A 74-year-old woman is brought to the emergency department from a long-term care facility … — USMLE Step 3

A $74$ -year-old woman is brought to the emergency department from a long-term care facility due to worsening lethargy and confusion over the past $24$ hours. Staff members report that her urine has been noticeably dark and foul-smelling. Her past medical history includes type 2 diabetes mellitus, essential hypertension, and advanced Alzheimer dementia. Upon physical examination, she is minimally responsive to painful stimuli but her airway remains patent. Her skin is warm, flushed, and dry. Vital signs show a temperature of $39.4^{\circ}\text{C}$ ( $102.9^{\circ}\text{F}$ ), blood pressure of $76/40\text{ mm Hg}$ , heart rate of $122/\text{min}$ , and respiratory rate of $24/\text{min}$ . Oxygen saturation is $96\%$ on room air. Her capillary refill time is $4\text{ seconds}$ . Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select 2 answers)

Rapid administration of intravenous crystalloidsCevap
Administration of empiric intravenous broad-spectrum antibioticsCevap
C
Non-contrast computed tomography of the head
D
Lumbar puncture for cerebrospinal fluid analysis
E
Immediate transfer to the intensive care unit

Cevap

The most appropriate simultaneous initial steps are the rapid administration of intravenous crystalloids and the administration of empiric intravenous broad-spectrum antibiotics.

The correct answers are the rapid administration of intravenous crystalloids and the administration of empiric intravenous broad-spectrum antibiotics. This patient presents with classical signs of distributive (septic) shock, likely secondary to a severe urinary tract infection. The cornerstone of initial stabilization in undifferentiated and septic shock relies on the immediate, simultaneous initiation of aggressive fluid resuscitation (typically

30\text{ mL/kg}

of crystalloids) to restore intravascular volume, and broad-spectrum antibiotics to control the underlying infection. These interventions take absolute priority over definitive imaging, invasive testing, or ward transfer.

Adım Adım Çözüm

Identify the patient's acute clinical condition.

The combination of altered mental status, high fever, profound hypotension, tachycardia, and a suspected urinary source indicates uncompensated septic shock.

Recognizing the shock state prioritizes immediate life-saving interventions over definitive diagnostics or disposition planning.

Determine the highest-priority initial management bundle.

Simultaneous execution of intravenous fluid challenge and early broad-spectrum antimicrobial administration.

In septic shock, mortality increases significantly with every hour of delayed fluid resuscitation and antibiotic therapy.

Anahtar Kavram

Initial stabilization of septic shock requires the immediate and simultaneous administration of intravenous crystalloid fluids and broad-spectrum antibiotics prior to advanced imaging or disposition.

Soru

Cevap

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