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spinal fluid; CXR, chest x-ray; UA, urina lysis.

storm, transfusion reaction, malignancy, autoimmune disorders, or drug fever.

Use the history and physical examination to make decisions about testing and treatment. If the patient is stable and

there is an obvious source of infection, antipyretics should

be given and antibiotics when appropriate. In the hemodynamically unstable patient, intravenous fluid resuscitation

should be initiated along with monitoring, respiratory support, and antipyretics (see Chapter 34). Empiric antibiotic

treatment with broad-spectrum antibiotics should be started

immediately in the ED for unstable patients if an obvious

source cannot be found (Figure 33-1).

TREATMENT

Antipyretics (eg, acetaminophen or ibuprofen) are administered to increase patient comfort and reduce the metabolic

demand. Patients who are stable can be treated with hydration and appropriate antibiotics. Patients with signs and

symptoms of shock ( eg, AMS, hypotension, tachycardia)

require monitoring and aggressive fluid resuscitation.

Patients with signs of respiratory compromise or airway

obstruction may require intubation. In critically ill or

immunocompromised patients, administer antibiotic therapy early. If there is no known source of infection, administer broad-spectrum antibiotic therapy to cover aerobic

(gram-positive and gram-negative) and anaerobic organisms. The choice of antibiotic is based on the most likely

cause of the fever as well as patient considerations such as

neutropenia. Antibiotic dosing may be altered in patients

with renal insufficiency or in patients with specific conditions (eg, bacterial meningitis).

DISPOSITION

..... Admission

Patients who are unstable, immunocompromised ( eg, HN,

elderly, neonate), have serious localized infection (eg,

meningitis), or have serious comorbidities ( eg, pneumonia

and congestive heart failure) should be admitted to the

hospital for further stabilization and treatment. Admission

may also be warranted in patients with no obvious source

of infection, but signs of serious illness.

..... Discharge

Young healthy patients without comorbidities or serious

focal infections can usually be discharged home with c lose

follow-up.

FEVER

SUGGESTED READING

Bentley DW. Practice guideline for evaluation of fever and infection

in long-term care facilities. Clin Infect Dis. 2000;31:640-653.

Darowski A, Najim z, Weinberg JR. The febrile response to mild

infections in elderly hospital residents. Age Ageing .

1991;20:193-198.

Fontanarosa PB, Kaeberlein FJ, Gerson LW, Thomson RB.

Difficulty in predicting bacteremia in elderly emergency

patients. Ann Emerg Med. 1 992;2 1 :842-848.

Sepsis

Rakesh S. Engineer, MD

Key Points

• Identification of the septic patient is the important first

step. All other critical actions are missed if this does not

occur.

• Lactate measurement is critical to determining sepsis

severity, response to therapy, and prognosis.

INTRODUCTION

Sepsis is now defined as "infection plus systemic manifestations of infection" (Table 34-1) . Systemic inflammatory response syndrome is no longer a strict criteria.

There are 3 sepsis syndromes (stages) : uncomplicated

sepsis, severe sepsis, and septic shock. Sepsis becomes

severe sepsis when there is tissue hypoperfusion or organ

dysfunction (Table 34-2). Septic shock is defined as a

systolic blood pressure (SBP) <90 mmHg or 40 mmHg

below one's baseline blood pressure, despite two 20- to

30-mL/kg boluses.

Sepsis affects 75 1 ,000 patients per year, with an

annual mortality that exceeds that of AIDS and breast

cancer and approaches that of myocardial infarction. The

lungs, abdomen, and urinary tract are the most frequent

source of infection, but sepsis can come from anywhere

in the body. In approximately 20% of cases, the etiology

cannot be determined. Risk factors for the development

of sepsis syndromes are extremes of age, immunosuppression (chemotherapy, organ transplantation, steroid

use, HIV, etc.), severe comorbid disease, exposure to

multiple drug-resistant organisms, vascular catheters

and other indwelling devices, intravenous (IV) drug

abuse, trauma, and burns.

• Early administration of appropriate antimicrobials

and early goal-directed therapy are the mainstays of

treatment.