ABCDE circualtion

Question 1

Assessment ABCDE circualtion

Answer 1

Vitals:
- HR
- BP

Look:
- JVP
- Fluid status (mucous membranes, oedema) and balance (charts/catheter bag)

Feel:
CRT central and peripheral
Skin turgor
Temperature of peripheries
Pulse

Listen:
Heart sounds for pericardial rub, third heart sound, new murmur

Question 2

Investigations circulation ABCDE

Answer 2

IV access
Bloods: FBC, U&E, LFT,
Sepsis: CRP, lactate, blood cultures
Haemorrhage/surgical emergency: coagulation and cross-match
ACS: troponin
Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
PE: d-dimer if wells score
Overdose: toxicology
Anaphylaxis: consider serial mast cell tryptase levels
ECG
Bladder scan
Urine pregnancy test
Other cultures/swabs
Catheter if need to monitor urine output

Question 3

Interventions circualtion ABCDE

Answer 3

Fluid challenge/resuscitation
Blood transfusion
Consider continuous cardiac monitoring

Question 4

what conditions are you looking for in C?

Answer 4

Shock
–> hypovolemic (haem/non-haem)

–> distributive SEPSIS, ANAPHYLAXIS, ADDISONIAN CRISIS

–> obstructive
PE, TAMPONADE

–> cardiogenic
MI, ARRYTHMIA,

Fluid overload
Bleeding

Question 5

if someone is bleeding, what do you do? ABCDE circualtion

Answer 5

If hemodynamically unstable = major haemorrhage = major haemorrhage protocol

If hemodynamically stable = check Hb to guide transfusion

Question 6

define shock

Answer 6

Shock is defined as a global tissue hypoperfusion state, leading to cellular hypoxia and dysfunction.

Question 7

causes of non-haemorrhagic hypovolemic shock

Answer 7

GI losses: any diarrhoea or vomiting…

Renal losses: Diuretic therapy, osmotic diuresis from hyperglycemia (DKA, HHS, poorly controlled diabetes)

Skin: loss of skin barrier eg burns

Question 8

causes of distributive shock?

Answer 8

Sepsis
SIRS
Anaphylaxis
Neurogenic
Endocrine eg addisonian crisis and myxedema

Question 9

what is neurogenic shock?

Answer 9

It is a type of distributive shock

Neurogenic shock results from damage to the spinal cord above the level of the 6th thoracic vertebra

Neurogenic shock - loss of sympathetic tone and thus unopposed parasympathetic response driven by the vagus nerve. Consequently, patients suffer from instability in blood pressure, heart rate, and temperature regulation.

It can occur after damage to the central nervous system, such as spinal cord injury and traumatic brain injury.

bradycardia; hypotension; poikilothermy, hypothermia, or both, causing a flushed appearance; warm, dry skin (from vasodilation); and flaccid paralysis below the spinal injury level.

need ICU

Question 10

causes of cardiogenic shock

Answer 10

cardiomyopathies

arrhythmia

severe valve insufficiency

Question 11

Causes of obstructive shock?

Answer 11

Pulmonary vascular - due to impaired blood flow from the right heart to the left heart. Examples include hemodynamically significant pulmonary embolism, severe pulmonary hypertension.

Mechanical - impaired filling of right heart or due to decreased venous return to the right heart due to extrinsic compression. Examples include tension pneumothorax, pericardial tamponade, restrictive cardiomyopathy, constrictive pericarditis.

Question 12

If a fluid challenge doesn’t work, what should you consider as the cause of shock?

Answer 12

cardiogenic shock – don’t give any more fluids – as this will likely only fluid overload the patient.

If BP is high, then heart failure is likely, and give furosemide 20mg and wait for response – make sure you have catheterised to measure urine output first

Question 13

what is sepsis?

Answer 13

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

Question 14

what is septic shock, how should it be treated?

Answer 14

a more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone

Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion. This leads to a rise in blood lactate as the organs begin anaerobic respiration. This can be measured as either:
Systolic blood pressure less than 90 despite fluid resuscitation
Hyperlactaemia (lactate > 4 mmol/L)

This should be treated aggressively with IV fluids to improve the blood pressure and the tissue perfusion. If IV fluid boluses don’t improve the blood pressure and lactate level then they should be escalated to high dependency or intensive care where they can use medication called inotropes (such as noradrenalin) that help stimulate the cardiovascular system and improve blood pressure and tissue perfusion.

Question 15

what score can be used outside ICU to assess a patients risk of mortality from sepsis if there is a ?infection

Answer 15

qSOFA

Respiratory rate > 22/min
Altered mentation (GCS)
Systolic blood pressure < 100 mm Hg

qSOFA Scores 2-3 are associated with a 3- to 14-fold increase in in-hospital mortality. Assess for evidence of organ dysfunction with blood testing including serum lactate and calculation of the full SOFA Score.

Patients meeting these qSOFA criteria should have infection considered even if it was previously not.

Question 16

red flags for sepsis ?

Answer 16

A
B
- RR >25

C
- systolic bp <90 or drop of >40 from normal
- heart rate >130
- not passed urine in last 18hr/ UO < 0.5ml/kg/hr
- lactate > 2

D
- responds only to voice or pain/unresponsive
- acute confusional state

E
- non blanching rash, mottled, ashen, cyanotic

MHx
- recent chemo

Question 17

when should the sepsis 6 be started?

Answer 17

when there are any red flags/ there is a suspicion of sepsis

Question 18

what are the sepsis 6?

Answer 18

1. Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
2. Take blood cultures
3. Give broad-spectrum antibiotics
4. Give intravenous fluid challenges
   NICE recommend a bolus of 500ml crystalloid over less than 15 minutes
5. Measure serum lactate
6. Measure accurate hourly urine output

Question 19

what is the SOFA score

Answer 19

used in ICU for patients ?sepsis

A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.

Question 20

amber flags for sepsis

Answer 20

A
B
- rr 21–24

C
- systolic bp 91-100
- heart rate 91-130 or new dysrhythmia
- not passed urine in last 12-18 hours

D
- relatives concerned about mental status

E
- clinical signs of wound, device or skin infection
- temp <36

MHx
- acute deterioration in functional ability
- immunosuppressed
- trauma/surgery/procedure in last 6 weeks

Question 21

risk factors for sepsis

Answer 21

extremes of age; people who are frail, immunocompromised or immunosuppressed; people who have had recent trauma or surgery; people with a breach in skin integrity; and women who are pregnant, are post-partum, or have had a recent termination of pregnancy or miscarriage.

Question 22

what are the sepsis 7 and 8

Answer 22

7. Transfer to critical care may be needed to assess the need for central venous access and initiation of inotropes (increase cardiac output by increasing cardiac contractility) or vasopressors (increase blood pressure by increasing peripheral vascular resistance), to maintain perfusion pressure.
8. Finding a source:
   FBC: WCC may be high or low, thrombocytopaenia may indicate DIC

CRP - infection or inflamamtion

Creatinine, urea and electrolytes - dehydration, aki

LFTs - increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction.

Clotting screen — if abnormal may indicate coagulopathy/DIC.

Urine analysis and culture, chest X-ray, CT for intra-abdo infection or abscess, LP for meningitis/encephalitis

additional investigations depending on the person’s clinical presentation — this may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery.

Question 23

what is neutropenic sepsis

Answer 23

It is sepsis in a patient with a low neutrophil count of less than 1 x 109/L.

Low neutrophil counts are usually the consequence of anti-cancer or immunosuppressant treatment.

Question 24

drugs that can cause neutropenia

Answer 24

Anti-cancer chemotherapy
Clozapine (schizophrenia)
Hydroxychloroquine (rheumatoid arthritis)
Methotrexate (rheumatoid arthritis)
Sulfasalazine (rheumatoid arthritis)
Carbimazole (hyperthyroidism)
Quinine (malaria)
Infliximab (monoclonal antibody use for immunosuppression)
Rituximab (monoclonal antibody use for immunosuppression)

Question 25

recognition and management of neutropenic sepsis ?

Answer 25

Have a low threshold for suspecting netropenic sepsis in patients taking immunosuppressants or medications that can cause neutropenia

Treat any temperature above 38C as neutropenic sepsis in these patients until proven otherwise.

Treatment is with immediate broad spectrum antibiotics such as piperacillin with tazobactam (tazocin).

The other aspects of management are essentially the same as for sepsis however extra precaution needs to be taken. Time is precious so don’t delay antibiotics while waiting for investigation results.

Question 26

Abx of choice for neutropenic sepsis

Answer 26

Tazocin