Barounis     Septic Shock

Early intervention in the ED affects the trajectory of sepsis illness throughout the hospital course.

The mortality rate of septic shock is still @20%.  Death from sepsis is due to multi-organ dysfunction syndrome.  Early intervention can prevent the development of multi-organ dysfunction syndrome.

There has been no single clinical intervention that has been shown to improve mortality from sepsis.  However, sepsis mortality has decreased over the last decade.   This is likely due to earlier diagnosis and more attentive care of sepsis patients.

SIRS criteria are insensitive for identifying all sepsis patients. There is no definitive biomarker to identify sepsis.  Clinical evaluation and judgment are the best tools to identify sepsis.

Encephalopathy=acute brain failure.   It is a sign of sepsis.

Other signs indicate sepsis: Hypotension, tachycardia, oliguria, acute brain failure, poor peripheral perfusion, acidosis, and respiratory distress.

The management of hypotension is an emergency.

In all large RCT’s on sepsis the average volume of fluid that a septic patient received was 4 liters.  Most septic patients will likely need somewhere close to that volume over the first day or so.

Dave showed an echo in which the LV was hyper-contractile with the walls of the LV “kissing” in systole.  If the walls of the LV are touching in systole, the patient is likely hypovolemic or severely vasodilated.

You have to trend lactates every 4 hours in septic patients.

Chloride (normal saline) is a renal toxin and has been shown to increase the incidence of AKI in septic patients. Dave prefers LR because it is safe and more physiologic.  LR has potassium in it but it is still OK in patients with hyperkalemia.  

Dave made the point that in a recent study, healthy volunteers receiving 2 liters of NS had a transient decrease in their GFR.  Elise comment: I am not so worried about NS in a patient who needs 1-2 liters.  If a patient needs 3 or 4 or 5 liters you need to be giving LR. 

Dave’s first-line pressor is norepinephrine.   If a second pressor is needed he uses vasopressin.  If you have not corrected hypotension with these two pressors you need to take cognitive stop and say to yourself,  “What the heck is going on?” 

Motzny Study GuideEMS

 Unfortunately I missed the majority of this excellent lecture.

Bioweapons

Acute Radiation Sickness.   Most commonly noted indicator of poor prognosis is low total lymphocyte count on CBC.

Set up your cammand center for a HAZMAT response up-wind and up-hill.

The most common barrier to an effective disaster response is problems with communication.

Nejak   Oxygen Delivery

Dan did an awesome job discussing and demonstrating various oygen delivery devices available in the ED.

April Kennedy/Felder/Urumov     Dental Procedure Lab

Much Thanks to April Kennedy DDS for leading an outstanding dental procedure lab!