![Page 1: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/1.jpg)
Fever Phobia and the ED Doc
Ran Goldman, MD ([email protected])BC Children’s Hospital,
Professor, University of British ColumbiaSLIDES ON : www.ClinicalPeds.com/Whistler
![Page 2: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/2.jpg)
![Page 3: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/3.jpg)
![Page 4: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/4.jpg)
Define Fever –
38.0o Doesn’t matter how you measureo Neonateso Iimmunocompromised patientso Home, office or ED
![Page 5: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/5.jpg)
How to Measure Temperature ?
o Rectal, oral, axillary, forehead, tympanic
o In < 3 m always rectal (core body temp)
o Avoid forehead, tympanic at all cost
![Page 6: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/6.jpg)
When to Worry ?
38 38
![Page 7: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/7.jpg)
When to Worry ?
38 38
![Page 8: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/8.jpg)
When to Worry ?
38 38
39
40
![Page 9: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/9.jpg)
The Fear Factor – R/O Sepsis• Toxic Appearance :
• Lethargy• Poor perfusion• Cyanosis• Hypoventilation• Hyperventilation
• Lethargy :• Poor/no eye contact• No interaction with parents
![Page 10: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/10.jpg)
The Fear Factor – R/O Sepsis
• Look unwell• Un‐immunized• Neonates• Transplant recipients
(Bone marrow, Solid organ)
• Oncology patients(Undergoing therapy, mucositis, central line)
• Asplenic patients (sickle cell)
![Page 11: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/11.jpg)
CASE
![Page 12: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/12.jpg)
• 3‐week‐old Jonathan is brought to the ED at 1 am.
• He felt warm on the forehead, and the nurse on the health help line said “go to the Emergency”.
• Normal pregnancy and delivery, Apgar 8,9, no complications post‐natal, no respiratory distress, breastfeeding (exclusive) like a champ
• No Vx, Dx, Cx, some spitting at times, burping like Louis the XVI
• No immunizations yet
![Page 13: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/13.jpg)
• Vitals : Rectal Temp : 38.1 (100.5 F), HR : 140/m, RR : 44/m, BP : Cant measure, restless in triage.
• Normal physical exam, normotensive fontanel, good reflexes, great pink color, breastfeeding well while waiting for your exam.
![Page 14: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/14.jpg)
o CBC with differentialo Electrolyteso Blood cultureo Catheterized
urinalysis and urine cultureo Lumbar puncture
• Gram stain and culture• Cell count and differential• Protein and glucose• Extra tube for additional studies
o Enteroviral PCR, HSV PCR, CA encephalitis project
![Page 15: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/15.jpg)
o Chest x‐ray ?o Stool sample ? o ESR/CRP ? o Venous Blood Gas oLactate ?o Procalcitonin ?
![Page 16: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/16.jpg)
Procalcitonin and C‐reactive protein
• Prospective study
• 408 children 7‐days ‐ 36‐months, fever without source
• SBI was diagnosed in 94 children (23%)
• Procalcitonin + CRP were valuable markers in predicting SBI
• Perform better than WBC and ANC• PCT more accurate at the beginning of infections
Andreola. Pediatr Infect Dis J. 2007 Aug
![Page 17: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/17.jpg)
Procalcitonin for SBI
Eight studies were included (1,883 children) • Procalcitonin (OR 10.6; 95% CI 6.9 to 16.0),• C‐reactive protein (OR 9.83; 95% CI 7.05 to 13.7),• Leukocytosis (OR 4.26; 95% CI 3.22 to 5.63).
Overall sensitivity• procalcitonin 0.83 (95% CI 0.70 to 0.91), • CRP 0.74 (95% CI 0.65 to 0.82) • Leukocytosis 0.58 (95% CI 0.49 to 0.67)
Yo. Annals EM. 2012 Nov
![Page 18: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/18.jpg)
Fever without a source in normal Hx, healthy, well‐looking children :
o 0‐28 days – full septic workupo 29d – 3m ‐ partial septic workupo 3m – 3y ‐ based on presentation (whenever possible obtain urine)
Clinical impression always override this !
![Page 19: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/19.jpg)
• If 0‐28 days oldo Ampicillin AND gentamicin ORo Ampicillin AND cefotaxime
• Consider acyclovir
• Oldero Ceftriaxone ± Ampicillin OR Vancomycin
o Some centers : until CSF results are known (cell count, protein, glucose), initiate therapy with meningitic dosing regimen
![Page 20: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/20.jpg)
![Page 21: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/21.jpg)
CASE
![Page 22: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/22.jpg)
• 5‐month‐old Cassie is brought to the ED at 1 am.
• Her parents report that she woke up with a troubling cough and she cant breath.
• Symptoms started 2‐3 days after an onset of fatigue, not eating well and a runny nose.
• She has no allergies and immunized UTD.
![Page 23: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/23.jpg)
On Exam :
• Cassie is a well‐appearing girl
• You identify the cough before entering the room, as croup
• Fever to 39.3 (102.74 °F)
![Page 24: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/24.jpg)
On Exam :
• Cassie is a well‐appearing girl • You identify the cough before entering the room,
as croup • Fever to 39.3 (102.74 °F)
What additional evaluation would you do at this point?
![Page 25: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/25.jpg)
• Likely a viral origin (parainfluenza and others)• Severe disease – think influenza A, parainfluenza 3, and measles
• Consider nasopharyngeal wash/rapid test• Secondary bacterial less likely in a well‐appearing child
• No additional workup is necessary….. except
![Page 26: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/26.jpg)
Children with proven VIRAL infection can still have UTI
• Rate of SBIs was 11.4% (133 of 1169)• Rate of SBIs in the RSV‐positive 7% (17 of 244)
RSV‐negative 12.5% (116 of 925)• Rate of UTI in RSV‐positive infants 5.4% (14 of 261)
RSV‐negative 10.1% (98 of 966
…… consider obtaining urinalysis/urine culture
Levine. Pediatrics. 2004 Jun;113(6):1728‐34
![Page 27: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/27.jpg)
CASE
![Page 28: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/28.jpg)
11‐year old John with ALL, in induction, came to the ED at 1 am, after feeling warm for 3‐4 hours
No vomiting, diarrhea , cough or other symptoms
Skin over central‐line site looks clean
On exam 38.5 (101.3 F), chills, and dizziness
![Page 29: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/29.jpg)
• Acute decompensation • Acute care setting/monitoring• Vital signs frequently• Lab – blood (culture peripheral and central line), urine, chest x‐ray
• IV antibiotics immediately• IV Bolus(es)
• Protocol driven care for fever‐neutropenia and based on clinical picture.
![Page 30: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/30.jpg)
BCCH Guidelines
![Page 31: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/31.jpg)
BCCH Guidelines
![Page 32: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/32.jpg)
BCCH Guidelines
![Page 33: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/33.jpg)
CASE
![Page 34: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/34.jpg)
George is an 8 month old.
Had fever earlier today 38.5
Mom heard a strange voice coming from his crib
Found him seizing
![Page 35: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/35.jpg)
• One of the scariest things parents can endure
• History elements are important
• Physical exam critical
• Decide if simple or complex
![Page 36: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/36.jpg)
• 6m – 6y
• Familial in nature
• 50% recurrence in 1 year when febrile
• No increased incidence of epilepsy
![Page 37: Fever Phobia and the ED Doc - distribute.cmetoronto.cadistribute.cmetoronto.ca/EMR1401/0224-1630... · Fever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children’s](https://reader033.vdocument.in/reader033/viewer/2022041705/5e444f26433b713fab44d688/html5/thumbnails/37.jpg)
Febrile Seizure
38 38