Febrile child Flashcards
Describe the common causes of fever in infancy and childhood
Mostly Viral infection URTI Influenza Gastroenteritis ENT infections Always consider serious bacteria infections Septicaemia Meningitis Arthritis, Osteomyelitis Pneumonia CAP UTI If fever persists beyond 5 days consider Kawasaki’s disease Juvenile onset Rheumatoid arthritis Endocarditis rheumatic fever Malaria TB Post vaccination fever
Causes of fever and rash presentation
common = virus
echovirus, arbovirus, EBV, roseola infantum.
Parechovirus - presents with septic picture
Dengue - Fever, rash, LN, pain
Adenovirus - Resp, GI, Fever, Rash
Measles - Conzya, conjunctivitis, Koffplit spot, fever, Cough, rash spreads from top to bottom
Don’t want to miss
Meningococcus
Henoch Schonlein purpura
Kawasaki’s disease
Juvenile onset Rheumatoid arthritis
Scarlet fever - rest, tonsilitis, fever - tx with penicillin.
Red flag in a child with fever in history
young
Red flag diseases that cause fever in child
Pneumonia UTI Bone or joint infection Kawasaki disease Influenza Meningitis and meningococcal septicaemia
Complications of fever in child
Febrile convulsion - occur in 6 months to 6yr old in an acute febrile illness with no hx of seizures and no CNS abnormalities or infection.
Things to ask on history of a febrile child
Fever - pattern, duration, Measured or not.
Behaviour and colour.
Clingy, miserable, irritable but before and after paracetamol.
Up and down pattern is reassuring
Persistently drowsy or irritable bad.
Other symptoms - cough, coryza, headache, photophobia, diarrhoea, vomiting, abdominal pain, joint symptoms
System review - to identify location of infection
ear nose throat - pulling at ear?, rhinitis
Resp - cough, rattling, children rarely have productive cough.
GI - abdominal pain.
Urology - struggling to pass urine?
PmHx - frequent infection important.
Review fluid input and output
Immunisation status
Recent vaccination
Sick contacts
Travel Hx
Contact with animals
Complete standard paediatric Hx.
What to examine for in a febrile child
Degree of hydration (feeding, urination, sunken eye, dry mucus membranes, RR, fontelle, skin turgor) Source of infection/fever How sick they are - Colour - Activity - Degree of respiratory effort - Hydration - Red flags signs
Red flags signs on examination in a child with fever
5 days of fever
swelling of limb or joint
New lump >2cm
Signs of good hydration in a child
Normal skin and eyes and moist mucous membranes
Signs of moderate dehydration in child
Dry mucous membranes
Poor feeding in infants
CRT >3sec
Reduced urine output
Signs of severe dehydration in a child
Reduced skin turgor Dry mucous membranes Poor feeding in infants CRT >3sec Reduced urine output
Signs of sepsis including meningococcal sepsis
Non-blanching rash
Increase HR
Increased RR for age
Capillary refill time >2s
Signs of meningitis including meningococcal meningitis
Non blanching rash
Neck stiffness may not be present in very young
Bulging fontanelle may or may not be present
Depressed LOC (worrying)
Seizures
Signs of herpes simplex encephalitis
Focal neurology may or mayn’t be present
Focal or generalised seizures
Depressed LOC
Signs of Pneumonia
Tachypnoea, nasal flaring, and chest recession
Chest crackles
O2 desaturation
May be silent and only detected on CXR
Signs of UTI
Vomiting, poor feeding, with or without abdominal pain or tenderness
Lethargy or irritability
Urinary frequency or dysuria
Haematuria
Signs of septic arthritis or osteomyelitis
Swelling of limb of joint
Not using an extremity, non weight bearing
Signs of Kawasaki disease
Fever >5 + at least 4 of the following
- bilateral conjunctival injection
Change in URT mucous membranes with injected pharynx, dry crackles lips or strawberry tongue
Change in peripheries with oedema, erythema or desquamation
Polymorphous rash
Cervical lymphadenopathy
What examination finding would suggest a febrile child is at low risk of serious illness
Colour - normal in skin, lips, and tongue
Activity - responds normally, content and smiling, stays awake or awakens quickly and strong normal cry
Breathing - normal
Hydration - normal
Other - no fever at time of examination
What examination finding would suggest a febrile child is at moderate risk of serious illness
Colour - pallor reported by parent
Activity - not responding normally and ⇩ activity. Hard to wake up.
Breathing - nasal flaring, tachypnoea >50 in 6-12 m or >40 in >1yr.
3s
Other - fever >5d, swelling of limb or joint, non-wt bearing or not using an extremity, a new lump >2cm
What examination finding would suggest a febrile child is at High risk of serious illness
Colour - pale, mottle, ashen or blue
Activity - unresponsive, appears ill, barely rousable, weak high pitched cry or continuous cry
Breathing - grunting, severe distress
Hydration - reduced skin turgor
Other - non blanching rash, fever at time of examination, bulging fontanelle, neck stiffness, seizures or focal neurology, bile stained vomiting.
Mx of less than 1 month old with fever
“Discuss with registrar/consultant
Full sepsis work up
FBC/FIlm, Blood Culture, urine culture (SPA), LP+/- CXR
Admit for empirical antibiotics”
Mx of 1-3 months corrected age with fever
“Discuss with registrar/consultant
Full sepsis workup:
FBC/Film, blood culture, urine culture (SPA)+/- CXR (only if Resp sign and symptoms) +/- LP
Discharge home with review within 12 hours if the child is
previously healthly
Look well
WCC 5,000-15,000
Urine microscopy clear
CXR if taken is clear
CSF if taken negative
If the child is unwell or above criteria are not all satisfied, admit to hospital for observation +/- empiric IV antibiotics”
Mx of > 3 months with clear focal cause of infection
"Child looks well treat as clinically indicated Child looks unwell Discuss with registrar/consultant Investigate as appropriate for clinical focus Admit for treatment"
Mx of >3m with fever and no clear focus of infection in a child that looks well
Urine MCS if less for 12 m then SPA,
Discharge home on symptomatic treatment
Arrange medical review within 24 hr or sooner if deteriorates
Mx of >3m with fever and no clear focus of infection in a child that miserable but still relatively alert, interactive and responsive,
Urine MCS if less for 12 m then SPA,
Discuss with registrar or consultant prior to any investigations.
Mx of >3m with fever and no clear focus of infection in a child that looks unwell
Discuss with senior reg
Full sepsis workup - FBC, Blood cultures, urine culture +-CXR (if respiratory symptoms or signs) +/- LP
Admit to hospital for observation +/- IV antibiotics.
Discharge requirements
Infants less than 1 month of age with fever should be admitted. Infants 1 to 3 months of age: The child is well All investigations are normal The child has been reviewed by a senior registrar/consultant Follow up in 12 hours has been arranged Children older than 3 months: The child is well Follow up has been arranged
Signs of septic shock
Fever or hypothermia Tachycardia hypotension warm shock - wide pulse P, rapid CRT Cold shock - Narrowe Pulse P, prolonged CRT ⇑HR +/- Hypoxia ALOC unwell appearance
Management of septic shock
Danger
Response
Send for help
Airway
B - O2 via face mask
C - continued cardiorespiratory monitoring, IV access (IO)
BC, Blood gas, Blood glucose, FBC, UEC, Coags)
Antibiotics - IV or IM if needed. Benzylpenicillin/cefotaxime/look up
IV fluid resus- 20ml/kg bolus of NS as push over 10mins.
Inotropes if no improvement- warm shock (noradrenaline) cold shock (Dobutamine)
Ventilatory support if distress+ALOC
Correct hypocalcaemia etc.. monitor BSL,
Secondary rests as needed.
Ix in suspected Meningococcal
Blood culture Meningococcal PCR FBC and differential Glucose, urea and electrolytes Coagulation screen LP - would not be recommended in the initial management of an unwell child with fever and purpura. But may be appropriate in suspected meningitis when no other contraindication exist increase ICP Increase WBC - neutrophils Increase protein Decrease glucose
Mx of Meningococcal
DRSABC - resus, ICU Notifiable on suspicion IV assess or IO BC and nasal culture, ABG, U&E, FBC, PLT, coagulation studies IV ABX- Ceftriaxone Supportive therapy - 20ml/kg NS (shocked) and dexamethasone to reduce swelling if needed. Fluid management Admit Chemoprophylaxis - rifampicin
