Feverish Child

Question 1

What is a likely diagnoses from the video?

Answer 1

Meningococcal disease

Meningitis

Question 2

How urgent is this situation?

Answer 2

Emergency

Question 3

What are the causes of meningitis?

Answer 3

Neissaria meningitis
Streptoccocus pneumoniae
Haemphilius influenzae

Question 4

What is meningitis?

Answer 4

Infection of the protective membranes that surround the brain and spinal cord (meninges)

Most common in babies, young children, teenagers and young adults

Can cause life-threatening blood poisoning (septicaemia) and result in permanent damage to the brain or nerves

Question 5

What are the sign and symptoms of meningitis?

Answer 5

Fever
Vomiting
Headache
Non-blanching rash
Altered mental state

Photophobia
Kernig’s sign
Brudzinski’s sign

Question 6

What are the sign and symptoms of meningococcal disease?

Answer 6

Fever
Vomiting
Headache
Non-blanching rash
Altered mental state

Question 7

What are the sign and symptoms of septicaemia?

Answer 7

Fever
Vomiting
Headache
Non-blanching rash
Altered mental state

Shock
Hypotension
Increased cap refill
Cold

Question 8

What is Kernig’s sign?

Answer 8

Kernig’s sign is performed with the individual lying on their back with their hips and knees bent. The clinician will then slowly attempt to straighten the leg. If pain or resistance is felt, the Kernig’s sign is said to be positive

Question 9

What is Brudinski’s sign?

Answer 9

Brudzinski’s sign is positive when passive forward flexion of the neck causes the patient to involuntarily raise his knees or hips in flexion

Question 10

What is the management of suspected meningitis in primary care?

Answer 10

Organise immediate transfer to hospital by telephoning 999

Single dose of parenteral (IM/IV) benzylpenicillin asap, unless allergic

Question 11

What do you do if there is a non-blanching rash?

Answer 11

Transfer without antibiotics

Question 12

What would you do for the child in hosptial?

Answer 12

IV antibiotics ASAP
Fluids
Blood - PCR to look for nisseria
Lumbar puncture? but can be problematic if raised ICP

Question 13

What are fontanelles?

Answer 13

Fontanelles are the soft spots on an infant’s head where the bony plates that make up the skull have not yet come together

Question 14

Why do we do a lumbar puncture?

Answer 14

Look at WCC
Check protein in CSF
Glucose
Gram staining
Microbiological cultures

Question 15

How do we judge if there is raised ICP?

Answer 15

CT is unreliable in judging raised ICP
Clinical assessment should be used
e.g. feeling fontanelles

Question 16

What does bacterial CSF look like?

Answer 16

Turbid
Lots of protein
+ve gram staining in 60-90%
Raised pressure

Question 17

What does viral CSF look like?

Answer 17

Clear
Not a lot of protein
Normal or raised pressure

Question 18

What does fungal CSF look like?

Answer 18

Fibrin

Not a lot of protein

Question 19

When calling the SpR anaesthetist what information would you want to convey?

Answer 19

Patient details - name, DOB, age, weight etc.
Current condition of the infant (stable/unstable), how urgently they need to be seen
Drug allergies
AMPLE
(Allergies, medication, past history, last meal, events)

Question 20

What is considered a normal temperature?

Answer 20

36.5 - 37.2
lower in axilla
higher in ear
high temp = >38

Question 21

What is important in the history from the parent?

Answer 21

how long? 
rash? blanching or non-blanching? 
abnormal crying?
limb or join problems?
vomiting or diarrhoea?
travel?
feeding? urine output?

Question 22

What else is important to consider in the parental history?

Answer 22

Parental anxiety and instinct
Social and familial circumstances
Other illnesses affecting the child

Question 23

How do you measure temperature in infants younger than 4 weeks?

Answer 23

Electronic in axilla

Question 24

How do you measure temperature in a child between 4 weeks and 5 years?

Answer 24

Electronic in axilla, chemical dot in axilla or infrared tympanic

Question 25

What other than temperature should be examined in a child?

Answer 25

Skin, lips and tongue colour
Examine respiratory system
Examine cardiovascular system

Question 26

How is tachypnoea defined in children?

Answer 26

> 60 breaths per minute at age 0-5 months.
50 breaths per minute at age 6-12 months.
40 breaths per minute at age older than 12 months

Question 27

How do we assess level of hydration in a child?

Answer 27

Eyes normal?
Reduced skin turgor?
Are the mucous membranes moist?
Cap refill?
Extremities temp?
Feeding and urine ouput

Question 28

What other differentials should be considered in a acutely unwell child?

Answer 28

Herpes simplex encephalitis
Pneumonia
UTI
Septic arthritis and osteomyelitis 
Kawasaki disease

Question 29

What system should be used to assess risk of serious illness?

Answer 29

NICE Traffic light

Any symptoms in a certain column warrants that degree of risk

Question 30

What do green/amber/red symptoms require?

Answer 30

Red - seen within 2 hours if not considered life-threatening

Amber - Assessor to judge urgency of appointment

Green - Managed at home with advice for parents

Question 31

What is home pyretic treatment for children?

Answer 31

Do not under/over dress
Paracetamol/Ibuprofen
Regular fluids
Monitor for rashes
Away from school settings

Question 32

When should parents seek further help?

Answer 32

Seizure
Non-blanching rash
Less well than when assessed by healthcare professional
Parent is worried
Fever lasts longer than 5 days

Question 33

What ABs do we use to treat children 3 months or older?

Answer 33

IV Ceftriaxone

Question 34

What ABs do we use to treat children younger than 3 months?

Answer 34

IV Cefotaxime plus amoxicillin or ampicillin

Question 35

When would vancomycin also be used?

Answer 35

When there is a travel history

Prolonged or multiple exposure to ABs

Question 36

When must ceftriaxone not be used?

Answer 36

Premature babies

Babies in jaundice