01Approach to the Critical Patient/attcp40

Immediate stabilization

›High risk parasitic syndrome stabilization

›Airway risk

›If GCS < 13, airway preparation and critical care activation

›If ongoing seizure, benzodiazepine protocol and antiseizure loading

›Breathing risk

›If hypoxemia, oxygen escalation with continuous SpO2 monitoring

›If ARDS pattern, lung protective ventilation strategy

›Circulation risk

›If shock, sepsis pathway with early vasopressor if fluid nonresponsive

›If severe anemia with hemodynamic compromise, transfusion protocol

›Rapid severity screen

›Travel or residence in malaria endemic area with fever, presume malaria until excluded

›Immunosuppression with eosinophilia concern, presume Strongyloides risk before steroids

Time-critical diagnostics and consultation triggers

›Time-critical parasitic threats

›Malaria suspicion

›STAT thick and thin smear within 24 hours of presentation

›If initial smear negative with high suspicion, repeat every 12 to 24 hours for 3 sets

›CNS parasite concern

›New seizure, focal deficit, altered mental status, urgent neuroimaging pathway

›If raised ICP concern, avoid lumbar puncture until imaging

›Hydatid disease concern

›Large liver or lung cyst symptoms, avoid cyst aspiration without specialist plan

›Severe diarrhea with dehydration

›Rapid volume and electrolyte correction with stool pathogen testing plan

›Consult triggers

›If suspected malaria, infectious diseases and critical care early

02History/hx53

Exposure and risk profile

›Exposure and risk profile

›Travel itinerary and dates

›Countries and regions

›Departure and return dates

›Vector exposure

›Mosquito bites and nighttime exposure

›Tick exposure

›Water exposure

›Freshwater swimming or rafting

›Untreated drinking water

›Food exposure

›Undercooked pork, beef, fish, crab, crayfish

›Unwashed produce

›Animal exposure

›Dogs or livestock

›Cat feces exposure

›Sexual exposure

›Oral anal contact

›New partners with diarrheal illness

›Household and institutional exposure

›Daycare outbreaks

›Shelter or crowding exposure

›Host risk

›Pregnancy

›HIV or other immunosuppression

›Steroid use or planned steroid therapy

›Asplenia

03Physical Exam/exam42

General and vitals

›General and vitals

›Vitals trend

›Fever

›Hypotension

›Tachycardia

›Tachypnea

›Perfusion

›Capillary refill

›Mottling

›Mental status

›Agitation or somnolence

›Delirium features

›Hydration

›Mucous membranes

›Orthostasis

›Bleeding signs

›Petechiae

›Oozing at venipuncture sites

Focused systems

›Focused systems

›HEENT

›Scleral icterus

›Conjunctival pallor

›Cardiopulmonary

›Crackles

›Wheeze

›Signs of heart failure

04Differential Diagnosis/ddx45

Life-threatening and must not miss

›Life-threatening differential

›Severe malaria, Plasmodium falciparum, ICD-10 B50.9

›Altered mental status

›Acidosis

›Severe anemia

›Cerebral malaria, ICD-10 B50.0

›Coma

›Seizure

›Fulminant amoebic colitis, ICD-10 A06.0

›Toxic megacolon pattern

›Perforation risk

›Amoebic liver abscess, ICD-10 A06.4

›Fever with RUQ pain

›Pleuropulmonary extension risk

›Strongyloides hyperinfection, ICD-10 B78.7

›Immunosuppression

›Sepsis with Gram negative bacteremia pattern

›Neurocysticercosis, ICD-10 B69.0

›New onset seizure

›Hydrocephalus risk

›Echinococcosis with cyst rupture risk, ICD-10 B67.9

›Anaphylaxis risk

›Secondary seeding risk

Common syndrome-based alternatives

›Syndrome-based differential

›Febrile traveler

›Malaria

05Laboratory Tests/lt52

Core ED labs

›Core ED labs

›CBC with differential

›Anemia pattern

›Thrombocytopenia pattern

›Eosinophilia pattern

›Electrolytes and renal function

›Hypokalemia from diarrhea

›AKI from dehydration or severe malaria

›Liver panel

›Hemolysis pattern jaundice

›Transaminitis pattern for hepatitis differential

›Glucose

›Hypoglycemia concern in severe malaria

›Hyperglycemia stress pattern

›Venous blood gas with lactate

›Metabolic acidosis concern

›Lactate elevation for shock severity

›Coagulation studies

›DIC concern in severe systemic illness

›Blood cultures

›Sepsis pattern with possible Strongyloides hyperinfection translocation

Parasitology and targeted infectious testing

›Parasitology and targeted testing

›Malaria smear microscopy

›Thick smear for detection

›Thin smear for speciation and percent parasitemia

›If initial smear negative with high suspicion, repeat every 12 to 24 hours for 3 sets

06Diagnostic Tests/dt42

Scoring Systems

›Scoring systems

›Sepsis severity tools

›qSOFA for rapid bedside risk stratification

›NEWS2 for deterioration risk stratification

›Severe malaria criteria framework

›Any impaired consciousness or coma

›Multiple seizures

›Respiratory distress or ARDS

›Shock

›Acidosis with elevated lactate

›Hypoglycemia

›Severe anemia

›Hyperparasitemia percent parasitemia reporting on thin smear

MRI

›MRI indications and protocols

›Neurocysticercosis evaluation

›Parenchymal cysts and edema characterization

›Ventricular or subarachnoid disease assessment

›Spinal or cerebral parasite complications

›Myelitis concern

›Vasculitis concern

›Limitations

›Unstable patient transport risk

›Time to imaging delay risk

CT

›CT indications and protocols

›Head CT with contrast when safe

07Disposition/dispo31

Admission and higher level care

›Admission and higher level care criteria

›Suspected or confirmed malaria with severity features

›Altered mental status

›Acidosis or elevated lactate

›AKI

›Hypoglycemia

›Severe anemia

›Respiratory distress

›CNS parasitic infection concern

›New seizure

›Focal deficits

›Hydrocephalus concern

›Inability to tolerate oral therapy

›Persistent vomiting

›Severe dehydration

›Immunocompromised host

›Steroid therapy need with Strongyloides risk

›Advanced HIV with toxoplasmosis concern

›Social barriers

›Unreliable follow up

›Unsafe home environment

Discharge criteria and follow up

›Discharge criteria and follow up

›Nonsevere illness with stable vitals

›No altered mental status

›No significant dehydration

›Confirmed diagnosis with oral regimen and tolerance

08Treatment/t54

Immediate therapy for unstable presentations

›Immediate therapy for unstable presentations

›Sepsis bundle alignment

›If shock, vasopressor titration to perfusion targets

›If severe metabolic derangement, targeted correction with close monitoring

›Hypoglycemia management

›IV dextrose bolus for symptomatic hypoglycemia

›Dextrose infusion if recurrent hypoglycemia

›Seizure management

›Benzodiazepine first line

›Levetiracetam or phenytoin loading per institutional protocol

›Anaphylaxis management

›If suspected hydatid cyst rupture with anaphylaxis, epinephrine protocol and airway readiness

Antiparasitic regimens

›Antiparasitic regimens selection

›Severe malaria, initial parenteral therapy

›Artesunate IV 2.4 mg/kg at 0 hours

›Artesunate IV 2.4 mg/kg at 12 hours

›Artesunate IV 2.4 mg/kg at 24 hours

›Transition to complete oral antimalarial course after clinical improvement and parasite density decline

›Choice guided by species, resistance region, and local guidance

›Uncomplicated malaria, oral options

›Artemisinin-based combination therapy per local protocol

›Directly observed first dose when feasible

›Repeat smear plan to document clearance when indicated

›Strongyloidiasis, uncomplicated

›Ivermectin 200 microg/kg PO daily for 1 to 2 days

›Relative contraindication, suspected Loa loa coinfection

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Maternal fetal risk stratification

›Malaria in pregnancy with higher severe disease risk

›Lower threshold for admission and parenteral therapy if malaria suspected

›Obstetrics consultation for fetal monitoring plan

›Medication safety

›Avoid teratogenic antiparasitics when alternatives exist

›Shared decision making with obstetrics and infectious diseases

›Breastfeeding compatibility check for selected agents

›Diagnostic modifications

›Radiation sparing imaging when feasible

›Ultrasound first strategy for hepatobiliary concerns

›MRI preferred over CT when clinically equivalent and stable

Geriatric

›Geriatric considerations

›Atypical presentation risk

›Blunted fever response

›Delirium as primary sign of severe infection

›Lower threshold for admission

›Medication risk

›QT prolongation and polypharmacy interaction review

›Renal dosing adjustments with AKI risk

›Falls risk with dehydration and orthostasis

›Complication risk

›Higher risk from severe anemia and hypoxemia

›Lower physiologic reserve in sepsis physiology

›Early escalation planning

10Background/b47

Epidemiology

›Epidemiology

›Malaria importation relevance

›Returning traveler fever with malaria risk until excluded

›Many labs have limited smear experience in low incidence settings

›Repeat smears needed in nonimmune low parasitemia early disease

›Helminth exposure patterns

›Strongyloides endemic in tropical and subtropical regions

›Chronic infection possible for decades

›Hyperinfection triggered by immunosuppression

›Freshwater exposure patterns

›Schistosomiasis linked to contaminated freshwater exposure

›Symptom onset may be delayed after exposure

›Treatment timing after exposure affects efficacy

Pathophysiology

›Pathophysiology

›Malaria

›RBC infection with hemolysis

›Microvascular obstruction and tissue hypoxia in falciparum

›Multiorgan dysfunction pathways

›Protozoal diarrhea

›Enterocyte disruption and malabsorption

›Secretory diarrhea and dehydration

›Prolonged shedding and reinfection risk

›Helminth infections

›Tissue migration and eosinophilic inflammation

›Chronic granulomatous response in schistosomiasis

›Autoinfection in Strongyloides

11Patient Discharge Instructions/pdi27

copy discharge instructions

›copy discharge instructions

›Diagnosis and expectations

›Parasitic infection suspected or confirmed based on testing and clinical features

›Symptoms may improve over days after starting therapy

›Some tests may still be pending

›Medications

›Take antiparasitic exactly as prescribed

›Avoid alcohol with nitroimidazoles if prescribed

›Call if rash, severe nausea, jaundice, or new confusion

›Hydration and diet

›Oral rehydration solution for diarrhea

›Small frequent fluids

›Resume normal diet as tolerated

›Return to ED now

›Trouble breathing

›Fainting or severe weakness

›Confusion, severe headache, seizure

›Persistent vomiting with inability to keep fluids down

›Bloody stool or black stool

›Decreased urination or severe dehydration signs

›Fever with recent travel to malaria region, especially within months of return

›Worsening jaundice or dark urine

›New chest pain or severe abdominal pain

›Follow up

›Follow up with infectious diseases or travel clinic within recommended timeframe

›Repeat labs or stool testing if directed

›If malaria suspected, return for repeat smears if symptoms persist despite initial negative testing

12References/r10

Clinical guidelines and key sources

›Clinical guidelines and key sources

›CDC, Treatment of Severe Malaria, artesunate dosing 2.4 mg/kg at 0, 12, 24 hours

›CDC, Evaluation and Diagnosis of Malaria, repeat smears every 12 to 24 hours for 3 sets if high suspicion

›Canada, CATMAT, repeat smears at 12 and 24 hours if symptoms persist

›CDC, Clinical Care of Strongyloides, ivermectin 200 microg/kg PO for 1 to 2 days and contraindication considerations

›CDC, Clinical Care of Schistosomiasis, traveler treatment timing 6 to 8 weeks after freshwater exposure

›IDSA, Neurocysticercosis guideline, albendazole 15 mg/kg/day divided with max 1200 mg/day

›CDC, Clinical Care of Toxoplasmosis, pyrimethamine based regimen with leucovorin

›HIV clinical guidelines, toxoplasmosis dosing framework for adults

›Source specification and formatting requirements

Evidence & Review

Evidence & Review