed according to their generic names only
where drugs are clinically equally effective, the drugs will be compared on the
following factors:
the best cost advantage
the best researched
the best pharmacokinetic properties
the best patient compliance
the most reliable local manufacturer
a request for a new product to be included on the EDL must be supported by
scientific data and appropriate references on its advantages and benefits over an
existing product
Essential drugs are those that satisfy the needs of the majority
of the population.
They should therefore be available at all times, in adequate amounts, and
in the appropriate dosage forms.
v
How to use this book
To use these standard treatment guidelines optimally, you need to:
familiarise yourself with the contents
study the sections carefully
carry the book with you
comment on the guidelines
The treatment guidelines are presented in chapters according to the systems of the
body. Each chapter starts with a list of drugs used in that section, then gives the disease
condition and the ICD 10 number which refers to an international classification method
used when describing certain diseases and conditions. The second number in brackets
is the ICD 9 number which was used in the previous edition. A description of the disease
condition is then given, followed by the management objectives, the non-drug treatment,
the drug treatment and the criteria for referral.
Some of the drugs listed are only examples of a therapeutic class and not necessarily
the drug of choice, e.g. an example of a beta-adrenergic blocking agent is given as
atenolol oral. In such cases the Provincial Pharmacy and Therapeutics Committees
(PTCs) will decide on their drug of choice within that therapeutic class.
In order to find the relevant sections in the book easily, use the indices at the back of the
book. These have been divided into an index of drug names and a disease condition
index. The Essential Drugs List is the list of drugs derived from the treatment guidelines.
Each chapter commences with a list of drugs used in that section and at the back of the
book is the full list of drugs used in the whole book.
Information on the major Poison Centres in the country is given in the chapter on
Trauma and Emergencies.
Review of the first edition of the EDL/STGs for PHC indicated that there is a need to
have a problem-based approach to the handling of health conditions presenting to a
PHC facility. This has been accommodated for by the inclusion of flow charts and
information on how to use them.
The section provided at the front of the book called Patient Education in Chronic
Conditions aims to assist health workers to improve patient compliance and health
generally.
When treating patients, the final responsibility for the well-being of the individual patient
remains with the health worker. It is therefore important to remember that the
recommended treatments provided in this book are guidelines only and are based on
the assumption that the prescriber is competent to handle patients health conditions
that present at their facilities.
Comments that will improve these treatment guidelines when they are being reviewed
within 2 years will be highly appreciated. These should be accompanied by evidence-
vi
based motivation to add, delete or replace a drug, together with a proposed treatment
guideline. The form for motivation to amend the essential drugs list is included. It can
also be obtained from the address given below or copied and sent to the Provincial PTC
who will consider the motivation before sending it through for inclusion in the review
process. Motivations with no references and evidence to back them up will not be
considered.
Comments from persons and institutions outside the public service should be sent to:
The Essential Drugs Programme
Pharmaceutical Programmes and Planning
Department of Health
Private Bag X828
Pretoria
0001
The last date for submission of comments on this edition is June 2000.
vii
Motivation to amend the national
essential drugs list/treatment guidelines
Please indicate nature of submission by marking the appropriate box:
Deletion of a listed drug. (Please attach proven evidence on the
harmful/useless effects of the drug.)
Addition of a new disease. (Please attach epidemiological evidence
proving prevalence and a proposed treatment guideline.)
Addition of a new drug. (Please attach evidence on proven benefits of this
drug.)
Replacement of a listed drug. ( Please attach evidence on the proven
benefits of such a replacement over the existing drug.)
Name of drug (INN)/generic: ...........................................................................................
Dosage form and strength: .............................................................................................
Therapeutic class: ...........................................................................................................
Reason for amendment: .................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Reference/s: ....................................................................................................................
viii
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.........................................................................................................................................
.........................................................................................................................................
Advantages over existing drug(s) in same therapeutic class:
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Proposed Treatment Guideline: (Attach Guideline if necessary)
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Submitted by: ................................................................................................................
Address:...........................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
Contact Person:...............................................................................................................
Telephone Number:.........................................................................................................
Signature: ........................................................................................................................
Date: ................................................................................................................................
Please send to:
Director-General
Department of Health
Private Bag X828
PRETORIA
0001
ix
For attention: Enquiries:
Directorate: Pharmaceutical Programmes and PlanningTel: (012) 312 0369
Sub-directorate: Essential Drugs Programme Fax:(012) 324 4525
x
Disease notification procedures
The disease reporting system in South Africa is based on government law (Health Act,
Act 63 of 1977) and regulations where specific infectious diseases (see list of notifiable
medical conditions below) must be reported to the Provincial Health Departments, who
then report to the national Department of Health (see flow chart of data below). Disease
surveillance comprises mainly four types: Notifiable disease-reporting system,
Laboratory-based surveillance, Hospital-based surveillance and Population based
surveillance.
Notifiable disease reporting
A notification serves as the first step in a surveillance cycle, namely for data-capturing or
data collection. Notification can be done via the mail, fax or telephone to the local
authority concerned. Any person (not necessarily a health worker) can notify a notifiable
medical condition (see the Health Act regulations - legal obligations). The list of notifiable
medical conditions at the moment determines that 40 different diseases are notifiable
(see list below).
Process
Forms involved:
GW17/5: initial diagnosis (complete immediately)
GW17/3: line list of cases (complete weekly)
GW17/4: line list of deaths (complete weekly)
The initial diagnosis of a notifiable medical condition is done on a case-based form with
the relevant address and fine details on it, to make tracing of the case as easy as
possible, since a disease notification demands action (follow-up) at the lowest level
(GW17/5 - for cases and deaths).
In South Africa it is required by law that completed weekly disease notification forms are
submitted for all notifiable diseases from each local authority or district office to the
provincial office. These should be completed and sent by all reporting units, e.g.
hospitals, health centres, health posts, clinics, private practitioners, and private nurses,
to the district public health office. The initial diagnosis forms are summarised weekly on
separate line list forms for cases (GW17/3) and for deaths (GW17/4).
To ensure complete reporting of all EPI diseases, a zero report should be sent if
no cases of a notifiable disease were seen for the reporting period.
Reporting
from reporting units to district office within 9 days
reporting week is Sunday to Saturday
All the reporting units should submit their disease notifications to reach the district no
later than 9 days after the end of the reporting week. A reporting week is normally taken
from Sunday to Saturday. Thus, the weekly notifications are normally expected by the
following Monday.
xi
All reports received within that period are considered to be on time. After that period
has passed, any reports received is considered late.
Some diseases can be monitored more accurately through the laboratory because of
the non-specificity of the clinical syndrome, e.g. most types of food poisoning. For other
diseases, laboratory data acts only as a confirmation of the clinical diagnosis.
These include rabies, cholera and Crimean-Congo haemorrhagic fever.
Hospital-based surveillance
Hospital discharge information as well as mortality data can be used to monitor disease
trends and disease burden in a particular area served by the hospital.
Population-based surveillance
A population-based surveillance system collects and analyses medical information in a
well defined population.
Complete reporting is needed when doing surveillance on rarely occurring diseases as
well as for the elimination of diseases (e.g. polio eradication in SA by 2000 - surveillance
of Acute Flaccid Paralysis).
xii
FLOW CHART
Procedure to follow with notifiable medical conditions
Diagnosis
can be any health worker, not necessarily a doctor

GW 17/5
immediately

Local authority/Hospital/District
whoever is responsible for disease containment

GW17/3 (cases)
GW 17/4 (deaths)
weekly

Regional office
Health Information Unit
if data entry is done at regional level - province specific

computer disks
e-mail
weekly

Provincial office
Health Information Unit
if data entry is done at provincial level - province specific

computer disks
e-mail
weekly

National Department
Directorate HSR & Epidemiology
Private Bag X828, Pretoria 0001
xiii
Notifiable Medical Conditions
Acute flaccid paralysis
Anthrax
Brucellosis
Cholera
Congenital syphilis
Crimean-Congo haemorrhagic fever
Other haemorrhagic fevers of Africa
Diphtheria
Food poisoning
Haemophilus influenza type B
Lead poisoning
Legionellosis
Leprosy
Malaria
Measles
Meningococcal infection
Paratyphoid fever
Plague
Poisoning agricultural stock remedies
Poliomyelitis
Rabies
Rheumatic fever
Tetanus
Tetanus neonatorum
Trachoma
Tuberculosis primary
Tuberculosis pulmonary
Tuberculosis of other respiratory organs
Tuberculosis of meninges
Tuberculosis of intestines, peritoneum
Tuberculosis of bones and joints
Tuberculosis of genito-urinary system
Tuberculosis of other organs
Tuberculosis miliary
Tuberculosis total
Typhoid fever
Typhus fever (lice-borne)
Typhus fever (ratflea-borne)
Viral hepatitis type A
Viral hepatitis type B
Viral hepatitis non-A non-B
Viral hepatitis unspecified
Viral hepatitis total
Whooping cough
Yellow fever
xiv
A guide to patient education in chronic conditions
Poor therapeutic outcome of chronic conditions such as asthma, diabetes, epilepsy and
hypertension can, in many cases, be ascribed to:
poor or non-adherence to an otherwise sound therapeutic regimen
lack of communication between the various health care providers involved in the
patient's management
lack of effective communication between health care provider and patient
ineffective and/or insensitive regimens
inconsistency of medicine supply
Patient Compliance
A patient's compliance to his or her therapeutic regimen may be influenced by:
drug selection - prescribing should be the result of a process of concordance
whereby the patient's needs and preferences are matched to the available
therapeutic alternatives
patient education - this empowers the patient to make an informed decision as to
whether he or she should comply or not
Although both of the above require longer consultation time, this investment is rewarded
many times over during the subsequent years of management.
Other influencing factors might be:
adverse side-effects of the medicines
lifestyle behaviour
level of responsibility to manage and control the disease
Patients behaviour patterns contributing toward poor compliance
Patients may perceive treatment as unnecessary.
In conditions that are asymptomatic, e.g. hypertension, or those that only produce
transient symptoms such as epilepsy:
the patient often questions the validity of complying with therapy where there are no
obvious results. As a result he or she decides to abandon therapy particularly where
the therapy introduces new symptoms (side-effects)
the patient is compliant in a cyclical fashion - for a short period following transient
symptoms (e.g. seizure) or increased awareness (e.g. following a BP reading at the
clinic) but after a period returns to being non-compliant until the next episode of
symptoms or clinic visit
In conditions where symptoms show no improvement and where therapy merely
controls the pathophysiological process:
the patient often feels that his/her therapy has not contributed toward quality of life
and in many ways has placed certain demands upon his/her lifestyle
To be compliant on a sustained basis means that the patient must adjust his/her lifestyle
in such a fashion that the regimen becomes habit. Inclusion of a regimen into the
patient's lifestyle is determined by the magnitude with which this adaptation intrudes
upon his/her established pattern. The greater the demand, the less likely the patient is to
comply. Thus, for example, a lunchtime dose in a school-going child who remains at
xv
school for extramural activity is unlikely to succeed. A shift worker may need to take a
sedating drug in the morning when working night shifts, and at night, when working day
shifts.
Some patients' lifestyles make certain adverse responses acceptable which others may
find intolerable. Sedation is unlikely to be acceptable to a student but an older patient
with insomnia may welcome this side-effect. This is where concordance plays a vital
role.
Education points to consider
Focus on the positive aspects of therapy while being encouraging regarding the
impact of the negative aspects and offer support to deal with the latter.
Provide realistic expectations regarding:
normal progression of the illness - especially important in those diseases where
therapy merely controls the progression
the improvement that therapy and non-drug treatment can add to the quality of
life
Establish therapeutic goals and discuss them openly with the patient.
Any action to be taken with loss of control or when side-effects develop.
In conditions that are asymptomatic or where symptoms have been controlled,
reassure the patient that this reflects therapeutic success, and not that the condition
has resolved.
Where a patient raises concern regarding anticipated side-effects, attempt to place
this in the correct context with respect to incidence or the risks vs. the benefits, and
whether or not the side-effects will disappear after continued use.
Towards concordance when prescribing
Establish the patients:
occupation
daily routine
recreational activities
past experiences with other drugs
expectations of therapeutic outcome
Balance these against the therapeutic alternatives identified based on clinical findings.
Any clashes with the chosen therapy should be discussed with the patient in such a
manner that the patient will conform to a changed lifestyle.
Note:
Education that focuses on these identified problems is more likely to be successful than
a generic approach toward the condition/drug.
xvi
Improving continuity of therapy
Clear and concise records.
Patient involvement in the care plan.
Every patient on chronic therapy should know:
his/her diagnosis
the name of every drug
the dose and interval of the regimen
his/her BP or other readings
Note: The prescriber should reinforce this only once management of the condition has
been established.
When the patient seeks medical attention for any other complaints such as a cold or
headache he/she must inform the hjealth worker about any other condition/disease
and its management
If a patient indicates that he/she is unable to comply with a prescribed regimen,
consider an alternative - not to treat might be one option, but be aware of the
consequences e.g. ethical
Notes on prescribing in chronic conditions
Don't change doses without good reason.
Never blame anyone or anything for non-adherence before fully investigating the
cause.
If the clinical outcome is unsatisfactory - investigate compliance (remember
side-effects may be a problem here).
Always think about side-effects and screen for them from time to time.
When prescribing a new drug for an additional problem ask yourself whether or not
this drug is being used to manage a side-effect.
Compliance with a once daily dose is best. Twice daily regimens show agreeable
compliance. However, once the interval is decreased to three times a day there is a
sharp drop in compliance with poor compliance to four times a day regimens.
Keep the total number of tablets to an absolute minimum as too many may lead to
medication dosing errors and may influence compliance.
xvii
Ideal body weight
xviii
xix
xx
How to use a flow diagram
The flow diagrams read from top to bottom, and from left to right. They contain three
different types of blocks, with the following interpretation:
The hexagonal (6-sided) blocks contain information that will guide you on making
your clinical decision. Notice that these boxes always have a YES or NO attached to
them.
The square blocks usually describe a clinical state or diagnose a condition. If there
is a diagnosis, the standard treatment guideline (STG) for this condition appears in
the EDL. To find more information on the management of the condition, refer to the
index to find the page number for that particular condition.
The oval boxes are so-called do boxes. These boxes are a guide on how to
manage the patient. They have the following meanings:
Treat: see management details as described in the STG.
Refer: refer as appropriate for routine referral.
Refer urgently: these conditions require immediate action. The patient must
be stabilised, and immediate transportation must be arranged.
Example:
Flow diagram 2: Adult with generalised oedema:
Starting at the first hexagonal block, dyspnoea, read left to right:
if there are signs of basal crackles, enlarged liver or raised neck veins, suspect
congestive heart failure and refer urgently.
if not
continue from top to bottom, then left to right, second line:
if the patient is pregnant, and the BP is higher than 140/90 and/or there is
proteinurea, and there is pregnancy induced hypertension, refer.
Continue in this fashion from left to right and top to bottom;
then
if there are none of the symptoms listed from the top to the bottom, the patient must
be referred for further investigation, as the cause of this dyspnoea is unknown.
Standard Treatment Guidelines
for
Primary Health Care
22 Standard Treatment Guidelines for Primary Health Care 1998
Chapter 1 - Cardiovascular conditions
Drugs used in this section
atenolol
benzathine penicillin
erythromycin estolate
erythromycin stearate
hydrochlorothiazide
methyldopa
nifedipine
perindopril
phenoxymethylpenicillin
reserpine
1.01 Acute pulmonary oedema
(See Chapter 19 - Trauma and Emergencies)
J81
1.02 Cardiac arrest - cardio-pulmonary resuscitation
I46.9
1.03 Hypertension
I10 (410)
Description
A blood pressure (BP) elevated above normal measured on three separate occasions, a
minimum of 2 days apart.
children: age-related diastolic BP equal to or above:
less than 6 years: 80 mmHg
612 years: 84 mmHg
over 12 years: 90 mmHg
adults: systolic BP greater than 140 mmHg or diastolic BP greater than
90 mmHg
a hypertensive emergency is severe hypertension associated with some of the
following:
neurological signs, e.g. severe headache, visual disturbances, confusion, coma
or seizures
pulmonary oedema
LEVELS OF HYPERTENSION IN ADULTS
Chapter 1 Cardiovascular conditions 23
LEVEL OF
HYPERTENSION
SYSTOLIC
mmHg
DIASTOLIC
mmHg
mild more than 140 more than 90
moderate more than 169 more than 99
severe more than 170199 more than 100114
Management objectives
achieve and maintain the target BP with minimum adverse effects in adults:
systolic under 140 mmHg
and
diastolic under 90 mmHg
patients with co morbidity and BP equal to or above 140/90 mmHg
Non-drug treatment
all patients with hypertension require lifestyle modification
weight loss if above ideal weight
(see p. xvi)
regular physical exercise
stop smoking
moderate or no alcohol intake
restrict salt intake
restrict cholesterol intake
Drug treatment
in mild hypertension initiate drug therapy if there is poor response to lifestyle
modification measures after 36 months
in moderate hypertension initiate drug therapy as well as lifestyle modification at
diagnosis
check compliance with medication, this includes medication taken on the day of the
clinic visit because patients sometimes forget to take medication on the day of clinic
visits and this can be a reason of a high BP reading
monitor patients monthly and adjust therapy until the BP is stable
after target BP is achieved, patients can be seen at 3-monthly intervals
! CAUTION !
lower BP over a few days
a sudden drop in BP can be dangerous
STEP-WISE TREATMENT
STEP 1
ENTRY TO STEP 1 TREATMENT TARGET
mild to moderate
hypertension
no risk factors
lifestyle modification BP control within 3
6 months to less than
140/90 mmHG
STEP 2
mild hypertension and failure of
lifestyle modification alone to
reduce BP after 36 months
plus one risk factor
or
moderate hypertension at
diagnosis + risk factor
or
severe hypertension
lifestyle modification
and
hydrochlorothiazide
oral, 12.5 mg daily
BP control within
13 months to
less than 140/90
mmHg
STEP 3
failure of step 2 after
13 months
and
hydrochlorothiazide oral 25 mg daily
BP control within 1
3 months to less than
140/90 mmHg
STEP 4
failure of step 3 after
13 months
and
hydrochlorothiazide oral 25 mg daily
add
reserpine oral 0.1 mg daily
BP control within
1 month to less than
140/90 mmHg
STEP 5
ENTRY TO
STEP 5
TREATMENT TARGET
failure of step
4 after 1
3 months of
and
hydrochlorothiazide oral 12.5 mg daily
BP control within
12 months to
less than 140/90
compliance and
add
beta-adrenergic blocking agent, e.g. atenolol oral,
50 mg daily if not contra-indicated
mmHg with no
side-effects
STEP 6
ENTRY TO
STEP 6
TREATMENT TARGET
failure of step
5 after
2 months of
compliance
and
hydrochlorthiazide oral 12.5 mg daily
and
and
beta-adrenergic blocking agent, e.g. atenolol oral
50 mg daily if not contra-indicated
add
ACE inhibitor, e.g. perindopril oral, 4 mg to be
initiated by a doctor
BP control within
2 months to less
than 140/90
mmHg with no
side-effects
Contraindications
hydrochlorothiazide
gout
reserpine
depression
beta-adrenergic blocking agent e.g. atenolol
heart failure
diabetes mellitus
asthma and chronic obstructive airways disease
peripheral vascular disease
bradycardiac pulse rate less than 50/minute
ACE inhibitors
pregnancy
Special cases
pregnancy-induced hypertension
methyldopa oral, 250500 mg twice daily, use only during pregnancy
hypertension plus diabetes mellitus
hydrochlorothiazide 12.5 mg daily
assessment by a doctor
ACE inhibitor, e.g. perindopril, initiated by a doctor
perindopril oral, 4 mg once daily
hypertensive emergency , systolic BP above 130 mmHg, diastolic BP above
200 mmHg
nifedipine 5 mg oral, immediately, chewed or the contents of a capsule squirted into
the mouth
refer immediately
! CAUTION !
a hypertensive emergency needs immediate referral to hospital
administer nifedipine 5 mg immediately, chewed or the contents of a
capsule squirted into the mouth
Referral
Refer immediately (on the same day):
hypertensive emergency - administer nifedipine first (see above)
severe hypertensive - administer nifedipine first (see above)
systolic BP 200 mmHg or above, diastolic BP 115 mmHg or above
Refer within 1 week
children
young adults (under 30 years)
BP not controlled by step 5 where there is no doctor available, or step 6
pregnancy
diabetes mellitus
signs of target organ damage - oedema, dyspnoea, proteinuria, etc.
1.04 Ischaemic heart disease, angina pectoris
(See Acute myocardial infarction (AMI),
Chapter 19 - Trauma and Emergencies)
I21.9
1.05 Acute myocardial Infarction (AMI)
I21.9
1.06 Acute rheumatic fever
I01.9
Description
A condition in which the body develops antibodies against its own tissues following a
streptococcal throat infection.
patients present with a combination of symptoms and signs including:
arthralgia and arthritis that may shift
from one joint to another
cardiac failure
heart murmurs
rheumatic nodules
other complaints indicating a systemic
illness
chorea
prevent rheumatic fever and infective endocarditis
limit further damage to the heart valves
Referral
all cases
1.07 Valvular heart disease
I09.9
Description
Damage to heart valves commonly caused by rheumatic fever and occasionally by other
causes (congenital heart defects, ischaemic heart disease).
it may be complicated by:
heart failure
infective endocarditis
atrial fibrillation
systemic embolism
prevent infective endocarditis and heart failure
prevent repeated attacks of acute rheumatic fever
Non-drug treatment
refer all patients with heart murmurs for assessment
advise all patients with a heart murmur to inform health care providers of the presence
of the heart murmur when reporting for medical or dental treatment
Drug treatment
administer prophylactic antibiotic treatment prior to certain invasive diagnostic and
therapeutic procedures, e.g. tooth extraction, gastroscopy, cystoscopy and any
operation to prevent infective endocarditis
prophylactic antibiotic therapy for rheumatic fever
benzathine penicillin IM, every month
children under 30 kg: 600 000 IU
children and adults over 30 kg: 1.2 MU
or
phenoxymethylpenicillin oral 250 mg 12 hourly until 35 years old
or
for penicillin-allergic patients: erythromycin oral 12 hourly
children: erythromycin estolate 125 mg until able to swallow tablets
adults: erythromycin stearate 250 mg until 35 years old
Referral
any newly diagnosed heart murmur
development of cardiac symptoms and signs
worsening of clinical signs of heart disease
any other newly developing medical condition, e.g. fever
all patients with valvular heart disease must be referred for advice on prophylactic
antibiotics prior to any invasive diagnostic or therapeutic procedures to prevent
infective endocarditis
Chapter 2 Central nervous system conditions 29
Chapter 2 - Central nervous system conditions
benzylpenicillin
carbamazepine
ceftriaxone
chloramphenicol
diazepam
ethosuximide
phenobarbital
phenytoin
rifampicin
valproic acid
2.01 Epilepsy
G40.9 (345)
Description
Epilepsy takes several forms ranging from generalised tonic clonic seizures (grand mal)
to simple absence seizures (petit mal) that only involve a brief loss of consciousness.
Some clinical features of the different types of epilepsy:
there may be an aura (a warning symptom) before a seizure, e.g. a stomach cramp
that moves upwards
after a seizure some patients recover quickly while others may be confused and have
headaches for days
SEIZURE TYPE DESCRIPTION
generalised tonic
clonic
loss of consciousness preceeded by
a brief stiff phase followed by
jerking of all of the limbs
tonic one or more limbs become stiff without any jerking
simple partial no loss of consciousness
seizure on one side of the body
myoclonic jerking of one or more muscles in any part of the body with or
without loss of consciousness
jerking may start in any part of the body and spread
absence occurs in childhood
sudden cessation of activity followed by a blank stare
usually no muscle twitching
some children will smack their lips
prevent all or nearly all seizures with a minimum of side-effects so that patients may
lead normal lives
Non-drug treatment
epilepsy is associated with many legal, psychological and social problems - extensive
health education and counselling is necessary for the family and all concerned
patients should not take alcohol because it can cause or worsen seizures
see note on the management of chronic diseases (p. xi)
patients should keep a seizure diary which records the date and if possible the times
of the seizures - this will make assessment of therapy much easier
Drug treatment
GENERAL RULE
a single drug is best
Ask about the following as they can influence decisions on drug therapy:
has the patient been taking the medication regularly for at least 2 weeks or more
before the seizure? Ask about medication dosage and frequency
has the patient recently used some other medication?
is there a chance that alcohol or some other drug is involved?
if one or more of the above can be identified as a problem there is no need to adjust
therapy at this time
CHILDREN
SEIZURE DRUG TREATMENT* COMMENTS
generalised
tonic clonic
phenobarbital oral 3.55 mg/kg at night
or
carbamazepine oral 8 mg/kg daily for 2
weeks
then 1015 mg/ kg daily
maximum dose 20 mg/kg daily divided
23 times daily
or
phenytoin oral 47 mg/kg daily
once phenobarbital
treatment has been
initiated, review
behaviour profile and
academic performance
then try carbamazepine
use phenytoin as a last
resort
absences ethosuximide oral 30 mg/kg daily in two
divided doses
or
valproic acid (see dose below)
initiate with ethosuximide
mixed and
myoclonic
valproic acid oral 3040 mg/kg daily in
two divided doses
Note
valproic acid = sodium valproate X 0.87
avoid carbamazepine as
it may complicate
seizures
watch for weight gain
* Recommended doses - these are a rough guide and will work for most patients. Some patients
may need much higher or lower doses which will be guided by therapeutic monitoring.
ADULTS
SEIZURE DRUG TREATMENT* COMMENTS
generalised
tonic clonic
partial
phenytoin oral 4.55 mg/kg daily
on lean body mass (p. xvi)
maximum dose 400 mg at night
or
carbamazepine oral 200 mg twice
daily for first 2 weeks
then 300 mg twice daily
maximum dose 900 mg twice
daily
the choice between these two
agents must be made on the
acceptability of side- effects
and how the number of doses
influences lifestyle
watch for dose-related side-
effects with phenytoin
myoclonic valproic acid oral 500 mg twice
daily
maximum dose 2 500 mg daily
avoid carbamazepine
watch for weight gain
* Recommended doses - these are a rough guide and will work for most patients. Some patients
may need much higher or lower doses which will be guided by therapeutic monitoring.
Referral
all new patients - for diagnosis by a doctor
increased number of seizures or changes in the seizure type
patients who have been seizure free on therapy for 2 years or more (to review therapy)
pregnancy in known epileptics
development of neurological signs and symptoms
adverse drug reactions
Information that should accompany each referral case
Seizures
number of seizures per month (or year)
date and time of most recent seizure
detailed description of the seizure that includes:
aura or warning sign
what happened during the seizure? (give a step-by-step account)
was the patient conscious during the seizure?
how long do the seizures last on average?
what does the patient experience after the seizure?
how long does this experience last?
Family history of seizures
date of initial diagnosis
drug and alcohol use
any other medical conditions such as diabetes and medication used
name of the antiepileptic medication used to date and dosage
does the patient return on the correct date for repeat medication?
2.02 Febrile convulsions
(See Chapter 18 - Signs and symptoms)
R56.0
2.03 Meningitis
2.03.1 Meningitis, acute
G03.9 (036)
Description
The acute or recent inflammatory response of the meninges due to the following
organisms:
Haemophilus influenzae
Neisseria meningitidis (note: meningococcal meningitis is a notifiable condition; see
p. ix)
Streptococcus pneumoniae
This is a medical emergency.
initiate effective treatment as soon as possible to limit neurological complications
initiate antibiotic treatment immediately
stabilise patient prior to referral
prevent the spread to contacts
perform a lumbar puncture, if possible, and send CSF in a sterile container with
patients
Emergency measures
maintain airway
give oxygen
ensure hydration
Drug treatment
Initiate drug treatment before transfer
ceftriaxone IM or IV, single dose immediately
children:
50
mg/kg/day
adults in areas of high
penicillin resistance: 12
g
or
benzylpenicillin IM or IV, as a single dose immediately
children: 200 000 IU/kg
adults: 5 MU
and
chloramphenicol IM, single dose immediately (based on provincial policy)
neonates and infants:
see below
children 110 years:
500 mg
children over 10 years and adults:
1 000 mg
! SPECIAL CASES FOR NEONATES AND INFANTS !
benzylpenicillin IV or IM 200 000 IU/kg single dose immediately
and
chloramphenicol IV 6 hourly where indicated as above
age under 1 week: 6 mg/kg
age 12 weeks: 12 mg/kg
age over 2 weeks: 25 mg/kg
for convulsions
diazepam rectal 0.2 mg/kg for convulsions, single dose
children under 3 years: maximum dose 5
mg
children over 3 years: maximum dose 10 mg
adults: 10 mg, repeat up to a maximum of 30 mg
Referral
all patients
2.03.2 Meningitis meningococcal, prophylaxis
G00.9
Note: a notifiable condition
prevent the spread of proven meningococcal meningitis to close contacts:
same household
medical staff
day centre attendees
household members
notify the disease (see p. ix)
Drug treatment
initiate rifampicin oral 12 hourly for 2 days within 5 days of exposure to meningococcal
meningitis
children under 1 month:
5 mg/kg
children 1 month12 years:
10 mg/kg
children over 12 years and adults: 600 mg
2.04 Status epilepticus
(see Chapter 19 - Trauma and emergencies)
G41.9 (345.3)
Chapter 3 Dental and oral conditions 35
Chapter 3 - Dental and oral conditions
amoxycillin
0.2% chlorhexidine digluconate
0.5% gentian violet
2% lidocaine
metronidazole
2% miconazole
nystatin
paracetamol
3.01 Candidiasis, oral (thrush)
B37.0 (112.0)
Description
An infection of the mouth and sometimes of the pharynx caused by a yeast-like fungus
Candida albicans:
common in healthy babies up to 3 months
painful creamy white patches that can be scratched off the tongue and buccal
mucosae
C. albicans also exists in healthy individuals but only under certain conditions does it
cause infection:
poor hygiene
baby bottles sterilised with
hypochlorite
immunosuppression (severe cases
are common in AIDS)
prolonged use of broad spectrum
antibiotics or corticosteroids
some chronic diseases, e.g. diabetes
mellitus
due to trauma, e.g. poorly fitting
dentures
cure the condition
Non-drug treatment
preventive measures:
adequate rinsing of bottles after disinfecting
snugly fitting dentures
good oral hygiene
Drug treatment
0.5% gentian violet aqueous solution topically
paint the inside of the mouth three times daily
continue for 48 hours after cure
nystatin suspension oral 100 000 IU/mL
infants: 0.5 mL after each feed
keep nystatin in contact with affected areas for as long as possible
nystatin lozenges oral, sucked 6 hourly for 10 days
adults: 100 000 IU (1 lozenge)
in severe cases or if the above treatment fails:
2% miconazole oral gel
children and adults: apply twice daily for 10 days
Referral
no improvement
difficult or painful swallowing
uncertain diagnosis
pharyngeal spread
3.02 Dental abscess and caries
3.02.1 Dental abscess
K04.7 (522.5)
Description
Acute or chronic suppuration related to teeth due to infection:
acute - pain (sometimes very severe) continuous and gnawing
involved tooth is painful on tapping
the tooth may be loose after the infection has spread to the bone
swelling of upper or lower jaw
chronic - may have few symptoms including pain
cure abscess and eliminate pathogens
pain relief
improve oral hygiene
Non-drug prophylaxis and treatment
oral hygiene after each meal to remove plaque and food debris
frequent complete brushing of teeth
dental flossing at least once a day
Drug treatment
amoxycillin oral 8 hourly for 5 days
children 1020 kg:
125 mg
children over 20 kg and adults:
250 mg
or
for penicillin-allergic patients:
erythromycin oral 6 hourly before meals for 5 days
children 1115 kg: erythromycin estolate
125 mg
children over 15 kg: erythromycin stearate
or estolate 250 mg
adults: erythromycin
stearate 250 mg
and
metronidazole oral for 5 days
take tablets with or after food and the suspension 1 hour before food
children 13 years:
50 mg 8 hourly
children 37 years:
100 mg 12 hourly
children 710 years:
100 mg 8 hourly
200 mg 8 hourly
paracetamol oral 46 hourly when needed to a maximum of four doses daily
children 15 years:
510 mL (120 mg/5 mL syrup)
children 512 years:
1 tablet (500 mg tablet)
12 tablet(s)
Referral
all cases
3.02.2 Dental caries/toothache
K02.9 (521.0)
Description
Dental caries (decay of the teeth) is a general term for the formation of cavities.
early warning of tooth decay is sensitivity to hot or cold food or drinks
toothache is due to the decay setting up an inflammatory reaction in the affected tooth
and/or dental socket
other causes of toothache include:
trauma
abscess
loosening of dental filling/crown/bridge
wisdom teeth erupting
gum inflammation
reduce pain
improve dental hygiene
slow down or stop the progression of caries and its consequences
Non-drug treatment
oral hygiene after each meal, to remove plaque and food debris
frequent complete brushing of teeth (removal of plaque) with a fluoride toothpaste
limit frequency of sugar intake
educate on oral hygiene
Drug treatment
paracetamol oral, 46 hourly when needed to a maximum of four doses daily
children 15 years:
children 512 years:
12 tablet(s)
Referral to dentist
all cases
3.03 Gingivitis
3.03.1 Gingivitis, uncomplicated
K05.1 (523)
Description
Inflammation of the gum margin causing the gums to separate from the teeth.
pockets form between the gums and the teeth
pus and bacteria can collect in these pockets, eventually causing periodontitis
(disease in the tissue that surround and supports the teeth)
often found in smokers
characteristics:
change in the normal gum contour
may or may not be painful
redness
swollen gums
watery exudate/bleeding
gum recession may occur
gingivitis may recur
reduce pain
prevent recurrence to preserve teeth
Non-drug treatment
oral hygiene is usually adequate to prevent superficial mouth and gum infection
homemade salt mouthwash may help, e.g. teaspoon of table salt in a glass of
lukewarm water; gargle for one minute twice daily
Drug treatment
paracetamol oral, 46 hourly when needed to a maximum of four doses daily
children 15 years:
children 512 years:
12 tablet(s)
0.2% chlorhexidine digluconate mouthwash 24 times daily for 5 days
15 mL as a mouthwash after brushing and flossing
prolonged use of chlorhexidine may cause darkening of teeth
3.03.2 Acute necrotising ulcerative gingivitis
A69.1 (101)
Description
A non-contagious infection associated with the fusiform bacilli and a spirochaete.
also known as Vincents angina and is associated with:
poor oral hygiene
stress
blood disorders
heavy smoking
nutritional deficiencies (vitamin B and
C)
characteristics:
sudden onset
acutely painful bleeding gums
greyish membrane between teeth on
gums which can be removed
whole mouth or one tooth can be
affected
common in young adults
halitosis
no fever
reduce pain
eliminate infection
promote good oral hygiene
Non-drug treatment
improve nutrition
gentle removal of the membrane
Drug treatment
Treatment depends on the type of gingivitis:
children 1020 kg: 125 mg
children over 20 kg and adults: 250 mg
or
children 1115 kg: erythromycin estolate 125 mg
children over 16 kg: erythromycin stearate or
estolate 250 mg
adults: erythromycin stearate 250
mg
and
metronidazole oral for 5 days
take tablets with or after food and the suspension 1 hour before food
children 47 years:
100 mg 12 hourly
children 710 years:
100 mg 8 hourly
200 mg 8 hourly
children 15 years:
children 512 years:
12 tablet(s)
Referral
no improvement in 5 days
3.04 Herpes stomatitis/cold sore/fever blister
B00.2 (528.2)
Description
Inflammation of the mouth area due to infection by Herpes simplex virus type 1.
may complicate infections such as pneumonia, but usually occurs spontaneously
self-limiting and usually clears up within 10 days
shallow painful ulcers on the lips, gums and tongue
refusal of children to eat due to pain
relieve symptoms
prevent complications including secondary infection
Non-drug treatment
lukewarm water; gargle for one minute twice daily
adequate diet and hydration
fluid diet for children
avoid acidic drinks, e.g. orange juice or soft drinks as they may cause pain
Drug treatment
rehydration may be necessary
antipyretics may be indicated
children 3 months1 year:
2.5 mL (120 mg/5 mL syrup)
children 15 years:
510 mL
children 512 years:
12 tablet(s)
2% lidocaine gel may be indicated every 34 hours, for extensive oral herpes
apply thin layer as required on the affected areas only; maximum one tube
Referral
if the condition is severe
immunosuppressed patients, e.g. AIDS
no improvement after 1 week of treatment
dehydrated patients
3.05 Mouth ulcers
K12.0 (528.2)
Description
Acute painful ulcers on the lips or inside the mouth, including the tongue, or occurring
singly or in groups.
reduce discomfort
accelerate the healing process
Drug treatment
paracetamol orally 46 hourly when needed to a maximum of four doses daily
children 15 years: 5
10 mL
children 512 years:
12 tablets
Referral
recurrence
widespread ulcers
3.06 Periodontitis
K05.3
Description
Progressive gingivitis to the point where the underlying bone is eroded.
it is a cause of tooth loss in adults
due to the same causes as gingivitis (see section 3.03)
also known as pyorrhoea
teeth may be loose in their sockets
prevent further disease and preserve teeth
identify cases to refer to dentist
Non-drug treatment
remove all deposits on teeth, e.g. plaque, etc.
ongoing oral hygiene measures
regular re-evaluation
Drug treatment
Referral to dentist
all cases
Chapter 4 - Ear, nose and throat conditions
2% acetic acid in alcohol
1% acetic acid in 0.9% sodium chloride
amoxycillin
chlorpheniramine
flucloxacillin
oxymetazoline
paracetamol
phenoxymethylpenicillin
0.9% sodium chloride
trimethoprim/sulfamethoxazole
4.01 Allergic rhinitis (hay fever)
J30.4
Description
Recurrent inflammation of the nasal mucosa due to hypersensitivity to allergens, e.g.
pollen, house dust, grasses, animal proteins and foodstuffs.
allergic rhinitis is characterised by recurrent episodes of:
blocked stuffy nose
watery nasal discharge
frequent sneezing, often
accompanied by nasal itching and
irritation
conjunctival itching and watering
oedematous pale grey nasal mucosa
mouth breathing
snoring at night
try to exclude other causes, e.g. vasomotor rhinitis, overuse of decongestant drops,
side-effects of antihypertensives and antidepressants
prevent recurrent attacks
provide symptomatic management
Non-drug treatment
avoid allergens and irritants
Drug treatment
chlorpheniramine oral
1 mg twice daily
children 1 5 years:
12 mg 3 times daily
Chapter 4 Ear, nose and throat conditions 45
children 512 years:
24 mg 34 times daily
4 mg 34 times daily
Referral
chronic persistent attacks
severe symptoms
4.02 Tonsillitis and pharyngitis
4.02.1 Pharyngitis, viral
J03
Description
A painful red throat without pus.
Non-drug treatment
lukewarm water; gargle for 1 minute twice daily
Drug treatment
viral infections should not be treated with antibiotics
4.02.2 Tonsillitis, bacterial
J03.9 (463)
Description
Commonly caused by the beta-haemolytic streptococci group A.
clinical features of streptococcal tonsillitis are:
sore throat with pain while swallowing
inflamed tonsils with white patches (follicles)
tender, enlarged cervical lymph nodes
often associated with sudden onset of fever
untreated streptococcal tonsillitis or pharyngitis is serious and can result in:
acute rheumatic fever
acute glomerulonephritis
suppurative complications (retropharyngeal and peritonsillar abscesses)
a sandpaper-like generalised skin rash indicates scarlet fever:
red strawberry tongue, cutaneous eruption particularly on the throat, chest and/or
elbows
completely eradicate the infection
prevent heart and kidney complications
Non-drug treatment (supportive)
lukewarm water; gargle for 1 minute twice daily
Drug treatment
phenoxymethylpenicillin oral 6 hourly for 10 days (to prevent rheumatic fever and
glomerulonephritis)
children 510 kg: 62.5 mg
children over 30 kg: 250 mg
adults: 500 mg
or
if compliance with an oral course for 10 days is difficult, then give a single dose of
benzathine penicillin IM immediately
children under 30kg: 600
000 IU
children over 30kg and adults: 1.2 MU
or
62.5 mg
125 mg
or estolate 250 mg
adults: erythromycin stearate 250 mg
children 15 years: 510 mL
children 512 years:
12 tablets
Referral
any suppurative complications, e.g. retropharyngeal or peritonsillar abscess
suspected acute rheumatic fever
suspected acute glomerulonephritis
recurrent tonsillitis or tonsillitis accompanied by severe swallowing problems
history of previous rheumatic fever or rheumatic heart disease
heart murmurs not previously diagnosed
4.03 Otitis externa
H60.9 (380.1)
Description
Inflammation of the external ear may be one of the following two types:
TYPE DESCRIPTION
diffuse infections are usually due to:
mixed infections
allergic dermatitis (often caused by shampoo or soaps)
contaminated swimming pool or other water, etc.
furuncular may be caused by one or more of the following organisms:
Staphylococcus
Streptococcus
Pseudomonas aeruginosa
Proteus species
Escherichia coli
symptomatic relief
eliminate the cause
Non-drug treatment
exclude any underlying chronic otitis media before commencing treatment
keep the ear clean and dry
most cases recover after thorough cleansing and drying of the ear
do not leave anything in the ear
do not add anything to the ear
avoid getting the inside of the ear wet
Drug treatment
The treatment for the two types of otitis externa differs:
TYPE DESCRIPTION
diffuse does not usually require an antibiotic
2% acetic acid in alcohol topically 6 hourly for 5 days
make a wick where possible
use ribbon gauze or other suitable absorbent cloth
soak the wick in the drops and insert into the ear
instil 34 drops after cleaning and drying the ear
furuncular flucloxacillin oral 6 hourly for 5 days
children under 2 years:62.5 mg
children 210 years:125 mg
children over 10 years and
adults: 250 mg
or
children 510 kg: erythromycin estolate 62.5
mg
125 mg
children over 15 kg: erythromycin
stearate or estolate 250 mg
stearate 250 mg
Referral
no response
4.04 Otitis media, acute
H66.9 (381.0)
Description
Inflammation of the middle ear characterised by:
pain
loss of the normal light reflex of the eardrum
bulging eardrum
fever in about half of the cases
mild redness of the eardrum and rubbing the ear are not reliable signs
cure of the infection
management of complications
Non-drug treatment
do not instil anything in the ear
Drug treatment
children less than 10 kg: 62.5
mg
or
trimethoprim/sulfamethoxazole oral 12 hourly for 5 days
children 25 months: 2.5 mL
(40/200 mg/5mL suspension)
children 6 months 5 years: 5 mL
mL or 1 tablet (80/400 mg)
children over 12 years and adults: 2
tablets (80/400 mg)
children 3 months1 year: 2.5 mL
(120 mg/5 mL syrup)
mL
children 512 years:
tablets
Referral
eardrum perforation
no response after 5 days treatment
no pain relief
bulging eardrum, not responding to treatment after 24 hours
4.05 Otitis media, chronic suppurative
H66.3 (381.3)
Description
Pus discharging from the ear for more than 2 weeks.
if the eardrum has been ruptured for 2 weeks or longer a secondary infection with
multiple organisms usually occurs
multiple organism infection makes oral antibiotic treatment alone much less effective
and patients may need to be referred
TB is an important cause of a chronically discharging ear in South Africa
if pain is present suspect another condition or complications
Note
a chronically draining ear can only heal if it is dry
drying the ear is time-consuming for both the health worker and the caregiver but it is
the most important measure of effectiveness of treatment
keep the ear dry
cure the condition
prevent hearing loss
prevent mastoiditis and related complications
Non-drug treatment
dry mopping is the most important part of the treatment and it should be
demonstrated to the childs caregiver or patient if old enough:
roll a piece of clean absorbent cloth into a wick
soak in 1% acetic acid in 0.9% sodium chloride
insert carefully into the childs ear
leave in place for 1 minute
remove and replace with a clean dry wick
watch the patient or caregiver repeat this until the wick is dry when removed
dry the ear by wicking at home at least four times daily until the wick stays dry
if bleeding occurs, drying the ear should be stopped temporarily
do not leave anything in the ear
do not instil anything in the ear
Referral
painful swelling behind the ear
no improvement after 4 weeks treatment
4.06 Sinusitis, acute
J01.9
Description
Inflammation of one or more sinuses that most often occurs after a viral nasal infection
or allergic rhinitis.
bacterial sinusitis is characterised by:
purulent nasal discharge (persistent
or intermittent)
pain and tenderness over one or
more sinuses
nasal obstruction
post-nasal discharge
fever (occasional)
Non-drug treatment
steam inhalation may be effective in liquefying and removing secretions blocking the
nose
Drug treatment
children less than 10 kg: 62.5
mg
or
(40/200 mg/5mL suspension)
children 6 months5 years: 5
mL
mL or 1 tablet (80/400 mg)
children over 12 years and adults: 2 tablets (80/400 mg)
use 0.9% sodium chloride nose drops frequently and in fairly large volumes
(120 mg/5 mL syrup)
mL
children 512 years:
tablets
oxymetazoline nose drops, 2 drops in each nostril 68 hourly for not more than
5 days continuously
children: 0.025%
adults: 0.05%
Referral
dental focus of infection is present, e.g. apical tooth abscess causing maxillary
sinusitis
complications, e.g. periorbital cellulitis (periorbital swelling)
oedema over a sinus
fever lasting longer than 48 hours
poor response after 5 days
4.07 Epistaxis
Chapter 5 - Endocrine system
glibenclamide
insulin biphasic
insulin medium-acting
metformin
tolbutamide
5.01 Diabetes mellitus
5.01.1 Diabetes mellitus type 1
E10
Description
Diabetes mellitus type 1 is also known as insulin-dependent diabetes mellitus (IDDM) or
juvenile onset diabetes mellitus.
diabetes mellitus type 1 presents with:
hunge
r
weight loss
ketoacidosis
thirst
polyuria
tiredness
managed with insulin injections that are adjusted according to each patients individual
needs
all patients with diabetes mellitus type 1 should be referred at diagnosis for the
initiation and stabilisation of therapy
control the blood sugar level within acceptable limits (glycaemic control)
prevent chronic (long-term) complications
prevent acute complications (diabetic emergencies), e.g. hyperglycaemic and
hypoglycaemic coma
improve and maintain the quality of life
educate and counsel patients to provide self-care
5.02 Diabetes mellitus type 2
E11 (250)
Description
Diabetes mellitus is a chronic debilitating metabolic disease characterised by an
abnormally high blood glucose level with serious complications (acute and chronic).
Chapter 5 Endocrine system 53
in adults the condition may only be diagnosed accidentally or when complications are
discovered, e.g. deteriorating eyesight or foot ulcers
symptoms of an abnormally high blood sugar level are:
thirst (especially noticed at night)
polyuria
tiredness
periodic changes in vision due to fluctuations in the blood glucose level
susceptibility to infections (especially of the urinary tract, respiratory tract, skin)
NOTE
It is important to distinguish diabetes mellitus type 2
from diabetes mellitus type 1
Management of diabetes mellitus type 2
a stepwise approach to total care is needed because:
diabetes is often associated with other chronic illnesses and these should be
managed as they arise, e.g. hypertension, dyslipidaemia and obesity
a careful plan is important to prevent complications where possible, e.g. foot care to
prevent gangrene, BP monitoring
patients must be encouraged to take care of themselves
Non-drug treatment
Step 1
all patients require lifestyle modification:
appropriate diet and weight loss if overweight (see ideal body weight charts on p.
xvi)
regular exercise
stop smoking
moderate or no alcohol intake
appropriate diet and weight loss (if overweight) are the cornerstones of the
management and involve the following:
eliminating sugars from the diet
abstaining from eating between meals (snacks or sweets)
eating 23 regular meals with balanced energy (kilojoule) distribution
reducing total energy intake (if overweight)
not attempting to lose weight at an excessive rate, as this usually fails
adjusting energy intake to achieve a weight loss of about one kg per month
regular exercise (e.g. brisk walking for 30 minutes every day) helps to burn off
excessive fat (energy stores)
ENTRY TO STEP 1 TREATMENT AND
DURATION
TARGET
typical symptoms - thirst,
urinary frequency, polyuria
and
random blood glucose over
11 mmol/L
or
fasting blood glucose level
over 7 mmol/L (venous
plasma)
and/or
glycosuria
lifestyle
modification for life
appropriate diet
(see above)
weight loss until at
ideal weight (see
chart on p. xvi)
assess monthly
random blood glucose
below 10 mmol/L
or
fasting glucose 68 mmol/L
or
urine glucose 00.5%
(negative to +)
and
ideal body weight (weight
reduction may be a lengthy
process)
Symptoms of diabetes + 1 random glucose
11 mmol/L
Symptoms of diabetes + fasting glucose
PLASMA WHOLE/CAPILLARY BLOOD
Diabetes above 7 mmol/L above 6 mmol/L
Normal below 7 mmol/L below 6 mmol/L
Drug treatment
Step 2
continue lifestyle modification and initiate treatment with one drug as shown below
ENTRY TO STEP 2 TREATMENT AND
DURATION
TARGET
fasting blood glucose
over 10 mmol/L
or
urine glucose over
0.5% (++)
and
after 3 months of
compliance with
treatment plan, e.g.
weight loss
(see step 1)
and
initiate drug therapy
with
sulphonylurea
or
metformin if
severely
overweight
random blood glucose below
10 mmol/L
or
fasting glucose 67 mmol/L
or
urine glucose 00.5% (negative to +)
and
ideal body weight (weight reduction
may be a lengthy process)
Sulphonylureas (tolbutamide or glibenclamide)
contraindications:
pregnancy
renal failure
impaired liver function
diabetes mellitus type I (IDDM)
diabetes mellitus due to chronic
pancreatitis
! CAUTION !
do not take sulphonylureas if the patient misses a meal
reduce the dose in the elderly
Initiate monotherapy with one of the following sulphonylureas:
Tolbutamide is often the first drug of choice. Its relatively short duration of action makes
it less likely to cause hypoglycaemia.
tolbutamide oral 500 mg daily with breakfast
dose increments
if the blood or urine glucose is uncontrolled (see above)
increase by 500 mg daily at weekly intervals
if more than 500 mg daily is needed then divide the total daily dose into two initially,
and if needed into three approximately equal doses
if the doses are unequal then administer the largest dose in the morning
administer tolbutamide before meals
maximum total daily dose 2 000 mg (4 tablets)
or
glibenclamide oral 2.5 mg ( tablet) daily with breakfast
dose increments
if the blood or urine glucose is uncontrolled (see above)
increase by 2.5 mg daily at two-weekly intervals
if 7.5 mg or more daily is needed then divide the total daily dose into two, with the
larger dose in the morning
maximum total daily dose 15 mg (3 tablets)
Biguanides (metformin)
contraindicated in:
pregnancy
cardiovascular disease
respiratory disease
renal disease
hepatic disease
Only consider the addition of metformin if the:
patient is on maximum dose of a sulphonylurea (tolbutamide or glibenclamide)
targets for blood glucose or urine glucose are not reached
patient is overweight
Only indicated as supplementary medication in overweight diabetes mellitus type 2.
! CAUTION !
prescribe with care in the elderly
metformin oral 850 mg daily
dose increments
increase by 850 mg daily after 2 weeks
maximum daily dose 1 700 mg (850 mg twice daily)
Move to step 3 if:
fasting blood glucose is over 10 mmol/L
or
urine glucose is over 0.5% (++)
and
there has been adequate compliance with step 2 after 3 months of
maximum monotherapy dosage
confirmed lifestyle modification
Step 3
Combination therapy
This step involves the combination of biguanides (metformin) and one sulphonylurea
(tolbutamide or glibenclamide).
metformin is only indicated as supplementary medication in overweight diabetes
mellitus type 2
combination should only occur after step 2 when the maximum dose of the first drug
is reached
do not combine two sulphonylureas
the second drug is added incrementally (see the dose increments in step 2)
lifestyle modification for 3 months should be confirmed
Step 4
Insulin therapy
Insulin is indicated when combination therapy fails (see step 3).
continue lifestyle modification and initiate insulin therapy under the supervision of a
doctor as shown below. If the supervision is indirect, then patients must be reviewed
in person by a doctor as soon as possible
only discontinue oral therapy once the insulin therapy has been initiated
educate patients on the following:
insulin - types of preparations
insulin - injection technique and sites
insulin storage
glucose monitoring (urine and blood)
meal frequency - varies according to the type and frequency of insulin, e.g.
patients may need a snack at night (about 34 hours after the evening meal)
recognition and treatment of acute complications, e.g. hypoglycaemia and
hyperglycaemia
INSULIN
TYPE
STARTING DOSE INCREMENT MAXIMUM
DAILY DOSE
INSULIN
TYPE
STARTING DOSE INCREMENT MAXIMUM
DAILY DOSE
medium-
acting
as supple-
mentation
single dose, 10 units
30 minutes before breakfast
maintain oral dose
or
reduce oral dose by half
or
omit evening dose
or
stop oral antidiabetic
medication
4 units weekly
increase 0.6
units on a daily
basis
30 units at
PHC level
refer if more
than 30 units
are needed
biphasic
as
substitution
twice daily
total daily dose 15 units
divided as follows:
2/3 daily total daily
dose 30 minutes
before breakfast
(10 units)
1/3 daily total daily
dose 30 minutes
before supper
(5 units)
stop oral antidiabetic
medication
4 units weekly
increase 0.6
units on a daily
basis
first increment
is added to the
morning dose
second
increment is
before supper
30 units at
PHC level
refer if more
than 30 units
are needed
! CAUTION !
do not administer insulin if the patient misses a meal
Guidelines for reducing oral antidiabetic treatment
amount of time between reducing oral treatment doses:
decrease the oral antidiabetic drug dose at weekly intervals
and
increase the dose of insulin at the same time
if it is not possible to do this at weekly intervals it can be done at monthly intervals
dosage reduction
first reduction - initially reduce the evening dose by half a tablet
second reduction - tolbutamide: after that decrease the midday dose
or
second reduction - glibenclamide: the morning dose
third reduction and other reductions - reduce the evening dose once more, and
follow the above pattern, until all the tablets have been stopped
at the same time as the oral antidiabetic drugs are decreased, insulin dosage may
have to be increased:
use the method shown below and the type changed as shown below
if adequate control is not achieved with these dosages and drugs after step 4,
refer
Referral
There are three levels of referral:
immediate same-day referral for diabetic emergencies or acute diabetic
complications as listed below
6-monthly or annual referral for assessment of progress (depending on the control of
the diabetes mellitus and the complications)
automatic referral for certain conditions
Immediate same-day referral
initiation of IV infusion with 0.9% sodium chloride solution must be considered before
transfer of very ill patients with the conditions listed below
complications, e.g. infections which may have the following symptoms:
slow onset (sometimes over days)
of progressive apathy, leading to
confusion, stupor, pre-coma and
coma
sepsis, including gangrene
sudden deterioration of vision
serious infections, e.g. TB
metabolic complications:
dehydration and hypotension
nausea and vomiting
heavy ketonuria and ketosis
hyperglycaemia (over 20 mmol/L)
Six-monthly or annual referral for assessment of progress and potential
complications
fundoscopy
renal
cardiovascular
neurological
feet
laboratory
Chapter 6 Eye conditions 59
Automatic referral
pregnancy
failure of step 4 care to control the diabetes mellitus
all type 1 diabetics
NOTE
patients with diabetes mellitus type 2, especially the elderly, often have:
associated heart disease, e.g. ischaemic heart disease and cardiac failure
a variable degree of renal function impairment
hypertension
degenerative conditions of the peripheral and central nervous system
arterial disease (atherosclerosis and arteriosclerosis)
refer these patients in order to establish the optimum drug management of the
diabetes mellitus and the associated conditions
daily glucose testing using urine test sticks is as accurate and less costly than
blood glucose testing
Chapter 6 - Eye conditions
acetazolamide
1% chloramphenicol
chlorpheniramine
doxycycline
1% pilocarpine
tetracycline
0.025% oxymetazoline
6.01 Conjunctivitis
Description
A broad term used for inflammatory conditions of the conjunctiva:
it may be infectious, caused by bacteria or viruses
or have other causes such as allergy, foreign bodies, irritation (chemical)
consider a foreign body or acute glaucoma when there is conjunctivitis in one eye
only
6.01.1 Conjunctivitis, allergic
H10.1
Description
Inflammatory conditions of the conjunctiva caused by allergy to pollen, grasses, animals,
etc.
there is usually a history of allergies, including hay fever
itchy, runny eyes
recurrent and seasonal
relieve symptoms
Non-drug treatment
none
Drug treatment
0.025% oxymetazoline eye drops instilled in the eyes 6 hourly for 7 days
chlorpheniramine oral for severe cases
children 6 months1 year: 1
mg twice daily
mg three times daily
children 512 years:
24 mg 34 times daily
4 mg 34 times daily
Referral
person using contact lenses
non-response to treatment
6.01.2 Conjunctivitis, bacterial
H10.0
Description
An inflammatory purulent condition of the conjunctiva caused by bacteria.
relieve symptoms
remove the cause
identify conditions for referral
Non-drug treatment
personal hygiene is important in prevention and treatment
advise the patient to use only his/her own towels
to wash the face and cleanse the eyes frequently
to wash hands thoroughly before applying ophthalmic ointment
treat conjunctivitis in one eye with special care to avoid spread of infection to the
other eye
teach patient or caregiver how to apply eye ointment
Drug treatment
1% chloramphenicol ophthalmic ointment applied every 68 hours for 7 days
Referral
poor/no response after 7 days
6.01.3 Conjunctivitis, viral and epidemic viral
B30.9
Description
Inflammatory conditions caused by a virus. Many upper respiratory tract viral infections
are accompanied by conjunctivitis. These conditions are highly contagious and often
spread through whole communities. Both eyes are affected.
relieve symptoms
remove the cause
identify conditions for referral
Non-drug treatment
personal hygiene
encourage use of own towels
wash the face and cleanse the eyes frequently
discourage the use of home remedies, like milk, urine, saliva, etc. as this will cause
secondary infection
avoid spread of infection to the other eye and persons
teach patients or caregivers how to instill eye medication (ointment/drops)
Drug treatment
0.025% oxymetazoline eye drops instilled in the eyes 6 hourly for 7 days
Note
Patients must not share the same eye drops.
! CAUTION !
Exclude the following:
herpes keratitis
trauma
Referral
unilateral disease
corneal ulceration
corneal opacification (clouding)
pupil irregularity
diminished vision
severe pain
poor/no response after 7 days
6.02 Conjunctivitis of the newborn (ophthalmia neonatorum)
P39.1 (098.4)
Description
Inflammation of the conjunctiva in the neonatal period.
the most common cause is infection acquired during delivery
it is hard to differentiate between the various infectious causes
the condition is preventable and no baby should get it
prevent the condition from developing and spreading
cure it when it does occur
Drug treatment
Prophylaxis
routine administration of 1% chloramphenicol ophthalmic ointment at birth to all
babies
apply to both eyes
Referral
any pussy conjunctivitis in the newborn
6.03 Eye, chemical burn
6.04 Eye injury, foreign body
6.05 Glaucoma, acute
H40.9 (365)
Description
Raised intraocular pressure usually in one eye only.
clinical features:
severe pain in eye (acute)
redness
affected eyeball may feel firmer
haloes or bright rings around light
one pupil dilated
headache - unilateral, temporal
nausea and vomiting if severe
identify all cases of acute glaucoma
initiate treatment
relieve the increased pressure within 23 hours
refer all cases
Drug treatment
initiate treatment and then refer within 12 hours
acetazolamide oral, 500 mg immediately, followed by 250 mg 6 hourly
1% pilocarpine eye drops instilled into the affected eye every 1530 minutes for 4
doses
! CAUTION !
chronic glaucoma may cause blindness
due to continuous high ocular pressure
Referral
all cases immediately
6.06 Trachoma
A71.9 (076)
Note: a notifiable condition.
Description
An external eye infection caused by the organism Chlamydia trachomatis.
the common fly is often associated with cycles of infection and reinfection
common in underprivileged communities with poor hygiene
more prevalent in northern parts of South Africa (e.g. Northern Province)
it is one of the leading cause of preventable blindness in the world
clinical features:
presents during childhood as chronic conjunctivitis
visible conjunctival follicles and papillae
watery and mucoid eye discharge
severe scarring of the conjunctiva under the upper eyelid
folding in of the eyelashes (entropion)
corneal scarring and blindness
cure individual
prevent spread to others
notify condition (see p. ix)
Non-drug treatment
improvement of personal hygiene
it is especially important to wash the faces of children to prevent spread
Drug treatment
tetracycline ophthalmic ointment 12 hourly for 6 weeks
and
doxycycline oral 12 hourly for 10 days (repeated if no cure)
adults: 100 mg
62.5 mg
or estolate 250 mg
pregnant women: erythromycin stearate
500 mg
Referral
diagnosis uncertain
complicated cases
no response to treatment
Chapter 7 - Family planning
Z30.0 (V25)
levonorgestrel 0.03 mg
levonorgestrel (as progestogen) 0.15 mg and ethinyl oestradiol (as oestrogen) 0.03
mg
norgestrel (as progestogen) 0.5 mg and ethinyl oestradiol (as oestrogen) 0.05 mg
levonorgestrel (as progestogen) and ethinyl oestradiol (as oestrogen)
11 tablets levonorgestrel 0.05 mg and ethinyl oestradiol 0.05 mg
medroxyprogesterone acetate
norethisterone enanthate
spermicidal jelly
7.01 Contraception, barrier methods
Z30.9
condoms of varying makes, e.g. rubber latex, lubricated smooth surface with teat
closed end
7.02 Contraception, vaginal
Z30.9
spermicidal jelly 0.1 g active ingredient/5 g in 81 g tube with applicator
7.03 Contraception, intrauterine contraceptive device (IUCD)
Z30.1
250 - short type for a uterus with sound length of 6 cm
375 - standard type for a uterus with sound length of over 7 cm
Chapter 7 Family planning 67
7.04 Contraception, hormonal
7.04.1 Injectable contraceptives
Z30.0
medroxyprogesterone acetate 150 mg long-acting (2 types)
norethisterone enanthate 200 mg
7.04.2 Oral contraceptives
Z30.0
monophasic preparation progestogen only tablets
levonorgestrel 0.03 mg
monophasic preparations - combination formula containing in each tablet
formula 1 levonorgestrel (as progestogen) 0.15 mg and ethinyl
oestradiol (as oestrogen) 0.03 mg
formula 2 norgestrel (as progestogen) 0.5 mg and ethinyl
oestradiol (as oestrogen) 0.05 mg
biphasic preparations - combination formula
triphasic preparations - combination formula
7.05 Post-coital contraception
Z30.9
! CAUTION !
must be used within 72 hours of unprotected intercourse
Use monophasic preparations formula 2 (see section 7.04.2).
norgestrel (as progestogen) 0.5 mg and ethinyl oestradiol (as oestrogen) 0.05 mg
take 2 tablets after unprotected intercourse
and
2 tablets 12 hours later
Chapter 8 - Gastro-intestinal conditions
aluminium hydroxide/magnesium trisilicate
amoxycillin
bismuth subgallate compound
5% dextrose in 0.9% sodium chloride
half-strength Darrows solution with 5% dextrose
doxycycline
liquid paraffin
mebendazole
metronidazole
niclosamide
ORS (oral rehydration solution)
RingerLactate
sennosides A and B
sodium sulphate
tetracaine
8.01 Abdominal pain/dyspepsia/heartburn/indigestion
K30 (789)
Description
Abdominal pain/dyspepsia/heartburn/indigestion are common conditions which often
present with non-specific abdominal discomfort. The pain is not associated with the
following:
meals
weight loss
minimal change in bowel habits
blood in stools
stress or psychogenic conditions
any abdominal pain or discomfort must be assessed for the following features:
duration
severity
location
type
accompanying clinical features, e.g. nausea, vomiting, constipation, diarrhoea,
tenderness, fever, tachycardia, distension
activity level of patients with severe pain, e.g. restlessness or inability to lie still
ongoing heartburn or indigestion are difficult diagnostic problems because they are
often non-specific:
obtain clear description of the specific symptoms
perform a thorough physical examination to see if referral is needed
the differential diagnosis includes:
Chapter 8 Gastro-intestinal conditions 69
peptic ulcer disease
reflux oesophagitis
gastric cancer
pancreatitis
pancreatic carcinoma
gallbladder disease
worm infestation
abuse of purgatives
intermittent indigestion/ heartburn/ dyspepsia may be associated with:
spicy food
alcohol
carbonated drinks
excessive smoking
use of NSAIDs, e.g. ibuprofen,
aspirin
! CAUTION !
always consider the possibility of a differential diagnosis
remove the cause
relieve the pain
modify lifestyle
identify cases that need referral for further investigation
Non-drug treatment
stop smoking
limit alcohol intake
eat small frequent meals
check haemoglobin
check for a drug cause likely to be associated with dyspeptic symptoms
educate patients on normal bowel functions and frequency
Drug treatment
initiate drug therapy only after full assessment
aluminium hydroxide 250 mg/magnesium trisilicate 500 mg chewed or sucked
24 tablets when necessary (maximum - 16 tablets daily or continuous treatment
for 7 days)
Referral
abdominal pain at specific sites:
right iliac fossa
lower abdomen
epigastric
failure of treatment
uncertain diagnosis
blood in the stools
abdominal mass
signs of peritonitis
8.02 Amoebic dysentery
A06.0 (006)
Description
A condition characterised by loose stools or diarrhoea that is caused by the parasite
Entamoeba histolytica.
loose stools or diarrhoea (rarely) with:
blood
mucus
unpleasant odour
may alternate with constipation
usually there is no fever
rehydrate the patient in the acute phase
refer for investigation and treatment
Drug treatment
in case of dehydration see rehydration in acute diarrhoea (section 8.07.1)
in cases confirmed by identification of organisms on wet stools:
metronidazole oral for 5 days. Take tablets with or after food and the suspension 1
hour before food
children 13 years:
50 mg 8 hourly
children 47 years:
100 mg 12 hourly
children 810 years:
100 mg 8 hourly
200 mg 8 hourly
Referral
all suspected cases unless confirmed by laboratory diagnosis
8.03 Anal conditions
8.03.1 Anal fissures
K60.2
Description
Painful small cracks just inside the anal margin:
often seen together with a sentinel pile or external haemorrhoids
may cause spasm of the anal sphincter
treat symptomatically
refer severe cases
Non-drug treatment
dietary advice to promote soft stools
Drug treatment
bismuth subgallate compound ointment applied twice daily
1% tetracaine cream applied after each bowel action
liquid paraffin oral at bedtime may be indicated in some patients for short-term use
(35 days):
children: 5 mL
adults : 1525 mL
Referral
severe pain
recurrent episodes
poor response to symptomatic treatment
8.03.2 Haemorrhoids
I84.9 (455)
Description
Varicose veins of the ano-rectal area accompanied usually by a history of constipation.
in older patients consider a diagnosis of underlying carcinoma
symptomatic treatment
dietary advice
refer for surgical intervention if necessary
Non-drug treatment
high-fibre diet
counsel against chronic use of laxatives
straining at stool
Drug treatment
symptomatic treatment includes:
bismuth subgallate compound ointment applied 24 times daily
1% tetracaine cream applied after each bowel action
Referral
surgical referral if the following haemorrhoid features are present:
cannot be reduced
thrombosed
8.04 Appendicitis
K35
All patients with suspected appendicitis should be referred.
8.05 Bacillary dysentery (shigellosis)
A03.9 (004)
Description
Acute infection of the bowel usually caused by Shigella micro-organisms.
there is sudden onset diarrhoea with:
bloody stools
mucus in the stools
fever
prevent dehydration
prevent the spread to other people
refer serious cases
Non-drug treatment
prevent spread of micro-organism by:
preventing contamination of food and water through good sanitation
thorough hand washing before handling food
washing of soiled garments and bed clothes
Drug treatment
first confirm diagnosis of blood and mucus in watery stools
treat vigorously as follows (see 8.07.1):
oral rehydration solution sachet
homemade sugar and salt solution (see 8.07.1)
IV fluids
children: half-strength Darrows solution with 5% dextrose
adults: 5% dextrose in 0.9% sodium chloride
infants 06 months:
62.5 mg
children 6 months10 years:
125 mg
250 mg
Referral
malnutrition
severe illness
dehydration
no improvement after 3 days treatment
8.05 Cholera
A00.9 (001)
Description
Very acute severe watery diarrhoea due to infection with the micro-organism Vibrio
cholerae.
clinical features include:
rice water appearance of stools
no blood in stools
no pus in stools
no faecal odour
possible vomiting
rapid severe dehydration
prevent dehydration
prevent the spread to other people
refer serious cases
notify the condition (see p. ix)
Drug treatment
treat vigorously as acute diarrhoea (see 8.07.1)
oral rehydration solution
homemade sugar and salt solution (see 8.07.1)
IV fluids
children: half-strength Darrows solution with 5% dextrose
adults: 5% dextrose in 0.9% sodium chloride
doxycycline oral
children over 9 years: 2 mg/kg 12 hourly for two
days then 1 mg/kg 12 hourly for 3 days
adults: 200 mg immediately then100
mg 12 hourly for 5 days
or
children: (40/200
mg/5 mL suspension)
children 6 months5 yrs: 5 mL
or 1 tablet (80/400 mg)
children over 12 yrs and adults: 2
tablets (160/800 mg)
Referral
as stated in provincial and local policy
8.06 Constipation
K59.0 (564)
Description
A condition of decreased frequency of bowel action for the individual.
there is a wide variation of normal and this must be assessed in each patient
characterised by a change in usual bowel habits and dry, hard stools
constipation may have many causes, some of which are serious:
incorrect diet (fibre and fluid)
lack of exercise
pregnancy
old age
certain drugs
metabolic
endocrine
neurogenic
lower bowel abnormalities
psychogenic disorders
chronic use of enemas and
laxatives
cancer of the bowel
ignoring natures call
! CAUTION !
be suspicious of a sudden change in bowel habits
as there is a possibility of cancer of the large bowel
symptomatic relief
advise on diet and lifestyle
identify cases for referral
Non-drug treatment
encourage exercise
encourage food rich in fibre, e.g. vegetables, coarse maize meal and bran
encourage a regular time for bowel motion even if there is no urge
discourage continuous use of laxatives
Drug treatment
sennosides A and B oral 7.5 mg
2 tablets at night
may be increased to 4 tablets in resistant cases
! CAUTION !
prolonged severe constipation may present with overflow diarrhoea
Referral
recent change in bowel habits
faecal impaction
poor response to non-drug treatment
where the cause of constipation is uncertain

8.07 Diarrhoea, acute
A09 (009.2)
! CAUTION !
there is no place for antidiarrhoeal preparations
in the treatment of acute diarrhoea
8.07.1 Acute diarrhoea in children
Description
Sudden onset diarrhoea with or without vomiting in children.
the microbiological cause of these conditions cannot be diagnosed at a primary
care level without laboratory investigation
it is commonly caused by a virus but may be caused by a bacterial or parasitic
disease that may have diarrhoea as one of the main symptoms, e.g.:
cholera
shigellosis (bacillary dysentery)
giardiasis
worm infestation
consider that it may be an epidemic if many patients are infected at the same time
ASSESSMENT OF HYDRATION
DEGREE OF
DEHYDRATION
CLINICAL FEATURES
moderate* irritable
sunken eyes
thirst
skin turgor - skin pinch on the abdominal wall goes back in
less than 2 seconds
severe* apathetic/unconscious
sunken eyes
skin turgor - skin pinch on the abdominal wall goes back in
more than 2 seconds
delayed capillary refilling
* two of the signs in each category should be present to classify the severity of the
dehydration
maintain adequate hydration
prevent epidemics
Drug treatment
moderate dehydration - administer oral rehydration solution
75 mL/kg administered over 4 hours
severe dehydration - administer IV fluids (see schedule below)
Ringer-Lactate solution 100 mL/kg as follows:
AGE INITIALLY
30 mL/kg IN
FOLLOWED BY
70 mL/kg IN
Infants under 12 months 1 hour* 5 hours
Children 12 months5 years 30 minutes* 2 hours
* repeat once if pulse is still weak or not detectable or if capillary refilling is still delayed
following IV fluids maintain hydration at home with homemade sugar and salt
solution
HOMEMADE SUGAR AND SALT SOLUTION
children: level teaspoon of table salt
or
adults: 1 level teaspoon of table salt
and
8 level teaspoons of sugar (no more)
dissolved in 1 litre of boiled then cooled water
! CAUTION !
Referral
dehydration together with other complications
8.07.2 Acute diarrhoea without blood in adults
K52.9
Description
Acute diarrhoea is usually self-limiting and is managed by fluid replacement.
Drug treatment
homemade sugar and salt solution
or
and
Referral
diarrhoea with complications
! CAUTION !
8.07.3 Chronic diarrhoea in adults
K52.9
Description
Diarrhoea lasting more than 2 weeks.
serious underlying causes like cancer of the bowel or AIDS may be present
some causes may be easily treatable
Referral
all cases
8.08 Giardiasis
A07.1 (007)
Description
Acute or chronic diarrhoea that is unresponsive to conservative management.
the stools are characterised by:
bulky
greasy
frothy
smells offensive
Drug treatment
IV fluids: 5% dextrose in 0.9% sodium chloride
metronidazole oral for 5 days. Take tablets with or after food and the suspension
1 hour before food
children 13 years: 50 mg 8 hourly
children over 10 years and adults: 200 mg 8 hourly
Referral
all cases not responding to oral treatment
8.09 Helminthic infestation - excluding tapeworm
B82.0 (123.3)
Description
Types of worm infestation and the characteristics as shown in the table below.
check for anaemia
TYPE OF WORMS DESCRIPTION OTHER SIGNS
Roundworms
Ascaris lumbricoides
long pink/white worms
often seen in the
stools
cough
if there is vomiting consider
intestinal obstruction
Threadworms
Enterobius vermicularis
white and thread-like
often seen in the
stools
anal itching - worse at night
self-infection common
Hookworms
Ancylostoma duodenale
passed in the stool no symptoms or pain
severe anaemia
Whipworms
Trichuriasis
worms and eggs in
the stools
no symptoms light infestations
abdominal pain
diarrhoea
possible anaemia and rectal
prolapse
abdominal discomfort
weight loss
Non-drug treatment
patient counselling
wash hands with soap and water:
after passing a stool
before working with food
keep fingernails short
wash fruit and vegetables well or cook
keep toilet seats clean
teach children to use toilets and to wash hands
do not pollute the soil with sewage or sludge
dispose of faeces properly
Drug treatment
mebendazole oral for 3 days
mg twice daily. Only administer if there is
clinical problem like diarrhoea or
vomiting
adults and children over 2 years:
100 mg twice daily for 3 days
or
500 mg as a single dose
repeat after 4 weeks if needed
! CAUTION !
anthelmintic drugs including mebendazole are
not safe in pregnancy
as they may cause congenital defects
delay treatment until after delivery
treat underlying anaemia if present
Referral
abdomen tenderness
pain and vomiting
pregnancy
8.10 Helminthic infestation (tapeworm)
B68.9
Description
Infestation with one of the types of tapeworm listed below occurs after eating infected,
undercooked or raw meat like beef or pork.
beef tapeworm Taenia saginata
pork tapeworm Taenia solium
the infestation may present with:
vague abdominal pain
diarrhoea
weight loss
flat white worm segments seen in the stool
prevent spread
eliminate the tapeworm
Non-drug treatment
health education on adequate preparation of potentially infected meat
Drug treatment
if the patient has diarrhoea, wait for it to settle
sodium sulphate oral 250 mg/kg dissolved in 250 mL water as a single dose
purgative
if the patient is constipated, administer it the evening before treatment
administer it to all patients 2 hours after the dose of niclosamide
niclosamide oral 500 mg as a single dose after a light breakfast
children under 2 years:
1 tablet
children 26 years:
2 tablets, grind tablets finely and
mix with a little water
4 tablets, chew tablets and wash
down with water
! CAUTION !
treat pregnant women as there is a danger of neurocysticercosis
Referral
abdominal tenderness or pain
abdominal masses
vomiting
suspect cysts in the brain if there are:
seizures
severe headaches
nausea
vomiting
progressive loss of visual acuity
8.11 Nausea and vomiting, non-specific
R11 (787.0)
Description
There are many possible causes of nausea and vomiting.
it is called non-specific even when organic causes are known, e.g.:
early pregnancy
depression
gastro-intestinal disease
liver disease
renal failure
assess the vomiting because there are many possible serious causes
establish if the vomiting is associated with:
nausea
abdominal pain
diarrhoea
food intake
drugs, e.g. iron preparations,
digitalis
the sequence of the illness, e.g.
migraine
vomiting alone may be a symptom of many conditions, e.g. motion sickness (vertigo
and vomiting under specific circumstances)
exclude alcohol abuse as a cause
symptomatic relief
prevent dehydration
identify cases for referral
Non-drug treatment
withhold food for a period or give frequent small meals (do this with caution in
children)
clear fluids
Drug treatment
oral rehydration solution sachet
IV fluid rehydration for 3 days only (see acute diarrhoea 8.07.1)
or
and
Referral
immediately if patients are:
dehydrated (see 8.07.1)
shocked
septicaemic
digested or fresh blood present
infants with projectile vomiting
later referral if:
symptoms are prolonged longer
than one week
obvious causes
complex combination of
symptoms/signs
8.12 Typhoid fever
A01.0 (002)
Description
A septicaemic illness with fever caused by the micro-organism Salmonella typhi.
the cause of the fever is usually not obvious at first and may be difficult to diagnose
except in an epidemic
it may present with:
acute abdomen (see 8.01)
prolonged or high fever in previously healthy person
fever with a slower pulse than expected
headache and possible convulsions
diarrhoea may occur late in the illness and may be accompanied by frank
bleeding
confirmation is only by stool culture or blood tests
prevent dehydration
refer
prevent spread in the community
notify the condition (see p. ix)
Non-drug treatment
prevent spread in the community
if more than one case occurs, look for sources, e.g. carriers
Drug treatment
during epidemics initiate fluid therapy if necessary (see 8.07.1)
treat as diarrhoea with oral rehydration solution
and
IV fluids if necessary (see 8.07.1)
Referral
all cases
Chapter 9 Gynaecology and obstetrics 85
Chapter 9 - Gynaecology and obstetrics
anti-D immunoglobulin
chloramphenicol
ciprofloxacin
clotrimazole
half-strength Darrows solution with 5% dextrose
5% dextrose in water
dihydralazine
doxycycline
emulsifying ointment
ferrous sulphate
folic acid
ibuprofen
1% lidocaine
magnesium sulphate
methyldopa
metronidazole
oxytocin
pethidine
spectinomycin
vitamin K
9.01 Abortion
O06 (634)
9.01.1 Abortion, incomplete/spontaneous
O03
Description
Spontaneous termination of pregnancy before 28 weeks of gestation after the last
normal menstrual period.
ensure complete removal of the products of pregnancy
control bleeding
prevent bleeding
prevent Rh iso-immunisation
give psychological support
Non-drug treatment
monitor vital parameters, e.g. haemoglobin, pulse, blood pressure
treat for shock if indicated
give counselling and support to patients
Drug treatment
oxytocin IM 510 IU
or
oxytocin IV 2040 IU diluted in 1000 mL 5% dextrose in water
administered at 520 drops per minute, depending on the frequency of
contractions (contraction frequency should not exceed 5 in 10 minutes)
if bleeding continues repeat the treatment after 30 minutes
in Rh-negative mothers administer anti-D immunoglobulin IM 100 micrograms within
24 hours of delivery
Referral
all patients
! CAUTION !
Avoid using other myometrial hypertonic
agents together with oxytocin
9.02 Anaemia in pregnancy
O99.0
Description
Anaemia is pallor plus a haemoglobin (Hb) of less than 11 g/dL.
most commonly it is due to either iron deficiency, folic acid deficiency or a
combination of both
Prevention
all antenatal patients are given routine iron and folic acid supplementation as follows:
ferrous sulphate oral 200 mg daily with food
and
folic acid oral 5 mg daily
twin or multiple pregnancy
ferrous sulphate oral, 200 mg twice daily with food
and
folic acid oral 5 mg daily
Referral
Hb less than 8 g/dL at any stage
Hb less than 10 g/dL and patients over 34 weeks of gestation
non-responding Hb
a rise in the Hb of less than 1.5 g/dL over 2 weeks
or
less than 2 g/dL over 3 weeks in early pregnancy
any low Hb with an obstetric complication
symptoms or signs of acute or chronic blood loss
pallor (anaemia) plus signs of chronic disease, e.g. suspicion of TB, or the presence
of hepatosplenomegaly
evidence of cardiac failure
anaemia thought to be of sudden onset
Drug treatment of established anaemia
Hb less than 11 g/dL
assess peripheral blood smear (if facilities are available)
ferrous sulphate oral 200 mg three times daily with food for 1 month
thereafter as for prevention (see above)
9.03 Antepartum haemorrhage
O46.9
Description
Vaginal bleeding in pregnancy after 27 weeks of gestation to the end of the second
stage of labour.
Refer
all patients
9.04 Cracked nipples during breastfeeding
O92.1
Description
The areola and nipple are protected by the secretion of a lubricant from Montgomerys
glands. Excessive buffing (by e.g. a towel), elaborate nipple exercise and removing the
baby from the breast before suction is broken are causes of cracked nipples.
may lead to infection and mastitis
prevent cracked nipples:
avoid initial excessive suckling
break suction before removing baby from breast
check position of lips of newborn (the lower lip may be drawn in, causing
irritation, and ease out the indrawn lip)
avoid plastic feeding brassiere linings - use breast pads
Drug treatment
clean with mild soap and water
use an emollient, e.g. emulsifying ointment between feedings and remove by
washing before feeding
in more severe cases a nipple shield may be used
if too painful, the milk should be expressed and the baby nursed on the other
breast until improvement
watch for infection
allow milk to dry on the nipples between feeds, using a hair-dryer on low temperature
for 15 minutes
9.05 Delivery, normal
O80.9 (660.5)
Description
Normal delivery is characterised by:
the onset of regular uterine contractions at term
accompanied by progressive cervical dilatation
eventual delivery of the baby
labour is divided into three stages:
first stage: from onset of labour to full dilatation of cervix
second stage: from full dilatation to expulsion of the foetus
third stage: from delivery of the baby to delivery of the
placenta
support for the normal birth process
monitor the status of the mother and the baby
reduce maternal and perinatal morbidity and mortality
Non-drug treatment
supportive management:
psychological support
hydration and nourishment of the mother
Drug treatment
PROBLEM DRUG AND DOSAGE INDICATIONS AND
PRECAUTIONS
MOTHER
analgesia pethidine IM 100 mg
immediately
46 cm cervical dilatation first
stage
PROBLEM DRUG AND DOSAGE INDICATIONS AND
PRECAUTIONS
MOTHER
pethidine IM 100 mg
immediately
46 cm cervical dilatation first
stage
analgesia
1% lidocaine local anaesthetic for episiotomy -
second stage
do not exceed 20 mL
inadequate or
inco-ordinate
uterine
contractions
oxytocin IV 1020 IU in
1000 mL in 5%
dextrose in water
initiate with 0.10.2
mL/minute, increase by
0.10.2 mL/minute at
40-minute intervals until
the desired response is
achieved
only for primipara
titrate to individual needs
contraction frequency should
never exceed 5 in 10 minutes
only use if inadequate or
inco-ordinate uterine contractions
or
fetal distress
post-partum
haemorrhage
oxytocin IM 510 IU after the delivery of the shoulders
patients at high risk for bleeding
RH
incompatibility
anti-D immunoglobulin
IM 100 micrograms
must be given whenever required
for Rh-negative mother
BABY
neonatal
conjunctivitis
prophylaxis
1% chloramphenicol
ophthalmic ointment
administer routinely to baby
in each eye after birth
bleeding
prophylaxis
vitamin K IM 1 mg
immediately after birth
administer routinely to baby
prevent hypoprothrombinaemia
patients must be closely observed for 12 hours before transfer to the postnatal ward
Referral
prolonged labour
post-partum haemorrhage
incomplete delivery of the placenta
other complications of mother or baby
9.06 Dysmenorrhoea
N94.6
Description
Pain associated with menstrual cycles:
primary: no known cause
secondary: an organic cause exists
determine cause and treat accordingly
symptomatic relief
Non-drug treatment
advise and reassure women with primary dysmenorrhoea about the nature of the
condition
encourage patient to carry on with normal everyday activities
Drug treatment
primary dysmenorrhoea
ibuprofen oral 200400 mg three times daily after food when needed for 23 days
secondary dysmenorrhoea
treat for pelvic infection when present
Referral
poor response to treatment
if an organic cause is suspected
9.07 Ectopic pregnancy
O00.9
Description
Pregnancy outside the uterus presenting with missed menstruation, sudden lower
abdominal pain, shock, anaemia.
Refer
all cases if ectopic pregnancy is suspected
initiate treatment for shock if indicated
9.08 Vaginal bleeding
9.08.1 Abnormal vaginal bleeding during fertile years
N92.0
Description
Increased menstrual flow either in volume, duration and/or frequency, including
menorrhagia or dysfunctional uterine bleeding.
Non-drug treatment
assess current contraceptives used
Drug treatment
ibuprofen oral 200400 mg three times daily after food when needed for 23 days
ibuprofen may reduce blood loss in menorrhagia associated with:
t intrauterine contraceptive device (IUCD)
t chronic salpingitis (see STD syndrome treatment guidelines)
t menstruation following puberty when no ova are produced (anovulatory
cycles)
if blood loss has been severe or there are signs of anaemia
give ferrous sulphate oral 200 mg three times daily after food for 1 month
Referral
no improvement
all girls under 12 years with vaginal bleeding before the development of their
secondary sexual characteristics
to investigate for other causes such as sexual abuse, foreign bodies, tumours of the
genital tract
severe anaemia
9.08.2 Post-menopausal bleeding
N95.0
Description
Bleeding after menstruation has normally ceased for 2 years.
Referral
all cases, to exclude underlying malignancy and other pathology
9.09 Pregnancy-induced hypertension (PIH)
O16 (660.5)
Also known as pre-eclampsia, eclampsia, or as pre-eclamptic toxaemia (PET).
Description
Hypertension at 20 weeks of gestation or more with:
either proteinuria or oedema, or both
hypertension is a BP of 140/90 mmHg or higher on two occasions about 6 hours
apart
eclampsia is the presence of seizures in patients with hypertension
LEVELS OF SEVERITY
LEVEL BP LEVEL mmHg PROTEINURIA OEDEMA
MILD
systolic 140150
or
diastolic 90100 - +
MODERATE
systolic 150160
or
diastolic 100110 + ++
SEVERE
systolic above 160
and
diastolic BP above 100 ++ ++
reduce maternal and fetal morbidity and mortality
refer patients according to the level of severity of the hypertension
SEVERITY NON-DRUG TREATMENT DRUG TREATMENT
MILD may be managed without admission
before 38 weeks of gestation
weekly review of:
BP
weight
urine analysis
fetal heart rate
fetal size
bed rest
education on signs requiring
follow-up
admit at 38 weeks for delivery
none
MODERATE as above methyldopa oral 250500 mg
three times daily
maximum dose 500 mg
four times daily
SEVERE
(ECLAMPSIA)
oxygen
stabilise prior to urgent referral and
admission
0.9% sodium chloride IV
or
half-strength Darrows solution
with 5% dextrose
magnesium sulphate as
follows:
dilute magnesium sulphate
4 g in 1000 mL 5% dextrose
in water, infuse over at least
30 minutes
and
magnesium sulphate IM
10 g given as 5 g in each
buttock
SEVERITY NON-DRUG TREATMENT DRUG TREATMENT
then IM 5 g every 4 hours in
alternate buttocks
dihydralazine IV 6.25 mg over
2 minutes may be
administered if BP remains
high
Referral
Immediate
severe PIH - stabilise the patient prior to referral after initiating magnesium sulphate
infusion and IM injection
Routine
poor compliance in mild PIH
9.10 Vaginal discharge/lower abdominal pain in women
(STD Protocols 2 and 4)
A54.9
Description
One or more of the following symptoms:
excessive vaginal secretion
staining of underwear
change in vaginal secretion odour
change in vaginal secretion colour
itching or redness of the vulva
burning or pain on passing urine
lower abdominal pain
One or more of the following may be present on examination:
vaginal discharge
lower abdominal tenderness
pain on moving the cervix
In pregnant women, lower abdominal pain related to pelvic infection is rare.
if lower abdominal pain is present these patients are usually seriously ill and require
referral
Always look for another STD (if present use appropriate protocol).
Non-drug treatment
counsel on compliance and risk reduction for transmission of STD and HIV
provide and promote use of condoms
notify partners/contacts
Drug treatment
choose one of the options below
notify the partner and treat, take blood for RPR/VDRL
ask the patient to return after 1 week
Option 1: non-pregnant woman with a vaginal discharge and no pain on moving
the cervix
ciprofloxacin oral 500 mg immediately for suspected gonorrhoea
and
doxycycline oral 100 mg 12 hourly for 7 days
and
metronidazole oral
2 g immediately
or
400 mg 12 hourly for 7 days
Option 2: pregnant woman with a vaginal discharge and no pain on moving the
cervix
spectinomycin IM 2 g immediately for suspected gonorrhea
and
erythromycin stearate oral, 500 mg 6 hourly for 7 days
metronidazole oral
2 g immediately
or
400 mg 12 hourly for 7 days
! CAUTION !
metronidazole is contraindicated in the first trimester of pregnancy
Option 3: clinical evidence of vaginal candidiasis
If there is clinical evidence of vaginal candidiasis then add to the treatment used in
options 1 or 3:
clotrimazole inserted in the vagina, 500 mg at night as a single dose
Option 4: non-pregnant woman with pain on moving the cervix
ciprofloxacin oral 500 mg immediately
and
doxycycline oral 100mg 12 hourly for 7 days
and
metronidazole oral 400 mg 8 hourly for 7 days
Option 5: pregnant woman with pain on moving the cervix
refer, as lower abdominal pain in pregnancy is uncommonly related to pelvic infection
Referral
history of a missed or overdue period (consider ectopic pregnancy)
recent abortion or delivery
abnormal vaginal bleeding
temperature above 39C
abdominal rebound tenderness and/or guarding or other gastrointestinal symptoms
pregnant women with lower abdominal pain related to pelvic infection
9.11 Vaginal ulcers
(See Chapter 11 - Infections)
Chapter 10 - Immunisation
Z26.9 (V03.0)
BCG - Bacillus Calmette-Guerin vaccine
DPT - diphtheria, pertussis and tetanus vaccine
DT - diphtheria and tetanus vaccine
HepB - hepatitis B vaccine
Hib - Haemophilus influenzae type b vaccine
OPV - oral polio vaccine
- measles vaccine
TT - tetanus vaccine
10.1 Dosage and administration
Immunisation is the most important
and cost-effective care that can be given to a baby
and child
Description
Immunisation:
helps the child's body to produce antibodies against specific micro-organisms
prevents the specific organism from causing serious illness or complications
saves millions of children from death and disability every year
10.2 Vaccines for routine administration
(Tables on next three pages.)
Chapter 10 Immunisation 97
STORAGE DOSAGE /
ADMINISTRATION
INDICATIONS CONTRAINDICATIONS
children under 2 years
diluent and vaccine in
fridge at 08C
discard opened vial
at session end
place a drop of
reconstituted vaccine on
upper arm
press sterile vaccination
tool on the site twice,
turning slightly
at birth
repeat once at 6
weeks if no visible
scar
HIV+ patients
can be given with
measles vaccine
AIDS
diphtheria, pertussis and
fridge middle shelves
at 08
o
C
easily damaged by
freezing
keep opened vials for
next session if kept
at correct
temperature and not
contaminated
sterile IM 0.5 mL
under 1 year: outer side of
thigh
over 1 year: upper arm
side-effects: mild fever,
pain, local swelling
occasionally
6 weeks
10 weeks
14 weeks
18 months
catch-up doses: 4
weeks apart
use DT if:
over 2 years
previous severe
reaction to DPT
uncontrollable
neurological disease
diphtheria and tetanus
as for DPT as for DPT 2 years and over
or
sensitivity/past severe
DPT reaction
previous anaphylaxis
STORAGE DOSAGE /
ADMINISTRATION
protects against hepatitis
as for DPT sterile IM 0.5 mL
paediatric vaccine
under 1 year: outer side
of thigh
over 1 year: upper arm
use opposite side to
DPT/DT
side-effects: mild fever,
pain and local swelling
occasionally
6 weeks
10 weeks
14 weeks
previous anaphylaxis
protects against Hib
disease (meningitis,
pneumonia, otitis media)
as for DPT according to
manufacturers
instructions
6 weeks
10 weeks
14 weeks
according to
manufacturers
instructions
Oral polio vaccine
protects against polio
fridge - top shelf or
freezer
not damaged by
freezing
easily damaged by
temperature above
8C
vials can be reused
if the VVMs inner
square remains
lighter than the outer
circle
oral drops
if spat out or vomited,
repeat immediately
if diarrhoea, repeat next
visit
not affected by feeding
(breast or other)
birth
6 weeks
10 weeks
14 weeks,
18 months
5 years
none
STORAGE DOSAGE /
ADMINISTRATION
as for BCG as for DPT 9 months
18 months

protects against tetanus
as for DPT as for DPT areas at high risk of
neonatal tetanus
first pregnancy: three
doses 4 weeks apart
during antenatal period
subsequent pregnancy:
one dose during the
antenatal period
safe in early pregnancy
give booster after each
trauma episode (unless
given in previous 6
months)

10.3 Immunisation schedule
Vaccinations are given in a specific sequence at certain ages. This is known as the
immunisation schedule. Remember the following important points about the schedule:
never miss a chance to immunise
the schedule is not rigid - give a dose if a child is brought a few days earlier or later
than expected
give doses no closer than 4 weeks - make follow-up dates 4 weeks from the previous
dose
special immunisation clinic days are often convenient for mother and health worker,
but never turn a child away if an immunisation is needed even if it is not an
immunisation clinic day
open multidose vial for just one child if it is necessary
giving appropriate vaccines to children brought to the clinic for other reasons is a very
important way to reach the children who have missed immunisations
always check the RTH card for missing doses and then give them immediately
catching up on missed immunisations will ensure full immunological protection
give an extra dose if in doubt whether a child has had a certain dose already, as extra
doses are not harmful
all vaccines listed in the table can be given safely at the same time but not mixed in
the same syringe
when the child is hospitalised:
give a dose of measles vaccine on admission
give all other outstanding immunisations on discharge
There are very few contra-indications, but many missed opportunities!
Note
discard opened vials of measles and BCG at the end of an immunisation session
opened vials of other vaccines can be kept for up to 1 month if they have been kept
between 08C and are not contaminated. This applies to fixed clinics only.
!CAUTION!
past reaction to a vaccine indicates hypersensitivity and repetition of the vaccine
should be avoided
children with AIDS should not receive BCG vaccine
Give every baby the required immunisation as soon as possible according to the
schedule below. The vaccines listed are very safe and cause no or minimal side-
effects.
Immunisation Schedule
AGE VACCINE DOSE*
AGE VACCINE DOSE*
At birth BCG, OPV0
6 weeks OPV1, DPT1, HepB1, Hib1
9 months Measles1
18 months Measles2, OPV4, DPT4
5 years OPV5, DT
*The number that follows the immunisation name (e.g. DPT3) indicates the dose
number of that immunisation.
BCG vaccine against tuberculosis
OPV oral polio vaccine
DPT diphtheria, pertussis (whooping cough) and tetanus vaccine
HepB hepatitis B vaccine
Hib vaccine against Hib disease
DT diphtheria and tetanus vaccine
TT tetanus vaccine
An effective dose is one given on time with unspoiled vaccine.
10.4 Additional vaccines and target groups
Vaccines listed below are not part of the governments programme or are not routinely
available for adults. People who are able, are encouraged to buy these vaccines and
protect themselves or their children against the following diseases:
combination measles, mumps and rubella vaccine (MMR)
hepatitis B vaccine for adults in occupations at high risk, e.g.:
health workers/cleaners/incinerator staff
paramedics
traffic officers
give three doses of adult hepB vaccine administered according to manufacturers
instructions
a booster dose may be necessary every 10 years to ensure continued protection
the cost of this vaccination should be borne by the employing agency
10.5 Immunisation by injection
Use aseptic technique. Use one sterile needle and one sterile syringe for each person.
An injection abscess destroys the trust people have in health workers, and might cause
them to refuse further immunisations, leaving their children unprotected.
Dispose of syringes, needles and other sharps in the following way to ensure that no
needlestick injuries occur:
in an approved sharps container
never recap needles
dispose of the container properly, e.g. incineration or deep burial, not open pit burning
10.6 The cold chain
Maintaining the cold chain means keeping vaccines at the right temperature throughout
distribution, storage and use. The cold chain can be maintained by:
never exposing vaccines to heat, especially during transportation from one clinic to
another
always using a cold box to keep the vaccines cold during transport and
immunisation
Correct packing of the cold box
ice packs are placed on the bottom, at the sides and on top
if there are not enough ice packs then place available ice packs at the sides and on
top of the vaccines
DPT, DT, TT, HepB and Hib vaccines must not be allowed to freeze - wrap them in
paper to protect them
keep measles and polio vaccines very cold - place on bottom of the cold box, next to
the ice packs
BCG can be placed anywhere in the box
keep the lid firmly closed and the box out of the sun
keep a thermometer in the cold box with the vaccines and the temperature 08C
live vaccines (BCG, OPV, measles) contain weakened organisms and are very
sensitive to heat, sunlight and skin antiseptics
How to pack your fridge correctly
top shelf - measles and polio vaccines in the coldest part
middle shelf - BCG, DPT, DT, HepB, Hib and TT vaccines (do not freeze) with
sufficient diluent for the BCG and measles for 2 days
do not let DPT, DT, HepB, Hib and TT vaccines touch the evaporator plate at the
back of the fridge - they are destroyed by freezing
do not keep vaccines in the fridge door
store the same kind of vaccines together in one tray
leave about 5 cm space between each tray to allow the cold air to move around
bottles filled with salt water stored in the bottom of the fridge will keep the fridge
contents cold when the door is opened
do not keep food in the same fridge as the vaccines to avoid unnecessary opening of
the door
if there has been a power failure consult the supervisor
monitor and record temperature twice daily
!CAUTION!
do not use vaccines that have expired or missed the cold chain
keep the fridge temperature at 08 C
Have your DPT, Hep B, DT or TT vaccines frozen?
Never allow diphtheria, pertussis, tetanus or Hepatitis B vaccines to freeze - they
become useless.
Vaccine shake test
If you think that the vaccine has frozen, shake the vial and place it in a cool place where
there is enough light to see, but not in direct sunlight. Wait 15 minutes. If the solution is
still smooth and cloudy, you may use it.
If the solution at the top is clear, and there is a sediment at the bottom, you cannot use
it. It has lost its strength, and is now ineffective.
This vaccine is still potent.
You may use it !
This vaccine is useless.
Do not use it !
The temperature of this vaccine
was always kept between 2
o
C and
8
o
C
DPT, Hep B, DT or TT
after shaking
The temperature of this vaccine has
fallen below 0
o
C and has now lost its
strength
The liquid in the container is
smooth and cloudy
Now The liquid in the container contains
little particles
The liquid is still smooth and cloudy After 15 minutes The liquid is clear at the top. There is
a sediment at the bottom of the
container
The liquid begins to clear at the top,
but there is no sediment
After 30 minutes The liquid is clear at the top. There is
a thick sediment at the bottom of the
container
Chapter 11 - Infections (selected) and related conditions
amoxycillin
25% benzylbenzoate
calamine lotion
chloramphenicol
0.05% chlorhexidine
0.2% chlorhexidine digluconate
chloroquine
chlorpheniramine
ciprofloxacin
5% dextrose
doxycycline
0.5% gentian violet
hypochlorite
nystatin
paracetamol
1% permethrin
5% polyvidone iodine
praziquantel
proguanil
quinine
retinol (vitamin A)
sulfadoxine-pyrimethimine
tincture of iodine
11.01 Amoebic dysentery
(See Chapter 8 - Gastrointestinal conditions)
11.02 Bacillary dysentery
Chapter 11 Infections and related conditions 105
11.03 Bilharzia
B65.9 (120)
Description
A parasitic infestation with the bilharzia parasite (Schistosoma).
infestation occurs during washing, bathing or paddling in water harbouring snails
shedding this parasite
clinical features vary with the location of the parasite
some cases may be asymptomatic
chronic bilharzia may present with local or systemic complications, including urinary
tract obstruction with ensuing renal failure or other organ involvement
TYPE OF WORM Schistosoma haematobium Schistosoma mansoni
CLINICAL
FEATURES
initially (after exposure):
itching or rash
some weeks later:
blood in the urine
lower abdominal pain
low grade fever
recurrent cystitis
diarrhoea
abdominal pain
blood and mucus in the
stools
DIAGNOSIS eggs in urine or stool on microscopy
rectal biopsy
Non-drug treatment
if bilharzia is endemic, educate the community to avoid contaminated water and
infection
do not urinate or pass stools near water used for drinking, washing or bathing
do not swim in contaminated water
collect water from rivers and dams at sunrise when the risk of infestation is lowest
boil all water before use
Drug treatment
if eggs of S. haematobium and S. mansoni are found in the urine/faeces treat with
praziquantel oral (600 mg tablet)
children over 2 years: 40 mg/kg as a single
dose or 2 divided doses
adults: 40 mg/kg (4 tablets) as a
single dose
pregnant women: delay treatment until after
delivery as praziquantel is teratogenic
breastfeeding women: stop breastfeeding on
the day of drug administration and for the next 48
hours - give adult dose
Referral
if you are not equipped to check for parasites, do not treat
complications, e.g. urinary tract obstruction, systemic complications
11.04 Chickenpox
B01.9 (052)
Description
A mild viral infection which presents 23 weeks after exposure, with:
small, red, itchy spots that turn into blisters and burst to form scabs. These lesions
may all be present at the same time
lesions begin on the trunk and face, later spreading to the arms and legs
fever is usually mild and precedes the rash
infective for 6 days after the lesions have appeared or until all the lesions have crusted
infection is self-limiting with a duration of about 1 week
Complications of encephalitis and pneumonia occur rarely, more likely in adults.
provide symptomatic treatment
manage complications
Non-drug treatment
isolate from immunocompromised people and pregnant women until all lesions have
crusted
ensure adequate hydration
cut fingernails very short and discourage scratching
Drug treatment
avoid the use of aspirin in children because of risk of Reyes syndrome
calamine lotion topically for itch
(120 mg/5 mL syrup)
children 512 years:
tablets
mg twice daily
children 15 years: 12 mg
three times daily
mg 34 times daily
mg 34 times daily
if skin infection is present due to scratching, treat as for bacterial skin infection
Referral
complications such as:
meningitis
encephalitis
pneumonia
severely ill adults
babies under 6 months
pregnant women
11.05 Cholera
11.06 Giardiasis
11.07 HIV
B24
Description
Infection with the human immunodeficiency virus (HIV).
initial clinical features:
fever
rash
shingles
arthralgia
later clinical features:
generalised swollen glands
weight loss
intermittent fever
malaise
fatigue
chronic diarrhoea
anaemia
recurrent infections
later clinical features - such as opportunistic infections:
oral candidiasis - slow to respond to
treatment
TB
Pneumocystis carinii pneumonia
Kaposi's sarcoma
non-Hodgkin's lymphoma
diagnosis:
remember that there is a "window period" which is the time period between
becoming infected and the appearance of antibodies which are detectable by blood
tests
ensure that the diagnosis is recorded in such a manner that the patient's
confidentiality is not breached
HIV in adults must be confirmed by laboratory testing. All persons and especially
high-risk behaviour patients should be counselled on preventive methods to reduce
the spread of the disease
in infants recurrent infectious diseases, like pneumonia, must arouse suspicion of
HIV infection, which should be strengthened if the patient develops any of the
following:
t generalised lymphadenopathy
t failure to thrive
t skin rashes
t recurrent diarrhoea
t pneumonia
t otitis media
t sinusitis
t oral candidiasis
t chronic or recurrent fever for longer
than a month
Prevention of disease transmission
use condoms (male or female) during sexual intercourse
persons with STD infections are more likely to be infected with HIV (see STD
management, section 11.14)
avoid contact with blood and blood products, used needles and syringes
Transmission from HIV-positive mother to baby
may occur:
during pregnancy
at birth
in the neonatal period through breast milk
During pregnancy
if testing is done before 20 weeks of gestation and found to be positive, termination of
the pregnancy can be offered
as HIV treatment is rapidly changing, consult the latest departmental protocols
During birth
cleanse the birth canal with 10% polyvidone iodine solution as this has been shown to
decrease disease transmission
avoid traumatic procedures such as:
artificial rupture of membranes early in labour
instrument delivery of babies
Breastfeeding
breastfeeding is a recognised transmission route of HIV
mothers with AIDS may be advised not to breastfeed if alternate feeds are available.
Formula feeds come with their own risks/complications and the decision to breastfeed
needs to be taken by the mother after counselling by an informed health care worker
symptomatic relief
prevention and treatment of complications
Non-drug treatment
patients should be supported and encouraged to stay employed as long as possible
patients and their families must be supported and encouraged to join support/peer
groups
Drug treatment
there is no curative treatment for this disease
Referral
when the patient's condition deteriorates
needlestick injuries - immediate
Prevention of TB infection
patients with HIV are more susceptible to TB infection than HIV-negative persons
general infection control principles should be implemented such as:
separation of infectious TB patients
where possible good ventilation
as much sunlight exposure as possible
11.08 Infection control: the use of antiseptics and disinfectants
Description
Disinfectants are used to kill micro-organisms on working surfaces and instruments, but
cannot be relied on to destroy all micro-organisms.
Antiseptics are used for sterilising skin and mucous membranes.
do not mix products
Disinfecting surfaces
guidelines for the use of disinfectants
never use a chemical if other more reliable methods are available
cleansing is the first and most important step in chemical disinfection
the disinfection fluid must entirely cover the object and penetrate all crevices
use the recommended strengths for specific purposes
disinfectants cannot sterilise surgical instruments
no chemical agent acts immediately - note the recommended exposure time
equipment has to be rinsed after immersion in a chemical
recontamination is very easy at this stage
make sure that the rinsing water and all other apparatus are sterile
equipment must not be stored in chemical disinfectants
the best disinfectant for killing HIV and other pathogens is a chlorinated solution such
as bleach or hypochlorite:
solutions must be prepared freshly
and discarded after 24 hours to disinfect properly
do not use on the skin
Intact skin
alcohol swabs may be used to swab before injections
antiseptics like polyvidone iodine or chlorhexidine are used for surgical scrubbing, but
soap and water can be just as good
Wounds and mucous membranes
correctly diluted aqueous dilute solutions of chlorhexidine digluconate can be used to
clean dirty wounds
saline and sterile water are also used on clean wounds
0.5% gentian violet solution may be painted onto mucous membranes
DISINFECTANT INDICATIONS DIRECTIONS FOR
APPLICATION
chlorhexidine
solution
0.05% aqueous
solution
0.5% in 70% alcohol
skin disinfection before
surgery
cleaning dirty wounds
remove all dirt, pus and blood before
use
clean dirty wounds with 0.05%
aqueous solution
disinfection of instruments with 0.5%
in 70% alcohol solution
expensive, do not use for normal
cleaning
use the correct concentration for a
specific purpose
polyvidone iodine
solution 10%
ointment 10%
cream 5%
skin and wound
infections
use ointment for skin infection
use solution for cleaning skin and
wounds
avoid using on large wounds
because of danger of iodine
absorption
expensive, do not use for normal
cleaning
contraindication: iodine allergy
Articles and instruments
adhere to the appropriate cleansing and disinfection policy
11.09 Malaria
B54 (084)
Description
The most important element in the diagnosis of malaria is a high index of suspicion in
both endemic and non-endemic areas. Test any person resident in or returning from a
malaria area and who presents with fever and flu-like symptoms.
clinical features include, often in combination:
severe headache
fever above 38C
muscular and joint pains
sweat
shivering attacks
in more severe cases there may also be:
severe diarrhoea
fatigue
difficulty in breathing and cyanosis, blue discolouration around the mouth
These symptoms may progress to severe or complicated malaria when sleepiness,
unconsciousness or coma, convulsions or shock may occur.
Diagnosis
microscopic examination of thick and thin blood smears where possible:
thick films are more sensitive than thin films in the detection of malaria parasites
where rapid diagnostic tests, e.g. a plasma reagent dipstick are available, these can
be used to diagnose malaria within 1015 minutes. If neither microscopy nor rapid
tests are available diagnosis should be made on the basis of clinical symptoms. A
blood smear should be made and sent for microscopic examination. One negative
malaria test does not exclude the diagnosis of malaria
Non-drug treatment
monitor for complications
Drug treatment
Resistance to chloroquine was found in all the malaria-affected provinces. Chloroquine
is no longer recommended for the treatment of malaria. Sulfadoxine-pyrimethamine
is the first-line treatment of mild uncomplicated malaria.
UNCOMPLICATED MALARIA DRUG TREATMENT
sulfadoxine-pyrimethamine
500 mg/25 mg
Children:
under 1 year: less than 10 kg refer
14 years: 1019 kg tablet
58 years: 2030 kg 1 tablet
915 years: 3145 kg 2 tablets
Adults:
over 15 years: more than 45 kg3 tablets
High-risk groups
pregnant women
children under 5 years of age
Pregnant women and children 15 years with malaria should be given an immediate
dose of sulfadoxine-pyrimethamine and referred immediately. Do not give this immediate
dose to children under 1 year, but refer immediately.
Severe or complicated malaria
Malaria in high-risk groups (pregnancy):
quinine sulphate oral 8 hourly until referred
adults: 600 mg (maximum 7 days treatment)
always refer as soon as possible
Cerebral malaria
initiate treatment with quinine IV 20 mg/kg in 500 mL 5% dextrose, infused over 4
hours, and refer immediately
if immediate referral is not possible, continue treatment with 10 mg/kg IV over 8 hours.
After 48 hours reduce the dose to a maintenance dose of 5 mg/kg
Referral
all children
patients not responding to sulfadoxine-pyrimethamine treatment within 4 days
patients with symptoms of severe and complicated malaria
lack of experience or facilities to treat severe and complicated malaria
pregnancy
after initial treatment with quinine
burn-like skin reactions after starting treatment
Malaria prophylaxis (self care)
In the high-risk malaria areas from October to May, malaria prophylaxis should be used,
together with preventive measures against mosquito bites. For other countries see WHO
guidelines.
Non-drug treatment - preventive measures
preventive measures against mosquito bites include:
use treated mosquito nets, screens, coils or pads
apply insect repellent to exposed skin and clothing
wear long sleeves, long trousers and socks if outside between dusk and dawn, as
mosquitoes are most active at this time
visit endemic areas during the dry season
pregnant women should avoid visiting malaria-infested areas if possible
DRUG ADULTS CHILDREN
chloroquine 300 mg chloroquine base
(2 tablets) once every 7 days
start 1 week before entry to
area
once weekly while in the
area
and
weekly for 4 weeks after
leaving the area
5 mg chloroquine base/kg once every
7 days
proguanil
never use
proguanil on its
own
Use in combination with
chloroquine.
200 mg (2 tablets) once daily
start 1 day before entering
the area
daily while in the area
continue daily for 4 weeks
after leaving the area
3 mg/kg taken in the same intervals as
adults
Age Kg Dosage
under 1 yr
14 years
58 years
915 years
over 15 yrs
under 10
1019
2030
3145
over 45
tablet
tablet
1 tablet
1 tabs
2 tablets
11.10 Measles
B05.9 (055)
Note: A notifiable condition.
Description
A viral infection that is especially dangerous in malnourished children or in children who
have other diseases such as TB or AIDS.
initial clinical features occur 10 days after contact with an infected individual:
signs of a cold
patient may deteriorate with fever
diarrhoea may occur
conjunctivitis with discharge
cough, bronchitis and otitis media
Usually these features develop in the following order:
after 2 or 3 days a few tiny white spots like salt grains appear in the mouth
the skin rash appears 12 days later and lasts about 5 days
location, first behind the ears and on the neck
then on the face and body
lastly on the arms and legs
secondary bacterial infection (bronchitis, bronchopneumonia, otitis media) may occur,
especially in children with poor nutrition or concomitant conditions
to provide symptomatic treatment and prevent complications
prevention and catch-up through EPI
notify the disease (see p. ix)
Non-drug treatment
continued good nutrition
isolate the patient to prevent spread
Drug treatment
treat at home if:
over 6 months old
well nourished
uncomplicated (pneumonia or otitis media)
fever above 39C, pain, or a history of febrile convulsions
(120 mg/5 mL syrup)
mL
children 512 years:
tablets
diarrhoea
rehydrate for 24 hours
bronchitis or otitis media
infants 06 months:
62.5 mg
mg
mg
penicillin-allergic patients:
children 510 kg: erythromycin estolate 62.5 mg
children over 15 kg: erythromycin stearate or estolate
250 mg
adults: erythromycin stearate 250mg
purulent conjunctivitis
1% chloramphenicol ophthalmic ointment
all children with measles should be given vitamin A (retinol) oral as a single dose
children less than 12 months: 100 000 IU
children more than 12 months: 200 000 IU
Referral
children under 6 months
croup (which may need adrenaline inhalations)
severe or unresponsive bronchitis or pneumonia
malnutrition
dehydration
neurological signs or symptoms like confusion
immunocompromised and associated illness like AIDS, TB
asthma
severely ill adults
11.11 Meningitis
(See Chapter 2 - Central Nervous System)
11.12 Mumps
B29.9 (072)
Description
A viral infection involving the salivary glands.
symptoms of mumps appear 23 weeks after exposure:
fever
pain on opening the mouth or eating
about two days later a tender swelling appears below the ears at the angle of the
jaw
often first on one side and later on the other
the swelling disappears in about 10 days
provide symptomatic treatment
Non-drug treatment
bed rest during febrile period
isolate until swelling subsides
advise on oral hygiene
recommend plenty of fluids and soft food during acute stage
patient is infectious from 3 days before parotid swelling to 7 days after it started
children may return to school 1 week after initial swelling
Drug treatment
(120 mg/5 mL syrup)
mL
children 512 years:
tablets
Referral
high fever
severe headache
abdominal pain
painful testes or orchitis
suspected encephalitis
pancreatitis
11.13 Rubella (German measles)
B06.9 (056)
Description
A viral illness with skin lesions.
less severe than measles
lasting only 34 days
a rash starting in the face spreading to the trunk, arms and legs. It usually fades as it
moves on
seldom complicated by bacterial infections
infection during the first or second trimester of pregnancy may lead to severe
permanent deformities in the baby
clinical features:
include a scanty rash
swollen and tender lymph nodes behind the ears (suboccipital)
management of complications
Non-drug treatment
bed rest if needed
isolate from pregnant women or women of child-bearing age
Drug treatment
children 3 months1 year: 2.5 mL (120
mg/5 mL syrup)
children 512 years: 1 tablet (500 mg
tablet)
tablets
Referral
pregnancy
11.14 Sexually transmitted diseases (STD)
*O90
Description
The syndromic approach to STD diagnosis and management is to treat the signs or
symptoms (syndrome) of a group of diseases rather than treating a specific disease.
This allows for the treatment of one or more conditions that often occur at the same
time.
It is important to provide the patient with information and counselling on:
compliance with treatment
prevention of the complications of STDs
risk reduction for acquiring STDs
promotion and provision of condoms and demonstration of their use
tracing and management of sexual contacts
Protocol 1: Urethral discharge/burning micturition in men
Description
clinical features:
small or large amounts of mucus or pus at the end of the penis (penile discharge)
staining of the underwear
burning/pain on passing urine
always look for another STD (if present use appropriate protocol)
Non-drug treatment
counsel on compliance and risk reduction
provide and promote the use of condoms
take blood for RPR/VDRL
notify partner to be treated
ask to return in 1 week
Drug treatment
ciprofloxacin 500 mg oral immediately
then
doxycycline 100 mg twice daily for 7 days
treat partner with same drugs
Protocol 2 and 4: Vaginal discharge in women/lower abdominal pain in women
(see Chapter 9 - Gynaecology and Obstetrics)
Protocol 3: Genital ulceration in men and women
Description
One or more ulcers on or around the genitalia.
Non-drug treatment
notify partner to be examined and treated
Drug treatment
benzathine benzylpenicillin IM 2.4 MU immediately
then
erythromycin oral, 500 mg 6 hourly for 5 days
or
erythromycin oral 500 mg 6 hourly for 14 days
look for another STD (if present use appropriate protocol)
ask to return after 1 week
Referral
no response after 7 days
history of recent blisters, refer for management of suspected herpes
Protocol 5: Inguinal swelling/bubo - no ulcer present in men and women
Description
An inguinal bubo is a flitting/recurrent enlargement of the lymph glands in the groin.
clinical features:
swelling in one or both sides of the groin
swelling may be painful and tender
if an ulcer is present use protocol 3
Non-drug treatment
provide and promote the use of condoms, notify partner and treat, take blood for
RPR/VDRL
Drug treatment
Look for another STD (if present use appropriate protocol).
Provide treatment:
then
doxycycline oral 100 mg twice daily for 14 days
or
erythromycin oral 500 mg 6 hourly for 14 days
Protocol 6: Balanitis/balanoposthitis in men
Description
Patients complain of itching of tip of the penis and/or foreskin.
Clinical features:
thin white film on the glans and/or foreskin
refer to the appropriate protocol if there is an ulcer or urethral discharge
in the absence of other findings, the likely diagnosis is moniliasis (candidiasis); this can
be confirmed by microscopy of a wet smear
Also consider diabetes mellitus.
Non-drug treatment
personal hygiene, wash with water (avoid regular use of soap on mucous
membranes)
provide and promote use of condoms (male and female)
investigate blood for RPR/VDRL
Drug treatment
apply nystatin ointment 100 000 IU/g twice daily for 5 days
notify partner and treat
Protocol 7: Painful scrotal swelling in men
Description
Patients usually complain of a swollen and painful testis.
urethral discharge may be present in most STD cases
exclude other causes of this condition, e.g. mumps, TB
exclude sudden onset of testicular pain which may be caused by torsion of a testis
this may lead to gangrene in 612 hours, so immediate surgery is needed
Non-drug treatment
provide and promote use of condoms (male, female)
Drug treatment
ciprofloxacin oral 500 mg immediately
then
notify partner and treat
Referral
immediate referral:
suspected torsion of the testis (see above)
normal referral:
person who is not sexually active
sudden onset of pain
history of trauma
history of other serious non-STD disease
Protocol 8: Interpretation of syphilis serology - RPR/VDRL
RPR/VDRL negative result
record the result on patient's record
ask the patient to return for a repeat test in 3 months
when the patient returns in 3 months
if the result is negative after 3 months:
counsel and send home
if the result is positive after 3 months
treat for early syphilis
record titre on patient's record
RPR/VDR positive result
check if titre recorded in last 2 years
if current titre is lower than or the same as the previous titre
then
counsel and send the patient home
if current titre is higher than the previous titre
then
and
repeat RPR/VDRL in 3 months
if no previous titre was recorded
then
treat for late syphilis
and
In 3 months
if current titre is lower than or the same as the previous titre
then
patient was successfully treated, send home
and
if current titre is higher than previous titre
and
Early syphilis treatment
check if treated at initial visit
in penicillin-allergic patients:
or
if penicillin-allergic and pregnant
erythromycin oral 500 mg four times a day for 14 days
Late syphilis treatment
check if treatment was commenced at initial visit
benzathine benzylpenicillin IM 2.4 MU, once weekly for 3 weeks
in penicillin-allergic patients
doxycycline oral 100 mg twice daily for 1 month
or
if penicillin-allergic and pregnant
erythromycin oral 500 mg four times a day for 1 month
Protocol 9: Return visit after 1 week
This protocol refers to the return visit and applies to all STDs.
If cured
check and record RPR/VDRL result and follow RPR/VDRL protocol 8
complete treatment
counsel on risk reduction
If not cured
assess treatment compliance and possibility of re-infection
if there is poor compliance or re-infection then:
t repeat treatment
t ask to return after 1 week
if good compliance and no chance of re-infection refer
check RPR/VDRL result and follow RPR/VDRL protocol 8
11.14.1 Genital warts
A63.0
Referral
Refer all patiets with genital warts.
11.14.2 Pubic lice
B85.3
See lice (pediculosis).
Drug treatment
25% benzylbenzoate, apply and leave overnight, rinse off in the morning. Repeat once
weekly for 3 weeks
or
1% permethrin cream rinse
11.14.3 Genital scabies
B86
See scabies.
Drug treatment
benzylbenzoate 25% over whole body from the neck downwards
11.14.4 Molluscum contagiosum
B08.1
Drug treatment
apply tincture of iodine BP to the core of individual lesions using an applicator
11.14.5 Gonorrhoea neonatorum
See ophthalmia neonatorum.
11.15 Tick-bite fever
A79.9
Description
Rickettsial disease, spread by infected ticks. After an incubation time of 710 days,
there is fever, malaise, severe headache, a skin rash. The bite area develops into skin
necrosis (eschar), there often is regional lymphadenopathy. Patients are often severely
ill. Diagnosis is clinical, confirmed by serological tests.
elimination of the pathogen
prevention of complications
Non-drug treatment
symptomatic
Drug treatment
doxycycline oral
adults: 200 mg immediately, then 100 mg twice daily for 7 days
adults: 12 tablets (500 mg)
Referral
children
severely ill patients
pregnant women
diagnosis uncertain
11.16 Typhoid fever
11.17 Tuberculosis
(See Chapter 16 - Respiratory conditions)
Chapter 12 Musculoskeletal conditions 123
Chapter 12 - Musculoskeletal conditions
colchicine
ibuprofen
12.01 Arthralgia
(See Chapter 18 - Signs and Symptoms)
12.02 Gout
12.02.1 Gout, acute
M10.9 (274)
Description
A condition in which uric acid crystal deposition occurs in joints and other tissues:
features:
recurrent attacks of a characteristic acute arthritis - one joint, extreme pain, redness
and very hot
uric acid deposits in and around the joints and cartilages of the extremities (tophi)
occasional deformity due to uric acid deposits
interstitial renal disease - poor kidney function
uric acid kidney stones (nephrolithiasis)
increased serum uric acid concentration (above 0.5 mmol/L)
treat acute attacks
prevent recurrences of acute attacks
Non-drug treatment
bed rest
increased fluid intake
avoid alcohol
avoid aspirin
Drug treatment
Initiate adult therapy with:
non-steroidal anti-inflammatory drug (NSAID)
ibuprofen oral
800 mg immediately,
then
200400 mg 68 hourly (max dose 2400 mg per day) for 23 days
thereafter if needed
200400 mg 8 hourly until pain has subsided
or
if the patient does not respond to ibuprofen
colchicine oral 0.51 mg immediately
initiate treatment as early as possible in an acute attack as it becomes less effective
the longer the attack continues
then
0.5 mg 23 hourly until pain is relieved or gastrointestinal distress develops
do not exceed a total daily dose of 6 mg
do not repeat a course within 3 days
Prophylaxis
colchicine oral 0.5 mg once or twice daily until uric acid lowering agents can be
administered
Note
Colchicine is effective and specific for acute gout but it is not easy to use optimally due
to the development of gastrointestinal adverse effects.
Referral
failure to respond
uncertain diagnosis
chronic gout suspected
12.02.2 Gout, chronic
M10.9 (274.9)
Description
Gout with one or more of the following:
tophi
bony destruction
many acute attacks (more than four
per year)
kidney stones
poor renal function
serum uric acid over 0.5 mmol/L
lower the serum uric acid level below 0.5 mmol/L
prevent the complications resulting from uric acid crystal deposition
prevention of uric acid kidney stones
Non-drug treatment
check to see if a thiazide diuretic (e.g. hydrochlorothiazide) is prescribed and consider
an alternative diuretic
encourage controlled weight loss
advise avoidance of substances that may trigger acute gout:
alcohol, aspirin and certain foods, e.g. red meat
Chapter 12 Musculoskeletal conditions 125
Referral
refer all patients with chronic gout
12.03 Osteoarthritis/Osteoarthrosis
M19.9
Description
A degenerative disorder typically affecting weight-bearing joints. Patients complain of
pain, limited movement and joint swelling.
Referral
all cases
12.04 Rheumatoid arthritis
M06.9
Description
A chronic inflammatory systemic condition of fluctuating course, which may affect many
organs, predominantly joints with:
swelling
pain
limitation of movement
destruction often occurs
Referral
all patients with suspected rheumatoid arthritis
12.05 Septic arthritis
M00.9
Description
A condition involving infection of one or more of the large joints. Infection is usually
blood borne, but may follow trauma to the joint. The course may be acute or protracted.
A wide spectrum of organisms is involved, including staphylococci and Neisseria
gonorrhoea.
Note
Haemophiliacs may present with an acute arthritis similar to septic arthritis that is not
infected.
Referral
all patients with suspected septic arthritis should be referred immediately to confirm
the diagnosis, initiate appropriate treatment and prevent complications
Chapter 13 - Nutritional and blood conditions
elemental iron
ferrous sulphate
nicotinamide
pyridoxine (vitamin B6)
retinol (vitamin A)
thiamine
vitamin B complex
13.01 Anaemia
D50.9
Description
A condition characterised by pallor. Anaemia occurs when the total volume of red blood
cells and/or the amount of haemoglobin (Hb) is reduced below normal values.
it is commonly caused by one or more of the following:
defective red cell production (nutritional)
increased red cell destruction (haemolysis)
blood loss (parasites, ulcers, tumours, excessive menstruation)
other causes include infiltration/replacement of the bone marrow, abnormal
haemoglobin or red cells, chronic systemic diseases
clinical examination and assessment of a peripheral blood smear (if available) to
indicate the type of anaemia (normochromic, hypochromic, macrocytic or microcytic)
after which further investigations to identify the cause of the anaemia are required
Treatment
As for each specific treatable condition.
Referral
anaemia plus:
undiagnosed cause and type of anaemia
symptoms of anaemia - syncope, palpitations, shortness of breath
evidence of cardiac failure
signs of chronic disease, e.g. TB, hepato/splenomegaly
symptoms or signs of acute blood loss
blood in stool or malaena
pregnant women over 34 weeks of gestation
children with Hb under 8 g/dL
adults with Hb under 7 g/dL
no improvement after treatment with iron and/or folate such as
Hb increase under 1.5 g/dL over a 2-week period
or
under 2 g/dL over a 3-week period
Chapter 13 Nutritional and blood conditions 127
13.01.1 Anaemia, iron deficiency
D50.9 (280)
Description
iron deficiency is the most common cause of anaemia
most common in younger children and women of child-bearing age
in pregnancy and during the post-partum period: folate deficiency and/or combined
iron/folate deficiency are common in certain areas
diagnosis to be confirmed as:
women and children 15 years: Hb less
than 11 g/dL
males: Hb less
than 12 g/dL
Non-drug treatment
cause to be identified and removed if possible, e.g. in children hookworm is a
common cause
lifestyle adjustment
patient counselling
Drug treatment
elemental iron in three divided doses per day
children: 46 mg/kg
ferrous sulphate oral three times daily with food
adults: 200mg
Prevention
elemental iron oral, daily
children
premature babies day 151 year :2
mg/kg to a maximum dose of 15 mg per day
3 months1 year: 1
mg/kg
ferrous sulphate oral, daily
adults:
200 mg
follow up at monthly intervals
expected response is a rise in Hb of 2 g/dL or more in 3 weeks
continue for 34 months after Hb is normal to replenish body iron stores
! CAUTION !
iron is extremely toxic in overdose, particularly in children
intramuscular iron does not act faster - and is rarely indicated as there is a
significant risk of anaphylactic reactions
13.01.2 Megaloblastic/Macrocytic anaemia
B52.0/B53.1
Description
Anaemia with large red blood cells, commonly due to folate deficiency or vitamin B12
deficiency. Folate deficiency is common in pregnant women, and in the elderly. Vitamin
B12 deficiency occurs specifically in adult age groups. Special investigations are required
to confirm the diagnosis.
Referral
all patients with suspected macrocytic anaemia except in pregnancy should be
referred for diagnosis and treatment, especially:
people with
a history
suggestive
of vitamin
B12
deficiency
TB
bowel malabsorption
diarrhoea
weight loss
elderly patients
vegetarian diet
liver disease
hypothyroidism
any neurological signs/symptoms
13.01.3 Folate deficiency
(See chapter on pregnancy (section 9.02))
13.02 Vitamin deficiencies
E56.9
13.02.1 Vitamin A deficiency
E50.9 (264)
Description
A condition affecting the skin, mucous membranes and the eyes.
most common in children 15 years
it is the commonest cause of blindness in children in Africa if not identified and treated
early
night blindness
dry eyes (xerophthalmia) with eventual ulceration and perforation of the cornea
(keratomalacia)
small greyish triangular deposits near the cornea (Bitots spots)
prevent and treat vitamin A deficiency by ensuring vitamin A sources in the diet,
supplementing by vitamin A in areas where the diet is insufficient (see below)
Drug treatment
children with eye complications secondary to vitamin A deficiency
children with kwashiorkor and/or marasmus but no associated eye complications
secondary to vitamin A deficiency
children with measles at present or during the past 3 months
retinol (vitamin A) oral
under 12 months: 100 000 IU immediately and repeat 24
hours later and after 6 weeks
over 12 months: 200 000 IU immediately and repeat 24
hours later and after 6 weeks
Prophylaxis
children in communities where vitamin A deficiency is common
retinol (vitamin A) oral
under 12 months: 100 000 IU every 6 months
over 12 months: 200 000 IU every 6 months
Referral
All complicated cases.
13.02.2 Pyridoxine (Vitamin B
6
) deficiency
E56.9
Description
Pyridoxine deficiency is related to:
malnutrition
alcoholism
malignancy
Common manifestations include:
symptoms and signs of anaemia
signs of peripheral neuritis such as:
tingling sensation of the legs
leg pains
calf muscle cramps
muscle weakness
Note:
Signs of peripheral neuritis may occur during TB treatment (isoniazid).
correct pyridoxine deficiency
treatment of the cause
Drug treatment
Pyridoxine oral in the morning for 3 weeks:
deficiency
children: 25 mg
adults: 25 mg
drug-induced neuropathy
children: 50200 mg
adults: 50200 mg
followed by prophylactic doses of 2550 mg oral, in the morning
Referral
convulsions
hallucinations
anaemia
seborrhoeic dermatitis around the eyes, nose and mouth accompanied by stomatitis
and glossitis
13.02.3 Pellagra (nicotinamide deficiency)
E56.9
Description
Pellagra is a condition associated with nicotinamide deficiency, usually accompanied by
other vitamin deficiencies.
clinical features:
diarrhoea
dementia
dermatitis with darkening of sun-exposed skin
correction of nicotinamide deficiency
Non-drug treatment
patient counselling
discourage alcohol abuse
Drug treatment
nicotinamide oral, daily
children: 300 mg
in three divided doses
adults with less severe pellagra: 100 mg
adults with severe pellagra:
300500 mg in divided doses
Referral
confusion
depression
memory loss
psychosis
dementia
hallucinations
delusions
13.02.4 Thiamine deficiency (Wernickes encephalopathy and
beriberi)
E56.9
Description
Clinical features are:
confusion
paralysis of one or more of the ocular muscles (ophthalmoplegia)
nystagmus
ataxia
peripheral neuropathy
congestive heart failure
Note
Alcoholics may present with Wernickes encephalopathy, or with neuropathies
associated with multiple vitamin deficiencies.
Treatment objectives
correction of thiamine deficiency
treatment of beriberi
Non-drug treatment
patient counselling
Drug treatment
thiamine oral daily for 6 weeks
mild peripheral neuropathy 50 mg
severe peripheral neuropathy 50100 mg
Referral
Wernickes encephalopathy
congestive heart failure
severe peripheral neuropathy
13.03 Failure to thrive (FTT)
R62.8
Description
Children and infants showing less than normal growth according to their own record on
the Road to Health Card.
FTT is due to:
insufficient food intake
insufficient uptake of nutrients (e.g. malabsorption)
insufficient use of nutrients for growth due to chronic disease
Non-drug treatment
identify the cause
dietary management, see below (PEM)
nutrition education
Review every 2 weeks until weight gain is normal.
Drug treatment
anthelmintics, where indicated (see section 8.09)
iron, where Hb is less than 10 gm/dL (see section 13.01.1)
vitamin A (see section 13.02.1)
Referral
treatment failure
all children other than those with insufficient food intake
13.03.1 Protein energy malnutrition (PEM)
E46
Description
The various types of PEM are defined in the table.
kwashiorkor is a life-threateninng nutritional deficiency state affecting infants and
young children characterised by:
generalised oedema
apathy
skin lesions ranging from pigmentary changes to open sores
a marked tendency to superimposed infections, which may be difficult to detect due
to the bodys inability to mount an adequate response
marasmus is a deficiency of predominantly energy foods and is recognised by an
obvious lack of muscle tissue and subcutaneous fat
marasmic kwashiorkor is a combination of the above two
underweight is when the childs weight is below the 3rd percentile. This is by far the
most common presentation of PEM
Features of severe PEM:
impaired consciousness
temperature below 35C
open skin sores
pneumonia
persistent diarrhoea
obvious anaemia
failure of out-patient therapy
Wellcome Classification of Protein Energy Malnutrition
WEIGHT OEDEMA
(percentage of standard*) absent present
8060 kwashiorkor underweight
less than 60 marasmic kwashiorkor marasmus
*Standard= 50th percentile NCHS standards
Non-drug treatment
nutrition education:
initially give frequent small feeds of thin porridge with added milk powder, sugar and
margarine, mashed pumpkin and/or banana
on recovery give three meals per day with snacks in between, e.g. bread with
peanut butter
enrich the basic diet with animal or vegetable proteins and fats, e.g. amasi,
vegetable oil
review at weekly intervals until full recovery
Drug treatment
vitamin A oral 100 000 IU immediately and repeat after 1 week
anthelmintics when indicated (see section 8.09)
iron supplementation must not be given during the first 2 weeks of treatment
Referral
severe PEM
13.04 Vitamin B deficiencies
E56.9
Description
A condition in which multiple vitamin B deficiencies occur, such as:
malnutrition
pellagra associated with multiple vitamin B deficiency
physical and neurological complications of alcoholism
Correction of vitamin B deficiencies.
Non-drug treatment
patient counselling
Drug treatment
vitamin B complex oral
children: 5 ml syrup daily
adults: 2 tablets three times daily for 1 week, then one tablet
daily for 3 months
Referral
Wernickes encephalopathy
confusion
depression
memory loss
psychosis
dementia
hallucinations
delusions
Chapter 14 - Psychiatric illness
amitriptyline
chlorpromazine
fluoxetine
fluphenazine decanoate
haloperidol
lorazepam
orphenadrine
zuclopenthixol acetate
Note:
Psychiatric illness management at primary care level should only be undertaken
by health care workers trained in psychiatry (mental health).
14.01 Delirium - acutely confused, aggressive patient
(See Chapter 19 - Trauma and emergencies)
14.02 Depression
F32.9 (300.4)
Description
Disorder of emotion with a pervasive lowering of mood being the major feature.
characterised by:
feelings of lack of enjoyment of life (mood)
lowered physical energy (biological function)
negative thinking (thought)
depression is classified according to severity and manifestations:
major depressive episodes - depression of varying severity, usually lasting between
16 months
dysthymic disorders - a milder but more chronic illness
bipolar disorder - episodes of major depression alternating with episodes of mania
adjustment disorder with depressed mood - depressive symptoms as a response to
a major crisis/event lasting no longer than 6 months
Note
Telephonic consultation with a community psychiatrist is recommended to verify
diagnosis.
provide regular care, support and counselling
provide the correct medication
Non-drug treatment
Chapter 14 Psychiatric illness 135
treatment of the mentally ill requires more than medication
psychosocial interventions include:
supportive psychotherapy
counselling
rehabilitative therapies (including occupational therapy, finding accommodation and
employment)
Drug treatment
amitriptyline is indicated for:
major depressive episodes
moderate to severe adjustment disorders with depressed mood
amitryptyline oral, at bedtime
adults: initial dose of 75 mg increase by 25 mg per day at 710 day
intervals to a maximum of 150 mg. Consult if more than 150 mg is
needed
elderly: initial daily dose 25 mg per day increasing by 25 mg per day at
710 day intervals to a maximum of 100 mg
duration of treatment:
at least 6 months after symptoms have ceased in cases of first major depressive
episodes
longer treatment is indicated after relapse, old age or complicated cases
Note:
Do not increase the dose too quickly:
it takes up to 14 days before therapeutic effect occurs and often up to 8 weeks at
optimal doses
a single bedtime dose is optimal for most patients
doses should be increased slowly at intervals of 710 days in 25 mg dose increments
until the desired response
! CAUTION !
Do not issue more than 1 week's supply of amitriptyline:
as it may not be effective
to patients with suicidal ideation
because if overdosed it has a fatal toxic effect on the
heart
! CAUTION !
Do not give amitriptyline to a patient with bipolar disorder without consultation:
dysthymic disorders do not always respond but dosages are similar to those in
major depression
the elderly are more sensitive to side-effects and need lower doses
Avoid amitriptyline in patients with:
a history of heart disease
urinary retention
glaucoma
epilepsy
already on another antidepressant
Only for health workers with advanced psychiatric training
fluoxetine 20 mg daily in the morning
Note
Amitriptyline is as effective as fluoxetine and the main differences lie in the different side-
effect profiles.
consider fluoxetine when there is no response to amitriptyline
or
when amitriptyline treatment is associated with unacceptable side-effects
consult with a psychiatrist before initiating treatment
Referral
concurrent psychiatric illness without suicidal tendencies
bipolar disorders
suicidal tendency
failure to respond to available antidepressants
patients with concomitant medical illness, e.g. heart disease, epilepsy, symptoms of
urinary tract obstruction in elderly males, glaucoma
poor social support systems
pregnancy
children
14.03 Psychosis, acute
F03 (290.9)
Description
Schizophrenia is the most common psychosis:
it is characterised by abnormalities of perception, mood, thinking, behaviour and
contact with reality
it is one of the major psychiatric disorders
delusions - fixed, unshakeable false beliefs
hallucinations - perceptions without adequate stimuli, e.g. hearing voices
disorganised thinking or speech - incoherence and thought disorder
odd or peculiar behaviour
negative symptoms - apathy or blunted emotional state
social or occupational dysfunction
only make the diagnosis if:
symptoms and signs are present for at least 6 months
and
two or more of the main symptoms present almost continuously for at least 1 month
management of acute episodes
ongoing support by using medication and psychosocial interventions
Non-drug treatment
treatment of the mentally ill requires more than medication
psychosocial interventions include:
supportive psychotherapy
counselling
rehabilitative therapies including occupational therapy, finding accommodation and
employment
Note
Consultation with a community psychiatrist is recommended to verify diagnosis and
treatment.
once stabilised on maintenance medication it is usually not necessary for specialist
evaluation every 6 months and general practitioner review is recommended
Drug treatment
chlorpromazine oral, initiate with 25 mg three times a day:
gradually increase until symptoms are controlled
once stabilised, administer as a single bedtime dose
usual maintenance dose is 75300 mg at night, but may be as high as 1 000 mg
Only for health workers with advanced psychiatric training
other neuroleptics such as haloperidol
the management of acute psychosis includes the use of neuroleptics in order to:
tranquillise
sedate
have a positive effect on hallucinations, delusions and thought disorders
!CAUTION!
Always consult with a doctor,
preferably a psychiatrist, where possible
when prescribing neuroleptic drugs to:
children
the elderly
during pregnancy and lactation
Acute management of psychotic patients (including mania)
lorazepam and haloperidol IM immediately
lorazepam 24 mg
plus
haloperidol 25 mg
haloperidol may be repeated at hourly intervals (normally 48 hourly) if required, up
to a maximum of 20 mg in 24 hours. If higher doses are required the patient should
be referred
after the acute phase the haloperidol may be given oral, at doses 220 mg per day
in 23 divided doses. The usual dose is 48 mg per day
zuclopenthixol acetate IM 50100 mg may be used as an alternative to haloperidol in
the acute phase. The dose may be repeated after 4872 hours
Long-term therapy
haloperidol oral 220 mg per day divided into 23 doses
fluphenazine decanoate IM 25 mg monthly
Note
Long-term therapy should always be in consultation with a doctor, where possible a
psychiatrist.
Patients on long-term therapy should be assessed by a doctor every 6 months.
Extra pyramidal side-effects
if extrapyramidal side-effects occur with neuroleptics:
review choice of neuroleptic
reduce dose if abnormal movements occur, e.g. rolling of the eyes, tongue
protrusions, ataxia
an anticholinergic agent such as orphenadrine can be co-prescribed
orphenadrine oral, 50 mg 13 times daily according to individual response
50 mg twice daily is usually enough
do not prescribe more than 150 mg/day at primary care level
use with caution in the elderly
Referral
first psychotic episode
failure to respond
poor social support
intolerance to medication
where suicide risk is high
concurrent medical or other psychiatric illness
children
the elderly
pregnancy
Chapter 15 - Renal and urinary tract conditions
amoxycillin
15.01 Urinary tract infection, uncomplicated (acute uncomplicated
cystitis)
N39.0 (595)
Description
An acute condition caused by Escherichia coli in most cases. Other micro-organisms
may occur, especially in patients previously managed in hospitals. It occurs
predominantly in women, especially sexually active women. Urine is turbid and/or
bloodstained and tests positive for nitrites. Symptoms include:
burning or pain on passing urine (dysuria)
frequent passing of small amounts of urine
in more severe cases there is lower abdominal pain and tenderness
Note
Pelvic inflammatory disease must be excluded.
elimination of harmful micro-organisms
prevention of complications
Non-drug treatment
encourage liberal fluid intake
reduce the stasis of urine in the bladder
Drug treatment
adults
trimethoprim/sulfamethoxazole oral 160/800 mg 12 hourly daily for 5 days (one tablet
is 80/400 mg)
or
amoxycillin oral 250 mg 8 hourly for 5 days
Referral
all children
all males
recurrent infections
persons who have recently had urinary tract instrumentation
urinary tract infection not responsive to therapy (i.e. symptoms do not subside)
Chapter 15 Renal and urinary tract conditions 141
15.02 Acute pyelonephritis
N11.9
Description
Infection of the kidney parenchyma. Patients are often very ill with severe symptoms,
fever, rigors, toxaemia, backache and tenderness. May be complicated by shock and
septicaemia. Urine is turbid and/or bloodstained and tests positive for nitrites.
Referral
all patients
Chapter 16 - Respiratory conditions
adrenalin
aminophyllin
amoxycillin
beclomethasone
benzyl penicillin
5% dextrose
doxycycline
ethambutol
hydrocortisone sodium succinate
ipratropium bromide
isoniazid
medroxyprogesterone acetate
norethisterone enanthate
paracetamol
prednisone
pyridoxine
rifampicin
rifampicin, isoniazid combination (RH)
rifampicin, isoniazid, pyrazinamide combination (RHZ)
rifampicin, isoniazid, pyrazinamide, ethambutol combination (RHZE)
salbutamol
streptomycin (S)
theophylline
16.01 Asthma
16.01.1 Asthma, chronic
J45 (493)
Description
A chronic condition of the airways with reversible airways obstruction due to
inflammatory oedema and bronchospasm. It is characterised by wheezing, shortness of
breath (dyspnoea), cough (usually non-productive) and tends to vary in intensity. Acute
attacks may be caused by exposure to allergens (substances to which a patient is
allergic), viral diseases and non-specific irritating substances.
Chapter 16 Respiratory conditions 143
symptomatic relief
restore normal or best possible long-term function of the airways
reduce the risk of a severe attack
prevent relapse
Note
A comprehensive therapeutic approach is required to meet the above objectives,
including the following:
early diagnosis and assessment of severity
optimal use of medication to limit side-effects and cost
peak expiratory flow rate (PEFR) determinations at home and in the clinic are the
basis for optimising therapy
patient education including:
stressing the diagnosis and explaining the nature of the condition
teaching and monitoring the technique for use of inhalers
reassuring parents and patients of the safety of continuous regular therapy
control of the environment to exclude cigarette smoke and reduce exposure to triggers
such as viral infection and allergens
follow-up and regular re-evaluation
Non-drug treatment
stop smoking
avoid exposure to known allergens
educate on early recognition and management of acute attacks and respiratory
infections
Note
inhaled therapy is preferable
spacer devices should be used for all inhaled corticosteroids in all age groups,
especially in children
inhalation spacer devices enable parents to administer aerosol therapy even to small
children
Patient education on inhaler techniques
without a spacer
1. remove the cap from the mouthpiece and shake the inhaler well
2. while standing or sitting upright, breathe out as much air as you can
3. place the mouth piece of the inhaler between the lips and gently close the lips
around it
4. when you begin to inhale, depress the vial of the metered dose inhaler once against
the mouthpiece while breathing in as deeply as you can
5. hold your breath for as long as you can (510 seconds)
6. breathe out slowly and rest for a few breaths (3060 seconds)
7. repeat steps 26 for the second puff
Note
the patient should demonstrate steps 24 more than once to ensure the correct
technique
education requires time and patience, but correct inhaler technique is vital to the
successful use of the inhaler
Many patients have difficulty with co-ordination of the inhaler and inhalation, and a
spacer with or without a mask should be used.
with a spacer
1. remove the caps from both the inhaler and the spacer
2. shake the inhaler well
3. insert the mouthpiece of the metered dose inhaler into the back of the spacer
4. insert the mouthpiece of the spacer into the mouth and close the lips around the
mouthpiece. Avoid covering any small exhalation holes
5. press down on the vial of the metered dose inhaler to spray the drug into the spacer
6. immediately take a slow deep breath for 510 seconds. Do not breathe in too hard
7. repeat steps 46 for each puff prescribed, waiting at least 30 seconds between
puffs
for children
1. allow to breathe slowly in and out of the spacer continuously for 30 seconds
2. while still breathing, spray the drug from the inhaler into the spacer
3. continue breathing for 34 breaths
4. if breathing is through the nose, pinch the nose gently while breathing from the
spacer
with a spacer and mask for infants and small children
1. remove the caps from both the inhaler and the spacer
2. shake the inhaler well
3. infants may be placed on the caregivers lap or laid on a bed while administering the
medication
4. apply the mask to the face, ensuring that the mouth and nose are well covered
5. with the mask held firmly on to the face, press down on the vial of the metered dose
inhaler to spray the drug into the spacer
6. keep the mask in place for at least six breaths, then remove
7. repeat steps 46 for each puff prescribed, waiting at least 30 seconds between
puffs
Note
the patient or caregiver should demonstrate steps 26 of the relevant method
above more than once to ensure the correct technique
education requires time and patience, but correct inhaler technique is vital to
successful inhaler technique
Mild Asthma
Indications for intermittent inhaler therapy with beta2 agonists, e.g. salbutamol:
not more than one episode of cough and/or wheeze per week
no night-time cough and/or wheeze
no recent admission to hospital for asthma
PEFR more than 80% predicted
Moderate to severe asthma
Indications for inhaled corticosteroid therapy, e.g. beclomethasone therapy,
supplemented by intermittent inhaled salbutamol:
more than one episode of cough and/or wheeze per week
severe attacks even if infrequent, especially if hospitalisation was needed
night-time cough and/or wheeze, especially if more than once per week
the use of a beta2 agonist more than three times a week
PEFR less than 80% predicted
Drug treatment
inhaled salbutamol (short-acting inhaled beta 2 agonist) as required 46 hourly until
relief is obtained, and not continuously
children: 100200 micrograms (12 puffs) depending on age
adults: 200 micrograms (2 puffs)
indications for inhaled corticosteroid therapy, e.g. beclomethasone:
sleep is disturbed by asthma
symptoms are getting progressively worse
frequent use of salbutamol, i.e. more than twice a day (patients should keep a diary)
PEFR falls below 60% at the patient's best effort
emergency nebuliser or intravenous bronchodilators are needed
inhaled corticosteroid therapy, e.g. beclomethasone
initiate treatment with double the maintenance dose for 12 weeks until control is
achieved
once symptoms and PEFR have improved, the dose is reduced to the minimum that
maintains control
children: maximum dose 200 micrograms per day in PHC clinics
where PEFR can be monitored, otherwise 100 microgram per day
adults: maximum dose 400 micrograms per day in PHC clinics
where PEFR can be monitored, otherwise 200 micrograms per day
If salbutamol and the inhaled corticosteroids fail, the following may be added if initiated
by a doctor:
ipratropium bromide inhaler 80 microgram (2 puffs) 34 times daily
short course prednisone oral, once daily for up to 10 days, without tapering the dose
children: 12 mg/kg
adults: 20 mg
may be needed at any time and at any stage to control exacerbations of asthma
! CAUTION !
all metered dose inhaled medication in children to be
administered via a spacer device
no inhaled corticosteroids for COAD
Stepping down
3-monthly review of therapy is required
stop regular corticosteroid therapy, e.g. beclomethasone after 6 to 12 months with few
or no symptoms if symptoms are seasonal
slow release theophylline for acute exacerbations and in patients unable to use
inhaled bronchodialators (initiation by doctors only)
adults-general: 614 mg/kg (usually 1012
mg/kg) or 400 mg per day, whichever is the lowest dose,
divided into 812 hourly doses
adult smokers: 16 mg/kg maximum per day
adult non-smokers: 13 mg/kg maximum per day
elderly: 8 mg/kg maximum per day
Referral
failure to achieve goals of management
diagnosis in doubt
unstable asthma
when oral prednisone is required regularly
after a life-threatening episode
pregnant women with worsening asthma
when higher doses of theophylline appear to be required (control with serum levels)
16.01.2 Chronic bronchitis and emphysema
J44.9 (493)
Also referred to as chronic obstructive airways disease (COAD).
Description
Chronic bronchitis and emphysema are conditions manifested by chronic cough with or
without sputum production on most days and shortness of breath (dyspnoea). The
onset is very gradual with progressively worse symptoms. Due to the large reserve
capacity of the lungs, patients often present when there is considerable permanent
damage to the lungs. The airways obstruction is not fully reversible.
the main causes of chronic bronchitis and emphysema are chronic irritation of the
airways caused by smoking and air pollution, although there are many other causes.
It is not primarily an infection, but a degenerative condition
patients usually present with some of the following:
wheezing
shortness of breath
cough with or without sputum
manifestations of right-sided heart failure
acute bronchitis after a cold/flu with the above symptoms
Note
The airways obstruction of chronic bronchitis and emphysema is not completely
reversible as in asthma:
inhaled corticosteroids have no effect and should not be used
oral corticosteroids may be required, but these have severe long-term complications
and should only be used if benefit can be proved by lung function testing
obtain maximum relief and prevent deterioration of airways obstruction
prevent exacerbations
Non-drug treatment
stop smoking
Drug treatment
acute airways obstruction is treated similarly to that of asthma (see below)
the principles of chronic obstruction management are as for asthma, except that
inhaled corticosteroids are not recommended
oral theophylline and oral prednisone are doctor initiated
16.01.3 Acute bronchospasm associated with asthma and chronic
obstructive bronchitis
J46
Description
A sudden reversible or partially reversible narrowing of the airways.
this is an emergency situation
reverse the obstruction and relieve hypoxia as soon as possible
Recognition and assessment of severity of attacks in adults:
MODERATE SEVERE
Talks in phrases words
Alertness usually agitated drowsy/confused
Respiratory rate 1830/minute often more than 30/minute
Wheeze loud loud or absent
Pulse rate 100120/minute above 120/minute
PEFR after initial
nebulisation
approx. 5075% below 50%
PEFRs are expressed as a percentage of the predicted normal value for the individual or
of the patient's best value obtained previously when on optimal treatment.
Recognition and assessment of severity of attacks in children:
MODERATE SEVERE
Respiratory rate 4050/minute above 50/minute
Retractions or
recession
present present
PEFR 5075% of predicted below 50% of predicted
Speech normal/difficulty with speech unable to speak
Feeding difficulty with feeding unable to feed
Wheeze present absent
Heart rate below 140/min above 140/min
Consciousness normal impaired
Initiation of treatment
oxygen, high concentration
children: administer via nasal cannula (4 L per minute)
adults: use highest concentration mask (40% or higher)
except in chronic obstructive bronchitis
initiate treatment with 2428% oxygen because carbon dioxide
may otherwise suppress respiration
0.5% salbutamol solution nebulised over 3 minutes
children: 0.03 ml/kg in 23 ml 0.9% sodium chloride
adults: 12 ml in 3 ml of 0.9% sodium chloride
t repeated every 20 minutes in the first hour if no relief
t may be repeated 4 hourly thereafter
t if no nebuliser available, give 48 puffs from a salbutamol metered dose
inhaler, using a spacer device
0.025% ipratropium bromide solution nebulised over 3 minutes
children: 0.51 ml
adults: 2 ml
mixed with salbutamol nebulising solution
may be repeated 4 hourly
prednisone oral once daily
children: 12 mg/kg
adults: 2040 mg
administer initial dose early in a severe attack
Severe attack
only commence IV therapy if patient is dehydrated
use 5% dextrose in water
aim to maintain a state of normal hydration
encourage oral fluid intake
hydrocortisone sodium succinate IV
immediate dose given via IV line if oral prednisone cannot be taken
children: 12 mg /kg
adults: 100200 mg
followed by prednisone oral
avoid sedation of any kind
aminophylline IV 56 mg/kg IV infusion in 1 000 mL of 5% dextrose at a flow-rate not
exceeding 0.6 mg/kg/hour (35 drops/min). Treatment should be initiated by a doctor:
preferably used as a second line agent in patients who have not responded to initial
management
recommended for use in adults only
no loading dose to be given
reduce flow-rate in patients with congestive cardiac failure, the elderly and patients
with liver disease
avoid in patients already on long-term theophylline therapy
assess response during first 2 hours
Good response
in asthma and chronic bronchitis
continue with prednisone oral daily for 7 days
in asthma only
check patient's inhaler technique; then commence or continue
regular inhaled corticosteroid therapy, e.g. beclomethasone
t children: 50100 micrograms twice daily
t adults: 100200 micrograms twice daily
inhaled salbutamol (short-acting inhaled beta 2 agonist) regularly 46 hourly until
the acute attack has subsided
t children: 100200 micrograms (12 puffs) depending on
age
t adults: 200 micrograms (2 puffs)
in chronic bronchitis only
stop oral prednisone
check for acute infective bronchitis
refer for assessment of chronic oral corticosteroids use if still short of breath and/or
wheezing and for oral theophylline treatment
Poor response
refer immediately to hospital on oxygen therapy
Referral
immediate referral:
any life-threatening features, e.g. extreme tachycardia, drowsy, confused, absent,
wheeze, cyanosis, collapse
any features of a severe attack that may persist after the initial treatment
PEFR of less than 33% of the predicted normal or best value 1530 minutes after
nebulisation
poor response or incomplete response or high-risk patients - refer with oxygen
therapy
A lower threshold to admission is appropriate in patients when:
seen in the afternoon or evening, rather than earlier in the day
recent onset of nocturnal symptoms or worsening of symptoms
previous severe attacks, especially if the onset was rapid
16.02 Bronchitis, acute
J20.9 (465)
Description
A viral or bacterial infection of the bronchi.
clinical feature - cough with generalised coarse crackles, with or without wheezes. The
cough is initially often non-productive, but becomes productive with yellow or greenish
sputum, especially when a secondary bacterial infection is present
viral bronchitis is usually part of an upper respiratory viral infection accompanied by
other manifestations of viral infection
Non-drug treatment
None.
Criteria for antibiotic treatment
children
clinical criteria, if complicating factors such as:
a high temperature
nutritional deficiency
cardiac disease
previous pneumonia
bronchiectasis
immunocompromised
adults
clinical criteria for treatment with an antibiotic if complicating factors are present:
clear evidence of secondary bacterial infection, i.e. discoloured sputum observed by
the clinician
history of chronic bronchitis, evidence of chronic obstructive airways disease
(COAD) or known bronchiectasis
Drug treatment
doxycycline oral, with food for minimum of 5 days
adults: 200 mg immediately followed by 100 mg twice daily
or
infants 06 months:
62.5 mg
mg
mg
children 510 kg:
eythromycin estolate 62.5 mg
children 1015 kg:
erythromycin estolate 125 mg
children over 15 kg:
erythromycin stearate or estolate 250 mg
adults:
erythromycin stearate 250mg
children 3 months1year: 2.5 mL
(120 mg/5 mL syrup)
mL
children 512 years:
tablets
16.03 Common cold and influenza
J11.1 (460)
Description
Colds and influenza are self-limiting viral conditions; begin to clear within 3 days with
colds and 7 days in influenza. May last up to 14 days.
complications - secondary bacterial infections, including:
pneumonia
otitis media
streptococcal pharyngitis
sinusitis
Note
Children (especially if malnourished), the elderly and debilitated patients are at greater
risk of developing complications.
! CAUTION !
malaria and measles may present with flu-like symptoms
manage complications
Non-drug treatment
steam inhalations
bed rest if feverish
return to clinic if earache, tenderness or pain over sinuses develops, or cough persists
for longer than a week, or fever persists
ensure plenty of fluids which will prevent secretions from becoming thick and difficult
to cough up
Drug treatment
antibiotics are of no value for the common cold and influenza and could have serious
side-effects
if common cold or flu with no complications, treat symptoms if necessary:
fever
children 3 months1 year: 2.5 mL (120 mg/5 mL syrup)
children 512 years: 1 tablet (500 mg tablet)
children over 12 years and adults: 12 tablets
0.9% sodium chloride instilled in the nose for infants
Referral
Severe complications.
16.04 Cough
(See Chapter 18 - Symptoms and signs)
16.05 Croup (laryngotracheobronchitis)
J05
Description
in croup there is inflammatory swelling of the vocal cords and the subglottic portion of
the larynx, caused by infection
croup is a common cause of potentially life-threatening airway obstruction in childhood
most common causative pathogens are viruses - Parainfluenza or Herpes simplex
following measles in children
bacteria only occasionally cause croup, e.g. Streptococcus pneumoniae and
Haemophilus influenzae
croup due to diphtheria only occurs in incompletely immunised children
a clinical diagnosis of viral croup can be made if a previously healthy child develops
progressive inspiratory airway obstruction with stridor and a barking cough, in 12
days after the onset of an upper respiratory tract infection. A mild fever may be present
suspect foreign body aspiration if there is a sudden onset of stridor in an otherwise
healthy child
suspect epiglottitis if the following are present in addition to stridor:
very ill child
drooling saliva
unable to swallow
sitting upright with head held erect
Assessment of the severity of airway obstruction in croup:
SEVERITY INSPIRATORY
OBSTRUCTION
EXPIRATORY
OBSTRUCTION
PALPABLE PULSUS
PARADOXUS
Grade I +
Grade II + passive
Grade III + active +
Grade IV Marked retractions, apathy, cyanosis
Note
pulsus paradoxus is very difficult to determine
if the abdominal muscles are used actively during expiration (tenses the abdomen),
Grade III obstruction is present
Non-drug treatment
keep children comfortable and happy
continue oral fluids
encourage parents to remain with the child
Drug treatment
children 3 months1year: 2.5 mL (120
mg/5 mL syrup)
children 512 years: 1 tablet (500 mg
tablet)
tablets
always nebulise with oxygen at a flow rate of 4 L/minute
steroids are beneficial in viral croup
give an immediate dose if there has been no measles within the past month, fever is
below 38
o
C, and there is no evidence of oral herpes
prednisone oral 2 mg/kg as a single dose
or
hydrocortisone sodium succinate IV in a dose of 28 mg/kg in 24 hours - a repeat
dose is usually not indicated
antibiotics are seldom indicated in croup and should only be given in hospital
do not give sedatives or hypnotic agents
GRADE MANAGEMENT
I observe
II nebulise adrenaline by mask
mix 1 ml adrenaline 1:1 000 with 1 ml of saline
nebulise the entire volume with oxygen
repeat every 15 minutes until improved
refer for hospitalisation
III nebulise with adrenaline continuously
continuous endotracheal intubation if no improvement within 12
hours
refer to hospital promptly as it can get worse
IV immediate endotracheal intubation may be required
give 100% oxygen
nebulise adrenaline continuously
refer for hospitalisation promptly
Referral
uncertain diagnosis
all children with more than Grade I severity
suspected foreign body
suspected epiglottitis
16.06 Pneumonia
J18.9 (480.6)
Description
Infection of the lung parenchyma, usually caused by bacteria (e.g. Pneumococcus, H.
influenzae).
manifestations depend on the causative organism, the type of pneumonia (lobar
pneumonia or broncho pneumonia), the age and health status of the patient before
the pneumonia and the extent of the pneumonia
manifestations include malaise, fever (often with sudden onset with rigors), cough
which becomes productive of rusty brown or yellow-green sputum, pleuritic type chest
pain, shortness of breath and in severe cases shock and respiratory failure
on examination there is fever, tachypnoea, crackles and/or bronchial breath sounds.
There may be a pleural rubbing sound or signs of a pleural effusion
Note
Predisposing conditions include the very young and very old, other concomitant
diseases, malnutrition, immune deficiency. Pneumococcal pneumonia often occurs in
previously healthy adults.
Adults with mild to moderately severe pneumonia may be managed at PHC level,
depending on the response to initial treatment.
Pneumonia in adults
a chest X-ray should be taken in all patients if available
a sputum smear and sputum for culture is advisable in all patients, especially those
with predisposing conditions
Non-drug treatment
encourage high fluid intake
Drug treatment
initial treatment is benzylpenicillin 2 MU IM if not severely ill and suitable for home
treatment
followed by amoxycillin 500 mg oral 8 hourly for 7 days
in penicillin-allergic patients, give erythromycin stearate oral 500 mg 6-hourly for 10
days
paracetamol 1000 mg oral 46 hourly (max 4 doses per day) for pain and fever above
38.5C
Severe pneumonia in adults
Clinical features:
moderate or severe respiratory distress
fever of 39.5
o
C or above
confusion
respiratory rate 30 breaths/min or more
heart rate 120 beats/min or more
systolic BP less than 90 mmHg
diastolic BP less than 60 mmHg
cyanosis
age above 60
multilobar consolidation
concurrent severe illness, e.g. diabetes,
heart failure, epilepsy
NB
All patients with features of severe pneumonia should be referred immediately
on oxygen therapy and after the initial dose of antibiotic, e.g. benzylpenicillin IV
2 MU should be given every 6 hours until transferred.
Referral
severe pneumonia
patients with pneumonia from a poor socio-economic background, or who are unlikely
to comply with home treatment, live at considerable distances from the health centre,
have no rapid transport
pneumonia with other diseases
suspected atypical pneumonia
patients not responding to the above treatment
Pneumonia in children
Description
see adult condition
additionally, indrawing of the lower chest wall, cyanosis and inability to drink in small
children (2 months to 5 years) also indicate severe pneumonia needing urgent referral
for admission
pneumonia should be distinguished from bronchitis. The most valuable sign in
pneumonia is the presence of tachypnoea
Severe pneumonia in children
moderate respiratory distress:
tachypnoea
children 02 months: less than 60/min
children 2 months1 year: less than 50/min
children over 1 year: less than 40 min
severe respiratory distress:
tachypnoea and chest indrawing
unable to drink
cyanosis
Non-drug treatment
adequate fluid intake
oxygen 4 L/minute (mask, nasal cannula) for all with severe pneumonia
Drug treatment
infants 06 months:
62.5 mg
mg
children over 10 years: 250 mg
children 510 kg: eythromycin
estolate 62.5 mg
children 1015 kg: erythromycin
estolate 125 mg
or estolate 250 mg
children 3 months1 year: 2.5 mL (120 mg/5 mL
syrup)
children 512 years: 1 tablet (500
mg tablet)
children over 12 years: 12 tablets
in severe pneumonia initiate treatment with benzylpenicillin IV 500 000 IU immediately
and repeat 6 hourly until transferred
refer on oxygen therapy
mild cases may be managed at home
Referral
severe pneumonia
children under 6 months of age
children who cough for more than 3 weeks to exclude other causes such as TB,
foreign body aspiration, pertussis
16.07 Tuberculosis
A16.9 (011)
Description
A disease due to infection by Mycobacterium tuberculosis. Tuberculosis is a serious
growing health problem in South Africa, expanded and complicated by HIV/AIDS and
multiple drug-resistant disease.
cure the disease
promote directly observed therapy, short-term (DOTS)
prevent multi-drug resistance
Note
A standard TB register monitoring system and treatment guidelines have been
introduced in order to deliver a comprehensive service.
Non-drug treatment
important factor for compliance in patient-centred care:
the relationship between the person providing the care and the person suffering
from the disease
care providers should sympathetically explain the importance of completing treatment
care providers should discuss:
feelings
expectations
potential barriers/problems which will prevent success
habits and past experience
monitor
encourage
provide feedback on progress
lifestyle
avoid the use of tobacco
avoid alcohol
if more than two doses of treatment are missed, extra effort should be made to identify
and manage any problems the patient might have
Directly Observed Treatment Short-term (DOTS)
every dose of treatment is seen to be swallowed
if not possible a written contract, a pill-taking calendar and regular follow up are
strongly advised
each patient should have a treatment supporter chosen by the patient:
anyone responsible whom the patient trusts
community health workers
colleagues
employers
family members
friends
treatment supporters should:
keep the drugs
keep the treatment card
supply the medication
watch the patient swallow the treatment
sign the treatment card
Note
A private practitioner may elect to monitor the progress of the patient personally. In this
case, the patient should remain on the clinic TB patient register.
Drug treatment
the total daily amount of each drug should be administered in one dose and not
divided
NOTE
Rifampicin should not be available for TB at all in primary
health care facilities as a single drug, but in combination
with other TB drugs.
other single formulations, e.g. ethambutol and isoniazid, will be retained to facilitate
appropriate doses of available fixed-dose combinations in the continuation phase of
treatment
the use of fixed-dose combinations is strongly encouraged in adults to enhance
patient adherence and reduce the risk of inappropriate monotherapy
pyridoxine oral 25 mg on the mornings that TB drugs are taken should be given
routinely to TB patients:
during pregnancy
in alcoholics
with diabetes mellitus
with epilepsy
Important drug interactions
rifampicin reduces the efficacy of oral and injectable contraceptives, resulting in
possible unplanned pregnancies
see chapter 7: Family planning
ask about contraception and explain the problem and the consequences
if necessary, alter the oral or injectable contraceptive or suggest an IUCD
medroxyprogesterone acetate IM 150 mg should be given every 8 weeks in stead of
every 12 weeks
norethisterone enanthate IM 200 mg every 6 weeks instead of every 8 weeks
combined oral contraceptives should contain at least 50 micrograms of
ethinylestradiol
the pill-free interval should be reduced from 7 to 4 days
Side-effects of anti-TB drugs
The recommended TB drugs are safe.
do not give streptomycin to:
pregnant women
persons over 65 years old
persons with impaired renal function
do not give ethambutol to:
persons with impaired renal function
Chemoprophylaxis
children less than 5 years in close household contact with a smear-positive case of
pulmonary TB should be treated with:
rifampicin/isoniazid (RH 60/30) for a period of 3 months (see table on p. 148)
Note
children older than 5 years should not be given routine chemoprophylaxis
HIV/TB
sputum smears in patients with HIV and TB are often negative as cavitation often does
not occur until the TB is far advanced
HIV patients with suspected TB should have repeated sputum cultures for TB, with
sensitivity testing for isoniazid and riflampicin
standard short-course treatment also effectively cures tuberculosis disease in patients
with HIV/AIDS
HIV-positive patients with a positive Mantoux test who are not ill from TB, should be
informed of the following possible presenting symptoms:
persistent cough
night sweats
loss of weight
side-effects of TB drugs are more pronounced in HIV-positive patients
Multiple drug-resistant (MDR) TB
diagnosed when there is resistance to:
rifampicin and isoniazid on sputum culture sensitivity testing
prevent resistance by ensuring cure the first time round
MDR TB is the result of irregular treatment
it is much more expensive to treat
the cure rate is only between 3050%
cases should be referred to a specialised centre
the effectiveness of preventive therapy in persons exposed to MDR TB bacteria is not
known
all close contacts should be screened for signs and symptoms of MDR TB and by
sputum sampling to detect early disease
chest X-ray should be used, if available, as an ancilliary diagnostic tool
Initiation of treatment
treatment should be given five times per week in both the intensive and continuation
phases
in special circumstances, treatment may be given three times per week in the
continuation phase, provided it is properly supervised
Note
In order to avoid dosage errors, clinics should adhere to either a five-times per week or a
three-times per week dosage schedule in the follow-up treatment phase.
New adult patients (Regimen 1)
New smear- or culture-positive and other serious pulmonary and extra-
pulmonary tuberculosis.
2 months initial
phase
(treatment given 5
times/week)
4 months continuation phase
(treatment given 5 times/week)
Pretreatment
body weight
combination tablet
RHZE
120/60/300/200 mg
or
120/60/300/225 mg
combination
tablet
RH
150/100 mg
combination
tablet
RH
300/150 mg
less than 50 kg 4 tabs 3 tabs
more than 50 kg 5 tabs 2 tabs
combination tablets contain currently approved doses of component drugs
R=rifampicin; H=isoniazid; Z=pyrazinamide; E=ethambutol; S=streptomycin
2 months initial phase
(treatment given 5 times/
week)
(treatment given 3 times/week)
Pretreatment
body weight
combination tablet
RHZE 120/60/300/200 mg
or
120/60/300/225 mg
combination tablet
RH
150/100 mg and
isoniazid 100 mg
Combination
tablet
RH
300/150 mg
and isoniazid
100 mg
under 50 kg 4 tabs 3 tabs RH +
1 tab isoniazid
over 50 kg 5 tabs 2 tabs RH +
3 tabs
isoniazid
Retreatment adult cases (Regimen 2): smear-positive retreatment cases
(failure, relapse and return after interruption)
week)
3rd
month
(5 times/
week)
(5 times/week)
Pretreatment
body weight
RHZE
120/60/
300/
200 mg
or
120/60/
300/
225 mg
streptomycin RHZE RH
150/100 mg
and
ethambutol
400 mg
RH
300/150 mg
and
ethambutol
400 mg
under 50 kg 4 tabs 750 mg 4 tabs 3 tabs RH +
2 tabs
isoniazid
above 50 kg 5 tabs 1000 mg 5 tabs 2 tabs RH +
3 tabs isoniazid
Note: Streptomycin should be reduced to 750 mg per day to patients older than 45 years and
should not be given to patients over 65 years.
Three times per week regimens
! CAUTION !
certain circumstances may necessitate a three times/week regimen
increased dosages are involved
regimen should be applied to all patients at those facilities
use and packing of three times/week regimens should be
approved and co-ordinated at provincial level
week)
3rd
month
(5 times/
week)
(3 times/week)
Pretreatment
body weight
RHZE
120/60/300/
200 mg
streptomy-
cin
RHZE RH
150/100 mg
and
isoniazid
100 mg
and
ethambutol
400 mg
RH 300/150 mg
+
isoniazid
100 mg
and
ethambutol
400 mg
under 50 kg 4 tabs 750 mg 4 tabs 3 tabs RH
+ 1 tab H
+ 3 tabs E
above 50 kg 5 tabs 1000 mg 5 tabs 2 tabs RH
+ 3 tabs H
+ 4 tabs E
Children with tuberculosis (Regimen 3)
Pretreatment
body weight
2 months initial
phase
(treatment given 5
times/week)
(treatment given 5 times /week)
RHZ
60/30/150 mg
RH
60/30 mg
34 kg tab tab
57 kg 1 tab 1 tab
89 kg 1 tab 1 tab
1014 kg 2 tabs 2 tabs
R = rifampicin H = isoniazid Z = pyrazinamide E = ethambutol
Pretreatment
body weight
week)
(treatment given 3 times /week)
RHZ 60/30/150 mg RH 60/60 mg
34 kg tab tab
57 kg 1 tab 1 tab
89 kg 1 tab 1 tab
The fixed-dose combinations reflected here represent the current international
recommendations. These will be subject to continuous review in the light of new
information.
Referral
pregnancy
over 65 years old
impaired renal function
MDR TB patients
when a patient is sent to hospital, the referring nurse or doctor should provide a
discharge plan for how the patient will be handled and compliance assured when the
patient returns home. If an infant is admitted, the mother should also be admitted, if at
all possible
Chapter 17 - Skin conditions
amoxycillin
aqueous cream (UEA)
6% benzoic acid and 3% salicylic acid
5% benzoyl peroxide
25% benzyl benzoate
calamine lotion
chlorpheniramine
doxycycline
emulsifying ointment (UE)
ethyl chloride
flucloxacillin
griseofulvin
1% hydrocortisone
2% miconazole
monosulfiram
nystatin
1% permethrin
5% permethrin
polyvidone iodine
selenium sulphide
zinc oxide
17.01 Acne vulgaris
L70.0 (706.1)
Description
A skin condition of sebum gland hypertrophy leading to a blocking and/or infection with
Propionibacterium acnes.
ranges in severity from mild (few blackheads) to severe with nodules and cysts
more common in adolescence but may be protracted
distributed on face, chest and back
elimination of pathogens
improvement of skin condition
Non-drug treatment
Chapter 17 Skin conditions 165
wash with soap and water 23 times daily
avoid cosmetics and hair spray
do not squeeze lesions
Drug treatment
if there are many pustules, apply 5% benzoyl peroxide gel at night
severe cases of nodular acne
doxycycline oral 100 mg daily for 14 days
then
50 mg daily for 3 months
Note
Additional contraception is essential for the first 3 weeks if oral contraceptives are used.
Referral
no improvement after 3 months
development of severe complications
17.02 Bacterial infections of the skin
17.02.1 Boil, abscess
L02.9 (680.2)
Description
Localised bacterial skin infection of hair follicles or dermis, usually with Staphylococcus
aureus.
the surrounding skin becomes:
swollen
red
hot
tender to touch
Note
Boils in diabetic or immunocompromised patients require careful management.
elimination of the infection
Non-drug treatment
encourage general hygiene
apply local hot compresses three times daily until the boil/abscess starts draining
drainage of abscess is treatment of choice, surgical incision being performed only
after the lesion is mature
Drug treatment
systemic antibiotics only as supportive therapy if there are:
swollen lymph nodes in the area
fever
flucloxacillin oral 6 hourly for 5 days
children under 2 years: 62.5
mg
mg
mg
estolate 62.5 mg
estolate 125 mg
or estolate 250 mg
stearate 250mg
Referral
no response to antibiotic therapy
progression of the condition
17.02.2 Impetigo
L01.0 (684)
Description
A common skin infection due to S. aureus and streptococci that occurs mainly in
children.
clinical features:
pussy sores with crusts or scabs
painful
usually starts on the face
spreading to neck, hands, arms
and legs
elimination of the pathogen
promotion of healing
Non-drug treatment
prevention by keeping breaks in the skin clean
avoid insect bites
cut finger nails
wash and soak sores in soapy water to soften and remove crusts
instruct mother or patient to wash daily
continue with treatment until the sores are completely healed
Drug treatment
10% polyvidone iodine solution - apply three times a day
or
zinc oxide ointment
antibiotic treatment is only necessary if one of the following is present:
severely ill
fever
swollen glands
infants 06 months:
62.5 mg
mg
mg
Second-line treatment for staphylococcal infections:
62.5 mg
children 210 years:
125 mg
250 mg
pregnant and/or penicillin-allergic patients:
children 510 kg:
erythromycin estolate 62.5 mg
children 1015 kg:
children over 15 kg:
erythromycin stearate or estolate 250 mg
adults:
erythromycin stearate 250500mg
Referral
no improvement in 10 days
complications such as glomerulonephritis
17.03 Cellulitis
L03.9
Description
Usually caused by streptococci, but also staphylococci and occasionally other
organisms.
a diffuse spreading acute infection within solid tissues, characterised by:
oedema
increased local temperature
redness
without suppuration
occurs mainly on the lower legs, but may occur anywhere
may follow minor trauma or eczema, e.g. lower legs, varicose ulcers
there frequently is lymphangitis and regional lymph node involvement manifested by
tender swelling
there may be severe systemic manifestations:
fever
chills
tachycardia
headache
hypotension
delirium
may present as an acute fulminant or chronic condition
Drug treatment
mild cases
flucloxacillin oral 250 mg 6 hourly for 7 days
penicillin-allergic patients
erythromycin stearate oral 250 mg 6 hourly for 7 days
for proven streptococcal cellulitis
benzathine penicillin IM 1.2 MU as a single dose is usually adequate
severe cases
refer for parenteral antibiotics
Referral
recurrent cellulitis associated with underlying conditions, e.g. varicose ulcers
acute, severe or fuliminant cellulitis with systemic manifestations
17.04 Eczema
17.04.1 Eczema, atopic
L20.9 (691)
Description
itchy red rash or dry rough skin linked to allergy
in babies it appears at about 3 months
a family history of asthma, hay fever or atopic dermatitis is common
clinical features:
inner (flexural) surfaces of the elbows, knees and creases of the neck
in infants any part of the body can be affected
very itchy at night
can become chronic and infected
treat the condition actively
prevent spread to other areas
Non-drug treatment
avoid wearing clothes made from wool to prevent overheating
cut nails short
avoid scratching
expose affected areas to sunlight
avoid soap
Drug treatment
aqueous cream (UEA) to wash or bath and apply to dry areas as a moisturiser
1% hydrocortisone cream applied twice daily for severe eczema or no response within
7 days
treat for 7 days
apply sparingly to the face
do not apply around the eyes
if there is a response then reduce the use of the hydrocortisone cream over a few
days
and
maintain treatment with aqueous cream (UEA)
Referral
no improvement in 2 weeks
17.04.2 Seborrhoeic eczema
L21.9 (691)
Description
In its simplest form it is dandruff, which tends to be rather oily. Pruritus may or may not
be present, vesicles are not uncommon. It may become very extensive, particularly in
infants and obese persons.
treat the condition actively
prevent spread to other areas
Non-drug treatment
avoid wearing clothes made from wool to prevent overheating
cut nails short
avoid scratching
expose affected areas to sunlight
avoid soap
Drug treatment
aqueous cream (UEA)
or
emulsifying ointment (UE)
used to moisturise the skin and help it retain water after bathing
1% hydrocortisone cream applied 23 times daily until improved
then once or twice weekly for maintenance as needed
if no improvement, 2% miconazole cream can be applied twice daily as an alternative
to steroids
2% selenium sulphide suspension is indicated for scalp itching, scaling and dandruff
apply weekly by lathering on the scalp
rinse off after 10 minutes
17.04.3 Acute, moist or weeping eczema
L21.9
Description
A form of seborrhoeic eczema with vesicles (microscopic to large) with oozing and
eventual crusting and scaling.
Non-drug treatment
saline dressing daily or twice daily
avoid use of soap on affected areas
Drug treatment
Antibiotic for staphylococcal secondary infection:
62.5 mg
children 210 years:
125 mg
250 mg
children 510 kg:
erythromycin estolate 62.5 mg
children 1015 kg:
children over 15 kg and adults:
erythromycin stearate or estolate 250
mg
mg twice daily
children 1 5 years: 12
mg three times daily
mg 34 times daily
mg 34 times daily
Referral
not cleared up after the third visit
severe acute moist(weeping) eczema
17.05 Fungal infections of the skin
B35
17.05.1 Athlete's foot - tinea pedis
B35.3 (110.4)
Description
A common contagious fungal infection (tinea) of the foot:
itching, burning and stinging between toes spreading to the sole
secondary eczema of the hands may be an associated condition
vesicles may occur in inflammatory cases
reinfection is common
Non-drug treatment
discourage the use of shared bathing or swimming areas until healed
use own towels and toiletries
keep feet dry:
wear open shoes or sandals
wear cotton socks if socks are worn
dry between toes after washing the feet or walking in water
wash feet twice daily before treatment application
Drug treatment
topical treatment - apply to the affected area after drying
6% benzoic acid and 3% salicylic acid ointment twice daily for 4 weeks
or if unsuccessful
2% miconazole cream twice daily for 4 weeks
Referral
severe infection
secondary infection
no improvement after 4 weeks
involvement of the nails
17.05.2 Candidiasis, skin
B37.2 (112.0)
(Vaginal candidiasis: see STD syndrome section 9.09)
Description
A skin infection caused by Candida albicans.
most common sites for infection are any skin folds such as:
under the breasts
axilla
groin
perineum
nail folds
the skin lesions or sores:
appear moist (weeping)
may have peripheral white pustules
and scales
have clear edges
are red raw-looking patches
Note
infection often occurs in immune deficiency, thus:
exclude diabetes or other endocrine diseases
suspect HIV if the infection is severe or chronic
eliminate the organism
Drug treatment
nystatin ointment 100 000 IU/g applied 3 times daily for 14 days after healing
or
2% miconazole cream if nystatin ointment fails
apply three times a day for 14 days after healing
Referral
infections not responding to topical treatment
17.05.3 Napkin rash (candida)
L22
Treat as for candidiasis, skin: section 17.04.2.
Note
May be resistant to treatment due to the candida being harboured in the gastrointestinal
tract.
Non drug treatment
frequent changing of napkins to keep the affected area dry
exclude maternal candidiasis
Drug treatment
if topical treatment as above has failed
nystatin suspension oral 100 000 IU/mL 0.5 mL after each feed
17.05.4 Ringworm
B35.9 (110)
Description
A highly contagious fungal infection of the skin that can be found anywhere on the body:
arms and breast
around the waist
back
buttocks
groin
Clinical features:
itchy ringlike patches
raised borders
patches slowly grow bigger
as the patch extends a clear area
develops in the centre
Non-drug treatment
avoid spreading the infection to others
do not share:
clothes
toilet articles
towels
wash skin well and dry before applying ointment
Drug treatment
treat an infected child at once
treat any secondary skin infection first
apply 6% benzoic acid and 3% salicylic acid ointment 23 times daily for 46 weeks
(not in sensitive areas)
in groin areas or if the above treatment is unsuccessful, apply 2% miconazole cream
continue using ointment for at least 2 weeks after lesions have cleared
for nail and scalp infections:
griseofulvin oral, once daily for a minimum of 8 weeks
children: 10 mg/kg (125 mg tablets)
adults: 500 mg (1 tablet)
take with fatty meals or milk
do not give to women of child-bearing age unless they are using an effective
contraceptive
only initiated by a doctor once the diagnosis has been clearly established
Note
Avoid exposure to the sun.
Referral
severe infection
complications of infection of the scalp and face
infection is widespread
no response to treatment after 4 weeks
17.06 Parasitic infections of the skin
17.06.1 Lice (pediculosis)
B85.2 (132)
Description
An infestation of the hairy parts of the body with lice.
the eggs (nits) appear as fixed white specks on the hair
body lice live in the seams of clothing and only come to the skin to feed
clinical features:
itching
bite marks
secondary eczema and secondary infection may be present
Note
Body lice may carry typhus fever.
Non-drug treatment
use a fine comb to comb out the nits after using the shampoo
the head can be shaved but it may not be necessary
do not shave the pubic area
treat the whole family as the condition spreads easily
regularly wash bed linen and underclothes in warm water
leave in the sun to dry
Drug treatment
! CAUTION !
do not use commercial insect sprays - they can cause severe illness
the lotions used for the treatment of lice are toxic when swallowed
25% benzyl benzoate lotion
adults and older children:
apply lotion to the affected areas
avoid the eyes
do not dilute for adults
leave on overnight and wash off the next day
repeat once a week for up to 3 weeks
dilute lotion with equal parts of water
apply lotion to the affected areas
avoid the eyes
do not dilute for adults
leave on overnight and wash off the next day
repeat once a week for up to 3 weeks
or
1% permethrin cream rinse
use after shampoo
leave for 10 minutes before rinsing
do not apply to broken skin or sores
avoid contact with eyes
or
5% monosulfiram medicated soap
to be used daily for the whole body
lather the soap well on the body
allow the lather to dry on the body
rinse off the soap
Referral
secondary infection
swollen glands
fever
17.06.2 Scabies
B86 (133)
Description
An infestation with the parasite Sarcoptes scabei, most commonly in the skin folds.
spreads easily and usually more than one person in the household is affected
clinical features:
intense itching, much worse at night
small burrows where the parasite has burrowed under the skin between fingers,
toes, elbow areas and skin folds
secondary infection due to scratching with dirty nails
Non-drug treatment
all members of the household should be examined
cut finger nails and keep them clean
wash all linen and underclothes in hot water
thoroughly wash the whole body with a mild soap and water, scrubbing the affected
areas with a brush or wash-cloth
rub the affected areas with a wash-cloth, and dry well with a clean towel
put on clean, washed clothes after drug treatment
Drug treatment
25% benzyl benzoate lotion
apply to the whole body from the neck to the feet
avoid the eyes
allow the lotion to dry
leave on overnight and wash off after 24 hours
adults and older children: use undiluted and
repeat after 34 days
children under 6 years: dilute lotion with an
equal volume of water
repeat after 5 days
5% monosulfiram soap may be used for small children (less than 6 years)
if benzyl benzoate is unsuccessful, use 5% permethrin cream
Note
the lotion is toxic if swallowed
itching may continue for 23 weeks after treatment
do not continue if rash or swelling develops
avoid contact with eyes and broken skin or sores
Referral
severe secondary infection
swollen glands
fever
17.07 Napkin rash, non-fungal
L22 (691.0)
Description
A diffuse reddish eruption caused mostly by residual soap or detergents in napkins, and
irritation by diarrhoeal stools.
Non-drug treatment
educate caregiver and give advice on hygiene
change nappies regularly and rinse thoroughly after washing
do not use waterproof pants
expose napkin area to air and sunlight
Drug treatment
15% zinc oxide ointment applied after each nappy change - if napkins are used
if no response, suspect candida (see section 17.04.3)
Referral
no response after 5 days
17.08 Sandworm
B76.9
Description
Creeping eruption (cutaneous larva migrans) caused by hookworm of dog or cat,
Ancylostoma braziliense:
larvae of ovae in soil penetrate skin (feet, legs, buttocks, back)
cause a winding thread-like trail of inflammation with:
itching
scratching dermatitis and bacterial infection
Drug treatment
ethyl chloride spray
17.09 Urticaria
L50.9 (708.9)
Description
Urticaria is a skin disorder characterised by itchy weals (hives).
There are many causes, allergic, toxic or physical:
allergic urticaria may be caused by drugs, plant pollen, insect bites or foodstuffs, e.g.
fish, eggs, fruit, milk, meat
prevention
relief of itching
identify and remove the cause
Non-drug treatment
detailed history taking
Note
Aspirin is commonly found in many patent medicines, and may be the cause.
Drug treatment
chlorpheniramine oral for severe or refractory pruritus
mg twice daily
children 15 years: 12 mg three times
daily
mg 34 times daily
mg 34 times daily
Calamine lotion on the skin may help to relieve the itch of urticaria, if severe - as before
Referral
no improvement or response after 24 hours
progressive illness
Chapter 18 - Signs and symptoms
calamine lotion
chlorpheniramine
codeine phosphate
diazepam
ibuprofen
methylsalicylate
metoclopramide
morphine
paracetamol
pethidine
sennosides A and B
sorbitol
18.01 Arthralgia
R52.9 (714)
Description
joint pain without swelling, warmth, redness or systemic manifestations such as fever
may be a manifestation of degenerative joint conditions (osteo-arthrosis) or of many
local and systemic diseases, in which arthralgia may be an early manifestation
may follow injury to the joint, e.g. work, play, position during sleep
often accompanied by painful muscle spasm around the affected joint. Several joints
may be affected
any joint may be affected. Osteoarthrosis often affects hips, knees, back, neck,
shoulders
systemic causes of arthritis may start with pain only, e.g. rheumatoid arthritis, gout,
infective arthritis
in children rheumatic fever should always be suspected, especially if arthralgia affects
several joints in succession
re-examine frequently to exclude other diseases
Chapter 18 Signs and symptoms 179
exclude other conditions
pain relief
Non-drug treatment
apply heat locally to the affected joint, take precautions not to burn the patient
exercise after relief from pain
reduce weight if overweight to decrease stress on the joint
reassure patient after other causes have been excluded
Drug treatment
treat for 1 week (maximum 2 weeks) provided no new signs develop
methylsalicylate ointment, rub into affected areas
(120 mg/5 mL syrup)
tablets (500 mg tablet)
tablets
Referral
chronic pain for over 2 weeks
recurrent pain
incapacitating pain
backache
signs of arthritis (swelling, redness,
tender on pressure, warmth)
fever
18.02 Cough
R05 (786.2)
Description
cough is an extremely common symptom of a large variety of conditions in the
respiratory tract
cough is produced by inflammatory, mechanical, chemical and thermal stimulation of
cough receptors. Common triggering factors include infection, oedema, inhalation of
irritant dusts, gases, cold or hot air, foreign bodies, pressure by tumour, aneurism or
pleural effusion
common conditions that include cough are bronchitis, asthma, tuberculosis, tonsillitis,
lung edema, pneumonia, carcinoma, foreign bodies
cough may be productive of:
infected or non-infected sputum
blood (haemoptysis)
or may be non-productive (dry cough)
the elderly and children are inclined to swallow sputum, check therefore before
diagnosing dry cough
all patients with cough and haemoptysis need further investigation
any cough that persists for 3 weeks needs special investigation
a diagnosis of the cause of cough should always be made
the cause of the cough must be treated appropriately
make correct diagnosis of the cause
treat the cause
exclude serious underlying disease, e.g. TB, malignancy, asthma, foreign body
aspiration
stop smoking
Non-drug treatment
recommend hot water with honey and lemon
adequate hydration
avoid irritants
Drug treatment
cough mixtures have no effect on the course of the underlying condition
Referral
any unexplained cough present for more than 3 weeks
any cough which has any of the following associated symptoms:
blood in the sputum (haemoptysis)
weight loss
failure to thrive (children)
night sweats
unexplained chest pains
dyspnoea
persistent fever
any cough which has not improved after appropriate or specific antimicrobial therapy:
any persistent cough in immunocompromised patients, e.g. HIV, TB, diabetes
mellitus, rheumatoid arthritis
persistent cough in patients exposed to occupational lung diseases, e.g. miners,
chemical factory workers
suspected whooping cough (pertussis)
suspected pulmonary TB
lung cancer or other severe and chronic chest conditions
18.03 Febrile convulsions
R56.0 (780.3)
Description
A seizure triggered by a raised temperature.
there are two main kinds, simple and complex
simple febrile convulsions:
these seizures occur between ages 6 months and 5 years and have a good
prognosis
tends to occur at the beginning of the condition
often there is only one seizure which needs no specific treatment
complex convulsions are characterised by:
focal recurrent seizure (fit)
seizure lasts longer than 10 minutes
residual neurological abnormality
intracranial infection
Note
Fever has many serious and benign causes.
fever has its own symptoms, such as headache, body pains, rigors
needs investigation and proper examination
cause to be found and managed appropriately
convulsions can be due to:
serious intracranial disease (meningitis)
extracranial disease (pneumonia, viral disease)
malaria, tick bite fever
condition peculiar to age group/sex, e.g. urinary tract infection
hypoglycaemia
control convulsions
lower fever
make diagnosis
Non-drug treatment
clear the airway
treat for fever and its cause if these are known
cool the body by wiping with a cool damp cloth
remove excess clothing
Drug treatment
treat the underlying cause
(120 mg/5 mL syrup)
mL
diazepam rectal 0.2 mg/kg for convulsions, single dose
children under 3 years: maximum dose 5 mg
children over 3 years: maximum dose 10 mg
! CAUTION !
Do not give aspirin to children.
Referral
convulsions different from the convulsions described above
complex convulsions
18.04 Fever
R50.9 (780.6)
Description
Fever is a natural and sometimes useful response to infection.
Note
fever alone is not a diagnosis
fever can cause:
pain
myalgia
arthralgia
headache
insomnia
convulsions in children
fever and pain can be treated with one drug
measure temperature correctly
observe for signs of dehydration
temperature above 40C (hyperpyrexia) needs urgent lowering
do not treat low-grade fever (below 38C)
in neonates and the elderly fever is often absent or preceded by other symptoms like
confusion, failure to feed
malaria must be seriously considered in anyone with fever living in a malaria endemic
area or if a malaria area has been visited in the past 4 weeks
lower body temperature
prevent dehydration
prevent convulsions
stabilise before referral if necessary
Non-drug treatment
place patient in a cool place and use fans for cooling if available
remove excess clothing
cover only with a sheet or other light covering
tepid sponging of the body
if the patient feels cold and begins to shiver then cover lightly
Drug treatment
(120 mg/5 mL syrup)
mL
tablets
only treat for 3 days, then refer if a treatable cause cannot be found
! CAUTION !
do not treat undiagnosed fever with antibiotics
Referral
fever combined with:
neck stiffness
coma or confusion
toxic-looking patient
jaundice
convulsion
fever that lasts for more than 3 days without finding a treatable cause
fever that recurs
18.05 Headache, mild, non-specific
R51 (784.0)
Description
Headache can be benign or serious.
headache can have serious underlying causes such as hypertension, anaemia, stroke
or brain tumour:
organic headache will be associated with other neurological symptoms/signs:
t vomiting
t fever
t paralysis
t convulsions
t confusion
t impaired consciousness
t mood change
t visual disturbances
Note
investigate the cause
an organic headache should be referred within a week
chronic recurrent headaches are a special diagnostic problem
in a healthy patient treat for 1 month then refer if no improvement
tension headache due to muscle spasm:
may be worse in the afternoon
normally felt in the neck and the back of the head, but may be felt over the entire
head
often with dizziness and/or blurring of vision
often described as a tight band around the head
not progressive through stages like a migraine
treat for 1 month and refer
determine cause and treat
symptomatic support
Non-drug treatment
teach relaxation techniques
reassurance where applicable
Drug treatment
Paracetamol oral 46 hourly when needed to a maximum of four doses daily
tablets
Referral
headache in children lasting for 3 days
recent headache of increasing severity
headache with neurological complications
newly developed headache persisting for more than 1 week
chronic recurring headache if no improvement
suspected organic headache
18.06 Insomnia
G47.0 (780.5)
Description
Difficulty in falling sleeping or disturbed sleep patterns that is of concern to the patient.
problems with sleep are common and may have many causes
insufficient sleep has an impact on the patients psychological state and ability to
perform at work
insomnia may be:
primary: not due to environmental or psychological
stress or illness
secondary: due to pain, alcohol/drug abuse, anxiety
Note
History should include the following:
duration of the problem
at what time does the patient go to bed and how long does it take to fall asleep
does the patient sleep the whole night through and what times does he wake up
environmental factors, e.g. snoring partner, noise
does the patient sleep during the day
does the patient take any stimulants, e.g. caffeine
restore normal sleep rhythm
Non-drug treatment
patient counselling
teach the patient the importance of having a routine that prepares them for sleep:
food
drink
exercise
baths
environment
it helps to maintain a regular time for going to sleep and arising
Drug treatment
None.
Referral
chronic pain
psychiatric condition
18.07 Itching (pruritus)
L29.9 (698)
Description
A symptom characterised by:
localised or generalised Itching
may be accompanied by obvious skin lesions
many systemic diseases, e.g. hepatitis, may be accompanied by itching
causes may include scabies, insect bites
establish diagnosis
treat cause
symptomatic relief
Non-drug treatment
tepid baths
cut fingernails
Drug treatment
calamine lotion applied when needed
chlorpheniramine oral for severe or refractory pruritus
mg twice daily
three times daily
mg 34 times daily
mg 34 times daily
! CAUTION !
do not give an antihistamine to
children under 6 months
Referral
no response after 2 weeks
18.08 Pain control
R52.9
Description
A symptom described by the following:
duration
severity
site of pain
character, e.g. stabbing, throbbing, crushing, cramp like
persistent or intermittent
relieving or aggravating factors
accompanying symptoms

diagnosis of the cause and appropriate management
total pain relief with minimal side-effects
Non-drug treatment
patient counselling
Drug treatment
Mild to moderate pain
(120 mg/5 mL syrup)
mL
tablets
Pain associated with trauma or inflammation.
ibuprofen oral
adults: 200400 mg 68 hourly with food, to a maximum of 1 200
mg/day
Acute severe pain
following failure of paracetamol or ibuprofen, initiate one of the following opioids:
! CAUTION !
do not use morphine for any pain arising from the abdomen
morphine
adults: IM 1015 mg 46 hourly as needed (usually 0.2 mg/kg per
dose)
adults: IV 2.55 mg diluted and administered slowly over 45 minutes
and repeated in 12 hours as required
children 612 months: 0.02 mg/kg
children 15 years: 2.55 mg
pethidine
adults: IM 50100 mg (depending on weight) repeated every 4 hours
as required
adults: IV 50100 mg over 45 minutes
children over the age of 6 months: IM 1
mg/kg/dose
Precautions and special comments on the use of opioids
respiratory depression can be reversed by naloxone (see exposure to poisonous
substances, section 19)
do not give opioids where there is:
advanced liver disease
head injury
acute asthma
acute abdomen
hypothyroidism
use opioids with extreme care if there is:
hypovolaemia or shock, administer morphine IV with small incremental doses,
starting at 25 mg and increments of 2 mg every 10 minutes up to a maximum of
1015 mg depending on body weight
recent or concurrent alcohol intake or other CNS depressants
chronic respiratory disease with imminent respiratory failure, e.g. COAD
Referral
no response to oral pain control
uncertain diagnosis
management of serious underlying conditions
18.08.1 Chronic pain control in advanced or incurable cancer
R52.9
For specially trained health workers only.
Note
In palliative care:
home palliative care is provided by the family with the support of health care
professionals
pain severity and not the presence of pain determines the need for treatment
cancer pain is usually chronic and unremitting
pain assessment requires special training in:
history taking
physical examination
psychosocial assessment
assessment of the pain characteristics
effective pain control
provide moral support for caregivers
ensure quality of life and dying with dignity
Non-drug treatment
management of psychosocial factors
counselling/hospice care
Drug treatment
morphine is the preferred treatment of chronic cancer-related pain
Note
Drug treatment for pain should never be withheld.
Cancer pain in children is managed by the same principles but using lower doses of
morphine than adults.
Recommended steps to pain control in cancer patients
Step 1
(120 mg/5 mL syrup)
children 512 years: 11 tablets (500
mg tablet)
tablets
ibuprofen oral 46 hourly with food
children: do not exceed 500 mg per day
adults: 200600 mg to a maximum of 2 400 mg/day.
Discontinue if not effective after 23 days
Step 2
codeine phosphate in combination with step 1 above
codeine phosphate oral 4 hourly
children: 0.5 mg/kg (syrup 25 mg/5 mL), may be increased to 1
2 mg/kg per dose
adults: 3060 mg
Step 3
morphine is the treatment of choice
Note
Use the oral route where possible, if not possible, parenteral route
morphine sulphate oral solution, 4 hourly
adults:
510 mg
elderly adults or severe liver
impairment: 2.55 mg
morphine parenteral
adults: IM 1015 mg 46 hourly as needed
adults: IV 2.55 mg diluted and administered slowly over 45 minutes
and repeated in 12 hours as required
children under 1 year: 0.20.4 mg 4 hourly
children 15 years: 2.55 mg 4 hourly
metoclopramide oral, three times daily as needed for significant nausea and vomiting
children: do not exceed 5 mg 3 times per day
adults: 10 mg
constipation is a common problem due to long-term use of morphine
adults:
70% sorbitol oral, 15 ml daily
sennosides A and B oral, 15 mg (2 tablets) at night may be used
Break-through pain
Administer an extra dose of morphine equivalent to 510% of the 24 hour dose.
Dose increase
Titrate the dose upwards until pain is relieved.
increase dose by 3050 % at each step
allow 24 hours before considering dose increments. If patient experiences no pain
relief after eight hours, increase dose
no maximum dose for children and adults
double dose at night to allow reasonable sleep
Referral
uncontrolled pain
severe emotional or other distresses
18.09 Jaundice
Refer all patients with jaundice for diagnosis.
Chapter 19 Trauma and emergencies 193
Chapter 19 - Trauma and emergencies
The following conditions are emergencies and must be treated as such.
Drugs used for treatment must be properly secured and their use recorded (time,
dosage, routine) on the patients notes and on the letter of referral.
activated charcoal
acetylcysteine
adrenaline
amoxycillin
antiserum (snake)
aspirin, soluble
atropine
1% atropine
calamine lotion
1% chloramphenicol
0.05% chlorhexidine solution
chlorpheniramine
10% dextrose
50% dextrose
diazepam
1% fluorescein
furosemide
glyceryl trinitrate
half-strength Darrows with 5% dextrose
haloperidol
human tetanus immunoglobulin
hydrocortisone succinate
ibuprofen
2% lidocaine
lorazepam
morphine
naloxone
nifedipine
paracetamol
phenytoin
polyvalent antiserum (snake)
promethazine
rabies immunoglobulin
rabies vaccine
Ringer-Lactate
sodium sulphate
syrup of ipecacuanha
tetanus vaccine
0.5% tetracaine
19.01 Acute myocardial infarction (AMI)
I21.9
Description
The major clinical feature is severe chest pain with the following characteristics:
site: retro sternal or epigastric
quality: crushing or burning pain or discomfort
radiation: to the neck and/or down the inner part of the left arm
duration: at least 20 minutes lasting to several hours
occurs at rest
associated with:
pallor
sweating
arrhythmias
pulmonary oedema
a drop in BP
Note
AMI is caused by the complete or partial occlusion of a coronary artery and requires
prompt hospitalisation and intensive care management.
support and maintain vital functions
alleviate pain and anxiety
stabilise heart rhythm and BP
reduce further damage to the heart muscle
Emergency treatment before transfer
cardio-pulmonary resuscitation if necessary (see section 19.06)
100% oxygen continuously by nasal cannula
morphine for pain relief
1015 mg IM
or
small IV increments of 1 mg/minute and titrate to pain relief, maximum 10 mg
IV morphine must be diluted to 10 ml with water or 0.9% sodium chloride for
injection
aspirin, soluble oral, 150 mg as a single dose
glyceryl trinitrate sublingual 0.5 mg every 510 minutes for pain to a maximum of 5
tablets
! CAUTION !
do not allow systolic BP to decrease by more than 10 mmHg
or pulse rate to increase to above 90 per minute
monitor continuously and also during transfer
pulse
BP
respiration depth and rate (count for a full minute)
Referral
all suspected or diagnosed cases urgently
19.02 Acute pulmonary oedema
J81
Description
A life-threatening condition with abnormal accumulation of fluid in the lungs
causes are:
acute heart failure (common cause)
drowning or near drowning
over hydration with IV fluids
persons with pulmonary oedema may present with acute bronchospasm
it is important to distinguish this condition from an attack of acute asthma
! CAUTION !
morphine is contraindicated in acute asthma
establish the cause of the pulmonary oedema and treat
reduce the respiratory and cardiac workload by:
reducing agitation
inducing transient arterial and venous
dilatation
decreasing the respiratory rate
slowing down the heart rate
Emergency treatment
place the patient in a sitting, high or semi-Fowlers position
administer 100% oxygen by mask to deliver 40% oxygen
furosemide IV 20 mg to start diuresis in 1520 minutes
if no response administer 4080 mg after 30 minutes
if response inadequate follow with 2040 mg in 24 hours
morphine
1 mg/minute IV
or
510 mg IM
glyceryl trinitrate sublingual 0.5 mg 6 hourly
may be highly effective in causing dilatation of the veins and redistributing blood
volume away from the chest
pulmonary oedema due to a hypertensive crisis or significant systolic hypertension
may respond to a vasodilator
nifedipine oral, 5 mg immediately, chewed or the contents of a capsule squirted into
the mouth
Referral
urgent referral of all cases
administer oxygen therapy during transfer
19.03 Anaphylactic shock
T78.2 (995.0)
Description
A very severe allergic reaction that may occur after an injection or exposure to any
allergen
clinical features:
collapse with shock
bronchospasm
laryngeal oedema
prevent severe reactions by:
avoiding identified allergens
establishing the cause
arranging for a medical identity disc or bracelet
teaching patients about prevention, early warning signs and management principles
and ensuring the wearing of the medical identity discs
restore cardiovascular function as soon as possible
Emergency treatment
resuscitate (ABCD) immediately
assess breathing and heartbeat
breathing
if breathing, then give 100% oxygen
children: 46 L/min via nasal cannula
adults: 46 L/min face mask
if the patient is not breathing
secure airway, ventilate with ambubag or ventilator
cardiac
if there is no heartbeat
CPR
lay the patient flat if there is shock
intravenous solutions
0.9% sodium chloride IV
or
Ringer-Lactate solution
adults: run IV fast
or
half-strength Darrows with 5% dextrose solution
children: run IV at 20 mL/kg in first 2060 minutes
Drug treatment
adrenaline 1:1 000 IV, SC or endobronchial is the mainstay of treatment and should
be given immediately
adrenaline 1:1 000 IV, 1 mL diluted with 0.9% sodium chloride to make 10 mL - give
as a slow IV if unconscious
children: 0.1 mL/kg IV
or
endobronchial through endotracheal tube for cardio-respiratory arrest (same dose)
repeat every 5 minutes when necessary for a maximum of three doses
or
SC (subcutaneous)
adults: SC, 0.5 mL undiluted immediately
repeat every 1020 minutes as needed
check that heart rate is not over 140 beats/minute
hydrocortisone sodium succinate IV 100 mg immediately
promethazine IM may be given additionally to counteract ongoing histamine release
children: 0.25 mg/kg
adults: 2550 mg
19.04 Bites and stings
19.04.1 Animal and human bites
T14.1
Note: Rabies is a notifiable disease.
Description
Injuries which may result in:
infection - usually anaerobic bacteria
puncture wounds
tissue necrosis
complications from tetanus or rabies,
e.g. animal bites
animal bites - may be caused by:
domestic animals (horses, cows, rabid dogs, cats)
wild animals (meerkat, foxes, jackals, mongooses, fruit bats)
rabies incubation period is at least 9 days, could be 12 months
avoid infection
prevent tetanus and rabies
avoid disability and scar formation
pain relief
do not destroy rabid animals because rabies must be confirmed
notify rabies (see p. ix)
Non-drug treatment
pre-exposure vaccine may be given to those at risk, e.g. occupation, endemic areas,
laboratories
prevention by health education and regular vaccination of domestic cats and dogs
(legal requirement)
Emergency management
irrigate and cleanse (scrub) the wound with 0.05% chlorhexidine solution
or
10% polyvidone iodine solution
do not suture bite wounds
thorough and prompt treatment to all bite wounds and scratches
Suspected rabies
vaccine and immunoglobulin are usually available from the district surgeon or the
nearest district hospital
rabies immunoglobulin 20 IU/kg
dose should be injected in and around the wound
dose IM
NON-IMMUNE PATIENTS PREVIOUSLY
IMMUNISED
PATIENTS less than 48 hours
after exposure
more than 48 hours
after exposure
IMMUNO-
COMPROMISED
PATIENTS
do not administer
human anti-rabies
immunoglobulin
(RIG)
vaccine therapy
day 0 - single dose
day 3 - single dose
administer RIG for
category 3* exposure
only
vaccine therapy
day 0 - single dose
day 3 - single dose
day 7 - single dose
day 14 - single dose
administer RIG for
category 3 exposure
only
vaccine therapy
day 0 - double dose
day 3 - single dose
day 7 - single dose
administer RIG for
category 3 exposure
only
vaccine therapy
day 0 - double dose
day 3 - single dose
day 7 - single dose
* bites or scratches which penetrate the skin and draw blood.
non-immune patients (not immunised)
rabies vaccine IM
adults: deltoid muscle
children: anterolateral thigh
give rabies vaccine on day 90 if rabies immunoglobulin was given on day 0
previously immunised patients
rabies vaccine IM
do not give rabies immunoglobulin
Tetanus prophylaxis
tetanus adsorbed toxoid vaccine (TT) IM 0.5 mL
human tetanus immunoglobulin (TIG) IM
unimmunised or never
fully immunised
patients: 250 IU
children:
510 IU/kg
Note
in a fully immunised person, tetanus toxoid vaccine or tetanus immunoglobulin
might produce an unpleasant reaction, e.g. redness, itching, swelling or fever, but
in the case of a severe injury the administration is justified
prophylactic antibiotic use
infants 06 months:
62.5 mg
mg
mg
estolate 62.5 mg
estolate 125 mg
or estolate 250 mg
stearate 250mg
Non-rabid bites
flush and cleanse
do not suture extensive bite wounds
prophylactic antibiotic use
infants 06 months:
62.5 mg
mg
mg
estolate 62.5 mg
estolate 125 mg
or estolate 250 mg
stearate 250mg
Referral
all large wounds needing elective suturing
suspected rabid animal bites
shock and bleeding
deep wounds
19.04.2 Insect bites and stings
T63.2/3/4
Description
Injury from stings and bites by bees, wasps, spiders, scorpions and other insects:
bees and wasps - venom is usually mild but may provoke severe allergic reactions
such as laryngeal oedema or anaphylactic shock (see section 19.03)
spiders and scorpions - most are non-venomous or mildly venomous
if a highly venomous species is thought to be responsible for the bite/sting apply first
aid and supportive measures as for snakebite
Emergency treatment
if anaphylactic shock (see section 19.03)
if severe local symptoms treat as follows:
children 6 months1 year: 1 mg
twice daily
three times daily
mg 34 times daily
mg 34 times daily
calamine lotion applied if needed
(120 mg/5 mL syrup)
mL
children 512 years:
tablet(s)
very painful scorpion stings need a local anaesthetic
2% lidocaine 2 mL injected around the bite
Referral
if systemic manifestations are present
19.04.3 Snakebite
T63.0
Description
Envenomation.
the symptoms of snakebite with venom can be:
swelling (90%)
weakness with/without swelling (67%)
bleeding (0.5%)
venom diffuses mainly via the lymphatics, not via blood vessels, so tourniquets are of
no use
Treatment objectives
prevent serious early and late complications
prevent death from venom
relieve pain and anxiety
Emergency treatment
antivenoms should only be administered according to the recommendations because
they are:
difficult to store
difficult to use
may cause anaphylaxis
do not have clear efficacy
try to identify the snake
arrange for admission for 12 hours observation
first aid plus supportive therapy is adequate for most bites
venom in the eyes
0.5% tetracaine instilled into the eye(s)
irrigate extensively with water
1% chloramphenicol ophthalmic ointment instilled into the eyes and covered with
eye pads
venom on the skin or wound
wipe away excess venom from the skin and assess the wound to confirm fang
penetration
clean the wound with 0.05% chlorhexidine solution
apply a crepe bandage firmly to the entire limb to ensure constant pressure
immobilise the limb with a splint
reassure, keep calm and immobilise the patient
supportive therapy
treat shock if any, or if swelling is significant
analgesics according to severity of pain (see section 18.08)
children 6 months1 year: 1 mg
twice daily
three times daily
mg 34 times daily
mg 34 times daily
tetanus prophylaxis
children:
510 IU/kg
fully immunised
patients: 250 IU
Note
in a fully immunised person, tetanus toxoid vaccine or tetanus
immunoglobulin might produce an unpleasant reaction, e.g. redness,
itching, swelling or fever, but in the case of a severe injury the
administration is justified
! CAUTION !
Polyvalent antivenom is contraindicated for bites from:
berg adders
small adders
boomslang
Specific antivenoms are available from the SAIMR.
administration of snake antivenom
Note
90% of patients do not need and should not be given
antivenom
only administer antivenom to the 10% of patients with
snakebite who need it
criteria for antivenom administration
signs of systemic poisoning
spreading local damage
swelling of a hand or foot within 1 hour of a bite (80% of bites are on hands or feet)
swelling of elbows or knees within 3 hours of a bite
swelling of the groin or chest at any time or if actively advancing
associated bleeding disorder
significant swelling of head or neck to prevent airway obstruction
50 mL IV of polyvalent antiserum
muscle weakness and/or difficulty in breathing
100 mL repeated within 12 hours if no improvement
snake size or recognition of a venomous snake
Administration of antivenom
ensure that the antivenom solution is clear
check that the patient has no history of allergy
if there is a history of allergy and signs of systemic poisoning then administer
antivenom
but
prepare to treat possible reactions with hydrocortisone succinate and adrenaline
(see anaphylaxis section 19.03)
polyvalent antivenom slow IV infusion
adults and children: 100 mL in 300 mL of 0.9% sodium chloride
administer slowly for the first 15 minutes because most allergic reactions will occur
within this period
increase the flow rate gradually until the infusion is completed within one hour
repeat if there is no clinical improvement after the infusion
black mamba bites may require up to 200 mL or more to reverse respiratory
paralysis
Referral
all patients
19.05 Burns
T30.0 (940.9)
Description
Burns may be caused by heat (thermal burns), chemical compounds and physical
agents, e.g. electrical. The extent and depth may vary from superficial (epidermis) to full-
thickness skin and underlying tissues.
burns are usually initially sterile
speed healing while minimising the risk of infection
Emergency treatment
Throughout the first hour after the accident soak the affected area generously with, or
immerse in cold water to limit the extent of the burn. Examine carefully to determine the
extent of the burn and for respiratory obstruction due to thermal injury.
Fluid replacement
burns of over 8% of body surface area (in children the palm of the hand is 1%)
IV fluid for resuscitation, apply burns dressing and refer
less serious and superficial burns
give IV fluid according to the calculation below
Calculation of fluid replacement
the objective is to maintain normal physiology as reflected by urine output, vital signs
and mental status
general formula for use in first 24 hours
Ringer-Lactate IV 11.5 mL/kg x % body surface area burned
first 8 hours administer half the volume
second 8 hours administer one quarter of the volume
third 8 hours administer the balance
(120 mg/5 mL syrup)
mL
children 612 years:
tablet(s)
clean the wound gently with 0.9% sodium chloride or clean water
dress the burn with paraffin gauze dressing and then dry gauze on top
the bandage should be thick enough to prevent seepage through to the outer layers
change the dressing after 23 days, and as necessary thereafter
infected burn
5% polyvidone iodine cream applied daily
or
0.05% chlorhexidine solution daily
Tetanus prophylaxis
children: 510 IU/kg
fully immunised
patients: 250 IU
Note
immunoglobulin might produce an unpleasant reaction, e.g. redness,
Referral
all children under the age of 3 months
over 8% of body surface area burnt (in children the palm of the hand is 1%)
deep burns or burns of the face, neck, hands or perineum
circumferential burns
deep electrical
deep chemical
inhalation burns
infected burn
19.06 Cardiac arrest - cardio-pulmonary resuscitation
I46.9
19.06.1 Cardiac arrest - adults
Description
Cardiac arrest is the sudden and usually unexpected cessation of effective cardiac
output. Irreversible brain damage can occur within 24 minutes.
clinical features:
sudden loss of consciousness
absent carotid pulse
loss of spontaneous respiration
pupil dilatation
urgent restoration of effective cardiac output and peripheral perfusion
adequate oxygenation
Emergency treatment
diagnose rapidly and mentally note the time of starting
commence resuscitation immediately
call for skilled help
a precordial thump is recommended for immediate treatment where a defibrillator is
not immediately available
place the patient on a firm flat surface
initiate ABCD sequence of CPR
if possible, get someone to document medication and progress
or
collect all ampoules used and total them at the end
Aairway
try to wake the patient
clear vomit or foreign body from the mouth manually
tilt the head backwards with one hand on the forehead (do not do this where a neck
fracture is suspected)
lift the chin forward with the fingers of the other hand
raise the shoulders to tilt the neck backwards unless a neck fracture is suspected
insert artificial airway if available
when the patient is breathing well, lay him/her on the side to protect the airway and
support the patient by bending the uppermost arm and leg
! CAUTION !
no ventilation is possible
until the airway is open
Bbreathing
check for breathing
no breathing then apply artificial respiration
mouth-to-mouth
or
mouth-to-nose
or
ambubag
continue until spontaneous breathing occurs
oxygenation with 100% oxygen
endotracheal intubation is essential - use a tube of approximately the same diameter
as the child's little finger or of a size that will just fit into the nostril
if prolonged ventilation is required, intubation is the best method of securing the airway
pre-oxygenate well before intubation
Ccirculation
check for carotid or other large pulse
if no pulse, give a single precordial thump or defibrillate
initiate CPR if there is no pulse or no breathing
continue until return of the pulse and/or respiration
Ddrip, doctor, drugs
put up IV fluid with either 0.9% sodium chloride
or
summon the doctor without stopping CPR
Initial emergency drug treatment
adrenaline 1:1 000 IV, SC or endobronchial is the mainstay of treatment and should
be given immediately
adrenaline 1:1 000 IV, 1 mL diluted with 0.9% sodium chloride from the drip to make
10 mL
or
endobronchial through endotracheal tube for cardio-respiratory arrest (same dose)
repeat every 5 minutes when necessary for a maximum of three doses
or
SC (subcutaneous)
adults: SC, 0.5 mL undiluted immediately
repeat every 1020 minutes as needed
check that heart rate is not over 140 beats/minute
doctor initiated medication
2% lidocaine IV 50100 mg for ventricular tachycardia
or
atropine 0.51 mg diluted for bradycardia
reassess every minute until the patient shows signs of recovery
continue until transfer to hospital
consider stopping resuscitation attempts and pronouncing death if:
further resuscitation is clearly inappropriate clinically, e.g. incurable underlying
disease
no success after all the above procedures have been carried out after 30 minutes or
longer
consider carrying on for longer especially when:
the patient is young
hypothermia and drowning
assumed electrolyte imbalance
19.06.2 Cardiac arrest - children
Description
The most common underlying cause of cardiac arrest in children is respiratory failure
and hypoxia resulting from lung or airway disease or injury:
croup
bronchiolitis
asthma
pneumonia
birth asphyxia
inhalation of foreign body
pneumothorax
Hypoxia is the most common cause of bradycardia or cardiac arrest in children. Asystole
is the most common cardiac arrest rhythm in infancy and childhood, usually preceded by
bradycardia. Ventricular fibrillation is unusual in children and it is therefore inappropriate
to include a blind precordial thump or DC shocks in the management of cardiac arrest in
children. Cardiac arrythmias are unusual in children, unless due to severe electrolyte
abnormalities or drug overdose.
urgent restoring of effective cardiac output and peripheral perfusion
adequate oxygenation
Emergency treatment
diagnose rapidly and mentally note the time of starting
commence resuscitation immediately
summon skilled help
cardiac massage is recommended for immediate treatment
place the patient on a firm flat surface
initiate ABCD sequence of CPR
if possible, get someone to document medication and progress
or
collect all ampoules used and total them at the end
Aairway
try to wake the patient
clear vomit or foreign body from the mouth manually
tilt the head backwards with one hand on the forehead (do not do this where a neck
fracture is suspected)
lift the chin forward with the fingers of the other hand
raise the shoulders to tilt the neck backwards unless a neck fracture is suspected
insert artificial airway if available
when the patient is breathing well, lay him/her on the side to protect the airway and
support the patient by bending the uppermost arm and leg
! CAUTION !
consider the possibility of a foreign body; if suspected, apply Heimlich manoeuvre or
modification for size
Heimlich manoeuvre:
child over 5 years
make a fist with one hand
place immediately below the childs xiphisternum
grasp the child with the other hand
apply force (16 times) in the direction of the upper thoracic spine
child under 5 years
place the child face-down on one arm of the health worker
deliver 14 sharp blows to the lower thoracic back with the hand
! CAUTION !
do not use blind finger sweeps
of the mouth or posterior pharynx:
this can impact any obstruction further down the airway
! CAUTION !
Bbreathing
check for breathing
no breathing then apply artificial respiration
mouth-to-mouth
or
mouth-to-nose
or
ambubag and face mask are preferable if available
breathe (inflate the chest) at least 15 times/minute (faster in babies)
do not stop unless breathing starts or help arrives
continue until spontaneous breathing occurs
oxygenation with 100% oxygen
endotracheal intubation is essential - use a tube of approximately the same diameter
as the child's little finger or of a size that will just fit into the nostril
if prolonged ventilation is required, intubation is the best method of securing the airway
pre-oxygenate well before intubation
! CAUTION !
cardiac massage is useless unless there is an
airway and the lungs are being filled with air
Ccirculation
check the heartbeat
carotid in the older child
or
femoral
or
brachial pulse
no pulse, start cardiac compressions or massage
rate of compressions 80100 beats/minute
continue with ventilation in between chest compressions
initiate CPR if there is no pulse or no breathing
keep patient covered and warm while resuscitating
ventilate if there is a pulse, but no breathing
continue until return of the pulse and/or respiration
Ddrip, doctor, drugs
put up IV fluid with either 0.9% sodium chloride
or
summon the doctor without stopping CPR
Initial emergency drug treatment
adrenaline 1:1 000, initially 10 micrograms/kg IV or via endotracheal tube
adrenaline 1:1 000, 1 mL diluted to 10 mL from the drip
children: 0.1 mL/kg
following and subsequent doses, a 510 fold increase is recommended
repeat every 3 minutes when needed for 34 doses
bradycardia or slow heart rate
hypoxia is the most common cause of bradycardia, so adequate ventilation or
oxygenation is usually all that is needed
atropine IV 0.02 mg/kg to a maximum of 1 mg
alkalising agents, e.g. sodium bicarbonate have not been shown to be useful during
acute resuscitation
only use after clinical consideration of profound acidosis in patients with respiratory
or circulatory arrest
and
after the first dose of adrenaline
difficult or impossible IV access within 23 minutes
administer medication down the endotracheal tube
adrenaline dose via this route is 10 times the standard dose
atropine can also be given via this route
fluid therapy
administer a bolus of 0.9% sodium chloride to follow the IV or intraosseous injection
of any drug used in resuscitation
especially if the injection is peripheral
520 mL, depending on the size of the child
dextrose
sick children, especially infants, may be hypoglycaemic
look for evidence during resuscitation
treat proven hypoglycaemia with 10% dextrose solution IV, 5 mL/kg
avoid unnecessary or excessive treatment
drug administration route
IV via a free-running drip
ensure that excessive volumes of fluid do not run into the patient during the
resuscitation
use 60 drop per mL administrations sets for all drips unless hypovolaemia is
thought to be responsible for the arrest
intraosseous route
resuscitation drugs, fluids and blood can be safely given
drugs rapidly reach the heart
access is safe, simple, rapid
children of all ages and adults
tibial technique, 23 cm below the knee
19.07 Delirium with acute confusion and aggression
F03
Description
Delirium is an sudden onset state of confusion in which there is impaired
consciousness.
many possible causes, many outside the central nervous system
the differential diagnosis includes psychiatric conditions, like schizophrenia and the
manic phase of a bipolar disorder
consider organic or physical illness as a possible cause, which may include:
central nervous system disorders
drug-related problems
typhoid
rabies
metabolic disorders
clinical features:
restlessness
agitation
aggressiveness
violent behaviour alone occurs in exceptional cases only
risk factors for delirium include:
extremes of age
pre-existing dementia
cerebrovascular disease
space-occupying brain lesions
substance intoxication and
withdrawal
prescription drugs such as
anticholinergics and hypnotics
admission to intensive care units
epilepsy
main clinical features are:
confusion
disorientation
other symptoms may also be present:
restlessness
agitation
hallucinations
autonomic symptoms such as sweating, tachycardia and flushing
other patients may be hypo-active, with reduced responsiveness to the environment
a fluctuating course and disturbances of the sleep-wake cycle are characteristic
stabilise the patient
Emergency treatment
non-organic, non-psychotic causes
verbal intervention is the first step
if communication is difficult, restrain and give psychotropic medication
diazepam IV, 1020 mg for immediate sedative or hypnotic action
do not administer at a rate over 5 mg/minute
monitor for respiratory depression
or
lorazepam IM 24 mg
if no response
then
haloperidol IV, 510 mg slowly
or
haloperidol IM 25 mg hourly
Referral
refer to hospital as soon as possible
19.08 Nose bleed (epistaxis)
R04.0
Description
Most bleeding occurs from an area anterior and inferior on the nasal septum
(Kiesselbach area). This may be caused by local or systemic diseases or local trauma.
Always look for other conditions associated with nose bleeds, especially if recurrent, e.g.
hypertension, bleeding tendency.
Management
Acute episode
most bleeding can be controlled by pinching the nasal wings (alae) together for 510
minutes
if this fails, the bleeding site must be found and the patient must be referred
Referral
recurrent nose bleeds
attempt to stop the present bleed
refer for determination of cause
19.09 Eye, chemical burn
T26.5 (871 & 930)
Description
Damage to the eye caused by contact with irritating chemical substance, e.g. acids,
alkalis.
remove chemical
prevent damage
avoid infection
Emergency treatment
irrigate liberally with water or 0.9% sodium chloride and repeat several times if severe
test visual acuity before fluorescein test for corneal injury or breach
1% fluorescein instilled in the eyes for diagnosis of local or diffuse damage
local damage
administer antibiotic, cover with eye pad and review after 24 hours
diffuse damage
1% atropine ophthalmic drops instilled immediately, once only
1% chloramphenicol ophthalmic ointment instilled 34 times daily
oral analgesic
Referral
all patients
19.10 Eye injury, foreign body
S05.9 / S05.5 (871 & 930)
Description
A foreign body may be embedded in conjunctiva or cornea or deeper:
conjunctival or eyelid foreign body may cause corneal abrasion
disturbance of vision is serious
relieve pain
prevent infection
prevent permanent loss of function
Non-drug treatment
take proper history
check visual acuity first, before testing with fluorescein
stain with fluorescein for corneal foreign body or complication (abrasion)
check after removal of foreign body
Note
eye ointment may act as foreign body to abraded eye tissue
do not use an eye pad with
ecchymosis
lid oedema
bleeding
allow drainage
fluorescein confirms:
an embedded foreign body or rust ring
multiple foreign bodies
Emergency treatment
remove foreign body by washing
or
irrigation
or
with cotton-tipped stick (cotton bud)
or
back of needle (cornea)
visual acuity will be abnormal with a corneal foreign body or abrasion
the nature of the trauma determines the type of injury
1% fluorescein drops for diagnosis
0.5% tetracaine drops to remove foreign body only
0.9% sodium chloride or clean water to irrigate the eyes
1% chloramphenicol ophthalmic ointment instilled 34 times daily
1% atropine ophthalmic drops immediately, once only for deep injuries
review the problem daily
Referral
hyphaema (blood in the anterior chamber of the eye)
diffuse corneal damage after applying 1% atropine ophthalmic drops
scleral and corneal laceration
lid oedema
subconjunctival bleeding persisting for more than 24 hours
post-traumatic dilatation of the pupil
persistent corneal defect or corneal opacity
19.11 Exposure to poisonous substances
T65.8 (963.9)
Note: Poisoning from agricultural stock remedies is notifiable.
Description
the rapid and positive identification of the poison is essential:
keep a sample or the poison container
simple inspection or by assessing its smell or odour except in suspected cyanide
exposure
poisoning may also occur by inhalation and skin absorption
prevent further absorption of the toxic substance
maintain vital functions
reverse the effects of the poison
Non-drug treatment
Most cases of poisoning are accidental.
where there is no definite history, suspect poisoning from the signs and symptoms
treatment depends on:
type of poison
method of poisoning
time lapsed since poisoning
condition of the patient
prevention depends on parent education and proper child care
emphasize that drugs and poisons should be stored out of reach of children
phone the nearest hospital or poison centre for advice
MAJOR POISON INFORMATION CENTRES
Gauteng : 0800 111 990 or
(011) 495-5112 or
Free State : (051) 447-5353 or
(051) 405-3033
KwaZulu-Natal: 0800 333 444
Western Cape:
Red Cross: (021) 689-5227
Tygerberg: (021) 931-6129
perform resuscitation ABCD (section19.06.1) if the patient is unconscious
take a history and identify the nature and route of poisoning
thoroughly wash any poison off the skin and remove splashed clothes
Note
health care workers should avoid inhaling, swallowing poison or having skin contact
Ingested poisons
induce vomiting except in:
coma
convulsions
strong acids or alkalis
petroleum products
syrup of ipecacuanha oral with large volumes of water to drink
children 612 months:
15 mL
children 12 months to 12 years:
20 mL
25 mL
repeat after 20 minutes if no vomiting has occurred
Gastric lavage is of value within the first hour except where peristalsis is reduced.
activated charcoal
50 g activated charcoal provided in a 500 mL bottle
add 400 mL water and shake very well
make sure that all the charcoal has been wetted
dose 5 mL of this mixture per kg of body weight
remove by suction or with purgatives
repeat until a total of 100 g charcoal has been ingested and recovered
Specific antidotes
oxygen for the management of hypoxia, especially in carbon monoxide poisoning
atropine for the treatment or organophosphate and carbamate poisoning
adults: initial trial dose of atropine IV 12 mg
further dose if no adverse effects, 24 mg every 1015 minutes
naloxone
in the treatment of opioid drug overdose
dose 0.42 mg IV at appropriate intervals up to a maximum of 10 mg
! CAUTION !
if addiction is suspected or evident
use the lowest appropriate dose
to prevent withdrawal syndrome
acetylcysteine is the antidote of choice in paracetamol overdose (over 125
250 mg/kg). If transfer to hospital is delayed, the administration of acetylcysteine
should be initiated. Most effective if treatment is initiated within 8 hours of ingestion of
paracetamol
diazepam for convulsions
children: rectally 10 mg of the IV solution, repeated after 510
minutes if needed
children: IV 0.2 mg/kg slowly over 3 minutes
adults: IV 1020 mg administered at a rate of 2 mg/minute
until seizures stop
sodium sulphate oral, in a glass of water, single dose as a general purgative
children: 250 mg/kg
adults: 1020 g
Referral
all cases of severe poisoning
petroleum and paraffin products
corrosives acids and alkalis
send the following to hospital with the patient
written information
the container
any vomitus
19.12 Injuries
T14 (840)
Description
soft tissue injury may take many forms:
pain only
traumatic swelling
bruises (intact skin)
cuts
abrasions
puncture wounds
other open wounds of varying size
and severity
contamination with dirt and soil complicates the outcome of treatment
human and animal bites can cause extensive injuries and infection (see section
19.04.1)
fractures must be excluded, even when treatment with rest and ice is instituted
stop obvious bleeding
injury to internal organs must be recognised and referred:
including subtle signs for organ rupture
blood in the urine - kidney damage
shock - internal bleeding
referral must not be delayed by waiting for a diagnosis
an injury causing a sprain or strain may be overlooked, e.g. sport, exercise, sleep, and
the symptoms appear late
closed injuries and fractures of long bone may be serious and damage blood vessels
prevent further damage
avoid infection
avoid disability and scar formation
relieve pain and swelling
prevent tetanus through wound care and immunisation
immobilise injured limb
monitor heart rate
monitor pulses below an injury on a limb with swelling
Wound care
clean the wound
suture or splint when needed
avoid primary suture if the wound is:
infected
dirty/contaminated
crushed
in need of debridement
missile inflicted
caused by bites
Drug treatment
(120 mg/5 mL syrup)
mL
children 512 years:
tablet(s)
continue treatment for 1 week with periodic reviewing
Tetanus prophylaxis
tetanus adsorbed toxoid vaccine (TT) IM, 0.5mL
children:
510 IU/kg
fully immunised
patients: 250 IU
Note
immunoglobulin might produce an unpleasant reaction e.g. redness,
Referral
urgent referral:
extensive closed or open wounds
injury to vital structures/internal organs
sepsis
shock
anaemia
blood in the urine
babies and young children
enlarging and/or pulsating swelling
19.13 Shock
R57.9
Description
A life-threatening syndrome in which peripheral blood flow and tissue perfusion are
inadequate.
poor peripheral perfusion leads to:
inadequate oxygen delivery
anaerobic respiration
increased production of lactic acid
clinical manifestations include:
a low systolic BP under 80 mmHg
altered mental status
oliguria (low urine output)
clammy and pale extremities, often cyanotic, with poor capillary refill
mechanisms of shock include:
hypovolaemia due to acute haemorrhage or increased loss of other body fluids
(hypovolaemic shock)
heart failure due to reduced systolic function, disturbed heart rhythm or heart valve
defects (cardiogenic shock)
extracardiac obstructive mechanisms such as pulmonary embolism
maldistribution of blood flow due to increased vascular permeability occurring in
anaphylactic or septic shock
prompt diagnosis of the underlying causes is essential to ensure optimal treatment
restore peripheral tissue perfusion and oxygenation
support vital functions
keep patient warm
position with legs raised
control haemorrhage
initiate fluid resuscitation as soon as possible
Referral
refer to hospital as soon as possible after stabilisation
19.14 Sprains and strains
T14.3 (840)
Description
Overt or unnoticed soft tissue injuries.
sites include:
joints
near joints
parts of limbs
back or neck
causes include:
sport injuries
slips
twists
overuse of muscles
abnormal posture
clinical features:
pain, especially on movement
tenderness on touch
limited movement
no bruise or swelling
Note
In children always bear non-accidental injuries in mind.
diagnose correctly
exclude serious injuries
exclude infection
immobilise and relieve pain
Emergency treatment
immobilise with firm bandage and/or temporary splinting
ibuprofen oral 68 hourly
200400 mg
Contraindications

peptic ulcer
bleeding disorders
renal and hepatic impairment
pregnancy
(120 mg/5 mL syrup)
mL
children 512 years:
tablet(s)
the value of topical analgesics has not been proven
Referral
severe progressive pain
progressive swelling
extensive bruising
deformity
joint tenderness on bone
no response to treatment
severe limitation of movement
suspected serious injury
recurrence
19.15 Status epilepticus
G41.9 (345.3)
Description
A series of seizures lasting longer than 10 minutes without regaining consciousness.
adequate ventilation and oxygenation are crucial to prevent hypoxic brain damage
hypoglycaemia may cause convulsions
potential for high mortality
control convulsions
ensure adequate ventilation and oxygenation
exclude and treat causes such as hypoglycaemia and intoxication
control convulsions and maintain life-support measures during referral
Emergency treatment
place the patient in a supine position
do not place anything in the patient's mouth
maintain airway
assist respiration and give 100% oxygen
prepare for suction and intubation
check blood glucose
diazepam
children: IV 0.20.3 mg/kg (maximum 10 mg)
over 3 minutes
or
children under 10 kg: rectal 5 mg (1 ml)
or
children over 10 kg: rectal 10 mg (2 ml)
adults: IV 1020 mg slowly do not give
faster than 2 mg/minute
repeat within 1015 minutes if needed
maximum of 30 mg within 1 hour
expect a response within 15 minutes
or
adults: rectal 10 mg of the IV solution
repeat after 510 minutes, up to 30 mg in total
once the seizures are controlled an infusion of 5 mg/hour may be given until the
signs of cerebral abnormality have subsided
! CAUTION !
avoid diazepam IM since absorption is slow and erratic
do not mix with other drugs
phenytoin IV
children: 1020 mg/kg at a rate of 13 mg/kg/minute
adults: 1520 mg/kg at a rate not exceeding 50 mg/kg/minute
when stabilised, phenytoin oral 300600 mg as a single dose before transfer
Referral
all patients once stabilised
19.16 Hypoglycaemia and hypoglycaemic coma
E16.2
Description
Hypoglycaemia can rapidly cause irreversible brain damage and/or death.
clinical features:
sympathetic stimulation
pallor
sweating
tachycardia
abdominal pain
hunger
neurological
headache
irritability
impaired concentration
confusion
delirium
coma
convulsions
transient aphasia (speech
disorders)
there may be few or no symptoms if:
the blood sugar is chronically low
the patient is very ill
malnourished
impaired autonomic nervous system response, e.g. the elderly, very ill,
malnourished, or those with long-standing diabetes mellitus, beta-blocker
medication
people at risk of hypoglycaemia:
neonates with low birth weight, ill in any way, not feeding well
malnourished or sick children who have not eaten for over 8 hours
shocked, unconscious, convulsing patients
diabetic on treatment developing abnormal behaviour or symptoms
identify hypoglycaemia
treat hypoglycaemia
Emergency treatment
diagnose with testing strips for blood glucose
do not wait, but obtain blood for glucose determination if possible
conscious patient, able to feed
administer sweets, sugar, glucose by mouth
unconscious patient
50% dextrose solution IV, immediately
followed by
10% dextrose solution
if no access to veins, give the above by nasogastric tube
Referral
all patients
232 Abbreviations
Abbreviations
AIDS acquired immunodeficiency syndrome
BP blood pressure
CSF cerebrospinal fluid
dL decilitre (10 ml)
EPI Expanded Programme on Immunisation
HIV human immunodeficiency virus
IU intra-uterine
IUCD intra-uterine contraceptive device
IM intramuscular
IV intravenous
RPR/VDRL rapid plasma reagent test/venereal disease research laboratory
VVM vaccine vial monitor
Essential drugs list 233
Essential drugs list
Code Category
A ALIMENTARY TRACT AND METABOLISM
A01 Stomatological preparations
Chlorhexidine digluconate mouthwash 0.2%
Miconazole oral gel 20mg/g
Nystatin lozenges 100 000 IU
A02 Antacids, drugs for treatment of peptic ulcer and flatulence
Aluminium hydroxide 250 mg/Mag trisilicate 500 mg tab
A03 Antispasmodic and anticholinergic agents and propulsives
Metoclopramide tab 10 mg
A04 Antiemetics and antinauseants
A05 Liver therapy
A06 Laxatives
Magnesium sulphate inj 50%
Paraffin liquid
Sennosides A and B tab 7.5 mg
Sodium sulphate powder
Sorbitol 70%
A07 Antidiarrhoeals, intestinal anti-inflammatory/anti-infective agents
Half-strength Darrows solution/ 5% dextrose
Oral rehydration salt solution sachets (ORS)
A08 Antiobesity preparations
A09 Digestives, including enzymes
A10 Drugs used in diabetes
Glibenclamide tab 5 mg
Insulin biphasic 30/70
Insulin intermediate acting
Metformin tab 850 mg
Tolbutamide tab 500 mg
234 Essential drugs list
A11 Vitamins
Nicotinamide tab 100 mg
Pyridoxine tab 25 mg
Retinol (vitamin A) tab 50000 IU
Thiamine tab 100 mg
Thiamine tab 50 mg
Vitamin B complex tab
A12 Mineral supplements
Sodium bicarbonate inj 8.5%
Sodium chloride 0.9%
A14 Anabolic agents for systemic use
B BLOOD AND BLOOD-FORMING ORGANS
B01 Antithrombotic agents
B02 Antihaemorrhagics
Vitamin K1 inj 1 mg/0.5mL
B03 Antianaemic preparations
Ferrous sulphate oral 200 mg (65 mg elemental iron)
Ferrous sulphate syrup 300 mg/10 mL
Folic acid tab 5 mg
B04 Serum lipid reducing agents
B05 Plasma substitutes and perfusion solutions
Dextrose 10%
Dextrose 5%
Dextrose 5%/0.9% sodium chloride
Dextrose 50%
C CARDIOVASCULAR SYSTEM
C01 Cardiac therapy
Atropine inj 0.5 mg/mL
Glyceryl trinitrate tab sublingual 0.5 mg
C02 Antihypertensives
Dihydralazine inj 25 mg
Methyldopa tab 250 mg
Nifedipine cap 5 mg
Perindopril * tab 4 mg (sample of class)
Reserpine tab 0.1 mg
C03 Diuretics
Furosemide inj 20 mg/2mL
Hydrochlorothiazide tab 12.5 mg or 25 mg
C04 Peripheral vasodilators
C05 Vasoprotectives
Bismuth subgallate compound ointment
C07 Beta blocking agents
Atenolol tab 50 mg
D DERMATOLOGICALS
D01 Antifungals for dermatological use
Benzoic acid 6%/Salicylic acid 3% ointment (Whitfield)
Gentian violet 0.5% aqueous solution
Griseofulvin tab 125 mg
Griseofulvin tab 500 mg
Miconazole nitrate 2% cream
Nystatin ointment 100 000 IU/g
Nystatin susp 100 000 IU/mL
Selenium sulphide susp 2%
Tincture of iodine
D02 Emollients and protectants
Ung Emulsificans (UE)
Ung Emulsificans Aqueous (UEA)
Zinc oxide ointment 7.5g/50g
D03 Preparations for treatment of wounds and ulcers
D04 Antipruritics and topical anaesthetics
Calamine lotion BP
Ethyl chloride spray
Lidocaine gel 2%
Tetracaine cream 1%
D05 Antipsoriatics
D06 Antibiotics and chemotherapeutics for dermatological use
D07 Corticosteroids, dermatological preparations
Hydrocortisone cream 1%
D08 Antiseptics and disinfectants
Chlorhexidine solution 0.05% in water
Chlorhexidine solution 0.5% in 70% alcohol
Polyvidone iodine ointment 10%
Polyvidone iodine solution 10%
Polyvidone-iodine cream 5%
D10 Anti-acne preparations
Benzoyl peroxide topical gel 5 %
D11 Other dermatological preparations
G GENITOURINARY SYSTEM AND SEX HORMONES
G01 Gynaecological anti-infectives and antiseptics
Clotrimazole vaginal tablet 500 mg
G02 Other gynaecologicals
Oxytocin 10 IU inject
G03 Sex hormones and modulators of the genital system
Levonorgestrel 0.05/0.075/0.125 mg/ethinylestradiol 0.03/0.04/0.03 mg
(triphasic)
Levonorgestrel 0.05/0.125 mg/ethinylestradiol 0.05 mg (biphasic)
Levonorgestrel 0.15 mg/ethinylestradiol 0.03 mg
Levonorgestrel tab 0.03 mg
Medroxyprogesterone acetate inj 150 mg/mL
Norethisterone enanthate inj 200 mg/mL
Norgestrel 0.5 mg/ethinyl oestradiol 0.05 mg
Spermicidal jelly 0.1 g/5 g in 81g tube with applicator
G04 Urologicals
H SYSTEMIC HORMONAL PREPARATIONS, EXCLUDING SEX
HORMONES
H01 Pituitary and hypothalamic hormones
H02 Corticosteroids for systemic use
Hydrocortisone sodium succinate inj 100 mg
Prednisone tab 5 mg
H03 Thyroid therapy
H04 Pancreatic hormones
H05 Calcium homeostasis
J GENERAL ANTI-INFECTIVES FOR SYSTEMIC USE
J01 Antibacterials for systemic use
Amoxycillin cap 250 mg
Amoxycillin susp 125 mg/5mL
Benzathine benzylpenicillin inj 1.2 MU/vial
Benzathine benzylpenicillin inj 2.4 MU/vial
Benzylpenicillin vial 1 MU (=600 mg)
Benzylpenicillin vial 5 MU (=3 g)
Ceftriaxone vial 250 mg
Chloramphenicol vial 1g
Ciprofloxacin tab 500 mg
Doxycycline cap 50 mg
Doxycycline cap/tab 100 mg
Erythromycin estolate susp 125 mg/5mL
Erythromycin stearate tab/cap 250 mg
Flucloxacillin cap 250 mg
Flucloxacillin syrup 125 mg/5 mL
Phenoxymethylpenicillin susp 125 mg/5 mL
Phenoxymethylpenicillin tab 250 mg
Spectinomycin injec 2 g/vial eq to 400mg/mL base
Trimethoprim 80/sulfamethoxazole 400 mg tab
Trimethoprim/sulfamethoxazole susp 40/200 mg/5mL
J02 Antimycotics for systemic use
J04 Antimycobaterials
Ethambutol tab 400 mg
Isoniazid tab 100 mg
Rifampicin 120 mg/INH 60 mg/Pyrazinamide 300 mg/Ethambutol 200/225 mg
Rifampicin 150 mg/INH 100 mg
Rifampicin 60 mg/INH 30 mg/Pyrazinamide 150 mg
Rifampicin cap/tab 600 mg
Rifampicin syrup 100 mg/5mL
Streptomycin inj 1g/3 mL
J05 Antivirals for systemic use
J06 Immune sera and immunoglobulins
Anti-D-immunoglobulin inj 100mcg/2mL
Rabies immunoglobulin (RIG)
Snake bite antiserum
Tetanus immunoglobulin human 250 IU/2mL (TIG)
J07 Vaccines
BCG vaccine
DPT vaccine
DT vaccine
Haemophilus influenzae type b conjugated vaccine (Hib)
Hepatitis B vaccine
Measles vaccine
Oral polio vaccine (OPV)
Rabies vaccine
Tetanus vaccine 10Lf/0.5mL (tetanus adsorbed toxoid vaccine) TT
L ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS
L01 Cytostatic agents
L02 Endocrine therapy
L03 Immunomodulating agents
L04 Immunosuppressive agents
M MUSCULOSKELETAL SYSTEM
M01 Anti-inflammatory and antirheumatic products
Ibuprofen tab 200 mg
M02 Topical products for joint and muscular pain
Methylsalicylate ointment BPC
M03 Muscle relaxants
M04 Antigout preparations
Colchicine tab 0.5 mg
N CENTRAL NERVOUS SYSTEM
N01 Anaesthetics (including muscle relaxants used in anaesthesia)
Lidocaine inj 1%
Lidocaine inj 2%
N02 Analgesics
Aspirin soluble tab (scored) 300 mg
Codeine phosphate syrup 25 mg/5 mL
Codeine phosphate tab 30 mg
Morphine inj 10 mg/mL
Morphine oral solution
Morphine tab 10 mg
Paracetamol syrup 120 mg/5 mL
Paracetamol tab 500 mg
Pethidine inj 25 mg/mL
N03 Antiepileptics
Carbamazepine susp 100 mg/5 mL
Carbamazepine tab 200 mg
Ethosuximide cap 250 mg
Ethosuximide syrup 250 mg/5 mL
Phenobarbital elixer 16 mg/5 mL
Phenobarbital tab 30 mg
Phenytoin cap/tab 100 mg
Phenytoin cap/tab 50 mg
Phenytoin inj 250 mg/5 mL
Phenytoin paediatric susp 25 mg/5 mL
Phenytoin susp 125 mg/5 mL
Valproate sodium syrup 200mg/5 mL
Valproic acid cap 150 mg
N04 Antiparkinsonian agents
Orphenadrine tab 50 mg
N05 Psycholeptics (antipsychotics, anxiolytics and sedatives)
Chlorpromazine tab 100 mg
Chlorpromazine tab 25 mg
Diazepam inj 10 mg/2 mL
Fluphenazine decanoate inj 25 mg/mL
Haloperidol inj 5 mg/mL
Haloperidol tab 0.5 mg
Haloperidol tab 5 mg
Lorazepam inj 4 mg/mL
Zuclopenthixol acetate 50mg/mL inj
N06 Psychoanaleptics (antidepressants and psychostimulants)
Amitriptyline tab 10 mg
Amitriptyline tab 25 mg
Fluoxetine cap 20 mg
N07 Other nervous system drugs
P ANTIPARASITIC PRODUCTS
P01 Antiprotozoals
Metronidazole susp 200 mg/5mL
Metronidazole tab 200 mg
Quinine inj 300 mg/mL
Quinine sulphate tab 300 mg
Sulfadoxine/pyrimethamine tab 500/25 mg
P02 Anthelmintics
Mebendazole tab 100 mg
Niclosamide tab 500 mg
Praziquantel tab 600 mg
P03 Ectoparasiticides, including scabicides
Benzylbenzoate emulsion 25% (25g/100mL)
Monosulfiram soap 5%
Permethrin cream 5%
Permethrin cream rinse 1%
R RESPIRATORY SYSTEM
R01 Nasal preparations
Oxymetazoline nosedrops 0.025%
Oxymetazoline nosedrops 0.05%
R03 Antiasthmatic agents
Adrenaline inj 1 mg/mL
Aminophylline inj 250 mg/10mL
Beclometasone inhaler 100 mcg/actuation
Beclometasone inhaler 50 mcg/actuation
Ipratropium bromide metered dose inhaler 40mcg/actuation
Ipratropium bromide respirator solution 0.25mcg/mL
Salbutamol metered dose inhaler 100mcg/actuation
Salbutamol respirator solution 100 mg/20mL
Theophylline sustained release tab 200
Theophylline sustained release tab 300 mg
R05 Cough and cold preparations
R06 Antihistamines for systemic use
Chlorpheniramine syrup 2mg/5mL
Chlorpheniramine tab 4 mg
Promethazine inj 25 mg/mL
S SENSORY ORGANS
S01 Ophthalmologicals
Acetazolamide tab 250 mg
Atropine ophthalmic drops 1%
Chloramphenicol eye ointment 1%
Fluorescein drops 1%
Oxymethazoline eyedrops 0.025%
Pilocarpine drops 1%
Tetracaine eyedrops 5 mg/mL
Tetracycline eye ointment 1%
S02 Otologicals
Acetic acid 1% in sodium chloride 0.9%
Acetic acid 2% in alcohol
V VARIOUS
V08 Contrast media
V03 All other therapeutic products
Acetylcysteine 2g/10mL
Charcoal activated
Ipecacuanha syrup BP
Naloxone inj 0.04 mg/2 mL
Index of diseases and conditions 243
Index of diseases and conditions
Abdominal pain/dyspepsia/heartburn/indigestion ............................................................54
Abnormal vaginal bleeding during fertile years.................................................................75
Abortion ............................................................................................................................69
Abortion, incomplete/spontaneous ..................................................................................69
Acne vulgaris ..................................................................................................................150
Acute bronchospasm associated with asthma and chronic obstructive bronchitis.......133
Acute diarrhoea in children...............................................................................................61
Acute diarrhoea without blood in adults...........................................................................62
Acute, moist or weeping eczema...................................................................................155
Acute myocardial infarction (AMI) ..................................................................................177
Acute necrotising ulcerative gingivitis...............................................................................26
Acute pulmonary oedema ..............................................................................................178
Acute pyelonephritis .......................................................................................................127
Acute rheumatic fever ......................................................................................................15
Allergic rhinitis (hay fever).................................................................................................30
Amoebic dysentery ...........................................................................................................56
Anaemia..........................................................................................................................111
Anaemia in pregnancy......................................................................................................70
Anaemia, iron deficiency.................................................................................................112
Anal conditions .................................................................................................................56
Anal fissures .....................................................................................................................56
Anaphylactic shock.........................................................................................................179
Animal and human bites.................................................................................................180
Antepartum haemorrhage................................................................................................71
Appendicitis ......................................................................................................................57
Arthralgia.........................................................................................................................164
Asthma............................................................................................................................128
Asthma, chronic..............................................................................................................128
Athlete's foot - tinea pedis ..............................................................................................156
Bacillary dysentery (shigellosis) ........................................................................................58
Bacterial infections of the skin........................................................................................151
Bilharzia ............................................................................................................................90
Bites and stings ..............................................................................................................180
Boil, abscess...................................................................................................................151
Bronchitis, acute.............................................................................................................136
Burns ..............................................................................................................................186
Candidiasis, oral (thrush)..................................................................................................22
Candidiasis, skin.............................................................................................................157
Cardiac arrest - adults ....................................................................................................188
Cardiac arrest - cardio-pulmonary resuscitation ............................................................188
Cardiac arrest - children .................................................................................................190
Cardiovascular conditions ................................................................................................10
Cellulitis...........................................................................................................................153
244 Index of diseases and conditions
Central nervous system conditions ..................................................................................17
Chickenpox.......................................................................................................................91
Cholera .............................................................................................................................58
Chronic bronchitis and emphysema...............................................................................132
Chronic diarrhoea in adults ..............................................................................................63
Chronic pain control in advanced or incurable cancer ..................................................173
Common cold and influenza ..........................................................................................137
Conjunctivitis.....................................................................................................................46
Conjunctivitis, allergic .......................................................................................................46
Conjunctivitis, bacterial .....................................................................................................47
Conjunctivitis of the newborn (ophthalmia neonatorum) .................................................48
Conjunctivitis, viral and epidemic viral ..............................................................................47
Constipation......................................................................................................................59
Contraception, barrier methods........................................................................................52
Contraception, hormonal..................................................................................................53
Contraception, intrauterine contraceptive device (IUCD).................................................52
Contraception, vaginal ......................................................................................................52
Cough.............................................................................................................................165
Cracked nipples during breastfeeding .............................................................................71
Croup (laryngotracheobronchitis)...................................................................................138
Delirium with acute confusion and aggression ..............................................................193
Delivery, normal ................................................................................................................72
Dental abscess .................................................................................................................23
Dental and oral conditions................................................................................................22
Dental caries/toothache....................................................................................................24
Depression......................................................................................................................120
Diabetes mellitus...............................................................................................................38
Diabetes mellitus type 2....................................................................................................38
Diabetes mellitus type 1....................................................................................................38
Diarrhoea, acute...............................................................................................................61
Dysmenorrhoea................................................................................................................74
Ear, nose and throat.........................................................................................................30
Ectopic pregnancy............................................................................................................74
Eczema...........................................................................................................................154
Eczema, atopic...............................................................................................................154
Endocrine system.............................................................................................................38
Epilepsy.............................................................................................................................17
Exposure to poisonous substances...............................................................................197
Eye, chemical burn.........................................................................................................195
Eye conditions ..................................................................................................................46
Eye injury, foreign body..................................................................................................196
Failure to thrive (FTT) .....................................................................................................116
Family planning.................................................................................................................52
Febrile convulsions.........................................................................................................166
Fever...............................................................................................................................167
Fungal infections of the skin...........................................................................................156
Gastro-intestinal conditions ..............................................................................................54
Genital scabies ...............................................................................................................106
Genital warts...................................................................................................................106
Giardiasis ..........................................................................................................................63
Gingivitis............................................................................................................................25
Gingivitis, uncomplicated..................................................................................................25
Glaucoma, acute ..............................................................................................................49
Gonorrhoea neonatorum................................................................................................107
Gout ................................................................................................................................108
Gout, acute.....................................................................................................................108
Gout, chronic..................................................................................................................109
Gynaecology and obstetrics.............................................................................................69
Haemorrhoids...................................................................................................................57
Headache, mild, non-specific .........................................................................................169
Helminthic infestation - excluding tapeworm....................................................................64
Helminthic infestation (tapeworm) ....................................................................................65
Herpes stomatitis/cold sore/fever blister...........................................................................27
HIV....................................................................................................................................92
Hypertension.....................................................................................................................10
Hypoglycaemia and hypoglycaemic coma.....................................................................204
Immunisation ....................................................................................................................80
Immunisation: additional vaccines and target groups......................................................85
Immunisation by injection.................................................................................................85
Immunisation: dosage and administration........................................................................80
Immunisation schedule.....................................................................................................84
Impetigo..........................................................................................................................152
Infection control: the use of antiseptics and disinfectants................................................94
Infections (selected) and related conditions.....................................................................89
Injectable contraceptives..................................................................................................53
Injuries ............................................................................................................................199
Insect bites and stings ...................................................................................................183
Insomnia .........................................................................................................................170
Itching (pruritus)..............................................................................................................171
Jaundice .........................................................................................................................175
Lice (pediculosis) ............................................................................................................159
Malaria ..............................................................................................................................95
Measles.............................................................................................................................98
Megaloblastic/Macrocytic anaemia.................................................................................113
Meningitis..........................................................................................................................20
Meningitis, acute...............................................................................................................20
Meningitis meningococcal, prophylaxis............................................................................21
Molluscum contagiosum.................................................................................................106
Mouth ulcers.....................................................................................................................28
Mumps............................................................................................................................100
Musculoskeletal conditions.............................................................................................108
Napkin rash, non-fungal .................................................................................................161
246 Index of diseases and conditions
Napkin rash (candida) ....................................................................................................158
Nausea and vomiting, non-specific ..................................................................................66
Nose bleed (epistaxis) ....................................................................................................195
Nutritional and blood conditions.....................................................................................111
Oral contraceptives...........................................................................................................53
Osteoarthritis...................................................................................................................110
Otitis externa.....................................................................................................................32
Otitis media, acute............................................................................................................34
Otitis media, chronic suppurative .....................................................................................35
Pain control.....................................................................................................................172
Parasitic infections of the skin ........................................................................................159
Pellagra (nicotinamide deficiency)..................................................................................115
Periodontitis ......................................................................................................................28
Pharyngitis, viral ................................................................................................................31
Pneumonia .....................................................................................................................140
Post-coital contraception..................................................................................................53
Post-menopausal bleeding...............................................................................................75
Pregnancy-induced hypertension (PIH) ...........................................................................75
Protein energy malnutrition (PEM) .................................................................................117
Psychiatric illness............................................................................................................120
Psychosis, acute.............................................................................................................122
Pubic lice.........................................................................................................................106
Pyridoxine (Vitamin B6) deficiency..................................................................................114
Renal and urinary tract conditions..................................................................................126
Respiratory conditions....................................................................................................128
Rheumatoid arthritis........................................................................................................110
Ringworm.......................................................................................................................158
Rubella (German measles).............................................................................................100
Sandworm......................................................................................................................162
Scabies ...........................................................................................................................160
Seborrhoeic eczema ......................................................................................................155
Septic arthritis .................................................................................................................110
Sexually transmitted diseases (STD)..............................................................................101
Shock..............................................................................................................................201
Signs and symptoms......................................................................................................164
Sinusitis, acute..................................................................................................................36
Skin conditions ...............................................................................................................150
Snakebite........................................................................................................................184
Sprains and strains.........................................................................................................202
Status epilepticus............................................................................................................203
STD Protocol 1: Urethral discharge/burning micturition in men....................................102
STD Protocol 3: Genital ulceration in men and women.................................................102
STD Protocol 5: Inguinal swelling/bubo - no ulcer present in men and women ...........103
STD Protocol 6: Balanitis/balanoposthitis in men..........................................................103
STD Protocol 7: Painful scrotal swelling in men ............................................................104
STD Protocol 8: Interpretation of syphilis serology - RPR/VDRL..................................104
The cold chain..................................................................................................................86
Thiamine deficiency (Wernickes encephalopathy and beriberi) ...................................116
Tick-bite fever .................................................................................................................107
Tonsillitis............................................................................................................................31
Tonsillitis, bacterial ............................................................................................................31
Trachoma .........................................................................................................................50
Trauma and emergencies ..............................................................................................176
Tuberculosis ...................................................................................................................142
Typhoid fever ....................................................................................................................68
Urinary tract infection, uncomplicated (acute uncomplicated cystitis) ...........................126
Urticaria...........................................................................................................................162
Vaginal bleeding ...............................................................................................................75
Vaginal discharge/lower abdominal pain in women (STD Protocols 2 and 4) ................77
Valvular heart disease.......................................................................................................15
Vitamin A deficiency .......................................................................................................113
Vitamin B deficiencies.....................................................................................................118
Vitamin deficiencies ........................................................................................................113
248 Index of drugs
Index of drugs
acetazolamide...................................................................................................................49
2% acetic acid in alcohol ..................................................................................................34
1% acetic acid in 0.9% sodium chloride...........................................................................36
acetylcysteine..................................................................................................................199
activated charcoal ...........................................................................................................199
adrenaline ..............................................................................................139, 180, 189, 193
aluminium hydroxide/magnesium trisilicate......................................................................55
aminophyllin....................................................................................................................135
amitriptyline............................................................................................................ 121, 122
amoxycillin........................................23, 26, 35, 36, 58, 99, 126, 136, 140, 142, 152, 182
anti-D immunoglobulin............................................................................................... 70, 73
aqueous cream...............................................................................................................154
aspirin, soluble................................................................................................................177
atenolol .............................................................................................................................13
1% atropine............................................................................................................ 196, 197
atropine.......................................................................................................... 189, 193, 199
BCG..................................................................................................................... 81, 85, 86
beclomethasone.................................................................................................... 131, 135
benzathine penicillin.................................................................. 15, 32, 102, 103, 105, 153
6% benzoic acid and 3% salicylic acid.................................................................. 157, 158
5% benzoyl peroxide ......................................................................................................151
25% benzyl benzoate.................................................................................... 106, 160, 161
benzylpenicillin...........................................................................................20, 21, 140, 142
bismuth subgallate compound.........................................................................................57
calamine lotion.........................................................................................91, 163, 171, 183
carbamazepine.................................................................................................................19
ceftriaxone ........................................................................................................................20
1% chloramphenicol ................................................................... 47, 49, 73, 184, 196, 197
chloramphenicol .................................................................................................. 20, 21, 99
0.05% chlorhexidine................................................................................95, 181, 184, 187
0.2% chlorhexidine digluconate ........................................................................... 25, 27-29
chloroquine.......................................................................................................................98
chlorpheniramine........................................................30, 47, 91, 156, 163, 171, 183, 184
chlorpromazine...............................................................................................................123
ciprofloxacin...............................................................................................78, 79, 102, 104
clotrimazole.......................................................................................................................78
codeine phosphate.........................................................................................................174
colchicine........................................................................................................................109
5% dextrose............................................................................................................. 97, 134
5% dextrose in 0.9% sodium chloride................................................................. 58, 59, 63
5% dextrose in water ........................................................................................................73
10% dextrose......................................................................................................... 193, 206
50% dextrose..................................................................................................................206
Index of drugs 249
diazepam........................................................................................ 21, 167, 195, 199, 204
dihydralazine.....................................................................................................................77
doxycycline...................................................................50, 59, 78, 102-105, 107, 136, 151
DPT....................................................................................................................... 81, 85-87
DT......................................................................................................................... 81, 85-87
elemental iron ........................................................................................................ 112, 117
emulsifying ointment ................................................................................................ 72, 155
erythromycin .................................................................................................. 102, 103, 105
erythromycin estolate......................... 16, 24, 26, 32, 34, 50, 99, 136, 142, 152, 156, 182
erythromycin stearate . 16, 24, 26, 32, 34, 50, 78, 99, 136, 140, 142, 152, 153, 156, 182
ethambutol ............................................................................................................. 144, 148
ethosuzimide.....................................................................................................................18
ethyl chloride...................................................................................................................162
ferrous sulphate........................................................................................... 70, 71, 75, 112
flucloxacillin..............................................................................................34, 151, 153, 156
1% fluorescein....................................................................................................... 196, 197
fluoxetine.........................................................................................................................122
fluphenazine decanoate .................................................................................................124
folic acid..................................................................................................................... 70, 71
furosemide......................................................................................................................178
0.5% gentian violet .................................................................................................... 22, 95
glibenclamide.............................................................................................................. 41-43
glyceryl trinitrate ..................................................................................................... 177, 178
griseofulvin......................................................................................................................159
half-strength Darrows solution with 5% dextrose........................................ 58, 59, 77, 180
haloperidol ..................................................................................................... 123, 124, 195
HepB.................................................................................................................... 82, 85, 86
Hib........................................................................................................................ 82, 85, 86
human tetanus immunoglobulin............................................................182, 185, 187, 201
hydrochlorothiazide .................................................................................................. 12 - 14
1% hydrocortisone................................................................................................. 154, 155
hydrocortisone sodium succinate.................................................................. 134, 139, 180
hypochlorite ......................................................................................................................94
ibuprofen................................................................................... 74, 75, 108, 172, 174, 203
insulin................................................................................................................................42
biphasic insulin.................................................................................................43
medium-acting insulin ......................................................................................43
ipratropium bromide............................................................................................... 131, 134
isoniazid..........................................................................................................................145
levonorgestrel (as progestogen) 0.15 mg and ethinyl oestradiol (as oestrogen) 0.03 mg53
levonorgestrel (as progestogen) and ethinyl oestradiol (as oestrogen)...........................53
levonorgestrel 0.03 mg.....................................................................................................53
1% lidocaine .....................................................................................................................73
2% lidocaine .................................................................................................... 27, 183, 189
liquid paraffin.....................................................................................................................57
lorazepam.............................................................................................................. 124, 195
250 Index of drugs
magnesium sulphate ................................................................................................. 73, 77
measles vaccine ........................................................................................................ 83, 86
mebendazole....................................................................................................................64
medroxyprogesterone acetate................................................................................. 53, 144
Index of drugs 251
metformin.................................................................................................................... 40-42
methyldopa ................................................................................................................ 13, 76
methylsalicylate...............................................................................................................165
metoclopramide..............................................................................................................175
metronidazole ....................................................................................24, 26, 56, 63, 78, 79
2% miconazole ........................................................................................23, 155, 157, 158
monosulfiram......................................................................................................... 160, 161
morphine................................................................................................172, 174, 177, 178
naloxone .........................................................................................................................199
niclosamide.......................................................................................................................66
nicotinamide....................................................................................................................115
nifedipine.................................................................................................................. 14, 179
norethisterone enanthate ........................................................................................ 53, 144
norgestrel (as progestogen) 0.5 mg and ethinyl oestradiol (as oestrogen) 0.05 mg ......53
nystatin.....................................................................................................23, 103, 157, 158
OPV..................................................................................................................... 82, 85, 86
oral rehydration solution .................................................................... 58, 59, 61-63, 67, 68
orphenadrine ..................................................................................................................124
0.025% oxymetazoline .............................................................................................. 47, 48
oxymetazoline...................................................................................................................37
oxytocin.............................................................................................................................70
paracetamol ....................................24, 25, 27, 28, 32, 35, 37, 91, 99-101, 107, 137,139,
140, 142, 165, 167, 168,170, 172, 174, 183, 187, 199, 201, 203
perindopril .................................................................................................................. 13, 14
1% permethrin ....................................................................................................... 106, 160
5% permethrin ................................................................................................................161
pethidine .................................................................................................................. 73, 173
phenobarbital ....................................................................................................................18
phenoxymethylpenicillin............................................................................................. 16, 32
phenytoin ........................................................................................................... 18, 19, 204
1% pilocarpine..................................................................................................................49
polyvalent antiserum (snake)..........................................................................................185
5% polyvidone iodine............................................................................................... 95, 187
10% polyvidone iodine....................................................................................... 93, 95, 181
polyvidone iodine............................................................................................................152
praziquantel ......................................................................................................................90
prednisone............................................................................................. 131, 133-135, 139
proguanil ...........................................................................................................................98
promethazine..................................................................................................................180
pyridoxine............................................................................................................... 115, 144
quinine ..............................................................................................................................97
quinine sulphate................................................................................................................96
rabies immunoglobulin....................................................................................................181
rabies vaccine.................................................................................................................182
reserpine.................................................................................................................... 12, 13
retinol (vitamin A) ........................................................................................... 114, 117, 118
252 Index of drugs
RH...................................................................................................................144, 146-149
RHZ ....................................................................................................................... 148, 149
RHZE...................................................................................................................... 146-148
rifampicin.......................................................................................................... 21, 144, 145
Ringer-Lactate................................................................................ 61, 179, 187, 189, 192
salbutamol...................................................................................................... 131, 134, 135
selenium sulphide...........................................................................................................155
sennosides A and B ................................................................................................ 60, 175
0.9% sodium chloride....... 37, 44, 77, 134, 137, 179, 180, 186, 187, 189, 193, 196, 197
sodium sulphate ...................................................................................................... 66, 199
sorbitol ............................................................................................................................175
spectinomycin...................................................................................................................78
spermicidal jelly.................................................................................................................52
streptomycin .................................................................................................. 144, 147, 148
sulfadoxine-pyrimethamine........................................................................................ 96, 97
syrup of ipecacuanha .....................................................................................................199
0.5% tetracaine...................................................................................................... 184, 197
1% tetracaine....................................................................................................................57
tetracycline........................................................................................................................50
theophylline.................................................................................................... 132, 133, 135
thiamine ..........................................................................................................................116
tincture of iodine .............................................................................................................106
tolbutamide ............................................................................................................... 41 - 43
trimethoprim/sulfamethoxazole.................................................................... 35, 36, 59, 126
TT.........................................................................................83, 85-87, 182, 185, 187, 201
valproic acid............................................................................................................... 18, 19
vitamin B complex...........................................................................................................119
vitamin K ...........................................................................................................................73
zinc oxide............................................................................................................... 152, 162
zuclopenthixol acetate....................................................................................................124
MAJOR POISON INFORMATION CENTRES
Gauteng : 0800 111 990 or
(011) 495-5112
Free State : (051) 447-5353 or
(051) 405-3033
KwaZulu-Natal: 0800 333 444
Western Cape:
Red Cross: (021) 689-5227
Tygerberg: (021) 931-6129

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