CBL 4: A PATIENT IN SHOCK

Question 1

Q1. Outline your initial assessment of this woman and a possible differential diagnosis.

Answer 1

UTI - temp and confused
DKA / HHS
Necrotising pancreatitis - abdominal pain
Pyelonephritis

Question 2

Her clinical findings are as follows:
Examination:
* Confused
* Glasgow Coma Score 9/15
* Pulse 110 regular
* Blood pressure 84/43 mmHg
* Temperature 38.9 0C
* Oxygen saturations 93% on room air
* Chest Clinically clear
* Heart sounds Normal
* Abdomen Soft, no organomegaly, no peritonism
* No focal neurology

Q2. How do these findings help in your differential diagnosis? [3]

Answer 2

Septic shock secondary to UTI:
- Hypotensive
- O2 sats 93%
- GCS 9/15 - reduced perfusion to brain

Question 3

Define sepsis [1]
Define septic shock

Question 4

go over shock lecture

Question 5

Further investigations showed the following:
Venous blood gas:
* pH 7.24 (7.35-7.45)
* Bicarbonate 14 mmol/L (18-23)
* Sodium 138 mmol/L (135-145)
* Potassium 6.9 mmol/L (3.5-5.5)
* Urea 18.7 mmol/L (3.3-6.6)
* Creatinine 427 umol/L (75-95)
* Lactate 6.7 mmol/L (0.5-2.2)
* C-reactive protein 223 mg/l ( < 5)
* Haemoglobin 104 g /L ( 110-130)
* White cell count 23.5 x 109
* /L (3.5-9.0)

Urinalysis
* Blood ++
* Leucocytes +
* Nitrites +
* Protein ++
* Ketones - Neg

Chest radiograph Normal

Q3. Interpret these findings, including the ECG. Outline a problem list and
explain the likely underlying cause

Answer 5

pH 7.24 (7.35-7.45):
* metabolic acidosis

high lactate:
* marker of anaerobic respiration. present if hypoperfused tissue

CRP & urinalysis indicate an infection:
- leucocytes ++
- nitrates +

ECG:
- bradycardic
- tall tented T waves (V4)
- no p waves [?]

Question 6

What oxygen do you prescribe in an acute emergency? [1]

Answer 6

15 L

Question 7

How would you manage this patient? [4]

Answer 7

Fluids, monitor urine output, 15L oxygen, blood cultures (after antibiotics), antibiotics

Question 8

When do you give antibiotics in comparison to blood cultures? [1]

Answer 8

Antibiotics after blood culture

Question 9

What is the sepsis 6? [6]

Answer 9

Question 10

• no p waves on ECG?

Question 11

How does hyperkalaemia present on ECG? [3]

Learn

Answer 11

T tall tented T waves
Flattened / widened (or even flattened) P wave
Prolongation of PR interval

Question 12

UTIs are most commonly caused by which pathogen? [1]

Answer 12

Escherichia coli

Question 13

What indicates that an AKI is occuring? [1]

Answer 13

Protein in urinalysis

Question 14

What pathologies is this person suffering from? [3]

Answer 14

Septic shock secondary to UTI
Hyperkalaemia
AKI

Question 15

What is the risk of her acute hyperkalaemia [1], and how should this be managed? [4]

Answer 15

• ECG changes: calcium chloride or calcium gluconate, stabilises the myocardium
• Insulin dextrose: moves K intracellularly, but also giving glucose means don’t go hypoglycaemic
• Calcium resonium: removes excess K+ by exchanging for Ca2+
• Nebulised salbutamol: causes hypokalaemia [& can make tachycardic]

Question 16

State three risks of hyperkalaemia [3]

Answer 16

cardiac arrhythmia:
- established effects on cardiac excitability, hyperkalemia

peripheral neuropathy
renal tubular acidosis

Question 17

Explain what is meant by the term “Acute Kidney Injury” [3]

Question 18

Explain which medication can cause pre-renal AKI? [2]

Answer 18

ACE inhibitor (& ARB): cause vasodilation of afferent arteriole reduces blood flow to kidney

NSAIDs: COX-1 inhibiton causes vasoconstriction of efferent arteriole

Question 19

How is AKI diagnosed? [1]

Answer 19

26.5
27

Question 20

Describe how you classify the different stages of AKI [3]

Question 21

How would you manage this patients AKI? [2]

Answer 21

Fluids (to treat septic shock aspect)
Stop any nephrotoxic drugs

Question 22

Q7. How is CKD defined? What are it’s causes and how is it managed?

Answer 22

Given her background in diabetes and hypertension - manage these underlying causes of CKD.

Question 23

The two most common causes of CKD are? [2]

Answer 23

Diabetes (diabetic nephropathy)
Hypertension (damage to structure of kidney)

Question 24

Q8. Outline the three main forms of renal replacement therapy and explain
their advantages and disadvantages.

Answer 24

Haemodialysis:
* 3-4x week at a centre.
* Requires an A/V fistula - increases the risk of infection

Peritoneal dialysis:
* can do at home, every 8 hrs / daily
* SBP infection
* permenant catheter can cause hernia

Kidney transplant
- Rejection / failure
- Immunosuppressants
- Needs a match

Question 25

. Definition and causes of AKI 2. Clinical presentation of AKI 3. Management of AKI 4. Definition, causes and management of CKD 5. Long term management of end stage renal failure – including renal replacement therapy, management of anaemia and calcium etc.

Answer 25

LOs