Fever...

[JPINFV]

I've recently had a rash of calls for SNF patients suffering from fevers of around 105 degrees fahrenheit. The worst one that I've had was tonight with massive lethargy (still A/Ox4), tachycardia (~110) and hypertensive (SNF and NIBP at the hospital was in the 170's, I swear that I was getting ~210 without question). Due to the situation at the SNF (we were already at the SNF dropping off another patient and the closest ER was about a block away), I can't blame the SNF for not calling 911, but I am starting to wonder how high is too high and how lethargic is too lethargic. I've seen the danger levels for temperature being set anywhere from 106 (Silverthorn, Human Physiology) to 107.6 (http://health.allrefer.com/health/fever-info.html), with no mention of any specific level in my EMT-B book (Brady: Prehospital Emergency Care 7th Ed.). The EMT-B text doesn't directly cover infection and directs "hyperthermia" in elderly patients (both fever and enviromental causes) to the enviromental emergency section.

So, I am wondering if anyone could provide any hard barriers (106?) for when elevated temperatures becomes a problem and when exactly to include ALS (even if ALS can do pretty much nothing for an elevated temp) and/or emergency transport for these patients.

[brentoli]

SNF and NIBP at the hospital was in the 170's

Maybe it is the n00b in me, but define those two abbreviations?

[JPINFV]

SNF: Skilled Nursing Facility

NIBP: Non-Invasive Blood Pressure, AKA, blood pressure machine.

[ERDoc]

There are no set standards for temperatures. It has been widely accepted that 100.4 and above constitutes a fever. Any fever in an elderly person should be concerning. They can be severely septic and not manifest many outward signs until they are already going down. Their immune systems also aren't are efficient so infections are more worrisome. Fevers as high as 104.5 in kids are not concerning, assuming they look ok. Generally above 105 you start to get breakdown in metabolism. Infection will generally not cause a fever over 105. Neurologic injuries can cause problems with temperature regulation. I have seen stroke pts with temps in the 107-108 range. There is not much you can do at this point other than colling blankets, etc. Tylenol and Motrin will not do anything to help as their regualtory mechanisms are shot. Again, any fever can be concerning. Any infant under 2 months will get a full septic workup (including spinal tap) if their temp is 100.4 or greater. They cannot localize an infection and it is very easy for them to develop meningitis and sepsis as a result.

[Dustdevil]

There are no set standards for temperatures. It has been widely accepted that 100.4 and above constitutes a fever.

I just wanted to clarify for our audience that this is a RECTAL temperature standard.

There are different thresholds for oral and axillary temps, and probably for forehead and ear temps too, depending on what you have them set for.

[Ridryder 911]

All good points as well we are probably not going tot treat the fever as be concerned as much as the etiology of why they have the fever. At a BLS level provide a light sheet and obtaining an accurate history as much as possible would my best suggestion.

R/r 911

[ERDoc]

I just wanted to clarify for our audience that this is a RECTAL temperature standard.

There are different thresholds for oral and axillary temps, and probably for forehead and ear temps too, depending on what you have them set for.

I love it when you talk dirty, Dust. I should have clarified that. Anything other than rectal is inaccurate. I have seen people with up to 5 degree difference between rectal and other methods. If you get a non-rectal temp that is above 100.4, great, it's a fever. If it is a pt where a temp is going to sway my workup and I get a normal non-rectal temp, better believe we are getting a rectal temp. I used to have great hope for temporal artery temps, but after working with them for over a year I have been sorely let down. They are about as useful as ear temps. The only true temp is a rectal temp!

[Dustdevil]

Agreed. I have always been a big proponent of the anal probe.

I haven't had any experience with the temporal temps, other than it being used on me during physicals, so I wasn't aware of the problems with them. But I don't think I would have trusted them from the beginning... well, maybe a little more than ear temps, lol.

But yeah, I just didn't want anybody blowing off a 100.2 axillary temp because they read here that only 100.4 and above was a fever.

[katbemeEMT-B]

The biggest problem with an ear temp is that it can easily be manipulated by the environment such as the person was laying on the ear you used or has an infection in that ear. It will cause a rise in the temp in that ear. An auxiliary temp will at least give you a basic idea of what the true temp is. We have had a few patients with temps. exceeding 105 and the first thing we did is strategically place ice packs in the arm pits and groin and start and IV with saline for hydration. This was our only recourse to assist the patient in cooling down. I wish there was more we could do but as stated before until you know the etiology you have no course of treatment.

[Dustdevil]

The biggest problem with an ear temp is that it can easily be manipulated by the environment such as the person was laying on the ear you used or has an infection in that ear.

Actually, the biggest problem with the ear temp is that it must be properly aimed at the TM in order to work correctly. And how exactly are we supposed to do that? You can't see the TM with it. And most EMTs wouldn't know what a TM looked like if it is staring them in the face, much less how to find it. So, what happens is that the vast majority of the time, you end up taking the temp of the EAC or of a big ear booger instead of the TM. Not accurate in the least. The technology is sound. The application falls far short of the promise.

Oral temps are more affected by environmental factors. And again, too few people are good about finding and maintaining proper probe placement to get a good, steady reading. I watch medics all the time hand the thing to the patient and let the patient place it themselves without checking for placement. Bad form.

I find axillaries to actually be more consistent than orals, because they are subject to fewer environmental factors. But again, like the oral, proper placement is key, and must be maintained throughout the measurement. But while this may be acceptable for routine screening, there is no place for this in really sick patients.

Moot point since darn few ambos carry or regularly use thermometers anyhow. :roll: