The EM Educator Series: When sepsis care becomes not so straightforward

Author: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. We are working on retroactively doing this for the past posts as well. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Mini-Cases:

# 1: A patient with ESRD on hemodialysis presents with dysuria, frequency, and suprapubic pain with fever. VS include T 38.2C, HR 112, BP 88/48, RR 24, and Sats 98% on RA. UA is significant for large leukocyte esterase, nitrates, and WBCs.

# 2: A patient with liver transplant presents with fever, cough, chills, and generalized weakness. VS include T 78.4, BP 95/57, RR 19, Sats 91% on 2L. CXR shows RML infiltrate.

Considerations:

1. How do you incorporate sepsis metrics and criteria with the patient in front of you?
2. Why is my sepsis patient not improving with resuscitation?
3. How does sepsis evaluation and management change with ESRD?
4. How does sepsis evaluation and management change with ESLD?
5. How does sepsis evaluation and management change with CHF?
6. How does sepsis evaluation and management change with pulmonary hypertension?
7. How does sepsis evaluation and management change with valvular heart disease?
8. How does sepsis evaluation and management change with transplant? Does the specific transplanted organ affect your management?

Suggested Resources:

• https://emcrit.org/pulmcrit/sepsis-myths/
• http://www.emdocs.net/the-sepsis-patient-not-improving-after-iv-fluids-and-resuscitation-what-should-be-considered-how-can-we-improve/
• http://rebelem.com/occult-causes-of-non-response-to-vasopressors/
• http://www.emdocs.net/the-dangers-of-over-resuscitation-in-sepsis/
• http://www.emdocs.net/sepsis-comorbidities-management-strategies/
• http://www.emdocs.net/emdocs-cases-sick-esrd-patient/
• http://www.emdocs.net/approach-to-the-sick-cirrhotic-patient/
• http://www.emdocs.net/ed-management-heart-failure-pearls-pitfalls/
• http://www.emdocs.net/the-crashing-pulmonary-hypertension-patient/
• https://emergencymedicinecases.com/pulmonary-hypertension/
• http://www.emdocs.net/acute-valvular-emergencies-pearls-pitfalls/
• http://www.emdocs.net/transplant-emergencies-part-i-infection-rejection-and-medication-effects/
• http://www.emdocs.net/transplant-emergencies-part-ii-organ-specific-complications/