Part III of Dr. Rivers' talk on Severe Sepsis
Dr. Emanuel Rivers brought the concept of aggressive therapies for sepsis down to the Emergency Department with his seminal article on EGDT published in the NEJM in 2001. We were lucky enough to get an hour of his time to do a conference call with the NYC STOP Sepsis collaborative.
I broke the ~1 hour lecture into 3 parts.
If you haven't already, check out Part I and Part II.
In Part III, Dr. Rivers discusses:
- Protein C?
- Can you do EGDT in small community EDs?
- How do you handle the tachycardic patient with severe sepsis?
- Steroids in the ED?
- Procalcitonin?
Additional New Information
More on EMCrit
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Latest posts by Scott Weingart, MD FCCM (see all)
- EMCrit 385 – Eye Trauma I – Retrobulbar Hematoma, Orbital Compartment Syndrome, and Paracanthal Decompressions - October 5, 2024
- EMCrit Wee – Did this Really Just HAPPEN? – The HAPPEN Trial Hot Take – NIPPV for COPD - September 29, 2024
- EMCrit 384 – The Vascular Guy on Vascular Access - September 23, 2024
One thing I love about Dr. Rivers is his relatively rational approach to therapy. Intervene early, when appropriate and wait when appropriate. There’s a lot to learn from this.
How many other disease states are out there in which an earlier intervention is as powerful?
Pneumonia? Yes
Status epilepticus? Yes
ACS? Yes
Others?
Mike Jasumback, MD
absolutely Mike. Hypoglycemia and any exsanguination as well.
Thanks guys for a truly inspiring and informative podcast. Dr Rivers , you are a living legend. Scott, you are the international man of ED critical care.
in regard to digoxin use in the tachycardic patient with sepsis, totally agree. I use it a lot and rarely have issues when you are using it for acute rate control. Usually with rapid AF but Rivers is right you can use it for any supra ventricular tachycardia includin sinus tachy. And if they have some heart failure element to their sepsis it’s a useful inotrope as well.
Minh, you are too kind! I’m glad to hear you like dig for these folks. I’ll have to give it a try. How long after giving it do you see any tangible change in the heart rate?
s
Scott, generally you see a response within 60min after a 0.5mg IV load
I give another 0.5mg dose depending upon the response at 1hr.
You reduce the dose in renal dysfunction of course, generally halve the dose.
Hello,
Great advice. Suggested on rounds the other day for a tachy septic patient and it worked like a charm.
Also, I have used Scott’s method; opiates. I transfered a septic patient from the ED the other day only on a Propofol infusion. Up went the Fentanyl and the patient settled.
PS…Minh Le Cong: Did you post on Flight Web? You profile picture looks familar?
Cheers,
David
yep A1 sedation (analgesia first)!
good stuff, my friend
Hi David
yep I did post on Flight web for a while. Then I found EMCrit
Great set of podcsts by Dr Rivers. One question with respect to digoxin use. I was always taught that dig has a vagotonic effect and would have little benefit in high sympathetic states (hence does not prevent exercised induced fibrillation). Would its effect as an inotrope indirectly reduce heart rate?
Alex, I have always thought the exact same thing. I guess even a bit of vagal tone may be helpful.
PRICELESS PRESENTATION BY DR RIVERS, THANKS MATE.
KAUSHIK
SPECIALITY REGISTRAR IN ACUTE MEDICINE
HEART OF ENGLAND, BIRMINGHAM, UK.
My pleasure, my friend
great talks!
need your input. do you think early goal directed therapy w/ central line insertion should still be initiated even if a lactate of above 4 resolves or decreases after fluid resuscitation?
thanks!
In NYC we use serial lactates as per the Jones trial rather than central line/classic egdt. See https://emcrit.org/sepsis