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Flashcards in Fever Deck (72):
1

What do these abbreviations stand for?
SBI
FWS
FUO
PCV7/PCV13
RSV
SWU
LP
WOB

SBI- serious bacterial infection
FWS- fever without source
FUO- fever of unknown origin
PCV7- Prevnar® vaccine
PCV13- 13-valent version released 2010
RSV- Respiratory syncytial virus
SWU- septic work-up
LP- lumbar puncture
WOB-work of breathing

2

the sensitivity of even the best of these temperature taking devices is 66%. It is fine to screen suspected well young children with any of these 3 measures, but if the caregiver is reporting a fever or if your exam reveals a concern for SBI, the temperature needs to be taken ___.

rectally

3

How does the tympanic thermometer need to be placed inorder for accurate temperature reading?

The ear canal needs to be straightened in order for the device to be correctly aimed to take a temperature reading.

-In infants less than 6m, this is not possible so the device ends up aimed at their external auditory canal, potentially resulting in a falsely low reading.

4

Rectal readings are most accurate for children ____ y/o

less than 3y/o

5

Describe the different ways you can use to take a temperature

1. oral- impractical
2. tympanic- inaccurate
3. axillary- inaccurate
4. temporal artery- inaccurate
5. rectally-- most closely matches core body temperature

6

Fortunately, in developed countries with strong immunization policies, most children with febrile illness (approaching 90%) have ____ infections, which are ___

viral infections which are self-limited, and low risk of serious morbidity.

7

It is important to comment that there are a few viral illnesses to be concerned with in infants including:

1. Varicella and Herpes due to risk of dessimated disease
2. RSV due to risk of respiratory compromise
3. influenza due to risk of secondary infections and respiratory compromise.

8

The actual rate of bacteremia in EDs is now ___%

-For unimmunized children, the risk of bacteremia remains at __%

less than 1% due to Prevnar vx

5%

9

Bacteremia can be self-limited with the immune system eradicating the organism, but it can also seed the __ and ___ resulting in infections in those organs

meninges and kidneys

10

Probably the most feared of all bacterial infections is ___ , and now post-___ and ___ vaccines, the rate is low but the most serious organism, _____, remains a concern.

meningitis

Hib and Prevnar vx


N. meningitidis

11

WBCs is a poor predictor of infection with what organism

N. meningitidis

12

In the current era of vaccination, ___ and ____ remain the most likely SBI in a febrile child.

UTI
pneumonia

13

Septic joints and osteomyelitis are almost always a hematogenous spread in pediatrics so consider in a child with hx of:

1. sickle cell dz,
2. prematurity with NICU stay,
3. immunodeficiency,
4. indwelling vascular access,
5. hx of sepsis,
6. minor trauma with a bacteremia

14

Most common SBIs that practioners worry about in pediatrics with a fever

1. Bacteremia (S. pneumo)
2. Meningitis
3. UTI
4. Pneumonia
5. Septic joint, osteomyelitis, cellulitis
6. Kawasaki's
7. CA, Rheumatological dz (JIA, lupus)

15

It is reassuring that children with no history or physical exam findings consistent with ____ have an extremely low chance of pneumonia.

respiratory issues

*Unfortunately, it is not uncommon for a child with fever to have rhinorrhea, which was 1 parameter used in this study as a respiratory issue

16

What signs are more reliably associated with lower respiratory tract infection in children?

1. tachypnea
2. cough
3. increased WOB

17

___% of infants less than 3 months who had no clinical evidence of pneumonia had negative chest x-rays

__% of infants with at least 1 abnormality had a positive chest x-ray

100%

33%

18

"clinical evidence" for pneumonia in children includes:

1. tachypnea
2. abnormal sounds
3. cough
4. runny nose
5. respiratory distress

19

An ill-appearing child entails what criteria

1. lethargy
2. poor perfusion- general color, cap refill, turgor, BP
3. very slow or very fast breathing
4. cyanosis
5. abnormal cry

*young children who are hypothermic (less than 37C), especially neonates may not mount a febrile response

20

Regardless of the degree of fever, children who appear ill needs to be admitted to the hospital for:

1. stabilization,
2. a complete SWU,
3. admission and
4. empiric IV antibiotics pending culture results.

21

Children with sickle cell disease have a higher risk of __

pneumococcal sepsis

22

What kids do you need to be extra cautious with if they present with a fever?

Compromised children
1. immunocompromised
-sick cell disease
-HIV
-on chemotherapy
2. on prophylactic Abx
3. incompletely immunized

23

Children who are unimmunized or incompletely immunized unfortunately have a pre-90’s risk of what diseases?

1. H. influenzae bacteremia and
2. meningitis and
3. S. Pneumoniae invasive diseases such as meningitis, pneumonia, bacteremia


*They have some protection from the herd immunity of their immunized colleagues, but you will see on the algorithm that these kids need more testing when they have a febrile illness than kids who are immunized.

24

What history questions are important to ask when working up a febrile child

1. exposure to ill contacts
2. irritability
3. activity level
4. fluid intake
5. Urine output
6. associated sx
7. immunizations
8. recent abx
9. recent hospitalization
10. potential for osteomyelitis
11. birth hx if less than 28 days old

25

If 28d/o or less and presenting with a fever, it is important to ask about:

1. maternal infection/fever,
2. prematurity,
3. hospital course,
4. premature rupture of membranes.

26

What PE is important to do with a child presenting with fever

1. focus on activity level
2. alertness
3. hydration
4. rashes
5. skin disruptions/cellulitis
6. otitis media
7. throat
8. fontanel/neck
9. abnormal breath sounds
10. increased WOB
11. abdominal pain
12. joint mobility
13. erythematous/swollen joints

27

in children ____, it is common that PE and Hx do not reveal cause of their fever

less than 3 months

28

There is a role in children 29-90d/o for testing for respiratory pathogens using ____ which test for a large group of respiratory viruses simultaneously and, if positive, can help you avoid further invasive testing.

nasal wash PCR tests

29

if the child has a history of diarrhea, especially if there is blood and/or mucus present, you should entertain the possibility of a ____ as the cause of their fever.

bacterial gastroenteritis

30

Interestingly, the most common concomitant SBI in infants with RSV bronchiolitis is a ___

UTI

*as high as 7%- that same percent of the general population that gets UTI’s.

31

Presents with:
-barky cough
-preceding URI sx

croup

32

Tx of herpetic infections in very young infants

can be life-threatening if they become dessiminated, so sometimes these kids are hospitalized for observation and anti-virals.

33

When are rapid influenza tests helpful

(+) results only helpful if flu season

False positives are frequent

34

What diseases are unlikely to have concomitant SBI

1. croup
2. varicella
3. stomatitis

35

Otitis media has a low prevalence in children ____. Therefore be clear that your exam matches the current guidelines for the diagnosis of acute otitis media before you decide to defer further lab investigation into the cause of the fever. Many children have been hurriedly diagnosed with AOM, missing a SBI, and then have a complicated management course when their fevers don’t resolve and their SBI is now partially treated with the Abx given for the AOM.

less than 3 months

36

Risk factors for fever in a neonate of 0-28 days

1. Maternal infections
2. Recent hospitalization for birth
3. Immature immune system
4. Minimally reactive to environment
-Difficult to assess ill or well-appearing

37

Because of the risks for neonates with a fever, a rectal temp of ___ needs a ___

100.4 or higher (38C)

full septic workup

38

what does a full septic work up entail for a neonate 28 days or less?

1. CBC
2. blood c/s
3. UA
4. gram stain
5. urine culture
6. LP with CSF analysis and gram stain and culture
7. +/- CXR
8. +/- stool culture if diarrhea

39

When is a CXR indicated for a neonate 0-28 days with fever?

respiratory sx
1. cough
2. rhinorrhea
3. abnormal exam (tachypnea, WOB, abnormal breath sounds)

40

Management of Neonate with fever

admitted for IV Abx and observation until cultures were completed and neg and there is clinical improvement

41

Management for a neonate with fever even if the whole family had the flu last week and this neonate’s flu test is positive, or they have RSV, etc.

admitted for IV Abx and observation until cultures were completed and neg and there is clinical improvement

*While this results in a significant number of unnecessary hospitalizations for what turns out to be benign viral illnesses, these infants have a much higher risk of concomitant SBI so we err on the side of caution.

42

__% of neonates in the ED have SBI4

12-28%

43

The Rochester criteria or Philadelphia Protocol (low risk) for SBI in infants 29 days and older

1. WBC between 5-15K (cannot be neutropenic)
2. Bands not greater than 1.5
3. Band/neutrophil ratio of less than 0.2
4. U/A less than 10 wbc/hpf, negative gram stain
5. CSF (if obtained) less than 8 wbc/hpf, negative gram stain
6. CXR negative,
7. stool gram stain less htan5wbc/hpf (if obtained)

*Other proposals have been made to use CRP and/or Procalcitonin, which are inflammatory markers, as an adjunct to risk stratification

44

The combination of a positive ___ and positive __ was the best predictor of SBI compared to ___ or __

PCT (procalcitonin- over 2ng/ml)

CRP (over 80mg/L)

WBC or band count

45

what is the fever cut off to enter the algorithim in a infant 29-90d/o with FWS

100.4 or 38C or higher

46

What is the general septic workup for an infant 29-90d/o

1. CBC
2. blood c/s
3. UA
4. gram stain
5. urine c/s
6. +/- LP-- Must do if seizure or an empiric Abx has been or will be given
7. +/- stool culture if diarrhea
8. +/- CXR (resp. sx)

47

Management of an infant 29-90d/o whose appearance or lab values DON'T meet “Low Risk” criteria,

they must be admitted for further management/observation likely with IV abx pending cultures

48

Management of an infant 29-90d/o whose appearance or lab values meet “Low Risk” criteria,

consider ceftriaxone 50mg/kg IV/IM

*You should not give antibiotics if an LP was not done due to the risk of partially treating meningitis or another SBI.

-Most providers are leaning away from giving ceftriaxone. The infant may go home with only supportive care if they have follow-up in 24 hours, with access to telephone and transportation should clinical changes occur.

49

Once children are ___, most have usually received 1 round of immunizations protecting them from a host of diseases that feature prominently in SBI’s, and their exam findings become more reliable in terms of activity and discerning ill-appearing vs. well-appearing.

3-36 months

*Some studies suggest this upper cutoff should be 24 months, as most children are fully-immunized by then and they are more verbal.

50

For 3m/o +, the fever cut-off for work-up is

39°R (102.2°F)

51

What is the full septic W/U for a child 3-36 months

1. UA
2. urine gram stain
3. urine culture: only for the select population of: girls less than 24 months, uncircumcised boys less than 12 months and circumcised boys less than 6 months
4. CXR, if indicated by symptoms or exam and a blood c/s based on risk of bacteremia
5. It is not necessary to draw a CBC, but many providers do if they get a blood C/S since they are sticking the patient anyway.

52

What is the criteria for a urine culture for FWS in 3-36 month olds

only for the select population of:
1. girls less than 24 months,
2. uncircumcised boys less than 12 months and
3. circumcised boys less than 6 months

53

The risk of bacteremia criteria in 3-36 month olds are:

1. less than 2 Prevnar
2. temp over 40°C (104°F),
3. abnormal U/A, gram stain (less than 18m/o),
4. petechiae, or
5. prolonged diarrhea.

*As you can see, you will probably be doing a bit of blood work on kids between 3-4 m/o, but likely very little on kids older than 4m as they will have had 2 Prevnars by then.

54

If you have a patient with a higher risk for bacteremia (3-36months), and you got a CBC, if CBC indicates WBC over ___, you need to find the source by:

20K

1. start with a CXR
2. consider treating with ceftriaxone and
3. getting an LP,
4. discharge home with F/U in 24 hours.

55

If patient 3-36 months is low risk for bacteremia, management includes

they may go home, supportive care only and F/U in 24- 48 hours with telephone and transportation access necessary.

56

I would like you to recognize the oral antibiotics, such as ___, are a poor choice in children with FWS.

*you should use ___

Amoxicillin

*and Amoxicillin, specifically, is not an effective regimen for SBI eradication.

Use ceftriaxone.

57

*Use parenteral antibiotics for FWS awaiting cultures, preferrably ___*

Ceftriaxone

58

Occasionally, you will have a child, at any age, who presents with FWS that is prolonged. Typically a viral illness will run its course in ___ days, so these kids become worrisome that they may have a SBI that just hasn’t been located yet.

3-5days

*When they are less than 2y/o, these patients often end up hospitalized for further evaluation and monitoring

59

DDX of prolonged fever without a source

1. TB
2. Lymphoma and Leukemia
3. Juvenile Idiopathic Arthritis
4. Endocarditis
5. CMV, EBV
6. Malaria
7. Hyperthyroidism, Ectodermal dysplasia
8. Kawasaki’s disease-- FWS may be the only sx in infants

60

__ and ___ are common culprits in prolonged FWS, so these would be important tests in primary care

Cytomegalovirus and Epstein Barr virus

61

I use a ___ to help guide my decision making in kids with prolonged fever around a possible missed SBI.

CRP

62

cause of Kawasaki’s is unknown, but thought to be __.

viral

63

__ is currently the leading cause of acquired heart disease in the U.S.

Kawasaki's

64

sx of Kawaski's

1. include fever over 5d,
2. sometimes arthralgias manifested in a non-verbal child as refusal to walk or crawl,
3. a non-exudative conjunctivitis,
4. cracking, fissuring of lips, oral mucosa,
5. unilateral cervical lymphadenopathy,
6. a non-specific rash to trunk, extremities, and palmar/solar erythema
7. edema followed by peeling

65

complications of Kawaskis

1. myocarditis
2. pericarditis
3. an arteritis which predisposes the patient to cardiac aneurysms

66

If you suspect Kawasaki’s you might find abnormal labs with a CBC revealing:

1. leukocytosis,
2. thrombocytosis (after 1st week), and
3. an elevated ESR or CRP

67

In the case of infants with FWS, they could have atypical or incomplete Kawasaki’s. This should be considered in infants ___ months with FWS __ days, and all children with FWS __ days and __ symptoms of Kawasaki’s.

less than 6 months

7 days

over 5 days

2-3 sx

68

if you suspect Kawasaki’s or atypical Kawasaki’s, get a __ and __. If elevated get a ___

ESR or CRP

If they are elevated (over 40) or (3.0) respectively, get a baseline echo

69

What is the treatment for Kawasaki's?

1. hospitalization with
2. IVIG
3. high dose ASA
4. baseline echo/EKG
5. management by cardiologist

70

What is the mnemonic for the presentation of Kawaskai's?

CRASH and Burn

C- conjunctivitis (really red eyes)
R- rash on body (and cracked/fissured lips)
A- arthritis (joint paint)
S- Strawberry tongue (red and swollen tongue)
H- hands (peeling of skin)

and
BURN- unexplained fever for over 5 days

71

Signs of menigitis in young infants

whimpering
high WBC

72

What is criteria for the Ishimine algorithm protocols for an infant?

temp: 38C or greater and age less than 3 months