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Sepsis

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Topic updated on 09/02/17 12:41pm

Snapshot
  • A 33-year-old baker presents to the ED with new onset change in mental status.  When you ask him what his name is, he says Richard Nixon, and says that it is May 1942.  On physical exam you note a very confused young man.  His temperature is 102 deg F (38.9 deg C) blood pressure is 98/65 mmHg, and respirations are 25/min.
Introduction
  • Systemic Inflammatory response syndrome with a documented infection
    • systemic inflammatory response syndrome (SIRS) requires at least 2 of the 4 following criteria be met (no longer used, important to be aware of) 
      • body temperature less than 36 deg C or greater than 38 deg C
      • HR > 90 bpm
      • respiratory rate greater than 20/min
      • WBC count less than 4,000 or greater than 12,000 OR greater than 10% bands
    • quick SOFA - new guideline for diagnosing sepsis (2016) that has replaced SIRS
      • new or worsened mentation
      • respiratory rate greater than or equal to 22/min
      • systolic blood pressure less than or equal to 100 mmHg
  • Gram-positive shock results from exotoxins leading to fluid loss
    • common etiologies are staph and strep
  • Gram-negative shock is caused by endotoxin by bacteria
    • such as E. Coli, Klebsiella, Proteus, Pseudomanas
  • Group associations
Group Association
Neonates
  • Group B Strep, E. coli, Klebsiella
Children
  • H. influenzae, pneumococcus, meningococcus
Adults
  • Gram positive cocci, aerobic bacilli, anaerobes
IV drug users
  • S. aureus
Asplenic patients
  • Pneumococcus, H. influenzae, meningococcus
Line associated infections
  • Skin flora (e.g., coagulase negative staph)
 
Presentation
  • Symptoms
    • abrupt onset of fever (15% have hypothermia) and chills
    • often associated with hyperventilation and altered mental status
  • Physical exam
    • tachycardia
    • hypotension
    • tachypnea
  • May initially have warm skinned extremities that progresses to cold skin extremities
  • Petechiae or ecchymoses suggest DIC, which ocurs in 2-3% of the cases
  • In neonates, patient symptoms may be vague or absent. 
Evaluation
  • Laboratory findings include
    • neutropenia or neutrophilia with increased bands
    • thrombocytopenia occurs in 50% of the cases
    • coagulation studies and possible a DIC panel
  • Any neonate with a temperature of 100.4 deg F or higher should receive a full work-up:
    • blood and urine culture, UA, CBC, LP
Treatment
  • Patients often require ICU admission
  • Treat with IV fluids, pressors, empiric antibiotics
  • Send blood cultures
  • Remove all existing catheters, IV lines, central lines, culture


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Qbank (3 Questions)

TAG
(M2.ID.1) A 5-day-old full-term infant presents in the winter with decreased activity and a temperature of 100.5 F. His mother states that he has been fussy during breastfeeding and has some nasal discharge. His exam is notable for decreased activity, yellow sclerae, and subcostal retractions with nasal flaring. Which of the following is the most appropriate next step for the care of this infant? Topic Review Topic

1. RSV and influenza testing
2. Fluids and monitoring
3. CBC, UA, urine and blood cultures, lumbar puncture
4. CBC and sputum culture
5. Empiric antibiotics, followed by blood cultures and lumbar puncture

PREFERRED RESPONSE ▶
TAG
(M2.ID.57) An 87-year-old female presents to the emergency department for intermittent fevers over the last two days. A caretaker at her nursing home reports that the patient has had new-onset incontinence and foul-smelling urine during the past week. Which of the following combinations of laboratory results and vital signs would meet the criteria for a diagnosis of systemic inflammatory response syndrome (SIRS) in this patient? Topic Review Topic

1. T 36.7 C, HR 82 bpm, BP 125/85 mmHg, RR 12, O2 sat 97%, WBC 8,000 with 6% bands
2. T 38.5 C, HR 88 bpm, BP 125/85 mmHg, RR 18, O2 sat 92%, PaCO2 36 mmHg
3. T 37.8 C, HR 104 bpm, RR 22, O2 sat 96%, PaCO2 30 mmHg, WBC 5,500 with 9% bands
4. T 36.2 C, HR 89 bpm, BP 100/60 mmHg, RR 14, O2 sat 99%, WBC 12,500 with 11% bands
5. T 37.0 C, HR 76 bpm, BP 112/76, RR 16, O2 sat 97%, numerous bacteria on urine microscopy

PREFERRED RESPONSE ▶
TAG
(M2.ID.77) A 38-year-old male suffers a severe motorcycle accident and is admitted to the intensive care unit. As part of his care, he receives a central line. One week into his hospitalization he becomes septic, with a line-associated infection as the suspected cause. If this is true, which of the following is the most likely organism cultured from his blood? Topic Review Topic

1. P. aeruginosa
2. S. aureus
3. S. epidermidis
4. S. pyogenes
5. K. pneumoniae

PREFERRED RESPONSE ▶


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