EMGuidewire's Podcast

The EMGuideWire Team is visited by a prior crew member, Russell Trigonis, MD! Join them as they discuss how the patient diagnosed with Sepsis in your ED has their care continued in the ICU!

Pearls

• Start pressors with IVF (30-40cc/kg). NE at 7mcg/min peripherally can always be stopped, but better earlier than later.
• Increase NE until at 20mcg/min, if still hypotensive, then add a 2nd pressor like Vasopressin at 0.03units/min and 100mg Hydrocortisone Q8h.
• Start antibiotics early and identify source. CXR, US lungs/abd, UA, CT abd should all be considered.
• Procalcitonin is helpful for stopping abx. Doesn't change ED treatment.
• Don't order Vitamin C or thiamine in ED.

-Travis Barlock, MD

It it the end of Sepsis Awareness Month, but there is a BONUS Monday (Sept. 30th), so why not a BONUS episode! Join the EMGuideWire Team as they explore the challenges the children bring to this clinical condition. Let's review Pediatric Sepsis!

Pearls:

• Screening should be age adjusted. Identify severe sepsis. Treat w/early antibiotics, balanced fluid administration, and EPI if needed.
• SIRS in children must be age-adjusted. HR & RR > 2 standard deviations of nml; WBC age adjusted.
• Screen: high risk medical history + vital sign abnormalities (age based SIRS) require check of cap refill, mental status, and general appearance followed by a physician assessment.
• Identify: Severe sepsis = sepsis + organ dysfunction (CV/resp/neuro/renal/hepatic dysfunction). Order a lactate, CBC, CMP, and blood cultures, and consider CXR and UA. CRP is helpful for inpatient team.
• Higher lactate has higher mortality and is associated with septic shock.
• Treat: Start 20cc/kg bolus LR and reassess. Those with heart disease can't take anymore fluids after this, so only add pressors if needed. Continue to 40cc/kg and up to 60cc/kg total bolus prior to pressors for other patients.
• If still hypotensive, start 0.1 mcg/kg/min of EPI (peripheral or IO).
• Early antibiotics saves lives.
• LR is better than NS.

Summarized by: Travis Barlock, MD PGY-1 References:

• Emrath ET, Fortenberry JD, Travers C, McCracken CE, Hebbar KB. Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis. Critical Care Medicine. 2017 Jul;45(7):1177-1183

• Ventura et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Critical Care Medicine. 2015; 43(11):2292-302

Join the EMGuideWire Crew as they continue to explore the High Yield management points for Sepsis!

This week's Episode's Pearls:

• Early fluids save lives. Give 40cc/kg bolus in first 3 hours. But don't fluid overload the patient!

• U/S the heart and lungs: A plethoric IVC, immobile mitral valve, and B lines on the lungs should urge you to be more cautious with fluids.

• Goal in all patients is to establish an adequate MAP ASAP! Fluids + Vasopressors!

• Vasopressor titration algorithm: First low dose NE (10mcg/min); if still in shock, initiate vasopressin (0.04 units/min); do not wait on providing vasopressin if EPI is readily available (establish MAP ASAP!).

• Initiate vasopressors early with fluids! NE can be initiated peripherally, so don't wait for a central line!

• Only consider dopamine for absolute bradycardia.

• Methylene blue is a last resort consideration.

• Vasopressors are commonly needed at high doses (i.e., 1mcg/kg/min EPI).

• Hydrocortisone 50-100mg for patients with septic SHOCK, not sepsis alone.

Summarized by: Travis Barlock, MD PGY-1

References:

• Farkas J. PulmCrit- Epinephrine challenge in sepsis: An empiric approach to catecholamines. EMCrit Project. https://emcrit.org/pulmcrit/epi/. Published August 21, 2018. Accessed September 17, 2019.

• Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.

Join the EMGuideWire crew once again for this month's series on Sepsis in honor of Sepsis Awareness month. Episode 3 will cover antibiotic use and selection.

Antibiotics for Sepsis

• Take a history and perform a chart biopsy first! Consider past infections, bug susceptibilities, healthcare acquired vs. community acquired infection, foreign travel, and comorbidities.
• Always check local antibiogram and prior culture results.
• Septic shock - Start broad spectrum antibiotics within 1 hour.
• Stable patient - find the source! UA, CXR, and a good skin exam are fast and can help guide antibiotic choice. Remember some patients need surgical management!
• Antibiotic choice in septic shock.
• • 1st agent - Piperacillin/Tazobactam (covers GP/GN + Pseudo)
  • 2nd agent - Choose based on patient characteristics
  • • Ceftriaxone - simple community acquired infections.
    • Vancomycin - covers MRSA.
    • Meropenem - use for patients with a hx of ESBL.
    • Flagyl + cefepime/meropenem - Use for intra-abdominal infections.
    • Clindamycin - Useful for skin infections (toxin suppression).
    • Cefazolin - IV line infections, endocarditis, soft tissue infections w/o MRSA (covers MSSA, GAS, GBS).

Summarized by: Travis Barlock, MD PGY-1

References:

• Alam N et al. 2018. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet. Respiratory Medicine. 6(1): 40-50.
• Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.

Sepsis Awareness Month continues! Join the EMGuideWire Team as they dive into the issues of Fluid selection for resuscitation.

1) Fluids are not all created equal. Use balanced fluids for large volume resuscitation.

2) Lactated Ringers is likely the best choice available in the ED. Plasmalyte is also a good option, if you have it.

3) You can start low dose vasopressors peripherally if you need to, rather than continuing to flood patients with fluids for hypotension.

Join the EMGuideWire Team,from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. In this first episode, the team will discuss the definitions of Sepsis.

Pearls:

• Sepsis is a dysregulated systemic inflammatory response to infection causing intravascular inflammation, tissue ischemia, cytopathic injury, and dysregulated apoptosis.
• SIRS terminology is now outdated. Current terminology is "Sepsis" (SIRS, suspected source, end organ damage) and "Septic Shock."
• Septic shock: SBP 2 after fluids.
• qSOFA = RR > 22, AMS, SBP
• Epidemiology: 164,000 cases annually. Bacterial etiology most common. Mortality for sepsis and septic shock is 10 and 40% respectively.

Summarized by Travis Barlock, MD PGY-1

References:

• Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. New England Journal of Medicine 2003; 348:1546.
• Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:762.

Join the EMGuideWire Team, from Carolinas Emergency Medicine Residency Program in Charlotte, NC, as they explore the critical core concepts on the important topic of Sepsis. Over the course of September, Sepsis Awareness Month, the group will cover a variety of high-yield points to help make us all better at recognizing, evaluating, and managing Sepsis. This is the Intro to the month. Follow us every week for more information... and maybe even get a Bonus 5th episode as a reward!

Join the EMGuideWire team from Carolinas Medical Center Emergency Medicine Residency Program as they discuss the challenging condition of thyrotoxicosis and thyroid storm! From evaluation to management, this critical state requires our respect and attention!

Join the EMGuideWire crew as they explore the various skin and soft tissue infections that are commonly encountered and considered in the Emergency Department. While some may be minor, like furuncles, others can be life-threatening, like necrotizing fasciitis.

Join the EMGuideWire Team as they explore the Basic Principles that must be considered when managing a pediatric airway. Knowledge of the anatomic and physiologic differences that exist between adults and children is paramount! Assuming that all pediatric airways are going to be "difficult" may help keep us prepared.