injury or rupture of the globe, the involved eye should be protected from further damage by covering the eye with a hard shield after a brief physical examination, and arranging emergent ophthalmologic evaluation The head of the bed should be elevated 30 degrees Administration of intravenous antiemetics (e.g., ondansetron), antibiotics, pain control, and sedation should be considered Instillation of topical medications such as fluorescein should be avoided If the globe is intact and no penetration by a foreign body occurred, an ophthalmoscopic or slit lamp examination usually leads to the correct diagnosis These conditions include chemical burns of the cornea, hyphema, dislocation of the lens, vitreous hemorrhage, detachment or tear of the retina, and commotio retinae Severe Visual Loss Not Associated With Trauma With severe bilateral visual loss not associated with trauma, the possibility of toxins must be explored Also, cortical blindness may cause a similar picture, but this is rare and generally associated with another problem, such as hypoglycemia, leukemia, and cerebrovascular or anesthetic accidents If severe visual loss is unilateral and painful, endophthalmitis must be suspected, but such loss is usually the result of a previous penetrating injury or an extension of a local infectious process If a headache is associated with the visual loss, migraine may be implicated If the severe loss is unilateral and painless, retinal artery or vein occlusion, or retinal detachment, may be diagnosed by ophthalmoscopic examination Optic neuritis will also present similarly Mild Visual Loss With Trauma If the visual loss is unilateral, not severe, and if trauma recently occurred, corneal abrasions, traumatic cataracts, and small hyphemas should be sought A blowout fracture may cause diplopia, but if each eye is examined individually, the visual acuity should be normal If the process is bilateral, exposure to ultraviolet or infrared light should be considered Mild Visual Loss Without Trauma When the visual loss is mild and nontraumatic, and if the process is unilateral and painful, conjunctivitis, uveitis, and acute attacks of glaucoma are possible If the process is painless, retinal vein or artery branch occlusion may be suspected Any of these processes may also be bilateral Suggested Readings and Key References Albert DM, Miller JW Albert and Jakobiec’s Principles and Practice of Ophthalmology 3rd ed Philadelphia, PA: Saunders Elsevier; 2008 Beauchamp GR Causes of visual impairment in children Pediatr Ann 1980;9(11):414–418 Biousse V, Nahav F, Newman NJ Management of acute retinal ischemia: follow the guidelines! Ophthalmology 2018;125(10):1597–1607 Chabas D, Strober J, Waubant E Pediatric multiple sclerosis Curr Neurol Neurosci Rep 2008;8(5):434–441 Chen TH, Lin WC, Tseng YH, et al Posterior reversible encephalopathy syndrome in children: case series and systematic review J Child Neurol 2013;28(11):1378–1386 Chew E, Morin JD Glaucoma in children Pediatr Clin North Am 1983;30(6):1043–1060 Cleves-Bayon C Idiopathic intracranial hypertension in children and adolescents: an update Headache 2018;58(3):485–493 Cologno D, Torelli P, Manzoni GC Transient visual disturbances during migraine without aura attacks Headache 2002;42(9):930–933 Ellis MJ, Cordingley DM, Vis S, et al Clinical predictors of vestibule-ocular dysfunction in pediatric sports-related concussion J Neurosurg Pediatr 2017;19(1):38–45 Ganesh A, Al-Zuhaibi S, Pathare A, et al Orbital infarction in sickle cell disease Am J Ophthalmol 2008;146(4):595–601 Harrison DW, Walls RM Blindness following minor head trauma in children: a report of two cases with a review of the literature J Emerg Med 1990;8(1):21– 24 Keil S, Fielder A, Sargent J Management of children and young people with vision impairment: diagnosis, developmental challenges, and outcomes Arch Dis Child 2017;102(6):566–571 King MA, Barkovich AJ, Halbach VA, et al Traumatic monocular blindness and associated carotid injuries Pediatrics 1989;84(1):128–132 Kump LI, Cervantes-Castaneda RA, Androudi SN, et al Analysis of pediatric uveitis cases at a tertiary referral center Ophthalmology 2005;112(7):1287– 1292 Kwartz J, Leatherbarrow B, Davis H Diplopia following head injury Injury 1990;21(6):351–352 Levin AV Retinal hemorrhage in abusive head trauma Pediatrics 2010;126(5):961–970 Lim SA, Siatkowski RM, Farris BK Functional visual loss in adults and children patient characteristics, management, and outcomes Ophthalmology 2005;112(10):1821–1828 Lotze TE, Northrop JL, Hutton GJ, et al Spectrum of pediatric neuromyelitis optica Pediatrics 2008;122(5):e1039–e1047 Mackay MT, Chua ZK, Lee M, et al Stroke and nonstroke brain attacks in children Neurology 2014;82(16):1434–1440 Merrill K Don’t miss this! red flags in the pediatric eye examination: subnormal acuity J Binocul Vis Ocul Motil 2019;69(3):90–92 Raj S, Overby P, Erdfarb A, et al Posterior reversible encephalopathy syndrome: incidence and associated factors in a pediatric critical care population Pediatr Neurol 2013; 49(5):335–339 Recchia FM, Saluja RK, Hammel K, et al Outpatient management of traumatic microhyphema Ophthalmology 2002;109(8):1465–1470; discussion 1470– 1471 Salvin JH Systematic approach to pediatric ocular trauma Curr Opin Ophthalmol 2007;18(5):366–372 Schneider K, Nguyen-Tran H, Segura BJ, et al Ocular injury presenting to a level-III pediatric trauma center Pediatr Emerg Care 2018 [published online ahead of print, June 14, 2018] doi: 10.1097/PEC.0000000000001524 Spector J, Fernandez WG Chemical, thermal, and biological ocular exposures Emerg Med Clin North Am 2008;26(1):125–136 Spirn MJ, Lynn MJ, Hubbard GB 3rd Vitreous hemorrhage in children Ophthalmology 2006;113(5):848–852 Wagner RS, Aquino M Pediatric ocular inflammation Immunol Allergy Clin North Am 2008;28(1):169–188 Williams JR Optic neuritis in a child Pediatr Emerg Care 1996;12(3):210–212 Wong VC Cortical blindness in children: a study of etiology and prognosis Pediatr Neurol 1991;7(3):178–185 Woodward GA Posttraumatic cortical blindness: are we missing the diagnosis in children? Pediatr Emerg Care 1990;6(4):289–292 CHAPTER 31 ■ FEVER TODD A FLORIN, KERI A COHN, ELIZABETH R ALPERN INTRODUCTION Fever, the abnormal elevation of body temperature, has been recognized for centuries by physicians as a sign of disease Fever in a child is one of the most commonly encountered chief complaints in clinical pediatrics, accounting for as many as 20% of pediatric emergency department (ED) visits The problem of appropriate clinical and laboratory evaluation of febrile children, however, remains a major challenge The approach outlined in this chapter helps the physician evaluate and treat a febrile child in the ED, proceeding systematically with the appropriate diagnostic steps and management The principal causes of fever in children include infectious and noninfectious etiologies ( Tables 31.1 and 31.2 ) PATHOPHYSIOLOGY Fever is a complex process, involving the highly coordinated interplay of autonomic, neuroendocrine, and behavioral responses to a variety of infectious and noninfectious inflammatory challenges Fever is believed to be an adaptive response that is ubiquitous in animals Exogenous pyrogens (e.g., toxins, infectious agents, etc.) from many sources produce fever by inducing the production of endogenous pyrogens (e.g., interleukin-B1, interleukin-6, etc.) These pyrogens interact with specialized receptor neurons of the hypothalamus This leads to the production of prostaglandins as the critical mediators of the febrile response, resetting the hypothalamic thermostat to elevate body temperature There is some evidence that increased body temperature impairs replication of microbes and may aid phagocytic bactericidal activity Additionally, the febrile response includes adaptive neuroendocrine and metabolic effects that further enhance the host’s response to microbial invasion Rarely, fever results from central nervous system (CNS) dysfunction (e.g., hypothalamic tumor, infarction) that alters the thermostatic set point directly, rather than via pyrogen induction Finally, sometimes hyperpyrexia is not due to altered hypothalamic regulation, but rather to increased heat production (e.g., stimulant drug overdose; see Chapter 102 Toxicologic Emergencies ) or exposure to excess environmental heat (heat stroke; see Chapter 90 Environmental Emergencies, Radiological Emergencies, Bites and Stings ) ... is one of the most commonly encountered chief complaints in clinical pediatrics, accounting for as many as 20% of pediatric emergency department (ED) visits The problem of appropriate clinical... monocular blindness and associated carotid injuries Pediatrics 1989;84(1):128–132 Kump LI, Cervantes-Castaneda RA, Androudi SN, et al Analysis of pediatric uveitis cases at a tertiary referral center... Ophthalmology 2005;112(10):1821–1828 Lotze TE, Northrop JL, Hutton GJ, et al Spectrum of pediatric neuromyelitis optica Pediatrics 2008;122(5):e1039–e1047 Mackay MT, Chua ZK, Lee M, et al Stroke and nonstroke