SEPSIS and CRASH SYNDROMES IN THE ED

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SEPSIS and CRASH SYNDROMES IN THE ED

• Robert M. Rodriguez MD
• Clinical Professor of Medicine, UCSF
• Department of Emergency Services, San Francisco
  General Hospital

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Disclosure

• I do not have an affiliation (financial or
  otherwise) with any commercial organization that
  may have a direct or indirect connection to the
  content of my presentation.

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1) Treat sepsis in the ED with the same urgency
and organization as acute trauma, acute MI or
acute stroke. 2) Look out for CRASH syndromes
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Magnitude of Sepsis

• 750K patients400K start in ED
• 16.7 billion
• Mortality about 30-40
• Among 30 day survivors reduces lifespan about 4
  years

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Surviving Sepsis Campaign Guidelines

• Goal decrease mort 25 by 2009
• Crit care and infectious disease experts
• 11 international organizations
• Systematic reviews of literature
• Modified Delphi method to grade recs
• Updated 2008

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Systemic Inflammatory Response Syndrome (SIRS)

• Two or More
• 1) T gt 38 or lt 36
• 2) HR gt 90
• 3) RR gt 20 0r Pco2 lt 32
• 4) WBC gt 12 or lt 4 or bands gt 10

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SIRS

• Not specific/many causes (infection, burns,
  trauma, pancreatitis)
• Too sensitive (most ED and all ICU patients)
• No correlation with mortality

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Sepsis

• SIRS with infection (documented or presumed)

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Severe Sepsis

• Sepsis with organ dysfunction, hypoperfusion
  abnormalities or hypotension
• Hypoperfusion abnormalities lactic acidosis,
  oliguria or altered mental status

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Septic Shock

• Severe sepsis plus hypotension not responding to
  fluid bolus (usually 2 liters)

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Mortality Progression Sepsis to Septic Shock

• Mortality
• 45
• 20
• 15

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Multiple Organ Dysfunction Syndrome (MODS)

• Final common pathway
• 1 cause of death in ICU
• Resuscitate early and aggressively to prevent MODS

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MODSSpecific Organs

• Pulmonary - ARDS
• Renal - ATN
• Hepatic - Increased bili, LFTs
• GI - Ileus
• Heme - Coagulopathy, anemia, thrombocytopenia

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Resuscitation Movie Line 1

• Ha ha! You fool! You fell victim to one of the
  classic blunders! The most famous is never get
  involved in a land war in Asia, but only slightly
  less well-known is this never go in against a
  Sicilian when death is on the line! Ha ha ha ha
  ha ha ha! Ha ha ha ha ha ha ha!

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Diagnose and Stage Sepsis Early

• Diagnose sepsis promptly
• Stage it Risk stratify patients
• WHY? Prognosis and therapies depend on this

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MEDS score

• Prospective ED cohort of adults w/ Blood Cultures
  sent from ED
• Derivation/validation mort prediction rule
• Major Factors
• Tachypnea, hypoxia, AMS, Shock
• Thrombocytopenia, Bands gt 5
• Terminal CA, Nursing Home
• Pneumonia

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Lactate levels

• ED lactate good predictor of mortality
• gt 4 6 times mortality
• ED clearance (first 6 hours) of critical care
• associated with better sepsis survival
• Trzeciak S. Int Care Med 2007 970-77.

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C Reactive Protein

• Prospective cohort of critically ill, septic
• High (gt10) on admission--increased mort
• If remains gt 10 after 48 hours, 61 mort versus
  15 if decreases

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Therapy Antibiotics

• Broad for undifferentiated sepsis
• Give ASAP (within an hour for septic shock)
• Prepared regimens in ED
• Dont worry about renal failure dosing

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Goal Directed Therapy--Increasing O2 Delivery

• HUGE controversy in ICU
• Theory Increasing DO2 VO2 will prevent MODS
  and mortality
• No overall benefit in sepsis
• Perhaps benefit in surgical patients (Trauma and
  major surgery)

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Early Goal-Directed Therapy

• Perhaps ICU is too late
• Six hours goal-directed therapy in ED decreased
  absolute mortality 16
• NNT 6
• SVO2 catheter
• Can use ABG from distal port

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Bottom Line Pressors for Sepsis

• Norepinephrine prob best
• Dopamine---second line
• Consider adding low dose (0.03 u/min) fixed dose
  vasopressin if MAP lt 65
• Consider dobutamine if volume replete and low CO
  (low SvO2)

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Low Dose SteroidsAnnane

• Hydrocortisone (100 mg TID x 7 days)
  Fludrocortisone
• Improved survival NNT 7
• Reverses refractory hypotension in septic shock
• May also decrease PTSD
• Annane D. JAMA 2002 862-871.

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Hydrocortisone Annane vs Corticus

• Annane group sicker, more medical patients
• Corticus fewer non-responders to ACTH
• Steroid given later (within 24-72 hours)

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Bottom Line on Steroids

• Give hydrocortisone (50 q 6) for vasopressor
  resistant septic shock
• No Cosyntropin Stim test
• No fludrocortisone if use hydrocortisone If use
  Dex need fludrocortisone

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Anti-Cytokine Therapy

• Theory Blocking the excessive cytokine response
  will quell the deleterious inflammatory cascade
• Multiple failed trials of various agents

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Activated Protein C

• Modulates inflammation and improves
  microcirculatory perfusion
• NNT 16
• Expensiveapproximately 6-8K
• Increased bleedingmostly around large central
  lines

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Bottom Line on Act Prot C

• Only APACHE II gt 25 (2 or more organ failures)
• No kids
• Probably not an ED drug
• Make decision with your intensivist

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Other Sepsis Recs

• Low tidal volume mech ventilation
• No benefit of bicarbonate for acidosis from
  sepsis
• No benefit of colloid over crystalloid

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Discarded Tight Glucose Control

• Former guideline was tight control
• Based on post-cardiothoracic surgery study
• Newest guidelines will throw this out

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New Stuff--Glucose

• NICE Sugar study
• 81-108 vs lt 180
• Multicenter, 6104 patients
• Increased mortality with tight control regardless
  of whether surgical or medical
• 6.8 of intensive group had severe hypoglycemia
  (lt40)

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New Stuff --Etomidate

• Corticus study showed increased mortality when
  etomidate used for intubation
• Increased ICU stay and vent days in randomized
  trial
• Other studies not so clear
• Hildreth AN. J Trauma 2008 573-79

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Bottom line Etomidate

• Use alternatives to etomidate when possible
  (Ketamine, Fentanyl Versed)

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Crash syndromes

• Meningococcemia
• Neutropenia
• Necrotizing fasciitis
• Asplenic pneumonia
• Liver failure and anything
• MRSA pneumonia

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Necrotizing Fasciitis
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Necrotizing Fasciitis

• IDUblack tar heroin
• Progresses quickly sicker than appear
• Many Afebrile
• Tachycardia
• Elevated WBC
• Hyponatremia

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Necrotizing Fasciitis

• Hard to see gas on plain Xray---CT better
• Emergent surgical disease
• Aggressive fluid resuscitation
• Clindamycin

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Asplenia

• Encapsulated organisms Pneumococcus
• Purpura
• Routine pneumonia but progress quickly

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Clues History, midline scar, Howel Jolly Bodies
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Asplenia Recs

• Antibiotics the minute they hit the door
• Admit to higher level of care
• Pneumovax immunization in the ED

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Liver Failure

• Majorly immunocompromised
• Lactate levels spuriously high
• Thrombocytopenia
• Decreased urine output

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Difficult fluid management
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Liver failure recs

• Invasive monitoring
• Only time in which colloid may be better
• Resuscitate to urine output
• Watch for abdominal compartment syndrome

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MRSA Pneumonia

• Community acquired
• Young patients Adolescents
• Mimics flu
• Hypoxia, tachycardia
• Hemoptysis

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MRSA Pneumonia

• High suspicion
• Admit to higher level of care
• Prompt Vancomycin, Linezolid

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Resuscitation Movie Line 2

• Hitchhiker You heard of this thing,
• 8-Minute Abs? Ted Yeah, sure, 8-Minute Abs.
  Yeah, the exercise video. Hitchhiker Yeah, this
  is going to blow that right out of the water.
  Listen to this 7... Minute... Abs.

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Develop multidisciplinary sepsis programs

• ED interface with ICU
• Early (ED) non-trauma shock recognition
• Shock team (like trauma team)
• Protocols (EGDT)

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Sepsis Programs/Teams

• Boston Pathway of early empiric Abx, EGDT, APC,
  hydrocortisone, lung protective ventilation
• Start pathway in ED
• Mortality 20 vs historical 29

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Bottom line

• Treat sepsis like trauma!!
• Identify and stratify (lactate levels)
• Aggressive fluids and antibiotic regimens
• Look out for CRASH syndromes
• Develop protocols and teams

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Resuscitation Movie Line 3

• Hamburgers The cornerstone of any nutritious
  breakfast.

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Other Sepsis Recs for ED

• NE or dopamine first-choice pressors
• Patients with pressors should have arterial line
• Refractory shock after pressors and
  fluidsconsider vasopressin (fixed dose)

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