QuestionSBA
QuestionChoice
This patient does have cellulitis. They have a red, swollen leg after a history of penetrating trauma (that introduced infection to the leg). However, this is not the whole picture. Cellulitis is unlikely to cause such a high heart rate without being accompanied by sepsis. A heart rate above 130/min is a red flag symptom of sepsis. According to NICE guidelines, any patient with one red flag feature of sepsis should have an urgent senior review and be managed as sepsis until proven otherwise
33664
b
Cellulitis
QuestionChoice
Deep vein thrombosis (DVT) also presents with a red, hot, swollen leg. However, this patient has no risk factors for DVT – no surgery, long haul travel, malignancy, personal history of thrombosis or family history of thrombosis (which could suggest hereditary thrombophilia). A diagnosis of DVT would not explain why this patient developed these symptoms after a penetrating leg injury (unless this history clearly stated prolonged immobility after this injury). Pulmonary embolism (associated with deep vein thrombosis) can present with tachycardia; however, this patient has pyrexia of 38.6ºC, whereas DVT and PE typically present with a no fever or a low-grade fever
33665
c
Deep vein thrombosis
QuestionChoice
A ruptured Baker's cyst can present similarly to a DVT and cellulitis, with redness, swelling and pain. However, a ruptured Baker's cyst does not explain the presence of a fever and tachycardia. Symptoms of a ruptured Baker's cyst are usually only confined to the leg, without any systemic symptoms
33667
e
Ruptured Baker's cyst
QuestionChoice
Necrotising fasciitis is a life-threatening infection of the skin. It can present after a penetrating injury, typically as an area of erythema with a necrotic centre. This necrosis can spread, leading to sepsis and death. What differentiates this case from necrotising fasciitis is the time course. Necrotising fasciitis is rapidly progressive, so it is unlikely this patient will have a slow progression over a couple of days. There is also likely to be signs of necrosis on limb examination
33666
d
Necrotising fasciitis
QuestionChoice
Sepsis is a dysregulated immune response to infection, most often associated with a bacterial infection. In this case, this patient likely has cellulitis of their leg, which has progressed to sepsis. The examination findings suggest sepsis is the most likely diagnosis. He has a heart rate of 136/min, a red flag feature of sepsis (>130/min). They are also presenting with a high fever, which supports the diagnosis of cellulitis and sepsis. Heart rate can be raised for other reasons, including pain and anxiety. However, in the case of someone presenting with red flag features of sepsis in the clinical context of infection, they should be treated as sepsis until proven otherwise. If they have a high heart rate from anxiety or pain, they would probably also have high blood pressure as well. According to NICE guidelines, any patient with one red flag feature of sepsis should have an urgent senior review and be managed as sepsis until proven otherwise. In addition to a senior review, they should have the "sepsis 6" within 1 hour (including blood culture, blood lactate, urine output measurements, IV antibiotics, IV fluids and oxygen). This patient is quite well considering the likely diagnosis of sepsis. However, as they are a 27-year-old man, they probably have an excellent physiological reserve and compensate well. This patient should still be treated promptly to prevent rapid deterioration
33663
a
Sepsis
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Bruh :'(
22451
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Camiodarone
QuestionComment
Right but the overall diagnosis is cellulitis?
22813
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It’s asking for an explanation for the obs which show he is systemically unwell
25637
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rock bottom
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Liam
QuestionComment
why does this shit website want to catch you out all the time
23982
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who tf disliked this 
25882
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evieeee
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evieeee
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This gave me AIDS
25447
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Gastro Chronic
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quesmed can do one

26708
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Malignant Serotonin
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like bruh... were all trying to pass finals you dont have to catch us out 24/7
27187
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Schistosomiasis
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it says in the explanation he's 27 but in the vignette its saying 72?
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Serotonin Biopsy
Concept
Chapter
# Summary
 
Sepsis is a syndrome characterised by life-threatening organ dysfunction that occurs due to a dysregulated response to infection. Key signs and symptoms include fever, altered mental state, tachycardia, hypotension and dehydration, as well as localising signs of infection. The "Sepsis Six" bundle is used to guide care in the first hour following recognition of sepsis; this involves taking blood tests including cultures, a blood gas to measure lactate and monitoring urine output, and giving oxygen, IV broad-spectrum antibiotics and IV fluids.
 
# Definition

The terminology used to describe sepsis has changed, with terms like "severe sepsis" and SIRS (systemic inflammatory response syndrome) no longer in use.

**Sepsis** is defined as a syndrome of life-threatening organ dysfunction due to a dysregulated host response to infection.

**Septic shock** is another term used to describe some patients with sepsis who are at greater risk of death. To be classified as having septic shock, patients need to be persistently hypotensive, requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more **and** have a lactate of over 2 mmol/L despite adequate fluid resuscitation.  

# Epidemiology

- Due to variations in coding and definitions, statistics related to admissions to hospital with sepsis tend to be inconsistent
- Approximately 200,000 people are admitted to hospital with sepsis per year
- Approximately 20% of these (40,000 per year) require intensive care admission
- Mortality is also approximately 20%, with deaths estimated at up to 48,000 per year in the UK
- Men are more commonly affected than women
- Patients at the extremes of age (infants under a year and people aged over 75) are more at risk

# Aetiology

- The commonest sources of infection are respiratory, genitourinary, renal and gastrointestinal 
- Most causative pathogens are bacteria, although fungal, parasitic and viral infections can also lead to sepsis
- The commonest organisms identified are Staphylococcus aureus, Escherichia coli and Pseudomonas species
- In 50% of sepsis cases, no causative pathogen is identified 

**Risk factors** for sepsis include:

- Pregnancy
- Recent miscarriage or abortion
- Frailty
- Immunocompromise due to chronic comorbidities e.g. HIV, diabetes, sickle cell disease
- Immunosuppression secondary to medications e.g. chemotherapy, steroids
- Recent surgery or trauma
- Skin breaks or infections
- Drug or alcohol misuse
- Indwelling lines or catheters

# Signs and Symptoms

Symptoms include:

- General malaise
- Fevers, sweats or chills
- Localising signs of infection e.g. rashes, dysuria
- Decreased urine output
- Confusion
- Breathlessness
- Nausea and vomiting
- Myalgia
 
On examination, signs include:
 
- Tachycardia
- Hypotension
- Pyrexia or hypothermia
- Dehydration e.g. dry mucous membranes
- Altered mental state including delirium
- Irritability
- Respiratory distress e.g. tachypnoea, accessory muscle usage
- Cyanosis and hypoxia
- Delayed capillary refill time
- Cool extremities
- Skin appears mottled or ashen

# Differential Diagnosis

- **Acute alcohol withdrawal** causes altered mental state, tachycardia and sweating; patients are usually tremulous and may have withdrawal seizures if severe
- **Acute haemorrhage** may cause hypovolaemic shock with signs of shock including tachycardia, hypotension, delayed capillary refill and cool extremities; differentiated by signs of bleeding which may be overt or more subtle (e.g. abdominal pain)
- **Diabetic ketoacidosis** causes malaise, tachypnoea (with Kussmaul breathing), dehydration and confusion; metabolic acidosis may be seen in both but in diabetic ketoacidosis glucose will be very high
- **Pulmonary embolism** may cause tachycardia, hypotension, respiratory distress and a low-grade fever; may have haemoptysis and pleuritic chest pain (which could also be seen in sepsis secondary to pneumonia) - CTPA can be used to differentiate if unclear
- **Thyrotoxicosis** produces similar symptoms of confusion and fevers and signs of tachycardia; thyroid function testing shows high T4 and suppressed TSH
- **Drug reactions** e.g. neuroleptic malignant syndrome - shares features of fever, confusion, labile blood pressure and sweating; differentiated by a recent history of antipsychotic use, no localising signs of infection

# Investigations 

The **Sepsis Six** involves taking three key measures (as well as giving three key treatments):

- **Blood cultures** ideally prior to antibiotic administration
- **Lactate** (i.e. a blood gas - venous or arterial)
- **Urine output** (which may involve inserting a urinary catheter)

Other **bedside tests** should include:

- **Capillary blood glucose** as hypo or hyperglycaemia may contribute to confusion
- **Urine pregnancy test** in women of childbearing age
- **Urine dip** and send for **MC&S** looking for evidence of urinary tract infection
- **ECG** as in any acutely unwell patient, looking for arrhythmias and ischaemic changes

**Blood tests** should include:

- **FBC** and **CRP** for inflammatory markers
- **U&Es** looking for evidence of acute kidney injury
- **LFTs** as a baseline prior to giving antibiotics, may be deranged in sepsis
- **Coagulation screen** as this may be deranged in sepsis

**Imaging** should include:

- **Chest X-ray** as part of a septic screen

Other investigations should be targeted at a suspected underlying cause, e.g. respiratory or wound swabs, other imaging e.g. a CT abdomen or echocardiogram or special tests e.g. lumbar puncture when stable.

# Management 
 
The three things that should be given as part of the **Sepsis Six** are:

- IV fluid resuscitation (usually a 500ml bolus over 15 minutes initially)
- Supplementary oxygen to target saturations of 94-98% (88-92% if at risk of type 2 respiratory failure)
- Broad-spectrum IV antibiotics (as per local guidelines)

Other **conservative** management considerations involve:

- Close monitoring of observations, fluid balance, clinical condition and bloods including serial lactate measurement
- Early escalation for senior review and inform intensive care as may require interventions such as inotropes or vasopressors

Other **medical** management involves:

- Modify antibiotic therapy if a source of infection is identified or microbiological results become available
- Further IV fluids may be required however this should be done with careful fluid balance monitoring

**Surgical** management involves:

- Source control, e.g. draining abscesses or debriding infected tissue
- Infected devices may need to be removed
 
# Complications

- **Multi-organ failure** including renal failure, heart failure, acute respiratory distress syndrome and cholestasis
- **Coagulopathy** including disseminated intravascular coagulation
- **Delirium** which may be associated with long-term cognitive impairment e.g. difficulty concentrating and memory loss
- **Mental health impacts** including anxiety, depression and post-traumatic stress disorder
- **Secondary infections** which are often hospital-acquired
- **Polyneuropathy** i.e. critical illness polyneuropathy, characterised by generalised weakness and sensory loss
- **Death**

# Prognosis

- Overall mortality has been estimated at around 20-30%
- This increases to 64% in patients aged over 85 years
- Patients with septic shock also have higher mortality (40-60%) 
- Risk of death in survivors remains raised after recovery (15% of sepsis survivors die within a year of discharge, with 6-8% more dying each year for the following 5 years) 

# NICE Guidelines

[NICE - Sepsis: recognition, diagnosis and early management](https://www.nice.org.uk/guidance/ng51)

[NICE CKS - Sepsis](https://cks.nice.org.uk/topics/sepsis/)

# References 
 
[UK Sepsis Trust](https://sepsistrust.org/)

[Patient UK - Sepsis](https://patient.info/doctor/sepsis-septicaemia-pro)
1014
1072
Sepsis
Topic
39
Emergency Medicine
6733
A 72-year-old man presents to the emergency department with a two-day history of a painful, red, swollen left leg. 

His past medical history includes type 2 diabetes, hypercholesterolaemia and hypertension.

On examination, his respiratory rate is 18/min, heart rate is 136/min, blood pressure is 108/72 and temperature 38.6ºC. The left lower leg is erythematous and hot to touch. There are no discernible areas of necrosis. The left leg is 3.1cm larger than the right. The right leg is normal in appearance and temperature.

What is the most likely diagnosis?
a