Tasty Morsels of EM 083 – #FRCEM Sepsis Definitions

26 Jul

(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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