For use in emergency departments and inpatient units managing patients diagnosed with Chronic Inflammatory Response Syndrome
Clinical Diagnosis
Chronic Inflammatory Response Syndrome is an environmentally acquired illness involving innate immune system dysregulation following biotoxin exposure. It presents as a multisystem inflammatory condition and requires protocol-based management to prevent exacerbation. Diagnostic support is available through recognized laboratory and functional markers.
Clinical Risk in Acute Settings
Patients with CIRS are at high risk of inflammatory cascade when exposed to standard treatments that do not account for their underlying condition. This includes IV antibiotic administration, contrast exposure, and failure to control biotoxin load or cytokine activity. Complications may include rapid worsening of cognitive, pulmonary, gastrointestinal, and neurological symptoms.
Priority Labs for CIRS Patients
Obtain as early as clinically appropriate. If limited, prioritize starred items.
Priority 1 – Inflammatory cascade status
C4a *
TGF-beta1 *
MMP-9
Priority 2 – Regulatory dysfunction and treatment eligibility
ADH and serum osmolality *
HLA-DR if not already documented *
VIP
VEGF
Priority 3 – General clinical status and safety
CMP with electrolytes *
CRP *
CBC with differential
ESR
Lipase prior to VIP consideration
Coagulation profile if bleeding history present
Consider VCS testing if available
Supportive Measures to Reduce Inflammatory Risk
Binders
Initiate cholestyramine or colesevelam per protocol to bind circulating biotoxins. Administer 30 minutes before meals and medications if tolerated. Use compounded or low-reactivity forms if sensitivities are documented.
Hydration
Use slow IV fluids to support electrolyte balance and toxin mobilization. Avoid rapid boluses unless urgently indicated. Monitor sodium and osmolality during fluid therapy. If ADH dysfunction is known, consider DDAVP under electrolyte monitoring.
Antibiotic Considerations
Fluoroquinolones and other high-reactivity antibiotics may worsen inflammatory response in genetically susceptible patients. If antibiotics are required, pre-treat with binders and consider anti-inflammatory adjuncts such as omega-3 fatty acids. Track symptoms and biomarkers during treatment.
Environmental and Dietary Controls
Minimize patient re-exposure to water-damaged environments. Use low-amylose meals and avoid gluten and artificial sweeteners. Review and confirm medication tolerances. Avoid unnecessary additives or contrast agents without risk-benefit discussion.
Monitoring and Discharge Planning
Repeat MMP-9, C4a, TGF-beta1 if clinical picture worsens
Ensure ADH and osmolality normalize prior to discharge if they were abnormal
Assess for VIP eligibility only after confirmation of stable inflammatory profile and environmental safety
Include notation of CIRS diagnosis in discharge summary and advise follow-up with specialist trained in Shoemaker Protocol
Reference Framework
This protocol is based on peer-reviewed literature and the established Shoemaker Protocol as published in Annals of Medicine and Surgery 2024 and referenced in clinical case definitions for biotoxin-related illness. Protocol steps are sequential and evidence-based. Improper management may result in prolonged recovery or multi-system relapse.