A 35 year old man, recently returned from an African trek, is admitted with coma, severe hypoxia and dark urine. A thick film of blood shows malarial parasites. Outline your management over the first 48 hours
This is a medical emergency with a potentially high mortality due to plasmodium falciparum. Initial management of acute severe malaria with these features should include:
(a) Airway- the patient is unconscious so the airway will need to be secured. -
(b) Breathing - hypoventilation associated with the cerebral obtundation will necessitate IPPV
to normalise PC02• ARDS is common in this setting and will require titration of Fi02, PEEP
and ventilatory mode (?PRVC,IRV etc).
(c) Circulation - shock is not uncommon with severe malaria. Volume loading in clinical studies is usually counterproductive with associated worsening hypoxia. Inotropic support is usually indicated and renal failure my require CVVHD.
(d) Diagnosis - secondary infection is uncommon, but other precipitants of deterioration should
be excluded eg.. pneumonia.
(e) Definitive therapy with antimalariais. Depending on known sensitivities from the area
visited - quinine sulphate may be the treatment of choice (IV loading dose followed by eight hourly doses).
(f) Invasive monitoring.
(g) Metabolic support- hypoglycaemia is common.
(h) Exchange transfusion- not medically justified.
This question vaguely resembles Question 20 from the second paper of 2009. However, the answer there is not set up in a "systematic" fashion. Here I will attempt a systematic approach.
World Health Organization. "Severe falciparum malaria." Transactions of the Royal Society of Tropical Medicine and Hygiene 94 (2000): 1-90.
Riddle, Mark S., et al. "Exchange transfusion as an adjunct therapy in severe Plasmodium falciparum malaria: a meta-analysis." Clinical infectious diseases34.9 (2002): 1192-1198.
Reyburn, Hugh. "New WHO guidelines for the treatment of malaria." BMJ 340 (2010).
(the actual revised guidelines are available online for free)
Dondorp, Arjen M., et al. "Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial." The Lancet 376.9753 (2010): 1647-1657.
Trampuz, Andrej, et al. "Clinical review: Severe malaria." CRITICAL CARE-LONDON- 7.4 (2003): 315-323.
Maitland, Kathryn, et al. "Response to volume resuscitation in children with severe malaria*." Pediatric Critical Care Medicine 4.4 (2003): 426-431.
Maitland, Kathryn, et al. "Mortality after fluid bolus in African children with severe infection." New England Journal of Medicine 364.26 (2011): 2483-2495.