WEBVTT 00:00:00.000 --> 00:00:08.810 [This tape was duplicated from a 16mm film by Erickson Archival for the National Library of Medicine, September 2003. NLM call number HF4066] 00:00:16.710 --> 00:00:20.180 On the Ganges River delta where cholera has remained a problem for centuries lies Dhaka. 00:00:20.180 --> 00:00:25.650 [Ambulance driving along road] 00:00:25.650 --> 00:00:34.810 This laboratory, established for research on the prevention and treatment of cholera, was placed in Dhaka where the disease occurs every year. 00:00:34.810 --> 00:00:42.280 Patients with cholera are brought by ambulance from remote areas for treatment. 00:00:42.280 --> 00:00:49.580 By the time a patient reaches the hospital, he may have lost 10 percent of his body weight as diarrhea and vomitus. 00:00:49.580 --> 00:00:53.490 In a 50 kilogram man, this amounts to 5 liters. 00:00:53.490 --> 00:00:58.850 He may be in shock, pulse-less in all extremities, and profoundly weak. 00:00:58.850 --> 00:01:01.850 He cannot stand or even sit up. 00:01:01.850 --> 00:01:18.070 It is entirely possible in cholera to be reduced to such a state in a few hours, but usually it takes from 12 to 18 hours. 00:01:18.070 --> 00:01:24.330 His eyes are deeply sunken from fluid loss. 00:01:24.330 --> 00:01:31.250 His fingers and toes are shriveled and cold. 00:01:31.250 --> 00:01:38.690 His skin has lost its normal turgor. 00:01:38.690 --> 00:01:43.090 His mouth and tongue may be dry unless he has just vomitted. 00:01:43.090 --> 00:01:48.130 Patients are usually conscious and oriented, but senses may be dull. 00:01:48.130 --> 00:01:59.760 In extreme states, the patient may be unconscious and close to death. 00:01:59.760 --> 00:02:11.870 If the water and salt lost in the diarrhea of cholera are replaced swiftly and then a balance is maintained, survival is assured. 00:02:11.870 --> 00:02:17.370 This same individual is now well. 00:02:17.370 --> 00:02:22.000 With proper treatment, cholera patients recover quickly. 00:02:22.000 --> 00:02:27.840 [The U.S. Department of Health, Education, and Welfare Public Health Service presents] 00:02:27.840 --> 00:02:32.850 [a Public Health Service Audiovisual Facility production] 00:02:32.850 --> 00:02:38.830 [Produced in cooperation with the Southeast Asia Treaty Organization Cholera Research Program of the National Institutes of Health] 00:02:38.830 --> 00:02:47.600 [and the Agency for International Development] 00:02:47.600 --> 00:02:58.170 [Cholera Today. Bedside Evaluation and Treatment] 00:02:58.170 --> 00:03:05.660 When cholera strikes in areas where practitioners are not acquainted with modern treatment methods, many people lose their lives. 00:03:05.660 --> 00:03:11.180 Case fatality rates in some effected populations may be more than 60 percent. 00:03:11.180 --> 00:03:18.540 This unneccesary loss of life creates panic, seriously interferring with effective control measures. 00:03:18.540 --> 00:03:25.770 Panic can be avoided by proper treatment because treatment can prevent deaths in even the most severe cases. 00:03:25.770 --> 00:03:34.550 Although they represent only a small fraction of the number of infected persons, these severe cases are the greatest challenge to the physician. 00:03:34.550 --> 00:03:40.580 When a cholera patient is brought to a treatment center, he should be weighed on arrival. 00:03:40.580 --> 00:03:49.990 This information is used to judge the amount of fluid needed. 00:03:49.990 --> 00:04:10.090 After weighing, while the patient is being placed on a cholera cot, the doctor can rapidly evaluate the patient. 00:04:10.090 --> 00:04:14.810 The sunken eyes and cheeks indicate severe dehydration. 00:04:14.810 --> 00:04:24.170 As does tenting of the skin. 00:04:24.170 --> 00:04:27.270 The pulse can be felt quickly and easily. 00:04:27.270 --> 00:04:30.440 Both volume and rate should be noted. 00:04:30.440 --> 00:04:38.140 The blood pressure should be measured, if possible, by feeling the brachial pulse, as well as listening with a stethoscope. 00:04:38.140 --> 00:04:50.460 On admission, the brachial blood pressure is often unmeasurable in severe cases. 00:04:50.460 --> 00:04:58.410 The respiratory rate and depth are generally increased in cholera due to the accompanying metabolic acidosis. 00:04:58.410 --> 00:05:04.010 Prompt restoration of lost fluids and salt is the primary goal in treating cholera. 00:05:04.010 --> 00:05:08.940 Treatment must therefore begin immediately in patients with vascular collapse. 00:05:08.940 --> 00:05:15.470 Placement of an 18 or 20 gauge needle in an appropriate vein is crucial for rapid infusion of fluid. 00:05:15.470 --> 00:05:21.130 A second vein may have to be used to achieve adequate flow. 00:05:21.130 --> 00:05:27.530 In small infants and children or even adults with difficult veins, 00:05:27.530 --> 00:05:31.020 it is very important to be skilled in performaing vena punctures in a variety of sites. 00:05:31.020 --> 00:05:35.050 Any superficial vein of the legs or arms may be used. 00:05:35.050 --> 00:05:47.010 The external jugular vein may be the most accessible superficial vein in a young child and can be used in adults. 00:05:47.010 --> 00:05:53.790 The use of scalp vein needles has greatly facilitated entering small veins and maintaining infusions in them 00:05:53.790 --> 00:06:12.190 because they are easily manipulated and lie flat when taped down. 00:06:12.190 --> 00:06:26.680 If such a vein is not immediately found, the femoral vein should be used to give fluid. 00:06:26.680 --> 00:06:33.990 Cut-downs are not needed in cholera therapy. 00:06:34.650 --> 00:06:43.880 The initial rate of infusion in a severely dehydrated adult, like this one, should be a minimum of 1 liter in 15 minutes. 00:06:43.880 --> 00:06:48.440 Several liters are usually required for patients pulseless on admission. 00:06:48.440 --> 00:06:53.270 Such patients need fluids equal to 10 percent of their bodyweight. 00:06:53.270 --> 00:06:57.020 This 40 kilogram man required 4 liters. 00:06:57.020 --> 00:07:03.190 When rehydration is complete, a patient should have a strong radial pulse and and normal blood pressure. 00:07:03.190 --> 00:07:07.510 His eyes and cheeks are less sunken and his tongue is moist. 00:07:07.510 --> 00:07:15.610 His breathing should be slow and regular and his skin should have its normal turgor. 00:07:15.610 --> 00:07:26.240 After rehydration is complete, the rate of fluid therapy should match the measured rate of diarrhea. 00:07:26.240 --> 00:07:30.450 All excreta and vomitus must be collected and measured. 00:07:30.450 --> 00:07:36.440 The cholera cot channels all stool into a receptacle calibrated for easy monitoring. 00:07:36.440 --> 00:07:38.950 Urine is collected separately. 00:07:38.950 --> 00:07:44.950 A water-proof sheet with a sleeve attached assures quantative collection of the stool. 00:07:44.950 --> 00:07:54.170 Continuing monitoring of intake and output, recorded on a simple bedside chart, is essential to the best care. 00:07:54.170 --> 00:08:03.780 The characteristic rice water diarrhea of cholera is a straw colored watery fluid with a slightly fishy smell, not fecal in character. 00:08:03.780 --> 00:08:08.550 The fluid lost in cholera is primarly this liquid stool. 00:08:08.550 --> 00:08:12.990 Vomiting may contribute significantly during early rehydration. 00:08:12.990 --> 00:08:17.100 A patient can purge up to 14 liters in a 8 hour period. 00:08:17.100 --> 00:08:22.430 20 liters a day and 100 liters in a 5 to 7 day period. 00:08:22.430 --> 00:08:37.590 This fluid contains sodium, potassium, bicarbonate, and chloride. 00:08:37.590 --> 00:08:48.190 Fluids given in treatment should match the compostion of fluids lost. 00:08:48.190 --> 00:08:52.240 This is the composition of the so-called "5-4-1" solution. [Chart: Composition of Intravenous Solution [grams/l. NaCl 5. NaHCO3 4. KCl 1]] 00:08:52.240 --> 00:08:53.940 An intravenous solution commonly used to treat cholera. 00:08:53.940 --> 00:08:59.230 The salts are in the same proportions as in the cholera diarrhea of adults. 00:08:59.230 --> 00:09:03.850 Children have slightly less sodium and more potassium in their diarrhea, 00:09:03.850 --> 00:09:11.620 but patients of all ages can be treated with the same intravenous solution provided they are allowed oral water as desired. 00:09:11.620 --> 00:09:15.270 Special electrolyte solutions are not nessecary. 00:09:15.270 --> 00:09:20.580 Acetate or lactate can be substituted for bicarbonate in this solution. 00:09:20.580 --> 00:09:28.400 Ringers lactate, or normal saline, can be given if extra potassium and bicarbonate are given by mouth. 00:09:28.400 --> 00:09:38.850 Since children with cholera sometimes become hypoglycemic, the addtion of 2 percent glucose to their intervenous fluid is recommended. 00:09:38.850 --> 00:09:43.810 After rehydration is complete, or if the blood pressure is normal on admission, 00:09:43.810 --> 00:09:48.190 patients should be treated with oral instead of intravenous fluids. 00:09:48.190 --> 00:10:04.940 Use of oral therapy can markedly reduce the amount of expensive intravenous fluids needed to treat cholera patients. 00:10:04.940 --> 00:10:12.450 The oral solution used for cholera has less sodium and more potassium than the intravenous solution [Chart: Composition of Oral Solution] [grams/l. NaCl 4.2. NaHCO3 4.0. KCl 1.8. Glucose 20.0 00:10:12.450 --> 00:10:16.350 and is suitable for treating children as well as adults. 00:10:16.350 --> 00:10:22.620 Glucose is necessary since the solution can only be absorbed in the presence of glucose. 00:10:22.620 --> 00:10:27.190 If glycine is availabe, its addition further faciliates absorption. 00:10:27.190 --> 00:10:33.370 8.25 grams can be added to each liter. 00:10:33.370 --> 00:10:44.810 The ingredients of this solution are readily available in most areas. 00:10:44.810 --> 00:10:55.520 As the solution is given by mouth, ordinary drinking water is used and the solution should not be autoclaved. 00:10:55.520 --> 00:11:01.340 Oral maintenance therapy cuts intravenous needs of serverely ill patients by 80 percent. 00:11:01.340 --> 00:11:09.390 In milder cases, oral therapy can completely replace intravenous therapy. 00:11:09.390 --> 00:11:17.240 The solution can be administered by nurses or medical assistants on the orders of a physician. 00:11:17.240 --> 00:11:30.950 Once a patient's blood pressure is normal, oral fuid can be given either by mouth or way of a nasogastric tube to match continued diarrheal losses. 00:11:30.950 --> 00:11:34.760 After treatment has been started, a rectal swab should be taken. 00:11:34.760 --> 00:11:42.600 Culture of this specimen will confirm the diagnosis and permit accurate public health reporting. 00:11:42.600 --> 00:11:49.530 Once culture specimens have been collected, tetracycline or furazolidone should be given. 00:11:49.530 --> 00:11:58.550 This will stop the diarrhea early, reducing the requirement for fluids and shortening hospitalization. 00:11:58.550 --> 00:12:08.290 [Clipped soundtrack] villages, field treatment centers have been established. 00:12:08.290 --> 00:12:14.720 At this center, in a tent, successful therapy has been given with only the simplest of equipment. 00:12:14.720 --> 00:12:18.460 The only true essentials for satisfactory cholera treatment 00:12:18.460 --> 00:12:25.810 are an individual skilled in judging and replacing fluid losses, the proper solutions, the tubing and needles with which 00:12:25.810 --> 00:12:35.670 to give intravenous fluids, and tetracycline or furazolidone. 00:12:35.670 --> 00:12:49.060 During epidemic situations, this irreducible minimum has been used with over 99 percent recovery. 00:12:49.060 --> 00:12:59.250 To recapitulate the important points of therapy: the patient is quickly evaluated as he enters the treatment center. 00:12:59.250 --> 00:13:06.030 Intravenous therapy of severely dehydrated patient is begun immedietly. 00:13:06.030 --> 00:13:14.690 The wrinkled fingers known as "Washer Woman's Hands" and the loss of skin turgor signals severe dehydration. 00:13:14.690 --> 00:13:20.270 The rapid deep breathing suggests metabolysis. 00:13:20.270 --> 00:13:28.010 Absence of the radial pulse and unobtainable blood pressure indicate hypovolemic shock. 00:13:28.010 --> 00:13:35.740 The heart sounds are faint and in severe cases almost inaudible. 00:13:35.740 --> 00:13:40.820 Initial rehydration can be quickly accomplished through any large vein. 00:13:40.820 --> 00:13:47.490 In small children and infants, a scalp vein needle in the external jugular vein is often succesful. 00:13:47.490 --> 00:13:51.550 The femoral vein is used if necessary. 00:13:51.550 --> 00:13:57.120 Oral fluid should be used to reduce the need for intravenous fluids. 00:13:57.120 --> 00:14:04.810 It must always be remembered that proper regulation of the rate of intravenous and oral fluid replacement 00:14:04.810 --> 00:14:08.140 is the key to survival of all cholera patients. 00:14:08.140 --> 00:14:14.330 Careful bedside records of output are essential to the correct administration of replacement fluids. 00:14:14.330 --> 00:14:19.720 Tetracycline or furazolodine is used to stop the diarrhea early. 00:14:19.720 --> 00:14:24.830 Proper treatment is the most important part of any cholera control program. 00:14:24.830 --> 00:14:31.520 With intravenous and oral fluid replacement therapy, patients recover and confidence is restored. 00:14:31.520 --> 00:14:35.180 Person-to-person spread is not important in transmission. 00:14:35.180 --> 00:14:43.150 Medical personnel and laboratory workers should not be fearful of their own safety. They almost never become ill with cholera. 00:14:43.150 --> 00:14:51.360 With modern treatment methods, cholera need no longer be thought of as a dread disease. 00:14:51.360 --> 00:14:57.040 [Technical advisors. Original Film--1966. Dr. Robert S. Gordon. Dr. W.B. Greenough, III. Dr. Norbert Hirschhorn] 00:14:57.040 --> 00:15:03.780 [Revised Film--1971. Dr. John N. Lewis. Dr. Eugene J. Gangarosa. Dr. Abram S. Benenson. Dr. David R. Nalin] 00:15:03.780 --> 00:15:09.830 [The end. M-1012. MCMLXXI]