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SIR WILLIAM OSLER
“HUMANITY HAS BUT THREEGREAT ENEMIES: FEVER,FAMINE AND WAR; OF THESEBY FAR THE GREATEST, BY FARTHE MOST TERRIBLE, ISFEVER.”
Tc 37.5 °C
• subfebrility
Tc < 40 °C
• fever
Tc > 40 °C
• hyperpyrexia
External and internal factors affectingfever
• Cold environment: pyrogens might inducehypothermia rather than fever
• Hypoxia: decreased pyrogen effect
• Newborn, old patients: hypothermia is more frequent
• Less fever in those fasting
►There is no association between the extent of
fever and severity of illness
The biological value of fever
• metabolic changes: synthesis of acute phaseproteins
• high temp is associated with decreased serum ironlevels: decreased bacterial growth
• high temp might be bacteriostatic, even bactericid
• augmentation of cytokine effects: 5-6 x increase inactivity @ 39 °C vs. @ 37 °C
• increased cellular and humoral immunity
Unfavourable effects of fever
• heat-stroke like high temp (rare)
• febrile convulsions (from 6 months to 6 yrs, above 39°C -14%)
• cerebral metabolic derangement: delirium, hallucinations
• cardiac patients, elderly: increased CO, decompensation
• increased minute ventilation: increased work of breathing
• prolonged febrile states: anorexia + increased core temp
• diabetics: some cytokines have antiinsulin effects
• early pregnancy: teratogenesis?
• too high temp inhibits immune functions
HYPOTENSION
AGE
HEADACHE
PETECHIAE
LOW BACK PAIN
AMS IVDA TRAVEL (CONTACT) TC > 41⁰C, DURATION
IMMUNSPURESSION / ASPLENIA
NIGHT SWEATS, WEIGHT LOSS
ALONG WITH ANTIBIOTICS
FOLLOWING HOSPITALIZATION(NOSOCOMIAL) LARGE NUMBER OF PATIENTS WITH SAME SYMPTOMS(BIOTERROR)
> 40-41°C
EXTERNALHEAT CHALLENGES
INTERNALHEAT CHALLENGES
DRUGS
SUSCEPTIBLE DISEASE
OTHERS
ENVIRONMENTRAL HEAT; RADIATING HEAT, HUMIDITY
INCREASED PHYSICAL ACTIVITY
DRUGS INHIBITING SWEATING (ANTICHOLINERG, ANTIHYSTAMIN)COMPOUND INCREASING METAB. RATE (COCAIN, LSD, AMPHETAMINE)DIURETICS; ALCOHOL
EXSICCOSIS; SKIN (BURNS; FIBROSIS; SCLERODERMA); OBESITY; INCREASED METAB. RATE-ACTIVITY (PARKINSON, HYPERTHYREOIDISM, PHEOCHROMOCYTOMA)
INABILITY TO ADAPT; PREVIOUS HEAT STROKE;INSOMNIA; INFECTION; EXTREMES OF AGE; CLOTHING
HYPERTHERMIA
NMSANTICHOL
SYMH
HEATSTROKE
SER.SY
D2 Ca (ICP)ANTICHOL
GABA5HT
EP-RIGID CONTR FLACCID NORM. INCREASED
+++ +++ -- --- +
Fever and toxins
PHYSOTIGMIN (*)
MYDRIASIS BLURRED VISION FEVER DRY SKIN FLUSHING ILEUS URINARY RET. TACHYCARDIA HYPERTENSION PSYCHOSIS COMA SEIZURESMYOCLONUS
ANTIHYSTAMINEATROPINBACLOFENTCAD*PHENOTHIAZINESCOPALAMINE
IRRITABILITY HYPERREFLEXIA FLUSHING DIARRHEA DIAPHORESIS FEVER TRISMUS TREMORMYOCLONUS
FLUOXETINEMEPERIDENIEPAROXETINESERTRALTINETRAZODONECLOMIPRAMINE
BENZODIAZEPINE
FEVER
MUSCLE RIGIDITY
AUTONOMIC DYSFUNCTION
ALTERED MENTAL STATE
HYPOTHALAMUS
NIGRO-STRIATUM
MEDULLA OBL.
MESOCORTEX
CENTRAL DOPAMINERGIC (D2) DYSFUNCTION
PARKINSONIAN HYPERPYREXIAN SYNDROME
NEUROLEPTIC MALIGNANT SYNDROME
OCCURS IN 0,1-0,2 % IN PTS TAKING NEUROLEPTIC MEDS
AFFECTS MAINLY YOUNG MALE PTS (< 40 YRS)
HIGH MORTALITY(50-70%)
NEUROLEPTICS
CYCL. ANTIDEPRESSANTS
MAO INHIBITORS
ANTIEMETICS
LITHIUM / ECT
Heat exhaustionand heat stroke
HOT, SWEATY SKINPROFUSE SWEATING DIZZINESSSEVERE WEAKNESS NAUSEA, VOMITING TACHYCARDIA OLIGURIA (CONC. URINE)AMS
HOT, DRY SKIN Tc> 40°C AMS - OBS TACHYCARDIA TACHYPNOEMUSCLE SPASMS
HEAT EXHAUSTION HEAT STROKE
> 40-41°C
OXYGENVOLUME EXPANSION
PYROGEN?• INFECTION• INFLAMMATION• NEOPLASM
HEAT STROKE?• ENVIRONMENT• INCREASED ACTIVITY• HYPOVOLEMIA
DRUGS?• MH• MNS*• ANTICHOLINERGICS• ANTISEROTONERGICS
STOP MEDSACTIVE COOLINGMUSCLE RELAX.DANTROLEN
0.8-1.5 mg/kg/6hAMANTADIN*BROMOCRIPTIN*
ACTIVE COOLING
• ISOLATION• SURFACE• INTERNAL• PHARMACEUTICAL
Symptoms Possible Cause Action to Take
Intense pain in the lower right side of the abdomen. Slight fever.
Appendicitis Go to an emergency room now
Severe pain in the upper abdomen and often spreads to the sides and the back. Nausea, vomiting, fever, …
Pancreatitis Call 911 or go to an emergency room right away.
In a woman: dull, constant pain in the lower abdomen along with vaginal discharge and fever.
Pelvic inflammatory disease. See a doctor promptly.
Pain and feverA few examples
Abdominal pain
Environmentalinteractions
Pain behaviour
Suffering
Pain perception
Nociception
The multi-dimensional approach of pain
Bio-Psycg-Social Model
General considerations
• Accounts for 10 % of ED visits
• Can be associated with simple problemsbut also with serious conditions
• 1/3 of cases are UDAP
Types of abdominal pain
• Visceral– caused by distension, ischaemia of hollow organs– colicky, crampy pain
• Parietal– caused by inflammation, ischaemia or distension of the
parietal peritoneum– more circumscribed,provoked by cough, movement– guarding is due to this type of pain
• Referred– radiates to distant locations from the affected organs– afferent fibers from different locations travel together– e.g. AMI – epigastrial pain
ruptured aortic aneurysm traumamesenterial ischaemia ileus ACS visceral perforation visceral rupture
Physical examination
• Palpation and auscultation
• Cough test: pt holds hands over affected area
• Heel drop test
• Murphy-sign: palpating RUQ inspiration stops
• Psoas-test: pt flexes hips against resistance
• Obturator-test: hip is rotated in and out
• Rovsing-jel: palpating LLQ provokes pain inRUQ
Imaging(US, X-ray, CT)
• FAST
• abdo US by radiologists
• X-ray
– plain: free air, niveaus, distension
• CT
– highly informative, can be plain or contrastenhanced
Bloods, biomarkers
• FBC
• LFTs
• amylase, lipase
• serum lactate and lactate clearence
RANSON SCORE
Disposition
• One can not always clarify the exactpathophysiology of abdo pain in the ED.
• Primary goal is to recognize critical and emergent conditions, start painmanagement, stabilization and start diagnostic procedures
• Abdominal pain management is team-work!
SEPSIS
SIRS2 OR MORE
36°C < T < 38°CBPM > 90/minRR > 20/MIN (PaCO2 < 32 Hgmm)4 > WBC > 12 / 10% ÉRETLEN ALAK
SEPSIS1 OR MORE
SIRS + DOCUMENTED INFECTIONALTERED MENTAL STATEHYPOXAEMIA (FiO2 = .21 paO2 < 72 Hgmm)se.LACTAT EOLIGURIA (UOP < 0.5 ml/kg/h)
SEVERE SEPSIS SEPSIS + ORGAN FAILUREHYPOPERFUSION
SEPTIC SHOCK SEPSIS (INDUCED)SBP < 90 HgmmMAP < 60 HgmmDIFFERENT FROM USUAL BP (-40 Hgmm) VOLUME REFRACTER
2012
2011
2010
2009
2008
2007
2006
2005
20042003
2002
The Barcelona Declaration
SSC GUIDELINES 2004
SSC GUIDELINES 2008
SSC GUIDELINES 2012
0 20 40 60
HALÁLOZÁS (%)
SEPTIC SHOCK
SEVERE SEPSIS
SEPSISMORTALITY (%)
ORGANISMSYSTEMIC INFLAMMATION OR
INFLAMMATORY RESPONSE
SEVERE SEPSISGLOBAL TISSUE HYPOXIA
AND ORGAN DYSFUNCTION
DIFFUSE ENDOTHELIAL DISRUPTION AND MICROCIRCULATION DEFECTS
MOD AND REFRACTORY HYPOTENSIONSEPTIC SHOCK
Nguyen H.B. – Ann Emerg Med 2006; 48:28-54
TLR-Toll-like receptor, CLR-C-type lectin receptor, NLR- nucleotid binding oligomerization (NOD) receptors
What to do?
New England Journal of Medicine, 2001; 345(19), 1368–1377.
33%
2006.
SEPSISRESUSCITATION
BUNDLES
SEPSISMANAGEMENT
BUNDLES
EARLYRECOGNITION
TRIAGE
CHAIN OF SURVIVAL IN SEPSIS
TRIAGE
EARLY RECOGNITION
CHAIN OF SURVIVAL IN SEPSIS
GENETIC VARIABILITYE.G.DIFFERENT CYTOKINE
RESPONSE
INTRINSIC FACTORSAGE
COMORBID STATEIMMUNSUPRESSION
NUTRITIONGATES OF INFECTION
SURGICALINCISION
STERILE vs CONTAMINATEDACUTE vs ELECTIVE
IMPLANT
EXTRINSIC FACTORSENVIRONMENT
WORKCONTACT
EXPOSITION
HOSPITAL FACTORSDURATION OF HOSPITALISATIONLOCATION OF HOSPITALISATION
LOCAL INFECTIVE AGENTSMEDICATION
INTERVENTIONSVENOUS CANULAE
URINARY CATHETERWOUND - DECUBITUS
TRIAGE
P REDISPOSITION
I NFECTION
R ESPONSE
O RGAN DYFUNCTION
TRIAGE
SBAR COMMUNICATION
SITUATION
B ACKROUND
A SSESMENT
RECOMMENDATION
SITUATION SUSPICION OF SEVERE SEPSISBACKGROUND SIRSSUSPICION OF INFECTION PERFUSISON DEFECT (ORGAN MANIFSTATION)ASSESSMENTTRIAGE (EVALUATION OF VITALS AND SpO2)
TRIAGERECOMMENDATION DECISION ± HELP ABG-LACTATE-FBC SAMPLING (MICRO+LAB) HYPOPERFUSION– HYPOTENSION: IV-LINE (SALINE 20ml/kg IV )
SEPSIS TEAM
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7
CHANCE OF SURVIVAL (%)
EVERY HOUR DELAY IN GIVING ANTIBIOTICS IN SEPTIC SHOCK DECREASES THE CHACE OF SURVIVAL BY 7.6%!!
(DELLINGER- 2004; KUMAR – 2006)
ANTIBIOTICS
(< 3 HRS / < 1 HR)
Do not missdiagnoses!
DEXAMETHASON 1mg (before AB!)CEFTRIAXON 2gVANCOMYCIN 10-15mg/bw kgAMPICILLIN 3gACYCLOVIR 10mg/ttkg
MENINGITIS ENCEPHALITIS
MENINGOCOCCAEMIA
MORTALITY > 70%
CEFTRIAXON - 2G
STEROID (DEXAMETHASON) – 10MG
TOXIC SHOCK SYNDROME
HIGH FEVERSHOCKERYTHRODERMAMUC.MEMBR. HYPERAEMIAMYALGIAPHARYNGITISDIARRHOEA
EXTREME PAINNECROTISING FASCIITIS
MORTALITY 30 - 80%→ FACIITIS (70%) 60%→ MYOSITIS 85-100%
PENICILLIN - 10MECLINDAMYCIN – 900MG
IMMUNGLOBULINSURGICAL DRAINAGE
RESUSCITATIVE BUNDLE
TOXIC SHOCK SYNDROME