Sim Lab 2 - Septic Shock

Diagnosis/Assessment:

Septic Shock


Chief Complaint: 

Altered Mental Status


HPI/Patient Presentation:

76yo female presents to ED via EMS from a nursing home after being found to have altered mental status by the staff. ALS was unavailable and pt. was brought in BLS. Transport time was 5 minutes. As a result, IV access has not been established. (only given if asked for by team leader: accucheck= 80)


PMH:

A. Fib - warfarin 4mg qd

HTN - HCTZ 25mg qd

CAD - ASA 81mg qd


Monitor and Vital Signs:

Monitor: atrial fibrillation. Degenerates to VT if students take too long to start fluids and manage the patient appropriately.

Vitals:

  1. initially unstable
    1. BP: 68/12
    2. HR: 132
    3. RR: 24
    4. O2%: 78%
    5. Temp: 102.3
    6. glucose: 80 (remains 80 throughout scenario)
    7. VS remain the same until norepi is started. If norepi isn't started after 10 minutes put the patient into VT.
  2. after 5 minutes of 2L NSS running wide open, and NRB at 30 lpm:
    1. BP: 76/20
    2. HR: 128
    3. RR: 20
    4. O2%: 86%
    5. Temp: 102.3
  3. after Norepi (or other appropriate pressor) drip is started and ran for a few minutes:
    1. BP: 96/50 (MAP ~65)
    2. HR: 116
    3. RR: 16 (pt. fatiguing, sternal retractions present)
    4. O2%: 82%
    5. Temp: 102.3
  4. if patient is managed INAPPROPRIATELY: 
    1. BP drops to 40/0 and pt. enters pulseless VT until ACLS protocol followed correctly and the team manages the patient appropriately

Physical Findings:

  • Mental Status: AOx0, not following commands appropriately, verbal response is to pain only, eyes open only to pain
  • HEENT: NC/AT, PERRLA
  • Cardiac: tachy, a. fib, otherwise normal
  • Respiratory: rales present in right lung bases/posterior lobe
  • Neuro: reflexes normal, patient not following commands appropriately, cannot perform FAST evaluation for stroke.
  • Rectal: hemoccult negative

Diagnostics/Management Sequence:

  1. assess mental status and obtain VS, expose patient, obtain 2 large bore IVs.
  2. start 2L NSS wide open. Place patient on NRB 30 lpm. Simultaneously perform physical exam and/or POC U/S. Obtain 12-lead.
  3. consider placing arterial line for continuous BP monitoring
  4. Once rales heard, order stat portable CXR, unless dx made on U/S
  5. after 5 minutes repeat VS (VS the same unless norepi started) should at least consider starting norepinephrine.  
  6. once POC U/S or CXR is interpreted and pneumonia is Dx'd:
  7. Draw blood cultures
  8. start patient on broad spectrum ABX: cefepime 2g + Azithromycin 500mg + Vancomycin 2g (20mg/kg) because this pt. is presenting from a nursing home. (source: EMRA ABX app 16th edition)
  9. Once BP rises sufficiently, intubate patient. Confirm ETT placement with auscultation in 5 spots, CXR. Once CXR confirms placement, start sedation drip, place OG tube and foley catheter.
  10. Order: CBC, CMP, lactate, PT/INR, ABG, VBG, troponin.
  11. Consider CT head non-contrast to r/o stroke if pt's INR returns subtherapeutic/very supratherapeutic

Right Lung:

Left Lung:

Pertinent Diagnostics Results:

  • POC U/S (more specific and sensitive than CXR for pneumonia, see sources below): Lung windows show air bronchograms and consolidations in Right 6-9 intercostal spaces. Left lung windows are clean.  cardiac windows and FAST windows normal.
  • CXR (link to image: pneumonia in right posterior and lower lobes. ø pneumothorax, rib fractures, cardiomegaly, or pleural effusion, trachea midline (if taken post intubation, cxr would show ETT in proper position: link to a normal ETT placement CXR (ignore the rest of this cxr for this case).
  • CT Head non-contrast: no acute intracranial pathology (no stroke, no bleed)
  • EKG: tachy a. fib, ST depressions w/ T wave inversions in lateral leads
  • Lactate: 9.2
  • WBC: 30,000
  • Hgb/Hct: normal
  • CMP: AG of 25 (Na 140, Cl 100, HCO3 15) K is 4.0. Cr is 1.6
  • PT/INR: 2.8
  • ABG: 6.9/33/70/15
  • Troponin: 0.06 (reference is <0.04 but this is possibly due to AKI; trend troponins before activating cath lab)
  • UA: grossly wnl

Take-Home Points:

  • sepsis= SIRS + source
  • severe sepsis= sepsis + end organ damage (elevated Cr, LFTs, Troponin)
  • septic shock= severe sepsis + hypotension and/or lactate ≥4
  • two most common sources of sepsis in the elderly= pneumonia and urinary tract infection (but don't forget about meningitis, esp. for peds and immunocompromised patients!)
  • septic shock requires immediate IV fluids, at least 2L in first 6 hours for all septic patients. Obviously more if pt. is in septic shock but be careful not to flood the patient if they have concomitant CHF.
  • Norepinephrine is the pressor of choice in septic shock (source)
  • Norepinephrine should be considered early in sepsis and especially in patients presenting with profound septic shock
  • lung ultrasound is more sensitive and specific than CXR for pneumonia (sources below). Two great resources for learning to Dx a pneumonia via lung U/S: The ultrasound podcast on lung ultrasound part two and this ultrasound of the week post.
  • blood cultures should be drawn before ABX administered to septic patients so that abx sensitivities can be acquired
  • broad spectrum abx should be given for patients with presumed or confirmed sepsis as soon as possible (but after cultures are drawn)

Sources:

EMRA ABX App

Landmark articles on Sepsis care: 

  1. ProCESS Trial [PMID 24635773]
  2. Arise Trial [PMID 25272316]
  3. ProMISE Trial [PMID 25776532]
  4. Note: EGDT based on the trial done by Rivers in 2001: EGDT Trial [PMID 11794169]

Vasopressors for the Treatment of Septic Shock

Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED

Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis

Lung ultrasound for diagnosis of pneumonia in emergency department.

Tintinalli's Emergency Medicine a Comprehensive Study Guide 7th Edition