FEVER Flashcards
What is a massive red flag
Fever >5 days
What does it suggest
Malignancy
What are common organisms in neonates
Group B strep
E.coli
Listeria monocytogenes
HSV / VZV = high mortlality
What are common organisms in children
S.pneumonia H.influenza Meningococcal Strep A S.aureus
What are non infectious causes of fever
Kasawaki JIA SLE Leukaemia / lymphoma Neuroblastoma Medication
What are symptoms of sepsis / unwell child
Fever Rigors Hypothermia Hypoglycaemia D+V Rash Shock DIC Dehydration
What suggests dehydration
Low BP Increased CRT Increased RR + HR Cool periphery Sunken fontanelle Dry mouth Decreased urine output Skin turgor
What suggests altered mental status
Lethargy Irritable Floppy Seizure Decreased GCS
What suggests poor perfusion
Long CRT Cold periphery Cold Mottled Pale Cyanosed Decreased urine
What suggests septic shock
Tachycardia Tachypnoea Poor perfusion Altered mental CRT >4s Cool periphery Decreased urine BE <5 Agitated / drowsy Hypotension = very late sign - Child can be normotensive and very ill
What are amber signs requiring further assessment / safety net / senior advice / observation
3-6 months
Colour
Pallor
Activity No smile Not responding to social cues Decreased activity Will wake with prolonged stimulation Poor feeding
Resp Nasal flaring RR >50 - THINK SEPSIS / ACIDOSIS Sats <94 Crackles
Circulation Tachycardia - Difficult due to anxiety / crying CRT >3s Dry membrane Decreased urine - Wet nappy suggest hydrated
Other
Rigors
Fever >5 days
What are red flags = urgent assessment and senior support
Colour
Mottled
Cyanosed
Activity No response Appear ill Not awake High pitched weak cry - Suggest meningeal irritation Continuous cry
Resp
RR >60
Recessions / undraping
Grunting
Circulation
Reduced turgor
Other <3 month If <1 month will get full work up with culture and LP even if look well Rash non-blanching Bulging fntanelle Stiff neck Seizure / status Focal neuro
What are special circumstances where child should always be referred
<3 months
Immunocompromised - post chemo / steroids
Fever >5 days
What should be done for a child with fever of unknown origin
Bloods
Blood culture
Imaging
When is it not needed
If source of fever known
What bloods
FBC Film U+E LFT CRP Coag X match Glucose Ca, Mg Blood gas
What bloods are part of full septic
FBC for WCC U+E Coag for DIC CRP - rise faster in infection ESR - rise faster in AI Glucose Blood gas
What should you culture
Relevant to Hx Blood Throat Urine Stool if diarrhoea CSF Skin / wound NPA - Helpful for viral bronchiolitis to prove RSV
What cultures if doing full septic
Blood
Urine
CSF
Throat
What imaging should be done in full septcic
CXR
What other imaging and what should be done to show end organ
Abdo USS
Limb X-Ray
CT / MRI
ECHO
U+E
LFT
Bone profile
When should a child get a full septic screen + LP if present with fever (even if well)
<3 months
Immunocompromised
>5 days
What should you do if child >3 months + red flags
FBC
Blood culture
CRP
Urine
What should you do if no features serious illness
Urine dip
Assess for pneumonia
What should you record in all children
Temp HR RR CRT Signs of dehydration
How do you treat child with fever if admitted
Monitor and observe
Anti-pyretic - Paracetamol - Ibuprofen Encourage fluid Can give ORS if dehydrated
Ax / sepsis 6 if appropriate
O2 if <92%
20ml / kg bolus saline if shock
Inotropic support if no improvement
What do you do for <3 months with fever
Admit for assessment
Full septic screen as fever may be only Sx of severe illness
LP when stable
What Ax to neonate and <3 months
Gent and benpen to neonate
Ceftriaxone and amox
Aciclovir
What do you do for immunocompromised
Specific policy
When would you give IV Ax
<1 +-
Impaired consciousness +-
Shock +-
Signs of meningococcal +-
What do you do if you suspect encephalitis
IV Aciclovir
How do you safety net
Open access Give regular fluid Check child at night Blood in stool Signs of dehydration Non-blanching rash Contact If get worried or fever >5days
Should you ever prescribe Ax without a source
NO
What are CI to LP
Raised ICP -Focal neuro -Papilloedema -Bulging fontnelle DIC Cerebral herniation Meningococcal septicaemia
What is important in the history of fever / any unwell child
Do they require urgent intervention
- ABCDE
- PEWS / vital signs
- Do they appear well or sick - according to person
General Onset, duration, progression, variation Systemic symptoms Urine? Bowel? E+D? Any rash / skin change? Activity? Crying? FTT
Specific Resp Sx - apnoea / grunt / distress / same as adult ENT - sore throat / ears / discharge GI - D+V / pain Urinary - pain / freq / nocturia / change colour or smell CVS - FTT / sweat / poor feed Neuro - behaviour Derm - skin change Ortho - limp / not using
Other RF Contacts Vaccination Hx Recent travel PMH - Underlying disease - Medications
How do you examine a child with fever
ABCDE If unstable = anaesthesistist PEWS / Vitals (temp, HR, RR, CRT, BP, sats) Respiratory - wheeze, effort, added sounds CVS - murmur, perfusion, dehydration Abdomen - tender? distension? Rash Nodes ENT
What causes persistent fever
Malignancy Kawasaki HSP Endocarditis UTI Aspecific viral = common
What is a maculopapular rash
Red bumps on flat red skin
Macules + papules
BLANCH
What causes maculopapular rash
Viral Early meningococcus so beware Drugs Enterovirus Parovirus EBV CMV HIV Measles
What is a purpuric rash
Petechiae >2cm
NO BLANCH
What causes purpuric rash
Meningococcal HSP ITP Enterovirus Rubella CMV TORCH Trauma
What causes vesicobullous rash
Enterovirus
HSV
VZV
Why should a child with joint swelling / non weight bear <3 be referred
More likely SA / trauma
What should child with green symptoms
Treated at home
Safety net
When do you really worry with fever
<1 month
Full septic screen
What is a fever
Elevation exceeding normal
>37.5 = low grade
>38 = fever
Does not predict severity
What is fever with no focus
Common in first 48 hours as illness may not have progressed
More investigation need
What is prolonged
Longer than expected for disease
e.g. GI 10 days or EBV 3 weeks
Fever unknown origin
> 3 weeks with no cause identified
What is early onset sepsis
Neonatal - 48 hours
Usually GBS etc
What is late onset
48 hours to one month
Can be from mother or environment
What is neutropenic
<1 neutrophils but temp >38
When is a fever not always present
Newborn
Immunocompromsied
Steroid
More vulnerable and show less signs so low threshold for Ax
What does fever do
Increase BMR - Weight loss if chronic Increase insensible - Increase fluid requirement Increased HR - Sepsis vs response of fever
What causes fever
Pyogene from infection / inflammation. / malignancy release cytokines and change core temp at hypothalamus
What is Multi-System Inflammatory Syndrome
Fever >3 days Hypo / shock / myocardial dysfunction / coagulopathy / GI upset Raised inflammatory - CRP / ESR / proclacitonin Evidence of COVID contact No other cause
What should you write in notes
What you think it is
No signs of
- Conditions you don’t want to miss
What conditions
SEPSIS
Other serous bacterial.- meningitis / pneumonia / UTI
Leukaemia
SA etc.
What are options
Send home with safety net
Admit for observation
Admit for screen
