Sepsis is a clinical syndrome induced from the host response to an infection. Severe sepsis is the leading cause of death in critically ill patients. The introduction of the early goaldirected therapy (EGDT) has been able to reduce mortality in patients with severe sepsis/septic shock. However, sepsis mortality rates remain high compared to other critical illnesses. Many studies have pointed out that the use of arterial line placement and the execution of central venous pressure and central venous oxygen saturation measurements are the most difficult EGDT elements to carry out in community hospitals. For these reasons, the present independent review examines recent pathogenic, diagnostic, and therapeutic development in sepsis with particular relevance to the emergency practice, following the latest guidelines published in February 2013 and several recent studies. We propose a non-invasive alternative protocol which can replace the standard treatment with non-substantial changes in the patient outcome though overcoming the obstacles of a invasive method.
Evans syndrome is a rare autoimmune disease presenting hemolytic anemia, thrombocytopenia and/or neutropenia. It may be associated with other autoimmune or lymphoproliferative diseases. It can have an extremely serious disease course and, in rare cases, this can even be life-threatening. First-line treatment consists of steroids and/or immunoglobulin. Further therapy with rituximab, vincristine, cyclophosphamide and other immunosuppressive drugs can be considered in unresponsive patients. We report a case of Evans syndrome in a 54-year old woman admitted to the Emergency Department (ED) for asthenia. Etiopathogenic, clinical, therapeutic and evolutive aspects are discussed. In contrast to many cases described in the literature, our patient had a satisfactory response to corticoids. We also discuss how to make a specific diagnosis, even in a suburban ED with limited resources, in order to admit patients to the appropriate hospital department and allow the correct therapy to be started as early as possible.
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