Emergency Medicine

Fever Without Localizing Signs (FWLS)

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eFigure 13-1

Algorithm for the management of fever without localizing source in patients 0 to 2 months of age. (Adapted from Texas Children’s Hospital: Evidenced based clinical guideline on fever without localizing signs 0–60 days old).

eFigure 13–2

Algorithm for the management of fever without localizing signs in patients 2 to 36 months of age. (Adapted from Texas Children’s Hospital: Evidenced based clinical guideline on fever without localizing signs in 2–36 mo.)

Fever and Petechiae

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Comparison of Testicular Torsion, Epididymitis, and Torsion of Testicular Appendage

eFigure 13–3

Algorithm for differential diagnosis and treatment of fever with petechiae/purpura. (Adapted from http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5270.)

Scrotal Pain and Swelling

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eFigure 13–4

Differential diagnosis of scrotal swelling.

Comparison of Testicular Torsion, Epididymitis, and Torsion of Testicular Appendage

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Testicular Torsion

Epididymitis

Torsion of Testicular Appendage

Age group

Neonatal, 12–28 yo (66%)

Sexually active adolescents

7–14 yo

Onset

Sudden

Gradual

Gradual/sudden

Testicular lie

High

Low

Low

Cremasteric reflex

Usually not present

Present

Present

Prehn’s sign*

Negative

Positive

Variable

Urinalysis

Normal

+WBCs on UA

Normal

Presentation

Acute onset of pain, nausea/vomiting, purple, swollen, painful testes

Fever, chills, urethral discharge, nausea, neonatal, 12–28 yo (66%), edematous and tender epididymis

Pain located in the superior pole of testicle; mild erythema or edema; blue dot sign (21%)

Doppler ultrasonography

↓ or absent flow

Normal or ↑ flow in epididymis

Torsed appendage with ↓ flow but normal flow to testes

Treatment

Emergency surgery: Bilateral fixation of testes (irreversible damage possible in 5–6 h)

Manual detorsion (open book technique) if timely surgical intervention not available

Scrotal support (briefs), NSAIDs

Antibiotics†

  • Prepubertal: Most commonly no antibiotics required; may consider Trimethoprim–sulfamethoxazole
  • Sexually active: Ceftriaxone + azithromycin/doxycycline

Scrotal support (briefs) NSAID

Resolves within 2–12 days

*Relief of pain with elevation of testicle.

†Etiologic agents include coliform bacteria, viruses in prepubertal boys and Neisseria gonorrhea, Chlamydia in adolescents.

Limping and Joint Pain

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  • Definition: Uneven alteration in natural gait (secondary to pain, weakness, deformity).
  • Etiology: Trauma is the most common cause of limp. See the table below for causes of limp when there is no history of trauma.

Causes of Non-Traumatic Limp/Joint Pain in Children

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% of non-traumatic causes

Fracture

2%

Overuse (soft tissue injury, muscular strain, Osgood-Schlatter’s disese, hematoma of the thigh)

18%

Osteomyelitis

Other (appendicitis, PID, torsion constipation, etc.)

2%

Transient synovitis

40%

Legg-Calve-Perthes syndrome (avascular necrosis of the femoral head)

2%

Inflammation (rheumatologic: JRA, SLE, reactive arthritis or HSP)

Infection (skin, soft tissue, joint, septic arthritis)

3%

4%

Foreign body

Tumor

“Toddler’s fracture” (nondisplaced spiral fracture of the tibial shaft)

Trauma

1%

1%

—

SCFE

Sickle cell pain crisis

<1%

*Adapted from: J Bone Joint Surg Br 1999;81(6):1029.

  • Diagnosis
    • History: Time of onset, mechanism (trauma, change in activity), location, severity, radiation, effect on ADLs, aggravating or alleviating factors. Ask about fever, recent infections (viral or GABHS), weight loss, back, abdominal pain, cough, joint swelling, stiffness, erythema, incontinence, recent IM injection (sterile abscess). Prior h/o of family h/o cellulitis/abscesses or sickle cell disease connective tissue disease, IBD, or bleeding or neuromuscular disorder.
    • Physical exam
      • Inspection: Rash, inflammation, warmth, erythema, deformity, limb length discrepancies
      • Palpation: Joint or bone tenderness, joint effusion, neurovascular status
      • ROM: Active and passive ROM, grade strength
      • Neurovascular exam: Pulse, perfusion, sensation
      • Other: Do not forget to examine the spine, back, abdomen, and GU area
    • Laboratory studies: See table below for appropriate workup based on H&P.

Correlating History, Physical Exam, and Diagnostic Studies for a Child with a Limp

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Category

History

Physical Examination May Reveal

Laboratory Studies

Radiology

Traumatic

High–impact fall

Localized pain, swelling, loss or ↓ ROM

None unless infection is suspected

X-rays

Infectious

Fever, chills, erythema, induration, pain

Guarding, warmth, erythema, induration, discharge

CBC, ESR, CRP, blood cx, joint aspirate, skin or abscess culture

X-rays, MRI (deep infection or onset <1–2 weeks prior), bone scan (unclear site)

Inflammatory

Acute onset

Guarding, can bear weight, allows passive ROM ± swelling, ± erythema

CBC, ESR, CRP

X-rays

Chronic: Pain >6 mo ± FHx of RA

Warmth or erythema, one or more joints

CBC, ESR, CRP, joint aspiration

Neoplastic

Night pain, pain unrelated to activity, not relieved by OTC meds, ± fever

Mass, local tenderness

CBC, ESR, CRP, Alk Phos, calcium, electrolytes; joint aspirate

X-rays, MRI or CT, bone scan, staging workup

Congenital

Problem since birth

Deformity, leg length discrepancy, loss of ROM

None

X-rays

Neurologic

Ataxia, loss of balance, disorganized gait

↑ or ↓ muscle tone, ↑ or ↓ DTR, cavus foot or claw toes

CK (if DMD is in differential diagnosis)

X-rays

Developmental

Painless limp (LCP disease), knee pain (LCP disease, SCFE)

Loss of ROM in joints, asymmetric ROM, pain with ROM

None

X-rays

Adapted from Am Fam Physician. 2000;61(4):1011. LCP, Legg-Calve-Perthes

Differentiating Septic Arthritis from Transient Synovitis

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Septic arthritis

Transient synovitis

History and physical exam

Fever (usually >101.3°F)*; refusal to bear weight*; warm red, swollen joint; ↓ ROM (may be rigid); if septic hip (hip flexed and abducted); most sxs ∼3 days duration; recent URI (53%) trauma (31%)

Recent URI, low grade to normal temperature, allows passive ROM, can bear some weight

Laboratory studies

CBC* (↑ WBC, usually >12,000/mm3), ↑ ESR* (usually >40), ↑ CRP (>2)

None required; CBC usually normal, ESR or CRP mild elevation

Radiologic studies

US of joint (85% show effusion), MRI ⊕ in 88%, radiography (20% reveal joint space widening)

U/S or Ultrasound, MRI not needed unless need to help distinguish from septic arthritis. Consider X-rays to rule out femoral neck fractures.

Etiology

Staphylococcus aureus (MRSA) > Kingella > Streptococcus pneumoniae > Salmonella; consider GBS in neonates

Postinfectious reactive fluid in joint (joint fluid cx results negative)

Treatment

Orthopedic emergency (needs immediate drainage), joint aspiration (send for WBC, protein, cx), blood cx

Antibiotics: MRSA coverage (eg, vancomycin) + GNR coverage (eg, cefotaxime/gentamicin) ± MSSA, strep coverage (eg, nafcillin) X-rays → modify based on cx results; usual duration, 3–4 wk total

NSAIDS scheduled until symptomatically improved

*Positive predictive value of septic arthritis using findings in table above denoted by an asterisk: one sign, 3%; two signs, 40%; three signs, 93%; and four signs, 99.6% (J Bone Joint Surg Am 1999;81:1662). In addition, CRP >2 ↑ likelihood of septic arthritis.

Bites

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  • Treatment:
    • Irrigation is very important for infection prevention (100 mL NS, sterile water, or tap water per cm laceration)
    • Debride devitalized tissue
    • If wound appears infected, culture but do not close
    • First-degree closure should be avoided in puncture wounds, wounds on hands and feet, and wounds through cartilage
    • Antibiotic prophylaxis is not routinely recommended except in special cases (see table below)
    • Tetanus vaccine status should be verified for all patients and prophylaxis provided as indicated.
    • Rabies prophylaxis:
      • Consider when exposure to saliva is sufficient for infection (bite not required); saliva exposure to bats [most common cause in United States], raccoons, foxes, skunks (uncommon in small rodents (squirrels, rats) and rabbits).
    • Treatment
      • No suspicion → no treatment.
      • Any suspicion → attempt to quarantine and observe animal and discuss with local health department.
      • High suspicion or animal not in custody → one-time dose of human rabies immunoglobulin (20 IU/kg, with half given IM and half infiltrated locally at the wound site if feasible) followed by 4 IM injections of human diploid cell vaccine (1 mL) to be given on days 0, 3, 7, and 14 (CDC: ACIP Provisional Recommendations for the Prevention of Human Rabies: http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf or MMWR 2010;59(02):1

Characteristics and Treatment Recommendations for Cat, Dog, and Human Bites

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Cats

Dogs

Humans

Percentage

5–10%

80–90%

2–3%

Appearance

Puncture wounds

Tears and punctures

Moon shaped

Suture?

Do not close punctures

Can close if <12h old

Can close if <8h old

Infection rate

50%

30%

60%

Organisms

Pasteurella multocida, Streptococcus spp., Staphylococcus spp.

Streptococcus spp., Staphylococcus spp., Eikenella corrodens, anaerobes

Treat with prophylactic antibiotics

Prophylaxis for all high risk wounds (deep puncture wounds (e.g cat bites), moderate to severe wounds with associated crush injury, wound in area of underlying venous and/or lymphatic compromise, wound on the hand or close to a bone or joint, wounds requiring closure, wounds in compromised hosts (eg, immunocompromised, asplenia or splenic dysfunction)

First line: Amoxicillin/clavulanate

Second line: First-generation cephalosporin

PCN allergic: Doxycycline or clindamycin, + Trimethoprim/Sulfamethoxazole

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Jan 9, 2019 | Posted by in PEDIATRICS | Comments Off on Emergency Medicine

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