A 31-year-old man presents to the Emergency Department with shortness of breath, fever and a cough productive of green sputum. This has been worsening over the course of 3 days, however, today he has been feeling very weak and faint, so decided to seek medical attention. His observations are as follows:

Respiratory rate 24 breaths per minute, oxygen saturations 95% on 2 litres of oxygen by nasal cannula, heart rate 123 beats per minute, blood pressure 91/63 and temperature 38.4. His Glasgow Coma Score (GCS) is 15.

His chest x-ray is displayed below:

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What is the most appropriate next step in the management of this patient?

Options:
explanation: The patient will need to be admitted and will receive at least 48 hours of intravenous antibiotics, however, this is not the best option - it does not address the need for other items within the sepsis 6, including taking blood cultures and giving fluids
name: Admit patient to complete a minimum of 48 hours of intravenous antibiotics
label: c
answer: no
explanation: Giving beta-blockers to lower the heart rate would be unhelpful here acutely - it would not address the cause of the tachycardia which is ultimately sepsis from severe infection. In some circumstances infection can trigger tachyarrhythmias which do require rate control, however nothing in the stem suggests that this has occurred
name: Give beta-blockers to help control his tachycardia
label: d
answer: no
explanation: Young patients often do receive significant volumes of fluid resuscitation quickly when unwell, however, this is not the single best answer here. This option does not address the need for other items within the sepsis 6, including taking blood cultures and giving intravenous antibiotics
name: Give 1 litre of 0.9% sodium chloride over 1 hour and then return to reassess the patient
label: e
answer: no
explanation: This patient is clearly very unwell and triggering as potentially septic within all of his observation parameters - he requires inpatient admission, intravenous antibiotics and careful monitoring during this stage of his illness. Additionally, it's important to be aware that young patients can tend to underscore on the CURB-65 model for assessing CAP severity - in these circumstances, it is important to also look at any oxygen demand and consider co-morbidities when assessing their risk of deterioration
name: Discharge home to complete a course of oral antibiotics
label: b
answer: no
explanation: This patient has a diagnosis of community acquired pneumonia (CAP) from his history and chest x-ray. Respiratory rate of >20 breaths per minute, heart rate of >90 beats per minute, low oxygen saturations and hypotension are all markers of sepsis, and this patient's presentation should prompt immediate action with "sepsis 6". The sepsis 6 involves taking **blood cultures** and a blood gas for a **lactate** measurement, giving **oxygen** and **intravenous antibiotics and fluids**, as well as careful monitoring of **fluid input/output** (usually with a catheter) all within 1 hour of recognition of sepsis. This is evidence-based and shown to improve mortality
name: Perform the "sepsis 6" within the next 1 hour
label: a
answer: yes

Correct answer: a