EWS and sepsis and drugs that lead to surgical presentation

Question 1

what are the different things recorded for EWS?

Answer 1

resp rate, heart rate, BP, oxygen sats, temperature, AVPU and urine output

Question 2

why is EWS useful?

Answer 2

quick way to score someone for how unwell they are and an easy way to communicate.
can watch to see if a patient deteriorates/progresses

Question 3

what is the most important parameter of EWS?

Answer 3

Resp rate - good indicator of many different systems

Question 4

when should you worry about someones heart rate?

Answer 4

when it is outside the range of blood pressure

Question 5

what is the SOFA score? what is the short version of this?

Answer 5

a score using resp rate, platelets, bilirubin, mean arterial pressure, Glasgow coma scale , creatinine and urine output

qSOFA score is the short hand version:

• resp rate >22 = 1 point
• altered mental state = 1 point
• systolic BP <100mmHg = 1 point

these scoring systems are used for diagnosing sepsis

for a patient with a known infection a SOFA score of 2 indicates sepsis

Question 6

what is red flag sepsis?

Answer 6

sepsis + red flag symptoms.

Question 7

how is septic shock defined?

Answer 7

red flag sepsis + lactate >2

Question 8

what are the red flag symptoms of sepsis?

Answer 8

red flag symptoms include:

• resp rate >25, HR >130, low BP
• need O2, not alert, cyanotic
  - low urine output
  - neutropenic (chemo in last 6 weeks),
  - non blanching rash, mottled.

Question 9

what is the difference between SIRS and sepsis?

Answer 9

systemic inflammatory response syndrome - deranged acute response to illness - inflammatory markers go up and response is exaggerated and harmful. can be caused by sepsis

sepsis = infection + SIRS

Question 10

what are the clinical features of sepsis?

Answer 10

general symptoms of infection: tired, fever
SIRS:
- Temperature >38oC/<36oC
- Tachycardia (>90bpm)
- Tachypnoea (RR>20b/min)/PaCO2<4.3kPa
- WBC>12x109/L
- low BP

Question 11

how do you manage sepsis?

Answer 11

BUFALO

• bloods - FBC (raised WCC), U&E (incase kidney failure), CRP (raised in infection). Also blood cultures ( before Abx given)
• urine output
• fluids
• IV Abx - meropenem
• lactate - if >2 get ITU help
• oxygen- even if they are not desaturating, if they are severe sepsis, give 100% at 15L/m via a non-rebreath mask. (unless COPD)

CXR - if cause is pneumonia
urinalysis if suspect UTI
may need a throat swab or stool culture if still unsure
important to find this source and treat it.

Question 12

what is septic shock?

Answer 12

sepsis + hypotension despite adequate fluid resuscitation

Question 13

what drugs lead to surgical problems?

Answer 13

Aspirin/ NSAIDs
steroids
warfarin
COCP

Question 14

why can aspirin / NSAIDs lead to surgery?

Answer 14

risk of gastric ulcers and bleeding and perforation.

Question 15

what are the risk factors for NSAID ulceration?

Answer 15

>60yrs
previous peptic ulcer
type - ibuprofen is safest
simultaneous steroid use
on anticoagulants

Question 16

what surgical presentations can warfarin result in?

Answer 16

intraperitoneal bleeding
retroperitoneal haematoma
rectus sheath haematoma

Question 17

how can COCP lead to a surgical issue?

Answer 17

DVT/ P.E

mesenteric thrombosis and ischaemic colitis

Question 18

which drugs can cause pancreatitis?

Answer 18

4A, 3Ts, 2S, 1M
alcohol , aminoglycosides, azathioprine, ACE inhibitors

tamoxifen, thiazides, tetracyclines

steroids, sulphonamides

metronidazole

Question 19

one complication of surgery is ischaemia to part of tissue due to disruption of end arteries. how can this be avoided?

Answer 19

identify end arteries and avoid diathermy or vasoconstriction of these using adrenaline

Question 20

How can positioning a patient with a chest infection help aid gas exchange?

Answer 20

want to maximise V:Q
perfusion will follow gravity, therefore lie the patient on their side with their good lung down so that this gets more perfused.

if secretions in all of lung - continually keep switching position so by the time the secretions have dropped to that area of lung you move them again so areas with no secretions are perfused

Question 21

name 2 ionotropes and 2 vasopressors?

Answer 21

vasopressors: NA and vasopressin
ionotropes: Dopamine, adrenaline