Fever/Seizures Flashcards
What is considered a fever?
100.4
What causes a fever? What influences severity?
- 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
What is the average normal body temperature
98
What is the most accurate way to take a temperature?
- 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)
What differential should be considered for fever in the adult?
- Localized bacterial or viral infection
- Sepsis
- Hyperthermia
- Serotonin syndrome
- Neuroleptic malignant hyperthermia
- Fever of unknown origin
If a patient has hyperthermia, what medication will they not respond to?
Antipyretics
skin hot and dry
What are causes of hyperthermia
- Environmental exposure
- Metabolic heat production due to dysfunction in thermoregulation (thyroid storm, medication induced)
What is serotonin syndrome
Reaction to drugs that increase serotonin (SSRI/SNRI, MAOIs, TCAs)
What is neuroleptic malignant syndrome?
- Lethal reaction to neuroleptic medications (ex haloperidol and fluphenazine)
- Associated with muscular rigidity, altered mental status, and autonomic dysfunction
What is a fever of unknown origin?
Fever over 100.9 on multiple occasions over 3 weeks without a diagnosis made
What are etiologies of fever of unknown origin?
- Autoimmune disorders
- Vasculitis
- SLE
- Infections (TB)
- Malignancy (leukemia, lymphoma)
- Thyroid storm
- Lyme disease
If a patient has a history of ill contact exposure, what is a likely cause of fever?
Viral illness
If a patient has history of travel with a fever, what is a likely cause?
- Dengue fever
- Malaria
- TB
- Typhoid
If a patient has injection drug use in their history, what causes of fever should be considered
- Endocarditis
- Spinal epidural abscess
- Osteomyelitis
- Cutaneous abscess
- Cellulitis…
If a patient has a history of consititutional symptoms: weight loss, night sweats, etc. what should you consider as a cause of fever?
- Cancers
- TB
Which medications could cause fever in adults?
- Penicillins
- Cephalosporins
- Carbapenems
- Allopurinol
What are signs of hemodynamic instability on physical exam?
- Fever with
- Low BP
- Tachycardia
- Hypoxia
- Cool clammy
- Flushed face
- Hot, dry skin
What are common causes of systemic infection?
- Pneumonia and UTI
- If suspicion for PNA with normal CXR get CT
- Don’t wait for hours on urine, get a straight cath
What is criteria for SIRS?
- HR >90
- Resp >20
- Temp <96.8 or >100.4
What is criteria for sepsis?
SIRS + source of infection
What is criteria for severe sepsis? Septic shock?
- Severe sepsis: sepsis + organ dysfunction
- Septic shock: persistent hypotension after bolus and lactate >4.0
What are general measures to manage fever?
- Cold or alcohol compresses
- Ice bags
- Ice water enema
- Ice baths
- Administer antipyretics around clock to avoid chills/sweats
What antipyretics can be given for fever?
- Acetaminophen
- Ibuprofen
When would you avoid ibuprofen?
If GI upset/hx of gastric ulcers
If <6 months old
What antipyretic should be avoided in pediatrics <18 yo?
Aspirin due to Reye’s syndrome risk
If the temperature remains uncontrolled after administration of acetaminophen/ibuprofen what can you do?
Alternate between acetaminophen and ibuprofen every 3 hours early in course of fever if temperature remains uncontrolled
When would you consider empiric antimicrobials for fever in adult
- 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))
When would you admit a fever?
- 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
If discharged, how soon should follow up be scheduled for fever?
24-72 hours
What is different between adults and pediatric fevers?
- Lack of mature immune system –> vague symptoms and greater risk of serious infection
What is the rectal temperature threshold at which evaluation by healthcare provider is recommended by AAPA?
- 100.4 F in children <3 months of age
- 102.2 in children 3-36 months of age
What is the most common cause of fever in infants less than 3 months of age?
Virus: Influenza A/B, Covid, RSV, HSV, Varicella, Enterovirus, adenovirus, cytomegalovirus, rubella
What bacterial pathogens commonly cause fever <3 months of age
- Group B strep
- Listeria
- E coli
- S. pneumoniae
- Treponema pallidum
What do chickenpox lesions look like?
macular rash –> vesicle –> scab in various stages of development
dewdrop on a rose petal
What does measles look like?
High fever with rash that starts at head and goes down
What does roseola look like?
Rash starts on abdomen and spreads outward
What symptoms can be signs of serious illness in infants <3 months of age
Nonspecific such as crying/irritability, poor feeding
What vital signs are normal in infant <3 months of age?
HR: 120-160 bpm
RR: 30-60 breaths/min
What are general signs of sepsis in infant <3 months of age?
- Grunting
- Respiratory distress
- Lethargy
- Irritability
- Fever or hypothermia
- Hypo or hyperglycemia
- Apnea/cyanotic spells
- Poor feeding
- Petechiae
- Unexplained jaundice
If a patient <3 months of age has a cough, tachypnea, or hypoxia what does that suggest?
Lower respiratory tract infection
If a patient <3 months of age has inconsolable crying during handling and bulging fontanelle, what does that suggest?
Meningitis
What can infant <3 months of age with vomiting and diarrhea indicate?
- Gastroenteritis
- OM
- UTI
- Meningitis
What is diagnostic evaluation for pediatric fever <3 months of age?
- 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
What criteria must be met for <3 month old to be labeled low risk?
- 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
What immediately makes a baby <3 months old high risk according to the step by step approach?
- Age <21 says old
- Leukocytes in urine
- Procalcitonin >.5 ng/mL
What makes a infant intermediate risk according to step by step approach?
CRP>20 mg/L or ANC >10000
How is an infant <28 days of age managed with fever?
Admit for parenteral antibiotics
How is an infant 1-3 months old managed with fever?
- Admit for parenteral antibiotics if failure to meet low risk criteria
What is the preferred abx regimen for infants <3 months of age?
AMP up the Taxes for these babies!
Ampicillin Cefotaxime
but get blood cultures first
How would you manage infants 1-3 months who meet low risk?
- 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
How would you manage infants 1-3 months with identifiable viral illness?
UA and blood cultures
What is the most common etiology for fever in infants 3-36 months of age?
- Viral
What history should be obtained on an infant 3-36 months of age with fever?
- Maximum temp, method obtained, timing, antipyretic use
- Past medical history- including birth history
- Ill contacts
- Immunization status, particularly with Hib and S. pneumoniae
What are associated symptoms of a infant 3-36 months of age with fever due to viral URI/LRI?
- Rhinorrhea
- Cough
- Tachypnea
- Hypoxia
What are associated symptoms of an infant 3-36 months of age with OM and fever?
- Fussy
- Pulling on ear/otalgia
What are associated symptoms of UTI in infant 3-36 months of age with fever?
- Fever may be only symptoms
- Foul smelling urine
- Crying during urination
What are associated symptoms of gastroenteritis of an infant with fever 3-36 months of age?
- Poor intake
- Vomiting
- Diarrhea
What are associated symptoms of cellulitis/abscess with fever in infant 3-36 months of age?
- Skin erythema
- Warmth
- +/- exudate
What are associated symptoms of septic arthritis in a 3-36 month old infant with fever?
- Not using extremity
- Erythema
- Swelling
- Warmth of joint
What are associated symptoms of meningitis in 3-36 month old infant with fever?
- Inconsolable crying
- Bulging fontanelle
- Vomiting
- Irritability that worsens when handled
- Seizure
- N. meningitidis: petechiae, hypotension, lethargy
What are associated symptoms of sepsis in infant 3-36 months of age with fever?
- Fussy
- Poor intake
- Lethargic
- Mental status change
What will be seen on physical exam of non-toxic infant 3-36 months of age?
- Alert and make eye contact
- Playful and console easily
- Positive responses to interactions
- Negative (bad) response to noxious stimuli
What will be seen on physical exam of 3-36 month old who is toxic?
- Lethargy
- Poor perfusion
- Hypo-or hyperventilation
- Acrocyanosis
How should you manage fever without a source in ill appearing (toxic) infant 3-36 months old?
- 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
How should you manage well appearing with immunizations UTD infant 3-36 months of age with fever?
- 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
Which patients 3-36 months should be admitted?
- Ill appearing
- Unable to maintain fluids
- Unlikely to f/u or return to ED
How would you treat infant 3-36 months of age if source of infection identified
- Abx choice based on type of infection, MC organisms, and local resistance
How would you treat fever in infant 3-36 months of age if no source of infection is found?
- Ceftriaxone
- pip/taz + vancomycin
three toddlers pip, taz, and vanc
What is general management of pediatric fever in all ages?
- 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
What is neutropenic fever?
- 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
Clinical presentation of neutropenic fever
- 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?
Why can chemotherapy cause neutropenic fever?
- Affects myelopoiesis and integrity of GI mucosa
Diagnostic evaluation of neutropenic fever
- 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
Management of neutropenic fever
Emperic antibiotics immediately after blood cultures: vancomycin + cefepime if no source of infection identified
neutrophils take the van to cefe
How would you treat outpatient neutropenic fever in low risk patient?
Ciprofloxacin or levofloxacin + augmentin or moxifloxacin
fluoroquinolones and augment
PCN allergy: clindamycin
If hemodynamic instability, catheter-related infection, skin/soft tissue infection, pneumonia, or known colonosication with resistant organism (cover gram +) what would you prescribe?
Monotherapy agent (cefepime/ceftazidime/imipenem cilastatin/meropenem/piptaz) plus vancomycin +/- metronidazole (if abdominal symptoms to cover anaerobes
What is the disposition of neutropenic fever patients?
- 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
Episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons
Seizures
Seizure with no cause identified? Seizure with identifiable neurologic condition identified ie mass lesion, previous head injury, stroke?
- No cause: primary (idiopathic)
- Neuro condition: secondary
Seizure that occurs within 7 days of insult? Seizure without acute precipitating factor?
- Provoked
- Unprovoked
Seizure activity for >5 minutes or two or more seizures without regaining consciousness between the seizures- multiple seizures back to back without recovery
Status epilepticus
Persistent seizure activity despite IV administration of 2 antiepileptic drugs
Refractory status epilepticus
Clinical history in seizures
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
Physical exam for seizures
- 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
Transient focal deficit after simple or complex focal seizure, will resolve within 48 hours. How must you work this up if new onset?
Todd’s paralysis
As stroke
What clinical features of seizures differentiate from other conditions?
- Abrupt onset
- Memory loss of activity
- Puposeless movement during
- Postictal confusion/lethargy
Diagnostic evaluation of seizures if hx of seizure disorder
- Glucose
- Serum anti-convulsant drug levels: low levels indicate non-compliance (MC cause of break-through seizures)
- hcg- females of reproductive age
Diagnostic evaluation of seizures if no hx of seizure disorder
- Glucose
- BMP
- Magnesium
- Hcg
- Toxicology
What are indications for CT scan head without contrast with seizure?
- First-ever seizure
- Change in pattern of normal seizure activity
- Concern for acute intracranial process (+ neuro s/s seen on H&P)
Indications for lumbar puncture in seizure
- Febrile
- Immunocompromised
- Suspicion for SAH
- Contraindications- avoid during active seizing
Management of active seizure
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
Management of status epilepticus
- 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
What does phenytoin require?
2nd IV line because incompatible with BZDs, fluids, dextrose
SE of phenytoin
Hypotension and cardiac arrhythmia if given too rapidly or in central line
Both fosphenytoin and phenytoin SE of repiratory depression
Management of refractory status epilepticus
- Intubation and coma induction
- EEG monitoring
What is used to induce coma?
- Midazolam IV then infusion or
- propafol IV followed by infusion or
- pentobarbital IV then infusion
- Titrate to seizure suppression
How is hypoglycemia in status epilepticus managed?
Infants: 4-5 mL/kg 10% dextrose IV
Older children: 2 mL/kg 25% dextrose IV
How is hyponatremia in status epilepticus managed?
3% NaCl 4-6 mL/kg
How is hypocalcemia in status epilepticus managed?
10% calcium gluconate .3 mL/kg over 10 minutes
How is hypomagnesemia in status epilepticus managed?
50 mg/kg of magnesium sulfate over 20 minutes
How is seizure with history of seizure disorder without status epilepticus managed?
- 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
When would you discharge a patient home who is conscious with no history of seizure disorder?
- Patient physical exam has returned to baseline
- Normal head CT scan
- Normal laboratory evaluation
What are discharge instructions for someone who is conscious who had a seizure and no history of seizure disorder?
- Discharge to supervision of reliable caregiver
- No driving or operating heavy machinery
- Follow up with neurology
When would you admit to neurology for conscious patient who had seizure without seizure history?
- Abnormal head CT
- Persistent focal abnormalities on PE
- Concerning lab abnormalities
How is suspected eclampsia treated?
IV magnesium sulfate IV x 1 dose and emergent consult to OBGYN
How does alcohol use lower seizure threshold?
- Increased likelihood of missed medication
- Risk of head injury
- Sleep deprivation
- Toxic co-ingestions
- Electrolyte abnormalities
- Alcohol withdrawal (delirium tremens)
What is management of alcohol use and seizure?
- Educate on alcohol use and avoidance of precipitating factors
- Use of BZD in ETOH withdrawal will often prevent seizure
What are usual characteristics of febrile seizure? How are they evaluated?
- Usually <15 minutes, status epilepticus possible in severe infections
- MC between 6 months and 6 years
- Evaluated by looking for source of infection
What is management of febrile seizures?
- 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
