Question Of The Day #7

question of the day
qod7 - sepsis

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient has a diagnosis of septic shock due to pneumonia. In all patients presenting to the Emergency Department, the initial assessment should involve the “ABCs” (assessment of Airway, Breathing, and Circulation). The patient is given supplemental oxygen for her hypoxemia with an improved oxygen saturation from 89% to 95%. Performing endotracheal intubation (Choice A) is too aggressive at this time as the patient is improving with non-invasive oxygenation techniques. The Centers for Medicare and Medicaid sepsis guidelines recommend a 30 mL/kg of isotonic crystalloid fluid bolus in patients with sepsis. However, there is limited data to support this recommendation, as some patients may benefit from less or more fluids than 30 mL/kg. The question stem indicates that an appropriate bolus of fluids has been given, so providing more IV fluids (Choice B) is not the best course of action. The use of passive leg raising or bedside ultrasonography to assess for Inferior Vena Cava (IVC) size may help a clinician discern if more or less fluids are required. For example, visualizing a flat, collapsible IVC on ultrasound indicates additional fluids may be helpful. An increase in blood pressure after a patient’s legs are raised above the level of the heart (“passive leg raise”) also supports the use of additional IV fluids. Giving acetaminophen (Choice D) will help reduce the patient’s fever and improve patient comfort. However, initiating vasopressor therapy (Choice C) is the more appropriate next course of action. Vasopressors (i.e. norepinephrine, epinephrine) are generally recommended after IV fluid boluses if a patient is persistently hypotensive with a MAP less than 65mmHg. Vasopressors help to maintain cerebral and organ perfusion in states of shock. They should be titrated to a dose that maintains a MAP of 65mmHg or above.  Correct Answer: 

References

Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. “Chapter 12: Approach to Nontraumatic Shock”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Cite this article as: Joseph Ciano, USA, "Question Of The Day #7," in International Emergency Medicine Education Project, August 7, 2020, https://iem-student.org/2020/08/07/question-of-the-day-7/, date accessed: December 7, 2022

Question Of The Day #6

question of the day
sepsis abdominal pain

Which of the following is the most likely cause of this patient’s condition?

This patient is in septic shock due to ascending cholangitis. Shock is a condition where the body is unable to deliver adequate perfusion to meet metabolic demands. Shock is often characterized by multiorgan dysfunction and hemodynamic changes (i.e. tachycardia, hypotension). Ascending cholangitis is a serious diagnosis that carries high mortality without prompt treatment and recognition. Causes of ascending cholangitis include choledocholithiasis, a biliary tract stricture, or compression by malignant disease. Some cases demonstrate Charcot’s Triad (fever, jaundice, right upper quadrant pain) or Reynolds’ Pentad (Charcot’s triad plus shock and altered mental status). This patient meets all 5 criteria of Reynolds’ Pentad. Rather than a gallstone obstructing the biliary tree, this patient has an underlying malignancy that is obstructing biliary outflow (hinted by weight loss and progressive jaundice over 3 months). Treatment includes antibiotics, IV fluids, and surgical management. The elevated white blood cell count, fever, history, and physical exam support the diagnosis of septic shock. Cardiogenic shock (Choice A) would be more likely in a patient with known baseline cardiac disease, a patient complaining of chest pain or shortness of breath, low ejection fraction seen on echocardiogram, and cold distal extremities. Conditions that can cause cardiogenic shock include STEMI, CHF, and myocarditis. Obstructive shock (Choice B) is seen in conditions, such as pulmonary embolism, tension pneumothorax, or cardiac tamponade. The patient’s history and physical do not support this diagnosis. Hypovolemic shock (Choice D) can be caused by severe dehydration or hemorrhagic shock (a type of hypovolemic shock). This patient likely has some component of dehydration, but septic shock is the primary condition in this patient. Septic shock is a form of Distributive shock (Choice C). Anaphylactic shock also is a type of Distributive shock. Correct Answer: C

References

Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. “Chapter 12: Approach to Nontraumatic Shock”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Donaldson, R. (2020, May 2). Ascending cholangitis. WikEm. https://www.wikem.org/wiki/Ascending_cholangitis

Cite this article as: Joseph Ciano, USA, "Question Of The Day #6," in International Emergency Medicine Education Project, July 31, 2020, https://iem-student.org/2020/07/31/question-of-the-day-6/, date accessed: December 7, 2022

From Experts to Our Students! – Sepsis