22 Critical Care Emergencies
SHOCKED PATIENT(iii) Severe sepsis
Sepsis plus either organ dysfunction, or with evidence of hypotension
or hypoperfusion (e.g. confusion, oliguria, raised lactate).
(iv) Septic shock
Subset of severe sepsis with sepsis-induced hypotension (SBP <90
mmHg), or hypoperfusion abnormality such as lactate ≥4 mmol/L
persisting despite adequate fluid resuscitation (20–30 mL/kg).
3 Initial symptoms are non-specific and include malaise, fever or rigors,
myalgia, nausea or vomiting and lethargy.
(i) Ask specifically about focal features such as headache, neck pain,
sore throat, ear ache, cough, breathlessness, abdominal pain,
frequency, dysuria, joint or skin changes.
(ii) Enquire about previous illnesses, use of antibiotics, allergies,
immunosuppression including diabetes, chemotherapy, steroids
or HIV, alcohol use or travel abroad.
4 Assess for features of circulatory shock including abnormal vital signs.
(i) Early signs are non-specific such as tachypnoea, tachycardia,
temperature change (high or low), and altered mental status.
(ii) Some patients will be hot and flushed with a bounding pulse, but
many others are normo- or hypothermic with a tachypnoea and
metabolic acidosis.
5 Examine for potential source areas such as the ears, throat, chest, heart,
abdomen, limbs and skin including between the toes (tinea), skin folds
(intertrigo), perineum and axillae (abscess).
(i) Look for a rash, particularly petechial.
6 Establish venous access with two large-bore (14- or 16-gauge) cannulae into
the antecubital veins and attach a cardiac monitor and pulse oximeter to the
patient.
7 Send blood for FBC, coagulation profile, ELFTs, CRP, lactate and two sets of
blood cultures from different sites.
(i) Check a venous or arterial blood gas.
(ii) Swab any infected areas.
8 Perform an ECG and request a CXR.
9 Insert a urethral catheter to measure the urine output, and check a urinalysis
for blood, protein, nitrites and sugar. Send for microscopy and culture if
positive.
(i) Oliguria suggests ongoing renal hypoperfusion.
(ii) Check a urinary -hCG pregnancy test in pre-menopausal
females.
10 Arrange an ultrasound, CT scan and/or lumbar puncture (LP) according to
the suspected source of infection, but these should never delay antibiotic
therapy.