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COMMON PEDIATRIC PROBLEMS
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Fever is the most common pediatric chief complaint in the emergency department (ED). Fever that is concerning for serious illness is typically defined as a rectal temp > 38°C (100.4°F) in infants < 3 months and 39°C (102.2°F) in children > 3 months. However, serious illness can certainly occur at temperatures below this range and have been associated with hypothermia as well. Evaluation and disposition of patients with fever are determined by age at presentation in conjunction with other factors such as underlying medical conditions (eg, cancer, immunosuppression) and coexisting factors (eg, immunization status). The emergency medicine (EM) physician’s primary role in evaluating fever is to rule out serious infections, the majority of which tend to be serious bacterial infections (SBIs) (Table 5.1).
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The most common causative organisms of SBI arise from maternal vaginal flora in this age group. An immature immune system and unvaccinated status place children < 28 days at higher risk for SBI.
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Fever > 38°C (100.4°F) indicates need for full sepsis evaluation in infants < 28 days.
Evaluation in this age range is based on the premise that the history and physical examination can be difficult to interpret. SBI can be present in the absence of any significant historical or physical examination findings. SBI can also be present in child with hypothermia or even in the absence of fever.
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KEY FACT
SBIs = Meningitis, pneumonia, urinary tract infection (UTI), bacteremia, sepsis
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All patients should have a complete blood count (CBC) with differential, blood cultures, catheterized urinalysis, urine culture, lumbar puncture (LP) with culture, and chest x-ray if lower respiratory symptoms are present.
Consider testing for herpes simplex virus (HSV) if any signs suggestive of disseminated HSV (vesicular rash, bloody LP not attributable to traumatic LP, elevated transaminases, seizures) or if the patient’s mother has a history of HSV (especially if vaginal delivery with active lesions).
Stool for white blood count (WBC) and culture should be obtained for those with diarrhea.
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Empiric intravenous (IV) antibiotics with ampicillin plus cefotaxime (gentamicin is an alternative) (Table 5.2).
IV acyclovir should be started immediately for those in whom HSV is suspected. This should be coupled with adequate IV hydration.
Admit all patients for IV ...