Pediatric Fevers Flashcards
Define a Fever
rectal body temp on who
Fever
- adapative temp regualtion response (no hyperthermia; which is conditions that overwhelmt he normal thermoreg. process)
normal rectal temp = 97-100 degress
infants: 0-56 days (8weeks) = 100.4 or 38C = fever
children 56+ days = 101.3 or 38.5C = fever
rectal temp MUST be obtained for those under 3months, often gotten for all kids under 2 years
who is considered a compromised host for a fever pt
- those under 56 days
- those with recent surgery
- those with internal deviceshardware
- immunodeficeint (primary or secondary to treatment)
in these pt…
- need to add testing
- rapid abx use
- stress dose steroids
Symptoms and Signs of a Fever in Kids
SYmptoms/Signs
- irratibility
- inconsoable crying
- lackk of appetite
- seeking mom (warm)
- sittign near warm objects and blanekts
- refusing cold things
- interacting less
- febrile seizure risk
Signs of Severe Disease in kids iwth fever
Toxic Appearing
- irraiblte
- non-interactive
- poor perfusion
meningitis/ecenphaitis
- altered sensorium: irriatbility, legthargic, obstuned or coma
- neuro signs: seizures, meningismusm, focal nero issues
- icp elevated: buldging fontelle, vomiting
- remebre infants under 1 may not show signs of meningismus
Upper airway
- eppiglottois: tripoding, drooling, extended neck
- croup: suprasternal retractions, stridor
- deep neck infection: dec. ROM neck, unilater swelling in nec/mouth
PNA
- fever + respirtaory sx. 3-4 days with hypoxia and tachypnea
bronchilotilits
- secretions
severe PNA, mycarditis, sepsis
- AMS
- tachypnea, tachycardia
- poor perfusion
- cyanosis
- heaptmeg.
Severe infections + fever
RMSF
menigiococcemia
sepsis syndrome
vs.
nec. fasc.
signs of these
- anxious, AMS, irratible
- petechail, purpura rash = errythema
Necrotizing fasciitis
- severe pain out of proportion to exam
- skin cahnges
- sepsis and rapid progression
Febrile Neonate: 0-56 days
what are some red flags
Febrile Neonate
- fever > 100.4 or 38C
- theyre at increased risk for infections and sequale of infections
Red Flags
- AMS: low tone, limp, weak cry
- buldged fontelle (meningitis)
- poor perfusion
- respiratory distress
- toxic? do sepsis workup
important history points
- tmax
- oral intake an durine output
- birth history
- moms HSV and GBS risk
- newborn screen results
PE findings with fever
- vitasl, wegiht
- looks for infection in eyes and ears
- cardiac
- neuro: tone and responsiveness
- skin: mottling is a sking of fever
- abd. omphalitils: infection ofo umbilical
Febrile Neonate: 0-56 days
HSV suspicion
HSV
- testing for all those 21 days and younger
- always considered moms risk of having it too
Testing
- CSF and serum HSV PCr
- unroof a vesicle and swab for HSV PCR
Febrile Infant
workup for those 0-21 days
for those 22-28 days
29-56 days
Workup 0-21
- POC gluocse
- CBC with diff, cultures
- CMP/BMP, HSV if needed
- UA and culutre (catheter is better)
- LP everyone under 21 days: csf from gram stain,culutre, protein, glucose, cell count and HSV
workup: 21-28 days
- decision for LP decided on by tha abnormal inflmmatory markers (procalcitonin) OR the UA results
- can admit and obs. - wait for culutres, etc. then decide on LP
workup: 29-56 days
- those with 1+ abnormal inflammatory marker = LP
- abnormal UA and abnormal infalmmatory = consider LP
Febrile Infant
but well appearing with no CSF finding
Treament
0-21 days
22-28 days
29-56 days
WELL APPEARING: NO CSF PLEOCYTOSIS
0-21 days
- ampicillin
- ceftazidime
- acyclovir
22-28 days = abnormal UA/inflams.
- ampucillin
- ceftazadime
- +/- acyclovir
29-56 days = abnormal inflams. normal UA
- ceftriaxone
29-56 days = abnormal UA
- ceftriaxone
- ampucillin
- +/- acyclovir
Febrile Infant: Ill Appearing OR CSF +
treatment
0-21 days
22-28 days
29-56 days
ILL APPEARING or CSF POSITIVE
0-21 days
- vancomycine
- cefepime
- acyclovir
22-28 days
- vancomycin
- cefepime
- +/- acyclovir
29-56 days
- vancomycine
- ceftriaxone
- +/- acyclovir
for those with risk of meningitis, under 28 days you cant used ceftriazone (bili issue) = so use cefepime instead
and give everyone vancyomycin to cover MRSA
meds to consider for those age 0-28 days
ampicillin = can be used for GBS and listera
Cetazadime = good for this age gropu
- doesnt penitrate CNS or cover MSSA
Ceftriazone = to be avoided
meds to consider in those 29-56 days
ceftriaxone
- can be used in this age
- GBS , strep penumniae, streptocuccos and enterobacterales
is you suspect enterococcus: ampicillin should be added
Postive UA results in peds. fever
postive blood culutres
postivie CSF
Positive HSV
Postive UA + culutre
target te abx to specific specices
RBUS: to look for abnoralities
can consider LP and empiric abx.
Postive Blood Culture
- repeat blood culutre prior to adjusting abx.
- consider broad coverage if pending results
- perform Lp and start abx. if not already done
Postivie CSF
- ensure meningitic dosing
- consult ID for broad coverage
Positive HSV
- consult ID and acyclovir duration
Criteria to discharge the febrile infant
- negative culutres
- well-appearing PO feeding
- D/C after 24 hours if CSF WBC is interpretable + negative
- D/C after 36 hours if unable to interpret CSF
- follow up wit hPCP in 72 hours
Sepsis in the Febrile Ped Pt.
criteria
Criteria for Sepsis
any of the following
- temperature fever or hypothermia (under 36)
- heart rate abnormality
PLUS
- mental status abnormality (crying, drowsy, restlenss, obtunded)
- perfusion abnormality (cool extremities, mottling, delayed cap. refill OR warm, flushed, flash cap refill,boudning pulses)
- hypotension
- tachypnea
= sepsis
________________________ other findings (organ dysfunction)
lab findings: metabolic acidosis, elevated lactae, low platelets, coag issues
PE findings: rash, erythroderma
high risk: under 60 days old, central line, immunocomp., preexisintg neuro condition
after determining sepsis, what is the initial mangement
Sepsis determined
- iv access and labs drawn
- fluid resusication : NS or LR
- abx. within 60-180 minutes
- reasses Q15min, MS, WOB, perfusion adn vitals
- correct hypoglycemia or hypocalcemina
- if unresponsive to fluids, initaition of vasopressors
Kawasaki Disease
when to conisder this with fever in peds
KD in…
- those with fever 3+ days and any features of KD (CREAM)
OR
- infants under 6 months with 7+ days of the unexplained fever
Clinical Features
- mucositis: starwberry tongue
- conjunctivitis: bilater injection without exudate and spares limbus
- rash: maculopap.
- lymphadenopathy
- extermities: desquam of palms and soles
Diagnosis made when…
fever 5+ days AND 4+ symptoms
or
fever 4+ days with all 5 features
MIS-C in peds.
MIS-C
multisystem inflammatory syndrome in children
etiology
- a syndrome that results from COVID: abnormal immune response with simialr features to KD but its due to covid realted immune reaction
- macrophage activaition and cytokine release
Symptoms
- rash: nonpustualr
- GI SYMPTOMS: diarrhea,abd pain and vomiting
- extremitiy cahnges : red and sweollen
- oral mucosa: cracking lips, starbweery tongue
- conjuntivitis: can involve limbus and no exudates
- lmpyh invovlement
- NEUROLOGIC SYMPTOMS: HA, irratibilty, AMS, neck stiffness, CN palsy
MIS-C
diagnosis
Diagnosis
-fever 3+ days
- symptoms of MIS-C 2+
labs
- cbc, cmp, crp, esr
- low Na+
- low lymphocytes
- low platelets
CRP > 3 or ESR >40 PLUS 1 of the following
- lymphopenia < 1k
- thrombocytopenia < 150k
- Na < 135
- abnormal creatinine for age
Treatment
- inpt. to PICU : monitor for shock
definition for
fever in immunocmp.
fever of uknonw origin
fever in immunocomp.
- fever 1x > 38.5
- fever 38 x 3times within 24 hours 1 hour apart
fever FUO
- fever daily > 38.5 for > 8 days
Febrile Seizures
who/etiology
simple v complex
Febrile Seizures
- age 6 months - 6 years most commonly
- occational family hx.
whos at risk of epilessy
- those with neurodevelopment sisues
- complex febrile seizures with focal onset
- febrile stats epi.
- family history
simple
- brief < 15 minutes
- general seizure
- no more thatn 1 in 24 hours
- assocatied with fever 38.4+
complex (defined by any 1 of the following)
- prolonged (more than 15 mins.)
- focal onset (starting at one place)
- recurrent: 1+ in 24 hours
febrile seizure
workup
Workup
- consider meningits!!!
LP consideration
- < 6 months : needs it
- 6-12 months: considere if not immunized to hib or pnumo.
- 12 months + : only if clincial conerns
labs
- glucose
- cbc, cmp, mag, phos,
imaging
CT/MRI = not for simple, yes for febrile status epilepticus
EEG: not for simple, could consider for complex, esp if focal onset
genetic testing: not for simple, conbe
Febrile Seizure
management
status epileticus
anti-pyretic do not prevent recurrent febrile seizures
continuous seziure meds are not recommended: rarely keppra used; recurrent can use dizapem rectal
cold baths not recommened
status epilepticus
- 5+ minutes of continuous seizure or EEG activity of seizure without retunr ot baseline
- prolong > 30-60 minutes resuls in neuronal injury
Treament = lorazepam, then lorazapam, then keppra!! in 5 minute intervals
FIRES syndrome
FIRES
- febrile infection related epilepsy syndreom
- subset or NORSE: clincal presentaion plust hx. of epilepsy with refractory status
FIRES
- priorhistory of febriles infection
- fever between 2-2 wweeks priot to the onset of teh status epi.
treament: phenobarb, ketamine or midazoplam coma induction
