Fevers and Seizures - Exam 1 Flashcards
What is considered a fever? What is the underlying cause?
100.4
Fever occurs due to the hypothalamus creating a new “set point” of body temperature
occurs due to the presence of pyrogenic cytokines released by infectious pathogens
What are 2 important questions to ask when first interviewing an adult that presents with a fever?
**Any new medications? Could this be a drug reaction?
**Any hx of injectable drug use??
Are fevers directly related to the severity of illness? What populations tend to present differently?
NOT directly proportional
children have a GREATER febrile response
geriatrics, neonates and patients taking NSAIDS for other conditions may have a normal or below normal temperature
What 3 populations tend to have a LOWER than normal temperature even when they are sick and should have one?
geriatrics, neonates and pts taking NSAIDs
What is the average normal body temp? When the temp is taken orally, what 3 things can cause it to be NOT accurate?
98.0F
- Pt who is hyperventilating
- Pt who did not close their mouth
- recent food/drink ingestion
_______ temps are more accurate than peripheral/ **Which one is the most accurate?
CORE temps are better
rectal temps are the most accurate
How are rectal and tympanic temps reading different when compared to oral temps?
Rectal and tympanic temps are 0.5°C (0.9° F) higher (Take a ° (degree) Off the Orifices)
How are axillary and forehead temps reading different when compared to oral temps?
Axillary and forehead temps are 0.5°C (0.9° F) lower (I visualize the outside air brings down the temp a little)
______ is a fever in the adult that will NOT get better with NSAIDs/Tylenol. What are 3 general causes?
hyperthermia
environmental exposures
thyroid storm
medication induced
muscular rigidity
altered mental status
autonomic dysfunction (fever)
What am I?
What causes it?
Neuroleptic malignant syndrome
a lethal reaction to neuroleptic medications (e.g. haloperidol and fluphenazine)
aka these pts will be VERY HOT
What is the criteria to dx fever of unknown orgin? What should you do next?
fever over 38.3°C (100.9° F) on multiple occasions over 3 weeks without a diagnosis being made
call infectious dz!! etiology is very vast: autoimmune disorders, vasculitis (giant cell arteritis), SLE, infectious (TB), malignancy (leukemia, lymphoma), Thyroid Storm, Lyme Disease
What are 4 s/s that indicate hemodynamic instability?
low BP, tachycardia, hypoxia, fever
When looking for signs of infection, ______ and ______ are big offenders
PNA and UTI
should NOT wait for the pt to urinate, straight cath if the pt cannot urinate in a timely manner
CXR for PNA, if negative with high suspicion, get CT!
**What are the SIRS criteria?
WBC less than 4K or greater than 12K
HR > 90
Resp > 20
Temp less 96.8 or greater than 100.4
What is considered sepsis? Severe sepsis?
SIRS criteria plus source of infection
severe sepsis: sepsis and organ dysfunction
What is considered septic shock?
persistent hypotension after bolus AND
lactate above 4.0
What is the Tylenol dose for a pediatric pt? What if older than 12? What is the ibuprofen dosing in kids?
10-15mg/kg for peds
if greater than 12 years old 325-650 q4 hours
5-10 mg/kg pediatric dose
What is the age restriction for ibuprofen? ASA?
no ibuprofen if less than 6 months
no ASA if less than 18 due to risk of Reye’s Syndrome Risk
What is an alternative for fever control if the temp remains uncontrolled?
alternate between acetaminophen and ibuprofen every 3 hours early in course of fever
What are the empiric abx indications for fever management in an adult?
neutropenic
hemodynamically unstable
asplenic: surgical or secondary to sickle cell
immunosuppressed
What are the indications to admit if an adult pt has a fever? If discharged, when do they need to f/u?
Concomitant vital sign abnormalities
Evidence of end-organ damage when sepsis is suspected or confirmed
Temperature > 41°C (105.8° F)
Associated seizure or other mental status change
Underlying condition requires admission
24-72 hours if discharged
pediatric fever is due to a lack of a mature immune system and development leads to _____ at presentation and a greater risk of ______
vague symptoms
serious infection
_____ is the MC CC presenting in this pediatric population. How is management classified? Give the ranges
FEVER
based on age:
0 to 28 days of age (aka neonate)
1 to 3 months of age
3 to 36 months of age
**What is considered a fever in a pt who is LESS than 3 months old?
**kid 3-36 months old?
**how does the temp need to be obtained?
38°C (100.4° F) in children < 3 months of age
39° C (102.2) in children 3-36 months of age
must be RECTAL
**______ is the MC cause of fever in pts less than 3 months old? Then _______
viral sources: flu A, flu B, COVID, RSV, HSV, chickenpox, enterovirus, adenovirus, CMV, rubella
bacteria: group B strep, listeria, E coli, S pneu, T pallidum
What is classic chickenpox presentation?
will have red spots all over with various stages of healing present
ulcer, papule and blister
**What is the classic presentation of measles? Are they contagious?
high fever with rash that starts at HEAD and goes DOWN the body
YES!! need to isolate
**What is the classic presentation of roseola?
rash that starts on the abdomen and spreads outward towards the extremities
typically moves very fast
+/- febrile seizures
What are important history questions you want to ask in a pt with a fever who is less than 3 months old?
What are normal vital signs for pt less than 3 months old?
HR 120-160 bpm
RR 30-60 breaths/min
What are the s/s of a pt less than 3 months old who has a respiratory tract infection? meningitis?
Cough, tachypnea or hypoxia
Inconsolable crying during handling and a bulging fontanelle
What should be included in your w/u of a pt less than 3 months old who has a fever? What is important to note about the lumbar puncture?
if younger than 28 days old, getting a LP
_______ may be elevated if the source of infection is bacterial or due to tissue injury
procalcitonin
If order for a pt who is less than 3 months old to go home from ER with a fever, what criteria must be met?
must be labeled “low risk” and ALL criteria must be met
What are 3 criteria according to the Step by Step protocol that automatically label the ped pt “high risk” if you have a fever? Intermediate risk? What are the criteria the kid must meet in order to qualify for the Step by Step criteria?
high risk:
younger than 28 days old
leukocytes in the urine
procalcitonin is greater or equal to 0.5ng/mL
intermediate risk:
CRP > 20mg/L or ANC > 10,000
must be:
term baby
temp greater than 100.4
be sick for at least a couple hours
previously healthy
no hospitalizations
no previous abx
normal PE
What is the management of an pt who is less than 28 days old who has a fever? ped pt 1-3 months old? What is the medication of choice?
Infants ≤ 28 days of age: admit for IV abx
1-3 months old: admit for parenteral antibiotics if FAILURE to meet “low risk” criteria
ampicillin PLUS cefotaxime
What is the management for ped pts 1-3 months old who meet the “low risk” criteria?
can do either
Outpatient with or without antibiotics and a required f/u in 24 hours
or inpt +/- abx
all depending on the provider’s comfort level and pt’s normal pediatrician (if they can get f/u or not)
What should you do next if the ped pt 1-3 months old presents with an identifiable viral illness?
UA (with C&S if positive findings)
Blood cultures
get consults!!
______ is the MC etiology of a ped pt who is 3-36 months old. **Very important to ask _______ in this patient population
viral is MC but serious bacterial illness need to be ruled out
**need to assess vaccination status!!
routine vaccination of ____ and ______ in infants has reduced the risk of occult bacteremia from 5% to 1%
Hib
**S.pneumoniae
**What are some PE findings in the 3-36 month population that clues you in that they are NON-toxic? **What will toxic patients present like?
non-toxic patients will be alert and make eye contact, be playful and console easily, have positive response to interactions, negative (bad) response to noxious stimuli
**toxic: lethargy, poor perfusion, hypo- or hyperventilation, and/or acrocyanosis
aka sick babies will just lie there
When should you get a CXR in a 3-36 month pt? If needed, what is the associated timeframe goal of IV abx?
tachypnea or WBC≥ 20,000/µL
Parenteral antibiotics given within 1 hour of arrival
What age is strep throat common after?
strep is common after 2 years old
What is the tx for a well appearing pt 3-36 months old who is also UTD on immunizations? If negative, what should you do next? If positive?
Catheterized urine collection
UA only in girls < 24 m,
uncircumcised boys < 12 m
circumcised boys < 6 m
negative UA: d/c home with antipyretics
positive: single dose of parenteral antibiotics with f/u in 12-24 hours
What vaccines are needed to be UTD?
What is the management for ped pts 3-36 months old who are well appearing and NOT UTD on vaccines?
not UTD (or doesn’t have 3 Hib and Pneumococcal vaccines)
need blood cultures from 2 different spots
What is the management for ped pts 3-36 months old who are ill appearing, unable to maintain fluids or who are unlikely to f/u or return to ED?
ADMIT pt
if infection source is known. treat it
if not: empirically tx with
ceftriaxone (Rocephin) OR piperacillin/tazobactam (Zosyn) PLUS vancomycin
_____ should be administered early in the emergency department course to improve the patient’s comfort level. What is the preferred medication?
Antipyretics
Acetaminophen: 10-15mg/kg q4 hours
Response to antipyretic doesn’t affect ______.
disposition
aka CAN discharge a pt home with a fever
What should you do if a patient is discharged home and blood cultures later reveal bacteremia?
repeat eval of pt!!! aka they need to come back to ER
well appearing, afebrile: outpt 10 day course of abx and f/u with Ped
ill appearing/febrile: ADMIT with IV abx
**What is a neutropenic fever defined as?
** Temp ≥ 38°C (100.4° F) for 1 hour or a single temp ≥ 38.3°C (101° F)
Neutropenia - ANC < 1000 cells/mm³ (Absolute Neutrophil Count)
Severe Neutropenia - ANC < 500 cells/mm³
ANC: absolute neutrophil count
in a neutropenic fever, _____ is usually the earliest and often only sign of infection
fever
A specific source of infection is identified in only 20% to 30% patients
**What is usually discovered in a pts hx with neutropenic fever? Are symptoms correlated with extent of infection?
History of recent chemotherapy treatment
The severity of symptoms may NOT be proportional to the severity of infection
Why does chemotherapy cause neutropenic fevers?
chemotherapy affects myelopoiesis and the integrity of GI mucosa allowing bacterial colonization and transposition across mucosa
When are neutrophil counts usually the lowest?
lowest 10-15 days after chemotherapy and increase 5 days after reaching nadir (the lowest point)
**______ need to be avoided in pt with neutropenic fever until AFTER abx are on board
DRE
What is the w/u on a pt with neutropenic fever? Where do the blood cultures need to be obtained from?
all the things!!!!
obtained from 2 different sites: one from peripheral vein, the other from central catheter (if present)
**What is the empiric tx for neutropenic fever? At what point during the w/u should you start them?
**Vancomycin + Cefepime
Empiric antibiotics should be administered immediately after blood cultures are obtained (within 1 hour of arrival)
______ is a good abx choice for covering gram +
vanc
If hemodynamic instability, catheter-related infection, skin/soft tissue infection, pneumonia, or known colonization with resistant organism, need to cover for ______. If abdominal symptoms are present need to cover for ______
cover gram + (use vanc)
anaerobes (metro, clinda, or something that ends in -penem)
a pt with neutropenic fever, need to consult ______ with regards to disposition. What is considered a high risk NF pt?
consult oncology!!
high risk:
profound neutropenia expected to last > 7 days
comorbid medical conditions
acute liver/renal injury
_______ is the risk assessment tool used by oncology to determine disposition in NF pts. What score = admission?
MASCC
0-20 requires admission
_____ no cause can be identified
______ identifiable neurologic condition is identified such as a mass lesion, previous head injury, stroke
primary (idiopathic) seizure
secondary (symptomatic) seizure
______ a seizure that occurs within 7 days of an insult
_______ no acute precipitating factor can be identified
Provoked seizure
Unprovoked seizure
What is status epilepticus? What is considered refractory status epilepticus?
seizure activity for ≥ 5 minutes or two or more seizures without regaining consciousness between the seizures - multiple seizures back to back without recovery
persistent seizure activity despite IV administration of 2 antiepileptic drugs
What are the 2 different presentations of seizures in the ED?
recently had a seizure or actively seizing!
** is this seizure new or is it a known condition??
What are some things you want to note about the seizure?
______ is very suggestive of a true seizure
postictal confusion or lethargy
What are 4 things should you closely examine if the pt had a seizure?
POC glucose
assess for injuries: neck/spine, posterior shoulder dislocation, tongue/mouth laceration, dental fx
pulm exam: risk of aspiration
neuro exan with serial exams
_____ can occur in patients who are in status epilepticus
hyperthermia
**______ a transient focal deficit (usually unilateral) after a simple or complex focal seizure. What is the management? When will it resolve?
Todd’s paralysis
if new onset: need to w/u as a stroke
within 48 hours
What are 4 clinical features that differentiate a seizure from another condition?
abrupt onset
memory loss of activity
purposeless movement during seizure
postical confusion/lethargy
What is the Soto saline sign for a pseudoseizure?
squirt 10cc of saline or tap water through a syringe into the pt’s eye
true seizure will not flinch
pseudoseizure: pt will turn/move out of the way
What is the w/u of a pt who presents with a seizure and has a hx of seizure disorder?
glucose (fingerstick/point of care)
serum anti-convulsant drug levels
hcg - females of reproductive age
_____ is the MC cause of break-through seizures in pts with a hx of seizures
non-compliance
What is the w/u of a pt who presents with a seizure who does NOT have a hx of seizure disorder?
glucose (fingerstick/point of care)
BMP: looking for electrolyte disturbances
magnesium
Hcg
UDS: cocaine, phencyclidine (PCP), heroin, methamphetamines, inhalants can all cause seizures
What are the head CT w/o indications in pt with seizure?
first-ever seizure
change in pattern of normal seizure activity
concern for acute intracranial process
abnormal neuro exam
What are the LP indications in a seizure pt?
febrile
immunocompromised
suspicion for subarachnoid hemorrhage
What is the management for a pt who is actively seizing?
What is the management for status epilepticus?
insert nasopharyngeal airway and prepare for ET intubation (SECURE an airway)
IV lorazepam
monitor airway and give oxygen
What should you do if the pt is still seizing after 5 minutes?
repeat dose of IV lorazepam
status epilepticus, once the seizing stops, what should you do next?
anticonvulsant should be initiated to prevent recurrence
What are 2nd line options for medication management in Status Epilepticus? Which one is preferred? Why?
fosphenytoin (Cerebyx) or phenytoin (Dilantin)
fosphenytoin is preferred - less SE
phenytoin requires a 2nd IV line
Why is phenytoid NOT preferred over fosphenytoin?
phenytoin requires a 2nd IV line
incompatible with BZD’s, fluids, dextrose
SE of hypotension and cardiac arrhythmia if given too rapidly or in a central line
What are the SE of fosphenytoin and phenytoin?
respiratory depression
What are second line alternatives to fosphenytoin and phenytoin?
levetiracetam (Keppra),valproic acid phenobarbital
What is the treatment for Status Epilepticus if the first and second line tx options fail?
prepare for intubation and coma induction (midazolam, propofol and pentobarbital)
EEG monitoring
If the seizure was due to hypoglycemia what is the tx?
Infants: 4-5 mL/kg 10% dextrose IV
Older children: 2 mL/kg 25% dextrose IV
If the seizure was due to hyponatremia what is the tx?
3% NaCl 4-6 mL/kg
If the seizure was due to hypocalcemia what is the tx?
10% calcium gluconate 0.3 mL/kg over 10 minutes
If the seizure was due to hypomagnesemia what is the tx?
50 mg/kg of magnesium sulfate over 20 minutes
If a refractory status epilepticus patient does get intubated, _____ needs to be monitor. What does it help with? _____ is proportionate to ______
ABG
helps to determine adequate ventilation
hypercapnia is proportionate to hypoventilation
What is the management of a pt with a seizure who has a hx of seizure disorder w/o status epilepticus?
Obtain serum drug levels
Replenish anticonvulsant if drug levels are therapeutically low
Provide loading dose of anticonvulsant then restart or adjust regular regimen
What is the management of a pt with a seizure who has a hx of seizure disorder w/o status epilepticus and their seizure drug levels are therapeutically normal with only 1 breakthrough normal seizure?
discharge home to reliable caregiver and a prompt f/u with neurology
What is the management of a pt with a seizure who has a hx of seizure disorder w/o status epilepticus and seizure is outside of what is considered “normal” for them and no precipitants are identified?
consultation with patient PCP or neurology should be made
if adjusted meds, need to f/u with neurology in 1-3 days
What are the requirements to go home in a pt who is conscious post seizure without a hx of seizure disorder? What are the discharge instructions?
patient physical exam has returned to baseline
normal head CT scan
normal laboratory evaluation
any abnormalities noted -> admit to neurology
discharge instructions:
-discharge to supervision of reliable caregiver
-no driving or operating heavy machinery
-follow up with neurology
**What is the tx for suspected eclampsia?
IV magnesium sulfate 4-6 g IV x 1 dose and emergent consult to OBGYN
Use of_____ in ETOH withdrawal will often prevent seizure
benzos
What is considered a febrile seizure? What age range is MC?
Generalized seizure activity usually lasting <15 minutes
MC between 6 months and 6 years
tx the underlying cause
if _______ occurs it is usually associated with more severe infections
febrile seizure status epilepticus
