Title: Pre-referral treatment of severe malaria at the Health Post level
Course: Communicable Diseases Part 1 - Ethiopia (Full)

Pre-referral treatment of severe malaria at the Health Post level

It is important that all patients are assessed for the danger signs of severe malaria that you learned about in Study Session 7 (Section 7.2.2). If a patient comes to the Health Post with danger signs, or is found to have any of them, he or she will require urgent medical attention and should be referred to a health centre as soon as possible.

Always remember that a delay in referral could cause death of the patient. The risk of death for severe malaria is greatest in the first 24 hours.

Before referring the patient, give pre-referral treatment for all patients presenting with any of the danger signs of severe malaria, regardless of whether the RDT result is negative or positive. The pre-referral treatments that you should give the patient include:

- The first dose of rectal Artesunate (see Table 8.4 below for the dosages), or if available, an intramuscular injection of Artemether in a dose of 3.2 mg/kg body weight.
- If an Artesunate suppository is expelled from the rectum within 30 minutes of insertion, insert a second suppository.
- In young children, hold the buttocks together for 10 minutes to ensure retention of the rectal dose of Artesunate.

Table 8.4 Rectal Artesunate dosage for pre-referral treatment by body weight and age.

Weight (kg) | Age | Artesunate dose (mg) | Formulation of the regimen (given all at the same time)
5–8.9 | 0–12 months | 50 | One 50 mg suppository
9–19 | 13–42 months | 100 | One 100 mg suppository
20–29 | 42–60 months | 200 | Two 100 mg suppositories
30–39 | 6–13 years | 300 | Three 100 mg suppositories
40–59 | >13 years | 400 | One 400 mg suppository
60–80 | Adults | 800 | Two 400 mg suppositories
80+ | Adults | 1,200 | Three 400 mg suppositories

- Remember to give supportive treatment as indicated in Section 8.1.3 of this session if the patient has high fever, or dehydration, and in case of breastfed infants, encourage mothers to provide extra breastfeeding.
- If the patient is unconscious, in addition to the above mentioned pre-referral treatments, perform the activities indicated in Box 8.3.

Box 8.3 Steps in managing an unconscious patient

Ensure ABC of life support, as follows:

- A = Airway: in the unconscious or convulsing patient it is imperative that the airway is free of obstructions. In the convulsing child you may thrust the jaw forward to ensure a clear airway. Show family members how to position the patient (on his or her side) to ensure a clear airway is maintained.
- B = Breathing: check that the patient is breathing by looking for chest movements and listening for breath sounds.
- C = Circulation: feel or observe that hands and fingers are not cold, and colour is normal. Also check that the capillaries are refilling with blood by applying pressure for few seconds to a fingernail bed, then release the pressure to see if the blood returns fast, which is normal. Monitor and record vital signs (blood pressure, pulse, respiration rate).

For all the patients you are referring, ensure that the referral form is completed with detailed information, including:

- Clinical presentation/patient's medical history.
- Suspected diagnosis.
- RDT tests performed and results.
- List of all drugs/medication given, route, dose and time of administration.
- Reason for transfer to health centre.