Treatment

Once JE is suspected, case should be referred to big Hospitals. Following Precautions & care must be taken while transporting the patient.

1.Make the patient to lie down on the side.
2.Keep the mouth cavity and nose clean. If available, use a mucous sucker to clear secretions.
3.Discourage bending of Neck.
4.In case of high fever, do rapid sponging of the body to reduce the temperature.
5.Loud noises and bright light should be avoided.

Investigations :

Investigations are required to exclude pyogenic meningitis, Tuberculous meningitis, Cerebral Malaria, Hypoglycemia, dyselectrolytemia, Reye's syndrome and other metabolic condition.

Cerebro Spinal Fluid (CSF) changes in JE :

CSF is usually clear and show mild pleocytosis ( 100 - 1000/ cmm) initially polymorphonuclear but in few days predominantly lumphocytosis. The CSF protein levels shows mild elevation. CSF sugar and chlorides remain within normal limits.

Routine investigations like CBP, ESR & CSF do not help much except to exclude pyogenic, tuberculous meningitis and cerebral malaria.

Aetiological diagnosis of JE is established by testing

1. Acute phase serum collected early in the illness for the virus specific IgM antibodies (IgM captured Elisa) in CSF or in blood within 4-7 days.

2. Demonstrating the four fold rise IgG. Antibody titres by paired,acute and convalescent sera.

3. If facilities are available, the virus can be identified by PCR (Polymerase chain reaction).

Management of JE :

The patient with JE needs early recognition of symptoms and treatment at various settings with acute neurological deterioration in patient. JE may be a life threatening event associated with diverse clinical presentation. Patients with progressive neurological signs must be quickly stabilised to avoid further injury to the brain by early recognition of the condition.

For JE, no specific therapy is available. Proper supportive and adequate nursing care are of prime importance.

CASE MANAGEMENT PROTOCOL OF CHANDIPURA VIRAL ENCEPHALITIS

A) At PHC level – Basic supportive protocol.
1. Assessment of vital signs.

· Airway maintenance.

· Breathing – Respiratory rate, abnormal / irregular.

· Circulation – Pulse, BP, Capillary refill time.

2. Investigations : HB %, Total Leucocyte Count (TLC) / Differrential Leucocyte Count (DLC), Peripheral Smear (PS) for MP.

3. Basic support :

· Maintain Air way (Suction, Position – supine with head elevated by 300 , Oxygen therapy by nasal catheter, by face mask, oxygen tent with flow rate of oxygen 3-5 lt. per minute.

· Ambu bag and face mask for manual resuscitation.

· Maintain nutrition – IV fluid maintenance.

· Adequate nursing care – care of eyes, mouth, skin, bladder, bowel & back.

4. Drugs :

· Paracetamol – per rectal suppository, inj. 10 mg / kg / dose or oral dose at the interval of 8 hrs.

· I.V. fluid maintenance – 100 ml / Kg. in 24 hrs.

· Anti malarial – I.V. Quinine 10 mg / kg in 10 % dextrose 10 ml / kg. drip over a period of 2 hrs and repeat 8 hrly.

OR

· Inj. I. V. Artisunate 3 mg / kg state followed by 1.5 mg / Kg OD for 3 days.

· I.V. Mannitol – 5 ml / kg. single dose bolus stat. in 20 minutes and can be repeated 6 hourly for 48 hours.

· I.V. Dizepam (Only if seizure present) – 0.3 mg / kg over a period of 5 to 10 minutes if seizure recurs.

· Antibiotics –

Inj. Ampicillin- 100 mg / kg / day in 8 hrly divided doses.

Inj Gentamycin – 5 to 7.5 mg / kg./ day twice daily.

Inj. Cirpofloxacine – 10 mg/kg/dose BD.

If necessarym early referral to nearest hospital after giving basic supportive care and while referring a referral slip with details of medication should be given with the patient.

B) RH / SDH / Dist. Hospital level – Standard Encephalitis Management Protocol.

1. Immediate hospitalization and examination by the available specialists / within shortest time.

2. Basic supportive care as per protocol for PHC.

3. Investigations should be done urgently as below : HB %, TLC/DLC, PS for MP, CSF study, Blood sugar, Serum electrolytes, Bleeding Time (BT) / Clotting Time (CT), Platelet count, widal test,Liver Function Test (LFT) if necessary. Serum & CSF sample should be preserved and sent for serology and virology study as per NIV Pune, guidelines.

Standard Encephalitis Management Protocol.

· If air way maintained & no shock – continue basic support care with timely monitoring the patient and medication.

· If does not maintained air way

- Head position – elevation of the head by 300.

- Head tilt & chin lift.

- Suction.

- Tracheostomy if necessary.

- Nil by mouth – Insert GI tube and watch for bleeding.

· Assesment of shock :

- Pulse rate and volume (tachycardia, feeble, absent. )

- Systolic BP (mm Hg) – 1-10 yrs - <70+ (2 x age in yrs) mm Hg. & > 10 yrs - <90 mm Hg.

- Delayed capillary refill time more than 3 seconds.

No shock :

· Maintain airway.

· Ambu bag and face mask for manual resuscitation.

· Stare I.V. fluid maintenance – DNS / Isolyte – P doses or I.V. fluid.

o Below 1 yr – 100 ml / kg / 24 hrs.

o 1 to 3 yrs – 1200 ml / 24 hrs.

o 3 to 6 yrs – 1500 ml / 24 hrs.

o 6 to 12 yrs – 1800 ml / 24 hrs.

o above 12 yrs – 2000 ml / 24 hrs.

o (if I.V. access not available,

o intraosseous or intragastric can

o be used.)

· Continue drug management as above.

If signs of shock present –

Treatment of shock –

1. Fluid resuscitation – 30 ml / Kg RI. NS over a period of 30 minutes.

2. If shock persist – start vasopresers.

a) Dopamine – 10/20 micrograms / kg / min in I.V. infusion & maintenance drip (0.6 X body wt = dose in mg) dissolved in 100 ml I.V. fluid rate to be adjusted for appearance of pulse.

b) If not responding to dopamine drip- adrenaline drip – 0.06 x wt. in kg = amount mg of adrenaline to be dissolved in 100 ml of I.V. fluid, given slowly till pulse appears.

3. Drugs for seizures –

a) I.V. diazepam 0.3 mg / kg bolus slowly over a period of 3 to 5 minutes can be repeated after 10 minutes, upto maximum 3 times.

b) I.V. dilantin sodium – 10 to 15 mg / kg bolus dose followed by 5 mg / kg / day in two divided doses daily OR

c) If not responding above treat ment, I.V. Midazolam – 0.1 mg / kg / bolus dose stat followed by 0.1 – 0.4 mg / kg in the maintenance infusion drip.

4. Drugs for raised intracranial pressure.

a) I.V. mannitol – 5 ml / kg (1.2 gm / Kg) over a period of 20 minutes every six hourly fore 48 hours. OR

b) I.V. lasix – 2 mg / kg – 12 hourly.

5. Other drugs

Antimalarial – IV Quinine – if not responding, Inj. Artether / Inj. Artesunate 1-5 mg / kg once a day – IM / IV.

Antibiotics – Broad spectrum –

1. Inj. Amoxicillin – 100 mg / kg/ day.

2. Inj. Cefataxine – 100 mg / kg / day divided in 8 hourly. OR

Inj. Ceftriaxone – 50 – 100 mg / Kg / day divided in twice a

day. OR

Inj. Ciprofloxacine – 10 mg / kg / dose 12 hourly.

· Management of GIT bleeding – Inj. Vitamin K 5 mg / Im stat. Cold bowel wash, blood / fresh frozen plasma / platelet transfusion.

Referral – If patient is not responding as above management, need ventilator support, profuse bleeding, refractory seizures not responding to treatment. THEN patient must be referred to tertiary care hospital – Medical college Hospital or specialist hospital in Ambulance with basic life support and detailed referral slip.