and his weight is 160 lbs. His blood sugar is
normal. His blood pressure is 189/98 mmHg,
heart rate is 110, and his respiratory rate is
34 breaths per minute. His SpO2 is 85% on
room air and his EtCO2 is 28 mmHg. He
has an oral temperature of 101.2 degrees F
( 38. 4 degrees C).
You immediately place him on 100% oxygen administered via non-rebreather mask and
his SpO2 rises to 98%.
As you turn the patient to place him on
your scoop stretcher, you notice a large decubitus ulcer on his sacrum.
Field diagnosis: Advanced septic shock of
unknown origin, but the untreated decubitus
ulcer is likely the source.
The strong prognostic indicators here are
body temperature > 100.9 degrees F, heart rate
> 90, and respiratory rate > 20. The secondary
indicator is the EtCO2, which is < 35 mmHg.
In this case, with the late signs of intravenous septicemia with hypoxia, the patient is
trying to compensate for the infectious process by increasing BMR and cardiac output,
as well as a myriad of anti-infection factors,
all increasing CO2 production, which causes a
compensatory increase in respiratory rate and
a decrease in EtCO2.
Complicating the field diagnosis here are
his chronic hyperglycemia from his diabetes, with likely peripheral vascular disease,
and his chronic hypoxemia from his COPD.
These are relative distractors to his advanced
underlying condition of septicemia, of which,
as stated previously, increased temperature is a
late physical indicator in the elderly.
KIDS ARE DIFFERENT
Although EMS may be called to the home of
an ill child due to markedly elevated tempera-
tures as high as 105–107 degrees F, providers
are more likely to encounter patients with
lower grade fevers (101–103 degrees F) and
who have had a seizure. (Table 2 indicates the
normal body temperature range for pediatric
patients at various age ranges.)
Fever is commonly encountered in children, and more often represents a benign viral
illness vs. more serious pathologies such as
sepsis, meningitis or leukemia. Despite this,
fever is a considerable source of stress for parents and providers who don’t frequently care
There’s also considerable variability in the
appearance of the febrile child. Some children can present with an ill appearance and
lethargy with moderate temperatures, while
others are playful and happy despite markedly
Further, fever can significantly impact other
presenting vital signs, most notably the heart
rate and respiratory rate, making strict criteria for sepsis difficult, especially knowing that
these vital signs are already age and body habitus dependent.
There are, however, aspects of the febrile
child that should warrant further evaluation
in the prehospital setting and may impact your
treatment and transport decisions.
There are a number of important points
to consider. First, does the maximum temperature matter? In children who are both
ill-appearing or well-appearing, a markedly
elevated temperature gives most parents and
providers some pause.
We know, however, that the ability to mount
a fever response—our body’s way of fighting
most infections—varies between individual
children. Influenza, adenovirus and roseola
are some of the more common causes of high
fever in children.
With that in mind, most physicians will
evaluate children with high-grade fever, especially those with hyperpyrexia, which is defined
as > 106 degrees F.
A 2007 study conducted by researchers
at the Texas Children’s Hospital found that
hyperpyrexia occurs in approximately 1 of every
1,200 patients presenting to the ED. Somewhat
surprisingly, it was noted that 18% of patients
had a confirmed serious bacterial infection
with positive cultures from the blood or urine. 1
In evaluating the workup of these patients,
the authors found no aspect of the physical
exam (i.e., the presence of viral symptoms),
or the laboratory evaluation (i.e., total white
blood cell count, acute phase reactants) that
allowed practitioners to distinguish between
patients with bacterial or viral illnesses. 1
They did note that a known viral illness
(i.e., influenza) reduced the likelihood of bacterial co-infection. 1 As a result, these patients
will often receive empiric antibiotics, and, if
ill-appearing, will likely be hospitalized.
A frequent reason for EMS requests for
children are febrile seizures, or seizures in the
setting of febrile illness where no prior seizure
Seizures in the setting of fever are common
in children from six months to six years of age,
with an incidence of approximately 2–5% in
North America and Europe.
Simple febrile seizures, defined as a tonic-clonic (and previously referred to as “grand
mal”) seizure that last < 15 minutes and doesn’t
recur or rest in any deficit, are often disconcerting to parents and providers. These seizures are
provoked by rapid elevations in temperature,
Complex febrile seizures are those that last
> 15 minutes, are focal in nature, present in
status epilepticus, or result in a postictal deficit.
The presence of both simple and complex
febrile seizures increases the risk of epilepsy
(i.e., seizure disorder), but only marginally
(from 0.5–1% to 1–2%).
Historically, emergency medicine providers
have performed more detailed ED evaluations,
including CT scans of the brain, blood work
and diagnostic lumbar punctures (i.e., spinal
taps), and many institutions still admit these
children for electroencephalography and evaluation by a pediatric neurologist.
There is, however, evidence that the need
for a lumbar puncture to evaluate for meningitis is unnecessary, especially in children
Table 2: Pediatric normal body
temperature range according to age
0– 1 year 99.4–99.7°F 37. 5–37. 7°C
3–5 years 98.6–99.0°F 37.0– 37. 2°C
7–9 years 98.1–98.3°F 36. 7–36. 8°C
≥ 10 years 97.8°F 36. 6°C
Adapted from: Potts NL, Mandleco BL. Pediatric
nursing: Caring for children and their families, 3rd
edition. Delmar Cengage Learning: Clifton Park,
N. Y., p. 444, 2012.