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Medical tactics for acute fever of unknown origin
Vanyukov Dmitry Anatolievich
Fever is an increase in body temperature above 37 ° C when measured in the armpit and 37.5 0 C in the mouth or rectum. If the fever lasts up to 2 weeks, it is called acute; if it lasts for more than 2 weeks, it is called chronic.
Thermoregulation processes
The body always maintains a balance between the formation of heat (as a product of all metabolic processes) and heat loss (through the skin, lungs, feces and urine). These processors are regulated by the heat center of the hypothalamus, which acts as a thermostat. When the temperature rises, the hypothalamus gives the command for vasodilation and sweating. When the temperature drops, a command is received to constrict the skin vessels and muscle tremors.
Fever is the result of various stimuli that rewire the hypothalamus to maintain the temperature at a higher level than normal. For example, he was “programmed” for level 35-37, but began to work at level 37-39.
Endogenous pyrogen is a low molecular weight protein produced in the body. Some tumors are capable of autonomously producing endogenous pyrogen (eg, hypernephroma) and, therefore, fever will be present in the clinical picture.
Stimulation of the hypothalamus may be associated not with pyrogens, but with dysfunction of the endocrine system (thyrotoxicosis, pheochromocytoma) or the autonomic nervous system (neurocirculatory dystonia, neuroses), with the influence of certain medications (penicillins and sulfonamides, salicylates, methyluracil, novocainamide, antihistamines).
Fever of central origin is caused by direct irritation of the thermal center of the hypothalamus as a result of acute cerebrovascular accident, tumor, or traumatic brain injury.
Diagnostic tactics
Fever itself is rarely life-threatening. But under the guise of a banal respiratory infection, serious diseases that require specific therapy (for example, diphtheria, acute pneumonia, the febrile phase of HIV infection, etc.) can be hidden.
In some cases, an increase in temperature is accompanied by characteristic complaints and/or objective symptoms, which allows one to immediately navigate the diagnosis and treatment of the patient. But often, especially at the beginning, the first examination does not reveal the cause of the fever. Then the patient’s health status before the disease and the dynamics of the disease become the basis for decision-making.
1. Acute fever against the background of complete health
If fever occurs against a background of complete health, especially in a young or middle-aged person, in most cases one can assume an acute respiratory viral infection with spontaneous recovery within 5-10 days. When diagnosing ARVI, it should be taken into account that with infectious fever there are always complaints (cephalgia, myalgia, chills, etc.) and catarrhal symptoms of varying severity. After collecting an anamnesis and physical examination, a mandatory re-examination is scheduled in 2-3 days and in most cases no tests (except for daily temperature measurements) are required.
When re-examined after 2-3 days, the following situations are possible:
2. Acute fever with a changed background
If the temperature rises against the background of an existing pathology or the patient’s serious condition, the possibility of self-healing is low. An examination is immediately prescribed (the diagnostic minimum includes general blood and urine tests, chest x-ray). Such patients are also subject to more regular, often daily, monitoring, during which indications for hospitalization are determined. Main options:
3. Acute fever in patients over 60 years of age
Acute fever in the elderly and senile is always a serious situation, because due to a decrease in functional reserves, such patients can quickly develop acute disorders, for example, delirium, cardiac and respiratory failure. Therefore, such patients require immediate laboratory and instrumental examination and determination of indications for hospitalization. One more important circumstance should be taken into account: at this age, clinical manifestations may be asymptomatic and atypical.
In most cases, fever in old age has an infectious etiology. The main causes of infectious and inflammatory processes in old age:
Less common causes of fever in old age include herpes zoster, erysipelas, meningoencephalitis, gout, polymyalgia rheumatica and, of course, acute respiratory viral infections, especially during epidemic periods.
Treatment tactics
Treatment tactics for acute fever of unknown origin are presented in the table below.
| No treatment required | Antipyretics indicated | Antibacterial agents indicated |
|
Short-term fever (up to 4 days) Satisfactory condition The fever occurred against the background of complete health Young and middle age |
At temperatures above 38 0 C: children under 5 years of age, diseases of the circulatory and respiratory organs, nervous system At temperatures above 41 0 C for all patients |
Reliable signs infectious process Immune deficiency Severe general condition Elderly and senile age |
1. No treatment required
In case of acute fever of unknown origin in young patients and in satisfactory condition, routine use of antipyretic and antibacterial drugs is usually not required, since they have virtually no effect on the prognosis and duration of the disease. Such patients require a comfortable regime, sufficient and varied nutrition, and the elimination of stressful duties. The doctor is only required to monitor the development of the disease; it is possible to prescribe antiviral drugs.
Please note that:
2. Prescription of antipyretics
It is important to remember the following points:
The prescription of antipyretics is justified in the following cases:
The most commonly used antipyretics are acetylsalicylic acid, ibuprofen and paracetamol.
3. Antimicrobial therapy
If the fever is associated with bacterial infection, then appropriate antibacterial therapy is required, but for short-term fever they are usually not prescribed.
The exceptions are patients with a high probability of an infectious process or the presence of immune deficiency, patients with severe general condition, often in old age.
Antibiotics should be preferred wide range actions:
Literature
- V.P. Pomerantsev. Acute febrile conditions of unknown origin in outpatient practice.- and. Therapeutic Archives, 1993.
- ON THE. Geppe. On the issue of the use of antipyretics in children.- and. Clinical pharmacology and therapy, 2000.
- I. Bryazgunov. Infectious and non-infectious hyperthermia.- “Medical newspaper”, 2001
- A.L. Vertkin. Diagnostic algorithm and management tactics for patients with fever prehospital stage. - http://cito.medcity.ru/sreports.html
“White” hyperthermia is characterized by the following signs: pale, “marbled” skin, cyanotic shade of nail beds and lips, sim-tom “ white spot" positive. The extremities are usually cold;
Excessive tachycardia, increased breathing, and behavioral disturbances in the child (indifference, lethargy, possible agitation, delirium, etc.) are noted. The effect of antipyretics for “white” hyperthermia is insufficient.
Urgent Care
In accordance with the recommendations, antipyretic therapy should be carried out in initially healthy children at a body temperature above 38.5 °C. However, if a child has a fever, regardless of the severity of hyperthermia, the condition worsens, chills, myalgia, poor health, pallor appear skin and other manifestations, antipyretic therapy should be prescribed immediately.
Children from the “risk group for the development of complications due to fever” must be prescribed antipyretic drugs at a “red” temperature above 38 ° C, and at a “white” temperature - even at a fever. This group includes children with a history of febrile seizures, central nervous system pathology, chronic diseases heart and lungs, hereditary metabolic diseases.
Treatment of “red” hyperthermia
- Physical cooling methods.
- The child must be uncovered and access to fresh water must be ensured.
spirit. - Prescribe plenty of fluids (0.5-1 liters more than age norms)
We). - You can blow the child with a fan, apply cool
wet bandage on the forehead, cold (ice) on the area of large vessels
to the head (at a distance of 10-15 cm), perform vodka-vinegar-
rubdowns (vodka, 6% vinegar solution, equal water
large volumes) with a cotton swab; the procedure can be repeated
2-3 times.
- Antipyretic drugs. Can be given inside paracet
they say at a dose of 10-15 mg/kg or rectally in suppositories - 15-20 mg/kg; ibupro-
hairdryer in a single dose of 5-10 mg/kg. - If body temperature does not decrease within 30-45 minutes, it is necessary
dimo inject an antipyretic mixture intramuscularly: 50% analgin solution
0.1 ml/year of life (up to 1 year use 0.01 ml/kg), 2.5% solution of Pi-
polfen (diprazine) 0.1-0.15 ml/year of life, but not more than 2 ml (up to 1 year
yes use 0.01 ml/kg). A combination of drugs is acceptable
products in one syringe. If there is no effect after 30-60 min.
The application of the antipyregic mixture can be repeated.
Treatment of “white” hyperthermia
For “white” hyperthermia, simultaneously with antipyretics, vasodilators are administered orally or intramuscularly: papaverine or (2% papaverine solution is used at a dose of 0.1-0.2 ml/year of life or noshpa solution at a dose of 0.1 ml/year of life) . In addition, you can use a 0.25% solution of droperidol at a dose of 0.1-0.2 ml/kg IM. After microcirculation is normalized, physical cooling methods are used.
In hyperthermic syndrome, body temperature is monitored every 30-60 minutes. After body temperature drops to 37.5 °C, therapeutic hypothermic measures are stopped, since in the future it can decrease without additional interventions.
Children with hyperthermic syndrome, as well as with intractable “white” fever after treatment emergency care needs to be hospitalized. The choice of hospital department and etiotropic therapy depends on the nature and severity of the underlying pathological process that caused the fever.
Due to the proven connection with the development of Reye's syndrome in patients with influenza and other viral infections, acetylsalicylic acid is prohibited from being used to reduce fever in children under 15 years of age. The refusal of many countries to use analgin (metamizole), especially for oral administration, is associated with the risk of developing agranulocytosis.
Therapeutic tactics for acute fever are presented in the table below.
| No treatment required | Antipyretics indicated | Antimicrobial agents indicated |
|---|---|---|
| Short-term fever (up to 4 days). Satisfactory general condition. | At temperatures above 38 0 C: children under 5 years of age, decompensated diseases of the circulatory and respiratory organs, nervous system, psychosis, dementia, condition after surgery. | Reliable signs of an infectious process or immune deficiency. |
| The fever occurred against the background of complete health. Young and middle age | At temperatures above 41 0 C - for all patients. | Severe general condition. Elderly and senile age. |
1. No treatment required
In case of acute fever in young patients without complicating factors and with a satisfactory general condition, the routine use of antipyretic and antimicrobial drugs is usually not indicated, since it has virtually no effect on the prognosis and duration of the disease. Such patients need to be provided with a comfortable regime, sufficient and varied nutrition, and eliminate stressful duties. The doctor is only required to monitor the development of the disease; it is possible to prescribe antiviral drugs.
Please note that:
- First, fever itself is rarely life-threatening. Usually, in infectious diseases, if the temperature is not reduced, it does not exceed 41 0 C. For example, with acute respiratory infections, a temperature above 40.5 0 C is observed in only 0.1-0.3% of patients.
- Secondly, you need to remember that fever is a protective reaction of the body, so striving to normalize body temperature is not always advisable. During infections against the background of elevated temperature, the reproduction of viruses and bacteria is suppressed, and at temperatures above 38 0 C it is 2-3 times more active than at low-grade or normal body temperature.
- Third, antipyretic drugs can cause negative side effects (eg, gastroduodenal bleeding, agranulocytosis, Reye's syndrome).
- And finally, fever can serve as the only symptom of the disease, and antipyretic therapy “blurs” the picture and contributes to the later prescription of etiotropic treatment.
2. Prescription of antipyretics
It is important to remember the following points:
- A course of antipyretic drugs is never prescribed!
- If antibiotics are prescribed, then additional antipyretics are not used!
- Physical methods of cooling (fan jet, rubbing with warm water or alcohol) are usually ineffective, and without prior (30 minutes before the procedure) taking antipyretics are contraindicated, because they lead to a further increase in temperature.
The prescription of antipyretics is justified in the following cases:
- Fever above 41 0 C (possible damage to the nervous system).
- Fever above 38 0 C in patients with decompensated diseases of the cardiovascular or bronchopulmonary systems, the course of which may worsen as a result of increased oxygen demand.
- Fever above 38 0 C in postoperative period; for psychoses (including alcoholic) and senile dementia; in children under 5 years of age (risk of developing febrile seizures).
- Poor tolerance to fever of any level.
The most commonly used antipyretics are acetylsalicylic acid, ibuprofen and paracetamol.
Aspirin (acetylsalicylic acid) is an effective antipyretic. In 1999, the Pharmacological Committee of Russia included in the section of contraindications instructions for the use of aspirin for acute viral infections in children under 15 years of age, due to the risk of developing Reye's syndrome, a fatal toxic encephalopathy. The use of instant forms of aspirin does not eliminate the systemic effect of the drug on the synthesis of “protective” prostaglandins in the gastric mucosa and does not reduce the risk of gastrointestinal bleeding, but only reduces the local irritant effect of the drug on the gastric mucosa. Aspirin is not prescribed if there is a high risk of bleeding, at the same time as anticoagulants, or during pregnancy.
Paracetamol is the only antipyretic that is approved for use in children starting from 3 months of age. It is the drug of choice for the treatment of fever. The action of paracetamol begins after 30-60 minutes and lasts 4 hours. Unlike ibuprofen and other non-steroidal anti-inflammatory drugs, paracetamol has mainly central action, does not suppress the synthesis of prostaglandins outside the central nervous system, therefore does not cause undesirable reactions such as gastric erosion, gastroduodenal bleeding, aspirin asthma. Paracetamol is part of complex drugs (Coldrex, Lorraine, Panadol, Solpadeine, Theraflu, Fervex). The notorious hepatotoxicity of paracetamol occurs only with a single dose of huge doses (140 mg/kg) of the drug.
Ibuprofen. The antipyretic effect of ibuprofen is comparable to that of paracetamol, but lasts longer. Unlike paracetamol, it can cause skin reactions and disorders. gastrointestinal tract, worsen the course of bronchial asthma. Therefore, ibuprofen is considered a 2nd line antipyretic; it is used in cases of intolerance or limited effectiveness of paracetamol. Without medical supervision, ibuprofen can be prescribed to children over 1 year of age.
Metamizole sodium(analgin) is banned for use in more than 30 countries and withdrawn from the pharmaceutical market, because it contributes to the development of agranulocytosis (in studies, this complication developed on average in 1 out of 1,700 patients). It is not prohibited in Russia, but in 2000 the Russian Pharmacological Committee introduced restrictions: use in children under 12 years of age only as prescribed by a doctor, and the duration of treatment without medical supervision should not exceed 3 days. For fever, it is often used parenterally as part of a lytic mixture with diphenhydramine (the latter acts as a synergist of antipyretics).
3. Antimicrobial therapy
If the fever is associated with a bacterial infection, then appropriate antimicrobial therapy is required (usually not prescribed for short-term fever). The question of antimicrobial therapy is necessarily raised in patients with a high probability of an infectious process or the presence of immune deficiency, in patients with severe general condition, in elderly and senile patients.
Preference should be given to broad-spectrum antibiotics:
- protected aminopenicillins: amoxicillin with clavulanic acid (amoxiclav, augmentin),
- fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin, sparfloxacin),
- II generation macrolides (roxithromycin, clarithromycin, azithromycin).
Sources
- Bryazgunov I. Infectious and non-infectious hyperthermia. - “Medical Newspaper”, 2001, No. 89 and 90.
- Vertkin A.L. Diagnostic algorithm and tactics for managing patients with fever at the prehospital stage. - 2003. - http://cito.medcity.ru/sreports.html
- Geppe N.A. On the issue of the use of antipyretics in children. - and. Clinical Pharmacology and Therapeutics, 2000, 9 (5), pp. 51-53.
- Murtagh J. Doctor's Directory general practice . Per. from English - M.: “Praktika”, 1998. - 1230 p. (Ch. 45. Fever - pp. 453-461).
- Pomerantsev V.P. Acute febrile conditions of unknown origin in outpatient practice. - and. Therapeutic archive, 1993, no. 6, pp. 77-80.
- Tabalin V.A., Osmanov I.M., Dlin V.V. The use of antipyretics in childhood. - and. Clinical Pharmacology and Therapeutics, 2003, 12 (1), pp. 61-63.
General diagnostic principles
emergency conditions in children
The need for productive contact with his parents or guardians to collect anamnesis and ensure a calm state of the child during examination.
The importance of getting answers to the following questions:
reason for seeking emergency medical care;
circumstances of illness or injury;
duration of the disease;
timing of deterioration of the child’s condition;
means and medications previously used before the arrival of the EMS doctor.
The need to completely undress the child at room temperature with good lighting.
Compliance with the rules of asepsis when examining a child with the obligatory use of a clean gown over uniform, a disposable surgical mask, especially when providing care to newborns.
Tactical actions of an EMS doctor
The decision to leave the child at home with the mandatory transfer of an active call to the clinic is made if:
the disease does not threaten the patient’s life and will not lead to disability;
the child’s condition has stabilized and remains satisfactory;
The child’s material and living conditions are satisfactory and he is guaranteed the necessary care that excludes a threat to his life.
The decision to hospitalize a child if:
the nature and severity of the disease threatens the patient’s life and can lead to disability;
unfavorable prognosis of the disease, unsatisfactory social environment and age characteristics of the patient suggest treatment only in a hospital setting;
Constant medical supervision of the patient is required.
Hospitalization of a child should only be accompanied by an emergency physician.
4. Actions in case of refusal of hospitalization:
if the treatment measures carried out by the EMS doctor are ineffective, and the child in a state of decompensation remains at home due to the parents or guardians’ refusal to hospitalize, then it is necessary to report this to the senior ODS doctor and act on his instructions;
any refusal to undergo examination, medical care, or hospitalization must be recorded in the EMS doctor’s call card and signed by the child’s parent or guardian;
if the patient or parent (or guardian) of the child does not want to formalize the refusal of hospitalization in the form prescribed by law, then it is necessary to attract at least two witnesses and record the refusal;
in case of refusal of hospitalization and the possibility of deterioration of the child’s condition, it is necessary to ensure the continuation of treatment at home with active dynamic visits to the child by a pediatrician at an outpatient clinic or an emergency physician.
Any forms of medical intervention require agreement with the child’s parents (guardians) based on the principle of informed voluntary consent in the framework of the Fundamentals of the Legislation of the Russian Federation on the protection of the health of citizens, Articles 31, 32, 61.
Features of transporting children
Children who are conscious and in a state of moderate severity are transported with one accompanying person. Young children are held in arms or on laps. In case of pneumonia, bronchial asthma, stenosing laryngotracheitis, foreign bodies in the upper respiratory tract, after suffering from pulmonary edema, children are kept upright. In these cases, older children are transported on stretchers with a raised headboard. Children in extremely serious condition requiring resuscitation measures are transported separately from their parents.
To avoid the introduction of infection into a medical institution, the doctor, before bringing the child into emergency department, should ask the medical staff of the hospital about the availability of quarantine for a particular infection.
Newborn children, premature babies or with any pathology from maternity hospital or transported from apartments in an ambulance by hand. The child must be wrapped in a warm blanket, covered with heating pads with a water temperature of 40-50 Cº (at the same time, there must be a sufficient layer of fabric between the heating pads and the child’s body), since these children, due to insufficient thermoregulation function, are especially sensitive to cooling. On the way, care must be taken to ensure that no aspiration of vomit occurs during regurgitation. To do this, hold the child half-turned in your arms, and during vomiting, transfer him to a vertical position. After vomiting, you need to clean the child's mouth using a rubber balloon.
Fever
Fever (febris, pyrexia) - This is a protective-adaptive reaction of the body that occurs in response to exposure to pathogenic stimuli, and is characterized by a restructuring of thermoregulation processes, leading to an increase in body temperature, stimulating the natural reactivity of the body.
Classification:
Depending on the degree of increase in axillary temperature:
Subfebrile 37.2-38.0 C.
Moderate febrile 38.1-39.0 C.
High febrile 39.1-40.1 C.
Excessive (hyperthermic) over 40.1 C.
Clinical options:
"Red" ("pink") fever.
"White" ("pale") fever.
Hypertensive syndrome .
Reducing body temperature is necessary in the following cases:
in children under 3 months. life at body temperature more than 38.0 o C;
in previously healthy children aged from 3 months to 6 years, with a body temperature of more than 39.0 o C;
in children with heart and lung diseases, potentially dangerous for the development of AHF and ARF, at a body temperature of more than 38.5 o C.
moderate febrile fever (more than 38.0 C) in children with convulsive syndrome (of any etiology), as well as in diseases of the central nervous system that are potentially dangerous for the development of this syndrome:
all cases of pale fever at a temperature of 38.0 C or more.
Pink fever- an increase in body temperature, when heat transfer corresponds to heat production, clinically this is manifested by the normal behavior and well-being of the child, pink or moderately hyperemic skin color, moist and warm to the touch, increased heart rate and respiration corresponds to an increase in temperature (for every degree above 37 C. shortness of breath increases by 4 breaths per minute, and tachycardia - by 20 beats per minute). This is a prognostically favorable variant of fever.
Pale fever- increase in body temperature, when heat transfer due to a significant impairment of peripheral circulation is inadequate to heat production, the fever takes on an inadequate course. Clinically, there is a disturbance in the condition and well-being of the child, persistent chills, pale skin, acrocyanosis, cold feet and palms, tachycardia, shortness of breath. These clinical manifestations indicate a pathological course of fever, are prognostically unfavorable and are a direct indication of the need for emergency care at the prehospital stage.
Hypertensive syndrome – an extremely serious condition caused by pale fever in combination with toxic damage to the central nervous system; clinic of pale fever with cerebral symptoms and varying degrees of impairment of consciousness.
|
1. Scope of examination |
|
Complaints Increased body temperature. Headache Autonomic disorders. |
|
Anamnesis Time of onset of the disease The nature of hyperthermia (daily temperature fluctuations, maximum value, effect antipyretic drugs- if used) Past illnesses Determination of concomitant pathology; allergy history. |
|
Inspection Assessment of general condition. Assessment of vital functions (respiration, hemodynamics). Auscultation of the lungs. Examination of the skin. Measurement of respiratory rate, blood pressure, heart rate, Sat O 2, body temperature; Determining the type of fever. |
|
2. Scope of medical care |
|
Emergency care for pink fever Physical cooling methods: open the child, expose as much as possible, provide access to fresh air, avoiding drafts, water at least 37.0 C, wipe with a damp swab, allow the child to dry, repeat 2-3 times with an interval of 10-15 minutes, blowing with a fan, cool wet bandage on forehead, cold on the area of large vessels. Intramuscular administration of antipyretic drugs, if hyperthermia does not stop within 30 minutes: 50% solution of Metamizole sodium (Analgin) 0.01 ml/kg for children of the first age years of life, over one year - 0.1 ml/year in combination with a 1% solution of Diphenhydramine (Diphenhydramine) 0.01 ml/kg for children of the first year of life, over 1 year - 0.1 ml/year, but not more than 1 ml. or Clemastine (Suprastin), Chloropyramine (Tavegil) 2% - 0.1-0.15 ml. for 1 year of life, but not more than 1.0 ml. i/m. Continue physical cooling methods. Emergency care for pale fever Paracetamol orally in a single dose of 10-15 mg/kg. Nicotinic acid orally in a single dose of 0.05 mg/kg rub the skin of the limbs and torso, apply a warm heating pad to the feet. intramuscular administration of antipyretic drugs, if hyperthermia does not stop within 30 minutes: 50% solution of Metamizole sodium (Analgin) 0.01 ml/kg for children of the first year of life, over one year - 0.1 ml/year in combination with a 1% solution of Diphenhydramine (Diphenhydramine) 0.01 ml/kg for children of the first year of life, over 1 year - 0.1 ml/year, but not more than 1 ml or Clemastine (Suprastin), Chloropyramine (Tavegil) 2% - 0.1-0.15 ml. for 1 year of life, but not more than 1.0 ml. Papaverine 2% - up to 1 year - 0.1-0.2 ml, over 1 year - 0.2 ml/year of life or No-spa 0.05 ml/kg IM. Emergency treatment and tactics for hyperthermic syndrome: Providing venous access. Infusion therapy - a solution of 0.9% sodium chloride or 5% glucose - 20 ml/kg/hour. For seizures - Diazepam (Relanium) 0.3-0.5 mg/kg IV. 50% solution of Metamizole sodium (Analgin) 0.01 ml/kg for children of the first year of life (from 3 months), over one year - 0.1 ml/year in combination with a 1% solution of Diphenhydramine (Diphenhydramine) 0.01 ml/ kg children of the first year of life, over 1 year - 0.1 ml/year, but not more than 1 ml or Clemastine (Suprastin), Chloropyramine (Tavegil) 2% - 0.1-0.15 ml. for 1 year of life, but not more than 1.0 ml. Papaverine 2% - up to 1 year - 0.1-0.2 ml, over 1 year - 0.2 ml/year of life or No-spa 0.05 ml/kg (with caution in case of bradycardia) i.m. If there is no effect within 30 minutes, intravenous Droperidol 0.25% -0.1 ml/kg. Oxygen therapy. |
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● Calling the resuscitation team: Ineffectiveness of spontaneous breathing (need for tracheal intubation and mechanical ventilation); Impaired consciousness according to GCS 8 points or less; Unstable central hemodynamic parameters. Unstoppable fever. |
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3. Performance criteria |
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Stabilization of condition |
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Complete relief of fever |
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No disturbances in vital functions |
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Delivery to a specialized medical facility |
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4. Tactical actions of brigades |
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Children with “white” or non-stopping fever, or with a combination of fever and convulsive syndrome, are subject to hospitalization. At a temperature of 39.5 C and above, children are not transportable! At least 10-15 minutes before arrival at the emergency room - inform about transportation heavy patient, doctors from a specialized department, indicating age and therapy performed. The accompanying document must indicate: the degree of severity at the time initial examination, RR, heart rate, blood pressure, body temperature, therapy performed. |
Catad_tema Pediatrics - articles
Fever in children: Differential diagnosis, therapeutic tactics
I.N. Zakharova,T.M.Tvorogova
Fever continues to be one of the leading reasons for seeking emergency care. medical care in pediatric practice.
It is noted that an increase in body temperature in children is not only one of the most common reasons for visiting a doctor, but also the main reason for the uncontrolled use of various medicines. At the same time, various non-steroidal anti-inflammatory drugs (salicylates, pyrazolone and para-aminophenol derivatives) have traditionally been used as antipyretic drugs for many years. However, at the end of the 70s, convincing evidence appeared that the use of salicylic acid derivatives in viral infections in children may be accompanied by the development of Reye's syndrome. Considering that Reye's syndrome is characterized by an extremely unfavorable prognosis (mortality rate - up to 80%, high risk of developing serious neurological and cognitive impairments in survivors), in the United States in the early 80s it was decided to introduce a ban on the use of salicylates in children for influenza and ARVI and chickenpox. In addition, all over-the-counter medications that contained salicylates began to be labeled with a warning that their use in children with influenza and chickenpox may lead to the development of Reye's syndrome. All this contributed to a significant decrease in the incidence of Reye's syndrome in the United States. Thus, if before the restriction of the use of aspirin in children (in 1980), 555 cases were registered of this disease, then already in 1987 - only 36, and in 1997 - only 2 cases of Reye's syndrome. At the same time, data on serious side and undesirable effects of other antipyretics were accumulating. Thus, amidopyrine, often used by pediatricians in past decades, was also excluded from the nomenclature due to its high toxicity. medicines. Convincing evidence that analgin (dipyrone, metamizole) may adversely affect Bone marrow, inhibiting hematopoiesis, up to the development of fatal agranulocytosis, contributed to a sharp limitation of its use in medical practice in many countries of the world.
A serious analysis of the results of scientific studies studying the comparative effectiveness and safety of various analgesics-antipyretics in children has led to a significant reduction in antipyretic drugs approved for use in pediatric practice. Currently, only paracetamol and ibuprofen are officially recommended for use in children with fever as safe and effective antipyretic drugs. However, despite clear recommendations from the World Health Organization on the selection and use of antipyretics for fever in children, domestic pediatricians still often continue to use acetylsalicylic acid and analgin.
Development of fever
Before active implementation in medical practice antipyretic and antibacterial drugs, analysis of the characteristics of the course of the febrile reaction played an important diagnostic and prognostic value. At the same time, specific features of fever in many infectious diseases (typhoid fever, malaria, typhus, etc.) were identified. At the same time, S.P. Botkin, back in 1885, drew attention to the conventionality and abstractness of the average characteristics of fever. In addition, it is necessary to take into account the fact that the nature of the fever depends not only on the pathogenicity, pyrogenicity of the pathogen and the massiveness of its invasion or the severity of aseptic inflammation processes, but also on the individual age and constitutional characteristics of the patient’s reactivity and his background conditions.
Fever is usually assessed by the degree of increase in body temperature, the duration of the febrile period and the nature of the temperature curve:
Depending on the degree of temperature increase:
Depending on the duration of the febrile period:
It should be noted that currently, due to wide application etiotropic (antibacterial) and symptomatic (antipyretic) drugs are already available early stages infectious disease, typical temperature curves are rarely seen in practice.
Clinical variants of fever and its biological significance
When analyzing the temperature reaction, it is very important not only to assess the magnitude of its rise, duration and fluctuations, but to compare this with the child’s condition and the clinical manifestations of the disease. This will not only greatly facilitate the diagnostic search, but will also allow you to choose the right tactics observation and treatment of the patient, which will ultimately determine the prognosis of the disease.
Particular attention should be paid to the clinical equivalents of the correspondence of heat transfer processes increased level heat production, because depending on the individual characteristics and background conditions, fever, even with the same level of hyperthermia, can occur differently in children.
Highlight "pink" and "pale" fever variants. If, with an increase in body temperature, heat transfer corresponds to heat production, then this indicates an adequate course of fever. Clinically this manifests itself "pink" fever. In this case, normal behavior and satisfactory well-being of the child are observed, the skin is pink or moderately hyperemic, moist and warm to the touch. This is a prognostically favorable variant of fever.
The absence of sweating in a child with pink skin and fever should raise suspicion of severe dehydration due to vomiting and diarrhea.
In the case when, with an increase in body temperature, heat transfer due to a significant impairment of peripheral circulation is inadequate to heat production, the fever acquires an inadequate course. The above is observed in another variant - "pale" fever. Clinically, a disturbance in the condition and well-being of the child, chills, pallor, marbling, dry skin, acrocyanosis, cold feet and palms, and tachycardia are noted. These clinical manifestations indicate a prognostically unfavorable course of fever and are a direct indication of the need for emergency care.
One of the clinical options for the unfavorable course of fever is hyperthermic syndrome. The symptoms of this pathological condition were first described in 1922. (L. Ombredanne, 1922).
In children early age the development of hyperthermic syndrome in the vast majority of cases is due to infectious inflammation accompanied by toxicosis. The development of fever against the background of acute microcirculatory metabolic disorders underlying toxicosis (spasm followed by capillary dilatation, arteriovenous shunting, platelet and erythrocyte sludge, increasing metabolic acidosis, hypoxia and hypercapnia, transmineralization, etc.) leads to aggravation of the pathological process. Decompensation of thermoregulation occurs with a sharp increase in heat production, inadequately reduced heat transfer and lack of effect from antipyretic drugs.
Hyperthermic syndrome, in contrast to adequate (“favorable”, “pink”) fever, requires the urgent use of complex emergency therapy.
As a rule, with hypertemic syndrome, there is an increase in temperature to high numbers (39-39.50 C and above). However, it should be remembered that the basis for distinguishing hypertemic syndrome into a separate variant of the temperature reaction is not the degree of increase in body temperature to specific numbers, but clinical features course of fever. This is due to the fact that, depending on the individual age and premorbid characteristics of children, concomitant diseases the same level of hyperthermia can be observed with different options course of fever. In this case, the determining factor during fever is not the degree of hyperthermia, but the adequacy of thermoregulation - the correspondence of heat transfer processes to the level of heat production.
Thus, Hypertemic syndrome should be considered a pathological variant of fever, in which there is a rapid and inadequate increase in body temperature, accompanied by impaired microcirculation, metabolic disorders and progressively increasing dysfunction of vital organs and systems.
In general, the biological significance of fever is to increase the body's natural reactivity. An increase in body temperature leads to an increase in the intensity of phagocytosis, an increase in the synthesis of interferon, an increase in the transformation of lymphocytes and stimulation of antibody genesis. Increased body temperature prevents the proliferation of many microorganisms (cocci, spirochetes, viruses).
However, fever, like any nonspecific protective-adaptive reaction, when compensatory mechanisms are depleted or in the hyperthermic variant, can cause the development of severe pathological conditions.
It should be noted that individual factors of aggravated premorbitis can have a significant impact on the development of adverse consequences of fever. Thus, in children with serious diseases of the cardiovascular and respiratory systems, fever can lead to the development of decompensation of these systems. In children with central nervous system pathologies (perinatal encephalopathy, hematocerebrospinal fluid syndrome, epilepsy, etc.), fever can trigger the development of an attack of convulsions. The age of the child is no less important for the development of pathological conditions during fever. How younger child, the more dangerous for him is a rapid and significant rise in temperature due to high risk development of progressive metabolic disorders, cerebral edema, transmineralization and disruption of vital functions.
Differential diagnosis of pathological conditions accompanied by fever.
An increase in body temperature is a nonspecific symptom that occurs in numerous diseases and pathological conditions. When carrying out differential diagnosis, you need to pay attention to:
Fever in newborns and children of the first three months requires close medical supervision. Thus, if a fever occurs in a newborn baby during the first week of life, it is necessary to exclude the possibility of dehydration as a result of excessive weight loss, which is more common in children born with a large birth weight. In these cases, rehydration is indicated. In newborns and children in the first months of life, there may be an increase in temperature due to overheating and excessive excitement.
Similar situations often occur in premature infants and children born with signs of morphofunctional immaturity. At the same time, the air bath helps to quickly normalize body temperature.
Combination of fever with individual clinical symptoms and her possible reasons are given in table 1.
When compiling the table, we used many years of clinical observations and experience of the staff of the Department of Pediatrics of the Russian Medical Academy of Postgraduate Education, as well as literature data.
Table 1 Possible causes of fever in combination with individual clinical symptoms
| Symptom complex | Possible reasons |
| Fever accompanied by damage to the pharynx, pharynx, and oral cavity | Acute pharyngitis; acute tonsillitis, sore throat, acute adenoiditis, diphtheria, aphthous stomatitis, retropharyngeal abscess |
| Fever + damage to the pharynx, as a symptom complex of infectious and somatic diseases. | Viral infections: Infectious mononucleosis, flu, adenovirus infection, enterovirus herpangina, measles, foot and mouth disease. Microbial diseases: tularemia, listeriosis, pseudotuberculosis. Blood diseases: agranulocytosis-neutropenia, acute leukemia |
| Fever associated with cough | Influenza, parainfluenza, whooping cough, adenoviral infection, acute laryngitis. Bronchitis, pneumonia, pleurisy, lung abscess, tuberculosis |
| Fever + rash in combination with symptoms characteristic of these diseases | Childhood infections (measles, scarlet fever, etc.); typhus and paratyphoid; yersiniosis; toxoplasmosis (congenital, acquired) in the acute phase; drug allergies; exudative erythema multiforme; diffuse diseases connective tissue(SLE, JRA, dermatomyositis); systemic vasculitis(Kawasa-ki disease, etc.) |
| Fever accompanied by hemorrhagic rashes | Acute leukemia; hemorrhagic fevers (Far Eastern, Crimean, etc.); acute form histiocytosis X; infective endocarditis; meningococcal infection; Waterhouse-Friderickson syndrome; thrombocytopenic purpura; hypoplastic anemia; hemorrhagic vasculitis. |
| Fever + erythema nodosum | Erythema nodosum as a disease; tuberculosis, sarcoidosis, Crohn's disease |
| Fever and local increase in peripheral lymph nodes as part of symptom complexes of these diseases | Lymphadenitis; erysipelas; retropharyngeal abscess; diphtheria of the throat; scarlet fever, tularemia; cat scratch disease; Kaposi's syndrome |
| Fever with generalized enlargement of lymph nodes | Lymphodenopathy due to viral infections: rubella, chicken pox, enterovirus infections, adenoviral infection, infectious mononucleosis; for bacterial infections: listeriosis, tuberculosis; for diseases caused by protozoa: leishmaniasis, toxoplasmosis; Kawasaki disease; malignant lymphomas (lymphogranulomatosis, non-Hodgkin lymphomas, lymphosarcoma). |
| Fever, abdominal pain | Food poisoning, dysentery, yersiniosis; acute appendicitis; Crohn's disease, ulcerative colitis, gastrointestinal tumors; acute pancreatitis; pyelonephritis, urolithiasis disease; tuberculosis with damage to mesenteric nodes. |
| Fever + splenomegaly | Hemato-oncological diseases (acute leukemia, etc.); endocarditis, sepsis; SLE; tuberculosis, brucellosis, infectious mononucleosis, typhoid fever. |
| Fever + diarrhea in combination with symptoms observed with these diseases | Foodborne illnesses, dysentery, enterovirus infections (including rotavirus); pseudotuberculosis, foot and mouth disease; nonspecific ulcerative colitis, Crohn's disease; collagenosis (scleroderma, dermatomyositis); systemic vasculitis; |
| Fever associated with meningeal syndrome | Meningitis, encephalitis, poliomyelitis; flu; typhoid and typhus; Q fever. |
| Fever combined with jaundice | Hemolytic anemia. Hepatic jaundice: hepatitis, cholangitis. Leptospirosis. Neonatal sepsis; cytomegalovirus infection. Prehepatic jaundice: acute cholecystitis; |
| Fever headache | Influenza, meningitis, encephalitis, meningo-encephalitis, typhus and typhoid fever |
From the data presented in Table 1, it follows that the possible causes of fever are extremely diverse, therefore only a thorough history taking, analysis of clinical data in combination with an in-depth targeted examination will allow the attending physician to identify the specific cause of fever and diagnose the disease.
Antipyretic drugs in pediatric practice.
Antipyretic drugs (analgesics-antipyretics)
- are one of the most commonly used drugs in medical practice.
Drugs belonging to the group of non-steroidal anti-inflammatory drugs (NSAIDs) have an antipyretic effect.
The therapeutic possibilities of NSAIDs were discovered, as often happens, long before their mechanism of action was understood. Thus, in 1763, R.E. Stone made the first scientific report on the antipyretic effect of a drug obtained from willow bark. It was then found that active active principle Willow bark contains salicin. Gradually, synthetic analogs of salicin (sodium salicylate and acetylsalicylic acid) completely replaced natural compounds in therapeutic practice.
Subsequently, salicylates, in addition to the antipyretic effect, had anti-inflammatory and analgesic activity. Others were synthesized at the same time chemical compounds, to one degree or another, having similar therapeutic effects(paracetamol, phenacetin, etc.).
Medicines characterized by anti-inflammatory, antipyretic and analgesic activity and not being analogues of glucocorticoids began to be classified as non-steroidal anti-inflammatory drugs.
The mechanism of action of NSAIDs, which consists in suppressing the synthesis of prostaglandins, was established only in the early 70s of our century.
Mechanism of action of antipyretic drugs
The antipyretic effect of analgesics-antipyretics is based on the mechanisms of inhibition of prostaglandin synthesis by reducing the activity of cyclooxygenase.
The source of prostaglandins is arachidonic acid, which is formed from phospholipids cell membrane. Under the action of cyclooxygenase (COX), arachidonic acid is converted into cyclic endoperoxides with the formation of prostaglandins, thromboxane and prostacyclin. In addition to COX, arachidonic acid is subjected to enzymatic action with the formation of leukotrienes.
IN normal conditions the activity of arachidonic acid metabolic processes is strictly regulated by the physiological needs of the body for prostaglandins, prostacyclin, thromboxane and leukotrienes. It is noted that the direction of the vector of enzymatic transformations of cyclic endoperoxides depends on the type of cells in which arachidonic acid metabolism occurs. Thus, thromboxanes are formed in platelets from most of the cyclic endoperoxides. While in the cells of the vascular endothelium, prostacyclin is formed predominantly.
In addition, it has been established that there are 2 COX isoenzymes. So, the first one - COX-1 functions in normal conditions, directing the metabolic processes of arachidonic acid to the formation of prostaglandins necessary for the implementation physiological functions body. The second isoenzyme of cyclooxygenase, COX-2, is formed only during inflammatory processes under the influence of cytokines.
As a result of blocking COX-2 with non-steroidal anti-inflammatory drugs, the formation of prostaglandins is reduced. Normalization of the concentration of prostaglandins at the site of injury leads to a decrease in the activity of the inflammatory process and the elimination of pain reception (peripheral effect). Blockade of cyclooxygenase by NSAIDs in the central nervous system is accompanied by a decrease in the concentration of prostaglandins in the cerebrospinal fluid, which leads to normalization of body temperature and an analgesic effect (central action).
Thus, by acting on cyclooxygenase and reducing the synthesis of prostaglandins, non-steroidal anti-inflammatory drugs have anti-inflammatory, analgesic and antipyretic effects.
In pediatric practice, various non-steroidal anti-inflammatory drugs (salicylates, pyrazolone and para-aminophenol derivatives) have traditionally been used as antipyretic drugs for many years. However, by the 70s of our century, a large amount of convincing data had accumulated on the high risk of developing side effects and unwanted effects when using many of them. It has been proven that the use of salicylic acid derivatives for viral infections in children may be accompanied by the development of Reye's syndrome. Reliable data were also obtained on the high toxicity of analgin and amidopyrine. All this has led to a significant reduction in the number of approved antipyretic drugs for use in pediatric practice. Thus, in many countries of the world, amidopyrine and analgin were excluded from national pharmacopeias and the use of acetylsalicylic acid in children without special indications was not recommended.
This approach was also supported by WHO experts, according to whose recommendations Acetylsalicylic acid should not be used as an analgesic-antipyretic in children under 12 years of age.
It has been proven that among all antipyretic drugs, only paracetamol and ibuprofen fully meet the criteria of high therapeutic efficacy and safety and can be recommended for use in pediatric practice.
table 2 Antipyretic drugs approved for use in children
Application in pediatric practice analgin (metamizole) as an antipyretic and analgesic is permissible only in certain cases:
So currently Only paracetamol and ibuprofen are officially recommended for use in children with fever as the safest and most effective antipyretic drugs. It should be noted that ibuprofen, unlike paracetamol, by blocking cyclooxygenase both in the central nervous system and at the site of inflammation, has not only an antipyretic, but also an anti-inflammatory effect, potentiating its antipyretic effect.
A study of the antipyretic activity of ibuprofen and paracetamol showed that when using comparable doses, ibuprofen exhibits greater antipyretic effectiveness. It has been established that the antipyretic effectiveness of ibuprofen in a single dose of 5 mg/kg is higher than that of paracetamol in a dose of 10 mg/kg.
We conducted a comparative study of the therapeutic (antipyretic) effectiveness and tolerability of ibuprofen ( Ibufen-suspension, PolPharma, Poland) and paracetamol (Calpol) for fever in 60 children aged 13-36 months suffering from acute respiratory infections.
An analysis of the dynamics of changes in body temperature in children with an initial fever of less than 38.50C (a risk group for the development of febrile seizures) showed that the antipyretic effect of the studied drugs began to develop within 30 minutes after their administration. It was noted that the rate of decrease in fever was more pronounced with Ibufen. A single dose of Ibufen was also accompanied by a more rapid normalization of body temperature compared to paracetamol. It was noted that if the use of Ibufen led to a decrease in body temperature to 370C by the end of 1 hour of observation, then in children from the comparison group the temperature curve reached the specified values only 1.5-2 hours after taking Calpol. After normalization of body temperature, the antipyretic effect from a single dose of Ibufen persisted for the next 3.5 hours, whereas when using Calpol it lasted 2.5 hours.
When studying the antipyretic effect of the compared drugs in children with an initial body temperature above 38.50C, it was found that a single dose of ibuprofen was accompanied by a more intense rate of reduction in fever compared to calpol. In children of the main group, normalization of body temperature was noted 2 hours after taking Ibufen, while in the comparison group children continued to have a low-grade and febrile fever. The antipyretic effect of Ibufen, after reducing fever, persisted throughout the entire observation period (4.5 hours). At the same time, in the majority of children receiving Calpol, the temperature not only did not decrease to normal levels, but also increased again starting from the 3rd hour of observation, which required readmission antipyretic drugs in the future.
The more pronounced and prolonged antipyretic effect of ibuprofen that we noted compared to comparable doses of paracetamol is consistent with the results of studies by different authors. The more pronounced and prolonged antipyretic effect of ibuprofen is associated with its anti-inflammatory effect, potentiating antipyretic activity. It is believed that this explains the more effective antipyretic and analgesic effect of ibuprofen compared to paracetamol, which does not have significant anti-inflammatory activity.
Ibufen was well tolerated, and no side effects or undesirable effects were recorded. At the same time, the use of calpol was accompanied by the appearance of allergic exanthema in 3 children, which was relieved by antihistamines.
Thus, our studies have shown high antipyretic efficacy and good tolerability of the drug - Ibufen suspensions (ibuprofen) - for relieving fever in children with acute respiratory infections.
Our results are fully consistent with literature data indicating the high effectiveness and good tolerability of ibuprofen. It was noted that short-term use of ibuprofen has the same low risk of developing undesirable effects as paracetamol, which is rightfully considered the least toxic among all analgesics-antipyretics.
In cases where clinical and anamnestic data indicate the need for antipyretic therapy, it is necessary to follow the recommendations of WHO specialists, prescribing the most effective and safest medications - ibuprofen and paracetamol. It is believed that ibuprofen can be used as initial therapy in cases where the use of paracetamol is contraindicated or ineffective (FDA, 1992).
Recommended single doses: paracetamol - 10-15 mg/kg body weight, ibuprofen - 5-10 mg/kg . When using children's forms of drugs (suspensions, syrups), it is necessary to use only the measuring spoons included with the packages. This is due to the fact that when using homemade teaspoons, the volume of which is 1-2 ml less, the actual dose of the drug received by the child is significantly reduced. Reuse antipyretic drugs are possible no earlier than 4-5 hours after the first dose.
Paracetamol is contraindicated
at serious illnesses liver, kidneys, hematopoietic organs, as well as deficiency of glucose-6-dehydrogenase.
Simultaneous use of paracetamol with babriturates, anticonvulsants and rifampicin increases the risk of developing hepatotoxic effects.
Ibuprofen is contraindicated
with exacerbation of gastric and duodenal ulcers, aspirin triad, severe violations liver, kidneys, hematopoietic organs, as well as diseases of the optic nerve.
It should be noted that ibuprofen increases the toxicity of digoxin. With simultaneous use of ibuprofen with potassium-sparing diuretics, hyperkalemia may develop. While the simultaneous use of ibuprofen with other diuretics and antihypertensive drugs weakens their effect.
Only in cases where oral or rectal administration of first-line antipyretic drugs (paracetamol, ibuprofen) is impossible or impractical, parenteral administration of metamizole (analgin) is indicated. In this case, single doses of metamizole (analgin) should not exceed 5 mg/kg (0.02 ml of 25% analgin solution per 1 kg of body weight) in infants and 50-75 mg/year (0.1-0.15 ml 50% analgin solution per year of life) in children older than one year . It should be noted that the emergence of convincing evidence of the adverse effects of metamizole (analgin) on the bone marrow (up to the development of fatal agranulocytosis in the most severe cases!) contributed to a sharp limitation of its use.
When identifying “pale” fever, it is advisable to combine the use of antipyretic drugs with vasodilators (papaverine, dibazol, papazole) and physical cooling methods. In this case, single doses of the drugs of choice are standard (paracetamol - 10-15 mg/kg, ibuprofen - 5-10 mg/kg). Among the vasodilator drugs, papaverine is most often used in a single dose of 5-20 mg, depending on age.
In case of persistent fever, accompanied by a violation of the condition and signs of toxicosis, as well as with hyperthermic syndrome, a combination of antipyretics, vasodilators and antihistamines. For intramuscular administration, a combination of these drugs in one syringe is permissible. These drugs are used in the following single dosages.
50% analgin solution:
2.5% solution of diprazine (pipolfen):
2% papaverine hydrochloride solution:
Children with hyperthermic syndrome, as well as with intractable “pale fever” should be hospitalized after emergency care.
It should be especially noted that course use of antipyretics is unacceptable without a serious search for the causes of fever. This increases the danger diagnostic errors(“skipping” symptoms of serious infectious and inflammatory diseases such as pneumonia, meningitis, pyelonephritis, appendicitis, etc.). In cases where a child receives antibacterial therapy, regular use of antipyretics is also unacceptable, because may contribute to unjustified delay in deciding whether to replace the antibiotic. This is explained by the fact that one of the earliest and most objective criteria for the therapeutic effectiveness of antimicrobial agents is a decrease in body temperature.
It must be emphasized that “non-inflammatory fevers” are not controlled by antipyretics and, therefore, should not be prescribed. This becomes understandable, because with “non-inflammatory fever” there are no points of application (“targets”) for analgesics-antipyretics, because cyclooxygenase and prostaglandins do not play a significant role in the genesis of these hyperthermia.
Thus, to summarize the above, rational therapeutic tactics for fever in children are as follows:
- In children, only safe antipyretic drugs should be used.
- The drugs of choice for fever in children are paracetamol and ibuprofen.
- Prescribing analgin is possible only in case of intolerance to the drugs of choice or if parenteral administration of an antipyretic drug is necessary.
- The prescription of antipyretics for low-grade fever is indicated only for children at risk.
- The prescription of antipyretic drugs in healthy children with a favorable temperature reaction is indicated for fever >390 C.
- For “pale” fever, a combination of analgesic-antipyretic + vasodilator drug (if indicated, antihistamine) is indicated.
- Rational use of antipyretics will minimize the risk of developing their side and undesirable effects.
- The course use of analgesics-antipyretics for antipyretic purposes is unacceptable.
- The use of antipyretic drugs is contraindicated for “non-inflammatory fevers” (central, neurohumoral, reflex, metabolic, medicinal, etc.)
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