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Fever: A Syndromic and General Approach
- 1. Fever Chapter Review Khalfan AL Amrani R5 McGill Emergency Program
- 2. Outline Fever: the basics Definition of terms Pathogenesis Normal temperature Etiology Fever: Initial resuscitation Fever: approach Syndromes approach General approach Quizzes
- 3. Definitions Fever: elevation in body core temperature resulting from a resetting of the thermostatic regulatory system caused by pyrogens. Febrile response: a complex physiologic reaction to disease, involving a cytokine-mediated rise in the core temperature, the generation of acute-phase reactants, and the activation of numerous physiologic, endocrinologic, and immunologic systems Hyperpyrexia: fever >41.5 ºC Hyperthermia:
- 4. Fever hyperthermia Involve pyrogenic Failure in cytokines thermoregulatory Change in homeostasis hypothalamic set Hypothalamic set point point normal Rarely exceed 41C Can exceed 41C Complications are Can be detrimental rare Absence of diurnal variation
- 5. Pathogenesis
- 6. What is fever? 1. T>38 ºC 2. T>37.7 ºC 3. T>37.2 ºC 4. Non of the above
- 7. Normal temperature Set within a narrow range There is a diurnal variation: higher in the evening, lower in the morning. The mean is in 36.0 range. Wide difference in literature about the upper and lower limits of normal Elderly has lower range of normal but not studied well. Conflict in the literature weather women has higher or lower temp compared to men.
- 8. Normal temp 148 m/f 18-40y over 3 d Mean: 36.8 ± 0.4 ºC PO maximum at 6 AM is 37.2 ºC PO- 99th percentile maximum at 4 PM is 37.7 ºC 99th percentile A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Underlet Mackowiak PA et al. JAMA 1992.
- 9. Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review Sund-Levander M. Scandinavian Journal Of Caring Sciences,2002.
- 10. Name 2 conditions that fever is part of their diagnostic criteria.
- 12. Initial Resuscitation General look Vital signs(HR/BP/RR/O2 sat) Hyperpyrexia/hyperthermia Altered consciousness Chest pain Cutaneous hemorrhages Returning traveler be careful about cutaneous pain and normal skin
- 13. What are the causes of fever + petechia/purpura? Gram negatives Neisseria meningitidis rickettsiae RMSF Plasmodium falciparum viral hemorrhagic fevers: Dengue, lassa, Ebola, crimen-congo
- 14. Critical Diagnoses Non-infectious Acute myocardial infarction Pulmonary embolism/infarction Intracranial hemorrhage Cerebrovascular accident Neuroleptic-malignant syndrome Thyroid storm Acute adrenal insufficiency Transfusion reaction Pulmonary edema
- 15. Fever is present in Patients with Angiographically Proven PTE : 15% 43% 60%
- 16. Initial Resuscitation Recognize early and occult sepsis and treat early. Be familiar with different stages of infection severity Sirs Sepsis Severe sepsis Septic shock
- 17. SIRS oral temperature of >38° C or <36° respiratory rate of >20 breaths/min or PaCO2 of <32 mm Hg heart rate of >90 beats /min leukocyte count of >12,000/µl or <4000/µL or >10% immature (band) forms
- 18. Sepsis Mortality
- 19. Non infectious cont Emergent Diagnoses Nonemergent Diagnoses Congestive heart failure Drug fever Dehydration Malignancy Recent seizure Gout Sickle-cell disease Sarcoidosis Transplant rejection Crohn’s disease Pancreatitis Postmyocardiotomy syndrome Deep venous thrombosis
- 20. Approach to fever Syndromic approach: Community acquired Nosocomial infection Post-op fever Fever in a patient with F.B.(indwelling catheters, VP shunt, metallic valve) Fever in an immunocompromised Fever in a returning traveler Drug fever
- 21. General approach Fever Hx: height, duration, frequency, any associated chills or sweating. Analysis of presenting complaint. System review
- 22. Hx of travel Hx of antibiotics use Hx of sick contact
- 23. Past med/surg Hx Hx of chronic illnesses. Hx of previous surgeries. Hx of any F.B. Hx of previous infections Vaccination Hx
- 24. Medication Hx Any recent abx Any chemotherapy Illicit drug use
- 25. Travel hx Destination Duration of stay Date of return Any prophylaxis Hx of pre-travel vaccination Level of hygiene at destination Any exposure to fresh water Any unprotected sex
- 26. <10 Days (short incubation) <21 Days (intermediate Traveler's diarrhea incubation) Dengue fever and arboviral Leptospirosis infections Viral hemorrhagic fevers Yellow fever Malaria Spotted feversAnthrax Enteric fevers (typhoid, Diptheria paratyphoid) Malaria Typhus Rabies Africa trypanosomiasis Typhoid fever Meningococcal infectionsPlague Tularemia Typhus (louse and flea borne)
- 27. >21 Days >Month Viral hepatitis (A, B, C, D, E) Tuberculosis MalariaAcute HIV Malaria caused by Plasmodium infectionAmebic liver abscess vivax Shistosomiasis (Katayama Filariasis fever) Viral hepatitis B, C leishmaniasisFilariasis HIV Visceral leishmaniasis Rabies Syphillis African and American (Chagas disease) trypanosomiasis
- 28. The following rare low risk are for Malaria: 1. Oman 2. Mount Everest 3. Ukraine 4. All of above
- 29. Physical Vital signs:HR, BP, RR, Temp, O2 sat Lymphadenopathy H&N Chest CVS Abd Ext Skin CNS
- 30. Investigation Hb D-dimer WBC Peripheral smear Platelet LFT CK Urine analysis Blood cultures ESR, CRP
- 33. Summary Fever > 37.2 ºC PO at 6 AM > 37.7 ºC PO at 4 PM > 38.0 ºC PR Recognize sepsis early and treat aggressively Think about life threatening non-infectious causes early.