A 19-year-old male university student is carried into the triage area by his roommates because he became profoundly confused and lethargic over the last several hours. They state he complained of severe muscle aches and a headache earlier in the day. Vital signs reveal a temperature of 39.5°C (103.1°F), blood pressure of 72/38 mmHg, heart rate of 142/min, respiratory rate of 24/min, and oxygen saturation of 95% on ambient air. Physical examination demonstrates marked nuchal rigidity and a diffuse, non-blanching purpuric rash spreading across his lower extremities and trunk. He only groans in response to sternal rub. Which of the following represents the most urgent initial step in this patient's care?
- Begin aggressive volume expansion using balanced crystalloids along with empiric antibioticsAnswer
- BRelocate the patient for an immediate computed tomography scan of the head
- CProceed directly to a lumbar puncture to identify the causative organism
- DRequest urgent magnetic resonance imaging of the brain to evaluate for encephalitis
- EAdmit the patient to a standard isolation room on the general medical-surgical ward
Answer
Begin aggressive volume expansion using balanced crystalloids along with empiric antibiotics
The patient is presenting with septic shock likely secondary to meningococcemia (triad of headache, stiff neck, and purpuric rash combined with profound hypotension). In any unstable patient, hemodynamic stabilization (ABCs) is the highest priority. Rapid administration of isotonic intravenous fluids and early empiric antibiotics are life-saving and must not be delayed by attempts to obtain definitive imaging or perform a lumbar puncture.
Step-by-Step Solution
Key Concept
In hemodynamically unstable patients, immediate stabilization with fluid resuscitation and empiric life-saving therapies (such as antibiotics for suspected sepsis) must occur prior to diagnostic testing like neuroimaging or lumbar puncture.