Small People Get Sepsis Too

Recognition

  1. Fever
  2. Deranged vitals
  3. AMS
  4. Hydration status
  5. Looks unwell

Investigation

  1. Temperature
  2. VBG – lactate >4mmol/L an alarm value
  3. FBC, UEC + Ca++
  4. CRP. PCT
  5. Full septic screen if <3/12
    1. Blood cultures
    2. LP
    3. Urine M/C/S by SPA or IOC
    4. CXR at discretion of clinician (not standard)
  6. If >3/12, LP optional

Empirical Antibiotics

  1. <6/12: Amoxycillin + cefotaxime + vancomycin
  2. >6/12: Cefotaxime + flucloxacillin
  3. If meningitis excluded and <4/12: amoxycillin + gentamicin
  4. If meningitis excluded and >4/12: cefotaxime + flucloxacillin

Fluids and Pressors

  1. 20ml/kg of balanced crystalloid (FEAST should be at the back of peple’s minds here)
  2. Guide further fluid treatment with ultrasound where feasible
  3. Calcium bolus if hypocalcemic
  4. Norad; can be given through GOOD large bore peripheral line if distributive shock
  5. Dobutamine; give through good peripheral line if peripherally shut-down

Downstream Management

  1. Repeat lactate
  2. Monitor BSL and Ca++
  3. Await culture / NAAT
  4. In big people, PROCESS showed no difference EGDT, the Surviving Sepsis-esque bundle and care as usual (controversial)

The Alcoholic Patient

Quand je bois du vin clairet,
Amis, tout tourne,
Aussi désormais
je bois Anjou ou Arbois.
Chantons et buvons,
à ce flacon faisons la guerre,
chantons et buvons,
mes amis, buvons donc.

Liver

  1. Good history and examination
  2. If the liver is failing, determine if decompensated or not
    1. Decreased synthetic function
    2. Hepatic encephalopathy
    3. Ascites
    4. Portal hypertension
  3. FBP + film
    1. Pancytopenia from blood cell suppression
    2. Premature destruction of RBC due to faulty synthesis
    3. Megaloblastic anaemia from folic acid deficiency
    4. Thrombocytopaenia
  4.  LFTs
    1. AST:ALT >2 is suggestive
    2. Isolated rise in GGT
    3. Albumin may be low
  5. Coags – INR is a marker of synthetic function
  6. Magensium – deficient

 

GIT concerns

  1. Mallory-Weiss tear
    1. Conservative management
  2. General nutritional defieincy

 

Alcohol Withdrawl

  1. Progresses through stages
    1. Agitation
    2. Hallucinations
    3. Tonic-clonic seizures
    4. Delirium tremens
  2. Manage with Alcohol Withdrawl Scale
    1. Titrate to symptoms
    2. Benzodiazepines
    3. Barbituates
    4. Propofol + tube

 

Neurological concerns

  1. Repeated falls + decreased synthetic function – subdural bleeds
    1. Full neurological exam
    2. CT head
    3. INR
  2. Wernicke-Korsakoff
    1.  Wernicke’s encephalopathy
      1. Opthalmoplegia
      2. Ataxia
      3. Confusion
    2. Korsakoff pyschosis
      1. Retrograde and atenrograde amnesia
      2. Confabulation prominent
    3. Thiamine
      1. Thiamine 500mg IV TDS for 3/7 then 250mg IV daily until clinical improvement ceases
      2. Prophylaxis: 100mg PO OD
      3. If giving glucose to alcoholic people, thiamine 200mg IV OD for 3/7 then switch to PO

Metabolic concerns

  1. Beer potomania
    1. Hyponatremia
    2.  Beer has little salt; coupled with minimal food intake, hypotonic fluid intake exceeds the ability of the kidneys to excrete dilute urine (maximal dilution to 50Osm/L)
    3. Fluid restrict
    4. Normal saline, follow the Rule of 6s (http://fluidtrials.org/correction-of-hyponatremia/)
  2. Folic acid defieincy
    1. Supplement as needed based on FBP
  3. Thiamine deficiency
    1. Due to inadequate intake
    2. Always supplement
    3. Special care if giving glucose
      1. Reduced enzme activity due to lack of cofactor -> excessive carbohydrate load -> toxic metabolites

 

Lung concerns

  1. Pneumonia
    1. Aspiration
    2. Alcohol related
      1. Klebsiella ‘currant-jelly sputum’
      2. Serratia – ESCAPPM organism
      3. Burkholderia pseudomallei
      4. Acinetobacter baumanii
  2. CXR
  3. Empirical antibiotics
    1. Aspiration – BenPen 1.2g IV QID + metronidazole 500mg IV BD
    2. Suspected complicated – consider ceftriaxone + gentamicin (TGA guidelines does not stratify)

 

Model plan for the undifferentiated alcoholic patient

  1. FBC
  2. LFT
  3. Coags
  4. UEC
  5. CXR
  6. CT head
  7. AWS
  8. Falls precautions
  9. Drugs and alcohol to see
  10. Social worker

 

Antiarrythmics

A bit disorganised; reflects how I think about these drugs. Basically, it boils down to amiodarone is safe-ish and requires less clever thinking then other options. I’d talk more about the other options in the guidelines but no-one in Australia seems to use anything other than amiodraone, beta blockade, lignocaine and occasionally CCBs and dig.

 Class I – Sodium channel blockade

  • Class Ia affects the QRS – not avilable in Australia (I think); Class Ib and Ic don’t affect the QRS
  • Class Ib
    • Fast association/disassociation
    • Lignocaine 1mg/kg for VT
  • Class Ic
    • Slow association/disassociation
    • Flecainide
      • Not great acutely: oral form + need to confirm structurally normal heart
      • PSVT / PAFib 50mg PO bd
      • VT 100mg bd

Class III – K+ efflux

  • Amiodarone
    • AF: 300mg in 100ml bag of D5W over 30 minutes + 900mg over remaining 24 hours
    • VT: 300mg in 10ml D5W over 3 minutes

Class IV – Calcium channel blockade

  • Verapamil – personally not first line due to lack of experience
    • PSVT / PAFib / PAFlutter – 5mg IV over 2 minutes

 

 

Cardiac Arrest

DRS ABCDE

  • Run through basic DRS ABCDE first, then do the extended version to cover the Hs and Ts
  • A: BVM, early use of LMA. Consider hooking up BVM to a CPAP machine and using both hands to mask to get better ventilation (two hands thumbs down > one hand C-grip). Look for tracheal deviation (pneumothorax)
  • B: Auscultate both lungs for airways entry (pneumothorax). Percuss if unsure. Get a sats probe on.
  • C: Fingers on femorals. Feel peripheries (hypovolemia), skin turgor and capillary refill. Early use of adrenaline (1mg IV) or atropine (0.6mg IV for bradycardia)
  • D: Defibrillator pads on. Get a 12 lead where you can. Eyes out for low voltage, electrical alterans (tamponade) or infarct. Auscultate briefly for muffled heart sounds (tamponade)
  • E: Electrolytes – VBG as soon as possible (toxins indirectly through the AG, severe acidosis, K and glucose)
  • F: Four chamber view + pneumothroax scan
  • G: Glucose. Please don’t forget.

 

Some Hs and Ts specifics

  • Hypokalemia
    • 10mmol of K by IV over 5 minutes; consider early CVL
  • Hyperkalemia
    • 10mL of 10% calcium (chloride > gluconate, risks for extravasation injury present but good large bore peripheral IV should be OK temporarily)
    • 0.5mg IV salbutamol
    • Adrenaline (1mg IV resus dosing) helps
    • Bicarb if in acidosis
    • 10U actrapid, 50mL of 50% glucose once ROSC
    • Intra-CPR CVVHD well-documented
  • Tension pneumothorax
    • Finger or needle  thoracostomy
  • Tamponade
    • Pericardiocentesis +/- US guidance
  • Thrombosis
    • Thrombolyse: rTPA 1.5mg/kg is maximum dose

 

Post-Partum Haemorrhage

Definitions

  • >500ml by SVD or 1000ml by C/S in first 24 hours after delivery

Aetiologies

  • Tone of uterus – 70%
  • Trauma – 20%
    • Fist degree tear – vaginal mucosa or perineal skin
    • Second degree tear – perineal body (ischio- and bulbo-cavernosus, superficial transverse perineal) +/- levator ani (pubococcygeus, puborectalis, iliococcygeus)
    • Third degree tear – anal sphincter disruption
    • Fourth degree tear – Extension into anal epithelium
  • Tissue (retained POC) – 10%
  • Thrombin (coagulation defects) – <1%

Management

  •  Active management of the third state – pretty standard policy – 30U syntocinin in 500ml of CSL at 120ml/hr
  • If that doesn’t work…
    • DRSABC including early activation of massive transfusion protocol
    • Identify the substrate
      • Check placental completeness
      • Check genital tract for repair
      • Send off coags, FBP, cross-match 4 pints of claret
      • Palpate the uterus
    • Misoprostol 1000mcg PR
    • 250mcg ergometrine IV stat; 250mcg to syntocinon infusion) [CI in hypertension]
    • Fundal massage of uterus
    • Empty the bladder (full bladder prevents uterus coming down)
    • Bimanual compression (fist tamponade)
  • Redirect to intervational radiology for uterine artery embolisation or…
  • Off to theatre
    • Removal retained POC if indicated
    • Intramyometrial PG F2 alpha 5mg in 20ml NS
    • Ballon tamponade ir uterine packing with gauze
    • Laparotomy
      • B Lynch suture
      • Liagtion of uterine arteies or internal iliiac
      • Hysterectomy
  • Controversies
    • Conventional teaching of 3.5L of crystalloid as OK – BUT – should we be applying the principles of damage control resuscitation to this uncontrolled bleeding source? Is hypotensive resuscitation something to be considered?

Important Drugs Crib Sheet

Work in progress, will be updated as and when.

 

Adenosine for SVTs – 6mg bolus; repeat 12mg after 1 minute; repeat 12mg again if needed IV

Adrenaline for cardiac arrest – 1mg IV

Adrenaline for anaphylaxis – 0.01ml/kg of 1:1,000 ampoule IM OR 0.05ml/kg of 1:10,000 ampoule IV

Amiodarone for AF – 300mg over 30 minutes followed by 900mg over 24 hours IV

Hypertonic saline for hyponatremia – 2ml/kg/h; titrate to bloods

Magnesium for torsade – 1g over 1 minute, repeat in 5 minutes IV

Metoprolol for rate control – 1mg per minute titrating to  art line; usual dose 10mg IV

Salbutamol – 5mg nebs, continuous if required

An Astonishingly Applicable Alliterative Approach to the ABG

1.       Determine the pH

pH>7.45                               Alkalosis
pH<7.35                               Acidosis

2.      Determine the primary cause

Bicarbonate pCO2 pH
Metabolic acidosis <7.35
Metabolic alkalosis >7.45
Respiratory acidosis <7.35
Respiratory alkalosis >7.45

The bicarbonate and pCO2 should trend in the same direction. If they do not, this is an indication for a mixed metabolic/respiratory picture. For example, an acidotic patient with decreased bicarbonate and increased pCO2 would lead you to suspect a metabolic acidosis with a respiratory acidosis.

3.     Determine if there has been adequate compensation

If the bicarbonate and pCO2 are trending the same way, there is still the possibility of a mixed acidosis/alkalosis picture. Rule this out by calculating the expected compensations.

Metabolic acidosis pCO2 = 1.5 [HCO3] + 8 mmHg +/- 2
Metabolic alkalosis pCO2 = 0.7 [HCO3] + 20 mmHg +/- 5

For respiratory alkalosis/acidosis, use the 1,2,3,4,5 rule of thumb

 10 mmHg change in pCO2

HCO3

Acute

Chronic

1

4

2

5

4.      Calculate the anion gap

The anion gap is useful in cases of metabolic acidosis
It is calculated by Na+ K– Cl– – HCO3

Since organic acids are anions, any increase in an organic acid will result in a high-anion gap metabolic acidosis (HAGMA)
A normal anion-gap metabolic acidosis, on the other hand, is likely due to excessive loss of bicarbonate

The mnemonic for HAGMA causes is MUDPILES (Methanol, uremia, DKA, propylene glycol, infection, lactic acidosis, ethylene glycol, salicylates)

The mnemonic for NAGMA causes is HARDUP (hyperalimentation, acetazolamide, renal tubular acidosis, diarrhoea, uretoenteric fistula, pancreaticodudodenal fistula)

5.     Calculate the delta ratio

The delta ratio is given by Change in Anion gap : Change in bicarbonate

The theory is that any change in anion gap due to an organic acid should be reflected by a corresponding change in bicarbonate
The ratio should be used with caution and with corroborative evidence

If the ratio is 0.4-0.8; the implication is that the HAGMA alone is not sufficient to explain the change in bicarbonate and a mixed HAGMA NAGMA may be present.

If the ratio is >2; the implication is that there is a pre-existing elevated bicarbonate which can be due to a concurrent metabolic alkalosis or a pre-existing compensated respiratory acidosis