# Fever/chills



## Blake (Aug 24, 2012)

So i have a pt. that is complaining of a sore throat 8/10 extreme swelling and has thrown up three times. Pt. states he is cramping all over and "his bones hurt" Pt. temp is 103.4 and he is shivering and saying he is freezing. Now here is my question.... Ok to my understanding at 106 your brain starts boiling. So in that situation you are supposed to cover up your pt. so they dont shake because if they do shake it is going to increase their temp more. Right? Now another question at what point do you say look you dont get a blanket you are to hot. And if you do that is that all you do? As far as the temp issue.


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## Hockey (Aug 24, 2012)

Give them a light sheet pretty much.

If you're a medic, IV, O2, Monitor pretty basic.  Watch temp, and possible seizure.

Some areas allow tylenol administration.


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## gw812 (Aug 24, 2012)

I bet this call came in at, like, 0100. Oh, wait, that's me right now...

Ditto above. See how much of the PCR you can get done on the way. Complain about 911 abuse afterwards.


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## PVC (Aug 24, 2012)

Blake said:


> So i have a pt. that is complaining of a sore throat 8/10 extreme swelling and has thrown up three times. Pt. states he is cramping all over and "his bones hurt" Pt. temp is 103.4 and he is shivering and saying he is freezing. Now here is my question.... Ok to my understanding at 106 your brain starts boiling. So in that situation you are supposed to cover up your pt. so they dont shake because if they do shake it is going to increase their temp more. Right? Now another question at what point do you say look you dont get a blanket you are to hot. And if you do that is that all you do? As far as the temp issue.



If your patient is an adult a temperature of 103.4 is potentially serious. One important factor is the speed of the onset of fever. A rapid onset fever 102 degrees or higher can produce seizures as opposed to a fever with a more prolonged onset. The patient's LOC is important as a differential in determining if the shivering is seizure activity or febrile shivering.

As a basic I would begin to cool the patient, even if they are shivering, with cool compresses to the arpits, and groin, forehead, abdomen, and transport. I would not cover the patient, to the contrary I would provide an environment where they could loose  disipate heat through evaporation.

I would prepare for seizures with suction and a Berman or Guedel as well as O2 for the postictal state. I prefer the Berman especially if I expect the need to suction at some point.


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## sir.shocksalot (Aug 24, 2012)

gw812 said:


> I bet this call came in at, like, 0100. Oh, wait, that's me right now...
> 
> Ditto above. See how much of the PCR you can get done on the way. Complain about 911 abuse afterwards.


As a flip side to this, what if this patient is 88 years old? I would be pretty concerned for an 88 year old with a high fever like that. I can see where you're coming from (especially if the patient is between the ages of 14-55 ish, surrounded by friends and family with cars) but I wouldn't necessarily label it 911 abuse. I'm not trying to pick on you or anything but I just wouldn't be too quick to chastise someone for calling 911 for a high fever and weakness.



PVC said:


> If your patient is an adult a temperature of 103.4 is potentially serious. One important factor is the speed of the onset of fever. A rapid onset fever 102 degrees or higher can produce seizures as opposed to a fever with a more prolonged onset. The patient's LOC is important as a differential in determining if the shivering is seizure activity or febrile shivering.
> 
> As a basic I would begin to cool the patient, even if they are shivering, with cool compresses to the arpits, and groin, forehead, abdomen, and transport. I would not cover the patient, to the contrary I would provide an environment where they could loose  disipate heat through evaporation.
> 
> I would prepare for seizures with suction and a Berman or Guedel as well as O2 for the postictal state. I prefer the Berman especially if I expect the need to suction at some point.



My understanding is that there is no evidence permanent tissue damage until the temp reaches 104+, also I read that there is no correlation between the severity of the disease and the temperature of the fever. 

Fever is a protective mechanism, your body's immune system works better in febrile states and antipyretics are really only used as a comfort measure. Also, adults do not have febrile seizures (barring hyperthermia which is different than a fever, at least this is my understanding), and there is still some debate as to the cause of febrile seizures in children (be it the rate of temperature increase or some part of the disease process). I would not actively cool this patient unless this was a true case of hyperthermia where there is a CNS disorder of the hypothalamus or whatever that is causing the body to raise it's temperature in a pathological fashion (not as a compensatory mechanism for an infection). I'm definitely not as good with pathology as some of our posters so hopefully they'll chime in and correct me if I'm talking out my ***.

Personally, as a medic, I would rule out (to the best of my ability) the big stuff like stroke, hyperthermia, meningitis etc, I would keep him comfortable, start a line, and transport to the hospital. As far a sheets/blankets, I would pretty much do whatever makes the patient comfortable. Does he want lots of blankets? Sure. Just a sheet? No problem.


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## Veneficus (Aug 24, 2012)

Blake said:


> So i have a pt. that is complaining of a sore throat 8/10 extreme swelling and has thrown up three times.



Does this patient have an age?



Blake said:


> Pt. states he is cramping all over and "his bones hurt" Pt. temp is 103.4 and he is shivering and saying he is freezing.



Sounds like dehydration with a fever.



Blake said:


> Now here is my question.... Ok to my understanding at 106 your brain starts boiling.



I think you need better understanding.

At 106c the water in your body would already be vapor. At 106F that is 1/2 of water boiling.

An increase in temperature or acid denatures proteins. Sometimes they can go back to normal, sometimes they can't the body has several mechnisms in place to help.



Blake said:


> So in that situation you are supposed to cover up your pt. so they dont shake because if they do shake it is going to increase their temp more. Right? Now another question at what point do you say look you dont get a blanket you are to hot. And if you do that is that all you do? As far as the temp issue.



The feeling of cold in a fever is because of a new set point of body temp from having an increase of body temp in the hypothalmus. As the body temperature decreases below the "new" set point, the patient feel cold. 

So the fever is actually decreasing from what it was. (long detailed explanation on IL 1 and tnf withheld) 

If the patient feels cold, i'd give them a blanket, sheet, whatever I had. 
When they start to feel hot they will take it off themselves.

Most people go through cyclical "hot/cold" feelings with fever.

I think you will find the most success in keeping them hydrated or rehydrating them.


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## Doczilla (Aug 24, 2012)

Where is this "swelling"? Lymph nodes? Mandibular? Cervical? What about tonsils? Cheeks/Jaw line like a squirrel? 

Did you look inside the throat? (A lot of paramedics don't do this. ) if it was tonsillar swelling, we don't measure it on a 1-10 scale. Tonsils go 1+, 2+,3+ etc, to demonstrate the distance between them. Also, make sure you check to see if the uvula is midline. If its deviated, that could be a peritonsillar abcess, that could complicate your airway. 

Fever that high points more to bacterial infection. Other clues, such asence of cough, asymmetrical tonsils, and tender cervical lymphadenopathy would point to Group A strep with over a 90% probability. 

The chills come from the fever. 

For cases of severe trismus, dysphagia,or any degree of stridor you would probably be able to ask the receiving facility if they're cool with 250mg of methylprednisolone, or 6-8mg of dexamethasone, in conjunction with other supportive care.


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## Doczilla (Aug 24, 2012)

Crap, just realized OP wasn't a medic. Oh well, everyone can benefit from that post.


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## PVC (Aug 24, 2012)

Doczilla said:


> Crap, just realized OP wasn't a medic. Oh well, everyone can benefit from that post.



We can know what to do when we get there. Nice post.


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## JakeEMTP (Aug 24, 2012)

sir.shocksalot said:


> My understanding is that there is no evidence permanent tissue damage until the temp reaches 104+, also I read that there is no correlation between the severity of the disease and the temperature of the fever.



Not enough information was given to know how the temperature was taken or how long ago.  

"Fever" seems to have a negative stigma and some fail to follow through with a good assessment or history therefore lack an understanding of the many disease processes which produce an elevated temperature even at 0100 in the morning regardless of age.  You could also look at the average age of the H1N1 patients a couple years ago or the recent hanta virus which in Yosemite Park which sickened 2 people and one of them died earlier this week.


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## the_negro_puppy (Aug 24, 2012)

From what I understand, with fevers you shiver as your body temp rises and once it plateaus you have the general feeling of being 'hot' with sweating etc.

Dangerous fever? 

Cooling via evaporation
Ice packs in groin and axilla
IV access
Anti-pyretics
treat/consider underlying causes including infection, heat stroke, malignant hyperthermia


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## VFlutter (Aug 24, 2012)

the_negro_puppy said:


> malignant hyperthermia



Do you use volatile aesthetics in EMS down under? Nitrous oxide? I think it can happen with succ too


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## PVC (Aug 24, 2012)

Other considerations would be drugs or medications ASA overdose and street drugs.


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## Doczilla (Aug 24, 2012)

Ven mentioned the "setpoint". 

The hypothalmic setpoint is basically the thermostat. Infection alters this setpoint, which is akin to cranking up the thermostat. What comes from that is vasoconstriction (to preserve heat), shivering (to generate heat) and chills (to convince you to take environmental measures to preserve heat.) 

When you take antipyretics, the inflammatory mediators that signal the hypothalmus to crank up the thermostat are supressed, thus "resetting" the setpoint. This is known by everyone as "my fever broke." 

Here comes the warmth, sweating, vasodilation (antipyretics also vasodilate by blocking thromboxane a2 ) , and youll start taking off all those sweaters you piled on. 

Hope this helps.


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## JPINFV (Aug 24, 2012)

gw812 said:


> I bet this call came in at, like, 0100. Oh, wait, that's me right now...
> 
> Ditto above. See how much of the PCR you can get done on the way. Complain about 911 abuse afterwards.



You're reading tonight is to find an emergency medicine, critical care medicine, or internal medicine medicine textbook (or use UptoDate if you have access to it) and do some light reading on sepsis if you think that infections are automatically 911 abuse.


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## Doczilla (Aug 24, 2012)

Add rheumatic fever and post-streptococcal glomerulonephritis to that too.


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## Shishkabob (Aug 24, 2012)

PVC said:


> If your patient is an adult a temperature of 103.4 is potentially serious. One important factor is the speed of the onset of fever. A rapid onset fever 102 degrees or higher can produce seizures as opposed to a fever with a more prolonged onset. .



Febrile seizures for adults are pretty darn rare in relation to rapid onset fever.   The vast majority of febrile seizures happen to infants before the hypothalamus is fully capable of controlling body temperature.


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## MSDeltaFlt (Aug 24, 2012)

Blake said:


> So i have a pt. that is complaining of a sore throat 8/10 extreme swelling and has thrown up three times. Pt. states he is cramping all over and "his bones hurt" Pt. temp is 103.4 and he is shivering and saying he is freezing. Now here is my question.... Ok to my understanding at 106 your brain starts boiling. So in that situation you are supposed to cover up your pt. so they dont shake because if they do shake it is going to increase their temp more. Right? Now another question at what point do you say look you dont get a blanket you are to hot. And if you do that is that all you do? As far as the temp issue.



As an EMT, I wouldn't cover them. Protect dignity, but don't cover them with blankets.  If they've already got blankets, pull them.  Replace them if and only if they start shivering.


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## PVC (Aug 24, 2012)

Linuss said:


> Febrile seizures for adults are pretty darn rare in relation to rapid onset fever.   The vast majority of febrile seizures happen to infants before the hypothalamus is fully capable of controlling body temperature.



Absolutely.


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## Handsome Robb (Aug 24, 2012)

Light sheet covering them, consider antipyretics, consider active cooling but like JP said, ( I think it was JP) your body increases it's temperature for a reason. 103 is pretty high and I'd watch it carefully and start being more aggressive if it continued to rise or the patient's condition worsened. 

Someone mentioned street drugs. 0100 and a younger patient ecstasy would be a possibility. Malignant hyperthermia would usually present as altered though if I'm not mistaken?


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## EpiEMS (Aug 24, 2012)

NVRob said:


> Someone mentioned street drugs. 0100 and a younger patient ecstasy would be a possibility. Malignant hyperthermia would usually present as altered though if I'm not mistaken?



Probably would -- I've seen a few patients who were altered due to MDMA, Ecstacy, and those sorts of "club drugs." They are pretty altered (and sweaty, ewwww). The best tx for MDMA or Ecstacy-related hyperthermia at the BLS would probably be rapid cooling, with AED and BVM ready to go, and rapid transport. If you can get ALS coming, you'd probably be best to do it -- seizure activity might occur, as could cardiovascular problems (so ALS is indicated to provide benzos, IV fluids, and possibly cardiac monitoring).


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## Handsome Robb (Aug 24, 2012)

If it's a true MDMA OD and hyperthermic they'd absolutely be going on the monitor. Dysrhythmias and SCA aren't all that unheard of in MDMA ODs. 

With that said, if you're close to the hospital just go, don't wait for us to show up so we can put some stickers on and monitor them.


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## EpiEMS (Aug 24, 2012)

NVRob said:


> If it's a true MDMA OD and hyperthermic they'd absolutely be going on the monitor. Dysrhythmias and SCA aren't all that unheard of in MDMA ODs.
> 
> With that said, if you're close to the hospital just go, don't wait for us to show up so we can put some stickers on and monitor them.



Makes sense. I'm curious how common SCA is (in these types of OD's) -- I can't really do much for a dysrythmia without a monitor (as a BLS provider), but I can surely help for SCA.


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## Handsome Robb (Aug 24, 2012)

EpiEMS said:


> Makes sense. I'm curious how common SCA is (in these types of OD's) -- I can't really do much for a dysrythmia without a monitor (as a BLS provider), but I can surely help for SCA.



I have an article about it laying around here somewhere. If I can find it I'll try to find a scanner and post it up or post a link if there is one.


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## EpiEMS (Aug 24, 2012)

NVRob said:


> I have an article about it laying around here somewhere. If I can find it I'll try to find a scanner and post it up or post a link if there is one.



Cool, thx! I expect to see a lot of ODs of this sort in the coming fall season...woohoo <_<


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## PVC (Aug 24, 2012)

EpiEMS said:


> Cool, thx! I expect to see a lot of ODs of this sort in the coming fall season...woohoo <_<



Here is a great article about what kids are taking these days.

http://www.emsworld.com/article/10687155/toxicology-today-what-are-they-using


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## Doczilla (Aug 24, 2012)

Just curious, (not trying to sharpshoot) but how did we do from sore throat and fever to illicit drug use? The time of morning of the call? 

Who here has seen a true MDMA OD? Was their chief complaint chills, malaise, and sore throat? 

The typical presentations ive faced have been hot/dry skin, agitation or obtundation, rigors (not shivers) , and tachyarrythmias.


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## EpiEMS (Aug 24, 2012)

Doczilla said:


> Just curious, (not trying to sharpshoot) but how did we do from sore throat and fever to illicit drug use? The time of morning of the call?
> 
> Who here has seen a true MDMA OD? Was their chief complaint chills, malaise, and sore throat?
> 
> The typical presentations ive faced have been hot/dry skin, agitation or obtundation, rigors (not shivers) , and tachyarrythmias.



Oh, I was sort of just expanding on the MDMA OD comments. Certainly not seen sore throat as a complaint for that. Sort of got off track. MDMA OD complaint was none -- because they were so agitated or obtunded. Had one MDMA OD involving a seizure, but fortunately, ALS was there for that part. They were tachy, as well. And hot. Very hot. I've seen sweaty MDMA users who were pretty out of it, but not a call for one.


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## Doczilla (Aug 24, 2012)

yeah, was just checking to make sure people weren't correlating the time of the call to drug shenannegans. 

"Call me at 1am, eh druggy? Enjoy your ice sheets, sh*tbag."


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## EpiEMS (Aug 24, 2012)

Doczilla said:


> "Call me at 1am, eh druggy? Enjoy your ice sheets, sh*tbag."



Thread has been won.


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## the_negro_puppy (Aug 24, 2012)

ChaseZ33 said:


> Do you use volatile aesthetics in EMS down under? Nitrous oxide? I think it can happen with succ too



Methoxyflurane


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## Handsome Robb (Aug 24, 2012)

Doczilla said:


> Just curious, (not trying to sharpshoot) but how did we do from sore throat and fever to illicit drug use? The time of morning of the call?
> 
> Who here has seen a true MDMA OD? Was their chief complaint chills, malaise, and sore throat?
> 
> The typical presentations ive faced have been hot/dry skin, agitation or obtundation, rigors (not shivers) , and tachyarrythmias.



Sorry, that's mostly my fault. Just saw something about it and expounded on it from the hyperthermia standpoint. I highly doubt the specific scenario at the beginning of the thread was an MDMA OD.


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