Febrile Illness - Exam 3 Flashcards
What is considered hypothermia? What is considered a fever? How does a child’s core temp compare to an adults core temp?
Hypothermia is defined as a core temperature < 36.5° C (97.7° F)
Fever usually is defined as a core body (rectal) temperature ≥ 38.0° C (100.4° F).
Young children tend to have slightly higher core temps than adults
Fever is a ______ of body temperature mediated by the _____
regulated elevation
anterior hypothalamus
When does a fever occur?
Fever occurs when there is a rise in the hypothalamic set-point in response to endogenously produced pyrogens - the result of an insult stimulating the body’s inflammatory defenses
An insult, most commonly ____ in kids, induces _____ to release_____that function as endogenous pyrogens (fever producing substance)
viral
macrophages
cytokines (IL-1 and 6)
_____ stimulate the production of _____by the hypothalamus; ______ readjust and elevate the temperature set point.
Cytokines
prostaglandins
prostaglandins
What is the core temperature defined as?
defined as the temperature of blood within the pulmonary artery
How does the body physiologically create more heat to increase the core body temperature to the new up-regulated set point?
Setting skeletal muscles to shivering and stimulating cellular metabolism
The body does this by minimizing heat loss to the environment by vasoconstricting the skin and turning off sweat glands
Give 3 reasons having a fever be a good thing?
Fever can disrupt the growth and reproduction of many invasive pathogenic microorganisms, both bacterial and viral
It also appears to lower the amount of iron that is available to invading bacteria, many of which have a higher iron requirement
It also enhances neutrophil migration, T-Cell proliferation, and interferon activity
What is the most accurate way to measure a fever? What age range using this way?
rectal
birth to 3 years
How does oral temp compare to rectal temp? What age range using oral temps?
oral is generally 0.6 ⁰F lower than rectal d/t mouth breathing or recent ingestion of cold liquids
4 years and older
How does axillary temp compare to oral?
Axillary is 0.5-1 F lower than an oral
_____ ways of measuring temperate is one of the MC due to being quick. When can it give a false reading? What age range should you NOT use this in?
tympanic
if not positioned properly or the external ear canal is occluded by wax
Not reliable in children under 6 months
How does the HR change with a fever in kiddos? What 2 things should you pay close attention to when deciding whether or not to send a febrile child home?
10-15 beat pulse increase with every 1◦C
Pay attention to child’s degree of toxicity and hydration status
Most febrile illnesses are the result of infections affecting the _____ and _____. Most have a _____ origin
respiratory
GI tracts
viral
What is the MC reason to treat a kiddos fever?
if the child appears uncomfortable!!!
Decision to treat is based on child’s behavior, not on any particular threshold
What is the minimum age for APAP? Ibuprofen? ASA?
Acetaminophen: 3 months and up
Ibuprofen: 6 months and up
No aspirin!! only approved for 18 years old and up
How long is a child considered contagious?
Contagious until fever free for 24 hours
What are the criteria to see a child immediately in the office/hospital?
kiddos is less than 3 months old
fever is greater than 105.8
Child is crying unconsolably or whimpering
Child is crying when moved or even touched
Child is difficult to awaken
Child’s neck is stiff
Purple spots or dots are present on the skin
Drooling or unable to swallow
No urine output in >6 hours or 4 times in 24 hours
Uncontrollable vomiting
What are the fever guidelines to see a kiddos within 24 hours?
Child is 3-6 months old (unless fever occurs within 48h after a Dtap vaccine with no other serious symptoms)
Fever exceeds 40◦C or 104◦F
Burning or pain occurs with urination
Fever has subsided for greater than 24h without use of fever reducers, then returned
Fever has been present greater than 72 h
_____ account for most bacterial infections in infants under 90 days of age
UTI’s
What are the risk factors for an invasive bacterial infection (IBI) or serious viral infection?
Age - especially under 28 days
Ill appearance: lethargy, listlessness, toxic appearance, respiratory distress, petechiae/purpura, inconsolability
Rectal temp greater than 104F
Not immunized or under immunized (specifically first dose of Hib and pneumococcal )
Prematurity
Comorbidities
Received antibiotics in last 3 to 7 days (can mask s/s)
Risk of maternally transmitted diseases
When would a kiddos undergo a complete evaluation with a fever?
all ill-appearing children with toxic look will undergo full evaluation regardless of age
What would be in a work up of a kiddo less than 3 months old, who is well appearing, has a fever without an apparent source of infection? What is the pt education?
UA, blood cultures, inflammatory markers
consider HSV
would want to add LBP if less than 28 days old or abnormal inflammatory markers
mom should continue breastfeeding even while kiddo is sick
**What are considered elevated inflammatory markers in a kiddo?
Laboratory values of inflammation are considered elevated at the following levels:
(1) procalcitonin >0.5 ng/mL
(2) CRP >20 mg/L
(3) ANC >4000 to 5200 per mm3
When should you consider discontinuing IV abx in a kiddo? to be discharged
- Culture results are negative for 24 to 36 hours or only positive for contaminants
- The infant continues to appear clinically well or is improving (eg. no fever, feeding well)
- No other reasons for hospitalization
ALL criteria must be met
For a kiddo between 3 and 36 months old, what does the plan of care depend on?
immunization status!!! and if they present well or sickly
What does lesions in the oropharynx make you think?
think more viral causes (ulcers or vesicles in gingivostomatitis and hand, foot, mouth)
What is the w/u for a kiddo 3-36 months old, well appearing but NOT UTD?
CBC
blood culture if WBC> or = to 15K
UA and culture: girls under 24m, boys uncircumcised under 12 months and circumcised under 6 months
CXR: if WBC > or = to 20K
WBC > or = to 15K give ceftriazone IM or clinda IV
What is the w/u for a kiddo 3-36 months old, well appearing and UTD?
lab work is NOT recommended
can f/u in 24-48 hours if pt remain febrile
When is a kiddo at risk of febrile seizures? _____ are the likely culprit
6 months to 5 years
self-limited viral infections the increased risk of febrile seizures
describe a simple febrile seizure. What are the common cause?
A generalized tonic or tonic-clonic seizure usually lasting less than 5 minutes and occurring once within 24 hours of the onset of fever; may begin without warning
Viral illnesses are the most common cause
What should you do if your kiddo has a febrile seizure?
Child must be evaluated to exclude CNS infection -> could be meningitis or encephalitis
CMP, CBC, blood culture
Most experts recommend LP if child is younger than 6 months
What is considered complex febrile seizure? What is the chance of recurrence?
More than one febrile seizure in a 24 hour period is considered
febrile seizures have a 1 in 3 chance of recurrence
Define Fever of Unknown Origin (FUO)? What are the general common causes?
Defined as a daily temp greater than 38.3◦C or 101◦F, lasting for at least 8 days, in whom no diagnosis is apparent after initial outpatient or hospital evaluation that includes careful H&P and initial lab test
Usually caused by common disorders often with an unusual presentation
What are the 3 MC etiologic categories for FUO?
infectious diseases
connective tissue/rheumatologic diseases
neoplasms
What are some infectious causes of FUO that need to be ruled out? What test would you want to order?
cytomegalovirus, EBV, osteomyelitis, hepatitis, adenovirus, enteroviruses, and bartonellosis (cat-scratch disease) are some of the common FUO causes that should be ruled out
Since infectious causes are most common, pursuing specific serological tests for Hepatitis A and B, EBV, toxoplasmosis, bartonellosis, and cytomegalovirus would be reasonable
What is the MC AI dz of FUO that need to be ruled out? What 2 malignancies?
systemic idiopathic juvenile arthritis
leukemia and lymphoma
When assessed a kiddo for FUO, when should the PE be performed? What are some characteristics you would want to know?
while the pt is febrile
How was assessed?
Confirmed by someone else?
Pattern of fever?
Does respond to antipyretics?
Associated sweating?
What does FUO with bilateral red eyes make you think?
Kawasaki disease
What would you want to do next in a kiddo with FUO if ill with persistent fever and no diagnosis?
can do IgG, IgA, IgM
What are the FUO intervention recommendations for a fever? What are the abx recommendations?
Discontinue nonessential medications. Do NOT give antipyretics RTC or if temperature not >100.4 degrees
We generally AVOID empiric antimicrobial therapy except those where a life-threatening condition is suspected
If all testing in FUO is negative, what do you do next?
little can be done other than observation
can refer to ID, rheumatology or hem/onc
Fortunately, most FUO’s for which a cause cannot be found will resolve over time
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