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