(Featured image nathan reading on wikimedia commons, CC license)
I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.
You can find more things on the FRCEM on this site here.
From NICE 2016 on Sepsis
Sepsis?
- “life-threatening organ dysfunction due to a dysregulated host response to infection”
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Septic Shock?
- “persisting hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or more OR having a serum lactate level of greater than 2 mmol/l despite adequate volume resuscitation”
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Who is at higher risk from sepsis?
At risk for sepsis
- <1 year, >75 years
- immunosuppression
- chemo or immune drugs for eg RA
- diabetes, splenectomy
- long term steroids
- Surgery within 6 weeks
- Breaches in skin integrity (blisters etc)
- IDU
- Indwelling lines
- Pregnancy
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What does NICE consider as high risk features?
High risk physiology (Note NICE has low, medium and high risk categories which i find a bit cumbersome… they work much better in a table they provide and would be useful in real life I suspect)
- altered mental state
- RR>25 or new need for FiO2>0.4
- HR>130
- BP<90
- Urine <0.5ml/kg/hr (or usefully, no PU for 18 hrs!)
- Mottled, cyanosis, non blanching rash
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What are signs of organ dysfunction
- lactate >2 following fluids
- BP<90 or MAP<65
- New oxygen requirement for SaO2>90
- Urine output <0.5/ml/kg for 2 hrs in spite of fluid
- creat>177
- Bili>70
- BSL>7.7
- INR>1.5
- Platelets<100
- Altered mental status
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What fluids should be used
- crystalloids (any allowed it seems)
- 500mls over <15 mins and reassess. If no improvement repeat
- albumin can be considered but only in septic shock
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How should the source be identified?
- clinical stuff drives source identification
- CXR and urine of course
- if initial assessment doesn’t come up with an answer then CT abdo pelvis (I paraphrase here. This is good to have in a guideline I must say)
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