laboratory findings/markers of severe leptospirosis
1.CBC – leucocytosis (WBC>12,000 cells/cumm) neutrophilia and thrombocytopenia (<100,000 cells/cu mm)
2. Serum creatinine > 3 mg/dL (or CrCl < 20 ml/min) and BUN > 23 mg/dL
3. Liver function tests - AST/ALT ratio > 4x Bilirubin > 190 umol/L
4. prolonged prothrombin time (PT) < 85%
laboratory findings/markers of severe leptospirosis
5. Serum potassium > 4 mmol/L
6. ABG- severe metabolic acidosis (ph< 7.2, HCO3 < 10) hypoxemia (PaO2 < 60 mmHg, SaO2 < 90%)
7. Chest radiograph - extensive alveolar infiltrates
8. Electrocardiogram - heart block, myocarditis
Antibiotic Treatment :
1.Doxycycline - drug ofchoice - Alternative drugs : amoxicillin and azithromycin dihydrate. [Grade B]
2. For moderate-severe leptospirosis : - penicillin G - the drug of choice - Alternative drugs : parenteral ampicillin, 3rd generation cephalosporin (cefotaxime, ceftriaxone), and parenteral azithromycin dihydrate. [Grade A]
Antibiotic therapy should be completed for 7 days, except for azithromycin dihydrate which could be given for 3 days. [Grade A]
Oliguria - <0.5 ml/kg/hr or <400 ml/day or self-report of low or no urine output in 12 hrs.
Mean Arterial Pressure </=65 mm Hg
Start Norepinephrine and titrate to keep MAP >65 mmHg
Assess Fluid Status
Hypovolemic?
• Fast drip Normal Saline Solution, 20 ml/kg/hr and reassess after 15 minutes• Continue hydration till euvolemic•Adjust IVF rate to suit patient needs
YES
NO
YES
NO
Furosemide 40 mg IV bolus or Bumetamide 1 mg IV
Urine Output>/= 0.5ml/kg/hr?
Double dose of furosemide (or Bumetamide) hourly up to a maximum of 160 mg (or 4 mg)
Urine Output>/= 0.5ml/kg/hr?
Acute Renal Replacement Therapy
Urine Output>/= 0.5ml/kg/hr?
• Monitor hourly and adjust rate of IVF to maintain euvolemia
• Reassess kidney status
• Monitor hourly and adjust rate of IVF to maintain euvolemia
• Reassess kidney status
• Monitor hourly and adjust rate of IVF to maintain euvolemia
• Reassess kidney status
Yes
No
Yes
No
No
Yes
PHILIPPINE SOCIETYOF NEPHROLOGY
DISASTER RESPONSE TO
CRUSH INJURY / CRUSH SYNDROME
Crush injury - a direct injury caused by collapsing material and debris resulting in manifest muscle swelling and/or neurological disturbances in the affected parts of the body
Crush Syndrome - patients with crush injury and systemic manifestation due to muscle cell damage which would include: acute kidney injury, sepsis, acute respiratory distress syndrome, diffuse intravascular anticoagulation, bleeding, hypovolemic shock, cardiac failure, arrhythmias, electrolyte disturbances
VICTIM UNDER THE RUBBLE
VEIN IS AVAILABL
E
YES GIVE 1L/HR OF ISOTONIC SOLUTION FOR THE 1ST 2 HRS.2,10-13
NO
ATTEMPT ORAL HYDRATION FOR THOSE THAT CAN
BE REACHED
GIVE SALINE AT 0.5 L/HR (REASSESS EVERY 2-4
HRS)
YESIS IT SAFE TO HYDRATE THE
VICTIM?
LIMIT HYDRATION TO 1L/DAY
NO
CONTINUE MANAGEMENT UNTIL EXTRICATION WITH CONTINUOUS CLOSE MONITORING OF FLUID STATUS ONCE EXTRICATED PLEASE PROCEED TO POST-EXTRICATION ALGORITHM
EXTRICATED VICTIM
PRIMARY SURVEY
PRESENCE OF OTHER MEDICAL
CONDITION
DOES THE VICTIM NEED TO BE HYDRATED?
VICTIM MAY BE DISCHARGED WITH PROPER ADVICE
MULTIDISCIPLINARY REFERRAL (PLEASE REFER TO SPECIFIC
INDICATIONS FOR NEPHROLOGY REFERRAL)
INDICATIONS FOR NEPHROLOGY REFERRAL(Please see nephrology notes)
1.Hyperkalemia on ECG2.Presence of reddish-brown urine3.Decreased urine output (<0.5 ml/kg/hr x 4 hours)4.Fluid overload
GIVE 1L/HR OF ISOTONIC SOLUTION FOR 2HRS
REASSESS AFTER 2HRS
IS IT SAFE TO MAINTAIN
HYDRATION?
GIVE SALINE AT 0.5L/HR
REASSESS EVERY 2-4 HRS
LIMIT HYDRATION TO 1L/DAY
MAY DO SECONDARY SURVEY AS NEEDED
ADMIT TO HOSPITAL
YES
NO
YES
NOYES
NO