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Guidelines for the treatment of malaria – 2 edition

8.2 treatment objectives
The main objective is to prevent the patient from dying. Secondary objectives are
prevention of disabilities and prevention of recrudescence.

The mortality of untreated severe malaria (particularly cerebral malaria) is thought
to approach 100%. With prompt, effective antimalarial treatment and supportive care
the mortality falls to 15–20% overall; although within the broad definition there are
syndromes associated with mortality rates that are lower (e.g. severe anaemia) and higher
(metabolic acidosis). Death from severe malaria often occurs within hours of admission
to hospital or clinic, so it is essential that therapeutic concentrations of a highly effective
antimalarial are achieved as soon as possible. Management of severe malaria comprises
four main areas: clinical assessment of the patient, specific antimalarial treatment,
adjunctive therapy and supportive care.

8.3 clinical assessment

Severe malaria is a medical emergency. An open airway should be secured in unconscious
patients and breathing and circulation assessed. The patient should be weighed or body
weight estimated, so that medicines, including antimalarials and fluids, can be given
accordingly. An intravenous cannula should be inserted and immediate measurements
of blood glucose (stick test), haematocrit/haemoglobin, parasitaemia and, in adults, renal
function should be taken. A detailed clinical examination should be conducted, including
a record of the coma score. Several coma scores have been advocated. The Glasgow coma
scale is suitable for adults, and the simple Blantyre modification or children’s Glasgow
coma scale are easily performed in children. Unconscious patients should have a lumbar
puncture for cerebrospinal fluid analysis to exclude bacterial meningitis.

The degree of acidosis is an important determinant of outcome; the plasma bicarbonate
or venous lactate level should, therefore, be measured, if possible. If facilities are available,
arterial or capillary blood pH and gases should be measured in patients who are
unconscious, hyperventilating or in shock. Blood should be taken for cross-match, full
blood count, platelet count, clotting studies, blood culture and full biochemistry (wherever
possible). The assessment of fluid balance is critical in severe malaria. Respiratory
distress, in particular with acidotic breathing in severely anaemic children, often indicates
hypovolaemia and requires prompt rehydration and, where indicated, blood transfusion
(see also Section 8.10.3).

8.3.1 Diagnosis

The differential diagnosis of fever in a severely ill patient is broad. Coma and fever
may result from meningoencephalitis or malaria. Cerebral malaria is not associated

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