Critical Illness

Question 1

Definition of Sepsis and RF

Answer 1

• = Life threatening organ dysfunction due to dysregularion of host response to infection.
• At risk groups:
  
  • Age <1y, >75y
  • Immunosuppression - DM, HIV, asplenic, iatrogenic **?neutropoenic sepsis?**
  • Surgery <6w
  • Skin breach- cuts, burns
  • IVDU
  • Indwelling catheters, lines
  • Pregnancy/ post-partum/ TOP

Question 2

qSOFA criteria

Answer 2

• Hypotension <90mmHg
• Altered mental state GCS <15
• Tachypnoea >22/min

Question 3

SIRS criteria

Answer 3

2 or more of:

• Temp <36 or >38.3
• HR >90
• RR >20
• WCC >12x10⁹ or <4x10⁹/L
• Acutely altered mental state
• BM >7.7 mmol/L in absence of DM

Sepsis= SIRS with source of infection

Severe sepsis= Sepsis + 1 sign of organ failure

Septic shock= Sepsis with SBP <90 or drop >40mmHg

Question 4

Signs of organ failurue in Sepsis

Answer 4

• SBP <90mmHg
• Lactate >2mmol/L
• Platelets <100x10⁹/L
• UO <0.5mL/kg/h for 24h
• Creatinine >177 micromol/L
• Bilirubin >34 micromol/L
• INR >1.5 or APTT >60s

Question 5

Sepsis Ix and Tx

Answer 5

• Ix:
  
  • Bedside- NEWS ** temp **, Urine dip, ECG, BM
  • Bloods- FBC ** WCC ** , U+Es, LFTs, CRP, ABG, culture, lactate, procalcitonin
  • Imaging - CXR, local
  • Special - LP
• Tx= SEPSIS 6
  
  • 3 out: Blood cultures, lactate, UO
  • 3 in: ABx, IVT, o2

Question 6

Definition and presentation of Shock

Answer 6

• = Circulatory failure –> inadequate organ perfusion
  
  • SBP <90mmHg
  • MAP <65mmHg + evidence of tissue hypoperfusion
• Tissue hypoperfusion:
  
  • Mottled skin
  • UO <0.5ml/kg/h
  • Serum lactat >2mmol/L
• Presentation:
  
  • Pallor
  • Reduced GCS/ confusion
  • Tachycardia
  • Chest pain
  • Prolonged CRT
  • Oligouria
  • Dizzy
  • Cool peripheries

Question 7

Caues of shock

Answer 7

Inadequate CO

• Hypovolaemia:
  
  • Haemorrhagic - trauma, AAA, GI
  • Fluid loss- vomiting, burns, heat, panreatitis (3rd space), Addisonian crisis, DKA
• Pump failure:
  
  • Cardiogenic - ACS, arrhythmias, dissection, valve failure, hyperkalaemia
  • Secondary causes (obstructive): PE, tension pneumothorax, tamponade
• Peripheral circulation failure:
  
  • Septic shock
  • Anaphylactic shock
  • Neurogenic shock - SC injury, epidural, spinal anaesthesia

Question 8

What are the general consequences of an OD and general management?

Answer 8

• Effects of OD:
  
  • Hypotension
  • Arrhythmias
  • Seizures
  • Acidosis
• General management:
  
  • ABCDE + GCS, pupils, reflexes
  • ?charcoal if <1h
  • Glucose
  • ECG - arrhythmia, QTc
  • Blood - CK, electrolytes (Mg2+, phosphate, Ca2+)
  • VBG - ?acidosis
  • Antidote?

Question 9

Paracetamol OD - features, Ix, Tx

Answer 9

• Features - vomiting, RUQ pain, jaundice, encephalopathy
• Ix: Paracetamol level >4h, clotting, LFTs, ABG
• Tx:
  
  • <1h - activated charcoal
  • –> NAC - Indications: Above Tx line, staggered OD, unsure of onset, paracetamol intake >150mg/kg
  • Adverse reaction to NAC- anaphylactoid. Stopi if urticaria/ pruritis/angiodema –> adrenaline + hydrocortisone –> restart 1h. (Don’t restart if low BP, anaphylaxis)
  • Criteria for transplantation - pH <7.3 24h later or all of: PTT >100s, creatinine >300, grade III/IV encephalopathy

Question 10

Salicylate poisoning - Presentation, Ix and Tx

Answer 10

• Presentation:
  
  • Hypoglycaemia
  • Pyrexial + sweating
  • Tinnitus
  • Vomiting
  • Resp alkalosis –> metabolic acidosis. Mixed.
  • Agitation, delirium, confusion, coma
• Ix:
  
  • Salicylate + paracetamol level. Salicylate >500mg/kg = severe
  • U+Es, ABG, glucose
• Tx:
  
  • Supportive - airway
  • Activated charcoal
  • Serum bicarbonate
  • Urinary alkalinsation
  • Haemodialysis - pH <7.3, renal failure

Question 11

Opiate OD - Presentation, Tx

Answer 11

• Presentation:
  
  • Pin point pupils
  • CNS + resp depression
  • Tachycardia, hypotension
  • Rhabdomyolysis
• Tx= naloxone (competitive opiod receptor antagonist). Indications- RR <10/min, GCS <10/15
• Shorter half life –> may get Sx of withdrawal. Unmasks pain, hypertension, fits, arrhythmias, pulm oedema.

Question 12

TCA poisoning - features, Ix and Tx

Answer 12

• Features:
  
  • Metabolic acidosis
  • Dilated pupils
  • Hypotension, tachycardia
  • Fits
  • Prolonged QTc –> arrhythmias
• Ix: ECG, U+Es, glucose, ABG
• Tx:
  
  • Activated charcoal
  • Sodium bicarbonate
  • Correct K+

Question 13

Benzodiazepine OD - presentation, antidote

Answer 13

• Presentation - depressed GCS and resp
• Antidote= flumazenil

Question 14

Key features of Seratonin syndrome and neuroleptic malignant syndrome

Answer 14

• Seratonin sydrome:
  
  • Causes - SSRIs, MAOi, ecstasy
  • Faster onset - hours
  • Increased reflexes, clonus
  • Dilated pupils
  • Tx of severe - cyproheptadine, chlorpromazine
• Neuroleptic Malignant syndrome:
  
  • Cause: Anti-psychotics
  • Slower onset - h-days
  • Reduced reflexes, lead pipe rigidity
  • Tx of severe - dantrolene

Question 15

Iron OD - presentation, Ix, Tx

Answer 15

• Presentation:
  
  • N+V, abdo pain
  • Black offensive stools
  • Acute liver necrosis
• Ix:
  
  • How much elemental Iron. >100mg/kg= serious
  • Iron level after 4h
  • Bloods - WCC, U+Es, bicarb, glucose, clotting, LFTs
• Tx:
  
  • <1h - gastric lavage (not charcoal)
  • Desferroxamine= antidote
  • Indication = severe toxicity (CI renal failure)

Question 16

Beta blocker OD - features, Tx

Answer 16

• Bradycardia - atropine
• Hypotension - glucagon

Question 17

Ethylene glycol poisoning - presentation, Tx

Answer 17

• = Anti-freeze
• Features - metabolic acidosis, intoxication
• Tx: ethanol, haemodialysis

Question 18

Digoxin OD - presentation, Tx

Answer 18

• Presentation:
  
  • Low GCS
  • Yellow green visual halos, blurry
  • Arrhythmias,
  • Lethargy, confusion
  • GI
• Tx:
  
  • Activated charcoal <1h
  • Anti-digoxin Ab