Should We Reconsider Antipyretics For Fever?

What is Fever?

Although often used interchangeably, the terms fever and hyperthermia refer to different processes, and the distinction is key. In fever the thermoregulatory set-point is elevated, and the body actively raises its temperature with chills and rigors to reach the new set-point. In hyperthermia the body’s temperature exceeds the set-point, due to increased heat production (eg hypermetabolic state) or decreased dissipation (eg high humidity or ambient temperature).1

Fever is generally defined as temperature ≥38°C (100.4°F) and results from a complex mechanism. The body produces pyrogens (specific cytokines) that act on the thermoregulatory center in the hypothalamus to increase the set-point. This is thought to occur by increased prostaglandin synthesis, and antipyretic drugs lower the set-point likely by inhibiting prostaglandin synthesis.2 There are also numerous endogenous antipyretics (cryogens).

Increased temperatures enhance immune function in many ways, including improved neutrophil migration and secretion of antibacterial substances, increased interferon, and increased T cell proliferation.1

2

Fever Anxiety

A 1980 study titled “Fever phobia: misconceptions of parents about fever” surveyed parents, and found 94% thought fever may have harmful effects, 18% thought brain damage or serious harm could result from fever <38.9°C (102°F), and 16% thought fever could rise up to 48.9°C (120°F) if untreated.3 A 2001 study re-examined similar questions, and found 76% believed serious harm could occur at ≤40°C (104°F).3

This phobia also exists among healthcare workers. A 1992 survey by the American Academy of Pediatrics in Massachusetts showed 65% of pediatricians thought fever alone is potentially dangerous, 72% “always or often” prescribed antipyretics for fever, and 89% recommended antipyretics for fever of 101-102°F.4 A 2000 study of pediatric emergency department nurses, with a median experience of 8 years, found 11% were unsure what temperature constituted fever, 29% thought permanent brain injury or death could occur from high fever, and 18% believed it is dangerous for children to be discharged from the emergency department if still febrile.5

Is Fever Harmful?

Some providers have concerns that the increased temperature or metabolic demand from fever will harm patients. Humans generally tolerate temperatures below 41°C (105.8F) without harm. In contrast to hyperthermia, it is extremely rare for fever as a host defense against infection to reach dangerous temperatures in neurologically normal patients, since the body is actively adjusting both the set-point and actual temperature.3 A 2011 American Academy of Pediatrics policy paper states “There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications.” 6 Continue reading

Perusing the Literature (PTL): Haloperidol for Migraines

Introducing the newest blog section – Perusing the Literature (PTL). This section includes summaries of recent articles that residents and attendings have stumbled across that have raised an eyebrow. These monthly posts are meant to spark a discussion and do not represent a change in the standard of care (unless otherwise noted).

Let’s get the ball rolling!

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November 2015: Haloperidol for Migraines

The Article: Gaffigan ME, et al. A Randomized Control Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.

The One-Liner: Intravenous haloperidol appears to be as safe and effective as metoclopramide for the ED treatment of migraine headaches.

Background: Headache accounts for 2–5% of ED visits and is the 5th most common ED complaint. Current first-line ED therapies include dopamine receptor antagonists such as prochlorperazine and metoclopramide, often with diphenhydramine. Studies have shown these medications to be safe and more effective than opiates, NSAIDs, and sumatriptan. Haloperidol is another dopamine antagonist and has been reported to be effective in the treatment of migraine headaches.

Methods: This was a prospective, double-blinded, randomized, controlled trial at a single emergency department of patients presenting with migraine headache. Each subject was given a 1L normal saline bolus and a baseline ECG completed. Diphenhydramine 25mg IV was administered, followed by the study medication – metoclopramide 10mg IV or haloperidol 5mg IV. Pain, nausea, restlessness, and sedation were assessed at 0, 20, 40, 60, and 80 min. After 80 min, the subject was either discharged home or offered rescue therapies at the discretion of the treating physician. Prior to discharge, a second ECG was obtained. Subjects were to be contacted at 48-hours after discharge and were asked if they were happy with the medication received, and if they had any recurrent or persistent symptoms specifically, headache, sleepiness, restlessness, agitation, nausea, vomiting, or chest pain.

Results:

  • A total of 64 patients were enrolled – 31 randomized to haloperidol and 33 metoclopramide.
  • Mean reduction in pain from baseline was statistically and clinically significant for both haloperidol and metoclopramide groups.
  • Pain scores between the groups did not differ at baseline, at the last measurement, in the magnitude of the pre-post treatment change, or in the time to pain relief.
  • More patients in the metoclopramide group required a rescue medication for pain relief (p < 0.02).
  • Sleepiness was statistically more common in the group that was to receive haloperidol (p < 0.02). There were no other differences between the groups in any of the other side-effect questions asked (nausea, restlessness, chest pain).
  • Mean QTcs were equal and normal in the two groups and did not change after treatment for either group.
  • 43/64 patients were reached for 48-hour follow up. Restlessness reported more by the haloperidol group (43% vs 10%, p < 0.015).

Limitations:

  • The study was single centered and admittedly small.
  • The study used a convenience sample, subjects were relatively young and mostly female (81%).
  • Post-treatment ECGs were obtained in only 45% of subjects.
  • Telephone follow up was obtained in only 67% of subjects.

 

Posted by Adam Janicki, MD, PGY4

Reviewed by Gita Pensa, MD, Clinical Assistant Professor, Department of Emergency Medicine

Orthopedic Review: Distal Radius Fracture Reduction

Case: 64 yo F presents to the Emergency Department after tripping over a curb and suffering a FOOSH (fall on outstretched hand) injury. There is obvious deformity about the wrist with associated swelling and tenderness. X-ray imaging reveals the following:

Her exam and imaging are consistent with a distal radius fracture. How do you treat this?

Page ortho?

Providing adequate analgesia, reduction of fracture, and proper splinting is well within the scope of EM practice, especially in the community setting. This post will review the technique of hematoma block for analgesia as well as the different techniques for reduction of distal radius fractures and application of splint.

Hematoma Block

  • Can be used alone or in combination with other analgesic modalities such as IV narcotics or benzodiazepines
  • Simple technique
  • Very few complications

 

But is hematoma block effective?

  • In 2011, prospective randomized controlled trial comparing hematoma block to conscious sedation with IV Propofol
  • 96 patients underwent randomization and researchers compared patients’ pain using VAS (visual analog scale) during the procedure and after the procedure
  • Patients who received Propofol had pain scores of 0 during the procedure compared to 0.97+/-0.7 in patients who received hematoma block
  • After the procedure, patients who received Propofol had pain scores of 2.72+/-0.7 compared to 2.25+/-0.2 in patients who received hematoma block
  • Patients who received hematoma block had significantly shorter ED stay times (0.9hrs vs 2.6 hrs)

Hematoma blocks result in similar analgesia as conscious sedation with IV Propofol AND leads to shorter ED stay times

Setting up for the procedure:

  • 10cc 1% Lidocaine
  • 10cc syringe with 2 large needles (one for drawing up Lidocaine, one for injecting)
  • Skin cleanser (betadine, Chloraprep, or alcohol wipe)

Procedure Technique:

  1. Identify the fracture site by palpating along the dorsal aspect of the forearm to feel for bony step-off. Cleanse this entire area thoroughly with skin cleanser.
  2. Insert needle attached to syringe filled with 10cc 1% Lidocaine at that site and advance needle along periosteum until needle falls into fracture site.
  3. Draw back on plunger to aspirate blood confirming the needle is in the fracture site.
  4. Inject 10cc Lidocaine into fracture site and remove needle.
  5. Allow 10-15min to pass to ensure full analgesic effect.

Continue reading

Nerve Blocks Rule

Jon and I did this awesome ultrasound-guided superficial cervical plexus nerve block the other day for a R IJ central line placement– taught to us by none other than the amazing Dr. Otto Liebmann.

It was so neat we made a video about it. Check it out!