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Flashcards in Febrile child Deck (32):
1

Describe the common causes of fever in infancy and childhood

Mostly Viral infection
URTI
Influenza
Gastroenteritis
ENT infections
Always consider serious bacteria infections
Septicaemia
Meningitis
Arthritis, Osteomyelitis
Pneumonia CAP
UTI
If fever persists beyond 5 days consider
Kawasaki’s disease
Juvenile onset Rheumatoid arthritis
Endocarditis
rheumatic fever
Malaria
TB
Post vaccination fever

2

Causes of fever and rash presentation

common = virus
echovirus, arbovirus, EBV, roseola infantum.
Parechovirus - presents with septic picture
Dengue - Fever, rash, LN, pain
Adenovirus - Resp, GI, Fever, Rash
Measles - Conzya, conjunctivitis, Koffplit spot, fever, Cough, rash spreads from top to bottom
Don’t want to miss
Meningococcus
Henoch Schonlein purpura
Kawasaki’s disease
Juvenile onset Rheumatoid arthritis
Scarlet fever - rest, tonsilitis, fever - tx with penicillin.

3

Red flag in a child with fever in history

young

4

Red flag diseases that cause fever in child

Pneumonia
UTI
Bone or joint infection
Kawasaki disease
Influenza
Meningitis and meningococcal septicaemia

5

Complications of fever in child

Febrile convulsion - occur in 6 months to 6yr old in an acute febrile illness with no hx of seizures and no CNS abnormalities or infection.

6

Things to ask on history of a febrile child

Fever - pattern, duration, Measured or not.
Behaviour and colour.
Clingy, miserable, irritable but before and after paracetamol.
Up and down pattern is reassuring
Persistently drowsy or irritable bad.
Other symptoms - cough, coryza, headache, photophobia, diarrhoea, vomiting, abdominal pain, joint symptoms
System review - to identify location of infection
ear nose throat - pulling at ear?, rhinitis
Resp - cough, rattling, children rarely have productive cough.
GI - abdominal pain.
Urology - struggling to pass urine?
PmHx - frequent infection important.
Review fluid input and output
Immunisation status
Recent vaccination
Sick contacts
Travel Hx
Contact with animals
Complete standard paediatric Hx.

7

What to examine for in a febrile child

Degree of hydration (feeding, urination, sunken eye, dry mucus membranes, RR, fontelle, skin turgor)
Source of infection/fever
How sick they are
- Colour
- Activity
- Degree of respiratory effort
- Hydration
- Red flags signs

8

Red flags signs on examination in a child with fever

5 days of fever
swelling of limb or joint
New lump >2cm

9

Signs of good hydration in a child

Normal skin and eyes and moist mucous membranes

10

Signs of moderate dehydration in child

Dry mucous membranes
Poor feeding in infants
CRT >3sec
Reduced urine output

11

Signs of severe dehydration in a child

Reduced skin turgor
Dry mucous membranes
Poor feeding in infants
CRT >3sec
Reduced urine output

12

Signs of sepsis including meningococcal sepsis

Non-blanching rash
Increase HR
Increased RR for age
Capillary refill time >2s

13

Signs of meningitis including meningococcal meningitis

Non blanching rash
Neck stiffness may not be present in very young
Bulging fontanelle may or may not be present
Depressed LOC (worrying)
Seizures

14

Signs of herpes simplex encephalitis

Focal neurology may or mayn't be present
Focal or generalised seizures
Depressed LOC

15

Signs of Pneumonia

Tachypnoea, nasal flaring, and chest recession
Chest crackles
O2 desaturation
May be silent and only detected on CXR

16

Signs of UTI

Vomiting, poor feeding, with or without abdominal pain or tenderness
Lethargy or irritability
Urinary frequency or dysuria
Haematuria

17

Signs of septic arthritis or osteomyelitis

Swelling of limb of joint
Not using an extremity, non weight bearing

18

Signs of Kawasaki disease

Fever >5 + at least 4 of the following
- bilateral conjunctival injection
Change in URT mucous membranes with injected pharynx, dry crackles lips or strawberry tongue
Change in peripheries with oedema, erythema or desquamation
Polymorphous rash
Cervical lymphadenopathy

19

What examination finding would suggest a febrile child is at low risk of serious illness

Colour - normal in skin, lips, and tongue
Activity - responds normally, content and smiling, stays awake or awakens quickly and strong normal cry
Breathing - normal
Hydration - normal
Other - no fever at time of examination

20

What examination finding would suggest a febrile child is at moderate risk of serious illness

Colour - pallor reported by parent
Activity - not responding normally and ⇩ activity. Hard to wake up.
Breathing - nasal flaring, tachypnoea >50 in 6-12 m or >40 in >1yr.
3s
Other - fever >5d, swelling of limb or joint, non-wt bearing or not using an extremity, a new lump >2cm

21

What examination finding would suggest a febrile child is at High risk of serious illness

Colour - pale, mottle, ashen or blue
Activity - unresponsive, appears ill, barely rousable, weak high pitched cry or continuous cry
Breathing - grunting, severe distress
Hydration - reduced skin turgor
Other - non blanching rash, fever at time of examination, bulging fontanelle, neck stiffness, seizures or focal neurology, bile stained vomiting.

22

Mx of less than 1 month old with fever

"Discuss with registrar/consultant
Full sepsis work up
FBC/FIlm, Blood Culture, urine culture (SPA), LP+/- CXR
Admit for empirical antibiotics"

23

Mx of 1-3 months corrected age with fever

"Discuss with registrar/consultant
Full sepsis workup:
FBC/Film, blood culture, urine culture (SPA)+/- CXR (only if Resp sign and symptoms) +/- LP
Discharge home with review within 12 hours if the child is
previously healthly
Look well
WCC 5,000-15,000
Urine microscopy clear
CXR if taken is clear
CSF if taken negative
If the child is unwell or above criteria are not all satisfied, admit to hospital for observation +/- empiric IV antibiotics"

24

Mx of > 3 months with clear focal cause of infection

"Child looks well
treat as clinically indicated
Child looks unwell
Discuss with registrar/consultant
Investigate as appropriate for clinical focus
Admit for treatment"

25

Mx of >3m with fever and no clear focus of infection in a child that looks well

Urine MCS if less for 12 m then SPA,
Discharge home on symptomatic treatment
Arrange medical review within 24 hr or sooner if deteriorates

26

Mx of >3m with fever and no clear focus of infection in a child that miserable but still relatively alert, interactive and responsive,

Urine MCS if less for 12 m then SPA,
Discuss with registrar or consultant prior to any investigations.

27

Mx of >3m with fever and no clear focus of infection in a child that looks unwell

Discuss with senior reg
Full sepsis workup - FBC, Blood cultures, urine culture +-CXR (if respiratory symptoms or signs) +/- LP
Admit to hospital for observation +/- IV antibiotics.

28

Discharge requirements

Infants less than 1 month of age with fever should be admitted.
Infants 1 to 3 months of age:
The child is well
All investigations are normal
The child has been reviewed by a senior registrar/consultant
Follow up in 12 hours has been arranged
Children older than 3 months:
The child is well
Follow up has been arranged

29

Signs of septic shock

Fever or hypothermia
Tachycardia
hypotension
warm shock - wide pulse P, rapid CRT
Cold shock - Narrowe Pulse P, prolonged CRT
⇑HR +/- Hypoxia
ALOC
unwell appearance

30

Management of septic shock

Danger
Response
Send for help
Airway
B - O2 via face mask
C - continued cardiorespiratory monitoring, IV access (IO)
BC, Blood gas, Blood glucose, FBC, UEC, Coags)
Antibiotics - IV or IM if needed. Benzylpenicillin/cefotaxime/look up
IV fluid resus- 20ml/kg bolus of NS as push over 10mins.
Inotropes if no improvement- warm shock (noradrenaline) cold shock (Dobutamine)
Ventilatory support if distress+ALOC
Correct hypocalcaemia etc.. monitor BSL,
Secondary rests as needed.

31

Ix in suspected Meningococcal

Blood culture
Meningococcal PCR
FBC and differential
Glucose, urea and electrolytes
Coagulation screen
LP - would not be recommended in the initial management of an unwell child with fever and purpura. But may be appropriate in suspected meningitis when no other contraindication exist
increase ICP
Increase WBC - neutrophils
Increase protein
Decrease glucose

32

Mx of Meningococcal

DRSABC - resus, ICU
Notifiable on suspicion
IV assess or IO
BC and nasal culture, ABG, U&E, FBC, PLT, coagulation studies
IV ABX- Ceftriaxone
Supportive therapy - 20ml/kg NS (shocked) and dexamethasone to reduce swelling if needed.
Fluid management
Admit
Chemoprophylaxis - rifampicin