Pediatric emergency medicine trisk 0659 0659
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (76.53 KB, 1 trang )
However, the rate of occult UTI is 2% to 5% in children with concurrent
bronchiolitis. Therefore, evaluation for UTI should still be considered in the very
young infant with fever and clinical signs of bronchiolitis.
An additional dilemma involves the very young infant who presents to the ED
with a description of either tactile fever alone or fever confirmed by rectal
temperature at home but who is afebrile on arrival. In general, lack of tactile fever
at home is a reliable indicator of lack of fever, but evidence is conflicting as to
whether the presence of tactile fever at home correlates with measured fever.
However, all infants who were found to have serious bacterial infections
(including five who were afebrile on presentation) were observed to have had an
abnormal initial clinical profile and/or laboratory workup. Although there is no
consensus on the approach to this situation, it seems prudent to consider a careful
clinical evaluation in all young infants with a history of fever, including one or
more repeat temperatures over 1 to 2 hours in the ED after the baby is unbundled.
If there is a reliable history of elevated rectal temperature, a sepsis workup should
be seriously considered, as described above, along with a subsequent disposition
based on the clinical findings and laboratory results. The infant with only a
history of tactile fever whose repeated temperatures are normal and who has an
entirely normal clinical evaluation may be assessed as not requiring laboratory
studies. All such infants discharged home warrant close follow-up and
appropriate short-term monitoring of rectal temperature. An additional
conundrum is the young infant with fever who recently received vaccinations.
One study addressed this question and recommends that children with recent
vaccinations and fever be treated similarly to those who have not recently
received vaccinations, mainly due to risk of UTI.
Infants younger than 1 month are usually admitted to the hospital for
observation with presumptive antibiotic therapy (e.g., ampicillin and ceftazidime)
after full evaluation as noted above in the ED. Acyclovir should be considered for
febrile infants younger than 21 days of age or in those with risk factors or
findings concerning for HSV (including ill appearance, vesicular rash, hepatitis,
or seizures). Studies have found that children between 1 and 2 months of age,
who are not pretreated with any antibiotics and who have a completely normal
physical examination and completely benign laboratory evaluation (see Fig. 31.2
), may be safely discharged home with careful observation and close follow-up.
For such a disposition, parents should be able to watch the infant closely for
changes in symptoms, should have ready access to health care, and should be
willing to return for evaluation. These studies have found that either close
