sepsis

Cholangitis should be considered in patients with undifferentiated sepsis. Ruling in or out the diagnosis of cholangitis is no longer based on clinical exam alone. The addition of imaging and bloodwork to the clinical exam are much more reliable. Resuscitation, antibiotics and consultation for early biliary decompression are the mainstays of cholangitis treatment.

In the midst of flu season with patients flooding your ED with similar presentations, what else do you need to consider? This post examines mimics of the flu, with pearls and pitfalls.

There is no data driven or evidence based research that demonstrates time to antibiotic administration in severe sepsis/septic shock as a reliable quality metric. Sepsis is a heterogeneous spectrum of illness and as such, one size does not fit all.

Sepsis is a common, serious medical condition diagnosed and managed in the ED. What do EM providers miss, and how can we improve?

In 2002, a new standard of care was established when the Surviving Sepsis Campaign (SSC) highlighted the importance of recognizing sepsis and initiating treatment early. Once we find that a patient meets Systemic Inflammatory Response Syndrome (SIRS) criteria with a source of infection, rapid and appropriate treatment including resuscitation is a must. Early fluid resuscitation is necessary for septic patients, but there is large variance on the aggressiveness of fluid resuscitation. There is disagreement amongst the experts on the total amount of fluids that should be administered and the end points for resuscitation. We must ask ourselves, at what point does our aggressive resuscitation actually start to harm our patients?

Does your choice of fluids for resuscitation in sepsis matter? Multiple studies have been performed to determine whether septic patients benefit from colloid versus crystalloid IV fluids, and other studies have specifically looked at the different kinds of fluids within those specific groups. Debate now exists as to which fluid will improve patient outcomes.

The CMS guidelines for sepsis…What are the measures you need to meet, and are they supported by the literature?

A great deal of literature exists on sepsis and providing state of the art care in the ED. As EM physicians, we pride ourselves on resuscitating sick patients, and we are well aware that septic patients can rapidly decline clinically. Finding the source and providing appropriate antibiotics, adequate preload with IV fluids, and vasopressors if necessary are key components. The SIRS criteria are our first line of defense in the early identification of sepsis. But, it is important to recognize that just because a patient has multiple SIRS criteria, they may not actually be septic.

You are in the midst of caring for a 62 year-old male who is tachycardic with HR 120, BP 88/42, T 101.2 oF, RR 26, and SpO2 98%. He was brought in by EMS for fever and myalgias, and with one look at his vital signs, he triggered the protocol for SIRS.

Your initial exam showed similar vital signs, with dry mucous membranes but otherwise normal HEENT exam, clear lungs, normal mental status, nontender abdomen, normal skin and genitourinary exams, and normal extremities/back. Due to his vital signs and SIRS criteria, you were concerned and ordered CBC, RFP, LFT, lactate, blood cultures, urinalysis/culture, and chest xray. You started 1 L NS, and his VS did not improve.