problem 2 kgd angelia.pptx
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8/11/2019 Problem 2 KGD Angelia.pptx
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Problem 2
Angelia Christiani
405090078
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BURNS
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SEPSIS
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1. Description
Systemic inflammatory response triggered by an infectionin the host and mediated by chemical messengers: Decreased peripheral vascular resistance Elevated cardiac output in response to vasodilatation
Later in septic shock, myocardial depression, and reducedcardiac output (due to injury at the cellular level or mediatorsacting on the heart)
Multiple organ dysfunction syndrome (MODS) if sepsis isineffectively treated
Adult respiratory distress syndrome (ARDS) Acute tubular necrosis and kidney failure Hepatic injury and failure Disseminated intravascular coagulation
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2. Etiology
Gram-negative bacteria most common:
Escherichia coli
Pseudomonas aeruginosa
Rickettsiae
Legionella species
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Gram-positive bacteria:
Enterococcus species
Staphylococcus aureus
Streptococcus pneumoniae
Fungi (Candida species)
Viruses
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Pediatric Considerations
Children with a minor infection may havemany of the findings of SIRS.
Major causes of pediatric bacterial sepsis
Neisseria meningitis
Streptococcal pneumoniae
Haemophilus influenzae
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3. Classification
Sepsis is classified by the systemicinflammatory response syndrome (SIRS): Temperature >38C or 90 beats/minute Respiratory rate >20/minute or PaCO212,000/mm3, 10% bandforms
Sepsis: two or more of the SIRS criteria withan underlying infection
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Severe sepsis: Sepsis with organ dysfunction as manifested by
one of the following:
Acidosis Renal dysfunction
Acute change in mental status
Pulmonary dysfunction
Hypotension Thrombocytopenia or coagulopathy
Liver dysfunction
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Septic shock:
Sepsis-induced hypotension despite fluidresuscitation
Systolic blood pressure (BP) 40 mm Hg from baseline
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4. Signs and Symptoms
General:
Fever
Tachycardia
Tachypnea
Hypothermia (poor prognosis)
Hypoxemia
Diaphoresis
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Cardiovascular:
BP
Normal early in sepsis
Hypotension when septic shock occurs
Poor perfusion with septic shock:
Prolonged capillary refill
Cool and clammy extremities
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Gastrointestinal/Genitourinary: Abdominal pain Nausea, vomiting Diarrhea
Dysuria/Frequency Reduced urine output Abdominal tenderness:
Diffuse Localized to right upper quadrant (liver or gallbladder source) Right lower quadrant (appendicitis with or without abscess) Suprapubic area or lower quadrants (urinary tract or pelvic source or
diverticulitis)
Flank pain: With pyelonephritis or retroperitoneal abscess
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Pulmonary:
Shortness of breath
Tachypnea:
Present even when the lungs are not the source ofsepsis
Productive cough
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CNS:
Change in mental status
Confusion
Delirium
Coma
Neck stiffness (meningitis)
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Dermatologic: Any rash is important. Localized erythema with lymphangitis (streptococcal or
staphylococcal cellulitis) Rash involving palms of hands and soles of feet (rickettsial
infection) Petechiae scattered on the torso and extremities
(meningococcemia) Ecthyma gangrenosum (pseudomonas septicemia) Round, indurated, painless lesion with surrounding erythema
and central necrotic black eschar Decubitus ulcers Indwelling catheter:
Surrounding skin erythematous with or without purulent drainage
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Hematocrit:
Needed to determine whether adequate oxygen
delivery can be achieved Patients should be maintained with a hematocrit >30%
and hemoglobin >10 g/dl.
Platelets:
May be elevated in the presence of infection or sepsis-induced volume depletion
Low platelet count is a significant predictor ofbacteremia and death.
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Electrolytes, blood urea nitrogen, creatinine,glucose: Low bicarbonate suggests inadequate perfusion. Renal dysfunction or failure indicates a worse
prognosis. Ca, Mg, Ph C-reactive protein Cortisol level International normalized ratio/prothrombin
time/partial thromboplastin time
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Type and screen Liver function tests Arterial blood gas:
Mixed acidbase abnormalities: respiratory alkalosiswith metabolic acidosis
Blood cultures: From two different sites
One may be drawn through an indwelling central line(i.e., Broviac).
Urine analysis and culture
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(B) Imaging
Chest radiograph:
Determine whether pneumonia is the infectioussource.
Fluffy, bilateral infiltrates may indicate that ARDSis already present.
Free air under the diaphragm indicates the sourceof the infection in intraperitoneal and a surgicalintervention
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CT scan of the abdomen and pelvis Suspicion of abdominal source of infection:
Diverticulitis, appendicitis, necrotizing pancreatitis,microperforation of the stomach or bowel, or formation of anintra-abdominal abscess
Abdominal ultrasound: Indicated for suspected cholecystitis
Pelvic ultrasound: Tubo-ovarian abscess or
MRI: May be useful to identify soft tissue infections or epidural
abscess
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(C) Diagnostic Procedures/Surgery
Lumbar puncture: Indicated when meningeal signs are present or altered
mental status without a source of infection Cerebrospinal fluid analysis:
Cell count and differential, tube 1
Total protein and glucose, tube 2
Culture and gram stain, tube 3 Cell count and differential, tube 4
Depending on the clinical situation: cytology, venerealdisease research laboratory, AFB stain/culture, fungal stain
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Central venous access:
Central venous pressure (CVP) and ongoingmeasurement of central venous oximetry catheter
may be helpful in guiding resuscitation
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6. Treatment
Pre Hospital Aggressive fluid resuscitation for hypotension
Initial Stabilization
ABCs Supplemental oxygen to maintain PaO2>60 mm
Hg
Intubation and mechanical ventilation if shock orhypoxia are present
Administer 0.9% NS IV
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ED Treatment
Early goal-directed therapy: 500 cc boluses of 0.9% saline up to 12 liters empirically
Place central line
Continue 500 cc saline boluses until CVP >8 cm H2O
If the mean arterial pressure 8, theninitiate pressors:
Dopamine or norepinephrine to raise blood pressure
Norepinephrine is preferred if tachycardia or dysrhythmias arepresent.
Phenyl epinephrine for cases where shock is refractory to otherpressors
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If the ScvO230, then adddobutamine.
Administer antibiotics early based on the mostlikely organisms or site of infection.
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If no source identified after initial assessment:
Normal immune function:
Second- or third-generation cephalosporin and gentamicin
Nafcillin and gentamicin Add vancomycin if there is a history of methicillin resistant
staphylococcus aureous or the patient resides in a nursingfacility or there is a history of recent hospitalizations.
Immunocompromised host: Piperacillin and gentamicin
Ceftazidime and either nafcillin or vancomycin andgentamicin
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If source identified, or highly suspected, treatthe most likely organisms: Pulmonary source:
Second- or third-generation cephalosporin andgentamicin, and possibly erythromycin
Intra-abdominal source: Ampicillin and metronidazole and gentamicin
Cefoxitin and gentamicin Urinary tract source:
Ampicillin or piperacillin and gentamicin
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Pediatric Considerations
Antibiotic therapy based on age:
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Admission Criteria
Sepsis with toxicity, septicemia, or septicshock requires admission generally to anintensive care unit.
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6. Differential Diagnosis
Pancreatitis Trauma Toxic shock syndrome
Anaphylaxis Adrenal insufficiency Drug or toxin reactions Heavy metal poisoning Hepatic insufficiency Neurogenic shock
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