EM Student Lecture Series

CASE 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/ O2 sat 96% PE: significant for mild lethargy (but she is A&Ox4); mild diffuse abdominal tenderness to palpation – otherwise WNL

WHAT NOW? List 5 initial steps in the management of this patient List 5 differential diagnoses List 5 tests or interventions

SEPSIS A continuum … from SIRS Sepsis Severe Sepsis Septic Shock DEATH

SIRS Requires 2 out of 4 of the following: Temp >38.0 or <36.0 HR>90 RR>24 or PaCO2<32 WBC OR bands >10%

SEPSIS 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...

SEVERE SEPSIS Sepsis + organ failure OR lactate level >4 CNS Pulmonary (ALI) Heme (coags & platelets) Liver ( bili) Kidney (AKI) Circulatory system

SEPTIC 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 25mmHg below baseline

EPI/PATH OF SEPSIS 10 th leading cause of mortality 750,000 hospitalizations/year Most common sources: Lung Abdomen GU Skin/soft tissue CNS

ED 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

ED 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

>50% collapse during inspiration indicates low CVP/likely fluid responsiveness

TREATING 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

EGDT ALGORITHM

THE ABCs of EGDT “Are you OK?” Rapid identification of the septic patient Initiating diagnostic steps immediately (IV, monitor, early lactate measurement)

THE 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

THE 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

THE 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

THE 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!)

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 Circulation CVP 8-12 (must measure thru central line; also use IVC) Uop >0.5 cc/kg/hr MAP mmHg

ADJUNCT 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

PATIENT 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

BACK 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??

SEPSIS: TIME=MORTALITY