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ACUTE MEDICAL EMERGENCIES - PART 4

Phát ban có thể được nội địa hóa nói chung và có xu hướng dẫn đến desquamation sau khi một hoặc hai tuần trong những người sống sót. Hệ thống thông thường có liên quan đến đường tiêu hóa (tiêu chảy và nôn mửa); thần kinh | THE PATIENT WITH SHOCK Table 9.3 Haemodynamic variables in shock adult mean values Left atrial pressure mm Hg Cardiac output l min Systemic vascular resistance dyn s cm2 Normal 10 5 1200 Left ventricular failure 25 2 3000 Haemorrhage 0 3 3000 Sepsis and anaphylaxis 2 12 300 As described before the type of septic shock known as the toxic shock syndrome has many potential causes. However the clinical presentation remains the same temperature greater than 38-9 C macular blanching rash hypotension evidence of involvement of at least three systems. The rash can be localised or general and tends to lead to desquamation after one or two weeks in survivors. Common systems which are involved are gastrointestinal diarrhoea and vomiting neurological confusion drowsy renal impaired function muscle myalgia high creatine phosphokinase hematological leucocytosis disseminated intravascular coagulation thrombocytopenia . Key points Maintain a high index of suspicion because diagnosing septic shock can be difficult Always check for the non-blanching purpuric rash of meningococcal septicaemia Consider the diagnosis in any ill patient with an altered conscious level and haemodynamic instability without any obvious cause Management If these patients are to survive the source of infection needs to be removed. Repeated blood cultures are required to determine the causative organism. Antibiotic therapy should be aimed at the most likely organism. However often a combination of a penicillin aminoglycoside and metronidazole is used according to the hospital antibiotic policy. If meningococcal septicaemia is suspected give benzyl penicillin 2-4 g and ceftriaxone 1 g intravenously immediately.When there is a collection of pus drainage will be required by either surgery or percutaneously under imaging control. The patient will require cardiovascular and respiratory support as well as intensive monitoring of their fluid and antibiotic regimes. The former aims to maintain a high cardiac index .