362 Paediatric Emergencies
FEBRILE CHILD3 The risk of a significant bacterial infection in fever without a focus is propor-
tional to temperature and inversely proportional to age, with those most at
risk aged <3 years. Common bacterial infections without localizing signs
can include:
(i) Meningitis and septicaemia.
(ii) Bone and joint infections.
(iii) UTI.
(iv) Pneumonia.
(v) Occult bacteraemia (usually the patient is non-toxic and appears
well).
4 Examine the child for signs of serious systemic compromise; i.e. that are
potentially ‘toxic’:
(i) Lethargy, poor arousal and reduced activity.
(ii) Respiratory distress: nasal flaring, tachypnoea and grunting
respirations.
(iii) Circulatory impairment: poor peripheral perfusion, hypotension
and tachycardia.
(iv) Signs of dehydration, reduced oral intake and reduced urine
output.
(v) Sinister ‘red flag’ signs such as apnoea, cyanosis and convulsions.
5 Send blood for FBC, blood sugar, U&Es, blood cultures and urine culture
if clearly unwell (lethargic, poorly interactive, difficult to rouse, inconsol-
able, tachypnoea, tachycardia, poor peripheral perfusion and any ‘red f lag’
signs.)
(i) Obtain the urine sample by either clean catch (midstream urine
[MSU]), suprapubic aspirate (SPA) ideally under ultrasound
guidance, or a catheter specimen (CSU) and send for urgent
microscopy, culture and sensitivity
(a) a UTI cannot be diagnosed on symptoms alone, nor by
culture of urine from a bag specimen (contaminants)
(b) urinary dipstick testing is a screening test only for UTI with
poor sensitivity and specificity in young children, so always
send a specimen for microscopy and culture if suspicion is
high.
6 Request CXR in patients with respiratory distress, bradypnoea, abnormal
breat h sounds or ox ygen saturations less t han 95%.
7 Indications to perform a lumbar puncture are based on clinical grounds and
or as part of t he f ull sepsis work-up of a toxic infant <3 mont hs of age.
(i) Only perform a lumbar puncture after consulting with the senior
ED doctor.
(ii) Lumbar puncture should not be performed in a child with an
impaired conscious state or focal neurological signs.