EM Student Lecture Series. CASE STUDY A 53-year old woman presents complaining of several days of...
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![Page 1: EM Student Lecture Series. CASE STUDY A 53-year old woman presents complaining of several days of fever, generalized malaise, nausea & vomiting. She has.](https://reader035.fdocuments.in/reader035/viewer/2022062407/56649dc85503460f94abe8e1/html5/thumbnails/1.jpg)
SEPSISEM Student Lecture Series
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CASE STUDYA 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
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WHAT NOW?List 5 initial steps in the management of this
patient
List 5 differential diagnoses
List 5 tests or interventions
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SEPSISA continuum … from
SIRSSepsisSevere SepsisSeptic ShockDEATH
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SIRSRequires 2 out of 4 of the following:
Temp >38.0 or <36.0HR>90 RR>24 or PaCO2<32WBC<4000 or >12000 OR bands >10%
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SEPSISSystemic response to host infectionSIRS + 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 ...
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SEVERE SEPSISSepsis + organ failure OR lactate level >4
CNSPulmonary (ALI)Heme (coags & platelets)Liver ( bili)Kidney (AKI)Circulatory system
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SEPTIC SHOCKSepsis + 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
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EPI/PATH OF SEPSIS10th leading cause of mortality750,000 hospitalizations/yearMost common sources:
LungAbdomenGUSkin/soft tissueCNS
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ED WORKUP OF SEPSISCAREFUL history
Complaints may be nonspecific, especially very old/young
VITAL SIGNS ARE JUST THAT … but lack of fever rules out nothing
CAREFUL physicalInspect every inch/every orifice
BE SUSPICIOUS
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ED WORKUP OF SEPSISLabs
The usuals – CBC, CMP, U/A, CXR, EKGThe unusuals:
Lactate ?procalcitonin? Cultures of every fluid
ImagingXRUS – RUSH protocol/IVC collapseCT
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>50% collapse during inspiration indicates low CVP/likely fluid responsiveness
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TREATING SEPSIS: EGDTLandmark study (2001) showed that
“bundling” sepsis management techniques and starting them in the ED showed mortality benefit (NNT=6)
Focuses on aggressively managingPreloadAfterloadOxygenationSource control
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EGDT ALGORITHM
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THE ABCs of EGDT“Are you OK?”
Rapid identification of the septic patientInitiating diagnostic steps immediately (IV,
monitor, early lactate measurement)
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THE ABCs of EGDTA & B – oxygenation status & work of
breathingObvious 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
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THE ABCs of EGDTOther adjuncts to A&B
Transfusion if hematocrit <30%Lactate – measure of anaerobic metabolism of
tissues Even mild elevations (>2) associated with increased
mortality
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THE ABCs of EGDTC – circulatory statusBP is an imperfect gauge of true circulation!
Look for subtle signs of hypoperfusion … like:
Going IN: Rapid central venous access (<2hr)Preload – multiple IVF bolusesAfterload – pressors (generally
norepinephrine)Coming OUT: measure strict UOP
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THE ABCs of EGDTD&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!)
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GOALS OF EGDT – when to stop?Airway/Breathing
ScvO2 >70% By means of: intubation/ventilation; transfusion +/- addition of inotrope if Hct<30% Improving lactate level
CirculationCVP 8-12 (must measure thru central line;
also use IVC)Uop >0.5 cc/kg/hrMAP 65-90 mmHg
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ADJUNCT SEPSIS THERAPIESSteroids – 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 precautionsTight glucose controlGI/ulcer & DVT prophylaxis
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PATIENT DISPOAdmit, admit, admit!!To the floor ONLY if mild sepsis and
responding to ED therapyTHESE PATIENTS GET WORSE QUICKLYMortality rates
20% sepsis40% severe sepsis60% septic shockIncrease with every organ system involved
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BACK TO THE CASE …Significant labs:
WBC 9,000 15% bandsH/H 9.2/28.3Glu 186HCO3 16U/A + nitritesCXR clear
How would you manage this patient??
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SEPSIS: TIME=MORTALITY