What is the management for a patient with dengue fever presenting with headache and vomiting?

Management of Headache with Vomiting in Dengue Fever

For patients with dengue fever presenting with headache and vomiting, the primary management should focus on adequate hydration, appropriate pain control with acetaminophen, and careful monitoring for warning signs of severe dengue. 1, 2

Initial Assessment and Monitoring

• Dengue fever typically presents with fever, headache, retro-orbital pain, muscle and joint pain, and rash 3, 2
• Headache in dengue can be particularly intense, especially in classic dengue fever compared to dengue hemorrhagic fever 4
• Daily monitoring of complete blood count is essential to track platelet counts and hematocrit levels, which helps detect early signs of progression to severe disease 1, 2
• Monitor for warning signs including persistent vomiting, severe abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 2

Management of Headache and Vomiting

• Acetaminophen/paracetamol is the recommended medication for headache management in dengue fever 1, 2
• Strictly avoid NSAIDs and aspirin due to increased risk of bleeding, especially with the thrombocytopenia that often accompanies dengue 1, 2
• For patients with persistent vomiting:
  • Consider hospitalization for intravenous fluid administration and closer monitoring 1
  • If the patient cannot swallow or has persistent vomiting, intravenous fluid therapy should be initiated 3
  • The IV fluid of choice is 5% dextrose with 1/2 normal saline, which provides glucose to prevent hypoglycemia 3

Hydration Management

• Ensure adequate oral hydration with fluids containing electrolytes to prevent dehydration 1, 2
• For patients who can tolerate oral intake but have moderate dehydration, oral rehydration solutions should be provided, aiming for more than 2500ml daily 2
• In patients who cannot drink due to vomiting, administer 20 mL/kg oral rehydration solution with glucose via nasogastric tube every 4 hours 3
• For severe cases with shock, administer an initial fluid bolus of 20 mL/kg with careful reassessment afterward 2

Indications for Hospitalization

• Hospitalization should be considered for patients with:
  • Persistent vomiting that prevents adequate oral hydration 1, 2
  • Rapidly decreasing platelet count 1
  • Other warning signs of severe dengue 2
• During hospitalization, continue close monitoring of vital signs, fluid status, and laboratory parameters 1, 2

Monitoring for Complications

• Watch for signs of plasma leakage and shock, such as rising hematocrit (>20% increase from baseline) or cold, clammy extremities 1
• Monitor for hypoglycemia, which can be a complicating factor and should be suspected whenever there is a deterioration in clinical status 3
• Be vigilant for signs of bleeding, which may require blood transfusion in severe cases 2

Common Pitfalls to Avoid

• Do not delay fluid resuscitation in patients showing signs of shock 2
• Avoid fluid overload, which can precipitate pulmonary edema or adult respiratory distress syndrome 3
• Never administer steroids, as they have been shown to have adverse effects in dengue management 3
• Do not neglect daily laboratory monitoring, as trends in platelet count and hematocrit are crucial for early detection of complications 1, 2

The prognosis is generally good with appropriate supportive care, with most patients recovering without complications within 1-2 weeks 1, 5.