Points that are most useful to those of us assessing kids in ED.
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Temperature measurement myths dispelled
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The NICE guidance clarifies the numbers:
(a) 0-3 m.o. with BT > 38 ==> RED
(b) 3-6 m.o. with BT > 39 ==> AMBER
(C) >6 m.o. BT height does NOT correlate with severity of the illness
Diagnosis
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Consider signs of meningitis; UTI; pneumonia; meningococcal disease; herpes simplex encephalitis. But also don’t forget about septic arthritis or osteomyelitis (easily missed). As an additional point always think of Kawasaki disease in a fever lasting more than 5 days.
The importance of tachycardia
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This is one of the most valuable lessons I have learned and it has changed my practice over the last couple of years. I rarely send home a child with tachycardia when they have a fever of no clear focus.
NICE now says that tachycardia puts the child into amber.
Age <12 months HR >160
Age 12-24months HR>150
Age 2-5 years HR >140
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Consider signs of meningitis; UTI; pneumonia; meningococcal disease; herpes simplex encephalitis. But also don’t forget about septic arthritis or osteomyelitis (easily missed). As an additional point always think of Kawasaki disease in a fever lasting more than 5 days.
The importance of tachycardia
--------------------------
This is one of the most valuable lessons I have learned and it has changed my practice over the last couple of years. I rarely send home a child with tachycardia when they have a fever of no clear focus.
NICE now says that tachycardia puts the child into amber.
Age <12 months HR >160
Age 12-24months HR>150
Age 2-5 years HR >140
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Investigate fever with no source if they have any red features – FBC, CRP, B/C and urine. Consider LP, CXR, UEC and gas if indicated.
Investigate fever with no source if there are any amber features unless deemed unnecessary by an experienced paediatrician. This is clearly the greyest area. My rule of thumb is that if they look well (clinical judgement), and are not tachycardic then I would not bother doing bloods – NICE doesn’t offer any further advice on this unfortunately.
Check urine for all children with fever and no source, even if they are green.
Antipyretics
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As well as the meds, children should not be over-wrapped or underdressed. And tepid sponging is not recommended.
Use either paracetamol or ibuprofen but only for a child who appears distressed and not simply to bring down the fever. Don’t give both agents together and only switch agents if the child remains distressed.
When to discharge
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Do not rely on the temp coming down with antipyretics to distinguish between serious and non-serious illness.
Any child with amber or red features should be reassessed after 1-2 hours.
When to admit
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Use your usual markers of clinical conditions but also other social factors should help with decision: social circumstances; parental anxiety and instinct; serious infectious contacts; travel abroad; repeated presentations; when the child has remained ill for longer than expected for a self-limiting illness.
How to discharge
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Give the parents advice on recognising red or amber signs by providing written information and/or arranging follow-up.
New in 2013
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Assess children using the new traffic light system to predict risk of serious illness (red: high-risk, amber: intermediate-rish, green: low-risk)
Recognise the importance of tachycardia and that this puts children into the amber (intermediate-risk category)
Any child younger than 3 months with fever should be investigated
Alternate antipyretics and don’t use both at the same time
Recognise that lowering the temp does not prevent febrile convulsions