Fevers and Seizures Flashcards
What is the job of the ER
Stabilize and get to the appropriate department
When is fever the scariest?
pediatric patients - sometimes the only symptom they present with
What is a fever and why is it that number?
100.4
because we chose it to be this number and have done studies accordingly
What controls the body temperature?
hypothalamus makes a set point and cytokines are released
Why are children more susceptible to febrile seizures?
Their body temperature increases too fast
What demographic is fever not reliable?
Elderly
Average body temperature
Probably around 98F
worst place to take a body temperature?
peripheral areas
What are the two main ways we take temperatures?
Oral or rectal
When might you get an abnormally low oral temp?
Cold drink
Panic attack that are
What do you default for fever if they come into the ER?
Bacterial
Viral infection
What is most important to look at for fever?
Vitals to r/o sepsis
When is hyperthermia common and what clues you into this?
Environmental exposure
Warm skin
Do not respond to antipyretics
What drugs can cause fever?
Serotonin
What is neuroleptic malignant syndrome
Very high fever with muscle rigidity, AMS, and autonomic dysfunction
What is the length of FUO?
38.3 = 100.9 F for 3 weeks w/out diagnosis
Why is age important for fever?
Use common sense
What history question should you ask for all patients with fever?
Ill contacts
Travel
IV drug use (EVER)
What are you worried about for IV drug use EVER?
endocarditis
spinal epidural abscess
once in the system, it can be there for ever
Apart from cancer, what are you worried about for constitutional symptoms w/ fever
TB
When is fever also common for meds?
New meds or dose changes
What makes you worried about sepsis
Hemodynamic instability
If a patient comes in with weird vitals but no symptoms?
PNA (CXR is sometimes normal - get a CT if not a clear)
UTI (UA is not always positive)
SIRS criteria
HR > 90
Resp > 20
Temp <96.8 F (flip the digits of normal) or > 100.4
What is sepsis?
SIRS + infection
What do you do for fever?
Tylenol or ibuprofen
When do you use tylenol over ibruoprfen?
Tylenol is for younger
Ibuprofen for > 6 months
If you have pain + fever, what is used?
Toradol IV/IM which is ibuprofen
If you have a neutropenic patient or is expected to be neutropenic in next few days, what do you do?
Throw broad spectrum w/out waiting for culture
What med suffix is common for immunocompromised patients?
-mab
When do you admit patient in ER?
vital sign abnormalities
end-organ damage
>41 C
seizure
meet criteria
Why are pediatric fever worrisome?
Lack of mature immune system leads to VAGUE symptoms + risk of spread of infection from system to system (from GU to another tract)
Hard to do a good PE in these patients
MC presenting CC in pediatric ER population?
fever :(
What age is the MOST worrying for pediatric fever?
< 3 months is REALLY worrying
3+ months is not as worrying
When should a patient see a medical provider for peds fever
38C in children < 3 months
39 C in children >3 months
What are you most worried about for infants <3 months with fever?
SEPSIS
meningitis
encephalitis
osteomyletis
What is the MC pediatric fever cause?
Viral - not as concerning
should r/o others with history
What is more concerning, viral or bacterial in kids?
Bacterial
group B strep, listeria, E coli is worrying
If there is a fever + rash, what likely is it?
MMR
unvaccinated
Roseala vs measels
rosealo starts at bottom and goes up
measles starts at top and goes down
What is important history to get for infant < 3 month?
Birth history
if a patient is 1 week early, then they are considered minus 1 week to be their true age
Symptoms of fever in child?
NONSPECIFIC
sometimes they do not respond
What must a PE of a newborn be?
undressed completely to look for infection
If you have cough, tachypnea, hypoxia, what do you think?
respiratory infection
In a child <3 months with fever what should you do right away?
Urinary straight catheter right away
also
CBC w/ diff
LP
CXR
Stool sample
CRP and procalcitonin
What criteria must be met to be low risk per tinitinally?
well-appearing
no immunization w/in 45 hours
(look this over)
What population is admitted no matter what?
<21 days
some same <28 days
leukocytes in urine
procalcitonin > 0.5
CRP > 20 or ANC > 1000
if not, then send to pediatrician w/in 24 hours
When a patient is admitted that is <28 days or 1-3 months high risk, what do you give?
Ampicillin + cefotaxime
amped up kid with taxes
Infants that are 1-3 months and are low risk, what do you do?
F/o with a pediatrician w/in 24 hours IF they have a way to get there.
Inpatient w/ or w/out AB
depends on provider comfort level
Etiology of fever in 3-36 months?
Viral
How do you determine toxicity?
general assessment
lethargic, no responses
look at ears for infection
If kids are not UTD on immunizations, what do you do?
Get all labs
When should you admit 3-36 months?
If they look sick
Rocephin + Vanc
Does response to antipyretics change admission?
NO
can mask infection
If a patient is well appearing but blood cultures grow something, what do you do?
Repeat ER evaluation
well-appearing = 10 day outpatient
not well appearing = admit with IV AB
What is a neutropenic fever often seen in?
Cancer patients
What is a neutropenic fever?
Temp > 100.4 for an hour or a single temp >
Neutrophil 501-1000 = mild/mod
Neutrophil < 500 = severe neutropenia (ADMIT)
What is sometimes the only symptom of infection in neutropenic fever?
fever alone
often don’t look sick!
What is a common history of neutropenic history?
chemotherapy
What w/o does neutropenia have?
Full work up!
Blood cultures
What is the treatment of neutropenic fever?
Vanc + a cephalosporin
broad spectrum
When would you NOT admit a neutropenic fever?
score > 20 on MASCC
rare occasion
What are the different types of seizures?
Primary (idiopathic) seizures no cause can be identified
Secondary (symptomatic) seizures - identifiable neurologic condition is identified
mass lesion, previous head injury, stroke
Provoked seizure - a seizure that occurs within 7 days of an insult ¹
Unprovoked seizure - no acute precipitating factor can be identified
Status epilepticus - seizure activity for ≥ 5 minutes² or two or more seizures without regaining consciousness between the seizures - multiple seizures back to back without recovery
Refractory status epilepticus -
what makes a seizure provoked?
A seizure within 7 days of an insult
What is status epilepticus?
seizure activity for ≥ 5 minutes² or two or more seizures without regaining consciousness between the seizures - multiple seizures back to back without recovery
what is refractory status epilepticus?
persistent seizure activity despite IV administration of 2 antiepileptic drugs
What is SUPER important history to get for seizure?
Witnesses!
duration
proceeding aura
abrupt or gradual onset
Do you remember a seizure?
NO
if they say they do, then they are likely lying
What is almost 100% sensitive for a seizure?
Biting of lateral tongue
ask about cheek pain, if they wet themselves
What is the biggest deal in seizure
First time seizure or has it happened before
history of seizures = get them out of the door in 15 minutes
If a patient has a history of seizure and comes into ER, what do you do?
Ask if there is a change, if no, then just out the door
If you have a new seizure, what do you do?
Consider CT
Get finger stick glucose and it might fix right away
What is Todd’s paralysis?
A transient focal deficit unilateral after a simple focal seizure.
Must do a w/o for stroke in case
How to differentiate a seizure from a non-seizure
Abrupt onset
Memory loss of the event
Purposeless movement the whole time
Positical confusion/lethargy
What can you use to verify psedoseizure?
Use a saline flush and if they move, then it is not a seizure
If hx of seizure disorder, what do you do?
Get glucose
Check to make sure they take meds
Get serum anti-convuslant drug levels for next provider
HCG
Imaging of seizure
CT w/out contrast (only w/ if worried of tumor)
When do you get a LP for seizure?
Fever to r/o meningitis
Subarachnoid
What supportve treatment do you do for seizures?
Large IV nasapharyngeal airway
IV access for glucose
Get a monitor and adminster O2
Most self-resolve in 5 minutes
What is the manage of status epiltehtics
IV lorazepam 1st line
if it doesn’t work, give it again or go to 2nd line med:
fosphenytoin (preferred)
monitor O2 and stop patient from hurting themselves
seizing precautions if it works
If 1st and 2nd line methods do not work for seizure control what do you do?
Induce COMA
EEG
When can hyponatremia lead to seizure?
<120
give NaCl but titrate slow
If a patient has a seizure but not status epliepticus and you see low serum drug levels, what do you do?
Can start a new drug or increase drug
if drug level is normal than go home
If a patient is doing fine but has no history of seizure, what do you do?
Discharge home if normal imaging
NEED to have someone there
no driving
If a patient is sus or eclampsia what do you do?
IV magnesium sulfate
for recently postpartum patients (patients that just recently gave birth)
Febrile seizures, are they concerning?
NO only if status epilepticus
<15 minutes
often viral onset
spike in fever (so peds MC)
6 months to 6 years
treat underlying infection
useful resource for Height/weight/vitals for
pedicalc
