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BMC Medical Protocol – 2010
Malaria
The treatment of malaria is now with 2 drugs at all times. Malaria in adults can be treated with Artesunate and
Amodiaquine, Malarone, Mefloquine, and Quinine in various combinations. The quinine should be combined
with either fansidar, clindamycin, or doxycycline. Artesunate (50 mg)/amodiaquine (150 mg base) is the
combination for Nalerigu (Artesunate 4 mg/kg/day and Amodiaquine 10 mg/kg/day) given for 3 days.
Inpatient: Quinine. Adults and children IV 10 mg/kg Q8, change to PO as soon as possible. IM regimens are the
same. IM dosing requires dilution of quinine 1:3 in sterile saline and given in the anterior thigh in children. The
PO doses are given 10 mg/kg TID to complete 7 days total of quinine. If the patient is not responding after 2
days, the dose of IV quinine should be reduced by 1/3 to ½ to prevent toxic accumulations.
Treatment with quinine should be combined with doxycycline 3 mg/kg daily, clindamycin 10 mg/kg BID or
fansider (4-10 kg, ½ tab; 10-14 kg, 1 tab; 14-19 kg, 1 ½ tab; >20 kg, 3 tab). Oral dosing of quinine (50 mg/5 mL)
is as follows:
Artemether. If patients have not improved after the first 2 doses of quinine, a resistant strain may be the problem.
Quinine should be switched to Artemether 3.2 mg/kg IM x 1 dose, then 1.6 mg/kg IM daily x 4 days for a 5 day
total. If the patient is taking PO before the 5 days is completed, one can switch to A/A or A/L (Lonart) to
complete the treatment course.
Be vigilant to treat hypoglycemia, anemia, septicemia, pneumonia, seizures, and dehydration. Fluid overload,
pulmonary edema, and renal failure are uncommon in childhood malaria in hyperendemic areas.
Outpatient:
Artesunate/Amodiaquine (50/150 tab)
Note: The does in mg/kg body weight is Artesunate 4 mg/kg + Amodiaquine 10 mg/kg daily x 3 days. The dose can be divided and given twice daily to decrease GI upset (i.e. 3 month old weighing 8 kg could get ½ tab daily or ¼ tab BID).
Artemether/Lumefantrine (Lonart) (40/240 tab; 20/120 ped tab exists). Dosing is BID for 3 daysWeight (kg) Malarone (arovaquone/proguanil). Adults and children: 6-8 mg/kg/day for 3 days. In adults, this is equivalent to 4 tab daily x 3 days. This may also be used with artesunate 4 mg/kg/day for 3 days.
Mefloquine. 15 mg/kg (base) as an initial dose followed by 10 mg/kg 8-24 hours later. This should be given along with artesunate 4 mg/kg/day.
BMC Medical Protocol – 2010
Pregnancy. First line in the 1st trimester is quinine 10 mg/kg TID x 7 days. During the 2nd and 3rd trimesters,
artesunate is the drug of choice. Both quinine and artesunate should be combined with clindamycin 20 mg/kg/day
divided BID. Fansider may be given prophylactically 2-3 times during pregnancy, which Public Health does if
the patient has gotten prenatal care there.
Typhoid Fever
Ciprofloxacin 500 mg PO or IV BID x 14 days in adults
Rocephin: Adult: 1-2 g daily x 1 week
Azithromycin: Adult: 1 g PO daily x 5 days Children: 20 mg/kg (up to 1 g) daily x 5 days
In severe cases with depressed LOC or shock, dexamethasone 3 mg/kg IV loading dose followed by 1 mg/kg Q6H
x 8 doses of steroids
Chloramphenicol 2-3 g divided QID or 75-100 mg/kg divided Q6 x 10-14 days
Amoxicillin 100 mg/kg/day divided TID x 2 weeks
Septra 8-10 mg/kg/day TMP divided QID
Be vigilant to treat children for this with persistent fever and no evidence of malaria. Be cognizant of these
patients developing acute abdomens from ileal perforation.
Pneumonia
Outpatient: No recent antibiotic therapy (>3 months):
Amoxicillin
Adults: 1000 mg TID x 7 days Children: 6-12 yrs: 500 mg TID x 7 days
Recent antibiotic therapy (<3 months): Amoxicillin/Clavulanic acid Adults: 500/125 mg (625 mg) TID x 7 days Children: 6-12 yrs: 400/57 mg (10 mL) TID x 7 days 1-5 yrs: 200/28.5 mg (5 mL) TID x 7 days <1 yr: 100/14 mg (2.5 mL) TID x 7 days If penicillin allergy or atypical organism suspected:AzithromycinAdults: 500 mg PO day 1, 250 mg PO QD x 4 days after Children: 10 mg/kg day 1, then 5 mg/kg daily x 4 days Erythromycin Adults: 500 mg Q6H x 7 day Inpatient:
Ceftriaxone
Adults: 2 g IV daily x 7 days
Ampicillin
Adults: 500 mg IV Q6 or other regimen depending on situation (aspiration)
If aspiration is suspected, add Metronidazole 500 mg IV Q8
Children: 200 mg/kg/day IV/IM divided Q6-8 or benzylpenicillin 200K units/kg/day divided QID for at least 3
days
Very severe: ampicillin 200 mg/kg/day IV/IM divided Q6-8 + gentamicin 2-2.5 mg/kg IV Q8 x 1 week
Oral therapies:
Cefuroxime:
>12 yrs: 500 mg Q12H x 7 days
2-12 yrs: 15 mg/kg (max 250 mg) Q12H x 7 days
3 months-2 yrs: 10 mg/kg (max 125 mg) Q12H x 7 days
Amoxicillin/Clavulanic acid: double outpatient doses
NOTE: while effective, the WHO recommends AGAINST use of fluoroquinolones (i.e. ciprofloxacin) for
pneumonia due to role in treating MDR tuberculosis
Serious Neonatal Bacterial Infection
This includes meningitis, pneumonia, septicemia.
Ampicillin 100 mg/kg/day divided BID in the first week of life and then divided TID between weeks 2 and 4 of
life
+ Gentamicin 5 mg/kg/day given once daily (premie 3 mg/kg/day) in the first week of life; between weeks 2 and 4
of life, 7.5 mg/kg daily
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BMC Medical Protocol – 2010
Meningococcal meningitis and others
Penicillin 300K units/kg/day IV or IM divided Q6 x 7 days (adults 3 mu Q4)
Chloramphenicol 75-100 mg/kg/day PO/IV divided Q6 (adults 1 g Q6). There is no evidence that the
combination of penicillin and chloramphenicol works better than either drug alone.
Rocephin: adult 1-2 g IV daily, children 80-100 mg/kg/day IV/IM x 1 week
Dexamethasone 0.15 mg/kg Q6 x 4 doses in children, 12 mg Q 12 x 4 doses in adults
Single dose regimens of rocephin and chloramphenicol in oil are effective in epidemic situations
Upper respiratory tract infections
Pharyngitis/Tonsillitis (streptococcal)
Amoxicillin
Adults: 500 mg Q6H x 10 days Children: 6-12 yrs: 250 mg Q6H x 10 days
Erythromycin (if penicillin allergy) Adults: 500 mg Q6H x 10 days Acute Epiglottitis (H. influenza) Chloramphenicol: 25 mg/kg Q6H IV x 7 days (change to PO when appropriate at following doses <1 yr: 6.25 mg/kg Q6H >1 yr: 12.5-25 mg/kg Q6H Ceftriaxone: 50 mg/kg IV daily, change to PO cefuroxime at 125 mg Q12H x 10 days Ampicillin: 200 mg/kg/day x 10 days Acute Otitis Media/Sinusitis Amoxicillin Adults: 500-1000 mg Q6-8H x 10 days Children: 6-12 yrs (<40 kg): 250 mg TID x 10 days 1-5 yrs (<20 kg): 125 mg TID x 10 days Note: despite above dosing in children <40kg, amoxicillin 80-90 mg/kg/day is preferred over standard dosing due to concentration-dependent resistance of S. pneumonia Amoxicillin/Clavulanic acid Adults: 500/125 mg (625 mg) BID x 10 days Children: 6-12 yrs: 400/57 mg (10 mL) BID x 10 days 1-5 yrs: 200/28.5 mg (5 mL) BID x 10 days <1 yr: 100/14 mg (2.5 mL) BID x 10 days Penicllin Allergy: Co-trimoxazole (septra) Adults: 800/160 mg (2 SS tab) BID x 7 days Children: 6-12 yrs: 400/80 mg (1 SS tab) BID x 7 days 6 months-5 yrs: 200/40 mg (5mL) BID x 7 days 6 wks-5 months: 100/20 mg (2.5 mL) BID x 7 days Erythromycin Adults: 250 mg Q6H x 10 days If severe pain or pus still present after 5 days of therapy: Cefuroxime Adults: 500 mg BID x 10 days Azithromycin Adults: 500 mg daily x 3 days Urinary Tract Infection
Uncomplicated: Co-trimoxazole
Adults: 960 mg BID
Children: 6-12 yrs: 360-720 mg (7.5-15 mL) BID x 3-5 days 1-5 yrs: 180-360 mg (3.75-7.5 mL) BID x 3-5 days Uncomplicated: Ciprofloxacin Adults: 250 mg BID x 3-5 days Complicated: Ampicillin 1-2 g IV QID PLUS Gentamicin 2.5 mg/kg IV BID x 7-10 days OR Ciprofloxacin 500 mg BID x 7-10 daysPyelonephritis: Ceftriaxone 1-2 g IV daily x 14 days BMC Medical Protocol – 2010
Ciprofloxacin 500 mg IV BID x 14 days
Ampicillin 1-2 g IV QID PLUS Gentamicin 2.5 mg/kg IV BID x 14 days
Change to PO drug when appropriate
Pneumococcal
Penicillin 400K units/kg/day Q6 x 10 days
Intestinal Parasites
Hookworm Albendazole 400 mg x 1 or 200 mg daily x 3 days
Mebendazole 500 mg x 1
Cutaneous Larva Migrans Albendazole 400 mg daily x 7 days
Ascaris Albendazole 400 mg x 1
Tricuris Albendazole 400 mg x 1
Mebendazole 500 mg x 1
Pinworms Albendazole 400 mg x 1
Esophagostomum Albendazole 400 mg daily x 5 days
Strongyloides Albendazole 400 mg daily x 3 days
H. nana Praziquantel 25 mg/kg x 1 dose
Giardiasis Metronidazole 500 mg PO TID x 5 days (children 5 mg/kg TID x 5 days)
Entamoeba histolytica Metronidazole 750 mg TID x 10 days (children 7.5 mg/kg TID x 10 days)
T. Saginata Praziquantel 10 mg/kg x 1
T. Solium Praziquantel 10 mg/kg x 1
Cysticercosis treatment with albendazole is controversial due to cerebral reaction to dying parasites
Onchocerciasis Ivermectin 150 mcg/kg x 1
Bancroftian filariasis Ivermectin 150 mcg/kg x 1
Tetanus
Management: prevent toxin release, neutralize unbound toxin, and minimize the effect of already bound toxin
Prompt debridement
Metronidazole 500 mg QID, penicillin (3 g Q4) is an option but high doses may exacerbate the effects of tetanus
Antitoxin TIG 500 units IM or 200 units intrathecally, also equine anti-tetanus serum
Complete tetanus immunization
Potent analgesia, IV/IM pethidine, magnesium sulfate is an option
Spasms-valium
Keep in a quiet, dark room
Rabies
Uniformly fatal here. Differential diagnosis includes tetanus, drug intoxications, hysteria, Guillian-Barre
syndrome, viral encephalitis
Suspected rabies. Kill animal and send brain for evaluation to Pong Tamale OR observe animal for 10 days
Post-bite treatment. Immediate cleansing with a virucidal agent and debridement under anesthesia if necessary.
Avoid suturing wound.
Active immunization for Rabies. Tissue culture vaccine-0.1 mL intradermal at 2 sites (both deltoids) on days 0, 3,
7, and on day 28 give 0.2 mL at one site (deltoid). A vial of vaccine can remain open in the refrigerator for 8
days, so try to immunize others at the same time. No RIG available.
Stop vaccination if the animal survives 10 days.
Post-exposure prophylaxis in previously vaccinated individuals. 0.1 mL intradermal on days 0 and 3, RIG not
necessary.
Passive immunization. Rabies Immune Globulin (RIG) 40 IU/kg of equine RIG or 20 IU/kg of human RIG.
Inject into wound site and at a remote site (not on buttocks). Not available in Nalerigu.
Osteomyelitis
This disease is almost always seen in the advanced stages when the affected bone is already dead (the sequestrum)
and the new bone (the involucrum) is being formed around it. Antibiotics do nothing for this. Surgery is needed
when the involucrum is adequate to replace the affected bone (i.e. adequate for weight bearing on the lower
limb). Order an x-ray of the affected limb with 2 views to assess the adequacy of the involucrum. If this is
BMC Medical Protocol – 2010
adequate, a sequestrectomy is scheduled. If the involucrum is not adequate, the patient should return in 3 months
for follow-up x-ray.
Diarrhea in children
The child should be assessed for the degree of dehydration and rehydrated appropriately with either IV solution or
ORS. Antibiotics should not be used routinely. They are only helpful for bloody diarrhea (shigellosis), suspected
cholera, and other serious non-intestinal infections such as pneumonia. Anti-diarrheal drugs are useless and
dangerous.
Acute Severe dehydration
Infants < 12 months – NS or RL, 6 hours total = 100mL/kg (30 ml/kg in the first one hour and then 70ml/kg
over the next 5 hours)
12 months to 5 years – NS or RL, 3 hours total = 100ml/kg (30 ml/kg in the first 30 minutes and then 70ml/kg
over the next 2-1/2 hours)
If unable to place an IV, place an NG tube with ORS solution given at 20mL/kg/hour for 6 hours
If the child is still dehydrated after the above, repeat the IV infusion. If the child is improving the IV can be
stopped and ORS given for 4 hours (see below)
Mild to moderate dehydration
Give ORS during the first 4 hours according to the following regimen
< 6kg 200-400 ml
6-9kg 400-700 ml
10-11kg 700-900ml
12-19 kg 900-1400ml or (kg x 75)
This can be given via NGT or the mother can give a teaspoon every 1-2 minutes or frequent sips from a cup.
No dehydration
Breastfeed frequently
ORS – Give mother 2 packets (0-2 years 50 -100mL, >2 years 100- 200 ml, after each loose stool as sips from a
cup)
If the child is not exclusively breast-fed, give ORS and food based fluid (soup, rice water, yogurt drinks) or plain
water
Continue feeding
Micronutrients – folate, zinc, vitamin A, iron copper, magnesium
P
ersistent diarrhea (14 days or longer )
Consider recurrent viral infections, non-intestinal infections (pneumonia, sepsis, UTI, oral thrust and otitis media)
If the child has bloody diarrhea treat for Shigella (ciprofloxacin 10-15 mg/kg BID for 5 days. Septra and
ampicillin are no longer effective.
Amebiasis is treated with metronidazole 7.5mg/kg/dose TID for 5 days.
Giardia is treated with metronidazole 5mg/kg TID for 5 days.
Also consider intussusception
Feeding is critical. If a glucose test strip is positive in the stool, give a diet low in lactose such as whole eggs, rice,
vegetable oil, glucose and finely ground chicken. Encourage breast-feeding. Encourage micronutrients as above.
Traveller’s Diarrhea
Caused by enterotoxigenic and enteroaggresive Escherichia coli. Only 5% caused by Salmonella, Shigella,
Campylobacer, Giardia or Amebiasis. It is only necessary to treat when the patient has more than 3 bowel
movements in addition to symptoms (fever, bloody diarrhea)
Treatment options are Ciprofloxacin 500mg b.i.d for 1-3 days , Zithromax 1 G x 1-3 days, or Rifimaxin 200mg
t.i.d. x 3 days. Imodium may be used for symptomatic relief if there is no blood or fever.
Cholera
WHO definition – acute watery diarrhea in a patient 5 years or older with or without vomiting in an area where
cholera is likely to occur. Laboratory diagnosis in our situation is impossible. Treatment is primarily fluid
management. Antimicrobials are secondary. Tetracycline and Doxycycline are the drugs of choice. Septra is also a
choice
Anthrax
BMC Medical Protocol – 2010
The hospital is in an area endemic for Anthrax, especially the village of Nagbo and the surrounding villages. The
presentation is usually a cutaneous (ulcer with eschar and malignant edema) and occasionally systemically
presenting with superior vena caval syndrome and severe respiratory distress which is uniformly fatal. One case
of anthrax meningitis has been documented.
Unlike cases that are related to bioterrorism, the treatment for cutaneous anthrax is Pen VK 250 mg q.i.d x 7 days.
Most cases will actually resolve spontaneously over 2-6 weeks. Alternatively, ciprofloxacin 500mg PO t.i.d for 7-
10 days can be used. Severe systemic infections may be treated with 4-6,000,000 units of penicillin q.6.h for 10
days. Systemic steroids can also be used
Seizures
Diazepam
Newborn-5 yrs: 0.1-0.3 mg/kg IV Q10-15 minutes with a maximum dose of 5 mg daily (may be given rectally if
no IV access)
5-12 yrs: 0.1-0.3 mg/kg IV Q10-15 minutes with a maximum dose of 10 mg daily
>12 yrs: 5-10 mg IV Q10-15 minutes
Phenobarbital
Acute treatment: 10-20 mg/kg as initial dose, then 5-10 mg/kg IV Q 15-30 minutes with a maximum dose of 40
mg/kg
Post-seizure
<2 months: 3-5 mg/kg PO/IV daily
>2 months: 5-8 mg/kg/day
WARNING: THE COMBINATION OF DIAZEPAM AND PHENOBARBITAL MAY CAUSE SIGNIFICANT CNS
AND RESPIRATORY DEPRESSION. PROPHYLACTIC PHENOBARBITAL IS NOT RECOMMENDED IN
CEREBRAL MALARIA.
Snake Bite
The most common poisonous snake is the carpet viper (Echis carinatus). Its venom acts as an anticoagulant. The
other common poisonous snake is the spitting cobra. Cobras are generally provoked into attack, whereas carpet
vipers are more aggressive by nature. The effect of the bite is assessed by the whole blood clotting time
(WBCT). Assume that bites are never dry bites. If the WBCT is reported as “no clot”, order ASV (anti-snake
venom) x 1 amp. Clotting times are ordered twice daily (4 AM and 4 PM generally, and on admission). Adequate
coagulation is assumed when there are 3 consecutive WBCT of < 5 minutes, and the patient may be discharged
home.
The bite of the spitting cobra (Naja Nigricollis) causes primarily significant skin necrosis that extends to the
fascia. The cobra also spits poison into the eye, creating a snake venom ophthalmia, characterized by corneal
abrasions. Treatment is with ASV and, in case of ophthalmia, sterile eye irrigation and /or antibiotic eye drops x 1
week to prevent secondary infection.
Scorpion Bite
The scorpion bites in this area produce primarily a local effect of severe pain. Rarely is there systemic
envenomation. Treatment is with local injection of lidocaine or marcaine. Potent narcotic analgesics are often
necessary. There is pethidine (meperidine) 50-100 mg Q4-6 hour PRN or in children 1-1.75 mg/kg PO/SC/IM
Q3-4 hour PRN. If given IV, dilute prior to use and administer slowly.
Incarcerated Hernia
Usually involves inguinal hernias in men. Often these patients may be watched for 1-2 hours before surgery
should be alerted. Put the patient in trendelenburg and administer pethidine or ketamine (1 mg/kg IV) to allow
muscles to relax and see if the hernia can be reduced or if it will reduce on its own. If the hernia hasn’t reduced
and the pain persists, urgent surgical consultation is needed.
Asthma
Treatment modalities are limited. Nebulization with albuterol is available. For severe cases, aminophylline 250
mg IV Q6 may be given. In less severe cases, Aminohylline 200 mg PO QID is available. This is the only
maintenance regimen at this time. In young children the dose is 50 mg IV/PO QID; older children, 100 mg IV/PO
QID. For exacerbations, prednisone 1 mg/kg/day PO x 5 days is available. Dexamethasone IV is available but
has never been shown more effective than oral steroids.
Pregnancy-Induced Hypertension
BMC Medical Protocol – 2010
Preeclampsia. Blood pressure > 140/90 in a previously non-hypertensive patient with the onset of proteinuria
(1+) after 20 weeks gestation. Management can be expectant until 37 weeks at which time induction should be
pursued. There is no evidence that anti-hypertensive therapy prevents progression of mild preeclampsia or
improves maternal/fetal outcomes and may complicate the diagnosis of severe preeclampsia.
The patient should have intrapartum seizure prophylaxis with magnesium sulfate as follows:
MgSO4 IM 5 g (or 1 10 mL vial) in each buttocks, followed by 5 g IM Q4 hours (keep in mind that if the patient
needs caesarian section she cannot receive the epidural until 2 hours have passed since the last Mg dose).
The patient should have treatment for her blood pressure if it is >160/105 using Hydralazine 5 mg IM Q20-30
minutes until the BP is 140/90 or better, or Nifedipine 10mg Q20-30 minutes to a maximum dose of 30 mg.
Caution should be used with short-acting Nifedipine when combined with MgSO4 as it may cause a precipitous
drop in blood pressure. Aldomet is also available and may be used in doses up to 500 mg QID.
Severe Preeclampsia (>160/110). Hospitalize for the remainder of the pregnancy. After 32-34 weeks stabilize
and deliver the fetus. Prior to 32 weeks individualize decisions based on risks (i.e. G1, BP severity, symptoms,
hyperreflexia). If labor is imminent, antenatal corticosteroid therapy is appropriate, given optimally 24 hours
before delivery with protection lasting 7 days. In Ghana, the dexamethasone protocol is 12 mg IM Q12 hours x
48 hours.
Intrapartum: Start MgSO4 but the loading dose should be IV 4 g (8 mL of a 50% solution mixed with 12 mL of
normal saline for a 20 mL load in total) + 10 g IM, followed by 5 g IM Q4. Start management of hypertension as
above.
Eclampsia, First, control the seizures, correct hypoxia, control BP (diastolic <90-100) and then deliver vaginally
if possible. Seizure control: higher loading doses of MgSO4 4-6 g (8-12 mL). Valium 5-10 mg IV (may cause
respiratory depression). BP control as above.
Tocolytic Therapy
MgSO4: 6 g (12 mL) IV followed by 5 g IM Q4
Nifedipine: load with 30 mg and if the contractions persist after 90 minutes give additional 20 mg. if labor is
suppressed, give maintenance dose of 20 mg Q6 for 24 hours then Q8 for another 24 hours.
Antibiotics may prevent subclinical chorioamnionitis (ampicillin). Antenatal steroids as above
Labor Induction with Cytotec
Missed abortion (0-12 weeks): 800mcg PV or sublingual q3h x 2 and leave 1-2 wks
Incomplete abortion (0-12 week): 600mcg PO (single dose) , leave to work for 2 weeks unless bleeding or
infection
Missed abortion* (13-22 weeks): 400mcg PV q3h x 5. Use 200mcg if CS scar
IUFD (13-17 wks): 200 mcg pv q6h, 18-26 wks 100 mcg pv q6h, 27+ wks 25-50 q4h
Induction of labor (>24 weeks): 25mcg PV q6 h or 50 mcg PO q4h. Do not use if previous caesarian section.
Alternatively 25mcg PV and then after 4 hours start a 25 mcg solution PO q2h (200mcg tablet dissolved in 200ml
of water = 25mcg/25mL). In Primips increase dose to 50mcg (50mL q2h). In cases of IUFD, if there is no
response after 2 doses, the dose may be doubled
Postpartum hemorrhage: 1000 mcg per rectum. May shiver. A dose of 600mcg may be given to prevent bleeding
Molar pregnancy: may use to evacuate uterus, using doses appropriate for the size as above and somewhat greater
doses. This removes a significant portion of the mole and makes a vacuum D&C much easier.
Cervical Ripening: 400 PV 3h before procedure(D&C, IUD) or before delivery 50 mcg q6h x 4 doses followed by
Pitocin (See separate dosing sheet, specific for Nalerigu)
Cytotec is not in high supply. If a patient presents with retained products and less than 20 weeks, a D&C may be
a better option especially if she is well-dilated. D&C are usually the standard of care here as opposed to cytotec
or watchful waiting as many patients may not receive appropriate follow up.
Labor Augmentation with Oxytocin
Oxytocin may be indicated for augmenting labor in multiparous women whose uterus is hypotonic after several
vaginal deliveries. Use caution to assess for cephalo-pelvis discordance and avoid in such instances. The drip
protocol is as follows:
Oxytocin 5u injected into 500 mL LR (or 10u/1L LR)
Start drip at 5 drops/minute, increase by 5 drops/minute every 30 minutes to a maximum rate of 20 drops/minute,
titrating according to the contraction pattern.
If fetal distress occurs, the drip should be stopped, patient put on her right side and fluids given.
Molar Pregnancy
Suction D&C
BMC Medical Protocol – 2010
See above for Cytotec induction
Prophylactic chemotherapy is not necessary as 90% resolve spontaneously
Follow up with a pelvic exam q2 weeks x 3 months, then monthly x 3 months and the q6 months for a total of 2
years
Chest X-ray monthly or less often if the pregnancy test is negative
Pregnancy test at 8 weeks should be negative
No pregnancy for one year and do not use oral contraceptives
Vaginal Candidiasis
Oral: Fluconazole 150 mg PO x 1
Vaginal: Clotrimazole 100 mg x 2 vaginal tabs nightly x 3 days OR
2% cream 5 g vaginally nightly x 3 days
Nystatin 100,000 u vaginal tab nightly x 7-14 days
Sexually Transmitted Infections
Gonorrhea
Ciprofloxacin 500 mg PO x 1 (do not use if pregnant)
Ceftriaxone 250 mg IM x 1
Treat Chlamydia as well
Chlamydia
Doxycycline 100 mg PO BID x 7 days
Erythromycin 500 mg Q6H x 7 days
Azithromycin 1 g PO x 1
Syphilis
Benzathine penicillin 2.4 MU IM x 1
If penicillin allergic:
Doxycycline 100 mg BID x 14 days
Erythromycin 500 mg Q6H x 14 days
Azithromycin 2 g PO x 1
Ceftriaxone 1 g IM or IV daily x 8-10 days
Plus treat for chancroid as below
Chancroid
Ciprofloxacin 500 mg BID x 3 days
Ceftriaxone 250 mg IM
Malnutrition
Malnutrition is highly prevalent in the area. The Baptist Medical Centre has an extensive program of inpatient and
outpatient care. If one wants the Public Health Dept. to assist with the patient on the ward, they can be asked to
come by writing “Feeding List” on your hospital order sheet. They can also be asked to come to assist in the
outpatient department. There is an outpatient malnutrition program in which patients may graduate to, for post-
hospital management. Malnourished children may also be referred there from the outpatient department
For those children with Severe Malnutrition, such as Kwashiorkor (Protein–Energy Malnutrition) and Marasmus,
hospitalization may be necessary. 2/3 of deaths from acute severe malnutrition occur within the first week of
admission. Special care is necessary. The basic principle is, after initial resuscitation, to give high energy foods
with increased protein.
Resuscitation (days 1-7)
Avoid IV therapy due to the tendency to develop fluid overload.
ORS – 5mL /kg every 30 minutes for 2 hours, then 5-10ml/kg hourly for 4-10 hours. When hydrated start milk
feeding 130mL/kg/day (100 ml/kg for edematous children)
If IV therapy is required, give Ringers’ Lactate with 5% dextrose 15ml/kg over one hour and then 10mL/kg/hour
over the next 5 hours.
Specific issues
Diarrhea - lactose intolerance may be treated with yogurt or a cereal/oil/sugar, if available. Treat Giardia with
Metronidazole.
Hypothermia- keep the child warm
Hypogylcemia – Check blood glucose and if low give 50 ml of 10% glucose solution or sugared water (1
teaspoon sugar in 3 1/2 tablespoons of water) followed by milk feedings. If glucose remains low, repeat glucose
solution. If unconscious or convulsing, give 5mL/kg 10% dextrose IV/NGT
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BMC Medical Protocol – 2010
Infection – For mildly sick children showing no signs of infection give Septra (5mg/kg TMP ) bid for 5 days. In
ill children, give Ampicillin 50mg/kg IV q6h for 2-3 days and then oral amoxicillin 15mg/kg q8h for 5 days +
Gentamicin 7.5mg/kg daily for 7 days. If the child is not responding after 48 hours add Chloramphenicol or
Ceftriaxone in meningitis doses
Anemia – for Hgb <4, or 4-6 in the very sick give 10ml/kg of whole blood
Electrolytes and minerals –potassium supplementation along with zinc and magnesium are important
Vitamin A – If vitamin A has not been given within the last month, give as follows
<6 months 50,000 units 6-11 months 100,000 units >12 months 200,000 units
Antimalarials- give as indicated
Intestinal parasites – In children over 12 months, give Mebendazole 500mgx1 dose or 100mg bid x 3 days
Post-resuscitation – The Public Health Malnutrition Team will continue to be involved with the patient on the
ward and then the patient will be discharged to the Feeding Kitchen for daily care up to 6-8 weeks, as necessary
Additional treatments – Multivitamins with Folate should be used for at least 2-3 months. Iron supplements may
begin 2 weeks after admission when the child has regained appetite and starts to gain weight.
Nephrotic Syndrome. Commonly seen as a complication of malaria or the treatment of malaria. Confirm with
urine specimen. Treatment is with salt restriction (2-4 g/day), furosemide to control edema, and using lisinopril to
control any hypertension. Steroids are helpful, prednisone 1-2 mg/kg/day for a couple of months until the
proteinuria is resolved for a few weeks, then tapering over months. Maximum dose is 60 mg/day.
Postoperative pain management. Pethidine(Demerol) 50-70mg IM q 4-6h p.r.n (children 1-1.75mg/kg
(PO/SC/IM) q3-4h
Necrotizing Fasciitis. The infection is usually mixed, so treat for Strep, Clostridium and Anaerobes with
antibiotics such as Crystalline Penicillin, Flagyl and Gentamycin IV. The primary treatment is wide, aggressive
surgical debridement. Often more than 2 debridements are necessary. If it is a Buruli ulcer (purple edges that are
undermined), wide surgical debridement is the only treatment. Recent evidence shows that a course of Rifampicin
with Streptomycin leads to a resolution of small lesions and enables larger lesions to be treated by less extensive
excision and reduces the risk of recurrence after surgery.
Acute psychosis. The only anti-pyschotic drug is chlorpromazine (Largactil). A typical dose is 50-100 mg IM
followed by 25mg PO b.i.d. Valium is also available for sedation.
Poisoning. This is usually the result of kerosene poisoning or DDT poisoning. Observation is all that is needed.
Anesthesia
Ketamine 1 mg/kg IV
Pressors: mix ½ vial of ephedrine in 5ml saline and give as a bolus
May also put ½ vial of adrenaline (1/1000) in 500 ml of fluid.
Spinal: Marcaine (0.5%) amputation or hernia = 3ml
C-section = 2ml
Prostate = 4 ml
Adolescent(7yo) = 2 ml
Lidocaine C-section = 1 ml
Hernia = 2 ml
Adolescent(7yo) = 1 ml
Hypertension. First line is bendroflumethazide (thiazide diuretic we have), 2.5 or 5 mg (no evidence that 5 mg
lowers better than 2.5). Beta-blocker is atenolol, ACE inhibitor is lisinopril, calcium channel blocker is nifedipine
20 mg BID. Lasix, aldactone, aldomet, and propranolol are also available.
Diabetes
Glibenclamide is the sulfonylurea of choice, up to 10 mg BID. Metformin is available. Insulin availability is
variable. Regular insulin or NPH are usually what is available, and patients may be sent home with insulin to be
kept in a shaded place. Monitoring is with RBS (random blood sugar) or FBS (fastiing).

Source: http://www.baptistmedicalcenter.org/wp-content/uploads/2010/12/2010-BMC-Protocol.pdf