Emergency medicine- infective emergencies
A great deal of overlap exists in these guidelines, it is also true in clinical medicine that cases
can overlap and a diagnosis is uncertain. It is sometimes necessary to ‘cover’ for the worst case
scenario for example an unconscious patient coming in may be reasonably treated for severe
malaria, sepsis and hypoglycaemia.
Sepsis
Sepsis is a very serious condition which is often fatal, it refers to a condition where there is
infection and evidence of physiological response such as fever or tachycardia.
There is an initial focus of infection for example in the chest, urine, wound which is now causing
problems throughout the body.
It is a serious condition which can progress to cause organ dysfunction and septic shock. This is
where the infection is so bad the body has dilated all its blood vessels and cannot supply
oxygen properly to the cells and remove their waste products.
Look for evidence of severe sepsis
Signs
This depends on the site of initial infection but on examining the patient you will find…
Signs of sepsis
 Distress
 Tachypnoea (respiration >20 per minute)
 Tachycardia (>100bpm)
 Hypoxia (<90% SaO2)
 Fever/Hypothermia(temp >38.0 or <35.0 oC)
 Pallor
 Decreased capillary refill
Signs of severe sepsis
 Low blood pressure (<90mmhg systolic)
 Poor urine output (<0.5 ml/kg/hr, usually <20ml/hr)
 Confusion
 If lab tests are available lactic acidosis and hepatic dysfunction are also signs
Septic shock is where there is not enough blood pressure to perfuse the tissues.
Symptoms
Provided by T. Whitfield 2012
Unwell, related to underlying cause. They will complain of fever or coldness. A septic patient
will display a marked deterioration in their condition compared to a few days previously.
Approaching a septic patient
All emergency patients are best dealt with using the ABCDE approach to ensure nothing is
missed
A-airway
Is this clear, do you need to suction, or change to recovery position.
B- Breathing
Check oxygen saturations
Examine the chest
Measure the respiratory rate
Give oxygen if respiratory distress (tachypnoeic, short of breath)
C- Cardiovascular system
Examine cardiovascular system including pulse rate
Measure BP
Ensure two good lines (try to take blood at this stage
Give fluids
If low BP due to sepsis give fluids quickly(fluid challenge), i.e. 250-500ml stat and reassess BP. If
BP low after fluid challenge give another bolus of 250-500ml.
At least 3 litres a day are needed for septic patients with no heart failure. If the patient is in
septic shock they will need much more than this, (see fluid management handout).
D- Disability
Measure Glasgow Coma Score
Check blood sugar
Check pupils
Check temperature
Check status
MPS
Check blood sugar
Give antibiotics at this point (ceftriaxone 2g BD usually given in Malawi)
E- Exposure
Expose patient look for the cause ? wound etc
? catheter needed. Yes if BP low or acute kidney injury suspected
Provided by T. Whitfield 2012
It is important to continue to monitor these patients to ensyre the fluid balance is correct.
If blood pressure remains low despite fluids then ionotropic support may be necessary on
HDU/ICU, if available.
Hypoxia despite oxygen will need increased support in HDU or ICU
Common sources of sepsis:
 Chest (pneumonia)
 Urine
 Wounds/ canula
 Skin (cellulitis)
 Heart (endocarditis)
Septic patients are very ill and are likely to continue to deteriorate to cardiac or respiratory
arrest if left untreated. Early instigation of treatment will provide the best prognosis for your
patient.
Malaria
A very common disease in Malawi, often adults have some immunity to Malaria preventing
severe complications. However severe malaria is easily treated and diagnosed, it must be
suspected/ ruled out in any seriously unwell patient.
Signs




Fever
General body pain
Rigors
Coma
Symptoms
 Fever
 General body pain
 Headache
 Malaise
 Vomiting
 Diarrhoea
Severe Malaria
Indications of severe malaria
Provided by T. Whitfield 2012
Suspected severe malaria should be treated before test results are obtained. If malaria is not
severe then the clinician can wait for lab tests before starting treatment.
Any one of the following indicates severe Malaria:
 Decreased level of consciousness
 Respiratory distress
 Convulsions
 Pulmonary oedema
 Abnormal bleeding
 Jaundice
 Haemoglobinuria
 Prostration
Lab features of severe malaria:
 Severe anaemia <5 g/dl
 Hypoglycaemia
 Hyperlactaemia
 Hyperparasitaemia
 Electrolyte imbalance
Use the ABCDE approach when managing severe Malaria as detailed above.
In severe Malaria it is important to ensure good amounts of fluids and monitor blood glucose
level as the parasite and quinine both cause hypoglycaemia.
Treating Malaria
IV quinine is used to treat severe Malaria 1.2g IV stat followed by 600mg IV BD. Switch to the
oral LAR tablets 4 BD when the patient stable.
Complications in severe malaria
Cerebral Malaria: characterized by headache, low GCS often with seizures. Neck stiffness and
kernigs sign are not as prominent as they would be in meningitis. If meningitis is suspected
treat both to cover.
Blackwater fever/Renal Dysfunction: the haemolysis of the red blood cells causes the urine to
be dark like coco-cola. This damages the kidneys and can cause renal failure. These patients
need large voulmes of fluid to wash out the haemoglobinuria, paying close attention to urine
output and fluid balance in case the kidneys fail and dialysis is needed.
Severe Anaemia: caused by the haemolysis of the red blood cells. Monitor Hb and transfuse if
necessary.
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Shock: seen by low blood pressure and tachycardia, start antimalarials, IV fluids instantly and
consider ionotropic support if ineffective.
Disseminated Intravascular Coagualtion: the parasite causes the blood to start clotting in a
disordered manner in the blood vessels. This means the normal clotting factors are used up and
the patient starts to bleed from their mouth, nose, canula site and other places. These patients
need fresh frozen plasma and intensive support in HDU.
Severe Malaria and Sepsis can appear very similar in newly presenting patients and it may be
appropriate to treat both blindly until further information is available.
Meningitis
Meningitis is a serious life threatening condition. The most serious form of meningitis is caused
by bacteria. This is often rapidly fatal and is the first condition to treat if meningitis is
suspected.
Bacterial meningitis typically comes on over a few hours to two days. Occassionally subacute
meningitis can come on over a week or so. This differentiates bacterial meningitis from
tuberculous and cryptococcal meningitis which tend to come on over a longer period. Though
as bacterial meningitis is a quick killer it is always best to treat it if you are uncertain.
Symptoms
Patients complain of…
 Headache
 Neck pain
 Fever
 Malaise
Signs
When examining the patient key findings are…
 Decreased GCS (it may be appropriate to treat comatose patents of unknown cause)
 Neck stiffness (very indicative of meningitis)
 Photophobia
 Non- blanching rash (indicates septicaemia, usually in N.meningitidis)
 Confusion
 Fever
Management of bacterial meningitis
Use the ABCDE approach.
Look for other causes of illness such as malaria and hypoglycaemia.
Provided by T. Whitfield 2012
IV ceftriaxone 2g bd for 7 days
If ceftriaxone unavailable give Christapen 4 MU QID and Chloramphenicol 1G QID for 10-14
days
Lumbar puncture should be performed immediately
IV fluid but monitor patient fluid balance
Monitor obs
You may decide the meningitis has progressed to septic shock. In which instance combine the
two management plans. (LP and cef are still priorities but ensure fluid management.)
Other Meningitis
The two other types of concern are TB meningitis and cryptococcal meningitis.
Analyzing the CSF results can give a diagnosis.
Bacterial
TB
Viral
Cryptococcal
Cloudy
Clear mostly
Clear
Clear mostly
WCC/mm
90-1000+
10-1000
50-1000
Raised
Type wcc
dominant
Polymorph
Lymphocyte
Lymphocyte
Lymphocyte
Glucose
<1/2 blood
<1/2 blood
>1/2 blood
<1/2 blood
Protein (g/L)
>1.5
1-5
<1
>1
Organisms
Seen
Rarely seen
Not seen
India Ink stains
Yeast
Appearance
3
The normal ranges are…
 WCC (< 5 x 106 /L)
 Red cells (should be none)
 Protein (0.15-0.4 g/L)
 Glucose (2.8-4.2 mmol/L, or > ½ blood levels)
Provided by T. Whitfield 2012
The first clue it may be bacterial is during lumbar puncture; the CSF should be cloudy. An
increased number of polymorphs is also highly suggestive of bacterial meningitis.
Cryptococcal meningitis only occurs in the immunocompromised, which in Malawi the largest
group is HIV patients. During LP the CSF tends to shoot out in a stream due to increased
pressure. India ink stain will be positive in around 70-80% of patients. Cryptococcal meningitis is
treated with fluconazole 1200mg od for 2 weeks followed by 800mg od for 8 weeks then 200mg
for life. Amphotericin B 1mg/kg od for one week can also be given, (monitor renal function can
cause renal failure). If a patient will cryptococcal meningitis deteriorates repeating LP can
improve intracranial pressure and allow patient recovery.
The case for TB meningitis can be strengthened if the patient has classical TB signs and
symptoms (fever, weight loss, night sweats and lymph nodes). TB meningitis is treated with TB
medications for 6-8 months under the supervision of the TB control team. In severe
deterioration steroid can be tried such as prednisolone 1m/kg/day, or its equivalent. (see BNF
for steroid equivalents.
Viral meningitis is a benign condition which is treated with analgesia.
Provided by T. Whitfield 2012