CBL 4: A PATIENT IN SHOCK Flashcards
Q1. Outline your initial assessment of this woman and a possible differential diagnosis.
UTI - temp and confused
DKA / HHS
Necrotising pancreatitis - abdominal pain
Pyelonephritis
Her clinical findings are as follows:
Examination:
* Confused
* Glasgow Coma Score 9/15
* Pulse 110 regular
* Blood pressure 84/43 mmHg
* Temperature 38.9 0C
* Oxygen saturations 93% on room air
* Chest Clinically clear
* Heart sounds Normal
* Abdomen Soft, no organomegaly, no peritonism
* No focal neurology
Q2. How do these findings help in your differential diagnosis? [3]
Septic shock secondary to UTI:
- Hypotensive
- O2 sats 93%
- GCS 9/15 - reduced perfusion to brain
Define sepsis [1]
Define septic shock
go over shock lecture
Further investigations showed the following:
Venous blood gas:
* pH 7.24 (7.35-7.45)
* Bicarbonate 14 mmol/L (18-23)
* Sodium 138 mmol/L (135-145)
* Potassium 6.9 mmol/L (3.5-5.5)
* Urea 18.7 mmol/L (3.3-6.6)
* Creatinine 427 umol/L (75-95)
* Lactate 6.7 mmol/L (0.5-2.2)
* C-reactive protein 223 mg/l ( < 5)
* Haemoglobin 104 g /L ( 110-130)
* White cell count 23.5 x 109
* /L (3.5-9.0)
Urinalysis
* Blood ++
* Leucocytes +
* Nitrites +
* Protein ++
* Ketones - Neg
Chest radiograph Normal
Q3. Interpret these findings, including the ECG. Outline a problem list and
explain the likely underlying cause
pH 7.24 (7.35-7.45):
* metabolic acidosis
high lactate:
* marker of anaerobic respiration. present if hypoperfused tissue
CRP & urinalysis indicate an infection:
- leucocytes ++
- nitrates +
ECG:
- bradycardic
- tall tented T waves (V4)
- no p waves [?]
What oxygen do you prescribe in an acute emergency? [1]
15 L
How would you manage this patient? [4]
Fluids, monitor urine output, 15L oxygen, blood cultures (after antibiotics), antibiotics
When do you give antibiotics in comparison to blood cultures? [1]
Antibiotics after blood culture
What is the sepsis 6? [6]
- no p waves on ECG?
How does hyperkalaemia present on ECG? [3]
Learn
T tall tented T waves
Flattened / widened (or even flattened) P wave
Prolongation of PR interval
UTIs are most commonly caused by which pathogen? [1]
Escherichia coli
What indicates that an AKI is occuring? [1]
Protein in urinalysis
What pathologies is this person suffering from? [3]
Septic shock secondary to UTI
Hyperkalaemia
AKI
What is the risk of her acute hyperkalaemia [1], and how should this be managed? [4]
- ECG changes: calcium chloride or calcium gluconate, stabilises the myocardium
- Insulin dextrose: moves K intracellularly, but also giving glucose means don’t go hypoglycaemic
- Calcium resonium: removes excess K+ by exchanging for Ca2+
- Nebulised salbutamol: causes hypokalaemia [& can make tachycardic]
State three risks of hyperkalaemia [3]
cardiac arrhythmia:
- established effects on cardiac excitability, hyperkalemia
peripheral neuropathy
renal tubular acidosis
Explain what is meant by the term “Acute Kidney Injury” [3]
Explain which medication can cause pre-renal AKI? [2]
ACE inhibitor (& ARB): cause vasodilation of afferent arteriole reduces blood flow to kidney
NSAIDs: COX-1 inhibiton causes vasoconstriction of efferent arteriole
How is AKI diagnosed? [1]
26.5
27
Describe how you classify the different stages of AKI [3]
How would you manage this patients AKI? [2]
Fluids (to treat septic shock aspect)
Stop any nephrotoxic drugs
Q7. How is CKD defined? What are it’s causes and how is it managed?
Given her background in diabetes and hypertension - manage these underlying causes of CKD.
The two most common causes of CKD are? [2]
Diabetes (diabetic nephropathy)
Hypertension (damage to structure of kidney)
Q8. Outline the three main forms of renal replacement therapy and explain
their advantages and disadvantages.
Haemodialysis:
* 3-4x week at a centre.
* Requires an A/V fistula - increases the risk of infection
Peritoneal dialysis:
* can do at home, every 8 hrs / daily
* SBP infection
* permenant catheter can cause hernia
Kidney transplant
- Rejection / failure
- Immunosuppressants
- Needs a match
