Fever Without Focus PDF
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Uploaded by SelfSatisfactionHeliotrope9824
Duhok College of Medicine
2022
Walaa Yousif
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Summary
This document presents a comprehensive analysis of fever in children based on observations in different age groups and provides important information on managing different types of fever in infants and children, discussing benefits, and disadvantages.
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Fever without localizing sign in children e Dr. Walaa Yousif September 5th, 2022 Objectives Definitions How to evaluate & treat patient with fever. What laboratory studies are indicated for various age group. Patients are at high risk for dev...
Fever without localizing sign in children e Dr. Walaa Yousif September 5th, 2022 Objectives Definitions How to evaluate & treat patient with fever. What laboratory studies are indicated for various age group. Patients are at high risk for developing sepsis?. Whom should be hospitalized. Whom need antibiotics &when to initiate empiric therapy. DEFINITION OF FEVER elevationof bodyten Fever is an elevation of body that exceeds normal daily variation.in temperature that exceeds the normal Yas inmpoth daily variation, in conjunction with an e.ff increase in hypothalamic set point. Fever is defined as a before-noon temperature of more than 37.2°C or an after-noon temperature of more than 37.7°C. before noon 737.2 afternoon 327 It We use howdidyou measure I highgradeantipyretics respondsto or lowgrade continousintermittent iimD iimiiiiiti.ae → seizures tympanic axillaryoral oral rectal > tympanic> axillary each by ≈ 0.5° PHYSIOLOGY OF FEVER Fever is not a disease but a body response to exogenous or endogenous Pyrogens: Substances that can induce fever Exogenous pyrogens: Bacteria virus FungalAllergen Bacteria, Virus, Fungus, Allergen,… Endogenous pyrogens (EPs) Immunecomple Immune complex, lymphokine,… 141 126 TNF Major EPs: IL1, IL6, TNF x Pathogenesis of fever Pyrogen & destroyed cell activation of macrophage & Toxin cell in RES IL-1B & cytokine prostaglandin E2 which act on hypothalamus up word elevation of temp 37-40c IL1,6,TNFa increases PGE2 in hypothalamus which increases Paracetamol & Ibuprofen Mefanemic acid temperature set point. Antipyretics prevent PGE2 production coke by blocking Benefits of fever hypothalmus does not of above allow rise temp 41 The hypothalamus will not allow the temp to rise above 41.5c. WBCs work best & kill most bacteria at 38-40c. Increase the activity of interferon. Coxsackie and polio virus replication is directly inhibited. IEEE HR 1 Temp Disadvantages of fever anythmin iiiii.itii iii Disadvantages of fever is well known that it may cause hyper catabolism leading to nitrogen wastage , G weight loss and weakness. Due to sweating it may lead to electrolyte imbalance. sweating electrolyte imbalance Febrile convulsion and brain damage in case of high fever. Circulatory overload & arrhythmia. - ? sweating overran convulsions intermitten i ie m remitten Infective endocarditis i Hodgkin lymphoma whenisfevernot present newbonsusuallyhypo in hypothermia usually hypothermia repns ↓PGEz Production UTI → freeway urgency ,..... pneumonia → cough sputum , - - - - - ? i. i. mutilateddioonous > 7 days < 7 days Fever without localizing signs Hays Fever of acute onset with duration of < 1wk. Fever accounts about 70% of all consultations to pediatricians. Etiology, evaluations & management is an age dependent, because younger the age, the greater possibilities of sever Serious bacterial infection (SBI) which inclues: mOs O Septicemia, bone & joint infection, UTI, o meningitis……………….. highriva chief Children at higher risk of serious bacterial infection include: - infants under 3 months of age with temperature ≥38°C; - infants aged 3-6 months with temperature >39°C. ( high ) half -3 year risk - children aged 6-36 months who are not fully immunized or appear unwell. child ) ( toxic Patients with primary & secondary immunodeficiency (malignancy, sickle……). These groups should usually have investigations performed. Evaluation of patient with fever without localizing sign: Step 1: detailed headto toe Search for the cause (history and physical examination) Step 2: Re-evaluation and specific laboratory tests and accessory studies, where appropriate. Step 3: Critical assessment of the child and decision about the next steps to be taken (hospitalization vs. outpatient care)& the need for antibiotics. Evaluations & management is an age dependent: signof Three age group: Neonate less than one month I Infant 1- 3 months 3- 36 months ( 3m -3 years) 11 1 children UP the month sepsis of features Lee 1.3 -. ✗ Risk factors for neonatal sepsis premature rupture of membrane > 12 h. Maternal fever >38c Foul smelling of amniotic fluid : Pathogens in neonatal period GBS( group B streptococcus) E. coli Staph aureus Klebsiellae Listeria monocytogenes Fungi Herpes simplex virus Neonate with temp> 38c HX Examination exclude environmental - Ix Exclude excessively warm clothing as a cause of fever, & repeat the temp checking after half an hour if still >38c, should be admitted → Full septic screen should be done to identify the pathogen which include: Full septic screen CBC with differential & CRP GUE & Culture Blood Culture Stool Culture I CXR +- Lumbar puncture because clinical signs of meningitis are not reliably present in infant under 15 months of age. IL6, procalcitonin, & PCR for rapid detection of bacterial pathogen. Management In general Any child < 1 mo and temp > 38c should be: Hospitalize , broad cultures plus other tests & parenteral antibiotics, combination of ampicillin gentamycin or 3rd generation cephalosporin, add 0 flucloxacillin if staph infection, & acyclovir if HSV infection is suspected. Neonatal sepsis can cause death( mortality up to 16%), or permanent damage to CNS, mental retardation……………. infants RSU them Literature suggest that serious bacterial infection continues to occur in the presence of concomitant viral infections with as many as 5% of patients Common Bacterial infection between 1- 3 months ✓ SHN Group B strep ✓ Listeria monocytogenes ✓ SH Pneumococcus S Pneumoniae 7. - H influenzae ✓ - ✓ Staph aureus Salmonella Meningococcus N meningitidis - ✓ ✓ E coli - ↳ Same as those of neonatal sepsis Child 1-3 mo and temp >38c KeepinHos underadmin or go tohospital it any deterioration Referral for immediate investigation. Full sepsis workup: CBE & differential, r 0suprapubic aspiration CRP blood culture, urine culture (SPA/catheter), CXR ± LP Low risk: seems healthy : - Non toxic, previously healthy Uncomplicated medical history Normal physical examination Normal laboratory studies Urine: negative leukocyte < 5 WBC/HPF Peripheral blood: 5000- 15000 WBC/ mm³; 39c ,and new signs and symptoms 3 months- 3 years Temperature >39C and no clear source of infection Child well appearing, fully immunized, and over 6 months of age. a Check urine & Discharge home on symptomatic treatment; Arrange medical review within 24 hrs, or sooner if deteriorates High risk patient(Toxic child) admit to ICU lethargy, poor conscious state R. distress, grunting, R.R >60 Evidence of poor perfusion such as pallor, mottled or cool skin. Sign of dehydration Those children have a much higher risk of serious bacterial infection. Child toxic Admit to PICU, Referral for immediate investigation at an appropriate facility. Full sepsis workup: CBE, CRP, electrolytes, venous blood gas, blood culture, Urine culture (SPA or catheter urine), CXR (if respiratory symptoms / signs or WCC>20,000), lumbar puncture. Start I.v fluid & empiric antibiotics(ceftriaxone plus flucloxacillin or vancomycin if MRSA ). if not TOXIC Important Other antipyretic drugs Ibuprofen Mefenamic acid }NSAIDs Combination---NO I.V fluid Febrile children can be made to feel better even without antipyretic as long as they are given enough fluid by mouth or Intravenous. aspirin Reye's syndrome Don’t give aspirin to children under 18 years because of risk of Reye’s syndrome. Try tepid water sponge bath 27 C Remove blankets and heavy clothing; Keep room at comfortable temperature, avoid ice and alcohol. Kawasaki disease and acute rheumatic arthritis are the only conditions where we need to give aspirin (exceptions) References Pediatric-Decision making strategies, 2nd, 2016 Nelson-pediatric Symptom-Based Diagnosis, 1st, 2018