1. Case report A 26 year old man came to hospital by ambulance with girlfriend, very high fever >40C, and unconscious, dyspnea, tachypnea, So what do you do?

2. Remember ABCDE in sepsis and other emergencies A-airway, B-breathing, check C-circulation D-disability E-exposure

3. Septic shock basic management -make sure airway is patent, intubate if needed -IV access, if 3 tries fail within 5 mins, IO access -give fluids due to hypotension -once enough fluids, can use vasopressors like norepinephrine or dopamine -take blood samples, and culture ASAP - x ray the lungs, check other organ functions -give antibiotics, empiric within 60 mins, change when microbe is known, in this case what would you give -check ABCDE, -keep in intensive care unit under observation

5. History + basic physical exam -Heart rate, 110/min -respiratory rate, 25/min, -PaCO2 30mmHg, PaO2 60 mmHg -cold we skin, -hypotension 80/60 -x ray showed diffused pneumonia with abcess -GF said he had an episode of bacterial pneumonia a weeks ago, received augmentin from GP but didn’t help, other wise no other problems, was always healthy

6. SIRS Systemic inflammatory response syndrome [2] Temp 38 °C (100.4 °F) HR>90/min [2] RR>20/min or PaCO2<32 mmHg (4.3 kPa) WBC 12x10 9 /L (>12,000/mm³), or 10% bands - Diagnosis of SIRS when 2 or more are met

7. Sepsis, septic shock, if there is suspected or confirmed bacteremia then sepsis is diagnosed, Severe sepsis is diagnosed with 1 or more end organ dysfunction, examples: liver, kidney failure, altered mental status, elevated serum lactate >2mmol/L if hypotension (<sBP90, or <mBP65) then septic shock is diagnosed, manage accordingly Serum lactate more than 4mmol/L

8. Antibiotics Imipenem, Meropenem, Tigecycline Piperacillin-tazobactam, Sulbactam-ampicillin Moxifloxacin Cephalosporin, aminoglycoside, vancomycin, if anarobes suspected metronidazole, If beta lactam allergic use levofloxacin or aztreonam instead of cephalosporin Correct the antibiotic therapy when culture comes back In this case it was MRSA that’s why the augmentin didn’t work for community acquired pneumonia, so which ones we use?