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#53 - Assumptions Do One Thing...


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#21 TexRNmedic

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Posted 12 June 2010 - 03:02 AM

Just a few things we're going to clarify before I toss out the next update. Everyone's doing well here at the hospital. I'm on the laptop, but I don't really have an hour or so to go through all of the posts. Supposed to go home tomorrow, so we'll see.

1) Where do we stand on the airway management issue? What drugs do we want to use?

2) Anything in his physical exam that is jumping out at you? Dave, what are you thinking?

3) He's hispanic, no strange religious practices.


1) Versed 0.1mg/kg IV. Cuffed ETI. P-GCS is low enough that this is all it should take. Don't know enough about his hx. Duchenne MD etc. Hesitating to give a paralytic when probably not needed here.

2) Pupils, petechiae/rash/hand print, dirty hands and wounds. Lot of things little boys can get into. Has he been digging in the liter box, playing with racoons or bats, eating dirt, splashing around in ditches, handling nasty shrooms etc? Need more neuro details to help me pick tox, bug or TBI.

3) Que bueno.
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Wes Seale
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#22 jjones1418

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Posted 12 June 2010 - 03:29 AM

Just to start…

This facility sounds like many of the East Texas EDs that are not much more than a tech, RN and mid-level or an on call family practice MD. iSTAT labs and flat plate xray on film is usually all they have.


Exactly.



Now, to discuss everyone’s points.

Speed –
I’ll get to the labs you have at the end of my post. TexRNmedic hit it exactly right on the description of the facility. You won’t get much out of them. His parents are Mexican, moved up from Mexico a few months ago. His dad is a farm worker and they live in a house on the farm. No abnormal religious practices to speak of.

TexRNmedic –
Rectal Temp is 100.3 F. Capillary blood glucose is 104 mg/dL. Your RN partner (who was mine on this flight) is absolutely awesome and pops in a nice 18ga in the kid’s arm. No medical history that the parents are aware of. Our Spanish, between the two of us, consisted of “Where el hurto?” The little bit of information we got from the parents is that he had multiple seizures, and that’s why he was brought to the ER. The seizures were described as “violent, generalized seizures” by the PA in the ER.

Sean –
No neuro workup, but I’ll hit a few details further down the post. Clear CXR , lung sounds clear, heart sounds = normal S1,S2, no murmur. We don’t have a urine dipstick available. Weight is approximately 22kg. The GCS and SpO2 are accurate.

JLP –
We don’t have anyone available other than a security guard that answers “kinda” when you ask if he can help translate. No language line available. The father is very standoff-ish when asked to answer questions and will not give answers other than yes/no. The mother is obviously upset, says that the child just wouldn’t stop seizing. She didn’t know what to do other than bring the child to the ER. You are able to ascertain that he has no medical history and has been healthy until this recent “illness.” She says that the child was just sick for a day and she brought him to the ER the few days before. The RN that is taking care of him today said that the doctor just looked at him for a few minutes then discharged him home. She said he thought he just had a little virus. We thought it was rather abnormal that they sent a 4 year old home in diapers.

Dave –
I see you clued in on his physical exam. What made you think twice about the handprint on his throat and the petechial hemorrhages?


Neuro Exam – Patient’s GCS is 6 as charted. He moans and exhibits decorticate posturing to deeply painful stimuli. No response to IV stick or glucose check. His pupils are sluggishly responsive at 6mm. They are equal. No abnormal reflexes noted.

Skin – Warm and Moist (Not diaphoretic, just moist)

While you’re setting up to manage this kid’s airway, you note that his heart rate has dropped to 106, his respiratory rate is 6 and ataxic in pattern. His BP is still around 90/50. Your partner starts assisting ventilations with a BVM. You also note a lot of secretions around the patient’s mouth and in his mouth that require suctioning.

You get one shot at an iStat cartridge. (I’ll go ahead and warn you, it’s not going to give you any enlightening information anyway)
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Jason Jones, EMT-P

#23 TexRNmedic

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Posted 12 June 2010 - 04:09 AM

Just to start…



Exactly.



Now, to discuss everyone’s points.

Speed –
I’ll get to the labs you have at the end of my post. TexRNmedic hit it exactly right on the description of the facility. You won’t get much out of them. His parents are Mexican, moved up from Mexico a few months ago. His dad is a farm worker and they live in a house on the farm. No abnormal religious practices to speak of.

TexRNmedic –
Rectal Temp is 100.3 F. Capillary blood glucose is 104 mg/dL. Your RN partner (who was mine on this flight) is absolutely awesome and pops in a nice 18ga in the kid’s arm. No medical history that the parents are aware of. Our Spanish, between the two of us, consisted of “Where el hurto?” The little bit of information we got from the parents is that he had multiple seizures, and that’s why he was brought to the ER. The seizures were described as “violent, generalized seizures” by the PA in the ER.

Sean –
No neuro workup, but I’ll hit a few details further down the post. Clear CXR , lung sounds clear, heart sounds = normal S1,S2, no murmur. We don’t have a urine dipstick available. Weight is approximately 22kg. The GCS and SpO2 are accurate.

JLP –
We don’t have anyone available other than a security guard that answers “kinda” when you ask if he can help translate. No language line available. The father is very standoff-ish when asked to answer questions and will not give answers other than yes/no. The mother is obviously upset, says that the child just wouldn’t stop seizing. She didn’t know what to do other than bring the child to the ER. You are able to ascertain that he has no medical history and has been healthy until this recent “illness.” She says that the child was just sick for a day and she brought him to the ER the few days before. The RN that is taking care of him today said that the doctor just looked at him for a few minutes then discharged him home. She said he thought he just had a little virus. We thought it was rather abnormal that they sent a 4 year old home in diapers.

Dave –
I see you clued in on his physical exam. What made you think twice about the handprint on his throat and the petechial hemorrhages?


Neuro Exam – Patient’s GCS is 6 as charted. He moans and exhibits decorticate posturing to deeply painful stimuli. No response to IV stick or glucose check. His pupils are sluggishly responsive at 6mm. They are equal. No abnormal reflexes noted.

Skin – Warm and Moist (Not diaphoretic, just moist)

While you’re setting up to manage this kid’s airway, you note that his heart rate has dropped to 106, his respiratory rate is 6 and ataxic in pattern. His BP is still around 90/50. Your partner starts assisting ventilations with a BVM. You also note a lot of secretions around the patient’s mouth and in his mouth that require suctioning.

You get one shot at an iStat cartridge. (I’ll go ahead and warn you, it’s not going to give you any enlightening information anyway)


I've been to a few of the rural ETMC facilities. Basically a room or two off the clinic.
Labs= chem and gas combo.
Reread the original post. No active vommiting today. Incontinent of bowel and bladder with seizures. No mention of diarrhea. Skin is pretty normal for a well hydrated kid. By your above post I'm going to assume that the labs will be pretty close to normal. Symptoms x4 days. I'm starting to lean to towards neurogenic cause. Especially with the biot's respiration, periorbital petechiae, decorticate posturing, mydriasis and hand print mark. Was the kid choked and/or assaulted? Fever may be neurogenic too. Signs of increased ICP, medulla compression and probable herniation. Looks like the kid has a head injury/bleed for one reason or another. Still gonna tube. Ventilate for ETCO2 goal of 30. Not a big fan of mannitol unless we are looking at herniation. Well JLP lets give it. Going to load up on our phenytoin dose. This will not end well with an hour trip ahead of us. I'm not going to get tunnel vision either. I'll still keeping hunting for an ID and/or tox cause as well. Life threats first then Sherlock Holmes later.
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Wes Seale
Houston , TX

#24 redlingc

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Posted 12 June 2010 - 05:06 AM

OK- I'll give this a shot, I'm reeeeeealllly new to the critical care world (Still just riding a ground ALS bus/teching in an ER) so please be gentle. Most of my initial actions are the same as what has already been discussed. The kiddo is really starting to decompensate, I would give 0.5mg Atropine to try and dry him up and clear the secretions and and knock the kid down enough with versed 0.1mg/kg to be able to intubate him without paralyzing him, it shouldn't take a whole lot, cuffed tube and ventilate to an etCO2 of 30-40. IV is already taken care of so I'd give him a 20ml/kg bolus to start with and be try to get him tanked up a little bit.

Most of my differentials have already been said including a head bleed of some type and a toxic exposure. I've seen more than one hispanic family that have done WIERD things to people seizing, is the bruising from them trying to get him to stop seizing possibly? Who knows what chemicals the kiddo could have gotten into on the farm, some farmers in our area have no idea what they have on their land. The other thing that comes to mind is what are their living quarters like? We have had more than one migrant family living in a chicken coop or barn, shed whatever. Could the kid have gotten into some sort of pile o' poo of some sort (Hanta virus or something of the like?) The only other thing that I could throw out would be a neurocysticercosis/gi tapeworm infestation. We have a heavy migrant worker population in our district and they eat a TON of pork. The kiddo is only four but they just got here from Mexico so who knows what he ate before he got here and where they got it from. The kiddo has a little brain so a little tapeworm could cause a huge issue for the little dude. Not too familiar with the istat so I don't know what you can get from a cartridge, but I would at least like to see some chemistrys and abg on him. Just my thoughts....

Chris
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#25 DartmouthDave

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Posted 12 June 2010 - 05:07 AM

Hello,

I am not sure if this patient is a chronic carrier from birth. Or has just acquired it from the scratches on his had or from his father whom is a farmer. I am leaning towards a recent infection because I assume a chronic toxo infection would cause some sort of developmental delay by 4 years of age.

From what I recall, toxoplasmosis cause flu like symptoms in most cases. Acute cases can cause meningitis, seizures and cutaneous eruptions (i.e. urticaria on the neck)and petechial hemorrhages (i.e. around the eyes). I think (not sure) that the parasites can damage the heart and other organs as well.

However, this is difficult because I have never seen a case of toxo nor have I delt with peds too much. Sorry, no references at the moment. I have been off work for the past 8 weeks. New baby in the house. LOL....trying to hammer out this post ASAP.

For treatment, still would stick with fluids, tube, and sedate with Fentanyl and Versed. I would deeply sedated this poor little fellow (RAAS -4) and see if that stops the posturing before I would give Manitol 20%.

Cheers
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#26 DartmouthDave

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Posted 12 June 2010 - 05:12 AM

Hello,

I almost forgot to ask; Is Dexamethsone a part of a you CNS-Sepsis protocol?

Cheers
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#27 TexRNmedic

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Posted 12 June 2010 - 05:53 PM

Hello,

I am not sure if this patient is a chronic carrier from birth. Or has just acquired it from the scratches on his had or from his father whom is a farmer. I am leaning towards a recent infection because I assume a chronic toxo infection would cause some sort of developmental delay by 4 years of age.

From what I recall, toxoplasmosis cause flu like symptoms in most cases. Acute cases can cause meningitis, seizures and cutaneous eruptions (i.e. urticaria on the neck)and petechial hemorrhages (i.e. around the eyes). I think (not sure) that the parasites can damage the heart and other organs as well.

However, this is difficult because I have never seen a case of toxo nor have I delt with peds too much. Sorry, no references at the moment. I have been off work for the past 8 weeks. New baby in the house. LOL....trying to hammer out this post ASAP.

For treatment, still would stick with fluids, tube, and sedate with Fentanyl and Versed. I would deeply sedated this poor little fellow (RAAS -4) and see if that stops the posturing before I would give Manitol 20%.

Cheers



Heavy sedation is definitely important to minimize ICP spikes. Mannitol is going to pull out some of the edema/fluid and hopfully reduce ICP and maximize CPP (even if only transiently)-see Monro-Kellie doctrine. I would throw both therapies at this kid as it is starting to look like current or impending herniation. I would hesitate to give steroids until I know this isn't an ID. I've given tons of decadron to neurotrauma/neurosurg patients in ICU, but no infection was present.
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Wes Seale
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#28 jjones1418

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Posted 12 June 2010 - 06:35 PM

Interesting twist coming soon... Waiting on more replies to my last update.
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Jason Jones, EMT-P

#29 TexRNmedic

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Posted 12 June 2010 - 07:07 PM

Interesting twist coming soon... Waiting on more replies to my last update.


Sounds good Jason. I'd be surprised if his ABG and chem aren't at least a little off. Respiratory acidosis and some lyte issues from puking for 4 days. Really need more data before I commit to any particular treatment. Looks like imminent herniation with what you've given. Need to cross some things of my diff dx list as treating one problem will cause harm with others. Sedating, tube, bag down to 30mmHg CO2 and going to take a deep breath and another look at the kid. I'll probably get another line/IO or two in the kid. Not all the possible drugs are compatible and some of them (KCl, vanc, pressors) have a high probability of causing the vessel to fail and site to go bad.
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Wes Seale
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#30 DartmouthDave

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Posted 12 June 2010 - 09:30 PM

Hello,

"I would hesitate to give steroids until I know this isn't an ID. I've given tons of decadron to neurotrauma/neurosurg patients in ICU, but no infection was present." TexasRNmedic

That is what I thought. However, where I currently work Dexametsone is a part of the Sepsis protocol. At first, I was very perplex. Steroids and infection don't mix. However, the logic (as explained to me and on Up To Date) is that for patient's that survive long-term neurological sequelae. Also, I am not sure if the same potential benefit applies to children. Lastly, I have spoken with friend and colleagues and none of them have heard of this practice.

Just wonder if anybody has heard of this??

Have to run....

Cheers
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#31 SerendepitySaki

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Posted 12 June 2010 - 09:37 PM

you're giving concommitant abx.
http://www.ncbi.nlm....pubmed/17253505
this ref is specific to meningitis, BUT directly applicable to rationale for administration during sepsis... giving you a twofer.... PM me off line if you want me to go into it in greater detail....
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LET THE WILD RUMPUS BEGIN !!!!!!
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#32 TexRNmedic

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Posted 12 June 2010 - 09:53 PM

Hello,

"I would hesitate to give steroids until I know this isn't an ID. I've given tons of decadron to neurotrauma/neurosurg patients in ICU, but no infection was present." TexasRNmedic

That is what I thought. However, where I currently work Dexametsone is a part of the Sepsis protocol. At first, I was very perplex. Steroids and infection don't mix. However, the logic (as explained to me and on Up To Date) is that for patient's that survive long-term neurological sequelae. Also, I am not sure if the same potential benefit applies to children. Lastly, I have spoken with friend and colleagues and none of them have heard of this practice.

Just wonder if anybody has heard of this??

Have to run....

Cheers


Was just talking offline with Sean about this. Prevents/limits inflamation from the WBC sludge build up and the fibrosis of the meninges, commonly leading to hydrocephalus and other sequlae. Low and controlled doses of corticosteroids are appropriate to meet metabollic needs secondary to adrenal supression found in sepsis. I'd want a cortisol level to document the need for steriod in sepsis.

Decadron takes 12-24 hours to become therapuetic in the tx of cerebral edema. With all that said, I'm cool with giving a 2-4mg dose of decadron with the understanding that we would also be concurrently covering with broad-spectrum abx.
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Wes Seale
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#33 SerendepitySaki

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Posted 12 June 2010 - 10:10 PM

ahhhhh.... i wonder if i'm making myself clear.... my understanding is that you get a two-fer with corticosteroids in sepsis....BOTH compensation for the adrenal suppression AND prophylactic suppression of inflammatory response.....dex can also allegedly help in some cases of cerebral/cord edema, which wes alluded to offline.... in any case, it certainly is VERY unlikely to hurt anything here and may help....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#34 onearmwonder

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Posted 12 June 2010 - 10:45 PM

Don't know if this can help clear up anything, but try going here: www.survivingsepsiscampaign.com... Check out the guidelines and bundles... Good luck!

Matt
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#35 BrianACNP

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Posted 12 June 2010 - 10:52 PM

ahhhhh.... i wonder if i'm making myself clear.... my understanding is that you get a two-fer with corticosteroids in sepsis....BOTH compensation for the adrenal suppression AND prophylactic suppression of inflammatory response.....dex can also allegedly help in some cases of cerebral/cord edema, which wes alluded to offline.... in any case, it certainly is VERY unlikely to hurt anything here and may help....


Sorry....this is side-barring, but I can't help myself.....

You're partly correct.....You do give corticosteroids in SEPSIS for identified or suspected adrenal insufficiency. You're not giving them to suppress the inflammatory response. The inflammatory response is so dramatic in sepsis that it would take a high dose of steriods to even attempt to suppress it. And high dose steriods in sepsis has been shown to worsen mortality. This was proven many years ago. Anyone care to answer the question as to why? The only way to lessen the SIRS response to treat the underlying problem.

One last comment......hydrocortisone is the drug of choice to treat adrenal insufficiency in sepsis. It has both mineralocorticoid and glucocorticoid activity. If you choose to use dexamethasone (which is not the preferred drug), then you need to add Fludrocortisone, which is primarily has mineralocorticoid activity.

This all comes from the Surviving Sepsis Campaign guidelines. The latest edition is from 2008. Also, there was a concensus conference that provided recommendations on the management of adrenal insufficiency in critical illness.....that concensus conference reflects what I've typed above along with other additional recommnedations on stim testing, etc. The article on the Consensus Conference is in the Critical Care Medicine journal.

Brian
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Brian, MSN, ACNP, CCRN

#36 SerendepitySaki

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Posted 12 June 2010 - 10:55 PM

thanks brian....here's the link: it's .ORG, not .com....

http://www.surviving...es/default.aspx
http://www.surviving...seSteroids.aspx


Sorry....this is side-barring, but I can't help myself.....

You're partly correct.....You do give corticosteroids in SEPSIS for identified or suspected adrenal insufficiency. You're not giving them to suppress the inflammatory response. The inflammatory response is so dramatic in sepsis that it would take a high dose of steriods to even attempt to suppress it. And high dose steriods in sepsis has been shown to worsen mortality. This was proven many years ago. Anyone care to answer the question as to why? The only way to lessen the SIRS response to treat the underlying problem.

One last comment......hydrocortisone is the drug of choice to treat adrenal insufficiency in sepsis. It has both mineralocorticoid and glucocorticoid activity. If you choose to use dexamethasone (which is not the preferred drug), then you need to add Fludrocortisone, which is primarily has mineralocorticoid activity.

This all comes from the Surviving Sepsis Campaign guidelines. The latest edition is from 2008. Also, there was a concensus conference that provided recommendations on the management of adrenal insufficiency in critical illness.....that concensus conference reflects what I've typed above along with other additional recommnedations on stim testing, etc.

Brian


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LET THE WILD RUMPUS BEGIN !!!!!!
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#37 TexRNmedic

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Posted 12 June 2010 - 10:59 PM

ahhhhh.... i wonder if i'm making myself clear.... my understanding is that you get a two-fer with corticosteroids in sepsis....BOTH compensation for the adrenal suppression AND prophylactic suppression of inflammatory response.....dex can also allegedly help in some cases of cerebral/cord edema, which wes alluded to offline.... in any case, it certainly is VERY unlikely to hurt anything here and may help....

http://www.annals.org/content/141/1/47.full

No problem with a neuro-protective dose or adrenal replacement therapy at all. The drug reference I have have states for cerebral edema: loading dose of 1-2mg/kg IV max 16mg. Maintenance dose of 1-1.5 mg/kg/day divided q4-6h. Adrenal insufficiency: 0.03-0.3 mg/kg/day divided q6-12 hours. Bacterial meningitis: 0.6 mg/g/day divided q 6 hours x2 days. Spinal cord injury: 2mg/kg/day divided q6 hours.

So who's gonna step up and push 16mg of decadron on this kid? :blink: ;)

Trying to wrap my head around where in the inflamatory cascade the steroids work in sepsis. Does it inhibit PMN activation and therefore a reduction in leukotriene and thromboxane A2 generation? Supression of IL1, IL2 and/or TNF? Maintenance of APC levels? As in the above article, glucocorticoid therapy has been shown to be associated with a decreased dependance on vasopressors. So I'm guessing a minimally immunosupresive effect on the PMN and T-cell activation leading to a decreased negative impact on cardiac output and vasodialation. Thoughts?
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#38 TexRNmedic

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Posted 12 June 2010 - 11:09 PM

Sorry....this is side-barring, but I can't help myself.....

You're partly correct.....You do give corticosteroids in SEPSIS for identified or suspected adrenal insufficiency. You're not giving them to suppress the inflammatory response. The inflammatory response is so dramatic in sepsis that it would take a high dose of steriods to even attempt to suppress it. And high dose steriods in sepsis has been shown to worsen mortality. This was proven many years ago. Anyone care to answer the question as to why? The only way to lessen the SIRS response to treat the underlying problem.

One last comment......hydrocortisone is the drug of choice to treat adrenal insufficiency in sepsis. It has both mineralocorticoid and glucocorticoid activity. If you choose to use dexamethasone (which is not the preferred drug), then you need to add Fludrocortisone, which is primarily has mineralocorticoid activity.

This all comes from the Surviving Sepsis Campaign guidelines. The latest edition is from 2008. Also, there was a concensus conference that provided recommendations on the management of adrenal insufficiency in critical illness.....that concensus conference reflects what I've typed above along with other additional recommnedations on stim testing, etc. The article on the Consensus Conference is in the Critical Care Medicine journal.

Brian



Thanks Brian. Snuck in here while I was typing my reply. Seemed a little wishy washy. Seems like big doses would overly suppress the immune system allowing for a surge in primary infection and the potential for nasty secondary infections. Pretty standard bundle out there now for sepsis including lab diagnostics and recommendations for corticoid replacement. Only "anti-inflammatory" drug I know for treating sepsis is Xigris for replacement of activated Protein C. Florinef & Cortef for adrenal replacement therapy.
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Wes Seale
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#39 SerendepitySaki

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Posted 12 June 2010 - 11:11 PM

not going there tiger... even though my background IS research molecular biology, with an emphasis on immunology.... suffice to say i don't agree with Brian 110% and would love to see specific definitive references.....i agree with MOST of Brian's points right down the line, (especially the PRIMARY reason for giving steroids in sepsis and that dex is NOT the agent of choice) others, not so much.... no time to look it up myself AND we're coming at it from slightly different angles to begin with....

my ENTIRE point was that empiric dex probably would not hurt anything, but that it was not high upon the "to-do" list....
poor Dave muddled things by first lumping CNS and Sepsis together, then separating them....we've sidebarred this more than long enough...my apologies to Jason and CONGRATS again on the beautiful boy!

http://www.annals.or...t/141/1/47.full

No problem with a neuro-protective dose or adrenal replacement therapy at all. The drug reference I have have states for cerebral edema: loading dose of 1-2mg/kg IV max 16mg. Maintenance dose of 1-1.5 mg/kg/day divided q4-6h. Adrenal insufficiency: 0.03-0.3 mg/kg/day divided q6-12 hours. Bacterial meningitis: 0.6 mg/g/day divided q 6 hours x2 days. Spinal cord injury: 2mg/kg/day divided q6 hours.

So who's gonna step up and push 16mg of decadron on this kid? :blink: ;)

Trying to wrap my head around where in the inflamatory cascade the steroids work in sepsis. Does it inhibit PMN activation and therefore a reduction in leukotriene and thromboxane A2 generation? Supression of IL1, IL2 and/or TNF? Maintenance of APC levels? As in the above article, glucocorticoid therapy has been shown to be associated with a decreased dependance on vasopressors. So I'm guessing a minimally immunosupresive effect on the PMN and T-cell activation leading to a decreased negative impact on cardiac output and vasodialation. Thoughts?


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LET THE WILD RUMPUS BEGIN !!!!!!
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#40 TexRNmedic

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Posted 12 June 2010 - 11:19 PM

my ENTIRE point was that empiric dex probably would not hurt anything, but that it was not high upon the "to-do" list....[/u]poor Dave muddled things by first lumping CNS and Sepsis together, then separating them....we've sidebarred this more than long enough...my apologies to Jason and CONGRATS again on the beautiful boy!


Agreed on all above points! Not pointing any fingers at who tipped the first domino over. I'm not the sharpest crayon in the box. Sorry everyone for beating this one to death. Needed a little clarification on rationale. Moving right along. Has any weather moved in during the flight and while on scene? Can change at the drop of a hat down here in the Houston area.
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Wes Seale
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