CASE STUDY A 53year old woman presents complaining of several days of fever generalized malaise nausea amp vomiting She has a PMH of diabetes and HTN and takes Glucophage and Lisinopril ID: 929652
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Slide1
SEPSIS
EM Student Lecture Series
Slide2CASE STUDY
A 53-year old woman presents complaining of several days of fever, generalized malaise, nausea & vomiting. She has a PMH of diabetes and HTN and takes
Glucophage
and
Lisinopril
.
Initial VS: 105/54 110 24 100.4 O2 sat 96%
PE: significant for mild lethargy (but she is A&Ox4); mild diffuse abdominal tenderness to palpation – otherwise WNL
Slide3WHAT NOW?
List 5 initial steps in the management of this patient
List 5 differential diagnoses
List 5 tests or interventions
Slide4SEPSIS
A continuum … from
SIRS
Sepsis
Severe Sepsis
Septic Shock
DEATH
Slide5SIRS
Requires
2 out of 4
of the following:
Temp >38.0 or <36.0
HR>90 RR>24 or PaCO2<32
WBC<4000 or >12000 OR bands >10%
Slide6SEPSIS
Systemic response to host infection
SIRS + A SOURCE
Encompasses body’s own response to pathogen – characterized by derangements in inflammation, coagulation &
fibrinolysis
May progress to abnormal
vasodilation
, tissue
hypoperfusion
, microcirculation thrombosis … to ORGAN DYSFUNCTION
Increased risk in ...
Slide7SEVERE SEPSIS
Sepsis + organ failure OR lactate level >4
CNS
Pulmonary (ALI)
Heme
(
coags
& platelets)
Liver (
bili
)
Kidney (AKI)
Circulatory system
Slide8SEPTIC SHOCK
Sepsis + hypotension
Unresponsive to initial bolus (20-30 cc/kg)
Most septic patients are UNDER-resuscitated
Hypotension = SBP<90 OR 40 mmHg below baseline
OR MAP <65 mmHg or >25mmHg below baseline
Slide9EPI/PATH OF SEPSIS
10
th
leading cause of mortality
750,000 hospitalizations/year
Most common sources:Lung
Abdomen
GU
Skin/soft tissue
CNS
Slide10ED WORKUP OF SEPSIS
CAREFUL history
Complaints may be nonspecific, especially very old/young
VITAL SIGNS ARE JUST THAT … but lack of fever rules out
nothing
CAREFUL physical
Inspect every inch/every orifice
BE SUSPICIOUS
Slide11ED WORKUP OF SEPSIS
Labs
The
usuals
– CBC, CMP, U/A, CXR, EKG
The unusuals
:
Lactate
?
procalcitonin
?
Cultures of every fluid
Imaging
XR
US – RUSH protocol/IVC collapse
CT
Slide12>50% collapse during inspiration indicates low CVP/likely fluid responsiveness
Slide13TREATING SEPSIS: EGDT
Landmark study (2001) showed that “bundling” sepsis management techniques and starting them in the ED showed
mortality benefit
(NNT=6)
Focuses on aggressively managing
Preload
Afterload
Oxygenation
Source control
Slide14EGDT ALGORITHM
Slide15THE ABCs of EGDT
“Are you OK?”
Rapid
identification of the septic patient
Initiating
diagnostic steps immediately (IV, monitor, early lactate measurement)
Slide16THE ABCs of EGDT
A & B – oxygenation status & work of breathing
Obvious airway compromise/respiratory distress = easy!
Measures of poor oxygenation:
Lethargy, restlessness, altered MS
Pulse Ox/RR/PaCO2
ScvO2
– what the heck is that??
poor
oxygen delivery to tissues/overwhelming oxygen
debt
(<70% = poor O2 delivery)
Early intubation
& mechanical
ventilation
Slide17THE ABCs of EGDT
Other adjuncts to A&B
Transfusion
if
hematocrit
<30%
Lactate
– measure of anaerobic metabolism of tissues
Even mild elevations (>2) associated with increased mortality
Slide18THE ABCs of EGDT
C – circulatory status
BP is an imperfect gauge of true circulation!
Look for subtle signs of
hypoperfusion
… like:
Going IN: Rapid
central venous
access (<2hr)
Preload –
multiple
IVF boluses
Afterload
–
pressors
(generally
norepinephrine
)
Coming OUT: measure strict
UOP
Slide19THE ABCs of EGDT
D&E – disability & exposure
WHERE IS THE SOURCE?? Full inspection of the patient
Lung – most common
Kidneys/bladder
Skin/soft tissue
GI
GU/GYN
Other (FBs, CNS, bone, etc)
UNKNOWN in up to 1/3 of cases
BROAD
Abx
coverage until you know what bug (culture, culture, culture!)
Slide20GOALS OF EGDT – when to stop?
Airway/Breathing
ScvO2 >70%
By means of: intubation/ventilation;
transfusion +/- addition of
inotrope
if
Hct
<30%
Improving lactate level
Circulation
CVP 8-12
(must measure thru central line; also use IVC)
Uop
>0.5 cc/kg/hr
MAP 65-90 mmHg
Slide21ADJUNCT SEPSIS THERAPIES
Steroids – very controversial
Generally reserved for the patient in septic shock unresponsive to
pressor
& fluid therapy
Mechanical ventilation lung-protective strategies
Low TV, low plateau pressures
Aspiration precautions
Tight glucose control
GI/ulcer & DVT prophylaxis
Slide22PATIENT DISPO
Admit, admit, admit!!
To the floor ONLY if mild sepsis and responding to ED therapy
THESE PATIENTS GET WORSE QUICKLY
Mortality rates
20% sepsis
40% severe sepsis
60% septic shock
Increase with every organ system involved
Slide23BACK TO THE CASE …
Significant labs:
WBC 9,000 15% bands
H/H 9.2/28.3
Glu
186
HCO3 16
U/A + nitrites
CXR clear
How would you manage this patient??
Slide24SEPSIS: TIME=MORTALITY