A-E and Sepsis Flashcards
NEWS2 - what parameters are examined?
- respiration rate
- oxygen saturation
- systolic blood pressure
- pulse rate
- level of consciousness or new confusion*
- Temperature
*The patient has new-onset confusion, disorientation and/or agitation, where previously their mental state was normal – this may be subtle. The patient may respond to questions coherently, but there is some confusion, disorientation and/or agitation. This would score 3 or 4 on the GCS (rather than the normal 5 for verbal response), and scores 3 on the NEWS system.
If you are concerned about your pt based on NEWS2 score what can you do in UHL?
Remember - Contact Critical Care Outreach Team (CCOT) or the Out of Hours Response Team (OOHRT) via phone or bleep if you are concerned about your patient.
AVPU is now ACVPU… what does this mean?
NEW confusion
New confusion includes disorientation, delirium, and altered mental state
Is this ‘normal’ for your patient? ask relatives/carers if this is a change
Thinking of NEWS2 score, what score would indicate a clinical deterioration and prompt an urgent clinical response from a clinician?
i.e. think SEPSIS
A NEWS2 of 5 or above
https://www.rcpjournals.org/content/clinmedicine/22/6/514
NEWS2 - how many points are added to your score if you require 02?
2 points added if need supplementary 02
What is qSOFA? what score is this used for?
QUICK SOFA for Sepsis - used to predict mortality not to diagnose SEPSIS.
NEWS2 better at diagnosing / raising alarm of sepsis
What does qSOFA look at?
- Altered mental status GCS<15
- Resp rate >22
- Systolic BP <100
What qSOFA is high risk?
2-3 - increase in mortality. Assess for evidence of organ dysfunction and do full SOFA score
What does the SOFA score stand for? what does it dO?
Also another score APACHE II
Sequential Organ Failure Assessment (SOFA) Score
* Predicts ICU mortality based on lab results and clinical data to determine level of organ dysfunction.
What paraemeters does SOFA assess?
NOTE: Use the worse value in a 24 hours period
- Pa02 (kpa)
- Fi02 (% of inhaled 02)
- mechanical ventilation? (including CPAP) y/n
- Platelets (x103/ul)
- GCS
- Bilirubin (mg/dl)
- Mean arteral pressure or administration of vasoactive agents required
- Creatinine (mg/dl)
gives a score based on this of mortalitly prediction
What is SIRS? when does it become sepsis?
SIRS = Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy, to name a few) to
SIRS with a suspected source of infection is termed sepsis.
https://www.ncbi.nlm.nih.gov/books/NBK547669/#:~:text=Even%20though%20the%20purpose%20is,of%20infection%20is%20termed%20sepsis.
SIRS, Sepsis, and Septic Shock Criteria
Will add picture
https://www.mdcalc.com/calc/1096/sirs-sepsis-septic-shock-criteria
UHL adult sepsis screening and Action tool:
will add picture
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Sepsis%20and%20Septic%20Shock%20(Includes%20UHL%20and%20Kettering%20Sepsis%20Pathway)%20UHL%20Guideline.pdf
A-E assessment what to ASSESS in A?
RESUS COUNCIL
Airway obstruction?
* See-saw respirations due to paradoxical chest and abo movements
* accessory muscle use
* central cyanosis (late sign)
* no breath sounds mouth or nose (complete obsruction)
* noisy sounds (partial obstuction)
UHL sepsis 6 bundle
will add picture
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Sepsis%20and%20Septic%20Shock%20(Includes%20UHL%20and%20Kettering%20Sepsis%20Pathway)%20UHL%20Guideline.pdf
A- E assessement, what to DO in A?
RESUS COUNCIL
- airway manoeuvres
- airway suction
- oropharyngeal / nasopharyngeal / igel
- tracheal intubation if above fail
A-E Assessment: what do ASSESS in B?
RESUS COUNCIL
- Look listen and feel for signs of resp distress
- Resp rate (12-20 normal)
- depth/ rythm of each breath
- chest expansion equal
- chest deformity?
- Presence / patency of any chest drains?
- percuss chest - dull/hyperresonant?
- auscultate chest - bronchial breathing/ absent/ reduced sounds?
- trachea central?
- feel chest for surgical emphsyema /crepitus (pnuemothorax until provne otherwise)
A-E Assement
B - what to DO?
- Give 02 - 15L non-rebreathe mask.
- COPD- venturi mask 28% 4 L a min and reassess via serial ABGs (target Sp02 88-92%)
- Consider NIV in pts with COPD
- ABG
- Chest X-ray
sess
A-E assessment
C - what to ASSESS
RESUS COUNCIL
- colour of hands / digits - blue/pink/mottled
- temp of hands - cool/warm
- CRT - <2s
- Pulse rate - pref on heart with stethescope
- peripheral and central pulses - presence, quality, regular, equal? bounding - sepsus, barely present- poor cardiac output
- BP
- raised JVP?
- Auscultate heart - murmur / pericardial rub / muffled / does aubible HR correspond to pulse rate -AF
- signs of poor cardiac output - reduced concsious level, oliguria
A-E Assessment - C what to DO in C?
- Insert 1 or ideally 2 large 14G orange/ grey 16G cannula
- take bloods - FBC, coag, blood cultures, G+S, Crossmatch
- 500 ml bolus of 0.9& sodium chloride in 15 mins - listen for chest crackles after each bolus
- reassess HR and BP every 5 mins aim ? 100mmHg systolic
- no improvement? repeat fluid challenge
- symptoms of cardiac failure (dyspnoea, increased HR, raised JVP, third heart sound, pulmonary crackles - stop/decrease infusion. Seek senior help for improving profusion e.g. inotropes / vasopressors
- ECG
- consider catheterisation if needed and input/output monitoring
patients blood pressure: what might a low diastolic BP suggest ?
A low diastolic blood pressure suggests arterial vasodilation (as in anaphylaxis or sepsis).
What might a narrowed pulse pressure (difference between systolic and diastolic pressures; normally 35–45 mmHg) suggest?
Arterial vasoconstriction (cardiogenic shock or hypovolaemia) and may occur with rapid tachyarrhythmia.
Immediate general treatment for ACS?
RESUS COUNCIL
- Aspirin 300 mg, orally, crushed or chewed, as soon as possible.
- Nitroglycerine, as sublingual glyceryl trinitrate (tablet or spray).
- Oxygen: only give oxygen if the patient’s SpO2 is less than 94% breathing air alone.
- Morphine (or diamorphine) titrated intravenously to avoid sedation and respiratory depression.
A-E Assessment
D - what to ASSESS and DO?
RESUS COUNCIL
- review and treat ABCs- exlude/treat hypoxia and hypotension
- check drug charrt for reversible depressed consciousness e.g. naloxone for drug toxicity
- examine pupils for size, equal, reaction to light
- ACVPU
- GCS - supraorbital pressure at supraorbital notch
- Blood glucose (if peri arrest use a venous or arterial blood sample as fingertip can be unreliable in sick patients)
- temperature reading - cold - give warmed fluids, blankets, bairhuggers
A-E Asessment
what to ASESS and DO In Exposure
- Examine top to toe, back to front for rashes, wounds, bleeding
- Respect pts dignity and minimise heat loss
- check calves for DVT
What after finished A-E?
- take history from patient, relatives etc.
- review pts notes and charts
- check prescribed meds are being given
- review lab / imaging results
- consider what level of care needed for patient (ITU, HDU, ward)
- document in notes, findings, assessemnt and treatment and pts response
- SBARD to colleague
FROM ART DAY
* Repeat A-E
* Repeat, bloods, ECG, Chest Xray
