Malaria: recognition, severity and parenteral treatment

Management— do this, in order

• Decide severity first, because the severity decision determines the route of the drug: oral therapy for uncomplicated disease, immediate parenteral therapy for severe disease and for any patient unable to swallow, and if the species is uncertain, treat as falciparum.
• Intravenous artesunate is the treatment of choice for all patients with severe malaria, in all age groups and in every trimester of pregnancy — 2.4 mg/kg IV at 0, 12 and 24 hours, then once daily; children 20 kg and over as adult, children under 20 kg 3 mg/kg per dose on the same schedule.Doctor / Nurse
• Reconstitute artesunate correctly: 60 mg of dried powder with the supplied ampoule of 5% sodium bicarbonate, shaken until completely clear, diluted to approximately 10 mg/mL with 5% dextrose or 0.9% sodium chloride for intravenous use (about 20 mg/mL for intramuscular use), given as a slow bolus over 1–2 minutes — discard any solution that remains cloudy.Doctor / Nurse
• No venous access: artesunate 2.4 mg/kg IM (under 20 kg 3 mg/kg IM) on the same schedule; where only pre-referral treatment is possible give rectal artesunate 10 mg/kg as a single dose (children 10 mg/kg) and transfer for parenteral therapy.Doctor / Nurse
• No artesunate — quinine dihydrochloride IV: loading dose 20 mg/kg of quinine salt (maximum 1.4 g) IV over 4 hours, then 10 mg/kg (maximum 700 mg) over 4 hours 8-hourly for 48 hours, then 12-hourly until oral therapy is possible; children the same mg/kg regimen, paired with clindamycin rather than doxycycline.Doctor / Nurse
• Omit the quinine loading dose and give 10 mg/kg instead if the patient has received quinine, quinidine or mefloquine within the previous 24 hours; monitor the ECG continuously and reduce the infusion rate if the corrected QT prolongs by more than 25% of baseline; measure glucose every 4–6 hours and co-administer 5–10% dextrose.Doctor / Nurse
• Artemether IM is an inferior alternative: 3.2 mg/kg IM immediately, then 1.6 mg/kg IM daily, same mg/kg regimen in children.Doctor / Nurse
• Continue parenteral treatment for at least 24 hours regardless of how much the patient improves, then, once swallowing is safe, complete a full three-day course of an artemisinin-based combination therapy — or oral artesunate 2 mg/kg once daily to a total cumulative dose of 17–18 mg/kg. Parenteral artesunate alone does not cure malaria.Doctor / Nurse
• Correct hypoglycaemia and recheck: adult 50 mL of 50% glucose intravenously, or 100–200 mL of 10% glucose, then a 10% infusion (glucagon may be ineffective); child 2 mL/kg of 10% glucose intravenously or intraosseously (neonate 2.5 mL/kg), then a 10% infusion — 25% or 50% glucose must not be given peripherally in a child.Doctor / Nurse
• Coma: maintain the airway, nurse on the side (aspiration pneumonia is a recognised and lethal complication), exclude hypoglycaemia and bacterial meningitis, and intubate if the airway cannot be protected.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Convulsions: treat promptly with intravenous or rectal diazepam, or paraldehyde where diazepam is unavailable.Doctor / Nurse
• Fluids are a drug with a dose and a toxicity: give balanced crystalloid in small aliquots — 250–500 mL over 15 minutes in a hypotensive adult, 10 mL/kg over 10–20 minutes in a child — reassessing pulse, blood pressure, capillary refill, lung bases and mental state after each.Doctor / Nurse
• Severe anaemia: transfuse fresh whole blood or packed cells (10 mL/kg in children); a packed cell volume below 15% is the widely used threshold where blood is short.Doctor / NurseNot available at your setup — Blood & blood products.
• Pulmonary oedema: nurse at 45 degrees, give oxygen, stop intravenous fluids and give a diuretic; add CPAP or intubation with PEEP for life-threatening hypoxaemia — venesection of 250 mL appears in WHO guidance as an immediate measure but must never be used in a patient who is anaemic or shocked.Doctor / Nurse
• Hyperpyrexia: tepid sponging, fanning and paracetamol.
• Give empirical antibacterial therapy alongside the antimalarial in every child with severe malaria in an endemic area (with activity against non-typhoidal *Salmonella* from the outset), in every adult with a parasitaemia above 20%, in every patient with shock, and in any severely ill patient who fails to respond or deteriorates unexpectedly — ideally take blood cultures in all severe malaria.Doctor / NurseNot available at your setup — Blood culture.
• Uncomplicated falciparum malaria — oral ACT: artemether–lumefantrine (20/120 mg) 4 tablets orally twice daily for 3 days, or the 6-dose schedule of 4 tablets at 0, 8, 24, 36, 48 and 60 hours, each dose with milk, yoghurt or a fatty meal because lumefantrine bioavailability is considerably increased by fat; observe for vomiting for one hour and repeat any dose vomited within that hour.
• Non-falciparum malaria: chloroquine approximately 25 mg base/kg over three days — 600 mg base orally, then 300 mg at 6, 24 and 48 hours (CMDT expresses this as chloroquine phosphate 1 g then 500 mg at 6, 24 and 48 hours); children 10 mg base/kg immediately then 5 mg base/kg at 6, 24 and 48 hours — then radical cure with primaquine 0.25–0.5 mg/kg per day orally for 14 days (commonly 30 mg base daily) once G6PD status is known.