Setting the Scene
Imagine it’s your first moonlighting shift at a small rural community hospital. The nearest referral center for both adults and children is 90-minutes away by ground. The annual census of the emergency department is 15,000 patients per year, of which only 5% is pediatric. There are 2 hours left in your 12-hour shift and your energy is all but spent. You are looking forward to winding down at home after an extremely busy and high-acuity shift when your 35th patient of the day checks in. The patient’s chief complaint is fever. You give yourself an internal fist pump thinking that you’re about to see your 12th viral URI of the day and that you’ll be in-and-out of that room no in time. In the midst of your premature celebration you scan the nursing note and see the age of the patient: 6 weeks…You’re hopes of a quick and easy disposition suddenly melt away leaving you with many more questions regarding this patient’s care than answers…You muster your remaining energy and make your way toward the patient’s room.
You walk in the room...
The patient is an otherwise healthy ex-full term 6-week old male. The mother denies any prenatal or neonatal complications. Patient has been in a good state of health until yesterday evening when he became irritable, febrile, and refused oral intake. These symptoms have persisted throughout the last 24 hours with a Tmax of 103. When asked about associated symptoms the mother endorses decreased urine output and periods of decreased activity. She denies cough, rash, cyanosis, decreased body tone, diarrhea, bloody stool, foul-smelling urine, and seizures. The patient has not yet received his 2 month shots. There has been no recent travel and no known sick contacts.
T 102.5 HR 180 BP 70/45 RR 45 O2 Sat 97%
The infant is intermittently irritable but consolable. He does not interact or make eye contact with the care provider and only intermittently with the mother and is appropriately sized for his age. His fonteanelles are flat, he has mild erythema of both tympanic membranes, mild clear rhinorrhea, normal conjunctiva, a normal oropharyx and pupils are equal, round, and reactive to light. He has non-labored breathing without retractions faint wheezing at the right lung base but his lungs are otherwise clear to auscultation. His cardiac exam reveals a regular tachycardia without any murmurs, rubs, or gallops. His abdomen is soft and non-tender without any masses or hepatosplenomegaly. His extremities are well perfused, he has brisk cap refill. His skin, neck, and neurological exam are all normal.
As you finish your assessment with tears welling in her eyes the mother asks you “is he going to be OK?” You want to tell the mother that everything is fine, but at the same time you know that your assessment wasn’t 100% reassuring. Although your suspicion is low, you cannot rule out a serious bacterial infection (SBI) at this point. As you sit next to the mother carefully contemplating what to say, your phone rings. “Thank God!”, you tell yourself and you rush out of the room. And as you make your way back to your work station a flood of questions regarding management of the febrile infant hit you all at once…
Q&A with the Experts in Pediatric Emergency Medicine at Cincinnati Children's Hospital
You have no identifiable source of infection. The differential ranges from otitis media, to UTI, to early pneumonia, to bacteremia, to meningitis. What is the incidence of SBI in this patient population? What labs, if any, are indicated in this patient population?
Does this child need a lumbar puncture?
Should you decide to do an LP, it will undoubtedly take a while to perform as you’re ED is full and your nurses and techs are already stretched thin. When, if ever, should empiric antibiotics started? What antibiotics should be given?
If everything comes back normal what is the most appropriate disposition if there is still concern for SBI? Discharge with close PCP follow up? Admit and wait on culture results?
The patient has rhinorrhea and some scant wheezing at the right lung base. However, your suspicion of bacterial pneumonia is low. What is the utility of an CXR in this patient? You foresee a hedge read from the radiologist of atelectasis vs pneumonia? What are the chances that this patient has a bacterial pneumonia that will benefit from antibiotics?
Might a normal ANC and Procalcitonin level indicate a low enough risk of meningitis that we can forgo the LP?
A special thank you to Dr. Benjamin Ostro, PGY-4 Emergency Medicine Resident at University of Cincinnati Medical Center, for facilitating this discussion and Dr. Brad Sobolewski, Assistant Professor in Pediatric Emergency Medicine at Cincinnati Children's Hospital Medical Center, and Dr. Adam Vukovic Clinical Fellow in Pediatric Emergency Medicine at Cincinnati Children's Hospital Medical Center, for participating in our expert commentary. Be sure to check out Dr. Brad Sobolewski's PEM Blog for more pediatric emergency medicine FOAM.
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