Case of the Month
April 2007

73-year-old male, fever and confusion

Dispatch
"Aid 271 to an adult family home for a 73-year-old female with a fever”

En route your crew discusses the following considerations:

• Scene safety
• Causes of fever
• Infectious disease prevention measures (BSI)

While en route the dispatcher advises that the patient has a fever and is acting lethargic and confused.

Scene Size-up
You arrive at the group home and a staff member leads you into the patient. The patient is lying in bed with her mouth open and appears to be mildly short of breath. There is a strong smell of urine in the room.

Initial Assessment
As you approach she looks at you and moans. She has pale, moist skin, but she is very warm to the touch. She has a radial pulse of 110/min. You hear no abnormal breath sounds and her breathing looks labored and at an elevated rate—about 24/min.

Initial Treatment
Due to her decreased level of consciousness, poor skin signs, sustained tachycardia** and difficulty breathing you deem her to be SICK. As your partner starts a non-rebreathing mask at 12 lpm, you call for an ALS unit. You also ask for the patient’s chart and find her medical history and resuscitation orders.

**A persistent heart rate of 100-120/min or greater caused by a clinical condition such as hypoxia or impending shock.

Event and Recent History
The caregiver states that she went to wake the patient up this morning and she was lethargic and confused.  Though she suffers from some mild dementia, she is usually in good spirits and needs little assistance in getting around. Two days ago she was complaining of a burning sensation when she urinated and was going to the bathroom frequently. Yesterday, the patient was complaining of a burning feeling in the left flank. A message was left with the physician’s answering service, however the call was never returned.  

Further Evaluation and Treatment
Your partner reports the vital signs as follows:

• BP 90/40
• Heart rate 110/min
• Respirations 28/min
• Glucometry 88 mg/dl
• Oral temperature 102 degrees F

You give an update to the ALS unit and have the staff make copies of important documents for to be sent with the patient when transferred. 

The ALS unit arrives and evaluates the patient. After a consult with medical control, a second set of vital signs and since the condition did not have an acute onset, the decision is made for a BLS transport. The patient is loaded into the back of your rig and the ride to the hospital is uneventful. Soon after arrival at the hospital the patient is determined to have a mild case of sepsis that likely progressed from a urinary tract infection. 

Urinary Tract Infections and Urosepsis
Urinary tract infections (UTIs) are a relatively common and mild infection of the ureter and/or bladder. Women are more susceptible to UTIs, but both men and women are vulnerable in the elderly population. These infections can spread into the kidneys causing pain or a burning discomfort in the flanks. Very severe cases can lead to sepsis, which is a bacterial infection of the blood stream. If not treated, sepsis can lead to death. 
This is not the only condition that can cause sepsis, but it is one of the more common reasons for it to arise. Other common sites where sepsis can originate include:

• Liver or gall bladder
• Bowel (usually seen in peritonitis)
• Skin (cellulitis)
• Lungs (bacterial pneumonia)