Saturday, February 25, 2006

Hot to Trot

My chances against pneumonia are great!

This guy might have a good chance against pneumonia, if that was his problem.

He looks like he's having a massive anterior MI.

Or his wife's meatloaf keeps repeating on him.

I think he's having an acute anaphylactic reaction to the decor.

Who puts an ass (pardon me, I meant donkey), complete with a saddle, on their end table as a decoration?

The child will need theraputic counseling for years after this traumatic attempt at fever assessment.

hhhhhhhhhhhhhhhhhh

Do you know, when a patient tells me they think they are running a fever, I instinctively feel their forehead and then I take their temp?

I have no doubt that the first humans did the same thing. I imagine this scene, set in a pre-historic cave:

Caveman: "Feel hot!"

Cavewoman: "No. Have pain in head."

Caveman: "Not that. Skin hot!"

Cavewoman: "Me feel face." (Puts hand on forehead.) "Skin hot. Eat two of berries. Call giver of health when light comes."

Caveman: "Me sick. No care for self. Must have all things done."

Sorry guys, but some things never change.

hhhhhhhhhhhhhhhhhh

And now it's time for an Emergi-disclaimer: the following is not intended to be medical advice (1) because I'm not a doctor and (2) you should always check with your child's pediatrician for any illness or concern. There, now that that is out of the way:

Do you run into your emergency department in a state of panic because your child has an "extremely high" fever of 101 degrees?

Do you take your child's temperature under their arm because, well, who wants to do a rectal temperature?

Do you get nauseated at the thought of taking a rectal temp?

Do you become faint when the triage nurse takes your child's temperature and tells you that the number 40.6 centigrade is actually 105 degrees?

Are you concerned when your child's temperature does not "break" after a dose of Tylenol?

Are you amazed when the temperature comes back to its pre-Tylenol level approximately four hours after the last dose?

What, you say? You can give ibuprofen for fever?

Does the fact that your child even has a fever cause your pulse to race, your breathing to become labored and your anxiety level to skyrocket?

You, my friend, are suffering from acute fear of fever, or, as it has been coined in the literature I'm familiar with, "Fever Phobia".

You are not alone.

Here are some things to keep in mind. These are things I've picked up regarding pediatric fevers in the ER and during my stint as an advice nurse in a pediatric clinic.
  • Fevers are not dangerous.
    • They are the body's way of fighting off an infection, either viral or bacterial.
    • Fevers are more likely to be bacterial and should definitely be evaluated if
      • They last longer than three days.
      • They go over 105 degrees.
    • The exception to the rule: fevers in any child under 8 weeks old should be evaluated immediately by a physician.
  • The height of the fever is not as important as how the child is acting/looking.
  • Febrile seizures are the scariest things you will ever see as a parent.
    • They are also harmless.
    • Usually it is related to how fast the fever rises or drops.
    • They will stop on their own.
      • Turn your child on their side to allow any secretions to drain.
      • Protect them from injuring themselves on surrounding items.
    • The child should be evaluated immediately after the first febrile seizure.
      • The doctor will need to confirm that the seizure was truly due to the fever and not an underlying medical condition.
      • Discuss with your pediatrician what steps you should take if your child has repeated febrile seizures.
  • Both acetaminophen (Tylenol) and ibuprofen (Motrin, Advil) can be used for fever.
    • There is some difference of opinion on whether or not both medications can be used together, i.e. alternated. Ask your pediatrician what they prefer you to use.
    • Pediatric dosages are based on weight. The dose your child took six months ago will not be the correct dose today. If your child's weight is not listed on the bottle, call your pediatrician or an advice line to get the correct dosage for the weight.
    • Ask your pediatrician at what age they suggest using Motrin. It has been my experience that ibuprofen is not used under six months old.
    • Expect the fever to return as the medication wears off. It will.
  • Do not wrap your child up if they have a fever.
    • Right: a diaper and light covering - just enough so they do not shiver.
    • Wrong: a diaper, two onesies, a terry-cloth one-piece with "footsies", a sweater, a blanket-sleeper with "footsies", a coat, a hat and a fifty pound afghan hand- crocheted by grandma. At the same time.
  • Most children with fever will not want to eat, but they will be thirsty. Fluids are important.
    • Encourage them to drink as much as they want of whatever they want.
    • Make sure the fluid has calories in it. That sounds silly to mention, but offering diet sodas will not contribute calories or nutrition.
hhhhhhhhhhhhhhhhhh

When I worked in pediatric triage, my facility used protocols written by pediatrician Barton Schmitt, MD. I have to recommend this book as one of the best books on child health that I have ever read. It is based on the same protocols we used at the clinic. I have given it as a gift at at least six baby showers. Apparently it has been updated in 2005. Here is the amazon.com link for those who are interested:

15 Comments:

At 2/26/2006 04:10:00 AM, Blogger Flea said...

Bless you, Kim!

Thanks for that post. It was so good I feel ashamed to comment on it - but I'm only half-way through my first cup of coffee so here goes:

Fevers are more likely to be bacterial and should definitely be evaluated if
They last longer than three days.
They go over 105 degrees.


I recommend seeing me if the fever crosses the 96 hour mark, that's 4 days, or if the child begins to appear more ill, as you suggest. That does not mean I'm right and you're wrong about duration of fever, only that in my experience the likelihood of acute bacterial illness is greater at 4 days than at 3.

Also keep in mind two very important factors:

1) Parents often need help calculating when fever started.

Q: Mom tells you patient has had fever for two days. When did the fever begin?

A: Yesterday.


I say to parents "Okay, today is Thursday afternoon. When did the fever begin?" That usually helps.

2) Parents often don't know how to take temps. Sounds dopey I know. Nevertheless it is unfortunate and true.

Parents take temps too much! In a fully-immunized child over 6 months of age, particularly one who appears well, I recommend against taking a temperature. It only panics parents and tells me nothing about the sickness or wellness of the child.

RE: 105. Not strictly true. Again, appearance is important, magnitude is not.

Please help me discourage parents to take temps. One of the ways I do this is to model behavior in the office by not taking temps in older, well-appearing, not-hot feeling babies.

I realize you probably can't do that in the ED, but hey, I can dream, can't I?

all the best,

Flea

 
At 2/26/2006 07:50:00 AM, Blogger the depressed nurse said...

I touch a persons forehead first, too. My mother didn't use her hand, she would put her lips up to my forehead. She still does it to my children.

 
At 2/26/2006 08:02:00 AM, Blogger tk said...

Again, another great post. While I understand what flea is saying, I wish that my patient's parents would take their temperatures. They bring them in for fever. You ask how high and for how long and they respond "he felt really hot on Saturday". When we get that response, we give them one of those cheap digital thermometers and show them how to use it.

 
At 2/26/2006 11:15:00 AM, Blogger Flea said...

TK, the first mistake was having the patient brought to your office for fever.

Fever out of context is not a symptom, like chest pain, that rises to the level of requiring the ministrations of a physician.

At the very least, someone in your office should triage fever calls with appropriate screening questions.

If this is happening, then you've got an argument for temperature taking.

best,

Flea

 
At 2/26/2006 12:22:00 PM, Blogger Nurse Practitioners Save Lives said...

I also touch my patients first. It's a natural instinct and I have gotten pretty good at guessing the temp before actually taking it. I always tell my patients that fever is the body's way of helping to fight infections. As long as it doesn't get too high.. Nice post!

 
At 2/26/2006 01:18:00 PM, Blogger Jo said...

Awesome advice!
When Ari had her very first real fever on Christmas day I resigned to wait until the 48 hour mark at 102F degrees to call the MD. She was better by then.
My Mother was spazzing out wanting to take her to the ER.
I held my ground, she was fine. I'm sure her immune system will probably thank me for it if it could.

 
At 2/26/2006 08:13:00 PM, Anonymous difficult patient said...

Kim--I need a book on dealing with a teenager!!!!! Hormones abound in our home!

 
At 2/27/2006 06:16:00 AM, Blogger mary said...

About that donkey figurine (and yes, I do feel silly posting about the donkey after all the other great comments about more pressing matters! but still, someone has to!): we had two similar figurines when I was growing up in the fifties. One was a little donkey whose saddle bags held toothpicks, and it was about the size of that little statue there. The other was a planter, and it was larger. The saddle was actually a hollow space that a flower pot fit into.

I guess donkeys were popular? That picture looks pre-1950, though...

OK, back to fevers.

:-)

 
At 2/27/2006 12:56:00 PM, Blogger kenju said...

AMEN!

I admit to getting scared once when my daughter's fever spiked to 106*. She had pneumonia and empyema. In the hospital, her lung collapsed. It was started by Asian flu (1973), an ear infection, and a pediatrician who was not thorough enough. It was a very scary time; she spent all of Feb. in the hosp.

 
At 2/28/2006 02:52:00 AM, Blogger PaedsRN said...

Ok, I may be about to get thoroughly glared at but I have posted a note of caution in response to this article over at GeekNurse.

As always, Your Mileage May Vary ;)

 
At 2/28/2006 04:34:00 AM, Blogger TC said...

"If your child's weight is not listed on the bottle, call your pediatrician "

I had no idea that the bottle of tylenol knew my childs's weight! Only kidding, I was just thinking of the legions of parents I've seen in peds ER who would actually look on the bottle to see how much their kid weighs. At one ER I used to work in, we would get tons of parents who'd return the next day after we gave them an Rx for an antibiotic because,"it's not working yet" This was really a lack of patient education. So I'd always remember to tell my parents, give it a few days to work.

 
At 3/01/2006 08:24:00 AM, Anonymous d said...

I just felt like commenting that my parents always took my temperatures by feeling my stomach under my clothes. This has worked out as a useful alternative since now my rosacea is so bad that my face is *always* warm to the touch, so when I feel ill, I have my boyfriend check my stomach, rather than my face.

 
At 3/01/2006 01:42:00 PM, Blogger filmwidow said...

AskDrSears.com has dosage charts for different medicines that I've found to be very helpful since my daughter's weight isn't on a dosage chart. It's faster than calling the dr. It hasn't let me down for my daughter who isn't on the dosage chart on the meds.

 
At 3/03/2006 07:25:00 AM, Blogger That Girl said...

I take my infant's temp because the first question is always - does he have a temp? I realize not everyone has my son but a 101 fever IS something to be worried about (another exception) and I realized when it was too late (he already had a fever) that I didnt know if/how his aspirin had to be staggered against giving him tylonel.
Being a fairly nonchelant first-time mom and primary caretaker to 14 nephews I have learned 2 things - It's embarrassing to constantly be told by a doctor that you're worrying over nothing but it's unacceptable to let your child suffer or die because your afraid of being embarrassed or wasting someone's time.
I had to learn this the hard way (luckily before my 2nd son was born) being the type of person who thinks vitamin C, ginger ale and sleep (or a bandaid and a hug) will cure most anything.

 
At 3/09/2006 05:52:00 AM, Blogger nat said...

my son goes into convulsive status convulsivus which require iv in a&e with a temp over 100. even moderately high temps can be dangerous.

 

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