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Fever... How hot is too hot pt 2

 In the last blog, here, I explained why we develop a fever sometimes due to infection. I also explained some other characteristics of the person with a fever that would require that I take a closer look: overall appearance, extremes of age, a poorly functioning immune system, and some social issues I must consider. 

I had alluded to the fact that not all fevers are due to an infection. Now, I want to explain some of the issues that can cause elevated body temperature when no bacterial or viral culprit is to blame.

Illicit Drugs

Certain illicit drugs, like amphetamines, can cause body temperature to elevate higher than what we usually see with infectious causes. MDMA (ecstasy), a common rave drug, causes users to want to have move their bodies more (like dance), it causes increases in serotonin, and it causes the cells themselves to release energy as heat rather than storing it. 

Drug-drug interactions

Sometimes prescription or over-the-counter drugs can interact with one another to cause elevated body temperature. The aforementioned chemical serotonin is often the culprit. This disease process is called serotonin syndrome, and it is characterized by elevated temperature, muscle rigidity, and confusion. 

Specific Drug Classifications

Some psychiatric drugs themselves can rarely cause elevated body temperature. This condition is called neuroleptic malignant syndrome. A similar phenomenon can occur with inhaled anesthetics in the operating room, and this is called malignant hyperthemia. 

Heat Stroke

Another noninfectious cause of fever is heat stroke. That occurs when a person is in a hot environment, their body temperature gets really high, and they are not able to release the heat their body is producing. They frequently stop sweating. That’s a situation in which you can see temperatures that are higher than what we normally see coming from just an infection. 

Febrile Seizures

Let’s talk about a special consideration of fever in children: the febrile seizure. Febrile seizures occur in children age 6 months to 5 years who have a sudden increase (or decrease) in their body temperature. If the child is normal afterwards, we really just evaluate them for their fever, meaning we look to see if we think there is a serious infection causing the fever. For the most part, though, the fact that the child had a seizure alters the workup very little.  

Treatment of Fever

When we have a fever due to an infection it’s usually the fever itself that is making us feel bad, so most doctors recommend treating it. But how?

Most people know Tylenol (acetaminophen) and Motrin (ibuprofen) can be used to treat fever, but how much and when? Do we alternate them?

The best means of reducing a fever is with acetaminophen and ibuprofen. Come closer and let me share a little secret to you. You can take them both at the same time. Yes, if you don’t have any conditions that prevent you from taking both acetaminophen and ibuprofen, it’s perfectly safe to take them at the same time. You can also alternate between the two, but I prefer to just hit the fever with both meds and be done.

In summary, there are many issues that go into evaluating a person who has a fever, and most, but not all, elevated body temperatures are due to infection.  When you get a fever and you feel poorly, skip grandma’s antidote and just take some Tylenol and ibuprofen, rest, and recover. 

 


Full Transcript:

All right, so before we talk about ways to treat the fever and how to handle that when it happens, let's actually go through a list of some things that can cause a fever, but infection isn't involved at all. One of the first of those that come to mind is illicit drugs. So illegal drugs, maybe you've heard of a rave. So what happens at a rave is people are doing amphetamines or, more specifically, usually MDMA or Ecstasy, and so that can cause them to want to move their body more and they're in a hot, tight, small environment, and maybe they're not drinking enough water and so what we can see, there are a couple of things happening all the way down in the cell level, the mitochondria, how it's handling energy. It's not using that energy, it's actually dissipating it. So what happens is that causes our core body temperature to rise. Then MDMA also releases serotonin, and so you have, again, a bunch of people feeling empathetic, and lovey, and dancing, and staying up all night. So drug use, illicit drug use, is one of those things that can cause our body temperature go really high to those dangerous levels: 106, 107, 108, and those require rapid cooling and rapid attention in order to prevent somebody from losing their life.

Another thing that can happen that can cause a fever is drug-drug interactions. Now, don't get freaked out if you're already on some medications, you don't have to go look and see what those interactions are, but it's something that we're going to think about if we think that your fever is not caused from an infection, we start thinking about, okay, what combinations of drugs are you on? Because some of those can interact and cause what I already mentioned was serotonin, so serotonin syndrome. You have drugs that actually each in and of themselves will increase serotonin levels and then they get together and they start partying in your body, and it causes the serotonin levels to go higher. That can cause elevated body temp and muscle rigidity, confusion. So drug-drug interactions is going to be something that can cause elevated body temperature or fever without infection.

Another thing that comes to mind is there's some psychiatric drugs that can cause that that. They cause a phenomenon called neuroleptic malignant syndrome. So if you come in with confusion and altered mental status and elevated body temperature, we might take a look at your list of drugs and see if we think that anything there is contributing to that. Along those lines is some people react adversely to inhaled anesthetics in the operating room. So not really something that I'm going to see at our office or in the ER, but certainly anesthesiologists need to be aware of this phenomenon called malignant hyperthermia. Usually, you have a history of that or a family history of that, but that's going to be another thing that can cause unwanted elevated body temperature.

Then one of the last things that comes to mind is heat stroke. So you guys have probably heard of that, but maybe you're unclear what that is. So really what happens is we're in an environment where the heat is really high, but our body loses its ability to really dissipate that heat. So it's like we're in an easy bake oven, so our temperature starts rising and our body is not sweating. It's not letting go of that excess heat. So, again, that's going to be elevated temperature not related to fever, and those degrees of temperature, we can see 107, 108, and those are, unlike fever related to infection, primarily dangerous. So, again, that's going to be one of those things where when you see an emergency physician, he or she is going to act quickly to try and get your temperature down to save you a bad outcome.

So let's not overlook a really important aspect of fevers, especially in kids. If you have children, you've probably heard of this idea of febrile seizures or fever seizures. Surely, Dee, that has got to be something that's serious and life-threatening, right? Well, the good news is that febrile seizures usually come from infection and because they are fevers related to infection, they themselves are not usually dangerous. Now, what happens with a febrile seizure is our body temperature changes rapidly, and when our brains are immature, usually we should see this happening in kids five and under, when our brains are immature they have a lower seizure threshold, so elevated temperature, or, even get this, a rapid drop in temperature. So you got a high fever and that drops quickly has been reported to cause febrile seizures. So when that happens, where are you going to do? Well, you're going to freak out. I have five boys. If one of my kids has a febrile seizure, I'm a seasoned emergency physician, I'm probably still going to freak out a little bit.

So if your kid has a febrile seizure, you're going to bring him to the emergency Department or get in right away to see your doctor. But then as the physician evaluated that child, I'll let you in on a little secret, we really just evaluate your child in light of the fact that he or she has a fever and then given his age group we figure out how concerning that is. That is assuming that everything else is planned out like normal. As an example, usually if a kid has a febrile seizure at home, by the time I see them in the Emergency Department, they're waking up, they're looking around, they're acting themselves. They usually look great. They might still have the fever, but the seizure part of it has gone away so when I see a kid who's alert and playful, had a febrile seizure at home, I kind of rest assured that everything's probably okay.

We still evaluate the kid and maybe run some tests or at least do a good exam, but in the end we take the fact that there was a seizure out of the picture and evaluate your child for the fever, and then give you some reassurances. I always tell parents, "This could come back. Your kid could have another febrile seizure and when she does, you're going to bring them back to the Emergency Department and we're happy to re-evaluate and make sure that everything still looks okay." But there are some families out there that have had this common enough that maybe the parents don't always get overly worked up. They see it's happening, they make sure that the child is safe. So you want to make sure that you help him or her to the ground, and that you just stay there with them, and usually these seizures are over in less than five minutes. By definition, they have to be over in less than 15 minutes, but 15 minutes feels like 15 hours when your child is seizing, so I get it. Parents all the time, we're like, "How long did it last?" They're like, "Oh, it lasted for like 20 minutes," and really looking back, it was probably two or three minutes. It just seemed like an eternity.

So that gets us to the point in the little chat where we talk about how do you treat fever? Like what should we be doing at home? Do we give Tylenol and Motrin? Do we not? I'm here to tell you that I'm a huge fan of Tylenol, Motrin in my children when they're sick, and in me when I'm sick. I don't want to feel a fever. I don't want to feel like pooh, and so I treat myself with Tylenol, Motrin, and I'll let you in on a little insider secret. Come here, listen. You can give Tylenol and Motrin at the same time. Yes, acetaminophen and ibuprofen, different classes of drugs with different side effect profiles, absolutely safe for you to give at the same time.

Now, you do not want to give either of them too frequently. So for example, if you're a fan of alternating Tylenol and Motrin, every two, three, four hours, you can't then give both Tylenol and Motrin every two hours, that's not good. So you still have to keep with the dosing schedule of each drug. Normally, Tylenol, we think of doses as every four to six hours, and ibuprofen is dosed more every six hours or so, six to eight hours. But if your kid has a fever and you want to give a dose of both Tylenol and ibuprofen at the same time, absolutely safe and I would commend you.

What about other things? Well, there's a lot of things, like I said, that grandmas pass around. There's the alcohol baths. Don't do that. That's not necessary. There's putting them in cold water. Again, if you have a fever related to infection, like from a bacteria or virus, there's no need to go to that point. You could maybe do some lukewarm water if you want it. Probably no harm in that. But my experience is that, in general, if you give a weight-appropriate dose of Tylenol and Motrin to your child, the fever goes away. Now, I do find that the bottles tend to underdose those, so if you're giving ... So the directions on the bottle tend to underdose those. So if you're giving it and it's not working, if you're a member like of our direct primary care membership, you can just text me or on the north side, Dr. Parker and say, "Hey, I just ... Little Johnny's got a fever and this is what I'm giving. Is my dosing correct?" and we'll be glad to assist you with that.

But in general, once you treat with, especially if you treat with Tylenol and ibuprofen, and the fever is still there, you're stuck. Like we don't have any other drugs that we can use that are going to be safe to add to those. But I'll tell you that really treating kids with fever comes back to like treat the kid, not the number. So literally, if my son has a temperature of 103 and he's running around acting fine, it's absolutely acceptable for me to not get a medication for that. I really only need to give a medication to the degree that he's miserable with his symptoms. Now, sometimes in the Emergency Department, I really want to get that fever down because sometimes kids really look bad, like sick. They look sick with their fever, but then when that fever breaks, they look like a million bucks. Having done this for 25 years, I'll tell you that when somebody has a really serious infection, especially in that pediatric age group, they have a really serious infection and we get the fever down with Tylenol and Motrin, these kids still look pretty sick.

So one of the distinctions that I try to make as I educate parents on what a sick kid looks like to an emergency doctor is if I started an IV on your child, would he or she fight me? So parents throw around this term lethargic, which to them just means his activity level's down. He's normally running around playing and he just wants to lay on my lap. Medically, if you told me that your kid is lethargic, to me that means that if I tried to start an IV or if I try to do that lumbar puncture, Little Johnny is just going to lay there. Now, that's a kid that I'm really concerned about. So sometimes seeing a kid in the office or in the Emergency Department, I really want that fever to come down because as the kid looks to me right now, I'm concerned because he is listless. But I'm thinking if that fever comes down, he looks great, I don't have to do as broad of a workup on him because he's just really under the weather because of the fever, not because there's a more serious underlying bacterial infection going on.

So in conclusion, let me just say fevers are okay. They don't have to be this big, scary thing and it's fine to treat them. Now, people that I said have the fever not related to a bacterial or viral cause, so the fever is not related to infection, I'm going to tell you right now when somebody has that, they look sick, they look horrible. That's somebody that right away, if that's a family member of yours, you are going to be overly concerned because they're not acting right, they're confused or out of their head, they're doing strange things, and their fever is really high and they look horrible. So don't think that a little elevated fever in a friend or family member automatically points to that they've got something horrendous, that they've been partying at the rave, or they've got a heat stroke or something like that. People with that level elevated temperature, 106, 108, they look horrible. So, and for everyone else, the fever related to the virus or bacteria, it's really just treat the fever and try to feel better, and then drill down to the underlying cause.

Most of the time, most fevers are caused by viruses and you guys get tired of us telling you that. You come see us and we're like, "Well, you have a virus. Not a whole lot to do. Treat your symptoms and you'll be better in a couple of days." But for the most part that's truth, and I know that people get really concerned about going and spending their healthcare dollars on an urgent care visit or an ER visit just to be told that they have a virus. I think that's part of the beauty of the membership model that we're going with, so if you do get sick with a fever and you need to come see me, I tell you, if it's a virus, I'm going to tell you, I'm not just going to indiscriminately throw antibiotics at you. I'd rather take the time and explain why antibiotics won't help, why they'll simply give you diarrhea, and they won't make you better any faster, but at least you didn't spend a ton of money and you just came in to see me and all that's included in your membership price.

So when it comes to fever, it's okay to just take a pause, take a breath, evaluate the overall situation and yourself or your spouse or your children. Treat it with some Tylenol and Motrin, provided no one's allergic to Tylenol or ibuprofen; no one's got kidney or liver problems that shouldn't be taking that. That's a different discussion for you to have with your doctor. But hopefully you find this helpful. If it's brought value to you, please click the share button, distribute it. I think there's a lot of people around that could benefit from learning more about fever and I'll be back on here sharing some other insightful information about medicine and health and wellness, and we'll just try to give you guys a bunch of good stuff so that we can help you save your healthcare dollars and maybe not spend a fortune when you don't really have to. All right, I love you, guys. Bye.

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