Clinical Scenarios

Question 1

Define SEPSIS

Answer 1

life-threatening organ dysfunction caused by a dysregulated host response to infection

Question 2

Define Septic shock

Answer 2

a more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone’
these patients can be clinically identified by a vasopressor requirement to maintain a MAP ≥ 65mmHg and serum lactate >2mmol/L in the absence of hypovolemia

Question 3

qSOFA score >2

Answer 3

HIGHER MORTALITY 10%
Respiratory rate > 22/min
Altered mentation
Systolic blood pressure < 100 mm Hg

Question 4

SEPSIS Red Flags

Answer 4

Responds only to voice or pain/ unresponsive
Acute confusional state
Systolic B.P <= 90 mmHg (or drop >40 from normal)
Heart rate > 130 per minute
Respiratory rate >= 25 per minute
Needs oxygen to keep SpO2 >=92%
Non-blanching rash, mottled/ ashen/ cyanotic
Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr
Lactate >=2 mmol/l
Recent chemotherapy

Question 5

SEPSIS Amber Flags

Answer 5

Relatives concerned about mental status
Acute deterioration in functional ability
Immunosuppressed
Trauma/ surgery/ procedure in last 6 weeks
Respiratory rate 21-24
Systolic B.P 91-100 mmHg
Heart rate 91-130 OR new dysrhythmia
Not passed urine in last 12-18 hours
Temperature < 36ºC
Clinical signs of wound, device or skin infection

Question 6

SEPSIS 6

Answer 6

1. Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
2. Take blood cultures
3. Give broad spectrum antibiotics
4. Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes
5. Measure serum lactate
6. Measure accurate hourly urine output

Question 7

FULL SOFA SCORE

Answer 7

low platelets
high billlirubin
GCS 
Cretanine
Urine Output

Question 8

NEONATAL SEPSIS
- organisms
- RFs
-Sx
- Ix
Mx -

Answer 8

• GBS (also E.coli)
• mother GBS and temp, low birth weight, permature
• grunting, temp, apnoea, jaundice, siezure
• BC, CRP, CRP, gas, urine, lumbar puncture
• IV BENPEN and gentamycin, prevent hypocglycaemia and metabloic acidosis

Question 9

Neutropenic sepsis

• Mx
• propylaxis
• neurtorpil less than 0.5

Answer 9

• antibiotics must be started immediately, do not wait for the WBC
  NICE recommends starting empirical antibiotic therapy with piperacillin with tazobactam (Tazocin) immediately
• florquinolone

Question 10

Sepsis Causes

Answer 10

• neonatal
• neutropenic
• urosepsis - catheter/UTI
• post splenectomy
• pneumonia
• meningitis
• IVDU
• post miscarriage

Question 11

SEPSIS RFs

Answer 11

Take into account that people in the groups below are at higher risk of developing sepsis:

the very young (under 1 year) and older people (over 75 years) or people who are very frail

people who have impaired immune systems because of illness or drugs, including:

people being treated for cancer with chemotherapy (see recommendation 1.1.9)

people who have impaired immune function (for example, people with diabetes, people who have had a splenectomy, or people with sickle cell disease)

people taking long-term steroids

people taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis

people who have had surgery, or other invasive procedures, in the past 6 weeks

people with any breach of skin integrity (for example, cuts, burns, blisters or skin infections)

people who misuse drugs intravenously

people with indwelling lines or catheters.

Question 12

Sepsis Examination points

Answer 12

Examine people with suspected sepsis for mottled or ashen appearance, cyanosis of the skin, lips or tongue, non-blanching rash of the skin, any breach of skin integrity (for example, cuts, burns or skin infections) or other rash indicating potential infection
ALWAYS ASK PATIENT OR CARER ABOUT FREQUENCY OF URINE

Question 13

people who may not develop a temperature

Answer 13

old, young, cancer, severly ill

Question 14

SEPSIS bloods

Answer 14

blood gas including glucose and lactate measurement

blood culture

full blood count

C-reactive protein

urea and electrolytes

creatinine

a clotting screen (high risk)

Urine analyis and chest xray

Question 15

Sepsis - who to tell?

Answer 15

arrange for immediate review by the senior clinical decision maker[2] to assess the person and think about alternative diagnoses to sepsis
Discuss with consulatant (high risk)
lactate over 4 or systolic less than 90 - call critical care

Question 16

sepsis monitoring

Answer 16

Monitor people with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting

Question 17

Antibiotics in spesis GIVE WITHIN 1 HOUR

Answer 17

Meningitis - comm = benpen, hospital IV ceftiaxone

Local antimiccrobial guidance

Question 18

Informing Families

Answer 18

an explanation that the person has sepsis, and what this means

an explanation of any investigations and the management plan

regular and timely updates on treatment, care and progress.

Question 19

Asthma Attach Features

Answer 19

worsening dyspnoea, wheeze and cough that is not responding to salbutamol
maybe triggered by a respiratory tract infection

Question 20

Asthma Moderate

Answer 20

PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm

Question 21

Asthma Severe

Answer 21

PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm

Question 22

Asthma Life threatening

Answer 22

PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Normal PCo2 = exhaustation

Question 23

Near-fatal asthma

Answer 23

raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.

Question 24

ABG sats in Asthma

Answer 24

less than 92%

Question 25

xray in asthma

Answer 25

life-threatening asthma suspected pneumothorax failure to respond to treatment

Question 26

Asthma Admission

Answer 26

all patients with life-threatening should be admitted in hospital patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night

Question 27

Asthma treatment

Answer 27

nebulised SABA + ipratropium bromide +40 PO prednisiolone 5 days consider Mg sulphate and aminophylline 4xICS

Question 28

Escalating asthma

Answer 28

patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include: intubation and ventilation extracorporeal membrane oxygenation (ECMO)

Question 29

discharge critera asthma

Answer 29

been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours inhaler technique checked and recorded PEF >75% of best or predicted

Question 30

asthma Ix

Answer 30

ABG if low sats, PEF (best of 3), xray if life threatening

Question 31

Asthma Review

Answer 31

Any possible triggers for the attack. Inhaler use and technique. Optimisation of treatment and a plan for preventing further exacerbations. follow up within 4 days of discharge

Question 32

COPD feautures

Answer 32

increase in dyspnoea, cough, wheeze there may be an increase in sputum suggestive of an infective cause patients may be hypoxic and in some cases have acute confusion

Question 33

COPD bacteria

Answer 33

Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis

Question 34

COPD Tx

Answer 34

increase frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Question 35

COPD Triggers

Answer 35

respiratory tract infections (most commonly rhinovirus), smoking, and environmental pollutants.

Question 36

Wheezing bloods

Answer 36

FBC, U and E, theophylline levels in on it, BNP, Trop, D Dimer

Question 37

COPD discussions

Answer 37

End-of-life issues should be discussed when appropriate and advance care planning offered.

Question 38

COPD admit

Answer 38

Severe breathlessness. Inability to cope at home (or living alone). Poor or deteriorating general condition. Acute confusion or impaired consciousness. Cyanosis or reduced oxygen saturation. Worsening peripheral oedema. A new arrhythmia.

Question 39

COPD oxygen

Answer 39

Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available).

Question 40

COPD target o2

Answer 40

88-92

Question 41

if symptoms dont imporve for long time COPD

Answer 41

sputum culture

Question 42

CURB 65

Answer 42

C Confusion (abbreviated mental test score <= 8/10) U Urea >7 mmol/L R Respiration rate >= 30/min B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg 65 Aged >= 65 years

Question 43

CURB 65 Management

Answer 43

Patients with a CURB-65 score of 0 should be managed in the community. Patients with a CURB-65 score of 1 should have their Sa02 assessed which should be >92% to be safely managed in the community and a CXR performed. If the CXR shows bilateral/multilobar shadowing hospital admission is advised. Patients with a CURB-65 score of 2 or more should be managed in hospital as this represents a severe community acquired pneumonia. The CURB-65 score also correlates with an increased risk of mortality at 30 days with patients with a CURB-65 score of 4 approaching a 30% mortality rate at 30 days.

Question 44

Pneumonia causes

Answer 44

Community acquired pneumonia (CAP) may be caused by the following infectious agents: Streptococcus pneumoniae (accounts for around 80% of cases) Haemophilus influenzae Staphylococcus aureus: commonly after the 'flu atypical pneumonias (e.g. Due to Mycoplasma pneumoniae) viruses Klebsiella pneumoniae is classically in alcoholics

Question 45

Pneumonia CRP

Answer 45

CRP < 20 mg/L - do not routinely offer antibiotic therapy CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy

Question 46

Pneumonia Investigations

Answer 46

Investigations chest x-ray in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests CRP monitoring is recommend for admitted patients to help determine response to treatment

Question 47

Management of moderate and high-severity community acquired pneumonia

Answer 47

dual antibiotic therapy is recommended with amoxicillin and a macrolide a 7-10 day course is recommended NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia

Question 48

Causes of hyperkalemia

Answer 48

``` acute kidney injury drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's disease rhabdomyolysis massive blood transfusion ```

Question 49

ECG hyperkalemia

Answer 49

``` Peaked or 'tall-tented' T waves (occurs first) Loss of P waves Broad QRS complexes Sinusoidal wave pattern Ventricular fibrillation ```

Question 50

Hyperkalemia treatment

Answer 50

STOP AGGRAVATING FACTOR E.g. ACE I Stabilisation of the cardiac membrane intravenous calcium gluconate does NOT lower serum potassium levels Short-term shift in potassium from extracellular to intracellular fluid compartment combined insulin/dextrose infusion nebulised salbutamol Removal of potassium from the body calcium resonium (orally or enema) enemas are more effective than oral as potassium is secreted by the rectum loop diuretics dialysis haemofiltration/haemodialysis should be considered for patients with AKI with persistent hyperkalaemia

Question 51

Pneumothorax RFs

Answer 51

pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia connective tissue disease: Marfan's syndrome, rheumatoid arthritis ventilation, including non-invasive ventilation catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax

Question 52

Pneumothorax Symptoms

Answer 52

``` dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia ```

Question 53

primary pneumothorax Tx

Answer 53

Recommendations include: if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise, aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Question 54

secondary pneumothorax Tx

Answer 54

Recommendations include: if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted. otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours regarding scuba diving, the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

Question 55

pneumothorax aspiration

Answer 55

2nd intercostal space in the midclavicular line (above rib to avoid neurovascular bundle on posterior aspect of second rib)

Question 56

Stroke Asessment score

Answer 56

``` Assessment Scoring Loss of consciousness or syncope - 1 point Seizure activity - 1 point New, acute onset of: • asymmetric facial weakness + 1 point • asymmetric arm weakness + 1 point • asymmetric leg weakness + 1 point • speech disturbance + 1 point • visual field defect + 1 point ```

Question 57

Stroke Management

Answer 57

aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded - if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation - thrombolysis (within 4.5 hours) - thrombectomy (within 6hours) - clopidrogrel for secondary prevention

Question 58

Thrombolysis

Answer 58

Thrombolysis with alteplase should only be given if: it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial) haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Question 59

Contraindications to thrombolysis

Answer 59

- Previous intracranial haemorrhage - Seizure at onset of stroke - Intracranial neoplasm - Suspected subarachnoid haemorrhage - Stroke or traumatic brain injury in preceding 3 months - Lumbar puncture in preceding 7 days - Gastrointestinal haemorrhage in preceding 3 weeks - Active bleeding - Pregnancy - Oesophageal varices - Uncontrolled hypertension >200/120mmHg

Question 60

Thrombectomy

Answer 60

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have: acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes): confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes): who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 61

With regards to carotid artery endarterectomy:

Answer 61

- recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled - should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria

Question 62

stroke anatomy

Answer 62

Site of the lesion Associated effects Anterior cerebral artery - Contralateral hemiparesis and sensory loss, lower extremity > upper Middle cerebral artery - Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral homonymous hemianopia Aphasia Posterior cerebral artery Contralateral homonymous hemianopia with macular sparing Visual agnosia Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain) Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus Anterior inferior cerebellar artery (lateral pontine syndrome) Symptoms are similar to Wallenberg's (see above), but: Ipsilateral: facial paralysis and deafness Retinal/ophthalmic artery Amaurosis fugax Basilar artery 'Locked-in' syndrome

Question 63

stroke management: fluids, glucose, blood pressure and feeding,

Answer 63

fluids - Oral = best. isotonic saline without dextrose as the agent of choice in most patients glucose - NICE guidelines recommend maintaining a blood sugar level between 4 and 11 mmol/L in people with acute stroke BP - Use of anti-hypertensive medications should only be used for blood pressure control in patients post ischaemic stroke if there is a hypertensive emergency with one or more of the following serious concomitant medical issues (according to the NICE guidelines): Hypertensive encephalopathy Hypertensive nephropathy Hypertensive cardiac failure/myocardial infarction Aortic dissection Pre-eclampsia/eclampsia

Question 64

Over hydration leads to

Answer 64

cerebral oedema, cardiac failure and hyponatraemia, therefore it is important to regularly review fluid status in these patients

Question 65

DKA

Answer 65

CHECK KETONES in urine