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fever_adult

The febrile adult presenting to the ED

see also:

  • patients with severe sepsis or meningitis MUST have EARLY resuscitation and iv antibiotics within 60 minutes
  • patients on cytotoxic chemotherapy within past 2wks should be treated as per febrile neutropenia and triaged as 2 and given empirical antibiotics within 30 minutes of arrival

early recognition of possible sepsis at ED triage is critical

identify the seriously ill who require urgent intervention:

triage as 2 or 3 plus do VBG/lactate ASAP if risk factors of having sepsis and any one of

  • new onset of confusion or decreased mental state
  • temp > 38.5degC or temp < 35.5
  • HR < 50 or HR > 120
  • systolic BP < 100 mmHg
  • SaO2 < 95%

risk factors of having possible sepsis

  • age > 65yrs
  • immunocompromised (eg. on chemotherapy, organ transplant recipient or on steroids)
  • fevers / rigors
  • recent surgery
  • implanted device
  • fall
  • signs or symptoms of infection:
    • skin - cellulitis or wound
    • urine - dysuria, frequency, malodour
    • abdominal pain
    • chest - cough or SOB
    • neuro - headache, neck stiffness, or mental state change
red flags for severe sepsis:
  • lactate >= 4.0
  • base excess < -5.0
  • SBP < 90mmHg
  • age > 65yrs
  • imunocompromised

if red flag and not NFR then

if no red flag then

  • early medical assessment
  • iv access, FBE, U&E, blood cultures
  • iv fluids
  • iv antibiotics within 60 minutes preferably if considered possible sepsis

adjunctive clinical assessment

identify those with localisable or easily diagnosed diseases:

  • examine and Ix for sources of infections:
    • chest
    • abdomen
    • meningitis
    • skin
    • urine
    • joints / bone
  • BUT be aware of 3 main traps:
    • focal symptoms and signs may not be present or obvious early in the course of infection:
      • rash in measles
      • cough in pneumonia
      • diarrhoea in gastroenteritis
    • localised features may be misleading:
      • diarrhoea may reflect septicaemia or appendicitis
      • RIF or RUQ pain may be due to pneumonia, pyelonephritis, etc
      • crepitations or effusion in the lung may be due to subdiaphragmatic conditions
      • early meningococcal rash may look like early measles rash
    • fever or delirium may be caused by non-infective causes such as:

is the patient an "at-risk" patient:

the elderly:

  • often do not mount much of a febrile response & fever may be absent in 20-30% with serious infections
  • infections often present with non-specific or atypical presentations
  • a temperature higher than 38degC is highly suggestive of a serious infection
  • UTI and pneumonia are the most frequent infections but focal symptoms are frequently absent
  • urinalysis & CXR will identify ~50% of occult infections
  • any unexplained fever in persons > 50yrs age should be regarded as being bacterial and should generally be admitted to hospital
  • most elderly patients who are not NFR and who have a delirium should have:
    • FBE, U&E, glucose
    • ECG to exclude AMI
    • CT brain
    • CXR
    • urine culture
    • bladder scan to exclude retention
    • consider a lactate level / VBG

the alcoholic:

  • often present with multiple problems, many of which cause fever
  • the commonest infection is pneumonia
  • non-infectious causes of fever which usually require admission:
    • subarachnoid haemorrhage
    • alcohol withdrawal
    • alcoholic hepatitis
  • admit if no obvious cause found

the IV drug user:

the diabetic:

  • in general, IDDM pts, esp. if over 50yrs age, with fever & no source should be Ix and admitted
  • foot infections tend to be mixed flora including anaerobes so usually require admission for:
    • ampicillin + gentamicin + metronidazole
    • exclusion of underlying osteomyelitis and surgical opinion

the febrile neutropenic:

  • ie. if febrile and absolute neutrophil count < 500/uL or <1000/uL and falling rapidly
  • must be admitted for IV antibiotics regardless of their clinical appearance, as infections may become fulminant within hours, & clinical manifestations are frequently modified.
  • see Sepsis in the oncology patient - febrile neutropenia

the splenectomized:

  • should generally be admitted for IV antibiotics

the immunocompromised:

  • transplant pts or those with HIV / AIDS
  • have a lower threshold for admission

the overseas traveller:

the patient who has special contact with diseases:

  • animal handlers - zoonoses
  • close contacts of meningococcal cases

the pregnant patient:

  • at higher risk of pyelonephritis so low threshold for admission if UTI
  • avoid antibiotics not safe in pregnancy such as trimethoprim, tetracyclines, metronidazole
  • certain viral infections may effect the fetus:
  • contact with varicella when no PH exposure warrants serology & zoster Ig within 72hrs

are there any clinical feature "alarm bells":

severe muscle pains

  • even in the absence of fever may be an early symptom of staph. or strept. bacteraemia
  • also consider myositis or necrotizing fasciitis

impaired conscious state:

  • may be the sole presentation of sepsis, esp. in the elderly

vomiting:

  • unexplained vomiting, esp. with headache or abdominal pain should raise concern
  • do not attribute it to gastroenteritis in the absence of diarrhoea
  • consider CNS infections & occult sepsis

severe headache:

  • obviously meningitis is a concern and if not contraindicated, CT +/- LP should be considered
  • if CSF is normal then before just attributing it to a viral infection, consider:
    • pneumonia, bacterial enteritis, cerebral abscess or prodromal bacterial meningitis

unexplained rash:

  • regard as meningococcal until proven otherwise
  • don't forget toxic shock syndrome - eg. tampons

jaundice:

  • unlikely to be due to viral hepatitis & is more likely to be due to either of:
    • bacteraemia, cholangitis, pyogenic liver abscess, or non-vital infections such as malaria

sore throat/dysphagia:

  • consider epiglottitis, retropharyngeal abscess, quinsy, infectious mononucleosis

repeated rigors:

  • should be regarded as indicators of sepsis eg. abscesses, bacteraemia, endocarditis, cholangitis, pyelonephritis

fever > 3 days:

  • should be regarded as bacterial

double check to ensure you have not missed an infection that requires urgent Rx:

  • meningococcaemia
  • falciparum malaria
  • bacterial meningitis
  • postsplenectomy sepsis
  • toxic shock syndromes
  • infections in the febrile neutropenic
  • necrotizing soft tissue infections
  • space-occupying lesions of head & neck
  • focal intracranial infections

disposition:

  • in general, admit if:
    • sick enough to warrant blood cultures
    • age > 50yrs, diabetic, alcoholic, IV drug user, immuno-compromised, or overseas traveller
    • those with clinical alarm bells as above
  • if discharging home:
    • ensure you have current contact details clearly documented
    • ensure pt is seen by a doctor within 24-72hrs or earlier if:
      • T > 39degC then see within 24hrs
      • LP performed and normal then see within 6-12hrs
fever_adult.txt · Last modified: 2018/03/31 10:10 (external edit)