_OHFP.indb 469 _OHFP.indb 469 30/05/2014 16:18 30/05/2014 16:18 470 CHAPTER 15 Emergency department Anaphylaxis in adults (OHCM9 b p806) p y If airway involved \200\223 CALL anesthetist If no respiratory eff ort \200\223 CALL ARRE ST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if anaphylaxis suspected. \200 Sit patient up unless hypotens ive, then lay fl at with legs elevated \200 15l/min O2 in all patients \200 Monitor pul se oximeter, BP, defi brillator ECG leads if unwell \200 Request full set of observations \200 Take brief history if possible/check drug chart/ask ward staff \200 Examine patie nt: look for early signs of anaphylaxis (see box) \200 Establish likely cause and stop fu rther exposure (eg IV antibiotics) \200 Adrenaline, 1:1000 solution, 0.5ml (0.5mg) intram uscular: repeat after 5min if no improvement Large-bore venous access, take bloods if time permits: \200 FBC, U+E, mast cell tryptase (see \200\230Investigations \200\231) IV infusion of 1l 0.9% saline STAT \200 Consider nebulised b-agonist for bronchospasm: salbutamol 5mg, or \200 adrenaline 1:1000 solution, 5ml (5mg) Re-assess \200 Consider adjuncts to treatment: antihistamine, eg chlorphenamine 10mg slow IV \200 hydrocortisone 200mg slow IV Ensure senior help has been requested. Intramuscular adrenaline should be given if the diag nosis of anaphylaxis is likely but not if the symptoms are mild or the patient is well. Early signs of anaphylaxis Urticaria \200 Bronchospasm/stridor \200 Vomiting and/or diarrhea Flushing \200 Abdominal pain \200 Sense of impending doom. OHFP.indb 470 OHFP.indb 470 30/05/2014 16:18 30/05/2014 16:18 471 ANAPHYLAXIS IN ADULTS 3Anaphylaxis Worrying signs BP <90mmHg systolic, dO2 sats, chest tightness, stridor. Common precipitants Drugs Penicillins, anesthetic drugs, contrast media, blood products Latex, stings, eggs, fi sh, s trawberries, nuts Environmental Symptoms chest tightness, wheeze, breathlessness, itching, swelling, anxiety/fear/agitation , GI disurbance (vomiting, abdominal pain, diar- rohea). Signs see box; later hypotension, tachycardia, tongue/periorbital swelling, wheeze, cyanosi s. Treat all patients with physical signs. Investigations 3if you suspect anaphylactic shoc k commence treatment (see b p470): seconds count. Subsequently check for serum mast cell tryptase to confi rm gl obal mast cell degranulation (send three samples of clotted blood: one during the reaction once adrenaline has been given, one 1h post-reaction, and one 6 \200\22324h post-reaction). Follow-up by immunologist; consider adrenaline for self-injection (eg EpiPen \200\232). Adrenaline (epinephrine) preparations 1:1000 1:10,000 Preparation \200\223 1ml ampoule. Give 0.5ml (0.5mg) IM 1mg in 1ml Preparation \200\223 1 0ml syringe in cardiac arrest drugs, or 10ml ampoule 1mg in 10ml Intramuscular adrenaline should be given if the diagnosis of anaphylaxis is likely but not if the symptoms are mild or the patient is well. _OHFP.indb 471 _OHFP.indb 471 30/05/2014 16:18 30/05/2014 16:18 472 CHAPTER 15 Emergency department y Hypotension emergency yp g If airway involved \200\223 CALL anesthetist If no respiratory eff ort \200\223 CALL ARRE ST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if patient deteriorating Systolic <100mmHg: \200 Lay patient fl at and elevate the legs if dizzy \200 15l/min O2 if SOB or sats <94% \200 Monitor pu lse oximeter, BP, defi brillator ECG leads if unwell \200 Request full set of observation s and ECG \200 Take brief history if possible/check notes/ask ward staff \200 Examine p atient: condensed RS, CVS, abdo and neuro exam \200 Establish likely cause of shock \200 Large-bore venous access, take bloods: FBC, U+E, CRP, D-dimer, cardiac markers, blood cultures IV infusion of 1l 0.9% saline STAT \200 Treat most likely cause, see following sections \200 Arterial blood gas, but don \200\231t leave the patient alone \200 Consider request ing urgent CXR, portable if too unwell \200 Call for senior help \200 Reassess, startin g with A, B, C \200 Life-threatening causes Hypovolaemic/haemorrhagic shock (b p478) \200 Septic shock (b p480) \200 Cardiogenic sh ock (tamponade/tension pneumothorax/heart failure) (b p479) \200 Anaphylactic shock (b p4 70) \200 Neurogenic shock (spinal shock) (b p481). OHFP.indb 472 OHFP.indb 472 30/05/2014 16:18 30/05/2014 16:18 473 HYPOTENSION (SYSTOLIC <100mmHG) Hypotension (systolic <100mmHg) yp g) Worrying features dGCS, idHR, stridor, dO2 sats, blee ding, chest pain, diz- ziness, durine output, renal failure, severe back pain, non-blanchin g rash. ( y Think about life-threatening shock (hypovolaemic/haemorrhagic, septic, cardiogenic, anaphyl actic, neurogenic), dysrhythmia (brady- or tachyarrhythmia); other postural hypotension, va sovagal episode, Addison \200\231s disease/adrenal insuffi ciency, drugs (B-blockers, ACEi, Ca2+ channel blockers, diuretics, nitrates). Ask about assess severity shortness of breath , dGCS, feeling faint/ dizzy on standing, what is timecourse, and what BP does patient usua lly run (inspect recent obs charts); consider cause palpitations, chest pain, blood loss (h aematemesis, melaena, PV bleeding), trauma, abdominal/back/loin pain, diarrhea, vomiting, p olyuria, fever, sweats, cough, urinary symptoms, itch/urticaria, spinal trauma or anestheti c, weight loss, skin darkening; PMH AAA, gastroduodenal ulcers, pregnancy, diabetes insipid us and DM, infections (urinary, chest, cardiac, blood), immunocompromise, angina, MI, previ ous DVT/PE, Addison \200\231s disease, postural hypotension; DH cardiac medications (B-bloc kers, ACEi, Ca2+ channel blockers, diuretics, nitrates), blood transfusions, antibiotics, a nticoagulants, recent anesthetics, steroids (?withdrawal), allergies (?anaphylaxis); FH PE/ DVT, Addison \200\231s/autoimmune disease; SH smoking, alcohol, recreational drug abuse. Ob s HR, BP, postural BP, RR, sats, temp, GCS, fl uid balance. Look for volume status (b p380) , pulse rate/rhythm/volume, evidence of diarrhea or vomiting, source of bleeding (limbs, ch est, abdomen, back, mouth, PR, PV), palpable abdominal aortic aneurysm, abdominal guarding or tenderness, warm peripheries or fever, fl ushed appearance, sweating, urticaria, dyspnoe a, focal signs in the chest (consolidation, tension pneumo- thorax, or pulmonary oedema), c alf swelling or tenderness, wasting of small muscles of the hands or iskin pigmentation. In vestigations serial BP repeat BP manually to confi rm diagnosis and check bilateral BP; ECG dysrhythmia, evidence of LVH/strain/MI; blds FBC, U+E, glucose, G+S (X-match if hemorrhage ), CRP; consider D-dimer, cardiac markers, clotting, blood cultures, mast cell tryptase; ur ine dipstick and M,C+S, consider catheter; CXR consolidation, mediastinal widening; do not request if you suspect tension pneumothorax \200\223 perform immediate needle decompressio n (b p279); pelvic X-ray in trauma; CT chest may be nec- essary if aortic dissection suspec ted. Consider also central venous pressure monitoring via a central line, continuous arteri al pressure can be monitored via an arterial line; urgent echo LV function, aortic root dil ation/dissection, pericardial fl uid (tamponade eff ect), massive PE, aortic/mitral valve p rolapse. Treatment 3Call for senior help early Secure airway; O2 (15l/min), lie as fl at as tolerated 9elevate legs; monitor BP; IV access (secure appro- priately large-bore cannula in antecubital fossa). If active bleeding give IV colloid and consider urgent blood transfu sion (O-negative, type specifi c, or full X-match, b p400). Otherwise give fl uid challenge (b p381) at rate appropriate for degree of compromise and comorbidities (eg 1l 0.9% saline STAT if young, septic and dGCS; 250ml 0.9% saline 30min if elderly, CCF and alert). Try to establish and treat the likely cause. _OHFP.indb 473 _OHFP.indb 473 30/05/2014 16:18 30/05/2014 16:18 474 CHAPTER 15 Emergency department Postural (orthostatic) hypotension Drop in BP of >20/10mmHg measured >1min after standing f rom lying position; can occur when sitting from a lying position in severe disease. Causes volume depletion dehydration, bleeding; iatrogenic antihyper- tensives, diuretics, nitrates , antidepressants; autonomic neuropathy DM, Guillain \200\223Barr , syphilis, Parkinson \200\231s disease, ageing. Symptoms dizziness loss of consciousness when standing. Signs dsystolic BP >20mmHg or ddiastolic >10mmHg upon standing; iHR (in most instances; absence of tachycardia suggests autonomic etiology). Investigations lying/standing BP usually diagn ostic. Other investigations as appropriate to investigate cause of syncope/collapse (b p442 ). Acute treatment ensure patient safety. Review medications and identify likely precipitan ts; can these be stopped or changed for a drug without this side eff ect? Optimize control of DM. Identify and treat precipitating disease. Chronic treatment advise simple lifestyle changes such as elevating the head of the bed, getting out of bed/chairs slowly and holding onto something as standing. In autonomic neuropathy, consider graduated stockings for lowe r legs, increasing salt and fl uid intake, and mineralocorticoids (eg fl udrocortisone 100 \200\223200micrograms/24h PO). Complications falls and subsequent bone and soft tissue inju ries including intracranial bleeding and fractured neck of femur. intracranial bleeding and fractured neck of femur. Assessing the hypotensive in-patient When on-call, you will frequently be asked to assess p atients with low BP. Key factors to help identify the acutely unwell include a sudden dBP ( inspect recent obs charts), other abnormal obs (itemp, iRR, durine output, dGCS, iHR \200 \223 but beware those on a B-blocker). Early warning scores (b p224) can be helpful in this regard: Patients with worrying obs require urgent IV fl uids and further assessment (?curr ent diagnosis, ?sepsis, ?shock \200\223 b p473), whilst the fi t 30-year-old in the bed op posite, who feels quite well with his BP of 90/50mmHg, may safely be left to sleep. 3Leaking abdominal aortic aneurysm (AAA) (OHCM9 b p656) Most AAAs are asymptomatic, enlargi ng gradually until their dramatic presentation with sudden rupture and an associated dismal mortality. In the UK, the NHS AAA screening program off ers all men USS screening at 65yr, allowing elective repair where necessary. If you suspect a ruptured/leaking AAA: \200 Fa st-bleep for senior help and vascular surgeon immediately \200 Order urgent O \210\222ve blood and urgent X-match 8 units. Symptoms severe constant or colicky abdominal pain radia ting to the back, collapse or feeling faint. Risk factors iage, male, iBP, smoking, IHD, ic holesterol, known AAA. Signs expansile abdominal mass (pushes hands apart, not just pulsati ng) \200\223 examination will not cause rupture; iHR, dBP, iRR, pale, sweating, cool ext remities, distension, tenderness, dperipheral pulses in legs. Investigations none if unstab le; urgent CT aids diagnosis and management. Management emergency O2 (15l/min); resuscitate large-bore IV access for bloods and STAT colloid/blood (keep systolic BP 90 \200\223100mmH g, do not raise above this as irisk of leak from AAA); prepare to transfer to theater or in terventional radiology suite; observations every 15min. Those unfi t for intervention requi re palliative care (b p91). OHFP.indb 474 OHFP.indb 474 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 476 CHAPTER 15 Emergency department Shock Classi \201 cation of shock Shock has many defi nitions, but is essentially a proble m at the cellular level and results from inadequate tissue perfusion. There are several cau ses, and the key to treating shock successfully is establishing the precipitating factor(s) quickly, based upon cutaneous signs and a very brief history. See Tables 15.12 \200\22315. 14. \200 Hypovolaemic shock (b p478) is caused by a reduced circulating volume, often secondary to hemorrhage. The patient is usually pale, cool to touch, has mois t skin and is tachycardic Septic shock (b p480) is mediated by a loss in vascular tone due to pathogenic toxins and e ndogenous infl ammatory mediators. The circulatory volume is likely to be normal, but loss of peripheral vascular resistance results in dBP and inadequate tissue perfusion. The patie nt is usually warm, fl ushed, vasodilated and tachycardic \200 Cardiogenic shock (b p479) results from pump failure (heart failure) or inadequate fi lling of the pump (eg massive PE). This can occur as part of a chronic pictur e or acutely following a massive MI. The patient is pale and clammy, feels cool to touch an d usually tachycardic, though a profound bradycardia may itself result in cardiogenic shock . iJVP and peripheral oedema if right ventricular failure, basal lung crepitations if left ventricular failure \200\223 both if biventricular failure Anaphylactic shock (b p470), like septic shock, results from loss of vascular tone, mediated by histamine release, amongst other endogenous factors. Like septic shock, the patient is often fl ushed and peripherally warm, with a rapid weak pulse, wheez e, stridor, urticaria and oedema Spinal shock (b p481) also results from loss of vascular tone, but mediated by trauma of the cord or following spinal anesthesia. Loss of sympathetic innervat ion of the vascular beds or the heart can produce a drop in BP and a reduced cardiac output . Patients have mixed cutaneous clinical signs, but the most striking feature will be the n eurological defi cit. Treat all hypotensive patients, especially if HR >100. A BP of 100mmH g systolic may be critically low if the patient is normally hypertensive (eg elderly); use HR and other clinical markers as a guide. Always consider giving a fl uid challenge (b p381 ) early, particularly if you remain unclear on the type of shock you are faced with. In the absence of fl orid evidence of failure, you are unlikely to push any adult into gross card iac failure with eg 500ml 0.9% saline IV STAT, which should help with circulatory support w hilst you assess and plan further. See Table 15.15. Complications whatever the cause of sho ck, prolonged hypotension will result in hypoperfusion of vital organs and subsequent disru ption to physi- ology, which may be irreversible (eg brain \200\223 dGCS/coma, kidneys \200\223 ARF/ ATN, liver \200\223 ischaemic hepatitis, heart \200\223 myocardial ischaemi a/MI). Table 15.12 Clinical markers in shock Hypovolaemia Sepsis Cardiogenic Anaphylaxis Spinal i/d d d i n/d d i d d i n/d d i/d d i HR BP JVP Peripheries Cool Warm Cool Cool/warm Warm OHFP.indb 476 OHFP.indb 476 30/05/2014 16:18 30/05/2014 16:18 477 SHOCK Table 15.13 Main causes of shock External blood loss (eg scalp laceration) \200 Internal blood loss (eg ruptured AAA/pelvi c fracture) \200 Severe dehydration Hypovolaemic inadequate fl uid intake (eg starvation) \200 excessive fl uid loss (eg diarrhea, polyuri a) \200 3rd-space loss (eg pancreatitis) Septicaemia Septic blood-borne infection, ?source Pump failure/ineff ective pump \200 severe LV dysfunction \200 outfl ow tract obstructi on (eg aortic dissection) \200 dysrhythmia (tachy- or bradyarrhythmia) Cardiogenic Inadequate pump fi lling \200 pulmonary embolism \200 cardiac tamponade \200 tension pneumothorax (or large simple) \200 Systemic infl ammatory response/vasodilatation \200 Loss of sympathetic (vascular) tone dcardiac output Anaphylactic Spinal dilatation of arterioles/venous pooling \200 loss of sympathetic drive of the heart (T1 \200\223T4) Table 15.14 Causes of lactic acidosis \200\223 metabolic acidosis with ilactate Tissue hypoxaemia Inadequate perfusion Severe anemia Severe hypoxia Catecholamine excess Se vere exercise Drug-induced Metformin Methanol Ethanol Aspirin (salicylates) Salbutamol Non-hypoxaemic tissues Sepsis Renal and hepatic failure Uncontrolled DM Acute pancreatitis Paracetamol overdose Rare hereditary causes Glucose-6-phosphatase defi ciency Fructose-1,6- diphosphatase defi ciency Table 15.15 Estimated blood loss \200\223 classi \201 cation of haemorrhagic shock Based on an otherwise healthy 70kg adult man Class I Class II Class III Class IV <750 750 \200\2231500 1500 \200\2232000 >2000 Blood loss (ml) Blood loss (% blood volume) HR BP <15% n/i n 15 \200\22330% 30 \200\22340% ii d >40% ii dd i n The key message is that dBP is a relatively late sign in bleeding and requires prompt manag ement to stop the source of bleeding and give adequate fl uid resuscitation. Seek urgent se nior help _OHFP.indb 477 _OHFP.indb 477 30/05/2014 16:18 30/05/2014 16:18 478 CHAPTER 15 Emergency department 3Hypovolaemic shock (OHAM3 b p315) ) yp ( p Common causes Hemorrhage Salt + water loss Diarrhea, vomiting, burns, polyuria (DI and DM) \200\2303rd-s pace \200\231 loss Trauma (external/internal bleeding), ruptured AAA, GI bleed Acute pancreatitis, ascites Worrying signs BP <90mmHg, dGCS/restlessness, oliguria, mottled skin, unre- sponsive to fl uid challenge, ongoing bleeding 3call senior help. Symptoms dizziness on standing ( lying) , SOB, chest pain; symptoms of underlying disease trauma to limb/chest/abdomen/pelvis, p ain (eg chest/ back/abdomen), melaena/haematemesis, diarrhea, urinary frequency, epi- gastr ic pain radiating to back, abdominal swelling/bloating. Signs BP <100mmHg systolic, iHR, we ak/thready pulse, postural hypotension, cool peripheries/cap refi ll >2s, dJVP, dGCS/restle ssness, oliguria, mottled skin in severe hypotension. Signs of underlying disease obvious source of bleeding: external (wound/GI bleed) or intern al (haemothorax, ascites/tense abdomen, pelvic instability, swollen thighs); burns, palpabl e AAA (b p474), tender epigastrium, Gray-Turner \200\231s sign/ Cullen \200\231s sign (b p2 96), melaena on PR. Investigations blds FBC (dHb; may be normal early in acute blood loss), U+E (iurea in GI bleed, dK+ in diarrhea/vomiting), LFT, amylase, clotting, osmolality, X-m atch (consider O-ve and type-specifi c blood whilst awaiting match); ABG acidosis in hemorr hage, DKA and pancreatitis, alkalosis in vomiting; ECG ischaemia; CXR haemothorax; pelvic X -ray pelvic fracture; abdo USS/CT AAA (though if ruptured AAA may need theater before imagi ng) or free intra-abdominal fl uid; urine Na+ and osmolality in diabetes insipidus stool M, C+S (ova, cysts and parasites, C. diff . toxin). Acute treatment of severe hemorrhage call senior help; lay fl at and elevate legs; O2 (15l/ min); IV access (2 large-bore cannulae in antecubital fossa, take blood for FBC, clotting, urgent X-match); 1l 0.9% saline STAT; attempt to stop bleeding by compression if appropriat e, further 1l 0.9% saline STAT if no iBP or dHR; consider urgent blood transfusion (O-negat ive, type spe- cifi c, or full X-match, b p400); identify likely cause of hemorrhage and co mmence appropriate management. Seek early involvement of surgeons/ ICU. \200\230Permissive hypotension \200\231 is employed in the early phase of resuscitation in haemorrhagic shock so do not push systolic BP >100mmHg. Acute treatment of non-hemorrhage hypovolaemia call senior help; lay fl at and elevate legs ; O2 (15l/min); IV access (secure appropriately large-bore cannula in antecubital fossa); 1 l 0.9% saline STAT; further 1l 0.9% saline STAT if no iBP or dHR; identify likely cause of hypovolaemia and commence appropriate treatment; pancreatitis (b p296), severe diarrhea (b p306), vomiting (b p304), burns (b p466), fever and sweating (b p482), ascites (b p316). Se ek early involvement of ICU. Further treatment once appropriate management initiated, recheck observations, including gl ucose, repeat U+E and FBC ( ABG); catheterise and monitor urine output; reassess frequentl y, starting with A, B, C. OHFP.indb 478 OHFP.indb 478 30/05/2014 16:18 30/05/2014 16:18 479 SHOCK 3Cardiogenic shock (OHAM3 b p314) ) g ( p Common causes Pump failure LV dysfunction (post-ACS), aortic dissection, dysrhythmia Inadequate fi lling Pulmonary embolism, pneumothorax, cardiac tamponade Worrying signs BP <90mmHg, dGCS/restlessness, oliguria, mottled skin, chest pain, hypoxaemi a 3call senior help. Symptoms dizziness on standing ( lying), SOB, chest pain symptoms o f underlying disease chest pain pleuritic, radiating to back/left arm/jaw, breathlessne ss, orthopnoea, palpitations. Signs BP <100mmHg systolic (check both arms), i/d HR, weak pu lse, cool peripheries, iJVP, dGCS, oliguria, mottled skin in severe hypotension. Signs of u nderlying disease dO2 sats, signs of pneumothorax (dexpansion, ipercussion note, dbreath so unds on aff ected side, tracheal deviation), pul- monary oedema, pitting oedema, stigmata o f hyperlipidaemia, Beck \200\231s triad in cardiac tamponade (dBP, iJVP, faint heart sounds ). Investigations 3if you suspect cardiogenic shock identify most likely cause and treat pr ior to undertaking investigations; seconds count. Most useful investigation will be immedia te ECG ischaemia, dysrhythmia, small complexes; CXR pneumo- thorax, cardiomegaly, fl uid ov erload; ABG hypoxaemia; blds FBC, U+E, glucose, clotting, X-match; other imaging as appropr iate, including echocardiogram (car- diologist on-call or ED senior) for dissection, massiv e PE, cardiac tamponade, LVF. gy Acute treatment 15l/min O2. Further management depends on pathology: g p p 2 Causes of cardiogenic shock covered elsewhere b p258 b p250 b p282 b p247 b p278 b p279 Bradyarrhythmia Tachyarrhythmia Heart failure Aortic dissection Pulmonary embolism Pneumothorax 3Cardiac tamponade (OHAM3 b p156) Collection of fl uid (usually blood) in pericardium, comp ressing ventricles and reducing ability of heart to fi ll. Causes trauma, pericarditis, pos t-MI, dissecting aortic aneurysm. Signs tachycardia, hypotension, Beck \200\231s triad (dBP , iJVP, faint heart sounds). Investigations CXR cardiomegaly, pulmonary oedema; ECG small c omplexes, tachycardia, ischaemia; echo pericardial fl uid, poor stroke volume. Acute treatm ent 15l/min O2, IV access, needle pericardiocentesis. 3Emergency needle pericardiocentesis (OHAM3 b p158) Get senior help \200 Monitor heart rh ythm on ECG monitor; have IV fl uids running and defi brillator close Clean skin on chest/upper abdomen with antiseptic \200 Connect 18G cannula to 20ml syring e via a 3-way tap \200 Advance needle to the left of xiphisternum, aiming for tip of left scapula \200 Withdraw syringe as advancing, watching for ectopics on ECG \200 Ectopics imply needle in myocardium, withdraw a little into the pericardial space \200 Aspirating 20 \200\22340ml can improve BP, but fl uid likely to reaccumulate \200 Patient needs def i nitive cardiothoracic input urgently. _OHFP.indb 479 _OHFP.indb 479 30/05/2014 16:18 30/05/2014 16:18 480 CHAPTER 15 Emergency department 3Septic shock (OHAM3 b p376) ) ( p p Common sources of infection resulting in septicaemia Chest Pneumonia Skin/soft tissues Cellulitis; gangrene Urinary tract UTI; pyelonephritis He art Endocarditis Intra-abdominal Perforation; biliary tract Post-op Wound infection; bowel leak Worrying signs BP <90mmHg, dGCS/restlessness, DIC, oliguria, mottled skin, petechial rash, unresponsive to fl uid challenge 3call senior help. Symptoms dizziness on standing ( lying ), SOB, chest pain symptoms of underlying disease sweats, shivers, nausea and vomiting, b reathless- ness, cough, dysuria, urinary frequency, abdominal pain, wound/skin pain, headac he, confusion. Signs fever, BP <100mmHg systolic, tachycardia bounding pulse, warm perip heries, dJVP, dGCS, oliguria, mottled skin in severe hypotension. Signs of underlying disea se cellulitis, non-blanching petechial rash (menin- gococcal septicaemia), chest crepitatio ns (pneumonia), abdominal/loin/ suprapubic tenderness (intra-abdominal infection). Investig ations blds FBC (iWCC dHb), U+E, LFT, iCRP/ESR, glucose, clotting/fi brinogen, procalcito nin;1 bld cultures try to take at least 2 sets from diff erent sites, plus additional cultu res from any central lines; ABG acidosis, dBE, ilactate; ECG ischaemia; urine dipstick bloo d, protein, nitrites, leucocytes; send for M,C+S; erect CXR consolidation, free air under d iaphragm; culture skin/wound swabs, sputum; echo val- vular lesion/vegetation (if suspect e ndocarditis; transoesophageal more sensitive than transthoracic); other imaging as appropri ate. Acute treatment call senior help; lay fl at and elevate legs; O2 (15l/min); IV access (secure appropriately large bore cannula in antecubital fossa); 1l 0.9% saline STAT; give I V antibiotics appropriate to likely source of infection (see b p179); repeat 1l 0.9% saline bolus STAT if no iBP or dHR. Consider central line to monitor CVP and arterial line for se rial ABGs and invasive BP monitoring. Seek early involvement of ICU as may need inotropic/v entilatory support. Goal-directed therapy in sepsis aims to restore tissue perfusion and O2 delivery and ensure early admin- istration of antibiotics; this greatly improve outcomes ( see b p481). Further treatment continue broad-spectrum antibiotic therapy until advised of alternative, more targeted therapy by microbiologist. Aggressive fl uid therapy may be requ ired to ensure adequate tissue per- fusion. Monitor for the development of DIC which can re sult in necrosis and gangrene, as well as profound bleeding (b p405). 3Toxic shock is a spe cifi c form of septic shock, caused by the produc- tion of a toxin by Gram-positive bacteri a (typically Staphylococcus aureus). Risk factors 5 (in association with the use of tampons ). Signs and symptoms fever (T >38.9 \210\236C), dBP (<90mmHg systolic), diff use macular r ash desquamation, vomiting, diarrhea, dGCS. Treatment is the same: fl uid resuscitation, broad-spectrum antibiotics initially, remove source of infection/pus, support impaired orga n function. ICU admission is often required. 1 Procalcitonin levels rise in bacterial sepsi s; normal levels in setting of raised infl ammatory markers suggest non-septic cause of infl ammation and may help reduce inappropriate antibiotic use. OHFP.indb 480 OHFP.indb 480 30/05/2014 16:18 30/05/2014 16:18 481 SHOCK SIRS, sepsis, and survival Some useful defi nitions in sepsis include: SIRS (Systemic Infl ammatory Response Syndrome): present if \211 2 of: \200 HR>90 \200 Temp <36 or >38.3 C Sepsis: SIRS + known or suspected infection. Severe sepsis: sepsis + signs of hypoperfusi on or organ failure including durine output, elevated urea or creatinine, abnormal LFTs, co agulation disturbance, hypoxia or ARDS, or a raised serum lactate. Septic shock: hypotensio n persists despite adequate fl uid challenge, or requires use of vasopressors or inotropes. Septic shock is common, serious, and survivable. This simple maxim has driven intensivists to seek better ways of managing sepsis. One vital realization was the importance of early intervention, which may often be delivered by non-intensivists and junior doctors. A key st udy by Rivers1 in 2001 showed a clear survival benefi t in patients with sepsis who were ra ndomized to receive initial care according to a standardized approach referred to as \200 \230Early Goal Directed Therapy \200\231 (EGDT). Since 2002, the \200\230Surviving Sepsis \200\231 campaign has represented an international attempt to improve diagnosis, survival a nd management in sepsis, through education, audit and research, and provides an excellent r ange of resources ((cid:27)www.survivingsepsis.org). Key steps in sepsis management include : \200 Early measurement of serum lactate: if \211 4mmol/l commence EGDT \200 Collecti on of blood cultures prior to antibiotic administration \200 Administration of broad-spec trum antibiotics within 3h of admission RR >20 or PaCO2 <4.3 kPa \200 WCC <4 or >12 x 109/l with sepsis, or within 1h of recognition of severe sepsis Aggressive early fl uid therapy (30ml/kg crystalloid as boluses until lactate <4mmol/l, sys tolic BP \211 90mmHg and MAP \211 65mmHg). Other key steps include ongoing fl uid resuscitation to keep CVP 8-12mmHg, the appropriate use of vasopressors to maintain MAP \211 65mmHg, mechan- ical ventilation and good glycaem ic control, all of which the ICU team will be only too happy to undertake after you have he lped to save the patient \200\231s life with the simple measures listed. 1 Rivers, E. et al . NEJM 2001 345:1368 available free at (cid:27)www.nejm.org/doi/full/10.1056/ NEJMoa010307 3Spinal (neurogenic) shock Common causes p ( g ) Trauma Iatrogenic Traumatic transection of spinal cord at any level Spinal anesthesia Symptoms usually motor/sensory dysfunction below level of lesion; bowel and bladder dysfunc tion. Signs dBP, warm peripheries; may not be able to mount tachycardia if lesion above T1 \200\223T4 (origin of sympathetic supply to the heart), focal neurology up-going plantar relaxes, loss of anal tone. Investigations imaging of spinal cord as appropriate. When to t reat BP <100mmHg systolic, symptomatic of dBP, organ failure. Acute treatment call senior h elp; lay fl at and elevate legs (providing spinal injury not suspected); O2 (15l/min); 1l 0 .9% saline STAT; catheterise. If trauma involve spinal/orthopedic surgeons. If iatrogenic, (eg epidural) stop epidural and consult anesthetist. Seek early involvement of ICU. _OHFP.indb 481 _OHFP.indb 481 30/05/2014 16:18 30/05/2014 16:18 482 CHAPTER 15 Emergency department Pyrexia Worrying features iHR, dBP, dGCS, \211 40 C, purpuric rash, +ve blood cultures. Think about serious septic shock (b p480); most likely infection including UTI, pyelonephri tis, cellulitis, septic joint, wound infection, URTI, pneumonia, gastroenteritis, endocardi tis, abscesses, meningitis; iatrogenic transfusion reaction, infected line, drug reaction, neuroleptic malignant syn- drome; other PE/DVT, infl ammatory conditions and malignancy. Ask about urinary frequency, dysuria, pyuria; respiratory cough, sputum production and colo r, haemoptysis, breathlessness, chest pain, sore throat/ear, coryza, contact and immunizati on to TB; joints/ skin arthropathy, rash, erythema, breaks to skin; neurological head- ache , photophobia, neck stiff ness; systemic appetite, weight loss, night sweats; PMH immunosup pression (DM, lymphoma/leukemia, HIV, transplant, cystic fi brosis), underlying lung diseas e, TB, recurrent UTI, prosthetic heart valve or valvular lesion; DH immunosuppression (incl uding steroids), blood transfusions, new drugs commenced (eg antipsychotic), allergies; SH any contacts with similar symptoms, expo- sure to TB, smoking, recreational drug use (IVDU, ecstasy). Obs temp (?swinging), HR, BP, RR, sats, blood glucose, urine output. Look for pulse rate/rhythm/volume, cap refi ll, warm peripheries, sweating, fl ushing, tach ypnoea, tremor, splinter hemorrhages, break in skin, needle tracks in arms/feet/groin, foca l skin/wound infection, bronchial breathing/crackles/reduced air entry, heart murmur, supra pubic/loin tenderness, red catheter/line sites, joint swelling. Investigations septic scree n (b p483); urine dipstick and M,C+S (b p590); blds FBC, iN \230 (bacterial), iL \230 (vira l), iE \230 (drugs/parasites/ allergy), blood fi lm (may suggest hematological malignancy/m alaria), U+E, LFT, infl ammatory markers (CRP, ESR), cultures (b p515); consider: D-dimer i f DVT/PE suspected (b p450) and procalcitonin (b p480); sputum C+S, if active TB suspected request urgent \200\230smear \200\231 microscopy for acid-fast bacilli (AFB); stool cultur e, skin swabs; ABG respiratory failure or metabolic acidosis (b p584); CXR pneumonia/eff us ion; echo if you suspect bacterial endocarditis; transoesophageal is more sensitive than tr ansthoracic;1 LP if meningitis suspected (after CT head). Treatment assess the severity of illness, have a low threshold for treat- ment as septic sh ock (b p480). If signs of infection, consider broad- spectrum antibiotics (b p179) until cu lture results known. Repeat septic screen if new rise in temp >38 C even if already commen ced on antibi- otics. Symptom management paracetamol (1g/6h PO) ibuprofen (400mg/6h PO) f or pyrexia; an electric fan may also produce symptomatic relief. Give adequate analgesia (b p86) and ensure adequate hydration (consider IV fl uids if nauseated or NBM); supplementar y O2 if sats <94%. Request early senior review if in doubt of diagnosis or patient unwell. 1 This may be true, but the cardiologists may take a good deal of persuading. OHFP.indb 482 OHFP.indb 482 30/05/2014 16:18 30/05/2014 16:18 483 PYREXIA The septic screen In many patients the likely source of a fever will be obvious, and invest igations and management can be tailored specifi cally towards that; in others it is less cl ear, and a more widespread approach is required. History a thorough history can sometimes s hed new light on the potential cause or highlight the potential for immunocompromise. Exami nation of all the patient \200\231s systems and a top to toe examination of the skin and jo ints may reveal a source of infection. All line sites should be inspected and changed if ol d or infl amed \200\223 send the tips of removed lines to microbiology for culturing. Inve stigations see box. Septic screen \200 FBC (repeat every 2d) \200 Infl ammatory markers, ESR, CRP (repeat e very 2 \200\2234d) \200 Urine culture (separate samples from any nephrostomies/urostomies ) \200 Sputum culture, if indicated \200 Blood cultures (3 sets at 6 \200\2238h interva ls from diff erent veins; additional sets from any central lines) Microbiology swabs of wounds/pressure areas/cannula or central line sites \200 CXR if pro ductive cough or abnormal clinical signs present. If infectious source still not identifi e d, consider: \200 Procalcitonin (will be negative if non-infective cause, b p480) \200 Stopping all antibiotics (if stable) and repeating all cultures after 48h \200 Echocardio gram if new murmur or new stigmata of bacterial endocarditis \200 Check sickle-cell statu s \200 Blood fi lm for parasites (if malaria is suspected) \200 Lumbar puncture if CNS infection suspected or needs excluding (CT fi rst). Pyrexia of unknown origin (PUO) (OHCM9 b p388) Classically defi ned as a recurrent fever (T >38.3 C), persisting for >3wk, without obvious cause despite >1wk of in-patient investiga tions. Causes include infection (30%), malignancy (30%), non-infectious infl ammatory disea se (eg connective tissue disease, vasculitis; 20%), and drug reactions. Always repeat a det ailed history and examination, clearly summarize all inves- tigations and results so far an d discuss with an infectious disease physician. Despite your best eff orts, in 710% of case s a cause is never found. Iatrogenic causes of pyrexia \200 Transfusion reactions (b p402) \200 Infected lines: cannula, central lines, arterial lines, urinary catheters, long-lines, etc. Drug-induced (most due to hypersensitivity reactions): antibiotics (eg erythromycin, nitrofurantoin, isoniazid, penicillins) \200 cardiovascular medications (eg atropine, hydralazine, nifedipine) \200 malignant hyperthermia (eg anest hetic agents) \200 neuroleptic malignant syndrome (eg antipsychotic drugs) \200 miscell aneous (eg aspirin, allopurinol, phenytoin, opioid withdrawal). Post-operative: atelectasis (often 24h post-op). _OHFP.indb 483 _OHFP.indb 483 30/05/2014 16:18 30/05/2014 16:18 484 CHAPTER 15 Emergency department Urinary tract infection, including pyelonephritis (OHCM9 b p292) Worrying signs dBP/shock ( b p480), temp >40 C, new renal impairment. Elderly patients can be afebrile or hypothermic but heavily bacteraemic. Symptoms cystitis urinary frequency, dysuria, urgency, pyuria, ha ematuria, suprapubic pain; pyelonephritis fever, rigors, vomiting, loin pain. Risk factors 5, sexual intercourse, catheterisation, DM, immunosuppression, pregnancy, structural abnorm alities of urinary tract, stones, elderly. Signs warm peripheries, vasodilation, tachycardi a, suprapubic/loin pain. Investigations Urine dipstick (see box and b p590) C+S if clinical suspicion of UTI and in all pyrexial/vomiting children; blds FBC (iWCC, iN \230), U+E (iur ea, icreatinine if outfl ow tract obstruction b p377), iinfl ammatory markers, iglu- cose ( ?DM); bld cultures if itemp or systemically unwell. Acute treatment (UTI) if dBP/shock trea t as septic shock (b p480); other wise paracetamol (for fever) and consider empirical antib iotic therapy (eg trimeth- oprim 200mg/12h PO, or co-amoxiclav 1.2g/8h IV if septic) whilst awaiting sensitivities; ioral fl uid intake. Treat for 3d (simple infection in 5) or 7d (i f structural urinary tract abnormality, immunosuppressed or 4). Acute treatment (pyelonephr itis) if dBP/shock treat as septic shock (b p480); admit for IV antibiotics if septic, preg nant, frail elderly, immunosuppressed or structurally abnormal urinary tract. Give paraceta mol and start empirical antibiotic therapy (eg co-amoxiclav 625mg/8h PO or 1.2g/8h IV) whil st awaiting sensitivities; ioral fl uid intake. Treat for 7 \200\22310d. Further investigat ion consider renal USS referral to urology if: failure to respond to treatment, recurrent UTIs (especially in 4), pyelonephritis (after 1st episode in 4, 2nd episode in 5), Proteus species isolated or microscopic haematuria persisting after resolution of symptoms. haemat uria persisting after resolution of symptoms. Simple measures to prevent urinary tract infections \200 Voiding before bedtime and after sexual \200 Drink >2l fl uid day \200 Voiding at 2 \200\2233h intervals \200 Wipe fr ont to back after micturition (5). \200 Double voiding intercourse Recurrent urinary tract infections \200 Avoidance of constipation \200 Drinking cranber ry juice1 1 Kontiokari, T. et al. BMJ 2001 332:1571 available free at (cid:27)www.bmj.com Antibiotic prophylaxis (eg trimethoprim) \200 Avoidance of irritants in bathwater (bubble (prevents outfl ow obstruction) bath etc). Just how useful is a urine dipstick? A MSU culture demonstrating a urinary pathogen at >105 CFU/ml is the gold standard test in suspected UTI. Dipsticks allow \200\230near patient \200\231 testing for various markers that may allow for a modest improvement in clinical di agnosis: \200 Nitrites many uropathogens reduce nitrate to nitrite; +ve in 730% confi rme d UTIs, but highly specifi c. False \210\222ves occur with organisms that do not reduce ni trate or polyuria \200 Leucocyte esterase a marker for pyuria; will be positive in 780 \200\22390% confi rmed UTIs; false-positives occur with contamination from eg vagina \200 Blood +ve in 770 \200\22380% confi rmed UTIs; false +ves occur with contamination from eg menstrual bleeding, renal stones \200 Protein refl ect organisms and cells in urine; +ve in 750% confi rmed UTIs. Study data from UK primary care2 show that where clinical suspicio n of a UTI exists, the presence of nitrites, leucocytes or blood can support a diagnosis, b ut that evalu- ation of protein provides no additional information. Combining test results increases sensitivity, but decreases specifi city. Even when all tests are \200\223ve, 24% of symptomatic women will have a UTI confi rmed by MSU culture. If UTI suspected, send an MSU. 2 Little, P. et al. Health Technol Assess 2009 13(19) available free at (cid:27)www.jo urnalsli- brary.nihr.ac.uk/hta/volume-13/issue-19 OHFP.indb 484 OHFP.indb 484 30/05/2014 16:18 30/05/2014 16:18 485 PYREXIA