Test Your Knowledge: Rash and Fever in the Pediatric Patient January 21, 2020


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Rash and fever are some of the most common chief complaints presenting in emergency medicine. The evaluation of skin rashes in the febrile pediatric patient includes a broad differential diagnosis and utilizing the signs and symptoms to identify red flags, such as hemodynamic instability, erythroderma, desquamation, petechiae/purpura, mucous membrane involvement, and severe pain, in the history and physical examination that require a high index of suspicion for worrisome disease.

Test your knowledge of characteristics of common rashes in a pediatric patients!


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The correct answer: B.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on common and life-threatening skin rashes with fever in children, guidance for differentiating the types of infections based on signs and symptoms, indications for diagnostic studies, and recommendations for treatment of pediatric skin rash with fever in the emergency department.

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What’s Your Diagnosis? A 1-year-old Boy With Rhinorrhea January 3, 2020


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But before we begin, check out if you got last month’s case right, about a 4-year-old with fever, right leg pain, and difficulty walking. Click here to check out the answer!

Case Presentation: a 1-year-old boy with rhinorrhea, congestion, cough, and fever

You arrive to a busy afternoon shift in the ED. Your first patient is a 1-year-old boy with rhinorrhea, congestion, cough, and 3 days of fever up to 39.4°C (103°F), measured rectally. His parents state that he has been playful at home and continues to eat and drink normally. They have been giving him acetaminophen and ibuprofen sporadically, but today he developed a generalized rash, and they became concerned. His vital signs are as follows: temperature, 38.7°C (101.7°F); heart rate, 135 beats/min; and blood pressure, 85/55 mm Hg. On examination, the rash is macular, erythematous, and blanching, but his eyes and mouth appear normal.

Does he need laboratory workup, or can you safely offer supportive care? Should he be on isolation, either for his own safety or for the safety of others?

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Test Your Knowledge: Pediatric Septic Arthritis and Osteomyelitis Management in the ED December 18, 2019


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Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Patients with SA or OM classically present with fever, ill appearance, malaise, pain, and swelling of the involved joint. Given the large differential diagnosis for a limping child, obtaining a thorough history and physical examination is paramount to narrowing the differential diagnosis and to obtain the appropriate testing and treatments.

Test your knowledge!


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The correct answer: A.


Review this Pediatric Emergency Medicine Practice issue to get up-to-date evidence-based recommendations for the diagnosis and management of pediatric patients with septic arthritis and/or osteomyelitis and offers guidance for appropriate antibiotic treatment.

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Pitfalls To Avoid With Septic Arthritis And Osteomyelitis In Pediatric Patients December 11, 2019


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Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Septic arthritis and osteomyelitis in pediatric patients represent true emergencies, and can quickly threaten life and limb. A high index of suspicion should be maintained, as these conditions often present with a subacute course of illness and vague signs and symptoms. Septic arthritis and osteomyelitis can occur concurrently, so suspicion for one should also prompt investigation for the other.

The diagnostic evaluation should include blood work as well as samples from the infected joint or bone for culture. Management with antibiotics is a standard approach, but the duration of antibiotic therapy is controversial.

These risk management pitfalls will help you avoid unwanted outcomes in pediatric patients with septic arthritis and osteomyelitis in your ED.

1. “The patient did not have a fever, so I attributed the pain to minor aches and pains.”
Not all patients with SA and OM will present with fever. Patients may present with a subacute presentation with some pain and refusal to bear weight. There may also be a history of preceding minor trauma.

2. “The patient presented with vague/nonspecific pain. I didn’t consider a bone or joint infection.”
Both pediatric SA and OM present in a similar fashion, and the initial symptoms may be vague and nonspecific, so it is important to maintain a high index of suspicion. A thorough musculoskeletal examination should be completed and imaging should be obtained in order to fully assess the joint/bone involved.

3. “The x-ray was normal, so I did not obtain further labs or imaging studies.”
X-rays are often normal in cases of both pediatric SA and OM, especially early in the disease course. Signs on plain radiography that are consistent with SA include distention of the joint capsule, increased opacity within the joint, displacement of muscle surrounding the joint by capsular distention, increased distance between the subchondral ends of bone, and, occasionally, subluxation of the joint. Findings on plain radiography that are consistent with OM are bone destruction and periostitis, which appears as soft-tissue swelling, periosteal elevation, and lytic sclerosis.

4. “The MRI was negative, so we did not pursue further investigation for SA and OM.”
MRI is not 100% diagnostic and can give a false-negative result. In such cases, CT imaging can be pursued.

5. “The ESR and WBC results were below the established Kocher criteria.”
The ESR may be normal early in the course of SA, and neonates may have low WBC counts due to leukopenia. CRP is a useful early marker of disease and can be trended to monitor the response to antibiotics. Even in the absence of an elevated ESR and WBC, a patient with fever and refusal to bear weight still has a 40% risk of having SA.

6. “The initial lab results were not consistent with SA, so I decided to forego obtaining the arthrocentesis.”
Synovial fluid analysis remains the gold standard for diagnosis of a septic joint. The joint fluid analysis can be completed via arthrotomy, arthrocentesis, or ultrasound-guided needle aspiration.

7. “I wanted to start the antibiotics promptly, so I did not obtain a blood culture.”
With an increase in antibiotic-resistant organisms, it is essential to obtain culture specimens from as many sites as possible, such as blood, joint fluid, and bone, so initial empiric antibiotics can be modified to treat the specific microbiologic pathogen.

8. “I wanted to tailor the antibiotics to the specific microbial pathogen, so I decided to wait for culture results prior to starting antibiotic therapy.”
Ideally, empiric antibiotic therapy should be started after obtaining a reliable culture sample, but the initiation of antibiotics should not be delayed while awaiting results of culture samples. The antibiotics are geared toward the organisms known to be the most likely cause of SA and OM.

9. “We were so busy in the ED that I decided to discharge some other patients first before obtaining the appropriate labs and imaging studies.”
Time is of the essence for both pediatric SA and OM. It is imperative that the appropriate workup be initiated as soon as either diagnosis is suspected so that antibiotics can be initiated in order to avoid danger to both life and limb.

10. “I instructed my patient to continue antibiotics at least until his symptoms improved.”
Incomplete antibiotic treatment duration and/or microbial coverage can attribute to antibiotic resistance and recurrence of symptoms. Both OM and SA require initial inpatient parenteral antibiotic therapy followed by oral antibiotic therapy lasting several weeks.

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Influenza Risk Management Pitfalls to Avoid in the Emergency Department December 11, 2019


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Patients presenting to the ED with “influenza-like illness” (cough, sore throat, fever) are typical in the fall and winter. How can you tell whether a patient might have influenza and infect others with a potentially dangerous strain?

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management.

Because influenza infections can present with a wide range of nonspecific clinical signs and symptoms and numerous possible complications, emergency clinicians must be keenly alert to this possible diagnosis. A knowledge of the local seasonal prevalence of influenza as well as the specific strains circulating within a particular region are crucial for appropriate diagnostic and treatment decisions and will help to limit unnecessary testing when empiric therapy would be more appropriate.

These risk management pitfalls will help you avoid unwanted outcomes when treating a patient with a flu-like symptoms in the ED.

1. “The fever was low-grade; I thought the baby just had a cold.”
The presenting signs and symptoms of influenza infection are nonspecific, and a diagnosis based on clinical presentation alone becomes less accurate in children aged < 3 years. Although many children will experience a mild disease course and can be managed with supportive therapy, patients aged < 2 years are at high risk for a more severe clinical course. Be vigilant and have a high index of suspicion for possible influenza infection in high-risk populations, especially when disease prevalence is high.

2. “The patient had an infiltrate on chest x-ray, so bacterial pneumonia appeared to be the clear diagnosis.”
Numerous secondary complications can stem from a primary influenza infection. When addressing and treating these complications, do not overlook the possibility of a primary influenza infection and the need for medical management. In certain clinical situations, treatment with antiviral medications as well as antibacterial medications may be indicated.

3. “I thought I would just let it run its course.”
Many previously healthy people can be treated with supportive therapy alone; however, you must be aware of the numerous risk factors that are likely to result in a more severe disease course. For patients deemed well enough to be safely discharged from the ED, utilize shared decision-making with the patient and ensure a follow-up strategy is in place.

4. “It is the summer. Influenza occurs in the fall and winter, so I do not need to be concerned about it at this time of the year.”
Although influenza certainly exhibits seasonal fluctuations and regional outbreaks, the disease can occur year-round. Testing and possible empiric treatment of patients with an influenza-like illness are influenced by the regional prevalence of the disease, so monitor medical agencies that track the prevalence of influenza on a regional and national level, such as the CDC.

5. “My patient is pregnant and has influenza. The side-effect profile of antiviral medications concerns me, so I feel better treating her with supportive care.”
Pregnancy is a risk factor for a more severe disease course during an influenza infection. Initial CDC epidemiologic data from the last 10 influenza seasons indicate that some of the highest rates of morbidity and mortality are among pregnant women, which confirms the necessity of antivirals in this population.

6. “Medical knowledge has advanced over the past few decades, and now we have great antiviral medications. I do not need to worry about a devastating influenza infection today.”
While it is true that medical science has advanced considerably since the pandemic of 1918, influenza remains a significant threat. The ability of the virus to undergo genetic reassortment allows for the rapid development of new influenza strains to which the population has little or no immunity. Resistance to antiviral medications has been known to develop quickly for certain influenza strains and appears to be a rapidly increasing concern over time.

7. “Flu is everywhere. I don’t have the time to consult the CDC website. I will just give oseltamivir to my patient and be done with it.”
Even in times of epidemic influenza infection, numerous strains can be circulating at a given time within a particular region. In past epidemics, there have been reports of influenza strains resistant to oseltamivir. Thus, without knowing the prevalence of local strains, one might mistakenly choose an antiviral agent that will prove less effective on those strains. Treatment with more than 1 agent may even be indicated in some regions until more formal strain-specific diagnostic testing can be undertaken. Since certain medications are effective against only influenza type A, the local prevalence of any type B influenza should be determined in order to select the appropriate drug therapy.

8. “I see so many patients in the ED every hour. I can’t possibly wear a mask and wash my hands for every patient. Plus, I must have been exposed to influenza 100 times already.”
Maintaining effective infection control is crucial to protecting not only other patients in the ED but also healthcare staff. Patients suspected of having influenza require appropriate isolation, and strict hand-washing as well as personal protective equipment (eg, masks) are necessary to protect healthcare staff who are in direct contact with patients. The Strategic Plan for Management of an Influenza Outbreak, published by the American College of Emergency Physicians, is a good resource to ensure the highest level of preparedness on the part of the ED staff as well as their ability to handle a surge in patient volume that can be expected during a disease pandemic.

9. “The WHO has declared a pandemic. I feel better giving all my suspected influenza patients antiviral therapy, since I don’t want anyone to have a poor outcome.”
Declaration of a pandemic does not necessarily mean that the particular infectious organism is more virulent. It merely recognizes that the disease is spreading worldwide. Pandemics can occur during both mild and more severe disease outbreaks.

10. “I performed a rapid influenza test and it was negative, so I am safe sending my patient home on supportive therapy alone.”
Numerous forms of testing are available to detect influenza infection. Rapid diagnostic tests help guide clinicians in their immediate management decisions, but the quality of the specimen and the skill of the technician performing the assay can influence results. Certain rapid assays are specific for influenza type A, so knowing which strains are circulating locally is important. In times of high disease prevalence, the chance that a given patient with an influenza-like illness actually has the disease is increased, as are the number of false-negative results obtained from rapid diagnostic testing. At such times, empiric therapy based on clinical presentation alone is advised for patients at high risk. In more severely ill patients, viral culture and PCR testing are indicated when the initial rapid test yields a negative result.

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What’s Your Diagnosis? A 4-year-old with fever, right leg pain, and difficulty walking November 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case right, about a 7-year-old boy after a generalized seizure lasting 2 minutes Click here to check out the answer!

Case Presentation: a 4-year-old with fever, right leg pain, and difficulty walking

A 4-year-old boy presents to the ED with intermittent fever, right leg pain, and difficulty walking the last 3 days. His parents report that the child has a history of sickle cell disease and takes folic acid and penicillin for infection prophylaxis. The patient has never had surgery. On physical examination, there is point tenderness over the right thigh and an area of overlying edema, and the boy’s vital signs are within the normal limits for his age. You order a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, blood cultures, bone culture, and plain radiography.

What special bacterial pathogen must be considered in this case? How does this affect antibiotic treatment?

Case Conclusion

The 4-year-old boy with intermittent fever, right leg pain, and difficulty walking over the last 3 days was diagnosed with OM of the right femur. Since Salmonella is the most common cause of OM in patients with sickle cell disease, empiric treatment covering Salmonella was started. The bone culture grew out Salmonella. The patient was treated with vancomycin and ciprofloxacin parenterally for 5 days; he was then transitioned to oral therapy with a third-generation cephalosporin to complete 4 weeks of antibiotic therapy.

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Summary of Recommendations for ED Management of the Acute Bronchiolitis in Pediatric Patients November 7, 2019


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Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness.

Acute bronchiolitis is the most common lower respiratory tract infection in young children that leads to emergency department visits and hospitalizations. Bronchiolitis is a clinical diagnosis, and diagnostic laboratory and radiographic tests play a limited role in most cases. While studies have demonstrated a lack of efficacy for bronchodilators and corticosteroids, more recent studies suggest a potential role for combination therapies and high-flow nasal cannula therapy. Frequent evaluation of patient clinical status including respiratory rate, work of breathing, oxygen saturation, and the ability to take oral fluids are important in determining safe disposition.

This summary of the treatment recommendations for pediatric bronchiolitis, supported by various guidelines provides, a systematic approach to ED assessment of such patients.

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Summary of Recommendations for ED Management of the Acute Bronchiolitis in Pediatric Patients

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What’s Your Diagnosis? a 9-month-old infant gasping for air September 30, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 1 comment so far

But before we begin, check out if you got last month’s case right, about the 11-year-old boy with acute abdominal pain. Click here to check out the answer!

Case Presentation: an 9-month-old infant gasping for air

As your shift is winding down at 4 AM, a mother brings in her 9-month-old infant, whom she describes as “gasping for air.” The baby has had a runny nose and cough for a few days as well as a low-grade fever, but now he is breathing rapidly and wheezing, with lower intercostal retractions.

The mother states that the infant has had wheezing in the past, and she asks if he might have asthma since “it runs in the family.” She also indicates that in the last 12 hours, he has not taken his usual amount of fluids.

His oxygen saturation level is 87% on room air.

You begin to think… should I treat this as reactive airway disease, asthma, or bronchiolitis? When should I give the patient albuterol, nebulized epinephrine, or oxygen? Does the infant need steroids? You also wonder whether this patient is going to tire and require assisted ventilation or whether there are any other alternatives to intubation.

Case Conclusion

You quickly determined that your patient had severe bronchiolitis, and you knew that aggressive management was required. You placed the patient on pulse oximetry because the infant had wheezed previously, and started a trial of a nebulized bronchodilator with oxygen while closely monitoring his clinical response to treatment. Your patient’s respiratory rate was still in the 70s, with minimal decreases in the work of breathing. His pulse oximetry level was 87% on room air, so you administered supplemental oxygen via HFNC. The patient started to cry without tears, and you noticed his dry mucous membranes, so you administered IV fluids. His respiratory rate was 55 breaths/min with no retractions, and he was able to take his bottle for only a brief period even after the nurse suctioned his nasal secretions. His SpO2 level remained at 90% on room air. You decided to admit the patient because his tachypnea was leading to compromised oral intake and because of his persistent hypoxia, and you kept him on the HFNC in the meantime.

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Most Common Risk Stratification Criteria for Management of Febrile Young Infants July 18, 2019


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Due to an immature immune system and pathogens often specific to the age group, the young infant (generally aged < 60-90 days, depending on the specific study or review) is at high risk for serious bacterial infections (SBIs); in particular, urinary tract infection (UTI), bacteremia, and bacterial meningitis. Consequently, the febrile young infant with a rectal temperature ≥ 38°C (100.4°F) is commonly encountered in the emergency department (ED). The incidence of SBI in febrile infants aged < 90 days is 8% to 12.5%, and it is nearly 20% in neonates (aged ≤ 28 days). The incidence of potentially life-threatening bacteremia and/or bacterial meningitis (ie, invasive bacterial infection [IBI]) is approximately 2%.

Due to their lack of social responsiveness (eg, social smile) and verbal cues, even well-appearing febrile young infants may harbor an SBI, in contrast to well-appearing febrile older infants and children who are at lower risk for IBI. Multiple studies have demonstrated that both observation scales and clinician suspicion for SBI are poorly predictive of bacterial infection in febrile infants. Additionally, bacterial meningitis is the most common diagnosis involved in pediatric medical malpractice claims in the emergency department (ED).

Over 2 decades ago, several risk stratification criteria were created to identify febrile young infants at low risk for SBI, and the criteria have been utilized to potentially avoid hospitalization of certain low-risk patients. More recently, newer risk stratification algorithms that incorporate biomarkers such as procalcitonin (PCT) and C-reactive protein (CRP) have been developed and validated in febrile infants.

Among well-appearing febrile infants, neonates have the highest prevalence of SBI and IBI and the least reliable clinical examination. These infants should undergo a full sepsis evaluation, including CSF testing. While the Rochester criteria and the recently published PECARN prediction rule do not include routine CSF testing in this age group (see table below), infants classified as low-risk by any criteria may still have bacterial meningitis, so CSF testing is generally recommended for all infants aged ≤ 28 days. Consideration should be given to testing for HSV in the neonate aged ≤ 21 days, even in the absence of vesicles or maternal history of HSV infection.

This table will help you predict the risk stratification criteria for management of febrile young infants. Download now.

Table 4. Most Common Risk Stratification Criteria for Management of Febrile Young Infants

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Brain Teaser: What is the appropriate management of this infant? July 17, 2019


Posted by Andy Jagoda, MD in: Brain Tease , 1 comment so far

Test your knowledge and see how much you know about management and treatment of young infants presenting with fever.

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The correct answer: C.


Review this Pediatric Emergency Medicine Practice issue to get up-to-date on novel diagnostic tools such as procalcitonin, C-reactive protein, and RNA biosignatures as well as new risk stratification tools such as the Step-by-Step approach and the Pediatric Emergency Care Applied Research Network prediction rule to determine which febrile young infants require a full sepsis workup and to guide the management of these patients in the emergency department.

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