FEVER and HYPOTHERMIA................pptx

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1. SEMINAR APPROCH TO PATIENT WITH FEVER Modertator : Dr.Urji (MD) Presenter: Adanech Ashango C-I Student 1

2. OBJETIVES TO Define fever To describe: Pathophysiology Etiology Pattern & Management of fever. 2

3. OUTLINE Introduction Definition Etiology Pathophysiology Approach to patient Investigations Treatment 3

4. Introduction Thermoregulation of core body temperature is one of the most important mechanisms in mammalian and human physiology. Body temperature is controlled by the hypothalamus. Neurons in the both preoptic anterior hypothalamus and the posterior hypothalamus receive two kinds of signals: peripheral nerves that transmit information from warmth/cold receptors in the skin the temperature of the blood bathing the region 4

5. Cont… These are integrated by the hypothalamus to maintain normal temperature. The core body temperature is normally maintained within a very narrow range. In a neutral temperature environment, the human metabolic rate produces more heat than is necessary to maintain the core body temperature in the range of 36.5–37.5°C. 5

6. Cont… Although significant levels of hypothermia are tolerated, multi organ dysfunction occurs rapidly at temperatures >41°c. Due to this fever is one of the most common problems requiring medical evaluation 6

7. Fever/pyrexia Definition  — An elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point. Mostly increased by 1–2°C. Heat production: Muscle -- Shivering. Liver-- Non shivering 7

8. Hyperpyrexia is the term for extraordinarily high fever >41.5°C or 106.7°F Can occur in patients with severe infections most commonly observed in CNS hemorrhages 8

9. Pathophysiology Pyrogens Pyrogenic cytokines Exogenous pyrogens Heat production exceeding loss Malignant hyperthermia Defective heat loss. Victims of severe heat exposure 9

10. CON-- 10

11. Etiology Infectious agents Bacterial Viral Parasitic Non infectious Malignancies Miscellaneous Drug fever Ectodermal dysplasia Factitious fever 11

12. Benefits of fever 1. Enhances immune function by; increase motility and activity of the WBCs, stimulate the interferon production & increase phagocytic function. 2. Inhibits grow of some microbial agents. many of microbial agents grow best at normal body temperature 12

13. Sites for temperature measurement Oral Lower-esophageal Rectal Tympanic membrane Axillary Temporal The maximum normal oral temperature is 37.2°C at 6 a.m. and 37.7°C at 4 p.m 13

14. The patterns of fever 14

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20. History Character of fever Associated symptom Travel history Heat exposure Drug use Contact to other infectious individuals Known medical illness Known psychological problem 20

21. Cont… Physical examination General appearance V/S Clinical findings skin – Wet Vs dry or Cold Vs hot 21

22. Investigation CBC Blood film Urine analysis Serum electrolytes BUN & Cr. Liver enzymes TFT Toxicology screening Acute phase reactants CXR 22

23. Management Treat the underlying cause Give antipyretic Cooling internal external 23

24. Fever of unknown origin(FUO) The term (FUO) identifies a pattern of fever with temperatures greater than 38.3° C (101° F) on several occasions over more than 3 weeks after an initial diagnostic work-up for which the diagnosis remains uncertain. 24

25. Classification 1. Classic fever of unknown origin, Common causes are infections(25% to 50%) malignancies, and noninfectious inflammatory disorders 2. Health care–associated FUO, Surgical procedures, Urinary and respiratory tract instrumentation, Intravascular devices, Drug therapy, and immobilization. 25

26. Cont… 3. Immune Deficiency–Associated FUO Neutropenic (immune-deficient) FUO, Persons with profound neutropenia are at high risk for bacterial and fungal infections. HIV-related FUO. In patients with impaired cell-mediated immunity, FUO often results from conditions other than pyogenic bacterial infections (e.g., fungi, CMV). 26

27. Patient approach Verification that the patient has fever, Consideration of the fever pattern, A comprehensive history, A repeated physical examinations, Appropriate laboratory investigations, Key imaging studies, and Invasive diagnostic procedures. 27

28. Investigation Work-up of a patient with a FUO should focus on the History, Physical examination, and Initial laboratory data. In place of rational diagnostic thinking, there is a temptation to order multiple comprehensive laboratory and imaging studies 28

29. Management A fundamental principle: Therapy should be withheld, whenever possible, until the cause of the fever has been determined, so that treatment can be tailored to a specific diagnosis. The exception is in the setting of the immuno compromised host because rapid empirical treatment is most often needed 29

30. Hypothermia Moderator - Dr. Urji (MD) By: A hmed (C 1 ) 30

31. DEFINITION internal temperature <358C [<958F] (by rectal, tympanic, or esophageal thermometer). Hypothermia may be mild(34 358C [93 958F]), moderate (30 348C[86 938F]), or severe (<308C [<868F]) 31

32. CAUSES INCREASED HEAT LOSS ENVIRONMENTAL ; cold exposure DERMATOLOGIC ; burns, extensive psoriasis, vasodilation (drugs, alcohol, sepsis, pancreatitis) IATROGENIC cold fluid infusion, CPR , renal replacement therapy 32

33. ALTERED REGULATION CENTRAL : stroke, Parkinson’s disease, multiplesclerosis , hypothalamic dysfunction, anorexia nervosa, drugs (barbiturate, TCA, sedatives, alcohol) PERIPHERAL neuropathies, diabetes 33

34. DECREASED METABOLISM ENDOCRINE hypothyroidism, hypopituitarism, adrenal insufficiency, hypoglycemia METABOLIC anorexia nervosa, malnutrition 34

35. RISK FACTORS extremes of age, alcoholism, malnutrition, homelessness, mental illness 35

36. HISTORY exposure to cold (duration, environment) shivering, confusion, delirium, palpitations, weakness, ulcers, frostbite, fever, weight loss, past medical history (hypothyroidism, diabetes,alcoholism, psoriasis), medications, social history 36

37. Physical examination vitals(bradycardia,apnea,hypertension/hypotension,hypoxemia), respiratory and cardiovascular examination (arrhythmia), skin examination (frostbite, burns, psoriasis) GCS(rigidity, hyporeflexia), 37

38. INVESTIGATIONS BASIC LABS CBC, lytes , urea, Cr, glucose, CK, troponin, AST, ALT, ALP, bilirubin, TSH, urinalysis, blood cultures ECG Osborn wave (elevated J point), prolonged RR, PR, QRS, and QT intervals 38

39. COMPLICATIONS hypothermia affects most organs, causing cognitive (coma), neuromuscular(rigidity), respiratory (pulmonary edema), cardiac(arrhythmia), and cutaneous complications (frostbite). Sepsis, pneumonia, hypokalemia, hypoglycemia, and rhabdomyolysis may also occur 39

40. MANAGEMENT ABC, O2 to keep sat >94%, IV. Caution with fluid overload (decreased cardiac output in hypothermic patients) and vasopressors ( arrhythmogenic potential). Resuscitation should continue until patient completely rewarmed 40

41. MONITORING continuous cardiac monitoring. Also closely monitor electrolytes and glucose. Vagotonic maneuvers (e.g. intubation or suctioning) may precipitate asystole 41

42. REWARMING environment (remove cold clothing. Warming blanket). Active rewarming (warm IV fluids 40 428C [104 1088F]. If severe hypothermia,consider colonic/bladder irrigation, peritoneal or pleural lavage, extracorporeal blood rewarming. Goal of rewarming is 0.5 28C/h [1.88F/h] to minimize risk of VF and hypovolemic shock) 42

43. Hyperthermia Heat related illnesses (Heat cramp, exhaustion, stroke…) Malignant hyperthermia Neuroleptic malignant syndrome Hormonal hyperthermia Therapeutic hyperthermia Miscellaneous causes of hyperthermia 43

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61. References Harrison principle of internal medicine 21 st edition Cecil essentials of medicine 10 th edition Up-to-date 21.6 61

62. Thank you! 62