Session 3 - Acute Sepsis in the ED

Question 1

State the features associated with acute sepsis.

Answer 1

• Pale, cool extremities
• High temperature around 39.5 deg C.
• High pulse with a low BP
• High resp rate, 30+/min
• Widespread purpuric rash (a fixed non blanching rash that stays red/purple when pressed on using a glass tumbler), not always seen.
• Neck stiffness (associated with meningitis)
• May still be Mentally alert on the GCS..

Question 2

What examinations would you conduct on someone in sepsis?

Answer 2

• FBC, urea and electrolytes
• Blood sugar
• Liver function tests
• CRP – acute phase protein found in inflammation
• Clotting studies
• Blood gases
• Blood cultures – confirm the diagnosis along with CSF examination.
• CSF examination by lumbar puncture – Note appearance, microscopy (WBCs and RBCs), glucose and protein content (changes in response to infection).

Question 3

What is SIRS and what is it comprised of?

Answer 3

Systemic inflammatory response syndrome. SIRS is response to a non specific insult.

Comprised of TWO or more of:

1) Temperature - 38deg C.
2) Heart rate - >90/min
3) Resp rate - >20/min 4

) WBC - 12x109L

Question 4

What is severe sepsis

Answer 4

SIRS + organ dysfunction or hypoperfusion

Question 5

What is septic shock?

Answer 5

Severe sepsis + low BP despite IV fluid administration

Question 6

How do MOs trigger the inflammatory cascade?

Answer 6

1) Pathogen invades and releases toxins
2) This toxin binds to local macrophages and stimulates production of cytokines. Cytokines stimulate the inflammatory response to promote wound repair and recruit the macrophage system
3) Cytokines released into circulation and stimulate growth factor, macrophages and platelets with the aim of inducing homeostasis.
4) SIRS occurs when homeostasis is not restored and cytokines lead to the activation of the humoral cascades (antibodies) and the macrophage system. This leads to circulatory insult.

Question 7

How does the inflammatory cascade damage the body?

Answer 7

1) Cytokines initiate production of thrombin and therefore promote coagulation
2) Cytokines also inhibit fibrinolysis
3) Coagulation cascade leads to microvascular thrombosis and therefore organ ischaema, dysfunction and failure.
4) This is a major cause of shock and multiorgan failure.

Question 8

What are the supportive treatments for acute sepsis?

Answer 8

• Symptom relief
• Physiological restoration – includes resuscitation, ensuring adequate fluid and metabolite administration, and empiric antibiotics (best guess antibiotics).

Question 9

What are specific treatments for acute sepsis?

Answer 9

• Antimicrobials
• Surgery – drainage, debridement (removal of dead or dying tissue), and/or dead space removal

Question 10

What is the sepsis 6 and when is it to be administered?

Answer 10

The Sepsis Six – To be delivered within 1 hour:

1) Deliver high flow oxygen
2) Take blood cultures and other cultures
3) Administer empirical IV antibiotics
4) Measure serum lactate – lactate occurs when tissues in the body undergo anaerobic respiration
5) Start IV fluid resuscitation
6) Commence accurate urine output measurement – Low urine output could be due to renal failure.

Question 11

Describe the features of neisseria meningitidis

Answer 11

• Gram negative diplococcus
• Outer membrane acts as an endotoxin
• Many serogroups (antigens on surface) which are based on the polysaccharide capsular antigen. This antigen evades immune response by preventing phagocytosis

Question 12

How is neisseria meningitidis spread?

Answer 12

Aerosols and nasopharyngeal secretions