EM Quick Hits 36 – Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome

Topics in this EM Quick Hits podcast

Brit Long on Surviving Sepsis Campaign: 2021 Updates (0:38)

Nour Khatib on rural medicine case: angle closure glaucoma (11:59)

Reuben Strayer on bougie vs endotracheal tube and stylet on first-attempt intubation (20:51)

Justin Hensley on management of frostbite (31:35)

Sarah Foohey on the hot and altered patient (39:50)

Andrew Petrosoniak on central cord syndrome (47:47)



Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Raymond Cho, edited by Anton Helman

Cite this podcast as: Helman, A. Long, B. Khatib, N. Strayer, R. Hensley, J. Foohey, S. Petrosoniak, A. EM Quick Hits 36 - Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome. Emergency Medicine Cases. March 2022. https://emergencymedicinecases.com/em-quick-hits-march-2022/. Accessed [date].

Surviving Sepsis Campaign: 2021 Updates relevant to EM

Screening for Sepsis



* New guidelines recommend against using qSOFA as a single screening agent

* Commentary: NEWS score is likely a better single screening tool that is easy to use and can be done at triage



Resuscitation



* Fluids



* Guidelines now only suggest rather than recommend using 30 cc/kg of IV crystalloid within the first 30 minutes of resuscitation

* Balanced crystalloids such as Plasmalyte and Lactated Ringer's recommended as a first line over normal saline





* Vasopressors



* In most patients, norepinephrine is the first-line vasopressor, followed by vasopressin, then epinephrine

* In patients with cardiac dysfunction, use norepinephrine as first line then dobutamine or epinephrine alone

* In septic shock resistant to vasopressors, guidelines now support using IV hydrocortisone





* Monitoring resuscitation



* Use dynamic parameters (e.g. passive leg raise, stroke volume/pulse pressure variation, ultrasound) rather than using static parameters

* Point-of-care ultrasound can be used to assess volume status (IVC, B-lines, cardiac activity)

* For patients in septic shock, target a MAP of 65 mmHg

* Adjunctive markers: use capillary refill, lactate to guide resuscitation





* Antimicrobial therapy



* In patients with possible sepsis without shock, consider investigating for other causes for up to 3 hours before starting antimicrobial therapy (adjusted from 1 hour from previous guidelines)

* Choice of antimicrobials in the empiric phase



* High risk of multi-drug resistant organisms: 2 agents with gram negative coverage

* Low risk of multi-drug resistant organisms: 1 agent with gram negative coverage

* High risk of MRSA: provide coverage for MRSA (eg. vancomycin)

* No risk factors for MRSA: no routine MRSA coverage









* Other



* IV vitamin C is not recommended in septic shock







Update 2023: A multicenter randomized controlled trial including 1563 patients with sepsis-induced hypotension refractory to initial treatment with 1-3L of IV fluids comparing a restrictive fluid strategy (prioritizing vasopressors and low intravenous fluid volumes) and a liberal fluid s...