Lecture 3: Fevers and Seizures Flashcards
What is the general temp for a fever?
~100.4F or 38C.
What temperatures must be adjusted?
- Rectal and tympanic are 0.5C/0.9F higher
- Take a degree Off Orifices
- Axillary and temporal temps are lower.
For an adult fever, what are top DDx for someone with recent travel?
- Dengue fever
- Malaria
- TB
- Typhoid
What additional PE features on top of fever may suggest sepsis?
- Hypotension
- Tachycardia
- Hypoxia
- Flushing
- Localized infection
Signs of hemodynamic instability
If fever is present and PNA is suspected but CXR is normal, should we order a CT?
Yes
What is SIRS criteria?
- HR > 90
- Resp > 20
- Temp < 96.8F or > 100.4F
- WBC > 12k or < 4k
Progression of SIRS to septic shock image
Basic antipyretic management for a fever
- Acetaminophen (>12 yo = 325-650 q4h, 10-15mg/kg for peds)
- Ibuprofen (avoid if GI upset/gastric ulcer, not for pts < 6mo)
- Avoid ASA in non-adults (Reye’s syndrome)
When are empiric ABX indicated for a fever?
- Neutropenic or soon to be
- Hemodynamic instability
- Asplenic (surgical or 2/2 SCD)
- Immunosuppressed
When should we admit for fever?
- Concomitant with vital sign abnormalities
- Evidence of end-organ dmg
- Extremely high temp > 41C/105.8F
- Seizure/AMS
- Underlying condition
Different from empiric abx indications
What are the 3 age categories we divide pediatric fever into?
- 0-28d (neonate)
- 1-3mo
- 3-36mo
MC presenting CC in pediatrics EM
What is considered a fever in children < 3mo? 3-36mo?
- Rectal of 38C = fever in children < 3mo
- Rectal of 39C = fever in children 3-36mo
What is the MCC of fever in children < 3mo?
Viral (flu A/B, covid, RSV, HSV, Varicella, Entero, adeno, CMV, rubella)
In infants < 3mo of age with fever, what history do we need?
- Birth history (gestation, maternal hx)
- Immunizations
- Ill contacts
- Fever max temp
- Symptoms (crying/irritability/poor feeding)
What is considered normal HR and RR for a neonate?
- 120-160 BPM
- 30-60 RR
When performing PE on an infant < 3mo, what must be done?
Full exam, fully undressed
What suggests lower respiratory tract infection in an infant < 3mo?
- Cough
- Tachypnea
- Hypoxia
What suggests meningitis in an infant < 3 mo?
- Bulging fontanelle
- Inconsolable crying
What is the criteria for an infant < 3 mo to be considered low risk with a fever?
- Low risk (Well-appearing w/o hx of premature or perinatal complications)
- 0 immunizations in last 48h or recent abx
- WBC 5-15k
- Regular UA (<= 10 WBCs/hpf)
- Imaging good (CXR normal)
- Stool < 5 WBCs
- CSF with < 5 WBCs
L0W RISC
s/o to seth
If we have a high risk neonate, what do we give for empiric abx?
Ampicillin + cefotaxime both 50mg/kg/q8
New Amp and Tax
Rocephin is CId in neonates
How do we manage a low risk infant 1-3 months with a fever?
- OP with f/u in 24h
- Consider IP with or w/o abx
- Based on your personal comfort level
What is the most likely etiology for a pediatric fever for an infant 3-36mo?
Also most likely viral, but r/o serious bacterial.
When can urine catheterization be utilized in infants 3-36 mo with fever?
- UA only in girls < 24m
- UA only in circumcised males < 6m or < 12m if uncircumcised
What two vaccines reduce risk of occult bacteremia greatly in infants 3-36mo?
Fever
Hib and Pneumococcal vaccine
If an infant doesn’t have these UTD, do full w/u.
If an infant 3-36mo presents with fever, is well-appearing, but has a WBC >15k and does not have their 3rd Hib vaccine, what is the abx of choice?
IV Rocephin
What is empiric ABX for pediatric fever in an infant 3-36mo?
(Rocephin or piptazo) + Vanco
Rock the van or pimp the van for the infant
Who can ibuprofen not be used in?
Infants younger than 6mo.
If an infant discharged home from fever has a positive culture but returns well-appearing and afebrile, what is the recommended course of treatment?
10 days of Outpt abx.
Otherwise, admit for IV abx
Define neutropenic fever.
- Temp >= 38C/100.4F for 1hr or single temp >= 38.3C/101F
- ANC < 1000
Must meet both criteria
Severe is ANC < 500
MC in pts on chemotherapy
What recent history suggests neutropenic fever?
Recent chemotherapy tx (10-15days ago)
What is included in w/u of a neutropenic fever?
- CBC w/ diff
- 2 blood cultures, one peripheral, one central
- UA with C&S
- CMP
- CXR
- Bodily fluid assessment/cultures
- CT/US of abd w/ con if abd pain present
When do we start empiric ABX for suspected neutropenic fever and what is it?
- Start immediately after cultures are drawn (within 1 hr).
- Vanco + Cefepime if no source identified
neu = newest cephalosporin + vanco
How do we assess risk for admitting neutropenic fever?
MASCC, with a score 0-20 = admit, but > 20 = low risk.
Low MASCC = admit
If you cant (low) mask the fever, then you admit (how i think of it)
Define status epilepticus
Seizure activity >= 5mins or 2+ seizures without recovery inbetween
What is the w/u for a first-time seizure?
- Indepth history
- Confirm if it was a seizure
- Non-con head CT
- Labs
What is Todd’s paralysis?
Transient focal deficit post simple/complex focal seizure.
If it is new onset, workup as a stroke
Normally resolves in 48h
What clinical features differentiate seizures from other DDx?
- Seizures are usually abrupt onset
- Memory loss of activity
- Purposeless movement
- Postictal confusion/lethargy
If a patient has a hx of seizure disorders, what do we want to double check lab-wise?
- Glucose POC
- Serum of their anti-convulsant drug level (MCC of break-through seizures)
- hCG in females of age
When is non-con CT head indicated in seizure eval??
- First-time
- Change in pattern from normal seizure activity
- Concerned for acute intracranial process
When is LP indicated in seizures?
- Febrile
- Immunocompromised
- Suspicion for SAH
- Do not do during active seizing
Meningitis r/o
How do you manage an acutely seizing pt? (non-pharm)
- Turn on side to avoid aspiration
- Obtain 2 large bore IVs
- Attach monitors
- Monitor airway and try to keep O2 at 100% (also prep for NP airway)
- Ideally self-resolves within 5 minutes
Also clear any obstacles nearby that they could hit.
Management of status epilepticus
- Insert NPA and prep for ET intubation
- DOC IV lorazepam or diazepam (IM) or midazolam (IM)
- Monitor, give anticonvulsant if seizing ceases to prevent recurrence.
- Can repeat another lorazepam dose in 5 mins.
What are the 2nd line tx for status epilepticus?
- Fosphenytoin (DOC)
- Phenytoin (requires 2nd IV)
Both can cause Respiratory depression
What is the concern with giving phenytoin for seizure?
- Requires 2nd IV
- Incompatible with BZDs, fluids, dextrose
- SE of hypotension and arrhythmia if given centrally or too quickly.
Google says phenytoin may precipitate into crystals in NS
If serum drug levels are obtained for a seizing patient and levels are low, what should we do? What if the drug levels are normal?
- If low: replenish via loading and then readjust.
- If normal: If it was only a single normal breakthrough seizure, discharge home and prompt f/u with neurology
If a female presents with seizure and has suspected eclampsia, what is the tx?
IV MgSO4 4-6g IV single dose and then consult OBGYN.
Delays pregnancy + helps with seizures
What substance abuse lowers seizure threshold?
Alcohol
Usage of what drug class during alcohol withdrawal will help prevent seizures?
BZD
When is febrile seizure MC in terms of age?
6mo-6y
six six sick = BAD
Why does febrile seizure occur?
Rapid change in temperature
Not how high the fever went.
Roseola is a common condition that can do this.
If febrile seizure occurs, how should we approach?
- Generally, do NOT treat it as a first time seizure
- Look for source of infection
- If status epilepticus is occurring, sign of severe infection.
