A 71-year-old woman is transported from a skilled nursing facility to the emergency depart… — USMLE Step 3

A 71-year-old woman is transported from a skilled nursing facility to the emergency department due to a sudden decline in responsiveness over the past six hours. The accompanying documentation notes that she had foul-smelling urine earlier in the shift. Her past medical history includes advanced vascular dementia and type 2 diabetes mellitus. On presentation, she is lethargic, muttering incomprehensibly, and opens her eyes only to painful stimuli. Vital signs reveal a blood pressure of $72/40 \text{ mm Hg}$ , a heart rate of $134/\text{min}$ , a respiratory rate of $26/\text{min}$ , and a core temperature of $39.5^\circ\text{C}$ ( $103.1^\circ\text{F}$ ). Oxygen saturation is $95\%$ on ambient air. Physical examination demonstrates warm, flushed extremities with bounding peripheral pulses. A chronic indwelling urinary catheter is in place, draining turbid, dark fluid. Which of the following interventions should be ordered SIMULTANEOUSLY as the most appropriate initial steps in management? (Select all that apply)

Rapid intravenous infusion of a balanced crystalloid solutionCevap
B
Non-contrast computed tomography of the head
Procurement of peripheral blood and urine culturesCevap
Intravenous administration of broad-spectrum antibioticsCevap
E
Immediate transfer to the intensive care unit

Cevap

The most appropriate simultaneous initial steps are the rapid intravenous infusion of a balanced crystalloid solution, procurement of peripheral blood and urine cultures, and intravenous administration of broad-spectrum antibiotics.

This patient is presenting with severe sepsis progressing to septic shock, evidenced by profound hypotension, hyperpyrexia, tachycardia, and altered mental status secondary to a likely catheter-associated urinary tract infection. The standard of care for septic shock requires an immediate, simultaneous bundle of interventions within the first hour of recognition. This bundle includes measuring lactate, obtaining appropriate cultures (blood and urine), administering empiric broad-spectrum antibiotics, and rapidly infusing

30 \text{ mL/kg}

of crystalloid fluids. These steps address the underlying distributive shock and begin treating the systemic infection concurrently.

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Assess the patient's primary physiologic derangement.

The patient exhibits severe hypotension, tachycardia, tachypnea, high fever, and altered mental status with a suspected urinary source.

Identifying the clinical syndrome as decompensated septic shock dictates the urgency and nature of the required interventions.

Determine the priority of care in undifferentiated shock.

Immediate stabilization of perfusion and treatment of the underlying systemic infection take absolute precedence over finding secondary diagnoses.

Delaying resuscitation in septic shock exponentially increases morbidity and mortality.

Select the appropriate simultaneous orders according to the sepsis bundle guidelines.

Orders are placed simultaneously for blood and urine cultures, broad-spectrum antibiotics, and a

30 \text{ mL/kg}

rapid crystalloid fluid bolus.

These interventions form the critical 'first-hour' stabilization bundle and must be executed in parallel without waiting for disposition or advanced imaging.

Anahtar Kavram

In patients presenting with septic shock, initial stabilization requires the simultaneous execution of a resuscitation bundle that includes drawing cultures, administering broad-spectrum antibiotics, and initiating aggressive fluid resuscitation.

Soru

Cevap

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