This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC). To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
The Interacion of Clothing & ThermoregulationMayayo Oxigeno
Scientific research by George Havenith on the interaction of clothing and thermoregulation.
Consult & download this and other outdoor related documents at http://carrerasdemontana.com/informes/
The drawbacks of climate change are so overt. The Disturbance of Great Ocean Conveyor currents led to the extreme changes in temperature around the globe in the form of a cooler northern, warmer tropical and cooler snowy winter, warmer summer. Many deaths from hypothermia were reported especially in refugee camps as it is not well equipped. Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6 F (37 C). Hypothermia occurs as the body temperature falls below 95 F (35 C). When body temperature drops, heart, nervous system and other organs can't work normally. Left untreated, hypothermia can eventually lead to complete failure of heart and respiratory system and eventually to death.
This is a lecture by Dr. Jessica Holly from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Baseball and softball umpires are affected by heat-related illness like other professionals who work in the outdoor environment. Many officials are volunteers while other receives compensation for their efforts. Regardless of the level of officiating from Little League to the Major Leagues, most are affected by heat-related illness in the summertime. Although heat-related illness is discussed in general by some colleges and high schools in their programs, the umpiring associations engaging these officials has failed to recognize the hazard and risks. In order to provide awareness of heat-related illness and how it affects an umpire’s performance on the field, a presentation was created to train officials to understand what happens when they fail to hydrate, rest, and take the necessary precautions that can affect their health. Heat exhaustion is the primary cause for umpires to make poor judgments for calling balls and strikes as well as making critical decisions on rotating into position to make calls on plays. Many lower level officials will take assignments for doubleheaders or multiple game assignments in the summer without regard for their ability to meet expectations. By creating awareness, we hope to improve the lives of baseball and softball officials and improve their performance on the field by understanding the effects of heat-related illness.
Thermoregulation is a process that allows your body to maintain its core internal temperature. All thermoregulation mechanisms are designed to return your body to homeostasis. This is a state of equilibrium. A healthy internal body temperature falls within a narrow window.
GEMC- Heat Related Illnesses- Resident TrainingOpen.Michigan
This is a lecture by Randall Ellis, MD MPH from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC). To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
The Interacion of Clothing & ThermoregulationMayayo Oxigeno
Scientific research by George Havenith on the interaction of clothing and thermoregulation.
Consult & download this and other outdoor related documents at http://carrerasdemontana.com/informes/
The drawbacks of climate change are so overt. The Disturbance of Great Ocean Conveyor currents led to the extreme changes in temperature around the globe in the form of a cooler northern, warmer tropical and cooler snowy winter, warmer summer. Many deaths from hypothermia were reported especially in refugee camps as it is not well equipped. Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6 F (37 C). Hypothermia occurs as the body temperature falls below 95 F (35 C). When body temperature drops, heart, nervous system and other organs can't work normally. Left untreated, hypothermia can eventually lead to complete failure of heart and respiratory system and eventually to death.
This is a lecture by Dr. Jessica Holly from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Baseball and softball umpires are affected by heat-related illness like other professionals who work in the outdoor environment. Many officials are volunteers while other receives compensation for their efforts. Regardless of the level of officiating from Little League to the Major Leagues, most are affected by heat-related illness in the summertime. Although heat-related illness is discussed in general by some colleges and high schools in their programs, the umpiring associations engaging these officials has failed to recognize the hazard and risks. In order to provide awareness of heat-related illness and how it affects an umpire’s performance on the field, a presentation was created to train officials to understand what happens when they fail to hydrate, rest, and take the necessary precautions that can affect their health. Heat exhaustion is the primary cause for umpires to make poor judgments for calling balls and strikes as well as making critical decisions on rotating into position to make calls on plays. Many lower level officials will take assignments for doubleheaders or multiple game assignments in the summer without regard for their ability to meet expectations. By creating awareness, we hope to improve the lives of baseball and softball officials and improve their performance on the field by understanding the effects of heat-related illness.
Thermoregulation is a process that allows your body to maintain its core internal temperature. All thermoregulation mechanisms are designed to return your body to homeostasis. This is a state of equilibrium. A healthy internal body temperature falls within a narrow window.
GEMC- Heat Related Illnesses- Resident TrainingOpen.Michigan
This is a lecture by Randall Ellis, MD MPH from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Patho-physiology of Fever : Dr Faisal AbdullahFaisal Abdullah
Find the lecture on Approach to a patient with Fever (in Bangla) by Dr. Faisal Abdullah. This Powerpoint presentation describes the mechanism of Fever, How body temperature is maintained, Normal body temperature, Concept of Set Point, Role of pyrogens etc. The difference between Fever, Hyperpyrexia & Hyperthermia is clearly explained here.
https://youtu.be/uqqIH6OfX4o
For any queries, please contact:
faisalabdullah@platform-med.org
facebook.com/faisalization.17
youtube.com/faisalization
faisalization.wordpress.com
Temperature practical cum theory part by Pandian M, From DYPMCKOP. This PPT f...Pandian M
INTRODUCTION
HOMEOTHERMIC ANIMALS
POIKILOTHERMIC ANIMALS
BODY TEMPERATURE
Normal Body Temperatures
VARIATIONS OF BODY TEMPERATURE
Pathological Variations
HEAT GAIN OR HEAT PRODUCTIONIN THE BODY
HEAT LOSS FROM THE BODY
Regulation of Body Temperature
Hypothalamus has two centers which regulate the body temperature:
Applied
A fever is a temporary increase in your body temperature, often due to an illness. Having a fever is a sign that something out of the ordinary is going on in your body. For an adult, a fever may be uncomfortable, but usually isn't a cause for concern unless it reaches 103 F (39.4 C) or higher.
It's a fever when a child's temperature is at or above one of these levels: measured orally (in the mouth): 100°F (37.8°C) measured rectally (in the bottom): 100.4°F (38°C) measured in an axillary position (under the arm): 99°F (37.2°C)
vitals sign is the basic parameter used for all the patients to know the vital and general parameter for the patients and any changes in this parameter can cause the life threatening condition for the patients or clients life the proper technique and its alternatives assessment knowledge can help the nurses to improve academic performance and can be apply this knowledge in their clinical practices
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Jim Holliman, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Rapid Sequence Intubation & Emergency Airway Support in the Pediatric E...Open.Michigan
This is a lecture by Michele Nypaver, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Disorders of the Pleura, Mediastinum, and Chest Wall- Resident TrainingOpen.Michigan
This is a lecture by Andrew Barnosky, DO from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Dental Emergencies and Common Dental Blocks- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Arthritis and Arthrocentesis- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Bursitis, Tendonitis, Fibromyalgia, and RSD- Resident TrainingOpen.Michigan
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Right Upper Quadrant Ultrasound- Resident TrainingOpen.Michigan
This is a lecture by Jeff Holmes from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: Nursing Process and Linkage between Theory and PracticeOpen.Michigan
This is a lecture by Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
2014 gemc-nursing-lapham-general survey and patient care managementOpen.Michigan
This is a lecture by Dr. Jeremy Lapham from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC: The Role of Radiography in the Initial Evaluation of C-Spine TraumaOpen.Michigan
This is a lecture by Dr. Stephen Hartsell from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Sickle Cell Disease: Special Considerations in Pediatrics- Resident Tra...Open.Michigan
This is a lecture by Hannah Smith, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
GEMC- Ghana Grab Bag Pediatric Quiz- Resident TrainingOpen.Michigan
This is a lecture by Hannah Smith, MD and Ruth S. Hwu, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Ruth S. Hwu, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Ryan LaFollette, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
GIÁO ÁN DẠY THÊM (KẾ HOẠCH BÀI BUỔI 2) - TIẾNG ANH 8 GLOBAL SUCCESS (2 CỘT) N...
GEMC- Alterations in Body Temperature: The Adult Patient with a Fever- Resident Training
1. Project: Ghana Emergency Medicine Collaborative
Document Title: Alterations in Body Temperature: The Adult Patient with a
Fever
Author(s): Joe Lex, MD (Temple University)
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3. Alterations in Body
Temperature: The Adult Patient
with a Fever
Joe Lex, MD, FAAEM
Temple University Hospital
22 April 2010
3
4. Objectives
• Differentiate fever from
hyperthermia
• Explain what causes a fever
• Describe an appropriate fever
work-up
• Recognize life-threatening causes
of fever, both infectious and non-infectious
4
5. Objectives
• Explain reasons to either treat or
not treat fever
• Describe appropriate methods of
treating fever
• Explain how acetaminophen and
aspirin reduce fever
• Describe treatment for NMS
5
6. Fever
• 6% of adult visits
• 20 – 40% of pediatric visits
• Benign self-limited diseases
• 10% to 15% of >65 years old
70 – 90% hospitalized
7 – 9% die within one month
6
7. Fever
Three body systems
account for more than
80% of infections
• Respiratory tract
• Urinary tract
• Skin and soft tissue
Patrick J. Lynch (Wikimedia Commons)
Gray's Anatomy (Wikimedia Commons)
7
US-Gov (Wikipedia)
8. Hypothalamus
Neurons in preoptic anterior and
posterior hypothalamus receive
signals…
...from peripheral nerves that
reflect warmth / cold receptors
...from temperature of blood
bathing the region
8
9. Hypothalamus
• Signals integrated by thermo-regulatory
center to maintain
normal temperature
• In neutral environment, human
metabolism produces more heat
than necessary to maintain core
body temperature at 37°C
9
11. Hypothalamus
• Normal body temperature
maintained despite environment
• Hypothalamic thermoregulatory
center balances heat production
from metabolic activity in muscle
and liver with heat dissipation
from skin and lungs
11
12. Normal Temperature
• In healthy 18 to 40 year-olds,
mean oral temperature 36.8° ±
0.4°C (98.2° ± 0.7°F)
• Lowest 6 a.m., highest 4 - 6 p.m.
• Maximum normal oral:
– 37.2°C (98.9°F) at 6 a.m.
– 37.7°C (99.9°F) at 4 p.m.
12
13. Fever
• Fever: morning temperature
>37.2°C (98.9°F) or evening
temperature >37.7°C (99.9°F)
• Normal daily variation: 0.5°C
(0.9°F)
• If recovering from virus, can
be 1.0°C
13
14. Location, Location, Location
• Rectal temperature higher than
oral by about 0.4°C (0.7°F)
• Distal esophageal best core
temperature
• Freshly-voided urine also accurate
14
16. Physiologic Elevation
• Women: morning temperature
lower in 2 weeks before ovulation,
then rises about 0.6°C (1°F) with
ovulation and stays there until
menses
• Body temperature also elevated in
postprandial state
16
17. Physiologic Elevation
• Daily temperature
variation fixed in
early childhood
• Elderly have
reduced ability to
develop fever,
may have modest
fever even in
severe infections
17
19. Fever vs. Hyperthermia
• Fever: body temperature that
exceeds normal daily variation
• Occurs in conjunction with in
hypothalamic set point
• Like resetting home thermostat to
a higher level in order to raise
ambient room temperature
19
20. Fever vs. Hyperthermia
• Hypothalamic set point raised
activates vasomotor center
neurons vasoconstriction first
noted in hands and feet
• Blood shunted from periphery
heat loss from skin feels cold
20
21. Fever vs. Hyperthermia
• Shivering heat production from
muscles
• If heat conservation mechanisms
raise blood temperature enough,
shivering not required
• heat production from liver
21
22. Fever vs. Hyperthermia
• In humans, behavioral
instinct (e.g., putting
on more clothing or
bedding) leads to
reduction of exposed
surfaces helps raise
body temperature
22
23. Fever vs. Hyperthermia
• Heat production (shivering,
metabolic activity) and heat
conservation (vasoconstriction)
continue until temperature of
blood bathing hypothalamic
neurons matches new thermostat
setting
23
24. Fever vs. Hyperthermia
• Hypothalamus maintains febrile
level by same mechanisms
operative in afebrile state
• When reset downward heat lost
through vasodilation and sweating
24
Lamiot (Wikimedia Commons)
25. Fever vs. Hyperthermia
• Fever >41.5°C (106.7°F)
hyperpyrexia
• Can develop in severe infections
• Most common in patients with
CNS hemorrhages
• Preantibiotic era: fever due to
infection rarely >106°F
25
26. Fever vs. Hyperthermia
• “Hypothalamic fever” caused by
abnormal hypothalamic function
• Most patients with hypothalamic
damage have subnormal body
temperature
26
27. Fever vs. Hyperthermia
Hyperthermia is characterized
by a normothermic setting of
thermoregulatory center in
conjunction with uncontrolled
increase in body temperature
that exceeds the body's ability
to lose heat
27
28. Fever vs. Hyperthermia
• Exogenous heat exposure or
endogenous heat production
• Over-insulating clothing core
temperature
• Work or exercise in hot
environment heat production >
peripheral heat loss
28
29. Fever vs. Hyperthermia
• Thermoregulatory
failure with warm
environment
exertional or
nonexertional
(classic) heat
stroke
29
30. Fever vs. Hyperthermia
• Classic heat stroke: elderly during
heat waves
– Chicago: July 1995, 465 deaths
certified as heat related
– Europe: Summer 2003, estimated
17,000 additional deaths
30
37. Fever vs. Hyperthermia
• Hyperthermia can be rapidly fatal
• No rapid way to differentiate from
fever
• Physical aspects may be a clue
– History of drug that blocks sweat
– Skin hot and dry
– No response to antipyretics
37
38. Pyrogen
• Any substance that causes fever
• Exogenous: microbial products or
toxins, whole microorganisms
– Classic: lipopolysaccharide
endotoxin from all Gram-negatives
– Enterotoxin from Staphylococcus
aureus and group A and B strep
toxins (superantigens)
38
39. Pyrogenic Cytokines
• Cytokines: small proteins that
regulate immune, inflammatory,
and hematopoietic processes
• Endogenous pyrogens IL-1, IL-6,
tumor necrosis factor (TNF),
ciliary neurotropic factor (CNTF),
and interferon (IFN) all known to
cause fever
39
40. Pyrogenic Cytokines
• Induced exogenous
pyrogens, mostly from
bacterial or fungal
sources
• Viruses induce
pyrogenic cytokines by
infecting cells
40
41. Pyrogenic Cytokines
• Inflammation, trauma, tissue
necrosis, and antigen-antibody
complexes cause production of IL-
1, TNF, and IL-6, which trigger
hypothalamus to raise set point to
febrile levels
• Cellular sources: monocytes,
neutrophils, lymphocytes
41
44. How to Make a Fever
• IL-1, IL-6, and TNF released into
systemic circulation
• Induce central and peripheral
synthesis of PGE2
– Peripheral PGE2 causes nonspecific
myalgias, arthralgias
– Central PGE2 raises hypothalamic
set point
44
45. How to Make a Fever
• PGE2 not a neurotransmitter
• Triggers receptor on glial cells
rapid release of cyclic adenosine
5'-monophosphate (cAMP, which
is neurotransmitter)
• Activates neuronal endings from
the thermoregulatory center
45
47. Taking a History
“It is in the diagnosis of a febrile
illness that the science and art of
medicine come together. In no
other clinical situation is a
meticulous history more
important…”
William Osler?
Harvey Cushing?
18th edition
Harrison’s
47
48. Taking a History
“Painstaking attention must be paid
to the chronology of symptoms in
relation to the use of prescription
drugs (including drugs or herbs
taken without a physician's
supervision) or treatments such
as surgical or dental
procedures…”
48
49. Taking a History
• Occupational
history: exposure
to...
...animals?
...toxic fumes?
...potential
infectious agents?
• Other febrile
individuals at
home, work, or
school?
• Prosthetic
materials?
• Implanted
devices?
49
50. Taking a History
• Travel history,
including military
service
• Unusual hobbies
• Sexual orientation
– Practices
– Precautions
• Dietary
– raw or poorly
cooked meat
– raw fish
– unpasteurized
milk or cheese
• Household pets
50
51. Taking a History
• Tobacco,
marijuana,
intravenous
drugs, alcohol
• Trauma
• Animal bites
• Tick or other
insect bites
• Prior transfusion
• Immunizations
• Drug allergies or
hypersensitivity
51
52. Taking a History
Family history
• Tuberculosis,
• Other febrile or
infectious
diseases
• Arthritis /
collagen vascular
disease
Unusual familial
symptomatology:
•Deafness
• Urticaria
•Fevers and
polyserositis
•Bone pain
•Anemia
52
53. Taking a History
Ethnic origin
• Hemoglobinopathies: more
common in African-American
• Familial Mediterranean fever:
more common in Turks, Arabs,
Armenians, Sephardic Jews
53
54. Fever Pattern
• Usual times of peak and trough
may be reversed in typhoid fever
and disseminated tuberculosis
• Temperature-pulse dissociation
(relative bradycardia) occurs in
typhoid fever, brucellosis,
leptospirosis, some drug-induced
fevers, and factitious fever
54
55. Fever Pattern
• Normothermia, hypothermia
despite infection: newborns,
elderly, patients with chronic renal
failure, and patients taking
glucocorticoids
• Hypothermia observed in septic
shock
55
56. Fever Pattern
• Relapsing fevers: separated by
intervals of normal temperature
• Tertian fever: paroxysms on 1st
and 3rd days (e.g. Plasmodium
vivax)
• Quartan fever: on 1st and 4th
(Plasmodium malariae)
56
57. Fever Pattern
• Borrelia infections and rat-bite
fever: several days of fever
followed by a several afebrile
days, then relapse of fever days
• Pel-Ebstein fever: 3 to 10 days
fever followed by afebrile 3 to 10
days
– Hodgkin's disease, lymphomas
57
58. Fever Pattern
• Cyclic neutropenia: fevers every
21 days accompany neutropenia
• Familial Mediterranean fever: no
periodicity
58
59. Physical Examination
• All vital signs are relevant
• Temperature may be oral or
rectal, but consistent site used
– Axillary temperatures unreliable
• Daily physical examination until
diagnosis certain and anticipated
response achieved
59
60. Physical Examination
• Special attention to skin, lymph
nodes, eyes, nail beds,
cardiovascular system, chest,
abdomen, musculoskeletal
system, and nervous system.
• Rectal examination imperative
60
71. Algorithm: Young and Healthy
Initial history and
physical examination
Stable vital signs, no
serious symptoms
Obvious source of
fever
Treat focal bacterial
infection with oral
antibiotics, antipyretics
No obvious source of
fever
Supportive care
antipyretics, antiemetics
rehydration
Unstable vital signs, serious
symptoms (stiff neck, mental
status changes, petechial rash)
Monitor, IV access, respiratory
support, appropriate cultures,
appropriate antibiotics, ancillary
testing as indicated
71
72. Algorithm: Elderly or Chronically Ill
Unstable vital signs?
Toxic appearance?
Serious symptoms? (e.g.,
mental status changes,
stiff neck, shock,
respiratory distress)
Yes
Chest x-ray, UA, urine culture,
blood culture, assess need for LP,
appropriate antibiotics, admit to
special care unit
Identify source of fever?
Treat source of infection.
Many require admission
Chest PA and lateral film, CBC
with differential, indwelling
devices may need to be removed
and/or cultured, consider LP, most
require admission with cultures
and empiric antibiotics, consider
noninfectious causes
No
No
Yes
72
73. Laboratory Studies
• Many diagnostic possibilities
• If history, epidemiology, or
physical examination suggests
more than simple viral illness or
streptococcal pharyngitis, then
laboratory testing is indicated
73
74. Laboratory Studies
• Tempo and complexity of work-up
depends on pace of illness,
diagnostic considerations, immune
status of host
• If findings focal, laboratory
examination can be focused
• If fever undifferentiated, more
studies warranted
74
75. Complete Blood Count
• Highly insensitive
• Highly nonspecific
• Most valuable use: ensure
adequate immune response
(polymorphonuclear neutrophil
leukocyte count) in elderly or
those with immune compromise
75
Source Undetermined
76. Complete Blood Count
• Manual or automatic differential
sensitive to identification of
eosinophils, band forms, toxic
granulations, and Döhle bodies
• Last three associated with
bacterial infections
Source Undetermined
76
77. Other CBC Clues
• If febrile illness prolonged,
examine smear for malarial or
babesial pathogens (where
appropriate) as well as classic
morphologic features
• Erythrocyte sedimentation rate
• C-reactive protein
77
78. Fever and Neutropenia
• Viral infection,
particularly
parvovirus B19
• Drug reaction
• Systemic lupus
erythematosus
• Typhoid
• Brucellosis
• Infiltrative
diseases of bone
marrow:
– Lymphoma
– Leukemia
– Tuberculosis
– Histoplasmosis
78
80. Fever and Other WBCs
Monocytosis
• Typhoid
• Tuberculosis
• Brucellosis
• Lymphoma
Eosinophilia
• Hypersensitivity
drug reactions
• Hodgkin's
• Adrenal
insufficiency
• Metazoan
infections
80
81. Other Labs – Possible
• Urinalysis with examination of
urine sediment
• Any abnormal fluid accumulation
(pleural, peritoneal, joint) needs
exam in undiagnosed fever
• Stool for fecal leukocytes, ova, or
parasites may be indicated
81
82. Other Labs – Possible
• BMP recommended
• Liver function tests if other organ
cause not obvious
• Blood, urine, and abnormal fluid
collections culture
• Additional labs added as work-up
progresses
82
83. Other Labs – Possible
• Smears and cultures of throat,
urethra, anus, cervix, and vagina
• Sputum for Gram's stain, acid-fast
bacillus staining, culture
• CSF if meningismus, severe
headache, mental status change
83
84. Radiography
• Chest x-ray part of evaluation for
significant febrile illness
Source Undetermined
Source Undetermined
84
85. Resolution
• Most patients recover without
treatment or history, physical
examination, and initial studies
lead to diagnosis
• Fever 2 to 3 weeks, examination
and laboratory tests unrevealing
provisional diagnosis FUO
85
88. Antipyretics
• By reducing fever with antipyretic,
assume no diagnostic benefit
gained by allowing fever to persist
• Daily highs and lows of normal
temperature exaggerated in most
fevers
88
89. Antipyretics
• PGE2 synthesis depends on
enzyme cyclooxygenase (COX)
• COX substrate is arachidonic acid
released from cell membrane
• Release of arachidonic acid is
rate-limiting step
• COX inhibitors: antipyretics
89
90. Antipyretics
• Potency correlated with inhibition
of brain COX
• Acetaminophen
– Poor peripheral COX inhibition
– Poor anti-inflammatory
– Oxidized in brain by cytochrome
p450 potent COX inhibitor
90
91. Acetaminophen
• Discovered 1889 by Karl Morner
(8 years before aspirin)
• Principal active metabolite of
phenacetin and acetanilid
• As effective as phenacetin, but
less toxic
• APC=aspirin/phenacetin/caffeine
• Widespread use after 1949
91
92. Acetaminophen
• McNeil Laboratories first sold in
1955 (Tylenol Children's Elixir)
• Package looked like fire truck!
92
96. Aspirin
• Hippocrates: willow tree leaves
for eye diseases and childbirth
• Leviticus: “boughs of goodly
trees, ... willows of the brook”
• Dioscorides (AD1): “…leaves of
willow...excellent formentation for
ye Gout…”
96
97. Aspirin
• AD 60 Caius Plinius Secundus:
poplar bark for sciatica
• 1763 Reverend Edward Stone:
willow bark as remedy for agues
• Standard treatments until 1800s
– Pain: opium
– Fever: Peruvian cinchona bark
97
98. Aspirin
• 1828 Johann Büchner: salicin
• 1838 Raffaele Piria derived
salicylaldehyde from salicin, then
converted to salicylic acid
• 1874 Heyden Chemical Company
produced commercial salicylic acid
98
99. Aspirin
• August, 1897:
Felix Hoffman,
working for
Frederick Bayer,
synthesized
acetylsalicylic acid
(ASA)
Danielm (Wikimedia Commons) 99
100. Aspirin
• A few weeks later, Hoffman
synthesized diacetylmorphine
• Initial subjects felt “heroic”
• Bayer sold commercially: “Heroin”
• Aspirin required prescription,
heroin sold over the counter
100
101. 101
New York Times (Wikipedia) Mpv_51 (Wikipedia)
102. Antipyretics
• Oral aspirin and acetaminophen
equally effective in reducing fever
in humans
• Nonsteroidal anti-inflammatory
agents (NSAIDs) also excellent
antipyretics
102
103. Antipyretics
• Chronic high-dose aspirin or
NSAID therapy in arthritis does
not reduce normal core body
temperature
• Thus, PGE2 appears to play no
role in normal thermoregulation
103
104. Antipyretics
• Glucocorticoids act at two levels
– Reduce PGE2 synthesis by inhibiting
activity of phospholipase A2, which
is needed to release arachidonic
acid from the cell membrane
– Block transcription of mRNA for the
pyrogenic cytokines
104
105. Antipyretics
• Drugs that interfere with
vasoconstriction (phenothiazines)
or block muscle contractions can
also lower fever
• Not true antipyretics: reduce core
temperature independent of
hypothalamic control
105
107. Reasons to Treat
• Fever increases oxygen demand
• Every of 1°C over 37°C 13%
in O2 consumption
• Fever can aggravate preexisting
cardiac, cerebrovascular, or
pulmonary insufficiency
107
108. Reasons to Treat
• Fever mental changes in
patients with organic brain
disease
• Fever oxygen consumption
• Fever metabolic demands
• Fever protein breakdown
• Fever gluconeogenesis
108
109. Reasons to Treat
• Peripheral PGE2 production is
potent immunosuppressant
• Treating fever does not slow
resolution of common viral and
bacterial infections
• Reducing fever with antipyretics
reduces headache, myalgias,
arthralgias
109
110. Reasons to Not Treat
• Moderate elevations of body
temperature may increase
chemotaxis, decrease microbial
replication, and improve
lymphocyte function
• Fever directly inhibits growth of
certain bacteria and viruses
110
111. Reasons to Not Treat
• No proof that treating fever with
antipyretics has beneficial effect
on outcome or prevents
complications
…but no evidence that fever
facilitates recovery from infection
111
112. Treating Fever
• Objectives: reduce elevated
hypothalamic set point and
facilitate heat loss
112
113. Treating Fever
• Acetaminophen is preferred
antipyretic
• Oral aspirin and NSAIDs reduce
fever, but can affect platelets and
gastrointestinal tract
• Children: aspirin increases risk of
Reye's syndrome
113
114. Treating Fever
If patient unable to take oral:
• Parenteral preparation of NSAID
• Rectal suppository preparations of
antipyretics
• Rectal dose: 30-45 mg/kg
114
115. Rectal Acetaminophen
• Antipyretic plasma concentration
range: 10 – 20 μg/ml
• 45 mg/kg rectal APAP mean peak
concentration <15 μg/ml more than 3
hours after insertion
• Rectal absorption unpredictable
• 2 to 4 hours to peak concentrations
• Bioavailability 30 – 50% oral
115
116. Treating Fever
• In hyperpyrexia, cooling blankets
facilitate temperature reduction
• Don’t use without oral antipyretic
• When your house is too hot, do
you turn down the thermostat, or
hose down the roof with cold
water?
116
118. Malignant Hyperthermia
• Stop anesthesia, succinylcholine
• Cool externallly
• Dantrolene sodium: 1 – 2.5 mg/kg
of body weight
• Procainamide to prevent
ventricular fibrillation
118
119. Treating NMS
• Supportive care
• Discontinue offending medication
• Treat agitation, hyperactivity,
rigidity with IV benzodiazepines
• If refractory, RSI and
neuromuscular blockade with
nondepolarizing agent (e.g.,
pancuronium, atracurium)
119
120. Treating NMS
• Manage hyperthermia: IV fluids,
active external cooling
• Treat rhabdomyolysis
• Dopamine antagonists
(bromocriptine, amantadine): no
consistent benefit, response
requires at least 24 hours, linked
to stroke, seizure, MI, etc
120
121. Treating NMS
• Dantrolene inhibits calcium
release from sarcoplasmic
reticulum
• No proven benefit
• Muscular rigidity of NMS due to
brain abnormality, not muscle
• No advantage over neuro-muscular
blockade, benzos
121
122. Conclusion
• Fever is symptom, not a disease
• Careful history and physical will
reveal source of most fevers
• Recognize life-threats early
• Make decision about benefits of
treating fever before doing so
• Acetaminophen is drug of choice
122