Clinical Case 036: Silent, sitting sepsis

This case is part of my “Sepsis week” at Broome Docs.  Lets say this case happpens in January, just after the first big rain for the wet season.

58 yo Aboriginal man, presents to triage at ED complaining of “cold sick” [flu] symptoms. Has been feeling hot, sweating and had a non-productive cough intermittently for a week.  No good localising symptoms.

Obs:  P= 110,   temp = 38.9,    RR = 20,   BP 110/50,   SpO2 = 97% RA   BGL = 17.7 mmol

PMHx:  type 2 DM, untreated.   Hypertension,  gout and  recently investigated for PR bleeding = diverticulosis, old rheumatic heart disease – mild MR on ECHO.  “Drinks a bit”

Meds = perindopril / hydrocholothiazide,  allopurinol, aspirin.

Examination:  Sitting up, smiling.  ENT – normal, chest clear, systolic murmur c/w MR, abdomen soft, though mildly tender in the RUQ.  No loin tenderness.  No skin lesions. Alert and quiet, happy to sit…  Urinalysis = gluc 3+, protein 2+, blood +

This man gets a triage score of 3 – which means he should be seen within 30 minutes.  So after waiting his allotted 30 minutes he collapses in the ED waiting room and gets carried into the Resus bay….

Obs: pulse = 150 thready, BP = 70/30,  RR = 35 shallow,  Spo2 unrecordable, GCS = 8ish.  Groaning, localising to pain.   A bedside BSL = 20.3 mmol.

A portable CXR is done, and an ABG is drawn on 15L via NRB

pH = 7.19

PaO2 = 84

PaCO2 = 29

HCO3 = 12

Lactate = 6.3

BE  – 14

Here are the questions?  I will give it a day or two for answers to come in from the readers…

Q1:  What is your next move?

Q2:  What bugs do you need to cover to ensure you give adequate early empirical antibiotics?

Q3:  If you chose to intubate this man – what ventilator settings would you go for?

 

 

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