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Fever

Fever. Tintinalli Chapter 115. Fever. Most common chief complaint of children presenting to the emergency department. Pathophysiology. Fever – rise in body temperature associated with a resetting of the body’s thermostat Preoptic region of the anterior hypothalamus

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Fever

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  1. Fever Tintinalli Chapter 115

  2. Fever • Most common chief complaint of children presenting to the emergency department

  3. Pathophysiology • Fever – rise in body temperature associated with a resetting of the body’s thermostat • Preoptic region of the anterior hypothalamus • Exogenous pyrogens stimulate endogenous pyrogens Bacteria Interleukin I Bacterial endotoxin Interleukin VI Yeast TNF Viruses

  4. Clinical Features • Body temperature • Naturally varies with circadian rhythm • 1.1C (2F) • Fever threshold • Varies – most agree 38C (100.4) warrant evaluation • Higher temperatures are associated with higher incidence of bacteremia

  5. Infants up to 3 Months • Diagnosis • Old school: high risk for life threatening infection • Recent studies: 3 – 4% risk for serious infection • Presentation History • Birth history – infection birth related? • Length of gestation • Use of antibiotics • Complications

  6. Infants up to 3 Months • Physical Exam • Undress • Vitals • Head to toe exam • Anterior fontanelle • Lack of diagnostic abnormalities in exam should warrant lab work • CBC, SED, blood culture, LP, CXR, UA and culture • Stool culture if diarrhea • (UTI associated with bacteremia in up to 30% of febrile infants)

  7. Infants up to 3 Months • Rochester criteria; • Risk of serious bacterial infection in the absence of these variables is about 0.2% • Non toxic appearance • No soft tissue infection • WBC between 5000 – 15,000 • Fewer than 1500 bands • Normal UA • Stool with fewer than 5 WBC / hpf (if diarrhea)

  8. Infants up to 3 Months • Management • Admission / discharge; varies by community • Made in consult with pediatrician • Younger / smaller infants admit • May be discharged : • Low risk by criteria • Reliable caretaker • Rocephin 50 mg / kg

  9. Infants 3 – 24 Months • Diagnosis • Group at higher risk of occult bacteremia • Clinical appearance valuable in older infants Incidence of Serious Bacterial Infection with Fever in Infants 3 to 24 Months Risk with temperature >= 39.5 5% before pneumococcal vaccination Higher risk of bacteremia WBC >15,000 Bands >500 Absolute neutrophils >10,000

  10. Infants up to 3 to 24 Months • Presentation • History and exam usually reveal source • Viral • Respiratory • Gastrointestinal • Bacterial • Respiratory tract • Pneumonia • Otitis (S. pneumoniae, H influenzae) • Pharyngitis • Meningitis • Common signs may be absent up to 2 years of age • Bulging fontanelle, vomiting, irritability, seizures • Petechiae • Up to 20% have bacteremia / meningitis

  11. Infants up to 3 to 24 Months • Presentation • Fever severity • Occult pneumococcal bacteremia by temperature: Temperature C Rate 39.0 – 39.4 1.2% 39.5 – 39.9 2.5% 40.0 – 40.4 3.2% > 40.5 4.9% • Vaccination status • Incidence of bacteremia in the 39.5C group was 5 – 6 % prior to the pneumococcal vaccine

  12. Infants up to 3 to 24 Months • Management • Well appearing; • Temperature < 39 • No blood testing; incidence of occult bacteremia < 1% • Temperature >39 • CBC (incidence of occult bacteremia is 2.6%) • If absolute neutrophils >10,000, blood culture and Rocephin 50 mg/kg q 24 hours x 2 doses while awaiting cultures • If cultures negative – no further treatment necessary • Oif cultures are positive – recall for evaluation; complete course of antibiotics if afebrile, well appearing. • Any child without good follow up, at high risk, or remains febrile should be admitted.

  13. Older Febrile Children • Diagnosis • Easier to evaluate • Risk of bacteremia lower in this group • Higher incidence of Strep pharyngitis (5-10 yrs) • Mononucleosis more prevalent

  14. Older Febrile Children • Emergency Department Care • Manage fever • Febrile seizures • Administration of 2 drugs is synergistic (ie tylenol/motrin) • Supportive care / rehydration • Outpatient follow up

  15. Questions?

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