Pediatric emergency medicine trisk 2311 2311
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Clinical assessment: Diagnosis is made by blood culture. Stool cultures are positive in approximately 30% of
bacteremic patients. Bone marrow cultures may be useful because they remain positive long after treatment has
been initiated and are more sensitive than blood culture. Serology is not recommended as it often cross-reacts with
other Salmonella serotypes.
Management: Empiric management of children with suspected typhoid is reviewed in
e-Table 94.18 .
Historically, fluoroquinolones have been the treatment of choice. However, the recent evolution and recognition of
multidrug-resistant Salmonella isolates has complicated empiric therapy. In general, fluoroquinolones should not
be first-line therapy if typhoid fever in patient from South Asia or other regions where there is a known increase in
resistance to fluoroquinolones. For travelers to this area, use of third-generation cephalosporins and high-dose
azithromycin (1 g) is recommended. Bacteremia should be treated for a total 7- to 10-day total course, with
transition from parenteral to oral therapy after bacteremia has cleared and antibiotic susceptibilities are available.
In some sub-Saharan African nations, up to 40% of Salmonella isolates are cephalosporin. In patients with severe
systemic illness, such as typhoid-associated shock or encephalopathy, dexamethasone (3 mg/kg followed by 1
mg/kg every 6 hours for 48 hours), should be considered. The chronic carrier state can be eradicated by 4 weeks of
oral fluoroquinolones. Contact and standard precautions should be used for providers caring for children with
suspected typhoid fever.
Dengue
CLINICAL PEARLS AND PITFALLS
Dengue is the most prevalent mosquito-transmitted viral illness and should be considered in the
differential diagnosis of any febrile patient presenting in the ED within 2 weeks of return from a
tropical or subtropical region.
Clinical manifestations include self-limited dengue fever to life-threatening dengue hemorrhagic fever
with shock syndrome.
Treatment is with supportive care and fluid resuscitation, including blood transfusion.
Current Evidence
Dengue is transmitted by the Aedes aegypti mosquitoes, which are most active during the day, but can bite at any
time of day or night. The disease is endemic to central and South America, sub-Saharan Africa, the Indian
subcontinent, and Southeast Asia. Recently there has been a broadening of the geographic distribution of the
disease. In the last decade, outbreaks have been reported in Texas, Florida, and Hawaii, and the mosquito vector
already is widespread throughout the southern United States. The worldwide incidence has been increasing in the
past several decades due to a number of factors including population growth, overcrowded urban living with poor
sanitation, increasingly mobile/transient population and therefore increased mobility of the mosquitoes, virus and
infected individuals, and lack of effective mosquito control. Each year there are an estimated 50 to 100 million
dengue infections, with >500,000 cases of dengue hemorrhagic fever, and >22,000 deaths, primarily in children.
Goals of Treatment
The goal of dengue management is to identify which children are at risk for dengue based on travel history and for
the PEM clinician to be aware that rapid fluid shifts after fluid resuscitation can lead to volume overload.
Clinical Considerations
Clinical recognition: The differential diagnosis includes febrile illness with similar clinical manifestations such as
influenza, enteroviral infection, measles, and rubella. The diagnosis is typically a clinical one when treating
patients with recent travel to dengue endemic regions. Only 50% of patients infected with dengue develop
symptoms. Clinical manifestations range from self-limited dengue fever to dengue hemorrhagic with shock
syndrome. Symptoms typically develop within 3 to 14 days after the bite of an infected mosquito; the risk of
severe disease is much higher in sequential infections. In 2009, the World Health Organization (WHO) published
revised dengue case definitions ( e-Table 94.19 ). Three distinct phases exist. The first is the febrile phase. Here,
children develop pyrexia (or hyperpyrexia), vomiting, joint pain. Some develop a transient maculopapular rash,
lasting approximately 3 to 7 days. Most patients do not progress to the next phase and improve without
