How far do you go young febrile tachy pt?

[shoal007]

This is always a preplexing subject and one I've done the whole gamut (h&p then street vs full body imaging and set of labs).

Let's say, a 38 yo M comes in with fevers (tmax 102), generalized bodyaches, no respiratory symptoms, no urinary symptoms, no rashes. Denies drugs,alcohol, no daily meds. No exam findings.

VS HR 130, BP 120/80, 98% RA.

This is a relatively rare ED presentation but I see similar every couple months

Options
1. Looks good must be viral, dc home without workup with close outpt Fu
2. Go nuts (labs,fluids,imaging, blood cultures)
3. Give tylenol, fluids and discharge after short observation
4. Do #2 and #3 but pt remains tachycardic so admit to the hospital...

I can say my collegues almost always go nuts on these pts, is that a good use of resources?

Anybody know of any data regarding the otherwise healthy adult with fever without a source with isolated tachycardia?

Thanks!

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[throckmortonDO]

With otherwise benign exam and no IVDU, immunocompromised, organ transplant, cancer etc etc - IVF, antipyretics, treat symptomatically, close PCP f/u and strict return precautions as long as vitals improve.

Vitals not improving, pt worsening or looking toxic, any RF - go nuts.

 

[GonnaBeADoc2222]

I think with HR around 130s you're pretty obligated to work it up.

EKG to make sure sinus tach.

If truly asymptomatic, would get labs, give antipyretics, fluids, see if HR improves. If not unwell appearing / septic, I don't get blood cultures.

If HR not improving, I get concerned for things like myocarditis. Would add on cardiac labs, admit for echo, etc.

Also might consider flu swab. I've seen flu present in wacky ways this year and it's really messed up a couple patients I've had.

 

[BJJVP]

If the pt truly looks good and isn't acting like they are dying, then Tylenol and dc. I would likely blame the tachycardia on fever, anxiety, pain/discomfort.

If the pt looks good but is somewhat dramatic and acts like he/she is dying (moans when you sit them up, grimaces when they talk, acts super weak, had to be wheel-chaired from triage to the gurney, etc), then I give tylenol, IVF, labs, influenza swab, maybe even CXR/UA, then document improving HR (not necessarily nl) and then dc.

Obviously, if they have focal sx's such as CP, abd pain, HA or if they have risk factors (chemo therapy, IVDU), then I approach things differently.

 

[shoal007]

Looks like we all approach these pts similarly and err on the side of caution, its sometimes hard to sell these soft admits, and/or get the horrible knot iny stomach after discharging them home.

Guess that is why we get paid the big bucks.

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[alpinism]

Assuming a completely normal H/P in a healthy patient with no risk factors there's no reason for any further tests or imaging.

Fever and pain both explain the tachycardia which doesn't require anything more than some tylenol and fluids.

 

[Birdstrike]

double post

 

[Birdstrike]

This is always a preplexing subject and one I've done the whole gamut (h&p then street vs full body imaging and set of labs).

Let's say, a 38 yo M comes in with fevers (tmax 102), generalized bodyaches, no respiratory symptoms, no urinary symptoms, no rashes. Denies drugs,alcohol, no daily meds. No exam findings.

VS HR 130, BP 120/80, 98% RA.

This is a relatively rare ED presentation but I see similar every couple months

Options
1. Looks good must be viral, dc home without workup with close outpt Fu
2. Go nuts (labs,fluids,imaging, blood cultures)
3. Give tylenol, fluids and discharge after short observation
4. Do #2 and #3 but pt remains tachycardic so admit to the hospital...

I can say my collegues almost always go nuts on these pts, is that a good use of resources?

Anybody know of any data regarding the otherwise healthy adult with fever without a source with isolated tachycardia?

Thanks!

Sent from my Pixel 2 using Tapatalk

You handle it on a patient by patient basis. I know that sounds like a cop out, but clinical judgment matters here. Not all cases are cookbook, no matter what the decision-tree people want you to think.

That being said, I don’t think you can completely blow off a HR that high. It does give you an excuse to give a fluid bonus and an antipyretic on board. If that patient looks like a million bucks, is afebrile and the heart rate normalize after defervescing, that’s a whole different animal than the patient who remains tachy and toxic appearing despite a normalized heart rate.

Although tachycrdia in the presence of infection can at times indicate sepsis, sinus tachycardia can be from fever alone. If so, it should resolve when the fever resolves. If it doesn’t, or you can’t even get the fever temporarily down to get a glimpse of what their afebrile heart rate is, then you’re a little bit stuck in assuming there’s a higher chance of an underlying serious bacterial infection.

In 2018, there’s much greater incentive to assume the worst and prove otherwise, working backwards, than there is to assume the most likely condition which is benign, and risk being wrong if it turns out to be something more severe.

 

[GeneralVeers]

I've found that young females get extremely tachy with even the slightest fever. My approach is that if they have benign symptoms, look good, and are otherwise healthy, I order no workup (except maybe UA and preg), give fluids, toradol, tylenol, and anti-emetics. 90% of these patients feel better, have resolved tachycardia and go home.

There's a push for calling "code sepsis" on all these people, and I refuse. Mainly because I don't want a label of "sepsis" anywhere on a patient I'm likely to discharge home.

 

[BoardingDoc]

Recently had this. 30M still tachy after 3L of NS. No longer febrile after tylenol. Couldn't find a source anywhere. Flu neg, CXR neg, labs all reassuring except for a WBC of 16. Looked fine except I couldn't get his damn HR down with a crapton of fluids. Admitted him for presumed bacteremia. Followed up on him a couple days later. BCx grew out GPCs.

 

[bravotwozero]

Recently had this. 30M still tachy after 3L of NS. No longer febrile after tylenol. Couldn't find a source anywhere. Flu neg, CXR neg, labs all reassuring except for a WBC of 16. Looked fine except I couldn't get his damn HR down with a crapton of fluids. Admitted him for presumed bacteremia. Followed up on him a couple days later. BCx grew out GPCs.

I'm thinking he's probably an IVDA, or has some kind of mediport/catheter that got infected....

 

[Rendar5]

Had a patient yesterday healthy 40yo M fever without source, net. W/u except borderline elevated lactic, and had sinus tach to 140 bpm range on a 101 fever. Had to admit him. relative tachycardia is usually an indication of something wrong since HR should only go up 10 for every degree above normal so the guy should be resting around 110-120 at that temp. Hydration and antipyretics only do so much.

 

[TooMuchResearch]

Recently had this. 30M still tachy after 3L of NS. No longer febrile after tylenol. Couldn't find a source anywhere. Flu neg, CXR neg, labs all reassuring except for a WBC of 16. Looked fine except I couldn't get his damn HR down with a crapton of fluids. Admitted him for presumed bacteremia. Followed up on him a couple days later. BCx grew out GPCs.

But why?

 

[emergentmd]

I don't treat numbers unless ridiculously high. I will send someone home with a HR less than 120. Over 120 and fever/dehydration corrected, I prob gonna chicken out and admit.

 

[hoot504]

Interesting conversation.

So referring to the original post, no one is going w/ #1. Vitals demand something. Best case scenario they get an anti-pyretic, the tachycardia vanishes, and they go home.

The highest HR I'm comfortable discharging is 110, and that's only if they have an ongoing documented fever and otherwise look absolutely pristine, and typically I'd prefer they have an identified source in their workup. Even with this, in my relatively short career I've seen all manner of these patients bounce back the next day looking worse, in rare cases, dramatically so. The clinical judgement comes into play trying to determine which one of your patients that one is likely to be.

 

[engineeredout]

Young, healthy, obvious source (viral), antipyretics +\- IVF, and reassess. Don't automatically through the entire lab at them just because they had an initial hr of 130.

On the other hand just yesterday, had a young, healthy guy, who was afebrile, normal HR, normal SpO2, who just looked like crap. Came in for a cough for three days. Labs and XR - whole right lung looked like poopy. CT Chest - Empyema.

Like someone said above, it really comes down to a case by case basis.

 

[Petypet]

abnormal vitals that don't improve like I expect, obs or at least shared decision making. Couple good review articles demonstrating abnormal vital signs and association with morbidity and mortality and having had a bad outcomes.

 

[BoardingDoc]

But why?

Why did he have GPCs in his blood? Ultimately had strep pharyngitis and got bacteremic from it based on what I can see in his chart.