Page 98 - JSOM Summer 2024

The recommended interventions include: Differential Diagnosis
• While an abdominal source of infection is likely, a complete Perforated appendicitis is most likely. Perforated diverticulitis
physical exam should be performed to rule out other causes and complicated cholecystitis are also possible. Pyelonephritis
of sepsis. is less likely. Cellulitis or necrotizing soft tissue infection is un-
• Remove clothes and inspect the skin, groin, and axillae, likely based on a physical exam; however, this should always
looking for cellulitis or signs of infection or abscess. be a consideration in a septic patient with an unknown source.
• Take off boots and socks and inspect feet, checking be- Consider endemic infections based on recent travel and port
tween toes. Inspect feet and lower extremities for cellulitis calls. Given that he joined the ship in Guam, consider leptospi-
or evidence of infection. rosis or dengue fever.
• Perform a digital rectal exam and inspect the gluteal cleft to
look for evidence of perianal or perirectal abscess or pilon- The recommended interventions include:
idal abscess with cellulitis. • Continuous patient monitoring, including HR, BP, MAP,
• Ultrasound the abdomen for evidence of abdominal fluid and pulse oximetry.
collection. (Note: DDG medical departments do not have • Intravenous (IV) access × 2. 18 gauge or larger is rec-
ultrasound capability). ommended. If unobtainable, consider intraosseous (IO)
• Determine NEWS Score – National Early Warning Score access for the initial resuscitation and attempt IV after
(Table 1). NEWS score=11. resuscitation.
• Immediately after identification of a septic patient, perform
Diagnosis an initial rapid infusion of 30mL/kg with normal saline
This patient has evidence of sepsis and potentially septic (NS) or lactated Ringer (LR) solutions. LR may be prefera-
shock. Based on fever and peritonitis, he has suspected infec- ble if available, but both are acceptable. If the patient does
tion from an intra-abdominal source. There is evidence of cir- not have an appropriate UOP response after the initial fluid
culatory dysfunction based on hypotension, tachycardia, and bolus, the patient may need another 30mL/kg bolus.
delayed CRT. The tachypnea is also concerning. There was no • Continue LR or NS to maintain a goal urine output (UOP).
evidence of cellulitis or abscess on physical exam. His delirium Goal UOP: 0.3–0.5mL/kg/h. Increase or decrease fluid rate
is a strong warning sign: delirium is organ failure (in this case, by 20%. However, if UOP is inadequate, the patient may
brain failure), and delirium in the setting of an acute infection need fluid bolus or another intervention (see below). LR is
means that the patient is likely to be septic. preferred over NS.
• Early antibiotics: Need to determine the most likely source
Sepsis Treatment Principles 3,4,10 based on history, physical exam, and imaging.
Early recognition of impending sepsis and immediate treat- • Antibiotics for sepsis from a likely abdominal source.
ment with antibiotics are imperative to improve the chances Better: TCCC antibiotics: ertapenem 1g IV every 24h.
of survival. Maintain high suspicion for signs of early and pro- Best: ceftriaxone 2g IV/IO every 24h, PLUS metronidazole
gressing sepsis while performing continuous triage. In severely 500mg IV/IO/by mouth every 8h. Vancomycin 1.5mg/kg
hypotensive patients (MAP <65mmHg), fluid resuscitation is IV/IO every 12h could be considered, but it may not be
the priority. Ideally, antibiotics and fluid resuscitation should necessary if an abdominal source is likely. Furthermore, it is
be administered simultaneously. unavailable on Cruisers or Destroyer (CRUDES) platforms.
Discuss patient via telemedicine consultation.
The recommended interventions include: • Laboratory data. While the following will help obtain
1. Early antimicrobial therapy. clinical information, none of these labs are lifesaving and
2. Fluid resuscitation. should not delay the initial therapy of antibiotics and IV
3. Source control. fluids: CBC, urine analysis, blood glucose. (Note: Meta-
4. Patient monitoring through trending patient information. bolic panel not available on CRUDES platforms).
5. Early telemedicine consultation. • Supplemental O by nasal cannula if hypoxemic (e.g., SpO
2
2
6. Evacuate to definitive care. <92%).
• Pain medication: Unable to give oral medications due to
Probable Source of Infection gastrointestinal symptoms.
Given the physical exam, it is likely the abdomen. Therefore, • Consider IV narcotics such as morphine, but this may cause
source control is not possible onboard the ship. The Sailor will hypotension early on (see below). If giving IV morphine,
ultimately need surgical or procedural intervention. give during fluid bolus to avoid hypotension.

TABLE 1 Physiologic Parameters and NEWS Score*
Physiologic parameters 3 2 1 0 1 2 3
RR (breaths/min) ≤8 9–11 12–20 21–34 ≥25
Oxygen saturation (%) ≤91 92–23 94–95 ≥96
Temperature (°C) ≤35.0 35.1–36.0 36.1–38.0 38.1–39.0 ≥39.1
Systolic BP (mmHg) ≤90 91–100 101–110 111–219
HR (beats/min) ≤40 41–50 51–90 91–110 111–130 ≥131
Level of consciousness Alert V, P, U
5
*Adapted from the Prolonged Casualty Care Clinical Practice Guidelines. For the level of consciousness determination: A=Alert; V=Not alert but
arouses to verbal stimulation; P=Not alert but responds to painful stimulation; U=Unresponsive.
NEWS = National Early Warning Score; RR = respiratory rate; BP =blood pressure; HR = heart rate.

96 | JSOM Volume 24, Edition 2 / Summer 2024