Pediatric emergency medicine trisk 0663 0663
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include meningococcemia, Rocky Mountain spotted fever, and pyelonephritis.
Early institution of presumptive therapy may be lifesaving in some of these
situations, so the possibility must be borne in mind with toxic, febrile children at
any age. Additionally, one should consider history of travel, animal/insect, raw
foods, and activity exposure in the evaluation of the febrile child and broaden the
differential diagnosis accordingly. Several emerging infections deserve mention
in this category including mosquito-borne West Nile virus, Ebola virus disease,
Zika virus, and novel Coronaviruses such as those implicated in severe acute
respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS).
Increasing outbreaks of reemerging infectious diseases such as measles and
mumps in variably immunized patients should be considered.
Simple febrile seizures occur in 3% to 5% of all children (see Chapter 72
Seizures ). They are defined as generalized tonic–clonic seizures without focal
neurologic findings, occurring only once per febrile illness (usually in the first 12
hours of onset of fever) in children 6 months to 5 years of age and lasting less
than 15 to 20 minutes in duration. By definition, they are seizures accompanied
by fever that occur in children without CNS infection or other underlying cause.
The dilemma that faces the emergency physician is to decide whether a febrile
seizure is truly such, or if a child presenting with a fever and seizure requires a
lumbar puncture to rule out meningitis. The American Academy of Pediatrics
published guidelines which address this critical issue. The decision to perform a
lumbar puncture should be determined by the presence of signs or symptoms of
meningitis or other CNS infection. As such, any child with irritability, lethargy,
abnormal mental status findings after a usual postictal period, or signs of
meningitis such as bulging fontanelle, should have a lumbar puncture performed.
Because of the difficulty in recognizing signs and symptoms of meningitis in very
young infants, particular care should be taken in the assessment of children
younger than 12 months of age (especially in infants who have not received their
scheduled immunizations or in whom immunization status cannot be determined),
and in children pretreated with antibiotics (because symptoms of partially treated
meningitis may be minimal or absent). Children with atypical or complex febrile
seizures should be closely evaluated for CNS infection. Neuroimaging,
electroencephalogram (EEG), and routine laboratory testing should not be
performed in the evaluation of a neurologically healthy child with simple febrile
seizure.
Other causes of acute febrile episodes should be kept in mind, including
intoxications, environmental exposure, immunization reactions, and
autoimmune/inflammatory disease processes. Toxic exposures, particularly
