40. Fever Flashcards
In febrile infants 0-3 months old, what to do?
- Recognize the risk of occult bacteremia.
- Investigate thoroughly (e.g., blood cultures, urine, lumbar puncture +/- chest X-ray).
With patients with fever of unknown origin appropriately, name investigations
- hémocultures
- échocardiographie
- scintigraphies osseuses
In febrile patients, consider life-threatening infectious causes, such as?
- endocarditis
- meningitis
In the febrile patient, consider causes of hyperthermia other than infection. Name examples.
- heat stroke
- drug reaction
- malignant neuroleptic syndrome
In an elderly patient, be aware that no good correlation exists between the presence or absence of fever and the presence or absence of serious pathology.
Describe : Fever Unknown Origin
T>38.3 C for >3w without etiology
Name causes : Fever Unknown Origin
- Infectious (Endocarditis, TB, osteomyelitis, intraabdominal abscess, dental abscess)
- Malignancies (Hematologic, metastatic, renal cell carcinoma)
- Connective tissue diseases (Giant cell arteritis, PMR, RA, IBD)
- Drug (antibiotics, methyldopa, phenytoin)
- DVT
Name labs to consider for FUO
- Blood cultures r/o endocarditis
- CBC
- ESR/CRP
- LDH
- HIV Ab and Viral load
- RF
- Heterophile antibody test
- CPK
- ANA
- TB skin test (or interferon-gamma release assay)
- Serum protein electrophoresis
Name imaging for FUO
- CT abdo/chest (r/o abscess, malignancy)
- Echocardiography (r/o endocarditis)
- PET-CT (r/o malignancy/inflammation)
- Referral to ID, rheumatology, oncology
Describe difference between Distinction Hyperthermia and Fever
1) Hyperthermia (fatal): Thermoregulatory center unchanged despite increasing temperature
Suspect based on history
Suspect if skin hot and dry(heat stroke or atropine), or if antipyretics do not decrease body temperature
2) Fever: Thermoregulatory center compensates for increasing temperature
Describe tx : Hyperthermia
- Must be treated by RAPID reduction of body temperature by PHYSICAL means → find underlying cause
- Ice packs, cool damp sponges/towels/water, fan
- Avoid cooling blankets (vasoconstriction → less heat loss)
- IV fluids for dehydration
Describe : Nonexertional/Exertional heat stroke
- Consider heat stroke in T>40C, CNS dysfunction (altered mental status), exposure to heat, and absence of other explanation
- ABC, may need intubation and ventilation
- Rapid cooling and rehydration
- Continuous rectal probe temperature monitoring
- Labs (CBC, lytes, UA, CK, LFT, Coags)
*
Describe management : Pharmacology/drug-induced (atropine, ecstasy)
- Charcoal if <1-2h ingestion
- Benzodiazepines for agitation/seizure (eg. lorazepam until hypertension controlled or patient sedated)
- Consult Poison Control Center
- Atropine - consider antidote
- Ecstasy - only correct hyponatremia if severe/symptomatic
What’s the antidote of atropine ?
physostigmine
When to suspect thyroid storm (6)
- tachycardia
- hyperpyerxia
- CNS dysfunction
- GI symptoms
- goiter
- hyperthyroidism on labs
Describe tx : Tempête thyroïdienne (5)
- B-Blockers (Propranolol)
- Propylthiouracil PTU
- Solution iodée (retardée 1h après la PTU)
- Radiocontraste iodé
- Hydrocortisone IV à haute dose 100 mg IV toutes les 8 heures
Describe tx : Anesthetics (malignant hyperthermia)
- Discontinue anethestic, add charcoal fibers to anesthesia breathing circuit
- Hyperventilate with 100% O2
- Dantrolene
Describe tx : Neuroleptic (neuroleptic malignant syndrome)
- Discontinue neuroleptic
- Supportive
- Consider dantrolene, bromocriptine, amantadine if do not respond after 1-2 days
Describe dx : Serotonin syndrome
Diagnose clinically if on serotonergic agent and one of the following:
* Spontaneous clonus
* Inducible clonus PLUS agitation or diaphoresis
* Ocular clonus PLUS agitation or diaphoresis
* Tremor PLUS hyperreflexia
* Hypertonia PLUS temperature above 38°C PLUS ocular clonus or inducible clonus
Describe tx : Serotonin syndrome (6)
- Discontinue serotonergic agent
- Supportive care aimed to normalize vital signs
- Benzodiazepine sedation
- Serotonin antagonist
- Consider sedation, paralysis, intubation
- Consider Cyproheptadine (antidote)
