fever

FeverFeverChapter ReviewChapter Review

Khalfan AL AmraniKhalfan AL AmraniR5R5

McGill Emergency ProgramMcGill Emergency Program

Outline Outline

Fever: the basicsFever: the basicsDefinition of termsDefinition of termsPathogenesisPathogenesisNormal temperatureNormal temperatureEtiology Etiology

Fever: Initial resuscitationFever: Initial resuscitationFever: approachFever: approach

Syndromes approachSyndromes approachGeneral approachGeneral approach

Quizzes Quizzes

Definitions Definitions

Fever: elevation in body core temperature resulting from Fever: elevation in body core temperature resulting from a resetting of the thermostatic regulatory system caused a resetting of the thermostatic regulatory system caused by pyrogens.by pyrogens.

Febrile response: a complex physiologic reaction to Febrile response: a complex physiologic reaction to disease, involving a cytokinedisease, involving a cytokine--mediated rise in the core mediated rise in the core temperature, the generation of acutetemperature, the generation of acute--phase reactants, phase reactants, and the activation of numerous physiologic, and the activation of numerous physiologic, endocrinologic, and immunologic systems endocrinologic, and immunologic systems

Hyperpyrexia: fever >41.5 Hyperpyrexia: fever >41.5 ººC C

Hyperthermia:Hyperthermia:

Fever hyperthermiaFever hyperthermia

Involve pyrogenic Involve pyrogenic cytokinescytokinesChange in Change in hypothalamic set hypothalamic set pointpointRarely exceed 41CRarely exceed 41CComplications are Complications are rare

Failure in Failure in thermoregulatory thermoregulatory homeostasishomeostasisHypothalamic set Hypothalamic set point normalpoint normalCan exceed 41CCan exceed 41CCan be detrimentalCan be detrimentalAbsence of diurnal Absence of diurnal variation

rarevariation

PathogenesisPathogenesis

What is fever?What is fever?

1.1. T>38 T>38 ººCC2.2. T>37.7 T>37.7 ººCC3.3. T>37.2 T>37.2 ººCC4.4. Non of the aboveNon of the above

Normal temperature Normal temperature

Set within a narrow rangeSet within a narrow rangeThere is a diurnal variation: higher in the There is a diurnal variation: higher in the evening, lower in the morning.evening, lower in the morning.The mean is in 36.0 range.The mean is in 36.0 range.Wide difference in literature about the upper Wide difference in literature about the upper and lower limits of normaland lower limits of normalElderly has lower range of normal but not Elderly has lower range of normal but not studied well.studied well.Conflict in the literature weather women has Conflict in the literature weather women has higher or lower temp compared to men.higher or lower temp compared to men.

Normal tempNormal temp

148 m/f 18148 m/f 18--40y over 3 d40y over 3 dMean: 36.8 Mean: 36.8 ±± 0.4 0.4 ººC POC POmaximum at 6 AM is 37.2 maximum at 6 AM is 37.2 ººC POC PO-- 99th 99th percentile percentile maximum at 4 PM is 37.7 maximum at 4 PM is 37.7 ººC 99th C 99th percentilepercentile

A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, andother legacies of Carl Reinhold August Underlet Mackowiak PA et al. JAMA 1992.

Normal oral, rectal, tympanic and axillary body Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic temperature in adult men and women: a systematic

literature reviewliterature review

Sund-Levander M. Scandinavian Journal Of Caring Sciences,2002.

Name 2 conditions that fever Name 2 conditions that fever is part of their diagnostic is part of their diagnostic

criteria.criteria.

Initial ResuscitationInitial Resuscitation

AirwayAirwayBreathingBreathingCirculation Circulation


General look General look Vital signs(HR/BP/RR/O2 sat)Vital signs(HR/BP/RR/O2 sat)Hyperpyrexia/hyperthermiaHyperpyrexia/hyperthermiaAltered consciousnessAltered consciousnessChest painChest painCutaneous hemorrhagesCutaneous hemorrhagesReturning traveler Returning traveler be careful about cutaneous pain and normal skin be careful about cutaneous pain and normal skin

What are the causes of fever + What are the causes of fever + petechia/purpura?petechia/purpura?

Gram negatives Gram negatives Neisseria meningitidisNeisseria meningitidis

rickettsiae rickettsiae RMSFRMSF

Plasmodium falciparumPlasmodium falciparumviral hemorrhagic fevers:viral hemorrhagic fevers:

Dengue, lassa, Ebola, crimenDengue, lassa, Ebola, crimen--congo congo

Critical Diagnoses Critical Diagnoses NonNon--infectiousinfectious

Acute myocardial infarctionAcute myocardial infarction

Pulmonary embolism/infarctionPulmonary embolism/infarction

Intracranial hemorrhageIntracranial hemorrhage

Cerebrovascular accidentCerebrovascular accident

NeurolepticNeuroleptic--malignant syndromemalignant syndrome

Thyroid stormThyroid storm

Acute adrenal insufficiencyAcute adrenal insufficiency

Transfusion reactionTransfusion reaction

Pulmonary edemaPulmonary edema

Fever is present in Patients with Fever is present in Patients with Angiographically Proven PTE :Angiographically Proven PTE :

15%15%43%43%60%60%


Recognize early and occult sepsis and Recognize early and occult sepsis and treat early.treat early.Be familiar with different stages of Be familiar with different stages of infection severityinfection severity

SirsSirsSepsisSepsisSevere sepsisSevere sepsisSeptic shock Septic shock

SIRSSIRS

oral temperature of >38oral temperature of >38°° C or <36C or <36°°respiratory rate of >20 breaths/min or respiratory rate of >20 breaths/min or PaCO2 of <32 mm Hg PaCO2 of <32 mm Hg heart rate of >90 beats /min heart rate of >90 beats /min leukocyte count of >12,000/leukocyte count of >12,000/µµl or l or <4000/<4000/µµL or >10% immature (band) L or >10% immature (band) forms forms

Sepsis MortalitySepsis Mortality

Non infectiousNon infectious contcont

Emergent Diagnoses Emergent Diagnoses Congestive heart failureCongestive heart failure

DehydrationDehydration

Recent seizureRecent seizure

SickleSickle--cell diseasecell disease

Transplant rejectionTransplant rejection

PancreatitisPancreatitis

Deep venous thrombosis

Nonemergent Diagnoses Nonemergent Diagnoses Drug feverDrug fever

MalignancyMalignancy

GoutGout

SarcoidosisSarcoidosis

CrohnCrohn’’s diseases disease

Postmyocardiotomy syndromePostmyocardiotomy syndrome

Deep venous thrombosis

Approach to feverApproach to fever

Syndromic approach:Syndromic approach:Community acquiredCommunity acquiredNosocomial infectionNosocomial infectionPostPost--op feverop feverFever in a patient with F.B.(indwelling Fever in a patient with F.B.(indwelling catheters, VP shunt, metallic valve)catheters, VP shunt, metallic valve)Fever in an immunocompromised Fever in an immunocompromised Fever in a returning travelerFever in a returning travelerDrug feverDrug fever

General approachGeneral approach

Fever Hx: height, duration, frequency, any Fever Hx: height, duration, frequency, any associated chills or sweating.associated chills or sweating.Analysis of presenting complaint.Analysis of presenting complaint.System reviewSystem review

Hx of travelHx of travelHx of antibiotics useHx of antibiotics useHx of sick contactHx of sick contact

Past med/surg HxPast med/surg Hx

Hx of chronic illnesses.Hx of chronic illnesses.Hx of previous surgeries.Hx of previous surgeries.Hx of any F.B. Hx of any F.B. Hx of previous infectionsHx of previous infectionsVaccination HxVaccination Hx

Medication HxMedication Hx

Any recent abxAny recent abxAny chemotherapyAny chemotherapyIllicit drug useIllicit drug use

Travel hxTravel hx

DestinationDestinationDuration of stayDuration of stayDate of returnDate of returnAny prophylaxisAny prophylaxisHx of preHx of pre--travel vaccinationtravel vaccinationLevel of hygiene at destinationLevel of hygiene at destinationAny exposure to fresh waterAny exposure to fresh waterAny unprotected sexAny unprotected sex

<10 Days (short incubation)<10 Days (short incubation)Traveler's diarrhea Traveler's diarrhea Dengue fever and arboviral Dengue fever and arboviral

infectionsinfectionsYellow fever Yellow fever Spotted feversAnthraxSpotted feversAnthraxDiptheriaDiptheriaMalariaMalariaRabiesRabiesTyphoid feverTyphoid feverMeningococcal infectionsPlagueMeningococcal infectionsPlagueTularemiaTularemiaTyphus (louse and flea borne)

<21 Days (intermediate <21 Days (intermediate incubation)incubation)

LeptospirosisLeptospirosisViral hemorrhagic feversViral hemorrhagic feversMalariaMalariaEnteric fevers (typhoid, Enteric fevers (typhoid,

paratyphoid)paratyphoid)TyphusTyphusAfrica trypanosomiasisAfrica trypanosomiasis

Typhus (louse and flea borne)

>21 Days>21 DaysViral hepatitis (A, B, C, D, E)Viral hepatitis (A, B, C, D, E)MalariaAcute HIV MalariaAcute HIV infectionAmebic liver abscessinfectionAmebic liver abscessShistosomiasis (Katayama Shistosomiasis (Katayama fever)fever)leishmaniasisFilariasis

>Month>MonthTuberculosisTuberculosisMalaria caused by Malaria caused by Plasmodium Plasmodium vivaxvivaxFilariasisFilariasisViral hepatitis B, CViral hepatitis B, CHIVHIVVisceral leishmaniasisVisceral leishmaniasisRabiesRabiesSyphillisSyphillisAfrican and American (Chagas African and American (Chagas disease)disease)trypanosomiasis

leishmaniasisFilariasis

trypanosomiasis

The following rare low risk are for The following rare low risk are for Malaria:Malaria:

1.1. OmanOman2.2. Mount Everest Mount Everest 3.3. Ukraine Ukraine 4.4. All of aboveAll of above

Physical Physical

Vital signs:HR, BP, RR, Temp, O2 satVital signs:HR, BP, RR, Temp, O2 satLymphadenopathy Lymphadenopathy H&NH&NChestChestCVSCVSAbd Abd ExtExtSkin Skin CNSCNS

Investigation Investigation

Hb Hb WBCWBCPlatelet Platelet LFTLFTCKCKUrine analysisUrine analysisBlood culturesBlood culturesESR, CRP

DD--dimerdimerPeripheral smearPeripheral smear

ESR, CRP

ECGECGCXRCXRCTCTUS/echoUS/echoLPLPArthrocentesis Arthrocentesis

Summary Summary

Fever Fever > 37.2 > 37.2 ººC PO at 6 AM C PO at 6 AM > 37.7 > 37.7 ººC PO at 4 PM C PO at 4 PM > 38.0 > 38.0 ººC PR C PR

Recognize sepsis early and treat Recognize sepsis early and treat aggressivelyaggressivelyThink about life threatening nonThink about life threatening non--infectious infectious causes early.causes early.

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