Capsule 4 - Bronchiolitis & Fever

Question 1

Cause of bronchiolitis

Answer 1

RSV

Question 2

Proportion of kids needed to be admitted with RSV

Answer 2

1-2%

Question 3

What is bronchiolitis

Answer 3

Swelling of bronchioles with mucus production

Question 4

Sx of bronchiolitis

Answer 4

Coryzal symptoms & blocked nose
Reduced feeding
Cough
Wheeze / apnoeas

Question 5

Risk factors for severe bronchiolitis

Answer 5

Chronic lung disease
Congenital heart disease
Under 3 months old
Premature
NMD
Immunodeficiency

Question 6

What is the usual disease duration of bronchiolitis

Answer 6

7 days

Question 7

What key Qs do you need to ask about in bronchiolitis Hx?

Answer 7

Feeding and hydration
Apnoeas - especially young babies
Risk factors for severe bronchiolitis

Question 8

Ix for bronchiolitis

Answer 8

Clinical Ix mainly
Observations - O2 sats, temp

Question 9

Admission criteria for bronchiolitis

Answer 9

1. Do they need respiratory support? –> O2 sats <90% / difficulty in breathing / apnoeas
2. Do they need feeding support? –> poor hydration or <50% of feeds
3. Do they look sick?

Question 10

Mx of bronchiolitis

Answer 10

Feeding support - oral (2nd = NG, 3rd = IV fluids)
Resp support - O2 sats <90%, then given O2

Question 11

When can bronchiolitis pt be dischraged?

Answer 11

Look well, clinically stable
Sats >90%
Feeding >50% of normal
Caregiver can manage at home
Safety netting

Question 12

When to step up care in bronchiolitis?

Answer 12

SaO2 persistently below 90% despite on O2
Signs of impending resp failure - tachypnoeic then bradypnoeic
Recurrent apnoeas
Look exhausted
Desaturations despite O2

Question 13

How to step up in bronchiolitis?

Answer 13

Cap blood gas for resp distress
Optiflow or CPAP
Consider CXR is clinical deterioration
Talk to PICU

Question 14

What is the approach to the febrile child?

Answer 14

Depends on age, degree of clinical concern
Can you find a cause?
Use NICE traffic light system
Identify life threatening features early

Question 15

How can you measure fever?

Answer 15

Take parents perception of fever seriously, especially in young kids
Tools: Axillary electronic / axillary chemical dot / tympanic infra red
NOT ANYTHING ELSE - forehead strips, non touch infrared, hand on forehead

Question 16

What features are considered in the NICE traffic light system?

Answer 16

Colour, respiration, circulation and hydration and other factors

Question 17

What specific infections are you looking for in febrile child?

Answer 17

Meningococcal disease
Bacterial meningitis
Herpes simplex encephalitis
Pneumonia
UTI
Septic arthritis
Kawasaki disease

Question 18

Sx of Bacterial meningitis

Answer 18

Older children - stiff neck, photophobia, headache
Babies - irritability, vague symptoms

Question 19

Causative organisms of fever in under 1 month

Answer 19

(usually maternal)
GBS
E.Coli
Listeria
HSV

Question 20

Ix & initial Mx for fever in under 1 month old

Answer 20

Full septic screen - blood culture, urine culture, LP
Give full ABx within 1 hour - cefotaxime and amoxicillin
Always admit

Question 21

Causative organisms of fever in 1-3 months

Answer 21

Maternal - GBC, E.Coli, listeria
Post-natal - meningococcal, strep, staph, HiB
Viruses - RSV, enterovirus, adneovirus, HSV

Question 22

Ix for fever in 1-3 months

Answer 22

FBC, blood culture
CRP
Urine MC&S
CXR if resp signs
Stool culture if diarrhoea
LP if look unwell or have WCC out of normal range

Question 23

When do you start IV Abx in fever in 1-3 month olds

Answer 23

Child looks unwell, WCC out of normal range

Question 24

How do you get a urine sample in an under 1 year old?

Answer 24

Suprapubic aspiration with USS guidance is gold standard but rarely done
Clean catch but high chance of contamination
NOT cotton wool sample or bag sample

Question 25

Causes of fever in >3 month olds

Answer 25

Rare to get perinatally acquired infections Meningococcal/strep/e.coli/staph/HiB Viral - RSV/influenza etc --> HSV is the one to worry abou

Question 26

Ix for fever in >3 months old (traffic light system)

Answer 26

Red features = FBC, cultures, CRP, urine +/- LP/CXR/blood gas Amber features = urine, bloods, maybe LP. CXR if fever >39 or WCC high Green features = no bloods, urine test only

Question 27

Mx of fever >3 months

Answer 27

Consider period of observation in hospital Don't rely on decrease / lack of fever after anti-pyretics Abx if needed - ceftriaxone +/- acyclovir

Question 28

Tachycardia in <1 year

Answer 28

>160

Question 29

Tachycardia in 1 to 2 years

Answer 29

>150

Question 30

Tachycardia in 2-5 year olds

Answer 30

>140

Question 31

Tx of fever in children

Answer 31

20ml/kg 0.9% saline bolus then reassess and ABx if shocked If signs of meningococcal disease / unrousable, then give immediate IV ABx

Question 32

How do you discharge a febrile child?

Answer 32

Always safety net Make judgements based on family and their social situation - consider ambulation (send home but come back in for ABx) if clinically well

Question 33

Give the green / amber / red COLOUR features of a febrile child

Answer 33

Green = normal colour Amber = pallor Red = mottled/pale/ashen/blue

Question 34

What are the green activity features of a febrile child?

Answer 34

Responds normally to social cues Content/smiles Stays awake or awakens quickly Strong normal cry or not crying

Question 35

What are the amber activity features of a febrile child?

Answer 35

Not responding to social cues normally No smiling Reduced activity Wakes only to prolonged stimulation

Question 36

What are the red activity features of a febrile child?

Answer 36

No response to social cues Appears ill Does not wake or stay awake Cry is weak / high pitched / continuous

Question 37

What are the amber respiratory features of a febrile child?

Answer 37

Nasal flaring Tachypnoea - RR >50 breaths/minute (6–12 months) OR RR >40 breaths/minute (>12 months) Oxygen saturation ≤95%

Question 38

What are the red respiratory features of a febrile child?

Answer 38

Grunting Tachypnoea: RR >60 breaths/minute Moderate or severe chest indrawing

Question 39

What are the amber circulation/hydration features of a febrile child?

Answer 39

Tachycardia: - >160 beats/minute, age <12 months OR - >150 beats/minute, age 12–24 months OR >140 beats/minute, age 2–5 years CRT ≥3 seconds Dry mucous membranes Poor feeding in infants Reduced urine output

Question 40

What are the red circulation/hydration features of a febrile child?

Answer 40

Reduced skin turgour

Question 41

List other amber features of a febrile child

Answer 41

Age 3–6 months, temperature ≥39°C Fever for ≥5 days Rigors Swelling of a limb or joint Non-weight bearing limb/not using an extremity

Question 42

List other red features of a febrile child

Answer 42

Age <3 months, temperature ≥38°C* Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs or focal seizures