Sepsis, Shock, Anaphylaxis & Cardiac Arrest Flashcards

1
Q

What are the symptoms of anaphylaxis?

A
  • chest tightness
  • wheeze
  • breathlessness
  • itching
  • swelling
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2
Q

What are the EARLY signs of anaphylaxis?

A
  • urticaria
  • bronchospasm / stridor
  • vomitting / diarrhoea
  • flushing
  • abdominal pain
  • impending sense of doom
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3
Q

What are the LATER signs of anaphylaxis?

A
  • hypotension
  • tachycardia
  • tongue / preorbital swelling
  • cyanosis
  • wheeze
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4
Q

Which drugs can commonly cause anaphylaxis?

A

penicillins, anaesthetic drugs, contrast, blood products

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5
Q

What are the worrying signs of anaphylaxis?

A
  1. No respiratory / cardiac effort
  2. BP <90 systolic
  3. Falling o2 sats
  4. Chest tightness
  5. Stridor
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6
Q

If worrying signs of anaphylaxis are present, what should you do?

A
  1. Dial 2222 - get the crash trolley

2. Get senior help!

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7
Q

What are the steps for immediate anaphylaxis management?

A
  1. Dial 2222 - get the crash trolley.
  2. Call for senior help.
  3. Check if px has any known allergy.
  4. Give 0.5ml 1:1000 adrenaline (epinephrine) - can repeat after 5 mins if no better.
  5. Stop exposure if possible e.g. IV Abx / blood transfusion.
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8
Q

Rx for anaphylaxis?

A

0.5 ml, 1:1000, IM adrenaline (500 micrograms) - repeat after 5 mins if no better.

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9
Q

ABCDE for anaphylaxis

A

A = GCS <8 or airway concerns - call anaesthetist + consider adjunct.

B = sit px up + 15L/min o2 nrb mask + pulse oximetry + full set of obs + auscultate chest + consider nebulised salbutamol/adrenaline for bronchospasm.

C = ECG + wide-bore bilateral IV access (FBC, U+E, mast cell tryptase) after adrenaline given.

D = monitor GCS

E = examine px for rash + chlorphenamine 10mg IM or slow IV (adults) + hydrocortisone 200mg IM or slow IV.

REPEAT MAST CELL TRYPTASE - 1hr/ 6-24hr post reaction.

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10
Q

Define SIRS?

A

“Systemic Inflammatory Response Syndrome”

  • HR >90
  • RR >20 or PaCO2 <4.3
  • WCC >12 or <4
  • Temp >38.3 or <36
  • Altered mental status
  • Glucose >7.7 in non-diabetics.

NEED 2+ TO BE SEPSIS.

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11
Q

Define:

  1. Sepsis
  2. Severe sepsis
  3. Septic shock
A
  1. SIRS criteria + identified/ suspected source of infection.
  2. Above + evidence of end organ dysfunction. 35% mortality.
  3. Hypotension despite adequate fluid resusitation (BP <90/60, MAP <65, lactate >4).
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12
Q

How does severe sepsis affect:

  1. Lungs
  2. Kidneys
  3. Liver
  4. Other
A

Lungs:

  • Sp02 <90% or <94% despite O2 therapy
  • Acute lung injury (PaO2/FiO2 ratio)

Kidneys:

  • Urine output = <0.5ml/kg/hr for 2+ hrs
  • Creatinine >176.8

Liver:

  • INR >1.5 or PTT >60 (without anticoagulation therapy)
  • Billirubin >34.2

Other:

  • Platelets <100
  • Lactate >2
  • Ileus / absent BS
  • CRT >3 seconds
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13
Q

Explain ‘BUFALO’

A

B = Blood cultures - peripheral blood, urine, lines, wound swabs, sputum, stool, CSF.

U = Urine output - catheterise + start fluid balance chart.

F = Fluids - 500ml crystalloid bolus (250ml if elderly / congestive cardiac failure).

A = Abx - consult guidelines, start within 1 hr of diagnosis sepsis.

L = Lactate = measure via ABG/ VBG.

O = O2 to maintain sats as appropriate (88-92% - COPD + 95-98% - normal).

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14
Q

What are the aims of sepsis Rx?

A
  1. BP >100 systolic or MAP >65
  2. Urine output >0.5ml/kg/hr
  3. Lactate <2 after fluid resuscitation
  4. Maintain BG <8.3
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15
Q

What can critical care offer?

A
  • 1:1 / 1:2 nursing.
  • Invasive BP monitoring (via arterial/ central lines) + control.
  • Vasopressor therapy (e.g. noradrenaline).
  • Renal support - haemofiltration.
  • Sedation + intubation (reduce metabolic demands, give respiratory support - optimisation).
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16
Q

Name the complications of sepsis?

A
  1. Acute Respiratory Distress Syndrome (ARDS).
  2. Disseminated intravascular coagulation.
  3. Acute renal failure.
  4. Circulatory failure.
17
Q

Define:

  1. Shock

2. Undifferentiated shock

A
  1. “A state of cellular and tissue hypoxia due to reduced o2 delivery and/or increased o2 consumption or inadequate o2 utilisation”.
  2. Shock with an unrecognisable/unclear cause.
18
Q

Name the 5 different types of shock.

A
  1. Anaphylactic
  2. Septic
  3. Hypovolaemic (haemorrhagic)
  4. Cardiogenic
  5. Neurogenic
19
Q

What is hypovolaemic shock and what are the causes?

A
  1. reduced circulating volume = low BP
    • Haemorrhage - trauma (‘on the floor + 4 more’), ruptured AAA, GI bleed.
  • Salt/ water loss - D+V, burns, polyuria (diabetes insipidus/ DKA).
  • 3rd space loss - pancreatitis, ascites.
20
Q

What are the signs & symptoms of hypovolaemic shock?

A

Signs = low BP, tachycardia, weak/thready pulse, postural drop, oliguria, prolonged cap refil, cool peripheries, reduced GCS, mottled skin (severe).

Symptoms = dizziness, SOB.

21
Q

Describe a typical px with hypovolaemic shock.

A

Pale, cool to touch (peripheries) + tachycardic

22
Q

How do you manage hypovolaemic shock?

A
  1. Call senior
  2. Lie px flat + ABCDE.
  3. Bloods = FBC, U+E, amylase, clotting, G&S.
  4. ABG/VBG - check lactate.
  5. Fluids - IL crystalloid STAT + repeat if no improvement.
  6. Identify cause e.g. pancreatitis, burns.
  7. No response to fluid challenge? - involve Outreach / ICU - will require inotropic support.
  8. Catheterise - monitor urine output.
  9. Keep reassessing.
23
Q

Name the 2 common causes of cardiogenic shock.

A
  1. Pump failure - LV dysfunction, aortic dissection, dysrhythmia.
  2. Inadequate filling - PE, pneumothorax, cardiac tamponade.
24
Q

What are the signs of cardiogenic shock?

A

tachy/bradycardia, ?deviated trachea, ?reduced breath sounds, decreased o2 sats, Beck’s triad (if tamponade).

Beck’s triad = muffled heart sounds, raised JVP, shock.

25
Q

How do you manage cardiogenic shock?

A
  1. Call a senior.
  2. ABCDE
  3. ECG - may see ischaemia etc.
  4. CXR - may see cardiomegaly, pulmonary oedema.
  5. ABG - likely hypoxic
  6. Bloods - FBC, U+E, clotting, glucose, G&S (group + save).
  7. Maybe urgent echo.
26
Q

What are the 1. causes of neurogenic (spinal) shock? 2. symptoms? 3. signs?

A
  1. Trauma - transection of the spinal cord at any level, Iatrogenic - spinal anaesthetic.
  2. motor/sensory dysfunction below the level of the lesion, bladder + bowel dysfunction.
  3. warm peripheries, may NOT be tachycardic if lesion about T1-T4, focal neurology, loss of anal tone on PR.
27
Q

How do you manage neurogenic shock?

A
  1. Call senior
  2. Lay flat + elevate legs (in absence of spinal)
  3. IL crystalloid STAT
  4. Catheterise
  5. If trauma suspected - contact spinal/orthopaedic surgeons.
  6. If iatrogenic (if caused by injections etc) - stop epidural if in situ + call anaesthetist.
28
Q

How long should you wait before starting chest compressions in a suspected cardiac arrest?

A

No longer than 10 seconds.

Shout for help, check for response, open airway.

If no pulse/respiration = start chest compressions + 2222 (crash call) + crash trolley.

29
Q

What are the 2 ‘shockable’ rhythms in cardiac arrest?

What do you do?

A
  1. VF
  2. Pulseless ventricular tachycardia (negative spikes on ECG)

What to do:

  1. Deliver shock + reassess rhythm every 2 mins.
  2. Give adrenaline + amiodarone after 3rd shock.
  3. Repeat adrenaline every 3-5 mins.
30
Q

Name the ‘non-shockable’ rhythms in cardiac arrest?

What do you do?

A
  1. Pulseless electrical activity (PEA)
  2. Asystole

What to do:

  1. Do not give shock.
  2. Reassess rhythm every 2 mins.
  3. Give ONLY adrenaline (no amioderone).
  4. Repeat adrenaline every 3-5 mins.
31
Q

Name + dosage of drugs used in cardiac arrest.

A
  1. Adrenaline - 1mg IV
  2. Amioderone - 300mg IV

GIVE AFTER 3rd SHOCK IN SHOCKABLE RHYTHMS OR IMMEDIATELY IN NON-SHOCKABLE.

32
Q

Name the 4 H’s + 4 T’s of reversible causes of cardiac arrest.

A

H:

  1. hypoxia
  2. hyper/hypo-kalaemia
  3. hypovolaemia
  4. hypothermia

T:

  1. tension pneumothorax
  2. thrombus
  3. tamponade
  4. toxins
33
Q

You are called to see an adult patient on the ward because they have developed
stridor. They have a known penicillin allergy (not anaphylactic) and have just been
given a dose of IV meropenem. Once you have asked for help, which 3 drugs would
you give?

A: 0.5ml 1:1000 adrenaline IM, chlorphenamine 10mg IV/IM, hydrocortisone 200mg
IV/IM

B: 0.5ml 1:10000 adrenaline IV, chlorphenamine 30mg IV/IM, hydrocortisone 200mg
IV/IM

C: 0.5ml 1:1000 adrenaline IM, chlorphenamine 10mg IV/IM, prednisolone 40mg PO

D: 1ml 1:1000 adrenaline IM, chlorphenamine 20mg IM/IV, hydrocortisone 200mg
IV/IM

A

A:

  1. 0.5ml 1:1000 adrenaline IM
  2. chlorphenamine 10mg IM/IV
  3. hydrocortisone 200mg IM/IV
34
Q

You are called to see a patient on the surgical ward who is hypotensive following a
bowel resection earlier. When you assess him he is warm to the touch, hypotensive
and tachycardic, and unable to move his legs. When you review his chart, he has an
epidural running. Which type of shock is most likely in this man?

A: Hypovolaemic shock
B: Anaphylactic shock
C: Cardiogenic shock
D: Spinal shock

A

D: Spinal (Neurogenic) shock

35
Q

Which of these is NOT a cause of hypovolaemic shock?

A: Burns
B: Pulmonary embolism
C: Haemorrhage
D: Pancreatitis

A

B: Pulmonary embolism = type of cardiogenic shock - causes inadequate filling.

36
Q

According to ALS protocol, which of the following is not one of the reversible causes that
you should treat immediately in a patient with cardiac arrest?

A. Saddle pulmonary embolus
B. Opiate toxicity
C. Acute subarachnoid haemorrage
D. Hypovolaemia secondary to overwhelming sepsis

A

A: Saddle pulmonary embolus

37
Q

You are called to a non-responsive patient who is showing no signs of life. You
commence CPR and attach defibrillator pads. When you assess the rhythm the following
tracing showing VENTRICULAR FIBRILATION is obtained, the patient has no central pulse palbable:

What is the correct response?
A: No shock advised, give amiodarone 300mg and adrenaline 1mg immediately

B. Deliver a shock and give adrenaline 1mg immediately

C. Deliver a shock and give adrenaline 1mg and amiodarone 300mg after the 3rd shock

D. No shock advised, give adrenaline 1mg immediately

A

C: Deliver a shock and give adrenaline 1mg and amiodarone 300mg after the 3rd shock

38
Q

Which of the following patients meets criteria for having a systemic inflammatory
response syndrome?

A. HR 80, BP 110/70, Temp 38.0, RR 22, Sats 98 on air

B. HR 95, BP 135/75, Temp 36.8 RR 18, Sats 100 on air

C. HR 95 BP 125/65, Temp 37.2 RR 22, Sats 96 on air

D. HR 120, BP 95/55, Temp 38.0, RR 18, Sats 97 on air

A

C. HR 95 BP 125/65, Temp 37.2 RR 22, Sats 96 on air

Systemic Inflammatory Response Syndrome (SIRS) - 2 or more of…

HR > 90

RR > 20 or PaCO2 <4.3

WCC >12 OR <4

Temp >38.3 or <36

Altered mental status

Glucose >7.7 in non-diabetics