2000 Words A 62-year-old female with a history of type 2 diabetes mellitus and hypertension was admitted to a trauma center following a Motor vehicle accident. Examination revealed blunt thoracic and abdominal trauma and a fractured right femur. The patient was dyspneic, tachycardic, hypotensive, and her skin was pale and cool. A right-sided hemothorax was managed by chest tube insertion. Imaging studies, along with exploratory surgery, revealed extensive trauma and bleeding within the abdominal cavity. Surgical management of the abdominal hemorrhage and the fractured femur resulted in significant improvement in vital signs, and the patient was moved to the ICU. Four days later, the patient became febrile (39.8) and her WBC count was elevated >10,000. Sepsis was immediately suspected, broad-spectrum IV antibiotic therapy was initiated, and blood cultures were obtained. During the following 24-48 hours, the patient experienced increasing respiratory distress (28 RR) and hypotension 90/40 BP. Urine output decreased and the serum creatinine and blood urea nitrogen were elevated. Deteriorating blood gases necessitated intubation and mechanical ventilation. The patient was determined to be in severe sepsis leading towards septic shock. Clinical findings: Vital Signs on Fourth Day Temperature: 39.8, Bp 90/40, RR 28, HR 136, patient became confused and showed signs of abdominal distension and rebound tenderness. Define: Sepsis, Severe Sepsis and Septic shock. One of the first indications of altered proinflammatory/anti-inflammatory balance and the emergence of sepsis is the development of SIRS. Discuss SIRS in relation to the above patient and what “criteria” does she have to indicate SIRS. Discuss the Pathophysiology and clinical signs/symptoms of Severe Sepsis and the progression to septic shock. Review and discuss the diagnostic tests that would be requested in this case study to investigate the severity and source of infection/sepsis. Include in your answer coagulation studies, blood chemistries, WCC differential, lumbar puncture, blood cultures, urine analysis, x-rays, Ultrasound, MRI and CT scans. Progressive Sepsis can lead to disseminated intravascular coagulation (DIC) and Multi organ Dysfunction (MODS). Discuss these two conditions in relation to severe sepsis/septic shock. The major focus of resuscitation from septic shock is on supporting cardiac and respiratory functions. Discuss in your answer types of fluid resuscitation including crystalloid or colloid solutions and frequently administered Vasopressors. How will you monitor your client’s fluid resuscitation status? Include in your answer Central Venous Pressure monitoring, Arterial Line Monitoring and kidney function. What are the signs and symptoms of a client in fluid overload? How can we address this issue? As this client has an abdominal distention and an abdominal trauma, research the following antibiotics metronidazole, meropenem, piperacillin-tazobactam, ciprofloxacin, ceftazidime and cefepime and report on their use of action and side effects and why these drugs are recommended for abdominal infections. Discuss why the above patient needed intubation and the benefits of intubation to a patient in Septic shock, include in your answer “deteriorating blood gases” and what this would indicate.

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