Toxic Shock Syndrome


CAUSES

Inflammatory cascade similar to that seen in sepsis, triggered by exotoxin release Two distinct syndromes:

Staphylococcal toxic shock syndrome (TSS)

Streptococcal toxic shock syndrome (STSS)

LABS/TESTS

DIAGNOSIS

CDC Criteria for TSS
  • Fever > 38.9 C (102 F).
  • Rash
  • (Diffuse, blanching, erythematous with desquamation occurring approximately 1-2 wks later)
  • Hypotension with SBP < 90 mmHg
  • Evidence of involvement of ≥3 organ systems (GI, muscular, mucus membranes, renal, hepatic, CNS, hematologic)
  • Absence of serologic evidence of:
    • Rocky Mountain spotted fever
    • Leptospirosis
    • Measles
    • Hepatitis B
    • Antinuclear antibody
    • Positive VDRL
    • Monospot
CDC Criteria for STSS
  • Isolation of group A streptococcus (CSF, surgical wound, throat, blood)
  • Hypotension with SBP < 90 mmHg.
  • Involvement ≥ 2 organ systems


TREATMENT

Agent Receptor Activity Effects Indication
a1 b1 b2 DA
(Levophed)
Norepinephrine
1-30 mcg/min
+++

 

++ 0 0 SVR ↑↑
CO ↔↓↑
Sepsis
Phenylephrine
(Neo-synephrine)
40-180 mcg/min
+++

 

0

 

0

 

0

 

SVR ↑↑
CO ↔/↑
Sepsis,
Neurogenic shock
Epinephrine +++

 

+++ ++ 0

 

CO ↑↑
SVR ↓ (L)
SVR ↔/↑ (H)
Anaphylaxis,
ACLS,
Sepsis
Dopamine (mcg/kg/min)
Low-dose (0.5-2) 0 + 0 ++ CO ↑
SVR ↑↓
Sepsis,
Cardiogenic shock
Mid-dose(5-10) + ++ 0 ++ CO ↑
High-dose(10-20) ++ ++ 0 ++ SVR ↑↑
Doubutamine
2.5-20 mcg/kg/min
0/+ +++ ++ 0 CO ↑
SVR ↓
Cardiogenic shock
Isoproterenol
2-10 mcg/min
0

 

+++ +++ 0 CO ↑
SVR ↓
Cardiogenic shock w/
bradycardia
Vasopressin
(Adjunct)
0.01-0.04 U/min
        V2 receptors Vasoconstriction
Augments catecholamine

Receptor Functions
Receptor Function
α1  vascular smooth muscle contraction
pupillary dilator muscle contraction (mydriasis), 
intestinal and bladder sphincter muscle contraction
α2 sympathetic outflow, 
Insulin release
 lipolysis, 
platelet aggregation
β1 Heart rate
Contractility
Renin release
Lipolysis
β2 Vasodilation
Bronchodilation 
Heart rate
 Contractility
lipolysis
 Insulin release
 Uterine tone (tocolysis)
Ciliary muscle relaxation
 Aqueous humor production
M1 CNS, enteric nervous system
M2  Heart rate and contractility of atria
M3  exocrine gland secretions (e.g., lacrimal, salivary, gastric acid), 
gut peristalsis, 
bladder contraction,
Bronchoconstriction, 
pupillary sphincter muscle contraction (miosis),
Ciliary muscle contraction (accommodation)
D1 Relaxes renal vascular smooth muscle
D2 Modulates transmitter release, especially in brain
H1 nasal and bronchial mucus production, 
vascular permeability
Contraction of bronchioles
Pruritus
Pain
H2 gastric acid secretion
V1 vascular smooth muscle contraction
V2 H2O permeability and reabsorption in the collecting tubules of the kidney (V2 is found in the 2 kidneys)