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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Wednesday, July 27, 2016

Occult Sepsis in Traumatic Injuries

emDocs - July 26, 2016 - Author: Long B - Edited by: Koyfman A
..."Sepsis and Trauma patients may both demonstrate positive SIRS criteria. The qSOFA score may also be positive in these patients, which raises questions regarding the use of Sepsis 3.0 to differentiate sepsis and trauma.
The best tools for diagnosis likely include the use of history, vital signs, physical examination, ultrasound, laboratory markers, and clinical gestalt.
One recent review article published in 2015 compares the classic approaches to resuscitation in trauma and sepsis patients.
Management priorities in trauma from Frankel HL, Magee GA, Ivatury RR. Why is sepsis resuscitation not more like trauma resuscitation? Should it be? J Trauma Acute Care Surg 2015 Oct; 79 (4): 669-77.
This diagram reflects the primary strategies for trauma management: (1) fix the problem (often bleeding source), (2) provide fluids (usually blood products), and (3) utilize appropriate tests and monitoring. The authors advocate that sepsis should be cared for similar to trauma, with targeted source control and minimizing “collateral damage,” including over-resuscitation.
The initial management strategy of the patient in extremis for trauma and sepsis is similar. Resuscitate first and ask questions later. As discussed above, go through Airway, Breathing, Circulation, Disability/D-stick, Exposure, E-FAST exam/fetus (is the female patient pregnant?). Obtain IV access, attach monitors, and be prepared to provide supplemental O2.
Finally, when diagnosing sepsis, a potential source needs to be found. The LUCCASSS pneumonic is helpful toward assisting in a search for the source: source: lung (pneumonia), urine (cystitis/pyelonephritis), cardiac (endocarditis), CNS (meningitis, encephalitis), abdominal (abscess, cholecystitis), spine (osteomyelitis, abscess), skin (cellulitis, IV line/PICC infection), and septic arthritis. Fortunately, an accurate history, physical examination, and appropriate laboratory tests and imaging can usually pinpoint the source of sepsis, but a systematic approach should be followed. Look for biomarkers that are not improving, and evaluate for hypotension, altered mental status, and RR ≥ 22/min. These are markers for mortality and should trigger consideration of sepsis."