Encik KS, a 55 year old Malay gentleman from

Kajang with history of ethmoidal ca undergone 6

times of chemotherapy at Kajang Hospital admitted
due to altered mental status. He was brought in the
emergency department at around 11.15 p.m. by his
wife and was triage red. Further history was unable
to be obtained.

Youǯre the doctor on call that night and have to see

this patient. What would you do?
ëhinking of ABC? OF
COURSE
 Airway - clear
Breathing Ȃ He was given oxygen 2l/min via face mask
Circulation Ȃ IV access * 2 (wide bore) secured, run fast 2 pints of NS
Insert urinary catheter (usually in shock ( oliguria)
Send for investigations:
º FBC (WBC high or low, platelet)
º Urine FEME (source of infection UëI?)
º CRP (inflammation)
ÿ ABG (patient tachypnea leading to
   

 Low Pco2, pH >7.45),
may counterbalances lactic acidosis)
º Glucose
º LFë, Pë APëë (coagulopathy)
º Renal profile (elevated urea & creatinine -> ARF)
º 2 times blood culture
º Serum lactate level
Generally, patient was irritable, flushed, tachypneic
GCS was Ȃ 11
Eye opening 4 (Spontaneous eye opening)
Verbal response 2 (incomprehensible)
Motor 5 (localizing to pain)

Skin Ȃ warm, bounding pulse

Vital signs Ȃ ëemperature 39 degrees
Pulse rate 130 beats per minute
Respiratory rate 30 breath per minute (bacterial
endotoxins act on the medullary respiratory center. )
Blood pressure 84/50
Infection

Bacteremia

Sepsis

Severe Sepsis

Septic Shock
º SIRS
å Widespread inflammatory response involving cytokine cacades, free
radicals production, and release of vasoactive mediators.
å ëwo or more of the following
 ëemp>38 C<36 C
 Heart Rate >90 bpm
 ëachypnea RR>20 or hyperventilation PaCO2 <32 mmHg
 WBC >12,000<4000 or presence of >10% immature neutrophils.
º Õ
ÕÕ
  


º Severe Sepsis: Sepsis + organ dysfunction, hypoperfusion, or
hypotension
º Septic shock:
å Severe sepsis with hypotension(systolic <90mmHg)
despite adequate fluid resuscitation or required
vasopressors/inotropes to maintain BP
å Perfusion abnormalities
 Lactic acidosis
 Oliguria
 Impaired CNS

å Multiple Organ System Failure: Abnormal function of

two or more organs such that homeostasis cannot be
achieved without intervention.
NIDUS OF INFECëION ORGANISMS EXOGENEOUS ëOXINS ENDOGENOUS
Pneumonia MEDIAëORS
Organism
Peritonitis Structural Component
Cellulitis CYëOKINES
Exotoxin (ëSSë-1, ëoxin A) *Interleukin 1,2,ǥ.6
Abscess Endotoxin
Other Infection Sites *ëumor Necrosis Factor
PLAëELEë ACë FACëOR
ARACHID ACID MEëAB
HUMORAL CASCADES
*Complement
*Kinins
*Coagulation
Severe Decrease SVR

MYOCARDIUM
HYPOëENSION
Depressed CO *Depression
CARDIOVASCULAR *Dilatation
DEAëH
INSUFFICIENCY
VASCULAëURE
Multiple Organ System
MOSF *Vasodilation
Failure
*Vasoconstriction
*Endothelial Damage
*Maldistribution of flow
RECOVERY
 


 
 
  
 

  
 

      "( 

       
   )*'+,&&-+,&
)*'+, -+,&.

 
!"#

$ Õ" %"

&& '



# !
 j !"
 ".&/0!
ÿHigh cardiac output
ÿIncrease respiratory rate
ÿLow peripheral vascular resistance
occurs first.
ÿLeaky capillaries - Vasodilation from
the effects of histamine, bradykinins,
serotonin.
ÿProfound diuresis - ëhis develops
because of the high osmotic load
being handled by the kidneys, the
result of all those dead and dying
bacteria, phagocytie cells, tissue
breakdown, and end products of
cellular metabolism.
ÿCoagulopathy
 !"
 "
Hypotension
Hypoperfusion
Cold and clammy hands
Subnormal temperature
ÿlow white blood cell count (with many
immature cells)
ÿPulse and respirations will still be rapid
because of the continued firing of
sympathetic nerves and increased
catecholamine levels.
ÿMultisystem failure (APO, ARDS, liver,
kidney failure, DIVC)
ÿABG Ȃ hypoxemia, acidemia,
hypoventilation
HEMODYNAMCS ORGAN PERFUSION

PCWP >10 but <20 mm Hg CNS - improved sensorium

MAP > 60 mm Hg Skin - warm, well perfused
CI > 3 L/min/m2 Renal - UOP > 1 cc/kg/hr

O2 DELIVERY ADEQUACY

Arterial Hgb SpO2 > 95%

Hb concentration > 10 gm/dL
SVO2 > 30 mm Hg
Blood Lactate Conc < 2 mM/L
´ Secure airway if respirations ineffective or patient unable to protect his
airway.
´ Patients with hypotension not responding promptly to acute volume

expansion should also be intubated to prevent respiratory arrest.

´ Supplemental O2

´ Fluid resuscitation- follow BP, respiration, pulse, UOP, mental status, and
CVP to assess response.

´ If circulatory status fails to improve after 2-3 L or signs of fluid overload

develop consider vasoactive agents.
´ Consider placing a PAC as this will allow better titration of hemodynamic
drugs and assessment of circulatory status.
´ Starting initially with NE in low doses (2-5 mcg/kg/min) (improve
perfusion pressure but may help preserve renal function.
´ ëhe dose can then be titrated upward or other inotrope added to
achieve and maintain a MAP of at least 60 mm Hg.
´ Blood cultures and initial laboratory values which assess end organ
function should be sent off
´ Early institution of appropriate antibiotic therapy is crucial. Delay
in initiating antibiotics or initiation of antibiotic therapy which
does not cover the offending agent are associated with a worse
outcome.(IV cefuroxime/gentamicin + antipseudomonal ticarcilin)
´ ëhis initial resuscitation should ideally be accomplished within 1
hour.
º Study design: Prospective, randomized study in
urban emergency department enrolling 263 patients
º Inclusion Criteria: Adults severe sepsis, septic shock,
or sepsis syndrome. SIRS. SBP<90 (after fluid
bolus) or lactate>4.
º Exclusion Criteria: Age<18, pregnancy, acute CVA,
ACS, pulmonary edema, status asthmaticus,
arrhythmia, GIB, seizure, drug OD, burns, trauma,
immediate surgery, uncured cancer,
immunosupressed, DNR.
 º ëreatment:
1. In ER 500 ml crystalloid given q 30 min to achieve CVP 8-12
mmHg.
2. Vasopressors given to achieve MAP >65.
3. If MAP >90 vasodilators given until <90.
4. If ScvO2<70, transfused to Hct of 30. +/-Dobutamine.

º Results: Improved in-hospital mortality (30.5% vs. 46.5%).

Higher mean ScvO2, lower lactate, lower base deficit and a
higher pH. Lower APACHE scores.
º Resuscitate: ABCs
º Restore tissue perfusion
º Identify and eradicate source of infection
º Assure adequate tissue oxygenation
º Activated Protein C
º Steroids
º Glucose Control
º Nutrition
ÿ An Ig E mediated, hypersensitivity response to a
foreign substance to which a patient previously
sensitized (type I hypersensitivity)
ÿ Clinical features:
Skin: urticaria, angioedema, pruritic or burning rash
CVS: arrhythmia, shock (vasodilatation)
Respiratory: bronchospasm (wheeze), laryngeal edema
(stridor)
GIë: abdominal cramps (GI&uterine smooth muscle
contraction)
ÿ Immediately discontinue causative agent
ÿ ABC
Ensure airway is free
Oxygen given by face mask. Eëë, cricothyroidectomy/tracheostomy
may be necessary** anticipate laryngo/bronchospasm will happen(
consider to intubate beforehand
Monitor vital signs & oxygen saturation frequent (2-3mins)
Insert 2 large bore cannulae
Adrenaline
ÿ 0.3-0.5 mg (of 1:1000) SC/IM Ȃ repeat twice at 20min intervals, until 3 doses
ÿ IV adrenaline: only if you know the titration cause the SE( tachycardia( Vë,VF+ pain
ÿ Major airway compromise/hypotension: 3-5ml of 1:10000 IV. Can repeat 5-
10 mins as required
ÿ Patient requiring multiple dose of IV adrenaline Ȃ start on IV infusion. Dilute
5mg adrenaline in 500ml NS or D5 (10 µg/ml). Start with 1 µg/min and
titrate to desired effect (up to 0.2 µg/kg/min)
º Dilute adrenaline:
å 1 ampoule=1mg= 1:1000
 1:10000= 1mg in 10ml
 1:100000= 1mg in 10x10ml
 Give IV slow infusion
ÿ IV fluids
500-1000ml crystalloid or colloid; followed by titration to
elicit acceptable BP & urine output
Persistent hypotension ( inotropes (dopamine,
isoprenaline, adrenaline infusions)

ÿ Bronchodilator
Patient + bronchospasm = salbutamol 2.5-5mg every 15-
30mins(other option commonly used:ipratropium,MgSO4)
Refractory bronchospasm Ȃ aminophylline( narrow
therapeutic window

ÿ Glucocorticoids
Hydrocortisone 4-ǥmg/kg or 250 mg IV (or oral
prednisolone 20mg)***
ÿ Antihistamines
Chlorpheniramine 10g IV or diphenhydramine 25-50mg IV
Diphenhydramine + (ranitidine 50mg IV 4-6hrly OR cimetidine 300mg IV 8-12hrly) (
block both H1 & H2 receptors
ÿ Glucagon
In refractory cases not responding to adrenaline because beta adrenergic blocker (ie if
patient taking beta blocker)
1mg IV bolus. Continuous infusion 1-5mg/hr may be given if required.

ÿ Others:
Elevate lower extremities (increase venous return)
Severe anaphylaxis ( ICU. Continuous ECG monitoring, ABG, CVP, BP
Can give short course of antihistamine (2-3 days) and steroids (7-10 days) to prevent
relapse or for patient with bronchospasm/hypotension
Epinephrine pen: ptx education for self-injecting adrenaline for next anaphylaxis
Encourage patient to wear a medical alert bracelet/necklace/keychain: to warn
emergency personnel of anaphylaxis risk
Avoid cause of allergy, do skin prick test to know allergen
º Anaphylaxis vs anaphylactoid
å Anaphylactoid: not involve IgE primary
involvement to mast cell degranulation
 Never been exposed to the allergen
 Common: rx to voltaren

º Effect:
å Immediate
å Delayed (~4h)
å Prolonged (~weeks)