Question of the Week

For May 31, 2016

A 68-year-old male nursing home resident with a history of type 2 diabetes, recent diabetic foot infection, peripheral arterial disease, hypertension, and osteoarthritis is brought to the emergency department via ambulance for evaluation of altered mental status. The nursing home staff reports that he was talkative yesterday but appeared confused upon awakening today. He does not respond to any attempts to obtain further history.

A brief review of his medical record demonstrates a recent glycated hemoglobin level of 9.6% (3.8%–5.6%), a recent resting ankle–brachial index of 0.58 on the left and 0.95 on the right, and recent initiation of amoxicillin–clavulanate for a diabetic foot infection.

On physical examination, the patient has a temperature of 35.4°C, a heart rate of 106 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 88/58 mm Hg. The lungs are clear, the cardiac examination demonstrates tachycardia, and the abdomen is nontender. The left foot appears red with obvious foul-smelling pus draining from a 6-cm ulcer on the heel; a weak pulse is palpable in that foot. The patient responds only to noxious stimuli and palpation around the foot ulcer, with a groan.

There is no advance directive or POLST (physician orders for life-sustaining treatment) form.

A complete blood count demonstrates a leukocyte count of 22,000 per mm3 (reference range, 4500–11,000) with 11% bands (0–10), 78% neutrophils (40–70), and 11% lymphocytes (22–44). The creatinine level is 1.6 mg/dL (0.8–1.3), and the serum lactate level is 2.4 mmol/liter (0.6–1.7).

Blood cultures are drawn, and two large-bore peripheral intravenous catheters are placed. Intravenous fluids are initiated immediately for volume resuscitation.

Before admitting this patient to the intensive-care unit, what is the most important action to take immediately?

Obtain a radiograph of the left foot
Start vancomycin, cefepime, and metronidazole
Measure central venous oxygenation
Measure central venous pressure
Obtain surgical consultation