Fevers and Seizures Flashcards
Fever occurs due to ?
- the hypothalamus creating a new “set point” of body temperature
- occurs due to presence of pyrogenic cytokines released by infectious pathogens
when would the fever not be directly proportional to severity of illness?
- children - febrile response > adults
- geriatrics, neonates and pts taking NSAIDS for other conditions may have a normal to below normal temperature
Average normal oral body temperature ?
36.7°C (98.0° F)
what type of temperatures generally more accurate than peripheral
Core - bladder, esophageal, pulmonary arterial catheter, rectal
what/who can alter accurate temp.
Recent food and drink ingestion can also alter accuracy.
hyperventilation or patients whose mouth is not closed
differences on how you take a temp?
- 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
DDX for fever in adults
- Localized bacterial or viral infection (look for source on H&P)
- Sepsis
- Hyperthermia
- Serotonin Syndrome
- neurolpetic malignant syndrome
- fever of unknown origin
would hyperthermia respond to antipyretics?
no
causes for hyperthermia
- environmental exposure
- metabolic heat production due to dysfunction in thermoregulation
- thyroid storm, medication induced
a reaction to drugs that increase serotonin (e.g. SSRI/SNRI, MAOI’s, TCAs)
serotonin syndrome
- a lethal reaction to neuroleptic medications (e.g. haloperidol and fluphenazine)
- muscular rigidity, altered mental status, and autonomic dysfunction
Neuroleptic malignant syndrome
what characteristics are indicativ of Fever of unknown origin?
fever over >38.3°C (100.9° F) on multiple occasions >3 wks w/o a dx being made
causes of fever or unknown origin
Etiologies: autoimmune disorders, vasculitis (giant cell arteritis), SLE, infectious (TB), malignancy (leukemia, lymphoma), Thyroid Storm, Lyme Disease
usually more autoimmune/chronic
important hx info for adult fevers
- 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…)
Fever in an adult with h/o ill contact exposure is MC caused by?
viral
ddx for fever in an adult with h/o travel
Dengue Fever, Malaria, TB, Typhoid
ddx for fever in adult with any h/o IVDU?
Endocarditis, Spinal Epidural Abscess, Osteomyelitis, Cutaneous Abscess, Cellulitis
what additional PE features along with fever indicate hemodynamic instability?
low BP, tachycardia, hypoxia
- extremities are often cool (vasoconstriction) and skin may be clammy
- Flushed face
- Hot, Dry skin
localizing signs of infection can be seen in where during a PE?
Skin, ENT, pulmonary, heart, abdomen, GU, neuro/meningeal, joints
what 2 conditions are often the culprit with systemic infection
Pneumonia and UTI
get UA for UTI ASAP
If suspicion for PNA but pt has a normal CXR, what other imaging modality can you choose?
CT!
Progression/severity of fever in adults
SIRS - sepsis - severe sepsis - septic shock
criteria for SIRS
- HR >90
- Rsp >20
- Temp < 96.8 or >100.4
Criteria for sepsis
SIRS + source of infection
criteria for severe sepsis?
sepsis + organ dysfunction
criteria for septic shock?
- persistent HoTN after bolus
- Lactate >4.0
Basic management for fever
Reduce body temperature
- General - cold/alcohol compresses, ice bags, ice-water enema, ice baths
- Antipyretics - administer around the clock instead of intermittently to avoid period chills/sweats
types of antipyretics
- Acetaminophen
- Ibuprofen 400-600 mg q6h (Toradol IV/IM)
avoid ibuprofen in who?
- GI upset / h/o gastric ulcers
- children < 6 mo
Avoid ASA in who?
pediatrics < 18yo!! - Reye’s Syndrome Risk
alt us of antipyretic
alternate between acetaminophen and ibuprofen q3h early in course of fever if temperature remains uncontrolled - not generally necessary
Empiric antimicrobials are avoided unless patient is
adult
- neutropenic or expected to become neutropenic in next few days
- hemodynamically unstable
- asplenic - surgical or secondary to sickle cell disease
-
immunosuppression - HIV, medications
- systemic corticosteroids, azathioprine, cyclosporine, chemotherapy, DMARDs, Immunosuppressive agents (end in -mab)
indications to admit a fever
- Concomitant VS abnormalities
- Evidence of end-organ damage when sepsis is suspected or confirmed
- > 41°C (105.8° F)
- Associated seizure or other mental status change
- Underlying condition requires admission
Follow up within 24-72 hours if discharged
Pediatric fever lacks of a mature immune system and development leads to ?
vague sx at presentation and a greater risk of serious infection
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
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
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
MCC of fever in infants
viral
- Influenza A & B, Covid, respiratory syncytial virus (RSV)
- HSV, Chickenpox (Varicella), Enterovirus, adenovirus, cytomegalovirus (CMV), rubella
common pathogens to cause fever in Infants ≤ 3 months of age
- Viral (MC)
- bacterial - group B Streptococcus, Listeria, Escherichia coli, S. pneumoniae, Treponema pallidum
Hx of pediatric fever in Infants ≤ 3 months of age
- Birth history
- length of gestation, maternal infections, use of peripartum antibiotics in mother/neonate, hospital course/neonatal complications - Immunization status
- Ill contact exposure
- Fever: maximum temp, method obtained, timing, antipyretic use
- sx are often nonspecific of a serious illness - crying/irritability, poor feeding
PE of fever in Infants ≤ 3 months of age
- Undress infant completely for entire exam
- Assess VS
- 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
Normal VS for neonate
- HR 120-160 bpm
- RR 30-60 breaths/min
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
T/F: Even if a local source of infection is suspected EMB recommends testing for an occult infectious etiology
T
diagnostics for fever in Infants ≤ 3 mo of age
- CBC w/ diff
- UA with C&S via catheter/suprapubic specimen
- LP - Gram stain and CX, glucose, protein, cell count w/ diff.
- CXR if tachypnea, cough or hypoxemia
- Stool sample if diarrhea
- Serum biomarkers: CRP and procalcitonin
criteria for neonates/Infants ≤ 3 months of age to be “low risk” for serious bacterial infections
- Well-appearing w/o a history of prematurity or perinatal complications
- No immunizations w/n 48 hr and no recent abx
- WBC 5,000 - 15,000/mm³ - Bands ≤ 1,500/mm³
- Nml UA - ≤WBC 10/hpf
- CSF with < 5 WBCs/hpf
- Stool with < 5 WBCs/hpf if diarrhea
- nml CXR - no evidence of acute cardiopulmonary disease
factors that consider an infant high/intermediate risk when prsenting with fever
from picture
- age < 22 d old (or 28 d for improved sensitivity)
- leukocytes in urine
- procalcitonin > 0.5ng/mL
- CRP >20 mg/L or ANC >1000 - intermediate risk
management for fever in Infants ≤ 3 months of age (inpatient)
- ≤ 28 d - admit for parenteral abx
- 1-3 mo - admit for parenteral abx if FAILED to meet “low risk” criteria
- ampicillin PLUS cefotaxime: both 50 mg/kg q8
Infants 1-3 months who meet “low-risk” management options:
-
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 - Inpatient w/ or w/o abx
Overall decision is based on the provider’s comfort level
management for Infants 1-3 months with identifiable viral illness
- UA (with C&S if positive findings)
- Blood CX
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
hx in infants 3-36 mo with fever
- Fever: maximum temp, method obtained, timing, antipyretic use
- Past medical history - including birth history
- Ill contacts
- Immunization status
- routine vaccination of Hib and S.pneumoniae in infants has reduced the risk of occult bacteremia from 5% to 1%
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
PE of fever in infants 3-36 mo of age
- General assessment will identify toxicity
- Full PE with close attn to the skin, TM‘s, oropharynx, lungs, abdominal and genitourinary systems
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
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
management for fever in Infants 3-36 months of age - Well appearing and immunizations UTD
- Catheterized urine collection: UA only in girls < 24 m, uncircumcised boys < 12 m, circumcised boys < 6 m
- 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
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)
- CBC with diff
- UA with C&S (same population as well appearing with immunization UTD)
- Blood CX if WBC > 15,000/µL
- CXR if WBC ≥20,000/µL
- 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
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
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
Infants 3-36 months of age - If no source of infection is found, what is recommended
empiric abx: ceftriaxone / pip/taz PLUS vancomycin
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
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
Neutropenic fever is defined as:
- Temp ≥ 38°C (100.4° F) x 1 hr or a single temp ≥ 38.3°C (101° F)
- Neutropenia - ANC < 1000 cells/mm³ (Absolute Neutrophil Count)
- Severe Neutropenia - ANC < 500 cells/mm³
presentation/hx of neutropenic fever
- fever - earliest and MC only sign of infection
- h/o recent chemotherapy tx
- Hx should focus on searching for site of infection
- severity of sx may not be proportional to the severity of infection
chemotherapy affects ___ and the ___ allowing bacterial colonization and transposition across mucosa
myelopoiesis
integrity of GI mucosa
neutrophil counts usually are lowest when and increase when?
- 10-15 days after chemotherapy
- 5 days after reaching nadir (the lowest point)
presentation/PE of neutropenic fever
should focus on locating sight of infection - signs are often minimal compared to severity of infection
- oral cavity, oropharynx
- lungs
- heart
- abdomen
- skin
- IV and catheters sites
- perianal area - abscess, infected fissure - avoid DRE until after abx are initiated - neuro - meningeal signs
diagnostics for neutropenic fever
- CBC w/ diff
- 2 blood CX - 2 different sites: one from peripheral vein, the other from central catheter (if present)
- UA with C&S
- CMP - attn to electrolytes, renal and liver function
- CXR
- 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) - CT/US of abd w/ contrast - if abdominal pain/tenderness
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
neutropenic fever - High risk patients require admission (3)
- profound neutropenia expected to last > 7 days
- comorbid medical conditions
- acute liver/renal injury
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
seizures that has no cause can be identified
Primary (idiopathic) seizures
seizure with identifiable neurologic condition
Secondary (symptomatic) seizures
mass lesion, previous head injury, stroke
a seizure that occurs within 7 days of an insult
Provoked seizure
seizure with no acute precipitating factor can be identified
Unprovoked seizure
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
persistent seizure activity despite IV administration of 2 antiepileptic drugs
Refractory status epilepticus
what to ask about in Seizure activity
- duration
- 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
what to ask if pt has h/o seizures
- What is the baseline seizure activity?
- Are there precipitating factors?
what to ask if pt has had no previous h/o seizures?
Obtain a more indepth history to determine underlying cause
- similar episodes, unexplained injuries, nocturnal tongue biting
- head injury, headaches
- pregnancy or recent delivery (eclampsia)
- hx of metabolic or electrolyte disorders, hypoxia, CA, coagulopathy or anticoagulation disorders, exposure to toxins, drug or alcohol ingestion/withdrawal
PE for seizures
- VS and finger stick glucose
- Assess for injuries
- neck/spine, posterior shoulder dislocation
- tongue/mouth laceration, dental fracture - Pulmonary - risk of aspiration
- Neurologic exam with serial exams
- attn to LOC and mentation to avoid non-convulsant status epilepticus
what VS abnormality/condition can occur in patients who are in status epilepticus
hyperthermia
a transient focal deficit (usually unilateral) after a simple or complex focal seizure
Todd’s paralysis
will resolve within 48 hours
additional work-up for Todd’s paralysis
stroke if new onset
4 Clinical features to differentiate seizure from other conditions
- abrupt onset - most SZ are abrupt
- memory loss of activity
- purposeless movement during attack
- postictal confusion/lethargy
DDX for sizures in infants and children
- Breath-holding spells
- Vasovagal event
- Movement disorders
- Night terrors
- Hypoglycemia
- Hypovolemia
- Acute dystonic reactions
DDX for seizures in adults
- seizures
- syncope
- pseudoseizures or psychogenic seizures
- hyperventilation syndrome
- migraine HA
- movement disorders
diagnostics for seizure If hx of seizure disorder
- glucose (fingerstick/point of care)
- serum anti-convulsant drug levels
- low levels indicate non-compliance (MC cause of break-through seizures) - hcg - females of reproductive age
diagnostics for seizure if no hx of seizure disorder
- glucose (fingerstick/point of care)
- BMP
- Mg
- Hcg
- toxicology
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)
Lumbar Puncture indications
for seizures
- febrile
- immunocompromised
- suspicion for subarachnoid hemorrhage
- CI - avoid during active seizing
Management - Active Seizure
- turn on side to avoid aspiration
- suction or NG tube to prevent aspiration - obtain large bore IV access x 2
- administer glucose if hypoglycemic - attach cardiac, pulse, end-title capnography, O2, temp monitors
- monitor airway, O2 100%
- prepare for nasopharyngeal airway if needed - most seizures self-resolve within 5 min
Management - Status Epilepticus
- Insert nasopharyngeal airway
- prepare for ET intubation - 1st-line: IV lorazepam
- Alt: diazepam; midazolam - Monitor airway and oxygenation d/t SE of rsp depression
- If seizing ceases - anticonvulsant initiated to prevent recurrence
- 2nd-line: fosphenytoin / phenytoin
- alt: levetiracetam, valproic acid, phenobarbital
which second-line medication for status epilepticus is more preferred than the other?
fosphenytoin - less SE
phenytoin is incompatible with what other medications?
BZD’s, fluids, dextrose
SE phenytoin
- hypotension and cardiac arrhythmia if given too rapidly or in a central line
- phenytoin requires a 2nd IV line
SE fosphenytoin & phenytoin
respiratory depression
Management - Refractory Status Epilepticus
- Persistent seizure after 1st- and 2nd-line tx prepare for intubation and coma induction
- EEG monitoring
- Propofol MC; midazolam, pentobarbital
Management - Status Epilepticus if suspecting other causes (lyte abnormalities)
- Hypoglycemia - dextrose IV
- Hyponatremia - 3% NaCl
- Hypocalcemia - 10% calcium gluconate
- Hypomagnesemia - magnesium sulfate
what management/lab to obtain for Status Epilepticus if intubated
ABG
helps to determine adequate ventilation
hypercapnia is proportionate to hypoventilation
Management - Status Epilepticus if hyperthermia present
general cooling measures
Management - H/o Seizure Disorder w/o Status Epilepticus
-
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 - 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
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
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
management for Suspected eclampsia
IV magnesium sulfate 4-6 g IV x 1 dose and emergent consult to OBGYN
management for seizures if alcohol use
- Educate on alc and avoidance of precipitating factors
- BZD for ETOH withdrawal will often prevent seizure
alcohol use lowers seizure threshold by:
- increased likelihood of missed medication
- risk of head injury
- sleep deprivation
- toxic co-ingestions
- electrolyte abnormalities
- alcohol withdrawal (delirium tremens)
Febrile Seizures - Generalized seizure activity usually lasting how long
< 15 minutes
febrile seizures are MC in who?
6 months - 6 years old
management for febrile seizures
- tx underlying infection and fever if seizure has ceased
- if status tx as previously discussed including CT/MRI brain, CSF analysis
- consider abx and acyclovir
