First Things First (assess & treat for the following)

• IF A PT IS IN SHOCK, RESUSCITATE & SUSTAIN THE ABCs FIRST, THEN ASCERTAIN THE ETIOLOGY AFTER TREATMENT IS INITIATED!
• Sepsis is the leading cause of death in noncardiac ICUs.
• Speed and appropriateness of therapy administered in the initial hours after severe sepsis are likely to influence outcome.
• Does the patient have sepsis?
  • Systemic inflammatory response syndrome (SIRS) criteria
  • SIRS: two or more criteria
    • Temperature >38C or < 36C
    • Heart rate >90 beats/min
    • Respiratory rate >20 breaths/min or PaCO2 < 32 mmHg
    • WBC >12,000 or < 4,000 cells/mm3 or >10% immature forms (bands)
  • Sepsis: SIRS secondary to documented or suspected infection
• Does the patient have severe sepsis?
  • Severe sepsis: acute organ dysfunction secondary to infection or tissue hypoperfusion
    • Sepsis-induced hypotension:
    • SBP < 90 mmHg
    • Reduction of SBP of >40 mmHg in adults
    • Mean arterial pressure < 70 mmHg
    • Perfusion abnormalities present
    • Elevated lactate greater than upper limits of normal
    • Elevated creatinine >2.0 mg/dl
    • Bilirubin >2 mg/dl
    • Platelet count < 100,000/mm3
    • Coagulopathy (INR >1.5)
    • Urine output < 0.5 mL/kg hr for >2 hrs, despite fluid resuscitation
    • Acute lung injury (ALI) with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
    • ALI with PaO2/FiO2 < 200 in the presence of pneumonia as infection source
    • Altered mental status
• Does the patient have septic shock?
  • Septic shock: severe sepsis plus hypotension not reversed with fluid resuscitation
• Consider noninfectious causes of SIRS.
  • Differential diagnosis
    • MI, PE, pancreatitis, anaphylactic reaction, toxic shock syndrome, drug overdose or poisoning, hypothermia, delirium tremens, transfusion reaction, cardiac tamponade, UGI bleed, acute adrenal insufficiency