Fevers and Seizures Flashcards
(111 cards)
1
Q
Fever occurs due to ?
A
- the hypothalamus creating a new “set point” of body temperature
- occurs due to presence of pyrogenic cytokines released by infectious pathogens
2
Q
when would the fever not be directly proportional to severity of illness?
A
- children - febrile response > adults
- geriatrics, neonates and pts taking NSAIDS for other conditions may have a normal to below normal temperature
3
Q
Average normal oral body temperature ?
A
36.7°C (98.0° F)
4
Q
what type of temperatures generally more accurate than peripheral
A
Core - bladder, esophageal, pulmonary arterial catheter, rectal
5
Q
what/who can alter accurate temp.
Recent food and drink ingestion can also alter accuracy.
A
hyperventilation or patients whose mouth is not closed
6
Q
differences on how you take a temp?
A
- 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
7
Q
DDX for fever in adults
A
- Localized bacterial or viral infection (look for source on H&P)
- Sepsis
- Hyperthermia
- Serotonin Syndrome
- neurolpetic malignant syndrome
- fever of unknown origin
8
Q
would hyperthermia respond to antipyretics?
A
no
9
Q
causes for hyperthermia
A
- environmental exposure
- metabolic heat production due to dysfunction in thermoregulation
- thyroid storm, medication induced
10
Q
a reaction to drugs that increase serotonin (e.g. SSRI/SNRI, MAOI’s, TCAs)
A
serotonin syndrome
11
Q
- a lethal reaction to neuroleptic medications (e.g. haloperidol and fluphenazine)
- muscular rigidity, altered mental status, and autonomic dysfunction
A
Neuroleptic malignant syndrome
12
Q
what characteristics are indicativ of Fever of unknown origin?
A
fever over >38.3°C (100.9° F) on multiple occasions >3 wks w/o a dx being made
13
Q
causes of fever or unknown origin
A
Etiologies: autoimmune disorders, vasculitis (giant cell arteritis), SLE, infectious (TB), malignancy (leukemia, lymphoma), Thyroid Storm, Lyme Disease
usually more autoimmune/chronic
14
Q
important hx info for adult fevers
A
- 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…)
15
Q
Fever in an adult with h/o ill contact exposure is MC caused by?
A
viral
16
Q
ddx for fever in an adult with h/o travel
A
Dengue Fever, Malaria, TB, Typhoid
17
Q
ddx for fever in adult with any h/o IVDU?
A
Endocarditis, Spinal Epidural Abscess, Osteomyelitis, Cutaneous Abscess, Cellulitis
18
Q
what additional PE features along with fever indicate hemodynamic instability?
A
low BP, tachycardia, hypoxia
- extremities are often cool (vasoconstriction) and skin may be clammy
- Flushed face
- Hot, Dry skin
19
Q
localizing signs of infection can be seen in where during a PE?
A
Skin, ENT, pulmonary, heart, abdomen, GU, neuro/meningeal, joints
20
Q
what 2 conditions are often the culprit with systemic infection
A
Pneumonia and UTI
get UA for UTI ASAP
21
Q
If suspicion for PNA but pt has a normal CXR, what other imaging modality can you choose?
A
CT!
22
Q
Progression/severity of fever in adults
A
SIRS - sepsis - severe sepsis - septic shock
23
Q
criteria for SIRS
A
- HR >90
- Rsp >20
- Temp < 96.8 or >100.4
24
Q
Criteria for sepsis
A
SIRS + source of infection
25
criteria for severe sepsis?
sepsis + organ dysfunction
26
criteria for septic shock?
* persistent HoTN after bolus
* Lactate >4.0
27
Basic management for fever
Reduce body temperature
1. General - cold/alcohol compresses, ice bags, ice-water enema, ice baths
1. Antipyretics - administer around the clock instead of intermittently to avoid period chills/sweats
28
types of antipyretics
1. Acetaminophen
2. Ibuprofen 400-600 mg q6h (Toradol IV/IM)
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avoid ibuprofen in who?
1. GI upset / h/o gastric ulcers
1. children < 6 mo
30
Avoid ASA in who?
pediatrics < 18yo!! - Reye’s Syndrome Risk
31
alt us of antipyretic
alternate between acetaminophen and ibuprofen q3h early in course of fever if temperature remains uncontrolled - not generally necessary
32
Empiric antimicrobials are avoided unless patient is
| adult
1. **neutropenic** or expected to become neutropenic in next few days
1. **hemodynamically unstable**
1. **asplenic** - surgical or secondary to sickle cell disease
1. **immunosuppression** - HIV, medications
- systemic corticosteroids, azathioprine, cyclosporine, chemotherapy, DMARDs, Immunosuppressive agents (end in -mab)
33
indications to admit a fever
1. Concomitant **VS abnormalities**
1. Evidence of **end-organ damage** when sepsis is suspected or confirmed
1. > 41°C (**105.8° F**)
1. Associated **seizure** or other **mental status change**
1. **Underlying condition** requires admission
Follow up within 24-72 hours if discharged
34
Pediatric fever _lacks of a mature immune system_ and development leads to ?
**vague sx** at presentation and a **greater risk of serious infection**
35
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
36
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
37
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
38
MCC of fever in infants
viral
* Influenza A & B, Covid, respiratory syncytial virus (RSV)
* HSV, Chickenpox (Varicella), Enterovirus, adenovirus, cytomegalovirus (CMV), rubella
39
common pathogens to cause fever in Infants ≤ 3 months of age
* Viral (MC)
* bacterial - group B Streptococcus, Listeria, Escherichia coli, S. pneumoniae, Treponema pallidum
40
Hx of pediatric fever in Infants ≤ 3 months of age
1. Birth history
- length of gestation, maternal infections, use of peripartum antibiotics in mother/neonate, hospital course/neonatal complications
1. Immunization status
1. Ill contact exposure
1. Fever: maximum temp, method obtained, timing, antipyretic use
1. sx are often **nonspecific** of a serious illness - crying/irritability, poor feeding
41
PE of fever in Infants ≤ 3 months of age
1. Undress infant completely for entire exam
1. Assess VS
1. 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
42
Normal VS for neonate
* HR 120-160 bpm
* RR 30-60 breaths/min
43
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_
44
T/F: Even if a local source of infection is suspected EMB recommends testing for an occult infectious etiology
T
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diagnostics for fever in Infants ≤ 3 mo of age
1. CBC w/ diff
1. UA with C&S via _catheter/suprapubic_ specimen
1. LP - Gram stain and CX, glucose, protein, cell count w/ diff.
1. **CXR** if _tachypnea, cough or hypoxemia_
1. **Stool sample** if _diarrhea_
1. Serum biomarkers: CRP and procalcitonin
46
criteria for neonates/Infants ≤ 3 months of age to be “low risk” for serious bacterial infections
1. _Well-appearing_ w/o a history of prematurity or perinatal complications
1. No immunizations w/n 48 hr and no recent abx
1. WBC 5,000 - 15,000/mm³ - Bands ≤ 1,500/mm³
1. Nml UA - ≤WBC 10/hpf
1. CSF with < 5 WBCs/hpf
1. Stool with < 5 WBCs/hpf if diarrhea
1. nml CXR - no evidence of acute cardiopulmonary disease
47
factors that consider an infant high/intermediate risk when prsenting with fever
| from picture
1. age < 22 d old (or 28 d for improved sensitivity)
2. leukocytes in urine
3. procalcitonin > 0.5ng/mL
4. CRP >20 mg/L or ANC >1000 - *intermediate risk*
48
management for fever in Infants ≤ 3 months of age (inpatient)
1. _≤ 28 d_ - **admit** for parenteral abx
2. _1-3 mo_ - **admit** for parenteral abx if _FAILED to meet “low risk” criteria_
3. **ampicillin PLUS cefotaxime**: both 50 mg/kg q8
49
Infants 1-3 months who meet “low-risk” management options:
1. **Outpatient w/ or w/o abx** and a required **f/u in 24 hours**
- take into consideration reliability of guardians, phone access, transport, ability to maintain hydration etc...
- discuss discharge with pediatrician to ensure f/u can be made
2. **Inpatient w/ or w/o abx**
Overall decision is based on the provider’s comfort level
50
management for Infants 1-3 months with identifiable viral illness
* UA (with C&S if positive findings)
* Blood CX
51
DDX of infectious and noninfectious fever in infants 3-36 mo
* Infectious: URI, pharyngitis, OM, pneumonia, bronchiolitis, croup, varicella, roseola, gastroenteritis, meningitis, bacteremia/sepsis, septic arthritis, skin/soft tissue infections
* NonInfectious: drug fever, immunization reaction, CNS dysfunction, malignancy, chronic inflammatory conditions
52
hx in infants 3-36 mo with fever
1. Fever: maximum temp, method obtained, timing, antipyretic use
1. Past medical history - including birth history
1. Ill contacts
1. Immunization status
- routine vaccination of Hib and S.pneumoniae in infants has reduced the risk of occult bacteremia from 5% to 1%
53
associated sx of fever in infant 3-36 mo
* Viral URI/LRI - rhinorrhea, cough, tachypnea, hypoxia
* OM - fussy, pulling on ear/otalgia
* UTI -fever may be only symptom, foul smelling urine, crying during urination
* Gastroenteritis - poor intake, vomiting, diarrhea
* Cellulitis/Abscess - skin erythema, warmth, +/- exudate
* Septic arthritis - not using extremity, erythema, swelling, warmth of joint
* Meningitis - inconsolable crying, bulging fontanelle, vomiting, irritability that worsens when handled, seizure (meningeal signs may be absent) - N. meningitidis - petechiae, hypotension, lethargy
* Sepsis - fussy, poor intake, lethargic, mental status change
54
PE of fever in infants 3-36 mo of age
1. General assessment will identify toxicity
2. Full PE with close attn to the skin, TM‘s, oropharynx, lungs, abdominal and genitourinary systems
55
difference between non-toxic infants vs toxic infants
* non-toxic patients - alert and make eye contact, be playful and console easily, have positive response to interactions, negative (bad) response to noxious stimuli
* Toxic patients may also present with: lethargy, poor perfusion, hypo- or hyperventilation, and/or acrocyanosis
56
w/u for Fever w/o a source in ill-appearing in Infants 3-36 months of age
- CBC, blood CX
- UA with C&S
- CSF if s/s of meningitis
- CXR if tachypnea or WBC≥ 20,000/µL
- Parenteral antibiotics given within 1 hour of arrival
- Consult pediatrician and admit
57
management for fever in Infants 3-36 months of age - Well appearing and immunizations UTD
1. Catheterized urine collection: UA only in girls < 24 m, uncircumcised boys < 12 m, circumcised boys < 6 m
1. urine collection bag for young boys outside of window ( 4% chance of UTI)
- Negative - d/c home with antipyretics
- Positive - single dose of parenteral antibiotics with f/u in 12-24 hrs
58
management & tx for fever in Infants 3-36 months of age - Well appearing and immunizations are not UTD (or doesn’t have 3 Hib and Pneumococcal vaccines)
1. CBC with diff
1. UA with C&S (same population as well appearing with immunization UTD)
1. Blood CX if WBC > 15,000/µL
1. CXR if WBC ≥20,000/µL
1. Treatment
- _If all negative_ - **f/u in 12-24 hours**
- _WBC > 15,000/µL_ - **ceftriaxone IM** (alt. clindamycin), f/u in 24 h
- _UA or CXR (+)_ - **tx accordingly**
59
who to admit if fever in infants 3-36 mo of age
* ill appearing (toxic)
* unable to maintain fluids
* those who are unlikely to f/u or return to ED
60
Infants 3-36 months of age - If source of infection is identified abx choice will be based upon ?
type of infection
MC organisms
local resistance
61
Infants 3-36 months of age - If no source of infection is found, what is recommended
empiric abx: ceftriaxone / pip/taz PLUS vancomycin
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Pediatric Fever - General management of all ages
Antipyretics should be administered early to improve comfort level.
- Acetaminophen is 1st-line, esp < 6 mo old
- Ibuprofen if > 6 mo
- Remove excess clothing and blankets
*Response to antipyretic doesn’t affect disposition*
63
If pt is DC home and blood CX later reveal bacteremia, what are the next steps?
repeat evaluation
* _well-appearing and afebrile_ = **outpatient 10-day course of abx** based on culture sensitivity is recommended
* _ill-appearing or remains febrile_ = **admit with parenteral abx** based on culture sensitivity and repeat work-up considered
64
Neutropenic fever is defined as:
1. Temp ≥ 38°C (100.4° F) x 1 hr or a single temp ≥ 38.3°C (101° F)
1. Neutropenia - ANC < 1000 cells/mm³ (Absolute Neutrophil Count)
- Severe Neutropenia - ANC < 500 cells/mm³
65
presentation/hx of neutropenic fever
1. fever - earliest and MC only sign of infection
1. h/o recent chemotherapy tx
1. Hx should focus on searching for site of infection
- severity of sx may not be proportional to the severity of infection
66
chemotherapy affects ___ and the ___ allowing bacterial colonization and transposition across mucosa
myelopoiesis
integrity of GI mucosa
67
neutrophil counts usually are lowest when and increase when?
* 10-15 days after chemotherapy
* 5 days after reaching nadir (the lowest point)
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presentation/PE of neutropenic fever
should focus on locating sight of infection - signs are often minimal compared to severity of infection
1. oral cavity, oropharynx
1. lungs
1. heart
1. abdomen
1. skin
- IV and catheters sites
- perianal area - abscess, infected fissure - _avoid DRE until after abx are initiated_
2. neuro - meningeal signs
69
diagnostics for neutropenic fever
1. CBC w/ diff
1. 2 blood CX - _2 different sites_: one from peripheral vein, the other from central catheter (if present)
1. UA with C&S
1. CMP - attn to electrolytes, renal and liver function
1. CXR
1. Bodily fluid assessment/culture if indicated
- sputum (productive cough), stool (diarrhea), wound drainage (if present), LP with CSF analysis if sx dictate (HA, AMS, stiff neck)
2. CT/US of abd w/ contrast - if abdominal pain/tenderness
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tx for neutropenic fever
* Empiric abx ASAP after blood cx are obtained (within **1 hour of arrival**)
* **Vancomycin + Cefepime** if no source of infection identified
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neutropenic fever - High risk patients require admission (3)
1. profound neutropenia expected to last > 7 days
1. comorbid medical conditions
1. acute liver/renal injury
72
What is the MASC
Multinational Association for Supportive Care in Cancer Risk Index
* used by oncology
* Score of **0-20 requires admission**
* Score >20 has < 5% risk for severe complication and < 1% chance of mortality
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seizures that has no cause can be identified
Primary (idiopathic) seizures
74
seizure with identifiable neurologic condition
Secondary (symptomatic) seizures
mass lesion, previous head injury, stroke
75
a seizure that occurs within 7 days of an insult
Provoked seizure
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seizure with no acute precipitating factor can be identified
Unprovoked seizure
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seizure activity for ≥ 5 min or two or more seizures without regaining consciousness between the seizures - multiple seizures back to back without recovery
Status epilepticus
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persistent seizure activity despite IV administration of 2 antiepileptic drugs
Refractory status epilepticus
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what to ask about in Seizure activity
1. **duration**
1. preceding aura
1. abrupt or gradual onset
1. progression of motor activity
1. localized or generalized activity
1. symmetric or unilateral activity
1. loss of bowel or bladder control
1. presence of injury - oral, head, shoulder etc.
1. postictal confusion or lethargy
80
what to ask if pt has h/o seizures
1. What is the baseline seizure activity?
1. Are there precipitating factors?
81
what to ask if pt has had no previous h/o seizures?
Obtain a more indepth history to determine underlying cause
1. similar episodes, unexplained injuries, nocturnal tongue biting
1. head injury, headaches
1. pregnancy or recent delivery (eclampsia)
1. hx of metabolic or electrolyte disorders, hypoxia, CA, coagulopathy or anticoagulation disorders, exposure to toxins, drug or alcohol ingestion/withdrawal
82
PE for seizures
1. VS and finger stick glucose
1. Assess for injuries
- neck/spine, posterior shoulder dislocation
- tongue/mouth laceration, dental fracture
3. Pulmonary - risk of aspiration
4. Neurologic exam with serial exams
- attn to LOC and mentation to avoid non-convulsant status epilepticus
83
what VS abnormality/condition can occur in patients who are in status epilepticus
hyperthermia
84
a transient focal deficit (usually unilateral) after a simple or complex focal seizure
Todd’s paralysis
will resolve within 48 hours
85
additional work-up for Todd's paralysis
stroke if new onset
86
4 Clinical features to differentiate seizure from other conditions
1. abrupt onset - most SZ are abrupt
1. memory loss of activity
1. purposeless movement during attack
1. postictal confusion/lethargy
87
DDX for sizures in infants and children
1. Breath-holding spells
1. Vasovagal event
1. Movement disorders
1. Night terrors
1. Hypoglycemia
1. Hypovolemia
1. Acute dystonic reactions
88
DDX for seizures in adults
1. seizures
1. syncope
1. pseudoseizures or psychogenic seizures
1. hyperventilation syndrome
1. migraine HA
1. movement disorders
89
diagnostics for seizure If hx of seizure disorder
1. glucose (fingerstick/point of care)
1. serum anti-convulsant drug levels
- low levels indicate non-compliance (MC cause of break-through seizures)
1. hcg - females of reproductive age
90
diagnostics for seizure if no hx of seizure disorder
1. glucose (fingerstick/point of care)
1. BMP
1. Mg
1. Hcg
1. toxicology
91
seizures: CT scan head - non-contrast indications
* first-ever seizure
* change in pattern of normal seizure activity
* concern for acute intracranial process (+ neuro s/s seen on H&P)
92
Lumbar Puncture indications
for seizures
* febrile
* immunocompromised
* suspicion for subarachnoid hemorrhage
* CI - avoid during active seizing
93
Management - Active Seizure
1. turn on side to avoid aspiration
- suction or NG tube to prevent aspiration
1. obtain large bore IV access x 2
- administer glucose if hypoglycemic
1. attach cardiac, pulse, end-title capnography, O2, temp monitors
1. monitor airway, O2 100%
- prepare for _nasopharyngeal airway_ if needed
1. most seizures self-resolve within 5 min
94
Management - Status Epilepticus
1. Insert nasopharyngeal airway
- prepare for ET intubation
1. 1st-line: **IV lorazepam**
- Alt: diazepam; midazolam
1. Monitor airway and oxygenation d/t SE of rsp depression
1. If seizing ceases - anticonvulsant initiated to prevent recurrence
2. 2nd-line: fosphenytoin / phenytoin
- alt: levetiracetam, valproic acid, phenobarbital
95
which second-line medication for status epilepticus is more preferred than the other?
fosphenytoin - less SE
96
phenytoin is incompatible with what other medications?
BZD’s, fluids, dextrose
97
SE phenytoin
* hypotension and cardiac arrhythmia if given too rapidly or in a central line
* phenytoin requires a 2nd IV line
98
SE fosphenytoin & phenytoin
respiratory depression
99
Management - Refractory Status Epilepticus
* Persistent seizure after 1st- and 2nd-line tx prepare for intubation and coma induction
* EEG monitoring
* Propofol MC; midazolam, pentobarbital
100
Management - Status Epilepticus if suspecting other causes (lyte abnormalities)
* Hypoglycemia - dextrose IV
* Hyponatremia - 3% NaCl
* Hypocalcemia - 10% calcium gluconate
* Hypomagnesemia - magnesium sulfate
101
what management/lab to obtain for Status Epilepticus if intubated
ABG
helps to determine adequate ventilation
hypercapnia is proportionate to hypoventilation
102
Management - Status Epilepticus if hyperthermia present
general cooling measures
103
Management - H/o Seizure Disorder w/o Status Epilepticus
1. **Obtain serum drug lvl**
- _Replenish anticonvulsant_ if levels are _therapeutically low_
- If _nml and pt has had one breakthrough “nml” seizure_ - DC home to reliable caregiver and a prompt f/u with neurology
2. If had _seizure outside of “nml” and no precipitants_ identified - consult pt PCP / neurology
- If maintenance dose is adjusted f/u with neurology in 1-3 days
104
Conscious with no history of seizure disorder - Discharge home if:
* patient physical exam has returned to baseline
* normal head CT scan
* normal laboratory evaluation
Admit if abnormal head CT, persistent focal abnormalities on PE, concerning lab abnormalities
105
Discharge Instructions for conscious pt w/ no history of seizure disorder
* discharge to supervision of reliable caregiver
* no driving or operating heavy machinery
* follow up with neurology
106
management for Suspected eclampsia
IV magnesium sulfate 4-6 g IV x 1 dose and emergent consult to OBGYN
106
management for seizures if alcohol use
* Educate on alc and avoidance of precipitating factors
* BZD for ETOH withdrawal will often prevent seizure
107
alcohol use lowers seizure threshold by:
1. increased likelihood of missed medication
1. risk of head injury
1. sleep deprivation
1. toxic co-ingestions
1. electrolyte abnormalities
1. alcohol withdrawal (delirium tremens)
108
Febrile Seizures - Generalized seizure activity usually lasting how long
< 15 minutes
109
febrile seizures are MC in who?
6 months - 6 years old
110
management for febrile seizures
1. tx underlying infection and fever if seizure has ceased
1. if status tx as previously discussed including CT/MRI brain, CSF analysis
- consider abx and acyclovir
