Clinical Scenarios Flashcards
Define SEPSIS
life-threatening organ dysfunction caused by a dysregulated host response to infection
Define Septic shock
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’
these patients can be clinically identified by a vasopressor requirement to maintain a MAP ≥ 65mmHg and serum lactate >2mmol/L in the absence of hypovolemia
qSOFA score >2
HIGHER MORTALITY 10%
Respiratory rate > 22/min
Altered mentation
Systolic blood pressure < 100 mm Hg
SEPSIS Red Flags
Responds only to voice or pain/ unresponsive
Acute confusional state
Systolic B.P <= 90 mmHg (or drop >40 from normal)
Heart rate > 130 per minute
Respiratory rate >= 25 per minute
Needs oxygen to keep SpO2 >=92%
Non-blanching rash, mottled/ ashen/ cyanotic
Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr
Lactate >=2 mmol/l
Recent chemotherapy
SEPSIS Amber Flags
Relatives concerned about mental status
Acute deterioration in functional ability
Immunosuppressed
Trauma/ surgery/ procedure in last 6 weeks
Respiratory rate 21-24
Systolic B.P 91-100 mmHg
Heart rate 91-130 OR new dysrhythmia
Not passed urine in last 12-18 hours
Temperature < 36ºC
Clinical signs of wound, device or skin infection
SEPSIS 6
- Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
- Take blood cultures
- Give broad spectrum antibiotics
- Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes
- Measure serum lactate
- Measure accurate hourly urine output
FULL SOFA SCORE
low platelets high billlirubin GCS Cretanine Urine Output
NEONATAL SEPSIS - organisms - RFs -Sx - Ix Mx -
- GBS (also E.coli)
- mother GBS and temp, low birth weight, permature
- grunting, temp, apnoea, jaundice, siezure
- BC, CRP, CRP, gas, urine, lumbar puncture
- IV BENPEN and gentamycin, prevent hypocglycaemia and metabloic acidosis
Neutropenic sepsis
- Mx
- propylaxis
- neurtorpil less than 0.5
- antibiotics must be started immediately, do not wait for the WBC
NICE recommends starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately - florquinolone
Sepsis Causes
- neonatal
- neutropenic
- urosepsis - catheter/UTI
- post splenectomy
- pneumonia
- meningitis
- IVDU
- post miscarriage
SEPSIS RFs
Take into account that people in the groups below are at higher risk of developing sepsis:
the very young (under 1 year) and older people (over 75 years) or people who are very frail
people who have impaired immune systems because of illness or drugs, including:
people being treated for cancer with chemotherapy (see recommendation 1.1.9)
people who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease)
people taking long-term steroids
people taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis
people who have had surgery, or other invasive procedures, in the past 6 weeks
people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections)
people who misuse drugs intravenously
people with indwelling lines or catheters.
Sepsis Examination points
Examine people with suspected sepsis for mottled or ashen appearance, cyanosis of the skin, lips or tongue, non-blanching rash of the skin, any breach of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection
ALWAYS ASK PATIENT OR CARER ABOUT FREQUENCY OF URINE
people who may not develop a temperature
old, young, cancer, severly ill
SEPSIS bloods
blood gas including glucose and lactate measurement
blood culture
full blood count
C-reactive protein
urea and electrolytes
creatinine
a clotting screen (high risk)
Urine analyis and chest xray
Sepsis - who to tell?
arrange for immediate review by the senior clinical decision maker[2] to assess the person and think about alternative diagnoses to sepsis
Discuss with consulatant (high risk)
lactate over 4 or systolic less than 90 - call critical care
sepsis monitoring
Monitor people with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting
Antibiotics in spesis GIVE WITHIN 1 HOUR
Meningitis - comm = benpen, hospital IV ceftiaxone
Local antimiccrobial guidance
Informing Families
an explanation that the person has sepsis, and what this means
an explanation of any investigations and the management plan
regular and timely updates on treatment, care and progress.
Asthma Attach Features
worsening dyspnoea, wheeze and cough that is not responding to salbutamol
maybe triggered by a respiratory tract infection
Asthma Moderate
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Asthma Severe
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Asthma Life threatening
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma Normal PCo2 = exhaustation
Near-fatal asthma
raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.
ABG sats in Asthma
less than 92%
xray in asthma
life-threatening asthma
suspected pneumothorax
failure to respond to treatment
Asthma Admission
all patients with life-threatening should be admitted in hospital
patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment.
other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night
Asthma treatment
nebulised SABA + ipratropium bromide +40 PO prednisiolone 5 days
consider Mg sulphate and aminophylline
4xICS
Escalating asthma
patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include:
intubation and ventilation
extracorporeal membrane oxygenation (ECMO)
discharge critera asthma
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
asthma Ix
ABG if low sats, PEF (best of 3), xray if life threatening
Asthma Review
Any possible triggers for the attack.
Inhaler use and technique.
Optimisation of treatment and a plan for preventing further exacerbations.
follow up within 4 days of discharge
COPD feautures
increase in dyspnoea, cough, wheeze
there may be an increase in sputum suggestive of an infective cause
patients may be hypoxic and in some cases have acute confusion
COPD bacteria
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
COPD Tx
increase frequency of bronchodilator use and consider giving via a nebuliser
give prednisolone 30 mg daily for 5 days
it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
COPD Triggers
respiratory tract infections (most commonly rhinovirus), smoking, and environmental pollutants.
Wheezing bloods
FBC, U and E, theophylline levels in on it, BNP, Trop, D Dimer
COPD discussions
End-of-life issues should be discussed when appropriate and advance care planning offered.
COPD admit
Severe breathlessness.
Inability to cope at home (or living alone).
Poor or deteriorating general condition.
Acute confusion or impaired consciousness.
Cyanosis or reduced oxygen saturation.
Worsening peripheral oedema.
A new arrhythmia.
COPD oxygen
Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available).
COPD target o2
88-92
if symptoms dont imporve for long time COPD
sputum culture
CURB 65
C Confusion (abbreviated mental test score <= 8/10)
U Urea >7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
CURB 65 Management
Patients with a CURB-65 score of 0 should be managed in the community.
Patients with a CURB-65 score of 1 should have their Sa02 assessed which should be >92% to be safely managed in the community and a CXR performed. If the CXR shows bilateral/multilobar shadowing hospital admission is advised.
Patients with a CURB-65 score of 2 or more should be managed in hospital as this represents a severe community acquired pneumonia.
The CURB-65 score also correlates with an increased risk of mortality at 30 days with patients with a CURB-65 score of 4 approaching a 30% mortality rate at 30 days.
Pneumonia causes
Community acquired pneumonia (CAP) may be caused by the following infectious agents:
Streptococcus pneumoniae (accounts for around 80% of cases)
Haemophilus influenzae
Staphylococcus aureus: commonly after the ‘flu
atypical pneumonias (e.g. Due to Mycoplasma pneumoniae)
viruses
Klebsiella pneumoniae is classically in alcoholics
Pneumonia CRP
CRP < 20 mg/L - do not routinely offer antibiotic therapy
CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
CRP > 100 mg/L - offer antibiotic therapy
Pneumonia Investigations
Investigations
chest x-ray
in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
CRP monitoring is recommend for admitted patients to help determine response to treatment
Management of moderate and high-severity community acquired pneumonia
dual antibiotic therapy is recommended with amoxicillin and a macrolide
a 7-10 day course is recommended
NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia
Causes of hyperkalemia
acute kidney injury drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's disease rhabdomyolysis massive blood transfusion
ECG hyperkalemia
Peaked or 'tall-tented' T waves (occurs first) Loss of P waves Broad QRS complexes Sinusoidal wave pattern Ventricular fibrillation
Hyperkalemia treatment
STOP AGGRAVATING FACTOR E.g. ACE I
Stabilisation of the cardiac membrane
intravenous calcium gluconate
does NOT lower serum potassium levels
Short-term shift in potassium from extracellular to intracellular fluid compartment
combined insulin/dextrose infusion
nebulised salbutamol
Removal of potassium from the body
calcium resonium (orally or enema)
enemas are more effective than oral as potassium is secreted by the rectum
loop diuretics
dialysis
haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia
Pneumothorax RFs
pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
connective tissue disease: Marfan’s syndrome, rheumatoid arthritis
ventilation, including non-invasive ventilation
catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax
Pneumothorax Symptoms
dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia
primary pneumothorax Tx
Recommendations include:
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
secondary pneumothorax Tx
Recommendations include:
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
regarding scuba diving, the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
pneumothorax aspiration
2nd intercostal space in the midclavicular line (above rib to avoid neurovascular bundle on posterior aspect of second rib)
Stroke Asessment score
Assessment Scoring Loss of consciousness or syncope - 1 point Seizure activity - 1 point New, acute onset of: • asymmetric facial weakness + 1 point • asymmetric arm weakness + 1 point • asymmetric leg weakness + 1 point • speech disturbance + 1 point • visual field defect + 1 point
Stroke Management
aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
- if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation
- thrombolysis (within 4.5 hours)
- thrombectomy (within 6hours)
- clopidrogrel for secondary prevention
Thrombolysis
Thrombolysis with alteplase should only be given if:
it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
haemorrhage has been definitively excluded (i.e. Imaging has been performed)
Contraindications to thrombolysis
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
Thrombectomy
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):
who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
With regards to carotid artery endarterectomy:
- recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled
- should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria
stroke anatomy
Site of the lesion Associated effects
Anterior cerebral artery - Contralateral hemiparesis and sensory loss, lower extremity > upper
Middle cerebral artery - Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
Posterior cerebral artery Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain) Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Anterior inferior cerebellar artery (lateral pontine syndrome) Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness
Retinal/ophthalmic artery Amaurosis fugax
Basilar artery ‘Locked-in’ syndrome
stroke management: fluids, glucose, blood pressure and feeding,
fluids - Oral = best. isotonic saline without dextrose as the agent of choice in most patients
glucose - NICE guidelines recommend maintaining a blood sugar level between 4 and 11 mmol/L in people with acute stroke
BP - Use of anti-hypertensive medications should only be used for blood pressure control in patients post ischaemic stroke if there is a hypertensive emergency with one or more of the following serious concomitant medical issues (according to the NICE guidelines):
Hypertensive encephalopathy
Hypertensive nephropathy
Hypertensive cardiac failure/myocardial infarction
Aortic dissection
Pre-eclampsia/eclampsia
Over hydration leads to
cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients
DKA
CHECK KETONES in urine
