Unit 3 Case 1: Sepsis Flashcards
systemic inflammatory response syndrome SIRS
systemic inflammation
symptoms are fast heart rate (tachycardia), low blood pressure, very low or very high body temperature, very low or very high white cell count
sepsis
type of SIRS caused by infection
subsequent systemic inflammatory response
can result in hypoperfusion and dysfunction of major organ groups
septicaemia
name sometimes used for sepsis
bacteremia
presence of bacteria in the bloodstream
the innate immune system is a large part of this case
learn immune response
inflammatory response
started by innate immune cells, pro inflammatory cytokines and complement
localise and contain the infection
1.vasodilation and increased blood flow
2.increased vascular permeability
3.release of inflammatory mediators
4.neutrphil chemotaxis
5microvascular coagulation
6.systemic features
7.upregulation of costimulatory molecules
5 cardinal signs of inflammation
dolor
calor
rubor
tumor
functio laesa
what is cellulitis
bacterial infection of the skin
acute spreading pyogenic inflammation of the dermis and subcutaneous tissue
most commonly from staphylococci and streptococci
4 stages of wound healing
hemostasis
inflammation
proliferation
remodelling
hemostasis stage
stopping of bleeding by narrowing blood vessels
blood begins clotting by platelets forming a plug held together by fibrin
inflammation begins so the body can heal so blood flow is increased again
inflammation stage
overlaps slightly with homeostasis
neutrophils will aid in immune response followed by macrophages
proliferative stage
macrophages arrive
collagen is produced, angiogenesis
remodelling stage
involves collagen
continuously broken down and produced
to balacne the need for tensile strength and remodelling of new tissue
symptoms of sepsis in younger children
blue pale or blotchy skin, lips or tongue
rash that doesn’t fade when you press on it
difficulty breathing, breathlessness or rapid breathing
weak high-pitched cry not like normal cry
fatigue
symptoms of sepsis in adult or older child
acting confused
slurred speech
blue pale or blotchy skin lips or tongue
rash that doesn’t fade when pressed
breathlessness or fast breathing or difficulty breathing
what will doctors look for in sepsis assessment
fever
low blood pressure
high heart rate
blood tests
electrolyte imbalances
urine, wound and respiratory secretions
x ray or ultrasound
what could a blood test be used to identify in sepsis
evidence of infection
clotting problems
abnormal liver or kidney function
impaired oxygen availability
what is sepsis 6
3 diagnostic and 3 therapeutic steps to be delivered within one hour of initial diagnosis of sepsis
ensure a senior clinician attends
what does the sepsis 6 include
give high-flow oxygen
give IV antibiotics
give a fluid challenge
take blood cultures
measure lactate
measure urine output
gram negative bacteria
more difficult for uptake of nutrients as it has 2 membrane layers
cytoplasmic membrane and outer membrane
one peptidoglycan layer
gram positive bacteria
thick peptidoglycan layer
cytoplasmic membrane
more rigid
stronger cell wall
gram negative bacteria stains
stains red
thin layer of peptidoglycan and the dye will leak out and stain cell red
diderms
gram positive bacteria stains
stains purple
thick peptidoglycan layer
retains dye
monoderms
normal blood pressure
120/80 mmHg
normal heart rate
60 to 100 bpm
normal respiratory rate
12 to 16
normal o2 saturation
96% equal or higher
normal body temperature
36.1-38
GCS
assess wakefulness and awareness to determine consciousness
lower value the less conscious
AVPU scale
scored up to 15
itu monitoring
pain
urine output
consciousness
temp
pulse
resp rate
spo2
role of the paramedics in the emergency department
ambulance pre alert the ED if transporting patient needing to be received by a clinical team
patients are received by an appropriate medical team upon arrival
paramedics manage treatment until this point
triage
patients who are unheralded then seen by a triage nurse on arrival
assess severity of the condition
NHS major incident triage tool
catastrophic bleeding
walking
breathing
responds to voice
aged over 2
breathing rate 12-23
heart rate 100 or more
answers lead to ranking of severity
MDT involved in emergency departments
consultants
registrars
hospital medical officers
nurse practitioners
physiotherapists
emergency department pharmacists
mental health emergency team
admin staff
drugs involved in this case
flucloxacillin
co-amoxiclav
flucloxacillin
narrow spectrum
type of penicillin beta lactase antibiotic
gram positive bacteria in skin and soft tissue infections
contains beta lactam ring
brand name: floxapen, fluclox
co-amoxiclav
broad spectrum
type of penicillin beta lactase antibiotic
mix of clavulanic acid and amoxicillin
should be reserved for infections likely caused by beta lactase producing strains egg, influenzae, s aureus
gram positive and negative
brand name: augmentin, clavulin
flucloxacillin mechanism of action
binds to transpeptidase, penicillin binding protein
inside bacterial cell wall
inhibits 3rd and last stage of bacterial cell wall synthesis
prevents PBPs from cross-linking D-ala-D-ala chain on a tetra peptide
cross linking of peptidoglycan walls fail to happen, walls are weak, cell lyses occurs by autolytic enzymes called autolysis
hydrolyse mucopeptide polymers in bacterial cell wall
if they attempt to divide, cell walls will collapse and kill them in the process
co-amoxiclav mechanism of action
amoxicillin binds to transpeptidase
prevents PBPs from cross-linking with D-ala-D-ala chain
cell lyses occurs
clavulanic acid prevents beta lactamases from breaking down amoxicillin by binding to it
side effects for penicillins
D&V
nausea
skin reaction
hypersensitivity
thrombocytopenia
side effects of flucloxacillin
gastrointestinal disorders
allergy presenting as a skin rash
anaphylactic reactions, hypotension, bronchospasm, orofacial,pharyngeal and laryngeal oedema, liver toxicity
side effects of co-amoxiclav
increased risk of infection
dizziness, dyspepsia, headache
colitis haemorrhagic, crystalluria, hypersensitivity vasculitis, meningitis aseptic
sampling and testing pus by gram staining
5ml pus using sterile syringe
smear onto microscope slide and spread with a sterile loop
fix using methanol
apply crystal violet and iodine
then acetone or ethanol
apply stafranin
view under microscope
results of gram staining with pus
positive= purple
negative= pink
cocci= round
bacilli=rod
catalase testing
differentiates between staphylococci and streptococci
is an enzyme produced by microorganisms that mediates breakdown of hydrogen peroxide into oxygen and water to prevent oxidative damage to microorganisms
if effervescence then enzyme is present
catalase testing results
staphylococcus is catalase positive
streptococcus is catalase negative
coagulase test
staphylococcus aureus produces coagulase enzymes
converts fibrinogen in blood plasma to insoluble fibrin
coats bacteria
protects them from phagocytosis
coagulase test results
staphylococcus aureus tests coagulase positive
any other staphylococci will test coagulase negative
mannitol testing
based on the presence of sodium chloride
inhibits most gram negative and positive
differentiation based on ability or not to ferment the mannitol
if fermentation induces acidification which leads at pH levels below 6.9 to yellow colouration of medium in presence of phenol red
mannitol testing results
if mannitol positive (ferments the sugar)
likely to be S.aureus
antimicrobial sensitivity testing
uses agar plates
with antimicrobial discs
measure the zones of inhibition
to calculate efficacy of drugs or resistance of bacteria
treatment options for sepsis
beta lactam/beta lactase inhibitor combinations
prevents active beta lactam from being hydrolysed so can still inhibit transpeptidases
public health involvement for sepsis
CDC get ahead of sepsis
uk sepsis trust
sepsis 6
NEWs
factors that may link to sepsis mortality
low income
high poverty
lack of health insurance
lower education status
access to healthcare
factors contributing towards mental health
social isolation or loneliness
social disadvantage, poverty or debt
severe or long-term stress
having a long-term physical health condition
unemployment or losing job
childhood abuse, trauma or neglect
substance misuse
homelessness or poor housing
long term caring for someone
factors affecting mental health in this case
relationship strains
redundancy form job
long-term stresses
lack of work-life balance
zero hour contract
blood test results for iron deficiency anaemia
Hb: normal at first but will fall as anaemia worsens
RBC size/ MCV: may be decreased
RBC amount/ MCHC: may be decreased
RBC variation in size: increased
further tests a doctor may do to confirm iron deficiency anaemia
serum iron
total iron binding capacity
transferrin saturation index
ferritin
blood test results for pernicious anaemia
low Hb level
MCV often high
blood film results for pernicious anaemia
abnormally large RBCs
abnormal shaped RBCs
occasional giant white blood cells
other tests for pernicious anaemia
vitamind B12
folic acid level
methylmalonic acid
homocysteine
reticulocyte count
antibodies to intrinsic factor or parietal cell antibodies
sometimes a bone marrow aspiration
blood test results for aplastic anaemia
haemoglobin may be low
RBC and WBC counts are low
platelet count is low
MCV may be normal or slightly raised
differential white blood cell count shows decrease in most types of cells but not lymphocytes
additional testing for aplastic anaemia
reticulocyte count
erythropoietin
bone marrow aspiration
tests for infections such as hepatitis,EBV, CMV
test for arsenic
iron tests for vitamin B12
antibody tests for ANA
pure red cell aplasia
only red blood cell precursors are absent
testing for haemolytic anaemia
test for haemoglobin variants such as haemoglobin electrophoresis
DNA analysis
G6PD test
osmotic fragility test
