Transcript Slide 1

Chapter 6
Fever
Case II
Case study: Asha
Asha, a 4 year old girl brought to hospital after 2
weeks of fever, not eating or drinking. On the day of
referral she could not be woken up and had a seizure.
What are the stages in the management
for any sick child?
Stages in the management of a sick child
(Ref. Chart 1, p. xxii)
1.
Triage
2.
Emergency treatment
3.
History and examination
4.
Laboratory investigations, if required
5.
Main diagnosis and other diagnoses
6.
Treatment
7.
Supportive care
8.
Monitoring
9.
Discharge planning
10.
Follow-up
Have you noticed any emergency or priority
signs?
Temperature: 39.50C, pulse: 140/min, RR: 50/min;
breathing noisy but regular, no cyanosis,
intermittently shaking left arm and leg,
unresponsive to voice, withdraws to pain
Triage
Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration
Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable
• Referral
• Malnutrition
• Oedema of both feet
• Burns
What emergency treatment will Asha need?
Emergency treatment
• Airway management?
• Oxygen?
• Intravenous fluids?
• Anticonvulsants?
• Immediate investigations?
□ Blood sugar
Emergency treatment - how do you position
the unconscious child?
(Ref. Chart 6, p. 17)
How to give oxygen
• Place the prongs just inside
the nostrils and secure with
tape.
(Ref. Chart 5, p. 11
p. 312-315)
• Use an 8 F size tube
• Measure the distance from the
side of the nostril to the inner
eyebrow margin with the
catheter
• Insert the catheter to this depth
and secure it with tape
Start oxygen flow at 1-2 litres/minute, in
young infants at 0.5 litre/minute
Emergency treatment (continued)
□ How do you treat acute convulsions?
Give diazepam (or paraldehyde) rectally (Ref.
Chart 9, p. 15)
Loading with phenobarbitone if convulsions
continue
□ How do you treat hypoglycaemia (Blood glucose
<1mmol/l)?
 Give IV glucose urgently (Ref. Chart 10, p. 16)
Give emergency treatment until the
patient is stable
History
• Asha was well until two weeks ago when she developed
high fever and was eating and drinking poorly. She was
taken to the health centre, where she was given benzyl
penicillin for three days, but the fever persisted and she
became more lethargic. On the day of referral she could
not be woken up and had a seizure.
• Family history: Asha's aunt has tuberculosis, which was
diagnosed recently.
• Social history: she lives with an extended family including
her parents, grandparents and her uncle's family in a
three-room house.
Examination
Asha was thin, pale looking, unconscious but withdrew to pain.
She was intermittently shaking her left arm and leg.
Vital signs: temperature: 39.50C, pulse: 140/min, RR: 50/min
Weight: 14 kg Height: 100cm
□ Use (Ref. p. 391-392) for weight-for-length
Neck: enlarged non-tender right-sided lymph nodes
Chest: gurgling upper airway sounds. On chest auscultation
only transmitted upper airway sounds
Cardiovascular/Abdomen: normal
Neurology: Asha was unconscious and withdrew only to pain
(squeezing her earlobe) and only on the right side. Her neck
was stiff and she grimaced when it was moved. Her pupils
were unequal. Apart from the intermittent jerking of her left
arm and leg, she did not move her left side.
Differential diagnoses
• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p. 24-25, p. 151)
Differential diagnoses (continued)
• Bacterial meningitis
• TB meningitis
• Cerebral malaria
• Viral encephalitis
• Trauma / head injury
• Poisoning / drug overdose
• Brain haemorrhage
• Hypoglycaemia
• Shock (secondary to severe sepsis)
□ Use references to suggest which are most likely


Ref. Table 3 p. 24-25
Ref. p. 151
Additional questions on history
• Head injury?
• Prior illnesses?
• Drug or toxin ingestion? • Immunization history
• Prior convulsions?
• Tuberculosis in family?
• Stiff neck or neck pain?
• Malarious area?
• Headache or vomiting?
•Traditional medicine?
(Ref. Table 3, p. 24-25)
Further examination based on
differential diagnoses
Assess first the depth of coma
– AVPU (Ref. p. 18)
 A alert
 V responds to voice
 P Responds to pain
 U unconscious
– Pupil size and light reaction
 Unequal pupils
– Abnormal posturing (Ref. p. 167-168)
– Tense or bulging fontanelle (only in infants)
Raised intracranial pressure
(Ref. p. 168, p. 56)
Neck Stiffness
(Ref. p. 168)
Further examination based on
differential diagnoses (continued)
• Look for signs of the cause of coma and fever:
– Neck stiffness (suggesting meningitis)
– Other signs of tuberculosis (Ref. p. 115-118, p. 171)
– Splenomegaly and pallor (suggesting malaria)
– Signs of trauma
– Rash (e.g. purpuric rash of sepsis) (Ref. p. 168, p. 153)
• Assess nutrition
– Weight-for-age, weight-for length (Ref. 379-402)
– Look for wasting and oedema
What investigations would you like to
do to make your diagnosis?
Investigations
●
Full Blood Examination
●
Blood glucose
●
Film or RDT for malarial parasites
●
Chest x-ray
□ Would you do Lumbar Puncture in this child
(Ref. p. 346-347) ?
Investigations (continued)
Full blood examination:
Haemoglobin:
89g/l
(115-140)
Platelets:
758x109/l (150 – 400)
WCC:
30.6x109/l (5.5 – 15.5)
Neutrophils:
21.4x109/l (1.5 – 8.5)
Lymphocytes:
8.0x109/l
(2.0 – 8.0)
Monocytes:
1.2x109/l
(0.1 – 1.0)
Investigations (continued)
• Blood sugar: <1mmol/l initially, then 4.5 mmol/l after
emergency treatment
• Chest x-ray: enlarged perihilar lymph nodes, some calcified
• Blood film: malaria parasites were not seen in both samples,
and RDT negative
• Other tests that could be done:
– Mantoux test (Tuberculin skin test: TST)
– Gastric aspirate (ZN stain, TB culture)
□ Lumbar puncture was not done because Asha had unequal
pupils and focal seizures (Ref. p. 346-347)
Diagnosis
Summary of findings:
• Examination: comatose state and focal
seizures, cervical lymphadenopathy, positive
contact history for tuberculosis; failure to
improve after 3 days of antibiotic treatment
• Chest x-ray: enlarged perihilar lymph nodes,
some calcified
• Blood examination shows moderate anaemia,
moderate neutrophilia with significant left shift
and thrombocytosis
Diagnosis (continued)
Suspected Meningitis
Tuberculosis
How would you treat Asha ?
Treatment
 Clinical meningitis, possibly bacterial, possibly TB
meningitis
 Ceftriaxone for 10 days (Ref. p. 169)
 TB treatment (Ref. p. 116-117)
 First 2 months (initial phase): isoniazid and
rifampicin and pyrazinamid and ethambutol (or
streptomycin) daily,
 Followed by next 8 months (continuation phase):
izoniazid and rifampicin daily
 Dexamethasone for tuberculous meningitis (Ref. p.
152)
What supportive care and monitoring
are required?
Supportive Care
(Ref. p. 172-174)
• Maintain a clear airway
• Positioning and turning
• Fluid and nutritional management:
– Early attention to nutrition is crucial to outcome
– Nasogastric feeding early
– Continue to monitor the blood sugar level
• Fever control
• Anticonvulsants
• Oxygen if convulsions, respiratory distress or apnoea
• Physiotherapy
Monitoring
• Nurses should monitor frequently the child's state of
(Ref. p. 174):
 Level of consciousness
 Adequacy of breathing (airway, RR, oximetry)
 Pupil size
 Record and treat seizures
• Use a Monitoring chart (Ref. p. 320, 413)
• Medical review at least twice daily
• Consider the complications
What acute complications might occur?
• Aspiration
• Convulsions (Ref. p.15, Chart 9)
• Hypoglycaemia (Ref. p.16, Chart 10)
• Fluid overload (Ref. p.173)
• Skin pressure areas
• Progressive malnutrition
• Constipation
• Urinary retention
• Limb contractures
• Nosocomial infection
What long term complications might occur?
• Hearing loss (Ref. p.174)
• Motor, visual and intellectual complications
• Nutritional
Progress and Discharge planning
• Within 3 days Asha started to regain consciousness.
• She still had a left-sided residual hemiparesis and her
weight had decreased to 12.6 kg
 She was fed more frequently (6 times a day) with
nutritious foods (Ref. p. 298, 209) once she was
conscious enough to swallow. The nasogastric milk
was continued for several weeks to provide some
additional supplementation.
• Physiotherapy was commenced for Asha’s hemiparesis
and her mother was also taught some passive exercises
• After three months her clinical condition has improved:
she was alert, eating and sleeping normally, although she
had a mild left sided hemiparesis and walked with a limp
• On discharge, Asha still had a residual left-sided
hemiparesis but she had gained over 1.5 kg
Follow-up
On follow-up visit:
• Assess neurological complications
• Assess nutritional state
• Screen for hearing loss (Ref. p. 173)
• Continue physiotherapy
- and give simple suggestions to the mother for passive
exercises
• Follow-up family screening & TB contact tracing
• Monitor frequently if antituberculous treatment
is taken at home
Summary
• A case of probable tuberculous meningitis
• Think of tuberculous meningitis if
– the illness is prolonged
– there are other signs of TB (e.g.
lymphadenopathy, malnutrition, family history)
• Children in coma are at risk of many complications
that need to be anticipated: aspiration, hypoxia,
hypoglycaemia, malnutrition, constipation, urinary
retention, pressure sores, joint contractures
• Early attention to nutrition is very important