Year 3 Induction — Disease Index & Clinical Criteria

Use: Classify infection-related illness severity.

• Sepsis = identifiable source of infection + SIRS
• Severe sepsis = sepsis + organ dysfunction
• Septic shock = sepsis + cardiovascular collapse (requiring vasopressor support)

• Sepsis = life-threatening organ dysfunction caused by a dysregulated host response to infection
• Septic shock = vasopressors needed for MAP >65 mmHg + lactate >2.0 mmol/L despite adequate fluid resuscitation
• Abandoned: SIRS criteria for identifying sepsis; "severe sepsis" term

Use: Identify systemic inflammatory response. ≥2 criteria required.

• Temperature: ≥38°C or ≤36°C
• Heart rate: ≥90 bpm
• Respiratory rate: ≥20/min OR PaCO₂ ≤32 mmHg (or mechanical ventilation)
• WBC: ≥12,000/µL OR ≤4,000/µL OR ≥10% band forms

Use: Bedside screening tool to identify patients at risk of poor outcome from infection. Score ≥2 → start sepsis care pathway.

• Respiratory rate >22/min
• Altered mental status
• Systolic BP <100 mmHg

Limitation: Poor sensitivity — likely excludes its use as an early sepsis screening tool on its own.

Use: Predicts mortality risk for ICU patients based on lab and clinical data. A score of ≥2 is associated with a 10% or greater increase in mortality.

Use: Within the first hour of sepsis recognition. Key stat: 7.6% mortality increase for every hour delay in giving antibiotics.

• Supplemental Oxygen (high flow 15 L/min via non-rebreathe, target sats >94%)
• Establish IV access and start crystalloid (30 ml/kg)
• Insert a urinary catheter (hourly output monitoring)
• Draw a blood culture before starting antibiotics
• Administer empirical antibiotics
• Determine a lactate level

Ensure Hb >7 g/dl. Consider vasopressors if hypotensive after fluid resuscitation. Control the source of sepsis.

• Measure lactate level
• Obtain blood cultures prior to administration of antibiotics
• Administer broad-spectrum antibiotics
• Administer 30 ml/kg crystalloid for hypotension or lactate ≥4 mmol/L

• Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain MAP ≥65 mmHg
• In persistent hypotension despite volume resuscitation or initial lactate ≥4 mmol/L: measure CVP and central venous oxygen saturation (ScvO₂)
• Remeasure lactate if initial lactate was elevated

• CVP ≥8 mmHg
• MAP ≥65 mmHg
• Urine output ≥0.5 ml/kg/h
• ScvO₂ ≥70%
• Normalisation of lactate

Use: Supports clinical suspicion of necrotising soft tissue infection. Score ≥6 → high suspicion (PPV 92%, NPV 96%).

• Total WBC count
• Haemoglobin
• Sodium
• Glucose
• Serum creatinine
• C-reactive protein

• WBC ≥15,400/µL
• Serum sodium <135 mEq/L

Limitation: Failed to distinguish those with or without septic shock/death — should not be solely relied on for diagnosis.

Use: Classify severity of haemorrhagic shock by physiological parameters.

Compensation sequence: peripheral vasoconstriction → tachycardia → postural hypotension → recumbent hypotension

BP is the LAST parameter to drop — normal BP does NOT rule out significant blood loss.

Use: Activate massive transfusion protocol (e.g., dial 2222). Communication via SBAR. Nominate a coordinator/scribe.

• Replacement of entire blood volume in 24 hours
• Total transfusion >8–10 packed RBC units in 24 hours
• Replacement >50% blood volume in 3 hours
• Blood loss ≥150 ml/min
• Transfusion of ≥4 RBC units in 1 hour with ongoing haemorrhage
• Patient predicted to need ≥8 packed RBC units within 2 hours

Component ratio PRBC : FFP : Platelets = 1:1:1. Use permissive hypotension. Don't over-fluid (dilutes coagulation factors).

TXA (Tranexamic Acid): 1g bolus over 10 min then 1g infusion over 8h. Every 15-min delay decreases survival by 10%.

Use: Vertical approach for trauma resuscitation. For multiple trauma patients, use a horizontal approach (simultaneous, team-based task execution with delegated roles).

• A — Airway
• B — Breathing
• C — Circulation
• D — Disability (neurological assessment — GCS, pupils, lateralising signs, blood glucose)
• E — Exposure / Environment (remove clothing, logroll, prevent hypothermia, keep dignity, remove spine board ASAP)

Adjuncts: e-FAST, CXR, PXR, ± lateral cervical spine, ± whole-body CT, ± angiography/IR; analgesia (pharmacological, psychological, physical).

Planning round (STOP): all life-threats identified? all investigations done? analgesia given? what is the Plan? non-essential team disbanded? relatives informed?

Use: Concise medical history during trauma secondary survey, performed only when all immediately life-threatening conditions have been treated.

• A — Allergies
• M — Medications
• P — Past medical history
• L — Last meal
• E — Events leading to presentation

Use: Classify timing of surgical intervention. NCEPOD = National Confidential Enquiry into Patient Outcome and Death.

Use: American Society of Anesthesiologists physical status classification.

Use: Risk stratification for surgical patients. POSSUM = Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity.

Composition: 12 physiological + 6 operative parameters.

• Age, cardiac, respiratory, ECG, systolic BP, pulse rate, haemoglobin, WBC, urea, sodium, potassium, GCS

• Operation type, number of procedures, operative blood loss, peritoneal contamination, malignancy status, CEPOD (timing)

Use: Airway assessment based on visible oropharyngeal structures.

Three axes to align for intubation: oral, pharyngeal, laryngeal. Mr Douglas airway-difficulty factors: rheumatoid arthritis; cervical spine surgery; limited mouth opening.

Use: Predict difficulty of intubation. Score range 0–14 (higher = greater predicted difficulty).

Use: Predict perioperative cardiac risk. Strong predictor.

• Walking endurance: Can the patient walk a mile?
• Stair tolerance: Can they climb a flight of stairs?
• Day-to-day function: Activities of daily living
• Severity & stability of comorbidities; current medications; previous surgery & anaesthetics (problems? family history?)

• Correct the correctable (low Hb, low potassium, high INR)
• Stabilise/improve medical co-morbidities
• Explain & sign informed consent
• Premedication (as appropriate)
• Cross match & save blood
• Antibiotic & DVT prophylaxis
• Check for LATEX allergy

Medication rule: Continue preoperative medications. Exceptions: insulin; oral hypoglycaemics; ACE inhibitors (sometimes); anti-coagulants.

Hip fracture timeframe: Standard time-to-fix = 48 hours. Risks of delay >48h: DVT, pneumonia. Specialist consultation: cardiologist & pulmonologist (goal: optimise).

• Sign In (before induction): identity, site, consent, pulse ox, allergies, airway risk
• Time Out (before skin incision): team intro; antibiotic prophylaxis (<60 min); critical events anticipated
• Sign Out (before patient leaves): instrument/needle counts; specimen labelling

Goal: Reduce surgical stress to retain anabolic homeostasis.

• Carbohydrate drinks 2 hours before surgery (replaces overnight fasting)
• Minimally invasive approaches
• Fluid management (balance vs large volumes)
• Early removal of drains/tubes
• Early mobilisation
• Serving drinks/food day of operation

• Shorter hospital stay (30–50%)
• Reduced complications
• Reduced cost

• Antimicrobial prophylaxis — 5 sub-elements: name; timing; weight-based dose; re-dosing; discontinuation
• Skin antisepsis — standardised peri-operative practices
• Temperature control — normothermia maintenance
• Glycaemic control — glucose control optimisation
• Oxygenation — supplemental oxygen
• MRSA — screening/decolonisation
• Aseptic measures — traffic control; attire; audit

• Step 1: Non-opioid ± adjuvant
• Step 2: Opioid for mild to moderate pain ± non-opioid ± adjuvant
• Step 3: Opioid for moderate to severe pain ± non-opioid ± adjuvant

Golden Rule: Treat the PATIENT, not the number.

• S — Site
• O — Onset (sudden/gradual)
• C — Character
• R — Radiation
• A — Associations
• T — Time course (pattern)
• E — Exacerbating/Relieving factors
• S — Severity

Use: Pain assessment in children or non-verbal patients. Total score 0–10 (Merkel et al, 1997).

Frequency: Every time vital signs are taken.

• Autonomic (BP, HR, RR), cortical level

• Verbal: "mild" / "moderate" / "severe"
• Visual Analogue Scale (10 cm line)
• Verbal Numerical Rating Scale (0–10)
• Wong-Baker FACES: 0 (No Hurt) to 10 (Hurts Worst)

• Assess — Treat — Reassess — Escalate

Use: Systematic check for principal sources of postoperative fever. Fever = temperature >38°C (occurs in ~40% of post-op patients).

• Wind — atelectasis or pneumonia
• Water — urinary tract infection
• Walk — thrombophlebitis
• Wound — wound infection

• Look at surgical incisions
• Look at IV sites for septic thrombophlebitis
• Order blood/urine/sputum cultures
• Obtain chest X-ray if breath sounds worrisome

Early causes (1–3 days): atelectasis (traditional). Late causes (~2 weeks): septic thrombophlebitis (from IV line); occult intra-abdominal abscesses.

Use: Mnemonic for correctable causes of postoperative delirium. Postop delirium ~50% of cases (especially elderly + orthopaedic surgery).

• P — Pain
• IN — Infection
• C — Constipation
• H — Dehydration
• M — Medications
• E — Environment

Other causes to consider: electrolyte disturbance, hypo/hyperglycaemia, acid-base disturbance, organ failure, sedatives, hypoxia or hypercapnia.

• Sustained >6 hours before surgery
• Significant devitalised tissue
• Puncture injury
• Contact with soil/manure
• Associated clinical sepsis, foreign body, or compound fracture

• Standard: 250 IU IM
• High risk / >24h elapsed / heavy contamination / burns: 500 IU

Use: Determine whether the primary acid-base problem is respiratory or metabolic.

• Respiratory Opposite — pH and CO₂ move in opposite directions
• Metabolic Equal — pH and CO₂ move in the same direction

Compensation always goes in the same direction as the primary problem. CO₂ is an acid. Remember: ABG steps = Oxygenation → pH → pCO₂ → HCO₃ → Compensation → Anion Gap.

Use: Common causes of respiratory alkalosis.

• Anxiety / panic (including panic attacks)
• Pregnancy
• Early sepsis
• Mechanical ventilation at excessive rate or volumes

Use: Diagnose SLE. Patient must have ≥4 of these 11 manifestations at any time since disease onset.

• Malar rash: fixed red rash over the cheeks
• Discoid rash: red patches with scaling and plugging of hair follicles
• Photosensitivity: rash after sunlight exposure
• Mucosal ulcers: small sores in mouth and nose
• Serositis: inflammation of delicate tissues covering internal organs; abdominal pain
• Arthritis: very common; pain in the joints
• Renal disorder: usually detected by routine blood and urine analysis
• Neurological disorder: seizures or psychosis
• Haematological disorder: haemolytic anaemia, leukopenia, thrombocytopenia
• Immunologic disorder: tests on LE cells, anti-DNA, and anti-Sm antibodies
• Anti-Nuclear Antibody (ANA): positive (when patient is not taking drugs known to cause a positive test)

• Score 1: Decreased within 50–70% of normal requirements
• Score 2: 25–60% of normal requirements
• Score 3: 0–25% of normal requirements

• Score 1: >5% weight loss in 3 months
• Score 2: >5% in 2 months · BMI 18.5–25 · impaired general condition
• Score 3: >5% in 1 month · BMI <18.5 · impaired general condition

• Score 1: Diabetes; oncology; chronic patients (COPD or cirrhosis) with acute complications; chronic haemodialysis; hip fractures
• Score 2: Major surgery; stroke; severe pneumonia; haematological malignancy
• Score 3: ICU patients; head injury; bone marrow transplantation

• Age adjustment: if age >70, add 1 to give "age-adjusted total score"
• Score ≥3: patient nutritionally at risk → initiate nutritional care plan
• Score <3: weekly rescreening
• Score <3 but scheduled for major operation: consider preventive nutritional care plan