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UKMLA & FY1te HIGH YIgLDIS BaneaDr Rashad Abdelrahmanooma Ali T Feedbackr roti igF FeeTessiocompletion (including our On-upon Demand Viewers!) J Defineine sepsis and understand its pathophysiology Recogniseieze the clinical presentation Learning ront Objectives gpFlyply NICE & UK Sepsis Trust guidelines achiUnderstandtand the types of shock Te andmanagementd contrast the types based on cause, features & contrastLife-threatening organ da dysregulsnpsis shock)e sepsis, response Froinfection outdated but still Traferenced Sepsis Pathophysiology r TriggerrnInfection leak → hypotensionndothelial injury → capillary Tech ischaemiaon cascade → microthrombi → organ General: Fever, rigors, malaise CVS: Hypotension, tachycardia Clinical nte Features oFrosp: Tachypnoea, hypoxia Sepsishig CNS: Confusion, agitation Tec Renal: Oliguria peripheriesed, cyanosed, cool WHOUR:irGCULTURES ront Sepsis 6 gIV ALACTARESUSCITATION achi Te URINE OUTPUT MONITORING Sepsis + persistent flridsnsion despite rnRequires vasopressors Septic SigcF ≥65 mmHgain MAP Teah Lactate >2 mmol/L cultures,clottinge, ntir InvestigatiFnsfocus unclear CT if hig Tea dip, LP (if meningitis suspected) r Types of ◦ rardiogenic – pump failure loss Overviein◦ Obstructive – physical blockageg. septic, Teah ◦ Neurogenic – spinal cord injuryKey terms ◦CVP measures the preisure in the central veins near the heart, reflecting the circulation.helpr assess fluid status and guide fluid resuscitation to improve In ◦sepsis, SVR typically decreases due to widespread blood vessel dilationd vessels. In ◦ CO (Cardiac Output)ributing to low blood pressure and poor tissue perfusion. reflecting how well the heart compensates for the changes in vascular resistance and fluid status.• 1. CVPement decisions • In treatment:s: CVP gives a rough estimate of preload (the volume of beoor filling the heart). • High CVP might indicate fluid overload or heart failure, so aggressive fluids could be harmful, andis ◦ 2. SVR (Systemic Vascular Resistance)etics or inoFropes) might be needed. • In treatment:s: SVR indicates how consnrictgd or dilated the blood vessels are. • restore blood pressure, improving organ perfusion.) are used to constrict vessels, raise SVR, and • Why it matters: CO shows how well the heart is pumping blood to meet the body’s needs. • In t•eaIf CO is low - inotropic agents may be used to increase heart contractility and improve blood flow. • supporting blood vessels and fluids rather than boosting CO.low SVR, so treatment focuses more on Comparative Table of Shock Central Systemic Cardiac Key Clinical Features Management Type of Shock Cause Pressure Resistance Output Blood/fluid hypotension, r Hypovo◦ See accompanying notes or handout for full table. Low cold/clammytskin, low lossluids (crystalloids), stop fluid JVP n Cardiogenicw CVP, arrhythmia,ngesHigh clinicaHighatures. Low r pulmonary oedema, Inotropes, diuretics, treat hyrdiomyopat F extremities cool underlying cause, avoid overload g High Distributive anaphylaxis, Low/Nor Lowi n (early), (early), bounding pulse,luids, vasopressors, treat spinal injury mal c h (late) wide pulse pressure underlying cause a Obstructive tamponTde, e High High Low JVP, distended neck thrombolysis, needle(e.g. pneumothorax sounds muffled heart decompression) Hypotension, Neurogenic injury cord Low Low Low bradycardia, warm/dry bradycardiaopressors, atropine for extremitiesScenario 1 ◦ Mr. John Doe 67 yo ientleman arrives to thes: surgery.Surgery re90% proximal stenosisCABG (LAD): ◦ PMHx: MI, HgN, T2mid-vessel stenosis,ry (RCA): 95% ◦ He isaclerked by 85% lesionnt doctor and was1): following day.re-op pt for surgery on theScenario 1 ◦ LIMA to disnal LADtful – Pt had triple bypass: ◦ SVG to OF1oRCA ◦ Post –op CICU then stepped down to ward for post-op care and discharge.tinal drains metTormin, furosemide.atins, bisoprolol, prophylactic BD enoxaparin, ramipril,Scenario 1 ◦ CXR:ay 4 poni-op ◦ ECG: SR Fro ◦ Plts 230 ◦ Normal U+EsScenario 1 ◦ Remains stable – had all morning meds ◦ Prep discrarge letter !! ingF ◦ OTviously breathless, lightheaded and dizzy.Scenario 1 ◦ Obs: ◦ Oier ◦ HR 12474 r◦quiet voice.t and oriented, ◦ Sats 95% RAg F ◦overtly distressed.t not ◦ CRT 4aseconds ◦ HR: quiet and muffled. TeScenario 1 ◦ VBG: Hb 70 , riesed lactate ◦and RV, swinring heart, and IVC dilationricardial effusion with diastolic collapse of RA ◦ Immediate plan: ◦ IV aacess x2, fluids continued cautiously—avoid overload.ery. ◦phone.nt for pericardial drainage attempted—verbal assent obtained from family over ◦ Pericardiocentesis tray prepared under ultrasound guidance at bedside. roti chnF Te ti (Cagdiac Tamponade) echBeck’s Triad !! TScenario 2 ◦ PMHx: HTN, nDM, hiatus hernia, back pain (uses NSAIDS), overweight ◦ Fever – Femperature of 38.3C, cold + shakes, myalgia.h, ◦ Denies CPcent travels or mixing with ill individualsore throat, runny nose. ◦ FTels sick with poor oral intake, some vomiting (nbnb) Scenario 2 ◦ Obs: T 38.9C, HR 128 ◦ Cardio: ◦ eI:r SpO2 95% 2L48, RR 24, • no murmuric, hypotensine,t • soundsded, sluggish bowel ◦ Pale, clammy, drowsy but • Cold peripheFiesr weak • Mild generalised rousable • Cap nefill >5 seconds • Neuro:ness, no guarding ◦ membraneses, dry mucous c ◦ Resp: • drowsy but oriented T e a • Bibasal crackles, otherwise• PICC line in situ – flushed clear easily, no signs of infectionScenario 2 ◦ Labs: ◦ CXR ieNAD ◦ PLT: 43 culturesg line and peripheral ◦ Creatinine: 168g(↑ ◦ Negative viral throat swab ◦ CRP: 186ac.hin ◦ Urea: 15.8 ◦ Na⁺: 131 | K⁺: 3.0Scenario 2 ◦ Fluid resuscitation: IVF bolus 500 mL over <15 mins, repeat up to 2L based on allergies). Broad-Spectrum Antibiotics: mostly likely IV meropenem (check ◦ Monihor urine OP ◦ CTeae cultures and monitor bloods ti (Negtropenic Sepsis) echn TScenario 3 ◦ Previously fit and well, staring "I can’t move my legs" after a motorbike accident ◦ Airway: Patent, speakinn in full sentences ◦ Disability: GCS 15, complete motor and sensory loss from T4 down Bedsideure: Noiexternal bleeding, no long bone fractures • Bladdee scan: Full bladder BloodsTscan: Negative (no free fluid) • ABG: Mild metabolic acidosis (lactate 3.0 mmol/L) due to hypoperfusionScenario 3 Continued investigations: • CT spinro(urgent): Fracture dislocation at T3-T4, spinal cord compression • CT hinF + trauma series: No intracranial injury or chest/abdominal bleeding TecScenario 3 ◦ Resuscitation (ABCDier • •phrenic nerve)rh cervical cord injury suspected (C3–C5 innervates diaphragm via • Circulation:pFratory effort closely •cordaperfusione.g. norepinephrine) to maintain MAP >85–90 mmHg for spinal •AtTopine or glycopyrrolate for severe bradycardiaScenario 3 ◦ Spinal Injury Managieent • Consider methyrprednisolone (controversial; check local protocol) ◦• DVT prophylaxis – increased risk with immobility • Stool softeners – bowel dysfunction is common • EaTly involvement of neurorehab teamScenario 3 r Neurogaftro spinal cord injurye shock with bradycardia and hypotension • Diffirentiate from hypovolemic shock (cold, tachycardic, low CVP)potensive state • RTecires vasopressors, spinal support, and multidisciplinary care ti NeugFgenic shock echn T ABCDE approach Oxygenation & monitoring Management rnti PrincipigsFIV access & fluid resuscitation Teah causefic treatment for underlying Early escalation to ITU ti QgFrtions echn TA 64-year-old man is admitted to the emergency department as his wife is infection. She reports that he has not improved after a course ofst On examination, his respiratory rate is 30/min, blood presrure 88/60 chest.heart rate 120/min. Crackles are noted on nhetright side of his What is the most appropriate fluid theFapy to give? -1)---1L Hartmann’s over 2 hours g 4) 500ml stat bolus of Hartmann’s 5) None, in case of fluid overloadA 64-year-old man is admitted to the emergency department as his wife is infection. She reports that he has not improved after a course ofst On examination, his respiratory rate is 30/min, blood pressure 88/60 chest.heart rate 120/min. Crackles are noted on thn rtgit side of his What is the most appropriate fluid theraFy to give? -1)---1L Hartmann’s over 2 hours g 4) 500ml stat bolus of Hartmann’s 5) None, in case of fluid overloadA 68-year-old man is admitted to the hospital with a two-day history of confused and disorientated. His temperature is 38.9°C, BP is 85/50 mmHg, right lower zone. Blood results show:examination reveals crepitations in the White blood cell count: 18 × 10^9/L (4–11 × 10^9/t)i Serum lactate: 3.5 mmol/L (<2 mmol/L)) r o n What is the most appropriate initial management for this patient? -------------------------- i n 2) Administer high-flow oxygen and monitor without further intervention 4) Arrange an urgent CT chest obtaining culture results 5) Begin corticosteroid therapy to reduce inflammationA 68-year-old man is admitted to the hospital with a two-day history of confused and disorientated. His temperature is 38.9°C, BP is 85/50 mmHg, right lower zone. Blood results show:examination reveals crepitations in the White blood cell count: 18 × 10^9/L (4–11 × 10^9/L)t i Serum lactate: 3.5 mmol/L (<2 mmol/L)) r o n What is the most appropriate initial management for this patient? -------------------------- in 2) Administer high-flow oxygen and monitor without further intervention 4) Arrange an urgent CT chest obtaining culture results 5) Begin corticosteroid therapy to reduce inflammationdue to poor response to methotrexate. Two weeks later, she presents with enlarged cervical lymph nodes. Her blood tests are as follows:l ulcers and White cell count: 1.0 x10^9/L (4.0-11.0) t ie r Platelets: 150 x10^9/L (150-400)5) r o n What is the most appropriate next gtep in her management? -------------------------h i 2) Reduce azateioprine dose and monitor blood counts 5) Switch azathioprine to leflunomideor neutropenic sepsisdue to poor response to methotrexate. Two weeks later, she presents with enlarged cervical lymph nodes. Her blood tests are as follows:l ulcers and White cell count: 1.0 x10^9/L (4.0-11.0) t i e r Platelets: 150 x10^9/L (150-400)5) r o n What is the most appropriate next gtep in her management? -------------------------h i 2) Reduce azateioprine dose and monitor blood counts 5) Switch azathioprine to leflunomideor neutropenic sepsisexamination, he is febrile (39.2°C), hypotensive (BP 84/50 mmHg),day per minute. His oxygen saturation is 95% on room air. Caprllary refill is and a raised white cell count.. Initial blood tnststshow elevated lactate Which of the following best describes Fhe type of shock this patient is -------------------------- in g 2) Neurogenic ehockk h 5) Hypovolaemic shockexamination, he is febrile (39.2°C), hypotensive (BP 84/50 mmHg),day minute. His oxygen saturation is 95% on room air. Capillaryrrefill is delayed, white cell count.++. Initial blood tests show elenattd lactate and a raised Which of the following best describes tFe type of shock this patient is -------------------------- in g 2) Neurogeniceshockk h 5) Hypovolaemic shock