Sir William MacGregor, MD, at the end of his term as Papua New Guinea’s colonial governor, wrote: “Dysentery causes more deaths than any other disease in tropical countries. No other malady is so universally distributed and of such constant occurrence … [Dysentery has become] the chief agent in the rapid depopulation of the Pacific.”1
Rehydration does not have the drama of other medical interventions—but it saves more lives than all other disease treatments combined.
Diarrhea causes most cases of lethal dehydration, especially among infants and children. Acute diarrhea is three or more loose or watery stools per day or a definite decrease in stool consistency and an increase in stool frequency for the individual. The volume of fluid lost through stools can vary from 5 mL/kg body weight/day (approximately normal) to ≥200 mL/kg body weight/day.2 Because of the use of oral rehydration therapy (ORT), the annual worldwide deaths from diarrhea have decreased from >5 million in 1978 to 2.6 million in 2009 (1.1 million people >5 years old and 1.5 million children <5 years old).3
Assessing a child’s level of dehydration is a clinical diagnosis. This assessment should be no harder in austere situations than in standard practice—except that the confounder of malnutrition may play a big role in a child’s appearance. Laboratory studies, including serum electrolytes, are usually unnecessary.4 Stool cultures are indicated in dysentery, but are not usually indicated in acute, watery diarrhea for an immunocompetent patient.
Although studies in Africa and the United States have shown dehydration assessment scales to be relatively unreliable, they give clinicians a starting point to evaluate these children. Tables 11-1 and 11-2 are two scales that are easy to use in austere settings and have good inter-rater reliability.5,6
TABLE 11-1Clinical Pediatric Dehydration Scoring System |Favorite Table|Download (.pdf) TABLE 11-1 Clinical Pediatric Dehydration Scoring System
| ||Points for Physical Findings |
|Finding ||1 ||2 ||3 |
|Alertness ||Normal ||Restless, irritable, abnormally quiet, drowsy, or floppy ||Delirious, comatose, or shocky: “very ill” |
|Pulse ||Strong, <120/min ||120-140/min ||>140/min |
|Respirations ||<30/min ||30-40/min ||>40/min |
|Skin elasticity ||Normal ||Moderately reduced ||Extremely reduced |
|Eyes: sunken eyeballs ||Normal ||Moderate ||Extreme, hypotonic |
TABLE 11-2WHO Scale for Dehydration in Children 1 Month to 5 Years Old |Favorite Table|Download (.pdf) TABLE 11-2 WHO Scale for Dehydration in Children 1 Month to 5 Years Old
| ||A ||B ||C |
|General Conditiona ||Well, alert ||Restless, irritable ||Lethargic or unconscious |
|Eyesb ||Normal ||Sunken ||Sunken |
|Thirst ||Drinks normally, not thirsty ||Thirsty, drinks eagerly ||Drinks poorly or not able to drink |
|Skin Pinchc ||Springs back quickly ||Goes back slowly ||Goes back very ...|
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