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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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