Capsule 4 - Bronchiolitis & Fever Flashcards
Cause of bronchiolitis
RSV
Proportion of kids needed to be admitted with RSV
1-2%
What is bronchiolitis
Swelling of bronchioles with mucus production
Sx of bronchiolitis
Coryzal symptoms & blocked nose
Reduced feeding
Cough
Wheeze / apnoeas
Risk factors for severe bronchiolitis
Chronic lung disease
Congenital heart disease
Under 3 months old
Premature
NMD
Immunodeficiency
What is the usual disease duration of bronchiolitis
7 days
What key Qs do you need to ask about in bronchiolitis Hx?
Feeding and hydration
Apnoeas - especially young babies
Risk factors for severe bronchiolitis
Ix for bronchiolitis
Clinical Ix mainly
Observations - O2 sats, temp
Admission criteria for bronchiolitis
- Do they need respiratory support? –> O2 sats <90% / difficulty in breathing / apnoeas
- Do they need feeding support? –> poor hydration or <50% of feeds
- Do they look sick?
Mx of bronchiolitis
Feeding support - oral (2nd = NG, 3rd = IV fluids)
Resp support - O2 sats <90%, then given O2
When can bronchiolitis pt be dischraged?
Look well, clinically stable
Sats >90%
Feeding >50% of normal
Caregiver can manage at home
Safety netting
When to step up care in bronchiolitis?
SaO2 persistently below 90% despite on O2
Signs of impending resp failure - tachypnoeic then bradypnoeic
Recurrent apnoeas
Look exhausted
Desaturations despite O2
How to step up in bronchiolitis?
Cap blood gas for resp distress
Optiflow or CPAP
Consider CXR is clinical deterioration
Talk to PICU
What is the approach to the febrile child?
Depends on age, degree of clinical concern
Can you find a cause?
Use NICE traffic light system
Identify life threatening features early
How can you measure fever?
Take parents perception of fever seriously, especially in young kids
Tools: Axillary electronic / axillary chemical dot / tympanic infra red
NOT ANYTHING ELSE - forehead strips, non touch infrared, hand on forehead
What features are considered in the NICE traffic light system?
Colour, respiration, circulation and hydration and other factors
What specific infections are you looking for in febrile child?
Meningococcal disease
Bacterial meningitis
Herpes simplex encephalitis
Pneumonia
UTI
Septic arthritis
Kawasaki disease
Sx of Bacterial meningitis
Older children - stiff neck, photophobia, headache
Babies - irritability, vague symptoms
Causative organisms of fever in under 1 month
(usually maternal)
GBS
E.Coli
Listeria
HSV
Ix & initial Mx for fever in under 1 month old
Full septic screen - blood culture, urine culture, LP
Give full ABx within 1 hour - cefotaxime and amoxicillin
Always admit
Causative organisms of fever in 1-3 months
Maternal - GBC, E.Coli, listeria
Post-natal - meningococcal, strep, staph, HiB
Viruses - RSV, enterovirus, adneovirus, HSV
Ix for fever in 1-3 months
FBC, blood culture
CRP
Urine MC&S
CXR if resp signs
Stool culture if diarrhoea
LP if look unwell or have WCC out of normal range
When do you start IV Abx in fever in 1-3 month olds
Child looks unwell, WCC out of normal range
How do you get a urine sample in an under 1 year old?
Suprapubic aspiration with USS guidance is gold standard but rarely done
Clean catch but high chance of contamination
NOT cotton wool sample or bag sample
Causes of fever in >3 month olds
Rare to get perinatally acquired infections
Meningococcal/strep/e.coli/staph/HiB
Viral - RSV/influenza etc –> HSV is the one to worry abou
Ix for fever in >3 months old (traffic light system)
Red features = FBC, cultures, CRP, urine +/- LP/CXR/blood gas
Amber features = urine, bloods, maybe LP. CXR if fever >39 or WCC high
Green features = no bloods, urine test only
Mx of fever >3 months
Consider period of observation in hospital
Don’t rely on decrease / lack of fever after anti-pyretics
Abx if needed - ceftriaxone
+/- acyclovir
Tachycardia in <1 year
> 160
Tachycardia in 1 to 2 years
> 150
Tachycardia in 2-5 year olds
> 140
Tx of fever in children
20ml/kg 0.9% saline bolus then reassess and ABx if shocked
If signs of meningococcal disease / unrousable, then give immediate IV ABx
How do you discharge a febrile child?
Always safety net
Make judgements based on family and their social situation - consider ambulation (send home but come back in for ABx) if clinically well
Give the green / amber / red COLOUR features of a febrile child
Green = normal colour
Amber = pallor
Red = mottled/pale/ashen/blue
What are the green activity features of a febrile child?
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry or not crying
What are the amber activity features of a febrile child?
Not responding to social cues normally
No smiling
Reduced activity
Wakes only to prolonged stimulation
What are the red activity features of a febrile child?
No response to social cues
Appears ill
Does not wake or stay awake
Cry is weak / high pitched / continuous
What are the amber respiratory features of a febrile child?
Nasal flaring
Tachypnoea - RR >50 breaths/minute (6–12 months) OR
RR >40 breaths/minute (>12 months)
Oxygen saturation ≤95%
What are the red respiratory features of a febrile child?
Grunting
Tachypnoea: RR >60 breaths/minute
Moderate or severe chest indrawing
What are the amber circulation/hydration features of a febrile child?
Tachycardia: - >160 beats/minute, age <12 months OR
- >150 beats/minute, age 12–24 months OR >140 beats/minute, age 2–5 years
CRT ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
What are the red circulation/hydration features of a febrile child?
Reduced skin turgour
List other amber features of a febrile child
Age 3–6 months, temperature ≥39°C
Fever for ≥5 days
Rigors
Swelling of a limb or joint
Non-weight bearing limb/not using an extremity
List other red features of a febrile child
Age <3 months, temperature ≥38°C*
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs or focal seizures
