ABCDE and Sepsis

Question 1

A

Answer 1

• Is the patient alert and talking to you
• look, look feel, listen for airway obstruction
• medical emergency - oxygen, airway manoeuvres, suction, oro/nasopharygneal airway, bag and mask

Question 2

B

Answer 2

• look - respiratory rate, cyanosis, accessory muscle, chest wall movement
• Feel - percussion, expansion, tracheal deviation
• Listen - lung fields
• Oxygen stats - aim for oxygen above 94%
• consider CXR, ABG, peak flow, nebulisers

Question 3

C

Answer 3

• Assessment - pulse rate/rhythm, blood pressure, heart sounds, perfusion, capillary refill, JVP, oedema
• investigation and intervention - IV access, blood tests, IV fluids, 3/12 lead ECG, ACS
• IV fluid bolus = 500ml (130-154 mmol/L Na+) crystalloid/ <15 min

Question 4

D

Answer 4

5 point disability check

1. AVPU/GCS
2. Pupils
3. Lateralising neurology
4. nick stiffness
5. DEFG - don’t ever forget glucose

what does the patient respond to 
A- alert 
V- voice 
P - pain 
U - unresponsive

Question 5

E

Answer 5

Expose the patient

• abdomen and focused neurology
• injury and haemorrhage
• joint/calves and for infection
• temperature and antibiotics
• history

Question 6

what is sepsis

Answer 6

• life threatening organ dysfunction caused by a dysregulated host response to infection

Question 7

How do you predict sepsis

Answer 7

• extremes of age
• recent trauma or invasive procedure
• impaired immunity.
• indwelling lines or catheters
• IV drug use
• breaches of skin integrity
• pregnant or recently pregnant

Question 8

What are the high risk for patients with sepsis

Answer 8

• new altered mental state - objective
• RR greater than 25/min or new need for oxygen
• HR 130 BPM or above
• systolic BP <90mmHg or >40mmHg below baseline
• not passed urine in 18 hours
• mottled or ashen appearance
• cyanosis of skin, lips or tongue
• new non-blanching skin rash

Question 9

what are the moderate risk factors for patient with sepsis

Answer 9

• new altered mental state - subjective
• RR - 21-24/min
• HR 91-130bpm or new arrhythmia
• systolic BP 91-100mmHg
• not passed urine in 12-18 hours
• tympanic temperature <36 degrees
• signs of infection at surgical site or wound
• history of acute function deterioration
• impaired immune system
• trauma or invasive procedure within 6 weeks

Question 10

when should you do sepsis 6 management

Answer 10

1. One high risk criteria
2. Two moderate risk criteria and lactate
   >2 mmol/L or AKI
3. SBP 91-100 mmHg
   and lactate >2 or AKI

Question 11

What is sepsis 6 management

Answer 11

1. Oxygen: target saturations 94-98%
   (88-92% in risk of hypercapnic respiratory failure)
2. IV fluid resuscitation
3. IV antibiotics (within 1 hour)
4. Cultures and Source control
5. Blood lactate and blood tests
   (Blood gas, FBC, CRP, U/Es + Creatinine, LFTs, Clotting screen)
6. Fluid balance (hourly)

Question 12

what is the antimicrobial therapy that should be given to patients with suspected sepsis

Answer 12

• IV antibiotics within 1 hour
• blood cultures before antibiotics providing <45 min treatment delay
• broad spectrum antibiotics as trust policy if unclear source
• antivirals/antifungals to be considered

Question 13

What are the indicators of organ dysfunction

Answer 13

• acute lung injury
• new altered GCS
• sepsis induced hypotension
• rise in bilirubin
• low platelets
• acute kidney injury

Question 14

What volume resuscitation should you give in sepsis

Answer 14

Immediate IV fluids if SBP< 90mmHg or lactate >2mmol/L2

• IV crystalloid (130-154 mmol/L Na+) bolus 500ml in <15min2

• Up to 30ml/kg for hypotensive patients with frequent
reassessment3

Question 15

When should you escalate a sepsis patient to critical care

Answer 15

• sepsis (or high risk) with systolic BP <90mmHg and/or lactate >4 mmol/L

Question 16

What is septic shock

Answer 16

• sepsis with persisting hypotension despite adequate volume resuscitation (lactate >2mmol/L and vasopressor requirement)

Question 17

what should you look for when assessing the limb

Answer 17

• including colour, temperature, and state of veins

Question 18

what does low diastolic BP indicate

Answer 18

• indicates arterial vasodilation such as sepsis

Question 19

What does a narrow pulse pressure indicate

Answer 19

• Narrow pulse pressure indicates arterial vasoconstriction (e.g. cariogenic or hypovolemic shock)

Question 20

what does each colour mean in terms of the type of blood

• pink
• purple
• gold
• blue

Answer 20

• pink = group and save/x match as appropriate
• purple - FBC
• gold - U+Es, LFTs
• blue - coagulation

Question 21

assume the patient is…

Answer 21

hypovolemic unless cardiogenic shock is suspected

Question 22

What should you do if a patient has abnormal BP

Answer 22

if the patient has a normal BP give a fluid challenge which is a rapid infusion of 500ml of a warm crystalloid (if needed it can be repeated)

Question 23

name the type of volume expanders that you can have

Answer 23

• crystalloid volume expanders

- colloid volume expanders

Question 24

name the crystalloid volume expanders, what it is and what it does

Answer 24

• normal saline/hartmanns solution
• aqueous solution of mineral salts and water soluble molecules
• can cause harm-dilution

Question 25

name the colloid volume expanders, what it is and what it does

Answer 25

• blood, albumin, plasma, gelofusine
• contains larger insoluble molecules such as gelatin
• maintains colloid osmotic pressure in the blood

Question 26

What are the negatives of colloids

Answer 26

• expensive
• can cause coagulopathy
• anaphylactic reaction
• can precipitate cardiac failure
• can cause renal failure

Question 27

What are the negatives of crystalloids

Answer 27

• dilute plasma proteins
• in cases of shock may result in hypoxia
• causes peripheral oedema
• potential for pulmonary oedema