QuestionSBA
QuestionChoice
There is no indication for adenosine, which is used in SVT in the absence of adverse features.
10015738
c
Adenosine
QuestionChoice
Flecanide is used for paroxysmal AF. The patient appears septic and this is the likely cause for this patient's arrythmia and thus should be addressed first.
10015740
e
Flecanide
QuestionChoice
Although DC cardioversion can be considered if the patient is significantly hypotensive in the context of a tachyarrythmia, a common cause of fast atrial fibrillation is dehydration and sepsis, both of which can be treated initially with a fluid bolus as part of routine resuscitation, which is the next best step. 
10015737
b
DC cardioversion
QuestionChoice
This patient appears to be septic. Their tachycardia and hypotension suggest a fluid bolus is required. If shock remains fluid unresponsive, the patient may require inotropes. Additionally, a common cause of Atrial Fibrillation is dehydration so a reasonable first line treatment in ED is to give a fluid bolus to manage this.
10015736
a
Fluid bolus
QuestionChoice
Beta blockers should not be used in sepsis or hypotension.
10015739
d
Bisoprolol
QuestionComment
if the systolic bp was less than 90 would be answer bc DC Cardioversion?
40934
QuestionComment
I think the principle here is that you don't cardiovert AF if there is a clear reversible cause. Most of cases of AF in an unwell patient IS them being unwell (sepsis, electrolyte imbalances, etc). 

So you would treat the cause first (e.g. fluids and abx), then reassess :)
41760
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Amnesia Defibrillator
QuestionComment
Yes you have to treat the reversible cause, otherwise it’ll continue 
46850
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Uremic Serotonin
QuestionComment
Also you don't cardiovert after 48 hours for risk of dislodging a possible clot (formed as the result of the AF) which could go on to cause a CVA
52621
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Juice Hypertension
QuestionComment
yes and no. If you thought the patient would die faster than rehydrating them would increase the bp, yes. If you were willing to continuously monitor BP and watch it rise while having the crash team nearby ready to cardiovert, then I don't see why not wait for the bolus to go through
58997
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moins que
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Serotonin Jaundice
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)
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Sepsis
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Emergency Medicine
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Sepsis
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Acute and emergency
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Sepsis
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Infection
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Sepsis
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Obstetrics and gynaecology
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A septic patient with tachycardia and hypotension may benefit from initial management with a fluid bolus.
Presentation
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Deteriorating patient
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Acute and emergency
Presentation
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Deteriorating patient
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General practice and primary healthcare
A 75 year old man is brought to the emergency department after being found unwell at home. His ECG shows evidence of fast atrial fibrillation.

Observations show:

* Pulse rate 130

* Blood pressure 96/64

* Temperature 38.8 degrees celcius

* Respiratory rate 24 breaths/minute

What is the most appropriate next step in management?
a