A Confused 72-Year-Old in the Waiting Room: Sepsis, Triage and Escalation

Quantify the derangement:

• Shock index = HR ÷ systolic BP = 124 ÷ 86 ≈ 1.44 (normal <0.9). A value above 1.0 in an older adult signals significant haemodynamic compromise.
• MAP = (86 + 2×50) ÷ 3 ≈ 62 mmHg - at or below the perfusion threshold.
• qSOFA-type features: respiratory rate ≥22, altered mentation, systolic BP ≤100 - three of three present, plus fever, delayed capillary refill and probable infection source.

Priority: immediate (red) - resuscitation area, not the waiting room. This is septic shock until proven otherwise.

First 30 minutes:

1. Move him to a monitored space with oxygen; continuous SpO2, cardiac monitoring, non-invasive BP cycling.
2. IV access ×2 and draw blood cultures before antibiotics (do not delay antibiotics more than a few minutes for cultures).
3. Lactate and full septic screen (urine, chest, bloods, glucose).
4. Broad-spectrum antibiotics within 1 hour of recognition.
5. Crystalloid 30 mL/kg for hypotension or lactate ≥4 - roughly 2.1 L for a 70 kg man - as rapid boluses with reassessment after each, watching for fluid overload if he has cardiac or renal disease.
6. Catheterise to measure hourly urine output; check pain, temperature control, and glucose.

Why the order matters: cultures taken after antibiotics lose sensitivity and leave the patient on the wrong drug for days; antibiotics delayed while chasing a lactate sample cost survival; and a single 2 L bolus given without reassessment causes pulmonary oedema in an elderly heart. Sequence, then reassess against targets (MAP ≥65, urine output ≥0.5 mL/kg/h, lactate clearance).

Advocacy here is a concrete, escalated request - not a complaint.

State the risk plainly to the nurse in charge:

• 'This man has a shock index of 1.44, a MAP of about 62, is hypoxic at 91% on room air and has new confusion. He is in septic shock. If he waits in the waiting room unmonitored, he will arrest there and no one will see it happen.'
• Ask for a specific action, not sympathy: 'Who can be moved to create a monitored space in the next five minutes?'

Practical options to put on the table:

• Use the curtained space beside triage and assign a nurse to him - proximity to the desk is better than a corridor.
• Move a clinically stable admitted patient (or a walking well ambulatory patient) out of a bay; escalate to the bed manager for admitted-patient boarding.
• Recall the nurse from break and escalate the staffing gap to the duty manager as a formal capacity concern.

If refused:

• Use the chain of command - emergency physician in charge, then duty manager/hospital coordinator; document who was told what and when, and the clinical findings at the time.
• Start treatment where he is rather than waiting for the ideal space: oxygen, IV access, cultures, fluids and antibiotics can begin immediately.
• Record the refusal and the escalation. 'The department was busy' is not a clinical justification for an unmonitored patient in shock, and the documentation is what protects both the patient and you.

Interpretation: fluid-refractory septic shock. He has received an adequate volume challenge and remains hypotensive with a rising lactate - tissue hypoperfusion is worsening, not resolving.

• MAP = (78 + 2×44) ÷ 3 ≈ 55 mmHg, well below the 65 mmHg target.
• Rising lactate after adequate fluids means the microcirculation is still failing; more boluses alone will not fix a vasodilated, leaking circulation and will increase the risk of pulmonary oedema.

Next steps:

1. Start a vasopressor - norepinephrine is first line - and give it through a central line if available, or peripherally with a documented extravasation plan if not, rather than delaying. Titrate to MAP ≥65.
2. Escalate to critical care now for ICU referral and probable intubation/central access; do not wait for the next set of observations.
3. Confirm source control: has the source been identified (urinary, respiratory, abdominal, line, skin)? Antibiotics alone will not rescue an undrained abscess or an obstructed infected kidney - escalate to the relevant team.
4. Check the simple, reversible causes of shock before assuming it is all sepsis: bleeding, pneumothorax, adrenal insufficiency, anaphylaxis, cardiac ischaemia (ECG and troponin).
5. Reassess fluid responsiveness rather than giving open-ended boluses - passive leg raise, stroke volume/echo, capillary refill and skin temperature; reassess after each intervention.
6. Document the fluid total, vasopressor start time and dose, and the escalation times. The clinical picture has changed from 'sepsis' to 'refractory shock' - the communication to the ICU team must say so explicitly.