Septic shock

Introduction

Sepsis is a clinical syndrome characterized by systemic inflammation due to infection. There is a continuum of severity ranging from sepsis to severe sepsis and septic shock.

sepsis, when an infection reaches the bloodstream and causes inflammation throughout the body

severe sepsis, which occurs when infection disrupts blood flow to the brain or kidneys, leading to organ failure. Blood clots cause gangrene (tissue death) in the arms, legs, fingers, and toes.

septic shock, when blood pressure drops significantly. This can lead to respiratory, heart, or organ failure and death.

(Healthlinecom, 2015)

Septic shock is what happens as a complication of an infection where toxins can initiate a full-body inflammatory response. It often occurs in people who are elderly or have a weakened immune system.

It is thought that the inflammation resulting from sepsis causes tiny blood clots to form, which can block oxygen and nutrients from reaching vital organs. As a result, the organs fail, causing a profound septic shock. This may cause a drop in blood pressure and may result in death.(Wwwnhsuk, 2015)

Presentation
Signs & symptoms
·         patches of discolored skin
·         noticeably lower amounts of urination
·         confusion
·         problems breathing
·         abnormal heart functions, such as palpitations or rapid heart rate
·         chills due to fall in body temperature
·         extreme weakness or lightheadedness (Mayoclinicorg, 2015)

To be diagnosed with severe sepsis, you must exhibit at least two of the following symptoms:

·         Significantly decreased urine output

·         Abrupt change in mental status

·         Decrease in platelet count

·         Difficulty breathing

·         Abnormal heart pumping function

·         Abdominal pain

Causes

Sepsis can be caused by any type of infection: bacterial, fungal, or viral. Bacterial infections often develop while a person is still in the hospital. Sepsis commonly originates from:

·         abdominal or digestive system infections

·         lung infections like pneumonia, bronchitis, or lower respiratory tract infections, which are responsible for around 25 percent of cases

·         urinary tract infection

·         reproductive system infection

Risk factors 

·         Too old or to young

·        People with a compromised immune system have and increased risk of developing septic shock. This includes:

• newborn babies
• elderly people
• pregnant women
• people with long-term health conditions, such as DM, cirrhosis, kidney failure
• people with lowered immune systems, such as those with HIV AIDS or those receiving chemotherapy 

·         Have wounds or injuries, such as burns

·         Have invasive devices, such as intravenous catheters or breathing tubes

Investigations
·         bacteria in the blood

·         problems with clotting due to low platelet count

·         excess waste products in the blood

·         abnormal liver or kidney function

·         decreased amount of oxygen

·         electrolyte imbalance

Other laboratory tests

·         Urine. urine checked for signs of bacteria.

·         Wound secretions. 

·         Respiratory secretions.  coughing up mucus (sputum), it may be tested to determine what type of germ is causing the infection.

Imaging scans

·         X-ray. Using low levels of radiation, X-rays are good for visualizing problems in the lungs.

·         Computerized tomography (CT)

·         Ultrasound

·         Magnetic resonance imaging (MRI). MRIs may be helpful in identifying soft tissue infections, such as abscesses within the spine. 

Management

The earlier sepsis is diagnosed and treated, the more likely you are to survive. Once sepsis is diagnosed, you will most likely be admitted to an Intensive Care Unit (ICU) for treatment. Doctors use a number of medications to treat septic shock, including:

·         intravenous antibiotics to fight infection

·         vaso pressure medications – drugs that constrict blood vessels and help increase blood pressure

·         insulin for blood sugar stability

·         corticosteroids to help with inflammation

Large amounts of IV fluids will be administered to prevent dehydration and help increase blood pressure. A respirator for breathing may also be necessary. Surgery may be performed to remove a source of infection, such as draining a pus-filled abscess or removing infected tissue.

According to guidelines... 

THERAPEUTIC PRIORITIES — The early administration of fluids and antibiotics is the cornerstone of management for patients with severe sepsis and septic shock.

Therapeutic priorities for patients with severe sepsis or septic shock include:

●Early initiation of supportive care to correct physiologic abnormalities, such as hypoxemia and hypotension

●Distinguishing sepsis from systemic inflammatory response syndrome (SIRS).  Because, if an infection exists, it must be identified and treated as soon as possible. This may require appropriate antibiotics as well as a surgical procedure

EARLY MANAGEMENT — The first priority in any patient with severe sepsis or septic shock is stabilization of their airway and breathing. Next, perfusion to the peripheral tissues should be restored and antibiotics administered

Stabilize respiration — Intubation and mechanical ventilation

Chest radiographs and arterial blood gas analysis should be obtained following initial stabilization. These studies are used in combination with other clinical parameters to diagnose acute respiratory distress syndrome (ARDS), which frequently complicates sepsis.

Assess perfusion — Once the patient's respiratory status has been stabilized, the adequacy of perfusion should be assessed. Hypotension is the most common sign but critical hypoperfusion can also occur in the absence of hypotension, especially during early sepsis. Clinical signs of impaired perfusion include the following:

●Hypotension – Hypotension is the most common indicator that perfusion is inadequate (eg, systolic blood pressure [SBP] <90 mmHg, mean arterial pressure <70 mmHg, decrease in SBP >40 mmHg).

●Signs of poor end-organ perfusion – Warm, flushed skin may be present in the early phases of sepsis. As sepsis progresses to shock, the skin may become cool due to redirection of blood flow to core organs.

●Elevated lactate – An elevated serum lactate (eg, >2 mmol/L) can be a manifestation of organ hypoperfusion in the presence or absence of hypotension and is an important component of the initial evaluation [9,13,14]. A serum lactate level ≥4 mmol/L is consistent with, but not diagnostic of, severe sepsis

Establish venous access — Venous access should be established as soon as possible in patients with suspected sepsis.

ADDITIONAL THERAPIES

Glucocorticoids — Glucocorticoids therapy is most likely to be beneficial in patients who have severe septic shock (defined as a systolic blood pressure <90 mmHg) that is unresponsive to adequate fluid resuscitation and vasopressor administration.

Nutrition 

Intensive insulin therapy — Hyperglycemia and insulin resistance are common in critically ill patients, independent of a history of diabetes mellitus. The optimal blood glucose range is controversial. Most clinicians target blood glucose levels between 140 and 180 mg/dL (7.7 to 10 mmol/L).

External cooling — Controlling fever during severe sepsis and septic shock has potential benefits and adverse effects, the net effects of which are uncertain. A trial was performed to compare the effects of external cooling with no external cooling. External cooling consists of using either an automatic cooling blanket, or ice-cold bed sheets and ice packs, to achieve a core body temperature of 36.5 to 37°C for 48 hours. It decreases the time to fever control without exposing the patient to potential adverse effects of antipyretic drugs.

Investigational therapies — A variety of investigational therapies including cytokine and toxin inactivation, as well as hemofiltration, statins, and beta blockade. (Uptodatecom, 2015)

References

Healthlinecom. 2015. Healthline. [Online]. [28 April 2015]. Available from: http://www.healthline.com/health/septic-shock

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [28 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/sepsis/basics/symptoms/con-20031900

Uptodatecom. 2015. Uptodatecom. [Online]. [28 April 2015]. Available from: http://www.uptodate.com/contents/evaluation-and-management-of-severe-sepsis-and-septic-shock-in-adults

Wwwnhsuk. 2015. Wwwnhsuk. [Online]. [28 April 2015]. Available from: http://www.nhs.uk/conditions/septic-shock/Pages/Introduction.aspx

Anaphylaxis

Introduction
Anaphylaxis is a serious, life-threatening allergic reaction. The most common anaphylactic reactions are to foods, insects,latex, exercises, medications.

If someone allergic to a substance, their immune system overreacts to the allergen by releasing chemicals that cause allergy symptoms. 

The flood of chemicals released by immune system during anaphylaxis can causes to go into shock; blood pressure drops suddenly and airways narrow, blocking normal breathing.

Some are susceptible to a much more serious anaphylactic reaction. This reaction typically affects more than one part of the body at the same time.

Anaphylaxis requires immediate medical treatment, including an injection of epinephrine. 

Accurate diagnosis and successful management of allergies is essential.

Presentation 
Signs & symptoms

Symptoms of anaphylaxis generally begin within minutes to a few hours after exposure to a trigger.

The most common symptoms of anaphylaxis are hives (urticaria) and swelling of the skin (angioedema), which occur in 80 to 90 percent of reactions. Respiratory symptoms occur in about 70 percent of reactions, and are especially common in people who also have asthma or another chronic respiratory disease. Extremely low blood pressure causing lightheadedness, dizziness, blurred vision, or loss of consciousness (passing out) occurs in up to about 70 percent of reactions.(Uptodatecom, 2015)

●Skin – Itching, flushing, hives (urticaria), swelling (angioedema)

●Eyes – Itching, tearing, redness, swelling of the skin around the eyes

●Nose and mouth – Sneezing, runny nose, nasal congestion, swelling of the tongue, metallic taste

●Lungs and throat – Difficulty getting air in or out, repeated coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice, sensation of choking

●Heart and circulation – Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, low blood pressure

●Digestive system – Nausea, vomiting, abdominal cramps, diarrhea

●Nervous system – Anxiety, confusion, sense of impending doom

Triggers

●Foods – hen's eggs, cow's milk, peanuts, tree nuts, fish, wheat, soy, peanuts, tree nuts, fish, and crustaceans (shellfish such as shrimp) 

●Medications, such as antibiotics (penicillins and cephalosporins) and analgesics (aspirin, ibuprofen).

●Venom from insects, including bees, yellow jackets, wasps, hornets, and fire ants.

●Latex from natural rubber, found in some latex gloves, balloons, condoms, sports equipment, and medical supplies.

●Allergen immunotherapy ("allergy shots"), such as those given for the treatment of allergic rhinitis (hay fever).

●Exercise, either by itself, or after food ingestion (eg, wheat, celery, shrimp or other food) or after medication ingestion (eg, aspirin, ibuprofen).

●Less common triggers include exposure to airborne allergens (such as horse dander), human seminal fluid, cold water, or cold air.

(Mayoclinicorg, 2015)

Risk factors 

●Previous sudden severe allergic reaction involving the whole body

●Asthma and other chronic lung diseases

●Other diseases – People with cardiovascular disease, for example, and coronary artery disease, are also at greater risk of severe anaphylaxis.

Diagnosis

The diagnosis of anaphylaxis is based on symptoms that occur within minutes to a few hours after exposure to a potential trigger, such as a food, medication, or insect sting.

Tryptase is one of the natural chemicals released into the blood during an anaphylactic reaction. An increased amount of tryptase can sometimes be measured in a blood sample collected during the first three hours after anaphylaxis symptoms have begun.

Management 

Epinephrine is the only medicine that optimally treats anaphylactic reactions. It is most effective when it is given promptly, before symptoms become severe. Neither antihistamines, which mainly relieve hives and itching, nor asthma inhalers (puffers), which mainly relieve coughing and wheezing, can fully treat anaphylaxis effectively. These medications should not be substituted for epinephrine. (Uptodatecom, 2015)

References 

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [6 May 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/anaphylaxis/basics/symptoms/con-20014324

Uptodatecom. 2015. Uptodatecom. [Online]. [6 May 2015]. Available from: http://www.uptodate.com/contents/anaphylaxis-symptoms-and-diagnosis-beyond-the-basics

Cardiac arrest

Introduction 
Sudden cardiac arrest is the sudden, unexpected loss of heart function, breathing and consciousness. Sudden cardiac arrest usually results from an electrical disturbance in the heart that disrupts its pumping action, stopping blood flow to the rest of the body.

Sudden cardiac arrest is different from a heart attack, which occurs when blood flow to a portion of the heart is blocked. However, a heart attack can sometimes trigger an electrical disturbance that leads to sudden cardiac arrest.

Sudden cardiac arrest is a medical emergency. If not treated immediately, it causes sudden cardiac death. With fast, appropriate medical care, survival is possible. Administering cardiopulmonary resuscitation (CPR) — or even just compressions to the chest — can improve the chances of survival until emergency personnel arrive.         (Uptodatecom, 2015)

Presentation
Signs & symptoms 

·         No pulse

·         No breathing

·         Loss of consciousness

Sometimes other signs and symptoms precede sudden cardiac arrest. These may include fatigue, fainting, blackouts, dizziness, chest pain, shortness of breath, weakness, palpitations or vomiting. But sudden cardiac arrest often occurs with no warning. (Mayoclinicorg, 2015)

Heart conditions that can lead to sudden cardiac arrest

·         Coronary artery disease. 

·         Heart attack. 

·         Enlarged heart (cardiomyopathy). 

·         Valvular heart disease. 

·         Congenital heart disease. 

·         Electrical problems in the heart. 

Risk factors

·         A family history of coronary artery disease

·         Smoking

·         High blood pressure

·         High blood cholesterol

·         Obesity

·         Diabetes

·         A sedentary lifestyle

·         Drinking too much alcohol (more than one to two drinks a day)

Other factors that may increase your risk of sudden cardiac arrest include:

·         A previous episode of cardiac arrest or a family history of cardiac arrest

·         A previous heart attack

·         A personal or family history of other forms of heart disease, such as heart rhythm disorders, congenital heart defects, heart failure and cardiomyopathy

·         Age — the incidence of sudden cardiac arrest increases with age, especially after age 45 for men and age 55 for women

·         Being male — men are two to three times more likely to experience sudden cardiac arrest

·         Using illegal drugs, such as cocaine or amphetamines

·         Nutritional imbalance, such as low potassium or magnesium levels

Investigations 

Electrocardiogram

Blood tests

Blood tests may include:

·         Cardiac enzyme test. Certain heart enzymes leak into your blood if your heart has been damaged by a heart attack.

·         Electrolyte test. A sample of your blood may also be tested for levels of electrolytes, such as potassium, calcium and magnesium. Electrolytes are minerals in your blood and body fluids that help create electrical impulses.

·         Drug test. 

·         Hormone test. Testing for hyperthyroidism may indicate this condition as the trigger for your cardiac arrest.

Imaging tests

·         Chest X-ray.  check the size and shape of your heart and its blood vessels.

·         Echocardiogram.  An echocardiogram can help identify whether an area of your heart has been damaged by a heart attack and isn't pumping normally or at peak capacity (ejection fraction) or whether there are valvular abnormalities.

·         Ejection fraction testing. 

·         Nuclear scan. (Heartorg, 2015)

Other tests

Other tests that are often done include:

·         Electrical system (electrophysiological) testing and mapping. 

·         Coronary catheterization (angiogram). 

Immediate action for survival.

CPR

Immediate cardiopulmonary resuscitation (CPR

Advanced care for ventricular fibrillation

Management

·         Drugs. Doctors use various anti-arrhythmic drugs for emergency or long-term treatment of arrhythmias or potential arrhythmia complications. A class of medications called beta blockers is commonly used in people at risk of sudden cardiac arrest. Other possible drugs include angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers or a drug called amiodarone (Cordarone).

As with any medication, anti-arrhythmic drugs may have potential side effects. For example, an anti-arrhythmic drug may cause your particular arrhythmia to occur more frequently — or even cause a new arrhythmia to appear that's as bad as or worse than your pre-existing condition.

·         Implantable cardioverter-defibrillator (ICD) An ICD is a battery-powered unit that's implanted near your left collarbone. One or more electrode-tipped wires from the ICD run through veins to your heart.

·         Coronary angioplasty

·         Coronary bypass surgery

·         Radiofrequency catheter ablation. This procedure may be used to block a single abnormal electrical pathway. In this procedure, one or more catheters are threaded through your blood vessels to your inner heart. They're positioned along electrical pathways identified by your doctor as causing your arrhythmia. Electrodes at the catheter tips are heated with radiofrequency energy. This destroys (ablates) a small spot of heart tissue and creates an electrical block along the pathway that's causing your arrhythmia. Usually this stops your arrhythmia.

·         Corrective heart surgery

·         Heart transplantation

(Uptodatecom, 2015)

References

Heartorg. 2015. Heartorg. [Online]. [28 April 2015]. Available from: http://www.heart.org/HEARTORG/Conditions/More/CardiacArrest/About-Cardiac-Arrest_UCM_307905_Article.jsp

Uptodatecom. 2015. Uptodatecom. [Online]. [27 April 2015]. Available from: http://www.uptodate.com/contents/overview-of-sudden-cardiac-arrest-and-sudden-cardiac-death

Uptodatecom. 2015. Uptodatecom. [Online]. [27 April 2015]. Available from: http://www.uptodate.com/contents/post-cardiac-arrest-management-in-adults

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [27 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/symptoms/con-20042982

Acute stroke

Introduction
Stroke occurs when blood flow to an area of brain is cut off. This lead to brain cells are deprived of oxygen and begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain such as memory and muscle control are lost.

When blood flow to part of the brain stops for a short period of time, also called transient ischemic attack (TIA), it can mimic stroke-like symptoms. These symptoms appear and last less than 24 hours before disappearing. While TIAs generally do not cause permanent brain damage, they are a serious warning sign that a stroke may happen in the future and should not be ignored.

Strokes can be divided into two main types.  The first type, known as a hemorrhagic stroke, happens when an artery in the brain bleeds.  This kind of stroke may be caused by an aneurysm (a bubble in the artery wall) that bursts or by a condition called arterial venous malformation, a tangle of abnormal blood vessels in the brain that may bleed due to the fragility of the vessel structure. There are two types of hemorrhagic stroke called intracerebal and subarachnoid.

·         Intracerebral hemorrhage. In an intracerebral hemorrhage, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging brain cells. Brain cells beyond the leak are deprived of blood and also damaged. High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other conditions may cause an intracerebral hemorrhage.

·         Subarachnoid hemorrhage. In a subarachnoid hemorrhage, an artery on or near the surface of brain bursts and spills into the space between the surface of the brain and skull. This bleeding is often signaled by a sudden, severe headache.

The second and most common type of stroke, known as ischemic stroke, occurs when a blood clot blocks an artery that carries blood to the brain. Deprived of oxygen, brain cells die at a rate of two million cells per minute, increasing the risk of permanent brain damage, disability or death. Ischemic strokes account for about 87% of all strokes. 

The most common ischemic strokes include:

·         Thrombotic stroke. A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot may be caused by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions.

·         Embolic stroke. An embolic stroke occurs when a blood clot or other debris forms away from the brain, commonly in heart and is swept through the bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus.

A stroke is a medical emergency. Prompt treatment is crucial. Early action can minimize brain damage and potential complications.Recognizing symptoms and getting medical attention quickly can save a life and minimize disability. (Strokeorg, 2014)

Presentation
Symptoms and signs of stroke

• Anterior circulation strokes
• Unilateral weakness
• Unilateral sensory loss or inattention
• Isolated dysarthria
• Dysphasia
• Vision:
• Homonymous hemianopia
• Monocular blindness
• Visual inattention
• Posterior circulation strokes
• Isolated homonymous hemianopia
• Diplopia and disconjugate movement of eyes
• Nausea and vomiting
• Incoordination and unsteadiness
• Unilateral or bilateral weakness and/or sensory loss
• Nonspecific signs
• Dysphagia
• Incontinence
• Loss of consciousness (Mayoclinicorg, 2015)

Risk factors

•Male
•Over age 55
•African American
•Diabetes
•Hypertension
•Hyperlipidemia (presence of excess lipids in the blood)
•Smoking
•Atrial fibrillation (abnormal and irregular heart rhythm that can alter the heart's electrical system, resulting in poor blood flow to the body, shortness of breath and weakness)
•Family history of stroke

Investigations   

·         Blood tests

·         Computerized tomography (CT) scan

·         Magnetic resonance imaging (MRI)

·         Carotid ultrasound

·         Cerebral angiogram

·         Echocardiogram

Management 

Treatments

·         Aspirin. Reduce the chances of  having another stroke. Aspirin prevents blood clots from forming.

·         Intravenous injection of tissue plasminogen activator (TPA). Also, called alteplase. An injection of TPA is usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it's given in the vein.

Emergency procedures

·         Medications delivered directly to the brain. Using a long, thin tube (catheter) through an artery in groin and thread it to the brain to deliver TPA directly into the area where the stroke is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but is still limited.

·         Mechanical clot removal

·         .  Other procedures

·         Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes plaques from arteries that run along each side of your neck to your brain (carotid arteries

·         Angioplasty and stents

       Surgical blood vessel repair. 

·         Surgical clipping. 

·         Coiling (endovascular embolization).

·         Surgical AVM removal. 

·         Intracranial bypass. 

·         Stereotactic radiosurgery. 

References 

Strokeorg. 2014. Strokeorg. [Online]. [17 April 2015]. Available from: http://www.stroke.org/understand-stroke/what-stroke

Nihgov. 2015. Acute stroke. no-date. PubMed Central (PMC). [Online]. [17 April 2015]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071073/

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [15 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/dxc-20117265