Shock and Sepsis

Laura Glenn FY1 Liz Doxford-Hook FY1

Objectives
Shock Definition Classification Sepsis SIRS SEPSIS SEVERE SEPSIS SEPTIC SHOCK Real cases and management Slide show practice

Shock
SHOCK = Inadequate tissue perfusion.
Cardiac Output = SV x HR Tissue Perfusion = CO x Hb x Sats Oxygen delivery (mls O2/min) = Cardiac output (litres/min) x Hb concentration (g/litre) x 1.31 (mls O2/g Hb) x % saturation

Septic Shock Hypovoelamic

Anaphylactic

Cardiogenic

Hypovolaemic
Reduction in circulating volume 1) Haemorrhagic Internal vs. external
Internal: e.g. pelvic fracture, ruptured AAA External: e.g. laceration, stab injury

2) Severe dehydration

Anaphylactic

Exaggerated immunological response to an antigen Type 1 Hypersensitivity Reaction Antigen binds IgE Antibodies on Mast Cells + Basophils Histamine released

Clinical Features Cardiovascular Collapse, Bronchospasm, Angioedema, Urticaria, Rash, Erythema, wheeze

Scenario
16 year old girl 12 hours post lap appendix You are called to see her as she has become acutely SOB after receiving her IV antibiotics. What do you do first? Management ABCDE!!!! 5mg Adrenaline (5ml of 1 in 1000ml) 10mg IV Chloramphenamine 200mg IV hydrocortisone

Cardiogenic
Cardiogenic

Inadequate filling

Pump failure

- LV dysfuncyion (Post - Pulmonary ACS) embolism - dysrhythmia - Cardiac tamponade Signs Pnemothorax Pale, clammy patient. Tachycardic, low BP Right or left sided heart failure Pneumothorax Management = ABCDE look for and treat cause

Sepsis and Shock

VERY important Why? Leading cause of death in the UK Common Aggressive treatment and early intervention improves outcome!! As FY1 (especially on nights) you are likely to be the first one there OSCE stations/written exams

SIRS
What is it? Systemic Inflammatory Response Syndrome

Present if 2 of following present HR>90 Temp <36 or >38 RR>20 or PaCO2 <4.3kPa WCC <4 or >12

Sepsis

SIRS + source of infection

Possible sources??

Severe sepsis & Shock

Severe sepsis = Sepsis + hypoperfusion or organ failure

Septic Shock = persistent hypotension despite adequate fluid resuscitation (or use of inotropes/vasopressors)

Surviving sepsis campaign Early Goal Directed Therapy (EGDT)

Investigations

A patent/maintaing own airway? stridor? B RR, Sats + OXYGEN, Auscultation, ABG,CXR C HR, BP, CRT, JVP, Cannula, Bloods + cultures, fluid challenge (250 500ml colloid or 500-1000ml crystalloid stat), catheter, Clinical Signs D GCS E Abdomen, skin, surgical scars, oedema Specific Hx and Ex

Investigations
BLOODS FBC, Clotting, U+E, LFT, Amylase, CRP, Glucose ABG CXR/AXR ECG CULTURE Blood, Sputum, Urine, Wound Urine Output - >0.5mls/kg/hr (catheter to monitor fluid balance)

Management

Objective = Maintain tissue perfusion Fluid resuscitate

Increases preload Starlings Law: Increase preload = increase SV!! Remember CO = SV x HR ( therefore CO will increase and subsequently tissue perfusion)

Diagnosis Cultures should NOT delay antibiotics Treat with appropriate antibiotics (guidelines)

The Sepsis 6
BUFALO; Evidence based to improve outcomes B Blood Cultures U Urine output hourly (catheterise) F Fluids A Antibiotics (broad spec <1h) L - Lactate O - Oxygen

Bleep from the ward MEWS 12 68 year old male A.W. 6 days post sigmoid colectomy and anastomosis for colon cancer

Case

HR122 BP 85/52 RR 30 UO <80mls Sats 89% RA

You arrive - A.W is sat on the commode, foul smelling watery discharge evident on the floor Patient looks shocking!!

Management
What do you do first??? A + if possible get patient back into bed B C D E.

Management
A patent, talking in full sentences B raised RR, chest clear

GIVE OXYGEN (15 L O2) ABG PH 7.43, CO2 2.9, O2 18.6, HCO3 16, BE -9, LACTATE 5.4 CXR

C Tachycardic + bounding pulse, hypotensive, clammy hands

IV access, bloods, cultures, fluid challenge (how much?) + aggressive fluid resuscitation

Management

D
GCS E 4, V 4, M 6 = 14/15. PEARL BM 6.2 Moving all 4 limbs

E
Abdo: distended, tender, BS absent Calves = SNT Hx 4 days post operative ileus and vomiting (NG tube in situ) ?ABX GET HELP!! INFORM SENIORS!! CRITICAL CARE OUTREACH!

Further Management

Now what??? REASESS!!!!!

BP remaining between 88-94 despite fluid resuscitation (1000mls volplex and 1L running hourly) SEPTIC SHOCK

Slide Show/Question practice

Any questions so far????

This patient presented complaining of severe epigastric pain radiating through to the back 1. Name the clinical sign (1 mark) 2. What is the most likely diagnosis (1 mark)

1. What is the name of this investigation? (1 mark) 2. What is the likely diagnosis? (1 mark)

This is the ECG of a 85 year old male brought to A&E due to increasing confusion

1. What abnormality does this ECG suggest? (1 mark) 2. What treatment for this condition should be given immediately to this patient? (3 marks)

A 79 year old female with a background of Diverticular disease presents with abdominal pain

1.) What abnormality does the xray show? 2.) what is the most likely diagnosis?

A 3 year old girl with a fever and vomiting was taken to her GP 1.What is the diagnosis? (1 mark) 1.How would you treat this condition? (1 mark)

An 83 year old female 2 days post operatively presents with SOB and decreased saturations. This is her CXR 1.) What is the diagnosis? (1 mark) 2.) What are you immediate management steps? (2 marks)

ABG:
pH - 7.48 pO2 - 7.5 pCO2 - 3.4 HCO3- 24 BE -1.0 Lactate 0.9

A 54 year old male 6 days post fixation of a pelvic fracture presents with breathlessness. This is his ABG.

1.) What does this ABG show?

2.) What is the most likely cause? 3.) What is the gold standard diagnostic test?

References

www.survivingsepsis.org Oxford Handbook Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001; 345: 1368-77