Urgent considerations

See Differentials for more details

Obstetric emergencies

A sudden decrease in platelet count in the third trimester of pregnancy may indicate HELLP syndrome [hemolysis, elevated liver function tests, and low platelets]). This condition is associated with progressive and sometimes rapid maternal and fetal deterioration. Obstetric evaluation and management are essential. Generally, immediate delivery is an urgent consideration.[19][23]

Bleeding due to severe thrombocytopenia

The immediate goal is to stop the bleeding.

Close observation of respiratory and cardiovascular status is required. Intravenous fluid support and positive inotropic agents are given as required.

A thorough history and physical examination followed by a CBC and peripheral smear are usually sufficient to guide initial treatment. Prothrombin time, activated partial thromboplastin time, and fibrinogen can help distinguish disseminated intravascular coagulation from thrombotic thrombocytopenic purpura. CT head should be performed for suspected intracranial hemorrhage.

Any anticoagulant or antiplatelet drugs should be withdrawn.[24]

Patients with severe thrombocytopenia due to ITP often receive IV immunoglobulin and glucocorticoids. Antifibrinolytic agents may be used for life-threatening bleeding associated with ITP.[4]​​[24][25]

Platelet transfusion can be useful even in thrombocytopenia caused by immune platelet destruction.[24]

Sepsis

Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an infection.[26] Presentation ranges from subtle, non-specific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multi-organ dysfunction and septic shock. Patients may have signs of tachycardia, tachypnea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state, or reduced urine output.[27] Sepsis and septic shock are medical emergencies.

Risk factors for sepsis include: age under 1 year, age over 75 years, frailty, impaired immunity (due to illness or drugs), recent surgery or other invasive procedures, any breach of skin integrity (e.g., cuts, burns), intravenous drug misuse, indwelling lines or catheters, and pregnancy or recent pregnancy.[27]

Early recognition of sepsis is essential because early treatment improves outcomes.[27][28][Evidence C][Evidence C]​​​​​ However, detection can be challenging because the clinical presentation of sepsis can be subtle and non-specific. A low threshold for suspecting sepsis is therefore important.

The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Several risk stratification approaches have been proposed. All rely on a structured clinical assessment and recording of the patient’s vital signs.[27][29][30]​​​[31][32]​ It is important to check local guidance for information on which approach your institution recommends. The timeline of ensuing investigations and treatment should be guided by this early assessment.[31]

Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.[28][33] Recommended treatment of patients with suspected sepsis is:

  • Measure lactate level, and remeasure lactate if initial lactate is elevated (>18 mg/dL [>2 mmol/L]).

  • Obtain blood cultures before administering antibiotics.

  • Administer broad-spectrum antibiotics (with methicillin-resistant Staphylococcus aureus [MRSA] coverage if there is a high risk of MRSA) for adults with possible septic shock or a high likelihood for sepsis.

  • For adults with sepsis or septic shock at high risk of fungal infection, empiric antifungal therapy should be administered.

  • Begin rapid administration of crystalloid fluids for hypotension or lactate level ≥36 mg/dL (≥4 mmol/L). Consult local protocols.

  • Administer vasopressors peripherally if hypotensive during or after fluid resuscitation to maintain MAP ≥65 mmHg, rather than delaying initiation until central venous access is secured. Norepinephrine (noradrenaline) is the vasopressor of choice.

  • For adults with sepsis-induced hypoxemic respiratory failure, high flow nasal oxygen should be given.

Ideally these interventions should all begin in the first hour after sepsis recognition.[33] 

For adults with possible sepsis without shock, if concern for infection persists, antibiotics should be given within 3 hours from the time when sepsis was first recognized.[28] For adults with a low likelihood of infection and without shock, antibiotics can be deferred while continuing to closely monitor the patient.[28]

For more information on sepsis, please see our topics [Related Topic: Sepsis in adults] and [Related Topic: Sepsis in children].

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