Joint Pediatric/EM conference 6.14.2011

Topic:  Infectious Disease (panelists Dr. Maryanne Collins, Dr. Bill Schroeder, Dr. Omar Sawlani, Dr. Surasek P.)

1.  Consensus of panel-avoid alternating acetaminophen and ibuprofen.  Using both increases medication errors, doesn't significantly improve fever control, and adds to fever phobia.  To mitigate concerns of "brain damage" from fever, explain that fever is the body's internal response to illness and will not cause harm.  This is in contrast to the potential dangers of external/environmental heat such as heat stroke.

2.  The pediatricians in the audience encourage the continued culturing of SSTI (skin and soft tissue infections/abscesses).  When a child shows up in the office with a worsening SSTI, it help the PMD to know the resistance pattern.  FYI, at ACMC, approximately 50% of SSTI are MRSA.  

3.  When to admit pediatric SSTI?  Per Dr. Collins, consider age of patient, site, size of infection, prior infections, followup, and toxicity of patient.

4.  Periorbital vs. Orbital cellulitis.  We rely on globe pain, restricted eye movements/pain with eye movements, high fever, proptosis, spread/amount of erythema/swelling, overall toxicity when distinguishing the two clinically.  Orbit CT is indicated if concerned about orbital cellulitis, but for the gray zone cases, no need to CT in the ED.  Initial management is IV antibiotics, and if poor response, the CT can happen the next day.  Treatment difference for the two conditions is twofold:  potential for surgery and longer duration of antibiotic treatment for orbital cellulitis.

5.  Fever 3-36 months in well appearing child:  There is a variety of acceptable work-ups, ranging from nothing to partial septic work-up.  Much depends on followup/where you see the patient:  more tests usually performed in ED, when doctor doesn't know family and there may not be great followup.  Remember, children need the first two sets of vaccines (2 and 4 months) to be considered "immunized"; after this, no testing usually necessary except for the consideration of a UA and urine culture (always send both in diaper wearing kiddos).  Urine may be deferred for happy kids with one day of fever, but need to warn parents that if fever continues for more than 2 days, UA/culture may be needed.