Fevers and Seizures Flashcards
Fever occurs due to ?
- the hypothalamus creating a new “set point” of body temperature
- occurs due to presence of pyrogenic cytokines released by infectious pathogens
when would the fever not be directly proportional to severity of illness?
- children - febrile response > adults
- geriatrics, neonates and pts taking NSAIDS for other conditions may have a normal to below normal temperature
Average normal oral body temperature ?
36.7°C (98.0° F)
what type of temperatures generally more accurate than peripheral
Core - bladder, esophageal, pulmonary arterial catheter, rectal
what/who can alter accurate temp.
Recent food and drink ingestion can also alter accuracy.
hyperventilation or patients whose mouth is not closed
differences on how you take a temp?
- Rectal and tympanic temps are 0.5°C (0.9° F) higher - (Take a ° Off the Orifices)
- Axillary and forehead temps are 0.5°C (0.9° F) lower
DDX for fever in adults
- Localized bacterial or viral infection (look for source on H&P)
- Sepsis
- Hyperthermia
- Serotonin Syndrome
- neurolpetic malignant syndrome
- fever of unknown origin
would hyperthermia respond to antipyretics?
no
causes for hyperthermia
- environmental exposure
- metabolic heat production due to dysfunction in thermoregulation
- thyroid storm, medication induced
a reaction to drugs that increase serotonin (e.g. SSRI/SNRI, MAOI’s, TCAs)
serotonin syndrome
- a lethal reaction to neuroleptic medications (e.g. haloperidol and fluphenazine)
- muscular rigidity, altered mental status, and autonomic dysfunction
Neuroleptic malignant syndrome
what characteristics are indicativ of Fever of unknown origin?
fever over >38.3°C (100.9° F) on multiple occasions >3 wks w/o a dx being made
causes of fever or unknown origin
Etiologies: autoimmune disorders, vasculitis (giant cell arteritis), SLE, infectious (TB), malignancy (leukemia, lymphoma), Thyroid Storm, Lyme Disease
usually more autoimmune/chronic
important hx info for adult fevers
- age
- ill contact exposure
- events surrounding onset of fever
- Travel
- injection drug use
- vaccination history - Meningitis, Measles, Hepatitis B, , Cutaneous Abscess, Cellulitis, etc)
- localizing sx
- constitutional sx: wt loss, night sweats ect. (Cancers, TB)
- medications (Penicillins, Cephalosporins, Carbapenems, Allopurinol, etc…)
Fever in an adult with h/o ill contact exposure is MC caused by?
viral
ddx for fever in an adult with h/o travel
Dengue Fever, Malaria, TB, Typhoid
ddx for fever in adult with any h/o IVDU?
Endocarditis, Spinal Epidural Abscess, Osteomyelitis, Cutaneous Abscess, Cellulitis
what additional PE features along with fever indicate hemodynamic instability?
low BP, tachycardia, hypoxia
- extremities are often cool (vasoconstriction) and skin may be clammy
- Flushed face
- Hot, Dry skin
localizing signs of infection can be seen in where during a PE?
Skin, ENT, pulmonary, heart, abdomen, GU, neuro/meningeal, joints
what 2 conditions are often the culprit with systemic infection
Pneumonia and UTI
get UA for UTI ASAP
If suspicion for PNA but pt has a normal CXR, what other imaging modality can you choose?
CT!
Progression/severity of fever in adults
SIRS - sepsis - severe sepsis - septic shock
criteria for SIRS
- HR >90
- Rsp >20
- Temp < 96.8 or >100.4
Criteria for sepsis
SIRS + source of infection
criteria for severe sepsis?
sepsis + organ dysfunction
criteria for septic shock?
- persistent HoTN after bolus
- Lactate >4.0
Basic management for fever
Reduce body temperature
- General - cold/alcohol compresses, ice bags, ice-water enema, ice baths
- Antipyretics - administer around the clock instead of intermittently to avoid period chills/sweats
types of antipyretics
- Acetaminophen
- Ibuprofen 400-600 mg q6h (Toradol IV/IM)
avoid ibuprofen in who?
- GI upset / h/o gastric ulcers
- children < 6 mo
Avoid ASA in who?
pediatrics < 18yo!! - Reye’s Syndrome Risk
alt us of antipyretic
alternate between acetaminophen and ibuprofen q3h early in course of fever if temperature remains uncontrolled - not generally necessary
Empiric antimicrobials are avoided unless patient is
adult
- neutropenic or expected to become neutropenic in next few days
- hemodynamically unstable
- asplenic - surgical or secondary to sickle cell disease
-
immunosuppression - HIV, medications
- systemic corticosteroids, azathioprine, cyclosporine, chemotherapy, DMARDs, Immunosuppressive agents (end in -mab)
indications to admit a fever
- Concomitant VS abnormalities
- Evidence of end-organ damage when sepsis is suspected or confirmed
- > 41°C (105.8° F)
- Associated seizure or other mental status change
- Underlying condition requires admission
Follow up within 24-72 hours if discharged
Pediatric fever lacks of a mature immune system and development leads to ?
vague sx at presentation and a greater risk of serious infection
Peds pts are categorized for management based on age:
- 0 to 28 days of age (aka neonate)
- 1 to 3 months of age
- 3 to 36 months of age
temp threshold for ped fever
rectal
- 38°C (100.4° F) in < 3 mo of age
- 39° C (102.2) in 3-36 mo of age
DDx for Fevers in Infants ≤ 3 months of age
- Sepsis
- meningitis
- encephalitis
- osteomyelitis
- septic arthritis
- pneumonia
- UTI/cystitis
- syphilis
- skin/soft tissue infection
- gastroenteritis
- URI
MCC of fever in infants
viral
- Influenza A & B, Covid, respiratory syncytial virus (RSV)
- HSV, Chickenpox (Varicella), Enterovirus, adenovirus, cytomegalovirus (CMV), rubella
common pathogens to cause fever in Infants ≤ 3 months of age
- Viral (MC)
- bacterial - group B Streptococcus, Listeria, Escherichia coli, S. pneumoniae, Treponema pallidum
Hx of pediatric fever in Infants ≤ 3 months of age
- Birth history
- length of gestation, maternal infections, use of peripartum antibiotics in mother/neonate, hospital course/neonatal complications - Immunization status
- Ill contact exposure
- Fever: maximum temp, method obtained, timing, antipyretic use
- sx are often nonspecific of a serious illness - crying/irritability, poor feeding
PE of fever in Infants ≤ 3 months of age
- Undress infant completely for entire exam
- Assess VS
- Perform full PE - assess for general signs of sepsis
- grunting, rsp distress, lethargy, irritability, fever or hypothermia, hypo- or hyperglycemia, apnea/cyanotic spells, poor feeding, petechiae, and unexplained jaundice
Normal VS for neonate
- HR 120-160 bpm
- RR 30-60 breaths/min
Keys to the clinical presentation of fever in Infants ≤ 3 months of age
- Cough, tachypnea or hypoxia = lower rsp tract infection
- Inconsolable crying during handling and a bulging fontanelle = meningitis
- V/D can indicate many problems: gastroenteritis, OM, UTI, meningitis
T/F: Even if a local source of infection is suspected EMB recommends testing for an occult infectious etiology
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