Transcription

1 Fever Phobia and the ED Doc Ran Goldman, MD BC Children s Hospital, Professor, University of British Columbia SLIDES ON :

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4 Define Fever 38.0 o Doesn t matter how you measure o Neonates o Iimmunocompromised patients o Home, office or ED

5 How to Measure Temperature? o Rectal, oral, axillary, forehead, tympanic o In < 3 m always rectal (core body temp) o Avoid forehead, tympanic at all cost

6 When to Worry? 38 38

7 When to Worry? 38 38

8 When to Worry?

9 The Fear Factor R/O Sepsis Toxic Appearance : Lethargy Poor perfusion Cyanosis Hypoventilation Hyperventilation Lethargy : Poor/no eye contact No interaction with parents

10 The Fear Factor R/O Sepsis Look unwell Un immunized Neonates Transplant recipients (Bone marrow, Solid organ) Oncology patients (Undergoing therapy, mucositis, central line) Asplenic patients (sickle cell)

11 CASE

12 3 week old Jonathan is brought to the ED at 1 am. He felt warm on the forehead, and the nurse on the health help line said go to the Emergency. Normal pregnancy and delivery, Apgar 8,9, no complications post natal, no respiratory distress, breastfeeding (exclusive) like a champ No Vx, Dx, Cx, some spitting at times, burping like Louis the XVI No immunizations yet

13 Vitals : Rectal Temp : 38.1 (100.5 F), HR : 140/m, RR : 44/m, BP : Cant measure, restless in triage. Normal physical exam, normotensive fontanel, good reflexes, great pink color, breastfeeding well while waiting for your exam.

14 o CBC with differential o Electrolytes o Blood culture o Catheterized urinalysis and urine culture o Lumbar puncture Gram stain and culture Cell count and differential Protein and glucose Extra tube for additional studies o Enteroviral PCR, HSV PCR, CA encephalitis project

15 o Chest x ray? o Stool sample? o ESR/CRP? o Venous Blood Gas olactate? o Procalcitonin?

16 Prospective study Procalcitonin and C reactive protein 408 children 7 days 36 months, fever without source SBI was diagnosed in 94 children (23%) Procalcitonin + CRP were valuable markers in predicting SBI Perform better than WBC and ANC PCT more accurate at the beginning of infections Andreola. Pediatr Infect Dis J Aug

17 Procalcitonin for SBI Eight studies were included (1,883 children) Procalcitonin (OR 10.6; 95% CI 6.9 to 16.0), C reactive protein (OR 9.83; 95% CI 7.05 to 13.7), Leukocytosis (OR 4.26; 95% CI 3.22 to 5.63). Overall sensitivity procalcitonin 0.83 (95% CI 0.70 to 0.91), CRP 0.74 (95% CI 0.65 to 0.82) Leukocytosis 0.58 (95% CI 0.49 to 0.67) Yo. Annals EM Nov

18 Fever without a source in normal Hx, healthy, well looking children : o 0 28 days full septic workup o 29d 3m partial septic workup o 3m 3y based on presentation (whenever possible obtain urine) Clinical impression always override this!

19 If 0 28 days old o Ampicillin AND gentamicin OR o Ampicillin AND cefotaxime Consider acyclovir Older o Ceftriaxone ± Ampicillin OR Vancomycin o Some centers : until CSF results are known (cell count, protein, glucose), initiate therapy with meningitic dosing regimen

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21 CASE

22 5 month old Cassie is brought to the ED at 1 am. Her parents report that she woke up with a troubling cough and she cant breath. Symptoms started 2 3 days after an onset of fatigue, not eating well and a runny nose. She has no allergies and immunized UTD.

23 On Exam : Cassie is a well appearing girl You identify the cough before entering the room, as croup Fever to 39.3 ( F)

24 On Exam : Cassie is a well appearing girl You identify the cough before entering the room, as croup Fever to 39.3 ( F) What additional evaluation would you do at this point?

25 Likely a viral origin (parainfluenza and others) Severe disease think influenza A, parainfluenza 3, and measles Consider nasopharyngeal wash/rapid test Secondary bacterial less likely in a wellappearing child No additional workup is necessary.. except

26 Children with proven VIRAL infection can still have UTI Rate of SBIs was 11.4% (133 of 1169) Rate of SBIs in the RSV positive 7% (17 of 244) RSV negative 12.5% (116 of 925) Rate of UTI in RSV positive infants 5.4% (14 of 261) RSV negative 10.1% (98 of 966 consider obtaining urinalysis/urine culture Levine. Pediatrics Jun;113(6):

27 CASE

28 11 year old John with ALL, in induction, came to the ED at 1 am, after feeling warm for 3 4 hours No vomiting, diarrhea, cough or other symptoms Skin over central line site looks clean On exam 38.5 (101.3 F), chills, and dizziness

29 Acute decompensation Acute care setting/monitoring Vital signs frequently Lab blood (culture peripheral and central line), urine, chest x ray IV antibiotics immediately IV Bolus(es) Protocol driven care for fever neutropenia and based on clinical picture.

30 BCCH Guidelines

31 BCCH Guidelines

32 BCCH Guidelines

33 CASE

34 George is an 8 month old. Had fever earlier today 38.5 Mom heard a strange voice coming from his crib Found him seizing

35 One of the scariest things parents can endure History elements are important Physical exam critical Decide if simple or complex

36 6m 6y Familial in nature 50% recurrence in 1 year when febrile No increased incidence of epilepsy

37 Febrile Seizure 38 38