MRCEM Part A Fast Facts: Infectious Disease Pharmacology

MRCEM Part A Fast Facts : Microbiology

SEPSIS Bundles & Early goal directed therapy

SIRS = 2 or more of
Temp < 38.3 or < 36
WBC < 4 or > 12
Pulse > 90
Resp > 20

SIRS + Documented/suspected infection = Sepsis
Sepsis + end organ failure = Severe Sepsis
Sepsis + unresponsive hypotension = Septic Shock

2 bundles = Resuscitation Bundle in 6 hours and Management Bundle in 24 hours

Resuscitation Bundle:

1. Check Lactates
2. Blood Cultures
3. Antibiotics after culture within an hour
4. Treat Hypotension or lactatemia (> 4 mmol/L) with fluids and/or Vasopressors to keep MAP > 65
5. If persistent, CVC to be done to keep CVP > 8, and Mixed Venous Sats > 65

EGDT: Subset of resuscitation bundle:

• MAP > 65
• Mixed Venous Sat > 65 %
• CVP > 8
• Urine Output > 0.5 ml/kg/hr
• Sugars < 8.3
• Hemoglobin between 7 to 9 gm/dL

SEPSIS SIX are 6 Tasks to be completed by any ED physician staff within the first hour:

• Give High Flow Oxygen
• Obtain Blood Cultures
• IV Antibiotics
• IV Fluids
• Check Lactates
• Monitor hourly urine output

(N.B.: Consider low dose steroids if a patient with septic shock do not respond to fluid resuscitation or vasopressors and has persistent hypotension)

Needlestick/Splash Injuries in the ED

Often we are faced with scenarios where we are approached by a healthcare worker who has sustained contact with contaminated bodily fluid wither through a needlestick or splash incident.

I would recommend the following approach for the OSCE Exams and in your day to day practice. Remember, approach these cases as an urgency and do not make the patient wait in the waiting areas. In case you need to start Post Exposure Prophylaxis (PEP), you should ideally do it within 1 hour of exposure.

• Introduction

Hi, my name is Dr. XYZ, one of the ED registrars on duty and would be helping you out today. May I know your name please? your age? and What is your designation in the hospital? 

As I understand you have sustained a needlestick injury, Is it correct? 

When was it? and What have you done immediately after it?

Before going into further details, I want to ensure that you have encouraged bleeding and washed the injury site with copious amount of water and soap.

• History

Okay, Could you tell me what exactly happened in more detail?

When was it? 

What were you doing?

Was the needle hollow or solid? did it puncture the skin? Was there bleeding? Was the needle contaminated?

What is your Hep B Vaccination status? 

What do you know about the patient? Enquire about the age, gender, occupation, and reason for his current hospitalization? His current Hepatitis and HIV status? Classify as high risk or low risk

• Management

If high risk, the HCW will need to be started on PEP immediately, and if low risk, reassurance is required. Explain about the undetermined efficacy of PEP, and the side effects of medications like GI upset, and hepatic injury.

Ask the HCW to fill an incident form.

Give samples for estimation of Hep B titres, and storage for further testing if required.

Obtain samples of the patient for testing for Hep B, C and HIV after consent.

Ensure TT is given to exposed.

• Counseling

Referral to ID specialist and occupational health department.

Further testing will be required in 6 weeks, 3 months, and 6 months.

Advice of safe sex practice and avoid donating blood until 6 months.

CURB 65 Pneumonia Risk

CURB-65 Severity Score for Community-Acquired Pneumonia

(Calculates the CURB-65 Score to estimate pneumonia mortality to help determine inpatient vs. outpatient treatment)

Confusion                                                                                          1

BUN ­> 19 mg/dL                                                                             1

Respiratory rate > 30/minute                                                        1

Systolic Blood Pressure < 90 mm Hg or                                      1

Diastolic Blood Pressure < 60 mm Hg

Age > 65 Years                                                                                 1

Total Score

Risk Score	30 Day Mortality %	Recommendations
1 (Low Risk)	2.7 %	Consider Outpatient Treatment
2 (Moderate Risk)	6.8%	Consider Inpatient treatment or Outpatient Treatment with close follow up
3 (High Risk)	14%	Consider Inpatient treatment with possible intensive care admission
4 – 5 (Highest Risk)	27.8%	Consider Inpatient treatment with intensive care admission

ED Management of Sepsis & Septic Shock