Febrile child Flashcards Preview

MD 3: Paeds > Febrile child > Flashcards

Flashcards in Febrile child Deck (21):
1

What are common organisms causing fever in children?

S.aureus
E. coli
N. meningiditis
S. pneumoniae
GAS

In neonates - Listeria, enterococcus, Group B strep (s. agalactiae)

S. pnuemoniae and HIB less common now due to immunisations

2

What are the most common sources of serious bacterial infections in infants?

UTI

3

What is considered a clinically significant fever in a child?

> or equal to 38 degrees

4

What are red flags for an unwell child?

Appearance, behaviour = best indication - appear unwell (pale, drowsy, lethargic), poor interaction and response, change in cry (weak, high pitched, continuous, inconsolable)

Tachypnoea, tachycardia
Cyanosis, pallor
Poor tone
Rapid breathing, grunting, crackles, decreased breath sounds
Decreased wet nappies
Poor peripheral perfusion
High risk patient - immunosuppressed, chronic lung disease, congenital heart disease

5

What would you want to determine on history?

- Timeline and onset of illness
- Localising symptoms - cough, coryza, diarrhoea, vomiting, headache, photophobia, nucal stiffness, abdo or joint pain
- Vaccination hx
- Travel hx
- Sick contacts or exposures
- Immunocompromised ?
- Relevant PMHx, medication history

6

What examinations would you perform on a febrile child (in GP)?

Vitals - temp, HR, RR
Fluid ax - cap refill, tissue turgor, peripheries (temp, colour), mucus membranes
Assess neck muscle tone & movement
ENT examination - localising signs
Cardiac & resp exam - ax work of breathing, localising signs
Abdominal exam - acute abdo, localising signs
Rashes
Joints - swelling, heat, tenderness

7

How would you assess a febrile child as low risk (green)?

Colour - normal
Activity/behaviour - normal social response, appears content, alert or easy to rouse, normal crying/not crying
Respiratory - normal RR, no distress
Circulation/hydration - no signs of dehydration

8

How would you assess a febrile child as being intermediate risk (yellow)?

Colour -
Activity/behaviour -
Respiratory
Circulation/hydration

9

What are features on observation & examination are suggestive of a seriously unwell child?

CNS - conscious state, arousal, posture (normally flexed), neck stiffness, bulging fontanelle (sepsis), focal neurological symptoms/seizures

Cardiac - bradycardia (sign of hypoxia), signs of poor perfusion/hydration (esp. decreased tissue turgor), tachycardia, widened or narrowed pulse pressure (in sepsis wide initially, later narrowed)

Resp - tachypnoea, resp distress, signs of airway obstruction, apnoea

Non-blanching purpuric rash

10

What are the most common causes of fever generally?

Self-limiting viral infection most common

Infection > inflammation > malignancy

Neonates and infants <3 months more likely to have serious bacterial infection (1/3 cf. <1% when >3 mths)

UTI most common serious infection in <3 months and pneumonia then UTI in >3 months

11

Important DDx to consider in fever without a focus?

Pneumonia - clinical examination features not reliable in children, may not have bronchial breathing or crackles

UTI - common cause PUO, especially in <6 months. Consider if vomiting without diarrhoea

Meningitis - if <12 months + febrile convulsion need to LP to exclude

Septic arthritis - local signs very late feature, need to consider early, especially if pain with movement of joint and non-weight bearing. Remember septic hip pain often referred to groin and knee

Kawasaki disease - consider if persistent fever >5 days

Non-infectious causes

12

How can severity of febrile child be assessed?

Clinical appearance - well vs. unwell
Red flags on hx or examination
Stratification into traffic light system

13

What are important features of intermediate risk on traffic light system?

Abnormal activity/behaviour responses (prolonged stimulation to wake, no smile) and decreased cry

Pale, decreased cap refil, dry mucus membranes, poor feeding and reduced urine output

Tachypnoea, crackles, O2 <95% RA

Tachycardia, fever >5 days, fever >39, non-weightbearing or swelling in joint

14

What are important features of high risk on traffic light system?

Pale/mottled/blue

Abnormal response/behaviour - appears ill, very drowsy/unrousable

Decreased tissue turgor

Decreased breath sounds, grunting, chest in-drawing, severe tachypnoea

Weak, high pitched or continuous cry

Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs or seizures

15

How should the febrile child be investigated?

Ix determined by whether they appear well vs. unwell, assessment of severity (clinical features, traffic light system), age and whether focus of infection determined clinically

16

How should a neonate (<28 days) be Ix and Rx?

All should be admitted - high risk of serious bacterial infection

ABCD

All have septic work-up including LP +/- CXR (as clinical resp findings less reliable, most will have a CXR)
Add PCR for HSV, parcovirus and enterovirus to LP

Empirical antibiotics (for septacaemia)
- fluclox + gent (if CSF normal) or fluclox + cefotaxime (if CSF unknown)
- Add acyclovir if appear very unwell/suspect encephalitis

17

How should infant (1-3 months) be Ix and Rx?

Admit if appears unwell

Full sepsis work up (+/- LP and CXR) - LP if appear very unwell or other suspicion for CNS infection

Empirical antibiotics (septacaemia)
- Fluclox + gent (if normal CSF) or fluclox + cefotaxime (if unknown CSF)

Can be D/C with review in 12 hours if:
- Previously healthy
- looks well
- Urine clear
- WCC not markedly high and CXR/LP if taken clear

18

How should children >3 months be Ix and Rx?

If well - treat as appropriate +/- Urinalysis if focus not clear and boy <12 mths and girl < 2years

If look unwell admit child
If clear focus - treat with empirical antibiotics
If focus unclear - Ix with septic work-up +/- LP and CXR and empirical antibiotics

19

What are the empirical antibiotics for meningitis?

>2 months = ceftriaxone +/- acyclovir if very unwell (HSV)

<2 months = ceftotaxime (ceftriaxone can cause biliary sludge) + benzylpenicillin +/- acyclovir
This covers addition bugs - listeria, GBS, enterococcus

20

What are the empirical antibiotics for UTI?

Acutely unwell (treat as pyelonephritis until proven otherwise) - gentamycin + benpen

Well >6 months - trimethoprim

21

What are the empirical antibiotics for pneumonia?

Mild = amoxycillin or roxithromycin (mycoplasma suspected)

Moderate = amoxycillin + roxithromycin

Severe = gentamycin + roxithromycin + flucloxacillin