quizzER Vol 1.7

An 81-year-old woman is brought to the ED by her children who state that the patient is acting more tired than usual, has had fever for the last two days, and is more confused. Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. Her vital signs are BP 85/60 mm Hg, heart rate 125, respiratory rate 20, temperature 101.3°F, and pulse oxygenation 97% on room air. On examination, the patient has dry mucous membranes, but is otherwise unremarkable. She is oriented to person and place, but states that the year is 1925. Her lab results show a WBC 14,300/µL, hematocrit 31%, and platelets 350/µL. Her electrolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radiograph does not show any infiltrates. Urinalysis reveals 2+ protein, trace ketones, WBC >100/hpf, RBC 5-10/hpf, nitrite positive, and leukocyte esterase positive.  After administering a 500 cc normal saline fluid bolus and broad-spectrum antibiotics through her peripheral intravenous line, the patient’s blood pressure is 82/60 mm Hg. You suspect that the patient is in septic shock. Which of the following is the next most appropriate course of action to manage this patient with early-goal-directed therapy?

a.    Start vasopressor therapy, repeat blood pressure, if below a systolic of 90 mm Hg, increase the dose
b.    Check the hematocrit and if it is less than 30% prepare to transfuse packed red blood cells
c.    Place a central venous line into the right internal jugular vein, measure a central venous pressure (CVP), administer normal saline boluses if the CVP is less than 8 mm Hg
d.    Place a central venous line into the left subclavian vein, measure a central venous pressure (CVP), administer normal saline boluses if the CVP is less than 12 mm Hg
e.    Place a central venous line into the right femoral vein, measure a central venous pressure (CVP), administer normal saline boluses if the CVP is less than 8 mm Hg

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

17 Responses

  1. I believe the answer is C. A lactate >4 will help validate a diagnosis of urosepsis. Hopefully blood cultures were drawn prior to antibiotics.

  2. C

  3. c

  4. C

  5. C

  6. C

  7. answer is C.

  8. c

  9. c.

  10. C

  11. 1) C

  12. C

  13. C. Place a Central Venous line in the Right Internal Jugular and measure the CVP. If less than 8mmHg then administer normal saline bolus.

    Check out the algorithm in
    Rivers et al. N Engl J Med 2001 Nov 8;345(19):1368-77

    First objective is ET Intubation, Central venous and arterial cath.

    Our first step is measuring CVP. (We don’t know the CVP of our patien!)
    If CVP <8 then normal saline bolus.
    The Right Internal Jugular is a more appropriate central line than the Femoral with regard to line sepsis.
    Next step is MAP (Our Patients was 67mmHg)
    If MAP<65 then start vasopressors
    Next step is SvcO2
    If 30. (Our pts Hematocrit was 31%. If SvcO2 still admit.

  14. C – first step in EGDT is to get CVP 8-12, if <8 give fluids

  15. c

  16. C. central line, CVP, and give additional fluids if CVP is less than 8

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