Cases in sepsis
Please state your assessment and plan of action in order
Each student/s to work through one case and then present
1) A young man presents with confusion, he is tachycardic and
temperature 39 oC.
You try to rouse him he will groan to pain and push your
hand away. He opens his eyes slightly whilst doing this.
His family report him as well yesterday with no known PMH.
Key questions…
a) How will you approach this patient?
b) What other information would you like?
c) What are your key immediate investigations?
d) What is his GCS?
e) What is your differential and management?
2) 50 year old man presents with shortness of breath his resp
rate is 36 rpm and his sats 70% temp 38.5
He has a cough productive of sputum.
Key questions…
a) How will you approach this patient?
b) What treatment will you give first?
c) What other history would you like?
d) Once stable what investigations will you do?
3) A very thin female presents with diarrhoea, she has a
temperature of 33.5, BP 85/70. She states she has had
diarrhea for the past 3 days.
Key questions
a) How will you approach this patient?
b) What is your initial management of this patient likely to
be?
c) What history is missing?
d) What investigations will you perform?
Provided by T. Whitfield, 2012
4) A 50 yr old lady presents unwell with hr 130bpm, BP 65/40
and temp 38oC. she has been complaining of dysuria for the
past week.
Key questions
a) How will you approach this patient?
b) What is your initial management of this patient?
c) How will you investigate this patient at the bed side?
d) Please state further investigations when the patient is
stable
e) Where is tenderness likely to be on the abdomen?
Provided by T. Whitfield, 2012
Sepsis cases
All cases follow the below basic approach…
Approach
A-airway
Is this clear, do you need to suction, or change to recovery
position.
B- check sats
Examine the chest
Measure sats
Give oxygen if respiratory distress (tachypnoeic, short of breath)
C-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 (i.e 250-500ml stat and
reassess BP) at least 3 litres a day if no heart failure
May need repeated fluids
D- Measure Glasgow Coma Score
Check blood sugar
Check pupils
Check temperature
Check status
MPS
E- expose patient look for the cause ? wound etc
? catheter needed. Yes if BP low or acute kidney injury suspected
If sepsis suspected give ceftriaxone 2g BD
If blood pressure remains low despite fluids then inotropic support
may be necessary on HDU/ICU
Hypoxia despite oxygen will need increased support in HDU or ICU
Persistent tachypnoea can lead to exhaustion and the patient is at
risk of respiratory arrest. If the patient looks tired or exerting
themselves they may need extra support.
Provided by T. Whitfield, 2012
Specifics
Each case is deliberately vague to encourage thought about
what extra information is needed.
Case 1
a) ABCDE approach as above
b) We would like his HIV status, any symptoms he may of
complained of earlier, any sign of neck stiffness or rash.
c) Immediate investigations include RBS, MPS, HIV test (if
possible). As the confusion and ↓GCS are unexplained we
will need LP. Urine dipstick may show UTI, FBC
d) GCS 10
e) Malaria/ meningitis until proven otherwise: Give
antibiotics- Ceftriaxone 2g BD quinine 1.2g stat then 600mg
bd
Case 2
a) ABCDE appproach
b) This patient has respiratory compromise, it is important to
correct this as best possible. We should start O2 therapy
immediately and sit the patient up. Whislt awaiting the
response give antibiotic ceftriaxone 2g od or x-pen 3 MU
TID. He will likely need fluids but assess fluid status
If this does not work the patient would need resp support
on HDU/ ICU.
c) We would like a duration of illness weeks suggests TB/ CPT
rather than pneumonia. What colour is the sputum? Any
blood?
d) We would like a chest x-ray, sputum for AAFB, FBC.
Case 3
a) ABCDE approach as above
b) She will need fluid resuscitation (bolus 250-1L normal
saline) followed by regular fluid (3L in 24hrs), with urine
output monitoring via a catheter. antibiotics (cefuroxime
and metronidazole IV)
Provided by T. Whitfield, 2012
c) We need the frequency of diarrhea, the colour, any blood,
HIV status
d) Stool analysis, HIV test, blood culture
Case 4
a) ABCDE approach
b) This lady is in septic shock and needs fluid resuscitation, we
should plan to give fluids quickly and review her BP. Give
250-500ml stat and re-review BP. Give another bolus if no
improvement. Give antibiotics- Ceftriaxone 2g OD, Quinine
may be appropriate depending on the history.
c) If this doesn’t work she may need ICU care for inotropes to
improve BP.
d) Urine dipstick, to look for nitrites and leucocytes.MPS, RBS
and HIV test.
e) USS abdomen, chest x-ray, urinalysis+ culture, blood
culture.
f) Tenderness is likely at the renal angle or loin.
Provided by T. Whitfield, 2012