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Emergency Department Management of Rash and Fever in the Pediatric Patient

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Emergency Department Management of Rash and Fever in the Pediatric Patient January 2020 Emergency Department Volume 17, Number 1 Authors Management of Rash and Rhonda L. Philopena, MD Assistant Professor of Emergency Medicine and Pediatric Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY Fever in the Pediatric Patient Erin M. Hanley, MD Assistant Professor of Pediatrics and Emergency Medicine, SUNY Abstract Upstate Medical University, Syracuse, NY Kayla Dueland-Kuhn, MD SUNY Upstate Medical University, Syracuse, NY Rash and fever are some of the most common chief complaints Peer Reviewers presenting to the emergency department. The evaluation of Jeffrey R. Avner, MD, FAAP rashes in the febrile pediatric patient includes a broad differen- Chairman, Department of Pediatrics, Professor of Clinical Pediatrics, tial diagnosis and use of the history and physical examination Maimonides Children’s Hospital of Brooklyn, Brooklyn, NY Nicole Gerber, MD to identify red flags, such as hemodynamic instability, erythro- Assistant Professor of Clinical Pediatrics, Department of Emergency derma, desquamation, petechiae/purpura, mucous membrane Medicine, Division of Pediatric Emergency Medicine, New York- involvement, and severe pain, that should increase suspicion Presbyterian/Weill Cornell Medical Center, New York, NY for worrisome disease. This issue reviews characteristics of Prior to beginning this activity, see “CME Information” common rashes as well as rarer, potentially life-threatening on the back page. rashes, to guide management and treatment and improve pa- This issue is eligible for 4 Infectious Disease CME credits tient outcomes. and 0.5 Pharmacology CME credits. Editors-in-Chief Ari Cohen, MD, FAAP Alson S. Inaba, MD, FAAP Garth Meckler, MD, MSHS David M. Walker, MD, FACEP, FAAP Chief of Pediatric Emergency Pediatric Emergency Medicine Associate Professor of Pediatrics, Chief, Pediatric Emergency Ilene Claudius, MD Medicine, Massachusetts General Specialist, Kapiolani Medical Center University of British Columbia; Medicine, Department of Pediatrics, Associate Professor; Director, Hospital; Instructor in Pediatrics, for Women & Children; Associate Division Head, Pediatric Emergency Joseph M. Sanzari Children's Process & Quality Improvement Harvard Medical School, Boston, MA Professor of Pediatrics, University Medicine, BC Children's Hospital, Hospital, Hackensack University Program, Harbor-UCLA Medical of Hawaii John A. Burns School of Vancouver, BC, Canada Medical Center, Hackensack, NJ Jay D. Fisher, MD, FAAP, FACEP Center, Torrance, CA Medicine, Honolulu, HI Clinical Professor of Emergency Joshua Nagler, MD, MHPEd Vincent J. Wang, MD, MHA Tim Horeczko, MD, MSCR, FACEP, Medicine and Pediatrics, University Madeline Matar Joseph, MD, FACEP, Assistant Professor of Pediatrics Professor of Pediatrics and FAAP of Nevada, Las Vegas School of FAAP and Emergency Medicine, Harvard Emergency Medicine; Division Associate Professor of Clinical Medicine, Las Vegas, NV Professor of Emergency Medicine Medical School; Associate Division Chief, Pediatric Emergency Emergency Medicine, David Geffen and Pediatrics, Assistant Chair, Chief and Fellowship Director, Division Medicine, UT Southwestern Marianne Gausche-Hill, MD, FACEP, School of Medicine, UCLA; Core Pediatric Emergency Medicine of Emergency Medicine, Boston Medical Center; Director of Faculty and Senior Physician, Los FAAP, FAEMS Medical Director, Los Angeles Quality Improvement, Pediatric Children’s Hospital, Boston, MA Emergency Services, Children's Angeles County-Harbor-UCLA Emergency Medicine Division, Health, Dallas, TX County EMS Agency; Professor of James Naprawa, MD Medical Center, Torrance, CA University of Florida College of Clinical Emergency Medicine and Attending Physician, Emergency International Editor Editorial Board Pediatrics, David Geffen School Medicine-Jacksonville, Department USCF Benioff Jacksonville, FL Lara Zibners, MD, FAAP, FACEP, Jeffrey R. Avner, MD, FAAP of Medicine at UCLA; Clinical Children's Hospital, Oakland, CA Faculty, Harbor-UCLA Medical MMed Chairman, Department of Stephanie Kennebeck, MD Joshua Rocker, MD Center, Department of Emergency Associate Professor, University of Honorary Consultant, Paediatric Pediatrics, Professor of Clinical Associate Chief and Medical Emergency Medicine, St. Mary's Pediatrics, Maimonides Children's Medicine, Los Angeles, CA Cincinnati Department of Pediatrics, Director, Assistant Professor of Cincinnati, OH Hospital Imperial College Trust, Hospital of Brooklyn, Brooklyn, NY Michael J. Gerardi, MD, FAAP, Pediatrics and Emergency Medicine, London, UK; Nonclinical Instructor Steven Bin, MD FACEP, President Anupam Kharbanda, MD, MSc Cohen Children's Medical Center of of Emergency Medicine, Icahn Associate Clinical Professor, UCSF Associate Professor of Emergency Chief, Critical Care Services, New York, New Hyde Park, NY School of Medicine at Mount Sinai, Medicine, Icahn School of Medicine Children's Hospital Minnesota, School of Medicine; Medical Director, Steven Rogers, MD New York, NY Pediatric Emergency Medicine, UCSF at Mount Sinai; Director, Pediatric Minneapolis, MN Associate Professor, University of Emergency Medicine, Goryeb Benioff Children's Hospital, San Tommy Y. Kim, MD, FAAP, FACEP Connecticut School of Medicine, Pharmacology Editor Children's Hospital, Morristown Francisco, CA Associate Professor of Pediatric Attending Emergency Medicine Aimee Mishler, PharmD, BCPS Medical Center, Morristown, NJ Richard M. Cantor, MD, FAAP, FACEP Emergency Medicine, University of Physician, Connecticut Children's Emergency Medicine Pharmacist, Professor of Emergency Medicine Sandip Godambe, MD, PhD California Riverside School of Medicine, Medical Center, Hartford, CT Program Director – PGY2 Chief Quality and Patient Safety Officer, Riverside Community Hospital, Emergency Medicine Pharmacy and Pediatrics; Section Chief, Christopher Strother, MD Pediatric Emergency Medicine; Professor of Pediatrics, Attending Department of Emergency Medicine, Associate Professor, Emergency Residency, Valleywise Health Medical Director, Upstate Poison Physician of Emergency Medicine, Riverside, CA Medicine, Pediatrics, and Medical Medical Center, Phoenix, AZ Children's Hospital of The King's Control Center, Golisano Children's Melissa Langhan, MD, MHS Education; Director, Pediatric APP Liaison Hospital, Syracuse, NY Daughters Health System, Norfolk, VA Associate Professor of Pediatrics and Emergency Medicine; Director, Ran D. Goldman, MD Emergency Medicine; Fellowship Simulation; Icahn School of Medicine Brittany M. Newberry, PhD, MSN, Steven Choi, MD, FAAP MPH, APRN, ENP-BC, FNP-BC Chief Quality Officer and Associate Professor, Department of Pediatrics, Director, Director of Education, at Mount Sinai, New York, NY University of British Columbia; Pediatric Emergency Medicine, Yale Faculty, Emory University School Dean for Clinical Quality, Yale Adam E. Vella, MD, FAAP Research Director, Pediatric University School of Medicine, New of Nursing, Emergency Nurse Medicine/Yale School of Medicine; Director of Quality Assurance, Practitioner Program, Atlanta, GA; Vice President, Chief Quality Officer, Emergency Medicine, BC Children's Haven, CT Pediatric Emergency Medicine, Hospital, Vancouver, BC, Canada Nurse Practitioner, Fannin Regional Yale New Haven Health System, Robert Luten, MD New York-Presbyterian, Hospital Emergency Department, New Haven, CT Joseph Habboushe, MD, MBA Professor, Pediatrics and Weill Cornell, New York, NY Blue Ridge, GA Assistant Professor of Emergency Emergency Medicine, University of Medicine, NYU/Langone and Florida, Jacksonville, FL Bellevue Medical Centers, New York, NY; CEO, MD Aware LLC Case Presentations diagnosis is broad, most management decisions will be directed by key components of the history You arrive to a busy afternoon shift in the ED. Your first and physical examination, and any red flags. These patient is a 1-year-old boy with rhinorrhea, congestion, findings should prompt consideration of diseases cough, and 3 days of fever up to 39.4°C (103°F), mea- that would be severely detrimental to the child’s sured rectally. His parents state that he has been playful health if missed. at home and continues to eat and drink normally. They Some rashes, such as varicella, measles, and have been giving him acetaminophen and ibuprofen rubella, may represent a public health concern. sporadically, but today he developed a generalized rash, Diseases such as these have become slightly more and they became concerned. His vital signs are as follows: prevalent in the United States, due to caregiver temperature, 38.7°C (101.7°F); heart rate, 135 beats/min; concerns regarding vaccinations. Rates of meningo- and blood pressure, 85/55 mm Hg. On examination, the coccal disease have decreased; however, this disease 2 rash is macular, erythematous, and blanching, but his does have high rates of morbidity and mortality. eyes and mouth appear normal. This issue of Pediatric Emergency Medicine Prac- In the next room, there is a 3-year-old boy with a tice reviews various disease states, from benign to similar history who had mild rhinorrhea and a low-grade life-threatening, that can present as a fever with rash fever of 38.1°C (100.5°F) at home. His parents are con- in a child. Workup, treatment, and disposition rec- cerned that he has been complaining of pain in his legs, ommendations are provided based on key features on which they have noticed dark spots. He has continued of the history and physical examination. to drink well, though he has been eating slightly less. His vitals signs
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