D R M A H A T H A R A B D W A H A B

C O N S U L T A N T E M E R G E N C Y P H Y S I C I I A N

E M E R G E N C Y A N D T R A U M A D E P A R T M E N T

H O S P I T A L K U A L A L U M P U R , K U A L A L U M P U R M A L A Y S I A

THE UPSURGING FEVER:THE HEAT ON FRONTLINERS

RISING OUTBREAKS WORLDWIDE

• 2002-2003

• SARS-

• 2008

• H5N1

• 2009-2010

• H1N1

• - 2012

• MERS-CoVtill now

• 2014

• Dengue fever

ALARMING

• Dengue cases in Malaysia:

• Rapid increase as compared to

same time period last year- 2559

cases to 10000 cases

• Higher death toll- 22 death as

compared to 5 last year

SCENARIO 1

• 25 years, medium build lady

• Presented 3 days earlier to Clinic

• Fever, abdominal pain and diarrhoea

• Treated as AGE by GP

• Condition worsened at home and patient became

lethargic.

• Brought to ED HKL and noted T° spiking at 40°C

• Abdomen tender and guarded with altered

sensorium.

SCENARIO 1

• Severely dehydrated

• Erect CXR and AXR revealed pneumoperitoneum

• Resuscitated and pushed to OT stat.

• Laparotomy done: Perforated bowel with gross

intraabdominal contamination and bowel

ischemia.

• Prolonged ICU stay and ventilation.

• Discharged well after 15 days in ward with just

wound break down.

SCENARIO 2

• 23 years old medical student

• Presented with fever with abdominal pain for 4 days

at 2pm.

• No diarrhoea, no vomiting and looks well

• Room mate had dengue

• HCT noted 48%, platlet 78

• Diagnosed as dengue fever with warning signs.

• Was given initial fluid management as per protocol.

SCENARIO 2

• Stayed in ED for a good 8 hours- uneventful

• Transferred to medical ward, at 10pm.

• Midnight developed SOB and drop in BP

• Resuscitated, intubated and transferred to ICU

• Diagnosed as Severe Dengue Shock Syndrome.

• Passed away at 6am.

SCENARIO 3

• 58 years old man from Kelantan.

• Presented for fever and cough since past 2 months.

• Recurrent presentations to KK, GP’s and even

hospitals.

• Always treated as URTI and COPD

• 2 days prior to presentation was seen by GP and

given Levofloxacin for URTI

• Came to KL for daughter’s convocation and had

fever.

• Brought to HKL and……….

WHAT IS FEVER?

• FEVER is a Diagnostic Clue

• It is an essential host defense mechanism

• Associated with or without localizing signs

• Can be due to Infection, inflammation or neoplasm.

• Caution in

• Special group – Pediatric, Elderly & pregnant

• Co morbid – DM, HPT,IHD

• Immunocompromised patient

THE MOST COMMON PRESENTING COMPLAIN IN ED WORLDWIDE

FEVER PATTERNS

• Intermittent type

• T° return to normal once during most days

• Remittent

• T° do not return to normal each day

• Sustained/Continuous

• T° do not vary more than 1 ° C/day

• Relapsing

• recurrent over days to weeks

FEVER ASSESSMENT

• Focus History

• Magnitude & duration

• Localizing signs / symptoms

• Concurrent medical illness

• Travel history

• Endemic area (dengue, MERS- CoV, TB etc..)

• Contact

• Medications

• Allergies

• Drug or alcohol abuse

FEVER ASSESSMENT

• Physical examination

• Look @ focus area

• Mental status alteration

• Neck stiffness

• Rash

• Conjunctivitis, jaundice, otitis

• Pharyngitis

• Lungs findings

• Abdominal tenderness

• UTI symptoms

• Cellulitis

FEVER ‘THE ALARM BELL’

Jonathan Knott. Approach to undifferentiated fever in adults

Adult Textbook in Emergency Medicine 2012

FEVER CATEGORIZATION

• Stable Febrile pts

• Criteria;

• Alert, haemodynamically stable and non

toxic

• Tolerating the fever

• No serious underlying medical illness

• Normal detailed physical examination

• Probable viral URTI or non specific viral

fever if fever less than 1 week duration

FEVER CATEGORIZATION

• Unstable febrile patient

• Criteria;

• Hypotensive, altered mental status / clinically

toxic

• Prolonged fever > 1 week, non responsive to Rx

• Fever with localizing signs

• Serious underlying medical illness

• Fever with rash that indicate

DHF/meningoccaenia or malaria

RASHES IN DENGUE INFECTION

• Facial flushing

• Generalised erythema

• Maculopapular rash

• Positive Hess’s test

• Petechiae and other

haemorrhage

• “Island of white in the sea

of red” (convalescent)

• Desquamation

FEVER- COMMON CLUES

1. RESPIRATORY SYMPTOMS- URTI,LRTI,TB

2. URINARY SYMPTOMS- UTI, APN, CYSTITIS

3. ABDOMINAL SYMPTOMS- ABSCESS, ACUTE

ABDOMEN

4. ARTHRITIS SYMPTOMS- RA, SLE, AS

5. TRAVEL HISTORY

6. DIETARY HISTORY

7. OCCUPATIONAL HISTORY

8. SOCIAL HISTORY

TRAVEL HISTORY

• MALARIA• ENDEMIC AREA

• DENGUE FEVER • ASIAN countries

• MERS-CoV• Middle East countries

• ILI

• TYPHOID

• TUBERCULOSIS etc…..

DIETARY AND OCCUPATIONAL HISTORY

• Birds• Psittacosis

• Animal contact • Toxoplasmosis (cats), Leptospirosis (Rat)

• Uncooked meat/sea food • Hepatitis A&E, Salmonella

• Unpasteurized milk• Salmonella, TB

DRUG FEVER

• All drugs can produce drug induced fever

• Bradycardia, hypotension, skin rash, pruritus

• Notorious- Amphetamine group, TCA poisoning,

Suxamethonium..

• Others- penicillin, sulpha, ATT

• Eosinophilia

SYNDROMIC APPROACH TO FEVER

1. FEVER AND MYALGIA

2. FEVER WITH LOW PLATLETS

3. FEVER and NIGHT SWEATS

4. FEVER – Brady, Tachycardia

5. FEVER & EYE FINDINGS

6. FEVER WITH JAUNDICE

7. FEVER WITH GEN LYMPHADENOPATHY

8. FEVER WITH HEPATOSPLENOMEGALY

9. FEVER WITH MENTAL CONFUSION

10. FEVER WITH ARDS

11. FEVER WITH HIGH ESR

FEVER AND MYALGIA

• VIRAL FEVERS• LEUCOPENIA & THROMBOCYTOPENIA

• INFLUENZA/ILI • URTI SYMPTOMS

POLYMYOSITIS- Proximal muscle weakness, muscle pain &

tenderness, CK high

• Meningococcal infection• Rash

• SEPSIS

FEVER AND NIGHT SWEATS

• TB

• LYMPHOMA

• ABSCESS

• IE

• ALCOHOL WITHDRAWAL SYNDROME

FEVER – BRADY, TACHYCARDIA

• RELATIVE

BRADYCARDIA

TYPHOID FEVER

MALARIA

MENINGITIS

LEPTOSPIROSIS

VIRAL

DRUG FEVER

• DISPROPOTIONATE

TACHYCARDIA

TOXINS

FEVER WITH JAUNDICE

• LEPTOSPIROSIS

• HEPATITIS• DRUGS, VIRAL

• ALCOHOLIC HEPATITIS

• CIRRHOSIS OF LIVER

• HEPATOMA

• VIRAL FEVERS

• MALARIA

GENERALIZED LYMPHADENOPATHY

• LEUKEMIA • ALL, CLL

• LYMPHOMA

• HIV INFECTION• ORAL CANDIDIASIS, CACHEXIC

• TOXOPLASMOSIS • HEPATOSPLENOMEGALY

• DISSEMINATED TB• LIVER, SPLEEN INVOLVEMENT

EPITROCHLEAR LYMPH NODES

• MILIARY TB

• LYMPHOMA

• HIV INFECTION

• SYPHILIS

FEVER WITH HEPATOSPLENOMEGALY

• MALARIA

• TYPHOID

• LYMPHOMA

• LEUKEMIA

• IE

• FULMINANT TB

• KALA AZAR

FEVER WITH MENTAL CONFUSION

• MENINGITIS

• HIV

• CNS NEOPLASMS

• DRUG TOXICITY

FEVER- ARDS

• SARS INFECTION

• CEREBRAL MALARIA (PLASMODIUM

FALCIPARUM)

• HANTA VIRUS

• SEPSIS

HIGH ESR

• TB

• TEMPORAL ARTERITIS

• CARCINOMA

• LYMPHOMAS

• ABSCESS

FEVER AND LOW PLATLETS

• DENGUE, DENGUE, DENGUE

• CHIKUGUNYA

• VIRAL FEVERS

• LEUKEMIA

• LYMPHOMA

• HIV INFECTION

FACTS ABOUT FEVER

• Febrile illness

• can be localized to organ systems or non-localized,

commonly referred to as acute undifferentiated febrile illness

(AUFI).

• AUFI

• self-limited viral conditions in developed countries

• In the developing world-

• malaria, dengue fever, enteric fever, leptospirosis, rickettsiosis,

JE and Nipah Virus.

FEVER PANIC IMPLICATIONS

• Unnecessary investigations

• considerable cost to the government

• inappropriate prescribing of antimicrobial-resistance

• Rise in hospital admission rates

• Increase in mortality

• Increase burden and stress on healthcare workers.

• Increase in complaints and controversy

• POLITICAL PRESSURE ON HOSPITAL ADMINISTRATORS

FEVER CENTRE

• Management of Undifferentiated Fever

patients

• One stop centre for fever

• Specialized clinic

• Physician lead

• Assisted by trained nurse / assistant medical

officer

• After office hour

• For stable adult fever patient

FEVER CENTRE

• Categorization of Fever

• Focus history taking – checklist method

• Focus clinical examinations

• Standard base line point of care

investigations

• FBC

• Conventional radiograph

FEVER CENTRE

• STRUCTURAL

• Isolated room

• Separate wait area

• Good air exchange

• 12 AIR EXCHANGE per hour

• Air condition or fan with ventilation

FEVER CENTREASSESSMENT PACKAGE

• Management package• PPE for staff

• Mask for patients

• Standard clinical objectives• Step 1: identify the seriously ill patient who requires urgent

intervention• shock, coma/stupor, cyanosis, profound dyspnoea, continuous seizures

and severe dehydration

• Step 2: identify those with localized infections or easily diagnosable diseases• history and physical examination to localize the source of community-

acquired fever

• Step 3: look for the ‘at-risk’ patient• patient who may not appear overtly ill but who, nonetheless, requires

medical intervention

• Step 4: a final caveat• when the patient does not appear ill on presentation.

PROTOCOL FOR THE MANAGEMENT OF STABLE ADULT PATIENTS WITH ACUTE UNDIFFERENTIATED FEVER.

MANAGEMENT PACKAGE

• Stable febrile patients

• able to tolerate adequate volumes of oral

fluids, pass urine at least once every six

hours and

• do not have any of the warning signs (FOR

DENGUE SUSPECT)particularly when fever

subside

• TCA again if fever is persistent for more than

48 hours

• For home care.

FEVERHOME CARE PACKAGE 1

• The Home care instructions ;

• Clear instruction (verbal and written)

• Bed Rest

• Paracetamol

• Frequent oral fluids

• Coconut water / barley / juice etc

• Social support

• Follow up at the nearest clinic

• Access to nearest clinics / hospitals (999 etc)

FEVERHOME CARE PACKAGE 2

• Home care advice;

• Patient should be brought to hospital immediately if

any of the following occur:

• no clinical improvement, deterioration around the

time of defervesense

• severe abdominal pain, persistent vomiting, cold

and clammy

• extremities, lethargy or irritability/restlessness,

bleeding (e.g. black stools or coffee ground

vomiting),

• shortness of breath, not passing urine for more than

4−6 hours.

CONCLUSION

• Fever carries a wide range of disease spectrum

(iceberg theory)

• Look hard for the etiology and tally it with local

epidemiology

• ED is an extremely hectic environment and we face

the bulk of complaints from public.

• Waves of patients will hit ED first.

• We need all of your cooperation to aid us in

managing the patients in ED.

• Go easy on us

THANK YOU

•“ALL WE KNOW IS STILL

INFINITELY LESS THAN ALL THAT

REMAINS UNKNOWN”

-WILLIAM HARVEY-