Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Septic Shock - Early Recognition Saves Lives

Patient Demographics

• Age: 64 years
• Sex: Male
• Occupation: Retired factory worker

Chief Complaint

"I feel terrible and can't stop shaking."

History of Present Illness

A 64-year-old male presents with 2 days of progressive malaise, chills, and productive cough. He developed fever and rigors this morning. His wife reports he has been confused and "not acting right" since waking. He has been urinating frequently over the past week with some burning. He has type 2 diabetes and admits his glucose has been poorly controlled recently.

Initial Assessment

ESI Level: 1 - Septic shock with hypotension

First Impression:

• Appearance: Toxic-appearing, rigors, confused
• Work of breathing: Tachypneic
• Circulation: Mottled extremities

Vital Signs:

• Heart rate: 118 bpm
• Blood pressure: 82/48 mmHg
• Respiratory rate: 26 breaths/min
• SpO2: 91% on room air
• Temperature: 39.8C (103.6F)
• GCS: 13 (E3V4M6)

Sepsis-3 Criteria Assessment

qSOFA Score (Quick SOFA):

• Altered mental status: YES (+1)
• Respiratory rate ≥22: YES (+1)
• Systolic BP ≤100: YES (+1)
• Total: 3/3 (high risk for poor outcome)

SOFA Criteria:

• Sepsis = Life-threatening organ dysfunction due to infection
• SOFA score ≥2 indicates organ dysfunction

Septic Shock Definition:

• Sepsis PLUS
• Vasopressors needed to maintain MAP ≥65 mmHg PLUS
• Lactate >2 mmol/L despite adequate fluid resuscitation

Primary Survey

Airway: Patent, speaking (confused) Breathing: Tachypneic, crackles right base Circulation: Hypotensive, tachycardic, mottled, delayed cap refill (5 seconds) Disability: Confused (oriented to person only), GCS 13 Exposure: Warm peripherally (warm shock early), no rashes

Resuscitation - Sepsis Bundle (Hour-1)

Immediate Interventions:

1. Measure lactate: 4.8 mmol/L (elevated)
2. Obtain blood cultures BEFORE antibiotics
3. Administer broad-spectrum antibiotics
4. Begin fluid resuscitation: 30 mL/kg crystalloid

Antibiotics (within 1 hour):

• Piperacillin-tazobactam 4.5g IV (covers respiratory and urinary pathogens)
• Vancomycin 25 mg/kg IV (MRSA coverage given severity)

Fluid Resuscitation:

• 30 mL/kg = 2.4L (80kg patient)
• Given over 30-60 minutes
• Reassess after bolus

Secondary Survey

SAMPLE History:

• Symptoms: Fever, chills, cough, urinary symptoms, confusion
• Allergies: Penicillin (rash only - can use piperacillin-tazobactam with monitoring)
• Medications: Metformin, lisinopril, atorvastatin
• PMH: Type 2 diabetes (poorly controlled), hypertension, BPH
• Last Meal: Yesterday (poor appetite)
• Events: Progressive illness over 2 days

Physical Examination:

HEENT: Dry mucous membranes Neck: No meningismus Lungs: Crackles right lower lobe, dullness to percussion Cardiac: Tachycardic, no murmur Abdomen: Suprapubic tenderness, no guarding GU: Prostate enlarged on rectal exam Skin: Mottled lower extremities, warm Neuro: Confused, no focal deficits

Diagnostic Testing

Labs:

• WBC: 22,400 with 88% neutrophils, 15% bands (bandemia)
• Hgb: 10.2
• Plt: 98,000 (thrombocytopenia - DIC concern)
• BMP: Na 132, K 5.2, Cr 2.4 (baseline 1.1), glucose 342
• Lactate: 4.8 mmol/L
• Procalcitonin: 18.2 ng/mL (markedly elevated)
• Bilirubin: 2.4
• Coags: PT 16.2, INR 1.4

Urinalysis:

• Positive leukocyte esterase, positive nitrites
• >100 WBC, bacteria present

Chest X-ray: Right lower lobe consolidation

Likely Sources:

1. Urinary tract infection → urosepsis (primary)
2. Pneumonia (may be secondary aspiration vs. concurrent)

Response to Initial Resuscitation

After 2L crystalloid:

• BP: 88/54 (still hypotensive)
• MAP: 65 (borderline)
• Lactate: 4.2 (minimally improved)
• Mental status: Unchanged

Persistent Hypotension = SEPTIC SHOCK

Vasopressor Initiation

Norepinephrine:

• First-line vasopressor for septic shock
• Started at 0.1 mcg/kg/min via central line
• Titrated to MAP ≥65 mmHg
• Required: 0.25 mcg/kg/min

Additional Fluids:

• Continue cautious fluid resuscitation
• Assess fluid responsiveness (passive leg raise, pulse pressure variation)

Ongoing Management

Source Control:

• Foley catheter placed (urinary source)
• CT scan deferred initially due to instability
• Urology consulted for possible prostatic abscess

Additional Interventions:

• Stress-dose steroids: Hydrocortisone 50mg IV q6h (for refractory shock)
• Glucose management
• DVT prophylaxis when stable
• Stress ulcer prophylaxis

Clinical Course

Culture Results:

• Blood cultures: E. coli (pan-sensitive)
• Urine culture: E. coli >100,000 CFU/mL

Antibiotic Adjustment:

• De-escalated to ceftriaxone monotherapy (narrowed based on sensitivities)

Disposition

• ICU admission
• Vasopressors weaned by 36 hours
• Transferred to floor day 3
• Completed 7-day course of antibiotics
• AKI resolved (Cr 1.3 at discharge)
• Discharged day 7
• Follow-up for diabetes optimization and BPH management

Teaching Points

1. Hour-1 bundle saves lives: Lactate, cultures, antibiotics, fluids - all within 1 hour
2. Don't delay antibiotics: Each hour delay increases mortality; give before source is identified
3. 30 mL/kg crystalloid: Initial resuscitation volume; reassess and continue if needed
4. MAP goal ≥65 mmHg: Norepinephrine is first-line vasopressor
5. Lactate clearance: Repeat at 2-6 hours; goal >10% decrease
6. Source control: Identify and treat the source (drain abscess, remove catheter, etc.)
7. De-escalate antibiotics: Narrow based on culture results

Clinical Image

Image Description: Flowchart depicting the Hour-1 Sepsis Bundle components including measurement of lactate, blood cultures, broad-spectrum antibiotics, and crystalloid resuscitation for hypotension or lactate ≥4 mmol/L.

Attribution: Image adapted from Surviving Sepsis Campaign guidelines. Educational use. Source: https://www.sccm.org/SurvivingSepsisCampaign/Guidelines

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