JO - Sepsis, MODS, and Neurological Assessment in Paramedicine

Shock

Begins with localized tissue damage, may progress to organ failure and death.

Sepsis

Mild systemic response to bacterial infection or suspected infection.

Sepsis Criteria

Suspected or proven infection AND increase in sequential organ failure assessment with a score of 2 or more from baseline.

Septic Shock

Hemodynamic instability with SIRS.

Septic Shock Criteria

Sepsis AND vasopressor therapy required to maintain a MAP of greater than or equal to 65 mmHg AND lactate > 2mmol/L despite adequate fluid therapy.

SIRS

Systemic inflammatory response syndrome.

qSOFA

Quick Sequential Organ Failure Assessment.

qSOFA Criteria

Includes: Altered mental status, RR greater or equal to 22 breaths/min + SBP greater than or equal to 100 mmHg with a score of > or = to 2.

Lactate

A measure that indicates cellular metabolism abnormalities, with a threshold of > 2mmol/L in septic shock.

Mortality Assessment

qSOFA enhances specificity for short-term mortality assessment at the expense of lower sensitivity.

SIRS and Sepsis Relationship

Not every patient with SIRS will have sepsis/septic shock.

Organ Failure

May occur as a result of shock and sepsis.

Inflammatory Response

Inappropriate inflammatory response can lead to sepsis.

Complex Disorders

Sepsis may be caused by or lead to complex disorders.

NEWS 2 Score of 5

Indicates high risk for sepsis.

Vasodilation

Causes redness and heat production.

Smooth Muscle Contraction

Leads to difficulty breathing.

Increased Capillary Permeability

Results in edema and swelling.

Vasopressin (ADH)

A hormone essential for cardiovascular stability, stored in the pituitary gland.

Nitric oxide (NO)

An important gas in septic shock that regulates vascular tone.

Mitochondrial dysfunction

Sepsis disrupts mitochondria from generating ATP.

Hemodynamic Alterations

Principal problem is hypotension from systemic vasodilation.

Myocardial depressants

Proinflammatory cytokines promote cardiac dysfunction.

Neurologic impairment

Includes altered mental status and lethargy.

Pulmonary Involvement

Often involves easy infiltration with neutrophils and leads to ARDS.

Gastrointestinal Effects

Shock state causes significant deleterious effects on hollow viscus and its O2 supply.

Endocrine disorders

Includes conditions like hyperglycemia and adrenal insufficiency.

Cytokine-mediated inhibition

Inhibits pyruvate dehydrogenase, affecting ATP production.

Early Recognition of Sepsis

Focus on identifying abnormalities of behavior, circulation, or respiration.

Source of Infection

Common sources include respiratory tract, urinary tract, and abdominal tract.

Signs and Symptoms of Sepsis

Include tachypnea, altered mental status, hypotension, and mottling of the skin.

Sepsis Assessment

Involves maintaining a high index of suspicion and thorough patient history.

Sepsis Management

Early recognition and management are vital.

Fluid resuscitation

Volume expansion to optimize CO

Recommended fluid resus. Volume

30 mL/kg

Vasopressor + inotropic support

Includes Dobutamine, phenylephrine, epinephrine, vasopressin

Supportive care

Includes oxygen therapy, warmth + comfort etc.

Risk factors for sepsis

Older adults, immunocompromised and neutropenic patients, and having multiple comorbidities

Diagnostic evaluation for sepsis

Guided by thorough history, physical examination, and lab testing

Early treatment focus for sepsis

Appropriate identification, improvement of tissue perfusion/oxygenation, administration of antibiotics, and early identification of infections that may require surgery

Prompt administration of antibiotics

Essential and should be based on the suspected source of infection

Multiple Organ Dysfunction Syndrome (MODS)

A hypometabolic, immunodepressed state with clinical + biochemical evidence of decreased organ function due to an acute injury or illness

MODS mechanism

Includes comorbidities, medications, inflammation, coagulation cascade, neuro-endocrine factors

MODS assessment

Presence of a systemic inflammatory response (e.g., SIRS criteria) and dysfunction of at least 2 organs

Frontal Lobe

Responsible for executive function + motor strip

Frontal Eye Field

Responsible for voluntary + rapid eye movements

Broca's Area

Motor speech area vital for producing spoken language; damage leads to broken speech

Motor Cortex

Executes voluntary movements of the body by sending impulses through the brainstem + spinal cord to skeletal muscles

Somatosensory Cortex

Receives + integrates sensory information related to touch, temperature, pain, and the sense of body position/movement

Temporal Lobe

Involved in sound, language, and memory/emotion

Wernicke's Area

Responsible for comprehending written + spoken language; damage leads to weird speech

Brainstem

Responsible for vital functions + CN + conduit consciousness

Parietal Lobe

Involved in sensory perception + integration

Occipital Lobe

Responsible for vision

Cerebellum

Responsible for balance + coordination

Basal Ganglia

Cluster of nuclei crucial for regulating voluntary movement, planning + cognitive functions like reward

Thalamus

Acts as a central relay + integration station; processes most sensory info and directs it to the appropriate cortical areas

Internal Capsule

Serves as a major two-way pathway for ascending + descending fibers carrying info to and from the cerebral cortex, connecting it to the brainstem, spinal cord, and other subcortical structures

Homunculus

A map that shows how brain areas correspond to different body parts; helps locate strokes by predicting symptoms based on the affected brain region + its blood supply

Anterior Cerebral Artery

Supplies blood to the medial parts of front + parietal lobes; causes leg weakness

Middle Cerebral Artery

Largest artery, supplies lateral portions of cerebral hemispheres; most common site for strokes

Posterior Cerebral Artery

Supplies the occipital lobes + parts of the temporal lobes.

Internal Carotid Artery

Major blood vessel that supplies blood to the front of the brain.

Vertebral Artery

Major blood vessel that supplies blood to the back of the brain.

Circle of Willis

A ring-shaped network of arteries at the base of the brain where the internal carotid and vertebral arterial systems meet.

Midbrain

Controls eye movement, vision + hearing processing.

Pons

Coordinates facial expressions, balance, hearing + relays info between cerebrum and cerebellum.

Medulla Oblangata

Regulates vital autonomic functions like breathing, heart rate, blood pressure, and swallowing.

Brain Pathology DDX

Differential diagnoses based on the timing of symptoms: Sudden (vascular obstruction, seizure), Rapid (migraine, toxicity, metabolic disorders), Subacute (infection, CVST, autoimmune disorder, toxicological/metabolic disorders), Chronic (degenerative function, mass, toxicological/metabolic disorder).

Brain Localizing Signs

Signs such as gaze deviation, aphasia, hemineglect/VF deficits, cranial nerve deficits, crossed face/body, hemi body, increased reflex/Babinski.

Mental Status Testing

Assessing level of alertness and Glasgow Coma Scale.

Higher Cerebral Functions

Includes dominant vs. non-dominant features impacting language and visual inattention.

Cranial Nerves Examination

Includes pupil examination for constriction and response, affecting cranial nerve III.

Primary Sensory Modalities

Includes light touch, pinprick, position, vibration, and temperature sense.

Motor System Assessment

Muscle tone may be characterized as normal, decreased, or increased.

Reflexes

Patterns of reflex abnormalities may suggest a location of a problem within the CNS or peripheral nervous system.

Babinski Response

Expect feet to fan out in pediatrics or curl in adults; opposite reaction indicates upper motor neuron dysfunction.

Cerebellar Testing

Assesses involuntary activities of the CNS and helps with smoothing muscle movements and aiding with movement coordination.

Gait and Station

Observation of the patient walking and the posture assumed when stationary.

Nystagmus Eye Movements

Involuntary eye movement that may indicate cerebellar dysfunction.

Neurological Assessment

A comprehensive evaluation of mental status, cranial nerves, sensory modalities, motor system, reflexes, and cerebellar function.