An 82-year-old woman is brought to the emergency department due to several hours of confusion and lethargy. She resides in a nursing home, and her oral intake has been poor over the last 2 days. She has had no fever, cough, dyspnea, or abdominal or urinary symptoms. The patient has a history of hypertension, type 2 diabetes mellitus, chronic kidney disease, and coronary artery disease. Three months ago, she had a non-ST elevation myocardial infarction and underwent percutaneous coronary intervention. The patient has been taking her medications without issue, but her long-acting insulin was held last night. Temperature is 35.7 C (96.3 F), blood pressure is 90/40 mm Hg, pulse is 98/min, and respirations are 18/min. Pulse oximetry shows 94% on room air. The patient is unable to answer questions or follow commands. Cardiopulmonary examination reveals no abnormalities. No edema is present in the extremities, and the skin is warm to touch. Neurologic examination is limited due to the patient's mental status, but no obvious focal abnormalities are noted. ECG reveals normal sinus rhythm with minor T-wave abnormalities. Laboratory results are as follows: The patient is given a 500-mL bolus of normal saline. Repeat vital signs after the fluids are completed reveal blood pressure of 85/40 mm Hg and heart rate of 95/min. Which of the following is the most appropriate next step in management of this patient?

Question

An 82-year-old woman is brought to the emergency department due to several hours of confusion and lethargy.  She resides in a nursing home, and her oral intake has been poor over the last 2 days.  She has had no fever, cough, dyspnea, or abdominal or urinary symptoms.  The patient has a history of hypertension, type 2 diabetes mellitus, chronic kidney disease, and coronary artery disease.  Three months ago, she had a non-ST elevation myocardial infarction and underwent percutaneous coronary intervention.  The patient has been taking her medications without issue, but her long-acting insulin was held last night.  Temperature is 35.7 C (96.3 F), blood pressure is 90/40 mm Hg, pulse is 98/min, and respirations are 18/min.  Pulse oximetry shows 94% on room air.  The patient is unable to answer questions or follow commands.  Cardiopulmonary examination reveals no abnormalities.  No edema is present in the extremities, and the skin is warm to touch.  Neurologic examination is limited due to the patient's mental status, but no obvious focal abnormalities are noted.  ECG reveals normal sinus rhythm with minor T-wave abnormalities.  Laboratory results are as follows:  The patient is given a 500-mL bolus of normal saline.  Repeat vital signs after the fluids are completed reveal blood pressure of 85/40 mm Hg and heart rate of 95/min.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This elderly patient with hypothermia, hypotension, and leukocytosis likely has an ongoing infection from an undetermined source. The next step is to determine if the patient has sepsis, as early sepsis intervention is associated with significant reductions in mortality. Sepsis screening in the emergency department is most often performed with the qSOFA score, a simple bedside calculation that assigns 1 point each for respiratory rate >22/min, altered mentation, and systolic blood pressure <100 mm Hg. Patients with qSOFA scores >2 (as in this patient with confusion and hypotension) are likely to be septic.Two major initial interventions reduce the risk of sepsis-related mortality: Aggressive intravenous fluids: Typically, 30 mL/kg of crystalloid infusion (eg, normal saline) is given over the first 3 hours of treatment in 500-mL boluses. Early antibiotic therapy: Broad-spectrum empiric antibiotics should be administered within 1 hour of arrival. Coverage should be targeted at gram-negative and gram-positive organisms and often includes a combination of antibiotics (eg, vancomycin plus cefepime). Fungal and viral coverage is rarely necessary unless a patient is neutropenic. Ideally, blood cultures should be obtained prior to the initiation of antibiotics. (Choice A) Intravenous albumin is expensive and has not been shown to be superior to crystalloid fluids for the treatment of early sepsis. As such, albumin is not recommended. (Choices B, C, and E) Intravenous dopamine and norepinephrine are vasopressors used to maintain blood pressure in patients with sepsis who continue to have hypotension despite adequate fluid resuscitation (septic shock). This patient has received only a single 500-mL fluid bolus; additional fluid resuscitation is required prior to consideration of vasopressors. Patients with sepsis are not typically given glucocorticoids unless they have refractory hypotension after adequate fluid resuscitation and vasopressors. Educational objective: Sepsis is associated with high rates of death. Aggressive intravenous fluid resuscitation and the early initiation of antibiotics have been shown to reduce mortality. Empiric broad-spectrum antibiotics should be administered within 1 hour of presentation (ideally after blood cultures have been drawn).

An 82-Year-Old Woman Is Brought to the Emergency Department Due