Critically unwell surgical patient Flashcards
What does 2 or more of these symptoms indicate?
- Temp >38°C (100.4°F) or < 36°C (96.8°F)
- Heart Rate > 90
- Respiratory Rate > 20 or PaCO2 < 32 mm Hg
- WBC > 12,000/mm3, < 4,000/mm3
SIRS
systemic inflammatory response syndrome
(a cause of shock e.g. acute circulatory failure with inadequate tissue perfusion causing cellular hypoxia)
What is sepsis?
SIRS (systemic inflammatory response syndrome) + source of infection
What does this describe?
- organ dysfunction, hypotension, or hypoperfusion.
- Lactic Acidosis,
- SBP <90 or SBP Drop ≥ 40 mm Hg of normal
Severe sepsis
What is septic shock?
Septic shock = severe sepsis with hypotension, despite adequate fluid resuscitation
rememebring sepsis = SIRS (systemic inflammaotry response syndrome) + source of infection
What is multiple organ dysfunction syndrome?
evidence of >2 organs failing
What is the sepsis 6?
Rx for sepsis?
Take: Abg (lactate), cultures, UO
Give: oxygen, fluid challenge, abx
best guess abx –> @sgul = co-amoxiclav & gentamicin
- Change therapy based on cultures
- Physiotherapy
- ITU
- Surgery
- Interventional radiology
What is the equation for BP?
BP = CO x TPR [HR x SV (CO) x TPR}
What causes of hypotension are there?
- Hypovolaemia
- cardiogenic
- obstructive
- vasodilatory state
What cause of hypotension are these?
- PE
- Tamponade
- Tension pneumothorax
Obstructive hypotension
What causes of hypotension are these?
- Blood loss
- Plasma loss
- Saline loss
- Dehydration
Hypovolaemia
CO x TPR [HR x SV x TPR]
What causes of hypotension are these?
- MyocardiaI infarction
- Cardiac failure
- Myocardial contusion
- Arrhythmia
Cardiogenic
BP =CO x TPR [HR x SV x TPR] e.g. cardiogenic = decreased CO
What causes of hypotension are these?
- Sepsis
- Neurogenic
- Trauma & transection of spinal cord
- Epidural
- Anaphylaxis
- Adrenal insufficiency (LT steroids)
Vasodilatory state
e.g. BP: CO x TPR [HR x SV x TPR]
What can happens if you have hypotension in the body?
HYPOTENSION + HYPOXAEMIA = ARREST
:(
What should be given in these circumstances?
- Poor UO - 10ml/kg
- Low BP - 20ml/kg
- HF & poor UO - 5ml/kg
= Fluid challenge!
- Poor UO - 10ml/kg
- Low BP - 20ml/kg
- HF & poor UO - 5ml/kg
What happens to the bodys fluid in surgery?
Surgical insult and metabolic stress –> RAAS activated –> Na retention
BUT surgery also involved many losses of fluid –> NG aspirates, ileostomy & fistula outputs, diarrhoea, ileus, sweat
What should be done with fluid balance pre-, intra- and post- op?
Pre-op =
encourage oral fluids until 2hrs before,
6 hrs for foods
IV fluids if required e.g. mechanical bowel prep as this dehydrates
Intra-op =
monitored closely
post-op =
oral fluids, IV fluids should be Na poor (as RAAS system retaining Na is activated by surgical insult)
What should you replace lost blood with in massive haemorrhage?
simply replace with blood if bleeding (want the clotting factors and oxygenation capacity or RBC)
crystallois = saline w/K+ or hartmanns
rarely colloid (though in GI bleed can use colloid? according to grey book emergencies)
What can these conditions all cause?
- Cardiac – arrhythmias, MI, pericarditis, contusion
- Circulatory – shock, PE
- Inflammation / infection
- Metabolic – acidosis
- Haematological – anaemia
- Endocrine – Thyrotoxicosis
- Drugs – Aminophylline, digitalis toxicity, beta agonists
- Anxiety and pain
Tachycardia!
What can these conditions all cause?
- Hypovolaemia
- Sepsis
- Nephrotoxic drugs
Poor urine output!
What can these conditions all cause?
- Surgery
- Wind: Atelectasis, pneumonia
- Wound: infection
- Water: urine infection
- Walking: DVT/PE (3-4days post-op)
- Wonder drugs: blood transfusion reaction, malignant hyperpyrexia (reaction to anaesthetic
Fever!
What can these conditions all cause?
- Usually AB or C
- Exclude hypoglycaemia, narcotic OD & sepsis
- Alcohol? (day 3-4 post-op - get collateral history)
Confusion!
What conditions can cause tachycardia?
- Cardiac – arrhythmias, MI, pericarditis, contusion
- Circulatory – shock, PE
- Inflammation / infection
- Metabolic – acidosis
- Haematological – anaemia
- Endocrine – Thyrotoxicosis
- Drugs – Aminophylline, digitalis toxicity, beta agonists
- Anxiety and pain
What conditions can cause poor urine output?
- Hypovolaemia
- Sepsis
- Nephrotoxic drugs
What conditions can cause fever?
- Surgery (aka surgery ITSELF can cause fever)
- Wind: Atelectasis, pneumonia
- Wound: infection
- Water: urine infection
- Walking: DVT/PE (3-4days post-op)
- Wonder drugs: blood transfusion reaction, malignant hyperpyrexia (reaction to anaesthetic
What conditions can cause confusion?
- Usually AB or C
- Exclude hypoglycaemia, narcotic OD & sepsis
- Alcohol? (day 3-4 post-op - get collateral history)
What is the systematic approach to a critically unwell patient
(CCrISP course approach, RCS core trainee level)
- Immediate managmement - ABCDE
- Full patient assessment - chart review, Hx and Exam, available results
- decide and plan if STABLE or UNSTABLE
- if stable = daily managment plan
- if unstable/unsure => dx required w/specific investigations; defiitive rx - med, surg or radio
What does this initial management (until senior arrives) help with & what pathologies?
- -Chin lift / Jaw thrust
- -Suction
- -Oropharyngeal airway (guedel airway)
- -Endotracheal tube (small plastic tube)
- -(Protect the C-spine)
Used for A = Airway; as you want to obtain, secure and protect the airway
- useful for pathologies such as
- vomiting & aspiration
- unconscious airway
What does this initial management (until senior arrives) help with & what pathologies?
- Oxygen: Acutely - 15l/min with rebreathing bag. Longer term - humidified and monitored
- Sit up
- Treat underlying cause e.g. wheeze
- Physiotherapy
- Get help!
B - Breathing
- Atelectasis, sputum retention, pneumonia, PneumoThorax (risk in central line pts)
- COPD, asthma
- LVF, fluid overload –> lungs
- PE, ARDS, Fat embolism syndrome
What does this initial management (until senior arrives) help with & what pathologies?
- Establish adequate venous access
- -Choice of site
- -Take bloods
- Administer fluid bolus
- -10–20 ml/kg crystalloid
- -Repeat once if necessary
C - Circulation = As you want to STOP BLEEDING
Pathologies include bleeding and low BP
What is this the initial management (until senior arrives) of; what pathologies may cause this?
- A Alert
- V responds to Verbal stimulus
- P responds only to Pain
- U Unresponsive to any stimulus
- PUPILS
- Blood sugar level
D - dysfunction of CNS / DEF, dont ever forget glucose
Examples of pathology include Opiate OD & poorly managed diabetes –> dysfunction of CNS
What is this the initial management (until senior arrives) of; what pathologies may cause this?
- Adequate exposure for adequate assessment
- Prevent cold
- Preserve dignity
- E - exposure
- patholgies - huge rectal bleed (?idk its in emmas notes as this)
What is this statement known as?
among competing hypotheses, the one with the fewest assumptions should be selected (pick the simplest explanation).
Ockham’s razor
