Module 3 Fever & Febrile Seizure
If a fever has lasted over 7 days, it is now a fever of unknown origin (FUO) we must now add these to our differential in addition to bacterial infection
*Inflammatory diseases: Kawasaki disease, RA, SLE *Malignancies: Ewing sarcoma, Hodgkin disease, Leukemia *Osteomyelitis *Endocarditis
The following are appropriate treatments for fever
*Motrin/ibuprofen *Tylenol/acetaminophen
IF a child has a history of febrile seizures, and has one in the office, we do the following
*note the start time of the seizure *if seizure is greater than 5 minutes or prolonged recovery call EMS *place child on protective surface to avoid harm *do not restrain or hold the child *position on side or stomach *making sure nothing is in the mouth that would obstruct the airway. (administer rectal diazepam - only if you have this in the office and only if the seizure is prolonged Most offices don't keep this on hand)
These are parts of the history we need to illicit from the parents
*pattern of fever ( when it occurs, how long last, does it go away with meds, how long has the child had it) *Use of antipyretics ( how are they dosing, are they just needing them at night or around the clock, does the fever go away after an antipyretic, last dose) *Exposures (daycare, any other children in home sick, recent exposure from anyone else) *Immunization status (up to date?) *Any prior illness of this kind (history of UTI's, recurrent OM, fever)
This are NOT appropriate treatments of fever
*use of alcohol baths (does not provide appropriate cooling) *tepid baths (will lower temp but causes the child to be very uncomfortable and is not necessary)
Motrin/ibuprofen dosing
10 mg/ kg every 6 hours
What temperature is considered a fever?
100.4⁰ F
Febrile seizures most often occur in this age range
6 months to 6 years
If a child has a fever of unknown origin, they will need further evaluation consisting of_____________
Labs: CBC, U/A with culture, Blood cultures, ESR, CRP, Procalcitonin
If a baby less than 28 days presents with a fever, what does the APRN do?
Send patient to the emergency department for further evaluation
If this is the child's first seizure, what should the APRN do?
Send patient to the emergency department for further evaluation
Is it appropriate to pre-medicate a child with acetaminophen for vaccinations?
There is no evidence for benefit in pre-treating children with antipyretics prior to immunizations, and may actually reduce body's ability to provoke an immune response
These lab values are considered normal, and would indicate need for close observation and no ER referral
WBC 5-15 Absolute band count < 1500 Urine WBC < 10/hpf Stool WBC < 25/ hpf
If we know the cause of the fever, what do we do?
We treat the illness with no further work-up
At this age the APRN can start the workup in the office but may need to refer to ER if WBCs greater than 15,000 or urine has leukocytes and nitrates
age 1 to 3 months
At this age the APRN can narrow down the 2 most common causes of bacteremia as pneumonia and UTI and can often diagnose and treat outpatient
age 3 months to 3 years
At this age, a fever can be caused by a serious bacterial infection in nearly 30% of the cases
age less than 28 days
Children at this age generally require only a thorough history and physical, supportive care and treatment for the likely cause, but do not require labs unless indicated by history or physical exam.
age over 3 years
a child who has a seizure lasting longer than 15 minutes or has more that one in a 24 hour period.
complex febrile seizure
a focal seizure accompanied by a fever is classified as this
complex febrile seizure
Motrin/ibuprofen can be prescribed for this age
greater than 6 months of age
How do we diagnose a fever of bacterial origin?
history and physical (list findings)
Use of Motrin/ibuprofen in children under 6 months can cause this
kidney damage
Tylenol/acetaminophen dosing
may be given 10-15 mg/kg every 4 hours BUT no more than 5 doses in 24 hours; maximum daily dose: 75 mg/kg/day not to exceed 4 g daily
If the child appears generally well, is previously healthy, has no evidence of skin, soft tissue, bone joint or ear infections and labs are normal, we can do this
monitor closely
Tylenol/acetaminophen can be prescribed for this age
neonates and older
Once a fever is diagnosed as a febrile seizure, what further workup needs to be done?
nothing different from treating any fever - treat reason for fever
Febrile seizures are most common in this year of life
second
In most cases, fever is due to ____________
self-limiting viral infection
What is the most common cause of a febrile seizure?
self-limiting viral infection
A child who is developmentally and neurologically normal who has one seizure accompanied with a fever that lasts less than 15 minutes in a 24 hour period has this __________
simple febrile seizure
A fever without a source (FWS) and a fever of unknown origin (FUO) are differentiated by what?
time - FWS is a week, FUO is a fever lasting at least a week