Development of the siriraj clinical asthma score.

INTRODUCTION: Acute asthmatic attack in children commonly occurs despite the introduction of effective controllers such as inhaled corticosteroids and leukotriene modifiers. Treatment of acute asthmatic attack requires proper evaluation of attack severity and appropriate selection of medical therapy. In children, measurement of lung function is difficult during acute attack and thus clinical asthma scoring may aid physician in making further decision regarding treatment and admission. METHODS: We enrolled 70 children with acute asthmatic attack with age range from 1 to 12 years (mean ± SD = 51.5 ± 31.8 months) into the study. Twelve selected asthma severity items were assessed by 2 independent observers prior to administration of salbutamol nebulization (up to 3 doses at 20 minutes interval). Decision for further therapy and admission was made by emergency department physician. Three different scoring systems were constructed from items with best validity. Sensitivity, specificity and accuracy of these scores were assessed. Inter-rater reliability was assessed for each score. Review of previous scoring systems was also conducted and reported. RESULTS: Three severity items had poor validity, i.e., cyanosis, depressed cerebral function, and I:E ratio (p > 0.05). Three items had poor inter-rater reliability, i.e., breath sound quality, air entry, and I:E ratio. These items were omitted and three new clinical scores were constructed from the remaining items. Clinical scoring system comprised retractions, dyspnea, O2 saturation, respiratory rate and wheezing (rangeof score 0-10) gave the best accuracy and inter-rater variability and were chosen for clinical use-Siriraj Clinical Asthma Score (SCAS). CONCLUSION: A Clinical Asthma Score that is simple, relatively easy to administer and with good validity and variability is essential for treatment of acute asthma in children. Several good candidate scores have been introduced in the past. We described the development of the Siriraj Clinical Asthma Score (SCAS) in this report and reviewed the literature on the development of clinical asthma score for use in children.

Dengue hemorrhagic fever grade III with diabetic ketoacidosis: a case report.

A 16-year-old, previously healthy Thai girl presented with DHF grade III. Fifteen hours after the first episode of shock, she had received an excessive amount of crystalloid isotonic solution and 20 ml per kilograms of Dextran-40 however she still had persistently rapid pulse rate and high hematocrit but also had polyuria with more than 4 ml/kg/hr of urine output. She was re-evaluated. Clinical signs showed severe dehydration with some ascites without signs of pleural effusion. Blood gas revealed increased anion gap metabolic acidosis. The cause of polyuria and metabolic acidosis was identified with hyperglycemia, ketouria and glucosuria. Afterwards she was diagnosed and treated as DHF grade III and DKA. Besides insulin administration, fluid resuscitation was very crucial. Intravenous fluid rehydration was needed while the unnecessary extra-volume could cause massive plasma leakage and later on fluid overload. Volume replacement was adjusted to degree of dehydration when signs of volume overload were monitored closely. She was out of DKA at 14 hours after the start of insulin and the intravenous fluid was stopped at 27 hours (36 hours after the first episode of shock). The final diagnosis was DHF grade III, diabetes mellitus with DKA and hepatitis.