Chapter 7 Nausea, vomiting and fever
Introduction
Nausea, vomiting and fever are extremely common presenting complaints in community emergency medicine. They are often symptoms of a minor, self-limiting illness but can also be an early, or only, marker of an underlying, potentially life-threatening medical condition. Box 7.1 shows the objectives of this chapter.
Primary survey
On first contact with the patient an assessment needs to be made as to whether they are primary survey positive. If so the person requires immediate appropriate treatment and rapid transfer to hospital (see Chapter 2).
The primary survey box from Chapter 3 (Chest pain) is repeated here as a refresher and is also slightly expanded to include further important triggers for these symptoms (Box 7.2).
Box 7.2 Primary survey (adult)
If any observations below are present then treat immediately and transfer to hospital:
Since the signs/symptoms discussed in this chapter span the entire age spectrum some of the parameters will need to be age adjusted. Those parameters in Box 7.2 requiring adjustment are asterisked. Table 7.1 sets out an evidence based paediatric adjusted physiological range for these parameters in children who are OK even though they may be distressed or unhappy.1 As such they differ from the values derived from children who are behaving normally. Child blood pressure is notoriously difficult to take and requires special equipment rarely carried outside hospital. It is unlikely to be abnormal unless other, easier to assess, parameters are affected.
| Age (years) | Pulse rate | Respiratory rate |
|---|---|---|
| <2 | 90–180 | 20–50 |
| 2–5 | 80–160 | 15–40 |
| 6–12 | 70–140 | 10–30 |
If the patient is primary survey positive they will require immediate treatment appropriate to their findings (see Chapter 2). According to local guidelines this may include administering IM/IV/IO antibiotics and fluids if bacterial meningitis or meningococcal septicaemia is suspected.
In many ways finding something requiring urgent transfer to hospital makes management relatively easy – it is often not even necessary to make an accurate diagnosis of the underlying condition. In practice, however, the majority of patients seen with the symptoms dealt with in this chapter will not fall into this category and a more detailed assessment will be needed.2
Secondary survey
The above lists seem obvious but things are often not as simple as they appear.
Nausea and vomiting
Nausea is a non-specific term usually referring to feeling unwell for any reason. Its generality makes it an unhelpful diagnostic symptom. Vomiting is more precise and may or may not be associated with nausea. Table 7.2 lists the subjective and objective information that needs to be elicited from the patient presenting with nausea or vomiting.
Table 7.2 Information that needs to be elicited from the patient presenting with nausea or vomiting
| Subjective | Objective |
|---|---|
| The symptomHow long has the symptom been present? How long have the symptoms been a problem? How often has the person vomited in the past few hours? Is there any blood or mucus in the vomit? What colour is the vomit?Associated symptomsIs there any associated pain? Where is it and does it radiate anywhere? Is there any diarrhoea? If so is there any blood or mucus in it?Possible infective contacts/travelDoes anyone else in the family have the same problems? What does the patient/family think is the cause? Have they been abroad, if so where?Past historyIs there a significant past medical history of similar episodes or recent illness/surgery? Is the patient immunocompromised by pre-existing illness or recent treatment? They will usually have a letter from hospital explaining the risks, if this is likely Has the patient taken any drugs prescribed or otherwise? If not should they have? Is the patient pregnant? If so how pregnant? | GeneralBaseline vital signs are measured Is there any evidence of dehydration? Look in the mouth/ears. Check lymph glands Look for evidence of jaundice Is there rash or widespread muscle tenderness?Systems exam as indicated by historyNeurological Is there any headache, visual symptoms, altered level of consciousness, or neurological signs including abnormal tone in children? Chest As indicated by the history Abdomen Is there any abdominal pain? If so the abdomen should be palpated and listened to for signs of bowel disease or obstruction and the renal angles palpated for tenderness Are there any urinary or gynaecological symptoms, e.g. dysuria and frequency or vaginal discharge?Tests Check a urine specimen if possible (Nephur test or Combistix) checking for nitrites or cells Check a BM test in the very young and the elderly even if there is no history of diabetes |
Any abnormalities discovered may be treated, referred or transferred to hospital depending upon local protocols and resource availability. Box 7.3 lists common and less common causes of nausea and vomiting.
Any patient showing evidence of altered level of consciousness, dehydration, neurological symptoms/signs, unusual or uncertain rash, significant abdominal pain/distension or signs of jaundice should be transferred to hospital for further investigation3
Plan
If the likely diagnosis is a non-specific viral illness and the patient can be left at home (assuming there is someone to care for them or they are capable of looking after themselves) then symptomatic treatment should be offered.
It used to be held that, assuming no evidence of dehydration is present, at any age a period of 24 hours without food would reduce the overall duration of the symptoms. Recent work4 would now indicate that at least in children a sensible diet can be continued at all times as long as hydration continues to be maintained. Fluids should continue in small regular amounts at all times – flat, normal cola or lemonade is usually a very palatable option for patients over one year old. Adults over 16 years may be given an anti-emetic (IM or buccal) according to protocol. However if this is given within 12 hours of the onset of symptoms it can extend the duration of symptoms by altering the body’s natural reaction to the gastrointestinal irritant.
Fever
Generally speaking it is true that increased temperature (>38°C) is related to some degree of infection and statistically will normally be viral. However the temperature may be a response to the primary infection, as in flu-like illnesses, or may be a response to secondary infection from the primary cause, as in peritonitis from a ruptured appendix. It must also be remembered that non-infective inflammatory or allergic conditions of many types (inflammatory bowel disease, hay fever, lymphomas) will often present with a fever – sometimes as the only initial symptom. It is also important to remember that the high temperature itself may be the illness. Heat exhaustion or heat stroke can be very serious indeed and require specific treatment, though usually the circumstances of the consultation will lead one to the diagnosis.
If the presence of a fever is not particularly helpful as a diagnostic tool then is there anything about it that can be helpful? There is evidence that a rapidly rising temperature or a temperature >39°C are more likely to be associated with significant bacterial causes requiring further investigation and possible admission.5,6 Much of this evidence comes from research in A&E departments. This is a pre-selected group of patients and while the findings may not be fully applicable to the pre-hospital setting it is still a useful guide. From a practical perspective it is difficult to judge the rate of temperature rise pre-hospital. It requires you to spend 30 minutes or more with the patient or return and review fairly soon.
Higher temperatures in the very young or very old are more often associated with significant underlying illness and are more likely to require hospital admission and investigation.3,5,6 In addition these age groups tend to have associated carers who can provide useful information regarding the underlying cause and their ability to cope with the illness process.
Table 7.3 lists the subjective and objective information which needs to be elicited from the patient presenting with fever.
Table 7.3 Information that needs to be elicited from the patient presenting with fever
| Subjective | Objective |
|---|---|
| SymptomsHow long has the temperature been present? Is it constant or does it fluctuate? Have there been any episodes of ‘hot and cold’ shivers? Has any medication been taken to help it? If so what was it, how much was taken and how long ago? Did it work?Associated symptomsDo they have any pain or swellings anywhere? Are they aware of having a rash? Ask specifically about things such as unsteadiness/ vertigo, ability to concentrate, dysuria, frequency, offensive vaginal dischargeInfective contacts/travelHas anyone else in the family/at work had a similar problem? Has the patient recently returned from abroad? If so where from? Have they been in contact with anyone with a known infectious illness? | GeneralMeasure vital signs Take the temperature. If the fever seems very mild and the patient reasonably well then the back of your hand applied to the patients forehead in a ‘hot/not hot’ assessment is acceptable. If the fever seems significant or the patient looks ill then a more objective measurement is mandatory. This may be best provided by an electronic tympanic membrane temperature thermometer though there has been recent debate on their reliability Is there a rash – is it diagnostic of anything? Chickenpox blisters and non-blanching purpuric rashes are generally the only ones to be reliable as indicators of a specific cause Is there muscle tenderness? Is there any evidence of meningism or blunting of consciousness? The latter may be seen in the early stages of encephalitis Check the tympanic membrane, throat and cervical lymph glands Check the eyes for evidence of jaundiceSystems examListen to and percuss the chest Palpate the abdomen and renal angles. Ask the patient to cough – does it hurt their abdomen to do so? This may indicate a degree of peritonismTestsCheck a urine specimen for blood or nitrites if appropriate – it is always appropriate if no other obvious cause has been found even in the absence of urinary symptoms. This is especially true of the very young and the elderly |
Meningococcal septicaemia can progress rapidly from a patient with minor symptoms to cardiovascular collapse and death within an hour or two7
Plan
This will depend on a specific cause being found. If no specific diagnosis can be made it is only acceptable to treat the symptom. Antibiotics should certainly not be given to patients without a confirmed cause for their pyrexia as they may mask potentially important future symptoms. The exception would be a patient with suspected septicaemia who is going to be admitted as an emergency.
Paracetamol and ibuprofen may be given according to local protocols in age-related dosages on a regular basis. Check for contraindications such as peptic disease or asthma for ibuprofen. A plan, either patient or practitioner led, should be formulated so that if deterioration occurs or things do not improve within a certain time frame then a review can occur. The well worn advice to parents to tepid sponge or fan their hot child may be helpful in giving them something to do but has minimal effect, if any, over that of appropriate drug therapy.8
Oral antibiotics will be most commonly prescribed but topical preparations (ear drops, nasal ointment, skin cream) can be useful alternatives at times. In some circumstances, and with appropriate local support, people with conditions such as chest and skin infections may be treated with IV antibiotics at home. This requires a ‘hospital at home’ approach that is becoming more prevalent. Such a service will also provide oxygen, physiotherapy and haematological investigation as required to manage the patient. A blood count, differential white cell count and a CRP can be very useful in deciding what treatment a patient needs and whether or not hospital care is required.3,9 Significant anaemia, an abnormally high or low white cell count, or a CRP >20 are all indicators of significant disease requiring hospital investigation.
Nausea, vomiting and fever
Subjective and objective
Interestingly the only correlation between fever and severity of illness requiring hospital treatment is the presence of certain other symptoms and signs. One of the most predictive is vomiting. Thus a patient presenting with a high fever (>39°C) and vomiting is highly likely to require hospital admission.3,5
Table 7.4 shows the more important features in the history and examination which would point towards the patient requiring hospital admission. Any of the features make admission likely; the presence of any two makes it necessary unless there are local systems allowing a high level of home based investigation and review.
Table 7.4 Key points in history and examination (triggers for hospital admission)
| Nausea/vomiting | Fever |
|---|---|
| Primary survey positive | Primary survey positive |
| Pregnancy/pre-existing illness | >39°C |
| Age <6 months | Associated vomiting |
| Drug/alcohol ingestion | Associated jaundice |
| Blood in vomit | Meningism |
| Severe abdominal pain | Recent travel from a malaria area |
| Significant dehydration | High (or low) white cell count (if taken) |
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6 Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0–36 months with fever without source. Ann Emerg Med. 1993;22:108-119.
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9 Marco CA, Schoenfeld CN, Hansen KN, et al. Fever in geriatric emergency patients: clinical features associated with serious illness. Ann Emerg Med. 1995;26:18-24.
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