Clinical ReviewClinical Mimics: An Emergency Medicine–Focused Review of Sepsis Mimics
Introduction
Emergency physicians are well versed in the care of sepsis, as close to 750,000 patients per year are admitted for sepsis in the United States 1, 2, 3, 4. A wide range of estimates for prevalence exists, with 300 to 1000 cases per 100,000 persons per year. More than half of admitted septic patients will require at least step-down unit care or greater. Mortality rates vary from 20% to 50% 1, 2, 3, 4. Not only is the mortality severe, but studies have shown increasing costs of care for these patients 1, 2, 3, 4.
Systemic inflammatory response syndrome (SIRS) and sepsis are common clinical entities, and these conditions exist along a spectrum 2, 5, 6. The definition of sepsis has undergone several modifications with the Surviving Sepsis Campaign (2). The clinical syndromes involving SIRS, sepsis, severe sepsis, and septic shock are shown in Table 1. Unfortunately, these criteria are nonspecific, and the criteria alone do not provide a diagnosis or predict outcome (7). A recent intensive care unit study found a sensitivity of 88% for SIRS in patients with confirmed sepsis. However, associated organ dysfunction does predict poorer outcome (7).
Sepsis is a commonly investigated condition in the literature because of its potential for severe mortality and morbidity and its high prevalence. Emergency physicians are considered first-line for resuscitating patients in extremis, and septic patients can rapidly decline clinically. Resuscitation includes source evaluation, antimicrobials, ensuring adequate preload with intravenous (IV) fluids, and vasopressors if necessary as key components 2, 5. The SIRS criteria were established to diagnose sepsis quickly to begin management 2, 5, 6, 7. A deficit of studies is present in the current literature detailing conditions that mimic sepsis. This review provides an overview of these mimics and an approach to these conditions.
Section snippets
Why Does SIRS Occur in Patients with Sepsis?
Sepsis ultimately results from a complex interaction of proinflammatory, antiinflammatory, activated complement system, and coagulation mediators that trigger a host response in association with detector and signaling markers. Initiators (e.g., microbes, trauma, hypoxia, ischemia, and toxins) cause local tissue damage, which release local pro- and antiinflammatory markers. Proinflammatory signalers include tumor necrosis factor and interleukins-1 and -6, while anti-inflammatory markers include
Conclusions
SIRS and sepsis exist along a continuum resulting from uncontrolled systemic response. There are many mimics for sepsis. The most important aspect of managing these patients is resuscitation first. Obtaining rapid IV access, monitor placement, and supplemental oxygen while evaluating the ABCDE's (i.e., airway, breathing, circulation, disability, and exposure/examination) are essential in resuscitation. The history and examination are keys to diagnosis, but sepsis must always be considered.
References (60)
Pathophysiology of sepsis
Am J Pathol
(2007)- et al.
Who needs a blood culture? A prospectively derived and validated prediction rule
J Emerg Med
(2008) - et al.
Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis
Lancet Infect Dis
(2013) - et al.
Serum lactate as a predictor of mortality in emergency department patients with infection
Ann Emerg Med
(2005) - et al.
Older patients in the emergency department: a review
Ann Emerg Med
(2010) - et al.
Anaphylaxis
J Emerg Med
(2014) - et al.
Customizing anaphylaxis guidelines for emergency medicine
J Emerg Med
(2013) - et al.
Aspiration pneumonia: a review of modern trends
J Crit Care
(2015) - et al.
The clinical manifestations, diagnosis, and treatment of adrenal emergencies
Emerg Med Clin North Am
(2014) - et al.
Cooling methods in heat stroke
J Emerg Med
(2016)
Diuretic-induced severe hyponatremia. Review and analysis of 129 reported patients
Chest
Fever and pulmonary thromboembolism
Am J Med
Fever in acute pulmonary embolism
Chest
Leukocytosis in acute pulmonary embolism
Chest
Initial management of acute spinal cord injury
Contin Educ Anaesth Crit Care Pain
Prognosis of emergency department patients with suspected infection and intermediate lactate levels: a systematic review
J Crit Care
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012
Crit Care Med
Benchmarking the incidence and mortality of severe sepsis in the United States
Crit Care Med
Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003
Crit Care Med
Severe sepsis and septic shock: improving outcome in the emergency department
Emerg Med Clin North Am
Systemic inflammatory response syndrome criteria in defining severe sepsis
N Engl J Med
Does this adult patient with suspected bacteremia require blood cultures?
JAMA
Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis
Clin Infect Dis
Procalcitonin as a marker of infection, sepsis, and response to antibiotic therapy
Crit Care Med
Etiology and therapeutic approach to elevated lactate
Mayo Clin Proc
Sepsis and its mimics
Intern Med
Aspiration pneumonitis and aspiration pneumonia
N Engl J Med
Evaluation and management of intestinal obstruction
Am Fam Physician
Bowel obstruction and volvulus
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Reprints are not available from the authors.