Sepsis: The Basics (Definitions and Bundles)

Sepsis

I’m currently writing up a short presentation about how the ARISE Study and PROMISE Trials have affected our care of septic patients in the emergency department. Understanding sepsis requires a good understanding of the definitions,  and sometimes these definitions have a way of escaping us during day to day practice. So I thought I’d put it up here as well, for the benefit of those, who like me, have the memory span of a gnat.

Definitions: 

SIRS (systemic inflammatory response syndrome) is defined as having 2 or more of the following:
1. Temperature >38 C or <36 C
2. Pulse Rate >90/min
3. Respiratory Rate >20/min or PaCO2 <32 mmHg
4. White Cell Count >12 or >10% immature band forms

Sepsis is SIRS (systemic inflammatory response syndrome) with confirmed or presumed infections

Severe Sepsis is sepsis with organ dysfunction

Septic shock is defined as sepsis with refractory hypotension
1. Hypotension is defined as SBP <90 or MAP <70
2. Refractory means that hypotension persists after 30 mL/kg crystalloid
3. Vasopressor dependence after adequate volume resuscitation

Care Bundles: 

Surviving Sepsis 2012 consists of 2 bundles of care, the first being completed within 3 hours and the second within 6 hours.

Before 3 hours bundle:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L

Before 6 hours bundle:
1. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
2. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
3. Measure central venous pressure (CVP)
4. Measure central venous oxygen saturation (ScvO2)
5. Remeasure lactate if initial lactate was elevated

Lung Point Sign in Pneumothorax

lungpoint

The lung point is an ultrasound finding in cases of pneumothorax, where there is the fleeting appearance of a lung pattern (evidence of lung sliding) which is replaced by a pneumothorax pattern (absent lung sliding and exclusive horizontal lines) in a specific location of the chest wall. Essentially this the transition point between normal lung and air. It has an overall sensitivity of 66 % and a specificity of 100%, making this finding diagnostic if seen.

Reference: The “lung point”: an ultrasound sign specific to pneumothorax.

CPG Summary: The Diagnosis & Management of Bronchiolitis

The current Clinical Practice Guidelines by the American Academy of Pediatrics (AAP) has been rather consistent that care providers should let bronchiolitis run its course, unless the child is showing signs of respiratory distress, diminished alertness or poor feeding. This slider is a summary of the guidelines that I think are important in bronchiolitis management in the Emergency Department.

Note:  ‘Mousing’ over the image stops the scrolling.

Reference : Ralston, Shawn L., et al. “Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis.” Pediatrics (2014): peds-2014. http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742.abstract

It’s Back!

UNVERIFIED copy

After many, many years of arguing and lodging disputes with various domain registration companies, and thanks to some folks at the big boys, I finally have control of my one and only, single word top level domain. Yes that was a really narrow category and a really long sentence. I know it’s only a .org, but I’m thrilled that it’s finally back in my possession. It will automatically forward back to this site from now on until i figure out how best to use it. Such a wonderful day. :)

Still Doing It Wrong – Personal Protective Equipment Indecision 2014

IMG_6675 2(17).jpg

ppeposter1322I have given up on how many times the CDC has changed its guidance on Personal Protective Equipment for the EBOLA outbreak. I’m not going to bother explaining it because there is a really useful chart that explains it all.  Click on the chart to get a larger view. Some key points to note would be that no skin should be exposed and all health care providers are to be be double gloved.  After handling patient of bodily fluids, first glove needs to be wiped with disinfectant. It is then removed and the second glove wiped down. Then rest is as in the chart.

It also turns out that ‘doffing’ is actually a word.

The updated CDC guidance is located here.

Deliberate Small Moves

I TRAUMACHARGE3D1have been very deliberate about going slow with this blog. For the time being it will be part of my personal site. I haven’t decided fully what it will become, but i’m getting close to completing a draft plan. I was concerned about having the authenticity and the gravitas to do something like this, but I figured that as long as I write about things I’m comfortable preaching, then it should be alright. Incidentally, I was asked by a small Emergency Medicine blog to write for them. That was the fastest ‘no’ I have ever said. If it isn’t going to be my vehicle to my destination, I am going to say no. New policy ? Yes and  its already bearing fruit.

Cat Burglar!

This little Bengal has been robbing the cat food bowl for the past year. Finally had the time to catch him on video. This is why the cat food bill is so high!

EBOLA Update: Is Witholding Care Even Acceptable ?

Ebola

A horrible situation for patients. Withholding care when care is requested is a crime, especially when necessary safety precautions can be taken. Not doing it because of fear is tantamount to medical negligence.

Some U.S. hospitals weigh withholding care to Ebola patients (REUTERS)
The Ebola crisis is forcing the American healthcare system to consider the previously unthinkable: withholding some medical interventions because they are too dangerous to doctors and nurses and unlikely to help a patient.

Reference: http://www.reuters.com/article/2014/10/22/us-health-ebola-usa-interventions-idUSKCN0IB2OM20141022

EBOLA Update: United States Requiring Travellers from Affected States to Register Details

Ebola

The U.S. has put in place plans for travellers to have their details recorded upon arrival on U.S. soil. This still falls short of temporary border controls, a hot button issue for the President.

U.S. Plans 21-Day Watch of Travelers From Ebola-Hit Nations (NY Times)
The new federal rules take effect next Monday. All travelers who have visited Guinea, Liberia or Sierra Leone will be required to provide home and email addresses, telephone numbers and other contact details for themselves and at least one friend or relative.

Reference:

http://www.nytimes.com/2014/10/23/health/us-to-monitor-travelers-from-ebola-hit-nations-for-21-days.html?_r=0