What is the management approach for fever post head trauma?

Management of Fever Post Head Trauma

Fever following traumatic brain injury (TBI) should be promptly treated with controlled normothermia targeting 36.0-37.5°C using automated feedback-controlled temperature management devices to prevent secondary brain injury. 1

Understanding Fever in TBI

• Neurogenic fever (core temperature >37.5°C driven by neurological dysregulation without evidence of infection) is common in TBI patients and associated with increased risk of complications and unfavorable outcomes 1, 2
• Fever can precipitate secondary brain injury by increasing brain metabolic rate, cerebral blood flow, and intracranial pressure, regardless of whether it's caused by infection or impaired thermoregulation 1, 3
• Approximately 70% of febrile TBI patients do not have an identifiable source for their fever 4

Fever Detection and Monitoring

• Continuous core temperature monitoring (bladder, esophageal, or cerebral) is essential rather than intermittent or surface temperature measurements 3
• Brain temperature may be up to 2°C higher than systemic temperature and can vary independently based on cerebral pathology 3

Management Algorithm

Step 1: Initial Assessment

• Differentiate between neurogenic fever and infectious causes, though management should proceed regardless of source while investigation continues 1
• Evaluate for signs of increased intracranial pressure and risk of secondary brain injury 1

Step 2: Temperature Control Implementation

• For patients with severe TBI who are sedated and ventilated, initiate controlled normothermia reactively when fever is detected 1
• Target temperature range: 36.0-37.5°C 1, 3
• Utilize automated feedback-controlled temperature management devices for precise control 1
• Maintain temperature with minimal variation (≤ ±0.5°C per hour and ≤1°C per 24-hour period) 1

Step 3: Pharmacological Interventions

• Antipyretics such as acetaminophen (paracetamol) or NSAIDs have limited efficacy in controlling fever in severe TBI 1
• These medications may be used as adjuncts during the induction phase but should not be relied upon as primary management 1

Step 4: Duration of Treatment

• Continue controlled normothermia for as long as the brain remains at risk of secondary brain injury 1
• This is particularly important during the acute phase of TBI 1

Special Considerations

• Fever control is especially important in TBI patients with seizures or those at high risk of seizures 1
• While some controlled pyrexia may be allowed during the subacute phase, uncontrolled fever requires urgent management in the acute phase 1
• For patients with severe TBI with impending herniation or obliterated basal cisterns, more aggressive temperature management may be needed 1

Potential Pitfalls

• Relying solely on antipyretics is insufficient for temperature control in severe TBI 1
• Failing to differentiate between central fever and infectious causes may lead to antibiotic overuse or missed treatable conditions 1
• Inadequate monitoring of core temperature can result in undetected temperature fluctuations 3
• Discontinuing temperature control too early while the brain remains at risk of secondary injury 1