Page 140 - 2022 Ranger Medic Handbook

Malaria
DEFINITION: Protozoan infection transmitted by the female Anopheles mosquito; prevention through personal preven-
tive measures is the key (antimalarial meds, DEET, permethrin, bed nets, and minimized skin exposure). Malaria should
be in the differential diagnosis of any patient with a fever in an endemic area. Malaria CDC Hotline: 770-488-7788,
After Hrs: 770-488-7100.
S/Sx: Hx of travel to malaria-endemic area; noncompliance with antimalarial medications and/or personal preventa-
tive measures. Prodrome of malaise, fatigue, and myalgia may precede febrile paroxysm by several days; paroxysm
characterized by abrupt onset of fever, chills, rigors, profuse sweats, HA, backache, myalgia, abdominal pain, nausea,
vomiting, diarrhea (may be watery and profuse) in P. falciparum; intermittent or continuous fever in P. falciparum malaria;
classic “periodicity” is usually absent. Profuse sweating between febrile paroxysms; tachycardia, orthostatic hypoten-
sion, tender hepatomegaly, and delirium (cerebral malaria).
SECTION 3 lab capability, CBC looking for anemia and low platelets. If unavailable and malaria is suspected, treat empirically. Can
MANAGEMENT: If available, test with rapid assay test (BinaxNow NSN 6550-08-133-2341) or blood smear or if limited
use acetaminophen 1,000mg q6hr prn for fever. Do not use same treatment as was used for prophylaxis. If any treat-
ments are started medics must contact a medical officer.
1. Malarone (atovaquone 250mg/proguanil 100mg) 4 tabs PO qd × 3 consecutive days with food or milk OR
2. Coartem (artemether 20mg/lumefantrine 120mg) 1tab initial dose, repeat single dose 8 hours later, then one dose PO
bid for following 2 days with food or milk OR
3. Quinine sulfate 542mg base PO tid for 3–7 days PLUS doxycycline 100mg PO bid for 7 days AND if known
chloroquine-resistant use: option 1) or 3) and ADD primaquine phosphate 30mg (can cause hemolytic anemia in
G6PD deficiency) base PO qd × 14 days as well.
DISPOSITION: Urgent treatment and evacuation for complicated malaria (cerebral/altered mental status, pulmonary
changes with fever, or abnormal vital signs) these indicate a medical emergency. Priority evacuation for uncomplicated
cases (normal vital signs, normal mental status, no nausea and vomiting, no cough/shortness of breath).
SPECIAL CONSIDERATIONS:
1. Malaria MUST be considered in all febrile patients currently in or recently returned in, a malarious area.
2. It is not uncommon for malaria to present like pneumonia or gastroenteritis (with vomiting and diarrhea).
3. It is appropriate to treat suspected malaria cases empirically if diagnostic test (blood smears or rapid test) are not
available.
4. However, the BinaxNow rapid Diagnostic test is now FDA approved and should be used, if available, to guide treat-
ment selection.
5. The use of chemoprophylaxis does not rule out malaria.
6. Consider bacterial meningitis in evaluating the patient – treat for both disorders if meningitis is suspected.
7. Patients who cannot tolerate PO meds MUST be evacuated.
PROPHYLAXIS AND POST EXPOSURE PROPHYLAXIS
1. Insecicides and preventing mosquito bites are primary prevention.
2. Chemoprophylaxis most commonly done with doxycycline 100mg daily, begin 1–2 days before travel and continue
for 4 weeks after leaving. Cannot miss a dose to be effective.
3. For terminal prophylaxis primaquine 52.6mg daily for 14 days (contraindiciated in G6PD deficiency, ensure all are
screened prior to prescribing).

126 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL