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Difficulty: EasyInitial Stabilization and Triage

A 71-year-old female resident of a skilled nursing facility is brought to the emergency department due to profound lethargy. Staff report she has been increasingly confused since yesterday. Her temperature is 39.5°C (103.1°F), blood pressure is 78/42 mm Hg, heart rate is 134/min, and respiratory rate is 24/min. Pulse oximetry shows 95% on room air. Physical examination reveals warm, flushed extremities, dry mucous membranes, and cloudy, malodorous urine in her collection bag. Which of the following simultaneous initial emergency orders are most appropriate? (Select all that apply)

  1. Provide a rapid intravenous bolus of isotonic crystalloid.Answer
  2. Draw peripheral blood cultures and administer empiric broad-spectrum antibiotics.Answer
  3. C
    Begin norepinephrine infusion via a central venous catheter.
  4. D
    Obtain an urgent computed tomography scan of the head.
  5. E
    Delay fluid resuscitation until bedside echocardiography assesses left ventricular function.

Answer

The correct simultaneous initial emergency orders are to provide a rapid intravenous bolus of isotonic crystalloid, draw peripheral blood cultures, and administer empiric broad-spectrum antibiotics.
This patient presents in septic shock, likely secondary to a severe urinary tract infection. The initial stabilization of septic shock requires immediate and simultaneous interventions focused on restoring tissue perfusion and targeting the infection. This includes a rapid bolus of isotonic crystalloids (typically 30 mL/kg) to correct hypovolemia from vasodilation and capillary leak. Concurrently, blood cultures must be drawn, followed immediately by the administration of empiric broad-spectrum antibiotics. These steps are standard components of the initial sepsis bundle and significantly reduce mortality when executed promptly.

Step-by-Step Solution

1
Identify the clinical syndrome.
The patient's fever, hypotension, tachycardia, altered mental status, and likely urinary source indicate septic shock.
Recognizing the etiology of shock guides the immediate resuscitation priorities.
2
Prioritize initial stabilization interventions.
The immediate focus must be on restoring perfusion and treating the underlying infection simultaneously.
In distributive shock caused by sepsis, the intravascular space is depleted, requiring immediate volume expansion and source control.
3
Select the appropriate orders.
Isotonic crystalloids are ordered for volume expansion, and blood cultures are drawn immediately prior to administering broad-spectrum antibiotics.
This aligns with evidence-based initial sepsis bundles to reduce mortality.

Key Concept

Initial stabilization of septic shock requires simultaneous administration of rapid isotonic crystalloid fluids, obtaining blood cultures, and initiating broad-spectrum antibiotics within the first hour.
Estimated Time:1m 15s
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Topics

Initial Stabilization and Triage

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