MLP EM Education Curriculum Dave Markel September 15 2015 What will be covered Basic concepts and definitions Initial management Septic shock Pearls and pitfalls What will not be covered ID: 755075
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Slide1
Management of Adult Fever and Sepsis
MLP EM Education Curriculum
Dave Markel
September 15, 2015Slide2
What will be covered
Basic concepts and definitions
Initial management
Septic shock
Pearls and pitfallsSlide3
What will not be covered
Pediatric fever (Scheduled for May 2017, Dr. Justice)
Febrile seizures
Hyperthermia
Environmental
Drug-inducedSlide4
Basic concepts and definitions
Fever: temp > 37.8 C = 100
F
(CDC definition)
Not “I’m usually at 96 degrees so 98.6 is a fever for me”
Not “It feels kinda warm in here”
Not “I had a chill the other day”
Most reliable way of checking the temperature?
No axillary temps, please!Slide5
Basic concepts and definitions
Systemic inflammatory response syndrome (SIRS)
At least 2 of the following:
Oral temperature > 38
or
< 35 C
Respiratory rate > 20
or
PaCO
2
< 32 mmHg (requires ABG)
Heart rate > 90
Leukocytes > 12,000
or
< 4,000
or
>10% bands
Sepsis
: + microbial source
Severe sepsis
: + organ dysfunction
Septic shock
: + hypotension unresponsive to fluids
Multiple organ dysfunction syndrome (MODS
)Slide6
Sick vs Not Sick
Patients with any of the following need IMMEDIATE intervention
Altered mental status
Respiratory distress
Cardiovascular instability
Prolonged temp > 41 C = 105.8 FSlide7
Most aren’t critically ill… take a history!
Localizing
symptoms
Atypical symptoms
Fever patterns
Tubes, lines, drains (incl. pacemakers, heart valves,
PICC lines, etc
)
Living situation (nursing home, dorm, jail, etc)
Recent hospitalizationsSlide8
Never trust the elderly
Symptoms are often atypical
May not even mount a fever response
Abdominal exam often deceptively benign
3 critical things to do when evaluating fever
in the elderly
Completely undress and examine skin
Chest x-ray (2-view if possible)
Urinalysis (straight cath if possible
)Slide9
Sepsis: a problem with perfusion
For MIS:
sepsis is caused by a complex disarray of pro-inflammatory and anti-inflammatory mediators which are triggered by infection, leading to tissue ischemia, direct tissue injury, alterations in apoptosis
For us:
sepsis = poor perfusion… fix it
Hypotension
Elevated lactate
Tachycardia
Decreased urine outputSlide10
How to fix the perfusion problem
IV fluids
Initial choice: 0.9% NS
Optimal volume unknown… usually will get 3-5 liters over first 6 hours
Watch for pulmonary edema
Vasopressors
Initial choice: norepinephrine (Levophed)
Consider phenylephrine if tachycardia or dysrhythmiasSlide11
Targets: first 6 hours
MAP ≥ 65 mmHg
UOP ≥ 0.5 mL/kg/hr (eg, 35 mL/hr in a 70 kg patient)
Central venous pressure (CVP) 8-12 mmHg
Central venous oxyhemoglobin saturation (ScvO
2
) ≥ 70%
Slide12
ProCESS, 2014:
“In
a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes
.”
ARISE, 2014:
“In
critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days
.”
ProMISe, 2015:
“In
patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome
.”Slide13
Bonus: empiric abx (if source unknown)
Gram-positives and MRSA:
vancomycin
Gram-negatives:
3
rd
- or 4
th
generation cephalosporin (eg, ceftriaxone)
Pseudomonas:
zosyn, ceftazidimeSlide14
Bonus: Vasopressors