Fever Hot Case
GENERAL APPROACH
Infectious
- community acquired
- nosocomial (surgical site, lines, chest, urine, sinusitis)
- ‘hidden’ sepsis (endocarditis, neuraxial infection, retroperitoneum, sinusitis)
Non-infectious
- head injury
- VTE
- drug/toxin
- SIRS (post surgery, trauma, burns, ICH, aspiration, pancreatitis, CTD)
- Hypermetabolic syndromes (e.g. thyroid storm, NMS, MH, heat stroke, pheochromocytoma)
INTRODUCTION
CUBICLE
- isolation (multi-drug resistant organisms, MDRO)
- long stay patient (new problem -> nosocomial infection)
INFUSIONS
- antibiotics (MDRO) – ask! (may not be running)
- noradrenaline (sepsis)
- heparin (VTE, MI, vascular occlusion, systemic anticoagulation for CVVH)
- blood products (febrile reactions)
- TPN (pancreatitis, intra-abdominal sepsis, line sepsis)
VENTILATOR
- level of support
- level of oxygenation (FiO2, PEEP)
- disease specific questions (ARDS: plateau pressure, bronchospasm: dynamic hyperinflation, intrinsic PEEP)
MONITOR
- temperature
- tachycardia (SIRS)
- ETCO2 (hypermetabolic syndrome)
- CVP (number, waveform)
- arterial trace (pressure, swing, pulsus paradoxus)
EQUIPMENT
- intra-abdominal drains (fluid, amount)
- EVD (recent cell count and culture)
- rectal tube (diarrhoea)
- active cooling (severe hyperthermia)
- epidural (inspect site and examine neurology)
- intercostal drains (number, bubbling, drainage)
- urine (colour, output, myoglobin, microscopy)
QUESTION SPECIFIC EXAMINATION
- hands/arms -> head -> chest -> abdo -> legs/feet -> back
-> cardiovascular
-> respiratory
-> abdominal (cholecystitis, pancreatitis, collections)
-> haematological (bleeding, organomegaly, bone tenderness, lymphadenopathy)
- neurological
-> paralysed
-> quick examination
-> unconscious
-> conscious
- scars, wounds, cellulitis
- prosthetic devices
- track marks
- ask to see under bandages
- meningism
- otoscopy (otitis media)
- fundoscopy (Roth spots, chorioretinitis, endophthalmitis)
- check for signs of endocarditis
- limbs for DVT (esp if long-term lines) and tone (MH, serotonin syndrome)
- vaginal examination for retained tampon
- age of lines
- recent anaesthetics (MH)
- recent antibiotic exposure (drug fever)
RELEVANT INVESTIGATIONS
- CXR
- FBC: WCC
- microbiology: sputum, blood cultures, urine, line cultures, intra-abdominal samples
- burn biopsy
OPENING STATEMENT
- I believe that this patient has multiple possible causes for fever:
- List headings of causes and provide evidence/ clinical signs associated with list
- Infectious causes…
- Non-infectious causes…
- To confirm or rule out these suspected diagnoses I would…:
DISCUSSION
- activated protein C (now unlikely)
- vasopressin in refractory septic shock
- corticosteroids in septic shock
- role of double GNB cover in gram negative sepsis
- MROs in ICU
- VTE management
- care bundles
- neutropenic sepsis
- hyperthermia
- heat stroke
References and Links
- Foote C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine (2nd Edition), Elsevier 2011. [Google Books Preview]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC