“The fever will not burn the brain in the fever yesterday, but these dangerous signals must be careful …” (here is the portal) we talk about fever definition, mechanism, common causes, impact on the body, and danger early warning signals Essence
Today, this article will focus on discussing the diagnosis and treatment of children’s emergency and outpatient clinics.
The article is very long, all of which are the key, first look at the summary
1. Heating type
2. Accompanied by symptoms and signs
1. Lack of little babies accompanied by symptoms
2. Smasm
3. Candidum congestion
4. Accompanimental symptoms and signs
5. lymphatic swelling
6. Bone/joint swelling and pain
7. Symptoms/signs with circulating system
8. Symptoms and signs of gastrointestinal system
9. Symptoms and signs with urinary tract
10. Symptoms or signs with nervous system
11. Symptoms/signs with blood system
Third, the application of blood routine and CRP in the fever disease
1. When will the blood routine be checked?
2. Can blood conventional/CRP distinguish bacterial infection or virus infection?
3. How to interpret the blood routine?
Fourth, serum science and pathogenic examination
5. Diagnostic treatment
A large number of studies have shown that infectious diseases are the primary causes of children’s fever, especially for children under 5 years old.
The diagnosis and treatment of acute infectious diseases includes two aspects -positioning and reasons, that is, to identify the infection site and infection pathogens.
Positioning and fixed causes are mainly based on 5 aspects:
At first glance, different diseases have different types of fever, such as the heat and relaxation of heat, but due to the often interference of drugs, it is difficult to determine the heat type;
Second, look at the symptoms and signs: according to the symptoms and signs of different systems, consider the infection of the corresponding system;
Third, look at conventional examination and inflammation indicators: According to the blood routine and inflammation indicators, preliminary judgments can be made to the infection category, especially for the accuracy of the baby;
Fourth -seeing serum science and pathogenic examination: Different seasons often have different pathogenia, combined with clinical manifestations and epidemiological characteristics, you can be targeted to determine the type of pathogen;
Five -looking diagnostic treatment: If the above steps are still not clear, the diagnostic treatment can be diagnosed according to the above comprehensive information, and then the diagnosis can be evaluated.
1. Heating type
Jiushu is more common in typhoid fever, deputy typhoid fever, Kawasaki disease, adenovirus infection, and large leaf pneumonia, etc.;
Choir fever is more common in sepsis, bureaucracy, purulent infections (such as purulent tonsillitis), rheumatism, infectious endocarditis, young special arthritis, etc.;
Intermittent fever is more common in malaria (malaria, three -day malaria);
Irregular fever is found in purulent, rheumatism, malignant malaria, and exudate pleurisy, etc.;
Wave fever is found in Bronobacteria, lymphoma, periodic fever, etc.
2. Accompanied by symptoms and signs
With symptoms and signs, it is an important reference for determining the infection site of the child. For children’s infection diseases, the most common is respiratory tract infection, followed by digestive tract infection, and once again the urinary tract infection and nervous system infection. A few are cardiovascular system infections.
1 Lack of little babies with symptoms
If the child’s body temperature is very high, lack of symptoms and signs, generally good, mental and stomach, etc., are common in the fever during the emergency department of children; with the development of the disease, the lattice of the back of the ears and the post -pillow is swollen, the fever retreats Later rashes can be produced. The author calls “young children’s acute rashes are red and fine, and the heat retirement rash will be together for a day.”
For small babies who lack respiratory symptoms and digestive system symptoms, pay special attention to the possibility of urinary tract infection and nervous system infection. You should be vigilant, pay attention to physical examination, and do the necessary examination to identify.
2 with rash
Heating is accompanied by rash, which is more common in infectious diseases, and can also be seen in non -infectious diseases. First of all, it is necessary to distinguish whether hemorrhagic rash or congestive rash.
■ Bleeding rashes are more common in influx, sepsis, infective endocarditis, epidemic hemorrhage fever, and drape fever. In a few cases, special platelet reduction purpura (mostly no fever) can also appear fever and hemorrhagic rash due to combined infection. Similar situations are also found in allergic purpura and should be identified in detail.
■ Pediatrics are more common to be congested rash, such as rubella, chickenpox, scarlet fever, smallpox, measles, typhoid fever, drug rash, young children’s rash, hand, foot and mouth disease, and so on. Regarding this kind of disease, the author has discussed in detail in “The Best Pediatric Infectious Outstanding Disease Memory Strategy” (here is a portal).
The congestive rash can also be found in the hyperplasia of infectious mononuclear cells and intestinal virus infections.
Other diseases accompanied by rash also include bacteria scald-like skin syndrome (SSSS), Steven-Johnson syndrome, Kawasaki disease, systemic lupus erythematosus, young special arthritis, dermatitis, nodular polymeritis Wait, this kind of disease has obvious clinical characteristics, but it is easy to be ignored because of rare.
3 accompanied by condensate congestion
It can be seen in Kawasaki disease, hook -end spiral disease, and pharyngeal end fever caused by adenovirus.
4 Accompanimental symptoms and signs
Accompanied by symptoms and signs such as cough, runny nose, nasal congestion, sneezing, soreness, shortness of breath, breathing, breathing difficulties, etc., it is common in various respiratory tract infections and is the most common cause of clinical fever.
There are many types of diseases, acute upper respiratory infections, bronchitis, pneumonia, and so on. The most common pathogen of respiratory disease is virus, followed by bacteria, and rare cases include special pathogens such as tuberculosis. Such diseases are more common in clinical clinical and are repeatedly described. 5 accompanied lymphatic swelling
It is found in the hyperplasia, lymphitis, rubella virus infection, hemorrhoids, and Kawasaki disease. Most of the lymph inflammation has the reactivity, purulent or tuberculosis lymph nodes caused by neighboring tissue infection. Pay attention to the distinction of identification.
6 accompanying bone/joint swelling and pain
Seen in purulent arthritis and osteomyelitis. Such children are more common in older children and have a history of trauma. It can also be seen in leukemia, systemic lupus erythematosus, young special arthritis and allergic purpura.
7 Symptoms/signs with circulatory system
Seen in infective endometritis (fever+heart murmur, children with valve disease are more likely to occur), pericarditis (including purulent and tuberculosis, often chest tightness, chest pain, auscultation heart sounds far or low cubic) It is manifested as vomiting, mental fatigue, chest tightness, chest pain, panic, etc., is not typical, often missed diagnosis).
In addition, it is worth mentioning:
If the child’s fever, low heart rate, low blood pressure, extension of CRT, cold fingers, and differential disorders such as reaction, you need to be alert to infectious shock and purulent ledmia. , Urine Trail infection and other Gram -negative bacteria infections.
8 Symptoms and signs of the digestive system
The digestive system infection is second only to respiratory infection in pediatric infectious diseases, and the symptoms and signs of digestive tract can also be seen in respiratory infection diseases. Common symptoms include nausea, vomiting, diarrhea, bloating, abdominal pain, hepatobolia, and jaundice.
■ If accompanied by abdominal pain, you should identify surgical diseases for the first time. Pay attention to checking the abdomen (appendicitis, intestinal cases, pancreatitis, necrotic small intestinal colon, intestinal obstruction and gallbladder vessels, intestinal obstruction, gallbladder vesicles, intestinal obstruction, gallbladder vesicles Yan, etc.).
When identifying surgical acute abdomen, pay attention to the condition of the stool, and the color Doppler ultrasound or radiation inspection should be identified if necessary.
■ If you have diarrhea, you should first follow the appearance and routine of the stool, which is distinguished or non -invasive pathogen infection.
If it is rotten or diluted, the stool does not have mucus or blood, and the stool is normal, and the infection of non -invasive pathogen is considered; otherwise, the invasive pathogen infection is considered.
In addition, symptoms such as vomiting, abdominal pain, and diarrhea often occur in gastrointestinal colds. Pay attention to identification.
■ Accompanied by hepatoblasty and jaundice, it can be seen in the early stage of viral hepatitis, hook body disease, hemorrhoid disease, acute cholangitis, sepsis, and infectious mononucleucleic cell hyperplasia.
What you need to pay special attention is:
Explosive myocarditis can sometimes be manifested as vomiting, and it is often accompanied by symptoms such as poor mental, circulatory disorders, and chest tightness and chest pain. As a result, children who complain about vomiting should be alert to myocarditis.
9 With urinary tract symptoms and signs
Older children, urinary infections, can have obvious signs of bladder irritation such as frequent urination, urgency, and dysuria.
But it is worth mentioning:
The urinary system infection is more common in small babies. Most of the lack of typical symptoms of urinary systems, but manifested as simplicity and high fever, or accompanied by circulating disorders.
Therefore, if a baby is fever clinically, those with lack of respiratory and digestive system symptoms should pay special attention to the possibility of urinary tract infection. Some literatures even recommend infants and young children under 1 year old. Reasons for unknown reasons require routinely check urine analysis.
What needs to be reminded is:
If the baby has unknown reasons (no breathing, digestive symptoms), the blood check and CRP believe that the possibility of bacterial infection is high. Before using antibiotics, urinary tract infections should be identified to avoid the use of antibiotic infections and affect the prognosis. Essence
Due to the differences in anatomical structures, infants and young children’s urinary tract infection is more common in women. If urinary tract infections occur in children with children, or women with urinary tract infection multiple times, special attention should be paid to eliminating the possibility of urinary tract deformities.
10 Symptoms or signs of the nervous system
Children’s common nervous system manifestations include headache, spray vomiting, coma, convulsions, meningiomycardia, raid disorders, motor disorders, uplifting of infants and young children, or widening bone seams.
Common diseases include viral encephalitis, purulent meningitis, small encephalitis, and polio.
It is worth reminding:
Due to fever, children often experience mental fatigue. Parents may tell doctors to sleep significantly and reduce physical activity. Pay attention to whether it is drowsiness and physical activity disorders.
In addition, autoimmune encephalitis can also show mental symptoms, and changes in fantasy vision, changes in personality, and irritability will often be misdiagnosed as mental illness and need to be further identified.
Inflammation of other system diseases can sometimes occur, and symptoms of nervous system can also occur. If the child has obvious headaches and vomiting, and no other nervous system manifestation, sinusitis should be considered.
11 Symptoms/signs with blood system
The fever is accompanied by skin stasis and ecchymosis, which can be seen in the merging brain, hook body disease, nephropathy syndrome bleeding fever, DIC, etc.; It can also be seen in allergic purpura and ITP combined infection.
Third, the application of blood routine and CRP in the fever disease
In most cases, it is difficult for family members to receive intravenous blood collection examinations. Therefore, it has become a commonly used method for clinical use through peripheral blood testing blood and CRP, which has the characteristics of convenient, efficient and fast.
However, it should be reminded that the peripheral blood is sometimes more prone to blood concentration. When interpreting, pay special attention to identification.
1 When will the blood routine be checked?
Guidelines for thermal fever in 2016: Generally, the cause of good situation is unknown acute fever and newborn fever 12 h before 12 h, the sensitivity and specificity of severe bacterial infection is better (1D level evidence) Essence
For children of other ages, the guidelines have not given suggestions.
2 Can blood conventional/CRP distinguish bacterial infection or virus infection?
Many pediatric clinicians like to be rising according to whether the blood conventional white blood cells (WBC) and the proportion of neutral granulocytes (NE) to judge whether it is bacterial infection or virus infection. So, can blood routine and CRP distinguish bacterial infection or virus infection? There is a large VPP in the pediatric private clinic to criticize the clinical strategy, but the author has his own opinion on this issue.
Big V believes that pediatric fever diseases have a large proportion of respiratory diseases, while respiratory diseases have a large proportion of virus infections. In addition, they can give it as an example that WBC and NE may occur at the same time in the simultaneous increase of WBC and NE, which cannot be judged as bacterial infections. The pathogens of these two diseases are clearly infected with virus.
In fact, many clinicians also judge whether hand, foot and mouth disease need to be used according to the blood routine, which is actually ridiculous. They will excuse, in case of combined with bacterial infection? Of course, this reason is very good, but the mixed infection is rare in clinical, and it can be identified according to certain clinical characteristics, instead of saying that the Hand -foot and mouth disease WBC and NE are high, and the prescription antibiotics are given.
Similar situations are also found in Norru virus infection, also known as vomiting in winter, outstanding vomiting symptoms, and routine blood tests are significantly higher in WBC and NE. The specific mechanism is unclear, which may be related to Nuo Ru virus that causes frequent vomiting, and may be related to vomiting and stimulating white blood cells into the cycle pool.
In fact, many clinical stress reactions may occur in the rise of white blood cells/neutral granulocytes, such as seizures.
However, the criticism of Big V went to another extreme, that is, the blood routine cannot identify bacterial or virus infections. Philosophical thinking tells us that it is necessary to discriminate to see the problem, not to this or the extreme.
First of all, let’s take a look at what the heating guide said in 2016: The heating guide said:
<3rd year -old causes unknown acute fever children, WBC <Critical value 15 × 10^9/L or neutral granulocyte absolute counting <critical value 10 × 10^9/L, diagnose severe bacterial infection (level 1B level (1B level level evidence);
When the cause is unknown acute fever children, when taking CRP> Top 20 mg/L, the possibility of diagnosis of severe bacterial infection is less likely; when taking CRP> 40 mg/L, diagnosis of severe bacterial infection is greater; > When the critical value is 80 mg/L, diagnosis of severe bacterial infection is very likely (level 1B evidence).
In other words, the combination of simple blood routine or blood conventional+CRP can still be learned to a certain extent whether it is bacterial infection or virus infection.
3 How to interpret the blood routine?
Blood routine is currently the most commonly used and convenient examination items in pediatrics. It can provide valuable reference data for the timely diagnosis, severity and efficacy judgment of common diseases.
In the diagnosis and treatment of fever, in addition to paying attention to white blood cells and its constituent proportions, we should also pay attention to the situation of platelets and hemoglobin. This article mainly talks about the composition of white blood cells and its sub -category.
First of all, it is necessary to know that children’s WBC counting is higher than adult levels. Such as the newborn can be as high as (15 ~ 20) × 10^9/L, about 12 × 10^9/L in 1 week after birth, about (10 ~ 12) × 10^9/ L, gradually declined to adult level (4 ~ 10) × 10^9/L.
Secondly, in terms of composition, the composition of different ages is different. We all know that children’s WBC has a “two cross”, that is, the neutral granulocytes 4 to 6 days and 4 ~ 6 years after birth are equal to lymphocytes, each accounting for 50%. The two ends of the two cross points are dominant at neutral granulocytes; the age between the two cross points, lymphocytes dominate. The specific figure below:
Third, under the circumstances of infection, poisoning, acute blood loss or hemolysis, stress response, etc., WBC counting can increase; most virus infection, re -hematopoietic incomplete diseases, and certain autoimmune diseases may occur. Decrease, but the above phenomenon is caused by NE changes.
Ferry bacterial infections are mostly caused by increased NE, and viral infections are mostly caused by NE. However, in the early stage of acute virus infection, when the stress state such as high fever is in the stage of high fever, NE is often accompanied by a temporary increase in Temporary. It needs to be determined according to the results of clinical manifestations, CRP and pathogens. In addition, when the Gram -negative infection (such as typhoid fever, etc.) and severe purulent leather, NE can be reduced.
Interpretation of the division of the blood conventional results
WBC/NE elevated: acute purulent infection, the degree of increased white blood cells depends on the type, lesion, severity, and body response ability of the infection. WBC/NE, accompanied by nuclear movement left, prompts bacterial infection, inflammatory response, and stress response, etc.; A small number of virus infections may also have similar manifestations such as the Brain. WBC/NE decreases: Prompt virus infection or severe bacterial infection in infants and young children. If other “two departments” are reduced, you should also pay attention to re -obstacles, blood -baling cell syndrome, ionizing radiation, systemic lupus erythematosus, and hepatoplastics.
WBC/LY elevation: Prompt virus infection. Those with elevated hetero -lymphocytes should pay attention to infectious monocytes or class leaflets. Some bacterial infections may also appear like blood elephants, such as pertussis.
WBC/LY decrease: Ask high -risk factors, be alert to HIV infection or congenital cell immune defects.
Finally, it is worth mentioning:
The clinical identification of bacterial or virus infections has never been identified by simple blood routines, but should be identified through symptoms, signs, infection sites, possible pathogens and evidence of evidence.
Fourth, serum science and pathogenic examination
Serum science and pathogenic examinations should choose appropriate examinations according to the epidemic season and clinical manifestations, and detect pathogens in a targeted manner. If the condition is more complicated or dangerous, it is recommended to stay or income for further inspection.
The examination of pathogenics includes antigenic examinations, antibody examinations, and nucleic acid examinations. Among them, nucleic acid examination is the highest.
It is worth mentioning that:
The antigen examination is sometimes high -positive. If it is highly doubtful, it is recommended to combine clinical or further nucleic acid examinations.
5. Diagnostic treatment
This is often encountered in clinical practice, that is, the above four steps are still unable to confirm what kind of infection, at this time, the diagnostic treatment method can be used to verify the clinical judgment.
That is, according to the possibilities of suspicion, the corresponding disease treatment is performed to observe the efficacy to finally determine or exclude a diagnosis. However, at the same time, you should also pay attention to the main treatment of diagnostic treatment, do not give up the test of pathogenic science, but also need to adjust the treatment plan based on the curative effect.
references:
1. Wang Yi, Wan Chaomin. China 0 to 5 -year -old children’s unknown acute heating diagnosis treatment guidelines (simplified version). Chinese evidence -based pediatric magazine, 2009 (3): 310
2. Luo Shuanghong and so on. Several issues (standard edition), an acute heating diagnosis treatment for children 0 to 5 years old for children aged 0 to 5. Chinese evidence-based pediatric magazine, 2016 (2): 81-96
3. Renwei Publishing House “Pediatric Science” (8th edition)
4. Renwei Publishing House “Zhu Futang Practical Pediatric Science” (8th edition)
5.NICE Clinical Guideline.feverish Illness in Children: Assessment and Initial Management in Children Younger than 5 Years. 2013.may
6. People’s Health Publishing House “Federation of Pediatric Symptoms” (3rd edition, editor -in -chief of Liao Qingkui)
