Fever In Children Flashcards
Differentials Intro
Viral - Respiratory/ Gastroenteritits/ encephalitis
Bacterial- UTI/ Meningitis/ CAP/ cellulitis/ Septic arthritis
KAwasaki’s disease (fever > 5days)
Malignancy
Inflammatory disease- IBD/ SLE/ JIE
Respiratory- Bronch/ pneumonia/ croup/ epigottitis
GI/GU- Gastroenteritis/ UTI? Ruptured appendicitis
MSK- Septic joint/ Juvenile idiotpathic arthritis
Differentials Intro
Viral - Respiratory/ Gastroenteritits/ encephalitis
Bacterial- UTI/ Meningitis/ CAP/ cellulitis/ Septic arthritis
KAwasaki’s disease (fever > 5days)
Malignancy
Inflammatory disease- IBD/ SLE/ JIA
Respiratory- Bronch/ pneumonia/ croup/ epigottitis
GI/GU- Gastroenteritis/ UTI? Ruptured appendicitis
MSK- Septic joint/ Juvenile idiotpathic arthritis
Bronchiolitis
Cause-
Age
Risk factors: 3
Symptoms 6
Signs 5
Investigations 3
Management 6
Cause- RSV
Age <2 years old
Risk factors:
• CHD
• CF
• Premature
Symptoms • Coryza dry cough progressive SOB • Wheeze • Feeding difficulties • Apnoeic episodes
Signs • Cyanosis • Tachypnoea • Recession • Prolonged expiration • Fine end inspiratory crackles
Investigations
• Oxygen sats
• Consider CXR
• NP swab (RSV immunofluorescence)
Management • May require admission if signs of respiratory distress • Supportive care • Humidified oxygen • Oxygen if sats <92% • NG feeds/IVT if poor oral intake • ventilatory assistance?
Bacterial Pneumonia Common pathogens if <5 years: • most common pathogen- 1 Causes of atypical pneumonia in <5 y/o: 3
if >5 years
• most common pathogen 1
Symptoms 3 classic
Signs 6
Investigations 3
Management 4
Antibiotics
• 1st line: 1
Alternatives: 2
- If atypical consider – 1
- If severe pneumonia then 3
Common pathogens if <5 years: • Group B strep most common pathogen Causes of atypical pneumonia in <5 y/o: • Strep pneumoniae • Mycoplasma pneumoniae • Chlamydia trachomatis
if >5 years
• Strep pneumonia most common pathogen
Symptoms
• SOB
• Fever
• Productive cough (older children)
Signs • Reduced sats • Crackles / creps • Reduced breath sounds • Grunting • Nasal flaring • Intercostal / subcostal recession
Investigations
• Bloods
• CXR
• Blood/sputum cultures
Management • Oxygen if sats <92% • Antibiotics • Fluids • Analgesia
Antibiotics
• 1st line: amoxicillin
Alternatives:
- Erythromycin
- Co-amoxiclav
- If atypical consider – erythromycin
- If severe pneumonia then IV – co-amox, cefotaxime, cefuroxime
Croup vs Epiglottitis
Croup
CAUSE:
TIMING:
ASSOCIATED SYMPTOMS:
Epiglottitis
CAUSE:
TIMING:
ASSOCIATED SYMPTOMS:
Croup Management Asses severity by 1 mild + home = 1 Hospital admission if 2 In hospital give 4
Epiglottitis Management They will need urgent hospital admission - REMEMBER...2 Give 1 Recieve 1 IV... 1 or 1 For contacts... 1
Croup CAUSE: Parainfluenza, influenza, RSV TIMING: Days ASSOCIATED SYMPTOMS: Barking cough • Harsh stridor • Hoarse voice • Prodrome of coryza and temp • Symptoms worse at night
Epiglottitis CAUSE: Haemophilus Influenza TIMING: Hours ASSOCIATED SYMPTOMS: • Minimal / no cough • Soft stridor • Weak voice / silent • Drooling • Temp • No prodromal symptoms
Croup
MANAGEMENT
Assess severity by:
• Degree of chest retraction and stridor
• If chest recession and stridor present ONLY when crying / active = mild + home
• If serious obstruction or <12 months old = hospital
• Humidified air
• Steroids – dexamethasone
• Nebulised adrenaline
• May require intubation if severe
Eoiglottitis MANAGEMENT Urgent hospital admission • Stabilise the child, try to calm – distress can precipitate airway obstruction • Do NOT examine the throat • ITU, ENT, anaesthetists • +/- Intubation • Blood cultures • IV cefuroxime or cephalosporin • Rifampicin for contacts
GASTROENTERITIS
• Common pathogens: 5/7
Symptoms & Signs: 6
Investigations 3
Management • ONE MAIN ONE! • (linked) • Consider ... • .... - rarely required only if.... 3
GASTROENTERITIS
• Common pathogens:
Rotavirus, salmonella, campylobacter, shigella, E.coli, C.diff, B.cereus
Symptoms & Signs: • Diarrhoea +/- blood and mucus • Vomiting • Fever (tends to be <38.5) • Abdominal pain • Abdominal distension • Dehydration
Investigations
• Stool sample (inc. C.diff)
• Blood tests (bacterial infection / dehydration)
• Blood culture
Management
• FLUID REPLACEMENT
• Assess fluid deficit
• Consider NG / IV fluid replacement – if shocked, continuous
vomiting
• Antibiotics - rarely required
• If severe systemic illness, <6 months old, bacterial
Meningitis
Common Pathogens Bacterial -Infant < 3months- 1* + 2 - Older infant/ child- 1* + 2 - Adolescents- 1*
Viral- 2
TB- 1
Symptoms Infants 7
Older children 9
2 Signs to know
2 other sings to look out for
Investigations 4
Bloods
- Bacterial: What will you see in bacterial? 2
LOOK AT THE DRAWN OUT TABLE WHEN REVISING!
Common Pathogens
Bacterial
-Infant < 3months- *Group B strep, E.coli, Listeria
- Older infant/ child- *Steptococcus pneumonia, Neisseria meningitides, Haemophilus influenza
- Adolescents- Neisseria meningitides
Viral- Enterovirus, EBV
TB- Myobacterium tuberculosis
Symptoms Infants • Fever • Lethargy • Irritability • Reduced feeding • D&V (diarrhoea + Vom) • Respiratory distress • Seizures
Older children • Fever • Headache • Neck stiffness • Photophobia • N&V • Confusion • Lethargy • Irritability • Seizures
2 Signs to know
- Brudzinski’s sign- Flex neck and automatically flex at knee and hip
- Kernig’s Sign- Inability to straighten leg when hip flexed at 90 degrees
Non-blanching rash!
Sunken anterior fontanelle
Investigations
- Bloods
- ABG
- Blood culture/ PCR
- Lumbar puncture
Bloods
- Bacterial: Increase Neutrophils from 0 to 100-10,000 x 10^6 and Lymphocytes < 100 compared to usually < 5x10^5 in bacterial
LOOK AT THE DRAWN OUT TABLE WHEN REVISING!
Meningitis & Meningococcal
septicaemia: Management
1) First thing to always do when suspected sepsis…
2) What anti-biotics? Hospital and Community
3) What next? When do you admit to PICU?
4) If not shocked what investigations should you do and what to check? 4
5) Next…
6) Prophylaxis…
7) Follow up…
Paediatric Sepsis 6- Know this like the back of your hand!
Need to do this within….
Meningitis & Meningococcal
septicaemia: Management
1) ABCDE & senior input
• Sepsis 6
Hospital: IV Cefotaxime (plus amoxicillin if <3 months of age)
Community: IM benzylpenicillin
Fluids (boluses if shocked, PICU if not responding after 2 boluses)
• LP if not shocked/no other CIs; haemodynamic instability, raised ICP,
coagulopathy/DIC, site infection
• Notification – ‘proper officer’ at local authority who will then inform
Public Health England
• Prophylaxis – Ciprofloxacin for close contacts of confirmed or probable
cases during the seven days before onset of illness
• Follow up – Audiology assessment as hearing can be damaged
Paediatric Sepsis 6 Within 60 mins 1) High Flow O2 2) IV fluids- 20ml/kg NaCl 0.9% 3) IV or IO Antibiotics (Hospital = Cefotaxmine plus amoxacillin if < 3months and Community = Benzylpenecillin) 4) IV access for Blood culture 5) IV access for serum lactate (and blood glucose from ABG) 6) Urine output
extra- Early inotropes such as IV adrenaline if >40l/kg of fluid
Purpuric Rash Differentials
6
4 different blood results/ observations to differenciate
Purpuric definition
1) Henoch-Schonlein purpura
2) Idiopathic thrombocytopenic purpura (ITP)
3) NAI (Non- accidental injury)
4) Leukaemia
5) DIC ( Disseminated Intravascular Coagulation)
6) Kawasaki Disease
- If ill + ↓ platelets= meningococcal septicaemia, leukemia, DIC
- If ill + Neut/↑ platelets = Kawasaki
- If well + N platelets + no trauma = HSP
- If well + ↓ platelets = ITP
Definition- Purple-coloured spots/ patches 4-10mm in size, that occur on skin when underlying small blood vessel have burst (bigger than petechiae which are 2mm).
MSK
Name 3 differentials 3
1) Name Definition 1 - extra - Cause 1 - typically presents 1 - Management: 2 RULE OUT...
2) Name
Definition: + which joint is most commonly affected?
- Causes: Can develop through 3
- Pathogens vary greatly depending on age: most common 1
Investigations: 5
Management 3
3) Name Definition: 1 • Common in ages • Commonly affected bones: 2 • Spread often from... 2 Management: 2
1) IRRITABLE HIP / TRANSIENT
SYNOVITIS
Definition: temporary inflammation of the lining of the hip joint
(most common cause of limping in children)
• Cause unknown
• Typically presents following a viral infection
• Management:
Supportive management – analgesia – gets better within 1-2 weeks
• Rule out other causes (septic arthritis)
2) SEPTIC ARTHRITIS
Definition: bacterial infection in a joint (hip joint most commonly affected)
- Causes: can develop through haematogenous spread/ osteomyelitis/ wound
- Pathogens vary greatly depending on age: staph aureus is the most common
Investigations: • Bloods - infl markers • Imaging • X-ray - extent of the infection • MRI (osteomyelitis) • Joint aspiration – culture
Management
• Iv antibiotics (up to 3 weeks)
• Theatre and washout
• Splint and physio
3) OSTEOMYLITIS
Definition: infection of the bone caused by bacteria
• Common in <2 years
• Commonly affected bones: femur, tibia
• Spread often from haematogenous/ infected wound
Management:
• IV antibiotics (extended course)
• may require surgical debridement
Tonsilits
Viral is 2/3 of cases- 1
Bacterial 1/3 of cases- 1
CENTOR criteria for the bacterial .... (LEAF) 1) 2) 3) 4)
Scores 3
Management
- Viral 1
- If bacterial 1 BUT DO NOT give… due to….
Long term 1
Tonsilitis
- Viral 2/3 – Epstein-Barr virus
- Bacterial 1/3 – group A strep
CENTOR criteria for group A strep (LEAF): • tender anterior cervical Lymph nodes • tonsillar Exudate • Absence of cough • history of Fever
Score:<1 – unlikely GAS infection
2 – consider testing with throat swab
>3 – likely GAS – antibiotics indicated
Management
• If viral – self-limiting
• If bacterial – penicillin V for 10 days BUT DO NOT give amoxicillin (glandular fever)
• Tonsillectomy – if recurrent infections
Otitis Media • Definition: 1 • Pathogens: Most common = (general) 3 eg's
• Triad of:
Examination:
• What will you see, always check for….
Management:
• 1
• Only give…( +eg) if:
2 reasons why you should
Otitis media
• Definition: Infection of the middle ear
• Pathogens: Viral (most common), pneumococcus, group A beta haem. Strep, H. influenza
• Triad of:
1. Pain
2. Fever
3. Irritability
Examination:
• Red and bulging tympanic membrane with loss of light reflex. (?acute perforation)
Management:
• Supportive with advice given to parents (pain/fever)
• ? Antibiotics – co-amoxiclav
• Children <2 years with bilateral acute otitis media
• Children with otorrhoea / perforation who have acute otitis media
Febrile Convulsions
Definition: 1
Age range: 1
Extra:
•2
• If ….. requires medical
management for seizure
• Causes:
5
Management:
• 3
Safety netting information & first aid:
• 3
Febrile Convulsions
Definition:
Seizure with temperature >38C without CNS infection
Age range: 6 months – 6 years
Extra: •Commonest cause of seizures in children • Mostly benign – treat underlying cause! – Supportive management for viral infections • If >5 mins requires medical management for seizure
• Causes:
viral infections, Otitis Med, tonsillitis, gastroenteritis, post-immunisation
Management:
• Reassurance (Usually benign)
• Fever management
• Antipyretics (paracetamol/ibuprofen), encourage PO fluids, removing XS clothing
Safety netting information & first aid:
• Recovery position, removed hard/sharp objects away, timing
• 999 if holds breath>30s, convulsion >5mins
• Signs of worsening underlying infection/sepsis to return
Prolonged Fevers Differentials: 7/10
Prolonged Fevers Differentials.: • Secondary bacterial infections • Tuberculosis • Epstein-Barr • Parasitic infection • Systemic onset juvenile idiopathic arthritis • Lupus • Kawasaki disease • IBD • Malignancy • Fabricated illness
Kawasaki disease
Cause- not understood but potentially 3
Dx Criteria
1 key point and then 4/5 of the following criteria (there is a way of remembering)
Investigations
5 and one sounds like the royal…
Complications
1
Management
2
Cause
Poorly understood – potential viral, environmental or autoimmune.
Dx Criteria
• Fever for >5 days plus 4/5 of:
- Bilateral (non purulent) conjunctivitis
- Mucous membrane changes- strawberry tongue,
- Tender cervical lymphadenopathy
- Polymorphous rash
- Peripheral changes – oedema/erythema/desquamation
Investigations
• ASOT (antistreptolysin titre blood test), echo, platelets, ESR, CRP.
Complications
• Coronary artery aneurysm and other cardiac problems.
Management
• IV Ig (Intra-venous Immunoglobulin)
• High dose aspirin (Benefit of aspirin in this case outweighs risk of Reye syndrome)
