Contents
Sepsis & Septic Shock
Sepsis Definitions (Sepsis-3)
- Sepsis: Life-threatening organ dysfunction caused by dysregulated host response to infection
- SOFA Score ≥2 points = Organ dysfunction
- qSOFA (Quick SOFA): RR ≥22, AMS, SBP ≤100 - screening tool
- Septic Shock: Sepsis + vasopressors needed to maintain MAP ≥65 + lactate >2 despite fluids
Sepsis Hemodynamic Profile
- Early (warm) shock: Low SVR, High CO, warm extremities, bounding pulses
- Late (cold) shock: Low SVR, Low CO, cool extremities, poor perfusion
- Elevated lactate indicates tissue hypoperfusion
- SvO2 may be high early (cells not extracting O2) then low
Hour-1 Bundle
- Measure lactate level
- Obtain blood cultures before antibiotics
- Administer broad-spectrum antibiotics
- Begin rapid fluid resuscitation (30 mL/kg crystalloid for hypotension or lactate ≥4)
- Apply vasopressors if hypotensive during/after fluid resuscitation
Sepsis Management
- Source control: Drain abscesses, remove infected devices
- Norepinephrine: First-line vasopressor
- Add vasopressin if refractory (not titrated)
- Consider hydrocortisone for refractory shock
- Target MAP ≥65 mmHg
- Reassess fluid responsiveness (avoid over-resuscitation)
Multiple Organ Dysfunction Syndrome
MODS Overview
- Progressive dysfunction of 2+ organ systems
- Common triggers: Sepsis, trauma, burns, pancreatitis, massive transfusion
- Pathophysiology: Systemic inflammation → endothelial dysfunction → organ failure
- Primary MODS: Direct insult to organs
- Secondary MODS: Response to systemic inflammation
Organ System Manifestations
- Pulmonary: ARDS (P/F ratio <300)
- Cardiovascular: Hypotension requiring vasopressors
- Renal: AKI (elevated creatinine, decreased UOP)
- Hepatic: Elevated bilirubin, coagulopathy
- Hematologic: DIC, thrombocytopenia
- Neurologic: Encephalopathy, decreased GCS
MODS Management
- Treat underlying cause
- Supportive care for each failing organ
- Minimize iatrogenic harm: Lung-protective ventilation, avoid nephrotoxins
- Nutritional support: Early enteral nutrition when possible
- Prevent complications: DVT prophylaxis, stress ulcer prophylaxis
- Higher number of failing organs = higher mortality
MDROs & Hospital-Acquired Infections
Multi-Drug Resistant Organisms
- MRSA: Methicillin-resistant Staphylococcus aureus
- VRE: Vancomycin-resistant Enterococcus
- CRE: Carbapenem-resistant Enterobacteriaceae
- ESBL: Extended-spectrum beta-lactamase producers
- Risk factors: Prior antibiotics, prolonged hospitalization, invasive devices
Healthcare-Associated Infections
- CLABSI: Central line-associated bloodstream infection
- CAUTI: Catheter-associated urinary tract infection
- VAP: Ventilator-associated pneumonia
- SSI: Surgical site infection
- C. difficile colitis: Often antibiotic-associated
Infection Prevention Bundles
- CLABSI: Hand hygiene, maximal barriers, chlorhexidine prep, daily line necessity review
- CAUTI: Avoid unnecessary catheters, daily review of necessity, aseptic technique
- VAP: HOB elevation, oral care, sedation vacation, spontaneous breathing trials
- Contact precautions for MDRO patients
- Antimicrobial stewardship: Appropriate antibiotics, de-escalation
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Practice Now →Toxic Ingestions & Overdose
Toxidrome Recognition
- Sympathomimetic: Tachycardia, hypertension, hyperthermia, dilated pupils, agitation
- Anticholinergic: "Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter"
- Cholinergic (SLUDGE): Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis
- Opioid: Respiratory depression, miosis (pinpoint pupils), decreased LOC
- Sedative-hypnotic: CNS depression, normal pupils, normal vitals
Common Overdoses & Antidotes
- Acetaminophen → N-Acetylcysteine (NAC)
- Opioids → Naloxone (Narcan)
- Benzodiazepines → Flumazenil (use cautiously - seizure risk)
- Beta blockers → Glucagon, High-dose insulin
- Calcium channel blockers → Calcium, High-dose insulin
- Organophosphates → Atropine, Pralidoxime
- Tricyclic antidepressants → Sodium bicarbonate
General Management
- ABCs: Secure airway if GCS ≤8 or loss of protective reflexes
- Decontamination: Activated charcoal within 1-2 hours if appropriate
- Enhanced elimination: Dialysis for certain toxins
- Supportive care: Temperature management, seizure control
- Contact Poison Control: 1-800-222-1222
Influenza & Respiratory Viruses
Influenza Overview
- Types A (most severe) and B cause seasonal epidemics
- Transmission: Respiratory droplets, contact with contaminated surfaces
- Incubation: 1-4 days
- Symptoms: Sudden onset fever, myalgia, headache, cough, sore throat
- High-risk groups: Elderly, immunocompromised, pregnant, chronic disease
Complications
- Primary viral pneumonia
- Secondary bacterial pneumonia (S. aureus, S. pneumoniae)
- ARDS
- Myocarditis, pericarditis
- Encephalitis
- Rhabdomyolysis
- Exacerbation of chronic conditions
Treatment & Prevention
- Antivirals: Oseltamivir (Tamiflu), Zanamivir, Baloxavir
- Most effective within 48 hours of symptom onset
- Consider for high-risk patients even after 48 hours
- Supportive care: Fluids, antipyretics, oxygen as needed
- Prevention: Annual vaccination, hand hygiene, respiratory precautions
- Droplet precautions for hospitalized patients
Critical Care Considerations
- Severe cases may require mechanical ventilation
- ARDS management with lung-protective ventilation
- Prone positioning for refractory hypoxemia
- ECMO for refractory respiratory failure
- Bacterial superinfection: Empiric antibiotics if suspected
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Priority actions in first hour of sepsis (Hour-1 Bundle):
- Administer a bolus of fluids, draw blood cultures, administer broad-spectrum antibiotics, and measure lactate
- Administer broad-spectrum antibiotics, draw blood cultures, initiate vasopressors, and monitor urine output
- Measure lactate, administer broad-spectrum antibiotics, and draw urine cultures
- Draw blood cultures, administer broad-spectrum antibiotics, administer crystalloids (30ml/kg) for hypotension, and vasopressors if hypotensive
Rationale: Cultures must be drawn before antibiotics (if it doesn't delay start >45 mins)....
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Antidote for Tylenol (Acetaminophen) toxicity:
- Protamine Sulfate
- N-Acetylcysteine (NAC)
- Vitamin K
- Flumazenil
Rationale: Restores glutathione. Most effective within 8 hours....
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The primary mechanism causing hypotension in sepsis is:
- Increased afterload
- Increased contractility
- Peripheral vasodilation
- Reduced vascular permeability
Rationale: Sepsis triggers the release of inflammatory mediators that cause massive peripheral vasodilation (low SVR) and capillary leak, leading to hypotension....
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Practice Multisystem Questions
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Take Multisystem Quiz →Frequently Asked Questions
What percentage of the CCRN exam is multisystem?
Multisystem accounts for 14% of the Adult CCRN exam — about 18 of the 125 scored questions — covering conditions that affect multiple organ systems at once.
What multisystem topics are tested on the CCRN exam?
Expect sepsis and septic shock (the hour-1 bundle), multiple organ dysfunction syndrome, toxic ingestions and overdoses, post-cardiac-arrest care and targeted temperature management, pain, sedation and delirium management, and end-of-life care.
What sepsis numbers does the CCRN expect me to know?
Know the hour-1 bundle: measure lactate, draw blood cultures before antibiotics, give broad-spectrum antibiotics, infuse 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L, and start vasopressors (norepinephrine first-line) to keep MAP ≥ 65 mmHg.
How should I study multisystem for the CCRN exam?
Start with sepsis — it is the single highest-yield topic in this category. Then cover MODS progression, common overdose antidotes, and post-arrest care. Multisystem questions often combine systems, so practice full scenario-style questions rather than isolated facts.