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A child with high fever and pain

A child with high fever and pain. J C Mulder Rotary Doctors Nederland 8 januari 2014. WHO IMCI. Assess and classify the sick child Treat the child 2 months-5 years Aim: reduction morbidity and mortality. WHO triage systeem: ETAT (Emergency Triage and Treatment). 1 emergency 2 priority

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A child with high fever and pain

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  1. A child with high fever and pain J C Mulder Rotary Doctors Nederland 8 januari 2014

  2. WHO IMCI • Assess and classify the sick child • Treat the child • 2 months-5 years • Aim: reduction morbidity and mortality

  3. WHO triage systeem:ETAT (Emergency Triage and Treatment) • 1 emergency • 2 priority • 3 nonurgent • (compare APLS)

  4. Children High fever and pain • What to do in a setting with limited lab facilities, X-ray, CT and MRI access and no consultants/referral possibilities

  5. Case 1 • History: Peter 3 years of age, since 3 days a cold. Tonight suddenly more ill with high fever of 40º C . Grasping right ear. Refuses to drink. • Examination: An ill looking child, tilted head, non- coöperative. Right ear stands away. You are not allowed to touch it. • What else do you want to know? • What do you examine? • What is your dd? • What is your action?

  6. Mastoiditis • Status after otitis media acuta • Ear stands away/ pitting oedema behind ear • Pain and high fever • Admission! to hospital Lab.; OR? Depends on age and duration and facilities (Surgeon ENT experience) • When full mastoidectomy is feared,make abscess incision • antibiotics i.v. Start 1st dose orally! WHO:Chloramphenicol and benzylpenicillin 10 days • Pain relief: paracetamol Complications: extradural abscess, meningitis, brain-abscess, facial nerve paralysis, sinus trombosis

  7. OMA Otitis Media Acuta • Pain!!! Paracetamol • Paracentesis? • Causes: Pneumococ, Haem. Infl. En Moraxella C. • Meestal spontane perforatie< 48 uur • Antibiotics (?) : Amoxicilline 7 days or cotrimoxazole Chronicearinfection/ cholesteatoom: attico-antrotomia (chronicmastoiditis)-ENT DD otitis externa

  8. Tonsillitis (NTVG 4 januari) • Volwassenen: complicaties moeilijk voorspelbaar: peritonsillairabsces, otitis media, sinusitis, huidinfectie-(late Streptococ A complicaties: Scarletfever, PSGNefritis, acuut rheuma.) • Direct voorgeschreven AB verlagen kans daarop niet (Britse h.a. studie 600 pr.) Meer kans op Strept. A bij: koorts, purulente tonsillen, halsklieren, pijn • Veelal virale oorzaak DD M. Pfeiffer • Hoe te handelen bij kinderen in de tropen? • Smal spectrum penicilline 3-6 dagen

  9. Epiglottitis • High temperature • Haemophilus influenzae • vaccination • Inspiratory stridor ++ • Inspection throat on OR with pediatrician, ENT specialist and anaesthesiologist • Often need for intubation and PICU • Alternative: tracheostomia • Dd pseudocroup (laryngitis subglottica): less ill;lower temperature • Antibiotics

  10. Acute lymfadenitis colli • Snel ontstaan • Hoge koorts • Cave abscedering: fluctuatie? Evt. echo • Evt. incisie en drainage • Amoxicilline/clavulaanzuur ivm naast GAS ook SAureus

  11. Ethmoiditis • Upper respiratory tract infection • Ill looking/in pain • Red eye or chemosis • Oedema of the orbita • Always admission • X ray and lab • I.V. a.b.Start 1st dose orally! • Sometimes OR • Complication: sinus-trombosis

  12. Case 2 • Sabine, 9 years of age refuses to walk because of a painful right knee+ upper leg. T.: 39º5 C • 1 What do you want to know • 2 What do you examine • 3 What is your dd • 4 What is your action?

  13. Artritis≠artralgia • Cave septic artritis: always admission for proper diagnosis and treatment • Dd osteomyelitis in young children especially • Acuut Rheumatic Fever • PSRA • JIA • trauma

  14. Septic artritis 1(pyogenic bacteria) • Clinical Features: • Mostly knee or hip(80%): Why? • Unilateral • High fever and pain: Site/Age/Agent dependant • Poly-articular: neonates: Why? • Examination:Hip: • Flexed leg/abduction/exorotation • Pain on passive movement/refusal to walk • Artritis hip can present with kneepain! • Signs of inflammation: • red, hot, painful, swollen and loss of function

  15. Septic artritis 2 • Causative agents: • Staph.Aureus and strept.A • N.gon. (adolescents) • Strep.B and gram – bact. In neonates

  16. Septic artritis 3 Management No delay ( hip catastrophic ) • Always joint aspiration: synovialfluid: gram/WBC/culture • Start iv antibiotics (tropics: chloramphenicol) • X ray? • Ultrasonography? • Lab.: ESR,CRP,CBC c. diff.,Culture, ASO-titer • Follow up temperatureand CRP or ESR

  17. Osteomyelitis • Acute/subacute/chronic • Extremities: 70% tibia, femur, andhumerus Hematogenous in children • Site of entry/localinvasion • Clinical features: • agerelatedpainandimmobility • the younger, the more signs on P/E: cellulitis Causes: 20-50% culture negative! • S.Aureus ( beware of MRSA)> 3years • Strep.B(infants) Strep.A /S. Pneum.and Hib(in toddlers) • Salmonella(sicklecelldisease) Lab.: High WBC, ESR and CRP: follow up X-ray?

  18. Osteomyelitis treatment • Depending on age and causative agent: • In general < 3 years chloramphenicol • > 3years cloxacillin or flucloxacillin or clindamycine older children (or chloramphenicol) • Africa: chloramphenicol <3 y or sickle cell • Duration 3 weeks minimum • Switch from I>V to oral depending on clinical course(pain and fever) and lab CRP • Chronic o.: surgery Cave TB

  19. Acute Rheumatic Fever 1 • 2-4 w afterstrep.Atonsillo-pharyngitis • Age 5-15 yearspreferrably • Clinical diagnosis Jones criteria:2+1 or 1+2 • Major: 1.migratory artritis 2. pancarditis (leadingtovalvulardamageand CHF) 3. cnsinvolvement(Chorea) 4. erythema marginatum 5. s.c. nodules Minor:arthralgia, fever, elevated ESR and CRP, prolonged PR interval • Lab.: ESR CRP ASO • Recurrent disease not easy to establish • Complications RHD f.e. Mitral regurgitation

  20. ARF 2 • DD: also PSRA • Shorter interval tothroatinfection • Mostlyone joint • Lessill • No reactiontoaspirin • No cardiac symptoms • Don’t meet Jones Criteria • Management of ARF: • Eradicate streptococcal infection • Aspirin for 2 weeks • Prednisolone in case of carditis (then postpone aspirin) • ECG • Joint aspirationwhenfluid is present: sterile

  21. Myocarditis • High fever, acute onset • Viral: many different viruses/part of ARF • Tachypneua, increased respiratory efforts • Tachycardia • Dilated heart on chest Xray • Congestive Heart Failure • DD cardiomyopathy, sometimes very difficult to distinguish • Treatment supportive

  22. Case 3 • Boy, 7 years, since 2d pain right lower abdomen,slight fever, nausea,vomiting. After 2d more abdominal pain, fever 39.5C. • O/E sick boy, knees up. Defense musculaire right lower abdomen pain on palpation Laparoscopy: perforated appendix! • Patient delay!

  23. Peritonitis • Primaire peritonitis: complicatie GAS • DD o.a. Typhus • Cave bij Nefrotisch Syndrome: Staph. Aureus Th./ breed spectrum antibiotica • Secundair: Appendicitis- perforatie • Buikpijn, percussiepijn en défense Th./ chirurgie

  24. Brucellosis • Persistent or relapsing fever (Malaria -) • Malaise • Musculoskeletal pain • Lower backache • Splenomegaly • Anaemia • History of drinking unboiled milk • Low wbc PCR Serology Elisa Culture • R./ adults: doxycycline + 1 week gentamycine i.m. • children: cotrimoxazole with gentamycine 1 w or rifampicine 6-8 weeks

  25. Urgent illnesses with high fever in children • Meningitis-Encephalitis-Mastoiditis-Ethmoiditis-URTI • Sepsis • Meningococcal • Urosepsis after pyelonefritis • NTSS • Pneumonia: pleural effusion • Peritonitis NS • Malaria! • Septic Artritis • Rheumatic Fever • Osteomyelitis sickle cell! • Epiglottitis • Typhoid Fever • Myocarditis • Pyomyositis Brucellosis

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