## Severe Malaria Management **Key Point:** Artemether (IV or IM) is the WHO-recommended and Indian guideline-endorsed drug of choice for severe *Plasmodium falciparum* malaria, regardless of drug resistance patterns. **High-Yield:** Severe malaria is defined by the presence of any one of: cerebral malaria (altered mental status), severe anaemia (Hb <7 g/dL), renal failure (creatinine >3 mg/dL), pulmonary oedema, hypoglycaemia, acidosis, or parasitemia >5%. This patient has cerebral malaria (altered mental status) and high parasitemia (8%), meeting criteria for severe malaria. ## Why Artemether? | Feature | Artemether | Chloroquine | Atovaquone-Proguanil | Mefloquine | |---------|-----------|-------------|----------------------|-----------| | Severe malaria indication | Yes, first-line | No, ineffective in severe | No, for uncomplicated | No, oral only | | Onset of action | Rapid (hours) | Slow (days) | Slow | Slow | | Parenteral form | IV/IM | Oral/IM (rarely used) | Oral only | Oral only | | Cerebral malaria efficacy | Superior | Poor | Not indicated | Not indicated | | Mortality reduction | 35% vs quinine | — | — | — | **Clinical Pearl:** Artemether is superior to quinine in severe malaria with a 35% reduction in mortality. It achieves rapid parasite clearance and prevents sequestration in cerebral vessels. **Mnemonic:** **SEVERE = Artemether** (Artemisinin derivatives for SEVERE malaria). ## Treatment Algorithm ```mermaid flowchart TD A[Suspected Malaria]:::outcome --> B{Severe features present?}:::decision B -->|Yes| C[Artemether IV/IM]:::action B -->|No| D{P. falciparum?}:::decision D -->|Yes| E[Artemisinin-based combination<br/>or Atovaquone-Proguanil]:::action D -->|No| F[Chloroquine]:::action C --> G[Switch to oral ACT<br/>after 3 doses]:::action ``` [cite:KD Tripathi 8e Ch 52; WHO Guidelines 2021]
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