What is a symptoms sieve?
Symptom sieve is used to get broad categories explaining pathological processes behind a condition
What does the A in the A-E assessment stand for and what does it involve looking for?
Airways - if compromised, treat before moving on
- Verbalising intermittently
- No foreign objects in mouth or excessive secretions
- No snoring/stridor
- No mouth or tongue swelling
What does the B in the A-E assessment stand for and what does it involve looking for?
Breathing
- Resp rate - 14
- No cyanosis
- Sats at 94 on 2L oxygen and initially 90%
- No evidence of respiratory disease
- Mild wheeze
- Smoker
- Auscultation of chest - wheeze
- Do Arterial Blood Gas - to give info about CO2
What does the C in the A-E assessment stand for and what does it involve looking for?
Circulation
- Blood pressure
- Heart rate
- Heart sounds
- 12 lead ECG
- Peripheral capillary refill brisk bilaterally < 2 seconds
- Warm peripheries
What does the D in the A-E assessment stand for and what does it involve looking for?
Disability
- Blood glucose - 5.7
- Temperature - 38.2°C
- ACVPU/GCS E3 V5 M6
- PEARL: pupils equal and reacting to light
How does the GCS score work?
3 is lowest and means you are not doing anything or saying anything - 1 in each category
Eye - 4 is max and means spontaneous eye opening
Verbal - 5 is max and means you are orientated
Motor - 6 is max and means you are obeying commands
What does the E in the A-E assessment stand for and what does it involve looking for?
Exposure
- Rashes
- Sites of injection/track marks
- Evidence trauma to head or limbs
- Evidence of external bleeding
- Abdominal examination: abdomen distension, tenderness
What should be done when systolic is less than 90?
This is concerning and should be intervened with by giving IV fluids to increase blood pressure.
This also tells us if the BP is low due to hypovolemia (if responds).
If not treated, this could lead to hypovolemic shock.
What is meant by circulatory shock?
Used when inadequate blood flow results to damage to body tissues
List the four types of circulatory shock and explain briefly what causes each of them
- Hypovolemic: loss of blood volume
- Obstructive: physical obstruction to blood flow
- Cardiogenic: due to ventricular failure
- Distributive: due to vasodilation due to sepsis, anaphylaxis (allergic reaction), neurogenic
Why is altered mental state considered a sign of sepsis?
Decreased cerebral perfusion due to histamine and cytokine release leading to vasodilation and this can cause altered mental state
The decreased cerebral perfusion can be due to circulatory shock initiated by sepsis
What is a renal sign of hypoperfusion?
Another sign is low urine output as kidneys are not receiving enough blood
What are 2 other signs of hypoperfusion?
Mottled skin and tachycardia also shows hypoperfusion
What is the diagnosis criteria for SIRS?
≥2 of:
- Temp >38 or <36 (elderly)
- Heart rate >90bpm
- Resp rate >20
- First sign of deterioration is tachypneoa
- WBC Count >12x10^9 or <4x10^9/L
Other than meeting criteria for SIRS, what else is required for a sepsis diagnosis?
- Meets SIRS criteria and evidence of infection
- Blood cultures
What is needed to diagnose a patient with severe sepsis?
- Sepsis with evidence of organ dysfunction, hypotension or hypoperfusion
- Lactate, Urine output
When would someone be considered to be in septic shock?
Severe sepsis with hypotension despite adequate fluid resuscitation
If you suspect sepsis, you are supposed to do the Sepsis 6, what are these?
- Give Oxygen to keep stats above 94%
- Take blood cultures - sign of sepsis
- Give IV Abx - if you suspect sepsis then give Abx within an hour
- Give a fluid challenge - give a bit of fluid fast 250-500ml of crystalline solution within 15 mins (stat)
- Measure lactate - sign of hypoperfusion
- Measure urine output - sign of hypoperfusion
After seeing the patient has increased CRP, Lactate and WBC/Neutrophilia, why are these each suggestive of sepsis?
CRP - inflammation
Produced by liver and produced when we have an inflammatory response
Lactate - anaerobic respiration
Part of sepsis 6
Vasodilation meaning hypoperfusion which means there is no oxygen and so anaerobic respiration occurs and this leads to increased lactate
WBC and neutrophilia - sign of infection
Neutrophil is suggestive of bacterial infection
Why is abnormal urea not suggestive of sepsis?
There are too many causes of abnormal urea and renal injury therefore not specific to sepsis
Why is raised GGT in this case not used to suggest sepsis diagnosis?
Not GGT due to chronic elevated levels of ethanol - history of alcohol abuse
