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Rosen’s pediatric fever
1. MANAGEMENT IS AGE DEPENDANT
• Management of the infant/child/adolescent with
a fever, varies based on the age of the pt.
• Common/arbitrary age divisions:
• 0-28 days
• 1-2 months
• 2-3 months
• 3-6 months
• 6-36 months
• 3 years to adulthood (Rosen’s, p2094)
2. FEVER DEFINED/ ROSEN’S
• “Fever is defined as any elevation in body temperature
equal to or above 38.0 C (100.4 F).” p 2094 THIS IS A
RECTAL TEMP!!!
• Rectal temps are the most reliable, as axillary, oral,
and tympanic temps are not reliable.
• No rectal temps in pts who are immunocompromised,
such as cancer pts on cytotoxic medications.
• HYPERTHERMIA: Is an elevation of the body’s set point,
as in ASA od, Heatstroke, malignant hyperthermia, etc.
3. SERIOUS BACTERIAL ILLNESS (SBI)
• Typically defined as “The presence of
pathogenic bacteria in a previously sterile site.
• This includes: Urinary tract infections (UTI),
bacteremia, meningitis, osteomyelitis,
bacterial gastroenteritis, bacterial pneumonia,
cellulitis or septic arthritis.
• RISK of SBI in for infants < 3 mo old, with a
fever, is between 6% to 10%!!!
4. Common pathogens vary by age
• 0-28 days: group B strep/ L monocytogenes/
Herpes Simplex Virus (HSV).
• 1 to 2 Months: S. Pneumoniae/ H Influenzae/
N Meningitidis/ E coli. Varicella (CHICKENPOX)
• ALL CHILDREN < 3MO, URINARY TRACT IS THE
MOST COMMON SITE OF INFECTION(2094).
• Infants < 3mo may present with a viral
syndrome and still have a serious bacterial
illness.
5. N Meningitidis
• Bimodal distribution.
• Highest incidence in children < 12 mo Old.
• 2nd peak: adolescents, with highest group in
the college students living in dorms.
6. Case: Sick looking 28 day old infant
with temp > 39 C
• What are the most likely organisms???
• What antibiotic therapy should be started??
7. Case: Sick looking 28 day old infant
with temp > 39 C
• MOST COMMON ORGANISMS: L.
monocytogenes, GP B strep, N meningitidis, S
Pneumoniae, and E Coli.
• TREATMENT:
• Ampicillin (100mg/kg/24 divided Q 6 hours).
• Plus either Gentamycin 5mg/kg/24 hours
divided Q 8 to 12 hours) OR Cefotaxamine
(150mg/kg/24 hours divided Q 8 hours). (R
2098)
8. HISTORY OF PEDIATRIC FEVER
• Infants, 28 days: Ask about exposure to
HSV, OR group B Strep.
• Decrease in fever in response to Tylenol
and/or Motrin use “HAS NOT BEEN SHOWN
TO RELIABLY EXCLUDE BACTEREMIA (2096).”
• Any HX of lethargy/ irritability/ or altered
mental status: MUST include
Meningitis/Encephalitis in the diff Dx.
9. PHYSICAL EXAM
• Physical exam should be age adjusted. Look for
the most serious problems based on the age of
the pt and the serious infections in that age
group.
• RASH: Beware the rash!! Rashes are found in life
threatening conditions: Meningococcemia/ Rocky
Mountain spotted fever/ Toxic Shock Syndrome
(TSS)
• Watch the child: does the child stop breathing??
10. APPARENT LIFE THREATENING EVENT
(ALTE)
• Definition: ALTE is an episode that is
frightening to the observer!! Findings:
Combination of Apnea, color change ( red,
blue, choking episode, and a marked decrease
in muscle tone.
• Pathologic apnea is a respiratory pause > 20
sec, or associated with cyanosis, pallor,
hypotonic, or bradycardia.
• “Near miss SIDS” IS NO LONGER USED!!!
12. PE: PURPURA
• HENOCH-SCHONLEIN PURPURA.
• What defines the syndrome??
• PHYSICAL EXAM AND HX> How to identify the
syndrome??
• See the Handouts from Knoop,K.J. et al. “The
Atlas of Emergency Medicine” 3rd ed. Pub
• DISCUSSION!!!
• Contrast with MENINGOCOCCEMIA!!!!
13. A child with a fever and a evolving
petechial rash
• “A CHILD WITH A FEVER AND AN EVOLVING
PETECHIAL RASH MUST BE PRESUMED TO HAVE
MENINGOCOCCEMIA (Knoop,K.J.; Atlas of
Emergency Medicine, 3rd ED., Pub 2010, pg 423.)”
• Henoch-Schonlein Purpura (HSP): The child
usually has Abdominal Pain, Arthralgias, and
lower body purpura, BUT DOES NOT LOOK SICK
AND DOES NOT HAVE A HIGH TEMP (2180-2182)
14. PEER VII TQ #94
• Compared to other purpuric eruptions, Henoch-
Schonlein Purpura is more commonly found to:
• A. Begin over the distal joints and spread
centrally?
• B. Frequently be associated with Bullae or
infarcted areas?
• C. Have lesions with necrotizing ecchymosis?
• D. Occur in areas of pressure or minor trauma?
• E. Occur symmetrically in the lower extremities?
15. PEER VII TQ #94 ANS
• ANS: E. HSP THE PURPURIC LESIONS OCCUR
SYMMETRICALLY IN THE LOWER EXTREMITIES.
• Purpura is “bleeding in the skin that causes
NON BLANCHING LESIONS.” tq 94 PEER VII.
• Purpura are >3mm. Petechia are <3mm.
• PURPURA FULMINANS: =Bullae or infarcted
areas, associated with DIC from septic shock
and bacteremia. Review/discuss case
#90, Clin Emerg Med Casebook. By Levis &
Garmel
16. PEER VII TQ # 131
• Which of the following is included in the
diagnostic criteria for KAWASAKI DISEASE?
• A At least one coronary artery aneurysm?
• B Fever unresponsive to acetaminophen?
• C Many ulcerating lesions on both hands?
• D Marked features of geographic tongue?
• E Unilateral cervical lymphadenopathy?
• Rosen’s pg 2161-2164, see pg2163, fig 169-14
17. PEER VII TQ 131: KAWASAKI DX
• Unilateral cervical lymphadenopathy (E).
• Kawasaki Dx: aka Mucocutaneous lymph node syndrome.
Dx of young children. Apprx 80% of cases are in children< 5
y/o (peerVII).
• Dx criteria: Fever for 5 or more Days (per Peer and no
other dx found). Plus 4 of the 5 other:
• Bilateral nonpurulent conjunctival injection +
• Inflammation of lips and oral mucosa +
• Erythema or swelling of the Hands or Feet +
• Cervical lymphadenopathy (peer VII usually unilateral) +/or
• Rash Nonvesicular, and Nonbullous. (R 2162/ box 169-17)
18. KAWASAKI DISEASE: Rosen’s p 2161-
2164.
• Originally described by Dr T. Kawasaki in 1967
• It is “ a significant cause of acquired cardiac
Dx in children in the U.S. (2161).”
• Annual US cases is: 3000 to 5000.
• Up to 20% of untreated children develop
some degree of coronary artery abnormality.
• Etiology: UNKNOWN. Postulated to be a
possible infectious agent. Nontransmissible
person to person.
19. KAWASAKI DISEASE
• Pathology: Vasculitis of the small and medium
vessels. 25% of pts develop a mild diffuse
myocardial inflammation (R 2162).
• “All children with suspected Kawasaki Dx,
either classic or incomplete, should undergo
ECHOCARDIOGRAM to detect the presence
and degree of coronary aneurysm (p 2162).”
• Death: Due to MI due to coronary artery
occlusion. (R 2164).
20. KAWASAKI DX: TREATMENT
• 2 MAJOR parts of RX are: IV immunoglobulin
infusion of 2 g/Kg over 10 to 12 hours. Pts must
have EKG monitoring during the Rx.
• Aspirin is started at 80 to 100 mg/kg/PO divided
QID.
• Aspirin is continued at this dose till the child has
been afebrile for > 48 to 72 hrs.
• Aspirin is then reduced to 3 to 5mg/kg each day
for up to 6 to 8 weeks (R 2164).
• IBUPROFEN MUST NOT BE GIVEN AS IT CAN
ANTAGONIZE THE ANTIPLATELET EFFECT OF ASA.
21. KAWASAKI DX: COMPLICATIONS
(TINTINALLI-PG 827)
• Cardiac complications are the most severe sequelae of Kawasaki Dx.
Included are:
• Coronary artery aneurysms,
• Myocarditis,
• Pericarditis,
• Pericardial Effusions,
• Valvular dysfunctions,
• Left ventricular dysfunction
• Arrhythmias.
• MI- Myocardial infarction is a complication of coronary artery
aneurysm, and is the leading cause of death in Kawasaki Dx. (T-826)
22. ROSEN’S GENERAL APPROACH to the
Febrile Infant & Child (p2098)
• The “SICK” INFANT AND CHILD may need active
resuscitation by following the A-B-C’s.
• Evaluate the Airway and Breathing for need for intervention
via O, BVM>>RSI.
• Aggressively evaluate the “sick” Childs circulation, and
start 0.9NS, check glucose, and give a 20mL/Kg bolus.
• IV fluid bolus can be repeated up to 60 to 100mL/Kg.
• Immediately start antibiotics. The pt with meningitis may
be too ill to have a spinal tap (2098).
• The CSF may become sterile in 15min to 2 hours in
Meningococcal meningitis and within 4 to 10 hours in pts
with Pneumococcal Meningitis (R-2098).
23. SERIOUS BACTERIAL ILLNESS
• INFANTS: 0 TO 28 DAYS OF AGE
• <28 DAYS OF AGE + fever > 38.0 C are at high risk
for bacterial infection. Rates = 12%.
• Hospitalization the pt and continue the work up
“EVEN IF THE CHILD IS WELL APPEARING” (R-
2098).
• SEPSIS w/u includes cath urine and CSF studies.
• “LUMBAR PUNCTURE IS INDICATED EVEN IN THE
PRESENCE OF A UTI DUE TO THE RISK OF
CONCOMITANT MENINGITIS (R-2098)”
24. SERIOUS BACTERIAL ILLNESS
• Infants 0 to 28 days of age:
• “All children in this age group should be admitted
to the hospital on EMPIRICAL antibiotics until
culture data become available( R-2098).”
• Rx: Ampicillin-100mg/Kg/24hours divided into 4
doses + either: Gentamycin 5mg/Kg/24 hours
divided each 8 to 12 hours OR: Cefotaxime
150mg/Kg/24 hours divided each 8 hours.
• Add empiric Acyclovir for risk of HSV at 60
mg/Kg/24 hours, divided each 8 hours.
25. SERIOUS BACTERIAL ILLNESS
• Infants 0 to 28 Days of age.
• NO CEFTRIAXONE IN INFANTS UNDER 28
DAYS!
• NO CEFTRIAXONE IN INFANTS<28 DAYS DUE
TO A “THEORETICAL RISK” OF INDUCING
ACUTE BILIRUBIN ENCEPHALOPATHY!!!
• ROCEPHIN CAUSES BILIRUBIN TO BE
DISPLACED FROM ITS PROTEIN BINDING SITES.
26. SERIOUS BACTERIAL ILLNESS
• Infants 29 to 90 days of age:
• May allow for an “outpatient follow up” only if
the child looks “good” and lab work and
possibly CSF studies are all in a normal range.
• Boston criteria allows for next day follow up,
with a CBC, blood culture, cath UA & spinal
tap being obtained, and IM ceftrixone
50mg/Kg IV or IM prior to D/C (R-2099).
27. FEBRILE SEIZURES (FS)
• FS= Common cause of convulsions in children
less than 5 Y/O.
• Definition: A seizure accompanied by a fever
WITHOUT the presence of a CNS infection.
• “FEBRILE SEIZURES CAN BE THE PRESENTING
COMPLAINT OF INFANTS AND CHILDREN WITH
CNS INFECTION SUCH AS MEMINGITIS (R-2101).”
• The AAP suggests LP be “strongly considered” for
Pt<12 mo old with 1st febrile seizure, or in pts
with prior antibiotics, or for “worrisome” pts.
28. SIMPLE FEBRILE SEIZURES (T-878)
• Tintinalli, 7th ED. Pub 2011, pg 878.
• Simple febrile seizure: It is most important to
decide if the child appears well or sick.
• The definition of a SIMPLE FEBRILE SEIZURE:
• -A generalized tonic-clonic seizure lasting <15
min. With a fever equal to, or higher than 38.0 C
(Over 100.4 F).
• Age: 6mo to 5 years old.
• Only one seizure in 24 hours (p 878).
29. Tintinalli’s Simple Febrile Seizure
• If the seizure is consistent with a simple febrile
seizure, AND:
• THE CHILD LOOKS WELL, Then>
• The evaluation can focus on the cause of the
fever, AND:
• BLOOD WORK, LUMBAR PUNCTURE, AND
Imaging are not mandated (p 878).
30. SIMPLE FEBRILE SEIZURE
• Only 50% of pts <12 mo old and 30% of pts > 12
mo old will have another febrile seizure.
• Having a febrile seizure DOES NOT mean a child
will develop epilepsy.
• Anticonvulsant therapy is not recommended for
simple febrile seizures (T 878).
• Children who appear “SICK” post seizure, and
have petechial lesions, and/or have neck
stiffness> Treat as meningitis, start decadron, and
give IV antibiotics appropriate for age!!!
31. PEER VII TQ #262
• A pt sent in by local peds, for “possible febrile seizure”.
Which pt is most likely to fit the Dx?
• A. 2 week old, afebrile, well appearing, generalized seizure
at home < 10 min.
• B. 4 Mo old, fever on arrival, generalized seizure at
home,10 min, Dx with UTI in ED.
• C. 19 Mo old, febrile, appears well. Generalized seizure at
home, < 10 min.
• D. 23 Mo old, appears well, with 2 seizures at home , each <
5 min.
• E. 9 Y/O febrile, generalized seizure that started in right
hand in the ED, lasted < 10 min, the pt also had a seizure at
home.
32. PEER VII TQ # 262 ANSWERS
• The ANS is C.
• A “Simple Febrile Seizure” is
Generalized, lasts<15 min, occurs in pts 6 Mo
to 5 Y/0, 1time in 24 hours, with No evidence
of CNS infection, ( cns exam is normal, NO sx
of meningitis, and the child appears well).
• A,B, and E are outside the acceptable age.
• D & E both had more than one seizure
in<24hours.
33. Rosen’s fever and Petechiae
• Petechial Rash + Febrile illness has been
associated with Meningococcal infection.
• Meningococcal infection was found in 7% to
11% of pts hospitalized with a fever and
petechiae (R 2101).
• Diff Dx of fever + petechiae:
DIC, RMSF, Pneumococcal
bacteremia, ITP, HSP, LEUKEMIA, and
Meningococcal Infection.
34. TOXIC SHOCK SYNDROME
Due to a toxin mediated clinical syndrome.
Caused by: infection with S. Aureus, or Group A
Strep.
The toxin implicated is an exotoxin termed TSS
toxin 1.
The classic syndrome was originally identified with
tampon use.
Pts present SICK. +Fever, >38.9 C, +
Hypotension/shock, Diffuse erythroderma, and 3
major organ systems involved: CNS, Renal, GI, See
Table 165-3 CDC case definition (p 2102).
36. TINTINALLI’S TOXIC SHOCK SYNDROME
7th Ed, 2011, Ch #145, pg 999-1003
• This is an excellent chapter and I recommend that
everyone review it, Dr G Ekblad.
• Definition: Toxic Shock Syndrome (TSS), is:
• A toxin-mediated, severe, life threatening Dx.
• Findings: High fever, septic shock presentation, severe
hypotension, diffuse erythema, mucous membrane
hyperemia, pharangitis, and diarrhea. (see Table 145-
1).
• TSS vs Kawasaki DX. Kawasaki Dx does not have multi-
system failure, there is no profound hypotension, and
no renal failure, diarrhea and thrombocytopenia is not
found. (T-1000).
37. Tintinalli’s TOXIC SHOCK SYNDROME
• TSS is related to many risk factors.
• TSS is not only related to tampon use during
menses. 12% cases are from use of vaginal
contraceptive sponges and diaphragms.
• Causes: Toxin from S. Aureus or Streptococcal
TSS.
• Approx10% of pts are Male (T-999).
• Mortality rate for men is 3.3X > women.
38. Tintinalli’s TSS
• Children < 2 Y/O: TSS risk factors include
burns, Non surgical skin injuries
(abrasions, lacerations), Infected VARICELLA
VESICLES.
• (Jump question: What is VARICELLA vs
VARIOLA, what are the findings between
both, what are the skin findings, what are the
public health issues??)
39. Tintinalli’s TSS: Clinical features
• “Consider tss in pts with: unexplained FEBRILE
illness, with
ERYTHRODERMA, HYPOTENSION, AND DIFFUSE
ORGAN PATHOLOGY (p 1000)”
• Headache is the most common complaint.
• Fever occurs 1 to 4 days prior to the presentation.
• The vast majority of pts develop watery diarrhea
and repeat vomiting.
50% to 75% of pts have pharangitis with a
“strawberry red tongue” (p 1001).
41. Tintinalli’s TSS
Treatment and disposition
• Aggressively treat the shock and admit to ICU,
• Get early Inf Disease consult (They never want
to miss this one).
• During the first 24 hours pts may require 4 to
20 LITERS OF IV FLUID AND FFP.
• Antibiotics do not “affect the outcome of the
acute illness (p1002). However they are given
to eradicate the toxin producing bacteria and
decrease the recurrence rate.”
42. Tintinalli’s TSS: TREATMENT
• Antibiotic options for adults:
• Nafcillin or oxacillin: 2 gms IVPB each 4 hours.
• Or LINEZOLID 600mg IVPB each 12 hours.
• Some recommend clindamycin 600 to 900 mg
IVPB each 8 hours or LINEZOLID because they
may decrease toxin production.
• Vancomycin 1 gm IVPB each 12 hours for pts
with possible MRSA.
