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Difficulty: EasyInitial Stabilization and Triage

A 74-year-old man is brought to the emergency department from a long-term care facility due to worsening confusion and fever over the past 24 hours. He has a history of benign prostatic hyperplasia and relies on an indwelling Foley catheter.

On arrival, the patient is obtunded. His skin is warm and flushed.

Vital signs are:
Temperature: 39.4°C (102.9°F)
Blood pressure: 74/42 mm Hg
Pulse: 124/min
Respirations: 24/min
Oxygen saturation: 95% on room air.

The urinary catheter bag contains cloudy, dark urine.

Which of the following is the most appropriate initial step in the management of this patient?

  1. Rapid infusion of intravenous crystalloid fluidsAnswer
  2. B
    Administration of intravenous norepinephrine
  3. C
    Computed tomography of the abdomen and pelvis
  4. D
    Transthoracic echocardiography
  5. E
    Immediate transfer to the intensive care unit

Answer

Rapid infusion of intravenous crystalloid fluids
The correct answer involves the immediate administration of intravenous crystalloid fluids. This patient is in septic shock, indicated by his severe hypotension, compensatory tachycardia, altered mental status, fever, and a suspected urinary source. The foundation of initial stabilization for septic shock is prompt and aggressive fluid resuscitation (typically 30 mL/kg of crystalloids) to treat the relative hypovolemia caused by systemic vasodilation and capillary leak. This step must be taken immediately upon presentation to restore end-organ perfusion.

Step-by-Step Solution

1
Assess the patient's hemodynamic status and recognize the signs of shock.
The patient has a blood pressure of 74/42 mm Hg, tachycardia (124/min), and altered mental status, confirming distributive shock.
Identifying the severity of hemodynamic instability determines the urgency and type of intervention required.
2
Identify the likely etiology of the shock.
Fever, warm flushed skin, and cloudy urine from a Foley catheter strongly suggest septic shock secondary to a urinary tract infection.
Understanding the mechanism of shock (distributive/vasodilatory) guides the appropriate stabilization therapy.
3
Select the most urgent initial stabilization step.
Rapid infusion of intravenous crystalloid fluids is selected as the primary intervention.
Current sepsis guidelines mandate immediate fluid resuscitation to restore intravascular volume and improve tissue perfusion before initiating vasopressors or pursuing advanced imaging.

Key Concept

The immediate management of septic shock requires aggressive hemodynamic stabilization with intravenous crystalloid fluids prior to advanced imaging, vasopressor use, or unit transfer.
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Topics

Initial Stabilization and Triage

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