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Emergency Medicine > Fever/Seizures > Flashcards

Fever/Seizures Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is considered a fever?

A

100.4

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2
Q

What causes a fever? What influences severity?

A
  • Hypothalamus creating new set point of body temperature due to pyrogenic cytokines by pathogens
  • May not be directly proportional to severity of illness ie children greater response than adults
  • Geriatrics, neonates, and patients taking NSAIds may have normal or below normal temperature
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3
Q

What is the average normal body temperature

A

98

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4
Q

What is the most accurate way to take a temperature?

A
  • Core ie bladder, esophageal, pulmonary arterial catheter, rectal
  • Most taken orally, rectal and tympanic are .5 C (.9F) higher (take a degree off the orifices)
  • Axillary and forehead temps are .5 C (.9F lower –> outside air bringing temp down a bit)
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5
Q

What differential should be considered for fever in the adult?

A
  • Localized bacterial or viral infection
  • Sepsis
  • Hyperthermia
  • Serotonin syndrome
  • Neuroleptic malignant hyperthermia
  • Fever of unknown origin
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6
Q

If a patient has hyperthermia, what medication will they not respond to?

A

Antipyretics

skin hot and dry

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7
Q

What are causes of hyperthermia

A
  • Environmental exposure
  • Metabolic heat production due to dysfunction in thermoregulation (thyroid storm, medication induced)
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8
Q

What is serotonin syndrome

A

Reaction to drugs that increase serotonin (SSRI/SNRI, MAOIs, TCAs)

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9
Q

What is neuroleptic malignant syndrome?

A
  • Lethal reaction to neuroleptic medications (ex haloperidol and fluphenazine)
  • Associated with muscular rigidity, altered mental status, and autonomic dysfunction
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10
Q

What is a fever of unknown origin?

A

Fever over 100.9 on multiple occasions over 3 weeks without a diagnosis made

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11
Q

What are etiologies of fever of unknown origin?

A
  • Autoimmune disorders
  • Vasculitis
  • SLE
  • Infections (TB)
  • Malignancy (leukemia, lymphoma)
  • Thyroid storm
  • Lyme disease
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12
Q

If a patient has a history of ill contact exposure, what is a likely cause of fever?

A

Viral illness

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13
Q

If a patient has history of travel with a fever, what is a likely cause?

A
  • Dengue fever
  • Malaria
  • TB
  • Typhoid
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14
Q

If a patient has injection drug use in their history, what causes of fever should be considered

A
  • Endocarditis
  • Spinal epidural abscess
  • Osteomyelitis
  • Cutaneous abscess
  • Cellulitis…
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15
Q

If a patient has a history of consititutional symptoms: weight loss, night sweats, etc. what should you consider as a cause of fever?

A
  • Cancers
  • TB
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16
Q

Which medications could cause fever in adults?

A
  • Penicillins
  • Cephalosporins
  • Carbapenems
  • Allopurinol
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17
Q

What are signs of hemodynamic instability on physical exam?

A
  • Fever with
  • Low BP
  • Tachycardia
  • Hypoxia
  • Cool clammy
  • Flushed face
  • Hot, dry skin
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18
Q

What are common causes of systemic infection?

A
  • Pneumonia and UTI
  • If suspicion for PNA with normal CXR get CT
  • Don’t wait for hours on urine, get a straight cath
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19
Q

What is criteria for SIRS?

A
  • HR >90
  • Resp >20
  • Temp <96.8 or >100.4
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20
Q

What is criteria for sepsis?

A

SIRS + source of infection

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21
Q

What is criteria for severe sepsis? Septic shock?

A
  • Severe sepsis: sepsis + organ dysfunction
  • Septic shock: persistent hypotension after bolus and lactate >4.0
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22
Q

What are general measures to manage fever?

A
  • Cold or alcohol compresses
  • Ice bags
  • Ice water enema
  • Ice baths
  • Administer antipyretics around clock to avoid chills/sweats
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23
Q

What antipyretics can be given for fever?

A
  • Acetaminophen
  • Ibuprofen
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24
Q

When would you avoid ibuprofen?

A

If GI upset/hx of gastric ulcers
If <6 months old

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25
Q

What antipyretic should be avoided in pediatrics <18 yo?

A

Aspirin due to Reye’s syndrome risk

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26
Q

If the temperature remains uncontrolled after administration of acetaminophen/ibuprofen what can you do?

A

Alternate between acetaminophen and ibuprofen every 3 hours early in course of fever if temperature remains uncontrolled

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27
Q

When would you consider empiric antimicrobials for fever in adult

A
  • Neutropenia or expected neutropenia in next few days
  • Hemodynamically unstable
  • Asplenic: surgical or secondary to sickle cell
  • Immunosuppression ie HIV or immunosuppressive meds (corticosteroids, azathioprine, cyclosporine, chemo, DMARDs, immunosuppressive agents (mabs))
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28
Q

When would you admit a fever?

A
  • Concomitant vital sign abnormalities
  • Evidence of end-organ damage when sepsis suspected or confirmed
  • Temperature >105.8 F
  • Associated seizure or other mental status change
  • Underlying condition requires admission
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29
Q

If discharged, how soon should follow up be scheduled for fever?

A

24-72 hours

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30
Q

What is different between adults and pediatric fevers?

A
  • Lack of mature immune system –> vague symptoms and greater risk of serious infection
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31
Q

What is the rectal temperature threshold at which evaluation by healthcare provider is recommended by AAPA?

A
  • 100.4 F in children <3 months of age
  • 102.2 in children 3-36 months of age
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32
Q

What is the most common cause of fever in infants less than 3 months of age?

A

Virus: Influenza A/B, Covid, RSV, HSV, Varicella, Enterovirus, adenovirus, cytomegalovirus, rubella

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33
Q

What bacterial pathogens commonly cause fever <3 months of age

A
  • Group B strep
  • Listeria
  • E coli
  • S. pneumoniae
  • Treponema pallidum
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34
Q

What do chickenpox lesions look like?

A

macular rash –> vesicle –> scab in various stages of development
dewdrop on a rose petal

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35
Q

What does measles look like?

A

High fever with rash that starts at head and goes down

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36
Q

What does roseola look like?

A

Rash starts on abdomen and spreads outward

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37
Q

What symptoms can be signs of serious illness in infants <3 months of age

A

Nonspecific such as crying/irritability, poor feeding

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38
Q

What vital signs are normal in infant <3 months of age?

A

HR: 120-160 bpm
RR: 30-60 breaths/min

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39
Q

What are general signs of sepsis in infant <3 months of age?

A
  • Grunting
  • Respiratory distress
  • Lethargy
  • Irritability
  • Fever or hypothermia
  • Hypo or hyperglycemia
  • Apnea/cyanotic spells
  • Poor feeding
  • Petechiae
  • Unexplained jaundice
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40
Q

If a patient <3 months of age has a cough, tachypnea, or hypoxia what does that suggest?

A

Lower respiratory tract infection

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41
Q

If a patient <3 months of age has inconsolable crying during handling and bulging fontanelle, what does that suggest?

A

Meningitis

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42
Q

What can infant <3 months of age with vomiting and diarrhea indicate?

A
  • Gastroenteritis
  • OM
  • UTI
  • Meningitis
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43
Q

What is diagnostic evaluation for pediatric fever <3 months of age?

A
  • Even if local source of infection suspected test for occult infectious etiology
  • CBC with diff
  • UA with C&S via catheter or suprapubic specimen
  • Lumbar puncture: gram stain and culture, glucose, protein, cell coung with diff
  • Chest x ray if tachypnea, cough, or hypoxemia
  • Stool sample in infants with diarrhea
  • Serum biomarkers: CRP and procalcitonin
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44
Q

What criteria must be met for <3 month old to be labeled low risk?

A
  • Well-appearing without history of prematurity or perinatal complications
  • No immunizations within 48 hour and no recent abx
  • WBC 5,000-15,000/mm (bands <1500/mm)
  • Normal UA <WBC 10/hpf
  • CSF with <5 WBC/hpf
  • Stool with fewer than 5 WBCs/hpf in infants with diarrhea
  • Normal CXR with no evidence of acute cardiopulmonary disease
45
Q

What immediately makes a baby <3 months old high risk according to the step by step approach?

A
  • Age <21 says old
  • Leukocytes in urine
  • Procalcitonin >.5 ng/mL
46
Q

What makes a infant intermediate risk according to step by step approach?

A

CRP>20 mg/L or ANC >10000

47
Q

How is an infant <28 days of age managed with fever?

A

Admit for parenteral antibiotics

48
Q

How is an infant 1-3 months old managed with fever?

A
  • Admit for parenteral antibiotics if failure to meet low risk criteria
49
Q

What is the preferred abx regimen for infants <3 months of age?

A

AMP up the Taxes for these babies!
Ampicillin Cefotaxime

but get blood cultures first

50
Q

How would you manage infants 1-3 months who meet low risk?

A
  • Outpatient with or without antibiotics and a required f/u in 24 hours if reliable guardians, phone access, ability to maintain hydration etc, discuss discharge with pediatrician to ensure f/u
  • Inpatient with or without antibiotics
  • Overall decision based on provider’s comfort level
51
Q

How would you manage infants 1-3 months with identifiable viral illness?

A

UA and blood cultures

52
Q

What is the most common etiology for fever in infants 3-36 months of age?

A
  • Viral
53
Q

What history should be obtained on an infant 3-36 months of age with fever?

A
  • Maximum temp, method obtained, timing, antipyretic use
  • Past medical history- including birth history
  • Ill contacts
  • Immunization status, particularly with Hib and S. pneumoniae
54
Q

What are associated symptoms of a infant 3-36 months of age with fever due to viral URI/LRI?

A
  • Rhinorrhea
  • Cough
  • Tachypnea
  • Hypoxia
55
Q

What are associated symptoms of an infant 3-36 months of age with OM and fever?

A
  • Fussy
  • Pulling on ear/otalgia
56
Q

What are associated symptoms of UTI in infant 3-36 months of age with fever?

A
  • Fever may be only symptoms
  • Foul smelling urine
  • Crying during urination
57
Q

What are associated symptoms of gastroenteritis of an infant with fever 3-36 months of age?

A
  • Poor intake
  • Vomiting
  • Diarrhea
58
Q

What are associated symptoms of cellulitis/abscess with fever in infant 3-36 months of age?

A
  • Skin erythema
  • Warmth
  • +/- exudate
59
Q

What are associated symptoms of septic arthritis in a 3-36 month old infant with fever?

A
  • Not using extremity
  • Erythema
  • Swelling
  • Warmth of joint
60
Q

What are associated symptoms of meningitis in 3-36 month old infant with fever?

A
  • Inconsolable crying
  • Bulging fontanelle
  • Vomiting
  • Irritability that worsens when handled
  • Seizure
  • N. meningitidis: petechiae, hypotension, lethargy
61
Q

What are associated symptoms of sepsis in infant 3-36 months of age with fever?

A
  • Fussy
  • Poor intake
  • Lethargic
  • Mental status change
62
Q

What will be seen on physical exam of non-toxic infant 3-36 months of age?

A
  • Alert and make eye contact
  • Playful and console easily
  • Positive responses to interactions
  • Negative (bad) response to noxious stimuli
63
Q

What will be seen on physical exam of 3-36 month old who is toxic?

A
  • Lethargy
  • Poor perfusion
  • Hypo-or hyperventilation
  • Acrocyanosis
64
Q

How should you manage fever without a source in ill appearing (toxic) infant 3-36 months old?

A
  • CBC, blood culture
  • UA with C & S
  • CSF if s/s of meningitis
  • CXR if tachypnea or WBC >20,000/uL
  • Parenteral antibiotics given within 1 hour of arrival
  • Consult pediatrician and admit
65
Q

How should you manage well appearing with immunizations UTD infant 3-36 months of age with fever?

A
  • Catheterized urine collection: UA only in girls <24 m, uncircumcised boys <12 m, circumcised boys <6 m
  • Consider urine collection bag for young boys outside of window as 4% chance of UTI, if negative d/c home with antipyretics if positive single dose of parenteral antibiotics with f/u in 12-24 hours
66
Q

Which patients 3-36 months should be admitted?

A
  • Ill appearing
  • Unable to maintain fluids
  • Unlikely to f/u or return to ED
67
Q

How would you treat infant 3-36 months of age if source of infection identified

A
  • Abx choice based on type of infection, MC organisms, and local resistance
68
Q

How would you treat fever in infant 3-36 months of age if no source of infection is found?

A
  • Ceftriaxone
  • pip/taz + vancomycin

three toddlers pip, taz, and vanc

69
Q

What is general management of pediatric fever in all ages?

A
  • Antipyretics as early as possible to improve comfort: acetaminophen, especially <6 months old; ibuprofen 6 months and older, remove excess clothing and blankets
  • Response to antipyretic doesn’t affect disposition
  • If patient discharged home and blood cultures reveal bacteremia, repeat evaluation–> see below
  • If well-appearing and afebrile outpatient 10 day course of antibiotics based on culture sensitivity
  • If ill-appearing or remains febrile, admit with parenteral antibiotics based on culture sensitivity and repeat work-up considered
70
Q

What is neutropenic fever?

A
  • Life threatening condition that can lead to fulminant systemic infection if not managed appropriately
  • Temp >100.4 for 1 hour or single temp >101
  • Neutropenia: ANC <1000 cells or severe neutropenia <500 cells
71
Q

Clinical presentation of neutropenic fever

A
  • Fever (often only sign, early)
  • History of recent chemo treatment, neutrophil lowest 10-15 days after chemo and increase 5 days after nadir (lowest point)
  • Severity of symptoms may not be proportional to severity of infection
  • Signs of local infection and systemic?
72
Q

Why can chemotherapy cause neutropenic fever?

A
  • Affects myelopoiesis and integrity of GI mucosa
73
Q

Diagnostic evaluation of neutropenic fever

A
  • CBC with diff
  • Two blood cultures from 2 sites, one from peripheral vein one from central catheter
  • UA with C&S
  • CMP: attn to electrolytes, renal and liver function
  • CXR
  • Bodily fluid assessment/culture if indicated: sputum, stool, wound drainage, LP
  • CT/US of abdomen with contrast- if abdominal pain/tenderness
74
Q

Management of neutropenic fever

A

Emperic antibiotics immediately after blood cultures: vancomycin + cefepime if no source of infection identified

neutrophils take the van to cefe

75
Q

How would you treat outpatient neutropenic fever in low risk patient?

A

Ciprofloxacin or levofloxacin + augmentin or moxifloxacin

fluoroquinolones and augment

PCN allergy: clindamycin

76
Q

If hemodynamic instability, catheter-related infection, skin/soft tissue infection, pneumonia, or known colonosication with resistant organism (cover gram +) what would you prescribe?

A

Monotherapy agent (cefepime/ceftazidime/imipenem cilastatin/meropenem/piptaz) plus vancomycin +/- metronidazole (if abdominal symptoms to cover anaerobes

77
Q

What is the disposition of neutropenic fever patients?

A
  • Consult oncology regarding disposition
  • High risk admit: profound neutropenia expected to last >7 days, comorbid medical conditions, acute liver/renal injury
  • Risk assessment using MASCC: used by oncology, score 0-20 requires admission, score >20 have <5% risk severe complication and <1% chance of mortality
78
Q

Episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons

A

Seizures

79
Q

Seizure with no cause identified? Seizure with identifiable neurologic condition identified ie mass lesion, previous head injury, stroke?

A
  • No cause: primary (idiopathic)
  • Neuro condition: secondary
80
Q

Seizure that occurs within 7 days of insult? Seizure without acute precipitating factor?

A
  • Provoked
  • Unprovoked
81
Q

Seizure activity for >5 minutes or two or more seizures without regaining consciousness between the seizures- multiple seizures back to back without recovery

A

Status epilepticus

82
Q

Persistent seizure activity despite IV administration of 2 antiepileptic drugs

A

Refractory status epilepticus

83
Q

Clinical history in seizures

A

Either recent seizure or actively seizing

Duration important!
* Can have preceding aura
* Abrupt or gradual onset
* Progression of motor activity
* Localized or generalized activity
* Symmetric or unilateral activity
* Loss of bowel or bladder control
* Presence of injury: oral, head, shoulder, etc.
* Postictal confusion or lethargy

84
Q

Physical exam for seizures

A
  • Vital signs and finger stick glucose (hyperthermia can occur in status epilepticus)
  • Assess for injuries ie neck/spine, shoulder dislocation, laceration, dental fracture
  • Pulmonary: risk of aspiration
  • Neurologic exam with serial exams with attn to LOC and mentation
85
Q

Transient focal deficit after simple or complex focal seizure, will resolve within 48 hours. How must you work this up if new onset?

A

Todd’s paralysis
As stroke

86
Q

What clinical features of seizures differentiate from other conditions?

A
  • Abrupt onset
  • Memory loss of activity
  • Puposeless movement during
  • Postictal confusion/lethargy
87
Q

Diagnostic evaluation of seizures if hx of seizure disorder

A
  • Glucose
  • Serum anti-convulsant drug levels: low levels indicate non-compliance (MC cause of break-through seizures)
  • hcg- females of reproductive age
88
Q

Diagnostic evaluation of seizures if no hx of seizure disorder

A
  • Glucose
  • BMP
  • Magnesium
  • Hcg
  • Toxicology
89
Q

What are indications for CT scan head without contrast with seizure?

A
  • First-ever seizure
  • Change in pattern of normal seizure activity
  • Concern for acute intracranial process (+ neuro s/s seen on H&P)
90
Q

Indications for lumbar puncture in seizure

A
  • Febrile
  • Immunocompromised
  • Suspicion for SAH
  • Contraindications- avoid during active seizing
91
Q

Management of active seizure

A

Supportive and protective
* Turn on side to avoid aspiration, suction or NG tube
* Large bore IV access x2
* Administer glucose IV if hypoglycemic
* Attach cardiac, pulse, end-title capnography, O2, temp monitors
* Monitor airway and administer 100% O2, prepare for NPA if needed

Most self-resolve in 5 mins

92
Q

Management of status epilepticus

A
  • NPA and prepare for ET intubation
  • DOC IV lorazepam (alt diazepam PR/IO/ET, midazolam IM)
  • Monitor airway and oxygenation d/t SE of respiratory depression
  • Seizing ceases anticonvulsant should be initiated to prevent recurrence
  • Second line: fosphenytoin or phenytoin (fosphenytoin preferred)
  • ABG if intubated (determine adequate ventilation, hypercapnia proportionate to hypoventilation)
  • General cooling measures if hyperthermia present
  • Consult neurology for admission

can also use levetiracetam, valproic acid, phenobarbital

93
Q

What does phenytoin require?

A

2nd IV line because incompatible with BZDs, fluids, dextrose

94
Q

SE of phenytoin

A

Hypotension and cardiac arrhythmia if given too rapidly or in central line
Both fosphenytoin and phenytoin SE of repiratory depression

95
Q

Management of refractory status epilepticus

A
  • Intubation and coma induction
  • EEG monitoring
96
Q

What is used to induce coma?

A
  • Midazolam IV then infusion or
  • propafol IV followed by infusion or
  • pentobarbital IV then infusion
  • Titrate to seizure suppression
97
Q

How is hypoglycemia in status epilepticus managed?

A

Infants: 4-5 mL/kg 10% dextrose IV
Older children: 2 mL/kg 25% dextrose IV

98
Q

How is hyponatremia in status epilepticus managed?

A

3% NaCl 4-6 mL/kg

99
Q

How is hypocalcemia in status epilepticus managed?

A

10% calcium gluconate .3 mL/kg over 10 minutes

100
Q

How is hypomagnesemia in status epilepticus managed?

A

50 mg/kg of magnesium sulfate over 20 minutes

101
Q

How is seizure with history of seizure disorder without status epilepticus managed?

A
  • Obtain serum drug levels (if emergently available in lab) and replenish if therapeutically low (loading dose then regular regimen); if normal and one breakthrough normal provider discharge to caregiver with prompt neurology follow up
  • If seizure outside of what is considered normal with no precipitants: consultation with PCP or neurology should be made. If maintenance dose adjusted f/u with neurology in 1-3 days
102
Q

When would you discharge a patient home who is conscious with no history of seizure disorder?

A
  • Patient physical exam has returned to baseline
  • Normal head CT scan
  • Normal laboratory evaluation
103
Q

What are discharge instructions for someone who is conscious who had a seizure and no history of seizure disorder?

A
  • Discharge to supervision of reliable caregiver
  • No driving or operating heavy machinery
  • Follow up with neurology
104
Q

When would you admit to neurology for conscious patient who had seizure without seizure history?

A
  • Abnormal head CT
  • Persistent focal abnormalities on PE
  • Concerning lab abnormalities
105
Q

How is suspected eclampsia treated?

A

IV magnesium sulfate IV x 1 dose and emergent consult to OBGYN

106
Q

How does alcohol use lower seizure threshold?

A
  • Increased likelihood of missed medication
  • Risk of head injury
  • Sleep deprivation
  • Toxic co-ingestions
  • Electrolyte abnormalities
  • Alcohol withdrawal (delirium tremens)
107
Q

What is management of alcohol use and seizure?

A
  • Educate on alcohol use and avoidance of precipitating factors
  • Use of BZD in ETOH withdrawal will often prevent seizure
108
Q

What are usual characteristics of febrile seizure? How are they evaluated?

A
  • Usually <15 minutes, status epilepticus possible in severe infections
  • MC between 6 months and 6 years
  • Evaluated by looking for source of infection
109
Q

What is management of febrile seizures?

A
  • Treat underlying infection and fever if seizure has ceased
  • If status treat as previously discussed including CT/MRI brain, CSF analysis, and consider antibiotics and acyclovir

Emergency Medicine (13 decks)

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