The patient is a 30 year old solicitor who presents with flu-like symptoms including a dry cough, loss of appetite, chills, nausea, and vomiting. He reports feeling much worse than ever before and is lightheaded. His friends said he looked terrible and was not making sense. On examination, he is anxious, pale, tachycardic, hypotensive, tachypneic, and has cold hands and feet. Based on his worsening symptoms and signs of infection with organ dysfunction, sepsis should be considered and managed promptly according to guidelines.

1. 30 Year old solicitor attends surgery. He has a 2 day history of feeling flu like.
He reports a dry mild cough, anorexia and feeling shivery. Today his is feeling
‘absolutely awful’, ‘worse then ever before’, with some nausea and 1 x vomit.
He was also feeling very light headed. He came to see you because his
friends said he looked terrible and wasn’t really making sense. Usually very fit
and runs marathons
SE
Mild loose stool
Not sure re urinary symptoms as hasn’t pee’d much
PMHx
RTA 10 years previously
Meds Nil
Allergies Nil

2. O/E
Anxious
Pale, T 37.8, Hr 90, BP 100/67, RR 28, Sats not picking up
Very cold hands and feet ( he says this is normal for him)
Chest Clear
Abdo soft

3. O/E

4. ACUTE PRESENTATIONS IN
PRIMARY CARE
Anita Louise Sandison

5. • 280,000,000 GP Consultations (average 5/yr/person)
• 2/3 acute
• Acute Minor
• Acute Major

6. Acute Minor
Undifferentiated/partially developed
‘ Temporarily dependent patient’
‘ Test of time’ as a therapeutic tool may not be appropriate
Acute Major
Self limiting vs Need Rx
Alarm symptoms /Red flags
Marginalising danger vs Marginalising uncertainty
Acute serious illness
Self evident
New serious illness numbers small
40% of patients observed over two weeks get better
Acute on Chronic presentation
Shared plan

7. SEPSIS
• Commonly missed diagnosis
• (‘at its inception is difficult to recognise but easy to treat; left
unattended it becomes easy to recognise but difficult to treat’
Machiavelli )
• 100,000 hospital admissions /year 40% MR ( 37,000)
• Due to delay in recognition, diagnosis and therapy

8. SEPSIS
• Spectrum of infective process >> clinical syndrome
• Infection >>> SIRS>>> Sepsis>>>Severe Sepsis>>>Septic
Shock>>>MODS
MR (10%) (35%) (50%)
• Difficult to recognise ; nonspecific symptoms and non localised
• May not always have a fever
• Consider risk factors
• Sepsis = organ dysfunction
• SIRS Criteria

9. SEPSIS
SIRS CRITERIA ( 2 or more)
• Confusion or altered mental state
• T >38.3’c or < 36’c
• HR > 90
• RR >20
• Glucose >7.7
• WCC > 12 or <4 or > 10% band
forms
• Lactate >2
Red Flags
• SBP < 90 ( or a 40mmhg drop)
• HR 130
• O2 sats <91%
• RR >25
• LOC decreased
• Lactate >2

10. SEPSIS RECOGNITION
• Avoid Cognitive Errors
• Always ask the question
• See or talk to the patient on the phone
• Listen to collateral from family/friends/carers
• Take full obs
• Interpret HR and BP in context
• Interpret difficulties in measuring Sats
• Changes to cognition may be subtle

11. SEPSIS RECOGNITION
Consider Context
• Evidence of infection
• Patients where considering antibiotics or stewardship
• Suspected ‘Flu’
• Suspected Gastroenteritis
• Obviously unwell and no clear cause
• Elderly
• Already on antibiotics

12. SEPSIS TRUST MNEMONIC
PROFESSIONALS PATIENTS
• Slurred speech
• Extreme shivering or pain
• Passing no urine
• Severe breathlessness
• I feel like I may die
• Skin mottled and discoloured
• Shivery, cold, fever
• Extreme/worst ever pain or discomfort
• Pallor/discoloured skin
• Sleepy/ difficult to arouse/ confused
• I feel like I may die
• Shortness of breath

13. SEPSIS RISK FACTORS
• Very Young (<1) and old ( > 75)
• Immunocompromised
Cancer / Chemotherapy
Long term steroids
Other immunosuppressant drugs
Impaired immune function
( diabetes, sickle cell, splenectomy)
• Surgery or invasive procedures
• Misuse of drugs and alcohol
• Pregnancy
• Malnutrition
• Chronic illness
• Haematological disorders
• Indwelling catheters and lines
• Hospitalisation
• Breach of skin
Trauma
Burns

14. SEPSIS FEATURES
• Clinical manifestations non specific
• Superimposed on primary /underlying illness
• Temperature
• Early signs – hyperventilation,
confusion and disorientation
• Encephalopathy
• Skin lesions
• Nausea, vomiting and diaorrhea

15. SEPSIS MANAGEMENT
• Moderate/High Risk features >>>> Hospital >>> Pre Alert
• Community Management >>>> back up /safety netting
• Suspected Meningitis/Meningococcaemia Guidelines VS Sepsis origin
unknown
• Sepsis Bundles (Surviving Sepsis campaign)
• Blood cultures pre antibiotics
• Antibiotics in the first hour
• High flow 02
• Fluids
• Hunt for Infection

16. COGNITIVE ERRORS
• Wellness bias
• Premature anchoring
• Practice worst case scenario
• Ask yourself ? What else could it be?
What is the most dangerous thing it could be?
Is there any evidence at odds with the working diagnosis?

17. ANTIBIOTIC GUIDELINES IN NORTH DEVON
• Fever and a purpuric Rash
Benzylpenicilln 1.2 g IM/IV or Cefotaxime 1g IM/IV
• Sepsis of Unknown origin
Flucloxacillin 2g QDS + Amoxicillin 2g QDS + Gentamicin IV
or
Vancomycin IV + RifampicinIV 600mg BD PO + Gentamicin IV
• Severe sepsis or Septic Shock
Meropenem 2g TDS IV +/- Vancomycin +/- Clarithromycin

18. SUMMARY
• Be Vigilant
• Spectrum of infective disease is changing.
• Common things are common but uncommon things kill
• Be a ‘glass half empty’ person
• Look for ‘RED Flags’

19. ANAPHYLAXIS
• ABC
• Use Adrenaline Early
• IM 1:1000 Adrenaline repeat after 5 mins if not better
Adult >12 yrs 500mcg (0.5ml)
6-12 yrs 300mcg (0.3ml)
Less than 6yrs 150mcg (0.15ml

20. OTHER ACUTE PRESENTATIONS
76 year old woman attends with severe back pain (new onset) and
unable to mobilise because she feels faint when she sits up.
40 year old man holiday maker attends with a high fever and sore
throat. He repeated spits out into a bowl.
18 year old lower abdominal pain and feeling faint.
56 year old farmer pain in his jaw , intermittently, especially on cold
mornings
26 year old tall, thin, male smoker with a cough and pain on
inspiration