Pediatric emergency medicine trisk 0656 0656
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Given these general considerations, an algorithmic approach to the child with
an acute (less than 5 days) febrile illness can be formulated using the following
key features: overall degree of toxicity and presence of signs or symptoms of lifethreatening disease, immunocompromised host status, patient’s age, unusual risk
factors (immunization status, travel, animal exposures), and presence of
localizing features on history and physical examination (see Table 31.3 ).
Laboratory studies are indicated only for selected situations as defined by clinical
features. Most older febrile children do not need routine laboratory testing.
Infants younger than 2 months of age are at increased risk of serious bacterial
infections and bacteremia and are more difficult to assess clinically than older
children. The management of febrile young infants is particularly challenging
because of the relatively high prevalence of serious bacterial infections (up to
15%) and the inability to easily distinguish those with serious bacterial disease or
herpes simplex virus from those with uncomplicated, common viral illnesses such
as respiratory syncytial virus (RSV), parainfluenza, influenza, adenovirus, human
metapneumovirus, or enteroviruses.
Thus, for infants with fevers of 38°C (100.4°F) or higher who are younger than
2 month of age, many authorities recommend a laboratory investigation for
serious infection (“sepsis workup”), including some combination of complete
blood count (CBC), blood culture, urine analysis, urine culture. Lumbar puncture
with cerebrospinal fluid (CSF) for cell count, glucose, protein, Gram stain, and
culture is generally recommended for all febrile infants less than 1 month of age
and in infants 1 to 2 months of age if they are high risk. Figure 31.2 shows an
algorithm for the evaluation of infants younger than 2 months. Clinical
examination alone, without further laboratory evaluation, is generally not
considered sensitive enough to identify serious illness in these very young infants.
In addition, the peripheral blood WBC count has been shown to be inadequate as
an indicator of young febrile infants at risk for meningitis. Herpes simplex virus
polymerase chain reaction (PCR) or culture from blood and CSF with
presumptive antiviral treatment should be considered in acutely ill neonates less
than 3 weeks of age and in those with historical concerns or physical findings of
skin, eye, or mouth lesions; respiratory distress; seizures; signs of sepsis; or CSF
pleocytosis. Stool for leukocytes and culture should be obtained if diarrhea is
present. Respiratory findings are good predictors of clinically significant positive
chest radiographs in children younger than 3 months; therefore, chest radiographs
may be obtained only when there are clinically evident respiratory signs. During
local enteroviral season, CSF enterovirus PCR testing has been shown to decrease
length of hospitalization and unnecessary antibiotic use in neonates and young
