What is the initial management for a patient with fever and chills following knee trauma?

Management of Fever with Chills Following Knee Trauma

The initial management for a patient with fever and chills following knee trauma should include blood cultures, radiographic evaluation, and appropriate antimicrobial therapy if infection is suspected, as fever in this context may indicate septic arthritis or other serious infection. 1

Initial Assessment

• Obtain blood cultures immediately when fever and chills develop, as these symptoms strongly indicate possible bloodstream infection 1
• Perform radiographic evaluation of the knee with at least anteroposterior and lateral views to assess for fractures or other traumatic injuries 1
• Evaluate for signs of joint effusion, which in combination with fever may indicate septic arthritis, especially in the setting of recent trauma 2
• Monitor temperature regularly (every 5 minutes if temperature is below 36°C) to guide appropriate warming or cooling strategies 1

Diagnostic Workup

• Blood cultures should be obtained by fresh venipuncture, avoiding contaminated sites, with proper skin sterilization using 70% isopropyl alcohol or iodine-containing solution 1
• Consider additional laboratory tests including complete blood count (looking for leukopenia which may suggest antibiotic-induced fever) and C-reactive protein (elevated in infection) 3, 4
• If radiographs are negative but clinical suspicion for fracture remains high, consider advanced imaging such as CT to detect occult fractures 1
• Joint aspiration may be necessary if effusion is present to rule out septic arthritis 2

Management Strategies

For Suspected Infection:

• Initiate empiric antimicrobial therapy after obtaining cultures if septic arthritis or other serious infection is suspected 1, 5
• Fever with chills in trauma patients is an ominous sign associated with greater risk of bacteremia, sepsis, and mortality, particularly in older adults 5
• Consider surgical consultation for possible joint irrigation and debridement if septic arthritis is suspected 2

For Temperature Management:

• For fever >38°C, implement cooling measures while investigating the source 6
• For temperature <36°C, initiate warming strategies based on recorded temperature 1
• Use combination of passive and active warming strategies for hypothermia, including heating blankets, warm intravenous fluids, and forced-air warmers 1

For Pain Management:

• NSAIDs may be appropriate for pain control and can help reduce fever, but should not be relied upon as the sole management for fever in this context 1
• If using NSAIDs, limit duration to less than 1 month unless specifically indicated for ongoing inflammatory condition 1

Special Considerations

• Fever occurring 2-4 weeks after knee trauma or surgery with elevated inflammatory markers may indicate early acute periprosthetic infection 4
• Consider antibiotic-induced fever in patients receiving antimicrobial treatment, particularly if they have good general condition despite high temperature and progressive leukopenia 3
• Older adults with fever following trauma require more aggressive intervention as they are at higher risk for adverse outcomes 5
• Fever can increase metabolic demands and may worsen outcomes in trauma patients, so prompt management is essential 1, 5

Monitoring and Follow-up

• Continue regular temperature monitoring until fever resolves 1
• Reassess response to antimicrobial therapy within 24-48 hours 1
• Follow inflammatory markers (CRP) to track response to treatment 4
• Consider repeat imaging if symptoms persist despite appropriate management 1