Contraindications to acetaminophen
- Allergy or hypersensitivity
- Hepatic impairment
- Severe hypovolemia
- PKU or other liver disease
- Chronic malnutrition
Diarrhea?
Discharge criteria
- Reassuring vital signs
- Laboratory findings reassuring
- Tolerating PO
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Parents comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
Consider pediatric or neonatal consult
Contraindications to acetaminophen?
Follow up within 24 hours
Toxic appearing?
UTI?
Respiratory symptoms?
- Fever > 38.0 C (100.4 F) x1 at home, OSH or in ED
- Hypothermia < 36.0 (96.8 F) x1 at home, OSH or in ED
- Immunosuppressed, cancer
- Central venous catheter
- Ventriculoperitoneal shuts
UTI?
Focal skin bacterial infection (ex. cellulits)?
Meets discharge criteria?
Start abx immediatly if ill-appearing, otherwise after CSF Cx is obtained
Respiratory Symptoms
- Respiratory rate > 50
- Rales, rhonchi, wheezing, stridor
- Retractions
- Cough, coryza
- Grunting
- Nasal flaring
If LP attempted and unsuccessful
- Send any CSF obtained for Cx
- Repeat LP within 24 hours if possible
- Admit
- No antibiotics unless ill-appearing
If caregivers refuse LP
- Diagnostic tests almost never are obtained by court order
- Admit
- No antibiotics unless ill-appearing
If patient is well appearing after a period of observation it may be reasonable to give IV or IM ceftriaxone and consider discharge.
Clinically well-appearing features
- Reassuring vital signs
- Tolerating PO with no signs of dehydration
- Normal tone
- Interactive with
- Fussiness consolable by caregivers
If testing for RSV or Influenza is positive
- May defer LP, but serum and urine tests should still be obtained as UTI and bateremia are still prevalent
Stool Cx/Gastroenteritis PCR, contact isolation
Meets ALL low risk criteria?
- Fever less than 41 C (106 F)
- Clinically well appearing with normal vitals
- Previously healthy
- Full term (>37 wks)
- No bacterial skin infection (cellulitis, etc.)
- Serum WBC > 5k and < 15k mm3
- Absolute bands < 1.5k mm3
- Procalcitonin < 0.3 ng/mL
- Normal CXR (if done)
- No previous antibiotic use
CSF WBC >10/mm3?
- Admit to ICU
- Respiratory and contact isolation
If patient on prophylactic antibiotics
- Full septic workup including LP
- If labs neg, consider admission and observation for 24 hours
