168.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
2 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, HR 125, RR 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 laboratory results
show a WBC 14,300/μL, hematocrit 31%, and platelets 350/μL. Her elec-
trolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radi-
ograph does not show any infiltrates. Urinalysis reveals 2+ protein, trace
ketones, WBC > 100/hpf, RBC 5 to 10/hpf, nitrite positive, and leukocyte
esterase positive. After administering a 500 cc normal saline fluid bolus and
broad-spectrum antibiotics through her peripheral IV line, the patient’s BP
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 BP, 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 (RBC)
c. Place a central venous line into the right internal jugular vein, measure a cen-
tral 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 CVP, admin-
ister 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 CVP, adminis-
ter normal saline boluses if the CVP is less than 8 mm Hg
178 Emergency Medicine