# Ice/cold packs for fever



## FourLoko (Nov 2, 2011)

Transported a 5 y/o with fever from the ER the other night. Nurse said highest was 105 F. In moving blankets found a cold pack under each leg and then one under his neck.

My "partner" admonished me for removing the one behind his neck after loading him on the gurney.

Didn't recall much about cold packs and fever (just heatstroke). Quick Google search seems to indicate they are a bad idea. Vasoconstriction and shivering might lead to increased temps.

Silly ER nurses or what?


----------



## Shishkabob (Nov 2, 2011)

No, they aren't a 'bad idea'.  

Yes, we do need to be wary of the shivering.




Kids can tolerate higher body temps for longer than adults, but that's no reason to let them sit there and bake.  Cool em down to a reasonable level at a reasonable speed.




Oh, and ps, chance are the doctor is the one that ordered the cold packs for the kid, the nurses didn't just do it on their own.


----------



## Handsome Robb (Nov 2, 2011)

What Linuss said.

That hot for too long could open a can of worms that makes the situation a whole lot worse. Read: febrile seizure.


----------



## jjesusfreak01 (Nov 2, 2011)

FourLoko said:


> Transported a 5 y/o with fever from the ER the other night. Nurse said highest was 105 F. In moving blankets found a cold pack under each leg and then one under his neck.
> 
> My "partner" admonished me for removing the one behind his neck after loading him on the gurney.
> 
> ...



Was this an IFT ride? Why were you taking them "out" of the ER? (I assume going to a peds ER) A standard fever is going to be EMS fixable with Tylenol and some minor active cooling. If the hospital felt the need to throw cold packs under every artery, the kid probably had some sort of nasty systemic infection, and 105 degrees would be way way outside of my comfort zone for any period of time. I'd probably have done the same thing.


----------



## Akulahawk (Nov 2, 2011)

A current temp of 105 in a kid should have me VERY worried, even if there's ice packs in use. I'd keep those ice packs in place... and gotten on you about removing the ice pack that's behind the neck too. If the current temp is lower than 105, but still a fever, I would still worry greatly. I don't want to get this kid shivering, but I don't want the body temp to climb either. 

One of the things that seems to kick off the febrile seizures is the rate of temp increase. Those ice bags may have been keeping the temp in check...


----------



## mycrofft (Nov 2, 2011)

*Just to be contentious, I'd like to see proof that trick works.*

Can't hurt, but the BTU reduction from a chemical cold pack just isn't that much. And an artery doesn't present much surface area versus cross section. And the blood is moving right along through there. Cooling capillary beds would yield a faster reduction; if the capillaries start constricting, the venules and arterioles won't (at least not as fast). Theoretically that would lose you the capillary bed to radiate heat, but on the other hand you have converted the skin and subcutaneous tissues into a heat sink.

That said, new studies cited earlier in EMTLIFE show even cold water baths are not as bad as everyone was saying...and which empirically has been demonstrated time and again over the decades. If shivering can build a deadly temp, then every person with a fever who falls into cold water is going to be dead from hyperthermia. 

If the medical order was to leave the chemical cold packs in place, then do it. As long as the pt doesn't try to drink the liquid.
edit: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361150/
Fever reduction protocols found to be determined by MD orders, and vary regionally.


----------



## abckidsmom (Nov 3, 2011)

Space.bar.is.broken.

While.a.temp.of.105.is.nothing.awesome,it's.also.not.a.huge.deal.in.and.of.itself...it's.how.the.kid.is.reacting.to.that.fever.that.really.matters...What's.his.mental.status?..How's.his.activity.level.etc.


----------



## Shishkabob (Nov 3, 2011)

I had a mental pause after every word due to the periods :wacko:


----------



## mycrofft (Nov 3, 2011)

*Another somewhat related article*

It's about control of hyperpyrexia in TBI patients with hypothalamic damage.
http://www.upgneurosurgery.com/admin/journal/journalpdf/Thompson.pdf
Notes from it (go to page 169) include that damage from shivering is from the consumption of oxygen by the shivering muscles; that shivering while cooling might be minimized by covering the extremities (i.e., DON'T cool the arms and legs, just the trunk/core); and that external cooling might be contraindicated for TBI. The article is from 2003 and states scientific study of cooling devices and intravascular cooling is (was) not conclusive (yet).


----------



## EMSrush (Nov 3, 2011)

abckidsmom said:


> Space.bar.is.broken.
> 
> While.a.temp.of.105.is.nothing.awesome,it's.also.not.a.huge.deal.in.and.of.itself...it's.how.the.kid.is.reacting.to.that.fever.that.really.matters...What's.his.mental.status?..How's.his.activity.level.etc.



That's too funny. You know you're a dedicated EMTlifer when..... LOL!


----------



## EMSrush (Nov 3, 2011)

Akulahawk said:


> One of the things that seems to kick off the febrile seizures is the rate of temp increase.



Yes, and decrease. Any sudden change in body temperature can provoke a seizure (as can a multitude of other things). We had a call for a seizure not too long ago. Apparently, the kiddo had a fever (101 or so... nothing too bad) and grandma decided to plunk the kid in an icy bath. He seized while in the tub. At the hospital, the kiddo's temp was low 98 something, if I remember correctly. Doc explained that it was the sudden change in temp, not the temperature itself.


----------



## FourLoko (Nov 3, 2011)

Temp wasn't 105 when we transported, was down to 101. He was taken to a Pediatrics unit at a nearby hospital FYI. Kid was calmly sleeping but was fine and responsive upon waking him up. He wasn't melting or anything dramatic.

I did see febrile seizures mentioned in my search. The couple of forum topics I found was from allnurses.com and in both the majority said they DO NOT use ice packs for child fevers.


----------



## FourLoko (Nov 3, 2011)

mycrofft said:


> It's about control of hyperpyrexia in TBI patients with hypothalamic damage.
> http://www.upgneurosurgery.com/admin/journal/journalpdf/Thompson.pdf
> Notes from it (go to page 169) include that damage from shivering is from the consumption of oxygen by the shivering muscles; that shivering while cooling might be minimized by covering the extremities (i.e., DON'T cool the arms and legs, just the trunk/core); and that external cooling might be contraindicated for TBI. The article is from 2003 and states scientific study of cooling devices and intravascular cooling is (was) not conclusive (yet).



interesting stuff, no TBI in our case and as mentioned, one pack under each limb and one under his neck

he was covered in a blanket but not wrapped, no shivering


----------



## mycrofft (Nov 3, 2011)

*Not finding chilling as a seizure trigger.*

I suppose that if someone was all set for a seizure the sudden "shock" might tip them over. Little ones can sort of muscularly "lock up" when they shiver too much but it is not a seizure, they are still breathing.


----------



## FourLoko (Nov 3, 2011)

Since I can't edit, here's a couple of the threads from allnurses:
http://allnurses.com/general-nursing-discussion/febrile-interventions-428304.html

http://allnurses.com/general-nursing-discussion/packing-child-ice-285582.html


----------



## mycrofft (Nov 3, 2011)

*We nurses can be so picky sometimes.*

Liked the references. No research citations. It seems to be mostly empiric and no organized interlocking  studies have been undertaken.


----------



## FourLoko (Nov 3, 2011)

mycrofft said:


> Liked the references. No research citations. It seems to be mostly empiric and no organized interlocking  studies have been undertaken.



Aside from the links you posted it doesn't seem like there is much research. They did have their own threads on TBI and hyperthermia management but I didn't read those.

I just wanted to know what the current accepted protocol was so I can be more informed and so I can tell my partner whats what.

I'm sticking with NO on ice packs.


----------



## Brandon O (Nov 16, 2011)

There is little evidence that degree of fever in a kid is correlated with severity of infection, OR that it typically needs to be managed aggressively -- until you get over 106-107 F there is no damage to the brain. You are far more likely to cause complications by putting them in the freezer etc. And febrile seizures are not apocalyptic events either. Let it be.

High numbers and febrile seizures... two great ways to catch our attention without actually meaning much clinically.


----------



## txffmedic (Feb 10, 2017)

FourLoko said:


> Temp wasn't 105 when we transported, was down to 101. He was taken to a Pediatrics unit at a nearby hospital FYI. Kid was calmly sleeping but was fine and responsive upon waking him up. He wasn't melting or anything dramatic.
> 
> I did see febrile seizures mentioned in my search. The couple of forum topics I found was from allnurses.com and in both the majority said they DO NOT use ice packs for child fevers.


No need to cool someone's fever to prevent brain damage unless there is a problem/damage to the hypothalamus. Brian won't let fever get to level to cause brain damage unless this is damaged or outside source (heat stroke/drugs ect). Temperature above 107 can start causing brain damage. Febrile seizure also don't cause brain damage. The risk from febrile seizure is trauma from the seizure or airway. Febrile seizure are caused by the spike in temperature not how high it is. I would not use icepacks. I don't know of any evidence to show they are helpful for fever. Stick to passive cooling and medications. ER docs/nurse aren't always right. There are ER docs/nurses that are really great and there are those that are dumb and make bad choices/treatments. It best if you could have noticed it before getting to the ambulance and discuss it with the doc/nurse. I would not have keep the icepacks. If there are no protocols and its "best practice" or similar situation do what you think is best for you pt and be able to back-up your decision.


----------



## akflightmedic (Feb 10, 2017)

Hope he learned this valuable lesson.....FIVE YEARS AGO when this thread was relevant.


----------



## NomadicMedic (Feb 10, 2017)

akflightmedic said:


> Hope he learned this valuable lesson.....FIVE YEARS AGO when this thread was relevant.



Ohhh! You sent him to the BURN UNIT!


----------



## OnceAnEMT (Feb 10, 2017)

NomadicMedic said:


> Ohhh! You sent him to the BURN UNIT!



Somebody get this guy an ice pack.

Oh wait.


----------



## VentMonkey (Feb 10, 2017)

NomadicMedic said:


> Ohhh! You sent him to the BURN UNIT!





Grimes said:


> Somebody get this guy an ice pack.
> 
> Oh wait.


Whoa, whoa cool down everyone.


----------



## NomadicMedic (Feb 10, 2017)

VentMonkey said:


> Whoa, whoa cool down everyone.



ohhhh... I seizure what you did there


----------



## ERDoc (Feb 10, 2017)

txffmedic said:


> ER nurse aren't always right.



Fixed it

I've started printing this out and giving it to worries parents when they bring in their pumpkins at 0300.
http://www.seattlechildrens.org/medical-conditions/symptom-index/myths-about-fever/


----------



## EpiEMS (Feb 11, 2017)

ERDoc said:


> Fixed it
> 
> I've started printing this out and giving it to worries parents when they bring in their pumpkins at 0300.
> http://www.seattlechildrens.org/medical-conditions/symptom-index/myths-about-fever/



Excellent resource, and easy to read. Ought to be mandatory for our (sadly minimal) pediatrics training...


----------



## Bullets (Feb 11, 2017)

abckidsmom said:


> Space.bar.is.broken.
> 
> While.a.temp.of.105.is.nothing.awesome,it's.also.not.a.huge.deal.in.and.of.itself...it's.how.the.kid.is.reacting.to.that.fever.that.really.matters...What's.his.mental.status?..How's.his.activity.level.etc.


Should have just used the clap emoji because thats how i read that


----------



## zzyzx (Feb 12, 2017)

ER Doc, you should hand that resource out to nurses and medics too!
Most healthcare workers don't understand that fevers are not dangerous, and that fever and hyperthermia are two entirely different things.


----------



## ERDoc (Feb 12, 2017)

zzyzx said:


> ER Doc, you should hand that resource out to nurses and medics too!
> Most healthcare workers don't understand that fevers are not dangerous, and that fever and hyperthermia are two entirely different things.



It is just so ingrained in our society that it is hard to change, much like antibiotics for ear infections.  I never give my kids tylenol or motrin until they are feeling uncomfortable.  If we could, at a societal level, educate parents about fevers we could cut a huge number of PCP and ER visits.  I like to give the print out because it comes from some mecca of pediatric medicine and not just some crazy er doctor from bumblefuck, Michigan.


----------



## NysEms2117 (Feb 12, 2017)

ERDoc said:


> It is just so ingrained in our society that it is hard to change, much like antibiotics for ear infections.  I never give my kids tylenol or motrin until they are feeling uncomfortable.  If we could, at a societal level, educate parents about fevers we could cut a huge number of PCP and ER visits.  I like to give the print out because it comes from some mecca of pediatric medicine and not just some crazy er doctor from bumblefuck, Michigan.


Do i see a Parenting 101 on the horizon? I'd support it !


----------



## ERDoc (Feb 13, 2017)

Nope.  I've managed to keep my kids alive this long, it's not hard.


----------



## EpiEMS (Feb 13, 2017)

@ERDoc, the fever-phobia makes me wonder -- are we seeing incidences of overdose as a result of over-aggressive use (misuse) of antipyretics?


----------



## ERDoc (Feb 13, 2017)

I know I've had several cases where we had to discuss with the parents the proper dosing of meds.  Nothing toxic, just a little too much.  I haven't searched the literature but it wouldn't surprise me.


----------



## NomadicMedic (Feb 13, 2017)

EpiEMS said:


> @ERDoc, the fever-phobia makes me wonder -- are we seeing incidences of overdose as a result of over-aggressive use (misuse) of antipyretics?



I just listened to a This American Life radio show all about APAP overdoses. Fascinating story. 

https://m.thisamericanlife.org/radio-archives/episode/505/use-only-as-directed


----------



## EpiEMS (Feb 13, 2017)

@NomadicMedic, that's fascinating stuff (just from the description alone)! I'll give it a listen!
I think the first time I heard about an APAP overdose, it was Vicodin related (APAP/Hydrocodone combo) and somebody took their usual prescribed Vicodin PLUS a bit too much additional APAP.


----------



## ERDoc (Feb 13, 2017)

EpiEMS said:


> @NomadicMedic, that's fascinating stuff (just from the description alone)! I'll give it a listen!
> I think the first time I heard about an APAP overdose, it was Vicodin related (APAP/Hydrocodone combo) and somebody took their usual prescribed Vicodin PLUS a bit too much additional APAP.



That's why they don't make Vicodin anymore, you can only get Norco.


----------



## EpiEMS (Feb 13, 2017)

ERDoc said:


> That's why they don't make Vicodin anymore, you can only get Norco.



Certainly makes sense! (I see the FDA set the APAP component of opioid/APAP combos to 325mg.)


----------

