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: 105/54 110 24 100.4 O2 sat 96%
 PE: significant for mild lethargy (but she is A&Ox4);
mild diffuse abdominal tenderness to palpation –
otherwise WNL
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<4000 or >12000 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 <65 mmHg or >25mmHg below baseline
EPI/PATH OF SEPSIS
 10th 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 65-90 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