Febrile Infant (AAP Guidelines Summary by Journal Feed)

Febrile infant algorithms published by AAP and summarized by Journal Feed

https://journalfeed.org/article-a-day/2021/epic-new-febrile-neonate-febrile-infant-guideline-from-the-aap

“For eligibility, this guideline addresses febrile infants who

  1. are well appearing,
  2. have documented rectal temperatures of ≥38.0°C or 100.4°F at home in the past 24 hours or determined in a clinical setting,
  3. had a gestation between ≥37 and <42 weeks, and (4) are 8 to 60 days of age and at home after discharge from a newborn nursery or born at home.”

Guidelines exclude (quoted below):

  1. “Preterm infants (<37 weeks’ gestation).
  2. Infants younger than 2 weeks of age whose perinatal courses were complicated by maternal fever, infection, and/or antimicrobial use.
  3. Febrile infants with high suspicion of herpes simplex virus (HSV) infection (eg, vesicles).
  4. Infants with a focal bacterial infection (eg, cellulitis, omphalitis, septic arthritis, osteomyelitis). These infections should be managed according to accepted standards.
  5. Infants with clinical bronchiolitis, with or without positive test results for respiratory syncytial virus (RSV). A review by Ralston et al of 11 studies of bronchiolitis found no cases of meningitis, and researchers in 8 studies reported no cases of bacteremia.
  6. Infants with documented or suspected immune compromise.
  7. Infants whose neonatal course was complicated by surgery or infection.
  8. Infants with congenital or chromosomal abnormalities.
  9. Medically fragile infants requiring some form of technology or ongoing therapeutic intervention to sustain life.
  10. Infants who have received immunizations within the last 48 hours. The incidence of postimmunization fevers ≥38.0°C is estimated to be >40% within the first 48 hours.”

Of note, each algorithm refers to numbered Key Action Statements (KAS), 1-21 +/- a subheading (i.e. “7” or “7b”). The list of all Key Action Statements is in Table 1. Each of the images below has an extensive explanatory footnote in the original article. You must read these, but it’s just way too much to try to include all that text in this post. Just click the image, and it will take you to the original AAP document.

Status Epilepticus Seizure

Generalized convulsive activity >5mins or repeated seizure without full recovery

ABC – O2 early as seizure prevents effective respirations

Frost Line: Lorazepam or Midazolam 0.1mg/kg. Yes it’s a big dose but better to snow them than allow prolonged seizure. Max dose 8mg. Repeat @5min.

Second Line: Levetiracetum 60mg/kg (max 4500mg). Phenobarbital 20mg/kg. Valproic Acid 40mg/kg (max 3000mg)

Probably intubating at this point (15-20mins) Propofol 1.5mg/kg and Ketamine 2mg/kg and Paralytic

Neuroimaging especially if focal seizure

POC Electrolytes and Glucose – 150ml 3% Hypertonic Saline or 2 Amps Bicarbonate

Immediately start Propofol drip (3-5mg/kg/hr) or Midazolam drip

GC Gonorrheal Chlamydia STI Updated Treatement

Summary

What is already known about this topic?

Neisseria gonorrhoeae is an important cause of sexually transmitted infections that can have severe reproductive health consequences. N. gonorrhoeae can rapidly develop antibiotic resistance.

What is added by this report?

Based on review of recent evidence, CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded.

What are the implications for public health practice?

Continuing to monitor for emergence of ceftriaxone resistance will be essential to ensuring continued efficacy of recommended regimens.

https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm?s_cid=mm6950a6_w

Intracranial Hemorrhage

  • ABCs first –> intubate if needed
  • BP control <140 (labetolol pushes, nicardipine drip)
  • Dexamethasone 6mg q6h
  • Brain MRI w and w/o –> brain mass protocol to assess for malignancy
    • Consider full body CT scan to assess for primary
  • HOB 30˚
  • NSGY and NEURO consult
  • ICU for q1h neuro checks

Ultrasound Tips mostly From Core US

Peter Weimersheimer (Cardiac):

Basics:

  • Depth – Make sure that the image you’re trying to see is as big as you can make it.  Don’t have any wasted space in your clips or images.
  • Gain – Make sure your image is bright enough.  But don’t over gain!
  • Exam type – If you’re doing a FAST exam, don’t scan in the “lung” setting. 
  • Video clips – Be conscientious of the clips and images you take.  Focus on the thing you want to record and record a long enough clip of it, but also don’t record multiple clips of subpar exams.

Specific exams:

  • DVT – Make sure that the vein you’re evaluating is actually a deep vein. Deep veins paired, while superficial veins may be solitary.  Also, don’t confuse a lymph node for a DVT.
  • FAST exam – Slow sweeps of the regions your evaluating.  Fast sweeps can miss subtle fluid collections. Don’t forget to look at the inferior pole of the kidney/caudal tip of the liver interface on the right side.  Be careful with the seminal vesicles in the pelvis.
  • Intrauterine pregnancy (IUP) – Make sure that gestational sac is actually inside the uterus.
  • Thorax – Make sure to look at the back of the thorax when evaluating your patient with suspected pneumonia
  • Aorta vs IVC – To identify the IVC, first find the right atrium then look for the thing coming off of the right atrium. That’s your IVC.  Know your left and your right.  Most of the time, the IVC will be on the patient’s right.  Also, put color flow on it.  The less pulsatile one is the IVC.
  • BEN SMITH on AORTA/RENAL:
  • If you think you see mild hydro, use color flow to differentiate between mild hydro and prominent renal vessels
  • Scan from the back; the ribs are farther away from each other back there so may get better windows.
  • We aren’t good at finding the actual ureteral stone, but were pretty good at hydro
  • For getting past bowel gas when looking at the aorta – start up high where there is less gas (epigastric). Then when you come up on gas, use other hand to apply steady pressure (often 30-60 seconds). Use curvilinear probe, hurts less than the phased array.
  • Transhepatic view of aorta – not bad for aneurysm, but not great for dissection
  • We are good at looking at the aorta as long as we can actually see the aorta. Research that show great accuracy of bedside sonographic aorta exam only included studies where the aorta was able to be visualized.
  • Find the beating thing first.
  • Use lots of gel, and lot of pressure to get your view.
  • Get your ultrasound beam parallel with the heart.
  • Start your exam with your patient in the left lateral decubitus position.
  • Do one maneuver at a time (rotate, fan, rock, etc).
  • Start with the probe at the clavicle/sternal interface, slide down until you see the heart.
  • You don’t always need all the 4 views of the heart.
  • If ventricle is round, subtle hand rotations will fix.