Tasty Morsels of EM 094 – #FRCEM Paediatric Fever

29 Jul

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

I used to see a lot of kids but that was before the NICE 2013 guidance on fever in under 5 in children appeared and to my shame this is my first read through it.

How should we be measuring temp?

  • avoid oral or rectal in <5
  • electronic in the axilla for <4 weeks
  • 4 weeks-5 years
    • electronic in the axilla
    • dot in the axilla
    • tympanic
  • the report of fever by parents is valid

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How do we do risk assessment?

http://emergencymedicineireland.com/wp-content/uploads/2017/07/NICE-traffic-light.pdf

This contains a lot of information but it’s genuinely really useful and should be readily available in your ED and readily available in your head for exams

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When should we diagnose Kawasaki?

  • think in fever >5 days AND 4 of the 5 below
    • conjunctivits
    • the cracked lips or strawberry tongue
    • limb oedema or desquamation
    • polymorphous rash
    • cervical nodes

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What investigations should be done in fever in the paeds ED?

  • <3 months
    • FBC
    • blood culture
    • CRP
    • urine
    • CXR only if resp signs
    • stool only if diarrhoeah
  • LP and IV antibiotics (should be cefotaxime/ceftriaxone AND ampicillin/amoxicillin)
    • <1 month
    • 1-3 months who are unwell
    • 1-3 months with WCC <5 or > 15
  • >3 months if 1 or more “red” features and no source
    • FBC
    • CRP
    • Blood cultures
    • urine
    • “consider”
      • LP
      • CXR
      • electrolytes and VBG
  • 1 or more “amber” features and no source (there is an additional get out here that these can be omitted if an “experienced paediatrician” says so)
    • blood culture, FBC, CRP
    • urine
    • consider LP if <1
    • CXR if T>39 and WCC>20
    • (a little non exam reflection here: of note it’s pretty easy to get into this group and this suggests a lot of testing (more than i might do in real life). That being said – this is for “fever without source” kids and if you’re confident it’s a bad case of the sniffles then maybe you don’t need to go down this pathway.)
  • all green features but no clinical source apparent
    • test the wee wee
  • >3 months with fever without source
    • observation with or without testing is reasonable

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How should we manage these kids?

(largely common sense so i’ve written my own interpretation to make it easy to remember…)

  • under 3 months and sick all get antibiotics
    • under 1 month and fever
    • 1-3 months and looks unwell
    • 1-3 months WCC<5 and >15
  • in general IV antibiotics for all ages if
    • shocked
    • unrousable
    • signs of meningococcal
    • but remember aciclovir if encephalitis a possibility
  • 20ml/kg the bolus of choice with saline as the choice

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What about treating fever?

  • don’t do it to stop seizures
  • don’t rely on it coming down to exclude serious illness
  • tepid sponging is physical method of choice

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