WikEM - User contributions [en]

Intraosseous access

2015-06-23T02:35:34Z

Hannodavel: Spelling Osteogenesis

==Indications==
[[File:ez-IO.jpg|thumbnail|3 EZ-IO sizes]]
*immediate access required for administration of drugs/fluids
*cardiac arrest, resuscitaion when no other IV in place
*IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved<ref>Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.</ref>
[[File:IO sizes.JPG|thumbnail|15 Gauge IO sizes]]
==Contraindications==
*Osteoporosis
*[[Osteomyelitis]]
*Osteogenesis imperfecta
*[[Fractures_(Main)|Fractured bone]]
*Recent IO infusion in same bone
*[[Cellulitis]], Infection, or Burn, at insertion site

==Equipment==
*Multiple different types of IO needles and products available

#EZ-IO drill
#Appropriate IO needle with extension set
#Chloraprep or alcohol to clean skin
#Saline Flush
#Lidocaine (2% lidocaine without epi)

==Site Selection==
#Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
#Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
#Proximal humerus (adults only, use yellow needle)
#Distal Femur (generally only in infants and children)
#Pelvic ASIS

==EZ-IO Needle selection (based on weight of patient)==
#Pink 15mm (3-39kg)
#Blue 25mm (40kg and above)
#Yellow 45mm  (excessive tissue)

==Procedure==
#Identify landmarks
#Clean skin
#Place appropriate needle on drill and remove safety cap
#ADVANCE needle through skin to bone
#DRILL needle perpendicular into bone at site with gentle, constant pressure
#When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)
#Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
#Remove stylet (''caution: stylet is extremely sharp'' - place in sharps container)
#Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
#Aspirate blood/marrow to confirm placement
#If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)
#Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
#Apply dressing

===Removal===
#Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
#*Can attach syringe via luer lock to act as handle
#Apply dressing.

==Complications==
*Compartment syndrome
*Incomplete penetration of cortex
*Penetration of posterior cortex
*Infection (cellulitis, osteomyelitis)
*Fracture
*Growth plate damage
*Fat embolism

==Labs drawn via IO==
*Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
**There is not good correlation with Sodium, Potassium, CO2, and calcium levels.<ref name="miller">Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.</ref>
**Potassium is often elevated due to hemolysis
*CANNOT use IO blood for CBC
**WBCs are higher and platelet counts are lower<ref name="miller"></ref>

==IO Medications==
*Any medication that can be given in peripheral IV can be given through IO
**Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line<ref>Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.</ref>
**RSI medications can be given through IO with the same efficacy<ref>Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]</ref>
*Same doses as IV meds
*Follow with flush
*Drips or IV fluids should be given with pressure bag or infusion pump

==See Also==
*[[Access options]]

==Source==
<references/>
[[Category:Procedures]][[Category:Airway/Resus]]

Template:TIMI Score

2014-08-02T15:32:37Z

Hannodavel: Age should be >65 not <65 to score a point.

===NSTEMI TIMI Score<ref>Antman, Elliot et al. The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI A Method for Prognostication and Therapeutic Decision Making. JAMA. 2000;284(7):835-842. doi:10.1001/jama.284.7.835. [http://jama.jamanetwork.com/data/Journals/JAMA/4748/JOC00458.pdf PDF]</ref>===
;Used to estimate percent risk at 14 days of MI, or revascularization

#Age >65 yrs (1 point)
#Three or more risk factors for coronary artery disease: (1 point)
##family history of coronary artery disease
##hypertension
##hypercholesterolaemia
##diabetes
##current smoker
#Use of aspirin in the past 7 days (1 point)
#Significant coronary stenosis (stenosis >50%) (1 point)
#Severe angina (e.g., >2 angina events in past 24 h or persisting discomfort) (1 point)
#ST-segment deviation of ≥0.05 mV on first ECG (1 point)
#Increased troponin and/or creatine kinase-MB blood tests (1 point)

{| class="wikitable"
|+TIMI Risks
! align="center" style="background:#f0f0f0;"|'''points'''
! align="center" style="background:#f0f0f0;"|'''% risk of mortality, MI, or revascularization'''
|-
| 0||5%
|-
| 1||5%
|-
| 2||8%
|-
| 3||13%
|-
| 4||20%
|-
| 5||26%
|-
| 6||41%
|}

Head trauma (peds)

2014-04-30T23:39:02Z

Hannodavel:

== Definition ==
*Normal mental status at the initial examination
*No abnormal findings on neuro exam
*No physical evidence of skull fx

== Background ==
*Persistence of HA, confusion, and amnesia suggests concussion
*Worsening of symptoms suggests intracranial injury
*Scalp hematoma in <2yo is assoc w/ incr risk of skull fx, ICH
*Clinical symptoms (HA, vomiting, behavior change) do not correlate well with ICH

== Work-Up ==

(Consider PECARN Study. PECARN Pediatric Head Injury/Trauma Algorithm at http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/) 
Do I need to obtain a head CT?
===< 2yr old===
*No CT is necessary if ALL are found:
#Normal mental status
#No scalp hematoma except frontal
##LOC <5s
#Non-severe mechanism
##Severe mechanism = pedestrian or bicyclist w/o helmet struck by motorized vehicle
##Severe mechanism = fall >1m or 3ft
##Severe mechanism = head struck by high-impact object
#No palpable skull fracture
#Normal behavior per parents

===>2yr old===
*No CT is necessary if ALL are found:
#Normal mental status
#No LOC
#No vomiting
#Non-severe mechanism:
##Severe mechanism = pedestrian or bicyclist w/o helmet struck by motorized vehicle
##Severe mechanism = fall >2m or 5ft
##Head struck by high-impact object
#No signs of basilar skull fracture
#No severe headache

==Disposition==
*Discharge if:
**Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
**Head CT normal (delayed deterioration after normal CT is near zero)
*Consider discharge if:
**Nondisplaced fx w/o intracranial injury (in consultation w/ neurosx)

== See Also ==
*[[Head Trauma (Main)]]
*[[GCS (Peds)]]
*[[Concussion]]
*[[Skull Fracture]]
*[[Abuse (Nonaccidental Trauma)]]
*[[Maxillofacial Trauma]]

== Source ==
*Tintinalli
*Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696): 1160, 2009
*Holmes et al. Do Children With Blunt Head Trauma and Normal Cranial CT Require Hospitalization for Neurologic Observation?, Annals of Emergency Medicine, vol 58, 2011

[[Category:Peds]]
[[Category:Trauma]]

Hyponatremia

2014-04-09T14:23:47Z

Hannodavel: fixed wiki link formatting

==Background==
*Urine Na only useful before beginning tx
*Low = <135meq/L
*Symptomatic = <120meq/L (may be higher if occurs abruptly)

==Clinical Features==
*N/V
*Anorexia
*Muscle cramps
*[[AMS]]
*[[Seizure]] (esp if Na < 113)
*Coma
*Rapid correction can cause [[CHF]] & CPM ([[AMS]], dysphagia, dysarthria, paresis)

==Diagnosis==
*Must determine volume status and calculated osm
**In true hyponatremia the osm is reduced

===Work-Up===
Prior to giving treatment

#Urine
##UA
##Urine electrolytes
##Urine urea
##urine uric acid
##urine osmolality
##urine creatinine
#Serum
##Chemistry
##Serum osmolality
##Uric acid
##TSH
##Cortisol

==DDX==
#Hypertonic hyponatremia (osm > 295)
##[[Hyperglycemia]]
###[Na+] decreases by 1.6-1.8mEq/L for each 100mg/dL increase in glucose
##[[Mannitol]] excess
#Isotonic (pseudo) hyponatremia (osm 275-295)
##Hyperlipidemia
##Hyperproteinemia
#Hypotonic hyponatremia (osm < 275)
##Hypovolemic
###Renal
####Thiazide diuretic use
####Na-wasting nephroathy (RTA, CRF)
####Osmotic diuresis (glucose, urea)
####Aldosterone deficiency
###Extra-renal
####GI loss
####3rd space loss
#####Burns
#####Pancreatitis
#####Peritonitis
##Hypervolemic
###Urinary Na > 20
####[[Renal Failure]]
###Urinary Na < 20
####[[CHF]]
####[[Nephrotic Syndrome]]
####Cirrhosis
##Euvolemic (urine Na usually > 20)
###SIADH
####Pain, stress, nausea
###[[Hypothyroidism]]
###Drugs
####NSAIDs, sulfonylureas
###H20 intoxication
###Glucocorticoid deficiency

==Treatment==
*1. Hypertonic hyponatremia
**Correct underlying disorder
**Often volume depleted (give NS)
*2. Isotonic (pseudo) hyponatremia
**No tx needed
*3. Hypotonic hyponatremia
**A. Hypovolemic
***Give NS (see below)
**B. Euvolemic
***Water restrict
***Treat underlying cause
**C. Hypervolemic
***Water restriction
***Diuresis
***Treat underlying cause

===Na Therapy===
*Max correction 10mEq/L in 24hr (avoids CPM)
*NS = 154 meq/L
*3% NS = 513 meq/L
*each 100 ml will raise sodium by ~2 mmol/l

====Asymptomatic====
*Step 1: Calculate total body water
**TBW = Wt(kg) x 0.6
*Step 2: Calculate mEq deficit
**(Desired Na - Measured Na) ~ must be ≤ 10
*Step 3: Calculate NS rate to be given over 24hr
**NS rate (cc/hr) = TBW x mEq deficit x 0.27
***If using 3% NS (to avoid volume overload) divide above rate by 3.33

====Symptomatic====
*3% NS 100cc bolus over 10min; repeat after 10min x1 if no improvement
**Each 100 ml will raise sodium by ~2 mmol/l
*Fluid restrict

==Disposition==
*Admit if Na <125

==See Also==
*[[Electrolyte Abnormalities (Main)]]

==Source ==
*Tintinalli
*Pontine and extrapontine myelinoslysis: a neurologic disorder following rapid correction of hyponatremia Medicine/ 1993;72(6):359-373
*emcrit.org (http://emcrit.org/podcasts/hyponatremia/)
*Review by Schrier (Curr Opin Crit Care 2008;14:627)
*Review of Drug-Induced Hyponatremia (Am J Kidney Dis 2008;52:144)
*Understanding Lab Testing for Hyponatremia (Clin J Am Soc Nephrol 2008;3:1175)
*The hyponatremia formulas do not work so well (Clin J Am Soc Nephrol 2007;2:1110 and Nephrol Dial Transplant 2006;21:1564)

[[Category:FEN]]

Pediatric Quick Emergency Reference Card

2014-04-07T05:30:06Z

Hannodavel: Ativan -> Lorazepam (for international audience)

== Intubation ==
*'''Atropine 0.02 mg/kg''' (min 0.1mg; max 1mg; Always for pts <5yrs or before 2nd dose of Succinylcholine)
*'''Lidocaine 1 mg/kg''' (blunts increase in ICP)
*'''[[Succinylcholine]] 1.5-2 mg/kg''' (avoid in incr K, renal failure, h/o neuromuscular disorder or [[Malignant Hyperthermia]])
*'''Rocuronium 1.2 mg/kg''' (onset 1min, lasts 30min)
*'''Etomidate 0.3 mg/kg''' (less hypotension than other sedatives)
*'''Versed 0.05-0.1 mg/kg''' (decreases BP,HR,RR)
*'''Fentanyl 2-5 mcg/kg''' (can cause chest wall rigidity if given rapidly)
*'''Ketamine 2 mg/kg''' (preferred in Asthma)

== Cards ==

*'''Epinephrine 0.1 cc/kg of 1:10,000''' (ETT dose is 0.1 cc/kg of 1:1000 epi)

*'''Atropine 0.02 mg/kg''' (min 0.1mg; max 1mg; may repeat once after 5min)

*'''Adenosine 0.1-0.2 mg/kg''' (max 1mg; may repeat x2 at 0.2 mg/kg)

*'''Defib 2J/4J/4J per kg'''

 

== AMS/SZ ==

*'''D25W 2 cc/kg''' (repeat as needed)

*'''Lorazepam 0.05-0.1 mg/kg''' (may repeat 1-2 times)

*'''Fosphenytoin 18-20 mg PE/kg''' (rate 150mg PE/min; PE=Phenytoin equivalent)

*'''Phenytoin 18-20 mg/kg''' (give SLOW, max rate 1mg/kg/min, 2nd choice after Fosphenytoin)

*'''Phenobarb 10-20 mg/kg''' (rate 1mg/kg/min slow)

*'''Valium rectal 0.5 mg/kg'''

*'''Mannitol 1 gm/kg'''

 

== Tubes ==
*'''Endotracheal tube (ETT) = (age-in-years/4) + 4 (uncuffed) OR (Age/4)+3 (cuffed)'
*'''ETT depth at the lips = ETT size x 3'''
*'''OG/NG/Foley = ETT size x 2)'''
*'''Chest Tube = ETT size x 4'''
*[[Pediatric Central Line]]

== See Also ==
*[[Adult Quick Drug Card]]
*[[Airway Sizes (Peds)]]
*[[PALS (Main)]]
*[[Pediatric Vital Signs]]

== Source ==

2/8/06 DONALDSON (from 'Peds board')

[[Category:Drugs]] [[Category:Airway/Resus]] [[Category:Peds]]
[[Category:EMS]]

Head trauma (peds)

2014-04-07T03:48:28Z

Hannodavel:

== Definition ==
*Normal mental status at the initial examination
*No abnormal findings on neuro exam
*No physical evidence of skull fx

== Background ==
*Persistence of HA, confusion, and amnesia suggests concussion
*Worsening of symptoms suggests intracranial injury
*Scalp hematoma in <2yo is assoc w/ incr risk of skull fx, ICH
*Clinical symptoms (HA, vomiting, behavior change) do not correlate well with ICH

== Work-Up ==

(Consider PECARN Study. PECARN Pediatric Head Injury/Trauma Algorithm at http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/) 
Do I need to obtain a head CT?
===< 2yr old===
*No CT is necessary if ALL are found:
#Normal mental status
#No scalp hematoma except frontal
##LOC <5s
#Non-severe mechanism
##Severe mechanism = pedestrian or bicyclist w/ohelmet struck by motorized vehicle
##Severe mechanism = fall >1m or 3ft
##Severe mechanism = head struck by high-impact object
#No palpable skull fracture
#Normal behavior per parents

===>2yr old===
*No CT is necessary if ALL are found:
#Normal mental status
#No LOC
#No vomiting
#Non-severe mechanism:
##Severe mechanism = pedestrian or bicyclist w/o helmet struck by motorized vehicle
##Severe mechanism = fall >2m or 5ft
##Head struck by high-impact object
#No signs of basilar skull fracture
#No severe headache

==Disposition==
*Discharge if:
**Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
**Head CT normal (delayed deterioration after normal CT is near zero)
*Consider discharge if:
**Nondisplaced fx w/o intracranial injury (in consultation w/ neurosx)

== See Also ==
*[[Head Trauma (Main)]]
*[[GCS (Peds)]]
*[[Concussion]]
*[[Skull Fracture]]
*[[Abuse (Nonaccidental Trauma)]]
*[[Maxillofacial Trauma]]

== Source ==
*Tintinalli
*Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696): 1160, 2009
*Holmes et al. Do Children With Blunt Head Trauma and Normal Cranial CT Require Hospitalization for Neurologic Observation?, Annals of Emergency Medicine, vol 58, 2011

[[Category:Peds]]
[[Category:Trauma]]

Head trauma (peds)

2014-04-07T03:41:10Z

Hannodavel:

== Definition ==
*Normal mental status at the initial examination
*No abnormal findings on neuro exam
*No physical evidence of skull fx

== Background ==
*Persistence of HA, confusion, and amnesia suggests concussion
*Worsening of symptoms suggests intracranial injury
*Scalp hematoma in <2yo is assoc w/ incr risk of skull fx, ICH
*Clinical symptoms (HA, vomiting, behavior change) do not correlate well with ICH

== Work-Up ==

(Consider PECARN Study. PECARN Pediatric Head Injury/Trauma Algorithm at http://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm/) 
Do I need to obtain a head CT?
===<2yr old===
*No CT is necessary if ALL are found:
#Normal mental status
#No scalp hematoma except frontal
##LOC <5s
#Non-severe mechanism
##Severe mechanism = pedestrian or bicyclist w/ohelmet struck by motorized vehicle
##Severe mechanism = fall >1m or 3ft
##Severe mechanism = head struck by high-impact object
#No palpable skull fracture
#Normal behavior per parents

===>2yr old===
*No CT is necessary if ALL are found:
#Normal mental status
#No LOC
#No vomiting
#Non-severe mechanism:
##Severe mechanism = pedestrian or bicyclist w/o helmet struck by motorized vehicle
##Severe mechanism = fall >2m or 5ft
##Head struck by high-impact object
#No signs of basilar skull fracture
#No severe headache

==Disposition==
*Discharge if:
**Asymptomatic after 2-4hr obs (not vomiting, nl neuro exam, nl mental status)
**Head CT normal (delayed deterioration after normal CT is near zero)
*Consider discharge if:
**Nondisplaced fx w/o intracranial injury (in consultation w/ neurosx)

== See Also ==
*[[Head Trauma (Main)]]
*[[GCS (Peds)]]
*[[Concussion]]
*[[Skull Fracture]]
*[[Abuse (Nonaccidental Trauma)]]
*[[Maxillofacial Trauma]]

== Source ==
*Tintinalli
*Kupperman N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696): 1160, 2009
*Holmes et al. Do Children With Blunt Head Trauma and Normal Cranial CT Require Hospitalization for Neurologic Observation?, Annals of Emergency Medicine, vol 58, 2011

[[Category:Peds]]
[[Category:Trauma]]

Sepsis (main)

2014-04-07T03:36:52Z

Hannodavel:

==Background==
*Pancreatitis may appear identical to sepsis
*Infection sources:
**Pulm, skin, GU (account for 80%), abd, CNS
***Childbearing age woman: septic abortion, postpartum endometritis
***No obvious source: consider bacteremia, endocarditis

==Diagnosis==
#SIRS
##2 or more of the following:
###Temp >38.3 or <36
###HR >90
###Resp rate >20 or CO2 <32
###WBC >12K, <4K, or >10% bands
#Sepsis
##SIRS + documented or suspected infection
#Severe sepsis
##Sepsis AND 1 or more of the following signs of organ dysfunction:
###Lactate > upper limit of normal
###Urine output <0.5 mL/kg for >2hr, despite adequate fluid resuscitation
###Cr >2 (presumed to be new)
###Bilirubin >2 (presumed to be new)
###Plt <100K (presumed to be new)
###INR >1.5 (presumed to be new)
###ALI
####PaO2/FIO2 <250 in absence of PNA as infection source
####PaO2/FIO2 <200 in presence of PNA as infection source
#Septic shock
##SBP <90 after adequate fluid challenge OR
##Lactate >4

==DDx==
*[[Adrenal Insufficiency]]
*[[Salicylate Toxicity]]
*Anticholinergic Toxidrome ([[Anticholinergic Toxicity]])
*[[Neuroleptic Malignant Syndrome]]
*[[Malignant Hyperthermia]]
*[[Thyrotoxicosis]]
*Other shock
**Cardiogenic
**Hypovolemic
**Anaphylactic
**Neurogenic
**Obstructive

==Work-Up==
*CBC
*UA/UCx
*Blood cx
*CXR
*Chem
*LFT
*Lipase
*VBG
*Lactate
*Coags
*DIC panel (fibrinogen, D-dimer, FDP)
*T&S
*?CT head/LP

==Early Goal Directed Therapy==
#Goals
##Preload Goal: CVP >8 (>12 if intubated)
##Afterload Goal: MAP >65
##Perfusion goal: ScvO2 >70% OR lactate clearance >10%
##Hb >10 (if ScvO2 target not otherwise met)
##Lactate clearance of at least 10%
##Urine output >0.5 mL/kg/hr
#Airway
##Careful - sedatives for intubation may worsen hypotension
##Careful - PPV reduces preload and CO
#Breathing
##Maintain O2 sat >93%
##Maintain PaCO2 at 35-40
##Consider early mechanical ventilation
###Rationale:
####Ensures efficient oxygenation
####Decreases O2 demand by respiratory muscles
###Settings
####Tidal volume 6mL/kg ideal wt
####Plateau pressure <30
#Circulation
##IVF - Reassess after each bolus
###Average is 5-6L w/in first 6hr
###IVF can be harmful in cardiogenic shock or in pts w/ pulm edema
##Pressors
###Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
###Best if given when the vascular space is filled; ok if it's not
###Options:
####Norepi (5-20mcg/min) - 1st line
####Dopamine (5-20mcg/kg/min)
##Inotropes
###Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10
#Infection Control
##Source Control
###Remove infected lines, surgery if indicated
##Abx
###Give ASAP
###See [[Initial Antibiotics in Sepsis (Main)]]
#Coagulation
##Consider FFP if INR >1.5
##Consider plts if <50K
#Steroids
##Controversial
##Consider hydrocortisone 100 mg if pressor resistant

==See Also==
*[[Initial Antibiotics in Sepsis (Main)]]
*[[Sepsis (Peds)]]

== Source ==
*Tintinalli
*Surviving sepsis campaign 2012
*Backer et al. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med. 2012;40(3):725
*PEER VIII Q&A

[[Category:Airway/Resus]]
[[Category:ID]]

Sepsis (main)

2014-04-07T03:36:30Z

Hannodavel: Linked to Anticholinergic Toxicity page

==Background==
*Pancreatitis may appear identical to sepsis
*Infection sources:
**Pulm, skin, GU (account for 80%), abd, CNS
***Childbearing age woman: septic abortion, postpartum endometritis
***No obvious source: consider bacteremia, endocarditis

==Diagnosis==
#SIRS
##2 or more of the following:
###Temp >38.3 or <36
###HR >90
###Resp rate >20 or CO2 <32
###WBC >12K, <4K, or >10% bands
#Sepsis
##SIRS + documented or suspected infection
#Severe sepsis
##Sepsis AND 1 or more of the following signs of organ dysfunction:
###Lactate > upper limit of normal
###Urine output <0.5 mL/kg for >2hr, despite adequate fluid resuscitation
###Cr >2 (presumed to be new)
###Bilirubin >2 (presumed to be new)
###Plt <100K (presumed to be new)
###INR >1.5 (presumed to be new)
###ALI
####PaO2/FIO2 <250 in absence of PNA as infection source
####PaO2/FIO2 <200 in presence of PNA as infection source
#Septic shock
##SBP <90 after adequate fluid challenge OR
##Lactate >4

==DDx==
*[[Adrenal Insufficiency]]
*[[Salicylate Toxicity]]
*Anticholinergic Toxidrome [[Anticholinergic Toxicity]]
*[[Neuroleptic Malignant Syndrome]]
*[[Malignant Hyperthermia]]
*[[Thyrotoxicosis]]
*Other shock
**Cardiogenic
**Hypovolemic
**Anaphylactic
**Neurogenic
**Obstructive

==Work-Up==
*CBC
*UA/UCx
*Blood cx
*CXR
*Chem
*LFT
*Lipase
*VBG
*Lactate
*Coags
*DIC panel (fibrinogen, D-dimer, FDP)
*T&S
*?CT head/LP

==Early Goal Directed Therapy==
#Goals
##Preload Goal: CVP >8 (>12 if intubated)
##Afterload Goal: MAP >65
##Perfusion goal: ScvO2 >70% OR lactate clearance >10%
##Hb >10 (if ScvO2 target not otherwise met)
##Lactate clearance of at least 10%
##Urine output >0.5 mL/kg/hr
#Airway
##Careful - sedatives for intubation may worsen hypotension
##Careful - PPV reduces preload and CO
#Breathing
##Maintain O2 sat >93%
##Maintain PaCO2 at 35-40
##Consider early mechanical ventilation
###Rationale:
####Ensures efficient oxygenation
####Decreases O2 demand by respiratory muscles
###Settings
####Tidal volume 6mL/kg ideal wt
####Plateau pressure <30
#Circulation
##IVF - Reassess after each bolus
###Average is 5-6L w/in first 6hr
###IVF can be harmful in cardiogenic shock or in pts w/ pulm edema
##Pressors
###Indicated if MAP<60 despite adequate IVF or if IVF are contraindicated
###Best if given when the vascular space is filled; ok if it's not
###Options:
####Norepi (5-20mcg/min) - 1st line
####Dopamine (5-20mcg/kg/min)
##Inotropes
###Dobutamine (2-20mcg/kg/min) if perfusion goal not met despite Hb >10
#Infection Control
##Source Control
###Remove infected lines, surgery if indicated
##Abx
###Give ASAP
###See [[Initial Antibiotics in Sepsis (Main)]]
#Coagulation
##Consider FFP if INR >1.5
##Consider plts if <50K
#Steroids
##Controversial
##Consider hydrocortisone 100 mg if pressor resistant

==See Also==
*[[Initial Antibiotics in Sepsis (Main)]]
*[[Sepsis (Peds)]]

== Source ==
*Tintinalli
*Surviving sepsis campaign 2012
*Backer et al. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med. 2012;40(3):725
*PEER VIII Q&A

[[Category:Airway/Resus]]
[[Category:ID]]