A 73-year-old man is brought to the emergency department due to increasing confusion for the last day. The patient has a history of type 2 diabetes mellitus, neuropathy, nonhealing foot ulcer, and coronary artery disease. On arrival, he is lethargic. Temperature is 37.6 C (99.7 F), blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 18/min. Pulse oximetry on room air shows an oxygen saturation of 97%. Mucous membranes are moist. Cardiopulmonary examination reveals no abnormalities. The abdomen is soft and nontender. Neurologic examination shows no focal findings. A nonhealing diabetic ulcer with small eschar is present over the right heel; there is no purulence, tenderness, or surrounding erythema. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient within the first hour of arrival in the emergency department?

Question

A 73-year-old man is brought to the emergency department due to increasing confusion for the last day.  The patient has a history of type 2 diabetes mellitus, neuropathy, nonhealing foot ulcer, and coronary artery disease.  On arrival, he is lethargic.  Temperature is 37.6 C (99.7 F), blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 18/min.  Pulse oximetry on room air shows an oxygen saturation of 97%.  Mucous membranes are moist.  Cardiopulmonary examination reveals no abnormalities.  The abdomen is soft and nontender.  Neurologic examination shows no focal findings.  A nonhealing diabetic ulcer with small eschar is present over the right heel; there is no purulence, tenderness, or surrounding erythema.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient within the first hour of arrival in the emergency department?

Quizplus · Accepted Answer

Explanation: This patient's confusion, hypotension, acidosis (bicarbonate of 16 mEq/L), and foot eschar raise suspicion for sepsis due to diabetic foot infection. Although sepsis is often associated with hypothermia or fever, patients with diabetes mellitus often cannot mount a significant inflammatory cytokine response due to leukocyte dysregulation from hyperglycemia. Therefore, diabetic foot infections often present with no significant local (eg, erythema, warmth, draining purulence) or systemic (eg, fever) manifestations despite limb or life threating infection. The following early interventions reduce risk of death in patients with suspected sepsis: Aggressive fluid resuscitation: Rapid administration of large-volume (eg, 30 mL/kg) intravenous crystalloid fluids should be performed within the first 3 hours; 500-mL boluses are typically given. Assessment for pulmonary edema (eg, worsened hypoxia) occurs between doses. Indicators of adequate response include mean arterial pressure of 60-70 mm Hg and urine output of >0.5 mL/kg/hr. As tissue perfusion improves, acidosis (eg, lactic acidosis) usually improves. Broad-spectrum antibiotics within an hour: A beta-lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam), carbapenem (eg, meropenem), or fourth-generation cephalosporin (eg, cefepime) is typically administered empirically; vancomycin is often added to cover methicillin-resistant Staphylococcus aureus. Blood cultures should be drawn before antibiotic initiation to identify the causative pathogen. (Choice A) CT scan of the head can identify hemorrhage, tumor, or stroke. However, acidosis and hypotension indicate that tissue hypoperfusion is likely causing the confusion in this patient. Fluid resuscitation and antibiotics should be given before additional testing is performed. (Choice B) Because investigation (eg, imaging) and treatment (eg, debridement) of diabetic foot infection often take several hours, empiric antibiotics are usually initiated before conclusive diagnosis. (Choice D) Vasopressors are required for refractory hypotension (continued hypotension after >3 L of fluid resuscitation over the first hour). This patient has not yet received significant fluid resuscitation. Furthermore, norepinephrine, not dopamine, is the preferred vasopressor for most cases of sepsis. (Choice E) Diabetic ketoacidosis (DKA) can cause hypotension, confusion, and acidosis but is most often seen in type 1 diabetes. Patients with type 2 diabetes may develop a hyperosmolar hyperglycemic state (HHS), which can cause confusion and hypotension, but significant acidosis is less common. Both conditions are associated with much higher blood glucose levels (eg, >350-500 mg/dL in DKA, up to ~1,000 mg/dL in HHS) than this patient's 220 mg/dL, which does not require urgent, short-acting insulin. Educational objective: Patients with suspected sepsis require early, aggressive fluid resuscitation and broad-spectrum antibiotics. They should receive rapid infusion of large volume (eg, 30 mL/kg) crystalloid fluid within the first 3 hours and broad-spectrum empiric antibiotics within an hour.

A 73-Year-Old Man Is Brought to the Emergency Department Due