Credits:
Dr Tim Horeczko with Pediatric Emergency Playbook: http://pemplaybook.org/
Dr Kelly Young with PEM Source http://pemsource.org/algorithms/
Dr Levine with Carolinas Medical Center Levine Childrens Hostpial Fever Algorirthm http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/infant_fever_lch_algorithim.pdf
CC: Pediatric Fever
HPI:
Pertinent positives/negatives:
Vaccines up-to-date
Significant complications of birth history
Well hydrated based upon hx of PO intake/frequency of urinary output
—————————-
Complaint specific findings on exam:
evaluated for potential source of fever on exam: _
—————————–
ED COURSE:
Evaluated for toxic appearance: (lethargy, signs of poor perfusion, hypoventilation/marked hyperventilation, cyanosis).
Per caregiver, vaccines UTD for age of patient
DDx: bacteremia, sepsis, OM, PNA, strept pharyngitis, meningitis, HSV, myocarditis, intra-abd pathology, rash, UTI, Kawasaki disease, URI, influenza, RSV
MDM (with A/P):
Assessment: Toxic pediatric patient with suspect infectious etiology
Diagnostically:
cbc
bmp
BCx x1
lactate
UA w/ micro
UCx
CXR
LP
if has/develops diarrhea, stool studies
Therapeutically:
Abx:
_ amp 100 mg/kg / gen 5mg/kg
_ amp 100 mg/kg / cefotaxime 50-100 mg/kg
_ ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low > 6 wks)
_ considered acyclovir 20 mg/kg
IVF: 20 cc/kg, repeat PRN evaluation of hydration status
MDM: Toxic appearing pediatric patient. Given pt’s high risk for deterioration, morbidity, mortality, conservative approach of full septic work up pursued. Further treatment plan per discretion of inpatient team where there exists luxury of watching patient’s clinical trajectory.
Dipso: Admitted
Assessment: Non-toxic, patient in 0- 90 day evaluating for fever
_ Afebrile in ED with no hx of recent antipyretics. Therefore suspect pt is afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
_ Afebrile in ED with recent anti-pyretic use. Given history of recent anti-pyretic, patient was observed in the emergency department for duration of time where based upon time of administration of antipyretics and known duration of action of anti-pyresis, lack of fever on repeat vital signs not likely attributable to anti-pyretics. Therefore patient is likely afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
_ Febrile
Diagnostically:
cbc
bmp
BCx x1
lactate
UA w/ micro
UCx
CXR
LP
_ considered if has/develops diarrhea, stool studies
_ considered URI viral studies (RSV, influenza, biofire)
Therapeutically:
Abx:
_ amp 100 mg/kg / gen 5mg/kg
_ amp 100 mg/kg / cefotaxime 50-100 mg/kg
_ ceftriaxone 50-100mg/kg (risk of precipitating hyperbilirubinemia sufficiently low > 6 wks)
_ considered acyclovir 20 mg/kg
IVF: 20 cc/kg, repeat PRN evaluation of hydration status
MDM: Febrile infant. Incomplete development of blood brain barrier, incomplete vaccination status. Therefore, while I appreciate literature that may lead to a more liberal approach, given pt’s high risk for deterioration, morbidity, mortality, conservative approach of full septic work up pursued. Further treatment plan per discretion of inpatient team where there exists luxury of watching patient’s clinical trajectory.
Dipso: Admitted
Assessment: Non-toxic, patient in 90 day – 3 yr vaccinated pediatric pt evaluating for fever
_ Afebrile in ED with no hx of recent antipyretics. Therefore suspect pt is afebrile. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
_ Temp < 39 in ED with recent anti-pyretic use. Discussed possibility of antipyretics causing temp in ED to not be reflective of true Tmax and therefore possbility of hyper-pyrexia (T >39). Offered observation until anti-pyretics would have worn off and then recheck temp and decision on further diagnostics based upon that data. However, parents elected for discharge and to return if detected hyperp-paresis at home. This approach is not unreasonable given on thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and imported return precautions with parents.
_ T 38 – 39 in ED (febrile without hyperpyrexia). Therefore suspect pt is febrile though not sufficiently high fever to warrant additional diagnostics given on thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
_ T > 39 in ED in 90d – 3 mo (hyperpyrexia)
_ With suspect source _. Given suspected source and T <39, will guide treatment for source and diagnostics for alternative sources not sufficiently likely to warrant further diagnostics at this time.
_ Fever of unclear source _. Will risk stratify and guide diagnostics for possible UTI based upon pre-test probabilities:
_ Female. given < 3 yr, UA w/ mciro/UCx indicated
_ Male, uncircumcised, only if < 12 mo. UA w/ micro /UCx indicated
_ Male, circumcised, only if < mo. UA w/ mirco/UCx indicated
_ No UA indicated given gender, age, circumcision status.
Assessment: Non-toxic, fever in pediatric patient > 3 yr vaccinated pediatric pt evaluating for fever
_ bacterial source identifiable on hx/exam or suggestions of UTI prompting UA.
Antibiotics guided for bacterial source of _
_ suspect fever of benign etiology, likely viral source. On thorough history and physical exam, no evidence of malignant process nor bacterial infection. Patient is well hydrated based upon history and exam. Therefore patient is appropriate for outpatient care, prompt follow up with primary care physician and discussed return precautions with parents.
Assessment: Non-toxic, persistent fever if patient for > patient in 90 day – 3 mo vaccinated pediatric pt evaluating for fever
Given fever without remittence for >= 5 days, pt evaluated for Kawasaki disease:
Classic Kawasaki Dz:
[BURN and CRASH mnemonic] BURN = 5 days of fever AND 4 out of 5:
C – conjunctivitis (usually bulbar, bilateral, non-purulent)
R – rash (just about anything except vesicles, bullae)
A – adenopathy (usually cervical, singular, >1.5cm)
S – strawberry tongue (or other changes like lip redness, cracking)
H – hand and feet swelling/erythema, (peeling later in course)
_ Meets sufficient criteria fever > 5d AND 4/5 Kawasaki criteria,
_ Admit for IVIG and echo
_ Meets sufficient criteria for incomplete but not not full Kawasaki Dz
_ CRP, ESR, CBC, albumin, ALT, UA w/ micro
_ Dipso and treatment contingent upon results of laboratory analysis.
Disposition: Home with outpatient follow up
– Based upon the above characterization of the patient in terms of age, vaccine status, well appearing versus toxicity, history, examination, the pretest probability is sufficiently low for detection of alternative pathologic infectious etiologies and risks of procedures outweigh benefits. As such patient does not meet criteria at this time for further diagnostics.
– Counseled parents on appropriate use and dosing of antipyretics. Counseled parents on importance of maintaining hydration status. Counseled parents on return precautions specifically for signs of toxicity or dehydration. Provided parents with Information for obtaining prompt follow-up outpatient care and advised if for whatever reason unable to obtain prompt follow-up outpatient care, may return to emergency department for reevaluation.
– Assessed social considerations for safe discharge: family has functioning telephone number, transportation available, parental maturity in my opinion, Thermometer available or easily to be obtained for home use, stable social situation, and travel to emergency department in under 30 minutes.
– Given the above history, exam, and consideration for diagnostics with special consideration for outpatient safe care, the patient appears to be appropriate for outpatient management which is the request of the family. As such , the patient was discharged an additional discharge paperwork and instructions were provided in paper format.