InflammationMatt and Tom

Jenga Williams, aged 62, enters your clinic. He twisted his ankle jumping over a bollard, and is worried that he might have sprained it. You observe his ankle and note there are signs of acute inflammation. What might you see? (5)Rubor (redness)Calor (heat)Tumor (swelling)Dolor (pain)Functio laesa (loss of function)

Jenga’s ankle is very painful. What 3 substances activate pain pathways from cell damage? (3)

K+5-HT (serotonin)Bradykinin

What substance sensitises pain pathways by binding to prostanoid receptors, increasing activity of Na+ channels?

Prostaglandins

*This is why NSAIDS (which inhibit production of prostaglandins) have analgesic properties.

Marvin is a 22 year old man who comes into your clinic complaining of a 5 week history of bloody stools, colicky pain located in the right iliac fossa, and weight loss. Name 2 possible diagnoses? (1)

Crohn’s (most likely given pain location and age)Ulcerative colitisAppendicitisIBSGastroenteritisTapeworm

One of the features of Crohn’s disease is stricture formation. Strictures form due to chronic inflammation and scarring. What are the 3 key features of chronic inflammation? (1)

Ongoing inflammationOngoing tissue destructionOngoing attempts at repair

***THIS IS EXTREMELY HIGH YIELD. KNOW IT.***

So what’s going on with this fairly busy diagram?

What are the 4 processes, in sequence that leads to the recruitment of neutrophils to the acute inflammatory site?

1. Margination: prostaglandins/nitric oxide dilate vessel, reduction in laminar flow, neutrophils move to side of vessels

2. Adhesion:-TNF and IL-1 encourage P/E-Selectin expression on endothelial cells- Chemokines activate integrins on neutrophils from low affinity state to a high affinity state, which interact with ICAM

3. Emigration:- Histamine and nitric oxide cause retraction of endothelial cells- Neutrophils emigrate through endothelium (diapedesis)

4. Chemotaxis: neutrophils move up concentration gradient of inflammatory mediators

A 44 year old man, Graham Slee, is on the wards with suspected pneumonia. You are asked by the nurse to take a routine set of observations. You take the following:

BP 130/80Temperature 37.9o

HR 85RR 21

Which of the following can we say is true of this patient?

a) This patient has SIRSb) This patient has sepsisc) This patient has severe sepsisd) This patient has septic shocke) We cannot tell if any of the above are true

You check Graham’s bloods, which were taken earlier that morning, and you note the WBC under your observations in the patient notes:

BP 130/80Temperature 37.9o

HR 85RR 21WBC 14 X 109/L

Now which of the following can we say is true of this patient?a) This patient has SIRSb) This patient has sepsisc) This patient has severe sepsisd) This patient has septic shocke) We cannot tell if any of the above are true

So we know that severe sepsis = sepsis with organ dysfunction. Which of the following in combination with positive SIRS criteria most strongly indicate severe sepsis?

a) Resp rate of 28b) Coughing up lots of thick green sputumc) Oxygen sats < 90%d) Acidosise) Pleuritic chest pain

Name a decision making tool that can be used to decide to admit someone with pneumonia or not

• Confusion• Urea• Resp rate 30+• BP less than 90 systolic or 60 diastolic

• Over 65 years old

So we know that severe sepsis = sepsis with organ dysfunction. Which of the following in combination with positive SIRS criteria most strongly indicate severe sepsis?

a) Very high levels of serum creatine kinaseb) Very high levels of serum creatininec) Low serum calciumd) Loin paine) Vomiting

What is the management for someone with Sepsis?• Give high-flow oxygen• Take blood cultures• Give empirical IV antibiotics• Measure FBC & serum lactate• Start IV fluid resuscitation• Start accurate urine output measurements