Toxic shock syndrome (TSS): Nursing

Definitions & Key takeaways

Toxic shock syndrome, or TSS, is caused by an immune response to bacterial toxins produced by bacteria such as Staphylococcus aureus or Streptococcus pyogenes. The main risk factor is improper use of tampons during menstruation, but intravaginal contraceptive devices can also pose a risk for TSS. Other sources, such as infected wounds or burns, can also be causative factors.

In TSS, the body initiates a systemic inflammatory response that involves multiple organ systems, leading to complications like capillary leakage, organ failure, and disseminated intravascular coagulation (DIC). Signs and symptoms of TSS include fever, hypotension, edema, myalgias, and a sunburn-like rash, as well as specific signs of complications and organ dysfunction. Diagnosis involves a thorough history and physical examination along with laboratory tests, and blood cultures

Treatment involves supportive therapy, including IV fluids, vasopressors, antibiotics, and immunoglobulins. Priority goals of nursing care are focused on eliminating the infection and monitoring for alterations in hemodynamic status. Client and family teaching centers on how to prevent toxic shock syndrome, recognizing signs and symptoms of TSS, and when to seek medical attention.

Chapters:

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Introduction0:00–0:15

Toxic shock syndrome, or TSS, is an acute condition caused by a bacterial infection. TSS can be life threatening, as it involves multiple organ systems.

Causes & risk factors0:15–0:57

TSS is caused by the immune response to bacterial toxins produced by Staphylococcus aureus or Group A Streptococcus species, like Streptococcus pyogenes.The most widely recognized risk factor for developing TSS is improper use of tampons during menstruation, but some contraceptive methods, such as a sponge or diaphragm, can also pose a risk.
However, TSS can also present in other settings such as soft tissue infections, post-surgical infections, burns, or retained foreign objects such as nasal packing and dialysis catheters.

Pathophysiology0:57–2:40

Now, let’s look at the pathophysiology of TSS. For example, TSS can happen when a tampon or a contraceptive device is left in the vagina for too long.
During menstruation, menstrual blood accumulates and provides a good medium for the bacteria to grow on. Both Staphylococcus aureus and Streptococcus pyogenes produce exotoxins that are able to cross the vaginal mucosa through a mucosal break or via the uterus and enter the bloodstream.
For Staphylococcus aureus, the main culprit is called toxic shock syndrome toxin 1, or TSST 1 for short. That should be easy to remember!
Streptococcus pyogenes, on the other hand, has an M protein in its structure that can overstimulate the immune system, causing TSS.
Alternatively, bacteria can also grow in infected tissues such as wounds or burns, and from there, they enter the bloodstream.
Once in the bloodstream, these toxins over activate some immune cells called T cells, which further leads to the overactivation of cytokines and inflammatory cells.
The end result of this is a massive systemic inflammatory response, which can cause capillary leakage, meaning fluid leaks out of the capillaries as well as severe end-organ failure, including liver dysfunction and renal failure, as well as acute respiratory distress syndrome and impaired coagulation, which can progress to disseminated intravascular coagulation.Clinical manifestations of TSS typically develop within five days after the onset of menstruation.

Clinical manifestations2:40–3:48

For non-menstrual cases of TSS, the onset of illness can be preceded by pain, as well as signs of local inflammation and sloughing off of skin.
Once in full swing, TSS manifestations include fever, chills, edema, hypotension, a diffuse rash that often looks like sunburn, and myalgias.
Additionally, there can be hyperemia, meaning redness and inflammation, of the eyes, oropharynx or vagina. Left untreated, it causes multiple organ system dysfunction.
Signs of liver dysfunction include jaundice, while signs of renal impairment can include oliguria or anuria; and acute respiratory distress syndrome can manifest as dyspnea, or shortness of breath.
Additionally, there can be severe hypotension, bleeding, vomiting or diarrhea; and signs of sepsis or disseminated intravascular coagulation.
Diagnosis of TSS starts with the client’s history and physical assessment. Laboratory tests typically include a CBC, which can show anemia, thrombocytopenia, or leukocytosis with a left shift, meaning more immature WBCs are present in the blood; a comprehensive metabolic panel or CMP, which can show high levels of creatinine and elevated BUN, as well as elevated bilirubin and liver enzymes.

Diagnosis3:48–4:42

Creatine phosphokinase or CPK, can be higher than two times the upper limit of normal, while coagulation studies can show prolonged coagulation times.
Blood cultures should also be obtained, as well as cultures from any suspected source. In clients with fever and altered mental status, a lumbar puncture should be performed to evaluate for meningitis.

Treatment4:42–5:49

Treatment of TSS starts with removing the source of infection. Supportive therapy should be provided, including IV fluids to restore fluid and electrolyte balance, vasopressors such as norepinephrine to correct the hypotension, as well as IV immunoglobulins to neutralize the activity of the toxins.
Initially, broad spectrum antibiotics that are effective against both staphylococcal and streptococcal TSS should be provided.
After identification, antibiotics should be optimized and narrowed in spectrum depending on the identified bacteria. So, for TSS caused by group A Streptococcus species, clindamycin is usually effective, while for TSS caused by methicillin sensitive Staphylococcus aureus, a beta-lactamase-resistant penicillin such as nafcillin or oxacillin can be used; or vancomycin if the client is allergic to penicillin.
Finally, if the source of TSS is a necrotizing Group A Streptococcus infection of a wound, surgical debridement should be done.Alright, let’s talk about the care you’ll be providing to your client with toxic shock syndrome.

Management and care5:49–7:33

Your priority goals of care are focused on eliminating the infection and monitoring for alterations in hemodynamic status.
First, assist with the identification and removal of the source of infection and [break] collect culture and sensitivity samples, as ordered.
Establish IV access and administer the prescribed IV fluids to support tissue perfusion; and administer IV antibiotics and immunoglobulins, as prescribed.
Then, institute pulse oximetry and administer the ordered supplemental oxygen per nasal cannula to keep the SpO2 greater than 90%.
Continuously monitor your client for hemodynamic status by doing frequent checks of their vital signs, capillary refill, temperature and color of their extremities, and level of consciousness.
Insert an indwelling urinary catheter and keep a close eye on their urine output. Also, continue to monitor relevant lab work, such as WBC, band neutrophils, CBC, and CMP.
Immediately report to the healthcare provider if your client experiences a sudden decrease in urine output; weak and thready peripheral pulses; a narrowing pulse pressure; severe tachycardia; and signs of respiratory distress.
Administer the prescribed fluid bolus and vasopressors; and assist with the insertion of an arterial line and central venous catheter to provide closer monitoring.Okay, moving on to client and family teaching.

General client and family teaching7:33–8:56

First, teach your client that TSS is a life-threatening condition caused by bacteria that release poisons called exotoxins into the bloodstream, resulting in rashes and skin damage, low blood pressure, and potential damage to other organs.
Then, review strategies that will help them prevent future episodes of TSS. For a client that’s menstruating, teach them the importance of handwashing before inserting a tampon, using clean tampons, and inserting a tampon into the vagina carefully to avoid injury to the tissue.
Advise them to change their tampon every 3 to 6 hours, and to avoid superabsorbent tampons. Also instruct them to use pads while sleeping.
If they use barrier methods for birth control, such as a contraceptive sponge or diaphragm, stress the importance of not leaving them in place for more than 12 hours.
Finally, instruct all clients to immediately seek medical attention for signs of TSS, such as a sudden onset of a high fever; vomiting; diarrhea; a sun-burn like rash; increased redness of the mouth or eyes; or a feeling of lightheadedness when standing from a lying or sitting position.
Alright, as a quick recap... Toxic shock syndrome, or TSS, is caused by an immune response to bacterial toxins produced by bacteria such as Staphylococcus aureus or Streptococcus pyogenes.

Review8:56–10:35

The main risk factor is improper use of tampons during menstruation, but intravaginal contraceptive devices can also pose a risk for TSS.
Other sources, such as infected wounds or burns, can also be causative factors. In TSS, the body initiates a systemic inflammatory response which involves multiple organ systems, leading to complications like capillary leakage, organ failure and DIC.
Signs and symptoms of TSS include fever, hypotension, edema, myalgias, and a sunburn-like rash, as well as specific signs of complications and organ dysfunction.
Diagnosis involves a thorough history and physical examination along with laboratory tests, including CBC, CMP, CPK, BUN, bilirubin, creatinine, and liver enzymes.
Blood cultures, along with cultures from the suspected source are also collected and evaluated. Treatment involves supportive therapy, including IV fluids, vasopressors, antibiotics, and immunoglobulins.Priority goals of care are focused on eliminating the infection and monitoring for alterations in hemodynamic status.
Client and family teaching centers on how to prevent toxic shock syndrome, recognizing signs and symptoms of TSS, and when to seek medical attention.