logging in or signing up 0705 Manfred Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1292 Category: Education License: All Rights Reserved Like it (1) Dislike it (0) Added: March 03, 2008 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... By: galaxist (9 month(s) ago) good topics Saving..... Post Reply Close Saving..... Edit Comment Close By: helenking (37 month(s) ago) Great presentation! Would you share some aspects of the slide? Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Diagnostic Approach of the Patient with Fever in ER: Diagnostic Approach of the Patient with Fever in ER 新 光 吳 火 獅 紀 念 醫 院 急 診 醫 學 科 林 秋 梅 92-07-05Definition of fever: Definition of fever Elevation of body temperature above the normal circadian range, depend on approaching timing Based on individual situation, someone keeps relative low or high body temperature DDx:Fever, hyperthermia: DDx:Fever, hyperthermia Fever, the balance is shifted to increase the core temperature Hyperthermia is an elevation of body temperature above the hypothalamic set point Normal body temperature: Normal body temperature Diurnal variation Rectal temperature>0.6o C oral temperature Range: 36.8o C 0.4 o C to 37.7o C Fever: early morning >37.2o C PM >37.7o C Methods to determine body temperature: Methods to determine body temperature Routine temperature measurements: oral, rectal settings Ear thermometry Intraesophageal infrared thermometry Lethal temperature: < 26o C , >43o C Metabolic and physiologic responses in fever patient : Metabolic and physiologic responses in fever patient Metabolic rate increases 10~12%/1o C Increased insensible water loss, 300-500ml/m2/o C/day Heart rate increases of up to 15bpm/o C Electrolytes depletion Pyrogens: Pyrogens Exogenous or endogenous Exogenous pyrogen-microorganism, their products, or toxins Endogenous pyrogens: by host, monocytes /macrophages Fever inducing cytokines: Fever inducing cytokines Interleukin 1 and 1 - the most pyrogenic Tumor necrosis factor Interferon Interleukin 6 cytokines>fever develop within 1h Hypothalamic control of temperature: Hypothalamic control of temperature Body temperature is controlled by the hypothalamus 1. Preoptic anterior hypothalamus 2. Posterior hypothalamus Neurons receive two kinds of signals 1. Peripheral nerves 2. Blood bathing the region Initiate fever-arachidonic acid metabolites-PGE2 Why fever: Why fever Elevation of body temperature increases chance for survival Temperatures in the febrile range appear to increase the phagocytic and bactericidal activity of neurtrophils and the cytotoxic effects of lymphocytes Type III Pneumococci are particularly sensitive to nigh temperature and 41 o C grow poorly and may autolyze Fever Patterns: Fever Patterns Intermittent fever Remittent fever Hectic fever Sustained fever Recurrent fever(Relapsing) Drug feverFever Pattern: Fever Pattern Fever pattern cannot be considered pathognomonic for a particular infection Hyperpyrexia> 41 o C , is an elevation of body temperature above the hypothalamic set point due to insufficient heat dissipation Fever Patterns: Fever Patterns Fever with extreme fever: gram-negative bacteremia, Legionnaires‘ disease, and bacteremic pyelonephritis Noninfectious cause of extreme pyrexia: heat stroke, intracerebral hemorrhage, hemorrhagic pancreatitis Fever may sometimes absent:seriously ill newborns, elderly patients, uremic patient,significantly malnourished individuals, receiving corticosteroids or contineous treatment with anti-inflammatory or antipyretic agents Reasons to treat fever: Reasons to treat fever To avoid potentially harmful secondary effects For the patient‘s comfort Methods of lowering temperature 1. Antipyretics a. Aspirin b. Acetaminophen c. Ibuprofen 2. Sponging the body 3. Cooling blankets 4. Turkish message of Weinstein Accompaniments of fever: Accompaniments of fever Back pain, generalized myalgias, arthralgias, anorexia and somnolence Fever may be reduced by cyclooxygenase inhibitors Chills, CNS response to the thermoregulatory set point‘s call for more heatFUO(Fever of unknown origin): FUO(Fever of unknown origin) Definition: febrile illness of more than 3 weeks‘ duration >38.3 o C on several determinations with no diagnosis reached after 1 week of study Classic FUO Nosocomial FUO Neutropenic FUO HIV-associated FUO FUO: FUO Causes 1. Infection 2. Collagen vascular disease 3. Malignancy 4. Others Do not forget: abdominal abscess, endocarditis, hepatobiliary disease, TB, CMV infection Approach to fever: Approach to fever Rule out common infection 1. Careful history: chronology of symptoms, use of drugs, surgical treatment, exposure 2. Physical examination 3. Basic laboratory screens a. Blood count b. Blood culture c. Urinary dialysis d. Urine culture e. CXR f. Stool examination Approach to fever: Approach to fever Patterns of fever Alter the course of fever antipyretics, glucocorticords, and antibiotics etc. Reversed body temperature: typhoid fever, disseminated tuberculosis Treatment of fever: Treatment of fever For comfort Hyperthermia 1.Heat stroke 2.Classic heat stroke 3.Drug-induced hyperthermia 4.Malignant hyperthermia Definition: Definition Sepsis SIRS Severe Sepsis Septic shock Hypotension Refractory septic shock Definition: Definition Sepsis: SIRS due to infection Bacteremia: presence of viable bacteria in the bacteria Hypotension: SBP<90mmHg or a reduction of >40mmHg from baseline in the absence of other causes of hypotension Infection: microbial inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms Definition: Definition MODS(Multiple organ dysfunction syndrome): presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention Septic shock: sepsis with hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities Severe sepsis: sepsis associated with organ dysfunction, hypoperfusion or hypotension Definition: Definition Systemic inflammatory response syndrome(SIRS) 1. Variety of causes 2. BT> 38 o C or < 36 o C 3. HR> 90/min 4. RR>20/min or PaCO2 <32 5. WBC(serum)>12000 or <4000, or band>10%Antibiotics using in ER : Antibiotics using in ER Pathogens,infection focus, host factors(Immune factors) Common infection in ER 1. UTI 2. Respiratory tract infection 3. CNS infection 4. Cellulitis Antibiotics using-UTI: Antibiotics using-UTI Low urinary tract infection 1. Dysuria, low abdominal pain, frequency, urgency 2. E.coli, Proteus, Klebsiella etc 3. Antibiotics: Baktar, amoxicillin ,1 o cephalosporin duration: 3-7 days 4. Urinalysis continuingAntibiotics using-UTI: Antibiotics using-UTI Upper urinary tract infection 1. Fever, flank pain, dysuria 2. Pyuria, bacturia=75% patient 3. 1 o or 2 o Cephalosporin aminoglycoside, duration: 7-10 days 4. Renal sonography: intractable s/s,underlying disorder(DM,stone) Antibiotics using-Respiratory tract infection: Antibiotics using-Respiratory tract infection Pneumonia 1. Cough, fever, sputum or not 2. CXR, clinical manifestations, sputum gram‘s stain 3. Labor pneumonia, interstitial pneumonia, atypical pneumonia, bronchopneumonia infiltration, consolidation, cavity, pleural effusion 4. Underlying disordersAntibiotics using-Pneumonia: Antibiotics using-Pneumonia Streptococcus, H.influenzae,G(-) etc. Community- acquired pneumonia 1.G(+) Major, e.g. Penicillin agents 2.Young adult, dry cough, CXR-Mycoplasma 3. Fluminant course-3o cephalosporin+ macrolide+ anti-pseudomonas agent continuingAntibiotic using-respiratory tract infection: Antibiotic using-respiratory tract infection Nosocomial pneumonia 1. Asp. Pneumonia-PCN+GM, or clindamycin+GM 2. G(-)-DM patient, consider K.P infection Empyema –drainage, anti-G(+) aminoglycosideAntibiotics using-CNS infection: Antibiotics using-CNS infection Bacterial meningitis 1. Aggressive antibiotics-due to prognosis and sequence 2. Penicillin G+3o cephalosporin Vancomycin Viral meningitis 1. Observation, s/s Tx 2. Herpes meningitis- acyclovir continuingAntibiotic using- CNS infection: Antibiotic using- CNS infection TB meningitis 1. Anti-TB agents 2. Prognosis: variation Fungal meningitis: antifungal agentsAntibiotics using-cellulitis: Antibiotics using-cellulitis Pathogens: common streptococcus, or staphylococcus Cellulitis fasciitis pyomyositis osteomyolitis Progression: rapid means severe infection Antibiotics: PCN G or oxacillin Pitfalls: Pitfalls Depend on laboratory data Incomplete Hx. PE Atypical presentation 1. Immunocompromised patient 2. Newborn 3. Early sign 4. Dehydration You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
0705 Manfred Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1292 Category: Education License: All Rights Reserved Like it (1) Dislike it (0) Added: March 03, 2008 This Presentation is Public Favorites: 1 Presentation Description No description available. Comments Posting comment... By: galaxist (9 month(s) ago) good topics Saving..... Post Reply Close Saving..... Edit Comment Close By: helenking (37 month(s) ago) Great presentation! Would you share some aspects of the slide? Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Diagnostic Approach of the Patient with Fever in ER: Diagnostic Approach of the Patient with Fever in ER 新 光 吳 火 獅 紀 念 醫 院 急 診 醫 學 科 林 秋 梅 92-07-05Definition of fever: Definition of fever Elevation of body temperature above the normal circadian range, depend on approaching timing Based on individual situation, someone keeps relative low or high body temperature DDx:Fever, hyperthermia: DDx:Fever, hyperthermia Fever, the balance is shifted to increase the core temperature Hyperthermia is an elevation of body temperature above the hypothalamic set point Normal body temperature: Normal body temperature Diurnal variation Rectal temperature>0.6o C oral temperature Range: 36.8o C 0.4 o C to 37.7o C Fever: early morning >37.2o C PM >37.7o C Methods to determine body temperature: Methods to determine body temperature Routine temperature measurements: oral, rectal settings Ear thermometry Intraesophageal infrared thermometry Lethal temperature: < 26o C , >43o C Metabolic and physiologic responses in fever patient : Metabolic and physiologic responses in fever patient Metabolic rate increases 10~12%/1o C Increased insensible water loss, 300-500ml/m2/o C/day Heart rate increases of up to 15bpm/o C Electrolytes depletion Pyrogens: Pyrogens Exogenous or endogenous Exogenous pyrogen-microorganism, their products, or toxins Endogenous pyrogens: by host, monocytes /macrophages Fever inducing cytokines: Fever inducing cytokines Interleukin 1 and 1 - the most pyrogenic Tumor necrosis factor Interferon Interleukin 6 cytokines>fever develop within 1h Hypothalamic control of temperature: Hypothalamic control of temperature Body temperature is controlled by the hypothalamus 1. Preoptic anterior hypothalamus 2. Posterior hypothalamus Neurons receive two kinds of signals 1. Peripheral nerves 2. Blood bathing the region Initiate fever-arachidonic acid metabolites-PGE2 Why fever: Why fever Elevation of body temperature increases chance for survival Temperatures in the febrile range appear to increase the phagocytic and bactericidal activity of neurtrophils and the cytotoxic effects of lymphocytes Type III Pneumococci are particularly sensitive to nigh temperature and 41 o C grow poorly and may autolyze Fever Patterns: Fever Patterns Intermittent fever Remittent fever Hectic fever Sustained fever Recurrent fever(Relapsing) Drug feverFever Pattern: Fever Pattern Fever pattern cannot be considered pathognomonic for a particular infection Hyperpyrexia> 41 o C , is an elevation of body temperature above the hypothalamic set point due to insufficient heat dissipation Fever Patterns: Fever Patterns Fever with extreme fever: gram-negative bacteremia, Legionnaires‘ disease, and bacteremic pyelonephritis Noninfectious cause of extreme pyrexia: heat stroke, intracerebral hemorrhage, hemorrhagic pancreatitis Fever may sometimes absent:seriously ill newborns, elderly patients, uremic patient,significantly malnourished individuals, receiving corticosteroids or contineous treatment with anti-inflammatory or antipyretic agents Reasons to treat fever: Reasons to treat fever To avoid potentially harmful secondary effects For the patient‘s comfort Methods of lowering temperature 1. Antipyretics a. Aspirin b. Acetaminophen c. Ibuprofen 2. Sponging the body 3. Cooling blankets 4. Turkish message of Weinstein Accompaniments of fever: Accompaniments of fever Back pain, generalized myalgias, arthralgias, anorexia and somnolence Fever may be reduced by cyclooxygenase inhibitors Chills, CNS response to the thermoregulatory set point‘s call for more heatFUO(Fever of unknown origin): FUO(Fever of unknown origin) Definition: febrile illness of more than 3 weeks‘ duration >38.3 o C on several determinations with no diagnosis reached after 1 week of study Classic FUO Nosocomial FUO Neutropenic FUO HIV-associated FUO FUO: FUO Causes 1. Infection 2. Collagen vascular disease 3. Malignancy 4. Others Do not forget: abdominal abscess, endocarditis, hepatobiliary disease, TB, CMV infection Approach to fever: Approach to fever Rule out common infection 1. Careful history: chronology of symptoms, use of drugs, surgical treatment, exposure 2. Physical examination 3. Basic laboratory screens a. Blood count b. Blood culture c. Urinary dialysis d. Urine culture e. CXR f. Stool examination Approach to fever: Approach to fever Patterns of fever Alter the course of fever antipyretics, glucocorticords, and antibiotics etc. Reversed body temperature: typhoid fever, disseminated tuberculosis Treatment of fever: Treatment of fever For comfort Hyperthermia 1.Heat stroke 2.Classic heat stroke 3.Drug-induced hyperthermia 4.Malignant hyperthermia Definition: Definition Sepsis SIRS Severe Sepsis Septic shock Hypotension Refractory septic shock Definition: Definition Sepsis: SIRS due to infection Bacteremia: presence of viable bacteria in the bacteria Hypotension: SBP<90mmHg or a reduction of >40mmHg from baseline in the absence of other causes of hypotension Infection: microbial inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by those organisms Definition: Definition MODS(Multiple organ dysfunction syndrome): presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention Septic shock: sepsis with hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities Severe sepsis: sepsis associated with organ dysfunction, hypoperfusion or hypotension Definition: Definition Systemic inflammatory response syndrome(SIRS) 1. Variety of causes 2. BT> 38 o C or < 36 o C 3. HR> 90/min 4. RR>20/min or PaCO2 <32 5. WBC(serum)>12000 or <4000, or band>10%Antibiotics using in ER : Antibiotics using in ER Pathogens,infection focus, host factors(Immune factors) Common infection in ER 1. UTI 2. Respiratory tract infection 3. CNS infection 4. Cellulitis Antibiotics using-UTI: Antibiotics using-UTI Low urinary tract infection 1. Dysuria, low abdominal pain, frequency, urgency 2. E.coli, Proteus, Klebsiella etc 3. Antibiotics: Baktar, amoxicillin ,1 o cephalosporin duration: 3-7 days 4. Urinalysis continuingAntibiotics using-UTI: Antibiotics using-UTI Upper urinary tract infection 1. Fever, flank pain, dysuria 2. Pyuria, bacturia=75% patient 3. 1 o or 2 o Cephalosporin aminoglycoside, duration: 7-10 days 4. Renal sonography: intractable s/s,underlying disorder(DM,stone) Antibiotics using-Respiratory tract infection: Antibiotics using-Respiratory tract infection Pneumonia 1. Cough, fever, sputum or not 2. CXR, clinical manifestations, sputum gram‘s stain 3. Labor pneumonia, interstitial pneumonia, atypical pneumonia, bronchopneumonia infiltration, consolidation, cavity, pleural effusion 4. Underlying disordersAntibiotics using-Pneumonia: Antibiotics using-Pneumonia Streptococcus, H.influenzae,G(-) etc. Community- acquired pneumonia 1.G(+) Major, e.g. Penicillin agents 2.Young adult, dry cough, CXR-Mycoplasma 3. Fluminant course-3o cephalosporin+ macrolide+ anti-pseudomonas agent continuingAntibiotic using-respiratory tract infection: Antibiotic using-respiratory tract infection Nosocomial pneumonia 1. Asp. Pneumonia-PCN+GM, or clindamycin+GM 2. G(-)-DM patient, consider K.P infection Empyema –drainage, anti-G(+) aminoglycosideAntibiotics using-CNS infection: Antibiotics using-CNS infection Bacterial meningitis 1. Aggressive antibiotics-due to prognosis and sequence 2. Penicillin G+3o cephalosporin Vancomycin Viral meningitis 1. Observation, s/s Tx 2. Herpes meningitis- acyclovir continuingAntibiotic using- CNS infection: Antibiotic using- CNS infection TB meningitis 1. Anti-TB agents 2. Prognosis: variation Fungal meningitis: antifungal agentsAntibiotics using-cellulitis: Antibiotics using-cellulitis Pathogens: common streptococcus, or staphylococcus Cellulitis fasciitis pyomyositis osteomyolitis Progression: rapid means severe infection Antibiotics: PCN G or oxacillin Pitfalls: Pitfalls Depend on laboratory data Incomplete Hx. PE Atypical presentation 1. Immunocompromised patient 2. Newborn 3. Early sign 4. Dehydration