CanadiEM Frontline Primer

CanadiEM Frontline Primer – Fever & Sepsis

In Medical Concepts by Afsheen MeharLeave a Comment

Can’t Miss Diagnoses

  • Sepsis (obviously) – but critically important to find the source and control it!
  • Meningitis / Encephalitis (Not to miss since may need LP for full diagnosis)
  • Febrile neutropenia (especially if recent chemotherapy)
  • Alcohol Withdrawal (hyperthermia, tachycardia, diaphoresis)
  • Benzodiazepine Withdrawal (hyperthermia, tachycardia, diaphoresis)
  • Toxic ingestions – cocaine, methamphetamines, crystal meth
  • Thyroid Storm
  • Serotonin Syndrome
  • Neuroleptic malignant syndrome

Points to focus upon

Approximately 0.5% of ED visits are related to sepsis, with the majority of cases (55-70%) occurring in patients 60 and older.​1,2​ Most patients diagnosed with sepsis are admitted to hospital (75-90%), with up to a third of these patients admitted to ICU. Septic shock is a rare (<5%) but serious complication.​2​

Resuscitation Needs

IV, O2, monitoring and complete vitals.

Hx:

Recognizing the source of infection, travel, immunocompromised status and sick contact history.

Remember: Not all fever is from an infectious source. Some non-infectious causes of fever: PE, thyrotoxicosis, crystal arthropathy, toxic ingestions, withdrawal syndromes, etc.

Also Remember: Not all septic patients have a fever. Those without fever have been shown to have worse in-hospital outcomes.

Approach
Often vague initial presentation with broad differential in older patients, however, it is critical to initiate empiric therapy as soon as possible. Therefore having a high index of suspicion is important, particularly in vulnerable populations (e.g. advanced age, immunosuppressed, diabetes, malignancy, recent hospitalization).

Considerations in the age of COVID-19 for your safety:
Not all COVID-19 patients will present with fever and cough, and older patients can often present atypically. If the rate of COVID-19 is high in your community, take appropriate precautions when assessing patients with concern for sepsis or other infectious syndromes.

Investigations

  • CBC, BUN, Cr, Lytes, Glucose, VBG
  • Consider NPS, Blood Cultures
  • Consider CXR, Urinalysis (+/- culture),
  • Imaging based on suspected source of infection – e.g. CNS imaging (brain, spine), CT KUB for Septic urolithiasis, Ultrasound of biliary tree for cholangitis/cholecystitis, CT Abdo/Pelvis for other intraabdominal sources.
Consider adding the following:
  • Troponin / ECG – depending on suspicion for end-organ dysfunction
  • Liver enzymes – – depending on suspicion for end-organ dysfunction
  • Liver function tests (Bilirubin, INR, Albumin, Glucose) – depending on suspicion for end-organ dysfunction
  • Lipase
If coagulopathy suspected, may want to consider:
  • INR/PR
  • PTT
  • Fibrinogen
  • D-Dimer

Clinical Decision Tools

Sepsis Scores
  • qSOFA Mnemonic -HAT (Hypotension, AMS, Tachycardia)
  • SOFA (current criteria – surviving sepsis 2016)
  • NEWS
  • NEWS2 (Most recent criteria – calculated at triage without bloodwork)
Pneumonia Scores

Management

The mainstay of sepsis resuscitation is:
1) Supportive measures (including fluid resuscitation and intubation as needed);
2) Early antibiotics and/or source control.

Fluid resuscitation should be targeted to support perfusion of end-organs. And vasoactive agents (a.k.a. “pressors”) can be used to help as well, and maybe started peripherally (yes, even norepinephrine).
The first choice fluid is currently Ringer’s Lactate for large-volume fluid resuscitation. Please see below for First 10:EM summaries of the three recent IV Fluids Papers (SPLIT, SMART, and SALT-ED).

For patients with COVID-19 (or suspected COVID-19), conservative fluid resuscitation and early use of vasoactive agents is advised since higher volumes of fluids may be harmful. See the JAMA SSC Summary (Published March 26, 2020).

Recommended reading, videos, and podcasts

The following is part of the CanadiEM Frontline Primer. An introduction to the primer can be found here. To return to the Primer content overview click here.

This post was edited by Dr. Sonja Wakeling MD. This post was copyedited and uploaded by Evan Formosa.

References

  1. 1.
    Strehlow MC, Emond SD, Shapiro NI, Pelletier AJ, Camargo CA Jr. National Study of Emergency Department Visits for Sepsis, 1992 to 2001. Annals of Emergency Medicine. September 2006:326-331.e3. doi:10.1016/j.annemergmed.2006.05.003
  2. 2.
    Wang HE, Jones AR, Donnelly JP. Revised National Estimates of Emergency Department Visits for Sepsis in the United States*. Critical Care Medicine. September 2017:1443-1449. doi:10.1097/ccm.0000000000002538
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Afsheen Mehar

Afsheen Mehar

Dr. Afsheen Mehar is a resident physician at the University of Toronto in the RCPSC Emergency Medicine Training Program. Her greatest passions are medical education, POCUS and austere medicine. She holds an RDMS certification in ultrasound.
Afsheen Mehar
- 2 days ago
Ryan O'Reilly

Ryan O'Reilly

Ryan O'Reilly is a medical student at McMaster with interests in EM, infectious diseases, and primary care. He previously completed a PhD at the University of Toronto with a focus on decision analysis and health administrative data.
Teresa Chan

Teresa Chan

Senior Editor at CanadiEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Chief Strategy Officer of CanadiEM. Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University.
Teresa Chan
- 7 hours ago