21d Fever Discussion V1

Author: Emergency Medicine

Hello again. It's Joseph Becker with the Stanford International Emergency Medicine. We're here to discuss fever and our case questions for the fever case discussion. So without further ado, we'll start with our case. And as you'll see in the upcoming movie, this is a case initially about two patients-- Donna and Katherine.

They are trauma patients, at least initially. Victims of what is supposedly a motor vehicle accident. On of them presents in critical distress, with altered mental state. And we'll see how the rest of the case develops as we watch. So here we go.

[VIDEO PLAYBACK] -OK fellas, heads up let's go. -Donna Gallagher, unrestrained teen driver, ejected when her car flipped. Hit a jogger coming into the next rig.

GCS 7, BP 90 palp. -Greg, trauma one. Passenger with facial injuries from airbag, and shoulder pain, vitals stable. -What's your name, sweetie? -Katherine Olcowski. -Oh, I feel you. I used to be Abigail Wazinski. -My friends call me Katie-O.

21d Fever Discussion V1

-Donna, can you hear me? -BP 75 systolic, pulse 130. -How we doing in here? -Nothing in the belly, no tamponade. Why is she hypotensive? Ecchymoses on the thighs.

-Distal extremities too. -She's in DIC. -You have to be hemorrhaging somewhere to cause DIC. -All right, let's get her to the scanner. -Oh, her IV sites are oozing. -She needs platelets and FFP. -No, not with this blood shortage.

We can't give her our last platelets. She'll just chew them up. -She's unresponsive. She's bleeding everywhere. She could have a head bleed.

-We don't know that. All right. Can someone give me a gram of Acetaminophen? [END VIDEO PLAYBACK] OK, so in that short clip we just watched there you can see how these two patients had their care initially managed. And several questions can be posed. The first of which is what are the important actions that can be performed when evaluating an undifferentiated and critically ill patient? So very important. How do we initially approach a patient who is critically ill? And then number two-- the patient Donna appears to be in shock. What do the characters in this scene do to differentiate between the different causes of shock? So you can see there was a discussion there about the patient's blood pressure and the potential ideologies of that.

And a we can discuss what these characters did to determine what this patient's shock is from. Ok. Moving on to the next video.

[VIDEO PLAYBACK] -Give me tablets please. Secure her airway. Let's see what we find on CT.

-By then, it could be too late. -OK, Katie, move your head from side to side. Does that hurt? -It's just a little stiff. -ok.

-And I hurt all over. -And your forearms are bruised up. -I must have hit them on the dashboard, or something.

-Now, do you remember what happened? -We were at the mall. -No school? -It was the last day before spring break so we cut. But Donna got a headache and she said she wanted to go home. -ok. OK, follow my finger. -The light really hurts. -The airbag could have scratched your cornea.

-BP 115 over 80, pulse 104. -OK, I'm going to press on your abdomen. Let me know if it hurts. -She fainted on the way home.

I tried to stop the car, but I couldn't. -Chest, x-ray, shoulder series, icon UA, and visual acuity. -I'll set up a slit lamp. -And then the car was upside down. I looked over at Donna but she wasn't there anymore. -It's OK. [END VIDEO PLAYBACK] So as you saw the work up of both patients there progress, an interesting question can be posed. And essentially it's how can an emergency provider make the correct diagnosis in situations such as the one presented in this video? So as you might imagine, this is a discussion about fever, yet we have two trauma patients here.

So it is likely that there's something else going on here. When we provide care to emergency patients, how can we make the correct diagnosis, given that the history and the characteristics of the history that we often learn are often inaccurate or incomplete? All right, moving along to the next video. [VIDEO PLAYBACK] -Did you reach my parents? -They're on their way in. So are Donna's. -Is she OK? -She's got some really good doctors taking care of her. -Can I get something for my headache? -Sure. -Temp is up 101.8.

-ok. 600 of Ibuprofen. -And about my bruises, when will they go away? -They've spread. -Yeah.

-Abby? OK. Chuny, put on a mask. Call the lab for stat blood cultures. Hang 2 grams of Ceftriaxone on IV. Make sure she stays in isolation. -Don't worry, Mr. Highsmith.

You'll be back jogging in no time. -Luca? -Time of death 12:17. -It's meningococcemia. -Are you sure? -My patient has rapidly progressing purpura and fever, and I bet this one does too. -It's DIC from trauma. -Yeah, I don't think so. My girl complained of headache, stiff neck, and sensitivity to light. -I'll call infection control -I put her in isolation, started her on Ceftriaxone.

-We need immediate prophylaxis for all hospital staff exposed to these patients. -That's a lot of people. -We're all at risk. [END VIDEO PLAYBACK] OK, so as we saw in this case, it seems to have developed. And these two initially trauma patients are now thought to be suffering from meningococcal meningitis. So a couple of questions to be posed based on this new information. The first of which is-- what is the role of lumbar puncture the diagnosis of meningitis? Number five-- is it necessary to wait for the results of the lumbar puncture before initiating antibiotic treatment? And this is very important because as the lumbar puncture is the only way of establishing this diagnosis, if there are delays in its performance, that will also subsequently delay the provision of antibiotics. Number six-- this case you seems to be one of Neisseria meningitidis, bacterial meningitis.

What other treatment can be provided in this case aside from the antibiotics already discussed? And number seven-- why is it important to maintain universal precautions and be vigilant for diagnoses that require higher levels of isolation? We'll discuss that a little bit as well. Now, the next several questions are going to be based on a second case. And this is another case discussion of a patient with fever. And as we see in this case, this is a child who has fever and some upper respiratory infection symptoms, as well as a fever of unknown etiology for some time now. So moving along to the video itself. [VIDEO PLAYBACK] -All right.

OK, buddy, not feeling so great, huh? What's the temperature? -103. -OK, Carter, this is a good place for you to start. Why don't you come get me and present your findings? -No problem. I'm going to listen to your chest.

Ok. Take a deep breath for me. [END VIDEO PLAYBACK] All right.

So this introductory clip we have the question number eight-- this child appears to have a fever of unknown source and for a longer than usual duration. As we'll learn, this fever was present for about seven days. What broad differential diagnostic domains must be considered in this case? When we approach a patient such as this, what do we need to consider? All right, subsequent clip. [VIDEO PLAYBACK] -So that's your diagnosis? That the kid has the flu? -Viral syndrome. I prescribed fever control measures and fluids. -He has a rash, conjunctivitis, swollen glands.

How long has he had the fever? -His mom said about a week. -Fever of unknown origin for seven days. -Did I miss something? -What color is his tongue? -Pink. -Not strawberry? -Maybe. I'm not sure. -Did you notice his chapped lips? [END VIDEO PLAYBACK] So based on this clip, what differential diagnosis could be generated from the findings of the two providers in this clip? So these two providers have been discussing several findings of the physical exam. What differential diagnosis can be generated based on this information? What mistakes are made by the first provider in caring for this patient? So you could see the patient and the two providers discussing the case.

And the second provider seems to have some information that the first did not. All right. So moving on to the final clip.

[VIDEO PLAYBACK] -All right. Give him an aspirin and order an echocardiogram. -Aspirin? I thought you never give aspirin to a child. -Unless, of course, he's diagnosed with Kawasaki's. -Kawasaki's-- -Kawasaki's is a cluster of unremarkable symptoms that can lead to coronary aneurysms. Fever, chapped lips, and strawberry tongue are the tip-offs. Admit the boy to the peds unit.

-Right away. [END VIDEO PLAYBACK] OK, so following that final clip, two questions. Number 11-- what is Kawasaki's Arteritis and how is it treated? And number 12-- Why it is important to make this diagnosis and differentiate between Kawasaki's and a simple febrile illness? All right. So these are the questions based on these two fever cases. Please enjoy answering them, and we will welcome Dr. Mahadevan as our expert discussant for the fever case discussion upcoming. Thank you very much.

21d Fever Discussion V1

Hello again. It's Joseph Becker with the Stanford International Emergency Medicine. We're here to discuss fever and our case questions for the fever case discussion. So without…

By: Emergency Medicine