Malaria: recognition, severity and parenteral treatment

Manage now— do this, in order

• Decide severity first, because it determines the route of the drug: oral therapy for uncomplicated disease, immediate parenteral therapy for severe disease and for any patient unable to swallow; if the species is uncertain, treat as falciparum.
• IV artesunate is the treatment of choice for all 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 under 20 kg get 3 mg/kg per dose on the same schedule — the commonest dosing error is giving the small child the adult 2.4 mg/kg. Check the weight before drawing up.Doctor / Nurse
• Reconstitute artesunate correctly: 60 mg dried powder with the supplied ampoule of 5% sodium bicarbonate, shaken until completely clear, diluted to about 10 mg/mL with 5% dextrose or 0.9% sodium chloride for IV use (about 20 mg/mL for IM), given as a slow bolus over 1–2 minutes — discard any solution that remains cloudy.Doctor / Nurse
• No artesunate — quinine dihydrochloride IV: loading dose 20 mg/kg of quinine salt (max 1.4 g) over 4 hours, then 10 mg/kg (max 700 mg) over 4 hours 8-hourly for 48 hours, then 12-hourly; omit the loading dose and give 10 mg/kg instead if quinine, quinidine or mefloquine has been received within 24 hours; monitor the ECG continuously, and measure glucose every 4–6 hours with co-administered 5–10% dextrose — quinine causes hyperinsulinaemic hypoglycaemia, a genuine cause of death, especially in pregnancy.Doctor / Nurse
• Continue parenteral treatment for at least 24 hours regardless of improvement, then complete a full three-day course of an oral ACT (or oral artesunate 2 mg/kg daily to a cumulative 17–18 mg/kg). Parenteral artesunate alone does not cure malaria; never use an artemisinin as monotherapy, and never use mefloquine as follow-on (post-malaria neurological syndrome).
• Correct hypoglycaemia and recheck: adult 50 mL of 50% glucose IV, or 100–200 mL of 10% glucose, then a 10% infusion; child 2 mL/kg of 10% glucose IV or IO (neonate 2.5 mL/kg), then a 10% infusion. 25% or 50% glucose must not be given peripherally in a child, and never treat the coma without first excluding hypoglycaemia.
• Coma and convulsions: maintain the airway, nurse on the side (aspiration pneumonia is a recognised and lethal complication), exclude hypoglycaemia and bacterial meningitis, intubate if the airway cannot be protected; treat convulsions promptly with IV or rectal diazepam (paraldehyde where unavailable). Fluids are a drug with a dose and a toxicity: 250–500 mL over 15 minutes in a hypotensive adult, 10 mL/kg over 10–20 minutes in a child, reassessing after each — restrict fluid the moment urea or creatinine rises despite adequate rehydration.Doctor / Nurse
• Severe anaemia: transfuse fresh whole blood or packed cells (10 mL/kg in children); a PCV below 15% is the widely used threshold where blood is short. Pulmonary oedema: nurse at 45 degrees, oxygen, stop IV fluids, give a diuretic; CPAP or intubation with PEEP for life-threatening hypoxaemia.Doctor / NurseNot available at your setup — Blood & blood products.
• Give empirical antibacterial therapy alongside the antimalarial in every child with severe malaria in an endemic area (covering non-typhoidal *Salmonella* from the outset), every adult with parasitaemia above 20%, every patient with shock, and any severely ill patient who fails to respond — ideally with blood cultures in all severe malaria. Never give the four harmful ancillary treatments: glucocorticoids, prophylactic phenobarbitone, heparin and adrenaline.Doctor / NurseNot available at your setup — Blood culture.