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Emergency Med > Fevers and Seizures - Exam 1 > Flashcards

Fevers and Seizures - Exam 1 Flashcards

1
Q

What is considered a fever? What is the underlying cause?

A

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

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2
Q

What are 2 important questions to ask when first interviewing an adult that presents with a fever?

A

**Any new medications? Could this be a drug reaction?
**Any hx of injectable drug use??

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3
Q

Are fevers directly related to the severity of illness? What populations tend to present differently?

A

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

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4
Q

What 3 populations tend to have a LOWER than normal temperature even when they are sick and should have one?

A

geriatrics, neonates and pts taking NSAIDs

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5
Q

What is the average normal body temp? When the temp is taken orally, what 3 things can cause it to be NOT accurate?

A

98.0F

  1. Pt who is hyperventilating
  2. Pt who did not close their mouth
  3. recent food/drink ingestion
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6
Q

_______ temps are more accurate than peripheral/ **Which one is the most accurate?

A

CORE temps are better

rectal temps are the most accurate

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7
Q

How are rectal and tympanic temps reading different when compared to oral temps?

A

Rectal and tympanic temps are 0.5°C (0.9° F) higher (Take a ° (degree) Off the Orifices)

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8
Q

How are axillary and forehead temps reading different when compared to oral temps?

A

Axillary and forehead temps are 0.5°C (0.9° F) lower (I visualize the outside air brings down the temp a little)

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9
Q

______ is a fever in the adult that will NOT get better with NSAIDs/Tylenol. What are 3 general causes?

A

hyperthermia

environmental exposures
thyroid storm
medication induced

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10
Q

muscular rigidity
altered mental status
autonomic dysfunction (fever)

What am I?
What causes it?

A

Neuroleptic malignant syndrome

a lethal reaction to neuroleptic medications (e.g. haloperidol and fluphenazine)

aka these pts will be VERY HOT

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11
Q

What is the criteria to dx fever of unknown orgin? What should you do next?

A

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

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12
Q

What are 4 s/s that indicate hemodynamic instability?

A

low BP, tachycardia, hypoxia, fever

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13
Q

When looking for signs of infection, ______ and ______ are big offenders

A

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!

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14
Q

**What are the SIRS criteria?

A

WBC less than 4K or greater than 12K

HR > 90

Resp > 20

Temp less 96.8 or greater than 100.4

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15
Q

What is considered sepsis? Severe sepsis?

A

SIRS criteria plus source of infection

severe sepsis: sepsis and organ dysfunction

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16
Q

What is considered septic shock?

A

persistent hypotension after bolus AND

lactate above 4.0

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17
Q

What is the Tylenol dose for a pediatric pt? What if older than 12? What is the ibuprofen dosing in kids?

A

10-15mg/kg for peds

if greater than 12 years old 325-650 q4 hours

5-10 mg/kg pediatric dose

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18
Q

What is the age restriction for ibuprofen? ASA?

A

no ibuprofen if less than 6 months

no ASA if less than 18 due to risk of Reye’s Syndrome Risk

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19
Q

What is an alternative for fever control if the temp remains uncontrolled?

A

alternate between acetaminophen and ibuprofen every 3 hours early in course of fever

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20
Q

What are the empiric abx indications for fever management in an adult?

A

neutropenic

hemodynamically unstable

asplenic: surgical or secondary to sickle cell

immunosuppressed

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21
Q

What are the indications to admit if an adult pt has a fever? If discharged, when do they need to f/u?

A

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

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22
Q

pediatric fever is due to a lack of a mature immune system and development leads to _____ at presentation and a greater risk of ______

A

vague symptoms

serious infection

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23
Q

_____ is the MC CC presenting in this pediatric population. How is management classified? Give the ranges

A

FEVER

based on age:
0 to 28 days of age (aka neonate)
1 to 3 months of age
3 to 36 months of age

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24
Q

**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?

A

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

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25
**______ 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
26
What is classic chickenpox presentation?
will have red spots all over with various stages of healing present ulcer, papule and blister
27
**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
28
**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
29
What are important history questions you want to ask in a pt with a fever who is less than 3 months old?
30
What are normal vital signs for pt less than 3 months old?
HR 120-160 bpm RR 30-60 breaths/min
31
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
32
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
33
_______ may be elevated if the source of infection is bacterial or due to tissue injury
procalcitonin
34
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
35
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
36
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
37
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)
38
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!!
39
______ 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!!
40
routine vaccination of ____ and ______ in infants has reduced the risk of occult bacteremia from 5% to 1%
Hib **S.pneumoniae
41
**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
42
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
43
What age is strep throat common after?
strep is common after 2 years old
44
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
45
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
46
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
47
_____ 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
48
Response to antipyretic doesn’t affect ______.
disposition aka CAN discharge a pt home with a fever
49
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
50
**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
51
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
52
**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
53
Why does chemotherapy cause neutropenic fevers?
chemotherapy affects myelopoiesis and the integrity of GI mucosa allowing bacterial colonization and transposition across mucosa
54
When are neutrophil counts usually the lowest?
lowest 10-15 days after chemotherapy and increase 5 days after reaching nadir (the lowest point)
55
**______ need to be avoided in pt with neutropenic fever until AFTER abx are on board
DRE
56
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)
57
**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)
58
______ is a good abx choice for covering gram +
vanc
59
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)
60
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
61
_______ is the risk assessment tool used by oncology to determine disposition in NF pts. What score = admission?
MASCC 0-20 requires admission
62
_____ 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
63
______ a seizure that occurs within 7 days of an insult _______ no acute precipitating factor can be identified
Provoked seizure Unprovoked seizure
64
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
65
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??
66
What are some things you want to note about the seizure?
67
______ is very suggestive of a true seizure
postictal confusion or lethargy
68
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
69
_____ can occur in patients who are in status epilepticus
hyperthermia
70
**______ 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
71
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
72
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
73
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
74
_____ is the MC cause of break-through seizures in pts with a hx of seizures
non-compliance
75
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
76
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
77
What are the LP indications in a seizure pt?
febrile immunocompromised suspicion for subarachnoid hemorrhage
78
What is the management for a pt who is actively seizing?
79
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
80
What should you do if the pt is still seizing after 5 minutes?
repeat dose of IV lorazepam
81
status epilepticus, once the seizing stops, what should you do next?
anticonvulsant should be initiated to prevent recurrence
82
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
83
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
84
What are the SE of fosphenytoin and phenytoin?
respiratory depression
85
What are second line alternatives to fosphenytoin and phenytoin?
levetiracetam (Keppra),valproic acid phenobarbital
86
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
87
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
88
If the seizure was due to hyponatremia what is the tx?
3% NaCl 4-6 mL/kg
89
If the seizure was due to hypocalcemia what is the tx?
10% calcium gluconate 0.3 mL/kg over 10 minutes
90
If the seizure was due to hypomagnesemia what is the tx?
50 mg/kg of magnesium sulfate over 20 minutes
91
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
92
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
93
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
94
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
95
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
96
**What is the tx for suspected eclampsia?
IV magnesium sulfate 4-6 g IV x 1 dose and emergent consult to OBGYN
97
Use of_____ in ETOH withdrawal will often prevent seizure
benzos
98
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
99
if _______ occurs it is usually associated with more severe infections
febrile seizure status epilepticus
100

Emergency Med (21 decks)

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