PEM Source

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All posts with tag: "fever"

Tips and Tricks

Nothing slows down the ED flow like waiting for the urine flow of an infant or toddler. Whether or not to screen for UTI with a clean catch urine vs obtain a catheterized specimen will be left for another discussion, but here are some of the latest techniques described for obtaining clean catch specimens. (For all, clean genital area thoroughly first) "CCU" procedure, first described by Herreros Fernandez et al, Arch Dis Child 2013;98:27, 80 infants aged < 30 days. Patient held under armpits with legs dangling in upright position. Suprapubic area gently tapped at 100 taps/minute x 30 seconds, followed by light circular massage of the lower back x 30 seconds. Repeat these maneuvers until urine collected. Successful in 86% of the infants with median time to collection 45 seconds. Labrosse et al, Pediatrics 2016;138(3):320160573 studied this CCU method with the addition of another person flexing the hips of female children, 126 infants < 6 months old. CCU method successful in providing urine sample within 300 seconds in 49%, median time 45 seconds. More successful in < 3 months old than 3-6 months old. "Quick-Wee" method, Kaufman et al, BMJ 2017;357:j1341, 354 infants aged 1-12mos With patient supine, suprapubic skin was rubbed with gauze soaked in cold saline. 31% voided within 5 minutes using Quick-Wee vs. 12% in the standard collection group. Finally, Naimer in Pediatr Emerg Care 2017;33:446 describes cutting a slit in an infant's diaper to push the urine collection bag through when obtaining a bag urine. This both helps to secure the bag and allows parents and nurses to see when the specimen has been obtained.
Explain to parents - colds are called colds because viruses thrive in cold temperatures, so fevers are the body's natural way to fight off the cold


(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 10 week old infant with a 38 degree fever of 6 hours duration. He has mild rhinorrhea as does Dad. He is otherwise well and feeding well. Point of care RSV and influenza are negative, and urine shows no pyuria or bacteriuria. Review of the chart shows mom was GBS+ and was treated with intrapartum penicillin as recommended. Baby was observed for 2 days in the nursery but not treated with antibiotics. [poll id="21"]
A 2 month old was seen in the ED 36 hours ago with a temperature of 39.2. The CBC had a WBC of 11.2 with 70% lymphocytes and no bandemia. Urinalysis was negative. The lab calls you to report that 1 of 2 blood culture bottles is growing gram positive cocci in clusters. You call the patient and the parent reports that he is doing well, is now thought to be afebrile (tactile, parents have not checked the temperature in 24 hours), and is feeding well. What do you do? (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="18"]
Do you do a CT and LP on all complex febrile seizure patients? [poll id="16"]
3 week old infant is brought in with fever of 38.5. The baby is well appearing and does not have any high risk factors in the birth history. You plan to get urine, blood, and CSF cultures and give empiric IV antibiotics. [poll id="8"]
You are seeing a 15 month old female with 36 hours of fever, current temp in ED 38.9 rectal (last antipyretic 6 hours prior), no other symptoms, well-appearing, no past medical history. Which would you do? [poll id="5"]
How much work-up do you do in the well-appearing, term, feeding, 29-60 day old infant with low-grade fever (38-38.5) without source? What about the 61-89 day old? [poll id="2"]
You're seeing a febrile well-appearing 29-60 day old with clear lab evidence of UTI and benign CBC. Do you do an LP? Do you admit and do you give parenteral antibiotics? What about for a 61-90 day old?

PEM Questions

A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]

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