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Most people may think that toxic shock syndrome, a very interesting and deadly disease, is not seen anymore. The Centers for Disease Control and Prevention's (CDC) 1987 statistics show that this is incorrect, because toxic shock syndrome is seen in approximately 1-2/100,000 women (Department of Health, 2005). The CDC also states that 5% of people die from this disease (Department of Health, 2005). In 1995, Dr. Dennis L. Stevens wrote an article on Streptococcal toxic shock syndrome stating that it had a 30% death rate even with aggressive treatments (Stephens, 1995). This disease is caused by either the Group A Streptococcus bacteria, or the Group A Staphylococcus pathogen.
There are over 30 different types of Staphylococcus bacterium and these bacterium can cause health issues including skin infections, pneumonia, blood poisoning, endocarditis, and toxic shock syndrome (Medline Plus, 2010). Staphylococcus bacterium is commonly found on human skin and causes no complications, but once they enter a wound or the blood stream they can cause mild or life threatening diseases. When found just on the skin they cause minor skin infections that are easily treated, but if they progress to the blood stream then they can cause systemic damage to organs and/or organ systems. Staphylococcus usually develops in hospitalized patients or people who are immunocompromised, such as people with Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency syndrome (AIDS). Healthy people can develop these life-threatening diseases as well. Staphylococcus Aureus' severity depends on where the infection takes hold and can cause a very wide range of symptoms. This pathogen can survive drying, extreme temperatures, high levels of salt and can also live on inanimate objects long enough to be transported from one person to another (Mayo Clinic Staff, 2009). This bacterium is wide spread in hospitals, despite the attempts to sterilize everything by the common practice of deep cleaning. Staphylococcus tends to attack the most susceptible patients including those with weakened immune systems, burns, surgical wounds, and patients with serious preexisting medical histories such as diabetes (Mayo Clinic Staff, 2009).
Group A streptococcus bacterium.
Group A streptococcus bacterium is a pathogen that is commonly found on people's skin and in the throat. These pathogens usually cause no signs or symptoms of infection in these locations. Over a large amount of time they can cause strep throat or impetigo which is the formation of blisters that will burst, scab and wear away and is typically seen in children (WordNet, n.d.). This bacteria can occasionally spread into places where bacteria is not regularly found and can cause life threatening disorders, syndromes, and diseases. When Streptococcus enters these areas it becomes known as Invasive Group A Streptococcus. Two of the most common are necrotizing fasciitis, a skin eating disease, and streptococcal toxic shock syndrome; both of these diseases are rarely seen. Streptococcal toxic shock syndrome is not associated with staphylococcus toxic shock syndrome, and it is accompanied by a large, sudden drop in blood pressure and organ damage. Necrotizing fasciitis kills approximately 25% of its victims whereas Streptococcus toxic shock syndrome claims more than 35% of its victim's lives (Department of Health, 2008). This bacterium also preys on the immunocompromised, such as cancer patients, HIV/AIDS patients, diabetics, post-operative patients, and people using steroids (Department of Health, 2008).
The epidemiology of toxic shock syndrome varies among each individual situation. Since Staphylococcus and Streptococcus bacterium stay on the skin this makes it a danger for anyone who has had surgery because the infection can transfer to the wounds that result from the surgery. Patients that have traumatic injuries can also be at risk for these infections. Immunosuppression can also cause toxic shock syndrome to become more dangerous. Any illness weakens the immune system and makes the body more susceptible to infection. A woman's menstruation can also cause this infection.
The pathophysiology behind toxic shock syndrome results from the Staphylococcus or the Streptococcus pathogen as it binds to the major histocompatibility complex which is a set of molecules on cells' surfaces that helps regulate the immune system (Cleveland Clinic, 2010). This binding causes a mass increase of T cells and an overproduction of cytokines, which make up the messenger system for the immune system, causing vascular permeability that leads to the tissue damage of organs and shock (Cleveland Clinic, 2010). This syndrome causes many serious complications that can last long after the initial infection has been taken care of. Toxic shock syndrome's long lasting effects can lead to problems such as cardiac and renal dysfunction, amputation of an extremity, neuropathy, acute tubular necrosis which results in damage to the tubule cells in the kidneys that can cause acute kidney failure, and adult respiratory distress syndrome (MD Consult, 2007).
Stages of infection
Being familiar with the stages of Toxic Shock Syndrome can help the pre-hospital provider know how treatment should vary. The most life-threatening form of toxic shock syndrome is very similar to septic shock. The plan of treatment for this infection can change as the stages become more severe as the infection spreads.
Onset of toxic shock syndrome is very sudden and it advances quickly. Patients have a
sudden onset of fever, chills, muscle aches, a sunburn like rash, nausea, vomiting, and diarrhea (DynaMed, 2011). These are the first signs of this disease starting to manifest.
When blood pressure drops into a hypotensive level, toxic shock syndrome becomes classified as moderate. This drop in blood pressure can cause dizziness or syncope. Patients may also become dehydrated if they have been vomiting or had diarrhea and because of accompanied vascular permeability (DynaMed, 2011).
This disease becomes very deadly when the patient starts having severe hypotension; this will lead to shock and organ damage or organ death if not treated properly (DynaMed, 2011). A patient with this phase of toxic shock syndrome in the pre-hospital setting is a critical patient that needs to be transported quickly to the nearest hospital for medical treatment. This condition is above and beyond the scope of practice and requires medicine that is not carried on ambulances.
The diagnosis of this disease is a long and drawn out process, because other conditions such as Kawasaki disease and scarlet fever must be ruled out before a diagnosis is made (DynaMed, 2011). A diagnosis must be made by blood cultures and urine specimens to determine which exact pathogen is causing the toxic shock syndrome (DynaMed, 2011). Another way to detect this disease is by placing a culture in mannitol and seeing if the bacterium ferments the mannitol (DynaMed, 2011).
Toxic shock syndrome is treated with high powered antibiotics such as nafcillin and clindamycin as well as giving fluids and vasopressors (DynaMed, 2011). Fluids and vasopressors are given to help increase the fluid in the vascular space and to cause vasoconstriction which raises the blood pressure and helps to perfuse the whole body until the antibiotics have time to defeat the infection causing the toxic shock syndrome (DynaMed, 2011).
Gender issues can easily arise with this condition. Many women who develop this disease could be uncomfortable when talking to a male paramedic about menstrual cycles and their use of tampons. This can make for a difficult assessment and can cause the paramedic to treat the patient incorrectly due to inaccurate or dishonest answers.
Many religions are extremely critical of a woman's privacy and female menstruation. Muslims believe that a woman's private areas should never be seen except by her husband. This can cause problems with male paramedics in the field. Religious beliefs can have a very large impact on healthcare and on a patient's acceptance of healthcare providers' duties.
Treatment with rationale.
Pre-hospital providers are able to treat the most serious effects of toxic shock syndrome in the field by using 0.9% Sodium Chloride or Ringer's Lactate and giving them in fluid bolus' to help raise the volume of fluid in the vascular space that was lost due to vascular permeability. The pre-hospital provider can also start dopamine or epinephrine drips to cause vasoconstriction that will result in the patient's blood pressure rising. Dopamine can be started at 5 micrograms per kilogram per minute (mcg/kg/min) and titrated to effect until there is a blood pressure of at least 90 or until the dopamine reaches a dosage of 20mcg/kg/min (Guy, 2010). Dopamine at 2-10mcg/kg/min activates the beta adrenergic receptors causing increased cardiac output while maintaining the inotropic effects (Guy, 2010). At high dosages, greater than 10 mcg/kg/min, alpha adrenergic receptor activation takes over and causes increased peripheral vascular resistance and vasoconstriction results (Guy, 2010). An epinephrine drip can also be used because epinephrine activates both alpha and beta receptors causing increased blood pressure and heart rate.
Issues that could interfere with treatments.
If patients are already tachycardic, have renal failure, or have untreated hypovolemia, dopamine cannot be used and the treatment of toxic shock syndrome will be hampered (Guy, 2010). Diabetes is another pre-existing problem that could interfere with treatment due to the fact that epinephrine is contraindicated in diabetics (Guy, 2010).
Risks associated with treatments.
If a patient has renal disease or congestive heart failure, they could easily become overloaded with fluid because of the amount given to help with the hypotension. If a patient has a history of cardiac disease, epinephrine cannot be used because it can cause tachycardia, cardiac arrhythmias, nervousness, tremors, and anxiety which could increase the risk for other heart complications (Guy, 2010). Dopamine must be used carefully in patients with heart disease because it also can cause tachycardia, arrhythmias, severe hypotension, dyspnea, and angina (Guy, 2010). There are also limitations to the patient's quality of care and outcome if patients are allergic to medications used to treat toxic shock syndrome or if they cannot tolerate them due to other medical issues. If a patient's blood pressure cannot be controlled then the percentage for mortality dramatically increases and there is an increased risk for negative impacts on activities of daily living due to lack of perfusion to important organs.
Although it is becoming more rare, toxic shock syndrome is still seen today. The long lasting side effects of this syndrome can be crippling. Prevention is the easiest way to keep this disease from becoming more widespread. Constant hand washing and good hygiene are top priorities that will keep the staphylococcal and streptococcal infections down and decrease the risk of developing this dangerous condition. Education on this disease is very important due to the fact that most people think that only menstruating women are at risk for it, but in reality everyone has a risk of developing it. Prevention, education, rapid diagnosis, and rapid treatment are steps that can keep toxic shock syndrome from claiming another victim.