What age should we use for the febrile ex-premie? At what temperature does a fever become dangerous? How should we approach the unvaccinated febrile infant? How many blood cultures should we get in febrile infants?..these questions and many more will be answered on this episode of ERcast
Interviewee: Dr. Andy Sloas
Interviewer: Dr. Rob Orman
Transcript: Dr. Justin Arambasick
Does the height of the fever affect your work up in a fully vaccinated child between 3 and 12 months – example very high fever though looks great after antipyretics? Also, does a higher fever correlate to a higher liklihood of bacteremia?
Evaluate appearance using the TICLS mnemonic
- “Tickles” (TICLS) mnemonic – Criteria to evaluate the well appearing “sick” kid
- Disposition based on initial assessment (if fever but meet TICLS criteria, probably ok to go home)
|Is he/she moving around or resisting examination vigorously and spontaneously? Is there good muscle tone?|
How alert is he/she? How readily does a person, object, or sound distract or draw attention? Will they reach out, grasp and play with a toy or new object, like a penlight or tongue blade?
Can he/she be consoled or comforted by the caregiver or by the clinician?
Can he/she fix her gaze on the clinician’s or caregiver’s face or is there a “nobody home,” glassy-eyed stare?
Is their speech/cry strong and spontaneous? Or weak, muffled, or hoarse?
Does height of fever influence management?
Once there’s a fever…there’s a fever. How high it goes isn’t too important.
- Bring fever down for to make child feel better
- Feeling better helps the patient stay hydrated
- Dehydration is a main reasons they will bounce back to the ER.
- Recent evidence suggests that with the advent of prevnar, there is little correlation with bactermia and height of fever
- 106.7 F/41.5 C-brain proteins start to denature.
- PARENTS SHOULD BRING BACK ANY CHILD WITH A TEMP OF 106.7 F or 41.5 C
What are acceptable sources of fever?
- Apthous stomatitis
- HSV **
- Hand, foot and mouth **
- Viral exanthem **
- Otitis media in a child >2months **
NOTE: Some sources add these infections**
What are the 5 Main sources of fever?
Work through the LUCAS mnemonic when you cannot find a source. Never heard of the LUCAS mnemonic? That’s because we just made it up…an ERcast original.
What is the likelihood of serious bacterial infection based on age?
- 1/100 at 1 month
- 1/1000 at 3 months with a set of vaccines
What are the concerns in an unvaccinated child up to 6 months with fever without a source?
- IF child looks good, may apply TICLS Mnemonic and check a urine and be done
- May do middle of the road and get urine with blood work
- OR Conservative with full work-up including LP
What is the correct dosing of ceftriaxone?
- If meningitis 100mg/kg
- Most providers use cefotaxime for <1 month due to biliirubin displacement from ceftriaxone
When should steroids be used in meningitis?
- Do not give at less than 6 months
- DO use after 2 years
- Difference of opinion between 6moths -2years- most often given in this range only if severely ill or concern for adrenal insufficiency
- 25, 50, 100mg/kg/m squared(BSA) –calculate the BSA
- In kids, BSA is generally 0.8-1 approx 1
- Small kids 25mg- i.e. newborn
- Medium 50mg—i.e. 1 year old
- Large 100mg- >1 year
- 0.6mg/kg or max of 10mg
- Some centers use 0.15, 0.30, or 0.5 mg/kg
Who is the best person to hold the child during the lumbar puncture and what position?
- NOT THE PARENT
- Person with most experience holding the child (who can hold them still)
- One hand on upper back/neck, one on hamstring/hips
- OK to flex neck intermittently-(Not constantly-can make hypoxic). An example of this is to flex the patient to identify landmarks and place local angelsia-then relax the position and flex them again
- Sedation recommended for kids > 6-months old due to muscle development /strength
Should we order a CRP or Procalcitonin in the workup of a febrile child?
- Sloas says no. The best data shows wide sensititivity of 60-90%
How do we actually calculate ‘AGE’
When evaluating the febrile child who is an ex-premie, do we calculate their age from the time they were born or their relationship to 40 weeks (e.g. a child was born at 35 weeks and presents with a fever 8 weeks after birth, for the purposes of fever, are they considered 8 weeks old or 4 weeks old?)
4 types of age
- Gestational – how many weeks actually inside the uterus
- Post menstrual-age from date actually conceived
- Chronological age- THE ONLY THING YOU CARE ABOUT FROM IMMUNE STATUS STANDPOINT – the time since birth to the time seen in ED. Another way to think about this is the patient’s “time in the atmosphere”
- Corrected age- Used by paediatricians for growth, feeding and milestones. Corrected age = Chronological age weeks premature
- CHRONOLOGICAL AGE- time in the atmosphere