Rosen & Barkin's 5-Minute Emergency Medicine Consult (643 page)

• Ampicillin: 1–2 g (peds: 50–200 mg/kg/24 h) IV q4–6h
  
• Cefoxitin: 1–2 g (peds: 100–160 mg/kg/24 h) IV q6–8h
  
• Ceftazidime: 1–2 g (peds: 100–150 mg/kg/24 h) IV q8–12h
  
• Dopamine: 1–5 μg/kg/min (renal dose); 5–10 μg/kg/min (pressor dose)
  
• Gentamicin: 1–1.5 mg/kg (peds: 2–2.5 mg/kg q8h) IV q8h
  
• Hydrocortisone: 100 mg IV q6–8h
  
• Metronidazole: Load with 1 g (peds: 15 mg/kg) IV, then 500 mg (peds: 7.5 mg/kg q6h)
  
• Nafcillin: 1–2 g IV q4h (peds: 50 mg/kg/24 h div. q4–6h)
  
• Norepinephrine: 2–8 μg/min
  
• Piperacillin: 3–4 g IV q4–6h
  
• Vancomycin: 500 mg (peds: 10 mg/kg) IV q6h
  

• Normal immune function without an identifiable source:
  
  • 2nd- or 3rd-generation cephalosporin and gentamicin
    
  • Nafcillin and gentamicin
    
  • Add vancomycin if there is a history of methicillin-resistant
    S. aureus,
    or the patient resides in a nursing facility, or there is a history of recent hospitalizations.
    

Immunocompromised host without an identifiable source:

• Piperacillin and gentamicin
  
• Ceftazidime and either nafcillin or vancomycin and gentamicin
  

FOLLOW-UP

Sepsis almost always requires inpatient care.

Patients with less severe infections (e.g., streptococcal pharyngitis) meeting the criteria for sepsis with stabilized vital signs

Sepsis with toxicity, septicemia, or septic shock requires admission, generally to an ICU.

• Start antibiotics as soon as sepsis is suspected.
  
• Failure to recognize multiorgan failure and initiate aggressive fluid resuscitation in the initial presentation of sepsis is a pitfall.
  

• Barochia AV, Cui X, Vitberg D, et al. Bundled care for septic shock: An analysis of clinical trials.
  Crit Care Med
  . 2010;38:668–678.
  
• Martin JB, Wheeler AP. Approach to the patient with sepsis.
  Clin Chest Med
  . 2009;30:1–16.
  
• Rivers E, Nguyen B, Havstad S, et al.; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock.
  N Engl J Med
  . 2001;345(19):1368–1377.
  
• Schuetz P, Jones AE, Aird WC, et al. Endothelial cell activation in emergency department patients with sepsis-related and non-sepsis-related hypotension.
  Shock
  . 2011;36(2):104–108.
  
• Shapiro NI, Wolfe RE, Moore RB, et al. Mortality in Emergency Department Sepsis (MEDS) score: A prospectively derived and validated clinical prediction rule.
  Crit Care Med
  . 2003;31(3):670–675.
  

CODES

• 038.42 Septicemia due to escherichia coli [E. coli]
  
• 038.43 Septicemia due to pseudomonas
  
• 995.91 Sepsis
  

BASICS

• Constellation of signs and symptoms from excessive stimulation of central and peripheral serotonergic receptors
  
• Spectrum of symptoms may range from mild and subtle findings to severe and sometimes fatal toxicity
  
• Results from use of serotonergic agents, alone or in combination with other serotonergic agents (may be therapeutic, intentional overdose, recreational, drug interactions)
  
• Classic triad:
  
  • Autonomic dysfunction: Hyperthermia, diaphoresis, tachycardia, and hypertension
    
  • Cognitive changes: Confusion, agitation, hallucinations, decreased responsiveness
    
  • Neuromuscular excitability: Hyperreflexia, myoclonus, tremors
    

• SSRIs implicated most often, alone or in combination with other drugs
  
• Incidence higher in females but fatalities greater in males
  
• Highest incidence in ages 19–39
  
• Most fatalities from drug/drug interactions or recreational abuse
  

• Serotonin produced by metabolism of L-tryptophan
  
• Exerts action on 5-hydroxytryptophan (5-HT) receptors of which there are 7 types located in central and peripheral nervous systems:
  
  • Influences sleep and temperature regulation, affective behavior, food intake, migraines, emesis, sexual behavior, nociception, motor tone, GI motility, and vascular tone
    
• Extensive list of serotonergic agents, with psychiatric meds most common (SSRIs, SNRIs):
  
  • Examples: Citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, trazodone, venlafaxine
    
• Other serotonergic agents include (not exhaustive):
  
  • Buspirone, cocaine, dextromethorphan, fentanyl, lithium, MAOIs, MDMA (ecstasy), meperidine, methadone, metoclopramide, ondansetron, selegiline, St. John’s wort, TCAs, tramadol, triptans (controversial)
    

DIAGNOSIS

• May be difficult to obtain:
  
  • Family, friends, EMS personnel, may provide additional information
    
• Patient medication list: Prescribed medications, over-the-counter medications, herbal supplements
  
• Medical history:
  
  • Seizures, migraines, attention deficit/hyperactivity disorder, Parkinson, recent illnesses
    
• Psychiatric history
  
• Illicit drug abuse history
  
• Onset of symptoms:
  
  • Mental status/behavioral changes, development of hyperthermia, muscular rigidity/clonus
    

• Vital signs:
  
  • Hyperthermia
    
  • Tachycardia
    
  • Hypertension or hypotension (may evolve into frank shock and cardiovascular collapse)
    
• Dermatologic:
  
  • Diaphoresis, normal color
    
• GI:
  
  • Hyperactive bowel sounds
    
  • Diarrhea
    
• Mental status/neurologic:
  
  • Agitation
    
  • Altered mental status
    
  • Ocular clonus
    
  • Hallucinations
    
  • Waxing/waning delirium
    
• Musculoskeletal:
  
  • Clonus: Most helpful finding in diagnosis, greater in lower extremities
    
  • Hypertonicity and rigidity, greater in lower extremities
    
  • Hyperreflexia, greater in lower extremities
    

• Careful history and physical exam as it is a clinical diagnosis
  
• Hunter criteria – most sensitive (84%) and specific (97%) criteria for diagnosis. Requires having taken/been on a serotonergic agent and 1 of the following:
  
  • Spontaneous clonus
    
  • Inducible clonus plus agitation or diaphoresis
    
  • Ocular clonus plus agitation or diaphoresis
    
  • Tremors plus hyperreflexia
    
  • Hypertonia plus temperature >38°C plus ocular clonus or inducible clonus
    
• Consider other etiologies (sepsis, CVA, etc.)
  

• Blood chemistry/electrolytes, renal function
  
• Urine and serum tox screens may detect coingestants
  
• Lactate, pH
  
• Total CK
  
• Cell count, blood/urine cultures if infectious process suspected
  

• Consider CT head if appropriate (trauma, infectious)
  

• EKG:
  
  • Evaluate QRS/QT intervals, dysrhythmias
    

• Other intoxications (cocaine, amphetamines, anticholinergic agents, ecstasy, PCP):
  
  • Neuroleptic malignant syndrome
    
  • Sympathomimetic toxicity
    
  • Malignant hyperthermia
    
  • Anticholinergic toxicity
    
  • Infectious process (meningitis, encephalitis)
    

TREATMENT