Lecture Day 1 Febrile Flashcards
What is pyrexia?
> 38
High grade >38.5
What causes a puerperal rash?
Vascular necrosis
Adults: Vasculitis
How can you measure temp?
Axilla:
Ear thermometer
Oral thermometer: under tongue, vallecullar fossa
Rectal
Skin Temp: perfusion & core temperature
What temperature do cellular processes break down
Heat stroke >42 Malignant hyperthermia (reaction to suxamethonium)
Why does fever matter
- Sign of serious infection
- Uncomfortable (give paracetamol-calpol, ibuprofen, cool clothing
- Febrile seizures
Febrile convulsions
6 months-6 years
Typical
- generalised tonic-clonic, < 5mins, associated with fever, rousable afterwards, no focality
- one convulsion per fever
- Any focality = worried
Often family Hx
How many will have a second febrile convulsion?
Is it associated with epilepsy?
1/3rd (1/3rd of those will have 3rd)
Only associated if repeated seizures
Signs of atypical febrile convulsions
- Prolonged
- Repeated
- Focal
- Difficult to rouse after
- Older or younger children
- (Not associated with high temp)
What are the differential diagnoses for typical/atypical febrile convulsions?
- CNS infections (Meningitis & enchephalitis
- Non febril seizure/epilepsy
• Primary
• Symptomatic (SOL) - (head injury)
Management of febrile convulsions
- Admit for 1st episode
• parental reassurance & education (leaflet)
• observation only - advise parents what to do if further episode
• safe position
• call 999 if > 5 mins
Investigate if atypical
- CNS infection
- Epilepsy
Cause of pyrexia in children
- viral infection
- ENT
Otitis media (mastoiditis)
Rhinitis (sinusitis)
tonsilitis (apiglottitis)
Bacterial cause of
Resp:
Pneumonia/empyema
Renal:
UTI/Pyelonephritis
CNS:
Meningitis/encephalitis
Blood:
Septicaemia
Bone
Osteomyelitis/septic arthritis
Malignancy
Rheumatological
Parasites
Malaria
D&V
Persistent fever
Kawasaki’s disease
What is Kawasaki Diseae
Self limiting acute vasculitis
How long does the fever last
> 5 days
4 clinical feature of what
1. Changes in extremities
• desquamation
• erythema, edema
2. Bilateral conjunctivitis
3. Rash
4. Cervical lymphadenopathy
5. Changes in lips/oropharynx
• Cracked lips, red tongue
Irritable
Differentials
Scarlet fever
Measles
What are the difference between purpura and petechia?
What are petechia
Petechia < 3mm
Micro bleeding
Think: thrombocytopenia
Parents report baby ‘felt hot’
- what questions do you ask
- when would u take them seriously
Must determine if temp was taken, how it taken, is it a true pyrexia?
- if they are very young
6 week, crying & irritable
What likely cause and what would you need to exclude
Probably viral BUT
meningitis sepsis UTO pneumonia non-accidental injury
What questions should you ask for an infective Hx
- mental: irritable
- urine output
- feeding
Presenting complaint: When was baby last well? Feeding pattern? Cry (consolable, high-pitched)? Vomiting? Diarrhoea? Cough? Rash? Is she herself?
What questions for PMHx
Birth history: Vaccinations: Past medical history: Family history: Medications (antibiotics) Social history: Systems review:
Examination
General: Appearance irritable, mottled B: RR, Sats C: HR, Cap refil, BP D: Temp, Glucose E: Skin, ENT, abdo CNS: fontanelle, neck stiffness, fundi, reflexes
Whats normal of the following Irritable Mottled Cap refill - 4 secs HR 180/min RR50/min Temp 38oC BP 75/40 mmHg
RR & TEMP
Do babies get neck stiffness in meningitis?
What age does this develop
No
>2 yrs
Immediate management
Call for help ABCDE - Give fluids (tachy & prolonged cap refill) - Start antibiotics - Regular observations
Investigations for infection
Septic screen: Blood cultures Urine sample Chest X-ray Lumbar puncture
FBC, CRP, glucose, U&E
Contraindications for LP
↑ ICP
Intracranial lesion
Relative: clotting or skin infection
When to do LP
Immediate
After antibiotics
- PCR, WCC & glucose/protein still useful
After CT head
Normal results for ↑ ICP
Summary of normal CSF results
Appearance Clear and colourless
Glucose >2.2mM/L (~70% blood glucose level)
Protein <0.4g/L - mainly albumin (up to 0.9g/L in neonates and elderly)
Cell count <4/mm3 lymphocytes, no polymorphonuclear neutrophils
IgG <15% of total CSF protein; no oligoclonal bands
Pressure 6-15cm H2O (patient’s head in line with sacrum), * with coughing
Some guidelines suggest that in traumatic taps you can allow 1 white blood cell for every 500 to 700 red blood cells
Causes of meningitis in neonates
(think birth canal) Group B strep Escherichia coli Listeria Viral
Causes of infants and children
Viral H influenzae (vaccination) S pneumoniae N meningitidis TB
Talk over CSF results in children (must record blood sugar when send off)
- compare neutrophils between bacterial vs viral
- Compare lymphocytes
- bacterial 100-10,000, viral < 100
- bacterial < 100, viral 10-1000
If you diagnose bacterial meningitis who must you inform
Public health (prophylaxis for contacts)
Complications of meningitis in children
- cerebral palsy in <2 yrs
- deafness
- epilepsy
- coning & death
Pyrexia + vomiting + abdominal pain
- viral gastritis
- UTI/pyelonephritis
- Acute appendicitis
- pneumonia (irritation of diaphragm)
- tonsillitis
How can urine infections present in children
dysuria, urgency, bed wetting
Prolonged fever.. think
kawasaki
