Ronald Chrisbianto Gani

405090223
Faculty of Medicine
Tarumanagara University
EMERGENCY MEDICINE BLOCK
SEPSIS SYNDROME
SEPSIS SYNDROMES
DEFINITIONS
Activated Inflammatory cascade cause the
bodyd defenses and regulatory system
become overwhelmed leading to disruption of
hemeostasis
Systemic Inflammatory Response Syndrome
(SIRS) 2 or more : tachycardia, tachypnea,
hyperthermia or hypothermia, high or low
WBC count, bandemia.
Rosens Emergency Medicine 7th Ed
DEFINITIONS
Sepsis : SIRS + infection
Severe Sepsis : Sepsis + Organ Dysfunction
Septic Shock : Severe Sepsis + hypotension
which is not responsive to fluid challange
Approach : PIRO (predisposition, infection
source, response of host, organ dysfuntion)
Bacteremia is not obligatory in diagnosis of
sepsis
Rosens Emergency Medicine 7th Ed
EPIDEMIOLOGY
In United States :
10th most common
cause of death
571.000 cases of severe
sepsis
Mortality rate 20-50%
Incidence
Rosens Emergency Medicine 7th Ed
PATHOPHYSIOLOGY
Infection host response neutrophil and
macrophage mobilization to injury site
release cytokines inflammatory cascade
synthesis is not well regulated sepsis
Ongoing toxin persistent inflammatory
response mediator activation cellular
hypoxia, tissue injury, shock, Multi-Organ
Failure, death
Rosens Emergency Medicine 7th Ed
PATHOPHYSIOLOGY
Mediators of Sepsis
Proinflammatory : IL-1, IL8, TNF
Anti-inflammatory IL-10, IL-6 TGF B, IL-1ra
Growth promoting
Arachidonat acid pathway peripheral
dilation, vasocontriction, leukocyte and
platelet aggregation
PG fever
Rosens Emergency Medicine 7th Ed
PATHOPHYSIOLOGY
Vasopressin release in stress condition,
cause vasoconstriction, osmoregulation,
maintenance of normovolemia
NO Regulating vascular tone, platelet
adhesion, insulin secretion,
neurotransmission, tissue injurt, inflammation
and cytotoxicity
Rosens Emergency Medicine 7th Ed
ORGAN SYSTEM DYSFUNCTION
AND DEATH
Rosens Emergency Medicine 7th Ed
ORGAN SYSTEM DYSFUNCTION
Neurologic
Altered mental status and lethargy septic
encephalopathy
Cardiovascular
Myocardial depression : killed organism / bacteria
Distributive shock : toxic mediators
Early sepsis : Cardiac output , vascular
resistance
Reversible cardiac function usually in 10 days
Rosens Emergency Medicine 7th Ed
ORGAN SYSTEM DYSFUNCTION
Pulmonary
Right-to-left shunting, arterial hypoxemia,
intractable hypoxemia
Sepsis : High catabolic state + airway resistance
ARDS
Gastrointestinal
Ileus hypoperfusion. splanchnic blood flow.
Aminotransferase + bilirubin hepatic
failure (rare)
Rosens Emergency Medicine 7th Ed
ORGAN SYSTEM DYSFUNCTION
Endocrine
Adrenal insufficiency
IL-1 & IL-6 activate hypothalamic-pituitary axis
TNF-A & corticostatin, depressed bloow flow,
depress pituitary function and secretion
Hematologic
DIC, fibrin deposition, microvascular thrombi
Associated with Protein C
Rosens Emergency Medicine 7th Ed
CLINICAL SIGNS & SYMPTOMS
Identify systemic infection and the source
Altered conciousness intubation
Systemic Infection : tachycardia, tachypnea,
hypo/hyperthermia, hypotension (severe)
Flushed/warm skin while in vasodilation state
Hypoperfused mottled and cyanotic
Shock exclude other shock etiologies
Use MEDS score for risk stratification
Rosens Emergency Medicine 7th Ed
MEDS
SCORE
Rosens Emergency Medicine 7th Ed
SOURCE OF INFECTIONS
Respiratory (most common) : cough, fever, chills,
throat and ear pain, pneumonia, etc
GI (2nd most common) : abdominal pain, Murphy
sign, McBurney Sign, etc
Neurologic : meningitis
Genitourinary :Flank pain,dysuria,polyuria, etc
Musculoskeletal
IV drug abuse, artificial heart valve, endocarditis
Rosens Emergency Medicine 7th Ed
DIAGNOSTIC FEATURES
Hematology
Leukocytosis
Febrile neutropenic admission, isolation,
empirical IV antimicrobial
Bandemiarelease of immature cell from marrow
Ht >30%, Hb >10g/dL
Acute phase platelet
Low platelet shock
Thrombocytopenia, pTT & aPTT , fibrinogen ,
DIC & severe sepsis syndrome

Rosens Emergency Medicine 7th Ed
DIAGNOSTIC FEATURES
Chemistry
bicarbonate acidosis & inadequate perfusion
serum creatinine ARF
Lactate inadequate perfusion, shock
Arterial blood gas detect acid base disturbance
Metabolic acidosis inadequate perfusion
Bilirubin source from gallbladder
Amilase & Lipase pancreatitis
Rosens Emergency Medicine 7th Ed
DIAGNOSTIC FEATURES
Microbiology
Culture from blood, sputum, urine, CSF, tissue
Obtained before/soon after AB administration
Start with empirical therapy
Radiology
Chest pneumonia, ARDS
Bowel perforation free air aunder diaphragm
Pneumomediastinum esophageal perforation,
mediastinitis
Rosens Emergency Medicine 7th Ed
DIAGNOSTIC FEATURES
Ct-Scan diverticulitis, appendicitis, necrotizing
pancreatitis, microperforation, intra-abdominal
abscess
Head CT septic emboli
Abdominal USG Cholycystitis
Pelvic USG endometritis
Transesophageal USG --> endocaditis
MRI soft tissue
Rosens Emergency Medicine 7th Ed
DIFFERENTIAL DIAGNOSIS
Rosens Emergency Medicine 7th Ed
MANAGEMENT
Principles
AB therapy
Maintenance of adequate tissue perfusion

Rosens Emergency Medicine 7th Ed
MANAGEMENT
Respiratory Support
Airway protection, intubation, mechanical
ventilatory support if needed
Cardiovascular support
Initial therapy 2L of isotonic crystalloid
Normal Saline/ LR.
Maintain MAP >65mmHg, but 75mmHg in patient
ith history of severe hypertensive patient
Rosens Emergency Medicine 7th Ed
MANAGEMENT
Drugs : Vasopresin, Norepinephrine, Dopamine,
Phenylephrine, Epinephrine.
Inotropic agents : Dobutamine, Bicarbonate, AB
Novel Therapies
Activated Protein C
Steroid Therapy

Rosens Emergency Medicine 7th Ed
MANAGEMENT
Rosens Emergency Medicine 7th Ed
Rosens Emergency Medicine 7th Ed