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PED-EM-L  February 2008

PED-EM-L February 2008

Subject:

Re: Tympanic temps

From:

"Chamberlain, Jim" <[log in to unmask]>

Reply-To:

Chamberlain, Jim

Date:

Fri, 15 Feb 2008 04:03:51 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (732 lines)

Allow me to clarify my previous posting (below), lest we have neonates
dying of sepsis or Herpes encephalitis. As a good friend pointed out to
me this evening, I have gone out on the proverbial limb here with saw in
hand.

 

The neonate is a special patient deserving of a very low threshold for
aggressive workup.

 

1. The signs of illness are subtle.

2. The host is immunodeficient.

3. The organisms are virulent.

 

Any neonate with a documented fever (and many without) deserves a full
sepsis workup.

 

I have used the Observation Unit in a handful of cases in which I
doubted the presence of fever because the report of an elevated
temperature did not make sense.

 

Cases I can recall:

The patient who presented to the Surgery Clinic for evaluation of a
non-incarcerated inguinal hernia and had a routine temperature taken. It
was borderline elevated. There were no neonatal risk factors. Exam was
normal and repeat temperatures were normal.

 

The patient who presented to PCP for routine checkup and had a
borderline elevated temperature. Was referred in to ED. There were no
neonatal risk factors. Exam was normal and repeat temperatures were
normal. Parents did not want a sepsis workup. PCP and parents agreed to
repeated assessments in Observation Unit.

 

The mother who felt her baby was warm after a nap. She inserted her
infrared ear thermometer in the baby's rectum (because the display said
"Rectal" [equivalent]) and the temperature was elevated (again
borderline). Temperature and exam were normal in ED and there were no
neonatal risk factors. After Mom and I both stopped laughing, serial
temperatures and exams in Observation Unit were normal.

 

A similar story with an infant pacifier thermometer which simply read
fever (it did not display a temperature). Assessment in ED was normal.
Serial exams and temperatures were normal.

 

The neonate who came to the ED with a lump on the clavicle and was
bundled. The bump was a healing clavicle fracture. Exam was otherwise
normal and there were no neonatal risk factors. The borderline elevated
temperature in triage was repeated serially and was normal.

 

Hope this clarifies.

 

Jim 

 

 

James Chamberlain, MD

 

Division Chief, Emergency Medicine

 

Children's National Medical Center

 

111 Michigan Avenue, NW

 

Washington, DC

 

202.476.3253 (O)

 

202.476.3573 (F)

 

202.476.5433 (Emergency Access)

 

 

-----Original Message-----
From: Chamberlain, Jim 
Sent: Thursday, February 14, 2008 9:06 AM
To: Martin Herman; [log in to unmask]
Subject: RE: Tympanic temps

 

Well, looking at the article about bundling infants (which said a single
isolated "fever" was OK as long as it went away with unbundling), I go
with clinical assessment plus a repeat temperature > 38.

 

To summarize:

 

One elevated temp plus otherwise well-->observe for X hours of repeated
temperatures (X depends on family/PCP situation)

Two elevated temps or some other sign of illness-->sepsis workup

 

I have no evidence for this, only clinical experience...

 

Jim

 

James Chamberlain, MD

Division Chief, Emergency Medicine

Children's National Medical Center

Washington, DC

202.476.3253 Office

202.476.3573 Fax

202.476.5433 Emergency Access

 

 

-----Original Message-----

From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Martin Herman

Sent: Thursday, February 14, 2008 12:30 AM

To: [log in to unmask]

Subject: Re: Tympanic temps

 

Jim,

 I like what I am hearing. Especially admitting to a OBS or Clinical

Decision Unit for observation and serial temps. Just curious at what
point

do you intervene with cultures of urine, blood or CSF? Do you base that

entirely on your clinical assessment? IS there a temperature ( method is
not

the issue now) at which you would routinely culture an infant? Does age
make

a difference. Say 0-29 days versus 30-90 days? 

 

Looking for enlightenment.

 

Marty

 

 

------------------------------------

Pediatric Emergency Specialists, P.C.

Martin Herman, M.D.,FAAP,FACEP

President

[log in to unmask]

PO box 637

Ellendale TN 38029

tel: 901 405 1407

fax: 901 405 1524

mobile: 901 219 9202 

------------------------------------

 

-----Original Message-----

From: Pediatric Emergency Medicine Discussion List

[mailto:[log in to unmask]] On Behalf Of Chamberlain, Jim

Sent: Wednesday, February 13, 2008 10:58 AM

To: [log in to unmask]

Subject: Re: Tympanic temps

 

I admit them to our Observation Unit for serial temperatures (q 2 h), no

testing unless they get sicker...

 

Jim

 

James Chamberlain, MD

Division Chief, Emergency Medicine

Children's National Medical Center

Washington, DC

202.476.3253 Office

202.476.3573 Fax

202.476.5433 Emergency Access

 

 

-----Original Message-----

From: Pediatric Emergency Medicine Discussion List

[mailto:[log in to unmask]] On Behalf Of Foltin, George

Sent: Wednesday, February 13, 2008 7:56 AM

To: [log in to unmask]

Subject: Re: Tympanic temps

 

So now we come to the well appearing two week old with a 100.5 or 100.4

temp. So precise but so inaccurate.

 

 

George L. Foltin, MD, FAAP, FACEP

Director, Center for Pediatric Emergency Medicine

Bellevue Hospital and NYU Medical Centers

 

Associate Professor of Pediatrics and Emergency Medicine

New York University School of Medicine

 

(O) 212 562-3161

(F) 212 562 -7752

(Cell) 917 842-5428

[log in to unmask]

 

----- Original Message -----

From: Pediatric Emergency Medicine Discussion List

<[log in to unmask]>

To: [log in to unmask] <[log in to unmask]>

Sent: Wed Feb 13 00:31:30 2008

Subject: Re: Tympanic temps

 

We published norms on infrared ear temperatures in Annals of Emergency

Medicine circa 1995. I would use those.

 

The rectal site was chosen arbitrarily in the late 1800s. The thought at

the time was that it was a core body temperature. We now know that blood

supply is poor to the colon and stool has an insulating effect, thus

damping any changes.

 

For any who believe rectal temperature is accurate, there was a paper

out of Israel in mid 1990s that showed that rectal temperature varied by

up to 1 deg C, depending on depth of insertion.

 

As far as a valid test to detect illness, temperature doesn't come close

to anything we would normally accept for test performance. Sensitivity

and specificity are both poor.

 

So, why torture a kid and touch stool when the test is inaccurate

anyway?

 

Jim Chamberlain

Washington, DC

 

-----Original Message-----

From: Pediatric Emergency Medicine Discussion List on behalf of Peter

Auerbach

Sent: Tue 2/12/2008 9:06 PM

To: [log in to unmask]

Subject: Re: Tympanic temps

 

Thanks for making this point,

with which I agree completely.

It's not that a rectal temp is as "accurate" as a "core body temperture"

(as if that matters anyway),

it's that a rectal temperature is what has been used the most by the

medical community to come up with arbitrary fever standards to help

guide decision-making.

If we all decide to use some other type of temperature measurement in

very young infants, fine, but what are the chances that everyone's going

to agree on that?!

 

 

 

> Date: Tue, 12 Feb 2008 19:34:52 -0600

> From: [log in to unmask]

> Subject: Re: Tympanic temps

> To: [log in to unmask]

> 

> Isn't the rectal temp the "gold standard"?  I mean isn't it the next

best to

> core temperature that we can access? I realize that core temp is the

body

> temp when measured via an indwelling probe and that the next best

surrogate

> is  an esophageal probe but really isn't the rectal temp what the

entire

> medical community has used for decades to decide who is sick and who

isn't? 

> 

> 

> Marty

> 

> 

> ------------------------------------

> Pediatric Emergency Specialists, P.C.

> Martin Herman, M.D.,FAAP,FACEP

> President

> [log in to unmask]

> PO box 637

> Ellendale TN 38029

> tel: 901 405 1407

> fax: 901 405 1524

> mobile: 901 219 9202 

> ------------------------------------

> -----Original Message-----

> From: Pediatric Emergency Medicine Discussion List

> [mailto:[log in to unmask]] On Behalf Of Chamberlain, Jim

> Sent: Tuesday, February 12, 2008 4:19 PM

> To: [log in to unmask]

> Subject: Re: Tympanic temps

> 

> Rectal temperature is inaccurate compared to core body temperature.

When

> temperature is changing (as in febrile conditions), rectal lags behind

> other sites (esophageal, oral, tympanic, and infrared ear thermometer)

> by 20-30 minutes.

> 

> Rectal temperature is also non-hygienic.

> 

> James Chamberlain, MD

> Division Chief, Emergency Medicine

> Children's National Medical Center

> Washington, DC

> 202.476.3253 Office

> 202.476.3573 Fax

> 202.476.5433 Emergency Access

>  

> 

> -----Original Message-----

> From: Pediatric Emergency Medicine Discussion List

> [mailto:[log in to unmask]] On Behalf Of Julia Whitefield

> Sent: Tuesday, February 12, 2008 1:37 AM

> To: [log in to unmask]

> Subject: Tympanic temps

> 

> Dear all, I am finally breaking down... while in favor of rectal temps

> in < 36 months old... I don't feel like having to re-invent the wheel:

> who of you do tympanic temps in your ED - do you have good literature

> support? - and how many of you are in support of rectal temps? I

thought

> we had cleared that issue for once and for all - but I guess not!

Would

> you please give me your input?

> Thank you so

> Julia S. Whitefield MD, Ph.D.

> UNM

> ABQ, NM

> For more information, send mail to [log in to unmask] with

the

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